Based on interview and record review, it was determined that the facility failed to inform residents or resident's representative of the risk and benefits of psychotropic medication use for 2 out of 5 residents reviewed for unnecessary medications in final sample of 17 residents. (Resident identifiers are #16 and #50.) Findings include: Resident #16 Review on 3/12/25 of Resident #16's medical record revealed a physician's order for Ativan Oral Tablet 0.5 MG[milligram] (Lorazepam) Give 0.5 tablet by mouth two times a day for anxiety monitor for anxiousness, restlessness and other signs of anxiety, start date of 1/21/25. Further record review revealed there was no documentation of consent for the psychotropic medication use for Resident #16. Resident #50 Review on 3/12/25 of Resident #50's medical record revealed a physician's order for Buspirone HCL Oral tablet 15 MG (Buspirone HCL) Give 1 tablet by mouth two times a day for anxiety monitor for increased anxiousness, restlessness and other signs of anxiety, start date of 9/10/24. Further record review revealed there was no documentation of consent for the psychotropic medication use for Resident #50. Interview on 3/12/25 at approximately 2:20 p.m. with Staff D (Clinical Lead) confirmed the above findings. Review on 3/13/25 of the facilities policy Behaviors: Management of Symptoms Revision Date, 7/1/24 revealed .6. When a medication is ordered for behavioral symptoms: 6.1 Obtain Consent .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined that the facility failed to follow the professional standards of care for 3 residents in a final sample of 17 residents. (Resident identifiers are #33, #55 and #7.) Findings include: Standard: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .It is essential to verify the accuracy of every medication you give to your patients with the patient's order. If the medication order is incomplete, incorrect, or inappropriate, or if there is a discrepancy between the original order and the information on the MAR [Medication Administration Record]. consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication .` Resident #33 Interview on 3/12/25 at approximately 7:35 a.m. with Staff F (Licensed Practical Nurse) revealed that Resident #33's CBG (capillary blood sugar) had obtained by a nurse on the the previous shift and was 151. Staff F had the CBG result written on a piece of paper. Further interview revealed that Staff F would use the CBG to decide if Resident #33 required insulin based on their physician order. Staff F thought the CBG was obtained around 6:45 a.m Observation on 3/12/25 at approximately 7:45 a.m. revealed Staff F administered 2 units of insulin to Resident #33 for the CBG of 151. Review on 3/12/25 of Resident #33's physician orders revealed the following order: Humalog Solution 100 unit/ml (milliliters) . inject as per sliding scale: . 151-200= 2 units, .subcutaneously before meals for sliding scale insulin coverage for diabetes must take finger stick blood glucose prior to administration., Start Date 1/18/25. Interview on 3/12/25 at approximately 1:30 p.m. with Staff E (Nurse Practitioner) revealed that he/she would expect CBG's to be performed closer to administration/meal time when a sliding scale is being used for insulin. Resident #55 Review on 3/11/25 of Resident #55's physician orders revealed the following order: Ertapenem Sodium Injection Solution Reconstituted 1 GM (gram), Use 1 gram intravenously in the morning for infection until 3/27/25, Start Date 2/20/25. Interview on 3/11/25 at approximately 11:00 a.m. with Staff B (Registered Nurse) and Staff D (Clinical Lead) confirmed the the above order did not have an infusion rate. Observation on 3/12/25 at approximately 8:30 a.m. of Resident #55's IV pole in his/her room revealed a bag that was empty with a hand written orange label 3/13/24 0730 without a pharmacy label or infusion rate. Standard: [NAME], P.A, [NAME], A.G., Stockhart, P.A., & Hall, A. (2021). Fundamentals of Nursing. Elsevier. Page 1262. Changing Dressings A Health care provider's order for wound care indicates the dressing type, the frequency of changing, and any solutions or ointments to be applied to the wound. Resident #7 Observation on 3/11/25 at approximately 9:50 a.m. revealed a dressing on Resident #7's lower left thigh that was undated. Interview on 3/11/25 at approximately 9:50 a.m. with Resident #7 revealed that Staff G (Registered Nurse) confirmed the above observation. Staff G stated that the dressing was applied the previous day. Review on 3/12/25 of Resident #7's Treatment Administration Record revealed that there was no active order on 3/11/25 to apply a dressing to Resident #7's left thigh. Interview on 3/12/25 at approximately 2:40 p.m. with Staff G confirmed that he/she applied the dressing without a physician's order.

Resident #55 Observation on 3/11/25 at approximately 11:15 a.m. with Staff B (Registered Nurse) revealed Staff B accessing Resident #55's Peripherally Inserted Central Catheter (PICC) line without a face shield or protective gown on. Interview on 3/11/25 at approximately 11:15 a.m. with Staff B confirmed the above findings. Interview on 3/11/25 at approximately 2:15 p.m. with Staff A (Infection Preventionist) confirmed that staff should be wearing PPE when accessing a PICC line. Review on 3/11/25 of the facility policy titled, Infection Control Standards, Dated 10/24 revealed: . Standard Precautions are used during all resident care procedures that potentially expose the clinician to blood and bloody fluids is anticipated or there is the potential for splash or spray of blood or body fluids. Single use disposable gown, . Eye protection/face shield. Review on 3/11/25 of the facility policy titled, IC308 Enhanced Barrier Precautions, Revision Date 12/16/24 revealed: .Patient Status, Has a wound or indwelling medical device without secretions or excretions that are unable to be covered or contained and not known to be infected or colonized with MDRO (Multidrug Resistant Organisms), Use EBP. Review on 3/11/25 of the facility policy titled, Enhanced Barrier Precautions, Revision Date 5/1/24 revealed: .Enhanced Barrier Precautions, . Chronic wounds and/or indwelling medical devices (e.g., central line, .), .Device care or use central line, . Gown, gloves prior to high contact care activity, (Change PPE before caring for another patient) (Face protection may also be needed if performing activity with risk of splash or spray) Based on observation, interview, and record review, it was determined that the facility failed to follow policies and procedures for 1 of 2 residents reviewed for Enhanced Barrier Precautions (EBP) (Resident identifier is #55) and 1 of 3 residents reviewed for disinfection of glucometer (Resident identifiers are #165 and #166). Findings include: Observation on 3/11/25 at approximately 11:40 a.m. of Staff C (Medication Nursing Assistant) revealed he/she went from Resident #165's room to Resident #166's room with a glucometer and a cup with alcohol wipes, lancets, and test strips in it, and no cleaning/disinfecting wipes. The glucometer was observed to not be visibly soiled. Review on 3/11/25 of Resident #165's and Resident #166's Medication Administration Record revealed provider orders for capillary blood glucose (CBG). Interview on 3/11/25 at approximately 11:40 a.m. with Staff C revealed that he/she tested capillary blood glucose for Resident #165 and then Resident #166. Further interview revealed he/she had not disinfected the glucometer between these residents. Staff C stated that he/she should have disinfected the glucometer between resident use with an Environmental Protective Agency (EPA) disinfectant. Review on 3/13/25 of facility policy titled Fingerstick Glucose Measurement with a review/revision date of 6/15/22 revealed .4. Clean and disinfect meter before use with EPA approved disinfectant, following manufacturer instructions .19. Clean and disinfect the blood glucose meter after use with EPA approved disinfectant, following manufacturer's instructions . Review on 3/13/25 of glucometer manufacturer instructions revealed 4. To disinfect your meter, clean the meter with one of the validated disinfecting wipes listed below. Other EPA registered wipes may be used .

Based on observation, interview and record review, it was determined that the facility failed to maintain patient care equipment per manufacturer's instruction for 1 of 2 residents reviewed for respiratory care in a final sample of 17 residents. (Resident identifier is #7). Findings include: Interview on 3/11/25 at approximately 9:50 a.m. with Resident #7 revealed concerns that his/her Continuous Positive Airway Pressure (CPAP) machine parts needed replacement for a long time and no one is assisting with replacing the parts of his/her headpiece. Observation on 3/11/25 at 9:50 a.m. revealed that the head strap had brownish discoloration, areas of the head piece were in disrepair, and the tubing to the mask was yellowish in color. Interview on 3/12/25 at approximately 10:00 a.m. with Staff D (Clinical Lead) confirmed the above findings. Interview on 3/13/25 at approximately 10:40 a.m. with Staff K (Unit Manager) revealed that the face mask, tubing, and headgear have not been changed since Resident #7 was admitted to the facility. Review on 3/13/25 of Resident #7's medical record revealed that Resident #7 had been admitted to the facility in July of 2024. Review on 3/13/25 of Resident #7's March 2025 Treatment Administration Record (TAR) revealed a treatment order dated 2/10/24 for CPAP: Change or clean intake filter and disposable supplies(e.g., tubing) per manufacturer?s [sic] instructions. Every night shift, every Saturday and was completed on 3/1/25 and 3/8/25. Review on 3/13/25 of the manufacturer's instructions revealed . If any visible deterioration of system component is apparent ( .discoloration, .) the component should be discarded and replaced.3. Check the air filter and replace every six months .

Based on interviews and record reviews, it was determined that the hospice agency and the facility failed to provide collaborative services for 1 of 1 resident reviewed for hospice services in a final sample of 18 residents (Resident Identifier #44). Findings include: Review on 4/2/24 of Resident #44's care plan for hospice revealed the following: Hospice Nursing 2-3x (times) a week and PRN (as needed) to assess and manage symptoms, comfort/pain, and bowel function, date initiated: 2/26/24 Hospice Nursing Assistant 1-2x a week to complement ADL (activities of daily living) care and provide comfort, date initiated: 2/26/24 Hospice Social Work 1x month and PRN to provide psychosocial support related to end of life care, date initiated: 2/20/24 Hospice Volunteer 1x month and PRN for companionship, date initiated 2/20/24 Review on 4/2/24 of Resident #44's Hospice Certification and Plan of Care (POC) dated 2/19/24 - 5/18/24, revealed: Frequency/Duration of Visits: SN 7x week x1, 3x week x12; Master of Social Work (MSW) 1x month x1; and Chaplain (CH) 1x month x1 Review on 4/2/24 of Resident #44's medical record revealed the following Communication/Continuation Notes from hospice: On 2/19/24 SN visit (medication recommendations), on 3/1/24 SN visit (medication recommendations), on 3/18/24 SN visit (medication recommendations), and on 4/1/24 SN visit (medication recommendations). Interview on 4/2/24 at approximately 12:00 p.m. with Staff C (Unit Manager) revealed there were no other notes from hospice visits than the above Communication/Continuation Notes. Staff C also revealed that he/she was only aware of SN from hospice coming in on Mondays. Staff C also confirmed that Resident #44's care plans and Hospice POC did not match. Interview on 4/2/24 at approximately 1:20 p.m. with Staff D (Administrator), who is the acting Hospice Liason, revealed that there was no communication between the hospice agency and the facility as to when visits would occur. Staff D also revealed that the hospice did not have any nursing assistants or volunteers available to visit with Resident #44. Review on 4/3/24 of the facility's policy titled OPS118 Hospice revision date 3/1/18 revealed: .5. The Center: .5.2 is responsible for ensuring that the hospice services provided meet professional standards and principles for the timeliness of those services. 6. The hospice and center must communicate, establish, and agree upon a coordinated plan of care which reflects the hospice philosophy and is based on an assessment of the patient's needs. The plan of care must include: . 6.2 The most recent hospice plan of care; .7.2.1.5 Obtaining the following information from the hospice; 7.2.1.5.1 Most recent hospice plan of care .

Based on observations, interviews, and record reviews it was determined that the facility failed to ensure the medication error rate was not 5 percent (%) or greater for 2 out of 4 residents observed for medication administration (Resident Identifiers #24 and #41). Findings include: Resident #24 Observation on 4/2/24 at approximately 7:30 a.m. of Staff A (Licensed Practical Nurse (LPN)) preparing medication for Resident #24 revealed Staff A was going to administer Aspirin 81 milligrams (mg). Further observation revealed Staff A removed Resident #24's Novolin N Insulin Pen and placed it on the medication cart. Staff A dialed the pen to 16 units. Staff A proceeded to administer the 16 units of insulin without rolling the pen (to ensure that the insulin in the pen was the correct dosage). Staff A did not prime the insulin pen and did not wait the 5 seconds prior to removing the insulin pen from Resident #24's abdomen. Review on 4/2/24 of Resident #24's April 2024 Medication Administration Record (MAR) revealed the following physician's orders: Novolin N Subcutaneous Suspension 100 UNIT/ML [milliliters], inject 16 units subcutaneously in the evening for DM [Diabetes Mellitus], start date 3/13/24; Aspirin EC [enteric coated] tablet delayed Release 81 mg, give 1 tablet by mouth one time a day for cardiac health, start date 2/2/24. Interview on 4/2/24 at approximately 7:35 a.m. with Staff A confirmed the above findings. Review on 4/2/24 of the manufacturer's instructions for Novoliln N FlexPen, revision date 6/22, revealed: .To resuspend FlexPen, gently move the pen up and down 20 times so the glass ball moves from one end of the cartridge to the other until the suspension appears uniformly white and cloudy. Inject immediately. Mixing by rolling and inverting the Pen is important to make sure you get the right dose .Priming your Pen .Prime before each injection. Priming your Pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin .To prime your Pen, turn the dose knob to select 2 units .Slowly push the plunger of the syringe all the way in, and then leave the needle in the skin for 10 seconds. If you are using a pen, while holding the base against the skin, push down on the injection button. You will hear a loud click. This will insert the needle and start the injection. Keep holding the pen against your skin until you hear a second click in about 5 to 10 seconds . Review on 4/2/24 of the facility's procedure titled Skills Checklist 8: Insulin Medication Administration, undated, revealed: .8 .c. Dial up 2 units of insulin (or per manufacturer's recommendations); hold pen upright and perform an air shot to prime the pen .18. During injection with a pen, push the plunger and slowly inject the insulin; hold the pen in place for 5-10 seconds per manufacturer's instructions . Resident #41 Observation on 4/2/24 at approximately 9:00 a.m. of Staff B's (LPN) medication administration with Resident #41 revealed: Staff B administered Resident #41's Miralax Oral Powder through his/her Jejunostomy tube. Review on 4/2/24 of Resident #41's April 2024 MAR revealed the following physician's order: Miralax Oral Powder 17 gm [grams]/scoop, give 1 scoop by mouth one time a day for bowel management, order date 3/29/24. Interview on 4/2/24 at approximately 9:00 a.m. with Staff B confirmed the above findings. There were 3 medication errors out of a total of 29 medication administration opportunities resulting in a 10.34% error rate.

Based on observations, interviews, and record reviews, it was determined that the facility failed to ensure open injectable medications were labeled in accordance with the manufacturer's instructions in 1 out of 2 medication carts and in 1 of 1 medication rooms observed and refrigeration temperatures were not monitored daily for medications storage in 1 out of 1 medication rooms observed. Findings include: Observation on 4/1/24 at approximately 8:10 a.m. of Webster Street Medication Cart revealed an open Lantus Insulin Pen without an open or open expiration date. Interview on 4/1/24 with Staff F (Registered Nurse) confirmed the above finding. Review on 4/2/24 of the Lantus Insulin Pen manufacturer's instructions revealed After 28 days, throw your opened Lantus pen away - even if it still has insulin in it. Observation on 4/1/24 at approximately 8:20 a.m. of the Derryfield Medication Room revealed an open vial of Tuberculin Purified Derivative without an open or open expiration date. Interview on 4/1/24 at approximately 8:20 a.m. with Staff G (Registered Nurse) confirmed the above finding. Review on 4/2/24 of the Tuberculin Purified Derivative manufacturer's instructions revealed: .Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency . Review on 4/2/24 of the facility's policy titled 5.3 Storage and Expiration Dating of Medications, Biologicals dated January 2022 revealed: .5.3 If a multi-dose vial of injectable medication has been opened or accessed (e.g. needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial . Review on 4/1/24 of the medication refrigerator logs for March 2024 revealed missing temperatures on 3/2, 3/4, 3/8, 3/22, 3/29, and 3/30. Interview on 4/1/24 at approximately 8:20 a.m. with Staff G confirmed the above findings. Review on 4/2/24 of the facility's policy titled 5.3 Storage and Expiration Dating of Medications, Biologicals dated January 2022 revealed: .10.3.1 Facility should monitor the temperature of medication storage areas at least once a day .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to give written notice to the resident before the resident's room or roommate in the facility was changed (Resident identifiers are #1, #2, #3, #4). Findings include: Resident #1 Interview with Resident #1 on 5/4/23 at 8:53 a.m. revealed that he/she was admitted on [DATE] and liked his/her old room. The resident stated that they asked him/her to move and then was moved immediately. The resident stated that they did not give him/her a reason for the move. Resident #1 thinks his/her room change occurred around 12 p.m. on 5/3/23. Resident #1 stated that he/she was not given any paperwork regarding the room change. Record review on 5/4/23 at 10:15 a.m. revealed a Social Service note dated 5/3/23 stated Left VM [voice mail] for DPOA [Durable Power of Attorney] to alert [pronoun omitted] of room change. Interview with Resident #1's DPOA on 5/4/23 at 10:07 a.m. DPOA stated that he/she received a voice mail around 10 a.m. from the facility on 5/3/23, which stated that they had moved family member to a different room in the facility. The facility never gave him/her a reason why the room change had to happen and he/she had not spoken to anyone at the facility. Resident #3 Record review of Resident #3 on 5/4/23 revealed no documentation that the resident was told that he/she would be getting a new roommate. Resident #2 Interview with Resident #2 on 5/4/23 at 9:04 a.m. Resident #2 stated that they had moved from a different room yesterday. Resident #2 was originally asked to change rooms on 5/1/23 but did not want to. Resident #2 stated that they had to move because of the new Rehabilitation Program. Resident #2 stated that on 5/3/23, facility staff came into their room with boxes and stated that Resident #2 had to move. Resident #2 stated that they do not like the new room because they had a private room and now they have a roommate. Resident #2 stated that he/she would have stayed in his/her previous room if he/she could have, but did not know that they had the right to refuse a room change. Resident #2 stated that he/she did not receive any paperwork regarding the room change. Resident #2 stated that he/she told the staff that he/she did not want to move while they were packing Resident #2's belongings. Resident #2 stated that he/she spoke to the Ombudsman's office about their room change. Record review on 5/4/23 at 10:30 a.m. of a Social Service note dated 5/1/23 revealed TW [This writer] and Admissions Director spoke with patient about changing rooms. Resident expressed that he/she knew this was coming and asked if it had anything to do with insurance. He/She was assured that this had nothing to do with anything financial and that because he/she is LTC [long term care] the thought was to transition him/her into a long term care room with a roommate. Patient was initially upset about this but ultimately agreed and said he/she would change rooms. Resident #4 Record review of Resident #4 on 5/4/23 revealed no notification that the resident was told that he/she would be getting a new roommate. Interview on 5/4/23 at approximately 9:45 a.m. with Staff A (Social Service Director) revealed that they do not provide written notification to residents, or resident representatives, upon room change. Upon the completion of a room change Staff A stated that a note is put in the resident's medical record that the room change occurred. Review on 5/4/23 of the Facility's Policy titled Room Transfers revision date 3/9/20. Policy .The patient has the right to refuse to transfer to another room in the Center, if the purpose of the transfer is: To relocate a resident of a SNF [Skilled Nursing Facility] from the distinct part of the institution that is SNF to a part of the institution that is not a SNF; or to Relocate a resident of a NF [Nursing Facility] from the distinct part of the institution that is a NF to a distinct part of the institution that is a SNF. Solely for the convenience of staff. Process .#3 Social Services or designee will process and coordinate all request for room changes in accordance with state and federal regulations. 5.1 Give the patient/resident representative as much notice as possible including an explanation of the reason for the move #7. For a patient who is receiving a new roommate: 7.1 give the patient as much notice as possible 7.4 If requested by patient/resident representative or per state regulation, give patient/resident representative a copy of the Room Transfer/New Roommate change form #11. Maintain the Room Transfer/New Roommate Change Form (electronic or non-electronic), in the medical record.

Based on interview and record review, the facility failed to recognize a resident's right to refuse transfer for 1 of 2 residents reviewed for a room change (Resident identifier is #2). Findings include: Interview with Resident #2 on 5/4/23 at 9:04 a.m. Resident #2 stated that he/she had moved to a different room yesterday. Resident #2 stated that on 5/3/23, facility staff came into his/her room with boxes and stated that he/she had to move right now. They proceeded to pack his/her belongings and moved him/her into his/her new room. Resident #2 stated that he/she would have stayed in his/her previous room if he/she could have but did not know that he/she could have refused to be moved. Resident #2 stated that he/she told the staff that he/she did not want to be moved while facility staff was packing Resident #2's belongings. Interview on 5/4/23 at approximately 9:45 a.m. with Staff A (Social Service Director) revealed that Staff A does not provide written notification to residents, or resident's representatives, upon room change. Upon the completion of a room change Staff A stated that a note is put in the resident's medical record that the room change occurred. Review on 5/4/23 of the Facility's Policy titled Room Transfers revision date 3/9/20. Policy .The patient has the right to refuse to transfer to another room in the Center, if the purpose of the transfer is: To relocate a resident of a SNF [Skilled Nursing Facility] from the distinct part of the institution that is SNF to a part of the institution that is not a SNF; or to Relocate a resident of a NF [Nursing Facility] from the distinct part of the institution that is a NF to a distinct part of the institution that is a SNF. Solely for the convenience of staff. Process .#3 Social Services or designee will process and coordinate all request for room changes in accordance with state and federal regulations. 5.1 Give the patient/resident representative as much notice as possible including an explanation of the reason for the move #7. For a patient who is receiving a new roommate: 7.1 give the patient as much notice as possible 7.4 If requested by patient/resident representative or per state regulation, give patient/resident representative a copy of the Room Transfer/New Roommate change form #11. Maintain the Room Transfer/New Roommate Change Form (electronic or non-electronic), in the medical record.

Based on observation and interview, it was determined that the facility failed to provide a clean and safe environment in 1 out of 2 kitchenettes used by residents and staff. Observation on 3/8/23 at 9:00 a.m. of the Derryfield kitchenette revealed a countertop ice machine dripping water into a cabinet drawer and a wet area in the right back corner of the cabinet. Inside the cabinet drawer were condiments and snacks. Further observation revealed 2 damp packages of instant oatmeal and 2 damp packages of hot chocolate mix. Observation on 3/8/23 at 9:03 a.m. of the Derryfield kitchenette revealed a large, black, and moist area in the back of a cabinet under the sink. Further observation of the cabinet revealed the wood along the front right and bottom side of the cabinet was damp, cracked, and jagged. Interview on 3/8/23 at 9:04 a.m. with Staff A (Director of Culinary Services) confirmed the above findings. Interview on 3/9/23 at 11:45 a.m. with Staff B (Regional Property Manager) revealed that facility uses an electronic work order system. Interview with Staff B further revealed that staff would notify facilities of any issue through work orders. Interview on 3/9/23 at 11:50 a.m. with Staff C (Maintenance Manager) revealed that there was a leak in the sink that happened a while ago and the wood has been rotted for a long time but he/she was not aware it was damp. Staff C stated that he/she was aware of the leak but there was no work order created. Interview on 3/9/23 at 11:55 a.m. with Staff C revealed that he/she was responsible for performing environmental rounds but did not. Interview on 3/10/23 at 1:30 p.m. with Staff D (Administrator) revealed that environmental rounds should be maintained in the electronic work order system.