**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to perform a PASARR (Pre-admission Screening and Resident Review) rescreen after the emergence of a newly diagnosed severe mental illness for one of three residents (R103) reviewed for PASARR screening, in the sample of 40. Findings include: The facility policy, Preadmission Screening and Annual Resident Review (PASARR), dated (effective) 11/18/2023 documents, This facility promotes and supports a resident centered approach to care. The purpose of this guideline is to define and set expectations regarding the appropriate preadmission assessment of all individuals with a mental disorder and individuals with intellectual disability. This includes incorporating the recommendations from the PASARR level 11 determination and evaluation in the residents' assessment, care plan and transition of care; and referring all level 11 residents and all residents with new or evident conditions related to Level 11 review upon significant change in status assessment. R103's current Physician Order Sheet, dated October 2024 documents that R103 was admitted to the facility on [DATE] with the following diagnoses: Depression and Anxiety Disorder. R103's current Care Plan, dated 11/23/2022 includes the following Focus Areas: (R103) is at risk of possible abuse/neglect related to admission to the facility for long term care, a history of perpetrating/being a victim of abuse, cognitive deficits, emotional deficits, and relying on others for care needs. 12/15/23 LCSW (Licensed Clinical Social Worker) seeing (R103) for therapy session. Dx (Diagnosis) of PTSD (Post Traumatic Stress Disorder) added. On 10/22/24 at 2:27 P.M., V3/Social Services Director verified that R103 has not had a PASAAR rescreen upon the emergence of a newly diagnosed severe mental illness, on 12/15/23.

Based on observation, interview, and record review, the facility failed to provide grooming assistance for one of three residents (R12) reviewed for activities of daily living assistance in a sample of 40. Findings Include: The facility policy, ADL (Activities of Daily Living) Care, dated 11/2015 directs staff, To meet the grooming and hygiene needs of residents with dignity and privacy. Shaving: If the resident is a woman, shave only the areas with facial hair and apply moisturizer instead of aftershave. R12's current Physician Order Sheet, dated October 2024 documents the following diagnoses: Vascular Dementia, Osteoporosis, Cervical Spondylolysis, Polyosteoarthritis, Polymyalgia Rheumatica, Rheumatoid Arthritis and Weakness. R12's current Care Plan, dated 10/15/2024 includes the following Focus areas: (R12) has a deficit in ADL (Activities of Daily Living), physical mobility and requires staff moderate to total assistance from staff. (R12) has generalized weakness, impaired balance, strength and endurance. Also included are the following Interventions: Assist with dressing and grooming tasks. On 10/21/24 at 10:03 A.M., R12 was seated in a wheelchair in her room. 1/2-inch long facial hair was present to R12's entire chin. On 10/21/24 at 1:45 P.M., V2/Director of Nursing verified the presence of the chin hairs on R12 and that R12 should be shaved.

Based on observation, interview, and record review the facility failed to ensure range of motion was implemented for a resident with functional limitations and failed to ensure an assistive device was in place for a resident with a contracture for four of four residents (R19, R38, R1 and R6) reviewed for range of motion in a sample of 40. Findings include: The facility's Range of Motion and Contractor Assessment and Preventions policy, dated 10/2019, documents that the objectives of range of motion exercise is to preserve resident's present range of motion. 1. R19's Restorative Program Note, dated 9/11/24, documents that R19 requires AAROM, active range of motion program, along with dressing and grooming. R19's Functional Abilities and Goals, dated 9/11/24, documents that R19's has an impairment to one side of her upper extremities. This form documents that R19 required substantial/maximal assistance for activities of daily living. On 10/24/24 at 10:15 AM, R19's Rehab/Restorative Assessment, dated 9/11/24, active assist range of motion-to prevent limitations, to be performed BID (twice daily) to bilateral upper and lower extremities. From 8/1/24 through 10/23/24 there were 43 times that R19's AAROM was not signed out as being completed. 2. R38's diagnosis include: Hemiplegia and hemiparesis, affecting the left non-dominate side. R38's Functional Abilities and Goals Assessment, dated 7/5/24, documents that R38 has an impairment to one side of her upper extremity. This form also documents that R38 requires substantial/maximal assistance for all cares. R38's Care Plan, dated 11/16/23, documents that R38's has a deficit in activities of daily living abilities and requires staff assistance due to impaired mobility and weakness with left sided hemiplegia following recent cerebral infarction. R38 requires active range of motion programming at least twice daily by working each joint using extension, flexion, abduction, and adduction 10-15 repetition, do not pass the point of resistance. If pain is seen, stop activity immediately and notify the nurse. R38's Rehab/Restorative: Passive Range of Motion-To prevent limitations to be performed BID (twice daily) was not started until 10/15/24. R38's Range of motion was only completed 6 times from 10/15/24 through 10/23/24. R38's range of motion was not completed prior to 10/15/24 as documented in R38's care plan. On 10/23/24 at 1:45pm, V6 Restorative Nurse, stated that range of motion is to be completed twice daily. V6 stated that there are two restorative aides that do the range of motion during the week on day shift, but on the weekends the floor staff are to do the range of motion. V6 verified that if it is not signed out it is not being done. V6 stated that there are residents that refuse daily, so the staff will quit asking or attempting to do the range of motion. V6 verified that there is no documentation that either R19 or R38 refused range of motion. On 10/24/24 at 8:45am, V2, Director of Nursing stated that R38's range of motion was not started until 10/15/24. V2 also verified that since 10/15/24, R38's range of motion was not being done as care planned. 3. R1's current medical record documents the following diagnoses: Difficulty in Walking; Primary Generalized Osteoarthritis; Muscle Weakness; Cachexia, and Neuralgia and Neuritis. R1's Minimum Data Set Assessment (dated 09/16/24) Section GG, documents R1 has impairment of both sides to her lower extremities. On 10/21/24 at 09:37 AM, R1 was lying in bed covered with a blanket with her eyes closed. R1 appeared comfortable, and two 1/2 side rails were attached to R1's bed and were secured in the upright position. R1 stated she utilizes her bed rails to turn herself in bed. R1 then stated she prefers to spend most of her time in bed. On 10/22/24 at 12:35 PM, V12 (R1's son) stated R1 recently admitted under Hospice services. V12 stated his biggest concern is that R1, Needs to continue to receive consistent exercises to maintain her mobility. Especially in her legs. R1's medical record documents the following restorative programming exercises are currently in place: Restorative AAROM (Active Assistive Range of Motion) program: To prevent limitations to BUE (bilateral upper extremities) and BLE (bilateral lower extremities), to be performed BID (twice daily). R1's Monthly Restorative Documentation Report (dated 08/2024 - 10/2024) documents R1 did not receive range of motion exercises twice daily as ordered on 42 days during this time frame. On 10/23/24 at 12:50 PM, V2 (Director of Nursing) confirmed R1's range of motion exercises have not been completed twice daily as indicated. 4. R6's medical record documents the following diagnosis: Hemiplegia and Hemiparesis following Cerebral Infarction affecting the left non-dominant side. R6's Minimum Data Set Assessment (dated 09/30/24), Section C, documents a Brief Interview for Mental Status of 15, indicating R6 is cognitively intact. Section GG of this same assessment documents R6 has impairment of one side of her upper and lower extremities. R6's Restorative Program Note (dated 09/30/24) documents the following: Restorative Programs: Active Range of Motion, Splint/Brace Assistance, Dressing/Grooming. This same form documents, Splint/Brace Assistance: Carrot splint to be applied to left hand at rest, may remove during ADLs (activities of daily living), transfers and activities. R6's medical record documents the following restorative programming exercises are currently in place: Restorative AAROM (Active Assistive Range of Motion) program: To prevent limitations to be performed BID (twice daily) to RUE (right upper extremity) and BLE (bilateral lower extremities). R6's Monthly Restorative Documentation Report (dated 08/2024 - 10/2024) documents R6 did not receive range of motion exercises twice daily as ordered on 33 days during this time frame. On 10/23/24 at 12:50 PM, V2 (Director of Nursing) confirmed R6's range of motion exercises have not been completed twice daily as indicated. On 10/21/24 at 09:30 AM, R6 was reclined in her wheelchair watching television covered with a blanket. R6 was receiving oxygen at 3 liters via nasal cannula from an oxygen condenser and had a full mechanical lift sling in place underneath of her. R6's cell phone, call light and several personal items were within her reach. R6 stated she was recently sent to the hospital for my breathing and just returned to the facility and has been taking antibiotics since she returned. R6 stated her biggest concern is, the food is horrible. I don't have any teeth and they give me toast. R6 denied any other complaints at this time. R6's left wrist and hand was contracted, and the digits of her left hand appeared rigid and stiffened. No therapeutic appliance was in place at this time. On 10/23/24 at 01:05 PM, R6 was sitting in her wheelchair with her bedside table positioned in front of her eating a large salad. V10 (R6's Daughter) was sitting next to R6 assisting her with lunch. A washcloth was loosely in place in R6's left hand at this time. V10 stated, They never put the carrot in my hand. They forget and just stick a washcloth in it. V10 stated, She is rarely ever holding the carrot when I visit. R6 stated staff does not assist her with range of motion exercises twice daily, I try to exercise my (left) arm myself. R6 pointed out a carrot-shaped hand orthosis device that was sitting on a nearby dresser and stated, The carrot is sitting right over there. On 10/23/24 at 01:25 PM, V11 (Licensed Practical Nurse) confirmed R6 does not have her carrot splint in place and stated, It should be in place.

Based on observation, interview, and record review, the facility failed to ensure a respiratory treatment was administered according to facility policy for one (R54) of one residents reviewed for breathing treatments during medication administration; and failed to ensure a residents respiratory equipment is routinely cleaned for two (R12 and R78) of four residents reviewed for respiratory care in a sample of 31. Findings include: 1. The facility's policy Administering Medications through a Small Volume (Handheld) Nebulizer, dated 11/2013, documents The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway .Steps in the Procedure: 6. Obtain baseline pulse, respiratory rate and lung sounds .16. Monitor for medication side effects, including rapid pulse, restlessness and nervousness throughout the treatment .21. When treatment is complete turn off nebulizer and disconnect T-piece, mouthpiece and medication cup .23. Obtain post-treatment pulse, respiratory rate and lung sounds. 24. Rinse nebulizer pieces after use: a. Wash pieces with warm water. b. Allow to air dry on a paper towel .26. When equipment is completely dry, store in a plastic bag with the date on it. R54's current Physician Order Sheet/POS documents an order for Ipratropium Bromide & Albuterol 0.5mg (milligrams)/3mg per 3ml (millimeters) vial. One vial inhale orally four times a day related to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. Rinse nebulizer set-up after each use and allow to dry. Once dry put in plastic bag with residents name and date. On 9/27/23, at 11:08am, R54 was lying in bed. V9 Registered Nurse/RN put Ipratropium Bromide & Albuterol liquid in the nebulizer medication cup, handed R54 the mouth piece, then turned on the nebulizer machine and left the room. At this time, V9 stated that V9 typically does not stay in the room during the treatment if the resident can do the treatment by themselves. (R54) is very good and will even shut it off by herself when done. On 9/27/23, at 11:21am, V9 returned to R54's room and waited two to three minutes for the treatment to be completed. V9 turned off the nebulizer machine. R54 handed V9 the mouth piece. V9 rinsed the medicine cup and mouth piece with water, shook off excess water, then attached them to the tubing and put them back into R54's blue canvas bag on R54's bed. On 9/27/23, at 2:26pm, V9 RN stated that this is her normal way of administering a nebulizer treatment. I only listen to their lungs if there is a problem or reason to, or if they were recently put on nebulizer treatments. I usually rinse it then shake it out and place it back in (R54's) bag without letting it air dry on a paper towel. On 9/28/23, at 2:15pm, V2 Director of Nursing/DON stated the following: It is expected for the nurse to stay in the room during nebulizer treatments or return periodically to monitor the resident, and to assess lungs and vitals before and after the treatment. Staff are expected to rinse the nebulizer equipment with water, and let it dry on a paper towel. 2. The facility's CPAP/BiPAP (Continuous Positive Airway Pressure/BiLevel Positive Airway Pressure) Support policy, dated 11/2014, documents General Guidelines for Cleaning: 1. These are general guidelines for cleaning. Specific cleaning instructions are obtained from the manufacturer/supplier of the PAP device .4. Machine cleaning: Wipe machine with warm, soapy water and rinse at least once a week and as needed. 5. Humidifier (if used): b. Clean humidifier weekly and air dry. c. To disinfect, place vinegar-water solution (1:3) in clean humidifier. Soak for 30 minutes and rinse thoroughly. 6. Filter cleaning: a. Rinse washable filter under running water once a week to remove dust and debris. Replace this filter at least once a year. b. Replace disposable filters monthly. 8. Headgear (strap): Wash with warm water and mild detergent as needed. Allow to dry. R12's current Physician Order Sheet/POS documents Cpap every shift - patient may apply and remove per self at bedtime and when napping with oxygen at 4 liters to bleed (flow) in. On 9/26/23, at 11:13am, R12 is lying in bed with the CPAP on. R12 stated that her CPAP equipment does not get cleaned and has not been changed for six months. On 9/28/23, at 11:00 AM, V12 Registered Nurse/RN was unable to find any parameters for routine cleaning of R12's CPAP in R12's clinical record; V12 is unaware of cleaning being done. On 9/28/23, at 11:24am, V7 Minimum Data Set/MDS Coordinator V7 stated that R12's CPAP nasal mask and tubing was replaced in June, but R12's CPAP equipment should be cleaned routinely. 3. On 9/28/23 at 10:10 am, a BiPap machine was resting on R78's night stand with the tubing and mask resting over top of the machine. On 9/28/23 at 10:15 am, R78 stated her tubing and mask are not being cleaned regularly. The current POS (Physician Order Sheet) for R78, documents BiPap 12/5/5% Frequency: HS (hour of sleep) every evening and night shift. On 9/28/23 at 11:30 am, V7 MDS (Minimum Data Set) Coordinator stated respiratory equipment should be cleaned routinely.

Based on observation, interview, and record review the facility failed to ensure a diagnosis, targeted behaviors, and indication for the use of an antipsychotic medication was in place for a resident with Dementia for one (R10) and failed to ensure a PRN (as needed) psychotropic medication did not exceed a duration of 14 days without a physician evaluation and rationale for continued use for one (R20) of five residents reviewed for unnecessary medications in the sample of 31. Findings include: The facility's Psychotropic Medication policy and procedure, dated 11/2013, defines This same policy defines A psychotropic drug is any drug that affects brain activities associated with mental processed and behavior. These drugs include, but are not limited to, drugs in the following categories: Anti-psychotics, anti-depressants, anti-anxiety and hypnotics. This same policy documents The prescribing and administration of psychotropic drugs is based on a comprehensive assessment of the resident. Residents who have not used psychotropic dugs are not given these dugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. Residents must be free of unnecessary drugs. (Unnecessary drugs are any drug when used in excessive dose, excessive duration, without adequate monitoring or without adequate indications for its use or in the presence of adverse consequences which indicate the dose should be reduced or discontinued.) Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record: Schizophrenia; Schizo-affective disorder; Schizophreniform disorder; Delusional disorder; Mood disorders (e.g. bipolar disorder, depression with psychotic features, and major depression); Psychosis in the absence of dementia; Medical illnesses with psychotic symptoms and/or treatment-related psychosis or mania (e.g. high dose steroids); Tourette's Disorder; Huntington Disease; Hiccups, Pruritus (for short term of 7 days); or nausea and vomiting associated with cancer or chemotherapy. Residents do not receive psychotropic drugs pursuant to PRN/as needed orders unless that medication is necessary to treat a diagnosed specific condition. PRN orders for psychotropic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for appropriateness of the medication and documents their rationale for continued use in the resident's medical record for the duration of the PRN order. 1. The Order Summary Report for R10, dated 9/28/23, lists the following diagnoses: Dementia with behavior disturbance, Restlessness and Agitation, and Anxiety Disorder. This same Report documents a Physician Order for the Antipsychotic medication Quetiapine Fumarate 25 mg (milligrams): Give 0.5 (half) tablet by mouth at bedtime every Monday, Tuesday, Wednesday, Thursday, Friday and Sunday for potential for harm to self or others related to Dementia with behavioral disturbance. The Order Summary Report for R10, dated 9/28/23, also documents a generic generalized order Monitor behaviors: Afraid/Panic, agitated, angry, anxiety, biting, crying, pacing, screaming/yelling, withdrawal, fighting, hallucinations, kicking, pinching, pulling lines, slapping/hitting, throwing objects, spitting, etc. Interventions 1. Activities; 2. Change Position; 3. Fluids; 4. Food; 5. Redirection; 6. Remove from environment; 7. Toilet; 8. 1:1 (one-on-one) every shift for Behavior Monitoring. Indicate number of behaviors per shift (use C for continuous). Indicate non-pharm (pharmacological) interventions used and outcome. Outcomes 1. Improved; 2. Same; 3. Worse. The CNA (Certified Nursing Assistant) electronic computer charting system does not document any identified targeted behaviors for R10 that are to be monitored. The MAR (Medication Administration Record) for R10, dated July through September 2023, documents the same generic list of behaviors in R10's Order Summary Report: Monitor behaviors: Afraid/Panic, agitated, angry, anxiety, biting, crying, pacing, screaming/yelling, withdrawal, fighting, hallucinations, kicking, pinching, pulling lines, slapping/hitting, throwing objects, spitting etc. Interventions 1. Activities; 2. Change position; 3. Fluids; 4. Food; 5. Redirection; 6. Remove from environment; 7. Toilet; 8. 1:1 every shift for behavior monitoring. Indicate number of behaviors per shift. (Use C for continuous) Indicate non-[harm interventions used and outcome. Outcomes 1. Improved; 2. Same; 3. Worse. July through September MAR's all document no generic behaviors identified. There are no specific individualized targeted behaviors listed for R10 to be documented. The Quarterly MDS Assessment, dated 11/1/22, documents R10 as cognitively intact, with no identified behaviors, and no SMI (Serious Mental Illness) diagnoses. The Quarterly MDS Assessment, dated 12/31/22, documents R10 with moderately impaired cognition with no identified behaviors, and no SMI diagnoses. The Quarterly MDS Assessment, dated 4/1/23, documents R10 as cognitively intact, with no identified behaviors, and no SMI diagnoses. The Annual MDS (Minimum Data Set) Assessment, dated 7/1/23, documents R10 is moderately impaired for cognition, 1 to 3 days for rejection of cares, and no SMI diagnoses. The current Care Plan for R10 documents, date initiated 5/12/2020 Focus area as: (R10) Uses psychotropic medication Quetiapine R/T (related to) Dementia with sundowning with no resident specific identified behaviors to monitor for. The generic interventions listed include: Monitor/record occurrence of for target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others etc. and document per facility protocol. On 9/26/23 at 11:16 am, R10 began talking quickly with some mumbling and talking through her teeth and became anxious when talking about clothing that a family member had not yet brought in for her. On 9/27/23 at 8:45 am and on 9/28/23 at 9:40 am, R10 was sitting in her room in a wheelchair watching television with no behaviors, and on 9/28/23 at 9:40 am R10 smiled and waved at this writer. On 9/28/23 at 9:40 am, V14 LPN (Licensed Practical Nurse) stated (R10) will only holler out or yell if you disrupt her routine, otherwise she is good and doesn't exhibit any other behaviors. (R10) does not hit or have any physical behaviors, and is pleasant and cooperative as long as her routine stays the same and you don't enter her room in the morning until after she has opened the door. V14 LPN stated the only behaviors R10 exhibits is occasional hollering or yelling out. On 9/28/23 at 3:39 pm, V2 DON (Director of Nursing) confirmed there are no individualized identified targeted behaviors listed for R10, is unsure what behaviors R10 exhibits, and stated the CNA's (Certified Nursing Assistants) only document in the computer system if the resident has a behavior which alerts the Nurse. At that same time, V2 stated the staff do not have an individualized resident centered behavior type tracking that they do each shift for (R10), and only document if a behavior occurs. On 9/28/23 at 4:00 pm, V3 ADON (Assistant Director of Nursing) stated she does all the psychotropic medication tracking and monitoring for the residents. V3 stated R10 is receiving Quetiapine for Dementia with behavioral disturbances. When asked what the identified behaviors were for R10, V3 stated Dementia with sun downing. 2. The Order Summary Report for R20, dated 9/28/23, documents the following diagnoses: Dementia with behavioral disturbance, Mental Disorders due to known physiological condition, and PTSD (Post Traumatic Stress Disorder), and MDD (Major Depressive Disorder). This same Report documents a physician order on 9/11/23 as: Lorazepam 2 mg (milligrams), Give 1 tablet by mouth every 30 minutes as needed for seizures, if more than 3 doses are required contact hospice. The Order Summary Report does not list seizures as a current diagnosis for R20, or a stop date for the Lorazepam. The Order Summary Report for R20, dated 9/28/23, documents a generic generalized order Monitor behaviors: Afraid/Panic, agitated, angry, anxiety, biting, crying, pacing, screaming/yelling, withdrawal, fighting, hallucinations, kicking, pinching, pulling lines, slapping/hitting, throwing objects, spitting, etc. Interventions 1. Activities; 2. Change Position; 3. Fluids; 4. Food; 5. Redirection; 6. Remove from environment; 7. Toilet; 8. 1:1 (one-on-one) every shift for Behavior Monitoring. Indicate number of behaviors per shift (use C for continuous). Indicate non-pharm (pharmacological) interventions used and outcome. Outcomes 1. Improved; 2. Same; 3. Worse. The MAR (Medication Administration Record) for R20, dated July through September 2023, documents the same generic list of behaviors in R20's Order Summary Report: Monitor behaviors: Afraid/Panic, agitated, angry, anxiety, biting, crying, pacing, screaming/yelling, withdrawal, fighting, hallucinations, kicking, pinching, pulling lines, slapping/hitting, throwing objects, spitting etc. Interventions 1. Activities; 2. Change position; 3. Fluids; 4. Food; 5. Redirection; 6. Remove from environment; 7. Toilet; 8. 1:1 every shift for behavior monitoring. Indicate number of behaviors per shift. (Use C for continuous) Indicate non-[harm interventions used and outcome. Outcomes 1. Improved; 2. Same; 3. Worse. July through September MAR's all document no generic behaviors identified. There are no specific individualized targeted behaviors listed for R20 to be documented. The current Care Plan for R20 documents, date initiated 4/20/2022 Focus area as: (R20) Uses antianxiety medication as needed for end of life care, air hunger, restless and comfort. This plan of care does not mention R20 with seizure diagnosis, activity, or interventions related to seizures. On 9/26/23, 9/27/23, and 9/28/23 between the hours of 9:00 am through 4:00 pm, R20 was observed lying in bed with eyes closed, up in a reclining wheelchair, and covered with a blanket for breakfast and noon meals. R20 was fed by staff and taken back to his room and put back into bed. R20 did not exhibit any behaviors or seizure activity on these days. On 9/29/23 at 12:20 pm, V4 SSD (Social Service Directed) stated R20 had a seizure one evening that was pretty extensive and he was given medication for it that night. On 9/28/23 at 3:40 pm, V2 DON stated R20 had a seizure one evening and the doctor ordered Lorazepam for it and only gets the Lorazepam as needed. On 9/28/23 at 4:00 pm, V3 ADON stated she does all the psychotropic medication tracking and monitoring for the residents. V3 stated R20 receives Lorazepam on a PRN (as needed) basis if he has a seizure, and confirmed there is no stop date for R20's Lorazepam order.

2. On 9/26/23 at 9:56am, R108's room had oxygen tubing and a humidifier dated 9/24/23. On 9/27/23 at 11:30am and 9/28/23 at 3:08pm, R108 was in her room with oxygen on. R108's current order summary report, dated 9/29/23, documents Oxygen per Nasal Cannula at (3) L/min (liters/minute) continuous every shift with an order date of 7/28/23. R108's current care plan does not include her oxygen use. On 9/29/23 at 12:19pm, V13 MDS/Minimum Data Set Director stated I just updated (R108's) care plan yesterday to include her respiratory and oxygen status. It should have been on the care plan.Based on observation, interview, and record review, the facility failed to revise Care Plans to be resident specific for five (R10, R12, R20, R78, and R108) of 25 residents reviewed for Care Plan revision in a sample of 31. Findings include: The facility's Care Plans, Comprehensive Person-Centered Policy, dated 4/2017, documents Policy Statement: A comprehensive, person-centered care pan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 1. On 9/26/23 at 11:13am and on 9/28/23 at 11:00am, R12 was lying in bed with her CPAP (Continuous Positive Airway Pressure) mask on and machine running. R12's current Physician Order Sheet/POS documents CPAP every shift - patient may apply and remove per self at bedtime and when napping with oxygen at 4 liters to bleed (flow) in. R12's current Care Plan does not include any cleaning of or cares for the CPAP machine and equipment. On 9/28/23, at 11:24am, V7 Minimum Data Set/MDS Coordinator confirmed that R12's Care Plan does not include any care of R12's CPAP machine and it should. 3. On 9/26/23 at 11:15 am, R10 was sitting in a wheelchair in her room watching television. During conversation R10 began talking through clenched teeth with some anxiety when talking about her clothing at home that her family member had not yet brought to her. On 9/27/23 at 8:45 am, and 9/28/23 at 9:40 am, R10 was sitting up in a wheelchair in her room watching television. There were no behaviors observed. R10's current Care Plan does not document any identified behaviors for R10. On 9/29/23 at 2:15 pm, V7 MDS (Minimum Data Set) Coordinator confirmed R10's behaviors were not identified on R10's Care Plan and should be. 4. On 9/28/23 at 9:18 am, R20 was sitting in a reclining wheelchair in the dining room being assisted with breakfast meal. No behaviors observed. On 9/28/23 at 9:43 am, V14 LPN (Licensed Practical Nurse) stated R20 does not exhibit any behaviors at all, speaks in a word or two but no behaviors or issues. The current POS for R20 documents the following Physician Orders: Celexa 10 mg, 0.5 tablet by mouth one time a day for Major Depressive Disorder; Donepezil 10 mg 1 tablet by mouth in the evening Dementia with Behavioral Disturbance; Lorazepam 2 mg, Give 1 tablet by mouth every 30 minutes as needed for seizures if more than 3 doses are required contact hospice; and Risperdal 0.25 mg, Give 1 tablet by mouth one time a day every Monday, Wednesday, Friday, Saturday related to PTSD (Post Traumatic Stress Disorder). R20's current Care Plan does not document any identified behaviors. On 9/29/23 at 12:20 pm, V4 SSD (Social Service Directed) confirmed R20's Care Plan has not been revised to include identified behaviors or triggers due to R20's decline, and R20 only gets agitated with cares at times due to his dementia, not the PTSD. 5. On 9/26/23 at 10:24 am, 9/27/23 at 11:00 am, and 9/28/23 at 10:10 am, R78 was sitting in a wheelchair in her room. An eight ounce mug with a lid was resting on the overbed table, and a BiPap (Bilevel Positive Airway Pressure) machine was resting on the night stand with the mask and tubing connected to the machine, and hanging over top the machine. On 9/28/23 at 10:10 am, R78 stated she had been monitoring her fluids at home prior to coming to the facility and strictly follows what her doctor told her to do. R78 stated she is on a 1500 ml fluid restriction and uses the same 8 ounce mug she used at home so she can track her fluid intake easily. R78 stated she does not take the water from the nurse to drink with her medications and uses her own mug water. R78 stated she rents a BiPap machine from a local company who comes to the facility monthly to check the machine and change the tubing and mask. R78 stated no staff have cleaned her tubing or mask since she came to the facility. The current POS (Physician Order Sheet) for R78 documents 1500 ml (milliliters) Fluid Restriction every day; Breakfast 420 ml; Lunch 400 ml; and Nursing 200 ml for total of 1020 ml for day shift. Dinner 180 ml and Nursing 200 ml for total of 380 ml. Every night shift 100 ml. Record total amount consumed in 24 hours 1500 ml. The current Care Plan for R78, documents R78 with a 1200 ml Fluid Restriction; 720 ml from dietary and 480 ml from nursing daily and was not revised to the current 1500 ml Fluid Restriction order. This same Care Plan does not include cleaning of or cares for R78's BiPap machine and equipment. On 9/29/23 at 2:15 pm, V7 MDS Coordinator confirmed R78's fluid restriction and Bipap machine were not correct/identified on R78's Care Plan and should be.

Based on observation, interview, and record review, the facility failed to ensure the staff covered hair in a sanitary manner while in the kitchen. This failure has the potential to affect all 124 residents at the facility. Findings include: The facility's Hair Restraints/Jewelry/Nail Polish/False Eyelashes Policy, Dated 2017, documents: Food and nutrition services employees shall wear hair restraints and beard guards. Hairnets will be worn at all times in the kitchen. On 9/26/23 at 10:25am, V6 Dietary Manager was observed with staff in the facility kitchen. V6's hair on the back of her head was uncovered. V10 [NAME] and V11 [NAME] were preparing the facility's lunch meal for residents. V10 and V11 were observed to have hair uncovered on the sides and/or back of their heads. On 9/26/23 at 10:25am, V6 Dietary Manager and V10 [NAME] stated that for kitchen staff, all their hair was supposed to be covered. V6 stated, I have been running around a lot and it came out. On 9/27/23 at 2:05pm, V6 Dietary Manager stated: Anyone who enters the kitchen should have a hairnet on and staff should have all their hair covered when in the kitchen. The Resident Census and Conditions of Residents (Centers for Medicare and Medicaid Services/CMS 672) form, dated 9/26/23, documents 124 residents reside in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to identify a potential viral infection, immediately report signs and symptoms to the Medical Director, remove potential symptomatic staff from work, obtain stool/emesis specimens, and delayed diagnosis. These failures resulted in continuation of the spread of an unknown virus to 53 (R1 through R53) of 129 residents and 24 staff experiencing varying symptoms of nausea, vomiting, diarrhea, chills and elevated temperature. Findings include: The facility's Infection Control Plan, Revised 6/2022, documents Infection control and prevention program refers to a multidisciplinary program that includes a group of activities to ensure that recommended practices for the prevention of healthcare-associated infections are implemented and followed by Healthcare Personnel, making the healthcare setting safe from infection for residents. An effective Infection Control Program utilizes the following components; Surveillance: monitoring residents and healthcare personnel for acquisition of infection and/or colonization; Investigation: identification and analysis of infection problems or undesirable trends; Prevention: implementation of measures to prevent transmission of infectious agents and to reduce risks for device-and procedure-related infections; Control: evaluation and management of outbreaks; and Reporting: provision of information to external agencies as required by state and federal law/regulation. This same policy documents Outbreak: When symptoms suggesting and infectious outbreak occur, and an investigation to define the nature and magnitude of the outbreak. The goal of the investigation is to promptly identify problematic organisms, stop ongoing transmission and reduce the risk of further events. A systematic approach is needed to verify the diagnosis, form a case definition, create a line list, implement infection control and prevention measures, and contact (State Agency) to report and maintain communication for further guidance. Actions may include but are not limited to . Implementing policies to prevent the spread of infections that include promoting consistent adherence to Standard Precautions, transmission based precautions and other infection control practices; Contract with a lab to provide supplies needed, to collect and process any testing required. Include arrangements for reporting results to any required authorities . Notify the local Department of Public Health, State Officials and other key stakeholders and make arrangements for a more detailed investigation by experts if the status of the outbreak warrants such measures; Develop a unit: maintain rooms to isolate residents as needed, who have viral respiratory infections, gastroenteritis, and other infectious diseases that are transmitted by airborne droplets, contaminated food or water, etc. so that new cases can be prevented . Institute screenings for anyone entering the facility . The IP (Infection Preventionist) will develop a testing place and response strategy to address infectious disease outbreaks. Pursuant to the plan and response strategy, the facility shall test residents and facility staff for infectious diseases listed in Section 690.100 of the Control of Communicable Diseases Code in a manner that is consistent with current guidelines and standards of practice . The IP will arrange for testing of residents and staff for the control or detection of infectious diseases when: The facility is experiencing an outbreak; or Directed by the Department or the certified local health department where the chance of transmission is high, including, but not limited to, regional outbreaks, epidemics, or pandemics. The facility's General guidance for Managing an Outbreak, Revised 6/2022, documents An Outbreak is Generally Defined as: .Occurrence of three (3) or more cases of the same infection over a specified period of time an in a defined area . food poisoning is defined as two (2) or more cases in persons who shared the same meal . diarrhea is defined as anything exceeding the endemic rate, or a single case if unusual for the facility. The Administrator or designee will be responsible for: Telephoning a report to the health department. The Infection Preventionist and Director of Nursing Services will be responsible for . notifying the Medical Director and the Attending Physicians. The nursing staff will be responsible for notifying the Director of Nursing Services of symptomatic residents; Providing infection surveillance data in a timely manner; Initial testing or obtaining laboratory specimens as directed . Initiating isolation precautions as directed or as necessary. If an outbreak is identified, personnel will be responsible to: Notify Administrator, DON (Director of Nursing)/designee, IP and/or Medical Director of any unusual signs and symptoms or events . Follow Core Principals of infection prevention and control . Use PPE appropriately . Notify their supervisor immediately if any new case is suspected both residents and staff. The facility's Stool Cultures in a Suspected Enteric Organism or Food-borne Outbreak, Revised 6/2022, documents An outbreak of suspected food-borne illness is defined as three (3) or more residents with clinically significant diarrheal or loose stools that occur within 24 hours of each other who have common exposure to each other, or share common space, or have consumed the same food. When an outbreak is suspected, the facility takes immediate action to confirm diagnosis and investigate appropriately. 1. When an outbreak is suspected, a stool specimen will be sent to the laboratory for culture and sensitivity. Any residents or staff who exhibit similar symptoms after that time also will have stool samples sent to laboratory for culture and sensitivity. 2. Enteric (food-borne) pathogens should be considered under these circumstances and would include Salmonella, shigella, Campylobacter, and E. Coli etc. 3. Until lab results are available, isolation precautions should be considered and residents who are ill should be assisted to perform good hand hygiene after a stool, should not be included in the dining room, recreational activity, or other group activities until symptoms resolve. 4. Staff exhibiting symptoms should be sent home pending lab results and symptoms resolved. 5. The Infection Preventionist has the authority to order these cultures under the direction of the Medical Director. The facility's Surveillance & Investigation policy and procedure, dated 5/2022, documents Infections that should be included in routine surveillance include those with . a. Evidence of transmissibility in a healthcare environment; b. Available processes and procedures that prevent or reduce the spread of infection . d. Specific pathogens that are associated with serious outbreaks. (e.g., invasive Streptococcus Group A, acute viral hepatitis, norovirus, scabies, influenza.). If a communicable disease outbreak is suspected, this information will be communicated to the Charge Nurse and Infection Preventionist immediately. When infection or colonization with epidemiologically important organisms is suspected, cultures may be sent, if appropriate, to a contracted laboratory for identification . The Charge nurse will notify the Attending Physician and the Infection Preventionist of suspected infections . When transmission of Healthcare-Associated Infections continues despite documented efforts to implement infection control and prevention measures, the appropriate state agency and/or specialist in infection control and epidemiology will be consulted for further recommendations. The facility's HCW (Healthcare Worker) Self-Reporting of Infection policy and procedure, dated 6/2022, documents As part of the facility infection prevention program it is the employee's responsibility to notify their supervisor or the Infection Preventionist of any identified or potential infection with an infectious disease . In compliance with our established policies governing employee health, you must report the following conditions to your supervisor, or to the Infection Preventionist: 1. Temperature of 100 degrees Fahrenheit or greater; 2. Nausea/Vomiting; 3. Acute diarrheal illness (severe) with other symptoms (i.e., fever, abdominal cramps, bleeding, etc.) or diarrhea lasting longer than twenty-four (24) hours . 13. Any other conditions as required by the (State Agency) or CDC. 14. Failure to comply with reporting will result in disciplinary action. The facility's Isolation - Categories of Transmission - Based Precautions, Revised 1/2014, documents Contact Precautions: In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental services or resident-care items in the resident's environment. The decision on whether precautions are necessary will be evaluated on a case by case basis . wear gloves when entering the room . wear a disposable gown upon entering the Contact Precautions room. The facility's Contact Precautions policy and procedures, Revised 5/22, document: Contact Precautions are intended to prevent transmission of infectious agents, like MDRO's (Multiple Drug Resistive Organisms), that are spread by direct or indirect contact with the resident or the resident's environment. In addition to Standard Precautions, use Contact Precautions to prevent nosocomial spread of organisms that can be transmitted by direct resident contact (hand or skin-to-skin contact that occurs when performing resident-care) or by indirect contact (touching) of environmental surfaces or contaminated resident care equipment. Contact Precautions require the use of gown and gloves on every entry into a resident's room . Contact Precautions may be considered for residents who have: 4. diarrhea and fecal incontinence, or 5. Other epidemiologically significant organisms as determined by the facility's Infection control staff and Medical Director. Masks and eye protection, under Standard Precautions, should be worn during resident care activities that are likely to generate splashes of sprays of blood, body fluid, secretions, and excretions. The facility's I-NEDSS (Illinois' National Electronic Disease Surveillance System) Infectious Disease Reporting policy and procedure, dated 5/22, documents Should any resident (s) or staff be suspected or diagnosed as having a reportable communicable/infectious disease according to State-specific criteria, such information shall be promptly reported to appropriate local and/or state health department officials. If the disease or condition is also listed as a Nationally Notifiable Infectious Disease according to the CDC (Centers for Disease Control), the Infection Preventionist, or designee, shall notify the CDC of the occurrence(s). All reportable infectious diseases (residents' or employees') must be reported to the infection Preventionist as soon as definite diagnosis is made or strongly suspected . Infectious Diseases Reportable Immediately by Telephone include: Any unusual case or cluster of cases that may indicate a public health hazard . Botulism, foodborne . Influenza A, variant. The facility's Infection Control Guideline for the Dietary Department, Revised 1/2014, documents Dietary staff: 1. Maintain good health . 6. Are monitored for compliance with policies, procedures, and practices . 8. Do not work if they are ill with a gastrointestinal illness, or have been diagnosed with a food-borne illness. On 7/20/23 at 1:30 pm there was no signage at the entrance of the facility informing visitors that the facility was currently in outbreak status. The facility's Outbreak Line Listing, provided on 7/20/23, documents two symptomatic residents on 7/17/23 (R10 and R11); 28 residents on 7/18/23 (R3, R5, R7, R9, R12 thru R35); and 14 residents on 7/19/23 (R2, R4, and R36 thru R47); and three residents on 7/20/23 (R1, R6, and R48). The Outbreak Line Listing, provided on 7/21/23, documents three additional symptomatic residents (R8, R49 and R50). The Outbreak Line Listing, provided on 7/26/23 documents one additional symptomatic resident (R51) was added on 7/23/23; one additional symptomatic resident (R52) was added on 7/24/23; and one additional resident (R53) was added on 7/26/23. The facility's Outbreak Line Listing, provided on 7/26/23, documents the first symptomatic staff member was V7 Assistant Dietary Manager, with onset of 7/13/23 with fever, diarrhea, nausea, muscle aches, and fatigue. The second symptomatic staff member was V20 [NAME] for second shift, with onset date of 7/14/23 with diarrhea, nausea and fatigue. The third symptomatic staff member was V21 Dietary Manager, with onset date of 7/17/23 with vomiting, fever, and diarrhea. On 7/20/23 at between 1:30 pm through 3:05 pm, a tour of the facility was completed. There was no Outbreak signage noted at the entrance to the facility and no staff were visible wearing masks, gowns, or gloves in common areas, on the hallways, or when entering resident rooms. The facility Wings identified the following wing and Residents as being in isolation for the facility's Outbreak: 200 Wing identified R35; 500 Wing identified R2, R4, R9, R10, R12 through R17, R36 through R42; 600 Wing identified R43 through R47; 800 Wing identified R3, R18 through R30 and 400 Wing identified R4 and R31 through R34. At the entrance to the 400 Wing (Alzheimer's locked unit) a sign was posted to the door that read Guests: Masks are to be worn at all times. After entering the 400 Wing staff, various residents, and visitors were noted throughout the open floor plan and in resident rooms not wearing any PPE. On 7/21/23 at 9:00 am, a sign announcing Facility is in Outbreak was noted on a table in front of the entrance door in an eight by ten frame and was not visible until after entering the facility automatic double doors. On 7/21/23 between 12:00 pm through 1:00 pm, a tour of the facility was completed. During this tour there were multiple staff wearing masks in all areas of the facilities, visitors not wearing masks and random staff not wearing masks in the hallways and common areas. The facility Wings identified the following wing and Residents as being in isolation for the facility's Outbreak; 200 Wing identified R8 and R50; 500 Wing did not identify any residents this day; 600 Wing identified R6 and R47; 800 Wing identified R1 and R3 and V R3's Family Member was visiting R3 and walked to the community dining area without wearing PPE; and 400 Wing identified R4, R31, R48 and R49. On this same date at 12:30 pm, the 800 Wing dining room had residents being served the noon meal. R26 and R29 who were previously symptomatic on 7/18/23 were being assisted in the dining room. On 7/20/23 at 1:30 pm, V1 Administrator stated the facility is currently in an outbreak status and the LHD (Local Health Department) came and just left and is helping us. V1 stated the facility started an investigation on 7/19/23 and feel it started with V7 Assistant Dietary Manager who had symptoms but didn't think it was a big deal and worked anyway. That's how it happened. V1 stated three kitchen staff and a CNA (Certified Nurses Aide) were symptomatic first. V1 stated a few residents were sent to the local hospital but not GI (gastrointestinal) symptoms. V1 also stated there was one resident who passed away who had vomited one hour prior to passing but she had not been sick. V1 stated the LHD reached out to her yesterday (7/19/23) morning and came to the facility today to investigate and help and just left the facility. V1 Administrator stated the facility did not report to the LHD or the State Agency because the LHD called her on 7/19/23 so they were aware. V1 stated she has no confirmed tests for Noroviurs but is treating it as Norovirus. V1 stated first symptomatic residents exhibiting symptoms was on 7/17/23. V1 stated the facility collected and sent stool samples out for R1, R2, and R9 but has not received results yet. Confirmed Outbreak rooms are identified with Orange Stock paper with black I due to not have enough regular Isolation signs to use. On 7/20/23 at 2:48 pm, V7 Assistant Dietary Manager stated on 7/13/23 he was having some bodyaches and a low grade temperature but he felt ok, tested for COVID and it was negative, called his supervisor and was told to go ahead and go into work. V7 stated later in the day I had a diarrhea stool but that is not out of the ordinary for me due to my stomach issues. V7 stated the next day (7/14/23) he still had body aches and diarrhea but went to work and confirmed he did not call his supervisor. V7 stated he was off the weekend (7/15 and 7/16) and returned to work on Monday (7/17/23) without symptoms. V7 stated that V20 [NAME] for second shift went to the doctor on 7/12/23 and reported that the doctor tested her for strep and it was positive, got medicine and then returned to work on Wednesday (7/17/23) and worked through 7/19/23 and was sent home today (7/20/23) due to having diarrhea. V7 Assistant Dietary Manager also stated V21 Dietary Manager called in on Monday (7/17/23) because she wasn't feeling well and came back to work yesterday (7/19/23) to do inventory and then got sent home. V7 stated he had been around his best friends daughter who had thrown up a couple of times and wonders if he maybe he got something from her. V7 stated symptomatic residents are eating in their rooms and everyone else eats in the dining room. On 7/21/23 at 9:00 am, V1 Administrator stated Health Department had a meeting with (State Agency) yesterday and the Health Department told us to stop the dining room meals and now all residents are eating in their rooms. V1 Administrator stated V21 Dietary Manager went to her doctor yesterday and was told she had a stomach virus but did not test V21. V1 also stated the facility is still waiting for the stool culture results for R1, R2, and R9 and the lab said it could take two to five days to get results. On this same date at 10:02 am V1 Administrator stated as of noon yesterday (7/20/23) everyone is eating in their rooms and we placed a sign at the entrance table for visitors, and all staff have been inserviced and should be wearing mask, gown and gloves when entering symptomatic resident rooms and washing their hands before exiting the residents room. On this same date at 11:37 am, V1 Administrator stated the virus seems to have started with V7 Assistant Dietary Manager who has chronic IBS (Irritable Bowel Syndrome) and not sure what to do about that. V1 also stated We are keeping everyone in isolation until 48 hours after they are symptom free. The same with staff. On 7/21/23 at 9:34 am, V6 LPN (Licensed Practical Nurse)/IP (Infection Preventionist) stated an investigation was started on 7/19/23 because there were so many people who became symptomatic. V6 LPN/IP stated We traced it back to V7 Assistant Dietary Manager in the kitchen, who said that he had to relieve himself during one of the meal services. V6 stated It started in the kitchen with V7 Assistant Dietary Manager, so he didn't do something right. V6 LPN/IP stated the CNA's and Nurses were told if someone had a loose stool they were supposed to let me know so we could stool/emesis samples but by the time we got down there it was either on the floor, in the garbage can, or the staff had already cleaned it up. I was not going to get a sample off the floor or from the garbage can. V6 LPN/IP stated stool samples were obtained from R2 and R9 on 7/19/23 and from R1 on 7/20/23. On 7/26/23 at 12:30 pm, V2 DON (Director of Nursing) stated she worked the morning of 7/19/23 on the 800 wing and was not aware of any of the residents having symptoms until that morning upon arriving at the facility. V2 stated generally the staff call about everything and I would have expected them to notify myself and V6 LPN/IP. They did not notify V6 LPN/IP either. V2 DON stated, I called V54 Medical Director on the morning of 7/19/23 and told (V54) what was going on with symptomatic residents on the 500 and 800 wings and asked if we could do Norovirus tests and he said to go ahead and get stool samples. (V54) said we should do four or five. V2 DON stated As of 7/19/23 we kept everyone symptomatic in their rooms in contact isolation with sign and bin outside their room. V2 DON stated residents who were not symptomatic were able to be in the dining room separated from others and everyone was to wear a gown, gloves, and mask in symptomatic resident rooms. V2 DON stated we had two residents with symptoms on the 17th but it is not abnormal for some residents to have diarrhea. The evening of 7/18/23 is when everything really started happening. I was not aware. I do feel that if things would have been started earlier, or we would have known, we could have helped stop the rapid spread of this virus. On 7/25/23 at 2:55 pm and 7/26/23 at 2:30 pm, V21 DM (Dietary Manager) stated she does not recall V7 Assistant Dietary Manager calling in to work sick this month. V7 Assistant Dietary Manager comes to work, does his job, and knows if he is sick he should not be working. V21 DM stated she was on vacation the week of 7/17/23 and is not aware of anyone working while being sick or they would have been sent home, no one reported anything to her, and stated they all (dietary staff) know that if they are ill with nausea, vomiting, diarrhea or fever they cannot work. V21 stated she did not know that V7 Assistant Dietary Manager had not been feeling well until she returned from her vacation. V21 DM stated V65 Dietary Aide/Cook did call her on Sunday 7/10/23 while (V21) was on vacation and (V21) told V65 that she would need to call V7 Assistant Dietary Manager. V21 stated she did remind V65 that it is her scheduled weekend staff are supposed to try and find their own replacement before calling in and all V65 said was she was not going to be able to find anyone to work and said I'll just go to work. V21 DM stated This to me is that you're not really sick or you wouldn't be going to work. V21 DM stated again, They all know that if they are ill with nausea, vomiting, diarrhea, fever they cannot work. V21 DM stated she did not know what happened while she was gone on vacation. 1. The Quarterly MDS (minimum data set) assessment, dated 5/6/23, documents R1 is cognitively intact, requires extensive assist of one with bed mobility, transfers, walking, locomotion, toileting, personal hygiene, and bathing and limited assist with set up for eating. R1 is frequently incontinent of urine and occasionally incontinent of bowel. The current Care Plan for R1, documents (R1) is on contact isolation related to Norovirus symptoms. The Order Summary Report, dated 7/21/23, documents Clear liquid diet every shift until 7/21/23 1:59 am and Contact Isolation every shift until 7/21/23. On 7/20/23 at 3:20 pm, R1 was in lying in her bed with isolation signage posted to the frame of her door. On 7/21/23 at 1:18 pm, R1 was sitting up in a wheel chair in her room with the same isolation signage posted on door frame. On 7/21/23 at 1:18 pm, Entered R1's room with gown, gloves, and mask on. When asked R1 if staff wear gown, gloves, and/or mask in her room, R1 stated, Oh no, no one has come in here dressed like you, this is the first I have seen. No one has worn a gown or gloves into my room, just a mask. R1 stated, I was so sick. Have never had such extreme diarrhea ever in my life. It was diarrhea on top of diarrhea. The Nurse told me it was some kind of flu. R1 stated a stool sample was sent to the laboratory yesterday and she has not heard any results yet. R1 also stated her son got sick after visiting her. The Progress Note for R1, dated 7/19/23 at 4:19 pm, documents Resident c/o (complained) of diarrhea. Loose, watery brown colored stool noted in toilet. No other GI (gastrointestinal) c/o at this time. The Note, dated 7/20/23 at 8:02 am, documents Stool sample collected at this time d/t (due to) diarrhea. The Note, dated 7/20/23 at 10:52 am, documents Covid swab completed with negative result. The Note dated, 7/20/23 at 2:16 pm, documents POA (Power of Attorney) and MD (Medical Doctor) notified. The Laboratory results for R1's stool sample, dated 7/22/23 documents stool specimen obtained on 7/20/23 with diagnosis listed as Diarrhea, unspecified. The Final result for Norovirus PCR (polumerase chain reaction) test: Test not performed and Canceled on 7/22/23 at 2:23 pm; Incorrect collection container submitted. 2. The Quarterly MDS for R2, dated 5/22/23, documents R2 is cognitively intact, requires limited assist of one for bed mobility, locomotion, and personal hygiene. R2 requires extensive assist of one for transfers, toileting, and bathing. R2 requires limited assist with set up for eating and is occasionally incontinent of urine and always continent of bowel. The current Care Plan for R2, does not document anything for R2 regarding the facility's current outbreak or isolation precautions. The Order Summary for R2, dated 7/21/23, does not document any orders regarding the facility's current outbreak. On 7/20/23 at 2:14 pm, R2 was lying in bed with visitors in his room who were not wearing PPE. Isolation signage was on the door frame. On 7/21/23 at 12:30 pm, R2 was sitting up in a wheel chair in his room eating lunch. On 7/21/23 at 12:46 pm, R2 stated the day before yesterday (7/19/23) he had diarrhea for about half of the day and the facility only fed him bread and water. R2 stated he doesn't understand what has been going on and doesn't like it. It was only half a day and then I was fine, nothing else. R2 stated his roommate had it worse than (R2) but is better now. R2 stated They (staff) don't know what is going on here. Someone said they think it was food poisoning but no one will say and they won't let us come out of our room now. I just find it all crazy. The Progress Note for R2, dated 7/19/23 at 11:21 am, documents R2 received Tylenol. The Note at 4:02 pm, documents Resident presents with diarrhea, low grade temp (temperature), Tylenol given. POA and APN (Advance Practice Nurse) aware. The Note at 4:36 pm, documents Resident swabbed for Covid 19, results negative. The Note at 6:14 pm, documents Stool obtained, sent to lab. The Laboratory results for R2's stool sample, dated 7/22/23, documents stool specimen obtained on 7/19/23 with diagnosis listed as Acute gastroenteropathy due to other. The Final result for Norovirus PCR test: Test not performed and Canceled on 7/22/23 at 2:27 pm; Incorrect collection container submitted. 3. The Annual MDS for R3, dated 5/18/23, documents R3 has moderately impaired cognition and requires extensive assist of two staff for bed mobility, transfers, walking, and toileting; requires extensive assist of one for locomotion, personal hygiene and bathing and supervision with set up assist for eating; and is occasionally incontinent of urine and always continent of bowel. The current Care Plan for R3, documents R3 was hospitalized and received IV (intravenous) fluids for hydration. R3's Care Plan does not address the facility's current outbreak or isolation status for R3. The Hospital discharge records for R3, dated 7/20/23, documents R3 was hospitalized from [DATE] through 7/20/23 with diagnoses: Respiratory Insufficiency and Hypoxemia and returned to the facility on antibiotics. The Order Summary Report for R3, dated 7/21/23, does not include isolation orders or any orders regarding the facility's current outbreak status. On 7/20/23 at 3:19 pm, R3 was lying in bed, no isolation signage to room. On 7/21/23 at 1:10 pm, R3 was sitting up in a wheel chair in her room with an isolation sign posted to the door frame of her room. V19 R3's Family Member was visiting without wearing PPE. On 7/21/23 at 1:55 pm, V19 R3's Family Member exited R3's room, without performing hand hygiene and walked to the empty dining area. On 7/21/23 at 1:55 pm, R3 stated she had diarrhea before she went to the hospital and hasn't had any since she came back. R3 stated she wasn't sure why she went to the hospital. On 7/21/23 at 2:00 pm, V19 R3's Family Member stated (R3) only had diarrhea one day and went to the hospital and I don't know why she is in isolation. V19 did state the facility had informed him of the facility outbreak status. The Progress Note for R3, dated 7/18/23 at 6:30 am, document Nausea, vomiting and diarrhea. Anti diarrheal medication given. In bed, eyes closed at this time, Call light within reach. Colace and Miralax (medications) held due to diarrhea. The Note at 1:02 pm, documents Resident seen by V60 NP (Nurse Practitioner). No new orders noted. The evening doses of Colace and Miralax held. The Progress Note for R3, dated 7/19/23 at 10:22 am, documents Observed resident in bed HOB (head of bed) elevated responding lethargically. Vitals taken. Temp (temperature) 98.0, B/P (blood pressure) 93/61, P (pulse) 85, R (respirations) 15, SpO2 (blood oxygen level) 83%, (V61) NP notified. Supplemental oxygen started at 2L (liters) via nasal cannula. The note at 10:48 am, documents SOB (shortness of breath), lethargic, altered mental status. The Note at 10:52 am, documents New order to send to ED (emergency department) per (V61 NP). 911 here to transport. Call placed to (V19 R3's Family Member.) The Progress Note for R3, dated 1/19/23 at 11:06 am, V60 NP documented NP was called to see (R3) because of altered mental status and low oxygen saturations. Yesterday (7/18/23) she had GI symptoms of vomiting and diarrhea. This morning the nurse noticed she was more out of it and not acting herself. She (R3) is usually up in her chair and talking. This morning she did not want to get out of bed. She is having a hard time answering questions and following commands. Her oxygen saturation was initially 83% and she was placed on 2L. When I (V60 NP) arrived she was only at 87-88% and titrated her (R3) oxygen up to 4L and she eventually came up to 95%. She (R3) still could not follow commands and was very slow to respond to questions. She knew her birthday but not where she was or the year. 911 was called and she was sent out with EMS (emergency management systems.) . Altered mental status: Acute, unstable . Low oxygen saturation: Acute, Unstable continue 4L nasal cannula. Send to ER (emergency room) via 911 . Diagnoses: 1.) Altered metal status, unspecified. 2.) Hypoxemia. The Laboratory reports for R3 do not include any stool specimens being collected or sent to the facility lab. 4. The Quarterly MDS for R4, dated 5/2/23, documents R4 with moderately impaired cognition, requires extensive assist of two staff for bed mobility, dressing, toileting; totally dependent of two staff for transfers and bathing; extensive of one staff for eating and personal hygiene; and is frequently incontinent of urine and bowel. The current Care Plan for R4 documents (R4) is on contact isolation related to Norovirus symptoms. The Order Summary Report for R4, dated 7/21/23, documents order 7/21/23 Clear liquid diet every shift until 7/22/23 1:59 am. No isolation orders are included in R4's current physician orders. On 7/20/23 at 2:22 pm, R4 was lying in bed. No Isolation signage is posted to R4's door or door frame. On 7/21/23 at 1:00 pm, R4 was lying in bed with isolation signage posted to R4's door frame. V62 CNA (Certified Nursing Assistant) was standing[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's call light was answered in a timely manner to meet the resident's need for one of four residents (R3) reviewed for accommodation of needs in the sample of four. Findings include: The facility's Call Lights Policy, dated 8/14/21, states, Purpose: 1. To respond promptly to resident's call for assistance. Procedure: 1. All facility personnel must be aware of call lights at all times. 2. Answer all call lights promptly whether or not the staff person is to the resident. 3. Answer all call lights in a prompt, calm, courteous manner; turn off the call light as soon as possible. The Residents' Rights for People in Long Term Care Facilities, dated 11/18, documents the facility must provide residents services to keep their physical and mental health at their highest practical level and the facility must provide care that promotes residents' quality of life. The facility's Certified Nursing Assistant/CNA Job Description, undated, states, Essential Duties and Responsibilities: Answers residents' call lights promptly and courteously. The facility's Resident Council Minutes for May 2023 states, We need more CNAs/Certified Nursing Assistants on the floor. R3's Facesheet documents R3 admitted to the facility on [DATE] with diagnoses to include but not limited to: Nondisplaced Traverse Fracture of Right Patella; Morbid Obesity; Nondisplaced Fracture of Greater Trochanter of Right Femur; Generalized Muscle Weakness; Difficulty Walking; Unsteadiness on Feet; and a Previous Fall. R3's Minimum Data Set/MDS Assessment, dated 5/23/23, documents the following: R3 is cognitively intact with no memory impairments, scoring a 15 out of 15 on the Brief Interview of Mental Status (BIMS); R3 is always continent of urine and bowel; R3 requires extensive assistance of two plus persons physical assist for transfers, bed mobility, walking in room, and toilet use; R3 is not steady, only able to stabilize with staff assistance for moving on and off the toilet; R3 has range of motion impairment on one side of R3's lower extremities; and prior to R3's current illness, R3 was independent for R3's self care needs, including toilet use. R3's Current Care Plan at the time of R3's admission documents the following: (R3) has a deficit in ADL/Activities of Daily Living abilities and requires staff assistance due to fall in the community with fracture of right patella. WBAT (Weight Bearing as Tolerated) to RLE (Right Lower Extremity) with immobilizer in place at all times. (R3) is alert oriented and able to make needs known. with an intervention of Assist with all transfers and maintain any weight bearing restrictions.; (R3) is at risk of falls due to history of fall in the community with fracture. (R3) has impaired mobility and weakness and requires assistance with transfers. (R3) takes medications that increase her risk of falls. with an intervention of Call light in reach and answer in a timely fashion.; and Assist me with my personal cares as needed. On 5/31/23 at 10:26 AM, V13 (R3's Family Member) stated, On 5/23/23 shortly after 8:00 AM, I came to visit (R3). (R3's) call light was on when I got there. I asked (R3) how long her light has been on and she said at least a half hour. (R3) said she had to go to the bathroom badly. I took (R3) to the bathroom myself. The nurse came in the room when we were finishing and told me to not transfer (R3) on my own. I talked to (V2/Director of Nursing) right after that happened because I shouldn't have to be the one who helps (R3) to the bathroom. A couple days later, (5/25/23) (R3) called me very upset that she had to go to the bathroom so bad and had been waiting over an hour for help. (R3) ended up soiling herself because no one ever came. (R3) knows when she has to go to the bathroom. That shouldn't have happened. I came to the facility and went to the Administrator (V1). I let her know I wanted to take (R3) home that day with me since no one seemed to be taking care of her there (at the facility). On 5/31/23 at 3:19 PM, R3 stated, I wasn't at the facility for a very long time. I didn't need very much, just help to go to the bathroom. One day (5/23/23), (V13) had to help me to the bathroom because no one was coming in. I had already been waiting a half hour. The day I came home (5/25/23) was even worse. I waited over an hour. I remember I saw a male nurse in the hallway. I was thinking, 'Why is no one coming in? Why does it take that long?' I had to pee so bad that it hurt. They were giving me laxatives and I didn't know it. I kept pushing my button over and over. I don't know if that does anything, but I really needed help, so I just kept pushing it. I was screaming and hollering for someone to 'please, help me.' No one came. I ended up having an accident. I had to be cleaned up of (urine and stool). I know when I have to go to the bathroom, I shouldn't be having accidents. Before I broke my leg, I could get up and down and do everything on my own. I can't do that right now. I ended up going home later that day. I now have a commode here in my living room. I would rather do that and be able to go to the bathroom when I need instead of waiting hours for help over there. On 5/31/23 at 12:40 PM, V2 (Director of Nursing) stated that on 5/23/23, V13 came to V2's office upset with R3's call light wait times. (V13) said that (R3) had waited over a half hour and that (V13) took (R3) to the bathroom herself. V2 stated this occurred around 8:30 AM, which was breakfast time. V2 stated, I could see longer (call light) wait times if it was around breakfast. On 5/31/23 at 1:13 PM, V6 (Social Service Director) stated that V6 was aware of R3 and V13's concerns regarding call light wait times. V6 stated R3 was offered to change rooms earlier in the week to a floor that wasn't as heavy and R3 declined due to the rooms being smaller. V6 stated on 5/25/23, V13 was very upset and went to V1 stating that V13 wanted to take R3 home. V6 stated R3 complained to V6 that it takes a while for staff to get to R3. V6 stated that V6 would normally complete a grievance or complaint form for R3 and V13's concerns but V6 overlooked that. V6 stated a whole investigation was completed after V13's concerns. V6 verified R3 discharged home the day of the 5/25/23 incident per R3's and V13's request. On 6/1/23 at 9:57 AM, V15 (Licensed Practical Nurse) stated that V15 walked into R3's room on 5/23/23 as V13 was walking R3 back from the bathroom. On 6/1/23 at 10:38 AM, V14 (Certified Nursing Assistant) stated the following: R3 was alert and oriented and able to make needs known; R3 was continent of urine and bowel; R3 required assistance to use the bathroom; and V14 assisted R3 in being cleaned up of urine and bowel in R3's bed. On 5/31/23 at 3:09 PM, V1 (Administrator) stated that is the expectation that call lights are to be answered as soon as possible. V1 stated all staff was re-educated on 5/25/23, during the investigation into R3 and V13's call light concerns. V1 stated that no staff member should walk past a call light without going in to check on the resident. V1 stated that if the resident needs something that person cannot provide, the staff member should let the resident know they will get someone to help. V1 stated, If anyone is waiting 20 minutes or more, that is too long.

Based on observation, interview, and record review, the facility failed to follow a treatment dressing change order for one (R1) of four residents reviewed for treatments in a sample of four. Findings include: R1's current treatment orders, dated 11/28/22, document: Right lateral calf: Cleanse hematoma with wound cleanser. Pat dry. Apply skin prep, non-adherent gauze, calcium alginate, silicone boarder foam; every day shift every other day for wound management. R1's current diagnosis include: Personal history of other venous thrombosis and embolism; personal history of diseases of the skin and subcutaneous tissue; venous insufficiency (chronic/peripheral). R1's Skin Only Evaluations, dated 11/22/22 and 11/28/22 document: Traumatic wound. Right lower extremity lateral; right lower extremity wound bed is moist red and granular, no slough erythema or odor. Edges flat and intact. Tolerates dressing change well. R1's current Care Plan documents: (R1) is at risk for skin breakdown due to fragile skin due to normal aging process, history of skin issues, fluctuations in oral intake. R1's Treatment Administration Record (TAR) dated 12/2022, indicated no wound treatment to R1's right lateral calf for scheduled treatment date of 12/2/22. On 12/8/22 at 12:05pm, V9 Certified Nursing Assistant (CNA) stated that on 12/4/22, she assisted V8 Licensed Practical Nurse (LPN) with R1's wound treatment and dressing change to R1's right lower extremity; stated that she saw a date of 11/30/22 on R1's soiled dressing. V9 stated that V8 asked V10 Licensed Practical Nurse (LPN) and V9 (CNA) to look at the soiled dressing to make sure she was not reading the date wrong. V9 stated that both she and V10 verified the date was 11/30/22. On 12/8/22 at 12:35pm, V8 (LPN) stated that R1 had an order to treat the wound on R1's right lower extremity every other day; that V8 changed R1's dressing on 12/4/22 after she removed a soiled dressing dated 11/30/22 with (V11 Licensed Practical Nurse/LPN's) initials written on it. (Noted that the TAR for R1 indicated that V11's signed off the treatment for 11/30/22.) V8 stated that the next treatment for R1's right lower extremity should have been done on 12/2/22. At this time, V8 also stated that the soiled dressing had adhered to R1's wound area and stated that both she and V10 (LPN) were able to remove the soiled dressing after some time by using saline to soak the dressing for several minutes, being careful not to cause any undue skin irritation with the least amount of damage to R1's skin. Stated that R1 was concerned with the amount of saturated blood on the soiled dressing and that R1 stated, Look at that blood. On 12/8/22 at 12:50pm, V10 (LPN) stated that she assisted V8 (LPN) on 12/4/22 with R1's dressing change; stated that she does have wound care certification; that V8 was unable to get R1's soiled dressing off due to it was saturated with blood, stiff, and stuck and adhered to R1's leg. V10 stated, After soaking the dressing, was able to pull it off in a safe manner; no signs of infection were noted. On 12/8/22 at 2:35pm, V3 (LPN)/Wound Nurse stated that she was scheduled to do R1's wound treatment on 12/2/22 but did not. V3 stated, I did not do (R1's) treatment; don't know for sure if I asked someone else to do it; just did not get time to do it, ran out of time. V3 stated that (V8 Licensed Practical Nurse/LPN) advised V3 regarding issue with R1's treatment and that (V8) had changed the dressing on 12/4/22 (per schedule).

Based on observation, interview and record review, the facility failed to ensure fall interventions were implemented to prevent further falls and implement safety interventions to prevent foot injuries for two of 11 residents (R56, R49) reviewed for accidents/hazards in the sample of 41. Findings include: The facility's Fall Risk Screening Policy (Revised 05/2015) documents the following: The staff and attending Physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. R56's Fall Investigation (dated 10/30/21) documents R56 fell in his room while attempting to self transfer, and the following fall prevention intervention was implemented: Tab alarm while up in wheelchair and in bed due to impaired cognition with poor safety awareness. R56's Fall Investigation (dated 11/01/21) documents R56 fell while attempting to transfer himself to the toilet. This same investigation documents R56's tab alarm was not in place at the time of his fall. R56's Fall Investigation (dated 11/29/21) documents R56 fell while attempting to ambulate in his room. This investigation also documents R56's tab alarm was not in place prior to his fall, and the following fall prevention intervention was implemented, Staff to ensure tab alarm is in place and properly working every shift due to (R56's) poor cognition. R56's Fall Investigation (dated 12/28/21) documents R56 stood from his wheelchair in the dining room and fell. This investigation also documents R56's tab alarm was not in place at the time of R56's fall. The following fall prevention intervention was implemented: Staff to ensure tab alarm is in place at all times. Physical Therapy/Occupational Therapy to screen and treat as needed. On 04/13/22 at 02:15 PM, V9 (Restorative Director) verified that R56's fall prevention intervention of a tab alarm was not in place at the time of R56's falls on 11/01/21, 11/29/21, and 12/28/21, and stated, It should have been in place. 2) R49's current Physician's Order Sheet indicates order initiated on 4/12/22 to cleanse left lateral 5th toe ulcer, cleanse with normal saline/apply skin prep/cover with dressing. R49's current Physician's Order Sheet indicates order initiated on 4/13/22 to cleanse left foot 2nd digit with normal saline or wound cleanser. Apply skin prep to two scabbed areas and cover with dressing to make sure dressing covers in between toes. On 4/13/22 at 10:45am V8, LPN (Licensed Practical Nurse) provided wound care to R49's bilateral heels and left 2nd and 5th toes. R49's left foot 2nd toe noted with two thick scabs along the top of the toe; R49's 5th (pinky) toe observed with one scab on top/outer area. At that time, R49 was seen in bed with bilateral heel protectors which covered heels and ankles only - R49's toes were left open/exposed. At that time, V8 stated she was unsure if wounds on R49's toes were caused by pressure or injury. Skin Progress note dated 4/11/22 at 1:39pm indicates skin issue: left lateral 5th toe pressure ulcer Stage II - partial thickness skin loss; Length 0.3cm (centimeters), Depth 0.1cm, Wound Bed Granulation, Wound Exudate: Serosainguinous, Peri Wound Erythema. Note indicates wound is painful. Left lateral 5th toe noted to have circular open area to lateral aspect. Note further indicates, (R49) observed repetitively rubbing and bumping foot on carpet and bottom of tray table. Has heel protectors in place and wears with encouragement. (R49) does not wear shoes and is non-ambulatory. Note indicates POA (Power of Attorney) and Hospice notified of new area. This Skin Note indicates Clinical Suggestion: Advised R49 to frequently shift weight and raise buttocks while sitting in chair. No interventions were included to prevent further injury to R49's left 5th toe wound or other toes/foot due to repetitive rubbing and bumping foot on carpet and bottom of tray table . The Clinical suggestions in the progress note of 4/11/22 addressed shifting weight and raising buttocks in chair. Incident Report dated 4/13/22 at 10:00am indicates new toe wounds were found on R49's left 2nd toe (on 4/13/22) When doing dressing change to left foot, noted two scabs on top of 2nd digit and some redness between 2nd and 3rd digit - Proximal site measures 0.7cm x 0.6cm; Distal site measures 0.4cm x 0.4cm. The Incident Report Note dated 4/13/22 indicates R49 was observed sitting on bed with both feet on floor with left foot swinging back and forth on the floor dragging on the carpet. Note indicates R49 is often observed kicking objects near him such as foot board, bedside table and garbage can due to constant movement of his feet and dragging on carpeted floor and/or striking objects near him. No interventions were included to prevent further injury to R49's left 2nd and 5th toe wounds. The Incident report notes did not include interventions to protect R49's toes from dragging on the carpet or kicking nearby objects in his room until intervention identified on 4/14/22 (Incident Report Note). Incident Report Note dated 4/14/22 indicates, (R49) is no longer moving his feet appropriately to propel his (Hospice provided wheelchair). Hospice will provide a (different) chair that gives support to his feet to prevent them from dragging on carpeted areas and thus prevent injury. Current Care Plan identifies R49's left lateral 5th toe Stage II ulcer on 4/11/22. Care plan does not include left foot 2nd toe wounds. Intervention dated 4/12/22 indicates, Nutritional supplements as ordered to promote wound healing. No other interventions were initiated to prevent further injury to R49's toes/feet. On 4/14/22 at 9:45am V10, Wound/RN (Registered Nurse) stated that she identified the wound on R49's 5th toe on 4/11/22 as a Stage II pressure wound. V10 stated that she does not recall seeing scabs/wound on R49's 2nd toe on (4/11/22) when she identified the wound on R49's 5th toe. V10 stated she believes R49's toe wounds are a combination of friction and mechanical injury due to his bumping into things with his feet. V10 was unable to identify the interventions that were initiated to prevent further pressure or further injury to R49's toe wounds. Facility Policy/Accidents and Incidents dated 5/2015 documents: Identification of Risks and Hazards: The areas assessed include the residents' room and surrounding environment. This allows the facility to communicate information about observed hazards and make corrections if possible, identify resident specific information, develop and implement an individualized plan of care to address resident's needs and to monitor the results of the planned interventions. Implementation of Interventions: Interventions include supervision and other actions that could address and reduce the potential for negative outcomes.

Based on interview and record review, the facility failed to attempt a gradual dose reduction of a psychotropic medication for one of four residents (R63) reviewed for psychotropic medications in the sample of 41. Findings include: The facility's Psychotropic Medication policy (dated 11/2013) documents the following: Residents who use psychotropic drugs receive gradual dose reductions, unless clinically contraindicated, and behavioral interventions. The facility's Gradual Dose Reduction policy (dated 03/2017) documents the following: Gradual dose reduction is seeking the optimal dose, duration and minimizing the risk for adverse consequences or to determine whether continuing use of the medication is benefiting the resident. This policy also documents, Sometimes the decision to continue a medication is clear as in the case of someone with a history of multiple episodes of depression. They may need an antidepressant indefinitely. Often, however the only way to know whether a medication is needed indefinitely and if the dose remains appropriate is to try reducing the dose and monitoring the resident closely for improvement, stabilization or decline. R63's current Physician's Orders documents the following medication order: Seroquel (antipsychotic) 25 milligrams by mouth one time daily. R63's medical record does not contain documentation of a Pharmacy Recommendation sheet for a gradual dose reduction of R63's Seroquel within the past year. R63's Behavior Monitoring Sheets (dated 02/2022 - 04/2022) document zero episodes of adverse behaviors displayed by R63 during this time. On 04/14/22 at 10:35 AM, V3 (Assistant Director of Nursing) stated that R63 has not displayed any adverse behaviors for several months. V3 then stated that a gradual dose reduction of R63's Seroquel has not been suggested or attempted for over 18 months.