Based on observation, interview, and record review the facility failed to place a soiled incontinence brief in a trash receptacle and failed to remove soiled gloves before touching clean items in a resident room for one of three residents (R2) reviewed for infection control in the sample of six. Findings include: The facility's Infection Prevention and Control Program policy, revised 11/28/17, documents, Purpose: To comply with a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for All residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. Guidelines: 1. The facility has established an Infection Control Program which addresses all phases of the organization's operation to reduce or prevent the risk of nosocomial infections in residents and health care workers. On 12/10/24 at 11:00am V3 (RN/Registered Nurse) was preparing to do wound care on R2. Upon unfastening R2's incontinence brief, it was noted that R2 had a bowel movement. While wearing clean gloves, V3 removed R2's stool covered wound dressing, placed it in the soiled incontinence brief, rolled the brief, removing it from R2, and placed it on the floor by V3's feet. While wearing the same soiled gloves, V3 grabbed the door handle to R2's room and looked out into the hallway for V10 (Certified Nursing Assistant/CNA). V10 entered R2's room with clean towels and wash rags. V3 (RN) took the clean linens from V10 with V3's soiled gloved hands. V3 (RN) went to the side of R2's bed, moved the soiled incontinence brief, that was on the floor, with V3's shoe and proceeded to provide incontinence care to R2 while wearing the same soiled gloves. On 12/10/24 at 11:30am V3 (RN) stated she usually places dirty incontinence briefs in a trash can if available but if not places on the floor, then picks them up when she is done with cares. V3 (RN) also stated she was not aware she should not touch clean items with soiled gloves on.

Based on interview and record review the facility failed to employ a certified Infection Prevention Nurse. This failure has the potential to affect all 62 residents residing in the facility. Findings include: On 12/10/24 at 9:00am V1 (Administrator) stated the facility just hired an Infection Prevention Nurse (V3), but she is not certified yet. V1 (Administrator) also stated V3 is signed up for the courses, but has not started them. On 12/11/24 at 9:45am V1 (Administrator) stated that V3 (Registered Nurse/Infection Preventionist) was hired in October 2024 and started work October 29, 2024. On 12/11/24 at 10:00am V3's (Registered Nurse/Infection Preventionist) employee file was reviewed and documents a hire date of October 29, 2024. No certification or Infection Preventionist Training was noted. The Resident Census dated 12/6/24 documents 62 residents currently reside in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to perform a PASARR (Pre-admission Screening and Resident Review) rescreen after the emergence of a newly diagnosed severe mental illness for one of two residents (R2) reviewed for PASARR screening, in the sample of 30. Findings include: The facility policy, Preadmission Screening and Annual Resident Review (PASARR), reviewed 11-13-18 documents, It is the policy to screen all potential admissions on a individualized basis. As part of the preadmission process, the facility participates in the Preadmission Screening and Resident Review screening process (Level 1) for all new and readmissions per requirement to determine if the individual meets the criteria for mental disorder (SMI/SMD), intellectual disability (ID) or related condition. Annually and with any significant change of status, the facility will complete the PASARR Level 1 screen for those individuals identified per the Level 11 screen requiring specialized services. R2's current Physician Order Sheet, dated May 2024 documents that R2 was admitted to the facility on [DATE] with the following diagnoses: Bipolar Disorder and Major Depressive Disorder. R2's current PASAAR screen, provided by V2/Director of Nurses on 4/29/24, documents R2 was originally admitted to a Skilled Nursing Facility on 3/26.97 with no diagnosis of Severe Mental Illness. On 4/29/24 at 12:27 P.M., V2/Director of Nurses verified that R2 has not had a PASAAR rescreen upon admission to the facility, despite R2's diagnoses of severe mental illness.

Based on interview, observation and record review, the facility failed to ensure a resident was safely during transport in the facility's transport van for one of two residents (R7) reviewed for falls in the sample of 30. Findings include: R7's medical record documents R7's diagnoses to include: Dependence on wheelchair; Diabetes Mellitus doe to underlying condition with Diabetic Autonomic Neuropathy; and Acquired Absence of Left Leg. R7's Fall Investigation (dated 02/14/24) documents R7 fell in the facility's transport van while in route to a doctor's appointment. R7's current Fall Risk Care Plan documents the following fall prevention intervention implemented on 02/14/24: Educate bus driver and resident on seatbelt safety while in wheelchair. On 04/30/24 at 01:30 PM during the group meeting, R7 stated he fell in the facility's transport van while he was being transported to a doctor's appointment. R7 stated he had pain in his right leg and was transported to a local hospital emergency room for evaluation, and then returned to the facility later that same day once he was discharged from the emergency room. On 05/02/24 at 09:35 AM, R7 was sitting in his electric wheelchair in his room going through items in drawer of a storage bin. R7 was dressed and groomed, and a full mechanical lift was in place underneath of him. R7 stated he can recall the fall he had in the facility van on 02/14/24. R7 stated he was not sitting in the usual spot he sits in the transport van due to another resident present in the van being transported to an appointment. R7 lifted up his shirt exposing his wheelchair seat belt, which was fastened. R7 stated he was not wearing his wheelchair seatbelt at the time of his 02/14/24 fall, and the transport van's lap belt that goes across his lap during transport was loose enough to allow him to slip forward out of his wheelchair when the van came to a stop. On 05/02/24 at 08:50 AM, V14 (Van Driver) entered the facility's transport van parked in front of the facility and stated the following: I had just started this job when (R7) fell in the van. I believe it was my second week. I had two residents in the van that day. They were both going to doctor's appointments. We approached a stop sign, and (R7) fell out of his wheelchair. I did not know it at the time, but he has a seatbelt on his electric wheelchair and it was not fastened. His wheelchair was secured in place, but the seatbelt in the van was not tight enough. (R7) had me loosen it before we took off that day because he said it was uncomfortable. It should have been much tighter. I know better than to allow this now. V14 then pointed to the seatbelt in the van and demonstrated how to tighten it.

Based on interview, observation and record review, the facility failed to attempt a gradual dose reduction twice in two separate quarters within the first year prescribed and document a consistent pattern of adverse behaviors for one of three residents (R38) reviewed for one of four residents (R38) reviewed for psychotropic medications in the sample of 30. Findings include: The facility's Psychotropic Medication - Gradual Dose reduction policy (revised 02/01/18) documents the following: Residents who use psychotropic drugs shall receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to discontinue or reduce the medication. A gradual dose reduction shall be encouraged at least twice yearly unless previous attempts at reduction have been unsuccessful or reduction is clinically contraindicated. The drug reaction will continue until eliminated or the clinical condition of resident worsens. R38's medical record documents R38's diagnoses to include: Major Depressive Disorder, Recurrent severe without psychotic features; Alcoholic Polyneuropathy, Insomnia, Deficiency of specified B group vitamins; Generalized Anxiety Disorder; Alcohol Dependence with Alcohol-induced persisting Amnestic Disorder; Amnesia; and Dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. R38's current Physician's Orders document the following medication order: Seroquel (antipsychotic) give 50 milligrams by mouth two times a day (initial date of order 05/18/23). On 04/29/24 at 01:20 PM, R38 was sitting up in bed with the head of the bed elevated approximately 60 degrees operating his laptop. R38 was dressed and groomed, and a call light and oral fluids were within his reach. Several personal items were present in R38's room, including a large keyboard. R38 stated, I used to be a music teacher and caused some issues in my brain when I used to drink alcohol. I now am writing songs on my tablet since I am here and cannot teach anymore. R38 stated all is going well at the facility and he is currently in the process of applying for disability, Once I get disability I want to discharge and get my own place. R38 did not display any adverse behaviors during this time. R38's Monthly Behavior Monitoring Sheets (dated 11/2023 - 4/2024) document R38 is being monitored for the following target behaviors: Agitation/Anxiety/Restlessness; Verbally Aggressive. These forms document R38 displayed 5 or less episodes of these behaviors each month, except R38 displayed 7 episodes of Agitation/Anxiety/Restlessness in March 2024. On 05/01/24 at 01:20 PM, V2 (Director of Nursing) stated the following when asked what behaviors R38 displays: Loud noises will trigger and agitate (R38). V2 stated R38 is not a harm to himself of others, and the behaviors that R38 displays do not warrant the use of an antipsychotic medication. V2 confirmed R38 has been on the same dose of the antipsychotic, Seroquel, since it was initially ordered a year ago, and a gradual dose reduction has not been attempted.

Based upon observation, interview and record review, the facility failed to provide clean, stain-free linens for bathing for 9 residents (R7, R15, R22, R25, R30, R32, R44, R48 and R57) of 9 residents reviewed for dignity, in a sample of 30. The facility policy, Dignity, dated (reviewed) 4/23/18 directs staff, The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. 1. On 4/29/24 at 10:38 A.M., R44 held up two (2) discolored wash clothes which had brown/tan stains. R44 stated Would you want to wash yourself with these? This is gross. This is supposed to be my house and I sure wouldn't use this to wash my car. It's not dignified. I even posted pictures on (Social Media). Ever since this new company took this place over, they can't get wipes, so they (staff) have to wipe our a***s with them. Then they just put them right back in the laundry. I bet those washing machines are full of feces and that's not right. Go culture them and see what grows out of them. I feel so contaminated 2. On 4/29/24 at 9:46 A.M., R25 was seated in her wheelchair, in her room. At that time, R25 stated, I'm so upset about this. Look at this filthy washcloth. Staff brought this into my room this past weekend and wanted me to use it to wash my face. It's a dignity problem. It is so undignified to even think of using something that someone else used to wipe their butt with. They took away our disposable wipes and told us we have to use these stained up washcloths. Last week when I went to take my shower, they wanted me to sit on a community shower chair that was covered with a blood stained white towel. R25 held up a greyish-looking washcloth covered with brown stains. On 4/29/24 at 10:55 AM, V7 (Housekeeping Manager) stated If the laundry is stained after we wash it, we pull it out and give it to housekeeping or the kitchen to use as rags. Over there (pointed at multiple boxes on clean side of laundry room) are full of brand new towels and wash clothes. If it is really bad (dirty washcloth), the CNA's are suppose to wash it in the hopper and put it in a bag before they put it in the laundry. It gets cleaned with all other whites. Soiled (wash clothes saturated with brown substances.) laundry was observed in the laundry bin in front of the washing machine. V7/Housekeeping Manager verified the laundry in the bin with the soiled material was ready for wash. 3. On 4/29/24 at 2:47 P.M., V48 stated, I am the (facility) Resident Council President. Many residents have voiced concerns to me about dingy, brown stained washcloths that we are given for bathing. We feel demeaned by being forced to use (feces) stained washcloths to wash ourselves. On 4/30/24 at 1:00 P.M., during the facility Group Meeting, R48 stated, Please do something about these dirty, stained wash cloths they make us wash with. It is demeaning to be treated this way. At that time, the other residents in attendance (R7, R15, R22, R30, R32 and R57) were in agreement. On 4/30/24 at 2:40 P.M., V1/Administrator stated, Our company policy is that we no longer buy (disposable) wipes for incontinence care. Staff have to use washcloths for peri care. They're not supposed to use the stained ones. I will talk to laundry and remind them to throw the stained ones away.

Based on interview and record review, the facility failed to conduct the required quarterly Quality Assurance meetings and failed to ensure the required Quality Assurance committee members were in attendance. These failures have the potential to affect all 63 residents currently residing in the facility. FINDINGS INCLUDE: The facility policy, Quality Assurance and Performance Improvement Plan, dated (effective) January 02, 2024 documents, The QAPI program at (the facility) will aim for safety and high quality with all clinical interventions and service delivery while emphasizing autonomy, choice and quality of daily life for residents and family by ensuring our data collection tools and monitoring systems are in place and are consistent for proactive analysis, system failure analysis and corrective action. The Quality Assessment and Assurance Committee reports to the executive leadership and Governing Body and is responsible for meeting for: Meeting, at a minimum, on a quarterly basis; more frequently, if necessary. The Quality Assessment and Assurance Committee will consist of the Medical Director/Designee, Director of Nursing Services, Administrator/Owner/Board Member/Other Leader, Infection Prevention and Control Officer, Maintenance, Business Officer Manager, Minimum Data Set Nurse, Wound Nurse, Social Services Director, Activity Director, Dietary Manager and Housekeeping Supervisor. The facility Quality Assurance Performance Improvement Meeting Minutes attendance sign-in sheets, provided by V1/Administrator include April 12, 2023 (missing Medical Director signature); February 8, 2024 and April 3, 2024 (missing Medical Director and Director of Nurses signature). No Quality Assurance Performance Improvement Meeting Minutes are available for July and October 2023 or January 2024. On 05/02/24 at 9:09 A.M., V1/Administrator verified the missing signatures for the 4/12/23 and 4/3/24 sheets. At that time, V1 also confirmed the missing sign in sheets for July 2023, October 2023 and January 2024. The facility Resident Census and Conditions Report for Medicare and Medicaid Services (CMS), dated 4/30/2024 and signed by V1/Administrator documents 63 residents currently reside in the facility.

2. 4/29/24 at 12:30pm, V4, Registered Nurse, entered R60's room to pass medications. R60's has a RED ZONE sign on the door, indicating that R60 is on droplet precautions and full personal protective equipment is required. V4 had on a surgical mask, then donned a plastic face shield. V4 entered R60's and gave her the medication. V4 exited R60's room and used hand sanitizer and removed the plastic face shield. V4 continued to pass the medication on the unit. V4 verified that she did not don full PPE prior to entering R60's droplet isolation room. V4 also stated that she did not change her change her mask after leaving R60's room. The facility's Long-Term Care Facility Application for Medicare and Medicaid form, dated 4/30/24, documents that 63 residents reside in the facility. Based on observation, interview, and record review the facility failed to utilize PPE (Personal Protective Equipment), failed to audit for appropriateness/compliance of PPE and failed to screen staff during a COVID-19 outbreak. This has the potential to affect 63 residents residing in the facility. Findings include: The Infection Control-Interim COVID-19 policy, dated 7/24/23, PPE Use in Red & Yellow Zone Residents with Suspected or Confirmed COVID-19 Infection HCP (Health Care Providers) who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH (National Institute of Occupational Health) approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Respirators should be used in context of a comprehensive respiratory protection program, which includes medical evaluations, fit testing and training in accordance with the Occupational Safety and Health Administration's (OSHA) Respiratory Protection standard. PPE including N95 should be discarded and new applied between each resident encounter, Testing of Staff and Residents: Newly identified COVID-19 positive staff or resident in a facility that can identify close contact. Test all staff regardless of vaccination status that had a higher-risk exposure with a COVID-19 positive individual. Test all residents, regardless of vaccination status that had close contact with a COVID-19 positive individual. The Infection Surveillance, Tracking and QA (Quality Assurance) Reporting policy, dated 2/14/18, Purpose: To identify, monitor, track and report infections and monitor adherence to infection control practices. Infection surveillance for compliance may include but is not limited to: Direct observation of care and procedures performed by staff. Direct observations of adherence to hand hygiene and proper use of PPE. Monitoring the availability of PPE. The Center for Disease Control (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 3/18/24, Personal Protective Equipment HCP (Health Care Providers) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH. Approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). The CDC's NIOSH-Approved Particulate Filtering Facepiece Respirators this list is reviewed and updated weekly, A respirator labeled as a KN95 respirator is expected to conform to China's GB2626 standard. NIOSH does not approve KN95 products or any other respiratory protective devices certified to international standards. R317's Physician's Orders, dated 4/29/24, Follow Facility Protocol for COVID19 Screening/Precautions Droplet Precautions. On 4/29/24 at 10:06 AM, outside of R317's room posted on wall next to the door was a Droplet and Contact/Red Zone precautions signage. On 4/29/24 at 10:07 AM, V6 (Agency Certified Nursing Assistant) donned PPE and entered R317's room without tying the gown closed. V6 stated I'm Agency. This is my first rodeo here. They asked me to come in 15 minutes early to get the door codes and had a basic quick introduction and then I got started. On 4/29/24 at 10:10 AM, R317 was observed to leave the room with a mask on and no other PPE. R317 walked down to nurse's station and was then redirected back to R317's room by V4 (Registered Nurse). On 4/29/24 at 10:11 AM, V4 (Registered Nurse) was observed to enter R317's room without donning PPE (N-95, goggles, gloves and/or gown). V4, sat R317 down in a chair, took disposable stethoscope and blood pressure cuff out of R317's hands and put it on the overhead table. V4 exited the R317's room and performed hand hygiene. On 4/29/24 at 10:13 AM, V4 stated, R317 wanders out in the hall all day and has to be redirect back to R317's room. On 4/30/24 at 11:55 AM, R317 was walking down B-hall with a mask donned and V10 (Registered Nurse) redirected and escorted R317 back to R317's room. R317 was observed to immediately walk out of room, past V10 and walked to the nurse's station approximately 45 ft. V9 (Registered Nurse) was observed at the Nurses Station and redirected and escorted R317 back to R317's room. At 11:58 AM, R317 walked back out into the B-hall, again walked past V10 to nurse's station where the V9 stated I Know you are hungry. Lunch is coming soon and escorted R317 back to her room. The Infection Prevention COVID positive tracking list, dated 3/1/24 through 5/1/24, documents R317 tested positive for COVID-19 on 4/23/24, R60 tested positive for COVID-19 on 4/23/24 and R63 tested positive for COVID-19 on 4/29/24. On 4/30/24 at 10:00 AM, a Droplet and Contact/Red Zone precautions sign was post outside of R63's and R60's room (directly across from one another) in B-hall. On 5/1/24 at 1:00 PM, two PPE supply cabinets in the B-hall outside of R63's room and outside of R317's room each contained 1 (one) box each with 20 (twenty) KN95 Disposable Non-Medical Face Masks Product Model: JDK-01, Jinhue Jiadaifu Medical Supplies Company. The CDC guidelines do not list KN95 Disposable Non-Medical Face Masks Product Model: JDK-01, Jinhue Jiadaifu Medical Supplies Company as NIOSH approved mask. On 5/1/24 at 2:08 PM, V13 (Agency CNA) stated If I have to go into one of those rooms (R63 and/or R60's COVID isolation rooms), I use the PPE out of that cabinet (V15 pointed at the cabinet outside of R63's room which contained the non-approved NIOSH KN95 masks.) V15 (CNA) was present and stated V15 would as well use the PPE in the cabinet. On 5/1/24 at 2:10 PM, V16 (Occupational Therapy Assistant) was observed in R63's room with the non-approved NIOSH mask donned. On 5/1/24 at 12:49 PM, V3 (Infection Control Preventionist) stated I'm going to start doing PPE audits since we have had this big outbreak. I only monitor hand hygiene compliance now. The Daily Shift Assignment form dated 4/20/24 through 4/30/24 documents the following: 10 Agency staff worked on 4/23/24; 5 agency staff on 4/26/24; 4/29/24 7 agency staff. On 5/1/24, the Staff Source Testing binder included facility staff rapid COVID-19 testing results conducted on 4/23/24, 4/26/24 and 4/29/24. The binder lacked documentation that Agency staff were tested. On 5/1/24 at 12:35 PM, V17 (Agency Certified Nurse Aide/CNA) stated Our Agency doesn't have us test (COVID-19). No, they didn't test me here. On 5/1/24 at 12:45 PM, V13 (Agency CNA) stated Our Agency does not require testing (COVID-19). I just got done doing the on-boarding paperwork with the DON (Director of Nursing) and nothing was said about testing. They (facility) haven't tested me. On 5/2/24 at 1:00 PM, V3 stated Agency staff are not included in source testing for COVID-19. V3 agreed without including the Agency staff in the source testing, the sampling would be skewed and not all-inclusive.

Based on interview and record review, the facility failed to immediately report and investigate a fall for one of three residents (R35) reviewed for accidents and supervision in the sample of 30. Findings include: The facility's Incident and Accidents policy, reviewed 4/7/2019, states, Policy: The Incident/Accident Report is completed for all unexplained bruises or abrasions, all accidents or incidents where there is injury or the potential to result in injury, allegations of theft and abuse registered by residents, visitors or other, and resident-to-resident altercations. Procedure: An 'incident' is defined as any happening, not consistent with the routine operation of the facility, that does not result in bodily or property. An 'accident' is defined as any happening, not consistent with the routine operation of the facility that results in bodily injury other than abuse. An incident/accident report will be completed for: 1. All serious accidents or incidents of residents. 2. All injuries of staff, families, and visitors. 3. All unusual occurrences. 6. All unexpected events that occur that cause actual or potential harm to a resident or employee. 1. An incident/accident report is to be completed by a RN (Registered Nurse) or LPN (Licensed Practical Nurse), and is to include: a. Date and time of an incident/accident. b. Full written statement and possible cause of incident, physical assessment, injuries noted, vital signs, treatment rendered, and notification of appropriate parties. 4. Documentation in nurses' notes is to include: a. A description of the occurrence, the extent of the injury (if any), the assessment of the resident, vital signs, treatment rendered, and parties notified. The facility's Fall Prevention Program, revised 11/21/17, states, Accident/Incident Reports involving falls will be reviewed by the Interdisciplinary Team to ensure appropriate care and services were provided and determine possible safety interventions. R35's Facesheet documents R35 admitted to the facility with diagnoses to include but not limited to: Morbid (Severe) Obesity; Abnormal Posture; Other Lack of Coordination; Other Low Back Pain; Muscle Spasm of Back; Difficulty in Walking; Shortness of Breath and Dependence on Supplemental Oxygen. R35's Fall Risk Assessment, dated 4/9/23 documents R35 is at risk for falls. R35's Interdisciplinary Team/IDT Note on 5/4/2023 at 8:37 AM documents a late entry note stating that R35 became weak and was assisted to the floor while transferring. R35's Current Care Plan documents R35 is at risk for falls and documents that R35 was lowered to the floor when transferring. R35's Census List documents that R35 was transferred to the local area hospital on 4/11/23. No further transfers to the hospital are documented for April or May 2023. R35's Witnessed Fall Report, dated 5/3/23 and completed by V2 (Director of Nursing), states, (Local State Agency Surveyor) had notified this writer (V2) that (R35) stated she had fallen the day she was sent to ER (Emergency Room) (4/11/23). Immediate Action Taken: Investigation was initiated on (R35) stating she fell. No injuries were noted. (R35) became weak and O2 (Oxygen) was 86% (percent). (R35) was COVID positive at time. (R35) was sent to ER due to having low sat (oxygen saturation), increased RR (Respiratory Rate) and SOB (Shortness of Breath). I notified POA (Power of Attorney) and MD (Medical Doctor). Predisposing Situation Factors are documented as during transfer. Witnesses are documented as V8 (Registered Nurse/RN), V5 (Wound Nurse/Licensed Practical Nurse), and V10 (Certified Nursing Assistant). V8's witness statements states, (RN) stated she was called into the room because (R35) was weak. When transferring (R35), she was lowered to the floor. Sent on stretcher to ER. V5's witness statements states, (R35) had been lowered to the floor due to being weak and I was assisting staff with (mechanical lift) to get her off the floor. V10's witness statements states, We were transferring (R35). She became weak and stated she was going to fall. She was sitting half on the bed and said she couldn't stand. We lowered her (R35) to the floor. R35's Nursing Note on 4/11/2023 at 1:12 PM states, At 12:00 PM, Staff called the writer (V8) while doing medication pass to help resident to get on her chair. Upon entering the room, (R35) appears to be pale, weak and has increase RR (respiratory rate) and has difficulty of breathing. Tried to position (R35) on comfortable position. VS/Vital Signs taken : 110/73 RR: 30, temp; 97.0, O2 (Oxygen) sat/saturation : 86. Put on oxygen via mask but resident took out, refusing mask to put on despite explaining the benefits of having the mask. Resident Oxygen goes below 86% on 3lpm (three liters per minute). Increased to 4 lpm to keep the oxygen @ (at) 90% but oxygen is going down. Notified MD @ 12:14 and ordered to send to hospital. As of 5/12/23, this same Nursing Note did not contain any documentation that R35 had to be lowered to the floor by staff during a transfer. On 5/12/23 at 9:14 AM, V9 (Certified Nursing Assistant/CNA) stated that on 4/11/23, R35 was sitting on the side of the bed holding onto R35's walker, trying to stand up. V9 stated that V9 was called into the room by V10 (CNA) because R35 kept trying to get up without help. V9 stated that R35's bottom began sliding off the side of the bed, so R35 was then lowered to the ground by staff. V9 stated the mechanical lift was used to get R35 off the floor and back into bed and that R35 transferred to the hospital soon after. V9 stated, Since (R35) ended up on the floor, I would definitely report that to my nurse. V9 stated that R35's nurse (V8) was present in the room during V8's fall. V9 denied that a witness statement was obtained from V9 regarding R35's fall. On 5/12/23 at 10:11 AM, V10 (CNA) stated that around lunch time on 4/11/23, R35 had been sick and was sitting up on the side of R35's bed. V10 stated that R35 seemed confused and kept trying to transfer to R35's wheelchair without assistance. V10 stated that V10 yelled for help and V8 and V9 came into R35's room to assist. V10 stated that R35 said she could not stand and was going to fall. V10 stated that the staff members could not get R35's bottom on the bed enough, so R35 was instead, lowered to the floor. V10 stated a mechanical lift was used to get R35 off the floor and into R35's bed. V10 stated this fall occurred the same day that R35 was sent to the hospital for COVID. V10 stated, It is still considered a fall even if it is planned. V10 denied that a witness statement was obtained from V10 regarding R35's fall before 5/3/23. On 5/10/23 at 11:10 AM, V5 (Wound Nurse/Licensed Practical Nurse) stated that in mid April, R35 was diagnosed with COVID and had to be hospitalized . V5 stated that V5 walked into R35's room when the staff was using the mechanical lift to get R35 off of the floor. V5 stated that V10 (Certified Nursing Assistant) was in the room and reported to V5 that R35 had been lowered to the floor by staff. V5 stated R35's fall should have been reported and is unsure if it was. V5 denied reporting R35's fall to V2 (Director of Nursing). On 5/10/23 at 12:12 PM, V2 (Director of Nursing) stated that last week a surveyor with the local state agency had notified V2 that R35 had communicated that on the day R35 transferred to the local area hospital (4/11/23), R35 had fallen to floor with staff. V2 stated that a fall investigation was opened up on 5/3/23, the day V2 became aware that a fall had occurred with R35. V2 stated that V2 investigates falls in the facility and V2 would expect to be notified about R35's fall and that V2 was not. V2 stated that V2 did not know R35 had to be lowered to the ground by staff until it was reported by the surveyor. V2 stated that even though R35 was lowered to the ground by staff and R35 was not injured, the incident still requires immediate reporting by staff. V2 stated V8 should have created an incident report on 4/11/23 when R35 fell, but V8 did not. V2 stated all staff was in-serviced on reporting of falls and resident transfers. V2 denied that R35 has had any falls since returning back from the hospital. On 5/10/23 and 5/12/23, attempts were made to speak with V8. Phone calls were not returned and V8 was not observed in the facility. As of 5/12/23, R35's medical record did not contain any documentation that R35's 4/11/23 fall was reported or investigated prior to 5/3/23.

Based on observation, interview and record review the facility failed to follow interventions to decrease anxiety and re-traumatization, failed to identify triggers related to history of trauma/abuse and failed to develop a comprehensive care plan to provide Trauma Informed Care for two residents (R11, R47) of five residents reviewed for Trauma Infromed Care in the sample of 30. Findings include: Facility Policy/Behavioral Health Services (Program) dated 10/24/22 documents: The facility will attempt to identify, to the extent possible, any previous history of mental illness, trauma, abuse, substance use, comorbidities, pattern of behaviors, preferences, interests, daily routines, medication use and effective behavior management interventions in developing an individualized plan of care. The care plan should include a well-defined problem-statement and should outline the goals of care. It should include measurable objectives and timetables for individualized interventions. The care plan should reflect: Identified or suspected triggers specific to each resident that may initiate or exacerbate behavioral symptoms. Specific individualized interventions for responding to target behaviors/triggers and expressions of distress. Individualized, person-centered approaches should be implemented to address expressions of distress. On 5/12/23 at 12:30pm V1, Administrator stated that the facility does not currently have a specific policy addressing PTSD (Post Traumatic Stress Disorder) or Trauma Informed Care. 1. Current POS (Physician Order Sheet) indicates R47 has diagnoses that include Alzheimer's Disease with Late Onset, Major Depressive Disorder and Generalized Anxiety Disorder. Current Care Plan indicates R47 has a history of trauma related to sexual and physical abuse - date initiated 5/5/20. Care plan does not list specific, individualized triggers to decrease potential for re-traumatization. Care Plan indicates R47 is non-compliant/resistive to care with showers, baths and frequently refuses to change soiled briefs and bedding. Interventions for this problem include: -have staff that is most compatible provide care and (dated 5/11/21); -leave (R47) alone and re-approach later as needed (dated 5/11/21); -if response is aggressive, staff to walk away calmly and approach later (dated 2/21/19); -if (R47) resists with ADL's (Activities of Daily Living) reassure, leave and return 5-10 minutes later and try again (dated 5/6/21); -provide care with teams of 2 staff members (dated 6/10/19); -keep routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion (dated 11/6/20). Social Service LookBack Summary dated 5/2/23 at 1:10pm indicates R47 has a history of physical/emotional trauma and sexual violence. Summary indicates R47 experienced sexual abuse at the age of 4 and was abused by her husband when he was drinking. Incident Investigation dated 4/25/23 indicates R47 initially stated that she was roughed up by V15, Agency CNA (Certified Nurse Assistant) on that date at 5:30am. Incident report indicates R47 was incontinent of a large amount of stool and required incontinent care as stool was not only spilling out of R47's brief, but had also soiled her gown and bedding. Report indicates R47 told V15 it was not time to be cleaned up because it was not 2pm and she only gets cleaned up at 2pm. V15's witness statement dated 4/23/23 indicates R47 verbally resisted care, but was not physically aggressive. V15 indicated she only wanted to get R47 cleaned from the bowel movement. Witness statement dated 4/25/23 from V17, LPN (Licensed Practical Nurse) indicates she told R47 that they couldn't leave her with feces all over. Statement indicates V15 washed the feces off of R47 while R47 cursed at V15. Statement indicates V17 thought R47 had these behaviors because she yells, screams and calls people names when cares are performed. On 5/10/23 at 10:30am R47 was seen in bed and remembered meeting briefly on 5/9/23. R47 denied being hit or abused by V15 (on 4/23/23) but did state that she has the right to refuse care. R47 stated that she just woke up (on 4/23/23) and doesn't like to be woke up because she can't go back to sleep. R47 stated she wasn't even fully awake when V15 told her she had to get cleaned up. R47 stated that V15 proceeded to change her clothes and bedding even though she told V15 not to do it. On 5/11/23 at 11:50am V19, CNA stated that she frequently provides care to R47, but it took about 6 months for R47 to be really comfortable with V19. V19 stated that at first she assisted another CNA when providing care to R47 until R47 became comfortable allowing V19 to provide care But it took a long time. V19 stated R47 can be verbally rude if she doesn't like them. V19 stated she followed V15 on 4/23/23 when R47 was upset with V15. V19 stated that V15 is a very sweet and caring CNA and would never abuse a resident but V15 should have just left the room - even though R47 had feces all over - and told someone else to clean up R47. V19 stated that it's better to back away and re-approach (R47) does calm down after awhile. V19 stated she was unaware of R47's history of trauma But now it makes sense that she acts the way she does when she needs to have personal care. On 5/11/23 at 1:30pm V7, SSD (Social Service Director) stated that he recently asked R47 more specific questions regarding her history of trauma and abuse and was told she was sexually abused at four years of age and physically abused by her spouse when he was drinking. V7 stated if R47 told staff No they should've left, notified the nurse and either re-approached or got someone else to provide the care. V7 stated that really goes for any resident but especially a resident with a history of trauma/abuse. 2. The Diagnosis Report for R11 documents the following diagnoses for R11 as: Schizoaffective Disorder, Paranoid Schizophrenia, Bipolar disorder, Major Depressive Disorder, and unspecified Psychosis. The SS (Social Service) - Lookback Summary for R11, dated 6/15/21, documents R11 was assessed for Trauma Informed Care on 6/15/21 with documentation Resident will not talk about her past. Per history on previous assessments, resident has experienced physical/emotional trauma. Behavioral health diagnoses are listed as Paranoid Schizophrenia and Schizoaffective Disorder. Triggers that alarm or distress as indicated by individual or loved one/responsible party include: loud noises, change in routine or living arrangement, and crowded/confined spaces. The Care Plan section, numbered 2 on this assessment form documents Trauma informed care planning was not completed. R11's current Care Plan does not include or mention Trauma Informed Care Plan or triggers to trauma. On 5/9/23 1:57 pm, R11 was in her room, the lights were out and curtains pulled at the window. R11 was lying in bed with blankets pulled up around her neck. During conversation R11 was raising voice and frowning. R11 stated she does not like to use the community shower room because she is fearful of rape and stated she does not like to socialize with a lot of people and prefers to be by herself. On 5/10/23 at 8:30 am, R11 came out of her darkened room with head down and was walking toward the dining room. On 5/10/23 at 2:43 pm, R11 was in her room, the lights were not on and room dark with curtain pulled at the window. R11 was coming out of her bathroom and stated someone is always telling her what to do and when to do it. R11 pulled bedding back and laid down in bed and pulled her blankets up to her neck. On 5/12/23 at 9:25 am, V7 SSD (Social Service Director) stated he started working at the facility about a year ago and has not been able to get all the trauma informed care assessments completed yet for all the residents and has a plan in place to do them when their quarterly assessments come due. V7 SSD stated the assessments are to be done upon admission, quarterly and annually. V7 SSD confirmed the last Trauma Informed Care assessment was last completed for R11 on 6/15/21 and the care plan was not developed. V7 SSD stated he is going to complete R11's assessment with her next quarterly assessment period.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide indication for use of an antipsychotic medication and failed to identify specific target behaviors for two residents (R24, R25) who receive antipsychotic medications with diagnosis of Dementia of three reviewed for unnecessary psychotropic medications in the sample of 30. Findings include: Facility Policy/Psychotropic Medication - Gradual Dose Reduction dated/revised 2/1/18 documents: Informed consent shall be obtained as follows: Psychotropic medication shall not be administered without the informed consent of the resident or the authorized resident representative. Facility Policy/Behavioral Health Services (program) dated/revised 10/24/22 documents: The care plan should reflect: For psychotropic medications include indication/rationale for use, specific target behaviors, monitoring for efficacy and/or adverse consequences and (when applicable) plans for gradual dose reduction (GDR) if an antipsychotic medication is used. 1. Consent For Psychotropic Medications indicates R24 signed a consent on 12/23/21 to receive Seroquel (antipsychotic) 50mg (milligrams) three times per day for Vascular Dementia with Behaviors and on 3/30/23 to receive Seroquel 50mg at bedtime for Bipolar Disorder. Psychotropic consents do not identify target behaviors or specific indication for use for administration of Seroquel. Current POS (Physician Order Summary) indicates R24 receives Seroquel 50mg at bedtime (initiated 3/30/23) for Bipolar Disorder, Current Episode Manic Severe with Psychotic Features. On 5/10/23 at 11:57am R24 was pleasant, social and appropriate with conversation. R24 stated he takes Seroquel to Relax. Current Care Plan (dated Initiated 12/24/21) indicates R24 uses psychotropic medications related to behavior management, disease process (Bipolar Disorder, Dementia, Major Depressive Disorder, Insomnia, Pain) Potential for injury to self or others. Interventions: Monitor/record occurrence of/for target behavior symptoms (pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) On 5/12/23 at 11:40am V3, Psychotropic Nurse stated that the behaviors to monitor in R24's care plan populate and are not specific to R24. V3 stated that she is only aware of anxiety and a history of suicidal ideation for R24. Behavior monitoring (April and May 2023) indicates R24 had one episode of abusive language. Current Comprehensive Assessment indicates R24 has no psychosis and no behaviors identified on assessments dated 12/12/23 and 3/13/23. On 5/11/23 at 3:30pm V7, SSD (Social Service Director) stated R24 receives Seroquel for anxiety. V7 was not aware of any other behaviors displayed by R24. V7 acknowledged antipsychotics are not generally prescribed just for anxiety. 2) Current POS indicates R25 is [AGE] years old and has diagnoses that include Unspecified Dementia, Mild without Behavioral, Psychotic, Mood Disturbance and Anxiety. POS indicates R25 has orders for Risperdal (0.5mg) daily for Schizoaffective Disorder. R25 was seen in her room/milieu at various times of the day on 5/9/23, 5/10/23 and 5/11/23. R25 did not display any observable behaviors, was cooperative and appropriate. Consent for Psychotropic Medications dated 9/23/21 indicates consent was received for Risperdal 0.5mg twice daily for psychosis. Consent does not indicate target behaviors, specific psychotic behaviors or specific indication for use. Current Care Plan (date initiated 11/10/20) indicates R25 has a history of being non-compliant/resistive related to history of rejecting care, dementia with behavioral disturbance. Care Plan indicates R25 has a history of accusing her family of trying to hurt her. Care Plan indicates R25 has delusions related to her daughter trying to kill her and has made false accusations toward staff. Care Plan indicates R25 uses psychotropic medication related to behavior management and pain management. Care plan does not specifically identify antipsychotic medication or specific target behaviors. Behavior monitoring (April and May 2023) indicates R25 had one incident of abusive language. On 5/11/23 at 3:30pm V7, SSD (Social Service Director) stated R25 receives Risperdal for a history of hallucinations and delusions. V7 was not aware of any other behaviors or recent hallucinations and/or delusions displayed by R25.

Based on observation, interview and record review the facility failed to provide a written reason for Transfer/Discharge for four Residents (R10, R13, R16 and R59) and failed to notify the local Ombudsman of a Resident discharge for three Residents (R10, R13 and R59) of 18 reviewed for hospitalization and discharge in a sample of 30. Findings include: Facility Notice of Transfer and Discharge Policy, revised 10/24/22, documents: Notify the resident and the Resident's Representative of the Transfer or Discharge and the reasons for the move in writing in a language and manner they understand. The facility will send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. This may be done by submitting a monthly list of discharges to the Ombudsman. The facility's monthly admission and Discharge Reports emailed to the local Ombudsman, dated February through April 2023 do not include R10, R13, or R59's discharges to the local hospital. 1. R10's Face Sheet, dated 5/12/23, documents that V13 (R10's Power of Attorney/POA) is R10's Emergency Contact/Health Care Power of Attorney. R10's Nursing Note, dated 4/13/23 at 6:12 pm and 7:11 pm, documents that R10 was sent to the local Emergency Department for evaluation of not feeling right and feeling the same way as last time when R10 had a stroke. R10's Nursing Notes, dated 4/13/23 through 4/14/23, does not document that a written notification was provided to R10 or V13. On 05/10/23 at 12:14 pm, V2 (Director of Nursing) stated, I do not see that any written notification or Bed Hold Policy was given to R10 or V13 (R10's Responsible Party). 2. R59's Face Sheet, dated 5/12/23, documents that V14 (R10's Power of Attorney/POA) is R59's Emergency Contact/Health Care Power of Attorney. R59's Nursing Note, dated 2/6/2 at 11:26 pm and 11:31 pm, documents that R59 was sent to the local Emergency Department for evaluation via Local Emergency System Ambulance for a change in condition. R59's Nursing Notes, dated 2/5/23 through 2/6/23, does not document that a written notification was provided to R59 or V14. On 05/10/23 at 12:14 pm, V2 (Director of Nursing) stated, I do not see that any written notification or Bed Hold Policy was given to R59 or V14 (Responsible Party).4. Upon entrance to the facility on 5/9/23, R16 was not observed or able to be located in the facility. On 5/09/23 at 11:12 AM V1 (Administrator) stated, The original census number we gave you is incorrect. (R16) transferred out last night, after midnight. R16's Census Report documents that R16 was transferred out to the hospital on 5/9/23 at 12:46 AM. R16's Transfer to Hospital Summary on 5/9/23 at 12:51 AM, documents that V20 (R16's Physician) was notified of R16's complaints of severe abdominal pain, abdominal distention and hypoactive bowel sounds. V20 ordered to send R16 to the local area emergency room for evaluation and treatment. Around 12:35 AM, R16 was transported via ambulance to the local area hospital. R16's Nursing Note on 5/10/23 at 6:38 PM documents R16 was hospitalized related to a Bowel Obstruction. As of 5/12/23, R16's medical record did not document that a written reason for R16's transfer was provided to R16 or R16's Representative for R16's 5/9/23 transfer to the local area hospital. On 5/10/23 at 12:12 PM, V2 (Director of Nursing) stated that written reasons for a resident's transfer out of the facility are not provided to the resident or the resident's representative. V2 stated, We just call. 3. On 5/9/23 at 12:18 pm, R13 stated They keep on sending me to the hospital. I was sick. I can't remember what was going on but I am better now. The Progress Note for R13, dated 2/18/23 through 2/19/23 document R13 was sent to the local hospital for an evaluation and was admitted to the hospital for Altered Mental Status. The Progress Note for R13, dated 3/18/23 documents R13 was transferred to the local hospital for an evaluation and was admitted to the hospital for Hypercapnia. There is no documentation regarding the written notification of R13's transfers to the local hospital being provided to R13 or R13's Responsible Party for R13's 2/18/23 and 3/18/23 hospital transfers. On 5/10/23 at 12:20 pm, V2 DON/Director of Nursing confirmed there was no written notification of transfer given to R13 or to R13's representative. On 5/10/23 at 12:30 pm, V7 SSD/Social Service Director confirmed there were no discharge notifications made to the facility's Ombudsman for R10, R13, or R59 for their discharges to the local hospital because the report system did not pull those residents names and therefore they did not generate onto the report.

Based on observation, interview and record review the facility failed to provide the resident and/or the resident representative with the facility bed-hold policy upon hospital transfer for four (R10, R13, R16 and R59) of 18 residents reviewed for Transfer/Discharge in a sample of 30. Findings include: The Facility Bed Hold and Return to Facility Policy and Procedure, revised 9-16-17, documents: To ensure that residents and/or resident representatives are notified of the facility bed-hold policy and conditions for return to facility upon admission and at the time of a transfer from the facility. 1. R10's Face Sheet, dated 5/12/23, documents that V13 (R10's Power of Attorney/POA) is R10's Emergency Contact/Health Care Power of Attorney. R10's Nursing Note, dated 4/13/23 at 6:12 pm and 7:11 pm, documents that R10 was sent to the local Emergency Department for evaluation of not feeling right and feeling the same way as last time when R10 had a stroke. R10's Nursing Notes, dated 4/13/23 through 4/14/23, does not document that notification, in writing, was provided to R10 or V13. On 05/10/23 at 12:14 pm, V2 (Director of Nursing) stated, I do not see that any written notification or Bed Hold Policy was given to R10 or V13 (R10's Responsible Party). 2. R59's Face Sheet, dated 5/12/23, documents that V14 (R10's Power of Attorney/POA) is R59's Emergency Contact/Health Care Power of Attorney. R59's Nursing Note, dated 2/6/2 at 11:26 pm and 11:31 pm, documents that R59 was sent to the local Emergency Department for evaluation via Local Emergency System Ambulance for a change in condition. R59's Nursing Notes, dated 2/5/23 through 2/6/23, does not document that notification, in writing, was provided to R59 or V14. On 05/10/23 at 12:14 pm, V2 (Director of Nursing) stated, I do not see that any written notification or Bed Hold Policy was given to R59 or V14 (Responsible Party).4. Upon entrance to the facility on 5/9/23, R16 was not observed or able to be located in the facility. On 5/09/23 at 11:12 AM V1 (Administrator) stated, The original census number we gave you is incorrect. (R16) transferred out last night, after midnight. R16's Census Report documents that R16 was transferred out to the hospital on 5/9/23 at 12:46 AM. R16's Transfer to Hospital Summary on 5/9/23 at 12:51 AM, documents that V20 (R16's Physician) was notified of R16's complaints of severe abdominal pain, abdominal distention and hypoactive bowel sounds. V20 ordered to send R16 to the local area emergency room for evaluation and treatment. Around 12:35 AM, R16 was transported via ambulance to the local area hospital. R16's Nursing Note on 5/10/23 at 6:38 PM documents R16 was hospitalized related to a Bowel Obstruction. As of 5/12/23, R16's medical record did not document that the facility's Bed Hold Policy was provided to R16 or R16's Representative. On 5/10/23 at 12:12 PM, V2 stated that Bed Hold Policies are given to the Resident/Resident's Representative upon each transfer out of the facility by the nurses. V2 stated that there should be some type of documentation in the resident's medical record documenting that the Bed Hold Policy was provided. At this time, V2 verified that R16's medical record did not document that a Bed Hold Policy was provided to R16 or R16's Representative for R16's 5/9/23 transfer to the local area hospital and should. 3. On 5/9/23 at 12:18 pm, R13 stated she has been to the hospital a few times this year and was not given any information regarding the facility's bed-hold policy when she went to the hospital. The Progress Note for R13, dated 2/18/23, documents R13 was sent to the local hospital and was admitted for change in mental status. There is no documentation regarding the facility bed-hold policy being given to R13 or R13's Representative at the time of R13's transfer. On 5/10/23 at 12:20 pm, V2 DON/Director to Nursing confirmed R13 was sent to the local hospital and does not know if the bed-hold policy was given to R13 or R13's representative and there is no documentation that it was provided.

Based on observation, interview, and record review, the facility failed to follow physician orders to obtain daily weights for one resident (R1) with a diagnosis of Congestive Heart Failure (CHF) of three residents reviewed for resident care and change in condition in a sample of three. Findings include: The facility's Weights policy, revised 10-17-19, documents Guidelines: 1. Each resident shall be weighed on admission and and at least monthly thereafter, or in accordance with Physician orders or plan of care. On 1-4-22, at 9:35am, R1 was lying supine in a bariatric bed with bilateral lower extremity edema noted. R1's clinical record documents diagnoses including Chronic Respiratory Failure with Hypoxia, Morbid (Severe) Obesity due to Excess Calories, Unspecified Atrial Fibrillation, Essential (Primary) Hypertension, and Dyspnea. R1's chest x-ray, dated 11-13-22, documents Findings consistent with mild to moderate CHF (Congestive Heart Failure) or volume overload in the appropriate clinical setting; consider concomitant bronchitis and interstitial pneumonia in the appropriate clinical setting. R1's Physician Order Sheet/POS, dated 11-14-22, documents an order for Daily Weights, Notify Medical Doctor (MD)/Nurse Practitioner (NP) if resident has a weight gain of 3 lbs (pounds) in a day or 5 lbs in a week; every day shift for CHF (Congestive Heart Failure) Program. R1's current clinical record documents daily weights were not completed on the following dates: 11-19-22 and 11-20-22, 12-5-22 through 12-13-22, 12-15-22 through 12-19-22, and 12-22-22 through 1-2-23. On 1-5-22, at 12:20pm, V2 Director of Nursing confirmed that R1 was not weighed daily in the months of November and December. V2 stated that R1's daily weights should have done as ordered. V2 stated We were not without a scale for (R1). There is no reason for (R1) not to be weighed daily. (R1) should have been. On 1-5-22, at 2:00pm, V1 Administrator stated Nurses are to follow the orders that the doctor put in.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a PASARR (Preadmission Screening and Resident Review) Level II screening for three of three residents (R37, R58, R69) reviewed for PASARR screenings in the sample of 33. Findings include: The facility's Preadmission Screening and Annual Resident Review policy, dated 11/17/17, documents, It is the policy to screen all potential admissions on an individualized basis. As part of the preadmission process, the facility participates in the PASARR screening process (Level 1) for all new and readmissions per requirement to determine if the individual meets the criterion for mental disorder, intellectual disability or related condition. Based upon the Level 1 screen, the facility will not admit an individual with a mental disorder or intellectual disability until the Level II screening process has been completed and the recommendations allow for a nursing facility admission and the facility's ability to provide the specialized services determined in the Level II screen. The policy also documents, If the facility disagrees with the specialized services and PASARR recommendations, it will document the rationale in the medical record. The facility may apply for Level II reconsideration. 1. R37's Physician's orders, dated 5/11/22, document that R37 was admitted to the facility on [DATE], and has the following diagnoses: Psychosis, Generalized Anxiety, and Major Depressive Disorders. R37's OBRA Initial Assessment, dated 6/17/18, documents that there is reasonable basis for the suspicion of R37 having a MI (mental illness) or DD (developmentally disabled). The assessment also documents, Yes the individual has been formally diagnosed with a mental illness verified by a DSMIV classification which substantially impairs the persons cognitive, emotional and/or behavioral functioning. However, there is no documentation of a Level II PASARR screening being completed. R37's Care plan, dated 7/29/21, documents, I have a history of criminal behavior. I was arrested in 1985 for criminal sexual assault and home invasion. In 1992 (R37) was convicted for manufacturing and delivery of drugs. I have demonstrated stability during the admission screening process, and does not appear to present at risk. fits the criteria for an 'Identified offender. R37's Care plan, dated 7/29/21, documents, I am a non-reliable responder due to my history of visual hallucinations. I will hallucinate in a sexual way about staff members, and I make false accusations about these hallucinations and other beliefs. 2. R58's Physician's order, dated 5/11/22, documents that R58's most recent admission was 1/29/22, and R58 has the diagnoses of Intellectual Disabilities and Schizoaffective disorder. R58's Careplan, dated 1/14/22, documents, I have impaired cognitive function/dementia or impaired thought processes related to difficulty making decisions, impaired decision making, intellectual disabilities. R58's OBRA Initial Assessment, dated 11/1/10, documents that R58's initial admission to the facility was on 11/3/10, and there is reasonable basis for the suspicion of R58 having a MI (mental illness) or DD (developmentally disabled). The assessment also documents, The individual has been formally diagnosed with Mental Retardation and the condition manifested prior the the age of 22, and the individual has received special education and/or day program services. However, there is no documentation of a Level II PASARR screening being completed. 3. R69's Physician's orders, dated 5/11/22, document that R69 was admitted to the facility on [DATE], and R69 has the diagnoses of Schizoaffective disorder, Bipolar disorder manic severe with psychotic features, and Major Depressive Disorder. R69's OBRA Initial Assessment, dated 7/24/21, documents that there is reasonable basis for the suspicion of R69 having a MI (mental illness) or DD (developmentally disabled). The assessment also documents, Yes the individual has been formally diagnosed with a mental illness verified by a DSMIV classification which substantially impairs the persons cognitive, emotional and/or behavioral functioning, has a history of psychiatric hospitalizations, and history of outpatient health services. R69's Level I Notice of Determination, dated 7/26/21, documents, R69 has a past history of mental health issues. Has a current diagnosis of Bipolar Disorder, and was admitted to hospital with complaints of pain. R69 appropriate for nursing facility for 120 days, with additional screen if stay is extended. However, there is no documentation of an additional screen being completed nor a Level II screening. On 05/11/22 at 11:58 AM, V3 (Business office manager) stated, I receive the OBRA screen, then I hand them off to social services unless there is a cut off date. R69 did not have another OBRA/Level II done. On 05/11/22 at 12:01 PM, V7 (Social Services Director) stated, I don't get the OBRA/PASARR screens. I don't even know what you're talking about. I don't know who (R58) even is. On 05/11/22 at 12:40 PM, V5 (Cooperate Nurse) stated, I know (R58) had to have one because he came from a (DD) Developmentally disabled group home. V5 confirmed Level II were not completed for R37, R58, and R69.

Based on observation, interview, and record review, the facility failed to follow a physician ordered treatment, and perform hand hygiene during wound care for one of two residents (R69) reviewed for non-pressure ulcer wounds in the sample of 33. Findings include: The facility's Skin Condition Assessment & Monitoring Pressure & Non-Pressure policy, dated 6/8/18, documents, Conduct hand hygiene in accordance with facility standard/universal precautions. The policy also documents, Physician ordered treatments shall be initiated by the staff on the electronic Treatment Administration Record after each administration. The facility's Hand Hygiene/Handwashing policy, dated 1/20/20, documents, Examples of when to perform hand hygiene: After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressing. R69's Current Electronic Physician's orders, as of 5/9/22, document an order to cleanse R69's wound to the top of R69's foot with wound cleanser, pat dry, apply Leptospermum honey and collagen, and cover with dry dressing every day shift. R69's Care plan, dated 5/9/22, documents, I currently have an arterial wound to top of left foot. The care plan also documents the following intervention, Provide wound care per treatment order. R69's Wound Evaluation & Management Summary, dated 5/3/22, documents, R69 presents with a wound on his left, dorsal foot. Arterial wound of the left dorsal foot full thickness. Wound size: 4.2 cm (centimeters) x 2.4 cm x 0.1 cm. The summary also documents the following dressing treatment plan: Primary dressing-Leptospermum honey and collagen sheet; Secondary dressing-gauze island with border to be completed three times a week. On 05/09/22 at 12:20 PM, V8 (Registered Nurse) removed soiled gauze border dressing from R69's left foot. R69's dressing had moderate amounts of brown drainage. Then, V8 picked the brown saturated collagen sheet from R69's wound. Without changing her gloves and performing hand hygiene, V8 cleansed R69's wound with normal saline. Then, R69 removed her gloves and performed hand hygiene. Then, V8 applied the Leptospermum honey with her gloved finger, covered with a sheet of collagen, and then a boarder foam dressing. V8 stated, The dressing I took off was a border gauze and the one I just put on is boarder foam. It doesn't matter which one I use. I just have to cover it with a dressing. V8 confirmed that she did not change gloves or perform hand hygiene after removing the soiled dressing.

Based on observation, interview, and record review, the facility failed to provide ROM (Range of Motion) restorative programming for one of two residents (R37) reviewed for ROM in the sample of 33. Findings include: On 05/09/22 at 12:40 PM, R37 was alert sitting up in his wheel chair in the dining room. R37's left hand was contracted into a closed position. R37 stated, I'm contracted at the elbow as well. Demonstrating that he was unable to move his elbow from a 90 degree angled position. R37 stated, I'm supposed to have surgery on my elbow sometime because of it. They don't do any elbow or hand exercises with me whatsoever, but it would probably help. R37's Orthopedist note, dated 3/22/22, documents, The following issues were addressed: left elbow pain; contractor of muscle, left upper arm; entrapment of left ulnar nerve; hemiplegia of left nondominant side as late effect of cerebrovascular disease. R37's Therapy screening, dated 3/8/22, documents, R37 has continued difficulty with wheel chair seating, mobility, and left upper pain and contractor. Physical/Occupational/Speech Therapy is recommended. However, R37's medical record has no documentation of R37 receiving a therapy evaluation or treatment. R37's Electronic CNA(Certified Nursing Assistant) tasks have no documentation of R37 receiving any ROM restorative programming. On 05/11/22 at 12:12 PM, V2 (Director of Nursing) stated, We do not have a formal ROM assessment in the facility, so (R37) doesn't have an actual ROM assessment, but he does have contractures. (R37) isn't on any ROM programming. V2 confirmed that the facility does not have a policy regarding contractures and ROM.

Based on observation, interview and record review the facility failed to a implement personalized dementia program for one of one (R40) residents reviewed for dementia care in a sample of 33. Findings include: R40's current face sheet documents a diagnosis of Vascular Dementia with behavioral disturbances. R40's current care plan does not address R40's Vascular Dementia, or specialized activities for R40. On 5/9/22 at 10:00am, R40 was in bed sleeping. At 12:00pm, R40 was sitting up eating lunch. R40 is very friendly and talkative. At 2:00pm, R40 remained friendly and cooperative. On 5/10/22 at 9:00am, R40 was in bed sleeping. At 2:30pm, R40 remained in his bed, R40 stated that he just likes to talk to people, but they don't have time. On 5/11/22 at 9:00am, R40 remained in bed sleeping. At 12:00pm, R40 was in bed eating lunch. At 1:30pm, R40 remained friendly and talkative. During the survey no adverse behaviors were observed from R40. Multiple observations were made of R40 from 5/9/22 to 5/11/22, at various times of the day. R40 did not leave his room, nor were any one on one activities were offered. On 5/10/22 at 1:50pm, V1 Adminsitrator verifies that the facility does not offer specific programing for residents with a diagnosis of dementia. On 5/11/22 at 10:00am, V2, Director of Nursing, stated that R40 stays to himself in his room. V2 verified that one on one activities are not offered and the facility does not have specialized Dementia Programs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R75's Physician Order Sheet documents for R75 to take Depakote (Anticonvulsant Sprinkles Delayed Release capsule 125mg (Milligram) twice daily for Schizophrenia. R75's medical record does not contain a Depakote or Valporic Acid level to monitor the therapeutic levels of the Depakote Sprinkles. On 5/11/22 at 10:00am, V2 verified that R75 has not had a Valporic Acid level done, to monitor the therapeutic blood level of R75's Valporic Acid level in the last year. V2 stated that the facility does not have a specific policy, but they should be done at least every 6 months. Based on observation, interview, and record review, the facility failed to monitor for the adequate effectiveness of insulin and for anticonvulsants used for psychotic disorders for three of 18 residents (R54, R74 and R75) reviewed for medication monitoring in the sample of 18. Findings include: The facility policy, Psychotropic Medication- Gradual Dosage Reduction, dated (revised) 2/1/18 directs staff, To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice, and are prescribed at the lowest therapeutic dose to treat such conditions. 1. On 05/09/22 at 10:44 AM, R54 was alert and oriented sitting up in his bariatric bed. R54 stated, I had some recent blood sugar issues that they had to manage because I was refusing my insulin. R54's Physician's orders document that R54 has an order to receive Basaglar 76 units subcutaneously daily at bed time, blood glucose monitoring every morning, a no concentrated sweets diet for the diagnosis of Type 2 Diabetes Mellitus. R54's Physician's orders also have an order for R54 to have a CMP (Comprehensive Metabolic Panel) blood draw on 1/6/22 all for the diagnosis of Type 2 Diabetes Mellitus. However, R54's medical record has no documentation of the results of the CMP. R54's Care plan, dated 2/15/22, documents, I have Diabetes Mellitus insulin dependent. Goal: I will have minimal complications related to diabetes through the review date. R54's MAR (Medication Administration Record), dated 5/2022, documents that for the month of May (1-11th) R54 had blood glucose level checked in the morning and then in the evening prior to his insulin injection. R54's results of the blood glucose level ranged from 177-493 with 19 out of 21 being over 200. R54's current electronic record has no documentation of monitoring for the effectiveness of R54's insulin usage. On 05/11/22 at 12:12 PM, V2 (Director of Nursing) stated, I would expect if (R54) was diabetic and receiving insulin therapy I would expect a HGA1C (Hemoglobin A1C) and CMP to be completed. It was ordered for (R54) to get a CMP in [DATE] but for some reason it was canceled, and I don't know why. 2. R74's current Physician Order Sheet, dated May 2022 includes the following diagnoses: Anxiety Disorder, Schizoaffective Disorder Bipolar type. This same document includes the following physician orders: Depakote ER (Valproic Acid) (antipsychotic)Tablet Extended Release 24 Hour 500 MG (milligrams) Give 2 tablets by mouth in the evening every Monday, Tuesday, Wednesday, Thursday, Friday and Saturday. Valproic Acid level on 8/9/2021 and every six months. R74's current Care Plan, dated 8/30/2021 includes the following Care Areas: Psychotropic medications. This same document also includes the following Interventions: Administer medications as ordered and monitor for any adverse effects. Report to Physician as needed. A review of R74's electronic Medical Record shows no Valproic Acid levels, as ordered by the Physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify adverse reactions to an antipsychotic medication and document a diagnosis nor behaviors to warrant the use of an antipsychotic for two of six residents (R13, R40) reviewed for psychotropics in the sample of 33. Findings include: The facility policy, Psychotropic Medication- Gradual Dosage Reduction, dated (revised) 2/1/18 directs staff, To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice, and are prescribed at the lowest therapeutic dose to treat such conditions. The facility's AIMS Side Effect Monitoring policy, dated 1/11/18, documents, Abnormal Involuntary Movement Scale (AIMS) records the occurrence of tardive dyskinesia (TD-a neurological disorder characterized by involuntary movements of the face and jaw) of residents receiving psychotropic medications. To assess the presence of movement and non-movement side effects, and to follow the severity of TD over time. The policy also documents, Assessment results will be conveyed to attending psychiatrist and Nurse Practitioner when abnormal findings or increasing in severity and side effects is noted. 1. R13's Physician's orders, dated 5/11/22, document that R13 has an order to receive Risperdal (antipsychotic) 5 mg (Milligrams) by mouth at bedtime for the diagnosis of Paranoid Schizophrenia dated 7/20/21. On 05/09/22 at 10:38 AM, R13 was alert sitting up in her wheel chair in her room. R13 was alert and oriented, however at times would become delusional thinking she was pregnant. R13 had tremors at rest in R13's in bilateral hands. R13 occasionally would have a pill roll action with her left thumb and index finger. R13 also had a towel around her neck and was notable drooling. On 05/11/22 at 11:55 AM, R13 was alert sitting up in her wheelchair at the dining room table. R13 had tremors to R13's bilateral hands, and was pill rolling her left thumb and index finger. R13 was also notably drooling. R13's Care plan, dated 7/27/21, documents, I use anti-psychotic medications, Risperdal related to Diagnosis of Paranoid Schizophrenia with delusions and hallucinations. The care plan also documents the following goal: I will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment while on lowest effective dose. An intervention to help achieve the goal was Monitor/document/report PRN (as needed) any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia, EPS (Extra pyramidal symptoms-shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. R13's AIMs scale, dated 3/10/21, documents a score of 0 no abnormalities. R13's AIM scale, dated 9/10/21, documents a score of 6 due to: Mild jaw, e.g. biting, clenching, mouth opening, lateral movement; moderate upper extremity and lower extremity movements; Severity of abnormal movements-mild; Incapacitation due to abnormal movements-mild; resident's awareness of abnormal movements-awareness with mild distress. R13's current medical record has no documentation of R13's physician being notified of R13's change in abnormal movements. R13's AIM Scale, dated 3/10/22, documents a score of 3 due to: minimal muscles of facial expression movements; minimal lips and perioral area movements; minimal jaw movements. On 05/11/22 at 12:12 PM, V2 (Director of Nursing), confirmed that there was a change in R13's AIMs scores. V2 stated, If there is a change the nurse should notify the physician and make a note in the nurses' notes regarding the change. 2. On 5/9/22 at 10:00am, R40 was in bed sleeping. At 12:00pm, R40 was sitting up eating lunch. R40 is very friendly and talkative. At 2:00pm, R40 remained friendly and cooperative. On 5/10/22 at 9:00am, R40 was in bed sleeping. At 11:00am, R40 was stating that he needed his bandage put on his back wound. R40 was cooperative and friendly during wound care. At 2:30pm, R40 remained in his bed, R40 stated that he just likes to talk to people, but they don't have time. On 5/11/22 at 9:00am, R40 remained in bed sleeping. At 12:00pm, R40 was in bed eating lunch. At 1:30pm, R40 remained friendly and talkative. During the survey no adverse behaviors were observed from R40. R40's current POS, Physician Order Sheet, documents to take Quetiapine Fumarate (Antipsychotic) 50mg three times daily, for the diagnosis of Vascular Dementia with behavioral disturbances. R40's current care plan does not document any adverse behavioral goals or interventions. R40's medical record does not document any adverse behaviors, nor attempted gradual dose reductions of a psychotropic medication. since admission on [DATE]. 05/11/22 09:10am, V2, Director of Nursing stated that R40 has not had any adverse behaviors at all and there is no documentation in his medical record. V2 also verified that R40's care plan does not contain adverse behavioral goals and interventions. V2 also stated that R40 has not has a gradual dose reduction done since his admission.

Based on observation, interview and record review the facility failed to answer call lights in a timely manner for four residents (R9,R32,R62 and R74, ) of 18 reviewed for call lights in a sample of 33. Findings include: The facility Call Light policy, revised 1/5/22, documents to respond to residents' requests and needs in a timely and courteous manner. All staff should assist in answering call lights. Nursing staff members shall go to resident room to respond to call system and promptly call call light when the room is entered. Bathroom light should be viewed as emergencies and immediate attention given. 1. On 05/09/22 at 10:52 A.M., R74 was seated in a wheelchair, in her room. At that time, R74 stated, The call light wait times are terrible, especially at night. I need help going to the bathroom at night and it is often an hour or more to get help. It is worst on evenings or night times. 2. On 05/09/22 at 11:22 A.M., R62 was seated in her room. At that time, R62 stated, Call light times often exceed one hour, usually between midnight and 8 A.M. I don't know what the problem is. It's hard to wait one hour when you have to go to the bathroom. 3. On 5/9/22 at 11:30 A.M., R9 was seated in a wheel chair, in the facility B Hall hallway. R9 stated, It takes a long time to get a call light answered. Usually thirty to sixty minutes. 4. On 5/9/22 at 1:30 P.M., R32 was lying in bed. At that time, R32 stated, On nights and week ends, call light wait times are horrible. It takes forever to get your call light answered, at least an hour. If you want to go to bed at 6:00 P.M., you have to put your call light on at 5:00 P.M. The (facility) Monthly Resident Council Minutes, dated January 17, 2022 documents, Nursing: Call light (s) are taking to long on second and third shift. On 5/10/22 at 3:21 P.M., V1/Administrator stated, I know call light times are something the resident complain about. We are working on it.

Based on record review and interview, the facility failed to conduct quarterly Quality Assurance meetings with the required members present. This failure affects all 74 residents in the facility. Findings include: The facility's QA (Quality Assurance) Committee meeting sign-in sheets, provided by V1 Administrator, dated 1-21-22 and 4-2-22, document the facility conducted these two QA meetings without the Medical Director's attendance. The sign-in sheets, dated 1-21-22 and 4-2-22, do not document V4 Medical Director's signature. On 5-11-22, at 10:45am, V1 Administrator confirmed that V4 Medical Director did not attend the QA meetings in January 2022 or April 2022. V1 stated that V1 was not yet working here for the January meeting and did not send (V4) any notes from the April meeting. The facility's Resident Census and Conditions of Residents dated 5-9-22 documents 74 residents reside in the facility.