2. The clinical record for Resident 54 was reviewed on 2/12/25 at 2:26 p.m. The diagnoses included, but were not limited to, dementia, psychotic disturbance, mood disturbance, and anxiety. A care plan, dated 11/29/23, indicated the resident had the potential for cardiovascular distress related to a diagnosis of hypertension. Interventions included, but were not limited to, administer medications as ordered and obtain vital signs as ordered. A physician's order, dated 10/24/24, indicated to give metoprolol tartrate (a medication used to treat high blood pressure) 12.5 milligrams (mg) twice a day with special instructions to hold the medication for a systolic blood pressure less than 110. A Medication Administration Record (MAR), dated 11/1/24 through 11/30/24, indicated metoprolol tartrate 12.5 mg was given with a recorded systolic blood pressure of less than 110 on the following dates: On 11/1/24, the morning dose was given with a systolic blood pressure of 105. On 11/1/24, the evening dose was given with a systolic blood pressure of 107. On 11/6/24, the morning dose was given with a systolic blood pressure of 100. On 11/12/24, the morning dose was given with a systolic blood pressure of 107. On 11/14/24, the morning dose was given with a systolic blood pressure of 104. On 11/17/24, the morning dose was given with a systolic blood pressure of 103. On 11/17/24, the evening dose was given with a systolic blood pressure of 108. On 11/18/24, the morning dose was given with a systolic blood pressure of 109. On 11/19/24, the morning dose was given with a systolic blood pressure of 100. On 11/22/24, the morning dose was given with a systolic blood pressure of 100. During an interview, on 2/12/25 at 10:30 a.m., LPN 5 indicated vital signs should be checked and hold parameters should be followed. Based on interview and record review, the facility failed to ensure the physician's orders for a medication hold parameter was followed, hospice was notified of low blood glucose readings, and staff obtained a blood glucose reading as ordered for 3 of 3 residents reviewed for quality of care. (Resident 30, 54 and 24) Findings include: 1. The clinical record for Resident 30 was reviewed on 2/10/25 at 2:38 p.m. The diagnoses included, but were not limited to, atrial fibrillation, hypertensive heart and chronic kidney disease with heart failure, type 2 diabetes mellitus with diabetic chronic kidney disease and neuropathy, and nonrheumatic aortic valve stenosis. a. A physician's order, dated 1/4/25, indicated to give metoprolol tartrate (a medication used to treat high blood pressure) 25 milligrams (mg) twice a day with special instructions to hold the medication for a systolic blood pressure less than 100. A Medication Administration Record (MAR), dated 1/1/25 through 1/30/25, indicated metoprolol tartrate 25 mg was given with a recorded systolic blood pressure of less than 100 on the following dates: On 1/13/25, with a systolic blood pressure of 84. On 1/16/25, with a systolic blood pressure of 88. On 1/18/25, with a systolic blood pressure of 96. On 1/19/25, with a systolic blood pressure of 97. On 1/20/25, with a systolic blood pressure of 93. On 1/24/25, with a systolic blood pressure of 89. On 1/30/25, with a systolic blood pressure of 99. During an interview, on 2/12/25 at 10:30 a.m., LPN 5 indicated vital signs should be checked and hold parameters should be followed. b. A physician's order, dated 1/31/25, indicated to call hospice if the resident's blood glucose reading was greater than 250. A MAR, dated 1/31/25 through 2/11/25, indicated Resident 30 had the following blood glucose readings greater than 250: On 2/1/25, the resident's blood glucose reading was 256. On 2/5/25, the resident's blood glucose reading was 273. On 2/9/25, the resident's blood glucose reading was 307. There was no documentation hospice was notified of the resident's blood glucose readings greater than 250 in the medical record. During an interview, on 2/13/25 at 10:11 a.m., the Clinical Support Nurse indicated the facility did not have any documentation of hospice being notified of the elevated blood sugars and the nurse should have called the hospice provider per the order. 3. The clinical record for Resident 24 was reviewed on 2/12/25 at 9:42 a.m. The diagnoses included, but were not limited to, diabetes mellitus, hypertension, and depression. A care plan, dated 4/22/21, indicated the resident was at risk for hypoglycemia and hyperglycemia related to diabetes mellitus. Interventions included, but were not limited to, monitor blood sugar, give medications as ordered, and observe the resident for signs of hypoglycemia or hyperglycemia. A physician's order, dated 5/8/22, indicated to check the resident's blood glucose reading at 4:00 a.m. to prevent hypoglycemia (low blood sugar). There was no documentation in Resident 24's Electric Health Record the 4:00 a.m. blood glucose readings were obtained, or the physician was notified the order was not completed. During an interview, on 2/14/25 at 12:00 p.m., the Clinical Support Nurse indicated the nurse entered the physician's order wrong and the 4 a.m. blood glucose reading was never obtained and recorded as ordered. During an interview, on 2/17/25 at 11:43 a.m., LPN 8 indicated when a physician gave a verbal order she would repeat the order back to the physician, go straight to the computer, and enter the order into the computer. The management team verified the new orders and made sure they were entered into the computer correctly. During an interview, on 2/17/25 at 12:25 p.m., RN 9 indicated verbal orders needed to be entered into the computer and the pharmacy made aware of the new orders. The management team reviewed the orders to ensure they were checked twice. During an interview, on 2/17/25 at 12:35 p.m., the Director of Nursing indicated he did not look at the residents' orders on the Medication Administration Record (MAR). The only reason he would check the orders was if the residents' blood glucose readings were triggered high or low. The facility did not have a policy for blood glucose monitoring. A current facility policy, titled Guidelines for Medication Orders, dated as reviewed 12/17/24 and received by the Clinical Executive Director Support on 2/12/25 at 9:15 a.m., indicated .A current list of orders will be maintained in the electronic clinical record of each resident .Standing orders .The admitting nurse shall review the standing order list with the physician when verifying admission orders .The physician shall inform the admitting nurse if any of the standing orders should be eliminated, modified and/or other standing orders added for the specific resident .Standing orders shall be in the medical record with the other physicians orders 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure oxygen was administered at the physician's ordered level and to obtain an order to administer oxygen for 4 of 4 residents reviewed for oxygen. (Resident 118, 51, 9 and 58) Findings include: 1. During an observation, on 2/10/25 at 12:49 p.m., Resident 118 was sitting on her recliner wearing oxygen. The oxygen concentrator was set on 0.5 liters via nasal cannula. During an observation, on 2/11/25 at 3:30 p.m., the resident was sitting on her recliner wearing oxygen. Her oxygen concentrator was set on 1 liter via nasal cannula. During an observation, on 2/14/25 at 10:20 a.m., the resident was lying in bed eating her breakfast. The resident's oxygen concentrator was set on 3 liters via nasal cannula. During an interview, on 2/14/25 at 10:25 a.m., LPN 5 indicated Resident 118's concentrator was set on 3 liters, and she was not sure of the resident's oxygen order. The clinical record for Resident 118 was reviewed on 2/12/25 at 10:01 a.m. The diagnoses included, but were not limited to, chronic obstruction pulmonary disorder (COPD), congestive heart failure (CHF), hypertension, depression, dementia, and anxiety disorder. A physician's order, dated 2/7/25, indicated to administer oxygen at 2 liters when needed. A care plan, dated 2/10/25, indicated the resident had the potential for shortness of breath while lying flat. The interventions included, but were not limited to, administer oxygen per physician's order and elevate head of bed or place in upright position when needed. A care plan, dated 2/10/25, indicated the resident had the potential for complications, functional and cognitive status decline related to respiratory failure. The interventions included, but were not limited to, administer oxygen per physician's order and to monitor lung sounds. During an interview, on 2/13/25 at 9:50 a.m., LPN 7 indicated that when a resident wore oxygen, she would check the Medication Administration Record (MAR) and verify the liter flow the resident was ordered. When a resident was wearing oxygen without an order, she would call the physician a get the order. During an interview, on 2/14/25 at 10:36 a.m., LPN 7 indicated the resident's oxygen should be set on 2 liters. 4. During an observation, on 2/10/25 at 11:07 a.m., Resident 58 was sitting in his room wearing 3.5 liters of oxygen via a nasal cannula. During an observation, on 2/11/25 at 11:02 a.m., the resident was sitting in his room wearing 3.5 liters of oxygen. The clinical record for Resident 58 was reviewed on 2/12/25 at 9:57 a.m. The diagnoses included, but were not limited to, Parkinson's disease, pneumonia, acute respiratory failure with hypoxia (low oxygen), and heart failure. There was no physician's order for Resident 58 to receive oxygen until after the survey start date. During an interview, on 2/12/25 at 10:54 a.m., LPN 8 indicated the resident now had a physician's order for 2 liters of oxygen. She would check the physician's order to verify how much oxygen to give a resident when she was adjusting the flow rate. The resident should have had an order for the oxygen administration. A current facility policy, titled Administration of Oxygen, dated 12/13/24 and provided by the Clinical Support Nurse on 2/11/25 at 4:54 p.m., indicated .Verify physician's order for the procedure .Adjust the oxygen delivery device so that .the proper flow of oxygen is administered A current facility policy, titled Guidelines for Medication Orders, dated as reviewed 12/17/24 and received by the Clinical Executive Director Support on 2/12/25 at 9:15 a.m., indicated .A current list of orders will be maintained in the electronic clinical record of each resident .Oxygen orders When recording oxygen orders specify .The rate of flow, route and rationale (i.e: 02, 2L/min per nasal cannula PRN for SOB) 3.1-47(a)(6) 2. During an observation, on 2/10/25 at 10:43 a.m., Resident 51 was sitting in a Broda chair wearing oxygen. His oxygen concentrator was set on 3 liters per nasal cannula. The clinical record for Resident 51 was reviewed on 2/13/25 at 10:48 a.m. Diagnoses included, but were not limited to, acute respiratory failure with hypoxia, interstitial pulmonary disease, sick sinus syndrome, atrial fibrillation, and chronic systolic congestive heart failure. A physician's order, dated 1/9/25, indicated the resident was to receive oxygen at 2 liters continuously. A care plan, dated 1/23/25, indicated the resident had the potential for complications related to congestive heart failure. The interventions included, but were not limited to, administer oxygen according to the physician's order. A care plan, dated 1/23/25, indicated the resident had the potential for cardiovascular distress. Interventions included, but were not limited to, administer oxygen according to the physician's order. On the following dates, the resident was documented on the vitals report to have been on oxygen at 3 liters per nasal cannula: On 2/3/25 at 4:32 p.m. On 2/4/25 at 7:23 p.m. On 2/5/25 at 3:59 p.m. On 2/6/25 at 7:30 p.m. On 2/7/25 at 3:41 p.m. On 2/8/25 at 8:19 a.m. On 2/8/25 at 4:23 p.m. On 2/11/25 at 3:36 p.m. On 2/12/25 at 3:11 p.m. On 2/8/25 at 8:19 a.m., the resident was documented to be on oxygen at 1.5 liters. 3. During an observation, on 2/10/25 at 11:04 a.m., Resident 9 was lying in bed wearing oxygen. His oxygen concentrator was set on 4 liters per nasal cannula. During an observation, on 2/11/25 at 4:29 p.m., the resident was sitting up in his bed wearing oxygen. His oxygen concentrator was set on 3.5 liters per nasal cannula. The clinical record for Resident 9 was reviewed on 2/11/25 at 1:32 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease with acute exacerbation, chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, systolic (congestive) heart failure (CHF), atrial flutter, emphysema, nicotine dependence- cigarettes, and pulmonary fibrosis. A care plan, dated 1/6/25, indicated the resident had the potential for cardiovascular distress. Interventions included, but were not limited to, administer oxygen per the physician's order. A care plan, dated 1/6/25, indicated the resident had the potential for complications, functional and cognitive status decline related to respiratory disease. Interventions included, but were not limited to, administer oxygen per the physician's order. There was no physician's order for Resident 9 to receive oxygen until after the survey start date. On the following dates, the resident was documented on the vitals report to have been on the following oxygen liters: On 1/27/25 at 4:58 p.m., the resident was on 4 liters of oxygen. On 1/28/25 at 9:09 a.m., the resident was on 4 liters of oxygen. On 1/28/25 at 09:05 p.m., the resident was on 6 liters of oxygen. On 1/29/25 at 4:07 p.m., the resident was on 4 liters of oxygen. On 1/30/25 at 10:41 a.m., the resident was on 7 liters of oxygen. On 1/30/25 at 4:47 p.m., the resident was on 4 liters of oxygen. On 1/31/25 at 4:54 p.m., the resident was on 4 liters of oxygen. On 2/2/25 at 8:09 p.m., the resident was on 4 liters of oxygen. On 2/3/25 at 3:37 p.m., the resident was on 4 liters of oxygen. On 2/4/25 at 3:06 p.m., the resident was on 4 liters of oxygen. On 2/5/25 at 3:57 p.m., the resident was on 4 liters of oxygen. On 2/6/25 at 7:40 p.m., the resident was on 4 liters of oxygen. On 2/7/25 at 8:48 a.m., the resident was on 2 liters of oxygen. On 2/9/25 at 09:01 p.m., the resident was on 4 liters of oxygen. On 2/10/25 at 8:46 p.m., the resident was on 4 liters of oxygen. On 2/11/25 at 3:35 p.m., the resident was on 4 liters of oxygen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident rooms and hallways were maintained and kept in clean and sanitary condition for 3 of 8 rooms (room [ROOM NUMBER], 106 and 107) and 3 of 3 hallways (hallway 100, 200 and 300) reviewed for environment. Findings include: During room observations, starting on 2/10/25 at 11:18 a.m., the following were observed: a. The 100-hallway had a very strong urine and bowel movement odor. b. room [ROOM NUMBER] had a large uneven area with peeling paint and cracks on the wall next to the bathroom. c. room [ROOM NUMBER] had an unsecured outlet on the wall at the foot of the resident's bed. The outlet was pulled away from the wall with black cords plugged into the outlet. The room had a very strong urine and bowel movement odor. d. room [ROOM NUMBER] had a large basketball-size dried blood smear on the wall by the first bed near the door. The resident's sheets had dried blood on both sides of the resident. The bed by the window had two little black bugs flying around the resident and in the bathroom, there was one little black bug sitting on the toilet paper mounted on the wall. The room had a very strong urine and bowel movement odor. e. The 200-hallway had multiple mechanical lifts lined down the hall and resident wheelchairs were stored in the hallway. During an observation, on 2/12/25 at 11:05 p.m., room [ROOM NUMBER] had an unsecured outlet on the wall at the foot of the resident's bed. The outlet was pulled away from the wall and black cords were plugged into the outlet. During an observation, on 2/17/25 at 8:20 a.m., the 100-hallway had a strong urine and bowel odor. There was a very strong urine and bowel odor in rooms [ROOM NUMBERS]. During an interview, on 2/10/25 at 11:10 a.m., LPN 5 indicated he was aware the resident in room [ROOM NUMBER] had blood smeared on the wall and his sheets. The CNA was busy with another resident and had not cleaned the resident up yet. During an interview, on 2/10/25 at 11:28 a.m., the Regional Support Executive Director indicated the dialysis sewer backed up and went into room [ROOM NUMBER]'s bathroom. He indicated there were little flying bugs in the room. During an interview, on 2/12/25 at 2:13 p.m., the Maintenance Director indicated he had fixed the outlet in room [ROOM NUMBER] once before. The cover had been pulled away from the wall when the nursing staff pushed the bed against the wall and lifted the bed up and down. During an interview, on 2/13/25 at 10:59 a.m., the Regional Support Executive Director indicated the 200-hallway had multiple mechanical lifts lined down the halls. The residents' wheelchairs were stored in the hallway when the residents were in bed. The facility had no other place to store the equipment and the residents' rooms were too small to store wheelchairs. The facility did not have an environmental policy, and the facility followed the state guidelines. A current facility policy, titled Resident Rights, dated as reviewed on 12/17/24 and received from the Clinical Support nurse on 2/17/25 at 4:12 p.m., indicated .To ensure resident rights are respected and protected and provide an environment in which they can be exercised .Our residents have a right to .be treated with dignity and respect .Personalize their apartment This citation relates to Complaint IN00450780. 3.1-19(f)(4) 3.1-19(f)(5)

Based on record review and interview, the facility failed to ensure there was documentation to show the resident or resident's representative made the choice about the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for 2 of 3 residents reviewed for beneficiary notification. (Resident 27 and 315) Findings include: 1. The Notice of Medicare Non-Coverage (NOMNC) for Resident 27 indicated rehabilitation services would end on 12/26/23. The SNF ABN form, for Resident 27, indicated the resident no longer required skilled services but wanted to continue to reside in the SNF. Medicare would not pay for the stay at the facility since the resident did not require daily skilled care. The resident had three options to choose and was to choose only one option. The options included the resident wanted the services to continue and to bill Medicare for an official decision on payment, the resident wanted to continue the services and do not bill Medicare, or the resident did not want the services. The facility could not choose the option for the resident. The resident/representative signed the form, on 12/21/23, and did not choose an option. The Electronic Health Record (EHR) did not have a note to include the facility talked to the resident or representative about which option was chosen. 2. The Notice of Medicare Non-Coverage (NOMNC) for Resident 315 indicated rehabilitation services would end on 12/22/23. The SNF ABN form, for Resident 315, indicated the resident no longer required skilled services but wanted to continue to reside in the SNF. Medicare would not pay for the stay at the facility since the resident did not require daily skilled care. The resident had three options to choose and was to choose only one option. The options included the resident wanted the services to continue and to bill to Medicare for an official decision on payment, the resident wanted to continue the services and do not bill Medicare, or the resident did not want the services. The facility could not choose the option for the resident. The resident/representative signed the form, on 12/20/23, and did not choose an option. The EHR did not have a note to include the facility talked to the resident or representative about which option was chosen. During the interview, on 1/8/24 at 1048 a.m., the Social Services Director indicated it was an oversight and she did not verify the resident chose an option on the SNFABN form. She did not document in the EHR which option the resident or representative wanted. During an interview, on 1/9/24 at 2:59 p.m., the Social Services Director indicated the facility did not have a policy on SNF ABN forms. 3.1-4(f)(3)

Based on observation, interview and record review, the facility failed to ensure a cognitively impaired resident who resided on the memory care unit was provided with preferred activities while in isolation for Covid-19 for 1 of 4 residents reviewed for activities. (Resident 45) Finding includes: During an observation, on 1/3/24 at 10:37 a.m., Resident 45 was lying in bed, in her room, and her eyes were closed. There was no music playing and no reading material noted on the resident's bedside table. During an observation, on 1/4/24 at 10:21 a.m., Resident 45 was lying in bed and her eyes were closed. There was no music playing and the television was not on. During an interview, on 1/4/24 at 11:20 a.m., CRCA (Certified Resident Care Assistant) 3 indicated the television in the resident's room did not work. The resident would watch television in the common area when she was not in isolation. During an observation, on 1/4/24 at 2:47 p.m., the resident was lying in bed, her eyes were opened. There was no music, the television was not on, and there were no books on the resident's side of the room. The record for Resident 45 was reviewed on 1/5/24 at 10:17 a.m. Diagnoses included, but were not limited to, dementia without behavioral disturbance, cognitive communication deficit, and anxiety disorder. An activity care plan, dated 1/2/24, indicated the resident had a history of enjoying Scripture, pet therapy, and exercise. The resident would positively respond to one-to-one activities of interest at least 6 times per week. The approaches included, but were not limited to, it was important to be around animals, and important to do things with groups of people. The group activities meaningful to the resident included pet therapy, religious, and exercise. A progress note, dated 12/26/23 at 5:06 a.m., indicated the resident was positive for Covid-19 and was placed into droplet isolation. A progress note, dated 12/28/23 at 4:11 a.m., indicated the resident continued in isolation. A progress note, dated 1/1/24 at 10:28 a.m., indicated the resident remained in isolation. A progress note, dated 1/5/24 at 8:43 a.m., indicated an order was obtained to discontinue the isolation. During an observation and interview, on 1/8/24 at 11:07 a.m., the Legacy Unit Manager indicated she did not know where the remote was for the resident's television. The Unit Manager was able to turn on the television without using the remote control. During an interview, on 1/8/24 at 11:03 a.m., Life Enrichment Staff 4 indicated documentation showed the resident did not participate in activities on December 25, December 26, December 27, December 29, December 31, January 2, January 3, or January 4. During an interview, on 1/8/24 at 11:16 a.m., the Life Enrichment Clinical Support indicated the staff would go in the isolation room based on the resident's care plan and the family input. They would provide some type of independent activity if the resident was capable such as coloring pencils. The visits should have been charted in the electronic health record. The staff was not great at charting check-in visits with the residents in isolation. The Life Enrichment Team was new, and they still needed education. She could not show what activities Resident 45 participated in while in isolation since there was no documentation of the activities in the electronic health record. A Daily Rhythms Activity Protocol, not dated and received from the Life Enrichment Clinical Support on 1/8/24 at 11:39 a.m., indicated .Through research and experience, we have learned that those living with the challenges of Alzheimer's disease and related forms of dementia benefit from a structured, predictable daily program of activities. Benefits of such a program include improved sleeping patterns, decreased depression, lower anxiety levels, fewer falls A current policy, titled Program Components/Standards, dated 6/3/2016 and received from the Life Enrichment Clinical Support on 1/8/24 at 11:48 a.m., indicated .The Life Enrichment Department designs program which are meaningful, diverse, stimulating, and consistent with the needs, preferences, and abilities of each individual resident/patient .Programs are designed to provide opportunities for each resident/patient to meet their social, physical, cognitive, and emotional needs and recreation interests .The Life Enrichment Director will ensure that the life enrichment program contains the following programming standards/programming components . Intellectual/Cognitive Programs .Social Programs .encourage interaction with others .Dementia Programs .Programs that stimulate the 5 senses help to promote resident connection A current policy, titled Resident Rights-Life Enrichment, dated 6/3/2016 and received from the Life Enrichment Clinical Support on 1/8/24 at 11:56 a.m., indicated .Special care must be taken to assure the ongoing preservation of the rights of each resident in the provision of Life Enrichment services .All residents will be informed of opportunities, and provided assistance as needed, to participate in Campus and community opportunities of their choice 3.1-33(a)

Based on interview and record review, the facility failed to follow the physician's order to call the provider and complete a re-check for low blood sugars for 1 of 1 resident reviewed for quality of care related to insulin. (Resident 1) Finding includes: During an interview, on 1/2/24 at 3:05 p.m., Resident 1 indicated she had to go to the hospital for high blood sugars in the past. The record for Resident 1 was reviewed on 1/4/24 at 12:02 p.m. Diagnoses included, but were not limited to, type 2 diabetes with history of ketoacidosis (uncontrolled production of ketones) without coma, peripheral vascular disease, iron deficient anemia, and cognitive communication deficit. A physician's order, with a start date of 10/27/22 and an end date of 9/19/23, indicated the resident received insulin lispro (short acting insulin) per sliding scale 3 times per day. If the blood sugar was less than 70, call the MD. A current physician's order, dated 3/2/2020, indicated for blood sugars between 50-69, give a 15-gram carbohydrate oral feeding, wait 15 minutes, and recheck the blood sugar. If less than 70, than repeat the 15-gram carbohydrate 4 times a day as needed. A blood sugar log indicated the following: a. On 5/24/23 at 9:35 a.m., the blood sugar was 69. There was no documentation there was a call to the provider or a 15-minute re-check was completed. b. On 5/31/23 at 10:04 a.m., the blood sugar was 53. There was no documentation there was a call to the provider or a 15-minute re-check was completed. c. On 7/5/23 at 10:00 a.m., the blood sugar was 63. There was no documentation there was a call to the provider or a 15-minute re-check was completed. d. On 7/29/23 at 8:14 a.m., the blood sugar was 54. There was no documentation there was a call to the provider or a 15-minute re-check was completed. e. On 8/6/23 at 8:06 a.m., the blood sugar was 59. There was no documentation there was a call to the provider completed. f. On 8/21/23 at 5:33 a.m., the blood sugar was 53. There was no documentation there was a call to the provider or a 15-minute re-check was completed. g. On 8/24/23 at 3:40 a.m., the blood sugar was 55. There was no documentation there was a call to the provider or a 15-minute re-check was completed. h. On 9/4/23 at 3:35 a.m., the blood sugar was 55. There was no documentation there was a call to the provider or a 15-minute re-check was completed. i. On 9/5/23 at 3:26 a.m., the blood sugar reading indicated Low. There was no documentation a 15-minute re-check was completed. j. On 9/8/23 at 8:43 a.m., the blood sugar was 67. There was no documentation there was a call to the provider or a 15-minute re-check was completed. During an interview, on 1/4/24 at 4:11 p.m., the DHS (Director of Health Services) indicated they could not find any notification or re-checks for the low blood sugars and there should have been provider notification and re-checks completed. There was no policy for blood sugar monitoring provided by exit. 3.1-37(a)

Based on interview and record review, the facility failed to identify a weight loss, notify the physician, and implement interventions for 1 of 3 residents reviewed for nutrition. (Resident 12) Finding includes: The record for Resident 12 was reviewed on 1/5/24 at 12:18 p.m. Diagnoses included, but were not limited to, dementia without behavioral disturbance, type 2 diabetes mellitus, adult failure to thrive, anxiety, and major depressive disorder. A physician's note, dated 4/3/23 at 6:04 p.m., indicated the resident tested positive for Covid-19 on 3/30/23. If the resident had signs of dehydration an intravenous line should be considered for fluid resuscitation. The resident was to be monitored for falls, increased thirst, urination, weight loss, constipation, and diarrhea. The resident had the following weights: a. On 3/1/23, the weight was 114.4 pounds. b. On 4/7/23, the weight was 106.8 pounds which was a 6.64% weight loss in 37 days. The Electronic Health Record (EHR) did not include notification to the physician of the weight loss, a nutrition note, or interventions in place for the weight loss. During an interview, on 1/8/24 at 4:08 p.m., the Clinical Support Nurse indicated the facility should have notified the physician of the significant weight change and document the significant weight loss was noted. A current policy, titled Guidelines for Weight Tracking, dated as revised on 1/16/2021 and received from the Clinical Support Nurse on 1/8/24 at 4:45 p.m., indicated .To ensure resident weight is monitored for weight gain and/or loss to prevent complications from arising from compromised nutrition/hydration .Unless otherwise indicated or ordered by the physician the resident will have their weight taken and recorded monthly .The facility dietitian or representative will review the resident's nutritional status, usual body weight and current weight to implement a nutritional program when warranted .The physician, resident representative and dietitian shall be notified of a weight variance of 5% in 30 days, 7.5% in 90 days, and 10% in 180 days 3.1-46(a)(1)

Based on interview and record review, the facility failed to assess a resident for the preferred time to get out of bed for 1 of 2 residents reviewed for choices. (Resident B) Finding includes: During an observation, on 11/15/22 at 11:56 a.m., Resident B was laying, in bed, in her room. During an interview, on 11/15/22 at 2:03 p.m., Resident B indicated she would like to get out of bed earlier although the staff did not usually get her up until 11:00 or 11:30 a.m. During an observation, on 11/16/22 at 10:37 a.m., the resident was still in bed and had on a hospital gown. She indicated she was waiting for the CNA to come in and get her up. During an observation, on 11/17/22 at 10:29 a.m., the resident was laying, in bed, in her room and had on a hospital gown. During an interview, on 11/17/22 at 10:34 a.m., RN 6 indicated the resident liked to get out of bed between 10:00 a.m., and 12:00 p.m. Usually it was the same staff who worked on the unit, and they just knew what time the resident wanted to get up. There was nothing in writing to indicate what time the resident preferred to get out of bed. During an observation, on 11/18/22 at 10:28 a.m., the resident was laying, in bed, in her room and was wearing a hospital gown. The record for Resident B was reviewed on 11/16/22 at 4:12 p.m. Diagnoses included, but were not limited to, acute respiratory failure with hypoxia, morbid obesity, body mass index 70 or greater, chronic pain, depression, mild cognitive impairment, deformity of the right ankle, and paraplegic immobility syndrome. A care plan, dated 3/30/20, indicated the resident had an impairment in functional status related to transfers and bed mobility. The approaches included, but were not limited to, the resident required assistance with transfers and bed mobility. A care plan, dated 3/30/20, indicated the resident presented with a diagnosis of depression and had symptoms of isolating, poor self-care, and poor hygiene. The approaches included, but were not limited to, monitor the resident's participation in ADLs (activities of daily living) and leisure activities. A care plan, dated 3/23/22, indicated the resident demonstrated non-compliance with physician orders and or the plan of care. The approaches included, to encourage the resident to participate in decision making by offering choices. A Profile Care Guide, dated 3/17/22, indicated the resident utilized a motorized scooter for mobility and the Maxi Move (a floor lift designed to enable a single caregiver to transfer or reposition a resident who weighs up to 500 pounds). A resident preference sheet, dated 9/15/22, indicate the resident wanted to wake up at 3:00 a.m. The preference sheet did not include the time the resident wanted to get out of bed. A current policy, titled Resident Rights Guidelines, dated as revised on 5/11/17 and received from the Clinical Support Nurse on 11/17/22 at 4:17 p.m., indicated .To ensure resident rights are respected and protected and provide an environment in which they can be exercised .Residents shall not leave their individual personalities or basic human rights behind when they move to a health campus. The following is a list of rights recognized by staff .Be given the information necessary to participate in decisions which affect them both individually and corporately .Be consulted and encouraged to have input into their care plan which guides the services delivered to the resident This Federal tag relates to Complaint IN00388949. 3.1-3(u)(1)

2. The record for Resident 47 was reviewed on 11/16/22 at 10:22 a.m. Diagnoses included, but were not limited to, bipolar disorder, schizoaffective disorder (a disorder which affects a person's ability to think, feel and behave clearly), pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder), anxiety disorder, cognitive communication deficit, vascular dementia without behavioral disturbance, psychotic disturbance, and mood disturbance. A physician's order, dated 4/14/21, indicated the resident's diet was a Controlled Carbohydrate (CCHO) and regular liquids. Resident 47 had a 12.58% weight gain in 6 months. a. On 5/10/2022, the weight was 244.8 pounds. b. On 11/09/2022, the weight was 275.6 pounds. A dietary note, dated 5/30/22 at 12:32 p.m., indicated the resident's intake was 68% in 7 days. The dietitian was unsure of the cause of the weight gain. The physician was not notified of the resident's significant weight gain. A care plan, dated 5/27/21, indicated the resident had continued weight gain since admission. Interventions included, but were not limited to, assist with meals as needed, dietitian to re-evaluate, offer alternate food and beverages items as needed, provide diet, supplements, medications, and adaptive equipment as ordered. During an interview, on 11/21/22 at 9:12 a.m., the Director of Nursing was not aware Resident 47 gained a significant amount of weight and did not believe the residents edema was being monitored. A current policy, titled Guideline for Weight Tracking, dated as revised 1/16/21 and received from the Director of Nursing on 11/17/22 at 2:30 p.m., indicated .To ensure resident weight is monitored for weight gain and/or loss to prevent complications arising from compromised nutrition/hydration .Residents will have their weight taken and recorded upon admission to establish a baseline .Unless otherwise indicated or ordered by the physician the resident will have their weight taken and recorded monthly .Residents who have a weight that seem out of normal range shall be re-weighed to determine the accuracy of the original weight .The physician, resident representative and dietitian shall be notified of a weight variance of 5% in 30 days, 7.5% in 90 days, and 10% in 180 days (unless on a planned weight loss or gain program A current policy, titled Notification of Change in Condition, not dated and received from the Director of Nursing on 11/17/22 at 2:30 p.m., indicated .To ensure appropriate individuals are notified of change in condition. The facility must inform the resident, consult with the resident's physician and if known notify the resident's legal representative when: A significant change in the resident's physical, mental or psychosocial status. A need to alter treatment significantly .Documentation of notification attempts should be recorded in the resident electronic health record 3.1-5(a)(2) Based on interview and record review, the facility failed to ensure the physician was notified of a significant weight gain for 2 of 2 residents reviewed for notification. (Resident 1 and 47) Findings include: 1. The record for Resident 1 was reviewed on 11/16/22 at 10:25 a.m. Diagnoses included, but were not limited to, type 3 diabetes mellitus, hypertension, and reduced mobility. The resident had the following weights: a. On 5/13/22, the weight was 154 pounds. b. On 7/5/22, the weight was 164.4 pounds. c. On 8/2/22, the weight was 170 pounds which was a 10.39% weight gain in 81 days. A registered dietician (RD) note, dated 8/27/22 at 11:25 a.m., indicated the resident had a significant weight gain of 10.8% since admission. The note did not include the physician was notified of the significant weight gain. An RD note, dated 10/28/22 at 11:51 p.m., indicated the resident had a significant weight gain since admission. There were no new recommendations. The note did not include the physician was notified of the significant weight gain. An RD note, dated 11/16/22 at 1:20 p.m., indicated the resident triggered for a significant weight loss of 14.3% in the last 180 days. There were no new recommendations. An RD note, dated 11/20/22 at 11:51 p.m., indicated the IDT (interdisciplinary team) reviewed the resident and was noted to have a significant weight loss. There was a new order for weekly weights and the resident would be followed on clinically at risk (CAR) and by the RD as warranted. The physician was notified. The resident had a significant weight gain and not a weight loss. During an interview, on 11/21/22 at 10:42 a.m., the Clinical Support Nurse indicated there was no notification to the physician of the significant weight gain in August. The resident did not have a significant weight loss as was documented on 11/20/22 and the documentation was in error.

Based on interview and record review, the facility failed to complete a comprehensive care plan to reflect a significant change for 1 of 1 resident reviewed for hospice services. (Resident 15) Finding includes: The record for Resident 15 was reviewed on 11/21/22 at 9:30 a.m. Diagnoses included, but were not limited to, coronavirus disease (COVID-19) (an infectious disease caused by the SARS-CoV-2 virus), pneumonia, Alzheimer's disease (type of dementia which affects memory, thinking and behavior), Parkinson's disease (brain disorder which causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), ischemic heart disease (disease in the heart's major blood vessels), and pleural effusion (buildup of fluid between the tissues that line the lungs). The record indicated Resident 15 was on hospice. An admission Minimum Data Set (MDS) assessment, dated 9/15/22, indicated she was admitted from an acute care hospital, and she was not on hospice. A physician's order, dated 9/28/22, indicated to contact Hospice for any condition change or medication change requests. A Significant Change in Status MDS assessment, dated 11/15/22, lacked indication she was on hospice. During an interview, on 11/21/22 at 9:58 a.m., the MDS Coordinator indicated the 14-day Significant change assessment for Resident 15 was not completed after she was enrolled into a hospice program. A significant change assessment should have been completed within 14 days of the change in status when Resident 15 was admitted to hospice on 9/28/22. During an interview, on 11/21/22 at 10:00 a.m., the Corporate Support MDS indicated the facility would refer to the RAI for the timing of submissions and a Significant Change in Status should have been completed within 14 days of Resident 15 starting on Hospice. The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Manual version 3.0, dated 10/19, indicated a Significant Change in Status Assessment must be completed by the end of the 14th calendar day following determination a significant change had occurred. 3.1-31(d)(1)

2. The record for Resident 47 was reviewed on 11/16/22 at 10:22 a.m. Diagnoses included, but were not limited to, bipolar disorder, schizoaffective disorder (a disorder which affects a person's ability to think, feel and behave clearly), pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder), anxiety disorder, cognitive communication deficit, vascular dementia without behavioral disturbance, psychotic disturbance, and mood disturbance. A PASARR level I, dated 6/11/21, indicated the resident had a diagnosis of major depressive disorder, bipolar disorder, anxiety disorder and dementia. A physician's order, dated 7/14/22, indicated Seroquel (an antipsychotic medication) 75 mg (milligram) at bedtime for hallucinations. A diagnosis of schizoaffective disorder with hallucinations was added 7/18/2022. During an interview, on 11/21/22 at 10:51 a.m., the Social Service Director indicated Resident 47 did not have a PASARR Level I completed when starting an anti-psychotic medication. The Level I should have been done when the resident started on Seroquel. 3. The record for Resident 55 was reviewed on 11/16/22 at 11:06 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, dementia with behavioral disturbance, anxiety disorder, falls, hallucinations (8/2/22), and hypertension. A PASARR level I, indicated the resident was not on an antipsychotic. A physician's order, dated 11/1/22, indicated Risperdal (an antipsychotic) 1 mg tablet at bedtime for hallucinations. A diagnosis of hallucinations was added 8/2/22. During an interview, on 11/21/22 at 10:51 a.m., the Social Services Director indicated Resident 55 should have had a new PASARR Level I when Risperdal was added for hallucinations. A current policy, titled PASARR Quick Sheet, undated and received from Clinical Support on 11/16/22 at 4:58 p.m., indicated .New Admissions: If any of the following triggers a positive response, the Level I (MAP 409) will be check YES on Section I and /or II and contact the PASARR office .Individual has a severe mental illness/behavioral health (BH) diagnosis. ex. Schizophrenia, Bipolar Disorder, Major Depression Disorder, Anxiety Disorder .These diagnoses must be given by a Psych MD/ARNP and not by a PCP or some other type of treatment provider other than psychiatry .If an individual with BH has a Primary Diagnosis of Dementia from a Psychiatrist, the Level I (MAP 409) is marked NO on the Level I and a Response to Referral Form is needed .Provisional admission to a Nursing Facility (MAP 4093) Is to be completed when an individual needs an emergent nursing facility admission from a location other than a hospital, it is completed by a nursing facility representative and individual/family, and the resident is expected to stay less than 14 days 3.1-16(d)(1)(B) Based on interview and record review, the facility failed to ensure a new PASARR (preadmission screening and resident review) was completed when an antipsychotic medication and new mental health diagnosis was added for 3 of 3 residents reviewed for PASARR. (Resident 12, 47 and 55) Findings include: 1. The record for Resident 12 was reviewed on 11/15/22 at 4:46 p.m. Diagnoses included, but were not limited to, anxiety disorder, depressive episodes, and unspecified dementia with behavioral disturbance. A PASARR, dated 8/30/22, indicated the resident had depression and there were no known recent or current mental health symptoms. The only medication listed was Zoloft (an antidepressant) for depression. There was no evidence of a serious behavioral health condition. If changes occurred or new information refuted the findings, a new screen must be submitted. A physician order, dated 9/1/22, indicated Seroquel (an antipsychotic) 50 mg (milligram) once a day. During an interview, on 11/16/22 at 2:19 p.m., the Clinical Support indicated the resident's PASARR, dated 8/30/22, did not include the antipsychotic medication Seroquel or a mental health diagnosis of psychosis. A new PASARR was not completed when the Seroquel was added and should have been.

Based on interview and record review, the facility failed to ensure a resident who was diagnosed with dementia with no previous mental health diagnosis met the criteria for a new diagnosis of schizophrenia for 1 of 6 residents reviewed for professional standards of quality. (Resident 47) Finding includes: The record for Resident 47 was reviewed on 11/16/22 at 10:22 a.m. Diagnoses included, but were not limited to, bipolar disorder, schizoaffective disorder (a disorder which affects a person's ability to think, feel and behave clearly), pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder), anxiety disorder, cognitive communication deficit, vascular dementia without behavioral disturbance, psychotic disturbance, and mood disturbance. A PASARR level I, dated 6/11/21, indicated the resident had diagnoses of major depressive disorder, bipolar disorder, anxiety disorder, and dementia. A physician's order, dated 7/14/22, indicated Seroquel (an antipsychotic medication) 75 mg (milligram) at bedtime for hallucinations. A diagnosis of schizoaffective disorder with hallucinations was added 7/18/2022. During an interview, on 11/21/22 at 10:51 a.m., the Social Service Director indicated the resident started Seroquel (an antipsychotic) on 7/14/22. The resident had a diagnosis of schizoaffective disorder. A current policy, titled Psychotropic Medication Usage and Gradual Dose Reduction, revised 10/9/17 and received from Clinical Support on 11/21/22 at 2:30 p.m., indicated .To ensure every effort is made for residents receiving psychoactive medications to obtain the maximum benefit with minimal unwanted side effects through appropriate use, evaluation and monitoring by the interdisciplinary team .Residents shall receive psychotropic medications only if designated medically necessary by the prescriber, with appropriate diagnosis or documentation to support its usage. The medical necessity will be documented in the resident's medical record and in the care planning process .Efforts to reduce dosage or discontinue psychotropic medications will be ongoing, as appropriate .Reviews of medication use will be conducted by the consultant pharmacist monthly and will .Monitor psychotropic drug use in the campus to ensure that medications are not used in excessive doses or for excessive duration 3.1-35(g)(1)

Based on observation, interview and record review, the facility failed to assess and document abnormal mouth movements for 1 of 3 residents reviewed for potential medication side effects. (Resident 1) Finding includes: During an observation, on 11/14/22 at 1:39 p.m., Resident 1 was sitting up, in a chair, in her room. She continuously was moving her tongue in and out of her mouth and her tongue appeared swollen. During on observation, on 11/15/22 at 11:45 a.m., the resident was ambulating in the hallway, with her walker, and her tongue was sticking out. During an observation, on 11/16/22 at 10:34 a.m., the resident was ambulating in the hallway, with her walker, and her tongue was sticking out. During an observation, on 11/17/22 at 10:27 a.m., the resident was ambulating in the hallway, with her walker, her tongue continued to move in and out of her mouth even while the resident was talking. The record for Resident 1 was reviewed on 11/16/22 at 10:25 a.m. Diagnoses included, but were not limited to, atrial fibrillation, type 2 diabetes mellitus, pain in the right hip, reduced mobility, and stiffness of the right knee. The list of diagnoses did not include anything about the resident's tongue movements or swollen tongue. The face sheet listed the resident's allergies as chlorpromazine (an antipsychotic which can cause uncontrollable movements of any part of the body), codeine and penicillin. An admission observation, dated 5/12/22 at 3:43 p.m., indicated the resident's oral cavity had no ulcers, lesions, halitosis, dry membranes, or bleeding gums. The admission assessment did not include continuous movements of the resident's tongue or swelling of the tongue. A physician's progress note, dated 5/24/22, indicated the resident had macroglossia (an enlarged tongue). The physician note did not include the continuous movements of the tongue in and out of the mouth. The diagnoses list did not include the macroglossia. During an interview, on 11/16/22 at 10:56 a.m., the Social Service Director (SSD) indicated the resident was admitted from another facility and there was nothing in the history about the resident having any psychiatric concerns or using antipsychotics. During an interview, on 11/16/22 at 2:16 p.m., the Executive Director (ED) indicated she did not know how the facility was aware the resident had an allergy to chlorpromazine. During an interview, on 11/16/22 at 5:04 p.m., the SSD indicated she talked to the resident who denied a history of any mental health diagnosis. The resident indicated she had been placed in a state facility for several years and then a new physician came, and she was discharged . The resident did not know where she would have received chlorpromazine. During an interview, on 11/21/22 at 3:18 p.m., the Clinical Support nurse indicated when the physician would add a new diagnosis the facility should have added it to the diagnoses list on the face sheet and the macroglossia was not listed. An AIMS (abnormal involuntary movement scale) assessment would not be completed unless the resident was currently taking an antipsychotic. During an interview, on 11/21/22 at 3:52 p.m., the ADHS (Assistant Director of Health Services) indicated the continuous moving of the resident's tongue in and out of her mouth were a baseline for the resident. There was no documentation to show the resident had the mouth movements upon admission and no documentation to show if the mouth movements were the same, better, or worse. A current policy, titled Guidelines for: Abnormal Involuntary Movement Scale, dated as revised on 5/22/2018 and received from the Clinical Support Nurse on 11/16/22 at 4:58 p.m., indicated .To assess residents that have been prescribed antipsychotic medications to identify symptoms that may indicate the presence of Tardive Dyskinesia; a neurological disorder characterized by abnormal involuntary movements which may occur as an undesired side effect of dopamine blocking medications as well as other medications such as Reglan and Levsin .A licensed nurse will complete an AIMS scale assessment on all residents on antipsychotic medications and or other medications known to cause Tardive Dyskinesia .The AIMS assessment score will be communicated to the attending physician if positive for signs and or symptoms of Tardive Dyskinesia The Nursing Drug Handbook indicated chlorpromazine was indicated for the use of psychosis, mania, nausea, vomiting, intractable hiccups and tetanus. The adverse reactions included tardive dyskinesia and seizures. The nursing considerations included, but were not limited to, monitor for tardive dyskinesia which may not appear until months or years later and may persist for life despite stopping the medication. 3.1-37(a)

Based on observation, interview and record review, the facility failed to identify the unique characteristics and abilities, provide supervision, monitor the effectiveness of interventions, and modify the care plan with fall prevention interventions for 1 of 1 resident reviewed for falls. (Resident 15) Finding includes: During an observation, on 11/15/22 at 9:13 a.m., Resident 15 was observed in her room, lying in bed, as she kicked her legs over the edge of the bed. She begun to yell for help as she reached up in the air. During an observation, on 11/15/22 at 2:12 p.m., Resident 15 was observed in her room, lying in bed, she yelled out help me. The fall mat was lying up next to the wall, on the right side of the room, near the door. Resident 15 had attempted to get out of bed, her right leg was over the top of the bed rail. During an observation, on 11/15/22 at 2:45 p.m., Resident 15 was observed in the lounge near the nurse's station, with five other residents, and no staff within sight. She was seated in her Broda chair in a slightly reclined position, holding a white stuffed animal. At 2:47 p.m., Resident 15 begun to yell out, hey, help me, help me. Resident 15 was leaning forward, trying to rock forward with her back off the backrest of the chair. Staff were observed to walk past the lounge and had no interactions with the residents. The record for Resident 15 was reviewed on 10/4/22 at 8:30 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, dementia, Parkinson's disease, and falls. A Significant Change Minimum Data Set (MDS) assessment, dated 11/15/22, indicated the resident had a severe cognitive impairment, was totally dependent on staff for transfers, bed mobility, dressing, eating, oral hygiene, toilet hygiene, and bathing. A care area assessment (CAA), dated 11/15/22, indicated the resident had triggered for falls and dementia. She was non-ambulatory and used a Broda chair for her mobility. Resident 15 had multiple falls since her last assessment with minor injury and required assistance with all the activities of daily living. A Fall Event report indicated, on 10/6/22, Resident 15 had an unwitnessed fall in her room. She was transferring herself, had mild pain in her back, and an abrasion. The risk factors were indicated as cognitive impairment, required assistance with transfers, had difficulties understanding and following directions. Staff initiated an immediate intervention for Resident 15 and placed a mat next to her bed. Additional intervention added was to place Dycem (Non-Slip product) in her Broda chair. A Fall Event report indicated, on 10/12/22, Resident 15 had an unwitnessed fall in her room and was found between her bed and the wall. Resident 15 had complained of mild pain in her right flank area and redness was observed. The risk factors were indicated as cognitive impairment, required assistance with transfers, had difficulties understanding and following directions, and refused to comply with safety measures. Immediate intervention initiated was having the bed in the lowest position. The safety measures in place at the time of the fall was Resident 15 had nonslip socks on. A Fall Event report indicated, on 10/15/22, Resident 15 had an unwitnessed fall in her room when she was self-transferring. The safety equipment in place at the time of the fall included a Broda chair and the bed in lowest position. She had complained of mild pain in her heel. The risk factors were indicated as cognitive impairment, required assistance with transfers and ambulation, had difficulties understanding and following directions, refused to comply with safety measures, and she had restlessness present. New interventions initiated immediately were bed in lowest position and repositioned to the opposite side of bed. A nurse progress note, dated 10/15/22, indicated Resident 15 had been attempting to climb out of bed and was yelling. A nurse progress note, dated 10/16/22, indicated the resident was found on the floor when the nurse brought in Resident 15's morphine and Ativan for pain and restlessness. She had blood in her mouth where she had bit her tongue. A Fall Event report indicated, on 10/24/22 at 5:21 p.m., Resident 15 had an unwitnessed fall when self-transferring in her room. She had no safety equipment ordered. Interdisciplinary Team (IDT) reviewed and added no new interventions. A Fall Event report indicated, on 10/24/22 at 10:03 p.m., Resident 15 had an unwitnessed fall when self-transferring and was found on the floor by a family member, lying on her side, in front of the Broda chair. The report indicated she had a fall mat next to her bed as a new intervention. IDT reviewed and indicated to put the bed in a low position as a new intervention. A physician progress note, dated 10/27/22, indicated Resident 15 had multiple falls. A Fall Event report indicated, on 10/28/22, Resident 15 had an unwitnessed fall in her room and was found on the floor against the dresser next to bed. She was self-transferring and toileting just prior to fall. She was agitated and had restlessness. A fall mat was in place for safety equipment. The risk factors were indicated as cognitive impairment, required assistance with transfers and ambulation, had difficulties understanding and following directions, refused to comply with safety measures, and required the use of assistive device and forgot to use them. New interventions initiated immediately after the fall were to put her bed in the lowest position. IDT reviewed and added a specialty mattress with bolsters. A Fall Event report indicated, on 11/8/22, Resident 15 had an unwitnessed fall in her room when transferring herself and had no safety equipment in place. She was found in front of her Broda chair. New interventions initiated immediately after the fall were to put her bed in the lowest position. IDT reviewed and added to encourage resident after meals for a new intervention. A Care Plan, dated 9/20/22, indicated Resident 15 was at risk for falling related to diagnoses, medication use, and mobility and indicated the following interventions: a. On 9/20/22, to encourage her to assume standing position slowly. b. On 9/22/22, ensure the floor is free of liquids and foreign objects. c. On 9/20/22, to keep call light within reach. d. On 9/20/22, to keep her personal items and frequently used items within reach. e. On 9/20/22, to provide non-skid footwear. f. On 9/20/22, to staff to assist resident with transfers. g. On 9/20/22, therapy evaluation and treatment as needed. h. On 10/7/22, to use Dycem to Broda chair. i. On 10/17/22, to encourage her to sit in common area while up. j. On 10/17/22, use touch pad call light. k. On 10/25/22, to put the bed down low. l. On 10/25/22, to administer medication. m. On 10/31/22, to use specialty mattress with bolsters. n. On 11/9/22, to encourage resident to lay down after meals. The Care Plan lacked indications for staff to provide supervision or frequent supervisions. During an interview, on 11/15/22 at 3:10 p.m., Licensed Practical Nurse (LPN) 4 indicated staff would bring Resident 15 out to the lounge and let her sit in her Broda chair. The nursing staff are busy with medications to pass and treatments to provide. Supervision of the lounge occurs when she attempted to get out of her chair or yell out. She did well when she had one on one interactions or when she was in a quiet, calm environment. Resident 15 needed supervision while she was in her room or in the lounge to reduce the number of falls. During an interview, on 11/21/22 at 9:30 a.m., the Clinical Support nurse indicated fall preventions were put into place for Resident 15 and each fall was reviewed. During an interview, on 11/21/22 at 5:20 p.m., the Executive Director indicated a root cause analysis was completed for Resident 15. A request for a copy of the Root Cause Analysis for each fall was requested and was not provided. The Fall Event Reports indicated a root cause was found but lacked the information of the findings. A review of a facility document, titled Recorded Falls Report, dated from 5/2/22 to 11/13/22, indicated the facility had a total of 134 falls. A current facility policy, titled Fall Management Program Guidelines, with a revision date of 5/31/17, indicated the Fall Event, included an investigation of circumstances surrounding the fall to determine the cause, reassessment to identify possible contributing factors, interventions to reduce risk of repeat episodes and a review by the interdisciplinary team (IDT) to evaluate the thoroughness of the investigation. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a resident with a Gastrostomy tube (GT) feeding received care and services for the feeding tube to meet the resident's needs, related to not checking for residual volume prior to administration of tube feeding, ensure the catheter syringe and graduated cylinder were labeled, dated, and stored appropriately for 2 of 2 residents reviewed for tube feeding. (Resident 61 and 115) Findings include: 1. During an observation, on 11/14/22 at 12:45 p.m., Resident 61 was observed in his room, lying in bed, on a low air loss mattress. The head of the bed was elevated to a 30-degree angle. His upper body was positioned to the right side of the bed with his right temple area resting on the bed rail. During an observation, on 11/16/22 at 9:36 a.m., to 9:45 a.m., Resident 61 was observed in his room, lying in bed, with the head of bed at a 50-degree angle. Two small black fruit flies flew around the bedside table and landed on the tube feeding equipment. A catheter syringe for the tube feeding was not dated and was laid on top of the bed side table which was more than 50 percent dirty. Another catheter syringe and graduated cylinder was open and undated on the bed side table. An intravenous (IV) pole with a tube feeding pump was unplugged. The IV pole had a tan colored dried formula on the upper part of the IV pole and on the touch screen of the pump. During an observation, on 11/16/22 at 2:09 p.m., Resident 61 was leaning to the right side of the bed with his head resting on the side rail. The head of the bed was elevated to 30 degrees. During an observation and interview, on 11/17/22 11:35 a.m., Resident 61 was observed lying to the right side of the bed with his head over to the edge of the bed and near the bed rail. A Qualified Medication Aide (QMA) and Registered Nurse (RN) 6 repositioned Resident 61 and removed the abdomen compression band which had covered his G-tube. RN 6 had reviewed the orders and gathered the supplies for Resident 61's tube feeding. He connected a 60 ml catheter syringe to the opening of the G-tube and aspirated gastric contents. The 60 ml syringe was filled slightly above the 60 ml line and the G tube was filled with tan colored formula. RN-6 pushed the formula back into the G-tube, and then flushed with water. He administered a water flush before and after he gave Resident 61's his medication. After the medication administration, RN-6 administered 300 ml of Jevity formula and 120 ml of water. Resident 61 had facial grimacing, moaning out, a distended stomach, and audible expiratory wheezes (relatively high-pitched whistling noise produced by movement of air through narrowed or compressed small airways). RN 6 indicated the physician's order lacked indication of how many times he needed to pull back for the residual volume or when to notify the physician. The record for Resident 49 was reviewed. Diagnoses included, but were not limited to, cerebral infraction (stroke), non-st elevation myocardial infarction (heart attack), dementia, chronic kidney disease (kidney failure), dysphagia (swallowing difficulties), and chronic obstructive pulmonary disease (diseases which cause airflow blockage). A Care Area Assessment (CAA), dated 9/22/22, indicated Resident 61 received tube feedings and water flushes. Resident 61 required assistance from staff for all activities of daily living. Resident 61's Physician Order Report, dated 9/17/22 to 11/18/22, included, but were not limited to, a. On 10/20/22 to 11/12/22, staff were to change irrigation set every day. b. On 10/20/22 to current, check tube placement by air bolus and aspirating stomach contents before medication delivery. c. On 10/20/22 to 11/15/22, staff were to check residual every shift and document the amount of residual. d. On 11/17/22 to current, check residual every shift and document amount of residual. A Care Plan, dated 10/12/22, indicated Resident 61 required tube feeding, related to a stroke. Interventions included, but were not limited to, a. Assess for complications. b. Administer enteral feeding per doctor's order. c. Assess for hydration. d. Check for gastric residuals per doctor's order. Hold enteral feedings as ordered. Resume feedings as ordered. e. Check placement and patency of feeding tube before each feeding or medication administration. A Care Profile, dated 10/12/22, directed staff to keep the head of the bed elevated to 30 to 45 degrees. A Registered Dietitian progress note, dated 11/14/22 at 2:40 p.m., indicated Resident 61 was recently hospitalized and remained nothing by mouth. Resident 61's feeding was clarified to Jevity 1.5 300 milliliters (ml) four times a day as the current rate did not provide enough calories and had too much protein for the diagnosis of chronic kidney disease stage 4. The new rate and formula will provide 1200 mL total volume, 1800 calories, 76 grams protein, and 911 mL water. Resident 61 would receive water flushes after each feeding four times a day and 160 mL with med passes three times a day to meet fluid needs. A nurse progress note, dated 11/16/22 at 4:17 p.m., indicated Resident 61's tube feeding was clarified to Jevity 1.5 300 ml four times a day as the current formula and rate did not provide enough calories and was too high in protein for chronic kidney disease. This would provide 1200 ml total volume. Water flushes of 120 ml after each feeding four times a day and 160 ml with med passes three times a day to meet fluid needs. A review of Resident 61's weights indicated: a. On 9/21/22 at 11:46 a.m., his weight was 172 pounds. b. On 9/28/22 at 10:56 a.m., his weight was 170 pounds. c. On 10/5/22 at 1:38 p.m., his weight was 166.2 pounds. d. On 10/14/22 at 11:57 a.m., his weight was 164.1 pounds. e. On 11/14/22 at 6:44 a.m., his weight was 162.7 pounds. f. On 11/21/22 at 10:33 a.m., his weight was 157.2 pounds. A nurse progress note, dated 11/20/22 at 6:23 a.m., indicated Resident 61 had a emesis of mucous feeding like material, he was placed on his side. Resident 61's record lacked indication staff should hold feeding if residual volume was over a certain amount. During an interview, on 11/16/22 at 9:45 a.m., Corporate Support Nurse (CNS) indicated the tube feeding supplies were not labeled and were undated, lying on the dirty table. She indicated the staff were responsible for storing the tube feeding equipment and to ensure the supplies were labeled and dated. During an interview, on 11/17/22 at 12:20 p.m., the CNS indicated she did not expect staff to pour the contents of the syringe into a cylinder and continue to aspirate. Staff should follow the policy and procedure. During an interview, on 11/17/22 at 12:36 p.m., the Corporate Registered Dietitian indicated the nursing staff should follow the physician's order of when to hold a feeding with a certain residual volume. Staff should assess the total stomach content to get the residual volume. When the nurse pulled back and filled the syringe with formula, he should empty the contents into a graduate cylinder and continue to pull back until all stomach contents are emptied. Resident 61 would be at risk for aspiration. During an interview, on 11/18/22 at 12:25 p.m., the CNS indicated staff should follow the policy and procedures. During an interview, on 11/21/22 11:15 a.m., the CNS indicated staff should follow the procedure for residual volume and the policy and procedure were the most recent the staff should follow. During an interview, on 11/21/22 at 12:15 p.m., the Director of Health Services (DHS) indicated staff should pull back for full stomach contents to check for residual. The nurse should dump the contents of the syringe in a container, and aspirate until no further tube feeding. 2. During an observation, on 11/17/22 at 3:17 p.m., Nurse 9 entered the resident's room and washed her hands. She then donned gloves. Resident 121 was sitting in an upright position in her bed. The nurse placed an air bolus with 30 ml air in the feeding tube and listened in the upper abdominal region for placement with stethoscope. While the nurse was retrieving water, the Assistant Director of Nursing was holding the syringe and separating the plunger from the syringe. No aspiration was performed. The record for Resident 121 was reviewed on 11/16/22 at 09:59 a.m. Diagnoses included, but were not limited to, hemiplegia with hemiparesis following cerebral infarction effecting left non dominant side, facial weakness, speech and language deficits. A care plan, dated 11/14/22, indicated the resident required tube feedings and an oral diet to meet her nutrition and hydration needs. Interventions included, but were not limited to, check for proper placement of the feeding tube prior to the feeding and check the residual per physician order. A physician's order, dated 11/7/22, indicated check the feeding tube for residual every shift and record. A physician's order, dated 11/10/22, indicated Glucerna (liquid nutrition) 1.2 calorie 350 milliliter bolus 3 times daily with 60 milliliter bolus water flush. A progress note, dated 11/10/22 at 12:08 p.m., indicated the resident had a 60-milliliter residual. The feeding was held, and the nurse practitioner was called for new orders. During an interview, on 11/17/22 at 3:17 p.m., the Assistant Director of Health Services indicated aspiration for stomach contents should be completed. A current policy, titled Tube Feedings-CNS, dated 11/11/21 and received from the Dietitian indicated .residual practices are based on resident tolerance or nursing protocol .tube feeding tolerance should be monitored and charted by nursing and followed by registered dietitian A procedure, titled Feeding Tube: Enteral Nutrition via Nasoenteric, Gastrostomy, or Jejunostomy Competency, dated 9/7/16, indicated Step 4. For intermittent or bolus feeding, have a clean, enteral, large catheter tip syringe ready. Step 5. Place the resident in high Fowler position or elevate the head of bed 30 to 45 degrees. Step 6. Verify tube placement. Attach a catheter tip 60 ml syringe to the proximal end of the feeding tube and attempt to aspirate a sufficient amount of secretions for evaluation. Observe the appearance of the aspirate. Step 7. Check residual volume before each intermittent feeding. a. Draw 30 ml of air into a catheter tip 60 ml syringe, attach the syringe to the proximal end of the feeding tube, and inject air. b. Pull back and aspirate the total amount of gastric contents. c. Return aspirate contents to stomach unless the volume exceeds 500 ml or an amount determined by the organization's practice, or physician's order. d. Flush the tube with 15 to 30 ml of water. Step 8. Initiate the feeding as ordered volume. Step 9. Keep the head of bed at 30 to 45 degrees during intermittent feeding administration. 3.1-44(a)(2)

Based on interview and record review, the facility failed to provide Peripherally Inserted Central Catheter (PICC) care for 1 of 2 residents reviewed for PICC line care. (Resident 323) Finding includes: During an observation, on 11/14/22 at 1:16 p.m., Resident 323 was seated in his chair with a short-sleeved button on shirt. His left arm was exposed to reveal a PICC line dressing on the upper left forearm. The PICC line dressing had been peeling up on the left corner, with a date of 11/4/22. No date was found on the IV tubing hung on the IV pole. The record for Resident 323 was reviewed on 11/14/22 at 1:30 p.m. Diagnoses included, but were not limited to, neurosyphilis, Alzheimer's disease, and dementia. An admission assessment, dated 11/4/22, indicated Resident 323 had a midline with a dressing which was clean, dry, and intact. A care plan, dated 11/8/22, indicated Resident 323 required intravenous medication related to neurosyphilis. Interventions included, but were not limited to, notify the physician of any complications, assess for complications from the IV (localized infection, systemic infection, electrolyte imbalance, air embolus dislodgement, infiltration, phlebitis, fluid overload and dehydration ever shift and as needed), IV as ordered, and observe IV site for swelling, redness, tenderness, and warmth. A physician's order, dated 11/4/22, indicated to give Penicillin G potassium (antibiotic) 3,000,000 units per 50 milliliters by intravenous route every 4 hours until 11/15/22. Documentation indicated Resident 323 had not received his antibiotic on 11/4/22 and 11/5/22 until 9:00 p.m. Resident 323 missed five doses. A physician's order, dated 11/14/22, indicated to flush the PICC line with 5 ml of normal saline before and after medications. There was no documentation staff had flushed the PICC line from 11/4/22 to 11/13/22. A physician's order, dated 11/14/22, indicated to monitor the IV site for signs and symptoms of infiltration. There was no documentation staff had monitored the PICC line from 11/4/22 to 11/13/22. A physician's order, dated 11/14/22, indicated to change the end cap every 96 hours. There was no documentation staff changed the end cap from 11/4/22 to 11/13/22. A physician's order, dated 11/14/22, indicated to change the dressing every five days, measure external catheter length, and enter the measurements in the notes. There was no documentation staff completed the dressing changes from 11/4/22 to 11/13/22. A physician's order, dated 11/14/22, indicated to change the IV tubing primary and secondary sets every 24 hours. There was no documentation staff changed the IV tubing from 11/4/22 to 11/13/22. A review of the nursing progress notes indicated the following: On 11/4/22 at 9:22 p.m., the pharmacy was called for the IV Penicillin, and it was currently not available. On 11/5/22 at 9:45 p.m., the resident received his IV antibiotic. During an interview, on 11/14/22 at 2:01 p.m., Registered Nurse (RN) 3 indicated Resident 323's PICC line dressing had not been changed since it was placed on 11/4/22, when he was discharged from the hospital. The PICC line dressing was to be changed every five days. A current policy, titled Catheter Insertion and Care, dated 12/15 and provided by the Corporate Nurse Support (CNS) on 11/18/22 at 3:34 p.m., indicated .Guidance: a. Apply and maintain sterile dressing on intravenous access devices. Dressings must stay clean, dry, and intact. Explain to the resident that the dressing should not get wet. b. Change dressings if any suspicion of contamination is suspected. c. Catheter site care and dressing changes will include removal of the old dressing, observation and evaluation of catheter skin junction and surrounding tissue, cleansing with an approved antiseptic solution, replacement of any stabilization device and application of a sterling dressing. d. Change transparent semi-permeable membrane dressing every five to seven days and as needed when wet, soiled, or not intact 3.1-47(a)(2)

Based on observation, interview and record review, the facility failed to obtain a physician's order, develop a care plan, obtain a consent, ensure the bed rails were installed correctly, and perform scheduled maintenance for the use of side rails for 2 of 2 residents reviewed for accident hazards. (Resident 15 and 61) Findings include: 1. During an observation, on 11/15/22 at 9:13 a.m., Resident 15 was observed in her room, lying in bed, with bed rail up on the left side, and she had begun to yell for help. During an observation, on 11/15/22 at 2:12 p.m., Resident 15 was observed in her room, lying in bed, the left side bed rail was up, she was yelling out help me. Resident 15 put her right leg over the top of the bed rail. The record for Resident 15 was reviewed on 11/21/22 at 9:32 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, dementia, Parkinson's disease, and falls. A Significant Change Minimum Data Set (MDS) assessment, dated 11/15/22, indicated Resident 15 required an extensive assistance of two staff for bed mobility and transfers. She was dependent on staff for activities of daily living (ADL). She had an unsteady balance. A Bed Rail Assessment, dated 10/25/22 at 6:23 p.m., had been completed. The assessment indicated she had one half bilateral grab bars and used the bed rails for an enabler. The risk indicated for implementing the bed rails included accidental hazards such as climbing over, around or through the rails. The risk was also included over the foot board or could be caught between the mattresses. A Bed Rail Consent, dated 10/25/22 at 6:23 p.m., lacked indication it was signed. The record lacked indication a physician's order, a care plan, or a signed consent for the use of the side rails was obtained. A nurse progress note, dated 10/25/22 at 6:23 p.m., indicated Resident 15 had a bed rail assessment completed. One-half bilateral bed rails were used for an enabler. The risk for implementing the bed rails were accidental hazards such as climbing over, around, between, or through the rails, or over the foot board. The resident could be caught between the mattresses. During an interview, on 11/21/22 at 10:30 a.m., the Maintenance Director indicated he had not performed an inspection of the bed rails for Resident 15 because the bed rails were provided by hospice. He would only inspect the bed rails incase an incident would occur. During an interview, on 11/20/22 at 11:00 a.m., the Clinical Nurse Consultant (CNS) indicated Resident 15 did not have an order, a care plan, consent, or an assessment for the use of side rails and she should have had them documented in her medical record. 2. During an observation, on 11/15/22 at 9:18 a.m., Resident 61 was lying with the head of bed up to a 30-degree angle. He was slumped over to the right side with his right temple resting on the side rail and calling out with a moaning tone. During an observation, on 11/17/22 at 10:06 a.m., Resident 61 was observed in his room, lying in bed, with both bed rails up. A MDS assessment, dated 11/7/22, indicated he was totally dependent on staff for transfers, required extensive assistance with bed mobility, and had a severe cognitive impairment. An admission Care Area Assessment (CAA), dated 10/18/22, indicated he was readmitted to the facility after a hospitalization for gastrointestinal hemorrhage, hemiplegia (muscle weakness on one side) and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia (swallowing difficulties) following cerebral infarction (stroke). A physician's order, entered after the start of survey on 11/16/22, indicated Resident 61 had an order for bed rails to be assessed as an enabler for safe transfers or increased mobility. A review the facility document, titled Bed System Measurement Devices Test Result Worksheet, on 11/17/22 at 3:27 p.m., lacked indication Resident 61 had a bed rail maintenance assessment was completed. During an interview, on 11/17/22 at 10:51 a.m., the Corporate Support Nurse (CSN) indicated Resident 15 would not be able to manually use the bed rails and put them down on her own. Resident 15 did not have an order or care plan to use or monitor bed rails. During an interview, on 11/18/22 at 9:00 a.m., the CSN indicated she felt Resident 15 was appropriate for bed rails because she was able to push herself up. Maintenance did inspect the bed rails when Resident 15 was in a different room before she moved into a new room. Resident 61 was not appropriate for bed rails. A current facility policy, titled Semi Annual Bed Rail Inspections Life Safety, with a revision date of 5/8/19, indicated to inspect bed rails every six months. A current facility policy, titled Guidelines for the Use of Bed Rails, dated 10/9/17, indicated must ensure correct installation, use, and maintenance. Staff should assess for the potential risk for climbing over, around, between, or through the bedrails. The policy indicated to complete a resident assessment which should include, but was not limited to, medical diagnosis, conditions, symptoms, and behavior symptoms, size and weight, sleep habits, medications, acute medical/surgical conditions, underlying medical conditions, existence of delirium, ability to safely toilet self, cognition, communication, mobility in and out of bed, and the risk for falling. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with professional standards for 2 of 2 residents (Resident 61, 323) and failed to dispose of loose pills in 4 of 7 carts reviewed for medication storage. (Dementia cart, 200 hall cart, 300 hall cart and 600 hall cart) Findings include: 1. During a random continuous observation of a medication cart, on 11/15/22 at 9:20 a.m., located in the 600 hall, an intravenous (IV) bag filled with Penicillin G (a medication used to treat infections) was found lying on top of the cart visible to staff and residents who walked by. No staff were observed next to the medication cart, down the hallway was two housekeeping staff entering a resident's room. At 9:25 a.m., Registered Nurse (RN) 2 walked out of a resident's room about 12 feet from the medication cart. The record for Resident 323 was reviewed on 11/14/22 at 1:30 p.m. Diagnoses included, but were not limited to, neurosyphilis, Alzheimer's disease, and dementia. A physician's order, dated 11/4/22, indicated to give Penicillin G potassium (antibiotic) 3,000,000 units per 50 milliliters by intravenous route every 4 hours until 11/15/22. During an interview, on 11/15/22 at 9:25 a.m., RN 2 indicated the IV Penicillin was left on top of the medication cart unsecured. She left the Penicillin on top of the cart to warm up to room temperature before administering the medication to Resident 323. She was not sure of where she should put the IV bag to warm up to room temperature. 2. During an observation and interview, on 11/16/22 at 9:45 a.m., Resident 61 was observed, in his room, lying in bed. Sitting to the right of his television was a bottle of polymyxin B sulf-trimethoprim (antibiotic for the eyes) and ammonium lactate (medication used to treat dry, scaly skin conditions). The Corporate Support Nurse (CSN) indicated the medication in his room and all medications should be locked and secured in the medication cart or storage room. The record for Resident 61 was reviewed. Diagnoses included, but were not limited to, gastrointestinal hemorrhage, hemiplegia (muscle weakness on one side) and hemiparesis following cerebral infarction affecting left non-dominant side, and dysphagia (swallowing difficulties). A MDS assessment, dated 11/7/22, indicated he was totally dependent on staff for transfers, required extensive assistance with bed mobility, and had a severe cognitive impairment. During an interview, on 11/16/22 at 10:05 a.m., the Corporate Support Nurse (CSN) indicated no medications should be left in resident's room or on the medication cart. All medications be locked up in the medication cart.4. During a medication storage observation, on 11/17/22 at 1:52 p.m., the 300/200 hall medication cart had a bottle of polymyxin eye drops with no label, and five vials of eyes drops were found opened in the cart without an open date. The 600-hall medication cart had 5 vials of opened eye drops without an open date on them. During an interview, on 11/17/22 at 1:55 p.m., the Certified Resident Medication Aide indicated the eye drops should be dated when opened and there should not be loose medications in the cart. A current policy, titled Medication Storage in the Facility, dated 11/18 and received from the Clinical Support Nurse on 11/15/22 at 3:30 p.m., indicated .Medications and biologicals are stored safely, securely and properly .medication storage areas are kept clean, free of clutter .certain medications such as .ophthalmics .once open required an expiration date shorter then the manufacturer's expiration date to insure medication purity and potency 3.1-25(j) 3.1-25(m) 3.1-25(o) 3. During an observation, on 11/19/22 at 12:16 p.m., the medication cart on the skilled dementia unit had two unidentified loose pills in the bottom of the second drawer. The fourth drawer had four unidentified loose pills. During an interview, on 11/19/22 at 12:18 p.m., Certified Resident Medication Aide (CRMA) 10 indicated having loose pills in the bottom of the medication cart was not a good thing. The pills were to be destroyed using the drug buster in the medication room. During an interview, on 11/17/22 at 12:25 p.m., the Dementia Care Director indicated she would investigate the loose pills. During an interview, on 11/21/22 at 9:03 a.m., the Director of Nursing indicated there should not be loose pills in the medication carts. The pills were to be disposed of in the sharps container or drug buster.

Based on observation, interview and record review, the facility failed to ensure a resident's food preferences were accommodated by the facility for 1 of 1 resident reviewed for food preferences. (Resident 323) Finding includes: During an observation and interview, on 11/14/22 at 1:17 p.m., Resident 323 was seated in his chair picking at his teeth with a toothpick. His lunch plate appeared untouched and consisted of one-half inch cut up sausage, cabbage, carrots, and potatoes. The resident indicated he did not like the food because it got caught in his teeth and he would spend an hour digging it out. He had reminded the staff multiple times, when he had not eaten his lunch on other occasions, he had requested a hotdog or bologna which were not provided. It was upsetting he could not receive a hotdog which was something he enjoyed. A physician's order, dated 11/4/22, indicated Resident 323 had an order for a regular diet and thin liquids. A nurse progress note, dated 11/6/22 at 5:55 p.m., indicated a family member reported Resident 323 practiced fasting on Tuesday, Friday, and Sunday until 3:00 p.m. Resident 323 had declined breakfast and lunch but did accept a nutritional drink in the early afternoon. A Dining and Nutrition Preference note, dated 11/6/22 at 9:29 a.m., indicated the resident's favorite foods were chicken and favorite snacks were chips and crackers. A physician's order, dated 11/16/22 at 1:21 p.m., indicated Resident 323 had a regular diet and thin liquids. His order indicated for every meal to serve a hot dog sliced down the middle and cut up into small pieces and Vienna sausages cut up with bell peppers cooked per resident's request. A Dining and Nutrition Preference note, dated 11/17/22 at 7:49 a.m., indicated Resident 323's favorite foods were hot dogs and bologna sandwiches. During an interview, on 11/16/22 at 11:00 a.m., the Kitchen Manager indicated he was not notified Resident 323 had requested and had a preference to have a hotdog or bologna. He could accommodate Resident's 323 food preferences if he was notified. A facility policy, titled Resident Dining and Nutrition Preferences, dated 11/22/17, indicated the resident's preference information will be obtained and be a part of the resident medical record. 3.1-21(a)(4)

Based on observation, interview and record review, the facility failed to serve food in accordance with professional standards for food service safety when four kitchen and dietary staff failed to wear a hair restraint which completely covered the hair while preparing and serving food for 4 of 4 randomly observed kitchen staff. (Cook 1, [NAME] 2, DSA 1 and DSA 2) and failed to store food in a safe and sanitary manner. Findings include: 1. During an initial tour, on 11/14/22 at 12:00 p.m., to 12:24 p.m., with the Dining Service Manager (DSM), two female cooks were walking throughout the kitchen through the food prep area with a black hat on and a ponytail longer than 10 inches sticking out the back unsecured and not covered with a hair net. Dining Service Assistant (DSA) 1 had walked into the kitchen through the dining room door, between the dish room area and the food prep area. An unidentified DSA 2 with black colored hair, pulled on top of her head into a three-inch ponytail had no hat or hairnet on and walked in the kitchen area. The hairnets were located at the back of the kitchen more than 12 feet away near the employee entrance. During an interview, at that time, the Dietary Manager indicated all staff should be wearing a hairnet or wearing a ball cap to secure their hair. He would need to review the facility's policy to whether the long ponytail needed to be secured or covered. 2. During an initial tour, on 11/14/22 at 12:00 p.m., the following one-gallon containers of salad dressing were observed opened, and in a reach-in cooler: a. Buttermilk Ranch dressing with a received date of 10/26/22. b. Thousand Island dressing. c. Caesar dressing. d. Two containers of California French dressing e. Honey Mustard dressing quarter full and had a date received of 7/27/22. During an interview, on 11/14/22 at 12:24 p.m., the DSM indicated the salad dressing containers were opened and lacked indications of when the salad dressing was opened. Staff were expected to remove the received label and replace the label with a new label which would indicate the use by date. During an interview, on 11/16/22 at 11:00 a.m., the Corporate Certified Dietary Manager (CDM) and DSM indicated all staff should be wearing hairnets in the kitchen when food was being prepped. The CDM indicated all containers should be labeled with a received date when the shipment was brought in, and a new label would be placed with an open date to ensure the product was used within the appropriate time frame. A facility policy, titled Hair Restraint, undated, indicated a hat would be worn to effectively keep hair from contacting exposed food. Employees with hair extruded out of the cap will be required to have the hair wrapped into a bun style or tucked under a hat. A food service employee will wear hair restraints while in all food preparations area. A facility policy, titled Food Labeling and Dating Policy, indicated foods were in production when the seal had been broken. The policy lacked indication the staff should document an open date on containers. 3.1-21(i)(1) 3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to ensure an oxygen nasal cannula was dated, failed to ensure a physician's order was followed, failed to ensure a nebulizer mask and tubing were dated, and failed to ensure a resident had an order with BIPAP (machine used to treat sleep apnea) settings for 4 of 4 residents reviewed for respiratory care. (Resident 23, 38, 61 and 18) Findings include: 1. During an observation, on 11/14/22 at 12:51 p.m., Resident 23 was seated in her bed with the head of bed elevated to 50-degrees. Her oxygen tubing was positioned to her right cheek. Her door lacked indication she was on oxygen. No date or label was found on her tubing. She indicated it felt too big and it kept falling off. During an observation, on 11/16/22 at 1:40 p.m., Resident 23 was seated in her wheelchair. Her nasal cannula was observed to be hung over her left leg. Her door lacked indication she was on oxygen. No date or label was found on her tubing. During an observation, on 11/17/22 at 10:29 a.m., Resident 23 was seated in her wheelchair drinking water. Her nasal cannula was hanging under chin. She indicated it kept falling off. Her door lacked indication she was on oxygen. No date or label was found on her tubing. During an observation, on 11/17/22 at 10:58 a.m., to 11/17/22 at 11:08 a.m., Resident 23 was seated in her wheelchair with her oxygen nasal canula under chin. Her door lacked indication she was on oxygen. No date or label was found on her tubing. During an observation, on 11/17/22 at 1:34 p.m., a housekeeper walked into Resident 23's room. Her nasal cannula was lying on her lap. Resident 23 indicated it kept falling off. Her door lacked indication she was on oxygen. No date or label was found on her tubing. Resident 23's physician orders included, but were not limited to, clean external concentrator filters every two weeks, change oxygen tubing monthly, oxygen at two liters per minute by nasal cannula continuous. A care plan, dated 10/4/22, indicated Resident 23 had a functional and cognitive decline related to respiratory disease related to the diagnosis of respiratory failure, shortness of breath, and chronic obstructive pulmonary disease. Interventions included, but were not limited to, monitor oxygen saturations by pulse oximetry as ordered, and administer oxygen per orders. 2. During an observation, on 11/14/22 at 1:01 p.m., Resident 38's oxygen concentrator and portable oxygen tank were observed in the hallway, to the right side, of the resident's door. Resident 38 was seated in his recliner, curled with his knees up, and wrapped in a blanket. His oxygen tubing was unlabeled or dated. The oxygen concentrator was set to three liters per minute. A sign hung on the door frame and indicated no smoking oxygen in use. During an observation, on 11/15/22 at 9:15 a.m., Resident 38's oxygen concentrator and portable oxygen were observed in the hallway, to the right side, of the resident's door. The oxygen tubing was unlabeled or dated and was running under the door. Resident 38 had received oxygen at three liters per minute by his nasal cannula. A sign hung on the door frame and indicated no smoking oxygen in use. During an observation, on 11/16/22 at 9:34 a.m., Resident 38's oxygen concentrator and portable oxygen were observed in the hallway, to the right side, of the resident's door. The oxygen tubing was unlabeled and was running under the door. A sign hung on the door frame and indicated no smoking oxygen in use. Resident 38's oxygen via nasal cannula was turned to 3 liters. The record for Resident 38 was reviewed on 11/16/22 at 9:21 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease with exacerbation, hypertensive heart and chronic kidney disease with heart failure, cardiomegaly, and pulmonary hypertension. Resident 38's physician orders included, but were not limited to, change oxygen tubing monthly, clean external concentrator filter every two weeks on Sunday, use oxygen at four liters per minute by nasal cannula continuously. Resident 38's care profile indicated Resident 38's oxygen concentrator was supposed to be in the hallway, and oxygen set at three liters. During an interview, on 11/16/22 at 12:18 p.m., the Director of Health Services (DHS) indicated the oxygen concentrator was set at three liters per minute and he had orders for four liters per minute. The oxygen tubing was not labeled, and it should have been. 3. During an observation, on 11/14/22 at 9:05 a.m., on Resident 61's nightstand was a nebulizer machine with clear tubing and nebulizer mask connected. The chamber of the nebulizer had a dry white residue and was uncovered and undated. During an observation, on 11/15/22 at 10:30 a.m., on Resident 61's nightstand was a nebulizer machine with clear tubing and nebulizer mask connected. The chamber of the nebulizer had a dry white residue and was uncovered and undated. During observation, on 11/16/22 at 9:45 a.m., on Resident 61's nightstand was a nebulizer machine with clear tubing and nebulizer mask connected. The chamber of the nebulizer had a dry white residue and was uncovered and undated. The record for Resident 61 was reviewed on 11/16/22 at 11:00 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (diseases which causes airflow blockage and breathing-related problems), hypoxemia (below-normal level of oxygen in your blood), and COVID-19. During an interview, on 11/16/22 at 9:45 a.m., the Corporate Nurse Support (CNS) indicated the nebulizer supplies were not covered or dated and were lying on the nightstand. The nebulizer equipment should be cleaned after each use and labeled with a date. This was an infection control issue. During an interview, on 11/18/22 at 9:09 a.m., the CNS indicated if staff noticed a resident did not have the oxygen on, they should replace it or notify the nursing staff. Staff should ensure all respiratory equipment was labeled and dated. 4. The record for Resident 18 was reviewed on 11/16/22 at 11:39 a.m. Diagnoses included, but were not limited to, acute respiratory failure with hypoxia, history of pneumonia with covid, obstructive sleep apnea, and chronic lung disease. A physician's order, dated 1/19/2022, indicated to use the BiPap (a machine to help breathing) at night. No BiPap settings were indicated in the order. A care plan, dated 1/31/22, indicated a potential for complications due to respiratory disease related to obstructive sleep apnea and respiratory failure. Interventions included, but not were not limited to, oxygen per order, monitor lung sounds, and oxygen saturations. There was no intervention for the BiPap at night. A care plan, dated 1/31/22, indicated a potential for shortness of breath while lying flat related to obstructive sleep apnea and respiratory failure. Interventions included, but were not limited to, oxygen per physician's order, and elevate the head of the bed. There was no intervention for the BiPap at night. During an interview, on 11/16/22 at 04:57 p.m., the Corporate Nurse Consultant indicated the BiPap settings would follow the manufacturers guidelines. During an interview, on 11/17/22 at 10:50 a.m., Nurse 6 indicated the BiPap was preset, and the order did not necessarily need to include settings. The resident took the BiPap mask off and did not use it anyway. He would look in the chart to locate settings if he needed to verify them. During an interview, on 11/21/22 at 12:08 p.m., the Clinical Support Nurse indicated the policy for respiratory and medication treatment orders would cover the BiPap settings. The BiPap order was set by the respiratory therapy company. She and the new Director of Health Services indicated the order should include settings for the BiPap. There were no directions for the BiPap order in the medication or respiratory policy. No manufacturer's guidelines were received at the time of exit. A current policy, titled Respiratory Equipment, dated 12/1/21, indicated .mark water bottle with date and initials upon opening and discard after 24 hours .change oxygen cannula and tubing monthly and as necessary A facility policy, titled Administration of Oxygen, dated as revised 5/18, indicated to verify physician's orders, place the nasal cannula around the resident's ears and in the nose, place an Oxygen in Use sign outside the room entrance door, date the tubing for the date it was initiated. Tubing should be changed monthly and as needed and place the nasal cannula into the nostrils and adjust the plastic slide to position to hold in place. A facility policy, titled Respiratory Inhalation Treatments, dated as revised 5/11/16, indicated to clean the equipment and leave to air dry. 3.1-47(a)(6)

6. During an observation, on 11/14/22 at 3:39 p.m., Resident 18 was sitting, in his Broda chair, and snoring during lunch. During an observation, on 11/16/22 at 3:09 p.m., the resident was lying flat, in bed, and was snoring. During an observation, on 11/16/22 at 4:14 p.m., the resident was resting in bed, lying flat, with his eyes closed. The record for Resident 18 was reviewed on 11/16/22 at 11:39 a.m. Diagnoses included, but were not limited to, encephalopathy, urinary tract infection, Parkinson's disease, dementia in other diseases without behavioral disturbances, schizophrenia, anxiety, and depression. A care plan, dated 3/14/22, indicated the resident demonstrated physically abusive and resistive behavior toward staff during hands-on care. Interventions included, but were not limited to, approach resident in a calm manner, and explain the care process. A care plan, dated 3/14/22, indicated the resident demonstrated inappropriate behaviors by putting self on the floor mat. Interventions included, but were not limited to, assess for unmet needs, and determine cause of inappropriate behaviors. A care plan, dated 4/5/22, indicated the resident was at risk for consequences related to receiving antipsychotic medication for Parkinson with psychosis. Interventions included, but were not limited to, administer medication as ordered by physician, observe and report signs of sedation, anticholinergic and/or extrapyramidal symptoms. Current physician's orders included, but were not limited to, Ativan (antianxiety) 1 milligram, Benadryl (antihistamine) 25 milligram, Haldol (antipsychotic) 1 milligram and Reglan (nausea and gastric medication) 10 milligram cream (ABHR cream) 1 packet topical every 4 hours. A psychiatry progress note, dated 4/17/22, indicated the resident was showing increased sexual behavior, by making sexual comments to staff. The resident had episodes of restlessness and anxiety and the primary care doctor ordered Ativan. His wife had indicated he was more tired recently and it could be the Paxil (an antidepressant). The patient was being treated for psychosis with Parkinson's disease with Seroquel 75 milligrams. No psychosis was present the day of visit. A physician's order, dated 7/18/22, indicated to add to the diagnosis of schizoaffective disorder. A psych CAR (clinically at risk) note, dated 7/30/22 at 11:24 a.m., indicated the resident had a diagnosis of schizoaffective disorder as well as psychotic disorder, however, all behaviors related to these diagnoses have resolved. No current issues with mood or behaviors. A psych CAR progress note, dated 8/24/22 at 12:19 p.m., indicated the resident received Seroquel for a diagnosis of schizoaffective disorder. Behaviors have stabilized over the last few months with fewer and fewer episodes. A progress note, dated 10/6/22, indicated new orders were received to discontinue Seroquel and lorazepam and add ABHR cream TID. During an interview, on 11/21/22 at 11:13 a.m., the Social Service Director indicated she was unable to find any documentation as to why a diagnosis of schizophrenia was added. 7. During an observation, on 11/16/22 at 11:00 a.m., Resident 106 was sitting in a recliner, in her room, with her feet elevated. She was smiling and friendly. Her daughter was in the room styling her hair. During an observation, on 11/16/22 at 4:16 p.m., the resident was resting, in the recliner, with her feet elevated and her eyes were closed. The record for Resident 106 was reviewed on 11/16/22 at 11:34 a.m. Diagnoses included, but were not limited to, encephalopathy, delusional disorders, altered mental status, and dementia with behavioral disturbances. A psych CAR note, dated 7/30/22, indicated medications, behaviors, diagnosis, and care plans were reviewed. The resident received Seroquel for delusional disorder. She had a history of delusions. She would become combative with care and would refuse hygiene and medications at times. No psychosocial concerns. A physician's order, dated 9/30/22, indicated Seroquel 50 milligrams twice daily. A diagnosis was not included with the physician's order. A behavioral progress note, dated 10/17/22, indicated the facility had requested an evaluation due to a history of delusions and hallucinations. The resident was taking Seroquel 50 milligrams twice daily. The resident was observed to be calm, cooperative, and pleasant. The resident had a Seroquel increase due to an increase in hallucinations and delusions. No delusions noted during the visit. No hallucinations had been documented or noted by patient recently. A psych CAR note, dated 10/31/22 at 10:25 a.m , indicated Seroquel was continued for the diagnosis of delusional disorder and dementia with behaviors. During an interview, on 11/16/22 at 4:23 p.m., Nurse 6 indicated the resident did not have behaviors. The use of the medication was due to dementia with behavioral disturbances. During an interview, on 11/17/22 at 10:24 a.m., the Social Service Director indicated the resident was admitted with Seroquel due to aggressive behavior and believed the resident had a gradual dose reduction. The resident had hallucinations. The diagnosis of dementia with behaviors was for the use of Seroquel. The resident may have had a urinary tract infection but was not sure if she did. During an interview, on 11/21/22 at 3:01 p.m., the Pharmacist indicated Seroquel was an antipsychotic used for psychosis, hallucinations and delusions related to dementia and agreed this was an off-label use. She would not recommend the use of antipsychotics for the diagnosis of dementia alone. The labeled use for Seroquel was schizophrenia. A recent publication of PDR.net indicated .Depakote was indicated for the treatment of bipolar disorder including mania .the black box warning indicated antipsychotics are not approved for the treatment of dementia-related psychosis in geriatric patients and the use of Depakote in this population should be avoided if possible due to an increase in morbidity and mortality . A recent publication of PDR.net indicated .Risperdal was indicated for the treatment of schizophrenia .the black box warning indicated antipsychotics are not approved for the treatment of dementia-related psychosis in geriatric patients and the use of Risperdal in this population should be avoided if possible due to an increase in morbidity and mortality A recent publication of PDR.net indicated .Haldol (haloperidol) was indicated for the treatment of schizophrenia .the black box warning indicated antipsychotics are not approved for the treatment of dementia-related psychosis in geriatric patients and the use of Haldol in this population should be avoided if possible due to an increase in morbidity and mortality A current policy, titled Psychotropic Medication Usage and Gradual Dose Reduction, dated 11/15/21 and received from the Clinical Support Nurse on 11/21/22 at 2:30 p.m., indicated .residents shall receive psychotropic medications only if designated medically necessary .with appropriate diagnosis, or documentation to support usage .regular monthly review of antipsychotics in CAR (clinically at risk meetings) for continued need, appropriate diagnosis, side effects, risks and/or benefits will be conducted, to ensure the use of psychopharmacologic medications are therapeutic and remain beneficial to the resident 3.1-48(a)(1) 3.1-48(a)(4) Based on interview and record review, the facility failed to ensure residents had an appropriate diagnosis for the use of psychotropic medications and the use of multiple antipsychotics was avoided for 7 of 7 residents reviewed for psychotropic medication use. (Resident 46, 47, 55, 5, 12, 18 and 106) Findings include: 1. The record for Resident 46 was reviewed on 11/16/22 at 11:32 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, dementia with behavioral disturbance, mood disorder, personality change due to known physiological condition, anxiety disorder and depressive disorder. A physician's order, dated 12/3/21, indicated valproic acid solution (an anticonvulsant) 250 mg (milligram)/5 ml (milliliter) give 5 ml by mouth twice a day for a diagnosis of a mood disorder. A care plan, dated 4/14/22, indicated the resident received an anticonvulsant medication. The medication was for the diagnosis of a mood disorder. The approaches included, but were not limited to, administer medications per the physician's order, monitor for adverse side effects of the medication, observe mood, affect, and behaviors with all hands-on care and contacts, and to titrate the medication to the lowest effective dose. A PASARR (preadmission screening and resident review), dated 12/17/21, indicated the resident had no known or suspected bipolar disorder and had a dementia diagnosis. The mental health medication listed was Lexapro (a Selective Serotonin Reuptake Inhibitor) for depression and generalized anxiety, lorazepam (benzodiazepine) for anxiety and valproic acid (an anticonvulsant medication) for seizures. There were no other mental health medications listed on the PASARR A pharmacy recommendation, dated 7/28/22, indicated the resident had been on valproic acid 250 mg twice a day since 12/2021. The resident's chart was reviewed, and the chart reflected no signs of depression and no behavioral disturbances have been documented in the progress notes in the last 30 days. To reach the minimal effective dose, consider a dose reduction to valproic acid 250 mg at bedtime. A progress note, dated 10/31/22 at 10:50 a.m., the Social Service Director (SSD) indicated the resident's mood had remained stable and continued to be social with staff and peers. There were no current psychosocial concerns. During an interview, on 11/21/22 at 11:01 a.m., the SSD indicated the facility physician normally would put the resident on valproic acid when they had a diagnosis of dementia. 2. The record for Resident 47 was reviewed on 11/16/22 at 10:22 a.m. Diagnoses included, but were not limited to, bipolar disorder, schizoaffective disorder (a disorder which affects a person's ability to think, feel and behave clearly), pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder), anxiety disorder, cognitive communication deficit, vascular dementia without behavioral disturbance, psychotic disturbance, and mood disturbance. A PASARR level I, dated 6/11/21, indicated the resident had diagnoses of major depressive disorder, bipolar disorder, anxiety disorder, and dementia. A physician's order, dated 7/24/22, indicated Seroquel (an antipsychotic medication) 75 mg (milligram) at bedtime for hallucinations. A diagnosis of schizoaffective disorder with hallucinations was added 7/18/2022. During an interview, on 11/21/22 at 10:51 a.m., the Social Service Director indicated Resident 47 had a diagnosis of dementia and was on Seroquel for hallucinations. 3. The record for Resident 55 was reviewed on 11/16/22 at 11:06 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, dementia with behavioral disturbance, anxiety disorder, and hallucinations. A PASARR level I, indicated the resident was not on an antipsychotic medication. A diagnosis of hallucinations was added 8/2/22. A physician's order, dated 11/1/22, indicated Risperdal (an antipsychotic) 1 mg tablet at bedtime for hallucinations. During an interview, on 11/21/22 at 10:51 a.m., the Social Services Director (SSD) indicated the resident had a diagnosis of dementia. 4. The record for Resident 5 was reviewed on 11/16/22 at 3:02 p.m. Diagnoses included, but were not limited to, Parkinson's disease, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, depressive episodes, and generalized anxiety disorder. A physician's order, dated 4/1/22, indicated Seroquel (an antipsychotic) 50 mg at bedtime. A physician's order, dated 12/31/22, indicated Nuplazid (an antipsychotic) 34 mg once a day. A progress note, dated 10/31/22 at 11:09 a.m., indicated the resident utilized Seroquel and Nuplazid for a diagnosis of Parkinson's with delusions. The resident continued to have distressing hallucinations on occasion. The Nursing Drug Handbook indicated Nuplazid increased the QT interval (a heart arrhythmia which causes fast, chaotic heartbeats and can cause sudden death) and use with other drugs which increased the QT interval should be avoided. The Nursing Drug Handbook indicated Seroquel can increase the QT interval and use with other medications which increase the QT interval should be avoided. The black box warning indicated the medication was not indicated for use in elderly patients with dementia related psychosis because of the risk of sudden death from cardiovascular disease. 5. The record for Resident 12 was reviewed on 11/15/22 at 4:46 p.m. Diagnoses included, but were not limited to, generalized anxiety disorder, depressive episodes, unspecified dementia with behavioral disturbance, and age-related physical debility. A physician's order, dated 9/1/2022, indicated Seroquel 50 mg once a day for unspecified dementia with behavioral disturbance. A care plan, dated 9/20/22, indicated the resident had a diagnosis of dementia with behaviors such as physical aggression with care which was treated with an antipsychotic medication. The approaches included, but were not limited to, give medications per orders, and monitor for the side effects of the medication. A social services progress note, dated 10/31/22, indicated the resident used Seroquel for a diagnosis of dementia with behaviors such as physical and verbal aggression. The resident's mood and behaviors had been stable since admission. During an interview, on 11/16/22 at 10:49 a.m., the SSD indicated the use of Seroquel with dementia for behaviors was a gray area with the diagnosis dementia.