Based on interview and record review the facility failed to ensure the resident and/or their resident representative was fully informed about treatments being provided to one Resident (#5) out of a total sample of 26 residents. Specifically, for Resident #5, the facility failed to ensure the Resident's activated Health Care Proxy (HCP - representative designated by a resident to make decisions for him/her when he/she is no longer able to do so) was informed of the current dose and frequency of an antipsychotic medication (Seroquel) and an antidepressant medication (Zoloft) that were actively being administered to the Resident. Findings include: Review of the facility policy title Psychotropic Medications, revised 2/24/25, indicated the following: >Purpose: -To ensure psychotropic medication is used appropriately, with written informed consent, as part of the care of the resident's psychiatric/behavioral health care plan. >Procedure: -The written informed consent for each psychotropic medication shall be initiated with any newly prescribed psychotropic medication and renewed annually. Review of the facility policy titled Admission/Discharge Drug Regimen Review, including Medication Reconciliation Policy, implementation date 10/15/21, indicated the following: -As part of medication reconciliation, the facility will obtain and document a complete list of the resident's current medication upon the resident's admission/readmission/discharge to the organization with the involvement of the resident or the family or resident representative. Resident #5 was admitted to the facility in June 2025 with diagnoses including Parkinson's related Dementia with Agitation, Depressive Disorder, and a history of delusional thinking. Review of Resident #5's Massachusetts HCP Form, dated 9/2022 indicated he/she appointed Resident Representative #1 as his/her HCP. Review of Resident #5's Physician Determination Concerning Massachusetts Health Care Proxy Form (HCP Invocation Form) dated 5/5/25, indicated the attending Physician declared Resident #5 unable to make his/her own medical decisions and the duration of Resident #5's incapacity was permanent due to a diagnosis of Dementia. Review of Resident #5's Hospital Discharge Medications dated 6/23/25, indicated the following: -Quetiapine (Seroquel - antipsychotic medication) 25 milligrams (mg) oral tablet When: Daily at Bedtime Instructions: Take around 8:00 A.M. and daily at supper. Hold morning dose as needed if excessive lethargy. {sic} Review of Resident #5's Medication Reconciliation Form dated 6/23/25, indicated the following: -Seroquel 25 mg three times daily. The Medication Reconciliation Form failed to indicate that Resident #5's HCP had been consulted regarding Resident #5's medications. Review of Resident #5's Behavioral Health Note dated 6/26/26 {sic} (correct date 6/25/25), indicated the following recommendation: -Zoloft (brand name for Sertraline - antidepressant medication) 25 mg daily. Review of Resident #5's July 2025 Physician's orders indicated: -Seroquel 25 mg.three times daily.start date of 6/23/25 -Sertraline 25 mg.once daily.start date of 6/27/25 Review of the Nurse Practitioner (NP) Progress Notes dated 6/24/25, 6/27/25, and 6/30/25, indicated behaviors stable on Seroquel 25 twice daily (BID). Review of Resident #5's Medication Administration Record (MAR) for June 2025 and July 2025, indicated Resident #5 was administered:-Seroquel 25 mg three times daily as ordered from 6/23/25 through 7/21/25.-Sertraline 25 mg once daily from 6/27/25 through 7/21/25. Review of Resident #5's Informed Consent for Psychotropic Administration Form, for the administration of Seroquel, dated 3/26/25 (form from Resident #5's previous admission to the facility) indicated the name of the medication and a range of 0mg-800mg daily. No dose of frequency was documented on the form. Review of Resident #5's Informed Consent for Psychotropic Administration Form, for the administration of Sertraline dated 4/11/25 (form from Resident #5's previous admission to the facility) indicated the name of the medication and a range of 0 mg - 200 mg daily. The Informed Consent Form failed to indicate the dose and frequency for the Sertraline medication. During an interview on 7/21/25 at 9:08 A.M., Nurse #4 said Informed Consent for Psychotropic Administration Forms are completed at the time a Resident is admitted to the facility. Nurse #4 said if a Resident discharged home and returned to the facility at a later date a new Informed Consent Form was to be completed. During an interview on 7/21/25 at 9:18 A.M., Nurse #5 said Informed Consent for Psychotropic Administration Forms are completed at the time a Resident is admitted to the facility. Nurse #5 said medication reconciliation is done at the time of admission. Nurse #5 said a medication reconciliation form was completed by the admitting Nurse who reviewed the hospital records and then relayed the information to the attending Physician to verify the orders, and the admitting Nurse then inputs them into the electronic medical record (EMR). During an interview on 7/21/25 at 9:27 A.M., Nurse #2 said medication reconciliation is done at the time of admission. Nurse #2 said she completed Resident #5's medication reconciliation at the time of his/her admission to the facility. Nurse #2 said she utilized the discharge summary from the hospital and reviewed the medication list with the Resident or a family member and then informed the doctor to get the medication orders. Nurse #2 said since Resident #5 had been admitted to the facility previously in the last year, no new Informed Consent for Psychotropic Administration Forms had been completed at the time of his/her most recent admission to the facility. Nurse #2 said the facility staff puts a dose range on the forms and does not include the current dose or frequency. During an interview on 7/21/25 at 10:00 A.M., Nurse #2 said when she reconciled Resident #5's medications with the hospital records she reviewed the hospital documentation and understood the hospital documentation as Resident #5 was on Seroquel three times daily. Nurse #2 said she told the attending Physician that the hospital recommended Seroquel three times a day, which was why the order was entered that way. During an interview on 7/21/25 at 11:08 A.M., NP #1 said Resident #5 was on Seroquel three times a day (TID) and the documentation in the NP notes stating Seroquel BID must have been an error. During a phone interview on 7/21/25 at 12:35 P.M., Resident Representative (RR) #1, said he/she managed Resident #5's medication in the community and Resident #5 was on Seroquel 25 mg once daily at bedtime prior to his/her hospitalization. RR #1 said he/she was unaware that Resident #5's Seroquel had been changed to three times daily and no staff from the facility had informed him/her of this change or asked him/her to sign any documentation that explained this change. RR #1 said there had been times he/she had visited Resident #5, and he/she was unable to be roused because he/she was so tired. RR #1 said Resident #5 had a history of responding negatively (too sleepy) to increased doses of psychotropic medications in the past. RR #1 further said Resident #5 was not on Sertraline in the community and he/she was unaware Resident #5 had been started on Sertraline and no staff from the facility had informed him/her of the addition of Sertraline or asked him/her to sign any documentation that explained the addition of Sertraline medication. Review of the Nursing Progress Notes from 6/23/25 through 7/1/25 failed to indicate documentation that RR #1 had been informed at the time of Resident #5's admission to the facility that he/she was on Seroquel three times daily or that Resident #5 had been started on and administered Sertraline beginning on 6/27/25. During an interview on 7/21/25 at 1:50 P.M., with the Director of Nursing (DON) and Nurse #2, the DON said at the time of admission, Residents and/or their HCP should be informed of any psychotropic medications they are going to receive while at the facility. The DON said dose and frequency was to be documented on the Informed Consent for Psychotropic Administration Form which was signed by the Resident and/or HCP. The DON reviewed the Hospital Records from 6/23/25 and said the order for Seroquel from the hospital was unclear and the process for reconciling the medication should have been done with the family as well as the attending Physician. The DON said reconciling the medications with the family and completing the Informed Consent for Psychotropic Administration Form should have been done with RR #1 and this did not happen at the time Resident #5 was admitted to the facility. During an interview on 7/21/25 at 2:30 P.M., Nurse #2 said she was unable to find any documentation RR #1 was informed that Resident #5 was started on and administered Sertraline starting on 6/27/25. Nurse #2 said a new Informed Consent for Psychotropic Administration Form should have been completed with RR #1 prior to the medication being started and this was not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to ensure that as needed (PRN) orders for antipsychotic medications were limited to 14 days for one Resident (#7), of five applicable residents reviewed for unnecessary medications, out of a total sample of 26 residents. Specifically, for Resident #7, the facility failed to ensure that Physician's orders for PRN Seroquel and Haldol medications were limited to 14 days.Findings include:Review of the facility policy titled Psychotropic Medications, revised 2/24/25, indicated in caring for residents with psychiatric/behavioral health conditions, properly ordered psychotropic medications may be used when non-pharmaceutical interventions are ineffective or inadequate. Psychotropic medications can affect mood and behavior and include but not limited to.antipsychotics. The policy further indicated:-As with all medications, psychotropics shall only be administered following an order by a physician.<As needed (PRN) medications will require a 14-day order.-Antipsychotics must be stopped following completion of the PRN 14-day order. A new order may be written if the prescriber deems it appropriate following a direct assessment of the patient including (but not limited to) documentation of improvement of distress based on previous use of as needed (if applicable). Resident #7 was admitted to the facility in March 2023 with diagnoses including Dementia with behavioral disturbance, history of Traumatic Brain Injury (TBI), and Depression with Anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #7:-was severely cognitively impaired as evidenced by Brief Interview for Mental Status (BIMS) score of seven out of 15.-reported mood symptoms of loss of interest, depression, fatigue, thoughts of failure, and trouble concentrating.-rejected care, wandered, and demonstrated physical, verbal, and other behaviors during the seven-day look back period. -was prescribed antipsychotic medications on both a routine and PRN basis. Review of Resident #7's Physician's orders from 4/1/25 through 7/31/25 indicated the following:- Haloperidol (antipsychotic) 2 milligram (mg)/1 milliliter (ml) solution sublingual (under the tongue) 0.5 mg (0.25 ml), every four hours as needed for agitation, initiated 4/18/25.- Haloperidol 2 mg/1 ml solution 1 mg = (0.5 ml) sublingual, every four hours as needed for agitation, initiated 6/3/25.- Haloperidol 2mg/1ml solution 1 mg = (0.5 ml) sublingual, every four hours as needed for agitation, initiated 7/18/25.- Seroquel (antipsychotic) 25 mg tablet, 25 mg oral, every six hours as needed for increased agitation/restlessness, initiated 6/12/25.- Seroquel 25 mg tablet, 25 mg oral, every six hours as needed for increased agitation/restlessness, initiated 7/18/25. Review of Resident #7's Medication Administration Records (MAR) from 4/1/25 through 7/22/25 indicated that the Resident received the following:>Haloperidol 0.5 mg PRN on:-April: 4/19/25, 4/24/25, 4/23/25, 4/27/25, 4/29/25, 4/30/25-May: 5/1/25, 5/10/25, 5/14/25, 5/25/25, 5/28/25, 5/29/25, 5/31/25-June: 6/2/25>Haloperidol 1 mg PRN:-June: 6/3/25, 6/5/25, 6/8/25, 6/12/25, 6/17/25, 6/19/25, 6/20/25, 6/24/25 - 6/26/25, 6/28/25, 6/29/25-July: 7/1/25, 7/4/25, 7/9/25, 7/13/25, 7/14/25>Seroquel 25 mg PRN:-June: 6/13/25, 6/15/25, 6/17/25, 6/24/25, 6/25/24, 6/26/25, 6/28/25 - 6/30/25-July: 7/4/25, 7/9/25 - 7/11/25, 7/14/25. Review of the Resident #7's Pharmacy Medication Regimen Review, dated 5/21/25, indicated the following: -Please reassess the need for PRN Haloperidol every 14 days. Review of Resident #7's Physician's Visit Progress Notes indicated the following:-4/16/25: Follow up, serve as regulatory visit. Medications reconciled.it was recommended . to add PRN Haldol q4h PRN.-7/8/25- LTC NP regulatory visit. Medications were reviewed by Provider. Medication list reviewed included:<Haloperidol 0.25 mls sublingual q4h prn<Seroquel 25 mg po q 6 prn agitation Review of Resident #7's medical record failed to indicate any evidence the PRN Haldol and Seroquel medication orders were limited to 14 days, as required. During an interview on 7/22/25 at 9:38 A.M., the surveyor and Unit Manager (UM) #4 reviewed Resident #7's medical record, and UM #4 said that Resident #7 was receiving Haldol PRN and Seroquel PRN. UM #4 said the process for PRN antipsychotic medications should be to trial the medications for 14 days and then on Day 14, the medication would be reviewed to see if it was utilized. UM #4 said she would then notify the Nurse Practitioner (NP) or Medical Doctor (MD) to review the medication and determine if it was necessary for the Resident. UM #4 said for Resident #7, Haldol 1 mg PRN that was started on 6/3/25, should have been reviewed around 6/17/25, and that the Seroquel PRN started on 6/12/25 should have been reviewed around 6/26/25. UM #4 said that the MD orders for Seroquel PRN and Haldol PRN should have been limited to 14 days and were not. During an interview on 7/22/25 at 11:51 A.M. the Director of Nursing (DON) said that PRN antipsychotic medications are typically ordered for 14 days and that Physician's orders for PRN antipsychotic medications should have a re-evaluation date to review for effectiveness and continued use. The DON said this would be documented in the Resident's electronic record.

Based on interview and record review, the facility failed to ensure that a Significant Change in Status Minimum Data Set [MDS] Assessment (SCSA) was completed for one Resident (#22) out of a total sample of 26 residents. Specifically, for Resident #22, the facility failed to ensure that a SCSA was completed when the Resident experienced a decline in the Activity of Daily Living (ADL) function, change in bowel and bladder continence, and experienced a significant weight decline (weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days). Findings Include: Review of the CMS Resident Assessment Instrument (RAI) Version 1.19.1 dated October 2024, indicated the following: -A SCSA is a comprehensive assessment for a resident that must be completed when the Interdisciplinary Team (IDT) has determined that a resident meets the significant change guidelines for either major improvement or decline. -A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting.2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/ or revision of the care plan. Resident #22 was admitted to the facility in December 2024 with diagnoses including Cerebral Vascular Disease. Review of the MDS Assessment, dated 12/24/24, indicated Resident #22:-required moderate assistance for bathing, dressing, lying to sitting on the side of bed and sit-to-stand ability. -required moderate assistance for ambulation of 10 feet. -required moderate assistance for wheelchair mobility. -was independent to roll from left to right. -had no rejections of care. -was continent of bowel and bladder. -weighed 250 lbs. (pounds). Review of the Quarterly MDS Assessment, dated 3/22/25, indicated Resident #22: -required maximum assistance for bathing, dressing, lying to sitting on side of bed, and sit-to-stand ability. -did not ambulate. -required maximum assistance to roll from left to right. -did not use a wheelchair. -had no rejections of care. -was occasionally incontinent of bowel. -was occasionally incontinent of bladder. -weighed 234lbs., had a significant weight loss, and was not on a Physician prescribed weight loss regimen. Review of Resident #22's medical record failed to indicate that a SCSA had been completed after the Resident had a decline in status that was not self-limiting. During an interview on 7/22/2025 at 9:00 A.M., the MDS Nurse said Resident #22 had a significant change in status from December 2024 to March 2025, and according to the RAI manual a SCSA should have been completed. The MDS Nurse said that a SCSA for the Resident should have been completed when the Quarterly MDS Assessment with an ARD (Assessment Reference Date) of 3/22/25 was completed, but was not.

Based on observations, interviews, and record reviews, the facility failed to provide care and services related to hearing devices for one Resident (#38), out of a total sample of 26 residents. Specifically, for Resident #38, the facility failed to ensure hearing aids were applied per recommendations from the Audiologist and the Resident's plan of care. Findings include:Review of the facility policy titled Activities of Daily Living (ADL), approved 12/22/16, indicated each resident will receive the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological wellbeing, consistent with the resident's comprehensive assessment and plan of care.The policy also included the following:-the facility will provide care and services for the following activities of daily living .communication, including speech and language, functional communication systems .-the care and services for ADL will be based on the resident's ability as identified in Minimum Data Set (MDS) assessment, Rehabilitation evaluation, nursing assessment, and person-centered care plan.-assistive devices and adaptive equipment are provided as needed . Resident #38 was admitted to the facility in December 2017, with diagnoses including Dementia, Major Depression, Anxiety, and impacted cerumen-bilaterally. Review of the Consent for Audiology Service Form, dated 6/5/19, indicated the Physician consented to have Resident #38 evaluated due to complaints of newly decreased hearing. Review of the Hearing Aid/Assistive Listening Device Delivery/Purchase Agreement dated 12/16/21, indicated Resident #38 was issued two new hearing aids. Review of the Audiology Consult, dated 9/21/23, indicated Resident #38 was evaluated for a hearing aid check and request to be seen related to complaints of newly decreased hearing.The Consultant Audiologist indicated the following:-Resident #38 had hearing aids for the left and right ears.-the batteries in the hearing aids were changed, the devices were cleaned, and both hearing aids fit well.-a listening check using the hearing aids was good and the Resident was pleased with sound quality.-Hearing aid insertion and removal were reviewed with the Nurse and the Resident.-the Resident required assistance with insertion and manipulation of hearing aids daily.-the Nurse will insert and remove the Resident's hearing aids.-the Nurse will change the hearing aid batteries- please open battery doors when not in use to extend battery life.-Resident should wear hearing aids daily . Review of the Communication Care Plan, initiated 2/8/24, indicated Resident #38 had a communication decline related to hearing loss and Dementia.The plan of care included the following interventions also initiated on 2/8/24:-monitor for declines and report changes to the charge Nurse.-hearing aids as tolerated. Review of the ADL Care Plan dated 3/27/25, indicated Resident #38 had an alteration in ability to provide self-care/perform ADL's related to cognitive deficits and included the following interventions also initiated 3/27/25:-partial to moderate assistance of staff with grooming needs, and-maximum assistance of staff with dressing needs. Review of the Annual MDS Assessment, dated 6/18/25, indicated Resident #38:-had minimal difficulty hearing and did not have hearing devices.-usually makes self-understood.-sometimes understands others.-had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of six out of a possible 15 points.-required substantial to maximum assistance of staff with dressing and personal hygiene. During an interview on 7/16/25 at 9:21 A.M., Resident #38 was observed unable to understand what the surveyor was asking and repeatedly said what? The surveyor observed that Resident #38 was not wearing hearing aids and did not have any hearing devices in use. On 7/16/25 at 3:52 P.M., the surveyor observed Resident #38 was dressed and seated in the common area with other residents. The surveyor observed that Resident #38 was not wearing hearing aids. Review of the Certified Nurse Aide (CNA) Care Card, reviewed on 7/18/25, failed to indicate that Resident #38 had hearing devices/hearing aids. During an interview on 7/18/25 at 12:48 P.M., CNA #4 said Resident #38 required total assistance from staff with ADLs. CNA #4 said Resident #38 was heard of hearing and CNA #4 was not sure if he/she had hearing aids. CNA #4 said she could recall the Resident having hearing aids at one point, but it has been a long time since she had seen him/her wearing the hearing aids. CNA #4 said the Nurse may know more about the Resident's hearing aids. During an interview on 7/18/2025 at 12:56 P.M., Nurse #6 said Resident #38 had difficulty with hearing and was followed by Audiology services. Nurse #6 said she was not aware if Resident #38 had hearing aids, but to the best of her knowledge he/she did not have hearing aids. During an interview on 7/18/25 at 1:19 P.M., Unit Manager (UM) #3 said she had worked at the facility as the UM since 2020. UM #3 said she was not aware if Resident #38 had hearing aids but would look into this. During a follow-up interview on 7/18/25 at 4:47 P.M., UM #3 said she reviewed Resident #38's clinical record and was unable to find evidence of what occurred with his/her hearing aids. UM #3 said there was an Audiology Consult that indicated hearing aids were issued, but she was unsure where the Resident's hearing aids were at this time. On 7/18/25 at 5:10 P.M., UM #3 provided the surveyor with hearing aids labeled with Resident #38's name. During an interview at the time, UM #3 said the Resident's hearing aids were located in the medication room on the unit. UM #3 said she was not sure why the Resident's hearing aids were not being utilized and why there were no instructions for the Nurses to administer and remove the Resident's hearing aids daily on the Medication Administration Record (MAR) and there should be. UM #3 said she also reviewed Resident #38's CNA Care Card and there was no indication that Resident #38 had hearing aids.

Based on interviews, and record reviews, the facility failed to ensure that the medication regimen reviews (MRRs) performed by the Consultant Pharmacist were acted upon timely for one Resident (#28) out of a total sample of 26 residents. Specifically, for Resident #28, the Attending Physician failed to document in the Resident's medical record that irregularities identified by the Consultant Pharmacist during the MRRs performed on 6/26/24 and 7/23/24 were reviewed and addressed timely.Findings include: Review of the facility policy titled Drug Regimen Review/Medication Regimen Review dated 11/17/16 and revised on 10/6/22, indicated but was not limited to the following:>Policy:-In accordance with State and Federal Regulations, the Consultant Pharmacist will review each resident's clinical chart monthly, or more frequently depending on the resident's condition and the risks for adverse consequences related to current medications. This review of the clinical chart shall be comprehensive, and findings shall be documented on the Consultant Pharmacist Review/Signature sheet in the chart (or in the electronic medical record (eMR) if applicable). -Apparent irregularities including, but not limited to, the use of any drug that meets the criteria for an unnecessary drug will be reported in writing to the Director of Nursing, Medical Director, Attending Physician, and Administrator. -The facility shall follow-up on Consultant Pharmacist recommendations to ensure all residents maintain the highest practicable level of functioning.>Purpose:-To ensure drug and medication regimen reviews are completed, received, and reviewed by appropriate personnel in a timely manner to promote positive patient outcomes and to prevent or minimize adverse consequences related to medication therapy, to the extent possible.>Procedure:-Consultant Pharmacist identified irregularities may include, but are not limited to one or more of the following: -Unnecessary drugs, which may include: .Without adequate indications for its use. -Any non-urgent recommendation(s)/irregularities must be addressed within 30 days of the consultant pharmacist monthly visit. -Outstanding recommendation(s) not resolved within the expected timeframe will be forwarded for action to the Medical Director and/or Director of Nursing.The Director of Nursing and Medical Director have 30 days to resolve any remaining (Pending/No Response) recommendations unless the Consultant Pharmacist upgrades the recommendation to an urgent clinically significant medication issue. -Clinical justification will be documented in the clinical chart if a recommendation is declined by the prescriber. Resident #28 was admitted to the facility in November 2022, with diagnoses including gastro-esophageal reflux disease (GERD) without esophagitis, anemia in chronic kidney disease, history of repeated falls, and history of rib fracture. Review of Resident #28's June 2024 through July 2025 Physician's orders indicated:-Omeprazole (proton pump inhibitor [PPI] medication to treat acid reflux) 40 milligram (mg) capsule, Delayed Release. One capsule oral twice daily at 6:00 A.M. and 4:00 P.M. Start date 11/28/23, end date 6/23/25. Review of Resident #28's Consultant Pharmacist MRRs, dated 6/26/24 and 7/23/24, indicated the following:-A medication replacement request was made by the Consultant Pharmacist.-Consultant Pharmacist Medication Recommendation:>This Resident is prescribed Omeprazole. Per package insert, this medication is not indicated for long term use. Recent studies have implicated PPIs in increased risk for falls w/fractures, vitamin B12 deficiency, hypomagnesemia, pneumonia and clostridoides difficile (C. diff) infection (bacterial infection that primarily affects the colon, often causing severe diarrhea and inflammation). >Please consider a short-term change (four to six weeks then as needed [PRN]) to a Histamine Type-2 Receptor Antagonist (H2) blocker such as Famotidine 20 mg twice daily (BID) may be an option. If no change is indicated, please note medical necessity of current therapy and potential risk versus current therapeutic benefit in Progress note.>Non-urgent medication recommendation. Must be addressed within 30 days of recommendation.-Nursing/Provider Response: Not documented. Review of Resident #28's Medication Administration Records (MARs) dated June 2024, and July 2024 indicated the Resident was administered Omeprazole 40 mg twice daily. Review of Resident #28's Pharmacist MRR dated 6/9/25, indicated the following:-A medication discontinuation request was made by the Pharmacist.--The Consultant Pharmacist MRR was the same recommendation made on 6/26/24 and 7/23/24 (12 and 11 months prior, respectively).-Nursing/Provider Response: Physician/Prescriber agreed with recommendation. Review of Resident #28's clinical record failed to indicate evidence of the Attending Physician review and response to the Consultant Pharmacist's drug regimen reviews on 6/26/24 and 7/23/24, until another drug regimen review was completed on 6/9/25 that indicated the same recommendations. During an interview on 7/22/25 at 10:17 A.M., the Director of Nursing (DON) said there was no evidence that Resident #28's 6/26/24 and 7/23/24 Pharmacist MRRs had been reviewed by the Attending Physician. The DON said the expectation was that any Pharmacy recommendations were reviewed per facility policy. During an interview on 7/22/25 at 10:25 A.M., Unit Manager (UM) #3 said the process is the DON notified the Unit Managers when Pharmacist MRRs were completed, and the Unit Managers were responsible for reviewing any recommendations made by the Consultant Pharmacist with the Provider (Attending Physician/NP/PA). UM #3 said the Provider would indicate a response to the Consultant Pharmacist's recommendations in a progress note or on the Pharmacist MRR Form, which was then uploaded into the Residents' electronic medical records (EMR). During an interview on 7/22/25 at 11:16 AM, UM #3 said there was no evidence that the Provider reviewed Resident #28's Consultant Pharmacist MRR recommendations made on 6/26/24 and 7/23/24. UM #3 said the order to administer Omeprazole was discontinued in July 2025, and the order to administer Famotidine was initiated in July 2025 (12 months and 11 months, respectively), after the original Consultant Pharmacist recommendations were made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records reviewed, the facility failed to maintain complete and accurate medical records for one Resident (#51), out of a total sample of 26 residents. Specifically, for Resident #51, the facility failed to ensure complete and accurate documentation was maintained for urinary catheter output (documentation indicating the volume of urine collected in a urinary drainage bag connected to a urinary catheter) as required. Findings include: Review of the facility policy titled Monitoring of Intake and Output (I & Os), revision date 10/30/18, indicated the following:>Procedure:-Record output amounts (in ccs [cubic centimeter]) including:*Urine-Total shift and daily intake and output records>Document >Intake and output; in resident's medical record Resident #51 was admitted to the facility in July 2025 with diagnoses including Neurologic Neglect Syndrome, Urine Retention, and history of Cerebral Infarction (Stroke). Review of Resident #51's July 2025 Physician's Orders indicated the following order:-Foley catheter continuous.start date of 7/10/25. Review of the Nursing assessment dated [DATE], indicated the Resident #51 had a Foley Catheter. Review of Resident #51's Care Plan titled Urinary Catheter, date of 7/11/25, indicated the following interventions:-Empty [urinary] drainage/collection bag every shift, document output, effective date 7/11/25. On 7/17/25 at 11:20 A.M., the surveyor observed Resident #51 lying in bed, with his/her foley catheter tubing visible at the side of the bed. The surveyor further observed the urinary catheter bag was contained in a privacy bag hanging on the side of the Resident's bed. Review of Resident 51's Urinary Review by Day Report, from 7/10/25 through 7/17/25, indicated no documentation of urine output:-during the day shift (7:00 A.M. to 3:00 P.M.) on 7/12/25 and 7/14/25 -during the night shift (11:00 P.M. to 7:00 A.M.) from 7/10/25 through 7/16/25. During an interview on 7/17/25 at 11:46 A.M., Nurse #7 said urine output for residents with urinary catheters was recorded at the end of each shift or when a urinary catheter bag was emptied. Nurse #7 said documentation should be maintained on each shift for total urine output and recorded in the electronic medical record. Nurse #7 further said either the Certified Nurses' Aides, or the Nurse can record the Resident's urine output. During an interview on 7/17/25 at 12:15 P.M., the surveyor and Unit Manager (UM) #1 reviewed Resident #51's Urinary Review by Day Report. UM #1 said Resident #51's urine output documentation was incomplete, and staff should be recording the Resident's total urine output each shift. UM #1 said it was important for staff to document urine output for the Resident so staff could watch for urinary retention, and without this documentation staff could not be sure what the Resident's current output was on the days with no documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility failed to ensure infection control practices for cleaning medical equipment was maintained to prevent the potential spread of infection within the facility on two Units (100s and 400s), out of four units observed. Specifically, 1. On the 100s Unit, the facility failed to ensure staff cleaned and disinfected the portable vital signs machine (medical device that takes temperature, blood pressure, and blood oxygen readings) in between resident use. 2. On the 400s Unit, the facility failed to ensure that staff disinfected the glucometer machine while performing finger sticks, and portable vital signs machine in between residents, increasing the risk for the potential spread of infection between residents.Findings include: 1a. Review of the facility policy titled Policy for Environmental Surface Cleaning, approved 12/22/16, indicated the following: -PDI Super Sani Plus (type of disinfecting wipe)…should be used by nursing staff to clean all equipment used by multiple residents. This includes…thermometers, blood pressure cuffs…pulse oximetry monitoring… On 7/16/25 from 7:47 A.M. to 7:53 A.M., the surveyor observed the following on the 100’s unit: -Certified Nurses Aide (CNA) #2 obtained the vital signs of the resident in room [ROOM NUMBER]. -CNA #2 exited room [ROOM NUMBER], entered room [ROOM NUMBER], and obtained the vital signs of the resident in room [ROOM NUMBER]. - CNA #2 exited room [ROOM NUMBER], entered room [ROOM NUMBER], and obtained the vitals of the resident in room [ROOM NUMBER]. -CNA #2 exited room [ROOM NUMBER] and began to enter room [ROOM NUMBER], at which time the surveyor intervened after observing CNA #2 did not disinfect the vital signs machine after each use. During an interview immediately following the observation, CNA #2 said she was taking vital signs from residents and that included taking blood pressures, checking temperatures, and obtaining oxygen saturations. CNA #2 said she only cleaned the vital signs machine after she was done with obtaining all of the resident's vitals and was not cleaning and disinfecting the vital sign machine between residents. 1b. On 7/16/25 from 8:12 A.M. to 8:18 A.M., the surveyor observed the following on the 100’s unit: -CNA #3 obtained the vital signs of the resident in room [ROOM NUMBER]. -CNA #3 exited room [ROOM NUMBER], entered room [ROOM NUMBER], and obtained the vital signs of the resident in room [ROOM NUMBER]. -CNA #3 exited room [ROOM NUMBER], entered room [ROOM NUMBER], and obtained the vitals of the resident in room [ROOM NUMBER]. -CNA# 3 did not disinfect the vital signs machine after each resident use. During an interview immediately following the observations, CNA #3 said she was taking vital signs from residents and that included taking blood pressures, checking temperatures, and obtaining oxygen saturations. CNA #3 said she was supposed to clean the vital signs machine between residents, but she had not cleaned the vital signs machine between taking vitals from the residents who resided in rooms [ROOM NUMBER]. CNA #3 said it was important to clean the vital signs machine between residents as it helped to reduce the spread of infection. During an interview on 7/17/25 at 1:27 P.M., the Infection Preventionist (IP) said the vital signs machines should be cleaned between patients to reduce the risk for spreading infection. 2. Review of the facility policy titled Blood Glucose Meter Cleaning and Disinfection, revised 8/3/20, indicated: -Shared blood glucose meters are disinfected after every resident use per manufacturer instructions to prevent carry-over transmission of Bloodborne pathogens and infectious agents. Review of the Assure Prism Blood Glucose Monitoring System for multiple patient use, user instruction manual provided by the facility indicated: >Cleaning and Disinfecting Procedures: -Clorox Healthcare Bleach Germicidal Wipes, Super Sani-Cloth Germicidal Wipes: -Cleaning 1.Wear appropriate protective gear such as disposable gloves. 2.Open the cap of the disinfectant container and pull out one towelette and close the cap. 3.Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using one towelette to clean blood and other body fluids. 4.Dispose of the used towelette in a trash bin. 5.Pull out one new towelette and wipe the entire surface of the meter three times horizontally and three times vertically using a new towelette to remove blood borne pathogens. 6.Dispose of the used towelette in a trash bin. 7.Allow exteriors to remain wet for the corresponding contact time for each disinfectant. 8.After disinfection, the user’s gloves should be removed to be thrown away and hands washed before proceeding to the next patient. On 7/16/25 at 8:08 A.M., the surveyor observed Nurse #2 obtain a resident’s blood pressure with the portable vital sign machine. The resident was observed to be on Enhanced Barrier Precaution (EBP). Nurse #2 exited the room after obtaining the vital signs and left the vital signs machine in the hallway. Nurse #2 was not observed disinfecting the vital signs machine, the blood pressure cuff or pulse oximeter finger probe. On 7/16/25 at 9:10 A.M., the surveyor observed Nurse #2 pull the vital signs machine into another resident’s room and closed the door. Nurse #2 came out of the room and left the vital signs machine in the hallway. During an interview at the same time, Nurse #2 said she did not have any cleaning wipes on her medication cart and that the vital signs machine should have been disinfected before and after each use but was not. On 7/16/25 at 3:59 P.M., the surveyor observed Nurse #1 entering and exiting three individual residents’ rooms with a glucometer machine. On 7/16/25 at 4:17 P.M., the surveyor observed Nurse #1 check a resident's blood sugar via finger stick using a glucometer machine who was seated in the common area across from the Fourth-floor nursing station. Nurse #1 was observed with gloves on and after checking the resident’s blood sugar, placed the glucometer machine back in the medication cart, removed his gloves and sanitized his hands. During an interview on 7/16/25 at 4:21 P.M., Nurse #1 said the cleaning agent for the glucometer machine was a hand sanitizer. Nurse #1 said he had checked four residents’ blood sugar but had forgotten to clean and disinfect the glucometer machine in between all four residents. During an interview on 7/16/25 at 4:33 P.M., Unit Manager (UM) #2 said the cleaning agent for the glucometer machine was Super Sani-Cloth Germicidal Wipes, that was available at the nurses station. During an interview on 7/18/25 at 1:53 P.M., the Infection Prevention Nurse (IP) said Nurse #1 should have cleaned the glucometer machine and the vital sign machine and equipment with the Super Sani-Cloth Germicidal Wipes and waited two minutes for dry time, but he did not.

Based on interview and record review, the facility failed to coordinate an assessment with the Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. PASRR requires that: 1) all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting]; and 3) receive the services they need in those settings) program for one Resident (#76) out of a total sample of 27 residents. Specifically, the facility failed to complete a new Level I assessment for a change in condition timely and refer Resident #76 for a Resident Review (person-centered assessment taking into account all relevant information) when he/she had a significant change in condition, a new diagnosis of Schizoaffective Disorder (serious chronic mental illness, characterized by symptoms of Schizophrenia such as hallucinations or delusions and symptoms of a mood disorder such as mania and depression) while in the facility, and was being treated with an antipsychotic (used to treat symptoms of mental illness, including delusions, fixed, false conviction in something that is not real or shared by other people) medication. Findings include: Review of the facility's policy titled Preadmission Screening and Resident Review (PASARR) last revised 9/22/23, indicated: -Ensure that Level I screen was completed for all individuals before admission or upon significant change in condition. -Make referrals to the Department of Developmental Services (DDS) and or the Department of Mental Health (DMH)/Designees in a timely manner when required. -Resident significant change, must notify the state mental health authority or state intellectual disability authority, as applicable promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability (ID) for resident review. Resident #76 was admitted to the facility in February 2023, with diagnoses including Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and Anxiety (intense, excessive, and persistent worry and fear about everyday situations). Review of Resident #76's Level I PASARR evaluation dated 2/18/23, did not indicate that the Resident had diagnosis of Schizophrenia. Review of Resident #76's Psychiatric Evaluation dated 2/8/24, indicated that the Resident had a new diagnosis of Schizoaffective Disorder. During an interview on 5/1/24 at 10:50 A.M., Social Worker (SW) #1 said Resident #76 needed a new PASRR Level I to be completed. During a follow-up interview on 5/1/24 at 11:07 A.M., SW #1 said Resident #76 had a new diagnosis of Schizoaffective Disorder on 2/8/24. SW #1 also said a new Level I PASARR should be completed, and a Resident Review should be requested from the PASARR office for Resident #76. SW #1 said the new Level I assessment had not been done, as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to communicate and implement a Physician's recommendation to start medication for one Resident (#2) out of a total sample of 27 residents. Specifically, for Resident #2, the facility failed to verify the ordered dosage and frequency and appropriately communicate the Physician recommendation of Tylenol medication for pain management for the Resident, resulting in potential delay in treatment. Findings include: Resident #2 was admitted to the facility in October 2019 with the following diagnoses: Vascular Dementia (dementia resulting from impaired blood flow to the brain), Spinal Meningioma (a tumor in the thin membranes that cover the spinal cord), Idiopathic Peripheral Neuropathy (sensory disturbances in the limbs causing numbness, tingling, burning and/or weakness with no known cause) and Renal Mass (an undefined abnormal growth in the kidney that may or may not be cancerous). Review of Lippincott Manual of Nursing Practice - 11th Ed. (2019), Box 2-1 Common Legal Claims for Departure from Standards of Care included the following: -Failure to act as a patient advocate, such as not questioning illegible or incomplete medical orders Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE], indicated: -that the Resident was rarely/never understood -was severely cognitively impaired -had frequent physical, verbal and other behavioral symptoms Review of the Resident's Provider Progress Note dated 2/15/24, indicated that Resident #2 was noted repetitively biting his/her blanket and pulling the blanket through his/her mouth with no clear cause, and a recommendation was made to try scheduled Tylenol (medication to treat pain or fever) in the event that the Resident was experiencing pain that could not be conveyed (to caregivers). Review of the Resident's Provider Progress Note dated 4/25/24, indicated a recommendation had been given to try scheduled Tylenol for Resident #2 for a question of pain that could not be communicated (by the Resident). Review of the Resident's Physician's orders from February 2024 to May 2024 indicated no active or discontinued orders for Tylenol. Review of the Resident's Nursing Notes from February 2024 through May 2024 did not indicate any documented evidence that the Physician made a recommendation for scheduled Tylenol. On 5/1/24 at 3:54 P.M., the surveyor observed Resident #2 lying in bed, chewing on his/her blanket, then removing the blanket from his/her mouth and making grunting repetitive noises. On 5/3/24 at 10:55 A.M., the surveyor observed Resident #2 lying in bed fidgeting with the bedsheet. On 5/3/24 at 3:07 P.M., the surveyor observed the Resident lying in bed fidgeting with his/her blankets. On 5/7/24 at 8:06 A.M., the surveyor observed the Resident lying in bed, and grinding his/her teeth. During an interview on 5/7/24 at 9:47 A.M., Certified Nurses Aide (CNA) #6 said she had provided the Resident with a blanket with a device on it used for excessive chewing. CNA #6 said that the Resident did not use the blanket and instead continued to use his/her sheet or shirt to bite on repetitively. During an interview on 5/7/24 at 10:32 A.M., Nurse #8 said that he was familiar with Resident #2 and his/her care. Nurse #8 said when the Resident's Primary Care Physician (Physician #1) communicates with the nursing staff related to obtaining orders, she does not provide written orders, but relays the orders verbally to the nursing staff. Nurse #8 further said that Physician #1's visit progress notes were sometimes faxed to the facility, but orders were given verbally. During an interview on 5/7/24 at 3:59 P.M., Unit Manager (UM) #2 said typically when Physician #1 was in the facility, she sees the Resident, asks questions of the nursing staff if needed, then leaves and calls facility staff later in the day if there were orders or recommendations to implement. UM #2 said she could not say if Physician #1's recommendation to start scheduled Tylenol for Resident #2 was addressed. UM #2 said that the expectation relative to obtaining Physician orders was that the Nurse who received the order would enter the order into the Resident's medical record, and then would write a progress note indicating that a new order for the Resident was received. The surveyor and UM #2 reviewed Physician #1's Progress Note dated 2/15/24. UM #2 said that typically Physician #1's progress notes were sent to the facility 1-2 days after the visits, and upon receiving the Physician's notes, she would review them for recommendation/orders. UM #2 further said the Physician's Note dated 2/15/24 was not in the Resident's medical record, and if she had seen this specific note, she would have entered an order for Tylenol for Resident #2. During an interview on 5/7/24 at 4:11 P.M., the Director of Nurses (DON) said the recommendation for scheduled Tylenol referenced in Physician #1's Progress Note dated 2/15/24, she would expect the Nurse to clarify with Physician #1 or the on-call Provider the dose and the frequency of the scheduled Tylenol medication recommended for Resident #2. The DON said the dose and the frequency information was not included in the Physician recommendation therefore was not a complete order. The DON said the Nurse would be expected to document the clarification communication with Physician #1 in Resident #2's Nurses Progress Notes.

Based on observation, interview, record and policy review, the facility failed to ensure that Physician's orders were implemented for one Resident (#10), of seven applicable residents identified with pressure ulcers (injury to underlying tissue resulting from prolonged pressure on the skin), out of a total sample of 27 residents. Specifically, the facility failed to ensure that the Physician orders for the setting of a pressure reducing mattress (air mattress) was implemented for Resident #10, who had an existing pressure ulcer and remained bedbound (confined in bed). Findings include: Review of the Operation Manual for the Relief Alternating Pressure System with Low Air Loss, undated and provided by the facility, included the following: -the alternating pressure system with low air loss was designed to treat and prevent wounds by facilitating blood circulation and decreasing pressure of each tissue's contact area. -Always consult the Physician before using the mattress system. -Press the weight button to adjust the patient's weight from 100 pounds (lbs.) to 325 lbs. according to the patient's weight. Resident #10 was admitted to the facility in May 2022, with diagnoses including Dementia (progressive or persistent loss of intellectual functioning and memory) and Protein Calorie Malnutrition (state of inadequate intake of food including protein, calories and other essential nutrients). Review of the Minimum Data Set (MDS) Assessment, dated 1/3/24, indicated the following: -Resident #10 exhibited moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 9 out of a possible 15 -Required partial/moderate assistance from staff with rolling left/right -Required substantial/maximum assistance from staff with transfers -Was at risk for pressure ulcers -had a pressure-reducing device for the bed Review of the Potential for Skin Breakdown Care Plan, initiated 6/13/22, included the following intervention: -air mattress in place, initiated 3/13/24 Review of the Initial Skin Observation Record, dated 2/8/24, indicated Resident #10 had a Stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed or an intact or open/ruptured blister) present on his/her coccyx (small triangular bone at the base of the spinal column). Review of the May 2024 Physician's orders included the following: -Air Mattress every shift, ensure inflation and correct setting every shift. Setting at 100 (lbs.) based on weight and manufacturers' recommendations, initiated 3/13/24 Review of the Treatment Administration Record (TAR) from 4/1/24 through 5/6/24 indicated the Resident's air mattress inflation was checked by the nursing staff and was at the correct setting (100 lbs) every shift. On 4/30/24 at 10:12 A.M., the surveyor observed Resident #10 lying in bed with his/her eyes closed. The surveyor observed that an air mattress was in place and was set to 325 lbs. The sticker observed on the top of the air mattress pump box indicated the setting was to be 100 lbs. On 5/2/24 at 9:22 A.M., the surveyor observed the Resident lying in bed on his/her right side with eyes closed. The surveyor observed that an air mattress was in place and set to 325 lbs. On 5/3/24 at 7:37 A.M., the surveyor observed Resident #10 lying in bed with eyes closed. The air mattress was observed set to 325 lbs. Certified Nurses Aide (CNA) #5 entered the Resident's room during the surveyor observation. During an interview at the time, CNA #5 said that she worked with Resident #10 frequently and was very familiar with his/her care. CNA #5 said the Resident required total assistance from staff, did not typically get out of bed and that his/her family had requested to keep the Resident comfortable and allow him/her to sleep. CNA #5 said Resident #10 spent most of the time in bed sleeping. The surveyor and CNA #5 reviewed the Resident's air mattress setting at this time. CNA #5 said that it was set to 325 lbs. and should be at 100 lbs. per the sticker on the air mattress pump box. CNA #5 said the Nurses would be monitoring the setting of the air mattress to ensure it was at the correct setting, she was not sure why it was set incorrectly and would relay the observation to the Nurse. During an interview on 5/7/24 at 11:29 A.M., Nurse #5 said Resident #10's air mattress was monitored by the nursing staff every shift to ensure that it was set at the correct setting according to what was specified in the Physician's orders and determined by the Resident's weight. Nurse #5 said Resident #10 was ordered to be set at 100 lbs. The surveyor relayed previous observations of the Resident's air mattress set to 325 lbs., and Nurse # 5 said that it should not have been set to 325 lbs. because there was a Physician's order for the air mattress to be set at 100 lbs. During an interview on 5/7/24 at 1:44 P.M., Unit Manager (UM) #2 said Resident #10's air mattress was determined by his/her weight. UM #2 said that stickers were added to the air mattress pump box to remind staff of what the air mattress setting should be set at. UM #2 further said that the nursing staff were responsible for ensuring that the Resident's air mattress was set to the correct settings as ordered by the Physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to provide an environment that was free of potential accidents and hazards for one Resident (#384), out of a total sample of 27 residents. Specifically, for Resident #384, the facility staff allowed the Resident to smoke in an undesignated area on the sidewalk in front of the building without any smoking safety equipment available for use in the event of an accidental fire in the vicinity. Findings include: Review of the facility's policy titled Resident Smoking, last revised 7/15/22, indicated the following: -The facility strived to maintain a safe, injury-free environment while respecting those residents who have expressed a desire to smoke. -Smoking is allowed only in designated locations to be determined in collaboration with the facility leadership and local fire chief. -Educate staff regarding the facility's smoking policy, designated smoking location and smoking schedule. -Adaptive equipment (cigarette holder, etc.) will be provided for the residents. -Protective equipment will be provided in the designated smoking location: fire blanket, safety ashtrays, fire extinguisher . Resident #384 was admitted to the facility in April 2024 with diagnoses including Malignant Neoplasm of the brain (brain cancer), Cerebral Infarction (stroke: damage to tissues in the brain caused by blood clots, disrupted blood supply and restricted oxygen supply to the specific area) and weakness. Review of Resident #384's Smoking assessment dated [DATE], indicated the Resident lacked adequate judgment towards his/her ability to smoke safely and that the Resident's Responsible Party accompanied when he/she went to smoke. Review of the Nursing Progress Note dated 4/26/24 at 4:57 P.M., indicated that Resident #384 would be allowed to smoke with family members outside of the facility. On 4/30/24 at 1:23 P.M., the surveyor observed Resident #384 seated in a wheelchair smoking on the sidewalk in front of the building with the Resident's Responsible Party holding an umbrella over his/her head while he/she was smoking. On 5/1/24 at 2:24 P.M., the surveyor observed Resident #384 seated in a wheelchair smoking on the sidewalk in front of the building with the Resident's Responsible Party by his/her side. During an interview on 5/7/24 at 12:59 P.M., Unit Manager (UM) #3 said Resident #384 smoked on the sidewalk in front of the building. UM #3 further said there was no fire extinguisher, fire blanket or ash tray/receptacle in the location where the Resident was smoking. During an interview on 5/7/24 at 1:05 P.M., with UM #3, Resident #384 and his/her Responsible Party, the Resident and his/her Responsible Party said the facility staff had never informed them of the smoking area until today (5/7/24), when the Hospice Nurse educated them about utilizing the gazebo (a designated smoking area) away from the front of the building. During an interview on 5/7/24 at 2:09 P.M., Nurse #3 said Resident #384 had been observed smoking on the sidewalk in the front of the building. Nurse #3 said that she had provided the Resident with a smoking apron for safety, but there was no fire extinguisher or any other safety equipment in that location because the sidewalk was not a designated smoking area. During an interview on 5/7/24 at 2:21 P.M., the Administrator said the sidewalk in front of the building was not a designated smoking area. The Administrator said she had observed Resident #384 seated in that area but had not been made aware that the Resident had been smoking in the same area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record and policy review, the facility failed to ensure that Enhanced Barrier Precautions (EBP- targeted gown and glove use during high contact resident care activities, designed to reduce transmission of infections) were adhered to for three Residents (#12, #17, #42), of five applicable residents, out of a total sample of 27 residents, to prevent the spread of infections. Specifically, the facility staff failed to: 1. For Resident #12, ensure that the required personal protective equipment (PPE) was worn when providing high contact wound care when the Resident was identified as being on EBP. 2. For Resident #17, ensure the required PPE was worn when assisting the Resident with toileting activities. 3. For Resident #42, ensure the required PPE was worn when assisting the Resident with repositioning when in bed. Findings include: Review of the facility policy titled Enhanced Barrier Precautions, dated 1/10/23, indicated: Enhanced Barrier Precautions will be used in these conditions: -Residents with an infection or colonization with Multi Drug Resistant Organism (MDRO - organism that is resistant to one or more classes of antimicrobial agents) when they do not need to be on Contact Precautions. -All Residents on the unit with indwelling medical devices, example central line, urinary catheter, feeding tube, . -All Residents on the unit with wounds. -Enhanced Barrier Precautions (EBP) require gowns and gloves for all high contact care with examples like dressing, bathing/showering, transferring, providing hygiene, changing linens, device care or use such as central line, urinary catheter, feeding tube, wound care. 1. Resident #12 was admitted to the facility in February 2024 with diagnoses including Osteomyelitis (inflammation of bone or bone marrow due to infection) and open leg wound. Review of Resident #12's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of total possible 15. Further review of the MDS Assessment indicated Resident #12 had an infection of the foot and diabetic foot ulcers (an open sore or wound that is commonly located on the bottom of the foot and occurs in patients with Diabetes). On 5/3/24 at 11:12 A.M., the surveyor observed an EBP sign outside of Resident #12's room. The surveyor observed Nurse #9 performing a leg wound dressing on Resident #12 and Nurse #9 was kneeling on the floor while she performed the leg wound dressing change. Nurse #9 did not don (put on) a gown to perform the leg wound dressing procedure. The surveyor observed that Nurse #9 stood up after completing the Resident's wound dressing, removed her gloves, and walked out of the Resident's room. During an interview on 5/3/24 at 11:18 A.M., Nurse #9 said the EBP sign did not apply to Resident #12. The surveyor and Nurse #9 reviewed the EBP sign outside Resident #12's door and Nurse #9 said she should have worn a gown when she provided the wound care for the Resident, but she did not. 2. Resident #17 was admitted to the facility August 2018, with diagnoses including Cerebral Infarction (Stroke: damage to tissues in the brain caused by blood clots, disrupted blood supply and restricted oxygen supply to the specific area) with left-sided hemiparesis (paralysis on one side) and resided on Unit Four. Review of the MDS assessment dated [DATE], indicated Resident #17 was severely cognitively impaired as evidenced by staff interview and had a Stage 3 Pressure Ulcer (full thickness tissue loss where subcutaneous fat may be visible) and an unstageable Pressure Ulcer (full-thickness pressure injury in which the wound base is obscured by slough [yellow/white material in the wound bed] and/or eschar [dead tissue that eventually sloughs off healthy skin after an injury]) present. Review of the May 2024 Physician's orders included the following: -Left heel wound . -Coccyx (triangular bone at the base of the spine) wound . On 4/30/24 at 10:03 A.M., the surveyor observed Resident #17 lying in bed with eyes closed. The surveyor observed that EBP signage was posted outside of the Resident's room door and a PPE bin was observed outside of the room and contained gowns and gloves. On 5/2/24 at 9:13 A.M., the surveyor observed Resident #17 awake, lying in bed and leaning against the side rail. The surveyor observed that EBP signage was posted outside of the Resident's room door. During an interview at the time, Resident #17 said he/she was not comfortable with his/her current position in bed. The surveyor relayed to facility staff that the Resident said he/she was not comfortable with their current position in bed. The surveyor observed Certified Nurses Aide (CNA) #4 and Nurse #5 enter the Resident's room shortly after, don gloves (but did not a gown) and assisted Resident #17 with repositioning in his/her bed by using a sheet positioned under the Resident. After the Resident was repositioned, CNA #4 and Nurse #5 removed their gloves, performed hand hygiene and exited the room. During an interview on 5/7/24 at 11:33 A.M., Nurse #5 said that Resident #17 was on EBP because he/she had wounds. Nurse #5 said that anytime direct care was provided to the Resident, a gown and gloves were required to be worn. Nurse #5 further said that repositioning in bed would be considered direct care and when she and CNA #4 assisted the Resident with repositioning, gowns should have been worn. During an interview on 5/7/24 at 1:34 P.M., Unit Manager (UM) #2 said facility staff were required to wear a gown in addition to gloves when repositioning Resident #17 in bed, because repositioning would be considered direct care. 3. Resident #42 was admitted to the facility in February 2024, with a diagnosis including Protein Calorie Malnutrition (state of inadequate intake of food, such as protein, calories or other essential nutrients) and resided on Unit Four. Review of the MDS assessment dated [DATE], indicated Resident #42 had moderate cognitive impairment as evidenced by a BIMS score of 10 out of 15, and was at risk for pressure ulcers. Review of the May 2024 Physician's orders included the following: -Left buttock day and night; >cleanse area gently with Normal Saline (mixture of sodium chloride and water) 30 milliliter (ml) and pat dry, >do not remove previous layer of triad (sterile coating used on broken skin to protect from incontinence [inability to control the flow of urine from the bladder] that could adhere to wet skin) present. >Reapply triad over layer present - leave open to air, initiated 4/28/24 On 5/2/24 at 3:44 P.M., the surveyor observed Resident #42 lying in bed with his/her call light initiated. The surveyor observed an EBP sign was posted outside of the Resident's room and a PPE bin was observed near the outside of the room door which contained gloves and gowns. The surveyor observed CNA #10 enter the Resident's room, don gloves (but did not don a gown) and assisted Resident #42 out of bed, into a wheelchair and then into the bathroom. At 3:50 P.M., the surveyor observed CNA #10 exiting the Resident's room after removing her gloves and completing hand hygiene. During an interview on 5/2/24 at 3:52 P.M., CNA #10 said that she was regular staff at the facility and knew Resident #42 very well. CNA #10 said the Resident required assistance with dressing, transfers, and personal hygiene and when assisting the Resident with these tasks, she would wear gloves. The surveyor and CNA #10 reviewed the EBP signage posted outside of the Resident's room, and CNA #10 said Resident #42 currently had an open area so she should have also worn a gown when providing transfer and toileting assistance, but did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #4 was admitted to the facility in April 2023 with diagnoses including Cerebral Infarction (stroke: damage to tissues in the brain caused by blood clots, disrupted blood supply and restricted oxygen supply to the specific area) and Hyperlipidemia (elevated cholesterol in the blood) and resided on Unit Three. Review of Resident #4's MDS assessment dated [DATE], indicated the Resident had moderate cognitive impairment as evidenced by a BIMS score of 12 out of total possible 15. During an interview on 4/30/24 at 2:00 P.M., Resident #4 said that most of the time, the facility staff failed to provide him/her with coffee for his/her meals. During an interview on 5/2/24 at 12:55 P.M., Resident #4 said that he/she did not get coffee for his/her breakfast and lunch. Resident #4 further said that he/she had just finished eating his/her lunch. On 5/2/24 at 12:58 P.M., the surveyor observed CNA #8 walking in the hallway on Unit Three with the coffee/tea/hot chocolate beverage cart. The surveyor observed that CNA #8 went from room to room and passed coffee to the residents. During an interview at the time, CNA #8 said the residents had finished eating but the coffee/tea/hot chocolate beverages had not been passed with the lunch trays. CNA #8 said the facility staff were supposed to serve the coffee/tea/hot chocolate before the residents received their meal tray but this was not done. During an interview on 5/2/24 at 3:13 P.M., Unit Manager (UM) #3 said the coffee/tea/beverage cart should be served before the residents received their meals. During an interview on 5/2/24 at 3:36 P.M., the DON said that coffee/tea/hot chocolate beverages were served before the residents received their meals. On 5/7/24 at 8:50 A.M., the surveyor observed Resident #4 having breakfast in his/her room. The surveyor observed there was orange juice in a cup on the Resident's breakfast tray. Resident #4 said that he/she had asked for his/her coffee when the breakfast tray was delivered and was told the coffee would be delivered. On 5/7/24 at 9:04 A.M., the surveyor observed CNA #3 enter Resident #4's room and pick up and take away the Resident's meal tray. During an interview on 5/7/24 at 9:10 A.M., CNA #9 said there was not enough coffee mugs to finish the coffee/tea/hot chocolate beverage pass and that she could not serve Resident #4 his/her coffee and had informed Nurse #4. During an interview on 5/7/24 at 9:15 A.M., Nurse #4 said she had called down to the kitchen for coffee mugs but did not think Resident #4 drank coffee. Nurse #4 said she went and spoke with Resident #4 and said he/she had been waiting for coffee but never received it. Based on observation, interview and record review, the facility failed to ensure a homelike environment was provided relative to dining for two Residents (#44 and #4) out of a total sample of 27 residents, on two of four units observed (Unit Three and Unit Four). Specifically, the facility failed to ensure: 1. -For Resident #44, that meals were provided timely when he/she was dining with other residents and that blood sugar (glucose) checks were not completed in the dining room. -that residents seated together in a dining area, were served their meals at the same time. 2. For Resident #4, that the Resident's preference for beverages was provided timely with meals. Findings include: 1. Resident #44 was admitted to the facility in February 2023 with diagnoses including Encephalopathy (disease in which the functioning of the brain is affected by some agent or condition such as a viral infection of toxins in the blood), Dementia with agitation (progressive or persistent loss of intellectual functioning and memory) and Type 2 Diabetes Mellitus (DM II: condition in which the body has difficulty controlling blood sugar [glucose] levels in the blood), and resided on Unit Four. Review of the Minimum Data Set (MDS) Assessment, dated 3/5/24, indicated Resident #44: -was severely cognitively impaired as evidenced by a Brief Interview of Mental Status (BIMS) score of 0 out of possible 15. -had upper and lower bilateral range of motion deficits. -required substantial/maximum assistance with eating. Review of the May 2024 Physician's orders included the following: -Check blood glucose levels with meals, initiated 4/17/24. On 5/1/24 at 12:13 P.M., the surveyor observed Resident #44 seated at a table in the small dining area located on Unit Four with two other residents. The lunch meals were observed on a rack positioned in the hallway and the facility staff were observed passing meal trays. One of the residents seated with Resident #44 was provided with his/her meal, was assisted with set up by the staff and was observed to feed him/herself. Resident #44 and the other resident seated at the table were not provided with their lunch meals. At 12:18 P.M., Resident #44 was provided with his/her lunch meal. The surveyor observed Nurse #6 who was already wearing gloves, approach Resident #44 at this time, and informed the Resident that he/she needed to have a blood sugar check. Resident #44 had his/her lunch tray (which was covered) and was seated with two tablemates, one resident who was eating and the other resident who was still not provided a lunch meal. Nurse #6 was observed to obtain Resident #44's blood sugar reading using a glucometer (device used to measure the concentration of glucose in the blood). After obtaining the blood sugar reading, Nurse #6 said she was going to get some Insulin (medication used to regulate glucose level in the blood) to administer to the Resident. At 12:21 P.M., Nurse #6 returned to the dining room where Resident #44 remained seated with his/her tablemates who were eating lunch, holding a syringe containing Insulin. Resident #44's tray remained covered and was positioned in front of him/her. Nurse #6 told Resident #44 that his/her blood sugar was high and that he/she required Insulin prior to lunch. The Resident was observed refusing to have his/her Insulin administered at this time, was crying and said that he/she wanted to go home. Nurse #5, who was seated next to Resident #44 was observed to comfort him/her, uncover his/her lunch meal and encouraged the Resident to eat and offered assistance. At 12:33 P.M., (20 minutes later) the resident who was seated with Resident #44 was provided with his/her meal and was assisted by facility staff. On 5/2/24 at 12:14 P.M., the surveyor observed the lunch meal distribution on Unit Four. At 12:24 P.M., five residents were observed in the small dining room on the Unit, and Resident #44 was observed seated at a small table with three other residents. One of the residents seated with Resident #44 had his/her lunch meal and was observed to be eating. At 12:27 P.M., lunch trays were provided to Resident #44 and the remaining two residents seated at the table. Resident #44's tray was observed to be positioned in front of him/her and was covered. At 12:38 P.M., (14 minutes later), Nurse #5 was observed to sit next to Resident #44, uncover the lunch tray, and assist him/her with the lunch meal. During an interview on 5/3/24 at 3:28 P.M., Nurse #6 said that she was very familiar with Resident #44 and had provided care to him/her for about a year. Nurse #6 said Resident #44 was diabetic and required blood sugar checks before each meal. When the surveyor asked about the procedure for obtaining blood glucose levels, Nurse #6 said that she would approach the Resident, explain the procedure, conduct hand hygiene, put on gloves, and then proceed with checking the blood glucose level and administration of insulin. Nurse #6 said that this procedure should occur in the Resident's room to provide privacy. Nurse #6 said she should not have checked the Resident's blood glucose when he/she was seated in the dining room with other residents during the lunch meal on 5/1/24 and should have assisted the Resident back to his/her room to complete the task. During an interview on 5/7/24 at 1:40 P.M., the surveyor relayed the mealtime observations of Resident #44 to Unit Manager (UM) #2, who said that the Resident's blood glucose should be checked prior to the meal. UM #2 said the procedure should be completed in a private area, like the Resident's room and not when the Resident was seated at the dining room table with others who were eating. During an interview on 5/7/24 at 2:30 P.M., Certified Nurses Aide (CNA) #4 said that residents who eat in the dining room on Unit Four required assistance with their meals. CNA #4 said that the residents should not receive their meals unless there was staff there to assist them and that the residents should be served and assisted at the same time if seated together at a table. CNA #4 said that residents should not be seated at a table without a meal or without assistance and watching other residents eat. CNA #4 further said that trays are provided when serving residents their meals in the dining room, that staff do not offer to remove the meals from the trays. CNA #4 said he was not sure why staff do not offer to remove the meals from the trays because for other places he had worked, the staff have removed the trays because it provided a good dining experience. During an interview on 5/7/24 at 3:44 P.M., the Food Service Director (FSD) said that the facility had one dining area located on each unit where residents dine together, but there had not been a large communal dining area since he started in February 2022. The FSD said that residents either eat in their rooms or in the small dining rooms located on each unit. The FSD said he was not a part of the communal dining experience on the units, did not have a part in the dining experience once the food left the kitchen and thought that the unit staff were the ones overseeing the communal dining experience, but that he would like to be a part of the process. The surveyor requested the facility policy relative to the dining experience from the FSD at that time. During a follow-up interview on 5/7/24 at 3:46 P.M., the FSD said the facility did not have a policy relative to the resident dining experience. During an interview on 5/7/24 at 4:20 P.M., the Director of Nurses (DON) said that the nursing staff were responsible for assisting residents who required assistance with their meals. The DON said that residents' meals should be warm and to the residents' liking. The DON further said if residents are seated together in a dining area, they should be served at the same time. During an interview on 5/7/24 at 4:51 P.M., the surveyor relayed observations of the dining service with the Administrator. The Administrator said if meals were provided to residents, were within temperature, and there were no verbalizations from the residents that they wanted assistance with their meal, it would be reasonable to expect that residents may have to wait for their meals and/ or receive assistance with meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #9 was admitted to the facility in January 2010, with the following diagnoses: Stage 3 Pressure Ulcer of the left buttock (a wound caused by prolonged pressure usually over an area where the bone is close to the surface), Lymphedema (swelling due to a buildup of fluid when the lymph nodes do not drain properly), Type II Diabetes (DM II - condition in which the body does not produce enough insulin and has trouble controlling blood sugar levels), Depression, and Anxiety. Review of Resident's Weekly Wound Physician Progress Note dated 7/27/23 indicated, Resident #9 no longer wanted to be evaluated weekly by the Consultant Wound Physician and that wound care would be provided by nursing staff going forward due to the Resident's request. Review of Resident #9's clinical record indicated no documented evidence that Weekly Wound Assessments including the measurement of the wound were completed from 7/27/23 through 12/27/23. Review of Resident #9's Nursing Progress Notes from August 2023 through December 2023 indicated no documentation of acceptance or refusal of the Weekly Wound Assessments by the Resident. Review of Resident #9's Minimum Data Set (MDS) assessment dated [DATE], indicated that the Resident was interviewable and had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15. The surveyor attempted to interview Resident #9 on the following dates/times, but he/she refused: -4/30/24 at 11:10 A.M. -5/1/24 at 9:29 A.M. -5/2/24 at 9:14 A.M. On 5/7/24 at 8:35 A.M., the surveyor requested wound tracking or wound assessment data for Resident #9 from August 2023 through December 2023 and the facility was able to provide evidence that a Weekly Wound Assessment was completed on 12/28/23. During an interview on 5/7/24 at 10:57 A.M., the Wound Nurse said she could not provide documentation that Resident #9's Weekly Wound Assessments were completed during August 2023 through December 2023, because the Resident refused to have the Weekly Wound Assessments completed. The Wound Nurse said she did not document the Resident's refusals and should have entered a Nurse's note indicating that the Resident refused the Weekly Wound Assessments. During an interview on 5/7/24 at 2:03 P.M., UM #2 said the expectation would be for the Wound Nurse to assess the Resident's wound weekly on the Weekly Wound Assessment form and if the Resident refused, this information would be relayed to the nursing staff and documented within the Resident's clinical record in a progress note. 3. Resident #384 was admitted to the facility in April 2024 with diagnoses including Malignant Neoplasm of the brain (brain cancer), Cerebral Infarction (stroke: damage to tissues in the brain caused by blood clots, disrupted blood supply and restricted oxygen supply to the specific area) and weakness. Review of Resident #384's April 2024 Physician's orders indicated: -Foley catheter (also known as a urinary catheter - a medical device that drains urine from the bladder into a collection) care every shift, size 16 French (fr) with retention bulb [balloon]10 milliliters (ml), ordered 4/26/24. -Foley catheter site care every shift, ordered 4/26/24. Review of the Hospice Narrative Progress Note dated 4/26/24, indicated Resident #384 had a Foley catheter that was a size 18 Fr with 5 to 10 ml retention balloon. On 5/2/24 at 11:58 A.M., the surveyor and Nurse #3 observed Resident #384's Foley urinary catheter. The Resident's Foley catheter size was observed to be 18 Fr with 5 to 10 ml balloon. During an interview at the time, Nurse #3 said Resident #384's Foley catheter size did not match the Physician's order in the Resident's record, that was initiated 4/26/24. Based on observation, interview and record review the facility failed to ensure they maintained an accurate and complete medical record for five Residents (#53, #99, #384, #42 and #9) out of a total sample of 27 residents. Specifically, the facility staff failed to: 1. For Resident #53, accurately document the Resident's status regarding being transferred to the hospital and returning to the facility after a blood transfusion. 2. For Resident #99, accurately document, and obtain the correct consent and Physician order for the specific type of side rails being utilized by the Resident. 3. For Resident #384, ensure that the indwelling Foley urinary catheter size accurately reflected the Physician ordered size Foley catheter. 4. For Resident #42, accurately document a dental procedure that was performed, and rationale for a prescribed antibiotic that was being administered to the Resident. 5. For Resident #9, document the Resident's refusals to have weekly wound measurements completed. Findings include: Review of the facility policy titled Documentation-Clinical, dated 10/31/23, indicated the following: -This facility meets Department of Public Health (DPH) requirement for weekly summary of resident condition by ensuring documentation of medication and treatment administration every shift, interdisciplinary progress notes as needed, skin evaluations weekly, and functional performance point of care documentation every shift. -Resident status, including change in condition, nursing or other services provided and resident response or progress will be documented as warranted. -If the condition of the resident calls for his/her transfer to an acute care facility, the date, time of admission, name of the healthcare facility and the mode of transportation surrounding the transfer will be documented in the nursing notes. 1. Resident #53 was admitted to the facility in April 2024 with the diagnosis of Congestive Heart Failure (CHF-a condition where the heart does not pump blood as well as it should, and fluid builds up in the lungs that can cause shortness of breath, in addition to arms, feet and other organs). Review of the Laboratory Blood Work Report dated 4/23/24, indicated the following: Hemoglobin (Hb: a protein in red blood cells that carries oxygen [normal level for males: 13.5 - 17.5 g/dL (grams per deciliter) and females: 11.6 - 15 g/dL] ) 5.6 - critical result. This result has been called to the facility on 4/23/24 . Hematocrit (percentage by volume of red cells in blood [normal range for males: 41 - 50 percent and females: 36 - 44%] ) 18.5 - critical result. This result has been called to the facility on 4/23/24 . Review of the Physician's Progress Note, dated 4/23/24, indicated the Resident had agreed to a blood transfusion but did not want to go to the emergency room (ER). Review of the Physician's orders dated 4/1/24 through 5/1/24, indicated the following: -Send to emergency room for blood transfusion, date initiated 4/26/24. Review of the Nurses Progress Notes dated 4/2/24 through 5/2/24 indicated no documented evidence that the Resident had received a blood transfusion as ordered by the Physician. Further review of the Medical Record indicated no documented evidence that the Resident had received a blood transfusion. During an interview on 5/3/24 at 12:39 P.M., Nurse #5 said the Resident had gone out last Saturday (4/27/24) for a blood transfusion. Nurse #5 said she was not working, but she had received this information in shift-to-shift report. Nurse #5 said the transfer for a blood transfusion should have been documented in the Nurses Progress Notes. During an interview on 5/3/24 at 1:00 P.M., Unit Manager (UM) #2 said the Resident had received the blood transfusion. UM #2 said that initially the Resident did not want to leave the facility for the transfusion but later agreed to go to the hospital. UM #2 said that the transfer to the hospital for blood transfusions and return to the facility should have been documented in the Nurses Progress Notes. UM #2 further said she would locate the documentation regarding the blood transfusion. During an interview on 5/3/24 at 2:10 P.M., UM #2 provided the surveyor with documentation faxed to the facility on 5/3/24 at 1:34 P.M., from the Hospital Medical Day Stay Unit, dated 4/27/24 indicating the Resident had received two units of packed red blood cells. UM #2 said the Nurse should have written a progress note when the Resident was transferred out of the facility. UM #2 further said the Resident should have had written progress notes that included a respiratory assessment for 48 hours after his/her return to the facility. During an interview on 5/3/24 at 2:16 P.M., the Director of Nurses (DON) said the Nurse should have written a progress note indicating the Resident had been transferred out of the facility for a blood transfusion and returned to the facility. 2. Resident #99 was admitted to the facility in October 2023 with the following diagnoses: Parkinson's Disease (a chronic and progressive disorder that affects the nervous system and causes movement problems) and Dementia (a decline in intellectual functioning, including problems with memory, reasoning and thinking). Review of the May 2024 Physician's orders indicated: -order for transfer bar side rails on side of bed, initiated on 10/2/23. Review of the admission Nursing assessment dated [DATE] indicated: - yes the Resident used side rails. -Section 1z. indicated upright (transfer bar) right side and upright (transfer bar) left side. -Other options available were full rails (right, left), half rails (right, left), quarter rails (left, right) upper, quarter rails (left, right) lower. -None of these options were selected. Review of the Quarterly Side Rail Assessments dated 1/8/24 and 4/8/24, indicated that bilateral upright (transfer bars) were in use. Review of the Side Rail Informed Consent signed by the invoked Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself) on 10/2/23 indicated the HCP consented to upright (transfer bar), right and left side. On 5/1/24 at 9:50 A.M., Resident #99 was observed lying in bed with bilateral upper and middle quarter side rails in place. During an interview on 5/1/24 at 10:37 A.M. Nurse #1 said that the Resident had a special bed with side rails, like a hospital bed. When the surveyor asked what assessments are completed for side rails use, Nurse #1 said that the UM typically would do an assessment to determine if the Resident was safe with the side rails. During an interview on 5/1/24 at 11:22 A.M., with the DON and UM #2, UM#2 said that side rail assessments are completed and documented upon admission, quarterly and annually on a UDA (User Defined Assessment). The DON said that the bars selected on the UDA assessment were called transfer bars. During an interview on 5/1/24 at 3:16 P.M., UM #1 said that she believed the bed rails that were on Resident #99's bed were quarter side rails, not transfer side rails, and that it was not documented correctly on the admission Nursing Assessment or the other assessments. UM #1 further said that the Resident has had the bed for over two year (at the hospital previously) and to the best of the facility staff's knowledge, the bed rails had never changed. UM #1 said that it was just a coding error as the Resident has had quarter side rails on the upper and middle section of his/her bed since admission and it should have been coded as bilateral upper and middle quarter side rails. During an interview on 5/1/24 at 3:51 P.M., the DON said that the facility would also have to obtain a new consent signed by the HCP that reflected the correct side rails being used on the Resident's bed as the consent that was currently on record does not reflect the correct side rails being used on Resident #99's bed. 4. Resident #42 was admitted to the facility in February 2024, with a diagnosis including Protein Calorie Malnutrition (state of inadequate intake of food including protein, calories and other essential nutrients). Review of the May 2024 Physician's orders included the following: -Keflex (an antibiotic) 500 milligrams (mg) every 8 hours daily (three times daily) for 10 days for infection, initiated 4/23/24 Review of the April 2024 and May 2024 Medication Administration Record (MARs) indicated Keflex 500 mg was administered three times daily to Resident #42 from 4/23/24 through 5/2/24, with the exception of 4/26/24 where an M was documented at 10:00 P.M. Review of the Resident's clinical record did not indicate why the Keflex medication was prescribed. During an interview on 5/3/24 at 11:10 A.M., Nurse #6 said Resident #42 was prescribed the Keflex because he/she had a root canal and had an abscess (a swollen area within the body tissue containing an accumulation of pus). During an interview on 5/3/24 at 11:34 A.M., UM #2 said that Resident #42's family member brought him/her to a dental appointment outside of the facility, the Resident had a root canal procedure and was put on antibiotics prior to the appointment and the antibiotics were continued after the appointment. The surveyor requested information pertaining to the Resident's dental appointment from UM #2 at this time. During a follow-up interview on 5/3/24 at 11:51 A.M., UM #2 said she reviewed the Resident's clinical record and was unable to find information pertaining to the Resident's dental appointment. UM #2 said there should be documentation, including nursing notes about the Resident going out to the appointment and the results of the appointment including the initiation of the antibiotics. UM #2 further said Resident #42 had an appointment on 4/23/24 and had the root canal procedure on 4/25/24. UM #2 provided the surveyor with an After Completion of Endodontic Therapy form, that was undated and initialed by the Provider, which indicated instructions for aftercare for Resident #42. Further review of the After Completion of Endodontic Therapy form included a handwritten notation that stated called Dentist, did not prescribe antibiotics. The surveyor reviewed the After Completion of Endodontic Therapy form with UM #2, and UM #2 said she was not sure what the handwritten notation meant since the Resident remained on antibiotic therapy. UM #2 said she would have to contact the dental office to follow-up since there was no information about the Resident's dental work since 4/23/24 and there should be. On 5/3/24 at 2:10 P.M., UM #2 said that she would expect to see documentation in Resident #42's clinical record about his/her dental appointments, what occurred at the appointments and any follow-up needed. UM #2 said if the Resident's family makes an appointment outside of the facility for the Resident and no paperwork was provided after the appointment, the facility staff should contact the Provider and request the information about what occurred at the appointment and follow-up instructions if applicable. UM #2 said she requested the information from Resident #42's Dentist today, but it should have been received previously. During a interview on 5/7/24 at 9:49 A.M., UM #2 said she obtained the consult sheets from the Resident's dental appointments on 4/23/24 and 4/25/24. UM #2 said the appointments were with different dental Providers, and the appointment on 4/23/24 was for the Resident's mouth abscess and the appointment on 4/25/24 was for the root canal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that its staff provided access to the call bell system that alert staff to resident needs, for one Resident (#17), out of a sample of 27 residents. Findings include: Review of a facility policy titled: Call Light, Answering, dated 5/2/05, indicated the call light should be placed within reach of the resident. Resident #17 was admitted to the facility in May 2021. Review of the Minimum Data set Assessment (MDS) dated [DATE], indicated Resident #17 scored 6 out of 15 on the Brief Interview of Mental Status (BIMS), was cognitively impaired, and required extensive assist with activities of daily living (ADLs) including transfers. During an observation on 12/13/22 at 9:56 A.M., the surveyor observed Resident #17 seated in an armchair in his/her room. The Resident's call bell was attached to the transfer rail on the bed, out the Resident's reach, approximately four feet away from where the resident was sitting. During subsequent observations on 12/15/22 at 9:01 A.M., and 10:00 A.M., and on 12/19/22 at 10:26 A.M., the surveyor observed the Resident seated in the armchair or wheelchair in the resident's room. The call bell was attached to the transfer rail on the bed approximately 4-5 feet away from the Resident, and out of the Resident's reach. Review of the Nursing Care Plan for ADLs initiated 5/16/21, indicated: call light within reach - encourage use. Review of the Communication Decline care plan, initiated 5/16/21, indicated: keep call bell and personal items within reach. Review of the Risk for Falls care plan initiated 5/16/21, indicated that the Resident was at risk for falling and to keep call bell within reach. During an interview on 12/15/22 at 10:00 A.M., Nurse #2 said that Resident #17 was capable of using the call bell. The surveyor and Nurse #2 went to the Resident's room for an observation and after viewing the position of the Resident and the call bell, Nurse #2 said that the call bell should be within the resident's reach and it was not. During an interview on 12/19/22 at 10:30 A.M., Unit Manager #2 said the Resident could use the call bell and that it should be positioned within reach of the Resident and it was not as required.

2. For Resident #36, the facility staff failed to ensure that the emergency transfer form was completed and filed after an emergency transfer to the hospital. Resident #36 was admitted to the facility in May 2014. Review of a nursing progress note dated 4/8/22, and timed 11:27 P.M., indicated: -that at 5:00 P.M., the Resident was lethargic and not responsive when name was called. -his/her Blood Sugar was 55 and glucose gel was administered. -The note further indicated that Resident #36 was transported to the hospital by ambulance at 6 P.M. Further review of the medical record indicated no documented evidence that a facility specific transfer form - an SBAR, was completed and sent with the Resident upon transfer. During an interview on 12/14/22 at 10:37 A.M., UM #1 said she was unable to locate the transfer documentation, it was not in the resident record for Resident #36's transfer to hospital on 4/8/22. She further said that the transfer documents should be available in the Resident's record and they were not as required. Based on record review and interview, the facility failed to ensure its staff completed the required transfer documentation and communicated the appropriate information to the receiving health care institution for two Residents (#117 and #36), out of a sample of 27 residents, putting the Residents at risk for complications and adverse events upon transfer to the receiving facility. Findings include: Review of the facility policy titled Admission/Transfer/Discharge Rights, last reviewed on 10/24/22, indicated the following in part: Emergency Transfer: - Complete emergency transfer form specific to facility (Situation, Background, Assessment, Recommendation) (SBAR) .if unable to complete the information, verbally communicate the necessary information and fax when complete. Information provided to the receiving provider must include at a minimum: -Special instructions or precautions for ongoing care, as appropriate. -Copy of resident discharge summary 1. Resident #117 was admitted to the facility in August 2022 with diagnoses including Acute Respiratory Failure, and Sepsis (a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues), due to Methicillin Resistant Staphylococcus Aureus (MRSA - an infection caused by a type of staph bacteria that becomes resistant to many of the antibiotics used to treat infections). Review of a nurse's note dated 10/22/22, indicated (in part) that Resident #117: - presented with drowsiness and sluggish behavior for most of the day -had a fall at approximately 6:30 P.M -continued on neurological checks related to a fall . -blood pressure 79/45 . -nurse called the on call doctor and received an order to send the Resident to the Emergency Department for an evaluation. Review of the Neurological Check Flowsheet (a monitoring system initiated after the Resident sustained a fall) dated 10/22/22, indicated the following blood pressure readings and times: 6:30 P.M. - 146/34 6:45 P.M. - 114/48 7:00 P.M. - 131/90 7:15 P.M. -79/45 (indicating a low blood pressure) Review of the clinical record did not include documented evidence of a completed SBAR or transfer summary indicating important information such as: -the basis for the transfer -contact information of the practitioner responsible for the care of the Resident -Advance Directive information -and/or any special instructions or precautions for ongoing care During an interview on 12/15/22 at 11:54 A.M., the Director of Nursing (DON) said that she was unable to locate the required documentation that should have been completed when the Resident was sent to the hospital via 911. During an interview on 12/19/22 at 8:28 A.M., Unit Manager (UM) #3 said that when a Resident is sent out via 911, the staff are supposed to complete all the required paperwork. She further said that if there was a true emergency the Emergency Medical Technicians (EMTs) may not wait for all the paperwork. She said that if that occurs, the facility staff are required to verbally provide information to the receiving facility. She further said that she expected the staff to complete all the paperwork as required and fax it to the receiving facility if they are not able to complete the necessary documentation at the time of the transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure its staff developed and implemented a comprehensive person-centered plan of care for two Residents (#89, and #103), out of a sample of 27 residents. Specifically, the facility failed to: 1. develop and implement a care plan for a Resident (#89) with Dementia, and 2. failed to implement a mood and psychotropic medication care plan for a Resident (#103) with Dementia with behavioral disturbance. Findings include: 1. For Resident #89, the facility failed to monitor mood and affect daily and also failed to develop a care plan for cognition. Resident #89 was admitted to the facility in May 2022 with a diagnosis of Parkinson's Disease. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident scored 13 out of 15 on the Brief Interview of Mental Status (BIMS), had non-Alzheimer's Dementia, and Parkinson's Disease. Review of the nursing progress notes indicated Resident with the following behaviors on the following dates: Confusion: 6/4/22 at 6:08 P.M., 6/11/22 at 10:36 P.M., 10/23/22 Hallucinations: 7/17/22 at 7:15 P.M., 9/10/22 at 6:56 A.M., Refusal of medications: 10/23/22, 11/2/22, 11/9/22 Refusal of care: 11/5/22 and 11/6/22 Review of the Trauma care plan initiated 5/12/22, indicated that nursing staff should monitor mood and affect daily. Review of the Mood care plan initiated 8/8/22, indicated that the resident should be monitored for changes in: -appetite -expressions -sleep pattern -excessive crying In addition, the Mood care plan indicated that the Resident should be assessed for any signs and symptoms of depression including: -sad affect -decreased participation -insomnia -decreased appetite -hopelessness Review of the clinical record indicated no evidence that an individualized care plan had been initiated for the Resident when diagnosed with Dementia. Further review of the clinical record indicated no documented evidence that Resident #89's mood, affect and behaviors were monitored, and there was no plan in place as to how to manage the behaviors when they occurred. During an interview on 12/15/22 at 11:48 A.M., Unit Manager (UM) #1 said that once the Resident was diagnosed with Dementia, a cognition care plan should have been initiated, an order put in place to monitor the Resident's mood and behaviors, and document them on the Treatment Administration Record, and that was not done. 2. For Resident #103, the facility failed to implement the care plan for monitoring depression and the side effects of psychotropic medication. Resident #103 was admitted to the facility in August 2022, with diagnoses including major depressive disorder and unspecified Dementia without behavioral disturbance. The diagnosis of unspecified Dementia with agitation was added on 10/1/22. Review of the Minimum Data Set Assessment (MDS) dated [DATE], indicated staff assessed the Resident as having severe cognitive impairment, and received antipsychotics and antidepressants on a routine basis. Review of the December 2022 Physician's Orders indicated the following orders: -Remeron (a medication to treat Depression)15 milligram (mg: denotes strength) tablet: give 1/2 tablet oral at 5pm for depression, order date 11/23/22 -Zyprexa (an antipsychotic used to treat mood disorders) 2.5 mg tablet for unspecified Dementia, with agitation and anxiety, order date 11/23/22 Review of the Nursing Care Plan Psychotrophic Medications, initiated 8/20/22, indicated to monitor for effectiveness, monitor for side effects and report. Review of the Nursing Care Plan for Mood initiated 8/18/22 indicated to: -monitor for expressions -sleep pattern -excessive crying In addition, the Mood care plan indicated to assess for signs and symptoms of depression including: -sad affect -insomnia -hopelessness -monitor for new onset or change in mood/behaviors Further review of the record indicated that there was no documented evidence that licensed staff had monitored the resident for side effects and behavior. During an interview on 12/19/22 at 10:30 A.M., UM #1 said that residents on psychotropic medications should be monitored for medication effectiveness and side effects, there should be an order for the monitoring and it should be documented in the electronic Treatment Administration Record (TAR) but there was no evidence that this was done as required. She further said that behavior is monitored by the Certified Nursing Assistants and they fill that out every shift, but nurses should be monitoring behaviors as well if the resident is on psychotropic medications. During a subsequent interview on 12/19/22 at 10:52 A.M., UM #1 said that there was no evidence that the Resident had been monitored for depression as per the mood care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #78 was admitted to the facility in October 2019 with a diagnosis of Psoriasis (a chronic skin condition characterized by red raised itchy and scaly patches). During an observation and interview on 12/13/22 at 8:33 A.M., Resident #78 said that he/she has had psoriasis since the age of 14 and had patches on both sides of back and elbows. Resident #78 opened the drawer of the bedside table and showed the surveyor a tube of Betamethasone Dipropionate 0.05% cream with a prescription label with the Resident's name on it. The surveyor asked Resident #78 who applied the cream to his/her rash, and the Resident said he/she applied it as needed, that sometimes he/she had the rash on his/her scalp. When the surveyor asked if the staff check his/her rash, the Resident said the staff do not need to check it. Review of the Minimum Data Set Assessment (MDS) dated [DATE], indicated the Resident scored 11 out of 15 on the Brief Interview of Mental Status (BIMS), which indicated moderate cognitive impairment, had psoriasis, and needed supervision for personal hygiene. Review of the December 2022 Physician's Orders indicated orders for Diprolene 0.05% ointment (also known as Betamethasone - a steroid cream used to treat skin conditions) apply to Psoriasis areas daily, order date 3/4/22. Review of the December 2022 Medication Administration Record (MAR) indicated nursing signed off the application of the Betamethasone cream daily. Review of the Nursing Annual Assessment Summary dated 10/4/22, indicated the Resident did not wish to administer his/her own medications. Further review of the medical record indicated no documented evidence that the Resident had been assessed for self-administration of medications. During an interview on 12/15/22 at 9:25 A.M., Unit Manager (UM) #1 said that before anyone gives themselves their own medication they have to go through a self-administration assessment and get signed off, and then, if appropriate, there has to be a Physician's order for the self-administration. During an observation and interview on 12/15/22 at 9:33 A.M., the surveyor and UM #1 went to Resident #78's room and the Resident showed UM #1 the cream kept in the bedside table. The resident said the cream was used for Psoriasis and that there was another full tube of it in his/her drawer. When asked, the Resident responded that the drawer was never locked, and he/she did not have the means to lock the drawer. After meeting with the Resident, UM#1 said prescription creams should not be stored in a resident room, there was no assessment regarding the self-administration of medications for Resident #78, nor was he/she care planned to self-administer the cream as required. During an interview on 12/19/22 at 8:58 A.M., the Director of Nurses (DON) said that only licensed personnel should apply prescription cream. The DON further said, that if a resident wanted to self-administer medication, there should be an assessment that he/she is competent to self-administer, and that should be documented in the medical record and there should be a Physician's order for self-administration in the chart. See F689 Based on observations, record review, and interviews, the facility failed to ensure its staff provided quality of care according to the plan of care, facility protocols, and professional standards of practice for two Residents (#104 and #78), out of a total sample of 27 residents. Specifically, the facility failed to ensure that a medicated cream/lotion for both Residents' #104 and #78 was applied by licensed staff only. Findings include: Review of the facility policy titled Medication Storage in the Facility dated 6/1/10 indicated the following: -Only licensed nurses, pharmacy personnel and those lawfully authorized to administer medications (such as medication aides) are allowed to access medications. -Medication rooms, carts and medication supplies are locked or attended by persons with authorized access. 1. Resident #104 was admitted to the facility in April 2021 with diagnoses including dermatitis (inflammation of the skin, typically characterized by itchiness, redness, and a rash). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview of Mental Status (BIMS) score of 14 out of 15, indicating that Resident #104 was cognitively intact. During an interview on 12/13/22 at 10:00 A.M., the surveyor observed three bottles of lotion on the Resident's over-the-bed table. The prescription label read: Triamcinolone Acetonide Lotion (a corticosteroid medication used to treat a variety of skin conditions). Resident #104 said that the medicated lotion was kept on the over-the-bed table so that the Certified Nurses Assistants (CNAs) did not have to leave the room while they were providing care, as they were the ones who put the lotion on after they completed morning care. He/she said that the medicated lotion is for his/her skin, specifically behind the ears. During an interview on 12/13/22 at 10:01 A.M., Nurse #4 and the surveyor observed the three bottles of lotion on the Resident's over-the-bed table. Nurse #4 said that the three bottles should not have been stored there. She said that the CNA's apply the medication after completing personal care for the Resident. During an interview on 12/19/22 at 8:58 A.M., the Director of Nursing (DON) said that only licensed nurses should be applying the medicated cream and the medicated cream should be kept in the medicine cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility and its staff failed to ensure that routine assessments and devices used to maintain hearing were provided for one Resident (#78), out of 27 sampled residents. Specifically, the facility staff failed to offer and encourage the use of hearing aids when Resident #78 complained of difficulty hearing. Findings include: Resident #78 was admitted to the facility in October 2019. During an observation on 12/13/22 at 8:28 A.M., the surveyor observed Resident #78 in his/her room. When the surveyor asked if she could enter the room, the Resident indicated the surveyor should come closer as he/she had a hard time hearing. The Resident said that his/her hearing is poor on his/her left side and when asked, indicated that there had not been a recent audiological (hearing) exam. During an observation and interview on 12/15/22 at 8:33 A.M., Resident #78 said he/she had a hard time hearing, had hearing aids but gave them back to the nurses because they never worked. The Resident said he/she does not know what happened to them, and had not been evaluated by the Audiologist since. The surveyor noted that the Resident asked for clarification of what was said when the surveyor was at the room doorway, but if the surveyor moved closer, the Resident was able to understand what was said and did not require clarification. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident scored 11 out of 15 on the Brief Interview of Mental Status (BIMS) which indicated moderate cognitive impairment, had minimal hearing difficulty, and no hearing aids were used during the lookback period. During an interview on 12/14/22 at 11:22 A.M., Nurse #2 said that Resident #78 kept his/her hearing aids in his/her room and uses them as he/she sees fit. Nurse #2 further said Resident #78 was his/her own person (made own decisions). Review of the clinical record indicated that the Resident's Health Care Proxy (HCP) was invoked (makes care decisions when an individual is unable to do so) on 10/21/19. Review of the audiology group assessment dated [DATE] indicated a hearing exam was completed and daily hearing aid use was recommended. There was no documented evidence that an audiology exam had been completed in 2022. Review of the Care Plan: Risk for communication decline related to cognitive status and hearing loss, dated 12/17/20 indicated that hearing aids to be applied daily with assistance from staff per resident request. Review of the December 2022 Treatment Administration Record (TAR) indicated no documented evidence that Resident was offered, and assisted to apply the hearing aids, or had refused the hearing aids. During an interview on 12/15/22 at 9:25 A.M., Unit Manager (UM) #1 said that Resident #78 hasn't had an exam since 2021. She said residents go on a rotating list for audiological exams, but that system was not working correctly, and Resident #78 dropped off the list. She further said the Resident had hearing aids in the back room (medication room) but believed that they were old. During an observation and interview on 12/15/22 at 9:33 A.M., the surveyor and UM #1 went to Resident #78's room and the Resident said that he/she did not have the hearing aids in the room and that they had been returned to the nurse as they did not work. After meeting with the Resident, UM #1 said Resident #78 should have had an order entered to assist the resident to apply hearing aids, to document the assist in the electronic Treatment Administration Record (TAR) to comply with the care plan, and there was no order and the assist was not documented as required. UM #1 went to the medication cart and with Nurse #2, located the Resident's hearing aids in the bottom drawer of the medication cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #78, facility staff failed to ensure a prescription medication was being properly stored, putting the resident and other residents at risk for inappropriate use. Resident #78 was admitted to the facility in October 2019 with a diagnosis of Psoriasis (a chronic skin condition characterized by red raised itchy and scaly patches). During an observation and interview on 12/13/22 at 8:33 A.M., Resident #78 opened the drawer of the bedside table and showed the surveyor a tube of Betamethasone Dipropionate 0.05% cream (Diprolene- a steroid cream used to treat skin conditions) with a prescription label with the Resident's name, which he/she said was kept stored in the bedside drawer. Review of the drug Betamethasone Dipropionate (Diprolene) in Nursing 2021 Drug Handbook, indicated that Diprolene was a corticosteroid and: -should be applied sparingly to prevent skin damage -should not be applied near eyes, mucous membranes, ear canal, groin or arm pits -is considered a medium to high potency drug based on it's vasoconstrictive (the narrowing of blood vessels resulting in an increase in blood pressure) properties -can cause an increase in glucose level -if used for a long time or extensively on the body, systemic absorption can occur which can cause [NAME] Syndrome (a syndrome characterized by a high level of cortisol, a hormone, caused by long term steroid use that can result in high blood sugar and diabetes, high blood pressure, weight gain, muscle weakness, fractures, excess hair growth, anxiety, depression, decreased memory, difficulty concentrating and insomnia). Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident scored 11 out of 15 on the Brief Interview of Mental Status (BIMS), which indicated moderate cognitive impairment, and needed supervision for personal hygiene. Review of the December 2022 Physician's Orders indicated orders for Diprolene 0.05% ointment (also known as Betamethasone - a steroid cream used to treat skin conditions) apply to Psoriasis areas daily, order date 3/4/22. Review of the December 2022 Medication Administration Record (MAR) indicated nursing signed off the application of the Betamethasone cream daily. Review of the Nursing Annual Assessment Summary, dated 10/04/22, indicated the Resident did not wish to administer his/her own medications. Further review of the medical record indicated no documented evidence that the Resident had been assessed for self-administration of medications. During an interview on 12/15/22 at 9:25 A.M., Unit Manager (UM) #1 said that before anyone gives themselves their own medication they have to go through a self-administration assessment and get signed off, and then, if appropriate, there has to be a Physician's order for the self-administration. During an observation and interview on 12/15/22 at 9:33 A.M., the surveyor and UM #1 went to Resident #78's room and the Resident showed UM #1 the cream kept in the bedside table. When asked, the Resident responded that the drawer was never locked, at which time UM #1 said that the medication could not be stored in the Resident's room until he/she had been assessed for self-administration and the medication could be locked in the drawer. The surveyor clarified that the top drawer of the bedside table could be locked if needed. See F684 Based on observations, policy review, and interviews, the facility and its staff failed to maintain an environment that was free from accident hazards by leaving medications at the Residents bedside, for three Residents (#8, #104 and #78), out of a sample of 27 residents. Findings include: Review of the facility policy titled Medication Storage in the Facility, dated 6/1/10, indicated the following: -Only licensed nurses, pharmacy personnel and those lawfully authorized to administer medications (such as medication aides) are allowed to access medications. Medication rooms, carts and medication supplies are locked or attended by persons with authorized access. -Except for those requiring refrigeration, medications intended for internal use are stored in a medication cart or other designated area. 1. Resident #8 was admitted to the facility in October 2021. Review of the Resident's clinical record indicated no documented evidence that he/she had been assessed to self-administer medication. During an interview on 12/13/22 at 8:35 A.M., the surveyor and Nurse #4 observed a medicine cup on the Resident's over-the-bed table, located in front of him/her, while he/she was sleeping. Nurse #4 confirmed that the medicine cup contained cough syrup and said that the cough syrup should not have been left there. She said that Resident #8 should have taken the medication at the time the nurse brought it in. She further said she should have ensured the medication was taken before she left the room and did not, as required. 2. Resident #104 was admitted to the facility in April 2021. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview of Mental Status (BIMS) score of 14 out of 15, indicating that Resident #104 was cognitively intact. During an interview on 12/13/22 at 10:00 A.M., the surveyor observed three bottles of lotion/cream on the Resident's over-the-bed table. The prescription label read: Triamcinolone Acetonide Lotion (a corticosteroid medication used to treat a variety of skin conditions). Resident #104 said that the medicated lotion was kept on the over-the-bed table so that the Certified Nurse's Assistants (CNAs) did not have to leave the room while they were providing care, as they were the ones who applied the lotion. He/she said that the medicated lotion is for his/her skin, specifically behind the ears. During an interview on 12/13/22 at 10:01 A.M., Nurse #4 and the surveyor observed the three bottles of lotion on the Resident's over-the-bed table. Nurse #4 said that the three bottles should not have been stored there. She said that all medications should be stored in the medicine cart for many different reasons; they could get old, they may need to be stored at a certain temperature, and staff may not know if the Resident received the medication, if it is left there. Nurse #4 further said that the medicated lotions should have been stored appropriately, in the locked medicine cart and they were not, as required.

Based on observation, interview, and record review, the facility failed to ensure its staff stored a feeding tube syringe (syringe used to administer a nutrition supplement into a feeding tube) per Physicians' orders and failed to store and/or dispose of unused nutrition supplement per manufacturers guidelines for one Resident (#50), out of 27 sampled residents. Findings Include: Review of the facility policy titled: Enteral Therapy Feeding Administration via Pump, Continuous Pump, Gravity Bag, and via Syringe, revised June 10, 2022, indicated the following: - .ensure feeding administration are administered per Medical Doctor orders . Review of the IsoSource (nutrition supplement used by the Resident) instructions indicated the following: -Once opened, unused portions should be tightly covered, refrigerated, and used within 24 hours. Resident #50 was admitted to the facility in February 2020 with diagnoses including Dementia, Gastrostomy status (the Resident had a Gastrostomy Tube/G-tube a tube that brings nutrients from outside the body directly into the stomach), and dysphagia (difficulty swallowing). Review of the December 2022 Physician Orders indicated the following: -Replace and Date feeding syringe daily NOC (night) with a start date of 11/29/22 On 12/13/22 at 9:50 A.M., the surveyor observed a bagged G-tube feeding syringe on the Resident's bedside table. The bag was not labeled or dated. On 12/14/22 at 3:13 P.M., the surveyor and the Director of Nursing (DON) observed an opened half used container of IsoSource on the Resident's bedside table. During the time of observation, the DON said any unused nutrition supplement that the Resident did not receive at a feed should not be stored at bedside, and should be discarded immediately after each administering the feed. On 12/15/22 at 11:52 A.M., the surveyor observed the Resident's G-tube feeding syringe bagged but again unlabeled and undated at bedside, as well as an opened half used container of IsoSource. During an interview following the observation, Nurse #6 said he should have disposed of the unused nutrition supplement instead of leaving it on the bedside table after administering it to the Resident and he did not. He further said the Resident's G-tube feeding syringe should have been labeled and dated by the night shift, and that was not done, as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility and its staff failed to ensure the attending Physician reviewed recommendations from the Behavioral Health care team to aid in treating increased anxiety and depression for one Resident's (#107), out of 27 sampled residents. Findings include: Resident #107 was admitted to the facility in October 2021 with diagnoses including Anxiety Disorder and Depressive Disorder. During an interview on 12/13/22 at 9:16 A.M., the Resident expressed feeling down and having a bout of seasonal depression, he/she further could not remember when he/she last saw Behavioral Health services, and said he/she thought he/she would like to talk to someone more about how he/she was feeling. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident scored a 14 out of 15 on the Brief Interview of Mental Status (BIMS) indicating the Resident was cognitively intact. Further review of the MDS Assessment indicated a Patient Health Questionnaire-9 (PHQ9) score of 5 out of 27 indicating mild depression and indicated the Resident expressed: - feeling down -depressed, or hopeless -had trouble sleeping -staying asleep -or sleeping too much -and felt tired or had little energy Review of the Physician Progress Note dated 11/30/22, indicated the Resident reported increased anxiety and depression at night. Further review of the note indicated the attending Physician deferred to the Behavioral Health team relative to the possibility of increasing the antianxiety medication. Review of the Behavioral Health care team's Physician's Assistant (PA) progress note dated 12/5/22, indicated a recommendation to increase the Resident's Mirtazapine (an antidepressant) at bedtime to 15 milligrams (mg) related to his/her depression/insomnia. Review of the Resident's medical record indicated the Resident did not have a Physician's order for Mirtazapine, and that it had been discontinued 4/3/22. During an interview on 12/15/22 at 10:43 A.M., Nurse #5 said the Resident had stopped taking the Mirtazapine back in April 2022. She reviewed the Behavioral Health team's recommendations and stated she would need to speak with the Unit Manager regarding the recommendations that were made. During an interview on 12/15/22 at 12:23 P.M., Unit Manager (UM) #2 said the Resident's Mirtazapine had been stopped in April 2022 related to weight gain, and that she was unsure why the PA wrote a recommendation to increase the dose when the Resident was not on Mirtazapine. She further said she could not be sure if the Resident's Physician had reviewed the Behavioral Health team's recommendation and/or why an alternate medication change had not been considered. She also said that behavioral health notes should be reviewed by the Resident's Physician within one to two days of being received by the facility.

Based on interview and record review, the facility failed to ensure its staff had the Physician review and respond to monthly medication regimen reviews (MRRs) for two Residents (#36 and #89), out of 27 sampled residents. Findings include: Review of the facility policy titled: Drug Regimen Review/Medication Regime Review, revised 10/6/22, indicated the following: -Any non-urgent recommendation(s)/irregularities must be addressed within 30 days of the consultant Pharmacist monthly visit. 1. Resident #36 was admitted to the facility in May 2014. Review of the MRR dated 4/22/22 indicated no documentation that the Physician had reviewed and responded to the MRR. During an interview on 12/19/22 at 11:08 A.M., Unit Manager (UM) #1 said the MRR from 4/22/22 did not appear to have been reviewed and responded to by the Physician, as required. 2. For Resident #89, the facility failed to ensure that pharmacy recommendations were reviewed, completed and filed in the Resident record. Resident #89 was admitted to the facility in May 2022. Review of the Resident's clinical record indicated that Pharmacy Medication Regimen Reviews (MRRs) were completed on the following dates with recommendations: 8/23/22, 9/28/22, 10/25/22 and 11/21/22. Further review of Resident #89's clinical record indicated no documented evidence: -of the results of the review or the Pharmacist's recommendations, -that the Physician had reviewed the recommendations, had indicated whether in agreement or disagreement and signed that the review was completed. During an interview on 12/14/22 at 10:37 A.M., UM #1 said when the pharmacy recommendations are made they are emailed to the Director Of Nurses (DON), they are printed out and given to the unit managers and they are provided to the doctors who will agree or disagree with the recommendations, sign and then the recommendation forms are filed in the chart. She said the recommendations should be signed and placed in the record and they are not as required. During an interview on 12/15/22 at 10:53 A.M., when asked for copies of the MRRs, UM #1 said she was unable to locate the signed MRRs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that its staff arranged for routine dental care for one Resident (#49), out of 27 sampled residents. Findings include: Resident #49 was admitted to the facility in November 2020. During an interview on 12/13/22 at 10:07 A.M., Resident #49 told the surveyor he/she had some missing teeth and wanted to see the dentist. He/she was unable to say when he/she had last seen the dentist. Review of the Resident's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident had scored a 13 out of 15 on the Brief Interview of Mental Status (BIMS), indicating he/she was cognitively intact. Further review of the MDS assessment indicated the resident had obvious or likely cavities and/or broken natural teeth. Review of the HealthDrive Dental Group (company that provided dental services to the facility) note dated 4/22/21, indicated a recommendation for an Annual Exam. Further review of the Resident's medical record provided no evidence that the Resident had been seen again since 4/22/21. During an interview on 12/14/22 at 9:38 A.M., Unit Manager (UM) #1 said she believed residents should be seen annually for routine dental care. During a follow up interview on 12/14/22 at 10:18 A.M., UM #1 said Resident #49 had not had an annual dental exam this year. She said the dentist had been at the facility recently for routine dental exams but Resident #49 was not on the list.

Based on interview and record review, the facility failed to ensure its staff maintained complete and accurate medical records for two Residents (#100 and #36) of 27 sampled residents. Specifically, the facility failed to ensure that its staff: 1. provided complete and accurate documentation relative to transfer/discharge/bed hold rights for Resident #100, and 2. that a) meal intakes and b) pharmacy consultation documentation were accurate for Resident #36. Findings include: 1. For Resident #100 the facility failed to ensure documentation relative to transfer/discharge/bed hold rights was complete and accurate. Resident #100 was admitted to the facility in November 2021. Review of the Resident's medical record included INTERACT SBAR Communication Forms (INTERACT- an acronym for Interventions to Reduce Acute Care Transfers, SBAR- an acronym for Situation, Background, Assessment, Recommendation, a tool used to communicate pertinent patient information between members of the health care team about a patient's condition) indicating the Resident was sent to the hospital on the following dates: 12/10/21, 5/29/22, and 11/19/22. Further review of the Resident's medical record included multiple incomplete copies of the required notices: -Notice of Intent to Transfer Resident with Less than 30 Day's Notice (Expedited Appeal) -Discharge/Transfer Request for a Fair Hearing -Bed Hold Notification forms. For the 12/10/21 transfer, the following was reviewed: - The Notice of Intent to Transfer Resident With Less than 30 Days' Notice (Expedited Appeal) Form was undated, - did not indicate the name and address of the Resident and/or his/her representative, -did not indicate whether the notice was hand delivered to the Resident. -The second page, where the Resident could request a Fair Hearing did not include the facility's Social Worker's name and phone number. For the 5/29/22 transfer, the following was reviewed: - There was no evidence the medical record included page one or page three of the Notice of Intent to Transfer Resident with Less than 30 Days' notice (Expedited Appeal). - the Discharge/Transfer Request for a Fair Hearing Form only included the month (written as the number 5) for a date. For the 11/19/22 transfer, the following was reviewed: - the Notice of Intent to Transfer Resident did not include the Resident Representative information and whether the notice was hand delivered to the Resident. -In addition, the facility social worker name and telephone number was left blank. -Page two of the form did not include the facility's Social Worker's name and phone number. During an interview on 12/14/22 at 5:00 P.M., Social Worker (SW) #1 said the required notices of transfer/discharge and bed hold notices were not complete and should have been. During an interview on 12/15/22 at 12:16 P.M., SW #2 said the notices of transfer/discharge and bed hold notices for this Resident were not completed fully and should have been. She further said the facility clearly had work to do in ensuring these documents were accurate in the medical records. 3. For Resident #36 the facility failed to ensure their contracted Pharmacy staff documented correctly on the Medication Regimen Reviews (MRRs) in the electronic medical record (EMR). Resident #36 was admitted to the facility in June 2014. Review of the August 2022 and September 2022 MRRs from the consulting Pharmacist indicated the following: -Were any medication irregularities found or any medication recommendations made for provider review: YES-See eDocuments or Pharmacy Review on physical chart to review specific recommendations/irregularities and Physician response. Review of the Resident's medical record indicated no consultant Pharmacist recommendations were in the electronic medical record or in the paper chart. During an interview on 12/19/22 at 10:10 A.M., the Director of Nursing (DON) reviewed the Pharmacy Review Report that is emailed to her each month and showed the surveyor that there were no MRR recommendations made for August 2022 or September 2022. She further said that the consulting Pharmacists' documentation was inaccurate and should have said there were NO recommendations made for those months. 2. Resident #36 was admitted to the facility in May 2014 with a diagnosis of Diabetes Mellitus. Review of a nursing progress note dated 4/8/22 and timed 11:27 P.M., indicated that at 5:00 P.M., the Resident was lethargic and not responsive when name was called, his/her Blood Sugar was 55 and glucose gel was administered. The note further indicated that Resident #36 was transported to the hospital by ambulance at 6 P.M. and the daughter and Ombudsman were notified. The record further indicated that the Resident returned from the hospital on 4/14/22. Review of the meals and snack summary dated 4/8/22 indicated the following: -no lunch intake recorded -dinner intake was 100% with 240 cc fluids recorded at 4:02 PM -evening snack intake was recorded at 4:02 PM as 100% of snack taken and 240cc's fluids taken. During an interview on 12/14/22 at 9:47 A.M., Certified Nursing Assistant (CNA) #2 said the dinner meal usually arrives on the unit around 5 P.M., and evening snacks are brought up by the kitchen on a tray after the meal service. He said that CNAs charted the meal intake when they could, after the meal and/or snack was taken. During an interview on 12/14/22 at 11:10 A.M., CNA #1 said he remembered the day Resident #36 was transferred. He said, the sugar was down, and the nurse had to send him/ her to the hospital. He said the Resident had a snack at 2 P.M., and then after change of shift, and before supper, was transferred to the hospital. CNA #1 said that Resident #36 was a good eater and drinker, usually consuming 100% of the meal. He viewed the documentation of the snack given early in the shift and said he had given the resident a snack when he came on duty. He viewed the documentation that indicated the resident took 100% of his dinner on 4/8/22 and said that was a documentation error. During an interview on 12/19/22 at 11:13 A.M., Unit Manager (UM) #1 said that the meal documentation should happen after the meal is consumed, not prior, and the evening snack is typically given between 8 and 9 P.M. She said the documentation on 4/8/22 for dinner and evening snack was inaccurate as it was charted prior to the meal and snack time on the unit. She further said that some of the documentation of intake on the Meals and Snacks Summary while the resident was hospitalized was also inaccurate, as it indicated the Resident had consumed meals and snacks and did not reflect that the Resident was on medical leave.

Based on observation and interview, the facility failed to ensure that its staff maintained a hygienic environment and performed hand hygiene at recommended intervals during wound care for one Resident (#103), out of 27 sampled residents. Specifically, the facility staff failed to create an aseptic (free from contamination) work area to place wound care supplies and perform hand hygiene between the removal of gloves after removal of old dressings and donning (putting on) new gloves for placement of new dressings during wound care. Findings include: Review of the facility policy titled Aseptic Dressing Change and Wound Measurement, effective date June 2010, indicated: -that the facility will adhere to the Nursing Standard of Practice, Centers for Disease Control and Infection Control Standards and provide a safe, hygienic environment for residents who need dressing application -a work area will be cleaned of personal items -the work area will be cleaned with facility approved wipes -a drape will be set up if no wrapping exists to provide a barrier -once old dressings are removed and discarded, gloves will be removed and discarded, and hand hygiene will be performed prior to donning clean gloves and cleaning the wound. Resident #103 was admitted to the facility in August 2022. During an observation on 12/13/22 at 8:15 A.M., the surveyor observed Resident #103 lying on a low bed, positioned on right side, with a pressure relief mattress on setting #4. Review of the facility matrix on 12/13/22 at 12:42 P.M., indicated that Resident #103 had a Stage II pressure area, and had acquired it in the facility. Review of the December 2022 Treatment Record indicated the Resident had daily dressing changes to coccyx and a foam dressing to right hip changed daily on the night shift. During an observation of wound care on 12/15/22 at 12:35 P.M., provided by the Wound Doctor and the facility Wound Nurse in Resident #103's room, the surveyor observed the Wound Nurse enter the room and place a stack of dressings, a pair of scissors and irrigant (a solution to wash the wound) on the Resident's overbed table next to the Resident's personal items. The table was not cleared or cleaned prior to the placement of the wound care supplies and there was no barrier placed on the table between the supplies and the tabletop. During wound care, the surveyor observed the Wound Doctor remove the old dressing, then remove his gloves and put on a new pair of gloves without performing hand hygiene prior to donning clean gloves. When the wound care was completed, the surveyor observed the left-over dressing supplies that had direct contact with the Resident's environment, returned to the treatment cart, and placed into the bottom drawer of the cart with the other clean dressing supplies. During an interview on 12/15/22 at 12:45 P.M., directly following the observation, the Wound Nurse said the overbed table should have been cleaned before placing dressing supplies on it. She further said it is an infection control concern to remove items from a resident's room and place back in the treatment cart because of the potential transfer of germs. During an interview at the same time, the Wound Doctor said he should have performed hand hygiene between the old dressing removal and the application of a new dressing and did not do that as required.

2. During a tour of the 200s, 300s, and 400s units and subsequent interview on 12/15/22 at 8:00 A.M., with the Director of Nursing (DON) and the Administrator, the following was observed: On the 200s, 300s, and 400s Units white boards were visible from the doorways to anyone passing by resident rooms. The white boards contained information including but not limited to: toileting status, how to apply medical devices the residents used, transfer status, and diet orders. On the 200s Unit the following information was observed on white boards in residents' rooms visible from the doorways: -Patient occasionally puts non-food items in room and is a feed assist. -No urinal please - cannot use properly On the 300s Unit the following information was observed on white boards in residents' rooms visible from the doorways: -Wears depends (an adult diaper) during the day. -No Toilet - check and change On the 400s Unit the following information was observed on white boards in residents' rooms visible from the doorways: -Patient does well with walker. -Hoyer (a type of mechanical lift that assists a resident from one surface to another) assist for transfers. -Dependent for all Activities of Daily Living (ADLs). During an interview following the observations, the DON and the Administrator both acknowledged that most of the white boards in the resident rooms were visible from the hallway and could be viewed by anyone walking by the resident's room. The DON further said having private information related to things such as toileting, behaviors, and diet orders displayed in a public location was a dignity concern and these things should not have been written on the white boards that were visible from the resident's doorways. Based on observation and interview, the facility failed to ensure its staff kept patient specific protected health information in a private location for Resident #89, and provided a dignified environment on three units (200s Unit, 300s Unit, and 400s Unit) out of four units observed. Findings Include: 1. For Resident #89, the facility staff failed to ensure patient specific protected health information was kept in a location not readily visible in a public area to non-clinical staff and visitors on the 400's Unit. Resident #89 was admitted to the facility in May 2022. During an observation on 12/13/22 at 9:44 A.M., the surveyor observed a white board/bulletin board on the wall in the Resident's room visible from the doorway. The white board had instructions regarding toileting and activities of daily living (ADLs) and indicated that the Resident used pull-ups diapers. On the bulletin board there was also a sheet of paper that was titled Therapy Communication to Nursing which had the Resident's full name on it, and in the Problems/Needs section there was a hand written note indicating that the Resident complained of sore buttocks. During subsequent observations on 12/14/22 at 8:51 A.M., and 1:22 P.M., and on 12/15/22 at 8:47 A.M., the same signage remained posted in the Resident's room. During an interview on 12/15/22 at 7:20 A.M., the Director of Nursing (DON) said posting signage with patient information that is visible to non-clinical staff is inappropriate and a violation of patient confidentiality.

4. For Resident #119 the facility staff failed to monitor for side effects of psychotropic medication use and obtain orders for PRN psychotropic medications that were limited to 14 days. Resident #119 was admitted to the facility in November 2022 with diagnoses including Dementia with agitation, Depressive Disorder, and Insomnia. Review of the December 2022 Physician Orders indicated the following: -Zyprexa (an antipsychotic medication), 2.5 milligrams (mg), give one tablet orally at noon, initiated 11/29/22 -Zyprexa 5 mg, give one tablet orally at bedtime, initiated 11/29/22 -Sertraline (an antidepressant medication) 50 mg, give three tablets orally at 8:00 A.M., initiated 11/29/22 -Trazodone (an antidepressant medication), 50 mg, give one tablet orally at bedtime, initiated 11/29/22 -Zyprexa 2.5 mg twice per day as needed, initiated 11/29/22 -Trazodone 50 mg, give one half tablet orally twice daily as needed, initiated 11/29/22 Review of Resident #119's medical record indicated no documentation that the Resident was being monitored for side effects related to psychotropic medication use. During an interview on 12/15/22 at 12:03 P.M., UM #1 said there was no order in place for staff to monitor for side effects of the psychotropic medications that the Resident was taking. She further said there should be a Physician's order in place and nursing staff should be monitoring and documenting side effects in the Resident's medical record and this was not happening, as required. Review of the December 2022 Physicians Orders indicated the following orders: -Zyprexa 2.5 mg twice per day as needed (PRN), initiated 11/29/22 -Trazodone 50 mg, give one half tablet orally twice daily PRN, initiated 11/29/22 Further review of the orders indicated neither the PRN Zyprexa order or the PRN Trazodone order had a stop date. During an interview on 12/14/22 at 9:34 A.M., Nurse #2 said PRN psychotropic medications should only be ordered for 14 days. During a follow up interview on 12/14/22 at 9:44 A.M., Nurse #2 said she did not see a stop date for either the PRN Zyprexa or the PRN Trazodone and that both medications should have a stop date after 14 days of use. She further said the PRN Trazodone would need to be reviewed and renewed by the doctor after 14 days, and the PRN Zyprexa would need a completely new order for the Resident to continue use after the initial 14 days. Based on observation, interview, and record review, the facility and its staff failed to ensure that psychotropic medications (drugs that affect mental processes and behavior, changing how your brain processes information, such as altering your mood, thoughts, perceptions, emotions, and behaviors) were managed and monitored to promote and maintain the highest practicable mental, physical, and psychosocial well-being for four Residents (#89, #103, #92, and #119), out of 27 sampled residents. Specifically, failure to ensure: a) that psychotropic medications were not given unless necessary to treat a specific condition, b) that psychotrophic medications were not given on an as-needed (PRN) basis, c) that residents on psychotropic medications were monitored for side effects, and d) that as-needed psychotropic medications were limited to 14 days. Findings include: Review of the facility policy titled Psychotropic Medications, reviewed 10/28/22, indicated the following: -As in the case of all other medications, psychotropic medications will only be administered following a written order of a Physician or others lawfully authorized to prescribe medications. -As-needed medications (PRN) will require a 14-day order -Residents receiving psychotropic medications shall be monitored for effectiveness of the medication and for adverse reaction, with the results of such monitoring documented in the resident's record. 1. For Resident #89, the facility staff failed to ensure that an appropriate diagnosis was given to justify the use of antipsychotic medications as recommended by the Pharmacist and an as-needed (PRN) psychotropic medication order was limited to 14 days, and then reassessed. Resident #89 was admitted to the facility in May 2022 with the diagnosis of Parkinson's Disease and Depression. Review of the December 2022 Physician's Orders indicated the following orders: -Quetiapine Fumarate (Seroquel- an antipsychotic used in the treatment of Schizophrenia and Bipolar Disorder) 25 mg one tab twice a day for anxiety, initiated 12/2/22 -Seroquel 25 mg one tablet oral once daily as needed for hallucinations, initiated 10/24/22 no stop date -Zoloft 100mg tablet oral at 8am for depressive episodes, initiated 7/22/22 -Psychotropic monitoring every shift, initiated 5/10/22 Review of the record indicated that Medication Regimen Reviews (MRRs) were completed on the following dates and recommendations were made: 8/23/22, 9/28/22, 10/25/22 and 11/21/22 and the facility was unable to provide them to the surveyor. During an interview on 12/14/22 at 3:10 P.M., Nurse #2 said that usually PRN doses have a 14 day stop date and then they are reviewed by the doctors and rewritten. There was no stop date entered for the PRN order as required. During an interview on 12/15/22 at 10:53 A.M., Unit Manager (UM) #1 said she was unable to locate the signed MRRs, but they were all the same recommendation which was to get an appropriate diagnosis for the use of the Seroquel. She further said that Behavioral Health saw the Resident and added a diagnosis, but it was not a diagnosis that the Pharmacy accepted (initial diagnosis was Dementia without behavioral disturbance). She said that Seroquel was trialed in September for 14 days then discontinued. It was restarted 10/24/22 as a PRN with no stop date where it continued until 12/14/22 when Nurse #2 updated the order to reflect a stop date. Copies of the MRRs, unsigned, were provided by the DON via fax after survey exit, on 12/22/22. Review of the MRR documentation submitted were as follows: On the MRRs dated 8/23/22, 9/28/22 and 10/25/22, the recommendations were requesting an allowable diagnosis to support the use of Quetiapine and indicated that Dementia without behavioral disturbance was not okay. The MRR dated 11/21/22 indicated to reassess the need for the PRN (as needed) Quetiapine every 14 days per CMS regulations. During a subsequent interview on 12/15/22 at 11:18 A.M., UM #1 said there should be documentation in the medical record about continuing an antipsychotic medication beyond the 14 days and she could not find a Physician's note on the record about continuation of the Seroquel. During an interview on 12/15/22 at 11:44 A.M., UM #1 said she reviewed the record with the other managers and they could not find documentation that the clinician had reviewed the PRN Seroquel dose after 14 days, there was no stop date entered once the order was written and both the stop date and the clinician documentation for continued use was not in the record as required. 2. For Resident #103 the facility failed to monitor for side effects of psychotropic medications. Resident #103 was admitted to the facility in August 2022 with diagnoses including Dementia with agitation. Review of the December 2022 Physician's Orders indicated the following orders: -Remeron (a medication to treat Depression)15 milligram (mg: denotes strength) tablet: give 1/2 tablet oral at 5pm for Depression, order date 11/23/22 -Zyprexa (an antipsychotic used to treat mood disorders) 2.5 mg tablet for unspecified Dementia, with agitation and anxiety, order date 11/23/22 There were no orders for monitoring for the side effects of the medication. Review of the Nursing Care Plan Psychotropic Medications, initiated 8/20/22, indicated to monitor for effectiveness, monitor for side effects and report. Review of the Nursing Care Plan Mood Decline, initiated 8/18/22, indicated to monitor for effectiveness, monitor for side effects and report. Further review of the record indicated that there was no documented evidence that licensed staff had monitored the resident for side effects and behavior. During an interview on 12/19/22 at 10:30 A.M., Unit Manager (UM) #1 said that residents on psychotropic medications should be monitored for medication effectiveness and side effects, there should be an order for the monitoring and it should be documented in the electronic Treatment Administration Record but there was no evidence that this was done as required. She further said that behavior is monitored by the Certified Nursing Assistants and they fill that out every shift, but nurses should be monitoring behaviors as well if the resident is on psychotropic medications. She said she doesn't know if the facility policy was to have both psychotropic medications and behavior monitoring in place for the resident on psychotropics. During a subsequent interview on 12/19/22 at 10:52 A.M., UM #1 said that there was no evidence that the Resident had been monitored for depression as per the mood care plan. 3. For Resident #92 the facility failed to ensure its staff monitored changes or side effects for the use of Seroquel (an antipsychotic used to treat certain mental/mood conditions and Remeron (an antidepressant). Resident #92 was admitted to the facility in September 2022. Review of the Active Order Report indicated the following: -Seroquel 25 milligram (mg) give 12.5 mg oral twice daily at 2:00 P.M. and 6:00 P.M. for distressing delusions with a start date of 12/2/22. -Remeron 15 mg tablet give one-half tablet oral at bedtime for Major Depressive Disorder with a start date of 10/26/22. During an interview on 12/14/22 at 3:06 P.M., UM #2 said that residents who are on psychotropic medications are monitored for changes and side effects. She said that the information is documented on a flow sheet and there should be an order to do so. She said there was no order in place to monitor changes and side effects for Resident #92 and there should have been as required.