Based on staff interviews, and record review the facility failed to ensure a Preadmission Screening/Resident Review Level II referral was made to ensure that individualized care and services were offered to meet resident needs for one resident (R 45) of 25 sampled residents. Findings: Review of the electronic medical record revealed diagnoses (dx) that included (but not limited to) Major Depressive Disorder, Anxiety, and Post Traumatic Stress Disorder (PTSD). Review of Level 1 does not indicate dx of a serious mental illness. Review of the care plan for R45 revealed a potential for psychosocial well-being problem related to anxiety, depression, and PTSD. Further review of the medical record revealed the following behaviors: 1. A Behavior Note dated 10/10/2023 indicated behaviors of yelling and cussing by R45 due to Certified Nursing Assistants (CNAs) coming into room to assist because the call light was on. 2. A second Behavior Note dated 10/10/2023 R45 sat dinner tray outside of room door and when told not to sit the tray outside R45 then kicked the tray further into the hallway. 3. There were several Behavior Note dated 2/3/2024 which revealed R45 getting up and talking loudly as he told war stories and waking up other residents due to the loud talking, R45 talking loudly and yelling at a housekeeper in the dining room while waiting for breakfast, and later in the morning R45 was noted to yell at the housekeeper again while at the nursing station in addition to yelling at another resident that was in the area. 4. There were two Behavior Note date 2/5/2024 which revealed an incident in the morning in which R45 yelled, cursed, and made threats towards a CNA who asked him to stop turning the dining room light on and off. There was a second incident later that night in which R45 continuously walked to the nursing station making forceful/aggressive remarks and questioning staff if they were threatened by him. 5. There was a Behavior Note dated 2/6/2024 in which R45 was documented yelling loudly at a resident in the hallway. 6. On 2/7/2024 there was a Behavior Note regarding an incident in which R45 began yelling at the nurse after responding to the call light being on. R45 is then documented as getting out of bed, coming into hallway, and again yelling at the nurse. 7. On 2/15/2024 there was a Behavior Note related to R45 coming out of his room yelling and cursing at CNA who had passed by his room. During an interview with the Social Services Director (SSD) on 3/9/2024 at 2:08 pm it was reported that information is put into the system (unnamed) and it determines if a Level II is needed and a referral would then be made. SSD reported that R45 needs a Level II but his Physician has verbalized in the past that he did not think the Level II would be beneficial. SSD denied that there was no documentation to support the conversation with the Physician. SSD acknowledged that R45 is currently receiving some psych services. During an interview with R45's Physician on 3/10/2024 at 10:51 am it was reported that conversations have been had about a Level II for R45 but without looking at the details in the medical record he could not explain why the referral was not sent. The Physician reported that R45 is lucid most of the time. PASARR/Level II policy requested but was not received as it was reported that the facility does not have a policy related to PASARR/Level II.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility policy titled, Care Plan-Comprehensive the facility failed to develop and implement a comprehensive, person-centered care plan for three resident's, resident (R) R30 for pain, R36 for diabetes and insulin usage, and R37 for implementing monitoring of behaviors while on psychotropic medications. The sample size was 25 residents. Findings included: Review of facility policy titled, Care Plan-Comprehensive with revised date 4/18/2017 revealed, under Policy Interpretation and Implementation number 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas. numbers 6. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident care interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 9. c. and d. The care planning/interdisciplinary team is responsible for the review and updating of care plans when the resident has been readmitted to the facility from a hospital stay; and at least quarterly. 1. R30 was an [AGE] year-old male who admitted [DATE], Basic Interview of Mental Status (BIMS) score 05 indicating cognitive impairment, with pertinent diagnoses that included but not limited to, unspecified osteoarthritis with unspecified site, and back pain. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed sections C-Cognitive pattern, BIMS 05. Section J-Received scheduled but not prn (as needed) pain meds (medications), and section N-Received opioid medications. Physician orders included but not limited to, Tramadol 50 mg (milligrams) po (by mouth/orally) bid (twice a day), and Tylenol 500 mg for back pain, give with Tramadol 50 mg bid, Colace 100 mg po bid for constipation, Divalproex Sodium bid for anxiety, evaluate resident for pain every (q) shift and record on the Medication Administration Record (MAR), indicate pain using numerical scale 0-10. Review of the care plan revealed there was no care plan with problem, goal, or interventions for pain, pain assessment, or pain medication usage. Observation on 3/9/2024 at 7:30 am, and on 3/9/2024 at 12:43 am of R30 sitting up in bed eating, no complaints of pain or other concerns. Interview on 3/9/2024 at 8:11 am with the Registered Nurse (RN) weekend supervisor confirmed R30 did not have behaviors or complaints of pain, he took pain medications, he used oxygen, he was a good resident, he kept to himself inside his room and called for help when needed. Interview on 3/10/2024 at 9:47 am with the Licensed Practical Nurse (LPN) MDS coordinator revealed they determine what care area was needed to be on the care plan by looking at the resident, talking with staff and family, and looking at the resident's medical chart. If there was a new issue or change in condition, they find out during morning meeting, they talk to staff and family, review the 24-hour report, get all the information they can and update the care plan. She looked at R30's physician orders in the electronic record and confirmed R30 did take scheduled pain medications bid, and confirmed she could not find a care plan for pain, pain medication usage, or pain assessments. Interview on 3/10/2024 at 9:53 am with the RN MDS coordinator confirmed she did not find anything where pain was care planned and did not find any other care areas that included pain or pain medication as interventions. A review of discontinued medication orders with the RN MDS Coordinator, she confirmed R30 had pain medication orders going back to at least April 2023, and they should have caught it doing the quarterly MDS assessment review because they review medications. She revealed there was always so much going on with R30 and they just missed it. She revealed the care plan should be person-centered and should include pain since R30 took it routine bid along with Tylenol. 2.Review of the medical record for R 36 revealed a readmission date of 1/23/2024 with a diagnosis that included type 2 diabetes without complications. Further review revealed an order for Humalog to be administered subcutaneously before meals and at bedtime for diabetes. Review of the quarterly Minimum Data Set (MDS) dated [DATE] in section N indicated medications that included injections, insulin, antidepressant, opiod, and hypoglycemic. There was not a care plan identified for diabetes and insulin usage. During an interview on 3/10/2024 at 9:47 am with Minimum Data Set (MDS) Licensed Practical Nurse (LPN) and MDS Registered Nurse (RN) it was reported that each resident's chart is reviewed to determine what the resident's needs are that will be reflected on the care plan. MDS LPN explained that they also discuss changes during the morning meetings in addition to interviews with residents and staff. MDS RN acknowledged that the facility had a care plan for hyperglycemia and thought this would be sufficient because hyperglycemia is associated with diabetes. She also reported that an intervention for hyperglycemia included medications as ordered. MDS RN later acknowledged that a person does not have to have diabetes to experience a hyperglycemic episode. It was further reported that she would typically include information about the actual diagnosis and usage of injections on the care plan and would update R36's care plan to include the diabetes diagnosis and usage of insulin. 3.Review of the medical record for R37 revealed diagnoses that included but was not limited to unspecified psychosis not due to a substance or known physiological condition, depression, and anxiety. Review of the care plan for R37 revealed R37 is at risk for adverse effects of antidepressant medication with an initiation date of 10/20/2023. There was an intervention to monitor/document side effects and effectiveness q-shift. Review of the care plan for R37 revealed R37 is at risk for adverse effects of anti-anxiety medication with an initiation date of 6/2/2023.There was an intervention to monitor for side effects and effectiveness every shift. During an interview with the Director of Nursing (DON) on 3/10/2024 at 11:41 am it was reported that nursing staff are to monitor and document behaviors on the MAR each shift. DON reviewed the eMAR for March 2024 but was unable to find any documentation for behavior monitoring or documented side effects of medications for R37.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review, and review of the facility policy titled, Tracheostomy Care, the facility failed to ensure the provision of respiratory services in accordance with professional standards for one of one resident (R) (R9) reviewed for tracheostomy (trach) care. Specifically, the facility failed to provide tracheostomy care supplies to include one size as ordered, and one smaller tracheostomy tube in emergency tracheostomy supplies at bedside. This failure increased R9's risk for compromise airway and respiratory distress. Findings include: Review of the facility policy titled, Tracheostomy Care dated 3/24/2017, under general Guidelines number 6. A replacement tracheostomy tube must be available at the bedside at all times. Review of admission Record for R9 located in the Electronic Medical Record (EMR), revealed R9 was admitted to the facility with multiple diagnoses including but not limited to encounter for attention to tracheostomy, chronic obstructive pulmonary disease, and aphasia following unspecified cerebrovascular disease. Review of the most recent Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated R9 was unable to complete the interview due to cognitive deficits. Review of the care plan for R9 revealed a tracheostomy related to respiratory difficulties. Observations made on 3/8/2024 at 9:58 am revealed R9 lying in bed with head of the bed elevated. R9 was non-verbal. Tracheostomy was in place and secured with ties. Oxygen (O2) via trach collar at 2 liters (L)/minute (min). Observation revealed there was no same size trach or smaller size trach at the bedside. Further observations revealed there was not an artificial manual breathing unit (AMBU) bag at the bedside. Review of Physician's Orders for R9 in the EMR revealed no order for the size trach, and no order for an emergency tracheostomy kit at the bedside. Interview on 3/8/2024 at 9:44 am with the Assistant Director of Nursing (ADON) and Licensed Practical Nurse (LPN) AA revealed the ADON and LPN AA verified that there was no same size trach or smaller size trach at the bedside, and there was not an artificial manual breathing unit (AMBU) bag at the bedside. Neither the ADON nor LPN AA could verbalize what trach supplies were needed at the bedside. When asked what would either do if R9's trach became dislodged, the ADON stated that they would be in trouble. LPN AA stated that they used to have a respiratory therapist but that was months ago. She stated that the nurses are now responsible for providing trach care. Interview on 3/8/2024 at 10:07 am with the Administrator revealed, the administrator verified that there was no same size trach or smaller size trach at the bedside, and there was not an artificial manual breathing unit (AMBU) bag at the bedside. The administrator stated that they were getting the supplies together. Administrator stated that she expects that emergency trach supplies should be at the bedside. Administrator further stated that she expected the nurses and the ADON to know what trach supplies are needed at the bedside for a resident with a trach. Interview on 3/10/2024 at 7:55 am with the Director of Nursing (DON) revealed they do not have a respiratory policy to address what is needed at the bedside. DON confirmed that there was no order for the size of trach for R9. DON stated that R9 has a size 6 trach in. DON stated that there should be at the bedside same size trach and a smaller size trach at the bedside. DON further stated that she expects the ADON along with the nurses to know what is needed at the bedside of a resident with a trach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review, and review of facility policy titled, Depression - Clinical Protocol, the facility failed to monitor behaviors and side effects of psychotropic medications for one resident (R37) of five residents reviewed for unnecessary medications. Findings: Review of the facility policy titled, Depression - Clinical Protocol dated 3/23/2017 Monitoring and Follow-up 2. The staff and physician will monitor the resident carefully for side effects specific to each class of medication as well as interactions between antidepressants and other classes of medications. Review of the medical record for R37 revealed diagnoses that included but was not limited to unspecified psychosis not due to a substance or known physiological condition, depression, and anxiety. Review of the Annual Minimum Data Set (MDS) dated [DATE] in Section N revealed medication usage that included antianxiety and antidepressants. There was an order for Effexor XR Oral Capsule Extended Release 24 Hour 37.5 MG (Venlafaxine HCl). Give 1 capsule by mouth one time a day for depression with a start date of 10/28/2023. There was an order for Lorazepam Oral Tablet 0.5 MG (Lorazepam). Give 1 tablet by mouth two times a day for Anxiety with a start date of 7/1/2023. Review of the March 2024 electronic Medication Administration Record (eMAR) did not reveal any behavior monitoring or documentation of side effects of psychotropic medications. During an interview on 3/10/2024 at 11:32 am Licensed Practical Nurse (LPN) DD regarding R37 it was reported that behavior monitoring, and medication usage side effects are documented in the eMAR. LPN DD was able to find some documentation related to behaviors in notes but was unable to find any documentation addressing the side effects of medications. During an interview with the Director of Nursing (DON) on 3/10/2024 at 11:41 am it was reported that nursing staff are to monitor and document behaviors on the MAR each shift. DON reviewed the eMAR for March 2024 but was unable to find any behavior monitoring for R37. DON then reviewed the orders for R37 and acknowledged seeing an order for anti-anxiety side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to maintain an effective infection control program related to labeling and storage of personal care equipment on one of four halls in six bathrooms. The facility census was 53 residents. Findings include: Observation on 3/8/2024 at 8:47 am revealed in the shared bathroom between rooms [ROOM NUMBERS] had four unlabeled, un-bagged wash basins stored stacked on the floor. Observation on 3/8/2024 at 8:58 am revealed in the shared bathroom between rooms [ROOM NUMBERS] urinal sitting inside of specimen hat, inside of bed pan on floor. None were labeled or bagged. An additional two wash basins were stacked unlabeled, un-bagged on the floor. Observation on 3/8/2024 at 9:05 am revealed in the shared bathroom between rooms [ROOM NUMBERS] a bedpan unlabeled and un-bagged. Interview on 3/8/2024 at 9:10 am with Assistant Director of Nursing confirmed the above findings and revealed resident care equipment should be labeled with the resident room number and bed and placed in a bag after each use. Interview on 3/9/2024 at 10:33 am with the Director of Nursing revealed her expectation is for the staff to place wash basins, urinals, and any other resident care items in a plastic bag after use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, and review of the facility policy titled, Infection Control Recommendations the facility failed to properly store suctioning equipment for two of three residents (R) (R#12 and R#63) with tracheostomies. Findings include: Review of facility policy titled, Infection Control Recommendations (not dated) revealed under section 'Suction Machines: suction tubing should be changed when soiled; Suction catheters are to be changed after use; discarded when soiled; Suction Yankauer are to be discarder when soiled; Equipment should be bagged when not in use. Observation on 5/17/22 at 9:39 a.m. of R#12 revealed in room [ROOM NUMBER] next to bed 'A' and 'B' revealed suction machines sitting on bedside table with tubing extending from the suction machines into a drawer. The cannisters on the suction machines had a large amount of cloudy watery substance. Observation on 5/18/22 at 8:33 a.m., 11:07 a.m., and 2:19 p.m. of R#63 revealed the residents suction tubing was lying uncovered on the bedside table and the suction cannisters had large amount of cloudy watery substance. The suction machines were partially covered with a plastic bag. Observation and interview on 5/19/22 at 10:10 a.m. with the Director of Nursing and Respiratory Therapist revealed the suction cannister should be cleaned after each use and all supplies should be changed at least monthly. Further revealed the suction equipment should be stored in a plastic bag when not in use. Both confirmed the suction machines and tubing were not stored properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and a review of the facilities Patient's Plan of Care procedural guidelines, the facility failed to develop comprehensive care plans for Activities of Daily Living (ADL) for two of four residents reviewed (R) (R#3 and R#23). Findings include: A review of the facilities Patient's Plan of Care procedural guidelines dated 2018 revealed, It is the intent of this center to develop and maintain an individualized plan of care for each patient. The compents of the guidelines consist of a problem statement - Problems, imitations, needs, behaviors, possibilities for improvement, and risks should be identified. Goal - should lead to an outcome and Interventions - should be specific individualized approaches that staff will take to assist the resident to achieve the identified goal. 1. Review of R #23's clinical record revealed that he had diagnoses that included: chronic kidney disease and type 2 diabetes mellitus (DM2). Review of the Quarterly Minimum Data Set (MDS) dated [DATE] for R#23 revealed that he had a Brief Interview for Mental Status (BIMS) score of 03 (a BIMS score of 00 to 07 indicates severe cognitive impairment); extensive assistance for and dressing, total dependence for transfers and bathing. Review of R #23's care plans revealed that one was not seen for ADL's as related to dressing, transfers or bathing. Further review of his care plans revealed that a care plan for self-care deficit addressed the family making physician appointments. Review of a Care Plan Review dated 2/28/19 and 5/29/19 revealed the IDT (interdisciplinary team) met for his plan of care meeting. Further review of this note revealed that R #23 was unable to mention any goals at this time. An interview on 4/30/19 at 1:29 p.m. with the family of R#23 revealed, he had a stroke, we don't expect him to be walking up and down the halls. They sent a staff person by herself in the room to transfer/pivot him. During an interview on 5/01/19 at 2:45 p.m. until 3:05 p.m. with the Registered Nurse (RN) Care Plan Coordinator BB, she confirmed the self-care deficit plan of care for R#23 stated the following: his family makes appointments and does not let the staff know. Care Plan Coordinator BB further revealed; it seems like there should be another care plan. There should be another self-care deficit care plan for the staff to provide personal care, bathing, and hygiene, I am not seeing it. During an interview on 5/02/19 at 10:37 a.m. the Administrator stated that staff find out what a resident's preferences are for bathing and provide as they desire; this is incorporated as part of their Resident Rights. When a resident refuses care, the facility honors that refusal as a preference/choice; patient centered care, honor their choices and refusing is a choice. She expects refusal of care to be care planned. It is something she is trying to implement. Policy on bathing, care plans, resident rights/preferences, ADL documentation, refusal of care. During an interview on 5/02/19 at 11:44 a.m. the Director of Nursing (DON) revealed the facility has no bathing policy. She also stated on 2/28/19 the staff had a meeting with a mix of all nursing staff related to developing the care plan, the DON further stated all licensed nursing staff are expected to complete the care plan. On 5/02/19 at 12:11 p.m. a further interview with the Administrator revealed the expectation would be that a resident's self-care deficit care plan would reflect his care needs, even if the Certified Nursing Assistants (CNA's) could see that care plan it wouldn't help them. 2. R#3 admitting diagnoses include but are not limited to schizophrenia, Alzheimer's dementia, diabetes mellitus and seizures. The annual Minimum Data Set (MDS) a resident assessment instrument (RAI) with an assessment reference date of 8/3/18 reflects a Brief Interview for Mental Status (BIMS) score of three (3) out of a possible 15 indicating severe cognitive dysfunction. The annual MDS also reflects that R#3 requires limited assistance with toileting and dressing activities and physical assistance of one staff person with bathing. A review of the comprehensive care plan for R#3 reveals no care area or problem related to a self-care deficit or activities of daily living including bathing, dressing or grooming. An interview conducted on 5/2/19 at 10:15 a.m. with the MDS Coordinator AA confirmed there is no care plan for R#3's self-care deficit even though she requires assistance with bathing by the staff. .

Based on observation, staff interview, and policy review the facility failed to label and date food items upon receipt. This had the potential to effect 78 of 88 residents that receive an oral diet. Findings include: Review of the policy Skilled Inpatient Services: Storage Areas revealed that it was the intent of this center to store food that maintained quality and safety. Under Bullet 1 the policy revealed that all items would be inspected for quality and temperature control upon receipt. The policy stated that items would be covered, sealed, labeled, and dated appropriately. Interview on 5/1/19 at 8:55 a.m. with the Kitchen Supervisor CC revealed that she used a first in-first out rotation system, that food items have a one-year shelf-life and that they use received by, use by and opened dates to verify that a food item was still suitable for consumption. Observation with the Kitchen Supervisor CC revealed a 1/3 of a tub of individual packets of saltines (more than 50 packets), four cans of pimentos with no received by date or use by date and four cans of sweet potatoes with the received by month and day but no year. The Kitchen Supervisor confirmed these findings and stated that she would have no way of knowing when the food items were received except that she knew that the food delivery truch delivered weekly on Fridays. She stated that the reason this happened was because there was such a high turnover of staff.