Based on observation, interview, and record review, the facility failed to follow professional standards related to assessing and monitoring a large bruise for 1 of 22 residents (Resident #33). Findings include: Per observation on 3/10/2025 at 1:42 PM Resident #33 was observed to have a large bruise on his/her left outer thigh, approximately seven-inches in diameter. Per review of the Lippincott Manual of Nursing [edition 11, 2018], The standards of care for professional nursing include assessment, diagnosis, implementation and evaluation. Departure from Standards of Care include Failure to adhere to facility policy or procedure guidelines. Failure to monitor or observe a patient's clinical status adequately, failure to make prompt, accurate entries in a patient's medical records. Per record review, there was no documented evidence that the bruise had been assessed or monitored. An interview was conducted with Licensed Practical Nurse (LPN) #1 and Registered Nurse (RN) #1 on 3/11/2025 at 2:30 PM. Per interview, LPN#1 and RN#1 confirmed there was no assessment of, or documentation related to the bruise on Resident #33's left outer thigh. The DON [Director of Nursing] was present during the interview. She confirmed that she was aware of the bruise, and stated Resident #33 did not know how it happened.

Based on observation, interview, and record review, the facility failed to ensure that 1 of 5 sampled resident's (Resident #45) was free from unnecessary psychotropic medications. Findings include: On 3/11/24 at 1:20 PM Resident #45 was observed sitting in the hallway sleeping in their wheelchair. After approximately 30 minutes an LNA (licensed nursing assistant) attempted to rouse resident #45. Resident #45 briefly woke up and indicated that they would like to go to their room. The LNA wheeled Resident #45 into their bedroom. At 3:00 PM on 3/11/25 Resident #45 was observed sitting in their wheelchair pointed directly at the corner of their room staring at the wall with no music, TV, or other stimuli present. When asked questions, Resident #45 did not respond. Per record review Resident #45 is prescribed 0.5 mg of Ativan every 6 hours as needed for anxiety for 30 days **reassess after 30 days**. This order was entered on 2/18/25. A facility policy titled Use of Psychotropic Medication, which was implemented by the facility on 12/20/2021, states If the attending physician or prescribing practitioner believes that it is appropriate for the PRN [as needed] order to be extended beyond 14 days, he or she shall document their rational in the resident's medical record and indicate the duration for the PRN order. There was no documented evidence that the attending physician documented a rational for extending Resident #45's Ativan for 30 days instead of 14 days as indicated in the facility's policy. In an interview on 3/12/25 at 9:50 AM the Unit Manager confirmed that the attending physician who extended Resident #45's Ativan order to 30 days and did not document a rational in Resident #45's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Per observation, interview, and facility policy review, the facility failed to ensure medications were removed from the medication storage room use when expiration date has been reached. Findings include: Per observation on [DATE] at 12:50 PM during the inspection of the facility's one medication storage room, the following medications were found to have expired: 1 box Bisacodyl 5 mg laxatives exp: 1/2024 2 Glucagon Emergency Kits (used in emergencies to treat significantly low blood sugars) exp: 1/2025 6 Salonpas pain patches exp: 5/2023 1 Pink Bismuth 8 oz bottle exp: 8/2024 5 Bottles of Aspirin 325 mg tab count: 100 per bottle exp: 2/2024 Per facility Medication Storage policy [last reviewed/revised [DATE]] states, Policy Explanation and Compliance Guidelines: 8. Unused Medications: The Pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. Per interview on [DATE] at 12:55 PM, LPN #1 confirmed the above medications had not been removed from the medication room when they expired.

Based on observation, interview, and record review, the facility failed to promptly provide routine and emergency dental services to meet the residents' needs related to loose decaying teeth for 1 of 17 residents in the applicable sample (Resident #7). Findings include: A record review reveals Resident #7 has resided at the facility since 01/6/21; diagnoses include adult failure to thrive. An interview on 12/4/23 at approximately 1:30 PM, Resident # 7 is observed to have several missing teeth and obvious decay on most of her/his remaining teeth; there are pockets of black decay evident in and around the gaps with broken teeth visible. Resident #7 explains that it has become difficult to chew food, and some of the teeth are loose and uncomfortable. She/he had a bottom bridge, but it has been missing for quite some time. Her/his son is aware and wants to use a family friend who is a dentist to save money. She/he has asked about the appointment but does not know if it is scheduled. A record review reveals a nursing note dated 9/28/23 indicating, [Resident # 7] came to this nurse regarding her bottom teeth [S/he] has had increased difficulty chewing food and feels embarrassed by having little to no bottom teeth .Resident #7's son was called and is going to come in to speak with [Resident #7] today and to set up an appointment with a family dentist that she will feel comfortable at. An interview with the Unit Manager on 12/6/2023 at approximately 9:29 AM reveals no evidence of any scheduled dental care for Resident #7. On 12/6/2023 at approximately 10:30 AM, the Director of Nursing and the Assistant Director of Nursing confirmed no evidence of scheduled dental care, and the facility had failed to assist Resident #7 in obtaining routine and 24-hour emergency dental care.