**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to protect a resident's right to dignity for two of two residents (R1, R11) by another resident (R5) reviewed for dignity in the total resident sample list of 27. Findings Include: The State of Illinois Ombudsman Program, Resident Rights in Long Term Care Facilities dated 11/2018 documents that all residents have a right to dignity and respect and the facility must care for residents in a manner that promotes their quality of life. The facility must provide services to keep each resident's mental health at the highest practical level. On 6/24/24 at 1:20 PM R11 stated R5 is very loud and constantly talking and he makes derogatory and prejudice comments as well as false comments. R11 states this makes him uncomfortable, bothers him a lot and also bothers others in the room. R11 stated he will often forgo activities or community outings if R5 is going because he doesn't want to be subjected to the negativity. R11 stated he has not complained about this to anyone in particular but staff are around and have heard these comments. R11 states staff tell R5 to stop but he just keeps doing it. On 6/24/24 at 1:25 PM R1 stated R5 does talk all of the time, is disruptive, and does make derogatory and racist comments about Chinese people. R1 stated it does bother her and she wishes that he would stop. R1's Medical Diagnoses list dated June 2024 documents R1 is diagnosed with Depression, Insomnia, and Obsessive Compulsive Disorder. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact. R11's Medical Diagnoses list dated June 2024 documents R11 is diagnosed with Diabetes. R11's Minimum Data Set, dated [DATE] documents R11 is cognitively intact. R5's Medical Diagnoses list dated June 2024 documents R5 is diagnosed with Depression, Cerebral Palsy, and Mental Disorder. R5's Minimum Data Set, dated [DATE] documents R5 is moderately cognitively impaired. On 6/24/24 at 1:30 PM V1 Administrator stated she had not been told about any prejudice or derogatory remarks made by R5 but will begin an investigation into the allegation. On 6/25/24 at 11:30 AM V1 Administrator stated she is conducting the investigation from the complaints of R1 and R11 and feels it is a resident rights issue. Residents have the right to be comfortable in their home and R5 should not be making comments that create a bad or negative atmosphere for others. Staff need to be more vigilant and intervene when necessary. V1 confirmed when R5 makes negative and prejudice comments it can impede on other resident's right to dignity.

Based on observation, interview and record review the facility failed to implement interventions in response to signs and symptoms of shortness of breath for a resident and ensure respiratory tubing is maintained in a sanitary manner for a resident receiving oxygen therapy. These failures affect one (R183) of three resident's reviewed for respiratory care from a total sample list of 27 residents. Findings include: The Facility provided Respiratory Assessment Policy dated 8/2003 documents that respiratory assessments and interventions are to be documented in the resident's medical record. R183's undated diagnoses sheet documents diagnoses including Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure. R183's care plan dated 6/19/2024 documents to monitor R183 for signs and symptoms of respiratory distress and to report to the physician changes in respiratory condition including respirations, pulse oximetry, tachycardia, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage and skin color. R183's progress notes document on 6/24/24 an oxygen saturation level of 88 percent. On 6/23/24 at 9:33AM, R183 appeared short of breath. Her color was pale, and she was using abdominal muscles to breathe. R183 was sitting up in the bed with oxygen at one liter being administered via nasal canula. The oxygen tubing nor water was dated, and the tubing was laying on the floor. On 6/23/24 at 9:35AM, R183 stated, This is a bad breathing morning. On 6/23/24 at 1:30PM, R183 remained in bed, resting her eyes and pursed lip breathing (breathing technique). On 6/24/24 at 10:35AM, R183 appears very short of breath and gray in color. R183 is breathing with accessory muscles and cannot speak due to shortness of breath. R183's oxygen continues at one liter per nasal cannula and the tubing, nor the water is dated. On 6/24/24 at 10:36AM, V15 Certified Nursing Assistant was taking R183's vital signs. R183's oxygen saturation was 89 percent on one liter of oxygen and her pulse rate was 125 beats per minute. R183 was not able to speak and was gasping. R183 is opening and closing her eyes and appears very uncomfortable. On 6/24/24 at 10:38AM, V2 Director of Nursing (DON) said that she had a discussion with R183 and V16 (Family Member) about hospice and comfort care options but that they were not wanting that at this time. When asked about the plan for R183's comfort during periods of air hunger, V2 DON said that it was a difficult situation to manage. On 6/24/24 10:40AM V4 Licensed Practical Nurse (LPN) stated, I just turned her oxygen up to two liters because of her vital signs. I will notify the doctor. On 6/24/24 11:00AM, V1 Administrator stated, I went down, and her coloring isn't good, and she doesn't look comfortable to me. We are going to send her to the ER. On 6/24/24 3:50PM V3 LPN stated, I saw that she was struggling before she went to the hospital and I'm sure that it is the Lasix (diuretic) that made the difference. On 6/25/24 at 9:30AM, R183's coloring is much improved to pale pink and R1 is able to speak while breathing more easily. On 6/25/24 at 9:31AM, R183 said that she was very scared yesterday and that she received an extra dose of Lasix (diuretic) in the hospital and that seems to have helped. On 6/25/24 at 10:44AM, R183's oxygen remains undated. On 6/25/24 at 10:45AM, V11 LPN stated, Oxygen tubing is supposed to be labeled weekly. They usually do it on nights.

Based on interview and record review the facility failed to document psychotropic medication assessments, identify and track targeted behaviors, and attempt non-pharmacological behavioral interventions for two (R15, R20) of five residents reviewed for psychotropic medication in a sample list of 27 residents. Findings Include: The facility's policy Psychotropic Medication Policy revised 11/28/17 states Residents who receive antipsychotic drugs shall receive gradual dose reduction and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Any resident receiving psychotropic medications will be reviewed at minimum of every quarter by the interdisciplinary team. 1. R15's Care Plan revised 6/25/24 includes the following diagnoses: Major Depression and Mild Dementia with Anxiety. R15's Medication Administration Record (MAR) for June 2024 includes the following active physician's orders for Psychotropic Medication: Sertraline HCL (antidepressant) Give 75 milligrams by mouth one time a day. Aripiprazole (antipsychotic) 20 milligrams by mouth in the morning. There is no documentation of psychotropic assessments observed for R15. No targeted behaviors are identified or tracked for R15. No non-pharmacological interventions are documented as initiated for R15. 2. R20's Care Plan revised 6/5/24 includes the following diagnoses: Dementia with Agitation and Major Depressive Disorder. R20's Medication Administration Record (MAR) for June 2024 includes the following active physician's orders for Psychotropic Medication: Fluoxetine HCl (antidepressant) Oral Capsule 40 MG Give 80 mg by mouth one time a day. Quetiapine (antipsychotic) 25 MG Tab Give 12.5 mg by mouth two times a day. Divalproex Sodium DR (neuroleptic) 125 MG Give 1 tablet by mouth two times a day for dementia with behaviors. R20's most recent Psychotropic Medication Assessment is dated 9/29/23 and includes only the Fluoxetine. No targeted behaviors are identified or tracked for R20. No non-pharmacological interventions are documented as initiated for R20. On 6/25/24 at 10:01AM V16, Care Plan Coordinator stated I wasn't aware I needed to do quarterly assessments for residents with psychotropic medications. I will be doing the assessments and documenting specific behaviors and non-pharmacological interventions in the future. I do see this was not done for (R15 and R20).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to dispose of expired schedule two narcotics for one (R6) of three residents reviewed for medications from a total sample list of 27 residents. Findings Include: The facility provided Procurement and Storage of Medications Policy dated [DATE] documents that all discontinued/expired non-controlled medications are to be removed from the active medication storage area, and the quantity should be noted on the medication sheet. All medications should then be returned to pharmacy or destroyed per facility policy as soon as practical. All controlled substances are to be destroyed according to the facility policy and procedure. R6 's undated physician order sheet documents an order for Morphine 20 milligrams per milliliter per 30 milliliter bottle, administer .25 milliliters, sublingually as needed, every four hours as needed for pain. On [DATE] at 9:30AM, two bottles of Morphine Sulphate were in cart two's narcotic box. One bottle had 13 cubic centimeters of medication left in it and one bottle was full with 30 cubic centimeters in it. Both bottles had expiration dates of [DATE]. On [DATE] at 9:35AM, V4 Licensed Practical Nurse stated, They are expired. It should have been destroyed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete wound treatments for one of four residents (R5) reviewed for wound care in the sample list of 22 residents. Findings include: R5's Medication Administration Record dated 5/1/23 through 5/31/23 documents diagnoses including Age Related Physical Debility, Cerebral Palsy, Functional Urinary Incontinence and Mental Disorder. R5's Nurse's Note dated 4/25/23 at 9:40 AM by V16 Wound Nurse documents R5 has MASD (Moisture Associated Skin Damage) to the buttocks and R5 was seen by the Wound Physician. R5's Minimum Data Set (MDS) dated [DATE] documents R5 had MASD. R5's Wound Assessment and Plan dated 4/4/23 by V22 Wound Nurse Practitioner, documents Wound Type as MASD and a treatment order to cleanse area, pat dry well, Zinc Barrier Cream 20% or greater, apply every shift and as needed and every half day cleanse wound with normal saline or sterile water, apply to wound bed, cover with dry clean dressing and as instructed, (disinfectant/antiseptic). R5's Treatment Administration Record (TAR) dated 4/1/23 through 4/30/23 documents an order with a start date of 4/5/23 at 6:00 PM and a discontinue date of 4/8/23 for the Sacrum: Cleanse wound with normal saline or sterile water- Apply to wound bed, cover with dry clean dressing, every shift. This TAR then documents an order with a start date of 4/9/23 for the Sacrum: Cleanse wound with normal saline or sterile water- Apply to wound bed, cover with dry clean dressing. everyday shift -Start Date- 4/08/2023 and a D/C (discontinue) Date- 4/12/2023. This treatment was not signed off as completed on 4/8/23 or 4/12/23. R5's Wound Assessment and Plan dated 4/11/23 by V22 documents the Wound Type as MASD and documents a treatment order to cleanse area, pat dry well, zinc barrier cream 20% or greater, apply every shift and as needed and twice a day cleanse wound with normal saline or sterile water, apply to wound bed, cover with dry clean dressing and as instructed. R5's TAR dated 4/1/23 through 4/30/23 does not document the 4/11/23 order. There is no treatment documented after 4/11/23. R5's Wound Assessment and Plan dated 4/18/23 by V22 documents the wound type as MASD to the Sacrum and documents a treatment order to cleanse area, pat dry well, zinc barrier cream 20% or greater, apply every shift and as needed and every twice a day cleanse wound with normal saline or sterile water, apply to wound bed, cover with dry clean dressing and as instructed, (gel forming moisture-retentive dressing), change as indicated and as needed. R5's TAR dated 4/1/23 through 4/30/23 does not document this order as being written or completed. R5's Wound Assessment and Plan dated 4/25/23 by V22 documents the Wound Type as MASD and documents a treatment order to cleanse area, pat dry well, zinc barrier cream 20% or greater, apply every shift and as needed and twice a day cleanse with normal saline or sterile water, apply to wound bed and cover with dry clean dressing and as instructed. R5's TAR does not document this order as being written or completed. R5's Wound Assessment and Plan dated 5/16/23 by V22 documents the Wound Type as MASD and documents a treatment order to cleanse area, pat dry well, skin barrier cream/ointment, apply every shift and as needed and twice a day cleanse wound with normal saline or sterile water, apply to wound bed, cover with dry clean dressing and as instructed. R5's TAR dated 5/1/23 through 5/31/23 documents an order with a start date of 5/16/23 to cleanse area. Pat dry well. Skin barrier cream/ointment-apply every shift and as needed for MASD. R5's TAR does not document that this has been completed. There are no signatures on the dates to indicate the treatments were completed. On 5/18/23 at 12:20 PM, V2 Director of Nursing confirmed the orders are not entered correctly according to V22's orders. V16 Wound Nurse confirmed that V22's orders are documenting things that are not getting completed. The facility policy titled 'Skin Conditioning Monitoring' revised 3/16/23 documents it is facility policy to provide proper monitoring, treatment and documentation of any resident with skin abnormalities. Upon notification of a skin lesion, wound, or any other skin abnormality, the nurse will assess and document the findings in the nurses notes and complete a skin evaluation. The treatment order will include type of treatment, location of area to be treated, frequency of how often treatment is to be performed, how area is to be cleansed and stop date if necessary. Any skin abnormality will have a specific treatment order until area is resolved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to transcribe physician orders and complete wound treatments and pressure risk assessments for one of four residents (R33) reviewed for wound care in a sample list of 22 residents. Findings include: R33's undated Face Sheet documents an admission date of 3/17/23 with medical diagnoses of Displaced Bimalleolar Fracture of Right Lower Leg, Atrial Fibrillation and Congestive Heart Failure. R33's Pressure Ulcer Risk assessment dated [DATE] documents R33 as high risk for skin breakdown. R33's Medical Record does not document any further Pressure Ulcer Risk Assessments after R33's Stage 2 Right Inner Ankle Pressure Ulcer was identified on 4/25/23. R33's Skin Only Evaluation dated 4/26/23 documents a Right Inner Ankle Stage 2 Pressure Ulcer measuring 3.0 centimeters (cm) long by 2.0 cm wide by 0.1 cm deep. This same evaluation documents R33's Stage 2 Right Inner Ankle Pressure Ulcer was first noted at the Physician office after cast removal. R33's Skin Only Evaluation dated 5/4/23 documents a Right Ankle Stage 2 Pressure Ulcer as having partial thickness skin loss with painful purulent tan and yellow drainage. This same evaluation did not have measurements. R33's Nurse Progress Note dated 5/4/23 at 9:26 AM documents (R33) seen by (V17) Wound Physician. New orders to Inner Ankle on Right R33's Nurse Progress Note dated 5/8/23 at 5:18 PM documents (R33) seen by (V18) Family Nurse Practitioner (FNP). FNP would like the dressing to pressure wound on Right Ankle changed daily instead of every other day. R33's Skin Only Evaluation dated 5/11/23 documents a Right Ankle Stage 3 Pressure Ulcer as measuring 2.5 cm long by 1.5 cm wide by no depth documented with full thickness skin loss. R33's Physician Order Sheet (POS) dated April 1-30, 2023, and May 1-31, 2023, does not document physician orders for treatment of R33's Right Inner Ankle Pressure Ulcer. R33's Treatment Administration Records (TAR) dated April 1-30, 2023, and May 1-31, 2023, do not document any treatment orders for R33's Right Ankle Pressure Ulcer. R33's Care Plan does not include a focus area, goal nor interventions for R33's Right Ankle Pressure Ulcer. On 05/15/23 at 7:30 AM R33 stated I fell at home and broke my Right Ankle in two areas. After I had my surgery, I came here (facility). R33 stated I have a pressure ulcer on my Right Ankle from where the cast rubbed. I think it has gotten worse since they (staff) first noticed it. On 5/15/23 at 7:35 AM Observed R33's Right Inner Ankle with a quarter sized dry intact dark brown/black scab. Another smaller dime sized area was just lateral to the larger area still on R33's Right Inner Ankle. No dressing was noted on R33's Right Ankle or in the bed linen. On 05/17/23 at 1:45 PM V2 Director of Nurses (DON) stated any newly admitted resident or established resident that has pressure ulcers documented should have those wounds measured, documented, care planned, and Physician should be notified to obtain wound orders. We (facility) documented that (R33) had a Stage 2 Pressure Ulcer that worsened to a Stage 3 and we (facility) had no orders on the POS or TAR. That is terrible. I have no way to say if the treatments were even getting done. By the documentation, (R33's) Right Inner Ankle Pressure Ulcer was being measured but there was no other follow up. I have been trying to educate all the nurses on how to document a pressure wound. I can't say why the nurses didn't have treatment orders on the POS or TAR, but I do know that they (staff) have been educated on this many times before. It looks like I will have to re-educate again. The undated facility policy titled 'Preventative Skin Care' documents all residents will be assessed using the pressure ulcer risk assessment at the time of admission and weekly for four weeks. Then will be reassessed at least quarterly and/or as needed. The facility policy titled 'Skin Conditioning Monitoring' revised 3/16/23 documents it is facility policy to provide proper monitoring, treatment and documentation of any resident with skin abnormalities. Upon notification of a skin lesion, wound, or any other skin abnormality, the nurse will assess and document the findings in the nurses notes and complete a skin evaluation. The treatment order will include type of treatment, location of area to be treated, frequency of how often treatment is to be performed, how area is to be cleansed and stop date if necessary. Any skin abnormality will have a specific treatment order until area is resolved.

3.) R16's Physician Progress Note dated 5/3/23 documents Chief complaint/Reason for visit: Wound on Left Knee. Diagnosis: Pressure Ulcer. Assessment and Plan: Recommend bordered foam to area to avoid further pressure. Replace every three days or as needed if soiled. On 05/17/23 at 10:13 AM Observed R16's Left Inner Knee Pressure Ulcer. V13 Licensed Practical Nurse (LPN) completed the dressing change. R16's Left Inner Knee Pressure Ulcer was dark red with three dark yellow dry areas in the center. R16's Left Inner Knee Pressure Ulcer did not have a bandage covering the area. On 5/17/23 at 10:20 AM V13 Licensed Practical Nurse (LPN) stated (R16's) Left inner Knee wound appeared to be a bug bite at first but now they (facility) called it a pressure ulcer. V13 stated I hadn't seen it for about a week because I was off work, but it looks like it has gotten worse. R16's Care Plan does not include a focus area, goal nor interventions for R16's Left Inner Knee Pressure Ulcer. On 05/17/23 at 11:30 AM V16 stated (R16) does have a pressure ulcer on (R16's) Left Inner Knee. (R16's) pressure ulcer should have been included on (R16's) comprehensive careplan and was not. 4.) R33's Nurse Progress Note dated 4/26/23 at 10:41 AM documents Skin Evaluation: Skin Issue: Pressure Ulcer / Injury. Skin issue location: Right Ankle Pressure Ulcer / Injury Stage: Stage II - Partial thickness skin loss. Length: 3.0 centimeters (cm) Width: 2.0 cm Depth: 0.1 cm. R33's Skin Only Evaluation dated 5/4/23 documents a Right Ankle Stage 2 Pressure Ulcer as having partial thickness skin loss with painful with purulent tan and yellow drainage. This same evaluation did not document measurements. R33's Care Plan does not include a focus area, goal nor interventions for R33's Right Ankle Pressure Ulcer. On 5/15/23 at 7:35 AM Observed R33's Right Inner Ankle with a quarter sized dry intact dark brown/black scab. Another smaller dime sized area was just lateral to the larger area still on R33's Right Inner Ankle. No dressing was noted on R33's Right Ankle or in the bed linen. On 05/15/23 at 7:30 AM R33 stated I fell at home and broke my Right Ankle in two areas. After I had my surgery, I came here. R33 stated I have a pressure ulcer on my Right Ankle from where the cast rubbed. I think it has gotten worse since they (staff) first noticed it. Based on observation, interview and record review the facility failed to develop a comprehensive care plan for four of 12 residents (R15, R16, R21, R33) reviewed for care plans in the sample list of 22. Findings include: The facility's Comprehensive Care Planning policy with a revised date of 11/1/17 documents, It is the policy of (the facility) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of this Resident assessment shall serve as the basis for determining each Resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care for each Resident that will describe the services that are to be furnished to attain or maintaining the resident's highest practicable physical, mental, and psychosocial well-being. Components of the CPC (Comprehensive Care Plan) may include: e. Care Plan - Plan of care describing a need/problem and indicating approaches/interventions to be instituted to assist the Resident in maintaining/receiving care in relation to the need/problem. 1.) R15's Medication Administration Record (MAR) dated 5/1/23 through 5/31/23 documents diagnoses including Rhabdomyolysis, Cellulitis of Unspecified Part of Limb, Localized Edema, Hypokalemia, Other Specified Infestations, Type 2 Diabetes Mellitus, Essential Hypertension and Hyperlipidemia. This MAR documents an admission date of 4/20/23 (28 days ago) and documents orders for blood glucose monitoring four times a day, oral Diabetic medications (Metformin and Onglyza), Insulin (Basaglar), oral Hyperlipidemia medications (Fenofibrate and Rosuvastatin), BPH (Benign Prostatic Hypertrophy) medication (Tamsulosin), diuretic (Furosemide) and Potassium Chloride. R15's Care Plan with a revision date of 4/27/23 only documents R15 is a high fall risk and R15 had an actual fall. On 5/17/23 at 12:13 PM, V16 Care Plan Coordinator confirmed R15 does not have a comprehensive care plan in place and stated R15 should have a comprehensive care plan in place at this time. 2.) R21's MAR dated 5/1/23 through 5/31/23 documents diagnoses including Dehydration, Muscle Weakness, Need for Assistance with Personal Care and Dysphagia. R21's Registered Dietician Notes dated 3/6/23 by V21 Dietician document a noted significant weight gain of 11% (16 pounds) in three months. This note documents R21 is on a regular, mechanical soft diet. R21's Nurse's Notes dated 5/17/23 document V2 Director of Nursing had a conversation with the family regarding R21's decline in condition. This note documents V2 discussed with R21's family that R21 is now having some swallowing difficulties at times. On 5/17/23 at 2:27 PM, V2 Director of Nursing stated that R21 has had a steady decline lately and hasn't wanted to get out of bed for meals. R21's Care Plan with a revision date of 5/1/23 does not address R21's diet orders or significant weight gain or R21's increased need for assistance during meals.

Based on observation, interview and record review the facility failed to maintain proper sanitation of serving utensils. This failure has the potential to affect all 36 residents residing in facility. Findings include: Daily Census Report dated 5/15/23 documents 36 residents residing in facility. On 5/15/23 at 7:30 AM Observed the commercial coffee pot dripping brown liquid from the front of the spigot. The Coffee pot was sitting on the kitchen counter directly above an open utensil drawer. Coffee was dripping from the coffee pot directly into the utensil drawer onto the serving utensils. Multiple serving spoons in the drawer of various sizes were covered with small brown dry spots. The bottom of the drawer was splattered with dried brown spots. On 5/15/23 at 7:35 AM V6 Certified Dietary Manager (CDM) stated That coffee pot has been dripping into the utensil drawer ever since they (supplier) moved it to the counter. It used to sit somewhere else so we (staff) could put something under it to catch the drips. Now it just drips all day into the utensil drawers. We (staff) use those utensils all day long. I have seen staff using those utensils to dish out resident's food. I have to come up with a better plan. The facility policy titled 'Kitchen Sanitation' issued October 2014 documents the Food Service Manager will monitor sanitation of the Dietary Department on a daily basis.

Based on observation, interview and record review, the facility failed to provide bedrooms that measure at least 80 square feet per resident bed for 28 resident rooms 2,4-11, and 14-32. Findings include: Historical room documentation and actual onsite measurements on 5/16/23 at 11:10 AM with V14 Maintenance Director, determine rooms 2, 4 through 11, and 14 through 32 are undersized, providing only 77.3 square feet per resident bed. The most recent Centers for Medicare and Medicaid Services Certification and Transmittal undated, documents 56 of the facility's 62 beds are certified Title 18 (Medicare) and/or Title 19 (Medicaid). Rooms 2, and 4 through 11 are double occupancy and dually certified for Medicare and Medicaid, while rooms 14 through 32 are double occupancy and certified for Medicaid. The facility's Daily Roster dated 5/14/23, documents 36 of these 56 certified beds are occupied by residents residing in the facility. On 5/16/23 at 11:20 AM, V1 (Administrator) stated, the rooms that we have waivers for not being the correct size are in the Annual Long Term Care Survey Information book.

Based on interview and record review the facility failed to develop a care plan for anticoagulant use for one (R11) of 20 residents reviewed for care plans in the sample list of 20. Findings include: R11's May 2022 Physician's Orders documents an order for Eliquis (anticoagulant) 2.5 milligrams by mouth twice daily. R11's Care Plan with a revision date of 4/19/22 does not document R11's use of an anticoagulant or interventions for monitoring for complications associated with anticoagulant use. On 5/17/22 at 2:48 PM V5 Care Plan coordinator stated R11's care plan does not include a problem area or interventions for anticoagulant use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to administer a nutritional supplement and accurately assess for significant weight loss for two (R32, R22) of four residents reviewed for nutrition in the sample list of 20. 1. R22's May 2022 Physician's Orders document R28's diet includes a frozen nutritional supplement with lunch and supper. R22's 2021 Weight Log documents R22 weighed 193.5 lbs (pounds) in August, 188 lbs in November and 193 lbs in December. R22's 2022 Weight Log documents R22 weighed 188 lbs in January, 165.7 lbs in February (an 11.8% loss in 1 month, and 14.37% loss in 6 months), and 166.2 lbs in March (13.89% loss in 3 months). R22's March and May 2022 Medication Administration Records document R22 weighed 163.4 lbs on 3/22, and 169.2 lbs on 5/10. R22's Dietary Notes document the following: On 2/16/22 R22 had an 11.06 % weight loss (21 lbs) in 3 months, and 13.59% loss (26.5 lbs) in 6 months. On 3/10/22 R22 had significant weight loss of 13.89% in 3 months and 13.93% in 6 months. R22 has had decline and weight loss and is dependent on staff for eating. On 4/6/22 R22 had a significant weight loss of 12.77 % in 3 months and 12.95 % in 6 months. On 4/29/22 a frozen nutritional supplement with lunch and supper was added to R22's diet. On 5/11/22, R22 had a significant weight loss of 11.6% in 6 months, and R22's diet includes a frozen nutritional supplement with lunch and supper. R22's Minimum Data Sets (MDS) dated [DATE] documents R22 weighed 164 lbs and does not document R22's significant weight loss (5% or more in 1 month or 10% or more in 6 months). On 5/16/22 at 12:45 PM and on 5/17/22 at 12:01 PM R22's noon meal did not include a frozen nutritional supplement. 2. R32's May 2022 Physician's Orders document R32's diet includes a frozen nutritional supplement with lunch and supper. R32's 2021 Weight Log documents R32 weighed 152.7 lbs in July, 152.6 lbs in August, 154.6 lbs in October, 150 lbs in November, and 137 lbs in December (an 8.67% loss in 1 month.) R32's 2022 Weight Log documents R32 weighed 140 lbs in January (10.28 % loss in 6 months), 151.4 lbs in February, 153 lbs in April, and 147 lbs in May. R32's Dietary Note dated 1/20/22 documents R32 had a significant weight loss of 9.44 % in 3 months. R32's MDS dated [DATE] documents R32's weight as 140 lbs and does not document R32's significant weight loss. On 5/17/22 at 12:35 PM V17 [NAME] stated the dietary aide is responsible for serving the frozen nutritional supplements. V17 confirmed R22's dietary tray card documents R22's and R32's diets include a frozen nutritional supplement at lunch and supper. On 5/16/22 at 12:45 PM and on 5/17/22 at 12:01 PM R32's noon meal did not contain a frozen nutritional supplement. On 5/17/22 at 12:38 PM V14 Certified Nursing Assistant (CNA) stated R32 was not served a frozen nutritional supplement at lunch. On 5/17/22 at 12:39 PM V15 CNA stated neither R22 or R32 received a frozen nutritional supplement at lunch, R22 and R32 only received the frozen nutritional supplement with supper. V15 stated dietary staff are responsible for serving the frozen nutritional supplements on the meal trays. On 5/17/22 at 3:04 PM V5 Care Plan Coordinator confirmed R22's and R32's MDS do not document significant weight loss. The facility's Supplementation and Nourishments policy revised October 2007 documents: It is the facility's policy to ensure that residents who require additional supplementation receive it in a timely and safe manner. Intake of physician ordered supplements will be monitored and recorded in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record the facility failed to safely install side rails for two residents (R18, R22) of seven residents reviewed for side rails in a sample list of 20 residents. Findings Include: 1. R18's Bed Rail assessment dated [DATE] documents R18 uses side rails to promote independence in turning from side to side. R18's Minimum Data Set (MDS) dated [DATE] documents R18 is moderately cognitively impaired and requires an extensive assist of staff to complete bed mobility and transfer. On 5/16/22 at 10:30AM R18 was in bed. Half side rails were up and in place to both sides of the bed. R18 was lying on her left side. Her mattress had slipped to the left side leaving a six inch gap between the edge of the mattress and the side rail. The springs on the bed were exposed in this gap. On 5/17/22 at 10:45AM V6, Maintenance Director stated I measure the distance from the side rails to the edge of the mattress when the mattress in centered in the bed. I never thought of it slipping and not being safe. I suppose a resident could get caught in that space. 2. R22's Physician's Order Sheet (POS) dated 5/1/22 to 5/31/22 documents a physician's order for 1/2 bilateral side rails to promote independence and encourage participation in bed mobility. On 5/17/22 at 11:00AM R22 was not in her bed, but the half side rails were up and in place to both sides of the bed. The rails were attached loosely to the bed by only the adjustment handle in the center of the rails. The rail could be turned in a complete circle by gentle pressure to either end of the rail. On 5/17/22 at 11:05AM V3 Administrator in training stated that this was unsafe and will be corrected immediately. The facility's policy Determining Need for Use of Bed Rail reviewed September 2019 states Zone assessments for the enablers will be conducted at the time they are placed on the bed and at least annually.

Based on interview and record review the facility failed to identify specific behaviors and targeted nonpharmacological interventions to warrant the use of psychotropic medications and failed to complete psychotropic medication assessments for one of five residents (R29) reviewed for unnecessary medications in the sample list of 20. Findings include: R29's Diagnosis List documents R29's diagnosis include Dementia, Depression, Anxiety and Psychotic Disorder. R29's May 2022 Physician's Orders document an order for Trazodone (antidepressant) 50 milligrams (mg) by mouth daily, an order for Lorazepam (antianxiety) 1 mg by mouth three times daily, and an order dated 2/24/22 for Seroquel (antipsychotic) 100 mg by mouth daily. R29's February 2022 Behavior Tracking documents R29 takes Ativan (Lorazepam), Trazodone, and Zoloft (antidepressant), and R29's targeted behavior is episodes of tearfulness. This form does not document behavior tracking for R29's obsessive compulsive behaviors or what nonpharmacological interventions to use in response to the behaviors. R29's Nursing Notes document the following. On 2/9/22 at 12:20 PM R29 had obsessive compulsive of constantly washing R29's hands. New orders implemented to increase Zoloft to 150 mg. On 2/18/22 at 5:08 AM R29 had obsessions over R29's clothing and refused to dress and come out of R29's room. On 2/19/22 at 1:55 AM R29 requested staff dress R29, and R29 was reminded to dress R29's self first as much as possible. On 2/20/22 at 7:00 PM R29 was yelling at staff and throwing R29's hands in the air. R29 was provided one to one, allowed to vent, and R29's mood and behavior improved. On 2/21/22 at 10:45 AM R29 was crying because R29 was out of incontinence briefs, R29 ripped decorations off of R29's wall, and cursed at R29's spouse. R29 was assured that the facility had more incontinence briefs and instructed on deep breathing exercises. R29 seemed calmer and came out for breakfast. On 2/22/22 at 3:00 PM R29 was tearful due to spouse not having someone to help cook at home, and R29 was allowed to vent and provided TLC (Tender Loving Care.) On 2/25/22 at 8:40 AM Seroquel was added due to outbursts, tearfulness, and periods of mania. R29's Pre-Psychoactive Medication Record dated 2/24/22 documents R29's medication changed from Zoloft to Seroquel related to Bipolar. The area to record non-medication approaches or interventions that have proven to be ineffective is left blank, and the reason/targeted behavior for the use of Seroquel is documented as Bipolar with mania and does not identify R29's specific behaviors. There are no documented assessments for the use of Trazodone in R29's medical record in the last 6 months. On 5/17/22 at 2:40 PM V2 Director of Nursing stated psychotropic medication assessments are completed quarterly, and V2 provided all of R29's psychotropic medication assessments that V2 could locate. V2 stated R29 began taking Seroquel for obsessive behaviors that included cleaning, sweeping, and changing clothes. V2 stated behaviors and interventions are documented in behavior tracking and nursing notes. V2 confirmed R29's pre-psychotropic medication assessment for Seroquel and February behavior charting/tracking does not document specific targeted behaviors and nonpharmacological interventions that were ineffective prior to initiating Seroquel. The facility's policy Psychotropic Medication Policy revised 11/28/17 states Residents who receive antipsychotic drugs shall receive gradual dose reduction and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Any resident receiving psychotropic medications will be reviewed at minimum of every quarter by the interdisciplinary team.

Based on observation, interview, and record review the facility failed to notify the physician of low blood sugar and that insulin was not administered for one (R28) of five residents reviewed for unnecessary medications in the sample list of 20. Findings include: R28's May 2022 Physician's Orders document an order to obtain R28's blood sugar before meals and bedtime and notify the physician for blood sugars of 70 or below; and an order dated 11/15/21 to administer Novolog (insulin) 45 units subcutaneous three times daily with meals. There is no order for parameters to hold R28's Novolog. R28's May 2022 Medication Administration Record documents R28's blood sugar at 11:00 AM was 57 on 5/5, 51 on 5/9, 50 on 5/10, 53 on 5/14, 44 on 5/15, and 56 on 5/16, and R28's Novolog was not administered on the dates listed. There is no documentation in R28's medical record that R28's physician was notified of R28's blood sugars and that Novolog was not administered on the dates listed. On 05/16/22 at 11:48 AM V13 Licensed Practical Nurse administered R28's noon medications. V13 did not administer Novolog. V13 stated R28's blood sugar was 56, and V13 held R28's Novolog due to R28's blood sugar being low. On 05/16/22 at 3:37 PM V13 confirmed R28's Novolog noon dose was held and R28's blood sugars were below 70 on 5/5, 5/9, 5/10, 5/14, 5/15, and 5/16/22. V13 stated V13 notified V18 Nurse Practitioner one day last week that R28's blood sugar was below 70, and V18 wanted R28's blood sugar monitored and would re-evaluate in a week. V13 stated V13 must have forgot to document the communication with V18. V13 confirmed V13 did not notify V18 each day that R28's blood sugar was below 70. On 5/17/22 at 12:25 PM V2 Director of Nursing confirmed there is no documentation in R28's medical record that V18 was notified of R28's blood sugars below 70 and that Novolog was held on the dates listed in May. The facility's undated Notification for Change in Resident Condition or Status policy documents to notify the physician of changes in a resident's physical condition including abnormal lab findings, and a need to alter medical treatment significantly.

Based on observation, record review and interview the facility failed to conduct periodic safety inspections of side rails in use for six residents (R20, R11, R184, R19, R22, and R28) of seven residents reviewed for side rails in a sample of 20 residents. Findings Include: Physician's Order Sheets for R20, R11, R184, R19, R22, and R28 dated 5/1/22 through 5/31/22 include physician's orders for half side rails to enable residents to assist with bed mobility. On 5/17/22 at 11:00AM R22 was not in her bed, but the half side rails were up and in place to both sides of the bed. The rails were attached loosely to the bed by only the adjustment handle in the center of the rails. The rail could be turned in a complete circle by gentle pressure to either end of the rail. On 5/17/22 at 10:45AM V6, Maintenance Director stated, do spot checks on the side rails, but I can't find the check list for every bed that has rails. On 5/17/22 at 11:00AM V3, Administrator in training stated, We don't have any documentation to support the periodic audits for side rails. There were no side rail safety audits provided for R20, R11, R184, R19, R22, and R28. The facility's policy Determining Need for Use of Bed Rail reviewed September 2019 states Zone assessments for the enablers will be conducted at the time they are placed on the bed and at least annually.

Based on interview and record review, the facility failed to provide the required eight hours of Registered Nurse staffing coverage per 24-hour period for three of fifteen days reviewed for staffing. This failure has the potential to affect all 33 residents in the facility. Findings include: The facility Nurse Schedule (May 2022) documents the facility did not have any Registered Nurse working anytime on 5/1/2022, 5/8/2022, and 5/15/2022. The same schedule documents no Registered Nurse is scheduled to work in the facility on 5/22/2022 and 5/29/2022. On 5/15/2022 at 10:58AM, V2 (Director of Nursing) reported the facility did not have any Registered Nurse working any hours on the above days. V2 reported the facility only has one part-time Registered Nurse. The facility Resident Census and Conditions of Residents report (5/16/2022) documents 33 residents reside in the facility.