Based on record review, policy review, and interview, the facility failed to ensure staff developed baseline or comprehensive care plan within 48 hours of the resident's admission, which included the instructions needed to provide effective and person-centered care to the resident which meet professional standards of quality care for one Resident (#12), in a total sample of 18 residents. Specifically, the facility failed to ensure a baseline care plan was developed for the Resident's: a. diagnosis of Post Traumatic Stress Disorder (PTSD-results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being); and b. use of the antipsychotic medication Quetiapine (Seroquel). Findings include: Review of the facility's policy titled Baseline Care Plan, last revised 4/2022, indicated but was not limited to: -A baseline care plan to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission. -The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders; b. Physician's orders; c. Dietary orders; d. Therapy services; e. Social services; and f. PASARR recommendations, if applicable. Resident #12 was admitted to the facility in February 2025 and had diagnoses including fracture of the left humerus, anxiety, depression, and PTSD. Review of the Minimum Data Set (MDS) assessment, dated 2/20/25, indicated Resident #12 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 13 out of 15, expressed having little interest or pleasure in doing things (2-6 days during the review period) and feeling down depressed or hopeless (2-6 days during the review period), had a diagnosis of PTSD, and received antipsychotic medication daily. Review of an initial Nursing Evaluation, dated 2/14/25, indicated but was not limited to: -Admitting diagnosis: PTSD -Is the Resident currently ordered antipsychotic medication: yes -Name of medication: Seroquel a. Review of baseline and comprehensive care plans failed to indicate a care plan had been developed that includes the instructions needed to provide effective and person-centered care for Resident #12's diagnosis of PTSD within 48 hours as required. During an interview on 4/7/25 at 2:45 P.M., the Social Worker said she was aware Resident #12 had a diagnosis of PTSD but does not know what the trauma is or what the Resident's triggers may be. She said she should have developed a care plan for PTSD within 48 hours, but didn't do it. b. Review of Physician's Orders included but was not limited to: -Quetiapine 100 milligrams (mg), give 100 mg at bedtime (2/13/25) Review of February 2025 through April 2025 Medication Administration Records indicated Quetiapine 100 mg was administered according to physician's orders. Review of baseline and comprehensive care plans failed to indicate a care plan had been developed that includes the instructions needed to provide effective and person-centered care for Resident #12's use of the antipsychotic medication Quetiapine within 48 hours as required. During an interview on 4/8/25 at 2:25 P.M., Unit Manager #1 and the surveyor reviewed Resident #12's medical record. She was unable to find a baseline or comprehensive care plan that addressed the Resident's use of antipsychotic medication and said it should have been developed within 48 hours, and it was not.

2. Review of Massachusetts healthcare proxy act M.G.L C201D, Section 6 indicated, but was not limited to the following: The authority of a health care agent shall begin after a determination is made, pursuant to the provisions of this section, that the principal lacks the capacity to make or to communicate health care decisions. Such determination shall be made by the attending physician according to accepted standards of medical judgment. The determination shall be in writing and shall contain the attending physician's opinion regarding the cause and nature of the principal's incapacity as well as its extent and probable duration. This written determination shall be entered into the principal's permanent medical record. Resident #4 was admitted to the facility in June 2024 and had diagnoses including: Dementia with psychotic disturbance and anxiety. Review of the MDS assessment for Resident #4, dated 3/12/25, indicated the Resident was severely cognitively impaired with a BIMS score of 4 out of 15. Review of the medical record on 4/8/25 indicated the Resident's HCP had been invoked on 11/22/24 by Nurse Practitioner (NP) #1, the form indicated the following: The Resident lacks the capacity to communicate health decisions. This determination is made in accordance with accepted standards of medical judgement. The cause, nature, extent and probable duration of the resident's incapacity are described below: the cause and nature of the medical judgement on the form remained blank, the extent was completed as moderate/severe and duration as lifelong. During an interview on 4/8/25 at 12:18 P.M., NP #1 said he invoked Resident #4's HCP back in November of 2024 for an increase in cognitive decline. He reviewed the HCP activation form and said the form was not fully completed as it should be and it was his error. He said completing the cause and nature was standard practice. During an interview on 4/8/25 at 2:25 P.M., the Director of Nurses said the HCP invocation form should be complete, in accordance with the regulatory requirements. During an interview on 4/8/25 at 3:24 P.M., the Administrator said she saw the incomplete HCP invocation form for Resident #4 and the incomplete form is not in line with the standard or practice. Based on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards for two Residents (#29 and #4), out of a total sample of 15 residents. Specifically, the facility failed to: 1. Ensure a physician's order for the application of compression stockings were applied to Resident #29 daily; and 2. Ensure a healthcare proxy (HCP) invocation was completed for Resident #4 in accordance with the standard of practice. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated but was not limited to: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber 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. 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. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. 1. Resident #29 was admitted to the facility in October 2021 with diagnoses including chronic kidney disease, stage III, chronic diastolic congestive heart failure, and dementia. Review of Resident #29's Minimum Data Set (MDS) assessment, dated 1/22/25, indicated he/she was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) of 0 out of 15. Furthermore, the MDS assessment indicated Resident #29 required substantial assistance to complete activities of daily living including but not limited to bathing, dressing and transferring. Review of Resident #29's Physician's Orders indicated but were not limited to the following: - 2/28/23: apply compression stockings to bilateral lower extremities (BLEs) in the A.M., remove at HS (at bedtime). On 4/6/25 at 8:34 A.M., the surveyor observed Resident #29 seated in a stationary chair next to his/her bed. Resident #29's BLEs were swollen and discolored. Resident #29 did not have compression stockings applied to his/her lower extremities. On 4/8/25 at 9:27 A.M., the surveyor observed Resident #29 sitting at the edge of his/her bed. Resident #29's BLEs were swollen and he/she did not have compression stockings applied to his/her lower extremities. On 4/8/25 at 10:13 A.M., the surveyor observed Resident #29 lying in bed. A Certified Nursing Assistant (CNA) was in the room with Resident #29 taking his/her vitals. Resident #29's BLEs were swollen and he/she did not have compression stockings applied to his/her lower extremities. On 4/8/25 at 1:00 P.M., the surveyor observed Resident #29 seated in a stationary chair next to his/her bed. Resident #29 had his/her BLEs elevated on a four-wheeled walker. Resident #29's BLEs were swollen and he/she did not have compression stockings applied to his/her lower extremities. Review of Resident #29's April Medication Administration Records (MAR) indicated compression stockings were applied as ordered. Review of Resident #29's medical record failed to indicate application of the compression stockings was on hold or discontinued. Further review of the medical record failed to indicate documentation related to the reasoning for compression stockings to not be applied. During an interview on 4/8/25 at 1:05 P.M., Nurse #8 said she was not sure if she was supposed to check for application of compression stockings to her residents throughout the day. Nurse #8 confirmed Resident #29 had an order for compression stockings. Nurse #8 said Resident #29 did not have any compression stockings on at this time. During an interview on 4/8/25 at 1:15 P.M., the Assistant Director of Nursing (ADON) said Resident #29's compression stockings should be applied unless there is other documentation in the medical record indicating they were on hold or discontinued. The ADON said nursing should document in the MAR or a nursing note if a resident is refusing compression stockings or if the medical team changes the status of the order.

Based on record review and interview, the facility failed to assess a history of trauma and failed to assess and to develop a plan of care accounting for Resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for one Resident (#12), with a history of trauma, out of a total sample of 18 residents. Findings include: Review of the facility's policy titled Trauma Informed Care, last revised 4/2022, indicated but was not limited to: -Purpose: To guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. -Nursing staff are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization. - As part of the comprehensive assessment, identify a history of trauma or interpersonal violence when possible. -Identifying past trauma or adverse experiences may involve record review or the use of screening tools. -Utilize trained and qualified staff members who have established a rapport with the resident to assess him or her for previous trauma. Resident #12 was admitted to the facility in February 2025 and had diagnoses including anxiety, depression, and post-traumatic stress disorder (PTSD). Review of the Minimum Data Set (MDS) assessment, dated 2/20/25, indicated Resident #12 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 13 out of 15, expressed having little interest or pleasure in doing things (2-6 days during the review period) and feeling down depressed or hopeless (2-6 days during the review period), and had a diagnosis of PTSD. Review of the facility's Consultant Psychiatric Nurse Practitioner's note, dated 3/19/25, indicated the clinician identified Resident #12 reported a history of PTSD. However, the documentation failed to indicate the nature of the trauma, its effects on the Resident or any interventions accounting for Resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization. Further review of the entire medical record failed to indicate any staff collaboration with the Resident, or any other health care professional who may have provided care to Resident #12 to gather information related to his/her self-reported and documented PTSD diagnosis in order to develop a person-centered plan of care which identified potential triggers or trauma with interventions to prevent re-traumatization. During interviews on 4/7/25 at 2:00 P.M. and 4/8/25 at 9:25 A.M., Resident #12 shared that he/she experienced significant trauma when he/she was eight or nine years old and also as an adult. During an interview on 4/7/25 at 2:45 P.M., the Director of Social Services said it is her responsibility for conducting the trauma assessments and developing care plans for PTSD and must have missed doing it for Resident #12. She said she was aware Resident #12 has a diagnosis of PTSD but does not know what the trauma was or what any triggers may be. The Social Worker said that she should have conducted a trauma assessment and developed a care plan to address the Resident's needs upon his/her admission to the facility. During an interview on 4/8/25 at 2:25 P.M., Unit Manager #1 and the Regional Nurse reviewed Resident #12's medical record with the surveyor. Neither Unit Manager #1 nor the Regional Nurse were able to identify the nature of Resident #12's PTSD or any triggers the Resident may have.

Based on observations, record review, and interviews, the facility failed to assess one Resident (#12), out of a sample of 18 residents, for the use of a bed rail. Specifically, the facility failed to assess the risk of entrapment from the use of a bed rail (side rails, bed side rails, safety rails, grab bars and assist bars: adjustable position, rigid bars that attach to the sides of a bed, ranging in sizes from full to one-half, one-quarter, or one-eighth lengths), review the risks and benefits of side rails and obtain informed consent from the resident prior to installation of a bed rail. Findings Include: Review of the facility's policy titled Proper Use of Side Rails Policy, last revised 4/2022, indicated but was not limited to: -An assessment will be conducted to identify the reason for using side rails and the risk of entrapment. When used for mobility or transfer, an assessment will include a review of the resident's: -Bed mobility -Ability to change positions, transfer to and from bed or chair, and to stand and toilet -Risk of entrapment from the use of side rails -That the bed's dimensions are appropriate for the resident's size and weight -The use of side rails as an assistive device will be addressed in the resident's care plan. -If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the physician or nurse practitioner, and input from the resident and/or legal representative about the benefits and potential hazards associated with side rails. -Consent for the use of side rail use will be obtained from the resident or legal representative. -When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of space may vary, depending on the type of bed and mattress being used). Resident #12 was admitted to the facility in February 2025 following an acute hospitalization for a left proximal humerus fracture after sustaining a fall at home. Review of the Minimum Data Set assessment, dated 2/20/25, indicated Resident #12 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 13 out of 15, and had functional limitation in range of motion on one side of both upper and lower extremity. During an interview on 4/7/25 at 8:10 A.M., the surveyor observed Resident #12 sitting upright in bed eating breakfast. A bed rail was attached to the left side of the Resident's bed with foam material covering it. The Resident said the facility attached the rail to the right side of the bed because he/she cannot use the other arm because it was fractured and is still painful. The Resident said he/she used to have a cast, but it was removed a few weeks ago. Resident #12 said he/she is not able to use the rail to reposition him/herself. On 4/8/25 at 9:25 A.M., the surveyor observed Resident #12 sitting upright in bed eating breakfast. A bed rail was attached to the left side of the Resident's bed with foam material covering it. Review of Resident #12's admission Nursing Evaluation, dated 2/14/25, indicated but was not limited to the following: Side Rail Assessment: -The Resident not currently using a grab bar for positioning or support -Type of rail needed: None During an interview on 4/8/25 at 2:25 P.M., Unit Manager #1 and Regional Nurse reviewed Resident #12's medical record. They said there was no physician's order, no care plan, and no informed/signed consent for use of the rail.

Based on interviews and record review, the facility failed to ensure monthly Medication Regimen Review (MRR) recommendations made by the pharmacy consultant were addressed timely and maintained as part of the permanent medical record for two Residents (#12 and #4), out of a total sample of 18 residents. Specifically, the facility failed: 1. For Resident #12, to ensure the February 2024 consultant pharmacist recommendation was acted upon timely by the physician to add instructions for Trelegy Ellipta inhaler (used to treat chronic obstructive pulmonary disease (COPD) and works by opening airways, reducing inflammation, and keeping the airways open and improving lung function) orders; and 2. For Resident #4, to ensure recommendations left by the consultant pharmacist were addressed in a timely manner, for a clarification for the continued appropriate use of Seroquel (an antipsychotic medication), including a rationale for the medication. Findings include: Review of the facility's policy titled Medication Regimen Review, dated November 2021, indicated but was not limited to the following: - The facility assures that the consultant pharmacist has access to the residents and their medical records - the consultant pharmacist reviews the medication regimen of each resident at least monthly - while monthly medication review (MRR) is generally conducted in the facility, off-site MRR are acceptable when a review is requested and the pharmacist is not in the facility and cannot possibly make it to the facility in a reasonable time frame - in performing MRRs the consultant pharmacist incorporates federally mandated standards of care, in addition to other applicable professional standards, such as the American society of consultant pharmacists practice standards, and clinical standards such as the Agency for healthcare research and quality clinical practice guidelines and American medical directors association clinical practice guidelines - the consultant identifies irregularities through a variety of sources including the resident's clinical record, pharmacy records, and other applicable documents; in addition to reviewing pharmacy and clinical records the pharmacist may need to interview facility staff, the attending physician and the resident - resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented in the resident's active medical record and reported to the Director of Nurses (DON), Medical director and/or prescriber as appropriate - notification mode is dependent on severity of irregularity and is determined through consultation between the consultant pharmacist and DON; if no irregularities are found the consultant pharmacist documents this as well - if a continuing irregularity is deemed to be clinically significant, or evidence of a valid clinical reason for rejecting the recommendation is provided, the consultant pharmacist will reconsider whether to report the irregularity again or make a new recommendation on an annual basis - recommendations are acted upon and documented by the facility staff and/or prescriber - prescriber accepts and acts upon suggestions or rejects and provides an explanation for disagreeing - the DON or designated licensed nurse address and document recommendations that do not require a physician's intervention (example: monitoring blood pressure) - at least monthly, the consultant pharmacist reports any irregularities to the attending physician, medical director and DON, at a minimum 1. Resident #12 was admitted to the facility in February 2025 and had diagnoses including COPD. Review of Physician's Orders indicated but was not limited to: -Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 10-62.5-25 micrograms/actuation, one puff inhale orally one time a day for COPD (2/14/25) Review of the medical record indicated a Pharmacy progress note/recommendation to the Physician/Prescriber, dated 2/16/25, to add instructions to the orders for use of Trelegy Ellipta inhaler to rinse mouth after using to avoid thrush (a fungal infection in the mouth caused by the overgrowth of Candida albicans yeast). Review of Resident #12's medical record failed to indicate that the Consultant Pharmacist recommendation was addressed by the physician. During an interview on 4/8/25 at 10:25 A.M., the Director of Operations said the pharmacy recommendation, dated 2/16/25, has not been addressed by the physician. During an interview on 4/8/25 at 1:30 P.M., the Director of Nursing (DON) said that she had just spoken to Resident #12's physician today to inform him of the Pharmacist's recommendation dated 2/16/25. She said the recommendation should have been addressed prior to 4/8/25. 2. Review of the facility's policy titled: Psychotropic Medication, dated as revised 2/2025, indicated but was not limited to the following: -The consultant pharmacist reviews the appropriateness of psychoactive medication orders as part of each drug regimen review and monitors for: appropriateness of psychoactive medication based on diagnoses, clinical indications and prescribing guidelines and reassessment for trial dose reduction in accordance with state and federal regulations. Resident #4 was admitted to the facility in June 2024 and had diagnoses including: dementia with psychotic disturbance and anxiety. Review of the Physician's Orders indicated Resident #4 has been receiving Seroquel (Quetiapine) since admission in June 2024, initially for sleep and currently for depression. Review of the consultant pharmacist recommendations indicated but were not limited to the following: - 7/23/24: The resident receives Seroquel, please consider a psych consult for review of appropriateness of medication and/or possible decrease in dosage if you feel warranted at this time. Please indicate rationale if you feel it is not needed below. Response: Disagree, no GDR (gradual dose reduction) at this time (7/26/24) The recommendation failed to indicate a rationale for the ongoing use of the medication. - 8/23/24: This resident has a diagnosis (DX) for Seroquel in PCC (point click care - the facility electronic medical record system) for sleep; this diagnosis is not sufficient. Please update the diagnosis, thank you. - 9/25/24: Recommendation: This resident has a diagnosis for Seroquel in PCC for sleep; this diagnosis is not sufficient. Please update the diagnosis; there had been no response in the status section of the report. 11/24/24: The resident receives Seroquel & Prozac please consider a psych consult for review of appropriateness of medication and/or possible decrease in dosage if you feel warranted at this time. Please indicate rationale if you feel it is not needed below. Response: Psych follow up (f/u); requires both per healthcare proxy (HCP) 1/27/25: Please update the current medical record with the following DX in the order within the medication direction field for medication Seroquel the diagnosis of sleep appears incorrect or not sufficient. There is no response to the recommendation available in the medical record, but the diagnosis on the medication changed in March 2025 from sleep to depression. During an interview on 4/8/25 at 1:33 P.M., the Unit Manager said the MRR process is that they are sent by email each month and once she receives them, she provides them to the Nurse Practitioner for completion and once they are completed it is documented on the form and the form is scanned into PCC. She said she tries to have them completed within a few days, but they definitely need to be completed before the next pharmacy visit so the pharmacist can see that they have been addressed in some way. She reviewed Resident #4's medical record and said there were no documents in the record to indicate the pharmacy recommendations from August 2024 or January 2025 for the Seroquel medication had been addressed in any way, which would indicate to her that they were incomplete. During a telephone interview on 4/8/25 at 2:42 P.M., the Pharmacy consultant said the facility typically uploads the recommendation sheets into PCC, but the physical recommendation is not always available in the computer system for him to review and he reviews orders and MD/NP progress notes as well to determine whether or not recommendations have been addressed timely or appropriately. He said he has left recommendations for this Resident four times regarding an appropriate diagnosis for or possible reduction of their Seroquel medication. He said at this point he has requested the clarification for the Seroquel or a GDR if no such DX exists but he has not yet been able to identify an appropriate diagnosis anywhere in the record or any evidence that these recommendations have been addressed appropriately. He said his expectation is that they are addressed either on the form directly, which is standard or at a minimum documented some way in the medical record, by his next visit and at this point that has not occurred routinely as it should and the process is not being followed. During an interview on 4/8/25 at 4:21 P.M., the DON said there are no additional documents or completed MRRs that she could provide or locate to demonstrate this repeat recommendation was addressed appropriately or timely.

Based on document review and interview, the facility failed for two Residents (#4 and #202), out of a total sample of 15 residents, to maintain a complete and accurate medical record. Specifically, the facility failed to: 1. Ensure the healthcare proxy (HCP) activation form was completed for Resident #4, including the cause and nature of the document, which were left blank; and 2. Ensure the administration of Tramadol (a pain medication) was documented on the medication administration record (MAR) for Resident #202 each time it was administered. Findings include: 1. Review of Massachusetts healthcare proxy act M.G.L. C 201 D, Section 6 indicated, but was not limited to the following: The authority of a health care agent shall begin after a determination is made, pursuant to the provisions of this section, that the principal lacks the capacity to make or to communicate health care decisions. Such determination shall be made by the attending physician according to accepted standards of medical judgment. The determination shall be in writing and shall contain the attending physician's opinion regarding the cause and nature of the principal's incapacity as well as its extent and probable duration. This written determination shall be entered into the principal's permanent medical record. Resident #4 was admitted to the facility in June 2024 and had diagnoses including: dementia with psychotic disturbance and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 3/12/25, indicated Resident #4 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 4 out of 15. Review of the medical record on 4/8/25 indicated the Resident's HCP had been invoked on 11/22/24 by Nurse Practitioner (NP) #1. The form indicated the following: The Resident lacks the capacity to communicate health decisions. This determination is made in accordance with accepted standards of medical judgement. The cause, nature, extent and probable duration of the resident's incapacity are described below: the cause and nature of the medical judgement on the form remained blank, the extent was completed as moderate/severe and duration as lifelong. During an interview on 4/8/25 at 12:18 P.M., NP #1 said he invoked Resident #4's HCP back in November of 2024 for an increase in cognitive decline. He reviewed the HCP activation form and said the form was not fully completed as it should be and it was his error. During an interview on 4/8/25 at 2:25 P.M., the Director of Nurses (DON) said the HCP invocation form should be complete and it not being complete makes the medical record incomplete and potentially inaccurate for Resident #4. During an interview on 4/8/25 at 3:24 P.M., the Administrator said she was not sure a policy existed for the accuracy and completion of medical records, however her expectation is that the records are complete and accurate to demonstrate the current conditions of the residents. She reviewed the HCP invocation form for Resident #4 and said the form was incomplete. 2. Review of the facility's policy titled Charting and Documentation, dated as revised 4/2022, indicated but was not limited to the following: - services provided to the resident, progress toward the care plan goals or any changes, shall be documented in the resident's medical record as indicated - the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care - the following information is to be documented in the resident's medical record: medication administration Resident #202 was admitted to the facility in April 2025 with diagnoses including spinal stenosis. Review of the nursing admission evaluation indicated the Resident was alert and oriented to person, place, and time; follows commands and has an intact memory. During an interview on 4/6/25 at 11:20 A.M., Resident #202 said they just recently underwent a laminectomy back surgery and are using Tramadol 50 milligrams (mg) two tabs for pain management as needed (PRN) every six hours and receives the medication about three to four times a day. Review of the Medication Administration Record (MAR) for Resident #202 on 4/7/25 at 4:42 P.M., indicated but was not limited to the following: - Tramadol 50 mg 1 tablet by mouth every six hours as needed for moderate to severe pain - administered once on 4/3/25 at 8:48 A.M. (ordered 4/2/25-4/3/25) - Tramadol 50 mg 2 tablets by mouth every six hours as needed for moderate to severe pain - not signed off administrations (ordered 4/3/25) Review of the Narcotic count book #28 for the second floor, pages 76 and 78 indicated 13 doses of Tramadol had been provided to the Resident from 4/2/25 through 4/7/25 at 4:45 P.M., and not documented as administered on the MAR. During an interview on 4/8/25 at 12:40 P.M., Nurse #2 said the process for administering a PRN pain medication is to evaluate the resident, verify the order, if necessary, sign the medication out of the narcotic book and then dispense the medication into a cup and document it on the MAR. She said on review of the MAR that she had administered Resident #202 Tramadol pain medication a few times and did not sign it off on the MAR. She said the MAR was incomplete and did not accurately reflect the medications the Resident was receiving as it should. During an interview on 4/8/25 at 2:18 P.M., the DON said staff are required to document the administration of medication on the MAR to ensure the record is complete and accurate. The DON reviewed the MAR and narcotic book pages for Resident #202 and said the staff did not document the administration of the medication as they should have and the MAR was incomplete and inaccurate. During an interview on 4/8/25 at 3:24 P.M., the Administrator said her expectation is that the records are complete and accurate to demonstrate the current conditions of the residents. The Administrator reviewed the missing documentation on the MAR for Resident #202 and said the record was incomplete and inaccurate.

Based on observation, interview and record review, the facility failed to ensure four Residents (#11, #30, #33, #35), out of a total sample of 15 residents, had their call bell devices accessible and within reach to utilize them to call for staff assistance while in their rooms. Findings include: Review of the facility's policy titled Answering Call Lights, revised 3/2022, indicated but was not limited to the following: - The purpose of this procedure is to respond to the resident's requests and needs. - Guidelines: 4.) Be sure that the call light is plugged in at all times; 5.) When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. A. Resident #11 was admitted to the facility in December 2024 with diagnoses including history of falling, adult failure to thrive, and anxiety. Review of Resident #11's Minimum Data Set (MDS) assessment indicated he/she was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of 15. During an observation with interview on 4/6/25 at 8:48 A.M., the surveyor observed Resident #11 in his/her room. The call light was on the ground by the nightstand beside the bed and out of reach. Resident #11 said he/she uses the call light to ask staff for help. Resident #11 was asked to locate his/her call light but said he/she was unable to find it. Resident #11 said if he/she is not able to locate the call light, he/she usually gets in their wheelchair and finds the nurse to ask for help. On 4/7/25 at 8:00 A.M., the surveyor observed Resident #11 sitting at the edge of his/her bed eating breakfast. Resident #11's call light was on the ground by the nightstand beside the bed and out of reach of the Resident. On 4/7/25 at 12:24 P.M., the surveyor observed Resident #11 sitting at the edge of his/her bed eating breakfast. Resident #11's call light was on the ground by the nightstand beside the bed and out of reach of the Resident. On 4/7/25 at 2:49 P.M., the surveyor observed Resident #11 sitting at the edge of his/her bed eating breakfast. Resident #11's call light was on the ground by the nightstand beside the bed and out of reach of the Resident. During an interview on 4/7/25 at 4:43 P.M., Certified Nursing Assistant (CNA) #3 said Resident #11 should have his/her call light within reach when he/she is in bed or in the wheelchair. During an interview on 4/7/25 at 4:44 P.M., Nurse #6 and the surveyor entered Resident #11's room. Resident #11 said his/her call light was on the floor on the side of their nightstand. Nurse #6 said the call light was not in reach of Resident #11 and should have been. B. Resident #33 was admitted to the facility in June 2024 with diagnoses including dementia and history of falling. Review of the MDS assessment, dated 3/19/25, indicated Resident #33 had a severe cognitive impairment as evidenced by a BIMS score of 1 out of 15. On 4/6/25 at 4:20 P.M., the surveyor observed Resident #33 in a low bed with his/her eyes opened. Resident #33's call light was draped over the far side of his/her nightstand out of Resident #33's reach. The surveyor asked Resident #33 if he/she knew where their call light was, Resident #33 did not respond. On 4/7/25 at 8:06 A.M., the surveyor observed Resident #33 in a low bed with his/her eyes closed. Resident #33's call light was draped over the far side of his/her nightstand out of Resident #33's reach. On 4/7/25 at 9:34 A.M. and 10:54 A.M., the surveyor observed Resident #33 in a low bed with his/her eyes opened. Resident #33's call light was draped over the far side of his/her nightstand out of Resident #33's reach. During an interview on 4/8/25 at 2:43 P.M., the Assistant Director of Nursing (ADON) said Resident #33 was a fall risk and should have had access to his/her call light regardless of if he/she could use it. C. Resident #30 was admitted to the facility in May 2024 with diagnoses of dementia and pelvic fracture. Review of the MDS assessment, dated 3/10/25, indicated Resident #30 had a severe cognitive impairment as evidenced by a BIMS score of 1 out of 15. On 4/7/25 at 7:58 A.M., the surveyor observed Resident #30 in a bed with his/her eyes closed. Resident #30's call light was draped over the far side of his/her nightstand with the call light button touching the floor, out of Resident #30's reach. On 4/7/25 at 9:30 A.M., the surveyor observed Resident #30 in bed with his/her eyes opened. Resident #30's call light was draped over the far side of his/her nightstand with the call light button touching the floor, out of Resident #30's reach. The surveyor asked Resident #30 if he/she knew where their call light was, but Resident #30 did not respond. On 4/7/25 at 10:50 A.M. and 2:52 P.M., the surveyor observed Resident #30 in bed with his/her eyes opened. Resident #30's call light was draped over the far side of his/her nightstand with the call light button touching the floor, out of Resident #30's reach. During an interview on 4/7/25 at 4:33 P.M, CNA #3 and the surveyor observed Resident #30's call light draped over the far side of his/her nightstand with the call light button touching the floor. CNA #3 said Resident #30 was unable to reach his/her call light but should have access to it regardless of if he/she could use their call light. D. Resident #35 was admitted to the facility in September 2023 with diagnoses including dementia and chronic pain. Review of the MDS assessment, dated 3/22/25, indicated Resident #35 had a severe cognitive impairment as evidenced by a BIMS score of 2 out of 15. On 4/6/25 at 8:58 A.M., the surveyor observed Resident #35 in bed his/her call light was on the floor on the far side of his/her nightstand, not within his/her reach. Resident #35 said he/she had a call light, but he/she could not find it and did not know where it was. On 4/6/25 at 12:21 P.M. and 4:24 P.M., the surveyor observed Resident #35 in bed with their eyes opened and his/her call light was on the floor on the far side of his/her nightstand, not within his/her reach. On 4/7/25 at 8:07 A.M., 9:35 A.M., 10:55 A.M., and 2:48 P.M., the surveyor observed Resident #35 in bed with their eyes opened and his/her call light was on the floor on the far side of his/her nightstand, not within his/her reach. On 4/7/25 at 4:40 P.M., Nurse #6 and the surveyor observed Resident #35 in bed with their eyes opened and his/her call light was on the floor on the far side of his/her nightstand, not within his/her reach. Nurse #6 said all residents should have access to their call lights regardless of whether they could use their call light or not. Nurse #6 said Resident #35 could not reach his/her call light and did not have access to his/her call light but should. During an interview on 4/8/25 at 3:09 P.M., the Director of Nursing (DON) said all residents must have access to their call lights regardless of their ability to use them. The DON said Resident #11, #33, #30, and #35 should have had access to their call lights.

Based on observation, interviews, and document review, the facility failed to ensure that residents were fully aware of the grievance process. Specifically, for 10 of 10 residents attending the resident group meeting during the facility survey, the facility failed to ensure residents were aware of and had access to grievance forms, and were aware they could formulate grievances anonymously, should they choose not to alert a staff member of their concern(s). Findings include: Review of the facility's policy titled Grievance, last revised 3/2022, indicated but was not limited to: -The resident and/or resident representative will be made aware of the right to voice grievances orally, in writing, and anonymously. -If a resident, and/or health care representative, or another interested family member of a resident has a complaint, a staff member should encourage and assist the resident, or person acting on the resident's behalf, to file a written grievance with the facility using the Grievances/Complaint Report form. -Grievances and complaints may be submitted orally or in writing. The resident, and/or health care representative, or the person filing the grievance or complaint on behalf of the resident, should be encouraged to sign written complaints or grievances. If the person filing the grievance is anonymous or wishes to remain anonymous, confidentiality will be maintained, to the extent possible. On 4/7/25 at 1:00 P.M., the surveyor held a resident group meeting with 10 residents, representing each of the facility's two units, in attendance. Four of 10 residents said that they have not seen any postings about the grievance process and do not know how to file a grievance except for telling a staff member about a problem. The residents said they have to ask for a grievance form, then fill it out and then give it to the Social Worker or Assistant Director of Nursing. One resident said he/she thought they saw grievance forms by the elevator but is not sure and does not know who the grievance officer is. The resident said they could not file a grievance anonymously. Six additional residents nodded their heads up and down in agreement. On 4/7/25 at 2:00 P.M., the surveyor toured the second-floor unit, which was comprised of two perpendicular hallways shaped like a T. There was no posting about the grievance process, grievance forms or instructions on where to find grievance forms. At the end of the long hallway, the walkway became a ramp with two signs posted indicating the ramp was a fall risk, and a stop sign with instructions for residents to wait for a staff member to accompany them down the ramp. At the end of the ramp and to the left, the surveyor observed a wall mounted document file holder with blank grievance forms inside on the wall outside the social worker's office. The social worker's office was not accessible to any residents that did not reside on that hallway without staff assistance, and there were no instructions on how to file the grievance anonymously. On 4/7/25 at 2:15 P.M., the surveyor toured the third-floor unit and was unable to locate any posting about the grievance process or any grievance forms. During an interview on 4/8/25 at 12:27 P.M., the Social Worker and the surveyor toured the second and third-floor units: -Second-floor unit: the Social Worker said there should be information posted on the unit about the grievance process, how to file a grievance and where to find the grievance forms and there was not. The Social Worker pointed out the wall mounted document holder outside her office at the end of the ramp with grievance forms in it. She said residents can take the forms, fill them out and give them to either her or the Administrator. She said she did not think about how residents could access the forms without staff assistance and file a grievance anonymously. -Third-floor unit: The Social Worker said there should be information posted on the unit about the grievance process, how to file a grievance and where to find grievance forms and there was not. She said she searched the unit and behind the nursing station and said there were no grievance forms available on the unit. She searched the nursing station and found an empty folder labeled grievances. She said she needs to consult with the team about how to ensure forms are available on the unit for residents and families to file and submit grievances and provide for grievances to be filed anonymously.

3. Resident #12 was admitted to the facility in February 2025 and had diagnoses including fracture of the left humerus, anxiety, depression, and post-traumatic stress disorder (PTSD). Review of the MDS assessment, dated 2/20/25, indicated Resident #12 was cognitively intact as evidenced by a BIMS score of 13 out of 15, expressed having little interest or pleasure in doing things (2-6 days during the review period) and feeling down depressed or hopeless (2-6 days during the review period), had a diagnosis of PTSD, and received antipsychotic medication daily. Review of Physician's Orders included but was not limited to: -Quetiapine 100 mg, give 100 mg at bedtime (2/13/25) Review of February 2025 through April 2025 Medication Administration Records indicated Quetiapine 100 mg was administered according to physician's orders. Review of comprehensive care plans failed to indicate Resident #12 was prescribed antipsychotic medication and failed to identify specific targeted signs/symptoms, Resident specific interventions, including non-pharmacological approaches, and measurable goals for the use of antipsychotic medication to meet the Resident's needs. During an interview on 4/8/25 at 2:25 P.M., Unit Manager #1 reviewed Resident #12's medical record and said a care plan should have been developed by nursing staff for the Resident's use of antipsychotic medication but was not. Based on document review, observation, and interview, the facility failed to develop, implement and individualize comprehensive plans of care for five Residents (#202, #4, #12, #33, and #36) out of a total sample of 15 residents. Specifically, the facility failed: 1. For #202, to individualize and implement the pain and risk for pain care plan; 2. For Resident #4, to develop and implement a care plan for the use of Seroquel (an antipsychotic medication) that included Resident-specific targeted behaviors, interventions and measurable goals of treatment; 3. For Resident #12, to develop and implement a care plan for the use of Seroquel that included Resident-specific targeted behaviors, interventions and measurable goals of treatment; 4. For Resident #33, to develop and implement a care plan intervention after he/she sustained a fall; and 5. For Resident # 36, to develop and implement a care plan for his/her oxygen use. Findings include: Review of the facility's policy titled Comprehensive Assessments and the Care Delivery Process, dated as revised 2/2025, indicated but was not limited to the following: - comprehensive assessments, care planning and the care delivery process involve collecting data and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions - information analysis steps include (how and why?): define issues, including problems, risk factors and other concerns (to which all disciplines can relate) - define and assess conditions and problems that are causing, or could cause, other problems; arrange conditions, problems and outcomes in their proper order based on information gathered - determine the most plausible relationship between conditions and their causes - define current treatments and services; link with problems/diagnoses - identify the current interventions and treatments and link the problem and diagnoses they are supposed to be treating - identify overall care goals and objectives of individual treatments and evaluate if these treatments are accomplishing the anticipated results - apply clinical reasoning to assessment information and determine the most appropriate interventions - assessments are used to develop, review and revise the resident's comprehensive care plan 1. Resident #202 was admitted to the facility in April 2025 with diagnoses including spinal stenosis. Review of the nursing admission evaluation indicated the Resident was alert and oriented to person, place, and time; follows commands and has an intact memory. Further review of the medical record indicated an initial pain interview indicated the Resident had almost constant pain over the last five days making it hard to sleep at night and limiting his/her day to day activities, describing the pain as severe. Review of the active Physician's Orders for Resident #202 included but was not limited to: - Tramadol HCL (a narcotic pain medication) tablet 50 milligrams (mg), give two tablets by mouth every six hours as needed (PRN) for moderate to severe pain Review of the current care plans for Resident #202 indicated but were not limited to the following: FOCUS: The Resident has pain (4/2/25) GOAL: The Resident will not have discomfort related to (r/t) the side effects of analgesia through review date; the Resident will verbalize adequate relief of pain or ability to cope with incomplete relieved pain through review date (4/2/25) INTERVENTIONS: Pain is alleviated by (specify); administer analgesic as per orders (specify medication); evaluate the effectiveness of pain interventions (specify frequency) review for compliance alleviating symptoms dosing schedules and resident satisfaction with results; monitor/record pain characteristics (specify frequency) and PRN: quality, severity, anatomical location, onset, duration, and aggravating factors; monitor/record/report to nurse resident complaint of pain or request for pain treatment (4/2/25) The care plan template was incomplete and did not include the Resident specific information. FOCUS: Risk for pain - chronic (4/6/25) GOAL: Resident will not experience a decline in overall function r/t pain through next review date (4/6/25) INTERVENTIONS: Administer and monitor for effectiveness and possible side effects of PRN pain medication (4/6/25) During an interview on 4/6/25 at 11:20 A.M., Resident #202 said they just recently underwent a laminectomy back surgery and are using Tramadol 50 milligrams (mg) two tabs for pain management as needed (PRN) every six hours and receives the medication about three to four times a day. Review of the Medication Administration Record (MAR) for Resident #202 on 4/7/25 at 4:42 P.M., indicated but was not limited to the following: - Tramadol 50 mg 1 tablet by mouth every six hours as needed for moderate to severe pain - administered once on 4/3/25 at 8:48 A.M. (ordered 4/2/25-4/3/25) - Tramadol 50 mg 2 tablets by mouth every six hours as needed for moderate to severe pain - no signed off administrations (ordered 4/3/25) Review of the Narcotic count book #28 for the second floor, pages 76 and 78 indicated 13 doses of Tramadol had been provided to the Resident from 4/2/25 through 4/7/25 at 4:45 P.M., and not documented as administered on the MAR. Review of the medical record including nursing progress notes and the MAR failed to indicate the Resident was evaluated for the use of their PRN pain medication before its administration on 13 occasions, or that the effectiveness of that medication was monitored and documented in accordance with the Resident's care plan. During a follow up interview on 4/8/25 at 11:46 A.M., Resident #202 said the Nurses do ask for a pain rating before they provide him/her with their Tramadol, but no one has returned to ask him/her if the medication is effective or what a new pain rating number may be after he/she has taken the medication. He/She said this would be a nice way for the staff to understand whether or not his/her pain medication is effective so they can notify the physician of necessary adjustments without him/her having to request them and provide the physician with a good picture of their overall pain management situation. During an interview on 4/8/25 at 12:21 P.M., Nurse Practitioner (NP) #1 said the Resident was admitted following back surgery and a failed discharge home related to poor pain control and required pain management. He said his expectation and the standard of practice was for the Nurses to evaluate the Resident's pain prior to administering the PRN medication and also after to determine if the current regimen was effective. He said in order to make medical decisions for managing the Resident's pain that information would be necessary and should be documented somewhere in the medical record. During an interview on 4/8/25 at 12:40 P.M., Nurse # 2 said she was unsure of the policy for pain management, but the standard of care includes speaking with a resident to determine where their pain is, have them provide a rating on the 0-10 pain scale and then administer the medication and sign it out of the narcotic book if necessary, then return at a later time to determine if the medication was effective and document that. She said for this Resident she has treated the pain when the Resident requests but she has not signed the medication off on the MAR, documented a pre-medication pain rating or a re-evaluation rating to determine if the medication is effective or not. She said the Resident informed her today that he/she feels the current regimen is ineffective and she has alerted the NP, but on review of the record she could not find any documentation of the Resident's pre-medicated pain rating or post medication rating to help the NP in determining if the current regimen is effective and that is her error, since she has only signed the medication out of the narcotic book and not documented it as required on the MAR. During an interview on 4/8/25 at 1:29 P.M. the Unit Manager reviewed the medical record and said the comprehensive care plan was not specific to the Resident and had many blanks that required personalization. She said in addition since the Nurses were not documenting a pre-medication rating for the use of the PRN pain medication and a post medication evaluation to determine whether or not the medication was effective, they were not implementing the care plan as they should. During an interview on 4/8/25 at 2:18 P.M., the Director of Nursing (DON) reviewed the care plans and medical record for Resident #202 and said the care plan for Pain is not specific to the Resident as it is supposed to be and had numerous blank areas. She said the Risk for pain care plan is complete and comprehensive, but on review of the medical record, MAR and narcotic book said there is no documentation to demonstrate whether or not the Resident's pain management regimen was effective, and therefore the care plan had not been implemented as it should have been. 2. Review of the facility's policy titled Behavior Management, dated as revised 4/2022, indicated but was not limited to the following: - the interdisciplinary team (IDT) will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a care plan accordingly - interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs and strives to understand, prevent or relieve the resident's distress or loss of abilities; psychiatric recommendations will be reviewed by the IDT and implemented as indicated - when medications are prescribed for behavioral symptoms, documentation will include: a rationale for use, potential underlying causes of the behavior, other approaches and interventions tried prior to the use of psychoactive medications, potential risks and benefits of medications, targeted behaviors and expected outcomes Resident #4 was admitted to the facility in June 2024 and had diagnoses including: dementia with psychotic disturbance and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 3/12/25, indicated Resident #4 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 4 out of 15. Further review of the MDS indicated the Resident did not exhibit any psychosis or behaviors, expressed having little interest or pleasure in doing things (2-6 days during the review period) and feeling down depressed or hopeless (2-6 days during the review period), diagnoses of dementia and anxiety, and received antipsychotic medication routinely. Review of the active Physician's Orders for Resident #4 included, but was not limited to: -Quetiapine (Seroquel) 25 mg, give 1 tablet by mouth at bedtime for depression (3/3/25) - Behavior monitoring: uncontrolled agitation, physical aggression towards self or others, continued screaming or yelling, danger to self/others. Antipsychotic: alternative interventions; 1 = offer calm area, 2 = diversional activity, 3 = 1:1 during active episodes, N/A (not applicable); number of episodes: 0,1,2,3,4; outcome: I - improved, U unchanged, N/A, every shift (11/5/24) Review of February 2025 through April 2025 MARs indicated Quetiapine 25 mg was administered according to physician's orders; and the Resident did not exhibit any behaviors. Review of comprehensive care plans failed to identify specific targeted signs/symptoms for Resident #4's use of the antipsychotic medication or specific interventions, including non-pharmacological approaches, and measurable goals for the use of antipsychotic medication to meet the Resident's needs. During an interview on 4/7/25 at 12:29 P.M., Certified Nurse Aide (CNA) #2 said she knows the Resident well and she had never known the Resident to exhibit yelling, physical aggression or agitation and said the Resident is very nice and compliant and had not ever exhibited any kind of behaviors that she is aware. During an interview on 4/7/25 at 4:47 P.M., CNA #1 said she knows the Resident well and she is unaware of any yelling or physical or verbal aggression or agitation of any kind, in fact, she said she does not know the Resident to have ever exhibited any type of behaviors and said the Resident is very calm and pleasant. During an interview on 4/8/25 at 9:15 A.M., the Resident's Healthcare Proxy (HCP) said she is not sure what Resident #4 takes the antipsychotic medication for and it may possibly be used as a sleep aid. She said the Resident had never had any type of behaviors including yelling or physical aggression or agitation. During an interview on 4/8/25 at 12:38 P.M., Nurse #2 said the Resident is on Seroquel for depression, as far as she knows, and on review of the medical record said there are no targeted behaviors care planned for for the use of the medication and the Resident never exhibits any behaviors. During an interview on 4/8/25 at 2:25 P.M., the DON said it appears the Seroquel is ordered for depression, but the NP notes indicate sleep. She reviewed the care plans and said there is no care plan indicating the reason for the antipsychotic, the targeted behaviors, measurable goal or non-pharmacological interventions. She said the Resident is very nice and doesn't exhibit any behaviors and the behavior monitoring on the MAR is the generic template and not specific to this Resident. 4. Review of the facility's policy titled Assessing Falls and Causes, dated March 2022, indicated but was not limited to: - Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. - The staff will monitor and document each resident's response to interventions intended to reduce falling or risks of falling. Resident #33 was admitted to the facility in June 2024 with diagnoses including dementia and history of falling. Review of the MDS assessment, dated 3/19/25, indicated Resident #33 had severe cognitive impairment as evidenced by a BIMS score of 1 out of 15. Review of Resident #33's unwitnessed fall incident report, dated 3/3/25, indicated but was not limited to: - At 6:00 A.M., Resident was found by the Certified Nursing Assistant (CNA) lying on his/her back, against the bed with no injury observed. Further review of Resident #33's medical record and care plans failed to indicate a care plan intervention had been implemented to minimize future falls. During an interview on 4/8/25 at 3:09 P.M., the DON reviewed Resident #33's fall incident report and medical record and said after a resident sustained a fall the nurse should put in an intervention to prevent or minimize future falls. The DON said she did not see an intervention in place for the fall Resident #33 sustained on 3/3/25 but there should have been an intervention implemented to prevent or minimize future falls but he/she did not. 5. Resident #36 was admitted to the facility in February 2022 with diagnoses including chronic obstructive pulmonary disease (progressive lung disease characterized by airflow obstruction, making it difficult to breathe). Review of the MDS assessment, dated 3/12/25, indicated Resident #36 had significant cognitive impairment as evidenced by a BIMS of 3 out of 15. Further review of Resident #36's MDS indicated he/she had shortness of breath or trouble breathing when lying flat. Review of Resident #36's Physician's Orders indicated but was not limited to: - Oxygen at 0.5 liters to 2 liters by nasal cannula continuously to keep oxygen saturations greater than 90%, dated 4/6/25 - Oxygen at 2 liters via nasal canula as needed for shortness of breath, dated 8/18/24 discontinued 4/6/25 Further review of Resident #36's medical record failed to indicate a care plan had been developed for the use of his/her oxygen. During an interview on 4/8/25 at 2:54 P.M., the Assistant Director of Nursing (ADON) reviewed Resident #36's medical record and said Resident #36 did not have a care plan addressing the use of his/her oxygen use but should have had one. During an interview on 4/8/25 at 3:21 P.M., the Regional Nurse said Resident #36 should have a care plan for the use of their oxygen use but he/she did not.

Based on observation and interview, the facility failed to ensure two Residents (#41 and #36), out of a total sample of 18 residents, were free of accident hazards. Specifically, the facility failed: 1. For Resident #41, to ensure a wound treatment cart was locked when unattended by licensed staff to prevent unauthorized access to potentially harmful items; and 2. For Resident #36, to ensure the Resident's freestanding oxygen cylinder was properly stored. Findings include: 1. Review of the facility's policy titled Medication Storage, revised March 2022, indicated but was not limited to the following: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Resident #41 was admitted to the facility in July 2024 and had diagnoses including moderate dementia with psychotic disturbance. Review of the Minimum Data Set (MDS) assessment, dated 1/29/25, indicated the Resident had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. On 4/7/25 at 8:13 A.M., the surveyor observed a wound treatment cart located on the 3rd Floor Unit television (TV) sitting area in front of the nurses' station stored against the left wall unlocked and unattended. Resident #41 was seated in close proximity of the cart watching TV. No staff were observed in the immediate vicinity. Contents observed inside the wound treatment cart included but were not limited to the following: Top drawer: -one bottle of ammonium lactate 12% lotion (treats dry or scaly skin) -one tube of clobetasol 0.05% topical cream (topical corticosteroid-treats skin conditions that involve inflammation and itchiness, including psoriasis). Warning includes, do not get this medication in your eyes, mouth, or vagina. -one tube of nystatin and triamcinolone acetate topical cream (treats fungal skin infections and reduces associated inflammation and itching). Proper use, do not use this medication in or around the eyes. -nystatin powder (treats fungal or yeast infections of the skin). This medication is for external use only. Do not take by mouth. -one tube of 1% silver sulfadiazine cream (topical antibiotic and antimicrobial agent). Only for use on the skin. Do not get topical silver sulfadiazine in your eyes. -hydrocortisone cream (type of topical steroid that treats eczema and other skin conditions that cause swelling, redness, itching, and rashes). Intended for topical use only, not for swallowing. Swallowing could lead to side effects like adrenal gland problems or other complications. -antimicrobial skin and wound gel (formulated to effectively kill a broad spectrum of microorganisms). For external use only and should not be swallowed. Ingesting these products can be harmful and even dangerous. -mupirocin ointment 2% (topical antibiotic). Mupirocin is only for use on your skin. Avoid getting it in your eyes. -diclofenac sodium topical gel 1% (non-steroidal anti-inflammatory drug (NSAID) that can be used to treat arthritis pain, swelling, and inflammation). Do not get topical diclofenac in your eyes, nose, or mouth. 2nd drawer: -clobetasol propionate cream 0.05% 3rd drawer: -one box of 1% hydrocortisone cream -bottom drawer 2 bottles of hydrogen peroxide 3% ,16 ounce -one bottle of povidone iodine 10% solution (topical antiseptic) 3/4 full. Not intended for oral consumption. Ingesting can cause nausea, vomiting, abdominal pain, thyroid problems, kidney damage, and cardiovascular complications. On 4/7/25 the surveyor made the following additional observations: 12:55 P.M. - Resident #41 opening drawers of treatment cart then sit down in chair next to unlocked treatment cart, housekeeping staff member observed to watch Resident #41 but did not alert any nursing staff or stop the Resident from rummaging through the drawers 12:57 P.M. - Resident #41 rummaging through the treatment cart, opened three to four drawers in the cart, stopped by a Certified Nursing Assistant (CNA) and the Resident gestured with his/her hands as though he/she was looking for something to eat, nurse got up from nurses' station desk and redirects the Resident but did not lock the treatment cart 1:01 P.M. - Resident #41 rummaging through unlocked treatment cart, housekeeping staff member walks over to the Resident and ask what he/she needs, Resident gestures and asks for a new pair of socks or shoes, staff member gets resident a new pair of socks 1:21 P.M. - Resident #41 pulled a chair from the table next to the treatment cart, Resident remains seated, treatment cart remains unlocked During an interview on 4/7/25 at 3:08 P.M., Nurse #6 and Nurse #7 said they didn't know the treatment cart wasn't locked but both said they didn't have a key for it to lock it. They said there are Alzheimer's disease and dementia residents residing on the unit and said the potential was there for the residents to gain access to items that could be harmful to them. During an interview on 4/8/25 at 10:54 A.M, the Director of Nursing (DON) said treatment carts are supposed to be locked at all times if left unattended. She said, if not, anybody can go in them, and they did not want that that to happen. She said nurses have keys so she wasn't sure why they wouldn't have been locked. The DON said there was a potential hazard for residents as they could ingest the medications. She said no residents should have access to medications. 2. Review of the National Fire Protection Association (NFPA) 99, Health Care Facilities Code, 2012 Edition Chapter 11: Gas Equipment, section 11.6.2.3 (11) states that freestanding oxygen cylinders shall be properly chained or supported in a proper cylinder stand or cart. Resident #36 was admitted to the facility in February 2022 with diagnoses including chronic obstructive pulmonary disease (progressive lung disease characterized by airflow obstruction, making it difficult to breathe). Review of the MDS assessment, dated 3/12/25, indicated Resident #36 had a significant cognitive impairment as evidenced by a BIMS of 3 out of 15. Review of Resident #36's Physician's Orders indicated but was not limited to: - Oxygen at 0.5 liters to 2 liters by nasal cannula continuously to keep oxygen saturations greater than 90%, dated 4/6/25 - Oxygen at 2 liters via nasal cannula as needed for shortness of breath, dated 8/18/24 discontinued 4/6/25 On the following days and times, the surveyor observed an E-Tank (cylinder or tank of compressed oxygen approximately 3 feet tall) standing next to Resident #36's nightstand against the wall, not secured to the wall or in a cylinder stand, and near his/her roommate's head of the bed: - 4/6/25 at 9:35 A.M., - 4/6/25 at 12:12 P.M., - 4/6/25 at 4:21 P.M., - 4/7/25 at 7:59 A.M., - 4/7/25 at 10:51 A.M., and - 4/7/25 at 2:53 P.M. During an interview on 4/8/25 at 7:18 A.M., Nurse #3 and the surveyor observed an E-Tank standing next to Resident #36's nightstand against the wall, not secured to the wall or in a cylinder stand, and near his/her roommate's head of the bed. Nurse #3 said the E-Tank should not be stored in a resident's room when not in use but should be stored in the oxygen storage room. Nurse #3 said if an E-Tank was in a resident's room then it should be secured in a cylinder stand. During an interview on 4/8/25 at 2:54 P.M., the Assistant Director of Nursing (ADON) said E-Tanks should not be left in a resident's room unattended and not secured but instead should be stored in the oxygen storage room when not in use. The ADON said if an E-Tank was in a resident's room then it should be stored in a secure cylinder stand or secured to the resident's wheelchair. During an interview on 4/8/25 at 3:09 P.M., the DON said E-Tanks should be stored in a cylinder stand or secured to the resident's wheelchair when in use. The DON said an E-Tank should not have been stored in a resident's room but instead should have been stored in the oxygen storage room. During an interview on 4/8/25 at 3:21 P.M., the Regional Nurse said E-Tanks should not be improperly stored in residents' rooms when not in use.

Based on observation, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC-a flexible tube inserted through a vein in one's arm and passed through to larger veins near the heart, used to deliver medications intravenously (IV)), consistent with professional standards of practice for one Resident (#200), out of a total sample of 18 residents. Specifically, the facility failed to: -ensure documentation of PICC line dressing changes -measure and document the external catheter length to ensure the PICC line had not migrated (moved from the heart to another area, which could have significant impact on treatment, or cause serious harm) -measure and document arm circumference -measure and document the total catheter length when the PICC line was pulled out by the Resident to ensure the catheter was intact. Findings include: Review of the facility's policy titled Central Venous Catheter Care and Dressing Changes, revised April 2022, indicated but was not limited to the following: Purpose: -The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. General Guidelines: -Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g. damp, loosened or visibly soiled). -Maintain sterile dressing (transparent semi-permeable membrane (TMS) dressing or sterile gauze) for all central vascular access devices. The type of dressing is based on the condition of the resident and his or her preference. -Change the dressing if it becomes damp, loosened, or visibly soiled and: a. at least every 7 days for TSM (transparent semi-permeable) dressing; b. at least every 2 days for sterile gauze dressing (including gauze under a TSM unless the site is not obscured); or c. immediately if the dressing or site appear compromised. 7. Measure the length of the external central vascular access device with each dressing change or if catheter dislodgement is suspected. Compare the length documented at insertion. 8. Assess the integrity of securement devices with each dressing change. 9. For PICCs, measure arm circumference and compare to baseline when clinically indicated to assess for edema and possibly deep-vein thrombosis. Resident #200 was re-admitted to the facility in March 2025 from the hospital with a triple lumen PICC line device inserted in the right arm and was being treated intravenously for a diagnosis of sepsis due to methicillin susceptible staphylococcus aureus. Review of the Minimum Data Set (MDS) assessment, dated 2/17/25, indicated Resident #200 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. During a telephonic interview on 4/6/25 at 2:41 P.M., the Resident's Representative said the Resident was on IV antibiotic therapy for an infection throughout his/her body. Review of current Physician's Orders indicated the following: -May have PICC line, 4/1/25 -Observe insertion site at least every shift and PRN with intermittent infusion, as needed every shift, observe for redness, swelling, or pain at site. If redness, swelling, or pain at site observed then contact MD, 3/28/25 -cefazolin sodium (antibiotic) solution reconstituted 1 gram (GM), use 2 GM IV every 8 hours for infection until 5/4/25 6:00 A.M., 4/3/25 Review of the PICC Insertion Record indicated Resident #200 had a new non-valved single lumen Power Injectable PICC placed in the left brachial vein on 4/1/25 at 3:20 P.M. with a total catheter length of 38 centimeters (cm) and post-procedure arm circumference of 34 cm. The external catheter length was documented as 0 cm. An adhesive securement device was used. There were no corresponding paper infusion therapy orders located in the medical record. Review of manufacturer's guidelines, revised November 2010, indicated but was not limited to the following: Indications: -The PowerPICC SV catheter is indicated for short- or long-term peripheral access to the central venous system for intravenous therapy, blood sampling, power injection of contrast media, and allows for central venous pressure monitoring. Warnings: -Do not use the catheter if there is any evidence of mechanical damage or leaking. Damage to the catheter may lead to rupture, fragmentation, possible embolism, and surgical removal. -The StatLock catheter stabilization device should be monitored daily and replaced at least every 7 days. -Caution: To minimize the risk of catheter breakage and embolization, the catheter must be secured in place. Suggested Catheter Maintenance: -Dressing changes: Assess the dressing in the first 24 hours for accumulation of blood, fluid, or moisture beneath the dressing. During all dressing changes, assess the external length of the catheter to determine if migration of the catheter has occurred. Periodically confirm catheter placement, tip location, patency, and security of dressing. Review of physician's orders did not indicate an order for PICC line dressing changes, measuring the length of the external central vascular access device with each dressing change or if catheter dislodgement is suspected and compare to the length documented at insertion, to assess the integrity of securement devices with each dressing change, and to measure arm circumference and compare to the baseline when clinically indicated to assess for edema and possibly deep-vein thrombosis. On 4/7/25 at 2:41 P.M., the surveyor observed Resident #200 lying in bed. A left single lumen PICC was observed in the brachial vein. The catheter stabilization device was intact, however, there was no transparent dressing observed over the device and insertion site potentially exposing it to environmental contaminants. A white gauze wrap was observed loosely around the Resident's left wrist. Resident #200 was observed touching and playing with the PICC line device. On 4/7/25 at 2:42 P.M., Nurse #2 entered the room with the surveyor and said she did a dressing change yesterday and the transparent dressing was intact at that time. She said the Resident must have taken it off. Review of the medical record failed to indicate a dressing change had been performed on Resident #200 the day before (4/6/25) by Nurse #2 including external catheter length and arm circumference measurements to compare to the baseline measurements for any potential adverse event. Further review of the medical record failed to indicate a dressing change had been performed on Resident #200 by staff after surveyor intervention on 4/7/25 including external catheter length and arm circumference measurements to compare to the baseline measurements for any potential adverse event including dislodgement of the catheter device by the Resident. During an interview on 4/8/25 at 10:36 A.M., Nurse #2 said the Resident was sent out to the hospital early this morning because he/she pulled out his/her PICC line again. Nurse #2 said they would replace the PICC line there. Review of a Nurse Progress Note, dated 4/8/25 at 4:02 A.M., indicated the Resident was transferred to the hospital after he/she pulled out his/her PICC line from the left upper arm. The note stated all pieces were there and intact. The note and medical record, however, failed to indicate the total catheter length measurement compared to the baseline to ensure the PICC was intact. During an interview on 4/8/25 at 11:34 A.M., Nurse Practitioner (NP) #1 said he was aware the Resident pulled out his/her PICC again this morning. He said while he isn't sure how the order sets go in by nurses, he said the PICC line dressing should be changed and the external catheter length measured during the dressing change. He said if it's pulled out by the Resident, then then nursing staff should be measuring the total catheter length to ensure it's intact and compare it to the insertion record. During an interview on 4/8/25 at 11:36 A.M., Nurse #2 said the Resident had a diagnosis of sepsis at the hospital associated with a urinary tract infection and that's why he/she was on IV antibiotics. The surveyor reviewed the medical record with Nurse #2 who said there should be an order to do dressing changes and check the external length for potential migration but there wasn't. She said she wasn't sure what the protocol was at the facility for dressing changes. Nurse #2 said she didn't measure the external catheter length when she did the dressing change yesterday when the surveyor informed her there wasn't one but should have. She said when the Resident pulled out the PICC earlier this morning it was documented by another nurse that it was intact, but said she wouldn't know how if there was no measurement taken. Nurse #2 and the Unit Manager reviewed the PICC insertion record with the surveyor and said the baseline total catheter length was 38 cm, arm circumference was 34 cm, and the external catheter length was documented as 0. The UM said the external measurement and total catheter length is usually something that's included in the batch orders but wasn't and there was nowhere on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) to document it. Nurse #2 said there was a potential risk of infection if dressing changes are not being done. During an interview on 4/8/25 at 2:15 P.M., the surveyor overheard the Director of Nursing (DON) ask the Assistant Director of Nursing (ADON) to enter a note from the IV incident the day before (4/7/25) for Resident #200 and to make sure he put everything in there. During an interview on 4/8/25 at 3:48 P.M., the ADON said he didn't write a progress note until today, but everything was fine, and said he measured the total catheter length, and it was 38 cm (PICC had not been removed at this time for the ADON to have measured it). During an interview with the DON and Regional Nurse #1 on 4/8/25 at 1:43 P.M., the DON said the Resident returned from the hospital with a PICC line for antibiotics related to sepsis. Regional Nurse #1 said there was no current order for dressing changes or measuring the external catheter and said it may have been dropped. She said staff follow the policy for dressing changes and measuring. The surveyor reviewed the policy with the DON and Regional Nurse #1 who said the dressing should be changed at least every seven days and as needed and the monitoring of external catheter length and arm circumference should be done with it. Regional Nurse #1 said the ADON changed the dressing on 4/1/25 and with all the commotion, documentation may have slipped from being done and she would have to ask him about it. She said the skilled nursing notes did not include measurement of external catheter length but said staff are monitoring it. The DON said Nurse #2 said she was going to measure it and didn't know why she didn't.

2. Resident #12 was admitted to the facility in February 2025 and had diagnoses including anxiety and depression. Review of the MDS assessment, dated 2/20/25, indicated Resident #12 was cognitively intact as evidenced by a BIMS score of 13 out of 15, had anxiety, depression (other than bipolar) and received antipsychotic medication daily. Review of the medical record indicated but was not limited to: -Quetiapine Fumarate 100 mg at bedtime (2/13/25) Review of February 2025 and March 2025 MARs indicated Quetiapine was administered as ordered by the physician. Further review of the medical record failed to indicate any resident-specific targeted behaviors were identified and monitored for Resident #12's use of Quetiapine. During an interview on 4/8/25 at 11:48 A.M., NP #1 said he did not know why Resident #12 was prescribed Quetiapine and could not identify any resident-specific targeted behaviors/signs or symptoms for its use. During an interview on 4/8/25 at 2:25 P.M., Unit Manager #1 and the Regional Nurse reviewed Resident #12's medical record. They said they did not know why the Resident was prescribed Quetiapine or any resident-specific targeted behaviors/signs and symptoms for its use. The Regional Nurse said they need to identify and monitor targeted behaviors for the use of all psychotropic medication, including antipsychotic medication. Based on document review and interview, the facility failed for four Residents (#4, #12, #24, and #30), out of a total sample of 15 residents, that psychotropic medications were provided in accordance with the federal regulations. Specifically, the facility failed: 1. For Resident #4, to ensure a rationale for use of Quetiapine (Seroquel) (an antipsychotic medication), and resident - specific targeted behaviors/signs and symptoms to ensure its use was necessary and effective; 2. For Resident #12, to identify and monitor resident-specific, targeted behaviors/signs and symptoms for the use of the antipsychotic medication Quetiapine; 3. For Resident #24, to ensure a gradual dose reduction (GDR) of the antipsychotic medication Seroquel was attempted, unless documented by the prescriber as clinically contraindicated in the medical record; and 4. For Resident #30, to ensure a PRN antipsychotic medication was limited to 14 days, or extended beyond 14 days following a documented evaluation by the prescriber for continued appropriateness of the medication. Findings include: Review of the facility's policy titled Psychotropic Medications, dated as revised 2/2025, indicated but was not limited to the following: - the policy is to monitor the effects of psychoactive medications when prescribed, which will be prescribed at the lowest possible dose and are subject to gradual dose reduction and re-review as needed Criteria for psychotropic drug use: - preventable causes are ruled out; behavior represents a danger to the resident or others or is a source of distress or dysfunction for the resident; the drug use maintains or improves the resident's functional capacity; dosage is appropriate for the resident and is not in excess of the suggested daily dosage maximum and dose reduction or re-evaluations are provided regularly, according to state/federal regulations Review of the facility's policy titled Antipsychotic Medication Use, dated as revised 4/2022, indicated but was not limited to the following: - antipsychotic medications may be considered for residents with dementia, but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed - antipsychotic medications will be prescribed at the lowest possible dosage, for the shortest period of time, and are subject to gradual dose reduction and re-review - residents will only receive antipsychotic medications when necessary to treat a specific conditions for which they are indicated and effective - the Attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others; and identify acute psychiatric episodes, and will differentiate them from enduring psychiatric conditions - the Attending physician will identify, evaluate and document with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications - residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use - the interdisciplinary team (IDT) will complete a PASRR screening if appropriate; re-evaluate the use of the antipsychotic medication at the time of admission and/or within two weeks to consider whether or not the medication can be reduced, tapered, or discontinued; based on assessing the resident's symptoms and overall situation, the Physician will determine whether to continue, adjust or stop existing antipsychotic medications - diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident - antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definitions in the diagnostic and statistical manual of mental disorders: Schizophrenia. Review of the facility's policy titled Behavior Management, dated as revised 4/2022, indicated but was not limited to the following: - the interdisciplinary team (IDT) will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a care plan accordingly - interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs and strives to understand, prevent or relieve the resident's distress or loss of abilities; psychiatric recommendations will be reviewed by the IDT and implemented as indicated - when medications are prescribed for behavioral symptoms, documentation will include: a rationale for use, potential underlying causes of the behavior, other approaches and interventions tried prior to the use of psychoactive medications, potential risks and benefits of medications, targeted behaviors and expected outcomes - if antipsychotic medications are used to treat behavioral symptoms, the IDT will monitor their indication and implement a GDR, or document why this cannot or should not be done 1. Resident #4 was admitted to the facility in June 2024 and had diagnoses including: dementia with psychotic disturbance and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 3/12/25, indicated Resident #4 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 4 out of 15. Further review of the MDS indicated the Resident did not exhibit any psychosis or behaviors, expressed having little interest or pleasure in doing things (2-6 days during the review period) and feeling down depressed or hopeless (2-6 days during the review period), diagnoses of dementia and anxiety, and received antipsychotic medication routinely. Further review of the medical record indicated the Resident's Healthcare proxy (HCP) had been invoked on 11/22/24. Review of the active Physician's Orders for Resident #4 included but was not limited to: -Quetiapine (Seroquel) 25 milligrams (mg), give 1 tablet by mouth at bedtime for depression (3/3/25) - Behavior monitoring: uncontrolled agitation, physical aggression towards self or others, continued screaming or yelling, danger to self/others. Antipsychotic: alternative interventions; 1 = offer calm area, 2 = diversional activity, 3 = 1:1 during active episodes, N/A (not applicable); number of episodes: 0,1,2,3,4; outcome: I - improved, U unchanged, N/A, every shift (11/5/24) Review of February through April 2025 Medication Administration Records (MAR) indicated Quetiapine 25 mg was administered according to physician's orders; and the Resident did not exhibit any behaviors. Review of the historic Physician's Orders indicated Resident #4 has been receiving Seroquel since admission in June 2024, initially for sleep until March 2025 at which time the indication was changed to depression. Review of the monthly regimen review recommendations left by the consultant pharmacist indicated a clarification for diagnosis and indicated use was left for the Attending physician in July 2024, August 2024, November 2024 and January 2025. Review of comprehensive care plans failed to identify specific targeted signs/symptoms for Resident #4's use of the antipsychotic medication or specific interventions, including non-pharmacological approaches, and measurable goals for the use of antipsychotic medication to meet the Resident's needs. During an interview on 4/8/25 at 9:15 A.M., the HCP said she is not sure what the Resident takes the Quetiapine for and it was not indicated on the informed consent. She said the Resident has been taking it since prior to admission and believes it may be related to sleep, because the Resident has never had any behaviors. She said no one has spoken to her about decreasing or eliminating the medication and she wouldn't mind agreeing to this if the Physician or Nurse Practitioner (NP) thought it was beneficial to her family member or they wanted to try something else; her family member's well-being was the priority. During an interview on 4/8/25 at 12:03 P.M., NP #1 said he believes Resident #4 is receiving Seroquel for problems sleeping. He said neither sleep nor depression are an appropriate diagnosis for the use of Seroquel and as far as he knows the Resident does not have any diagnoses that would be appropriate for Seroquel use. He said he cannot think of any behaviors he has ever been made aware of and he is not aware of the facility identifying any targeted behaviors for the use of Seroquel. He said if the medication was used for sleep, then there are other options and he would think they would be monitoring the Resident's sleep pattern, but it does not appear that is happening. He said it would be appropriate for this Resident's Seroquel to be re-evaluated for continued use and likely reduced or discontinued since there is no clear indication or targeted behavior for its use. During an interview on 4/8/25 at 2:25 P.M., the Director of Nurses (DON) said she could not identify any documented or care planned targeted behaviors for the Resident's use of Seroquel. She said the behavior monitoring on the medication administration record is the generic template and not specific to this Resident. She said her expectation is that the facility meets all regulatory guidelines and standards of care for antipsychotic medication use and it does not seem on review of this Resident's record that this has been followed. 3. Resident #24 was admitted to the facility in July 2023 with diagnoses including depression, vascular dementia, and cerebral infarction. Review of Resident #24's MDS assessment, dated 1/15/25, indicated he/she had a moderate cognitive impairment as evidenced by a BIMS score of 6 out of 15. The MDS assessment indicated he/she received antipsychotic medications on a routine basis only. Furthermore, the MDS assessment indicated Resident #24 did not have a GDR attempted and there was no physician documentation indicating a GDR was clinically contraindicated. Review of Resident #24's Physician's Orders included but were not limited to the following medications: - 6/19/24: Seroquel Oral Tablet 50 mg, give 50 mg orally at bedtime for depression; 8 P.M. Review of Resident #24's MAR from January 2025 to April 2025 indicated Seroquel was administered as ordered by the physician. Review of Resident #24's physician and NP's notes, dated 2/26/25, 1/2/25, 11/12/24, failed to indicate the Resident's treatment with Seroquel was evaluated for a GDR and failed to indicate a documented clinical rationale for a GDR of Seroquel was contraindicated. Review of the medical record indicated Resident #24 was followed by a consultant psychotherapy NP whose recommendations included continued use of Seroquel as its use outweighed the risks. Further review of the medical record failed to indicate this information was reviewed and indicated in the physician or NP documentation. During an interview on 4/8/25 at 12:35 P.M., NP #1 said providers were reliant on psychotherapy NPs for recommendations on continued use of antipsychotic medications. NP #1 said Resident #24 has utilized antipsychotic medications for treatment of his/her depression for a long standing period of time. NP #1 said he typically would follow up with any recommendations made by the consultant psychotherapy NP. NP #1 said he would document clinical rationale for a GDR or its contraindication in his documentation. During an interview on 4/8/25 at 1:54 P.M., the Assistant Director of Nursing (ADON) said residents on antipsychotic medications are regularly reviewed by the interdisciplinary team for continued use or need for a GDR. The ADON said the facility utilizes a consultant psychotherapy NP to review residents and make recommendations about their plan of care. The ADON said prescriber's need to document in the medical record the attempt of a GDR or why a GDR is contraindicated. 4. Resident #30 was admitted to the facility in May 2024 with diagnoses of dementia and depression. Review of the MDS assessment, dated 3/10/25, indicated Resident #30 had severe cognitive impairment as evidenced by a BIMS score of 1 out of 15. Review of Resident #30's current Physician's Orders indicated but was not limited to: - Haldol (antipsychotic medication) 2 mg/milliliters (ml). Give 0.5 ml (1 mg) every six hours as needed for agitation, order date 3/6/25. Review of Resident #30's medical record failed to indicate the Haldol had a stop date or was re-evaluated by the Physician/NP to extend the Haldol past 14 days. During an interview on 4/7/25 at 10:34 A.M., Nurse #7 said PRN antipsychotic medications should have a 14 day stop date and an order to re-evaluate the need for PRN medication. Nurse #5 reviewed Resident #30's physician's orders and said Resident #30 should have had a stop date for Haldol but did not. During an interview on 4/8/25 at 12:51 P.M., NP #1 said all PRN antipsychotic medications should have a 14 day stop date and must be re-evaluated by the Physician or NP prior to continuing. The NP said PRN antipsychotic medications should not be prescribed a standing order for an antipsychotic medication. NP #1 said Resident #30 should not have been prescribed the Haldol as a standing order. During an interview on 4/8/25 at 2:43 P.M., the ADON said Haldol is an antipsychotic medication and PRN psychotic medications should not be prescribed without a 14 day stop date. The ADON said after the 14-day original order the Physician/NP must re-evaluate the antipsychotic medication and either discontinue it or write a rational for extending the medication. The ADON reviewed Resident #30's medical record and said Resident #30's Haldol did not have a stop date and had not been re-evaluated by the Physician/NP but should have been.

Based on observation, interview, and document review, the facility failed to ensure all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Ensure medication carts were locked when not in direct supervision of the licensed nurse on one of two units; 2. Ensure two of two medication rooms were locked when not in direct supervision of the licensed nurse; and 3. Ensure the over the counter (OTC) medication room was locked when not in direct supervision of the licensed nurse on one of one units. Findings include: Review of the facility's policy titled Medication Storage, revised March 2022, indicated but was not limited to the following: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. -Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys. According to the facility's Resident Matrix (used to identify pertinent care categories for newly admitted residents in the last 30 days who are still residing in the facility and all other residents) five residents on the 2nd Floor Unit and 19 residents on the 3rd Floor Unit had a diagnosis of Alzheimer's disease or dementia of any type. 1. On 4/6/25 at 11:23 A.M., the surveyor observed the low side medication cart on the 2nd Floor Unit belonging to Nurse #2 unlocked and unattended in the hallway outside resident rooms. A housekeeper and Certified Nursing Assistant were observed walking by the cart. During an observation with interview on 4/6/25 at 11:25 A.M., the surveyor observed Nurse #2 return to her cart. Nurse #2 said her medication cart should have been locked but she got distracted by a family member who called her away and forgot to lock it when she walked away. Nurse #2 said the medication cart needed to be locked for safety when not in the direct line of sight of the nurse. 2a. 2nd Floor Medication Room During an observation with interview on 4/7/25 at 11:56 A.M., during the 2nd Floor Unit medication room storage review with Nurse #2, the surveyor observed the door to the medication room unlocked upon entry. The Unit Manager (UM) joined the surveyor and Nurse #2 and said the medication room door should have been locked when unattended. b. 3rd Floor Medication Room On 4/7/25, the surveyor made the following observations of the 3rd Floor Unit medication storage room: 8:09 A.M., 8:28 A.M., and 8:48 A.M. - room unlocked and unattended, no licensed staff in the immediate vicinity, two residents sitting directly outside the medication room in the television sitting area, one of two Residents (#41) diagnosed with dementia 12:29 P.M. - room unlocked and unattended, no licensed staff in the immediate vicinity, one Resident (#41) sitting directly outside the medication room in the television sitting area 3:02 P.M. - room unlocked and unattended, no licensed staff in the immediate vicinity During an interview on 4/7/25 at 3:08 P.M., Nurse #6 said she was just in the medication room and used her key to open the door and said it was locked. The surveyor asked Nurse #6 to attempt to open the medication room door without her key. Nurse #6 was able to freely open the door without her key and said it should have been locked. She said it was unlocked from the inside, that's why. Nurse #6 and Nurse #7 said there were Alzheimer's disease and dementia residents residing on the unit and said the potential was there for residents to gain access to items stored which could be harmful to them. 3. On 4/7/25 at 8:34 A.M., the surveyor observed the 3rd Floor Unit OTC medication room door unlocked. Four shelves of OTC medications were stored inside and accessible to any passersby. Nurse #7 joined the surveyor and said the door should have been locked when unattended. She said long term care residents, a few with diagnoses of Alzheimer's disease and dementia, resided on the unit and the potential was there for residents to enter the OTC medication room and either take or ingest the medications. During an interview on 4/8/25 at 10:54 A.M., the Director of Nursing (DON) said the medication carts and medication rooms are supposed to be locked at all times if left unattended. She said, if not, anybody can go in them, and they did not want that that to happen and to also avoid drug diversion. She said nurses have keys so she wasn't sure why they wouldn't have been locked. The DON said there was a potential hazard for residents as they could ingest the medications.

Based on observations, interviews, and meal test tray results, the facility failed to serve meals that were palatable and at appetizing temperatures on two of two units. Findings include: Review of the facility's policy titled Daily Food Temperature Checks, last revised 8/15/24, indicated but was not limited to: - It is the policy of the facility that temperatures be recorded at each meal to assure that all meals be served to the residents within the proper temperature range. - Cold food or beverage is to be at or below 41 degrees or hot food or beverage will be maintained at or above 135 degrees. During the Resident Council Meeting, on 4/7/25 at 1:00 P.M., 5 out of 10 residents, who actively participated, said the food at breakfast and lunch would come up cold and the facility needed to ensure there were enough staff passing trays. On 4/8/25 at 7:37 A.M., the surveyor requested a breakfast tray to the Second Floor Unit. The food truck left the kitchen at 7:44 A.M., and arrived at the unit at 7:46 A.M. The test tray was conducted with Dietary Aide #2 at 7:55 A.M., with the following results in degrees Fahrenheit (F): - Scrambled Eggs: 125.1, F lukewarm to taste and little flavor. - Waffle: 111.6 F, cold to taste, dry, and little flavor. - Sausage: 122.8 F, lukewarm to taste, Dietary Aide #2 confirmed the sausage was lukewarm. - Oatmeal: 164.5 F, palatable and hot. - Milk Carton: 51.3 F, lukewarm to taste. - Orange Juice: 46.5 F, lukewarm to taste and touch. On 4/8/25 at 7:44 A.M., the surveyor requested a breakfast tray to the Third Floor Unit. The food truck left the kitchen at 7:50 A.M., and arrived at the unit at 7:52 A.M. The test tray was conducted with the Food Service Director (FSD) at 8:00 A.M., with the following results: - Scrambled Eggs: 115.5 F, lukewarm to taste and little flavor. FSD confirmed lukewarm to taste. - Waffle: 102 F, cold to taste and soggy. FSD confirmed lukewarm to taste and parts of the waffle were soggy from touching the eggs. - Sausage: 126.6 F, lukewarm to taste. FSD confirmed lukewarm to taste. - Oatmeal: 153 F, palatable and hot. - Milk Carton 45 F, cool and palatable. - Orange Juice 45.9 F, cool and palatable. - Cup of coffee served on the unit was 165 F palatable and hot. During an interview on 4/8/25 at 10:23 A.M., the FSD said the temperatures were not within the appropriate ranges, and the hot items should have been hotter for the residents and colder foods colder. The FSD said her expectation was for hot foods to be served at 148 F to 150 F and food items should be hot and flavorful when served to the residents. The FSD said that one column of the plate warmer had not been working for a while; the dietary staff had to rotate hot plates from one side to the other and cover it with a stainless-steel pot. The FSD said the kitchen needed a new plate warmer and everyone was aware.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure food was properly stored in the walk-in freezer in the main kitchen; 2. Ensure to properly date, label, and store food and drink items in one of two kitchenettes; 3. Ensure, a. the wall in the main kitchen behind the dishwashing station was kept in a clean and sanitary manner; b. the counter next to the sink in one of two kitchenettes was kept in a clean and sanitary manner; 4. Ensure staff wore hair restraints in the main kitchen during meal preparation and service; and Findings include: Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated but was not limited to: -2-402 Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. -2-103 Duties 2-103.11 Person in Charge. The PERSON IN CHARGE shall ensure that: (B) PERSONS unnecessary to the FOOD ESTABLISHMENT operation are not allowed in the FOOD preparation, FOOD storage, or WAREWASHING areas, except that brief visits and tours may be authorized by the PERSON IN CHARGE if steps are taken to ensure that exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES are protected from contamination. 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3- 501.17(A), except time that the product is frozen; P (2) Is in a container or PACKAGE that does not bear a date or day; P or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A). 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. 4-101.19 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment that are exposed to splashes, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material. 1. On 4/6/25 at 7:31 A.M., the surveyor observed in the main kitchen walk-in refrigerator: - One opened container of thickened cranberry juice refrigerated, undated, manufacturer label stated: After opening may be kept up to 7 days under refrigeration; - One pouch of whipped cream, open date 3/24/25 use by 3/27/25; - Five canisters of Dessert Topping, all dated best by 11/16/24; - One open plastic container of chopped peppers, dated 4/1/25; - One plastic pop-top water bottle containing a staff member's drink; - Two cartons containing milk on the walk-in floor; On 4/6/25 at 7:36 A.M., the surveyor observed in the main kitchen refrigerator: - One bowl of icing covered with plastic wrap, open date 3/30/25 and use by 4/2/25. On 4/6/25 at 12:50 P.M., the Food Service Director (FSD) and surveyor observed in the main kitchen walk-in refrigerator: - One opened container of thickened cranberry juice refrigerated, undated, manufacturer label stated: After opening may be kept up to 7 days under refrigeration; - One pouch of whipped cream, open date 3/24/25 use by 3/27/25; - Five canisters of Dessert Topping, all dated best by 11/16/24; - One open plastic container of chopped peppers, dated 4/1/25; - Two cartons containing milk on the walk-in floor; and, On 4/6/25 at 12:50 P.M., the FSD surveyor observed in the main kitchen refrigerator: - One bowl of icing covered with plastic wrap, open date 3/30/25 and use by 4/2/25. During an interview on 4/6/25 at 12:50 P.M., the FSD said all refrigerators were checked daily for expiration dates. The FSD said all foods should be labeled with date opened and use by date, and food should be used and/or discarded by the use by the date. The FSD said the thickened cranberry juice should have been labeled with the date opened and used per manufacturer's guidelines. The FSD said the milk should not have been stored on the floor of the walk-in refrigerator. The FSD said there was a small area in the walk-in refrigerator where staff could keep their food. On 4/7/25 at 11:30 A.M., the surveyor observed in the main kitchen walk-in refrigerator: - Two plastic pop-top water bottles containing staff members' drinks; and - Plastic container containing a staff member's meal. During an interview on 4/7/25 at 4:08 P.M., the Director of Operations (DOO) said staff should store their food and beverages in the employee break room and not in the main kitchen. 2. Review of the facility's policy titled Family/Visitor Provided Food, effective date 1/9/18, indicated but was not limited to: - Disposal of Foods: - NOTE: to maintain sanitary conditions and resident safety, it is the facility's policy to discard resident food if observed or evidenced to be spoiled. - Nursing, Dietary, and housekeeping staff are responsible to discard: - Foods outside of the expiration dates. - Show signs of spoilage. - Foods received more than 3 days prior. On 4/6/25 at 9:12 A.M., in the Third Floor Kitchenette refrigerator the surveyor made the following observation: - One open vanilla very high calorie nutritional drink, undated, manufacturer label stated: once open refrigerate and use within 24 hours; - One frozen container of a resident's food brought in from home, dated 3/9/25; - One custard pastry of a resident's brought in from home, undated; - Five unopened containers of probiotic milk beverage labeled with a resident's name, date best if used by 3/11/25; - One container of a resident's store-bought soup, dated use by 3/9/25; - One container of applesauce open, undated; - Two open containers of dairy free milk, undated with open date and dated best by 10/27/24, manufacturer label stated: once open use within 7 days; - One open container of chocolate balanced nutritional drink, undated, manufacturer label stated: once open refrigerate and use within 24 hours; - One frozen closed container chocolate balanced nutritional drink, manufacturer label stated: DO NOT FREEZE; - Two frozen containers of a resident's food brought in from home, undated; - One container of a resident's food brought in from home, dated 3/9/25, with a black fuzzy looking substance under the cover; and - One broken plastic container with missing pieces of plastic containing a resident's food brought in from home, undated. On 4/6/25 at 12:14 P.M., during a follow tour of the Third Floor Kitchenette refrigerator, the surveyor made the following observations: - One open container of chocolate balanced nutritional drink, undated, manufacturer label stated: once open refrigerate and use within 24 hours; - One frozen closed container chocolate balanced nutritional drink, manufacturer label stated: DO NOT FREEZE; - One broken plastic container with missing pieces of plastic containing a resident's food brought in from home, dated 4/5/25 use by 4/8/25. On 4/6/25 at 12:46 P.M., during a follow tour of the Third Floor Kitchenette refrigerator, the FSD and surveyor made the following observations: - One open container of chocolate balanced nutritional drink, undated, manufacturer label stated: once open refrigerate and use within 24 hours; - One frozen closed container chocolate balanced nutritional drink, manufacturer label stated: DO NOT FREEZE; - One broken plastic container with missing pieces of plastic containing a resident's food brought in from home, dated 4/5/25 use by 4/8/25. On 4/7/25 at 12:39 P.M., during a follow tour of the Third Floor Kitchenette refrigerator, the surveyor made the following observations: - One open container of chocolate balanced nutritional drink, undated, manufacturer label stated: once open refrigerate and use within 24 hours; - One frozen closed container chocolate balanced nutritional drink, manufacturer label stated: DO NOT FREEZE; - One broken plastic container with missing pieces of plastic containing a resident's food brought in from home, dated 4/5/25 use by 4/8/25. During an interview on 4/6/25 at 12:46 P.M., the FSD said foods from home should be labeled and dated with a resident's name and the date brought in from home. The FSD said if a store bought food was brought in for a resident and is sealed it should be used by the expiration date or best by date. During an interview on 4/8/25 at 10:23 A.M., the FSD said the kitchenette refrigerators are cleaned daily, and the dietary staff go through the refrigerator daily to ensure foods brought in from home are labeled and stored appropriately. The FSD said the expectation was for foods to be labeled and stored appropriately and per manufacturer guidelines and expired foods to be discarded. 3a. On the following days and times, the surveyor observed the wall behind the soiled side of the dishwashing area with scattered black mold-like residue: - 4/6/25 at 7:31 A.M., - 4/6/25 at 12:38 P.M., - 4/7/25 at 11:40 A.M., and - 4/7/25 at 2:24 P.M. During an interview 4/7/25 at 2:30 P.M., the FSD and surveyor observed the soiled side of the dishwashing area with the scattered black mold-like residue. The FSD said after the wall behind the soiled side of the dishwashing area was wiped down each time the dietary staff would finish doing dishes. The FSD said the scattered black mold-like residue on the wall behind the dishwasher was caused by the water splashing onto the wall and not completely drying. During an interview on 4/7/25 at 2:56 P.M., the Administrator, the DOO, and the surveyor observed the soiled side of the dishwashing area with the scattered black mold-like residue. The Administrator said she would do environmental rounds weekly, but the kitchen was last checked a month ago. The DOO said the black mold-like residue needed to be scrubbed off and washed with bleach. b. On the following days and times, the surveyor observed on the countertop next to the sink in the third floor kitchenette to have a black mold-like residue: - 4/6/25 at 9:12 A.M., - 4/6/25 at 12:14 P.M., - 4/7/25 at 12:39 P.M., and - 4/7/25 at 1:08 P.M. During an interview 4/7/25 at 1:08 P.M., the FSD and surveyor observed on the countertop next to the sink to have a black mold-like residue. The FSD said housekeeping was responsible for cleaning the counters in the kitchenette, but the dietary department was responsible for ensuring they were clean. The FSD said the black mold-like residue was caused by moisture. 4. On 4/6/25 at 7:35 A.M., the surveyor observed the following: - [NAME] #1 plating breakfast. [NAME] #1 had her hair pulled back with a clip with loose hair sticking out. [NAME] #1 was not wearing a hair net. - Dietary Aide #1 was not wearing a hair net or beard cover. - The hair net holder inside the kitchen the door was empty. The surveyor asked for a hair net upon entering the kitchen. [NAME] #1 entered the storeroom and when she came out. [NAME] #1 said she could not find any hair nets. During an interview on 4/8/25 at 10:23 A.M., the FSD said staff should not be serving breakfast or be near the steam table without a hair net or beard cover on. The FSD said the expectation was for staff to wear an appropriate hair restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection 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. Specifically, the facility failed to: 1. Implement a complete and accurate infection surveillance plan to identify, track and monitor for infection; 2. Ensure treatment carts were secured and locked to prevent Resident #41 from gaining unauthorized access resulting in infection control concerns; and 3. For Resident #36, ensure oxygen concentrator filters were clean and free of debris. Findings include: 1. Review of the facility's policy titled Infection Surveillance, revised 2/2024, indicated but was not limited to the following: - The Infection Preventionist (IP) will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have a substantial impact on potential resident outcomes and that may require transmission-based precautions and other preventative interventions. - Infections that will be included in routine surveillance include those with a. evidence of transmissibility in a healthcare environment; b. available processes and procedures that prevent or reduce the spread of infection; c. clinically significant morbidity or mortality associated infections (e.g., pneumonia, UTIs (urinary tract infections), C. difficile (highly contagious bacterial infection of the colon); d. pathogens associated with serious outbreaks. - The Infection Preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data. The Infection Control Committee and/or QAPI Committee may be involved in the interpretation of the data. - For all residents with infections that meet the criteria for the definition of infection for surveillance, collect the following data as appropriate: a. identifying information (i.e., resident's name, age, room number, unit, and attending physician); b. diagnoses; c. admission date, date of onset of infection may list onset of symptoms, if known, or date of positive diagnostic test); d. infection site (be as specific as possible e.g., cutaneous infections should be listed as pressure ulcer, left foot, pneumonia as right upper lobe, ETC.); e. pathogens; f. invasive procedures or risk factors (i.e., surgery, indwelling tubes, Foley, ETC., fractured hip, malnutrition, altered mental status, ETC.); g. pertinent remarks (additional relevant information, i.e., temperatures, other symptoms of specific infection, white blood cell count, ETC.). Also, record if the resident is admitted to the hospital, or expires; and h. treatment measures and precautions (interventions and steps taken that may reduce risk). Review of the facility provided infection surveillance line listing for December 2024 indicated but was not limited to the following: - 2 of 2 HAI skin infections failed to include a complete and accurate listing of symptoms. - 1 of 2 HAI skin infections failed to include information related to site and results of cultures (both were left blank) and failed to indicate if the infection had cleared (blank). Review of the facility provided infection surveillance line listing for January 2025 indicated but was not limited to the following: - 2 of 2 HAI skin infections failed to include a complete and accurate listing of symptoms and culture site information was left blank. - 1 of 2 HAI skin infections failed to indicate if the infection had cleared. - 2 of 2 urinary tract infections (UTI) failed to include a complete and accurate list of symptoms. - 1 of 2 UTIs failed to include information regarding culture site (BLANK) and results (BLANK). - 1 of 1 Pneumonia infections failed to indicate a complete and accurate listing of symptoms. Review of the facility provided infection surveillance line listing for February 2025 indicated but was not limited to the following: - 1 of 1 UTIs failed to include a complete and accurate listing of symptoms and failed to indicate if the infection had cleared. - 2 of 2 skin infections failed to include a complete and accurate listing of symptoms, failed to indicate the culture results (BLANK), and failed to indicate if the infection cleared (BLANK). During an interview on 4/8/25 at 1:16 P.M., the Assistant Director of Nursing (ADON)/IP said he maintained a list of infections being treated throughout the facility and reviewed them on a daily basis. The ADON/IP said the facility utilized McGeer's Criteria for infections and has an assessment in the electronic medical record that he completes when a resident presents with potential signs/symptoms of an infection. The ADON/IP and the surveyor reviewed the monthly line listings. The ADON/IP said the information on the line listings should be complete and not left blank. The ADON/IP said the information about symptoms should include all information identified during his review and be complete. 2. Review of the facility's policy titled Medication Storage, revised 3/2022, indicated but was not limited to the following: - The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. - Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. On 4/7/25 at 12:55 P.M., the surveyor observed Resident #41 opening drawers of two treatment carts on the 3rd floor unit. Resident #41 was observed to reach his/her hand inside multiple drawers of each cart and touch items in the cart. The surveyor observed a housekeeping staff member watch Resident #41 rummage through the treatment cart drawers but did not stop the Resident or alert any nursing staff. Resident #41 was not observed to perform hand hygiene prior to rummaging through the drawers of the two treatment carts. On 4/7/25 at 12:57 P.M., the surveyor observed Resident #41 opening drawers of two treatment carts on the 3rd floor unit. Resident #41 was observed to reach his/her hand inside multiple drawers of each cart and touch items in the cart. The surveyor observed a Certified Nursing Assistant (CNA) staff member watch Resident #41 rummage through the treatment cart drawers but did not stop the Resident. The surveyor observed a nurse getting up from the nurses' station and redirect Resident #41 away from the treatment cart. Resident #41 was not observed to perform hand hygiene prior to rummaging through the drawers of the two treatment carts. On 4/7/25 at 1:01 P.M., the surveyor observed Resident #41 opening drawers of two treatment carts on the 3rd floor unit. Resident #41 was observed to reach his/her hand inside multiple drawers of each cart and touch items in the cart. The surveyor observed a housekeeping staff member redirect Resident #41 away from the two treatment carts and into his/her room. Resident #41 was not observed to perform hand hygiene prior to rummaging through the drawers of the two treatment carts. On 4/7/25 at 1:05 P.M., the surveyor observed Resident #41 opening drawers of two treatment carts on the 3rd floor unit. Resident #41 was observed to reach his/her hand inside multiple drawers of each cart and touch items in the cart. Resident #41 was not observed to perform hand hygiene prior to rummaging through the drawers of the two treatment carts. On 4/7/25 at 1:21 P.M., the surveyor observed Resident #41 opening drawers of two treatment carts on the 3rd floor unit. Resident #41 was observed to reach his/her hand inside multiple drawers of each cart and touch items in the cart. Resident #41 was not observed to perform hand hygiene prior to rummaging through the drawers of the two treatment carts. During an interview on 4/8/25 at 1:47 P.M., the ADON/IP said treatment carts should be locked at all times. The ADON/IP said he would expect anyone entering a treatment cart to perform hand hygiene as to not compromise any of the treatment items in the cart. The ADON/IP said it was a breach in infection control protocols to have a resident rummaging through treatment cart drawers. The ADON/IP said a resident on the unit should never have access to the treatment cart and the items inside the treatment cart were now compromised due to the infection control breach. 3. Review of the facility's policy titled Oxygen Use, dated April 2022, indicated but was not limited to: - Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Review of the manufacturer's guidelines, last updated March 2024, indicated but was not limited to: - Filters: Air enters the oxygen concentrator unit through an air intake gross particle filter located on the back of the oxygen concentrator. This filter removes dust particles and other impurities from the air - Filters: Do not operate the unit without the air intake gross particle filter in place. On a weekly basis, wash the air intake gross particle filter, located on the back of the unit. Your Equipment Provider may advise you to clean it more often depending on your operating conditions. - Follow these steps to properly clean the air intake gross particle filter: 1. Remove the filter and wash in a warm solution of soap and water. 2. Rinse the filter thoroughly and remove excess water with a soft absorbent towel. 3. Replace the filter. Review of the World Health Organization: Care, Cleaning and Disinfection of Oxygen Concentrators Checklist (2022) indicated: -Inspect and clean air intake filter (1-2 times per week) 1. Pull the filter gently out and replace with spare one. 2. Put the filter in cool, soapy water and swirl gently to remove debris. 3. Remove from soapy water and place it in [NAME] area until completely dry. 4. Store the spare filter until next cleaning is needed. Review of the National Library of Medicine (NLM), dated 1/19/22, indicated but was not limited to: -One of the main issues affecting the oxygen concentrators, is that related to the filters, which are designed to filter out dust, particles, and bacteria. https://pmc.ncbi.nlm.nih.gov/articles/PMC8768026/ Resident #36 was admitted to the facility in February 2022 with diagnoses including chronic obstructive pulmonary disease (progressive lung disease characterized by airflow obstruction, making it difficult to breathe). Review of Resident #36's Physician's Orders indicated but was not limited to: - Oxygen at 0.5 liters (L) to 2 L by nasal cannula continuously to keep oxygen saturations greater than 90%, dated 4/6/25 - Oxygen at 2 L via nasal canula as needed for shortness of breath, dated 8/18/24 discontinued 4/6/25 - Wipe down the concentrator, change oxygen tubing, date it and clean filter weekly. Every night shift on Wednesdays, dated 4/6/25 The Surveyor made the following observations: - On 4/6/25 at 9:35 A.M., 12:12 P.M., and 4:21 P.M., Resident #36 in bed with his/her oxygen on at 1.5L via nasal canula (undated), the filter of the oxygen concentrator had a filter that was caked with dust and gray/white debris. - On 4/7/25 at 7:59 A.M., 10:51 A.M., and 2:53 P.M., Resident #36 in bed with his/her oxygen on at 1.5L via nasal canula (dated 4/6/25), the filter of the oxygen concentrator had a filter that was caked with dust and gray/white debris. During an interview on 4/8/25 at 7:18 A.M., Nurse #3 said weekly on the 11:00 P.M. to 7:00 A.M. shift the nurses would change the oxygen tubing, and clean the filter and wash the oxygen concentrator. Nurse #3 examined Resident #36's oxygen concentrator and said Resident #36's was dirty and covered with dust. Nurse #3 said Resident #36's filter needed to be cleaned. During an interview on 4/8/25 at 2:54 P.M., the ADON reviewed Resident #36's medical record and said Resident #36 did not have an order to clean his/her oxygen concentrator and filter prior to 4/6/25 and did not know the last time their oxygen filter had been cleaned. During an interview on 4/8/25 at 3:09 P.M., the Director of Nursing (DON) said her expectation was for oxygen equipment to be clean and follow infection control protocols.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, document review, and policy review, the facility failed to ensure staff properly labeled all drugs and biologicals used in the facility in accordance with currently accepted principles. Specifically, the facility failed to ensure staff properly labeled all medications stored in one of three medication carts reviewed once opened. Findings include: Review of the facility's policy titled Medication Storage in the Facility, revised [DATE], indicated but was not limited to the following: -Certain medications or package types, such as intravenous solutions, multiple dose injectable vials, once opened, require an expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency. -Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is a multi-dose injectable vial or an item for which the manufacturer has specified a usable life after opening. -When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated, if applicable, for medications requiring a shortened expiration date. -The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration, if applicable. Examples of medications with shortened expiration dates include insulins and inhalers (Note: the best stickers to affix contain both a date opened and expiration notation line). Review of a facility document titled Insulin Stability Chart, undated, indicated but was not limited to the following: Long Acting: -Lantus (glargine), opened stability, room temperature, 28 days after opening On [DATE] at 9:22 A.M., the surveyor reviewed the 3rd floor unit main side medication cart with Nurse #1 and observed the following: -One opened (seal broken) multiple dose injection vial of Lantus (insulin glargine) 100 units/milliliter (ml) stored inside the packaging box in the top drawer of the medication cart, packaging box and multiple dose vial not labeled with the date when opened or the expiration date. During an interview on [DATE] at 9:22 A.M., Nurse #1 said, once opened, the insulin packaging box and vial should have been labeled with the open date and expiration date. She said the insulin had a shortened expiration date and was only good for 28 days. During an interview on [DATE] at 12:39 P.M., the Director of Nurses (DON) said as soon as staff opens medications including insulin, they must label both the packaging container and the vial stored inside with the date when opened and the expiration date to remind people to remove them from the cart and get a new one once expired. The DON said multidose vials of insulin have shortened expiration dates to make sure they are still effective.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to notify the physician (MD) and/or nurse practitioner (NP) of an abnormal chest X-ray for one Resident (#41), out of one of three closed records reviewed. Findings include: Review of the facility's policy titled Labs and Diagnostics, dated 4/2022, indicated but was not limited to the following: Assessment and Recognition -The physician will identify and order diagnostics and lab testing based on diagnostic and monitoring needs. -The staff will process test requisitions and arrange for tests. -The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. Review by Nursing staff -If the staff who first receive or view lab or diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. Deciding how urgently to contact the physician. -A nurse will identify the urgency of communicating with Attending Physician based on physician request, the seriousness of any abnormality, and the individual's current condition. Identifying Situations that Warrant Immediate Notification -Nursing staff will consider the following factors to help identify situations requiring prompt physician Notifications Concerning Lab or Diagnostic Test Results: -The physician has requested to be notified as soon as the result is received. -The result is something that should be conveyed to a physician regardless of other circumstances (that is the abnormal result is problematic regardless of any other factors). -Resident's clinical status is unclear or worsening. Options for Physician Notification. -A physician can be notified by phone fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent. -Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record and not on the lab result report, because test results should be correlated with other relevant information such as individual's overall situation, current symptoms, advanced directives, prognosis, etc. -Direct voice communication with the physician is preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification. Resident #41 was admitted to the facility in March 2024 with the following diagnoses: Newly diagnosed metastatic squamous cell carcinoma of the larynx (superior glottis), primary lung cancer on immunotherapy, pneumonia, chronic obstructive pulmonary disease (COPD), acute hypoxic (low oxygen in body tissue) respiratory failure, pleural effusion requiring drain placements. Review of Resident #41's Hospital Discharge summary, dated [DATE], indicated but was not limited to the following: -Patient presented to local hospital with several weeks of dyspnea (shortness of breath) on exertion and acute worsening of shortness of breath. The patient was transferred to a Boston Hospital, specifically due to concerns for airway obstruction in the setting of invasive squamous cell cancer. -Patient was treated for COPD exacerbation as well as pneumonia. -Eyes, nose, and throat specialist evaluated airway and did not see any airway obstruction. -Pulmonologist (Specializes in lung conditions) did a bronchoscopy that showed airway collapse on both sides; you had stents placed in the airways in both sides of your lungs. -You were treated for pneumonia with antibiotics. -You received five sessions of radiation therapy directed at the cancer in your lungs. -You had a clot in your right arm vein associated with your peripherally inserted central catheter (PICC) line (catheter inserted into the vein for delivery of medication). -You had some continued trouble breathing after receiving radiation, and you were found to have fluid around your left lung that was drained by the interventional Pulmonologist team. -You were given an infusion of pembrolizumab, which is a medication that is being used to treat your cancer. -Unfortunately, while you were admitted you had several episodes of diarrhea and were given treatment for a suspected infection called C diff. -Ultimately your breathing was stable, and you were ready to be discharged to rehab to help you regain your strength. Review of the facility's Physician's Orders indicated but were not limited to the following: -Stat chest x-ray, initiated 3/9/24. -Oxygen at 2 liters per minute via nasal cannula continuous to maintain oxygen saturation rate at 92%, initiated 3/8/24. -Orders may transfer to ER for evaluation 3/11/24 Review of the Medication Administration Record (MAR) indicated the stat chest x-ray was completed on 3/9/24. Review of the radiology report, dated 3/9/24, indicated the following: -Examination date:3/9/24 at 6:45 P.M., Reported date 3/9/24 at 10:20 P.M. -Reason for study acute respiratory failure unspecified whether with hypoxia or hypercapnia (high levels of carbon dioxide in your blood). -Conclusion: Near complete all opacification (becoming opaque- not transparent) of the left lung suggested of left pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest) and possible atelectasis (collapse of the whole lung or part of the lung) with cardio mediastinal shift to the left (an abnormal movement which may include the heart, trachea, esophagus, and major vessels, to one side of the chest cavity). An underlying abnormality cannot be excluded. If these are not known entities contrast-enhanced chest CT scan is recommended. -Reviewed by Director of Nursing (DON) on 3/14/24 at 4:04 PM. Review of nursing progress notes indicated but were not limited to the following: -On 3/9/24 at 7:33 A.M., Patient complained of shortness of breath (SOB), oxygen (O2) desaturated 87% on 2 liters (L) nasal canula (NC), increased to 3 liters (L), rechecked O2 to 89%. Patient given as needed DuoNeb (medication administered through nebulizer machine) treatment, O2 increased to 4.5 L NC. Patient O2 went to 91% on 4.5 L. On call Nurse Practitioner (NP) #1 notified. NP order to closely monitor patient and notify if patient needs to be sent out. -3/9/24 at 3:02 P.M., continues on supplemental O2, neb (nebulizer) treatment ineffective, O2 at 90 %. Resident denies SOB at this time. Heart rate (HR) and O2 saturation reported to on-call physician, new order obtained, 1. STAT chest X-Ray. -3/9/24 at 8:58 P.M., patient had stat x-ray. -3/10/24 at 6:42 A.M., patient had a good night, O2 saturation 95%, continue to monitor. -3/10/24 at 2:40 P.M., patient verbalized pain upon assessment, as needed Tylenol administered. Continue to monitor. -3/10/24 at 7:45 P.M., O2 at 96% via NC. given Dilaudid for pain and effective. -3/11/24 at 6:06 A.M., O2 saturation 96%. -3/11/24 at 11:25 A.M., Resident noted to have respiratory discomfort and reported to MD with no new orders. Staff offered resident transport to hospital; resident declined at this time. -3/11/24 at 1:08 P.M., Interdisciplinary Team (IDT) Discharge and recapitulation summary. Resident was transferred to the hospital. The reason for transfer is the safety of the individual in the facility would be endangered. Congestive heart failure and other psychiatric problems. At the time of transfer, the Resident was alert oriented and followed instructions. -3/11/24 at 4:00 P.M., Resident condition is deteriorating, using accessory muscles, severe SOB at rest despite 5 liters of O2. O2 saturation fluctuating from 92 to 94 %. MD notified, new orders to send patient to emergency room (ER). Patient continues to decline offer, but resident's boyfriend visited at this time and encouraged patient to go an acute care facility due to respiratory distress and a heart rate of 137. Nebulizer treatment administered and remained on O2 at 5 liters with poor effect. Resident left via 911 at 1:30 P.M. Further review of nursing progress notes did not indicate the x-ray results from 3/9/24 were communicated with MD or NP. Review of the nursing notes titled, RC Skilled Note- V3, on the following dates 3/9/24 at 8:58 P.M., 3/10/24 at 6:42 A.M., 3/10/24 at 2:40 P.M., and 3/10/24 at 7:45 P.M., indicated but was not limited to the following: -Indicated recent diagnostics conducted: None (Box available to check for radiology (x-ray) studies). During an interview on 5/14/24 at 2:00 P.M., Nurse #2 said the labs are printed at the start of the shift, she takes a picture and uses the facility's secure electronic system to send via cell phone to the covering MD or NP. She said the MD or NP calls or texts back any new orders and then she enters the information into her nursing progress note. During an interview on 5/14/24 at 2:13 P.M., the DON said she did review the x-ray report on 3/14/24 at 4:04 P.M. The DON reviewed the medical records and could not find documentation the MD or NP were notified of the abnormal x-ray results, dated 3/9/24, in the electronic medical record. The DON said there should be documentation through the electronic system the facility uses to communicate with the MDs or NPs. She retrieved the electronic system on her cell phone and could only view text conversations with the MDs or NPs going back to May 9, 2024 (text prior to that date are automatically deleted). The DON said the nurses, after texting through the secure electronic platform to the MDs or NPs, should document in the medical record the results of the x-ray, the physician notification, and any new orders. During an interview on 5/14/24 at 2:13 P.M., Nurse #3 said she was working on 3/9/24 and ordered the x-rays for Resident #41 but had left for the day and the next nurse was supposed to follow up with the x-ray results. She said the process would be to notify the MD or NP about the results and then write a nursing progress note with the doctor's response. During an interview on 5/14/24 at 2:24 P.M., NP #2 said he was on vacation when the x-ray results were reported to the facility. NP #2 reviewed his cell phone electronic medical records and said there was no documentation of the physician or NP receiving the x-ray results from the facility. NP #2 said the communications on the texting platform are automatically deleted after a period of time. He said the normal process was for the nurse to call or use the electronic secure texting platform to inform the MDs of the abnormal lab results, and the MD or NP would verbally or text back any new orders. NP #2 said they depend on the nurse to put new orders into the computer and or to write a note that the abnormal x-ray results were communicated with the MD and any new orders were recorded. During an interview on 5/15/24 at 12:56 P.M., the DON reviewed the RC Skilled Note- V 3 notes and said the notes should have indicated Resident #41 had x-rays and indicated the results and communication with the physician. The DON said she spoke to the nurse who was on the 3:00 P.M. 11:00 P.M. shift on 3/9/24 and was told the results had not been received in the facility before that nurse left for the evening. The DON said the Nurse that worked the 11:00 P.M. to 7:00 A.M. on 3/9/24 into 3/10/24 is no longer employed by the facility.

Based on observation and interview, the facility failed to maintain two of two resident nourishment kitchenettes in a clean and sanitary condition. Findings include: Review of the facility's policy titled Unit Kitchenettes, dated 8/15/23, indicated but was not limited to the following: -It is the policy of the Facility that unit kitchenettes be used for resident nourishments and snacks. These areas are to be maintained in a sanitary manner. Fridges, cabinets, counters, floors, and microwaves, where applicable, should be checked for cleanliness at a minimum when they are being stocked. Additionally, housekeeping will do a deep clean of refrigerators and microwaves weekly. The floors and rubbish removal will follow the same schedule as the unit where kitchenette is contained. On 5/10/24 at 10:35 A.M., the surveyor observed the resident kitchenette on the Third-floor and made the following observations: -The cabinet under the sink was a metal pest trap. Around the pest trap opening there were mice droppings and dried liquid stains. In the back right corner of the cabinet were dried liquid stains and additional mouse droppings. -The bottom cabinet, lower shelf had a clear plastic container with a red top and there were visible food remnants inside. The floor of the cabinet was stained with dried brownish liquid in multiple areas. -The bottom cabinet, top shelf had a cardboard box, unwrapped napkins, plastic cup on its side and dried liquid stains. -The drawer contained an Adidas labeled lunch bag with food contents inside. -The floor in front of the refrigerator had a dried liquid stain that was sticky to the touch. On 5/10/24 at 10:40 A.M., the surveyor observed the Second-floor resident kitchenette and made the following observations: -The microwave had food remnants on the sides and the top. In addition, there were four layers of paper towels on the glass plate, which were stained with food. -The floor of the kitchenette was observed to be tacky when walking on the floor and had visible food remnants on the floor. -There was a large food stain on the wall and floor to the left of the radiator. On 5/14/24 at 9:51 A.M., the surveyor observed the Second-floor kitchenette and made the following observations: -There was a caution wet floor sign posted outside the kitchenette. -The microwave had three paper towels on the glass plate, which were heavily soiled with food stains. The inside walls and the top had food remnants. -The floor of the kitchenette was audible tacky with every step. There continued to be food remnants visible on the floor. -The large food stain on the wall and floor to the left of the radiator was still present. During an interview on 5/14/24 at 9:53 A.M., Housekeeper #1 said she just finished cleaning the kitchenette on the Second-floor. She said she wipes down the countertops and the microwave and washes the floor. The surveyor and Housekeeper #1 entered the kitchenette and there was an audible tackiness to the floor. The food particles stuck to the floor were reviewed, the inside of the microwave including the dirty paper towels on the glass tray and the food stains on the inside walls and top of the microwave, and the food stains on the wall and floor to the left of the radiator. Housekeeper #1 said she just wipes down the outside of the microwave, and probably should clean the inside. She noticed the food stains on the wall and should have cleaned them and said she could have done a better job washing the floor. On 5/14/24 at 10:13 A.M., the surveyor observed the Third-floor kitchenette and made the following observations: -The cabinet under the sink had the same mouse droppings and dried liquid stains that were present in front of the pest trap and the back right corner. -In front of the refrigerator was the same sticky area. During an interview on 5/14/24 at 10:00 A.M., with the Administrator and the Corporate Consultant present, the surveyor reviewed the observations of both kitchenettes on 5/10/24 and 5/14/24. The Corporate Consultant said housekeeping should be cleaning inside the cabinets and the microwaves and making sure the floor is clean and free from food.

Based on records reviewed, interviews, and observations for one of three sampled residents (Resident #1), who was morbidly obese, incontinent of both bowel and bladder, and who required the assistance of two staff members with the use of a mechanical lift device to transfer in and out of bed, the Facility failed to ensure services provided were consistent with Resident #1's comprehensive assessment and plan of care, in an effort to maintain his/her Quality of Life. On 11/21/23, Resident #1 was observed out of bed in his/her wheelchair at 9:41 A.M. and observed again at 4:14 P.M. still in his/her wheelchair and per Resident #1's interview, he/she had not been provided with incontinent care or assisted with repositioning for comfort during that time. Finding include: Review of the Facility Policy titled, Activities of Daily Living (ADL), dated as last revised 3/2022, indicated that residents will be provided care, treatment, and services as appropriate to maintain or improve as able, their ability to carry out ADL's to ensure that their ADL's do not decline. The Policy further indicated the following for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with; -Hygiene (bathing, dressing, grooming, and oral care); -Mobility (transfer and ambulation, including wheelchair) -Dining (meals and snacks); -Communication (speech, language, and any functional communication systems); and -Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals, and recognized standards of practice. Resident #1 was admitted to the Facility in September 2023, diagnoses included bilateral lower extremity cellulitis (infection of the skin), atrial fibrillation, diabetes mellitus, morbid obesity, and anxiety. Review of Resident #1's Care Plan titled, Bladder Incontinence, dated 9/30/23, indicated he/she was incontinent of urine, required the use of disposable briefs, was to be changed every two hours and as needed (PRN). Review of Resident #1's admission Minimum Data Set (MDS) Assessment, dated 10/06/23, indicated he/she was alert, oriented, had a Brief Interview Mental Status (BIMS) score of 15, (13-15 indicates cognitively intact), and he/she was able to make his/her own decisions. The MDS also indicated that Resident #1 required total physical assistance of two staff members with a mechanical lift device to transfer in and out of bed, and he/she required extensive to total physical assistance of two staff members for toileting needs (which included incontinence care needs), bed mobility, and repositioning. During an observation on 11/21/23 at 9:41 A.M., Resident #1 was observed sitting in his/her wheelchair in his/her room. During an interview on 11/21/23 at 9:41 A.M., Resident #1 said he/she does not get out of bed everyday and said there are times he/she will refuse to get out of bed because he/she is afraid that he/she will not be assisted back to bed in a timely manner. Resident #1 said that he/she was also told by some nursing staff (exact names unknown), that once they transfer him/her out of bed via a mechanical lift device in the morning, that when they transfer him/her back to bed to provide incontinent care, that he/she has to stay in bed for the remainder of the day. During an observation at 4:14 P.M., Resident #1 was observed sitting in his/her wheelchair in his/her room. During a follow-up interview on 11/21/23 at 4:14 P.M., Resident #1 said that he/she has been in his/her wheelchair since this morning, when he/she was first interviewed by the Surveyor. Resident #1 said that he/she had not been assisted by nursing staff with repositioning or incontinent care since he/she had been transferred out of bed in the morning (at least six hours). Resident #1 said that the nursing staff will not transfer him/her to bed to provide incontinent care and then return him/her to his/her wheelchair because they told him/her it was too much work. Resident #1 said since it is not feasible for staff to transfer him/him into bed to change him/her and then transfer him/her back into the wheelchair, said he/she just sits in a wet adult brief until he/she goes back to bed. During a telephone interview on 11/22/23 at 11:08 A.M., Regional Clinical Director #2 said she had helped the Facility for approximately two weeks and said she was in direct contact with Resident #1 and Family Member #1. Regional Clinical Director #2 said staff would give her grief about having to transfer Resident #1 back to bed for incontinent care and then having to transfer him/her back into his/her wheelchair again, because of how much assistance he/she required. During a telephone interview on 11/28/23 at 11:44 A.M., Certified Nurse Aide (CNA) #4 said on 11/21/23 Resident #1 was on her assignment, but said she does not remember what time she transferred him/her out of bed that that morning. CNA #4 said when she left for the day at 3:00 P.M., she had not toileted or repositioned Resident #1 at all after he/she was transferred out of bed in the morning and put into his/her wheelchair. CNA #4 said that there are only two CNA's on the unit and that she does not have the time to do everything. CNA #4 said she is unable to transfer Resident #1 with a mechanical lift device to bed or provide incontinent care and then transfer him/her back out of bed again. During an interview on 11/21/23 at 4:43 P.M., Regional Clinical Director #1 (Interim Director of Nurses, DON), said it is the expectation of the Facility that all residents, regardless of their functional status and amount of staff assistance they require, that their care needs are provided and met by staff, including transfers, repositioning and incontinent care as frequently as possible.

Based on records reviewed, interviews and observations of one of three sampled residents (Resident #1) the Facility failed to ensure they maintained a complete and accurate medical record including but not limited to Activities of Daily Living (ADL) Flow Sheets that were to be completed by Certified Nurse Aides (CNA's) that should contain daily documentation of care provided to the resident by staff each shift. Findings include: Based on the Facility Policy titled, Charting and Documentation, dated as last revised 4/2022, indicated services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical records. Resident #1 was admitted to the Facility in September 2023, diagnoses included bilateral lower extremity cellulitis (infection of the skin), atrial fibrillation, diabetes mellitus, morbid obesity, and anxiety. Review of Resident #1's admission Minimum Data Set (MDS) Assessment, dated 10/06/23 indicated that Resident #1 required total physical assistance of two staff members to transfer (with a mechanical lift device), and he/she required total physical assistance of two staff members for toileting needs, bed mobility, and repositioning. Review of resident #1's Care Plan, titled ADL-Self-Care deficit, dated as last revised 11/14/23, indicated he/she required physical assistance of two staff members with all transfers (mechanical lift required), repositioning, and toileting/incontinent care. Review of Resident #1's ADL Flow Sheets, completed by CNA's, dated 10/01/23 through 10/31/23, indicated the for the following shifts, documentation on the flow sheets were incomplete. -7:00 A.M. to 3:00 P.M.- 22 days (out of 31) all ADL care areas were left blank. -3:00 P.M. to 11:00 P.M.- 7 days (out of 31) all ADL care areas were left blank. -11:00 P.M. to 7:00 A.M.- 9 days (out of 31) all ADL care areas were left blank. Review of Resident #1's ADL Flow Sheets, completed by CNA's, dated 11/01/23 through 11/21/23, indicated the for the following shifts, documentation on the flow sheets were incomplete. -7:00 A.M. to 3:00 P.M.- 15 days (out of 20) all care areas were left blank. -3:00 P.M. to 11:00 P.M.- 7 days (out of 20 ) all care areas were left blank. -11:00 P.M. to 7:00 A.M.- 8 days (out of 20) all care areas were left blank. Review of Resident #1's ADL flow sheet dated 11/21/23 (date of survey), for the 7:00 A.M. to 3:00 P.M., shift indicated there was no CNA documentation to support that care was provided to Resident #1, including but not limited to transfers and toileting. During an observation on 11/21/23 at 9:41 A.M., Resident #1 was observed sitting in his/her wheelchair in his/her room. During an additional observation on 11/21/23 at 4:14 P.M., Resident #1 was again seen still sitting in his/her wheelchair in his/her room. During an interview on 11/21/23 at 4:14 P.M., Resident #1 said that he/she has been in his/her wheelchair since that morning, when the surveyor first interviewed him/her. Resident #1 said that no staff members had assisted him/her with repositioning or incontinent care since he/she had been transferred out of bed and put into his/her wheelchair that morning (at least six hours). Review of Resident #1's Repositioning Sheets, dated 11/21/23, as documented by CNA #4, indicated the following; -10:00 A.M. he/she was repositioned onto his/her right side; -12:00 P.M. he/she was repositioned again onto his/her right side; and -2:00 P.M. he she was positioned on his/her back. However this conflicted with Resident #1's interview during which he/she said staff had not assisted him/her with positioning or incontinence care needs after he/she was transferred out of bed that morning. During a telephone interview on 11/28/23 at 11:44 A.M., Certified Nurse Aide (CNA) #4 said on 11/21/23 Resident #1 was on her assignment but said she does not remember what time she transferred him/her out of bed that morning. CNA #4 said when she left for the day at 3:00 P.M., she had not toileted or repositioned Resident #1 at all after he/she was transferred into his/her wheelchair for the day. During an interview on 11/21/23 at 4:13 P.M., the Administrator said it is the expectation of the Facility that all documentation be completed in a timely manner and that all documentation be accurate. During an interview on 11/21/23 at 4:43 P.M., Regional Clinical Director #1 (interim Director of Nurses, DON) said that Certified Nurse Aides are expected to complete their documentation accurately and in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for three of three sampled residents (Resident #1, Resident #2, and Resident #3), the Facility failed to ensure the residents and/or their family members or legal representatives participated in the development and implementation of their person-center care plans, which included conducting and inviting residents and/or their Representatives to an interdisciplinary care plan meeting following the completion of their comprehensive admission Minimum Data Set (MDS) assessments. Findings include: Review of the Facility Policy titled, Comprehensive Care Plans, dated as last revised 4/2022, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Policy also indicated that the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative develops and implements a comprehensive, person-centered care plan for each resident. The Policy further indicated that each resident has the right to the following; -Participate in the planning process; -Request meetings; -Request revisions of the Care Plan; -Participate in establishing the expected goals and outcome of care; -Participate in the determining the type, amount, frequency, and duration of care; -Receive the services and/or items included in the plan of care; and -See the care plan and sign it after significant changes are made. 1) Resident #1 was admitted to the Facility in September 2023, diagnoses included bilateral lower extremity cellulitis (infection of the skin), atrial fibrillation, diabetes mellitus, morbid obesity, and anxiety. Review of Resident #1's admission Minimum Data Set (MDS) Assessment, dated 10/06/23, indicated he/she was alert, oriented, had a Brief Interview Mental Status (BIMS) score of 15 (score of 13-15 indicates cognitively intact) and was able to make his/her own decisions. During an interview on 11/21/23 at 9:41 A.M., Resident #1 said that the Facility had not had any meetings with him/her or his/her family. Resident #1 said he/she would ask to speak to administration frequently but said he/she felt the requests were not met in a timely manner and at times were not met at all. Resident #1 said Family Member #1 was involved in his/her care and said that if there had been a care plan meeting held by the Facility, he/she would have wanted Family Member #1 present. During a telephone interview on 11/20/23 at 1:41 P.M., Family Member #1 said that there was no initial meeting at or with the Facility within the first few days of Resident #1's admission, and that there had been no care plan meetings held at all for Resident #1. Family Member #1 said she had to request that the facility hold a Family Meeting and said that meeting finally occurred on 11/10/23 (which was more than 10 weeks since Resident #1's admission). Review of Resident #1's Medical Record, indicated that there was no documentation to support he/she had an initial comprehensive care plan meeting since his/her admission. 2) Resident #2 was admitted to the Facility in October 2023, diagnoses included status-post fall with bilateral knee fractures, morbid obesity, urinary incontinence, and legal blindness. Review of Resident #2's admission MDS, dated [DATE], indicated he/she was alert, oriented, had a Brief Interview Mental Status (BIMS) score of 15 (score of 13-15 indicates cognitively intact) and was able to make his/her own decisions. During an interview on 11/21/23 at 12:29 P.M., Resident #2 said he/she does not think that he/she had any type of care plan meeting since his/her admission. Review of Resident #2's Medical Record, indicated that there was no documentation to support he/she had an initial comprehensive care plan meeting since his/her admission. 3) Resident #3 was admitted to the Facility in October 2023, diagnoses included status-post fall with a right lower tibial (lower leg) and ankle fractures, morbid obesity, and depression. Review of Resident #3's admission MDS, dated [DATE], indicated he/she was alert, oriented, had a Brief Interview Mental Status (BIMS) score of 15 (score of 13-15 indicates cognitively intact) and was able to make his/her own decisions. During an interview on 11/21/23 at 11:09 A.M., Resident #3 said he/she does not think that he/she had any type of care plan meeting since his/her admission. Review of Resident #3's Medical Record, indicated that there was no documentation to support he/she had an initial comprehensive care plan meeting since his/her admission. During a telephone interview on 11/22/23 at 12:24 P.M., Social Worker (SW) #1 said she had been covering the Facility for the last two weeks and was asked to visit with Resident #1 and address his/her concerns. SW #1 said that initial baseline care plan meetings (72-Hours) for newly admitted residents and the comprehensive admission Care Plan Meeting with residents and family member were not being conducted by the Facility. During an interview on 11/21/23 at 4:43 P.M., Regional Clinical Director #1 (interim Director of Nurses, DON) said that she was unable to find any documentation to support that 72-hour or Care Plan meetings occurred (were held) for Residents #1, #2, or #3. Regional Clinical Director #1 (interim DON) said that it is the Facility's expectation that all new admissions will have a 72-hour baseline care plan meeting, that a comprehensive care plan meeting be conducted in a timely manner and the Residents' and/or their Family Member/Legal Representative would be invited to attend and participate in the resident's plan of care.

Based on records reviewed and interviews, for one of three sampled residents (Resident #4), who had experienced a fall in the community resulting in significant head trauma requiring his/her need for hospitalization, and who upon admission to the facility was assessed by nursing to be at increased risk for falls, the Facility failed to ensure services provided by nursing met professional standards of care, when on 10/08/23, after Resident #4 had an unwitnessed fall to the floor and self-reported to nursing that he/she bumped his/her head, neurological assessments were not consistently completed by nursing, as required. Findings include: Review of the Facility Policy titled Neurological Assessment, dated as last revised 4/2022, indicated that a neurological assessment is indicated for the following reasons: -Upon a physician order; -Following an unwitnessed fall; -Following a fall if other accident/incident involving head trauma; or -When indicated by the resident's condition. The Policy indicated Neurological Signs are to include the following; -Determine resident's orientation to time, place, and person; -Observe resident's patterns of speech and speech clarity; -Obtain vital signs; -Check Pupil reaction; -Determine resident's motor ability; -Have resident move all extremities; -Determine sensation in all extremities; -Check gag reflex; and -Check eye opening, verbal, and motor responses using the Glasgow Coma Scale (used to objectively describe the extent of impaired consciousness). Resident #4 was admitted to the facility in October 2023, diagnoses include status post fall with a traumatic subdural hemorrhage (bleeding into the brain), fracture of vault (skullcap) of the skull, difficulty walking, osteoporosis, and long-term use of anticoagulants for chronic atrial fibrillation. Review of Resident #4's Physician's Progress Note, dated 10/08/23, indicated he/she had a history of recent falls, sustained a left subdural hematoma with hemorrhagic contusion on the left temporal (left side of brain near temple) lobe. The Note indicated that Resident #4 had a scheduled head CT scan and a neurology follow-up in place. Review of Resident #4's Nurse Progress Note, dated 10/08/23, indicated that he/she had an unwitnessed fall in his/her room. The Note indicated Resident #4 got up to close the door, he/she fell on the floor and bumped his/her head. Review of Resident #4's Facility Incident Report, dated 10/08/23, indicated his/her provider was notified of the fall and neurological checks were to be initiated. Review of Resident #4's Neurological Signs Form, dated 10/08/23, indicated the frequency of neurological/vital signs (unless otherwise ordered by the physician) were as follows: -Every 15 minutes times 4 times; -Every one-hour times 4 times; -Every four hours times six times; and -Every eight hours times six times -For a total of 77 hours of observation and assessment of the neurological sign. Further review of the Neurological Form, dated 10/08/23, indicated nurses began assessing and documenting Resident #4's neurological signs at 6:30 P.M. and only continued to obtain them through 3:15 A.M. on 10/09/23, therefore his/her Neurological signs were assessed by nursing for less than nine hours out of total 77 hours, as required. Also, Nurse #11, who initiated Resident #4's neurological signs failed to perform and document his/her blood pressure five out of seven required times throughout her 3:00 P.M. -11:00 P.M. shift and did not complete the section related to motor functions for his/her left lower extremity, right upper extremity, or his/her right lower extremity, as indicated of the Form. Review of Resident #4's Medical Record indicated that after the neurological assessment completed at 3:15 A.M. on 10/09/23 by nursing, there was no additional documentation to support that nursing continued to monitor his/her neurological status, as required. The entire back page of the Neurological form was left blank. During an interview on 10/17/23 at 1:09 P.M., Nurse #10 said she was aware that Resident #4 had a fall and required neurological checks. Nurse #10 said she performed and recorded his/her neurological checks on Resident #1's Form two times, during her 11:00 P.M.- 7:00 A.M. shift, (which was during the time he/she needed to be assessed every four hours times six times). Nurse #10 said she had three or four residents who had required neurological checks during that shift and said she passed each residents Neurological Form on to the oncoming day shift nurse. Nurse #10 said that there had not been consistent nursing staff in the facility and said that may be why Resident #1's neurological signs were not completed. During an interview on 10/17/23 at 3:15 P.M., the Regional Nurse said the Director of Nurses (DON) had been out sick and that the DON was usually the one who keeps track of neurological signs. The Regional Nurse said there has been a lot of agency usage and that could have been a factor in nursing not completing the neurological signs for Resident #1, as required. During an interview on 10/24/23 at 3:53 P.M., the interim Director of Nurses (DON) said it is the expectation that neurological signs are to be initiated and completed for any resident to sustains an unwitnessed fall, as a professional nursing standard.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an invoked Health Care Proxy, and had developed new pressure injuries, the Facility failed to ensure that nursing notified Resident #1's Health Care Agent (HCA) regarding his/her change in condition. Findings include: The Facility Policy, titled Change of Condition in a Resident Status, dated 3/2017, indicated the following: -the Facility shall notify the resident, his or her attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition -a significant change of condition is a decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions -Unless otherwise instructed by the resident, the Nurse will notify the resident's family or representative (sponsor) when: there is a significant change in the resident's physical, mental, or psychosocial status -Notifications will be made of a change occurring in the resident's medical/mental condition or status -The Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status Resident #1 was admitted to the Facility in February 2021, diagnoses included Dementia, Major Depressive Disorder, Generalized Anxiety Disorder, Fibromyalgia (widespread muscle pain and weakness), Spinal Stenosis and Gastro-esophageal Reflux Disease. Review of Resident #1's Health Care Proxy Form, dated 12/03/2011, indicated Family Member #1 was Resident #1's primary Health Care Agent. Review of Resident #1's Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy Act, dated 07/29/2021, indicated Resident #1's Health Care Proxy had been invoked. During an interview on 6/06/23 at 5:06 P.M., Resident #1's Health Care Agent (HCA, Family Member #1) said on 4/30/23 she held Resident #1's hand while two Certified Nurse Aides (CNA's) provided incontinent care to him/her, and that she saw his/her bottom was red and there were also three pressure injuries. The HCA said she was not aware of Resident #1's pressure injuries until she saw the pressure injuries herself that day and that she was not notified by anyone from the Facility. During an interview on 6/13/23 at 1:41 P.M., Nurse #2 said on 4/29/23 Resident #1's coccyx area was red, and she applied skin barrier cream per his/her treatment orders. Nurse #2 said when she applied the skin barrier cream to Resident #1's coccyx, there was a family member (exact name unknown) in his/her room that helped her to keep Resident #1 calm because he/she was refusing care. Nurse #2 said she had not documented, in Resident #1's progress notes that the family member was present or aware. Nurse #2 said that she was not sure who Resident #1's actual Health Care Agent was. Nurse #2 said she was aware that nurses were supposed to notify the Health Care Agent of any change in a resident's condition and said she should have looked in Resident #1's medical record for the name of his/her HCA, notified them and documented in his/her progress notes. During an interview on 6/12/23 at 1:15 P.M., Certified Nurse Aide (CNA) #4 said on 4/30/23 Resident #1's HCA (Family member #1) was in visiting him/her while she and another CNA were providing incontinent care to Resident #1 and could not turn him/her on his/her side. CNA #4 said the HCA offered to help them and when they turned Resident #1 onto his/her side, the HCA saw his/her buttocks. CNA #1 said Resident #1's buttocks was red and excoriated, and had several small open areas. During an interview on 6/08/23 at 2:33 P.M and a telephone interview on 6/14/23 at 10:37 A.M., the Director of Nurses (DON) said she was not aware Resident #1 had developed pressure injuries to his/her coccyx and buttocks and that his/her HCA was not notified. The DON said Resident #1's Health Care Proxy was invoked, and the Nurse should have notified his/her Health Care Agent and documented the notification in his/her medical record.

Based on records reviewed and interview for one of three sampled residents (Resident #1), who required daily assistance from staff for turning and repositioning, the Facility failed to ensure they maintained complete and accurate medical records related to Certified Nurse Aide daily documentation of care and assistance provided for Activities of Daily Living (ADL's), when documentation on Resident #1's positioning sheets for the day and evening shifts for April and May 2023 were incomplete and left blank. Findings Include: Review of the Facility's Policy tilted Charting and Documentation, dated as revised 4/2022, indicated that services provided to the resident shall be documented in the resident's medical record as indicated and the documentation in the medical record will be complete and accurate. Resident #1 was admitted to the Facility in February 2021, diagnoses included Dementia, Major Depressive Disorder, Generalized Anxiety Disorder, Fibromyalgia (widespread muscle pain and weakness), Spinal Stenosis, and Gastro-esophageal Reflux Disease. Review of Resident #1's Activities of Daily Living (ADL) Positioning sheets, dated 04/01/23 through 04/30/23 and 05/01/23 through 05/31/23, indicated that Certified Nurse Aides (CNAs) failed to consistently document ADL care provided to him/her related to his/her need for staff assistance with positioning. Review of Resident #1's Certified Nurse Aide (CNA) Positioning Flow Sheet for April 2023, indicated that the positioning sheets for the following dates and shifts were left blank: Day shift (7:00 A.M. to 3:00 P.M.) where CNA's should have documented his/her positioning at 8:00 A.M., 10:00 A.M., 12:00 P.M., and 2:00 P.M.; -04/02/23, 12:00 noon and 2:00 P.M., were left blank -04/03/23 through 04/30/23, were all left blank Evening shift (3:00 P.M. to 11:00 P.M.) where CNA's should have documented his/her positioning at 4:00 P.M., 6:00 P.M., 8:00 P.M., and 10:00 P.M.; -04/11/23 through 04/14/23, were all left blank -04/16/22 through 04/30/23, were all left blank Review of Resident #1's CNA Positioning Flow Sheet for May 2023, indicated that the positioning sheets for the following dates and shifts were left blank: Day shift (7:00 A.M. to 3:00 P.M.) where CNA's should have documented his/her positioning at 8:00 A.M., 10:00 A.M., 12:00 P.M., and 2:00 P.M.; -05/01/23 through 05/12/23, were all left blank -05/16/22 through 05/31/23, were all left blank Evening shift (3:00 P.M. to 11:00 P.M.) where CNA's should have documented his/her positioning at 4:00 P.M., 6:00 P.M., 8:00 P.M., and 10:00 P.M.; -05/01/23 through 05/12/23, were all left blank -05/16/22 through 05/31/23, were all left blank During an interview on 6/12/23 at 1:15 P.M., Certified Nurse Aide (CNA) #4 said all documentation for resident's care is supposed to be completed by the end of the shift. CNA #4 said she does not have time to document the care she provided to residents, but tries to remember to complete the documentation on the next scheduled day she works. During an interview on 6/14/23 at 10:37 A.M., the Director of Nursing (DON) said she was not aware that the CNA Positioning flow sheets were incomplete and said that CNAs should be documenting on the flow sheets by the end of every shift and should not be left blank.

Based on interview and record review, the facility failed to ensure staff promoted and facilitated Resident self-determination relative to the manner of bathing for one Resident (#27), out of a total sample of 14 residents. Findings include: Resident #27 was admitted to the facility in February 2022 with diagnoses which included major depressive disorder, left fibula fracture, and abnormal gait and mobility. Review of the Minimum Data Set (MDS) assessment, dated 11/21/22, indicated Resident #27 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Further review of the MDS indicated it was very important for the Resident to choose between tub bath, shower, bed bath, or sponge bath. In addition, the Resident was totally dependent on staff for showering and bathing. During an interview on 12/21/22 at 11:45 A.M., Resident #27 said he/she would like to take a shower as it would make him/her feel better. Resident #27 said it might be difficult to get into the shower chair, but staff do not offer a shower and he/she is provided with a bed bath. Review of the document titled Second Shift Certified Nurse Assistant (CNA) Assignment, dated 12/23/22, indicated Resident #27 was on the assignment to be provided a shower on Tuesdays, during the 3:00 P.M. - 11:00 P.M. shift. Review of the Activities of Daily Living (ADL) flowsheet (completed by the CNAs), dated December 2022, indicated Resident #27 was provided a bed bath during the day shift on the following dates: 12/1/22,12/2/22,12/4/22,12/6/22,12/7/22, and 12/8/22. 12/9/22 through 12/23/22 were left blank. Additional review of the document indicated Resident #27 was provided a bed bath on the 3:00 P.M. - 11:00 P.M. shift on 12/1/22. 12/2/22 through 12/23/22 were left blank. During an interview on 12/23/22 at 2:00 P.M., CNA #2 said she was unsure of Resident #27's shower status and did not believe Resident was on the shower schedule. CNA #2 said she only provided the Resident a bed bath. CNA #2 said if Resident declined to bath, she would report to the nurse in charge. During an interview on 12/23/22 at 2:15 P.M., Nurse #3 said Resident #27 often refused to get out of bed for a shower and preferred a bed bath. Nurse #3 said she did not document in the clinical record when the Resident declined a shower. During an interview on 12/27/22 at 3:30 P.M., CNA #3 said Resident #27 was provided a bed bath, required a Hoyer lift for transfers, and did not believe Resident #27 was on the CNA assignment for a shower. During an interview on 12/27/22 at 3:45 P.M., Unit Manager #2 and the surveyor reviewed the CNA Assignment sheet. Unit Manager #2 confirmed Resident #27 was on the assignment sheet for showers on Tuesdays. Unit Manager #2 and the surveyor also reviewed the ADL flowsheet and the blank dates for the month of December. Unit Manager #2 said staff should be offering Resident #27 showers on Tuesdays as indicated on the CNA Assignment sheet and documentation should be in place if the Resident declined. Review of the clinical record failed to include any documentation which indicated Resident #27 was offered a shower and/or refused a shower.

Based on observation, record review, policy review, and interview, the facility failed to ensure nursing staff followed professional standards of practice during medication administration and observed the Resident's consumption of medications prior to leaving the room for one Resident (#204), out of a total sample of 14 residents. Findings include: A review of the facility's policy titled Oral Medication Administration, dated as revised 4/22, indicated but was not limited to the following: -Remain with the resident until all medications have been taken. Resident #204 was admitted to the facility in December 2022 with diagnoses which included right hip hemiarthroplasty (replacement), diabetes mellitus, Alzheimer's disease, and dementia. Review of the Minimum Data Set (MDS) assessment, dated 12/16/22, indicated Resident #204 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated the Resident had severely impaired cognition. Review of the current Physician's Orders indicated but was not limited to: -Aspirin EC tablet delayed release 81 milligrams (mg) by mouth two times a day for four weeks, date ordered, 12/14/22 -Colace capsule 100 mg by mouth two times a day, date ordered, 12/13/22 -Fludrocortisone Acetate tablet 0.1 mg, give 0.05 mg by mouth one time a day, date ordered, 12/13/22 -Magnesium Chloride oral tablet give one tablet by mouth two times a day, date ordered, 12/25/22 -Magnesium Oxide 400 mg by mouth two times a day, date ordered, 12/12/22 -Metformin HCL tablet 1000 mg by mouth two times a day, date ordered, 12/13/22 -Namenda tablet 10mg by mouth once daily, date ordered, 12/13/22 -Norco tablet 5-325 mg one tablet by mouth three times per day, date ordered, 12/16/22 -Protonix tablet delayed release 40 mg give one tablet by mouth once daily, date ordered 12/13/22 -Sennosides tablet 8.6 mg give one tablet by mouth once daily, date ordered 12/12/22 -Tradjenta tablet 5 mg by mouth one time a day, date ordered 12/13/22 -Vitamin B12 tablet 500 micrograms (mcg) by mouth once daily, date ordered 12/13/22 Further review of the Physician's Orders indicated Resident #204 did not have an order to self-administer medication. On 12/21/22 at 9:25 A.M., the surveyor entered Resident #204's room and observed the Resident alone in his/her room seated in a chair with a medication cup on his/her overbed table and multiple medications in the medication cup. Resident #204 asked the surveyor if he/she should take the medication and asked what the medications were for. The surveyor instructed the Resident not to take the medication and to call for a nurse. On 12/21/22 at 9:35 A.M., the surveyor observed Nurse #2 enter Resident #204's room, see the medications in the cup, and ask the Resident what happened as he/she was taking the medication when she left the room. On 12/21/22 at 9:39 A.M., Nurse #2 and the surveyor verified the medications left at the bedside included: -Aspirin enteric coated, 81 mg -Colace, 100 mg -Fludrocortisone acetate 0.05 mg -Magnesium oxide, 400 mg -Metformin, 1000 mg -Namenda, 10 mg -Norco, 5 - 325 mg -Slow mag tablet -Protonix, 40mg -Tradjenta, 5 mg -Vitamin B12, 500 mcg -Sennoside, 8.6 mg During an interview on 12/21/22 at 9:39 A.M., Nurse #2 said she believed Resident #204 was going to take the medication when the Resident put the medication to his/her mouth. Nurse #2 said she should have sat and watched Resident #204 take the medication. During an interview on 12/22/22 at 3:08 P.M., the Regional Nurse and Director of Nurses said when administering medication, the nurse should stay with the resident until all medications have been consumed.