**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to ensure that staff developed and implemented a baseline care plan within 48 hours of the resident's admission to address the Resident's constipation management identified in the hospital discharge summary, for one Resident (#63), in a total sample of 23 residents. Findings include: Review of the facility's policy titled Care Plans-Baseline, undated, included but was not limited to: -A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission. -The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. Resident #63 was admitted to the facility in February 2020 with diagnoses which included muscle weakness and transient cerebral ischemic attack. Review of the Hospital Discharge summary, dated [DATE], indicated due to constipation found on Computed Tomography (CT), we increased his/her laxative, increased Colace from daily to twice daily. Continued MiraLAX and Senna. Added as needed laxative and suppository. Please follow progress and adjust as needed. Review of the medical record indicated no baseline care plan was developed to address the Resident's constipation care needs. The baseline/comprehensive care plan failed to include any person-centered care instructions or interventions to address the Resident's constipation management. During an interview on 9/29/23 at 4:30 P.M., Unit Manager #3 reviewed Resident #63's medical record. She said a baseline care plan or comprehensive care plan should have been developed with individualized, person-centered interventions to address the Resident's constipation within 48 hours of the Resident's admission. She said it was not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, record review, and interview, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for one Resident (#29), out of 23 sampled residents. Specifically, the facility failed to develop a care plan to address the Resident's use of a continuous glucose monitoring device. Findings include: Review of the facility's policy titled Comprehensive Person-Centered Care Plans, dated March 2022, indicated but was not limited to the following: - comprehensive care plans include measurable objectives and timetables to meet a resident's psychosocial needs - the comprehensive care plan should reflect currently recognized standards of practice for problem areas Resident #29 was admitted to the facility in July 2023 with diagnoses including diabetes mellitus, type 2. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/11/23, indicated Resident #29 is cognitively intact as evidenced by a Brief Interview for Mental Status score of 14 out of 15, requires extensive assistance from staff for activity of daily living and receives insulin injections. During an interview on 9/26/23 at 9:25 A.M., Resident #29 said he/she has a Libre sensor device that continuously monitors his/her blood glucose and is implanted in his/her left arm. The Resident said he/she uses an electronic device to check his/her blood sugar level. The Resident said the sensor is changed every two weeks and is alternated between the right and left arm. Resident #29 said he/she is unable to remove and insert the new sensor on his/her own and must have it inserted by Nursing staff. Review of [NAME] Freestyle Libre Continuous Glucose Monitoring (CGM- https://www.freestyle.[NAME]/us-en/home.html), included but was not limited to: -the Libre CGM is a small sensor-based system that provides real-time glucose readings day and night, without fingersticks; -The sensor is applied to the back of the upper arm with a simple, disposable device called an applicator. When the sensor is applied, a small (5 millimeter) filament is inserted just under the skin and held in place with a small adhesive pad; -There is a needle (sharp) in the applicator to insert the filament in the back of your upper arm so the sensor can monitor your glucose. Review of Resident #29's comprehensive care plans failed to indicate a care plan had been developed to address the Resident's use of the Freestyle Libre Continuous Glucose Monitoring system. During an interview on 9/28/23 at 8:23 A.M., Unit Manager #1 reviewed Resident #29's medical record. She said there was no care plan for the Resident's use of the continuous glucose monitoring system, but a care plan should have been developed for its use.

Based on observation, record review, and interview, the facility failed to ensure staff provided respiratory care consistent with professional standards for one Resident (#29), out of a total sample of 28 residents. Specifically, the facility failed to ensure proper care and storage of the Resident's CPAP (Continuous Positive Airway Pressure) machine to reduce risk of infection. Findings include: Review of the facility's policy titled CPAP/BIPAP Support, undated, included but was not limited to: - Machine cleaning: Wipe machine with warm, soapy water and rinse at least once a week and as needed humidifier use clean distilled water only in the humidifier chamber. -Clean humidifier weekly and air-dry. -Filter cleaning: Rinse washable filter under running water once a week to remove dust and debris. Replace this filter at least once a year. -Mask, Nasal Pillows and Tubing: Clean daily by placing in warm soapy water and soaking agitating for 5 minutes mild dish detergent is recommended. Rinse with warm water and allow to air dry between uses. -Headgear Strap: Wash in warm water and mild detergent as needed. Allow to air dry. According to the U.S. Food and Drug Administration (fda.gov), CPAP Machine Cleaning: Ozone, UV Light Products Are Not FDA Approved, included but was not limited to: - All types of CPAP machines need to be cleaned regularly so that these germs and contaminants do not grow inside of your equipment and make you sick. - Germs from your lungs, throat, or mouth can get into the CPAP mask or hose as you breathe in and out during sleep, or germs on your skin may get transferred to the CPAP mask or hose. Dust, mold, or other allergens may also get into the CPAP mask or hose. - All types of CPAP machines need to be cleaned regularly so that these germs and contaminants do not grow inside of your equipment and make you sick. Resident #29 was admitted to the facility in July 2023 with diagnoses including sleep apnea and legal blindness. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/11/23, indicated Resident #29 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 14 out of 15, has highly impaired vision, has a diagnosis of sleep apnea and uses non-invasive mechanical ventilation (CPAP). On 9/26/23 at 9:25 A.M., the surveyor observed Resident #29's CPAP machine on top of the Resident's nightstand. The headgear strap, nasal piece and tubing were lying on top of the machine. The nasal piece had droplets of condensation on all surfaces. The Resident said he/she uses the machine every night and replaces the nasal piece weekly his/herself. The Resident said neither he/she nor the staff clean the nasal piece daily or the CPAP unit weekly. On 9/27/23 at 8:17 A.M., the surveyor observed Resident #29's CPAP machine on top of the Resident's nightstand. The headgear strap and nasal piece were lying on top of the machine. The nasal piece had droplets of condensation on all surfaces. On 9/28/23 at 8:00 A.M., the surveyor observed Resident #29's CPAP machine on top of the Resident's nightstand. The headgear and nasal piece were lying on top of the machine. The nasal piece had droplets of condensation on all surfaces. Review of the medical record indicated the following Physician's Order: -CPAP nose piece at hour of sleep. Fill with distilled water. Settings 9cmH20, every evening shift (8/2/23) There were no orders for cleaning the CPAP headgear, nasal piece, tubing and machine according to facility policy and accepted standards of practice. Review of the August 2023 and September 2023 Medication Administration Record/Treatment Administration Records (MAR/TAR) indicated he/she wore the CPAP nose piece every evening from 11:00 P.M. to 7:00 A.M. during the month of August and September. During an interview on 9/28/23 at 8:47 A.M., Unit Manager #1 and the surveyor observed Resident #29's CPAP machine, headgear strap and nasal piece lying on top of the machine. She reviewed the medical record and said there are no orders in place for cleaning and storing the CPAP machine and equipment. The Unit Manager said they should be cleaned according to facility policy and stored in a plastic bag to prevent potential environmental contaminants.

Based on policy review, record review, and interview, the facility failed to ensure one Resident (#368) was free from a significant medication error, out of three closed records. Specifically, the facility failed to ensure three medications were administered to the Resident as ordered by the Physician. Findings include: Standard reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered nurse and Practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered nurse and practical nurse incorporate into the plan of care, and implement prescribed medical regimens. A nurse licensed by the Board shall not administer any prescription drug or non-prescription drug to any person in the course of nursing practice except as directed by an authorized prescriber. A nurse licensed by the Board shall document the handling, administration, and destruction of controlled substances in accordance with all federal and state laws and regulations and in a manner consistent with accepted standards of practice. Review of the facility's policy titled Medications Acquired or Brought to the Facility by a Resident or Responsible Party From an Outside Source, February 2019, indicated but was not limited to: -Medications acquired or brought into the facility by a resident or responsible party from an outside source are used only upon written order of the resident's attending practitioner; after the contents are verified, and if the packaging meets the facility's guidelines. -Use of medications acquired from an outside source is allowed only when the medication was ordered by the resident's practitioner, and was entered in the resident's Medication Administration Record (MAR) by the facility. Review of the facility's policy titled Unavailable Medications, February 2019, indicated but was not limited to: -The facility must make every effort to ensure that medications are available to meet the needs of each resident. -Nursing staff shall: -Notify the attending physician of the situation and explain the circumstances, expected availability and optional therapy(ies) that are available. -Obtain a new order and cancel/discontinue the order for the non-available medication. Resident #368 was admitted to the facility in August 2023 for a 9-day respite stay. The Resident had diagnoses including hyperlipidemia (high cholesterol), anxiety, and hypothyroidism (low thyroid hormone). During an interview on 9/29/23 at 12:44 P.M., Nurse #7 said when Resident #368 was admitted to the facility, she called the Resident's Health Care Proxy (HCP) to review and verify the medication list provided by the Resident's community Physician. She said she placed a checkmark next to each medication on the list after reviewing it with the HCP to indicate it was accurate. The Nurse said she then reviewed the medications with the Physician, who approved them. Nurse #7 said the Resident brought his/her medications from home in two pre-packaged multidose blister cards. She said the blister cards were filled with medications in two blisters labeled as either A.M. and P.M. Nurse #7 said the top of the blister cards listed each medication and dose packaged in the blisters as well as a picture of each pill. Review of the medical record indicated an 8/2/23 home medication list from the Resident's community provider including the following medications with handwritten checkmarks next to each medication: -Zoloft (antidepressant) 100 milligrams (mg), take 1.5 tablets (150 mg total) daily. -Synthroid (synthetic hormone) 50 micrograms (mcg), take one tablet daily. -Abilify (antipsychotic) 2 mg tablet, take 1 tablet daily. Review of the August 2023 Physician's Orders included but was not limited to: -Zoloft 100 mg, give 100 mg by daily at 8:00 A.M. -Abilify 2 mg, give 1 tablet daily at 8:00 A.M. The order for Zoloft was inaccurately transcribed as 100 mg daily and not 150 mg daily as indicated on the home medication list. Although the order for Synthroid was verified with the Resident's HCP and approved by the Physician, it was not included in the Physician's orders and therefore was not on the Medication Administration Record (MAR) and not administered. Review of August 2023 MAR indicated Zoloft 100 mg was administered to Resident #368 from 8/18/23 to 8/22/23 instead of 150 mg, and Abilify 2 mg was not administered on one occasion (8/22/23) and was noted as being unavailable. During an interview on 9/29/23 at 12:26 P.M., Nurse #10 said on 8/22/23 she did not see a blister pack of medications and retrieved Resident #368's medications from the electronic medication dispensing system. She said she did not administer Abilify because it was not available in the electronic medication dispensing system. Nurse #10 said she notified the Nurse Practitioner, but was not given any direction to either obtain a new order and cancel/discontinue the order for the non-available medication. During an interview on 9/29/23 at 1:32 P.M., the Director of Nursing (DON) said she was contacted by Resident #368's HCP three days after he/she was discharged from the facility with a concern that the Resident had not received all of his/her medications while at the facility. The DON said she initiated an investigation. She said not all of the nurses were comfortable using the Resident's blister cards brought in from home, and some nurses used the electronic medication dispensing system to retrieve the medication. She said her investigation revealed that during medication reconciliation upon admission, the Synthroid order was omitted from the Physician's orders. However, the Synthroid was in the blister cards and administered daily by nursing staff except for two occasions when nursing did not use the blister card. She said on two occasions where the medications were retrieved from the electronic medication dispensing system, it was noted that two doses of Synthroid were not retrieved, therefore assumed omitted, and on three instances, staff documented that Abilify was not available to administer, therefore assumed omitted. She said there was also a discrepancy with the dose of Zoloft. The Zoloft in the blister pack were 100 mg tablets and the home medication list indicated the Resident was to receive 150 mg and the discrepancy should have been discovered upon medication reconciliation at the time of admission and each time the medication was administered. She said the order was changed on 8/23/23 to 150 mg, but staff continued to administer Zoloft 100 mg. She said multiple medication errors occurred and it is her expectation that nursing staff accurately reconcile medications upon admission and administer medications according to physician's orders to ensure no medication errors occur, and that was not done.

Based on record review, Hospice contract review, and staff interview, the facility failed to ensure for one Resident (#102), out of a total sample of 23 residents, that hospice services were provided in accordance with the agreement between the hospice and the facility. Specifically, the facility failed to provide ongoing documentation of hospice staff visits to ensure prompt and effective communication and continuity of care for the Resident, in accordance with the hospice agreement. Findings include: Review of the facility's agreement with Hospice, dated February 2023, indicated but was not limited to the following: - the facility will identify space in the medical record of the hospice patient for ongoing documentation and communication by hospice personnel - the hospice will provide all hospice services in compliance with all federal, state, and local laws, rules and regulations - hospice responsibilities include, but are not limited to, providing medical direction and management of the patient, nursing, spiritual counseling, and social work for the palliation of symptoms associated with terminal illnesses and related conditions - the facility will prepare and maintain medical records for each hospice patient receiving services Resident #102 was admitted to the facility in July 2022 with diagnoses including dementia, psychosis, anxiety, and major depressive disorder. Review of the facility hospice integrated medical record for Resident #102 failed to indicate any schedule of hospice services or visit notes from any discipline after 9/6/23. During an interview on 9/27/23 at 3:23 P.M., Nurse #4 said she was unsure about how the facility receives hospice documentation of visits or where the hospice schedules of visits are kept and deferred the surveyor to the Unit Manager. During an interview on 9/27/23 at 3:24 P.M., Unit Manager (UM) #2 reviewed the hospice schedules with the surveyor and said there was no schedule for visits available for Resident #102 since 9/8/23. She said when hospice comes in, they stop and notify someone on staff, but she is unsure when that is and the schedules are sent to the Director of Nurses (DON) by e-mail and she does not have any since 9/8/23. She said hospice staff bring in the printed out hospice notes about once a week and the facility staff do not otherwise have access to the visit notes or any part of the hospice electronic system. She reviewed the hospice integrated medical record and said there were no notes available to communicate what services the hospice provided since 9/6/23. During an interview on 9/27/23 at 4:55 P.M., the Assistance Director of Nurses said she contacted the hospice and has received Resident #102's hospice visit notes from 9/6/23 to current. She said the notes are usually brought in by the hospice and placed in the medical record about weekly and she couldn't explain why the notes weren't available for the staff or survey team to review as they should have been. During an interview on 9/28/23 at 8:25 A.M. Hospice staff #1 said the hospice visit and communication notes are printed and brought into the facility every week or two and the staff are expected to verbally communicate with the facility if anything significant is occurring. She said she is aware the facility hospice integrated record did not have any documentation of hospice visits or communication for the last three weeks and just provided the facility with the notes on 9/27/23 after they were requested by the surveyor. She said there were some issues on the hospice end and the records were not complete until 9/27/23 as they should have been. During an interview on 9/28/23 at 1:47 P.M., the Director of Nurses said she was made aware that the communication of hospice visits and the visit schedules were not available on the nursing unit for Resident #102. She said the schedules should be printed and supplied to the units weekly to ensure they are aware of upcoming hospice visits with each discipline. She said the expectation for the visit documentation and communication is that the notes are printed out every week or so to ensure collaboration and communication between the hospice and facility staff regarding the Resident's care. She said sometimes getting documentation from outside services is a struggle.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #71 was admitted to the facility in July 2023 with diagnoses including essential hypertension (occurs when you have abnormally high blood pressure that is not the result of a medical condition). Review of the manufacturer's instructions for use (IFUs), revised September 2015, indicated but was not limited to the following: -Atenolol tablets USP are indicated for the treatment of hypertension, to lower blood pressure. Adverse Reactions: -Bradycardia (slowed heart rate), dizziness, light-headedness Review of Lippincott Nursing Procedures, eighth edition, 2019, indicated but was not limited to the following: Safe Medication Administration Practices Verifying the medication order: -Follow a written or typed order or an order entered into a computer order-entry system. -Explain the name and purpose of each medication. Discuss important and common adverse effects for each medication and what to do if the patient experiences any symptoms. Review of the facility's policy titled Medication Administration-General Guidelines, dated February 2019, indicated but was not limited to the following: -Medications are administered in accordance with written orders of the prescriber. On 9/28/23 at 8:53 A.M., the surveyor observed Nurse #3 prepare and administer 9:00 A.M. morning medications to Resident #71 in his/her room. Nurse #3 administered the Resident's Atenolol and did not check vital signs including a heart rate prior to the administration and did not explain the medication including any potential adverse effects to the Resident. After administration, the surveyor asked Nurse #3 if there were parameters (specific instructions that you can measure) for the medication. Nurse #3 said no and said the last time vital signs were taken was on 9/23/23, five days prior. Review of the current Physician's Orders on 9/28/23 at 9:55 A.M. indicated the following: -Atenolol Oral Tablet, give 12.5 milligrams (mg) by mouth one time a day related to essential (primary) hypertension, hold if AP <56, 7/8/23 Review of the September 2023 Medication Administration Record (MAR) failed to indicate documentation of the Resident's AP by Nurse #3 along with the entry that she had administered the Atenolol per her initials on 9/28/23. Further review of the medical record failed to indicate the Resident's heart rate had been assessed since 9/23/23. During an interview on 9/28/23 at 10:40 A.M., the surveyor reviewed the medical record with Nurse #3 who said there was an order to hold the Atenolol if the Resident's AP was less than 56, but she did not do it and should have. The surveyor asked to review the electronic MAR system with Nurse #3 who, when she clicked on the Atenolol medication, said it indicated a pop-up display with special instructions to hold the medication if the AP was less than 56. Nurse #3 said she did not see it previously. She said administering the medication if the heart rate is too low can be potentially harmful as it could lower the heart rate further. During an interview on 9/28/23 at 10:58 A.M., the Director of Nursing (DON) said parameters should have been documented in supplementary documentation on the electronic MAR, but there was no separate order attached to do so which would be where nursing staff would document it along with the administration. The DON said the AP should have been checked as the medication could decrease the heart rate. The DON said the last vital signs documented for Resident #71 were on 9/23/23. Based on observation, record review, policy review, and interview, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for two Residents (#29 and #71), out of a total sample of 23 residents, and for one Resident (#368) out of three closed records. Specifically, the facility failed: 1. For Resident #29, to ensure physician's orders were in place for the use and management of an implanted continuous glucose monitoring device; 2. For Resident #368, to accurately reconcile and administer medication according to physician's orders; and 3. For Resident #71, to follow a physician's order to check the Resident's apical pulse (AP) (pulse point on your chest at the bottom tip of your heart) to ensure it was greater than 56 prior to administering his/her Atenolol (beta blocker, treats high blood pressure, works by slowing down your heart rate making it easier for your heart to pump blood around your body) medication. Findings include: 1. Resident #29 was admitted to the facility in July 2023 with diagnoses including diabetes mellitus, type 2. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/11/23, indicated Resident #29 is cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15, requires extensive assistance from staff for activity of daily living and receives insulin injections. During an interview on 9/26/23 at 9:25 A.M., Resident #29 said he/she has a Libre sensor device on his/her left arm and uses an electronic device to check his/her blood sugar level. The Resident said the sensor is changed every two weeks and alternates arms. Resident #29 said he/she is unable to remove and insert the new sensor on his/her own, and he/she had taught Unit Manager #1 and Nurse #2 to insert the new sensor every 14 days. Review of [NAME] Freestyle Libre Continuous Glucose Monitoring (CGM- https://www.freestyle.[NAME]/us-en/home.html), included but was not limited to: -the Libre CGM is a small sensor-based system that provides real-time glucose readings day and night, without fingersticks; -The sensor is applied to the back of the upper arm with a simple, disposable device called an applicator. When the sensor is applied, a small (5 millimeter) filament is inserted just under the skin and held in place with a small adhesive pad; -There is a needle (sharp) in the applicator to insert the filament in the back of your upper arm so the sensor can monitor your glucose; -The sensor lasts up to 14 days and it is recommended to rotate application site of the sensor between arms. Review of the Physician's Orders included but was not limited to: -Insulin Lispro Injection Solution, 100 unit/milliliters (mL), inject as per sliding scale subcutaneously before meals (7/7/23): -if 100 - 139= no insulin required; -140 - 180=2 units; -181 - 220=4 units; -221 - 260=6 units; -261 - 300=8 units; -301 - 350=10 units; -above 351, call Physician Further review of the Physician's Orders failed to indicate orders for the use of the Libre continuous glucose monitoring device to implement the sliding scale, and orders to remove and reinsert the sensor device, alternating arms, every 14 days. Review of July, August, and September 2023 Medication Administration/Treatment Administration Records (MAR/TAR), indicated sliding scale insulin was administered on 166 occasions without an order to obtain blood glucose levels. Further review of the medical record failed to indicate any Physician or Nurse Practitioner notes to acknowledge Resident #29's use of the Libre continuous glucose monitoring device and instructions for its use. During an interview on 9/28/23 at 8:23 A.M., Unit Manager #1 said Resident #29's family brought in the Libre device two or three days after he/she was admitted to the facility and has inserted it into the Resident's arm several times herself. The Unit Manager reviewed the medical record and said there was no physician's order to insert the sensor device to the Resident's arm every 14 days, and no order for use of the device to obtain glucose levels to implement the insulin sliding scale. During an interview on 9/28/23 at 11:50 A.M., Nurse #2 said Resident #29 taught her how to change the Libre monitoring sensor. She said she changed it only once about a week ago, and did not document it in the medical record. During an interview on 9/29/23 at 9:15 A.M., Nurse Practitioner #1 said she was not aware Resident #29 had a Libre continuous glucose monitoring device until last week when the Resident told her about it. The NP said the sensor device has a prong that gets placed through the skin and remains in place for two weeks, then needs to be changed. She said she did not write any orders for Nursing to change the device or use the device to obtain glucose levels to implement the insulin sliding scale. 2. Resident #368 was admitted to the facility in August 2023 for a 9-day respite stay (8/17-8/26) with diagnoses that included hyperlipidemia (high cholesterol), anxiety, hypothyroidism (low thyroid hormone), and dementia. Review of the facility's policy titled Reconciliation of Medications on admission (Revised July 2017), indicated but was not limited to the following: Purpose: The purpose of this procedure is to ensure medication safety by accurately accounting for medications, routes, and dosages upon admission to the facility. Preparation: -Gather the information needed to reconcile the medication list: *All prescription and supplement information from the resident/family during the medication history. *Most recent medication administration record (MAR), if this is a readmission. General Guidelines: -Medication reconciliation is the process of comparing pre-discharge medications to post discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency route and indication for use for the purpose of preventing unintended changes or omissions at transition points in care -Medication reconciliation reduces medication error and enhances resident safety by ensuring that the medications the resident needs and has been taking continues to be administered without interruptions, in the correct dosage and routes, during the admission/ transfer process. -Medication reconciliation helps ensure that all medications, routes, and dosages have been accurately communicated to the attending Physician and care team. -Documentation: Document the medication discrepancy on the medication reconciliation form (assessment). During an interview on 9/29/23 at 12:44 P.M., Nurse #7 said that when Resident #368 was admitted to the facility (from the community), she called the Resident's Health Care Proxy (HCP) to review and verify the accuracy of the medication list provided by the Resident's community Physician. She said she verified the medications to be administered by placing/writing a checkmark next to each medication during the review with the HCP of the Resident's current medications. The Nurse said she reviewed the medications with the Physician, who then ordered the medications to be administered by the facility. Nurse #7 further said that when the Resident was admitted , the HCP had provided the facility with the Resident's home medications. The home medications were separated into two pre-filled blister packages (packs), one blister pack for the A.M. medications and another blister package for the P.M. medications. Within each bubble of the blister pack, there were multiple medications. Nurse #7 said the top of each blister pack indicated which medications (the names) were contained in each bubble with a corresponding picture of each medication in the bubble. Review of the medical record indicated a home medication list from the Resident's community provider (dated 8/2/23) which included but was not limited to the following medications: -Zoloft (antidepressant) 100 milligrams (mg), take 1.5 tablets (150 mg total) daily. -Synthroid (synthetic hormone) 50 micrograms (mcg), take one tablet daily. -Crestor (used to lower cholesterol) 40 mg tablet, take one tablet daily. -Abilify (antipsychotic) 2 mg tablet, take 1 tablet daily. Also noted on the medication list was a handwritten checkmark next to each medication, which Nurse #7 indicated she had done while reviewing the medications with the HCP. Review of the August 2023 Physician's Orders included, but was not limited to: -Zoloft 100 mg, give 100 mg by daily at 8:00 A.M. -Crestor 40 mg, give 1 tablet daily at 8:00 A.M. -Abilify 2 mg, give 1 tablet daily at 8:00 A.M. The order for Zoloft was inaccurately transcribed as 100 mg daily and not 150 mg daily as indicated on the home medication list. Although the order for Synthroid was verified with the Resident's HCP and approved by the Physician, it was not included on the physician's orders. Review of the August 2023 Medication Administration Record indicated Zoloft 100 mg was administered to Resident #368 from 8/18/23 to 8/22/23 instead of 150 mg, and Abilify 2 mg was not administered on three occasions and noted as being unavailable. During an interview on 9/29/23 at 1:32 P.M., the Director of Nursing (DON) said she became aware of the medication discrepancies after Resident #368 was discharged from the facility and she received a telephone call from his/her HCP with a concern that the Resident had not received all of his/her medications while at the facility. The DON said she initiated an investigation. She said not all of the nurses were comfortable using the Resident's blister cards brought in from home, and some nurses used the electronic medication dispensing device to retrieve the medication. She said she was not told that Abilify was not available in the electronic medication dispensing device, and three doses were not administered as ordered. The DON said the Zoloft in the blister pack from home was 100 mg and not 150 mg according to the home medication list, and it should have been discovered upon medication reconciliation at the time of admission and each time medications were administered. She said although the Synthroid order was not transcribed onto the physician's orders, it was in the blister card and was administered on all days except when the nurses retrieved medications from the electronic medication dispensing device on 8/18/23 and 8/20/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and interview, the facility failed to provide behavioral health services for two Residents (#102 and #24), out of a sample of 23 residents. Specifically, the facility failed to ensure collaboration with psychiatric (psych) services as deemed necessary according to the behavioral health psychiatric provider and the Residents' plan of care. Findings include: 1. Review of the facility's policy titled Behavioral Health Services, dated as revised on 9/2023, indicated but was not limited to the following: - The facility will provide behavioral health services as needed to residents to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the plan of care - Behavioral health services are provided to residents, as needed, as part of the interdisciplinary, person-centered approach Resident #102 was admitted to the facility in [DATE] with diagnoses including dementia, psychosis, anxiety, and major depressive disorder. The Resident is currently receiving hospice services. Review of the current care plans for Resident #102, included but were not limited to the following: Focus: Altered mood pattern related to anxiety, depression, forgetful, sleep pattern [sic] Goal: Will have improved mood through review date and will have improved sleep pattern through review date Interventions: Behavioral health consults as needed (psych) Review of the medical record for Resident #102 indicated the Resident received behavioral health services through the facility contracted psych group. Further review of the progress notes indicated the last psych progress note, dated [DATE], indicated the following: - Resident is seen for follow up and medical management of dementia and behavioral disturbance - Return for follow up in 12 weeks or earlier if needed There were no psych progress notes available following the [DATE] note, approximately 22 weeks prior to the record review by the survey team. During an interview on [DATE] at 3:47 P.M., Unit Manager (UM) #2 said the Resident is followed by the facility psych team regardless of his/her being on hospice services. She said the Resident can be verbally aggressive and paranoid and was last seen by behavioral health services on [DATE]. She said the Resident was supposed to be seen 12 weeks following the last visit and was not. During an interview on [DATE] at 4:55 P.M., the Assistant Director of Nurses (ADON) said the expectation is that psych would track and maintain the schedule of visits for each resident as they determine it to be necessary. She said the Resident should have been seen sometime in July and was not. She said the Resident did not receive behavioral health services in accordance with the plan of care. 2. Resident #24 was admitted to the facility in [DATE] with diagnoses including dementia, psychotic disturbance, mood disturbance, and anxiety disorder. Review of the current care plans for Resident #24, included but were not limited to the following: Focus: Altered mood problem related to anxiety and confusion Goal: Will have improved mood state with happier calmer appearance through review date Interventions: Behavioral health consults as needed (psych) Review of the medical record for Resident #24 indicated the Resident received behavioral health services through the facility contracted psych group. Further review of the progress notes indicated the last psych progress note, dated [DATE], indicated the following: - Resident is seen today ([DATE]) for increased depression, increased crying episodes and looking for his/her deceased spouse. - Resident exhibits symptoms of anxiety and symptoms of depressive disorder with increase in weepy episodes - Behaviors Resident is being seen for are new - Recommendations/Plan: start Trazodone (an antidepressant) 25 milligrams (mg) twice a day and 75 mg at bedtime to target crying episodes - call for worsening mood or behavior - follow up return in 3-4 weeks or earlier, if needed There were no psych progress notes available following the [DATE] note, approximately 17 weeks prior to the record review by the survey team. Further record review indicated the Resident had been started on Ativan (an anti-anxiety medication) by his/her attending physician in an effort to decrease episodes of anxiety, with the current order started [DATE], without notification or collaboration with behavioral health services. During an interview on [DATE] at 9:45 A.M., UM #2 said the Resident's last visit with psych services was on [DATE] and the Resident should have had a follow up visit three to four weeks after. She said the Resident was not seen by the behavioral health services team as they should have been. During an interview on [DATE] at 10:05 A.M., the Director of Nurses said neither Resident received behavioral health services as he/she should have according to the last available note from psych services and the facility struggles to monitor the visits and frequency of behavioral health services since they are always getting new providers. She said the system of ensuring the services were rendered as deemed necessary needed some work and the expectation was not met to ensure the Residents were seen as deemed necessary by the behavioral health services team. During an interview on [DATE] at 10:21 A.M., the Social Worker said the facility has experienced some difficulty with change over on the psych services team and the expectation is that they are providing services as needed to each individual resident. She said these two Resident (#102 & #24) have not received the necessary behavioral health services as they should have according to the documentation in their medical records and the expectations have not been met.

Based on observation, interview, and policy review, the facility failed to ensure five Residents (#15, #96, #32, #40, and #8), out of a total sample of 23 residents, had their call lights accessible in accordance with the facility policy. Findings include: Review of the facility's policy titled Answering the Call Light, dated as revised 9/2023, indicated but was not limited to the following: - The purpose of the call light is to ensure timely responses to resident's requests and needs - ensure the call light is accessible to the resident when in bed and from the floor Resident #8 was admitted to the facility in June 2021. Review of the most recent Minimum data set (MDS) indicated a Brief interview for Mental Status (BIMS) score of 14 out of 15, indicating the Resident is cognitively intact. Resident #32 was admitted to the facility in November 2012. Review of the most recent MDS indicated a BIMS score of 4 out of 15 indicating the Resident is severely cognitively impaired. Resident #40 was admitted to the facility in July 2023. Review of the most recent MDS indicated a BIMS score of 5 out of 15 indicating the Resident is severely cognitively impaired. Resident #96 was admitted to the facility in March 2022. Review of the most recent MDS indicated a BIMS score of 13 out of 15 indicating the Resident is cognitively intact. Resident #15 was admitted to the facility in February 2022. Review of the most recent MDS indicated a BIMS score of 3 out of 15 indicating the Resident is severely cognitively impaired. During the following days and times the surveyor made the following observations and interviews: 9/26/23: - 8:29 A.M., Resident #8's call light was clipped to itself at the plug by the wall and out of reach of the Resident who was in the bed. Resident #8 said the call light falls on the floor sometimes and the staff keep it up there so it will not fall; he/she was observed to try to reach for the call light and said he/she could not reach it and would have to call out if they needed the staff. - 8:36 A.M., Resident #32's call light was clipped to itself up on the wall behind the bed out of reach of the Resident who was in bed. Resident #32 said he/she does not know how to call for help but would yell if he/she needed something. - 8:39 A.M., Resident #40's call light was clipped to itself up by the plug on the wall behind the Resident's bed out of reach of the Resident who was sitting on the edge of the bed. Resident #40 said if he/she needed something or someone he/she would have to walk down the hall to find someone and said he/she was unaware there was a way to do so from inside his/her room. - 8:44 A.M., Resident #96's call light was clipped to itself up by the wall plug in, out of reach of the Resident who was sitting on his/her bed. Resident #96 said he/she was told the call light was for emergencies only and not to use it unless it was an emergency, which is why the call light is clipped up against the wall and not in reach. He/she said they would walk down the hall and look for a staff member if he/she needed something that was not urgent. - 8:58 A.M., Resident #15's call light was on the floor underneath his/her roommate's bed, out of reach of the Resident who was lying in bed. Resident #15 said if he/she needed help he/she would use the telephone to call their daughter or try to go look down the hall for someone. - 1:44 P.M., Resident #96's call light was not in reach of the Resident, who was sitting in his/her room chair by the window. The call light was clipped to itself up on the wall by the plug. - 1:49 P.M., Resident #32 was in bed with the call light not in reach; the call light was clipped to itself up against the wall behind the Resident's bed. - 1:51 P.M., Resident #8 was in his/her room sitting on the edge of the bed; the call light was not in reach and observed to be clipped to itself up against the wall by the plug in. - 2:03 P.M., Resident #15 was in his/her room chair with a family member present. The call light was on the floor in between the two beds and out of reach of the Resident. The family member for Resident #15 said the Resident does not always remember to use the call light for assistance, especially if it is out of reach or out of sight. She said if the call bell is very close to the Resident and can be visualized the Resident is more likely to use it to call for assistance. She said the Resident is a fall risk and she should inquire about alternate devices for the Resident to notify the staff when he/she needs assistance. 9/27/23: - 8:09 A.M., Resident #15's call light was placed on the roommate's bed and out of reach of the Resident who was lying in bed. - 8:13 A.M., Resident #40's call light was clipped up by the plug in portion of the cord at the wall behind the bed, out of reach of the Resident who was lying in bed. - 8:14 A.M., Resident #32's call light was clipped to itself behind the Resident's bed up against the wall, out of reach of the Resident who was lying in bed. - 8:23 A.M., Resident #96's call light was clipped to itself behind the Resident's bed up by the wall plug, out of reach of the Resident who was lying in bed. Resident #96 told the surveyor to not touch the call light because it is for emergencies only and they can only use it in the event of an emergency. During a tour of the Laurelwood unit on 9/27/23 at 9:40 A.M., the surveyor observed the call lights to be out of reach of Residents #8, #32, #40, #15 and #96. During an interview with observation on 9/27/23 at 9:47 A.M., Certified Nurse Assistant (CNA) #3 said she was assigned to Residents #8, #32, #40 #15, and #96 for the day shift. She walked the unit with the surveyor and observed Resident #8's call light not in reach. She said she forgot to give it to the Resident after making the bed. Resident #32's call light was observed clipped behind the Resident's bed and she said she did not notice that the Resident didn't have his/her call light. She observed both Resident #96 and #40 without their call lights in reach and said these Residents are care planned to not have their call lights in reach and they do not like them attached to or draped across their beds. She said she was unaware that Resident #96 believed he/she was not to use their call light unless there was an emergency. She observed Resident #15 without his/her call light in reach and said the call light is frequently on the floor and should be clipped to the bed but is not. She said CNAs are supposed to do one hour safety checks on the residents on the Laurelwood unit throughout the day and that includes ensuring call lights are in reach. She said she must not have been paying attention, but regardless of their cognitive ability all the residents are required to have a call light in reach at all times and they obviously did not. Review of the current care plans for Residents #96 and #40 failed to indicate the Resident's preference was to not have a call light in reach or the use of any alternative method for calling for assistance. During an observation with interview on 9/27/23 at 9:58 A.M., Nurse #4 said she is unaware of any resident that declines to have a call light in reach or available. She said if a resident had a preference for an alternative call method or not to use a traditional call bell on the call light system that would be documented in the care plans and she was not aware of any resident who had that intervention or provision. She said for all residents call lights should be in reach at all times regardless of their cognitive ability. She observed Residents #8, #32, #40, #15 and #96 with the surveyor, none of the five observed Residents had their call lights in reach or accessible to them. She said all five Residents should have had access to their call lights and they should have been in reach. During an interview on 9/27/23 at 3:56 P.M., Unit Manager #2 said she was made aware of the call light concerns earlier in the day and the call lights are required to be in reach of all residents regardless of their cognitive abilities. She said there are no residents on the unit who are care planned to not have their call bells in reach. During an interview on 9/28/23 at 12:21 P.M., the Director of Nurses said the policy and expectation is that all residents have their call bells in reach and accessible at all times and the expectation was not met as it should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility staff failed to identify and document the clinical rationale for the use of an antipsychotic medication for one sampled Resident (#22), out of a total sample of 19 residents. Findings include: Resident #22 was admitted [DATE] with diagnoses that included dementia and depression. Review of the medical record indicated the Resident had a fall in January 2021 and was sent to the hospital. At the hospital, he/she was diagnosed with a right intertrochanteric femur fracture and underwent surgery of a ORIF (Open Reduction Internal Fixation). Review of the hospital discharge information, dated 2/2/21, indicated that the Resident had a physician's order for Seroquel 25 milligrams (mg) every 6 hours as needed and was discharged from the hospital on this medication. Seroquel is an antipsychotic medication. The Nurse Practitioner (NP) saw the Resident on 2/2/21 when the Resident returned to the facility and noted the Resident complained of mild right leg pain and was calm and cooperative. The NP documented to continue the Seroquel 25 mg, as needed for agitation for 14 days. The medical record indicated on 2/3/21, the Seroquel was ordered to change to 25 mg at bed time. A nurse's note, dated 2/3/21 at 2:10 P.M., indicated the Resident when unsupervised, would yell out for help, several times and tried to get out of bed. The nurse wrote the Resident complained of pain of 10 out of 10 on the pain scale (severe) of the right hip and was medicated with pain medication at 7:30 A.M. The note also documented to start the Seroquel 25 mg, to be given at bedtime. A review of the quarterly Minimum Data Set (MDS) assessments dated 11/27/20 and the 2/8/21 Significant Change in Status MDS assessment, both indicated Resident #22 had no behaviors, no delusions, and no hallucinations. The 11/27/20 MDS assessed the Resident's cognitive status by the Brief Interview of Mental Status (BIMS) score of 3 out of 15 and the 2/8/21 assessment at 2 out of 15, both indicating severe cognitive impairment. Review of Resident #22's plan of care, dated 2/9/21, indicated the Resident has a behavior of yelling out for help, and when reminded to wear a mask, will often remove it. One of the interventions was to monitor for pain every shift. Another plan lists the Resident's antidepressant and antipsychotic medications and to monitor for side effects from the two medications. The psychiatry service had seen the Resident on 2/9/21 and added diagnoses of anxiety, adjustment disorder with depressed mood and unspecified dementia with no behaviors. The service made no documentation of the Resident receiving an antipsychotic medication. The surveyor observed the Resident on the following dates and times with no behaviors: - 4/13/21 at 10:10 A.M. sitting in a wheelchair, well-groomed, and when spoken to he/she repeatedly asked what the surveyor was saying. The Resident does have hearing loss and uses no devices. - 4/13/21 at 2:24 P.M. lying in bed with eyes closed. - 4/14/21 at 8:10 A.M. eating in the dining area on the unit, his/her wheelchair positioned at the table, ate all his/her breakfast, needed no assistance from staff to eat. The Resident was smiling at staff when they approached. - 4/14/21 at 10:40 A.M. sitting in activity area with assistant. Greeted other residents with a nod. - 4/15/21 at 7:47 A.M., sitting in wheelchair watching television, awaiting breakfast. - 4/15/21 at 10:45 A.M., sitting with activity assistant with an old movie playing, he/she was smiling and the activity assistant said we are waiting for the other residents to join us. During an interview on 4/15/21 at 10:20 A.M., Unit Manager #1 was asked about the Seroquel usage and what behaviors the Resident exhibited. She informed the surveyor that she was new here as of 4/1/21 and needed to review the record. During interview and record review on 4/15/21 at 3:12 P.M., Unit Manager #1 could not elaborate on the behaviors of Resident #22. She said there were no behavior records and had no other information. Reviewed with Unit Manager #1, that the Resident after having ORIF surgery was assessed using the MDS to have no behaviors, hallucinations or delusions. The Resident is deaf and has no appliances or aids. When the Resident has called out on two occasions for help the nurse's note indicated he/she was medicated for pain. Unit Manager #1 went on to say the Resident has put him/herself on the floor twice from the wheelchair. The surveyor asked the Manager if this was related to his/her pain and she could not answer. During an interview on 4/15/21 at 3:56 P.M., the Director of Nurses (DON) said they had been looking at psychotropic medications and she said she could find no information of why the Seroquel was used and said she had called the pharmacist to see if he had information. The DON presented on 4/16/21 at 8:30 A.M. a communication from the Pharmacist that was sent to the DON. Review of the Pharmacist note indicated he reviewed the medications of Resident #22 on 2/15/21 and noted the Resident was receiving Seroquel since 2/3/21. The pharmacist had made a recommendation for the diagnosis of Adjustment Disorder with depressed mood be added to the diagnosis list of Resident #22. The DON went on to say Resident #22 was not on the list of residents receiving psychotropic medications and had not been reviewed as part of the dose reduction project. The facility could offer no further documentation to substantiate for the continued use of the antipsychotic medication daily after having surgical repair of the hip, diagnosed with dementia, and having a hearing loss.

Based on observation, record review and staff interview, the facility staff failed to maintain complete, accurate and systemically organized medical records within accepted professional standards and practice. Specifically, the facility failed to: transcribe physician's orders: (a) for laboratory services, and (b) to transport the resident out of the facility for an acute medical evaluation, for one Resident (#96) out of three closed records. Findings include: Review of the medical record indicated Resident #96 experienced two falls on 2/24/21 (found sitting on the floor/chair) with no documented injuries or bruises. The physician was notified and ordered orthostatic vital signs (have patient lie down for 5 minutes, measure blood pressure and pulse. Have patient stand, repeat blood pressure and pulse after 1 and 3 minutes) twice a day for three days and a psychological evaluation of medications. Review of the physician's progress note, dated 2/25/21, indicated that nursing had reported that the Resident was in his/her usual state of health with weakness and had questioned low hematocrit (measurement of the amount of red blood cells) and hemoglobin (protein found in red blood cells that carries oxygen to the body) levels. Review of a nursing progress note, dated 2/25/21, indicated the physician requested, and the Resident's health care agent agreed, a complete blood count (CBC) and comprehensive metabolic panel (CMP) be obtained on 3/2/21. Review of the medical record on 4/16/21 failed to indicate an interim order for the Resident's laboratory blood tests. Although the blood test was obtained, facility staff failed to transcribe the order to obtain the laboratory blood test. Review of a nursing progress note, dated 3/2/21, indicated the Resident's laboratory results identified a critical hemoglobin (hgb) of 6.6 (normal range 12.1-15.7 g/dL). The nurse practitioner and nurse supervisor were notified and an ambulance was called to transfer the Resident to the hospital. Review of the medical record on 4/16/21, failed to indicate an interim physician's order for the Resident to be sent to the emergency room for further medical evaluation/treatment. During an interview, on 4/16/21 at 10:05 A.M., Unit Manager #2 said all physician orders, including interim orders were hand written and not electronic. Unit Manager #2 said the orders for lab work and the order to transfer the Resident to the emergency room should have been included in the medical record and were not.

Based on observation, interview, and record review, the facility failed to implement the plan of care to check the placement and function of a wander guard for one Resident (#50) in a total sample of 19 residents. Findings include: Resident #50 was admitted to the facility in March 2021 with a diagnosis of dementia. On 4/13/21 at 3:05 P.M., the surveyor observed Resident #50 in the unit dining room. The Resident was wearing a wander guard on his/her right ankle. Review of the medical record for Resident #50 included a wander assessment, dated 3/4/21, which indicated the Resident was at high risk to wander. Review of the care plans for Resident #50 indicated he/she was at risk for elopement with an intervention of wearing a wander guard at all times, for staff to check the placement every shift and for the staff to check the function every week on Wednesdays. A review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not include an order or documentation to indicate the wander guard was checked for placement every shift or for function every week. During an interview on 4/14/21 at 2:33 P.M., Nurse #1 said staff document wander guard placement and function on the TAR. During an interview on 4/15/21 at 10:35 A.M., Unit Manager #2 said an order had not been written to check the function and placement of the wander guard, therefore, the wander guard was not added to the TAR, and was not checked for placement and function per the care plan for Resident #50.