**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to timely develop a comprehensive care plan for one out of three sampled residents (Resident 1), who refused to wear a hearing aid (a small electronic device worn in or behind the ear to amplify [increase] sounds, designed to help people with hearing loss).This failure had the potential for miscommunication and Resident 1's needs not being met. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included systolic (congestive) heart failure ([CHF], a heart disorder that causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).During a review of Resident 1's care plan titled, Resident has difficulty hearing staff, dated 11/9/2022, the care plan indicated Resident 1 received hearing aids. The care plan goal indicated for Resident 1 to be able to hear effectively during conversation. During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool) dated 6/2/2025, the MDS indicated Resident 1 had moderate cognitive (ability to think, remember and solve problems) impairment. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) for Activities of Daily Living (ADLs) such as showering/bathing self and putting on/taking off footwear. The MDS indicated Resident 1 had minimal difficulty in hearing (in some environments such as when a person speaks softly or setting is noisy).During a concurrent observation and interview on 8/11/2025 at 10:20 a.m. with Resident 1 in Resident 1's room, Resident 1 stated, she could not hear and was observed not wearing hearing aids. During a concurrent observation and interview on 8/11/2025 at 10:36 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 1's room, CNA 1 was observed speaking directly into the resident's ear. CNA 1 stated, Resident 1 refused to wear her hearing aids. During an interview on 8/11/2025 at 2:46 p.m. with the Social Services Director (SSD), the SSD stated she offered Resident 1 hearing aids in the past and the resident refused to wear them. During a concurrent interview and record review on 8/12/2025 at 11:03 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 1's care plan titled, Resident has difficulty hearing staff, dated, 11/9/2022 was reviewed. LVN 2 stated that Resident 1 often refused to wear their hearing aid and communicated with Resident 1 by speaking closer to Resident 1's ear. LVN 2 stated that hearing aids were part of Resident 1's care and her refusal should have been care-planned when constant refusal was identified, however was not done.During an interview on 8/12/2025 at 2:41 p.m. with the Director of Nursing (DON), the DON stated, staff should have initiated a care plan to address Resident 1's refusal to wear her hearing aid when the problem was first identified. During a review of facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The P&P also indicated, The comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 1 and 2), received proper treatment and assistive devices to maintain hearing abilities by failing to:Assist Resident 1 when the resident reported her hearing aids did not work properlyAssist Resident 2 when the resident reported he had concerns with hearing and ensure Resident 2 was assessed by the Otolaryngologist ([ENT doctor] specializing in the care for ear, nose and throat conditions) routinely.These failures had the potential for Residents 1 and 2 not being able to hear adequately during conversations with staff and other residents and could lead to misunderstanding or miscommunication between the residents and staff. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included systolic (congestive) heart failure ([CHF], a heart disorder that causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).During a review of Resident 1's care plan titled, Resident has difficulty hearing staff, dated 11/9/2022, the care plan indicated Resident 1 received hearing aids. The care plan goal indicated for Resident 1 to be able to hear effectively during conversation. During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool) dated 6/2/2025, the MDS indicated Resident 1 had moderate cognitive (ability to think, remember and solve problems) impairment. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) for Activities of Daily Living (ADLs) such as showering/bathing self and putting on/taking off footwear. The MDS indicated Resident 1 had minimal difficulty in hearing (in some environments such as when a person speaks softly or setting is noisy).During a concurrent observation and interview on 8/11/2025 at 10:20 a.m. with Resident 1 in Resident 1's room, Resident 1 stated, she could not hear and was observed not wearing hearing aids. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 2's diagnoses included metabolic encephalopathy (a change in the brain's function due to an underlying cause).During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident did not have cognitive impairment. The MDS indicated Resident 2 required supervision or touching assistance (helper provides verbal cues and/or touching/steading and/or contact guard assistance) for ADLs such as bed mobility (the ability to roll from lying on back to left and right side and return to lying on back on the bed), and transfers. The MDS indicated Resident 2 had minimal difficulty in hearing and did not use a hearing aid or hearing appliance. During a concurrent observation and interview on 8/11/2025 at 11:49 a.m., with Resident 2 in Resident 2's room, Resident 2 stated, he couldn't hear as well as he used to and believed he needed hearing aids. Resident 2 stated he had informed the Social Services Director (SSD) (date/time not specified) of his concern regarding his hearing but had not received any follow-up. During a concurrent interview and record review on 8/12/2025 at 9:52 a.m., with Medical Records (MR), Resident 2's ENT Doctor exams were reviewed. MR stated Resident 2's most recent ENT exam was on 9/24/2024.During an interview on 8/12/2025 at 10:29 a.m. with Certified Nurse Assistant (CAN) 1, CNA 1 stated Resident 1 notified her that her hearing aids did not work and had informed Licensed Vocational Nurse (LVN) 2 and the SSD (date not specified). During an interview on 8/12/2025 at 11:03 a.m. with LVN 2, LVN 2 stated he was not aware of Resident 1's report that the resident's hearing aids did not work. LVN 2 stated Resident 1 was hard-of-hearing and had seen Resident 1 without her hearing aids and had to communicate with the resident by coming in closer while speaking with her.During a concurrent interview and record review on 8/12/2025 at 12:12 p.m., with the SSD, Resident 1's hearing exam, dated 5/18/2025, Resident 2's hearing exam, dated 9/25/2024, and Social Service Progress Notes for Resident 2 were reviewed. SSD stated all residents should be seen routinely by the ENT doctor every six months or at least twice a year. The SSD stated Resident 2 should have been seen by the ENT doctor on 05/2025 however the resident was not. The SSD also stated there was no documentation to indicate why Resident 2 was not seen by the ENT in 05/2025. The SSD stated there should have been documentation from Social Services to ensure Resident 2's hearing needs were assessed routinely.During an interview on 8/12/2025 at 2:24 p.m., with the Director of Nursing (DON), the DON stated CNAs should report and document any concerns with resident hearing devices as soon as they're identified so the resident's devices could be fixed as needed. During a review of facility's undated Job Description for, Director of Social Services, the job description indicated, General Duties and Responsibilities included: Coordinate social service activities with other departments as necessary and assure that the social service progress notes are informative and descriptive of the services provided and of the resident's response to the service.During a review of facility's undated policy and procedure (P&P) titled, Hearing Aid, Care of, the P&P indicated, The purpose of this procedure is to maintain the resident's hearing at the highest attainable level. The P&P indicated to, Assess the resident's knowledge of operating the hearing aid and to report complaints to the nurse supervisor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan for one of three sampled residents (Resident 1) who had a diagnosis of osteopenia (a decrease in bone mineral density and causes bones to get weaker). This deficient practice had the potential for staff not to properly care for Resident 1 and placed the resident at risk for further injuries and fractures (broken bone). Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included fracture, contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that caused the joints to shorten and become very stiff) and other specified disorders of bone density and structure of the right shoulder. During a review of Resident 1's History and Physical (H&P), dated 1/14/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 11/22/2024, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 was totally dependent on staff for activities of daily living (ADLs) such as eating, oral hygiene, toileting hygiene, showering, upper body dressing, bed mobility (the ability to roll from lying on back to left and right side and return to lying on back on the bed) and transfers. During a review of Resident 1's X-ray (image of the structures inside of the body, its organs and other internal structures for diagnostic purposes) Report dated 4/24/2021, the Report indicated Resident 1 had diffused osteopenia. During a review of Resident 1's care plan titled, Diffuse Osteopenia, Risk for: Joint deformities, pain, spontaneous fracture, decline Range of Motion (ROM), dated 3/15/2025, the care plan interventions included to handle resident gently during care especially when moving, turning and repositioning the resident and to observe for joint bone pain and stiffness and notify doctor accordingly. During an interview with the Director of Nursing (DON) on 5/5/2025 at 11:08 a.m., the DON stated the care plan for osteopenia did not have the location of the osteopenia. The DON stated the purpose of the care plan was to guide the care of the residents and the care plan should have been more specific for the resident. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated a comprehensive, person-centered care plan included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) assessments for three of 19 sampled residents (Residents 23, 19, and 24) were completed and documented accurately. This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding Residents 23, 19, and 24's health status. This deficient practice also created the potential for Residents 23, 19, and 24 to not receive the care and interventions needed to reach their highest practicable physical and psychosocial well-being. Findings: 1. During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was admitted to the facility on [DATE]. Resident 23's admitting diagnoses included oropharyngeal phase dysphagia (swallowing problems occurring in the mouth and/or the throat). During a review of Resident 23's Minimum Data Set (MDS, a resident assessment tool), dated 3/6/2025, the MDS indicated Resident 23 had mild cognitive impairment (a condition where memory and thinking problems are noticeable but not severe enough to interfere with daily activities). The MDS indicated Resident 23 required substantial to maximal assistance from staff to roll from left to right while in bed. The MDS did not indicate Resident 23 had any dental concerns, including broken natural teeth or fragments of teeth. During an observation on 3/25/2025 at 9:43 a.m., Resident 23 was observed with foul mouth odor and poor/missing dentition. The teeth present were black in color and appeared broken and/or fragmented. During an interview on 3/26/2025 at 10:48 a.m., with the Minimum Data Set Nurse (MDSN), the MDSN stated one of the purposes of the MDS assessment was to assist with care planning and to ensure residents received the care they needed. The MDSN stated that the MDS identifies the care areas that need to be addressed. During a concurrent interview and record review, on 3/26/2025 at 10:54 a.m., with the MDSN, Resident 23's MDS Section L, dated 3/6/2025, was reviewed. The MDSN stated she completed Resident 23's MDS dated [DATE], and stated the MDS did not indicate Resident 23 had any dental concerns. The MDSN stated Resident 23's current dental status met the MDS criteria for obvious or likely broken teeth and stated Resident 23's MDS was not accurate. The MDSN stated the MDS assessment should be accurate and stated an inaccurate MDS assessment could lead to Resident 23 not receiving necessary dental care. 2. During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including dysphagia (difficulty swallowing), dementia (progressive state of decline of mental abilities), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently) and muscle weakness. During a review of Resident 24's MDS, dated [DATE], the MDS indicated Resident 24's cognitive skills was intact. The MDS indicated Resident 24 required maximum assistance from staff for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves.) During concurrent observation and interview on 3/24/2025 at 11:13 a.m., in Resident 24's room, Resident 24 was observed sitting up in bed with no upper and lower teeth. Resident 24 stated she did not have any natural teeth and oft or puree foods. During a concurrent interview and record review on 3/25/2025 at 3:05 p.m., with the MDSN, Resident 24's MDS, dated [DATE] was reviewed. The MDSN stated Resident 24's MDS oral/dental assessment was coded incorrectly and did not reflect the resident's actual oral and/or dental status. The MDSN stated because Resident 24 did not have natural teeth, and the MDS should have been coded correctly. The MDSN stated inaccuracy of the MDS assessment had the potential to result in not meeting the resident's care needs and services. 3. During a review of Resident 19's admission Record, the facility admitted Resident 19 on 9/28/2023 and readmitted Resident 19 on 1/14/2025 with diagnoses including diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness (loss of muscle strength), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and anxiety (feeling of fear). During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 19 required maximum (helper does more than half the effort) assistance from staff for ADL's. During a telephone interview on 3/24/2025 at 2:59 p.m., with Resident 19's responsible party (RP 1), RP 1 stated Resident 19 did not have any natural teeth and was on a pureed diet (foods that have been blended or mashed into a smooth, pudding-like consistency). During an observation on 3/26/2025 at 9:40 a.m., in the facility's dining room, Resident 19 was observed sitting up in wheelchair eating pureed food with no upper and lower teeth. During a concurrent interview and record review on 3/26/2025 at 9:46 a.m., with the MDSN, Resident 19's MDS, dated [DATE] was reviewed. The MDSN stated she was aware of Resident 19 not having any natural teeth. The MDSN stated Resident 19's MDS oral/dental status assessment was coded incorrectly and did not reflect the resident's actual oral and/or dental status. The MDSN stated because Resident 19 did not have natural teeth, the MDS should have been coded correctly. The MDSN stated inaccuracy of the MDS assessment had the potential to result in not meeting the resident's care needs and services. During a review of the facility's policy and procedure (P&P) titled Certified Accuracy of the Resident Assessments, revised on 11/2019, the P&P indicated any person completing a portion of the Minimum Data Set must sign and certify the accuracy of that portion of the assessment. The P&P also indicated the information captured on the resident assessment should reflect the status of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR, a screening tool that helps identify possible serious mental illness [SMI], and if the resident requires specialized services) was submitted for one of four sampled residents (Resident 74). This deficient practice placed Resident 74 at risk of not receiving recommended or required treatments for diagnosed SMIs, or appropriate placement in a facility to meet Resident 74's needs. Findings: During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was admitted on [DATE] and was most recently readmitted on [DATE]. Resident 74's admitting diagnoses included psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), and anxiety disorder (a group of mental health conditions characterized by excessive and persistent fear or worry, often interfering with daily life). During a review of Resident 74's Minimum Data Set (MDS, a resident assessment tool), dated 2/5/2025, the MDS indicated Resident 74 did not have any cognitive impairments (difficulties with thinking, learning, remembering, and making decisions). The MDS indicated Resident 74 required substantial to maximal assistance from staff for bed mobility. During a review of Resident 74's Level I PASRR assessment, dated 1/15/2025, the Level I PASRR assessment indicated the individual completing the assessment was to indicate whether the resident had a diagnosed SMI. Resident 74's Level I PASRR did not reflect his SMI diagnoses of psychosis, depression, or anxiety disorder. During a review of Resident 74's PASRR determination letter, dated 1/15/2025, the determination letter indicated Resident 74 did not require a Level II PASRR Mental Health Evaluation because the Level I PASRR indicated Resident 74 did not have any SMIs. During an interview on 3/26/2025 at 1:22 p.m., with the Social Services Director (SSD), the SSD stated that the Level I PASRR was completed by the hospital, prior to the resident's admission to the facility. The SSD stated she reviewed the Level I PASRR's upon the resident's admission to the facility. The SSD stated that if the Level I PASRR was not completed accurately by the hospital staff, she completed a new Level I PASRR for submission to the required agencies. During a concurrent interview and record review, on 3/26/2025 at 1:26 p.m., with the SSD, Resident 74's Level I PASRR, dated 1/15/2025, was reviewed. The SSD stated the Level I PASRR did not reflect Resident 74's SMIs of psychosis, depression, and anxiety disorder. The SSD stated a new and accurate Level I PASRR should have been completed and submitted but was not. The SSD stated the purpose of the PASRR assessment was to ensure residents received mental health services and recommendations, and an inaccurate assessment prevented the resident from receiving those services. During a review of the facility's policy and procedure (P&P) titled Preadmission Screening and Resident Review, dated 4/2017, the P&P indicated all residents admitted to the facility were to have a Level I PASRR completed to identify residents with serious mental illness (SMI) and ensure those residents received the services they required for their SMI, and in the appropriate setting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 3/24/2025 at 10:05 a.m., in Resident 191's room, observed Resident 191 lying in bed receiving supplemental oxygen via a nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) at three liters per minute. Observed Resident 191's room did not have an oxygen sign posted outside of the room's doorway. During a review of Resident 191's admission Record, the admission record indicated Resident 191 was initially admitted on [DATE] and readmitted on [DATE]. The admission record indicated the following diagnoses which included Parkinson's (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), acute respiratory failure with hypoxia (when the lungs suddenly fail to adequately provide oxygen to the body, resulting in a dangerously low level of oxygen in the blood), dependence on supplemental oxygen, pneumonia (an infection/inflammation in the lungs), congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 191's History and Physical (H&P), dated 2/5/2025, the H&P indicated Resident 191 did not have the capacity to understand and make decisions. During a review of Resident 191's MDS, dated [DATE], the MDS indicated Resident 191's cognition was severely impaired. The MDS indicated Resident 191 was dependent (helper does all the effort) on staff for oral hygiene, toileting and bathing. During a review of Resident 191's Order Summary Report dated 3/26/2025, the order summary report indicated an order for oxygen via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) at 2 liters per minute (LPM) every shift for hypoxia. During a review of Resident 191's care plan titled, Congestive Heart Failure, undated, the care plan indicated Resident 191 had potential shortness of breath (difficulty breathing), chest pains, irregular pulse (heart rate), and elevated blood pressure (the force of your blood pushing against the walls of your blood vessels (like the tubes that carry blood) as your heart pumps) related to compromised cardiac (heart) function. The care plan interventions indicated to administer continuous oxygen at 2 LPM. During a concurrent interview and record review on 3/26/2025 at 12:40 p.m. with Licensed Vocational Nurse (LVN) 3, Resident 191's care plans were reviewed. LVN 3 stated she could not find a care plan regarding Resident 191's oxygen administration. LVN 3 stated an oxygen care plan was important because it would have oxygen parameters, when to call the doctor and how to use the oxygen safely. LVN 3 stated the MDS Nurse (MDSN) usually initiates a care plan upon admission, or any licensed nurse can initiate the oxygen care plan. LVN 3 stated if Resident 191's oxygen was started after admission, a change of condition should have been initiated along with an oxygen care plan. During an interview on 3/26/2025 at 12:48 p.m. with the MDSN, the MDSN stated the use of oxygen should be care planned. The MDSN stated the admitting nurse should have updated the care plans. The MDSN stated Resident 191's oxygen care plan should have been restarted when she was readmitted to the facility. The MDSN stated without a care plan there are no interventions (the actions a nurse takes to help residents achieve their health goals) on how to monitor Resident 191's oxygen saturation (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) and when to call the doctor. The MDSN stated without an oxygen care plan, Resident 191's oxygen therapy was not being monitored and there were no goals or outcomes of when to discontinue the resident's oxygen. During an interview on 3/27/2025 at 10:03 AM with the Director of Nursing (DON), the DON stated there should be a care plan for oxygen therapy. The DON stated moving forward, the facility would ensure an oxygen care plan was done for all residents receiving oxygen so that the nursing staff would know the parameters, when to call the doctor, when to change the tubing and apply the oxygen signage. During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated the care plan described the services staff were to provide to allow the resident to achieve their highest practicable physical, mental, and psychosocial well-being. During a review of the facility's P&P titled Bed Safety and Bed Rails, revised 8/2022, the P&P indicated additional safety measures were to be implemented for residents identified as having a higher than usual risk for injury. During a review of the facility's P&P titled, Resident Assessment: Care Planning - Interdisciplinary Team, undated, the P&P indicated the facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized care plan for each resident and the care plan is based on the resident's comprehensive assessment. Based on observation, interview, and record review, the facility failed to ensure care plans (a document that outlines a resident's care needs, diagnosis, and treatment goals) were developed and/or implemented for two of 19 sampled residents (Residents 288 and 191) when: 1. Resident 288 did not have padding on her siderails. 2. Resident 191, who was receiving oxygen, did not have an oxygen sign posted outside her doorway. These deficient practices placed Resident 288 at risk for physical harm and injury and had the potential to delay necessary monitoring and safety interventions (actions nurses take to help residents achieve their care plan goals) related to Resident 191's oxygen administration. Findings: 1. During a review of Resident 288's admission Record, the admission record indicated Resident 288 was admitted to the facility on [DATE]. Resident 288's admitting diagnoses included epilepsy (a neurological condition characterized by recurrent seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]). During a review of Resident 288's Minimum Data Set (MDS, a resident assessment tool), dated 3/8/2025, the MDS indicated Resident 288 had severe cognitive impairment (a significant decline in cognitive abilities that interferes with daily functioning and daily living). The MDS indicated Resident 288 had impairments to her lower extremities (legs) on both sides of her body and was dependent for staff for mobility while in and out of bed. During a review of Resident 288's care plan titled High risk for trauma/injuries related to: Seizure Disorder, dated 3/6/2025, the care plan indicated staff were to apply padding to both siderails while the resident was in bed. During an observation on 3/24/2025 at 2:29 p.m., at Resident 288's bedside, Resident 288 was observed lying in bed with metal siderails to both sides of her bed. No padding was applied to either siderail. During an observation on 3/25/2025 at 1:38 p.m., at Resident 288's bedside, Resident 288 was observed lying in bed with metal siderails to both sides of her bed. No padding was applied to either siderail. During an interview on 3/26/2025 at 2:52 p.m., with Registered Nurse Supervisor (RN) 1, RN 1 stated that when a resident has a diagnosis of seizure disorder, staff were to apply padding to the siderails of the bed. During a concurrent interview and record review on 3/26/2025 at 2:54 p.m., with RN 1, Resident 288's care plan titled High risk for trauma/injuries related to: Seizure Disorder, dated 3/6/2025, was reviewed. RN 1 stated the care plan indicated Resident 288 had a diagnosed seizure disorder and the care plan interventions indicated Resident 288 was to have padding on both of her siderails. RN 1 stated the purpose of padding the siderails was to prevent injury if Resident 288 were to have a seizure while in bed. During a concurrent observation and interview, 3/26/2025 at 2:56 PM, at Resident 288's bedside, with RN 1, Resident 288 was observed lying in bed with her head leaning against the siderail on the right side of her bed. RN 1 stated there was no padding to either of Resident 288's siderails. RN 1 stated Resident 288 was at risk for injury and could hurt herself if she were to have a seizure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure interventions to prevent the development or worsening of pressure ulcers (PU, localized damage to the skin and/or underlying tissue usually over a bony prominence) were implemented for four of seven sampled residents (Residents 288, 74, 23, and 191) when: 1. Low-air-loss-mattress (LALM, a mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) settings were incorrect for Residents 288, 74, and 191. 2. Resident 23 was not provided with a LALM as ordered by the resident's physician. 3. Resident 191's LALM was labeled with the wrong resident's name and weight settings. These deficient practices placed Residents 288, 74, 23, and 191 at risk for the development or worsening condition of existing pressure ulcers. Findings: 1. During an interview on 3/26/2025 at 9:15 a.m., with the Treatment Nurse (TN), the TN stated LALMs created air flow to stabilize pressure within the mattress, and relieved pressure placed on the resident's skin. The TN stated the LALM settings were based on the residents' weight, and stated the higher the weight setting, the more firm the mattress. The TN stated she, or any licensed nurse, could adjust the settings on the LALM to ensure that the settings were accurate to the resident's weight. The TN stated that if the LALM settings were not correct, there was the potential for a new PU to develop or for existing PUs to worsen. a. During a review of Resident 288's admission Record, the admission Record indicated Resident 288 was admitted to the facility on [DATE]. Resident 288's admitting diagnoses included generalized muscle weakness and other symptoms and signs involving the musculoskeletal system. During a review of Resident 288's Minimum Data Set (MDS, a resident assessment tool), dated 3/8/2025, the MDS indicated Resident 288 had severe cognitive impairment (a significant decline in cognitive abilities that interferes with daily functioning and daily living). The MDS indicated Resident 288 had impairments to her lower extremities (legs) on both sides of her body and was dependent for staff for mobility while in and out of bed. The MDS indicated Resident 288 was at risk for developing PUs. During a review of Resident 288's active physician order, dated 3/6/2025, the order indicated Resident 288 was to have a low air loss mattress (LALM) for wound management, at the 150-pound (lb., a unit of measuring weight) setting. During a review of Resident 288's weekly weight record, dated 3/25/2025, the record indicated Resident 288 weighed 154 lbs. on 3/25/2025. During an observation on 3/24/2025 at 2:18 p.m., at Resident 288's bedside, Resident 288 was observed lying in bed on a LALM. The mattress settings were set at the 350-lb. setting. During an observation on 3/25/2025 at 12:45 p.m., at Resident 288's bedside, Resident 288 was observed lying in bed on a LALM. The mattress settings were set at the 350-lb. setting. During an observation on 3/26/2025 at 8:40 a.m., at Resident 288's bedside, Resident 288 was observed lying in bed on a LALM. The mattress settings were set for the 350-lb. setting. During a concurrent interview and record review, on 3/26/2025 at 9:19 a.m., with the TN, Resident 288's LALM physician order dated 3/6/2025, and weight measurement record dated 3/25/2025, were reviewed. The TN stated the physician order indicated Resident 288's LALM was to be set at the 150-lb. setting, and stated Resident 288's most recent weight was 154 lbs. During a concurrent observation and interview, on 3/26/2025 at 9:20 a.m., at Resident 288's bedside, with the TN, the TN stated Resident 288's LALM was set for the 350-lb. setting, and stated this was not the correct setting. b. During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was admitted to the facility on [DATE] and was most recently re-admitted on [DATE]. Resident 74's admitting diagnoses included generalized muscle weakness, Stage 3 PU (full-thickness loss of skin, dead and black tissue may be visible) to the tailbone region, and Stage 4 PU (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) to the left hip, and Stage 2 PU (partial-thickness loss of skin, presenting as a shallow open sore or wound) to an unspecified buttock. During a review of Resident 74's MDS, dated [DATE], the MDS indicated Resident 74 did not have any cognitive impairments. The MDS indicated Resident 74 required substantial to maximal assistance from staff to roll left and right while in bed. The MDS indicated Resident 74 had unhealed PUs and was at risk for developing additional PUs. During a review of Resident 74's active physician order, dated 1/24/2025, the order indicated Resident 74 was to have a LALM for wound management. During a review of Resident 74's monthly weight record, dated 3/3/2025, the record indicated Resident 74 weighed 140 lbs. on 3/3/2025. During an observation on 3/25/2025 at 8:56 a.m., at Resident 74's bedside, observed Resident 74's LALM set for the 280-lb. setting. During a concurrent observation and interview on 3/25/2025 at 10:31 a.m., with Resident 74, at Resident 74's bedside, observed Resident 74's LALM set for the 280-lb. setting. Resident 74 stated the LALM was for his wounds, and stated that he would like for the mattress to be softer. Resident 74 stated the mattress was very firm, that when he woke up every morning his back hurt. Resident 74 stated the LALM was supposed to be set for his weight, and asked if the mattress could be softer. During an observation on 3/26/2025 at 8:47 a.m., at Resident 74's bedside, observed Resident 74's LALM set for the 250-lb. setting. During a concurrent interview and record review, on 3/26/2025 at 9:24 a.m., with the TN, Resident 74's LALM physician order dated 1/24/2025, and weight measurement record dated 3/3/2025, were reviewed. The TN stated Resident 74 had orders for a LALM, and stated Resident 74's most recent weight was 140 lbs. The TN stated Resident 74's LALM settings should be set according to Resident 74's weight. During a concurrent observation and interview on 3/26/2025 at 9:25 a.m., at Resident 74's bedside, with the TN, observed Resident 74's LALM set for the 250-lb. setting. The TN stated this was not the correct setting for the resident and stated it should be set for the 150-lb. setting. 2. During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was admitted to the facility on [DATE]. Resident 23's admitting diagnoses included symptoms and signs involving the musculoskeletal system and osteonecrosis (a condition where bone tissue dies due to a loss of blood supply) to his left arm. During a review of Resident 23's MDS, dated [DATE], the MDS indicated Resident 23 had mild cognitive impairment. The MDs indicated Resident 23 required substantial to maximal assistance from staff to roll from left to right while in bed. The MDS indicated Resident 23 was at risk for developing PUs. During a review of Resident 23's active physician order, dated 2/28/2025, the order indicated Resident 23 was to have a LALM for wound management. During an observation on 3/25/2025 at 9:12 a.m., at Resident 23's bedside, Resident 23 was observed lying in bed. Resident 23 did not have an LALM mattress in place. During an observation on 3/25/2025 at 12:50 p.m., at Resident 23's bedside, Resident 23 was observed lying in bed. Resident 23 did not have an LALM mattress in place. During an observation on 3/26/2025 at 8:44 a.m., at Resident 23's bedside, Resident 23 was observed lying in bed. Resident 23 did not have an LALM mattress in place. During a concurrent interview and record review, on 3/26/2025 at 9:27 a.m., with the TN, Resident 23's active physician orders were reviewed. The TN stated Resident 23 had orders for a LALM. During a concurrent observation and interview on 3/26/2025 at 9:27 a.m., at Resident 23's bedside, with the TN, the TN stated Resident 23 did not have a LALM mattress as ordered by the physician. The TN stated she could not state why Resident 23 did not have a LALM mattress. 3. During an observation on 3/24/2025 at 10:05 a.m., Resident 191's room, observed Resident 191 lying in bed on a LALM. The LALM control indicated the bed was set at 130 lbs. The LALM control was labeled with another resident's name and indicated the LALM should be set to 80 lbs. During a review of Resident 191's admission Record, the admission record indicated Resident 191 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 191's diagnoses iincluded Parkinson's (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), acute respiratory failure with hypoxia (when the lungs suddenly fail to adequately provide oxygen to the body, resulting in a dangerously low level of oxygen in the blood), contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the right and left lower legs, congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), sepsis (a life-threatening blood infection), and chronic kidney disease (damaged kidneys that cannot filter blood properly over a long period). During a review of Resident 191's History and Physical (H&P), dated 2/5/2025, the H&P indicated Resident 191 did not have the capacity to understand and make decisions. During a review of Resident 191's MDS, dated [DATE], the MDS indicated Resident 191's cognition was severely impaired. The MDS indicated Resident 191 was dependent (helper does all the effort) on staff for oral hygiene, toileting and bathing. During a review of Resident 191's Order Summary Report dated 3/26/2025, the order summary report indicated Resident 191 was ordered a LALM every shift for wound management on 3/14/2025. During a review of Resident 191's Order Summary Report dated 3/26/2025, the order summary report indicated Resident 191 was ordered a LALM set to 120 lbs. per the resident's weight of 115 lbs. every shift for wound management on 3/26/2025. During a review of Resident 191's care plan titled, Alteration in Skin Integrity: Actual Pressure Sore, undated, the care plan indicated Resident 191 had an unstageable (a type of full-thickness skin and tissue loss where the wound bed is covered by dead tissue making it impossible to determine the true depth or stage) PU to the coccyx (tailbone). The care plan goal indicated Resident 191's PU would decrease in size in the next 30 days and the risk for further skin breakdown would be reduced every day for three months. The care plan interventions indicated to use a LALM as ordered. During a review of Resident 191's care plan titled, Resident is incontinent (the inability to control the bladder [the organ that stores urine] or bowels [the organ responsible for digesting food and eliminating waste]) of Bowel and Bladder, undated, the care plan indicated Resident 191 was at risk for skin impairment and pressure sores. The care plan goal indicated Resident 191 would minimize the risks for skin impairments related to incontinence in the next three months. The care plan interventions indicated to use a pressure reducing mattress if necessary. During a review of Resident 191's Weight and Vitals Summary record, dated 3/26/2025, the Weights and Vitals Summary record indicated Resident 191 weighed 115 lbs. on 3/18/2025 and 3/25/2025. During a review of Resident 191's Braden Scale (measures the risk for development of a pressure sore) dated 3/21/2025, the Braden Scale indicated Resident 191 was chairfast (cannot walk safely and confined to a chair or wheelchair), had very limited (unable to make frequent or significant changes in position independently) mobility and was at high risk of developing PUs. During a concurrent observation and interview on 3/24/2025 at 10:25 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 191's LALM controls were observed. LVN 2 stated the LALM was for the wrong resident. LVN 2 stated the name and setting on the label was for a different resident and should not have been placed on Resident 191's LALM. LVN 2 stated having the wrong label on Resident 191's LALM could lead to confusion and an inaccurate weight setting. LVN 2 stated an inaccurate weight setting on Resident 191's LALM would cause the bed to not be therapeutic and cause skin issues if not set to the correct setting of 130 lbs. but labeled for at 80 lbs. LVN 2 stated the LALM was for the wrong patient and was not the right label or setting for Resident 191. LVN 2 stated having the wrong label and wrong LALM may have an inaccurate weight and could cause confusion. LVN 2 stated instead of being therapeutic for the resident it can cause more skin issues if it was not at set at the correct setting. During a concurrent interview and record review on 3/26/2025 at 10:29 a.m. with the TN and the Quality Assurance Nurse (QAN), Resident 191's weight was reviewed. The QAN stated Resident 191's weight was 115 lbs. and the LALM for the resident should have been set according to the resident's weight. The TN stated the LALM was administered to the wrong resident and the LALM was not set to the correct setting for Resident 191. The TN stated if Resident 191's LALM was not set according to the resident's weight, the resident's PU could worsen. The QAN stated the licensed nurse assigned to Resident 191 was responsible for ensuring the LALM was set according to the resident's weight and that the bed was labeled correctly. The QAN stated the licensed nurse did not double check to make sure Resident 191 was in the right bed. During an interview on 3/27/2025 at 10:08 a.m. with the Director of Nursing (DON), the DON stated the LALM was used to distribute airflow based on the resident's weight to prevent skin break down. The DON stated the licensed nurses should have made rounds to ensure Resident 191's LALM was set according to her weight. During a review of the facility's policy and procedure (P&P) titled Air Mattress, undated, the P&P indicated the purpose of using special air mattresses was to decrease pressure from the resident's weight in bed, and to promote the healing of or the prevention of pressure ulcers. The P&P further indicated to monitor the mattress to assure that it is functioning properly, and that air level assures that the resident's body does not touch the bed. During a review of the facility document titled Treatment Nurse Job Description, undated, the document indicated the treatment nurse was required to administer treatments as prescribed and implement interventions as indicated and as ordered by the physician. During a review of the facility's document titled, Drive: Med-Aire Melody Alternating Pressure Low Air Loss Mattress Replacement System Operating Manual, undated, the document indicated to determine the resident's weight and set the control knob to that weight setting on the control unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safety was maintained for one of two sampled residents (Resident 288) by failing to pad Resident 288's siderails. This deficient practice placed Resident 288 at risk for harm and injury. Findings: During a review of Resident 288's admission Record, the admission record indicated Resident 288 was admitted to the facility on [DATE]. Resident 288's admitting diagnoses included epilepsy (a neurological condition characterized by recurrent seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]). During a review of Resident 288's Minimum Data Set (MDS, a resident assessment tool), dated 3/8/2025, the MDS indicated Resident 288 had severe cognitive impairment (a significant decline in cognitive abilities that interferes with daily functioning and daily living). The MDS indicated Resident 288 had impairments to her lower extremities (legs) on both sides of her body and was dependent for staff for mobility while in and out of bed. During a review of Resident 288's care plan titled High risk for trauma/injuries related to: Seizure Disorder, dated 3/6/2025, the care plan interventions indicated staff were to apply padding to the siderails on both sides of the resident's bed while the resident was in bed. During an observation on 3/24/2025 at 2:29 p.m., at Resident 288's bedside, Resident 288 was observed lying in bed with metal siderails to both sides of her bed. No padding was applied to either siderail. During an observation on 3/25/2025 at 1:38 p.m., at Resident 288's bedside, Resident 288 was observed lying in bed with metal siderails to both sides of her bed. No padding was applied to either siderail. During an interview on 3/26/2025 at 2:52 p.m., with Registered Nurse (RN) 1, RN 1 stated that when a resident has a diagnosis of seizure disorder, staff were to apply padding to the siderails of the resident's bed. During a concurrent interview and record review on 3/26/2025 at 2:54 p.m., with RN 1, Resident 288's care plan titled High risk for trauma/injuries related to: Seizure Disorder, dated 3/6/2025, was reviewed. RN 1 stated the care plan indicated Resident 288 had a diagnosed seizure disorder and the care plan interventions indicated Resident 288 was to have padding on both of her siderails. RN 1 stated the purpose of padding the siderails was to prevent injury if Resident 288 were to have a seizure while in bed. During a concurrent observation and interview, 3/26/2025 at 2:56 PM, at Resident 288's bedside, with RN 1, Resident 288 was observed lying in bed with her head leaning against the siderail on the right side of her bed. RN 1 stated there was no padding to either of Resident 288's siderails. RN 1 stated Resident 288 was at risk for injury and could hurt herself if she were to have a seizure. During a review of the facility's policy and procedure (P&P) titled Bed Safety and Bed Rails, revised 8/2022, the P&P indicated additional safety measures were to be implemented for residents identified as having a higher than usual risk for injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to place oxygen signage at the room door entrance indicating oxygen was in use for one of six sampled residents (Resident 191) receiving oxygen therapy. This deficient practice had the potential to place all residents' and staff's safety at risk. Findings: During an observation on 3/24/2025 at 10:05 a.m., in Resident 191's room, observed Resident 191 lying in bed receiving supplemental oxygen via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) at three (3) liters per minute (LMP). Observed Resident 191's room did not have an oxygen sign posted outside of the doorway. During a review of Resident 191's admission Record, the admission record indicated Resident 191 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 191's diagnoses included Parkinson's (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), acute respiratory failure with hypoxia (when the lungs suddenly fail to adequately provide oxygen to the body, resulting in a dangerously low level of oxygen in the blood), dependence on supplemental oxygen, pneumonia (an infection/inflammation in the lungs), congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 191's History and Physical (H&P), dated 2/5/2025, the H&P indicated Resident 191 did not have the capacity to understand and make decisions. During a review of Resident 191's Minimum Data Set (MDS - a resident assessment tool), dated 3/18/2025, the MDS indicated Resident 191's cognition (ability to think, remember, and reason) was severely impaired. The MDS indicated Resident 191 was dependent (helper does all the effort) for oral hygiene, toileting and bathing. During a review of Resident 191's Order Summary Report dated 3/26/2025, the order summary report indicated an order for oxygen via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) at 2 LPM every shift for hypoxia. During a review of Resident 191's care plan titled, Congestive Heart Failure, undated, the care plan indicated Resident 191 had potential shortness of breath (difficulty breathing), chest pains, irregular pulse (heart rate), and elevated blood pressure (the force of your blood pushing against the walls of your blood vessels (like the tubes that carry blood) as your heart pumps) related to compromised cardiac (heart) function. The care plan interventions indicated to administer continuous oxygen at 2 LPM. During a concurrent observation and interview on 3/24/2025 at 10:25 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 observed that there was no oxygen signage posted outside of Resident 191's room. LVN 2 stated Resident 191 should have an oxygen sign posted for safety because the resident was receiving oxygen. LVN 2 stated the admitting nurse, or any staff member assigned to the resident should have made sure an oxygen sign was posted. LVN 2 stated all signs should have been posted upon admission of the resident or when the oxygen was started. LVN 2 stated the oxygen sign was important to prevent fires. During an interview on 3/27/2025 at 10:03 a.m. with the Director of Nursing (DON), the DON stated oxygen signage should have been placed on the doorway of Resident 191's room. The DON stated moving forward, the facility would ensure an oxygen care plan was done for all residents receiving oxygen so that the nursing staff would know the parameters, when to call the doctor, and to apply the oxygen signage for safety. During a review of the facility's policy and procedure (P&P) titled, Respiratory - Oxygen Administration, undated, the P&P indicated to place an Oxygen in Use sign on the outside of the room entrance door.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure their medication error rate was less than five percent (%) when Licensed Vocational Nurse (LVN) 1 failed to administer one of four randomly selected residents' (Resident 4) medications timely and as ordered by Resident 4's physician. The outcome was six medication errors out of 32 opportunities for errors, with resulted in a Medication Administration Error Rate of 18.75%, based on the following: 1. Resident 4 received six medications, Lidocaine cream (medication applied to the skin to prevent or treat pain), empagliflozin (hypoglycemic medication used to lower blood sugar levels), benztropine (anti-tremor medication), primidone (anticonvulsant medication used to treat seizure disorders [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), carbidopa-levodopa (anti-tremor medication), and docusate sodium (a stool softener), more than one hour after the permitted administration time. 2. LVN 1 applied the Lidocaine cream on Resident 4's right knee instead of Resident 4's left knee. These deficient practices had the potential for Resident 4 to experience pain, increase in tremors, low blood pressure, low blood sugar, constipation, diarrhea, and increase in seizure activity due to Resident 4's medications being administered incorrectly and outside of the scheduled time. Findings: During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscle rigidity, and slow, imprecise movements), type 2 diabetes mellitus ([DM], a disorder characterized by difficulty in blood sugar control and poor wound healing), and convulsions (also known as seizures). During a review of Resident 4's Minimum Data Set ([MDS], a resident assessment tool), dated 2/18/2025, the MDS indicated Resident 4's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 4 was dependent on staff's assistance with toileting, bathing, lower body dressing, and personal hygiene. The MDS indicated Resident 4 received hypoglycemic (low blood sugar) and anticonvulsant medication. During a review of Resident 4's History and Physical (H&P), dated 10/13/2024, the H&P indicated Resident 4 could make needs known but could not make medical decisions. During a review of Resident 4's Order Summary Report, active orders as of 3/26/2025, the Order Summary Report indicated to give: 1. Benztropine 1 milligram (mg, a unit of dose measurement), by mouth, in the morning for Parkinson's disease. 2. Carbidopa-levodopa 25-100 mg, by mouth, four times a day for Parkinson's disease. 3. Docusate sodium 100 mg, by mouth, two times a day for bowel management. Hold for loose stool or diarrhea. 4. Empagliflozin 25 mg, by mouth, in the morning for DM type 2. 5. Lidocaine cream 5%, apply to the left knee two times a day for pain management. 6. Primidone 50 mg, give 1.5 tablet, by mouth, two times a day for seizure disorder. During a concurrent observation and interview on 3/25/2025 at 11:10 a.m., in Resident 4's room, with Licensed Vocational Nurse (LVN) 1, LVN 1 checked Resident 4's blood sugar. LVN 1 stated Resident 4 did not require any insulin at that time. During a concurrent observation and interview on 3/25/2025 at 11:25 a.m., in Resident 4's room. LVN 1 reentered Resident 4's room and checked Resident 4's heart rate and blood pressure. LVN 1 stated Resident 4's blood pressure and heart rate did not meet the ordered parameters (specific instructions that dictate whether the medication is safe to administer) and she would not administer Resident 4 her blood pressure medication. LVN 1 stated she had to prepare the rest of Resident 4's medications. During a concurrent observation and interview on 3/25/2025 at 11:35 a.m., outside of Resident 4's room, LVN 1 prepared a total of six medications for Resident 4. After dispensing the medications, LVN 1 confirmed a total of five oral medications and one cream were to be administered to Resident 4. During a concurrent observation and interview on 3/25/2025 at 11:46 a.m., in Resident 4's room, LVN 1 reentered Resident 4's room and administered the five oral medications with lemonade. The five oral medications were benztropine, carbidopa-levodopa, docusate sodium, empagliflozin, and primidone. LVN 1 applied the lidocaine cream to Resident 4's right knee and after application, LVN 1 was notified of the incorrect application. LVN 1 stated the lidocaine cream was supposed to be applied to Resident 4's left knee. During a review of Resident 4's Medication Administration Audit Report, dated 3/25/2025, the Audit Report indicated Resident 4's Lidocaine cream, empagliflozin, benztropine, primidone, carbidopa-levodopa, and docusate sodium were scheduled to be administered at 9 a.m., but were administered by LVN 1 at 11:47 a.m. The Audit Report indicated Resident 4 was administered her second dose of carbidopa-levodopa at 1:10 p.m., less than two hours after the first dose administration. During an interview on 3/25/2025 at 2:15 p.m., with LVN 1, LVN 1 stated Resident 4's medications administered at 11:46 p.m. were scheduled for 9 a.m. LVN 1 stated medications had to be administered within the time permitted which was between an hour before and an hour after the scheduled time. LVN 1 stated each medication affected the body in their own way and administering them late could cause unwanted reactions. LVN 1 stated Resident 4 received the carbidopa-levodopa and benztropine late, which could cause an increase in Resident 4's tremors and shaking. LVN 1 stated she administered Resident 4's second dose of carbidopa-levodopa around 1 p.m. but the time in between the first and second dose were too close together. LVN 1 stated administering the two doses of carbidopa-levodopa too close together put Resident 4 at risk for increased confusion. LVN 1 stated Resident 4 received the empagliflozin late, which could cause a drop in Resident 4's blood sugar. LVN 1 stated Resident 4's primidone was administered late, which could cause an increase in preventable seizure activity. LVN 1 stated Resident 4's docusate sodium was administered late, which could potentially cause loose stool and diarrhea if the two doses were administered too close together. LVN 1 stated Resident 4's Lidocaine cream was administered late and initially onto the incorrect knee, which could cause Resident 4 to experience preventable pain. During an interview on 3/26/2025 at 2:52 p.m., with the Director of Nursing (DON), the DON stated residents' medications must be administered according to their physician's order. The DON stated medications could be administered an hour before and an hour after the scheduled administration time. The DON stated medications administered after the permitted time placed the resident at risk of experiencing adverse effects and symptoms the medications were used to treat. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 7/2024, the P&P indicated, Medications shall be administered in a safe and timely manner, and as prescribed. The P&P indicated, Medications must be administered in accordance with the orders, including at required time frame. Medications must be administered within one hour of their prescribed time, unless otherwise specified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a daily menu and offer alternative menu options for one of eight sampled residents (Resident 3). This deficient practice had the potential to impact Resident 3's nutritional status, quality of life and result in food dissatisfaction leading to insufficient food intake. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses included muscle wasting (weakening, shrinking, and loss of muscle) and atrophy (decreased size of a body part, cell, organ or tissue), dysphagia (difficulty swallowing), aphasia (a disorder that makes it difficult to speak) following cerebral infarction (stroke - loss of blood flow to a part of the brain), and severe protein-calorie malnutrition (inadequate intake of protein, calories and other essential nutrients). During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 3/5/2025, the MDS indicated Resident 3 was cognitively intact (the ability to think, remember and reason). The MDS indicated Resident 3 supervision (helper provides verbal cues and/or touching to assist resident) with eating and was dependent (helper does all the effort) on staff for toileting and bathing. During a review of Resident 3's Progress Notes Summary, dated 3/4/2025, the Progress Notes Summary indicated Resident 3 was oriented to person, place, and time and although non-verbal, Resident 3 was capable of effectively communicating her needs through a digital device. During a review of Resident 3's care plan titled, Altered Nutritional Needs, undated initiated, the care plan goal indicated Resident 3 would consume greater than 75% of each meal and would eat to desire and tolerance. The care plan interventions indicated to encourage Resident 3 to eat 75-100% of each meal. During a review of Resident 3's Order Summary Report, dated 3/26/2025, the order summary report indicated an active order starting 2/24/2025 for a Regular diet, pureed (foods that have been blended, mashed, or strained to a smooth, pudding-like consistency) texture, regular consistency (normal, everyday foods of various textures). During a concurrent observation and interview on 3/24/2025 at 10:51 a.m. with Resident 3, Resident 3 was observed lying in bed alert and oriented. There was no menu posted near the bed or on the nightstand. Resident 3 was unable to speak but used a tablet for communication. Resident 3 stated via tablet that she had difficulty swallowing and was on a pureed diet. Resident 3 stated the pureed meals were inedible and made her want to puke. Resident 3 stated she received the same meal every day. Resident 3 stated she had been in the facility for three weeks and had not received a menu. Resident 3 stated she complained about the food to the nursing staff and asked if she could have something with flavor such as chicken or beef. Resident 3 stated she was never offered alternatives even though she barely ate her meals. During a concurrent observation and interview on 3/25/2025 at 12:38 p.m. with Resident 3, observed Resident 3 while eating lunch. Resident 3's lunch plate consisted of 3 scoops of food and 2 bowls, one consisting of a clear liquid and the other with a white creamy substance. Resident 3 pointed to her tray and wrote on her tablet, What is this? Resident 3 stated she would only attempt to eat the meals served to prevent her from being hungry by midnight. Observed Resident 3 take a spoonful from the scoops of food on her lunch tray. Resident 3 wrote, I cannot eat this, it makes my stomach hurt and makes me want to vomit. During an interview on 3/25/2025 at 1:45 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 3 ate 25 to 50 percent (%) of her lunch meal. CNA 1 stated when a resident eats less than 50% of their meal, it is reported to the charge nurse and the resident would be offered an alternative. CNA 1 stated she did not offer Resident 3 an alternative for her lunch meal because she was on a pureed diet, and she was feeling sick. CNA 1 stated she did not ask Resident 3 why she felt sick. CNA 1 stated if Resident 3 was not on a pureed diet she would have offered her something else to eat. During a concurrent observation and interview on 3/25/2025 at 2 p.m. with Licensed Vocational Nurse (LVN) 2 and Resident 3, in Resident 3's room, LVN 2 searched for Resident 3's menu. LVN 2 stated Resident 3 did not have a menu in her room. LVN 2 stated all residents should have a menu posted in the room so that they can get a supplement meal ordered in advance if they do not like what is being served for that meal. LVN 2 stated if a resident ate less than 50% of their meal, she would offer the resident something else to eat or a nutritional shake. LVN 2 stated without a menu, Resident 3 was not able to see what was served and was unable to choose something she preferred. LVN 2 stated Resident 3 could have been served an alternative meal based on her diet. LVN 2 asked Resident 3 if she like her lunch? Resident 3 shook her head and stated No. LVN 2 stated she offered Resident 3 a nutritional shake but did not offer her an alternative lunch even though she was aware Resident 3 ate less than 50% of her meal. LVN 2 stated once she knew Resident 3 ate less than 50% of her meal, she should have asked the resident if she wanted something else and gone to the kitchen to order her an alternative lunch. LVN 3 stated Resident 3 could have weight loss and malnutrition from eating less than 50 percent of the food every day. LVN 2 stated Resident 3's meals should have been something that she enjoyed. During an interview on 3/25/2025 at 3:15 p.m. with the Dietary Services Supervisor (DSS), the DSS stated Resident 3 could get any item on the alternative menu served pureed or within the diet order. The DSS stated Resident 3 should have a menu in her room posted on the wall or on her nightstand. The DSS stated the Activities Department was responsible for providing the menu to the residents. During an interview on 3/27/2025 at 9:57 a.m. with the Director of Nursing (DON), the DON stated the Dietary Department was responsible for providing menus to the residents and not the Activities Department. The DON stated he would in-service his dietary supervisor regarding who was responsible for providing the menus to the residents and in-service the nursing staff that resident on pureed diets should also be offered alternatives. During a review of the facility's Policy and Procedure (P&P) titled, Nutrition Care - Resident/Patient Food Preferences, dated 2011, the P&P indicated the following: 1. If records indicate a food or beverage is routinely refused this should be documented on the Resident's profile card and tray card as a dislike. 2. Appropriate substitutions will be offered for individual resident dislikes. 3. All residents must be offered a substitute food item when an item they dislike is on the menu. 4. Ethic food preferences should be taken into consideration for all residents and ethnic food should be made available. During a review of the facility's policy and procedure (P&P0 titled, Menus, dated 2011, the P&P indicated the menus will be posted in the resident's dining room or other resident accessible areas. The P&P indicated menus will be written or available at least one week in advance of preparation and shall be posted in the facility at least one week in advance of service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure staff were knowledgeable of the facility's process on how to handle unlabeled resident clothes found in the laundry area and failed to complete a resident belonging list upon readmission for one of seven sampled resident's (Resident 1), to protect the resident's property from loss or theft. This failure had the potential to violate Resident 1's right to a safe and home like environment. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of encephalopathy (a group of conditions that cause brain dysfunction such as confusion and memory loss), after being sent out to a general acute care hospital on 7/16/2024. During a review of Resident 1's Minimum Data Set ([MDS], a federally mandated resident assessment tool) dated 2/14/2025, the MDS indicated Resident 1 had moderate (average) cognitive impairment (problems with the ability to think and solve problems) and was dependent (helper does all the effort) to perform Activities of Daily Living (ADL) such as showering/bathing self and performing toileting hygiene. During an interview on 2/27/2025 at 1:47 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated when a resident has clothes that are dirty during room transfers, resident's clothes should be given to the laundry and returned to the resident once clean. During an interview on 2/27/2025 at 2:53 p.m. with the Laundry Services (LS) 1, LS 1 stated any unlabeled resident clothes were placed directly to the facility's donation box. During an interview on 2/28/2025 at 9:33 a.m. with LS 2, LS 2 stated that when resident clothes not labeled with names, the clothes should be kept in the laundry room and should not be placed in the donation box. During a concurrent interview and record review on 2/28/2025 at 10:46 a.m. with the Medical Records (MR), Resident 1 belongings for 7/19/2024 was to be reviewed. The MR stated Resident 1 did not have a belongings list created upon readmission on [DATE]. During an interview on 2/27/2025 at 12:49 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated when residents are being moved to a different room, the residents' belonging lists should be checked to ensure their belongings go with them. During an interview on 2/28/2025 at 3:18 p.m. with Director of Nursing (DON), the DON stated that laundry staff are to keep unlabeled resident's clothes in a designated area and to refer and compare these unlabeled clothing to residents' belongings list should resident report clothes missing. The DON also stated that upon admission an inventory list should be created for each resident. During a review facility's policy and procedure (P&P) titled, Theft and Loss Program, dated 9/2016, the P&P indicated, upon admission, an inventory should be made of all the resident's property brought into the facility. During a review of facility's P&P titled, Admitting the Resident: Role of the Nursing Assistant, undated, the P&P indicated inventorying resident belongings should include all clothing, equipment, and valuables by providing quantity and description of each item.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policy and procedures (P&P) titled, Comprehensive Care Planning, and Falls by a Resident, for one of seven residents (Resident 2) who had a fall on 2/19/2025, by failing to: 1. Conduct an Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) meeting with Resident 2 and the family representative, to discuss and revise (change) the plan of care after Resident 2's fall on 2/19/2025. 2. Reassess and revise care plan interventions to ensure Resident 2's safety and to prevent recurrent fall. These failures placed Resident 2 at risk for recurrent falls and injuries. Findings: During a review of Resident 2's admission Record, the admission Record indicated, Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included polyneuropathy (a condition where multiple nerves in the body come damaged or dysfunctional) and aftercare following joint replacement surgery (a procedure that replaces a damaged joint with an artificial joint). During a review of Resident 2's Minimum Data Set ([MDS], a federally mandated resident assessment tool) dated, 2/13/2025, the MDS indicated Resident 2 was cognitively intact (having the ability to think, remember, and solve problems). The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) to perform Activities of Daily Living (ADL) such as oral hygiene, showering/bathing self, and to toileting hygiene. During a review of Resident 2's progress notes dated 2/19/2025, Resident 2 was transferred out to the hospital after suffering an unwitnessed fall. During a review of Resident 2's care plan titled, 2/19/2025 acute or suspected fall, resident attempted to reach for paper on her table, the goal indicated injury will heal without signs and symptoms of infection/ complication in 14 days. The care plan did not indicate any safety interventions or any updated interventions for Resident 2's actual fall on 2/19/2025. During a concurrent interview and record review on 2/28/2025 at 1:15 p.m. with Registered Nurse (RN) 1, Resident 2's care plan titled 2/19/2025 acute or suspected fall, resident attempted to reach for paper on her table, was reviewed. RN 1 stated a care plan should be updated if there was a change of condition. RN 1 stated, a new care plan should have been made after Resident 2 suffered a fall to ensure that measures were in place to prevent furtherfalls that could lead to a bigger problem. During an interview on 2/28/2025 at 3:18 p.m. with the Director of Nursing (DON), the DON stated any resident who [NAME] fall required the IDT to meet, including the resident and family, to ensure plans and measures are in place to prevent any future falls. During a concurrent interview and record review on 2/28/2025 at 3:47 p.m. with the DON, Resident 2's Change of Condition dated, 2/19/2025 and IDT meeting were reviewed. The DON stated that after Resident 2 fell on 2/19/2025, the care plan did not include intervention like the use of a reacher (a handheld mechanical tool used to increase the range of a person's reach and grasp when grabbing objects)to help Resident 2. The DON stated there was no documentation to support that an IDT meeting, including the resident and/or family representative was conducted after the Resident 2's fall on 2/19/2025. During a concurrent interview and record review on 3/4/2025 at 11:40 a.m. Resident 2's care plan titled, At risk for falls, dated 1/16/2025 was reviewed. The DON stated the intervention to provide reacher to Resident 2 to be able to reach items, should have been created and initiated on 2/19/2025 after Resident 2's first fall, and not on 2/28/2025. During a review of facility's P&P titled, Comprehensive Care Planning, dated 8/2015, the P&P indicated that a comprehensive care plan should be developed for each resident. The P&P indicated, care plan must be reviewed and revised periodically, at least quarterly, and on an ongoing basis to reflect changes in the resident and the services provided must be consistent with each resident's written plan. The P&P indicated, the MDS coordinator and/or Social Service staff should notify the resident, family and/or responsible party, and other interested parties designated by the resident, of the date and time of the scheduled care plan conference. The P&P indicated, to the extent possible, the resident, the resident's family and/or responsible party should participate in the development of the plan of care. During a review of facility's P&P titled, Falls by a Resident, dated, 7/2017, the P&P indicated after factors that contributed to the fall were identified, an update to an existing care plan should be generated. During a review of facility's P&P titled, Policy for the Interdisciplinary Team, dated 8/16, the P&P indicated that the Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The P&P indicated, the resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development and revisions to the resident's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement its infection prevention and control measures for five out of seven residents (Residents 1, 2, 3, 6, and 7) by failing to: a. Ensure Residents 1 and 3 were not cohorted (grouped together) with a resident (Resident 2) who had orders for contact isolation (a set of precautions used to prevent the spread of germs that can be transmitted by direct or indirect contact with a patient or their environment). b. Ensure clear signage was posted to inform staff and visitors the Enhanced Barrier Precautions ([EBP] use of gown and gloves during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms ([MDROs] bacteria or other microorganism resistant to multiple classes of antibiotics)) that were to be implemented when providing care for Residents 6 and 7. c. Ensure staff wore personal protective equipment ([PPE] specialized clothing or equipment such as gloves and gown worn to minimize exposure to serious illness) prior to entering and while inside a contact isolation room. This deficient practice had the potential to increase the risk of transmitting disease-causing organisms leading to illness. Findings: a. During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of encephalopathy (damage or disease that affects the brain), cerebral infarction (also known as a stroke, a condition caused by a disruption of blood flow to the brain). During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 9/4/2024, the MDS indicated Resident 1 had no cognitive (the ability to think and reason) impairment. The MDS indicated Resident 1 required substantial/maximal assistance (staff does more than half the effort) for Activities of Daily Living (ADLs) such as lower body dressing (the ability to dress and undress below the waist, including fasteners) and putting on/taking off footwear. During a review of Resident 1 ' s Order Summary Report (a list of current doctor ' s orders), dated 9/11/2024, The Order Summary Report did not indicate Resident 1 had orders for contact precautions. During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of cellulitis (a potentially life-threatening infection of the skin and tissue beneath) of neck and personal history of methicillin resistant staphylococcus aureus ([MRSA] a type of bacteria that are resistant to many antibiotics) infection. During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 2 had no cognitive impairment. The MDS indicated Resident 2 required substantial/maximal assistance for the ADLs of lower body dressing and showering/bathing self. During a review of Resident 2 ' s Order Summary Report, dated 9/11/2024, the Order Summary Report indicated Resident 2 had a physician ' s order on 9/5/2024 indicating to place Resident 2 on Contact Precautions due to MRSA to bilateral (both) lower extremities [BLE] one time for ten days. During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of hemiplegia (weakness on one side of the body that can affect the arms, legs, and facial muscles) and hemiparesis (partial muscle weakness on one side of the body that can affect the arms, legs, and facial muscles). During a review of Resident 3 ' s MDS dated [DATE], the MDS indicated Resident 3 had no cognitive impairment. The MDS indicated Resident 3 required substantial/maximal assistance for the ADLs of lower body dressing and to showering/bathing self. During a review of Resident 3 ' s Order Summary Report, dated 9/11/2024, The order summary report did not indicate Resident 3 had orders for contact precautions. During a review of the facility ' s census (list of residents currently living in the facility), dated 9/10/2024, the facility census indicated that Residents 1, 2, and 3 reside in the same room. b. During a review of Resident 6 ' s admission Record, the admission Record indicated Resident 6 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Covid-19 (an infectious disease caused by the SARS-CoV-2 virus) and colostomy (an opening into the colon from the outside of the body) infection. During a review of Resident 6 ' s MDS dated [DATE], the MDS indicated Resident 6 had no cognitive impairment. The MDS indicated Resident 6 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) to perform ADLs such as upper body dressing and personal hygiene. During a review of Resident 7 ' s admission Record, the admission Record indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of encephalopathy and heart failure (a serious condition that occurs when the heart cannot pump enough blood to meet the body ' s needs). During a review of Resident 7 ' s MDS dated [DATE], the MDS indicated Resident 7 had no cognitive impairment. The MDS indicated Resident 7 required partial/moderate assistance to perform ADLs showering/bathing self and lower body dressing. During a concurrent observation and interview on 9/10/2024 at 8:36 a.m. with Licensed Vocational Nurse (LVN) 1, a PPE supply drawer was observed outside of Resident 6 ' s room without signage indicating Resident 6 was on EBP. LVN 1 stated, Resident 6 should have signage alerting staff of the precaution. LVN 1 stated ESP was to protect residents and staff, and signage needed to be placed to communicate the type of precaution the resident was on as well as the type of PPE required. During an interview on 9/10/2024 at 8:51 a.m. with LVN 2, LVN 2 stated residents on EBP have a 6 Moments sign to indicate the 6 moments in which staff are to use PPE such as gown and gloves for residents on EBP. LVN 2 stated, examples of the 6 moments included residents who had gastrostomy tubes ([G-tube] a soft, plastic tube that is surgically placed into a patient ' s stomach to provide long-term nutritional support and deliver medicine) or wounds. During a concurrent observation and interview on 9/10/2024 at 9:04 a.m. with Certified Nurse Assistant (CNA) 1, Resident 7 ' s room was observed to have a PPE cart across Resident 7 ' s bed without signage for EBP. c. During a concurrent observation and interview on 9/10/2024 at 9:32 a.m. with Physical Therapy Assistant (PTA) 1, a Contact Precaution sign was observed on Residents 1, 2 and 3 ' s door. Physical PTA 1 was observed entering the resident ' s room without putting on PPE. PTA 1 stated they did not put on PPE prior to entering room because they were going to assist Resident 3 and that Resident 2 was the only resident in the room on contact precautions. During an interview on 9/10/2024 at 9:44 a.m. with Infection Prevention Nurse (IPN), IPN stated residents who have active infections were placed together in a single room. IPN stated staff were to always wear PPE in a room with contact isolation because the whole room was considered infected. During a concurrent observation and interview on 9/10/2024 at 9:51 a.m. with IPN outside of Resident 1, 2, and 3 ' s room, CNA 1 was observed removing PPE prior to exiting room and walked back into the room without putting on new PPE. IPN stated staff were to always wear PPE in a contact isolation room regardless of the task. During an interview on 9/10/2024 at 10:54 a.m. with IPN, IPN stated Resident 2 is the only resident with an active MRSA infection and the resident ' s roommates (Residents 1 and 3) were not on contact precautions with MRSA. During a concurrent interview and record review on 9/10/2024 at 11:27 a.m. with the Director of Nursing (DON), the facility policy and procedure (P&P) titled, Infection Control – Enhanced Standard Precautions, dated 03/2016 and photographs of Resident 6 and 7 ' s room were reviewed. The P&P stated patient placement for a patient on contact precaution indicated to, place the patient in a private room, when a private room was not available, place the patient in a room with a patient has an active infection with the same microorganisms but with no other infection (cohorting). Facility P&P also indicated, When a single resident rooms or not available, residents with the same MDRO will be cohorted in the same room. The DON stated proper signage was important because it lets staff and anybody entering the room know what was going on and for proper precautions to prevent spread of infection. The DON stated signs for EBP were to be behind a resident ' s bed to ensure that staff were wearing the proper PPE and signs were supposed be posted for Resident 6 and Resident 7. The DON also stated that the facility was not following their policy by placing Residents 1 and 3 in the same room with Resident 2. During a review of the facility ' s P&P titled, Infection Control – Enhanced Standard Precautions, dated 03/2016, the P&P indicated, Contact precautions are an extension of standard precautions in that gowns and gloves are required for all resident contact as well as contact with environmental surfaces in the residents ' room. In addition to standard precautions, use contact precautions for specified patients known or suspected to be infected or colonized with epidemiologically (a way that relates to epidemiology [the study of the occurrence, spread, and control of disease in a population]) important microorganisms that can be transmitted by direct with the patient.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow up and ensure all required documents were sent to the General Acute Care Hospital (GACH) Rehabilitation (Rehab) Center for evaluation, to address one of three sampled residents (Resident 1), requested transfer. This deficient practice resulted to the delay in transfer and physical therapies in a GACH Rehab and had the potential to affect in maintaining Resident 1 ' s highest practicable physical, mental, and psychosocial well-being. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis (weakness or paralysis on one side of the body), muscle weakness (loss of muscle strength), and difficulty in walking (gait disorders). During a review of Resident 1 ' s History and Physical (H&P), the H&P dated 1/15/2024, indicated Resident 1 did not have the mental capacity to understand and make medical decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized care assessment and care screening tool), the MDS dated [DATE], indicated Resident 1 ' s cognitive skills (thought process) was usually understood and understand by others. The MDS indicated Resident 1 was dependent with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). During a review of Resident 1 ' s GACH Rehab Center Case Management forms dated 5/24/2024, the form indicated Resident 1 ' s information was reviewed and noted. The form indicated Resident 1 ' s referral was incomplete and was unable to evaluate patient ' s functioning and ADLs. The notes indicated GACH Rehab Case Management called the facility but was unable to speak with the Social Services (SS). The notes indicated GACH Rehab spoke to a Charge Nurse (unidentified) and was informed Resident 1 ' s documentation sent were incomplete. The notes indicated Resident 1 ' s case would be closed at that time (5/24/2024). During a review of Resident 1 ' s SS progress notes dated 6/4/2024, the SS progress notes indicated SS sent a referral packet to GACH Rehab on 5/23/2024 after Resident 1 ' s family requested assistance to transfer Resident 1 to a GACH Rehab. The SS progress notes indicated the GACH Rehab Admissions Director did not accept Resident 1 (no reason indicated). During an interview on 8/15/2024 at 12:46 p.m., with the SS, the SS stated on 5/23/2024, she (SS) faxed Resident 1 ' s referral papers to GACH Rehab. The SS stated the Admissions Director (AD) at GACH Rehab called the SS requesting Physical Therapy (PT) notes. The SS stated she faxed the PT notes but could not provide fax confirmation and documentation when PT notes were faxed to GACH Rehab. During an interview on 8/15/2024 at 1:36 p.m., with the AD at GACH Rehab, the AD stated the GACH Rehab received Resident 1 ' s referral on 5/24/24 at 4:30 p.m., but the referral was incomplete. The AD stated Resident 1 ' s case was closed because of the missing documents that were never received. The AD stated on 6/4/2024 at 4:45 p.m., we received documents but were incomplete. The AD stated the nurse (unidentified) called the SS to request more information, however, there were no documents received that day. The AD stated on 6/11/2024, the nurse at GACH Rehab could not determine if Resident 1 met the criteria for admission to the GACH Rehab due to missing PT notes. The AD stated Resident 1 was not accepted to the GACH Rehab because of the bed availability but because of the missing PT documents. During an interview on 8/15/2024 at 2:10 p.m., with the SS, the SS stated it was important for her to follow up and send the required documents to the GACH Rehab so Resident 1 will be evaluated and admitted to GACH Rehab. The SS stated Resident 1 could have benefited the intensive therapy GACH Rehab can provide. During a review of the facility ' s policy and procedure (P&P) titled, Discharge Planning Process, dated 10/2017, the P&P indicated the facility will document an evaluation of the resident ' s discharge needs and discharge plan based on the resident ' s needs. The P&P indicated all relevant resident information should be incorporated into the resident ' s discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident ' s transfer.

Based on interview and record review, the facility failed to ensure the call light was within reach for one of 20 sampled residents (Resident 94). This deficient practice had the potential to cause avoidable harm to Resident 94 from an inability to call staff for assistance and the potential for falls and associated injuries. Cross Reference F-tag F656. Findings: During a review of Resident 94's admission Record, the record indicated the facility admitted Resident 94 on 2/13/2024. Resident 94's admitting diagnoses included difficulty walking, generalized muscle weakness, unsteadiness on his feet, and history of falling. During a review of Resident 94's Minimum Data Set (MDS, a standardized assessment and care screening/planning tool), dated 2/17/2024, the MDS indicated Resident 94 required substantial to maximal assistance from staff when transferring between surfaces, and when transitioning from a sitting to standing position, a sitting to lying position, or a lying to sitting position. During a review of Resident 94's medical record titled, Fall Risk Assessment, dated 2/13/2024, the record indicated Resident 94 experienced falls in the last three months and was at high risk for further falls. During a review of Resident 94's care plans, dated 2/14/2024, the care plans indicated Resident 94 was at risk for falls. The goals of care included the minimization of risks for falls, and a decrease in significant injury resulting from falls. Staff interventions indicated to maintain call light within reach . During a review of Resident 94's care plans, dated 2/25/2024, the care plans indicated Resident 94 had a communication impairment. The goals of care included Resident 94 being able to communicate his daily needs. Staff interventions indicated to keep Resident 94's call light within his reach. During an observation on 3/18/2024 at 1:34 p.m., at Resident 94's bedside, observed Resident 94's call light plugged into the wall and hanging behind Resident 94's bed. During an observation on 3/20/2024 at 10:17 a.m., at Resident 94's bedside, observed Resident 94's call light plugged into the wall and hanging behind Resident 94's bed. During a concurrent observation and interview, on 3/20/2024 at 10:21 a.m., with Licensed Vocational Nurse (LVN) 1, at Resident 94's bedside, LVN 1 stated residents used call lights when assistance was needed. LVN 1 stated the call lights were always supposed to be within the resident's reach. LVN 1 observed Resident 94's call light and stated Resident 94's call light was behind the bed and was not within the resident's reach. LVN 1 stated Resident 94 had a history of falls and stated Resident 94 not having his call light within reach increased his risk for experiencing another fall. During a review of the facility policy and procedure (P&P) titled, Falls and Fall Risk Managing, dated 6/2023, the P&P indicated the purpose of the policy was to identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The P&P further indicated the staff .will identify appropriate interventions to reduce the risk of falls. During a revie of the facility P&P titled Call Light, dated 4/2023, the P&P indicated the purpose of this procedure is to respond to the resident's requests and needs. The P&P further indicated that when the resident is in bed .be sure the call light is within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to implement or develop a resident-specific care plan for three of 20 sampled residents (Resident 40, Resident 94, and Resident 30) when the following occurred: 1. Resident 40's care plan did not indicate the level of assistance he required for eating and drinking. 2. Resident 94's care plans indicated his call light needed to be within reach, and Resident 94's call light was observed hanging behind his bed and not within reach. 3. Resident 30's care plan did not indicate a physician ordered medical appointment. These deficient practices placed Resident 40 at risk of not receiving his required level of assistance while eating and drinking, creating the potential for avoidable weight loss, dehydration, or complications such as aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident). These deficient practices also placed Resident 94 at risk of being unable to call for help, creating the avoidable potential for falls or unmet care needs, and placed Resident 30 at risk of health decline by not adequately following up with a physician ordered medical appointment. Cross Reference F-tag F656 Findings: 1. During a review of Resident 40's admission Record, the record indicated the facility admitted Resident 40 on 8/19/2019, and most recently re-admitted Resident 40 on 3/12/2024. Resident 40's admitting diagnoses included muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue), protein-calorie malnutrition (a nutritional status with reduced availability of nutrients leading to changes in body composition and function), dysphagia (difficulty swallowing foods or liquids), and dysarthria (weakness in the muscles used for speech, which often causes slowed or slurred speech). During a review of Resident 40's History and Physical (H&P), dated 3/15/2024, the H&P indicated Resident 40 did not have the capacity to understand and make decisions. During a review of Resident 40's Minimum Data Set (MDS, a standardized assessment and care screening/planning tool), dated 2/14/2024, indicated Resident 40 had impairments to the upper and lower extremities on one side of his body that interfered with daily functions. The MDS indicated Resident 40 required partial to moderate assistance from staff to eat and drink. The MDS indicated Resident 40 experienced a weight loss of 5 percent (%) or more in the last month, or 10% or more in the last six months. During a review of Resident 40's active physician orders, dated 3/12/2024, the orders indicated Resident 40 was on an altered texture diet (a diet where the texture of the food and liquids has been changed to allow it to be safely swallowed). The orders also indicated Resident 40 was receiving Lasix (furosemide, a medication that causes you to urinate more frequently). During a review of Resident 40's care plans, dated 11/2/2020 and revised on 3/12/2024, the care plans indicated Resident 40 had altered nutritional needs related to decreased ability to eat independently. The care plan indicated Resident 40 experienced a 12 pound (lb., a unit for measuring weight) weight loss in the last three months. Goals of care included Resident 40 not experiencing any signs or symptoms of choking or dehydration, and Resident 40 consuming greater than 75% of all meals. Staff interventions did not indicate that Resident 40 required assistance with eating and drinking. There were no care plans to indicate Resident 40's required level of assistance with eating or drinking. During an observation on 3/18/2024 at 3:27 p.m., at Resident 40's bedside, observed Resident 40's bedside table placed at the foot end of Resident 40's bed, with Resident 40's water pitcher on top of the bedside table. During an interview on 3/20/2024 at 2:22 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated she was instructed by licensed nursing staff to verbally encourage Resident 40 to eat and drink, and stated she was not informed that the resident required staff assistance to eat or drink. CNA 2 stated that if she saw Resident 40 struggling to eat or drink, she would assist him, but she did not stay at the resident's bedside for the duration of the meal. During a concurrent interview and record review, on 3/20/2024 at 2:33 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 40 required setup assistance for eating and drinking. LVN 1 stated setup assistance meant the staff would place Resident 40's meal tray in front of him and open any food and/or beverage containers but would not stay at the bedside to assist with the meal. LVN 1 stated she was not sure of how she determined Resident 40's required level of assistance. LVN 1 then reviewed Resident 40's care plans and stated that based on the care plan, Resident 40 had a decreased ability to eat independently and stated the care plan did not indicate what level of assistance Resident 40 required. During an interview on 3/21/2024 at 12:49 p.m., with the Director of Nursing (DON), the DON stated that Resident 40's care plan should include information related to the level of assistance required for eating and drinking. The DON stated that Resident 40 required staff to stay with him to assist with meals, and stated this was not indicated in the care plan. The DON stated it was important to have this information in the care plan to ensure staff were aware of the resident's needs and stated that staff being unaware of Resident 40's required level of assistance with ADLs put the resident at risk for malnutrition and dehydration. 2. During a review of Resident 94's admission Record, the record indicated the facility admitted Resident 94 on 2/13/2024. Resident 94's admitting diagnoses included difficulty walking, generalized muscle weakness, unsteadiness on his feet, and history of falling. During a review of Resident 94's MDS, dated [DATE], the MDS indicated Resident 94 required substantial to maximal assistance from staff when transferring between surfaces, and when transitioning from a sitting to standing position, a sitting to lying position, or a lying to sitting position. During a review of Resident 94's medical record titled, Fall Risk Assessment, dated 2/13/2024, the record indicated Resident 94 had experienced falls in the last three months and was at high risk for further falls. During a review of Resident 94's care plans, dated 2/14/2024, the care plans indicated Resident 94 was at risk for falls. The goals of care included the minimization of risks for falls, and a decrease in significant injury resulting from falls. Staff interventions indicated to maintain call light within reach . During a review of Resident 94's care plans, dated 2/25/2024, the care plans indicated Resident 94 had a communication impairment. The goals of care included Resident 94 being able to communicate his daily needs. Staff interventions indicated to keep Resident 94's call light within his reach. During an observation on 3/18/2024 at 1:34 p.m., at Resident 94's bedside, observed Resident 94's call light plugged into the wall and hanging behind Resident 94's bed. During an observation on 3/20/2024 at 10:17 a.m., at Resident 94's bedside, observed Resident 94's call light plugged into the wall and hanging behind Resident 94's bed. During a concurrent observation and interview, on 3/20/2024 at 10:21 a.m., with LVN 1, at Resident 94's bedside, LVN 1 stated residents used call lights when assistance was needed. LVN 1 stated the call lights were always supposed to be within the resident's reach. LVN 1 observed Resident 94's call light and stated Resident 94's call light was behind the bed and was not within his reach. LVN 1 stated Resident 94 had a history of falls and stated that Resident 94 not having his call light within reach increased his risk for experiencing another fall. 3. During a review of Resident 30's admission Record, the record indicated the facility admitted Resident 30 on 5/19/2021, and most recently re-admitted Resident 30 on 2/26/2024. Resident 30's admitting diagnoses included diabetes mellitus (a metabolic disease, involving inappropriately elevated blood sugar levels), end stage renal disease (ESRD, a condition in which the kidneys lose the ability to remove waste and balance fluids), heart failure (a chronic condition in which the heart does not pump blood adequately to the body), and malignant neoplasm of the kidney (a cancerous growth on the kidney). During a review of Resident 30's H&P, dated 2/26/2024, the H&P indicated Resident 30 had the capacity to understand and make decisions. During a review of Resident 30's MDS, dated [DATE], the MDS indicated Resident 30 was severely cognitively impaired and had required substantial assistance (staff did more than half the effort) with eating, dressing, and oral/personal hygiene. The MDS indicated Resident 30 was dependent on staff for toileting hygiene, bathing, and putting on footwear. During a review of Resident 30's general acute care hospital (GACH) discharge records, dated 2/26/2024, the GACH records indicated Resident 30 had an appointment with her primary care provider on 3/11/2024. During a review of Resident 30's active physician orders, dated 2/26/2024, the orders indicated Resident 30 had an appointment with her primary care physician on 3/11/2024. During a concurrent observation and interview on 3/18/2024, at 12:56 p.m., Resident 30 was observed awake, bed bound, and was being fed lunch by Family Member (FM) 1. Resident 30 was hard of hearing and had difficulty with speech. FM 1 stated Resident 30 missed her appointment with her doctor on 3/11/2024 even though he told the nurses a few weeks prior, and her appointment schedule was on the resident's hospital discharge papers. During an interview on 3/21/2024, at 10:58 a.m., with the Social Service Assistant (SSA), the SSA stated Resident 30 did not go to her appointment on 3/11/2024. The SSA stated nursing had to inform her of the appointment 72 hours in advance to coordinate transportation. During a concurrent interview and record review on 3/21/2024, at 11:19 a.m., with the Director of Nursing (DON), the DON stated for any medical appointments nursing would ensure the order was in the chart and the care plan updated to communicate the treatment plan to the team. The DON stated nursing would complete an appointment form to give to social services to coordinate transportation, but social services should have run a report to see which residents have appointments. The DON stated there is nothing in the care plan indicating coordination of Resident 30's medical appointments. During a review of the facility P&P titled, Referrals, Social Services, dated 12/2008, the P&P indicated the purpose of the policy is for social services to coordinate resident referrals with outside agencies, and for social services staff to collaborate with nursing staff or other disciplines to arrange for services ordered by the physician. During a review of the facility P&P titled, Transportation, Social Services, dated 12/2008, the P&P indicated the purpose of the policy is for the social services department to help arrange transportation for residents as needed, and all inquiries regarding resident transportation will be made to social services. During a review of the facility P&P titled, Comprehensive Care Planning, dated 8/2015, the P&P indicated the care plan must be reviewed and revised periodically . and on an ongoing basis and that care plans are driven not only by identified resident issues and/or conditions but also by the resident's unique .strengths and needs. During a review of the facility policy and procedure (P&P) titled, Baseline Care Plan, dated 10/2017, the P&P indicated the baseline care developed for each resident should include instructions needed to provide effective and resident centered care.

Based on interview and record review, the facility failed to ensure staff were aware of the level of assistance required by one of two sampled residents (Resident 40) for completion of activities of daily living (ADLs, activities related to personal care, including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). This deficient practice placed Resident 40 at risk of not receiving his required level of assistance while eating and drinking, creating the potential for Resident 40 to experience avoidable weight loss and dehydration, or complications such as aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident). Cross Reference F-tag F656 Findings: During a review of Resident 40's admission Record, the record indicated the facility admitted Resident 40 on 8/19/2019, and most recently re-admitted Resident 40 on 3/12/2024. Resident 40's admitting diagnoses included muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue), protein-calorie malnutrition (a nutritional status with reduced availability of nutrients leading to changes in body composition and function), dysphagia (Difficulty swallowing foods or liquids), and dysarthria (weakness in the muscles used for speech, which often causes slowed or slurred speech). During a review of Resident 40's History and Physical (H&P), dated 3/15/2024, the H&P indicated Resident 40 did not have the capacity to understand and make decisions. During a review of Resident 40's Minimum Data Set (MDS, a standardized assessment and care screening/planning tool), dated 2/14/2024, indicated Resident 40 had impairments to the upper and lower extremities on one side of his body that interfered with daily functions. The MDS further indicated Resident 40 required partial to moderate assistance from staff to eat and drink, and that Resident 40 had experienced a weight loss of 5 percent (%) or more in the last month, or 10% or more in the last six months. During a review of Resident 40's active physician orders, dated 3/12/2024, the orders indicated Resident 40 was on an altered texture diet (a diet where the texture of the food and liquids has been changed to allow it to be safely swallowed). The orders also indicated Resident 40 was receiving Lasix (Furosemide, a medication that causes you to urinate more frequently). During a review of Resident 40's care plans, dated 11/2/2020 and revised on 3/12/2024, the care plan indicated Resident 40 had altered nutritional needs related to decreased ability to eat independently. The care plan also indicated Resident 40 had experienced a 12 pound (lb., a unit for measuring weight) weight loss in the last three months. Goals of care included Resident 40 not experiencing any signs or symptoms of choking or dehydration, and Resident 40 consuming greater than 75% of all meals. Interventions did not indicate that Resident 40 required assistance with eating and drinking. There were no care plans to indicate Resident 40's required level of assistance with eating or drinking. During an observation on 3/18/2024 at 3:27 p.m., at Resident 40's bedside, observed Resident 40's bedside table placed at the foot end of Resident 40's bed, with Resident 40's water pitcher on top of the bedside table. During an interview on 3/20/2024 at 2:22 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated she was instructed by licensed nursing staff to verbally encourage Resident 40 to eat and drink, and stated she was not informed that he required staff assistance to eat or drink. CNA 2 stated that if she saw Resident 40 struggling to eat or drink, she would assist him, but she did not stay at the bedside for the duration of the meal. During a concurrent interview and record review, on 3/20/2024 at 2:33 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 40 required setup assistance for eating and drinking. LVN 1 stated setup assistance meant the staff would place Resident 40's meal tray in front of him and open any food and/or beverage containers but would not stay at the bedside to assist with the meal. LVN 1 stated she was not sure of how she determined Resident 40's required level of assistance. LVN 1 then reviewed Resident 40's care plans and stated that based on the care plan, Resident 40 had a decreased ability to eat independently and stated the care plan did not indicate what level of assistance Resident 40 required. During an interview on 3/21/2024 at 12:49 p.m., with the Director of Nursing (DON), the DON stated that Resident 40's care plan should include information related to the level of assistance required for eating and drinking. The DON stated that Resident 40 required staff to stay with the resident to assist with meals, and stated this was not indicated in the care plan. The DON stated it was important to have this information in the care plan to ensure staff were aware of the resident's needs and stated that staff being unaware of Resident 40's required level of assistance with ADLs put the resident at risk for malnutrition and dehydration. During a review of the facility policy and procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, dated 4/2023, the P&P indicated residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition . The P&P further indicated a resident's ability to perform ADLs will be measured using clinical tools, including the MDS and appropriate care and services will be provided to residents who are unable to carry out ADLs independently .including appropriate support and assistance with dining (meals and snacks) . During a review of the facility P&P titled, Baseline Care Plan, dated 10/2017, the P&P indicated the baseline care plan developed for each resident should include instructions needed to provide effective and resident centered care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain the nutritional status of one out of four residents (Resident 29) by not ensuring the registered dietitian (RD, health professional who has special training in diet and nutrition) recommendations were implemented for Resident 29. This deficient practice had the potential to cause further avoidable weight loss and malnutrition (lack of sufficient nutrients in the body) for Resident 29. Findings: During a review of Resident 29's admission Record, the record indicated Resident 29 was admitted to the facility on [DATE], and most recently re-admitted on [DATE]. Resident 29's admitting diagnoses included diabetes mellitus (elevated blood sugar levels), severe protein-calorie malnutrition, and adult failure to thrive (a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol). During a review of Resident 29's History and Physical (H&P), dated 10/23/2023, the H&P indicated Resident 29 did not have the capacity to understand and make decisions. During a review of Resident 29's Minimum Data Set (MDS, a standardized assessment and care screening/planning tool), dated 11/07/2023, the MDS indicated Resident 29 was severely cognitively impaired (ability to think and reason). The MDS indicated Resident 29 required set-up assistance for eating. During a review of Resident 29's Weights and Vitals Summary, dated 10/2023 through 3/2024, the summary indicated Resident 29 weighed 104 pounds (lbs) on 10/25/2023 and 89 lbs on 3/2/2024 for a total of 14.42 percent (%) weight loss over a four-month period. During a review of Resident 29's Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident) Weight Review, dated 2/13/2024, the review indicated Resident 29 had a 9% weight loss over the past 3 months. The review indicated the RD's recommendation indicated for the physician to consider ordering Resident 29 an appetite stimulant drug. During a concurrent observation and interview on 3/18/2024, at 12:28 p.m., Resident 29 was observed awake, cachectic (loss of body weight and muscle mass) and had only eaten 25% of her meal. Resident 29 stated she was not hungry. During a concurrent interview and record review, on 3/21/2024, at 10:05 a.m., with RD 1, Resident 29's Physician's Orders dated 2/14/2024 to 3/21/2024 was reviewed. RD 1 stated the IDT had been tracking Resident 29 regularly, and RD 1 recommended an appetite stimulant in the past with current plans to discuss an enteral nutrition (an invasive surgical procedure to bypass nutrition orally and feed via a tube) but that the facility needed to speak to Resident 29's family member. RD 1 stated there had been no appetite stimulants ever ordered. RD 1 stated she followed-up with the Director of Nursing (DON) on 2/22/2024 regarding the recommended appetite stimulant for Resident 29 but did not document it. RD 1 stated the nursing department was responsible for calling the physician with recommendations for orders, but due to the lack of follow-up Resident 29 continued to lose weight and had not received adequate nutrition. During an interview on 3/21/2024, at 10:40 a.m., with the DON, the DON stated RD 1 would email and verbalize her recommendations of residents, but that RD 1 had not followed-up with him (DON) on 2/22/2024 regarding Resident 29's appetite stimulant recommendation. The DON stated it was the whole IDT's responsibility to ensure that Resident 29 had her nutritional needs met, and the resident could be dehydrated and malnourished because of lack of recommendation follow-through. During a review of the facility policy and procedure (P&P) titled, Weight Variance Committee, dated 10/2011, the P&P indicated the purpose of the policy is for the facility to review and monitor residents with weight variances, at an interdisciplinary team meeting on a regular scheduled basis, and the recommendations from the committee will be carried out by the designated responsible discipline .[such as] medical intervention by the attending physician for conditions contributing to the reasons for weight variance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff accurately and thoroughly completed Resident 7's Intake and Output Weekly Assessments. This deficient practice placed Resident 7 at risk for avoidable fluid balance problems, such as dehydration or hypervolemia (a condition in which the liquid portion of the blood [plasma] is too high). Findings: During a review of Resident 7's admission Record, the record indicated the facility admitted Resident 7 on 4/12/2022, and most recently re-admitted Resident 7 on 2/26/2024. Resident 7's admitting diagnoses included neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal cord, or nerve problems), hydronephrosis (excess fluid in a kidney due to a backup of urine), generalized swelling, congestive heart failure (CHF, a chronic condition where the heart does not pump blood as well as it should), hypo-osmolality (where the levels of electrolytes, proteins, and nutrients in the blood are lower than normal) and hyponatremia (low sodium levels in the blood). During a review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care screening/planning tool), dated 3/1/2024, indicated Resident 7 had an indwelling catheter (a tube placed into the bladder to drain urine) and was taking diuretics (medicines that help reduce fluid buildup in the body). During a review of Resident 7's active physician orders, dated 2/27/2024, the orders indicated Resident 7 was receiving 20 milligrams (mg, a unit of dose measurement) of Lasix (furosemide, medication used to produce excess urine) for CHF. During a review of Resident 7's care plans, dated 11/14/2022 and revised on 2/27/2024, the care plan indicated Resident 7 had CHF and had potential for excessive fluid retention and swelling of her extremities. The care plan indicated that interventions to prevent excessive fluid retention and swelling of her extremities included administration of Lasix as ordered. During a review of Resident 7's discontinued physician orders, dated 1/31/2024 and 2/27/2024, the orders indicated staff were supposed to monitor Resident 7's output (including amount of urine voided), every shift for her diagnosis of CHF. During a review of Resident 7's medical record titled, Intake and Output Flowsheet, dated 2/1/2024 to 2/29/2024, the record indicated Resident 7's average 24-hour urine output from 2/8/2024 to 2/15/2024 was 1,242 milliliters (mL, a unit for measuring amounts of liquid). During a review of Resident 7's medical record titled, Intake and Output Weekly Summary, dated 2/15/2024, the record indicated Resident 7's 24-hour average urine output from 2/8/2024 to 2/15/2024 was 1,100 mL. The record was documented by the Quality Assurance Nurse (QAN). During a review of Resident 7's medical record titled, Intake and Output Flowsheet, dated 2/1/2024 to 2/29/2024, the record indicated Resident 7 was hospitalized from [DATE] to 2/22/2024. Resident 7's average 24-hour urine output from 2/15/2024 to time of discharge on [DATE] was 950 mL. During a review of Resident 7's medical record titled, Intake and Output Weekly Summary, dated 2/22/2024, the record indicated Resident 7's 24-hour average urine output from 2/15/2024 to 2/22/2024 was 1,100 mL. The record did not indicate Resident 7 was hospitalized or that urine output measurements were unavailable from 2/16/2024 to 2/22/2024. The record was documented by the QAN. During a review of Resident 7's medical record titled, Intake and Output Flowsheet, dated 2/1/2024 to 2/29/2024, the record indicated Resident 7 was hospitalized from [DATE] to 2/26/2024. Resident 7's average 24-hour urine output from readmission on [DATE] to 2/29/2024 was 1,400 mL. During a review of Resident 7's medical record titled, Intake and Output Weekly Summary, dated 2/29/2024, the record indicated Resident 7's 24-hour average urine output from 2/22/2024 to 2/29/2024 was 1,500 mL. The record did not indicate Resident 7 was hospitalized or that urine output measurements were unavailable from 2/22/2024 to 2/26/2024. The record was documented by the QAN. During a concurrent interview and record review, on 3/21/2024 at 11:55 a.m., with the QAN, the QAN stated she was a Licensed Vocational Nurse (LVN), and the primary staff person responsible for completing Resident 7's Intake and Output Weekly Summary assessments. The QAN stated this had been assigned to her by the Director of Nursing (DON). The QAN reviewed Resident 7's Intake and Output Weekly Summary assessments dated 2/15/2024, 2/22/2024, and 2/29/2024. The QAN stated she was not confident in her ability to complete the assessment, including calculation of the 24-hour average urine output. The QAN stated she had not reported this to the DON. The QAN stated the assessment was used for determining Resident 7's fluid balance, stating Resident 7 had CHF and was on Lasix, therefore documentation of Resident 7's fluid balance should be accurate. During an interview on 3/21/2024 at 12:31 p.m., with the DON, the DON stated the purpose of the Intake and Output Weekly Summary was to ensure that the resident's intake and output was sufficient and stated the assessment data should be accurate. The DON stated he was not aware the QAN did not know how to calculate the average 24-hour urine output. The DON stated that inaccurate documentation put the resident at risk for dehydration or overhydration because the assessment was used to guide the plan of care. During a review of the facility policy and procedure (P&P) titled, Intake and Output Measurement, dated 10/2015, the P&P indicated it was the responsibility of the licensed nursing staff to maintain an accurate record of the resident's fluid balance. During a review of the P&P titled, Documentation Principles, dated 1/2014, the P&P indicated that all entries in the resident's medical record were supposed to be accurate and objective - record facts and what it is, do not 'assume'.

Based on observation, interview, and record review, the facility failed to administer artificial tears drops (for dry eyes) on time for one out of three residents (Resident 79) according to their policies and procedures. This deficient practice had the potential to result in Resident 79's discomfort and worsening of dry eyes. Findings: During a review of Resident 79's admission Record, the record indicated the facility admitted Resident 79 on 11/1/2023 with admitting diagnoses that included diabetes mellitus (a group of diseases that result in too much sugar in the blood) and glaucoma (a group of eye conditions that can cause blindness from too much pressure on the nerve connecting the eye to the brain). During a review of Resident 79's History and Physical (H&P), dated 11/3/2023, the H&P indicated Resident 79 had the capacity to understand and make medical decisions. During a review of Resident 79's Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated 2/6/2024, the MDS indicated Resident 79 was cognitively intact (ability to think and reason). During a review of Resident 79's Visual Impairment care plan, revised 11/8/2023, the care plan indicated interventions included for Resident 79 to receive eye drops as ordered. During a review of Resident 79's current physician orders, dated 12/12/2023, the order indicated Artificial Tears Ophthalmic (eye) solution, one (1) drop was to be administered in both eyes two times a day for dry eyes. During a review of Resident 79's Medication Administration Record (MAR), dated 12/2023 through 2/2024, the MAR indicated Resident 79 had Artificial Tears eye drops scheduled for 9:00 a.m. and 5:00 p.m., but Resident 79 received the 5:00 p.m. dose at 10:46 p.m. by Registered Nurse (RN) 2. During a concurrent observation and interview, on 3/18/2024, at 9:56 a.m., with Resident 79, Resident 79 was ambulatory (walking), dressed, and reported concern of not receiving his eye drops timely by the nurse last evening (3/17/2024). During a concurrent interview and record review on 3/21/2024, at 9:25 a.m., the with Infection Preventionist (IP), Resident 79's MAR, dated 3/17/2024, was reviewed. The IP stated medications were to be administered from one hour before or after the scheduled time, however if medications were given late the physician should be notified and it should be documented in the resident's chart. The IP stated that Resident 79 was very familiar with his medications and was involved in his own care. The IP stated according to the MAR Resident 79 received his artificial tear drops scheduled for 5:00 p.m. at 10:46 p.m. by RN 2. During an interview on 3/21/2024, at 2:15 p.m., with the Director of Nursing (DON), the DON stated if a medication was administered late the nurse should document the reason why and notify the physician for follow-up instructions. During a review of the facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, dated 4/2028, the P&P indicated medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were not expired in the dialysis (treatment that helps your body remove extra fluid and waste products from the blood) emergency kit (E-kit, a small supply of medications to quickly treat symptoms in an emergency). This deficient practice had the potential to cause contamination and loss of efficacy of the medications in the dialysis E-kit. Findings: During a review of Resident 58's admission Record, dated 3/22/2024, the admission record indicated Resident 58 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses which included end stage renal disease (ESRD, the last stage of chronic kidney disease [gradual loss of kidney function]), type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), hypertension (high blood pressure), hyperlipidemia (an abnormally high concentration of fat particles in the blood), and dependence on renal dialysis. During a review of Resident 58's's History and Physical (H&P), dated 10/1/2023, the H&P indicated Resident 58 had the capacity to understand and make decisions. During a review of Resident 58's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 2/7/2024, the MDS indicated Resident 58 was cognitively intact (ability to understand and make decisions) for daily decision making. The MDS indicated Resident 58 required minimal assistance with personal hygiene and eating, and maximal assistance with toileting and bathing. During a review of Resident 58's Order Summary Report, dated 3/22/2024, the order summary report indicated an order for Resident 58 to receive dialysis on Mondays, Wednesdays, and Fridays starting on 12/23/2023. During a review of Resident 58's Order Summary Report, dated 3/22/2024, the order summary report indicated an order to place a dialysis E-kit at Resident 58's bedside at all times, every shift starting on 9/29/2024. During a concurrent observation and interview on 3/21/2024 at 9:51 a.m. with Licensed Vocational Nurse (LVN) 4, at Resident 58's bedside, observed Resident 58's dialysis E-kit in the top drawer of the Resident 58's bedside table. LVN 4 removed the contents from the dialysis E-kit. Observed several pairs of gloves, gauze, and a tourniquet inside of the E-kit. Also observed gel packages and an expired bottle of normal saline (a mixture of salt and water) with an expiration date of 12/5/2023. LVN 4 stated that the E-kits should not have expired medications and he was not sure how the expired normal saline got into the bag. During an interview on 3/21/2024 at 10:07 a.m., with the Director of Nursing (DON), the DON stated that a resident's dialysis E-kit should be checked upon admission and periodically checked by the central supply department. The DON stated that the central supply department would replace items in the dialysis E-kit as needed. The DON stated that there should not be expired normal saline in the dialysis E-kit because it could delay treatment. The DON also stated that expired products could lose their effectiveness which was why it was very important to ensure medications were changed. The DON stated the facility needed a process to ensure medications in the dialysis E-kit were fresh and up to date. During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated April 2008, the P&P indicated Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The P&P indicated that outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and recorded from the pharmacy if a current order exists.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent cross-contamination when placing soiled linens on top of a shared resident surface. This deficient practice had the potential to spread infectious microorganisms to staff and residents. Findings: During a concurrent observation and interview on 3/18/2024, at 9:42 a.m., with Certified Nursing Assistant (CNA) 1, in the shared resident bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], a soiled towel with brown and yellowish residue was observed on top of the toilet. CNA 1 entered the bathroom and picked up the soiled towel. CNA 1 stated she placed the dirty towel there temporarily while she went to get a bag to put it in. CNA 1 stated dirty linens should have gone directly into a plastic bag and not on community surfaces to prevent infection spreading to other residents. During an interview on 3/21/2024, at 8:52 a.m., with the Infection Preventionist Nurse (IPN), the IPN stated linen bags were easily accessible outside of residents' rooms in the clean linen cart, and soiled linens should have been placed in a bag right away after use, then discarded into the soiled linen hamper outside residents' rooms. The IPN stated placing a soiled towel on top of the shared resident bathroom could cause an infection for residents by cross-contamination. During an interview on 3/21/2024, at 11:13 a.m., with the Director of Nursing (DON), the DON stated soiled linens should not be placed on top of shared surfaces but should be bagged and then placed in the linen barrel to prevent transmission of organisms to staff or residents. During a review of the facility policy and procedure (P&P) titled, Infection Control Policy - Laundry Services, dated 5/2018, the P&P indicated: a. All soiled linen should be bagged or put into carts at the location where they have been used; it should not be sorted or pre-rinsed in resident care areas. b. Linen that is saturated with blood or body fluids should be deposited and transported in impervious bags. c. Soiled linen should be removed from resident care areas at least daily or more frequently if needed, depending on the amount of soiled linen is generated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that influenza (flu - a very contagious viral infection that affects the nose, throat, and lungs) and pneumococcal (any infection caused by bacteria called Streptococcus pneumoniae) vaccinations (a method used to protect against harmful germs), were offered as required to one of five sampled residents (Resident 83). This deficient practice placed Resident 83 at a higher risk of acquiring the flu and pneumonia (an infection of the lungs caused by bacteria, viruses, or fungi), which could increase the resident's risk of developing serious complications. This deficient practice also had the potential to increase the risk of flu and pneumonia transmission to other residents in the facility. Findings: During a review of Resident 83's admission Record, dated March 21, 2024, the admission record indicated Resident 69 was admitted to the facility on [DATE] with the following diagnoses which included fracture (break) of the neck and left femur (long bone of the thigh), sepsis (the body's overwhelming and life-threatening response to an infection [the invasion and growth of germs in the body] which could lead to tissue damage, organ failure, and death), type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), anemia (a condition marked by a deficiency of red blood cells), and hypertension (high blood pressure). During a review of Resident 83's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 12/31/2023, the MDS indicated Resident 83 required some assistance with eating and oral hygiene, and was totally dependent for toileting hygiene and bathing. During a review of Resident 83's History and Physical (H&P), dated 12/29/2023, the H&P indicated Resident 83 had the capacity to understand and make decisions. During a concurrent interview and record review on 3/20/2024 at 10:13 a.m., with the Infection Preventionist Nurse (IPN), Resident 83's immunization history was reviewed. The IPN was asked to provide the admission date of Resident 83 as well his most recent influenza and pneumococcal vaccines from the medical records. The IPN stated that according to Resident 83's medical records, the resident was admitted on [DATE]. The IPN stated Resident 83's immunization record indicated that the influenza and pneumococcal vaccines were not administered to the resident upon his admission to the facility. The IPN stated that she could not find any documentation that indicated Resident 83 had a contraindication or refused the influenza and pneumococcal vaccines. The IPN stated that an informed consent must be signed by the resident or the resident's representative if the vaccine was declined. The IPN stated that she was not able to locate an informed consent indicating Resident 83 refused the influenza or pneumococcal vaccine. The IPN then searched for Resident 83's immunization history in the California Immunization Registry (CAIR2 - a web-based, confidential, database that stores the immunization records for California residents). The IPN stated that according to the CAIR2 database, Resident 83 received his last influenza vaccine on 9/12/2019 and there was no history of a pneumococcal vaccine in the CAIR2 database. The IPN stated that according to the facility's policy, vaccines should be offered to residents upon admission. The IPN stated that the reason Resident 83's influenza and pneumococcal vaccines were missed was because there was another resident in the facility with a very similar name. The IPN acknowledged that she should have taken more precaution to ensure the resident received his vaccines since she knew there were residents with similar names. The IPN also stated that because Resident 83 did not receive the influenza or pneumococcal vaccines, the resident was at an increased risk of developing influenza or acquiring pneumonia. The IPN stated that she would offer Resident 83 the influenza vaccine since it was still within the time frame to receive it. The IPN stated that Resident 83 was immunocompromised, and catching the flu or getting pneumonia could cause Resident 83 to become very ill and his health to decline. During a review of the facility's policy and procedure (P&P) titled, Influenza Vaccine, dated October 2019, the P&P indicated the following: 1. All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. 2. Between October 1st and March 31st each year, the influenza vaccine shall be offered to resident and employees, unless the vaccine is medically contraindicated, or the resident or employee has already been immunized. 3. Employees hired or resident admitted between October 1st and March 31st shall be offered the vaccine within five (5) working days of the employee's job assignment or the resident's admission to the facility. 4. The infection preventionist will maintain surveillance data on influenza vaccine coverage and reported rates of influenza among resident and staff. During a review of the facility's P&P titled, Pneumococcal Vaccine, dated October 2019, the P&P indicated the following: 1. All residents will be offered pneumococcal vaccines in aid in preventing pneumonia/pneumococcal infections. 2. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 3. Assessments of pneumococcal vaccinations will be conducted within five (5) working days of the resident's admission if not conducted prior to admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Obtain informed consent, per its policy and procedure, prior to the initiation and administration of psychotropics (medications that affect the mind, emotions, and behavior) for four of 17 sampled residents (Residents 75, 40, 82, and 20). 2. Ensure that facility staff were aware of the facility policy and procedure for obtaining informed consent prior to the initiation and administration of psychotherapeutic medications (psychotropics). These deficient practices placed Residents 75, 40, 82, and 20 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotropic medication use. The above failures also removed the residents' rights to make decisions about the care and treatments they received in the facility. Cross Reference: F-tag F658 Findings 1. During a review of Resident 75's admission Record, the record indicated Resident 75 was admitted to the facility on [DATE] with admitting diagnoses that included transient cerebral ischemic attack (a brief blockage of blood flow to the brain). The admission record further indicated a new diagnosis of bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) that started on 3/8/2024. During a review of Resident 75's History and Physical (H&P), dated 2/8/2024, the H&P indicated Resident 75 could make his needs known but could not make medical decisions. During a review of Resident 75's Minimum Data Set (MDS), dated [DATE], the MDS indicated Resident 75 had moderately impaired cognitive (problems with a person's ability to think, learn, remember, use judgement, and make decisions) skills for daily decision making. During a review of Resident 75's current physician orders, the orders indicated Resident 75 was started on one (1) milligram (mg, a unit of dose measurement for medications) of Risperdal (risperidone, an antipsychotic medication used to treat certain mental and mood disorders) twice a day for bipolar disorder m/b [manifested by] aggressive agitative behavior AEB [as evidenced by] striking out behavior towards staff unprovoked. The orders indicated the medication was started on 3/8/2024. During a review of Resident 75's medical record titled, Facility Verification: Informed Consent to Physical Restraints, Psychotherapeutic Drugs, or 'Prolonged Use of a Device', dated 3/8/2024, the record indicated informed consent for administration of Risperdal was obtained from Resident 75 and Resident 75's Family Member (FM) 2. The record was signed by the Quality Assurance Nurse (QAN) and Nurse Practitioner (NP) 1. During a review of Resident 75's progress note, dated 3/8/2024, documented by the QAN, the note indicated informed consent obtained from [FM 2]. During an interview on 3/28/2024 at 9:08 a.m., with FM 2, FM 2 stated she did not receive a phone call on 3/8/2024 related to the initiation of or to provide informed consent for administration of Risperdal. FM 2 stated she received a call from facility staff on 3/12/2024 and stated, They only told me he (Resident 75) was being aggressive with staff. FM 2 stated the facility staff did not tell her about Resident 75's specific behaviors or that Resident 75 had been started on Risperdal. FM 2 stated that the interview (on 3/28/2024) was the first time she was made aware that Resident 75 was receiving Risperdal. During a review of Resident 75's care plan, dated 3/8/2024, the care plan indicated that potential adverse effects associated with administration of Risperdal included agitation, inability to sleep, anxiety, nausea, vomiting, akathisia (muscle quivering, restlessness, and inability to sit still), lightheadedness, dyspepsia (upper abdominal discomfort, described as burning sensation, bloating or gassiness), uncontrollable involuntary movements, low blood pressure when changing positions, and stiffness of the muscles. During a review of Resident 75's Medication Administration Record (MAR), dated 3/1/2024 to 3/31/2024, the MAR indicated Resident 75 received a total of 38 doses of Risperdal from 3/8/2024 to 3/27/2024. 2. During a review of Resident 40's admission Record, the record indicated Resident 40 was admitted to the facility on [DATE] and was most recently re-admitted on [DATE]. Resident 40's admitting diagnoses included dysarthria (difficulty speaking) and vascular dementia (brain damage caused by multiple strokes, that can cause memory loss in older adults). During a review of Resident 40's H&P, dated 3/15/2024, the H&P indicated Resident 40 did not have the capacity to understand and make decisions. During a review Resident 40's MDS, dated [DATE], the MDS indicated Resident 40 had severely impaired cognitive skills for daily decision making. During a review of Resident 40's progress note, dated 3/12/2024, the progress note indicated noted new order and carried out from [NP 1] to start [Resident 40] on Risperdal 0.5 mg 1 tablet by mouth twice a day .Informed consent obtained from [FM 1]. During a review of Resident 40's medical record titled, Facility Verification: Informed Consent to Physical Restraints, Psychotherapeutic Drugs, or 'Prolonged Use of a Device', dated 3/12/2024, the record indicated informed consent for the administration of Risperdal was obtained from FM 1. The record was signed by the QAN and NP 1. During an interview on 3/21/2024 at 2:49 p.m., with NP 1, NP 1 stated she would obtain an informed consent from the resident's family or responsible party if ordering a psychotropic medication, and stated she did not recall giving an order for Risperdal or obtaining informed consent to initiate Risperdal for Resident 40. During a concurrent interview and record review, on 3/21/2024 at 4:51 p.m., with the QAN, Resident 40's medical record titled, Facility Verification: Informed Consent to Physical Restraints, Psychotherapeutic Drugs, or 'Prolonged Use of a Device', dated 3/12/2024, was reviewed. The QAN stated she did not speak Spanish, so Registered Nurse (RN) 1 obtained the informed consent from FM 1 and she signed the record to indicate that informed consent was obtained. When asked why the record indicated NP 1's name and signature, dated 3/12/2024, the QAN stated the facility practice was for NP 1 to sign copies of blank informed consent forms ahead of time, and the staff fill in the resident's information when an informed consent for medication needed to be obtained. The QAN stated that two licensed nurses could obtain informed consent via telephone for psychotropic medications. The QAN stated she could not verify when RN 1 spoke to FM 1 in Spanish that information was provided related to informed consent, or that FM 1 consented or understood. The QAN confirmed that she still signed the document. During a concurrent interview and record review, on 3/22/2024 at 8:28 a.m., with RN 1, Resident 40's medical record titled, Facility Verification: Informed Consent to Physical Restraints, Psychotherapeutic Drugs, or 'Prolonged Use of a Device', dated 3/12/2024 was reviewed. RN 1 stated he assisted with translation for obtaining the informed consent for Resident 40's Risperdal order on 3/12/2024. RN 1 stated informed consent could be obtained by licensed nursing staff or the ordering NP or medical doctor. RN 1 stated he was not sure if NP 1 had obtained informed consent from FM 1. RN 1 stated he was just the translator for the QAN. During a review of Resident 40's physician orders, dated 3/18/2024, the orders indicated Resident 40's Risperdal was increased to 1 mg by mouth twice a day. During a review of Resident 40's medical record, there was no informed consent documented for the change in dose from Risperdal 0.5 mg ordered on 3/12/2024, and the new order of Risperdal 1 mg ordered on 3/18/2024. During a review of Resident 40's progress note, dated 3/18/2024, the progress note indicated [Medical Doctor (MD) 1] gave verbal orders .Risperdal increased to 1 mg PO [by mouth] BID [twice a day] .Orders noted and carried out. During an interview on 3/21/2024 at 3:52 p.m., with MD 1, MD 1 stated he did not obtain a new informed consent when Resident 40's Risperdal was increased from 0.5 mg to 1 mg on 3/18/2024. MD 1 stated that when a resident's psychotropic medication dose was increased, nursing staff notify the family or responsible party, but a new informed consent did not need to be obtained. MD 1 stated that residents with advanced dementia (progressive memory loss) on psychotropics have increased mortality risk and stated that long term use of psychotropic medications could cause additional adverse effects, including tardive dyskinesia (repetitive, involuntary movements) and somnolence (strong desire for sleep and feeling of drowsiness). During an interview on 3/22/2024 at 8:39 a.m., with the Director of Nursing (DON), the DON stated he provided training to all licensed staff related to obtaining informed consent using the facility policy and procedure. The DON stated informed consent was supposed to be obtained by the ordering provider, and stated licensed nursing staff were supposed to confirm with the resident or the resident's responsible party that the provider had obtained the informed consent. The DON stated it was not within the scope of the licensed nursing staff to obtain informed consent. During a review of Resident 40's MAR, dated 3/1/2024 to 3/31/2024, the MAR indicated Resident 40 received a total of 11 doses of Risperdal from 3/12/2024 to 3/18/2024, and was hospitalized on [DATE]. 3. During a review of Resident 82's admission Record, the record indicated Resident 82 was admitted to the facility on [DATE] with admitting diagnoses that included anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), unspecified psychosis (a mental disorder characterized by a disconnection from reality) not due to a substance or known physiological condition, metabolic encephalopathy, aphasia (language disorder that affects a person's ability to communicate). During a review of Resident 82's H&P, dated 1/15/2024, the H&P indicated Resident 82 did not have the capacity to understand and make decisions. During a review of Resident 82's MDS, dated [DATE], the MDS indicated Resident 82 had moderately impaired cognitive skills for daily decision making. During a review of Resident 82's discontinued and completed medication orders, the orders indicated Resident 82 received 0.5 mg of Ativan (used to treat anxiety [feelings of unease, excessive worry]) every six (6) hours, as needed, from 1/15/2024 to 1/30/2024. Resident 82 then received 0.5 mg of Ativan every six (6) hours, as needed, from 2/2/2024 to 2/16/2024. The orders further indicated Resident 82 received 1 mg of Risperdal every 12 hours from 1/15/2024 to 1/30/2024. During a review of Resident 82'a medical record titled, Facility Verification: Informed Consent to Physical Restraints, Psychotherapeutic Drugs, or 'Prolonged Use of a Device', dated 1/15/2024, the record indicated informed consent for the administration of 0.5 mg of Ativan was obtained from Resident 82's FM 3. During a review of Resident 82'a medical record titled, Facility Verification: Informed Consent to Physical Restraints, Psychotherapeutic Drugs, or 'Prolonged Use of a Device', dated 2/2/2024, the record indicated informed consent for the administration of 0.5 mg of Ativan was obtained from Resident 82's FM 3. During a review of Resident 82'a medical record titled, Facility Verification: Informed Consent to Physical Restraints, Psychotherapeutic Drugs, or 'Prolonged Use of a Device', dated 1/15/2024, the record indicated informed consent for the administration of 1 mg of Risperdal was obtained from Resident 82's FM 3. During a review of Resident 82's current physician orders, the orders indicated Resident 82 was started on 1 mg of Risperdal twice a day on 1/31/2024. The orders further indicated Resident 82 was then started on an additional dose of 0.5 mg of Risperdal twice a day on 2/2/2024. Resident 82 was receiving a total of 1.5 mg of Risperdal twice a day. During a review of Resident 82'a medical record titled, Facility Verification: Informed Consent to Physical Restraints, Psychotherapeutic Drugs, or 'Prolonged Use of a Device', dated 1/31/2024, the record indicated informed consent for the administration of 1 mg of Risperdal was obtained from Resident 82's FM 3. During a review of Resident 82'a medical record titled, Facility Verification: Informed Consent to Physical Restraints, Psychotherapeutic Drugs, or Prolonged Use of a Device, dated 2/2/2024, the record indicated informed consent for the administration of an additional 0.5 mg of Risperdal was obtained from Resident 82's FM 3. During a concurrent interview and record review, on 3/27/2024 at 2:31 p.m., with FM 3, Resident 82's records titled Facility Verification: Informed Consent to Physical Restraints, Psychotherapeutic Drugs, or 'Prolonged Use of a Device', dated 1/15/2024, 1/31/2024, and 2/2/2024 was reviewed. FM 3 stated his name and phone number were indicated on the form, but stated he did not receive a call form facility staff or provide informed consent for administration of Ativan and/or Risperdal. FM 3 stated facility staff told him Resident 82 was receiving Risperdal and Ativan, but did not discuss side effects, how long Resident 82 would be on the medications, or that the medication was not mandatory. FM 3 stated he asked for a copy of Resident 82's medications and had to research the medications by himself. During a review of Resident 82's care plan, dated 1/28/2024 and revised on 2/3/2024, the care plan indicated that potential adverse effects associated with administration of Risperdal included agitation, inability to sleep, anxiety, nausea, vomiting, akathisia, lightheadedness, dyspepsia, uncontrollable involuntary movements, low blood pressure when changing positions, and stiffness of the muscles. During a review of Resident 82's care plan, dated 1/28/2024, the care plan indicated that potential adverse effects associated with administration of Ativan included dizziness, unsteadiness, weakness, fatigue, drowsiness, confusion, depression, ataxia (loss of muscle control), sleep apnea (when you stop breathing while asleep), uncontrollable involuntary movements, dysarthria, low blood pressure, and liver complications. During a review of Resident 82's MAR, dated 1/1/2024 to 1/31/2024, the MAR indicated Resident 82 received a total of 29 doses of Risperdal and 9 doses of Ativan from 1/1/2024 to 1/31/2024. During a review of Resident 82's MAR, dated 2/1/2024 to 2/29/2024, the MAR indicated Resident 82 received a total of 58 doses of Risperdal and 14 doses of Ativan from 2/1/2024 to 2/29/2024. During a review of Resident 82's MAR, dated 3/1/2024 to 3/31/2024, the MAR indicated Resident 82 received a total of 53 doses of Risperdal from 3/1/2024 to 3/27/2024. 4. During a review of Resident 20's admission Record, the record indicated Resident 20 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE], with admitting diagnoses that included aphasia, bi-polar disorder, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves causing progressive inability to move over time). During a review of Resident 20's MDS, dated [DATE], the MDS indicated Resident 20 had severely impaired cognitive skills for decision making. During a review of Resident 20's medical record titled, Facility Verification: Informed Consent to Physical Restraints, Psychotherapeutic Drugs, or 'Prolonged Use of a Device', dated 3/11/2024, the record indicated informed consent was signed by Resident 20's family member (FM 3) and RN 2 for the administration of olanzapine (antipsychotic medication) oral tablet 5 milligrams at bedtime. During a review of Resident 20's current physician orders, dated 3/12/2024, the orders indicated olanzapine oral tablet 5 mg, was to be given by mouth at bedtime for bipolar disorder manifested by being in a calm state to sudden outbursts. During a review of Resident 20's H&P, dated 3/13/2024, the H&P indicated Resident 20 did not have the capacity to understand and make decisions. During a review of Resident 20's MAR, dated 3/1/2024 to 3/31/2024, the MAR indicated Resident 20 received a total of 16 doses of olanzapine from 3/12/2024 to 3/27/2024. During an observation on 3/27/2024, at 10:07 a.m., Resident 20 was observed awake, alert, seated in a Geri-chair (a reclining chair made for those who are bed bound or unable to hold up their own weight in a sitting position), unable to verbalize and unable to move. During an interview on 3/27/2024, at 11:24 a.m., with Resident 20's Representative Payee (RP) 1, RP 1 stated he had never received a phone call from RN 2, NP 1, or any other staff from the facility regarding Resident 20's psychiatric medication and had never heard of the medication olanzapine or Zyprexa. RP 1 further stated he was not Resident 20's responsible party, but his court ordered payee who only paid the resident's bills. RP 1 stated Resident 20 did not have a sister, and that the resident only had brothers. During an attempted interview on 3/27/2024, at 11:40 a.m., RN 2's telephone rang five times. A voicemail was left for RN 2 with request for a call back regarding the informed consent for Resident 20. During an attempted interview on 3/27/2024, at 3:43 p.m., RN 2's telephone rang twice before it went to voicemail. 5. During an interview on 3/29/2024 at 10:32 a.m., with MD 1, MD 1 stated that nursing staff were the primary staff responsible for obtaining informed consent for psychotropic medications from the resident and/or responsible party. MD 1 stated that if the nurses were unable to reach the responsible party by telephone to obtain the informed consent, then the staff would notify him, and he would attempt to call the responsible party himself. MD 1 stated it was rare that he obtained informed consent from the resident or their responsible party. During a review of the facility policy and procedure (P&P) titled, Informed Consent, dated 9/2018, the P&P indicated: a. The attending physician, PA [Physician Assistant], or NP must obtain the informed consent of the resident or their responsible party for purposes of prescribing, ordering or increasing an order for a medication. b. Seek the consent of the resident's responsible party, if the resident is not competent to make treatment decisions as designated in the medical record. The physician, PA, or NP shall make reasonable attempts .to notify the interested family member .of the prescription order of increase of an order for psychotherapeutic [psychotropic] medication. c. The facility shall verify the informed consent has been obtained prior to the administration of psychotherapeutic medication. d. It is the responsibility of the physician, PA or NP who orders the psychotherapeutic medication to obtain the resident or the resident's responsible party's informed consent prior to initiation of therapy .the physician, PA or NP cannot delegate the responsibility to the nurse to obtain the consent. e. The information material to a decision concerning the administration of a psychotherapeutic drug shall include: a. The reason for the treatment and the nature and seriousness of the resident's illness b. The probable degree and duration .of improvement or remission, expected with or without such treatment. c. The nature, degree, duration and probability of the side effects and significant risks d. The reasonable alternative treatments and risks, and why this particular treatment is recommended. e. That the resident has the right to accept or refuse the proposed treatment

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to ensure the care provided met professional standards for nine of 17 sampled residents (Residents 75, 82, 200, 94, 40, 20, 3, 13, and 60) when the following occurred: 1. Informed consents were not obtained per the facility's policy and procedure prior to the initiation of psychotropic medications for Residents 75, 40, 82, and 20. 2. Psychiatric care provided to Residents 75, 82, 200, 94, 40, 20, 3, 13, and 60 under Medical Doctor (MD) 2 (facility psychiatrist) and Nurse Practitioner (NP) 1 was not regularly overseen or monitored by the facility Medical Director (MD 1) for potential concerns or compliance with facility policies and procedures. 3. Performance of MD 1, serving as the facility's Medical Director, was not overseen by the facility Administrator (ADM). These deficient practices removed Resident 75, 40, 82, and 20's rights to make decisions related to their care and placed the residents at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotherapeutic medication use. These deficient practices also placed all facility residents at risk for undetected care concerns due to lack of physician or facility ADM oversight. Cross Reference: F-tags F552, F758, F835, and F841 Findings: 1a. During a review of Resident 75's admission Record, the record indicated Resident 75 was admitted to the facility on [DATE] with admitting diagnoses that included transient cerebral ischemic attack (a brief blockage of blood flow to the brain). The admission record further indicated a new diagnosis of bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) that started on 3/8/2024. During a review of Resident 75's History and Physical (H&P), dated 2/8/2024, the H&P indicated Resident 75 could make his needs known but could not make medical decisions. During a review of Resident 75's Minimum Data Set (MDS), dated [DATE], the MDS indicated Resident 75 had moderately impaired cognitive (problems with a person's ability to think, learn, remember, use judgement, and make decisions) skills for daily decision making. During a review of Resident 75's current physician orders, the orders indicated Resident 75 was started on one (1) milligram (mg, a unit of dose measurement for medications) of Risperdal (risperidone, an antipsychotic medication used to treat certain mental and mood disorders) twice a day for bipolar disorder m/b [manifested by] aggressive agitative behavior AEB [as evidenced by] striking out behavior towards staff unprovoked. The medication was started on 3/8/2024. During a review of Resident 75's medical record titled, Facility Verification: Informed Consent to Physical Restraints, Psychotherapeutic Drugs, or 'Prolonged Use of a Device', dated 3/8/2024, the record indicated informed consent for administration of the Risperdal was obtained from Resident 75 and Resident 75's Family Member (FM) 2. The record was signed by the Quality Assurance Nurse (QAN) and Nurse Practitioner (NP) 1. During a review of Resident 75's progress note, dated 3/8/2024, documented by the QAN, the note indicated informed consent obtained from [FM 2]. During an interview on 3/28/2024 at 9:08 a.m., with FM 2, FM 2 stated she did not receive a phone call on 3/8/2024 related to the initiation of or to provide informed consent for administration of Risperdal. FM 2 stated she received a call from facility staff on 3/12/2024 and stated, They only told me he was being aggressive with staff. FM 2 stated the facility staff did not tell her about Resident 75's specific behaviors or that Resident 75 had been started on Risperdal. FM 2 stated that the interview was the first time she was made aware that Resident 75 was taking Risperdal. During a review of Resident 75's care plan, dated 3/8/2024, the care plan indicated that potential adverse effects associated with administration of Risperdal included: agitation, inability to sleep, anxiety, nausea, vomiting, akathisia (muscle quivering, restlessness, and inability to sit still), lightheadedness, dyspepsia (upper abdominal discomfort, described as burning sensation, bloating or gassiness), uncontrollable involuntary movements, low blood pressure when changing positions, and stiffness of the muscles. During a review of Resident 75's Medication Administration Record (MAR), dated 3/1/2024 to 3/31/2024, the MAR indicated Resident 75 received a total of 38 doses of Risperdal from 3/8/2024 to 3/27/2024. 1b. During a review of Resident 40's admission Record, the record indicated Resident 40 was admitted to the facility on [DATE] and was most recently re-admitted on [DATE]. Resident 40's admitting diagnoses included dysarthria (difficulty speaking) and vascular dementia (brain damage caused by multiple strokes, that can cause memory loss in older adults). During a review of Resident 40's H&P, dated 3/15/2024, the H&P indicated Resident 40 did not have the capacity to understand and make decisions. During a review Resident 40's MDS, dated [DATE], the MDS indicated Resident 40 had severely impaired cognition. During a review of Resident 40's progress note, dated 3/12/2024, the progress noted indicated noted new order and carried out from [Nurse Practitioner 1] to start [Resident 40] on Risperdal 0.5 mg 1 tablet by mouth twice a day .Informed consent obtained from [FM 1]. During a review of Resident 40's medical record titled, Facility Verification: Informed Consent to Physical Restraints, Psychotherapeutic Drugs, or 'Prolonged Use of a Device', dated 3/12/2024, the record indicated informed consent for administration of the Risperdal was obtained from FM 1. The record was signed by the QAN and NP 1. During an interview on 3/21/2024 at 2:49 p.m., with NP 1, NP 1 stated she would obtain an informed consent from the resident's family or responsible party if ordering a psychotropic medication, and stated she did not recall giving an order for Risperdal or obtaining informed consent to initiate Risperdal for Resident 40. During a concurrent interview and record review, on 3/21/2024 at 4:51 p.m., with the QAN, the QAN reviewed Resident 40's medical record titled Facility Verification: Informed Consent to Physical Restraints, Psychotherapeutic Drugs, or 'Prolonged Use of a Device', dated 3/12/2024. The QAN stated she did not speak Spanish, so Registered Nurse (RN) 1 obtained the informed consent from FM 1 and she signed the record to indicate that informed consent was obtained. When asked why the record indicated the NP 1's name and signature, dated 3/12/24, the QAN stated the facility practice was for NP 1 to sign copies of blank informed consent forms ahead of time, and the staff fill in the resident's information when an informed consent for medication needs to be obtained. The QAN stated that two licensed nurses can obtain informed consent via phone for psychotropic medications. The QAN stated she could not verify that when RN 1 spoke to FM 1 in Spanish that information was provided related to informed consent, or that FM 1 consented or understood. The QAN confirmed that she still signed the document. During a concurrent interview and record review, on 3/22/2024 at 8:28 a.m., with RN 1, RN 1 stated he assisted with translation for obtaining the informed consent for Resident 40's Risperdal order on 3/12/2024. RN 1 stated informed consent could be obtained by licensed nursing staff or the ordering nurse practitioner or medical doctor. RN 1 reviewed Resident 40's medical record titled Facility Verification: Informed Consent to Physical Restraints, Psychotherapeutic Drugs, or 'Prolonged Use of a Device', dated 3/12/2024, and stated he was not sure if NP 1 had obtained informed consent from FM 1. RN 1 stated he was just the translator for the QAN. During a review of Resident 40's physician orders, dated 3/18/2024, the orders indicated Resident 40's Risperdal was increased to 1 mg by mouth twice a day. During a review of Resident 40's medical record, there was no informed consent documented for the change in dose from Risperdal 0.5 mg ordered on 3/12/2024 and the new order of Risperdal 1 mg ordered on 3/18/2024. During a review of Resident 40's progress note, dated 3/18/2024, the progress note indicated [Medical Doctor (MD) 1] gave verbal orders .Risperdal increased to 1 mg PO [by mouth] BID [twice a day] .Orders noted and carried out. During an interview on 3/21/2024 at 3:52 p.m., with MD 1, MD 1 stated he did not obtain a new informed consent when Resident 40's Risperdal was increased from 0.5 mg to 1 mg on 3/18/2024. MD 1 stated that when a resident's psychotropic medication dose is increased, nursing staff notify the family or responsible party, but a new informed consent does not need to be obtained. MD 1 stated that residents with advanced dementia on psychotropics have increased mortality risk and stated that long term use of psychotropic medications can cause additional adverse effects, including tardive dyskinesia (repetitive, involuntary movements) and somnolence (strong desire for sleep and feeling of drowsiness). During an interview on 3/22/2024 at 8:39 a.m., with the DON, the DON stated he provided training to all licensed staff related to obtaining informed consent using the facility policy and procedure. The DON stated informed consent was supposed to be obtained by the ordering provider, and stated licensed nursing staff were supposed to confirm with the resident or the resident's responsible party that the provider had obtained the informed consent. The DON stated it was not within the scope of the licensed nursing staff to obtain informed consent. During a review of Resident 40's Medication Administration Record (MAR), dated 3/1/2024 to 3/31/2024, the MAR indicated Resident 40 received a total of 11 doses of Risperdal from 3/12/2024 to 3/18/2024, and was hospitalized on [DATE]. 1c. During a review of Resident 82's admission Record, the record indicated Resident 82 was admitted to the facility on [DATE] with admitting diagnoses that included anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), unspecified psychosis (a mental disorder characterized by a disconnection from reality) not due to a substance or known physiological condition, metabolic encephalopathy, aphasia (language disorder that affects a person's ability to communicate). During a review of Resident 82's H&P, dated 1/15/2024, the H&P indicated Resident 82 did not have the capacity to understand make decisions. During a review of Resident 82's MDS, dated [DATE], the MDS indicated Resident 82 had moderately impaired cognition. During a review of Resident 82's discontinued and completed medication orders, the orders indicated Resident 82 received 0.5 mg of Ativan (medication used to treat anxiety [feelings of unease and excessive worry]) every six (6) hours, as needed, from 1/15/2024 to 1/30/2024. Resident 82 then received 0.5 mg of Ativan every six (6) hours, as needed, from 2/2/2024 to 2/16/2024. The orders further indicated Resident 82 received 1 mg of Risperdal every 12 hours from 1/15/2024 to 1/30/2024. During a review of Resident 82'a medical record titled, Facility Verification: Informed Consent to Physical Restraints, Psychotherapeutic Drugs, or 'Prolonged Use of a Device', dated 1/15/2024, the record indicated informed consent for the administration of 0.5 mg of Ativan was obtained from Resident 82's FM 3. During a review of Resident 82'a medical record titled, Facility Verification: Informed Consent to Physical Restraints, Psychotherapeutic Drugs, or 'Prolonged Use of a Device', dated 2/2/2024, the record indicated informed consent for the administration of 0.5 mg of Ativan was obtained from Resident 82's FM 3. During a review of Resident 82'a medical record titled, Facility Verification: Informed Consent to Physical Restraints, Psychotherapeutic Drugs, or 'Prolonged Use of a Device', dated 1/15/2024, the record indicated informed consent for the administration of 1 mg of Risperdal was obtained from Resident 82's FM 3. During a review of Resident 82's current physician orders, the orders indicated Resident 82 was started on 1 mg of Risperdal twice a day on 1/31/2024. The orders further indicated Resident 82 was then started on an additional dose of 0.5 mg of Risperdal twice a day on 2/2/2024. Resident 82 was receiving a total of 1.5 mg of Risperdal twice a day. During a review of Resident 82'a medical record titled, Facility Verification: Informed Consent to Physical Restraints, Psychotherapeutic Drugs, or 'Prolonged Use of a Device', dated 1/31/2024, the record indicated informed consent for the administration of 1 mg of Risperdal was obtained from Resident 82's FM 3. During a review of Resident 82'a medical record titled, Facility Verification: Informed Consent to Physical Restraints, Psychotherapeutic Drugs, or Prolonged Use of a Device, dated 2/2/2024, the record indicated informed consent for the administration of an additional 0.5 mg of Risperdal was obtained from Resident 82's FM 3. During a concurrent interview and record review, on 3/27/2024 at 2:31 p.m., with FM 3d Resident 82's records titled, Facility Verification: Informed Consent to Physical Restraints, Psychotherapeutic Drugs, or 'Prolonged Use of a Device', dated 1/15/2024, 1/31/2024, and 2/2/2024 was reviewed. FM 3 stated his name and phone number were indicated on the form, but stated he did not receive a call form facility staff or provide informed consent for administration of Ativan and/or Risperdal. FM 3 stated facility staff told him Resident 82 was on Risperdal and Ativan, but did not discuss side effects, how long Resident 82 would be on the medications, or that the medication was not mandatory. FM 3 stated he asked for a copy of Resident 82's medications and had to research the medications by himself. During a review of Resident 82's Medication Administration Record (MAR), dated 1/1/2024 to 1/31/2024, the MAR indicated Resident 82 received a total of 29 doses of Risperdal and 9 doses of Ativan from 1/1/2024 to 1/31/2024. During a review of Resident 82's MAR, dated 2/1/2024 to 2/29/2024, the MAR indicated Resident 82 received a total of 58 doses of Risperdal and 14 doses of Ativan from 2/1/2024 to 2/29/2024. During a review of Resident 82's MAR, dated 3/1/2024 to 3/31/2024, the MAR indicated Resident 82 received a total of 53 doses of Risperdal from 3/1/2024 to 3/27/2024. 1d. During a review of Resident 20's admission Record, the record indicated Resident 20 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE], with admitting diagnosis that included but were not limited to: aphasia, bi-polar disorder, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves causing progressive inability to move over time). During a review of Resident 20's MDS, dated [DATE], the MDS indicated Resident 20 had severely impaired cognitive skills for decision making. During a review of Resident 20'a medical record titled Facility Verification: Informed Consent to Physical Restraints, Psychotherapeutic Drugs, or 'Prolonged Use of a Device', dated 3/11/2024, the record indicated informed consent was signed by Resident 20's sister and RN 2 for the administration of olanzapine oral tablet 5 milligrams at bedtime. During a review of Resident 20's current physician orders, dated 3/12/2024, the orders indicated olanzapine (an antipsychotic medication) oral tablet 5 milligrams ([mg] a unit of measurement), was to be given by mouth at bedtime for bipolar disorder manifested by being in a calm state to sudden outbursts. During a review of Resident 20's H&P, dated 3/13/2024, the H&P idicated Resident 20 did not have the capacity to understand and make decisions. During a review of Resident 20's Medication Administration Record (MAR), dated 3/1/2024 to 3/31/2024, the MAR indicated Resident 20 received a total of 16 doses of olanzapine from 3/12/2024 to 3/27/2024. During an observation on 3/27/2024, at 10:07 a.m., Resident 20 was awake, alert, in a geri-chair (a reclining chair made for those who are bed bound or unable to hold up their own weight in a sitting position), unable to verbalize and unable to move. During an interview on 3/27/2024, at 11:24 a.m., with Representative Payee (RP) 1, RP 1 stated he had never received a phone call from RN 2, Nurse Practitioner (NP) 1, or any other staff from the facility regarding Resident 20's psychiatric medication and had never heard of the medication olanzapine or Zyprexa. RP 1 further stated he is not Resident 20's responsible party, but his court ordered payee who only paid his bills. RP 1 stated Resident 20 did not have a sister, he only had brothers. During an attempted interview on 3/27/2024, at 11:40 a.m., RN 2's phone rang five times. State Agency (SA) left a voicemail for RN 2 (was not on duty) with request for call back regarding the informed consent for Resident 20. During an attempted interview on 3/27/2024, at 3:43 p.m., RN 2's phone rang twice before it went to voicemail. During an interview on 3/29/2024 at 10:32 a.m., with MD 1, MD 1 stated that nursing staff were the primary staff responsible for obtaining informed consent for psychotropic medications from the resident and/or responsible party. MD 1 stated that if the nurses are unable to reach the responsible party by phone to obtain the informed consent, then the staff will notify him, and he will attempt to call the responsible party himself. MD 1 stated it was rare that he obtained informed consent from the resident or their responsible party. During a review of the facility policy and procedure (P&P) titled Informed Consent, dated 9/2018, the P&P indicated: a. The attending physician, PA [Physician Assistant], or NP [Nurse Practitioner] must obtain the informed consent of the resident or their responsible party for purposes of prescribing, ordering or increasing an order for a medication b. Seek the consent of the resident's responsible party, if the resident is not competent to make treatment decisions as designated in the medical record. The physician, PA, or NP shall make reasonable attempts .to notify the interested family member .of the prescription order of increase of an order for psychotherapeutic [psychotropic] medication c. The facility shall verify the informed consent has been obtained prior to the administration of psychotherapeutic medication d. It is the responsibility of the physician, PA or NP who orders the psychotherapeutic medication to obtain the resident or the resident's responsible party's informed consent prior to initiation of therapy .the physician, PA or NP cannot delegate the responsibility to the nurse to obtain the consent e. The information material to a decision concerning the administration of a psychotherapeutic drug shall include: 1. The reason for the treatment and the nature and seriousness of the resident's illness 2. The probable degree and duration .of improvement or remission, expected with or without such treatment 3. The nature, degree, duration and probability of the side effects and significant risks 4. The reasonable alternative treatments and risks, and why this particular treatment is recommended 5. That the resident has the right to accept or refuse the proposed treatment 2. During an interview on 3/29/2024 at 1:56 p.m., with the facility Administrator (ADM), the ADM stated he had been the ADM since 2/2024, and stated MD 1 was already serving as the Medical Director when he assumed the role. The ADM stated MD 1 had not reported any issues to him related to the findings identified by the survey team. The ADM stated MD 1, in the role of Medical Director, was responsible for overseeing the other physicians and advanced practice providers (APP, a health care provider who is not a physician but who performs medical activities typically performed by a physician, most commonly nurse practitioners or physician assistants). The ADM stated MD 1 was also responsible for serving on various facility committees to ensure staff were compliant with state and federal requirements and regulations to promote better health outcomes for the facility residents. During an interview on 3/29/2024 at 3:08 p.m., with the facility ADM, the ADM stated MD 1, in the role of Medical Director, was supposed to oversee the facility's physicians and APPs. The ADM stated there was no current system in place for monitoring or checking MD 1's performance as a primary physician for facility residents. The ADM stated there were no documented records indicating the facility's physicians and APPs were educated on the facility's current policies and procedures or being monitored for implementation of the facility's current policies and procedures. During an interview on 3/29/2024 at 3:32 p.m., with MD 1, MD 1 stated, I don't run the staff when asked about how he ensured facility staff, including other physicians and APPs were implementing facilities policies and procedures for patient care. MD 1 stated the facility Administrator (ADM) and the Director of Nursing (DON) were responsible for overseeing facility staff and ensuring that facility policies and procedures were being implemented. MD 1 stated he did not oversee other physicians and APPs in the facility because they're independent and he was not required to oversee the care they were providing to facility residents. MD 1 stated he did not collaborate with other physicians or APPs, including MD 2 (contracted facility psychiatrist). MD 1 also stated he did not supervise the nurse practitioners (NP) because they were supervised by their overseeing physician. MD 1 stated these practitioners were licensed by their respective boards (Medical Board of California and California Board of Registered Nursing) and were responsible for their own practice. During a review of facility document titled Resident Listing Report, dated 3/29/2024, the document indicated that in addition to serving as the Medical Director, MD 1 was also serving as the primary physician for 46 residents in the facility, including four residents identified as having concerns related to psychotropic medications and informed consents (Resident 200, Resident 40, and Resident 82, and Resident 13). During a review of the facility policy and procedure (P&P) titled Medical Director, dated 9/2016, the P&P indicated it was the Medical Director's responsibilities included: a. Implementation of resident care policies. b. Coordination of medical care. c. Assuring that medical care supports resident's health care needs, is consistent with current standards of practice, and helps the facility meet regulatory requirements. d. Reviewing and evaluating aspects of physician care and practitioner's services. e. Guiding physicians regarding specific expectations of their performance. 3. During an interview on 3/29/2024 at 1:56 p.m., with the facility ADM, the ADM stated he had been the facility ADM since 2/2024, and stated MD 1 was already serving as the medical director prior to his assumption of the ADM role. The ADM stated he was not made aware by MD 1 of any systemic facility issues when he assumed the role. The ADM further stated he was unaware of any concerns identified by the survey team related to psychotropic medications and informed consents. The ADM stated he was unsure of who oversaw MD 1 in his role as the Medical Director or as a primary physician, and stated it would likely be his responsibility as the ADM. The ADM stated he was not aware of any policies related to the governance of the facilities physicians or advance practice providers (APP, a health care provider who is not a physician but who performs medical activities typically performed by a physician, most commonly nurse practitioners or physician assistants). During an interview on 3/29/2024 at 3:08 p.m., with the facility ADM, the ADM stated MD 1, in the role of Medical Director, was supposed to oversee the facility's physicians and APPs. The ADM stated there was no current system in place for monitoring or checking MD 1's performance as a primary physician for facility residents. The ADM stated there were no documented records indicating the facility's physicians and APPs were educated on the facility's current policies and procedures or being monitored for implementation of the facility's current policies and procedures. During a review of facility document titled Resident Listing Report, dated 3/29/2024, the document indicated that in addition to serving as the Medical Director, MD 1 was also serving as the primary physician for 46 residents in the facility, including four residents identified as having concerns related to psychotropic medications and informed consents (Resident 200, Resident 40, and Resident 82, and Resident 13). During a review of the facility document titled Administrator Job Description, undated, the document indicated the primary purpose of the facility ADM was to direct the day-to-day functions of the facility in accordance with current federal, state and local guidelines and regulations that govern nursing facilities. The document further indicated that general duties and responsibilities of the ADM included, but were not limited to: a. Interpret the facility's policies· and procedures to employees .as necessary. b. Monitor that all employees .follow the facility's established policies and procedures. c. Review competence of work force and make necessary adjustments/corrections as required. d. Counsel/Discipline personnel as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff initiated the administration of psychotherapeutic (also called psychotropics, medications that affect the mind, emotions, and behavior) for eight of 17 sampled residents (Residents 75, 82, 200, 94, 40, 3, 13, and 60) without behavioral justification to warrant the necessity of the medications. This deficient practice placed Residents 75, 82, 200, 94, 40, 3, 13, and 60 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotherapeutic medication use. Findings 1. During a review of Resident 75's admission Record, the record indicated Resident 75 was admitted to the facility on [DATE] with admitting diagnoses that included transient cerebral ischemic attack (a brief blockage of blood flow to the brain). The admission record further indicated a new diagnosis of bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) that started on 3/8/2024. During a review of Resident 75's record titled, Social Services Assessment, dated 2/7/2024, the record indicated Resident 75 did not have history of mental illness, was not taking psychotropic medications, and did not have any mood or behavior concerns. During a review of Resident 75's History and Physical (H&P), dated 2/8/2024, the H&P indicated Resident 75 could make his needs known but could not make medical decisions. During a review of Resident 75's Minimum Data Set (MDS, a standardized resident assessment and care-screening tool), dated 2/10/2024, the MDS indicated Resident 75 had moderately impaired cognitive (problems with a person's ability to think, learn, remember, use judgement, and make decisions) skills for daily decision making. The MDS indicated Resident 75 did not have any evidence of hallucinations (seeing or hearing things that are not real), delusions (false beliefs), or any physical or verbal behaviors directed towards others. The MDS did not indicate Resident 75 had a diagnosis of bipolar disorder. During an interview on 3/27/2024 at 1:53 p.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated she was very familiar with Resident 75. CNA 3 stated Resident 75 tried to bite staff member once or twice in the last three weeks and that he had not had any other behaviors since. CNA 3 stated that when she alerts licensed nursing staff about resident behaviors, the licensed staff assess the residents and she (CNA 3) observes the licensed staff give medication. CNA 3 stated she did not recall observing licensed staff implement any other interventions. During an interview on 3/27/2024 at 2:46 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated that any time a resident exhibited a new behavior, licensed nursing staff were supposed to assess the resident, notify the doctor, and document the information on a specific form used for changes of a resident's condition. LVN 2 further stated a care plan related to the new behavior was supposed to be initiated with pharmacologic (using, involving, or having to do with a drug or drugs) and non-pharmacological interventions to address the behavior. LVN 2 stated staff would document the resident's behaviors and all interventions implemented on the resident's behavior monitoring flowsheet. During a review of Resident 75's current physician orders, the orders indicated Resident 75 was started on one (1) milligram (mg, a unit of dose measurement for medications) of Risperdal (brand name for risperidone, an antipsychotic medication used to treat certain mental and mood disorders) twice a day for bipolar disorder m/b [manifested by] aggressive agitative behavior AEB [as evidenced by] striking out behavior towards staff unprovoked. The orders indicated Risperdal was started on 3/8/2024. During a review of Resident 75's progress note, dated 3/8/2024, the progress note indicated Resident [75] alert, able to convey needs, not in any forms of distress, seen by [Nurse Pracitioner (NP) 1] .with noted new orders and carried out. [Resident 75] started on Risperdal .to give 1 mg twice a day by mouth for management of Bipolar Disorder m/b [manifested by] aggressive agitative behavior AEB [as evidenced by] striking out behavior towards staff unprovoked. During a review of Resident 75's progress note, dated 3/8/2024, the progress note indicated informed consent obtained from [resident's family member (FM 2)]. During a review of Resident 75's care plan for Risperdal administration, dated 3/8/2024, the care plan indicated that potential adverse effects associated with administration of Risperdal included: agitation, inability to sleep, anxiety, nausea, vomiting, akathisia (muscle quivering, restlessness, and inability to sit still), lightheadedness, dyspepsia (upper abdominal discomfort, described as burning sensation, bloating or gassiness), uncontrollable involuntary movements, low blood pressure when changing positions, and stiffness of the muscles. During a review of Resident 75's Medication Administration Record (MAR), dated 3/1/2024 to 3/31/2024, the MAR indicated Resident 75 received a total of 38 doses of Risperdal from 3/8/2024 to 3/27/2024. During an interview on 3/28/2024 at 9:08 a.m., with FM 2, FM 2 stated she did not receive a phone call on 3/8/2024 related to the initiation of or to provide informed consent for administration of Risperdal. FM 2 stated she received a call from facility staff on 3/12/2024 and stated, They only told me he was being aggressive with staff. FM 2 stated the facility staff did not tell her about Resident 75's specific behaviors or that Resident 75 had been started on Risperdal. FM 2 stated Resident 75 had never been previously diagnosed with or treated for bipolar disorder. During a concurrent interview and record review, on 3/28/2024 at 2:45 p.m., with the Director of Nursing (DON), the DON stated that if Resident 75 exhibited any behaviors, they would be documented in Resident 75's behavioral monitoring flowsheets, progress notes, and change of condition forms. The DON reviewed Resident 75's electronic medical record (EMR) and stated there was no documentation of Resident 75 striking out at staff prior to the initiation of Risperdal for striking out behavior towards staff. The DON further stated there was only one documented episode of Resident 75 biting staff prior to the initiation of Risperdal on 3/8/2024. The DON stated there were no behaviors documented as exhibited on 3/8/2024 when NP 1 assessed Resident 75 and ordered the Risperdal, and stated the diagnosis of bipolar disorder was new. The DON stated there were also no care plans in place for Resident 75's alleged behavior of striking out at staff, or for his behavior of biting staff, prior to initiation of Risperdal. The DON stated there should have been a care plan with non-pharmacologic interventions. The DON stated that based on the documentation in Resident 75's record there was no pattern of behaviors. 2. During a review of Resident 82's admission Record, the record indicated Resident 82 was admitted to the facility on [DATE] with admitting diagnoses that included anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), unspecified psychosis (a mental disorder characterized by a disconnection from reality) not due to a substance or known physiological condition, metabolic encephalopathy, and aphasia (language disorder that affects a person's ability to communicate). During a review of Resident 82's H&P, dated 1/15/2024, the H&P indicated Resident 82 did not have the capacity to understand make decisions. During a review of Resident 82's MDS, dated [DATE], the MDS indicated Resident 82 had moderately impaired cognitive skills for daily decision making. During a review of Resident 82's medical record titled, Change of Condition SBAR - Behavior Change COC, dated 1/15/2024, the record indicated Resident 82 was restless and verbalized people giving him commands that he did not want to follow. The record indicated Resident 82 stated he was being instructed to move from side to side and things like that. The record indicated that Medical Doctor 1 (MD) 1 (Resident 82's primary physician) and NP 1 were both notified, and orders were received for Ativan (brand name for lorazepam; a sedative that acts on the brain and nerves to produce a calming effect) 0.5 mg every six (6) hours as needed for anxiety and risperidone (generic name for Risperdal) 1 mg every 12 hours for hallucinations. During a review of Resident 82's discontinued and completed medication orders, the orders indicated Resident 82 received 0.5 mg of Ativan every six (6) hours, as needed, from 1/15/2024 to 1/30/2024. The orders also indicated Resident 82 received 1 mg of Risperdal every 12 hours from 1/15/2024 to 1/30/2024 for psychosis .m/b [manifested by] aggressive disruptive behavior. During a concurrent interview and record review on 3/28/2024 at 12:13 p.m., with Registered Nurse (RN) 1, Resident 82's medical records titled, Change of Condition SBAR - Behavior Change COC, dated 1/15/2024, and Behavioral Monitoring Flowsheet, dated 1/1/2024 to 1/31/2024, was reviewed. RN 1 stated he completed this assessment and stated there was no mention of hallucinations in the record and stated that facility staff would likely ask a resident to move from side to side or give commands. RN 1 stated the record also indicated that talking to Resident 82 helped to alleviate the restlessness and anxiety, and stated it was a reasonable response for someone to not want to follow instructions if they were in an unfamiliar environment or were previously independent and used to taking care of themselves. RN 1 stated that aside from talking to the resident, there were other non-pharmacological interventions that could be implemented to address the behaviors. RN 1 stated these non-pharmacological interventions were supposed to be attempted prior to initiating pharmacologic interventions. RN 1 stated there were no documented non-pharmacological interventions, however Resident 82 was started on Risperdal and Ativan. During a concurrent observation and interview, on 3/27/2024 at 1:29 p.m., with Resident 82's family member (FM 3), at Resident 82's bedside, FM 3 stated Resident 82 used to be very active and independent and did not have a history of aggressive behavior. FM 3 stated Resident 82 was likely having a hard time adjusting to a new environment. During the interview, Resident 82 was observed in bed, calm, with no apparent behavioral concerns. During an interview on 3/27/2024 at 1:32 p.m., with CNA 5, CNA 5 stated he had not observed Resident 82 exhibiting aggressive behavior towards staff or others. CNA 5 stated it was important to ask residents about their care preferences, and stated residents might refuse care if their preferences were not respected. During an interview, on 3/27/2024 at 2:31 p.m., with FM 3, FM 3 stated facility staff told him Resident 82 was on Risperdal and Ativan, but did not discuss their side effects, how long Resident 82 would be on the medications, or that the medication was not mandatory. FM 3 stated he asked for a copy of Resident 82's medications and had to research the medications by himself. FM 3 stated he then asked Medical Doctor (MD) 1 (Resident 82's primary physician) if the Risperdal and Ativan dose could be reduced, stating Resident 82 was not taking those medications previously and was now drowsy and did not want to eat. FM 3 stated he was told by facility staff that the Risperdal dose would be decreased, but the Risperdal dose was increased instead. FM 3 stated facility staff did not ask him about Resident 82's preferences for care. FM 3 stated, [Resident 82] is not like that, and stated Resident 82 might refuse care because he did not know the staff or was in an unfamiliar environment. During a review of Resident 82's MAR, dated 1/1/2024 to 1/31/2024, the MAR indicated Resident 82 received a total of 29 doses of Risperdal and 9 doses of Ativan from 1/1/2024 to 1/31/2024. During a review of Resident 82's psychiatry consult record, dated 2/2/2024, the record indicated Resident 82 demonstrated stability, absence of serious mental status abnormalities, and Resident 82's denial of suicidal/self-injurious thoughts, assaultive/homicidal intentions, hallucinations, or delusions was noted. The record also indicated Staff notes indicate stability and tolerance of the current medication regimen and indicated Resident 82 was not on Ativan. The record further indicated [Resident 82] expressed satisfaction with the current medication dosage, indicating no need for changes. During a review of Resident 82's progress note, dated 2/2/2024, the progress note indicated Received new order from MD to extend Ativan .0.5 MG .every 6 hours as needed for Anxiety for 14 Days .manifested by hallucinations verbalizing that people are giving him instructions and he does not like it. Noted and carried out. The progress note did not indicate the MD who ordered the medication. There were no other progress notes prior to 2/2/2024 indicating the presence or reporting of hallucinations or anxiety. During a review of Resident 82's record titled, Behavioral Monitoring Flowsheet, dated 2/1/2024 to 2/29/2024, there was no documentation of hallucinations or anxiety. During a review of Resident 82's records titled, Skilled Daily Charting, dated 1/15/2024 to 2/2/2024, the record indicated no documentation of hallucinations, rejection of care, or other symptoms, under the section titled Behaviors. During a review of Resident 82's discontinued and completed medication orders, the orders indicated Resident 82 was started on 0.5 mg of Ativan every six (6) hours, as needed, from 2/2/2024 to 2/16/2024. During a review of Resident 82's MAR, dated 2/1/2024 to 2/29/2024, the MAR indicated Resident 82 received a total of 14 doses of Ativan from 2/1/2024 to 2/16/2024. During a review of Resident 82's current physician orders, the orders indicated Resident 82 was started on 1 mg of Risperdal twice a day on 1/31/2024. The orders further indicated Resident 82 was started on an additional dose of 0.5 mg of Risperdal twice a day on 2/2/2024, for a total of 1.5 mg of Risperdal twice a day. During a concurrent interview and record review, on 3/27/2024 at 3:07 p.m., with LVN 2, Resident 82's care plans and Electronic Medical Record (EMR) were reviewed. LVN 2 stated there were no behavior care plans for Resident 82's alleged behaviors prior to the initiation of Risperdal and Ativan. LVN 2 stated there was supposed to be a care plan initiated when Resident 82 first exhibited the behaviors, which would include non-pharmacological interventions for staff to implement. LVN 2 then reviewed Resident 82's EMR and stated that based on the available documentation, there was no documentation to justify increasing Resident 82's dose of Risperdal on 2/2/2024 from 1 mg twice a day to 1.5 mg twice a day. During a review of Resident 82's records titled, Skilled Daily Charting, dated 1/15/2024 to 2/2/2024, the record indicated no documentation of behavioral symptoms, under the section titled Behaviors. During a review of Resident 82's record titled, Behavioral Monitoring Flowsheet, dated 1/1/2024 to 1/31/2024, there was no documentation of any behaviors on 1/31/2024. During a review of Resident 82's record titled, Behavioral Monitoring Flowsheet, dated 2/1/2024 to 2/29/2024, there was no documentation of any behaviors on 2/1/2024, prior to the increased dose of Risperdal ordered on 2/2/2024. During a review of Resident 82's MAR, dated 2/1/2024 to 2/29/2024, the MAR indicated Resident 82 received a total of 58 doses of Risperdal and 14 doses of Ativan from 2/1/2024 to 2/29/2024. During a review of Resident 82's MAR, dated 3/1/2024 to 3/31/2024, the MAR indicated Resident 82 received a total of 53 doses of Risperdal from 3/1/2024 to 3/27/2024. During a review of Resident 82's care plan, dated 1/28/2024 and revised on 2/3/2024, the care plan indicated that potential adverse effects associated with administration of Risperdal included: agitation, inability to sleep, anxiety, nausea, vomiting, akathisia, lightheadedness, dyspepsia, uncontrollable involuntary movements, low blood pressure when changing positions, and stiffness of the muscles. During a review of Resident 82's care plan, dated 1/28/2024, the care plan indicated that potential adverse effects associated with administration of Ativan included: dizziness, unsteadiness, weakness, fatigue, drowsiness, confusion, depression, ataxia (loss of muscle control), sleep apnea (when you stop breathing while asleep), uncontrollable involuntary movements, dysarthria (difficulty speaking), low blood pressure, and liver complications. 3. During a review of Resident 200's admission Record, the record indicated Resident 200 was admitted on [DATE], with admitting diagnoses that included schizophrenia (a disorder affecting a person's ability to think, feel, and behave clearly) and insomnia (persistent problems falling and staying asleep). During a review of Resident 200's progress note, dated 3/26/2024, the progress note indicated Per [Resident 200's] request, she wants Ambien for Insomnia. Order noted from [MD 1]. The progress note did not indicate any non-pharmacological interventions implemented prior to notifying MD 1 and obtaining orders for Ambien (brand name for zolpidem; a sedative, also called a hypnotic, that affects chemicals in the brain to treat insomnia), or that MD 1 had assessed or evaluated Resident 200 prior to giving the order. During an interview on 3/28/2024 at 11:13 a.m., with CNA 6, CNA 6 stated that if a resident reported they were not sleeping well, she would report it to the charge nurse. CNA 6 stated she was providing care to Resident 200, and stated she was not monitoring Resident 200 for sleep concerns. CNA 6 stated Resident 200 did not report any sleep issues. During a concurrent interview and record review on 3/28/2024 at 11:13 a.m., with LVN 4, Resident 200's care plan for insomnia was reviewed. LVN 4 stated that if a resident is on sleep monitoring, staff record how many hours of sleep the resident received. LVN 4 stated he was unsure where it would be documented. LVN 4 stated Resident 200 did not report any sleep issues and stated the previous nurse had not reported any sleep issues. LVN 4 reviewed Resident 200's care plan for insomnia and stated it was started on 3/27/2024, after initiation of the zolpidem tartrate. LVN 4 stated there were no care plans prior to 3/27/2024 to address Resident 200's insomnia. LVN 4 stated there were no other notes indicating Resident 200 had issues with sleeping or insomnia. LVN 4 stated there were non-pharmacological interventions to aid residents in sleeping better, and stated there was no documentation that non-pharmacological interventions were attempted prior to starting Resident 200 on zolpidem tartrate (generic name for Ambien). During a concurrent interview and record review, on 3/28/2024 at 3:54 p.m., with the DON, the DON stated that if a resident verbalized having a hard time sleeping, staff would monitor the hours of sleep prior to starting medications. The DON stated there were also non-pharmacologic interventions to implement, prior to initiating medication. The DON reviewed Resident 200's progress notes and stated there were no progress notes indicating MD 1 saw Resident 200 since admission, or prior to ordering zolpidem tartrate. The DON also stated there was no documentation indicating MD 1 had obtained informed consent for the zolpidem tartrate. During an interview on 3/29/2024 at 10:32 a.m., with MD 1, MD 1 stated that any medication that could alter the brain was a psychotropic, including zolpidem tartrate. MD 1 further stated facility staff usually start a resident on psychotropic medications prior to him seeing the resident. MD 1 stated that prior to initiating psychotropic medications, which included hypnotics such as zolpidem, he would want to see a pattern of behavior occurring at least 24 to 48 hours. During a review of Resident 200's physician orders, dated 3/26/2024, the orders indicated Resident 200 was started on zolpidem tartrate 5 mg as needed for insomnia m/b [manifested by] inability to sleep. The duration for administration was 30 days, from 3/26/2024 to 4/25/2024. During a review of Resident 200's care plan for zolpidem tartrate, dated 3/27/2024, the care plan indicated Resident 200 had a behavioral pattern of insomnia manifested by inability to sleep. The care plan indicated in compliance, medication should only be ordered as PRN [as needed] with 14 day duration, reinstatement will be done only if symptom still persist with the same 14 day duration .Consider supplements first, like melatonin, before prescribing sedative/hypnotic. The care plan further indicated that adverse effects of zolpidem included: headache, drowsiness, dizziness, .drugged feeling .and sleep disorder. During a review of Resident 200's records titled, Behavioral Monitoring Flowsheet and MAR, dated 3/1/2024 to 3/31/2024, the records indicated there was no documentation of sleep monitoring or evidence of insomnia for administration of zolpidem. 4. During a review of Resident 94's admission Record, the record indicated Resident 94 was admitted on [DATE] with admitting diagnoses that included metabolic encephalopathy, severe intellectual disabilities, bipolar disorder, and personal history of other mental and behavioral disorders. During a review of Resident 94's H&P, dated 2/16/2024, the H&P indicated Resident 94 did not have the capacity to understand and make decisions. During a review of Resident 94's MDS, dated [DATE], the MDS indicated Resident 94 had severely impaired cognitive skills for daily decision making. The MDS further indicated Resident 94 did not reject evaluation by staff or care necessary to achieve his goals for health and well-being. During a review of Resident 94's discontinued and completed physician orders, the orders indicated Resident 94 was receiving one (1) mg of Ativan every eight (8) hours as needed for anxiety m/b [manifested by] excessive physical restlessness. The medication was ordered for a duration of 14 days, from 2/29/2024 to 3/14/2024. During a review of Resident 94's psychiatry consult, dated 3/8/2024, the record indicated NP 1 assessed Resident 94 and no signs of anxiety were present. The record further indicated Resident 94 was receiving Ativan 1 mg every eight (8) hours as needed for 14 days. The record did not indicate there was or would be an increase in the duration of Resident 94's Ativan orders. During a review of Resident 94's active physician orders, the orders indicated a new order for 1 mg of Ativan every eight (8) hours, as needed, for anxiety m/b [manifested by] excessive physical restlessness. The medication was ordered for a duration of 30 days, from 3/15/2024 to 4/14/2024. During a review of Resident 94's care plan for Ativan, dated 2/14/2024, the care plans indicated Resident 94 had a behavioral pattern of anxiety manifested by excessive physical restlessness, and Resident 94 was at risk for adverse side effects as results of Ativan use. The care plan indicated adverse effects included: sedation, confusion, disorientation, depression, ataxia, respiratory depression (when you breathe too slowly or too shallowly), and low blood pressure. Non-pharmacological interventions on the care plan had not been updated since 2/14/2024. The care plan further indicated in compliance, medication should only be ordered as PRN [as needed] with 14 day duration, reinstatement will be done only if symptom still persist with supporting documentation from the psychiatrist. During an interview on 3/29/2024 at 12:32 p.m., with the Medical Records Director (MRD), the MRD stated there were no psychiatry consults or progress notes after 3/8/2024 and prior to the new Ativan order on 3/15/2024. During a review of Resident 94's medical record titled, Behavioral Monitoring Flowsheet and MAR, dated 3/1/2024 to 3/31/2024, the records indicated that from 3/7/2024 to 3/9/2024, Resident 94 exhibited anxiety manifested by excessive physical restlessness for which staff administered 1 mg of Ativan twice on 3/7/2024, three times on 3/8/2024, and twice on 3/9/2024. The records did not indicate any staff implementation of non-pharmacological interventions to address the behaviors prior to administration of Ativan. During a review of Resident 94's medical record titled, Behavioral Monitoring Flowsheet and MAR, dated 3/1/2024 to 3/31/2024, the record indicated that from 3/10/2024 to 3/14/2024, Resident 94 did not exhibit any behaviors of anxiety manifested by excessive physical restlessness. The records indicated that facility staff administered Ativan once on 3/10/2024, twice on 3/13/2024, and once on 3/14/2024, despite no documented behaviors. The records did not indicate any staff implementation of non-pharmacological interventions prior to or in addition to administration of Ativan. During an interview on 3/29/2024 at 2:30 p.m., with the DON, the DON stated he did not see any progress notes or documentation indicating which Resident 94's provider was contacted and ordered the 1 mg of Ativan every eight (8) hours as needed for 30 days on 3/15/2024. The DON stated there was supposed to be documentation from the ordering provider indicating the justification for extending the medication beyond 14 days. 5. During a review of Resident 40's admission Record, the record indicated Resident 40 was originally admitted to the facility on [DATE] and was most recently readmitted to the facility on [DATE]. The record indicated Resident 40's admitting diagnoses included dysarthria (difficulty speaking), hemiplegia (inability to move one side of the body). The record also indicated a new diagnosis of bipolar disorder starting on 3/12/2024. During a review of Resident 40's H&P, dated 3/14/2024, the H&P indicated Resident 40 did not have the capacity to understand and make decisions. During a review of Resident 40's MDS, dated [DATE], the MDS indicated Resident 40 had severely impaired cognition. The MDS did not indicate a diagnosis of bipolar disorder or any other psychotic disorder. During a review of Resident 40's MDS, dated [DATE], the MDS indicated Resident 40 had severely impaired cognitive skills for daily decision making. The MDS did not indicate a diagnosis of bipolar disorder or any other psychotic disorder. During a review of Resident 40's psychiatric consults, dated 4/28/2023, 5/17/2023, 10/27/2023, and 12/15/2023, the records indicated Resident 40 was not receiving Risperdal and did not include any mention of a diagnosis of bipolar disorder. During a review of Resident 40's psychiatric consult, dated 2/2/2024, the record indicated NP 1 assessed Resident 40, and indicated Resident 40 had a history of vascular dementia without behavioral disturbance and had been compliant with care and listening to staff. The record indicated there wasn't a clinical need for medication adjustment and indicated Resident 40 was not receiving Risperdal. The record did not include any mention of a diagnosis of bipolar disorder. During an interview on 3/21/2024 at 2:49 p.m., with NP 1, NP 1 stated that examples of behaviors indicating a potential bipolar diagnosis included auditory hallucinations and disorganized thought processes. NP 1 stated a diagnosis was not only based on the presenting behaviors, and a new diagnosis required a thorough assessment process. NP 1 stated they take the resident's medical history into consideration and rule out other potential causes of the behavior prior to identifying a new diagnosis of bipolar disorder. NP 1 stated she did not recall giving an order for Risperdal or obtaining informed consent to initiate Risperdal for Resident 40. During an interview on 3/21/2024 at 3:37 p.m., with the DON and the Quality Assurance Nurse (QAN), the QAN stated that on 3/12/2024 she reported to NP 1 that Resident 40 had been readmitted from the hospital, and asked NP 1 if she wanted to continue Resident 40's previous orders, which did not include Risperdal. The QAN stated she did not communicate Resident 40's current behaviors or condition to NP 1 when phone orders were received from NP 1 for Risperdal. The DON and QAN stated NP 1 did not come in on 3/12/2024 to see Resident 40 prior to initiating Risperdal, and stated there was no documentation of a visit on 3/12/2024 by NP 1. During a review of Resident 40's progress note, dated 3/12/2024, the progress noted indicated noted new order and carried out from [NP 1] to start [Resident 40] on Risperdal 0.5 mg 1 tablet by mouth twice a day for management of Bipolar Disorder .manifested by physically aggressive with striking out behavior towards staff for no apparent reason. During a review of Resident 40's record titled Behavioral Monitoring Flowsheet, dated 3/1/2024 to 3/31/2024, the record indicated Resident 40 was not being monitored for bipolar disorder or physical aggression and striking out at staff prior to 3/12/2024 when Risperdal was initiated. The record further indicated Resident 40 displayed the behaviors on 3/18/2024 during the 3:00 p.m. to 11:00 p.m. shift and non-pharmacological interventions were not attempted to address or alleviate the behaviors. During a review of Resident 40's progress note, dated 3/18/2024, the progress note indicated [MD 1] gave verbal orders for Ativan 1 mg .Risperdal increased to 1 mg PO [by mouth] BID [twice a day] .Orders noted and carried out. During a review of Resident 40's physician orders, dated 3/18/2024, the orders indicated Resident 40's Risperdal was increased from 0.5 mg twice a day to one (1) mg twice a day. The orders further indicated Resident 40 was also started on Ativan one (1) mg for anxiety manifested by refusal of care. During an interview on 3/21/2024 at 3:52 p.m., with MD 1, MD 1 stated Resident 40 had dementia and was being treated for a urinary tract infection (UTI, an illness in any part of the urinary tract, the system of organs that makes urine). MD 1 stated Resident 40's behavior of aggression and striking out at staff was a new behavior. MD 1 further stated Resident 40 had a history of stroke with dementia, which more likely explained the change in behavior. MD 1 stated he did not observe the behaviors directly and ordered the increase in Resident 40's Risperdal from 0.5 mg to one (1) mg based on report received from facility staff. MD 1 stated Resident 40 was redirectable when he did his own personal assessment of the resident. MD 1 stated that residents with advanced dementia on psychotropics, such as Risperdal or Ativan, have increased mortality risk (likelihood of death), and stated that long term use of psychotropic medications can cause unwanted adverse effects. During a review of Resident 40's care plan for Risperdal administration, dated 3/12/2024, the care plan indicated Resident 40 was at risk for adverse side effects related to use of Risperdal. During a review of Resident 40's MAR, dated 3/1/2024 to 3/31/2024, the MAR indicated Resident 40 received a total of 11 doses of Risperdal from 3/12/2024 to 3/18/2024, and was hospitalized on [DATE]. 6. During a review of Resident 3's admission Record, the record indicated the facility

Based on observation, interview, and record review, the facility failed to date food items for 89 out of 95 residents. This deficient practice had the potential to cause food borne illnesses (food poisoning, any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for 89 out of the 95 residents receiving food items from the facility. Findings: During an observation on 3/18/2024, at 8:22 a.m., in Refrigerator 1, pork sausage was dated 3/4 (March 4 th), with no year and no expiration date indicated. Freezer 2 had a box of beef and vegetable enchiladas dated 4/30 (April 30th), with no year indicated. During a concurrent observation and interview on 3/18/2024, at 8:45 a.m., of the facility's freezer, the freezer 5 had 15 single unit popsicles and ice cream that were undated, two of the wrapped popsicles and ice cream were stuck together and the plastic wrap was sticky. During an interview on 3/18/2024, at 9:09 a.m., with the Dietary Manager (DM), the DM stated he did not see or find any dates on the single unit popsicles and ice cream and did not know when the items expired. During an interview on 3/21/2024, at 8:22 a.m., with the DM, the DM stated all food items should be dated so staff knew when to discard items to prevent giving residents expired food. The DM stated when food arrived at the facility, he (DM) and the kitchen staff should have dated the items right away. During a review of the facility's policy and procedure (P&P) titled, Storage of Food and Supplies, undated, the P&P indicated the purpose of the policy was to store food properly and safely, and all food will be dated with the month, day, and year.

Based on interview and record review, the Administrator failed to demonstrate or provide evidence of sufficient oversight over the activities of the facility's Medical Doctor (MD 1), who also served as the facility's Medical Director. This deficient practice had the potential to affect all 90 facility residents as the Medical Director was responsible for providing adequate oversight to ensure care and services provided for the 90 in-house residents in the facility met professional standards of quality. Cross Reference: F-tag F658, F552, F758, and F841 Findings: During an interview on 3/29/2024 at 1:56 p.m., with the Administrator (ADM), the ADM stated he had been the facility ADM since 2/2024 and stated Medical Doctor (MD) 1 was already serving as the medical director prior to his assumption of the ADM role. The ADM stated he was not made aware by MD 1 of any systemic facility issues when he assumed the role. The ADM further stated he was unaware of any concerns related to psychotropic medications (medications that affect the mind, emotions, and behavior) and informed consents. The ADM stated he was unsure of who oversaw MD 1 in his role as the Medical Director or as a primary physician, and stated it would likely be his responsibility as the ADM. The ADM stated he was not aware of any policies related to the governance of the facility's physicians or advance practice providers (APP, a health care provider who is not a physician but who performs medical activities typically performed by a physician, most commonly nurse practitioners or physician assistants). During an interview on 3/29/2024 at 3:08 p.m., with the facility ADM, the ADM stated MD 1, in the role of Medical Director, was supposed to oversee the facility's physicians and APPs. The ADM stated there was no current system in place for monitoring or checking MD 1's performance as a primary physician for facility residents. The ADM stated there were no documented records indicating the facility's physicians and APPs were educated on the facility's current policies and procedures or being monitored for implementation of the facility's current policies and procedures. During an interview on 3/29/2024 at 3:32 p.m., with MD 1, MD 1 stated, I don't run the staff when asked about how he ensured facility staff, including other physicians and APPs were implementing facilities policies and procedures for patient care. MD 1 stated the facility Administrator (ADM) and the Director of Nursing (DON) were responsible for overseeing facility staff and ensuring that facility policies and procedures were being implemented. MD 1 stated he did not oversee other physicians and APPs in the facility because they're independent and he was not required to oversee the care they were providing to facility residents. MD 1 stated he did not collaborate with other physicians or APPs, including MD 2 (contracted facility psychiatrist). MD 1 also stated he did not supervise the nurse practitioners (NP) because they were supervised by their overseeing physician. MD 1 stated these practitioners were licensed by their respective boards (Medical Board of California and California Board of Registered Nursing) and were responsible for their own practice. During a review of facility document titled, Resident Listing Report, dated 3/29/2024, the document indicated that in addition to serving as the Medical Director, MD 1 was also serving as the primary physician for 46 residents in the facility, including four residents identified as having concerns related to psychotropic medications and informed consents. During a review of the facility policy and procedure (P&P) titled, Medical Director, dated 9/2016, the P&P indicated it was the Medical Director's responsibilities included: a. Implementation of resident care policies. b. Coordination of medical care. c. Assuring that medical care supports resident's health care needs, is consistent with current sta ndards of practice, and helps the facility meet regulatory requirements. d. Reviewing and evaluating aspects of physician care and practitioner's services. e. Guiding physicians regarding specific expectations of their performance. During a review of the facility document titled, Administrator Job Description, undated, the document indicated the primary purpose of the facility ADM was to direct the day-to-day functions of the facility in accordance with current federal, state and local guidelines and regulations that govern nursing facilities. The document further indicated that general duties and responsibilities of the ADM included, but were not limited to: 1. Interpret the facility's policies· and procedures to employees .as necessary. 2. Monitor that all employees .follow the facility's established policies and procedures. 3. Review competence of work force and make necessary adjustments/corrections as required. 4. Counsel/Discipline personnel as necessary.

Based on interview and record review, Medical Doctor (MD) 1, who also served as the facility's Medical Director, failed to follow the facility's policies and procedure outlining the responsibilities of the Medical Director. This deficient practice had the potential to affect all 90 facility residents due to a lack of facility staff oversight, and the potential for unidentified resident care concerns. Cross Reference: F-tag F658, F552, F758, and F835 Findings: During an interview on 3/29/2024 at 1:56 p.m., with the facility Administrator (ADM), the ADM stated he had been the ADM since 2/2024, and stated MD 1 was already serving as the Medical Director when he assumed the role. The ADM stated MD 1 had not reported any issues to him related to the findings identified by the survey team. The ADM stated MD 1, in the role of Medical Director, was responsible for overseeing the other physicians and advanced practice providers (APP, a health care provider who is not a physician but who performs medical activities typically performed by a physician, most commonly nurse practitioners or physician assistants). The ADM stated MD 1 was also responsible for serving on various facility committees to ensure staff were compliant with state and federal requirements and regulations to promote better health outcomes for the facility residents. During an interview on 3/29/2024 at 3:08 p.m., with the facility ADM, the ADM stated MD 1, in the role of Medical Director, was supposed to oversee the facility's physicians and APPs. The ADM stated there was no current system in place for monitoring or checking MD 1's performance as a primary physician for facility residents. The ADM stated there were no documented records indicating the facility's physicians and APPs were educated on the facility's current policies and procedures or being monitored for implementation of the facility's current policies and procedures. During an interview on 3/29/2024 at 3:32 p.m., with MD 1, MD 1 stated, I don't run the staff when asked about how he ensured facility staff, including other physicians and APPs were implementing facilities policies and procedures for patient care. MD 1 stated the facility Administrator (ADM) and the Director of Nursing (DON) were responsible for overseeing facility staff and ensuring that facility policies and procedures were being implemented. MD 1 stated he did not oversee other physicians and APPs in the facility because they're independent and he was not required to oversee the care they were providing to facility residents. MD 1 stated he did not collaborate with other physicians or APPs, including MD 2 (contracted facility psychiatrist). MD 1 also stated he did not supervise the nurse practitioners (NP) because they were supervised by their overseeing physician. MD 1 stated these practitioners were licensed by their respective boards (Medical Board of California and California Board of Registered Nursing) and were responsible for their own practice. During a review of facility document titled, Resident Listing Report, dated 3/29/2024, the document indicated that in addition to serving as the Medical Director, MD 1 was also serving as the primary physician for 46 residents in the facility, including four residents identified as having concerns related to psychotropic medications (medications that affect the mind, emotions, and behavior) and informed consent. During a review of the facility policy and procedure (P&P) titled, Medical Director, dated 9/2016, the P&P indicated it was the Medical Director's responsibilities included: a. Implementation of resident care policies. b. Coordination of medical care. c. Assuring that medical care supports resident's health care needs, is consistent with current standards of practice, and helps the facility meet regulatory requirements. d. Reviewing and evaluating aspects of physician care and practitioner's services. e. Guiding physicians regarding specific expectations of their performance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Treatment Nurse (TN) 3 had the specific competencies and skill sets necessary to safely perform a nephrostomy tube (small tube that helped drain urine from kidney) dressing change for one of one sampled resident (Resident 1). This failure resulted in Resident 1 ' s nephrostomy tube being cut, requiring transfer to a general acute care hospital (GACH) and increased the risk for infection and medical complications for the resident. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including hydronephrosis with renal and ureteral calculous (kidney swelling due to back up of urine), obstructive and reflux uropathy (inability for urine to drain through the urinary tract), and benign prostatic hyperplasia (enlarged prostate). During a review of Resident 1 ' s History and Physical (H&P) dated 12/27/2023, the H&P indicated Resident 1 had the mental capacity to understand and make medical decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 12/27/2023, the MDS indicated Resident 1 required partial, moderate assistance with activities of daily living (ADL) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). During a review of Resident 1 ' s physician orders dated 12/24/2023, the physician orders indicated to cleanse Resident 1 ' s pigtail (catheter in the renal pelvis) nephrostomy tube on the right and left flank (side of the body) with normal saline ([NS] sterile solution of sodium chloride in water), pat dry and cover with non-woven drain sponge (precut dressing with a slit used for drain tubes which helped absorb unwanted fluid ), every shift. During a review of Resident 1 ' s change of condition (COC) dated 12/27/2023 at 2:00 p.m.,the COC indicated, while providing treatment, the tegaderm film (transparent dressing that adhered to the skin) was tangled alongside the catheter and was difficult to remove therefore (TN 3) continued to cut the film around the tube to remove it and Resident 1 ' s nephrostomy tube to the left side was accidentally snipped. The COC indicated Resident 1 was transferred to a GACH for further for further evaluation and treatment. During a review of Resident 1 ' s GACH record dated 12/27/2023, the GACH record indicated Resident 1 presented to the emergency room with a lacerated (cut) tube caused by nursing at the skilled nursing facility. The GACH record indicated the resident needed placement of a new nephrostomy tube. During interviews on 2/2/2024 at 12:20 p.m. and 1:00 p.m. with TN 3, TN 3 stated, she was cleaning Resident 1 ' s wound and the tegaderm was stuck around the nephrostomy tube and difficult to remove so she grabbed scissors and tried to cut the tegaderm in pieces. TN 3 stated, as she was cutting the tape in the middle, she noted that she had cut the tube. TN 3 stated, she used scissors because the tegaderm was tangled. During an interview on 2/2/2024 at 1:23 p.m. with Registered Nurse (RN). RN stated, scissors should not be used to remove resident ' s bandages because there was a potential to cut the tube or cut the resident. RN stated, an adhesive removal could be used if the dressing became sticky or got stuck. scissors. RN also stated, it could be very risky to cut the tubing because it was very thin. During an interview on 2/2/2024 at 1:40 p.m. with the Director of Nursing (DON), the DON stated, Resident 1 ' s nephrostomy tube was still inserted in the resident ' s skin, but the lower half of the tube was cut, and needed to be replaced. The DON stated, when changing the nephrostomy tube dressing, the nurses must assess the site for redness, infection or swelling. DON stated scissors should be used away from the resident because there would be risk of cutting the resident and the resident ' s tube. The DON stated, nurses should be cautious with the tools being used and the incident with Resident 1 could have been avoided. During a review of the facility ' s undated Treatment Nurse Job Description, the Job Description indicated it was the general duty and responsibility of the Treatment Nurse to follow safety policies when administering treatments and to monitor inventory of supplies, equipment and/or treatment materials to meet resident needs. The Job Description indicated specific requirements included, demonstrating knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served. During a review of the facility ' s policies and procedures (P&P) titled, Nephrostomy Tube Care, dated, 9/2015 the P&P indicated to verify that there was a physician ' s order for the procedure and a plan of care to address the nephrostomy tube and any special needs the resident may have. The P&P indicated, equipment and supplies for dressing changes included sterile 4x4 drain dressing, cleansing solution and swabs as ordered by the physician, adhesive tape, disposable underpad, sterile drape and waste bag.

Based on observation, interview, and record review the facility failed to ensure one of one sampled residents (Resident 68) were treated with respect and dignity in an environment that maintained if not enhanced the resident's life by not ensuring: a. Resident 68's soiled incontinence briefs (disposable undergarments designed with absorbent material) was changed in a timely manner; and This deficiency had the potential to result in negatively affecting Resident 68 self- worth. FINDINGS: a. A record review of the admission record(face sheet) of Resident 68 dated 11/18/2021, indicated that the facility admitted Resident 68 on 6/21/2021 with a diagnoses including chronic obstructive pulmonary disease (breathing problems), gout (inflammation of joints that is very painful), muscle weakness, difficulty in walking, bilateral primary osteoarthritis of knee (swelling and damaged joints in both knees), type 2 diabetes (impairment of the way the body regulates and uses sugar [glucose] as fuel) , heart disease, history of falling, and morbid obesity (serious disease where person is too over weight). A review of the minimum data set (a standardized assessment and care screening tool [MDS]), dated 10/25/2021, indicated Resident 68 had the ability to express ideas and wants, and had the ability to understand others. The MDS further indicated Resident 68 had intact cognitive skills (the core skills your brain uses to think, read, learn, remember, reason, and pay attention) for daily decision making. The MDS indicated Resident 68 needed supervision in eating and extensive assistance with activities of daily living ([ADLs] tasks of everyday life, dressing, getting into or out of a bed or chair, taking a bath or shower and using the toilet). During a record review of Resident 68's Interdisciplinary team([IDT] a group of healthcare professionals developing care needs that meets the resident's needs and goals)/ Care plan conference dated 11/9/2021, IDT indicated Resident 68 was incontinent (no or insufficient control over urination or defecation) . The IDT conference summary indicated Resident 68 needed assistance with hygiene, dressing, bed mobility, and toileting. During a record review of Resident 68's care plan entitled, Resident is at risk for incontinence of bowel and bladder (revised 11/5/2021), the care plan indicated the following interventions: 1. Always treat resident with respect and dignity 2. Change incontinent briefs promptly when soiled/ soaked. 3. Check for incontinence every 2 hours 4. Establish incontinence toileting schedule (when to change resident) During an interview on 11/17/2021 at 10:32 AM with Resident 68 , Resident 68 stated that during the night shift (11:00 PM - 7:00 AM), after 11:00 PM, staff took several hours to change her soiled briefs. Resident chose to wear disposable briefs out of preference due to delayed staff response and physical limitations. Resident 68 explained that coupled with the slow response time of staff to place her on the bedpan and her lack of full control of her urinary urge, she would have urinated on herself had she not chosen to wear disposable briefs. Resident 68 stated she hated using the disposable briefs and it made her feel f-d up and worthless. Resident 68 verbalized her embarrassment and discomfort when she had to sit in a soiled disposable brief for extended periods. During an interview on 11/19/2021 at 6:33 AM, certified nurse assistant 7 (CNA 7) stated if nurses were tending to other residents sometimes residents must wait to get their incontinence briefs changed. During an interview with CNA 8 on 11/19/2021 at 7:00 AM, CNA 8 stated residents do have to wait to get incontinence care rendered specifically when the CNAs were occupied with tending to other resident's needs. Per CNA 8, if residents not in her assignment called, she did respond to the call light to determine the need and urgency of the request. Per CNA 8, she responded and assisted emergent needs but deferred residents who request to be changed to the assigned nurses because she had her own list of residents to care for. CNA 8 stated she ensured the nurse of the resident requesting incontinence care was made aware of the residents' request to be changed. During an interview on 11/19/2021 at 10:29 AM, the director of nursing (DON) acknowledged that residents left with soiled disposable briefs for extended periods of time can not only lead to skin breakdown but can have a negative psychosocial impact on their wellbeing. Per DON, being left soiled and wet can cause undue resident embarrassment. During a record review of Resident 68's care plan entitled Resident is at risk for incontinence of bowel and bladder (revised 11/5/2021), the care plan indicated the following interventions: 1. Always treat resident with respect and dignity 2. Change incontinent briefs promptly when soiled/ soaked. 3. Check for incontinence every 2 hours 4. Establish incontinent toileting schedule (when to change resident) During a record review of the facility's policy entitled, Resident's right to dignity and privacy (revised 9/2017), the policy indicated each resident shall be cared for in a manner that promotes dignity, respect and individuality and provides for resident privacy. The policy further stated that staff shall promote dignity and assist residents by promptly responding to a resident's request for toileting assistance.

Based on interview and record review, the facility failed to ensure one (1) of seven (7) sampled residents (Resident 22) formulated an advance directive (written statement of a person's wishes regarding medical treatment made to ensure those decisions are carried out should the person be unable to communicate them to a doctor) as he requested. This deficient practice had the potential to result in conflict with Resident 22's wishes regarding his personal health care. FINDINGS: During a record review of Resident 22's admission record (face sheet) dated 11/18/2021, the face sheet indicated the facility admitted Resident 22 on 9/22/2021 with adiagnosis including anemia (condition of lack of enough healthy red blood cells to carry adequate oxygen to the body), atrial fibrillation (abnormal heart beat), type 2 diabetes (impairment of the way the body regulates and uses sugar[glucose] as fuel), schizophrenia (brain disorder in which people interpret reality abnormally), and dysphagia (swallowing difficulty). The face sheet indicated Resident 68 was a self-responsible party. A review of the minimum data set (a standardized assessment and care screening tool [MDS]), dated 8/25/2021, indicated Resident 22 usually had the ability to express ideas and wants, and usually had the ability to understand others. Further review indicated Resident 22 had moderately impaired cognitive skills (the core skills your brain uses to think, read, learn, remember, reason, and pay attention) for daily decision making. Resident 22 had a Brief Interview of Mental Status (BIMS- an assessment of cognition) score of 11 (a score of 8-12 indicates moderately impaired cognition). The MDS indicated that Resident 22 had no disorganized thinking (rambling or incoherent conversation, unclear or illogical flow of ideas). The MDS indicated no potential indicators of psychosis (when person loses some contact with reality). MDS indicated Resident 22 needed limited assistance with eating and required extensive assistance with activities of daily living ([ADLs] tasks of everyday life, dressing, getting into or out of a bed or chair, taking a bath or shower and using the toilet). During a record review of Resident 22's Physician Orders for Life-sustaining Treatment (a medical order that helps give people with serious illness more control over their care during a medical emergency [POLST]) form, dated 5/15/2021 and signed by Resident 22 and the physician, the POLST indicated Resident 22 had no advance directive. During a record review of Resident 22's advance directive acknowledgement document dated and initialed on 6/24/2021 by Resident 22 and facility representative, the document indicated Resident 22 has been given written materials and informed about rights to accept or refuse medical treatment and Resident 22 had been informed of rights to formulate an advance directive. The document indicated Resident 22 understood that he was not required to have an advance directive to receive medical treatment at the healthcare facility. Document indicated Resident 22 understood that the terms of any advance directive that Resident 22 has executed will be followed by the health carefacility and caregivers to extent permitted by law. During an interview and record review of Resident 22's physical chart on 11/19/2021 at 11:56 AM, the social services assistant (SSA) confirmed that she was unable to locate Resident 22's advance directive. Per SSA, she had a list of residents (7 total)who wanted to formulate advance directives and Resident 22 was not on the list. Per SSA, Resident 22 was missed and moving forward Resident 22 will be added to the list of residents who wish to have advance directives created. During an interview and record review of Resident 22's advanced directive acknowledgement document on 11/19/2021 at 2:20 PM, social services director (SSD) confirmed that on 6/24/2021 Resident 22 requested an advance directive to be created and to date, approximately 5 months later, it has not been done. SSD stated if something were to occur with Resident 22 and he did NOT have an advance directive in place that it would potentialy violate Resident 22's wishes and rights. SSD acknowledged the facility should have assisted Resident 22 with the formulation of his advanced directive. A record review of the facility's policy entitled; Advance directive, dated 1/2014 indicated when an advance directive is NOT completed: a. Refer the resident with capacity to the Social Services Department if the resident would like to complete an advance directive. b. When there is expression to complete an advance directive or to when the resident is capable of independent decision making: Schedule the Ombudsman (state official appointed to provide a check on government activity in the interest of the citizen) or patient advocate to visit the resident promptly to assist the resident in completing an advance directive. Place a copy of the valid advance directive in the resident's health record upon completion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure one of one sampled residents (Resident 5) received the necessary care and services needed to attain the highest practicable level of physical, mental, and psychosocial well-being, by not enabling Resident 5 to ask for or get assistance for getting out of bed for activities of daily living (ADL: transfering from bed to chair, personal hygiene, toileting and getting dressed). These deficient practices had the potential to result in Residents 5, declining physically and psychosocially due to not getting the assistance she needed for ADL's. Findings: A review of Resident 5's Face Sheet (admission record) indicated Resident 5 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included Osteoarthritis (degeneration of joints and the underlying bone, that causes pain and stiffness, especially in the hip, knee, and thumb joints), Peripheral Vascular Disease ([PVD] a slow and progressive blood circulation disorder), Type II Diabetes Mellitus (inability of the body to process and use blood sugar), and a History of falls causing fractures. A review of Resident 5's Minimum Data Set (MDS a comprehensive assessment and care planning tool) dated 07/27/2021, indicated Resident 14 had intact cognitive function (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). A review of Resident 5's Care Plan (CP) for ADL's, dated 01/21/2019 indicated to assist Resident 5 to bathroom every two hours when awake and as needed, keep call light within easy reach and answer promptly and allow/encourage resident to decide reasonable preferred time for ADL's. During a concurrent observation and interview on 11/16/2021 at 11:44 a.m., with Resident 5, Resident 5 stated she was at times unsteady when she stood up. During an interview on 11/18/2021 at 08:12 a.m., Resident 5 stated that she can stand up but needed help because she got dizzy, and she had a history of falls which have resulted in a fracture. During a concurrent observation and interview on 11/18/2021 at 08:14 a.m., Resident 5's call light was left on the side of the bed covered with blankets. Resident 5 stated she could not reach her call light, and when she was able to use the call light for help, the staff did not come right away and sometimes she waited for 15 minutes, so Resident 5 decided to go to the bathroom by herself and she felt dizzy when she stood up and almost fell. During an interview on 11/19/2021 at 11:03 a.m., the Licensed Vocational Nurse (LVN 6) stated that Resident 5 must be provided with supervision and assistance when going to the bathroom for safety and to prevent falls. During a review of facility's undated policy and procedure (P/P) titled Answering Call Light, the P/P indicated it is the policy of the facility to answer the call light to respond to the resident's requests and needs by all staff. During the review of facility's policy and procedure (P/P) titled Resident Rights revised on 09/2017, indicated: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the tube feeding (liquid form of nutrients) administered through a gastrostomy tube [ (GT) a tube inserted into the stomach through an incision into the abdomen to deliver food and administer medications] was not expired. This deficient practice had the potential for Resident 21 to get an infection, and to not get adequate nutrition. Findings: During a review of Resident 21's admission record, the record indicated Resident 21 was admitted on [DATE] with diagnoses including dysphagia (inability to swallow), gastrostomy and dementia (a persistent disorder of the mental processes caused by brain disease or injury with symptoms including memory disorders, personality changes, and impaired reasoning). During a review of Minimum Data Set ([MDS], a comprehensive standardized assessment and care screening tool) dated 08/25/2021, MDS indicated Resident 21 had severely impaired cognitive skills for daily decision-making and was totally dependent on staff for transfer (how resident moves between surfaces including to or from bed, chair, wheelchair) and eating. During a record review of physician order dated 08/03/2020, the physician's order indicated an order for Jevity 1.2 (a fiber-fortified therapeutic nutrition that provides complete, balanced nutrition through tube feeding) at 60 cc/hour (a measure of volume per hour) for 20 hours a day to provide 1200 /1440 kilocalories (amount of nutrients prescribed to maintain body systems and functions). During an observation on 11/17/2021 at 11:08 a.m., Resident 21's tube feeding at bed sidewas Jevity 1.2, dated and timed 11/15/21 at 11 p.m. During an interview on 11/17/2021 at 02:00 p.m., License Vocational Nurse (LVN # 1) stated that tube feedings are changed every 24 hours. During an interview on 11/18/2021 at 09:10 a.m. with LVN 4, LVN 4 stated she was the assigned to Resident 21 on 11/17/2021. LVN 4 stated when she arrived yesterday at around 7:01 a.m. LVN 4 stated the tube feeding bag and water bag was dated11/15/2021 at 11:08 a.m. She stated she checked the flow rate but did not check the date of the bag at the beginning of the shift. LVN 4 acknowledged because the tube feeding has been open for more than 24 hours the tube feeding bag should be changed to prevent possible bacterial contamination and can make the resident sick. During an interview on 11/19/2021 at 09:00 a.m., with Director of Nursing (DON), DON acknowledged that the tube feeding set, per their policy should have been change every 24 hours to prevent possible bacterial contamination. During a record review of the facility policy (P/P), Appendix B: Preventing Contamination of Formula and Delivery System Used for Adults dated 09/22/2015, the P/P indicated that, to maintain a safe hangtime, open systems must have container/tubing changes at least every 24 hours. During a record review of a P/P titled, Diet Manual, Dietary Directions, Inc. dated 2018, the P/P indicated that tube feedings administration sets and bags should be changed every 24 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide sufficient staffing to accommodate the needs of six of six sampled residents (Resident 16, 19, 20, 22, 41, and 68) by failing to answer the resident's call lights and provide assistance for activity of daily living ([ADLs] daily self-care activities) in a timely manner. This deficient practice caused feelings of discomfort, frustration and had the potential for accidental falls, hypoglycemia (low blood sugar), unresolved pain, and not meeting the residents' needs and negativly affecting the resident's quality of life. Findings: a. A review of the facility's resident council (an organized group of residents who meet regularly to discuss and address concerns about their rights, quality of care and quality of life) meeting minutes dated 7/8/2021 and 9/2/2021 indicated the residents' concern included call lights be answered in a timely manner. A record review of resident council minutes dated 9/2/2021 indicated Resident 19 verbalized her call light was not being answered on time. During a review of Resident 19's admission Record (Facesheet), the facesheet indicated Resident 19 was readmitted to the facility on [DATE]. The record indicated Resident 19's diagnoses included posterior dislocation of right hip, has history of falling and difficulty walking. During a review of Resident 19's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 08/21/2021, the MDS indicated Resident 19's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions making was intact, and required extensive assistance of one staff person for activities of daily living. During an interview on 11/19/2021 at 09:45 a.m., Resident 19 stated a while ago she was upset because she pressed the call light to get help and to request for pain medication, but she waited for 30 minutes to get help. b. During a review of Resident 20's Face Sheet, the face sheet indicated Resident 20 was readmitted to the facility on [DATE]. The Face Sheet indicated Resident 20's diagnoses included Type 2 diabetes mellitus (inability to process and use sugar ([glucose] for energy and biological needs), long term use of hypoglycemic (medication that lowers blood sugar) drugs, visual loss both eyes, paraplegia [(paralysis or inability to move) of the legs and lower body], hemiplegia (paralysis of one side of the body). During a review of Resident 20's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 08/24/2021, indicated the cognitive skills for daily decisions making was intact, vision or ability to see in adequate light was severely impaired and required extensive assistance of one to two staff person for activities of daily living. During an interview on 11/18/2021 at 2:15 p.m., Resident 20 stated she felt the facility was short staffed because she did not always get help when she calls, and sometimes they come and just take care of the other residents in the room and when she called it took 30 minutes for someone to answer her call light. Sometime in October 2021 at around 2:30 a.m., Resident 20 was not feeling well, was sweating, and felt like her blood sugar was low so she pressed the call light but no one came so she needed to scream in order for someone to assist her. It took 30 minutes for someone to answer the call light when her blood sugar was low and they needed to give her juice. During an interview on 11/19/2021 at 3:00 p.m., Certified Nurse Assistant (CNA9) stated Resident 20 was diabetic so it was important to answer her call light quickly because the resident might have low blood sugar and die. During an interview and concurrent record review of Resident 20's Medication Administration Record for October and November 2021, on 11/19/2021 at 3:00 p.m., License Vocational Nurse (LVN6) stated Resident 20 was blind, and a diabetic, so it was important for Resident 20 to answer the call light right away in case of emergency like in the event of hypoglycemia or when there is a sudden drop of blood sugar level. LVN 6 stated Resident 20 was taking medications that can lower blood sugar and her blood sugar might go down anytime. A record review of MAR indicated Resident 20 had fluctuation of blood sugar from 69 to 384 (normal blood sugar range 80-130) A record review of Resident 20 Medication administration record (MAR) for 10/1/2021 to 10/31/2021 indicated on 10/20/2021 at 04:43 a.m. Resident 20 had blood sugar of 69 and was given glucagon (used to treat low blood sugar) 1 milligram [(mg) unit of measurement] for hypoglycemia (low blood sugar level) A record review of Resident 20's change of condition dated 10/20/2021 at 08:50 a.m. indicated Resident 20 had blood glucose [(BG) blood sugar level] of 54 and was exhibiting symptoms of hypoglycemia (sweating, trembling). A record review of Resident 20's MAR indicated an order for metformin (medication that lowers blood sugar) 500 milligram twice a day. A record review of Resident 20's MAR for October 2021 indicated an order of Levemir (medication that lowers blood sugar)16 unit subcutaneously twice a day from 9/19/2021 to 10/20/2021 at 08:50 a.m. A record review of Resident 20's Medication Administration for October 2021 indicated an order for Levemir 12 unit subcutaneously twice a day that was started on 10/20/2021 at 08:50 a.m. c.During a record review of Resident 68's face sheet, the face sheet indicated Resident 68 was admitted on [DATE] with a diagnoses including chronic obstructive pulmonary disease (a lung disease causing severe breathing problems), difficulty walking, history of falling, and morbid obesity (a disorder involving excessive body fat that increases the risk of health problems). During a review of the MDS dated [DATE], the MDS indicated Resident 68 had the ability to express ideas and wants, and had the ability to understand others. The MDS further indicated Resident 68 had intact cognitive skills (the core skills your brain uses to think, read, learn, remember, reason, and pay attention) for daily decision making. The MDS indicated Resident 68 needed supervision in eating and extensive assistance with activities ADL's. During an interview on 11/17/2021 at 10:32 AM with Resident 68, Resident 68 stated that occasionally during the 11:00 PM - 7:00 AM shift, staff took several hours to change her soiled briefs. Resident 68 denied incontinence (inability to control bowel and bladder functions), but chose to wear disposable briefs out of preference due to delayed staff response and physical limitations. Resident 68 further explained that coupled with the slow response time of staff to place her on the bedpan and her lack of full control of her urinary urge, she would have used the restroom on herself. d.During a record review of the Resident 22's face sheet, the face sheet indicated Residetn 22 was admitted on [DATE] with a diagnoses including anemia (condition of lack of enough healthy red blood cells to carry adequate oxygen to the body), atrial fibrillation (abnormal heart beat), type 2 diabetes (impairment of the way the body regulates and uses sugar as fuel), schizophrenia (brain disorder in which people interpret reality abnormally), and dysphagia (swallowing difficulty). During a review of the MDS, dated [DATE], the MDS indicated Resident 22 had the ability to express ideas and understand others. Further review indicated Resident 22 had moderately impaired cognitive skills (the core skills your brain uses to think, read, learn, remember, reason, and pay attention) for daily decision making. The MDS further indicated Resident 22 had no disorganized thinking (rambling or incoherent conversation, unclear or illogical flow of ideas). The MDS further indicated no potential indicators of psychosis (when person loses some contact with reality). The MDS indicated Resident 22 needed limited assistance with eating and required extensive assistance with ADLs . During an interview on 11/16/21 at 11:23 AM, with Resident 22, Resident 22 stated that he had issues with call lights being answered in a timely manner. Resident 22 did not indicate a specific time or shift and he stated that the problem occurred during the day and night. During an interview on 11/17/21 at 11:37 AM with Resident 22, Resident 22 stated that occasionally on night shift, when he asks for snacks, nurses don't return or forget to come back with his snack. e. During a record review of the Resident 22's face sheet), the face sheet indicated Resident 22 was admitted on [DATE], with a diagnoses including anemia (condition of lack of enough healthy red blood cells to carry adequate oxygen to the body), atrial fibrillation (abnormal heart beat), type 2 diabetes (impairment of the way the body regulates and uses sugar as fuel), and dysphagia (swallowing difficulty). During a review MDS dated [DATE], the MDS indicated Resident 22 had the ability to express ideas and wants, the ability to understand others. Further review indicated Resident 22 had moderately impaired cognitive skills (the core skills your brain uses to think, read, learn, remember, reason, and pay attention) for daily decision making. The MDS further indicated that Resident 22 had no disorganized thinking (rambling or incoherent conversation, unclear or illogical flow of ideas). The MDS further indicated no potential indicators of psychosis (when person loses some contact with reality). The MDS indicated Resident 22 needed limited assistance with eating and required extensive assistance ADLs. During an interview on 11/16/21 at 11:23 AM with Resident 22, Resident 22 stated that he was having issues with call lights being answered in a timely manner. Resident 22 did not indicate specific time or shift and he stated that the problem has occurred during the day or night. During another interview on 11/17/21 11:37 AM, Resident 22 stated that occasionally on night shift, when he asks for snacks, nurses don't return or forget to come back with his snack. f. During a review of Resident 16's Face Sheet, the Face Sheet indicated Resident 16 was readmitted to the facility on [DATE]. The Face Sheet indicated Resident 16's diagnoses included heart failure, epilepsy (a disorder in which brain activity becomes abnormal, causing uncontrolled muscle contractions, periods of unusual behavior, sensations and sometimes loss of awareness), and chronic obstructive pulmonary disease (breathing problem). During a review of Resident 20's MDS, dated [DATE], the MDS indicated the cognitive skills for daily decisions making was intact, vision or ability to see in adequate light was severely impaired and required extensive assistance of one to two staff person for activities of daily living. During an interview on 11/19/2021 at 09:34 a.m. with Resident 16, Resident 16 stated the facility was short staffed on 11/13/2021 at 11:00 p.m. to 7:00 a.m. shift, one CNA did not show up and the call lights were on but no one was answering, the nurses were at the nursing station but they do not help with answering call light. Resident 16 was concerned the residents would not get help in a timely manner during an emergency. g. During a review of resident 41's facesheet, the face sheet indicated the facility admitted Resident 41 on 9/22/2021 with diagnoses including fracture of the right tibia (broken bone in the right lower leg), difficulty in walking, muscle weakness, type 2 diabetes, insomnia (sleep disorder), and essential hypertension (high blood pressure [measure of force that the heart pumps blood around the body] that does not have a known cause). A review of the MDS dated [DATE], indicated Resident 41 had the ability to express ideas and wants, and had the ability to understand others. Further review of the MDS indicated Resident 41 had intact cognitive skills (the core skills your brain uses to think, read, learn, remember, reason, and pay attention) for daily decision making. The MDS further indicated that Resident 41 needed supervision in eating and required supervision to extensive assistance with ADL's. During an interview on 11/16/2021 at 10:33 AM, Resident 41 stated that during the night shift, delay of nursing care was a usual occurrence. Resident 41 stated there was a delay of pain medication administration; call lights weren't being answered quickly; and sometimes Resident 41 had to wait 2 hours for staff response. Per Resident 41, staff advised him that there were no supervisors on during night shift. Resident 41 stated this made him feel helpless and like he did not matter. During an interview on 11/19/2021 at 7:00 AM, with CNA 8, CNA 8 stated that she had 14 residents and that teamwork was essential to complete their difficult workload. CNA 8 admitted that sometimes she could not answer call lights at all because she was helping another resident in the room. During an interview and concurrent record review of Nursing Staffing Assignment and Sign -in sheet for November 13, 2021 on 11/19/2021 at 07:49 a.m., Director of Staff Developer (DSD) stated on 11/13/2021 at 11:00 p.m. to 7 a.m. shift, the Census (number of residents in the facility) was 79 and required 5 CNAs to adfequalty provide care for the residents, DSD stated 1 CNA called in sick, staffing was not able to find a replacement. DSD stated there were only 2 LVNs and 4 CNAs for the night shift. DSD stated she asked 2 staff to come in to work, but no one can work and did not call any other staff because it was already late. DSD stated she did not try to reach out to registry (an agency that provides professional staff for temporary facility needs), because she did not think they could provide staff and did not notify the Director of Nursing (DON) nor Administrator (ADM) that she did not have adequate staffing. During an interview on 11/19/2021 at 10:29 a.m.with the DON, the DON stated for a census of 79 they needed 5 CNAs for the 11:00 p.m. to 7:00 a.m. shift. The DON stated they have a contract with registry and the DSD, DON or ADM was able to reach the registry via telephone or internet for 24 hours a day 7 days a week to see if they have any available staff. DON stated he was not informed they needed a CNA for night shift until the following business day. During an interview on 11/19/2021 at 11:45 a.m., with ADM, ADM stated if they were short staffed, it was their process to ask staff to stay over, call staff who are not on duty, and stated they have a contract with registry who can be reached 24 hours a day, 7 days a week although there was no guarantee that the registry could provide staffing. ADM stated she was not aware of the staffing shortage until the following business day. During a review of the facility's undated policy and procedure (P/P) titled Staffing , P/P indicated the facility will maintain an adequate staffing on each shift to ensure the residents' needs and services are met. CNA are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan. A record review of the facility policy entitled, Answering call light (undated), indicated all staff will answer the call Iight to respond to the resident's requests and needs as soon as possible. The policy further delineated that if the staff responding to the call light was unable to assist the resident, he/she will report the resident's request/needs to the licensed nurse or staff who can respond to the request. Policy further indicated If the staff promises the resident to return with an item or information, staff will do promptly. During a review of facility's Mitigation Plan revised 11/12/2021, indicated if facility has staffing shortage facility will initiate a contract with staffing agency and the DSD and/or DON and/or administrator will review staffing on a daily basis to assess staffing status needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: a. Store one unopened insulin (a medication used to treat high blood sugar) Basaglar pen in the refrigerator (per manufacturer's recommendations) for Resident 45. b. Label opened date for one Nutricia UTI-Stat (oral supplement for urinary tract health) for Resident 45. These deficient practices increased the risk that Residents 45 and residents who receive Nutricia UTI-Stat to recieved medications or supplements that had become ineffective or toxic due to improper storage or labeling possibly leading to health complications resulting in hospitalization or death. Findings: a. On 11/16/21, at 11:35 a.m., during an inspection of Medication Cart 2 with Licensed Vocational Nurse (LVN) 2, one unopened insulin pen was stored in a manner contrary to their respective manufacturer's requirement for Resident 45. No date on insulin pen observed to indicate when the medication was removed from the refrigerator. According to the manufacturer's product labeling, unopened insulin Basaglar should be stored in the refrigerator. During a review of Resident 45's admission Record (Facesheet), the Facesheet indicated the resident was re-admitted to the facility on [DATE] with diagnoses that inclueded bacterial pneumonia (infection of one or both sides of the lungs that causes the air sacs of the lungs to fill with fluid or pus), sepsis (overwhelming reaction to infection that comes with high morbidity and mortality), type 2 diabetes mellitus (abnormal blood sugar), long term use of insulin, muscle weakness, heart failure (a condition in which the heart has trouble pumping blood thought the body), and difficulty in walking. During a review of the Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 10/4/21, the MDS indicated Resident 45 had no cognitive impairment and was on insulin injections for the past 7 day since entry into the facility. During a review of Resident 45's physician orders, dated 11/19/21, the physicans orders indicated orders for Basaglar KwikPen Solution Pen-injector 100 unit/milliliter (ml) to inject 30 units subcutaneously (under the skin) in the evening related to type 2 diabetes mellitus. During an interview with LVN 2 on 11/16/21, at 11:47 a.m., LVN 2 confirmed unopened insulin is supposed to be stored in the refrigerator because it was stated on the directions, LVN 2 could not explain why insulin needed to be refrigerated. During an interview with RN 1 on 11/16/21, at 1:34 p.m., RN 1 stated unopened insulin is supposed to be stored in the refrigerator until being used. The insulin is supposed to be dated once it is opened. RN 1 stated she ensures insulin is still viable by checking for the open date. RN 1 stated she forgot to label the date the insulin was removed from the refrigerator. During an interview with Assistant Director of Nursing (ADON) on 11/16/21, at 12:36 p.m., ADON stated insulin has to be refrigerated if unopened because it can affect the effectiveness of the medication. A review of the facility's policy and procedure (P/P) titled Medication Storage In the Facility, dated 4/2008, the P/P indicated medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Medications requiring storage at room temperature are kept at temperatures ranging from 15 degrees Celsius (59 degrees Fahrenheit) to 30 degrees Celsius (86 degrees Fahrenheit). b.During a concurrent observation of medication cart 3 inspection and interview with Director of Nursing (DON) on 11/19/21 at 11:17 AM, the DON confirmed the Nutrica UTI-stat (ready to drink medication) had no label indicating the date the container was opened. DON stated the product needed to be discarded 3 months after it was opened. Per DON, not labeling the container deemed the product contaminated since the date it was opened was not indicated. Per DON, the product should've had the label so we can follow the proper procedure of storage and discard it 3 months after it was opened to ensure potency of the product. A review of the facility policy entitled medication storage in the facility (4/2008) indicated medication storage conditions were monitored on a routine basis and corrective action taken if problems were identified. The policy further indicated outdated, contaminated, or deteriorated medications were immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its diet menu instructions for a mechanical soft texture (a diet that involved only foods that were physically soft, with the goal of reducing or eliminating the need to chew the food) for one of one resident, Resident 48 by not ensuring the parsley sprig (stem that has leaves) was in a proper mechanical soft form. This deficiency inadvertently put Resident 48 at high risk for aspiration (condition in which food, liquids, saliva, or vomit is breathed into the airways)and could have further compromised Resident 48's medical status. FINDINGS: During a record review of the Resident 48's admission record (face sheet) dated 11/19/2021, the face sheet indicated the facility admitted Resident 48 on 3/25/2021 with diagnoses including type 2 diabetes (impairment of the way the body regulates ad uses sugar [glucose] as fuel), muscle weakness, presbyopia (gradual loss of eyes ability to focus on nearby objects) , bilateral cataract (problem with both eyes that results in blurred vision), and essential hypertension (high blood pressure [measure of force that the heart pumps blood around the body] that does not have a known cause). During a review of the minimum data set (a standardized assessment and care screening tool [MDS]), dated 9/30/2021, the MDS indicated Resident 48 had the ability to express ideas and wants, and had the ability to understand others. Further review indicated Resident 48 had intact cognitive skills (the core skills your brain uses to think, read, learn, remember, reason, and pay attention) for daily decision making. The MDS further indicated that Resident 48 was independent in eating and required supervision or limited assistance with activities of daily living ([ADLs] tasks of everyday life, dressing, getting into or out of a bed or chair, taking a bath or shower and using the toilet). During a record review of Resident 48's order summary report, the report indicated Resident 48's diet order dated 3/25/2021, was for controlled carbohydrate (type of food), no added salt, mechanical soft texture, finely chopped. During an observation and interview on 11/18/2021 at 12:06 PM, the dietary supervisor assistant (DSA) placed a 2-3-inch-long parsley sprig on Resident 48's tray which was one of the mechanical soft diet trays. Per DSA, all mechanical soft and regular diets can have the parsley sprig garnish. Per DSA only puree diet does not get the parsley sprig. During an observation and interview on 11/18/2021 at 12:20 PM, licensed vocational nurse 5 (LVN 5) confirmed Resident 48 had a diet order for mechanical soft finely chopped diet according. Per LVN 5 she did confirm that Resident 48's tray had a parsley sprig on the plate. Per LVN 5, the parsley sprig should not have been on the plate because a mechanical soft diet required soft, cooked vegetables, not raw vegetables. Per LVN 5 the parsley sprig which had a stem and was raw should not have been on the plate because it was a vegetable accessible to residents for consumption. During a concurrent interview and record review of Resident 48's diet profile card on 11/19/2021 at 8:54 AM, with the ,dietary supervisor (DS), DS confirmed that Resident 48 had an order for mechanical soft finely chopped diet. Per DS, upon reviewing the daily menu, [NAME] 2021 spreadsheet, week 3, the menu indicated that mechanical soft and bite sized and minced and moist indicated it should have no parsley sprigs. DS verifiied Resident 48's tray should not have had a parsley sprig on the plate as per stated in the menu spreadsheet. During an interview on 11/19/2021 at 9:34 AM, with registered dietician (RD), RD stated mechanical soft diet, for residents not able to chew, should only have cooked vegetables. Per RD, although parsley was technically an herb and not a vegetable, a raw parsley sprig should not have been part of the mechanically soft- finely chopped diet served to Resident 48. Per RD, the menu spreadsheet should have indicated the proper form of parsley, whether it be a sprig or flakes. Per RD having a parsley sprig can be a cause for concern for those who might grab it, chew it unsuccessfully, swallow it, and choke. During a record review of a document titled Mechanical or dental soft suggested foods from the facility's diet manual, dietary directions, incorporated 2018, the manual indicated vegetables suggested to be cooked soft or diced. Per document, all other raw vegetables were of concern. During a record review of the facility's policy and procedure (P/P) entitled Dietary - Menus, food, and drink (revised 10/2017) , the P/P indicated the facility will have menus that will be followed, and that food will be prepared in a form designed to meet individual resident needs. During a record review of the facility's P/P entitled Menu planning (2020) indicated the facilities diet manual and the diets ordered by the physician should mirror the nutritional care provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide alternative options for snacks for two (2) of eight (8) sampled residents (Resident 22 and 41). This deficient practice had the potential for Residents 22 and 41 not getting adequate nutriotional intake due to not getting snacks of their choosing. FINDINGS: During a record review of the Resident 22's admission record (face sheet), the face sheet indicate the facility admitted Resident 22 on 9/22/2021 with diagnosis including anemia (condition of lack of enough healthy red blood cells to carry adequate oxygen to the body), type 2 diabetes (impairment of the way the body regulates and uses sugar as fuel), and dysphagia (swallowing difficulty). During a review of the minimum data set (a standardized assessment and care screening tool [MDS]), dated 8/25/2021, the MDS indicated Resident 22 usually had the ability to express ideas and wants, and usually had the ability to understand others. Further review indicated Resident 22 had moderately impaired cognitive skills (the core skills your brain uses to think, read, learn, remember, reason, and pay attention) for daily decision making. The MDS further indicated that Resident 22 had no disorganized thinking (rambling or incoherent conversation, unclear or illogical flow of ideas). The MDS indicated Resident 22 needed limited assistance with eating and required extensive assistance with activities of daily living ([ADLs] tasks of everyday life, dressing, getting into or out of a bed or chair, taking a bath or shower and using the toilet). During a review of resident 41's face sheet, the face sheet indicated the facility admitted Resident 41 on 9/22/2021 with diagnoses including fracture of the right tibia (broken bone in the right lower leg), difficulty in walking, muscle weakness, type 2 diabetes, and essential hypertension (high blood pressure [measure of force that the heart pumps blood around the body] that does not have a known cause). During a review of the MDS, dated [DATE], the MDS indicated Resident 41 had the ability to express ideas and wants, and had the ability to understand others. Further review indicated Resident 41 had intact cognitive skills (the core skills your brain uses to think, read, learn, remember, reason, and pay attention) for daily decision making. The MDS further indicated that Resident 41 needed supervision in eating and required supervision or extensive assistance with ADLs. During an interview on 11/17/2021 at 10:55 AM with Resident 41, Resident 41 stated that snack options during night shift, 11 PM - 7 AM shift, were lacking if there were any available. Per Resident 41, certified nurse assistants often failed to offer snacks and when Resident 41 requested snacks, staff stated that the kitchen was closed. During an interview on 11/17/2021 at 11:37 AM with Resident 22, Resident 22 stated that especially during the night shift, snacks weren't being provided when requested. Resident 22 stated that he doesn't get a lot of options of snacks to choose from. Per Resident 22, there are times on night shift, when he asks for snacks, nurses don't return or forget to come back with his snack. During an interview on 11/19/2021 at 7:00 AM with certified nurse assistant 8 (CNA 8), CNA 8 stated that for the 11PM to 7AM shift, snacks for residents can be found in a cart by the nursing station. Per CNA 8, once the cart was empty the staff was unable to provide more snacks to the residents. Per CNA 8, running out of snacks for residents, during the night shift, happened occasionally. During a record review of the facility's policy and procedure (P/P) entitled Dietary - Menus, food, and drink (revised 10/2017), P/Pindicated the facility will respect the residents right to make personal dietary choices. During a record review of the facility's P/P titled Nourishment policy (2018) , the P/P indicated, although the food and nutrition services shall provide nourishments up to three times per day at 10:00 AM, 2:00 PM, and 8:00 PM, snacks must also be provided to residents who want to eat at nontraditional times outside of scheduled snack times.

Based on observation, interview, and record review the facility failed to ensure one (1) out of 1 residents' refrigerator, used for storing residents' personal food from an outside source, were safe and sanitary by not ensuring all items therein were labeled with the date and resident's name; and the foods were in a sealed container to prevent cross contamination. This deficient practice had the potential to result in contamination of residents' food items stored in the resident refrigerator thereby causing food-borne illnesses (also called food poisoning, an illness caused by eating foods that have harmful organisms in them). FINDINGS: During an observation, interview, and record review on 11/16/2021 at 9:01 AM, at the communal dining room, licensed vocational nurse 6 (LVN 6) stated and confirmed there were undated and unlabeled items in the resident's refrigerator: a. Five (5) butter reddies (individual butter chips approximately I inch squares, on paper mat with parchment cover), and b. Seven (7) individually wrapped frozen burritos. Per LVN 6, the butter reddies should have been included in the resident's plastic bag. LVN 6 also confirmed the frozen burritos should have had a label of resident's name and date. During an interview on 11/19/2021 at 10:08 AM, the director of nursing stated items in the resident's refrigerator should be labeled with resident's name and date it was procured. During a record review of the facility Refrigerator rules, posted on the front of the refrigerator (undated), the rules indicated all items must be dated and labeled with resident's name, room number. Rules further indicated responsibility of the nursing staff to monitor the items placed in the refrigerator. Per rules, staff should have assisted residents and visitors in storing their labeled and dated food/ beverages in the resident's refrigerator. A record review of the facility's procedure and policy (P/P) titled, Refrigerator for Resident storage of food, indicated all food to be stored in the refrigerator will be in appropriate containers. Policy further sated all food will be labeled with the resident's name and the date the food is placed in the refrigerator.

Based on observations, interviews, and record reviews, the facility failed to store and prepare food under sanitary conditions in one (1) of 1 kitchen, by failing to: A. Ensure one of one ice machine was clean; B. Ensure the ice machine was cleaned following manufacturer's instructions; C. Ensure dry storage was free of items that were past storage date; D. Ensure foods in the dry storage area was removed from packaging boxes upon delivery. These deficiencies had the potential to result in cross contamination causing food-borne illness (also called food poisoning, an illness caused by eating foods that have harmful organisms in them), which can possibly lead to hospitalization and death. Findings: A. During a concurrent observation and interview on 11/17/2021 at 8:45AM, the dietary supervisor (DS) confirmed that the picture taken of the inside of the ice machine was a mineral scale build up on the upper left side of the ice machine interior by the chute where the ice was dispensed from. Per DS that mineral build up should have been removed. During an interview and record review of the photograph (11/17/2021) of the interior of the ice machine, on 11/19/21 at 9:34 AM, the registered dietician (RD) confirmed that the ice machine should be maintained and cleaned regularly to monitor for any dust, mold, and mineral build up. After reviewing the photograph of the interior of the facility ice machine and confirming the mineral build up noted on the interior of the ice machine, RD stated that the amount of the mineral build up noted in the interior of the facility ice machine was unacceptable. Per RD, facility residents utilize the ice machine and mineral build up can harbor bacteria (germs that can cause disease) that can cause food borne illness. During a record review of the ice machine manual titledC0322 through C1030 D series Air- and water-cooled user manual Cleaning, Sanitation, and Maintenance,dated 10/2014, the manual indicated the ice system required three types of maintenance: remove the buildup mineral scale from the ice machine's water system and sensors. Per manual, it was the user's responsibility to keep the ice machine and ice storage bin in a sanitary condition. Ice machine also required occasional cleaning of their water systems with a specifically designed chemical which dissolves mineral build up that forms during the ice making process. During a record review of the facility's policy entitled, Cleaning the ice machine dated 7/2019, the policy indicated facility will clean the ice storage bin monthly. B. During a concurrent observation and interview on 11/17/2021 at 8:39AM, the DS stated he cleaned the inside of the ice machine storage bin monthly using KLOR 300 chem mark (brand name of the chlorine-based sanitizer). Per DS, after emptying the ice machine, he used 10 ounces (oz.) sanitizer and lukewarm water and cleaned the inside of the ice bin thoroughly using a new scrubber and scrubbing pad. During a concurrent interview and record review of the ice machine manual (10/2014) titledC0322 through C1030 D series Air- and water-cooled user manual Cleaning, Sanitation, and Maintenance on 11/17/2021 at 10:00 AM, the DS confirmed that he should have followed manufacturer's instructions in cleaning the ice machine. Per DS, he should have used the recommended scale remover (Scotsman Clear 1 ice machine remover) to remove the mineral scale build up prior to sanitizing the ice storage bin as per instructions. A record review of the ice machine manual indicated that to clean the Ice storage bin, need to: a. Mix a solution of 7 ounces of Scotsman Clear 1 ice machine scale remover in 84 ounces of potable water and wash all interior surfaces of the ice storage bin to remove any mineral scale build up. b. Mix a solution of sanitizer and thoroughly wash all interior surfaces of the ice storage bin. During a review of the U.S. Food and Drug Administration's 2017 Food Code, the Food Code indicated in Chapter 1 part 1 201.10, ice is defined as food. According to Chapter 4, part 602.11 (Equipment Food Contact Surfaces and Utensils) section (E) item (4a and b), the items 4a and 4b state that the ice machines must be cleaned at a frequency specified by the manufacturer, or .at a frequency necessary to preclude accumulation of soil or mold. C. During a concurrent observation and interview on 11/16/2021 at 8:39 AM, the dietary supervisor assistant (DSA) confirmed the premium crouton box was opened on 7-15-2021 as indicated on the date. DSA acknowledged the box of croutons had been opened for more than a month and needed to be discarded. Pers DSA, the molasses with an open date 3/8/2021 should've also been discarded since they had been open for over six months. During an interview with the RD on 11/19/2021 at 9:34 AM, RD stated that opened container of croutons needed to be discarded as per dry storage guidelines of 1 month. Per RD, keeping items beyond shell life can compromise the integrity of the food and may cause inadvertent illness. A record review of the facility's Dry goods storage guidelines dated 2018 indicated that opened crouton containers should be discarded one month from opening. The guideline further indicated that croutons need to be kept dry and tightly covered. The guideline further indicated opened molasses should be discarded 6 months after opening. A record review of the facility's policy for storage of food and supplies dated 2020 indicated food and supplies will be stored properly and in a safe manner. According to the policy, all food will be dated (month, day, and year). All food products will be used per the times specified in the Dry Food Storage Guidelines. The storage times in the guidelines are intended to be on the safe side. D. During an observation and interview on 11/16/2021 at 8:39 AM, the DSA confirmed the premium crouton was stored in a corrugated cardboard box. The DSA further confirmed the lasagna was stored in a corrugated cardboard box. During a record review of the facility's policy and procedure (P/P) for storage of food and supplies dated 2020, the P/P indicated food and supplies will be stored properly and in a safe manner. According to the policy, foods need to be removed from the package box upon delivery to minimize pests. The policy further indicated dry bulk foods should be stored in seamless metal or plastic containers with tight covers, or in bins which are easily sanitized. Policy further stated dry food items which have been opened, such as pudding, gelatin, biscuit mix, pancake mix, dry cereal, spices, coffee, noodles, etc., will be tightly closed, labeled, and dated. These items are to be used per times specified in the Dry Food Storage Guidelines.