Based on observations, interviews, and record review, the facility failed to ensure a safe and homelike environment for one Resident (#133), out of 34 total sampled residents. Specifically, the facility failed to ensure Resident #133's sink was not leaking and good repair. Findings include: Review of the facility policy titled 'Homelike Environment', revised February 2021, indicated: - Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. Resident #133 was admitted to the facility in February 2024 with diagnoses including epilepsy (seizure disorder) and a history of a heart attack. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/4/25, indicated Resident #133 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 5/20/25 at 7:05 A.M., Resident #133 said his/her sink had been leaking for approximately two months. The surveyor and Resident #133 observed his/her bathroom sink which was actively dripping water into a plastic basin on the floor directly below. This plastic basin contained approximately an inch of discolored water. Resident #133 said staff were aware because he/she had asked for it to be repaired multiple times since it began leaking. Resident #133 said he/she must empty this basin by him/herself because staff has not done anything to help empty it or to repair the sink. Resident #133 said it's gross and it attracts bugs which he/she hates. During an interview on 5/20/25 at 7:08 A.M., Certified Nurse Assistant (CNA) #3 said she knew Resident #133's sink had been leaking for over a month. CNA #3 said if a sink was broken and in need of repair, it should have been written in the maintenance log so maintenance could follow-up. CNA #3 showed the surveyor the maintenance log, which had maintenance requests that began on 4/21/25. This maintenance log failed to indicate any concerns regarding Resident #133's leaking sink. CNA #3 said it should have been written here but it was not. During an interview on 5/20/25 at 7:10 A.M., Unit Manager #2 said if a sink needed to be repaired then a request should have been written in the maintenance log or Unit Manager #2 should have sent an email to maintenance. Unit Manager #2 said she was unaware of any maintenance requests or emails sent regarding Resident #133's concern about leaking sink. During an interview on 5/20/25 at 7:15 A.M., the Maintenance Director said he was not notified about Resident #133's concern about a leaking sink until this morning after the surveyor brought it to Unit Manager #2's attention. The Maintenance Director said he should have been notified by it being put in the maintenance log, but it was not. During an interview on 5/21/25 at 9:44 A.M., the Director of Nursing (DON) said staff should have notified maintenance immediately when the sink began leaking. The DON said over a month is too long to wait to notify maintenance of the need to repair.

Based on interviews and record review, the facility failed to identify and complete a Significant Change in Status (SCSA) Minimum Data Set assessment (MDS) for one Resident (#115), when he/she was discharged from hospice services, out of a total sample of 34 residents. Findings include: Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2024, indicated a SCSA comprehensive assessment must be completed by the end of the 14th calendar day following determination that a significant change has occurred. Resident #115 was admitted to the facility in January 2024 with diagnoses including Huntington's disease (an inherited condition that affects movement, thinking, and mood) and hypertension (high blood pressure). Review of the most recent Minimum Data Set (MDS) assessment, dated 2/25/25, indicated Resident #115 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. This MDS also indicated Resident #115 was receiving hospice services. Review of Resident #115's nursing progress notes, dated 4/30/25, indicated: - Per hospice team - pending dc (discharge) from hospice services. - Per DON (Director of Nursing) - Administrator informed nursing team of client will be off hospice services either today or tomorrow. Review of Resident #115 census summary indicated Resident was discharged from hospice services beginning 4/30/25. Review of Resident #115 nursing progress notes, dated 5/17/25 and 5/18/25, indicated Resident was receiving hospice services, when he/she was not. Review of Resident #115 plan of care related to nutritional status, revised on 10/31/24, indicated: - On hospice with goal of comfort and care. This care plan had not been updated since before the Resident was discharged from hospice services on 4/30/25. Review of Resident #115's medical record on 5/19/25 at 2:15 P.M. failed to indicate a SCSA assessment had been completed, which was 19 days after Resident was discharged from hospice services. During an interview on 5/19/25 at 2:17 P.M., Unit Manager #2 said Resident #115 was discharged from hospice services on 4/30/25. During an interview on 5/19/25 at 2:19 P.M., the MDS Nurse said a SCSA needs to be completed after any resident is discharged from hospice services as required by the RAI guidelines. During a follow-up interview on 5/19/25 at 2:35 P.M., the MDS Nurse said Resident #115 should have had a SCSA completed since he/she was discharged from hospice services on 4/30/25, but one was not completed. During an interview on 5/19/25 at 2:38 P.M., the Director of Nursing (DON) said she expects the MDS Nurse to follow RAI guidelines. The DON said a SCSA should have been completed for Resident #115 because he/she was discharged from hospice services.

Based on observations, interviews and record review, the facility failed to ensure staff provided appropriate care and services for one Resident (#140) with a gastrostomy tube (a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of 34 sampled residents. Specifically, the facility failed to ensure nursing changed the water flush bag (a bag containing water that is connected to and delivers water for hydration through a gastrostomy tube) every 24 hours as necessary to prevent infection and maintain the integrity of the feeding system. Findings include: Review of the facility policy titled 'Enteral Nutrition Feedings (tube feeding), revised 7/26/13, indicated: - An open system (bag and tubing) may hang up to 24 hours unless compromised. Resident #140 was admitted to the facility in June 2024 with diagnoses including diabetes and sepsis. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/11/25, indicated Resident #140 was rarely/never understood and had severe cognitive impairment as evidenced by a Staff Assessment for Mental Status. This MDS also indicated Resident #140 received 501 ml (milliliters) or more of average fluid intake per day by tube feeding. On 5/19/25 at 12:22 P.M., the surveyor observed Resident #140 in bed receiving his/her tube feeding and water flush through an enteral feeding pump with the water flush settings at flush 220 ml every 6 hours. The water flush bag was dated 5/17/25 at 4:20 A.M., which was 56 hours and 2 minutes before this observation. Review of Resident #140's physician's orders indicated: - Enteral feed order, flush enteral tube q (every) 6 hours with 220 ml of water, initiated 3/17/25. Further review of Resident #140's physician's orders failed to indicate any instructions regarding the frequency of water flush bag changes. Review of Resident #140's nursing progress notes, dated 5/17/25 to 5/19/25, failed to indicate any rationale for the water flush bag not being changed since 5/17/25. During an interview on 5/20/25 at 6:55 A.M., Nurse #2 and the surveyor observed Resident #140's water flush bag, which was now dated 5/19/25 at 6:30 P.M. (indicating the water flush bag was not changed for 62 hours and 10 minutes). Nurse #2 said water flush bags must be changed every 24 hours. Nurse #2 said she was assigned Resident #140 on night shift on 5/18/25 and 5/19/25. Nurse #2 said she did not change the water flush bag on 5/18/25 because it was the evening shift nurses responsibility to change it when she connected a new tube feeding container to the enteral feeding pump. During an interview on 5/20/25 at 12:43 P.M., Nurse #3 said she was assigned Resident #140 on the evening shift for 5/17/25 and 5/18/25. Nurse #3 said water flush bags must be changed every 24 hours. Nurse #3 said she poured more water into the water flush bag to make sure there was enough water in the bag for the scheduled flushes and connected a new tube feeding container to the enteral feeding pump, but she did not change the water flush bag on 5/17/25 or 5/18/25 because it was the night shift nurses responsibility. During an interview on 5/20/25 at 2:18 P.M., the Assistant Director of Nursing said there were no additional facility policies that specifically addressed water flush bags, but water flush bags should be changed every 24 hours. During an interview on 5/21/25 at 8:25 A.M., Unit Manager #2 said Resident #140's water flush bag should have been changed every 24 hours when a new tube feeding container was connected to the enteral feeding pump. During an interview on 5/21/25 at 9:44 A.M., the Director of Nursing (DON) said Resident #140's water flush bag should have been changed every 24 hours when a new tube feeding container was connected to the enteral feeding pump.

Based on observations, interviews and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#125) out of sample of 34 residents. Specifically, for Resident #125, the facility failed to provide oxygen to the Resident as indicated in the physician's orders. Findings include: Review of facility policy, titled Oxygen Administration, dated as revised October 2010, indicated the following: -Verify that there is a physician's order for this procedure. Review the physician's orders for facility protocol for oxygen administration. -Steps in the procedure: 9. Place appropriate oxygen device on the resident (i.e. mask, nasal cannula and/or nasal catheter). Resident #125 was admitted to the facility in July 2023 with diagnoses that included Chronic Diastolic Heart Failure, primary pulmonary hypertension and sleep apnea. Review of Resident #125's most recent Minimum Data Set (MDS) Assessment, dated 4/15/25, indicated a Brief Interview for Mental Status (BIMS) exam score of 15 out of 15, indicating that the resident was cognitively intact. Further review of the MDS failed to indicate the use of oxygen therapy. Review of Resident #25's physician's orders indicated the following: -O2 (oxygen) at 2L (liters) continuously via Nasal Cannula, dated 4/16/24. Review of Resident #125's active care plan indicated the following: -Cardiac disease related to CAD (coronary artery disease), Hypertension (high blood pressure), CHF (congestive heart failure), with interventions that included to administer oxygen as ordered, dated as revised 8/2/23. On 5/19/25 at 8:24 A.M., Resident #125 was observed sleeping in bed. The Resident was receiving oxygen at 3 liters per minute via a face mask. On 5/19/25 at 1:29 P.M., Resident #125 was observed awake in bed. The Resident was receiving oxygen at 3 liters per minute via a face mask. On 5/20/25 at 7:00 A.M., Resident #125 was observed sleeping in bed. The Resident was receiving oxygen at 3 liters per minute via a face mask. On 5/21/25 at 7:56 A.M., Resident #125 was observed lying in bed. The Resident was receiving oxygen at 3 liters per minute via a face mask. Resident #125 declined to be interviewed by the surveyor, or speak to his/her oxygen use. During an interview on 5/21/25 at 8:30 A.M., Nurse #1 said that oxygen should be delivered as indicated in the physician's orders. She said if the order is to receive oxygen via nasal cannula, then the resident should not be using a mask. During an interview on 5/21/25 at 9:06 A.M., the Director of Nurses said that oxygen should be administered based on the physician's order, including both the flow rate and means of which it is delivered to the resident.

Based on observations, interviews, and record reviews for two Residents (#62 and #126) out of five residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. Two out of three nurses observed made two errors out of 26 opportunities resulting in a medication error rate of 7.69%. Specifically, 1.) For Resident #62, the nurse administered the incorrect dose of atorvastatin calcium (a medicine used to treat high cholesterol). 2.) For Resident #126, the nurse failed to ensure an order for aspirin included a dosage prior to administration. Findings include: Review of the facility policy titled 'Administering Medications', revised April 2019, indicated: - Medications are administered in accordance with prescriber orders. - The individual administering medications checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 1.) Resident #62 was admitted to the facility in April 2019 with diagnoses including hypertension (high blood pressure) and hyperlipidemia (high cholesterol). Review of the most recent Minimum Data Set (MDS) assessment, dated 3/25/25, indicated Resident #62 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15. On 5/20/25 at 8:23 A.M., the surveyor observed Nurse #4 prepare and administer the following medication to Resident #62: - One atorvastatin calcium 10 mg (milligram) tablet. Review of Resident #62's active physician order, initiated 5/15/25, indicated: - Atorvastatin calcium oral tablet 20 mg, give 1 tablet by mouth one time a day. During an interview on 5/20/25 at 11:31 A.M., Nurse #4 said she administered one atorvastatin calcium 10 mg tablet to Resident #62 but should have administered two tablets because the dose was recently increased to 20 mg. During an interview on 5/20/25 at 2:08 P.M., the Director of Nursing (DON) said Nurse #4 should not have administered atorvastatin calcium 10 mg because the physician's order is for 20 mg. 2.) Resident #126 was admitted to the facility in April 2024 with diagnoses including hyperlipidemia and atrial fibrillation (irregular heart rhythm). Review of the most recent Minimum Data Set (MDS) assessment, dated 4/29/25, indicated Resident #126 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15. On 5/20/25 at 9:00 A.M., the surveyor observed Nurse #7 prepare and administer the following medication to Resident #126: - One chewable aspirin 81 mg tablet. Review of Resident #126's active physician order, initiated 4/26/24, indicated: - Aspirin oral tablet chewable, give 1 tablet by mouth in the morning. This order failed to indicate a dosage. During an interview on 5/20/25 at 11:39 A.M., Nurse #7 said all medications require a dosage to be included in the physician order. Nurse #7 said the aspirin should not have been administered without clarifying the physician order to include a dosage because the correct dosage could not be verified. During an interview on 5/20/25 at 2:08 P.M., the Director of Nursing (DON) said all medications require a dosage to be included in the physician order. The DON said there should have been a dosage included in Resident #126's physician's order for aspirin but there was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure diagnostic test results were maintained in the clinical record for one Resident (#120) out of a total of 34 sampled residents. Specifically, the facility failed to ensure the results of an ultrasound were reviewed and reported to the attending physician and filed in his/her clinical record. Findings include: Review of the Lab and Diagnostic Test Results Clinical Protocol policy dated November 2018 indicated: - When test results are reported to the facility, a nurse will first review the results. -A physician can be notified by phone, fax, voicemail, e-mail, pager or a telephone message. -Facility staff should document information about when, how and to whom the information was provided and the response. This should be done in the progress notes section of the medical record and not on the lab results report. Resident #120 was admitted to the facility in January 2024 with diagnoses including traumatic subdural hemorrhage immobility syndrome (paraplegic). Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #120 is cognitively intact evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status exam (BIMS). During an interview on 5/19/25 at 8:05 A.M., Resident #120 said he/she was having pain in his/her genitals and staff were aware. Review of the physicians' orders indicated an order, dated 5/13/25, for an ultrasound on his/her genitals. Review of the medical record indicated the ultrasound was obtained on 5/13/25. Review of the clinical record failed to include the results of Resident #120's ultrasound. During an interview on 5/20/25 at 8:11 A.M., seven days after the ultrasound was ordered, Unit Manager #1 was unable to locate Resident #120's test results in the clinical record and accessed the results electronically from the diagnostic center and printed out a copy. Unit Manager #1 said that she had not reviewed the results of the ultrasound or notified the attending physician of the ultrasound results. Unit Manager #1 said Resident #120 had the ultrasound done after he/she had reported pain in his/her genitals. During an interview on 5/20/25 at 9:39 A.M., Nurse #8 said that Resident #120 had reported gential pain yesterday. Nurse #8 said she thought Resident #8 had an ultrasound to his/her genitals because he/she was reporting pain. During an interview on 5/21/25 at 9:53 A.M., the Director of Nursing (DON) said that ultrasound results should be reviewed by staff and reported to the attending physician the day the results are in. The DON said that nurses can access the results on the computer if they're not automatically uploaded into the electronic health record. The DON was not aware that Resident #120's ultrasound results were not in his/her clinical record or reviewed until the surveyor inquiry on 5/20/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure physician visits were completed timely, completed as required for new admissions, and were alternated between the physician and the nurse practitioner for seven Residents (#26, #27, #144, #8, #129, #120 and #89) out of a total of 34 sampled residents. Specifically: 1. For Residents #26, #27 and #144, the facility failed to ensure they were seen by the physician as required after admission to the facility. 2. For Residents #8, #89, #120 and #129, the facility failed to ensure they were seen by the physician as required. Findings include: Review of Physician Visits policy, dated 2001 indicated: Policy Statement: The attending physician must make visits in accordance with applicable state and federal regulations. 1. The attending physician will visit residents in a timely fashion, consistent with applicable state and federal requirements, and depending on the individual's medical stability, recent and previous medical history and the presence of medical conditions or problems that cannot be handled readily by phone. 2. The attending physician must visit his/her patients at least once every thirty days for the first ninety days following the resident's admission and then at least every sixty days thereafter. 3. Non-physician practitioners may perform required visits, sign orders and sign certifications/re-certifications as permitted by state and federal law. 4. After the first 90 days, if the attending physician determines that a resident need not be seen by him/her every thirty days, an alternate schedule of visits may be established, but not to exceed every sixty days. A physician assistant or nurse practitioner may make alternate visits after the initial ninety days following admission, unless restricted by law or regulation. 5. The attending physician must perform relevant tasks at the time of each visit, including a review of the resident's total program of care and appropriate documentation. 1a. Resident #26 was admitted to the facility in February 2025 with diagnoses including vascular dementia and epilepsy. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated he/she was moderately cognitively impaired as evidenced by a score of nine out of a possible 15 on the Brief Interview for Mental Status Exam. Review of the physician's progress notes indicated Resident #26 had been seen once by the physician upon admission, on 2/28/25, and had no other visits by the physician or the nurse practitioner, every 30 days, as required. 1b. Resident #27 was admitted to the facility in February 2025 with diagnoses including diffuse traumatic brain injury and epilepsy. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #27 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status score of 9 out of 15, and required assistance with bathing, dressing and toileting. Review of Resident #27's physician progress notes indicated he/she was seen once upon admission by the physician on 2/28/25, and had no other visits, every 30 days, as required. 1c. Resident #144 was admitted to the facility in October 2024 with diagnoses including osteomyelitis and blindness. Review of the Minimum Data Set Assessment, dated 4/29/25, indicated Resident #144 is cognitively intact evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam. Review of Resident #144's physician progress notes indicated he/she was not seen by the physician until 1/15/25 (approximately three months after his/her admission) and then by the nurse practitioner on 4/28/25. 2a. Resident #8 was admitted to the facility in June 1999 with diagnoses including schizophrenia and intracranial injury. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #8 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 3 out of a possible 15, and required assistance with bathing. Review of Resident #8's physician progress notes from July 2024 through May 2025 indicated he/she had been seen by the nurse practitioner on 10/15/24 and 1/15/25 and only had one visit from the physician on 1/15/25. 2b. Resident #89 was admitted to the facility in July 2022 with diagnoses including chronic obstructive pulmonary disease and chronic kidney disease. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #89 is cognitively intact evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status Exam. Review of Resident #89's physician progress notes July 2024 and May 2025 indicated Resident #89 was seen by the Nurse Practitioner on 8/28/24, 9/24/24, 10/1/24, 10/8/24, 11/11/24, 11/12/24, 12/13/24, 1/15/24 and 2/19/25, and Resident #89 was seen once by the physician on 1/15/25. 2c. Resident #120 was admitted to the facility in January 2024 with diagnoses including traumatic subdural hemorrhage immobility syndrome (paraplegic). Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #120 is cognitively intact evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status exam (BIMS). During an interview on 5/19/25 at 8:06 A.M., Resident #120 said that he/she had not been seen by the nurse practitioner or physician in a while. Review of Resident #120's physician progress notes between June 2024 and May 2025 indicated he/she had been seen by the nurse practitioner on 6/11/24, 8/13/24, 8/28/24, and 1/15/25 and by the physician on 6/14/24 and 1/15/25. 2d. Resident #129 was admitted to the facility in January 2024 with diagnoses including paraplegia and communicating hydrocephalus. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #129 is cognitively intact evidenced by a score of 15 out of a possible 15 in the Brief Interview for Mental Status Exam (BIMS). The MDS also indicated Resident #129 is totally dependent on staff for eating, bathing and mobility. During an interview on 5/19/25 at 10:15 A.M., Resident #129 said he/she had not seen the nurse practitioner or physician in a while. Review of Resident #129's progress notes from June 2024 through May 2025 indicated he/she was seen by the physician on 1/15/25, 2/13/25, 3/10/25, and 4/18/25, and had visits from the Nurse Practitioner on 2/19/25 and 3/28/25. During an interview on 5/19/25 at 10:18 A.M., Unit Manager #1 said that each unit has their own nurse practitioner, and they come in weekly. Unit Manager #1 said that physician and nurse practitioner notes are located in the electronic record. During an interview on 5/19/25 at 2:25 P.M., the Assistant Director of Nursing (DON) said that the physician notes had been pulled directly from the physician's office and then should be uploaded by Medical Records. The ADON said that Residents should be seen every three months by the physician or nurse practitioner. During an interview on 5/20/25 at 10:21 A.M., Nurse Practitioner #1 said that residents are visited by the attending physician upon admission and that nurse practitioners alternate visits after. Nurse Practitioner #1 said notes are written after residents are seen and are accessible to staff electronically from their office. Nurse Practitioner #1 said resident visit frequencies are based on the regulation and that she did not think new admissions were being seen as required every 30 days for the first 90 days. During an interview on 5/21/25 at 9:34 A.M., Physician #1 said that residents are seen within 48 hours of admission by the physician and then visits are alternated with the nurse practitioners as required. Physician #1 said notes are written after each visit and then uploaded by staff into the record. Physician #1 said that there might be some residents who were missed for visits as an oversight.

Based on observations, interviews, and record reviews, the facility failed to accurately document in the medical record for one Resident (#11) out of 34 total sampled residents. Specifically, for Resident #11, the nurses inaccurately documented insulin was administered when it was not. Findings include: Review of the facility policy titled 'Charting and Documentation', revised July 2017, indicated: - Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Resident #11 was admitted to the facility in July 2018 with diagnoses including diabetes, stage four chronic kidney disease, and congestive heart failure. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/18/25, indicated Resident #11 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS also indicated Resident #11 received insulin daily. During an interview on 5/21/25 at 8:41 A.M., Resident #11 said his/her blood sugars are unstable and his/her insulin needs to be held if his/her blood sugar is below 200. Resident #11 said he/she is very involved in his/her insulin management and is happy because nursing always holds his/her insulin when needed. Review of Resident #11's active physician orders indicated: - All insulin to be held if fasting blood sugars are 200 and below, every shift, initiated 5/17/24. - Novolin 70/30 relion (a type of insulin) subcutaneous (under the skin) suspension 100 unit/ml (milliliter), inject 25 unit subcutaneously in the morning, hold insulin if fasting glucose is 200 or below, initiated 12/5/24. - Novolin n relion (a type of insulin) subcutaneous suspension, inject 18 units subcutaneously in the evening, insulin to be held if fasting blood sugar 200 and below, initiated 12/4/24. - Novolog (a type of insulin) solution 100 unit/ml, inject 8 unit subcutaneously in the evening, insulin to be held if fasting blood sugar 200 and below, initiated 3/5/25. Review of Resident #11's Medication Administration Record (MAR), dated April 2025, indicated: - On 4/1/25 at 5:00 P.M., Nurse #6 administered 18 units of novolin n insulin and 8 units of novolog insulin, when blood sugar was 90. - On 4/4/25 at 5:00 P.M., Nurse #6 administered 18 units of novolin n insulin and 8 units of novolog insulin, when blood sugar was 77. - On 4/6/25 at 5:00 P.M., Nurse #6 administered 18 units of novolin n insulin and 8 units of novolog insulin, when blood sugar was 114. - On 4/8/25 at 9:00 A.M., a nurse administered 25 units of novolin 70/30 insulin, when blood sugar was 198. - On 4/11/25 at 9:00 A.M., a nurse administered 25 units of novolin 70/30 insulin, when blood sugar was 133. - On 4/11/25 at 5:00 P.M., Nurse #6 administered 18 units of novolin n insulin and 8 units of novolog insulin, when blood sugar was 134. - On 4/14/25 at 5:00 P.M., Nurse #6 administered 18 units of novolin n insulin and 8 units of novolog insulin, when blood sugar was 194. - On 4/21/25 at 5:00 P.M., Nurse #4 administered 18 units of novolin n insulin and 8 units of novolog insulin, when blood sugar was 160. - On 4/27/25 at 5:00 P.M., a nurse administered 18 units of novolin n insulin and 8 units of novolog insulin, when blood sugar was 163. Review of Resident #11's Medication Administration Record (MAR), dated May 2025, indicated: - On 5/1/25 at 5:00 P.M., Nurse #6 administered 18 units of novolin n insulin and 8 units of novolog insulin, when blood sugar was 97. - On 5/2/25 at 5:00 P.M., Nurse #6 administered 18 units of novolin n insulin and 8 units of novolog insulin, when blood sugar was 191. - On 5/6/25 at 5:00 P.M., Nurse #6 administered 18 units of novolin n insulin and 8 units of novolog insulin, when blood sugar was 90. - On 5/8/25 at 5:00 P.M., Nurse #6 administered 18 units of novolin n insulin, when blood sugar was 177. - On 5/13/25 at 5:00 P.M., Nurse #6 administered 18 units of novolin n insulin and 8 units of novolog insulin, when blood sugar was 177. - On 5/16/25 at 5:00 P.M., Nurse #6 administered 18 units of novolin n insulin, when blood sugar was 90. - On 5/17/25 at 5:00 P.M., Nurse #6 administered 18 units of novolin n insulin, when blood sugar was 194. - On 5/19/25 at 5:00 P.M., a nurse administered 18 units of novolin n insulin and 8 units of novolog insulin, when blood sugar was 152. Review of Resident #11's nursing progress notes, dated 4/1/25 to 5/19/25, failed to indicate any clarifying information on insulin being administered or held on the above noted dates in the April 2025 and May 2025 MARs. During an interview on 5/21/25 at 7:59 A.M., Nurse #4 said Resident #11's insulin should always be held if his/her blood sugar reading was below 200. Nurse #4 said she had always held Resident #11's insulin when his/her blood sugar was below 200. Nurse #4 said insulin should not be documented as administered if it was not. During an interview on 5/21/25 at 8:25 A.M., Unit Manager #2 said Resident #11's insulin should always be held if his/her blood sugar reading was below 200. Unit Manager #2 said she was surprised that Resident #11's insulins were documented as administered when his/her blood sugars were below 200 because Resident #11 is very involved and aware of his/her insulin orders. Unit Manager #2 said she believed it was documented inaccurately. Unit Manager #2 said insulin should not be documented as administered if it was not. During a telephone interview on 5/21/25 at 8:50 A.M., Nurse #6 said he was aware that Resident #11's insulin needed to be held if his/her blood sugars were below 200. Nurse #6 said during April 2025 and May 2025 he always held his/her insulin if Resident #11's blood sugars were below 200. Nurse #6 further said that Resident #11 was very involved in his/her insulin management and always wanted to see the blood sugar reading. Nurse #6 said Resident #11 got excited if it was under 200 and would never allow any nurse to administer insulin if it were below 200. Nurse #6 said he must have documented Resident #11's insulin inaccurately. Nurse #6 said insulin should not be documented as administered if it was not. During an interview on 5/21/25 at 9:44 A.M., the Director of Nursing (DON) said Resident #11 would not allow insulin to be administered if his/her blood sugar was below 200 and felt the documentation was inaccurate. The DON said insulin should not be documented as administered if it was not.

Based on records reviewed and interviews, for one of three sampled Employee Personnel Records (Certified Nurse Aide #1), the Facility failed to ensure they conducted a Massachusetts Nurse Aide Registry background check before hire, in accordance with the Facility Policy. Findings include: Review of the Facility's Policy titled Background Screening Investigations, dated March 2019, indicated background checks are completed prior to employment. The Policy indicated that any employee applying for a position as a Certified Nurse Assistant, the state nurse aide registry is contacted to determine if any findings of abuse, neglect, mistreatment of individuals, and/or theft of property have been entered into the applicant's file. Review of Certified Nurse Aide (CNA) #1's Personnel File indicated he was hired on 06/07/22. Further review of the file indicated there was no documentation to support that CNA #1 had a Massachusetts Nurse Aide Registry background check conducted by the Facility before hire. During an interview on 07/09/24 at 3:30 P.M., the Administrator, Director of Nurses (DON) and Assistant Director of Nurses said a Massachusetts Nurse Aide Registry could not be located for CNA #1 to support it had been conducted prior to hire. During a telephone interview on 07/10/24 at 12:35 P.M., the DON said that although ongoing attempts were made by their offsite Human Resource department to locate CNA #1's Massachusetts Nurse Aide Registry check, it was not located.

Based on observation, record review and interview, the facility failed to monitor and assess the use of equipment being used as a potential restraint for one Resident (#57) out of a total sample of 31 residents. Specifically, the facility staff failed to: For Resident #57, conduct individualized monitoring and ongoing assessments for the use of thigh bands (used to secure the body in a wheelchair to prevent sliding down in the chair and designed to relieve pressure on certain body areas) while lying flat. Findings include: Review of the facility policy titled Restraints: Physical, dated revised 10/13/2017, indicated that the purpose of the policy is to ensure that if a restraint is indicated to treat medical symptoms that it is the least restrictive device possible, used for the least amount of time possible in order to treat the medical symptoms. Resident #57 was admitted to the facility in October 2018 with diagnoses including Huntington's disease, psychosis and depression. Review of the Minimum Data Set assessment, dated 4/9/24, indicated that Resident #57 was not able to complete the Brief Interview for Mental Status exam and is severely cognitively impaired. Further review indicated that Resident #57 is totally dependent for all activities of daily living. Further review failed to indicate that Resident #57 used a restraint. On 6/25/24 at 9:49 A.M., the surveyor observed Resident #57 lying flat in a Broda chair (a type of wheelchair that allows a resident to lay flat) in the Residents room with bilateral padded straps originating from the center of the seat, going up and over each thigh, across the hips and ending in a buckle behind the back of the chair, preventing the Resident from exiting the chair. On 6/25/24 at 1:27 P.M., the surveyor observed Resident #57 sitting in a Broda chair in the hallway with bilateral padded straps originating from the center of the seat, up going up and over each thigh, across the hips and ending in a buckle behind the back of the chair, preventing the Resident from exiting the chair. On 6/25/24 at 3:42 P.M., the surveyor observed Resident #57 sitting in a Broda chair in the hallway with bilateral padded straps originating from the center of the seat, up going up and over each thigh, across the hips and ending in a buckle behind the back of the chair, preventing the Resident from exiting the chair. On 6/26/24 at 7:40 A.M., the surveyor and Unit Manager #1 observed Resident #57 lying in a Broda chair in the Residents room with bilateral padded straps originating from the center of the seat, going up and over each thigh, across the hips and ending in a buckle behind the back of the chair, preventing the Resident from exiting the chair. Review of the medical record failed to indicate that Resident #57 used a restraint. Review of the doctor's orders failed to indicate an order for the use of a restraint or the use of thigh bands. Review of the care plan, dated and reviewed 3/25/24, failed to indicate a care plan for the use of a restraint. Further review failed to indicate the use of thigh bands. Further review indicated a behavior care plan related to Resident #57's behavior of purposefully sitting/placing self on the floor as a means of resistance to redirection when having behaviors. Review of the facility document titled Occupational Therapy Discharge Summary, dated 12/01/22, indicated that thigh bands are used to prevent forward sacral sliding, to promote skin integrity when in the Broda chair. Further review indicated that the thigh bands were placed to promote optimal positioning to promote safe swallowing and intake of high calorie nutritional beverage to help Resident maintain weight. Further review failed to indicate that the Broda chair with thigh bands was to be used while the Resident was lying flat. Review of the facility document titled Pre-Restraining Evaluation, dated 3/1/21, indicated that use of both thigh bands and a chest band in Broda chair provides positional support to maximize proper sitting without preventing any volitional movements. Further review indicated that the facility did not consider the thigh bands a restraint however, the document failed to indicate if the use of the thigh bands were appropriate while the Resident is lying flat in the Broda chair and whether their use while lying flat would act as a restraint. Review of the facility document titled Physical Restraint Elimination Review, dated as reviewed quarterly on 4/11/23, 7/11/23, 10/10/23 and 1/9/24 and 4/9/24, failed to indicate that the Resident was evaluated for the use of the thigh bands (a potential restraint) for purposes other than those recommended by Occupational Therapy. During an interview on 6/26/24 at 7:40 A.M. Unit Manager #1 said that the straps are used to prevent Resident #57 from exiting the chair. Unit Manager #1 said that Resident #57 sleeps in the Broda chair with the straps in place because he/she has a history of getting out of bed and then falls to the floor. Unit Manager #1 said that Resident #57 has been sleeping in the Broda chair with the straps in place for a long time. During an interview on 6/27/24 at 11:12 A.M., the Director of Nursing said that the use of the thigh bands while the Resident is lying flat in the Broda chair should have been evaluated, care planned and a doctor's order written.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to develop a comprehensive plan of care for one Resident (#132) out of a total sample of 31 residents. Specifically, the facility failed to develop an individualized plan of care for Resident #132 related to migraine headaches. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered, dated and revised 4/25/22, indicated the following: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. - The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Resident #132 was admitted to the facility in January 2024 with diagnoses including focal traumatic brain injury, major depressive disorder and epilepsy. Review of Resident #132's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated that the Resident had a Brief Interview of Mental Status score of 15 out of a possible 15 indicating that he/she is cognitively intact. During an interview on 6/25/24 at 8:35 A.M., Resident #132 said he/she gets migraines daily and he/she wears his/her sunglasses all the time as it helps. Review of Resident #132's pre-admission paperwork, dated 11/7/23, prior to entering the facility indicated the following written by a Nurse Practitioner: - During interview with this writer patient reports that he/she suffers migraine headaches. Review of Resident #132's physician's order, dated 1/3/24, indicated the following: - Excedrin Migraine Oral Tablet (a medication used to temporarily treat migraine headache pain) 250-250-65 MG (milligrams): Give 1 tablet by mouth every 12 hours as needed for pain related to unspecified focal traumatic brain injury. Review of Resident #132's medical diagnoses, care plans, and progress notes failed to mention that the Resident has migraine headaches. During an interview on 6/26/24 at 12:41 P.M., Resident #132's Family member said he/she has migraine headaches, and he/she says wearing the sunglasses helps them. During an interview on 6/27/24 at 7:25 A.M., Certified Nursing Assistant #1 said she is familiar with Resident #132 and said she was not sure why he/she wears sunglasses and did not know that the Resident gets migraine headaches. During an interview on 6/27/24 at 7:56 A.M., Unit Manager #1 said she was not sure why Resident #132 always wears sunglasses. She continued to say that she did not know Resident #132 has a history of migraine headaches and still has them. Unit Manager #1 said if a resident has migraine headaches, then a care plan should be developed so interventions can be implemented. During an interview on 6/27/24 at 8:41 A.M., the Director of Nurses (DON) said she did know Resident #132 has migraine headaches or has a history of them. She said if it was mentioned in the pre-admission paperwork then a care plan should have been implemented. The DON and surveyor reviewed Resident #132's preadmission paperwork and she said a care plan and medical diagnosis should have been developed for Resident #132's migraine headaches.

Based on record review and interview, the facility failed to follow professional standards of practice for two Residents (#150 and #151) out of two closed records reviewed. Specifically, 1. For Resident #150, the facility failed to obtain a doctor's order for a transfer to the hospital and 2. For Resident #151, the facility failed to obtain a doctor's order for a transfer home. Findings include: The facility policy titled Transfer or Discharge, Facility-Initiated, dated 2001, failed to indicate that a doctor's order would be obtained for resident discharges. 1. For Resident #150 the facility failed to obtain a doctor's order for a transfer to the hospital. Resident #150 was admitted to the facility in June 2023 with diagnoses including Huntington's disease, schizophrenia and depression. Review of the progress note, dated 4/4/24, indicated that Resident #150 was transferred to the hospital on 4/4/24 via ambulance. Review of the doctor's orders, dated April 2024, failed to indicate an order to transfer Resident #150 to the hospital. During an interview on 6/25/24 at 4:05 P.M., the Director of Nursing said that a doctor's order should be obtained for a transfer to the hospital. 2. For Resident #151 the facility failed to obtain a doctor's order for a transfer home. Resident #151 was admitted to the facility in January 2024 with diagnoses including alcohol dependence, alcoholic cirrhosis of the liver and psychosis. Review of the progress note, dated 5/11/24, indicated that Resident #151 was discharged home. Review of the doctor's orders dated May 2024 failed to indicate an order to discharge Resident #151 home. During an interview on 6/25/24 at 4:05 P.M., the Director of Nursing said she would expect a doctor's order would be obtained for a transfer home.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #123 was admitted to the facility in November 2022 with diagnoses including Post Traumatic Stress Disorder (PTSD). A review of the most recent Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15 indicating moderate cognitive impairment. Further review of the MDS indicated a PTSD diagnosis. A review of the social services admission assessment, dated 11/4/22, indicated the following: -Primary care PTSD screen with a list of traumatic events, a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone killed or seriously injured, and having a loved one die through homicide and suicide. -Resident #123 answered yes to experiencing one of the traumatic events. A review of the social services admission notes, dated 11/4/22, indicated the following: -Daughter reported that the Resident has a history of childhood trauma as well as a history of physical and verbal abuse by male partners. A review of Resident #123's trauma care plan, initiated 11/4/22, indicated the following: -Resident has had a previous traumatic event in his/her past that put him/her at risk for mood lability including depression and anxiety related to his/her trauma. During an interview on 6/27/24 at 7:37 A.M., the Social Worker said trauma is only assessed at admission for all residents, she said trauma is assessed again if a traumatic event occurs in the facility during the Resident's stay. The Social Worker said Resident #123 answered yes to experiencing one of the traumatic events listed in the trauma assessments, she said Resident #123's family member provided more specific details of the trauma the Resident experienced as indicated in the social service admission note. She said a personalized care plan should have been developed with the specific traumatic events Resident #123 experienced. The Social Worker said triggers should also have been identified and personalized in the care plan to prevent re-traumatization. During an interview on 6/27/24 at 9:50 A.M., the Director of Nurses said all trauma care plans should be personalized with the specific traumatic event, she said triggers should be identified and care planned as well. Based on record review and interview the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Specifically, the facility failed to conduct an assessment for trauma per the facility policy, and develop an individualized comprehensive plan of care for Post Traumatic Stress Disorder (PTSD) including triggers for re-traumatization for two Residents (#146 and #123) who had an active diagnosis of PTSD out of a total sample of 31 Residents. Findings include: 1. For Resident #146 the facility failed to conduct an assessment for trauma per the facility policy, and develop a comprehensive plan of care for Post Traumatic Stress Disorder (PTSD) including triggers for re-traumatization. Resident #146 was admitted to the facility in March 2024 with diagnoses including PTSD, traumatic brain injury and depression. Review of the Minimum Data Set (MDS) assessment, dated 3/21/24, indicated Resident #146 had a diagnosis of PTSD. Further review indicated Resident #146 scored a 15 out of 15 on the Brief Interview for Mental Status exam indicating intact cognition. Review of the doctor's orders, dated June 2024, indicated Resident #146 had a diagnosis of PTSD. Review of Resident #146's care plan, with a focus of PTSD, indicated a goal to avoid re-traumatization triggers, however, the care plan failed to indicate what the triggers for re-traumatization are, how Resident #146 exhibits an activation of PTSD when it occurs and what interventions are needed to help reduce the impact to the Resident during the triggered event.

Based on observations, record review and interview, the facility failed to provide dental services for one Resident (#132) out of a total sample of 31 residents. Specifically: For Resident #132, the facility failed to ensure dental services were provided after it was reported that Resident #132 had dental pain. Findings include: Review of the facility policy titled Dental Services, revised and dated December 2016, indicated the following: - Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. - Routine and 24-emergency dental services are provided to our residents through a contract agreement with a licensed dentist comes to the facility monthly. - Social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible. Resident #132 was admitted to the facility in January 2024 with diagnoses including focal traumatic brain injury, major depressive disorder and epilepsy. Review of Resident #132's Minimum Data Set (MDS) assessment, dated 1/10/24, indicated the following under Section L - Oral Dental Status: - Obvious or likely cavity or broken natural teeth Review of Resident #132's most recent MDS assessment, dated 4/2/24, indicated that the Resident had a Brief Interview of Mental Status score of 15 out of a possible 15 indicating that he/she is cognitively intact. During an observation and interview on 6/25/24 at 8:35 A.M., the surveyor observed a tube of Orajel (an over-the-counter medication used to temporarily treat dental pain) on Resident #132's bed side table. Resident #132 said his/her teeth hurt and it hurts to chew food and that his/her family member brought in the Orajel for his/her dental pain. Resident #132 was observed to have many black, dark spots on the visible teeth. Review of Resident #132's Care Conference Notes, dated 1/3/24, indicated the following: - He/she needs to see a dentist, he/she has some rotting teeth in the back of his/her mouth that is causing him/her discomfort. Review of Resident #132's physician's order dated 1/4/24 indicated the following: - Consults: Dental care as needed During an interview on 6/26/24 at 12:41 P.M., Resident #132's Health Care Representative's family member said Resident #132 really needs to see a dentist as his/her teeth are in bad shape and if a dentist could come into the facility that would be great as Resident #132 does not always want to get out of bed. The Health Care Representatives continued to say that Resident #132 has not been seen by a dentist since his/her admission and they would like one to see him/her. They continued to say that they brought in the Orajel for Resident #132's teeth pain. During an interview on 6/27/24 at 7:56 A.M., Unit Manager #1 said if it is known that a resident has dental pain then the facility would have a dentist see the resident as soon as possible. Unit Manager #1 said a dentist should have seen Resident #132 months ago since it was documented in January 2024 of his/her dental discomfort. During an interview on 6/27/24 at 7:33 A.M., the Director of Nurses (DON) said all residents have care conferences which is for their individualized care plans and if something appropriate is discussed then interventions will be implemented. The DON said if dental pain was discussed in a care conference, then the facility would have the resident see a dentist as soon as possible. The DON said she was not aware that Resident #132 was having dental pain since January, had dental issues or that the Resident's Health Care Representatives brought in Orajel for his/his teeth pain. The DON continued to say that a dentist and dental hygienist comes to the building every few months and they have been in the building since January. She continued to say if she knew about Resident #132's dental pain she would have made sure the dentist or dental hygienist saw the resident as Resident #132's representatives consented for dental care to be provided while in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and policy review, the facility failed to ensure that housekeeping staff maintained proper hand hygiene practices on one of four nursing units. Findings include: Review of facility policy titled Handwashing/Hand Hygiene, dated as revised 3/18/24, indicated the following: - The facility considers hand hygiene the primary means to prevent the spread of healthcare- associated infections. - 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents and visitors. - Indications for Hand Hygiene. 1. Hand hygiene is indicated. c. after contact with blood, body fluids or contaminated surfaces. e. after touching a resident's environment. g. immediately after glove removal. 5. The use of gloves does not replace hand hygiene/ hand washing. Review of facility policy titled Personal Protective Equipment- Gloves, dated July 2009, indicated the following: 2. Gloves shall be used only once and discarded into the appropriate receptacle located in the room in which the procedure is being performed. 8. Wash your hands after removing gloves. On 6/26/24 at 7:01 A.M., the surveyor observed Housekeeper #2, wearing gloves, emptying trash from a resident room on the [NAME] Park Unit. Housekeeper #2 exited the resident room, put the trash into a larger bag, and without doffing (removing) her gloves or performing any hand hygiene, she entered a second resident room with the same contaminated gloves on her hands. Housekeeper #2 continued this routine through five resident rooms, entering and exiting the rooms to empty trash wearing the same pair of contaminated gloves and without any hand hygiene in between rooms. During an interview on 6/26/24 at 11:22 A.M., the Housekeeping Manager said that staff should be removing gloves before exiting a room and sanitizing hands in between tasks or between moving on to another resident's room. During an interview on 6/26/24 at 2:32 P.M., the Infection Control Nurse said staff should not be wearing gloves in the hallway. He said gloves should be removed before exiting a room and hands should be sanitized upon exiting and before entering another resident room. During an interview on 6/27/24 at 6:55 A.M., the Director of Nurses said staff should not exit a resident room and go into the hallway with gloves on. The expectation is that no staff wear gloves in the hallway and gloves are changed and hand hygiene is performed between tasks or between resident rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Medical Orders for Life Sustaining Treatment (MOLST) were accurate for 1 Resident (#3), out of a total 37 sampled residents. For Resident #3, the facility failed to address the advance directives on the MOLST in the plan of care. Findings include: Review of facility policy titled Advanced Directives revision date, 9/2022 indicated the following: -Advanced directives are honored in accordance with state law and facility policy. -The plan of care for each resident is consistent with his or her documented treatment preferences and/or advanced directives. Resident #3 was admitted to the facility in February 2022, with diagnoses including severe protein calorie malnutrition, dysphagia, and muscle weakness. Review of Resident #3's most recent Minimum Data Set assessment dated [DATE], indicated a Brief Interview for Mental Status score of 4 out of a possible 15 indicating severe cognitive impact. Further review indicated Resident #3 was a Do Not Resuscitate (DNR) and a Do Not Intubate (DNI) Status. Review of Resident #3's medical record indicated the following: -A permanent Guardianship decree indicating updated advance directives to DNR/DNI on 2/7/22. -A Massachusetts Order for Life Sustaining Treatment (MOLST) form indicated A DNR/DNI status, signed by Resident #3's legal Guardian on 2/16/22. -A Care Plan dated 2/17/22 indicated Resident #3's advanced directives to be honored as a Full Code. -The medical record failed to indicate an active physician order for code status in the medical record. During interviews on 4/6/23 at 8:04 A.M. and 8:40 A.M., Unit Manager #2 said she was unsure if there should be an order for a Code Status for a Resident and would check with the Minimum Data Set (MDS) Nurse. Unit Manager #2 said Resident #3 would be treated as a Full Code as that is what the care plan indicated. During an interview on 4/6/23 at 8:33 A.M., the MDS nurse said that Resident #3's MOLST should match the care plan as well as a physician order in the electronic medical record (EMR). During an interview on 4/6/23 at 8:52 A.M., the Assistant Director of Nurses said Code Status needed to be placed as an order in the EMR. The Assistant Director of Nurses said the Care Plan and the MOLST should be the same and should be fixed right away.

Based on observation, record review and interviews, the facility failed to meet professional standards of practice during a medication pass with 1 Resident (# 34) out of 3 residents observed. Findings include: Review of facility policy titled ' Medication Administration' edited 5/21/19 indicated the following: Policy Interpretation and Implementation *27. Residents may self administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision making capacity to do so safely. On 4/5/23 at 8:09 A.M., the surveyor observed a medication pass on the Forthill resident care unit. Nurse #4 prepared and administered medications including the following: *Buspirone 10 mg (milligram) 2 tablets *Seroquel 25 mg 1 tablet *Notryptylin 25 mg 4 capsules (100 mg) *Pantoprazole dr (delayed release) 40 mg 1 tablet *Montelukast 10 mg 1 tablet *Strattera 40 mg 1 capsule *Effexor er(extended release) 150 mg 2 capsules *Cetrizine 10 mg 1 tablet *Folic acid 1000 mcg (microgram) 1 tablet *Flonase 50 mcg 1 spray each nostril *Advair diskus 250-50 mcg 1 inhaltion rinse after use. did not rinse *Budesonide suspension 0.5 mg/ 2 ml (milligram / milliliter) 1 application via inhalation. During the medication administration Nurse #4 walked away from Resident #34 and went to get gloves from her medication cart. Resident #34 self administered flonase nasal spray and administered 2 sprays to to each nostril. For advair diskus (steroid medication to treat breathing conditions) Resident #34 did not rinse his/her mouth after use per pharmacy label. During an interview on 4/5/23 at 11:51 A.M., Nurse #4 said Resident #34 is not assessed for self administration and she should not have let the Resident self administer the medications. Nurse #4 also acknowledged she should have Resident #34 rinse his/her mouth after using the advair inhaler. During an interview on 4/6/23 at 8:07 A.M., the Director of Nursing said nurses should stay with the residents until completion of medication administration, and should follow orders or manufacture guidance on use of steroid inhalers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to provide assistance with Activities of Daily Living (ADL) for 1 Resident (#148) out of a total sample of 37 residents. Findings include: Resident #148 was admitted to the facility in February 2023 with diagnoses including diabetes. Review of Resident #148's most recent Minimum Data Set (MDS), dated [DATE], indicates the Resident has a Brief Interview for Mental Status score of 15 out of a possible 15, indicating he/she is cognitively intact. The MDS also indicates Resident #148 is dependent on staff for bathing tasks. On 4/4/23 at 8:12 A.M., Resident #148 was observed in his/her reclining chair in the hallway. The Resident had significantly greasy hair with white flakes similar to dandruff throughout the head. The Resident said he/she has not had a shower since admitting to the facility and would like one so his/her hair can be washed. Review of the shower schedule indicated Resident #148 is scheduled for showers on Mondays and Thursdays during the 7:00 A.M. to 3:00 P.M. shift. Review of Resident #148's [NAME] (a form indicating the level of assistance a resident requires) indicates the following: *Assist to bath/shower. On 4/6/23 at 7:45 A.M., Resident #148 was observed in his/her reclining chair in the hallway. The Resident had significantly greasy hair with white flakes resembling dandruff throughout the head. The Resident said he/she had already gotten bathed and dressed for the day and even though it is his/her shower day he/she did not receive a shower. Resident #148 reiterated he/she would really like a shower but was told by the Certified Nursing Assistant (CNA) that he/she was to be given showers by the Occupational Therapist only. During an interview on 4/6/23 at 9:03 A.M., CNA #1 said Resident #148 requires maximal assistance from staff for bathing tasks. CNA #1 said Resident #148 needs to be cleared by the rehabilitation staff before being able to be showered by the nursing staff. During an interview on 4/6/23 at 9:09 A.M., the Director of Rehabilitation (DOR) said the nursing staff do not need to wait for the rehabilitation staff to clear residents for showers. The DOR said the nurses and CNAs can look up any resident's status in the medical chart to find out the level of assistance needed for ADLs. The DOR said the facility has a reclining, wide shower chair that is safe for Resident #148 to utilize and therapy does not need to be involved in providing showers, unless working on that skill as part of therapy. During an interview on 4/6/23 at 10:32 A.M., the Assistant Director of Nursing said the nursing staff can provide showers without waiting for the rehabilitation staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to follow recommendations of the optometrist for 2 Residents (#63 and #120) out of a total sample of 37 residents. Findings include: 1. Resident #63 was admitted to the facility in January 2017 with diagnoses including dementia and Human Immunodeficiency Virus disease. Review of Resident #63's most recent Minimum Data Set (MDS), dated [DATE], indicates the Resident was unable to complete the Brief Interview for Mental Status exam and staff has assessed him/her to have severe cognitive impairment. The MDS also indicates Resident #63 is dependent on staff for all activities of daily living. Resident #63 is not able to be interviewed. Review of an eye consult from 2/2/22, indicated the Optometrist made the following recommendation: *Artificial Tears Solution, apply 1 drop, Both eyes, three times daily for indefinitely. Review of an eye consult from 6/6/22, indicated the Optometrist made the following recommendation: *New Medication Order: Refresh Optive Gel, apply 1 drop, Both eyes, three times daily for indefinitely. Review of Resident #63's physician orders failed to indicate these recommendations were put in place. During an interview on 4/6/23 at 8:17 A.M., Unit Manager #1 said these recommendations were made prior to him working at the facility and did not have any information on why the Resident was not ordered eye drops as recommended. During an interview on 4/6/23 at 9:00 A.M., the Assistant Director of Nursing said the nurses on the floor should be ensuring all recommendations made by consulting specialties are followed. 2. Resident #120 was admitted to the facility in July 2019 with diagnoses including stroke, cataracts, myopia (near sightedness) and presbyopia (far sightedness). Review of Resident #120's most recent Minimum Data Set (MDS), dated [DATE], indicates the Resident has a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15, indicating he/she has moderate cognitive impairment. The MDS also indicated Resident #120 is independent with all daily self-care and mobility tasks. During an interview on 4/6/23 at 8:50 A.M., Resident #120 said he/she can't see half the time and he/she would like to see an eye doctor. Review of an eye consult from 1/24/22, indicated the Optometrist made the following recommendation: * New Medication Order: Artificial Tears Solution, apply 1 drop, Both eyes, twice daily for 90 days; Follow-Up: 3-4 Months Review of an eye consult from 7/1/22, indicated the Optometrist made the following recommendations: * New Medication Order: Artificial Tears Solution, apply 1 drop, Both eyes, twice daily for PRN; Follow-Up: Priority Comprehensive 02/08/2023. Review of Resident #120's physician orders failed to indicate these recommendations were put in place or the Resident was seen in February 2023 for his/her annual eye exam. During an interview on 4/6/23 at 8:17 A.M., Unit Manager #1 said these recommendations were made prior to him working at the facility and did not have any information on why the Resident was not ordered eye drops as recommended or why he/she was not seen for the annual eye appointment. During an interview on 4/6/23 at 9:00 A.M., the Assistant Director of Nursing said the nurses on the floor should be ensuring all recommendations made by consulting specialties are followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure its staff provided appropriate care and services for one Resident (#3) with a Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of 37 sampled Residents. Specifically, the facility failed to follow physician orders for accurate water flush amount. Resident #3 was admitted to the facility in February 2022 with diagnoses including severe protein calorie malnutrition, dysphagia, and muscle weakness. Review of Resident #3's most recent Minimum Data Set assessment dated [DATE], indicated a Brief Interview for Mental Status score of 4 out of a possible 15 indicating severe cognitive impact. Further review indicated Resident #3 required tube feedings while a Resident. During an observation on 4/5/23 at 11:48 A.M., Resident #3's tube feeding pump was programmed to receive a water flush of 150 milliliters (MLS) every 4 hours. During an observation on 4/5/23 at 3:11 P.M. and 4:56 P.M., Resident #3's tube feeding pump was still programmed to receive a water flush of 150 MLS every 4 hours. Review of Resident #3's medical record indicated the following: -Order date 4/3/23 with a start date of 4/4/23 indicated to flush every 4 hours with 200 MLS. -Medication Administration Record (MAR) for April 2023 indicated an order for a flush every four hours with 200 MLS, beginning the evening shift on 4/4/23. The MAR indicated the flush was administered as ordered by nursing staff. During an interview on 4/5/23 at 4:57 P.M., Nurse #5 said Resident #3 required tube feedings with flushes that were automatically programmed to flush every 4 hours. Nurse #5 said Resident #3 received 150 MLS every 4 hours. Nurse #5 reviewed the current orders and Medication Administration Record for Resident #3, and said she was unaware that the flush order was increased to 200 MLS despite her signature on the MAR. Nurse #5 said it is the expectation of nursing to read the physician orders. During an interview on 4/6/23 at 7:49 A.M., the Director of Nurses said it is the expectation of nursing to follow physician's orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, the facility failed to ensure that 1 Resident (#63), was seen by a physician every 90 days out of a total sample of 37 residents. Findings include: Resident #63 was admitted to the facility in January 2017 with diagnoses including dementia and Human Immunodeficiency Virus disease. Review of Resident #63's most recent Minimum Data Set (MDS), dated [DATE], indicates the Resident was unable to complete the Brief Interview for Mental Status exam and staff has assessed him/her to have severe cognitive impairment. The MDS also indicates Resident #63 is dependent on staff for all activities of daily living. Review of Resident #63's medical chart indicated he/she was seen by the nurse practitioner on 2/24/23 and 3/31/23. The medical chart failed to include any notes from the physician to indicate the Resident was seen by the physician in the last 90 days. During an interview on 4/6/23 at 1:09 P.M., the Director of Nursing (DON) said all residents in the facility need to be seen by the physician every 90 days. The DON said she believed Resident #63 was seen by the physician within the last 90 days and would bring the surveyor notes of these visits. The Director of Nursing never provided the surveyor with notes indicating Resident #63 was seen by the physician every 90 days.

Based on observations, record review and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. One nurse out of two nurses observed made 3 errors in 28 opportunities resulting in a medication error rate of 10.71%. These errors impacted 2 Residents (#111 and #22) out of 3 residents observed. Findings include: Review of facility policy titled 'Administering Medications' edited 5/19/21, indicated the following: Policy Statement: Medications are administered in a safe and timely and as prescribed. Policy Interpretation and Implementation *10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. On 4/5/23 at 7:28 A.M., the surveyor observed a medication pass on the Shed park resident care unit. Nurse #3 prepared and administered medications including the following to Resident #22: *chlorpromazine 50 mg (milligram) 3 tablets *diazepam 2 mg 2 tablets *colace 100 mg 2 tablets * gemfibrozil 600 mg 2 tablets * hydrochlorothiazide 25 mg 1 tablet *iron 325 mg 1 tablet *januvia 50 mg 1 tablet *lisinopril 2.5 mg 1 tablet At 7:40 A.M., Nurse #3 said she was ready to go administer medications to Resident #22, the surveyor asked Nurse #3 if those were all the medications that were to be administered in the morning. Nurse #3 responded with yes. Nurse #3 and the surveyor walked to Resident #22's door way. The surveyor asked Nurse #3 to return to the medication administration cart and look through the medication cup. Nurse #3 looked through the poured medications and realized she had 2 tablets of gemfirozil 600 mg (total dose 1200 mg) and did not have metformin 1000 mg (a diabetes medication). Nurse #3 prepared the medications again and administered them to Resident #22. Review of the current physician's orders indicated the following: *Gemfibrozil 600 mg give 1 tablet by mouth two times daily hyperlipidemia (high cholesterol) *Metformin 1000 mg give 1 tablet by mouth two times daily for type 2 diabetes During an interview on 4/5/23 at 11:39 A.M., Nurse #3 acknowledged that if the surveyor had not stopped her, she would have given the wrong dosage of gemfrozil and would have omitted metformin which is a medication error. Nurse #3 said she needs to do her 5 medication rights check thoroughly. On 4/5/23 at 7:46 A.M., the surveyor observed a medication pass on the Shed park resident care unit. Nurse #3 prepared and administered medications including the following to Resident #111: *Tylenol 325 mg (milligram) 2 tablets *Aspirin chew 81 mg 1 tablet *Lexapro 10 mg 1 tablet *Haldol 2 mg 2 tablets *Propranolol 40 mg 1 tablet *Tamsulosin 0.4 mg 1 capsule *Valproic acid 250 mg/5 ml (milligram/milliliter) 20 ml Review of the current physician's orders indicated the following: *Tamsulosin capsule 0.4 mg give one capsule by mouth one time a day. Do not crush/chew or open capsule. Take 30 minutes after the same meal each day. During an interview on 4/5/23 at 11:39 A.M., Nurse #3 acknowledged that she did not see the directions for the medication. During an interview on 4/6/23 at 8:07 A.M., the Director of Nursing said her expectation is that nurses will double check the orders and medication instructions before administering medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to provide dental services to 1 Resident (#120) out of a total sample of 37 residents. Findings include: Resident #120 was admitted to the facility in July 2019 with diagnoses including stroke and schizoaffective disorder. Review of Resident #120's most recent Minimum Data Set (MDS), dated [DATE], indicates the Resident has a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15, indicating he/she has moderate cognitive impairment. The MDS also indicated Resident #120 is independent with all daily self-care and mobility tasks. During interviews on 4/4/23 at 8:58 A.M., and 4/6/23 at 8:50 A.M., Resident #120 was observed with significant brown discoloration to his/her teeth. Resident #120 said he/she would like to be seen by the dentist to have a cleaning. Review of Resident #120's medical record indicated he/she was seen by the dentist on 1/23/22 with a recommendation to have annual exams. The record failed to indicate the Resident was seen for his/her annual exam in January 2023. During an interview on 4/6/23 at 8:17 A.M., Unit Manager #1 said the unit secretary makes all appointments and keeps track of the residents that need to be seen by consulting services, such as the dentist. Unit Manager #1 was unable to say why Resident #120 was not seen for his/her annual dental exam. During an interview on 4/6/23 at 11:59 A.M., the Director of Nursing (DON) said the consulting company that provides dental services comes in regularly and there have been no issues with appointments. The DON said the expectation is that if a resident is recommended to be seen by the dentist annually or within a certain timeframe they will be seen within that timeframe unless they refuse. Review of Resident #120's medical record failed to indicate the Resident had refused dental services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure staff maintained medical records that were accurate for one Resident (#3) out of a total sample of 37 residents. Specifically, the facility documented that the incorrect enteral flush order was administered. Resident #3 was admitted to the facility in February 2022 with diagnoses including severe protein calorie malnutrition, dysphagia, and muscle weakness. Review of Resident #3's most recent Minimum Data Set assessment dated [DATE], indicated a Brief Interview for Mental Status score of 4 out of a possible 15 indicating severe cognitive impact. Further review indicated Resident #3 required tube feedings while a Resident. During observations on 4/5/23 at 11:48 A.M., 4/5/23 at 11:48 A.M., 3:11 P.M. and 4:56 P.M., Resident #3's tube feeding pump was programmed to receive a water flush of 150 milliliters (MLS) every 4 hours. Review of Resident #3's medical record indicated the following: -Order date 4/3/23 with a start date of 4/4/23 indicated to flush every 4 hours with 200 MLS. -Medication Administration Record (MAR) for April 2023 indicated an order for a flush every four hours with 200 MLS, beginning the evening shift on 4/4/23. The MAR documentation indicated the flush was administered as ordered by nursing staff 2 times on 4/4/23 and 3 times on 4/5/23, when the pump was observed to be administering 150 MLS every 4 hours. During an interview on 4/5/23 at 4:57 P.M., Nurse #5 acknowledged documentation for Resident #3 was not accurate. During an interview on 4/6/23 at 7:49 A.M., the Director of Nursing said the expectation is that nursing documentation be accurate.