Lanessa Extended Care

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), whose physician's orders included parameters for blood pressure readings related to the administration of Lisinopril (antihypertensive, reduces blood pressure) medication, and who sustained two unwitnessed falls which resulted in head injuries, the facility failed to ensure professional standards of practice were provided and maintained when the nursing staff 1) administered the Lisinopril despite his/her blood pressure readings being outside of the physician ordered parameters, and 2) failed to monitor him/her for neurological changes following two unwitnessed falls, in accordance with nursing best practice and facility policy.

Inspectors wroteBased on observations, interview, and record review, the facility failed to notify the Provider as to whether treatment needed to be altered when a change in condition occurred for two Residents (#1 and# 53) out of total sample of 18 Residents. 1) Specifically for Resident #1, the facility failed to notify the Provider when the Resident experienced unanticipated weight loss, resulting in a significant weight loss (16.52% in 73 days) and malnutrition. 2) Specifically for Resident #53, the facility failed to notify the Provider and Occupational Therapist (OT) when the Resident was unable to tolerate the application of a left-hand palm guard as ordered by the Provider, and when therapy goals to tolerate the device were not being met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that one Resident (#13) out of a total sample of 18 residents received foot care and treatment in accordance with professional standards of practice, increasing the Resident's risk for medical complications. Specifically, the facility failed to ensure that Resident #13 received podiatry toenail care when the Resident's invoked Health Care Proxy (HCP) consented for the Resident to receive podiatry care, and the Resident's toenails were growing out to the length where the toenails curled against the ends of the Resident's toes, placing the Resident at risk for pressure injury, and infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that appropriate services to maintain or improve range of motion were implemented for one Resident (#53) out of a total sample of 18 residents. Specifically, for Resident #53, the facility failed to ensure the Physician's orders were followed relative to the use of the left-hand palm guard, resulting in a worsening contracture and increased pain when applying the left-hand palm guard.

Inspectors wroteBased on interviews, and record reviews, the facility failed to adequately provide nutritional services for one Resident (#1) out of total sample of 18 residents. Specifically, the facility failed to implement timely interventions to maintain nutritional needs when the Resident had a severe weight loss of 16.52% (30 pounds) (lbs.) between 2/1/26 and 4/15/26, resulting in Protein Calorie Malnutrition.

Inspectors wroteBased on observations, and interviews, the facility failed to maintain proper sanitation, food handling, and food storage practices to prevent the outbreak of foodborne illness in the main facility kitchen. Specifically, the facility failed to: 1) ensure that the minimum wash temperature necessary was maintained per manufacturer's guidelines for the dish machine utilized for cleaning and sanitizing dishware for resident use in the main facility kitchen, when the high temperature dish machine was operating at registered temperatures below acceptable ranges of 150 degrees Fahrenheit (F) for the wash cycle. 2) properly label and date prepared food items before storing them in the refrigerator and also failed to discard expired bread products that were being stored in the dry storage area.

Inspectors wroteBased on interviews, and record review, the facility failed to afford the opportunity to formulate an advance directive relative to orders for life sustaining treatment, for one Resident (#5) out of a total sample of 18 residents, increasing the Resident's risk for undesired care in the event of a medical emergency. Specifically, the facility failed to review life sustaining treatment options with Resident #5's healthcare proxy (HCP) when:-the Resident was incapacitated at the time of admission.-the Resident's HCP was invoked.-the Resident's Medical Orders for Life Sustaining Treatment (MOLST), indicating Do Not Resuscitate (DNR) and Do Not Intubate (DNI), was not signed by the Resident's invoked HCP.

Inspectors wroteBased on record review, and interview, the facility failed to resolve grievances timely for two Residents (#57 and #68) out of a total sample of 18 residents. Specifically, a) for Resident #57, the facility failed to ensure that the Resident's grievance for missing money was reviewed and followed through the grievance process when nursing staff filed the grievance on the Resident's behalf. b) for Resident #68, the facility failed to appropriately investigate the Resident's grievance related to missing clothing before documenting that the grievance was resolved.

Inspectors wroteBased on observation, and interview, the facility failed to ensure the safe and secure storage of medications as required to meet the needs of the facility residents and for one medication storage room (Windsor Unit) out of a total of two medication storage rooms. Specifically, the facility failed to: 1. ensure medications kits are replaced by the pharmacy after being opened with medications removed and not accounted for. 2. ensure the refrigerator that stored medications in the medication room was within the required temperature range of 36 to 46 degrees. 3. ensure medications were securely stored and only accessible by authorized staff on the Windsor Unit medication storage room.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to serve food that was palatable, attractive, and appetizing on one resident Unit (Elmwood) and the facility Main Dining Room, placing residents at risk for reduced meal consumption. Specifically, the facility failed to: -For the Elmwood Unit: >serve chicken that was attractive and easy to chew.>serve banana slices that could be identified as banana by taste. -For the facility's Main Dining Room: -serve chicken that was easy to cut and chew.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure staff served food that accommodated resident allergies, intolerances, and/or food preferences for three Residents (#49, #57 and #70) out of a total sample of 18 residents. Specifically, the facility failed to ensure that the meal preferences requested were provided for Resident's #49, #57 and #70 as requested.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to adhere to infection control standards of practice to prevent contamination and the spread of infections for one Resident (#61) out of a total sample of 18 residents. Specifically for Resident #61, the facility failed to ensure that appropriate Personal Protective Equipment (PPE: items such as gowns and gloves worn to prevent the spread of infection) was worn as required for the Resident on Enhanced Barrier Precautions (EBP) placing the Resident at increased risk of contamination and the spread of infections.

Inspectors wroteBased on interviews, and record review, the facility failed to administer the pneumococcal immunization to one Resident (#11) out of five applicable residents for immunizations, out of a total sample of 18 residents, placing the Resident at increased risk for pneumococcal infection. Specifically, the facility failed to administer the pneumococcal immunization to Resident #11 when the Resident:-was eligible to receive the pneumococcal immunization.-Consented for the pneumococcal immunization to be administered.

Inspectors wroteBased on interviews, and record review, the facility failed to offer and administer the 2025/2026 COVID-19 vaccine to one Resident (#11) out of five applicable residents for vaccinations, out of a total sample of 18 residents, in accordance with Centers for Disease Control and Prevention (CDC) recommendations, placing the Resident at increased risk for COVID-19 infection and COVID-19 infection complications. Specifically, the facility failed to offer and administer the 2025/2026 COVID-19 vaccine to Resident #11 in a timely manner when Resident #11 was eligible to receive the vaccine.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the daily required nurse staffing information was posted as required. Specifically, the facility failed to:-ensure the total hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift (Registered Nurses (RN), Licensed Practical Nurses (LPN) or Licensed Vocational Nurses (LVN), and Certified Nurses' Aides (CNA) were posted as required.-maintain a copy of the staffing records for 18 months.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had dementia, resided on a secured unit, was known by staff to exhibit exit seeking behaviors and was assessed at being at risk for elopement, the Facility failed to ensure that Resident #1 was provided with an adequate level of staff supervision to prevent an incident of elopement when on 01/05/26, Resident #1 exited the secured unit, through an alarmed door unbeknownst to staff and was found outside at the end of the block by the police.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident # 1), who developed a pressure related injury on his/her right wrist area and required wound care, the Facility failed to ensure nursing developed and implemented a comprehensive person-centered care plan with interventions, treatment goals and outcomes that addressed his/her wound care needs.

Inspectors wroteBased on interviews and records reviewed, for one of three sampled residents (Resident #1), who sustained a right distal humerus (long bone in upper arm ) fracture that would potentially need surgical intervention to treat, and who required a one week follow up appointment with his/her Orthopedic Surgeon, the Facility failed to ensure he/she was provided with quality care and services when transportation services were not properly arranged for several of his/her follow up appointments, which resulted in more than a months delay in him/her being seen and evaluated by an Orthopedic Surgeon.

Inspectors wroteBased on record review, and interview, the facility failed to maintain accurate records of controlled substance medications management and reconciliation for four locked medication carts on two Units (Elmwood Unit and Windsor Unit). Specifically, the facility failed to: -maintain accurate records of controlled substance medications that had been removed from locked medication carts and stored in the DON's office while awaiting disposal/ destruction. -maintain accurate records of controlled substance medications that were awaiting disposal/destruction for a period of six months.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure that the facility was free of pests on one Unit (Windsor) and the facility's Main Dining Room. Specifically, the facility failed to: -obtain routine pest control services. -obtain pest control services when staff and residents at the facility identified fruit flies in the facility's Main Dining Room and on the Windsor Unit.

Inspectors wroteBased on interview, and record review, the facility failed to accurately complete Minimum Data Set (MDS) Assessments for one discharged Resident (#82) out of three closed records reviewed, and for four Residents (#235, #38, #54, and #51) out of a total sample of 18 active resident records reviewed. Specifically, the facility failed to: 1. For Resident #82, code Hospice services on the Resident's Significant Change in Status Assessment (SCSA) when the Resident received Hospice services while at the facility. 2. For Resident #235, code that the Resident was taking antipsychotic, antidepressant, antianxiety, and anticoagulant medications when staff administered these medications to the Resident during the observation period for the MDS Assessment, while the Resident was at the facility. 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that one Resident (#23) out of a total sample of 18 residents, was free from a significant medication error when an order for twice daily Allopurinol (medication used to prevent Gout pain - caused by a high uric acid level in the blood, leading to joint pain and inflammation) was not accurately transcribed to a new monthly Medication Administration Record (MAR). Specifically, for Resident #23, the facility failed to ensure that the Allopurinol medication order for twice daily administration was accurately transcribed to a new month's MAR, resulting in decreased Allopurinol medication administration to once a day, and increasing the Resident's risk for gout pain not being appropriately managed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of four residents with a Physician ' s order for pureed texture diet received chicken at the lunch meal that was a pureed consistency (altered diet in which foods are ground and strained to a smooth soft pudding like consistency free of lumps or texture making them easier to chew and swallow).

Inspectors wroteBased on observation, and interview, the facility failed to maintain sanitary conditions in the facility kitchen and dining areas and follow safe sanitation and food handling practices while storing and serving food to prevent the risk of foodborne illness in accordance with professional standards for food service safety. Specifically the facility failed to: 1. Ensure staff stored a multi use thickening agent in the facility's main kitchen in a safe and sanitary manner. 2. Ensure staff stored food at the proper and safe holding temperature on the steam table prior to serving the food to residents on the Windsor Unit. 3. Ensure staff labeled and stored food in a sanitary and safe manner in the facility kitchen and unit nourishment kitchens and maintained the facility dishwasher at the proper temperature for sanitization of dishware.

Inspectors wroteBased on record review, and interview, the facility failed to provide notification to the invoked Health Care Proxy (HCP) and obtain consent for the use of psychotropic medications for one Resident (#23) out of a total sample of 18 residents. Specifically, the facility failed to obtain informed consent and provide information regarding the risks and benefits of the medication use to Resident #23's HCP prior to the administration of Ativan (psychotropic medication used for anxiety).

Inspectors wroteBased on interview, and record review, the facility failed to assess one Resident (#79) out of a total sample of 18 residents, for the clinical appropriateness to self-administer medications. Specifically, for Resident #79, the facility failed to complete an assessment for the appropriateness and safety of self-administration of medications when an order was received to leave a Benadryl cream at the Resident's bedside.

Inspectors wroteBased on interview, and record review, the facility failed to act upon, provide timely responses, and document written responses and rationale to grievances of resident care and services brought to facility administration by the Resident Council. Specifically, the facility failed to: A) address grievances related to staffing levels on the 11:00 P.M.- 7:00 A.M. shift when reported in Resident Council Meeting on 12/18/24. B) document response and rationale when concerns with staffing levels on 11:00 P.M.- 7:00 A.M. shift were reported in Resident Council Meeting on 1/21/25.

Inspectors wroteBased on record review, and interview, the facility failed to accurately execute Advance Directives for two Residents (#41 and #234) out of a total sample of 18 residents. Specifically, the facility failed to: 1. For Resident # 41, ensure that the MOLST (Massachusetts Medical Order for Life-Sustaining Treatment) form was valid and reflected the signature of Resident #41's invoked (made active by a Physician) Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself) after the Physician had determined that the Resident lacked the capacity for informed medical decision making. 2. For Resident #234, ensure that the MOLST form was valid and reflected the signature of the Resident who maintained his/her capacity for informed medical decision making.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that the 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/or 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 accurately issued for three Residents (#483, #63, #34) out of a total sample of 18 residents. Specifically, the facility failed to: 1. For Resident #483: >issue a NOMNC with Provider contact information inserted above the title of form. >provide the NOMNC two days prior to discharge. 2. For Resident #63: >provide a NOMNC with Provider contact information inserted above the title of form. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain a clean, comfortable, and homelike environment for one Resident (#54) out of a total sample size of 18 residents. Specifically, the facility failed to maintain Resident's #54 wheelchair in a clean and sanitary manner when the Resident was dependent on the wheelchair for mobility and the wheelchair was visibly soiled.

Inspectors wroteBased on record review, and interview, the facility failed to provide care and services that met professional standards of practice for two Residents (#56 and #51) out of a total sample of 18 residents. Specifically, the facility failed to: 1. For Resident #56, schedule a urology appointment when the Resident had been discharged back to the facility from the hospital with a kidney stone and related infection. 2. For Resident #51, implement a Physician order for a Pulmonary Consultation to evaluate the Resident for clinical symptoms and Chronic Obstructive Pulmonary Disease (COPD). 3. For Resident #51, implement the Physician's orders for weekly weight monitoring.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a smoking environment that was free of accidental hazards for one Resident (#62), out of a total sample size of 18 residents. Specifically, the facility failed to ensure that Resident #62 was appropriately supervised during smoking activity when the Resident was assessed as needing supervision, placing the Resident at risk of accident and/or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment in accordance with professional standards of practice relative to an indwelling urinary catheter for one Resident (#34) out of a total sample of 18 residents. Specifically, the facility failed to: -reassess Resident #34's indwelling catheter status upon re-admission when the Resident was hospitalized with indwelling urinary catheter associated complications. -obtain a Physician order to include the current indwelling urinary catheter size required for the Resident. -update the Resident's Indwelling Catheter Care Plan to reflect the Resident's current indwelling catheter status.

Inspectors wroteBased on interview and record review, the facility failed to maintain sufficient nursing staff to provide care to residents on one unit (Elmwood) out of two sampled nursing units, when no staffing waivers were in place. Specifically, the facility failed to: -ensure sufficient qualified nursing staff were available to provide care and respond to resident's basic needs on the 11:00 P.M. to 7:00 A.M. (night) shift. -ensure that positions are filled timely when there are staff call outs. -schedule the type and level of staff that reflect the expectations described in the facility assessment.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that competency in skills and techniques necessary to provide resident care were demonstrated for one Certified Nurses Aide (CNA [#3]), out of a total of five staff reviewed. Specifically, for CNA #3, the facility failed to ensure that annual competency training with demonstrated competency in the skills and techniques necessary to care for residents' needs was completed for 2024 as required.

Inspectors wroteBased on record review, and interview, the facility failed to provide the necessary Behavioral Health care and services to attain or maintain the highest practicable mental, and psychosocial well-being for two Residents (#51 and #23) out of a total sample size of 18 residents. Specifically, the facility failed to ensure that the Residents (#51 and #23) received follow-up Behavioral Health Services after recommendations for continued follow-up visits were made by the Provider.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that psychotropic medications (medication that affect the mind, emotions and behavior) administered were necessary for one Resident (#27) out of five applicable residents reviewed, out of a total sample of 18 residents. Specifically, the facility failed to ensure: -For Resident #27, that the obtained consent from the Resident's Health Care Proxy (HCP) for the use of psychotropic medications was necessary when the Informed Consent for Psychotropic Administration was obtained from and signed by another residents' HCP.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain complete and accurate medical records for one Resident (#24) out of a total sample of 18 residents. Specifically, the facility failed to maintain accurate documentation of meal intake percentages by Certified Nurse Aides (CNAs) when Resident #24 was identified as being at risk for weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to maintain infection control practices per professional standards for three Residents (#7, #47 and #11) out of a total sample of 18 residents. Specifically, the facility failed to: 1. For Resident #7, appropriately provide care for a urinary drainage bag that was not in use when the Resident interchanged the urinary drainage bags for daytime and nighttime use, placing him/her at risk for contamination and infection. 2. For Resident #47, assist with hand hygiene prior to eating, following the Resident's participation in a group activity when his/her hands were visibly soiled, placing the Resident at risk for contamination and infection. 3. [...]

Inspectors wroteBased on observation, and interview, the facility failed to post nursing staff data daily, at the start of each shift, relative to licensed and unlicensed nursing staff directly responsible for resident care per shift. Specifically, the facility failed to post nursing staff data that included: -total number and the actual hours worked for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Nurse Aides (CNAs) -resident census.

Inspectors wroteBased on interview, and record review, the facility failed to complete a Minimum Data Set (MDS) Assessment in a timely manner for one Resident (#82) out of three Residents reviewed in a closed record sample. Specifically, the facility failed to complete a significant change in status assessment (SCSA) by the fourteenth calendar day after the determination that a significant change in the Resident's status had occurred.

Inspectors wroteBased on records reviewed and interviews, for two of four sampled residents (Resident #1 who had a history of exit seeking and routinely wandered the unit during the evening shift and Resident #4, his/her roommate who was also ambulatory) the Facility failed to ensure that they were free from involuntary seclusion by being confined to their room by staff, when on 01/12/24 from approximately 9:30 P.M. to 11:30 P.M., a plastic bag was tied from the door handle of Resident #1 and Resident #4's room to the handrail in the hallway outside their room, by Certified Nurse Aide (CNA) #1 who admitted to doing it in order to prevent Resident #1 from exiting his/her room to wander the unit and exit seek.

Inspectors wroteBased on records reviewed and interviews, for two of four sampled residents (Resident #1 and Resident #4), the Facility failed to ensure staff implemented and followed their Abuse Policy related to the need to immediately report an allegation of involuntary seclusion to the Administrator or designee, when on 01/13/24, Nurse #1 and Nurse #2 became aware during the overnight shift, that the door to a bedroom occupied by two ambulatory residents was tied shut, preventing them from exiting the room at will. However, although both Nurse #1 and Nurse #2 were both aware of the incident, the Facility Administration was not made aware of the incident until 01/15/23 (two days later), when Director of Nurses (DON) #1 spoke with Nurse #1 and Nurse #2 after discovering a progress note about the incident.

Inspectors wroteBased on records reviewed and interviews, for two of four sampled residents (Resident #1 and Resident #4), the Facility failed to ensure that an allegation of involuntarily seclusion, was reported to the Department of Public Health (DPH) within two hours, as required, per Federal Regulations and Facility policy. When on 01/15/24 at approximately 7:30 A.M., Director of Nurses (DON) #1 became aware of an incident that occurred on 01/12/24, where the door to the bedroom occupied by Resident #1 and Resident #4 was found to be tied shut, however the incident was not reported that day to DPH until 6:07 P.M., more than ten hours later.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #2), who had dementia and was known by staff to wander the hallways and exhibited exit seeking behaviors, the Facility failed to ensure that Resident #2 was provided with an adequate level of staff supervision, in an effort to maintain his/her safety to prevent an elopement. On 03/11/2024, at some point during the day shift, unbeknownst to staff, Resident #2 exited the Facility, unit staff only became aware of the elopement after Resident #2's lunch tray was left untouched, and staff could not locate him/her. Resident #2 was found later that same day by the police, seated on the side of a road, four miles from the Facility.

Inspectors wroteBased on records reviewed and interviews, for two of four sampled residents (Resident #1 and Resident #2) the Facility failed to ensure they provided sufficient nursing staff so that the care and safety needs of the residents were adequately met, when on 01/12/24 during the evening shift, Resident #2 was able to wander off the locked unit he/she resided on, and that same night, Certified Nurse Aide (CNA) #1 admitted to securing the door to Resident #1's room to prevent him/her from exiting his/her room to wander and exit seek while she attended to another resident, because the unit was short staffed.

Inspectors wroteBased on observations, interviews, record and policy reviews, the facility failed to ensure that one Resident (#79) of one applicable resident, in a total sample of 19 residents, who received enteral nutrition (method of delivering nutrition through the stomach or the small intestine) via a gastrostomy tube (G-tube: tube inserted through the abdomen into the stomach to provide nutrition) received care and services to prevent complications. Specifically, the facility failed to ensure that all pertinent Physician's orders were implemented relative to the G-tube, that fluids were administered and monitored to maintain acceptable parameters of hydration, resulting in clinical signs of dehydration and need for the administration of intravenous fluids (IV fluids: specially formulated liquids that are injected into a vein to prevent or treat dehydration) for the Resident.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure that sufficient nursing staff were available to provide care and services to the meet the needs of four Residents (#40, #39, #47 and #78) on two Units (Windsor and Elmwood), out of two units observed. Specially, the facility failed to ensure that: 1) For Resident #40, scheduled medications were provided within the required timeframe. 2) For Resident #39, nursing staff were available to assess and medicate for pain as needed. 3) For Resident's #47 and #78, adequate staff were available to assist with the toileting needs. 4) adequate staff were available to assist with meals and dining.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the nursing staff completed training as outlined in the Facility Assessment Tool. Specifically, -the facility failed to provide documentation that staff competencies were completed for six (Nurse's #2, #5, #6, #7, #8 and #10) out of seven staff training records reviewed. -the facility could not verify that current licensed nursing staff (Nurse's #4, #2, #5, #6, #7, #8 and #10) had completed their required annual competencies.

Inspectors wroteBased on observations, interviews, record and policies reviewed, the facility failed to ensure care and services were provided for one Resident (#79) of two applicable residents with catheters, out of a total sample of 19 residents, who had an indwelling urinary catheter (flexible tube inserted into the bladder to allow for urine flow). Specifically, the facility failed to: -obtain Physician's orders for the care of the Resident's catheter, including irrigation orders and changing the urinary drainage bag. -accurately monitor urinary output. -ensure that an assessment was completed to determine rationale for continued use of the urinary catheter.

Inspectors wroteBased on observations, interviews, record and policy reviews, the facility failed to adhere to infection control practices to reduce the potential transmission of infection for one Resident (#25), out of a total sample of 19 residents, and for one unit out of two units observed. Specifically, the facility failed to ensure that: [...]

Inspectors wroteBased on observations, interviews, policy and record review, the facility failed to ensure the Physician was notified of a significant weight change and recommendations for scheduled appointments for one Resident (#79), out of a total sample of 19 residents. Specifically, the facility failed to notify the Physician when Resident #79 had: A) recommendations for a Computerized Tomography scan (CT: X-ray images taken from different angles of the body to create a cross sectional image of the bones, blood vessels, and soft tissue). B) an appointment to replace his/her gastrostomy tube (G-tube: tube inserted through the belly that brings nutrition directly to the stomach). C) a significant weight loss (weight change of 5 percent (%) or more in one month, 7.5% or more in three months or 10% or more in six months).

Inspectors wroteBased on observations, interviews, records and policy review, the facility failed to ensure that Physician orders were implemented for three Residents (#51, #79 and #43), out of a total sample of 19 residents. Specifically, the facility failed to: 1. ensure that weights were obtained as ordered by the Physician for Resident's #51 and #79 2. ensure a Dermatology Consult was obtained as ordered by the Physician for Resident #43

Inspectors wroteBased on record review and interview, the facility failed to ensure that annual performance reviews were completed as required for two out of four Certified Nurses Aides (CNAs). Specifically, the facility failed to ensure that expectations, individual performance and training requirements were communicated to two CNAs through the annual performance appraisal process.

Inspectors wroteBased on record reviews, policy reviews, and interviews, the facility failed to ensure that Pharmacy recommendations were addressed by the attending Physician for two Residents (#33 and #53), out of a total sample of 19 residents. Specifically, the facility failed: 1. For Resident #33, to report the Pharmacy recommendations to the attending Physician pertaining to orders needed for a psychotropic (medication that affects a person's mental state) medication. 2. For Resident #53, to report the Pharmacy recommendations to the attending Physician pertaining to an anti-nausea medication.

Inspectors wroteBased on interviews and records review, the facility failed to ensure that the use of as needed (PRN) medications were appropriately evaluated for two Residents (#58 and #79) out of a total sample of 19 residents. Specifically, 1) For Resident #58, that an as needed (PRN) psychotropic medication (medications that are used to treat a variety of conditions and affect mood, behavior and perceptions) was limited to 14 days and was re-evaluated for continued use by the Provider. 2) For Resident #79, that a PRN antipsychotic medication (class of medications that are used to manage psychosis [a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality]) was limited to 14 days.

Inspectors wroteBased on observation, record review and interview, the facility staff failed to ensure a medication error rate of less than five percent (%) for one Resident (#60), out of four residents, out of 34 opportunities. Specifically, the medication error rate was observed to be 11.76%, when four scheduled medications were administered beyond the required timeframe of one hour after the scheduled time.

Inspectors wroteBased on record review and interviews, the facility failed to maintain accurate medical records for one Resident (#37), out of a total sample of 19 residents. Specifically, the facility failed to maintain accurate records related to activities participation and refusals of participation.

Inspectors wroteBased on record review and interview, the facility failed to ensure that all required staff members attended the scheduled Quality Assurance Performance Improvement (QAPI) meeting, as required. Specifically, the facility Infection Preventionist (IP) failed to attend two of the last five quarterly QAPI meetings.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure that its staff administered the Influenza Vaccine as required, after obtaining consent for one Resident (#12), out of five applicable residents.

Inspectors wroteBased on record reviews and interviews, the facility failed to accurately complete the Minimum Data Set (MDS) Assessment for two Residents (#37 and #43), out of a total sample of 19 residents. Specifically, the facility failed to: 1) complete a Brief Interview for Mental Status (BIMS) exam and Mood Interview for Resident #37 2) accurately code the use of an antipsychotic (used to treat psychosis) medication for Resident #43

Inspectors wroteBased on records reviewed and interviews, the Facility failed to ensure that staffing included the services of a Registered Nurse (RN) for a minimum of 8 consecutive hours a day, 7 days a week as required, when during June 15, 2023 through July 15, 2023, the facility had no RN coverage for several days, for an entire 24 hour period.