**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record reviews, observations and interviews the facility failed to ensure medications were properly stored and safeguarded. Specifically, medications were observed on a bedside table in Resident (R)53's room. Review of the facility policy titled Medication Storage in the Healthcare Centers last revised 09/15/17 revealed, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel and pharmacy personnel.During an observation on 07/22/25 at 11:40AM by two surveyors, a disposable cup containing seven loose pills were observed on the bedside table of R53. Review of R53's Electronic Medical Record (EMR) revealed R53 was admitted to the facility on [DATE] with diagnoses including but not limited to: symptomatic epilepsy and epileptic syndromes with simple partial seizures and unspecified dementia. R53's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 07/14/25, revealed a Brief Interview of Mental Status (BIMS) of 10 out of 15 indicating R53 was moderately cognitively impaired.During an interview on 07/22/25 at 11:57AM, Licensed Practical Nurse (LPN)1, stated she is assigned to R53 today and acknowledged her mistake and understood that medications should never be left at a resident's bedside without confirming they have been ingested. LPN1 went back to give medication to the resident, in the last 10 or 15 minutes. Then LPN1, stated, I'm going to be honest, this is my first time working with the resident, she put the cup to her mouth, and I thought she had taken her meds. I should have looked to make sure the resident had taken her meds; this is all on me. There is no time that meds should be left at resident's bedside side without seeing resident take medication.During an interview on 07/24/25 at 12:30 PM, the Director of Nursing (DON), outlined her expectations for nurses regarding medication administration. Nurses are expected to administer residents' medication and observe them taking it. If a resident refuses to take the medication, nurses are to collect and discard the medication and then notify the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of the facility policy, record review, and interviews, the facility failed to refer Resident (R)8, with a new diagnosis of schizoaffective disorder/Bipolar type was screened for specialized services in a timely manner for 1 of 1 resident reviewed for new diagnosis of a mental illness. Findings include: Review of the facility's policy title Resident Assessment- Coordination with PASSAR Program with an implementation date of 10/30/23, states: This facility coordinates assessments with the preadmission screening and resident (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. Section 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level 2 resident review. Examples include: A: A resident who exhibits behavioral, psychiatric, or mood-related symptoms suggesting the presence of a mental disorder (Where dementia is not the primary diagnosis.) Review of R8's admission Record located in the Electronic Medical Record (EMR), revealed R8 was admitted to the facility on [DATE] with diagnoses including but not limited to: bipolar disorder, cognitive communication deficit, dementia, and encephalopathy. On 01/28/23, a new diagnosis of schizoaffective disorder/bipolar type was added to the resident's diagnosis list. Review of R8's EMR did not reveal any documentation of a PASARR Level II. During an interview on 03/21/24 at 11:23 AM, the Registered Nurse/Minimal Data Set Coordinator (RNMDS) stated that she is still learning the process related to PASSARs and has recently went through the training. The RNMDS confirmed there was no referral for a Level 2 PASSAR done for R8. The RNMDS stated that there is typically a form that is to be filled out, which she stated she didn't know how and has not been doing that. The RNMDS concluded she normally reaches out to her point of contact, which is another RN at CLTC (Community of Long Term Care), to confirm if her completion of PASSARs are done correctly. During an interview on 03/21/24 approximately at 12:25 PM, the Facility's Physician (FP) states that he is familiar with the resident and her diagnoses which were obtained from family interviews and her health chart. The FP further states that given R8's mental illness, and progressed paranoia, visual hallucinations, and metabolic concerns/symptoms since admission, he concluded the new diagnosis of schizoaffective disorder. The FP stated the resident has had a history of PTSD related to being sexually abused in her younger years and states that he rarely changes what psych has already put in place for the resident, still trying to adjust medications for the resident to be stable and are always having to increase her medication dosages up most of the time. During a phone interview on 03/21/24 at 2:10 PM, the RN from Community of Long Term Care (RNCLTC) stated, If a resident acquired a new diagnosis of mental health illness while residing in the facility, with progressed behaviors, the facility would have to send over the referral/form to DMH (Department of Mental Health) to determine if it's suitable for the resident to reside in the facility or be transferred to a specialized environment. DMH is supposed to follow up on the referral in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to completely assess Resident (R)29 for choices of self administration of medications, 1 of 1 reviewed for self-administration of medications. Findings include: Review of facility policy titled, Self Administration Policy last revised 11/28/16, revealed Each resident who desires to self-administer medication may be permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility. Self-administration should be written in the care plan once safety has been established. An observation and interview with R29 on 3/29/22 at 9:12 AM revealed R29 with medications in a cup. R29 was able to explain their Eliquis pill and what it is used for, and further stated that they do not like to take all of the medications at one time and that a few of the nurses often leave their medications in a cup for them to take later. R29 was admitted to the facility on [DATE] with diagnoses including, but not limited to; personal history of malignant carcinoid tumor of rectum, pulmonary hypertension, stage 3 pressure ulcer, and hypomagnesemia. Record review of R29's Quarterly Minimum Data Set (MDS) dated [DATE] with an Assessment Reference Date (ARD) of 2/1/22 revealed R29 has a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which reveals they are cognitively intact. Record review on 3/30/22 at 11:30 AM of R29's Electronic Medication Administration Record for March 2022 revealed R29 was administered on 3/29/22 at 9:00 AM the following medications: 1. Gabapentin 300 MG 2. Eliquis 5 MG 3. Stool Softener 100 MG Record review on 3/31/22 at 1:00 PM of R29's Self- Administration of Medication - Data Collection Tool revealed R29's assessment to self-administer only included Magic Mouthwash and did not document approval to self-administer any other medications. An interview on 4/1/22 at 2:17 PM with Registered Nurse (RN)1 revealed that residents that would like to self-administer medications should have an assessment completed for all of the medications they would be taking alone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of facility policy, the facility failed to update Resident (R)29's medical record to reflect their code status. Findings include: Review of facility policy titled: Coordination of Hospice Services last revised 11/27/17, revealed The facility will maintain communication with Hospice as it relates to the resident's plan of care and services to ensure each entity is aware of their responsibilities. R29 was admitted to the facility on [DATE] with diagnoses including, but not limited to; personal history of malignant carcinoid tumor of rectum, pulmonary hypertension, stage 3 pressure ulcer, and hypomagnesemia. Record review on 3/30/22 at 11:03 AM of R29's electronic medical record revealed their code status as Full Code as a Physician Order on the monthly orders for April 2022. Record review on 3/30/22 at 11:05 AM of R29's paper (physical) medical record revealed an Advanced Directive Acknowledgment of Receipt for R29 with Do Not Resuscitate (DNR) and two physician signatures dated 10/11/21. An interview on 4/01/22 at 1:56 PM with Licensed Practical Nurse (LPN)4 revealed that R29's code status is DNR and that staff are trained to review the paper medical record on the unit to ensure resident's code status. An interview on 4/01/22 at 2:17 PM with Registered Nurse (RN)1 revealed the paper medical record DNR order in R29's chart was written by the Hospice Physician and it should have been updated in the electronic medical record. She confirmed the electronic medical record and the physical medical record did not match for code status.

Based on interview, record review and review of facility policy and procedure, the facility failed to ensure 100% (one hundred percent) vaccination of all staff including those who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement. Specifically, the facility failed to ensure a process for tracking and securely documenting the Covid-19 vaccination status of contracted staff. Facility census 108. Findings include: Review of facility policy titled Employee Covid-19 Vaccinations revised date 03/22 revealed .2. Employees who provide any care, treatment, or other services for the facility and/or its residents regardless of clinical responsibility or resident contact are required to be fully vaccinated (CMS (Centers for Medicare and Medicaid Services) term) or up to date (CDC (Centers for Disease Control and Prevention) term) against Covid-19. These include the following: a. Facility employees b. Licensed practitioners c. Students, trainees, and volunteers; and d. Individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement .4. The facility will ensure that all staff (except for staff who have pending requests for, or who have been granted exemptions to the vaccination requirements, or staff for whom Covid-19 vaccination must be temporarily delayed, as per CDC recommendations, due to clinical precautions and considerations) have received, at a minimum, a single-dose Covid-19 vaccine, or the first dose of the primary vaccination series for a multi-dose Covid-19 vaccine prior to staff providing any care, treatment, or other services for the facility and/or its residents. 5. The facility will ensure that all staff (except for staff who have been granted exemptions to the vaccination requirements, or those staff for whom Covid-19 must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) are fully vaccinated (CMS term) or up to date (CDC term) for Covid-19 . Review of facility vaccination log identified one hundred and fifteen (115) employees of the facility and eighteen (18) contracted staff members for a total of one hundred and thirty-three (133) vaccination status for the facility. Further review identified two (2) staff granted exemptions (one for medical and one for religious), one (1) temporary delay/new hire exemption, and one (1) not vaccinated without exemption/delay. Review of facility contracts on 04/01/22 at 3:45 PM identified twelve (12) additional contracted services used by the facility to provide services to the residents. Review of facility Medical Vendors List dated 04/02/22 at 7:45 AM provided by the Assistant Director of Nursing (ADON) identified one hundred and twenty-two (122) additional employees that could potentially enter the facility and provide care, treatment, or other services to the residents. During an interview on 04/01/22 at 12:27 PM with the Assistant Director of Nursing (ADON)/ Infection Control Preventionist (IP) stated, I keep track of vaccination statuses for our staff, housekeeping, and therapy. We are trying to get every ones info (information) who is contracted. I have some info for hospice, nurse consultants, and RD (registered dietician) but it is not in a spreadsheet format. Pharmacy provides the vaccines for the facility and we set up a covid vaccine clinic every month when the pharmacist is here. I do not have information for the other contracted staff used by the facility .