Every finding on record at Navigator Homes of Martha's Vineyard

Based on observations and interviews the facility failed to maintain an environment free from accident hazards in 3 out of 3 occupied resident Houses. Specifically, the facility failed to ensure: 1. House 2a. secured and/or supervised kitchen sharps including chef knives (an all-purpose, versatile kitchen knife with a broad, 8 to 10-inch blade that curves toward a point, designed for chopping, slicing, dicing, and mincing), scissors and peelers,b. supervised accessible hot ovens, andc. secured cleaning chemicals. 2. House 3a. kitchen sharps including chef knives were secured and/or supervised, b. cleaning chemicals were secured, and c. potentially hazardous substances and items were not left unlocked and easily accessible to residents in the clean utility room and in one resident's room (#303). 3. House 4a. secured and/or supervised kitchen sharps including chef knives,b. secured cleaning chemicals, andc. potentially hazardous substances and items were not left unlocked and easily accessible to residents in the clean utility room. Findings include:Review of the facility's policy titled Hazardous Storage in the Home- Supporting Open Access to the Home, effective 1/1/26, indicated the following: To maintain the safety of the Elders but ensure a Real Home environment, most doors in the home will remain unlocked, with the exception of dangerous chemicals and sharp objects, will be secured in locked cabinets or rooms. -knives and other sharp objects will be stored in a locked drawer or cabinet in the home -clearly labeled/marked cleaning products will be stored in a locked utility/laundry room and locked cabinets in the kitchen when not in use -staff will not leave dangerous chemicals or sharp objects unattended 1. House 2 had a census of 13 residents, 10 of those residents had cognitive impairment. a. On 3/10/26 at 3:55 P.M., the surveyor observed the House 2 open concept kitchen area (directly open to dining area and accessible to residents). The kitchen island contained drawers, one with a broken child-safety latch and was able to be opened by the surveyor. The unsecured drawer contained two chef knives. Across from the island was counters with cabinets and drawers. One drawer contained kitchen scissors, a pizza cutter and a peeler. At this time there were two residents who were self-propelling in the dining area, one Resident was asking to leave the facility to catch the [NAME]. During an interview on 3/10/26 at 4:50 P.M., Certified Nursing Assistant (CNA) #7 said there were two CNAs on the 3:00 P.M. to 11:00 P.M. shift assigned to House 2 and one nurse that floated between House 2 and House 3. CNA #7 said she was usually assigned to the kitchen when she worked and was assigned this evening. She said this meant she was responsible for cleaning the dishes after dinner. She said cutting knives were kept in the locked drawer and pointed to the drawer with the broken child-safety lock and said she believed the lock was broken and had noticed it was broken the day prior, but the cooks were responsible for knife storage. During an interview on 3/10/26 at 5:23 P.M., the Administrator said the knives were kept in the pantry (behind an unlocked door accessible from the resident hallway and the kitchen), but in a cabinet and on a high shelf. She said the staff were supposed keep the knives out of reach from residents and not in the kitchen in drawers. b. On 3/10/26 at 3:50 P.M., the surveyor observed the open concept kitchen stacked ovens, a lower oven at waist height and a second oven directly above that. The surveyor observed the lower oven set at 175 degrees Fahrenheit (F) with no food in it from 3:50 P.M. through 4:15 P.M. The open concept kitchen remained accessible to residents without staff in the kitchen. During an interview on 3/10/26 at 4:40 P.M., [NAME] #2 said the current two cooks were prepping and cooking dinner in House 4 this evening and would bring the dinners over to the other two Houses when ready. He said the cooks use the lower ovens as warming ovens and leave them at 175 F, even when there was not a cook in the kitchen. He said there was always a CNA in the kitchen, and the ovens were not left unattended. On 3/10/26 at 4:48 P.M., the surveyor observed the kitchen in House 2 unattended with the lower oven on 175 F and three residents in the dining area (directly adjacent to the open concept kitchen), there were no staff members in the kitchen, dining room, or living room. During an interview on 3/10/26 at 4:50 P.M., CNA #7 said the ovens were not left on unless there was food in them and if there was food in them the cooks were responsible for the ovens. She said the CNAs were not responsible for cooking on the 3:00 to 11:00 P.M. shift and did not check the ovens. On 3/11/26 at 11:04 A.M., the surveyor observed the open concept kitchen in House 2. The lower oven was set at 175 F and [NAME] #2 was observed to exit House 2 to the center courtyard and enter another House. There were five residents in a sitting area next to the kitchen with an outside vendor conducting chair yoga. There were no facility staff in the area. [NAME] #2 returned to House 2 at 11:07 A.M. with cooking materials. On 3/12/26 at 9:52 A.M., the surveyor observed the upper oven set at 350 F and CNA #9 was wiping down countertops. During an interview at this time, CNA #9 said she was done with breakfast and there was nothing in the oven. At 11:10 A.M., the surveyor observed the House 2 upper oven continue to be set at 350 F. There were no staff in the kitchen or dining area. During an interview at 11:13 A.M., CNA #9 said she was coming from providing care to one of the residents. She said she must have left the oven on this morning when heating up a muffin for a resident and forgot to shut it off. She said this was her first time assigned to the kitchen and as far as she knew the dietary staff did not leave the ovens on, so it was not something she would have checked. c. On 3/10/26 at 12:38 P.M., the surveyor observed a 3-compartment sink in the open concept kitchen area. The cabinet below the sink had one half of a child-safety lock on the outside. Inside the cabinet was the other half of the child-safety lock and five one-gallon bottles of kitchen dish sanitizers, two of them were open with tubing directly to the compartment sinks. The cabinet below the 3-compartment sink continued to be unsecured for the following observations: 3/10/26 at 3:55 P.M., 3/11/26 at 8:05 A.M., and 3/12/26 at 11:13 A.M. On 3/10/26 at 3:51 P.M., the surveyor observed in a resident hall a door labeled closet. The closet contained housekeeping supplies including one gallon of glass cleaner and three 32-ounce bottles of bleach germicidal cleaner. The closet door did not have a mechanism to secure the door. On 3/11/26 at 11:54 A.M., the surveyor observed an outside vendor adding secure doorknobs to doors in House 2 and the vendor left House 2 at 12:30 P.M. On 3/11/26 at 12:30 P.M., the surveyor observed the Closet door to have no change in the doorknob, could not be secured and inside the closet there was one gallon of glass cleaner and three 32-ounce bottles of bleach germicidal cleaner. During an interview on 3/11/26 at 12:48 P.M., the Director of Environmental Services said the vendor was adding doorknobs with keypad only access to the Clean Utility closets and the Storage closets next to the Clean Utility Closet. He said there should not be bleach in any closet and it should be secured. 2. House 3 had a census of nine residents; eight of those residents had cognitive impairment. a. On 3/10/26 at 11:47 A.M., the surveyor observed the House 3 open kitchen area. The kitchen island contained drawers, one with an unfastened child-safety latch and was able to be opened by the surveyor. The unsecured drawer contained three chef's knives. An unsecured drawer below the chef's knives contained an unsheathed pizza cutter. At this time there was one resident who was self-propelling him/herself in the dining area and two residents sitting at the dining table unsupervised. During an interview on 3/10/26 at 5:34 P.M., [NAME] #1 said knives are kept in a locked drawer and he pointed out the small drawer on the center island. He said the lock was supposed to be fastened and it was not. [NAME] #1 said it is everyone's responsibility to ensure the drawer is locked. b. On 3/10/26 at 12:31 P.M., the surveyor observed a door labeled pantry in the kitchen area. The surveyor entered the unlocked pantry and observed a housekeeping cabinet with unlocked doors. The cabinet contained one 2.5-liter bottle of Pan-Clean Pot & Pan Detergent, two 1-quart bottles of Stainless-Steel Polish and three 1-quart bottles of Oven & Fryer Cleaner. During an interview with observation on 3/10/26 at 2:00 P.M., the surveyor observed a 3-compartment sink in the open concept kitchen area with an unfastened child-safety lock on the cabinet below. CNA #1 opened the unlocked cabinet doors below the sinks to reveal a one-gallon bottle of dish detergent and one-gallon bottle of dish sanitizer with tubing in each opened bottle leading to the compartment sinks. The cabinet below the 3-compartment sink continued to be unsecured for the following observations: 3/10/26 at 5:18 P.M. and 5:30 P.M. During an interview with observation on 3/10/26 at 5:34 P.M., [NAME] #1 said the cabinet under the 3-comparment sink contains chemicals and noted that it was unlocked. He said it is supposed to be locked, and it is everyone's responsibility to ensure the lock is secured. c. On 3/10/26 at 12:46 P.M. and 3/11/26 at 8:28 A.M., the surveyor entered the unlocked door of the clean utility room in the House 3 hallway. Inside the room were three unlocked cabinets with several hazardous items noted inside including: -Universal adhesive remover wipes -Hydrating Aqua Cream -Moisture Barrier Antifungal Cream -Body Wash and Shampoo -Mouthwash -Disposable razors On 3/10/26 at 12:52 P.M. and 3/11/26 at 8:15 A.M., the surveyor observed a plastic drinking cup with five diabetic glucometer lancets (small needle used to poke the skin) inside an unlocked compartment of the medication cabinet in room [ROOM NUMBER]. During an interview with observation on 3/11/26 at 12:54 P.M., the Director of Nursing (DON) and the surveyor entered the unlocked clean utility room and then room [ROOM NUMBER] and observed the above noted items that were unsecured. He said items in the clean utility room should be securely stored and not accessible to residents in any of the Houses. He said the items in the unlocked compartment of the medication cabinets should either be locked or the items stored in the locked medication room. 3. House 4 had a census of 10 residents, six of those residents had a cognitive impairment. a. On 3/10/26 at 4:05 P.M., the surveyor observed the House 4 open concept kitchen area (directly open to dining area and accessible to residents). On the countertop next to the refrigerator, the surveyor observed a personal knife pouch on the countertop. At the time, one resident was observed to be wandering in the dining room area and attempting to enter the kitchen area. The resident was redirected by staff to the lounge/TV area next to the kitchen. During an interview on 3/10/26 at 4:08 P.M., [NAME] #2 said the knife pouch on the countertop by the refrigerator was his personal set. [NAME] #2 said the pouch had a zipper and latch closure. On 3/10/26 at 4:14 P.M., the surveyor observed both [NAME] #1 and [NAME] #2 leave the kitchen area in House 4, with the personal knife pouch left on the countertop next to the refrigerator. The surveyor was able to zip/unzip and latch/unlatch the personal knife pouch and access the chef knives. [NAME] #1 did not return to the kitchen area in House 4 until 4:28 P.M. b. On 3/10/26 at 3:56 P.M., the surveyor observed in a resident hall a door labeled closet. The closet contained housekeeping supplies including 16 bottles of Simplex Crème-It Crème Cleanser and two bottles of Simplex Neutraquat Disinfectant/Detergent. On 3/11/26 at 8:17 A.M. and 12:32 P.M., the surveyor observed in a resident hall a door labeled closet. The closet contained housekeeping supplies including 16 bottles of Simplex Crème-It Crème Cleanser and two bottles of Simplex Neutraquat Disinfectant/Detergent. During an interview on 3/12/26 at 11:25 A.M., the Corporate Executive Chef (contracted with the facility for culinary services) said he had provided training to all facility staff on safety and hazards. He said the cooks at the facility were contracted through his company and there were no additional dietary staff. He said the facility had a hybrid culinary model where the CNAs were responsible for breakfast and the cooks were responsible for lunch and dinner. He said both the CNAs and the cooks know to secure sharps including knives and to secure sanitation products. He said the previous Food Service Director had decided to use child-safety locks and the locks had broken. He said the CNA staff were not trained to cook in the ovens and should only be using the stove tops. He said the cooks do leave the lower ovens on as warming ovens. He said the plan was to have a cook assigned to every house and that when the oven was on there were always staff around the facility. He said he had not thought about the CNA staff having other duties to do and having the oven unattended. He said this was important to look into because in one of the Houses there was a resident who often tried to enter the kitchen and he was not sure what the plan was when there was no cook assigned to a house. During an interview on 3/12/26 at 1:20 P.M., the Administrator said the facility plan for knives had not been followed by staff and they were not sure how the knives got moved to drawers in the kitchen and had not been communicated to management. She said the ovens were not used by the CNAs and they had not thought about the ovens being left on warm and being unattended. She said the under the sink chemicals should have been secured. She said the Clean Utility closets, Storage Closets and other Closets with supplies were not supposed to have any hazardous materials. She said the materials (cleaning supplies, treatment supplies, lancets) were stocked in the secure facility garage and only should have been taken out and put in secure areas when needed. c. On 3/10/26 at 1:26 P.M. and 3/11/26 at 8:25 A.M., the surveyor entered the unlocked door of the clean utility room in the House 4 hallway. Inside the room were three unlocked cabinets with several hazardous items noted inside including: -Universal adhesive remover wipes -Hydrating Aqua Cream -Moisture Barrier Antifungal Cream -Body Wash and Shampoo -Mouthwash -Disposable razors During an interview with observation on 3/11/26 at 12:54 P.M., the DON said items in the clean utility room should be securely stored and not accessible to residents in any of the Houses.

Based on record 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 dietitian or have a qualified dietary employee who met the minimum qualifications to serve as the FSD. Findings include:During an interview at the entrance conference on 3/10/26 at 12:16 P.M., the Administrator said there was not a FSD and the dietitian worked 20 hours per week at the facility. The Administrator said food services for the facility were contracted and overseen by a Regional Chef. During an interview on 3/11/26 at 10:45 A.M., [NAME] #1 said the FSD for the facility was the Regional Chef and he was on vacation. [NAME] #3 was in charge while he was gone. During an interview on 3/11/26 at 11:00 A.M., the Corporate Executive Chef said he was at the facility to support the kitchen staff during the survey process. The Corporate Executive Chef said he was not in charge of the kitchens at the facility but did support the dietitian and the Regional Chef in specializing menus for the facility. During an interview on 3/11/26 at 2:34 P.M., [NAME] #3 said he was the senior cook at the facility and was filling in for the Regional Chef while he was on vacation. [NAME] #3 said he was not the FSD. During an interview on 3/12/26 at 8:27 A.M., the Administrator brought the surveyor certifications for [NAME] #2 and the Corporate Executive Chef. The Administrator said the Regional Chef, who was on vacation, oversees the whole food service program at the facility. The Administrator said they did not have a FSD at this time. During an interview on 3/12/26 at 9:43 A.M., the Dietitian was not responsible for overseeing the kitchen staff or the running of the kitchen. The Dietitian said she is only at the facility 20 hours per week and is not responsible for the running of the food service program. During an interview on 3/12/26 at 9:45 A.M., the Administrator said the facility currently had no one in charge of the food service program with a certification. The Administrator said the Regional Chef was overseeing the program, but he is not the FSD and does not have credentials. The Administrator said the facility had a FSD, but they left in the past month and are awaiting a new hire to start. The Administrator said [NAME] #3 was overseeing the other cooks at the facility. The facility failed to provide any additional certifications for [NAME] #1, [NAME] #3 or the Regional Chef during the survey process.

Based on observations and interviews, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to:1. Ensure staff wore beard restraints in the main kitchen during meal preparation and service; and2. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another).Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated but was not limited to:-2-402 Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following:- 3-301.11 Preventing Contamination from Hands. (A) FOOD EMPLOYEES shall wash their hands as specified under S 2-301.12. (B) Except when washing fruits and vegetables as specified under S3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT.- 3-304.15 Gloves, Use Limitation. (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. 1. On 3/10/26 at 12:28 P.M., in House 4's kitchen area, the surveyor observed [NAME] #2 plating food items for the lunch meal service without a beard covering donned (on). On 3/10/26 at 3:55 P.M., in House 4's kitchen area, the surveyor observed [NAME] #1 and [NAME] #2 preparing food items for the dinner meal service. Both [NAME] #1 and [NAME] #2 did not have a beard covering donned. On 3/10/26 at 5:18 P.M., in House 3's kitchen area, the surveyor observed [NAME] #2 bringing food items into the kitchen area and placing the food items into the oven. [NAME] #2 did not have a beard covering donned. On 3/10/26 at 5:34 P.M., in House 3's kitchen area, the surveyor observed [NAME] #1 enter the kitchen area and remove food items from the oven. The surveyor observed [NAME] #1 retrieve plates and dishware from the kitchen and place them on the countertop. [NAME] #1 did not have a beard covering donned. On 3/11/26 at 8:17 A.M., in House #4's kitchen area, the surveyor observed [NAME] #1 preparing food items for the breakfast meal service. [NAME] #1 did not have a beard covering donned. On 3/11/26 at 10:45 A.M., in House 4's kitchen area, the surveyor observed [NAME] #1 peeling potatoes in the kitchen area. [NAME] #1 did not have a beard covering donned. On 3/11/26 at 10:45 A.M., in House 2's kitchen area, the surveyor observed [NAME] #2 preparing food items for lunch in the kitchen area. [NAME] #2 did not have a beard covering donned. On 3/11/26 at 12:15 P.M., in House 2's kitchen area, the surveyor observed [NAME] #2 slicing food items in the kitchen area. [NAME] #2 did not have a beard covering donned. During an interview on 3/11/26 at 2:34 P.M., the Corporate Executive Chef said beard coverings and hairnets should be worn at all times during preparation of food and serving of food items. 2. On 3/10/26 at 12:59 P.M., the surveyor made the following observations in House 4's kitchen area:- Certified Nursing Assistant (CNA) #1 delivered a resident's meal with gloved hands to the dining room table. CNA #1 then walked away from the resident, returned and began serving the resident their meal. CNA #1 did not change their gloves or perform hand hygiene prior to returning to the resident to assist with feeding.- CNA #1 moved the trash bin on wheels in the kitchen area with gloved hands. CNA #1 then, with the same gloved hands, began placing fruit into a dish and serve it to a resident. CNA #1, with the same gloved hands, then returned to the kitchen area to grab an ice cream cup from the freezer. CNA #1 then grabbed a spoon from a drawer in the kitchen area with the same gloved hands and delivered the spoon and ice cream to a resident seated at the dining room table. CNA #1 then doffed (removed) her gloves but never performed hand hygiene. During an interview on 3/10/26 at 1:13 P.M., CNA #1 said hand hygiene should be performed each time gloves are removed. On 3/10/26 at 3:55 P.M., the surveyor made the following observations in House 4's kitchen area:- [NAME] #2 took the temperature of food items prior to dinner service. [NAME] #2 cleaned the thermometer between food items with a dishcloth.- [NAME] #2 used the used the same dishcloth to wipe down the countertop of the prep island. [NAME] #2 also used the dishcloth as a potholder as he placed food items back into the oven.- [NAME] #2 touched his gloved hands to his face and hat. [NAME] #2 continued to complete food preparation without changing his gloves or performing hand hygiene. On 3/11/26 at 8:57 A.M., the surveyor made the following observations in House 4's kitchen area:- [NAME] #3 entered House 4 from House 3 with gloved hands, grabbing the door handle to enter. [NAME] #3 said he needed to grab eggs from House 4. [NAME] #3 did not change his gloves and opened the refrigerator in House 4's kitchen to grab a carton of liquid eggs. [NAME] #3 exited House 4 with the same gloved hands and carton of liquid eggs, touching the door handle while exiting. On 3/11/26 at 10:45 A.M., the surveyor made the following observations in House 4's kitchen area:- [NAME] #1 was peeling potatoes over a trash can next to the prep island in the kitchen area. [NAME] #1 was noted to stop peeling potatoes, touch a cell phone with his gloved hands and return to peeling potatoes without changing gloves or performing hand hygiene.- [NAME] #1 touched the side of the trash can and did not change gloves or perform hand hygiene prior to returning to peeling potatoes. On 3/11/26 at 12:29 P.M., the surveyor made the following observations in House 4's kitchen area:- [NAME] #2 entered House 4 from House 2 with gloved hands, touching the door handle when entering. [NAME] #2 entered House 4's kitchen pantry and grabbed a bag of salad mix. [NAME] #2 exited House 4 and returned to House 2 with gloved hands, touching the door handles of each on his entrance/exit. During an interview on 3/11/26 at 3:23 P.M., the Corporate Executive Chef said gloves should be changed when moving between tasks when working in the kitchen. The Corporate Executive Chef said staff should not be touching drawers, in/out of pantry, touching multiple surfaces, or going between Houses with gloved hands. The Corporate Executive Chef said staff should perform hand hygiene between glove changes.

Based on interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to maintain a water management program which included an assessment to identify where Legionella (a type of bacteria naturally found in water and soil that causes serious, sometimes fatal, pneumonia known as Legionnaires' Disease) and other opportunistic waterborne pathogens could grow and spread and failed to implement measures to prevent the growth of opportunistic waterborne pathogens (also known as control measures), and how to monitor them. Findings include: During the entrance conference on 3/10/26 at 12:15 P.M., the Administrator said the new facility had five separated Houses (numbered 1 through 5) and residents had moved into Houses 2, 3 and 4 on 2/4/26. On 3/11/26 at 2:15 P.M. the surveyor requested to review the facility water management program. During an interview on 3/11/26 at 2:20 P.M., the Director of Environmental Services said the previous location had a comprehensive water management program and that the water management program for the new, current location will be comprehensive but was not currently in place. He said there was previously a contract with a water management company for the previous location. He said the current facility location did not have any water management program in place. He said the facility was contracting with a water management company and provided a copy of the contract, dated 12/22/25, that the Administrator had signed with no date of signature and a blank section of signature for the water management company. No additional information was provided prior to the exit on 3/12/26.

Based on interview and record review, the facility failed to ensure monthly medication regimen reviews were maintained as part of the permanent medical record and failed to ensure recommendations made by the pharmacy consultant were addressed timely for three Residents (#4, #7, and #3), out of a total sample of 12 residents. Findings include:Review of the facility's policy titled Medication Regimen Review, dated last revised 6/1/24, indicated but was not limited to the following: - The consultant pharmacist will provide the resident's Medication Regimen Review (MRR) to facility identified personnel who will ensure that the attending physician, medical director, director of nursing and other necessary facility staff receive the recommendations. - For those issues that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected, as outlined in the State Operations Manual Appendix PP. - The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. - The attending physician/prescriber should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident per facility policy, or applicable state and federal regulations. - If the attending physician/prescriber has decided to make no change in the medication, the attending physician should document the rationale in the residents' health record. - The facility should maintain readily available copies of the consultant pharmacist reports on file in the facility, and as a part of the resident's permanent health record. 1. Resident #4 was admitted to the facility in January 2025 with diagnoses including type II diabetes, chronic pain, and depression. Review of the medical record indicated Resident #4 had a monthly pharmacy MRR and recommendations were made by the consultant pharmacist regarding medications on 9/25/25, 11/6/25, 12/19/25, and 1/26/26. During an interview on 3/12/26 at 8:34 A.M., the Administrator said the facility was working with the pharmacy to obtain the recommendations because the recommendations were made prior to the move to the new location on 2/4/26. During an interview on 3/12/26 at 8:52 A.M., the Director of Nurses (DON) said he was unable to find the original pharmacy recommendations. He said the process was that the pharmacy emailed him the recommendations, he distributed them to the physicians, the physicians would address the recommendations, sign the forms, then changes to the orders would be made as indicated and the forms would be uploaded to the electronic medical record. The DON provided the surveyor with copies of the recommendations for Resident #4 and said he would provide any documentation to indicate the physician had addressed the recommendations in the medical record. Review of the Consultant Pharmacy Report, dated 9/25/25, indicated the following: - Resident may benefit from deprescribing and receives the following medications: Multivitamin Injection (MVI) daily, Ocuvite Adult Plus 50 (eye vitamin and mineral supplement) daily and Coenzyme Q10 (antioxidant) 100 mg (milligrams) daily. - Please consider discontinuing MVI, Ocuvite and Coenzyme Q10 daily doses, monitor for any change in symptoms and periodically reevaluate. Review of the medical record failed to indicate the attending physician had reviewed the consultant recommendation for MVI, Ocuvite and Coenzyme Q10 and what, if any actions had been taken. Review of the medical record indicated as of 3/12/26 Resident #4 continued to receive the medications daily. Review of the Consultant Pharmacy Reports, dated 11/6/25 and 12/19/25, indicated the following: - Resident #4 receives a basal insulin analog twice daily for diabetes (Lantus 24 units in the morning and 40 units at bedtime). Basal insulin analogs typically exhibit a relatively constant serum concentration over 24 hours which permits once daily dosing up to 80 units. - Please change the administration of Lantus to 64 units once daily. Close monitoring (e.g., glucose) should accompany any change in diabetic therapy and guide further adjustments. Review of the medical record failed to indicate the attending physician had reviewed the consultant recommendation for Lantus and what, if any actions had been taken. Review of the medical record indicated as of 3/12/26 Resident #4 continued to receive the medications daily. Review of the Consultant Pharmacy Report, dated 1/26/26, indicated the following: - Resident #4 frequently receives PRN Motrin and Tylenol for pain but is not attaining adequate pain control according to documentation in the medical record. - Please evaluate pain status if pain is inadequately controlled, please consider adjustments to the current regimen scheduling a routine analgesic, Tylenol ES (extra strength) 500 MG three times daily. Review of the medical record failed to indicate the attending physician had reviewed the consultant recommendation for Motrin and Tylenol and what, if any actions had been taken. Review of the medical record indicated as of 3/12/26 Resident #4 continued to receive the medications daily. During an interview on 3/12/26 at 11:54 A.M., the DON said there was no documentation to indicate the physician specifically addressed the recommendations for MVI, Ocuvite, Coenzyme Q10, Lantus, Motrin and Tylenol. 2. Resident #7 was admitted to the facility in January 2025 with diagnoses including pulmonary embolism (blood clot in the lungs), hypertension, and heart failure. Review of the medical record indicated Resident #7 had a monthly pharmacy MRR and recommendations were made by the consultant pharmacist regarding medications on 12/22/25. During an interview on 3/12/26 at 8:34 A.M., the Administrator said the facility was working with the pharmacy to obtain the recommendations because the recommendations were made prior to the move to the new location on 2/4/26. During an interview on 3/12/26 at 8:52 A.M., the DON said he was unable to find the original pharmacy recommendations. He said the process was that the pharmacy emailed him the recommendations, he distributed them to the physicians, the physicians would address the recommendations, sign the forms, then changes to the orders would be made as indicated and the forms would be uploaded to the electronic medical record. The DON provided the surveyor with copies of the recommendations for Resident #7 and said he would provide any documentation to indicate the physician had addressed the recommendations in the medical record. Review of the Consultant Pharmacy Report, dated 12/22/25, indicated the following: - Clinical Priority Recommendation: Prompt Response Required - Resident #7 receives aspirin and Eliquis. - Concomitant use of apixaban or edoxaban and select medications may further increase the risk for serious, potentially fatal bleedings. Combination therapy with an antiplatelet agent may be an appropriate choice in select high risk individuals. - If concomitant therapy is to continue, it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual; and b) the facility interdisciplinary team ensures ongoing monitoring for effectiveness and potential adverse consequences (e.g., unusual bruising, bloody or black tarry stools, red or dark brown urine, abdominal pain or swelling, bleeding gums or nose). Any of these symptoms should be reported to the prescriber immediately. Review of the medical record failed to indicate the attending physician had reviewed the consultant recommendation for aspirin and Eliquis and what, if any actions had been taken. Review of the medical record indicated Resident #7 received the medications daily from 12/20/25 through 1/3/26. During an interview on 3/12/26 at 1:47 P.M., the DON said there was no documentation to indicate the physician specifically addressed the recommendations for aspirin and Eliquis. The DON said because the recommendation came over as a clinical priority, the physician should have been faxed and called immediately to address the recommendation. During an interview on 3/12/26 at 3:21 P.M., the Consultant Pharmacist said a prompt clinical recommendation should have a response within 30 days. The Consultant Pharmacist said the recommendation should be reviewed by the physician somewhat timely to ensure additional monitoring is being completed. 3. Resident #3 was admitted to the facility in September 2025 with diagnoses of dementia with agitation, allergies, and chronic pain. Review of the medical record indicated Resident #3 had a monthly pharmacy MRR. Review of the medication record indicated the pharmacist had made recommendations regarding medications on 10/20/25 and 1/26/26. Review of the paper and electronic medical records failed to include what the pharmacist recommendations were on 10/20/25 and 1/26/26. During an interview on 3/12/26 at 8:34 A.M., the Administrator said the facility was working with the pharmacy to obtain the recommendations because the recommendations were made prior to the move to the new location on 2/4/26. During an interview on 3/12/26 at 8:52 A.M., the DON said he was unable to find the original pharmacy recommendations. He said the process was that the pharmacy emailed him the recommendations, he distributed them to the physicians, the physicians would address the recommendations, sign the forms, then changes to orders would be made as indicated and the forms would be uploaded to the electronic medical record. The DON provided the surveyor with copies of the recommendations for Resident #3 and said he would provide any documentation to indicate the physician had addressed the recommendations in the medical record. Review of the pharmacy Consultation Report indicated the following recommendations for Resident #3:10/20/25: order for acetaminophen (Tylenol) 1000 mg every six hours: document the maximum daily dose of acetaminophen from all sources. If maximum dose is 3 grams daily, reduce acetaminophen to three times per day.1/26/26: order for acetaminophen 1000 mg every six hours: document the maximum daily dose of acetaminophen from all sources. If maximum dose is 3 grams daily, reduce acetaminophen to three times per day. Review of the medical record failed to indicate the attending physician had reviewed the recommendation for acetaminophen and what, if any actions had been taken. The medical record indicated as of 3/12/26 Resident #3 continued to receive acetaminophen 1000 mg every six hours. Review of the pharmacy Consultation Report, dated 10/20/25, indicated the following:Consider a trial dose reduction of Seroquel (an antipsychotic) to 25 mg at bedtime Review of the medical record failed to indicate the attending physician had reviewed the recommendation for a trial dose reduction of Seroquel and what, if any actions had been taken. The medical record indicated as of 3/12/26 Resident #3 continued to receive Seroquel 37.5 mg every day. Review of the pharmacy Consultation Report, dated 1/26/26, indicated the following:Reduce the dose of loratadine (a medication for allergy symptom relief) 10 mg to every other day or consider a trial discontinuation Review of the medical record failed to indicate the attending physician had reviewed the recommendation for a dose reduction of loratadine and what, if any actions had been taken. The medical record indicated as of 3/12/26 Resident #3 continued to receive loratadine 10 mg daily. During an interview on 3/12/26 at 10:56 A.M., the DON said there was no documentation to indicate the physician had addressed the recommendations regarding acetaminophen, Seroquel, or loratadine.

Based on observation, interview, and document review, the facility failed to ensure all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. Specifically, the facility failed to:1. Ensure the clean utility room, which contained topical treatments, was locked when not in direct supervision of a licensed nurse in two (#3 and #4) of three Houses; and2. Ensure for rooms #302, #303 and #306, that topical treatments were not left unsecured and unattended in the residents' rooms. Findings include:Review of the facility's policy titled Medication Storage and Transport, last revised 1/16/26, indicated but was not limited to:-Medications shall be stored, handled and administered in accordance with 105 CMR 150.008, and in a manner that ensures the security, integrity, and proper control of all medications, including controlled substances.-Medications will remain secured at all times unless directly under the supervision of a licensed nurse.-All medication preparation and storage will occur in the designated secured medication storage areas, including the Home Office and locked medication cabinets within each Elder's room, in alignment with Department of Public Health expectations for security and supervision.-Each Elder's room contains a dedicated, locking medication cabinet for storage of non-controlled prescribed and over-the-counter medication ordered by the physician and specific to that Elder. 1a. On 3/10/26 at 12:46 P.M. and 3/11/26 at 8:28 A.M., the surveyor entered the unlocked door of the clean utility room in the nursing unit hallway of House #3. Inside the room were three unlocked cabinets with several items noted inside including:-Vasche wound cleanser-Bacitracin Ointment USP (topical antibiotic)-Triple antibiotic ointment-Hydrocortisone cream 1% (topical steroid)-Calmoseptine Ointment (topical ointment and paste that contains menthol and zinc oxide)-Silicone Skin Guard Skin protectantb. On 3/10/26 at 1:25 P.M. and 3/11/26 at 8:25 A.M., the surveyor entered the unlocked door of the clean utility room in the nursing unit hallway of House #4. Inside the room were unlocked cabinets with several items noted inside including:-Bacitracin Ointment USP-Hydrogen Peroxide 3% (chemical compound used as a disinfectant)-Hydrocortisone cream-Anit-Itch cream-Wound cleanser2. On 3/10/26 at 12:52 P.M. and 3/11/26 at 8:15 A.M., the surveyor observed the following:-room [ROOM NUMBER] (door wide open): two bottles of Nystatin powder (topical antifungal used to treat fungal skin infections) unsecured and easily accessible to residents in an unlocked medication cabinet compartment.-room [ROOM NUMBER] (door wide open): one packet of triple antibiotic ointment (topical treatment to prevent infections in minor skin injuries).On 3/11/26 at 12:07 P.M., the surveyor and Nurse #3 observed a box containing multiple packets of skin prep wipes in the unlocked medication cabinet compartment in room [ROOM NUMBER]'s room (door wide open). Nurse #3 said chemicals and dressing supplies are not to be kept in residents' rooms or in any area where other residents could access them.During an interview with observation on 3/11/26 at 12:54 P.M., the Director of Nursing and the surveyor entered the unlocked clean utility room and rooms #303 and #306 and observed the above noted items that were unsecured. He said items in the clean utility room should be securely stored in the medication room and not accessible to residents in any of the Houses, and the items in the unlocked compartment of the medication cabinets should either be locked in the cabinet or stored in the locked medication room.

Based on document review and interview, the facility failed to notify Resident #35's Healthcare proxy (HCP) timely of ongoing changes to the Resident's care and condition for one of two discharged records reviewed. Findings include: Review of the facility's policy titled Change in Condition (Significant) and Notification of Change, dated [DATE], indicated but was not limited to the following: - it is the policy to inform the elder and to notify the elder's legal representative/family member when there is a change in status in a timely manner- significant change in status includes changes in an elder's status such as physical, mental, psychosocial, life threatening, clinical complications, need to discontinue treatment, commencement of new treatment- when there is a change in condition there is timely notification of the elder's legal representative/family and the appropriate observations/assessments are performed and documented- staff nurse will notify the family member/legal representative of the change in status in a timely manner; there may be occasions when it is appropriate for the social worker to contact the family; the specific date, time and name of the person notified and the details of what the person was notified of will be clearly documented in the elder's record Resident #35 was admitted to the facility in [DATE] and had diagnoses including: acute respiratory failure, chronic obstructive pulmonary disease (progressive irreversible lung disease that restricts air flow making it difficult to breathe - COPD), and peripheral vascular disease. The Resident was on hospice services and expired on [DATE]. Review of the Healthcare Facility Reporting System (HCFRS) indicated that the facility self-reported a family allegation of neglect on [DATE] regarding Resident #35, which the facility also investigated. Review of the family concern received by the facility on [DATE], indicated, but was not limited to, the family did not feel informed of changes in the Resident's care or condition following the facility's move to a new physical address on [DATE]. Review of the medical record for Resident #35 indicated but was not limited to the following:- Healthcare proxy (HCP) activation form was completed on [DATE], indicating the Resident no longer had the capacity to make or communicate healthcare decisions. Review of the progress notes from [DATE] through [DATE], indicated but were not limited to the following: - [DATE]: Resident very weak with unlabored breathing- [DATE]: New order for chest x-ray, nurse called physician to indicate time frame for completion and was informed not urgent- [DATE]: discontinue chest x-ray; Augmentin (an antibiotic) 875/125 milligrams by mouth twice a day for seven days- [DATE]: Resident had two nausea/vomiting [sic], Compazine (a medication to help eliminate nausea) administered as ordered, wet cough with no sputum or phlegm, very poor appetite despite encouragement- [DATE]: Resident had episode of COPD exacerbation [sic], as needed Morphine administered with some result, couple hours later, Ativan (antianxiety medication) administered with positive result, Resident calmer had some rest - [DATE]: complaint of dull pain in the left flank region, hospice contacted and notified, respirations shallow, Resident's feet show signs of minor mottling (a patchy discoloration of the skin, common in the final hours or days of life indicating circulatory slowdown) The progress notes and medical record failed to indicate Resident #35's HCP or family were notified of the ongoing changes in his/her condition and/or changes in the plan of care timely. During an interview on [DATE] at 12:37 P.M., the Director of Nurses (DON) said Resident #35 had a daughter, who was not the HCP, come to visit in February 2026 requesting a lot of medical information and he informed her that he could not release any information to her and he felt doing so would violate HIPAA (healthcare information portability and accountability). He said the Resident's HCP was activated, was a different daughter, and that person also lived out of state. He said the Resident had a small decline in January and then in February the Resident's condition continued to deteriorate. He said the HCP, who lived out of state, was informed of changes and made aware of the Resident's condition to the best of his knowledge. During an interview on [DATE] at 1:31 P.M., Nurse #1 said she regularly provided care to Resident #35 and is aware that the Resident had an activated HCP and was on hospice services. She said the Resident started having more complications with his/her respiratory status a month or so prior to him/her passing away. She said the family should always be notified of changes, especially since the Resident had an activated HCP. She reviewed the progress notes for Resident #35 from February 2026 and said it appeared there were multiple opportunities in which the family/HCP should have been updated, and weren't documented as being at bedside, but she could not find any evidence that that notification occurred. She said perhaps the Hospice Nurse had updated the family on all the ongoing changes since the Resident was on hospice. She said the standard expectation of care is to notify the HCP or family of any changes in orders, or a residents' condition to keep them informed of any progress or decline. She said she recalls speaking to the HCP a few times but cannot recall what those talks entailed and said she did not document any of those notifications/communications. During an interview on [DATE] at 2:27 P.M., the Hospice Nurse said the staff reached out to hospice as needed with changes in condition and for recommendations. She said when that occurs and recommendations are given, she would expect that the nurses at the facility would reach out to the family and update them on any changes. She said she was in the facility about twice a week visiting the Resident and would update the family at bedside at those times, but if she was offsite and providing recommendations, she would expect the facility staff to update the family with any changes. During a follow up interview on [DATE] at 1:58 P.M., the DON said his expectation is that the HCP/families are made aware of any new orders or recommendations and any change in condition and the staff should have been keeping Resident #35's family updated on the ongoing changes and documenting that in the medical record. He said if that is not documented in the medical record then he would assume it did not occur. During an interview on [DATE] at 2:07 P.M., the Administrator said she completed the investigations into the family's concerns. She said she did notice that during the investigation that although staff would tell her they felt they were communicating with the family and notifying them of changes in the Resident's condition or plan of care she could not find any documentation to support that was happening routinely and timely in an ongoing manner. She said timely would be right away, but never more than 48 hours. She said during her investigation she learned that the facility needs to do a better job of documenting notification of changes to the families/HCP. A telephone call was placed to Resident #35's HCP on [DATE] at 10:33 A.M., but no return call had been received.

Based on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans for one Resident (#21), out of a sample of 12 residents. Specifically, the facility failed for Resident #21, to develop and implement a care plan related to a history of leaving the residential area and expressing a desire to leave the facility. Findings include:Review of the facility's policy titled Elopement, revised on 1/8/26, indicated all Elders with any history, past or present, of wandering or confusion with associated wandering and especially those with a history of elopement will be identified. All instances of wandering will be documented and reviewed periodically to identify behavior patterns. All identified wandering Elders will have a care plan developed and implemented with specific approaches and time-measured goals. Resident #21 was admitted to the facility in June 2023 with a diagnosis of dementia. Review of the Minimum Data Set (MDS) assessment, dated 3/3/26, indicated Resident #21 scored 0 out of 15 on the Brief Interview for Mental Status, indicating a severe cognitive impairment. Review of Section E for behaviors indicated Resident #21 did not exhibit a behavior of wandering. On 3/10/26 at 1:00 P.M., the surveyor observed Resident #21 self-propelling in their wheelchair towards the front door. The Resident said they were upset because their son was missing. The Resident was observed seated in front of the vertical window that framed the front door, looking outside. Review of the nursing progress notes indicated the following:1/9/26: Resident with increased confusion and was anxious to catch the [NAME] because his/her mother was waiting for them and asking which town the [NAME] was going to.1/19/26: Resident exited their unit, went through another unit, into the elevator and down to the employee lounge. The Resident was found by the custodian on duty. Resident had said he/she was looking for their mom.2/4/26: Resident moved to the new facility location. Review of the medical record failed to include a care plan with interventions for wandering/elopement. Review of the Elopement Risk assessment, dated 3/6/26, indicated Resident #21 did not exhibit any contributing factors including elopement attempts in the past or verbalizing statements about leaving. In addition, the assessment indicated the Resident had not experienced any contributing factors including recent move to facility, recent room change or wandering. The Outcomes section indicated no interventions were necessary. On 3/11/26 at 12:06 P.M., the surveyor observed Resident #21 self-propelling in their wheelchair from their room towards the front door. During an interview on 3/11/26 at 12:08 P.M., Certified Nursing Assistant (CNA) #5 said she was a new employee at the new location as of February 2026. She said Resident #21 was often asking to go home and gravitated towards the front doors, like now. She said the doors were unable to be opened without a keycard or a master key. She said the master key was previously located in the keyhole until Resident #21 started to fidget with the keys and they were removed. She said staff attempt to sit outside with the Resident for a couple minutes or try to redirect the Resident to an activity. During an interview on 3/11/26 at 12:10 P.M., CNA #4 said she had been working at the previous facility and had not heard anything about Resident #21 leaving the residential units and going in the elevator. She said the Resident would not have been able to do this because staff were always around. During an interview on 3/12/26 at 9:42 A.M., Nurse #1 said she was working at the previous facility when Resident #21 exited the units and took the elevator downstairs. She said Resident #21 does wander, more often in the afternoons and mostly heads towards the exit door. She said she did not know if the Resident had a care plan and did not enter care plans into the electronic medical record. During an interview on 3/12/26 at 10:10 A.M., the Assistant Director of Nurses said Resident #21 had left the residential units at the previous facility and a wander guard was implemented at that time. She said this new facility had secure doors and there was no wander guard system. She said she was unable to find a care plan to indicate Resident #21 wandered or what the interventions were. During an interview on 3/12/26 at 10:35 A.M., the Director of Nurses said Resident #21 liked to hover around the exit doors and would attempt to use the door handles and that this should have been reflected on the assessment and the care plans.

Based on records reviewed and interviews, for one Resident (#1) from a sample of 12 residents, the facility failed to ensure Comprehensive Care Plans were reviewed and revised by the interdisciplinary team (IDT) after each assessment, including both the comprehensive and quarterly assessments to reflect the Resident's needs as required.Findings include:Review of the facility's policy titled Comprehensive Care Plan, dated 1/11/26, indicated but was not limited to:-Each Elder will have an individualized Comprehensive Care Plan that is developed, updated, and implemented by the interdisciplinary team with input from the Elder and family.Resident #1 was admitted to the facility in July 2025 and had diagnoses including adjustment disorder and a history of falls.Review of the Minimum Data Set (MDS) assessment, dated 10/7/25, indicated Resident #1 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and had an invoked health care proxy (HCP- health care agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions).Review of a Physician's progress note, dated 12/16/25, indicated that he performed an assessment and in his medical opinion, Resident #1 demonstrated capacity to make his/her own healthcare related decisions and therefore revoked his/her healthcare proxy activation.Review of the MDS assessment, dated 1/6/26, indicated Resident #1 was cognitively intact as evidenced by a BIMS score of 13 out of 15. The assessment indicated that the Resident did not have an invoked HCP. Review of comprehensive care plans indicated:-Problem: Cognitive Loss / Dementia. Resident (sic) has impaired decision making related to (sic) acute mental status changes (delirium), alcoholism, recent urinary tract infections (sic) (7/11/25)-Approach: Activated HCP (7/11/25)-Goal: Resident's (sic) needs will be anticipated and met by staff daily. He/she will be encouraged to participate in his/her care as much as he/she accepts (Target Date 1/1/26)Further review of the comprehensive care plans failed to indicate the care plan was reviewed and revised by the IDT to reflect the revocation of the Resident's HCP activation after the MDS assessment dated [DATE] as required.During an interview on 3/12/26 at 11:52 A.M., the Director of Nursing (DON) reviewed Resident #1's medical record and said he could not find any documentation to indicate the Resident's plan of care was reviewed or revised by the IDT following the last MDS assessment, dated 1/6/26, to reflect the revocation of the Resident's HCP activation on 12/16/25.During an interview on 3/12/26 at 3:20 P.M., the Assistant Director of Nursing reviewed Resident #1's medical record and said she could not find any documentation to indicate the Resident's plan of care was reviewed by the IDT following the last MDS assessment and the care plan was not reviewed and revised to reflect the revocation of the Resident's HCP activation on 12/16/25.

Based on observation and interview, the facility failed to ensure mechanical equipment, specifically a refrigerator, in one of three pantry kitchens was maintained in safe operating condition. Findings include:Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following:4-5 Maintenance and Operation 4-501 Equipment 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. Review of the facility's policy titled Safety and Equipment Maintenance, dated revised 1/2025, indicated but was not limited to the following:- If unsafe conditions are seen in the kitchen, report them immediately to your supervisor so they can be corrected. On 3/10/26 at 3:55 P.M., in House 4's kitchen pantry, the surveyor observed the pantry refrigerator door held shut by a plastic bin of oranges on the ground in front of the door. The refrigerator contained honeydew melons, salted butter, prepared desserts, dated 3/10/26, and packages of meat products. On 3/11/26 at 8:35 A.M., in House 4's kitchen pantry, the surveyor observed the pantry refrigerator door held shut by a plastic bin of oranges on the ground in front of the door. In addition, tape was placed on the top and sides of the refrigerator in an attempt to keep the door closed. The refrigerator contained honeydew melons, salted butter, prepared desserts, and packages of meat products. During an interview on 3/11/26 at 10:45 A.M., [NAME] #1 said the pantry refrigerator door in House 4 has not been closing all the way since yesterday. [NAME] #1 said he placed a plastic bin full of oranges on the ground in front of the door to make sure the door stayed closed. [NAME] #1 said he was not sure when someone was coming to take a look at the refrigerator door. On 3/11/26 at 12:35 P.M., in House 4's kitchen pantry, the surveyor observed the pantry refrigerator door held shut by a plastic bin of oranges on the ground in front of the door. In addition, tape was placed on the top and sides of the refrigerator in an attempt to keep the door closed. The refrigerator contained honeydew melons, salted butter, prepared desserts, dated 3/10/26, and packages of meat products. During an interview on 3/11/26 at 2:34 P.M., [NAME] #3 said he was the senior cook and in charge of overseeing all the House kitchens while the Regional Chef was on vacation. [NAME] #3 said he was told the pantry refrigerator in House 4 was not shutting appropriately this morning, but he had not assessed or done anything about it yet. During an interview on 3/11/26 at 2:35 P.M., the Corporate Executive Chef said he and [NAME] #3 would assess the pantry refrigerator in House 4. On 3/11/26 at 2:54 P.M., in House 4's kitchen pantry, the surveyor observed the pantry refrigerator door was held shut by a plastic bin of oranges on the ground in front of the door. In addition, tape was placed on the top and sides of the refrigerator in an attempt to keep the door closed. The internal thermometer of the refrigerator read 52 degrees Fahrenheit (F). The refrigerator contained meat products, butter, and prepared desserts dated 3/11/26. On 3/11/26 at 3:05 P.M., in House 4's kitchen pantry, the surveyor observed the pantry refrigerator door was held shut by a plastic bin of oranges on the ground in front of the door. In addition, tape was placed on the top and sides of the refrigerator in an attempt to keep the door closed. The internal thermometer of the refrigerator read 53 degrees F. The refrigerator contained meat products, butter, and prepared desserts dated 3/11/26. During an interview on 3/11/26 at 3:23 P.M., the Corporate Executive Chef and the surveyor reviewed the observations made of House 4's kitchen pantry refrigerator. The Corporate Executive Chef said he just put a work order into the system but had not gotten a chance to head over to House 4 to assess the refrigerator. The Corporate Executive Chef said temperatures in the refrigerators should be 41 F or below. The Corporate Executive Chef said all food items in the pantry refrigerator in House 4 would need to be discarded. During an interview on 3/11/26 at 4:56 P.M., the Administrator said kitchen staff should report any equipment malfunctions to the Plant Manager or herself. The Administrator said she should be notified immediately when equipment is not functioning so it can be assessed and fixed.

Based on review of the online Health Care Facility Reporting System (HCFRS: web-based system that health care facilities must use to report incidents and allegations of abuse, neglect, and misappropriation) and staff interview, the facility failed to ensure staff reported/reported timely to the Department of Public Health (DPH), bruises of unknown origin on two occasions for one Resident (#29), out of a total sample of 12 residents. Findings include Review of the facility's policy titled Abuse, Mistreatment, or Neglect, dated 8/11/94, indicated but was not limited to: -This policy establishes the commitment of the facility to ensure that residents are free from abuse, neglect, misappropriation of resident property, and exploitation; allegations or findings of prohibited conduct are reported and investigated in accordance with this Policy and applicable laws, rules and regulations; and that employees understand that they are required to report incidents or allegations of mistreatment and other conduct prohibited by this Policy and applicable law, as well as injuries of unknown origin to the Director of Nursing, Administrator and other officials as required by law. -Identification of possible incidents or allegations which need investigation-Physical marks on the Resident's body or physical injury of unknown source. -Notify the Administrator, Director of Nursing, and the State Survey Agency immediately, but not later than 2 hours after the allegation is made when the events that cause the allegation involve abuse or result in serious bodily injury. -Notify the Administrator, Director of Nursing, and the State Survey Agency immediately, but not later than 24 hours after the allegation is made if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Resident #29 was admitted to the facility in June 2024 and had diagnoses including Alzheimer's disease, dementia with other behavioral disturbances, vascular dementia with anxiety, and claustrophobia. Review of the Minimum Data Set assessment, dated 12/17/24, indicated Resident #29 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 00 out of 15, wandered daily and was independent/supervision for all activities of daily living (ADL). a. Review of Nurse's Notes, dated 2/6/25, indicated a Certified Nursing Assistant (CNA) reported to the nurse that Resident #29 was observed to have bruising to his/her bilateral upper extremities. The nurse assessed the Resident and noted a dark purple bruise on the right upper extremity measuring 3.5 centimeters (cm) x 3 cm and a faded bruise on the left upper extremity measuring 3 cm x 0.5 cm. The Resident's Health Care Proxy (HCP) and Physician were notified. Review of an Incident/Accident Report, dated 2/6/25, indicated a CNA reported that Resident #29 was found to have bruising to his/her bilateral upper arms. Further review of the investigation indicated that the Resident would yell out if injured, and due to his/her ambulatory status, the bruises appear to have occurred during his/her daily routine. b. Review of Nurse's Notes, dated 2/16/25, indicated Resident #29 had a bruise to his/her right thigh measuring 5.5 cm x 4.5 cm and was a mix of yellow/purple in color and a bruise to his/her left lateral plantar (the left side of the sole of the foot, specifically the outer portion) measuring 1.5 cm x 1 cm and was dark purple in color. The Resident's HCP and Physician were notified. Review of an Incident/Accident Report, dated 2/16/25, indicated while the Resident was being showered, a CNA notified the Nurse of a bruise to the Resident's left foot and a bruise to the left thigh. Further review of the investigation indicated Resident #29 ambulates independently in the facility and the day program (5 days a week) and it is possible that the Resident bumped into tables. Review of the HCFRS on 3/19/25 at 1:10 P.M., failed to indicate that the bruises of unknown origin to Resident #29's bilateral upper extremities identified 41 days prior on 2/6/25 and bruises of unknown origin to the Resident's right thigh and left foot identified 31 days prior on 2/16/25 were reported to DPH as required. During an interview on 3/19/25 at 1:19 P.M., Nurse #2 said he didn't know how the bruises on Resident #29's body occurred. During an interview on 3/19/25 at 1:34 P.M., the Nursing Supervisor said she completed the incident reports for the bruises identified on Resident #29's body on 2/6/25 and 2/16/25. She said they do not know how the bruises occurred, but assumes it happened because he/she wanders a lot and likes to obsessively clean things. She said the Resident may have bumped into something or it may have happened at the day program that he/she attends in the community five days a week. The Nursing Supervisor said she called the day program and was told they didn't know anything about the bruises. During an interview on 3/19/25 at 2:00 P.M., the Director of Nursing (DON) reviewed the incident reports, dated 2/6/25 and 2/16/25. She said they do not know how the bruises occurred because they were not witnessed, and the Resident could not explain what happened. She said the day program is a social program, not clinical at all, and many other people from the community attend. She said there is no true supervision of the Resident while he/she is there. The DON said the bruises of unknown origin were not reported because they assumed it happened at the day program, which the Resident attends five days a week for eight hours a day, or at the facility when he/she wanders around the unit. After reviewing incident reports, she said the bruises of unknown origin should have been reported but were not.

Based on observation, interview, and record review, the facility failed to develop and implement an individualized, person-centered care plan to meet the physical, psychosocial and functional needs for one Resident (#29), out of a total sample of 12 residents. Specifically, the facility failed to ensure a comprehensive care plan was developed to address the use of psychotropic medications that identified Resident specific target behaviors, non-pharmacological interventions, and measurable goals of treatment. Findings include: Review of the facility's policy titled Comprehensive Assessment and Interdisciplinary Care Planning, dated 8/11/19, indicated but was not limited to: -The care plan must identify resident specific targeted signs/symptoms of depression, resident specific interventions, including non-pharmacological approaches, and measurable goals for the use of antidepressant medication to meet the resident's needs. This must also be considered for all psychoactive medications, diuretics, anti-coagulants, and diabetic agents. Resident #29 was admitted to the facility in June 2024 and had diagnoses including Alzheimer's disease, dementia with other behavioral disturbances, vascular dementia with anxiety, and claustrophobia. Review of the Minimum Data Set assessment, dated 12/17/24, indicated Resident #29 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 00 out of 15, wandered daily and received psychotropic medication daily. Review of Resident #29's medical record indicated Physician's Orders for the following psychotropic medication: -Seroquel (antipsychotic) 25 milligrams (mg) once a day (7/9/24); and -Citalopram (Celexa-antidepressant) 20 mg once a day (6/20/24) Review of January 2025 through March 2025 Medication Administration Records indicated Seroquel and Citalopram were administered as ordered by the physician. Review of comprehensive care plans included but was not limited to: - Problem: Resident receives psychotropic medication Celexa related to depression (Initiated 6/30/24). - Approaches: Encourage Resident to attend activities of interest; provide 1:1 support as needed; monitor for effectiveness of medication; monitor mood and response to medication (sedation); pharmacy consult review. -Goal: Resident will be prescribed the lowest effective dose of medication (Target Date: 3/31/25). The care plan developed for the use of Celexa failed to identify Resident specific targeted signs/symptoms of depression and measurable goals of treatment to meet the Resident's needs. -Problem: Resident is receiving Seroquel (antipsychotic) related to vascular dementia with behaviors (initiated 6/21/24). -Approaches: Gradual Dose Reduction attempt started on 6/27/24, discontinued on 7/9/24; Abnormal Involuntary Movement Scale (AIMS) every 6 months; monitor for extrapyramidal symptoms (EPS-involuntary movements, muscle stiffness, and tremors), monitor Resident's behavior and response to medication, pharmacy consultant review. -Goal: Resident will not exhibit signs of drug related side effects or adverse drug reaction. The care plan developed for the use of Seroquel failed to identify Resident-specific targeted behaviors, Resident-specific interventions, including non-pharmacological approaches, and measurable goals of treatment to meet the Resident's needs. During an interview on 3/19/25 at 1:34 P.M., the Nursing Supervisor said she is responsible for care plan development. She said Resident #29's care plans should include specific behaviors, signs/symptoms for the use of Celexa and Seroquel and measurable goals but do not. During an interview on 3/19/25 at 2:00 P.M., the Director of Nursing reviewed Resident #29's medical record and said the care plan does not identify appropriate targeted behaviors, sign or symptoms to be monitored with non-pharmacological approaches for the use of psychotropic medications, but it should.

Based on document review, observation, and interview, the facility failed to maintain professional standards of practice for one Resident (#8), out of a total sample of 12 residents. Specifically, the facility failed to ensure physician's orders for compression stockings/edema care were clear and implemented as prescribed. Findings include: Review of Lippincott Manual of Nursing Practice 11th edition, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: - Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize errors. Resident #8 was admitted to the facility in June 2018 with diagnoses including: Chronic peripheral venous insufficiency, heart failure (inability of the heart to pump enough blood throughout the body resulting in swelling in the legs and feet), and polyneuropathy (damage or dysfunction of the nerves effecting the peripheral nervous system). Review of the Minimum Data Set (MDS) assessment, dated 1/14/25, indicated the Resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. During an observation with interview on 3/18/25 at 9:30 A.M., the surveyor observed Resident #8 in bed with their right leg elevated on a pillow. Resident #8 said he/she prefers to stay in bed full time related to an issue with their right lower extremity (RLE). The RLE was without any device, bandaging or anti-embolism stocking at this time and the skin appeared intact with some swelling observed. Review of the Physician's progress notes indicated but were not limited to the following: 2/21/25: Right leg is always swollen, but worse now. Can't tolerate compression stockings. Right leg swelling - primary: Occupational therapy ordered for manual drainage, elevate leg, compressive wrap (ace bandage) since unable to tolerate compression stockings. Review of the current Physician's Orders as of 3/19/25 indicated but were not limited to the following: Apply ace bandage to Right foot/leg every morning and remove at hour of sleep (HS), please document if refused (2/21/25) Thigh high compression stockings on both legs in the A.M. remove at HS. Please document if refused. (2/15/2024) Review of the March 2025 Treatment Administration Record (TAR) for Resident #8 indicated but was not limited to the following: Apply Ace bandage to right foot/leg every morning and remove at HS. *Documented as not administered: item not available on 4 of 19 opportunities *Documented as refused on 4 of 19 opportunities (indicating 3 of 4 of those times the Resident had compression stocking in place) The documentation indicated the Resident had the Ace bandage on his/her right leg/foot 11 out of 19 days. Thigh high compression stockings on both legs in the A.M., remove at HS *Documented as refused on 2 of 19 opportunities The documentation indicated the Resident had thigh high compression stockings on 17 out of 19 days. During an interview on 3/19/25 at 8:20 A.M., the surveyor observed Resident #8 in bed with their RLE elevated on a pillow. The Resident said he/she does not have a stocking or wrap on their RLE at this time. The Resident said he/she didn't know what the staff would put on him/her today because the staff put whatever they want on him/her and do not ask the Resident their preference for either the wrap or compression stocking. The Resident said he/she prefers the thigh high stocking that he/she had in the past, but that is never an option. It is either the ace bandage wrap or knee high compression stocking that is placed on their RLE. The surveyor made the following observations of Resident #8: 3/18/25 at 1:03 P.M. and 3:55 P.M., Resident had a knee high compression stocking in place to his/her RLE 3/19/25 at 9:50 A.M. and 12:59 P.M., Resident had a knee high compression stocking in place to his/her RLE During an interview on 3/19/25 at 9:50 A.M., Resident #8 said he/she was in a bit of a mood because the staff placed the knee high compression stocking on his/her RLE and didn't listen to him/her when he/she asked about the thigh high stocking. The Resident said he/she does not like the wrap because it is either too tight or too loose and pretty much does nothing. During an interview on 3/19/25 at 9:55 A.M., Nurse #3 entered the Resident's room and said the Resident has two orders to manage their RLE edema, the leg wrap or the compression stocking. She said which the staff uses is dependent on which one the Resident will allow on any given day as the Resident frequently refuses. The nurse observed the compression stocking in place on the Resident at this time and said the Resident is supposed to have a thigh high compression stocking not a knee high stocking according to the order. She looked around the room and asked the Resident if he/she would like the wrap instead and the Resident declined. She offered to remove the knee high stocking from the Resident until the ordered thigh high compression stocking could be retrieved but the Resident declined and said he/she prefers to keep something on the RLE. On review, she agreed the order does not indicate one or the other and the orders appear as though both should be in place, which would be clinically inappropriate. The Nurse said the physician's order for compression stockings is specific to thigh high stockings and that is not what is in place at this time, therefore the order is not being followed as written. She said she doesn't know how that knee high stocking got on the Resident and she had not signed off the order for compression stockings being applied yet on this day. During an interview on 3/19/25 at 10:46 A.M., the Director of Nurses said she was made aware of the situation with Resident #8's compression stockings. She said there should not be two conflicting orders. Physician's orders are to be followed as written by the prescribing physician and need clarification. She said the lymphedema is not new for the Resident and needed to be managed as tolerated by the Resident in accordance with the ordered treatment and then staff can document if the Resident refuses on any given day, but the documentation should be clear. She said the staff should have followed the order for thigh high compression stockings and not substituted them for knee high stockings as that was not what was ordered. She said it appeared the Nurses were signing off the thigh high compression stockings each day, although they were not in use, and they should have noticed the stocking in place was not the ordered length and retrieved the correct stockings but did not.

Based on record review and interview, the facility failed to ensure for one Resident (#133), out of a total sample of 12 residents, that the resident's drug regimen was free from unnecessary psychotropic medications to promote or maintain the Resident's highest practicable mental, physical, and psychosocial well-being. Specifically, the facility failed to ensure targeted behaviors and signs and symptoms of potential adverse consequences were monitored for the use of the antipsychotic medication Quetiapine. Findings include: Review of the facility's policy titled Psychotropic Medications Policy, dated 11/15/2017, indicated but was not limited to: -Facility should comply with the Centers for Medicare and Medicaid Services (CMS) State Operations Manual Appendix PP, and all other applicable laws relating to the use of psychopharmacologic medications including gradual dose reductions. -All medications used to treat behaviors should be monitored for efficacy, risks, benefits, and harm or adverse consequences. Resident #133 was admitted to the facility in March 2025 and had diagnoses including mild cognitive impairment and restlessness and agitation. The Minimum Data Set assessment was in progress. Review of the medical record indicated Physician's Orders including but not limited to: -Quetiapine (antipsychotic) 25 milligrams (mg) at bedtime for restlessness and agitation (3/14/25) Review of the March 2025 Medication Administration Record (MAR) indicated Quetiapine was administered as ordered by the physician. Further review of the medical record failed to indicate Resident #13's restlessness and agitation was monitored for efficacy of Quetiapine and that the Resident was monitored for potential adverse consequences for its use. During an interview on 3/19/25, the Director of Nursing reviewed Resident #133's medical record and said they were not monitoring the Resident's targeted behaviors to ascertain the effectiveness of the antipsychotic therapy and were not monitoring the Resident for potential adverse consequences but should be.

Based on observation, staff interview, and review of the manufacturers' recommendations for use, the facility failed to ensure that ophthalmic medications were labeled, dated, and stored to ensure the efficacy of the medication and prevent the potential for infection in 1 of 2 medication carts on 1 of 2 units inspected. Findings include: Review of the facility's policy titled General Dose Preparation and Medication and Administration, dated 12/1/07, indicated but was not limited to: -Facility staff should enter the date opened on the label of medications with shortened expiration dates. On 3/6/24 at 3:00 P.M., the surveyor inspected the Unit 3 Medication Cart with Nurse #5 and observed the following: The top drawer of the medication cart had multiple boxes stored which contained various eye medications. The individual boxes of eye medications were labeled with handwritten dates from 11/2023 to 1/2024 as follows: -a box containing a bottle of Artificial Tears for Resident #10 was labeled as opened on 11/11/23. -a box containing a bottle of Artificial Tears for Resident #9 was labeled as opened on 11/12/23. -a bottle of Artificial Tears for Resident #21 was labeled as opened on 12/31/23. -a bottle of Artificial Tears for Resident #1 was labeled as opened on 1/12/24. -a bottle of Timolol 0.5 % ophthalmic solution (used to treat glaucoma) for Resident #19 was not labeled with the date it was opened. During an interview on 3/6/24 at 3:00 P.M., Nurse #5 observed the various dates on the boxes containing the Artificial Tears and said she wasn't sure how long the Artificial Tears were safe to use after opening the bottle. She also said that there was no date that indicated when the medication should be discarded. Nurse #5 said she was not aware of the risk of infection that existed following the use of the eye drops past 4 weeks after opening. Nurse #5 did not know when the bottle of timolol eye solution was opened but said that Resident #19 received the eye medication twice/day. Review of the patient brochure for Tears Naturale (artificial tears) indicated that patients should Stop using the bottle 4 weeks after first opening, to prevent infections. Review of the manufacturer's instructions for use for Timolol 0.5% ophthalmic solution indicated to discard any solution remaining in the dropper bottle 4 weeks after the date on which the container is first opened due to the risk of infection. During an interview on 3/06/24 at 3:39 PM, the Director of Nursing (DON) said she understood the concern regarding the potential for infection of artificial tears/timolol eye drops after being open for greater than 4 weeks. She also said that the labeling of eye medications should reflect a shortened expiration date based on the manufacturer's expiration date due to the risk of infection.

Based on observation, document review, record review, and interviews, the facility failed to ensure hot beverages were served at a safe temperature for one Resident (#24), which resulted in a burn, from a total sample of 12 residents. Findings include: Resident #24 was admitted to the facility in March 2018 with diagnoses including dementia, dysphagia (swallowing difficulty), and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 12/4/23, indicated Resident #24 was unable to complete the Brief Interview for Mental Status as evidenced by a score of 99, had severely impaired skills for daily decision making, and required set-up assistance from staff with the activity of eating and drinking. Review of the facility's internal investigation report indicated that on 2/2/24 around 8:40 P.M., Resident #24 asked a Certified Nursing Assistant (later identified as CNA #1) for a cup of coffee while in the unit dining room. The investigation indicated the CNA brewed a cup of coffee utilizing a single-serve hot beverage brewing system in the staff break room and provided it to the Resident in two paper hot cups. The CNA's statement indicated the Resident spilled the hot coffee down the front of his/her body. The Resident was then taken to the bathroom by CNA #1 and CNA #2 and cold compresses were applied to his/her abdomen. On 3/6/24 at 9:46 A.M., the surveyor inspected the unit's staff break room and observed a single-serve hot beverage brewing system on the counter. No thermometers or instructions for ensuring beverages were served to residents at the proper temperature were noted. During an interview on 3/7/24 at 8:35 A.M., the Director of Nursing said they do not have a policy or anything in place right now on the units to ensure hot beverages are provided to residents at safe temperatures. On 3/7/24 at 2:55 P.M., a message was left for CNA #1 to return the surveyor's telephone call. On 3/8/24, CNA #1 returned the surveyor's telephone call, and during an interview at 9:05 A.M., the CNA said on 2/2/24 around 8:30 P.M., Resident #24 asked her for a cup of coffee. She said she looked in the kitchenette cabinet and found no coffee, then went to the staff break room. She said she found some coffee pods and brewed a cup of coffee in the single-serve hot beverage brewing system. CNA #1 said she used two cups so the coffee wouldn't be so warm for the Resident to hold on to. She said she did not measure the temperature of the coffee or otherwise make sure it was not too hot for the Resident. She said a short time after she gave the Resident the coffee, he/she spilled it on him/herself. She said the area on the Resident's abdomen was red for a week. She described it as a strip of redness across his/her abdomen that became like a thin burn mark. She said over the week, the area became darker and raised. CNA #1 said she is not aware of a policy about providing hot liquids to residents and has not received any education regarding serving hot liquids to residents.

Based on observation and interview, the facility failed to ensure staff provided residents with adequate supervision for four Residents (#22, #26, #1, and #8), out of 16 sampled residents, and an environment free from accident hazards on two of two units in the facility. Specifically, the facility failed to ensure: 1. For Resident #22, that effective care plan interventions were developed and implemented to prevent a fall with major injury; 2. For Resident #26, that effective care plan interventions were developed and implemented to prevent seven falls; 3. For Resident #1, that effective care plan interventions were developed and implemented to prevent three falls; 4. For Resident #8, that effective care plan interventions were developed and implemented to prevent four falls ; 5. The clean utility room on Unit 4 was locked and hazardous items including topical treatments were securely stored and not accessible to wandering residents; and 6. Medications were not left unsecured and accessible to residents on a medication cart on Unit 3. Findings include: Review of the facility's policy, Fall Prevention Program, last revised 8/2021, included, but was not limited to: -Goal: To identify residents at risk for falls and assure appropriate intervention for prevention of falls are implemented. To prevent injury with falls to the extent possible. -Procedure: Residents determined to be high risk for falls, may have the following preventative measures implemented: -Physical Therapy screen and follow recommendations -Frequent visual safety checks at regular intervals if necessary -Residents determined to be at risk will have the potential for falls reviewed at the weekly RISK team meeting and addressed on their care plan with the appropriate interventions documented. The CNA [Certified Nursing Assistant] assignment will indicate the resident is at risk for falls -The CNA Care Plan/Assignment & Resident Care -Plan will be updated with any change when the change occurs FALLS: 1. Resident #22 was admitted to the facility in March 2018 with diagnoses including dementia and a history of falls. Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #22 requires extensive assistance of two staff for transfers, bed mobility and utilized a wheelchair. The assessment indicated the Resident was unsteady and only able to stabilize with assistance when moving from a seated position to standing. Review of Resident #22's Interdisciplinary Care Plans included, but was not limited to: -Problem: Resident is at risk for falling related to a history of falls, dementia, incontinence and poor safety awareness (3/6/18) -Approach: Keep visible when up due to impulsive and history of falls (12/7/21); No chuck pad on wheelchair to prevent sliding from chair (7/6/20); Prefers to stay up until 10:00 P.M. (2/28/21); Encourage resident to assume a standing position slowly (3/6/18); Give resident verbal reminders not to ambulate/transfer without assistance (3/6/18); Keep bed in lowest position with brakes locked (3/6/18); Prompted toileting every A.M., P.M., before/after meals, bedtime and as needed (3/6/18) -Goal: Resident will remain free from injury with fall initiated (9/20/20) Review of the medical record indicated Resident #22 had seven falls from December 2021 to October 2022. Review of the falls indicated: 1.12/7/21 at 8:15 A.M., Resident was found on the floor mat next to bed. Review of the documentation failed to indicate what interventions were in place at the time of the fall, or interventions implemented to reduce the risk of future falls. 2. 2/9/22 at 10:15 P.M., Resident was found on the floor in the bathroom doorway in his/her room. Intervention identified to prevent the risk of falls was an eval. Review of the medical record failed to indicate an eval was conducted. No new interventions were put in place to prevent further falls. 3. 2/13/22 at 4:15 A.M., Resident was found on the floor mat next to bed. Intervention identified to prevent the risk of falls was an eval. Review of the medical record failed to indicate an eval was conducted. No new interventions were put in place to prevent further falls. 4. 6/18/22 at 10:00 A.M., Resident was found on the floor in the dining room on his/her back with blood coming from the head area. Review of the documentation failed to indicate what interventions were in place at the time of the fall. Intervention identified to prevent the risk of falls was an eval. A staff statement (CNA) indicated Resident #22 was toileted at 8:00 A.M. and was last seen sleeping in his/her wheelchair in the unit dining room. Review of the medical record failed to indicate any new interventions to prevent further falls. Review of a 6/18/22 Nursing Progress Note indicated that at approximately 10:00 A.M., the Nurse and CNA heard a thump, saw Resident #22 on the floor in the unit dining room on his/her back with blood coming from his/her head. The Resident was sent to the emergency room for evaluation. Review of the medical record and Hospital Discharge Summary, dated 6/18/22, indicated Resident #22 presented to the Emergency Department after having an unwitnessed fall from his/her wheelchair with a head strike and laceration to the right forehead. The documentation indicated facility staff report the Resident slides out of his/her wheelchair occasionally. The assessment and plan indicated the Resident did not sustain a fracture but had a large forehead laceration and hematoma. The wound was cleaned and was going to be repaired by the PA (Physician's Assistant), however the size of the hematoma made it impossible to approximate the wound edges. Even with removal of some clot, the wound was too gaping to suture. Review of a 6/19/22 Nursing Progress Note indicated the forehead laceration measured 4.9 centimeters (cm) x 1.5 cm. 5. 7/25/22 at 4:00 A.M., Resident was found on the floor mat next to bed. Intervention identified to prevent the risk of falls was a PT eval. Review of the medical record failed to indicate a PT eval was conducted and no interventions were implemented to prevent further falls. 6. 9/19/22 at 10:30 P.M., Resident was found on the floor mat next to bed. Intervention identified to prevent the risk of falls was PT to screen. Review of the Rehabilitation Screen documentation failed to indicate any new interventions were recommended. 7. 10/5/22 at 12:32 A.M., Resident found on the floor mat next to bed. Intervention identified to prevent the risk of falls was screen. Review of the Rehabilitation Screen documentation failed to indicate any new interventions were recommended. During an interview on 10/7/22 at 11:30 A.M., the surveyor and Nursing Supervisor reviewed Resident #22's falls. The Nursing Supervisor said that the team had discussed different interventions to prevent falls but had not implemented any. She could not explain why the Resident's fall on 6/18/22 was unwitnessed and the care plan intervention of being kept visible when up due to impulsive behavior was not implemented . The Nursing Supervisor confirmed that no new interventions have been developed or implemented to prevent Resident #22 from having further falls. Review of the medical record on 10/20/22 indicated that Resident #22 was found on the floor mat next to bed. Intervention identified to prevent the risk of falls was a raised perimeter mattress placed on the Resident's bed. 2. Resident #26 was admitted to the facility in August 2017 with diagnoses including hypertension. Review of the 8/22/22 Minimum Data Set assessment indicated that Resident #26 requires supervision for transfers, walking in his/her room, toileting and personal hygiene. The assessment also indicated that the Resident is unsteady while walking, turning around, turning around and facing the opposite direction while walking and moving on and off the toilet. Review of interdisciplinary care plans included, but was not limited to: Problem: Resident is at risk for falling related to unsteady gait, [CONDITION(S)] medication use (8/22/17) Approach: Keep call light and personal items in reach at all times (8/22/17); Encourage resident to use environmental devices such as hand grips, handrails, etc. (8/22/17); Provide verbal cues to stand tall and slow down during ambulation (12/9/19); Per request of Resident, handheld assist as required (2/6/20); Extra railing added along the wall to the bathroom for extra support (2/7/20) Goal: Resident will be free from injury (9/3/20) Review of the medical record indicated Resident #26 had seven falls from February 2022 to October 2022. Review of the falls failed indicated: 1. 2/18/22 at 1:45 A.M., Resident was found lying face down on the floor next to bed with pants around his/her ankles. A bruise was noted to the Resident's forehead and a skin tear to his/her left elbow. Review of documentation failed to indicate what interventions were in place at the time of the fall, or interventions implemented to reduce the risk of falls. 2. 4/3/22 at 12:15 A.M., Resident was found sitting on his/her buttocks in front of the toilet. Intervention identified to prevent the risk of falls was PT screen. Review of the Rehabilitation Screen documentation failed to indicate any new interventions were recommended. 3. 4/12/22 at 8:45 P.M., Resident was found on the floor lying on his/her right side in the bathroom. Intervention identified to prevent the risk of falls was PT screen. Review of the Rehabilitation Screen documentation indicated a recommendation for Occupational Therapy (OT) to evaluate and treat the Resident to increase safety and independence in room. The Physician wrote an order for an OT evaluation and treatment. Review of the 5/24/22 OT evaluation indicated the treatment plan would include therapeutic activity, therapeutic exercise, self-care/home management and balance twice a week for eight weeks. The OT evaluation failed to indicate any Resident specific interventions staff could implement to prevent further falls. 4. 5/21/22 at 9:05 P.M., Resident was found sitting on the floor in the bathroom. The section of the report to identify steps taken to prevent recurrence was blank. Review of the medical record failed to indicate any new interventions were implemented to prevent further falls. Review of a 5/27/22 OT treatment note indicated that while transferring to the toilet, Resident #26 continues to be unsafe due to increased knee flexion and shuffling gait. 5. 5/29/22 at 6:58 A.M., Resident was found on the floor in his/her room by custodial staff. The section of the report to identify steps taken to prevent recurrence was blank. Review of a 6/10/22 OT treatment note indicated Resident #26 presents with impaired insight into errors and deficits, requiring maximum cueing to maximize safety. Review of a 9/13/22 OT treatment note indicated Resident #26 walked to the bathroom with distant supervision and cueing and education for safety. 6. 10/2/22 at 8:44 P.M., Resident was found on the floor sitting on the floor in the bathroom. Interventions identified to prevent the risk of falls was: placed on falling star prevention program, encourage resident to ring call bell in bathroom for dressing/undressing. During an interview on 10/20/22 at 11:44 A.M., Physical Therapist (PT) #1 said she is aware Resident #26 has had multiple unwitnessed falls in the bathroom. She said the Resident participates in the Vitality program three days a week (ambulation by rehabilitation staff). The surveyor and PT reviewed the Resident's OT notes and were unable to identify any approaches identified for staff to implement to prevent further falls. She said every two-hour toileting program or increased supervision are interventions that could be implemented to prevent further falls, but she could not explain why they have not been attempted. During an interview on 10/20/22 at 12:25 P.M., Nurse #2 said that Resident #26 gets weak and falls in the bathroom. The surveyor asked Nurse #2 if she has any ideas of how to prevent the Resident from falling again and she said that he/she may be receptive to every 2-hour toileting, or distant supervision. The Nurse did not know why these interventions had not been attempted. 3. Resident #1 was admitted in 4/2010 with diagnoses which included, dementia in other diseases, [CONDITION(S)], delusional disorders, anxiety disorder, unspecified, and [CONDITION(S)]. The Resident's BIMS (Brief Interview for Mental Status) score of 6 out of 15, indicated the presence of severe cognitive impairment. Additionally, the Resident was identified by the facility to be at high risk for falls, according to a John Hopkins Fall Risk Assessment score of #18 (>#13 High Risk). According to the Resident's Plan of Care for: Resident at risk for falling R/T [CONDITION(S)], history of falls, poor safety awareness, was revised on 10/20/2022 (date of survey). The Goal was-Resident will remain free from injury. Approaches to achieve the goal were as follows: Start Date 10/18/22 -Resident identified as a fall risk. Place resident on Falling Star program. Start Date 7/30/2020 -Wander Guard placed on w/c (wheelchair) for safety. Start Date 4/30/2010 -Do not leave alone in bathroom. -Encourage resident to assume a standing position slowly. -Encourage resident to use environmental devices such as hand grips, hand rails, etc. -Give resident verbal reminders not to ambulate/transfer without assistance. -Keep call light in reach at all times. -Keep personal items and frequently used items within reach. -Provide resident with safety device /appliance: Gait belt, wheelchair. -Provide toileting assistance QAM, Before/after meals, HS and PRN. -Reacher within reach at all times. -Wheelchair for all mobility. Further Record review on 10/20/22, indicated that, despite the Plan of Care to prevent accidents and injury, the Resident experienced a total of 3 falls between the period of 5/2022 to 9/22/22 as indicated below: 1. On 5/13/2022 at 7:10 A.M., the Resident reportedly slid out of the wheelchair to the floor across from the nurse's station in the hallway by the clean utility room. The Resident was assessed by the nurse and no injuries were reported. The incident report indicated that steps taken to prevent recurrence included: PT eval (physical therapy) evaluation, refused wedge, frequent positioning, at times the Resident sits on the edge of the wheelchair. No additional interventions were listed following this fall to provide increased supervision and safety. 2. On 9/16/2022 at 2:45 A.M., the Resident was reportedly found lying on the floor (unwitnessed) in his/her room, sustained bruises to bilateral hands, right arm skin tear and bruises/abrasions on right lower leg. The incident investigation indicated that a PT eval would be done to prevent recurrence. No other interventions were listed to prevent further falls/injury, provide adequate supervision, and maintain the Resident's safety. 3. On 9/18/22 at 5:05 P.M., the Resident was reportedly found on the floor (unwitnessed) by a CNA (certified nursing assistant) on his/her knees with his/her head laying on the mattress at the foot of the bed. Interventions listed to prevent recurrence included use of the reacher (resident stated reaching for it unknown what) Encourage out of bed for meals d/t (due to) impulsivity. Although interventions were considered for this Resident, the Resident would not reliably remember information provided by staff, due to his/her severe cognitive decline. No additional interventions were implemented to provide greater supervision to maintain the Resident's safety and prevent injury. On 10/20/22 at 11:11 A.M., the Resident was observed in her room, sitting in his/her wheelchair, unsupervised, watching television. The Resident appeared to recognize this writer, and with garbled speech commented on their clothing. The Resident was observed rummaging through his/her drawers, wanted to shut his/her TV off but had difficulty doing so due to his/her debility in movement. Several minutes later, the Resident propelled the wheelchair to the doorway to his/her room, unsupervised, and appeared unsure of what to do. The Resident was non-ambulatory. The Administrator was interviewed on 10/20/22 at 1:50 P.M., regarding the frequent falls for this Resident, one fall with skin tears and bruises, and the risk for additional falls and injury remained due to ineffective safety interventions and supervision. The Administrator said that interventions to prevent falls had not been effective. 4. Resident #8 was admitted in 9/2017 with diagnoses which included unspecified dementia with behavioral disturbance. The medical record indicated that the Resident scored a 4 out of 15 on the BIMS (Brief Interview for Mental Status), which indicated severe cognitive impairment. Therapy indicated on 9/5/22, that an assist of 1 person continued to be required for all stand pivot transfers and the Resident was able to propel the wheelchair using BLE (bilateral lower extremities). On 9/5/22, a John Hopkins Fall Risk Assessment was performed which indicated a score of #18, placing the Resident at high risk for falls. The Resident's plan of care to address Falls was reviewed and indicated the following goals and interventions: GOAL: Resident will remain free from injury. Start Date: 9/26/2017 Approach: Provide toileting assistance per resident's toileting schedule -Give resident verbal reminders to use her call bell and wait for staff to assist her. Keep personal items in reach -Call light and personal items within reach. Night light on at HS (hour or sleep) Start Date: 12/14/21 Approach: Call before you fall/reminder sign posted at wheelchair height. Start Date: 10/18/22 Approach: Resident identified as a high risk for falls. Resident placed on Falling Star program. Falling star placed in resident shadow box for fall identification. Start Date: 10/19/22 Approach: Resident falls identified when reaching for items. Table ordered to allow resident to wheel wheelchair into, edges to prevent cards from slipping off, and is adjustable to resident. 1. On 6/15/22 at 5:00 P.M., the Resident fell and was found on the floor (unwitnessed) next to his/her wheelchair. Review of the incident/accident report, indicated that when asked, the Resident said that he/she was standing and reaching and then, I don't know. A small hematoma was found on the back of the Resident's head. The incident/accident report indicated that steps taken to prevent recurrence was a PT screen. 2. On 8/3/22 at 2:30 P.M., the Resident was found on the floor (unwitnessed) in his/her room next to his/her wheelchair. The incident/accident report indicated that the Resident was able to move all extremities, vital signs were stable, the Resident was alert and answering questions appropriately. The Resident was unable to state how he/she fell . The wheelchair was at reach beside the Resident. A reddened area was noted at the right, lower rib cage which resolved after 10 minutes. Steps taken to prevent recurrence noted on the incident/accident report were, PT eval and new tray table attempt for cards. No additional interventions were considered to prevent further falls/injury to the Resident. Physical therapy's evaluation of the Resident on 8/4/22, indicated, Frequent visual checks by all staff recommended and anticipation of needs to limit his/her reaching far forward. 3. On 8/17/22 at 1:45 P.M., Resident was reportedly heard yelling help. According to the incident/accident report, upon entering the room, the nurse found the Resident lying on the floor on his/her left side between the radiator and the closet. The Resident was alert, assessed by the nurse, and found to have no injuries. The incident/accident report indicated that, steps taken to prevent recurrence were, -encourage Resident to ring call bell for fallen cards, and -continue to reinforce call bell use. (Resident with severe dementia) 4. On 9/13/22 at 6:33 A.M., the Resident was found (unwitnessed) sitting on the floor in his/her room leaning against the bed. According to the incident/accident report, the Resident fell out of bed while trying to get to his/her wheelchair to use the bathroom. No apparent injuries were noted. The incident/accident report indicated that steps taken to prevent recurrence included, -educate resident on importance of waiting for assistance. -Reinforce call bell use. (Resident with severe dementia) In spite of approaches listed in the Resident's plan of care, the facility failed to provide adequate supervision and effective/appropriate interventions to prevent falls/accidents. Interview with the administrator on 10/20/22 at 1:55 P.M., said that the facility had a significant number of falls. She acknowledged that interventions, at times, were not effective and did not necessarily take into account the unique behaviors of residents and patterns associated with the falls. SAFETY HAZARDS 5. On 10/4/22 from 1:30 P.M. to 1:56 P.M., the surveyor observed two residents wandering the hallway on Unit 4 (secured unit/Memory Impaired). There was no facility staff visible in the unit hallway at the time of the observation. On 10/4/22 at 1:57 P.M. on Unit 4, the surveyor approached a closed door labeled clean utility. The door had a numerical combination lock on it, but the door was not pulled tight and secured and was easily pushed open. The room contained an unlocked treatment cart with a plastic caddy placed on top of the cart containing a bottle of fingernail polish remover, 12 bottles of fingernail polish, and one wooden manicure stick. The drawers of the treatment cart contained: -Drawer #1: two boxes of [MEDICATION(S)] skin protectant ointment, two boxes of hemorrhoidal ointment, two tubes moisture barrier antifungal cream, one bottle of skin prep spray. -Drawer #2: one box of 200 alcohol prep wipes -Drawer #3: one bottle of fecal occult blood developing solution, one bag of wooden specimen sticks -Drawer #4: one box of [MEDICATION(S)] Zinc antibiotic ointment Shelves in the clean utility room contained: -five bottles of baby powder -16 bottles of moisturizing body lotion with mineral oil -22 bottles of deodorant -15 bottles of shampoo -13 bottles of body wash -14 bottles of hand sanitizer -five cans of shaving cream -one box of 144 packets of [MEDICATION(S)] antibiotic ointment -four boxes of [MEDICATION(S)] ointment -30 packets of white petroleum skin protectant -three boxes of denture cleanser tablets -seven boxes of denture adhesive -seven boxes of toothpaste -18 bottles of mouthwash During an interview on 10/4/22 at 2:08 P.M., the surveyor showed Nurse #1 the unsecured clean utility room door. Nurse #1 pushed open the door and said the room is supposed to be locked at all times. 6. On 10/20/22 from 12:18 P.M. to 12:22 P.M., the surveyor observed one resident wandering the hallway on Unit 3. There was no facility staff visible in the unit hallways at the time of the observation. On 10/20/22 at 12:22 P.M. on Unit 3, the surveyor observed a medication cart positioned against the nursing station desk (opposite side that faces the unit dining room). There were 26 medication cards filled with prescription medication, two boxes of inhalers and a bag filled with medications and treatments on top of the medication cart. The surveyor observed Nurse #2 and a Certified Nursing Assistant in the unit dining room approximately 30 feet away from the medication cart. The line of sight from the dining room to the medication cart was obstructed by walls surrounding the nursing station. At 12:24, Nurse #2 approached the surveyor at the medication cart and said that she had to change out an oxygen tank for a resident seated in the dining room. She said that before changing the oxygen tank, she should have either locked the medications in the cart or brought them to the medication room.

Based on observation and interview, the facility failed to ensure all medications/treatments used in the facility were safely and securely stored in accordance with currently accepted professional principles on two of two units in the facility. Specifically, the facility failed to ensure: 1. medications were properly stored in locked compartments and not left on top of a medication cart on Unit 3; and 2. the Unit 4 clean utility room which contained an unlocked treatment cart was secured. Findings include: 1. On 10/4/22 at 1:57 P.M. on Unit 4 (secured unit/Memory Impaired), the surveyor approached a closed door labeled clean utility. The door had a numerical combination lock on it, but the door was not pulled tight and secured and was easily pushed open. The room contained an unlocked treatment cart. The drawers of treatment cart contained: -Drawer #1: two boxes of [MEDICATION(S)] skin protectant ointment, two boxes of hemorrhoidal ointment, two tubes moisture barrier antifungal cream, one bottle of skin prep spray. -Drawer #3: one bottle of fecal occult blood developing solution -Drawer #4: one box of [MEDICATION(S)] Zinc antibiotic ointment Shelves in the clean utility room contained: -one box of 144 packets of [MEDICATION(S)] antibiotic ointment -four boxes of [MEDICATION(S)] ointment -30 packets of white petroleum skin protectant During an interview on 10/4/22 at 2:08 P.M., the surveyor showed Nurse #1 the unsecured clean utility room door. Nurse #1 pushed open the door and said the room is supposed to be locked at all times. 2. On 10/20/22 at 12:22 P.M. on Unit 3, the surveyor observed a medication cart positioned against the Nursing station desk (opposite side that faces the unit dining room). There were 26 medication cards filled with prescription medication, two boxes of inhalers and a bag filled with medications and treatments on top of the medication cart. The surveyor observed Nurse #2 and a Certified Nursing Assistant in the unit dining room approximately 30 feet away from the medication cart. The line of sight from the dining room to the medication cart was obstructed by walls surrounding the nursing station. At 12:24, Nurse #2 approached the surveyor at the medication cart and said that she had to change out an oxygen tank for a resident seated in the dining room. She said that before changing the oxygen tank she should have either locked the medications in the cart or brought them to the medication room.

Based on record review, review of the QAPI (Quality Assurance Performance Improvement) Policies and Procedures, review of the QAPI Annual Plan, and staff interviews, the facility failed to ensure that its QAPI plans and procedures identified problematic clinical issues, such as falls, and failed to implement effective strategies in accordance with its QAPI Program, to correct or minimize the risk of falls and injury. Findings include: Review of the Administrative Policies and Procedures for Quality Assurance & Performance Improvement, dated 1/22/2013, indicated the Design and Scope of the QAPI program will be ongoing & comprehensive, dealing with the full range of services offered by the facility, including all departments. When fully implemented, the program will address all systems of care & management practices, & will include clinical care, quality of life, & resident choice. The QAPI policy further indicated that Our goal is safety & high quality with all clinical interventions while emphasizing autonomy & choice in daily life for residents (or resident's agents). Our plan utilizes the best available evidence to define & measure goals. During the course of the recertification survey from 10/4/22 to 10/20/22, the facility was identified as having multiple residents who had experienced a significant number of falls, some unwitnessed, and some with significant injury to include fractures and lacerations as noted below. Record review indicated that from 5/7/22 (QAPI COVID-19 waiver lifted) to 10/20/22, there were a total of 14 falls as indicated below: In June 2022, one resident fell and sustained a [CONDITION(S)]. In July 2022, three residents experienced a total of four falls. One resident had two falls. One resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] In August 2022, one resident experienced 2 falls, both on the same day. In September 2022, two residents experienced one fall each. One of two residents sustained head trauma and received 12 sutures for a right ear laceration. In October 2022, five resident experienced a fall. During an interview on 10/7/22 at 1:00 P.M., the surveyor reviewed the Facility's Annual QAPI Plan with the Administrator. The Administrator said monthly and quarterly meetings are held to discuss areas of concern and topics included but was not limited to: -Resident incidents -Quality and Safety Measures Further review of the QAPI Annual Plan (monthly and quarterly meetings), from 5/2022 to 10/2022, indicated, The annual QAPI work plan will be created with an effort to include initiatives from different domains to reflect a global approach to quality improvement. Domains listed in the QAPI work plan included Fall prevention &/or fall with injury. The facility was unable to provide information to support that falls had been reviewed by the QAPI committee. During an interview on 10/7/22 at 10:21 A.M., the Administrator said the facility's QAPI program/plan had not developed strategies, or identified a Root Cause Analysis, to address the significant number of resident falls identified by the survey team, or a documented plan (Performance Improvement Plan) to reduce/minimize falls/injury to residents in the future.

Based on observation, interview, and record review, the facility failed to ensure for two Residents (#6 and #25), out of a total sample of 16 residents, and for one unit (Unit 4-secured/memory impaired unit) of two units, an activity program was implemented that engaged the residents and supported their physical, mental, and psychosocial well-being. Findings include: Review of the facility's policies, Activities and Recreation, last revised 6/2001, and Memory Care at Windemere, dated 9/2022, included, but was not limited to: -This facility provides an organized program of purposeful activities and recreation suited to the needs and interests of all its residents, from those who are bed ridden to those who are fully ambulatory. -Knowing each person's past and current interests has allowed us to gear each day to meet the needs of all our residents. -The program is designed to fulfill basic psychological, intellectual, physical, social and spiritual needs and utilizes a range of community, social, recreational, public and voluntary resources to promote facility-community relationships and to provide a broad assessment of scheduled activities. -The Activities Director supervises all volunteer activities and arranges for religious services, and participates in resident reviews, staff meetings and in-service educational programs. -Ancillary staff are employed to assist the Activities Director and to provide a minimum of 20 hours of activity and recreation per unit per week. -All residents are evaluated by the Activities Department following admission to determine the resident's interests, dislikes, goals, and needs. From this assessment an activity care plan is developed which is specific to the needs of each resident and consistent with the findings. 1. Review of the August, September, and October 2022 monthly activity calendars failed to indicate 20 hours of scheduled activity and recreation per week on each unit (14 to 18 hours a week on Unit 3 and 6 hours a week on Unit 4) according to facility policy. On 10/4/22 at 11:15 A.M., the surveyor observed seven residents in the Unit 4 dayroom. The television was on and playing a children's movie. One resident was seated at a table watching/listening to a movie on a DVD player; one resident was doing a puzzle; one resident was asleep while seated at a table; two residents were seated at tables with their backs facing away from the television; one resident was asleep in a wheelchair and one resident was scooting him/herself in a wheelchair in the room. No activity staff were on the unit. During an interview on 10/4/22 at 11:18 A.M., Nurse #1 said some residents are taken off the unit when there is musical entertainment on Unit 3, but others stay behind and there are no activity staff on the unit regularly. On 10/4/22 at 1:55 P.M., the surveyor observed six residents in the Unit 4 dayroom. The television was on and playing a Christmas movie. One resident was watching the movie; three residents were sleeping while seated at tables; one resident was scooting him/herself in a wheelchair in the room, and one resident was sitting idly with his/her back to the television. No activity staff were on the unit. On 10/5/22 at 10:06 A.M., the surveyor observed eight residents in the Unit 4 dayroom. Four residents were sleeping in their chairs, two residents were watching television, and three residents were seated at tables with their backs to the television sitting idly. No activity staff were on the unit. At 10:16 A.M., a staff member came onto the unit and accompanied four residents off the unit to listen to musical entertainment. Four residents remained in the Unit 4 dayroom. On 10/6/22 at 3:03 P.M., the surveyor observed three residents in the Unit 4 dayroom. Two residents were sleeping in their chairs and one resident was awake watching television. 2. Resident #6 was admitted to the facility in February 2005 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Minimum Data Set (MDS) assessment, dated 9/12/22, indicated that it is somewhat important for Resident #6 to participate in religious services or practices. Review of the Annual Recreation Assessment, dated 9/12/22, indicated Resident #6's activity preferences included spiritual/religious activities with a focus of programming to include religious activities. Review of the August, September, and October 2022 Activity Calendars failed to indicate any religious or spiritual programming to meet his/her needs. 3. Resident #25 was admitted to the facility in August 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment, dated 8/1/22, indicated that it is somewhat important for Resident #6 to participate in religious services or practices. Review of the Annual Recreation Assessment, dated 8/2/22, indicated Resident #25's activity preferences included spiritual/religious activities with a focus of programming to include religious activities. Review of the August, September, and October 2022 Activity Calendars failed to indicate any religious or spiritual programming to meet his/her needs. Further review of the activity calendars failed to indicate residents were provided 20 hours of activity and recreation per unit per week. During an interview on 10/6/22 at 3:55 P.M., the Activity Director (AD) said only one activity is scheduled on Unit 4 daily because the residents on that unit get up in the morning, eat breakfast, a few residents go off the unit to listen to music, eat lunch, and then take a nap in the afternoon. She said that she is the only activity staff for the facility and the Certified Nursing Assistant on the unit can turn on the television for the residents if she wants to. The AD said that she does not have anyone come in from the community to meet the residents' religious/spiritual needs.