Based on observations, document review, and interviews, the facility failed to follow infection control prevention practices to prevent the transmission of communicable diseases and infections for one Resident (#13) out of one resident on transmission-based precautions, out of a total sample of 13 residents. Specifically, the facility failed to ensure staff wore the appropriate PPE (personal protective equipment) while providing care for Resident #13, who was on droplet and contact precautions. Findings include: Review of Centers for Disease Control and Prevention (CDC) guidance titled Transmission-Based Precautions, dated 4/3/24, indicated but was not limited to: -Contact Precautions: Use of PPE appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning (putting on) PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. -Droplet Precautions: Use personal protective equipment (PPE) appropriately. [NAME] mask upon entry into the patient room or patient space. On 5/6/25 at 11:22 A.M., the surveyor observed a yellow CDC Contact Precautions sign, and a dark green CDC Droplet Precautions sign posted at the doorway to Resident #13's room. A three-tiered cart containing PPE (masks, gloves, gowns, eye protection) was available below the signs. Review of the CDC Contact Precautions sign indicated the following: -Everyone must: >Clean their hands, including before entering and when leaving the room. -Providers and staff must also: >Put on gloves before room entry. Discard gloves before room exit. >Put on gown before room entry. Discard gown before room exit. >Do not wear the same gown and gloves for the care of more than one person. >Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. Review of the CDC Droplet Precautions sign indicated the following: -Everyone must: Clean their hands, including before entering and when leaving the room. -Make sure their eyes, nose and mouth are fully covered before room entry. -Remove face protection before room exit. During an interview on 5/6/25 at 3:36 P.M., the Infection Preventionist said Resident #13 was started on contact and droplet precautions on 4/22/25 related to unknown respiratory illness. On 5/6/25 at 3:40 P.M., the surveyor observed CNA #3 and CNA #4 in Resident #13's room (door was open and no privacy curtain was drawn) transferring him/her in a Hoyer lift (a mechanical device used to lift and transfer patients who cannot move themselves) wearing gloves only. A yellow CDC Contact Precautions sign and a dark green CDC Droplet Precautions sign were posted at the doorway to Resident #13's room and PPE was available in a cart below the signs. During an interview on 5/6/25 at 3:50 P.M., CNA #3 and CNA #4 said they did not think that Resident #13 was still on precautions and only wore gloves when they transferred the Resident. The surveyor directed the CNAs to the precautions signs posted at the Resident's doorway. The CNAs said they should have worn a gown, gloves, mask and eye protection when assisting the Resident but did not. During an interview on 5/6/25 at 4:00 P.M., the Infection Preventionist said Resident #13 is on contact and droplet precautions and staff are to wear a gown, gloves, mask and eye protection when providing all care to the Resident. The Infection Preventionist said staff are expected to read the precaution signs posted at the Resident's doorway and follow proper PPE protocol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for one Resident (#6), out of a total sample of 12 residents. Specifically, for Resident #6, the facility failed to ensure pain medication was not administered outside of parameters identified in the Physician's orders. Findings include: Review of [NAME], Manual of Nursing Practice 11ed, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. -In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. Review of the facility policy titled: Medication administration, dated as reviewed: 2/4/25, indicated but was not limited to the following: -medications shall be administered only upon the order of physicians who are members of the medical staff -nurses may administer medications in accordance with the regulations of the Board of Nursing Resident #6 was admitted to the facility in April 2025 with diagnoses including: fracture of the left femur, encephalopathy, and fall. Review of the most recent MDS, dated [DATE], indicated the Resident was taking opioid (narcotic) pain medication and was moderately cognitively impaired with a brief interview for mental status score of 11 out of 15. Review of the medical record indicated the Resident was their own person and capable of making their own medical decisions. Review of the physician orders for Resident #6, indicated but were not limited to the following: 4/24/25: Oxycodone (narcotic pain medication) 5 milligrams (mg), give half a tablet [2.5 mg]as needed (PRN) every four hours (Q4H) for moderate pain (discontinued (d/c) 4/30/25) 4/24/25: Oxycodone 5 mg give one tablet Q4H PRN for severe pain (d/c 4/30/25) 4/30/25: Oxycodone 5 mg give one tablet Q4H PRN for severe pain During an interview on 5/7/25 at 8:20 A.M., the Resident said they feel their pain is well managed and he/she is not interested in taking the oxy pain pills. Resident #6 further said the staff are giving the oxy pills to him/her without him/her asking for them. He/She said they were worried about becoming addicted and didn't want to stay on such a strong medication since they don't need it. The Resident said they are not having any pain that isn't manageable by other means. Review of the current pain care plan for Resident #6 indicated but was not limited to the following: -monitor and record pain characteristics PRN, severity on 1-10 scale Review of the Numerical Rating Scale for pain, indicated the following: -rating of zero indicates (=) no pain -rating of 1-3 = mild pain -rating of 4-6 = moderate pain -rating of 7-10 = severe pain Review of the Medication administration record (MAR) for both April 2025 and May 1st -7th, 2025 indicated, but was not limited to the following for Resident #6: April 2025: -Oxycodone 5 mg half tablet (2.5 mg) Q4H PRN for moderate (rating of 4 - 6) pain was administered outside of the ordered parameters four out of five times it was provided: >Twice for a rating of zero, >once for a rating of 9, >once for a rating of 7. -Oxycodone 5 mg one tab Q4H PRN for severe (rating of 7 - 10) pain was administered outside of the ordered parameters nine out of nine times: >Five times for a rating of zero, >twice for a rating of 1, >once for a rating of 3, >once for a rating of 4. May 2025: -Oxycodone 5 mg one tab Q4H PRN for severe pain was administered outside of the ordered parameters three of the four times it was provided. >Twice for a rating of 1, >once for a rating of 2. Further Review of the MARs indicated the Licensed Nurses were administering the PRN Oxycodone medication to Resident #6 outside of the prescribed parameters. During an interview on 5/7/25 at 11:25 A.M., Nurse #3 said the Resident is at the facility for rehab following a left femur fracture. Nurse #3 said she thought the Resident would not consistently participate in rehab without pain medications being given. Nurse #3 reviewed the MAR for April and May and said the Oxycodone orders are for PRN only and have parameters and the medication had been administered outside of the prescribed parameters and should not have been. Review of the skilled rehabilitation progress notes and evaluations failed to indicate that Resident #6 was limited in his/her rehab participation based on an excess of pain. During an interview on 5/7/25 at 11:56 A.M., Nurse #1 said the process is supposed to be that you ask the Resident how their pain is and you go strictly by what they say and provide the medications that are as needed, if they want them, according to the pain rating number they give you. Nurse #1 said pain is rated on a 1-10 scale and 1-3 is mild, 4-6 is moderate and 7-10 is severe. Nurse #1 reviewed the April and May MARs and said the Resident received the PRN Oxycodone multiple times outside of the ordered parameters and that should not have been happening and the Nurses should only be administering the medication in accordance with the Physician orders. During an interview on 5/7/25 at 1:01 P.M., the Occupational Therapist (OT) said she provides treatment to Resident #6 since admission and she has not ever known the Resident to refuse any therapy treatments based on pain and that is definitely something the therapists would have written in the rehab progress notes. The OT said nursing manages the residents pain and the therapists only intervene if a resident is incapable of participating in rehab because of excess pain and that did not occur for Resident #6. During an interview on 5/7/25 at 3:08 P.M., the Director of Nurses (DON) said her expectation is that the Licensed Nurses are administering medications in accordance with the Physician orders. The DON reviewed the April and May MARs for Resident #6, and said it appeared the Nurses had administered the PRN Oxycodone multiple times outside of the ordered parameters and that should not have happened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed for one Resident (#12), of 12 sampled residents, to maintain their catheter drainage bag below the level of the bladder at all times to prevent potential complications. Findings include: Review of the facility's policy titled Indwelling Urinary Catheter: insertion, routine care and removal, dated as effective 9/21/22, indicated but was not limited to the following: - always keep the drainage bag below the level of the individual's bladder, to prevent urinary tract infections caused by urinary reflux (urine flowing back up into the bladder) Resident #12 was admitted to the facility in August 2022 with diagnoses including: hydronephrosis (a condition in which urine cannot drain from the kidneys resulting in kidney swelling) and protein calorie malnutrition. Review of the most recent Brief Interview for Mental Status (BIMS), dated 3/12/24, indicated the Resident was cognitively intact with a score of 15 out of 15. During an observation with interview on 5/7/24 at 10:18 A.M., the surveyor observed Resident #12 lying in bed. Resident #12 said they had a cystoscopy (procedure in which a small camera is inserted through the urethra to investigate the urinary system) and has had the catheter since that time. The surveyor did not observe a catheter urine drainage bag anywhere. The Resident said the staff had placed a leg bag (a catheter drainage bag that attaches to the leg for use when out of bed) on them in case they were to get up for some reason they wouldn't need to worry about maneuvering the regular drainage bag. Review of Resident #12's care plan for Indwelling catheter, initiated 1/12/24, indicated but was not limited to the following: - position catheter drainage bag and tubing below the level of the bladder On 5/7/24, the surveyor made the following observations of Resident #12: - 1:59 P.M., Resident lying in bed, catheter drainage leg bag in place - 4:12 P.M., Resident lying in bed, catheter drainage leg bag in place During an interview on 5/7/24 at 4:43 P.M., Nurse #2 said Resident #12 is not capable of changing the catheter drainage bag from a leg bag to a regular drainage bag independently and the staff swap out the drainage bags. She said the Resident was in bed and should not have the leg bag on as it would not allow for proper drainage, since it does not sit below bladder level, and could cause potential complications. Review of the Resident care [NAME], dated 5/8/24, indicated but was not limited to the following: - Resident is bedbound as of 5/1/24 - Catheter: indwelling, position catheter drainage bag and tubing below the level of the bladder During an interview on 5/8/24 at 12:13 P.M., the Director of Nurses said Resident #12 should not have had a leg bag on while they were in bed, as it would prevent proper urine drainage, and the standard and care plan were not followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the facility's policy titled Enhanced Barrier Precautions, dated as reviewed 4/26/24, indicated but was not limited to the following: - enhanced barrier precautions (EBP) will be implemented for residents with wounds and indwelling medical devices at especially high risk for both the acquisition of and colonization with multi-drug resistant organisms (MDRO) - the decision to implement EBP will be made by the infection control nurse and healthcare leadership team - compliance with EBP will be monitored by the infection control nurse and healthcare leadership team - signage will be placed on the door of the resident's room and information will be documented in their care plan Review of the Centers for Disease Control and Prevention (CDC) guidance titled Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, dated as last reviewed 7/28/21, indicated that examples of indwelling medical devices include . tracheostomy/ventilator. Resident #17 was admitted to the facility in December 2020 with diagnoses including: malignant neoplasm of the larynx (tumorous cancer of the throat), malignant neoplasm of the right upper bronchus or lobe of the lung, and tracheostomy status (a surgically created opening into the windpipe to allow air flow into the lungs). Review of the most recent Brief Interview for Mental Status, dated 3/6/24, indicated Resident #17 was cognitively intact with a score of 13 out of 15. During an interview on 5/7/24 at 10:08 A.M., Resident #17 said the tracheostomy was long ago and now he/she just has a trach stoma (permanent opening in the throat for air passage). The surveyor observed the Resident to have a trach mask (device for delivering oxygen) over the stoma connected to an oxygen concentrator with humidified oxygen flowing at 2 liters per minute. On 5/7/24 at 10:08 A.M., the surveyor did not observe an EBP sign on the Resident's bedroom door, or anywhere in the immediate vicinity of the Resident's room and no personal protective equipment was available outside or inside the room for staff to use in the event the Resident should require assistance. Review of the medical record including progress notes, orders, and care plans for Resident #17 failed to indicate the Resident was on EBP. Review of the care [NAME] for Resident #17, as of 5/8/24, indicated but was not limited to the following: Bathing: - Provide sponge bath when a full bath or shower cannot be tolerated, Resident can require continual supervision to limited assist when bathing. During a follow up interview on 5/7/24 at 4:58 P.M., Resident #17 was in his/her room and said when he/she is at the hospital they are on special precautions since having the tracheostomy and the facility does not follow those or provide any additional safety barriers to protect the Resident from potential exposure to germs even though he/she is high risk to contract infections related to their medical diagnoses. On 5/7/24 at 4:58 P.M., the surveyor did not observe an EBP sign on the Resident's bedroom door, or anywhere in the immediate vicinity of the Resident's room and no personal protective equipment was available outside or inside the room for staff to use in the event the Resident should require assistance. During an observation on 5/8/24 at 8:39 A.M., the surveyor did not observe an EBP sign on the Resident's bedroom door, or anywhere in the immediate vicinity of the Resident's room and no personal protective equipment was available outside or inside the room for staff to use in the event the Resident should require assistance. During an interview on 5/8/24 at 8:49 A.M., the Director of Nurses reviewed the EBP policy for the facility with the surveyor. She said Resident #17 is not on EBP, but realizes that they should be since they have a trach stoma and is at high risk for infections. She said the Resident is mostly independent and only requires staff assistance at times but is rapidly declining and staff need to be aware of the potential infection risk to the Resident and EBP should have been implemented based on the facility policy. Based on observation, interview, and policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections within the facility for one Resident (#17), out of a total sample of 12 residents. Specifically, the facility failed to implement enhanced barrier precautions for a Resident who has a tracheostomy stoma and is at high risk for infection. Findings include:

Based on interview, the facility failed to implement and maintain an effective training program for all staff, which included laundry personnel, training on standards, policies, and procedures for the facility's infection prevention and control program as it relates to handling contaminated laundry. Findings include: According to the Centers for Disease Control and Prevention (2024), best practices for personal protective equipment (PPE) for laundry staff include but are not limited to: -If there is risk of splashing, for example, if laundry is washed by hand, laundry staff should always wear gowns or aprons and face protection (e.g., face shield, goggles) when laundering soiled linens. According to the American Healthcare Association (2023), Tips for Meeting the Linen Requirements in Skilled Nursing Facilities include but are not limited to: Linen and Laundry Handling: Staff should handle all used laundry as potentially contaminated and use standard precautions (e.g. gloves, gowns when sorting and rinsing). During an interview on 5/8/24 at 11:20 A.M., Laundry Staff #1 said she handles all linens with gloved hands and no other PPE. She said she has never been educated to utilize any other PPE for handling soiled infectious linen. During an interview on 5/8/24 at 1:00 P.M., the Maintenance/Housekeeping Director said he is responsible for the laundry department. He said a mask and gloves should be worn for sorting, handling and processing contaminated linens. He said he does not provide education to laundry staff on infection control related to laundry. During an interview on 5/8/24 at 2:30 P.M., the Infection Preventionist (IP) said she is responsible for providing all staff education on all aspects of infection control, including laundry staff, but she has not done it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to provide education, assess eligibility, and offer Pneumococcal Vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for three Residents (#10, #5 and #21), out of a sample of five residents. Specifically, the facility failed to ensure that staff offered, assessed, and provided education on the recommended Pneumococcal vaccine 20-valent (PCV20) (an active immunizing agent used to prevent infection caused by certain types of pneumococcal bacteria). Findings include: Review of the facility's policy titled Resident Immunization Policy, dated as last revised on 1/17/23, indicated but was not limited to the following: -Vaccines against tetanus and diphtheria, influenza, pneumonia, COVID-19 will be available to all residents. Residents and their Responsible Party will be educated and encouraged to consent to receiving immunizations as recommended by the Massachusetts Immunization Program unless medically contraindicated. -All residents will have their immunization status assessed upon admission and annually thereafter. Review of the Massachusetts Immunization Program indicated vaccine administration and clinical guidelines followed the Centers for Disease Control and Prevention (CDC) guidance. Review of the CDC guidelines for Pneumococcal Vaccine indicated the following: -Persons age [AGE] years or older who have previously received both PCV13 (Pneumococcal vaccine 13-valent) and PPSV23 (pneumococcal polysaccharide vaccine), AND PPSV23 was received at age [AGE] years or older: Based on shared clinical decision-making, give 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. 1. Resident #10 was admitted to the facility in February 2024 and was over the age of 65 at the time of the survey. Review of the medical record indicated the Resident/Representative signed the Resident Immunization Informed Consent form for Prevnar 13, 15, 20 (PCV 13, 15, 20) whichever is due based on CDC recommendation. Review of the immunization history for Resident #10 indicated the Resident had received PPSV23 in 2008 and had received PCV13 in 2012. Further review of the medical record failed to indicate Resident #10 was provided with PCV20. 2. Resident #5 was admitted to the facility in January 2010 and was over the age of 65 at the time of the survey. Review of the immunization history for Resident #5 indicated the Resident had received PPSV23 in 2010 and received PCV13 in 2015. Further review of the medical record failed to indicate Resident #5 was provided with PCV20. 3. Resident #21 was admitted to the facility in May 2021 and was over the age of 65 at the time of the survey. Review of the immunization history for Resident #21 indicated the Resident had received PPSV23 in 2014 and received PCV13 in 2017. Further review of the medical record failed to indicate Resident #21 was provided with PCV20. During an interview on 5/8/24 at 1:05 P.M., the Infection Control Preventionist said the process for immunizations was that the immunization history was reviewed on admission. She said when a resident is admitted she reviews the Massachusetts Immunization Information System (MIIS) and when most residents were admitted they had received the PPSV23 and the PCV13. She said she thought if the residents had both the PPSV23 and PCV13 they were fully vaccinated and were not eligible for PCV20. She said she did not know that residents who had previously been vaccinated greater than 5 years ago were eligible to receive the PCV20 vaccine. During an interview on 5/8/24 at 1:50 P.M., the Infection Control Preventionist said she had located the CDC guidance on PCV20 eligibility. She said the facility had not been offering or providing education on PCV20 to residents who had the vaccine series more than 5 years ago.

Based on observation, interview, policy review, and record review, the facility failed to treat one Resident (#19) with dignity and respect, out of a total sample of 14 residents, by not allowing the Resident to exercise his/her right to smoke without supervision and outside of the scheduled smoking times. Findings include: Review of the facility's policy titled Resident Smoking Policy, revised February 2023, indicated but was not limited to the following: -All residents who wish to smoke will be assessed by nursing for safety using the Assessment in the Electronic Health Record, upon admission, as identified with regards to safety and/or status changes and quarterly. A physician's order is required. -Resident smoking schedule is to be determined by the Risk Committee and visibly posted for all residents to view. -Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. Resident #19 was admitted to the facility in December 2020. Review of the Smoking-Safety Screen, dated 7/26/21 through 3/24/23, indicated Resident #19 was safe to smoke independently without supervision and had no cognitive loss. Review of the Smoking Agreement, signed by the Resident on 11/22/22, indicated but was not limited to the following: -Residents with smoking privileges requiring monitoring will require supervision. Review of the current Physician's Orders indicated the following: -Resident may smoke in designated smoking areas in accordance with OIH [Our Island Home] smoking policy, independently with supervision (2/17/23) During an interview on 4/23/23 at 11:50 A.M., Resident #19 said he/she felt his/her rights were being violated related to smoking times. Resident #19 said the scheduled smoking times were five hours apart and he/she was not allowed to go out to smoke outside of those times and had to be supervised/monitored. Review of the Resident Smoking Times and Location document posted in the facility indicated the following designated smoking times: Daily Times: 6:00 A.M. 9:30 A.M. 2:00 P.M. 6:30 P.M. 9:00 P.M. During an interview on 4/24/23 at 1:54 P.M., Resident #19 said, They treat me like a mental case and It's supervised. On 4/24/23 at 2:00 P.M., the surveyor observed Certified Nursing Assistant (CNA) #1 lead Resident #19 and three other residents outside onto the back patio to smoke. CNA #1 stayed outside for the duration supervising the residents. CNA #1 said the smoking times are scheduled and residents don't go out in between. She said they have to be supervised and do not come out independently. During an interview on 4/25/23 at 12:48 P.M., Nurse #3 said she wasn't sure why the physician's order said supervision or why the Resident can't go outside to smoke when he/she wants if he/she's independent without supervision and would have to ask the Director of Nurses (DON). On 4/25/23 at 1:22 P.M., the surveyor observed Resident #19 approach the nurses' station and ask Nurse #3 to go outside to smoke. Nurse #3 said we just don't have anyone to go outside with you right now. Resident #19 shook his/her head and walked away. During an interview on 4/26/23 at 8:04 A.M., Resident #19 said he/she wants to go outside to smoke by him/herself and asks staff but is told no. During an interview on 4/25/23 at 4:40 P.M., Physician #2 said she was asked by the facility to write a facility wide smoking mandate order but there was no reason as far as she was concerned that Resident #19 would need supervision for smoking. She said Resident #19 was more independent than all the other smokers and should be able to exercise his/her right to smoke. During an interview on 4/26/23 at 8:09 A.M., the Administrator said he sat down with the smoking residents, and they agreed to the smoking times, but the program is a work in progress and the times are not etched in stone. He said if there's staff availability, they'll try to allow residents to smoke outside of those times but no promises. He said the program is still fluid and can be changed. During an interview on 4/26/23 at 8:19 A.M., the DON said Resident #19 can smoke independently and can go out independently. She said staff don't need to go out with him/her but need to keep eyes on him/her for safety reasons.

Based on observations, interviews, and record review, the facility failed to ensure the Physician was notified of a Hospice recommendation for a change in treatment for one Resident (#27), in a total sample of 14 residents. Findings include: Resident #27 was admitted to the facility in May 2021 with diagnoses including a history of a stroke without residual deficits and atrial fibrillation. Review of the medical record indicated a 3/24/23 Physician's Order to admit to Hospice services. Review of Hospice documentation indicated a 4/14/23 Hospice Nurse progress note: -Observations: edema in both hands/forearms; very painful to the touch -Consider towel/washcloth rolls to both hands -Consider Tramadol (opioid analgesic) for pain in hands, 25 milligrams (mg) every six hours as needed (PRN) Review of the medical record failed to indicate the Hospice's Nurse's recommendations for towel/washcloth rolls to both hands and Tramadol for pain in hands was communicated to the Physician and addressed. On 4/23/23 at 3:00 P.M., the surveyor observed Resident #27 sitting in a Broda (positioning) chair in the unit hallway. The Resident's hands were contracted resting on pillows. There were no towels or washcloth rolls in either of his/her hands. During an interview on 4/25/23 at 10:30 A.M., Hospice Nurse #1 said she sees Resident #27 weekly and writes notes and recommendations in a communication book. The process is that facility staff inform the Resident's attending Physician of her recommendations for approval. The Nurse said she recommended bilateral rolled towels or washcloths for the Resident's hands and Tramadol last week because of painful contractures. The surveyor and Hospice Nurse #1 reviewed her 4/14/23 note with recommendations for towel/washcloth rolls for both hands and she said it had not been addressed by the Physician yet. On 4/25/23 at 11:15 A.M., the surveyor observed Resident #27 seated in a Broda chair in the dayroom. Both of the Resident's arms were elevated on pillows and no towel or washcloth rolls were in the Resident's hands. During an interview on 4/25/23 at 11:52 A.M., the surveyor and Nurse #3 reviewed Resident #27's medical record and Hospice communication book. She said the Hospice Nurse's recommendations for towel or washcloth rolls for the Resident's hands and Tramadol were not communicated to the Physician by facility staff. She said the Physician should have been notified timely so interventions for the Resident's contractures and pain could be implemented right away.

2. Review of the facility's policy titled Resident Smoking Policy, dated 9/2021, indicated but was not limited to the following: -All Residents who wish to smoke will be assessed by nursing for safety using the Assessment in the electronic medical record, upon admission, as identified with regards to safety and/or status changes, and quarterly. Resident #38 was admitted to the facility in November 2022 with diagnoses including chronic obstructive pulmonary disease. Review of documentation provided by the facility indicated Resident #38 was one of five smokers in the facility. Review of the medical record indicated smoking assessments were completed on 11/10/22, 11/15/22, and 11/22/22. No other assessments were in the medical record. According to facility policy, Resident #38 should have had a quarterly smoking assessment conducted in March 2023. During an interview on 4/25/23 at 11:52 A.M., Nurse #3 reviewed the Resident's medical record and said only the original smoking assessment was conducted in 11/2022. She said a schedule was not set up and the quarterly smoking assessment was not done. Based on record review, policy review, and interview, the facility failed to provide an environment that would remain free of accidents and hazards for two Residents (#39 and #38), in a total sample of 14 residents. Specifically, the facility failed to ensure: 1. Resident #39's wander guard device was checked weekly to ensure proper functioning; and 2. Resident #38 had a quarterly smoking assessment completed. Findings include: 1. Review of the facility's policy titled Wandering Monitoring Device Policy, dated 11/2020, included but was not limited to: -All residents assessed to be a wandering/elopement risk will wear a monitoring transmitter at all times. -The proper functioning of transmitters will be checked weekly by the nursing staff and as needed if malfunction is noted or suspected. -Transmitter checks will be documented on the log. -The wandering monitoring device will be checked for placement every shift by the nursing team. Resident #39 was admitted to the facility in December 2022 with diagnoses that included chronic atrial fibrillation, diabetes mellitus, dementia, and history of elopement. Review of the April 2023 Physician's Orders indicated the following: -Wander guard bracelet; Check placement every shift; Location right ankle (expiration date 7/23/23) -Check wander guard function every week Review of the Treatment Administration Record (TAR) for February, March, and April 2023 did not indicate that the wander guard had been checked weekly to ensure it was functioning per the physician's order and facility policy. During an interview on 4/25/23 at 2:40 P.M., Nurse #3 said the order to check the functioning of the wander guard weekly had been incorrectly entered into the Electronic Medical Record (EMR) and that the order for the weekly checks to ensure functioning was not carried over to populate onto the TAR. Nurse #3 said there was no documentation indicating the weekly checks were completed as ordered by the physician and per the facility policy and that it was not monitored to ensure proper functioning.

Based on record review, policy review, and interview, the facility failed to ensure that services were coordinated with the Hospice provider to implement the resident's plan of care as required for two Residents (#24 and #27), from of a total sample of 14 residents. Specifically, the facility failed to ensure an integrated care plan was developed to accurately reflect services provided by both the Hospice provider and facility staff. Findings include: Review of the facility's policy titled Hospice, undated, included but was not limited to: -Coordinated care plans for residents receiving Hospice services will include the most recent Hospice plan of care as well as the care and services provided by our facility, including the responsible provider and discipline assigned to specific tasks to maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. Resident #24 was admitted to the facility in September 2022 with diagnoses including Alzheimer's disease. Review of the April 2023 Physician's Orders included but was not limited to: -Admit to Hospice services (3/9/23) Review of Hospice documentation indicated Resident #24 received Hospice skilled nursing once a week for 13 weeks (3/9/23 - 6/3/23) and 4 as needed visits for 13 weeks (3/9/23 - 6/3/23). Review of interdisciplinary care plans included but was not limited to: Problem: Resident has a terminal prognosis and was admitted to Hospice on 3/9/23 (3/13/23) Interventions: Adjust provision of activities of daily living to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate (3/13/23); Encourage support system of family and friends (3/13/23); Keep the environment quiet and calm (3/13/23); Observe resident closely for signs of pain, administer pain medications as ordered (3/13/23); Work cooperatively with Hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met (3/13/23); Work with nursing staff to provide maximum comfort for the resident (3/13/23) Goal: The Resident's comfort will be maintained through the review date (3/13/23) The care plan was not integrated and failed to include a description of the facility and Hospice services provided to the Resident. 2. Resident #27 was admitted to the facility in May 2021 with diagnoses including dementia. Review of the April 2023 Physician's Orders included but was not limited to: -Admit to Hospice services (3/24/23) Review of Hospice documentation indicated Resident #27 received Hospice skilled nursing twice a week for 14 weeks (3/24/23 - 6/21/23), 4 as needed visits for 14 weeks (3/24/23 - 6/21/23) and 3 Hospice Aide visits every week for 14 weeks (3/24/23 - 6/21/23). Review of interdisciplinary care plans included but was not limited to: -Problem: Resident has a terminal diagnosis (3/24/23) -Interventions: Keep the environment quiet and calm (4/3/23); Observe resident closely for signs of pain, administer pain medications as ordered (4/3/23); Work cooperatively with Hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met (4/3/23); Work with nursing staff to provide maximum comfort for the resident (4/3/23). The care plan was not integrated and failed to include a description of the facility and Hospice services provided to the Resident. During an interview on 4/25/23 at 11:52 A.M., the surveyor and Nurse #3 reviewed Residents #24 and #27's medical records. She said the comprehensive care plans are not integrated and do not include a description of Hospice services and facility services provided to the Residents.

2. Resident #5 was admitted to the facility in April 2022 with diagnoses including congestive heart failure, type 2 diabetes mellitus, and adjustment disorder with mixed anxiety and depressed mood. Review of the 1/18/23 Minimum Data Set (MDS) assessment indicated Resident #5 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15, had mild depression as evidenced by a depression score of 6 out of 27, and received antidepressant medication daily. Review of April 2023 Physician's Orders included the following psychotropic medication: -Risperdal (antipsychotic) 0.5 mg at bedtime (4/14/23) Review of comprehensive care plans included but was not limited to: -Problem: The Resident uses the psychotropic medication Risperdal related to disease process, diagnosis of bipolar disorder (4/13/23) -Interventions: Administer psychotropic medications as ordered. Monitor side effects and effectiveness. Monitor/document/report any adverse reactions of the medication (4/13/23) -Goal: The Resident will be/remain free from psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date (4/13/23) Further review of the care plan failed to identify Resident specific targeted signs and symptoms for the use of Risperdal and any specific non-pharmacological approaches and measurable goals to meet the Resident's needs. During an interview on 4/25/23 at 11:52 A.M., Nurse #3 reviewed Resident #5's medical record. She said the care plans don't include Resident specific targeted behaviors, non-pharmacological interventions and measurable goals for the use of Risperdal but should. 3. Resident #24 was admitted to the facility in September 2022 with diagnoses including Alzheimer's disease. Review of the 3/15/23 MDS assessment indicated Resident #24 had severe cognitive impairment as evidenced by a BIMS score of 4 out of 15, had mild depression as evidenced by a depression score of 8 out of 27, and received antidepressant medication daily. Review of April 2023 Physician's Orders included the following psychotropic medication: -Lorazepam 0.5 mg, give one tablet every two hours as needed for mild to moderate anxiety (3/9/23) -Lorazepam 0.5 mg, give two tablets every two hours as needed for severe anxiety (3/9/23) -Mirtazapine 7.5 mg, give 7.5 mg in the evening for depression (3/17/23) Review of comprehensive care plans included but was not limited to: -Problem: Resident has depression related to dementia (3/16/23) -Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Monitor/document/report any signs/symptoms of depression including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing negative statements, repetitive anxious or health-related complaints, tearfulness (3/16/23) -Goals: Resident will remain free of signs/symptoms of distress, symptoms of depression, anxiety or sad mood through review date (3/16/23) Further review of the care plan failed to identify Resident specific targeted signs and symptoms for the use of Lorazepam and Remeron and any specific non-pharmacological approaches and measurable goals to meet the Resident's needs. During an interview on 4/25/23 at 11:52 A.M., Nurse #3 reviewed Resident #24's medical records. She said the care plans don't include Resident specific targeted behaviors, non-pharmacological interventions and measurable goals for the use of Lorazepam but should. 4. Resident #38 was admitted to the facility in November 2022 with diagnoses including opioid abuse with unspecified opioid-induced disorder. Review of the 2/15/23 MDS assessment indicated Resident #38 was cognitively intact as evidenced by a BIMS score of 11 out of 15, and had a diagnosis of opioid abuse with unspecified opioid-induced disorder. Review of the April 2023 Physician's Orders included but was not limited to: -Methadone HCI, 10 mg every eight hours for history of opioid abuse (11/9/22) Review of the medical record failed to indicate a person-centered care plan had been developed for the Resident's diagnosis of opioid abuse with unspecified opioid-induced disorder and use of Methadone that included interventions, measurable objectives and timeframes to meet the Resident's needs. During an interview on 4/24/23 at 3:50 P.M., the Director of Nursing (DON) said she did not develop a specific care plan for the Resident's opioid use disorder but added the diagnosis to another care plan. The DON said she should have developed a care plan to address the Resident's opioid use disorder that included interventions and measurable goals. Based on record review and interview, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for four Residents (#39, #5, #24, and #38), out of a total sample of 14 residents. Specifically, the facility failed to ensure that: 1. Resident #39 had a care plan developed for anticoagulant therapy; 2. Resident #5 had a care plan developed for the use of Risperdal (antipsychotic); 3. Resident #24 had a care plan developed for the use of Ativan (antianxiety) and Remeron (antidepressant); and 4. Resident #38 had a care plan developed for substance use disorder (SUD). 1. Resident #39 was admitted to the facility in December 2022 with diagnoses that included chronic atrial fibrillation, diabetes mellitus, and dementia. Review of the April 2023 Physician's Orders indicated the following: -Apixaban (Eliquis) Tablet (blood thinner/anticoagulant) 2.5 milligrams (mg); Give one tablet by mouth two times a day. Review of the April 2023 Medication Administration Record (MAR) indicated that the Resident was receiving the anticoagulant medication daily as ordered by the physician. Further medical record review of the comprehensive care plans failed to indicate that a care plan had been developed for the Resident addressing the administration of the anticoagulant/blood thinner Eliquis. During an interview on 4/25/23 at 2:40 P.M., Nurse #3 reviewed the comprehensive care plans and said that the facility failed to have an individualized comprehensive care plan for Resident #39 addressing the administration of the anticoagulant/blood thinner Eliquis.

5. Resident #19 was admitted to the facility in December 2020 with diagnoses including Type 2 diabetes mellitus with hyperglycemia and stage 1 through stage 4 chronic kidney disease. Review of the Minimum Data Set (MDS) assessment, dated 3/14/23, indicated Resident #19 received insulin injections daily. Review of current Physician's Orders indicated the following: -Novolog Solution (Insulin Aspart) (fast acting insulin to control blood sugar around mealtimes) 100 Units/Milliliter (ml), inject as per sliding scale (varies the dose of insulin based on blood glucose level) if: 200-250 = 2 units, Inject 2 units subcutaneously (SC) 251-300 = 3 units, Inject 3 units SC 301-350 = 4 units, Inject 4 units SC 351-400 = 5 units, Inject 5 units SC 401-999 = 6 units, Inject 6 units SC and call MD, SC one time a day related to Type 2 Diabetes Mellitus with hyperglycemia, 7/19/22 -Levemir Solution 100 Unit/ml (Insulin Detemir), 14 units subcutaneously in the morning related to Type 2 Diabetes Mellitus with hyperglycemia, 4/20/23 The physician's orders failed to include an order to monitor for signs and symptoms of hypo/hyperglycemia. Further review of physician's orders failed to indicate an order to perform CBG testing to correlate with the administration of sliding scale insulin and Levemir insulin and failed to indicate instructions/ranges for when the physician was to be notified of a low CBG result. During an interview on 4/25/23 at 2:59 P.M., Nurse #3 said there was no physician's order to monitor for signs and symptoms of hypo/hyperglycemia and it was not being done. She said if there was no order, then it would not be on the MAR or TAR for staff to document. 6. Resident #20 was admitted to the facility in May 2018 with diagnoses including Type 2 diabetes mellitus with ketoacidosis (serious diabetes complication where the body produces excess blood acids, ketones) without coma. Review of the current Physician's Orders indicated the following: -Metformin HCl ER Tablet, Extended Release 24 hour, give 500mg by mouth two times a day for Diabetes Mellitus Type 2, 7/19/21 The physician's order failed to include an order to monitor for signs and symptoms of hypo/hyperglycemia. Further review of physician's orders failed to indicate instructions/ranges for when the physician was to be notified of a high or low CBG result. During an interview on 4/25/23 at 3:28 P.M., Nurse #3 said there was no order to monitor for signs and symptoms of hypo/hyperglycemia so it would not be on the MAR or TAR for nurses to document. During an interview on 4/26/23 at 8:37 A.M., the Director of Nursing (DON) said side effects should be monitored for all high-risk medications including diabetic agents. She said staff should be monitoring for signs and symptoms of hypo/hyperglycemia. Based on interview, record review, and policy review, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for six Residents (#14, #27, #1, #39, #19, and #20), out of a total sample of 14 residents. Specifically, the facility failed: 1. For Resident #14, to ensure a Physician's order was obtained for psychotherapy; 2. For Resident #27: a. to ensure Physician's orders were in place for monitoring hyper/hypoglycemia and treatment interventions to address the potential for hyperglycemia, and b. to ensure Physician's orders were in place for fingerstick blood sugars (FSBS) in order to implement hypoglycemic protocol; 3. For Resident #1, to ensure orders were in place for FSBS to correlate with orders for sliding scale insulin; 4. For Resident #39, a. to ensure a range/instructions were identified for physician notification of either a low blood sugar or a high blood sugar and protocols/interventions for hyperglycemia, and b. to ensure weights were obtained according to physician's orders; 5. For Resident #19, to ensure orders were in place for FSBS to correlate with orders for sliding scale insulin; and 6. For Resident #20, to ensure orders were in place to monitor for signs and symptoms of hyper/hypoglycemia. Findings include: 1. Resident #14 was admitted to the facility in January 2023 with diagnoses including major depressive disorder. Review of the 3/6/23 Minimum Data Set (MDS) assessment indicated Resident #14 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15, had mild depression as evidenced by a depression score of 8 out of 27, and received antidepressant medication. Review of the medical record indicated Resident #14 received one to one (1:1) psychotherapy from the consultant psychiatric provider since admission to the facility. During an interview on 4/24/23 at 2:04 P.M., the Social Worker said that Resident #14 has 1:1 psychotherapy sessions every two weeks utilizing Zoom (a communication platform that allows users to connect with video, audio, phone, and chat) on a computer. Further review of the medical record failed to indicate a Physician's Order for the provision of psychotherapy. During an interview on 4/25/23 at 11:55 A.M., Nurse #3 said there was no Physician's order in place for 1:1 psychotherapy. 2. Review of the facility's policy titled Diabetic Management, dated 1/2023, included but was not limited to: Signs and symptoms of hyperglycemia: -increased thirst; -dry mouth; -increased urination; -headache; -lethargy; -restlessness; and -loss of appetite. Diabetic ketoacidosis (a serious complication of diabetes that can be life-threatening) or hyperosmolar (a condition in which the blood has a high concentration of salt (sodium), glucose, and other substances) coma includes the following symptoms: -high blood sugar; -ketones in the urine; -nausea and/or vomiting; -lethargy Signs and symptoms of hypoglycemia usually have a sudden onset and may include the following: -restless and/or muscle twitching; -tachycardia (increased heart rate) -pale, cool, moist skin -excessive perspiration; -irritability or bizarre changes in behavior; -blurred or impaired vision; -headaches; -numbness of the tongue and lips/thick speech; -stupor, unconsciousness and/or convulsions; and -coma Resident #27 was admitted to the facility in May 2021 with diagnoses including type 2 diabetes mellitus. Review of the April 2023 Physician's Orders included but was not limited to: -Glucagon (a hormone that your pancreas makes to help regulate your blood glucose (sugar) levels) 1 milligram (mg) inject 1 mg intramuscularly as needed for capillary blood glucose (CBG) less than 60 and if resident unresponsive/unable to swallow (5/25/21) -Glucose Gel 15 grams (gm) geltube, give 15 grams by mouth as needed for signs/symptoms of hypoglycemia and/or CBG less than 60, may repeat times 1 in 15 minutes if no improvement (5/25/21) The physician's orders failed to indicate an order to monitor for signs and symptoms of hyper/hypoglycemia (high/low blood sugar), failed to include an order for fingerstick blood sugars to obtain the capillary blood glucose level to implement the hypoglycemic protocol, and failed to include interventions for the potential of hyperglycemia. During an interview on 4/25/23 at 11:52 A.M., Nurse #3 said residents with diabetes should have orders in place to monitor for hyper and hypoglycemia as well as interventions. She said without orders in place to test the residents' capillary blood sugar, staff are not able to implement the hypoglycemic protocol. 3. Resident #1 was admitted to the facility in February 2021 with diagnoses that included diabetes mellitus and depression. Review of the April 2023 Physician's Orders indicated the following: -Tradjenta Tablet 5 MG, Give 1 tablet by mouth one time a day. Hold if does not eat breakfast. -Levemir Subcutaneous Solution 100 UNIT/ML (Insulin-Detemir) Inject 12 units subcutaneously in the morning -Novolog Solution 100 UNIT/ML (Insulin-Aspart) Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 999 = 8 units and notify MD, subcutaneously before meals at 6:30 A.M., 11:30 A.M. and 4:30 P.M. Further record review did not indicate a physician's order to obtain/perform Capillary Blood Glucose (CBG)/Finger Stick Blood Sugar (FSBS) checks at 6:30 A.M., 11:30 A.M., and 4:30 P.M. that correlated with the administration of the sliding scale insulin. During an interview on 4/25/23 at 2:31 P.M., Nurse #3 said that there should be an order for obtaining/performing the CBG/FSBS to correlate with the sliding scale and there was not. 4a. Resident #39 was admitted to the facility in December 2022 with diagnoses that included chronic atrial fibrillation, diabetes mellitus, and dementia. Review of the April 2023 Physician's Orders indicated the following: Capillary Blood Glucose (CBG) via fingerstick one time a day every Wednesday, Friday, Sunday related to Type 2 Diabetes Mellitus with other circulatory complications. The order start date was 12/12/23 at 8:00 A.M. Record review indicated on 4/12/23 the above order was discontinued, and the following order was initiated: Fasting Capillary Blood Glucose (CBG) via fingerstick one time a day every Wednesday, Friday, Sunday related to Type 2 Diabetes Mellitus with other circulatory complications at 6:00 A.M. Further review of the April 2023 Physician's Orders failed to indicate a range/instructions for physician notification of either a low CBG or a high CBG or protocols/interventions for hyperglycemia. During an interview on 4/25/23 at 2:40 P.M., Nurse #3 said the CBG results should have specific ranges for physician notification with protocols for low/high blood sugar interventions and there was not. b. Review of the April 2023 Physician's Orders indicated the following: Monitor weight; Notify physician if gain of 3 pounds in one day or 5 pounds in one week; In the morning every other day (start date 2/17/23). Review of the March 2023 and the April 2023 Medication Administration Records (MAR) and Treatment Administration Records (TAR) indicated the following weights were not obtained every other day as ordered by the physician: -3/5/23, 3/9/23, 3/11/23, 3/15/23, 3/21/23, 3/23/23, 3/25/23, 3/27/23, 4/4/23, 4/6/23, and 4/22/23. During an interview on 4/25/23 at 2:40 P.M., Nurse #3 confirmed that the Resident's weights had not been obtained every other day as per the physician's orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to ensure that the resident's drug regimen was free from unnecessary drugs without adequate monitoring for signs/symptoms of adverse consequences (i.e., side effects) to ensure the safe administration of medications for seven Residents (#11, #19, #7, #12, #5, #1, and #39), in a total sample of 14 residents. Specifically, the facility failed to ensure that: 1. Residents #11, #19, #7, #12, and #5 were monitored for signs/symptoms of adverse consequences (i.e., side effects) and the effectiveness of an anti-coagulant; 2. Resident #1 was monitored for signs/symptoms of adverse consequences (i.e., side effects) and the effectiveness of an anti-diabetic agent; and 3. Resident #39 was monitored for signs/symptoms of adverse consequences (i.e., side effects) and the effectiveness of an anti-coagulant and anti-diabetic agent. Findings include: 1. Review of the facility's policy titled Anticoagulation Therapy and International Ratio (INR) Testing (revised August 2020) indicated but was not limited to the following: -Residents on anticoagulation therapy (Warfarin, Low Molecular Weight Heparin, etc.) will have ongoing monitoring of therapy to assure safety and effectiveness of medications. -Residents on anticoagulation therapy will be monitored for any increased bleeding. A. Resident #11 was admitted to the facility in March 2023 and had diagnoses including a personal history of pulmonary embolism (PE- condition in which one or more arteries in the lungs become blocked by a blood clot). Review of the current Physician's Orders indicated the following: -Eliquis (Apixaban) Tablet 2.5 milligrams (mg), give 1 tablet by mouth two times a day for anticoagulant, 8/11/22 Review of the Bristol-[NAME] Squibb Eliquis (Apixaban) package insert, revised September 2021, indicated the following: -Eliquis is a factor Xa inhibitor indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation and for the prophylaxis of DVT (deep vein thrombosis), which may lead to pulmonary embolism. Warnings and Precautions: -Eliquis can cause serious, potentially fatal, bleeding. Promptly evaluate signs and symptoms of blood loss. Review of the April 2023 Medication Administration Record (MAR) indicated the following: -Eliquis Tablet, administered daily from 4/1/23 through 4/23/23 Further review of the medical record failed to indicate Resident #11 was being adequately monitored for signs and symptoms of bleeding related to the use of a blood thinner. During an interview on 4/25/23 at 3:26 P.M., Nurse #3 said there was no order to monitor for signs and symptoms of bleeding, so it would not be carried over to the MAR or Treatment Administration Record (TAR) to be monitored. B. Resident #19 was admitted to the facility in December 2020 with diagnoses including a personal history of pulmonary embolism and chronic embolism and thrombosis of other specified veins. Review of the current Physician's Orders indicated the following: -Xarelto Tablet (Rivaroxaban) 15mg, give 1 tablet by mouth in the evening for anticoagulation therapy, 12/29/20 Review of the [NAME] Pharmaceuticals Xarelto packet insert, revised February 2023, indicated the following: -Xarelto is a factor Xa inhibitor indicated for the treatment of deep vein thrombosis and pulmonary embolism Warnings and Precautions: -Risk of bleeding: Xarelto can cause serious and fatal bleeding Review of the April 2023 MAR indicated the following: -Xarelto Tablet, administered daily from 4/1/23 through 4/30/23 Further review of the medical record failed to indicate Resident #19 was being adequately monitored for signs and symptoms of bleeding related to the use of a blood thinner. During an interview on 4/25/23 at 3:24 P.M., Nurse #3 said there was no order to monitor for signs and symptoms of bleeding, so it would not be carried over to the MAR or TAR to be monitored. C. Resident #7 was admitted to the facility in January 2010 and recently diagnosed with an aortic thrombosis related to atrial fibrillation. Review of the April 2023 Physician's Orders indicated the following: Apixaban (Eliquis) Oral Tablet, 5 mg, Give one tablet by mouth two times a day (start date 4/12/23). The physician's orders failed to include monitoring of potential complications/adverse consequences for the use of Eliquis. Review of the April 2023 MAR indicated that the Resident was receiving the anticoagulant medication twice a day as ordered by the physician. Review of the comprehensive care plan indicated but was not limited to the following: -Problem-Resident is taking Anti-Coagulation Therapy Eliquis to prevent thrombus from Afib -Goal-Resident will show no signs/symptoms of bleeding (date initiated 4/13/23) -Interventions-Evaluate for blood in stools; Evaluate for bruising; Evaluate for signs and symptoms of bleeding Further medical record review failed to indicate the staff were monitoring for signs or symptoms of bleeding/potential adverse side effects related to the administration of the anticoagulant Eliquis. During an interview on 4/25/23 at 2:35 P.M., Nurse #3 said that the facility failed to monitor for signs or symptoms of bleeding/potential adverse side effects related to Resident #7 receiving an anticoagulant. D. Resident #12 was admitted to the facility in September 2014 with diagnoses including frontotemporal dementia with behavioral disturbances, depression, anxiety, and mood disorder, pulmonary emboli, and deep vein thrombosis. Review of the April 2023 Physician's Orders indicated the following: -Xarelto tablet 20 mg, Give 20mg by mouth in the evening for treatment to prevent reoccurrence of blood clot in the lung. The physician's orders failed to include monitoring of potential complications/adverse consequences for the use of Xarelto. Review of the April 2023 MAR indicated that the Resident was receiving the anticoagulant medication daily as ordered by the physician. Review of the comprehensive care plan indicated but was not limited to the following: Problem:Resident has a deep vein thrombosis related to immobility and takes Xarelto Goal- Resident will remain free of complications related to anticoagulation therapy Interventions- Monitor for signs and symptoms of bleeding due to the use of a blood thinner Further medical record review failed to indicate the staff were monitoring for signs or symptoms of bleeding/potential adverse side effects related to the administration of the anticoagulant/blood thinner Xarelto. During an interview on 4/25/23 at 2:35 P.M., Nurse #3 said that the facility failed to monitor for signs or symptoms of bleeding/potential adverse side effects related to Resident #12 receiving an anticoagulant/blood thinner. E. Resident #5 was admitted to the facility in April 2022 with diagnoses including atrial fibrillation. Review of the 1/18/23 Minimum Data Set (MDS) assessment indicated Resident #5 received anticoagulant medication daily. Review of the April 2023 Physician's Orders included the following anticoagulant medication: Apixaban 2.5 mg two times a day (4/20/22) The physician's orders failed to include monitoring for signs and symptoms of adverse consequences of taking anticoagulant medication. During an interview on 4/25/23 at 11:52 A.M., Nurse #3 reviewed Resident #5's medical record and said the Resident did not have an order for monitoring for side effects for the use of an anticoagulant medication such as increased bleeding. During an interview on 4/26/23 at 8:48 A.M., the Director of Nursing said it was her expectation that staff should be monitoring for signs and symptoms of adverse effects of anticoagulant medications. 2. Resident #1 was admitted to the facility in February 2021 with diagnoses that included diabetes mellitus and depression. Review of the April 2023 Physician's Order indicated the following: -Trajenta Tablet 5 MG (linaGLIPtin), Give 1 tablet by mouth one time a day, Hold if does not eat breakfast (8:00 A.M.) -Levemir Subcutaneous Solution 100 UNIT/Milliliter (ML) (Insulin Detemir) Inject 12 units subcutaneously in the morning at 6:00 A.M. -Novolog Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 999 = 8 units and notify MD, subcutaneously before meals at 6:30 A.M., 11:30 A.M., and 4:30 P.M. The physician's orders failed to include monitoring of potential complications/adverse consequences and for the monitoring for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar). Review of the April 2023 MAR indicated that the Resident was receiving the anti-diabetic medication and insulin as ordered by the physician. Review of the comprehensive care plan indicated but was not limited to the following: Problem- Metabolism altered- Resident has diabetes mellitus Goal-Resident will be free from any signs and symptoms of hypoglycemia and hyperglycemia. Interventions-Monitor/document/report as needed (PRN) any signs and symptoms of hypoglycemia; sweating, tremors, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait. Diabetes medication as ordered by doctor. Monitor for/document side effects and effectiveness. Further medical record review failed to indicate the staff were monitoring for signs or symptoms of hypoglycemia/hyperglycemia and potential adverse side effects related to the administration of the anti-diabetic medication and insulin. During an interview on 4/25/23 at 2:35 P.M., Nurse #3 said that the facility failed to monitor for signs or symptoms of hypoglycemia/hyperglycemia and potential adverse side effects related to Resident #1 receiving an anti-diabetic medication and insulin. 3a. Resident #39 was admitted to the facility in December 2022 with diagnoses that included chronic atrial fibrillation, diabetes mellitus, and dementia. Review of the April 2023 Physician's Orders indicated the following: Apixaban Tablet (Eliquis), 2.5 mg, Give one tablet by mouth two times a day. The Physician's orders failed to include monitoring of potential complications/adverse consequences for the use of Eliquis. Review of the April 2023 MAR indicated that the Resident was receiving the anticoagulant medication daily as ordered by the physician. Further medical record review failed to indicate the staff were monitoring for signs or symptoms of bleeding/potential adverse side effects related to the administration of the anticoagulant/blood thinner Eliquis. During an interview on 4/25/23 at 2:40 P.M., Nurse #3 said that the facility failed to monitor for signs or symptoms of bleeding/potential adverse side effects related to Resident #39 receiving an anticoagulant/blood thinner. b. Review of the April 2023 Physician's Orders indicated the following: Lantus SoloStar Subcutaneous Solution Pen-Injector 100 Unit/ml, Inject 8 units subcutaneously at bedtime. Metformin HCL tablet 1000 mg, Give one tablet by mouth twice a day. The physician's orders failed to include monitoring of potential complications/adverse consequences and for the monitoring for hypoglycemia and hyperglycemia. Review of the April 2023 MAR indicated that the Resident was receiving the anti-diabetic medication and insulin as ordered by the physician. Review of the comprehensive care plan indicated but was not limited to the following: Problem- Metabolism altered- Resident has diabetes mellitus Goal-Resident will be free from any signs and symptoms of hypoglycemia and hyperglycemia. Interventions-Monitor/document/report as needed (PRN) any signs and symptoms of hypoglycemia; sweating, tremors, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait; Diabetes medication as ordered by doctor. Monitor for/document side effects and effectiveness. Further medical record review failed to indicate the staff were monitoring for signs or symptoms of hypoglycemia/hyperglycemia and potential adverse side effects related to the administration of the anti-diabetic medication and insulin. During an interview on 4/25/23 at 2:40 P.M., Nurse #3 said that the facility failed to monitor for signs or symptoms of hypoglycemia/hyperglycemia and potential adverse side effects related to Resident #39 receiving an anti-diabetic medication and insulin.

3. Resident #11 was admitted to the facility in March of 2023 with diagnoses including Alzheimer's disease, anxiety disorder, major depressive disorder, unspecified psychosis, schizoaffective disorder bipolar type, and dementia. Review of current Physician's Orders indicated the following: -Lexapro (Escitalopram Oxalate) Tablet 5mg (milligram), give 3 tablets by mouth one time a day for depression, 9/10/22 -Trazodone (antidepressant and sedative) HCL tablet, give 25mg by mouth at bedtime for insomnia, 3/1/23 The physician's orders failed to include monitoring of side effects for the use of the psychotropic medications as required. Review of the March 2023 and April 2023 Medication Administration Records (MAR) indicated Resident #11 received the medications as ordered by the physician. During an interview on 4/25/23 at 3:26 P.M., Nurse #3 said there was no order to monitor for side effects for the Lexapro and Trazodone and, if no order, then it would not be carried over to the MAR or Treatment Administration Record (TAR) for nurses to document monitoring. 4. Resident #19 was admitted to the facility in December 2020 with diagnoses including major depressive disorder. Review of the current Physician's Orders included the following: -Fluoxetine HCL Capsule 40mg, give 1 capsule by mouth one time a day related to major depressive disorder, 3/23/21 The physician's orders failed to include monitoring of side effects for the use of psychotropic medication as required. Review of the April 2023 MAR indicated Resident #19 received the medication as ordered by the physician. During an interview on 4/25/23 at 9:24 A.M., Nurse #3 said there was no order to monitor for side effects for the use of Fluoxetine and it was not being monitored on the MAR or TAR. 5. Resident #20 was admitted to the facility in May 2018 with diagnoses including Alzheimer's disease, anxiety disorder, major depressive disorder, unspecified psychosis, and schizoaffective disorder bipolar type. Review of the current Physician's Orders included the following: -Cymbalta (Duloxetine) capsule delayed release particles 60mg, give 1 capsule by mouth one time a day related to major depressive disorder, 6/21/19 The physician's orders failed to include monitoring of side effects for the use of psychotropic medication as required. Review of the April 2023 Medication Administration Record indicated Resident #20 received the medication as ordered by the physician. During an interview on 4/25/23 at 3:29 P.M., Nurse #3 said there was no order to monitor for side effects for Cymbalta, so it was not carried over to the MAR or TAR for monitoring. During an interview on 4/26/23 at 8:47 A.M., the Director of Nursing (DON) said residents on psychotropic medications should be monitored for side effects.Based on record review, policy review, and staff interview, the facility failed to ensure for seven Residents (#24, #27, #11, #19, #20, #1, #12), out of a total sample of 14 Residents, that each Resident's drug regimen was free from unnecessary drugs to promote or maintain the Residents' highest practicable mental, physical, and psychosocial well-being. Specifically, the facility failed: 1. For Resident #24, an as needed (PRN) psychotropic medication was limited to 14 days; 2. For Resident #27, a PRN psychotropic medication was limited to 14 days; 3. For Resident #11, to monitor for side effects of Lexapro (antidepressant) and Trazodone (antidepressant and sedative); 4. For Resident #19, to monitor for side effects of Fluoxetine (antidepressant); 5. For Resident #20, to monitor for side effects of Duloxetine (antidepressant); 6. For Resident #1, to monitor for side effects of Zoloft (antidepressant); and 7. For Resident #12, to monitor for the side effects of Risperdal (antipsychotic), Ativan (antianxiety), Trazodone, and Zoloft (antidepressant). Findings include: Review of the facility's policy titled Psychotropic Medications, dated January 2023, indicated but was not limited to the following: -Based on comprehensive assessment of residents, the residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the medical record -The resident's need for the psychotropic medication shall be monitored, as well as when the resident has received optimal benefits from the medication and when the medication dose can be lowered or discontinued -Psychotropic drugs may be ordered by a physician when medically necessary to treat a specific condition or behavior, when indicated by an assessment of the resident, after non-pharmacological interventions have been tried and at the lowest possible dose -Behaviors for which these drugs are used must present a danger for residents or others, interfere with the staff's ability to provide care, or cause the resident frightful distress due to paranoia, hallucinations, or delusions -Licensed nurses shall be aware of potential side effects of psychotropic medications and report any side effects to the resident's attending physician 1. Resident #24 was admitted to the facility in September 2022 with diagnoses including Alzheimer's disease. Review of the MDS assessment indicted Resident #24 had severe cognitive impairment as evidenced by a BIMS score of 4 out of 15 and received psychotropic medication daily. Review of the April 2023 Physician's Orders included but was not limited to the following: -Lorazepam (antianxiety) 0.5 mg, give 1 tablet every 2 hours as needed for mild to moderate anxiety (3/9/23) -Lorazepam 0.5 mg, give 2 tablets every 2 hours as needed for severe anxiety (3/9/23) The physician's order failed to include a stop date or a re-evaluation date. 2. Resident #27 was admitted to the facility in May 2021 with diagnoses including dementia. Review of the April 2023 Physician's Orders included but was not limited to the following: -Lorazepam (antianxiety) 0.5 mg, give 1 tablet every 2 hours as needed for mild to moderate anxiety (3/24/23) -Lorazepam 0.5 mg, give 2 tablets every 2 hours as needed for severe anxiety (3/24/23) The physician's order failed to include a stop date or a re-evaluation date. During an interview on 4/26/22 at 8:48 A.M., the Director of Nurses said as needed psychotropic medications need to have a stop date and be re-evaluated for continued use.6. Resident #1 was admitted to the facility in February 2021 with diagnoses that included diabetes mellitus and major depressive disorder. Review of the April 2023 Physician's Orders indicated the following: -Zoloft 25 milligram (mg) tablet, Give 3 tablets (75 mg) by mouth one time a day (9:00 A.M.). Review of the comprehensive care plan included but was not limited to the following: Problem-Resident uses anti-depressant medication (Zoloft) related to depression Goal-Resident will be free from adverse reactions related to antidepressant Interventions-Monitor/document/report as needed (PRN) any adverse reactions to anti-depressant therapy-change in behavior/mood/cognition: hallucinations/delusions; social isolation; suicidal thoughts, withdrawal, decline in Activities of Daily Living(ADL) ability continence, no voiding, constipation fecal impaction, diarrhea, gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, nausea/vomiting, Dartmouth dry eyes. Further medical record review failed to indicate a physician's order or documentation by the staff for monitoring for signs or symptoms of adverse side effects related to the administration of the anti-depressant Zoloft. During an interview on 4/25/23 at 2:31 P.M., Nurse #3 reviewed the MAR, care plans, and TAR, and confirmed that the Resident was on an antidepressant and that no monitoring of these medications for side effects/adverse reactions or effectiveness was completed. 7. Resident #12 was admitted to the facility in September 2014 with diagnoses including frontotemporal dementia with behavioral disturbances, depression, anxiety, and mood disorder. Review of the April 2023 Physician's Orders indicated the following psychotropic medications: Lorazepam (anti-anxiety) Tablet 0.5 mg, Give one tablet by mouth in the afternoon Lorazepam Tablet 1 mg, Give one tablet by mouth in the morning Zoloft (anti-depressant) Tablet 25 mg, Give 4 tablets by mouth one time a day Risperdal (anti-psychotic) Tablet 0.5 mg, Give 0.5 mg tablet (dose is 0.25 mg) by mouth in the evening Trazodone (anti-depressant) Tablet 100 mg, Give one tablet by mouth in the evening Review of the comprehensive care plans indicated but was not limited to the following: -Problem- Resident is at risk for adverse reaction related to polypharmacy -Goal- Resident will be free of adverse drug reactions. -Interventions- Monitor for possible signs and symptoms of adverse drug reaction, falls, weight loss, fatigue, incontinence, agitation, lethargy, confusion, agitation, depression, poor appetite, constipation, gastric upset. -Problem- Resident uses psychotropic medications -Goal- Resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment. -Interventions- Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift. Monitor/document/report as needed any adverse reactions of psychotropic medications, unsteady gait, tardive dyskinesia, shuffling gait, rigid muscles, shaking, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Further medical record review failed to indicate a physician's order or documentation by the staff for monitoring for signs or symptoms of adverse side effects related to the administration of Lorazepam, Trazodone, Zoloft, and Risperdal. During an interview on 4/25/23 at 2:24 P.M., Nurse #3 reviewed the MAR, care plans and TAR, and confirmed that the Resident was on anti-depressants, anti-anxiety and anti-psychotics medications and that no monitoring of these medications for side effects/adverse reactions or effectiveness was completed.