Based on interview and record review, it was determined that the facility failed to ensure that each resident had a monthly MRR (Medication Regimen Review) by a pharmacist for 1 of 5 residents reviewed for unnecessary medications in a final sample of 8 residents. (Resident identifier is #5.) Findings include: Review on 6/25/25 of Resident #5's MRR's revealed he/she did not have a MRR for August 2024. Interview on 6/25/25 at approximately 8:30 a.m. with Staff B (Director of Nursing) confirmed the above finding. Review on 6/25/25 of the facility policy titled, 8.1 Medication Regimen Review and Reporting, Dated 1/24 revealed: . 2. The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly .

Based on record review and interview, it was determined that the facility failed to implement their established antibiotic stewardship protocols for monitoring the appropriate antibiotic use (Resident identifiers #13, #16, and #123). Findings include: Review on 6/24/25 of facility Antibiotic Stewardship Guidelines undated, revealed on page 5 revealed .Antibiotic Time Out Every time antibiotics are prescribed .3. Reassess within 48 hours and adjust Rx (treatment) if necessary or stop Rx (treatment) if indicated . Review on 6/24/25 of Resident #13's physician orders revealed an order dated 5/30/25 for Keflex 500mg 3 times a day for 5 days for wound infection. Review on 6/24/25 of Resident #16's physician orders revealed an order dated 5/30/25 for amoxicillin 875mg-potassium clavulante 125mg 2 times a day for 5 days for Urinary Tract Infection (UTI). Review on 6/24/25 of Resident #123's physician orders revealed an order dated 5/22/25 for Macrobid 100mg 2 times a day for 5 days for UTI. Review on 6/24/25 of Resident #13, #16, and #123's physician orders revealed no antibiotic time out completed for the orders listed above. Interview on 6/25/25 at approximately 9:45 a.m. with Staff A (Infection Preventionist) confirmed that Resident #13, #16, and #123 did not have completed antibiotic time outs.Staff A revealed that he/she did not report missed antibiotic timeouts or infections that do not meet criteria to the quality commitee.

Based on interview and record review, it was determined that the facility failed to ensure that a resident who was on antipsychotic medication had adequate indication of use that was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents reviewed for unnecessary medications in a final sample size of 12 residents (Resident Identifier is #17). Findings include: Review on 6/10/24 of Resident #17's active physician's orders revealed a physician's order for Quetiapine (antipsychotic) 37.5 milligrams (mg) by mouth twice a day with a start date of 4/30/24 and the indication of use was for the diagnoses of dementia with other behaviors. Review on 6/11/24 of Resident #17's provider note dated 5/1/24 revealed that the assessments and plans for dementia with other behavioral disturbances was the use of Donepezil (treats memory loss and confusion) 2.5 mg by mouth twice a day and Quetiapine 37.5 mg by mouth twice a day. Further review revealed no documentation of identified targeted behaviors and specific conditions related to dementia with other behaviors that indicated the use of the Quetiapine medication. Review on 6/11/24 of Resident #17's provider notes dated 5/7/24, 5/8/24, 5/15/24, and 5/22/24 revealed no documentation of identified targeted behaviors and specific conditions related to dementia with other behaviors that indicated the use of the Quetiapine medication. Review on 6/11/24 of Resident #17's active antipsychotic medication use care plan, dated 5/7/24, revealed no documentation of identified targeted behaviors and specific conditions related to dementia with other behaviors that indicated the use of the Quetiapine medication. Interview on 6/11/24 at approximately 12:30 p.m. with Staff D (Director of Nursing) confirmed the above findings. Review on 6/11/24 of the facility policy titled, Psychotropic Medication Use, dated July 2022, revealed: Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This include evaluation of the resident's signs and symptoms in order to identify underlying causes .Use of psychotropic medications may be considered appropriate in specific circumstances as specified in F758 . Review on 6/11/24 of the Quetiapine manufacturer's instruction from the FDA, retrieved from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020639s045s046lbl.pdf, revealed: .INDICATION AND USAGE .Schizophrenia .Bipolar Disorder .Special Considerations in Treating Pediatric Schizophrenia and Bipolar I Disorder .WARNINGS AND PRECAUTIONS .Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. SEROQUEL (Quetiapine Fumarate) is not approved for the treatment of patients with dementia-related psychosis (see Boxed Warning) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of personnel files, and review of facility's policy, it was determined that the facility failed to ensure that there were implemented measures to prevent abuse for 1 out of 7 employee personnel (Staff I) reviewed. Findings include: Review on 4/20/23 of Staff I's (Custodian) personnel file revealed that Staff I was hired on 1/18/23 and began working in the facility on 1/23/23. Further review of Staff I's personnel file revealed: 1. State of New Hampshire criminal background check was completed on 2/21/23. 2. Bureau of Elderly Adult Services ([NAME]) registry check was completed on 2/17/23. 3. Criminal background check was completed on 2/7/23. Interview on 4/20/23 at approximately 10:40 a.m. with Staff C (Human Resources Manager) confirmed that Staff I began employment before background checks were completed. Review on 4/20/23 of the facility's policy titled, Abuse Prevention Program, revision date 10/15/22 revealed: .A. Screening of Staff . i. Pre-employment screening will be completed on all post-offer applicants, to include: a. Criminal Background Check b. Background Check . e. Misconduct Registry f. OIG [Office of Inspector General] registry .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure that residents on anti-psychotics and psychotropic medications were monitored for side effects, failed to obtain consent prior to utilizing anti-psychotic and psychotropic medications, and failed to ensure that as needed (PRN) orders for anti-psychotic and psychotropic medications were limited to 14 days except when attending physician or prescribing practitioner evaluates the resident for appropriateness of that medication, he/she should document their rationale in the resident's medical record and indicate the duration for the PRN order for 1 out of 5 unnecessary medications reviewed (Resident identifier is #162). Findings include: Review on 4/20/23 of Resident #162's Electronic Medical Record (EMR) revealed that Resident #162 was admitted to the facility on [DATE] for hospice level of care. Review on 4/20/23 of Resident #162's March 2023 and April 2023 EMR revealed the following orders: 1. Risperdal (anti-psychotic) 1 milligram (mg), give 1 tablet oral twice daily, with a start date of 3/10/23, and discontinued date of 3/14/23. 2. Risperdal 1 mg give 1/2 tablet, oral every 6 hours PRN, with a start date of 3/11/23, with no indication of use and duration of the use and a discontinued date of 3/14/23. One (1) dose of this PRN Risperdal order was administered on 3/11/23. 3. Risperidone (anti-psychotic) 1mg/milliliter (ml) give 0.5 ml (0.5mg), oral every 6 hours PRN for agitation/hallucinations, with a start date of 3/13/23, and no indication of duration of use and was not limited to 14 days then discontinued on 4/16/23 (34 days from the start date of 3/13/23). This PRN Risperidone order was administered on 3/14/23, 3/15/23, 3/16/23, 3/17/23, 3/18/23, 3/19/23, 3/20/23, 3/21/23, 4/2/23, 4/4/23, 4/6/23, 4/10/23, 4/12/23, 4/13/23, and 4/15/23. 4. Risperidone 1 mg/ml give 0.5 ml (0.5mg), oral every 6 hours PRN for agitation/hallucinations, with a start date of 4/16/23, with no duration of use indicated. This Risperidone PRN was administered on 4/16/23. 5. Lorazepam (anti-anxiety) 2 mg/ml give 0.25 ml (0.5 mg), oral every 6 hours PRN for anxiety, with a start date of 3/27/23, and no duration of use indicated then discontinued on 4/16/23. This Lorazepam PRN order was administered on 3/28/23, 3/20/23, 3/31/23, 4/1/23, 4/2/23, 4/3/23, 4/5/23, 4/6/23, 4/7/23, 4/10/23, 4/11/23, and 4/12/23 6. Lorazepam 2mg/ml give 0.25 ml (0.5 mg), oral every 6 hours PRN for anxiety, with a start date of 4/16/23, and no duration of use indicated. Review on 4/20/23 of Resident #162's EMR revealed the following: 1. No documentation that the resident and/or the resident's representative consented to the use of the Lorazepam medication. No documentation that the facility provided any education to resident and/or resident's representative of side effects of the use of Lorazepam medication. 2. Resident #162's Psychotropic Medication Administration disclosure form (consent for medication use and disclosure of side effects) for Resident #162's Risperdal medication was signed by Resident #162's representative on 3/21/23, which was after the Risperdal or Risperidone start date as mentioned above. 3. No documentation of monitoring for any side effects for Lorazepam and Risperidone/Risperdal use. 4. No documentation of any Abnormal Involuntary Movement Scale (AIMS) assessment done before the start of the Risperidone and/or Risperdal medication as mentioned above (3/10/23, 3/11/23, 3/13/23, and 4/16/23). 5. No documentation of evaluation and rationale by the facility provider and/or hospice provider of extending PRN Lorazepam and PRN Risperidone/Risperdal beyond the 14 days. Review on 4/20/23 of the facility policy titled, Antipsychotic Medication Use, revised date of 12/2016, revealed .The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order .PRN order for antipsychotic medication will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for appropriateness of that medication .Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician .

Based on observation, interview, and record review, it was determined that the facility failed to ensure that expired medications were removed from the medication cart for 1 of 1 medication carts reviewed. Findings include: Observation on 4/18/23 at approximately 10:20 a.m. of the facility's medication cart revealed the following expired medication: Resident #154, Combivent Inhaler with a manufacturer's expiration date 2/23 Interview on 4/18/23 at approximately 10:20 a.m. with Staff A (Registered Nurse) confirmed that Resident #154 was administered the expired Combivent. Review on 4/19/23 of Resident #154 April 2023 Medication Administration Record revealed the following physician's order: Combivent Respimat 20 micrograms (mcg) actuation solution for inhalation mist inhaler PRN [as needed] every 6 hours as needed for wheezing, administered on 4/18/23 at 8:53 a.m. Review on 4/19/23 of the facility's policy titled, Adverse Consequences and Medication Errors, revised on 4/2014 revealed: .4. The staff and practitioner shall strive to minimize adverse consequences by: a. following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication; . 9. Facility staff monitor the resident for possible medication-related adverse consequences, including mental status and level of consciousness, when the following conditions occur: . f. Medication error, e.g. [for example], wrong or expired medication Review on 4/19/23 of the facility's policy titled, Storage of Medications, revised 11/20 revealed: . 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. .

Based on interview, it was determined that the facility failed to ensure that the activities program was directed by a qualified professional who is a qualified therapeutic recreation specialist. Findings include: Interview on 4/18/23 at approximately 10:30 a.m. with Staff G (Administrator) revealed that Staff F (Activities Director) had not completed necessary training required to direct an activities program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #162 Review on 4/20/23 of Resident #162 electronic medical records revealed that Resident #162 was admitted to the facility on [DATE]. Review on 4/20/23 of Resident #162's provider initial comprehensive visit, dated 3/15/23, revealed that the initial comprehensive visit was done by a Advance Practical Registered Nurse (APRN) and not a physician. Interview on 4/20/23 at approximately 1:40 p.m. with Staff G (Administrator) confirmed the above findings. Based on interview and record review, it was determined that the facility failed to ensure that residents were seen by a physician at least once every 30 days during the first 90 days after admission to the facility and at least once every 60 days thereafter for 3 out of 3 residents reviewed for physician visits in a final sample of 12 residents reviewed (Resident identifiers are #161, #162 and #163). Findings include: Resident #161 Review on 4/20/23 of Resident #161's medical record revealed the following: Resident #161 was admitted to the facility on [DATE]. Further review revealed that Resident #161 was seen by the Nurse Practitioner (NP) on the following dates: 10/21/22, 1/16/23, 2/15/23, and 4/6/23. There were no documented visits made by the physician. Interview on 4/20/23 at approximately 8:45 a.m. with Staff B (Director of Nurses) confirmed that there were no documented physician visits with Resident #161 since admission. Resident #163 Review on 4/20/23 of Resident #163's medical record revealed: Resident #163 was admitted to the facility on [DATE]. Further review revealed that Resident #163 was seen by the NP on the following dates: 1/16/23, 2/15/23, 2/22/23, 3/8/23, and 3/15/23. Resident #163 was not seen by a physician until 3/21/23. Interview on 4/20/23 at approximately 8:50 a.m. with Staff B confirmed the above findings.

Based on interview and record review, it was determined that the facility failed to ensure staff were provided annual training for the facility's ethics program for 2 out of 3 staff reviewed. Findings include: Review on 4/20/23 of Staff E's (Registered Nurse) educations/trainings revealed: Ethics and Compliance training was completed on 1/28/22. Review on 4/20/23 of Staff D's (Cook) educations/trainings revealed: Ethics and Compliance training was completed on 1/25/22. Interview on 4/20/23 at approximately 11:45 a.m. with Staff C (Human Resources Manager) confirmed that Ethics and Compliance trainings were not done annually. Review on 4/20/23 of the facility's policy titled, Covenant Living Communities and Services, Code of Conduct, dated 2019 revealed: .4.5 Training will be completed at or about the time of hire, when the employee's functions or duties change, when there are changes in the government regulations or policies and procedures occur, and also on an annual basis. Training will be provided annually and will be documented