Every finding on record at Regalcare at Sudbury

Based on observation, and interviews, the facility failed to ensure that medication storage was maintained in a clean and sanitary manner for three medication carts (Concord East, Concord West, and Concord Split) out of three medication carts observed. Specifically, the Concord East, Concord West, and Concord Split medication carts were not maintained in a clean and sanitary manner, placing residents receiving medications from the carts at risk for contamination of medications and the spread of infections. Findings include: On 3/4/26 at 9:08 A.M., the surveyor and Nurse #1 observed the Concord East medication cart. The surveyor observed the medication cart was soiled externally at the top of the preparation surface, on both sides, front and back with a splattered, dried, brown substance. The surveyor also observed an open apple sauce container dated 3/4/26, and a water pitcher used for medication administration to residents on the top of the medication cart and a thick coating of dust to the lower-outer perimeter of the medication cart with dried splatters of brown and orange substances mixed in the dust. In the top medication storage drawer, a dried pool of white substance and three unidentifiable loose, white tablets, in addition to the over-the-counter medication bottles used for resident medication administration were observed. In the third drawer down on the right was a pool of partially dried, tacky brown liquid with other bottles of liquid medication used for resident medication administration. During an interview at the time, Nurse #1 said he was unaware of what the dried substances were inside and, on the cart, or when the medication carts get cleaned at the facility. Nurse #1 said the medication carts should be cleaned by the Nurses. On 3/4/26 at 9:16 A.M., the surveyor and Nurse #4 observed the Concord [NAME] medication cart. The surveyor observed the medication cart was soiled externally at the top of the preparation surface, both sides, and down the front with a dripped, dried, brown substance. There was a thick coating of dust to the lower-outer perimeter of the medication cart edge. On the top of the medication cart an open apple sauce container dated 3/4/26, an unopened nutritional protein shake, and a water pitcher used for medication administration to residents were observed. In the right top medication storage drawer, which contained over the counter medications for resident use was a small, dried pool of a white, chalky substance and two unidentifiable pink pills. In the bottom drawer on the right was a pool of dried, dark brown substance. During an interview at the time, Nurse #4 said she was unable to identify the spilled substances in or on the medication cart. Nurse #4 said she thought the night shift Nurses were responsible for cleaning the medication carts weekly on Tuesday's (last night) but the medication cart did not appear to have been cleaned. On 3/4/26 at 9:21 A.M., the surveyor and Nurse #6 observed the Concord Split medication cart to have spillage of white and brown substances down the bilateral sides of the cart and front facing drawers. In the left sided third drawer down was a partly dried, sticky brown pool of substance, and on the right drawer a dried chalky white pool of substance with other medication bottles that were used for resident medication administration. During an interview at the time, Nurse #6 said she was unaware of who was supposed to clean or when the medication carts were supposed to be cleaned but all Nurses should wipe up the spills. During an interview on 3/4/26 at 2:14 P.M., the Director of Nursing (DON) said the facility did not have a policy for medication cart cleaning, but there needed to be one. The DON said she had observed the medication carts and had concern for the lack of cleanliness. The DON said the dirty medication carts could result in contamination between different resident's medications and would need to be cleaned.

Based on observations, and interviews, the facility failed to ensure that residents were treated with dignity during communal, shared dining experiences on one unit (Concord West, East and Split Units) out of two units observed, and that one Resident (#4) out of a total sample of 16 residents, was provided with a dignified dining experience when the Resident required assistance with eating. Specifically, the facility failed to:1. ensure that residents who resided on the Concord West, Concord East, and Concord Split nursing units were served their meals at the same time as other residents seated at the same table or seated in the dining room for meals.2. For Resident #4, provide assistance and supervision at mealtime as indicated on the Resident's care plan, resulting in an undignified dining experience for the Resident. Findings include: Review of the facility's policy titled Activities of Daily Living (ADLs), revised December 2025, included but was not limited to:*The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. -Care and services will be provided for the following activities of daily living:-Eating to include meals and snacks.-A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility's policy titled Promoting and Maintaining Resident Dignity, revised December 2025, included but was not limited to:*It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. -All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. -The resident's former lifestyle and personal choices will be considered when providing care and services to meet the resident's needs and preferences. -Each resident will be provided with equal access to quality of care regardless of diagnosis, severity of condition or payment source. On 3/4/26 at 11:55 A.M. through 12:19 P.M., the surveyor observed the following during the lunch meal in the shared dining room for the Concord West, Concord East and Concord Split nursing units: -At 11:55 A.M.: 20 residents were present and seated at seven different round tables in the dining room. -At 12:00 P.M.: Table one positioned next to the entrance of the dining room had four residents seated at a round table, three residents had been served their lunch meal, and one resident had not been served a lunch meal. -At 12:09 P.M.: Table two had three residents seated at a round table, two residents had been served their lunch meal, and one resident had not been served a lunch meal. The resident seated at the table who was not served a lunch meal, was observed to reach over the table and remove a chocolate cake desert from one of the residents who had been served their meal. -At 12:17 P.M.: The resident seated at table one without a meal tray continued to wait for their lunch meal, when three residents seated at the same table had already started eating. On 3/5/26 at 7:44 A.M. through 8:12 A.M., the surveyor observed the following during the breakfast meal in the shared dining room for the Concord West, Concord East and Concord Split nursing units: -At 7:47 A.M.: Seven residents were present and seated at seven different round tables. One of the seven residents, seated at a round table was provided with their breakfast tray, and the remaining six residents did not have their meal trays. -At 7:52 A.M.: A second resident was served their breakfast meal. A resident was observed entering the dining room, sat at the same table with the second resident and looked at the second resident's breakfast meal.-At 7:53 A.M.: One resident stood up from their table, exited the dining room and asked a staff member in the hallway next to the meal cart about their breakfast meal. -At 7:55 A.M.: The resident was observed returning to the dining room after speaking to the staff member and was served their breakfast meal. -At 8:07 A.M.: two residents out of the eight residents seated in the dining room were served their breakfast meals 20 minutes after the other residents in the dining room were served their breakfast meals. During an interview on 3/5/26 at 8:20 A.M., Rehabilitation Staff (RS) #1 said that it had been a challenge updating the dining room tables so residents who eat in the dining room got their meals served at the same time. RS #1 said it was not a dignified dining experience when residents had to be waiting for 20 minutes after other residents in the dining room had already been served their breakfast meals. During an interview on 3/5/26 at 8:55 A.M., Nurse #5 said that the facility should have coordinated better with the kitchen and determined when the meal trucks arrived on the unit for the residents in the dining room to receive their meals at the same time. Nurse #5 also said that it was not dignified to serve some residents in the dining room their breakfast meal and other residents had to wait for their meals to be served. Nurse #5 said that residents seated at the same table should be served their meal at the same time and not have to wait and look at other residents eating their meals. Nurse #5 said that it would have been nice if residents who eat in the dining room receive their meals at the same time from the kitchen. During an interview on 3/5/26 at 9:38 A.M., the Assistant Director of Nurses (ADON) said that residents seated at tables together should be served their meal at the same time and should not have to watch their tablemates eat their meals. The ADON said that a hungry resident who does not have their meal could potentially choke should they attempt to eat their tablemate's food if the food is not what they are prescribed. The ADON further said that all residents seated in the dining room should be served their meal at the same time their tablemates were served their meals. 2. Review of the facility policy titled, Preparing the Resident for a Meal, dated December 2025 included but was not limited to the following: -Purpose - To prepare the resident and the environment in order to help make mealtime pleasant for the resident. -Preparation - Review the resident's care plan and provide for special needs of the resident. Review of the facility policy titled Promoting/Maintaining Resident Dignity, last revised December 2025 included but was not limited to the following: Policy - It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. *Compliance: -All staff .to promote and maintain resident dignity and respect for resident rights. -Assist resident to participate in activities of choice. Resident #4 was admitted to the facility in February 2023 with diagnoses including need for assistance with personal care, weakness, unspecified lack of coordination, and Dementia. Review of Resident #4's Minimum Data Set (MDS) Assessment, dated 2/17/26, indicated: -was severely cognitively impaired as evidenced by a Brief Interview of Mental Status (BIMS) score of three out of a total possible score of 15. -required partial to moderate assistance (helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort) for eating. -has not demonstrated rejection of care. Review of Resident #4's medical record included but was not limited to the following: -A Person-Centered Care Plan, revised 2/16/26, which indicated Resident #4 was at nutritional risk and required supervision during meals. -An active Care Kardex (brief summary of specific care needs for an individual) which failed to indicate that Resident #4 required supervision at meals. On 3/5/26 between 8:15 A.M. through 8:43 A.M., the surveyor observed Resident #4 lying in his/her bed. Certified Nurse Aide (CNA) #9 was observed to enter the Resident's room, deliver and set up a breakfast tray for Resident #4 then exit the room. The surveyor further observed Resident #4 pick up his/her spoon from the breakfast tray and begin eating ground sausage patty and pureed pancakes with syrup. Resident #4 spilled three consecutive bites of ground sausage and pureed pancake with syrup on his/her chest. Resident #4 then dropped the spoon on his/her bed and began to eat the pureed pancake with syrup and ground sausage with his/her fingers. During an interview on 3/5/26 at 8:28 A.M., CNA #9 said she was the CNA that set up Resident #4's breakfast tray. CNA #9 said that she knew what each resident needed for assistance because the Nurse gives her a report at the start of the shift. CNA #9 said that the facility used to have Care Kardex's for each resident, but the Care Kardex's were no longer available. CNA #9 said that Resident #4 was able to feed him/herself. On 3/5/26 at 8:43 A.M., CNA #8 was observed removing Resident #4's breakfast tray from the Resident's room. During an interview at the time, CNA #8 said he has worked in the facility for a long time and was familiar with Resident #4's care needs. CNA #8 said Resident #4 did not require supervision at meals but did require set up for all meal trays. CNA #8 said the facility does not have Care Kardex's anymore, but he knew what each resident needed because he has worked in the facility for a long time. During an interview on 3/5/26 at 9:09 A.M., the Director of Nursing (DON) said the CNA's have Care Kardex's in the facility's electronic charting system that the CNA's should follow for each resident. The DON said that each resident's Care Kardex informs staff of individualized care needs. The DON said that Resident #4 was care planned for supervision at meals which meant a staff member should observe the Resident at all times during meal consumption. During an interview on 3/5/26 at 9:48 A.M., the Director of Rehabilitation said Resident #4 required supervision during meals because of his/her need for assistance to manage utensils and verbal cueing. The Director of Rehabilitation said Resident #4's Care Plan indicated a need for supervised meals which meant that staff needed to be in the room with the Resident at all times during a meal. During an interview on 3/5/26 at 10:32 A.M., the DON said Resident #4 required supervision and assistance at mealtimes to provide cues and help during the meal. The DON said when Resident #4 had eaten with his/her fingers after dropping the spoon and spilled food on him/herself, it was a concern for an undignified dining experience for the Resident.

Based on observations, interviews, and record review, the facility failed to provide food and drink at safe and appetizing temperatures to residents from three of three breakfast meal carts on one unit (Concord West, East and Split Units) out of two total resident units.Specifically, the facility failed to provide food and drink at safe and appetizing temperatures for the breakfast meal for residents eating breakfast on the Concord East Unit, Concord [NAME] Unit, and in the shared Concord Unit Dining Room, increasing the residents' risks for reduced food/fluid intake and foodborne illness. Findings include:Review of the facility's policy titled Food: Quality and Palatability, last revised February 2023, indicated the following:-Food will be . served at a safe and appetizing temperature. -Proper (safe and appetizing) temperature means food should be at the appropriate temperature as determined by the type of food to ensure residents' satisfaction . Review of the facility's Food Committee Meeting Minutes, dated 2/19/26, indicated resident reported concerns over cold food and coffee. On 3/4/26, Surveyor #1 observed the following in the facility's Main Kitchen:-All hot food being served for breakfast was held at temperatures greater than 135 degrees Fahrenheit (F).-Cold beverages being served for breakfast were held at temperatures less than 41 degrees F.-steam coming from the steam table where hot foods were held from the start to finish of the tray line process (7:35 A.M. through 8:16 A.M.).-Loaded breakfast carts left the Main Kitchen as follows: >7:44 A.M. to the Concord Unit Main Dining Room. >7:58 A.M. to the Concord East Unit. >8:16 A.M. to the Concord [NAME] Unit. On 3/4/26 at 8:05 A.M., when all resident meal trays were passed, surveyor #2 completed a breakfast meal test tray in the Concord Unit Dining Room as follows:-Milk 60 degrees F, not cold.-Orange juice 56 degrees F, not cold.-Coffee 124 degrees F, not hot.-Scrambled eggs 118 degrees F, not hot. On 3/4/26 at 8:31 A.M., once all resident meal trays were passed, surveyor #3 completed a breakfast meal test tray on the Concord East Unit as follows:-Pureed bread 101 degrees F, not hot.-Pureed eggs 110 degrees F, not hot.-Pureed ham 84 degrees F, not hot.-Pureed oatmeal 91 degrees F, not hot.-Milk 60 degrees F, not cold.-Orange juice 60 degrees F, not cold. On 3/4/26 at 8:39 A.M., once all resident meal trays were passed, surveyor #1 completed a breakfast meal test tray on the Concord [NAME] Unit as follows:-Toast 62 degrees, spongy, one side lightly toasted and one side not toasted.-Scrambled eggs 110 degrees, not hot.-Cooked ham slice 80 degrees, not hot.During an interview at the time, the Food Service Director (FSD) said she was concerned that the hot foods were not served hot to the residents during the breakfast meal on 3/4/26. During interviews at the Resident Group Meeting on 3/4/26 at 11:00 A.M., four Residents (#8, #18, #19, and #23) out of eight residents present for the meeting said food that was supposed to be served hot was not hot when served. During an interview on 3/4/26 at 1:45 P.M., surveyor #1 discussed the results of the three breakfast meal test trays and the FSD said food items should be served to residents at a safe and appetizing temperature. The FSD said it was important for foods meant to be served hot to be served hot, and foods/beverages meant to be served cold be served cold.

Based on observation, interview, and record review, the facility failed to provide foot care and treatment in accordance with professional standards of practice for one Resident (#9) out of a total sample of 16 residents.Specifically, for Resident #9, the facility failed to provide toenail care as required to assist the Resident in maintaining good foot health and also schedule podiatry services as ordered when two Podiatry visits occurred in the facility after the Resident was admitted , putting him/her at risk of podiatric complications. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs) -revised December 2025, indicated:-Care and services will be provided for.bathing, dressing, grooming and oral care.-A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. Resident #9 was admitted to the facility in September 2025 with diagnoses including Transient Ischemic Attack (TIA), Anoxic Brain Damage and Gastrostomy. Review of Resident #9's most recent Minimum Data Set (MDS) Assessment completed 12/10/25, indicated:-that a staff assessment was completed for the Brief Interview for Mental Status (BIMS) because the Resident was rarely or never understood. -was severely cognitively impaired.-was dependent on staff for all ADLs. Review of Resident #9's medical record indicated:-Physician's order for Podiatry Consult as needed, dated 9/10/25.-Request for Podiatry Services Form, signed by the Resident's Guardian (someone with the legal authority to make decisions on behalf of another person) on 9/12/25.-Foot care had been provided to the Resident daily at their hour of sleep (HS) every evening shift. On 3/3/26 at 10:44 A.M., the surveyor observed Resident #9's toenails were untrimmed with the free edge of most of the toenails on both feet grown significantly past the nail bed. On 3/4/26 at 11:12 A.M., the surveyor observed Resident #9's toenails remained untrimmed with the free edge of most of the toenails on both feet grown significantly past the nail bed. During an interview on 3/4/26 at 12:56 P.M., the Director of Nursing (DON) said that Resident #9 should have been seen by Podiatry because the Resident's Guardian had signed the consent for Podiatry when he/she was admitted and that he/she should have been placed on the Podiatry list to be seen but had not been seen. The DON said that Podiatry had been to the facility twice on 12/19/25 and 2/24/26 since his/her admission to the facility and the Resident had not been seen on either of the two dates.

Based on observations, interviews, and record review, the facility failed to provide respiratory care and services consistent with professional standards of practice for one Resident (#13) out of a total sample of 16 residents. Specifically, for Resident #13, the facility failed to ensure that the Resident's oxygen concentrator (device used to deliver supplemental oxygen) cabinet and filter were cleaned and maintained as required, placing the Resident at risk for infection, impaired oxygen delivery and equipment malfunction. Findings include: Review of the Manufacturer User Manual for the Invacare Platinum 10 XL oxygen concentrator provided by the facility indicated: -Warning: *Keep the openings free from lint, hair and the like. -Maintenance: *The Invacare concentrators are specifically designed to minimize routine preventive maintenance. Only qualified personnel should perform preventive maintenance on the concentrator. -Cleaning the cabinet filter: *There are two cabinet filters one located on each side of the cabinet. 1. Remove each filter and clean at least once a week depending on environmental conditions. NOTE: Environmental conditions that may require more frequent cleaning of the filters include but are not limited to: high dust, smoking, air pollutants, etc. *On a weekly basis, wash the air intake gross particle filter, located on the back of the unit. 2. Clean the cabinet filters with a vacuum cleaner or wash in warm soapy water and rinse thoroughly.3. Dry the filters thoroughly before reinstallation. -Cleaning the cabinet:1.UNPLUG the concentrator when cleaning. To avoid electrical shock, DO NOT remove cabinet. 2.Clean the cabinet with a mild household cleaner and non abrasive cloth or sponge. Resident #13 was admitted to the facility in February 2022 with diagnoses including Heart Failure and Dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #15 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of a total possible score of 15. Review of Resident #13's current Physician orders indicated: -Oxygen two liters per minute (LPM - flow rate for oxygen delivery) as needed every shift for shortness of breath (SOB), effective 9/18/25. Review of Resident #13's Person-Centered Care Plan, revised 2/16/26, indicated: -I am [sic] oxygen therapy at two liters per minute (as needed, continuous [sic]) with interventions that included maintaining supplemental oxygen via nasal cannula (NC - a soft flexible, plastic tube applied in the nares for oxygen delivery). On 3/3/26 at 8:48 A.M., the surveyor observed Resident #13 lying in bed with oxygen being delivered at 2 LPM via NC from the oxygen concentrator. The oxygen tubing was observed to be dated 3/3/26 on a piece of white tape. The oxygen concentrator cabinet had a large area of dried white substance across the top and down the front and there were copious dried brown particles of debris observed on the front and sides of the oxygen concentrator cabinet. The oxygen concentrator filters on the left and right side of the oxygen concentrator cabinet walls were coated in layers of thick, fuzzy, gray dust. On 3/4/26 at 7:53 A.M., the surveyor observed Resident #13's oxygen concentrator remained unchanged from the prior observation on 3/3/26. During an interview at the time, Nurse #4 said that she was assigned to Resident #13 and the oxygen concentrator cabinets and the filters should be cleaned and wiped down every week by the Nurses when the oxygen tubing was changed. Nurse #4 said that oxygen tubing was supposed to be changed by the night shift on Tuesdays. The surveyor and Nurse #4 observed the Resident's oxygen concentrator and Nurse #4 said that tubing had been changed by the night Nurse because it was dated 3/3/26 but it did not appear that the oxygen concentrator cabinet and filters had been cleaned. Nurse #4 said that the filters were coated in dust and the white substance looked like Ensure drink. Nurse #4 said the brown particles on the cabinet appeared to be food of some type and Resident #13 was at risk for exposure to germs that could cause infection due to the dirty oxygen concentrator and filters. During an interview on 3/4/26 at 7:59 A.M., the Infection Preventionist (IP) said all oxygen tubing should be changed once a week on Sundays in the facility. The IP said she thought the housekeeping and maintenance departments were responsible for cleaning the oxygen concentrators but was unsure how often that was done. The IP said that it was important for Resident #13 to have a clean oxygen concentrator due to bacteria contamination and infection risk. The IP further said that the dried white substance on the oxygen concentrator looked like vanilla Ensure and the dried brown debris were crumbs of food. During an interview on 3/4/26 at 11:23 P.M., the Director of Nursing (DON) said that she was not aware if there was a set cleaning schedule for the oxygen concentrators in the facility. The DON said that cleaning schedules would need to be addressed. The DON said that dirty concentrator filters could affect Resident #13 because the delivery of oxygen could be impaired or cause overheating that could cause a fire.

Based on observations, interviews, and record review, the facility failed to provide effective pain management consistent with professional standards of practice, for one Resident (#73) out of a total sample of 16 residents. Specifically, for Resident #73, the facility failed to: -ensure that ordered Oxycodone (opioid pain medication) medication was available for administration to manage the Resident's chronic pain when the pharmacy medication was not confirmed by the Nurse resulting in the oxycodone medication being unavailable for administration to the Resident for approximately 21 hours. -ensure alternative and/or emergency pain management instructions were obtained from the NP/Physician to treat the Resident's persistent pain in a timely manner, when an alternative STAT dosage of oxycodone medication had to be ordered by the Physician for pain relief more than two hours after the Resident was administered scheduled Acetaminophen which did not relieve the Resident's pain. Findings include: Review of the facility policy titled Reconciliation of Medications on Admission, last revised December 2025, indicated the following:-Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications . for the purpose of preventing unintended changes or omissions at transition points in care. -Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, ., during the admission . process. Review of the facility policy titled Pain Assessment and Management, last revised December 2025, indicated the following: - .pain management .is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. -Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. -Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. -Possible behavioral signs of pain: >negative verbalizations and vocalizations such as groaning, crying, screaming. >facial expressions such as grimacing, frowning, clenching of jaw, etc. >behavior such as resisting care, . > .inability to perform ADLs due to the presence of pain. >insomnia. -Possible physiological signs of pain: >somnolence. -Monitor the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain . Resident #73 was admitted to the facility in March 2026 with diagnoses including Osteoarthritis and Right Hip Pain. Review of Resident #73's February 2026, Hospital Discharge Summary indicated: -sustained a right femoral neck (hip) fracture and underwent a total hip arthroplasty (THA: replacement) in October 2025. -underwent a palliative care consult, and palliative care was providing support to the Resident. -has right lower extremity pain and required pain regimen adjustment. -has Osteoarthritis at multiple joints. -Oxycodone HCl 2.5 mg/2.5 mL oral syringe was ordered to be administered PRN every four hours for moderate (4-6/10 [pain scale of four to six out of ten]) pain. -was to be discharged from the hospital to the facility. Review of Resident #73's Nursing admission Assessment, dated 3/2/26, indicated: -Pain level using a numeric scale was two out of 10 (2/10) at 2:15 P.M. that same day (3/2/26). -Resident's verbal pain scale was reported as moderate and expressed right hip pain as throbbing. -The Resident reported repositioning and PRN pain medication alleviated the pain. -The Resident reported his/her pain affected ADLs and physical activity/mobility. -Pain treatment included PRN Oxycodone 2.5 mg BID (twice daily) for moderate to severe pain. Review of Resident #73's Pain Interview, dated 3/2/26, indicated the Resident had occasional pain rated at a level of 6/10 or was hurting in the last five days that: -made it hard to sleep at night. -limited day-to-day activities. Review of Resident #73's Pain Care Plan, initiated 3/2/26, indicated: -Has potential for increased pain related to OA, physical deconditioning, and fall with THA. -Goal was to verbalize adequate relief of pain or ability to cope with incompletely relieved pain. -Administer analgesia as per orders; give a half hour before treatments or care. -Anticipate need for pain relief and respond immediately to any complaint of pain. -Evaluate the effectiveness of pain interventions .; review for compliance, alleviating of symptoms, dosing schedules, and resident satisfaction with results, impact on functional ability, and impact on cognition. -Notify physician if interventions are unsuccessful or if current complaint is a significant change from Resident's past experience of pain. Review of Resident #73's March 2026 Physician Orders indicated: -Monitor for behaviors: refusal of care, yelling (3/2/26). -Monitor for pain every shift for surveillance (3/2/26). -Acetaminophen Oral Tablet 500 mg; give two tablets by mouth two times a day for pain (3/2/26; scheduled at 8:00 A.M. and 8:00 P.M.). -Acetaminophen Tablet 325 mg; give two tablets by mouth as needed for pain daily (3/2/26). -Oxycodone HCL Oral Tablet 5 mg, give 2.5 mg by mouth as needed for pain twice daily (3/2/26). Review of Resident #73's March 2026 Medication Administration History Report indicated: -Two tablets of 500 mg (total 1000 mg) each Acetaminophen Oral Tablets were administered to the Resident on: >3/2/26 at 7:31 P.M. (scheduled for 8:00 P.M.) >3/3/26 at 9:38 A.M. (scheduled for 8:00 A.M.) -no documentation of PRN Acetaminophen being administered to the Resident between 7:31 P.M. on 3/2/26 and 9:38 A.M. on 3/3/26. -no documentation of PRN Oxycodone being administered to the Resident on 3/2/26. -documentation of the first dose of Oxycodone (5 mg STAT dose) being administered to the Resident was on 3/3/26, documented at 12:05 P.M. Review of Resident #73's Nursing Progress Note, dated 3/3/26 and written at 6:07 P.M. by Nurse #1, indicated:-the Resident was groaning in pain that morning and was asking for his/her pain medication (oxycodone 2.5 mg) but the oxycodone 2.5 mg was not available from the pharmacy.-Nurse #1 got a script from the Physician and faxed the script to the pharmacy.-Nurse #1 also got a one-time order of oxycodone 5 mg from the facility E-Kit which was administered while awaiting the pharmacy delivery.-The 2.5 mg tabs (of oxycodone) were delivered from the pharmacy that afternoon.-At the time of the Nursing Progress Note at 6:07 P.M., the Resident rated his/her pain at 2/10. Review of Resident #73's March 2026 Medication Administration Record (MAR) indicated:-pain level of 2/10 documented on the 11:00 P.M. to 7:00 A.M. (Night) shift 3/2/26 - 3/3/26 by nursing staff.-pain level of 0/10 was documented for the 7:00 A.M. - 3:00 P.M. (Day) shift on 3/3/26.-pain level of 8/10 was documented for the 3:00 P.M. - 11:00 P.M. (Evening) shift on 3/3/26. On 3/3/26, between 10:43 A.M. and 11:18 A.M., the surveyor observed the following: -Resident #73 was positioned in bed, turned toward his/her right side and with his/her head resting on the quarter siderail. The surveyor observed the Resident rub his/her left leg and face repeatedly, then grasp the quarter siderail with his/her left hand and repeatedly call out, oh, oh, oh! -At 10:44 A.M., a staff member entered the Resident's room, and the surveyor heard the staff member ask the Resident what was wrong. The Resident replied, What is wrong with them here? I told everyone and no one does anything! I have a terrible headache and every time I lift my head, I am dizzy!. -At this time, the surveyor observed Resident #73 begin crying and the staff member offered the Resident pillows for repositioning. The surveyor then observed Resident #73 yell out, That's not going to help! I need more than pillows!. At this time, the staff member exited the Resident's room and the Resident continued to call out, oh, oh, oh! Oh, my head!. -At 10:52 A.M., the surveyor observed Certified Nurse Aide (CNA) #1 in the hallway outside of the Resident's room, say to another staff member, I think [he/she] is in pain. [He/she] is new. Do you want me to go clean [him/her] now?. -At 10:53 A.M., the surveyor observed CNA #1 enter Resident #73's room. CNA #1 said, I am going to wash you up and the Resident said he/she did not want to wash up. CNA #1 said, I am going to help you wash up and the Resident said, I don't want you to wash me up! I need pain medication!. CNA #1 exited the room and said, I tried. I'm going to someone else, then proceeded down the hallway and entered another resident's room. -At 11:00 A.M., the surveyor observed Resident #73 call out, Ahhh, oh, oh, ow, oh!. The surveyor observed the Resident rolled toward his/her right side, head resting on the quarter siderail. -At 11:04 A.M., the surveyor observed Resident #73 roll onto his/her back and bang on the bedside table, which was positioned next to the bed, with his/her left hand. -Between 11:06 A.M. and 11:17 A.M., the surveyor observed a housekeeper enter, clean, mop, and exit Resident #73's room as Resident #73 continued to intermittently call out, oh, oh, oh!. -At 11:18 A.M., the surveyor observed Resident #73 call out, help, help and the Resident was crying. During an interview on 3/3/26 at 11:20 A.M., Nurse #1 said that Resident #73 was in a lot of pain that morning. Nurse #1 said that the Resident was recently ordered for 2.5 mg of PRN Oxycodone and that the ordered medication was not available to be administered to the Resident. When the surveyor asked about the E-Kit (Emergency kit) oxycodone, Nurse #1 said the E-Kit oxycodone were 5 mg tablets and could not be broken for the 2.5 mg dose ordered for the Resident. Nurse #1 said that he administered the Resident's scheduled Acetaminophen earlier that morning and that the scheduled Acetaminophen did not alleviate the Resident's pain. Nurse #1 said he offered the Resident a PRN dose of Acetaminophen, and the Resident declined the administration of the PRN dose because Acetaminophen was not effective to treat his/her pain. Nurse #1 said the facility had not yet obtained the Resident's ordered PRN Oxycodone medication since ordered for the Resident on 3/2/26. Nurse #1 said he spoke with the Physician this morning (after 7:00 A.M.) to alert the Physician that the Resident was in pain and the ordered PRN Oxycodone medication had not been obtained from the pharmacy. Nurse #1 said the Physician instructed him to call the pharmacy for a STAT delivery of the Oxycodone, which he did, and the pharmacy was unable to deliver the Oxycodone for another four hours. Nurse #1 said the facility placed another call to the Physician and was awaiting a return call from the Physician to obtain alternative orders to treat Resident #73's pain. On 3/3/26, between 11:21 A.M. and 11:46 A.M., the surveyor observed the Resident still positioned in bed. -At 11:26 A.M., the surveyor observed Resident #73 call out, oh Jesus! Oh, oh!. -At 11:34 A.M., the surveyor observed Resident #73 call out, ow, ow! Ahhh! Oh, oh, help, help!. -At 11:41 A.M., the surveyor observed Resident #73's call light lit and the Resident called out, Ahhh, oh, oh, oh, .help, oh, ow, ow!. -At 11:42 A.M., the surveyor observed Nurse #1 enter Resident #73's room with a medicine cup, turn off the Resident's call light, and administer the medication to the Resident. -At 11:46 A.M., the surveyor observed Nurse #1 exit Resident #73's room. During an interview at the time, Nurse #1 said Resident #73's Physician provided an order for a one-time 5 mg dose of Oxycodone to be administered to the Resident until the Resident's ordered PRN Oxycodone doses were available. Nurse #1 said he administered the one-time 5 mg dose of Oxycodone to the Resident at 11:42 A.M. On 3/3/26 at 1:00 P.M., the surveyor observed Resident #73 was positioned in bed, on his/her back and head slightly elevated. The surveyor observed that Resident #73 was not calling out and crying. Resident #73 said he/she had chronic pain in different areas of his/her body and he/she had been experiencing headaches for many years since a young age, had experienced back pain for many years due to OA, and experienced pain in his/her right hip over the last few months related to right hip fracture and hip replacement. Resident #73 said he/she had been asking for PRN Oxycodone since approximately 7:00 P.M. the previous evening (3/2/26) and that the Nurse working at that time (Nurse #2) said the PRN Oxycodone was not available. Resident #73 said Nurse #2 approached him/her before leaving between 11:00 P.M. and 11:30 P.M. on 3/2/26 and said that she did not know when the Resident's PRN Oxycodone would be available. Resident #73 said the pain he/she experienced overnight (3/2/26 to 3/3/26) was very bad. Resident #73 said it was difficult for him/her to rate the pain he/she experienced overnight between 3/2/26 and 3/3/26 because he/she had different types of pain, between the pain in his/her head, back, and hip. Resident #73 said he/she just knew that he/she felt miserable due to the pain. Review of Resident #73's Physician Progress Note, dated 3/3/26, indicated: -Osteoarthritic changes are seen. -Range of motion (ROM) of right hip is reduced due to pain. -One extra dose of Oxycodone 5 mg will be administered today (3/3/26) and it will be taken from the emergency [kit]. On 3/3/26 at 2:13 P.M., the surveyor placed a call to Nurse #2 (the Nurse who faxed the Pharmacy order) and left a voicemail. Nurse #2 did not return the surveyor's call by the end of the survey period. During an interview on 3/3/26 at 4:20 P.M., the Director of Nursing (DON) said Nurse #2 was required to ensure the prescription for Resident #73's PRN Oxycodone was transmitted via fax to the pharmacy when the Resident was admitted to the facility and that the orders were verified with the on-call NP. The DON said Nurse #2 should have also called the on-call NP for alternative instructions to treat Resident #73's pain when the Resident reported pain and his/her ordered PRN Oxycodone was not available. During an interview on 3/4/26 at 9:44 A.M., the DON said she spoke with the pharmacy, who verified they never received a prescription from the facility for Resident #73's ordered Oxycodone on 3/2/26. During an interview on 3/4/26 at 1:01 P.M., the DON said she spoke with Nurse #2 who was responsible for communicating with the pharmacy after Resident #73 was admitted to the facility. The DON said Nurse #2 faxed the prescription for the ordered Oxycodone to the pharmacy but did not receive a fax confirmation and never contacted the pharmacy to follow-up on whether the pharmacy received the prescription. The DON said Nurse #2 thought the Resident was comfortable because the Resident had fallen asleep around 8:00 P.M. on 3/2/26. The DON said Nurse #2 reported leaving the facility around 11:00 P.M. on 3/2/26 and had not contacted the on-call NP for alternative instructions to treat Resident #73's pain any time before she left the facility at the end of her shift. On 3/4/26 at 1:20 P.M., the surveyor placed a second call to Nurse #2 (the Nurse who faxed the Pharmacy order) and left another voicemail requesting a return call. Nurse #2 did not return the surveyor's call by the end of the survey period. During an interview on 3/4/26 at 1:24 P.M., the Physician said if Resident #73 reported pain during off-hours and the ordered pain medication was not available to be administered, the facility staff should have called the on-call NP to obtain instructions to treat the Resident's pain. The Physician said he spoke with Nurse #1 during the morning on 3/3/26 relative to the facility not having the Resident's ordered PRN Oxycodone. The Physician said he instructed Nurse #1 to call the pharmacy for a STAT delivery of the Resident's ordered Oxycodone and that he also ordered a one-time 5 mg dose of Oxycodone to be administered to Resident #73. During an interview on 3/4/26 at 1:32 P.M., CNA #2 said she provided care to Resident #73 during the 3:00 P.M. through 11:00 P.M. (evening) shift on 3/2/26. CNA #2 said Resident #73 was able to make his/her needs known and was able to verbally report pain. CNA #2 said Resident #73 was complaining of pain, pain, pain in his/her leg around supper time and that CNA #2 alerted Nurse #2. CNA #2 said Resident #73 continued to complain of pain around 7:00 P.M., and CNA #2 notified Nurse #2 again. CNA #2 said Nurse #2 told her she had already administered medication to the Resident. CNA #2 said she went to speak with the Resident, told the Resident Nurse #2 already administered pain medication and that maybe the Resident just needed to wait a little longer for the medication to work. CNA #2 said Resident #73 fell asleep a little after 8:00 P.M. and did not call CNA #2 for any assistance between 8:00 P.M. and the end of the shift at 11:00 P.M. During an interview on 3/4/26 at 2:06 P.M., CNA #5 said Resident #73 expressed having pain around 5:45 P.M. on 3/2/26 and she alerted Nurse #2. CNA #5 said Resident #73 expressed having pain again at 8:00 P.M. on 3/2/26. CNA #5 said she alerted Nurse #2 and that Nurse #2 said the Resident was not due for anything, that she already gave the Resident his/her medication and that she would explain this to the Resident. CNA #5 said the Resident fell asleep a little after 8:00 P.M. During an interview on 3/4/26 at 2:14 P.M., Nurse #1 said he followed up with Resident #73 after he administered the one-time 5 mg dose of Oxycodone on 3/3/26. Nurse #1 said that the Resident reported the medication administration to be effective and rated his/her pain at a 3/10 around 4:00 P.M. on 3/3/26. Nurse #1 said Resident #73 had no further episodes of calling out in pain and crying after the Oxycodone took effect on 3/3/26. The surveyor placed phone calls to Nurse #3 on 3/4/26 at 1:22 P.M. and CNA #4 on 3/4/26 at 1:58 P.M., who both worked the overnight (11:00 P.M. through 7:00 A.M.) shift from 3/2/26 through 3/3/26 and were assigned to care for Resident #73. Neither Nurse #3 nor CNA #4 returned the surveyor's call prior to the end of the survey period. During an interview on 3/5/26 at 10:30 A.M., the DON said Nurse #2 should have contacted the pharmacy regarding the Resident's ordered PRN Oxycodone when she did not receive a fax confirmation after attempting to fax the prescription to the pharmacy on 3/2/26. The DON said Nurse #2 should have contacted the on-call NP for alternative orders to treat Resident #73's pain on the evening of 3/2/26 when the Resident verbalized persisting pain after receiving scheduled Acetaminophen and the ordered PRN Oxycodone was not available from the Pharmacy. The DON said alternative orders to treat Resident #73's pain when the Resident's ordered PRN Oxycodone was not available to be administered should have been in place before the Resident experienced persisting pain during the morning of 3/3/26 to avoid a delay in treatment for pain.

Based on observations, interviews, and record review, the facility failed to provide an environment that was free from physical restraints imposed for discipline or convenience for one Resident (#5) out of a total sample of 16 residents. Specifically for Resident #5, the facility failed to ensure that the Resident's freedom of movement or activity was not limited, that he/she was capable of unlocking his/her wheelchair, and was evaluated for the least restrictive restraint when staff locked his/her wheelchair brakes to restrict the Resident's movements while he/she was seated in the wheelchair. Findings include: Review of the facility policy titled Use of Restraints, revised December 2025 included but was not limited to the following: -Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. -Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the residents' body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. -Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted. -Prior to placing a resident in restraint, there shall be a pre-restraint assessment. -Restraints shall only be used upon the written order of a physician after obtaining consent from the resident and/or representative. Resident #5 was admitted to the facility in November 2017 with diagnoses including Dementia and difficulty walking. Review of the Minimum Data Set (MDS) Assessment, dated 2/12/26, indicated Resident #5: -was unable to participate in a Brief Interview of Mental Status (BIMS) because he/she was rarely/never understood. -had not demonstrated wandering behaviors. Review of Resident #5's medical record failed to indicate evidence of: -A pre-restraint assessment. -A Physician's order for restraint. Review of Resident #5's Person-Centered Care Plan indicated: -Focus - Impaired cognition with behaviors that included wandering and limited language. -Interventions - Engage Resident in simple, structured activities. Monitor for physical/nonverbal indicators of discomfort or distress. -Focus - Behavior symptoms of wandering. -Interventions - Redirect the Resident by taking him/her on a walk together, then sitting in a common area. -No evidence of a Resident Centered Restraint Care Plan. On 3/3/26 between 3:29 P.M. through 4:00 P.M., the surveyor observed Resident #5 seated in a wheelchair in the Concord Unit activity room. Resident #5 was forward leaning and perched to the front edge of the wheelchair seat. The Resident's wheelchair was observed with both the left and right sided brakes locked. Resident #5 was scooting in the wheelchair with the brakes locked, using his/her feet and hip thrusts to move the wheelchair forward towards the exit of the activity room. Resident #5 paused his/her forward movement occasionally and rocked side to side then continued to scoot the wheelchair to the exit of the activity room and entered the hallway using his/her feet and hip thrusts. Nurse #1 was observed at that time to ask Resident #5 where he/she was going. Resident #5 repeated to Nurse #1 where are you going. Nurse #1 then unlocked the Resident's wheelchair brakes, wheeled Resident #5 to a table in the activity room and relocked the Resident's left and right sided brakes. During an interview at the time Nurse #1 said Resident #5 was unable to make his/her needs known. Nurse #1 said that Resident #5 is able to propel the wheelchair independently with his/her feet. Nurse #1 said he locks the brakes on Resident #5's wheelchair to keep the Resident safe and to prevent the Resident from moving out of the activity room so that the Resident could be watched. Nurse #1 then offered Resident #5 a glass of water which he/she declined. Nurse #1 then returned to his medication cart in the hallway and Resident #5 immediately began to scoot away from the table in the locked wheelchair with his/her feet and attained a forward-facing position towards the activity room exit. Resident #5 then continued to scoot forward with his/her feet and hip thrusts which caused the back wheels of the wheelchair to lose contact with the floor several times. Activity Staff #1 was observed to approach Resident #5 at the activity room exit, said hello to the Resident and asked the Resident where he/she was going. Resident #5 did not respond, and Activity Staff #1 then unlocked the Resident's wheelchair brakes, returned the Resident to the same activity room table where he/she had been placed by Nurse #1 and relocked the Resident's left and right sided wheelchair brakes. During an interview at the time Activity Staff #1 said that Resident #5 was able to move themselves around the unit in the wheelchair. Activity Staff #1 said Resident #5 was not able to tell staff what he/she needed but can sometimes point to something he/she wants. Activity Staff #1 said she locks the Resident's wheelchair brakes so that the Resident cannot move too much, and the staff would know where the Resident was. Resident #5 then began to scoot the wheelchair away from the activity room table and toward the exit with the wheelchair brakes locked. Resident #5 was observed at the activity room exit and was greeted by CNA #5 in the hallway. CNA #5 asked Resident #5 if he/she needed to use the bathroom. Resident #5 nodded his/her head yes and CNA #5 then took Resident #5 to the bathroom. During an interview on 3/3/26 at 4:38 P.M., CNA #5 said that she had worked in the facility for many years and provided care for Resident #5. CNA #5 said that when Resident #5 was restless it usually meant that he/she needed the bathroom. CNA #5 said that when she had taken Resident #5 to the bathroom around 4:00 P.M., Resident #5 had a bowel movement. CNA #5 said that Resident #5's wheelchair brakes should not be locked because Resident #5 was able to move the wheelchair independently and locking the brakes would hold the Resident back from moving. During an interview on 3/4/26 at 2:14 P.M, the Director of Nursing (DON) said if Resident #5 was unable to unlock his/her wheelchair brakes then the wheelchair brakes being locked would be considered a restraint. The surveyor and the DON approached Resident #5 seated in a locked wheelchair in the Concord Unit activity room and the DON asked Resident #5 to unlock the wheelchair brakes. Resident #5 was unable to unlock the wheelchair brakes. The DON said that the locked wheelchair was a restraint that limited the resident's movement because the Resident was able to move the wheelchair themselves when the brakes were not locked.

Based on interviews, and record review, the facility failed to ensure that one Resident (#59) out of a total sample of 16 residents had been provided the right to participate in the care plan process.Specifically, for Resident #59, the facility failed to ensure that the Resident was invited to participate in the initial and quarterly care plan meetings that were conducted as required for him/her or provide rationale why Resident #59 did not participate in the care planning meetings. Findings include: Review of the facility policy for Care Planning - Interdisciplinary Team, December 2025 indicated:-The Resident, the Resident's family and/or the Resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the Resident's care plan.-Care plan meetings are scheduled at the best time of the date for the Resident and family when possible.-If it is determined that the participation of the Resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record. Resident #59 was admitted to the facility in February 2025, with diagnoses including Heart Failure (HF) and Chronic Obstructive Pulmonary Disease (COPD). Review of the MDS (Minimum Data Set) assessment dated [DATE], indicated Resident #59:-was moderately cognitively impaired as evidenced by a Brief Interview of Mental Status (BIMS) score of 11 out of 15.-was English speaking.-makes himself/herself understood and usually understands others. During an interview on 3/3/26 at 10:06 A.M., Resident #59 said that he/she had never been invited to a care plan meeting. Review of Resident #59's clinical record indicated no documented evidence that the Resident participated in the care planning process with the interdisciplinary team (IDT) during the Resident's care plan meeting reviews held on 2/17/25, 6/12/25, 11/11/25, and 2/2/26.Further review of the clinical record failed to indicate the rationale as to why the Resident did not or could not participate in any care plan meetings, or refusals to participate in the meetings in 2025 and 2026. During an interview on 3/5/26 at 10:32 A.M., the Director of Nursing (DON) said that Resident #59 had not been invited to attend his/her care plan meetings and should have been invited because it was a Resident's right to be invited to attend their care plan meetings.

Based on observation, interview, and record review, the facility failed to adhere to infection control standards of practice for one Resident (#10) out of a total sample of 16 residents. Specifically, for Resident #10, the facility failed to ensure that Enhanced Barrier Precautions (EBP's - the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), were appropriately utilized when providing high contact care for the Resident, to mitigate the risk of organism transmission and the spread of infection to the Resident and other residents within the facility. Findings include:Review of the facility policy titled Enhanced Barrier Precautions, revised December 2025, included but was not limited to:*Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. -Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents.-EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. >Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room).>Personal protective equipment (PPE: items such as gowns and gloves worn to prevent the spread of infection) is changed before caring for another resident>Face protection may be used if there is also a risk of splash or spray.-Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include:>dressing>bathing/showering>providing hygiene>changing brief's or assisting with toileting>device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc).>wound care (any skin opening requiring a dressing).-EBPs are indicated (when contact precautions do not otherwise apply) for residents infected or colonized with the following:>ESBL (Extended-spectrum beta-lactamase - infections caused by bacteria resistant to many common antibiotics [penicillin and cephalosporins] that are difficult to treat). -EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. -EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. -Staff are trained prior to caring for residents on EBPs.-Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required.-PPE is available outside of the resident rooms. Resident #10 was admitted to the facility in February 2026 with diagnoses including Urinary Tract Infections (UTI), Dysfunction of Bladder, and Urinary Retention. Review of the Minimum Data Set (MDS) Assessment, dated 2/13/26, indicated Resident #10:-has moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of ten out of a possible 15 points.-has an indwelling suprapubic catheter (a flexible medical tube inserted directly into the bladder through a small incision in the lower abdomen, just above the pubic bone to drain urine). -had a Urinary Tract Infection (UTI) in the last 30 days. Review of Resident #10's Person-Centered Care Plan, initiated 3/3/26, indicated: -required Enhanced Barrier Precautions due to the use of a suprapubic catheter, MDRO History (Hx) of ESBL.-wear gowns with dressing, transferring, bathing/showering, providing hygiene, toileting, changing linens, toileting/incontinent care. Review of Resident #10's March 2026 Physician's orders indicated: -Maintain Enhanced Barrier Precautions (EBP) at all times when providing direct care every shift for foley (a flexible, indwelling tube inserted through the urethra into the bladder to drain urine, secured by a small, water-filled [NAME] at the tip), initiated 2/6/26. On 3/3/26 at 3:10 P.M. through 3:21 P.M., the surveyor observed the following: -PPE supply bin positioned outside Resident #10's door and no EBP signage posted. -Certified Nurse Aide (CNA) #6 entered the Resident's room and ambulated the Resident to the bathroom without donning a PPE gown. During an interview on 3/3/26 at 3:26 P.M., CNA #6 said that Resident #10 was on EBP for infection in the urine and she should have used a gown when she was assisting the Resident to the bathroom, but she did not. CNA #6 said that the risk of not wearing a gown was spreading infection to Resident #10 and other residents. During a follow-up interview on 3/3/26 at 3:30 P.M., CNA #6 said that Resident #10 was on EBP for the use of the suprapubic catheter and she should have worn a PPE gown when she assisted the Resident to the bathroom. On 3/4/26 at 9:15 A.M., the surveyor observed CNA #7 enter Resident #10's room wearing gloves but no gown and assisted the Resident to the bathroom. CNA #7 was also observed leaving the Resident's room, did not discard gloves and/or perform hand hygiene and gathered clean towels from the hallway linen cart and re-entered the Resident's room and bathroom without donning a gown. On 3/4/26 at 9:27 A.M., Resident #10 was observed seated on the toilet in his/her bathroom with CNA #7 standing next to the Resident providing ADL care without wearing a PPE gown. The Resident's suprapubic catheter was observed hanging on the handrail in the bathroom. During an interview on 3/4/26 at 9:51 A.M., CNA #7 said that she provided morning care for Resident #10 and did not wear a PPE gown. CNA #7 said that she should have used a gown to protect herself and the Resident. CNA #7 also said that the risk of not wearing a gown was transferring infections to Resident #10 and other residents. During an interview on 3/4/26 at 10:10 A.M., the Director of Nursing (DON) said that staff providing direct care for Resident #10 should have had PPE on including a gown and gloves to protect Resident #10 from the transmission of infections.

Based on record review, and interview, the facility failed to provide notice of change in coverage by Medicare for one Resident (#75) out of a total sample of 16 residents.Specifically, the facility failed to issue a Notice of Medicare Non-Coverage to Resident #75 when the Resident had skilled days remaining, was being discharged from Part A services, and was leaving the facility immediately following his/her last covered skilled day. Findings include:Resident #75 was admitted to the facility in June 2025 for short term rehabilitation following a fall with hip fracture. Review of Resident #75's Social Service Progress Note, dated 6/13/25, indicated Resident #75's discharge plan was to return home. Review of the list of residents discharged from Medicare Part A services with skilled days remaining within the previous six months indicated Resident #75's last covered skilled day was 8/3/25. Review of Resident #75's Physician Progress Note, dated 8/4/25, indicated Resident #75 was being discharged home on 8/4/25. Review of Resident #75's Social Service and Nursing Progress Notes, dated 8/4/25, indicated the Resident was discharged home on 8/4/25. Review of Resident #75's clinical record failed to indicate any evidence that the facility issued a Notice of Medicare Non-Coverage (NOMNC) to the Resident. During an interview on 3/4/26 at 1:16 P.M., the Director of Clinical Operations said the facility did not have any evidence that a NOMNC was issued to Resident #75 when the Resident had skilled days remaining, was discharged from Medicare Part A services, and left the facility immediately following their last covered skilled day.

Based on record reviews and interviews, for one of three sampled residents, (Resident #3), who upon admission had been assessed by nursing as being at risk for weight loss, the Facility failed to ensure that he/she maintained acceptable parameters of nutritional status regarding usual body weight and desirable weight range, when he/she experienced an unplanned, undesired significant weight loss and after the weight loss was identified, no additional weight monitoring occurred for two (2) months. Findings include: Review of the Facility Policy titled Weight Monitoring, dated as last revised 12/22/21, indicated that the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss/gain for all residents. The Policy further indicated the following; -The nursing staff will measure resident weights on admission, and weekly for three weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly; -Weights will be recorded in the resident's medical record; -Any weight change of five (5) percent (%) or more since the last weight assessment will be retaken within 24 hours for confirmation. If the weight is verified, nursing will notify the dietician, physician, and the resident/responsible party. -The threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria; a. One (1) month-5 % weight loss is significant; b. Three (3) months-7.5 % weight loss is significant; c. Six (6) months- 10 % weight loss is significant; and -The Plan of Care is updated as needed. Resident #3 was admitted to the Facility in August 2024, diagnoses include anemia, chronic obstructive pulmonary disease, depression, and dementia. Review of Resident #3's Physician Orders, dated 08/08/24, indicated to obtain his/her weight weekly times four (4), then continue monthly weights. Review of Resident #3's Care Plan titled Potential Nutritional Risk, dated 08/12/24, indicated he/she would maintain adequate nutritional status as evidence by (AEB) maintaining weight within 3 % of 115 pounds. Review of Resident #3's Notice of Determination of Resident Incapacity, dated 08/13/24, indicated his/her Health Care Proxy (HCP) was activated. Review of Resident #3's Quarterly Minimum, Data Set (MDS) assessment, dated 11/13/24, indicated he/she had moderate cognitive impairment. Review of Resident #3's Weight Summary Log, indicated the following: -08/08/24, 115.0 pounds; -08/15/24, 111.6 pounds; -08/22/24, 112.2 pounds; -09/05/25, 112.6 pounds; -10/07/24, 102.4 pounds; -10/08/24, 105.2 (6.6% loss in 30 days) -there was no weight documented for the month of November 2024. Further review of the Nutrition Care Plan indicated that on 11/14/24, his/her goals had been revised indicating, Resident #3 will maintain adequate nutritional status AEB maintaining weight within 3% of 105 pounds. Review of Resident #3's Weight Summary Log, indicated the following: -12/22/24, 103.0 pounds; and -01/17/25, 101.6 pounds (which was just over a 3% weight loss since 11/2024, and a 12.1 % weight loss in 60 days). Review of Resident #3's Physician Orders, dated 01/15/25, indicated there was no documentation to support he/she had an active order to obtain his/her weight's. Review of Resident #3's medical record, including but limited to, nurse progress notes, physician notes and dietician notes indicated that there was no documentation to support nursing staff notified the physician, dietician, or his/her activated HCA of a significant weight loss in a timely manner. Further review of the medical record, indicated there was no documentation to support that once discovered, no monitoring of his/her weights had been conducted. During a telephone interview on 01/22/25 at 3:12 P.M., the Registered Dietician (RD) said that she does not remember being notified about a significant weight loss for Resident #3. The RD said she reviewed a physician's note dated 10/14/24 noting his/her weight and said she thought that documentation was sufficient considering they spoke about Resident #3's plan. During a telephone interview on 01/23/25, the Assistant Director of Nurse (ADON) said that she was unaware that Resident #3 had a significant weight loss. The ADON said that the Facility's expectation for monitoring any weight loss/gain is once a weight is obtained, the nursing staff will enter the weight into the Point Click Care (PCC, electronic medical record system). The ADON said that if a weight loss/gain is identified, the resident is to be re-weighed within 24 hours to ensure accuracy and once confirmed being accurate nursing staff will promptly notify the physician, dietician, the resident, and/or HCA. During an interview on 01/15/25 at 4:19 P.M., the Director of Nurses (DON) said that she was unaware that Resident #3 had a significant weight loss. The DON said that the Facility's expectation on identifying weight loss/gain is once the weight loss is identified and confirmed, the nursing staff must inform the resident's physician, HCA, and the dietician.

Based on observation, interview, and policy review, the facility failed to provide a dignified dining experience for one Resident (#2), out of a total sample of 19 residents. Specifically, the facility staff stood over and remained standing while assisting Resident #2 during a breakfast meal. Findings include: Resident #2 was admitted to the facility in November 2021, with diagnoses including Multiple Sclerosis (MS: a chronic autoimmune disorder of the central nervous system marked by numbness, weakness, loss of muscle coordination, and problems with vision, speech, and bladder control). Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2: -was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of nine out of a total possible score of 15. -required substantial/maximum assist with feeding. Review of the facility policy titled Assistance with Meals last revised July 2017, indicated the following: -Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: not standing over residents while assisting them with meals . On 11/4/24 at 8:48 A.M., the surveyor observed Resident #2 lying in bed with the head of the bed elevated. The surveyor also observed Certified Nurses Aide (CNA) #3 standing over Resident #2 while assisting him/her with the breakfast meal. During an interview and observation at the same time, Additional Staff (Nursing Supervisor) #1 said that CNA #3 should be seated next to the Resident and not standing over him/her while assisting with the breakfast meal. Additional Staff #1 also said that standing over the Resident while assisting him/her to eat is not homelike and undignified.

Based on record and policy review, and interview, the facility failed to appropriately review and accurately execute Advance Directives (legal documents that provide instructions for medical care and only go into effect if you are unable to communicate your own wishes) for one Resident (#26) out of a total sample of 19 residents. Specifically, the facility failed to ensure that the correct Resident's name was entered on Resident #26's MOLST (Massachusetts Medical Order for Life-Sustaining Treatment) form, when another individual's name and Resident #26's date of birth were included on the form placing the Resident at risk for not having his/her final wishes upheld. Findings include: Review of the facility policy titled Massachusetts Advanced Directives, revised 8/3/22, indicated the following: -to maximize the rights of each resident, ensuring that their wish(es) regarding medical decision making is upheld and the safety of each individual is met - . Elected staff will confirm that information is appropriately documented in the medical record . Resident #26 was admitted to the facility in November 2021 with diagnoses including Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment). Review of Resident #26's clinical record indicated a MOLST form, reflecting the Resident's wishes to forgo any life sustaining treatment, signed on 6/20/19, by Resident #26's invoked (put into effect by order of a Physician) Health Care Proxy (the legally appointed person chosen as the healthcare decision maker when the individual is unable to do so for themself). The MOLST form also indicated Resident #26's date of birth and the facility medical record number were entered accurately on the form. Further review of the MOLST form indicated that Resident #26's name had been inaccurately entered on the MOLST form. During an interview on 11/4/24 at 1:17 P.M., Additional Staff (Nursing Supervisor) #1 said that the name entered on the MOLST form was not Resident #26's name and the form was inaccurate. Additional Staff (Nursing Supervisor) #1 said that because the MOLST form was inaccurate it was considered invalid, and any life sustaining treatment wishes documented on the form would not be honored in the event that Resident #26 required emergency treatment in the facility or upon transfer to another facility.

Based on observation, interview and policy review, the facility failed to follow safe and sanitary food service practices in accordance with professional standards for food service safety to prevent the risk of foodborne illnesses for one Resident (#66), on the [NAME] Nursing Unit during a meal service observation. Specifically, the facility failed to ensure that staff training on food service safety was implemented when Certified Nurses Aide (CNA) #3 replaced a domed lid from a breakfast meal, that had fallen onto the floor in the [NAME] Unit hallway, over a meal plate on a breakfast tray and served the breakfast tray with the contaminated dome lid to Resident #66. Findings include: Review of the facility policy titled Assistance with Meals revised July 2017 indicated the following: -All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of food borne illness, including personal hygiene practices and safe food handling. Resident #66 was admitted to the facility in December 2021, with diagnoses including Cerebral Vascular Accident (CVA: when blood flow to a part of the brain is stopped either by a blockage or a rupture of a blood vessel). Review of Resident #66's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of seven out of a total possible score of 15. On 11/4/24 at 8:21 A.M., the surveyor observed CNA #3 and Nurse #7 passing breakfast meal trays on the [NAME] Nursing Unit. The surveyor observed CNA #3 remove a meal tray from the cart, place it on a table outside Resident #66's room, and remove the domed lid from the plate. The surveyor observed the domed lid fall on the floor while CNA #3 continued to cut up food on the meal plate. The surveyor observed CNA #3 then picked up the domed lid off the floor, placed it over the food plate on the breakfast tray, entered Resident #66's room, and set the meal tray in front of the Resident and removed the domed lid. During an interview at the time Nurse #7 said that CNA #3 should not have picked up the domed lid off the floor and placed it over the Resident's breakfast plate. The surveyor observed Nurse #7 then remove the breakfast tray from the Resident's access and ordered another breakfast meal for the Resident.

Based on observation, interview, policy and record review, the facility failed to adhere to infection control standards of practice for two Residents (#34 and #56) out of a total sample size of 19 residents. Specifically, the facility failed to: 1. For Resident #34, follow Physician orders for Enhanced Barrier Precautions (EBP's - the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), increasing the risk of organism transmission to the Resident and other Residents within the facility. 2. For Resident #56, perform hand washing procedure as required between glove changes while providing wound care to the Resident and appropriately disinfecting equipment to prevent contamination and the spread of infections. Findings include: 1. Review of the facility policy titled Enhanced Barrier Precautions, dated December 2022 with revision date February 2024 indicated: -EBP's are indicated for residents with any of the following: >Chronic wounds (a wound that has failed to heal within three months). -EBP's require gown and gloves to be put on prior to high contact care. -Examples of high contact care include: >Wound care Resident #34 was admitted to the facility in November 2021, with diagnoses including Pressure Ulcer (localized damage to the skin and/or underlying tissue that occurs as a result of long-term pressure) of the Sacral (triangular bone at the base of the spine) area, Stage 4 (a pressure ulcer that extends below the fat layer and into the deep tissues, including muscle, tendons, and ligaments, can extend to cartilage or bone). Review of Resident #34's Comprehensive Person-Centered Care Plan indicated: >Pressure ulcer, Stage 4 to the sacrum, effective December 2021. >EBP all shifts. >Administer treatments as ordered. Review of Resident #34's November 2024 Physician's orders indicated: >Maintain EBP every shift for precautions, effective 3/21/23. >Stage 4 Pressure wound of the sacrum: -Wash wound with wound cleanser, pat dry. -Apply Collagen (structural protein) dressing then apply Alginate (absorbent dressing made from seaweed) and cover with foam dressing. Change daily and as needed. -Skin prep (fast drying liquid skin protectant) to the peri-wound (surrounding area of the wound edge) daily as needed for wound. On 11/5/24 at 8:15 A.M., the surveyor observed Nurse #3, and the Nursing Supervisor provide the following wound care for Resident #34's sacral wound: -Nurse #3 and the Nursing Supervisor knocked on the Resident's door and entered the room without donning (putting on) gown or gloves. -Nursing Supervisor closed the room door and then pulled the privacy curtain closed without donning gown and gloves. -Nursing Supervisor and Nurse #3 then cleansed their hands with alcohol-based sanitizer and donned clean gloves. -The surveyor did not observe either the Nursing Supervisor or Nurse #3 don gowns. -Resident #34 was assisted by Nurse #3 and the Nursing Supervisor to a left side lying position in bed. -Nurse #3 then doffed (removed) his gloves, disposed of the gloves in the trash bag, and performed hand hygiene with alcohol-based sanitizer. -Nurse #3 then set up dressing supplies on the over the bed table which was lined with a clean towel. -Nurse #3 then performed hand hygiene with alcohol-based sanitizer and donned clean gloves but no gown. -Nurse #3 removed the old dressing from Resident 34's sacrum and placed the old dressing into the trash bag. -Nurse #3 then cleansed the sacral wound with wound cleanser and gauze using proper technique of spiral circle. -Nurse #3 doffed his gloves and placed the gloves into the trash bag, performed hand hygiene using alcohol-based sanitizer and donned clean gloves. -Nurse #3 then dressed the Resident's sacral wound with a Collagen dressing, followed by Alginate dressing, and followed by a foam dressing. -Nurse #3 doffed his gloves and placed the gloves into the trash bag, performed hand hygiene with alcohol-based sanitizer and donned clean gloves. -Nurse #3 dated the Resident's sacral dressing with a pen. -The Nursing Supervisor and Nurse #3 then repositioned Resident #34 in bed for comfort. -The Nursing Supervisor and Nurse #3 then doffed their gloves and put the gloves into the trash bag, performed hand hygiene with alcohol-based sanitizer, and left the Resident's room. During an interview with the Nursing Supervisor and Nurse #3 on 11/5/24 at 8:32 A.M., both Nurse #3 and the Nursing Supervisor said there were gowns and gloves available inside the Resident's doorway for use, but they forgot to put the gowns on. Nurse #3 said he forgot to put on a gown for EBP but he should have. The Nursing Supervisor said that all Residents with wounds should have EBP followed. During a follow-up interview on 11/5/24 at 8:37 A.M., the Nursing Supervisor said gowns and gloves should have been worn with the wound care provided for Resident #34. The Nursing Supervisor said gowns and gloves should be worn to protect the Resident from infection transmission to the wound as the wound was a portal of entry for bacteria. Durning an interview on 11/5/24 at 10:00 A.M., the Infection Preventionist (IP) said EBP is required for all Residents with chronic wounds. The IP said that Resident #34 has a chronic wound and was ordered to have EBP by the Physician. The IP said staff should wear gown and gloves when providing direct care with Residents on EBP because gowns and gloves were an important part of infection control. The IP said gowns and gloves should be used to prevent the Resident's wound from getting infected and also would prevent the staff members clothing from becoming contaminated with bacteria from the wound and spreading it to other Residents in the facility. 47901 2. Resident #56 was admitted to the facility in March 2024, with diagnoses including Methicillin Resistant Staphylococcus Aureus (MRSA - strain of gram-positive bacteria resistant to several antibiotics, making it difficult to treat, which spreads through contact with infected individuals) infection of wounds. Review of Resident #56's November Physician's orders indicated the following: -Maintain Enhanced Barrier Precautions (EBP) every shift, effective 10/2/24. -Maintain wound vac (Vacuum Assisted Closure - negative pressure wound therapy that involves a suction pump, tubing and a foam dressing to aid in wound healing) pressure setting at 125 mmHg (millimeters of mercury) on continuous suction every shift, effective 10/24/24. -To Left Hip Wound, cleanse with wound cleanser, pat dry, apply cut out foam and wound vac via Y CONNECTOR every Monday, Wednesday Friday and as needed, effective 10/28/24. -To wound on lower and mid abdomen, cleanse with wound cleanser, pat dry, apply cut out foam and wound vac via Y CONNECTOR every Monday, Wednesday, Friday and as needed, effective 10/28/24. On 11/4/24 at 8:56 A.M., the surveyor observed the following during wound care treatment for Resident #56: -Nurse #2 and Nurse #4 donned gloves, mask and gown at the entrance of Resident #56's room. -Nurse #2 pushed the treatment cart into Resident #56's room, removed the wound care supplies from the treatment cart and placed them on top of the treatment cart. -Nurse #2 and Nurse #4 repositioned Resident #56 on his/her right side in bed. -Nurse #2 removed the old dressing from Resident #56's left hip wound, cleansed the wound with wound cleanser, then doffed his gloves and donned new gloves without performing hand washing. -Nurse #2 covered the wound with foam dressing and sealed the wound with tape. -Nurse #2 doffed his gloves then donned new gloves without performing hand washing, then cut the edge of the tape with scissors and applied the wound vac dressing. -Nurse #2 gathered all the trash and placed them in a trash bag, then doffed his gloves. -Nurse #2 doffed his gown in the Resident's bathroom, did not perform hand washing, then pushed the treatment cart out of Resident #56's room and placed the treatment cart in the hallway. During an interview on 11/4/24 at 9:20 A.M., Nurse #2 and Nurse #4 said they did not wash or sanitize their hands before donning and doffing their gloves, and they should have. Nurse #2 said they should have sanitized their hands when they removed the gloves before wearing new gloves. Nurse #2 said they should have washed their hands after they discarded the trash in the Resident's bathroom. Nurse #2 also said they should have disinfected the treatment cart before bringing it out of the Resident's room, but this was not done.

Based on record and policy review, and interview, the facility failed to ensure that Physician's orders were correctly administered relative to dialysis care for one Resident (#5) out of a total sample of 19 residents. Specifically, for Resident #5, the facility failed to assess a complete set of vital signs (medical signs such as temperature, pulse rate, blood pressure, and respiratory rate, that indicate the status of the body's vital functions) prior to dialysis (a treatment in which a machine filters wastes, salts and fluids from your blood when your kidneys are no longer healthy enough to do the work) as ordered by the Physician putting the Resident at risk for dialysis related complications. Findings include: Review of the facility policy Titled End Stage Renal Disease(undated), Care of a Resident with, indicated: -Education and training of staff includes specifically: >The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis. Resident #5 was admitted to the facility in September 2024, with diagnoses including end stage renal disease (ESRD a medical condition where the kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis [a procedure to remove waste products and fluid from the body when the kidneys stop working] or a kidney transplant to maintain life), and dependence on renal dialysis. Review of the Physician's orders dated 9/11/24, indicated the following: -Dialysis on Tuesday, Thursday and Saturday, pick up at 10:00 A.M. -Vital signs before departing facility to dialysis center every day shift Tuesday, Thursday and Saturday Review of Resident #5's Medication Administration Record (MAR) for September 2024, October 2024 and November 2024 indicated the vital signs to be documented should include blood pressure, temperature, pulse, respiration rate, and oxygen saturation (SpO2 - measure of Oxygen in the blood as a percentage of the maximum Oxygen the blood could carry). Review of Resident #5's medical record indicated no evidence that temperature, pulse, respiration rate or oxygen saturation rate vital signs were assessed on the following dialysis treatment days: -9/19/24 -10/3/24 -10/17/24 -10/31/24 Further review of the Resident's medical record indicated no documentation in the progress notes as to why the vital signs before dialysis order was not completed. During an interview on 11/4/24 at 2:58 P.M., the Assistant Director of Nursing (ADON) said vital signs should have been documented as the Physician had ordered them. The ADON said if the Nurse on duty was unable to obtain the information the Nurse should write a progress note to address why the vital signs were not completed. The ADON said it is important to have this information to make sure the Resident remains medically stable and has no complications related to dialysis or ESRD diagnosis. During an interview on 11/5/24 at 7:56 A.M., Nurse #5 said she was not the Nurse working on the dates of the incomplete vital signs entries. Nurse #5 said if she was unable to obtain any of the information needed to complete the Physician's orders for vital signs, she would notify the Director of Nursing (DON) and the Doctor if needed and write a progress note on the reason the information was not assessed.

Based on observation, interview, record and policy review, the facility failed to provide care and services as required for an indwelling urinary/Foley catheter (a flexible tube that passes through the urethra and into the bladder to drain urine outside the body) for one Resident (#35) out of a total sample of 19 residents. Specifically, for Resident #35, the facility failed to verify and assess that the correct size indwelling urinary/Foley catheter as ordered by the Physician was re-inserted when the Resident required replacement of a urinary catheter after a failed voiding trial (a medical assessment used to determine if a patient can spontaneously urinate after urinary catheter removal). Findings include: Review of the facility policy for Foley Catheter Care, dated 5/1/22, indicated: -it is the policy of this facility to maintain Physician's orders for the care and maintenance of a Foley catheter. -the Physician's orders will include when the Foley is to be inserted, the size of the Foley lumen (catheter size), the size of the Foley balloon (retention balloon- a tiny balloon at the end of the indwelling urinary catheter that is inflated with water to prevent the indwelling urinary catheter from sliding out of the body). Resident #35 was admitted to the facility in June 2023, with diagnoses including benign prostatic hyperplasia (BPH- enlarged prostate gland, which blocks the flow of urine) and lower urinary tract symptoms. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #35 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Further review of the MDS assessment indicated that the Resident was dependent for toileting. Review of Resident #35's September 2024 Medication Administration Record (MAR) indicated that the Foley catheter had been discontinued on 9/26/24 for a voiding trial. Review of Resident #35's clinical record indicated a Nursing Progress Note dated 9/27/24, that indicated: -the Resident's Foley catheter had been discontinued for the Resident to participate in a voiding trial. -the voiding trial failed, and the Foley catheter had been re-inserted on 9/27/24. Further review of Resident #35's clinical record did not indicate that the Foley catheter had been replaced since 9/27/24 or that a care plan had been in place for an indwelling urinary catheter. Review of Resident #35's Treatment Administration Record (TAR) for September 2024 and October 2024 indicated the following pertaining to the Foley catheter placement: -Foley catheter size 0 and [NAME] size 0, had been checked every shift from 9/18/24 to 9/30/24 -Foley catheter size 0 and [NAME] size 0, had been checked every shift from 10/1/24 to 10/31/24 Review of Resident #35's November 2024 Physician's orders indicated: -Insert Foley catheter size 18 [Fr] with 10 cc (cubic centimeter or milliliter [ml]) balloon, start date 9/18/24 -Insert Foley catheter size 0 with size 0 balloon size, start date 9/18/24 On 11/3/24 at 9:26 A.M., the surveyor observed that Resident #35 had a Foley catheter in place, which was a size 16 Fr (French scale or system used to size catheters) Foley catheter with 30 ml balloon. During an interview at the time, Resident #35 said that he/she found the Foley catheter uncomfortable and wanted it taken out. On 11/4/24 at 12:02 P.M., the surveyor and the Assistant Director of Nursing (ADON) observed Resident #35's Foley catheter, and the ADON verified that the current Foley catheter that was in place was a size 16 Fr/30 ml balloon and not the size 18 Fr/10 ml balloon on the current Physician's orders. During an interview at the time, the ADON said that the incorrect size urinary catheter had been put into place after the Resident's voiding trial. The ADON also said that placing the incorrect size urinary catheter can lead to dislodgement, pain, and damage to the Resident's body.

Based on observation, interview, record and policy review, the facility failed to provide the necessary activities of daily living (ADLs - personal care activities including but not limited to, eating, grooming, and personal hygiene) care and services for one Resident (#4) out of a total sample of 19 residents. Specifically, for Resident #4, the facility failed to provide continual supervision by staff during mealtimes when the Resident required ADL assistance and supervision while eating. Findings include: Review of the facility policy titled Activities of Daily Living, dated 12/22/21, with revision date of December 2022, included: -A resident who is unable to carry out activities of daily living (ADLs) will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. -The facility will provide care and services for the following activities of daily living Dining-eating, including meals and snacks. Resident #4 was admitted to the facility in November 2021, with diagnoses including Alzheimer's Disease unspecified (a progressive disease beginning with mild memory loss and leading to the loss of the ability to carry on a conversation and respond to the environment, involves parts of the brain that control thought, memory, and language), Major Depressive Disorder Recurrent Severe with Psychotic Symptoms (a mental health disorder in which a person has Depression along with loss of touch with reality. [Depression- a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life]), Adult Failure to Thrive (a syndrome of global decline in older adults as a worsening of physical frailty that is frequently compounded by cognitive impairment, weight loss, decreased appetite or poor nutrition and inactivity) and Dysphagia Oropharyngeal Phase (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage). Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #4: -was severely cognitively impaired as evidenced by a score of 4 out of a total score of 15 on the Brief Interview for Mental Status (BIMS) exam. -required continual supervision from staff while eating. Review the Resident's Care Plan, last revised 10/30/24, indicated that Resident #4 had an ADL self-care performance deficit related to Dementia, Major Depression and Adult Failure to Thrive and required an intervention of continual supervision while eating. Review of the Resident's Certified Nurses Aides (CNA) Kardex (communication system that gives a brief overview of each Resident and is updated every shift), dated 11/4/24, indicated that Resident #4 required continual supervision while eating. On 11/3/24 at 9:16 A.M., the surveyor observed Resident #4 lying in bed with eyes closed, the head of the bed elevated, and a breakfast tray set up on the overbed table, directly in front of the Resident. The surveyor observed that the breakfast food was cut up into bite sized pieces but there was no staff member present in the Resident's room. On 11/5/24 at 8:35 A.M., the surveyor observed Resident #4 lying in bed with the head of the bed elevated. The surveyor observed that the Resident had not yet been served a breakfast tray. On 11/5/24 at 8:41 A.M., the surveyor observed a CNA walk into the Resident's room, and place a breakfast tray on the overbed table, directly in front of the Resident. The surveyor observed the CNA cut up the food into bite sized pieces and then exited the room. The surveyor observed that no staff member re-entered the Resident's room to assist or supervise the Resident with the breakfast meal. On 11/5/24 at 8:48 A.M., the surveyor entered the Resident's room and observed the Resident feeding him/herself breakfast with no staff present in the room. During an interview at the time, the Resident said he/she could not hold his/her milk and there was no staff member present in the room to provide assistance and supervision to the Resident. On 11/5/24 at 8:51 A.M., the surveyor observed CNA #3 walk into the Resident's room and place a warm beverage on the Resident's breakfast tray. CNA #3 then exited the Resident's room without providing assistance or supervision to the Resident. During an observation and interview on 11/5/24 at 8:55 A.M., the surveyor and the Assistant Director of Nursing (ADON) observed the Resident lying in bed, head of the bed elevated, feeding him/herself breakfast with no staff member present to provide supervision. The ADON said that they were unaware of the level of assistance that the Resident required during mealtime, and would look into it. The ADON left the room to review the Resident's care plan and the surveyor continued to observe the Resident during the breakfast meal. On 11/5/24 at 9:01 A.M., the surveyor observed that several staff members walked by the Resident's room without checking on the Resident. At 9:04 A.M., the surveyor observed two staff members enter the Resident's room, provide physical repositioning assistance in bed to the Resident, and then both staff members exited the room. The surveyor observed the Resident's breakfast tray was still in front of him/her and the Resident continued to feed him/herself the breakfast meal. During an interview on 11/5/24 at 9:15 A.M., the ADON said that the Resident was care planned for continual supervision at mealtime. The ADON also said that continual supervision meant that a staff member should stay with the Resident continually and supervise during the entire meal. The ADON said that the Resident had not been continually supervised during the breakfast meal served this morning, but should have been continually supervised. During an interview on 11/5/24 at 10:13 A.M., the MDS Director and Dietitian said that the Resident was care planned for continual supervision during meals. The MDS Director and Dietitian both said that the expectation was that staff would continually supervise the Resident when he/she was eating, as related to his/her diagnosis of Dysphagia and per recommendations made by the Speech Language Therapist [sic].

Based on interview, record and policy review, the facility failed to notify the Physician/Non-Physician (NPP) of a significant change in condition for one Resident (#19) out of a total of 19 total residents. Specifically, the facility failed to notify the Physician/NPP of a recommended change in treatment for Candida Glabrata (yeast infection) made by the Consulting Physician/NPP and obtain treatment orders for Resident #19, resulting in unmanaged itching and discomfort of the Resident's genital (external reproductive organ) area. Findings include: Review of the facility's policy titled Change in Resident's condition or Status and Notification, revised 1/1/20, indicated: -The Registered Nurse (RN) Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been a significant change in the resident medical/mental conditions and/or status including but not limited to a need to alter the resident's medical treatment. -Regardless of the resident's current mental or physical condition, the RN Nursing Supervisor/Charge Nurse will inform the resident of any changes in his/her medical care or nursing treatments. -The RN Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical condition or status. Resident #19 was admitted to the facility in August 2024, with diagnoses including Unspecified Disease of the Anus and Rectum and Diabetes Mellitus (DM - disease in which the body's ability to produce or respond to the hormone insulin is impaired resulting in variable blood glucose [sugar] levels in the blood). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #19 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIM) score of 15 out of 15. During an observation and interview on 11/3/24 at 3:21 P.M., Resident #19 said that he/she has and continue to experience consistent itching of his/her genital area which gave him/her extreme discomfort, but the facility staff had not followed up with a medication recommended by the Consultant Physician. Review of Resident #19's clinical record indicated the Resident had a consult with the Consultant Specialty Physician on 10/16/24, and the Specialty Physician recommended Boric Acid (medication used to treat yeast infection) application to the genital area once a day for 30 days, with a diagnosis of Candida Glabrata. Review of Resident #19's October 2024 and November 2024 clinical record indicated no documented evidence that the Consulting Physician recommended Boric Acid medication had been reported to, reviewed, and/or addressed by the facility Physician/NPP. During an interview on 11/4/24 at 8:29 A.M., Nurse #2 said the Boric Acid medication had not been ordered by the facility Physician/NPP. During an interview on 11/4/24 at 8:33 A.M., the Director of Nursing (DON) and the Administrator said they were not aware of the Consulting Physician recommended medication and that they would investigate. During a follow-up interview on 11/4/24 at 8:51 A.M., the DON said there was no evidence in the clinical record that the Boric Acid medication had been reported to the facility Physician/NPP. The DON and the Administrator both said they had notified the facility Physician after the surveyor inquiry today and the Physician had approved the Boric Acid medication to be ordered for Resident #19 (19 days after the Consulting Physician assessment and Boric Acid medication recommendation).

Based on interview, and record and policy review, the facility failed to inform three Residents (#5, #4, and #58) and or their Representatives in advance of changes to the plan of care relative to the use of psychotropic (medication that affects how the brain works and causes changes in mood, awareness, thoughts, feelings or behavior) medications, out of a total sample of 19 residents. Specifically, the facility failed to obtain written consent for the use of psychotropic medications before administering: 1. Seroquel and Zyprexa (antipsychotic - medication that treats psychosis (a collection of symptoms that affects one's ability to tell what's real and what is not) medications to Resident #5 for Bipolar Disorder (a mental health condition that causes extreme mood swings that include emotional highs [mania or hypomania] and lows [depression]) and Psychotic Disorder (a mental illness that causes abnormal thinking and perceptions. Psychotic illnesses alter a person's ability to think clearly, make good judgments, respond emotionally, communicate effectively, understand reality, and behave appropriately). 2. Topamax (Topiramate - anti-seizure/mood stabilizer) medication to Resident #4 for Behaviors. 3. Hydroxyzine (Atarax - anti-anxiety) medication to Resident #58 for Generalized Anxiety Disorder (a mental health condition that causes fear, worry and a constant feeling of being overwhelmed). Findings include: Review of the facility policy titled Psychotropic Medication Treatment in Long Term Care Centers, dated January 2021 indicated: -Prior to administering psychotropic medication .a facility will obtain the informed written consent of the resident, the resident's health care proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself) or the resident's Guardian (a court appointed person who makes important personal and healthcare decisions for an adult who lacks the capacity to make their own decisions). -certain controlled substances . used in the treatment of psychiatric diagnosis, symptom or behavior. This includes, but is not limited to, certain medications used to treat seizure disorders, certain beta-blockers, and other controlled substances. -When any of these controlled substances or any other medication is used to treat a psychiatric diagnosis, symptom or behavior, the facility shall obtain informed written consent prior to administering the medication to a resident. -In order to determine whether a facility must obtain written consent prior to administering a controlled substance .the facility should consider the circumstances that led to the order, including the resident's symptoms and any behaviors, and refer to the prescriber's order to determine the indication for use of the controlled substance. 1. Resident #5 was admitted to the facility in September 2024, with diagnoses including Bipolar Disorder with psychotic features (a mood disorder that features extreme shifts in mood that include emotional highs [mania or hypomania] and lows [depression], during which hallucinations or delusions can occur). Review of Resident #5's Minimum Data Set (MDS) Assessment completed on 9/30/24, indicated: -the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points. -the Resident had diagnoses of Bipolar Disorder (a mental health condition that causes extreme mood swings that include emotional highs [mania or hypomania] and lows [depression]) and Psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality) and was taking antipsychotic medications. Review of Resident #5's Clinical Record indicated a Physician's order dated 9/11/24, for the following medications: -Olanzapine (Zyprexa) tablet 2.5 milligrams (mg), give 3 tablets by mouth two times a day for psychotic features. -Quetiapine Fumerate (Seroquel) oral tablet 50 mg, give 1 tablet by mouth at bedtime for antipsychotic/antimanic agents. Review of the Medication Administration Records (MAR) for September 2024, October 2024, and November 2024, indicated the Zyprexa and Seroquel medications were administered to Resident #5 as ordered by the Physician. Further review of the clinical record indicated no evidence of signed consents for the Zyprexa or Seroquel medications. During an interview on 11/5/24 at 11:10 A.M., the Assistant Director of Nursing (ADON) said the Nurse who documents the Physician's order was responsible for completing the consent for psychotropic medication. The ADON said the facility should have had a signed consent in place for the Seroquel and Zyprexa medications before the medications were administered to Resident #5, but the ADON was unable to provide evidence that the staff had done so. 51571 2. Resident #4 was admitted to the facility in November 2021, with diagnoses including Alzheimer's Disease unspecified (a progressive disease beginning with mild memory loss and leading to the loss of the ability to carry on a conversation and respond to the environment, involves parts of the brain that control thought, memory, and language), Major Depressive Disorder Recurrent Severe with Psychotic Symptoms (symptoms lasting greater than two weeks of a persistently low or depressed mood and a loss of interest in activities that a person used to enjoy), Generalized Anxiety Disorder (an excessive, ongoing anxiety and worry that are difficult to control and interfere with day-to-day activities) and Delusional Disorder (is a type of mental health condition in which a person can not tell what is real from what is imagined). Review of the Resident's clinical record indicated that the Resident had appointed a designated Health Care Proxy (HCP: the person chosen as the healthcare decision maker when the individual is unable to do so for themself). The HCP was invoked (made active) on 5/10/18. Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #4 was severely cognitively impaired as evidenced by a score of 4 out of a total score of 15 on the Brief Interview for Mental Status (BIMS) exam. Review of the Resident's clinical record included a Behavioral Health Progress Note dated 10/14/24, that recommended to add Topamax 25 milligrams (mg) orally once at bedtime. Review of the Resident's Physician's Progress Note dated 10/14/24, indicated a new medication order for Topamax 25 mg at bedtime would be ordered as recommended by the Behavioral Health Consultant. Review of the Resident's October 2024, Physician's orders included: -Topamax Oral Tablet 25 mg (Topiramate). Give 1 tablet by mouth at bedtime for Behaviors, initiated 10/22/24 and start date of 10/23/24. Review of the Resident's 10/23/24 - 11/3/24 Medication Administration Record (MAR) indicated that the Topamax medication was administered to Resident #4 daily as ordered. Review of Resident #4's clinical record did not include a written informed consent for the administration of psychotropic medication, related to the administration of Topamax (Topiramate) for behavioral symptoms. During an interview on 11/4/24 at 1:08 P.M., the ADON said that Resident #4 should have had an informed written consent for the use of Topamax because the medication was being administered for behavioral symptoms. During an interview on 11/4/24 at 4:13 P.M., the ADON said she was not able to find a written informed consent signed by the HCP for the administration of Topamax for Resident #4. The ADON said that an informed consent for the use of psychotropic medication should have been reviewed with and signed by the HCP before the administration of the Topamax medication, but it had not been done. 45429 3. Resident #58 was admitted to the facility in July 2024, with diagnoses including Major Depressive Disorder and Generalized Anxiety Disorder. Review of Resident #58's Minimum Data Set Assessment (MDS) completed on 10/28/24, indicated: -a Brief Interview for Mental Status (BIMS) exam indicating that the Resident was cognitively intact as evidenced by a score of 13 out of a possible total score of 15. -the Resident had Depression and Anxiety. -was prescribed an antidepressant and an anti-anxiety medication. Review of Resident #58's November 2024 Physician's orders indicated: -Hydroxyzine HCl (hydrochloride) Oral Tablet 25 milligrams (mg). Give 0.5 tablet by mouth every 8 hours as needed for anxiety related to Generalized Anxiety, start date of 8/9/24 Review of Resident #58's Medication Administration Record (MAR) for August 2024, September 2024 and October 2024, indicated the Hydroxyzine medication was administered once daily on the following dates: -8/5/24 -8/11/24 -9/7/24 -9/14/24 -9/17/24 -10/3/24 -10/30/24 Further review of Resident #58's Clinical Record indicated no evidence of a signed consent for the Hydroxyzine medication. During an interview on 11/4/24 at 9:02 A.M., the ADON said that a psychotropic medication consent form should have been completed for the administration of the Hydroxyzine and it had not been.

Based on observations, interviews, record and policies reviewed, the facility failed to ensure that one Resident (#12) of seven applicable residents who experienced significant weight changes, in a total sample of 18 residents, maintained acceptable parameters of nutritional status. Specifically, the facility failed to ensure that Resident #12: -was provided with nutritional interventions as recommended by the Registered Dietitian (RD) and as ordered by the Physician to prevent further weight decline, -weight was monitored per facility policy when a weight change had occurred and the Resident experienced a significant weight loss. Findings include: Review of the facility policy titled Weight Monitoring, dated 12/22/21 and reviewed 12/21/22, indicated the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss/gain for residents. The policy also included the following: -The nursing staff will measure the resident's weights on admission, and weekly for three weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. -Weights will be recorded in the individual's medical record. -Any weight change of 5 percent (%) or more since the last weight assessment will be retaken within 24 hours for confirmation. If the weight is verified, Nursing will notify the Dietitian, Physician and the resident/resident responsible party. -The Dietitian will review the weights monthly to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. The plan of care will be updated as needed. -The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant b. 3 months - 7.5% weight loss is significant c. 6 months - 10% weight loss is significant If weight change is desirable, this will be documented and no change in the care plan will be necessary. Resident #12 was admitted to the facility in November 2021 with diagnoses including Adjustment Disorder (emotional or behavioral reaction to a stressful event or change in one's personal life) with mixed anxiety (feelings of worry, nervousness or unease) and Depressed Mood (loss of interest in activities causing significant impairment in daily life), Protein-Calorie Malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition/function), Irritable Bowel Syndrome (IBS - intestinal disorder causing pain in the belly, gas, diarrhea, and constipation), and Adult Failure To Thrive (FTT - syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, and impaired immune function). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #12 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 14 out of 15, had no behaviors, required supervision of one staff with meals, had no significant weight changes and was on a mechanically (texture modification) and therapeutically (meal plan that controls the intake of certain foods/nutrients) altered diet. On 10/31/23 at 10:27 A.M., the surveyor observed Resident #12 in his/her room, seated on the edge of the bed. He/she was observed to be very thin in appearance. Review of the RD Assessment, dated 10/2/23, indicated the following: -The Resident's weight on 10/1/23 was 86 lbs., with a goal weight of 100 lbs. -Diet: regular, mechanical soft, lactose free. -Significant weight loss and low Body Mass Index (BMI - a person's weight divided by the square of height, screens for categories that may lead to health problems. Healthy range is 18.5-24.9) less then 18. -Provide lactaid (lactose free) ice cream with lunch and dinner and prescribed snacks- offered in between meals and at bedtime. -Recommend: continue with diet, adhere to food requests as able, continue with lactaid ice cream and fortified (foods/fluids that have extra calories/protein added) foods as directed (super cereal at breakfast, super mashed potatoes at lunch/dinner). -Recommend Ensure Plus (nutritional supplement high in calories and protein) 237 milliliters (mls) twice daily for additional calories/protein. Review of an RD Progress Note dated 10/20/23, indicated Resident #12 had a weight of 80.8 lbs (obtained on 10/19/23) which indicated a significant weight loss of 6% over a one month period. A previous weight of 86.0 lbs was obtained on 10/7/23, and the RD recommended a re-weigh for accuracy at the time. Review of the clinical record did not indicate that a re-weight was obtained for Resident #12 after 10/19/23, as requested by the RD. Review of the Physician Progress Note dated 10/26/23, indicated Resident #12's weight loss to 80.8 lbs. remained a concern, that protein/calorie malnutrition was present, and that nutritional supplements were added. Review of a RD Progress Note dated 11/1/2023, indicated Resident #12 continued on a regular, mechanical soft, lactose free diet. The RD indicated in the progress note that the Resident was 80.8 lbs with a BMI of 15.8, had a non-significant, slow, gradual loss from 89.0 lbs on 4/13/23, and that he/she was provided with fortified cereal at breakfast, fortified mashed potatoes, and lactaid ice cream at lunch and dinner daily to enhance calories and protein. The RD recommended an interdisciplinary team (IDT) meeting to discuss the Resident's advanced directives and ongoing plan of care with use of enteral nutrition (delivery of nutrition via a feeding tube) for nutrition and hydration in order to promote a gradual weight gain closer to a healthier BMI. Review of the Nutrition Care Plan, revised 11/1/23, indicated Resident #12 at was at nutritional risk due to suboptimal oral intake. The following interventions were included in the plan of care: -Provide diet and supplements as ordered, initiated 11/1/23. -Monitor/record/report to the Physician as needed signs/symptoms of malnutrition: emaciation (state of being abnormally thin/weak), cachexia (wasting/weakness of the body due to severe chronic illness), muscle wasting, significant weight loss (3 pounds or lbs. in one week, greater then 5% in one month, greater then 7.5% in three months, greater then 10% in six months), initiated 12/14/21. -Provide, serve diet as ordered. Monitor intake and record every meal, initiated 12/14/21. -Dietitian to evaluate and make diet change recommendations as needed, initiated 12/14/21. -Weigh per facility protocol, revised 9/30/22. Review of the October and November 2023 Physician's orders, included the following: -Regular Diet, Mechanical Soft texture, thin liquids, Lactose free, initiated 11/23/21 -Lactaid ice cream to lunch and dinner twice daily, initiated 2/10/23 Further review of the October and November 2023 Physician orders did not indicate orders relative to the RD recommendation from 10/2/23 to add Ensure Plus supplement 237 mls. twice daily. During an interview on 11/2/23 at 11:54 A.M., RD #2 said that she was recently hired (on 10/17/23) and assessed Resident #12 on 11/1/23. RD #2 said that if there were recommendations for residents relative to obtaining weights, weight frequency, addition of nutrition interventions like supplements, she would email the Director of Nurses (DON) and Unit Manager (UM) #1. She said if there was a weight change for a resident, she would expect the facility staff to re-check the weight within 24 hours and that this information would be entered into the clinical record. RD #2 said if there was a diet or supplement recommendation, she would submit the order recommendation in the electronic health record (EHR) which immediately goes to the Physician for review and approval. On 11/2/23 at 12:40 P.M., the surveyor observed Resident #12 lying in bed prior to the lunch meal. During an interview at the time, Resident #12 said that he/she had lost weight and was surprised when the facility staff last weighed him/her and the weight was 80 lbs. The Resident said he/she did not want to lose weight, that his/her clothes no longer fit, but was unsure what his/her usual weight was. When the surveyor asked the Resident if he/she had spoken with the RD about his/her weight loss, the Resident said no. Resident #12 said that he/she has medications which make him/her not hungry, and that he/she would be receptive to taking nutritional supplements if they were offered to him/her. A lunch tray was provided by Certified Nurse Aide (CNA) #5 while the surveyor was still talking to Resident #12. The lunch meal consisted of ground meat with sauce, super mashed potatoes and cooked vegetables, 4 ounces of apple juice and a cup of cut-up fruit. The surveyor did not observe any lactaid milk, or lactaid ice cream as indicated on the Resident's meal ticket. Resident #12 said he/she gets ice cream once in a while but not all the time when asked by the surveyor. During an interview on 11/2/23 at 12:51 P.M., RD #1 reviewed Resident #12's clinical record with the surveyor via telephone. She said that since she worked remotely, a system had to be put into place relative to resident recommendations/communication. RD #1 said that a list of recommendations for each resident would be sent via email to the DON, Administrator and the Infection Preventionist (IP), and periodically she would follow up with the recommendations to ensure they were implemented. RD #1 said that she was unsure what happened relative to the previous recommendations from 10/2/23 and 10/20/23. She said that she sent her recommendations for Resident #12 via email to the DON, Administrator and the Infection Preventionist (IP) for follow-up and upon reviewing the sent emails said that she had sent one on 10/2/23 requesting the Ensure Plus 237 mls twice daily, but was unsure if an email was sent relative to her request for the Resident to be re-weighed on 10/20/23. When the surveyor relayed the observation of Resident #12's lunch meal from 11/2/23, RD #1 said that she had previous concerns about the lactaid ice cream getting on the Resident's tray, had expressed this to the Administrator who said that lactaid ice cream was always something available in the facility. RD #1 further said that if a Physician ordered supplement/meal addition was not available, the facility had her contact information so that they could come up with an alternative plan. During an interview on 11/2/23 at 2:24 P.M., the Corporate Director of Infection Control said that the RD recommendations for Resident #12 should have been followed-up on, and if there was a weight change when obtaining the Resident's weight, a follow-up weight should have been obtained. During an interview on 11/2/23 at 2:40 P.M., the Food Service Director (FSD) said that there was no lactaid ice cream in the building and was not aware of any residents who had it ordered as part of their meals. During an interview on 11/2/23 at 2:46 P.M., the Physician said he was unaware of the RD recommendations from 10/2/23 to add Ensure Plus 247 mls twice daily. He further said that if he was aware of the recommendation, he would have agreed to it as he thinks Resident #12 would benefit from the supplement. During an interview on 11/2/23 at 2:56 P.M., the Administrator said he was aware that Resident #12 had an order for lactaid ice cream but was not aware that there was no lactaid ice cream in the facility. He further said that if he had known, he would have contacted their food vendor. During a subsequent interview on 11/2/23 at 3:09 P.M., the FSD said she located a box of lactaid ice cream in the freezer, but that she was still not aware of any specific resident that was supposed to receive it. The surveyor provided the FSD with Resident #12's name and requested that she follow-up relative to the Physician's orders.

Based on interviews and records reviewed, for one of three sampled residents (Resident #3), the Facility failed to ensure that he/she was free from misappropriation, when in (MONTH) (YEAR), Certified Nurse Aide (CNA) #3 used Resident #3's credit card without his/her knowledge and/or consent, and made four unauthorized transactions totaling $241.75, using Resident #3's credit card number. Findings included: The Facility Abuse Policy indicated that residents had the right to be free from mistreatment of [REDACTED]. Resident #3's most recent Minimum Data Set Assessment, completed [DATE], indicated that his/her cognitive patterns were impaired. Resident #3's clinical record indicated that Resident #3 expired at the Facility prior to the Survey and therefore could not be interviewed. The Surveyor interviewed Family Member #3 on 12:15 P.M. at [DATE]. Family Member #3 said that Resident #3 had his/her purse and credit card with him/her on the day that he/she was admitted to the Facility. Family Member #3 said that she took Resident #3's purse home from the Facility the day after Resident #3's admission. Family Member #3 said that during (MONTH) 2019, transactions were noted on Resident #3's credit card statement which Resident #3 had not made. The Police Report, dated [DATE], indicated that when Resident #3's family members attempted to close Resident #3's credit card account after his/her death, four transactions were discovered to have occurred during (MONTH) (YEAR) which appeared not to have been made by Resident #3. The Police Report indicated that the following four transactions were questioned by Resident #3's family member: on [DATE] a $27.29 transaction; on [DATE] a $34.31 transaction; on [DATE] a $55.47 transaction, and, on [DATE] a $124.68 transaction. The Police Report indicated that the $124.68 transaction on [DATE] was a payment to an account in the name of CNA #3 and the transaction on [DATE] for $34.31 was a take out food delivery made to CNA #3's home. The Surveyor interviewed CNA #3 at 10:45 [NAME]M. on [DATE]. CNA #3 said that during (MONTH) (YEAR) she dated Housekeeper #1. CNA #3 said that Housekeeper #1 gave her a credit card number and told her that she could use it. CNA #3 said that she used the credit card number to pay a bill [DATE] and to order take out food on three separate occasions [DATE], [DATE] and [DATE]. CNA #3 said that on [DATE], a Police Detective informed her that the credit card she used for the four transactions was stolen and belonged to Resident #3. The Surveyor interviewed Housekeeper #1 at 3:00 P.M. on [DATE]. Housekeeper #1 said that he did not steal Resident #3's credit and said he did not give any credit card numbers to CNA #3. Housekeeper #1 said that he could not explain CNA #3's statements about him.

Based on record review and staff interview, the facility failed to provide safety measures, assistive devices and adequate supervision to prevent a fall from an elevated bed for one Resident in a total sample of 23, (Resident #8) and failed to ensure a hazard free environment. Findings include: 1. Resident #8 was admitted to the facility in 2011 with [DIAGNOSES REDACTED]. Review of the [DATE], quarterly minimum data set (MDS) assessment, indicated that the Resident was severely cognitively impaired, non-ambulatory, required total assistance of two staff for transfers via mechanical lift and required extensive assistance for all activities of daily living. The Resident had impaired balance and required a seat belt restraint in the wheelchair. Review of the care plan and Certified Nursing Assistant (CNA) care card, updated [DATE], indicated the Resident required: 2 half siderails when in bed, motion sensor alarm in bed and floor mats at bedside when in bed. According to the CNA care card, the Resident was dependent on staff for bathing, grooming, dressing transfers, sensor alarm when in bed and was a fall risk. Record review on [DATE] indicated the resident had fallen out of bed on [DATE] at 10:45 A.M., and sustained an injury requiring transfer to the hospital. Review of the facility incident report regarding the Resident's fall with injury on [DATE] revealed the following: Resident #8 was found on the floor beside the elevated bed by housekeeping staff who immediately called out for the nurse. The Resident was conscious and bleeding from a laceration on the left side of the face with a hematoma developing. First aid was provided, 911 called and the Resident was transferred to the emergency room for evaluation. The facility investigation report described the scene of the fall as follows: Bed up in highest position, no fall mat on floor. The motion sensor alarm was on the bed, but not completely functional. The facility investigation concluded the CNA left the Resident unsupervised and unattended in bed while searching for the Resident's shoe elsewhere on the unit. The Resident's bed was in the highest elevation, the floor mats were stored against the wall, half siderails were down, and the motion sensor alarm was malfunctioning. Further, the facility concluded the Resident must have attempted to transfer out of bed, lost balance and fell on to the nightstand hitting the left side of the face sustaining lacerations and hematoma. Review of the discharge summary from the hospital dated [DATE] indicated there was no evidence of intracranial hematoma. However, the resident sustained [REDACTED]. Additionally, a hematoma on the left face and neck developed. The Resident had elevated troponins in the Emergency Department resulting in an admission for observation to rule out a myocardial infarction, which subsequently was ruled out while at the hospital. The Resident was discharged back to the facility on [DATE]. On [DATE] at approximately 1:15 P.M. the Director of Nursing said the facility failed to ensure the Resident's safety by failing to provided the safety interventions identified in the plan of care, resulting in a fall with injury and hospitalization . 2. Based on observation, documentation review and staff interview, the facility failed to ensure water temperatures were maintained at safe and comfortable levels for the Residents. The survey team observed fluctuations in hot water temperatures that posed a potential hazard for scalding. On [DATE] at approximately 8:15 A.M., Surveyor #1 washed her hands in the lobby bathroom sink (this sink is used by visitors, staff and at times, some Residents). Surveyor #1 observed the hot water temperature becoming extremely hot after approximately 30 seconds. The temperature was then recorded at 130 degrees F (Fahrenheit). Surveyor #1 left the bathroom and alerted Surveyor #2 to assist in obtaining water temperatures on the Resident Units. At 8:40 A.M. to 9:00 A.M. water temperatures were taken by both surveyors on the 2nd floor and the temperatures fluctuated between 103 degrees F (Fahrenheit) to 126 degrees F. At this time the Surveyors immediately alerted the Maintenance Director and both Surveyors proceeded to the 1st floor to obtain water temperatures. The water temperatures taken by both surveyors and the Maintenance Director on the 1st floor fluctuated between 106 degrees F (Fahrenheit) to 130 degrees F. The Administrator and the Director of Nursing were notified/aware of the high water temperatures and the facility staff was notified and precautions were taken so that Residents were not at risk. The Surveyors then asked the Maintenance Director to review the water temperature logs. The Director of Maintenance stated the logs were computerized and that he would try to print the temperature logs for the surveyors, but was not really sure how to do that. The Maintenance Director also stated that when he arrived at the building at 7:00 A.M. he noticed that a piece of equipment called the "Cogen" was not functioning. He called the company to come out and service the equipment. According to the Maintenance Director, due to the malfunction of this piece of equipment, it caused fluctuation in temperatures from the boiler. However, the Maintenance Director did not alert the Administrator or the Director of Nursing as to the malfunction of this piece of equipment and the effects it would have on the water temperatures on the Resident units. The Surveyors did not receive the temperature logs from The Maintenance Director in a timely fashion, so the Surveyors proceeded to the Maintenance Director's office, to view the logs on the computer. It was then discovered the temperatures were not consistently monitored, with the last temperatures taken the weeks of [DATE] and [DATE]. Previous to that the temperature was monitored the week of [DATE]. There had been no temperature monitoring for the month of ,[DATE]. Review of the temperature logs also revealed that all of the temperatures were recorded as 110 degrees F. There had been no variation/fluctuation in the temperatures. The Maintenance Director stated that the temperatures were "all different, but he just rounded up to 110 degrees F. " Although, hot water temperatures had not been monitored, there was no evidence Residents were harmed from hot water temperatures. On [DATE] at 9:15 A.M. the Administrator and the Maintenance Director said the facility failed to properly monitor the temperature of the hot water accessible to the Residents resulting in failing to identify the potential hazard for scalding from elevated hot water temperatures. The facility informed the survey team that the facility will monitor water temperatures for the first 24 hours moving forward on [DATE] every 4 hours until the temperature is steadied between 100 and 110 degrees F, and then 3 times a day through [DATE] to ensure the temperatures have stabilized. In addition, a hot water temperature log for the building will be maintained as required.

Based on record review and staff interview, the facility failed to provide adequate supervision to prevent falls to 2 residents (#7, #9), in a total sample of 24 residents. Findings include: 1. For Resident #9, the facility failed to have the resident in a supervised area at all times and the resident fell and fractured a hip on 11/1/12. Resident #9 was cognitively impaired with [DIAGNOSES REDACTED]. Record review on 12/11/12 revealed that the resident had a history of [REDACTED]. The resident had the following interventions on the care plan: a) assure resident is wearing eyeglasses (8/3/11); b) close visual supervision when off the floor, care givers not move out of resident sight (10/17/11); c) frequent visual checks when resident is in bed/sleeping/napping (2/23/12); d) apply non-skid pad/dysum to wheelchair (4/1/12); e) have resident in a supervised area at all times unless sleeping in bed (8/16/12); and f) velcro alarmed seat belt to wheelchair as a reminder (9/28/12); According to the facility incident report, on 11/1/12 at 4:10 P.M., the resident unclipped the alarmed seatbelt in the dining room and attempted to self transfer from the wheelchair and fell to the floor. The statements from staff revealed the following: 1 nurse aide was in the hallway assisting other residents to the dining room for supper; 3 nurse aides were in other resident rooms providing care; 1 nurse was in the medication room. There were no staff in the dining room providing supervision to this resident who required supervision. The resident received a left hip fracture as a result of this fall. During interview on 12/12/12 at 11:50 A.M., the Unit Manager of the Sudbury Unit, stated that on 11/1/12 there was no one sitting in the day room at the time of Resident #9's fall. She said that the nurse aide that was assigned to watch the dining room was pushing another resident down the hallway. She said at that time, the policy on the unit was for the nurse aides to decide amongst themselves who was responsible for watching the dining room. She said this was an informal system. Following Resident #9's fall, the Unit developed a formal system where a nurse aide was assigned to monitor the dining room for 1/2 hour at a time unless there was an activity going on. 2. For Resident #7, the facility failed to have the resident in a supervised area at all times. Resident #7 was cognitively impaired with [DIAGNOSES REDACTED]. Record review on 12/12/12 revealed that the resident had a history of [REDACTED]. The resident had the following interventions on the care plan: a) assure resident is wearing eyeglasses (2/17/12); b) keep resident in a supervised area at all times when out of bed (5/11/12); c) place phone in reach when in bed or out of bed; d) resident to have blue water bottle at all times; e) supervise at all times when resident is in the day room for tendencies of trying to self transfer/assist other residents; f) non-skid pad/dysum to wheelchair (8/20/12); g) keep floor free of clutter (8/20/12); h) alarmed seat belt to wheelchair (8/20/12); i) perimeter mattress to bed (8/20/12); j) assist with all transfers in and out of bed (8/20/12); k) sensor alarm in bed and chair (8/20/12). According to facility incident report on 6/20/12 at 3:15 P.M., the resident was in the dining room/day room and tried to push the dining table away and slid off the wheelchair towards the floor. The statements from staff revealed the following: 1 nurse aide was in the hallway and 1 nurse was having nursing report with another nurse. There were no staff in the dining room providing supervision to this resident who required supervision. According to facility incident report on 7/25/12 at 3:18 P.M., the resident was in the dining room/day room and tried to push another resident closer to the table and fell out of the wheelchair. The statement of one nurse revealed she was sitting in the hallway with another resident when she heard a bang on the wall. She found the resident sitting on the floor. There were no staff in the dining room providing supervision to this resident who required supervision. During interview on 12/13/12 at 9:45 A.M., the Unit Manager on the Sudbury Unit stated that it did not appear that any staff were supervising the dining room/day room when Resident #7 fell on [DATE] and 7/25/12.

Based on record review and staff interview, the facility failed to provide services in accordance with the written plan of care for 3 residents (#7, #8, #9) in a total sample of 24. Findings included: 1. For Resident #9, the facility failed to implement the plan of care for a) providing supervision at all times when out of bed and b) placing a pillow between the resident's legs while in bed. a) Resident #9 was cognitively impaired with [DIAGNOSES REDACTED]. The resident had a [MEDICAL CONDITION] on 11/1/12. Review of the medical record on 12/11/12 revealed the resident had a care plan intervention for falls dated 8/16/12, to have resident in a supervised area at all times unless sleeping in bed. According to the facility incident report, on 11/1/12 at 4:10 P.M., the resident unclipped the alarmed seatbelt in the dining room and attempted to self transfer from the wheelchair and fell to the floor. The statements from staff revealed the following: 1 nurse aide was in the hallway assisting other residents to the dining room for supper; 3 nurse aides were in other resident rooms providing care; 1 nurse was in the medication room. There were no staff in the dining room providing supervision to this resident who required supervision. The resident sustained [REDACTED]. During interview on 12/12/12 at 11:50 A.M., the Unit Manager of the Sudbury Unit, stated that on 11/1/12 there was no one sitting in the day room at the time of Resident #9's fall. She said that the nurse aide that was assigned to watch the dining room was pushing another resident down the hallway. She said at that time, the policy on the unit was for the nurse aides to decide amongst themselves who was responsible for watching the dining room. She said this was an informal system. Following Resident #9's fall, the Unit developed a formal system where a nurse aide was assigned to monitor the dining room for 1/2 hour at a time unless there was an activity going on. b)The resident had a current physician's orders [REDACTED]. During observation on 12/12/12 at 2:15 P.M., the resident was observed in bed without a pillow between the legs. During interview on 12/12/12 at 2:15 P.M., the Unit Manager on the Sudbury Unit stated a pillow should be between the resident's legs while in bed.. 2. Resident #7 was cognitively impaired with [DIAGNOSES REDACTED]. Review of the medical record on 12/12/12 revealed the resident had a care plan intervention for falls dated 5/11/12, to have resident in a supervised area at all times unless sleeping in bed. Resident #7 was cognitively impaired with [DIAGNOSES REDACTED]. The resident had a [MEDICAL CONDITION] on 11/1/12. Review of the medical record on 12/11/12 revealed the resident had a care plan intervention for falls dated 8/16/12, to have resident in a supervised area at all times unless sleeping in bed. According to facility incident report on 6/20/12 at 3:15 P.M., the resident was in the dining room/day room and tried to push the dining table away and slid off the wheelchair towards the floor. The statements from staff revealed the following: 1 nurse aide was in the hallway and 1 nurse was having nursing report with another nurse. There were no staff in the dining room providing supervision to this resident who required supervision. According to facility incident report on 7/25/12 at 3:18 P.M., the resident was in the dining room/day room and tried to push another resident closer to the table and fell out of the wheelchair. The statement of one nurse revealed she was sitting in the hallway with another resident when she heard a bang on the wall. She found the resident sitting on the floor. There were no staff in the dining room providing supervision to this resident who required supervision. During interview on 12/13/12 at 9:45 A.M., the Unit Manager on the Sudbury Unit stated that it did not appear that any staff were supervising the dining room/day room when Resident #7 fell on [DATE] and 7/25/12. 3. For Resident #8, the facility failed to implement the plan of care for off-loading heels in bed. Resident #8 was cognitively impaired with [DIAGNOSES REDACTED]. The resident had a current physician's orders [REDACTED]. During observation on 12/10/12 at 4:30 P.M., the resident was observed in bed with boots on the feet. There was no pillow under the resident's calves to off-load the heels. During interview on 12/10/12 at 4:40 P.M., the Unit Manager on the Sudbury Unit stated that the resident's heels should be off-loaded in bed.