Pilgrim Place Health Services Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled staff (Certified Nursing Assistant [CNA] 1), who was involved in an allegation of staff to resident abuse involving one of three sampled residents (Resident 1), received a performance evaluation (PE - a review based upon an individual's job performance and assigned duties) at least once every twelve months in accordance with the facility's Employee Handbook, dated January 2026. The deficient practice resulted in the facility's failure to assess and evaluate the skills and competencies of CNA 1 and had the potential to result in CNA 1 being unable to recognize or communicate an abuse allegation due to the lack of a PE and the potential for inadequate and unsafe care to the residents under CNA 1's care.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of four sampled residents' (Resident 11, Resident 59 and Resident 73) had consistent and accurate records and information regarding Advance Directives (AD - legal document indicating resident preference on end-of-life treatment decisions) filed in the resident's medical records (chart). This failure had the potential to cause confusion among staff and Resident 11, Resident 59 and Resident 73 to receive inappropriate or medically unnecessary care and/or treatment or services regarding life-sustaining treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that physician orders for PRN (on as-needed basis) psychotropic drugs (a substance that affect the mind, emotions, and behavior) for Lorazepam (a commonly used drug to reduce anxiety and agitation) included the required 14-day stop-date for two of five sampled residents (Residents 98 and 101). This failure had the potential to result in unnecessary or prolonged exposure to psychotropic medications, risk of adverse drug reactions, oversedation, increased fall risk, and diminished ability to evaluate the resident's ongoing need for the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate treatment and services were provided, for two of two sampled residents (Resident 54 and Resident 87), who were at risk for skin breakdown and pressure injuries (PI, localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence or related to medical devices) to prevent skin breakdown. The facility failed to:A. Ensure Resident 54's low air loss mattress (LALM, air-filled mattress used to relieve pressure) was replaced after it was removed due to an air leak. B. Ensure Resident 87's LALM had the correct therapeutic settings. This failure had the potential to compromise pressure redistribution and increased the risk for skin breakdown and pressure injury development for Resident 54 and 87.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 7 and Resident 36), were provided an environment free of accident (refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident) hazards by failing to, A. Ensure Resident 7's bed was in a low position required to prevent a fall (refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force). B. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and services for two of three sampled residents (Resident 3 and Resident 48) who had indwelling catheters (a medical device that drains urine from your bladder into a bag outside your body) by failing to assess and monitor Resident 3 and Resident 48's indwelling catheter closely for changes in condition and recognizing such changes. This deficient practice could potentially result in serious complications due to the development of urinary tract infections (UTI - an infection in the bladder/urinary tract) to Resident 3 and Resident 48.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow safe and proper food storage practices in accordance with professional standards for food service safety and the facility's policy and procedure (P&P) by failing to:1. label/date and store food items properly in the kitchen.2. ensure cold foods were held at 41 degrees or lower during tray line in the kitchen.3. label/date food items inside the unit refrigerator. These deficient practices had the potential to result in a risk for serious complications from food-borne illness (illness caused by the ingestion of contaminated food or beverage) and/or affect the quality and palatability of food and adversely affect the health of the residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, sanitary and comfortable environment and help prevent the development and transmission of communicable diseases and infections when the facility failed to ensure:1. Twelve out of twelve facility staff (Licensed Vocational Nurse 4 [LVN 4], Certified Nursing Assistant [CNA] 6, CNA 7, CNA 8, CNA 9, Occupational Therapist 1, Physical Therapist 1, the Director of Staff Development (DSD), Infection Prevention Nurse (IPN), Treatment Nurse (TN), Housekeeper 1, and Activity Staff) wore mask during periods of higher levels of community respiratory virus transmission.2. Three out of Twelve facility staff (CNA 6, OT 1, and PT 1) influenza vaccinations were tracked, and the staff were provided education regarding influenza vaccination. 3. [...]

Inspectors wroteThe facility failed to follow the facility's policy and procedure for Antibiotic Stewardship (offer providers and facilities a set of key principles to guide efforts to improve antibiotic use to effectively treat infections, protect patients from harms caused by unnecessary antibiotic use, and combat antimicrobial resistance) for 4 out of 5 sampled residents (Resident 13, 12, 51 and Resident 100). This deficient practice had the potential to result in inappropriate use of antibiotics that could lead to antibiotic resistance (occurs when bacteria, viruses, fungi and parasites no longer respond to antibiotics. As a result of drug resistance, antibiotics and other antimicrobial medicines become ineffective and infections become difficult or impossible to treat, increasing the risk of disease spread, severe illness, disability and death). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility offer influenza (FLU - is a contagious respiratory illness caused by influenza viruses. It can cause mild to severe illness, and at times can lead to death) vaccine to two of five sampled residents (Resident 11 and Resident 20). This deficient practice had the potential to result in illness and physical declines to Resident 11 and Resident 20.

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan (CP) included administration of Lorazepam (a medication used to reduce anxiety [a feeling of worry, fear, or unease about future events] and agitation. A psychotropic drug [a substance that affects the mind, emotions, and behavior]), and Eliquis (anticoagulant, medication used to thin the blood and for clot prevention) for one of five sampled residents (Resident 98). This failure had the potential to result in uncoordinated care, no monitoring for adverse effects (unwanted, uncomfortable, or dangerous effects that a resident may have due to a medication) such as oversedation, increased fall risk, and bleeding complications. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop and/or implement an individualized, person-centered comprehensive care plan (CP) that included measurable objectives, defined time frames, and specific interventions that addressed a diagnosis of dementia (a group of conditions, progressive state of decline in mental ability that interfere with daily activities) for 1 of 1 sampled resident (Resident 9). This deficient practice had the potential to result in Resident 9's cognitive (ability to understand and process information), behavioral, and safety needs not being properly identified, monitored, or addressed, which could lead to inadequate treatment, unmet needs, and a decline in Resident 9's overall well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide education of a new prescribed pain medication for one of five sampled residents (Resident 99) during medication administration on 12/4/2025. This deficient practice resulted in Resident 99 being uninformed regarding Resident 99's pain treatment and had the potential to result in medication errors to Resident 99.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 11) received treatment and care in accordance with the facility's policy and procedure (P&P) titled, Intravenous Therapy, by failing to ensure Resident 11's need for a peripheral saline lock (S/L - a type of catheter placed intravenously [IV - within a vein] to administer medication or fluid into the bloodstream) access was assessed on 12/2/2025 and when Resident 11 had a PICC (Peripherally Inserted Central Catheter - a long thin tube inserted into a vein in the upper arm and threaded to a large central vein near the heart, used for long term IV fluids, medications, nutrition, blood transfusion and drawing blood avoiding repeated needle sticks). Additionally, the facility failed to ensure Resident 11's S/L site remained clean and Resident 11's PICC was dated. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to treat the skin and itching for one of seven sampled residents (Resident 2) in accordance with the facility's policies and procedures (P&P) titled, Wound Assessment and Treatment and Skin Assessment by failing to ensure: 1. Resident 2 was given diphenhydramine (medication used to treat allergies, sneezing, runny nose, and itching) for itching according to the physician's orders. Resident 2 had multiple open skin scratches all over the body from itching. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses accurately assessed and documented one of five sampled resident's (Resident 2's) skin condition weekly in Resident 2's medical record between 8/30/2025 and 10/15/2025. Resident 2 had multiple open skin scratches all over the body from itching. This failure had the potential for Resident 2 to receive inappropriate treatment for itching and put Resident 2 at risk for delayed treatment of infection when Resident 2's multiple skin scratches were not assessed and monitored.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three residents (Resident 3) received the correct medications at discharge. The discharge nurse provided Resident 3 with blister packs containing medications belonging to two other residents. This failure resulted in Resident 3 ingesting one of the incorrect medications, experiencing nausea, headache, and requiring hospital evaluation. During a review of Resident 3's admission Record (Face Sheet), the facility admitted Resident 3 on 7/17/2025, with diagnoses including diabetes mellitus (DM: long-term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated). [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its own policy and procedure by not documenting physician's communications, not documenting a Change of Condition (COC), and not documenting a reassessment after pain medication was given for one of three sampled residents (Resident 1). This failure had the potential to delay care, reduce clinical oversight, and negatively affect Resident 1's health and comfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an allegation of abuse for one of one resident (Resident 1). This deficient practice violated Resident 1's right and had the potential for delay in abuse investigation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) did not develop pressure ulcers-injury [PU/PI, localized injury to the skin and or underlying tissue usually over a bony prominence as result of pressure or pressure in combination with shear [mechanical force that cause the skin to break off] and/or friction [movement of one surface of the skin against the others]) as indicated in the facility's Policy and Procedure (P&P) titled, Pressure Injury Prevention and Management, by failing to ensure: 1. A comprehensive care plan (CP) was developed to address the risk for PIs after Resident 1's readmission to the facility on [DATE]. 2. A pressure injury wound risk assessment was conducted for Resident 1 upon readmission on [DATE]. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five sampled residents (Resident 9 and Resident 47) and/or their legal representative (RP) were informed and/or provided written information about Advance Directives (AD, legal document, which specifies the health-related actions in accordance with the resident's wishes, that is actuated when the resident is no longer able to make decisions for himself/herself due to illness or incapacity). These failures violated Resident 9 and Resident 47's right to formulate an AD and had the potential to receive inappropriate or medically unnecessary care and/or treatment or services regarding life-sustaining treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise/update the care plan for two of two sampled residents (Residents 2 and 39) who were assessed as at risk for fall (coming to rest on the ground or lower-level surface). These deficient practices had the potential for the residents not to receive care specific to their needs and placed the residents at risk for further falls and complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow safe food storage and food handling practices for one of one kitchen (Kitchen 1) and one of one snack/nourishment refrigerator (Refrigerator 1) in accordance with professional standards for food service safety and the facility's policies and procedures (P&P) by failing to: 1. Label/date food items in the kitchen and in the snack/nourishment refrigerator on the unit. 2. Maintain acceptable chemical sanitizing solution (used to sanitize food contact surfaces) concentration in the kitchen. 3. Maintain proper temperatures of the snack/nourishment refrigerator on the unit. 4. Discard expired foods in the snack/nourishment refrigerator on the unit and Resident 8's food that was brought from home. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain its infection prevention and control program for five of five sampled residents (Residents 14, 159, 208, 209 and 214) by failing to: a. Ensure the blood pressure (BP, the force of the blood pushing against the walls of the arteries) monitor was cleaned and disinfected (remove dirt or stains and apply a chemical to a surface in order to destroy germs) after using it with Resident 209 and before using it for Resident 214. b. Ensure Resident 208's urinal was properly labeled with initials, room number, and bed number. c. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a federally mandated resident assessment tool) for one of two sampled residents (Resident 43) was completed accurately in accordance with the facility's policy and procedure (P&P). This failure had the potential for Resident 43 to receive inappropriate care and services based on Resident 43's preferences, goals of care, functional and health status, strengths, and needs.

Inspectors wroteBased on interview and record review, the facility failed to complete and transmit the quarterly Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment in a timely manner for two of two sampled residents (Residents 28 and Resident 30) as indicated in the Centers for Medicare & Medicaid Services (CMS - a federal agency that manages health care programs in the United States) Resident Assessment Instrument (RAI, a tool used by nursing homes to assess the needs, strengths, and preferences of residents) manual. a. For Resident 28, the MDS was not transmitted within 14 days after discharge from the facility. b. For Resident 30, the MDS was not transmitted within 14 days after admission and discharge. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 42) who was admitted with a suprapubic catheter (a type of medical device tube that helps drain urine from your bladder) had a baseline care plan (CP provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan]) developed and implemented within forty eight (48) hours of admission in accordance with the facility's policy and procedure (P&P). This failure had the potential for Resident 42 not receiving continuity of care and the lack of communication among staff which could lead to decrease in Resident 42's safety and safeguard against adverse events.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop or implement an individualized person-centered care plan for one of one sampled resident(Resident 2) who was at risk for elopement (run away without permission) and had a history of elopement. This failure had the potential to result in unmet individual needs and the potential to affect the resident's safety and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 5 sampled residents (Resident 48), who was assessed as a high risk to develop pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) and was admitted without pressure ulcers, received the necessary care and services to prevent a development of a pressure ulcer. As a result, on 10/1/2024, Resident 48 was identified with a stage 2 pressure injury (an open wound that occurs when the skin breaks, wears away, or forms an ulcer) to the left buttock.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 35) receiving oxygen therapy was provided respiratory care and resident safety in accordance with the facility's policy and procedure titled Oxygen Administration, and professional standards of practice. There was no sign posted on the resident's door indicating oxygen in use. This deficient practice placed Resident 35's safety at risk regarding oxygen usage.

Inspectors wroteBased on interview and record review, the facility failed to have a full time Director of Nursing (DON) five (5) days a week, 8 hours a day beginning 3/6/24 up to the present (10/17/24). This deficient practice had the potential to significantly impact the quality of care, overall patient experience and nursing workforce operations in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility was free of a medication error rate of 5 percent (%) or greater during the medication pass observation for one of four sampled residents (Resident 109). The facility had 26 opportunities of medication administration (the act of giving a treatment) observed and three of the 26 medications administered were not in accordance with the physician's orders, resulting in a medication error rate of 11.54%. The medication errors consisted of: a. Resident 109's Eliquis (blood thinner) and Multiple Vitamin were not administered as ordered by the physician. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 109) observed during medication pass was free of significant medication errors by failing to ensure Resident 109's medication Eliquis (blood thinner) was administered as ordered by the physician. This failure had the potential to increase the risk of blood clot for Resident 109 that may cause embolism (a block in an artery caused by blood clot) leading to serious medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device used by a resident to signal the need for assistance) system was within reach for one of two sampled residents (Resident 25), as indicated on Resident 25's care plans (CP [provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan]) and in accordance with the facility's policy and procedure (P&P). This failure had the potential to result in Resident 25 not having Resident 25's needs met in a timely manner and/or Resident 25 to experience harm if Resident 25 was unable to alert staff during an emergency.

Inspectors wroteBased on interviews and record review, the facility failed to ensure two of two facility staff (the Director of Nursing [DON] and the Registered Nurse Supervisor [RNS]) had Infection Prevention (IP) certificates and had completed specialized training in infection prevention and control while covering the Infection Control Preventionist (ICP) role. This failure had the potential to result in the spread of infections throughout the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a home like environment for 53 of 53 residents by failing to ensure residents meal trays were in good condition. This failure had the potential to result in a non-home like environment for the residents which could affect the residents' quality of life.

Inspectors wroteBased on interview and record review, the facility failed to treat six of six sampled residents (Resident 6, Resident 18, Resident 19, Resident 22, Resident 28, and Resident 155) with respect and dignity when: a - d. Resident 6, Resident 18, Resident 22, and Resident 19's call lights (a visual cue that a patient needs assistance) were not answered in a timely manner. e. - f. Resident 28 and Resident 155's urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) bags were left exposed. These deficient practices resulted in Resident's 6, 18, and 19 to feel bad, terrible, and panicky. For Resident's 28 and 155, the deficient practice had the potential to result in feelings of humiliation and embarrassment due to urine being visible to staff and other residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure necessary care and services were provided for two of two sampled residents (Resident 55, and Resident 12) when: a. For resident 53, the facility failed to notify the physician Resident 53's arteriovenous fistula (AVF, a connection that's made between an artery and a vein for dialysis access) was clotted (blocked) and that Resident 53 was not hemodialyzed (dialysis [treatment to remove extra fluid and waste products from the body when the kidneys can no longer perform these functions naturally]) on 7/27/23. b. Resident 12 did not wear heel protectors while lying in bed. These failures had the potential to result in physical harm and decline for Resident 53 due to Resident 53 not receiving scheduled hemodialysis. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure six of six sampled residents (Residents 4, 5, 17, 18, 28, and 36) received necessary restorative nursing program (RNP, nursing interventions to promote resident's mobility and functioning as safely as possible) care and services to improve mobility, maintain and prevent further decline in range of motion (ROM, full movement potential of a joint) by failing to: a. Provide RNP services for ambulation and active-assisted ROM (AAROM, joint receives partial assistance from an outside force) exercises for both shoulders to Resident 4 five times per week from 9/1/2023 to 9/30/2023 as ordered by the physician. b. Provide RNP services for Nu-Step exercise (low-impact, full workout of arms and legs with the use of an equipment) to Resident 5 from 9/1/2023 to 9/30/2023 as ordered by the physician. c. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure sufficient nursing staff and Restorative Nursing Aides (RNA, nursing aide program that helps residents to maintain their function and joint mobility) were assigned to provide care to all the residents in accordance with the facility's Facility Assessment Tool for four of 10 randomly selected dates for the months of September and October 2023 (9/7/2023, 9/8/2023, 9/10/2023, and 9/11/2023). This failure had the potential to result in compromised quality of care, contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and tightness of the joints) to the residents who had orders for RNA and did not receive such services, and a decline in the residents' overall physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: a. label wheat rolls with a use by date and to label prepared food in the refrigerator. b. store resident's food at a temperature at or below 41 degrees Fahrenheit (F, unit of measurement) in the Nourishment Room refrigerator. These failures had the potential to result in food-borne illnesses (illness caused by consuming contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices to prevent and control the spread of infections in the facility, when two of two staff (Certified Nursing Assistant [CNA] 1 and CNA 2) entered resident rooms without wearing proper Personal Protective Equipment (PPE, protective clothing or equipment, designed to protect the wearer from the spread of infection or illness), as indicated in the facility's Policy and Procedure (P&P) and national health guidelines. These failures had the potential to result in the spread of infections throughout the facility and illness to the residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to provide one of five sampled residents (Resident 33) or Resident 33's family member/representative with information regarding the right to formulate an advance directive (AD, a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the individual is incapacitated). This deficient practice had the potential for Resident 33 and Resident 33's family member/representative to receive inaccurate or unnecessary care and/or treatment services regarding life-sustaining treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure facility staff notified the primary care physician regarding a change in condition, for one of one sampled resident (Resident 17), in August 2023. This failure had the potential to result in physical or psychosocial well-being decline for Resident 17 due to a possible delay in obtaining physician orders necessary for Resident 17's treatments and/or services.

Inspectors wroteBased on interview and record review, the facility failed to transmit a Minimum Data Set (MDS- a standardized assessment and screening tool) within 14 days after a resident was discharged from the facility for one of one sampled resident (Resident 30). Resident 30's MDS exceeded 120 days due for transmission. This failure had the potential to result in inaccurate assessments of the facility's quality indicators and/or care area concerns for Resident 30.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS, a standardized assessment and care-screening tool) was accurate for one of one sampled resident (Residents 39). Resident 39's MDS incorrectly indicated she had physical restraints (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body). This failure had the potential to result in Resident 39 not to receive appropriate treatment and/or services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a care plan for one of one sampled resident (Resident 17) that addressed Resident 17's sleeping patterns and the level of assistance required for Resident 17's activities of daily living (ADL, term used in healthcare that refers to self-care activities) in accordance with Resident 17's preferences and needs. This failure had the potential to result in diminished quality of life and a decline in Resident 17's physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the intravenous (IV, administered into veins) site promptly and ensure the site was secured and free of any complications for one of one sampled resident (Resident 18) in accordance with Resident 18's care plan, the facility's Policy and Procedure (P&P), and standards of practice. This failure had the potential to negatively affect Resident 18's physical and psychosocial well-being due to complications of IV therapy.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of 12 sampled residents (Residents 28, 33 and 155) received assistance from staff for activities of daily living (ADLs) including nail grooming. Residents 28, 33, and 155's fingernails were long and jagged. These deficient practices had the potential for Residents 28, 33 and 155 to hurt themselves and dirt and germs to get under the fingernails.

Inspectors wroteBased on interview and record review, the facility failed to assess one of one sampled resident (Resident 19) for risks for falling upon admission to the facility on 9/5/23 and implement care and services to prevent falls in according to the facility's Policy and Procedure (P&P). Resident 19, who had a history of falls (to move downwards from higher to a lower level), sustained a fall on 9/7/23, two days after being admitted to the facility. This failure had the potential to result in Resident 19 to develop injury and/or harm to herself.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 36) was provided appropriate treatment and services for care of a clinically-justified indwelling urinary catheter (a flexible tube which is inserted into the bladder to drain urine). Resident 36's indwelling catheter was not kept anchored and secured. This deficient practice had the potential to cause complications such as excessive tension on the catheter, which can lead to urethral (urethra, part of the body that is a tube that carries urine from the bladder to outside the body) tears and/or discomfort, dislodging the catheter, impeding flow of urine, and kinking of the catheter tubing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 48) received the necessary oxygen (O2) care as ordered. a. Resident 48 had an order of O2 at 2 liters (L, unit of measurement) per minute and was observed with 2.5 liters per minute via (through) nasal cannula (N/C, a tube used to deliver oxygen to help with breathing) on 10/3/23 at 12:54 p.m. b. Resident 48 had only one prong of the N/C in one of Resident 48's nostrils on 10/3/23 at 12:54 p.m. These deficient practices had the potential to result in untoward reaction to Resident 48.