**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment on 3 of 3 units. Findings: On 6/11/25 at 1:30p.m. during a tour of the facility with the Administrator, the following were observed and confirmed: Third Floor: -Doorway next to stairwell near room [ROOM NUMBER] needs corner protector replaced. -room [ROOM NUMBER]: Stained ceiling tile near window. -Room: 304Wall gouged near bathroom door. -Room: 308- Stained ceiling tile. -Room:310- Stained ceiling tile in corner. -Room: 313- Bathroom has two holes in the wall that need repair. -Room: 318- Stained ceiling tile. -Bathing Suite: Baseboard broken in two places and tile missing. Second Floor: -Common area: 2 holes in the wall behind coffee bar that need repair. -Room: 212- Stained Ceiling tile in the bathroom. -Room: 214- Bathroom door has two holes. -Room: 215- Water in sink took a long while to heat up. -Room: 222- Wall in bathroom has 5 holes that need repair. First Floor: -Sun room all the way to the left after entering has stained ceiling tiles. -Room: 101-Counter under sink needs repair - rough surface. -Room: 102- Bathroom door has 2 holes that need repair. -Room: 104- Bathroom wall has 2 holes that need repair. -Room: 117- Stained ceiling tile above toilet.

Based on observations and interviews, the facility failed to ensure that garbage and refuse were disposed of in a manner to prevent pest infestation for 1 of 3 survey days. (6/11/25). Findings: On 6/11/25 at 9:50 a.m. - Observed through the window that 1 of 2 dumpsters were uncovered, for 1 of 3 days of the survey. This was confirmed with the Food Service Director at the time of the observation.

2. On 06/09/25 at 12:20 p.m., observed an oxygen concentrator at the bed side of Resident #10. The tubing was still attached to the machine. Resident #10 stated that [he/she] no longer uses O2 but machine is at [his/her] bedside. Resident #10 stated that they have not used O2 for a month. On 6/10/25 at 1:10 p.m. the surveyor confirmed in an interview with the Unit Manager that Resident #10 no longer uses the O2, and she will remove the concentrator. Based on observations, record reviews, interviews, the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 2 of 3 residents reviewed for respiratory care. ( #10, #13 and #23) Findings: 1. On 6/9/25 at 9:24 a.m. during an observation of Resident #13 and Resident #23s room. The tubing on an oxygen (O2) concentrator next to Resident #23's bed was draped over the machine without being stored in a sanitary manner. The tubing on the concentrator next to Resident #23's bed was draped over the concentrator and the nasal cannula was directly on the floor. On 6/11/25 a surveyor reviewed Resident #13's Order Summary/Report shows the following order dated 2/26/25 Oxygen Continuous O2 at 2 liters/minute via nasal cannula. Attempt to wean O2 to keep sat at 90% or higher. every shift On 6/11/25 a surveyor reviewed Resident #23 Order Summary/Report shows an active order dated 5/5/25 Oxygen at 2 LPM via nasal cannula PRN. Monitor oxygen saturation every shift as needed for hypoxia. On 6/11/25 at 11:00 a.m. a surveyor interviewed Certified Nursing Assistant and was told that oxygen tubing should be stored coiled up in a bag when not in use. They did not know why the tubing for Resident #13 and Resident #23 were not stored in a bag. On 6/11/25 at approximately 11:15 a.m., the findings were discussed with the Charge Nurse who confirmed that Resident #13 and Resident #23 were currently using oxygen and the tubing needs to be stored in a sanitary manner between use. The tubing was immediately replaced and bags provided for sanitary storage.

Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the ceiling tile and support structure, and the large floor mixer, 3 of 3 days of survey. Additionally, the reach-in refrigerator was found to have a bag of cookie dough that was undated and unlabeled. Findings: On 6/9/25 at 9:15a.m. the initial tour of the kitchen was conducted with the Food Service Director (FSD) the following was observed: -an open bag of cookie dough not labeled and not dated in the reach in refrigerator; -several stained ceiling tiles throughout the kitchen; -rust covered support struts of the ceiling; - a long cob web hanging from the ceiling containing an insect; -discolorations of ceiling tile near dish machine, upon closer examination it was determined that the area was covered with a heavy layer of dust and when touched with the tip of a broom created a heavy falling of dust and debris in the area. On 6/10/25 at 7:30 a.m., during a tour of the kitchen the following was observed: dust strings hanging from the ceiling. On 6/11/25 at 9:50 a.m., during a tour of the kitchen the following was observed: -large cobwebs in several areas of the kitchen. -dust covering a glove holder positioned over the clean bowls. - large mixer that was covered with a plastic bag, and when the bag was removed a large amount of dried debris was seen around the machine. -Additionally, a small to moderate amount of dust was observed on the outside of the ice machine. The above was confirmed with the Food Service Director at that time and she stated that We have a lot of dusting to do.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy, observation, and interviews, the facility failed to ensure a resident was clinically appropriate to self administer an inhaler on 3 of 3 survey days. (R65). Findings: Review of facility policy Self-Administration of Medications reviewed 8/21 states, .Specific orders for self-administration of medication by the resident must be written by the physician .An Assessment for Self-administration of Medications will be completed and signed by a licensed nurse and resident prior to initiation of self-administration . Medication Nurse shall record each shift, name of medication, number of times self-medicated on medication administration record. R65 was originally admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), and a cognitive communication deficit. Review of R65's signed medication orders with start date of 9/8/21 for Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT 2 puff inhale orally every 6 hours as needed for SOB/ wheezing. The order did not indicate that it was a self-administrated medication. Review of R65's Medication Administration Record (MAR) dated July 2022 lacked evidence that a medication nurse recorded the number of times R65 self-administered his/her inhaler. Review of R65's clinical record lacked evidence that he/she was assessed to self-administrate an inhaler. During observations of R65 on 7/11/22 at 11:38 a.m., 7/12/22 at 10:35 a.m. and 2:15 p.m., and on 7/13/22 at 8:24 a.m. an albuterol inhaler was noted on the top shelf of the residents three teared side table. During an interview on 7/13/22 at 12:10 p.m. Registered Nurse (RN)4 indicated that R65 has had his/her inhaler at bedside for a long time and just assumed that a self-administration assessment was done and that an order was needed for a resident to have medications at bedside. RN4 indicated that she does not ask the resident if he/she used the inhaler. During an interview on 7/13/22 at 1:25 p.m., 2nd floor Unit Manger (UM) confirmed that R65 does not have an order to self-administer his/her inhaler and a self -administration assessment was not completed. On 7/13/22 at approximately 1:49 p.m., the surveyor confirmed the above findings with the Director of Nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to maintain a safe, clean, comfortable, and homelike environment on 3 of 3 resident units and in the facility's laundry room. Findings: On 7/11/2022, at 12:20 p.m., during observation of laundry room, with the Director of Environmental Services (EVS) and an EVS worker; there was a light to moderate level of dust on most flat surfaces in the room. Observed very heavy level of dust on top of the top of all washing machines and dryers. Both employees stated that there is no cleaning schedule for the area, and there is no list of things to be done/cleaned. This was confirmed with the Director of Environmental Services at that time. On 7/13/2022, at 12:00 p.m., during tour of the facility with the Director of Environmental Services and the Administrator the following was observed and confirmed at the time of the tour: First Floor findings: Resident room [ROOM NUMBER] - 2 stained ceiling tile Resident room [ROOM NUMBER] - 1 stained ceiling tile Second Floor findings: Resident room [ROOM NUMBER] - Two (2) broken ceiling tiles Resident room [ROOM NUMBER] - Gouge in wallpaper near bathroom door down to sheetrock, creating an uncleanable surface Resident room [ROOM NUMBER] - Bathroom door and door frame have deep gouges and part of frame missing Third Floor findings: Resident room [ROOM NUMBER] - Bathroom door has deep gouges near base and rough to touch Resident room [ROOM NUMBER] - Stained ceiling tile

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to care for 1 of 2 Residents (R) reviewed for new admissions (R72). Findings: Review of facility policy Care Planning revised 2/17 states, . Care, treatment, and services are planned to ensure that they are appropriate to the resident's needs, goals and preferences. Therefore, it is the policy of St. [NAME] Health Care Facility to provide an individualized, interdisciplinary plan of care for all residents that is appropriate to the resident's needs, strengths, preferences, limitations, and goals. Care planning will be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals with the resident that are reasonable and measurable . Within forty-eight (48) hours of admission, a baseline care plan is implemented for each resident which is to include instructions needed to provide effective and person-centered care. The plan of care shall be individualized, based on the diagnosis, resident assessment and personal goals of the resident and his/her family . R72 was admitted to the facility on [DATE] for rehabilitation with diagnoses to include osteomyelitis of right foot ulceration with IV(intravenous) antibiotics, wound vac, chronic obstructive pulmonary disease (COPD), and presence of PICC line (Peripherally inserted central catheter) for IV antibiotic use. Review of R72's clinical record reveled the following Social Service Notes: Social Service admission Note dated 6/24/2022 states, [ .SW and [he/she] discussed [his/her] chronic health issues, the uncertainty with this current issue and [he/she] admits to feeling depressed at times. [He/she] says [he/she] has been honest with his Cousin and told [him/her] that if [he/she] needs an amputation and goes home, [he/she] will end things. [He/she] reports [heshe] agreed to talk with [him/her] before doing anything and says [he/she] would do that. At this time, [he/she] is waiting to see if the current course of treatment will work . SW anticipates the need to closely monitor and support [his/her] psychosocial wellbeing as well as to assist with d/c planning.] Social Service note dated 6/27/2022 states, [ .Nursing reports [his/her] IV antibiotics are ordered to run through July 23rd and [he /she] has a wound vac placed on [his/her] heel.coupled with [his/her] therapy sessions ending early due to [his /her] verbal and near physical abuse, this has yet to be successful. Discussed [his /her] short temper, [his /her] calling therapy staff names, such as little asshole and Big asshole and yelling and gesturing wildly as if to hit them. [He/she] quickly became upset and said that they keep telling [him/her] not to put weight on [his /her] foot and [he/she] isn't, I only put my toes down. [He/she] further stated, then let me go home and I will end this. [Resident] states [he/she] has a bottle of sleeping pills that only [he /she] knows the location of and if [he/she] has to go home without [his/her] foot or otherwise physically limited, [he /she] will end things. SW confirmed that the pills are at home .Charlie's demeanor is somewhat gruff, simple and black and white minded with a quick temper when triggered .] Review of admission Minimum Data Set (MDS) dated [DATE] indicated R72 has a Basic Interview for Mental Status (BIMS) of 15 of 15. Review of Section D: Mood indicated that R72 had little interest or pleasure in doing things, felt down, depressed, or hopeless, had trouble falling or staying asleep, or slept too much and felt tired or had little energy . During an interview on 7/12/22 at approximately 12:14 p.m. R72 indicated that he/she lives alone and is not able to walk right now. He/she refused to discuss his/her statements made to social services at this time. During an interview on 7/12/22 at 1:09 P.m., the Social Services Director (SSD) indicated that R72's social worker was not in the facility, but she was aware of R72's statements of self-harm. She further indicated that social services were responsible to create and update their own care plans. At this time SSD confirmed that R72 did not have goals and interventions in place for his/her psychosocial needs. Review of R72's signed Provider orders dated 6/24/22 revealed the following: Order with start date of 6/22/22 to apply wound vac to right foot cleanse wound then apply black foam dressing cover with drape tac if needed. Run at 125 mm/hg and change M-W-F [Monday-Wednesday-Friday] and as needed QD [daily] PRN [as needed]. Order with start date of 6/23/22 Vancomycin HCL solution use 2000 mg intravenously. One time a day for osteomyelitis. Order with start date of 6/22/22 for cefepime HCL solution Reconstituted 2GM Use 2 gram intravenously every 123 hours for Osteomyelitis until 7/23/22. Review of R72's care plan initiated on 6/24/22 , most recently updated 6/27/22 does not include goals and interventions for mood and behavior, presence of a PICC line, IV antibiotic use, wound vac or therapy interventions. During an interview on 7/12/22 at 12:18 p.m. Certified Nursing Assistant (CNA)3 indicated that care she provides to the residents is charted on the kiosk and if an intervention is in place it should be on there and if there's anything new it should be reviewed during report. During an interview on 7/13/22 at 10:59 a.m., Registered Nurse (RN)4 indicated that the Unit Manager was responsible to complete baseline care plans upon admission, but they need to include goals and interventions for the resident's diagnoses. RN4 further indicated that the care plan is used to post to the CNA's task list. During an interview on 7/13/22 at 12:10 p.m. Registered Nurse (RN)5 indicated that baseline care plans were completed by the Unit Manager, but they should address the resident's diagnosis with interventions. On 7/13/22 at approximately 1:48 p.m., the surveyor confirmed the lack of a baseline care plan with the Director of Nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review and policy review the facility failed to update/implement a care plan in the area of respiratory for 1 of 23 residents (R) reviewed for comprehensive care plans. (R65). Findings: Review of facility policy Care Planning revised 2/17 states, . Care, treatment, and services are planned to ensure that they are appropriate to the resident's needs, goals and preferences. Therefore, it is the policy of St. [NAME] Health Care Facility to provide an individualized, interdisciplinary plan of care for all residents that is appropriate to the resident's needs, strengths, preferences, limitations, and goals. Care planning will be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals with the resident that are reasonable and measurable .The plan of care shall be individualized, based on the diagnosis, resident assessment and personal goals of the resident and his/her family . R65 was originally admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease (COPD). Review of R65's physical orders signed 7/12/22 revealed the following orders: Order with start date of 6/6/22 for Breo Ellipta Aerosol Powder Breath Activated 100-25 MCG/INH (Fluticasone Furoate-Vilanterol) 1 puff inhale orally one time a day for COPD. Rinse mouth out after use. Order with start date of 6/6/22 for Incruse Ellipta Aerosol Powder Breath Activated 62.5 MCG/INH (Umeclidinium Bromide) 1 puff inhale orally one time a day for COPD. Rinse mouth after use. Order with start date of 9/8/21 for Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT 2 puff inhale orally every 6 hours as needed for SOB/ wheezing. Review of R65's care plan initiated on 11/24/20 and most recently updated on 6/15/22 lacked interventions to address R65's respiratory diagnosis. During an interview on 7/13/22 at 12:10 p.m. Registered Nurse (RN)5 indicated that care plans were updated by the Unit Manager and the Director of Nursing, but they should address the resident's diagnosis with interventions. During an interview on 7/13/22 at 1:25 p.m., 2nd floor Unit Manger (UM) confirmed that R65's care plan does not address interventions for COPD and that she and the Minimum Data Set (MDS) nurse are responsible to update care plans. On 7/13/22 at approximately 1:48 p.m., the surveyor confirmed the lack of updating/implementing the careplan with the Director of Nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow their Elopement/Missing Resident policy and procedure for 1 of 1 sampled resident's. (#1) Finding: The facilities Elopement/Missing Resident policy and procedure directs staff to assess the resident upon admission for their risk of elopement. Resident #1 was admitted to the facility on [DATE]. On 7/11/22 a surveyor reviewed Resident #1's clinical record. Resident #1's clinical record lacked evidence that an elopement assessment was completed upon admission. On 7/12/22 at 1:55 p.m., during an interview with the Director of Nursing (DON), the surveyor confirmed that an Elopement assessment was not completed.

Based on observations, interviews and policy review the facility failed to ensure foods were dated and labeled in, the reach in freezer, dry storage room and walk in freezer. In addition, the facility failed to discard outdated and obvious freezer burned food on 1 of 3 survey days. Findings: Review of provided Dining Services Storage Policy, undated states, Leftover food that is to be put in the freezer for use again must be used within 90 days of date it was put into the freezer. If an item is open from the freezer, you must label item with what it is and an open on date. Item will be used by the expiration date on package if there is no expiration date on the package item will need to be used within 90 days. Review of facility policy Receiving and Storing of Food and Supplies reviewed 2/18 states, .Unserved foods from previously prepared menus must be discarded after ninety-six (96) hours. Foods that may be frozen safely, such as meat, may be frozen, retained and used within 90 days . During an initial walk through of the kitchen on 7/11/22 at 9:17 a.m. the following was observed: Reach in freezer contained 1-1-quart plastic container covered with saran wrap with obvious freezer burn labeled canned pumpkin dated 2/20/22; and 1 -4-quart clear plastic container with plastic cover labeled canned pumpkin dated 3/20/22 with obvious freezer burn. 1-1-quart clear plastic container covered with saran wrap with obvious freezer burn labeled apples dated 5/27/22. 1 -6-quart clear plastic container with plastic lid with obvious freezer burn, labeled lemon cheesecake dated 4/10/22. 1 opened large plastic bag wrapped in saran wrap labeled cranberry opened and undated. 1 pastry bag with a white substance, wrapped in saran wrap unlabeled and undated. Dry storage room 1-1.9-quart plastic bottle of pure sesame oil, 1/4 remaining open and undated on shelf. Walk in freezer 1 large bag of waxed beans wrapped in saran wrap opened und undated. 1 large bag of pepperoni wrapped in saran wrap with obvious freezer burn undated. During an interview on 7/11/22 at 9:20 a.m. Operations Coordinator (OC) stated it was her understanding that there was a 30-day limit to keeping opened food in the refrigerator or freezer and that they do no label food when opened and use the manufactures date for expiation even when opened. During a follow up interview at 10:15 a.m., OC indicated that the facility uses serve safe guidelines for food storage and the facility also uses the state regulations. At this time OC confirmed above findings. The facility did not provide serve safe guidelines by the end of survey. During an interview on 7/12/22 at 11:12 a.m. [NAME] Supervisor (CS) indicated that all food should be dated and labeled with open date regardless if it is in storeroom, freezer, or refrigerator and food in refrigerator should be thrown away in 3 days, and food can be in the freezer for up to 90 days. She further indicated that food with obvious freezer burn should be thrown away. On 7/13/22 at approximately 1:28 p.m., the above was discussed with the Director of Nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a care plan was updated to reflect the resident's current needs in the area of infection control for 1 of 18 sampled residents (#42). Finding: On 11/18/19 at 9:30 a.m., a surveyor observed the entrance to Resident #42's room was posted with signage instructing to stop and check with nurse before entering. The surveyor also observed personal protective equipment (PPE) hanging from the entrance door. On 11/18/19 at approximately 10:00 a.m., in an interview with the charge nurse, the surveyor asked if any residents were currently on infection control precautions. The charge nurse stated Resident #42 required contact precautions for VRE (Vancomycin Resistant Enterococcus) in his/her urine. On 11/19/19 at 11:50 a.m., in an interview with a Certified Nurses Aide-Medications (CNA-M), the surveyor asked what type of precautions the resident requires. The staff stated he/she's on precautions to prevent him/her from getting an infection. On 11/19/19 at 11:55 a.m., in an interview with the charge nurse, the surveyor asked what type of precautions the resident requires. The charge nurse stated he/she is on reverse precautions because his/her blood levels are low and he/she has cancer. It's to protect him/her. The surveyor asked if the resident has a history of VRE. The charge nurse stated he/she had VRE and we are treating him/her as if he/she is colonized. he/she has his/her own bathroom and we use universal precautions when we provide care for him/her. A review of Resident #42's clinical record revealed diagnoses that included Myelodysplastic syndrome, multiple myeloma, antineoplastic chemotherapy induced pancytopenia. Nursing documentation dated 3/25/19, revealed a note which stated, call to New England Cancer Specialist - [Resident #42] will continue on Neutropenic Precautions indefinitely status post chemotherapy due to chronic neutropenic condition. Neutropenic precautions include gloves and mask upon entry into room unless providing personal care, at which time, gloves, gown and masks need to be worn. A review of the current care plan, last revised 10/28/19, and a review of the CNA [NAME], last revised 8/13/19, did not indicate Resident #42's requirement for reverse precautions. In addition, the care plan and [NAME] did not indicate a diagnosis of VRE, a multidrug resistant organism, requiring contact precautions. On 11/19/19 at 12:15 p.m., in an interview with a surveyor, the Director of Nursing, confirmed Resident #42's care plan and CNA [NAME] did not include the necessary information of the resident's need for reverse precautions, or that contact precautions were required when staff provide care to prevent transmission of VRE, a multidrug resistant organism.