Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure they reported an allegation of abuse to the Department of Public Health (DPH) within two hours, as required. On 06/15/25, Resident #1 was observed with an injury of unknown origin and were also made aware of an allegation of physical abuse related to the injury, the Facility did not report the incident to DPH, until 06/17/25, 48 hours after the injury had been identified.Findings include:Review of the Facility Policy titled Abuse, Neglect, and Exploitation, dated as last revised 03/2025, indicated that the Facility is to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The Policy indicated that possible indicators of abuse, include, but are not limited to:-Resident, staff or family report of abuse;-Physical marks such as bruises or patterned appearances;-Physical injury of a resident of unknown source; and-Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning and positioning. The Policy further indicated that reporting of all alleged violations to the Administrator, state agency, adult protective services and all other required agencies (e.g. law enforcement when applicable) within specific time frames: -Immediate, but no later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury; or-Not later than 24 hours if the events that cause the allegation do not involve abuse and do not involve serious bodily injury.Review of the report submitted by the Facility via Health Care Facility Reporting System (HCFRS), dated 06/17/25, indicated that on 06/17/25, a Police Officer arrived at the Facility to speak to the Director of Nurses (DON) and Administrator regarding a recent incident involving Resident #1, a suspected fall with injury The Report indicated that the police officer informed the Facility that the Health Care Agent (HCA) of Resident #1 was alleging that the injury (laceration) had been intentionally inflicted.During a telephone interview on 07/22/25 at 2:22 P.M., Resident #1's HCA said that she had received a phone call from a nurse at the Facility on the morning of 06/15/25, informing her that Resident #1 had a fall and sustained a wound to his/her forehead.The HCA said she asked the Nurse how he/she could have possibly fallen because Resident #1 was immobile and unable to move by him/herself. The HCA said after she asked the Nurse that question, the Nurse changed the story and said that they found him/her with a wound on his/her forehead.The HCA said that once she arrived at the Hospital Emergency Department (ED) and saw the wound, thought it could not have been from a fall and said she thought the wound was inflicted intentionally.Resident #1 was admitted to the Facility in 10/2022, diagnoses include, but not limited to, dementia, adult failure to thrive, anxiety, and depression.Review of Resident #1's Document of Resident Incapacity Form dated 10/26/22, indicated his/her Health Care Proxy (HCP) had been activated.Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 03/27/25, indicated he/she required extensive to total assistance of one to two staff members with all Activities of Daily Living (ADL's).Review of Resident #1's Facility Incident Report, dated 06/15/25, indicated at 7:15 A.M., Nurse #1 was called into Resident #1's room by Certified Nurse Aide (CNA #3), and that Resident #1 was sitting in his/her wheelchair, dressed and ready for the day. The Report indicated that Resident #1 had an open area to his/her forehead that was bleeding, he/she complained of pain in his/her index and middle finger of his/her right hand, and Nurse #1 saw a small spot of blood on the floor next to the bed.The Report further indicated Resident #1 was transferred back to his/her bed, a dressing was applied to his/her forehead, and Resident #1 was transferred to the ED for treatment and evaluation. During a telephone interview on 07/24/25 at 10:18 A.M., CNA #2 said that when she got to work on the morning of 06/15/25, she went into Resident #1's room to get him/her up for breakfast, dressed him/her in bed and then transferred him/her into his/her wheelchair.CNA #2 said that she noticed some (what looked like) dry blood underneath his/her fingernails, said she did not see where it was coming from and thought Resident #1 must have scratched him/herself. CNA #2 said that she then called for CNA #3 to come into his/her room.CNA #2 said that when CNA #3 came into his/her room she had noticed the cut on Resident #1's forehead and called for Nurse #1.During a telephone interview on 07/28/25 at 9:50 A.M., Nurse #1 said that on 06/15/25 at approximately 7:18 A.M., CNA #3 called out to her to go to Resident #1's room. Nurse #1 said that she went into his/her room, and she saw a wound on Resident #1's forehead and asked why CNA #2 had gotten him/her out of bed instead of calling for her first.Nurse #1 said she asked Resident #1 what happened and that Resident #1 said that they tussled me and beat me, I think they broke my finger. Nurse #1 said that after she assessed Resident #1, he/she was put back to bed and was then transferred to the ED for evaluation.Nurse #1 said that when Emergency Medical Services (EMS) arrived she told them she did not know what happened and that the CNA reported to her that Resident #1 was found in his/her bed. Nurse #1 said that at approximately 8:00 A.M., she called the Assistant Director of Nurses (ADON, the manager on call) to inform her of the situation.During an interview on 07/23/25 at 12:45 P.M., the ADON said that on 06/15/25 at approximately 8:03 A.M., she received a call from Nurse #1 explaining the incident involving Resident #1.The ADON said that Nurse #1 reported that Resident #1 was found by CNA #2 in bed, with an injury of unknown origin and when Nurse #1 saw him/her, he/she was sitting up in his/her wheelchair and no one had reported to have found Resident #1 on the floor. The ADON said that the staff was unable to give her a clear answer as to what happened that may have caused the injury.The ADON said that she then called the Director of Nurses (DON) and Administrator to inform them of the incident. The ADON said that it was reported to her as a possible unwitnessed fall, however, she told the Administrator and DON that she had some concerns that the incident/injury was not related to a fall. The ADON said that she called Resident #1's HCA around 3:00 P.M., and the HCA told her that based on the look of the wound, that she (HCA) did not think it was from a fall, but felt that the injury had been inflicted intentionally.The ADON said she immediately called the DON to report what Resident #1's HCA had said and told the DON, she felt it was clearly an injury of unknown origin and should be reported as such.The ADON said that the DON told her that the injury/incident was being treated as an unwitnessed fall and they would continue to investigate.During an interview on 07/23/25 at 4:00 P.M., the Director of Nurse (DON) said that on 6/15/25, the ADON called to report an incident that had occurred with Resident #1. The DON said that it had been reported to him as an unwitnessed fall. The DON said that the ADON did tell him that Resident #1's HCA reported to her that she thought the injury had been intentionally inflicted and said it did not dawn on him at that time to report the event to DPH.The DON said that on Monday 06/16/25, when he began investigating and things were not making sense to him, because no one had reported Resident #1 ever being found on the floor. The DON said that he was about to report the event to DPH when the Local Police arrived and informed them of an allegation of suspected abuse on Resident #1.The DON said that it is the Facility's expectation that all alleged allegations of abuse, including injuries of unknown origin, be reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who was found on the floor on 07/19/25 after an unwitnessed fall, the Facility failed to ensure he/she was provided care and treatment that met professional standards of nursing practice related to initial and ongoing assessments, and physician notification. Findings include:Review of the Facility Policy titled Accidents and Incidents, dated as last revised 09/2024, indicated that an Accident refers to any unexpected or unintentional incident, which may result in injury and an Incident is defined as an occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization. The Policy further indicated; -Any injuries will be assessed by the licensed nurse or practitioner and the affected individual will not be moved until safe to do so;-The Supervisor will be notified of the accident/incident;-The Nurse will contact the resident's practitioner to inform them if the accident/incident, report any injuries or other findings, and obtain orders, if indicated; and-The Resident's Family or representative will be notified of the accident/incident and any orders obtained. Review of the Facility Form titled Incident and Accident Checklist, undated, indicated that the Checklist is to be completed for each incident and accident and signed off as complete by the DON and Administrator supporting that through a thorough and complete investigation has been completed. The Checklist further indicated that the bold items on the checklist are to be performed by the staff nurses and initiated at the time of the incident/accident, the bold items included; -Notify the Physician;-Obtain statements/interviews from staff, collected for each staff member regardless if directly involved;-Skin Check;-Pain Assessment;-Fall Assessment; and-Neurological signs for all unwitnessed falls. Resident #2 was admitted to the Facility in 10/2022 diagnoses include vascular dementia, adult failure to thrive, diabetes mellitus, and anemia. Review of Resident #2's Document of Resident Incapacity Form dated 08/03/22, indicated his/her Health Care Proxy (HCP) had been activated.Review of Resident #2's Facility Incident Report, dated 07/19/25, indicated that he/she was found on the floor and he/she was unable to state what had happened. Review of Resident #2's Nurse Progress Note, dated 07/19/25, written by Nurse #2, indicated that she heard a resident crying out for help, she went into Resident #2's room and found him/her on the floor. During an interview on 07/24/25 at 8:53 A.M., Nurse #2 said the day she received her orientation for the Facility, her preceptor told her that if she were to find Resident #2 on the floor, not to worry about it and that he/she does it all the time. Nurse #2 said that on 07/19/25 at approximately 9:30 P.M., she heard a resident calling out for help, went into Resident #2's room and found him/her on the floor mat beside his/her bed. Nurse #2 said she called two Certified Nurse Aides (CNA's)'s for assistance and attempted to transfer him/her back into bed, but they were unable to do so manually. Nurse #2 said she left the room to get a mechanical lift.Nurse #2 said that when she returned to Resident #2 room, the CNA's had cleaned and changed Resident #2 because he/she had been incontinent. Nurse #2 said that she did not assess Resident #2 until after he/she was transferred up off the floor and put back into bed.Review of Resident #2's medical record, there was no documentation to support that Nurse #2;-Notified his/her physician that he/she was found on the floor;-Completed a physical assessment prior to having him/her moved off the floor; -Completed a new Fall Risk Assessment; and-Initiated neurological signs, per facility policy.During a telephone interview on 07/28/25 at 11:08 A.M., the Nurse Supervisor said that she was not aware that on 07/19/25, Resident #2 had been found on the floor. The Supervisor said that when a resident is found on the floor or has an unwitnessed event the nurse must assess the resident before moving them, notify the physician, HCA, complete a fall, skin, and pain assessment and initiate neurological checks.During an interview on 07/23/25 at 4:00 P.M., the Director of Nurses (DON) said that he was not aware Nurse #2 had not followed the facility Fall Protocol until after the event occurred. The DON said that it is the Facility's expectation that if a resident has an unwitnessed fall the nurse must first assess the resident for injury, obtain vital signs, ensure the resident's safety and once the resident is assessed and may be safely moved, the nurse may then move the resident.The DON said that the nurse must initiate the Fall Protocol, including notification to the Physician, HCA, initiate neurological signs, and complete the appropriate follow-up assessments.

2. Resident #5 was admitted to the facility in June 2024 with diagnoses including adult failure to thrive and rheumatoid arthritis. Review of the MDS assessment, dated 2/27/25, indicated Resident #5 had severe cognitive impairment as evidenced by a BIMS score of 5 out of 15, and had an activated HCP. On 3/31/25 at 9:06 A.M., 4/1/25 at 7:01 A.M. and 4/2/25 at 9:39 A.M., the surveyor observed Resident #5 lying in bed sleeping; bilateral side rails were raised and in use. Review of the medical record indicated a physician's order, dated 7/17/24, for 1/2 lower side rails for movement and mobility. Review of July 2024 through April 2025 Medication/Treatment Administration Records (MAR/TAR) indicated 1/2 lower side rails were in place as ordered by the physician. Further review of the medical record indicated a side rail consent form, signed by Resident #5's HCP on 3/29/25. The form indicated that consent must be obtained prior to placing the side rails on the bed. The consent form included lines for the Resident's name, date of discussion with staff, date last reviewed by the facility that were blank. During an interview on 4/1/25 at 2:28 P.M., the DON said that nursing staff were supposed to provide information to residents and their representatives about the risks and benefits of side rails use and complete the consent form. During an interview on 4/1/25 at 3:20 P.M., Resident #5's HCP said that he was called by the facility a few weeks ago and told that he needed to sign admission paperwork because it was not done when the Resident was originally admitted in July 2024. He said he came into the facility on 3/29/25 and signed a stack of paperwork that was given to him and was not sure what they were. He said there was no nurse available to go over the paperwork with him, so he just signed it all. He said no one reviewed the risks and benefits for the use of side rails with him. During an interview on 4/2/25 at 10:05 A.M., the Social Worker said during a random medical record audit, she found that no admission consents were signed when Resident #5 was admitted in July 2024. She said she called the Resident's HCP and asked him to come in and sign admission paperwork. During an interview on 4/2/25 at 12:20 P.M., Unit Manager #1 said that Resident#5's HCP should have been provided admission paperwork including information about the risks and benefits of side rail use and signed the consent form before the siderails were put into place but was not. Based on record review and staff interview, the facility failed to ensure that the resident representative had information in advance to exercise their rights for two Residents (#77 and #5), out of a total sample of 18 residents. Specifically, the facility failed to ensure that for: 1. Resident #77, the legal guardian was provided information upon admission to sign or verbally consent to treatment at the facility and sign or consent verbally for a wound consultant; and 2. Resident #5, the Health Care Proxy (HCP: health care agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions) was provided information upon admission to sign or verbally consent to treatment at the facility including for the use of bilateral side rails. Findings include: 1. Resident #77 was admitted to the facility in January 2025 and had diagnoses including: Unspecified intracranial injury, abnormalities of gait and mobility, muscle wasting and atrophy, unsteadiness on feet, and abnormal posture. Review of the Minimum Data Set (MDS) assessment, dated 1/14/25, indicated Resident #77 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Further review of the medical record indicated Resident #77 had a court ordered temporary guardian in place at the time of admission and since November 2024, naming Family Member #2 his/her legal guardian. During an interview on 4/1/25 at 12:27 P.M., Resident #77 and Family Member #1 said Family Member #2 helps the Resident make treatment decisions. During an interview on 4/1/25 at 4:53 P.M., Family Member #2 said at the time of Resident #77's admission to the facility he was the legal guardian and remained the legal guardian until 2/11/25. He said he felt the facility did not communicate well with him during this time and consents, including a consent to treat and a wound consultant consent, were not provided to him or discussed with him for him to provide informed consent for the Resident's treatment. Review of the medical record for Resident #77 failed to indicate a Consent to admission and treat or a wound consultant consent was obtained and those documents were blank in the record. During an interview on 4/2/25 at 12:26 P.M., Nurse #7 reviewed the medical record and said it did not appear that any consents had been signed for the Resident at the time of admission. He said upon admission if the residents are not their own person the staff will try to contact the healthcare proxy or guardians to let them know there are consents that require signature. The consents remain in the record unsigned until that person comes in to sign them, and staff documents that they are pending signature. Review of the admission note for Resident #77 indicated signed/verbal consents: tbd (to be determined). During an interview on 4/2/25 at 1:02 P.M., the Social Worker said the consents upon admission were not signed or sent to the legal guardian to the best of her knowledge, but she is not responsible for getting those signed. The Social Worker said they remain unsigned at this time. During an interview on 4/2/25 at 2:16 P.M., the Unit Manager said she could not find any evidence that the consent to treat by a wound consultant was provided to the Resident's legal guardian or that the facility had those signed consents in the paper or electronic records. During an interview on 4/2/25 at 2:49 P.M., Consulting Staff #3 said there is no policy to obtain consents to treat or wound consultant consents, but the expectation is that upon admission they would be completed by the nurse on duty. She said even if the legally responsible party were out of state the staff could fax the consents to them or temporarily obtain verbal consent until the form could be provided for a signature. She said the staff should be following the standard of practice and regulation for obtaining informed consent for any treatment. During an interview on 4/3/25 at 10:09 A.M., the Director of Nurses (DON) said the expectation would be that the legal guardian had provided informed consent for both admission consent to treat and wound consultants and there was no evidence in the medical record that had occurred.

Based on document review and interview, the facility failed to ensure the legally responsible representatives were notified of changes in a resident's condition for two Residents (#77 and #44), out of a total sample of 18 residents. Specifically, the facility failed to: 1. Inform the legal guardian of Resident #77 of the development of a facility acquired deep tissue injury (DTI- a pressure-related injury to subcutaneous tissues under intact skin often appearing as a deep bruise) to the right heel on 2/2/25 or of the physician evaluation of the area on 2/4/25; and 2. Notify the Health Care Proxy (HCP) of Resident #44 of a significant weight loss. Findings include: Review of the facility's policy titled Notification of Changes, dated as reviewed/revised 10/2024, indicated but was not limited to the following: The purpose of the policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. DEFINITION: Clinical complications: examples - development of pressure injury Need to alter treatment significantly: commence a new form of treatment to deal with a problem COMPLIANCE GUIDELINES: The facility must inform the resident, consult with the resident's physician and/or notify the family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: - a significant change in the resident's condition, such as deterioration in health, mental or psychosocial status; this may include clinical complications - circumstances that require a need to alter treatment; this may include: new treatment Additional considerations: - Resident incapable of making decisions: the representative would make any decisions that have to be made 1. Resident #77 was admitted to the facility in January 2025 and had diagnoses including: unspecified intracranial injury, abnormalities of gait and mobility, muscle wasting and atrophy, unsteadiness on feet, and abnormal posture. Review of the Minimum Data Set (MDS) assessment, dated 1/14/25, indicated Resident #77 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Further review of the medical record indicated Resident #77 had a court ordered temporary guardian in place at the time of admission until 2/11/25, naming Family Member #2 his/her legal guardian. Review of the medical record indicated Resident #77 had developed a DTI on his/her right heel, first identified on 2/2/25 and evaluated by the wound physician on 2/26/25 at which time new orders were received. The record failed to indicate the Resident's legal guardian at the time, Family Member #2, was notified of the development of the pressure ulcer or any treatments necessary. During an interview on 4/1/25 at 12:27 P.M., Resident #77 and Family Member #1 said Family Member #2 was the legal guardian at the time the wound on the right heel developed and is the person that assists with treatment decisions for the Resident. During an interview on 4/1/25 at 1:27 P.M., Nurse #7 said when there is any change in condition, including the development of a wound, the Nurse would notify the physician or Nurse Practitioner (NP), the resident, and their HCP or legal guardian. He said he does not know if Family Member #2, who was the legal guardian for Resident #77 was notified at the time the right heel wound was identified. During an interview on 4/1/25 at 4:53 P.M., Family Member #2 said he was the legal guardian for Resident #77 from November 2024 until 2/11/25. He said he was not notified about the Resident developing a DTI pressure wound on their heel and was unaware any treatments or wound physicians were involved in the Resident's care. He said the facility did not communicate well with him, even when he was the legal court ordered guardian. During an interview on 4/2/25 at 10:21 A.M., the Unit Manager reviewed the medical record for Resident #77 and said she could not find any documentation or evidence that Family Member #2, who was the legal guardian at the time the right heel wound developed, was notified that the wound had developed or that the Resident was evaluated by a wound specialist and new treatment orders were received. She said since the guardianship was still valid and active at the time of the wound developing Family Member #2 should have been notified and it appears they were not. During an interview on 4/3/25 at 10:09 A.M., the Director of Nurses (DON) reviewed the medical record of Resident #77 and said there was no documentation to indicate Family Member #2, who was the legal guardian at the time, had been notified that the Resident had developed a wound on his/her right heel and he should have been in accordance with the policy and standard. 2. Resident #44 was admitted to the facility in October 2022 with diagnoses including dysphagia (difficulty swallowing). Review of the MDS assessment, dated 1/17/25, indicated Resident #44 had a severe cognitive deficit as evidenced by a BIMS score of 4 out of 15. Further review of Resident #44's MDS indicated he/she had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and his/her HCP was activated. Review of Resident #44's weight change note, dated 1/8/25, indicated but was not limited to: - On 1/6/25 Resident #44 weighed 108.8 pounds. On 10/2/24, Resident #44 weighed 124 pounds which is a weight loss of 15 pounds in the past 3 months, 12.2% considered significant. - NP/MD aware of weight trends. Further review of Resident #44's medical record failed to indicate his/her HCP was notified of his/her significant weight loss. During a telephonic interview on 4/2/25 at 10:29 A.M., Resident #44's HCP said they were not aware of Resident #44's weight loss. During an interview on 4/2/25 at 12:14 P.M., Nurse #5 said if a resident had a change in condition the facility must notify the Physician or NP and their Responsible Party/HCP if activated and document it in a nurse's note. Nurse #5 and surveyor reviewed Resident #44's medical record. Nurse #5 said she could not find any evidence of Resident #44's HCP being notified of their weight loss. During an interview on 4/2/25 at 2:19 P.M., the Unit Manager (UM) said if a resident had a change of condition their HCP or Guardian must be notified of the change and the notification must be documented in the resident's medical record. The UM and the surveyor reviewed Resident #44's medical record. The UM said Resident #44 had a significant weight loss in January 2025 and she could not find any documentation of his/her HCP being notified of the weight loss. The UM said Resident #44's HCP should have been notified of their weight loss but was not. During an interview on 4/2/25 at 4:02 P.M., the Director of Nursing (DON) and the surveyor reviewed Resident #44 medical record. The DON said he did not see any evidence of Resident #44's HCP being notified of their weight loss. The DON said Resident #44's HCP should have been notified of their weight loss but was not.

Based on document review and interview, the facility failed for one Resident (#77), out of a total sample of 18 residents, to involve the Resident's legal guardian in the baseline care plan process and offer or provide them with a copy of the baseline care plan summary. Findings include: Review of the facility's policy titled Baseline Care Plans, dated as reviewed/revised: 9/2024, indicated but was not limited to the following: - a baseline care plan will be developed within 48 hours of a resident's admission - a written summary of the baseline care plan shall be provided to the resident and representative in a language they can understand; the summary shall include the initial goals of care, summary of the resident's medications and dietary instructions, any services or treatments to be administered by the facility and personnel acting on behalf of the facility - the person providing the written summary of the baseline care plan shall obtain a signature from the resident/representative to verify the summary was provided and make a copy for the medical record - if the summary was provided by telephone, the nurse shall indicate the discussion, sign the summary document, and make a copy of the written summary before mailing the summary to the resident representative Resident #77 was admitted to the facility in January 2025 and had diagnoses including: Unspecified intracranial injury, abnormalities of gait and mobility, muscle wasting and atrophy, unsteadiness on feet, and abnormal posture. Review of the Minimum Data Set assessment, dated 1/14/25, indicated Resident #77 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15 Further review of the medical record indicated Resident #77 had a court ordered temporary guardian in place at the time of admission until 2/11/25, naming Family Member #2 his/her legal guardian. During an interview on 4/1/25 at 12:27 P.M., Resident #77 and Family Member #1 said they do not recall having any meetings regarding a care plan or what services the facility planned on offering the Resident, nor have they been offered or received any documents that summarize the care and plan for the Resident's stay. They said Family Member #2 was the legal guardian at that time and is the person that assists with treatment decisions for the Resident. Review of the medical record for Resident #77 failed to indicate a baseline care plan meeting was provided or summary was created within the first 72 hours of the Resident's stay at the facility. Further review indicated the facility did have an initial care plan meeting on 1/30/25, but the legal guardian was not in attendance, nor was the Resident, and a copy of the care plans was not documented as being offered (this question was left blank). During an interview on 4/1/25 at 4:53 P.M., Family Member #2 said he was the Resident's legal guardian from November 2024 until 2/11/25. He said the facility did not communicate well with him. He said he was not involved in any care plan meeting, or offered to be, nor was he offered a copy or summary of the baseline care plan summary. He said this involvement and these documents would certainly have been beneficial for him to have better insight into the care and services the facility was providing to Resident #77 since he lives out of state. Review of the progress notes for Resident #77 failed to indicate a discussion was had with Family Member #2 (the legal guardian at the time of admission) regarding the Resident's initial goals of care, summary of the resident's medications and dietary instructions, any services or treatments to be administered by the facility and personnel acting on behalf of the facility or a baseline care plan was mailed to or offered to Family Member #2. During an interview on 4/2/25 at 10:07 A.M., the Unit Manager reviewed the Resident's medical record and said she could not find any evidence or documentation that Resident #77's legal guardian was involved or offered a care plan summary or a copy of the baseline care plans as he should have been. She said the process for baseline care plans does not appear to have been followed. During an interview on 4/2/25 at 1:42 P.M., the Social Worker said she had a brief talk with Family Member #2 at the time of admission when she was doing her evaluation of the Resident. She said to the best of her knowledge Family Member #2 was not offered or mailed a copy of the baseline care plans and was not involved in the initial care plan meeting.

2. Resident #5 was admitted to the facility in June 2024 with diagnoses including adult failure to thrive and rheumatoid arthritis. Review of the MDS assessment, dated 2/27/25, indicated Resident #5 had severe cognitive impairment as evidenced by a BIMS score of 5 out of 15, and had an activated HCP. On 3/31/25 at 9:06 A.M., 4/1/25 at 7:01 A.M. and 4/2/25 at 9:39 A.M., the surveyor observed Resident #5 lying in bed resting with bilateral side rails up and in use. Review of the medical record indicated a physician's order, dated 7/17/24, for 1/2 lower side rails for movement and mobility. Review of July 2024 through April 2025 Medication/Treatment Administration Records (MAR/TAR) indicated 1/2 lower side rails were in place as ordered by the physician. Further review of the medical record indicated a side rail consent form, signed by Resident #5's HCP on 3/29/25 (255 days after the side rails were initiated). The form indicated that consent must be obtained prior to placing the side rails on the bed. The consent form included lines for the Resident's name, date of discussion with staff, date last reviewed by the facility that were blank. During an interview on 4/1/25 at 3:20 P.M., Resident #5's HCP said that he was called by the facility a few weeks ago and told that he needed to sign admission paperwork because it was not done when the Resident was originally admitted in July 2024. He said he came into the facility on 3/29/25 and signed a stack of paperwork that was given to him and was not sure what they were. He said there was no nurse available to go over the paperwork with him, so he just signed it all. He said no one reviewed the risks and benefits for the use of side rails with him. During an interview on 4/2/25 at 12:20 P.M., Unit Manager #1 said that Resident #5's HCP should have been provided with information about the risks and benefits of side rail use and provided informed consent before the side rails were put into place and was not. Based on observation, interview, and record review, the facility failed to ensure appropriate alternatives were attempted prior to installing a side or bed rail and risks and benefits of bed rails were reviewed with the resident and/or resident's representative and informed consent obtained prior to installation of bed rails for two Residents (#79 and #5), out of a total sample of 18 residents. Findings include: Review of the facility's policy titled Proper Use of Bed Rails, revised October 2024, indicated but was not limited to the following: -It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails. Resident Assessment: -As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs: a. Medical diagnosis, conditions, symptoms, and/or behavioral symptoms b. Size and weight c. Sleep habits d. Medication(s) e. Acute medical or surgical interventions f. Underlying medical conditions g. Existence of delirium h. Ability to toilet self safely i. Cognition j. Communication k. Mobility (in and out of bed) l. Risk of falling -The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. Informed Consent: -Informed consent from the resident or representative must be obtained after appropriate alternatives have been attempted prior to the installation and use of bed rails. This information should be presented in an understandable manner, and consent given voluntarily, free from coercion. -The information that the facility should provide to the resident, or resident representative includes, but is not limited to: a. What assessed medical needs would be addressed by the use of bed rails; b. The resident's benefits from the use of bed rails and the likelihood of these benefits; c. The resident's risks from the use of bed rails and how these risks will be mitigated; and d. Alternatives attempted that failed to meet the resident's needs and alternatives considered but not attempted because they were considered to be inappropriate. -Upon receiving informed consent, the facility will obtain a physician's order for the use of the specified bed rail and medical diagnosis, condition, symptom, or functional reason for the use of the bed rail. 1. Resident #79 was admitted to the facility in March 2025 and had diagnoses including anoxic brain damage, unspecified convulsions, abnormalities of gait and mobility, lack of coordination, restlessness and agitation, and extrapyramidal and movement disorder. Resident #79 had a temporary guardian in place upon admission. Court documents indicated an extension of the appointment of the temporary guardian on 3/26/25, expiring on 4/30/25. Review of the Minimum Data Set (MDS) assessment, dated 3/10/25, indicated a Brief Interview for Mental Status (BIMS) score of 99 indicating the interview was unable to be completed to assess Resident #79's cognitive function. On 3/31/25 at 8:53 A.M., 4/1/25 at 12:53 P.M., and 4/2/25 at 7:00 A.M., the surveyor observed Resident #79 lying in bed with bilateral upper side rails in the upright position and in use. Review of the medical record failed to indicate appropriate alternatives that had been attempted and failed. The Resident's Side Rail Consent Form was prefilled with the Resident's name and date of birth but the sections for when the consent was reviewed by the facility, signature of the Resident or Resident's Representative and date, and witness signature and date lines were blank. The form indicated consent must be obtained prior to placing the side rails on the bed. Further review of the medical record failed to indicate a physician's order was obtained prior to the installation and use of the bed rails. During an interview on 4/1/25 at 2:56 P.M., the Unit Manager (UM) said the side rail consent form was sent to the legal guardian, but she could not locate a completed form in the Resident's medical record. She said the consent should have been completed prior to the use of the side rails and there should be an order for them but there wasn't. A call was placed to the legal guardian on 4/1/25 at 3:40 P.M. with no call back. During an interview on 4/2/25 at 2:29 P.M., the Director of Nursing (DON) and Regional Nurse #1 said on admission, an admission assessment is done to determine if a resident needs side rails. They said if a resident is not their own person, then they contact the family to educate them on the risks vs. benefits and obtain consent. They said the assessment is done to determine the need for the side rails and said if they don't consent, then the facility will not use them. The DON said completed consent should have been obtained prior to the use of Resident #79's side rails. Regional Nurse #1 said the Resident's admission assessment was completed but did not include any alternatives attempted prior to their installation and did not know where it would be documented. She said upon receiving consent, an order would have been obtained for the use of the specified bed rail and medical diagnosis and functional reason for use but wasn't.

Based on observation, record review, and interview, the facility failed to ensure all drugs and biologicals were stored in a safe and secure manner as required for two Residents (#10 and #17) out of a total sample of 18 residents. Specifically, the facility failed to ensure: 1. For Resident #10, medication was not left unattended in the Resident's room; and 2. For Resident #17, ensure a medicated cream was not left unattended in his/her room. Findings include: Review of the facility's policy titled Medication Storage, last reviewed 9/2024, indicated but was not limited to: -Policy Explanation and Compliance Guidelines: - All drugs and biologics will be stored in locked compartments. -During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. 1. Resident #10 was admitted to the facility in September 2023 and had diagnoses including a history of stroke. Review of the Minimum Data Set (MDS) assessment, dated 3/6/25, indicated Resident #10 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15, and was administered anticoagulant (blood thinner) medication. On 3/31/25 at 9:00 A.M., the surveyor observed Resident #10 lying in bed awake. An overbed table was parallel to the bed with a clear medication cup lying on its side with one round dark yellow pill in it. Resident #10 said he/she did not know what the yellow pill was. Review of Resident #10's medical record failed to indicate Resident #10 was assessed to self-administer medications. On 3/31/25 at 9:39 A.M., the surveyor observed Nurse #3 adjust Resident #10's oxygen tubing while standing next to the overbed table with the clear plastic medication cup that contained the dark yellow pill. When the nurse finished adjusting the tubing, he left the Resident's bedside and walked to the door to exit the room. The surveyor asked the nurse to come back to the Resident's bedside and showed him the medication cup with the yellow pill in it. Nurse #3 said the pill was levothyroxine (thyroid hormone) and the third shift nurse must have left the Resident alone with it. He said the medication should not have been left on the table in the medication cup and the nurse should have stayed with the Resident to ensure he/she took it. Review of physician's orders failed to indicate Resident #10 was prescribed levothyroxine. During a subsequent interview on 3/31/25 at 2:22 P.M., Nurse #3 said he researched the pill left at Resident #10's bedside this morning and determined that it was Eliquis 2.5 milligrams (mg) and not levothyroxine as he told the surveyor that morning. He said the Resident is prescribed Eliquis 2.5 mg twice a day at 9:00 A.M. and 9:00 P.M. Nurse #3 said he discarded the pill. The nurse said he worked a double shift for the two days prior but could not explain why the pill was left at the Resident's bedside unattended and why the MAR indicated the medication was administered as ordered. During an interview with the Director of Nursing (DON) on 4/1/25 at 2:28 P.M., the surveyor reviewed the observation and interviews with Nurse #3 regarding the yellow pill in the medication cup left at Resident #10's bedside unattended. The DON said Resident #10's medication should not have been left at the bedside and the nurse should have stayed with the Resident to ensure it is taken and not leave the medication unattended in his/her room. 2. Resident #17 was admitted to the facility in November 2015 with diagnoses of muscle weakness and abnormal posture. Review of the MDS assessment, dated 2/20/25, indicated Resident #17 was cognitively intact as evidenced by a BIMS score of 15 out of 15. Review of Resident #17's current Physician's Orders indicated but was not limited to: - Silver Sulfadiazine Cream (antimicrobial) 1% Apply to buttocks/coccyx topically every shift for skin breakdown, dated 3/14/25 On the following days and times, the surveyor observed Silver Sulfadiazine Cream on Resident #17's nightstand: - 3/31/25 at 8:41 A.M., - 3/31/25 at 2:25 P.M., - 3/31/25 at 4:39 P.M., - 4/1/25 at 7:08 A.M., - 4/1/25 at 8:28 A.M., - 4/1/25 at 10:34 A.M., and - 4/1/25 at 4:39 P.M. During an interview on 3/31/25 at 8:41 A.M., Resident #17 said the nurses would put the Silver Sulfadiazine Cream on to his/her buttocks. During an interview on 3/31/25 at 8:46 A.M., Nurse #5 said Resident #17 should not have their Silver Sulfadiazine Cream on their nightstand. Nurse #5 said medicated creams should be locked up in the treatment cart and not left out unattended. During an interview on 4/1/25 at 4:39 P.M., Nurse #4 said Resident #17 should not have their Silver Sulfadiazine Cream on their nightstand and it should be locked up in the treatment cart. Nurse #4 said all medication and treatments should never be left out and unattended. During an interview on 4/2/25 at 2:55 P.M., the Unit Manager (UM) said all medication and treatments should never be left out and unattended. The UM said Resident #17 should not have Silver Sulfadiazine Cream on their nightstand. During an interview on 4/2/25 at 4:02 P.M., the DON said all medication and treatments should never be left out and unattended and not left in residents' rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the pneumococcal immunizations as requested/consented for three Residents (#10, #14, and #17), out of a total sample of five residents. Findings include: Review of the facility's policy titled Pneumococcal Vaccine, last revised January 2025, indicated but was not limited to: - It is our policy to offer our residents and staff immunization against pneumococcal disease in accordance with current Centers for Disease Control and Prevention (CDC) guidelines and recommendations. - Every resident will be offered a pneumococcal immunization unless it is medically contraindicated, or the resident has already been immunized. - Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization. - The resident/representative retains the right to refuse the immunization. A consent form shall be signed prior to the administration of the vaccine and filed in the individual's medical record. - The type of pneumococcal vaccine (PCV15, PCV20, PCV21 or PPSV23) offered will depend upon the recipients age, having certain risk conditions, and previously received pneumococcal vaccines, in accordance with current CDC guidelines and recommendations. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Recommended Adult Immunization Schedule for Ages 19 Years or Older, United States, 2025, indicated but was not limited to the following: Pneumococcal Vaccination Age 50 years or older who have: -Previously received both PCV13 and PPSV23, but no PPSV23 was received at age [AGE] years or older: 1 dose of PCV20 or 1 dose of PCV21 at least 5 years after the last pneumococcal vaccine dose. A. Resident #10 was admitted to the facility in September 2023 and is currently [AGE] years old. - Review of the immunization history for Resident #10 failed to indicate he/she had received the pneumococcal vaccine. Review of Resident #10's medical record indicated but was not limited to: - Immunization Consent, signed 9/22/23, consent to recommended administration of pneumococcal vaccination. During an interview on 4/2/25 at 2:58 P.M., Support Staff #1 said she had checked the MIIS (The Massachusetts Immunization Information System (MIIS) is a web-based immunization registry. All providers who administer immunizations in Massachusetts are mandated to report immunization data to the MIIS) and it failed to indicate Resident #10 had received a pneumococcal vaccine, but he/she should have. B. Resident #14 was admitted to the facility in October 2022 and is currently [AGE] years old. - Review of the immunization history for Resident #14 indicated but was not limited to: - PCV 13 pneumococcal vaccination, administered 11/25/19 Review of Resident #14's medical record indicated but was not limited to: - Immunization Consent, signed 10/20/23, consent to recommended administration of pneumococcal vaccination. During an interview on 4/2/25 at 1:08 P.M., Support Staff #1 said Resident #14 was overdue for the PCV20 pneumococcal vaccine and should have received it. C. Resident #17 was admitted to the facility in November 2015 and is currently [AGE] years old. Review of the immunization history for Resident #17 indicated but was not limited to: - Pneumococcal Unspecified Formation, administered 9/28/20 Review of Resident #17's medical record indicated but was not limited to: - Immunization Consent, signed 10/20/23, consent to recommended administration of pneumococcal vaccination. During an interview on 4/2/25 at 1:08 P.M., Support Staff #1 said she reviewed Resident #17's MIIS information and it indicated he/she received the PCV pneumococcal vaccination on 9/1/21. Support Staff #2 said Resident #17 was overdue for the PCV20 pneumococcal vaccine and should have received it.

Based on record review and interview, the facility failed to provide education and/or offer the COVID-19 vaccination as required or appropriate per the Centers for Disease Control and Prevention (CDC) recommendations for two Residents (#10 and #17), out of a total sample size of five residents reviewed for immunizations. Findings include: Review of the facility's policy titled COVID-19 Vaccine, last revised October 2024, indicated but was not limited to: - It is the policy of the facility to have an immunization program against COVID-19 disease in accordance with national standards of practice. - COVID-19 vaccination will be offered to residents when supplies are available, as per CDC and/or FDA guidelines unless such immunization is medically contraindicated, the individual has already been immunized during this time period or refused to receive the vaccine. Review of CDC guidance titled Use of COVID-19 Vaccines in the U.S., revised October 2024, indicated but was not limited to the following: - People ages 5-64 years should receive 1 dose of an age appropriate 2024-2025 COVID-19 vaccine. Ages 12-64 years (Previous COVID-19 vaccination before 2024-2025 vaccine): - Receive 1 dose of 2024-2025 vaccine - People ages 65 years and older, vaccinated under the routine schedule, are recommended to receive 2 doses of an 2024-2025 COVID-19 vaccine (i.e., Moderna, Novavax, or Pfizer-BioNTech) separated by 6 months (minimum interval 2 months) regardless of vaccination history, with one exception: Unvaccinated people who initiate vaccination with 2024-2025 Novavax COVID-19 Vaccine are recommended to receive 2 doses of Novavax followed by a third dose of any COVID-19 vaccine 6 months (minimum interval 2 months) later. Review of the Resident Council Minutes, dated 1/15/25, indicated but was not limited to: - Residents would like to know when the Covid booster will be available? A. Resident #10 was admitted to the facility in September 2023. - Review of the immunization history for Resident #10 failed to indicate he/she had received the COVID-19 vaccine. Review of Resident #10's medical record indicated but was not limited to: - Immunization Consent, signed 9/22/23, consent to administration of COVID-19 Vaccine/Booster. During an interview on 4/2/25 at 2:58 P.M., Support Staff #2 said she had checked the MIIS (Massachusetts Immunization Information System (MIIS) is a web-based immunization registry. All providers who administer immunizations in Massachusetts are mandated to report immunization data to the MIIS) and the Resident's chart and both failed to indicate Resident #10 had received a COVID-19 vaccine, but he/she should have. B. Resident #17 was admitted to the facility in November 2015. Review of the Minimum Data Set assessment, dated 2/20/25, indicated Resident #17 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15. During an interview on 3/31/25 at 8:41 A.M., Resident #17 said he/she had not received their COVID-19 vaccine for the 2024/2025 season. Resident #17 said he/she had asked for the vaccine numerous times and was told it was on order. Review of the immunization history for Resident #17 indicated but was not limited to: - COVID-19, administered 11/10/23 Review of Resident #17's medical record indicated but was not limited to: - Immunization Consent, signed 10/20/23, consent to administration of COVID-19 Vaccine/Booster. During an interview on 4/2/25 at 1:08 P.M., Support Staff #2 said Resident #17 had a consent to receive the COVID-19 booster but had not received it as he/she should have.

Based on observation, interview and record review the facility failed to develop, implement and individualize comprehensive care plans for four Residents (#10, #29, #12, and #73), out of a total sample of 18 residents. Specifically, the facility failed to ensure: 1. For Resident #10, a comprehensive care plan was developed to address the use of Quetiapine Fumarate (Seroquel-antipsychotic medication) that identified Resident specific targeted behaviors, non-pharmacological interventions, and measurable goals of treatment; 2. For Resident #29, a comprehensive care plan was developed to address the use of Risperdal (antipsychotic medication) that identified Resident specific targeted behaviors, non-pharmacological interventions, and measurable goals of treatment; 3. For Resident #12, to develop and implement a care plan to address the Resident's smoking status as well as his/her smoking preferences; and 4. For Resident #73, to ensure a comprehensive care plan was developed and implemented to address the Resident's use of a continuous positive airway pressure (CPAP-helps treat sleep apnea) machine. Findings include: Review of the facility's policy titled Comprehensive Care Plans, last revised 9/2024, indicated but was not limited to: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. -The comprehensive care plan will describe, at a minimum, the following: -The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. -Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. -The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. -The objectives will be utilized to monitor the resident's progress. -Alterative interventions will be documented, as needed. 1. Resident #10 was admitted to the facility in September 2023 and had diagnoses including bipolar disorder. Review of the Minimum Data Set (MDS) assessment, dated 3/6/25, indicated Resident #10 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15, and received antipsychotic medication on a daily basis. Review of the medical record indicated a physician's order for Quetiapine Fumarate 25 milligrams (mg) at bedtime for bipolar disorder (2/1/24). Review of January 2025 through April 2025 Medication Administration Records (MAR) indicated Quetiapine was administered as ordered by the physician. Review of comprehensive care plans included but was not limited to: - Focus: Resident uses antipsychotic medications related to Bipolar (initiated: 9/28/23). - Interventions: Administer medication per physician's orders. Observe for side effects and effectiveness each shift, report any negative signs/symptoms (s/sx) to physician (initiated 9/28/23). -Goal: Will be free from discomfort or adverse reactions related to antipsychotic medication through the review date (initiated 9/28/23; target date: 3/17/25). The care plan developed for the use of Quetiapine failed to identify Resident specific targeted signs/symptoms of bipolar disorder, non-pharmacological interventions and measurable goals of treatment to meet the Resident's needs. During an interview on 4/2/25 at 12:20 P.M., Unit Manager #1 said nursing staff are responsible for care plan development for psychotropic medications. She said Resident #10's care plans should include identification of all psychotropic medications administered with resident specific behaviors, signs/symptoms for their use as well as resident specific, non-pharmacological interventions and measurable goals but do not. 2. Resident #29 was admitted to the facility in October 2022 and had diagnoses including disorders of psychological development, anxiety disorder, and dementia, unspecified severity with anxiety. Review of the MDS assessment, dated 2/13/25, indicated Resident #29 had severe cognitive impairment as evidenced by a BIMS score of 6 out of 15, and received psychotropic medication on a daily basis. Review of the medical record indicated a physician's orders for: -Depakote (antiseizure medication used to treat mood) 125 mg, give two tablets two times a day for mood (2/11/25). -Risperdal 0.5 mg one time a day for impulsivity, intrusiveness, self-injurious behaviors (SIB) (3/20/25) -Risperdal 0.5 mg one time a day for disinhibition and behavior management (3/20/25) -Sertraline HCI (antidepressant) 100 mg in the morning related to anxiety disorder (12/26/24) -Sertraline HCI 25 mg in the morning related to anxiety disorder (2/14/25) -Trazodone HCI (antidepressant) 50 mg at bedtime for insomnia (2/14/25) Review of December 2024 through April 2025 MARs indicated the psychotropic medications were administered as ordered by the physician. Review of comprehensive care plans included but was not limited to: -Focus: Resident uses antidepressant medication (Trazodone) related to insomnia, depression (10/8/22) -Interventions: Administer antidepressant medications as ordered by the physician. Monitor/document side effects and effectiveness every shift (10/8/22); Follow-up with psych/physician as needed (12/7/23) -Goal: Resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date (10/8/22) The care plan for the use of Trazodone failed to include non-pharmacological interventions and measurable goals of treatment. Further review of comprehensive care plans failed to indicate care plans had been developed for the use of Depakote, Sertraline and Risperdal that identified Resident specific targeted behaviors, Resident-specific interventions, including non-pharmacological approaches, and measurable goals of treatment to meet the Resident's needs. During an interview on 4/2/25 at 12:20 P.M., Unit Manager #1 said nursing staff are responsible for care plan development for psychotropic medications. She said Resident #29's care plans should include identification of all psychotropic medications administered with resident specific behaviors, signs/symptoms for their use as well as resident specific, non-pharmacological interventions and measurable goals but do not. 4. Resident #73 was admitted to the facility in December 2024 with diagnoses including sleep apnea (sleep disorder in which breathing repeatedly stops and starts). Review of current Physician's Orders indicated the following: -CPAP @10 cm (centimeters of water pressure) H2O inspiration; 5 cm H2O expiration, on at HS (before sleep at bedtime), off in AM, at bedtime for sleep apnea, 12/26/24 During an observation with interview on 4/1/25 at 10:40 A.M., the surveyor observed a CPAP machine stored on top of the Resident's side table. Resident #73 said he/she used the machine for sleep apnea. Review of the medical record failed to indicate that an interdisciplinary comprehensive care plan was developed with measurable objectives and timeframes to address the Resident's use of the CPAP machine related to his/her diagnosis of sleep apnea. During an interview on 4/2/25 at 9:56 A.M., the surveyor reviewed the medical record with the Unit Manager who said there was no care plan for the Resident's use of the CPAP machine. During an interview on 4/2/25 at 3:13 P.M., the surveyor reviewed the medical record with the DON and Regional Nurse #1 who said the Resident used the CPAP machine for sleep apnea every night. Regional Nurse #1 said the Resident should have been care planned for the use of the CPAP equipment but wasn't. The DON said the focus, measurable goals and interventions would have been listed in the care plan for it. Regional Nurse #1 said she would expect it to have been completed but it wasn't. 3. Review of the facility's policy titled Smoking Policy -Residents, dated as revised 3/2024, indicated but was not limited to: - This facility shall establish and maintain safe resident smoking practices. - Smoking is permitted in designated resident smoking areas located outside of the facility. - Smoking is not allowed inside the facility under any circumstances. - The resident will be evaluated upon admission and/or when a resident chooses to smoke, to determine the resident's ability to smoke safely. - A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) as determined by staff. - Any smoking-related concerns will be noted in the resident care plan. Resident #12 was admitted to the facility in January 2024 with diagnoses including chronic obstructive pulmonary disease (COPD), hypertension, and peripheral vascular disease. Review of Resident #12's MDS assessment, dated 3/7/25, indicated he/she had moderate cognitive impairment as evidenced by a BIMS score of 9 out of 15. Furthermore, the MDS assessment indicated Resident #12 required assistance from staff for activities of daily living. Review of the list of smokers provided by the facility upon entrance indicated Resident #12 was a smoker residing in the facility. During an interview on 3/31/25 at 9:00 A.M., Resident #12 said he/she is a smoker and goes out several times a day during the facility's allotted smoking hours with the supervision of staff to smoke. Review of Resident #12's Smoking Evaluation, dated 12/9/24, indicated but was not limited to the following: - Protective Smoking Equipment: Not Applicable (NA). - Resident is an independent smoker. - Resident is independent with lighting cigarette. Review of Resident #12's Smoking Evaluation, dated 2/6/25, indicated but was not limited to the following: - Protective Smoking Equipment: not indicated. - Resident is safe to smoke with supervision without protective smoking equipment. - Resident is safe to light own cigarette with staff supervision. Review of Resident #12's comprehensive care plans failed to indicate a smoking care plan was developed or implemented. During an interview on 4/2/25 at 8:17 A.M., Nurse #1 said Resident #12 does go out during the allotted smoking times when he/she desires. Nurse #1 said Resident #12's smoking equipment, including cigarettes and lighters, are kept at the receptionist's desk in a locked box. During an interview on 4/2/25 at 8:50 A.M., Receptionist #1 said Resident #12 does participate in smoking during the scheduled timeframes. Receptionist #1 said all smoking equipment is kept in a locked box at the reception desk and he generally takes the residents who smoke out during the allotted times. Receptionist #1 said Resident #12 does require a protective apron during smoking times but is otherwise just supervised when he/she is smoking. During an interview on 4/2/25 at 11:15 A.M., Social Worker (SW) #1 said Resident #12 did not smoke when he/she was initially admitted to the facility but expressed interest in December. SW #1 said an initial assessment for Resident #12 smoking status was completed at that time. SW #1 said she was not sure how often nursing repeated the assessments but believed they would be completed with any change in condition. SW #1 said there was a period of time recently when Resident #12 did not go out to smoke at all but recently started to go out again throughout the day when he/she desired. SW #1 said she would expect there to be a care plan related to Resident #12 smoking status. During an interview on 4/2/25 at 11:36 A.M., the Director of Nursing (DON) said the expectation was for any resident in the facility who smoked to have a care plan related to their smoking status. The DON said the care plan should reflect any changes in the resident's smoking status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #5 was admitted to the facility in June 2024 with diagnoses including adult failure to thrive, rheumatoid arthritis, and a stage 2 (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) pressure ulcer to his/her coccyx and a stage 2 pressure ulcer to his/her right lateral dorsal foot. Review of the MDS assessment, dated 2/27/25, indicated Resident #5 had severe cognitive impairment as evidenced by a BIMS score of 5 out of 15, was at risk for developing pressure ulcers and had a pressure reducing device in bed. Review of Physician's Orders indicated but was not limited to: -Air mattress set at 100, check function and setting every shift for skin integrity (3/26/25) On 3/31/25 at 9:06 A.M., 11:37 A.M., 12:18 P.M. and 2:45 P.M., the surveyor observed Resident #5 sitting upright in bed. An air mattress was in place and set between 320 pounds (lbs.) and 400 lbs. On 4/1/25 at 7:01 A.M., the surveyor observed Resident #5 lying in bed sleeping. An air mattress was in place and set between 320 lbs. and 400 lbs. Review of the April 2025 Medication Administration Record/Treatment Administration Record (MAR/TAR) indicated nursing staff signed off that the air mattress was in place and set to 100 lbs. on all shifts on 3/31/25 during the time of the surveyor's observations of it set between 320 lbs. and 400 lbs. During an interview on 4/1/25 at 2:28 P.M., the DON said that although sometimes air mattress settings can be changed by mistake, such as if the dial is moved when staff change bed linens, nursing staff are to check the setting every shift to ensure it is set according to physician's orders. He said Resident #5's air mattress should be set to 100 lbs. according to physician's orders. 4. Resident #10 was admitted to the facility in September 2023 and had diagnoses including protein calorie malnutrition and weakness. Review of the MDS assessment, dated 3/6/25, indicated Resident #10 had severe cognitive impairment as evidenced by a BIMS score of 7 out of 15, was at risk for developing pressure ulcers, had a pressure reducing device in bed and received anticoagulant medication on a daily basis. Review of Physician's Orders indicated but was not limited to: -Eliquis (anticoagulant-blood thinner) 2.5 mg twice a day (7/9/24) -Pressure redistribution mattress, setting 180, check function and setting every shift (3/26/25) a. On 3/31/25 at 9:00 A.M., the surveyor observed Resident #10 lying in bed awake. A clear plastic medication cup with a round yellow pill inside was on the overbed table next to the Resident's bed. The Resident said he/she does not take medications independently and did not know what the pill was. Review of the medical record failed to indicate Resident #10 was assessed to self-administer any medications. On 3/31/25 at 9:39 A.M., the surveyor observed Resident #10 sitting upright in bed awake. Nurse #3 was at the Resident's bedside adjusting his/her oxygen tubing. A clear plastic medication cup with a round yellow pill inside was on the overbed table next to the Resident's bed. Nurse #3 then left the Resident's bedside and began to walk toward the door. The surveyor called the Nurse back to the Resident's bedside and showed him the pill in the medication cup. He said the pill was levothyroxine (thyroid hormone) and should have been administered at 6:00 A.M. The nurse said the night nurses sometimes leave medications for residents to take on their own when they shouldn't. Further review of the medical record indicated Resident #10 did not have a physician's order for levothyroxine. During a subsequent interview on 3/31/25 at 2:22 P.M., Nurse #3 said the medication left at Resident #10's bedside this morning was Eliquis 2.5 mg and not levothyroxine as he indicated to the surveyor previously. He said the Resident is not prescribed levothyroxine, but receives Eliquis at 9:00 A.M. and 9:00 P.M. He said he worked a double shift on 3/30/25 (7:00 A.M. to 3:00 P.M. and 3:00 P.M. to 11:00 P.M.) and was the only nurse to administer the Eliquis. He could not explain how the medication was left at the bedside. The nurse said after the surveyor brought the pill at the bedside to his attention, he discarded it. Nurse #3 said he did not inform the Resident's physician or nursing supervisor that a dose of Eliquis was found at the bedside and not administered. Review of the April 2025 Medication Administration Record indicated Nurse #3 signed off that Resident #10 was administered Eliquis 2.5 mg on 3/30/25 at 9:00 A.M. and 9:00 P.M. and 3/31/25 at 9:00 A.M. b. On 3/31/25 at 9:00 A.M. and 9:39 A.M., the surveyor observed Resident #10 sitting upright in bed. An air mattress was in place and set at 150 lbs. On 4/1/25 at 8:31 A.M., 1:59 P.M. and 2:20 P.M., the surveyor observed Resident #10 lying in bed asleep. An air mattress was in place and set at 150 lbs. Review of March and April 2025 MAR/TARs indicated nursing staff signed off that the air mattress was in place and set to 180 lbs. on 3/31/25 and 4/1/25 during the time of the surveyor's observations of it set at 150 lbs. During an interview on 4/1/25 at 2:28 P.M., the Director of Nursing (DON) said that although sometimes air mattress settings can be changed by mistake, such as if the dial is moved when staff change bed linens, nursing staff are to check the settings every shift to ensure it is set according to physician's orders. He said Resident #10's air mattress should be set to 180 lbs. according to physician's orders. The DON said that he was not notified that Resident #10's dose of Eliquis was left at the bedside and not administered. He said the physician should have been notified of the missed dose of Eliquis so he could determine if any blood work or monitoring is necessary. Based on observations, interviews, and records reviewed, for four Residents (#41, #63, #5 and #10) of 18 sampled residents, the facility failed to ensure care was provided to residents in accordance with professional standards of practice. Specifically, the facility failed: 1. For Resident #41, a. to ensure feeding tube formula was administered per physician's orders, and b. to ensure a dietary consult was obtained as ordered by the Physician; 2. For Resident #63, to ensure a physician's order was obtained prior to sending him/her to the hospital; 3. For Resident #5, to ensure the air mattress was set according to physician's orders and accurately documented in the medical record; and 4. For Resident #10, a. to ensure medication was administered as ordered; b. to ensure the air mattress was set according to physician's orders and accurately documented in the medical record. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: -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. 1. Review of the facility's policy titled Care and Treatment of Feeding Tubes, last revised September 2024, indicated but was not limited to: - It is the policy of the facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. - Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush. Resident #41 was admitted to the facility in October 2022 with diagnoses including cerebral infarction and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated 1/10/25, indicated Resident #11 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 2 out of 15. Further review of Resident #41's MDS indicated he/she had a feeding tube and received 51% or more of their total calories from the feeding tube. Review of Resident #41's Physician's Orders indicated but was not limited to: - Enteral feed Jevity 1.5 Calorie, administer 54 milliliters (ml)/hour (hr) for a total of 20 hours with 150 ml of free water flushes every 4 hours for total of 1080 ml of formula daily, dated 11/8/2024 a. On 3/31/25 at 8:54 A.M., the surveyor observed Resident #41 in bed with Jevity 1.5 Calorie running. On 4/1/25 at 7:10 A.M., the surveyor observed Resident #41 in bed with Jevity 1.5 Calorie running. On 4/1/25 at 8:26 A.M., the surveyor observed Resident #41 in bed with Jevity 1.5 Calorie off and not running. On 4/1/25 at 10:21 A.M., the surveyor observed Nurse #8 administer medications to Resident #41 and start Jevity 1.5 Calorie. During an interview on 4/1/25 at 10:21 A.M., Nurse #8 said she was starting Resident #41's tube feed because it was supposed to start at 10:00 A.M. Nurse #8 said the tube feed was supposed to be off for four hours and was due to be restarted at 10:00 A.M. During an interview on 4/2/25 at 6:57 A.M., Nurse #6 said she had worked the 11:00 P.M. to 7:00 A.M. shift from 3/30/25 to 3/31/25. Nurse #6 said Resident #41's tube feed was supposed to be turned off at 6:00 A.M. and remain off until 10:00 A.M. Nurse #6 said Resident #41's tube feed was supposed to run for only 20 hours a day. Nurse #6 said she must have forgotten to turn off Resident #41's tube feed on 3/31/25 at 6 A.M., but she should have shut it off per physician's orders. During an interview on 4/2/25 at 8:31 A.M., Nurse #5 said Resident #41 received Jevity 1.5 Calorie via gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication) for 20 hours a day. Nurse #5 said the tube feed is turned off at 6:00 A.M. every morning and is turned back on at 10:00 A.M. Nurse #5 said she thought the tube feed was turned off at 6:00 A.M. on 3/31/25 but she could not be sure because it is the responsibility of the 11:00 P.M. to 7:00 A.M. shift nurse to turn it off. Nurse #41 said she did not recall if she had started Resident #41's tube feed at 10:00 A.M. on 3/31/25. During an interview on 4/2/25 at 2:19 P.M., the Unit Manager (UM) said Resident #41 had an order for Jevity 1.5 Calorie for 20 hours a day, start at 10:00 A.M. and turn off at 6:00 A.M. The UM said all nurses must follow physician's orders and turn the Jevity 1.5 Calorie off at 6:00 A.M. and restart it at 10:00 A.M. as ordered. During an interview on 4/2/25 at 4:02 P.M., the Director of Nursing (DON) said his expectation was for all staff to follow physician's orders for feeding tubes. b. Review of Resident #41's Physician's Orders indicated but was not limited to: - Dietitian Consult related to weight gain, dated 3/11/25 Review of Resident #41's weights indicated but was not limited to: 3/31/25 212.0 pounds 3/17/25 211.0 pounds 3/10/25 211.0 pounds 3/10/25 211.0 pounds 3/3/25 210.5 pounds 2/5/25 202.0 pounds Further review of Resident #41's medical record failed to indicate a Dietitian Consult had been obtained on 3/11/25 or after. During an interview on 4/2/25 at 12:14 P.M., Nurse #5 reviewed Resident #41's medical record and said a Dietitian consult was ordered for Resident #41 due to his/her weight gain. Nurse #5 said if a consultation was conducted by the Dietitian, it would have been documented in a note. Nurse #5 said she did not see a note from the Dietitian. During an interview on 4/2/25 at 2:19 P.M., the UM said Dietitian consultations were documented either in a note or in a dietary assessment. The UM reviewed Resident #41's medical record and said she did not see a Dietitian note or dietary assessment in Resident #41's chart on 3/11/25 or after that. During a telephonic interview on 4/3/25 at 2:11 P.M., the Regional Registered Dietitian said the facility had a Registered Dietitian and she would conduct the dietary consults. The Regional Registered Dietician reviewed Resident #41's medical record and said she could not see that a Dietitian Consultation was conducted as ordered by the physician. During an interview on 4/2/25 at 4:02 P.M., the DON said his expectation was for all staff to follow physician's orders for a Dietary Consult and the dietary consult to be completed within a week. A call was placed to the facility's Registered Dietitian on 4/2/25 at 11:47 A.M. and on 4/3/25 at 7:48 A.M. with no call back. 2. Review of the facility's policy titled Transfer and Discharge (including AMA), last revised September 2024, indicated but was not limited to: - Emergency Transfer/Discharge- initiated by the facility for medical reasons to an acute care setting such as a hospital, for immediate safety and welfare of a resident. - Obtain physician's orders for emergency transfer or discharge. Resident #63 was admitted to the facility in February 2023 with diagnoses including dementia and chronic kidney disease. Review of the MDS assessment, dated 1/31/25, indicated Resident #63 had a severe cognitive deficit as evidenced by a BIMS score of 6 out of 15. Review of Resident #63's medical record indicated he/she was transferred to the hospital on [DATE] and 12/10/24 for a change in condition. Further review of the medical record failed to indicate an order was obtained prior to transferring Resident #63 to the hospital on [DATE] and 12/10/24. During an interview on 4/2/25 at 12:14 P.M., Nurse #5 said prior to transferring a resident to the hospital they must obtain an order from the physician or physician's extender. Nurse #5 said the order must then be transcribed in the resident's medical record. During an interview on 4/2/25 at 2:19 P.M., the UM said prior to transferring a resident to the hospital they must obtain an order from the physician or physician's extender. The UM said the order must then be transcribed in the resident's medical record. The UM reviewed Resident #63's medical record and said she did not see an order to the transfer Resident #63 to the hospital on [DATE] and 12/10/24 but he/she should have had an order. During an interview on 4/2/25 at 4:02 P.M., the DON reviewed Resident #63's medical record and said he did not see an order to transfer Resident #63 to the hospital on [DATE] and 12/10/24 but he/she should have had an order. The DON said all residents must have an order to be transferred to the hospital.

2. Resident #10 was admitted to the facility in September 2023 and had diagnoses including chronic obstructive pulmonary disease (COPD-lung disease causing restricted airflow and breathing problems). Review of the medical record indicated Pharmacy Consultant Notes, dated 8/14/24, 9/9/24 and 10/8/24 which indicated that recommendations were made and to see the Consultant Pharmacist report for the recommendations. Further review of the entire medical record failed to indicate consultant pharmacy recommendations dated 8/14/24, 9/9/24, and 10/8/24. During an interview on 4/2/25 at 10:35 A.M., the DON said the previous owners of the facility had all of the pharmacy recommendations in their computer system. He said after the survey team requested to review pharmacy recommendations yesterday, they had to call the previous owners and requested the past year of pharmacy recommendations. He said the 8/14/24, 9/9/24 and 10/8/24 pharmacy recommendations were addressed by Resident #10's Nurse Practitioner yesterday, 4/1/25 (more than 230 days since the first recommendation). Based on document review and interview, the facility failed to ensure monthly medication regimen reviews (MRR) were communicated to the physician and addressed in a timely manner for two Residents (#60 and #10), out of a total sample of 18 residents. Specifically, the facility failed to: 1. Ensure a recommendation from June 2024 left by the consultant pharmacist for Resident #60 to potentially reduce their medication load of Famotidine (a medication that decreases the amount of acid the stomach produces) from twice a day to once a day; and 2. For Resident #10, to ensure the August, September and October 2024 consultant pharmacist recommendations were acted upon timely to clarify the need for two as needed orders for Duoneb (inhalation solution to help open the airways in the lungs). Findings include: Review of the facility's policy titled Medication Regimen Review, undated, indicated but was not limited to the following: - the drug regimen of each resident will be reviewed at least once a month by a licensed pharmacist and includes a review of the medical record - the MRR is an evaluation with the goal to promote positive outcomes and minimize adverse consequences and potential risks associated with medications - the pharmacist will document, either manually or electronically, that each MRR was completed and document either no irregularity or the nature of any identified irregularities - written communications from the pharmacist will be a permanent part of the medical record - staff shall act upon all recommendations according to procedures for addressing MRR irregularities 1. Resident #60 was admitted to the facility in February 2024 with diagnoses including: adult failure to thrive, abscess of the pharynx, and dysphagia (inability to swallow well). Review of the medical record indicated a full MRR was completed by the consultant pharmacist in June 2024 and to see report for irregularities and/or recommendations. The record failed to indicate what those irregularities were or that they were addressed by a physician. Review of the MRR from June 2024 was a recommendation left to the prescriber and indicated the following: Resident has received Famotidine 20 milligrams (mg) twice daily since admission for gastroesophageal reflux disease (GERD). Would it be appropriate to consider reducing Famotidine dose to 20mg every night (QHS) as maintenance therapy? The physician response section was not completed by the physician, instead the Director of Nurses (DON) contacted the attending and completed the bottom of the form indicating disagree, but failed to indicate a rationale for the disagreement, and dated the recommendation as addressed on 4/1/25, 8 months after the recommendation was placed. During an interview on 4/2/25 at 12:25 P.M., the Director of Nursing (DON) said once the facility located the MRR recommendation yesterday, he contacted the Nurse Practitioner (NP) about Resident #60's recommendation from June 2024. He said he asked the NP if they ever had awareness of this recommendation in the past and they told him they couldn't recall it. He said he informed them of the recommendation and the NP at this time decided to decline the change and maintain the current orders of Famotidine 20mg twice daily until the Resident could be re-evaluated. He said he did not have a rationale for the declined recommendation and just signed it as completed on 4/1/25. He said the process for MRR being addressed is that they are completed by the NP or physician timely, which he considers to be within one month of the original recommendation being placed and that when a recommendation is declined a rationale is documented in the medical record. He said this process does not appear to have been in place or effective since Resident #60's June MRR recommendation was not addressed for eight months after it was placed.

Based on record review and interview, the facility failed to ensure for two Residents (#79 and #73), out of a total sample of 18 residents, that each resident's drug regimen was free from unnecessary psychotropic medications to promote or maintain the Resident's highest practicable mental, physical, and psychosocial well-being. Specifically, the facility failed: 1. For Resident #79, to ensure signs and symptoms of side effects were adequately monitored to evaluate the effectiveness of psychotropic medications; and 2. For Resident #73, to: a) ensure as needed (PRN) use of clonazepam (treats anxiety) was limited to 14 days and the prescriber documented an evaluation of the Resident's current condition and the appropriateness to continue the use of PRN trazodone, and b) ensure signs and symptoms of side effects were adequately monitored to evaluate the effectiveness of antidepressant and antianxiety medications. Findings include: Review of the facility's policy titled Use of Psychotropic Medication, revised September 2024, indicated but was not limited to the following: Policy: -Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Policy Explanation and Compliance Guidelines: 1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. 4. The indications for use of any psychotropic drug will be documented in the medical record and include non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentations that are initiated after admission. 9. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e., 14 days). a. If the attending physician or prescribing practitioner believes that it's appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. 12. The effects of psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as: d. In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care. 1. Resident #79 was admitted to the facility in March 2025 and had diagnoses including sleep disorder, anoxic (complete lack of oxygen) brain damage, encephalopathy (brain disease that alters brain function or structure), and extrapyramidal and movement disorder. Review of the Minimum Data Set (MDS) assessment, dated 3/10/25, indicated Resident #79 received antianxiety and antidepressant medications and exhibited mood symptoms. The MDS indicated the Resident did not exhibit any behavioral symptoms. Review of current Physician's Orders indicated the following psychotropic medications: -trazodone HCL oral tablet 50 milligrams (mg) (trazodone HCL), give 0.5mg tablet via PEG-tube every 8 hours as needed (prn) for anxiety for 14 days, then re-eval, 3/18/25 -sertraline HCL oral concentrate 20 mg/milliliters (ml), give 1.3 ml via PEG-Tube in the morning for anxiety, 3/4/25 Review of the March 2025 Medication Administration Record (MAR) indicated the following uses of PRN trazodone and sertraline: -administered PRN trazodone on 3/23/25, 3/24/25, 3/25/25, 3/26/25, 3/29/25, 3/30/25 -administered sertraline as ordered Further review of the medical record failed to indicate that staff monitored the Resident for significant side effects related to the use of the antidepressant and antianxiety medications as required. During an interview on 4/1/25 at 3:11 P.M., the surveyor reviewed the medical record with the Unit Manager (UM) who said there was no order for monitoring of side effects for the use of the medications. During an interview on 4/2/25 at 2:41 P.M., the Director of Nursing (DON) and Regional Nurse #1 said the Resident should have been monitored for side effects specific to the use of the medications but there's no order for it. The DON said staff need to be sure the Resident is not experiencing any symptoms to determine if a dose adjustment is needed and for effectiveness. 2a. Resident #73 was admitted to the facility in December 2024 and had diagnoses including diabetes mellitus type 2, complete paraplegia, anxiety, and depression. Review of the MDS assessment, dated 12/23/24, indicated the Resident received antidepressant and antianxiety medications daily and exhibited mood symptoms. The MDS indicated the Resident did not exhibit any behavioral symptoms. Review of current Physician's Orders indicated the following psychotropic medications: -clonazepam oral tablet 0.5 mg, give 1 tablet by mouth as needed for anxiety, 0.5 mg PO (by mouth) TID (three times a day) PRN (as needed) for anxiety, 2/20/25 (no stop date) -duloxetine (antidepressant) HCL oral capsule delayed release particles 60 mg, give 60 mg by mouth one time a day for depression, 12/17/24 -trazodone HCL oral tablet 50 mg, give 1 tablet by mouth at bedtime for insomnia, 12/20/24 -Wellbutrin SR oral tablet extended release 12-hour 150 mg (bupropion HCL), give 1 tablet by mouth two times a day for mood, 12/18/24, Further review of physician's orders failed to indicate a limited duration (i.e., 14 days) for the PRN clonazepam or documentation of a clinical rationale in the medical record for the medication to be extended beyond 14 days including an evaluation of the Resident's current condition and the appropriateness to continue the use of PRN clonazepam. Review of the December 2024 through March 2025 MAR indicated the following: -administered PRN clonazepam on 2/20/25, 2/21/25, 2/23/25, 2/28/25, 3/1/25 through 36/25, 3/8/25, 3/9/25, 3/12/25 through 3/15/25, 3/18/25, 3/22/25, 3/24/25 through 3/26/25, 3/20/25, and 3/31/25 -administered medications as ordered b. Further review of the medical record failed to indicate that staff monitored the Resident for significant side effects related to the use of the antidepressant and antianxiety medications as required. During an interview on 4/2/24 at 10:26 A.M., Family Member #6, who was interpreting for Resident #73, said the Resident gets very anxious every day, gets panic attacks, cries, and feels sad sometimes. During an interview on 4/2/25 at 1:43 P.M., the Unit Manager (UM) said the Resident takes clonazepam as needed for anxiety and also takes duloxetine, Wellbutrin, and trazodone. She said there was no stop date for the PRN clonazepam or re-eval and added it this day after surveyor intervention. She said there should have been an end date of 14 days and a note to re-evaluate after 14 days. She said the order duration was indefinite but shouldn't have been. The UM said there should have been a documented clinical rationale to continue the PRN medication but there wasn't. The surveyor reviewed physician's notes with the UM who said there wasn't a clinical rationale to extend its use. The UM said side effects for clonazepam, duloxetine, trazodone, and Wellbutrin should be monitored and there should be a coordinated order to do this but there wasn't. She said there's an order template that lists the side effects for each class of psychotropic medications. During an interview on 4/2/25 at 3:03 P.M., the DON and Regional Nurse #1 said the PRN clonazepam did not have a stop date on it or to re-evaluate and did not have a clinical rationale by the provider documented but should have. They said the 2/20/25 PRN order was open ended and if it was to be extended then there would be a lengthy note as to why the medication needed to be extended and for how long. The DON said there was no order for side effect monitoring either but there should have been.

Based on interview and review of the Health Care Facility Reporting (HCFS-State agency reporting system), the facility failed to provide written notice to the State Agency when a change in the facility's Administrator and Director of Nursing (DON) occurred. Findings include: During the entrance conference interview on 3/31/25 at 8:59 A.M., the Administrator said she was the facility's new Administrator, effective 3/10/25, and the facility had a new Director of Nursing (DON), effective 3/15/25. The Administrator said the changes were not reflected in HCFRS yet but were in process and would provide documentation of such to the surveyor. Review of the HCFRS indicated the last reported change in the facility's Administrator was 12/6/24 and the last reported change in the facility's DON was 5/23/24 but no changes were indicated that the Administrator and DON were no longer working at the facility. Further review of the HCFRS failed to indicate the State Agency was notified when the change took place for the current Administrator on 3/10/25 and DON on 3/15/25. During an interview on 3/31/25 at 3:10 P.M., the Administrator provided the surveyor with an email, dated 3/31/25, that indicated she did not have access to HCFRS yet, but the current DON did. During an interview on 3/31/25 at 4:15 P.M., the Administrator and DON said the previous company (prior to 3/1/25) said they would put the changes in HCFRS for them, but they did not. They said there were staff still working in the facility from the previous company that had access to HCFRS for reporting, but they did not report it either. They said it was their responsibility to ensure that it was done and said when there's a change in Administrator or DON it should be reported in HCFRS, but it wasn't. During an interview on 4/2/25 at 3:19 P.M., Regional Nurse #1 said the changes in Administrator and DON should have been reported in HCFRS prior to their start or immediately after.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Review of Lippincott Nursing Procedures. Eighth edition. [Philadelphia: Wolters Kluwer, (2019)] indicted but was not limited to the following: Continuous Positive Airway Pressure (CPAP) Use Administering CPAP: -When the treatment is over-in the morning or on discontinuation of the order-turn off the pressure generator and remove the headgear and appliance from the patient. -Clean and disinfect the equipment and store it properly. Resident #73 was admitted to the facility in December 2024 with diagnoses including sleep apnea (sleep disorder in which breathing repeatedly stops and starts). During an observation with interview on 4/1/25 at 10:40 A.M. and 2:06 P.M., the surveyor observed Resident #73 sitting up in bed. A CPAP machine was stored on top of the Resident's side table. The face mask and tubing were observed attached to the machine and resting on top of the side table potentially exposed to environmental contaminants. The face mask and tubing were not stored in a protective bag when not in use by the Resident. Resident #73 said he/she used the machine for sleep apnea. Review of current Physician's Orders indicated the following: -CPAP @10 cm (centimeters of water pressure) H2O inspiration; 5 cmH2O expiration, on at HS (before sleep at bedtime), off in AM, at bedtime for sleep apnea, 12/26/24 During an observation with interview on 4/1/25 at 2:49 P.M., the surveyor and Unit Manager (UM) entered the Resident's room and observed a CPAP machine stored on top of the Resident's side table. The face mask and tubing were observed attached to the machine and resting on top of the side table potentially exposed to environmental contaminants. The face mask and tubing were not stored in a plastic bag when not in use by the Resident. The UM said the mask and tubing should have been stored in a protective bag when not in use secondary to the potential for infection control concerns related to the danger of exposure to contaminants. On 4/2/25 at 6:58 A.M., the surveyor observed Resident #73 sitting up in bed. A CPAP machine was stored on top of the Resident's overbed tray table. The face mask and tubing were observed attached to the machine and resting on top of the tray table potentially exposed to environmental contaminants. The face mask and tubing were not stored in a protective bag when not in use by the Resident. During an interview on 4/2/25 at 3:13 P.M., the DON and Regional Nurse #1 said the Resident uses a CPAP machine for sleep apnea every night. They said the mask and tubing should be stored in a bag when not in use to avoid potential contamination. 5. Resident #77 was admitted to the facility in January 2025 and had diagnoses including: Unspecified intracranial injury, abnormalities of gait and mobility, muscle wasting and atrophy, unsteadiness on feet, and abnormal posture. Review of the MDS assessment, dated 1/14/25, indicated Resident #77 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Review of the current Physician's Orders for Resident #77 indicated but were not limited to the following: - Albuterol sulfate inhalation nebulizer solution (2.5 milligrams / 3 milliliters) 0.083% inhale one application orally via nebulizer every 12 hours, as needed (PRN) for shortness of breath (SOB) (1/8/25) Throughout the survey the surveyor made the following observations: 4/1/25: nebulizer mask and tubing on the bedside table touching other items on the table, exposed to environmental debris and germs in the environment, not stored in a plastic bag at 10:05 A.M., 10:52 A.M., 12:21 P.M. and 1:23 P.M. During an interview on 4/1/25 at 12:21 P.M., Family Member #2 and the Resident said they were unsure of the last time the Resident had received a nebulizer treatment. Family Member #2 said the nebulizer mask and tubing had been left on top of the bedside table and stored there consistently. During an interview on 4/1/25 at 1:23 P.M., Nurse #7 observed the nebulizer tubing and mask with the surveyor. He said the nebulizer tubing and mask were not supposed to be stored that way and the equipment was dirty and would need to be replaced. He said the Resident is on nebulizer treatments PRN and he had not provided a treatment to the Resident recently. During an interview on 4/2/25 at 10:09 A.M., the Unit Manager said nebulizer tubing and mask or mouthpiece equipment is to be cleaned after each use and then stored in a plastic bag to protect it from germs. She said it does not appear that the process was followed in this instance and the Resident's nebulizer mask and tubing should have been stored in a sanitary manner. During an interview on 4/3/25 at 10:14 A.M., the DON said the process for storing nebulizer tubing and mask or mouthpiece is to clean it after each treatment and store it in a bag once it is dried for infection control reasons. He said that process was not followed for Resident #77 based on the surveyor's observations. 4. Review of the facility's policy titled Oxygen Administration, dated last revised 9/2024, indicated but was not limited to the following: - Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered plans, and the resident's goals and preferences. - Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include a.) Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated; d.) If applicable, change nebulizer tubing and delivery devices weekly and as needed if it becomes soiled or contaminated; e.) Keep delivery devices covered in plastic bag when not in use. - Cleaning and care of equipment shall be in accordance with facility policies for such equipment. Review of the facility's policy titled Nebulizer Therapy, dated last revised 9/2024, indicated but was not limited to the following: - It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. - Care of Equipment: 1.) Clean after each use; 2.) Wash hands before handling equipment; 3.) Disassemble parts after every treatment; 4.) Rinse the nebulizer cup and mouthpiece with sterile or distilled water; 5.) Shake off excess water; 6.) Air dry on an absorbent towel; 7.) Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag; 8.) Change the nebulizer tubing every seventy-two hours or per facility policy; 9.) Periodically disinfect unit per manufacturer's recommendations. Resident #49 was admitted to the facility in January 2024 with diagnoses including pulmonary fibrosis and emphysema. Review of Resident #49's MDS assessment, dated 12/26/24, indicated he/she was cognitively intact as evidenced by a BIMS of 15 out of 15. Furthermore, the MDS assessment indicated he/she required assistance from staff for activities of daily living. Review of Resident #49's Physician's Orders indicated but was not limited to the following: - 3/27/25: May apply O2 (oxygen) at 1-3 L (liters) via NC (nasal cannula) to maintain saturation 94% of above; if saturation is 94 or above on O2, turn O2 down/off every shift - 3/26/25: Oxygen 1L per minute via NC and titrate to keep saturation above 93%. - 3/26/25: Duoneb Solution 0.5-2.5 3MG (milligrams)/3mL (milliliters); 3mL inhale orally via nebulizer every 8 hours as needed for SOB (shortness of breath). Review of Resident #49's March and April Medication Administration Records (MAR) indicated he/she received the Duoneb Solution treatment on 3/26/25. During an observation with interview on 3/31/25 at 2:46 P.M., the surveyor observed Resident #49 resting in bed; an oxygen concentrator was on and set to 2L of oxygen. Nasal cannula tubing was attached to the concentrator. The nasal cannula tubing was observed to be on the ground on the left side of the bed and the tubing was not dated. A nebulizer mask and tubing were noted to be resting on the nightstand next to Resident #49's bed. The nebulizer mask and tubing were exposed to the environment, was not dated, and was not covered with a plastic bag. Resident #49 said he/she was recently diagnosed with pneumonia and was requiring nebulizer treatments and oxygen. Resident #49 said none of the oxygen equipment, including nasal cannula tubing and nebulizer mask/tubing, had been changed since he/she started using the equipment. On 4/1/25 at 10:55 A.M., the surveyor observed Resident #49 resting in bed with nasal cannula tubing donned (on). The oxygen concentrator was set to 2L. The nasal cannula tubing was not dated. A nebulizer mask and tubing were noted to be resting on the nightstand next to Resident #49's bed. The nebulizer mask and tubing was exposed to the environment, was not dated, and was not covered with a plastic bag. On 4/1/25 at 4:11 P.M., the surveyor observed Resident #49 asleep in bed without nasal cannula tubing donned. The oxygen concentrator was set to 2L. The nasal cannula tubing was not dated and was found resting across Resident #49's lap exposed to the environment. A nebulizer mask and tubing were noted to be resting on the nightstand next to Resident #49's bed. The nebulizer mask and tubing were exposed to the environment, was not dated, and was not covered with a plastic bag. On 4/2/25 at 7:49 A.M., the surveyor observed Resident #49 resting in bed without nasal cannula tubing donned. The oxygen concentrator was set to 2L. The nasal cannula tubing was not dated and was found resting across Resident #49's lap exposed to the environment. A nebulizer mask and tubing were noted to be resting on the nightstand next to Resident #49's bed. The nebulizer mask and tubing were exposed to the environment, was not dated, and was not covered with a plastic bag. Review of Resident #49's medical record failed to indicate any documentation indicating that the oxygen tubing and/or nebulizer mask/tubing was changed. During an interview on 4/2/25 at 8:16 A.M., Nurse #1 said oxygen equipment is changed weekly at the facility or if it is soiled. Nurse #1 said when nebulizer or oxygen equipment is not in use it should be stored in a bag. Nurse #1 said tubing should be dated to indicate the last time it was changed. During an interview on 4/2/25 at 11:07 A.M., the Assistant Director of Nursing (ADON) said all oxygen equipment, including nebulizer equipment, should be stored in a bag when it is not in use. The ADON said oxygen and nebulizer tubing should be dated to indicate when it was last changed. The ADON and the surveyor reviewed the observations made during the survey process. The ADON said all items needed to be changed as they were potentially contaminated. The ADON said the items should have been stored properly when not in use. During an interview on 4/2/25 at 11:32 A.M., the DON said all oxygen equipment should be stored in a bag when not in use and should not be left on the ground or on a nightstand exposed to the environment. The DON said tubing should be dated to indicate to the staff how recently it was changed. The DON said Resident #49's oxygen and nebulizer equipment was not stored appropriately. Based on records reviewed and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Specifically, the facility failed to: 1. Perform surveillance activities to monitor and investigate causes of infections and the manner of spread throughout the facility; 2. Have a facility specific written water management plan to ensure a facility risk assessment was conducted to identify where Legionella (bacteria that can cause Legionnaires' disease, a serious type of pneumonia) and other opportunistic waterborne pathogens could grow and spread in the facility's water system; 3. For Resident #41, ensure Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication) equipment was maintained in a clean and sanitary manner to decrease the risk of potential contamination and infection; 4. For Resident #49, ensure respiratory equipment including oxygen and nebulizer tubing was properly stored in a clean and sanitary manner to decrease the risk of potential contamination and infection; 5. For Resident #73, ensure the proper care and storage of the Resident's continuous positive airway pressure (CPAP-helps treat sleep apnea) machine; and 6. For Resident #77, ensure nebulizer (drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask and tubing was stored in a sanitary manner. Findings include: 1. Review of the facility's policy titled Infection Surveillance, last revised September 2024, indicated but was not limited to: - A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. The purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices to reduce infections and prevent the spread of infections. - Infection surveillance refers to an ongoing systemic collection, analysis, interpretation, and dissemination of infection-related data. - The Facility will collect data to properly identify possible communicable diseases or infections among residents and staff before they spread. - The facility will communicate staff and/or prescribing practitioner's information related to infection rates and outcomes in order to revise interventions/approaches and/or re-evaluate medical interventions as indicated. - Monthly time periods will be used for capturing and reporting data. Line charts will be used to show data comparisons over time and will be monitored for trends. - All residents and infections will be tracked. On 3/31/25 at 3:27 P.M., the surveyor requested to see the facility's completed surveillance logs for December 2024, January 2025, and February 2025. During an interview on 3/31/25 at 4:31 P.M., Support Staff #2 said the facility did not have access to December 2024, January 2025, and February 2025 completed surveillance logs and was working on getting them. During an interview on 4/1/25 at 12:53 P.M., Support Staff #2 said the facility was not able to provide any surveillance logs prior to March 1, 2025, to the survey team. During an interview on 4/2/25 at 1:08 P.M., the Director of Nursing (DON) and Support Staff #2 said there were no surveillance logs that the facility could provide to the survey team. 2. Review of Centers for Medicare & Medicaid Services (CMS) Memorandum titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease, revised July 2018, indicated but was not limited to the following: - In manmade water systems, Legionella can grow and spread to susceptible hosts, such as persons who are at least [AGE] years old, smokers, and those with underlying medical conditions such as chronic lung disease or immunosuppression. Legionella can grow in parts of building water systems that are continually wet, and certain devices can spread contaminated water droplets via aerosolization. Review of the facility's policy titled Legionella Water Management Program, dated November 2017, indicated but was not limited to: -Policy: Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. -Guideline: - As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. - The water management team will consist of at least the following personnel: - Infection Preventionist - Administrator - Medical Director - Director of maintenance - Other members as assigned by the Administrator -The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionella Disease. -The water management program used by our facility is based on applicable federal and state regulations. The water management program may include the following elements: - A description and diagram of the water system in the facility is available upon request; - The Identification of area in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria; Review of the facility's Water Management Plan, dated 11/5/24, indicated but was not limited to: - Medical Director signature -Blank - Water enters the basement on the property - Hot water is distributed to plumbing fixtures in the basement - Areas where Legionella could grow and spread: - Fountains - Hydrotherapy During an interview on 4/1/25 at 4:44 P.M., the Director of Maintenance (DOM) said the Medical Director had never been part of the Water Management team. The DOM said the facility was built on a slab and did not have a basement. The DOM said the facility did not have any hydrotherapy and the only fountains in the facility were water fountains which were capped off and shut off over five years ago. The DOM said the water management plan was not specific to the facility and did not accurately represent the facility. During an interview on 4/2/25 at 1:08 P.M., the DON and Support Staff #2 said the Facility's water plan was not specific to the facility but should have been. 3. Review of the facility's policy titled Care and Treatment of Feeding Tubes, last revised September 2024, indicated but was not limited to: - Direction for staff on how to provide the following care will be provided: - Use of infection control precautions and related techniques to minimize the risk of contamination. Review of the facility's policy titled Flushing a Feeding Tube, last revised October 2024, indicated but was not limited to: - Change the 60 ml catheter tip syringe used every 24 hours or as needed. - Store in a bag or container. Resident #41 was admitted to the facility in October 2022 with diagnoses including cerebral infarction and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated 1/10/25, indicated Resident #11 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 2 out of 15. Further review of Resident #41's MDS indicated he/she had a feeding tube and received 51% or more of their total calories from the feeding tube. Review of Resident #41's current Physician's Orders indicated but was not limited to: - Enteral feed Jevity 1.5 Calorie, administer 54 milliliters (ml)/hour (hr) for a total of 20 hours with 150 ml of free water flushes every 4 hours for total of 1080 ml of formula daily, dated 11/8/2024 a. On the following dates and times, the surveyor observed dried splatters of a thick, tacky, tan colored substance on Resident #41's tube feeding pump, pole, the floor underneath the pump, the bedrail of his/her bed, and on their privacy curtain: - 3/31/25 at 8:58 A.M., - 3/31/25 at 10:18 A.M., - 3/31/25 at 12:06 P.M., - 3/31/25 at 2:30 P.M., - 3/31/25 at 4:43 P.M., - 4/1/25 at 7:10 A.M., - 4/1/25 at 10:01 A.M., - 4/1/25 at 10:21 A.M., - 4/1/25 at 11:57 A.M., and - 4/2/25 at 8:31 A.M. During an interview on 4/2/25 at 8:31 A.M., Nurse #5 and the surveyor observed the dried splatters of the thick, tacky, tan colored substance on Resident #41's tube feeding pump, pole, floor underneath the pump, the bedrail of his/her bed, and on their privacy curtain. Nurse #5 said it was the nurse's responsibility to wipe up any tube feeding formula they had spilled or dripped. Nurse #5 said housekeeping was responsible for cleaning the floor and cleaning the privacy curtain. During an interview on 4/2/25 at 8:38 A.M., Unit Manager (UM) #1 said the expectation was for all feeding tube equipment and the surrounding area to be kept in a clean and sanitary manner to promote healthy infection control practices. UM #1 said that whoever spilled the formula should have wiped down the spilled formula and notified housekeeping to clean and replace the privacy curtain. During an interview on 4/2/25 at 4:02 P.M., the DON said that the expectation was for all feeding tube equipment and the surrounding area to be kept in a clean and sanitary manner to promote healthy infection control practices. b. On 3/31/25, the surveyor observed Resident #41's piston syringe lying uncovered dated 3/29/25 on his/her dresser: - 8:58 A.M., - 10:18 A.M., - 12:06 P.M., - 2:30 P.M., - 4:43 P.M. On 4/1/25 at 8:26 A.M. and 10:01 A.M., the surveyor observed Resident #41's piston syringe lying uncovered, dated 3/29/25, on a towel his/her overbed table. On 4/1/25 at 10:21 A.M., the surveyor observed Nurse #8 administering Resident #41's medications using the piston syringe, dated 3/29/25. Nurse #8 said she used the syringe from Resident #41's overbed table because she could not find a new syringe and she needed to hang his/her tube feeding. Nurse #8 said she should not have used the piston syringe from Resident #41's overbed table because it was not stored in a clean manner and was outdated. Nurse #8 said piston syringes should be replaced daily and stored in a bag. On 4/1/25 at 3:23 P.M., Regional Nurse #1 said piston syringes should be changed daily and stored in a sealed bag. Regional Nurse #1 said piston syringes should not be stored out of a sealed bag when not in use.

Based on record review and interview, the facility failed to establish and maintain an infection prevention and control program that included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use. Findings include: Review of the facility's Antibiotic Stewardship Program policy, undated, indicated but was not limited to the following: - It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. On 3/31/25 at 3:27 P.M., the surveyor requested to see the facility's antibiotic use for December 2024, January 2025, and February 2025. During an interview on 3/31/25 at 4:31 P.M., Support Staff #2 said the facility did not have access to December 2024, January 2025, and February 2025 antibiotic use records. Support Staff #2 said the facility was working on getting the completed antibiotic use records for the facility. During an interview on 4/1/25 at 8:20 A.M., Support Staff #2 said the facility was still working on obtaining the facility's antibiotic use for December 2024, January 2025, and February 2025. During an interview on 4/1/25 at 11:03 A.M., Support Staff #2 said there was someone on their way to the facility with some files which may contain the completed records for antibiotic use. During an interview on 4/2/25 at 1:08 P.M., the Director of Nursing and Support Staff #2 said they were not able to provide any documentation of the facility's antibiotic use prior to March 1, 2025, to the survey team.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), who was severely cognitively impaired, unable to make his/her needs known to staff and was dependent on staff for all care, the Facility failed to ensure Resident #1 was free from restraints, when on 09/16/24, he/she was found in the day room by the Unit Manager in his/her Broda chair which was fully reclined, with a couch up against the left side of the Broda chair, and the right side was positioned against the wall, which restricted his/her movements on either side. Findings include: Review of the Facility's Policy, titled Use of Restraints, dated as revised January 2017, indicated the following: -physical restraints are defined as any manual method, or physical, or mechanical device, material or equipment attached to adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts access to one's body. -the definition of a restraint if based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition, and this restricts his/her typical ability change position or place, that device is considered a restraint. Resident #1 was admitted to the Facility in May 2024, diagnoses included dementia, left femur fracture, coronary artery disease, and dysphagia. Review of Resident #1's medical record indicated his/her Health Care Proxy was activated on 05/10/24, due to cognitive impairment related to Dementia. Review of Resident #1's Medical Record indicated he/she had a Physician's order, dated 07/31/24, for Hospice Care and an order for the Broda chair. Review of Resident #1's most recent Minimum Data Set (MDS) Assessment, dated 08/05/24, indicated Resident #1 was severely cognitively impaired, was dependent on staff for completion of Activities of Daily Living (ADLs) and required two staff members to assist with mobility, with handheld assistance. During an interview on 10/16/24 at 1:35 P.M., the Unit Manager said that on 09/16/24 at 7:20 A.M., when she went to the nurse's station [on Resident #1's unit] to check the schedule for the day, she noticed that Resident #1 was in the dayroom, in his/her Broda chair, that the chair was fully reclined back, the right side of the chair was against the wall and a couch was placed up against the left side of the Broda chair. The Unit Manager said she asked Nurse #1 why Resident #1 was placed in this position, because it would restrict Resident #1 movement. The Unit Manager said Nurse #1 reported that she had moved the couch away from Resident #1 chair earlier that night, and had questioned the overnight staff (later identified as CNA #1 and CNA #2) about it. The Unit Manager said both overnight CNAs had left at their shift's end and where not on the unit to question. The Unit Manager said that Resident #1 was at risk of falling due to weakness, unsteady gait and had a history of falls with injuries. The Unit Manager said Resident #1's intervention for safety included the use of the Broda chair and placing Resident #1 at the nursing station or in the day room, where he/she was visible to staff. The Unit Manager said Resident #1 sometimes would get up from the chair, that staff members would walk him/her around the unit, and that he/she required two staff member for assistance with mobility. During a telephone interview on 10/22/24 at 10:00 A.M., Nurse #1 said that at approximately 7:20 A.M. on 09/16/24, while conducting her last set of safety checks, she was approached by the Unit Manager who told her she found Resident #1 in the day room in his/her Broda chair, with the right side against the wall and a couch up against the left side of the Broda chair. Nurse #1 said she did not put the couch up against Resident #1's chair. Nurse #1 said that at approximately 1:00 A.M., she had found Resident #1 in the day room, in his/her Broda chair, and that Certified Nurse Aide (CNA) #1 reported that Resident #1 was restless. Nurse #1 said she noticed a couch was placed up against the left side of Resident #1's Broda chair and immediately moved it. Nurse #1 said that she educated both CNA #1 and CNA #2 that placing the couch beside Resident #1's chair was not an appropriate intervention, that they should report Resident #1's restlessness to her, and that they should not implement any intervention that could be considered a restraint. Nurse #1 said that both CNA #1 and CNA #2 denied placing the couch up against Resident #1's chair. During a telephone interview on 10/21/24 at 11:00 A.M., Certified Nurse Aide (CNA) #1 said before her shift ended at 6:30 A.M., with the assistance of CNA #2, they provided personal care for Resident #1 and placed him/her (in his/her Broda chair) in the day room where morning shift staff could keep their eyes on him/her. CNA #1 said Resident #1 was comfortable and sleeping when she left. CNA #1 denied moving the couch and placing it up against the left side of Resident #1's Broda chair. During a telephone interview on 10/21/24 at 1:18 P.M., Certified Nurse Aide (CNA) #2 said that approximately at 6:00 A.M., he assisted CNA #1 with completing personal care for Resident #1. CNA #2 said Resident #1 was placed his/her Broda chair in the day room. CNA #2 said after helping CNA #1, he left to provide care for other residents. CNA #2 denied the moving the couch and placing it against the left side of Resident #1's Broda chair. Although CNA #1 and CNA #2 denied placing the couch up against the left side of Resident #1's Broda chair, while it was also positioned up against the wall on the right side, (and Nurse #1 said she had not seen either of them actually put the couch there) they were the only other staff members working on the unit that night and Resident #1 was not physically capable of doing it him/herself. During an interview on 10/16/24 at 2:05 P.M., the Director of Nurses (DON) said that the Facility prides itself on being restraint-free, that the facility policy is designed to ensure the safety and well-being of their residents. The DON said placing the couch on the side of Resident #1's Broda chair (with the other side up against the wall) was inappropriate and considered a restraint. The DON said CNA #1 resigned and no longer works at the facility and CNA #2 was re-educated about restraints.

Based on record review and interview, the facility failed to assist a visually and hearing-impaired resident file a grievance for a lost hearing aid the staff were aware was missing for two months for one Resident (#52), out of a total sample of 19 residents. Findings include: Review of the facility's policy titled Grievances, dated 12/2018, indicated but was not limited to the following: Procedure: -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 Grievance/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. -Note: If a grievance is submitted orally, the facility employee taking the grievance must write it up on the grievance report form. The written grievance decisions will include: - The date the grievance was received - A summary statement of the resident's grievance - The steps taken to investigate the grievance - A summary of the pertinent findings or conclusions regarding the resident's concerns - A statement as to whether the grievance was confirmed or not confirmed - Any corrective action taken or to be taken by the facility as a result of the grievance - The date the written decision was issued -Upon receipt of a written grievance and/or complaint, the Administrator will refer it to the appropriate department head for investigation. The department head will submit a written report of such findings to the Administrator within 3 working days of receiving the grievance and/or complaint. The investigation and report should be completed using the Grievance/Complaint Report form. -The Administrator will review the findings with the person investigating the complaint to determine what corrective actions need to be taken. -The Administrator will document receipt of all grievances on the Grievance Log. Resident #52 was admitted to the facility in September 2023 with the following diagnoses: dementia without behavioral disturbances, mood disturbance, and anxiety. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/4/24, indicated that Resident #52 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Further review indicated Resident #52 had hearing aids and was able to hear (with hearing aid or hearing appliance if normally used) adequately, with no difficulty in normal conversation, social interaction, and listening to TV. During an interview on 3/07/24 at 5:05 P.M., Resident #52 said when he/she came to the nursing home he/she could hear using his/her left hearing aid. Resident #52 said since losing the left hearing aid, he/she has been living in a deaf world for months and it's awful. Resident #52 said he/she has asked the nurses to help get a hearing aid, but nobody helps. Resident #52 said he/she also keeps asking the nurses to have his/her ears cleaned out because of wax build-up, but they don't do that either. Resident #52 said he/she can't see anything out of the right eye, and the left eye, he/she can barely see anything, it makes him/her sad now that he/she can't hear. Review of Resident #52's care plan indicated the Resident is hard of hearing and has a left hearing aid. Review of the nursing notes from admission through 3/9/24 failed to indicate that there was documentation of Resident #52 having difficulties with hearing or a missing left hearing aid. Review of the facility's Grievance Log Binder from 9/1/23 through 3/8/24, indicated there was no grievance filed by Resident #52 or by staff assisting Resident #52 for the missing left hearing aid. Review of Resident #52's Recreation admission Assessment, dated 10/3/23, indicated Resident #52 has vision and hearing deficits. During a telephonic interview on 3/11/24 at 10:34 A.M., Family Member (FM)/Healthcare proxy (HCP) #1 said he/she does not know exactly when the left hearing aid went missing, but it has been a while and nobody ever called him/her about it, and it's frustrating. During an interview on 3/12/24 at 10:15 A.M., Nurse #3 said she was aware Resident #52's hearing aid was missing for about two months. She said it was discussed at a morning meeting on the unit with the previous Director of Nurses and previous Unit Manager. Nurse #3 said Resident #52 has expressed concerns about not being able to hear, but she thought it was taken care of by the Unit Manager. During an interview on 3/12/24 at 11:15 A.M., FM #3 said the left hearing aid has been missing for two months. FM #3 said when Resident #52 came to the facility, there was a working left hearing aid and Resident #52 could hear. FM #1, the HCP, said nobody ever told him/her about filing a grievance for the lost hearing aid. FM #1 said he/she can barely see and couldn't fill out a form. During an interview on 3/12/24 at 12:10 P.M., Social Worker (SW) #1 said, with Regional Nurse #1, the Administrator, and the Director of Nurses (DON) present, she was aware Resident #52's hearing aid was missing for a couple of months and the Resident was having difficulty hearing, but she thought it was resolved. SW #1 said there have been a few social workers in the building, and she was not sure if anyone was helping Resident #52 with the lost hearing aid. The Administrator said she was just made aware of Resident #52's difficulty hearing and the lost hearing aid on Friday (3/9/24). The surveyor informed the Administrator the grievance book was reviewed and no grievance had been filed for the missing hearing aid. During an interview on 3/13/24 at 1:45 P.M., Regional Nurse #1 said she was aware Resident #52's left hearing aid has been missing for a while. Refer to F685

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, policy review, and records reviewed, for two Residents (#15 and #60), out of 19 sampled residents, the facility failed to develop and implement comprehensive care plans to reflect the individual needs of the residents. Specifically, the facility failed: 1. For Resident #15, to develop and implement a care plan for the use of anticoagulant medication (used to prevent the blood from clotting, a blood thinner); and 2. For Resident #60, to develop and implement a care plan for care and monitoring of a peripheral inserted central catheter (PICC) line (A catheter that is inserted into the vein and goes up to your heart to deliver medication). Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, last revised January 2024, indicated but not limited to: - A comprehensive, person-centered care plan will be developed for each resident. The care plan will include objectives that meet the resident's physical, psychological and functional needs is developed for each resident. - The comprehensive care plan will identify problem areas and their causes as warranted and developing interventions that are targeted and meaningful to the resident. - Evaluation of residents is ongoing and care plans are revised as information about the resident and the resident conditions change. 1. Resident #15 was admitted to the facility in October 2022 with diagnoses which included cerebral infarction (stroke) due to embolism (blockage of an artery). Review of the most recent Minimum Data Set (MDS) assessment, dated 1/11/24, indicated that Resident #15 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 the Resident received anticoagulant medication. Review of Resident #4's Physician's Orders indicated but were not limited to: - Apixaban (anticoagulant) 5 milligrams (mg) by mouth two times daily, dated 5/16/23 Review of Resident #15's March 2024 Medication Administration Record (MAR) indicated he/she received Apixaban as ordered. Review of Resident #15's care plan failed to indicate that a care plan for the use of anticoagulant medication had been developed. During an interview on 3/13/24 at 2:24 P.M., Nurse #8 said that residents who were on an anticoagulant medication should have a care plan for it. During an interview on 3/13/24 at 3:02 P.M., Regional Nurse #1 said when a resident was on an anticoagulant medication, her expectation was that he/she should have a care plan developed for the medication. During an interview on 3/13/24 at 4:30 P.M, Regional Nurse #1 said Resident #15 did not have a care plan for his/her anticoagulant medication but should have had one. 2. Resident #60 was admitted to the facility in December 2023 with the following diagnoses: Abscess left hip bursa and methicillin resistant staphylococcus aureus infection (MRSA- type of staph bacteria that is resistant to certain antibiotics). Review of the most recent MDS assessment, dated 12/29/23, indicated that Resident #60 was cognitively intact as evidenced by a BIMS score of 15 out of 15. Review of the Hospital Discharge summary, dated [DATE], indicated but was not limited to the following: -Resident #60 was admitted to the hospital in February 2024 with left hip pain and was found to have an Abscess formation. -PICC line inserted at the hospital on 2/26/24, ultrasound guidance for venous cannulation. 4-French single lumen PICC placed in the right basilic vein. The catheter is 43 centimeters long. The tip of the catheter is at the cavoatrial junction, verified by fluoroscopy. -Resident #60 discharged back to the facility 2/26/24. Continue IV Vancomycin 1 gram (gm) every 12 hours for four weeks from 2/21/24. Review of Physician's Orders on 3/7/24 indicated but was not limited to the following: -Vancomycin intravenous solution, use 1 gm intravenously two times a day for infection, Initiated 2/27/24. There were no physician's orders in place to monitor for signs and symptoms of infection, external catheter length, dressing changes, arm circumference measurements or PICC flushes. On 3/07/24 at 11:30 A.M., the surveyor observed a PICC line in Resident #60's right arm and was marked BioFlo, Power Inject 3.5 Max. Review of Resident #60's care plan failed to indicate that a care plan was developed for the care and monitoring of the PICC line. During an interview on 3/07/24 at 2:25 P.M., Regional Nurse #2 said there should be a care plan for the PICC line.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, interviews, and record reviews for one Resident (#30) of 19 sampled residents, the facility failed to provide adequate supervision to prevent accidents. Specifically, the facility failed to ensure falls were thoroughly investigated and interventions were initiated/implemented to prevent further falls. Findings include: Review of the facility's policy titled Accidents and Incidents-Investigating and Reporting, revised 11/2017, indicated but was not limited to the following: -The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. -The following data, as applicable, shall be included on the Report of Incident/Accident form: -The date and time the accident or incident took place -The circumstances surrounding the accident or incident -Where the accident or incident took place -The name(s) of witnesses and their accounts of the accident or incident -The time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions -The time the injured person's family was notified and by whom -Any corrective action taken -The signature and title of the person completing the report Review of the facility's policy titled Assessing Falls and Their Causes, dated revised 1/2018, indicated but was not limited to the following: -Within 24 hours of a fall, the nursing staff will begin to try to identify possible or likely causes of the incident -Staff will evaluate chains of events or circumstances preceding a recent fall -When a resident falls, the following information should be recorded in the resident's medical record: -The condition in which the resident was found (e.g., resident found lying on the floor between bed and chair) -Assessment data, including vital signs and any obvious injuries -Notification of the physician and family as indicated -Completion of a falls risk assessment -Appropriate interventions taken to prevent future falls -The signature and title of the person recording the data -Notify the following individuals when a resident falls: -The resident's family -The Attending Physician -The Director of Nursing services -The Nursing Supervisor on duty Resident #30 was admitted to the facility in October 2021 with diagnoses that included dementia, anxiety, chronic atrial fibrillation, history of falling, difficulty in walking, and impulsiveness. Review of the Minimum Data Set (MDS) assessment, dated 1/24/24, indicated Resident #30 had a Brief Interview for Mental Status score of 6 out of 15 which indicated severe cognitive impairment. Further review of the MDS indicated Resident #30's transfer status was coded as substantial/maximal assistance. Review of the Physician's Progress Note, dated 10/2/23, indicated Resident #30 had been evaluated after he/she sustained a mechanical fall (an external force or object led to the fall). The diagnosis, assessment and plan indicated Resident #30 had frequent falls. Resident #30 had sustained a mechanical fall 10/2/23. The facility should continue to monitor the patient, monitor neuro checks, and update the clinical team if the patient has any change in condition. Further review of Resident #30's medical record indicated the facility failed to: - initiate and document investigation of the fall -investigate the cause of the fall -implement interventions to prevent future falls -complete a falls risk assessment During an interview on 3/8/24 at 8:08 A.M., Certified Nursing Assistant (CNA) #3 said Resident #30 has had a few falls. CNA #3 said she was unaware of any interventions to prevent Resident #30 from falling. During an interview on 3/12/24 at 8:14 A. M., the surveyor and Nurse #9 viewed the physician's assessment dated [DATE]. Nurse #3 said she was unaware that Resident #30 was assessed as he/she had sustained a fall. Nurse #9 said there are no nursing progress notes indicating Resident #30 had fallen. Nurse #9 said after a fall the nurse completes an incident report, gathers witness statements regardless of whether the fall was witnessed or unwitnessed, writes a nurse's note the day of the fall, and updates the resident's care plan. During an interview on 3/13/24 at 11:04 A.M., with the Administrator and Regional Nurse #1, the Administrator said falls are reviewed in the morning meeting. The Administrator said the Director of Nurses (DON) holds a weekly RISK meeting following residents who have fallen. The surveyor and Regional Nurse #1 reviewed Resident #30's physician's assessment dated [DATE]. Regional Nurse #1 said there were no nursing progress notes indicating Resident #30 had sustained a fall. Regional Nurse #1 said an incident report was not generated investigating Resident #30's fall on 10/2/23 to determine if new interventions needed to be implemented to prevent future falls.

Based on record review, employee education file review, and interviews, the facility failed to ensure four of five nurses reviewed completed their competencies for intravenous (IV) skills training. Specifically, the facility failed to: 1. Ensure three of three graduate nurses (practicing nursing as graduates and students in their last semester of nursing education programs in accordance with the guidance from the Massachusetts Board of Registration and Nursing (BORN)) completed their training and passed the competencies to provide direct care for IV care to residents residing in the facility; and 2. Ensure one nurse completed her competencies for intravenous treatment while overseeing one of the new graduate nurses providing care to a patient with a PICC line. Findings include: Review of the Massachusetts Department of Public Health notice titled Guidance for Nursing Practice by Graduates and Students in Their Last Semester of Nursing Education Programs Authorization Extended, dated 5/11/23, indicated but was not limited to the following: -pursuant to the legislation nursing practice by nursing students and supervision of nursing students must adhere to the following parameters issued by the board: -Nursing students in their last semester and graduate nursing students must practice under the direction and supervision of a licensed nurse, performing tasks within the scope of practice of the supervising nurse of equal or higher educational preparation. -The employing licensed healthcare facility or licensed healthcare provider provides nursing students with an orientation to the patient care environment that aligns with the individual student academic preparation and competencies. During a telephonic interview on 3/07/24 at 3:46 P.M., Corporate Nurse #3 said the nurses do competencies as needed. She said when the nurse must provide care for the first time, that is when the competency should be completed. She said a competency should be completed before the nurse is allowed to provide care to a patient. 1A. During an interview on 3/12/24 at 5:50 P.M., Nurse #10 said she was a graduate nurse who started in the facility in September 2023. She said her training was a lot of videos, and then she did observation with a nurse for a few weeks. Nurse #10 said she did not have any IV or PICC line training when she did her initial training on the 300 unit. She said after her training was completed, she worked on the 200 unit and did have some IV and PICC lines. Nurse #10 said she would just ask a nurse to help her out with the IV or PICC lines. Nurse #10 said she scheduled tonight to do her competencies for IV lines. Review of Nurse #10's educational file indicated there were no competencies for central venous catheter dressing change, central venous and midline catheter flushing, administration of IV fluids via peripheral venous access, or initiating a peripheral venous access. There were video modules completed electronically for IV care. B. During an interview on 3/07/24 at 2:18 P.M., Nurse #1, with Regional Nurse #2 present, said she was a graduate nurse, and she administered IV Vancomycin to Resident #60 today, and said there was no cap or needleless connector on the PICC hub. Nurse #1 said she was not aware it was supposed to have a cap on the end. Nurse #1 said she really hasn't had any training on PICC lines at this facility. Nurse #1 said she follows the orders for the medication administration and looks for signs of redness or swelling. Nurse #1 said she did not have any PICC lines when she was in training, but after she completed training, she had a couple PICC lines, and she just asked a licensed nurse in the building for help because she was not trained. During an interview on 3/07/24 at 2:40 P.M., Nurse #1 said she knows LPNs can't change a PICC line, but she thinks they can change the Tegaderm (clear) dressing. Nurse #1 said during her training she watched a lot of videos, observed a nurse on a cart for a few weeks, and when she passed the med pass, she was cleared to work on the cart alone. If she has questions, she can ask another nurse, but generally she just follows the physician's orders. Review of Nurse #1's education file indicated there were competencies electronically signed by Corporate Nurse #4 with a handwritten note indicating observed by previous Assistant Director of Nurses, dated 9/29/23, for the following competencies: Central venous catheter dressing change, central venous and midline catheter flushing, administration of IV fluids via peripheral venous access, initiating a peripheral venous access. C. During an interview with Nurse #2 and Nurse #1 on 3/07/24 at 3:15 P.M., Nurse #2 said he was a graduate nurse and started in September 2023. Nurse #2 said his training consisted of watching videos in which some of the videos were relative to nursing techniques. Nurse #10 said he was on the floor observing a nurse for a couple of weeks, during this time he was not performing nursing procedures it was only observation. Nurse #2 said Resident #60 is one of the residents he regularly takes care of and has administered Vancomycin through the PICC line. Nurse #2 said he knows how to clean the hub and do flushes. Nurse #2 said he did not have any specific training regarding the monitoring or care of a PICC line and said he is not aware of anything that should be measured on the PICC line. Nurse #2 said when he does a resident admission, he copies the orders from the hospital paperwork, he was not aware of any set facility orders for PICC line care. Nurse #1 said there is a drop-down menu which has a list of orders that should be put in place for something like a PICC line. Nurse #1 said she knew about them before today, but Regional Nurse #2 had her watch when she updated Resident #60's PICC line orders. Nurse #1 and Nurse #2 both said they did not receive any specific training for IV and PICC lines, they just ask other nurses working if they have questions. Review of Nurse #2's education file indicated there were competencies electronically signed by Corporate Nurse #4 with a handwritten note indicating observed by previous Assistant Director of Nurses, dated 10/16/23, for the following competencies: Central venous catheter dressing change, central venous and midline catheter flushing, administration of IV fluids via peripheral venous access, initiating a peripheral venous access. On 3/08/24 at 12:20 P.M., Corporate Nurse #1 provided the surveyor with Nurse #1 and Nurse #2's competencies, electronically signed by Corporate Nurse #4 (Who was off site) and handwritten on the paper that the competency was observed by the former Assistant Director of Nursing. The surveyor informed Corporate Nurse #1 that both Nurse #1 and Nurse #2 said they never did IV or PICC line training at this facility. During an interview on 3/11/24 at 3:45 P.M., Corporate Nurse #4 (present in building) said it is her expectation for the nurses to complete their education and competencies before treating patients. The surveyor informed Corporate Nurse #4 that both Nurses #1 and #2 said they received no IV and PICC line formal training or completed their competencies at this facility. Corporate Nurse #4 said she normally is offsite and can only go by what the nurse tells her. She said maybe the nurses forgot they did the training because it was done on a mannequin. During an interview on 3/11/24 at 4:05 P.M., Nurse #2 said, with Corporate Nurse #4 present, he did not receive training in this facility on PICC lines. Corporate #4 asked Nurse #2 if he had completed any PICC line training using the mannequin arm. Nurse #2 said no, he does not recall ever doing PICC line training on mannequins, or receiving any other PICC line training since he has started in this facility. Review of Nurse #10's educational file included the competencies that were signed by Nurse #10, but not signed by a nurse observer. The following competencies were completed: Blood glucose monitoring, administering medication via enteral tube, Foley catheter insertion female, Foley catheter insertion male, wound documentation, clean wound and apply a dry non-sterile dressing, care of a nephrostomy tube, administering intranasal Narcan, foreign body airway obstruction (Heimlich maneuver), medication administration, Binax now COVID-19 testing, subcutaneous injection skills. Additionally, there were no competencies for central venous catheter dressing change, central venous and midline catheter flushing, administration of IV fluids via peripheral venous access, initiating A peripheral venous access. 2. During an interview on 3/12/24 at 10:40 A.M., Nurse #3 said she was a new nurse and started in August 2023. Nurse #3 said she did not have IV or PICC line training during her orientation. Nurse #3 said when she did get assigned a Resident with an IV for the first time, the unit manager was very good at giving her instructions. Nurse #3 said when she is working with the graduate nurses, she does help them out with questions regarding the IV administration of medications. Nurse #3 said she did help Nurse #1 reprogram the IV machine because she was having difficulty. Nurse #3 said she is scheduled today to do her IV competency training. Review of Nurse #3 education file and competencies indicated the following: -Central Venous Catheter dressing change skills checklist, Central Venous and Midland Catheter Flushing Skills checklist. Signed as completed by Corporate Nurse #3 on 8/15/23. During an interview on 3/13/24 at 1:05 P.M., Nurse #3 said she completed her IV competencies yesterday shortly after she talked to the surveyor. Nurse #3 said she did not do IV competencies with Corporate Nurse #4 in August of 2023, only yesterday.

Based on record review, interviews, and policy review, the facility failed to ensure targeted behaviors and signs and symptoms of adverse reaction/side effects were adequately monitored to evaluate the effectiveness of psychotropic medication to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for one Resident (#52), out of a total sample of 19 residents. Findings include: Review of the facility's policy titled Psychotropic Medication, dated 7/20/23, indicated but was not limited to the following: -To administer and monitor the effects of psychotropic medications when prescribed. Psychoactive medications will be prescribed at the lowest possible dosage and are subject to gradual dose reduction and review as needed. -Criteria for psychotropic medication use: -Preventable causes of behavior have been ruled out. -The behavior presents a danger to resident or others, or it is a source of distress or dysfunction for the resident. -The drug use maintains or improves the resident's functional capacity. -The interdisciplinary team assesses and monitors the appropriateness, effectiveness and side effects associated with the psychotropic medications for each resident via resident care plan review. The resident, and when indicated, the family and responsible person will be included in this process prior to the administration of dose. -Nursing staff shall monitor for side effects and adverse consequences of the use of psychotropic medications and update provider as warranted. Resident #52 was admitted to the facility in September 2023 with the following diagnoses: anxiety, depression, suicidal ideation, cognitive communitive disorder, and altered mental status. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/4/24, indicated that Resident #52 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Review of the current Physician's Orders indicated the following: -Olanzapine (antipsychotic) 2.5 milligrams (mg) give one tablet by mouth at bedtime for suicidal ideation/anxiety/depression, and delusions, initiated 10/24/23. -Fluoxetine (antidepressant) 40 mg, give one tablet a day for depression, initiated 9/29/23. -Trazodone (antidepressant) 37.5 mg by mouth at bedtime for mood and behavior, initiated 9/28/23. Further review of the Physician's Orders failed to indicate an order to monitor for resident specific behaviors related to psychotropic medications including but not limited to suicidal ideation, delusions, grief, or depression. Review of the Medication Administration Record (MAR) for March 2024 indicated Resident #52 was administered psychotropic medications daily as ordered by the physician. Review of a facility consultant's Behavioral Health Group note, dated 2/9/2024, indicated but was not limited to the following clinical assessment: On assessment patient is alert, calm, in no apparent distress and in good behavioral control. Pleasant, makes good eye contact and engages easily. Patient is processing feelings about his/her child's death. No overt psychosis noted. Patient does not express thoughts of harm to self or others. Continue to monitor patient for changes in mood and behavior and notify consultant of changes. During an interview on 3/13/24 at 1:45 P.M., Regional Nurse #1 said they should be monitoring Resident #52 for behaviors related to antipsychotic medications.

Based on observation and interview, the facility failed to maintain a clean and sanitary environment for one Resident (#23), out of a total sample of 19 residents. Specifically, the facility failed to maintain the cleanliness of the Resident's room to avoid a strong smell of urine for four days of survey. Findings include: Resident #23 was admitted to the facility in September 2023 with diagnoses including emphysema, anxiety disorder, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment, dated 12/26/23, indicated Resident #23 had a moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11 out of 15. Further, review of the MDS indicated Resident #23 required substantial/maximum assistance with toileting and was frequently incontinent of urine. Review of Resident #23's Activities of Daily Living (ADL) care plan indicated but was not limited to: -Focus: ACTIVITIES OF DAILY LIVING: Resident has ADL Self-Care Deficit as evidenced by SOB (shortness of breath), Fatigues Easily. Needs assistance with BATHING, GROOMING, DRESSING, MOBILITY, TOILETING (Revision Date 10/20/23) -Goal: [Resident] will receive assistance needed in ADL Activities (Revision Date 1/6/24) -Interventions: Additional Approaches: -Toilet Use: Assist On 3/7/24 at 9:10 A.M., the surveyor smelled a urine odor in Resident #23's room. On 3/11/24 at 7:05 A.M., the surveyor smelled a strong pungent odor of urine when entering the building that grew stronger as entering the foyer. On 3/11/24 at 7:20 A.M., the pungent urine odor was still present; it continued to still smell pungent when the surveyor entered the 300 unit. During an interview on 3/11/24 at 7:34 A.M., Receptionist #1 said there is a pretty strong odor in the front foyer area. On 3/11/24 at 7:41 A.M., the surveyor smelled a pungent urine odor on unit 300 coming from Resident #23's room. During an interview on 3/11/24 at 7:50 A.M., Resident #23 said that he/she had bladder issues and cannot hold his/her urine and wears a pull-up. During an interview on 3/11/24 at 10:01 A.M., Nurse #6 said there was a urine odor coming out of Resident #23's room. Nurse #6 you could taste the urine smell. On 3/11/24 at 11:52 A.M., the surveyor smelled a strong urine odor outside of Resident #23's room and a strong urine odor entering the room. On 3/11/24 at 3:55 P.M., the surveyor smelled a strong urine odor outside of Resident #23's room and a strong urine odor when in the room. During an interview on 3/11/24 at 3:56 P.M., Certified Nursing Assistant (CNA) #1 said Resident #23's room smells like urine. CNA #1 said that Resident #23 is incontinent of urine. During an interview on 3/11/24 at 5:25 P.M., Family Member #4 said Resident #23's room usually had a urine smell but today it was stronger than normal. On 3/12/24 at 8:23 A.M., the surveyor smelled a urine odor coming onto the 300 unit and a stronger urine odor when entering Resident #23's room. On 3/13/24 at 7:11 A.M., the surveyor smelled a strong urine odor outside of Resident #23's room and a stronger urine smell when in the room. During an interview on 3/13/24 at 7:13 A.M., the Director of Housekeeping said Resident #23's room had a urine smell coming from it. She said Resident #23's room was cleaned daily by housekeeping and had been terminally cleaned (deep-cleaning method goes beyond the surface to tackle high-touch areas and hard-to-reach corners) in February. During an interview on 3/13/24 at 10:32 A.M., the Administrator said Resident #23's room had a smell to it coming from the mattress, but she is unable to describe it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #11 was admitted to the facility in February 2022 with diagnoses including: cerebral infarct, hemiplegia and hemiparesis, muscle wasting, and gastrostomy. Review of the MDS assessment, dated 2/8/24, indicated Resident #11 was rarely/never understood and a BIMS should not be conducted. Furter review of the MDS indicated the Resident had current, unhealed pressure ulcers/deep tissue injuries that were acquired at the facility as follows: -one stage 3 pressure ulcer -three stage four pressure ulcers -two unstageable, deep tissue injuries The MDS assessment also indicated there were five venous and arterial ulcers present. Review of Resident #11's active care plan indicated, but was not limited to: -potential alteration in skin integrity; follow physician's orders for skin care and treatments (utilize Best Practice Guidelines). Review of Resident #11's active Physician's Orders indicated but were not limited to: -Weekly Skin Check one time a day every Wednesday for skin integrity, revised 2/2/22. Review of the Physician's Note, dated 1/23/24, indicated Resident #11 was seen by the wound specialist and the Resident's wounds continue to worsen and may require amputation. Review of Resident #11's records indicated the most recent Weekly Skin Check evaluation was signed on 2/16/24, and included the following skin alteration description: -Sacral, left and right foot, and left and right buttock wound. Left first toe, left fifth toe, right and left ischium, right heel. Treatment in progress. During an interview on 3/13/24 at 8:32 A.M., Nurse #3 said nursing performs skin checks once per week for Resident #11. Nurse #3 said Resident #11's Weekly Skin Check was to be performed every Wednesday. Nurse #3 said the most recent Weekly Skin Evaluation documented by nursing was dated 2/15/24. During an interview on 3/13/24 at 4:43 P.M., the Regional Director of Nursing (RDON) said the last documented Weekly Skin Check was dated 2/15/24, and her expectation would be for Resident #11 to receive Weekly Skin Check evaluations based on the active order. The RDON said a skin check should have been performed by nursing on 2/22/24 and every subsequent week to help identify any potential new skin issues. 4. Resident #46 was admitted to the facility in October 2022 with diagnoses including: dementia, cataract, hypertension, acquired absence of left great toe and other toes, and type two diabetes. Review of the MDS assessment, dated 2/1/24, indicated Resident #46 had a BIMS of 2 out of 15, indicating severe cognitive impairment. Further review of the MDS indicated Resident #46 was dependent for all mobility, and indicated the Resident had one fall with no injury since admission. Review of Resident #46's active Care Plan indicated, but was not limited to, the Resident was high, moderate risk for falls related to impaired mobility and poor safety awareness; follow facility fall protocol; Physical Therapy (PT) evaluate and treat as ordered or PRN; safety. Review of Resident #46's Physician's Orders included but were not limited to: -Floor mat to be placed on side of bed while in bed for fall precaution, dated 8/11/23. Review of Resident #46's medical record included but was not limited to: -Nursing Note, dated 10/2/23, indicated Resident #46 fell while trying to get out of their wheelchair. -Incident Report, dated 10/2/24, indicated Resident #46 was found on the floor, lying on their side with the wheelchair. On 3/12/24 at 9:47 A.M., the surveyor observed Resident #46 in bed with their feet hanging off the bed. No mat was observed on the floor bedside or in the Resident's room. On 3/12/24 at 3:48 P.M., the surveyor observed Resident #46 in bed with two nursing aides providing patient care. The Resident remained in bed once the aides were finished with care. No floor mat was observed, as ordered, during or after the aides left the Resident's room. On 3/13/24 at 7:23 A.M., the surveyor observed Resident #46 asleep in bed. No floor mat was observed on the floor as ordered. During an interview on 3/13/24 at 7:37 A.M., Nurse #11, said she typically worked the 11:00 P.M. to 7:00 A.M. shift, and could not remember if a floor mat was placed bedside during the shift for Resident #46. Nurse #11 said Resident #46 had an order for a floor mat to be placed on the side of bed while in bed for fall precaution. Nurse #11 then walked to the Resident's room and said she observed no floor mat as ordered in Resident #46's room. Nurse #11's expectation is for a floor mat to be implemented as ordered for Resident #46. During an interview on 3/13/24 at 4:34 P.M., the RDON said Resident #46 had an order for a floor mat to be placed bedside while the Resident was in bed. The RDON said she did not see documentation in Resident #46's records that the floor mat was implemented as ordered. The RDON said the floor mat was not noted in Resident #46's care plan. During an interview on 3/13/24 at 4:34 P.M., the RDON said she expected: -the floor mat to be placed on the side of Resident #46's bed while the Resident is in bed for fall precaution; -staff to record in the medical record whether the floor mat was utilized as ordered; and -Resident #46's fall care plan to include the floor mat. Based on observation, interview, records reviewed, and policy review, the facility failed to provide care, consistent with professional standards of practice for four Residents (#60, #12, #11, and #46), out of a sample of 19 residents. Specifically, the facility failed to: 1. Monitor and care for peripherally inserted central catheter lines (PICC- a catheter that is inserted into the vein and goes up to your heart to deliver medication) for two Residents (#60 and #12), out of two of two PICC lines reviewed. Specifically, the facility failed to: A. For Resident #60, to obtain orders for care of a PICC line, including dressing change, external length measurements, arm circumferential measurements, and ensure the lumen was capped; and B. For Resident #12, to follow physician's orders for PICC line dressing change, measurement of external catheter length, and arm circumferential measurements, and ensure removal of PICC line followed the facility policy to ensure the measurement of the catheter length was obtained and confirmed the catheter tip was intact upon removal; 2. For Resident #11, to perform Weekly Skin Checks as ordered; and 3. For Resident #46, to implement a floor mat as ordered. Findings include: 1. Review of the facility's policy titled Venous Catheter Dressing Changes, last dated 12/2020, indicated but was not limited to the following: -The purpose of this procedure is to prevent catheter related infections that are associated with contaminated, lucid, soiled, or wet dressings: -Change transparent semi-permeable membrane (TSM) dressing every five to seven days and as needed (PRN) (when wet, soiled, or not intact). -While removing the paper around the edges of the dressing press down on the edges of the dressing. Place label with initials, date, and time. Review of the facility's policy titled Pharmscript: Central Venous Catheter, dated 2/2009, indicated but was not limited to the following: -Obtain physician order for dressing change. -Label dressing with nurse, date, and your initials. Review of Nursing Procedures, Lippincott's - 9th Ed (2023), Peripherally Inserted Central Catheter Use indicated but was not limited to: Performing a PICC dressing change: - Use a sterile measuring tape or the incremental markings on the catheter to measure the external length of the catheter from hub to skin entry to make sure that the catheter hasn't migrated. -Apply a transparent semipermeable (or gauze and tape) dressing to the insertion site. -Measure upper arm circumference when clinically indicated to assess for the presence of edema and deep vein thrombosis; take the measurement 4 (10 cm) above the antecubital fossa and compare this measurement to the baseline. -Label the dressing with the date of the dressing change or the date it's next due to be changed, as directed by your facility. Don't place the label over the insertion site. -Document the procedure. For dressing change, document the condition and length of the external catheter, the appearance of the site, and any reports of pain or tenderness. Record the date and the time of the dressing change, site care, dressing type, securement device type, any unexpected outcomes, and your interventions. A. Review of the BioFlo PICC with ENDEXO (Trademark) and PASV (Trademark) Valve Technology Navilyst Medical Directions on the manufacturer's website, Navilyst, included but was not limited to the following: -Intended use/Indications for use The BioFlo PICC with ENDEXO and PASV Valve Technology is indicated for short or long-term peripheral access to the central venous system for intravenous therapy, including but not limited to, the administration of fluids, medications, and nutrients; the sampling of blood; and for power injection of contrast media. -Apply a sterile end cap on the catheter hub to prevent contamination when not in use. -Catheter Maintenance: It is recommended that institutional protocols be followed for all aspects of catheter care, use and maintenance. The following care, use and maintenance information is not intended as a substitute for institutional protocol, but rather, to describe guidelines and recommendations that can be used successfully with the BioFlo PICC with ENDEXO and PASV Valve Technology. General Catheter Care and Use: -Use aseptic technique during catheter care and use. -Use Standard and Universal Precautions during catheter care procedures. -Never leave catheter uncapped. Care of Insertion Site and Dressing -Follow institutional protocol for dressing change. It is recommended that dressings be changed weekly and as necessary. Resident #60 was admitted to the facility in December 2023 with the following diagnoses: abscess left hip bursa and methicillin resistant staphylococcus aureus infection (MRSA- type of staph bacteria that is resistant to certain antibiotics). Review of the most recent Minimum Data Set (MDS) assessment, dated 12/29/23, indicated that Resident #60 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of the Hospital Discharge summary, dated [DATE], indicated but was not limited to the following: -Resident #60 was admitted to the hospital February 2024 with left hip pain and was found to have an Abscess formation. -PICC line inserted at the hospital on 2/26/24, ultrasound guidance for venous cannulation. 4-French single lumen PICC placed in the right basilic vein. The catheter is 43 centimeters long. The tip of the catheter is at the cavoatrial junction, verified by fluoroscopy. -Resident #60 discharged back to the facility 2/26/24. Continue intravenous (IV) Vancomycin 1 gram (gm) every 12 hours for four weeks from 2/21/24. Review of March 2024 Physician's Orders indicated but was not limited to the following: -Vancomycin intravenous solution, use 1 gm intravenously two times a day for infection, Initiated 2/27/24. There were no physician orders in place to monitor for signs and symptoms of infection, external catheter length, dressing changes, arm circumference measurements or PICC flushes. Review of February and March 2024 Medication Administration Records (MAR) indicated Resident #60 received Vancomycin intravenous solution 1 gm intravenously every 12 hours per physician's order. Further review of the February 2024 MAR and Treatment Administration Record (TAR) indicated there was no documentation for monitoring the PICC line site, dressing changes, measuring the external catheter length, arm circumference measurements, or PICC flushes. Review of Weekly Skin Check, dated 3/2/24, indicated there was no documentation of the PICC line. Review of Weekly Skin Check, dated 3/8/24, indicated there was no documentation of the PICC line. Review of Weekly Skin Check, dated 3/10/24, indicated there was no documentation of the PICC line. Review of Skilled Charting-V2, dated 3/2/24, indicated but was not limited to: -Direct skilled nursing included IV medication and wound care, monitor right arm PICC line insertion site for signs and symptoms of infiltration/infection. Continue IV Vancomycin for left hip abscess/infection. Insertion site no signs and symptoms of infection. -No measurements of catheter external length, arm circumference or the PICC line dressing was changed. During an interview on 3/07/24 at 11:30 A.M., Resident #60 said he/she had an abscess in the left hip and was on IV antibiotics. The surveyor observed the PICC line with the Resident's permission and observed the clear dressing over the PICC line to be soiled with dried blood and undated. The hub (tip) of the PICC line was observed not to have a cap. The external PICC line was marked BioFlo, Power Inject 3.5 Max. Resident #60 said the nurse changed the PICC dressing just once since returning from the hospital. During an interview on 3/07/24 at 2:15 P.M., the Director of Nursing (DON) and Regional Nurse #2 were informed that Resident #60's PICC line hub (tip) did not have a cap, and the PICC line dressing was not dated. The DON said the PICC line should be capped, and the dressing should be dated. The DON said it is her expectation that the nurses follow the physician's orders for the PICC line. During an interview on 3/07/24 at 2:25 P.M., Regional Nurse #2 said there should be physician's orders to monitor the PICC line site for signs and symptoms of infection, flushes, dressing changes, and for measuring the external PICC line catheter length and the arm circumference. The surveyor informed Regional Nurse #2 there were no physician's orders for the care and monitoring of the PICC line or care plan for the PICC line. Regional Nurse #2 said she has not gotten that far to look at the orders or the care plan. Regional Nurse #2 said the PICC dressing should have been changed on admission and then weekly and the nurses should have been measuring the external length of the PICC line. During an interview on 3/07/24 at 3:01 P.M., Regional Nurse #2, Nurse #1 and the surveyor observed Resident #60's PICC line and dressing. The surveyor observed the PICC line to have a large amount of bloody drainage at the point of entry into the skin. Regional Nurse #2 said the dressing needs to be changed, and we need to get an arm circumference, measure the external length of the catheter, clean the end of the catheter, and put a cap on it. Regional Nurse #2 said there are no orders for any PICC care or monitoring of the PICC site. B. Resident #12 was admitted to the facility in December 2023 with the following diagnoses: Right hip arthroplasty (joint replacement) infection and inflammatory reaction right hip prosthesis (hip hardware). Additionally, Resident recently underwent removal of right hip prosthesis hardware and was replaced with a joint spacer due to the infection and was started on IV antibiotics through PICC line. Review of the most recent MDS assessment, dated 12/18/23, indicated that Resident #12 was cognitively intact as evidenced by a BIMS score of 15 out of 15. Review of hospital documentation, dated 1/19/24, indicated Resident #12 had a Single power PICC placed in the right arm with exit site markings of 10 centimeters (cm) in length, and total length of the Power PICC was 50 cm. Review of Resident #12's Physician's Orders indicated but was not limited to the following: -Cefazolin (antibiotic) sodium injection solution 2 gm, use 2 gm intravenously three times a day for infection until 2/29/24, date initiated 1/30/24. -IV-PICC- change transparent dressing on admission, then weekly and as needed (PRN) thereafter, initiated 1/30/24. -IV-PICC- change needleless connector on admission, weekly and PRN thereafter, and change after every blood draw, date initiated 1/30/24. -IV-PICC- monitor site every shift for signs and symptoms of infection and/or infiltration, date initiated 1/30/24. -IV-PICC- measure catheter length on admission and with each dressing change thereafter, 10 cm, date initiated 1/30/24. -PICC catheter brand: Bard Lot #REHS2848, total length 50 centimeters, valid single lumen. Measure the arm circumference 3 inches above the insertion site, 10 inches, date initiated 1/30/24. Review of the February 2024 MAR indicated Resident #12 received Cefazolin Sodium 2 grams intravenously three times a day and the IV-PICC site was monitored every shift for signs/symptoms of infection and /or infiltration per physician's orders. Further review of the February 2024 MAR and TAR indicated the orders for the PICC-change needleless connector on admission, weekly and PRN thereafter, and the PICC-measure catheter length on admission and with each dressing change thereafter were not present on the MAR or TAR. Further review of nursing notes, dated 1/31/24 through 3/7/24, did not indicate the PICC line dressing was changed or the external length of the catheter was measured as per physician's orders. Review of the facility's policy titled Pharmscript: Removal of Central Venous Catheter, 2/2009, provided to the surveyor as the facility policy, indicated but was not limited to the following: -nurse must be aware of the catheter length prior to removal. Every effort must be made to obtain length of catheter prior to removal. If unable to obtain length of catheter, specific orders must be obtained to remove the catheter in facility without knowledge of catheter length. Procedure: -Apply antimicrobial ointment to sterile gauze. -After catheter is removed, immediately place dressing with antimicrobial ointment centered over insertion site. -Measure catheter length and assess catheter tip to ensure that the entire catheter was removed. Review of Nursing Procedures, Lippincott's - 9th Ed (2023), Peripherally inserted central catheter use indicated but was not limited to: Removing a PICC line: - Assess the site for signs of infection, including swelling, drainage, redness, and inflammation. -Cover the site with a petroleum-based ointment and a sterile dressing for at least 24 hours to seal the skin-vein tract and reduce the risk of air embolus. -Assess the integrity of the removed catheter. Compare the length of the catheter with the original insertion length to ensure that the entire catheter has been removed. -Document the procedure. For PICC removal, document the date and time of removal, the condition of the insertion site, the condition and length of the catheter, the reason you removed the device, and the patient's tolerance of the procedure. Record any nursing interventions that were necessary during removal, the patient's response to those interventions, and the type of petroleum-based ointment and dressing you applied to the site. Review of Resident #12's Physician's Orders indicated but was not limited to the following: -Remove PICC line 3/1, date initiated 2/28/24. Review of hospital documentation, dated 1/19/24, indicated Resident #12 had a Single power PICC placed in the right arm with exit site markings of 10 centimeters (cm) in length, and total length of the Power PICC was 50 cm. Review of the Nursing Note, dated 3/1/24, indicated Resident #12 had the right PICC line taken out this morning. Dressing applied with no bleeding at sight of removal. No complaints of pain at site. No redness or signs and symptoms of infection. The nursing note did not document the total length of the PICC line when removed or if the tip was still intact. There was no documentation that an antimicrobial ointment was placed at the site of the PICC removal per policy and professional standards. Review of skilled charting-V2, dated 3/1/24, Indicated but was not limited to: -Patient completed IV course (Cefazolin 2 gm IV every 8 hours) well tolerated, no adverse reaction noted. No complaints of pain/discomfort, IV insertion site no signs of symptoms of infiltration. PICC removal on 3/1. There was no documentation that the catheter length was measured with the removal of the PICC line, or the tip was intact. During an interview on 3/13/24 at 1:45 P.M., Regional Nurse #1 said if a nurse was going to remove a PICC in the facility, she would refer the nurse to the infusion manual on the unit. The surveyor and Regional Nurse #1 viewed the Pharmscript: Removal of Central Venous Catheter above. Regional Nurse #1 said the nurse should have followed the policy and documented the removal of the PICC line documenting the length of the catheter and the tip was intact. The surveyor reviewed Resident #12's nursing notes, MAR and TAR with Regional Nurse #1 and she said the nurses did not document the dressing changes or measurements of the external catheter of the PICC line to confirm it was completed. No further documentation was provided to the surveyor prior to exiting the facility. Refer to F726

Based on interview, record review, and observations, the facility failed to maintain hearing at an optimal level to maintain the highest practical emotional level for one Resident (#52), out of 19 sampled residents. Specifically, the facility failed to continue to assess the Resident for wax build up in the right ear and assist Resident #52 in obtaining audiology (hearing) services for a hearing evaluation to replace a lost hearing aid for two months, resulting in Resident #52 being isolated in his/her room due to hearing deficits. Findings include: Review of the facility's policy titled Ancillary Physician Services, dated 4/2018, indicated but was not limited to the following: -Routine and emergency Podiatry (foot care), Optometry (eye care), and Audiology (hearing care) services are available to meet the resident's health services by the resident's assessment and plan of care. -Social services or nursing representatives will assist residents with appointments, transportation arrangements, and for reimbursement of Podiatrist, Optometrist, and Audiologist services under the state plan, if eligible. -Direct care staff will assist residents with eyewear and hearing aid care, including removing, cleaning, and storage. -Lost or damaged assistive device will be replaced at the resident's expense unless an employee or contractor of the facility is responsible for accidentally or intentionally damaging the device. Resident #52 was admitted to the facility September 2023 with the following diagnoses: dementia without behavioral disturbances, psychotic disturbance, mood disturbance, anxiety, and suicidal ideology. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/4/24, indicated that Resident #52 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Further review indicated Resident #52 had hearing aids and was able to hear (with hearing aid or hearing appliance if normally used) adequately, with no difficulty in normal conversation, social interaction, listening to TV. It also indicated, Resident #52 had corrective lenses and in adequate light, could see fine detail including regular print and newspaper/books. On 3/07/24 from 8:45 A.M. through 5:05 P.M., the surveyor observed Resident in bed sleeping throughout the day. During an interview on 3/07/24 at 5:05 P.M., Resident #52 said when he/she came to the nursing home he/she could hear. Resident #52 said since losing the left hearing aid, he/she has been living in a deaf world for months and it's awful. Resident #52 said he/she has asked the nurses to help get hearing aids, but nobody helps. Resident #52 said he/she also keeps asking the nurses to have his/her ears cleaned out because of wax build-up, but they don't do that either. Resident #52 said he/she does not go out to activities anymore because he/she can't hear anything, and everyone must yell to talk to him/her. Resident #52 said she can't see anything out of the right eye and the left eye she can barely see anything, it makes him/her sad now that he/she can't hear. Resident #52 said it has been difficult to do anything since he/she lost the ability to hear, I just stay in bed all day. Review of Resident #52's care plan indicated Resident is hard of hearing and has a left hearing aid. Review of Physician's Orders indicated but was not limited to the following: -Activate health care proxy (HCP), initiated 10/11/2023. -Consults: Audiology (hearing), initiated 9/28/2023. -Debrox solution 6.5% (softens ear wax), instill 5 drops in both ears two times a day for cerumen (ear wax) for five days, initiated 10/16/23. -Debrox solution 6.5%, instill 5 drops in both ears two times a day for cerumen for five days, initiated 11/9/23. Review of a Physician's Note, dated 10/16/23, indicated but was not limited to: -The patient reports the right ear is still full and feels he/she has cerumen impaction. -I have conducted an otoscopic examination (inspects the ear canal) on the patient and the right external ear canal and he/she has a significant amount of hardened Cerumen. I will apply Debrox 5 drops twice a day times 5 days and will reevaluate. If the ear does not clean itself, the patient may need an ENT referral for removal of the cerumen via aspiration. The patient was made aware that I do not recommend flushing the external ear canal with water secondary to risk of complications of infection and eardrum perforation. Review of a Physician's Note, dated 10/19/23, indicated patient continues with right external ear canal sediment; currently the patient is on Debrox. Review of a Physician's Note, dated 11/9/23, indicated Resident #53 was evaluated for right ear fullness and cerumen. Right external canal evaluation with an otoscope, there is a moderate amount of hard cerumen. Resident #52 restarted on Debrox for five days. Hopefully that will be enough to dissolve the cerumen and with gentle cleaning of the external ear canal the patient might reestablish patency of the external ear canal. Further review of Physician and Nurse Practitioner notes from 11/9/23 to current date indicated there had been no further evaluation of the right ear for cerumen impaction. Review of the medical record indicated Resident #52 has not been seen by an audiologist (licensed professional that assesses and manages disorders of hearing) since admission. Review of the nursing notes from admission through 3/9/24 failed to indicate that there was documentation of Resident #52 having difficulties with hearing or a missing left hearing aid. Review of Resident #52's Recreation admission Assessment, dated 10/3/23, indicated but was not limited to the following: -Resident has vision and hearing deficits. -Resident's current general activity preferences include the following: cards/other games, crafts/art, music, spiritual/religious activities, trips/shopping, walking/wheeling outdoors, watching TV, talking/conversing, helping others, children, parties/socials, pets. During an interview on 3/12/24 at 2:06 P.M., the Activities Director (AD) said Resident #52 used to come to more activities, now he/she sleeps a lot and wakes up late in the day around 5:00 P.M. Review of Resident #52's activity log indicated the following participation monthly: October 2023: Eleven days November 2023: Seven days December 2023: Four days January 2024: Two days February 2024: One day On 3/11/24, the surveyor observed that the Resident was in bed during the morning, he/she woke up in afternoon, and was watching television at 3:30 P.M., listening to the television using ear buds. During an interview on 3/11/24 at 3:30 P.M., Resident #52 said he/she was watching television because there is nothing else to do. Resident #52 said he/she can't go activities because he/she can't hear anything. Resident #52 asked the surveyor to help get him/her hearing aids. During a telephonic interview on 3/11/24 at 10:34 A.M., Family Member (FM)/Healthcare proxy (HCP) #1 said Resident #52 needs hearing aids to hear, and he/she needs the wax cleaned out of the ears regularly. FM #1 said Resident #52 could hear at home and when he/she first came to the facility using the left hearing aid (the right hearing aid is broken). FM #1 said Resident #52 has been requesting to see a doctor about his/her hearing for a while and nothing ever gets done, and not hearing has been difficult. FM #1 does not know exactly when the left hearing aid went missing, but it has been a while and nobody ever called him/her about it, and it's frustrating. During an interview on 3/12/24 at 10:15 A.M., Nurse #3 said she was aware Resident #52's hearing aid was missing for about two months. She said it was discussed at a morning meeting on the unit with the previous Director of Nurses and Unit Manager. Nurse #3 said Resident #52 has expressed concerns about not being able to hear, but she thought it was taken care of by the Unit Manager. Nurse #3 and the surveyor went to Resident #52's room, and Resident #52 said the hearing aid has been missing and showed us a cardboard box with just hearing aid batteries. Resident #52 expressed frustration of not being able to hear, and everyone must yell at him/her when trying to talk. During an interview on 3/12/24 at 11:15 A.M., FM #3 said the left hearing aid has been missing for two months ago. FM #3 said last week he/she purchased an over-the-counter hearing aid to help Resident #52 try to hear. FM #3 said when Resident #52 came to the facility, there was a working left hearing aid and Resident #52 could hear. During an interview on 3/12/24 at 12:10 P.M., Social Worker #1 said with the Regional Nurse #1, the Administrator, and the Director of Nurses (DON) present, she was aware Resident #52's hearing aid was missing for a couple of months and the Resident was having difficulty hearing, but she thought it was resolved. SW #1 said there have been a few social workers in the building, she was not sure if anyone was helping Resident #52 with the lost hearing aid. The Administrator said she was just made aware of Resident #52's difficulty hearing and the lost hearing aid on Friday (3/9/24). The surveyor informed the Administrator and DON, Resident #52 expressed frustration throughout the survey with not being able to hear and not attending activities because of the hearing deficit. During an interview on 3/13/24 at 11:31 A.M., FM #3 said Resident #52 should not be sleeping all day and feels if he/she could hear, Resident #52 would go to activities. FM #3 said Resident #52 enjoys playing bingo and doing arts and crafts. During an interview on 3/13/24 at 1:45 P.M., Regional Nurse #1 said she was aware Resident #52's left hearing aid has been missing for a while. No further documentation was provided to the surveyor prior to exiting the facility.

Based on observations, records reviewed, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when 3 out of 4 nurses observed made 5 errors out of 39 opportunities, resulting in a medication error rate of 12.82%. Those errors impacted four Residents (#27, #19, #322, and #221), out of six residents observed. Findings include: Review of the facility's policy titled Administration Procedures for All Medications, dated August 2020, indicated but was not limited to: -Policy: Medications will be administered in a safe and effective manner. The guidelines in this policy apply to all medications. -5 Rights (at a minimum) -At a minimum, review the 5 rights at each of the following steps of medication administration. 1. Prior to removing the medication package/container from the cart/drawer: a. Check the MAR (medication administration record)/TAR (treatment administration record) for the order. 2. Prior to removing the medication from the container: a. Check the label against the order on the MAR. b. Note any supplement labeling that applies (fractional tablet, multiple tablets, volume of liquid, shake well, give with another medication, etc.) 1. For Resident #27, Nurse #5 administered: -the incorrect dose and formula of Calcium Citrate-Vitamin D (supplement used for bone health) -the incorrect form of Aspirin (reduces risk of heart attack) On 3/11/24 at 9:19 A.M., the surveyor observed Nurse #5 prepare and administer medications to Resident #27 including: -Chewable Aspirin 81 milligrams (mg) -Calcium Citrate + Vitamin D3 630 mg +12.5 micrograms (mcg) Review of Resident #27's Physician's Orders indicated the following: -Aspirin EC (enteric coated) Delayed Release 81 mg, give one tablet by mouth one time a day (4/3/23) -Calcium Citrate-Vitamin D 315-200 mg-unit, give one tablet by mouth one time a day (4/21/23) During an interview on 3/11/24 at 12:57 P.M., Nurse #5 said she administered the incorrect dose of Calcium Citrate + Vitamin D and the incorrect form of Aspirin 81 mg to Resident #27. 2. For Resident #19, Nurse #6 administered: -the incorrect dose and formula of Calcium Citrate-Vitamin D (supplement used for bone health) On 3/11/24 at 10:02 A.M., the surveyor observed Nurse #6 prepare and administer medications to Resident #19 including: -Calcium Citrate + Vitamin D3 630 mg +12.5 micrograms (mcg) Review of Resident #19's Physician's Orders indicated the following: - Calcium Citrate-Vitamin D 315-200 mg-unit, give one tablet by mouth one time a day (11/1/23) 3. For Resident #322, Nurse #7 administered: -the incorrect form of Multivitamin On 3/11/24 at 10:29 A.M., the surveyor observed Nurse #7 prepare and administer medications to Resident #322 including: -Daily Vitamin/Minerals Supplement Review of Resident #322's Physician's Orders indicated the following: -Multivitamin Oral Tablet, give 1 tablet by mouth one time a day (3/5/24) During an interview on 3/11/24 at 10:48 A.M., Nurse #7 said that she administered a Multivitamin with Minerals to Resident #322. Nurse #7 said Resident #322 has an order for a Multivitamin tablet daily. 4. For Resident #221, Nurse #7 administered: -the incorrect form of Multivitamin On 3/11/24 at 10:40 A.M., the surveyor observed Nurse #7 prepare and administer medications to Resident #221 including: -Daily Vitamin/Minerals Supplement Review of Resident #221's Physician Orders indicated the following: -Multiple Vitamin Oral Tablet, give 1 tablet by mouth one time a day (2/22/24) During an interview on 3/11/24 at 10:48 A.M., Nurse #7 said that she administered a Multivitamin with Minerals to Resident #221. Nurse #7 said Resident #221 has an order for a Multivitamin tablet daily. During an interview on 3/11/24 at 1:14 P.M., the Director of Nursing (DON) said the expectation was for medication to be administered per physician's orders.

Based on observation, interview and policy review, the facility failed to store and serve food in accordance with professional standards for food safety in two out of two nourishment kitchens. Specifically, the facility failed to properly label and date facility and resident food items and discard perishable food items by the use-by date. Findings include: Review of the facility's policy titled Food Brought into Facility, revised April 2019, indicated but was not limited to: -Perishable foods must be stored and identified with resident's name, food item, and use-by date. These can be stored in the nursing unit kitchen nourishment refrigerator. Review of the facility's policy titled Food and Supply Storage, revised June 2018, indicates but is not limited to: -Food, non-food items, and supplies used in food preparation and service shall be stored in such a manner as to maintain safety and sanitation of the food or supply for human consumption as outlined in the Federal Drug Administration (FDA) Food Code, state regulations, and city/county health codes. -Food products that are opened and not completely used should be labeled as to its contents and use by dates. -Refrigerated Time/Temperature Controlled for Safety (TCS), ready to eat food that is opened but not completed used and is held longer than 24 hours should be labeled with the common name and a use-by date with day one counted as the opened date. -The use-by date must not exceed the manufacturer's use-by date if the manufacturer determined a use-by date for food safety. -Discard food that exceeds their use-by date or expiration date, is damaged, is spoiled, has the time and temperature danger zone requirements, or incorrectly stored such that it is unsafe or its safety is uncertain. The surveyor made the following observations in the 200 Unit kitchenette: On 3/11/24 at 10:50 A.M., -One sign on the kitchenette refrigerator said all containers must be labeled and dated with the resident's name. -One cup and bag from a coffee shop chain on the counter had no label or date. -Store-bought cake in container on counter, half eaten, had no label or date. -Two takeout containers had partially eaten food, were labeled with resident names, not labeled with use-by date. -One cardboard pizza box labeled had resident name, not labeled with use-by date. -Three out of four juice pitchers labeled apple or orange juice, had use-by date of 3/9/24. -One carton of thickened, lemon-flavored water was opened with the seal broken. The manufacturer's label indicated: May be kept up to seven days in refrigerator after opening. The facility had not documented an opened date or use-by date on the carton. On 3/12/24 at 7:53 A.M., -Store-bought cake in container on counter, more than half eaten, had no label or date. -One carton of thickened, lemon-flavored water was opened with the seal broken. The manufacturer's label said: May be kept up to seven days in refrigerator after opening. The facility had not documented an opened date or use-by date on the carton. The surveyor made the following observations in the 300 Unit kitchenette: On 3/11/24 at 11:06 A.M., -Four of four juice pitchers labeled apple or orange juice, had use-by date of 3/9/24. -Two nutritional shakes when shaken, the contents felt fluid not solid. The manufacturer's label indicated to use within 14 days of thawing. The nutritional shakes had no manufacturer expiration date and were not labeled with a date or date they were thawed. On 3/12/24 at 7:41 A.M., -Three of three juice pitchers labeled apple or orange juice, had use-by date of 3/9/24. -28 nutritional shakes. The surveyor sampled the content properties of two random cartons by shaking them; liquid could be felt and heard inside. The manufacturer's label indicated to use within 14 days of thawing. The nutritional shakes had no manufacturer expiration date and were not labeled with a date or date they were thawed. -One carton of thickened, lemon-flavored water was opened with the seal broken. The manufacturer's label said: May be kept up to seven days in refrigerator after opening. The facility had not documented an opened date or use-by date on the carton. During an interview on 3/12/24 at 8:58 A.M., when asked about the carton of thickened, lemon-flavored water in the kitchenette refrigerator, a unit nurse on the 200 Unit said she thought the kitchen dated the cartons and brought a new carton of thickened fluid every day. During an interview on 3/12/24 at 5:21 P.M., the Regional Food Service Director (RFSD) said the following of the 200 Unit kitchenette: -Her expectation was for staff to label and date all opened food/drink items in the kitchenette per policy. -The partially eaten cake on the counter should have been labeled and dated per policy. -The opened carton of thickened, lemon-flavored water in the kitchenette refrigerator should have been dated when it was opened. The surveyor and RFSD read the manufacturer's usage label on the carton and the RFSD said she had not been aware of manufacturer's recommendation to use the product within seven days after opening. She said she would throw the carton away since there was no way of knowing when it was opened. -The surveyor and RFSD observed a plastic grocery bag containing several packaged store-bought food items. A resident's name was labeled on the plastic grocery bag. The RFSD said her expectation would be for the grocery bag that held the packaged food items to also be dated when it was brought into the facility. During an interview on 3/12/24 at 5:21 P.M., the RFSD said dietary aides check both kitchenettes at least once per day for stocking purposes. The RFSD said the dietary aide should also be looking at food labels and dates while stocking facility kitchenettes to ensure food and drink items are stored and discarded according to the policy. The RFSD said the policy for Food and Supply Storage also applies to the kitchenettes. During an interview on 3/12/24 at 5:36 P.M., the RFSD said the following of the 300 Unit kitchenette: -Her expectation was for all opened food/drink items in the kitchenette to be labeled and dated per policy. -The opened carton of thickened, lemon-flavored water in the kitchenette refrigerator should have been dated and used within the seven-day window per manufacturer's recommendation. The RFSD discarded the container. -The kitchen does not have a system for monitoring the nutritional shakes that expire 14 days after thawing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 3/11/24 at 8:40 A.M., the surveyor observed a stop sign outside of Resident #60's room which indicated: -What is needed for this room: - Gown - Gloves - Mask On 3/11/24 at 8:41 A.M., the surveyor observed Nurse #4 enter Resident #60's room without PPE. The surveyor observed Nurse #4 administer Resident #60's oral medication and examine Resident #60's PICC line without gloves or a gown. On 3/11/24 at 08:53 A.M., the surveyor observed the Director of Nursing (DON) enter Resident #60's room to assist Nurse #4. The DON was not wearing gloves, a gown, or a mask. During an interview on 3/11/24 at 9:00 A.M., Nurse #4 said she did not know Resident #60 was on precautions. Nurse #4 said the stop sign outside Resident #60's room was to help the Certified Nursing Assistants (CNA) know how to stock Resident #60's room. During an interview on 3/13/24 at 11:47 A.M., Regional Nurse #1 said Resident #60 was on precautions for MRSA infection. Regional Nurse #1 said the exception was for all staff that provided care for Resident #60 was to wear PPE. Regional Nurse #1 said the DON and Nurse #4 should have put on the appropriate PPE. Based on observation, interview, record review, and policy review, the facility failed to adhere to infection control practices to reduce potential transmission of infection for one Resident (#60), out of 19 sampled residents. Specifically, for Resident #60, the facility failed to: - Ensure contact precautions were maintained for methicillin resistant staphylococcus aureus (MRSA- type of staph bacteria that is resistant to certain antibiotics) in the left hip abscess, signage was posted at the entrance to the room, and personal protective equipment (PPE) was readily available outside the room, and - Ensure PPE was worn by staff when providing care to Resident #60 who was on Transmission-Based Precautions (TBP, used for patients who may be infected or colonized with certain infectious agents requiring additional precautions to prevent the spread of infection). Findings include: Review of the facility's policy titled Isolation-Initiating Transmission-Based Precautions, dated November 2017, indicated but was not limited to: -Protocol -Transmission Based (contact) Precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease. Transmission-Based Precautions may include Contact, Droplet Precautions, or Airborne Precautions. -The facility shall make every effort to use the least restrictive approach to managing individuals with potentially communicable infections. Transmission-Based Precautions shall only be used when the spread of infection cannot be reasonably prevented by less restrictive measures. -Guidelines 1. If a resident is suspected of, or identified as, having a communicable infectious disease, the Charge Nurse or Nursing Supervisor shall notify the Infection Preventionist and the resident's Attending Physician for appropriate Transmission-Based Precautions. 2. Transmission-Based Precautions shall remain in effect until the Attending Physician or Infection Preventionist discontinues them, which would occur after pertinent criteria for discontinuation are met. 3. When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee) shall: a. Ensure that the protective equipment (i.e., gloves, gown, mask, etc.) is maintained near the resident's room so that everyone entering the room have what they need. b. Post appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel will be aware of precautions or be aware that they must first see a nurse to obtain additional information about the situation before entering the room. According to the Centers for Disease Control and Prevention (CDC) Preventing Infections in Healthcare, last updated January 2020, indicated but not limited to: -CDC recommends the use of Contact Precautions in inpatient acute care settings for patients known to be colonized or infected with epidemiologically important multidrug-resistant organisms (MDROs) including MRSA. According to the CDC Transmission-Based Precautions, last updated January 2016, indicated but not limited to: -Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning (putting on) PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. Review of Resident #60's Hospital Discharge summary, dated [DATE], indicated but was not limited to the following: -Resident #60 was admitted to the hospital 2/16/24 with left hip pain and was found to have an Abscess formation. Blood and abscess cultures positive for MRSA. -Precautions: Yes for MRSA On 3/7/24 at 11:30 A.M., the surveyor observed the entrance to Resident #60's room and there was no precaution sign or personnel protective equipment outside the door. On 3/8/24 at 9:10 A.M., the surveyor observed Nurse #1 enter Resident #60's room, hang the IV medication, put on a pair of gloves, and access the Resident's peripherally inserted central catheter (PICC) line. Nurse #1 was not wearing a gown. There were no precaution signs posted outside Resident #60's room. During an interview on 3/8/24 at 9:15 A.M., Nurse #1 said Resident #60 is not on precautions. During an interview on 3/8/24 at 1:51 P.M., the Director of Nurses (DON) said she did not know if Resident #60 was supposed to be on contact precautions, she would have to look into it. During an interview on 3/8/24 at 2:55 P.M., the DON said Resident #60 should be on contact precautions for MRSA since returning from the hospital. Review of the physician's orders indicated Resident #60 did not have orders to maintain contact precautions since returning from the hospital 11 days ago.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #48 was admitted to the facility in October 2022 with diagnoses which included multiple sclerosis, anxiety, and schizophrenia. The HCP was activated on 10/27/22. Review of Resident #48's HCP indicated Family Representative (FR) #1 was named HCA. Review of the Physician's Orders indicated but was not limited to the following: -Activate HCP- poor insight and judgement, dated 10/2022 Review of [NAME] Healthcare's admission Packet included but was not limited to the following: -Attachment A: Consent to admission and Treatment -Attachment B: Optional / covered items and services -Attachment F: Bed hold policy -Attachment G: Management of resident's personal funds -Attachment H: [NAME] Healthcare Resident Handbook -Attachment L: Notice of privacy practices effective date: July 19, 2013 -Attachment M: Privacy act notification statement- healthcare records -Attachment N: Arbitration agreement -Long term care Resident Rights -Side rail consent form -Immunization consent Review of the medical record for Resident #48 indicated there were no signed consents. On 11/15/22 at 10:00 A.M., the surveyor observed Resident #48 lying in bed with side rails in the elevated position on both the right and left side of the bed. During a telephonic interview on 11/17/2022 at 6:01 P.M., FR #1 said he/she was Resident #48's HCA and he/she had not signed any admission papers. FR #1 said he/she was aware Resident #48's was going to be transferred to [NAME] Healthcare from the previous facility, but no one had contacted him/her when the transfer occurred. During an interview on 11/17/22 at 1:26 P.M., the Unit Manager said Resident #48 did not have any consents signed in the chart because Resident #48 had a guardian, and the facility was unable to get in touch with the guardian. The Surveyor and the Unit Manager reviewed the medical record, and Resident #48's HCP had been invoked naming FR #1 as the HCA. The Unit Manager said she called the number on the HCP form and there was no answer, and she left a message. The Unit Manager then called FR #1's number listed in the front of the medical record and spoke with FR #1 and asked him/her to come in and sign the consents. The Surveyor called the HCA phone number on the HCP form and the recording indicated the line was no longer in service. During an interview on 11/18/22 at 11:48 A.M., the DON said upon admission, the nurse doing the admission got a verbal consent for Resident #48 to receive treatment. The DON said there was no nursing note indicating a verbal consent was received and there were no other consents signed in the medical record. A review of the medical record indicated the admission nursing note was written by the Unit Manager and did not indicate the HCA was contacted or gave verbal consent. Based on record review and staff interview, the facility failed to ensure the resident and/or the resident representative had information in advance to exercise the resident's rights for two Residents (#25 and #48), out of a total sample of 19 residents. Specifically, the facility failed to: 1. Ensure Resident #25's Health Care Agent (HCA) was given information necessary to make health care decisions, including the risks and benefits of psychotropic medications; and 2. Ensure Resident #48's HCA was given the opportunity to review the admission package containing facility information including Resident Rights and sign informed consents for treatment and use of side rails in advance of receiving treatment. Findings include: 1. Resident #25 was admitted to the facility in October 2022 with diagnoses which included mood disorder, dementia, and schizophrenia. The Health Care Proxy was activated on 10/6/22. Review of the medical record indicated Resident #25 signed his/her admission documents, which included Informed Consents for the use of psychotropic medications, rather than the Health Care Proxy (HCP) which had been invoked. Review of the medical record indicated Resident #25 signed and consented for the following services and care: - Consent to admission and Treatment (Attachment A) - Consent and Acknowledgment Form for Psychiatric care and services - Consent Form for Surgical Procedure under Topical Anesthetic for wound care - Side Rail Consent Form - Immunization Consent Subsequent review of the medical record indicated Resident #25, not the HCA, signed the Informed Consent forms for the following Physician's Orders for psychotropic medications: - Abilify (antipsychotic) 2 milligrams (mg), give three tablets by mouth at bedtime for a total dose of 6 mg (ordered on 10/6/22). - Lexapro (anti-depressant) 10 mg, give one tablet one time a day (ordered 10/7/22). Review of the October and November 2022 Medication Administration Records, dated 10/6/22 through 11/18/22, indicated Abilify and Lexapro were administered as ordered by the Physician. During an interview on 11/8/22 at 10:25 A.M., the Director of Nurses said if the HCP was invoked, the HCA should have signed the admission consent documents including all Informed Consents for the psychotropic medications.

Based on observation, interview, and record review, the facility failed to accommodate the needs of two Residents (#48 and #115), out of a total of 19 sampled residents. Specifically, the facility failed to: 1. Evaluate Resident #48 upon admission for appropriate seating and positioning needs and provide the Resident with an appropriate chair to accommodate his/her poor trunk control; and 2. Evaluate Resident #115's ability to walk and allow him/her the opportunity to ambulate with an appropriate assistive device and supervision to maintain his/her highest functional level. Findings include: 1. Resident #48 was admitted to the facility in October 2022 with diagnoses which included multiple sclerosis, anxiety, and schizophrenia. The Health Care Proxy (HCP) was activated on 10/27/22. Review of Resident #48's HCP indicated Family Representative (FR) #1 was named Health Care Agent (HCA). Review of the Physician's Orders indicated but was not limited to the following: -Activate HCP- poor insight and judgement, dated 10/2022 -Social activities as tolerates During an interview on 11/15/22 at 10:00 A.M., Resident #48 said he/she had a wheelchair, but facility staff gave it to his/her roommate so now he/she has no way to get out of bed. The surveyor observed the Resident's room and noted that there was only one wheelchair in the room, and it was by the roommate's bed. During an interview on 11/15/22 at 12:20 P.M., Resident #48 said he/she did get out of bed for lunch. Resident #48 said it was not his/her choice, but the facility's choice, as he/she did not have a wheelchair to sit in. During an interview on 11/17/22 at 1:26 P.M., the Unit Manager said they did get Resident #48 up in a wheelchair one day, but he/she was not able to sit up, and basically was falling forward out of the chair and wanted to go back to bed. The Unit Manager said Resident #48 had not been screened by either physical or occupational therapy for a wheelchair because the Resident was a transfer from another building. The Unit Manager said Resident #48 would be screened by rehab soon. During an interview on 11/17/22 at 5:18 P.M., the Rehabilitation (Rehab) Director said Resident #48 had not been screened when he/she was admitted to the building. The Rehab Director admitted she was currently short staffed and was doing the best she could. The Rehab Director said she was not aware Resident #48 currently did not have a wheelchair or that Resident #48 had difficulty sitting up in a standard wheelchair. The Rehab Director said the facility had received a lot of transfers and not all the residents had been screened; Resident #48 was one of the transfers missed for screening. During a telephonic interview on 11/17/22 at 6:01 P.M., Family Representative (FR) #1 said Resident #48 had advanced multiple sclerosis and was unable to sit up in a regular wheelchair due to lack of trunk control. FR#1 said he/she spoke with the Unit Manager earlier in the day and asked if Resident #48 could have a reclining chair for support. FR#1 said the Unit Manager said no, as the reclining chair would be considered a restraint. FR#1 said Resident #48 had a recent decline at the previous facility after being sick with COVID-19 and weight loss during the fall. FR#1 said Resident #48 needed to get out of bed at least once daily and be brought to an activity, so he/she did not see the same four walls. FR#1 said he/she was aware Resident #48 was able to move the head of the bed up and down just to change position for relief of his/her pain. FR #1 said he/she felt if Resident #48 was able to get out of bed, it might help the Resident's back pain. 2. Resident #115 was admitted to the facility in November 2022 with diagnoses which included multiple sclerosis. Review of admission Interdisciplinary Care Plans included: - Focus: Resident is moderate risk for falls related to impaired mobility related to multiple sclerosis. - Goal: Resident will be free of falls through the review date. - Interventions: educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, follow facility fall protocol, and Physical Therapy evaluate and treat as ordered or PRN (as needed). During an interview on 11/15/22 at 10:05 A.M., and again at 2:57 P.M., Resident #115 said every time he/she stood up, staff told him/her to sit down as he/she had bad balance. The Resident said he/she was able to self-propel in a wheelchair but would like to walk again and wanted to work with physical therapy to improve his/her balance. Resident #115 said it did not appear physical therapy would provide services, and the Resident asked the surveyor for help to get therapy to provide the necessary services. Review of Resident #115's medical record failed to indicate a Physical Therapy evaluation was completed. During an interview on 11/18/22 at 10:00 A.M., the Rehabilitation (Rehab) Director said Resident #115 was a new admission as a transfer from a sister facility. The Rehab Director said she completed an informal screen on the Resident prior to and upon admission. She said the informal screen included a review of the Resident's needs prior to admission to the facility, including a baseline report and functional status from the transferring facility. She said she observed the Resident at admission and observed that the Resident was able to transfer independently to the wheelchair. The Rehab Director said, although she introduced herself to Resident, she did not engage in conversation with the Resident and was unaware the Resident had requested physical therapy services due to balance and ambulation concerns. She said the informal screen was not a written screen and she was unable to provide direct treatment with just an informal screen. The Rehab Director said she was the only physical therapist in the facility and was unable to provide the surveyor with any documentation related to the screen or treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for two Residents (#25 and #51), out of a total sample of 19 residents. Specifically, the facility failed: 1) For Resident #25, to develop and implement a plan of care for re-positioning; and 2) For Resident #51, to implement a plan of care for communication and provide the Resident with communication boards. Findings include: 1) Resident #25 was admitted to the facility in October 2022 with diagnoses which included morbid obesity, spondylosis with myelopathy, and contractures of the right and left knee. On 11/17/22 at 12:30 P.M., the surveyor observed Resident #25 in bed. The head of the bed was at a 45-degree angle and the Resident sat low in the bed. The Resident was listing/leaning to the left with his/her head against the left siderails. Resident #25 said he/she was unable to perform bed mobility and was dependent on staff. On 11/18/22 at 9:15 A.M., 9:45 A.M., 10:15 A.M., 10:30 A.M., 11:30 P.M., 12:05 P.M., and 12:52 P.M., the surveyor observed Resident #25 in bed. The Resident's head of the bed was at a 45-degree angle and the Resident sat low in the bed. The Resident was listing/leaning to the left with their head against the left siderails. The Resident's right and/or left foot was resting on the footboard of bed. On one observation at 12:05 P.M., his/her right foot was resting on the footboard of the bed and his/her left ankle/foot was off bed on the left side of the bed. Review of the care plans for Resident #25 indicated a focus of an alteration in Activities of Daily Living (ADLs) with an intervention of total assistance with Resident #25's bed mobility. Review of the medical record failed to indicate Resident #25 was evaluated by Occupational and Physical Therapy. No plan of care was developed for positioning. During an interview on 11/18/22 at 10:00 A.M., Certified Nursing Assistant #1 (CNA) was asked how she was informed of resident care needs. CNA #1 said when she arrives at the facility, she gets a worksheet and asks other staff about Resident care needs. CNA #1 said the facility does not provide a plan of care and is unaware of Resident #25's [NAME] for care purposes. Review of Resident #25's [NAME] failed to indicate the Resident's need for positioning while in bed. 2.) Resident #51 was admitted to the facility in April 2021 with diagnoses which included cerebral infarction with aphasia and hemiplegia. Review of the Interdisciplinary Care Plan, undated, indicated Resident #51 had a care plan for aphasia/communication. The goal identified was Resident #51 would be able to make daily basic needs known. Interventions to achieve this goal included: anticipate and meet needs, be conscious of resident positioning in groups to promote proper communication, allow adequate time to communicate his/her response, request clarification to ensure understanding, face resident when speaking, eye communication, turn off TV/radios, monitor for nonverbal indicators/frustration and utilize strategies for word finding including a communication board, writing or a computer as an alternate to speech. During an observation with interview on 11/17/22 at 9:15 A.M., Resident #51 was in bed. Resident #51 engaged easily, had word finding difficulties and was frustrated with his/her communization. The surveyor did not observe any communication tool and observed the Resident acting out her needs. During an observation and interview on 11/18/22 at 12:53 P.M., Resident #51 said he/she had difficulty communicating. The surveyor asked if he/she utilized other compensatory strategies for communication, such as writing or a communication board. The Resident shook his/her head no. When asked if he/she would want other communication tools, such as a communication board, Resident #51 shook his/her head yes. During an interview on 11/18/22 at 1:13 P.M., Nurse #1 said Resident #51 did not have any communication boards of any type.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure the nursing staff followed professional standards of practice during medication administration, including for two Residents (#165 and #166), out of a total sample of 19 residents. Specifically, the facility failed to: 1. Ensure staff did not pre-pour medication for two Residents in two different rooms and then bring both medication cups into a resident's room to administer the first cup of medication; 2. Ensure Resident #166's Omeprazole medication was administered as ordered by the physician, leaving one of the Omeprazole tablets on the Resident's dresser and signing the medication administration record indicating both tablets were administered; and 3. Ensure Resident #165 fully consumed the physician ordered Paxlovid and Guaifenesin dose prior to the nurse leaving the room. Findings include: A review of the facility's policy titled Administering Medications, dated 2/2020, indicated but was not limited to the following: -Medications are administered in a safe and timely manner and as prescribed. -Only persons licensed or permitted by the state to prepare administer or document the administration of medications may do so. -Medications are administered in accordance with prescriber orders, including any required time frame. -Medication errors are documented, reported, reviewed by QAPI committee to inform process changes and or the need for additional staff training. -Medications are administered within one hour before or after their prescribed time, unless otherwise specified or per resident preference. -The individual administering the medication initials the resident's medication administration record (MAR) on the appropriate line after giving each medication and before administering the next ones. -Staff follows established facility infection control procedures ( e.g., hand washing, antiseptic techniques, gloves, isolation precautions, etc.) for the administration of medications as applicable. 1. On 11/15/22 at 1:00 P.M., the surveyor was present in resident room [ROOM NUMBER] when Nurse #3 entered the room holding two glasses of water and two medication cups. Nurse #3 made eye contact with the surveyor and immediately turned around to exit the room shielding the medication cups from the surveyor. Nurse #3 continued to walk back to the medication cart. The surveyor observed the first medication cup to have two Tylenol pills and the second medication cup to have two Tylenol pills and a Divalproex pill. During an interview on 11/15/22 at 1:01 P.M., Nurse #3 said the first cup was Tylenol for a resident in room [ROOM NUMBER] and the second medication cup was for the resident in a different room. She said she normally does not pre-pour medication or bring another resident's medication into another resident's room. During an interview on 11/15/22 at 3:15 P.M., the Director of Nursing (DON) said Nurse #3 should not have pre-poured medications. She said Nurse #3 should have poured the medication for one resident, delivered the medication, and then poured the second resident's medication. 2. Resident #166 was admitted to the facility in November 2022 with diagnoses which included gastro-esophageal reflux (GERD), diaphragmatic hernia, and noninfectious gastroenteritis. Review of the Physician's Orders indicated but was not limited to: -Omeprazole tablet delayed release 20 milligrams (mg), give 40 mg by mouth two times a day for GERD Review of the Medication Administration Record (MAR) indicated Resident #166 was administered -Omeprazole two 20 MG tablets by Nurse #6 on 11/15/22 at 2:30 P.M. Further review of the Physician's Orders indicated the Resident did not have an order to self-administer medication. On 11/15/22 at 3:00 P.M., the surveyor entered Resident #166's room and observed a glass of water and medication cup containing one pill on the Resident's dresser. The surveyor had observed Resident #166's room that morning at 11:55 A.M., and there was no medication cup on the dresser. On 11/15/22 3:02 P.M., the surveyor informed Nurse #3 there was a medication cup with one pill in it on Resident #166's dresser. Nurse #3 went and got the medication pill cup and brought it to the Unit Manager. During an interview on 11/15/22 at 3:05 P.M., the Unit Manager said the pill was Omeprazole, and should not have been left on the dresser. The Unit Manager reviewed the MAR and said Nurse #6 signed off on giving Resident #166's Omeprazole 40 MG after lunch. She said Nurse #6 had left for the day and she was unable to say why Nurse #6 did not administer the medication but signed off that he did. During an interview on 11/15/22 at 3:15 P.M., the DON said the nurse should not have left the medication on the dresser and should not have signed off on the medication if he did not give it. 3. Resident #165 was admitted to the facility in October 2022 with diagnoses which included a pelvic fracture. The Resident was diagnosed with COVID-19 while at the facility. Review of the Physician's Orders indicated but was not limited to: -Guaifenesin tablet 200 mg, give two tablets by mouth two times a day for mucus. -Paxlovid (150/100) therapy pack, give two tablets by mouth two times a day for COVID positive. Further review of the Physician's Orders indicated the Resident did not have an order to self-administer medication. Review of the MAR indicated Resident #165 was administered the following medication: -Two Guaifenesin 200 mg tablets by Nurse #5 on 11/15/22 at 5:00 P.M. -Two Paxlovid (150/100) tablets by Nurse #5 on 11/15/22 at 5:00 P.M. On 11/15/22 at 5:05 P.M., the surveyor observed Resident #165 lying in his/her bed holding a pill cup with two different pinkish pills in the cup. During an interview on 11/15/22 at 5:05 P.M., Resident #165 said the nurse gave him/her the pills to take. The Resident said he/she knew the nurses were not supposed to leave the pills, but they did it all the time. Resident #165 said the medication was to treat COVID-19, one is Paxlovid and he/she forgot what the second pill was called. During an interview on 11/15/22 at 5:10 P.M., Nurse #5 said she gave Resident #165 his/her Paxlovid and Mucinex (Guaifenesin) with a glass of water and thought the Resident took the medication. She said she could not confirm the Resident took all the medication. Review of the nursing note, dated 11/15/22, indicated Resident #165 denied taking the medication reporting, I could not take it all; I need extra time to swallow.

Based on observation, interview, and record review, the facility failed to ensure podiatry services were provided, per a physician's order and a signed request for services upon admission for one Resident (#51), out of a total sample of 19 residents. Findings include: Resident #51 was admitted to the facility in April 2017. Review of Resident #51's clinical record indicated a signed request from Resident's Legal Representative, dated 4/28/17, for Podiatry Services. Further review of the clinical record indicated a Physician's Order, dated 11/9/22, for a podiatry appointment due to an infected toe. During an interview on 11/18/22 at 12:30 P.M., Resident #51 said he/she has not been to the Podiatrist and indicated he/she wanted to go. During an interview on 11/18/22 at 12:31 P.M., the surveyor informed Nurse #1 that Resident #51 said he/she had not seen the Podiatrist. Nurse #1 said she was unaware Resident #51 had not seen the Podiatrist, and the physician's order had not been followed.

Based on record review, policy review, and interview, the facility failed to monitor for signs/symptoms of adverse consequences (i.e., side effects) and the effectiveness of an anti-coagulant agent (blood thinner) prescribed for one Resident (#42), from a total sample of 19 residents. Findings include: Resident #42 was admitted to the facility in July 2021 with diagnoses which included cerebral-vascular disease. Review of the Physician's Orders, dated November 2022, included but was not limited to: -Eliquis (blood thinner which can be used to prevent stroke) 5 milligrams (mg) twice daily, order date, 4/25/22. Review of the Medication Administration Records (MAR), dated September 2022 through November 2022, indicated Eliquis was administered as ordered by the Physician. Further review of the medical record failed to indicate staff monitored the Resident for signs of bleeding as required. On 11/18/22 at 1:00 P.M., the Director of Nurses said the facility did not have a policy for anticoagulation therapy. She said the facility followed standards which included monitoring for signs/symptoms of adverse consequences (i.e., side effects) and the effectiveness of a prescribed anti-coagulant agent. During an interview on 11/18/22 at 03:30 PM, the Director of Clinical Operations reviewed the concerns related to monitoring for side effects and effectiveness of the anti-coagulant and said the staff were not consistently monitoring for side effects.

Based on record review, policy review, and interview, the facility failed to ensure a gradual dose reduction (GDR) of an antipsychotic medication was implemented for one Resident (#7), out of a total sample of 19 residents. Findings include: Review of the facility's policy titled Psychotropic Medication, dated 4/2018, indicated but was not limited to the following: - Psychotropic medications will be prescribed at the lowest possible dosage and are subject to gradual dose reduction and re-review as needed. - Dosage is appropriate for the resident and is not in excess of the suggested daily dosage maximum, unless specifically documented by the attending physician. - Dosage reduction or re-evaluations are provided regularly, according to state/federal regulations. Resident #7 was admitted to the facility in April 2022 with diagnoses which included unspecified psychosis, dementia, anxiety, and major mood disorder. Review of the Minimum Data Set (MDS) assessment, dated 10/27/22, indicated the Resident was severely cognitively impaired and was administered antipsychotic medication daily. Review of the Psychiatric Note, completed by the Nurse Practitioner, dated 10/17/22, indicated the following: - Patient denies depression, anxiety, suicidal ideation, auditory or visual hallucinations and delusions. Continues to have visions of dead people but is not distressed since he/she reports he/she is a medium. Per staff, patient remains behaviorally stable with no agitation or psychosis. No mood changes reported. Would attempt another GDR of Risperdal-decrease to 0.25 mg twice daily. Review of the Medication Administration Record (MAR), dated 10/1/22-10/31/22, indicated: - Risperdal 0.5 milligrams (mg) at hour of sleep, dated ordered, 6/8/22 - Risperdal 0.25 mg one time daily, dated ordered, 6/9/22 Review of the Psychiatric Note, completed by the Nurse Practitioner, dated, 11/7/22, indicated the following: - Patient denies depression, anxiety, suicidal ideation, auditory or visual hallucinations and delusions. Patient remains calm, cooperative and redirectable. No agitation or aggression reported-does still see dead people. No increase in depression or anxiety. Prior recommendations to GDR Risperdal not done, unclear why, so will recommend again. Would decrease Risperdal to 0.25 mg twice daily. Plan 1- Decrease Risperdal to 0.25 mg twice daily. Plan 2- Monitor closely for any change in mood or behaviors. Review of the Physician's Orders, dated 11/10/22, indicated: -Risperdal 0.25 mg twice daily for dementia psychosis. Subsequent review of Resident #7's clinical record failed to indicate the GDR order was implemented until 11/10/22, 25 days after the Nurse Practitioner implemented the order on 10/17/22. During an interview on 11/18/22 at 12:23 P.M., the Director of Nurses said she had reviewed the clinical record and was unable to locate any documentation to indicate why the GDR was not implemented on 10/17/22 and said all GDR implementation should be addressed as recommended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, policy review, and document review, the facility failed to follow their policy and ensure a resident's room was cleaned prior to a room-to-room transfer for one Resident (#166), out of a total sample of 19 residents. Findings include: Resident #166 was admitted to the facility in November 2022, with diagnoses which included failure to thrive, gastro-esophageal reflux (GERD), diaphragmatic hernia, and non-infectious gastroenteritis. Review of the facility's policy titled Transfer, Room to Room, dated 11/2017, indicated but was not limited to the following: -Ensure that the new room is ready for receiving the resident. The facility was unable to provide the surveyor with a policy for terminal room cleaning after a resident is discharged from the facility. On 11/15/22 at 11:55 A.M., the surveyor observed in Resident #166's room an intravenous (IV) pole with two empty Cefazolin 2 gram/100 milliliter IV bags hanging from it. One of the IV bags was dated 11/9 and both were labeled with Resident #61's information (previous resident to occupy the room). There were alcohol prep pads and a water pitcher on the windowsill and disposable gloves and gauze pads on the dresser. The surveyor observed IV supplies, alcohol prep pads and a syringe in the top drawer of the bedside table. Review of a paper filled out by Housekeeping, located on the bedside table, indicated the last time the room was sanitized and ready for a new admission was 10/22/22. Review of the Physician's Orders indicated that since admission Resident #166 had not received any intravenous fluids or medication while at the facility. During an interview on 11/15/22 at 11:57 A.M., Nurse #6 said Resident #166's room was changed last night. He said the previous resident in that room went to a doctor's appointment and was sent to the hospital on [DATE] and had been on IV antibiotics for a skin infection. He said he did not know if the room was cleaned before they moved Resident #166 into it, but the old IV bags should not be in there. During an interview on 11/15/22 at 12:45 P.M., the Housekeeping Director said she was informed when a resident was discharged , and the room would be cleaned of personal belongings and medical equipment. She said once the room was cleaned, a sign would be put in the room which indicated the room was ready for a new admission. She said if an IV pole and IV bags were still in the room with other medical supplies, the nurse would be notified and would remove the medical equipment, and housekeeping would clean the room. During an interview on 11/15/22 at 3:15 P.M., the Director of Nurses (DON) said Resident #166 had a room change the previous night after hours and she was not sure if the room had been cleaned. The DON said the expectation was a staff member would check the room to ensure that it was both empty and clean prior to moving a resident into the room. She said if the room had not been cleaned it would be an infection control issue. The surveyor and the DON viewed Resident #166's room and viewed the sheet indicating the last time the room was sanitized for a new admission was 10/22/22.