Based on observation, interview, and record review, the facility failed to implement their abuse policy and procedures when one Resident (#38), and their healthcare proxy (HCP), had reported an allegation of rough care on 4/8/25, resulting in emotional upset, in a total sample of 14 residents. Specifically, after the facility staff were notified of the incident they failed to recognize the allegation as potential abuse, report it to the Director of Nurses (DON) and protect the Resident from further interactions with the accused hospice aide. Findings include: Review of the facility policy titled: Abuse Prevention Program, dated as revised: 2/22/22, indicated but was not limited to the following: - as part of the resident abuse prevention, administration will: protect the residents from abuse by anyone including, but not necessarily limited to facility staff, consultants, staff from other agencies, or any other individual - develop and implement policies and procedures to aid in our facility preventing abuse, neglect or mistreatment of our residents - identify and assess all possible incidents of abuse; investigate and report any allegations of abuse within timeframes, as required by federal requirements and protect residents during abuse investigations Resident #38 was admitted to the facility in March 2025 with diagnoses including: Neurocognitive disorder with Lewy bodies, dementia and anxiety. Review of the most recent Minimum Data Set, dated : 3/20/25 indicated the Resident was receiving hospice services, suffered from hallucinations and had brief interview for mental status score of 8 out of 15 which indicated he/she was moderately cognitively impaired. During an interview on 4/16/25 at 9:13 A.M., the HCP said on 4/8/25 or there abouts (a week ago Tuesday) that Resident #38 left the room with their hospice aide to take a shower and when they returned they were crying and shaken and stated to their HCP they felt unsafe. She said the Resident told her the hospice aide handled them roughly and they were fearful to take another shower. The HCP said they reported this information to Nurse #2 and then directly to the hospice, including the name of the hospice aide who was involved. She further indicated other nurses on the unit were also aware of the situation. During an interview on 4/16/25 at 3:23 P.M., Resident #38 said they had a bad experience in the shower and felt the girl was rough with them and it hurt them and they felt uncomfortable getting back into the shower. He/She said they usually really enjoy taking showers and likes to take them numerous times a week but they were so uncomfortable with the way they were handled and it frightened them. He/She said this happened maybe about a week or two ago, but could not recall a specific date or the name of the girl. Review of the nursing progress notes indicated, but was not limited to the following: - 4/11/25 at 11:18 A.M., by Nurse #2: Hospice nurse reported Resident's daughter was unhappy with aide who provided Resident shower, but would not disclose the aides name. Resident reported the aide was rough with him/her when they came to visit and the Resident was informed the hospice would not be sending that aide and a different aide would come and provide showers. The note failed to indicate that the allegation of rough care was reported to the facility Administrator or Director of Nurses (DON). Review of the skilled nursing facility hospice visit log for 4/6/25 through 4/15/25 indicated the accused hospice aide was on duty on 4/8/25 and provided a shower to Resident #38 and returned to the facility and provided a second shower to the Resident on 4/15/25. During an interview on 4/16/25 at 3:42 P.M., the Director of Nurses (DON) reviewed the nurse progress note from 4/11/25 and was made aware of Resident #38's and their HCP's reported information and said she was unaware of the allegation. She said upon reading the progress notes that an incident of rough handling is a trigger of potential abuse and the staff should have alerted her to the allegation and implemented the abuse policy and protocol but did not. During an interview on 4/16/25 at 4:10 P.M., Nurse #3 said she did work on 4/8/25 and she recalls during shift report hearing about an incident in which Resident #38's HCP had reported an incident of rough care by the hospice aide. She said she feels there is potential that rough care is abuse and it should be reported as an allegation to the DON or Administrator. She said she did not report it because she had received the information from Nurse #2 and assumed she had already informed management of the incident. During an interview on 4/17/25 at 8:34 A.M., Nurse #2 said Resident #38's HCP had reported to her about a week or two ago on either Tuesday the 8th or Thursday the 11th that the Resident had a bad experience in the shower feeling rushed by the hospice aide and did not want any care provided by that aide anymore. She said the HCP did identify the hospice aide and she can confirm it is the aide that pretty consistently provides care to the Resident. She said she had spoken to one of the hospice Nurses about the situation when she saw them and that her note on 4/11/25 accurately reflects the terminology used by the HCP and Resident of rough handling. She said she did try to interview the Resident about the situation but the Resident did not want to talk about it. She said she didn't report it as a potential allegation of abuse to the DON or Administrator because she thought of it as maybe more of some type of dislike in the way the aide did things or a personality conflict. During a follow up interview on 4/17/25 at 5:19 P.M., the DON said she spoke to the Administrator, who was unavailable at the time of the survey, and he informed her he was also not made aware of any allegations of mistreatment in regards to Resident #38. She said the staff should have implemented the abuse policy and reported the situation at the time of the occurrence and notification of the situation by the HCP and did not.

Based on observation, interview, and record review, the facility failed to provide services that met professional standards of practice for one Resident (#38), out of a total sample of 14 residents. Specifically, the facility failed to ensure that an as needed (PRN) physician order for a supplement juice was complete with dosage frequency, amount and indication for use prior to administering the product. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice Title: Accepting, Verifying, Transcribing and Implementing Prescriber Orders Advisory Ruling Number: 9324, dated as revised July 10, 2002, indicated but was not limited to the following: It is the responsibility of the licensed nurse to ensure that there is a proper patient care order from a duly authorized prescriber prior to the administration of any prescription or non-prescription medication or activity that requires such order in accordance with accepted standards of practice and in compliance with the Board ' s regulations. In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. It is not within the scope of Licensed Practical or Registered Nurse practice to alter or change the directions provided for in orders from a duly authorized prescriber. Resident #38 was admitted to the facility in March 2025 with diagnoses including: Neurocognitive disorder with Lewy bodies, dementia and anxiety. Review of the most recent Minimum Data Set, dated : 3/20/25 indicated the Resident was receiving hospice services, suffered from hallucinations and had brief interview for mental status score of 8 out of 15 which indicated he/she was moderately cognitively impaired. Review of the medical record for Resident #38 indicated a dietician recommendation on 3/23/25 for Add order for Magic juice mixture as needed (supplied by family) The recommendation failed to indicate a dosage, time frame for the PRN or indication for the use of the Magic juice. Review of the physician orders for Resident #38 indicated, but were not limited to the following: 3/23/25 telephone order (t/o): Magic juice mixture as needed (supplied by family) The physician's telephone order failed to indicate a dosage, time frame for the PRN to be administered or indication for the use of the supplement Review of the medication administration record (MAR) for April 2025 up until 4/18/25 indicated the Resident had received the Magic juice almost daily During an interview on 4/18/25 at 2:12 P.M., Nurse #2 reviewed the Resident's orders and April MAR with the surveyor. She said the order for Magic juice contained no dosage amount, time frame for PRN use or indication for use of the PRN. She said the order was missing elements that would make it a complete physician order and would require clarification to ensure all the necessary pieces were in place. During an interview on 4/22/25 at 8:16 A.M., the Director of Nurses reviewed the magic juice order and said it was incomplete and missing necessary elements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review and interview, the facility failed to develop a person-centered plan of care which included trauma informed approaches and identified triggers to avoid potential re-traumatization for one Residents (#38) with a history of trauma, out of a total sample of 14 residents. Findings include: Review of the facility policy titled: [NAME] Nursing home, undated, indicated but was not limited to the following: Policy: to ensure residents emotional safety, Trauma-informed care acknowledges the need to understand a patient's life life experiences in order to deliver effective care. - The individual's experience of the event(s) determines whether it is a traumatic event - an event may be traumatic for one individual and not another - individual interpretation will determine whether or not the experience is traumatic - a social worker will conduct an initial interview and complete the usual mood and mental status screens, they could ask whether the resident has a history of trauma utilizing a 5 item Post traumatic stress disorder (PTSD) screen - refer to behavioral health services based on assessment/response in order to provide appropriate assessment and treatment by competent professionals - residents are in an environment they often feel they don't have much control over, are exposed to unpredictable noises, and are interacting with other residents and staff with whom they may not know very well and this can cause increase anxiety - when a resident has a prior history of being exposed to life-threatening traumatic events, all of these variables can trigger and intensify their emotional and behavioral response - it is important for facility staff to be able to: recognize trauma and its associated emotional sequelae (emotional consequences), respond with empathy and respect, keep a resident's trauma information private while providing the least amount of details that will allow for personalization of care while avoiding revictimization Resident #38 was admitted to the facility in March 2025 with diagnoses including: Neurocognitive disorder with Lewy bodies, dementia and anxiety. Review of the most recent Minimum Data Set, dated : 3/20/25 indicated the Resident was receiving hospice services, suffered from hallucinations and had brief interview for mental status score of 8 out of 15 which indicated he/she was moderately cognitively impaired. During an interview on 4/16/25 at 3:23 P.M., the Resident said they had a bad experience in the shower in which they felt the aide was rough and said they were uncomfortable getting back into the shower. He/She said the incident made them uncomfortable and he/she was frightened with the way they were handled and they became upset. Resident #38 said they have a long history of abuse in their childhood and first marriage and they felt triggered by the rough handling in the shower. He/She said they do not recall anyone at the facility ever asking about their trauma triggers, but said it would be helpful if staff helped him/her avoid any loud or aggressive situations or any rough physical situations to prevent any flash back to his/her personal history of physical abuse. Review of the medical record indicated but was not limited to the following: 3/18/25: Substance use/abuse screening tool that indicated a history of depression, anxiety and emotional and sexual abuse that indicated the facility would proceed with a care plan but not refer to psych services related to the Resident being on hospice services. 3/18/25: Trauma assessment that indicated Yes to: experienced something that made you feel threatened in the past or present (emotionally, sexually abused); Yes to: ever had nightmares about something that has happened to you or that you witnessed happen to someone else (hallucinations); what was your childhood like - answer: traumatic; if married or in a serious relationship, what was it like: 1st marriage abusive, divorced The Abuse screening and Trauma assessments failed to identify potential triggers to avoid potentially retraumatizing the Resident Review of the current care plans for Resident #38 indicated, but were not limited to the following: PROBLEM: Psychosocial well-being: Resident has a strong identification with past roles and life status has lived independently prior to admission to the facility (3/20/25) GOAL: Resident will continue to express feelings of connection with prior lifestyle (3/20/25) APPROACHES: Allow resident to express feelings, they had emotional and sexual trauma many years ago with their first marriage, watch for any signs of this; allow resident to make decisions, set personal goals and participate in self care as able; assist to identify personal strengths and assets; discuss significant roles they held and explore possible new roles; allow opportunity to maintain personal roles and interests; provide opportunity for resident to express individuality (3/20/25) PROBLEM: Behavior symptoms: Resident can become easily confused and overwhelmed with a lot of stimulation and has hallucinations and wanders (3/20/25) GOAL: Resident will feel safe in their surroundings and not attempt to leave the facility on his/her own (3/24/25) APPROACHES: wanderguard to left wrist; bed alarm when in bed; prevent sensory overload by keeping distraction to a minimum when communicating; monitor resident and attempt to redirect when hallucinating; report any new or increased behaviors to hospice/MD (3/13/25) Review of the Certified Nurse Aide care card for Resident #38, was blank with the exception of the Resident's name and did not indicate any trauma history or triggers The care plans failed to indicate Resident identified triggers related to the Resident's trauma history and ways the staff could assist in preventing the triggers and potentially avoid a retraumatization to the Resident. During an interview on 4/16/25 at 3:47 P.M., the Director of Nurses (DON) said she was unaware that Resident #38 had a trauma history or any known triggers that the staff should avoid to prevent potentially retraumatizing the Resident. She said the tools used by the facility to identify those things are completed by the social worker and the facility social worker has retired and is not available. During an interview on 4/17/25 at 6:59 A.M., Nurse #4 said she was unaware of any trauma history or potential triggers the staff should attempt to avoid for Resident #38. During an interview on 4/17/25 at 8:41 A.M., Nurse #2 said she had no knowledge or Resident #38 having an abuse or trauma history and she is not aware of any triggers or strategies for staff to avoid potentially retraumatizing the Resident. She said she is aware the Resident has behaviors and hallucinations with anxiety but was informed those were related to his/her diagnosis and was unaware of the trauma history. During a follow up interview on 4/17/25 at 9:12 A.M., the DON reviewed the Resident record and said she would expect that the information regarding the Resident's trauma would have been shared with the staff providing care. She said a detailed individualized care plan should have been created to ensure the Resident does not experience any potential triggers that he/she can identify to potentially avoid any retraumatization, and it appears that was not done. During an interview on 4/17/25 at 4:01 P.M., the MDS Nurse said she was unaware of any trauma history for Resident #38 until the DON asked her about it today. She said typically the social worker would alert her to the history and complete a care plan. She said the Resident does have a care plan for social well-being that mentions trauma and a behavior care plan, but nothing that identifies any potential triggers that the staff should attempt to avoid to ensure the Resident does not feel retraumatized.

Based on document review and interview, the facility failed for one Residents (#38), out of a total sample of 14 residents, to ensure that an as needed (PRN) psychotropic medication, Ativan (Lorazepam - an antianxiety medication) was initially limited to 14 days duration in accordance with the regulatory guideline. Findings include: Review of the facility policy titled: Medication management: Guidelines for psychotropic medication monitoring, dated: 1/2025, indicated but was not limited to the following: - In certain situations psychotropic medications may be prescribed on a PRN basis to address acute or intermittent symptoms, in an emergency, or while other medication dosages are being adjusted. Additional limitations for PRN psychotropic's: - time limitation to 14 days - order may be extended beyond 14 days if the attending physician or prescribing practitioner believes it is appropriate to extend the order and they should document the rationale for the extended time period in the medical record. Note: report of the resident's condition from the facility staff to the attending physician or prescribing practitioner does not constitute an evaluation Resident #38 was admitted to the facility in March 2025 with diagnoses including: Neurocognitive disorder with Lewy bodies, dementia and anxiety. Review of the most recent Minimum Data Set, dated : 3/20/25 indicated the Resident was receiving hospice services, suffered from hallucinations and had brief interview for mental status score of 8 out of 15 which indicated he/she was moderately cognitively impaired. Review of the current orders for Resident #38, indicated but were not limited to the following: - Ativan 0.5 milligrams (mg) every one hour (Q1h) PRN moderate anxiety (3/13/25) - Ativan 1mg Q1h PRN severe anxiety (3/13/25) The orders failed to indicate an end date or reevaluation date for the use of the PRN psychotropic medication Ativan Review of all telephone and admission order from March through 4/19/25 failed to indicate the PRN Ativan order was ever prescribed for an initial 14 day evaluation period or that any further orders or clarification to the PRN Ativan order were obtained. During an interview on 4/18/25 at 2:14 P.M., Nurse #2 said the process for PRN psychotropic orders is that they are only to be initially started with a 14 day stop or reevaluation date and then from there the medication may be extended if the physician agrees. She reviewed the admission orders and all the telephone orders for Resident #38 and said the original order from 3/13/25 never had a stop date as it should have and the order has gone beyond the 14 day mark at this point. During an interview on 4/22/25 at 8:17 A.M., the Director of Nurses said the expectation for PRN psychotropic medications is that the policy is followed and the medications if necessary are initially limited to 14 days. She said if the medication is required beyond that the physician would reevaluate the order, provide a new order and document the reason. She said Resident #38 having a PRN psychotropic medication since 3/13/25 without a stop date violates the facility policy and regulatory guideline and that should not be happening.

Based on observation and staff interview, the facility failed to ensure that trash, garbage, and refuse were disposed of properly in the dumpster, from the surrounding area. Findings include: Review of the 2022 Food Code (a model for safeguarding public health and ensuring food is unadulterated and honestly presented when offered to the consumer) by the U.S. Food and Drug Administration (FDA) indicated outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated. On 4/17/25 at 1:06 P.M., the surveyor observed the dumpster with the top lids closed, however, the right side cover was in the open position exposing the garbage to potential harborage and feeding of pests. The surrounding area had a buildup of trash and debris including but not limited to a walker, rolling desk chair, used blue gloves, spoons, wrappers, paper plates, Styrofoam cups, and plastic bags. The trash and debris were not properly contained in the dumpster. During an interview on 4/17/25 at 1:07 P.M., the surveyor reviewed the observations with the Maintenance Director who said the garbage is picked up twice a week on Tuesdays and Fridays between 7:30 A.M. and 9:00 A.M. and was last picked up two days ago. He said he checks for loose garbage and knew there was a walker and chair back there that needed to go in the dumpster, but was not aware of all the loose trash. He said the doors should be closed on top and on the sides to keep animals out.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Midline Catheter (type of catheter inserted into a peripheral vein, typically in the arm, near the armpit, used to deliver medications intravenously (IV)), consistent with professional standards of practice for one Resident (#7), out of a total sample of 14 residents. Specifically, the facility failed to: -document the administration of the prescribed antibiotic, Ertapenem, in accordance with physician's orders -consistently monitor the insertion site for signs and symptoms of infection per the comprehensive person-centered care plan -measure and document the catheter length upon removal to assess tip integrity for any damage or changes in shape (ensures the catheter was properly removed and there were no complications during removal such as catheter breakage or migration) Findings include: Review of the facility's policy titled Guidelines for Preventing Intravenous Catheter-Related Infections ([NAME]) indicated but was not limited to the following: Overview of [NAME]: Signs and symptoms that can indicate infection include: -fever, chills -hypotension, hyperventilation -altered mental status -tenderness at insertion site -erythema (redness), induration (thickening of the skin due to inflammation), purulent (pus)drainage -positive blood cultures or catheter tip -phlebitis (vein inflammation) Surveillance: -Observe the insertion site (and sutures if present) on every shift, on admission, and with dressing changes -Observe visually or by palpation through the intact dressing -If signs and symptoms of catheter related infection are present, contact the Physician -Any time the dressing is not intact, or end caps are missing, the catheter has the potential for contamination -Removal of a midline or any central line is to be performed upon the order of a Physician or authorized prescriber in accordance with the State Nurse Practice Act. Documentation: The following information should be recorded in the residents' medical record: -Objective information regarding appearance of insertion site, catheter, and dressing Review of the facility's policy titled Vascular Access Devices and Infusion Therapy Procedures; Catheter Removal indicated but was not limited to the following: -Document procedure including catheter length and integrity and patient's tolerance to procedure -Assess length and integrity of catheter and inspect catheter tip. Catheter tip should be straight or beveled. An uneven or ragged tip could indicate catheter breakage and must be addressed immediately. Review of manufacturer's instructions for use, dated August 2018, indicated but was not limited to the following: Precautions: -Follow universal precautions when inserting and maintaining the catheter -The catheter must be secured in place to minimize the risk of catheter breakage and embolization Suggested Catheter Maintenance: -Periodically confirm catheter placement, patency and security of dressing Possible Complications: The potential exists for serious complications including the following: -Air embolism (blockage of blood supply caused by air bubbles in the blood vessel), bleeding, catheter erosion, catheter embolism, catheter occlusion, catheter related sepsis, exit site infection, exit site necrosis (death of cells or tissue), extravasation (leakage of fluid)/infiltration (leakage of fluid or medication into the surrounding tissue instead of the vein), hematoma (collection of blood outside blood vessels) Resident #7 was readmitted to the facility in April 2025 from the hospital with diagnoses including urinary tract infection (UTI) and bacteremia (bacteria in the bloodstream) and had right cephalic vein midline placement. Review of the Minimum Data Set (MDS) assessment, dated 3/27/25, indicated Resident #7 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 5 out of 15. Review of Resident #7's comprehensive person-centered care plan indicated the following: Problem: -Resident returned from hospital with cholecystitis, UTI and bacteremia and is on IV antibiotics, initiated 4/4/25 Goal: -Signs and symptoms will resolve within 14 days. Resident will not develop complications related to IV use. Approach: -Administer IV antibiotic as ordered, see MAR for current orders .Has Peripheral midline IV in right forearm measuring 12 centimeters (CM), flushes and dressing changes as ordered, see MAR/Treatment Administration Record (TAR), monitor for signs and symptoms of infection, 4/4/25 Review of Pharmacy Infusion Therapy Orders, dated 4/3/25, indicated but was not limited to the following -Ertapenem (antibiotic) 1000 milligrams (mg)/1 gram (gm) daily x 10 days -Midline vascular access device -Considerations for catheter care (Midline and PICCs): Document baseline: total length, external length, and mid-upper arm circumference. Check external length with dressing change and PRN (as needed). Check arm circumference PRN. When catheter is removed, check total length and inspect catheter tip for tip integrity (refer to P/Ps - policies and procedures). Further review of the Infusion Therapy Order form did not indicate a prescriber's signature. Review of telephonic physician's orders indicated the following: -Ertapenem 1 gm/0.9% normal saline via midline daily, 4/3/25 Further review of physician's orders did not indicate the duration of treatment. Review of the April 2025 Infusion Therapy Medication Administration Record (MAR) indicated the name of the antibiotic medication Ertapenem but did not indicate the dose as required. Further review of the administration record failed to indicate the Resident's Ertapenem was documented as administered on 4/5/25 and 4/6/25 in accordance with physician's orders. Review of the April 2025 Peripheral Midline and CVAD Documentation Form and review of Nurse Progress Notes indicated but was not limited to the following: -Observation of the Resident's midline insertion site for signs and symptoms of infection or any adverse event was not consistently documented as being completed each shift per facility protocol and per care planned interventions on 4/4/25, 4/5/25, 4/6/25, 4/8/25, 4/9/25, 4/10/25, 4/15/25. Review of a Nurse Practitioner (NP #1) Progress Note, dated 4/15/25, indicated the following: -Patient has completed a course of IV antibiotics for bacteremia and had his/her midline removed today without incident, tip intact. Will continue to monitor for signs and symptoms of infection. Further review of NP #1's progress note failed to indicate the catheter length was measured upon removal to assess tip integrity for any complications during removal such as catheter breakage or migration. During an interview on 4/22/25 at 8:18 A.M., Nurse #1 said the midline catheter was removed by NP #1 on 4/15/25 and said the progress note did not indicate the total catheter length but should have. During an observation with interview on 4/17/25 at 10:18 A.M., Resident #7 showed the surveyor where the catheter insertion site had been on the right arm but said he/she didn't know if he/she had had an infection or why the catheter had been there. During an interview on 4/22/25 at 8:41 A.M., NP #1 said he removed the Resident's midline catheter on 4/15/25 after the Resident completed the course of antibiotics. He said he did not document the total catheter length upon removal but said the tip was intact. He said staff should be following the facility's protocol for catheter care including observing the site for any adverse events such as redness, swelling, and drainage. NP #1 said the antibiotic should be administered as ordered and wasn't aware if it was not administered 4/5/25 and 4/6/26. He said he did not receive any notification of such but said he wasn't aware of any issues with it. During an interview on 4/22/25 at 8:55 A.M., the surveyor reviewed Resident #7's medical record with Nurse #1 who said she could not determine if the antibiotic was administered on 4/5/25 or 4/6/25 if it wasn't documented and said there were no progress notes about it. She said it should be administered as ordered. Nurse #1 said staff should be observing the site for redness and swelling. She said she called NP #1 on 4/3/25 to obtain telephone order for the midline and had filled out the pharmacy infusion therapy order form but it was an oversight not having the prescriber sign it. She said the order sheet is the protocol staff follow for the midline orders. During an interview on 4/22/25 at 11:07 A.M., Nurse #2 said she was covering the 2nd floor on 4/5/25 and administered the antibiotic but forgot to document it and did not document that she observed the insertion site. Nurse #2 said it should be assessed to look for infection and phlebitis and to ensure its patent. She said she should have documented but didn't. During an interview on 4/22/25 at 11:51 A.M., Nurse #2 said the Infusion Therapy MAR had the medication Ertapenem listed but it did not have the dose. She said it should have and could not recall what the dose was. When asked how Nurse #2 verified the dose when administered to the Resident she said she got the dose in report, looked at the IV medication label, and could have sworn it was on a separate MAR which included the rest of the Resident's medications. The surveyor reviewed the separate MAR with Nurse #2 who said it was not on there. During an interview on 4/22/25 at 12:10 P.M., Nurse #1 said nurses should be verifying the 5 rights for medication administration including the dose. During an interview on 4/22/25 at 1:24 P.M., the Director of Nursing (DON) said the Infusion Therapy MAR should have had the dose listed but didn't. She said an agency person wrote it on there and should have known the policy to also write the dose on there. The DON said it wasn't on the other MAR either. She said the infusion order sheet was facility protocol straight from the pharmacy. The DON said when a midline catheter is removed, the total length should have been measured along with ensuring the tip was intact. She said there was no order to observe the insertion site but the Peripheral Midline and CVAD form listed it for nurses to document on it once a shift (7a-3p, 3p-11p, and 11p-7a). She said the record did not indicate the site was consistently being observed and documented to assess for infection control, infiltration, placement, signs and symptoms of infection, and any adverse events. She said the infusion therapy orders did not indicate a physician's signature but should have as they are considered orders.

Based on document review and interviews, the facility failed to ensure that licensed nursing staff and nurse aids had appropriate competencies, and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Findings include: According to the Board of Registration in Nursing, 244 CMR 9.00: Standards of Conduct, a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Review of the Matrix for Providers (listing of all residents in the facility and their pertinent care categories) completed and provided to the survey team on 4/16/25 indicated the following: -Census: 41 residents -29 residents diagnosed with Alzheimer's/Dementia -28 residents receiving high risk medications -4 residents with pressure ulcers not present on admission -4 residents with excessive weight loss without prescribed weight loss program -1 resident receiving tube feeding -1 resident with an indwelling catheter During an interview on 4/18/25 at 12:32 P.M., the Administrator said a facility-wide assessment had not been conducted to determine what resources and licensed nurses and nurse aid competencies are necessary to care for its residents competently during both day-to-day operations and emergencies. During an interview on 4/22/25 at 2:21 P.M., the Director of Nursing said she was unable to provide any evidence that licensed nursing staff and nurse aids specific competencies and skill sets was assessed to ensure they had the competency to care for residents needs as identified through resident assessments, and described in their plans of care.

Based on record review and interview, the facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, with no nurse staffing waivers in place as required, placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurse Aides (CNA) that the RN was responsible for overseeing with the provision of resident care. Specifically, the facility failed to provide the services of a RN for at least eight consecutive hours a day, seven days a week when no staffing waivers were in place on eight occasions for the period of 10/12/24 to 2/8/25 and failed to designate a Registered Nurse to serve as the Director of Nursing (DON) on a full time basis when no staffing waivers were in place. Findings include: Review of the as worked nursing schedules and timecards from 10/1/24 through 4/22/25 indicated there was no RN coverage during the day, evening, or night shift for the following days: -10/12/24 -11/16/24 -11/28/24 -12/14/24 -1/11/25 -1/12/25 -1/25/25 -2/8/25 During the Entrance Conference on 4/16/25 at 9:12 A.M., the Administrator said the facility did not have any nurse staffing waivers in place. During an interview with the Administrator, Director of Nursing (DON) and Administrative Assistant (responsible for staff scheduling) on 4/18/25 at 12:32 P.M., the surveyor reviewed the as worked nursing schedules, and staff and agency punch cards from 10/12/24 through 4/13/25 and they said there was no RN coverage on the days in question. The DON said they have had a difficult time getting RNs to work some shifts and need to hire another RN. She said she has worked at the facility since 11/3/24 and did not provide RN coverage during the shifts when they had no RN for eight consecutive hours. The Administrator said the former full-time DON left the faciity on 7/19/24 and the new full-time DON started working at the facility on 11/3/24, a span of 107 days without a full-time DON.

Based on observation, interview, and document review, the facility failed to ensure all drugs and biologicals used in the facility were stored in a safe and secure manner as required. Specifically, the facility failed to ensure: 1. For Resident #5, that prescribed topical treatment was not left unsecured and unattended at the Resident's bedside; 2. For Resident #92, that prescribed nasal spray was not left unsecured and unattended at the Resident's bedside; and 3. a. medications and treatments were not left at the second-floor nursing station unattended, b. treatment and medication carts were locked when not in direct supervision of the licensed nurse for one of two treatment carts for all days of survey and for one of two medication carts, 4. two of two medication carts were clean and free of loose pills and debris. Findings include: Review of the facility's policy, Storage of Medications, last revised April 2007, indicated but was not limited to: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. -Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. 1. Resident #5 was admitted to the facility in November 2023 and had diagnoses including Alzheimer's disease. On 4/16/25 at 8:30 A.M., the surveyor observed Resident #5 sitting upright in bed eating breakfast. A 400 gram jar of Silvadene® Silver Sulfadiazine 1% Topical Cream was noted on the Resident's bedside table. On 4/17/25 at 8:45 A.M., the surveyor observed Resident #5 sitting up in bed. A 400 gram jar of Silvadene® Silver Sulfadiazine 1% Topical Cream was noted on the Resident's bedside table. On 4/18/25 at 08:05 A.M., the surveyor observed Resident #5 sitting upright in bed. A 400 gram jar of Silvadene® Silver Sulfadiazine 1% Topical Cream was noted on the Resident's bedside table. Review of current physician's orders indicated, but was not limited to: -Silvadene to open areas on left buttock every shift and as needed -Silvadene to open areas on right buttock every shift and as needed 2. Resident #92 was admitted to the facility in April 2025 and had diagnoses including muscle wasting and atrophy. On 4/16/25 at 8:23 A.M., the surveyor observed Resident #92 sitting upright in bed. A bottle of fluticasone propionate nasal spray (a steroid medication used to reduce inflammation and swelling in the nose, airways, and skin) was noted on his/her over bed table. The Resident said he/she brought it with him/her from the hospital. Review of current physician's orders indicated, but was not limited to: -Fluticasone Propionate 50 mcg/act nasal spray, one spray each nostril daily 9:00 A.M. On 4/17/25 at 8:42 A.M. and 10:43 A.M. the surveyor observed Resident #92 sitting upright in bed. A bottle of fluticasone propionate nasal spray was noted on his/her over bed table. During an interview on 4/17/25 at 10:44 A.M., Nurse #1 said the Resident does not self-administer nasal spray. She said the bottle of fluticasone propionate the Resident brought from the hospital should not be left at the bedside. During an interview on 4/22/25 2:21 P.M., the Director of Nursing (DON) said that all medications and prescribed treatments for all residents, including Residents #5 and #92, are to be securely stored in the medication cart or medication room and not accessible to residents. 3. a. On 4/16/25 at 11:01 A.M., the surveyor observed Nurse #1 walk away from the nursing station and leave unattended a 4-pack of artificial tears, one box of Allegra 60 mg (over the counter antihistamine), one bottle of vitamin C tablets, and a spray bottle of wound cleanser on the desk at the second-floor unit nursing station. The surveyor observed the medication and treatments unattended at the nursing station on 4/16/25 at 11:24 A.M. and 11:48 A.M. b. On 4/16/25 at 8:39 A.M., the surveyor observed Nurse #1 walk away from an unlocked medication cart positioned in front of the nursing station on the second floor unit and walk down the hallway and around the corner. The unlocked medication cart was out of the line of sight of Nurse #1. On 4/18/25 at 12:08 P.M., the surveyor observed an unlocked medication cart positioned in the second-floor unit hallway. There were no nursing staff in the vicinity of the unlocked cart. Three residents were observed in the hallway unaccompanied at the time of the observation. On 4/16/25 at 11:06 P.M., the surveyor observed Nurse #1 enter the unlocked clean utility room on the second-floor unit and remove a tube from the top drawer of a multi-draw cart just inside the utility room, then leave the room and walk down the hallway and out of sight on the unlocked utility room with the unlocked cart inside it. At the time of the observation, two residents were observed ambulating in the hallway. On 4/16/25 at 11:07 A.M., the surveyor entered the unlocked clean utility room on the second-floor unit and noted an unlocked, multi-drawer treatment cart inside the room. Several items were noted on top and inside of the treatment cart including: -1 tube collaganease Santyl ointment (used to debride necrotic tissue) -1 tube pansement hydrophile (wound treatment) -1 tube PeriGuard Ointment (skin protectant with zinc) -2 tubes Tacrolimus ointment 0.1% (used to treat moderate to severe atopic dermatitis) -2 tubes diclofenac sodium 1% gel (topical anti-inflammatory cream used for controlling pain and inflammation ) -2 tubes mupirocin ointment 2% (topical pain reliever) -3 tubes betamethasone dipropionate ointment 0.5% (to relieve inflammation, itching, and redness associated with various skin conditions) -3 tubes hydrocortisone cream 1% (relieve redness, itching, swelling, or other discomfort caused by skin conditions) -1 tube fluocinimide cream .05% (relieves redness, itching, swelling, or other discomfort caused by skin conditions) -1 bottle ketoconazole shampoo 2% (used to treat dandruff) -1 bottle nystatin powder (antifungal) -individual packets of hydrocortisone cream 1% -1 bottle ammonium lactate lotion 12% (used to treat xerosis (dry or scaly skin) and ichthyosis vulgaris (an inherited dry skin condition)) -collagen dressing with silver (wound treatment) -calcium alginate wound dressing (wound treatment) -vitamin A & D ointment ( moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations) -4 jars hydrocortisone 1% cream Unlocked cabinets: -1 tube of stoma adhesive(topical adhesive) -1 bottle Hibiclens (antiseptic skin cleanser containing 4% chlorhexidine gluconate) -1 bottle 3% hydrogen peroxide (disinfectant) -1 bottle topical analgesic -1 can of shaving cream During an interview on 4/16/25 at 11:15 A.M., Nurse #1 said there is no way to lock treatment cart or the clean utility room. During an interview on 4/16/25 at 11:17 A.M., the Director of Nursing (DON) and the surveyor reviewed the contents of the unlocked treatment cart and unlocked cabinets in the second-floor clean utility room. She said the items in the treatment cart and cabinets should be secured and not easily accessible to residents in the unlocked clean utility room. On 4/17/25 at 7:12 A.M., the surveyor entered the unlocked clean utility room and opened all of the drawers of the unlocked treatment cart. All items identified in the treatment cart on 4/16/25 remained in the cart. These items were not secured and were easily accessible. At the time of the observation, one resident was observed walking in hallway outside the unlocked room. On 4/18/25 at 7:57 A.M., the surveyor entered the unlocked clean utility room and opened all of the drawers of the unlocked treatment cart. All items identified in the treatment cart on 4/16/25 remained in the cart. These items were not secured and were easily accessible. At the time of the observation, one resident was observed walking in hallway outside the unlocked room and one resident was propelling him/herself in the hallway. On 4/22/25 at 8:15 A.M., the surveyor entered the unlocked clean utility room and opened all of the drawers of the unlocked treatment cart. All items identified in the treatment cart on 4/16/25 remained in the cart. These items were not secured and were easily accessible. During an interview on 4/22/25 at 2:21 P.M., the DON said all medication carts should be locked when unattended by nursing staff. She said they have not yet secured the clean utility room or locked the treatment cart inside the clean utility room because the code cart is also stored in that room and staff need access to it in an emergency. The DON said they have not been able to find a place to keep the code cart that wouldn't be in the way of residents. 4. On 4/16/25 at 2:19 P.M., the surveyor observed the First Floor Unit medication cart to have a large amount of loose pills and paper debris on the bottom of the second drawer. On 4/16/25 at 2:37 P.M., the surveyor observed the Second Floor Unit medication cart to have the following: - A large amount of loose pills and paper debris on the bottom of the second drawer; - One box containing Latanoprost Ophthalmic solution (eye drops used to treat glaucoma), open and undated. Manufacture guidelines: You may keep the opened bottle in the refrigerator or at room temperature for up to 6 weeks. During an interview on 4/16/25 at 2:19 P.M., Nurse #2 said she was unaware of how often the medication carts were cleaned. Nurse #2 said the nurse assigned to the medication cart is responsible for its cleanliness. Nurse #2 said the medication cart should be kept clean and free of loss pills and debris. During an interview on 4/16/25 at 3:27 P.M., Nurse #1 said the 11:00 P.M. to 7:00 A.M. was responsible for cleaning the medication carts but she was unsure of how often. Nurse #1 said medications that had a shortened expiration date should be labeled with date opened and a use by date. Nurse #1 said the medication cart should be kept clean and free of loss pills and debris. During an interview on 4/16/25 at 3:12 P.M., the Director of Nursing (DON) said the expectation was for medication with shortened expiration date should be labeled with date opened and a use by date but this had not happened. The DON said the cleaning of the medication cart is the responsibility of the nurse on duty. The DON said the 11:00 P.M. to 7:00 A.M. was responsible for cleaning the medication carts but all nurses should clean the medication cart if they dropped something into it.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure food items were properly dated and stored in two of two kitchenette refrigerators. Findings include: Review of the facility's policy titled Foods Brought by Family/Visitors indicated but was not limited to the following: -Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility prepared food. -Perishable foods must be stored in re-sealable nonporous, disposable containers with tight fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item, and the use-by date. -The nursing staff will discard perishable foods on or before the use by date. -The nursing and/or food service staff will discard foods prepared for the residents that show obvious signs of potential foodborne danger (for example mold growth, foul odor, past due packaging expiration dates). Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 3-501.17 Ready to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date of day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3-29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by-date if the manufacturer determined the use-by-date based on FOOD safety. On 4/17/25 at 2:09 P.M., the surveyor reviewed the 1st Floor Unit kitchenette and observed the following: -one container of French onion dip inside a white plastic bag, labeled with resident's name and room number, not labeled with date when received or the use by date, manufacturer's expiration date 1/30/25, food item not discarded by staff when expired During an interview on 4/17/25 at 2:13 P.M., Certified Nursing Assistant (CNA) #8 said dietary aides check the refrigerators every morning for expired food items and are responsible for restocking. On 4/17/25 at 2:15 P.M., the surveyor reviewed the 2nd Floor Unit kitchenette and observed the following: -one 5.3 ounce (oz.) yogurt container, unopened, not labeled, manufacturer expiration 12/2/24, food item not discarded by staff when expired -one 8 oz. yogurt container, unopened, not labeled, manufacturer expiration 12/22/24, food item not discarded by staff when expired -one 5.3 oz. yogurt container, unopened, not labeled, manufacturer expiration 3/6/25, food item not discarded by staff when expired On 4/17/25 at 2:19 P.M., the surveyor reviewed the 1st floor and 2nd floor kitchenettes with the Line [NAME] (Certified Dietary Manager out on leave) who said dietary aides were responsible for checking the unit nourishment kitchenettes and said sometimes they don't throw away food because they're worried about the family that brought it in. The Line [NAME] said all resident food should be labeled with the name of the resident, date the food was received, and the use by date. She said the items should have been disposed of prior to expiration. She said the French onion dip container had rice pudding inside and because it wasn't labeled it needed to be disposed of. During an interview on 4/22/25 at 1:14 P.M., the Director of Nursing (DON) said all resident food should be labeled and disposed of when expired.

Based on document review 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. Maintain an accurate surveillance system that reflected potential illnesses and infections in the facility and calculate an accurate facility infection attack rate in accordance with their pre-defined McGeer criteria; 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; and 3. Ensure staff wore the appropriate personal protective equipment (PPE) while providing direct care and completing a wound dressing for Resident #28, who was on enhanced barrier precautions (EBP). Findings include: 1. Review of the facility policy titled: Surveillance for infections, dated as revised: July 2017, indicated but was not limited to the following: - the Infection Preventionist (IP) will conduct ongoing surveillance for healthcare-associated infections (HAI)s and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative measures - the criteria for such infections are based on the current standard definitions of infections - the IP is responsible for gathering and interpreting surveillance data - surveillance should include a review of any or all of the following information to help identify possible indicators of infection: lab records, skin sheets, infection control rounds, verbal report, infection control documentation, temperature logs, pharmacy records, antibiotic review and transfer summaries/logs - for residents with infections that meet the criteria for definition of infection for surveillance, collect the following data as appropriate: resident identifying information, diagnosis, date of onset of symptoms or infection, pathogen(s), infection site, risk factors, pertinent remarks, treatment measures and precautions - using the current suggested criteria for HAI's, determine if the resident has a HAI - Monthly: collect information from the infections reports and enter line listing of infections by resident for the entire month, summarize monthly data for each nursing unit by site and by pathogen - analyze the data to identify trends During entrance conference on 4/16/25 at 9:12 A.M., the Director of Nurses (DON) said she also serves as the facility IP. During an interview on 4/17/25 at 12:31 P.M., the DON said she was not sure what criteria the facility used to determine if an illness rises to the level of an infection. After review of the facility documents she said she would guess that the revised McGeer criteria is the criteria the facility is suppose to be using based on the policy references, and she would try to locate a copy of the McGeer criteria in her infection control surveillance stuff. Review of the revised 2022 McGeer criteria indicated but was not limited to the following: Syndrome: Urinary Tract Infection (UTI) without indwelling catheter Criteria: Must fulfill both 1 and 2 1. At least one of the following sign or symptom Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate Fever or leukocytosis, AND greater than 1 of the following: Acute costovertebral angle pain or tenderness, Suprapubic pain Gross hematuria, New or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency * If no fever or leukocytosis, then greater than 2 of the following: Suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency 2. At least one of the following microbiologic criteria 50,000 cfu/mL of no more than 2 species of organisms in a voided urine sample 20,000 cfu/mL of any organism(s) in a specimen collected by an in-and-out catheter Syndrome: Common cold syndrome or pharyngitis Criteria: Must fulfill at least 2 criteria Runny nose or sneezing Stuffy nose or nasal congestion Sore throat, hoarseness or difficulty swallowing Dry cough Swollen or tender glands in the neck Review of the facility monthly surveillance from January to March 2025 indicated but was not limited to the following: January 2025: Resident #193; category: LRI (lower respiratory infection); Date of onset (DOO): 1/8/25; Symptoms (S): cough, congestion; final status: HAI; count: Yes The January surveillance listings used a non-approved category for identification of the Resident's syndrome/category in accordance with the facility pre-determined McGeer criteria and did not have enough symptoms documented to indicate any McGeer infection for the lower respiratory tract (Pneumonia or Bronchitis) February 2025: Resident #192; category: UTI (urinary tract infection); DOO: 2/1/25; S: frequency; culture site: urine; results: multi-gram positive organisms; final status: HAI; count: Yes Resident #192 did not have sufficient documented symptoms to meet the criteria for a UTI in accordance with the facility pre-defined McGeer criteria and therefore should not have been counted as an HAI infection within the facility. March 2025: Resident #17; category: UTI; DOO: 3/31/25; S: foul odor (FO); culture site: urine; results: e-coli; final status: HAI; count: Yes Resident #37; category URI (upper respiratory infection); DOO: 3/5/25; S: cough, congestion; final status: HAI; count: Yes Resident #17 did not have sufficient symptoms documented on the surveillance sheet to meet McGeer criteria for a UTI and should not have counted an HAI infection. In addition, there is no such McGeer approved syndrome/category called URI. The surveillance was inaccurate and failed to indicate the use of the pre-defined McGeer criteria. During an interview on 4/18/25 at 10:51 A.M., the DON reviewed the surveillance with the surveyor and said she was not using the McGeer criteria, as she was suppose to, and instead was just using the general abbreviation lab key on the back of the surveillance sheets and then deciding for herself if they should be counted based on symptoms and treatments. She said she is new to this process and still learning. She said the categories and symptoms should have been in line with McGeer criteria and the surveillance for the last three months is inaccurate since the McGeer criteria was not used when making decisions on whether or not the illness was categorized appropriately, the illness rose to the level of an infection and the illness would therefore count as an infection within the facility. 2. Review of the facility policy titled: Legionella water management program, dated as revised: July 2017, indicated but was not limited to the following: - as part of the infection prevention and control program, the facility has a water management program, which is overseen by the water management team; the facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella - the purpose of the water management program is to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease - the water management program is based on the Centers for disease control and prevention recommendations for developing a Legionella water management program - the water management program includes: an interdisciplinary water management team, a detailed description and diagram of the water system in the facility, the identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, the identification of situations that could lead to growth, specific measures to control the introduction or spread of Legionella, control limits and a system to monitor them, a diagram of where control measures are applied, documentation of the program On 4/16/25 at 1:08 P.M., the survey team requested the facility Water management program for waterborne bacteria, including Legionella During an interview on 4/16/25 at 4:17 P.M., the Maintenance Director and Administrator said they did not have a Water management program and were not aware of the need for a water management program. They reviewed the criteria as set forth in their policy and they said they thought the policy was the program and there was some confusion, but there are no documents that could be produced to demonstrate the facility had a building specific water management program currently in place. 3. Review of the Enhanced Barrier Precautions (EBP) sign in use by the facility, indicated but was not limited to the following: - Stop, everyone must clean their hands including before entering and when leaving the room - Providers and staff must also: Wear gloves and a gown for the following high contact resident care activities: Wound care - any skin opening requiring a dressing. Resident #28 was admitted to the facility in February 2025 with diagnoses including: Neurocognitive disorder with Lewy bodies and pressure ulcer of the sacral region During a wound care observation on 4/17/25 at 11:19 A.M. Nurse #2 and Certified nurse aide (CNA) #8 were observed to perform alcohol based hand run (ABHR) hand hygiene (HH) and put on clean gloves to reposition Resident #28 in the bed to begin the wound treatment to the sacral area, neither staff were observed to put on a gown to provide the direct contact care. CNA #2 held the Resident on their left side facing towards her with her body touching both the Resident and the bed. Nurse #2 leaned over the bed and completed the wound care treatment including: removing the old dressing, cleansing the area, measuring the depth and placing a new dressing into the wound cavity and over the top of the primary treatment. Staff then repositioned the Resident in the bed for comfort boosting them higher in the bed and slightly onto one side. Nurse #2 and CNA #8 were not observed to have a gown on throughout the entire process of repositioning the Resident or providing the wound care. During an interview on 4/17/25 at 11:27 A.M., CNA #8 confirmed Resident #28 was on EBP. She said she should have put on a gown to reposition the Resident in the bed and assist with wound care but did not. During an interview on 4/17/28 at 11:28 A.M., Nurse #2 said the Resident is on EBP for his/her open wounds. She said both herself and the CNA should have been wearing a gown while providing direct care and completing the wound treatment to the Resident's sacrum, but they did not. During an interview on 4/17/25 at 12:29 P.M., the Director of Nurses said her expectation is that the staff would follow the EBP signs and wear the appropriate PPE when providing direct care and both Nurse #2 and CNA #8 should have been wearing gowns while they were repositioning and performing a wound care treatment on Resident #28.

Based on interviews the facility staff failed to ensure a system was in place to monitor that every Certified Nurse Aide (CNA) completed the required 12 hours of in-service training per year. Findings include: During interviews on 4/16/25 at 9:12 A.M. and 4/22/25 at 2:21 P.M., the Director of Nurses (DON) indicated she also carries the responsibility of the Staff Development Coordinator. She said she has not conducted any staff training since she started working at the facility in November 2024. The DON was unable to provide evidence that CNA staff completed the required 12 hours of in-service training prior to her employment at the facility in November 2024.

Based on document review and interview, the facility failed to designate a person who met the minimum qualifications to serve as the Food Service Director (FSD). Specifically, the facility did not employ a full-time dietician or have a qualified dietary employee in the facility who met the minimum qualifications to serve as FSD from 11/20/24 to throughout the survey period. Findings include: During an interview on 4/17/25 at 10:23 A.M., the Line [NAME] said the Certified Dietary Manager (CDM) had been out on leave for approximately four months now. The Line [NAME] said she was just a cook and did not possess the education or training to be the interim CDM while the CDM was out. She said the Dietician was only part-time and worked two days a week. She said no one from the company or sister facilities had been in to cover for the CDM while she was out. The Line [NAME] said, I'm the one doing the work, but said she'll call the CDM at home for advice on what to do if needed, if there were any issues, and when food orders were needed. The Line [NAME] said she's been in her role for 10 years now so knows what to do. Review of the Dietician's November 2024 through March 2025 punch cards indicated the Dietician worked part-time at the facility. The April 2025 punch card was not provided. During an interview on 4/17/25 at 12:12 P.M., the Director of Nursing (DON) said the Dietician was only part-time and was usually at the facility on Sundays and one day during the week. During an interview on 4/17/25 at 2:40 P.M., the DON said the CDM went out on leave on 11/29/24 but was expected to return soon. During an interview on 4/22/25 at 9:50 A.M., the Line [NAME] said she meets with the dietician only once a month when she's at the facility and doesn't even know her contact number to call if needed. During an interview on 4/22/25 at 1:14 P.M., the DON said there hasn't been a qualified dietary employee in the facility who met the minimum qualifications to serve as FSD since the CDM left that she knows of.

Based on interviews, the facility staff failed to comprehensively assess the facility resources needed to provide sufficient support and care for the resident population and develop a Facility Assessment as required. Findings include: During an interview on 4/18/25 at 12:32 P.M., the Administrator said he was unable to find a Facility Assessment document. He said he doesn't know if there is one because they have never reviewed it in their Quality Assurance Performance Improvement meetings. During an interview on 4/22/25 at 2:21 P.M., the Director of Nursing said she and the Administrator had thoroughly searched all of their documentation and said the facility had not conducted and developed a Facility Assessment document.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy review, the facility failed to maintain a clean, sanitary, and homelike environment for residents residing on two of two units. Findings include: Review of the facility's policy titled Cleaning of Common Areas, undated, indicated but was not limited to: -Ensure all common areas are clean and neat -All staff are responsible for seeing that the common areas are clean and neat -The following cleaning schedule will be maintained: Dining Room(s): Daily -Any area will be cleaned if found to be dirty, even if it not the scheduled day for cleaning that area Review of the facility's policy titled Cleaning Resident Rooms, undated, indicated but was not limited to: -Ensure resident rooms are clean and sanitary -A complete routine cleaning includes: a. Cleaning the bathroom. b. Dusting tops and sides of wood furniture using furniture polish. Carefully remove items on tops of furniture to dust and then replace items exactly as they were before moving. Clean top of windowsills and heating units. c. Using all-purpose cleaner, clean countertops, fronts of cabinets and inside of sink and faucet. d. Sweep or vacuum the floor of the room that is not obstructed by furniture. Review of the facility's policy titled Cleaning Bathrooms, undated, indicated, but was not limited to: -Ensure resident rooms are clean and sanitary -Spray bathroom cleaner (disinfectant) on exterior toilet bowl and base, seat and lid. Wipe clean with wet rag -Sweep or vacuum bathroom floor -Use a clean mop, medium-hot water and floor cleaner, mop bathroom floor working from the farthest side of the bathroom to the doorway. Be sure mop is wrung out properly to prevent puddles of water on the floor The surveyors made the following observations of environmental cleanliness concerns during the survey: First Floor: On 4/1/24 at 1:08 P.M., in room [ROOM NUMBER], the flooring was dirty with dust and gray/black debris around the perimeter of the room. In the bathroom, large amounts of dust and gray/black debris were noted along the perimeter and in the corners of the room. On 4/1/24 at 1:15 P.M., in room [ROOM NUMBER], the flooring was dirty with dust and gray debris around the perimeter of the room. On 4/1/24 at 8:35 A.M., in room [ROOM NUMBER], the flooring was dirty with dust and gray/black debris around the perimeter of the room and heavily noted behind the door to enter the room. A dry, yellow substance was noted on the floor at the entrance of the room. On 4/1/24 at 1:20 P.M., in room [ROOM NUMBER], the flooring was dirty with dust and gray/black debris around the perimeter of the room and heavily noted behind the door to enter the room. A dry, yellow substance was noted on the floor at the entrance of the room. The second bed wardrobe was delaminating. On 4/1/24 at 1:28 P.M., in room [ROOM NUMBER], the flooring was dirty with dust and gray/black debris around the perimeter of the room and was heavily noted behind the door and around the doorstop. On 4/1/24 at 1:29 P.M., in room [ROOM NUMBER], the flooring was dirty with dust and gray/black debris around the perimeter of the room, and trash/debris was noted behind and under the beds. On 4/1/24 at 8:50 A.M., the first-floor dining room, the flooring was dirty with dust and gray/black debris around the perimeter of the room, the wall had a large amount of vertical and horizontal brown stains, and there were scattered crumbs and debris on the floor. Second Floor: On 3/28/24 at 9:13 A.M., in room [ROOM NUMBER], the flooring was dirty with large amounts of gray/black debris on the floor and around the perimeter of the room. On 4/1/24 at 8:09 A.M., in room [ROOM NUMBER], the flooring was dirty with dust and gray/black debris around the perimeter of the room, debris was heavily noted around the doorframes. On 4/1/24 at 12:30 P.M., in room [ROOM NUMBER], the flooring was dirty with dust and gray/black debris around the perimeter of the room, debris was heavily noted around the doorframes. In the resident bathroom (shared with room [ROOM NUMBER]), rust was noted on the vent and the floor was dirty with dust and gray/black debris, a dry, brown stain was observed on the floor. On 3/28/24 at 9:29 A.M., in room [ROOM NUMBER], the flooring was dirty and had brown staining by a resident bureau. Behind a resident chair, gray debris and shreds of black material were noted. Dust and gray/ black debris was observed along the perimeter of the entire room. On 4/1/24 at 8:16 A.M., in room [ROOM NUMBER], the flooring was dirty and had brown staining by a resident bureau. Behind a resident chair gray/black debris and shreds of black material were noted. Dust and gray/black debris was observed along the perimeter of the entire room and was very heavily noted around the doorframes. On 4/1/24 at 12:35 P.M., in room [ROOM NUMBER], the flooring was dirty and had brown staining by a resident bureau. Behind a resident chair gray/black debris and shreds of black material were noted. Dust and gray/black debris was observed along the perimeter of the entire room and was very heavily noted around the doorframes. In the bathroom, rust was noted on the vent and the floor was dirty with dust and gray/black debris. On 3/28/24 at 9:37 A.M., in room [ROOM NUMBER], the flooring was dirty with large amounts of dust and gray/black debris around the perimeter of the room and around the doorway jam, an empty medication cup was noted on the floor behind the door. On 4/1/24 at 8:20 A.M., in room [ROOM NUMBER], the flooring was dirty with large amounts of dust and gray/black debris around the perimeter of room and around the doorway jam, an empty medication cup was noted on the floor behind the door. Gray/black debris was heavily noted in the corner of the resident's closet. On 4/1/24 at 12:33 P.M., in room [ROOM NUMBER], the flooring was dirty with large amounts of dust and gray/black debris around the perimeter of room and around the doorway jam, an empty medication cup was noted on the floor behind the door. Gray/black debris was heavily noted in the corner of the resident's closet. On 3/28/24 at 9:51 A.M., in room [ROOM NUMBER], the flooring was dirty with dust and gray/black debris around the perimeter of the room and under the residents' beds. On 4/1/24 at 8:25 A.M., in room [ROOM NUMBER], the flooring was dirty with dust and gray/black debris around the perimeter of the room. On 4/1/24 at 12:13 P.M., in room [ROOM NUMBER], the flooring was dirty with dust and gray/black debris around the perimeter of the room and under a resident overbed table. On 4/1/24 at 8:29 A.M., in room [ROOM NUMBER], the flooring was dirty with dust and gray/black debris around the perimeter of the room/bathroom. On 4/1/24 at 12:38 P.M., in room [ROOM NUMBER], the flooring was dirty with dust and gray/black debris around the perimeter of the room/bathroom and under resident beds. A brown dry substance was noted on the floor in the corner of the room. On 4/1/24 at 8:42 A.M., in room [ROOM NUMBER], the flooring was dirty with dust and gray/black debris around the perimeter of the room and around resident furniture. A dry yellow substance was noted on the floor at the entrance of the room, a bin for personal protective equipment (PPE) had a dry brown substance on the cover, and the wall behind the PPE bin was streaked with vertical brown staining. In the bathroom, the flooring was dirty with dust and gray/black debris around the perimeter of the room/toilet and a dry yellow substance was noted on the floor in front of the toilet. On 4/1/24 at 12:52 P.M., in room [ROOM NUMBER], the flooring was dirty with dust and gray/black debris around the perimeter of the room, gray/black debris was heavily noted behind the room door, under the resident chairs, and under/around the heating unit. On 4/1/24 at 8:45 A.M., in room [ROOM NUMBER], the flooring was dirty with dust and gray/black debris around the perimeter of the room and resident bathroom. On 4/1/24 at 12:24 P.M., in room [ROOM NUMBER], the flooring was dirty with dust and gray/black debris around the perimeter of the room and in the resident bathroom. In the resident bathroom, rust was noted on the vent. On 4/1/24 at 12:44 P.M., in room [ROOM NUMBER], the flooring was dirty with large amounts of dust and gray/black debris around the perimeter of the room, gray/black discoloration was noted around and under the resident bureaus. Behind the door into the room, a distinct gray/brown discoloration was noted. In the bathroom, the flooring was dirty with large amounts of dust and gray/black debris, a dry brown substance was noted on the floor, and the vent was rusted. On 4/1/24 at 12:55 P.M., in room [ROOM NUMBER], the flooring was dirty with dust and gray/black debris around the perimeter of the room. The resident privacy curtain was noted to have several brown stains on it. In the bathroom, the flooring was heavily discolored with gray/black staining and large amounts of dust and gray/black debris was noted along the perimeter. On 4/1/24 at 12:57 P.M., in room [ROOM NUMBER], the flooring was dirty with dust and gray/black debris around the perimeter of the room and was heavily noted behind the door to enter the room. On 4/1/24 at 8:41 A.M., in the second-floor dining room, the flooring was dirty with dust and gray/black debris around the perimeter of the room, the trash barrel had a large amount of thick brown/yellow dry debris on the lid, the wall had horizontal black markings and brown staining vertically, and there was scattered crumbs and debris on the floor (breakfast had not been served yet). On 4/1/24 at 8:40 A.M., the second-floor shower room had a faint odor of urine, the flooring was dirty with gray/black debris around the perimeter of the room, and between the shower stall and floor the grout/caulking was dark black. On 4/1/24 at 12:21 P.M., the second-floor shower room had an odor of urine, the flooring was dirty with gray/black debris around the perimeter of the room, and between the shower stall and floor the grout/caulking was dark black. On 4/1/24 at 12:26 P.M., the second-floor men's resident bathroom had gray discolored tiles with dust and gray/black debris around the perimeter of the room, and the floor was sticky. During an interview on 4/1/24 at 12:44 P.M., Resident #1 said the room was cleaned weekly but the bathroom was cleaned even less. Resident #1 said he/she found herself trying to clean it often. Resident #1 said the edges of the room and around the toilet in particular could use some extra attention. During an interview on 4/1/24 at 1:28 P.M., Resident #37 said he/she thought the edges and corners of the room could be cleaned a lot better. Resident #37 said there was improvement to be made when cleaning around the toilet. During an interview 4/1/24 at 2:36 P.M., Resident #37 said his/her room had just been cleaned but the edges of the room and bathroom were still gross. During an interview on 4/1/24 at 2:42 P.M., Certified Nursing Assistant (CNA) #3 and #4 said the edges of the rooms could be a lot cleaner and housekeeping should move stuff around and clean behind everything. During an interview on 4/1/24 at 3:05 P.M., Nurse #3 said the facility had a room of the day cleaning schedule, but it was not consistently done. Nurse #3 said the rooms were not thoroughly cleaned and needed more attention. During an interview on 4/1/24 at 2:51 P.M., Housekeeper #1 said the process for cleaning resident rooms included sweeping and mopping every day, wiping down the mirrors and walls if needed. Housekeeper #1 said although the facility had a room of the day, all rooms were cleaned daily. The surveyor and Housekeeper #1 observed a room which had already been cleaned for the day. The surveyor pointed out behind the door, a large amount of dust/debris, Housekeeper #1 said the area had been overlooked and required further cleaning. During an interview on 4/1/24 at 4:32 P.M., the Minimum Data Set (MDS) Nurse, covering for the Director of Nurses, said housekeeping should be cleaning all surfaces of resident rooms and shared spaces daily. The MDS Nurse said the expectation included cleaning behind the doors and around the perimeter of the room and furniture. During an interview on 4/1/24 at 4:47 P.M., the Administrator said the cleanliness of the building could be better and the daily cleaning did not meet his expectations. The Administrator said the expectation was for the resident rooms and shared spaced to be clean and without buildup of dust and/or debris. The Administrator said walls and floors should not be stained and resident privacy curtains should be changed when visibly dirty.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure the environment remained free of accident hazards. Specifically, the facility failed to: 1. Ensure residents were provided an environment that was free from hazardous chemicals on one of two units; and 2. Ensure electrical outlets were securely covered. Findings include: 1. On 4/1/24 at 8:22 A.M., the surveyor observed the second-floor housekeeping closet door unattended and ajar. On 4/1/24 at 9:29 A.M., the surveyor observed the second-floor housekeeping closet door unattended and ajar. On 4/1/24 at 12:06 P.M., the surveyor observed the second-floor housekeeping closet door unattended and wide open. The contents of the housekeeping closet included: -1 bottle of disinfecting all-purpose spray and glass cleaner -1 open container of disinfecting wipes -1 one-gallon bottle of germicidal ultra-bleach -1 can of baseboard stripper -1 bottle of toilet bowl cleaner -1 gallon of finished floor cleaner -1 container of sanitizing hand wipes -1 can of heavy-duty multi-use silicone lubricant On 4/1/23 at 12:10 P.M., the surveyor observed Housekeeper #1 return to the housekeeping closet, at 12:12 P.M. Housekeeper #1 exited the housekeeping closet leaving the door wide open. Housekeeper #1 entered the soiled utility room with the door closed behind him. On 4/1/24 at 12:44 P.M., the surveyor observed the second-floor housekeeping closet door unattended and ajar. On 4/1/24 at 2:00 P.M., the surveyor observed the second-floor housekeeping closet door unattended and ajar. During an interview on 4/1/23 at 12:11 P.M., Housekeeper # 1 said the housekeeping closet should be locked and closed when not attended. 2. On 4/1/24 at 12:33 P.M., and on 4/2/24 at 11:01 A.M., in room [ROOM NUMBER], the surveyor observed one electrical outlet without a faceplate in place. The outlet was being utilized for an oxygen concentrator and resident bed. On 4/1/24 at 12:55 P.M., in room [ROOM NUMBER], the surveyor observed one electrical outlet without a faceplate in place. The outlet had one black cord plugged into it. On 4/1/24 at 1:15 P.M., in room [ROOM NUMBER], the surveyor observed one electrical outlet with the faceplate not flush to the wall with exposed wiring. During an interview on 4/1/24 at 2:42 P.M., Certified Nursing Assistant (CNA) #3 and #4 said residents should not have access to chemicals or cleaning products and the housekeeping closet door should be locked and closed when unattended. CNA #3 and #4 said when an outlet did not have a covering it was a safety issue and maintenance should be made aware so it could be repaired. CNA #3 and #4 said any room storing a chemical should be locked and not accessible to residents. During an interview on 4/1/24 at 3:05 P.M., Nurse #3 said the housekeeping closet should be closed and locked when unattended. Nurse #3 said outlets should always be covered with a faceplate. During an interview on 4/1/24 at 2:51 P.M., Housekeeper #1 said chemical products should be stored in locked closets. Housekeeper #1 said all electrical outlets should be covered with an intact faceplate. During an interview on 4/1/24 at 4:32 P.M., the Minimum Data Set (MDS) Nurse, covering for the Director of Nursing, said all chemical products should be stored in a locked closet, and not accessible to residents. The MDS Nurse said electrical outlets required a faceplate and should not have exposed wiring. During an interview on 4/1/24 at 4:47 P.M., the Administrator said all chemicals and hazardous chemicals should be stored in locked areas, and not accessible to residents. The Administrator said the housekeeping closet being opened and unattended on the second floor was a concern because there were cognitively impaired residents on the unit. The Administrator said all electrical outlets should be covered with a faceplate and wires should not be exposed. During an interview on 4/2/24 at 12:50 P.M., the Director of Housekeeping said all chemicals should be stored behind locked doors. The Director of Housekeeping said the facility did not have a policy for storage of chemicals/hazardous materials.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed for one Resident (#1), out of a sample of 12 residents, to: 1. Ensure Resident #1's code status was not changed from a Full Code to a Do Not Resuscitate (DNR) without notifying and obtaining the proper authority through the court system, and 2. Inform the court appointed guardian that Resident #1 and the facility physician signed the Medical Orders for Life-Sustaining Treatment (MOLST), changing the Resident's code status from a Full Code to a DNR. Findings include: Resident #1 was admitted to the facility in [DATE] with diagnoses of schizophrenia, manic depression (bipolar disease), anxiety, and altered mental status. Resident #1 has a court appointed guardian without an expansion to formulate and sign a MOLST. Review of the most recent Minimum Data Set (MDS) assessment, dated [DATE] indicated Resident #1 scored a 13 out of 15 on the Brief Interview for Mental Status, indicating he/she was cognitively intact. The MDS further indicated the Resident had disorganized thinking behavior which fluctuates (comes and goes, changes in severity). Review of the court document titled Letters of Guardianship for an incapacitated person, dated [DATE], indicated Resident Representative #1 was appointed on [DATE] as the permanent Guardian and the appointment is a determination that Resident #1 is incapacitated. There is no expansion granting authority for the Guardian to sign a MOLST. Review of Resident #1's MOLST, signed by Resident #1 and Physician #1 on [DATE], indicated but was not limited to the following: -This form should be signed based on goals of care discussions between the patient (or patient's representative signing below) and the signing clinician. -A guardian can sign only to the extent permitted by Massachusetts law. Consult legal counsel with questions about a guardian's authority. - Cardiopulmonary resuscitation (CPR): Do Not Resuscitate Review of Resident #1's current care plan indicated but was not limited to the following: a. Resident #1 has a Guardian and is a full code. Review full code status quarterly, change in condition or per Guardian request. b. Resident #1 has decided that he/she wants to be a DNR, O.K. to intubate, No decision on dialysis. Physician notified Guardian #1 via phone regarding Resident #1's decision regarding advanced directives. Review of Physician #1's progress note, dated [DATE] indicated the following: The patient is seen to discuss advanced care planning. The patient states he/she feels well today and denies fever, cough, or abdominal pain. Resident #1 is alert and conversant and willing to enter into discussion. Resident#1 does not have a MOLST currently and is a full code. He/She has a guardian but demonstrates good ability to understand the topics discussed. The patient is a former intensive care nurse and expresses pride in this and is familiar with resuscitation and issues involved. When asked if he/she would want CPR in the event of a cardiac arrest, he/she appropriately referenced the low likelihood of success of this, and the high likelihood of worst debility should it succeed. Resident#1 declined CPR at this time. He/She would want to be intubated, but short term only, expresses good understanding of prolonged ventilation and poor prognosis associated with this. Resident #1 would want to be hospitalized and would want intravenous fluids if necessary. Resident #1 would not want a feeding tube and expresses good insight into poor prognosis of feeding tubes at end of life. Resident #1 did not want to make a decision regarding dialysis, stating, I would need to see what my situation was at the time that I might need it. Again, understanding of the risk involved is good. MOLST filled out in accordance with these wishes and placed in the chart. Order for DNR entered. Message left with Guardian #1 to update. During an interview on [DATE] at 01:30 P.M., Social Worker (SW) #1 said Resident #1 does have a guardian in place. He said he has spoken with Guardian #1 and has asked her to fill out a MOLST, but she declined signing the MOLST stating she does not have the legal powers to sign the MOLST. He said Physician #1, who previously worked in the facility, said she knew Resident #1 and she would handle it. SW #1 said Physician #1 went to see Resident #1, evaluated him/her and had the Resident sign the DNR and then wrote orders for the advanced directives for the Resident #1 to be a DNR. SW #1 said he was under the impression a doctor could evaluate a resident and then sign the MOLST. During a telephonic interview on [DATE] at 11:30 A.M., Guardian #1 said SW #1 has asked her to sign a MOLST for Resident #1, but she has declined because she does not have the authority to make those end-of-life decisions. She said she told the facility they have to go to court and the court can make the decision regarding a MOLST form. Guardian #1 said she was not aware that Resident #1 had signed a MOLST form with the physician making Resident #1 a DNR. She said she was very upset nobody informed her or discussed with her that Resident#1 signed a MOLST form with a Physician. Guardian #1 said according to the Massachusetts courts, Resident #1 does not have the capacity to make end of life decisions and sign the MOLST.

Based on record review, policy review, and staff interview, the facility failed to ensure two Residents (#7 and #41), out of a total sample of 12 residents, had information in advance to exercise their rights. Specifically, 1. For Resident #7, the facility failed to ensure the Resident was given information necessary to make health care decisions, including the risks and benefits of psychotropic medications and failed to obtain consents for their use from the Resident, prior to administration; and 2. For Resident #41, the facility failed to obtain consent for care and treatment from a Resident who was able to sign the consents. Findings include: Review of the facility's policy titled, Psychoactive Medication, dated as revised 2/2022, indicated but was not limited to: - Obtain physician's order, a physician's order and appropriate diagnosis is required for all psychoactive medications. - An informed consent from the resident (or legally authorized individual in the case of resident incompetence) is required for administration of psychoactive medication. 1. Resident #7 was admitted to the facility in May 2018 with diagnoses including depression, schizoaffective disorder, and dementia. The HCP was invoked on 8/17/22 and was not in effect during the renewal of the psychotropic medication consents (2/14/22 - 8/17/22). Review of the medical record indicated the following current Physician's Orders for psychotropic medications: - Zoloft 75 milligrams (mg) daily (anti-depressant) - Abilify 10 mg daily (antipsychotic) - Risperidone 1 mg twice a day (antipsychotic) - Lithium carbonate 150 mg twice a day (mood stabilizer) Review of the Medication Administration Record (MAR) from 2/14/22 through 8/17/22 indicated Zoloft, Abilify, Risperidone and Lithium were administered as ordered by the Physician. Review of Resident #7's medical record failed to indicate the facility obtained an Informed Consent for Psychotropic Medication form, signed by the Resident, prior to the HCP being invoked. Instead, the Resident's Health Care Agent consented for use of the psychotropic medications. 2. Resident #41 was admitted to the facility in September 2022 with a fractured right hip. Review of Resident #41's medical record indicated the Health Care Proxy was not invoked during his/her admission from September 2022 through November 2022. Review of Resident #41's medical record failed to indicate the Resident had signed and consented to care and treatment, specifically, consent to treat, consent for immunization, consent for foot services, and information for the risk and benefits for side rails. Instead, the facility obtained informed consent from the Resident's family members for immunizations and podiatry services. During an interview on 12/2/22 at 11:48 P.M., the Director of Nurses (DON) said if the Residents (#7 and #41) were able to sign the consents, then staff should have followed up and reviewed the consent forms again in order to obtain signed informed consent from the Residents.

Based on interview and record review, the facility failed to ensure the right to formulate advanced directives was maintained for one Resident (#29), in a total sample of 12 residents. Findings include: Resident #29 was admitted to the facility in June 2021. Review of the medical record indicated Resident #29 had not formulated advance directives prior to admission in June 2021. Further review indicated the Resident continued to be capable of making their own medical decisions until the Health Care Proxy (HCP) was invoked on 8/31/22. Review of the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) indicated it was not signed by Resident #29. Further review indicated the MOLST was completed and signed by a family member of Resident #29's on 3/11/21. The MOLST indicated Resident #29 was to be a Do Not Resuscitate (DNR), Do Not Intubate/Ventilate (DNI/DNV), No dialysis, and No artificial nutrition. Record review (paper and electronic) failed to indicate the Resident had requested to formulate an advance directive and/or consented to the directives formulated on the MOLST form. During an interview on 12/2/22 at 11:48 P.M., the Director of Nurses (DON) said if the Resident was able to formulate and sign a MOLST form, staff should have followed up and reviewed the MOLST form again and obtain signed informed consent from the Resident.

Based on interview and record review, the facility failed to accurately document the administration of an as needed (PRN) Oxycodone in the Medication Administration Record (MAR) and nursing notes for one Resident (#12), out of a total sample of 12 residents. Specifically, the facility failed to: a. Document four times in the MAR or nursing notes for the month of October the ten administrations of PRN Oxycodone recorded in the narcotic book, and b. Document three times in the MAR or nursing notes for the month of November the six administrations of as needed Oxycodone recorded in the narcotic book. Findings include: Review of the facility's policy titled Documentation of Medication Administration, revised 2/2/22, indicated, but was not limited to: -A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR). -Administration of medication must be documented immediately after (never before) it is given. -Documentation must include, at a minimum: a. Name and strength of the drug; b. Dosage; c. Method of administration (e.g., oral, injection (and site), etc.); d. Date and time of administration; e. Reason(s) why a medication was withheld, not administered, or refused (as applicable); f. Signature and title of the person administering the medication; and g. Resident response to the medication, if applicable (e.g., PRN, pain medication, etc.). Resident #12 was admitted to the facility in July 2021 with diagnoses that included chronic pain syndrome. Review of the Minimum Data Set (MDS) assessment, dated 9/22/22, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. Review of the current Physician's Order indicated but was not limited to: -Oxycodone HCL IR 5 milligrams (mg) tablet, one tablet by mouth every four hours as needed for pain (scale 7-10). During an interview on 11/30/22 at 12:27 P.M., Resident #12 said he/she could not recall getting his/her pain medication on 11/29/22 and that he/she asked for it at 7:00 P.M. and then again at 8:00 P.M. Resident #12 said the staff told him/her that it had been administered. a. Review of the October 2022 Narcotic Book indicated that Oxycodone 5 mg tablet was signed out a total of ten times on the following dates: -10/2/22 -10/10/22 (twice) -10/16/22 (twice) -10/20/22 -10/21/22 -10/28/22 (twice) -10/31/22 Review of the October 2022 Medication Administration Record (MAR) indicated that administration of Oxycodone 5 mg tablet was documented on 2 of 10 opportunities on the following dates: -10/2/22, time of administration not recorded -10/31/22, time of administration and response to medication not recorded Review of October 2022 nursing notes indicated that the administration of Oxycodone 5 mg tablet was documented on 3 of 10 opportunities on the following dates: -10/20/22 at 11:00 A.M. -10/21/22 at 2:45 P.M. -10/31/22 at 6:00 P.M. 2. Review of the November 2022 Narcotic Book indicated that Oxycodone 5 mg tablet was signed out a total of six times on the following dates: -11/2/22 -11/7/22 -11/11/22 -11/18/22 -11/29/22 -11/30/22 Review of the November 2022 MAR indicated administration of Oxycodone 5 mg tablet was documented on 2 of 6 opportunities on the following dates: -10/2/22, time of administration not recorded -10/31/22, time of administration and response to medication not recorded Review of November 2022 nursing notes indicated that administration of Oxycodone 5 mg tablet was documented on 1 of 6 opportunities on the following dates: -11/29/22 at 2:45 P.M. During an interview on 12/1/22 at 12:27 P.M., the Director of Nurses (DON) said that when an as needed medication is administered the nurse should initial the MAR and then document on the back of the MAR. The nurse should include the purpose of use and a follow up including effectiveness. The DON said that at the very least the administration of the medication should be documented in a nursing note.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to hold a Medicaid-funded resident's personal funds in an interest-bearing account for one Resident (#1), out of a sample size of 12 residents. Findings include: Resident #1 was admitted to the facility in October 2020 with diagnoses of schizophrenia, manic depression (bipolar disease), anxiety, and altered mental status. Resident has a court appointed guardian. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/25/22, indicated Resident #1 scored a 13 out of 15 on the Brief Interview for Mental Status, indicating he/she was cognitively intact. The MDS further indicated Resident #1 had disorganized thinking behavior which fluctuates (comes and goes, changes in severity). Review of the court document titled Letters of Guardianship for an incapacitated person, dated 2/13/20, indicated Resident Representative #1 was appointed on 3/21/19 as the permanent Guardian and the appointment is a determination that Resident #1 is incapacitated. During a telephonic interview on 12/6/22 at 11:30 A.M., Resident #1's Guardian said [NAME] Nursing Home does not have a personal needs account system in place. She said she asked if they could set up one and she was told they do not do that. She said they requested cash be sent, because Resident #1 cannot go to the bank to cash a check and they don't have the means to cash a check. She said she would provide the accounting of the cash money she has sent to the facility via e-mail. Review of Resident #1's Guardian's accounting records indicated the following disbursements were made to the facility: On 12/30/21- $72.50 On 02/15/22- $72.50 On 03/16/22- $72.50 On 04/19/22- $72.50 On 05/20/22- $72.50 On 06/22/22- $72.50 On 07/18/22- $72.50 On 10/25/22- $220.00 On 11/08/22- $220.00 Total disbursement of $947.50 During an interview on 11/30/22 at 01:39 P.M., Social Worker (SW) #1 said Resident #1's Guardian has been sending cash to him for the past year to give to Resident #1. He said the Guardian was good at first sending the cash, but then fell behind. He intervened and the Guardian agreed in an e-mail, dated 10/26/22, to send $220.00 in cash to him for August, September, and October, and another $220.00 the following week for November, December, and January. He said when he received the first $220.00, he gave Resident #1 $80.00 in cash and put the remaining $140.00 in a locked box in the business office. He said he has not received the second $220.00 dollars. SW #1 said they do not have a system to open bank accounts for residents, they generally encourage families or responsible parties to handle the residents' money themselves. SW #1 said Resident #1's extra money is not kept in an interest-bearing account, it is kept under lock and key in the business office. During an interview on 11/30/22 at 02:26 P.M., the Administrator said the facility does not manage any personal needs accounts. The Administrator was informed SW #1 said he was managing Resident #1's money and currently had $140.00 locked in the business office. The Administrator said he was not aware the facility was managing Resident #1's money. The Administrator said he is aware if a resident has over $50.00, it should be maintained in an interest-bearing account. During an interview on 11/30/22 at 03:35 P.M., the Business Office Manager said she was holding an envelope of Resident #1's money in a lock box. She opened the lock box and showed the surveyor an envelope which contained $140.00.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to maintain accounting for cash money received for one Resident (#1), out of a sample size of 12 residents. Findings include: Resident #1 was admitted to the facility in October 2020 with diagnoses of schizophrenia, manic depression (bipolar disease), anxiety, and altered mental status. Resident has a court appointed guardian. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/25/22, indicated Resident #1 scored a 13 out of 15 on the Brief Interview for Mental Status, indicating he/she was cognitively intact. The MDS further indicated Resident had disorganized thinking behavior which fluctuates (comes and goes, changes in severity). Review of the court document titled Letters of Guardianship for an incapacitated person, dated 2/13/20, indicated Resident Representative #1 was appointed on 3/21/19 as the permanent Guardian and the appointment is a determination that Resident #1 is incapacitated. During a telephonic interview on 12/6/22 at 11:30 A.M., Resident #1's Guardian said [NAME] Nursing Home does not have a personal needs account system in place. She said she asked if they could set up one and she was told they do not do that. She said they requested cash be sent, because Resident #1 cannot go to the bank to cash a check and they don't have the means to cash a check. She said she would provide the accounting of the cash money she has sent to the facility via e-mail. Review of Resident #1's Guardian's accounting records indicated the following disbursements were made to the facility: On 12/30/21- $72.50 On 02/15/22- $72.50 On 03/16/22- $72.50 On 04/19/22- $72.50 On 05/20/22- $72.50 On 06/22/22- $72.50 On 07/18/22- $72.50 On 10/25/22- $220.00 On 11/08/22- $220.00 Total disbursement of $947.50 During an interview on 11/30/22 at 01:39 P.M., Social Worker (SW) #1 said Resident #1's Guardian has been sending cash to him for the past year to give to Resident #1. He said he does not know the exact amount he has received or has given to Resident #1. He said his computer crashed recently and he could not retrieve any accounting for Resident #1's money. SW #1 said they do not have a system to open bank accounts for residents, they generally encourage families or responsible parties to handle the residents' money themselves. During an interview on 11/30/22 at 02:26 P.M., the Administrator said the facility does not manage any personal needs accounts. The Administrator was informed that SW #1 has been receiving cash from Resident #1's Guardian and is unable to provide any accounting for the money received or distributed to Resident #1. He said there should be accounting of all the money received. During an interview on 11/30/22 at 03:35 P.M., the Business Office Manager said she was holding an envelope of Resident #1's money in a lock box. She said she does not provide any accounting for this money; she just holds it for the social worker.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure two of two nourishment kitchenettes were maintained in a safe and sanitary manner to prevent potential foodborne illness. Specifically, the facility failed to: 1. Ensure two of two microwaves were clean, free from rust on the inner frame, and the inside walls were intact for safe operation, and 2. Ensure food on Unit 2 was not stored in a closet containing staff clothing and other personal belongings. Findings include: 1. On 11/29/22 at 10:42 A.M., the surveyor observed the second-floor residents' microwave located in the dining room to be visibly stained on the inside bottom, top, and back wall. The inside bottom right and left back corners of the wall surface areas were bubbling/cracking, and the inside top center had a quarter size area with surface bubbling/cracking. The front inside border was heavily rusted on all sides with the white paint lifting off the surface. On 11/29/22 at 10:54 A.M., the surveyor observed the first-floor resident microwave located in the kitchenette room to be stained on the inside bottom. The bottom right and left back corner walls were bubbling/cracking and the inside top back wall surface was bubbling/cracking. There was visible food splattered on all four walls. During an interview on 12/01/22 at 03:30 P.M., the Director of Nurses (DON) viewed both microwaves with the surveyor, and said they needed to be replaced; they are old. 2. On 11/29/22 at 10:46 A.M. on Unit 2, the surveyor observed the top drawer of the cabinet to contain small packets of jelly, sugar, pepper, salt, Sweet Plus, syrup, and tea bags being stored with a pen and a couple of old pen caps. The lower cabinet stored a mix of paper products, a red bowl with a spoon (Not sure if it was clean), a bottle of hot sauce, bottle of Alkaline 88 purified water, container of Clorox wipes, a jar of fruit jelly, and bag of sweet plantain strips (chips). On 11/29/22 at 10:49 A.M. on Unit 2, the surveyor observed the closet across from the nursing station. Inside the closet there was resident food stored on the shelves. To the right of the stored food, hanging on hangers was staff clothing (sweater and jacket). On the top rack, there were staff lunch bags and boxes. On the bottom left shelf, there was a white bag that contained nail care items including nail polish. On the floor, in the corner, was a pile of Christmas decorations (green [NAME]). During an interview on 12/01/22 at 03:30 P.M., the DON said the residents' food should not be mixed with cleaning supplies or staff food. The DON and surveyor observed the food storage across from the nursing station, and the DON said she didn't know who put the food in the closet. She said the food should not be stored in a closet with the staff personal items.