Based on observation and interview the facility failed to ensure a residents room was maintained in a comfortable homelike environment. This applies to 1 of 12 residents (R33) reviewed for resident rights in the sample of 12. The findings include: On 3/11/25 at 8:45 AM, R33 was observed in her room lying in her bed. A section of the baseboard wall on the left lower side next to the bathroom door was missing approximately one foot fully exposed open hole. On the right lower side next to the bathroom door another section of the wall was missing approximately six inches with wood exposed and several ants observed around the area. R33 said she has notified the staff, but nothing has been done to repair the wall and ants are present year round. On 3/11/25 at 1:41 PM, V10 (Maintenance Supervisor) said the facility has been neglected over the years and it's catching up with lots of repairs needed. He is aware of the R33's room wall near the bathroom needing repair it has been like that for some time, but he is the only maintenance staff and has not had time to repair her wall. The facility did not provide a policy regarding maintenance of the building.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure activities that meet residents physical, mental, and psychosocial well being were provided for two of 12 residents (R22, R26) in the sample of 12. The findings include: 1. R22's admission Record shows he was admitted to the facility on [DATE] with diagnoses including bipolar disorder, psychotic features, obesity, alcohol abuse, major depressive disorder, and insomnia. R22's Care Plan written February 28, 2019 shows R22 independently structures his daily activities as evidenced by pursuing independent leisure activities daily and/or attending activities/groups of choice. Remind R22 of all activities available that are of his interest, R22 likes to go on dine outs with staff, donuts and coffee, offer one on one visits/activities as R22 will accept. R22's Minimum Data Set (MDS) dated [DATE] shows he is cognitively intact. R22's MDS shows it is somewhat important to have books, newspapers, and magazines to read and participate in religious services or practices. It is very important to him to do things with groups of people, do his favorite activities, and very important to go outside to get fresh air when the weather is good. On March 10, 2025 at 9:59 AM, R22 said, The activities suck. It is all second grade activities. I don't color pictures, I don't play second grade games, I don't like arts and crafts. I would like to do something age appropriate. We used to be able to go to restaurants. I like to read the newspaper, but we don't get that anymore now that the new company took over. R22 said he goes outside with the residents that smoke, but he does not smoke. 2. R26's admission Record shows he was admitted to the facility on [DATE] with diagnoses including major depressive disorder, alcohol abuse, cocaine abuse, generalized anxiety disorder, and insomnia. R26's MDS dated [DATE] shows he is cognitively intact. R26's Activity assessment was not completed. R26's MDS dated [DATE] shows it is somewhat important to him to have books, newspapers, and magazines to read and to do things with groups of people. It is very important to R26 to do his favorite activities, to get outside, and to listen to music he likes. On March 10, 2025 at 10:19 AM, R26 said the previous activity director quit. R26 said the new activity director is the social services person now. R26 said he cannot just go outside when he wants. R26 said there's not enough staff to be able to go outside when he wants. On Monday March 10, 2025 at various times throughout the day, there was no activity staff seen. There were a few residents playing cards in the TV room. There were no staff directing any activities on Monday March 10, 2025. On Tuesday, March 11, 2025, there was an activity calendar that was hanging up by the dining room. The activity calendar showed that at 9:00 AM there was devotions, 9:30 AM-exercise, 12:00 PM fast food, and 2:00 PM olympic games. There was no devotions going on at 9:00 AM and no exercise going on at 9:30 AM and no staff observed in the activity room. Multiple residents were observed wandering the halls back and forth. The facility's Resident Council Minutes dated February 2025 shows, Residents expressed that they would like to see more stem science activities and outside groups. On March 12, 2025 at 9:55 AM, V14 CNA (Certified Nursing Assistant) said the facility doesn't get the newspaper everyday. V14 said the newspaper comes in the mail. We get it when we get it. We just got the end of Februarys newspaper. V14 said when the facility gets the newspaper, its set on the CNA desk and residents can get it when they want. V14 said the facility gets one newspaper when they get the newspaper. On March 11, 2025 at 12:25 PM, V5 Activity Director/Social Services/CNA-Certified Nursing Assistant said she has been the facility's Activity Director for about two months. V5 said she works every other weekend. V5 said when she's not working, then the residents have activity packets to work on which include crosswords, sudoku puzzles, and coloring pages. The facility's Activities Policy reviewed September 2024 shows, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will be designed with the intent to: enhance the resident's sense of well-being, belonging, and usefulness. Create opportunities for each resident have a meaningful life, promote or enhance physical activity, promote self-esteem, dignity, pleasure, comfort, education, creativity, success and independence, reflect resident's interests and age .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement, develop, and provide resident centered mental health services for a resident with a diagnosis including PTSD (Post- Traumatic Stress Disorder). This applies to 1 resident (R142) reviewed for behavioral health in the sample of 12. The findings include: R142's face sheet shows R142 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including major depressive disorder, schizoaffective disorder, PTSD-chronic, borderline personality disorder and suicidal ideations. R142's PASRR II (Preadmission Screening and Resident Review) dated 1/30/25 shows the facility should provide R142 with rehabilitate services for systemic plans which are designed to change inappropriate behaviors, provision of a structured environment to keep yourself safe and other safe, programs to teach daily living skills to help promote independence, individual, groups and family psychotherapy to decrease mental health symptoms, development of appropriate support networks. The PASRR II shows behaviors & symptoms include serious difficulty interacting with others, excessive isolation from or avoidance of others. (R142) requires assistance thinking through or completing tasks. V11's Psych Progress noted dated 2/7/25 documents R142 has a history of sexual and physical abuse, (R142) is having panic attacks and crying every night, either sleeps all day or not at all. Has transitioned from female to either non-binary or male depending on personality. Gender Identity disorder, Possible DID (Dissociate Identify Disorder), reports multiple personalities .plan is for psychotherapy. On 3/10/25 at 9:37 AM, R142 was observed in R142's room with the door closed. R142 said R142 was recently hospitalized for suicide ideation and came to the facility for psych services and has been at the facility for about one month. R142 said she prefers to go by a different name and identifies as a male. R142 said R142 is in between therapists and has had one tele health session with the psych NP (Nurse Practitioner). R142 prefers to have in person visits and stated, I do better in person. R142 said R142 loves to be outside and likes to have tasks to do, likes reward-based systems, it helps motivate R142. R142 said R142 likes to draw and journal. R142 has history of family abuse and does not have contact with certain family members. On 3/11/25 at 11:35 AM, R142 was observed in R142's room with the door closed. R142 said prior to coming to the facility R142 was receiving counseling from a local counseling service, and is not receiving those services now. There are no groups for trauma, wellness, life skills or managing behaviors at the facility to attend. R142 said when R142 first came to the facility not all the staff were aware of R142's preference of pronouns, and R142 does not identify as female and prefers to be called by a different name. They placed me in a room with another female and a there was a sign on the door no males in female rooms. R142 told the nurse R142 identifies as male sometimes and felt triggered when the nurse asked what body part R142 was born with, R142 thought that it was creepy and inappropriate to ask what was in between a baby's legs. Another nurse referred me to as it is a she. R142's written note provided to the surveyors on 3/12/25 listed ideas to better this place. Having more groups/activities that promote and teach us ways to improve our health and wellness. A group for the demographics of us that plan on leaving here to work on life skills, like budgeting, cleaning and home safety would be a good idea. Having a group for learning life skills and tools for self-care. On 3/11/25 at 9:15 AM, V14 (CNA/Certified Nurse Assisstant) said there used to be group therapy every Tuesday and Thursday for the residents when the social worker was here. On 3/11/25 at 1:35 PM, V13 (CNA) said at first, she called R142 by her legal name and R142 told her that's not my name. I didn't know that. No one reported to me R142 prefers to be called they/them or refers to a male name. R142 does not identify as female, but V13 didn't know that. On 3/11/25 at 12:25 PM, V5 (Activity Director/Social Services) said she was a CNA at the facility for two years. She has been the activity director for about two months and started social services less than one month. There was no social service staff prior to her. The Administrator helps her with the referral and new admissions. She does 1:1 counseling service with the residents and started psychosocial groups weekly but does not have any behavioral health background. She is not sure what psych services the resident needs. V9 (MDS Coordinator) goes over the residents PASRR and updates the care plan. R142 goes out for counseling but does know what services R142 receives. R142 recently had a care plan meeting, R142 does not identify as a male and prefers to be called they/them. It's in the care plan and the CNAs should look at the residents care plan. On 3/11/25 at 2:03 PM, V9 (MDS/Care plan/Restorative Nurse) said she has been at the facility over 4 years. She asks the residents what psych services work for them and refers them to an outside counseling service. The facility offers tele health visits every two weeks with the psych NP. She makes sure the resident has a PASRR II, showing they have a mental illness, but she does not review it or implement the behavioral health services they need. We used to have behavioral health aides in the facility who were trained to manage residents with behaviors. On 3/12/25 at 11:54 PM, V11 (Psych Nurse Practitioner) said she does tele health visits with the residents every two weeks. The facility used to have an in-person psychiatrist, but he has retired, and the residents should receive outside mental health services. We are looking for an in-person psychiatrist the residents do better and would like to have more frequent visits. The previous social worker was having groups that would benefit the residents for trauma, anxiety, grief, PTSD, and behavior management and would like to see the groups come back. R142 is being worked up for DID with R142's previous psychiatrist, R142 would benefit with family counseling, and she is not sure why R142 is not receiving those services. R142's current care plan initiated on 3/10/25 (approximately one month after her admission) shows a history of suicidal thoughts, agitation, anxiety, and states different personalities the interventions show R142 is on a behavior management program. The care plan also shows R142 has ineffective coping or overt behaviors due to PTSD diagnosis. Known triggers include (Specify), known psychosocial issues/behaviors attributed to PTSD diagnosis (Specify) and other PTSD information (Specify). The care plan does not show R142's triggers or PTSD information. The care plan does not show how R142 prefers to be called and how R142 identifies. The care plan does not show R142 likes to journal, likes tasks and does well with reward based. The facility did not provide evidence of what psych services R142 is receiving. The facility did not provide a policy regarding psych services/behavior management/PTSD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure medications were administered as ordered and failed to ensure controlled medications were accounted for and reconciled. This applies to 3 of 4 residents (R41, R21, R22) reviewed for pharmacy services in the sample of 12. The findings include: 1. On 3/10/25 at 10:15 AM, R41 said on Saturday (3/9/25) he missed the evening medication pass because he was watching TV and was not paying attention to the time. About 12:30 AM, he went to the nurses station for his medications. The nurse said he was late and refused to give me my medications. She said I missed the window. He takes medication for his heart and was upset she refused to give my medications. No staff came to remind me about the time for his medications. On 3/10/25 at 11:17 AM, V2 (DON/Director of Nurses) said R41 did report to me yesterday he did not receive his evening medications on 3/9/25. If the resident does not show up to take their medications she would expect the staff to go to the residents room and remind them to go take their medications and document if the resident refuses or attempts made to remind the resident. R41's Medication Administration Record (M.A.R.) dated March 2025 shows orders to administer at 8:00 PM including lamotrigine 150 mg (milligrams) for mood stabilizer, melatonin 3 mg give two tabs at bedtime for insomnia, memantine 10 mg for anxiety, metoprolol extended release 50 mg for hypertension, singulair 10 mg, gabapentin 300 mg give three caps three times a day for anxiety. R41's M.A.R. shows these medications were not administered. 2. On 3/10/25 at 12:27 PM, during the narcotic count with V12 (LPN-Licensed Practical Nurse). R21's Controlled Substance Form dated March 2025 for hydrocodone 10-325 mg take one tablet every six hours shows two doses on 3/9/25 were not signed out and accounted for. V12 said when she did the narcotic count with the night nurse this morning the count was off, the nurse on Sunday did not sign out the medication. Who's to say he took his medications, because the nurse did not sign it off. Nursing had to fill in the dates on 3/9/25 and verified with R21 he took the medications. R21's Controlled Substance Form dated March 2025 for hydrodone 10-325 mg shows no nurse signature on 3/9/25 at 11:00 AM and 5:00 PM. This same form states, IMPORTANT: THE NURSE WHO SIGNS THIS RECORD MUST ALSO SIGN THE SEPARATE MEDICATION ADMINISTRATION RECORD FOR EACH DOSE GIVEN. R21's Medication Administration Record for March 2025 for orders including hydrocone 10-325 mg give one tablet every six hours as needed for pain. The M.A.R. on 3/9/25 shows hydrocodone 10-325 mg did not show it was documented as administered at 11:00 AM and 5:00 PM. 3. R22's admission Record shows he was admitted to the facility on [DATE] with diagnoses including bipolar disorder, psychotic features, obesity, alcohol abuse, major depressive disorder, and insomnia. R22's Order Summary Report dated March 10, 2025 shows an order that started May 1, 2023 for benztropine (cogentin) 1 MG two times a day for tremors related to bipolar disorder, current episode depressed, severe without psychotic features and haloperidol 2 MG tablet in the morning for agitation related to bipolar disorder. On March 10, 2025 at 9:59 AM, R22 said he has not received his cogentin. R22 said he did not know why. R22 said he will not take his haldol without his cogentin. On March 10, 2025 at 1:29 PM, V12 LPN (Licensed Practical Nurse) said R22 has not gotten his cogentin because it needs a prior authorization from the doctor. V12 said that R22 will not take his haldol without his cogentin. At 1:36 PM, V2 DON (Director of Nursing) said R22 needed a prior authorization for his cogentin starting on March 3, 2025. V2 said the nurse just told her that R22 will not take his haldol without his cogentin. V2 said the nurse first sent the prior authorization form on March 3, 2025 and V2 was not sure if R22's doctor responded. V2 said she sent the form again on March 5, 2025 and the doctor did not respond. V2 sent it again on March 7, 2025 and did not receive a response from the doctor. V2 said she called R22's primary doctor office on March 7, 2025 and left a message. V2 said she sent it to the doctor again on March 10, 2025. V2 said the doctor said to send it to the psychiatrist. V2 said she sent it to the psychiatrist and the psychiatrist signed the prior authorization form on March 10, 2025. The facility's Medication Administration Policy dated November 2024 shows, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The Pharmacy Recommendation Review from 2/1/25 to 2/28/25 shows recommendations for R33 to discontinue hydroxyzine PRN (as needed) for anxiety, also has an order for hydroxyzine 100 mg daily. If the medication cannot be discontinued at this time, please: fill in below. The form is blank below. On 3/12/25 at 10:17 AM, V2 (DON) said she had been at the facility less than two weeks. She found a pile of pharmacy recommendations forms in the DON's office not done. She confirmed R33's recommendation was not done. Based on interview and record review, the facility failed to address pharmacy recommendations for three of five residents (R18, R35, R33) reviewed for medication regimen review in the sample of 12. The findings include: 1. R18's admission Record dated March 12, 2025 shows R18 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, bipolar type, convulsions, bipolar disorder, major depressive disorder, generalized anxiety disorder, and insomnia. R18's Pharmacy Recommendations report dated February 12, 2025 shows, [R18] has orders for labs, but at the time of this review, they were not available in the medical record. The missing lab values include: CBC (Complete Blood Count), BMP (Basic Metabolic Profile), hepatic panel, GGT (Gamma-Glutamyl Transferase), ammonia, and A1C (Glycated Hemoglobin) every three months. Recommendation: Unless otherwise indicated, please ensure that ordered labs are obtained. Please disregard recommendation if these labs have been recently obtained. On March 12, 2025 at 11:49 AM, V2 DON (Director of Nursing) said the labs for R18 were not done. At 12:15 PM, V9 (MDS-Minimum Data Set/Care Plan Coordinator) said that she tries to review residents' charts to see if they got labs done. V9 said she did not know why R18's labs were not done. 2. R35's admission Record dated March 12, 2025 shows she was admitted to the facility on [DATE] with diagnoses including bipolar disorder, generalized anxiety disorder, post traumatic stress disorder, and borderline personality disorder. R35's consultant pharmacist report dated February 12, 2025 shows, [R35] had a high TSH (thyroid stimulating hormone) of 5.79 on September 17, 2024 and receives levothyroxine 25 mcg (micrograms) daily. Please increase levothyroxine to 37 MCG daily and obtain a follow up TSH concentration in six to eight weeks. This report was not addressed by R35's physician. R35's Medication Administration Record shows she has levothyroxine 25 mcg ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R31's Physician Order Sheets dated March 2025 shows order date of 11/21/24 for hydroxyzine tablet give two tablets every six hours as needed (PRN-as needed) for anxiety without a stop date. On 3/12/15 at 10:17 AM, V2 said PRN psychotropic medications should have a stop date of 14 days. V2 confirmed R33's recommendation was not done. The facility's Pharmacy Recommendation Review from 2/1/25 to 2/28/25 shows a recommendation to discontinue PRN hydroxyzine dose rationale for Recommendation: CMS requires that PRN orders for non-antipsychotic psychotropic drugs be limited to 14 days . Based on interview and record review the facility failed to address a gradual dose reduction and failed to ensure an as needed anti-anxiety medication had a stop date for two of five residents (R18, R33) reviewed for gradual dose reductions in the sample of five. The findings include: 1. R18's admission Record dated March 12, 2025 shows R18 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, bipolar type, convulsions, bipolar disorder, major depressive disorder, generalized anxiety disorder, and insomnia. R18's Consultation Report dated January 9, 2025 shows, [R18] has received buspirone 10 MG (milligrams) three times daily since February 27, 2025. Please attempt a gradual dose reduction of buspirone to 10 MG twice daily. This report was not addressed by the physician. On March 12, 2025 at 10:09 AM, V2 DON (Director of Nursing) said the DON and the MDS (Minimum Data Set) Coordinator are the staff members responsible for ensuring the gradual dose reductions are addressed. V2 said R18's gradual dose reduction has not been addressed. At 12:15 PM, V9 (MDS Coordinator) said she has not followed up to see if R18's gradual dose reduction was completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview and record review the facility failed to provide behavioral health care services for residents with diagnoses of mental illness. This applies to 4 of 4 residents (R32, R41, R26, R22) reviewed for behavioral services in the sample of 12. The findings include: 1. R32's face sheet shows he is a [AGE] year old male admitted to the facility on [DATE], with diagnoses including major depressive disorder, recurrent, severe with psychotic symptoms, PTSD (post traumatic stress disorder), generalized anxiety, and insomnia. R32's PASRR II (Preadmission Screening and Resident Review) dated 6/16/24 shows he has a diagnosis of schizophrenia, major depressive disorder, and PTSD. R32 has a hard time interacting with others, has unclear thoughts, gets easily upset, has feelings of worthlessness, hopelessness, trouble sleeping, sees and hears things, has nightmares R32 needs help to coordinate his care, needs encouragement and support to remain active and engaged in treatment, requires monitoring from supportive staff through the coordination and medical management of behavioral health symptoms programs to teach daily living skills, mental health education, crisis intervention services or plan, individual, group and family psychotherapy services. R32's facility assessment dated [DATE] shows he is cognitively intact, has little interest in doing things, feeling down and depressed, feeling tired, having little energy, and trouble concentrating. On 3/10/25 at 9:56 AM, R32 was observed in his room playing video games. He said he has been at the facility for seven months of complete boredom. He came to the facility because he was told there would be a counselor on site, he was lied to on what this place was. He said he goes out for counseling services every two weeks but that's not enough. He said it would help if they had services in the facility, life skills offered and someone to talk to. On 3/12/25 at 1:50 PM, R32 was observed walking up and down the hall. He said he wants something to do, he said he asked the staff if he could get a job working in the kitchen and wants to know when he will be discharged . On 3/11/24 at 9:33 AM, V13 (Certified Nursing Assistant-CNA) said R32 keeps to himself, he isolates, sleeps a lot and is really quiet. On 3/11/25 at 12:25 PM, V5 (Activity Director/Social Services) said she was a CNA at the facility for two years. She has been the activity director for about two months and started social services less then one month. There was no social service staff prior to her. The Administrator helps her with the referral and new admissions. She does 1:1 counseling services with the residents and started psychosocial groups weekly but does not have any behavioral health background. She is not sure what psych services the resident needs. V9 (MDS Coordinator) goes over the residents PASRR and updates the careplan. She said she is not sure what services R32 is receiving. He has expressed he wants to get a job and this is the first time she's assisting a resident with seeking employment. R32's Physician Progress note dated 1/9/25 documents he reported feeling depressed because he is still at facility and wants to be discharged . R32's current careplan shows initiated June 24, 2024 shows he is risk for depression and self harm with interventions to assess physiological needs and seek to resolve, assess for deepening depression-increased withdrawal, lack of appetite and change in self care .provide appropriate interactions/attention and practice appropriate coping/behavior management skills. R32 also has history of paranoid thoughts and behaviors with interventions including psychotherapy, encourage and praise participation in group therapy meetings. 2. R41's face sheet shows he is a [AGE] year old male admitted to the facility on [DATE] with diagnoses including major depressive disorder severe with psychotic features, bipolar, attention deficit disorder, and post traumatic stress disorder, disc displacement, lumbar region, and generalized anxiety. R41's PASSR II dated 1/10/25 shows he has diagnosis including anxiety, ADHD, depression, bipolar, and PTSD. The services and supports the facility staff are provide theses services include rehabilitate services including pharmotherpay including administration and monitoring, provision of a structured environment, socialization and recreation activities to decrease isolation, improve mood, and increase peer interaction. Your favorite past time is writing .crisis interventions services or plan, individual, group and family psychotherapy .supportive psychotherapy may be helpful to discuss your thoughts and feelings within a supportive setting and teach you healthy coping skills for self care. Substance use counseling to help identify triggers, avoid relapse, and maintain sobriety. Group therapy led by a behavioral heath professional to help learn practice strategies to cope with mental health concerns, build interpersonal skills and develop social support form others who may be able to relate to you development of appropriate personal support networks who can connect with you. R41's Physician Progress note dated 2/7/25 documents (R41) will be looking into another facility with more intense psych services as he thought that is what this facility was. R41's Physician Progress note dated 1/24/25 documents (R41) has been at facility for two weeks, it has been a big adjustment was sent from behavioral health to get more intensive care for mental health issues and said was going to a SMHRF (Specialized Mental Health Rehabilitation Facility) .will also look into another facility with more intense psych services as he thought that is what this facility was. On 3/10/25 at 10:15 AM, R41 was observed in his room with the door closed. He said he's been at the facility since January. He said he should have not been brought here, he was told he was going to a SMHRF to receive mental health services. He said since he's been at the facility, he found his own therapy. On 3/12/25 at 11:25 AM, R41 said he is feeling overwhelmed, there is no counselor or staff he can talk to when he feels this this. V9 (Social Services/Activity) is new to the role, she's nice but she also is in charge of activities. He said he's been invited to one group about being the best you can be while at the facility. He has therapist he's been seeing for about a decade, but there no psych services the facility provides him. On 3/11/25 at 12:25 PM, V5 (Activity Director/Social Services) said she was a CNA (Certified Nursing Assistant) at the facility for two years. She has been the activity director for about two months and started social services less then one month. There was no social service staff prior to her. The Administrator helps her with the referral and new admissions. She does 1:1 counseling services with the residents and started psychosocial groups weekly but does not have any behavioral health background. She is not sure what psych services the resident needs. V9 (MDS Coordinator) goes over the residents PASRR and updates the careplan. R41 came to the facility with a lot of his own services, he sees the psych NP (Nurse Practitioner), and does not know what psych services the facility is providing him. On 3/11/25 at 2:03 PM, V9 (MDS/Careplan/Restorative Nurse) said she has been at the facility over 4 years. She asks the residents what psych services work for them, and refers them to an outside counseling service. The facility offers tele health visits every two weeks with the psych NP. She makes sure the resident has a PASRR II, showing they have a mental illness but she does not review it or implement the behavioral heath services they need. We used to have behavioral health aides in the facility who were trained to manage residents with behaviors. On 3/12/25 at 11:54 PM, V11 (Psych Nurse Practitioner) said she does tele health visits with the residents every two weeks. The facility used to have an in person psychiatrist, but he has retired and the residents should receive outside mental health services. We are looking for an in-person psychiatrist the residents do better and would like to have more frequent visits. The previous social worker was having groups that would benefit the residents for trauma, anxiety, grief, PTSD, and behavior management and would like to see the groups come back. R41's current careplan does not include a careplan for his anxiety, bipolar disorder or PTSD. His careplan shows he may display sign and symptoms of depression but does not specify what signs with interventions to remain in contact with his therapist and group therapy. The facility did not provide evidence of any behavioral groups provided to residents. 3. R22's admission Record shows he was admitted to the facility on [DATE] with diagnoses including bipolar disorder, psychotic features, obesity, alcohol abuse, major depressive disorder, and insomnia. R22 is less than [AGE] years old. On March 10, 2025 at 9:59 AM, R22 said the facility only provides psych services on the screen. R22 said there is no psychiatrist that comes to the facility. R22 said he would rather see a psychiatrist in person. R22's Nursing Facility Placement Notice of Determination dated February 14, 2019 shows special services: Mental Health Rehabilitation activities, professional observation for medication monitoring, adjustment and/or stabilization, illness self management, and substance use/abuse management. 4. R26's admission Record shows he was admitted to the facility on [DATE] with diagnoses including major depressive disorder, alcohol abuse, cocaine abuse, generalized anxiety disorder, and insomnia. R26 is less than [AGE] years old. R26's Illinois preadmission screening and resident review dated February 1, 2024 shows, You need help with managing your mental health symptoms. You will benefit from continuous psychiatric services for monitoring your medication and how well your medication is working for you, individual, group, and family psychotherapy. On March 10, 2025 at 10:19 AM, R26 said he has been at the facility for three years. R26 said he's never met the psych doctor. R26 said the appointments are only on a screen. R26 said he would rather see a psychiatrist in person.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure medically related social services were provided for 4 of 4 residents (R32, R41, R142, R26) reviewed for social services in the sample of 12. The findings include: 1. R32's face sheet shows he is a [AGE] year old male admitted to the facility on [DATE], with diagnoses including major depressive disorder, recurrent, severe with psychotic symptoms, PTSD (Post Traumatic Stress Disorder), generalized anxiety, and insomnia. On 3/10/25 at 9:56 AM, R32 was observed in his room playing video games. He said he has been at the facility for seven months of complete boredom. He came to the facility because he was told there would be a counselor on site, he was lied to on what this place was. He said he goes out for counseling services every two weeks but that's not enough. He said it would help if they had services in the facility, life skills offered and someone to talk to. On 3/12/25 at 1:50 PM, R32 was observed walking up and down the hall. He said he wants something to do, he said he asked the staff if he could get a job working in the kitchen and wants to know when he will be discharged . R32's current care plan shows for discharge planning shows staff will establish pre-discharge plan with the resident and evaluate progress and revise. R32's electronic record does not show evidence of quarterly discharge plan. 2. R41's face sheet shows he is a [AGE] year old male admitted to the facility on [DATE] with diagnoses including major depressive disorder severe with psychotic features, bipolar, attention deficit disorder, and, post traumatic stress disorder, disc displacement, lumbar region, and generalized anxiety. On 3/12/25 at 11:25 AM, R41 was observed in room. The frame of his glasses were held together by tape. He said he was just informed by his insurance provider he qualifies for dental and vision. He said he needs new glasses and needs to see the dentist. No one at the facility has helped him. He said he is feeling overwhelmed, there is no counselor or staff he can talk to when he feels this this. V9 (Social Services/Activity) is new to the role, she's nice but she also is in charge of activities. On 3/12/25 at 12:32 PM, V2 (DON/Director of Nurses) said the facility should be providing arrangements for dental care, she could not find if any residents are on a list for dental or vision services. R41's current careplan shows his teeth are in poor condition with multiple cavities. Intervention shows to coordinate arrangements for dental care and transportation. R41's electronic health record shows there is no documentation of social service notes. 3. R142's face sheet shows R142 is a [AGE] year old female admitted to the facility on [DATE] with diagnoses including major depressive disorder, schizoaffective disorder, PTSD-chronic, borderline personality disorder and suicidal ideation's. On 3/10/25 at 9:37 AM, R142 was observed in R142's room with the door closed. R142 said R142 was recently hospitalized for suicide ideation and came to the facility for psych services and has been at the facility for about one month. R142 said R142 prefers to go by a different name and identifies as a male. R142 said R142 is in between therapists and has had one tele health session with the psych NP (Nurse Practitioner). R142 prefers to have in person visits and stated, I do better in person. On 3/11/25 at 11:35 AM, R142 was observed in R142's room with the door closed. R142 said prior to coming to the facility R142 was receiving counseling for Internal Family Counseling Services and is not receiving those services now. There are no groups for trauma, wellness, life skills or managing behaviors at the facility to attend. 4. R26's admission Record shows he was admitted to the facility on [DATE] with diagnoses including major depressive disorder, alcohol abuse, cocaine abuse, generalized anxiety disorder, and insomnia. R26 is less than [AGE] years old. R26's Illinois preadmission screening and resident review dated February 1, 2024 shows, You need help with managing your mental health symptoms. You will benefit from continuous psychiatric services for monitoring your medication and how well your medication is working for you, individual, group, and family psychotherapy. On March 10, 2025 at 10:19 AM, R26 said he has been at the facility for three years. R26 said he's never met the psych doctor. R26 said the appointments are only on a screen. R26 said he would rather see a psychiatrist in person. On 3/11/25 at 12:25 PM, V5 (Activity Director/Social Services) said she was a CNA (Certified Nurses Assistant) at the facility for two years. She has been the activity director for about two months and started social services less than one month. There was no social service staff prior to her. She does not have a degree or training for this position. She does not know what services residents are receiving or what services they should be receiving.

Based on interview and record review the facility failed to ensure the pneumonia vaccine was consented or declined prior to administration. This applies to 4 of 5 residents (R34, R35, R12 and R39) reviewed for immunizations in the sample of 12. The findings include: On 3/11/25 R35 and R34's EMRs (Electronic Medical Records) show that R35 received the PCV 20 vaccine on 12/21/23. No consents were found in R35 and R34's EMR. On 3/11/25 R12 and R39's EMRs show that R12 and R39 both declined the Pneumonia vaccine. No declinations were found in R12 and R39's EMR. On 3/12/25 V1 (Corporate Regional Director of Operations) confirmed that the facility did not have the pneumonia consents or declinations for these 4 residents. The facility policy entitled Pneumococcal Vaccine dated 10/2023 states, The resident/representative retains the right to refuse the immunization. The facility will document in the clinical record the reason for refusal or the medical contraindications of the immunization. and A consent form shall be signed prior to the administration of the immunization and filed in the individual's medical record.

Based on observation, interview, and record review, the facility failed to ensure the facility's activity program was directed by a qualified professional. This failure has the potential to affect all residents residing in the facility. The findings include: The facility's Resident Census and Condition form dated March 10, 2025 shows the facility census was 43. On March 11, 2025 at 12:25 PM, V5 Activity Director/Social Services/CNA-Certified Nursing Assistant said she has been the facility's Activity Director for about two months. V5 said she works every other weekend. V5 said when she's not working, then the residents have activity packets to work on which include crosswords, sudoku puzzles, and coloring pages. On March 11, 2025 at 3:30 PM, V1 (Regional Director of Operations) said that V5 does not have any activity director certifications.

Based on observation, interview and record review the facility failed to ensure the dishwasher sanitation solution was checked at the recommended level prior to use. This applies to all 43 residents in the facility. The findings include: The CMS 671: Application for Medicare and Medicaid dated 3/10/25 shows the facility census as 43 residents. On 3/11/25 at 8:31 AM V7 (Cook) was asked to check the sanitation level in the dishwasher. V7 found Quaternary Ammonia test strips in the drawer and handed them to V8 (Dietary Aide). V8 then put the strip into the water reservoir on the dishwasher. The strip turned yellow. V7 then noticed that the sanitizing solution bucket was almost empty and proceeded to change it to a full bucket. V7 then used the same strips again and tested the water in the same reservoir of the dishwasher. The strip was even lighter yellow. Surveyor looked at the bucket on sanitizing solution. It read, Hypochlorite. V8 then noticed there was another roll of testing strips on the floor, under the dishwasher. (The strips, the plastic container and the key (chart) were all scattered under the dishwasher). V8 picked up all three pieces and gave them to V7. V7 then tested the dishwasher water reservoir with those strips and it registered at 50 ppm (parts per million). V7 then showed Surveyor the log book. The form entitled Low Temp Dish Machine Log shows that V8 checked the dishwasher before use and the sanitizing solution measured 100 ppm. V8 was then asked if she checked the dishwasher prior to use and she stated, yes. On 3/11/25 at 8:50AM V6 (Dietary Manager) stated, The (sanitation level) of the dishwasher should be 100 (ppm). We were using quaternary ammonia until the new company took over. We ran out of the old chemicals about a month ago and switched to this one (Hypochlorite). They should be checking the dishwasher with every meal. At 9:46 AM V6 brought the strips the staff had used on the third test to the Surveyor and stated, These are the ones we always use. Surveyor stated, V8 stated she checked the dishwasher this morning however the strips were found under the dishwasher on the floor. V6 stated, Well we know that is not true, obviously. Well I know the strips were there on Sunday because I used them. The facility policy entitled Dishwasher Temperature dated 1/2025 states, The sanitizing solution shall be 50ppm Hypochlorite (chlorine) on dish surface in final rinse. This same policy states, Chemical solutions shall be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. Results of concentration checks shall be recorded.

Based on observation, interview, and record review the facility failed to ensure medications were administered in accordance with manufacturer's directions; failed to monitor residents during medication administration; and failed to provide ordered medications. This applies to 2 of 3 residents (R21 & R26) reviewed for medication administration in the sample of 13. The findings include: 1. R21's admission Record (Face Sheet) showed an admission date of 1/14/22 with diagnoses to include high triglycerides (a specific type of fat found in the blood); bipolar; and schizoaffective disorder. R21's Order Summary Report (Physician Orders, as of 5/7/24) showed an order for Icosapent Ethyl (medication to treat high triglycerides and reduce the risk of cardiovascular disease) to be given twice daily. The order showed it was started on 8/31/23 and the order was active. On 5/7/23 at 8:20 AM, V4 Licensed Practical Nurse (LPN) administered R21's morning medications. V4 failed to provide R21 his Icosapent Ethyl. V4 stated the medication was not available and it was also not available on her previous shift, which was 5/5/24. On 5/7/24 at 2:47 PM, V2 Director of Nursing (DON) stated R21's insurance denied payment for his Icosapent Ethyl medication. V2 stated the insurance company wanted R21 to be switched to an alternative medication. V2 stated she faxed the denial letter to V6 R21's physician on 3/6/24. V2 stated she spoke with V6 regarding the denial of payment and V6 stated the alternative medication would not work for R21. V2 said V6 wanted R21 to continue the Icosapent Ethyl medication. V2 stated R21 has not had Icosapent Ethyl since March 2024. V2 stated R21 has a diagnosis of high triglycerides and Icosapent Ethyl is to treat that condition. V2 stated if a medication is not available the physician should be notified, and the notification should be documented. R21's March 2024, April 2024, and May 2024 (As of 5/7/24) Medication Administration Records (MAR) showed the last documented dose of Icosapent Ethyl was given on 3/6/24. R21's 3/1/24 through 5/7/24 progress notes showed no documented notification of V6. The facility's Medication Administration Policy (Revised 11/18/17) showed .If a medication is not available for a resident, call the pharmacy and notify the physician when the drug is expected to be available .Notify the physician as soon as practical when a scheduled dose of medication has not been administered for any reason . 2. R21's admission Record (Face Sheet) showed an admission date of 1/14/22 with diagnoses to include high blood pressure, bipolar, and schizoaffective disorder. R21's Order Summary Report (Physician Orders, as of 5/7/24) showed an order for hydrochlorothiazide to be given daily to treat high blood pressure. On 5/7/24 at 8:20 AM, V4 Licensed Practical Nurse (LPN) was administering R21's medications. V4 dispensed all R21's morning medications into a plastic medicine cup. While V4 was looking at her charting, R21 swallowed his medications and threw the medicine cup away; however, a small peach colored pill remained and was thrown away by R21. V4 did not witness this. V4 then proceeded to dispense the next resident's medications. On 5/7/24 at 8:33 AM, the peach-colored pill was found in the garbage. V4 stated she did not notice R21 had failed to take the medication. V4 stated the peach-colored pill was R21's hydrochlorothiazide. On 5/7/24 at 11:04 AM, V2 Director of Nursing stated nurses should monitor residents during medication administration to ensure the resident's take their prescribed medications. 3. R21's admission Record (Face Sheet) showed an admission date of 1/14/22 with diagnoses to include chronic obstructive pulmonary disorder (COPD, lung/breathing disease), bipolar, and schizoaffective disorder. R21's Order Summary Report (Physician Orders, as of 5/7/24) showed an order for a combination budesonide (steroid) and fumoterol (medication to open airways) inhaler to treat his COPD. On 5/7/24 at 8:20 AM, V4 Licensed Practical Nurse (LPN) was administering R21's medications. V4 gave R21 his inhaler, he self-administered the inhaler, then left the nurse's cart. V4 did not stop R21 and have him rinse his mouth. The inhaler instructions showed, After you finish taking [the combination inhaler], rinse you mouth with water. Spit out the water. Do not swallow it. On 5/7/24 at 11:04 AM, V2 Director of Nursing stated V4 should have instructed R21 to rinse and spit after taking his combination inhaler. V2 said the purpose of rinse and spit is to prevent fungal infections in the mouth. V2 said nursing staff should follow manufacturer instructions for the resident's medications. 4. R26's admission Record (Face Sheet) showed diagnoses to include of diabetes, long-term use of insulin, and depression. R26's Order Summary Report showed, as of 5/7/24, an order for 10 units of Lispro Insulin (fast acting insulin) to be injected twice daily. On 5/7/24 at 7:56 V4 Licensed Practical Nurse (LPN) prepared R26's prefilled multiuse insulin syringe (commonly referred to as an insulin pen). V4 attached the needled to the pen and dialed in 10 units. V4 did not wipe the tip of the pen with an alcohol wipe, and she did not prime the pen. V4 injected the lispro into R26. The insulin pen manufacturer instructions showed, Step 1: pull the Pen Cap straight off .wipe the rubber seal with an alcohol swab. The instructions showed after the needle is attached, Prime before each injection. Priming your pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime the pen, turn the dose knob to select 2 units. Step 7: hold the ben with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Step 8: Continue holding your pen with needle pointing up. Push the dose knob until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat priming steps 6 to 8 . On 5/7/24 at 11:04 AM, V2 Director of Nursing stated V4 should have wiped the tip of the needle with alcohol to prevent infection and she should have primed the needle to ensure R26 received the correct dose of insulin. V2 stated nursing staff should follow manufacturer instructions for resident medications.

Based on interview and record review the facility failed to ensure RN (Registered Nurse) staffing data was accurately entered in the Payroll-Based Journal (PBJ) system. This applies to all 42 residents residing in the facility. The findings include: The Long-Term Care Facility Application for Medicare and Medicaid (CMS #671) dated 5/7/24 documents there are 42 residents residing in the facility. On 05/07/24 at 10:10 AM, V1 (Administrator) said, she is not sure what the problem with reporting is. V1 said, the issue may be that the corporate office, who is responsible for submitting the PBJ data, pulls punch codes from the time clock, but outside agency staff does not punch the time clock so those hours are not submitted. V1 said, it might also be how the time clock codes the nurses when they punch in. On 05/08/24 at 12:10 PM, V1 said, V17 (from the corporate office) is the person responsible for reporting the PBJ, V1 said, V17 only works the weekends and only does reporting. V1 said, she does not have a phone number for V17, but did provide V17's email address. On 05/08/24 at 12:44 PM, this surveyor attempted to email V17 and received an immediate automatic reply that was blank. This surveyor requested V17 contact me before 5pm or tomorrow (5/9/24) between 7AM and 9AM and have gotten no response. The October 1-December 31st, 2023, PBJ Staffing Data Report shows, No RN hours, and failed to have licensed nursing coverage 24 hours a day, triggered. The nursing schedule was reviewed for that period and showed that there was RN and licensed nursing coverage as required. This shows the reporting was not accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident safety by utilizing portable space heaters in hallways and not monitoring air temperatures. This failure affects all 43 facility residents. The findings include: The 1/15/24 facility data sheet showed 43 residents in the facility. On 1/15/24 at 7:13 AM, there were space heaters on the floor in the north hall outside room [ROOM NUMBER], 4, 6, and 14. The space heaters outside rooms [ROOM NUMBER] were plugged into outlets inside the room and the cord was on the floor. The space heater outside room [ROOM NUMBER] was plugged into a power strip which was plugged into an outlet in the hallway ceiling. The cord rested on the hallway floor. The space heaters on the floor in the south hall (outside rooms [ROOM NUMBERS]) were plugged into an outlet inside the rooms as the heater and cord were on the floor outside the rooms. A portable space heater outside room [ROOM NUMBER] was plugged into a power strip which was plugged into an outlet in the hallway ceiling. The cord rested on the hallway floor. At 7:22 AM, R1 was seated at a dining room table with a coat on. R1 said yes it was cold in the facility, but he wasn't complaining. R3 was seated at another table with a fleece jacket and gloves on. R3 said he was all set for the cold. At 7:28 AM, V1 Administrator said they were doing everything they can, so they don't have to send anyone out. V1 said the temperature in the facility dropped to 67 degrees Fahrenheit yesterday so they put space heaters out. At 7:35 AM, V2 Director of Maintenance checked ambient temperatures and were as follows: South Hall Dining room- four separate areas- 56 degrees, 61.4 degrees, 60.2 degrees, 62.6 degrees. Activity room (separated by a plastic zipped partition from the end of the south hallway- 51.2 degrees, 48.5 degrees. room [ROOM NUMBER]-62.9 degrees, 60.8 degrees. room [ROOM NUMBER]-64.7 degrees, 62.0 degrees. Wall outside medication room near main entrance-65.6 degrees, 67.0 degrees. North Hall Room10- 61.1 degrees, 63.5 degrees. room [ROOM NUMBER]- 62.6 degrees, 68 degrees. West Hall TV Room- 56.3 degrees, 59.9 degrees. room [ROOM NUMBER]- 60.8 degrees, 66.2 degrees. West hallway- 64.4 degrees, 63.2 degrees. room [ROOM NUMBER]- 68.3 degrees, 72.8 degrees. R1 was in room [ROOM NUMBER] visiting and said it's an icebox in his room with a steady breeze coming through the window. R1 said he sleeps with his coat on. The north hall contained the only thermostat in the building. It was on a wall inside a clear locked box. The box had white paper inside and therefore could not see the temperature that was registered. V2 unlocked the box, removed the paper and the temperature was 66 degrees. Resident rooms had an outside and inside room temperature checked. The outside wall temps were consistently the lower of the two readings. The space heaters were in use in the north and south halls. The resident rooms on the west hall had heaters built into the wall of the rooms. R1-3, and R6-9 said they were asked today if they wanted to move to a warmer room. On 1/15/24 at 6:55 AM, V3 Registered Nurse said it's cold in here. I've seen a lot of space heaters in the halls. At 7:03 AM, V4 Medical Records said I think we've had an issue with the heat forever. At 7:05 AM, V5 Licensed Practical Nurse (LPN) said she doesn't know what the plan is. They have the space heaters out. Maybe move some residents to a warmer hall. At 7:08 AM, V6 Certified Nursing Assistant (CNA) said if a resident complained of being cold, she would put heavier clothes on them and go to managers. V6 said she had been at work since 2:00 AM and the space heaters were out when she got there. At 7:11 AM, V7 CNA said there's been an issue with the heat for a few months now. Some residents complain of being cold since winter started. The space heaters were put out last night before 6:00 PM. V8 CNA Coordinator put them out. Last night we warmed up some blankets in the dryer and gave them to the residents and offered them warm beverages. At 7:28 AM, V1 Administrator said the west hall rooms have wall heaters, so the room temperatures are warmer if the door is kept closed. V1 said the portable heaters are being used on the north and south halls. At 7:45 AM, V2 said the lowest temperature recorded in a resident room was 63.5 degrees. V2 said he doesn't record all temperature readings he takes. At 7:52 AM, V2 said he had done daily temperature checks in random areas since October. V2 said he did not receive any calls about low facility temperatures necessitating the use of portable space heaters. When I left Saturday morning (1/13/24) there were no space heaters out. V2 could not explain why there were no temperature checks logged since 1/8/24. At 8:50 AM, V8 CNA Coordinator said it was colder than average in the building yesterday (1/14/24). V8 said he called V1 to notify her of the cold temps and she told him to get out the space heaters. V8 said the heaters were put out around 10:30-11:30 AM, before lunch. V8 said staff don't check the air temperature in the facility, only V2 does. V8 said they offer extra blankets to the residents when it's cold. V8 took this surveyor to the laundry room where there were two clean blankets available. The clean linen closet did not have any blankets available for use. V8 said no resident room changes had been done. V2 provided this surveyor with his ambient temperature logs. There were no temperature checks recorded since 1/8/24. The lowest temperature recorded was 64.7 degrees in room [ROOM NUMBER]. A water temperature log was provided. This log showed room temperatures added next to water temperature recordings. The lowest temperature on this log was 70 degrees. The facility's undated Power Strip Surge Protector Policy showed they can only be used for small electronics (alarms, TVs, media players) and can not be used with any medical equipment or supplies. The facility's undated Cold Weather Policy and Procedures showed to provide continuing, safe, and comfortable care to its residents in the event the facility heating, and furnace systems fail during periods of unseasonably cold outside temperatures, facility personnel shall take the following action: Staff will be assigned to do 15-minute temperature checks throughout all areas of the building. Residents will be offered the option of changing rooms to warmer rooms. Facility will implement the use of space heaters with visual monitoring of space heaters to assist in maintaining/elevating the temperature. The 1/14/24 facility census report printed at 7:28 AM, showed there were ten empty beds available on the west hall. Most of the facility residents have mental illness, impaired cognition and/or head injury status and self ambulate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to reconcile controlled medications and failed to ensure controlled medications were administered immediately after preparation for 3 of 3 residents (R16, R27, R35) reviewed for medication administration in the sample of 12 and 2 residents (R8, R1) outside the sample. The findings include: 1. On [DATE] at 09:23 AM, a locked cabinet in the medication room had a medicine inventory bag labeled with R35's name. This label showed the bag contains a bottle of Norco (schedule II drug) - quantity 6 and Ativan (schedule IV drug) - quantity 6. There was no dosage for the medications on the bag label. This surveyor requested a reconciliation form for the Norco and Ativan. V3 (Registered Nurse/RN) was unable to provide a reconciliation form for R35's stored controlled medications. On [DATE] at 9:23 AM, V3 she did not count R35's Norco and Ativan at shift change and wasn't aware they were in the cabinet. V3 said she would leave them on the counter to figure it out. R35's face sheet showed a [AGE] year old male admitted to the facility on [DATE]. R35's face sheet and Physician Order Sheet (POS) showed diagnoses of major depressive disorder, alcohol abuse, cocaine abuse, chronic pancreatitis, post traumatic stress disorder, anxiety and diabetes. R35's POS does not have an order for Norco. A photocopy of R35's medicine inventory bag showed a label dated [DATE] with an inventory of Norco quantity 6 and Ativan quantity 6. There was no dosage of the pills noted. 2. On [DATE] at 08:31 AM, there were two medication carts in the medication room. One cart held medications for residents with last names beginning with the letters A-K and the second for the residents with last names beginning with the letters L-Z. On [DATE] from 8:33 AM- 8:43 AM, the controlled drug count in both medication carts were counted and were accurate. All morning medications for the morning medication pass were already removed from the individual resident medication cards. The A-K cart had prepared medication cups with resident names written on them for R1, R8, R16. The L-Z medication cart had a prepared medication cup with R27's name written on it. On [DATE] at 02:01 PM, V3 (RN) said it was ok to pre punch meds because it's a closed locked room and she didn't leave it unattended. V3 said everything is double locked. V3 said Yes, she pre punched the resident medications including the controlled drugs. V3 said the nurse is the only person with keys to the medication room. R1's POC showed a [AGE] year old female with diagnoses of chronic catatonic schizophrenia partially resolved, bipolar-depressed, obsessive compulsive disorder, and hypertension. This order sheet showed medications for morning medication administration included lorazepam 1 mg (milligram) tablet. R8's POS showed a [AGE] year old female with diagnoses of schizoaffective disorder, hypertension, paranoid schizophrenia, bipolar disorder with psychotic features, obesity, and hypertension. This order sheet showed medications for morning medication administration included lorazepam 0.5 mg tablet. R16's POS showed a [AGE] year old male with diagnoses of schizoaffective disorder, diabetes, bipolar, coronary artery disease, major depressive disorder, and obesity. This order sheet showed medication for morning administration included lorazepam 0.5 mg tablet. R27's POS showed a [AGE] year old female with diagnoses of schizophrenia, paranoid delusions, depression, anxiety, agitation, congested heart failure, and hypertension. This order sheet showed medication for morning administration included lorazepam 0.5 mg tablet (1/2 a tablet). On [DATE] at 10:30 AM, V1 (Administrator) said, It is concerning that V3 saw nothing wrong with pre-punching resident medications including controlled drugs. The nurses are not supposed to prepare the medications ahead of time. A resident could go in the med room or the nurse could grab the wrong resident's medications. They should be looking at the MARs as they're preparing the medicine just before administration. The policy is in place to prevent medication errors and drug diversion. If we're not reconciling controlled drugs, we aren't preventing diversion. On [DATE], V2 (Director of Nursing) was called for an interview, and the call was not returned. The facility's [DATE] Controlled Substances Policy showed that all drugs listed as schedule II drugs are subject to specified handling, storage, disposal and record keeping. The policy showed at the time a Controlled Substance is delivered, the Charge Nurse and the Delivery Person will count the controlled substances together to verify the count. If the Controlled Substance count is correct, a control sheet for each prescription will be initiated. The control sheet will contain: resident's name, ordering physician name, issuing pharmacy, name and strength of drug, quantity received, and date and time received. All Schedule II drugs must be administered and recorded on a disposition sheet as follows: date and time of administration, signature of nurse administering the drug, and quantity on hand/balance left. The drugs in other schedules deemed necessary for control are placed under the same restrictions as Schedule II drugs by the pharmacist. The drugs in Schedule II (and those in other schedules which have been restricted and stored in the Controlled Substance cabinet) will be counted and reconciled by the nurse coming on duty with the nurse that is going off duty. These records shall be retained for at least one (1) year. The disposition sheet for a particular regulated drug is placed separately and it will be filed with the permanent record of the resident when that regulated drug had been administered or discontinued (Dc'd). Scheduled drugs may not be returned to the pharmacy upon a resident's discharge/transfer/death. Upon discontinuation of the medication or non-return of the resident within 7 days, the scheduled drug may be destroyed by the Director of Nursing and a Licensed Nurse, two (2) Licensed Nurses with documentation and signature of both on the drug disposition record. The facility's [DATE] Drug Release/Destruction Policy showed prescribed drugs left by a discharged resident or remaining due to a physician stop order shall be destroyed if the non-unit dose drugs do not qualify for returning to the issuing pharmacy. Discontinued medications or medications belonging to discharged residents should be destroyed as soon as practical and within 7 days of resident discharge or drug discontinuation. Drugs belonging to discharged residents who are expected to return within 7 days may be stored in the facility, under state and federal regulation and facility policy for up to seven days. Non-controlled drugs and schedule V controlled drugs may be destroyed in the presence of two (2) licensed nurses. Scheduled II, III, and IV controlled drugs must be destroyed by the Director of Nursing and a Licensed Nurse, two (2) Licensed Nurses or a Licensed Nurse and Consultant Pharmacist. The facility's [DATE] Procurement and Storage of Medications Policy showed newly admitted residents who have brought medication with them are to have new orders from the physician before any medication is administered. All other medication is sent home with the family of the resident. 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. The facility's [DATE] Medication Administration Policy showed the complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given. Document any medications not administered for any reason by circling initials and documenting on the back of the MAR (medication administration record) the date, the time, the medication and dosage, reason for omission and initials. Destroy medications prepared for a resident if not used immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to remove resident medications from storage and failed to destroy medications prepared and not administered for 2 of 2 residents (R15, R29) reviewed for medication storage in the sample of 12 and three residents (R20, R39, and R41) outside the sample. The findings include: 1. On [DATE] at 8:58 AM, during the medication storage task, in the bottom drawer of the A-K medication cart there were two large clear plastic storage bags with pill bottles in them. The pill bottles were labeled as belonging to R15. There was a total of 20 pill bottles. On [DATE] at 9:00 AM, V3 (Registered Nurse/RN) said R15, R41, R29 and R20's medications found stored in the medication room were probably brought in when the resident was admitted . V3 did not know who was responsible for overseeing the facility's medication storage. On [DATE] at 10:30 AM, V1 (Administrator) said resident medications should not be stored in the facility more than 7 days according to the facility policy. On [DATE], V2 (Director of Nursing) was called for an interview, and the call was not returned. R15's face sheet showed a [AGE] year old male admitted to the facility on [DATE] and diagnoses of schizophrenia, Type 2 Diabetes, morbid obesity, obstructive sleep apnea, and chronic obstructive pulmonary disease. The facility's [DATE] Drug Release/Destruction Policy showed prescribed drugs left by a discharged resident or remaining due to a physician stop order shall be destroyed if the non-unit dose drugs do not qualify for returning to the issuing pharmacy. Discontinued medications or medications belonging to discharged residents should be destroyed as soon as practical and within 7 days of resident discharge or drug discontinuation. Drugs belonging to discharged residents who are expected to return within 7 days may be stored in the facility, under state and federal regulation and facility policy for up to seven days. Non-controlled drugs and schedule V controlled drugs may be destroyed in the presence of two (2) licensed nurses. Scheduled II, III, and IV controlled drugs must be destroyed by the Director of Nursing and a Licensed Nurse, two (2) Licensed Nurses or a Licensed Nurse and Consultant Pharmacist. The facility's [DATE] Procurement and Storage of Medications Policy showed newly admitted residents who have brought medication with them are to have new orders from the physician before any medication is administered. All other medication is sent home with the family of the resident. 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. The facility's [DATE] Medication Administration Policy showed the complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given. Document any medications not administered for any reason by circling initials and documenting on the back of the MAR (medication administration record) the date, the time, the medication and dosage, reason for omission and initials. Destroy medications prepared for a resident if not used immediately. 2. On [DATE] at 8:58 AM, in the bottom drawer of the A-K medication cart was a pill bottle with R41's name and labeled as containing fluoxetine 40 mg (milligram) capsules and an expiration date of [DATE]. R41's face sheet showed a [AGE] year old female admitted on [DATE] with diagnoses of major depressive disorder, intellectual disabilities, schizoaffective disorder, asthma, and hypertension. 3. On [DATE] at 8:58 AM, in the bottom drawer of the A-K medication cart were two pill bottles with R29's name. One bottle showed escitalopram 20 mg tablets and was filled on [DATE]. There were three pills in this container. The second bottle showed bupropion XL 300 mg tablet. There were 16 pills in this container. R29's face sheet showed a [AGE] year old female admitted on [DATE]. R29's Physician Order Sheet does not include a current order for escitalopram or bupropion. R29's [DATE] post acute discharge orders (admission to facility orders) showed orders for escitalopram 10 mg tablet take 2 every day and no order for bupropion. 4. On [DATE] at 09:07 AM, there were 3 clear plastic med cups stacked on top of each other in the top drawer of the L-Z medication cart. The cups had R39's name on it. One cup had 2 medication tablets and one capsule. The other cup had one tablet and 1 capsule. On [DATE] at 9:07 AM, V3 (RN) identified the pills as R39's evening and bedtime medications from [DATE]. V3 said she worked [DATE] and reported to the second shift nurse that R39 left the facility for an overnight home visit. V3 said the nurse must have punched the medications, not given them, and left them in the cart. R39's face sheet showed a [AGE] year old female with diagnoses of bipolar disorder, chronic tension-type headache, and morbid obesity. R39's Medication Administration Record (MAR) showed famotidine 20 mg tablet, Geodon 20 mg capsule, gabapentin 300 mg capsule, and trazadone 100mg tablets (2) circled for the 4:00 PM and 8:00 PM doses on [DATE]. There was no documentation on the back of the MAR to explain why the medications were not given. There was no nurse's note showing R39 was out of the facility. The facility sign out log showed R39 left the facility for a leave to home on [DATE] at 7:15 AM and returned on [DATE] at 1:00 PM. 5. On [DATE] at 09:23 AM, there was a sealed dated security bag found in a locked medication cabinet in the medication room. The bag was labeled with R20's name. The label showed a date of [DATE]. The contents of the bag listed on the label included lithium 150 mg, lipitor 20 mg, trazadone 100 mg X 2, metoprolol 25 mg, lisinopril 10 mg, synthroid 88 mcg(microgram), and buspar 10 mg. A copy of R20's security bag showed a label dated [DATE] and the contents included the medications as listed above. R20's face sheet showed a [AGE] year old female admitted on [DATE] with diagnoses of bipolar disorder, recurrent depressive disorder severe with psychosis, chronic obstructive pulmonary disease, and generalized anxiety disease. R20's Physician Order Sheet showed no orders for lithium, Lipitor, trazadone 100 mg, Synthroid 88 mcg or buspar. R20's [DATE] discharge orders (facility admission orders) showed to stop taking lithium and buspirone. There was no order to take lipitor.