**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, review of the clinical record, facility documentation and policy, the facility failed to ensure that code status was accurate and consistent in the medical record for one resident, #242. The deficient practice could result in resident not receiving care consistent with their signed advance directive. Findings include: Resident #242 was admitted on [DATE] with diagnosis including hypotension, hypertension, presence of a cardiac pacemaker, major depressive disorder-recurrent, obstructive and reflux uropathy, diverticulitis of large intestine and edema. A review of the MDS (minimum data set) revealed that the admission MDS was still noted to be in progress. A review of the physician orders dated May 15, 2024, revealed that the resident was a full-code, meaning that cardiopulmonary resuscitation and other resuscitation procedures should be used to keep the resident alive. A review of the care plan, dated May 16, 2024, revealed that the resident's advanced directives were in effect. Further stating that the resident's wishes should be carried out in accordance with her advanced directives and to ensure that her wishes are recorded correctly in her chart and follow physician orders. The primary landing page in the resident's electronic health record, at the top of the page, noted the resident to be a full-code. Further review of the electronic health record for resident #242 revealed that the resident had signed for DNR (do not resuscitate) on May 15, 2024. An interview was conducted on May 21, 2024 at 7:48 A.M. with staff #452, CNA (certified nursing assistant). Staff #452 stated that staff are able to locate a resident's code status in the electronic health record. She stated that the code status can be found on the top of the landing page in the electronic health record. Staff #452 pulled up the record for resident #242 and when asked, stated that resident #242 was noted to be a full-code. She stated that the expectation is that information in the record is accurate, and if for some reason it isn't, then it could be a problem for the facility as they would be going against the resident's wishes. An interview was conducted on May 21, 2024 at 7:55 A.M. with staff #508, RN (registered nurse). Staff #508 stated that the advanced directives are generally done by the admitting nurse. She stated that the nurse would review everything on the form with the resident to ensure that the resident understands what they are selecting and signing. Staff #508 stated that if the DNR option was selected, then the resident would sign the orange DNR form, which is then uploaded into the resident's electronic medical record. She stated that if it was necessary to obtain the code a specific resident, staff would first look in the electronic record to determine the code status. She stated that the DNR form is also available in hard copy on the unit, but it's generally a lot quicker to look in the electronic record. Staff #508 pulled up the electronic health record for resident #242 and stated that this resident is a full code. When staff #508 was asked to pull up the actual DNR document, she stated that the resident should actually be a DNR. An interview was conducted on May 21, 2024 at 8:03 A.M. with staff #417, DON (director of nursing). Staff #417 stated that staff will try to get the advanced directives completed on admission, but if the resident is unable to make the decision, then staff will attempt to reach the authorized representative and the resident will be a full code, until the advanced directive or DNR form can be signed. Staff #417 stated that there is a binder on each nurses station where the paper DNR's are housed, additionally the advanced directive/ DNR is noted in the electronic health record at the top of the page. She stated, to ensure the accuracy of the records regarding advanced directives/ DNR's, medical records perform an audit process. Staff #417 pulled up the electronic health record for resident #242 and stated that the resident was a full-code, based on the record and physician orders; however, when asked to review the actually documentation that the resident had signed, she stated that the resident had a DNR in place. Staff #417 stated that her expectation is that the form, orders and entry in the electronic health records match, which she stated they did not for resident #242. She stated that the risk is, if a resident 'coded', staff would likely look in the electronic health record first to initiate the code and if that information is incorrect, then the resident's wishes would not be followed. Staff #417 stated that she would immediately have the orders changed. A review of the facility policy entitled Advanced Directives revised April 2013 revealed that advanced directives will be respected in accordance with state law and facility policy. The policy further indicated that the plan of care for each resident will be consistent with the resident's treatment preferences and or advanced directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#47) had the right to privacy. The deficient practice could result in residents being denied their rights and impact psychosocial well-being. Findings include: Resident #47 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with other behavioral disturbance, adjustment disorder, and major depressive disorder. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 6 indicating the resident had a severe cognitive impairment. Review of the care plan dated February 14, 2023 revealed a behavior care plan related to impaired cognition as evidenced by verbal aggression toward staff, rejecting needed care, yelling at staff, and obsessing over particular items. A progress note dated October 11, 2023 revealed that the resident gets easily irritated with other residents and staff, yells out and is often impulsive. A behavior health service provider is present in the facility and advised. A progress note dated October 16, 2023 revealed that a nurse was called into the unit due to a resident-to-resident confrontation. Residents were heard yelling at each other in their room and the certified nursing assistants (CNAs) went into the room where residents were found arguing and pulling on each other's clothes. The roommate (#47) was upset because resident #23 was rummaging through her closet. Resident #47 stated that resident #23 slapped her. The residents were separated and one was moved to another room to prevent any further altercations. Both residents were assessed by the nurse and no injuries or marks were noted, vital signs were stable, and no complaints of pain from either resident. A physician's note dated October 23, 2023 included that resident #47 recently had an altercation with another resident. Both residents were yelling at each other and arguing about clothes. Resident #47 reported that she was slapped by the other resident. The incident was unwitnessed and there were no signs of injuries reported by nursing staff. -Resident #23 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, hypertensive chronic kidney disease, anxiety disorder, and a major depressive disorder. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 3 indicating the resident had a severe cognitive impairment. Review of the the care plan dated September 12, 2023 revealed a behavior care plan related to dementia as evidenced by impaired safety awareness, physical behaviors, resistive to care, verbal behaviors, and wandering/exit seeking. Interventions included to administer medications as ordered, anticipate and meet the resident's needs, and encourage as much participation/interaction as possible during care activities. A behavior progress note dated September 16, 2023 revealed that a resident was restless, wandering/pacing the halls, and exit seeking. The resident was also noted hoarding objects in pockets and was difficult to redirect. A behavior progress note dated September 28, 2023 revealed that the resident was noted wandering into another resident's room this afternoon. The other resident became agitated and insisted that the resident leave. Staff was able to redirect both residents. Staff reported that the resident continues hoarding everyday objects in her purse, closet, and dresser drawers including dirty pull-ups. A progress note dated October 7, 2023 revealed that resident #23 was transferred to another room due to not getting along with her roommate. A progress note dated October 16, 2023 revealed that a nurse was called into the unit due to a resident-to-resident confrontation. Residents were heard yelling at each other in their room and the certified nursing assistants (CNAs) went into the room where residents were found arguing and pulling on each other's clothes. The roommate (#47) was upset because resident #23 was rummaging through her closet. Resident #47 stated that resident #23 slapped her. The residents were separated and one was moved to another room to prevent any further altercations. Both residents were assessed by the nurse and no injuries or marks were noted, vital signs were stable, and no complaints of pain from either resident. A progress note dated October 18, 2023 at 11:47 a.m. revealed that resident #23 continues to wander into other residents' rooms and take their belongings back to her room. Resident #23 took another resident's shoes and put them in her closet, upsetting the resident who looked for her shoes all morning. A progress note dated October 30, 2023 revealed that resident #23 wanders in and out of other residents' rooms and can become agitated and combative with redirection. Review of the facility's five-day written investigation dated October 20, 2023 revealed that on October 16, 2023 at approximately 7:20 p.m., the CNAs in the behavioral unit heard two roommates arguing with each other. They responded to the disturbance and found the residents yelling at each other and arguing over clothes. Resident #23 was topless and going through her roommate's (#47's) closet. The two resident's were close to each other pulling on each other's clothes. The resident's were separated immediately. Resident #47 stated that resident #23 slapped her, but there was witness to the slapping allegation. Both residents' were assessed, and no injuries were found, nor were there any complaints of pain. Review of the facility's five-day written investigation dated October 20, 2023 also included staff interviews: -a licensed practical nurse (LPN/staff #468), who stated that since the incident, resident #47 acts more defensive when anyone gets near her stuff. He also stated that resident #23 wanders into residents' rooms and grabs stuff. -(CNA/staff #425) stated that resident #23 goes into other residents' rooms and gets into their belongings. -(CNA/staff #407) stated that resident #47 gets upset when people bother her belongings. An interview was conducted on May 22, 2024 at 1:49 p.m. with (CNA/staff #425), who stated that resident #23 has a history of going into everybody's rooms and taking things. Resident #23 was going through resident #47's stuff and they got into it. The residents were pulling on the clothing back and forth. Staff #425 stated that a resident has a right to privacy and she has to always redirect resident's when they are entering another resident's space and resident #47 is possessive of her boundaries and stuff. An interview was conducted on May 22, 2024 at 1:58 p.m. with the Resident Relations Assistant (staff #459), who stated that resident #23 was digging through resident #47's closet and was trying to take it away. She stated that resident#23 has a history of taking other residents' things and staff have reported that resident #23 takes other peoples clothes; staff are supposed to redirect her to another area or activity. Staff #459 stated that a resident has a right to his/her own things, and this includes his/her own personal space. An interview was conducted on May 22, 2024 at 2:29 p.m. with the Director of Nursing (DON/staff #417), who stated that staff are trained on resident rights, which includes the right to privacy. She stated that if one resident has history of taking other peoples' things, it is her expectation that staff redirect the resident when it occurs. This is her plan to protect the other resident's right to privacy, and when monitoring residents who wander, staff should try to keep the resident in a safe environment, and report it to the nurse, so the nurse can assess the resident. The facility policy, Resident Rights dated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to privacy and confidentiality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to protect the rights of two residents (#50, and #3) to be free from abuse from each other. The deficient practice could result in further abuse of residents and appropriate action not taken. Findings include: Regarding incident involving residents #50 and 191: -Resident #50 (alleged victim) was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, auditory hallucinations, visual hallucinations, anxiety disorder, and disorientation. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident's cognitive skills for daily decision making is severely impaired. The MDS also indicated that the resident was negative for indicators of psychosis, behavioral symptoms, and wandering during the assessment period. However, the MDS noted that the resident exhibited rejection of care which occurred 1-3 days during the assessment period. An incident note dated October 6, 2023 documented that according to a CNA (certified nursing assistant), this resident yelled at another resident to be quiet. The other resident then approached this resident, told her nobody tells me what to do and slapped her on the left cheek. The note documented that no visible injuries were noted. The note also indicated that the sheriff's department was contacted and informed family, and indicated that resident would be taken to the hospital. A behavior care plan revised on January 24, 2024 revealed that the resident #50 had behavior problems related to the effects of Alzheimer's dementia as evidenced by poor awareness of needed personal care, combativeness, and verbal outburst during personal care. Interventions included to anticipate and meet needs, assist to minimize disruptive behaviors, if issues arise, remove from situation. A care plan revised April 26, 2024 indicated that the resident #50 had impaired cognitive function related to Alzheimer's dementia with impaired thought processes, difficulty making decisions, short term memory loss that is not anticipated to improve. Interventions included supervision/assistance with all decision making, and keep routine consistent. -Resident #191 (alleged perpetrator) was admitted to the facility on [DATE] with diagnoses that included dementia, malignant neoplasm of cerebral meninges, major depressive disorder, and anxiety disorder. A behavior note dated October 5, 2023 indicated documented that the resident was out of the room wandering the halls. The note stated that the resident had been tearful most of the afternoon and upset that her family had dropped her off. Resident was observed to be quickly agitated with loud sounds or voices but was easily redirected. Resident was noted as compliant with medication and care. A behavior note dated October 6, 2023 documented that a CNA (certified nursing assistant) reported that the resident was pacing, going in to another residents' room and yelling at CNA. The CNA indicated that the resident from room [ROOM NUMBER]-1 called out for the resident to be quiet. Resident #191 then went in to room [ROOM NUMBER]-1 yelled at resident to not tell her what to do then slapped her on the face on the left cheek. The note documented that the CNA assisted resident #191 out of the room at which time the resident continued pacing. The note also documented that 911 was called and that the state agency was notified via after hours number. Additionally, the note indicated that the DON (Director of Nursing) and POA (power of attorney), spouse were notified. An additional behavior note also dated October 6, 2023 documented that resident wandered into other residents' rooms. Resident was noted to become easily angered with other residents when asked to leave their rooms or stop standing behind their chairs at meal times. Another behavior note dated October 7, 2023 stated that CNA reported that resident #191 threw a blanket at her roommate and was yelling, calling her names, telling her to get out of her room. The note also documented that resident #191 grabbed roommates' belongings. Roommate was transferred to another room. Review of the facility's final investigation report dated October 9, 2023 indicated that resident #191 was admitted to the behavioral unit on October 4, 2023. The report indicated that on her second night in the facility, resident #191 was pacing the halls and making noise. She had to be redirected by staff a couple of times. Resident #191 was entering other residents' rooms and yelling at the CNA (certified nursing assistant. The report noted that early Friday morning on October 6, 2023, at approximately 5:50 a.m., she was up wandering the hall being loud. Resident #50 was bothered by this noise and shouted from her bed BE QUIET in Spanish. Resident #191 did not like this, so she entered resident #50's room and yelled at her don't tell me what to do and slapped her on her left cheek. According to the report when the CNA observed resident #191 enter the room, she immediately followed and went in and redirected resident #191 back to the room. However, the CNA was not able to get to resident #191 before the slap occurred. The report indicated that the CNA did witness the event. The report noted that both residents were assessed and no injury was sustained by either resident. Further review of the facility's final investigation report revealed interviews of both residents, other residents, and staff members. Neither one of the residents involved could recall the incident. Additional residents interviewed indicated they felt safe at the facility. The CNA (staff #486) interview stated that she tried to redirect and kept resident away from the perpetrator. Staff #486 indicated that following the incident, resident #50 (alleged victim) had shown more emotions and aggression. Additionally, staff #486 noted that resident #191 (alleged perpetrator) and resident #50 (alleged victim) did not recall the event and ignored each other. Review of the admission Minimum Data Set (MDS) assessment for resident #191 dated October 10, 2023 revealed that the resident's cognitive skills for daily decision making was severely impaired. The MDS also noted that the resident exhibited hallucinations for indicators of psychosis. The assessment indicated that the resident exhibited physical and verbal behavior symptoms directed toward others which occurred 4-6 days during the assessment period. The resident also exhibited other behavioral symptoms not directed towards others 4-6 days during the assessment period. The MDS assessment revealed that the resident's identified behavioral symptoms placed the resident and others at significant risk for physical injury. The assessment also indicated that the behavioral symptoms significantly interfered with the resident's care. The behavioral symptoms significantly intruded or the privacy or activity of others and significantly disrupted the care or living environment. A care plan initiated on October 17, 2024 indicated that the resident #191 required special care unit related to continued impaired thought process, and unawareness of own safety needs. Interventions included observe for changes in behavior. A behavioral care plan initiated on October 18, 2023 indicated that the resident #191 had a behavior problem related to impaired cognitive function, impaired safety awareness, physical behaviors, verbal behavior, wandering/exit seeking. Interventions included to anticipate needs, identify behavior triggers, and if issues arise, remove from the situation, intervene as necessary to protect the rights and safety of others. A cognition care plan initiated on October 23, 2023 revealed that the resident #191 has impaired cognitive function/dementia or impaired thought processes related to dementia with behaviors, and diagnoses of brain cancer. During an interview with a Certified Nursing Assistant (CNA/staff #463) conducted on May 23, 2024 at 10:37 a.m., staff #463 noted that she was not familiar with resident #191. However, she stated that she was a little familiar with resident #50. She said that the first few days after resident #50 was admitted , she screamed a lot. However, she stated that she had no knowledge about the altercation between the two residents. An interview was conducted with a Licensed Practical Nurse (LPN/staff #479) on May 23, 2024 at 10:55 a.m. Staff #479 stated that resident #191 had behaviors, was confused a lot, and wandered. The LPN also noted that resident #50 was funny and did not have behaviors. Staff #479 stated that she was not aware of any incidents between these two residents. An interview was conducted with the Social Services Manager (staff #459) on May 23, 2024 at 11:53 a.m. Staff #459 stated that she does not remember which resident slapped who in the incident between residents #50, and #191. Regarding incident involving residents #3 and #190: - Resident # 3 (alleged victim) was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included nonrheumatic aortic stenosis, paroxysmal atrial fibrillation, essential hypertension, type 2 diabetes mellitus, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating that the resident #3 was cognitively intact. The MDS also indicated that the resident was negative for indicators of psychosis, behavioral symptoms, rejection of care, and wandering during the assessment period. Review of the care plan did not indicate care planning for behaviors or involvement in any resident-to-resident altercation. A communication note dated June 19, 2023 documented that resident#3 sustained no injury when slapped in the face by former roommate. The note stated that no redness, swelling, or bruising noted. According to the note resident denied pain. The note documented that resident was upset over incident but is stable. The note also indicated that resident understood to keep distance from the other resident going forward. Review of an incident noted dated June 19, 2023 indicated that resident#3 reported being slapped in the face during conversation with another resident. According to the note the resident#3 had gone into the other resident's room to have a conversation regarding allegations of being a liar. The note documented that the other resident became agitated and attempted to leave the room then slapped resident across the face when she did not get out of the way fast enough. A Social Services progress note dated June 19, 2023 stated that it was a late entry from June 14, 2023. The note documented that resident came into office and wanted to discuss issues she was having with roommate. She came in on the 14th but social services was not available. The note indicated that the writer did go to the resident's room and was told resident preferred to discus the next day. Resident came in and discussed issue she was having with roommate. According to the note, resident#3 noted that roommate was calling her a liar and spreading rumors to others. Another incident note dated June 19, 2023 documented that resident #3 was calm without further signs and symptoms of anxiety regarding the resident to resident incident. The note indicated that resident appeared relaxed and went to the dining room for meal and socialization with others. Furthermore, the note stated that there was no complaint of residual pain form incident with the resident stating that I always have some pain but not from this, I'm fine really. A Social Services progress note dated June 20, 2023 indicated another late entry. The note documented that resident#3 is doing well and continued to dine in the dining room for lunch and dinner. The note indicated that the resident still had some sentiment regarding the other resident calling her a liar. The note stated that resident is not approaching the other resident and is being cordial. Resident was requested to discuss with family and friends but not with residents. A nurse practitioner encounter note dated June 21, 2023 documented that resident had a recent altercation with previous roommate. Resident#3 indicated that she was slapped on the face. The indicated that resident had no pain related to the incident. -Resident #190 was admitted to the facility on [DATE] with diagnoses that included hypertensive chronic kidney disease, type 2 diabetes mellitus, dementia, anxiety disorder, and depression. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that the resident #190 was independent for cognitive skills for daily decision making. Additionally, the MDS indicated that the resident was negative for indicators of psychosis, behavioral symptoms, rejection of care, and wandering during the assessment period. Review of the resident's #190 care plan did not reveal any plan of care related to behavior, mood and or resident to resident altercations at the time of the incident. A therapy note dated June 15, 2023 indicated that the resident#190 scored 11/30 on the SLUMS (St. Louis University Mental Status Examination) which indicated that she had moderate cognitive deficits. The note documented that despite maximum education and encouragement on cognitive therapy, resident declined cognition therapy. The note stated that resident was agreeable to dysphagia treatment. According to the note, the resident complained that she was having great difficulties with quality of life with her current roommate. The note stated that the resident prefers to have a quieter environment and is interested in a room change if possible. A Social Services progress note dated June 19, 2023 indicated a late entry documentation. According to the note the resident#190 was still shook up after the incident. The noted indicated that the resident's account of event changed from the initial explanation to the nurse. The note stated that the resident seemed calmer and noted that she would choose another table to eat at for meals. The resident indicated that she would eat lunch in her room that day. The note stated that it was discussed that it was okay for her to call her close friends and discuss the incident versus speaking with other residents to prevent anxiety. The note indicated that the resident agreed. An incident note dated June 19, 2023 documented that resident#190 had resident to resident altercation in her room. The note stated that resident became agitated and attempted to leave room. According to the note, the resident#190 reported that she attempted to get pass the other resident #3 and that she bumped into something with her arm. The note indicated that resident#190 was noted with 2 skin tears, one to left forearm and one to top of left hand with underlying bruising. The note documented that during the conversation with the resident, she was able to demonstrate the proximity of the altercation, possibly injuring her arm and bruising her leg on the foot board of her bed. The note stated that vital signs were stable after incident with slight anxiety regarding the incident. Another incident note dated June 19, 2023 document that resident#190 remained calm but somewhat anxious regarding the incident. The note indicate that the resident stated I never meant to hit anyone, I'm not like that. The note stated that resident denied pain to left arm and that there was no further sign or symptoms of acute bleeding from skin tears. A nurse practitioner note dated June 21, 2023 documented that a report was received indicating that resident#190 had an altercation with her roommate with some physical aggression. The note stated that no injuries were reported. Review of the facility's investigation report dated June 23, 2023 revealed that a resident to resident altercation occurred between residents #3 and 190 on June 19, 2023. According to the report resident #190 was lying in her bed sleeping when she was woken up by resident #3 talking to her in a loud and upset voice. The report noted that resident #3 told resident #190 I want to straighten things out. Resident #190 stated that she did not want to talk to resident #3 so she got out of the bed and attempted to leave the room. However, the report noted that resident #3's wheelchair was blocking resident #190's path. The report stated that resident #190 struggled to get around resident #3's wheelchair and slapped resident #3 on the face and made her way around the wheelchair. The report indicated that resident #3 shared room that the week prior, while the two were still roommates, she heard resident #190 say something derogatory about her. This made resident #3 upset and she confronted resident #190 about it. The report stated that resident #190 responded to the accusation stating you're a liar. The report indicated that in between the time of the incident on June 15 and the incident on June 19, resident #3 agreed to a room change. The investigation report noted that resident #3 stated that she had wheeled herself to resident #190's room to return a book she had borrowed and to confront her and set things straight. According to resident #3, while she was talking to resident #190 about the issue, resident #190 got out of the bed and attempted to leave the room. However, since resident #3's wheelchair was blocking the way, resident #190 slapped resident #3 in the face and scooted around her wheelchair. After resident #190 left the room, resident #3 followed resident #190 out of the room and informed a nurse that resident #190 had slapped her. Further review of the facility investigation report revealed a staff interview with a Care Coordinator (staff #438), who stated that residents were separated and social services involved following the incident. Staff #438 indicated that prior to the altercation the residents involved were passive aggressive towards each other. After the incident, the residents appeared anxious. Additionally, staff #438 noted that the alleged perpetrator and victim exhibited behavior of accusations and confrontations that provoked each other. Additionally, the facility investigation revealed that in an interview with the Resident Relations Assistant (staff #459), she noted that prior to the altercation, the residents involved were not friendly with each other. Following the incident, the residents stayed away from each other. During an interview with a Certified Nursing Assistant (CNA/staff #463) conducted on May 23, 2024 at 10:37 a.m., staff #463 stated that resident #3 was a nice lady but did not remember much, she liked to walk around the facility and could get lost but was easily redirected. The CNA stated that resident #190 was sweet but had memory problems. Staff #463 stated that she did not hear about the two residents having an altercation. The CNA said that they identify a resident is at risk for resident to resident altercation when they start making hostile statements and they get a mean/hostile look on their face. Staff #463 noted that when a resident to resident altercation occurs, they separate the residents and report the incident to the nurse, document what happened, and inform other CNAs. The CNA noted that when a resident to resident altercation occurs, the impact on the resident is that it is stressful for the resident that was abused and it causes a change in the resident's schedule. Staff #463 noted that it is important for them to identify those residents at risk for resident to resident altercation to ensure that they do not put those residents with other residents that are also the same in order to prevent incidents. An interview was conducted with a Licensed Practical Nurse (LPN/staff #479) on May 23, 2024 at 10:55 a.m. Staff #479 stated that she heard about the incident between residents #3 and #190 but was not sure about the details. The LPN noted that they were roommates at one point. Staff #479 stated that they identify residents as at risk for resident to resident altercation based on their behaviors. When a resident to resident altercation occurs, the residents are separated, the DON (Director of Nursing, administrator provider, family, and police are notified, assessments are completed and behaviors documented. Staff #479 noted that the impact on residents when a resident to resident altercation occurs is that the residents can have increased anxiety, they exhibit withdrawal/sadness/negativity/loss of appetite. The LPN stated that it is important to identify those at risk for resident to resident altercation since they are at higher risk for confrontation and therefore have to be watched so that behaviors can be communicated and incident prevented. An interview was conducted with the Social Services Manager (staff #459) on May 23, 2024 at 11:53 a.m. Staff #459 noted that residents #3 and #190 were roommates. She indicated that what she recalled about the incident between the two residents was that resident #190 was saying stuff/spreading rumors in the dining room area and resident #3 heard it and addressed it. Staff #459 said that resident #3 went to resident #190's room by her bed and blocked resident #190. Resident #190 slapped resident #3 resulting in a red mark on her face. Resident #190 hurt herself on the dresser as she was attempting to leave the room. Staff #459 noted that her role during abuse allegations is that she gathers preliminary information and provides it to the Executive Director (E.D.) so that he would know how to proceed. She noted that in instances of abuse, they interview 5 employees and 5 residents. The employees selected for interview are those that worked during the timeframe of the alleged incident and whoever would be knowledgeable about the incident. The residents selected for interview are those that were in the area or were witness to the incident. During an interview with the Director of Nursing (DON/staff #417) conducted on May 23, 2024 at 12:48 p.m., she stated that that her expectation is that staff reports incidents of resident to resident altercations and place interventions in order to prevent further incidents. Staff #417 stated that following a resident to resident altercation, the incident should be reported to the DON and administrator and ensure the safety of both residents and the entire unit. Review of the facility policy titled Abuse Policy version 0622, revealed that the facility strives to prevent the abuse of all their residents. The policy also noted that the resident suspected of being abused will be monitored and placed on alert charting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on documentation, staff interviews, and the facility policy and procedure, the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level I for one resident (#24), and failed to submit the PASRR Level II to the state agency. The deficient practice could result in residents not receiving additional services that are needed. Findings include: Resident #24 was admitted to the facility on [DATE] with diagnoses that included schizophrenia unspecified, bipolar disorder, and Parkinsonism. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 11 indicating the resident had a moderate cognitive impairment. Review of the PASRR Level I dated June 6, 2023 did not reveal any serious mental illnesses, anti-psychotic medication, or assessment for substantial functional limitations. Due to the form not being completed, it was not submitted to the state agency for a PASRR Level II. Review of the care plan dated June 12, 2023 revealed that the resident uses anti-psychotic medications (Haldol) related to a diagnosis of schizophrenia as evidenced by episodes of verbal agitation and physical aggression. Interventions included to administer medications as ordered and monitor for side effects and/or toxic symptoms. Review of the care plan dated June 27, 2023 revealed that the resident has episodes of impaired cognitive function or impaired thought processes related to schizophrenia-bipolar disorder as evidenced by short term memory loss, and episodes of miscommunication related to hearing impairment. Interventions included to provide the resident with necessary cues, stop and return if the resident is agitated and to engage the resident in simple, structured activities that avoid overly demanding tasks. An interview was conducted on May 21, 2024 at 8:28 a.m. with the Resident Relations Manager (staff #473), who stated that she checks the PASRR Level I and it is updated after 30 days as per the regulation. She reviewed the clinical record and stated that the resident was admitted to long-term care, so the PASRR Level I should have been updated. She also acknowledged that the resident had a diagnoses of schizophrenia and a bipolar disorder, so the PASRR Level II should have been submitted to the state agency. She reviewed documentation with medical records and stated that she did not have a completed PASRR Level I for the resident. An interview was completed on May 22, 2024 at 2:40 p.m. with the Director of Nursing (DON/staff #417), who stated that it is her expectation that the PASRR is reviewed by staff #473 if the resident is going to stay more than 30 days. If the resident has an appropriate diagnoses, staff #473 should submit the PASRR Level I to the state agency. the PASRR Level two agrees that the purpose is to determine that the facility meets the needs of the resident and if additional services are needed. The facility policy, Pre-admission Screening and Resident Review (PASRR) states that our facility will strive to verify that a Level I PASRR Screening has been conducted, in order to identify serious mental Illness (Ml) and/or an intellectual disability (ID) prior to initial admission of Individuals to the facility. If the resident is positive for potential Ml or ID, a Level II PASRR referral must be submitted. It Is the responsibility of the facility to make referrals for a Level II PASRR, or in some cases, to ensure the referral Is made by the Arizona Long-Term Care (ALTCs) case manager, if a Level II PASRR Is determined to be necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and policy review, the facility failed to ensure that physician's orders was followed regarding one resident's (#31) AV (arteriovenous) fistula. The deficient practice could result in the resident's AV fistula failing. Findings include: Resident #31 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, hypertensive chronic kidney disease, Parkinsonism, atherosclerotic heart disease of native coronary artery without angina pectoris, paroxysmal atrial fibrillation, and dependence on renal dialysis. Review of the order summary report revealed a physician order dated June 5, 2018 which indicated No Blood pressure or venipuncture to AV fistula site every shift for left arm. A care plan initiated on June 28, 2018 and revised on March 2, 2023 indicated that resident needs dialysis related to end stage renal failure. The goal was that the resident would not have signs and symptoms of complications from dialysis. Interventions included: Do not draw blood or take B/P (blood pressure) in left arm with graft, and check and change dressing daily at access site. However, review of the resident's blood pressure (BP) log over the last six months revealed that it was taken on the left arm on the following dates: - December 11, 2023 - December 18, 2023 - January 1, 2024 - May 13, 2024 Further review of the BP log revealed numerous occasions since the resident was admitted in which her BP was taken on the left arm. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. The MDS assessment also noted that the resident receives hemodialysis treatment. The assessment also indicated that the resident is dependent to renal dialysis. An interview with a Certified Nursing Assistant (CNA/staff #510) was conducted on May 22, 2024 at 4:19 p.m. Staff #510 stated that for residents on dialysis, you use the opposite arm to take BP. The CNA said that you do not take the BP on the arm with the fistula. Staff #510 noted that the nurse normally informs CNAs not to take the BP on the same arm as the fistula site. During an interview with a Licensed Practical Nurse (LPN/staff #513) conducted on May 22, 2024 at 4:32 p.m., staff #513 stated that you cannot take vitals on the same site as the fistula. The LPN noted that you want to check for bruit and thrill on the fistula site and do a skin assessment. An observation was conducted on May 23, 2024 at 9:49 a.m. During the observation the CNA (staff #462) accomplished hand hygiene, wiped/disinfected the vitals machine then took resident #31's vitals. Staff #462 explained that the reason she was using resident #31's right arm is due to her having a fistula on the left arm. An interview with the Director of Nursing (DON/staff #417) was conducted on May 23, 2024 at 9:49 a.m. Staff #417 stated that her expectation is that staff will take bp on the arm with the fistula before and after dialysis. The DON noted that she expects for staff to follow physician's orders when caring/treating residents. Staff #417 said that not following physician's orders with regards to not taking bp on the arm with the fistula could damage the fistula. The DON indicated that pre-dialysis vitals are inputted on Point of Care (POC) and includes temperature, pulse, bp, and weight. Staff #417 stated that staff do not have to document which arm they take the bp on since they do not take it on the fistula side. The DON noted that they run with consistent staff and it is communicated to CNAs not to take bp on side with the fistula. In the case of resident #31 if her fistula is on the left then bp should be taken on the right arm. Staff #417 stated that she does not know how the nurse knows that the bp is being taken on the appropriate arm. The facility policy titled End-Stage Renal Disease, Care of a Resident with revised September 2010, stated that residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. The policy noted that staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. Education and training of staff includes, the care of grafts and fistulas. Furthermore, the policy noted that the resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. Review of the facility policy titled Documentation: Charting and Documentation in effect on January 1, 2024, indicated that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. Additionally, the policy noted that documentation in the medical record will be objective, complete, and accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Regarding Resident #241: Resident #241 was admitted on [DATE] with diagnosis including atherosclerotic heart disease of the native coronary artery, chronic atrial fibrillation, essential hypertension, chronic obstructive pulmonary disease, obstructive sleep apnea, hypertensive heart disease with heart failure, pleural effusion, cardiomegaly, atelectasis, cirrhosis of the liver, hypo-osmolarity and hyponatremia, fracture of T7-T8 vertebra, wedge compression fracture of the second lumbar vertebra, diverticulosis, abdominal aortic aneurysm, obstructive and reflux uropathy, type II diabetes, major depressive disorder-recurrent, constipation, and muscle spasms. The admission MDS (minimum data set) was noted to be in progress. A review of the physician orders, revealed no evidence of an order for Orajel or an order for self-administration of medication. A review of the electronic medical record revealed no evidence of an assessment for self-administration of medications. A review of the care plan for resident #241 revealed no evidence of medication self-administration. A review of the progress notes revealed no evidence that the resident had been assessed for self-administration of medication. An observation was conducted on May 20, 2024 at 10:37 A.M. A tube of Orajel was observed at bedside for resident #241. The resident's spouse, who was present at the time of observation, stated that the resident has gum pain and that she had brought the medication from home. She further stated that nursing staff were aware of the medication and had seen it when it was brought in. An observation was conducted on May 20, 2024 at 1:40 P.M. It was observed that Orajel was still on the resident's bedside table in plain view. An observation was conducted on May 21, 2024 at 7:40 A.M. It was observed that Orajel was still on the resident's bedside table. Regarding Resident #75: Resident #75 was admitted on [DATE] with diagnosis including traumatic subdural hemorrhage , traumatic subarachnoid hemorrhage, traumatic hemorrhage of cerebrum, acute transverse myelitis in demyelinating disease of the central nervous system, ataxic gait, hypertension, hyperlipidemia, fibromyalgia, peripheral vascular disease, chronic pain syndrome, urinary incontinence, retention of urine, peripheral vascular angioplasty with implants and grafts, atrial fibrillation, convulsions, seasonal allergic rhinitis, lack of coordination, cognitive communication deficit, weakness, unsteadiness, abnormalities of gait and mobility, mild protein-calorie malnutrition, neuromuscular dysfunction, and displaced bimalleolar fracture of the right lower leg. A review of the MDS dated [DATE] revealed a BIMS (brief interview of mental status) score of 12, suggesting mild cognitive impairment. A review of the physician orders revealed no evidence of an order for Voltaren, Flonase or for self-administration of medication. A review of the care plan for resident #75 revealed no evidence noting self-administration of medication. A review of the progress notes revealed no evidence that the resident had been assessed for self-administration of medication. An observation was conducted on May 20, 2024 at 10:22 A.M. It was observed that Flonase 50mcg and Voltaren 2.32% were on the resident's bedside table. An observation was conducted on May 20, 2024 at 1:41 P.M. It was observed that both medications were still located on the resident's bedside table. An observation was conducted on May 21, 2024 at 7:41 A.M. It was observed that Voltaren was still on the resident's bedside table; however, Flonase was no longer visible. An interview was conducted on May 21, 2024 at 7:48 A.M. with staff #452, CNA (certified nursing assistant). Staff #452 stated a medication is anything what nurses give to patients, including: oral, inhalants, eye drops, intravenous or any over the counter medications. Any medications given to a resident have to be prescribed by the doctor and need to include the amount and frequency of the medication. Staff #452 stated that residents can't have a medication at bedside unless it's prescribed. She stated that the risk of having medications that are not prescribed at bedside can include overdose. An interview was conducted on May21, 2024 at 7:55 A.M. with staff #508, RN (registered nurse). Staff #508 stated medications can include pretty much anything, including creams, ointments, vitamins, and eye drops. Staff # stated that medications are not allowed at bedside unless prescribed and assessed for safety. Staff #508 stated that she checks for medications in resident rooms every day. Staff #508 stated that risk of unauthorized medications at bedside could include other residents accidentally picking up the medication and using it. An interview was conducted on May 21, 2024 at 8:03 A.M. with staff #417, DON (director of nursing). Staff #417 stated that residents are not able to have medications at bedside unless they have been assessed and a physician order for the medication is in place. Staff #417 stated that if medications are brought in by the residents or family, they are removed by nursing staff for safe keeping in a secure place and labeled with the resident's name. Staff #417 stated that the expectation is residents are assessed for ability and safety to self-administer medications and that orders are in place for any medications at bedside. Staff #417 stated that the risk could include duplication of medication and or other confused patients could wander into the room and take-off with it. The facility policy entitled Medications: Self-Administration of Medications dated January 1, 2024 revealed that as part of the evaluation comprehensive assessment, the interdisciplinary team assesses each resident's cognitive and physical abilities to determine whether self-administration of medications is safe and clinically appropriate for the resident. The policy further stated that if a resident is deemed safe and appropriate to self-administer medications, it is documented in the medical record and care plan; however, no evidence of documented assessment was evident in the care plan or the medical record as a whole. The facility policy, Resident Safety: Safety and Supervision of Residents dated January 1, 2024 states that the facility's individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that two residents (#75 , #241) were assessed, monitored and had orders for self-administration of medications and that one resident (#23) was monitored with appropriate level of supervision. The deficient practice could result in residents being injured. Findings include Resident #23 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, hypertensive chronic kidney disease, anxiety disorder, and a major depressive disorder. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 3 indicating the resident had a severe cognitive impairment. Review of the the care plan dated September 12, 2023 revealed a behavior care plan related to dementia as evidenced by impaired safety awareness, physical behaviors, resistive to care, verbal behaviors, and wandering/exit seeking. Interventions included to administer medications as ordered, anticipate and meet the resident's needs, and encourage as much participation/interaction as possible during care activities. A behavior progress note dated September 16, 2023 revealed that a resident was restless, wandering/pacing the halls, and exit seeking. The resident was also noted hoarding objects in pockets and was difficult to redirect. A behavior progress note dated September 28, 2023 revealed that the resident was noted wandering into another resident's room this afternoon. The other resident became agitated and insisted that the resident leave. Staff was able to redirect both residents. Staff reported that the resident continues hoarding everyday objects in her purse, closet, and dresser drawers including dirty pull-ups. A progress note dated October 7, 2023 revealed that resident #23 was transferred to another room due to not getting along with her roommate. A progress note dated October 16, 2023 revealed that a nurse was called into the unit due to a resident-to-resident confrontation. Residents were heard yelling at each other in their room and the certified nursing assistants (CNAs) went into the room where residents were found arguing and pulling on each other's clothes. The roommate (#47) was upset because resident #23 was rummaging through her closet. Resident #47 stated that resident #23 slapped her. The residents were separated and one was moved to another room to prevent any further altercations. Both residents were assessed by the nurse and no injuries or marks were noted, vital signs were stable, and no complaints of pain from either resident. A progress note dated October 18, 2023 at 11:47 a.m. revealed that resident #23 continues to wander into other residents' rooms and take their belongings back to her room. Resident #23 took another resident's shoes and put them in her closet, upsetting the resident who looked for her shoes all morning. A progress note dated October 30, 2023 revealed that resident #23 wanders in and out of other residents' rooms and can become agitated and combative with redirection. -Resident #47 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with other behavioral disturbance, adjustment disorder, and major depressive disorder. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 6 indicating the resident had a severe cognitive impairment. Review of the the care plan dated February 14, 2023 revealed a behavior care plan related to related to impaired cognition as evidenced by verbal aggression toward staff, rejecting needed care, yelling at staff, and obsessing over particular items. A progress note dated October 11, 2023 revealed that the resident gets easily irritated with other residents and staff, yells out and is often impulsive. A behavior health service provider is present in the facility and advised. A progress note dated October 16, 2023 revealed that a nurse was called into the unit due to a resident-to-resident confrontation. Residents were heard yelling at each other in their room and the certified nursing assistants (CNAs) went into the room where residents were found arguing and pulling on each other's clothes. The roommate (#47) was upset because resident #23 was rummaging through her closet. Resident #47 stated that resident #23 slapped her. The residents were separated and one was moved to another room to prevent any further altercations. Both residents were assessed by the nurse and no injuries or marks were noted, vital signs were stable, and no complaints of pain from either resident. A physician's note dated October 23, 2023 included that resident #47 recently had an altercation with another resident. Both residents were yelling at each other and arguing about clothes. Resident #47 reported that she was slapped by the other resident. The incident was unwitnessed and there were no signs of injuries reported by nursing staff. Review of the facility's five-day written investigation dated October 20, 2023 revealed that on October 16, 2023 at approximately 7:20 p.m., the CNAs in the behavioral unit heard two roommates arguing with each other. They responded to the disturbance and found the residents yelling at each other and arguing over clothes. Resident #23 was topless and going through her roommate's (#47's) closet. The two resident's were close to each other pulling on each other's clothes. The resident's were separated immediately. Resident #47 stated that resident #23 slapped her, but there was witness to the slapping allegation. Both residents' were assessed, and no injuries were found, nor were there any complaints of pain. Review of the facility's five-day written investigation dated October 20, 2023 also included staff interviews: -a licensed practical nurse (LPN/staff #468), who stated that since the incident, resident #47 acts more defensive when anyone gets near her stuff. He also stated that resident #23 wanders into residents' rooms and grabs stuff. -(CNA/staff #425) stated that resident #23 goes into other residents' rooms and gets into their belongings. -(CNA/staff #407) stated that resident #47 gets upset when people bother her belongings. An interview was conducted on May 22, 2024 at 1:49 p.m. with (CNA/staff #425), who stated that resident #23 has a history of going into everybody's rooms and taking things. Resident #23 was going through resident #47's stuff and they got into it. Staff #425 stated that a resident has a right to privacy and she has to always redirect resident's when they are entering another resident's space and resident #47 is possessive of her boundaries and stuff. An interview was conducted on May 22, 2024 at 1:58 p.m. with the Resident Relations Assistant (staff #459), who stated that resident #23 was digging through resident #47's closet and was trying to take it away. She stated that resident#23 has a history of taking other residents' things and staff have reported that resident #23 takes other peoples clothes; staff are supposed to redirect her to another area or activity. Staff #459 stated that a resident has a right to his/her own things, and this includes his/her own personal space. An interview was conducted on May 22, 2024 at 2:29 p.m. with the Director of Nursing (DON/staff #417), who stated that staff are trained on resident rights, which includes the right to privacy. She stated that if one resident has history of taking other peoples' things, it is her expectation that staff redirect the resident when it occurs. This is her plan to protect the other resident's right to privacy, and when monitoring residents who wander, staff should try to keep the resident in a safe environment, and report it to the nurse, so the nurse can assess the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure dental needs were met for one sampled resident (#41). The deficient practice could result in residents not receiving care and services for oral/dental conditions. Findings include: Resident # 41 was initially admitted to the facility on [DATE] with diagnoses that included hemiplegia, hemiparesis, dysphagia, atherosclerotic heart disease, hypertensive heart disease, chronic diastolic heart failure, and chronic obstructive pulmonary disease. A dental note dated September 8, 2022 revealed that a consultation visit was completed. The findings/recommendations was ext (extraction) of #26 (lateral incisor), 27 (cuspid), and 28 (first bicuspid). The next schedule appointment was marked as October 5, 2022. However, further review of dental referral notes did not reveal any documentation of that visit or if that visit occurred. A care plan initiated on February 28, 2023 revealed that the resident is at risk for acute oral/dental health problems related to missing and/or cavity prone teeth. Interventions included coordinate arrangements for dental care, transportation as needed/as ordered. Review of dental noted dated January 2, 2024 indicated that an initial exam was conducted and found that resident had broken teeth. During the exam it was discovered that resident had a worn FUD (full upper denture) for over 3 years and never had lower dentures. It was noted that FUD fit loosely and needs adhesive for retention. The note indicated that recommended treatment included surgical exts (extraction) #26 (lateral incisor), 27 (cuspid), 28 (first bicuspid), and 29 (second bicuspid); and FUD/FLD (full lower denture). Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating that the resident was cognitively intact. The MDS also documented that the resident had obvious or like cavity or broken natural teeth. An interview with the Unit Secretary (staff #424) was conducted on May 23, 2024 at 9:19 a.m. Staff #424 stated that nurse or providers informs her which residents need dental services. For new residents they sent the face sheet to the dental provider, for long term care residents, if they do not know if Medicare covers, they call the dental office to ask if they cover and if the dentist is contracted. One of the dental providers comes in and provides dental services and the other will send a list and they let her know which residents needs to be seen. Staff #424 noted that the process for scheduling is usually via email contact initiated by her. For example, if a resident has an appointment today, she annotates it then the day after, she calls and checks if the resident has a follow-up appointment. Regarding resident #41, her name was not on list prior to the dental provider coming in today. Looking at the chart, staff #424 stated that she does not see anything else in reference to resident #41 seeing dental services other than the initial visit in January 2, 2024 and the one prior to that was with another dental provider back in September 8, 2022. The Unit Secretary stated that she would need to ask Medical Records to see if there are any other appointment dates. Review of an email thread between the Unit Secretary (staff #424) and the Dental Office Manager (staff #620) dated May 23, 2024 revealed that resident #41 does not have any current scheduled appointment. Staff #620 indicated that they will be scheduling resident #41 in two to three weeks. During an interview with the MDS Coordinator/Care Coordinator (staff #415) conducted on May 23, 2024 at 10:10 a.m., staff #415 stated that during assessment if oral/dental issues is noticed, the resident is sent for dental services and dietary gets involved to adjust based on needs. Speech also does an eval when resident is first admitted and if they see something pertinent then dental services is also set up. The MDS and Care Coordinator stated Social Services is notified and they relay to them if resident has obvious cavity, broken teeth, pain or trouble swallowing. Usually Social Services will set up the appointment. Staff #415 stated that every 3 months there is a quarterly assessment and they note if there are changes. If a big issue is noticed with oral/dental then let Social Services know. Staff #415 noted that they also ask CNAs if there are any changes and if residents are eating okay. An interview was with resident #41 was conducted on May 23, 2024 at 10:49 a.m. Resident #41 pointed at her remaining teeth and stated that she has pain in the areas she is pointing to. She said that she does have dentures but they are temporary ones. Resident #41 said she has 3 teeth left in the lower. They looked decayed and needs attention/extracted. During an interview with the Director of Nursing (DON/staff #417) conducted on May 23, 2024 at 12:47 p.m., staff #417 stated that residents are seen by the dentist per facility protocol, family approval of cost, transportation, and if any pain or dental issues are noted, and per dentist recommendation. The DON noted that family can refuse cost. The facility tries to see if there is anything through insurance for additional coverage, donated funds, share of cost money to get payment plan for dentist. Family and Social Services is contacted if they need assistance getting dental care/paying for dental care. The DON stated that dental notes are faxed and scanned into the resident's records. Staff #417 said that she believes routine dental care is yearly but in the public setting, they try to go every six months but she does not know what the frequency is that residents needs to be seen. The DON indicated that if a resident needs follow-up services, receptionist will keep a list of needed follow-up and Social Services is involved in coordination and care conferences which the family attends. Dental issues are expected to be brought up during care conferences. She stated that she expects for provider to be notified and an order sent to the Social Services and scheduler to work on getting the resident a dental appointment. There should be a follow-up dentist note. She stated that for the annual there is no tracking system but there is if it is about a follow-up appointment. During the dental exam, dental issues would be addressed. An order is generated for dental. There is a batch order which allows to schedule without needing doctor's orders but if the resident has pain then the provider has to be notified. Staff #417 said that the impact of resident not getting dental services is potential weight loss, infection, and pain. Review of the facility policy titled Personal Care: Dental Services effective January 1, 2024, indicated that routine and emergency dental services are available to meet the resident's oral health in accordance with the resident's assessment and plan of care. Additionally, it noted that social services representatives will assist residents with appointments and transportation arrange

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that floor tiles, laminate flooring, shower drain, and door frame in common areas were safe for residents ambulating and showering. The deficient practice could result in residents falling and/or being injured. Findings include: On May 21, 2024 at 4:23 p.m., a walk through of the facility was conducted and the following environmental issues were observed: -one rectangular panel of the laminate flooring in Hall 100, between rooms #127 and #128, was broken and approximately half an inch was missing from one of the corners of the laminate. -the laminate panel in the doorway of room [ROOM NUMBER] was observed to have approximately 16.5 inches in length broken and missing. -six tiles in Hall 100 were cracked and/or broken. -the transition strip between the laminate flooring and the tile flooring on Hall 100 by room [ROOM NUMBER] was cracked in multiple areas. -in the hallway, near room [ROOM NUMBER] a piece of the flooring, circular in shape, was compressed, so that the floor was uneven and there was cracked and broken laminate around the circumference of the circle. -one rectangular laminate floor panel located near room [ROOM NUMBER] on Hall 100 was not secured to the floor. -there was no transition strip between the tile and the laminate flooring toward the end of Hall 100 by room [ROOM NUMBER]. -the drain in the bathroom shower on Hall 100 was approximately two inches in diameter and there was a square silver drain cover only partially covering the round open hole and the drain cover was not attached to the floor. -the doorframe of the bathroom on Hall 100 had areas were paint was missing and a brown rust color was observed. -upon entering the secured unit on Hall 100, one rectangular laminate floor panel was broken with approximately 3 inches by 1 inch of the panel missing. -in the hallway of the secured unit on Hall 100, a circular shape, approximately three inches in diameter, was compressed, so that the floor was uneven. -by the left door to the main dining room, the Azelea room, there were two eighteen by eighteen inch tiles broken and cracked. -by the right door to the main dining room, the Azelea room, the tile was not flush/even with the surrounding tiles, creating a dip of approximately one centimeter where residents would enter the dining room. -there was no transition strip between the tile and the laminate flooring near room [ROOM NUMBER] on Hall 200. An interview was conducted on May 22, 2024 at 8:37 a.m. with the Maintenance Manager (staff #430), who stated that anyone can put in a request for a repair and he prioritizes repairs based on resident safety, how it impacts the residents' stay, and anything to do with safety, should be repaired immediately. He stated that safety risks included falls and could include rust if the resident came into contact with the rust. He stated that he inspects the facility daily, and that he has laminate flooring, transition strips, and paint in stock. He stated that drain covers should be screwed down to make sure that the drain is covered. He also, stated that he has a company credit card and can purchase supplies when needed to make repairs. During the interview, a walk through the facility was conducted, so staff #430 could observe the above issues. He acknowledged that the uneven and broken flooring could be a fall risk for the residents and he had noticed the circular compressions in the floor sometime in the last six months. It was observed that he had begun fixing some of the tiles on Hall 100 by filling the broken and cracked areas with resin. He stated that he had removed the transition strip and would be replacing it before the end of the day. At approximately 9:21 a.m., the Environmental Engineer (staff #611) joined the interview. Staff #611 stated that he thought the circular compressions in the floor were a result of the drain below the flooring and the unevenness of the floor could be fixed. Staff #611 viewed the brown rust color on the bathroom doorframe on Hall 100 and stated that it was rust and could cause an infection to residents. He also acknowledged residents could be injured because the drain cover was bit secured to the shower floor. An interview was conducted on May 23, 2024 at 11:06 a.m. with the Administrator (staff #605), who stated that he supervises the maintenance department and was updated about the floors. He has been trying to fix the floor in the residents' rooms as needed and thinks some of the flooring in the facility is a potential risk for safety. It is expectation that staff put in requests for repairs and the repairs are done daily/weekly. The facility policy, Resident Safety: Safety and Supervision of Residents dated January 1, 2024 states that the facility strives to make the environment as free from accident hazards as possible. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes. The Maintenance Manager job description states that the Maintenance Manager must have knowledge of all areas facility maintenance and is responsible for the maintenance of the physical environment, including offices, common areas, and resident rooms.

Based on personnel file review, staff interview, and facility documentation and policy review, the facility failed to ensure the activities program was directed by a qualified professional. The deficient practice could result in the activities provided not meeting the assessed needs of the residents. Findings Include: A review of the personnel file for the role of activity manager (staff #432) was conducted on May 21, 2024. However, review of file did not reveal evidence that staff #432 possessed the qualifications required for the role of activities director. An interview was conducted on May 21, 2024 at 1:12 P.M. with staff #498, human resource manager. Staff #498 stated that the role of activity manager had no additional qualifications needed beyond the scope of qualifications that staff #432 had. She stated that the facility did not require licensure or registration for the activity manager. An interview was conducted on May 21, 2024 at 2:14 P.M. with staff #605 , administrator. Staff #605 stated that he was aware that the current activities director was not licensed or registered, but stated that staff #432 was in the process and getting ready to test soon. He further stated that the facility already had a performance improvement plan in place and that the Occupational Therapist, staff #536 was currently supervising the activities director since January 2024 until her licensing/ registration has been completed. An interview was conducted on May 22, 2024 at 8:03 A.M. with staff #432, activity manager. Staff #432 stated that she was the activity manager and that she had 4 additional staff members assisting in the activities department. She stated that she had initially started with the facility by working in the kitchen for 3 years and then had worked as an activity assistant for 2 years and further stated that she had been in the role of activity manager for 7 years. Staff #432 stated that she was certified at one point, but had lost the certification 2 years ago. She stated that she had been working on recertification and was scheduled to test on May 24, 2024. She stated that she had maintained her continuing education requirements in spite of not being certified. Additionally, staff #432 stated that she had maintained her active membership with the Arizona state professional's organization for activity directors. She stated that her current activity calendars were being reviewed by the therapy department, but could not recall when this process had started. She stated that there 2 therapist providing oversight, one was staff #533 and she was unable to recall the name or appearance of the other therapist, who was later identified as staff #536. She stated that staff #533 would review her calendar and at times make recommendations as they pertain to tasks involving therapy. An interview was conducted on May 22, 2024 at 8:22 A.M. with staff #533, PTA (Physical Therapy Assistant). Staff #533 stated that there is coordination between activities and therapy regarding outdoor activities and getting in or out of activities. He stated that he was not the supervisor for staff #432. He stated that he likes to look at the ideas the activity department brings forward and reviews them for safety. However, he stated that he only reviews the calendar and nothing else. He stated that he started reviewing the calendars in October of 2023. He further stated that the other staff member providing additional oversight was staff #536. An interview was conducted on May 22, 2024 at 8:28 A.M. with staff #536, OT (occupational therapist). Staff #536 stated that he had been checking on how the activities program is run and was involved in coordinating the program with the current activity's director. He stated that he was meeting with the activity manager approximately every two weeks, since the day he started with the facility back in April of 2024. An interview was conducted on May 22, 2024 at 10:03 A.M. with staff #605 (administrator). Staff #605 stated that he was uncertain when the activity manager licensure/ certification had lapsed. He stated that it was an identified deficiency when a home office audit was conducted at the beginning of the year. He further stated that he was unsure of the exact date when the OT started providing the oversight for the activity manager. Staff #605 further stated that his expectation is that staff who require licensure and or registration should never have it lapse. He stated that the risk for not having a licensed and or registered activity manager could include the scheduling of activities that might be inappropriate for the residents. A review of the facility policy entitled Hiring and Rehiring Employees dated January 1, 2024 revealed that the company policy is to hire qualified applicants. The policy further states that in order to qualify for a position, the facility looks at eligibility, qualifications, skills, attitude, dependability, cooperation and other legitimate business considerations. A review of the policy entitled Administrative Policies: Licensure, certification and registration of personnel dated January 1, 2024 revealed that personnel who require a license, certification or registration to perform their duties must present verification of the aforementioned to the human resources director/ designee prior to or upon employment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, staff interviews, and policy review, the facility failed to ensure that one resident (#17) was free from sexual abuse from another resident (resident #51). The deficient practice could result in further incidents of resident to resident abuse. Findings Include: -Resident #17 (Alleged victim) was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, dementia, depression, anxiety, chronic kidney disease, and type 2 diabetes. A behavioral care plan with a start date of August 29, 2023 revealed resident #17 has impaired cognitive function, impaired decision-making related to Alzheimer's dementia with noted interventions of resident needing approaches that maximize involvement in daily decision making and activity limit choices, use cueing, task segmentation, instructions, and to keep the residents routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident has major cognitive impairment. -Resident #51 (Alleged perpetrator) was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, anxiety, hypertension, type-2 diabetes, and hyperlipidemia. A behavioral care plan with a start date of January 5, 2023 revealed resident #51 was at risk for behavior problems related to end stage dementia, as evidenced by verbal aggression towards staff and groping female residents without their consent, with noted interventions of identifying behavioral triggers, and keep the resident at arm's length from other female residents. Review of the facilities Reportable Event Record revealed that on the afternoon of April 1, 2024, resident #17 was seated in a day room where the resident's watch TV when a Certified nursing assistant (CNA/staff #119) entered and observed resident #51 with his hand down resident #17's shirt, appearing to be touching her breast. The CNA (CNA/staff #119) removed resident's #51 hand from resident #17's shirt, which made resident #51 upset and visibly agitated towards the CNA (CNA/staff #119). An interview was conducted with a CNA (CNA/staff #119) on April 9, 2024, at 11:06 a.m., Staff #117 stated that on the day of the incident they were working as a med tech and was passing medications when they observed resident #51 rubbing the shoulders of resident #17, and had his hand in her shirt. The CNA further stated that the resident can be physical too, and likes to grab at staff members also. In an interview conducted with the Director of Nursing (DON/staff #200) on April 9, 2024 at 2:30 p.m. The DON stated that resident #51 has lots of behaviors, verbally sexually suggestive among others. The DON also stated that the care plan states not to allow the resident within arms reach of female residents. The DON also stated that her expectation is that the staff separate the resident's immediately which they did and report it to management. Review of the facility's policy titled 'Resident rights/dignity: Abuse, Neglect, exploitation or misappropriation dated 2022 revealed the objective of the facility is to provide a safe haven for our residents through preventative measures that protect every resident's right to freedom from abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure one resident (#32) and/or their representative was informed of the risks and benefits of psychotropic medications prior to administration. The sample size was 20. The deficient practice could result in residents and/or their representatives not being fully informed of the risks, benefits and alternatives to proposed treatment. Findings include: -Resident #32 admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease and post traumatic seizures. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status (BIMS) assessment, indicating intact cognition. The resident reported no feelings of depression, and he displayed no symptoms of psychosis or behaviors. A physician ' s order dated 11/30/22 revealed quetiapine fumarate (antipsychotic) 25 mg (milligrams): give one tablet at bedtime for traumatic brain injury (TBI). Review of the November 30, 2022 Medication Administration Record (MAR) revealed the medication was administered in accordance with the physician ' s order. The December 1 through 6, 2022 MAR revealed the resident received antipsychotic medication per orders. A psychotropic medication care plan dated 12/06/22 related to (traumatic brain injury) TBI had a goal for the resident to be/remain free from psychotropic drug-related complications. Interventions included to administer psychotropic medications as ordered by the physician. Monitor for side effects and effectiveness every shift. However, an informed consent relating to the risks and benefits of quetiapine fumarate was not identified in the resident's clinical record until 12/07/22. Another physician's order dated 12/12/22 included fluoxetine HCl (antidepressant) 20mg: give one capsule by mouth in the morning for depression. Review of the December 13 through 31, 2022 MAR revealed the resident received the antidepressant in accordance with the physician ' s orders. However, an informed consent relating to the risks and benefits of fluoxetine HCl was not identified in the resident's clinical record until 01/04/23. On 01/11/23 at 8:41 a.m. an interview was conducted with a Licensed Practical Nurse (LPN/staff #6). She stated that once an order is obtained for psychotropic medication, nursing will explain the risks and benefits of the medication, alternatives to drug therapy and non-pharmacologic interventions. She stated that if the resident was alert and oriented x4, she would obtain the consent from the resident. If they can give verbal consent, she will complete an e-signed consent for them. She stated that the consent would be added to the resident's medical record instantaneously. She stated that the e-consent does not require two witnesses for a verbal consent from the resident. An interview was conducted on 01/11/23 at 1:10 p.m. with the Director of Nursing (DON/staff #41). She stated that the provider will explain the risks and benefits of psychotropic medications to the resident prior to administration of the medication. She stated that nursing staff would be responsible for education and obtaining the consent after that. The Psychotropic Medication Use Policy, revised 11/28/16, included the facility should comply with the psychopharmacologic dosage guidelines created by the Centers for Medicare and Medicaid Services (CMS), the State Operations Manual, and all other applicable law relating to the use of psychopharmacologic medications including gradual dose reductions. Facility staff should inform the resident and/or representative of the initiation, reason for use, and the risks associated with the use of psychotropic medications, per facility policy or applicable state regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure an advanced directive was accurate for one resident (#54). The sample size was 20. The deficient practice could result in residents ' wishes not being honored. Findings include: Resident #54 admitted to the facility [DATE] with diagnoses that included Alzheimer ' s disease with late onset, dementia in other diseases classified elsewhere, without behavioral, psychotic, or mood disturbance and major depressive disorder, recurrent, in remission. An admission progress note dated [DATE] at 3:27 p.m. included that the resident had been admitted via medical transport. An Advanced Directive Statement dated [DATE] revealed the resident ' s directive included cardiopulmonary resuscitation measures (CPR), artificial hydration, hospitalization, antibiotic therapy, and pain medication. The resident signed the directive herself on [DATE]. A facility representative witnessed the directive on the same date. A Prehospital Medical Care Directive dated [DATE] revealed a Do Not Resuscitate (DNR) status. The document was noted with the resident ' s electronic signature which was time stamped at 4:33 p.m. The document was signed by a Licensed Practical Nurse (LPN/staff #59) at 4:32 p.m. and witnessed by an LPN (staff #32.) The witness statement acknowledged that the signer was present when the directive was signed (or marked) and that the resident/responsible party appeared to be of sound mind and free from duress. The electronic signature was time stamped at 4:32 p.m. A physician ' s order dated [DATE] included for DNR status. The admission Minimum Data Set assessment dated [DATE] revealed the resident scored 5 on the Brief Interview for Mental Status, indicating severe cognitive impairment. An interview was conducted on [DATE] at 11:37 a.m. with an LPN (staff #97). She stated that the admitting nurse provides education regarding an advance directive. She reviewed both advanced directives and stated that if the resident were to code, she would consider her a DNR. She stated that the provider had ordered a DNR. On [DATE] at 1:58 p.m. an interview was conducted with the Director of Nursing (DON/staff #41) and a Clinical Resource representative (staff #117). Staff #41 stated that an advance directive was completed upon admission. She stated that no nursing documentation would be expected when education was provided to the resident and/or their representative. She stated that they just attempt to get a declaration. She stated that if the resident is not alert and oriented, the responsible party would be contacted and the request would be made. She stated that was her expectation. She reviewed the advance directive signed by the resident and stated that the document would be honored, that it was a viable document. The DNR designation was reviewed and she stated that if the resident ' s advance directive election had changed, there should be documentation to indicate that was the case. She stated that once a discrepancy was identified, she would expect the nurse to reach out to the family/representative and ask them to clarify. Staff #117 stated that it did not meet the expectation for a nurse to have made the code designation. The Advanced Healthcare Directives Policy, revised 08/19, included that it is the policy of the facility to recognize the right of individuals to control decisions related to his/her medical care. This includes the right to consent, to refuse or to alter treatment plans and formulate advanced directives. Advanced directives executed in accordance with the applicable state law will be honored by the facility. At the time of admission, the Admissions Director/designee must determine whether a resident has executed an advanced directive or has given other instructions to indicate what care he/she desires in case of subsequent incapacity. The admitting nurse is responsible for documenting in the resident ' s medical record the discussion and any advanced directive that the resident executes, including the Arizona Prehospital Medical Care Directive (orange sheet). If a resident is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advanced directive, the facility may give the information to the resident ' s representative in accordance with state law. As long as an individual is competent and able to communicate, he/she will make their own decisions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, policy review and CMS regulations, the facility failed to ensure that one resident (#56) received a timely Advanced Beneficiary Notification, within 48-hours, for termination of part A Medicare services. Findings include: Resident #56 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia, Major Depressive Disorder-recurrent / moderate, and Primary insomnia. Review of the MDS (Minimum Data Set) for resident #56, dated December 4, 2022, revealed a BIMS (Brief Interview of Mental Status) score of 01, indicating severe cognitive impairment. Record review of the nursing progress notes revealed that resident #56 remained in the facility on private pay after termination of Medicare Part A services. On January 10, 2023 at 2:01 pm a form, SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review, was provided by the facility. The form included Part A services last covered day was on December 7, 2022. Per the document, the notice was signed via verbal signature on December 8, 2022 by the Director of Social Services. Further record review revealed no evidence that resident #56 received Advanced Beneficiary Notification or Notice of Medicare Non-Coverage timely. Review of the nursing progress notes from December 2022 through January 2023 did not reveal information regarding Advanced Beneficiary Notification or Notice of Medicare Non-Coverage. Further record review revealed no documentation that an Advanced Beneficiary Notification or Notice of Medicare Non-Coverage had been discussed or signed. An in-person interview was conducted on January 11, 2023 at 9:00 am, with staff # 54 DOSS (Director of Social Services). She stated that the process for the Advanced Beneficiary Notification, included resident notification 2 to 3 days prior to end of services. Staff would document in notes, if they are unable to reach the representative. An in-person follow-up interview was conducted with staff # 54 (Director of Social Services) on January 11, 2023 at 11:32 am. She stated, with a telephonic ABN, social service staff can sign on behalf of the representative, without a witnessed signature. She stated, the untimely Advanced Beneficiary Notice for resident # 56 was an oversight. An in-person interview was conducted on January 11, 2023 at 12:30 pm with the administrator, staff # 65 (Administrator). He stated that the Advanced Beneficiary Notice and the Notice of Medicare Non-Coverage are reviewed with residents and or representatives, 48-hours prior to end of skilled services. The stated identified risk is non-payment for the resident's stay. He stated, notes regarding notification review and signature is not required, per the facility guidelines but is best practices. A review of the facility policy that was revised in 2022, revealed that 2 days prior to end of skilled services, the facility will issue a Notice of Medicare Non-Coverage. The policy states that an Advanced Beneficiary Notice will be issued when a Medicare Part A stay will end and that the facility is expected to maintain compliance with Medicare Beneficiary Notices per CMS (Centers for Medicare and Medicaid Services) guidelines. Further record review revealed no documentation that an Advanced Beneficiary Notification or Notice of Medicare Non-Coverage had been discussed or signed. An in-person interview was conducted on January 11, 2023 at 9:00 am, with staff # 54 DOSS (Director of Social Services). She stated that the process for the Advanced Beneficiary Notification, included resident notification 2 to 3 days prior to end of services. Staff would document in notes, if they are unable to reach the representative. An in-person follow-up interview was conducted with staff # 54 (Director of Social Services) on January 11, 2023 at 11:32 am. She stated, with a telephonic ABN, social service staff can sign on behalf of the representative, without a witnessed signature. She stated, the untimely Advanced Beneficiary Notice for resident # 56 was an oversight. An in-person interview was conducted on January 11, 2023 at 12:30 pm with the administrator, staff # 65 (Administrator). He stated that the Advanced Beneficiary Notice and the Notice of Medicare Non-Coverage are reviewed with residents and or representatives, 48-hours prior to end of skilled services. The stated identified risk is non-payment for the resident's stay. He stated, notes regarding notification review and signature is not required, per the facility guidelines but is best practices. A review of the facility policy that was revised in 2022, revealed that 2 days prior to end of skilled services, the facility will issue a Notice of Medicare Non-Coverage. The policy states that an Advanced Beneficiary Notice will be issued when a Medicare Part A stay will end and that the facility is expected to maintain compliance with Medicare Beneficiary Notices per CMS (Centers for Medicare and Medicaid Services) guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, staff interviews and review of facility policy and procedure, the facility failed to ensure that an updated pre-admission screening and resident review (PASRR) was completed for one resident (#14). The deficient practice could lead to residents not receiving needed care and services. Findings include: Resident #14 was admitted [DATE] with diagnoses to include the primary diagnosis of Covid 19 and secondary diagnoses of schizoaffective disorder bipolar type, bipolar II disorder, generalized anxiety disorder, major depressive disorder and dementia with other behavior disturbance. The diagnosis of dementia is listed as having an onset of October 1, 2022. All the diagnoses were present upon admission. Review of the clinical record revealed a completed level 1 PASRR dated October 10, 2012. The level 1 PASRR revealed that the resident had serious mental illness and a level 2 PASRR should be completed. A letter dated October 19, 2012 from the PASRR coordinator revealed that that the resident was found to have a primary diagnosis of dementia at that time. The letter revealed that the PASRR coordinator should be made aware of any significant changes with the residents medical or psychiatric conditions. No evidence of any further PASRR documentation was found in the resident clinical record. Review of her minimum data set (MDS) dated [DATE] revealed that the resident scored a 5 on her brief interview for mental status (BIMS) indicating severe cognitive impairment. The diagnoses of non-Alzheimer's dementia, anxiety disorder, depression, bipolar disorder and schizophrenia were listed as active diagnoses on the MDS. A Physicians progress note dated January 9, 2023 revealed that the following problems were reviewed: Schizoaffective disorder - Onset: 09/29/2022 Schizoaffective disorder, bipolar type - Onset: 02/28/2020 Moderate recurrent major depression - Onset: 02/06/2019 Bipolar II disorder - Onset: 10/03/2018 Generalized anxiety disorder - Onset: 06/03/2021 An interview was conducted with the Social Services Director (SSD/ staff# 54) and the Director of Nursing (DON/ staff #41) on January 11, 2023 at 9:18 AM. Staff #54 stated that she and the DON were responsible to complete the PASRR process for the facility. She stated that updated level 1 PASRR's were completed with the help of the DON. If no update is required, the existing PASRR provided by the hospital of transferring facility would be uploaded in to the residents record. Staff #54 stated that she did not know the requirements for PASRR. She stated that she was aware that the DON reviewed the PASRR that was present on resident admission. The DON/Staff #41 stated that a level 1 PASRR should be done annually. She further stated that resident #14's paperwork had not been updated since 2012 and this does not meet the requirement for PASRR. She stated that she was not aware that a PASRR was to be done annually until very recently. She also stated that a new PASRR should be completed with any new mental health diagnoses. This resident not only has not had a new PASRR since her original admission in 2012 but she has also had several new mental health diagnoses since her readmission in 2018 which required a new PASRR. The DON stated that the current PASRR for resident #14 does not meet the facility requirement for PASRR's. Review of the facility policy Pre- admission Screening and Resident Review (PASRR. 2020) revealed that the facility was responsible to make referrals for a Level II PASRR. The policy further revealed that an updated PASRR Level I screening must be conducted for each resident in the facility who had a serious mental illness not less than annually.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Regarding Resident #56 Findings include: -Resident #56 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with other behavior disturbances, major depressive disorder, and primary insomnia. Review of admission nursing assessment dated [DATE] at 2:11 p.m., stated no open lesion on skin. However, in another section of the assessment included a note which stated the resident had a small scab on the chin. Further review of the assessment did not include measurement or assessment of the scab. Review of the facility form, Total Body Skin Assessment, dated December 9, 16, 20, 2022 and January 6, 2023 stated resident has no new wounds. Review of physician order dated January 2, 2023 stated to schedule an appointment for patient with a dermatologist for evaluation and treatment of the wound on the chin. However, record review revealed no evidence that the appointment has been set up. On January 9, 2023 at 12:12 p.m., during an observation rounds, resident #56 was observed with a wound to her chin. Review of nursing progress notes dated January 9, 2022 at 4:20 PM, stated the resident had an abrasion/sore on her chin that she picks at. Review of the resident's comprehensive care plan did not include the actual impairment to skin integrity related to the wound on the chin. Review of medication and treatment administration records dated December 2022, and January 2023, revealed no evidence of treatment for the wound on the chin. A second observation of resident #56 was conducted on January 12, 2023 at 8:05 a.m. Resident #56 was in the dining room sitting in the chair with no unusual behavior exhibited. She had a dime-sized wound on her chin, partially covered with a reddish/brownish scab. The surrounding tissue of the wound was reddened with scant amount of dried blood. A follow up interview was conducted with a certified nursing assistant (CNA/ staff #113) who was present in the dining room. Staff #113 stated she was familiar with resident #56 and that the wound on the resident's chin was almost healed but the resident picked on it. Staff #113 stated she keeps the resident's nails short and clean to help minimize the skin damage on her chin. An interview was conducted on January 12, 2023 at 8:18 a.m. with a licensed practical nurse (LPN/staff #97). She stated she was familiar with resident #56 and that the resident is independent with activities of daily living (ADLs), ambulatory using a walker. This staff member also stated the resident is awake most of the night. Staff #97 stated the wound/scab on the resident's chin was present during transfer from another unit. The wound heals then come back because she picks on it constantly, almost every day. She stated she redirected the resident and keeps the nails short, but the resident does not remember. The LPN stated she did not include the wound on the chin during the weekly skin assessment because it was not a new wound. She stated the wound on the chin was already present when the resident was transferred from another unit. Record review revealed no documentation of resident's behavior or care plan related to the changing status of the wound on the chin. Following staff #97's interview, it was noted that the resident's picture was placed by the entrance of her room. In the picture, it was noted that a scab (a size of a grain of rice) was present on resident's chin. An interview was conducted with a registered nurse consultant (RN/staff #117) on January 12, 2023 at 2:06 p.m. She stated that her expectation when a wound is identified or changing, the nursing staff must notify the physician and monitor the size weekly. Staff #117 stated the care plan for the wound should be developed at the time the wound is identified. The Care Plans, Comprehensive Person-Centered policy revised December 2016, included a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet resident ' s physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. Based on clinical record review, staff interviews and review of policy, the facility failed to ensure two residents (#51 and #56) care plans were updated/revised to meet their changing needs. The sample size was 20. The deficient practice could result in inadequate care and/or not meeting the needs of the resident. Findings include: -Resident #51 admitted to the facility 12/20/21 with diagnoses including paroxysmal atrial fibrillation, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease and rheumatoid arthritis. The admission Nursing Review dated 12/20/21 at 4:16 p.m. revealed the resident had no pressure sores, and that his skin was intact. Review of the Baseline Care Plan dated 12/20/21 at 4:44 p.m. included potential for skin breakdown/pressure ulcers due to decreased mobility and incontinence. No goal or interventions were identified in the plan of care. A potential risk for pressure ulcer development care plan initiated on 01/09/22 related to immobility had a goal for the resident to have intact skin, free of redness, blisters or discoloration. Interventions included to follow facility policies/protocols for the prevention/treatment of skin breakdown. The significant change MDS assessment dated [DATE] revealed the resident scored 7 on the brief interview for mental status, indicating severe cognitive impairment. He required extensive one-person physical assistance for most activities of daily living, including bed mobility, and he had no pressure ulcers/injuries. A Skin & Wound Evaluation dated 02/02/22 revealed a facility acquired deep tissue injury (DTI) to the resident's right lateral thigh. The wound measured at 1.7 centimeters (cm) x 2.2 cm. The wound bed was described as epithelial, 100% of wound covered, surface intact. Additional care included alternating pressure mattress and pressure reduction wheelchair cushion, nutrition/dietary supplementation and assistance with repositioning every 2 hours and as needed (PRN). Review of the potential risk for pressure ulcer development care plan dated 02/02/22 revealed an update to include a deep tissue injury to the resident ' s right thigh. The goal was for the resident's pressure ulcer to show signs of healing and remain free from infection. Interventions included to assess/record/monitor wound healing every week. The dietary progress note dated 02/04/22 at 6:44 p.m. included that the resident received 4 ounces of oral nutritional supplements 4 times per day with 100% intake. The note indicated that current meal and supplement intakes combined appeared to be meeting the estimated energy needs for wound healing. The Skin & Wound Evaluation dated 02/18/22 revealed a deteriorating unstageable pressure ulcer which measured 3.9 cm x 2.8 cm. The wound bed was described as 80% slough, with light serosanguineous exudate, the edges were noted as epithelialization with blanching and erythema of the surrounding tissue. Additional care remained the same. Review of the resident's potential risk for pressure ulcer development care plan did not include updated or revised interventions to address the changing wound status. Review of the Skin & Wound Evaluation dated 03/07/22 revealed a deteriorating unstageable pressure ulcer measuring 4.6 cm x 2.3 cm, with 90% of the wound bed filled with slough. Light serosanguineous exudate was noted, with edges identified as epithelialization with blanching and erythema of the surrounding tissue. Additional care remained the same. The Skin & Wound Evaluation dated 03/18/22 included a deteriorating unstageable pressure ulcer measuring 4.2 cm x 2.6 cm x 0.5 cm with 100% of the wound bed filled with slough. The wound exhibited warmth, and no exudate was identified. Wound edges were defined as epithelialized and surrounding tissue identified as blanching. The peri-wound temperature was described as warm. Additional care remained the same. A physician ' s order dated 03/21/22 included cephalexin capsule (antibiotic) 500 milligrams (mg): give 1 capsule two times a day for wound infection for 5 days. Further review of the resident's care plan did not reveal implementation of additional interventions or revisions to reflect the resident's changing needs. On 01/11/23 at 9:01 a.m. an interview was conducted with the Assistant Director of Nursing/wound nurse (staff #109). She stated that pressure ulcer interventions include a pressure reduction mattress, and if the resident is at high risk for developing wounds an overlay will be ordered, pressure relieving boots and dietary review. She stated that the facility does not have a repositioning program. She stated that per policy and PRN, every resident will receive a pressure-reduction cushion. She stated that if a resident developed a pressure ulcer, the care plan would be updated to reflect that. She stated that the care plan would be updated and revised if there were any wound changes, if it was resolved, or if there was a new wound classification. An interview was conducted on 01/11/23 at 1:27 p.m. with the Director of Nursing (DON/staff #41). She stated that when a resident has a new pressure ulcer they bring it to a stand-up meeting and the physician is notified. She stated that a new pressure ulcer/pressure injury would trigger for care planning. She stated that a change in wound status would not necessarily trigger new interventions in the care plan if the interventions that were in place were still appropriate. The Care Plans, Comprehensive Person-Centered policy revised December 2016, included a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure one resident (#183) did not receive oxygen without a physician ' s order. The sample size was 20. The deficient practice may increase the risk for residents to receive unnecessary medications. Findings include: Resident #183 was readmitted to the facility on [DATE] with pleural effusion, not elsewhere classified, acute and chronic respiratory failure with hypoxia and acute on chronic diastolic (congestive) heart failure. A baseline care plan dated 03/09/22 included oxygen related to difficulty breathing with increased activity related to effects of congestive heart failure, chronic obstructive pulmonary disease, pneumonia, etc. The goals included to maintain a normal breathing pattern as evidenced by non-labored respirations, normal skin color, and regular respiratory rate/pattern and to maintain a pulse oximetry level at or above 90%. Physician's orders dated 03/09/22 included albuterol sulfate hydro fluoroalkane aerosol solution (bronchodilator) 108 (90 base) mcg (microgram)/act (actuate). Inhale 2 puffs orally every hour as needed for shortness of breath/wheezing and for oxygen saturation levels were to be obtained in the morning. The physician's orders did not include administration of oxygen. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 14 on the Brief Interview for Mental Status, indicating intact cognition. The resident required extensive one-person physical assistance with most activities of daily living and she received oxygen prior to admission, while not residing in the facility. Review of the Oxygen Saturation Summary dated March 2022 revealed the resident received oxygen for more than 20 days. The resident ' s oxygen saturation rates were above 90% in all instances. The April 2022 Oxygen Saturation Summary revealed the resident received oxygen for 2 days. The resident's oxygen saturation rates were above 90% on both dates. On 01/13/23 at 8:09 a.m. an interview was conducted with a Licensed Practical Nurse (LPN/staff #103). She stated that oxygen administration requires a doctor's order, unless the nurse is being proactive in an acute situation. She stated that it would not be appropriate to use the oxygen on a regular basis without an order. An interview was conducted on 01/13/23 at 9:57 a.m. with the Director of Nursing (DON/staff #41). She stated that a physician ' s order should be obtained prior to administration of oxygen, unless it was an emergent situation. She stated that it would not meet her expectation for oxygen to be administered for several weeks prior to obtaining an order. She stated that risks of administering oxygen unnecessarily would include retention of carbon dioxide and worsening of the medical condition. She stated that it did not meet her expectations. The Medication and Treatment Orders Policy, revised April 2014, included orders for medications and treatments will be consistent with principles of safe and effective order writing. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. This includes standing orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of facility policy, the facility failed to ensure that a discharge summary for one resident (#3) contained a recapitulation of the resident's stay and all pre and post discharge medications. Findings include: -Resident #3 was admitted on [DATE] with diagnosis that included COVID-19, traumatic subarachnoid hemorrhage, periprosthetic fracture around internal prosthetic right knee joint, hypertensive chronic disease with stage 1 through stage 4, and type 2 diabetes mellitus. Review of the physician order summary revealed an order for occupational therapy and physical therapy 5 times a week for eight weeks starting September 29, 2022 for therapeutic exercises and gait training. A 5-day MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 11, indicating moderately impaired cognition. The assessment included that the resident required extensive physical assistance from two staff members for transfer, bed mobility, toilet use, and one-person physical assistance with personal hygiene, and dressing. Review of nursing progress notes dated November 10, 2022 at 1:00 p.m., stated resident required minimum physical assistance with bed mobility, transfer, supine to sitting position, and sitting to standing position. The note included the resident required stand by assistance with hygiene, and supervision with wheelchair mobility. Review of a provider Discharge summary dated [DATE] at 12:00 a.m., stated discharge planning for possible discharge to home tomorrow (December 30, 2022). The provider notes included patient is currently under long-term care, compliant with medications and cooperative with nursing care. Further, the notes stated the resident is discharging home with her daughter and that discharge instruction was provided. A nursing progress notes dated December 30, 2022 at 2:39 p.m., stated the patient was discharged home with daughter. The notes included discharge instruction/medications were reviewed to patient and daughter. Further record review revealed no evidence of nursing discharge instruction that contained a recapitulation of the resident's stay and the list of all pre and post discharge medications. On January 10, 2023 at 8:00 a.m., a document request for the Discharge summary dated [DATE] was requested from the facility. The facility failed to provide evidence of the nursing discharge instruction/summary that contained a recapitulation of the resident's stay and the list of all pre and post discharge medications. An interview was conducted with a registered nurse consultant (RN/staff #117) on January 12, 2023 at 2:06 p.m. She stated that her expectation included nursing staff to complete a discharge summary including the reconciliation of all pre and post medications. Staff #117 stated if the discharge summary and medications reconciliation is not completed, there is no continuity of care and the resident might not get the medication they needed. She stated if a discharge summary is not completed, the resident maybe at risk of missing the required follow up services. On January 13, 2023 at 2:30 p.m., a policy for discharge summary and discharge process were requested. The facility failed to provide the policies requested. According to CMS (Center for Medicare and Medicaid Services) regulations §483.21(c)(2) Discharge Summary, the following must be included: a recapitulation of the resident's stay, reconciliation of all pre-discharge and post-discharge medications, a post -discharge plan of care that is developed with the participation of the resident, and a final summary of the resident's status at the time of discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy, revealed the facility failed to ensure one resident (#56) received treatment and services in accordance with professional standards of practice. The deficient practice could result in resident not receiving the treatment based on their assessed need. Findings include: -Resident #56 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with other behavior disturbances, major depressive disorder, and primary insomnia. Review of admission nursing assessment dated [DATE] at 2:11 p.m., stated no open lesion on skin. However, in another section of the assessment included a note which stated the resident have a small scab on the chin. Further review of the assessment did not include measurement or assessment of the scab. A physician progress note dated September 15, 2022 at 9:00 a.m., stated the resident has a facial lesion on the chin that does not heal, acute, that it could be cancer or just a lesion. The note included the physician assured the nurse it does not need to be biopsied or removed. Further record review revealed no further diagnostic assessment to support the physician's diagnoses. Review of the facility form, Total Body Skin Assessment, dated December 9, 16, 20, 2022 and January 6, 2023 stated resident has no new wounds. A physician note dated December 17, 2022 at 1:35 p.m., stated the resident has a lesion on the chin area that has been present for several weeks and doesn't heal. A record review revealed no additional assessment or physician notification of the changing wound on the resident's chin. Review of physician order dated January 2, 2023 stated to schedule an appointment for patient with a dermatologist for evaluation and treatment. However, record review revealed no evidence that the appointment has been set up. On January 9, 2023 at 12:12 p.m., during an observation rounds, resident #56 was observed with a wound on her chin. Review of nursing progress notes dated January 9, 2023 at 4:20 PM, stated the resident have an abrasion/sore on chin that she picks at. Review of medication and treatment administration records dated January 2023, revealed no evidence of treatment for the wound on the chin. Further record review revealed no assessment and no physician notification of the changing wound status on the resident's chin. A second observation of resident #56 was conducted on January 12, 2023 at 8:05 a.m. Resident #56 was in the dining room sitting in the chair with no unusual behavior exhibited. She has a dime sized wound on her chin, partially covered with a reddish/brownish scab. The surrounding tissue of the wound was reddened with scant amount of dried beige crust. A follow up interview was conducted with a certified nursing assistant (CNA/ staff #113) who was present in the dining room. Staff #113 stated she was familiar with resident #56 and that the wound on the resident's chin was almost healed but the resident picked at it. An interview was conducted on January 12, 2023 at 8:18 a.m. with a licensed practical nurse (LPN/staff #97). She stated she was familiar with the resident, and that the wound/scab on the resident's chin was present when she was transferred from another unit. The LPN stated she did not include the wound on the chin during the weekly skin assessment because it was not a new wound. She stated the wound on the chin was already present when the resident was transferred from another unit. Further record review revealed no nursing documentation, no assessment and no physician notification of the changing wound on the chin. Following staff #97's interview, it was noted that there was a picture of the resident on the entrance of her door. On the picture, the resident has a scab on the chin the size of a grain of rice. An interview was conducted with a registered nurse consultant (RN/staff #117) on January 12, 2023 at 2:06 p.m. She stated that her expectation when a wound is identified or if they are changing, the nursing staff must notify the physician and monitor the size weekly. A facility policy, Skin/Wound Care Protocol, with a review dated May 2014, included the goal of a preventative skin program is to maintain skin integrity and provide guidelines for skin care. The procedure included all residents are assessed for risk of skin breakdown within 24 hours of admission, and a nurse will complete and document a total body skin assessment. The procedure stated a narrative nurse's documentation will include skin color, blisters, scabs, breaks or sores on the skin and pain or swelling anywhere on the body. Further, the procedure stated a licensed nurse completes a weekly skin assessment and documents the assessment on the weekly skin/pain assessment form which becomes a part of the resident's permanent clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and policy, the facility failed to ensure one resident (#54) was provided assistance with obtaining audiology services. The sample size was 20. The deficient practice may contribute to the resident ' s confusion and agitation. Findings include: Resident #54 admitted to the facility on [DATE] with diagnoses including Alzheimer ' s disease, dementia in other diseases classified elsewhere and major depressive disorder. An admission Nursing Review dated 07/06/21 revealed the resident had impaired hearing. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 5 on the Brief Interview for Mental Status (BIMS) assessment, indicating severe cognitive impairment. The resident was assessed to have minimal difficulty hearing and that she displayed no behavioral symptoms towards herself or others. A communication problem care plan initiated 08/03/21 related to a hearing deficit had a goal for the resident to maintain her current level of communication function by responding to yes or no questions. Interventions included to anticipate and meet the resident ' s needs. A nursing progress note dated 05/13/22 at 12:21 p.m. included that the resident was alert and oriented to person and place (x2) with intermittent confusion. The note indicated that the resident was severely hard of hearing and that she could become very agitated at times related to her hearing impairment. A nursing progress note dated 10/06/22 at 2:39 p.m. included that the resident had returned from an appointment with an ear, nose and throat (ENT) provider. Per the note, no new orders had been received and a follow-up appointment was recommended in one year. The note stated that the ENT did give a referral for hearing aid assistance and that the information was given to social services for follow-up. However, a review of the clinical record did not provide evidence that the resident had been provided an appointment for hearing aid evaluation or services. A physician note dated 10/27/22 at 12:28 p.m. included that upon interview that day, the resident was laying in bed, was verbal with clear speech. The note indicated that the resident was Spanish speaking and that a translator was assisting. Per the note, staff reported that the resident was hard of hearing and had trouble understanding what was being asked and that she responded with nonsense. The annual MDS assessment dated [DATE] revealed the resident scored 10 on the BIMS assessment, indicating moderate cognitive impairment. The resident was assessed to have moderate difficulty hearing and she displayed behavioral symptoms directed towards others and directed towards herself for 1 to 3 days in the 7 day look-back period. On 01/12/23 at 11:37 a.m. an interview was conducted with a Licensed Practical Nurse (LPN/staff #97). She stated that the resident had just come back from an ENT appointment. She stated that she did not know whether or not there had been a follow-up scheduled. She stated she had not asked the resident whether or not she would like a follow-up appointment. She stated that she had spoken about the resident obtaining hearing aids with another nurse and that they did not know whether the resident would keep them in or not. She stated that she did not know whether anyone had spoken to the resident about hearing aids. An interview was conducted on 01/12/23 at 1:58 p.m. with the Director of Nursing (DON/staff #41). She stated that at any point, she would expect nursing to notify the provider regarding the necessity for audiology services, She stated that she would anticipate that services would be coordinated with Hospice, the case manager and social services so that the resident could maintain her highest level of function. She stated that she thought that the interdisciplinary team and the resident ' s representative should have been involved. She stated that it should have been reviewed quarterly in the quarterly care conferences. She stated that issues with hearing could be contributing to agitation and confusion. She stated services should have been coordinated by everybody. On 01/13/23 at 8:59 a.m. an interview was conducted with the Director of Social Services (staff #54). She stated that ultimately, she was responsible to ensure that residents are getting annual hearing, dental and vision appointments. She stated that if an emergent situation were to arise, she would also arrange an appointment as needed. She stated that if the residents were not getting their appointments it would be because either she had not set one up or the resident had refused. She stated that the lack of dental services had been an error on her part. The Informing Residents of Health, Medical Condition and Treatment Options policy, revised December 2016, included that residents will be informed of their health, medical condition and options for treatment and/or care. The resident ' s Attending Physician, the facility ' s Medical Director, or the Director of Nursing Services will be responsible for informing the resident of his or her medical condition. Such information will include providing the resident with information, including his/her sensory and physical impairments, type of care or treatment recommended (based on the assessment and care plan), type of professional who will be providing the care or treatment and treatment alternatives or options.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, observations, staff interviews, facility documentation, and policy and procedures, the facility failed to ensure that one resident (#51) received care and services, consistent with professional standards of practice, to prevent, treat, and/or heal a pressure ulcer. The sample size was 20. The deficient practice could result in development, worsening, and/or infection of pressure ulcers. Findings include: Resident #51 admitted to the facility 12/20/21 with diagnoses including paroxysmal atrial fibrillation, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease and rheumatoid arthritis. The admission Nursing Review dated 12/20/21 at 4:16 p.m. revealed the resident had no pressure sores, and that his skin was intact. Review of the Baseline Care Plan dated 12/20/21 at 4:44 p.m. included potential for skin breakdown/pressure ulcers due to decreased mobility and incontinence. However, no goal or interventions were identified in the plan of care. A potential risk for pressure ulcer development care plan initiated on 01/09/22 related to immobility had a goal for the resident to have intact skin, free of redness, blisters or discoloration. Interventions included to follow facility policies/protocols for the prevention/treatment of skin breakdown. A physician ' s order dated 01/27/22 included monitoring the reddened, blanchable area to the right hip every shift for prevention. Review of the significant change MDS assessment dated [DATE] revealed the resident scored 7 on the brief interview for mental status, indicating severe cognitive impairment. He required extensive one-person physical assistance for most activities of daily living, including bed mobility, and he had no pressure ulcers/injuries. A Skin & Wound Evaluation dated 02/02/22 revealed a facility acquired deep tissue injury (DTI) to the resident ' s right lateral thigh. The wound measured at 1.7 centimeters (cm) x 2.2 cm. The wound bed was described as epithelial, 100% of wound covered, surface intact. Additional care included alternating pressure mattress and pressure reduction wheelchair cushion, nutrition/dietary supplementation and assistance with repositioning every 2 hours and as needed (PRN). Review of the potential risk for pressure ulcer development care plan dated 02/02/22 revealed an update to include a deep tissue injury to the resident ' s right thigh. The goal was for the resident ' s pressure ulcer to show signs of healing and remain free from infection. Interventions included to assess/record/monitor wound healing every week. The dietary progress note dated 02/04/22 at 6:44 p.m. included that the resident received 4 ounces of oral nutritional supplements 4 times per day with 100% intake.The note indicated that current meal and supplement intakes combined appeared to be meeting the estimated energy needs for wound healing. Review of the Treatment Administration Record dated February 1 through 4, 2022 revealed monitoring of the resident ' s right hip was completed as ordered. A physician ' s order dated 02/05/22 included application of a hydropolymer, adhesive foam dressing to the right hip every day shift, every 3 days for DTI. The February 5 through 17, 2022 TAR revealed dressings were applied per orders. A follow-up Skin & Wound Evaluation was not completed until 02/18/22. The evaluation revealed a deteriorating unstageable pressure ulcer which measured 3.9 cm x 2.8 cm. The wound bed was described as 80% slough, with light serosanguineous exudate, the edges were noted as epithelialization with blanching and erythema of the surrounding tissue. Additional care remained the same. No revision of the care plan was identified. Review of the February 2022 TAR revealed the order for application of a hydropolymer, adhesive foam dressing to the right hip every day shift, every 3 days for DTI was discontinued on 02/22/22, when the physician ' s order identified wound care to the resident ' s left hip. A subsequent Skin & Wound Evaluation was not completed until 03/07/22, and revealed a deteriorating unstageable pressure ulcer measuring 4.6 cm x 2.3 cm, with 90% of the wound bed filled with slough. Light serosanguineous exudate was noted, with edges identified as epithelialization with blanching and erythema of the surrounding tissue. Additional care remained the same, with no revision to the plan of care. Review of the March 2022 TAR revealed wound care was administered to the resident ' s left hip wound as ordered. No nursing documentation was identified for the resident ' s right thigh/hip wound. The Skin & Wound Evaluation dated 03/18/22 included a deteriorating unstageable pressure ulcer measuring 4.2 cm x 2.6 cm x 0.5 cm with 100% of the wound bed filled with slough. The wound exhibited warmth, and no exudate was identified. Wound edges were defined as epithelialized and surrounding tissue identified as blanching.The periwound temperature was described as warm. Additional care remained the same. A physician ' s order dated 03/21/22 included cephalexin capsule (antibiotic) 500 milligrams (mg): give 1 capsule two times a day for wound infection for 5 days. An interview was conducted on 01/11/23 at 9:01 a.m. with the Assistant Director of Nursing/wound nurse (ADON/staff #109). She stated that pressure ulcer interventions include a pressure reduction mattress, and if the resident is at high risk for developing wounds an overlay will be ordered, pressure relieving boots and dietary review. She stated that the facility does not have a repositioning program. She stated that per policy and PRN, every resident will receive a pressure-reduction cushion. She stated that if the resident develops a pressure ulcer, the physician and the dietitian will be notified. She stated that the expectation is that the pressure ulcer/injury will be reviewed and documented weekly. On 01/11/23 at 9:42 a.m. a follow-up interview was conducted with the ADON/wound nurse. She stated that the location of the wound was actually on the resident ' s right hip not thigh. She stated that she went on leave from March 2, 2022 through June 7 or 8, 2022. She stated that when she left the wound was a DTI, when she came back the wound was unstageable. She stated that someone in the facility was covering wound care and assessments on a weekly basis. The Skin/Wound Care Protocol policy, reviewed 5/14, included the goal of a preventative skin program is to maintain skin integrity and provide guidelines for skin care. A licensed nurse completes a weekly skin assessment and documents the assessment on the Weekly Skin/Pain Assessment form.

Based on personnel file review, staff interviews, and facility policy, the facility failed to ensure that two of two sampled Certified Nursing Assistants (CNA/staff #100 and #91) were able to demonstrate competencies and skills necessary to provide care for residents. The census was 80. The deficient practice could result in inadequate care for residents. Findings include: Review of a personnel file for a CNA (staff #100) revealed a hire date of 05/14/03, for hourly employment. The personnel record contained no evidence of a comprehensive evaluation for nursing skills and competencies for 2022. Review of a personnel file for CNA/staff #91 revealed a hire date of 08/12/20, for hourly employment. The personnel record contained no evidence of a comprehensive evaluation for nursing skills and competencies for 2022. On 01/11/23 at 12:52 p.m. an interview was conducted with the Staffing Coordinator (staff #1). She stated that staff are evaluated for skills upon hire. She stated that she was not sure how often CNAs are re-evaluated. She stated that Human Resources sends reports to department heads and that the department heads were responsible to ensure that staff completes training and is up to date. An interview was conducted on 01/11/23 at 3:30 p.m. with the Clinical Resource Nurse (staff #117) and the Human Resource Director (staff #61). They stated that there had been no skills training for staff in 2022. On 01/12/23 at 1:05 p.m. a follow-up interview was conducted with the Human Resource Director (staff #61). She stated that skills evaluations and training was missed in 2022 due to the impending transition [acquisition] by the new owners. She stated that staff competencies should be evaluated yearly and as needed. An interview was conducted on 01/13/23 at 10:08 a.m. with the Director of Nursing (DON/staff #41). She stated that CNAs should receive skills training annually. She stated that the training was scheduled, but canceled. She stated that skills training was important to ensure staff competency to meet the needs of the residents. The Employment Requirements/Verification of Skills policy, revised 1/18, included that an employee shall possess the specific skills and knowledge necessary to provide residents residing in the facility with the type of care and services necessary to support and respect each resident ' s individuality, choices, strengths and abilities.

Based on observations, staff interviews, and policy review, the facility failed to ensure their system of medication records is complete to enable accurate reconciliation and accounting for all controlled medications. The deficient practice could result in misappropriation of residents' medications. Findings Include: -Prior to medication pass observation conducted on January 11, 2023 at 8:26 a.m. with a licensed nurse (LPN/ staff #47), she was observed handed medication cards wrapped in the reconciliation sheets to the assistant director of nursing (ADON/staff #109). Staff #109 walked away with medication cards in her hands to another unit. Following this observation, an interview was conducted with staff #47 on January 11, 2023 at 8:50 a.m. Staff #47 stated the medications that was given to staff #109 are narcotic medications of the residents that have been discharged or have their orders discontinued. Staff #47 stated that staff # 109 or the director of nursing (DON/ staff #41) picks up the discontinued controlled medications once a week or whenever they have a chance. Staff #47 stated she did not know where the discontinued narcotic drugs are stored, or where it goes. An interview was conducted on January 11, 2023 at 9:00 a.m. with the DON (staff #41). The DON stated the process for the discontinued narcotic drugs included placing the narcotic drugs in a double locked safe in her office. During the narcotic medication destruction, the medications were placed in the red sharps container, then a bottle of Metamucil and water is added. She stated the red sharp container is placed in the red bag, then in the biohazard container. A second interview was conducted on January 11. 2023 at 10:58 a.m. with staff #41. She stated the process when narcotic medications are discontinued included the licensed nurse handing her the medications. Staff #41 stated she does not sign any document that she received the discontinued medications, and that she did not have a process, the nurses just hands it to her and she takes it. Further, staff #41 stated how she ensure the discontinued narcotic medications taken from the cart was given to her is that she trusts her staff and that she has been doing this job for a long time. Staff #41 stated she does not sign for the discontinued narcotic drugs given to her, and that she trusts her staff. On January 11, 2023 at 11:24 a.m., a joint review of the individual resident's-controlled substance record was conducted with the Federal Surveyor. The record review revealed that 14 of 65 sampled documents were incomplete. An interview was conducted on January 12, 2023 at 7:34 a.m. with staff #47. She stated the process when narcotic drugs are delivered from the pharmacy included an electronic signature and a paper signature that serves as the courier's receipts. She stated the narcotic medications is placed in the narcotic cart, then the new narcotic is added in the narcotic proof of use count sheet, indicated with a plus sign. She stated if a narcotic medication is discontinued, she would remove the medication card and individual narcotic sheet and give it to the ADON (staff #109) for destruction. She stated the narcotic proof of use sheet is marked with a minus sign indicating the card was removed. She stated she cannot determine by looking at the record with a minus mark, whether the resident went home with the medications, or was given to the ADON for destruction because there was no signature who took the narcotics. Staff #47 reviewed the form and stated the form was incomplete. She stated it could put her nursing license in jeopardy because she has no way of knowing by looking at the record who took the narcotics. She reviewed the form and said the columns marked destroyed or transferred were left blanks therefore the form was incomplete. Review of the facility form, Narcotic Proof of Use Count Sheet, dated December 13 through 31, 2022 revealed eight narcotic cards were removed from the narcotic cart. Further record review revealed that on January 1 through 5, 2023, three narcotic cards were removed from the narcotic cart. However, there was no signature to determine who took the discontinued narcotic medications, and the columns on the form indicating the drug disposition (completed, destruction, transferred) were left blanks. An interview was conducted with a registered nurse consultant (RN/staff #117) on January 12, 2023 at 2:11 p.m. Staff #117 reviewed the sampled form, Narcotic Proof of Use Count Sheet. After staff #117 completed the record review, she stated the chain of custody has insufficient details regarding the drug disposition. Review of the facility policy, Disposal of Medications, dated 2007, stated discontinued medications and/or medications left in the in the nursing care center after a resident's discharge, which do not qualify for return to the pharmacy, are identified and removed from current medication supply in a timely manner for disposition. The policy stated medications included in the Drug Enforcement Administration (DEA) classification as controlled substances (or those classified as such by state regulation) are subject to special handling, storage, and record keeping in the nursing care center in accordance with federal and state laws. The policy included that if a controlled medication is unused, refused, by the resident or not given for any reason, it cannot be returned to the container; it is destroyed, and a controlled medication disposition log or equivalent form, shall be used for documentation and shall be retained as per Federal privacy and state regulations. The policy stated the log shall contain signature of the required witnesses (two licensed nurses employed by the nursing care center).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure five out of five residents (#32, #41, #14, #37, and #25) receiving psychotropic medications received consistent monitoring for behaviors and side effects. The facility census was 80. The deficient practice could result in unnecessary medication use and adverse side effects. Findings include: Resident #41 admitted to the facility on [DATE] with diagnoses including COVID 19, Alzheimer's disease with late onset, and dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 06 on the Brief Interview for Mental Status (BIMS) assessment, indicating lack of cognition. A review physician order: Lexapro tablet 10 mg, give 1 tablet by mouth for depression ordered on 10/13/21 Lorazepam tablet 0.5mg, give 2 tablets by mouth every 4 hours as needed for anxiety for the duration of hospice. Ordered on 10/7/22. Olanzapine tablet 5mg, give 1 tablet by mouth in the evening for dementia with behaviors. Ordered on 9/7/22. Quetiapine furmarate tablet 50mg, give 1 tablet by mouth two times a say for dementia with behaviors/agitation. Ordered on 11/9/22. Trazadone HCI tablet 50mg, give 0.5 tablet by mouth two times a day for anxiety, agitation, insomnia. Ordered on 12/23/21. A review of care plan initiated on 2/14/22 revealed the following: focus: risk for signs and symptoms of adverse behaviors such as yelling out, crying, agitation, restlessness, exit seeking, and hallucinations associated with diagnosis of dementia. Goal: will demonstrate acceptance of needed help without aggressive outburst. Intervention: administer medications as ordered. Monitor and document for side effects and effectiveness. A review of care plan initiated 10/29/19 revealed the following: focus: is at risk for signs and symptoms of adverse effects of medication due to antidepressant use. Goal: will be free from discomfort or adverse reactions related to antidepressant therapy. Interventions: administer antidepressant medications as ordered by physician. Monitor and document side effects and effectiveness q-shift. Monitor/document/report PRN adverse reactions to antidepressant therapy. A review of care plan initiated on 1/14/22 revealed the following: focus: risk for sign and symptoms of adverse effects of medication due to use of psychotropic medications for management of dementia and depression. Goal: will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment. Resident will reduce the uses of psychotropic medication. Intervention: Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness q-shift. Consult with pharmacy MD to consider dosage reduction when clinically appropriate at least quarterly. Monitor, document, report prn any adverse reactions of psychotropic medications. Review of the October, November, and December 2022 Medication Administration Record (MAR) revealed the medication was administered in accordance with the physician ' s order. However, the clinical record did not include evidence of monitoring for side effects or effectiveness of the medication as well as adverse reactions. On 01/11/23 at 8:41 a.m. an interview was conducted with a Licensed Practical Nurse (LPN/staff #6). She stated that adverse side effects and behaviors will show up on the electronic MAR (eMAR). She stated that would also document in the resident ' s progress notes. She reviewed the resident ' s orders and stated that she did not see behavior monitoring. She stated that behavior monitoring should pop up on either the MAR or the Treatment Administration Record (TAR). She stated that she would want it to pop up so that she would be able to monitor whether or not the behaviors were new or unusual, and/or whether the medication was working. She reviewed the resident ' s orders and stated that she did not see behavior monitoring. She stated that the risks of not monitoring behaviors would include that the resident may receive unnecessary medication. An interview was conducted on 01/11/23 at 1:10 p.m. with the Director of Nursing (DON/staff #41). She stated that monitoring for psychotropic medications would include adverse side effects, AIMS and behaviors. She reviewed the resident ' s record and stated that there was no side effect monitoring. She stated that behaviors are documented under the Certified Nursing Assistant (CNA) tasks. She stated that the CNA ' s monitored the resident for behaviors including grabbing, hitting, kicking and pushing. Resident #25 admitted to the facility on [DATE] with diagnoses including hyperlipidemia, hypothyroidism, and lower back pain. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 13 on the Brief Interview for Mental Status (BIMS) assessment, indicating appropriate cognition. Physician orders: Escitalopram oxalate tablet 10mg, give 1 tablet by mouth in the morning for anxiety/agitation. Ordered on 3/18/22. Lorazepam tablet 0.5mg, give 1 tablet by mouth every 6 hours as needed for agitation for duration of hospice. Ordered on 10/7/22. Lorazepam 1 tablet 1mg, give 1 tablet by mouth at bedtime for anxiety. Ordered on 11/12/22. Quetiapine fumarate tablet 50mg, give 1 tablet by mouth three times a day for behaviors. Ordered on 3/18/22. A review of care plan initiated on 4/8/22: focus: uses psychotropic medications due to dementia with hallucinations. Goal: will remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment. Interventions: administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness q-shift. Review behaviors and interventions and alternate therapies attempted and their effectiveness. Monitor, document, and report PRN any adverse reactions of psychotropic medications. Review of the October, November, and December 2022 Medication Administration Record (MAR) revealed the medication was administered in accordance with the physician ' s order. However, the clinical record did not include evidence of monitoring for side effects or effectiveness of the medication as well as adverse reactions. Based on review of the clinical record , staff interviews and review of the facility policy, the facility failed to ensure the pharmacist identified adequate monitoring for the use of medications in the pharmacy review for 5 residents (#32,#14,#37, #41 and #25). The deficient practice could allow for medication side effects and adverse consequences to go unadressed. Findings include: Regarding Resident #14- Resident #14 was admitted [DATE] with diagnoses to include the primary diagnosis of Covid 19 and other diagnoses of schizoaffective disorder bipolar type, bipolar II disorder, generalized anxiety disorder, major depressive disorder and dementia with other behavior disturbance. In the care plan initiated March 14, 2019, a focus area revealed that the resident had a behavior problem and interventions included to administer medications as ordered and to monitor for effectiveness and side effects. The care plan further revealed that the resident received antidepressant medication and psychotropic medication and side effects and medication effectiveness were to be monitored and documented every shift. The minimum data set ( MDS) dated [DATE] revealed that the resident scored a 5 on the brief interview for mental status (BIMS) indicating severe cognitive impairment. Review of the active orders revealed the following: - 12/22/2022 Olanzapine 5 mg.( milligrams) 1.5 tablets at bedtime for schizoaffective disorder. -12/19/2022 Divalproex Sodium delayed release 125 mg- give 250 mg by mouth two times a day for schizoaffective disorder and mood stability - 12/02/ 2022 Sertraline HCL 100 mg tablet in the morning for depression -No evidence of orders for monitoring for side effects or effectiveness of these drugs were found. No evidence of pharmacy recommendations monitoring were found in the clinical record. Review of the December 2022 and January 2023 medication administration record (MAR) and treatment administration record (TAR) revealed that the medications were given as ordered. No evidence of monitoring for effectiveness or side effects were found. - Regarding Resident #31 Resident #31 was admitted [DATE] with diagnoses to include recurrent depressive disorder and chronic pain syndrome. Review of the residents care plan initiated on May 9, 2022 revealed the the resident had a behavior problem as evidenced by verbal aggression. An intervention for this issue was to monitor for behaviors and attempt to determine the underlying cause. This information was to be documented. The care plan further revealed that the resident was prescribed anti depressant medication and the interventions included that changes in mood and behavior were to be documented. The resident also received an anti anxiety medication that included an intervention of monitoring of side effects and effectiveness. The resident scored a 6 revealing severe cognitive impairment on the brief interview for mental status(BIMS) on the Quarterly minimum data set (MDS) dated [DATE]. 2022. Review of the active orders revealed the following: - 10/5/2022 Mirtazipine Tablet 15 mg(milligrams) at bedtime for depression - 4/5/2022 Cymbalta 30 mg in the morning for depression, 8/15/2022 60 mg at bedtime for chronic pain - 5/2/2022 Lorazapam 0.5 mg every 2 hours as needed for agitation -No evidence of orders for monitoring for side effects or effectiveness of these drugs were found. No evidence was found of pharmacy recommendations for monitoring of side effects or effectiveness in the clinical record. Review of the November, December 2022 and January 2023 medication administration record ( MAR) and treatment administration record (TAR) revealed the the medications were given as ordered. No evidence of monitoring for effectiveness and side effects were found. - Regarding Resident #37 Resident#37 was admitted [DATE] with diagnoses to include recurrent major depressive disorder and primary insomnia. Review of the residents care plan initiated on March 22, 2021 revealed that the resident used an antidepressant medication related to insomnia and depression. The listed interventions included monitor and document side effects and effectiveness every shift. The quarterly Minimum Data Set, dated [DATE] revealed that the resident scored 15 on the brief interview for mental status ( BIMS) indicating that the resident was cognitively intact. Review of the active orders revealed : - 12/29/2022 Remeron 7.5 mg. ( milligrams) by mouth at bedtime for depression. -No evidence of orders for monitoring for side effects or effectiveness of these drugs were found Review of the October, November, December 2022 and January 2023 medication administration record ( MAR) and treatment administration record (TAR) revealed the the medications were given as ordered. No evidence of monitoring for effectiveness or side effects were found. An interview was conducted with the facility medical director( staff #120) on January 13, 2023 at 11:21 am. He stated that he had been medical director for many years and had worked closely with staff. He stated that it was most important to monitor a resident when the resident first starts a new medication. He stated that as far as psychotropic's, things have changed over time. At this time, residents are monitored but residents were monitored more frequently previously. Staff #120 stated that if a resident is stable on a psychotropic medication it may be less critical to monitor every shift than to monitor someone displaying behaviors. Resident's psychotropic's are addressed and reviewed in the quarterly QAPI meetings. He stated that the staff were expected at convey any changes to him as well as what he observes himself during his visits. He stated that residents needs do change as they age and he was available for assessments as needed and he also works with attending physicians and pharmacists as needed. Staff #120 stated if there is a regulation requirement to document the monitoring, those changes can be made, as the facility makes an attempt to do things correctly and to meet the regulations. At 11:53 AM on January 13, 2023 an interview was conducted with pharmacist ( staff #118), Head pharmacist ( staff #119) and the director of nursing (DON / staff #41) -Staff #118 stated that as far as side effects or behavior monitoring the staff mainly rely on the the resident self reports They do also look at the residents clinical record and will look at the resident as a whole person. Staff # 119 stated that per regulations, monitoring is not required to be on a set schedule. He further stated that it was not a requirement to monitor for behaviors on a resident that receives an anti-depressant. Staff #119 stated that they, as pharmacists do not make recommendations to nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure five out of five residents (#32, #41, #14, #37, and #25) receiving psychotropic medications received consistent monitoring for behaviors and side effects. The facility census was 80. The deficient practice could result in unnecessary medication use and adverse side effects. Findings include: Resident #41 admitted to the facility on [DATE] with diagnoses including COVID 19, Alzheimer's disease with late onset, and dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 06 on the Brief Interview for Mental Status (BIMS) assessment, indicating lack of cognition. A review physician order: Lexapro tablet 10 mg, give 1 tablet by mouth for depression ordered on 10/13/21 Lorazepam tablet 0.5mg, give 2 tablets by mouth every 4 hours as needed for anxiety for the duration of hospice. Ordered on 10/7/22. Olanzapine tablet 5mg, give 1 tablet by mouth in the evening for dementia with behaviors. Ordered on 9/7/22. Quetiapine furmarate tablet 50mg, give 1 tablet by mouth two times a say for dementia with behaviors/agitation. Ordered on 11/9/22. Trazadone HCI tablet 50mg, give 0.5 tablet by mouth two times a day for anxiety, agitation, insomnia. Ordered on 12/23/21. A review of care plan initiated on 2/14/22 revealed the following: focus: risk for signs and symptoms of adverse behaviors such as yelling out, crying, agitation, restlessness, exit seeking, and hallucinations associated with diagnosis of dementia. Goal: will demonstrate acceptance of needed help without aggressive outburst. Intervention: administer medications as ordered. Monitor and document for side effects and effectiveness. A review of care plan initiated 10/29/19 revealed the following: focus: is at risk for signs and symptoms of adverse effects of medication due to antidepressant use. Goal: will be free from discomfort or adverse reactions related to antidepressant therapy. Interventions: administer antidepressant medications as ordered by physician. Monitor and document side effects and effectiveness q-shift. Monitor/document/report PRN adverse reactions to antidepressant therapy. A review of care plan initiated on 1/14/22 revealed the following: focus: risk for sign and symptoms of adverse effects of medication due to use of psychotropic medications for management of dementia and depression. Goal: will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment. Resident will reduce the uses of psychotropic medication. Intervention: Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness q-shift. Consult with pharmacy MD to consider dosage reduction when clinically appropriate at least quarterly. Monitor, document, report prn any adverse reactions of psychotropic medications. Review of the October, November, and December 2022 Medication Administration Record (MAR) revealed the medication was administered in accordance with the physician ' s order. However, the clinical record did not include evidence of monitoring for side effects or effectiveness of the medication as well as adverse reactions. On 01/11/23 at 8:41 a.m. an interview was conducted with a Licensed Practical Nurse (LPN/staff #6). She stated that adverse side effects and behaviors will show up on the electronic MAR (eMAR). She stated that would also document in the resident ' s progress notes. She reviewed the resident ' s orders and stated that she did not see behavior monitoring. She stated that behavior monitoring should pop up on either the MAR or the Treatment Administration Record (TAR). She stated that she would want it to pop up so that she would be able to monitor whether or not the behaviors were new or unusual, and/or whether the medication was working. She reviewed the resident ' s orders and stated that she did not see behavior monitoring. She stated that the risks of not monitoring behaviors would include that the resident may receive unnecessary medication. An interview was conducted on 01/11/23 at 1:10 p.m. with the Director of Nursing (DON/staff #41). She stated that monitoring for psychotropic medications would include adverse side effects, AIMS and behaviors. She reviewed the resident ' s record and stated that there was no side effect monitoring. She stated that behaviors are documented under the Certified Nursing Assistant (CNA) tasks. She stated that the CNA ' s monitored the resident for behaviors including grabbing, hitting, kicking and pushing. Resident #25 admitted to the facility on [DATE] with diagnoses including hyperlipidemia, hypothyroidism, and lower back pain. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 13 on the Brief Interview for Mental Status (BIMS) assessment, indicating appropriate cognition. Physician orders: Escitalopram oxalate tablet 10mg, give 1 tablet by mouth in the morning for anxiety/agitation. Ordered on 3/18/22. Lorazepam tablet 0.5mg, give 1 tablet by mouth every 6 hours as needed for agitation for duration of hospice. Ordered on 10/7/22. Lorazepam 1 tablet 1mg, give 1 tablet by mouth at bedtime for anxiety. Ordered on 11/12/22. Quetiapine fumarate tablet 50mg, give 1 tablet by mouth three times a day for behaviors. Ordered on 3/18/22. A review of care plan initiated on 4/8/22: focus: uses psychotropic medications due to dementia with hallucinations. Goal: will remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment. Interventions: administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness q-shift. Review behaviors and interventions and alternate therapies attempted and their effectiveness. Monitor, document, and report PRN any adverse reactions of psychotropic medications. Review of the October, November, and December 2022 Medication Administration Record (MAR) revealed the medication was administered in accordance with the physician ' s order. However, the clinical record did not include evidence of monitoring for side effects or effectiveness of the medication as well as adverse reactions. - Regarding Resident # 14- Resident #14 was admitted [DATE] with diagnoses to include the primary diagnosis of Covid 19 and other diagnoses of schizoaffective disorder bipolar type, bipolar II disorder, generalized anxiety disorder, major depressive disorder and dementia with other behavior disturbance. In the care plan initiated March 14, 2019, a focus area revealed that the resident had a behavior problem and interventions included to administer medications as ordered and to monitor for effectiveness and side effects. The care plan further revealed that the resident received antidepressant medication and psychotropic medication and side effects and medication effectiveness were to be monitored and documented every shift. The minimum data set ( MDS) dated [DATE] revealed that the resident scored a 5 on the brief interview for mental status (BIMS) indicating severe cognitive impairment. Review of the active orders revealed the following: - 12/22/2022 Olanzapine 5 mg.( milligrams) 1.5 tablets at bedtime for schizoaffective disorder. -12/19/2022 Divalproex Sodium delayed release 125 mg- give 250 mg by mouth two times a day for schizoaffective disorder and mood stability - 12/02/ 2022 Sertraline HCL 100 mg tablet in the morning for depression -No evidence of orders for monitoring for side effects or effectiveness of these drugs were found. Review of the December 2022 and January 2023 medication administration record ( MAR) and treatment administration record (TAR) revealed that the medications were given as ordered. No evidence of monitoring for effectiveness or side effects were found. - Regarding Resident #31 Resident #31 was admitted [DATE] with diagnoses to include recurrent depressive disorder and chronic pain syndrome. Review of the residents care plan initiated on May 9, 2022 revealed the the resident had a behavior problem as evidenced by verbal aggression. An intervention for this issue was to monitor for behaviors and attempt to determine the underlying cause. This information was to be documented. The care plan further revealed that the resident was prescribed anti depressant medication and the interventions included that changes in mood and behavior were to be documented. The resident also received an anti anxiety medication that included an intervention of monitoring of side effects and effectiveness. The resident scored a 6 revealing severe cognitive impairment on the brief interview for mental status(BIMS) on the Quarterly minimum data set (MDS) dated [DATE]. 2022. Review of the active orders revealed the following: - 10/5/2022 Mirtazipine Tablet 15 mg(milligrams) at bedtime for depression - 4/5/2022 Cymbalta 30 mg in the morning for depression, 8/15/2022 60 mg at bedtime for chronic pain - 5/2/2022 Lorazapam 0.5 mg every 2 hours as needed for agitation -No evidence of orders for monitoring for side effects or effectiveness of these drugs were found. Review of the November, December 2022 and January 2023 medication administration record ( MAR) and treatment administration record (TAR) revealed the the medications were given as ordered. No evidence of monitoring for effectiveness and side effects were found. - Regarding Resident #37 Resident#37 was admitted [DATE] with diagnoses to include recurrent major depressive disorder and primary insomnia. Review of the residents care plan initiated on March 22, 2021 revealed that the resident used an antidepressant medication related to insomnia and depression. The listed interventions included monitor and document side effects and effectiveness every shift. The quarterly Minimum Data Set, dated [DATE] revealed that the resident scored 15 on the brief interview for mental status ( BIMS) indicating that the resident was cognitively intact. Review of the active orders revealed : - 12/29/2022 Remeron 7.5 mg. ( milligrams) by mouth at bedtime for depression. -No evidence of orders for monitoring for side effects or effectiveness of these drugs were found Review of the October, November, December 2022 and January 2023 medication administration record ( MAR) and treatment administration record (TAR) revealed the the medications were given as ordered. No evidence of monitoring for effectiveness or side effects were found. An interview was conducted with certified nursing assistant ( CNA/ staff #94) on January 11, 2023 at 2:03 pm. She stated that the CNAs will chart in the CNA charting and make the nurses aware of any behavior concerns so it can de documented in a progress note. She stated that all the residents in the secured unit are monitored for behaviors related to their diagnoses but the monitoring is not related to medications. An interview with the director of nursing (DON/ staff #41) was conducted on January 11, 2023 at 2:10 pm. She stated that the facility does not monitor and has never monitored routine psychotropic's. She stated that the physicians do their own monitoring. Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure five out of five residents (#32, #41, #14, #37, and #25) receiving psychotropic medications received consistent monitoring for behaviors and side effects. The facility census was 80. The deficient practice could result in unnecessary medication use and adverse side effects. Findings include: -Resident #32 admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease and post traumatic seizures. An Abnormal Involuntary Movement Scale (AIMS) dated 11/17/22 revealed a score of Not Applicable (NA). The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status (BIMS) assessment, indicating intact cognition. The resident reported no feelings of depression, and he displayed no symptoms of psychosis or behaviors. A physician ' s order dated 11/30/22 revealed quetiapine fumarate (antipsychotic) 25 mg (milligrams): give one tablet at bedtime for traumatic brain injury (TBI). No specific target behaviors related to TBI were identified in the order. Review of the November 30 through December 6, 2022 Medication Administration Record (MAR) revealed the medication was administered in accordance with the physician ' s order. A psychotropic medication care plan dated 12/06/22 related to TBI had a goal for the resident to be/remain free from psychotropic drug-related complications. Interventions included to administer psychotropic medications as ordered by the physician. Monitor for side effects and effectiveness every shift. However, the clinical record did not include evidence of monitoring for side effects or effectiveness of the medication as evidenced by decreased episodes of target behaviors had been completed. Another physician ' s order dated 12/12/22 included fluoxetine HCl (antidepressant) 20mg: give one capsule by mouth in the morning for depression. Review of the December 2022 MAR revealed the resident received psychotropic medications in accordance with the physician ' s orders. However, review of the clinical record did not indicate monitoring for side effects or effectiveness of the medication as evidenced by decreased episodes of target behaviors had been completed. On 01/11/23 at 8:41 a.m. an interview was conducted with a Licensed Practical Nurse (LPN/staff #6). She stated that adverse side effects and behaviors will show up on the electronic MAR (eMAR). She stated that would also document in the resident ' s progress notes. She reviewed the resident ' s orders and stated that she did not see behavior monitoring. She stated that behavior monitoring should pop up on either the MAR or the Treatment Administration Record (TAR). She stated that she would want it to pop up so that she would be able to monitor whether or not the behaviors were new or unusual, and/or whether the medication was working. She reviewed the resident ' s orders and stated that she did not see behavior monitoring. She stated that the risks of not monitoring behaviors would include that the resident may receive unnecessary medication. She reviewed the resident ' s record and stated that adverse side effects were not being monitored. She stated that the risks of not monitoring for adverse side effects might include falls, risks to self or others, or that nursing may not be aware of adverse effects. An interview was conducted on 01/11/23 at 1:10 p.m. with the Director of Nursing (DON/staff #41). She stated that monitoring for psychotropic medications would include adverse side effects, AIMS and behaviors. She reviewed the resident ' s record and stated that there was no side effect monitoring. She stated that behaviors are documented under the Certified Nursing Assistant (CNA) tasks. She stated that the CNA ' s monitored the resident for behaviors including grabbing, hitting, kicking and pushing. She stated that the resident was receiving an antipsychotic for TBI. She stated that the provider had documented that the resident was receiving the antipsychotic for insomnia related to the TBI in one of her notes. She stated that the resident was not being monitored for insomnia/hours of sleep. She stated that the resident was receiving fluoxetine for depression, but that they had never monitored for depression.

Based on clinical record review, resident and staff interviews, and policy, the facility failed to ensure that one resident (#54) was assisted in obtaining routine dental care. The sample size was 20. The deficient practice could result in residents ' dental needs not being met. Findings include: Resident #54 admitted to the facility 07/06/21 with diagnoses that included Alzheimer ' s disease with late onset, dementia in other diseases classified elsewhere, without behavioral, psychotic, or mood disturbance and major depressive disorder, recurrent, in remission. Review of the admission Nursing Review dated 07/06/21 revealed the resident had no missing, broken, obvious or likely cavity or broken natural teeth. An activities of daily living self-care performance deficit care plan dated 08/03/21 related to dementia with behaviors had a goal to maintain current level of function. Interventions included supervision/limited assistance with personal hygiene and oral care. A physician ' s order dated 12/09/21 included acetaminophen (analgesic) 500 milligrams (mg). Give 500 mg every 6 hours as needed for pain of 1-5 on a pain scale; give 1000 mg for pain of 6-10. However, additional review of the physician ' s orders did not indicate that a referral for routine dental care had been ordered and/or was being performed. Review of the September 2022 Medication Administration Record (MAR) revealed acetaminophen was administered per orders for pain levels ranging from 4 to 7. However, a review of electronic MAR (eMAR) notes did not indicate the location of her pain. Further review of the pain scales revealed a general pain level of 0. A physician ' s order dated 10/13/22 included acetaminophen 325 mg. Give 2 tablets two times a day for generalized pain. Review of the October 2022 MAR revealed acetaminophen was administered in accordance with physician ' s orders. The pain scales indicated that the resident ' s pain was generally 0. Review of the as needed (PRN) administration of acetaminophen included pain levels of 3-6. A Pain Evaluation was conducted on 11/08/22 at 1:23 p.m. According to the evaluation, the resident was able to interview and that she reported rarely experiencing pain over the past 5 days. The November 2022 MAR included twice daily administration of acetaminophen per physician ' s orders. The pain scales revealed a general pain level of 0. PRN acetaminophen was administered on 11/24/22 for a pain level of 7. The December 2022 MAR revealed acetaminophen was administered twice daily for generalized pain. Pain scales included a general pain level of 0, and PRN acetaminophen was not administered. On 01/09/23 at 11:01 a.m. an interview was conducted with the resident ' s representative. The representative expressed concern regarding the resident ' s dental issues, including missing caps in front, and the need for her to see a dentist. A physician progress note dated 01/09/23 at 1:12 p.m. included that upon the visit, the resident reported feeling so so. The note indicated that the resident appeared calm and pleasant, and that she was observed to have poor dentition. On 01/11/23 at 8:06 a.m. an observation of the resident was conducted. The resident was noted to have black/brown broken remnants and missing teeth. She was observed to display a nearly continuous sucking motion with her mouth when not speaking. At 8:06 a.m. on 01/11/23 an interview was conducted with the resident with a Spanish-speaking interpreter/Certified Nursing Assistant (CNA/staff #82). Staff #82 stated that the resident was very hard of hearing and that she read lips. She stated that she communicates with the resident by coming close to her face so the resident can see her lips and by speaking loudly. The resident stated her teeth hurt a lot. On 01/12/23 at 11:37 a.m. an interview was conducted with a Licensed Practical Nurse (LPN/staff #97). She stated that the resident shows her where her pain is. She stated that she will ask the resident what her pain level is and the resident usually states 3 or 4. She stated that otherwise, she will observe the resident ' s appearance. She stated that she asks how bad the pain is, but that the resident does not always provide a number. She stated that the resident primarily complains of pain in her ear. She stated that acetaminophen has been ordered for scheduled administration. She stated that administration of the medication is preventative. She stated that she visually assesses the resident ' s pain using the Pain Assessment in Advanced Dementia Scale (PAINAD) and that she does not always ask her what her pain level is. At 11:43 a.m. on 01/12/23 with the assistance of an interpreter, the resident was asked what her pain level was. The resident stated that on a scale of 1-10, her pain was a 10. She stated that sometimes some of her teeth hurt, other times they all hurt. She stated that her pain was great. She stated that she would like to see a dentist so that she can feel better. An interview was conducted on 01/12/23 at 1:58 p.m. with the Director of Nursing (DON/staff #41). She stated that the resident did not complain of pain. She stated that the resident did not indicate that her teeth hurt. She stated that the resident is able to communicate when she has pain. She stated that the resident did not complain of tooth pain. On 01/13/23 at 8:59 a.m. an interview was conducted with the Director of Social Services (staff #54). She stated that the unit secretary schedules appointments. She stated that if mobile specialists were coming into the facility, and the nurse makes her aware, she will make sure the resident gets an appointment. She stated that ultimately, she was responsible to ensure that residents are getting annual hearing, dental and vision appointments. She stated that if an emergent situation were to arise, she would also arrange an appointment as needed. She stated that if the residents were not getting their appointments it would be because either she had not set one up or the resident had refused. She stated that the lack of dental services had been an error on her part. The Dental Services policy, revised December 2016, included that routine and emergency dental services are available to meet the resident ' s oral health services in accordance with the resident ' s assessment and plan of care. Routine and 24-hour emergency dental services are provided to residents through a contract agreement with a licensed dentist that comes to the facility monthly, referral to the resident ' s personal dentist, referral to community dentists and referral to other healthcare organizations that provide dental services. Social services representatives will assist residents with their appointments, transportation agreements, and for reimbursement of dental services under the state plan, if eligible. All dental services provided are recorded in the resident ' s medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, review of the Resident Assessment Instrument (RAI) manual, and policy and procedures, the facility failed to ensure that a significant change in status Minimum Data Set (MDS) assessment was completed for one resident (#20). The sample size was 20. The deficient practice could affect residents' continuity of care. Findings include: Resident #20 was admitted to the facility on [DATE] with diagnoses that included hypothyroidism and primary hypertension. The admission Minimum Data Set (MDS) assessment dated [DATE] included that the resident scored 12 on the Brief Interview for Mental Status, indicating moderately impaired cognition. The assessment revealed the resident required extensive 1-person physical assistance for most activities of daily living (ADLs) including bed mobility and transfers, and limited 1-person physical assistance for eating. In addition, the assessment indicated the resident had no signs or symptoms of a swallowing disorder, including holding food in mouth/cheeks, or residual food in mouth after meals. A physician progress note dated 09/10/21 at 2:11 p.m. stated that day the resident was unable to answer questions or follow directions. The note stated that nursing had reported that the resident had responded normally that morning, and that this was a sudden change in status. The note included that the resident had been sent to the hospital for evaluation due to the sudden change in mental status. Review of the clinical record revealed the resident was discharged on 09/10/21, and was subsequently readmitted on [DATE]. Review of the resident's Face Sheet dated 09/17/21 included for additional diagnoses of unspecified dementia without behavioral disturbance and severe protein calorie malnutrition. -Regarding the resident's mobility: A physician order dated 09/18/21 revealed for a Physical Therapy (PT) Clarification Order: PT to evaluate and treat 5 times per week for 4 weeks; to include gait training as indicated, therapeutic exercises and activities, neurological re-education; modalities, manual treatment and wheelchair training as needed. Review of the PT Evaluation & Plan of Treatment dated 09/18/21 revealed the resident's new baseline for bed mobility was total dependence without attempts to initiate. The evaluation included the resident's new baseline for transfers was total dependence without attempts to initiate. Review of the resident's care plan did not include a revision or update to include the resident's decline in functional mobility. -Regarding the significant weight loss: A skilled nursing progress note dated 09/19/21 at 2:14 p.m. included that the resident required 1:1 feeding. A physician's order dated 09/19/21 revealed for admission weight, then weekly for 3 weeks in the morning every Sunday. The Weight Summary dated 09/19/21 revealed that the resident's weight was 95.0 Lbs. A physician's order dated 09/21/21 revealed for Speech Therapy (ST) evaluation and treatment; resident to be seen 4-5 times per week for 4 weeks to address dysphagia and cognitive communication deficits. Another ST clarification order from the same date included a recommendation for puree and thin liquids, indicating that the resident must be sitting upright for intake by mouth (PO), preferably in a wheelchair, and that the resident required 1:1 assistance and encouragement for PO intake, and to provide frequent liquid wash following bites of solids to clear oral cavity. A Speech Therapy Evaluation & Plan of Treatment dated 09/21/21 revealed for diagnoses which included cerebral infarction. Treatments included for dysphagia following cerebral infarction, and dysphagia, oropharyngeal phase. The goals of treatment included improved swallowing abilities to minimal/close supervision as evidenced by the ability to safely and efficiently swallow the least restrictive diet with minimal to absent signs or symptoms of oral dysphagia, coughing, or wet vocal quality post swallowing pureed consistencies and thin liquids, successive swallows for primary nutritional intake with minimal/no signs or symptoms of dysphagia. Recommendation for supervision for oral intake included close supervision (1:1 assistance). A Social Service progress note dated 09/21/21 included that an Interdisciplinary Team (IDT) meeting had been held that day. The note included that the resident received a pureed diet texture, that a poor appetite was noted, and that the resident was dependent with all ADLs. Review of the Weight Summary dated 10/17/21 revealed the resident weighed 89.0 Lbs., for a total loss of 6.32% in one month. However, there was no evidence that a significant change in status MDS assessment had been initiated or completed. An interview was conducted on 10/28/21 at 11:06 a.m. with the MDS Coordinator (staff #33). She stated that she uses the RAI manual for instructions for the MDS, Care Area Assessment, and care plan completion. She stated that she usually completes the assessment in consultation with the nurses. Staff #33 stated that for example, nursing will tell her if there was a weight loss, cognitive changes, or ADL declines. She stated that in some cases she would need to have at least 3 areas of decline in order to trigger for a significant change. She stated that a significant change should be identified when it occurs/as changes occur. Staff #33 stated the facility would be out of compliance if they waited. She stated that once the change is identified, she has 14 days to complete the significant change assessment and 21 days to complete/update the care plans (CAAs). After reviewing the clinical record, staff #33 stated that the resident's decline in physical mobility would be considered significant and a 6.32% weight loss in one month would be considered significant. She stated that she had missed these changes. She stated that the dementia and swallowing difficulties were significant, and they were missed as well. Staff #33 stated that a significant change assessment should be triggered and interventions should be put into place to prevent and reverse other declines. Staff #33 also stated that the care plan should be changed to include the updated interventions. On 10/28/21 at 11:39 a.m., an interview was conducted with the Assistant Director of Nursing (ADON/staff #115). She stated that a significant change would be anything out of the norm for residents such as confusion, change in functional status, significant weight loss. She stated that a resident should be assessed for a significant change in status following an acute medical event and/or hospitalization. Staff #115 stated that changes in residents' status are discussed in the IDT meeting, and that they meet every morning Monday-Friday. She stated that ST/OT/PT communicate changes in weekly meetings and that they will put the orders in for services. Staff #115 stated that all communication will be in their notes, and then communicated to the staff verbally. She stated it also should be documented in the orders and in the secure communications (emails) amongst the staff, and that nursing should document any updates or changes in the clinical record. The ADON stated that if a resident was identified to have a significant change, she would expect a nursing progress note, a care plan update, that the physician would be notified, and that a significant change in status MDS assessment would be completed. She stated that she believed that a significant change assessment should be completed if a resident had an acute medical event, with significant decline in mobility/functional status and eating, and a significant weight change. The ADON stated that she did not know why a significant change assessment had not been triggered for resident #20. She stated that it did not meet her expectation. Review of the RAI manual revealed a significant change is a major decline or improvement in a resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; impacts more than one area of the resident health status; and requires IDT review and/or revision of the care plan. The facility policy titled Care Plan Development included that the IDT shall develop a comprehensive, individualized plan of care for each resident that is reviewed and revised in accordance with State and Federal regulations and professional standards of nursing care. The care plan guides the care and treatment provided to each resident. The care plan is reviewed at the IDT meeting and amended as needed. The MDS/Care Plan Coordinator normally chairs the team meeting. Nurses and nursing assistants who routinely provide care for the resident are part of the IDT and will be included in developing the plan of care. When there are changes in the resident's condition, either an interim care plan is used to address the problem or the comprehensive care plan is updated as needed to change goals, timeframes, or interventions. If the change meets the MDS 3.0 guidelines for a significant change, a comprehensive MDS assessment is completed as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure the baseline care plan included the minimum healthcare information necessary to care for one resident (#52). The sample size was 20. The deficient practice may result in residents not being provided the services and person-centered care necessary to meet their needs. Findings include: Resident #52 was admitted to the facility on [DATE], with diagnoses that included interstitial lung disease, dependence on supplemental oxygen, cardiovascular accident, and hypertensive heart disease. The Weights and Vitals summary included that on October 4, 2021 at 6:30 p.m., the resident's oxygen saturation was 100% with oxygen via nasal cannula. A physician order dated October 5, 2021 included for oxygen 1-5 liters via nasal cannula. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored an 11 on the Brief Interview for Mental Status (BIMS) which indicated the resident had moderately impaired cognition. The MDS assessment also included that the resident had shortness of breath, and received oxygen therapy. Addition review of resident #52's clinical record did not reveal a baseline care plan had been developed for the resident related to lung disease, dependency on supplemental oxygen and oxygen therapy. In an interview conducted with a Registered Nurse (RN/staff #23) on October 28, 2021 at 10:32 a.m., the RN stated after a resident is admitted , the licensed nurses are responsible for completing the baseline care plan. The RN stated once the baseline care plan has been completed, the Assistant Director of Nurses (ADON) will do all the updates. An interview was conducted with the ADON (staff /#115) on October 28, 2021 at 2:38 p.m. The ADON stated her expectation is to see oxygen administration as part of the baseline care plan. After reviewing the clinical record for resident #52, the ADON stated oxygen administration was not care planned and should be care planned. The facility's policy for care plan development reviewed January 2021 stated that the care plan guides the care and treatment provided to each resident. The policy included that after completing the admission nursing assessment, nursing will use the information available to develop the baseline care plan within 48 hours of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #29 was admitted to the facility on [DATE] with diagnoses that included dementia, chronic obstructive pulmonary disease, and major depressive disorder. A comprehensive care plan initiated on June 4, 2016 stated the resident is at risk for falls related to diagnoses of dementia, bilateral lower extremity weakness, deconditioning, gait/balance problems, and incontinence. The goal included the resident will be free of falls. The interventions included to anticipate and meet the resident's need; encourage resident to use call light for assistance as needed; encourage resident to participate in activities; and ensure the resident is wearing appropriate footwear. A 24-Hour Unusual Occurrence Report dated November 23, 2020 at 5:00 p.m., stated that the resident fell with minor injury, a laceration to back of head. Preventative measures included resident to be up in wheelchair, out to nurses' station for closer monitoring. The post fall assessment included continue with fall interventions and close monitoring. It also stated that the care plan was reviewed and revised. However, only the date of the fall was added on the care plan. The care plan was not revised/updated to include for close monitoring and to be up in the wheelchair out to the nurses' station for closer monitoring. A 24-Hour Unusual Occurrence Report dated March 30, 2021 at 9:00 p.m., stated a fall with minor injury, a small bump located to occipital lobe resulted from resident rolled out of bed. The preventative measures included remind resident to use the call light at all times for assistance and fall mat was put into place. The post fall assessment included to continue with current fall interventions and indicated that care plan was reviewed and revised. Review of the care plan revealed the date of the fall but did not reveal the intervention for fall mats was added. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 03 which indicated the resident had severely impaired cognition. The assessment included the resident had 2 falls with no injury and one fall with injury (except major). The MDS assessment also included the resident had frequent urinary incontinence and frequent bowel incontinence. The assessment also revealed the resident required extensive assistance with transfer, dressing, and personal hygiene, and limited assistance with toilet use. A physician order dated July 20, 2021 included for Fall Precaution every shift landing strip, low bed, alarms, foot rests on with calf pad attached. Resident should be discouraged from elevating feet on bed. Review of the care plan did not reveal evidence that these fall interventions had been added to the care plan. An interview was conducted on October 28, 2021 at 10:32 a.m. with a Registered Nurse (RN staff #23). The RN stated she was very familiar with the resident routine and care needs. She said when a resident frequently falls, she does frequent rounds for safety. She stated the resident was moved close to the nurse's station to be able to watch the resident closely. The RN stated that if the fall interventions are not effective, only the Assistant Director of Nurses (ADON) would update the fall care plan. Staff #23 stated the licensed staff only initiates the baseline care plan, thereafter, the ADON will continue all the updates. The RN stated that if the fall interventions are not working, she would write a progress note and wait for the ADON to update the care plan. The RN reviewed the 24-Hour Unusual Occurrence Report and stated the check mark on the interdisciplinary team (IDT) notes meant that the fall care plan has been updated. An interview was conducted on October 28, 2021 at 2:06 p.m. with the ADON (staff #115). She stated her expectation is that if a resident falls the nurses evaluates the resident for injury then notify the physician and the family of the incident. The ADON stated that she completes all post fall assessments and looks at the care plan interventions, review and update every morning. She stated that if the resident has repeated falls, the IDT reviews the interventions to see if they are still working. She also stated that she reviews the care plan and update the interventions. The ADON reviewed the policy for falls and stated the care plan and fall interventions should have been updated/revised each time the resident had fallen to prevent future falls. During the interview, the ADON accessed the resident's medical record and stated that she agreed the care plan goals was last updated on June 20, 2021 and agreed she did not add new interventions after the resident had fallen. She also stated that she thought updating the care plan meant adding a date on the problem area with the date indicating the most recent fall. The ADON also accessed the physician orders dated July 20, 2021 for fall precaution every shift, landing strip, low bed, alarms, foot rests on with calf pad attached, and resident should be discouraged from elevating feet on bed. She agreed the physician order should have been added on the resident's care plan for falls. A policy for Care Plan Development reviewed on January 2021 included the Interdisciplinary Team (IDT) shall develop a comprehensive, individualized plan of care for each resident that is reviewed and revised in accordance with State and Federal regulations and professional standards of nursing care. The Care Plan guides the care and treatment provided to each resident. The procedure included the care plan is to be reviewed and updated by all staff providing care or services for the resident on an ongoing basis. The care plan includes a statement of the problem; reasonable, measurable, and time-limited goals; and specific interventions, along with the discipline responsible. The care plan is individualized and addresses the resident's medical, nutritional, psychological, physical, functional, social, educational, and spiritual needs and the severity of the resident's condition, impairments, disability, or disease as indicated. The total Plan of Care includes established routines of care, professional standards of practice, physician's orders and progress notes, consultation reports, Medication Administration Records, Treatment Administration Records, flow sheets, various medical records and resident/family preferences. Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure care plans were updated and/or revised for 2 residents (#20 and #29). The sample size was 20. The deficient practice increases the risk of not meeting the changing goals, preferences, and needs of the residents. Findings include: -Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included unspecified severe protein-calorie malnutrition, paroxysmal atrial fibrillation, and unspecified dementia without behavioral disturbance. The admission Minimum Data Set (MDS) assessment dated [DATE] included that the resident scored 12 on the Brief Interview for Mental Status, indicating moderately impaired cognition. The assessment revealed the resident required limited 1-person physical assistance for eating. A skilled nursing progress note dated 09/19/21 at 2:14 p.m. included that the resident required 1:1 feeding. Review of a care plan initiated on 09/20/21 revealed the resident was at nutritional risk and the goals included the resident would not have no significant weight loss fluctuations. Interventions included to monitor intake and record at every meal and to provide and serve diet/fortified foods as ordered. A Speech Therapy Evaluation & Plan of Treatment dated 09/21/21 revealed the resident required close supervision (1:1 assist) for oral intake. A Social Service progress note dated 09/21/21 included that an Interdisciplinary Team (IDT) meeting had been held that day. The note included that the resident received a pureed diet texture, that a poor appetite was noted, and that the resident was dependent with all ADLs (activities of daily living). A Cardiovascular & Coagulations progress note dated 09/29/21 at 9:32 p.m. included that the resident needed extensive assistance with ADLs. The note stated that the resident dined in her room with 1:1 assistance but continued to have difficulty swallowing, and pocketed food and crushed medication in her mouth. Even when the resident was cued to swallow, the resident stared and said, uh-huh. However, further review of the care plan did not include for close supervision or 1:1 assistance with meals. An interview was conducted on 10/27/21 at 12:05 p.m. with a Licensed Practical Nurse (LPN/staff #38). She stated that the resident should have supervised meals and be offered 1:1 staff assistance. The LPN stated that 1:1 assistance during meals should be included in the resident's care plan. She stated that nursing would be in charge of updating the care plan. An interview was conducted on 10/28/21 at 11:39 a.m. with the Assistant Director of Nursing (ADON/staff #115). She stated that she knows the resident does need help with eating, but she could not tell why it had not been care-planned. She stated that it did not meet her expectation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident and staff interviews, and policy review, the facility failed to ensure fall safety measures were implemented for one of two sampled residents (#29). The deficient practice could result in residents having falls. Findings include: Resident #29 was admitted on [DATE] with diagnoses that included dementia, chronic obstructive pulmonary disease, and major depressive disorder. Review of the care plan initiated on June 4, 2016 and revised on June 7, 2021 revealed the resident was at risk for falls related to diagnosis of dementia, unaware of safety needs, poor judgement, bilateral lower extremities weakness, deconditioning, gait/balance problems, and incontinence as evidenced by the resident requires staff assistance with transfers and daily activities of daily living (ADL). Goals were that the resident would be free of minor injury, would not sustain serious injury, and would be free of falls. Interventions included to encourage the resident to use the call light for assistance as needed, ensure that the resident is wearing appropriate footwear (well fitting shoes with non-skid soles or non-skid socks) when ambulating, transferring or mobilizing in the wheelchair, and low bed with mats at bedside when occupied by the resident. The intervention initiated on June 6, 2016 for a pressure alarm while in bed and wheelchair was resolved February 23, 2018. Review of the fall risk evaluation dated September 2, 2021 revealed the resident had 1-2 falls within the last 3 months. It also included a fall risk score of 18 which indicated the resident was a high risk for falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 03 which indicated the resident had severe cognitive impairment. The MDS assessment included that the resident needed extensive assistance of one person for bed mobility, transfer, toilet use, and personal hygiene. The assessment also included the resident was frequently incontinent of urine and occasionally incontinent of bowel. Regarding the alarms A physician order dated July 20, 2017 included for Fall Precaution: every shift landing strip, low bed, alarms, foot rests on with calf pad attached. Resident should be discouraged from elevating feet on bed. Review of the Treatment Administration Records (TAR) for April 2021, May 2021, June 2021, July 2021, August 2021, September 2021, and October 2021 revealed the order had been transcribed onto the TARs and revealed a check mark for the fall precautions which included alarms. During observations conducted on October 26, 2021 at 8:45 a.m. and October 28, 2021 at 10:35 a.m. and 11:13 a.m., no alarms were observed on the resident's bed, wheelchair, or recliner. Regarding the call light A 24-Hour Unusual Occurrence Report dated November 29, 2020 stated that at 5:00 p.m., the resident was found sitting on the floor with both legs extended at the end of the bed. The preventative measures included to remind the resident to use the call light and wait for assistance. Review of the 24-Hour Unusual Occurrence Report dated January 9, 2021 revealed that at 10:45 a.m. the resident had a fall without injury. The preventative measures included to remind the resident to use the call light and wait for assistance. The 24-Hour Unusual Occurrence Report dated January 24, 2021 at 3:27 p.m. revealed the resident had a fall with injury. The preventative measures included to remind the resident to use the call light when needing assistance. Review of the 24-Hour Unusual Occurrence Report date February 27, 2021 revealed that at 6:00 p.m. the resident had a fall without injury. The preventative measures implemented at the time of the incident was that the resident was assisted to the toilette and bed rest. The report also included to remind the resident to ask for help for transfers and toileting to avoid falls and/or injury. A 24-Hour Unusual Occurrence Report dated March 30, 2021 stated that at 8:15 p.m. the resident rolled out of bed and sustained a small bump located to the occipital lobe. The report included the resident stated I wanted to get into my wheelchair to go to bathroom. The preventative measures included to remind the resident to use the call light and wait for staff assistance and that a fall mat was put into place. A 24-Hour Unusual Occurrence Report dated June 3, 2021 revealed that at 9:45 p.m. the resident had a fall with no injuries. The preventative measures included to remind the resident to use the call light when needing assistance. Review of the 24-Hour Unusual Occurrence Report dated June 6, 2021 at 1:33 p.m. revealed the resident had a fall without injury. The preventative measures included to remind the resident to ask for help with transfers and toileting. During an observation conducted on October 26, 2021 at 8:42 a.m., the resident was observed seated in the recliner, the room was dark, the window blinds were closed. A wheelchair was placed in front of the recliner in a locked position used to elevate the resident's lower extremities. The call light was located approximately 8 feet from the resident on top of the bedside table near the head of the bed. A call bell unit was observed on the wall near the recliner without a call bell cord attached. An interview was conducted with the resident during this observation. When the resident was asked how she would call staff for assistance, the resident stated by pressing the call light. The resident demonstrated by pressing the telephone connector attached on the call light unit without a call light cord. The resident stated sometimes it takes the staff about an hour to answer. During observations conducted on October 28, 2021 at 10:35 a.m. and 11:13 a.m., the resident was observed seated in the recliner located in the corner of the room. The call light was on top of the bedside table approximately 8 feet from the resident. The call light unit near the recliner remained missing the call light cord. A follow up interview was conducted with the resident on October 28, 2021 at approximately 10:37 a.m. The resident stated that the wait is over an hour sometimes after pressing the button (she pointed on the call bell unit with telephone cord). An interview with a Certified Nursing Assistant (CNA/staff #84) was conducted on October 28, 2021 at 10:57 a.m. The CNA stated she was familiar with the resident's care and needs. She stated the resident is alert with a little confusion but not combative, very cooperative, and does not refuse care. The CNA stated the resident uses the call light a lot, such as when she needs to go use the toilet, go to activities, go to the dining room, and when needing help with activity of daily living (ADLs). Staff #84 stated the resident was a high risk for falls. The CNA also stated the resident likes to go back and forth between the bed and the recliner therefore, the resident has a call light by the bed and by the recliner. On October 28, 2021 at approximately 11:13 a.m., an observation of the resident was conducted with the CNA. The resident was observed sitting in the wheelchair near the recliner. Staff #84 stated there is a call light by the resident's recliner but it was missing the call cord. She agreed that the telephone male adopter cord was attached to the call light unit and the call light cord was missing. Staff #84 stated there is supposed to be a call light button attached to the unit but it was missing. The CNA stated that she would notify maintenance to attach a cord to the call light near the recliner. On October 28, 2021 at 11:15 a.m., a conversation between staff #84 and a Licensed Practical Nurse (LPN/staff #58) occurred in the presence of the surveyor. Staff #84 notified staff #58 that a call light was missing near resident #29's recliner. Staff #58 walked with the surveyor into the resident's room and agreed that the call light was missing near the resident's recliner. Staff #58 stated that a call light cord should have been attached on the call light unit so that resident could ask for help when she is seated in the recliner and needs help. Staff #58 said the resident presses her call light although she could be confused at times. An interview was conducted on October 28, 2021 at 2:06 p.m. with the Assistant Director of Nursing (ADON/staff #115). The ADON stated that there should have been a call light cord by the recliner because it was there last week. She stated that she would tell maintenance to put another call light by the resident's recliner. The ADON also stated there is an increased risk for falls without the call light being available because the resident could not ask for help. During the interview, the ADON also reviewed the physician orders dated July 20, 2017 for fall precaution every shift, landing strip, low bed, alarms, foot rests on with calf pad attached, and resident should be discouraged from elevating feet on bed. Staff #115 stated the physician order was not followed because the facility had not used alarms for at least 3 to 4 years. The ADON stated the physician orders should have been taken off or clarified for a different order to prevent falls. Review of the facility's Fall Prevention Protocol policy reviewed July 2014 revealed the goal was to identify and eliminate or modify risk factors and thereby reduce the likelihood of an accident occurring or reoccurring. The policy included interventions should be immediate after every fall, assess the need for bed alarm, floor alarm, or chair alarm, and assess the environment and make appropriate changes (call light and fluids within reach, non-slip footwear, walker/wheelchair easily accessible, etc.).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure one resident (#20) received timely and adequate assistance at meal times. The sample size was 4. The deficient practice increased the risk for not meeting the nutritional needs of the resident. Findings include: Resident #20 was readmitted to the facility on [DATE] with diagnoses that included unspecified severe protein-calorie malnutrition, paroxysmal atrial fibrillation, and unspecified dementia without behavioral disturbance. A nursing progress note dated 09/17/21 at 6:56 p.m. included that the resident was alert to self, required maximum assistance for ADLs (activities of daily living), had right sided flaccidness, and right lower leg internal rotation. Additionally, the note stated that the resident needed assistance for feeding at that time, per the hospital, and that the resident's diet was pureed with thin liquids. Review of the baseline care plan dated 09/17/21 revealed the resident had potential for compromised nutritional status. The goal was that the resident would attain/maintain optimal nutritional status. Interventions included the resident would be encouraged to eat in the dining room. A physician's order dated 09/17/21 revealed for a regular diet, pureed texture, regular/thin liquids consistency and Medpass 2.0 (supplement) 3 ounces (oz), 3 times daily for supplement. A skilled nursing progress note dated 09/19/21 at 2:14 p.m. included that the resident required 1:1 assistance for meals, had a poor appetite for breakfast, but had a good lunch. The Weight Summary dated 09/19/21 revealed that the resident's weight was 95.0 Lbs. Review of the Plan of Care (POC) Certified Nursing Assistant (CNA) documentation dated 09/19/21 revealed the resident ate between 26% - 50% of breakfast, 0% of lunch, and the resident refused dinner. The documentation did not indicate whether or not the resident had been offered/given assistance with meals. A Speech Therapy Evaluation & Plan of Treatment dated 09/21/21 revealed the resident required close supervision (1:1 assist) for oral intake. A physician's order dated 09/22/21 revealed for Magic cup (supplement) twice daily between meals as a supplement. The Weight Summary revealed the resident's weight was 90.9 Lbs. on 09/26/21. Review of the CNA POC task documentation dated 09/28/21 revealed the resident had been provided setup help and supervision for breakfast and lunch. The documentation indicated that the resident had eaten 0-25% of both meals. The resident was provided with 1-person limited assistance with dinner, and ate 51%-75% of the meal. CNA POC task documentation dated 09/29/21 revealed the resident received 1-person physical assistance with all meals. The resident consumed 51%-75% of breakfast and dinner, and 0-25% of lunch. A Cardiovascular & Coagulations progress note dated 09/29/21 at 9:32 p.m. included that the resident needed extensive assistance with ADLs, transfers, and mobility. The note stated that the resident dined in her room with 1:1 assistance but that she continued to have difficulty swallowing, and pocketed food and crushed medication in her mouth. Even when the resident was cued to swallow, the resident stared and said, uh-huh. A registered dietitian progress note dated 10/01/21 at 1:31 p.m. revealed that the resident's current meal and supplements were likely to be meeting the resident's estimated energy needs, but that the current meal and supplement intakes did not explain the continued significant weight loss. The note included Medpass would be increased to 4 times per day to provide an additional 315 kcal and 13 grams of protein. A skilled nursing progress note dated 10/02/21 at 9:31 a.m. stated that the resident was now going to the dining room for assistance. Review of the Weight Summary dated 10/03/21 revealed the resident weighed 92.4 Lbs. The POC CNA meal documentation (percentage eaten/support provided) dated 10/03/21 through 10/11/21 revealed for the following: -The resident received no assistance or supervision/oversight for 9 meals. -The resident received limited assistance for 6 meals. -The resident received extensive-total assistance for 10 meals. -The resident refused 1 meal. -The resident ate 0-25% of 13 meals. -The resident ate 26%-50% of 3 meals, and -The resident ate 51%-75% or more of 10 meals. The Weight Summary revealed the resident weighed 89.2 Lbs. on 10/11/21. A Cardiovascular & Coagulations progress note dated 10/12/21 at 9:16 a.m. included that the resident continued to lose weight. The note stated that the resident needed to be encouraged to drink, eat, and swallow. The POC CNA meal documentation (percentage eaten/support provided) dated 10/12/21 through 10/17/21 revealed for the following: -The resident received supervision/oversight for 5 meals. -The resident received limited assistance for 3 meals. -The resident received extensive-total assistance with 10 meals. -The resident ate 0-25% of 9 meals. -The resident ate 26%-50% of 5 meals, and -The resident ate 51%-75% or more of 4 meals. Review of the Weight Summary dated 10/17/21 revealed the resident weighed 89.0 Lbs., for a total loss of 6.32% in one month. Further review of the POC CNA meal documentation dated 10/18/21 through 10/26/21 included for the following: -The resident received supervision/oversight for 13 meals. -The resident received limited assistance for 3 meals. -The resident received extensive-total assistance for 7 meals. -On 1 occasion, activity did not occur. -The resident ate 0-25% of 4 meals. -The resident ate 26%-50% of 9 meals, and -The resident ate 51%-75% or more of 14 meals. On 10/25/21 at 11:43 a.m., a dining observation was conducted in the [NAME] Room/dining room. Resident #20 sat alone at a horseshoe table and was observed as she repeatedly picked up an empty cup and put it to her mouth, as if to take a drink. She was also observed to pick up the knife, lightly poke it into the food, bring the knife to her mouth, and touch it to her lips. She then placed the knife into her lap. At 12:08 p.m. a Licensed Practical Nurse (LPN) sat next to the resident and began to assist the resident with her meal. After the resident had taken a few bites, the LPN got up to assist someone else. The resident was not observed to eat any more of the meal. A dining observation was conducted on 10/26/21 at 8:29 a.m. The resident sat in the wheelchair, alone in her room. The resident's meal tray had been left in front of her on the over-the-bed table. The plate covers had been left over the food. The resident looked confused as she touched the top of the plate cover. At 8:40 a.m., the resident drank the coffee but was not observed to eat any of the meal. On 10/26/21 at 12:40 p.m. the resident's family member was observed in the resident's room, assisting the resident with the meal. No staff supervision was observed. An interview was conducted on 10/27/21 at 12:05 p.m. with an LPN (staff #38). She stated that the resident should have supervised meals and be offered 1:1 staff assistance. She said the resident will generally not eat if staff do not assist her. Staff #38 stated that the resident will pick up a glass and drink from it on her own, but she will not generally eat without prompting and assistance. She stated that the resident's family visits almost every day and the family often provided the resident with assistance for meals, but that the family was not responsible for ensuring the resident eats. The LPN stated the resident should be monitored during meal time due to swallowing issues, and should not be left alone in her room to eat. The LPN stated a staff member should always be present while the resident's family assists the resident with meals. The LPN stated that if the resident was not being provided assistance with meals, and the resident was losing weight because of it, it would not meet her expectation. The LPN stated that it is her job to ensure that staff are assisting the resident at meal time. On 10/27/21 at 1:06 p.m., an interview was conducted with a Certified Nursing Assistant (CNA/staff #106). She stated that if a resident is unable to eat by themselves, she would help them to eat and offer encouragement to eat. The CNA stated that she has assisted the resident with eating when it looks like the resident needs it, but that the resident's family comes a lot and they help the resident. An interview was conducted on 10/28/21 at 11:39 a.m. with the Assistant Director of Nursing (ADON/staff #115). The ADON stated that she knows the resident needs assistance with eating. The facility policy titled Activities of Daily Living included that recognizing the potential for a resident's abilities in ADLs to decline, the facility promotes each resident's dignity and independence by providing needed ADL assistance to those residents who may need assistance with maintenance of nutrition. The charge nurse is responsible for communicating each resident's individualized needs for the appropriate level of assistance with ADLs and monitoring assistance being provided to the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident and staff interviews, and review of policy, the facility failed to ensure one of two sample residents (#52) was administered oxygen in accordance with the physician order. The deficient practice could result in residents receiving oxygen not according to physician orders. Findings include: Resident #52 was admitted to the facility on [DATE], with diagnoses that included interstitial lung disease, dependence on supplemental oxygen, cardiovascular accident, and hypertensive heart disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 11 on the Brief Interview for Mental Status (BIMS) which indicated the resident had moderately impaired cognition. The MDS assessment also included that the resident had shortness of breath, and received oxygen therapy. Review of the clinical record revealed a physician order dated October 12, 2021 for oxygen at 3 liters per nasal cannula with humidifier to keep oxygen saturation above 90%. A review of the care plan revealed oxygen administration was not included in the plan of care. During an observation conducted on October 25, 2021 at 12:24 p.m., the resident was observed sitting in a wheelchair receiving oxygen at 3.5 liters per nasal cannula. The oxygen humidifier container for 250 cc (cubic centimeters) of water was observed to be completely empty. The MAR (Medication Administration Record) for October 2021 revealed the resident's oxygen saturation was 95% on the day shift on October 25, 2021. On October 26, 2021 at 1:10 p.m., the resident was observed sitting in the wheelchair, receiving oxygen at 3.5 liters per nasal cannula. Again, the oxygen humidifier container was observed to be completely empty. Review of the MAR dated October 2021 revealed that the resident's oxygen saturation was 97% on the day shift on October 26, 2021. Continued review of the clinical record did not reveal a physician's order had been obtained to increase the oxygen to 3.5 liters or to discontinue the use of the humidifier. An interview was conducted on October 28, 2021 at 9:57 a.m. with an RN (Registered Nurse/staff #23). The RN stated oxygen therapy is only administered by the licensed nurses according to the physician order, because oxygen is considered a medication. The nurse stated that the humidifier and oxygen tubing are changed every 72 hours. An interview was conducted on October 28, 2021 at 2:38 p.m. with the ADON (Assistant Director of Nursing/staff #115). The ADON stated that her expectation is that oxygen therapy be administered according to the physician order. She stated if the staff changed the amount of oxygen to be delivered to the resident, the physician must be notified first. The ADON also stated the humidifier should have been filled with distilled water if ordered. The facility's policy for medication management reviewed January 2018 stated that in order to promote and maintain each resident's physical and mental well-being relative to his/her medication administration regimen, medication management shall be provided in accordance with professional standards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility documents, and staff interviews, the facility failed to ensure quality control testing for glucometers was complete. The deficient practice could result in not being aware of glucometers that were not functioning properly. Findings include: -An observation was conducted on October 28, 2021 at 01:58 PM of the Mesquite Med cart #1 with a Licensed Practical Nurse (LPN/staff #28). The blood glucose meter control solution record had no control test results recorded for the 25th or 18th of October. All other values for these two dates were filled in with the exception of the testing result. -An observation was conducted on October 28, 2021 at 02:28 PM of the La [NAME] unit med cart with an LPN (staff #58). The blood glucose meter control solution record for the month of October revealed that the control result for the 20th of October was left blank. The other values were filled in with the exception of the control solution test result. An interview was conducted on October 28, 2021 at 3:00 PM with the Assistant Director of Nursing (ADON/staff #115). The ADON stated that glucometers must be checked nightly for control readings and it is the expectation that the control result be filled in the same time the rest of the values are filled out on the control solution form. The ADON stated it does not meet her expectations that glucose control solution readings are not filled in when filling in the rest of the control solution record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Regarding expired medications and supplies -An observation was conducted on October 28, 2021 at 12:11 PM of the Mesquite Med Room with a Registered Nurse (RN/staff #23). The following were observed: two infusion set with Huber needle and wing with an expiration date of 08/31/2021; two stat-lock stabilization devices for PICC with an expiration date of 04/28/21 and 08/28/21; one 7-day vaginal cream miconazole nitrate USP 2% (antifungal) with an expiration date of 9/20/21; three bottles of unopened biotin (supplement) 500 mcg (micrograms) 60 tablets with an expiration date of 08/21/21; and three heparin lock flush 50 units per 5ml (milliliters) with an expiration date of 09/01/21. During this observation, an interview was conducted with the RN (staff #23), who stated expired medications should not be in the medication room, and should be disposed of in the biohazard bins. Staff #23 stated that the presence of expired medications in the medication room increased the risk of administering expired medications to residents. Staff #23 stated that three different entities are in charge of ensuring which portion of the medication room is kept up: Central Supply, the Pharmacy, and the nursing staff. The RN stated that typically, when an expired medication is located, central supply is notified, who is supposed to dispose of the medication in the biohazard bins and replace the medication with one that is in date. -An observation was conducted on October 28, 2021 at 12:44 PM of the Saguaro Med Room with a Licensed Practical Nurse (staff #58). The following were observed: three BD Vacutainer vials with an expiration date of 03/31/21; three BD vacutainer C&S (culture & sensitivity) Transfer straw kit with an expiration date of 09/2020, 05/2021, and 07/2021; a bottle of non-aspirin pm with acetaminophen 500 mg (milligrams) + diphenhydramine (antihistamine) 25 mg with an expiration date of 08/2021; ten E-swab collection and preservation of aerobic, anaerobic, and fastidious bacteria with an expiration date of 09/30/21. During this observation an interview was conducted with the LPN (staff #58), who stated expired medications are returned to the pharmacy by placing the medications in a brown return bag in the med room sink. Staff #58 stated that the Pharmacy is called to come and pick up the discarded medications. When prompted, staff #58 stated they were not aware of any biohazard medication disposal. Staff #58 stated expired meds in the med room enhance the risk of administering expired medications to residents. Staff #58 concluded the interview by throwing the expired meds in the med room trash can. Later at 2:28 PM, staff #58 stated that they were informed by another staff member that they had to dispose of expired meds in the biohazard bins. Staff #58 stated that she retrieved the medications from the trash and disposed of them in the biohazard bins. -An observation was conducted on October 28, 2021 at 01:58 PM of the Mesquite Med cart #1 with an LPN (staff #28). The med cart was observed to have an open BD testing solution with no open date on the testing solution box. Three heparin lock flush 50 units per 5ml in the cart were observed with an expiration date of 09/01/2021. During this observation an interview was conducted with staff #28. Staff #28 stated that no residents were currently on heparin flush, and medications are checked for expiration dates prior to administration of medications. Staff #23 stated that med carts are checked monthly when the Director of Nursing (DON) performs cart audits. -An observation was conducted on October 28, 2021 at 02:28 PM of the La [NAME] unit med cart with an LPN (staff #58). Observed in the med cart was one Optifoam gentle sacrum dressing with an expiration date of 03/20/21, and two BD Vacutainer Urine C&S Preservative specimen tubes with an expiration date of 05/2021. During this observation an interview was conducted with staff #58. The LPN stated the med cart is typically cleaned monthly. Staff #58 stated the BD Vacutainer tubes came from the pharmacy and therefore was overlooked for expiration dates as it was the pharmacy's responsibility to check. An interview was conducted on October 28, 2021 at 3:00 PM with the Assistant Director of Nursing (ADON/staff #115), who stated that the medications that cannot be given to residents are either disposed of in a biohazard bin or returned to the pharmacy. The ADON stated that med cart audits are conducted and nurses are to sign off on their carts to ensure that nothing is expired in the cart. The ADON stated that for the med rooms, three parties are responsible for maintenance. Staff #115 stated the central supply employee ensures the over the counter medications are managed, the pharmacy ensures prescription medications are maintained, and periodically nurses clean out the med room and ensure that things that are expired are located and removed. The ADON stated it does not meet her expectations that there be expired meds in the med rooms or med carts. The ADON stated it does not meet her expectations that expired medications and biologicals are disposed of in the trash. A facility policy titled Medication Management stated in the subsection Medication storage that expired or discontinued medications should be disposed of in accordance with the Pharmacy policies and procedures. Based on observations, staff interviews and facility policy review, the facility failed to ensure medication was securely stored, and expired medications and supplies were not available for use. The deficient practice could result in misappropriation of resident medications, expired medications being administered to residents, and expired supplies being used. The census was 70. Findings include: Regarding unsecured medication During a medication administration observation conducted on October 27, 2021 at 07:52 am, a Licensed Practical Nurse (LPN/staff #116) was observed preparing medication for a resident. The staff was observed to prepare oral medications and was observed drawing up 5 units of Insulin Lispro Solution 100 unit/ml (milliliters) in an insulin syringe. At 7:56 am, the staff was observed to leave the insulin syringe containing 5 units of Insulin Lispro on top of the medication cart unattended while she went to administer oral medications. The resident was sitting in the wheelchair in a lounge area right next to the nook where the medication cart was located. A wall separated the lounge area and the nook. When the nurse went to give the oral medication to the resident, the medication cart was not observed to be visible. An interview was conducted with another LPN (staff #6) on October 27, 2021 at 1:16 pm. She stated the staff cannot leave any medications unattended on top of the medication cart as anyone can grab the medications. She stated all medications should be secured and not easily accessible to the residents. An interview was conducted with staff #116 on October 27, 2021 at 1:29 pm. She stated that she will label and store any prepared medications inside the medication cart when the resident is not available. The LPN stated medications cannot be left on top of the medication cart unattended as another resident can grab it or the nurse can easily make a mistake and give it to the wrong resident. She further stated that it is ok to leave the medication on top of the medication cart if she is standing right by the cart but it is not ok if she leaves the medication on top of the medication cart and leaves the cart. She agreed that she left the prepared insulin syringe on top of the medication cart. The LPN stated that she placed it towards the back of the cart. She then agreed that when she went to give the resident his oral medication, she was not able to view the medication cart. She further stated that she visually looked all directions to see if anyone was coming and probably thought at the time it was safe for her to leave the insulin filled syringe on top of the cart. An interview was conducted with the Director of Nursing (DON/staff #115) on October 28, 2021 at 12:40 pm. She stated her expectation is for the staff to follow the facility policy regarding medication storage. The DON stated her expectation is for the staff not to leave any medication on top of the medication cart when walking away from the medication cart. She further stated if the medications are left unattended on top of the medication cart then another resident can come by and pick up the medication. The facility's policy titled Medication Management revised on January 2018 included, Staff shall not leave medication unattended under Medication storage.

Based on observations, staff interviews, and policies and procedures, the facility failed to ensure that food items stored in the walk-in refrigerator and freezer were stored in accordance with professional standards for food service safety. The deficient practice could result in foodborne illnesses. Findings include: -An observation of the walk-in refrigerator in the kitchen was conducted at 10:56 a.m. on October 25, 2021. During the observation, a medium sized (about 2 quarts) stainless storage container with sliced mushroom was observed without a label, date, and was partially covered with plastic wrap. The walk-in refrigerator also contained partially covered sliced turkey dated October 20, 2021. -An observation of the walk-in freezer located outside the kitchen was conducted at 11:15 a.m. on October 25, 2021. During the observation, a clear plastic bag which contained frozen mixed vegetables (about 4 quarts) was observed with a large hole, no label, no date, and was partially discolored. During the observation, there were also approximately eight packages (about 12 rolls in each package) of submarine rolls inside an opened unlabeled brown box without a freeze date. The submarine rolls were in a regular plastic bag with an expiration date stamped of April 28, 2021. During these observations an interview was conducted with the assistant food service manager (staff #80), who stated the mushrooms, sliced turkey, and frozen vegetables should be thrown out, and the frozen vegetables should have been dated and labeled. She also stated it is the policy of the facility to throw away all left-overs after three days. Staff #80 stated that she does not know how long the submarine rolls had been in the freezer because it did not have a freeze date. -A dining room observation was conducted at 11:53 a.m. on October 25, 2021. During the observation a full pitcher of pineapple juice dated 10/19/2021 was observed on the lunch beverage cart. An interview was conducted at 11:56 a.m. on October 27, 2021 with the food service manager (staff #108). She stated that if a large can was opened, such as sliced mushrooms, her expectation would be to store the unused portion in the walk-in refrigerator with the beginning date and end date. She stated her expectation included following the facility policy of discarding unused food items within 72 hours. Staff #108 also said that it is her expectation to throw away expired bread, not freeze the bread and that left-overs in the walk-in refrigerator must be dated with date placed and ending date. Review of the facility food storage and date marking policy and procedure revealed that food items should be stored, thawed, and prepared in accordance with good sanitary practice. Any expired or outdated food products should be discarded. The policy included all products should be inspected for safety and quality and be dated upon receipt, when open, and when prepared. The procedure in the policy included food must be covered, labeled, dated, and any expired or outdated food products should be discarded. The policy also included foods to be frozen should be stored in airtight containers and dated.

Based on facility documents, staff interviews, facility policy, the Center for Medicare and Medicaid Services (CMS) Interim Final Rule requirements, and the Centers for Disease Control (CDC) guidance, the facility failed to ensure that that staff were tested for COVID-19 at the required frequency and failed to ensure testing for COVID-19 was conducted in a manner that is consistent with current standards of practice for conducting COVID-19 tests. The deficient practice could result in the spread of infection. Findings include: Regarding testing During the entrance conference meeting conducted on October 25, 2021 at 11:00 AM with the Chief Operating Officer (COO/staff #140) and the Director of Nursing (DON/staff #65), they stated that there were no active COVID-19 infections for residents and staff. They also stated unvaccinated staff are tested twice weekly for COVID-19 and that COVID-19 testing is conducted as needed for vaccinated staff. -A COVID-19 Vaccination Record Card included that staff #135, a Certified Nursing Assistant (CNA), had her first dose on September 28, 2021 and second dose on October 26, 2021. An employee time card included that staff #135 had worked on October 17 and 20, 2021. However, review of the facility testing logs revealed that staff #135 was not tested for COVID-19 during the month of October. -A COVID-19 Vaccination Record Card included that staff #64, a CNA, had her first dose on September 28, 2021 and second dose on October 26, 2021. An employee time card included that staff #64 had worked on October 18, 2021. However, review of the facility testing logs revealed that staff #64 was not tested for COVID-19 during the week of October 18, 2021 through October 24, 2021. -A facility vaccination record included that staff #102, a CNA, had been administered her first dose of COVID-19 vaccine on October 27, 2021. An employee time card included that staff #102 had worked on October 16, 17, 20, 21, 25, 2021. However, review of the facility testing logs revealed that staff #102 was not tested for COVID-19 during the month of October. -A COVID-19 Vaccine Intake Form included that staff #17, a CNA, received her first dose of vaccine on September 28, 2021. A COVID-19 Vaccination Record Card included that staff #17 had her second dose on October 26, 2021. An employee time card included that staff #17 had worked on October 19 and 21, 2021. However, a review of the Staff Testing Logs revealed that staff #17 had not been tested for COVID-19 for the week of October 18, 2021 through October 24, 2021 until the 23rd, and had not been tested at all in the prior week. An interview was conducted with the Infection Preventionist Registered Nurse (IP/staff #112) on October 28, 2021 at 3:35 PM. She stated that the current county transmission rate is high for the month of October and that testing is conducted every 3 to 7 days for high rate. Staff #112 stated that testing is conducted weekly in the facility and that the work week is Sunday through Saturday but for testing the week is Monday through Sunday. Staff #112 stated that the receptionist is supposed to check the list when staff walk in to see if they need to be tested. She stated that was all the testing that had been done on those staff. She reviewed the records and said those staff do not meet her expectation for testing. The IP stated the staff could be positive while working and that could cause a spread of the virus. An interview was conducted on October 28, 2021 at 4:31 PM with the Assistant Director of Nursing/Acting Director of Nursing (ADON/staff #115), who stated that her expectation for staff testing is that the non-vaccinated staff test per the county transmission rate. She reviewed the testing record and stated that it does not meet her expectations. A facility policy for COVID testing revealed that it is the policy of the facility to follow current CDC and CMS guidelines regarding testing of employees and that employees that are eligible for testing will be required to test based on the current county transmission rate. This policy also included that employees that are not tested per the current county transmission rate will need to be removed from the schedule until they can provide a negative COVID-19 test. The CMS Interim Final Rule related to Long-Term Care facility testing requirements stated that in response to an outbreak, all staff and residents, regardless of vaccination status, should be tested immediately, and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. Routine testing of unvaccinated staff should be based on the extent of the virus in the community. Fully vaccinated staff do not have to be routinely tested. Facilities should use their county positivity rate in the prior week as the trigger for staff testing frequency. Minimum testing frequency for unvaccinated staff for county positivity rate in the past week less than 5% (low) is once a month, for 5% - 10% (moderate) once a week, and for greater than 10% (high) twice a week. Regarding COVID-19 testing An observation was conducted on October 28, 2021 at 12:00 PM of COVID-19 testing. A Certified Nursing Assistant (CNA/staff #17) was waiting at the front reception area and had already filled out the log. The IP (staff #112) and this CNA went into a room behind the reception and closed the door. The IP was wearing a surgical mask. She opened the card and removed the swab stick from package. She donned gloves and turned to the CNA. The CNA pulled down her mask and the IP inserted the testing swab stick in each nostril, then made approximately 6 turns and then placed drops into the card and inserted swab stick into the card and turned the stick several times. The IP removed her gloves and sanitized her hands and started the clock at 12:05 PM. She checked the test at 12:20 PM. She said that the test was negative, removed solution and test from the room, took it to the front desk and handed the bottle to the receptionist then disposed of the testing swab stick and test in the trash. This IP removed the trash bag with the trash and the kit, sanitized her hands on the way and took the kit to a hazardous waste tub, then sanitized her hands. An interview conducted with this IP immediately after, included that the receptionist would sanitize the room between testing with peroxide cleaner. An interview conducted on October 28, 2021 at 1:50 PM with this CNA (staff #17) who stated that it was a normal test and that the IP (staff #112) was wearing everything that she normally wears. During an interview that was conducted on October 28, 2021 at 3:35 PM with the IP (staff #112), she stated that a face mask and gloves are the normal PPE that she wears for testing if the person is not symptomatic because she did not see any guidelines that said she had to wear any higher level of PPE. An interview was conducted on October 28, 2021 at 5:33 PM with the Chief Operating Officer (COO/staff #140), who stated that PCR tests are conducted in full PPE and point of care testing is just a mask and gloves. She stated that the facility did not have a policy on this and that they follow the CDC recommendations if they do not have a policy. The CDC Interim Guidelines for Collecting and Handling of Clinical Specimens for COVID-19 Testing, Updated Oct. 25, 2021 included, For healthcare providers collecting specimens or working within 6 feet of patients suspected to be infected with SARS-CoV-2, maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or face mask if a respirator is not available), eye protection, gloves, and a gown. This document also included that Healthcare providers can minimize PPE use if patients collect their own specimens while maintaining at least 6 feet of separation. For example, the provider should wear a face mask, gloves, and a gown.