F 0552 -Trazodone 50 milligrams, give 0.5 tablet by mouth at bedtime related to major depressive disorder. Start date 6/29/23. Level of Harm - Minimal harm or potential for actual harm A review of the May 2025 Medication Administration Record (MAR) indicated that Risperidone and Trazadone was administered as ordered. Residents Affected - Few Further review of the medical record indicated psychotropic informed consent forms indicating the following:

-Trazadone-signed and dated by Resident #22 on 9/18/24.

-Risperidone-signed and dated by Resident #22 on 7/10/24.

During an interview and record review on 5/21/25 at 9:52 A.M., Unit Manager #1 said Resident #22 signed

the Trazadone and Risperidone psychotropic consent forms. Unit Manager #1 said Resident #22 has an invoked HCP. Unit Manager #1 said the HCP should have been informed of the psychotropic medications

the Resident was taking so he/she could provide consent to continue to administer the psychotropic medications.

During an interview on 5/21/25 at 10:11 A.M., the Social Worker said Resident #22's HCP should have provided consent prior to the administration of the psychotropic medications. The Social Worker said she just informed the HCP about the Resident taking psychotropic medications and the need to obtain consent from him/her.

During an interview on 5/21/25 at 10:59 A.M., the Director of Nurses (DON) said residents' responsible parties should be informed of the residents' treatment and care. The DON said the HCP should have been informed of the facility administering psychotropic medications prior to administering the medications so he/she could provide consent.

During a telephone interview on 5/23/25 at 2:02 P.M., the HCP said he/she was not aware of the specific psychotropic medications Resident #22 was taking. He/she said he/she got a call from the facility a day ago asking him/her to come into the facility to sign the psychotropic consents. The HCP said prior to that call, he/she was aware the Resident was taking medications in general, but had no knowledge of the specific psychotropic medications he/she was taking, their benefits, risks and side effects.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 6 225469 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225469 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Laurel Ridge Rehab and Skilled Care Center 174 Forest Hills Street Boston, MA 02130

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During an interview and record review on 5/21/25 at 10:04 A.M., the Social Worker said a person-centered substance use care plan should be developed for Resident #43. She said the substance use care plan with Level of Harm - Minimal harm or interventions should be in place even if the Resident is not currently actively using substances. The Social potential for actual harm Worker said the Resident has a risk of getting triggered to start using substances at any time which could trigger a relapse and a risk of an overdose. Residents Affected - Few

During an interview on 5/21/25 at 10:51 A.M., the Director of Nurses said a substance use care plan should be developed even if the Resident is not actively using substances.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 6 225469 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225469 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Laurel Ridge Rehab and Skilled Care Center 174 Forest Hills Street Boston, MA 02130

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Review of Resident #15's physician's order dated 4/23/25 indicated the following:

Level of Harm - Minimal harm or - Low Airloss mattress, check function and settings to (specify weight or comfort) every shift. potential for actual harm

Review of Resident #15's pressure injury development care plan dated 4/23/25 indicated the following Residents Affected - Few interventions:

- Administer treatments as ordered and monitor for effectiveness.

- Low Airloss mattress, check function and settings to (specify weight or comfort) every shift.

Review of Resident #15's Norton Scale Predicting Risk of Pressure ulcer scale (an assessment that indicates

the risk of developing pressure ulcers) dated 4/23/25 indicated that the Resident scored a 10 which indicated that the Resident is at a high risk of developing pressure ulcers.

Review of Resident #15's weight loss history indicated that the Resident's last documented weight on 5/12/25 was 164.1 lbs. (pounds).

Review of Resident #15's Wound Evaluation and Management Summary assessed by the facility's wound physician indicated that the Resident currently has a stage 3 pressure ulcer to his/her coccyx and a stage 4 pressure ulcer to his/her right heel.

During an interview on 5/21/25 at 9:59 A.M., Nurse #2 said air mattress settings should be specified by the physician's order.

During an interview on 5/21/25 at 10:06 A.M., Nurse #1 said air mattresses in the facility are typically set to

the resident's most recent weight. Nurse #1 and the surveyor reviewed Resident #15's physician's order, and

she said it should specify a weight setting or comfort. Nurse #1 continued to say that 450 pounds was way too high of a setting for Resident #15's air mattress and it would be too firm.

During an interview on 5/21/25 at 10:21 A.M., the Director of Nursing (DON) said Resident #15's physician's order needs to be clarified for the appropriate settings. The DON said Resident #15's air mattress set to 450 pounds is too high.

During an interview on 5/21/25 at 11:02 A.M., the Administrator said he spoke with the company who provides the air mattresses for the facility and they are coming to review Resident #15's air mattress unit as it may be faulty.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 6 225469