Based on observations, record reviews, and interviews, the facility failed to ensure 4 residents sitting at one of four tables were treated in manner of dignity and respect related to staff spraying cleaner directly onto the table in front of the residents, and failed to dress one (#107) out of 7 residents sampled on the memory care unit in clothing belonging to them. Findings included: 1. On 4/9/24 at 8:41 a.m., Staff L, Certified Nursing Assistant (CNA), was observed spraying an unknown clear liquid onto a square table in the memory care unit where Resident #24, Resident #73, and 2 unknown others were sitting. The staff member wiped a cloth through the liquid, pushing crumbs towards one of the unknown residents. and off the edge of the table. On 4/9/24 at 8:58 a.m. Staff Q, Housekeeper was observed spraying a liquid onto a table in front of Resident #24 and another unknown resident; the staff member waited a few moments then wiped the liquid away. An interview was conducted with Staff Q on 4/9/24 at 9:02 a.m., the staff member reported the liquid was a name brand broad-spectrum disinfectant. Staff Q stated yes confirming she normally does spray the liquid in front of the residents. During an interview on 4/11/24 at 3:11 p.m., the Director of Nursing (DON) stated it was not appropriate to spray cleaner(s) on table in front of residents. She said they are supposed to spray the cleaner on a towel (demonstrated pumping trigger-motion in front of flattened hand). 2. On 4/8/24 at 9:49 a.m. Resident #107, a male resident, was observed sitting at table on the secured memory care unit wearing an orange t-shirt and matching orange ankle socks. On 4/8/24 at 10:22 a.m., the orange socks worn by Resident #107 was observed as labeled with Resident #98's last name and first initial., a female resident. An interview and observation was conducted with Staff M, Certified Nursing Assistant (CNA) on 4/8/23 at 10:34 a.m. The staff member confirmed the resident (#107) was wearing Resident #98's socks and reported not being Resident #107's aide on that day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to assess, obtain physician orders, revise the person-centered comprehensive care plan and educate one resident (#32) out of three sampled residents during medication pass, related to self- administering medications. Findings included: A medication administration observation was conducted on 06/03/2024 at 8:55 a.m. with Staff J, Licensed Practical Nurse (LPN) for Resident #32 Fluticasone Propionate (Nasal) spray, and Budesonide-Formoterol Fumarate Inhaler were observed in the resident's room. The medications were in a container beside the resident's bed not secured. Latanopsin eye drops were observed in a locked container in the room. Curoxen ointment was observed sitting on the overbed table. Resident #32 stated the facility would not get her the Curoxen ointment, so she had a friend bring it in. Resident #32 stated she had been administering her nasal sprays for months. The resident stated the facility had given the medications to her to administer so she would not complain about her medications being late. Staff J, LPN stated she would get the orders for Resident #32 to self-administer her medications. Resident #32 was admitted on [DATE] and readmitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to, Wernicke's encephalopathy, unsteadiness, insomnia, hypertension (HTN), chronic pain, anxiety disorder, recurrent major depressive disorder, and mood disorder. Record review of the Minimum Data Set (MDS), dated [DATE], showed a Brief Interview of Mental Status (BIMS) score of 15 (cognitively intact). Section N: Medications showed she was taking antianxiety medications. Review of the Physician Order Summary Report as of June 2024 showed: -Resident may self-administer all eye drops ordered. Eye drops may be kept in locked container in resident's room -Latanoprost ophthalmic solution 0.005% instill 1 drop in right eye at bedtime for glaucoma as of 05/06/2024. Order changed to unsupervised self-administration on 06/04/2024 -ProAir HFA inhalation Aerosol solution 108 (90 base) mcg/act (Albuterol Sulfate) 2 puffs inhale orally three times a day for wheeze-cough/ congestion for 5 days and 2 puffs inhale orally every 6 hours as needed for wheeze-sob, ordered on 10/09/2023. Revised to unsupervised self-administration as of 06/03/2024 -Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 mcg/act 2 puffs inhale orally two times a day for asthma, ordered on 02/01/2024 and revised to unsupervised self-administration rinse mouth out after use as of 06/03/24 -Flonase Nasal Suspension 50 mcg/act 1 spray in both nostrils two times a day for allergies, ordered on 01/20/2023. Revised to unsupervised self-administration as of 06/03/2024 -Curoxen ointment apply to affected area every 6 hours as needed for mouth sore as of 3/28/24 Review of the May and June 2024 MARS showed the following: -Curoxen had not been administered for May nor June of 2024 -ProAir HFA inhalation Aerosol solution 108 (90 base) mcg/act (Albuterol Sulfate) 2 puffs inhale orally three times a day for wheeze-cough/ congestion for 5 days and 2 puffs inhale orally every 6 hours as needed for wheeze-sob, ordered on 10/09/2023 shown as given -Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 mcg/act 2 puffs inhale orally two times a day for asthma, ordered on 02/01/2024 shown as given -Flonase Nasal Suspension 50 mcg/act 1 spray in both nostrils two times a day for allergies, ordered on 01/20/2023 shown as given Record review of the nursing progress notes showed: On 06/03/2024, May self-administer Flonase Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal) as well as Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 MCG/ACT (Budesonide-Formoterol Fumarate Dihydrate. At approximately 0930 resident was educated by this writer. Resident made aware of new orders obtained. Review of the Self-Administration of Medication Resident Assessment, dated 03/04/2024, showed the resident can demonstrate secure storage for medication kept in room, can correctly state the proper dose for each medication, can correctly state what each medication is for, can state what time or how often medication is to be taken. Can correctly self-administer eye drops / ointments. The resident is deemed able to safely self-administer medications and that it is clinically appropriate. The capability to self-administer nasal drops / sprays and inhalants / diskus were not documented as evaluated. Record review of Resident #32's Care plans showed the resident wishes to self-administer eye drops and can demonstrate secure storage, can identify medication, knows the dosage, side effects and knows it's purpose, can read instructions, can take medication as ordered. Some of their medications (eye drops). Rest of medication kept by nurse as of 03/04/2024. Interventions included but not limited to: assessment by Interdisciplinary team (IDT) completed & self-administration approved on 03/04/2024. Ongoing teaching regarding medication administration, dosage, purpose, secure storage, self-documentation, side effects, and reporting to nurse for documentation. Physician order obtained. Verify medications are safely secured daily. During an interview on 06/03/2024 at 9:25 a.m. Staff J, LPN stated she had called the Nurse Practitioner (NP) and received the okay for Resident #32 to self-administer her Flonase and get a second locked box. During an interview on 06/03/2024 at 5:35 p.m. the Director of Nursing (DON) verified the medication Lantoprast (eye drop) did not have an order to self-medicate. The DON verified there were not orders to self-administer inhalers or nasal sprays and an evaluation for self-administration for these medications had not been completed. The DON stated the resident did not have a locked box at bedside for these medications, only for the eye drops. The DON stated the Curoxen should not have been in the resident's room. The DON verified the resident was only care planned to self-administer the eye drops. The DON stated she performed the self-administration of nasal sprays and inhaler medications today, 06/03/2024. Review of the facility's policy, Medication Administration, as of 09/18, showed the following: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. 15. Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care centers' Interdisciplinary Team (IDT), and in accordance with procedures for self-administration of medications and state regulations. Review of the facility's policy, Self-Administration by Resident, dated 11/17, showed the following: Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration. Procedures: 1. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process. 2. The interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment conducted as part of the care plan process. the nursing care center may use the following as a guideline or establish an alternate procedure: a. the resident is instructed in the use of the package, purpose of the medication, reading of the label, and scheduling of medication doses. 3. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment, which is placed in the resident's medical record. 4. If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted. 5. The resident is instructed in the proper cleaning of inhalers where applicable, proper storage and the necessity of reporting each medication dose used to the nursing staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility's policy titled physician notification, the facility failed to ensure one Resident (#12) out of five residents reviewed for unnecessary medications had a significant change in condition assessment completed prior to antibiotic use. Findings included: A review of the admission Record showed Resident #12 was admitted to the facility on [DATE] with diagnoses that included but was not limited to unspecified focal traumatic brain injury without loss of consciousness, major depressive disorder, other seizures, schizophrenia and anxiety disorder, unspecified. Review of the Order Summary Report revealed a physician order dated 04/03/24 for Doxycycline Hyclate Oral Tablet 100 MG [milligrams] (Doxycycline Hyclate)- Give 1 tablet by mouth every 12 hours for UTI [urinary tract infection] for 10 Days. Review of Resident #12's care plan revealed, Focus: ANTIBIOTIC: The resident is on Antibiotic Therapy r/t Has a Bacterial Infection (UTI). Goal: Minimize the risk of spread and Will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. Interventions: Administer medication as ordered, Report pertinent lab results to MD, Standard Precautions, Observe for possible side effects every shift, Observe diarrhea, nausea, vomiting, anorexia, and hypersensitivity /allergic reactions. Monitor for adverse reaction, Offer and/or encourage fluids through out the day. Antibiotics are non-selective and may result in the eradication of beneficial microorganisms and the emergence of undesired ones, causing secondary infections such as oral thrush, colitis, and vaginitis and Monitor for presence or absence of pain; level & effectiveness of pain medication. Review of Resident #12's lab results showed no urinalysis (UA) available for the dates of 04/01/24-04/03/24 prior to the use of antibiotic treatment. Review of Resident #12's Standard Evaluations for change of condition (CoC) evaluations, showed one CoC dated 09/07/23. There were no CoC available for Resident #12's weakness and antibiotic use for symptom onset of 04/01/24. Review of Progress Notes revealed the following: -A progress note dated 04/8/2024 at 10:44 p.m., showed, Resident continued on [oral] PO [antibiotic] ABT for [urinary tract infection] UTI No adverse reaction noted on this shift. No sign of discomfort noted. Resident denied dysuria. -A progress note dated 04/7/2024 at 10:35 p.m., showed, Resident on [antibiotic] ABT for UTI no adverse reactions noted will continue with care plan. -A progress note dated 4/3/2024 at 5:20 a.m., showed, Unable to collect urine for testing. Had resident in bathroom but, he could not urinate at that time. Will ask 7-3 shift to try or get a cath order. -A progress note dated 04/01/23 at 2:48 p.m., showed, MD [medical doctor] in to see resident noted with increased weakness. New order received for stat and routine labs. During an interview on 04/11/24 at 8:40 a.m., Staff E Registered Nurse (RN) Unit Manager (UM) stated Well here is the thing, we tried three times to get a urine sample and was unsuccessful. Staff E RN/UM stated the doctor decided to order Resident #12 Doxycycline as a preventive measure without confirming the urinary tract infection because Resident #12 looked pale and was weak. During an interview on 04/11/24 at 9:35 a.m.,, the Director of Nursing (DON) was asked for the facility's policy and procedure for urinary tract infection (UTI) protocol but stated, there was no policy or procedure for UTI. During an interview on 04/11/24 at 9:40 a.m., the Infection Preventionist (IP) confirmed the progress notes showed staff were going to straight cath Resident #12 but when Staff E RN/UM talked to the physician, the physician chose not to straight cath Resident #12 and just put him on an antibiotic. The IP confirmed there was no change of condition assessment completed which she would have expected there would have been one. Review of the facility's policy titled,Physician Notification dated October 2021 revealed, Procedure: 1. Licensed nurses will ensure that physicians are notified of changes in diagnostic results that occur between visits. Changes may include but are not limited to: - Change in condition, mental or physical - A change in the status of a wound - the development of a new wound -Laboratory Results - Diagnostic Results - Consultant reports and recommendations - Family concerns related to medical care - events - Resident's refusal to take medication - Any time a medication is not ordered or administered

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure multiple Minimum Data Set (MDS) assessments accurately reflected diagnoses of one Resident (#85) out of 33 sampled residents. Findings included: A review of the admission Record showed Resident #85 had an admission date of 10/11/23 with diagnoses that included but not limited to encounter for orthopedic aftercare following surgical amputation, acquired absence of left above the knee, lack of coordination, schizophrenia, and major depressive disorder, recurrent. A review of the Order Summary Report revealed a physician order dated 04/04/24 for Doxycycline Hyclate Oral Tablet 100 MG [milligrams] (Doxycycline Hyclate)- Give 1 tablet by mouth every 12 hours for UTI [urinary tract infection] for 10 Days. Review of Resident #85's care plan revealed, Focus: PSYCHOTROPIC MED: The resident uses psychotropic medications r/t Antidepressant to manage: depression Antipsychotic to manage: schizophrenia with initiated date of 10/13/24. Goals: Resident will be at the lowest does required to reduce symptoms while minimizing adverse side effects to ensure maximum functional ability both mentally and physically through the next review with initiated date of 10/13/24. Interventions: Obtain and review lab/diagnostic work as ordered. report results to MD and follow up as indicated, Psychotropic Side Effects Monitoring, Administer medication as ordered and observe/document for side effects and effectiveness, Psychological services per order and as needed, Psychiatry services per order as needed per protocol, Consult with pharmacy, MD to consider dosage reduction when clinically appropriate and Report to physician negative outcomes associated with use of drug with initiated date of 10/13/24. Review of all available Minimum Data Sets (MDS) in Resident #85's medical record revealed the following: -Review of the in progress Quarterly MDS dated [DATE] revealed Section I -Active Diagnoses under Psychiatric/Mood Disorder Schizophrenia was marked No with response locked. -Review of the Quarterly MDS dated [DATE] revealed, Section I -Active Diagnoses under Psychiatric/Mood Disorder Schizophrenia was marked No -Review of the admission MDS dated [DATE] revealed, Section I -Active Diagnoses under Psychiatric/Mood Disorder Schizophrenia was marked No During an interview on 04/10/24 at 4:50 p.m., the Regional Nurse Consultant (RNC) confirmed Resident #85 had Schizophrenia on admission with onset date of 10/11/23 shown on the admission record. During an interview on 04/11/24 at 5:00 p.m., the MDS Coordinator, Registered Nurse (RN) stated that Resident #85 did have schizophrenia upon admission to the facility. During an interview on 04/10/24 at 5:06 p.m. the Director of Nursing (DON) provided an admission document titled Chart Summary dated 10/08/23 from local area hospital and stated this was used during Resident #85's admission to show he had the diagnosis of schizophrenia at admission. Review of the Chart Summary dated 10/08/23 from [local area hospital] showed History of schizophrenia psychiatry following- Feels patient does not have capacity at the moment. During an interview on 04/11/24 at 10:15 a.m., the Clinical Reimbursement Director (CRD), Registered Nurse (RN) stated Resident #85 did have a diagnoses of Schizophrenia and the diagnosis was missed on the admission MDS dated [DATE], the Quarterly MDS dated [DATE] and showed an answer of no for schizophrenia on the Quarterly MDS dated [DATE] in progress. The CRD, RN stated, Resident #85's diagnoses of Schizophrenia was just missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #15 admission face sheet included a diagnosis of post-traumatic stress disorder (PTSD), chronic dated 01/04/2020. Review of the Pre-admission Screening and Annual Resident Review signature dated 7/27/2023 in Section 1: PASRR Screen Decision-Making has other (specify) checked for PTSD. A review of Resident 15's care plan has a focus area of Trauma Informed Care initiated 10/28/2022 with a revision date of 11/22/2023 and a target date of 4/29/2024. The goal for focus is as follows: -Staff will assist in managing the resident's response to the trigger initiated on 10/28/2022, revised on 11/22/2023 with target date of 4/29/2024. -Staff will make efforts to avoid the flashback or trigger initiated on 10/28/2022, revised on 11/22/2023 with a target date of 4/29/2024. -The frequency or severity of my trauma related signs and symptoms will not increase initiated on 10/28/2022, revised on 11/22/2023 with a target date of 4/29/2024. Interventions for focused area of trauma informed care include the following for Resident #15: o Coordinate psychology or psychiatric services on admission and as needed, Initiated 10/28/2022. o Coordinate support groups as requested, initiated 10/28/2022. o Encourage to express feelings, concerns, and thoughts, initiated 10/28/2022. o Know what triggers are and minimize exposure, if possible, initiated 10/28/2022. o Observe for reported symptoms of a trigger, initiated 10/28/2022. o Provide with meaningful activities, initiated 10/28/2022. A review of Resident #15 Minimum Date Set Section C- Cognitive Patterns, dated February 1, 2024, shows a Brief Interview for Mental Status of 15, indicating resident is cognitively intact. Section I- Active Diagnoses has PTSD checked in the Psychiatric/Mood Disorder (I6100). On 4/10/24 at 09:59 a.m., an interview was conducted with Staff R, Certified Nursing Assistant (CNA). Staff R, CNA was not able to recall the triggers for Resident #15 in relation to PTSD. On 4/10/24 at 11:10 a.m., an interview was conducted with Staff F, Certified Nursing Assistant. Staff F, CNA was not able to recall the triggers for Resident #15 in relation to PTSD. On 4/10/24 at 11:15 a.m., an interview was conducted with Staff D, Licensed Practical Nurse/ Unit Manager, (LPN/UM). Staff D, LPN was not able to recall the triggers for Resident #15 in relation to PTSD. On 4/10/24 at 1:30 p.m., an interview was conducted with the Director of Nursing, Assistant Director of Nursing and the Regional Nurse Consultant. All were unable to state how the diagnosis of PTSD was placed into the chart other than in error by a past hospitalization. Resident #15 was hospitalized on [DATE] for three days and readmitted to their facility on 1/04/2020. The hospital discharge summary was reviewed by all three and verbally acknowledged PTSD was not listed as a discharge diagnosis. On 4/11/24 at 10:59 a.m., an interview was conducted with the Clinical Reimbursement Director/Registered Nurse (CRD/RN). The CRD/RN stated Resident #15's chart was thoroughly reviewed last night for any clinical documentation from a hospital and current chart. CRD/RN stated, I even called the former staff member in this role to see if they had any information but she could not recall any information regarding Resident #15. The CRD/RN stated the initial care plan is initiated or driven by diagnoses placed in the resident's medical records. A generalized care plan is electronically implemented with interventions initiated in a drop-down box. It is when the care plan is updated and revised by the Interdisciplinary Team (IDT) to become a more resident-centered care plan. A review of the facility's policy on Care Plans- Interdisciplinary Plan of Care from Interim to Meeting, effective February 2024, revealed the following for their policy the facility shall support each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues relevant to individual residents, to include, but not be limited to, monitoring resident condition, and responding with appropriate interventions. The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives and time frames and describes the services to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The care plan is reviewed and revised periodically and the services provided or arranged are consistent with each resident's written plan of care. Procedure 1. Interim plan of care a. The immediate needs of the resident are addressed following admission by initiating an interim plan of care. b. An interim plan of care is developed by nursing and / or other interdisciplinary team (IDT) members. c. The interim plan of care is developed utilizing the admission Data Collection format or other data collected to include the admission physician orders, medication, treatment, therapy orders, social services, diet orders, and any specialized services indicated from PASRR evaluations, when applicable, and is completed hard copy or electronically. 2. Update to Care Plans a. Ongoing updates to care plans are added by a member of the IDT, as needed. 6. Quarterly Update of the Plan of Care a. The comprehensive care plan is reviewed and revised by members of the IDT and the resident, resident's family, or representative, as appropriate, in consultation with completion of the quarterly assessment. b. The IDT members make a quarterly care plan review note within the designated disciplines progress notes which includes: i. If goals are met or unmet ii. If care plan will remain in effect for resident period 8. Care Plan Meeting e. Care plans are discussed aloud, to include discussion goals, interventions, and evaluations. 9. Care Plan Meeting Participation Record a. The copy of the care plan meeting invitation letter is also the participation record. Attendees signed names, indicated relationship, or title and date of attendance at care planned meetings. b. If the resident or resident representatives cannot participate in the care plan meeting, the reason is documented on the copy of the letter in the indicated section. c. The completed care plan meeting invitations last participation record is maintained in the medical record under the care plan tab. Based on observations, record reviews, and interviews, the facility failed to revise the care plan for one (#52) of thirty-two initially sampled residents in regards to the Advance Directive of code status, failed to revise the care plan of one (#107) out of twenty-five final sampled residents, and failed to revise the care plan of one (#15) of one resident sampled for the diagnosis of Post-Traumatic Stress Disorder. Findings included: 1. On 4/8/24 at 10:39 a.m. Resident #52 was observed sitting at a table with others in the common area of the secured memory care unit. Review of Resident #52's electronic record, on 4/8/24 at 3:31 p.m., revealed a Do Not Resuscitate Order signed by resident's Power of Attorney (POA) on 3/13/24 and signed by the physician on 3/18/24. Review of Resident #52's care plan revealed a focus for Advance Directives as follows: Resident/authorized responsible party request FULL CODE wish to be honored, initiated 10/9/23. The goal was the resident's Advance Directives would be honored through next review, initiated 10/9/23, revised on 1/3/24, and a target date of 6/19/24. The related interventions included Request resident and/or appointed health care representative to provide copies to the facility of any updated Advance Directives initiated 10/9/23. During an interview with the Clinical Reimbursement Director (CRD) on 4/11/24 at 10:14 a.m., the CRD reported their responsibility were Minimum Data Set (MDS) assessments and to update care plans. An interview was conducted with the CRD, on 4/11/24 at 11:45 a.m., the CRD reported just fixed Resident #52's care plan regarding Advance Directives. 2. On 4/8/24 at 9:49 a.m.,Resident #107 was observed sitting at one of four tables in the common area of the secured memory care unit with right leg resting on the table. Multiple observations were made of the resident between 4/8/24 and 4/11/24 that did not show the resident was wearing an electronic wander bracelet. Review of Resident #107's admission Record showed the resident was admitted on [DATE] and re-admitted on [DATE]. The record included diagnoses not limited to metabolic encephalopathy, unspecified altered mental status, unspecified mood disorder due to unknown physiological condition, and mild protein-calorie malnutrition. Review of Resident #107's care plan showed the resident was at risk for elopement, initiated 3/10/24 and interventions included: Apply electronic wander bracelet (check function after placed), date Initiated: 03/10/2024, Apply electronic wander bracelet due to elopement risk, date Initiated: 03/10/2024, and Verify the location of the electronic wander bracelet during routine care, date Initiated: 03/10/2024. Review of Resident #107's admission Minimum Data Set assessment, dated 3/12/24 did not reveal a wander/elopement alarm was utilized to monitor the resident's movements. Review of the Order Listing Report for Wander Bracelets, as of 4/10/24 at 11:15 a.m., revealed Resident #107 was amongst the twenty-eight residents listed as having a wander bracelet. Review of Resident #107's Elopement Risk Evaluation, dated 3/10/24, revealed Resident #107 was exit-seeking and wandering. The evaluation showed the nurse was to place an electronic wander bracelet, staff were to check function of bracelet after placement, verify the location of bracelet, and to check placement every shift and functioning daily. Review of Resident #107's April Medication and Treatment Administration Records revealed no documentation related to checking the placement, functioning or verifying the location of Resident #107's electronic wander bracelet. The facility did not provide March Medication and Treatment Administration Records as requested. An interview was conducted with Staff L, Certified Nursing Assistant (CNA) on 4/10/24 at 11:12 a.m., the staff member stated no one on the secured unit had a Wanderguard except for one who went off the unit (not Resident #107). An interview was conducted with the Clinical Reimbursement Director (CRD) on 4/11/24 at 10:14 a.m., the CRD reviewed Resident #107's care plan and elopement risk then stated it (wander bracelet) should have been resolved, sometimes if a resident was on the primary unit staff put a bracelet on then the resident is moved to the secured unit. A review of the Resident #107 placement within the facility showed the resident had not been on the primary unit but was admitted to secure unit. The CRD stated someone must have gotten click happy while doing the admission Elopement Risk evaluation. Review of the policy - Care Plan - Interdisciplinary Plan of Care from Interim to Meeting, effective February 2024, The facility shall support that each resident must receive, and the facility must provide the necessary care, and services to attain or maintain the highest practical physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to, monitoring resident condition, and responding with appropriate interventions. The overall care plan should be oriented towards: 1. Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence (e.g., palliative approaches and end of life situation, coordination with Hospice plan of care). Managing risk factors to the extent possible or indicating the limits of such interventions. d. Respecting the resident's right to choose to decline treatment, request treatment, or discontinue treatment. 2. Using an appropriate interdisciplinary approach to care plan development to improve the resident's functional abilities. b. Assessing and planning for care to meet their residents medical, nursing, mental, and psychosocial needs. Procedure 2. Update to Care Plans: a. The procedure showed I'm going updates to care plans are added by a member of the interdisciplinary team (IDT) as needed. Procedure 3. Dates and documentation on the care plan: a. New, revised, or discontinued Problems, Goals, or Interventions are dated for the date the documentation was made. Procedure 5. Comprehensive Plan of Care: b. The comprehensive care plan describes or includes: i. The services that are furnished in goals that reflect the residents wishes, choices, in the exercise of rights. ii. Any services that would normally be provided but are not provided due to the residents exercise of rights, including the right to refuse treatment, and any alternative means or options to address the problem.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure the catheter of one (#107) out of one resident sampled with an urinary catheter was stored in a manner that promoted proper infection control. Findings included: On 4/8/24 at 9:49 a.m., Resident #107 was observed sitting in a wheelchair at a table in the common area of the secured memory care unit. The observation revealed a urinary catheter drainage bag with a privacy device was hanging from the below the resident's wheelchair seat with the catheter tubing lying on the floor. On 4/8/24 at 10:22 a.m., Resident #107 was observed with catheter tubing coming from the end of ankle-length pant leg with the tubing lying on the floor underneath the wheelchair. On 4/8/24 at 10:46 a.m., Resident #107 was observed with catheter tubing coming from under left ankle-length swear pants with the tubing lying on the floor of the unit's common area. On 4/9/24 at 8:46 a.m., Resident #107 was observed sitting in the common area of the secured memory care unit with urinary catheter tubing lying on floor under the resident's wheelchair. On 4/9/24 at 8:46 a.m., Resident #107 was observed sitting at table with 3 other residents in the common area. The resident's catheter tubing containing pale yellow urine was observed lying on the floor. On 4/9/24 at 10:35 a.m., Resident #107 was observed sitting in the common area of the unit with catheter tubing lying on the floor. On 4/9/24 at 11:37 a.m., Resident #107 was observed in the common area with the catheter tubing lying on the floor which had remnants of food on it. On 4/10/24 at 9:20 a.m., Resident #107 was observed sitting in wheelchair in the common area of the unit, the urinary catheter drainage bag was seen dragging on floor. Staff I, Registered Nurse/Unit Manager, confirmed the bag was on the floor and should not be. Staff N, Certified Nursing Assistant (CNA) stated the drainage bag should not be on the floor. A small amount of blood-tinged urine was observed in the bag. Review of Resident #107's admission Record showed the resident was admitted on [DATE]. The record revealed the resident's diagnoses included not limited to metabolic encephalopathy, unspecified altered mental status, and generalized muscle weakness. Review of Resident #107's Medication Administration Record (MAR) showed the resident was being administered Finasteride and Tamsulosin for benign prostatic hyperplasia (BPH). The resident's Treatment Administration Record (TAR) showed staff were performing daily and as needed (prn) urinary catheter care. Review of the facility-provided - Competency: Perineal Care/Catheter Care, undated, described the technique for performing perineal care on female and male residents and the cleaning of a catheter for both male and females. The competency did not show where the staff should hang the drainage bag or if tubing and bag of the resident's urinary catheter should be stored on the floor. During an interview on 4/11/24 at 9:27 a.m., the Nursing Home Administrator (NHA), in regards to a request for the facility's policy regarding Care and Maintenance of urinary catheters, the NHA reported not thinking the facility had a policy on urinary catheters just the competency but would check. The facility did not provide the requested policy. During an interview on 4/11/24 at 2:55 p.m., the Director of Nursing stated neither the tubing or (drainage) bag should be on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to document and monitor the behaviors of two (#24 and #83) out of five residents reviewed for unnecessary medications resulting in the physician being notified and orders for additional as needed psychotropic medications were obtained. Findings included: 1. On 4/8/24 at 10:36 a.m., Resident #24 was observed sitting at one of four tables in the common area of Melody unit, a secured memory care unit. The observation showed the resident was looking at a magazine while sitting with 3 other residents at the table. On 4/9/24 at 10:29 a.m., Resident #24 was observed sitting at table in common area coloring with markers. On 4/9/24 at 11:14 a.m., the resident's Power of Attorney (POA) was visiting with the resident. On 4/11/24 at 11:15 a.m., Resident #24 was observed sitting at table in common area with three other residents drinking coffee. Review of Resident #24's admission Record revealed the resident was re-admitted on [DATE]. The diagnoses included unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified recurrent major depressive disorder, generalized anxiety disorder, and other bipolar disorders. Review Resident #24's April Medication Administration Record (MAR) revealed a physician order had been obtained for the resident on 4/9/24 at 3:21 p.m., for the anxiolytic medication Alprazolam. The order read Alprazolam 0.5 milligram (mg) - Give 1 tablet by mouth every 8 hours as needed for anxiety for 14 days. The MAR revealed Staff J, Registered Nurse (RN), had administered the psychotropic medication at 4:13 p.m. on 4/9/23. Review of Resident #24's April MAR did not reveal behaviors associated with the resident's use of the psychotropic medications: Alprazolam as needed, Duloxetine daily, Mirtazapine at bedtime, Quetiapine at bedtime, Trazodone at bedtime, Buspirone twice daily, Lithium twice daily, and Risperdal twice daily were monitored and documented by licensed nursing staff. The MAR showed a list of side effects were being monitored for by nurses every shift however did not reveal the medication(s) associated with the side effects listed. The electronic Behavior Monitoring Form (BMF) had no data and when requested it was not received from the facility. Review of Resident #24's progress notes, dated 3/12/24 to 4/11/24 showed a note dated 3/13/24 at 4:04 p.m., revealing activities had painted the resident's nails, on 4/9/24 at 7:47 p.m., the as needed administration of Alprazolam was effective, and on 4/10/24 at 2:57 p.m., dietary services documented the resident had a significant weight change. The review revealed no other progress notes during 3/12/24 to 4/11/24. The notes did not reveal the behavior exhibited, the amount of times the behavior had been exhibited, if any non-pharmaceutical interventions had been attempted, or the outcome of the those non-pharmaceutical interventions had occurred, and if the resident's representative had been notified of the behavior that occurred requiring a physician order for as needed Alprazolam. Review of Resident #24's care plan revealed the following focuses, goals, and interventions: - Behavioral: The resident is noted with the following behaviors: placing self on the floor. Can be aggressive at times, refuses labs at times, refuses therapy at times, refuses medications at times, and sometimes can be physically aggressive to staff, initiated 10/4/23 and revised 1/19/24. The goal was to risk for complications r/t behavior will be minimized through review date. The interventions instructed staff to encourage as much participation/interaction by the resident as possible during care activities and Medication as ordered, report missed or refused meds to physician, discuss possible alternatives with MD and resident. - Psychotropic Med: resident uses psychotropic medications r/t antidepressant to manage depression, antianxiety to manage anxiety, (and) antipsychotic to manage bipolar, initiated and revised 9/20/23. The goal was the resident would be at the lowest dose required to reduce symptoms while minimizing adverse effects to ensure maximum functional ability both mentally and physically through the next review. The interventions included instructions to staff to monitor for psychotropic side effects and to administer medications as ordered - observe/document for side effects and effectiveness. An interview was conducted with Staff J. Registered Nurse (RN), on 4/11/24 at 3:45 p.m. The staff member stated the reason for the as needed Alprazolam order on 4/9/24 was Resident #24 had been screaming and agitated so Staff I, RN/Unit Manager (UM), had called the Nurse Practitioner and received an order for Xanax (Alprazolam) 0.5 milligrams. During an interview on 4/11/24 at 2:52 p.m., the Director of Nursing (DON) reported the facility uses a blanket consent to treat, not specific to use of psychotropic medications, staff talk to the families for new medications, and psychiatry was really good about speaking with families. 2. On 4/8/24 at 10:41 a.m., Resident #83 was observed sitting outside on the covered patio of the secured memory care unit with 3 other residents. On 4/8/24 at 1:32 p.m., Resident #83 was observed sitting on covered patio with no activity. On 4/9/24 at 8:38 a.m., Resident #83 was observed sitting in patio area by self with no activity. On 4/11/24 at 10:59 a.m., Resident #83 was observed sitting on patio of secure unit and appeared to be asleep in chair. Review of Resident #83's admission Record revealed a re-admission date of 6/9/23 and included diagnoses not limited to unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified recurrent major depressive disorder, unspecified mood (affective) disorder, and unspecified anxiety disorder. Review of Resident #83's Medication Administration Record (MAR) revealed an order for 5 mgs of Diazepam every 12 hours for anxiety for 14 days had been obtained on 4/9/24 at 3:24 p.m. The MAR showed Staff J, RN administered the anxiolytic medication, Diazepam at 3:30 p.m. on 4/9/24. Review of Resident #83's MAR revealed the resident was administered: Remeron 7.5 mg at bedtime, Two tablets of Depakote three times daily (increased from twice on 4/5/24), Valium (Diazepam) 5 mg twice daily, and Quetiapine 25 mg three times a day. The MAR showed staff were monitoring for a list of side effects every shift. The MAR did not show licensed nursing staff were monitoring for the target behaviors associated with the use of the resident's psychotropic medications. Review of Resident #83's physician orders did not reveal an order for the monitoring of behaviors related to the use of anxiolytic's, antidepressants, and antipsychotic medications. A request was made to the facility to provide Resident #83's April Behavior Monitoring Flowsheet (BMF) it was not provided. A previous review of the resident's March and April BMF showed no data. Review of Resident #83's progress notes revealed on 4/9/24 no behaviors were documented requiring the necessity to obtain an order for as needed Diazepam. The progress notes did not reveal if Resident #83's responsible party was notified of the behavior or the order for Diazepam, amount of times the behavior had been exhibited, and did not reveal if any non-pharmaceutical interventions had been attempted and the outcome. During an interview with Staff I, Unit Manager and Staff J, RN on 4/10/24 at 3:48 p.m., Staff I stated Resident #83 had behaviors and was just yelling (on 4/9/24). The Unit Manager, Staff I, stated staff document (behaviors) in progress notes or with the medication. The staff member stated she didn't give the medications, she just calls the doctor. Staff I stated Resident #83 normally will pull at things and staff tries to minimize with activities, I believe that was (resident) was doing, (resident) gets in that mode and they order sometimes an extra dose or 14 days. Staff I stated the expectation was for staff to document the type of behavior(s) exhibited. Staff J admitted to administering the medication (Diazepam) for behaviors but did not document the behavior exhibited yesterday (4/9/24) prior to the as needed Diazepam order. Review of Resident #83's progress notes printed on 4/10/24 at 5:55 p.m. revealed a LATE ENTRY note effective 4/9/24 at 3:25 p.m., documenting the resident with agitation. Grabbing chairs and attempting to throw. Nurse Practitioner (NP) called and notified. New order for Diazepam prn received. Review of the late entry note and prior notes did not reveal if Resident #83's responsible party was notified of the behavior or the order for Diazepam, the amount of times the behavior was exhibited, and did not reveal if any non-pharmaceutical intervention had been attempted. Review of the Interdisciplinary (IDT) Notes regarding behaviors showed the latest note 2/20/24 revealed medications and behaviors reviewed. A IDT note dated 1/18/24 showed resident played with fecal matter and was combative at times. Review of Resident #83's care plan revealed the following focuses, goals, and interventions: - The resident is noted with following behaviors: combative towards staff and other residents. Resident will play with/handle feces at times. Resident will state that the demons are coming. The goal showed the resident was at risk for complications related to (r/t) behavior will minimized through review date (target date 2/16/25). The interventions included Enhanced monitoring and Observe/document for side effects and effectiveness. - The resident uses psychotropic medications related to (r/t) antidepressant to manage: depression, Antianxiety to manage: anxiety, antipsychotic related to mood disorder, anticonvulsant to manage: behaviors. The goal was for resident will be at the lowest dose required to reduce symptoms while minimizing adverse effects to ensure maximum functional ability both mentally and physically through the next review. The interventions instructed to administer medications as ordered. Observe/ document for side effects and effectiveness and use of psychotropic medications will be reviewed at least quarterly with the IDT/ MD to review continued need for the medication and ensure lowest dose. During an interview on 4/9/24 at approximately 5:00 p.m., the Regional Nurse Consultant (RNC) reported looking for a policy regarding the use of psychotropic medications. A request was made on 4/9/24 for the facility's policy regarding Psychotropic Use, on 4/10/24 the facility responded no specific policy. A request was made for a policy regarding Behavior Documenting, the facility responded no policy. During an interview on 4/10/24 at 5:19 p.m., the Director of Nursing stated the expectation was whenever there is a behavior they (staff) should be documenting, in progress notes, in the behavior monitoring form, and document why they are giving the prn (medication). The DON reviewed the progress notes for Resident #83 and was informed the late entry note was made after a conversation with Staff I and Staff J. The DON confirmed the note should have been made prior to the conversation. An interview was conducted with the Assistant Director of Nursing (ADON) and Regional Nurse Consultant (RNC) on 4/11/24 at 4:24 p.m. The ADON stated expectation was for nurses to document reason for obtaining as needed (prn) psychotropic medication. The RNC stated she wished they could make it that when putting in an prn order staff have to document the reason.

Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-seven medication administration opportunities were observed and two errors were identified for two (#31 and #13) of five residents observed. These errors constituted a 7.41% medication error rate. Findings included: 1. On 4/10/24 at 8:05 a.m. an observation of medication administration with Staff E, Registered Nurse/Unit Manager (RN/UM), was conducted with Resident #31. The staff member dispensed the following medications: - chewable Aspirin 81 milligram (mg) over-the-counter (otc) (placed in separate medication cup) - Docusate sodium 100 mg otc softgel tablet - Fluticasone propionate 50 microgram (mcg) nasal spray (she documented it was administered) - Sodium chloride 1 gram (gm) otc tablet - Risperidone 3 mg tablet - Carbamazepine 100 mg chewable - Lisinopril 5 mg - 2 tablets - Benztropine 1 mg tablet - Divalproex delayed release (DR) 250 mg tablet - Spironolactone 50 mg tablet - Terazosin 5 mg capsule The staff member confirmed dispensing 11 tablets. The staff member sat the Fluticasone of the over-bed table and resident refused it. Staff E placed a blood pressure wrist cuff on the resident's left wrist and was unsuccessful twice to obtain blood pressure. The staff member retrieved a manual BP cuff and stethoscope successfully obtaining a BP of 138/90 and radial pulse of 67. Staff E went to the medication cart and dispensed a half 25 mg tablet of Metoprolol. The staff member informed the resident to chew the aspirin however the resident swallowed it. Immediately following the observation with Resident #31 Staff E confirmed the Carbamazepine tablets were chewable and should have been in with the aspirin, despite resident swallowing the aspiring and while holding cell phone in hand reported was going to call doctor to notify them the resident had refused the nasal spray. Review of Resident #31's Medication Administration Record (MAR) revealed a chart/follow up code legend showing a checkmark equaled Administered. The MAR revealed Staff E had documented a checkmark for Fluticasone nasal spray on 4/10/24, showing the nasal spray had been administered prior to its discontinuation. 2. On 4/10/24 at 8:31 a.m. an observation of medication administration with Staff C, Licensed Practical Nurse (LPN) was conducted with Resident #13. Staff C obtained a pain level of 8 out of 10 from the resident. The staff member dispensed the following medications: - Nicotine 14 mg transdermal patch - dated patch and initialed - Oxycodone Immediate Release (IR) 10 mg tablet - Famotidine 20 mg tablet - Celecoxib 100 mg capsule - Memantine 10 mg tablet - Buspirone 30 mg tablet - Sertraline 100 mg tablet The staff member confirmed dispensing 6 tablets and one patch. Staff C administered the medications, removed a nicotine patch from the right should and placed the new one on the left shoulder. The resident returned to the cart. Review of Resident #13's Medication Administration Record showed Staff C had documented a 25 mg tablet of Metoprolol Tartrate had also been administered in addition to the observed medications. This medication had not been observed. Review of the Medication Admin Audit Report revealed Staff C had documented the observed medications and the tablet of Metoprolol had been administered at 8:41 a.m. on 4/10 and documented as given at 8:45 a.m. An interview was conducted with the Director of Nursing (DON) on 4/11/24 at 8:35 a.m., the DON reviewed the Audit Report for Resident #13, the observed medications, and the confirmation of Staff C dispensing 6 tablets and one patch. The DON confirmed the resident's scheduled Metoprolol as documented as given at the same time of other medications. The DON reviewed Resident #31's MAR and stated if the resident had refused it (Fluticasone) it should be documented as a refusal not as administered. An interview was conducted with Staff C, LPN on 4/11/24 at 1:30 p.m. The staff member reported giving all the medications to Resident #13 during the medication observation. Staff C reported giving all the medication cards to this writer other than the narcotic (which was noted from the narcotic box). The staff member stated all medications were in the same cup and when the confirmation of 6 tablets was made, the narcotic hadn't been counted, there was 7 medications. Review of the policy - Medication Administration, dated 9/18, showed Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. -3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule on the resident's MAR with the medication label. If the label and the MAR are different, and the container is not flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the Prescriber's orders are checked for the correct dosage schedule. Apply a direction change sticker to apply if directions have changed from the current label. The documentation section of the policy revealed: -2. If a dosage of regular scheduled medication is withheld, refused, or given at other than the scheduled time (for example, the resident is not in the nursing care center at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for as needed (PRN) documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified.

Based on observations, record reviews, and interviews, the facility failed to maintain two (#107 and #31) out of fifty (50) resident records accurately related to documenting a medication was administered when refused by the resident and to obtain vital signs daily for the skilled notes. Findings included: 1. On 4/8/24 at 1:40 p.m., Resident #107 was observed sitting at a table in the secured memory care unit, Melody, with three other residents. On 4/9/24 at 8:48 a.m., Resident #107 was observed sitting a table with three other residents, no activities were occurring and the resident's catheter tubing was lying on the floor under the wheelchair. Review of Resident #107's admission Record revealed an admission date of 3/30/24 and diagnoses of metabolic encephalopathy, generalized muscle weakness, mild protein-calorie malnutrition, and multiple sites muscle wasting and atrophy not elsewhere classified. Review of Resident #107's Daily Skilled Note, dated 4/1/24 at 2:21 p.m., revealed a temperature 98.9 taken on 3/31/24 at 12:25 a.m., blood pressure 132/70 taken on 3/31/24 at 2:15 p.m., pulse of 78 on 3/31/24 at 2:15 p.m., respiration of 18 on 3/31/24 at 12:25 a.m., and oxygen saturation (O2 sat) of 97% room air on 3/30/24 at 5:30 p.m. The note revealed the resident continued to participate in Physical Therapy (PT). Review of Resident #107's Daily Skilled Note, dated 4/3/24 at 2:09 a.m., revealed a temperature obtained on 3/31/24 of 98.9, blood pressure obtained on 3/31/24 of 132/70, a pulse of 78 obtained on 3/31/24 at 2:15 p.m., a respiration rate of 18 obtained at 12:25 a.m. on 3/3/124, and O2 sat of 97% obtained on 3/30/24. The note revealed the resident continued to participate in PT. Review of Resident #107's Daily Skilled Note, dated 4/3/24 at 2:50 p.m. showed a temperature 98.9 taken on 3/31/24 at 12:25 a.m., blood pressure 132/70 taken on 3/31/24 at 2:15 p.m., 78 pulse 3/31/24 at 2:15 p.m., respiration of 18 on 3/31/24 at 12:25 a.m., and oxygen saturation (O2 sat) of 97% room air on 3/30/24 at 5:30 p.m. The note revealed the resident participated in PT. Review of Resident #107's Daily Skilled Note, dated 4/3/24 at 8:33 p.m., revealed a temperature obtained on 3/31/24 at 12:25 a.m. of 98.9, blood pressure obtained on 3/31/24 of 132/70, a pulse of 78 obtained on 3/31/24 at 2:15 p.m., a respiration rate of 18 obtained at 12:25 a.m. on 3/3/124, and O2 sat of 97% obtained on 3/30/24. The note revealed the resident continued to participate in PT. Review of Resident #107's Daily Skilled Note, dated 4/4/24 at 12:53 a.m., showed a temperature of 98.9 was obtained on 3/31/24 at 12:25 a.m., a blood pressure of 132/70 was obtained on 3/31/24 at 2:15 p.m., a pulse of 78 was obtained on 3/31/24 at 2:15 p.m., a respiration rate of 18 had been obtained on 3/31/24 at 12:25 a.m., and an oxygen saturation level of 97% had been obtained at 5:30 p.m. on 3/30/24. The note showed the resident continued to participate PT. Review of Resident #107's Daily Skilled Note, dated 4/4/24 at 2:26 p.m., revealed a temperature of 98.9 was obtained on 3/31/24 at 12:25 a.m., a blood pressure of 132/70 and pulse of 78 was obtained on 3/31/24 at 2:15 p.m., a respiration rate of 18 had been obtained on 3/31/24 at 12:25 a.m., and an O2 saturation of 97% had been obtained at 5:30 p.m. on 3/30/24. The note showed the resident continued to participate PT. Review of Resident #107's Daily Skilled Note, dated 4/4/24 at 9:03 p.m., showed a temperature of 98.9 was obtained on 3/31/24 at 12:25 a.m., a blood pressure of 132/70 was obtained on 3/31/24 at 2:15 p.m., a pulse of 78 was obtained on 3/31/24 at 2:15 p.m., a respiration rate of 18 had been obtained on 3/31/24 at 12:25 a.m., and an oxygen saturation level of 97% had been obtained at 5:30 p.m. on 3/30/24. The note showed the resident continued to participate PT. Review of Resident #107's Daily Skilled Note, dated 4/5/24 at 12:40 a.m., revealed a temperature of 98.9 was obtained on 3/31/24 at 12:25 a.m., a blood pressure of 132/70 and pulse of 78 was obtained on 3/31/24 at 2:15 p.m., a respiration rate of 18 had been obtained on 3/31/24 at 12:25 a.m., and an O2 saturation of 97% had been obtained at 5:30 p.m. on 3/30/24. The note showed the resident continued to participate PT. Review of Resident #107's Daily Skilled Note, dated 4/5/24 at 12:31 p.m., showed a temperature of 98.9 was obtained on 3/31/24 at 12:25 a.m., a blood pressure of 132/70 was obtained on 3/31/24 at 2:15 p.m., a pulse of 78 was obtained on 3/31/24 at 2:15 p.m., a respiration rate of 18 had been obtained on 3/31/24 at 12:25 a.m., and an oxygen saturation level of 97% had been obtained at 5:30 p.m. on 3/30/24. The note showed the resident continued to participate PT. Review of Resident #107's Daily Skilled Note, dated 4/6/24 at 2:56 p.m., revealed a temperature of 98.9 was obtained on 3/31/24 at 12:25 a.m., a blood pressure of 132/70 and pulse of 78 was obtained on 3/31/24 at 2:15 p.m., a respiration rate of 18 had been obtained on 3/31/24 at 12:25 a.m., and an O2 saturation of 97% had been obtained at 5:30 p.m. on 3/30/24. The note showed the resident continued to participate PT. Review of Resident #107's Daily Skilled Note, dated 4/7/24 at 4:12 p.m., showed a temperature of 98.9 was obtained on 3/31/24 at 12:25 a.m., a blood pressure of 110/68 was obtained on 4/7/24 at 12:03 p.m., a pulse of 81 was obtained on 4/7/24 at 12:03 p.m., a respiration rate of 18 had been obtained on 3/31/24 at 12:25 a.m., and an oxygen saturation level of 97% had been obtained at 5:30 p.m. on 3/30/24. The note showed the resident continued to participate PT. Review of Resident #107's Daily Skilled Note, dated 4/8/24 at 12:49 a.m., revealed a temperature of 98.9 had been obtained on 3/31/24 at 12:25 a.m., a blood pressure of 110/68 was obtained on 4/7/24 at 12:03 p.m., a pulse of 81 was obtained on 4/7/24 at 12:03 p.m., a respiration rate of 18 was obtained on 3/31/24 at 12:25 a.m., and an oxygen saturation level of 97% had been obtained at 5:30 p.m. on 3/30/24. The note showed the resident continued to participate PT. Review of Resident #107's Daily Skilled Note, dated 4/9/24 at 12:17 a.m., showed a temperature of 98.9 was obtained on 3/31/24 at 12:25 a.m., a blood pressure of 110/68 and a pulse of 81 was obtained on 4/7/24 at 12:03 p.m., a respiration rate of 18 had been obtained on 3/31/24 at 12:25 a.m., and an oxygen saturation level of 97% had been obtained at 5:30 p.m. on 3/30/24. The note showed the resident continued to participate PT. Review of Resident #107's Daily Skilled Note, dated 4/10/24 at 12:12 a.m., revealed a temperature of 97.8, a blood pressure of 118/68, pulse of 68, a respiration rate of 18, and an oxygen level of 96% had been obtained at 7:27 a.m. on 4/9/24. The note showed the resident continued to participate PT. During an interview with the Director of Nursing (DON) on 4/11/24 at 2:57 p.m., the DON stated Daily Skilled Notes were for anyone getting therapy and vital signs should be updated daily in the skilled notes. An interview was conducted with the Assistant Director of Nursing (ADON) and Regional Nurse Consultant (RNC) on 4/11/24 at 4:24 p.m., the RNC stated the facility did not have a policy for Daily Skilled notes. 2. On 4/10/24 at 8:05 a.m., Staff E, Registered Nurse/Unit Manager (RN/UM), was observed for medication administration with Resident #31. The staff member dispensed the following: chewable Aspirin 81 milligram (mg) over-the-counter (otc), Docusate sodium 100 mg otc softgel tablet, Fluticasone propionate 50 microgram (mcg) nasal spray, Sodium chloride 1 gram (gm) otc tablet, Risperidone 3 mg tablet, Carbamazepine 100 mg chewable, 2 tablets of Lisinopril 5 mg, Benztropine 1 mg tablet, Divalproex delayed release (DR) 250 mg tablet, Spironolactone 50 mg tablet, and Terazosin 5 mg capsule. On 4/10/24 after Staff E dispensed the medication, the staff member entered Resident #31's room and sat the box of Fluticasone on the over-bed table. The resident immediately refused it. Staff E administered the medication, obtained a blood pressure then administered a half tablet of 25 mg of Metoprolol . Immediately following the observation with Resident #31 Staff E confirmed the Carbamazepine tablets were chewable and should have been in with the aspirin, despite resident swallowing the aspirin and while holding cell phone in hand reported was going to call doctor to notify them the resident had refused the nasal spray. Review of Resident #31's Medication Administration Record (MAR) revealed a chart/follow up code legend showing a checkmark equaled Administered. The MAR revealed Staff E had documented a checkmark for Fluticasone nasal spray on 4/10/24, showing the nasal spray had been administered prior to its discontinuation. An interview was conducted with the Director of Nursing (DON) on 4/11/24 at 8:35 a.m., the DON reviewed Resident #31's MAR and stated if the resident had refused it (Fluticasone) it should be documented as a refusal not as administered. Review of the policy - Medication Administration, dated 9/18, showed Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. -2. If a dosage of regular scheduled medication is withheld, refused, or given at other than the scheduled time (for example, the resident is not in the nursing care center at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for as needed (PRN) documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified. ·

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of facility's policies titled, Infection Prevention and Control Program, Tracking: Monitoring, Antibiotic Prescribing, Use and Resistance, Individuals Accountable for Antibiotic Stewardship Activities, and Antibiotic Stewardship, the facility failed to ensure one Resident (#12) out of one Resident reviewed for antibiotics was appropriately assessed for the use of an antibiotic. Findings included: A review of the admission Record showed Resident #12 was admitted to the facility on [DATE] with diagnoses that included but was not limited to unspecified focal traumatic brain injury without loss of consciousness, major depressive disorder, recurrent , other seizures, schizophrenia and anxiety disorder, unspecified. Review of the Order Summary Report revealed a physician order dated 04/03/24 for Doxycycline Hyclate Oral Tablet 100 MG[milligrams] (Doxycycline Hyclate)- Give 1 tablet by mouth every 12 hours for UTI [urinary tract infection] for 10 Days. Review of Resident #12's care plan revealed, Focus: ANTIBIOTIC: The resident is on Antibiotic Therapy r/t Has a Bacterial Infection (UTI). Goal: Minimize the risk of spread and Will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. Interventions: Administer medication as ordered, Report pertinent lab results to MD, Standard Precautions, Observe for possible side effects every shift, Observe diarrhea, nausea, vomiting, anorexia, and hypersensitivity /allergic reactions. Monitor for adverse reaction, Offer and/or encourage fluids through out the day. Antibiotics are non-selective and may result in the eradication of beneficial microorganisms and the emergence of undesired ones, causing secondary infections such as oral thrush, colitis, and vaginitis and Monitor for presence or absence of pain; level & effectiveness of pain medication. Review of Resident #12's lab results showed no urinalysis (UA) available for the dates of 04/01/24-04/03/24 prior to the use of antibiotic treatment. Review of Resident #12's Standard Evaluations for change of condition (CoC) evaluations, showed one CoC dated 09/07/23. Review of Progress Notes revealed the following: -A progress note dated 04/8/2024 at 10:44 p.m., showed, Resident continued on PO [antibiotic] ABT for [urinary tract infection] UTI No adverse reaction noted on this shift. No sign of discomfort noted. Resident denied dysuria. -A progress note dated 04/7/2024 at 10:35 p.m., showed, Resident on ABT for UTI no adverse reactions noted will continue with care plan. -A progress note dated 4/3/2024 at 5:20 a.m., showed, Unable to collect urine for testing. Had resident in bathroom but, he could not urinate at that time. Will ask 7-3 shift to try or get a cath order. -A progress note dated 04/01/23 at 2:48 p.m., showed, MD [medical doctor] in to see resident noted with increased weakness. New order received for stat and routine labs. During an interview on 04/11/24 at 8:40 a.m., Staff E Registered Nurse (RN) Unit Manager (UM) stated Well here is the thing, We tried three times to get a urine sample and was unsuccessful. Staff E RN/UM stated the doctor decided to order Resident #12 Doxycycline as a preventive measure without confirming the urinary tract infection because Resident #12 looked pale and was weak. During an interview on 04/11/24 at 9:35 a.m.,, the Director of Nursing (DON) was asked for the facility's policy and procedure for urinary tract infection (UTI) protocol but stated, there was no policy or procedure for UTI. During an interview on 04/11/24 at 9:40 a.m., the Infection Preventionist (IP) stated that the progress notes stated that they would straight cath him but when Staff E RN/UM talked to the physician, the physician chose not to straight cath Resident #12 and just put him on an antibiotic. The IP confirmed there was no change of condition assessment completed which she would have expected there would have been one. The IP was asked if the McGreer Criteria was used for antibiotics ordered and administered to Residents and the IP stated, this situation is not going to meet the McGreer Criteria as it would not be considered an infection because there was no UA to look at for antibiotic resistance. The IP did not talk with the physician regarding antibiotic stewardship program as IP stated Staff E RN/UM was the one who talked to the doctor about this situation. Review of the Monthly Line Listing Worksheet dated April 2024 showed Resident #12 had on onset date of 04/01/24 with symptoms included as increased weakness. The worksheet also revealed no culture obtained with Results and Pathogens not applicable na. The antibiotic ordered was Doxycycline. Review of the facility's policy titled, Infection Prevention and Control Program dated May 2020 showed, Antibiotic Stewardship is an ongoing tracking of antibiotic prescribing, antibiotic use and developing antibiotic resistance patterns with documentation and education. Review of the facility's policy on Antibiotic Stewardship titled, Tracking: Monitoring, Antibiotic Prescribing, Use and Resistance dated April 2017 showed, The infection Preventionist has information to provide strategies to improve antibiotic use. This includes tracking of antibiotic start, evaluation an management of treated infections and reviewing antibiotic resistance patterns. Provide education relating to antibiotic stewardship questions and act as a resource .Antibiotic prescribing elements will be addressed for a presence: 1.) Dose 2.) Route 3.) Duration 4.) Start date 5.) End date 6.) Planned days of therapy 7.) Indication Review of the facility's policy on Antibiotic Stewardship titled, Individuals Accountable for Antibiotic Stewardship Activities dated March 2017 showed, Infection Preventionist has information to provide strategies to improve antibiotic use. This includes tracking of antibiotic starts, evaluations, and management of treated infections and reviewing antibiotic resistance patterns. Provide education to antibiotic stewardship questions and act as a resource. Review of the facility's policy on Antibiotic Stewardship titled, Policy and Procedure dated March 2017 showed, Policy: Facility administration will be committed to improving antibiotic use. Administration will include, but not limited to, the Administrator, Director of Nursing, Infection Preventionist, and Risk Manager. Procedure: 5.) Administration and the Infection Preventionist will communicate with nursing staff and the prescribing clinicians the facility's expectations regarding use of antibiotics and the monitoring and enforcement of stewardship policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to maintain a homelike environment on one (300) of four units and failed to ensure one of two resident patios was not used for storage of facility housekeeping equipment, sunshade, rolled up mattresses, and an unused bed frame. Findings included: On 4/8/24 at 10:02 a.m., Resident #103 reported to this writer that the unit was cold. The observation of a hallway thermostat read 71 Fahrenheit (F). An observation of Resident #103's room revealed a bedside dresser without drawers beside the resident's bed, the window blinds in the window of room the room were broken, the string used to maneuver the blinds to an open/close position had been cut/frayed. Resident #103 was observed maneuvering the individual slats of the blinds into a closed position. The observation revealed in the bathroom shared with room [ROOM NUMBER] a roll of toilet paper on back of the toilet while a toilet paper holder attached to the wall above a safety handle on the mutual wall of room [ROOM NUMBER] did not have a tube and two tube holders were sticking out. Photographic evidence was obtained. An observation was conducted on 4/8/24 at 2:34 p.m. of the covered patio outside of the main Dining Room (DR). The observation of one side of the patio revealed 2 rolled mattresses with air pumps, a patio umbrella stand, an unfolded tan-colored piece of woven mesh, and two commercial floor buffers. The observation of the opposite side of the patio revealed an industrial floor scrubber. The middle area of the patio held multiple tables, along the bottom edge of the sliding door was a piece of rubber-type material with a black/brownish substance covering it. The area between the patio and smoking area contained a blue 5-gallon insulated water jug which held a minimal covering of water (well below spigot level) with pieces of unidentified substance floating in it, an insulated chest sat on the ground beside the hydration cart which had black and brown substances attached to the inside and outside of it, and a rusty industrial stand-up fan next to it. A sign posted next to the fan and above the dirty insulated chest read Sun Safety Center - Stay Hydrated. A bed frame was observed on the patio outside of the covered area. An observation was conducted on 4/9/24 at 3:12 p.m. of the covered patio area outside of the main dining room where 8 residents were participating in an activity of Charades. The bed frame observed outside of the area on 4/8/24 had a mattress lying on it. An extension ladder was propped against the railing of the uncovered patio area. An industrial floor scrubber continued to be stored near the entrance to the smoking patio under the covered patio, and the two rolled mattresses with pumps and the two previously viewed floor buffers were stored next to the sliding doors between the main dining room and covered porch. The rusty fan was observed in the Hydration area. An interview and observations were conducted with the Environmental Director (ED) on 4/11/24 at 2:10 p.m., the ED stated the temperature on the secure unit had been turned down and the box covering the thermostat had been unlocked. The ED stated the dresser without drawers in room [ROOM NUMBER] was used as a television stand so it had been removed. During the observation of the covered and uncovered patio outside of the main dining room with Environmental Director, he reported not considering the patio area a resident area but did confirm residents did come out onto the covered patio with families and with therapy. The observation revealed a Physician Assistant sitting at one of tables with an unknown resident or representative. The ED stated the previously observed mattresses were to be picked up by a vendor and they needed an area accessible for unknown pickup, the brown/tan colored mesh was a sunscreen that had been taken down and the floor equipment was housekeeping. He stated the problem with this building was it didn't have any storage. The ED viewed the floor equipment, currently stored on the resident's patio and stated they probably shouldn't store them there, and confirmed the residents had an activity on the covered patio earlier in the week. A request was made on 4/9/24 for a policy regarding Maintaining a Homelike Environment. The facility wrote no policy on the returned request list.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident #25 admission Record shows a primary diagnosis of diffuse traumatic brain injury (TBI) with loss of unconsciousness of unspecified duration subsequent encounter with a secondary diagnosis of unspecified mood [affective] disorder both dated 11/07/2015. A review of the Minimum Data Set for Section I- Active Diagnoses dated February 05, 2024, for Neurological Section, 15500 [Traumatic Brain Injury] has a check mark. A review of the Pre-admission Screening and Annual Resident Review, dated 7/17/2023, revealed TBI or unspecified mood [affective] disorder not checked. 2. A review of the admission Record showed Resident #85 had an admission date of 10/11/23 with diagnoses that included but not limited to encounter for orthopedic aftercare following surgical amputation, acquired absence of left above the knee, lack of coordination, schizophrenia, and major depressive disorder, recurrent. A review of Resident #85's level I PASRR assessment, dated 01/05/24 revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkboxes for the selections schizophrenia was not checked. Based on observations, staff interviews and record review, the facility failed to ensure residents received either a timely or accurate Level 1 Pre-admission Screening & Resident Review (PASRR) for eight (#96, #163, #28, #1, #32, #31, #25, and #85) of thirty-eight sampled residents. Findings included: 1. On 4/8/2024 the medical record for resident #96 was reviewed and revealed Resident #96 was admitted to the facility on [DATE] for long term care services. Review of the Advance Directives revealed the resident had a decision maker in place to make her medical and financial decision. Review of the admission diagnosis sheet revealed mental illness/suspected mental illness (MI/SMI) diagnoses to include but not limited to: Anoxic Brain Disorder (onset 12/21/2023). Review of both the electronic and physical medical record did not include a Level 1 PASRR screen. On 4/11/2024, during an interview, the Director of Nursing (DON) provided a Level 1 PASRR screen completed by her on 4/10/2024. She confirmed there were no previous PASRR screens. On 4/8/2024 the medical record for resident #163 was reviewed and revealed Resident #163 was admitted to the facility on [DATE]. Review of the advance directives revealed the resident was her own responsible party. Review of the admission diagnosis sheet revealed MI/SMI diagnoses to include but not limited to: Anxiety (onset 3/29/24), Major Depression (onset 3/29/24), Mood Disorder (onset 3/29/2024). Review of the Level 1 PASRR screen revealed it was completed by a Registered Nurse (RN), while at the current facility, on 4/5/2024, (seven days after initial admission). On 4/8/2024 the medical record for Resident #28 was reviewed and revealed Resident #28 was admitted to the facility on [DATE] for long term care services. Review of the advance directives revealed the resident had a responsible party in place to make her medical and financial decisions. Review of the admission diagnosis sheet revealed MI/SMI diagnoses to include: Schizophrenia (onset 8/24/2021), Bipolar (onset 8/24/2021), Obsessive Compulsive Disorder OCD (onset 8/24/2021), Anxiety (onset 8/24/2021). Review of the Level 1 PASRR screen revealed it was completed by a Physician at the hospital on 9/23/2016. Section I of the Level 1 PASRR screen revealed diagnoses checked for Schizophrenia and other - Neurocognitive Disorder; the Screen did not include diagnoses of Bipolar, OCD, and Anxiety. Further, there was no evidence of a corrected or updated Level 1 PASRR screen to reflect these diagnoses. On 4/8/2024 the medical record for Resident #1 was reviewed and revealed Resident #1 was admitted to the facility on [DATE] for long term care services. Review of the advance directives revealed the resident had a responsible party in place to make her medical and financial decisions. Review of the admission diagnosis sheet revealed MI/SMI diagnoses to include: Alzheimer's disease (onset 01/21/2020), Major Depression (onset 3/8/2017), PTSD [post traumatic stress disorder] (onset 1/21/2020), Anxiety (onset 3/7/2017), Mood affective disorder (01/21/2020). Review of the Level 1 PASRR screen revealed it was completed by an RN at the current facility on 7/21/2023 (three years after admission.). Review of Section I of the PASRR revealed MI/SMI diagnoses did not include: Anxiety, PTSD, Alzheimer's disease, Mood disorder. A second Level 1 in the chart dated 1/5/2024 revealed it was completed by RN at the facility. Anxiety and depression MI/SMI were checked. However, PTSD, Alzheimer's disease and Mood disorder were not identified, as per Resident #1's admission diagnoses. On 4/8/2024 the medical record for Resident #32 was reviewed and revealed Resident #32 was admitted to the facility on [DATE] for long term care services. Review of the advance directives revealed the resident was her own decision maker. Review of the admission diagnosis sheet revealed MI/SMI diagnoses to include: Psychosis (onset 06/01/2018), Major Depression (onset 02/20/2018), Mood (onset 02/13/2018), Anxiety (onset 12/28/2017). Review of the Level 1 PASRR screen revealed it was completed by an RN at the current facility on 11/13/2013. Review of Section I did not include the resident's MI/SMI diagnosis of Psychosis. On 4/8/2024 the medical record for Resident #31 was reviewed and revealed Resident #31 was admitted to the facility on [DATE] for long term care services. Review of the advance directives revealed the resident was his own decision maker. Review of the admission diagnosis sheet revealed MI/SMI diagnoses to include: Parkinsonism (onset 10/01/2023), Anxiety (onset 01/09/2020), Bipolar (onset 08/31/2019), Schizophrenia (onset 08/31/2019), PTSD (onset 08/31/2019), Major Depression (08/31/2019). The Level 1 PASRR was reviewed as completed by an RN at the current facility on 04/15/2021. Section I did not indicate MI/SMI diagnoses including Parkinsonism, PTSD, Major Depression. On 4/11/2024 at 1:45 p.m. an interview was conducted with the Nursing Home Administrator (NHA), the Director of Nursing (DON), and the Assistant Director of Nursing (ADON). The NHA revealed it was the responsibility of the Admissions Director during normal business days and an admission nurse on the weekends to obtain PASRR screens. The DON and NHA both confirmed the Admissions Director has close contact with the weekend nurse when there are admissions on the weekends. The NHA and DON also confirmed the Interdisciplinary Team will all review new weekend admissions and Level 1 PASRR screens from the weekend, on the next business working day. The NHA and DON revealed if a Level 1 PASRR is found not accurate or not completed correctly after admission, they will correct one as soon as possible, usually within one business day, in order to have correct Level 1 PASRR screen. The DON and ADON confirmed it is their responsibility to ensure the accuracy of all Level 1 PASRR screens. The NHA and DON revealed they perform weekly and quarterly audits to ensure Level 1 PASRR screens are correct and completed timely. During this interview, the NHA revealed currently they did not have a Quality Assurance (QA) Performance Improvement Plan (PIP) in place with regards to Level 1 PASRR screen accuracy and submission timeframe. The NHA also confirmed that the facility staff (DON, ADON) are responsible to update with a new Level 1 PASRR screen should there be any MI or SMI diagnoses developed after the resident's admission. The NHA, DON and ADON all confirmed the above listed residents were not reflective with all current MI/SMI diagnoses, and they needed to be updated. On 4/11/2024 at 2:00 p.m. the Nursing Home Administrator provided the Pre-admission Screening &Resident Review PASRR policy and procedure with an effective date 2/2021 for review. The policy revealed; Preadmission screening will be conducted prior to admission as the PASRR process is a federally mandated pre-admission screening program, required to be performed on all individuals prior to admission to the Nursing Home. The screening is reviewed by Admissions for suspicion of serious mental illness & intellectual disability to ensure appropriate placement in the least restrictive environment & to identify the need to provide applicants with needed specialized services. PASRR screening applies to all new admissions into a Medicaid certified nursing facility & includes private pay, Medicare, & Medicaid admissions regardless of payor source. - The screening is typically done by discharge planners & hospital staff as a step in the discharge process. It is separate from a medical needs assessment, which most often occurs after a person applies for Medicaid, & is required step to qualify for Medicaid long-term care assistance. The procedure section revealed the following but not limited information; 1. During the admission process, Business Development will communicate with the facility regarding prospective admissions. A level 1 PASRR will be provided prior to admission to the skilled nursing facility. The facility administration will confirm that a Level 1 review has been completed prior to transfer to the SNF setting. 2. Determine if a serious mental illness &/or intellectual disability or a related condition exists while reviewing the PASRR form completed by the Acute Care Facility for Level 2 completion. 3. If a serious Mental Illness or ID is indicated, determine if the resident/patient will be admitted for m a hospital for an acute care stay and the attending physician has certified that the individual is likely to require less than 30-days of Nursing Facility services. Assure that the certification is signs and dated. A second PASRR Requirements Level 1 and 2 policy and procedure with an effective date 2/2021 revealed; Assure that sections 1-5 are completed prior to admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident/staff interviews, and record review, the facility failed to provide Activities of Daily Living (ADL) care, to include feet nail care for one (#163) of thirty-eight sampled residents (#163). Findings included: On 4/8/2024 at 10:20 a.m. Resident #163 was observed in her room and seated on the edge of her bed and facing the door. Upon entering the room, she was noted with both feet bare and touching the floor tiles. Further observations revealed both of her feet were swollen, red and with all ten toenails elongated and curled inward. Some of the nails were observed approximately one inch past the tip of her nail beds. All her nails were also a dark yellowish color. The resident, through interview, revealed her feet hurt as well as her hip. She confirmed both of her feet had very long nails and that her feet felt uncomfortable as a result. Resident #163 revealed she had been residing at the facility about two weeks and she planned on going back to the community after her rehabilitation. Resident #163 said she was unable to cut her fingernails and toenails herself. Resident #163 denied she was diabetic but confirmed staff would have to help her with some of her Activities of Daily Living (ADL) to include shower/bathing assistance, and nail care. Resident #163 was asked if staff had offered to cut any of her toenails and she denied any staff offering. She explained since her admission, she had spoken to night shift aides several times to have them help cut her toenails. She could not remember who she spoke to but remembered they were Certified Nursing Assistants (CNAs). Resident #163 revealed she was told by the CNAs that they would get back to her, but they never did. Resident #163 confirmed since her admission, she had never had any staff do any type of foot care to include trimming of any toenails. Resident #163 was observed to slip both of her feet in what appeared to be open toed sandals. She had some discomfort slipping on the sandals and then stood up and utilized her walker device to ambulate out from her room and out into the main hallway. On 4/9/2024 at 9:30 a.m. Resident #163 was observed walking to the nurse station. Upon using the phone, she was observed wearing open toed sandals and her toenails on both of her feet were observed in the same condition as seen the day before on 4/8/2024. On 4/10/2024 at 7:39 a.m. Resident #163 was observed in her room and seated on the edge of her bed. Her feet were noted on the floor and with no shoes or socks on. Both of her feet were exposed and all ten toenails were yellowed, elongated and some curled inward. Resident #163 confirmed her nails were still long and that nobody will cut them for her. She revealed both her feet hurt but not just because of her nails being long. The floor next to the over the bed table and next to Resident #163's Left foot, was observed with white/tan slip on deck shoes. Further observations revealed approximately a four inch slit/cut into the toe box of both shoes. Resident #163 revealed that she had to cut slits in both of these closed toed shoes due to her toenail feet discomfort, and that it eliminated pressure. She was observed to slip on both of these closed toe shoes and exhibited some discomfort in doing so. She then stood up and used her walker device to leave the room and go outside to the smoking area/back porch area. Review of Resident #163's medical record revealed she was admitted to the facility on [DATE]. Review of the Diagnosis sheet revealed Resident #163 had diagnoses to include but not limited to: Cognitive Communication Deficit, Muscle wasting and atrophy, Lack of coordination, Anxiety, Mood disorder. Review of the most current Minimum Data Set (MDS) admission assessment, dated 3/31/2024 revealed; (Cognition/Brief Interview Mental Score or BIMS score - 14 of 15, which indicated resident #163 was cognitively intact. Review of the most current skin sheets last dated 4/8/2024 did not list any concerns with skin areas near and or at feet. Review of the admission assessment/not dated 3/29/2024 21:39 did not have any documentation related to toenails or toe ADL care. Review of daily skilled notes dated 4/1/2024 09:46, 4/2/2024 09:38, 4/3/2024 06:30, all did not indicate any documentation related to elongated toe nails or foot concerns. There were no nurse progress notes or daily skilled notes documented after 4/5/2024. Review of the facility ADL tasks section of the electronic record revealed: (d) NAIL CARE = only date indicated was on 3/31/2024 at 03:26 a.m. and revealed nail care was provided. There were no other dates documented related to nail care. Review of the current care plans with a next review date 7/3/2024 revealed the following but not limited to: - Communication the resident has a problem with communication: Usually understood - usually expresses ideas or want, usually understands others, with interventions in place - ADL - Resident has an ADL self care performance deficit due to fall prior to admission which resulted in a back fracture, unsteady gait, weakness, with interventions in place to include but not limited to: Bathing = Check nail length and trim and clean on bath day and as necessary. - Pain the resident has pain or a potential for pain receives/requires PRN pain meds for pain management, fx [fracture]., with interventions in place. On 4/10/2024 at 1:20 p.m. an interview with the resident's 7-3 Certified Nursing Assistant (CNA) Staff B who revealed she was a floating aide and she does not routinely have the resident on her schedule. She further revealed she had just returned from leave and did not know the resident well. Staff B revealed she was assigned to the resident today and the resident has as scheduled shower plan for today. At 2:20 p.m. on 4/10/2024 a follow-up was conducted with Staff B. She confirmed she had seen the resident's feet today and thought her nails were long and did not know what type of care and services were in place and who was responsible for nail care. Staff B revealed she did not know who was responsible for nail care for the resident. On 4/11/2024 at 8:30 a.m. an interview with the Social Service Director revealed she was knowledgeable about the resident. The Social Service Director confirmed she has been assisting with the goal of discharge planning with both the resident and her daughter. The Social Service Director was asked if she knew anything related to the resident's ADL care and what type of assistance she requires. The Social Service Director explained she did not know what type of assistance the resident required related to her ADLs, but explained the resident was able to do most things with supervision. She did not know if the resident required any assistance with personal hygiene to include nail care (both hands and feet). On 4/11/2024 at 9:25 a.m. an interview with Staff C, Licensed Practical Nurse (LPN) revealed he had Resident #163 on his assignment routinely and knows her and her care expectations. He confirmed he was aware of her feet toenails that were elongated and knew that podiatry was coming out within the next few days. He revealed she has presented with both foot pain and her feet are swollen as well, and this has been since admission. He confirmed that CNAs are responsible for assessing and doing body checks for long nails and other skin areas, and they are to report that to the nurse for further evaluation. Staff C also confirmed CNAs and/or Nurses can clip nails and if the resident is Diabetic, only a Registered Nurse can clip nails. He confirmed Resident #163 was not a Diabetic, and that either CNA or Nurse could clip her nails. Staff C also confirmed he has not been aware of Resident #163 ever refusing care and services and did not know why her nails were not clipped. On 4/11/2024 at 1:10 p.m. an interview with the 200 Unit Manager Staff D revealed she was knowledgeable of Resident #163 and her care needs. She confirmed Resident #163 has been at the facility for about two weeks and that her daughter comes in routinely and lives nearby. She further revealed the resident does ambulate using a rolling walker and she normally goes outside and in the dining room and then hangs out in her room. Staff D revealed she was aware Resident #163 had elongated toe nails and that she tried to assist her with nail care yesterday (4/10/2024). She revealed that she did not have the type of clippers to clip all the nails to the end of the nail bed. She revealed the resident's toe nails were so long and thick, some needed a different type of clipper to trim. Staff D was not aware the resident was not comfortable and had toe pain when she wore her shoes. She also confirmed that staff to include Aides and Nurses would evaluate and observe the resident for any skin issues and nail maintenance during daily care and shower/bathing opportunities. On 4/11/2024 at 1:00 p.m. both Staff D and the Nursing Home Administrator confirmed the facility did not have any specific Activities of Daily Living (ADL), and/or Nail care maintenance policy and procedure for review. Staff D revealed that nail care would be a standard of practice for staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to provide activities in an appropriate and stimulating manner on one of one (secured memory care) unit. Findings included: Review of an April 2024 calendar located on the facility's secure memory care unit, revealed the activities on April 8th was 9:00 a.m. - Easy Listening, 9:30 a.m. - Arts & Crafts Time, 10:00 a.m. - Morning Social, and at 1:00 p.m. - Move and Groove. An observation on 4/8/24 at 10:18 a.m. of the secured memory care unit revealed 13 residents sitting in the common area at four 4-person tables in each corner of the room, stacks of magazines had been placed each of the tables. One female resident appeared interested in a magazine, a cooking show was playing on television which was muted and a radio was playing, no other resident appeared to be interested in any of these activities. Two tables were placed in corners on each side of the television which was hung in the center of the wall. An observation on 4/8/24 at 10:36 a.m. showed Resident #24 sitting in the common area of the unit at table with 3 other residents looking at a magazine. An observation on 4/8/24 at 10:39 a.m. showed Resident #52 was sitting at a table in the common area with 3 other residents, Resident #52 was eating crackers. An observation on 4/8/24 at 1:17 p.m., revealed 13 residents sitting at 4 tables in the common area of the secured memory care unit, a television was muted, radio was playing, and no interaction between staff and residents was occurring. An observation on 4/8/24 at 1:21 p.m., showed Resident #52 was sitting in the common area of the unit, in a corner, facing the nursing station perpendicular to the television. Staff P, Registered Nurse (RN), woke resident up to administer medications. An observation on 4/8/24 at 1:26 p.m. revealed Staff O, Certified Nursing Assistant (CNA) moved to the music, playing lowly, for a few movements without interacting with any resident. The observation showed 14 residents in the unit's common area and 2 magazines were available to two of the four tables. An interview was conducted with Staff P, Registered Nurse (RN) on 4/8/24 at 1:36 p.m. The staff member stated normally they have an activity person back here who throws parties and the activity person must not be here today. During the interview, Staff O stated the activity person was off on Mondays. During the interview the music changed to a [NAME] song, Staff M, CNA, while sitting next to Resident #52 asked who was the singer, the resident did not answer. Staff O left the area and Staff P continued to administer medications to other residents, and Staff I (RN/Unit Manager) was sitting in the nursing station and Staff L was at an unknown location. The schedule showed one nurse and three aides were assigned to the unit. On 4/8/24 at 1:40 p.m., Resident #107 was observed sitting at a table in the secured memory care unit with 3 other residents. The observation revealed no activity was occurring, television was playing and muted, with a low-volume radio was playing. On 4/9/24 at 10:34 a.m., Resident #107 was observed sitting at table facing exterior wall with head bowed, other residents were coloring at nearby tables (Resident #24), and little to no interaction with staff members. An observation on 4/10/24 at 9:07 a.m., revealed 13 residents sitting in the common area of the secured Melody unit, music was playing and some residents were interested in magazines. An interview was conducted with the Activity Director (AD) on 4/10/24 at 9:32 a.m The AD reported having an assistant that came in on weekends but was generally the only activity staff member at the facility. The AD stated some of the activities provided on the secured unit was sensory stimulating, music and dance, arts and crafts, adult coloring, and admitted sometimes planned activities get thrown out due to the resident's preferences. The AD stated the assistant was in the facility on 4/8/24, as the AD was not in the facility. The AD stated the assistant was on the main unit's patio on Tuesday (4/9) doing Charades (with AD) and probably should have had the assistant doing something on the secured unit. The AD stated the residents' on the secured unit need stimulation, tries to provide the stimulation, and expectation was for staff to interact with the residents if activity staff were not on the unit. During an interview on 4/11/24 at 2:57 p.m., the Director of Nursing (DON) reported the resident's were usually very active on the secured unit, stating, they usually have puzzles on the table. Review of Resident #24's admission Record showed the resident was admitted on [DATE] and readmitted on [DATE]. The resident's Quarterly Brief Interview of Mental Status (BIMS), dated 3/22/24, showed a score of 3 out of 15, indicating severe cognitive impairment. Review of Resident #24's Quarterly Activity Assessment, dated 2/15/24, showed the resident preferred morning activities and required assistance with activity pursuit. The assessment revealed the resident enjoyed socializing with peers, painting, arts and crafts, music and dance. Also the resident loved singing and dancing, enjoyed visits from the therapy dogs, and enjoyed having nails painted. The resident enjoyed helping others and participating in a wide variety of activities presented. The assessment revealed goals were exceeded and changes were to continue to stimulate the resident socially, spiritually, physically, and cognitively. Review of Resident #24's care plan showed the resident required staff assistance with involvement of activities related to cognitive deficits. The interventions revealed the resident prefers/would benefit from: General Activities Program. Review of Resident #52's admission Record showed the resident was admitted on [DATE]. Review of Resident #52's other Activity Assessment, dated 4/1/24, revealed the resident preferred afternoon activities and required assistance with activity pursuit. The resident's passive activities included sitting outside, listening to music and pet interaction. The creative activities was cooking and showed the resident loved pasta and lasagna, country music, and liked snacking and socializing with peers. The previous goals were met and changes were to continue to stimulate the resident physically, socially, spiritually, and cognitively. Review of Resident #107's admission Record revealed the resident had been admitted on [DATE]. Review of the re-entry Activity Assessment, dated 4/2/24, showed the resident preferred activities during the afternoon and required assistance with activity pursuit. The assessment revealed the resident preferred sitting outside, watching TV, listening to music, and building projects. The description of favorite activities showed the resident enjoyed socializing with peers, listening to music and was curious about how things were put together. The previous activity goals were met and changes to goal were to continue to stimulate the resident physically, socially, spiritually, and cognitively. Review of the facility policy - Activities Overview, effective October 2021, revealed Activities Department employees will provide activities that include sensitivity and an understanding of each individual resident's needs and requirements including medical, emotional, spiritual, therapeutic, and recreational needs. The Activity Programs will reflect individual needs and provide/promote the following: -Stimulation or solace -Physical, cognitive, and/ or emotional health - Enhancement, to the extent practicable, of each resident is physical and mental status - Resident Self-respect by providing activities that support self-expression, social and personal responsibility, and choice. Programs will be designed to meet the resident at their level of functioning. - Support activities - for residents who may be severely impaired or unable to tolerate the stimulation of a group. - Maintenance activities- schedule events that promote the highest level of physical, emotional, cognitive, psychosocial, and spiritual well-being. - Empowerment activities- designed to promote self-expression, social and personal responsibility, and a sense of purpose in their daily lives. Activities will be provided at a frequency to meet the individual needs of the residents. Programs are designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. Programs are developed for the specialized groups and those with unique or special recreational/ activity needs. Each program developed is also designed to ensure maximum flexibility and responsiveness to individual needs. Residents are encouraged, but not required, to attend and participate in recreational and therapeutic activities on a 1:1 basis or in a group.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, facility policy review and the Plan of Correction review, the facility failed to ensure it had a functioning Quality Assurance and Performance Improvement (QAPI) Program. The facility was actively involved in the creation, implementation and monitoring of the Plan of Correction for deficient practice during a recertification and complaint survey conducted on 04/08/2024 to 04/11/2024 and was cited at F657, F677, F690, F758, F759, F842, and F880. On 06/03/2024 to 06/04/2024 a revisit survey was conducted and the facility was recited at F657, F677, F690, F758, F759, F842, and F880. The facility had developed a Plan of Correction with a completion date of 05/10/2024. Findings include: 1. Resident #24 was admitted initially on 04/10/2023 and readmitted on [DATE]. Review of the admission Record showed diagnoses included diabetes, mood disorder, dementia, recurrent major depressive disorder, generalized anxiety disorder, and bipolar disorders. Review of the Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 03 (severely impaired). Section N, medications showed she was prescribed antipsychotics, antianxiety medications and antidepressants. Review of the physician Order Summary Report showed the following: -Buspirone HCL 15 milligram (mg) twice a day for anxiety; -Depakote delayed release 250 mg twice a day for mood disorder and agitation; -Duloxetine HCL delayed release particles 30 mg daily for depression; -Lithium carbonate 150 mg twice a day for bipolar disorders; -Mirtazapine 7.5 mg at bedtime for depression; -Quetiapine Fumarate 100 mg at bedtime for bipolar disorders; -Risperdal 1 mg / milliliter (ml) give 0.5 ml twice a day for bipolar disorders; -Trazodone HCL 25 mg at bedtime for depression; -Xanax 0.5 mg every 8 hours as need for anxiety / agitation for 6 months as of 4/29/2024; -side effect monitoring: agitation, blurred vision, cardiac or blood abnormalities, confusion, constipation, dry mouth, difficulty urinating, disturbed gait, drooling, drowsiness, headache, hypotension, involuntary movement of mouth tongue, trunk or extremities, N and V, pacing, seizure activity, stiffness of neck, sore throat, tremors, rashes every shift; do not use if any side effects are present or resident appear to be lethargic, drowsy, or sedated. Report change to practitioner if needed. -Physician summary showed no order for behavior monitoring. Review of the May 2024 Medication Administration Record showed Xanax 0.5 mg every 6 hours as needed for anxiety / agitation was given on 05/14/24 at 16:16, 05/20/2024 at 13:40 and 05/21/2024 at 16:54. Review of the nursing progress notes showed: -On 05/14/2024 at 16:20: agitated, anxious. Gave Xanax 5 mg po according to medical order -On 05/20/2024 at 13:40: became agitated at another resident and verbally threatened the other resident. Redirected to her room to provide separation and calmer environment. Resident came back to common area and continued to be agitated, agreed to take prn medications. -No documentation on 05/21/2024 regarding Xanax or behaviors. Review of Resident #24's care plan showed the following: -Behavior, the resident was noted with the following behaviors: placing self on the floor, can be aggressive at times, refuses labs at times, refuses therapy at times, refuses medications at times and sometimes can be physically aggressive to staff, refuses care at times, will have verbal outbursts at times as of 10/04/2023. -Interventions included but were not limited to administering psychotropic medications as ordered, report missed or refused medication to physician (missed doses can lead to an acute event & should be reported to the physician); encourage as much participation/interaction by the resident as possible during care activities; Psychiatry Services as needed, Psychological Services as needed. -Psychotropic medications as the resident uses psychotropic medications related to antidepressant to manage depression, antianxiety to manage anxiety and antipsychotic to manage bipolar as of 09/20/2023. -Interventions included but were not limited to: Psychotropic side effects monitoring: agitation, blurred vision, cardiac or blood abnormalities, confusion, constipation, dry mouth, difficulty urinating, disturbed gait, drooling, drowsiness, headache, hypotension, involuntary movement of mouth, tongue, trunk or extremities, nausea and vomiting, pacing, seizure activity, stiffness of neck, sore throat, tremors, rashes as of 9/20/23; administer medications as ordered; observe/document for side effects and effectiveness. Review of psychiatric note, dated 05/21/2024, showed a follow up visit due to patient with multiple psych issues and bipolar and agitated and recent thread to others. Behavioral Mood showed anxious, flat, sad, friendly, calm, disorganized, and delusion. Medication showed Xanax 0.5 mg every 8 hours as needed. Assessment / Plan showed Anxiety: Continue Buspar and Xanax prn. During an interview on 06/03/2024 at 4:45 p.m. the Director of Nursing (DON) regarding Resident #24, she verified there were no interventions related to behavior monitoring nor the use of non-pharmacological interventions for behaviors. The DON stated these interventions should be in the care plans. 2. Resident #83 was admitted on [DATE] and readmitted on [DATE]. Review of the admission Record showed diagnoses included unspecified dementia, cognitive communication deficit, recurrent major depressive disorder, unspecified mood disorder, and anxiety disorder. Review of the MDS, dated [DATE], showed a BIMS score of 03 (severely impaired). Section N, medication showed she was taking antipsychotics, antianxiety and antidepressants. Review of the physician Order Summary Report, for June 2024, showed: -Depakote sprinkles delayed release sprinkle 125 mg give 2 capsules three times a day for mood disorder / agitation; -Quetiapine Fumarate 25 mg three times a day for mood affective disorder; -Remeron 7.5 mg at bedtime for depression; -Valium 5 mg bid for anxiety; -side effect monitoring: agitation, blurred vision, cardiac or blood abnormalities, confusion, constipation, dry mouth, difficulty urinating, disturbed gait, drooling, drowsiness, headache, hypotension, involuntary movement of mouth tongue, trunk or extremities, N and V, pacing, seizure activity, stiffness of neck, sore throat, tremors, rashes every shift; do not use if any side effects are present or resident appear to be lethargic, drowsy, or sedated. Report change to practitioner if needed. -Physician summary showed no order for behavior monitoring. Review of the nursing progress notes showed no documentation related to behaviors. Review of the psychiatric note, dated 05/21/2024, showed a follow-up visit due to patient with multiple psych issues and mood disorder with agitation. Mood disorder and agitation and can have combativeness, dementia and impaired memory, depression and sadness, anxiety and mood swings. Behavioral mood showed anxious, flat, sad, irritable, agitated, fidgety, restless, and memory deficits. Review of Resident #83's care plans showed: Behaviors: combative towards staff and other residents; resident will play with/handle feces at times; resident will state that the demons are coming initiated: 03/06/2023 with a revision on 02/09/2024. Interventions included but not limited to enhanced monitoring; administer psychotropic medications as ordered, report missed or refused medication to physician (Missed doses can lead to an acute event & should be reported to the physician); observe/document for side effects and effectiveness; observe for changes in behavior & report to physician i.e.; insomnia, nervousness, loss of interest, decreased ability to concentrate, repetitive movements, etc. (Could indicate impending relapse) as of 03/06/2023; Psychiatry Services as needed; Psychological Services as needed. -Psychotropic medications related to the resident uses psychotropic medications related to antidepressant to manage depression, antianxiety to manage anxiety, antipsychotic related to mood disorder, and anticonvulsant to manage behaviors initiated: 02/14/2023 and revised 02/09/2024. -Interventions include but not limited to psychotropic side effects monitoring: agitation, blurred vision, cardiac or blood abnormalities, confusion, constipation, dry mouth, difficulty urinating, disturbed gait, drooling, drowsiness, headache, hypotension, involuntary movement of mouth, tongue, trunk or extremities, nausea and vomiting, pacing, seizure activity, stiffness of neck, sore throat, tremors, rashes as of 9/20/23; administer medications as ordered; observe/document for side effects and effectiveness; Psychological services per order and PRN; Psychiatry Services per order\PRN\protocol; consult with pharmacy, MD to consider dosage reduction when clinically appropriate; use of psychotropic medications will be reviewed at least quarterly with the IDT/MD to review continued need for the medication & ensure lowest dose. During an interview on 06/03/2024 at 4:45 p.m. with the Director of Nursing (DON) regarding Resident #83, she stated by review of the care plan there was an intervention which stated observe for changes in behavior & report to physician i.e., insomnia, nervousness, loss of interest, decreased ability to concentrate, repetitive movements, etc. (Could indicate impending relapse) but did not address the use of non-pharmacological interventions for the behaviors. The DON stated these interventions should be in the care plans. 3. Resident #31 was admitted on [DATE]. Review of the admission Record showed diagnoses included Cerebral Infarction, diabetes, epilepsy, Parkinsonism, cognitive communication deficit, generalized anxiety disorder, schizophrenia, recurrent major depressive disorder, bipolar disorder, hypertension (HTN), and congestive heart failure CHF). Review of the MDS, dated [DATE], showed a BIMS score of 12 (moderately impaired). Section N, Medications showed antipsychotic medications. Review of the physician Order Summary Report, June 2024, showed: -Aspirin 81 mg daily for Coronary Artery Disease, -Benztropine Mesylate 1 mg three time a day for tremors, -Carbamazepine ER 12 hour 100 mg related to epilepsy, -Depakote delayed release 250 mg two times a day for bipolar, -Docusate Sodium 100 mg daily for constipation, -Lisinopril 2o mg twice a day for hypertension, -Risperdal (Risperidone) 3 mg twice a day for schizophrenia, -Sodium Chloride 1 gm four times a day for abnormal labs, -Spironolactone 50 mg daily for CHF, -Terazosin HCL 5 mg daily for urinary retention/HTN; -side effect monitoring: agitation, blurred vision, cardiac or blood abnormalities, confusion, constipation, dry mouth, difficulty urinating, disturbed gait, drooling, drowsiness, headache, hypotension, involuntary movement of mouth tongue, trunk or extremities, N and V, pacing, seizure activity, stiffness of neck, sore throat, tremors, rashes every shift; do not use if any side effects are present or resident appear to be lethargic, drowsy, or sedated. Report change to practitioner if needed. -Physician summary showed no order for behavior monitoring. Review of the progress notes did not show any documentation related to behaviors or non-pharmaceutical interventions. Review of the psychiatric visit, dated 05/21/2024, showed follow up visit due to patient with multiple psych issues and depression. Behavioral mood showed anxious, irritable, fidgety and restless. Resident #31 care plans showed: -The resident was at risk for episodes of delirium or an acute confusional episode related to bipolar initiated on 03/05/2020 and revised on 12/15/2020. -Interventions included but not limited to report changes in behavior, cognition, and mood to physician as indicated; administer medications as ordered as needed. -The resident had a potential mood problem related to bipolar, depression, initiated on 12/03/2019. -Interventions included but not limited to administer psychotropic medications as ordered; report missed or refused medication to physician (Missed doses can lead to an acute event & should be reported to the physician); observe/document for side effects and effectiveness; Psychiatry Services as needed. -The resident was noted with the following behaviors: delusions, hallucinations, outbursts, refusal of care, frequently chooses not wear hearing aids, refusal of treatments, episodes of confabulation, will keep urinal on bedside table, dresser etc. and will not allow staff to tore it properly at times, despite education. -Interventions included but not limited to administer psychotropic medications as ordered; report missed or refused medication to physician (Missed doses can lead to an acute event & should be reported to the physician); allow time to communicate effectively; encourage as much participation/interaction by the resident as possible during care activities; document episodes of behavior & review to determine the effectiveness of interventions. -The resident was noted with the following behaviors likes to lay in bed with just an absorbent brief on and no clothes, no covers; resident will at times hide hearing aid(s) and report they are missing. -Interventions included but were not limited to speak softly & clearly when communicating; encourage as much participation/interaction by the resident as possible during care activities; document episodes of behavior & review to determine the effectiveness of interventions; medication as ordered, report missed or refused meds to physician, discuss possible alternatives with MD and resident; Psychiatry Services as needed; Psychological Services as needed. -The resident was noted with the following behaviors: Potential/ Shows aggression to staff attempting to hit staff resident has behavior of going into bathroom, immediately turns on the bathroom call light, resident prefers to leave the call light on while in the bathroom. resident refuses to turn it off until he is done using the restroom; resident will swallow chewable meds. -Interventions included but not limited to: administer psychotropic medications as ordered; report missed or refused medication to physician (Missed doses can lead to an acute event & should be reported to the physician); allow time to communicate effectively; document episodes of behavior & review to determine the effectiveness of intervention; if resident shows s/s of agitation, reassure resident, leave and return 5-10 minutes later and try again; Do Not Corner if agitated; provide space, remove other Residents, remain calm & Call for assistance; Psychiatry Services as needed; Psychological Services as needed. -The resident uses psychotropic medications related to schizophrenia, bipolar disorder, initiated 09/03/2019 and revision on 05/30/2024. -Interventions included but not limited to administer medications as ordered; Observe/document for side effects and effectiveness; Anti-Psychotic: Observe for potential side effects may include, Tardive dyskinesia, dry mouth, constipation, blurred vision, drowsiness, weight gain, restlessness, stiffness, tremors, muscle spasms, extrapyramidal symptoms- EPS (shuffling gait, rigid muscles, shaking), , neuroleptic malignant syndrome. Anti-Anxiety: Observe for potential side effects may include, dizziness, drowsiness, confusion, headache, anxiety, tremors, stimulation fatigue, depression, insomnia, hallucinations, weakness, unsteadiness, orthostatic hypotension, blurred vision, tinnitus, constipation, dry mouth, nausea, vomiting, anorexia, diarrhea, rash, dermatitis. Anti-Depressant: Observe/document for potential side effects may include, dizziness, drowsiness, diarrhea, dry mouth, urinary retention, suicidal ideation, orthostatic hypotension. Psychological services per order and PRN. Psychiatry Services per order\PRN\protocol. Discuss with MD, res/resp party related to ongoing need for use of medication. Report to physician on negative outcomes associated with use of drug. During an interview on 06/03/2024 at 5:28 p.m. with the DON regarding #31, she stated the behavior monitoring was in the aide care plan only. She stated the resident will swallow his medications was an intervention in his care plans. 4. Resident #32 was admitted on [DATE] and readmitted on [DATE]. Review of the admission Record showed diagnoses included Wernicke's encephalopathy, unsteadiness, insomnia, hypertension (HTN), chronic pain, anxiety disorder, recurrent major depressive disorder, and mood disorder. Record review of the MDS, dated [DATE], showed a BIMS score of 15 (cognitively intact). Section N. Medications showed she was taking antianxiety medications. Review of the Physician Order Summary Report, June 2024, showed: -Resident may self-administer all eye drops ordered. Eye drops may be kept in locked container in resident's room; -ProAir HFA inhalation Aerosol solution 108 (90 base) mcg/act (Albuterol Sulfate) 2 puffs inhale orally three times a day for wheeze-cough/ congestion for 5 days and 2 puffs inhale orally every 6 hours as needed for wheeze-sob, ordered on 10/09/2023 and revised to unsupervised self-administration as of 06/03/2024; -Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 mcg/act 2 puffs inhale orally two times a day for asthma, ordered on 02/01/2024 and revised to unsupervised self-administration rinse mouth out after use as of 06/03/24; -Flonase Nasal Suspension 50 mcg/act 1 spray in both nostrils two times a day for allergies, ordered on 01/20/2023 and revised to unsupervised self-administration as of 06/03/2024; -Curoxen ointment apply to affected area every 6 hours as needed for mouth sore as of 3/28/24. Review of the May and June 2024 MARS showed the following: -Curoxen had not been administered for May nor June of 2024 -ProAir HFA inhalation Aerosol solution 108 (90 base) mcg/act (Albuterol Sulfate) 2 puffs inhale orally three times a day for wheeze-cough/ congestion for 5 days and 2 puffs inhale orally every 6 hours as needed for wheeze-sob, ordered on 10/09/2023 shown as given -Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 mcg/act 2 puffs inhale orally two times a day for asthma, ordered on 02/01/2024 shown as given -Flonase Nasal Suspension 50 mcg/act 1 spray in both nostrils two times a day for allergies, ordered on 01/20/2023 shown as given Review of the Self-Administration of Medication Resident Assessment, dated 03/04/2024, showed the resident can demonstrate secure storage for medication kept in room, can correctly state the proper dose for each medication, can correctly state what each medication is for, can state what time or how often medication is to be taken. Can correctly self-administer eye drops / ointments. The resident is deemed able to safely self-administer medications and that it is clinically appropriate. The capability to self-administer nasal drops / sprays and inhalants / diskus were not documented at evaluated. Record review of Resident #32's Care plans showed: -The resident wishes to self-administer eye drops and can demonstrate secure storage, can identify medication, knows the dosage, side effects and knows it's purpose, can read instructions, can take medication as ordered. Some of their medications (eye drops). Rest of medication kept by nurse as of 03/04/2024. -Interventions included but not limited to assessment by Interdisciplinary team (IDT) completed & self-administration approved on 03/04/2024. Ongoing teaching regarding medication administration, dosage, purpose, secure storage, self-documentation, side effects, and reporting to nurse for documentation. Physician order obtained. Verify medications are safely secured daily. During an interview on 06/03/2024 at 5:35 p.m. the Director of Nursing (DON) verified the resident was only care planned to self-administer eye drops. 5. Resident #3 was admitted on [DATE] and readmitted on [DATE]. Review of the admission Record showed diagnoses included metabolic encephalopathy, cerebrovascular disease, diabetes, congestive heart failure, generalized anxiety, mood disorder, depression, and hypertension. Review of the MDS, dated [DATE], showed a BIMS score of 13 (cognitively intact). Section N, Medications showed he received antianxiety and antidepressant medications. Review of the Physician orders and Medication Administration Review (MAR) for June 2024 showed: -ASA 81 mg chewable daily for coronary artery disease was not given during the observation but documentation showed it was given -Fluticasone Propionate nasal suspension 50 mcg/act 1 spray in both nostrils bid for allergy was not given during observation but documentation showed it was given. -Duloxetine HCL delayed release particles 30 mg daily for depression was administered after the capsule was opened -Multivitamin with minerals daily for supplement was ordered but Multivitamin plus iron was given Review of the progress notes did not show any documentation related to behaviors or non-pharmaceutical interventions. Review of Resident #3's care plans showed he was noted with a behavioral and psychotropic medication care plan. Interventions included but not limited to administering psychotropic medications as ordered. During an interview on 06/03/2024 at 5:47 p.m. the observation of medication pass was reviewed with the DON, she verified medications were documented as given when they were not observed, and incorrect medications were given. She stated the nurse must follow the physician's order. During an interview on 06/04/2024 at 11:32 a.m. the DON stated the non-pharmaceutical interventions should also be in the care plans. She verified the psychotropic care plans did not list any non-pharmaceutical interventions. During an interview on 06/04/2024 at 12:36 p.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) regarding the Plan of Correction book, they stated they reviewed the care plans for the three residents cited in the survey. They reviewed all the care plans for advanced directives, wander guard use, and Post Traumatic Stress Disorder (PTSD) diagnoses. The DON stated they did not look at the care plans for anything else, they focused on those things cited in the survey only. The DON stated they could have found the lack of behavior monitoring in the care plans if they had looked at the care plan as a whole instead of just the three examples. The DON stated they educated the nursing staff on the importance of the care plans being up-to-date and appropriate. The DON stated they audited the care plans for the three things only, advanced directives, wander guard placement and medical diagnosis. Review of the facility's policy, Care Plan - Interdisciplinary Plan of Care from Interim to Meeting, dated February 2024, showed the following: The facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to, monitoring resident condition, and responding with appropriate interventions. The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives and time frames and describes the services that are to be furnished to attain or maintain the resident's the highest practicable physical, mental, and psychosocial well-being. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care. The overall care plan should be oriented towards: 1. Preventing avoidable declines in functioning or functional levels .2. using an appropriate interdisciplinary approach to care plan development to improve the resident's functional abilities . Procedure: 2. Update to care plans a. ongoing updates to care plans are added by a member of the IDT, as needed. 3. b. problems and goals have IDT approaches and Interventions to assist the resident in their goal attainment. Comprehensive Plan of Care b. describes or includes: i. services that are to be furnished and goals that reflect the resident's wishes, choices, and exercise of rights. On 6/03/24 at 9:10 a.m., an observation was conducted of Resident #25 in his room. Resident #25 was observed with long fingernails on his right hand. Resident #25's right hand has a contracture with fingernails touching the palm of his hand. Resident #25 denied nails were offered to be trimmed in a timely manner. On 6/03/24 at 12:20 p.m., an observation was conducted of Resident #20 in the main dining room. Resident #20 was observed with long fingernails on both his hands. Resident #20 was non-verbal and waiting for lunch trays to be delivered. Upon delivery of Resident #20's lunch tray, the resident was observed eating his mechanical soft /pureed diet from a regular plate and dropping food on the table as the resident attempted to feed himself. Staff E, Certified Nurse Assistant (CNA), acknowledged the food on the table by stating, Oh my, and walked towards the resident who was picking up food from the table to eat with his hands, stating, You good?. On 6/03/24 at 12:35 p.m., an observation was made of Resident # 6 in his room. Resident #6 was eating his lunch with long fingernails seen on both his hands. Resident #6 stated he was amiable to getting his nails trimmed if it was offered. On 6/03/24 at 2:45 p.m., an interview and observation was conducted with Staff C, CNA regarding the length of fingernails for Resident #20. Resident #20 was in his bed during the interview. Staff C, CNA stated the resident's fingernails were not long, but observed the resident pulling at his brief and blanket and agreed some fingernails were long. Staff C, CNA stated due to his restlessness and ease of agitation it is difficult for one person to try and trim his nails. On 6/03/24 at 15:05 p.m., an interview and observation was conducted with Staff D, CNA regarding the length of the fingernails for Resident #25. Resident #25 was in his bed during the interview. Staff D, CNA inspected the resident's fingernails and stated they needed trimming. On 6/03/24 at 15:15 p.m., an interview and observation was conducted with Staff E, CNA regarding the length of fingernails for Resident #6. Staff E, CNA inspected the resident's fingernails and stated they needed trimming. Staff E, CNA told the resident she would get his CNA to trim his nails. A review of Resident #25's admission Record revealed an admission date of 11/07/2015 and a readmit date of 01/09/2024. Diagnoses include diffuse traumatic brain injury with loss of consciousness of unspecified duration,. Contracture right elbow and hand, dysphagia oral phase, and need for assistance with personal care. A review of Resident #25's care plan ,revision date of 02/16/24, has a Focus area of ADL for self-care performance deficit related to traumatic brain injury, seizures, decreased mobility and weakness. The Goal was to prevent decline in ADL self-performance through next review and will have ADL needs anticipated and met by staff through next review. The interventions included personal hygiene with one- person assistance. A review of Resident #20's admission Record revealed an admission date of 10/26/2020 with diagnoses including lack of coordination, Parkinsonism, dysphasia oral phase, age-related cognitive decline, hallucinations unspecified, unspecified mood [affective] disorder, generalized anxiety disorder, major depressive disorder single episode unspecified, Alzheimer's disease unspecified, and need for assistance with personal care. A review of resident #20's physician orders revealed regular diet pureed PU4 (level 4 pureed) texture, regular thin consistency, fortified foods order on 6/22/2021. A review of Resident #20's care plan revealed the following: Focus area of ADL for self-care performance deficit related to inability to perform/complete self-care cognitive deficit diagnosis of Parkinson's and Alzheimer's disease. The goal was to be anticipated and met by staff through the next review. The interventions included personal hygiene dependent by staff with assist of one and provide adaptive equipment lip plate for all meals. Focus area of alteration of skin integrity related to decreased mobility, episodes of incontinence removal of colostomy bag. The goal was to be free from injury through the next review date. The interventions included encourage the resident to allow staff to trim his nails to keep them short and maintained. A Focus area of behavior: follow behaviors: removing colostomy bag, getting feces on hands, touch items in his room with dirty hands, history of placing self on the floor, pulling brief off, resident has periods of aggressive periods. The goal was to have his needs anticipated and met by staff through the next review period. The interventions included two-person assist during ADL care. A record review of Resident #6's admission Record revealed an admission date of 7/11/2023 with diagnoses including unspecified sequelae of cerebral infarction (CVA),. Type I Diabetes Mellitus (DM), lack of coordination and functional quadriplegia. A review of Resident #6's care plan revealed the following: Focus area of ADL for self-care performance deficit related to history of CVA, DM, dementia and functional quadriplegia. The goal was to prevent decline in ADL self-performance through next review. The interventions included anticipating the resident's needs, and personal hygiene with the assistance of one. On 6/04/24 at 1:11 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated fingernail care falls under the CNAs duties but if the resident has a diagnosis of diabetes it would default to the nurses. A review of the facility's Competency Review Certified Nursing Assistant check list revealed under the section titled Resident Personal Hygiene, Care of the Fingernails (toenail care by podiatrist). A review of the facility's policy and procedures titled, Assistive Devices, revised January 2023, showed the following: Assistive devices are used by residents who need to improve their ability to independently feed themselves or to maintain their independence of self-feeding. Efforts should be made to ensure residents maintain their level of self-participation by the use of devices. The procedures for this policy are: 1. Upon request, verbal or written, from nursing, therapists should assess any potential problems identified. 2. If a feeding concern can be improved with therapy interventions, including assistive devices, a referral should be obtained from the physician. 4. Food and nutrition services will provide the prescribed, assistive devices at each meal period. The device should not remain in the residence room. A review of the admission record for Resident 107 revealed an initial admit date of 3/10/2024, and a readmission date of 5/04/24. Diagnoses included metabolic encephalopathy, systemic inflammatory response syndrome (SIRS) on non-infectious origin without acute organ dysfunction, dehydration, obstructive and reflux uropathy unspecified, moderate dementia, major depressive disorder recurrent, unspecified mood [affective] disorder, muscle wasting and atrophy multiple sites and need for assistance with personal care. A review of the physician orders, entered 5/04/24, revealed the following: urinary catheter care daily and PRN (as needed) for preventative measures, drain urinary catheter bag every sift and prn as needed, change urinary catheter bag as needed label with date,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. An observation on 04/08/24 at 12:12 p.m., revealed twelve residents in the main dining room. The main dining room consisted of Residents who resided on 100 and 200 hallways. Staff were observed passing hydration to the Residents prior to meal service with no hand hygiene provided. Two residents were observed using their hands/fingers to eat independently. On 04/08/24 at approximately 12:30 p.m., tray pass was observed on the 100 and 200 halls, no hand hygiene was offered to the residents prior to tray service. Based on observation, record review and interview, the facility failed to ensure hand hygiene was provided before and after meal service on four (100, 200, 300 and Melody-secured) of four units, and the facility failed to ensure hand hygiene was available after toileting for one unit (Melody-secured) out of four units observed. Findings included: An observation on 04/08/24 at 12:00 p.m., revealed a hydration cart was being utilized down 400 hallway. The staff provided hydration prior to meal but did not provide hand hygiene. An observation on 04/08/24 at approximately 12:30 p.m., the tray cart was delivered to 400 hallway. Staff were observed knocking on Residents' doors and delivering trays to each Resident. No hand hygiene was observed being conducted at tray delivery service. During an interview on 04/08/24 at 12:45 p.m. Staff E, Registered Nurse (RN)Unit Manager (UM) stated she did not know when hand hygiene was provided but she thought it was after lunch. During an interview on 04/08/24 at 12:50 p.m. Staff F, Certified Nursing Assistant (CNA) stated, I personally wash all my Residents hands during morning care. Staff F CNA was asked when Residents hand hygiene was expected to be conducted before meals? Staff F CNA again replied, I did all my residents hand hygiene during morning care. During an interview on 04/08/24 at 12:55 p.m. Staff H, Certified Nursing Assistant (CNA) stated Residents are to be provided hand hygiene both before and after the meal. Staff H CNA stated she always provided hand hygiene for her residents before lunch but today she was on break during that time. During an interview on 04/08/24 at 1:00 p.m. Staff G, Certified Nursing Assistant (CNA) stated Residents are to be provided hand hygiene during morning activities of daily living (ADL) care and then after lunch. During an interview on 04/08/24 at 1:05 p.m. Staff B, Certified Nursing Assistant (CNA) stated, Residents are to be provided hand hygiene care first thing in the morning and after lunch. An observation on 04/10/24 at 11:55 a.m., revealed a hydration cart was being utilized down 400 hallway. The staff provided hydration prior to meal but did not provide hand hygiene. During an interview on 04/10/24 at 12:20 p.m., Resident #93 stated she was not provided hand hygiene before each meal. During an interview on 04/10/24 at 12:35 p.m., Resident #16 stated she was not provided any hand hygiene prior to lunch today, but stated the staff do provide it sometimes before meals. During an interview on 04/11/24 at 3:15 p.m. , the Director of Nursing (DON) stated I would expect hand hygiene to be provided before meals. The DON stated, We heard this through the grapevine and we will be QAPI hand hygiene at the next meeting. 3. On 4/8/24 at 11:01 a.m., Staff I, Registered Nurse/Unit Manager (RN/UM) was observed cleaning the table where Resident #107 had been resting leg on a table in the secured memory care unit. The observation revealed on 4/8/24 at 11:03 a.m. of Staff M, Certified Nursing Assistant (CNA) of emptying artificial sweetener and milk into coffee cups then took the cups to resident's sitting in the common area. On 4/8/24 at 11:14 a.m., Staff P, RN stated the two meal carts (for Melody - memory care unit) come at different times, only four staff members to pass trays so may have some residents sitting without trays while some have them so the residents may say that's mine and demonstrated with outstretched hands and pulling back to chest. On 4/8/24 at 11:47 a.m. a meal cart arrived to the Melody care and Staff P informed Staff I of not knowing everything about the meal service so did not want to mess it up. The trays contained foam plates and plastic utensils. On 4/8/24 at 11:50 a.m., Staff L was observed taking meal tray into room [ROOM NUMBER]. Staff M and O, CNA's, were observed washing their hands at sink in common area of Melody unit. On 4/8/24 between times of 11:01 a.m. and 12:04 p.m., Staff L, M, and O were observed passing lunch meals, which included handheld bread, to 21 residents sitting in the common area and covered patio. During the observation on 4/8/24 of hydration and noon meal service residents were not offered hand hygiene prior to eating lunch. Review of the policy - Dining Services, effective January 2021, revealed To provide Residents a pleasurable dining experience by offering nutritious, attractive meals served in a courteous and dignified manner. The service procedure showed the dining room should be cleaned after each meal by nursing, dietary of other designated staff. The policy did not show resident's should be encouraged or assisted with hand hygiene prior to or after eating. 4. On 4/9/24 at 11:29 a.m. while observing the memory care unit, writer was approached by Resident #213 who reported would like to have towels in the bathroom. The resident stated after toileting would wash hands and had to wipe hand on clothes afterwards, demonstrating wiping hands across front of shirt. An observation was made with the resident, immediately following the interview, an observation was made of the resident's bathroom which was shared with 3 other residents. The observation revealed an empty towel wall dispenser and toilet paper sitting on edge of sink. The resident stated when the toilet paper sat on the back of the toilet it would end up in the toilet. Photographic evidence was obtained. An interview was conducted with Staff L, Certified Nursing Assistant (CNA) on 4/10/24 at 9:11 a.m., the staff member reported Resident #213 and Resident # 103 (a resident who shared bathroom with Resident #213) were continent (of bowel and bladder) during the day. The staff member stated residents who toilet can ask staff to assist in washing hands or they have tissues, which the staff member pointed out on top of Resident #213's dresser. Resident #213 asked Staff L and writer if they can get brown towels. The staff member stated if they fill the dispenser on the wall the towels end up in the toilet. During an interview on 4/10/24 at 3:56 p.m., Staff I, Registered Nurse/Unit Manager reported being unaware Resident #213 or #103 was asking for towels to dry hands. Staff I stated both residents were continent and it was tricky because of the shared bathroom. The staff member stated wiping hands on clothing was not appropriate and agreed if the residents were able to voice and identify something was missing (towels) they should have the opportunity to wash hands. Review of Resident #213's admission Record revealed the resident was admitted on [DATE] with diagnoses not limited to Parkinson's disease without dyskinesia without mention of fluctuations and mild dementia in other diseases classified elsewhere without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Review of Resident #213's Brief Interview of Mental Status (BIMS) evaluation completed on 4/3/24 by Staff I revealed a score of 6 indicating a severe cognitive impairment. Review of Resident #213's Continence report revealed the resident had been continent of urine 10 out 18 documentation's and continent of bowel 13 out of 18 documentation's. Review of Resident #213's care plan revealed the resident had an Activities of Daily Living (ADL) self care performance deficit related to recent hospitalization, history of falls, weakness, diagnoses of Parkinson. The goal was for the resident to improve level of self-performance by next review. The interventions showed the resident was incontinent of bowel and bladder, utilized the bathroom for toileting, praise efforts for participating in task, and self-performance level may fluctuate through out the course of the day, provided assistance as appropriate. Review of Resident #103's admission Record revealed the resident was admitted on [DATE] with diagnoses not limited to mild dementia in other diseases classified elsewhere with other behavioral disturbance and unspecified heart failure. Review of Resident #103's Cognitive Pattern assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 9, indicated moderate cognitive impairment and an admission Cognitive Pattern assessment, on 2/3/24 revealed a BIMS score 3, indicative of a severe cognitive impairment. Review of Resident #103's Bladder and Bowel 5-day assessment, dated 1/31/24 revealed the resident was frequently incontinent of bladder and bowel. Review of Resident #103's March Continence report revealed the resident was continent of bladder 52 out of 80 documentation's and was continent of bowel 55 out of 79 documentation's. Review of the resident's April Continence report revealed the resident was continent of bladder 16 out of twenty-five documentation's and continent of bowel 20 out of 25 documentation's. Review of Resident #103's care plan revealed the resident had an ADL self-care performance deficit due to recent hospitalization, unsteady gait, (and) generalized weakness. The goal was for the resident improve level of self performance by next review. The related interventions included self performance level may fluctuate through out the course of the day, provide assistance as appropriate , resident was incontinent of bladder and bowel with toileting assistance of 1, and staff would praise efforts for participating in task. The policy - Hand Hygiene, effective October 2021, revealed The facility considers hand hygiene the primary means to prevent the spread of infections. The policy showed the following: 1. Personnel shall be trained and regularly in-serviced on the importance of hand hygiene and preventing the transmission of healthcare-associated infections. 2. Personnel shall follow the handwashing/ hand hygiene guidelines to prevent the spread of infections to other personnel, residents, and visitors. 4. Residents, family members, visitors, volunteers and those who provide services under a contractual agreement will be encouraged to practice hand hygiene through the use of fact sheets, pamphlets, and other written materials provided at the time of admission and posted throughout the facility. The policy did not address when a resident should be encouraged or assisted with hand hygiene however did instruct employees when it was necessary for them to perform hand hygiene: - When hands are visibly soiled (hand washing with soap and water); - Before and after eating or handling food (hand washing with soap and water); - Before and after assisting a resident with meals (hand washing with soap and water); - After personal use of the toilet (hand washing with soap and water); - After blowing or wiping nose; - After performing your personal hygiene (hand washing with soap and water).

Based on observations, staff interviews and facility record review, the facility failed to ensure the kitchen's low temperature dish washing machine was operating effectively to include provision of correct chemical sanitizer during one of four days observed (4/8/2024). Findings included: On 4/8/2024 at 9:10 a.m. the main kitchen was toured with the Dietary Manager. The Dietary Manager was asked if she and her staff were at the time operating the dish washing machine. She confirmed they were and she noted the machine was a Low Temperature dish washing machine and operated with wash temperature expectation of 120 degrees F (Fahrenheit). and above, and with rinse temperature expectation of 120 degrees F. and above. She further revealed the chemical sanitizer should always test between 50 and 100 Parts Per Million (PPM). The Dietary Manager pointed out that Dietary Aide Staff A was running crates of dishes through the machine. An interview at that time with Staff A revealed she has been operating the dish washing machine for awhile and was knowledgeable on how it needs to operate. Staff A noted the machine operates with a wash cycle temperature of 120 degrees F., and with a rinse cycle temperature of 120 degrees F. Staff A also noted that the machine has a chemical sanitizer that runs through the machine and the sanitizer when tested, should read between 50 and 100 PPM. Staff A was asked how she knew the machine was a Low Temperature dish washing machine and what the temperature expectations were. She pointed at the front of the machine where there was a sticker that read; Wash Cycle 120 degrees F., Rinse Cycle 120 degrees F. She also revealed she had been inserviced by the dietary manager upon her hire date. She also confirmed she had been inserviced and educated on what the chemical sanitizer should be between; which was 50 to 100 PPM. At 9:17 a.m. on 4/8/2024 Staff A was asked to demonstrate the dish machine operation. She confirmed she had ran several crates of dishes through the machine already and there was no need to prime the machine to operate. After she pushed a crate of soiled dishes through the soiled side of the machine, the wash cycle revealed a temperature of 120 degrees for over ten seconds. The machine clicked and the rinse cycle revealed a temperature of 124 degrees F. for over ten seconds. The machine had an analog temperature gauge attached to the lower front portion of it. The Dietary Manager brought over to the machine a small cylindrical container with litmus paper test strips, (white in color). The Dietary Manager took out a white colored test strip and opened the slot door to the clean side of the machine and dipped the test strip into an internal water catch can. The strip was held for at least five seconds and when she brought the strip out from the machine, the white color test strip was now a deep dark blue/purple color. She took the test strip and placed it on the color legend on the cylindrical container and the color of the strip indicated the sanitizer PPM was well over 100. The Dietary Manager confirmed the machine was allocating too much chemical sanitizer, per the test strip read. Photographic evidence was taken of the test strip and the color legend on the cylindrical container. At 9:20 a.m. on 4/8/2024 Staff A was asked to do a second dish washing machine demonstration. Once she ran another crate of soiled dishes through the soiled side of the dish machine, the wash cycle temperature reached 123 degrees F. for over ten seconds, and the rinse cycle temperature reached 123 degrees F. for over ten seconds. The Dietary Manager then lifted the door lid and placed another new white in color test strip in the machine and placed it on a water spot on one of the clean dishes. The Dietary Manager held the strip in place for about five seconds and then removed it. The test strip was observed to be a very dark blue/purple in color and again, the strip indicated the sanitizer PPM was well over 100. The Dietary Manager again confirmed the strip color was way to dark and she would call the dish machine maintenance company to come out and take a look at the chemical sanitizer delivery system. The Dietary Manger also confirmed she would need to wash all dishes by way of the three compartment sink and they would also use paper and plastic for the next lunch meal service. On 4/9/2024 at 8:30 a.m. the Dietary Manager provided a dish machine maintenance company work order dated 4/8/2024, with a time of 7:21 p.m. The work order revealed; The chlorine sanitizer is reading too strong, and the machine has been shut down until fixed. The service comments revealed; Adjusted the cam timer to get the sanitizer at 75 PPM. The work order also included a pre work photo with a litmus paper sanitizer test strip reading well over 100 PPM and a post work photo with a litmus paper sanitizer test strip reading between 50 - 100 PPM. The Dietary Manager provided the last two months (3/2024 and 4/2024) dish machine temperature log and chemical sanitizer log for review. There were no indications the machine was not running correctly per the review of those logs. Further interview with Staff A at that time confirmed she had not tested the sanitizer this morning and did not know the machine was putting out too much. She revealed she and other kitchen staff will usually test the machine prior to washing dishes and then will document on the dish machine temperature log. She confirmed she had been inserviced to do so, but had not done so this a.m. On 4/11/2024 at 11:00 a.m. the Dietary Manager provided a photocopy of the dish washing machine specification plate, located on the machine itself. The specification plate read; Minimum Wash temperature 120 degrees F., Minimum Rinse temperature 120 degrees F., and Minimum Chlorine Sanitizer 50 PPM. Photographic evidence obtained. On 4/11/2024 at 11:00 a.m. the Dietary Manager also provided the Dish Machine Temperature Log policy and procedure with an effective date of 1/2021. The policy revealed; To monitor dish machine temperatures and chemical saturation (parts per million PPM for both high and low temperature machines at each meal prior to dishwashing to assure proper cleaning and sanitizing of dishes. The procedure continued; 1. Record month and year at the top of the form 2. Send an empty dish rack through the dish machine prior to recording temperature. (a) This allows the water to reach the appropriate temperature. (b) May take 3-4 times. 3. Record wash and rinse temperatures under appropriate meal column and initial. 4. Record chemical saturation level by indicating PPM using the appropriate litmus paper. (a) Required for low temperature/chemical sanitizing dish machines only. 5. Report discrepancies from standard temperatures and chemical saturation to the Food Service Manager. 6. Record action taken in the Comments/Action box if the temperature/PPM is not appropriate. 7. File form in the Food and Nutrition Services Department for one year.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to revise care plans and implement new interventions after falls for one (Resident #4) out of three residents reviewed for falls. Findings included: A review of records showed Resident #4 was admitted on [DATE] with diagnoses including hemiplegia, morbid obesity, lack of coordination, muscle wasting and atrophy, and cognitive communication deficit. A review of the quarterly Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns showed the resident had a Brief Interview for Mental Status (BIMS) score of 3, meaning she had severely impaired cognition. Section G, Functional Status, showed the resident required extensive assistance for bed mobility. A review of the facility's incident log showed Resident #4 had an unwitnessed fall on 7/2/23 at 8:30 a.m. The resident had a second fall on 7/4/23 at 10:53 a.m. A review of medical records revealed a progress note dated 7/2/23 at 9:04 a.m. This was an Initial Event Note that showed resident #4 had an unwitnessed fall on 7/2/23 at 8:30 a.m. The event was described as the resident was having breakfast and rolled off the bed. The resident was unable to describe the events. The intervention of a low bed was initiated. A review of records showed the care plan was never updated to add the low bed intervention after the fall on 7/2/23. The incident log showed the resident had an additional fall two days later, on 7/4/23 at 10:53 a.m. A progress note, dated 7/4/23 at 11:01 a.m. showed the resident's family member said the resident slipped out of bed. The physician was notified and gave an order to transfer the resident to the emergency room. Records show the resident returned from the hospital the same day with no new orders. The care plan did not show any interventions put in place on 7/4/23. The Initial Event Note was entered into the record on 7/5/23 at 7:54 a.m. The note showed the resident had a witnessed fall on 7/4/23 at 9:15 a.m. The location of event was shown as room. The resident was not able to provide a description of the event. There was no additional information about what happened to Resident #4. The note added the resident was not assisted from the floor. The resident was noted to be able to transfer from the floor with the assistance of a mechanical lift. The last time the resident was toileted: 7/5/23 8:00 AM. Please note the following intervention or interventions initiated: Low Bed. A review of records showed the care plan was never updated to add the low bed intervention after the fall on 7/4/23. A progress note was entered on 7/7/23 at 11:01 a.m. by the Director of Nursing (DON.) The note showed the IDT (Interdisciplinary Team) met to discuss resident being observed on the floor on 7/2/23 and 7/4/23. Interventions include bolsters to air mattress for positioning due to poor trunk control. As of the record review on 7/13/23, Resident #4's care plan did not include Low Bed. The resident was observed in her bed multiple times throughout the day on 7/13/23 with her bed at a normal height, not in a low position. An interview was completed on 7/13/23 at 12:15 p.m. with Resident #4's family member. He stated the resident had fallen out of bed twice. He said he was with the resident when she fell the second time. He said he was sitting on one side of the bed and the resident slipped off the other side. He said he was unable to get to her before she fell. He said he felt like the mattress was part of the problem. An interview was conducted on 7/13/23 at 3:53 a.m. with the DON. The DON said bolsters were added to Resident #4's bed on 7/5/23. She confirmed low bed was listed as an intervention that was supposed to be put in place after the fall on 7/2/23 and 7/4/23. The DON reviewed the care plan and confirmed it was not listed and it should have been added to the care plan by the nurse after the first fall on 7/2/23. The DON said when a resident falls on the weekend, the nurse notified the nurse manager on call and discussed the fall and interventions with them. The nurse could then update the care plan accordingly. She said when the IDT met to discuss the falls, they must not have noticed low bed was not in the care plan. A facility policy titled Fall and Injury Reduction Policy, dated March 2023, was reviewed. The policy stated the following: Overview: The facility has designated and implemented processes, which strive to reduce the risk for falls and injuries. Status post witnessed/unwitnessed fall or observed on floor event. Serious Injury 1. If there are signs/symptoms of serious injury, provide first aide if needed. 2. Ask the resident and/or witnesses what happened. 3. Obtain vital signs and document in the medication record. 7. Notify the resident representative of the fall, new interventions, and/or care given or location transferred. 8. Update the care plan with new interventions, communicate to the care staff to the oncoming nurses and CNA's during shift-to shift report. 11. Document the event in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to maintain complete and accurate documentation for two residents (Resident #7 and #2) out of seven sampled residents. Findings included: A review of Records showed Resident #7 was admitted on [DATE] with diagnoses including muscle wasting and atrophy, lack of coordination, dementia, and Alzheimer's disease. A review of the admission Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns showed the resident had a Brief Interview for Mental Status (BIMS) score of 99, meaning the interview was unable to be completed. Section G, Functional Status, showed the resident required limited assistance with 1-person physical assist with walking. A review of the facility's incident log showed Resident #7 had a fall on [DATE] at 10:31 a.m. A review of progress notes revealed the following: [DATE] 10:35 a.m.: PT lose [sic] the balance fell and hit the floor hard with his head. Dose not move from the floor, the MD is called, he orders transfer to ER family notify. 911 is called. [DATE] 2:21 p.m.: Patient returns and does not present any new orders family and MD is notify. [DATE] 9:01 a.m.: IDT met to discuss resident's fall on [DATE]. Resident was in the facility less than 24 hrs and not yet familiar with surroundings. [Resident #7] has dx of Alzheimer's and dementia. New interventions to include medication review with psych. NP and RP aware and agree with plan of care. [DATE] 10:22 p.m.: Patient returned form hospital approx. 1700 (5:00 p.m.) No new orders. Patient is a fall risk. One on one in place. Bed at lowest positions. Will continue to monitor. An interview was conducted with the Nursing Home Administrator (NHA) on [DATE] at 10:30 a.m. He stated Resident #7 fell on [DATE] and was sent to the hospital. He said they provided care to the resident, and he came back to the facility the same day with no new orders. He said the resident had been in the facility less than 24 hours before he fell. An additional interview was conducted on [DATE] at 1:00 p.m. with the NHA and the Director of Nursing (DON.) They both agreed when Resident #7 fell on [DATE] he returned to the facility the same day. They said this was his only fall. The DON also confirmed the Interdisciplinary Team (IDT) reviewed the fall on the morning of [DATE]. The DON and NHA did not know why there was a progress note in the record stating the resident came back from the hospital on [DATE]. They both stated they were going to look into it. At 2:15 p.m. the DON reviewed the record and was shown an Emergency Medical Services report from [DATE] and an emergency room After Visit Summary from [DATE]. She confirmed there is no additional information in the record about why the resident went to the emergency room on [DATE]. She stated she was unaware of anything happening. At 3:35 p.m. the DON stated she spoke with the nurse caring for Resident #7 on [DATE]. The nurse said she sent the resident to the hospital after he fell. The DON said the nurse did not document anything about the fall or report the fall to the supervisors. The DON said there was nothing completed under Risk Management either. She stated the nurse should have notified the DON, done a risk report, documented what happened, notified the doctor and the family. The DON said the resident had medications reviewed on [DATE] after the fall and labs were ordered, but the resident refused. The DON confirmed there was not IDT review or interventions put in place after the fall on [DATE] because they were unaware it happened. A review of admission records showed Resident #2 was admitted on [DATE] with diagnosis including major depressive disorder, malignant neoplasm of cervix, anxiety, altered mental status, muscle wasting and atrophy, senile degeneration of brain. A review of progress notes showed the following: [DATE] 12:36 a.m.: Dr. ordered Venous Doppler for edema. [DATE] 8:47 p.m.: COVID positive note. Resident placed on droplet precautions. There was no additional notes or evaluations in the record until [DATE] at 3:18 p.m. that stated, Hospice aid came in assisted with total care. On [DATE] at 6:40 p.m. a note showed, The resident is observed to by hypoactive. Vital signs are taken, reflecting and pulse and low saturation, the hospice is notified, who order 2 liters cannula oxygen, the family member who come [sic] here is notified. Hospide [sic] nurse come to assess resident. A review of the electronic and closed record did not show any hospice notes past [DATE]. An interview was conducted on [DATE] at 4:30 p.m. with the DON. The DON was asked why there was no documentation of care for Resident #2 from [DATE], when she tested positive for COVID, until [DATE] stating hospice provided care. She stated they implemented enhanced monitoring for the resident on [DATE], which includes vitals and observing for signs and symptoms of COVID. She said they are basically doing the charting on their monitoring. She said the resident had been declining but she did not remember how many days before her death on [DATE] she began to decline. The DON said the hospice notes should be in the record. She reviewed the residents record and was unable to find notes after [DATE]. Documentation was provided showing Resident #2's temperature and oxygen saturation were checked daily. Her heart rate and blood pressure were documented on [DATE] and [DATE]. A facility policy titled Charting and Documentation, revised [DATE], was reviewed. The policy stated the following: Services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Guideline: 1. Guidelines for implementation entries may only be recorded in the resident's record by licensed personal (e.g. RN LPN/LVN, physicians, therapist, etc.) in accordance with state law and facility policy. 2. Incidents, accidents, or changes in the resident's condition must be recorded. 3. For skilled residents, documentation will occur at least daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure residents had access to call lights that were functional for two (Residents #5 and #4) of four residents. Findings included: 1. On 07/13/23 at 10:48 a.m., Resident #5 was observed sitting on her bed. She stated sometimes it took staff a long time to respond to her call light. The resident did not know if there was problem with the call light or not. The Nursing Home Administrator (NHA) asked Resident #5 to activate her call light. The light outside the resident's room did not light up. The NHA stated they would replace the bulb and audit all call lights. The NHA confirmed if a staff was not at the nurse's station at the time the resident was calling, they would not know the resident needed help. The NHA stated the nursing staff conduct frequent rounds. A review of Resident #5's record revealed the resident was admitted to the facility on [DATE] with diagnosis of benign neoplasm of cerebral meninges, Epilepsy, hyperlipidemia, Type 2 diabetes with autonomic neuropathy, muscle wasting and atrophy. A minimum Data Set (MDS) for Resident #5 showed in Section C a Brief Interview for Mental Status (BIMS) score of 04, indicating severe impairment. Section G showed the resident is dependent on staff for toilet use and hygiene and requires limited assistance of one staff member. 2. On 7/13/23 at 12:15 p.m., an interview was conducted with Resident #4's family member. He stated he was concerned about her ADL (Activities of Daily Living) care. He said, It takes a while for staff to answer call bells. I document when she pushes the button and why. I don't know if [Resident #4] is capable of using the call bell if she needed to get staff attention. The family member stated when he would visit, he was the one that had to push it for her. He said, She also has a sacral wound that she got at another facility., but they do not reposition her at all. He said he had been at the facility since 9:00 a.m. and she had been in the same position. He stated when he was concerned that [Resident #4] did not have the ability to call staff for assistance and they were not checking on her. A review of Resident #4's record showed the resident was admitted to the facility on [DATE] with a diagnoses to include Hemiplegia and Hemiparesis, morbid severe obesity, narcolepsy, muscle wasting, cognitive communication deficit, atherosclerotic heart disease and presence of cardiac pacemaker. An MDS for Resident #4 dated June 5, 2023, showed a BIMS score of 03, indicating severe impairment. Section G showed the resident was totally dependent on staff for toilet use and personal hygiene, requiring 2 person's physical assistance. On 07/13/23 at 12:35 p.m., an interview was conducted with Staff A, Occupational Therapist (OT) who was in Resident #4's room assisting her with eating. Staff A was asked to confirm this resident's ability to use the call light. The call light was noted with a cylinder type hand-holder with a button on top. The resident would have to hold the cylinder on top and use her thumb to press the call button for assistance. Staff A asked the resident if she knew how to use the call bell and the resident said no. Staff A got the resident to put the call light in her hand and asked the resident to push the button. The resident was observed trying multiple times with one or two hands and was unable to push the call light button. The resident held the call light in one hand and attempted to push the button with the same hand and was unable. She then attempted to push the button with the second had and was unable to coordinate both hands to hold the call light and push the button. Staff A stated she had only worked with this resident a couple of times. She stated she would speak with the nurse and see about getting the resident a different style call light. Staff A confirmed the resident was not able to push the button on the call light. A review of a facility's document titled, Grievance/Concern log, dated April 2023 showed Resident #4's family member had filed grievances on 04/07/23 and 04/10/23. A review of the grievance log dated 04/07/23 showed the family member expressed concerns about the duration of unanswered call lights and the resident's inability to make her needs known. On 04/07/23 at 12:48 p.m., an interview was conducted with the Social Services Director (SSD). She stated the family member had expressed concerns related to excessive delays in answering call lights as he watched, and [Resident #4's] inability to manipulate the call light due to physical limitations. The SSD said, his main focus was the call light he stated she could not turn it on, and no one was checking on her. The SSD stated her response was to the CNAs. She stated they said sometimes they were busy assisting other residents and that was why there was a delay. She stated the nurse educated all CNAs. The NHA stated they did not assess the resident's ability to use the call light and they did not conduct any audits. The NHA stated they had just initiated the audits. On 07/13/23 at 2:16 p.m., an interview was conducted with Staff B, OT and Staff C, ST (Speech Therapist). They stated therapy had assessed Resident #4 clinically, to determine if the resident had fine motor skills and the ability to manipulate utensils which carries over to using a call light. Staff B stated their assessment had determined the resident was able to feed herself but needed cueing for attention to the task. She stated the resident had severe dementia. She stated the resident would need cuing to train the brain for use of a call light. Staff B stated they did not assess the resident's ability to use the call light. She confirmed a resident should have an equipment they are able to use. On 07/13/23 at 2:32 p.m., an interview was conducted with the NHA. He stated the Director of Maintenance (DOM) had conducted a full house call light audit. He stated Resident #4 had received a different style of call light that she can operate. He stated during their audit they switched out some call lights for residents who were not able to manipulate the call light button to one that they just squeeze the button. He stated they had found two call lights that were not working, one in the memory care shower room and one in the family room in the memory care unit. The NHA stated they conduct call light audits monthly but will move to weekly audits. On 07/13/23 at 4:15 p.m., Surveyor requested the facility's policy on call lights. The NHA stated they did not have one. Review of a facility policy titled, Safety and Supervision of Resident, dated 05/31/18 showed staff shall make routine resident checks to help maintain resident safety and well-being. Residents safety, supervision, and assistance, to prevent accidents are facility wide priorities. (3) Routine resident checks by nursing staff involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, policy and record review, the facility failed to ensure that a safety device of a protective smoking apron was worn for one (1) resident (Resident #29) of six residents who smoke, failed to ensure the red metal smoking receptacle in the smoking area contained only smoking butts, for two of four days (02/01/2022 and 02/04/2022); and failed to follow their policy related to providing a safe smoking environment by not placing a required smoking fire blanket in the smoking area for three of four days (02/01/2022, 02/02/2022 and 02/03/2022) observed during the survey. Findings included: On 02/01/2022 at 11:02 a.m., an observation was conducted of Resident #29 seated in a chair on the smoking patio. The resident was observed to be supervised by an unidentified staff member. Resident #29 was not wearing the smoking device of a safety apron while smoking. During the observation, the red metal smoking butt receptacle located on the smoking patio, was opened by the surveyor, which contained cigarettes, four (4) empty cigarette packages of which two (2) were red and two (2) green in color, with one white plastic knife in with the cigarette butts. A safety smoking blanket was not located in the smoking area. It was observed to be located where residents perform activities next door to the smoking patio. (Photographic Evidence Obtained.) During an observation conducted of facility smoking area on 02/02/2022 at 9:05 a.m., Resident #29 was smoking without a safety apron on and was being supervised by Staff A, Certified Nursing Assistant (CNA). The smoking safety blanket was seen again located in the same area as the previous day. An immediate interview was conducted with Staff A, (CNA) who was asked what her duties were while she was supervising the residents in the smoking area. Staff A, (CNA) stated I supervise them, and give them their cigarettes that are locked up, I document how many they started out with and how many they completed smoking. I also disinfect the tables, I do not empty the ashtrays or the red bins, the housekeeper does that. Staff A (CNA) indicated that the smoking safety blanket was in another room. A subsequent observation was conducted on 02/02/2022 at 11:17 a.m. conducted during the 11:00 a.m. -11:30 a.m. smoking time frame, which revealed that Resident #29 was not wearing the smoking apron and the smoking blanket was not seen to be in the smoking area. Record review of the care plan dated 11/17/2021, indicated Resident #29 should be observed for smoking safely by staff, and required an apron to be worn while smoking. The intervention was initiated on 01/10/2022. Review of the Quarterly Minimum data Set (MDS) dated [DATE], indicated the Brief Interview for Mental Status (BIMS) Score was 15, (on a 1-15 score range) indicating cognitively intact. On 02/02/2022 at 01:41 p.m., an observation was conducted of Resident #29 and the smoking area. Resident #29 was seen having his cigarette lit by Staff A, (CNA), and was not wearing a smoking apron. The smoking blanket was not observed to be in the smoking area. An observation was conducted on 02/03/2022 at 09:05 a.m. of Resident #29 not wearing a smoking apron while smoking, and the smoking blanket was not in the smoking area. An interview was conducted with the Director of Nursing (DON) on 02/03/2022 at 11:30 a.m. During the interview the DON confirmed that the fire blanket was not located in the smoking patio. At 11:38 a.m. the DON was asked about Resident #29 not wearing a smoking apron while smoking, as indicated in his care-plan. She stated I put in smoke with a smoking apron, because of an audit done that day, I am not sure why it was done. On 02/03/22 at 11:59 a.m., the DON stated I put up the fire blanket in the smoking area, and the smoking book shows that Resident #29 needs to be wearing an apron. The CNA should be giving the resident the apron. I will re-valuate him today at 1:30 pm to see if he really needs to wear the apron. On 02/03/2022 at 01:36 p.m., an observation was conducted of Resident #29 wearing a smoking apron, and the DON watching the resident while typing on her laptop. Staff A, (CNA) was outside supervising the resident at the time. On 02/04/2022 at 12:23 p.m., an observation was conducted of the red aluminum smoking receptacle containing two white pieces of unidentified material on top of the smoking butts. (Photographic Evidence Obtained.) An immediate interview was conducted with the NHA, who confirmed the presence of the material on top of the smoking butts, that should not be in there and stated, I just did training on this on Tuesday (2/01/2022), I would expect that they place nothing but cigarette butts in the red can and put in the garbage can other items. A review of Facility Policies and Procedures, Topic: Smoking/Tobacco Use Dated: October 2017, Pages 01-03 of 04, read as follows: POLICY: The objective of this policy and procedure is not to discourage or restrict one's smoking privileges, but to promote safety for residents, visitors, and employees within the facility. EMPLOYEE EXPECTATIONS: -Monitor residents in the smoking area -Ensure appropriate adaptive smoking equipment is available and in use for residents as care planned -Provide a smoking fire blanket and fire extinguisher (water) within the designated smoking area SMOKING SAFETY: 3. Donning a smoking apron is encourage for residents that smoke, but not required unless deemed necessary by the interdisciplinary team during individual review. 6. Remain with the smoker until the end of the smoking session and the cigarette has been successfully distinguished.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility policy and record review the facility failed to ensure that a resident centered care plan was developed and implemented related to hospice care for one resident (#90) of seven residents receiving hospice care. Findings included: On 11/03/2020 at 8:00 a.m., Resident #90 was observed to be lying in bed and indicated that he was being followed by hospice, for one of many diagnoses that he was admitted into the facility with. A medical record review for Resident #90 indicated that he was admitted on [DATE] with multiple diagnoses that included amyotrophic lateral sclerosis (ALS), quadriplegia, chronic inflammatory polyneuritis, and tachycardia. A review of the November 2020 Clinical Physician Orders revealed that Resident #90 was to be on a plan of care with Hospice Provider dated 10/14/2020. Record review of the admission Minimum Data Set (MDS) dated [DATE], identified in Section C, that Resident #90's Brief Interview for Mental Status (BIMS) score was 14, which indicated no cognitive impairment. Section O for Special Treatments, Procedures and Programs listed under 0100, K. Hospice Care while a resident in the facility. Further record review of Resident 90's active care plan dated 10/14/2020, with several revisions since admission did not include a focus area for hospice care with measurable goals and interventions/tasks to be followed by facility staff. On 11/6/2020 at 7:54 a.m., an interview was conducted with the Senior Clinical Reimbursement Director, temporarily filling in for the Care Plan Coordinator, who confirmed that Resident #90 was not care planned for hospices services. She further revealed that once a resident's physician orders, and MDS are changed, the care plan should also be adjusted at the same time. A review of the facility policy titled, Care Plan - Interdisciplinary Plan of Care from Interim to Meeting, with an effective date of March 2017, C.1, Pages 01- 02 of 04 read as follows: POLICY: The facility shall support that each resident must receive, and the facility must provide the necessary care plan and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence (e.g. palliative approaches in the end of life situation, coordination with the Hospice plan of care. 2. Daily Updates to Care Plans a. Daily updates to care plans are added by each member of the IDT at the time the change is implemented, the intervention is needed, or other care plan revision is indicated. Accuracy of the care plan is validated by the IDT during the daily clinical meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure therapy devices (splints) were applied to contracted limbs to maintain, and prevent, a decrease in range of motion for two residents (#57 and #45) of thirteen residents sampled as evidenced by: 1) For Resident #57, the facility did not ensure the right-hand splint was available for use by direct care staff and applied per therapy discharge orders to prevent further wrist and hand contracture. Additionally, the facility did not evaluate and update Resident #57's care plan to determine if the ordered ankle foot orthoses was required to prevent decreased mobility in the right lower extremity, and 2) For Resident #45, the facility failed to ensure direct care staff assisted with the application of the left-hand splint to maintain range of motion. Findings included: 1) Resident #57's admission Record revealed an initial admission date of 01/11/19 with admitting medical diagnoses of phlebitis and thrombophlebitis of other deep vessels of right lower extremity, altered mental status, personal history of traumatic brain injury, other reduced mobility, and stiffness of right hand, not elsewhere classified. Additional medical diagnoses with an onset date of 06/22/20 showed contracture of the right wrist and right hand, muscle washing, and atrophy. Resident #57's Minimum Data Set, dated 09/18/20, Section C: Cognitive Patterns revealed a Brief Interview of Mental Status score of 4, indicating disorganized thinking with difficulty in recall. Section G: Functional Status revealed that Resident #57 requires extensive assistance with one-person assistance for dressing and bed mobility. Resident #57 has total dependence on direct care staff for assistance with transfer and locomotion on the unit. Resident #57's Active Orders for November 2020 revealed a physician order, order date of 03/17/20, to, Apply right hand/wrist splint daily per patient tolerance. Remove and check skin every shift every day and evening shift as tolerated. OFF at night. Further review revealed, a physician order dated 02/28/20, Apply Right AFO [Ankle Foot Orthoses] when out of bed daily per patient tolerance. Remove and check skin every shift every shift remove for skin checks every shift. Resident #57's Care Plan, initiated on 01/28/20, revealed a focus of, ADL [Activities Daily Living]: The Resident has an ADL Self Care Performance Deficit as Evidence by: impaired mobility- right side . Interventions included, Apply Right AFO when out of bed or per patient tolerance . Right wrist/hand splint daily or per patient's tolerance. An observation on 11/04/20 at 12:00 p.m. revealed Resident #57 was sitting in a wheelchair inside of his room. His right hand was placed by his side and was contracted at the wrist with the fingers curled into a fist. The resident was not wearing a hand splint or a boot splint. An observation on 11/05/20 at 3:14 p.m. with an attempted interview with Resident #57 revealed a limited ability to communicate. The resident was lying in bed. He mainly responded to questions by shaking his head up and down for yes or side to side for no. When the resident was asked to open his right hand, he responded by smiling and lifting his left hand, opening and closing the fingers without assistance. An observation revealed the right hand tucked by the resident's side, contracted with no hand splint in place. An observation and interview on 11/06/20 at 7:05 a.m. revealed Resident #57 was lying in bed with the left hand on top of the bedsheets, and the right hand was underneath the bedsheets an unable to be seen from the hallway. When asked if he was wearing his hand splint, he squinted his eyes and shook his head no (from side to side). He lifted his left hand, opened and closed the fingers while smiling. He then slowly used his left hand to lift his right arm from underneath the covers to reveal the contracted right hand and wrist with no splint in place. A follow-up observation at 8:40 a.m. revealed Resident #57 was sitting in a wheelchair outside of his room without a foot or hand splint in place. Resident #57's OT [Occupational Therapy]-Therapist Progress & Discharge Summary, dated 07/25/20, page 2, section: Prosthetic/Orthotic Use revealed, The patient will tolerate R [Right] UE [Upper Extremity] wrist/hand orthosis for 6 to 8 hours and to tolerance without redness, swelling, or chaffing in order to properly position patients wrist/hand/digits due to contracture and hemiplegia End of Goal Status as of 07/25/2020 . the patient tolerates donning/doffing of R UE wrist/hand orthosis up to 6 hours without skin irritation or c/o [complaints] pain. Resident #57's PT [Physical Therapy]- Therapist Progress & Discharge Summary, dated 09/08/20, page 4, section: Precautions revealed, High fall risk. R [Right] sided spastic hemiplegia. Expressive aphasia. Single step commands. H/O TBI [History of Traumatic Brain Injury]. R arm trough on w/c [wheelchair] and R AFO when OOB [out of bed] . Record review revealed no instructions to discontinue the AFO boot. Resident #57's Splinting Program Form, with a start date of 3/24/19, revealed instructions to, R [Right] hand splint don/doff by CNA [Certified Nursing Assistant] staff daily on in AM (morning) ; off in PM (night), to tolerance. An interview on 11/06/20 at 9:11 a.m. with the Director of Rehabilitation (DOR) confirmed Resident #57 was discharged from PT on 09/08/20 and discharged from OT on 07/25/20. The discharge plans for PT and OT were to provide caregiver training on proper techniques for safe transfers, assisting the resident on getting out of bed. Precautions included wearing the AFO boot when out of bed and wearing a right-hand splint. The DOR stated that CNAs are responsible for applying the splints. To assist with this process every unit has a splint book with a picture the resident's splint and how to apply it. The splints are preventative devices. The DOR stated Resident #57's resting hand splint maintains the space between the finger digits and the wrist in the proper position. Overtime if the wrist continues to have over-flexion, it can break. Resident splints are kept in the residents' room. The DOR confirmed that for Resident #57, the CNA would have to place the splints on, he would not be able to do it himself. An interview and observation was conducted on 11/06/20 at 9:31 a.m. Staff M, CNA stated he floats units, meaning he works various units in the building to assist where needed. Staff M, CNA has been assigned to Resident #57's hallway for the past week, and was assigned to provide direct care to Resident #57. Staff M stated Resident #57 is accepting of care and doesn't acknowledge any pain. The resident might grimace when the mechanical lift is used, but overall is able to tolerate it. Staff M stated he uses a rolled-up towel for Resident #57's hand contracture and that the boot is worn while in bed; splints are kept in the resident's room. Staff M proceeded to Resident #57's room to confirm the presence of the splints. Upon room investigation, Staff M produced a cone splint, which did not offer wrist support, and a padded foot support device. Staff M stated that the cone splint was the only splint available in the resident's room over the past week, and the splint with the wrist support has not been in the room. During a follow-up interview on 11/06/20 at 9:43 a.m. Staff M stated that Resident #57 could wear the AFO boot both in and out of the bed. Staff M confirmed that therapy provides education on how to apply the splints. Resident #57's Treatment Administration Record for November 2020 revealed treatments to apply the right hand/wrist splint daily and to apply the right AFO when out of bed daily. Review of 11/01/20, 11/02/20, 11/03/20, 11/05/20, and 11/06/20, revealed check marks for all treatment order times and days. Check marks indicated the treatment was administered. During an interview on 11/06/20 at 10:54 a.m. the DOR said, When it comes to the cone splints, or using a towel, is that, they do not address the wrist portion. So that would be okay with a resident that's wrist is not contracted or is straight. The DOR confirmed that the AFO boot should only be worn while out of bed, saying, It should not be worn in bed because it may cause skin break down . I know the note [Therapy Note] states that the boot should be worn out of bed. A follow-up interview on 11/06/20 at 1:26 p.m. with the DOR confirmed the padded foot support in Resident #57's room was not an AFO boot, but a device used to prevent pressure ulcer development. An interview on 11/06/20 at 11:00 a.m. with the Director of Nursing confirmed that the expectation would be to follow therapy instructions, the care plan, and physician orders in place for a resident. During an interview on 11/06/20 at 11:19 a.m. the DOR stated that Resident #57 arrived at the facility with the AFO boot, but never wore it. Resident #57 was being screened to determine if the AFO boot is necessary or if it can be discontinued. The DOR stated Resident #57's hand splint was found in the therapy room in a laundry bag. An interview was conducted on 11/06/20 at 1:05 p.m. The Regional Nurse stated since therapy is contracted, the facility does not have a policy on therapy, splints, or range of motion. The Regional Nurse provided Splitting Program Instructions, stating it discusses education that should be provided to CNAs regarding applying a splint. A review of the facility policy titled, Splinting Program Instructions, no date, revealed, Complete the splinting program form. Include a picture of the splint showing how it is worn, complete all the sections, at time of discharge or the visit before discharge have charge nurse sign and CNA's . Have the in-service sheet completed for daily education that was performed leading up to discharge. Show multiple days of education and multiple shifts education . complete the therapy request for orders and have signed on the day of discharge . A review of the facility policy titled, Physician Orders, dated February 2020, revealed, At the time each resident is admitted , the facility will have physician orders for their immediate care. Physician orders will be dated and signed at next physician visit. Nurses, therapists and pharmacists may take verbal and/or telephone orders as permitted by their State licensure board Assigned nursing staff will complete a monthly review to ensure physicians orders are captured accurately on the monthly physician's orders. Identified errors or discrepancies should be clarified. This process should be completed 3 days before the end of the month. Reviewed to ensure scheduling of the medication, treatment, etc. entered correctly. 2.) On 11/3/20 at 9:30 a.m. Resident #45's room was approached and he was observed in his bed with an over the bed table positioned over his lap. He was observed with his left arm and hand positioned on his lower stomach area, under the over the bed table. His right hand and arm were positioned on the surface of the table. Further observations revealed a soft hand splint positioned on a box of personal items, near his bedside window. He was not observed wearing a splint on either of his hands. Additionally that day at 11:00 a.m., 12:56 p.m. and at 2:20 p.m. the resident was again observed in his room, while seated in his wheelchair and neither of his hands were observed with a splint applied. Further, the soft hand splint was observed placed in a box of personal items, near the bedside window. On 11/4/20 at 7:20 a.m., Resident #45 was observed in his room and in bed and not wearing a hand splint on either hand. Resident #45 was observed in his room at 8:01 a.m., seated in his wheelchair with the over the bed table placed in front of him. He was observed eating his breakfast meal and only using his right hand. His left hand and arm were observed positioned on his lap with no movement. His left hand was observed to contracted. The soft splint was again observed in the same previously observed spot, on a box of personal items near the bedside window. Various staff, to include his assigned CNA, Staff D and the unit nurse, Staff A, Registered Nurse (RN) had been observed in the room talking and communicating with the resident. None of the staff were observed to offer Resident #45 the left hand splint. On 11/4/20 at 9:10 a.m. Resident #45 was observed in a wheelchair and self-propelling up and down the hallway and using his right foot and right hand to propel the wheelchair. His left foot was resting on a foot pedal and his left hand and arm resting on the left wheelchair padded bolster. He was again observed not wearing a left hand splint. On 11/4/20 at 10:03 a.m. Resident #45 was observed in his room and seated in a wheelchair. His left arm was resting on the left armrest with the padded bolster. His left hand was hanging down towards his lap. He was noted not wearing his left hand splint. The splint was observed placed on a box of personal property near the window. The splint had been observed in the same place since 11/3/2020. On 11/4/20 at 11:45 a.m. Resident #45 was observed in his room and received a lunch meal tray. He was observed to eat with his right hand and with his left hand and arm resting on the bolstered arm rest. He was not moving his left hand and or arm. Further, the left hand splint was still not on resident's hand and was still observed placed on a box of personal property. On 11/4/20 at 12:47 p.m. Resident #45 was observed self-propelling up and down the hallway very slowly using his right hand and right leg to self propel. He was observed still not wearing the left hand splint. The splint was again observed placed on a box of personal property. On 11/4/20 at 12:50 p.m. Resident #45 was observed in his room using his right hand to write with a pen to paper. He was asked about the use of his left hand and he said, I can't really move it. He was asked if he wears anything on his left hand and he pointed over to the hand splint, that was placed on a box of his personal items. Resident #45 was asked if he wore it. He said that he did and needs help putting it on. He was asked when was the last time he wore it. Resident #45 replied,I don't know, it's been awhile and they don't help me with it. He said that he could wear it and it makes his hand feel better, but after awhile it hurts and he has to take it off. On 11//6/20 at 7:50 a.m. Staff B, CNA was observed to assist Resident #45 while he was seated in his wheelchair to the 400 hall dining room to be weighed. He was observed wearing his left hand splint. He was asked about his splint and he said, Yeah they helped me with it today, probably because you (state) is here. He further indicated that he was not helped to put it on for awhile that he could remember. He also confirmed that he appreciates having the splint on today and it makes his hand feel better. He said he has not had problems with wearing the splint and had no discomfort at that time. On 11/6/20 at 8:00 a.m. an interview was conducted with Resident #45's CNA, Staff D. Staff D confirmed that Resident #45 utilizes a hand splint. She confirmed that she did not put it on today, and didn't know who put it on. She did not believe Resident #45 has ever refused the splint and has seen him wear it at times. She did not know who's responsibility it was to apply the splint to his hand on a daily basis. On 11/6/20 at 8:45 a.m. an interview with the Restorative Aide, Staff B revealed she does the restorative program with residents and confirmed Resident #45 wears a left hand splint. She was unsure what the order was; if he was to wear it at night or during the day. She said residents who wear the splints all have different times to wear them. She did say that Resident #45 was already up this morning and had the left hand splint on when she went to get him for monthly weights. She was unsure who got him up for the day and applied the left hand splint. On 11/6/20 at 9:10 a.m. an interview with the 300 unit nurse, Staff C, RN. She confirmed that Resident #45 wears a left hand splint. She was asked if Resident #45 has ever presented with any behaviors of refusing to wear the left hand splint. Staff C revealed that she does not think Resident #45 has ever refused wearing the splint. She indicated that it is the responsibility of all nursing staff to assist with applying splints to residents. She did not know who applied Resident #45's splint this morning. On 11/6/2020 at 10:10 a.m. an interview with the Director of Nursing (DON), Assistant Director of Nursing (ADON) and MDS Coordinator was conducted and it related to Resident #45's left hand splint and who's responsibility it was to ensure it is offered and assisted with on a daily basis. The DON explained that in Resident #45's case, he is to have the left hand splint on daily, but as tolerated. The MDS Coordinator, the ADON and the DON could not confirm there had been any behaviors, or refusals by Resident #45 with reference to wearing the splint. They looked through the record and could not find any evidence he had ever refused the splint. The DON and ADON confirmed that usually the CNA would be responsible for putting on and taking off the splint, and if a resident were to refuse, that they should notify the nurse, so the behavior could be documented. The MDS Coordinator revealed that the resident was documented with behavioral care plans, but nothing related to refusing wearing the left hand splint. A review of Resident #45's medical record revealed he was admitted to the facility on [DATE] for long term care and resided in the secured dementia unit. Review of the diagnoses sheet revealed diagnoses to include: hemiplegia, contracture multiple sites, lack of coordination, stiffness elbow shoulder (L), and muscle wasting. Review of the current Physician Order Summary dated for the month of 11/2020 revealed: Enabler to right side of bed which is medically appropriate due to promotion of bed mobility; half lap tray to wheelchair while out of bed; Left hand splint daily per tolerance. Remove and check skin each shift (original order date 2/24/2020). Review of the last Occupational Therapy certification period assessment 8/5/2020 to 10/6/2020 revealed that Resident #45 had an onset diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Precautions included: Fall risk, Left sided weakness. Left wrist/hand contracture with Left hand splint on daily as tolerated. Review of the current care plans with the next review date of 11/11/2020 revealed the following areas: - ADL self care deficit and with impaired mobility Left side deficit, communication deficit and cognition deficit with interventions in place to include: Left hand splint on daily per md tolerance, Remove and check skin every shift, Left padded armrest bolster in wheelchair, offer to cut up food - Range of Motion (ROM) resident is at risk for developing and or has an impairment in functional joint mobility because of actual impairment Left hand, with interventions to include: Apply hand splint to Left upper extremity per therapy recommendations, splint to Left hand, Splint application: Left grip splint to be worn daily as tolerated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and review of the facility policy and plan of correction, the facility's Quality Assessment and Assurance committee failed to ensure that interventions for the plan of correction for splinting devices were comprehensively implemented by not ensuring the splinting devices were ordered, in place, or care planned for three residents (#1, #3 and #2) out of a total of six sampled residents. Findings included: A review of the facility's policy and procedure titled, Quality Assurance/Quality Improvement (QAPI), dated November 2019, revealed: The purpose of the Steering Committee is to review and analyze facility related data (See Agenda) and direct appropriate actions for the facility response. The appointment of a QAPI team may be necessary to explore the depth of the issue and identify the root cause so that interventions are appropriately resourced . Team members should be knowledgeable about the process/systems used that contribute to the assignment . The Steering Committee will provide the QAPI team the appointment and resources to review, inspect, validate and analyze concerns related to the assignment. A review of the facility's plan of correction revealed a completion date of 12/4/2020. The plan of correction stated, The Director of Nursing (DON)/Designee conducted an audit and observation of current residents with splinting devices and ensured devices are ordered, in place, and care planned. The facility audit was reviewed for splints with the criteria of, Recommendation in place and carried out for splint in [electronic medical record]. The audit did not reveal that splinting devices were ordered per the plan of correction as indicated. An interview was conducted at 2:29 p.m. with the Unit Manager that identified herself as a Registered Nurse (UMRN). She was asked about resident orders for splinting devices that were discontinued. She stated, Therapy are only recommendations. Like the standing orders for PT (physical therapy) to eval (evaluate) and treat. After the therapy department has finished with the resident, they only give recommendations for the splint. The recommendations are placed on the certified nursing assistant task list. She confirmed that certified nursing assistants can follow a recommendation, but they cannot perform a physician order. The UMRN went on to say, The MD [medical doctor/physician] orders were not consistent with the care plan. So, it would be easier to just delete the MD orders. An interview was conducted at 2:40 p.m. with the Nursing Home Administrator and she confirmed the therapy orders for splints were discontinued. She stated, Our corporate stated to discontinue the MD order. As they are only a therapy recommendation. An interview was conducted at 3:46 p.m. with the Director of Rehabilitation on their process for recommendations for a splinting device for a resident. She said, after it had been determined a resident needs a splint our process is to notify the physician and get an order. She was asked about the physician order as she stated, It's our protocol in therapy department to get a physician order. We can't just put a splint on them. We have to get a physician order. She went on to say after we receive the order, we hand it off to the nursing department. The nursing distributes the task to the staff that are available per day. The Director was asked about the facility discontinuing physician orders for splints. She stated, I was not aware that the facility was deleting the physician orders for splints. 1. On 12/21/2020 at 10:20 a.m. an interview was conducted with Staff B, Restorative Aide and she stated part of her job, . is to make sure residents are wearing their splints. She was asked if she had any recent training on splints and she stated, No. She was asked how she knows what residents are to wear what splints. Staff B said that she had been provided a list of residents that she monitors. She provided a copy of the list and it was titled, Tarpon Bayou Splint Program. The list had a column for the resident name, the device type, shift and wearing schedule. Staff B, Restorative Aide was asked about the column titled shift that documented times as 7-3 (7:00 a.m. - 3:00 p.m.), 11-7 (11:00 p.m. - 7:00 a.m.), 3-11 (3:00 p.m. to 11:00 p.m.), and PRN (as needed) and she stated, I don't know what that means. A review of the Tarpon Bayou Splint Program list showed that Resident #1 had a right elbow splint on the 11-7 shift and a right-hand splint on the 7-3 shift. The wearing schedule column indicated apply daily up to 8 hr (hours) or per pt tol. (patient tolerance). On 12/21/2020 at 10:45 a.m. Staff B was observed propelling Resident #1 in his wheelchair down the hallway. Resident #1 was wearing a right elbow splint and a brace/splint to his right lower extremity. A medical record review was conducted for Resident #1 and indicated on his admission Record documented that he had been at the facility for five years. The form included diagnoses information that contained the description of traumatic brain injury, muscle wasting and atrophy, stiffness of right elbow, and abnormalities of gait and mobility. Physician orders for December 2020 were reviewed and contained an order for check skin under splint every day shift, dated on 12/8/2020. It did not indicate were the splint was located. No current order was found in place for the right lower leg splint, right elbow splint nor the right-hand splint. Further record review was conducted that revealed the right elbow and right-hand splint were discontinued on 12/7/2020. Resident #1's care plan stated under the Focus for ROM [range of motion], initiated on 5/31/18 and revised on 10/16/18: The Resident is at risk for developing and/or has an impairment in functional joint mobility right upper extremity. The interventions included: Splint per therapy recommendation (initiated on 11/10/20 and revised on 12/8/20). On 12/21/2020 at 11:20 a.m. an interview was conducted with the Regional Nurse as she confirmed that she had been helping with the audits. She was asked about Resident #1 wearing a splint to his right lower leg. She said that she had not seen a splint on Resident #1's leg and stated, Some residents have preferences to when they wear the splints or not. She was asked why that had not been reflected in the resident's care plan. She did not respond. She was asked about Resident #1 not having physician orders for his splints, as the physician orders only reflected an order to check skin under splint every day shift, that was dated on 12/8/2020. She indicated that it is documented in the task section on the [NAME]. She was then asked how a nurse would know where to check skin under a splint every day when it did not reflect the splint location. She stated, They know to check the [NAME][certified nursing documentation]. The certified nursing documentation ([NAME]) was reviewed under the Task Reporting section. The section showed, Task: split application: R (right) elbow splint on daily for up to 8 hours or per patient tolerance 3-11 off 11-7, dated on 12/7/2020. The documentation was reviewed for the task section that revealed the resident right elbow splint was on 12/21/2020 at 1:20 a.m., on 12/20/2020 no documentation that it had been ever applied, on 12/19/2020 it was documented that it was on at 2:00 a.m., on 12/18 /2020 wearing at 12:06 a.m., on 12/16/2020 wearing at 12:20 a.m. , and on 12/15/2020 the resident was wearing the splint at 3:53 a.m. The Occupational Therapist (OT) -Therapist Progress & Discharge summary dated on 11/16/2020 was reviewed for Resident #1 and showed, Patient/ Caregiver Training since Last Report: Pt. [patient] caregiver training was provided regarding application, removal, skin monitoring, pt. removal, wearing R elbow orthosis daily as tolerated. FMP (Functional Maintenance Program) in place, education-in-service training record completed, and orders for wearing as tolerated in [electronic medical record], [NAME]. On 12/21/2020 at approximately 2:30 p.m. the Director of Therapy indicated that the right lower extremity brace that was observed on Resident #1 at 10:45 a.m. was called an ankle-foot orthosis (AFO). She provided a copy of a Physical Therapy Screening Form, dated 12/21/20. It stated that the reason for the screen was, pt. wearing BLE (Bilateral Lower Extremity) double upright AFOs without an order. After a short period of time the Regional Nurse and the Nursing Home Administrator said that an agency certified nursing assistant had cared for Resident #1 this morning. Apparently, she had found the right lower extremity splint in his closet and had placed it on him. 2. Resident #3 was observed at 2:06 p.m. sitting in his wheelchair outside of his room door with a splint placed on his left hand and wrist. He was asked about his splint at that time and he stated, It hurts. I don't know why am wearing it. He went on to say, I didn't have to wear it anymore and now they tell me I need to wear it. He was asked about the frequency of the splint use. Resident #3 stated, I don't wear it every day. Only when they tell me to. He began removing the hook and loop straps off the brace while stating it had been on for only 20 minutes now and it hurts too much. Resident #3 was asked if he wears the splint in the evening or at nighttime, he said only during the daytime. The medical record was reviewed for Resident #3. The admission Record indicated that he had been at the facility for over nine years. The form contained diagnoses information with the description of cerebral vascular disease, spastic hemiplegia affecting nondominant left hand, contracture of left wrist and hand and muscle wasting and atrophy. The December 2020 physician orders revealed no current order in place for the left-hand splint nor did the treatment administration record contain an order for a splint. An order was in place for check skin under splint daily every day shift, dated 12/8/2020. Further record review was conducted that revealed the left resting hand splint order was discontinued on 12/7/2020. A review of the Tarpon Bayou Splint Program list showed that Resident #3 had a left hand splint on 7-3 shift and the wearing schedule was to apply daily up to 8 hr or per pt tol. The Task Reporting section on the [NAME] showed, apply L [left] hand splint daily up to 8 hours per patient tolerance. The Task Reporting section on the [NAME] indicated the Task as hand splint daily up to 8 hours per patient tolerance. Review of recorded documentation in the task section revealed for 12/19/2020 at 6:38 p.m. the resident was wearing the splint, on 12/18/2020 at 5:28 p.m. the splint was in place, on 12/17/2020 at 4:48 p.m. the splint was in place, on 12/15/2020 at 10:59 p.m. the resident was wearing the splint, on 12/14/2020 at 8:14 p.m., 12/13/2020 at 6:41 p.m., and on 12/12/2020 at 8:56 p.m. The resident had indicated he wore the splint during the day. Resident #3's care plan was reviewed and showed a Focus for Range of Motion, initiated on 4/19/16 and revised on 11/8/17, that documented, The Resident has actual limitations in Range of Motion as evidenced by: contracture of left hand r/t CVA (related to Cerebrovascular accident) with hemiparesis. Interventions included: Splints per therapy recommendation. (initiated on 4/20/16) 3. A review of the Tarpon Bayou Splint Program list showed that Resident #2 had a right-hand splint on the 3-11 shift and the wearing schedule was to apply daily up to 8 hr or per pt tol. On 12/21/2020 at 3:25 p.m. Resident #2 was observed lying in bed and it was observed that she did not have her right hand splint on. She stated, I haven't had it on for a while now. A medical record review was conducted for Resident #2. Her admission Record contained the description of her diagnoses to include Parkinson's disease, right shoulder stiffness, right elbow stiffness and muscle wasting and atrophy. The December 2020 physician orders were reviewed and were without an order for a current splint device. Upon review of discontinued orders for Resident #2, dated on 12/7/2020, the orders revealed: patient to wear right hand splint per patient tolerance. Removed and check skin every shift every evening, and night shift related to muscle wasting and atrophy. Resident #2's care plan was reviewed and showed a Focus for ADL [activities of daily living]: The Resident has an ADL Self Care Performance Deficit r/t Parkinson's, initiated on 8/23/19 and revised on 8/26/19. The intervention included, Splint per therapy recommendation. An interview at 3:30 p.m. was conducted with the Resident #2's Unit Manager, who identified herself as a Licensed Practical nurse (UMLPN). She stated that she had been on the unit for approximately three months. The UMLPN entered Resident #2's room and verified the splint was not in place. She said she would find out if the resident had an order for a splint. The UMLPN went to the nursing station and was observed reviewing Resident #2's physician orders. Which was not found at that time, as she started to review the resident's care plans. After she reviewed the care plans, she then turned stated, I will have to check with therapy if she has an order. UMLPN did not review Resident #2's [NAME] where the splint application was documented. While the UMLPN had been in Resident #2's room, Staff A, Certified Nursing Assistant (CNA) stated she worked full time at the facility and works with Resident #2 three or four nights a week. She was asked about the process for Resident #2's splint. She was unable to verbalize if Resident #2 had worn a splint or not. She stated she only works with the resident three to four times a week on the 3:00 p.m. to 11:00 p.m. shift. The UMLPN exited Resident #2's room and said she could not find a splint. Staff A then stated, I don't know where it's at maybe it got misplaced.