Windsor Nursing & Retirement Home

F-F685

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 24 225349 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225349 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Nursing & Retirement Home 265 N Main St South Yarmouth, MA 02664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or 41106 potential for actual harm Based on record review, interview, and observation, the facility failed to follow professional standards of Residents Affected - Few practice for one Resident (#197), out of a total sample of 19 residents. Specifically, the facility failed to follow and provide care in accordance with the physician's order for management of the Resident's right upper extremity Peripherally Inserted Central Catheter (PICC-a thin flexible tube inserted into a vein in the upper arm and guided into a large vein above the right side of the heart called the superior vena cava) which included dressing changes, measurement of the external length of the catheter and upper arm, and monitoring of the insertion site for signs/symptoms of infection.

Findings include:

1. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, Advisory Ruling Number 9324, dated as revised July 10, 2002, indicated:

-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations.

-Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.

Review of the facility's policy titled Vascular Access Device (VAD) Insertion Care and Removal, dated 7/1/2018, indicated but was not limited to the following:

-Central vascular access device (CVAD): Dressing changes

-CVADs require a sterile transparent semipermeable membrane dressing and shall be changed with a practitioner order:

a. Upon admission or 24-hour post-insertion;

b. Every seven days;

c. As needed (PRN) if compromised.

-PICC Lines require measurements which include:

a. Total catheter length:

i. Upon admission or insertion;

ii. Obtained from insertion nurse or discharge facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 24 225349 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225349 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Nursing & Retirement Home 265 N Main St South Yarmouth, MA 02664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 b. External catheter length-measured from insertion site to beginning of WING HUB OR other location as determined by insertion nurse or admission nurse; compared to previous measurement; Level of Harm - Minimal harm or potential for actual harm i. Upon admission or insertion;

Residents Affected - Few ii. Every dressing change and PRN.

c. Upper arm circumference- three inches above insertion site or other location as determined by the insertion nurse or admission nurse; compare to previous measurement:

i. Upon admission or insertion;

ii. Every dressing change and PRN.

Resident #197 was admitted to the facility in December 2024 with diagnoses which included osteomyelitis (infection of the bone) of the right foot, right great toe amputation, and peripheral neuropathy.

Review of the Physician's Orders indicated but were not limited to the following:

-Change PICC line transparent dressing every evening shift, weekly on Wednesday.

-Measure external length on admission and each dressing change.

-Measure arm circumference on admission and with each dressing change.

-Monitor intravenous (IV) site every shift, assess IV right PICC for signs and symptoms of infection, dressing clean dry and intact.

On 01/2/25 at 10:01 A.M., the surveyor observed Resident #197 lying in bed and with the Resident's permission observed his/her right arm PICC line. The surveyor observed the transparent dressing to be dated 12/25/24, and observed a small amount of dried blood around the insertion site.

Review of Resident #197's Treatment Administration Record (TAR) indicated but was not limited to the following:

-12/18/24: PICC line dressing was changed, no documentation of external catheter length or arm circumference.

-12/25/24: PICC line dressing was changed, no documentation of external catheter length or arm circumference.

-1/1/25: Nurse #8 signed off PICC line dressing was changed; no documentation of external catheter length or arm circumference (On 1/2/25 and 1/3/25 the PICC line dressing was observed dated 12/25/24).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 24 225349 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225349 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Nursing & Retirement Home 265 N Main St South Yarmouth, MA 02664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Review of nursing notes on 12/18/24, 12/25/24, and 1/1/25 indicated there was no documentation the PICC line dressing was changed and no documentation of the external catheter length or arm circumference. Level of Harm - Minimal harm or potential for actual harm During an interview on 1/3/25 at 4:50 P.M., Nurse #9 observed Resident #197's PICC line dressing and said

it was dated 12/25/24. Nurse #9 returned to the medication cart and reviewed Resident #197's physician's Residents Affected - Few orders and TAR and said the PICC line dressing was signed off that it was changed on 1/1/25 and it was not. Nurse #9 said when checking the PICC line everyday you inspect the dressing, look for drainage, and signs and symptoms of infection.

During an interview on 1/3/25 at 5:01 P.M., the Director of Nurses (DON) said she would expect the nurses to change the dressing within 24 hours of admission and then weekly. She said the nurses should be inspecting the site daily for signs and symptoms of infection and drainage. The surveyor and DON viewed Resident #197's PICC dressing and it was dated 12/25/24. The DON said she will have to review Resident #197's orders.

During an interview on 1/7/25 at 8:57 A.M., the DON said when the nurses do a PICC line dressing change

they should be recording the catheter length and arm circumference on the TAR. She said that's the way the orders should be written and the nurses should be recording the information right on the TAR. The DON said

she will look for additional documentation.

During an interview on 1/9/25 at 11:25 A.M., the DON said she could not find nursing documentation of the external length or arm circumference in Resident #197's medical record. She said she spoke to Nurse #8 and Nurse #8 told her she did not get to change the PICC line on 1/1/25. The DON said Nurse #8 should not have marked the PICC line changed if she did not complete it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 24 225349 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225349 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Nursing & Retirement Home 265 N Main St South Yarmouth, MA 02664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0685 Assist a resident in gaining access to vision and hearing services.

Level of Harm - Minimal harm or 48084 potential for actual harm Based on observation, record review, and interview, the facility failed to ensure audiology services were Residents Affected - Some offered to ensure the highest practicable level of care for one Resident (#76), out of a total sample of 19 residents. Specifically, for Resident #76, when their hearing aids went missing, the facility failed to offer/provide alternative treatment, and/or to assist in arranging audiology services to obtain new hearing aids, resulting in a 98-day delay in services.

Findings include:

Review of the facility's policy titled Resident/Patient Belongings Policy, dated 1/20/17, indicated but was not limited to the following:

-Staff will respond in a timely manner to concerns about a missing item.

-An investigation will be initiated to assist in locating missing belongings.

-The results of the investigation will be reviewed with the resident and/or responsible party.

Review of the facility's policy titled Consulting Services; Podiatry/Dental/Optometry/Audiology, dated 11/22/16, indicated but was not limited to the following:

-Services are offered to all residents as a means of providing highest practicable level of functioning and care.

-Resident/resident representatives are provided information about consulting services upon admission and at any time when the need arises.

Resident #76 was admitted to the facility in April 2024 with diagnoses which included Alzheimer's dementia.

Review of the Minimum Data Set (MDS) assessment, dated 10/11/24, indicated Resident #76 scored 3 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she had severe cognitive impairment. Additionally, he/she was hard of hearing and wore hearing aids.

During an interview on 1/2/25 at 9:30 A.M., Resident #76 had difficulty hearing and understanding the surveyor. He/she expressed frustration with the inability to hear and converse with the surveyor.

Observations throughout the survey indicated Resident #76 was alert and confused, able to make his/her needs known, and staff needed to speak loud and slow for him/her to understand them without requesting

they repeat themselves multiple times.

Review of the medical record, including physician's orders, indicated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 24 225349 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225349 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Nursing & Retirement Home 265 N Main St South Yarmouth, MA 02664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0685 -Bilateral Hearing Aids information only. Hearing aids charging in the med room or by the nursing station. Put

on resident in the morning. Remove and place to charge in the evening. (4/14/24) Level of Harm - Minimal harm or potential for actual harm Review of the Medication Administration Record (MAR) indicated the following:

Residents Affected - Some -September 2024: hearing aids were documented as put in the morning and removed/charging from 9/1/24-9/22/24. On 9/23/24 hearing aids were documented as put in the morning and documented as missing on 9/23/24 at 7:39 P.M., and five of the next seven days they were documented as missing/not available/not located.

-October 2024: 25 of 31 days the hearing aids were documented as missing/misplaced/not available.

-November 2024: 24 of 30 days the hearing aids were documented as missing/not available/not located.

-December 2024: 15 of 31 days the hearing aids were documented as missing/not available/not located.

Review of the progress notes failed to indicate the facility had searched for the hearing aids, notified management, notified the family, filed a grievance for a missing item, offered him/her alternative hearing devices, or attempted to arrange an appointment with an audiologist at the time they were documented as missing (9/23/24).

Review of the medical record indicated on 12/30/24 the Director of Social Services filed a grievance after Resident #76's family reported the hearing aids missing. (98 days after they were documented as missing.)

During an interview on 1/7/25 at 1:20 P.M., Nurse #1 said Resident #76's hearing aids have been missing for

a few months. Additionally, she said usually if an item is missing, we would tell the supervisor, and they deal with it.

During an interview on 1/7/25 at 1:35 P.M., Desk Nurse #1 said he was aware the hearing aids were missing, but did not know for how long. He said alternate services should have been offered to Resident #76 sooner.

During an interview on 1/7/25 at 2:16 P.M., Certified Nursing Assistant #2 said they usually charge the hearing aids at the nurses' station, and she was not sure how long they have been missing this time, but it had been a while.

During an interview on 1/9/25 at 10:35 A.M., Social Worker #1 said she was not made aware the hearing aids were missing until 12/30/24 when the Resident's family reported it to her. Additionally, she said when staff noted the hearing aids to be missing back in September an appointment for audiology should have been made. She said she was unsure why the process was not followed.

During an interview on 1/9/25 at 12:05 P.M., the DON said she was not made aware the hearing aids had been missing since September 2024 and only found out last week when the family reported it to the Social Worker.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 24 225349 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225349 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Nursing & Retirement Home 265 N Main St South Yarmouth, MA 02664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0685 During an interview on 1/9/25 at 1:01 P.M., the Administrator said he was not made aware of the missing hearing aids until last week when the Resident's family notified the Social Worker. He said when an item like Level of Harm - Minimal harm or hearing aids are missing the facility should offer something like an amplifier pending an audiology potential for actual harm appointment for replacement hearing aids. He said at that time they offered Resident #76 an amplifier and he/she declined it; his/her family was going to take the Resident to see an audiologist for replacement Residents Affected - Some hearing aids. He said staff need education on the process because they identified the hearing aids were missing, but the progress notes do not indicate anything was done about it, and we were not made aware

they were missing until last week.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 24 225349 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225349 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Nursing & Retirement Home 265 N Main St South Yarmouth, MA 02664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49425

Residents Affected - Few Based on observations, record review, and interview, the facility failed to ensure post-fall interventions were developed and implemented to mitigate the risk of future falls resulting in two falls in three months, one of which resulted in a head strike causing bruising for one Resident (#78), out of a total sample of 19 residents.

Findings include:

Review of the facility's policy titled Fall Risk Reduction, dated as last revised 11/2/23, indicated but was not limited to the following:

-All residents will be assessed for fall risk factors. Those determined to have risk factors will receive individualized interventions based on the risk factors to reduce risk for falls and minimize the actual occurrence of falls.

-Complete a Resident Fall Risk Assessment on admission, readmission, change in condition.

-Develop individualized plan of care.

-Include fall interventions on Kardex and Care Plan.

-Review and revise Care Plan/Kardex regular to ensure individualized.

-Review resident new admit/new fall weekly for four weeks to determine effectiveness of interventions.

Review of the facility's policy titled Accidents and Incidents-Investigating and Reporting, dated as last revised 12/29/11, indicated but was not limited to the following:

-The nurse supervisor/charge nurse and/or the department director or supervisor must conduct an immediate investigation of the accident or incident.

-If Incident/Accident Report is completed for a fall, corresponding post fall investigation shall also be completed.

Review of the facility's policy titled Falls Management: Post Fall, dated as last revised 9/30/24, indicated but was not limited to the following:

-All residents experiencing a fall will receive appropriate care and investigation of the cause.

-Review resident's medical record and assessments to identify any causes that may have contributed to the fall.

-Complete an Incident Report/Post Fall Investigation/5 Whys analysis after the fall.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 24 225349 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225349 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Nursing & Retirement Home 265 N Main St South Yarmouth, MA 02664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 -Update the Care Plan/Kardex to reflect new interventions.

Level of Harm - Minimal harm or -Conduct interdisciplinary falls team meeting at the subsequent clinical morning meeting, review the 5 Whys potential for actual harm Analysis, Determine need for additional actions/interventions based on team evaluation of root cause, and communicate information to staff. Residents Affected - Few -Review resident at interdisciplinary morning meeting to determine effectiveness of interventions. Revise care plan accordingly.

-Remove any causes of fall and implement preventive measures to prevent recurrence.

Resident #78 was admitted to the facility in October 2022 with diagnoses which included muscle weakness, unspecified abnormalities of gait and mobility, and dementia.

Review of the Minimum DataSet (MDS) assessment, dated 10/18/24, indicated that Resident #78 scored 3 out of 15 on the Brief Interview for Mental Status (BIMS) indicating cognitive impairment. Additionally, he/she was dependent on staff with transfers and had a history of falls.

Review of the Comprehensive Care Plan indicated the following:

PROBLEMS/STRENGTHS: At risk for falls. The following risk factors have been identified. Change in mobility/gait, confused/forgetful, exhibits unsafe behavior. Recent witnessed fall.

GOALS: Resident will be free from injury related to falls through review period.

INTERVENTIONS:

-Fall risk assessment upon admission, re-admission, significant change in condition (11/1/22)

-Ask resident to sit back when noted to be sitting forward in wheelchair (11/2/23)

-Offer to get out of bed before dinner if in bed for nap (11/2/23)

-Check to see if wishes to get out of bed at change of shift (11/2/23)

-Offer the option to get out of bed early am 11-7 shift if awake (11/2/23)

-Likes safely sitting on the floor attempt to determine reason and attempt to mitigate risks preemptively, monitor for changes in frequency (11/2/23)

-Monitor for proper positioning in wheelchair (11/2/23)

-Rehab to review for alternate wheelchair seating (11/2/23)

-Bed will be positioned low when she is in bed to prevent falls (3/12/24)

-To be reclined in Broda (wheelchair that can tilt or recline) chair after meals (9/24/24)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 24 225349 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225349 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Nursing & Retirement Home 265 N Main St South Yarmouth, MA 02664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Review of the Fall Risk Evaluation from admission indicated the following:

Level of Harm - Minimal harm or -10/22/22 Score 8 (Fall risk score was not defined on evaluation), History of falls in the past 2-6 months, potential for actual harm moving from seated to standing position not steady, only able to stabilize with assist

Residents Affected - Few During an interview on 1/7/25 at 2:28 P.M., the Director of Nurses (DON) said the facility only completes fall risk assessments upon admission, re-admission, or with a significant change in condition. She said when a resident has a fall it is not considered a change of condition.

Review of the medical record indicated Resident #78 had two falls since June 2024, both falls were related to slipping out of the wheelchair.

Review of the facility Incident Reports, nursing progress notes for the falls indicated the following:

FALL 6/1//24:

-Observed sitting on the floor in front of Broda chair in dayroom.

-Report indicated Resident #78 attempted to stand

-Back of Broda chair was at a 90-degree angle may have contributed to the fall

-No additional predisposing factors were identified.

-No witness statements were provided.

-No injury was noted.

-New intervention identified to recline back of wheelchair short time after meals. Intervention had a line drawn through it and written below the crossed out intervention read would not necessarily have prevented fall

-No intervention added to the care plan or Kardex to prevent future falls/mitigate the risk of future falls.

FALL 9/20/24:

-Observed on floor in dayroom, fell out of wheelchair

-Predisposing factors indicated the wheelchair was not reclined

-No additional predisposing factors were identified.

-No witness statements were provided.

-Sustained bruising to right side of forehead, ice pack applied, and neurological checks completed

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 24 225349 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225349 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Nursing & Retirement Home 265 N Main St South Yarmouth, MA 02664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 -New intervention identified to recline wheelchair after meals

Level of Harm - Minimal harm or -Intervention, care plan and Kardex were updated as follows: Resident is to be reclined in his/her Broda chair potential for actual harm after meals (9/24/24)

Residents Affected - Few The facility identified that Resident #78 fell on [DATE REDACTED] from Broda/wheelchair. The facility failed to develop and implement additional interventions to prevent future falls/mitigate the risk of falls resulting in an additional fall from Broda/wheelchair sustaining a bruise to the right side of his/her forehead.

The surveyor made the following observations:

-1/6/25 at 11:28 A.M., Resident #78 sitting in Broda chair in activity room with back of chair in upright position, not reclined.

-1/7/25 at 12:30 P.M., Resident #78 sitting in Broda chair in dayroom after lunch, back of chair in upright position, not reclined.

During an interview on 1/6/25 at 2:48 P.M., Nurse #4 said she completes an incident report packet and updates the care plan with a new intervention to prevent the fall from occurring again. She said the incident report packet is then given to the DON for review.

During an interview on 1/9/24 at 7:51 A.M., the DON said when a fall occurs, the nurse completes an incident report packet. She said the packet consists of a root cause analysis to help the nurses determine a new intervention to reduce the risk of the fall occurring again. She said the nurse updates the interventions, care plans and updates the Kardex with information for the Certified Nursing Assistants (CNA) after the fall. The DON reviewed the incident report packet dated 6/1/24 and said the incident report is incomplete; there was no intervention put into place and the care plan was not updated as it should have been. She said the nurse identified an intervention, but does not know why it was crossed out and not implemented. She said she is new to the facility, and was not present at the time of this fall. The DON said all falls are reviewed the next morning and weekly for four weeks by the Interdisciplinary Team (IDT), and is unsure why it was not identified by the IDT that this fall report was incomplete.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 24 225349 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225349 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Nursing & Retirement Home 265 N Main St South Yarmouth, MA 02664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 49425 Residents Affected - Some Based on observation, interview, and document review, the facility failed to ensure all medications used in

the facility were stored and labeled in accordance with currently accepted professional standards in two of two medication carts reviewed.

Findings include:

Review of the facility's policy titled Storage of Medications, dated as revised 6/10/22, indicated but was not limited to the following:

-Orally administered medications are kept separate from externally used medications, such as lotions

-Outdated, contaminated or deteriorated medications and those in containers without secure closures are immediately removed from stock, and disposed

-Medication storage areas are kept clean

Review of the facility's policy titled Administration Procedures for all Medications, dated 9/20/13, indicated but was not limited to the following:

-Check expiration date on package/container before administering any medication. When opening a multidose container, place the date on the container.

-Once removed from the package or container, unused or partial doses should be disposed of.

Review of the facility's policy titled Equipment and Supplies for Administering Medications, dated 6/1/10, indicated but was not limited to the following:

-Charge nurse on duty ensure that equipment and supplies relating to medication administration are clean and orderly.

On 1/3/25 at 2:29 P.M., the surveyor completed a review of the medication cart on Unit A, low side, with Nurse #1, and made the following observations:

- In the top drawer on the right-hand side: two small clear plastic medication cups, uncovered and not labeled. One contained a thick creamy white substance with a spoon placed inside, and one contained approximately 15 milliliters (ml) of a clear liquid.

-On the bottom of the top drawer on the right-hand side: yellowish crusted substance stuck to the bottom of

the drawer, multiple loose pills, yellowish-white powdery substance on the bottom of the drawer.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 24 225349 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225349 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Nursing & Retirement Home 265 N Main St South Yarmouth, MA 02664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Nurse #1 said the cup with the white substance was Eucerin cream (moisturizer) that she needed to apply to

a resident, and the other cup contained normal saline (a mixture of sodium chloride and water). She said she Level of Harm - Minimal harm or was going to do treatments, and got called away, so she placed the two cups in the top of the medication potential for actual harm cart.

Residents Affected - Some -Two bottles of artificial tears, seal broken indicating it was in use, not labeled with an open or discard date.

-Multiple single dose prescription medications, not labeled with a resident name, scattered under the over-the-counter medication bottles.

-On the bottom of the second drawer on right-hand side, dried yellowish crusted substance, multiple loose pills and a powdery substance on the bottom of the drawer.

-One bottle of Timolol eye drops (used to treat high pressure in the eye), seal broken indicating it was in use, not labeled with an open or discard date.

-One bottle of Dorzolomide eye drops (used to treat high pressure in the eye), seal broken indicating it was in use, not labeled with an open or discard date.

-One Advair diskus inhaler (used to treat symptoms of asthma), foil packaging removed, indicating it was in use, not labeled with an open or discard date.

Nurse #1 said the eye drops and inhalers are in use but do not have a shortened expiration date upon opening. She said she goes by the expiration date on the outside of the container. Nurse #1 said the single dose prescription medications came from the omni cell (automated dispensing cabinet) and are supposed to remove only what you are going to administer at that time. She said the medications should not be stored in

the cart without a resident name. Nurse #1 said she is not sure who is responsible for cleaning the cart.

On 1/3/25 at 3:04 P.M., the surveyor completed a review of the medication cart on Unit B high side with Nurse #3, and made the following observations:

-Two bottles of Prednisolone eye drops (used to treat inflammation in the eyes), seal broken indicating it was

in use, not labeled with an open date.

-Three bottles of artificial tears eye drops, seal broken indicating it was in use, not labeled with an open date.

-Two bottles of Maxifloxin eye drops (used to treat infections of the eye), seal broken indicating it was in use, not labeled with an open date.

Nurse #3 said eye drops should be labeled upon opening with an open date because they have a shortened expiration date once opened. She said if they do not have an open date they cannot be used.

During an interview on 1/6/25 at 2:59 P.M., Desk Nurse #1 said the 11:00 P.M. - 7:00 A.M. shift nurse is responsible for cleaning and maintaining the medication carts. He said when a nurse notices loose medications in the cart, they should be removing and destroying the medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 24 225349 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225349 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Nursing & Retirement Home 265 N Main St South Yarmouth, MA 02664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 During an interview on 1/9/25 at 8:17 A.M., the Director of Nursing (DON) said no medications should be stored in the cart once prepared for administration, uncovered and not labeled. She said the 11:00 P.M. - Level of Harm - Minimal harm or 7:00 A.M. staff is supposed to remove all expired medications, clean and stock the medication carts nightly, potential for actual harm and housekeeping is responsible for thoroughly cleaning the carts monthly. The DON said she is unsure of expiration dates on specific eye drops; however, they are stored in a multi-use vial, and multi-use vials have Residents Affected - Some shortened expiration dates, and must be labeled upon opening.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 24 225349 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225349 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Nursing & Retirement Home 265 N Main St South Yarmouth, MA 02664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 41106

Residents Affected - Some Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another). In addition, to ensure the use of gloves was limited to a single use task.

Findings include:

Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following:

- 3-301.11 Preventing Contamination from Hands. (A) FOOD EMPLOYEES shall wash their hands as specified under S 2-301.12. (B) Except when washing fruits and vegetables as specified under S3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT.

- 3-304.15 Gloves, Use Limitation. (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.

Review of the facility's policy titled Dietary: Sanitary Conditions, dated 10/27/22, indicated but was not limited to the following:

-The facility will obtain food from sources approved or considered satisfactory by the federal, state or local authorities; and follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness.

-Safe food handling for prevention of foodborne illnesses begins when food is received from a vendor and continues throughout the facility food handling processes.

-Cross contamination: refers to transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces, sponges, cloth towels or utensils which were not cleaned after touching raw food and then touch ready-to-eat foods.

Hand Washing, Glove Use, and use of alcohol-based hand sanitizers:

-Since the skin carries microorganisms, it's critical that staff involved in food preparation consistently utilize good hygienic practices and techniques for hand hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 24 225349 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225349 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Nursing & Retirement Home 265 N Main St South Yarmouth, MA 02664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 -The appropriate use of utensils such as gloves, tongs, deli paper and spatulas are essential in preventing foodborne illness. Gloved hands are considered a food contact surface that can be contaminated or soiled. Level of Harm - Minimal harm or potential for actual harm -Failure to change gloves between tasks can contribute to cross contamination.

Residents Affected - Some -Disposable gloves are a single use item and should be discarded after each use.

NOTE: The use of disposable gloves is not a substitute for proper hand washing with soap and water.

On 1/2/25 at 8:30 A.M., the surveyor observed the breakfast tray line service in the main kitchen and made

the following observations:

-Cook #1 was plating breakfast plates wearing a disposable glove handling the pancakes, toast, and bacon with her gloved hands. [NAME] #1 used the scoop to plate the scrambled eggs and then arranged them on

the plates with her gloved hands.

-Cook #1 was observed leaving the steam table to cook pancakes on the griddle, touching multiple surfaces with her gloved hands. [NAME] #1 returned to the steam table continuing to plate breakfast as described above wearing the same gloved hands as above.

-Cook #1 left the steam table for a second time, cracked three eggs on the griddle and handled the spatula cooking the eggs. [NAME] #1 discarded one egg, cracked a fourth egg on the griddle and continued cooking. [NAME] #1 returned to the steam table continuing to plate breakfast as described above wearing the same pair of gloves. [NAME] #1 was not observed changing her gloves or performing hand hygiene at any time.

During an interview on 1/2/25 at 8:35 A.M., the Food Service Manager (FSM) said [NAME] #1 should be serving food from the steam table using utensils and not her gloved hands. He said she should be removing her gloves and performing hand hygiene in-between tasks like cracking raw eggs before returning to the steam table to serve food.

On 1/3/25 at 11:42 P.M., the surveyor observed lunch tray line service in the Main kitchen and made the following observations:

-Cook #2 was observed wearing two pairs of gloves while plating lunch plates.

-Cook #2 was observed leaving the tray line to obtain supplies and returning to the tray line, removing one pair of gloves and continuing to plate lunch service.

-Cook #2 was observed leaving the tray line a second time, handling a kitchen towel/potholder to remove meatloaf from the oven to replace a pan on the steam table. [NAME] #2 was observed removing the second pair of gloves and his hands were visible dripping a water like substance. [NAME] #2 obtained a new pair of gloves, entered the walk-in freezer (touching the door handle) and held his hands up to the fan in a waving motion. [NAME] #2 put on the new pair of gloves and returned to the lunch tray service line to continue plating meals.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 24 225349 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225349 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Nursing & Retirement Home 265 N Main St South Yarmouth, MA 02664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During an interview on 1/03/25 at 11:51 A.M., the FSM said [NAME] #2 should not be wearing two pairs of gloves, he should not be drying his hands in the walk-in and [NAME] #2 should be performing hand hygiene Level of Harm - Minimal harm or every time he changes his gloves. potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 24 225349 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225349 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Nursing & Retirement Home 265 N Main St South Yarmouth, MA 02664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 48084

Residents Affected - Some Based on record review and interview, the facility failed to ensure an accurate medical record for one Resident (#84), out of a total sample of 19 residents. Specifically, the facility failed to ensure the medical

record indicated the dietary recommendation for Mirtazapine (antidepressant used for an appetite stimulant) had been reviewed by the provider timely.

Findings include:

Resident #84 was admitted to the facility in September 2024 with diagnoses including dementia, anxiety, depression, obsessive-compulsive disorder (OCD), and had a history of falls with traumatic subdural hematoma.

Review of the Minimum Data Set (MDS) assessment, dated 9/23/24, indicated he/she scored 11 out of 15 on

the Brief Interview for Mental Status (BIMS) indicating he/she had moderate cognitive impairment.

Review of the weights documented in the medical record indicated the following:

9/18/24: 155.8 pounds (lbs.)

9/28/24: 130.4 lbs.

10/12/24: 124.2 lbs.

10/28/24: 124.8 lbs.

12/16/24: 112.8 lbs.

Review of the Dietitian's progress note, dated 10/17/24, indicated Resident #84 continues to present with variable and often inadequate intake of meals. Resident denies need for supplemental foods or oral supplements, which have been offered several times since admission. Weight change: unclear on accuracy of prior weights but would suggest severe weight loss. Resident presents with moderate signs of muscle wasting and moderate fat wasting and meets criteria for severe chronic disease related to malnutrition. Per discussion with team, plan will be to start on Mirtazapine (pending resident agreement) in effort to increase appetite as resident continues to refuse any oral supplements to halt weight loss.

Review of the medical record failed to indicate the recommendation had been reviewed with the physician and he/she approved/declined it or that the Resident declined the recommendation.

Further review of the progress notes indicated Resident #84 was accepting only ice cream as a supplemental food and he/she was being provided ice cream on trays and whenever he/she asked for it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 24 225349 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225349 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Nursing & Retirement Home 265 N Main St South Yarmouth, MA 02664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Review of the medical record indicated he/she was taking multiple psychotropic medications to manage disease process and symptoms and was followed by the Psych Nurse Practitioner (NP) and had recent Level of Harm - Minimal harm or medication changes. potential for actual harm

Review of the Dietitian's progress note, dated 12/17/24, indicated he discussed with the NP trialing Residents Affected - Some Mirtazapine to assist with appetite, which will be passed on to psych.

Review of the Physician's progress note, dated 12/17/24, indicated he/she had severe malnutrition, to continue Magic Cup (nutrient enhanced ice cream), plan to discuss Mirtazapine as an appetite enhancer with Psych NP. Additionally, noting his/her mental health is likely playing a role.

Further review of the medical record failed to indicate the recommendation for the Mirtazapine made in October had been addressed prior to December.

During an interview on 1/7/25 at 1:20 P.M., Nurse #1 said she was not aware of the dietary recommendation or the process on how they get addressed. She said Resident #84 will only take ice cream and the Magic Cups as supplements.

During an interview on 1/7/25 at 1:35 P.M., Desk Nurse #1 said when the dietitian has recommendations he reviews them with the NP. He said he was aware of the weight loss but not of a pending recommendation for Mirtazapine. Additionally, he said management does risk meetings and they discuss weight loss, but I only get report on the out of the ordinary stuff. He reviewed the medical record and was unsure if the recommendation had been addressed between 10/17/24 and 12/17/24 because there were not any notes indicating such.

During an interview on 1/9/25 at 9:12 A.M., NP #1 said initially she did not want to add another medication given recent medication changes and his/her extensive psych history. She said she could not recall if she documented that initially but should have. She said she wanted to watch his/her weights and intakes, when he/she continued to lose weight, it was discussed again, and the decision was to defer the recommendation to the Psych NP. She said the Psych NP was going to review Resident #84's medical record and advise at her next visit, which was yesterday, and she was waiting on the written progress note to review the Psych NP's recommendations today. She said the staff have continued to give him/her ice cream and Magic Cups and monitor his/her weights when he/she will allow them to.

The facility failed to ensure NP #1's review and decline of the recommendation was documented in the medical record for two months until the same recommendation was reconsidered in December 2024.

During an interview on 1/9/25 at 12:05 P.M., the Director of Nurses (DON) said the recommendation for Mirtazapine was discussed in the weekly risk meeting on 10/17/24 and they should have ensured the follow up was documented in the medical record. She said they need to have a better system in place to ensure recommendations are reviewed and documented timely. Additionally, she said Resident #84 is a hard one because he/she will not take any supplements except ice cream and Magic Cups. She said they talk about him/her frequently, give him/her all the ice cream he/she wants and monitor weights when he/she will get weighed. She said they do as much as they can for him/her, but they need to improve the documentation in

the medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 24 225349