Brandon Woods of New Bedford

Inspectors wroteBased on interviews and records reviewed, for one of three sampled residents (Resident #1) who had reported to and been witnessed by a staff member to have been subjected to alleged physical and verbal abuse by two other staff members, the Facility failed to ensure staff consistently implemented and followed the Facility Abuse Policy, when staff members did not immediately report the allegation to their shift supervisor or the Administrator/designee as required.

Inspectors wroteBased on record review and interview, the facility failed for one Resident (#106), in a sample of three closed records, to:-Establish and follow a written policy on permitting the Resident to return to the facility after being transferred to the hospital for evaluation; and -Through communication with the hospital, determine the treatments, medications, and services the facility would need to provide to meet the resident's needs upon returning to the facility and document why they could no longer meet those needs. Specifically, when Resident #106 was transferred to the hospital he/she was provided with a notice indicating he/she would have a bed hold. The following day, the facility informed the hospital that Resident #106 would not be allowed to return to the facility. [...]

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to:1. Monitor the dishwasher sanitation chemical agent after switching from high temperature dishwasher to chemical sanitation for 43 days to ensure all dishes were properly sanitized to prevent food borne illnesses; 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) and ensure glove use was limited to a single task.

Inspectors wroteBased on records reviewed and interviews, the facility failed to ensure staff maintained complete and accurate medical records for five Residents (#7, #42, #9, #14, and #4), out of a total sample of 21 residents. Specifically, the facility failed to:1. For Resident #7, ensure physician and nurse practitioner progress notes were accessible in the Resident's medical record; and2. For Resident #42, ensure physician and nurse practitioner progress notes were accessible in the Resident's medical record; and3. For Resident #9, ensure primary physician progress notes were accessible in the Resident's medical record; and4. For Resident #14, ensure primary physician and wound nurse practitioner progress notes were accessible in the Resident's medical record; and5. For Resident #4, ensure his/her monthly behavior sheets were complete and accurate. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the Resident Representative (guardian) was not extended authority of decision making beyond the extent required by the court to consent to the administration of an antipsychotic medication for one Resident (#81), from a total sample of 21 residents. Specifically, the court approved Treatment Plan allowed Resident #81 to be treated with Seroquel and Rexulti (antipsychotics) and the Resident Representative consented for Resident #81 to be administered Zyprexa, which was not an approved antipsychotic medication on the Treatment Plan.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Resident's Health Care Proxy (HCP, individual chosen by the resident to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications) about changes in their condition and potential need to alter the treatment plan for one Resident (#6), from a total sample of 21 residents. Specifically, the facility failed to notify the HCP of a change in the Resident's condition requiring transfer to the hospital and a significant weight loss.

Inspectors wroteBased on interview and record review, the facility failed for one Resident (#106), out of three closed records reviewed, to provide in writing, the reason for discharge to the Resident, and failed to send a copy of the notice to the Ombudsman office. Specifically, after transferring Resident #106 to the hospital, the facility determined they would not allow the Resident to return from the hospital and did not send any written notices to the Resident or the Ombudsman. Resident #106 remained in the hospital as of 3/26/26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement the person-centered plan of care for two Residents (#40, #7), out of 21 sampled residents. Specifically, the facility failed to:1. Implement interventions identified on Resident #40's care plan for falls; and2. Develop and implement interventions to address Resident #7's history of suicidal ideations.

Inspectors wroteBased on observations, interviews, and records reviewed, for two Residents (#7 and #40), of 21 sampled residents, the facility failed to ensure care was provided to residents in accordance with professional standards of practice. Specifically, the facility failed:1. For Resident #7, to document the Resident's 8 P.M. blood sugar levels, amount of sliding scale insulin administered, and the sites of insulin administration;2. For Resident #40, to ensure physician's orders were implemented:a. in response to accepted pharmacy recommendations; andb. for prosthetic eye care.

Inspectors wroteBased on interview and record review, the facility failed to address high blood glucose levels over a period of 34 days for one Resident (#66), out of a total sample of 21 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure one of one sampled resident with a pressure ulcer (Resident #14), out of a total sample of 21 residents, was provided accurate interventions and treatments to promote healing. Specifically, for Resident #14, the facility failed to:a. Set the air mattress per the physician's orders; andb. Ensure treatments for a left heel pressure ulcer were documented and consistent with current physician's orders.

Inspectors wroteBased on interviews and record review, the facility failed to develop a person-centered plan of care which included trauma informed approaches and identified triggers to avoid potential re-traumatization for one Resident (#32) with a history of trauma, out of a total sample of 21 residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure staff stored drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to properly secure Xanax (a controlled substance prescribed for anxiety and panic disorders) for one Resident (#44), out of a total sample of 21 residents.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had intact cognition and was dependent on staff to meet his/her care needs, the Facility failed to ensure staff implemented and followed their Abuse Policy when on 08/13/25, Family Member #1 (Resident #1's Health Care Agent) informed the Unit Manager that Resident #1 had alleged that CNA #1 was rough during the provision of care on 08/10/25, and the Executive Director was not notified until the next day (08/14/25).

Inspectors wroteBased on interviews and records reviewed, for one of three sampled residents (Resident #1), who was cognitively impaired, the Facility failed to ensure staff implemented and followed their Policy related to Reporting Resident Abuse Policy, when on 5/22/25, the Hospice Certified Nurse Aide (CNA) reported an allegation of verbal abuse of a resident by a staff member (CNA #1 or CNA #2) to Nurse #1, and Nurse #1 did not immediately report the allegation to their direct Supervisor as required, and facility Administration was not made aware until the next day.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide a safe environment free from physical abuse, sexual abuse, and neglect for one Resident (#77), from a total sample of 23 residents. Specifically, the facility failed to ensure Resident #77, with severe cognitive impairment and a history of aggression, violence, and sexually inappropriate behaviors toward staff and other residents, did not physically and sexually abuse other residents; and that Resident #77 was protected from being physically abused by other residents. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, and after being sexually abused.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide effective and appropriate treatment and services to attain the highest practicable mental and psychological well-being for one Resident (#77), with a known history of conduct disorder, dementia with behavioral disturbance, and major depression, out of a total sample of 23 residents. Specifically, the facility failed to develop, implement, and update the plan of care to meet the Resident's behavioral needs, resulting in wandering intrusively into other residents' rooms; standing at female residents' bedsides and fondling his/her genitals; exposing him/herself to another resident; physically assaulting and being physically assaulted by other residents. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, and after being sexually abused.

Inspectors wroteBased on record reviews and interviews, for one Resident (#77), out of a total sample of 23 residents, the facility failed to provide appropriate and sufficient staff to provide behavioral health care services as indicated in the facility assessment. Specifically, for Resident #77 with a known history of agitation, aggression, ongoing intrusive wandering into other residents' rooms, physically abusing other residents, being physically abused by other residents, and sexually inappropriate behaviors (including indecent exposure) toward female staff and residents, the facility failed to ensure staff had appropriate competencies and skill sets to effectively manage his/her behavioral health needs, including developing non-pharmacological interventions.

Inspectors wroteBased on interviews and record review, the facility failed to implement their abuse policy for one Resident (#77), out of a sample of 23 residents. Specifically, the facility failed to ensure nursing staff notified the Director of Nurses (DON) and Administrator about allegations of physical and sexual abuse; keep residents safe by implementing protective measures to prevent further abuse by Resident #77; keep Resident #77 safe by implementing protective measures to prevent further physical abuse by other residents; report and investigate abuse allegations as required; report allegations to the state agency (SA) and law enforcement; and ensure all staff received required abuse training. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, and after being sexually abused.

Inspectors wroteBased on interviews and record review, the facility failed to report allegations of abuse and neglect for one Resident (#77), out of a sample of 23 residents. Specifically, the facility failed to report five of five allegations of physical abuse, sexual abuse, and neglect to the state agency (SA) and two of five allegations to law enforcement as required. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, and after being sexually harassed and exposed to another person's genitals.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff thoroughly investigated five allegations of abuse and neglect, put measures in place to prevent further abuse and neglect, and report the results of the investigations for one Resident (#77), out of a total sample of 23 residents. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, and after being sexually abused.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff developed and implemented a comprehensive, person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs to address the behavior care needs of five Residents (#77, #60, #64, #25, and #105) to attain or maintain their highest practicable physical, mental, and psychosocial well-being, out of a total sample of 23 residents. Specifically, the facility failed to ensure comprehensive care plans were developed and implemented: 1. For Resident #77, to address the Resident's physically and sexually abusive behavior and address him/her being physically abused by other residents; 2. For Resident #60, to address a history of hypersexual behaviors; 3. For Resident #64, to address using pillows to prevent falls; 4. [...]

Inspectors wroteBased on observation, document review, and interview, the facility failed to ensure one Resident (#72), who was identified as being a high risk for skin breakdown, out of a total sample of 23 residents, received the care and services per professional standards of practice to help prevent the development of a facility acquired Stage III (full thickness tissue loss) right heel pressure ulcer and promote optimal wound healing. Specifically, the facility failed to implement recommendations made by the Wound Care Specialist timely and develop and implement a care plan that identified risk factors as well as interventions designed to reduce or prevent the development of pressure related ulcers/injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure Administration effectively utilized their resources to provide for the behavioral needs for one Resident (#77), who had a known history of aggressive and sexually inappropriate behaviors and provide a safe environment to protect other residents from physical abuse, sexual abuse, and neglect.

Inspectors wroteBased on document review and interview, the facility failed to conduct and implement a comprehensive facility wide assessment that was inclusive of resources necessary to provide both emergency and day to day care of the population the facility currently serves, including their short-term, long-term, and dementia specialty care residents.

Inspectors wroteBased on documentation review and interview, the facility failed to ensure direct care staff received mandatory effective communications training.

Inspectors wroteBased on document review and interview, the facility failed to ensure all staff received training on Resident's Rights.

Inspectors wroteBased on document review and interview, the facility failed to ensure all staff were trained in standards, policies, and procedures for the facility's abuse prevention and reporting protocols.

Inspectors wroteBased on documentation review and interview, the facility failed to provide training and education to their staff to outline elements and goals of the facility's Quality Assurance Performance Improvement (QAPI) program.

Inspectors wroteBased on document review and interview, the facility failed to ensure all staff were trained on standards, policies, and procedures for the facility's infection prevention and control program.

Inspectors wroteBased on document review and interview, the facility failed to provide their staff training on the facility ethics standards, policies, and procedures.

Inspectors wroteBased on document review and interview, the facility failed to maintain records of certified nurse aide (CNA) trainings for continuing competency that included no less than 12 hours of mandatory trainings per year for each CNA employed by the facility for five out of five CNAs reviewed.

Inspectors wroteBased on documentation review and interview, the facility failed to provide behavioral health training and education to their staff.

Inspectors wroteBased on record review and interview, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for three Residents (#64, #25, and #2), out of 23 sampled residents. Specifically, the facility failed: 1. For Resident #64, to ensure the MDS was accurately coded for: a. weight loss of greater than 10% over six months, and b. a Stage 3 wound (full thickness skin loss); 2. For Resident #25, to ensure the MDS was accurately coded for weight loss of greater than 10% over six months; and 3. For Resident #2, to ensure the MDS was accurately coded for a wound. Findings Include: Review of the facility's policy titled MDS Policy and Procedure, last revised March 2024, indicated but was not limited to: - Policy: It is the policy of this facility that all MDS assessments and tracking forms will be completed and submitted according to state and federal regulations. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care and services consistent with professional standards of practice for two Residents (#102 and #65), out of a total sample of 23 residents. Specifically, the facility failed to ensure: 1. For Resident #102, injection sites for intramuscular (IM-injection deep into muscle tissue) antibiotic medication were rotated to prevent potential adverse effects; and 2. For Resident #65, a physician's order was obtained to transfer the Resident to the hospital for an evaluation following identification of a change in condition to the Resident's surgical wound.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the Physician signed and dated all orders for one Resident (#102), out of a total sample of 23 residents.

Inspectors wroteBased on record review and interview, the facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, with no nurse staffing waivers in place as required placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) of Certified Nurse Aides (CNA) that the RN was responsible for overseeing with the provision of resident care.

Inspectors wroteBased on record review and interview, the facility failed to act promptly upon recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for two Resident (#2 and #77), out of a total sample of 23 residents. Specifically, the facility failed: 1. For Resident #2, to ensure the Pharmacist reviewed and reported irregularities related to the administration of Clonazepam (a benzodiazepine medication used to treat anxiety); and 2. For Resident #102, to ensure the physician reviewed and addressed gradual dose reduction (GDR) recommendations for the antipsychotic medication Seroquel.

Inspectors wroteBased on observation and interview, 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 thickened beverage items were properly dated and stored in three of three kitchenettes; and 2. Ensure staff were not eating in one of three kitchenettes.

Inspectors wroteBased on observation, document review, and interview, the facility failed to maintain accurate medical records in accordance with professional standards and practices for four Residents (#25, #64, #83, and #102), out of 23 sampled residents. Specifically, the facility failed: 1. For Resident #25, to ensure that: a. his/her medical records contained a copy of his/her Health Care Proxy Form (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) and HCP Activation Form, and b. documentation of physician visits was part of the medical record in a timely manner; 2. For Resident #64, to ensure that documentation of physician visits was part of the medical record in a timely manner; 3. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure the binding Arbitration Agreement presented to residents as part of the admission packet was explained to the resident and/or his/her representative in a form and manner that he/she understands for two Residents (#63 and #84), out of three sampled residents, that had signed arbitration agreements in the facility.

Inspectors wroteBased on document review and interview, the facility failed to ensure their arbitration agreement provides for the selection of a neutral arbitrator agreed upon by both parties.

Inspectors wroteBased on interview and document review, the facility failed to implement and maintain a Quality Assurance and Performance Improvement (QAPI) program which addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, quality of care, and services to residents in the facility. Specifically, the facility failed to ensure an ongoing QAPI program was implemented and maintained and addressed identified priorities including ongoing identified concerns of physical and sexual abuse involving Resident #77.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to: 1. Maintain a complete and accurate system of surveillance and analyze their collected surveillance data to identify any trends of actual or potential infections within the facility to validate the effectiveness of their program; 2. Maintain a written water management plan and documentation to ensure a facility risk assessment was conducted to identify where Legionella (bacteria that can cause Legionnaires' disease, a serious type of pneumonia) and other opportunistic waterborne pathogens could grow and spread in the facility's water system; and 3. [...]

Inspectors wroteBased on record review and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring of antibiotic use in accordance with the facility's antibiotic stewardship program.

Inspectors wroteBased on interview and record review, the facility failed to treat one Resident (#63) with dignity and respect, out of a total sample of 19 residents, by not allowing the Resident to exercise his/her right to smoke.

Inspectors wroteBased on record review and interview, the facility failed to ensure one Resident's (#363) representative, as designated by the Resident, was able to make medical decisions for the Resident, in a sample of 23 records reviewed. Specifically, the facility failed to ensure that Resident #363's representative was able to change the Resident's Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form to meet their wishes.

Inspectors wroteBased on interview and record review, the facility failed to notify the Physician of recommendations or changes in condition for one Resident (#102), out of a total sample of 23 residents. Specifically, the facility failed to notify the physician of the lack of availability and delay in administering intramuscular (IM- injection deep into muscle tissue) antibiotic medication as ordered for Resident #102.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure one Resident (#67), out of a total sample of 19 residents, was free from involuntary seclusion, when during the day shift on 1/14/25, staff applied a stop sign banner secured with Velcro strips (fabric and vinyl banner used to deter wandering residents from entering restricted areas) across the entry door to the Resident's room preventing him/her from coming out of their room.

Inspectors wroteBased on record review and staff interview, the facility failed to document the recapitulation of the Resident's stay that included his/her course of illness/treatment for one Resident (#112), of two closed records reviewed.

Inspectors wroteBased on record review and interview, the facility failed to ensure antibiotic treatment was administered as ordered by the physician for one Resident (#102), out of a total sample of 23 residents. Specifically, the facility failed to access the facility's electronic medication dispensing system to obtain intramuscular (IM-injection deep into muscle tissue) antibiotic medication prescribed to treat a urinary tract infection (UTI) which resulted in a delay in treatment.

Inspectors wroteBased on record review and interview, the facility failed to ensure services to assess urinary incontinence were implemented for one Resident (#63), out of a total sample of 23 residents. Specifically, the facility failed to perform a bladder scan (procedure that uses ultrasound to measure the amount of urine in the bladder and determine how well the bladder is emptying) for Resident #63's new complaints of urinary incontinence, retention, and dribbling per physician's orders.

Inspectors wroteBased on record reviews and interviews, for one Resident (#83) out of 23 sampled residents, the facility failed to ensure the Resident was seen by the Physician at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, with alternate visits by a Nurse Practitioner (NP) as indicated.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff developed and implemented a comprehensive, person-centered care plan to address the dementia care needs of one Resident (#79) to attain or maintain their highest practicable physical, mental, and psychosocial well-being, out of a total sample of 23 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure two Resident's (#2 and #102) drug regimen was free from unnecessary psychotropic medications, out of a total sample of 23 residents. Specifically, the facility failed: 1. For Resident #2, to ensure as needed (PRN) psychotropic medication was limited to 14 days, or extended beyond 14 days with a documented clinical rationale and duration; and 2. For Resident #102, to ensure a gradual dose reduction (GDR) of the antipsychotic medication Seroquel was attempted, unless clinically contraindicated and documented in the medical record, in an effort to discontinue the drug.

Inspectors wroteBased on observations and interview, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed: 1. To ensure medications were not stored in a medication cup in the top drawer of the medication cart in one medication cart out of three observed carts; and 2. To ensure treatment carts were locked when not in direct supervision of a licensed nurse on one of three units.

Inspectors wroteBased on observation and interview, the facility failed to ensure Nurse staffing information posted included the current date and actual hours worked per shift for licensed and unlicensed staff including Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Nurse Aides (CNA), as required.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC-notice issued to a resident who is receiving benefits under Medicare Part A when all covered services end) and a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN -notice issued to a resident when a facility determines the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all his/her Medicare benefit days) were issued for two Residents (#60 and #163) of three residents reviewed. Specifically, the facility failed: 1. For Resident #60, to issue the SNF ABN notice and NOMNC so the Resident/Resident Representatives could decide if they wished to continue receiving skilled services that may not be paid for by Medicare, and were aware of the financial responsibility they may have to assume; and 2. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a Notice of Transfer/Discharge was issued to one current Resident (#109), out of a total sample of 23 residents and one discharged Resident (#65), out of a sample of two discharge residents and failed to ensure the Ombudsman's office received copies of all resident notice of transfers as required.

Inspectors wroteBased on observation and interviews, the facility failed to practice acceptable standards of infection control and prevention for two Residents (#93 and #49), out of a total sample of 27 residents, and during staff COVID-19 testing. Specifically, the facility failed: 1. For Resident #93, to ensure staff utilized personal protective equipment (PPE) while providing care to the Resident who was on droplet precautions for COVID-19; 2. For Resident #49, to ensure staff performed hand hygiene and utilized PPE upon entering a room of a resident who was on Enhanced Barrier Precautions; and 3a. To ensure staff adhered to infection control protocols during COVID-19 testing, and b. To ensure staff followed the facility's policy and manufacturer's guidelines for specimen collection and handling for staff rapid COVID-19 antigen testing (Binaxnow COVID-19 AG Card) during a COVID-19 outbreak.

Inspectors wroteBased on record review and interview, the facility failed to notify residents, families, and/or resident representatives of COVID-19 positive staff cases that occurred in the facility by 5:00 P.M., the next calendar day during the recent COVID-19 outbreak in August 2023, as required.

Inspectors wroteBased on observation, policy review, and interview, the facility failed to ensure medications were properly stored and labeled in accordance with current accepted professional standards. Specifically, the facility failed to ensure: 1. For Residents #13 and #91, that medications were not unlabeled, not in their original packaging and stored at the bedside; and 2. Medications were not stored unsecured and easily accessible in the Director of Nursing's office.

Inspectors wroteBased on observation, meal test trays on 2 of 3 units, staff and resident interviews, the facility failed to provide residents with meals that were prepared and served in a manner that conserved flavor, were palatable, and served at safe and appetizing temperatures.

Inspectors wroteBased on record review, policy review, observation and interview, the facility failed to consistently follow professional standards for two Residents (#4 and #11), out of total sample of 27 residents. Specifically, the facility failed: 1. For Resident #4, to ensure a physician's order for an air mattress was implemented and accurately documented; and 2. For Resident #11, to ensure an undated, signed Application for an Authorization of Temporary Involuntary Hospitalization was not available in the Resident's medical record.

Inspectors wroteBased on record review and staff interview, the facility failed to document the recapitulation of the Resident's stay, medication reconciliation, and obtain physician orders for discharge from the facility for one Resident (#103 ), out of three closed records reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for three Residents (#64, #34, and #4). Specifically, the facility failed: 1. For Resident #64, to ensure Oxygen was administered according to Physician's orders and ensure oxygen tubing was changed weekly; 2. For Resident #34, to ensure oxygen tubing was changed weekly; and 3. For Resident #4, to ensure Oxygen was administered according to Physician's orders.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure for three Residents (#11, #93, and #57), out of a total sample of 27 residents, each Resident's drug regimen was free from unnecessary psychotropic medications. Specifically, the facility failed to ensure psychotropic medication ordered as needed (PRN) was limited to 14 days and was reviewed by the Physician with a documented rationale for its continued use and failed to monitor the Residents for adverse consequences of its use.

Inspectors wroteBased on interview and observations, the facility failed to post a notice of availability of survey results and prominently post the Department of Public Health Survey Inspection results binder.

Inspectors wroteBased on record review and interview, the facility failed to ensure for one Resident (#26), out of a total sample of 30 residents, the Resident, and/or representative was provided with a Discharge/Transfer Notice upon transfer.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure the Resident and/or the Resident's representative and the Ombudsman were provided with a written notice of transfer as required for three Residents (#64, #70, and #26), out of a total sample of 27 residents.

Inspectors wroteBased on record reviews, policy review, and interviews, the facility failed to provide a written notification of the bed hold policy to the Resident or Resident representative prior to discharge to the hospital, for three Residents (#64, #70, and #26), in a sample of 27 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff transmitted a discharge Minimum Data Set (MDS) assessment for two Residents (#22 and #82), out of 27 sampled residents. Specifically, the facility failed to ensure: 1. For Resident #22, a quarterly MDS assessment was transmitted to the Centers for Medicare and Medicaid Services (CMS) within 14 days of completion as required; and 2. For Resident #82, a discharge MDS assessment was transmitted to CMS within 14 days of completion as required.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the Resident's status for five Residents (#45, #19, #12, #93, and #102), out of a sample of 27 residents and one closed record. Specifically, the facility failed: 1. For Residents #45, #19, #12, and #93, to accurately reflect the use of a restraint device; and 2. For Resident #102, to accurately reflect the discharge location of the Resident.