Based on record review and interview, the facility failed to implement timely and effective interventions to prevent abrasions due to bed placement for 1 of 4 residents reviewed for skin alterations. (Resident B) Finding includes: A record review for Resident B was completed on 3/31/2025 at 9:58 A.M. Diagnoses included, but were not limited to: Alzheimer's disease, diabetes mellitus type 2, neuropathy, overactive bladder and peripheral angiopathy. A Quarterly MDS assessment, dated 1/8/2025, indicated Resident B had moderate cognitive impairment, required substantial/maximal assistance for bed mobility and had a pressure ulcer but no other treatments or open wounds. A Nursing Progress Note, on 12/20/2024 at 11:00 A.M., indicated Resident B had a fall and the intervention was to place the resident's bed against the wall. A Nursing Progress Note, on 1/6/2025 at 12:36 P.M., indicated Resident B had bilateral open areas on their knees. The right knee was scabbed, and the left knee was scabbed and red. Resident B complained of discomfort to the areas, but could not identify how the areas occurred. Triple antibiotic ointment was applied. There were no notes related to the MD/NP being notified or a treatment order. A Nurse Practitioner Progress Note, on 1/8/2025 at 8:04 A.M., indicated Resident B was seen for bilateral knee abrasions. Resident B was unaware of how the abrasions occurred and the abrasions were not related to the fall the resident had incurred the previous week. The plan of care included keeping the areas on the knees open to air and using bacitracin (ointment) sparingly. A Nursing Progress Note, on 1/8/2025 at 1:53 P.M., indicated the areas to the bilateral knees were still present. New orders from the nurse practitioner indicated to cleanse the bilateral knees with wound cleanser, pat dry, apply antibiotic ointment and leave the abrasions open to air. A Nursing Progress Note, on 2/14/2025 at 2:20 P.M., indicated Resident B had rolled to her left side and hit her knee on the wall which had caused an abrasion. The nurse practitioner was notified and an order for bacitracin (antibiotic ointment) was ordered. A Nursing Progress Note, on 3/6/2025 at 2:50 P.M., indicated Resident B had a small abrasion to her left lower leg as Resident B had her left lower leg against the wall when staff had noticed the abrasion. A Physician's Order, dated 3/6/2025, indicated staff were to place pillows against the wall when Resident B was lying towards the wall to prevent pressure sores from the wall. A Care Plan, initiated on 12/8/20022 and updated on 3/6/2025, indicated Resident B was at risk for skin breakdown. The goal was for the skin to stay intact. Intervention included, but were not limited to: have pillows on bed/against the wall dated 3/7/2025. During an interview, on 3/31/2025 at 2:42 P.M., the Director of Healthcare Services (DHS) indicated the facility was placing pillows against the wall for prevention of abrasions, but the pillows did not always stay in place. She indicated the bed was placed against the wall for a fall intervention. A current policy was provided, on 3/31/2025 at 4:17 P.M., by the DHS. The policy titled, Guidelines for General Wound and Skin Care, indicated, .To provide measures that will promote and maintain good skin integrity .4. Use pillows or wedges for positioning to avoid skin to skin contact .Utilize skin protection such as lambs wool This citations relates to Complaint IN00455619 3.1-37(a)

Based on record review and interview, the facility failed to identify a pressure ulcer until it was necrotic and deemed an unstageable ulcer, implement orders for treatment timely and obtain and implement timely nutritional interventions for 1 of 4 residents reviewed for pressure ulcers. (Resident B) Finding includes: A record review for Resident B was completed on 3/31/2025 at 9:58 A.M. Diagnoses included, but were not limited to: Alzheimer's disease, diabetes mellitus type 2, neuropathy, overactive bladder and peripheral angiopathy. A Quarterly Minimum Data Set (MDS) assessment, dated 10/8/2024, indicated Resident B had moderate cognitive impairment, required substantial/maximal assistance for bed mobility and was at risk for pressure ulcer development. A care plan related to the resident's potential for impaired skin, initiated on 12/8/2024 included interventions to conduct weekly skin assessments, use a pressure reducing mattress and pressure reducing chair cushion, use a moisture barrier product to the perineal area as needed, use a lift sheet to avoid sheering, encourage and assist to turn and reposition, float heels as needed and keep resident and linens clean and dry. Resident B had an as needed physician's order for Riley's butt cream, but there was no documentation of the cream used as needed. A Quarterly MDS assessment, dated 1/8/2025, indicated Resident B had an unstageable pressure ulcer that had not been present on admission. A Point of Care (CNA care documentation) entry, dated 12/23/2024, indicated Resident B had received a partial bath. There was no documentation of any impaired skin issue. However, Nursing Progress note, on 12/24/2024 at 7:51 A.M., indicated while changing Resident B an open area to the buttock with blackness in the middle was observed. The Nurse Practitioner was notified, and Riley's butt cream was ordered. An Interdisciplinary Team Progress Note, on 12/26/2024 at 10:25 A.M., indicated a buttock area with one-hundred percent eschar, reddened peri-wound and no drainage was identified. Interventions included skin measurements and weekly reviews at the clinically at-risk meeting. Documentation titled Wound Information, dated 12/27/2024 at 10:13 A.M., indicated an unstageable pressure ulcer, measuring 2.5 centimeters by 2 centimeters was present to the left buttock with necrotic tissue. A Physician's Order, dated 12/27/2024, indicated the following: Riley's butt cream apply a small amount to the open area on the buttock until healed three times a day. A Nutritional Review Progress note, on 12/30/2024 at 4:11 P.M., indicated a recommendation for LiquaCel protein supplement 30 milliliters daily until the wound heals was suggested. A Physician's Order, dated 1/7/2025, indicted the LiquaCel 30 milliliters daily for wound healing had been ordered. A Care Plan initiated, on12/30/2024, indicated Resident B had a left buttock pressure ulcer. Intervention included, but were not limited to: obtain a dietary consult, provide diet, supplements, vitamins and minerals as ordered and treatment per MD order. During an interview, on 3/31/2025 at 1:38 P.M., Certified Resident Care Assistant (CRCA) 3 indicated she was familiar with Resident B care. She indicated she did not need to do much for the resident reagrding bed mobility needs and she was not aware of any pressure ulcer. During an interview, on 3/31/2025 1.43 P.M., LPN 4 indicated weekly skin assessments were completed on shower days and her buttock had turned into something quick. During an interview, on 3/31/2025 at 2:42 P.M., the Director of Healthcare Services (DHS) indicated Resident B was diagnosed with shingles and did not want to get out of bed. She indicated the pressure ulcer was observed during incontinence care. The nurse practitioner was notified and an order for Riley's butt cream was obtained. The DHS indicated the treatment should have started right away when it had been ordered. The DHS indicated the dietician communicated with the facility for nutritional recommendations. A current policy was provided by the DHS, on 3/31/2025 at 4:17 P.M. by the DHS. The policy titled, Guidelines for Pressure Prevention, indicated, .To maintain good skin integrity and avoid development of pressure ulcers .Hygiene .Inspect the skin daily during care for signs of breakdown or changes to the skin. Notify Nurse of changes .Nutrition .Obtain dietary consult to ensure adequate calories, protein, vitamins, minerals, supplements, and/or if deficiencies are noted This citations relates to Complaint IN00455035 3.1-40(a)(1) 3.1-40(a)(2)

Based on record review and interview, the facility failed to notify the physician of medications held for 1 of 1 resident reviewed for physician notification (Resident 4). Finding includes: The clinical record for Resident 4 was reviewed on 10/9/2024 at 1:27 P.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease, chronic kidney disease, heart failure, schizoaffective disorder, psychotic disorder with known delusions, hypertension, bipolar disorder, depression, anxiety, diabetes mellitus, dementia and borderline personality disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 7/18/2024, indicated the resident was taking an antidepressant medication, an antianxiety medication and a diuretic medication. The current Physician's Orders for Resident 4, initiated on 8/22/2023, included Bumetanide medication (diuretic) 1 mg (milligram) 1 tablet orally, twice a day for chronic systolic and diastolic congestive heart failure. A current Care Plan, revised on 7/17/2024, indicated Resident 4 received diuretic medication. Interventions included, but were not limited to: medications per physician orders and report adverse drug reaction as needed. The June 2024 Medication Administration Record (MAR) indicated Resident 4 had the evening Bumetanide dose held due to low blood pressure on the following dates: 6/22/2024 and 6/24/2024. The August MAR indicated Resident 4 had the evening Bumetanide dose held due to low pressure on 8/4/2024. The September MAR indicated Resident 4 had Bumetanide dose held on 9/21/2024 in the evening for low blood pressure, on 9/22/2024 in the morning for low blood pressure and on 9/22/2024 in the evening for a low heart rate. There was no documentation the physician had been notified of the need to hold the Bumetanide medication due to Resident 4's low blood pressure or heart rate. During an interview, on 10/11/2024 at 10:59 A.M., QMA 1 indicated there was no policy or physician orders for parameters to hold diuretics for blood pressure or heart rate for Resident 4. QMA 1 indicated nursing staff should have notified the MD to obtain hold order for the Bumetanide medication. During an interview, on 10/11/2024 at 1:30 P.M., the Director of Nursing (DON) indicated staff should have notified the provider and documented the notification in the Electronic Medical Record (EMR). On 10/11/2024 at 1:34 P.M., the DON provided a policy titled, Physician: Provider Notification Guidelines, dated 12/31/2023 and indicated the policy was the one currently used by the facility. The policy indicated, ensure the resident's physician or practitioner is aware of .change in condition in a timely manner to evaluate condition for need of provision of appropriate interventions for care . 3.1-5(a)(1) 3.1-5(a)(2) 3.1-5(a)(3) 3.1-5(a)(4)

Based on record review, observation and interview, the facility failed to ensure interventions were in place to prevent a deep tissue injury (DTI) wound after admission for 1 of 2 residents reviewed for pressure ulcers. (Resident 105) Finding includes: The record for Resident 105 was reviewed on 10/10/2024 at 1:37 P.M. Diagnoses included, but were not limited to, right hip fracture, diabetes, chronic congestive heart failure and depression. A Hospital Transfer form, dated 10/4/2024, indicated Resident 105 had no skin issues to his heels at the time he was transferred to the facility. Resident 105 had been hospitalized for an acute right hip fracture with surgical repair. A facility admission Observation form, dated 10/4/2024, indicated Resident 105's pedal (feet) pulses were present to both feet and the resident had weakness to both lower extremities. Under the section of the form, titled, Skin impairment, Yes was documented and the form indicated an Occurrence progress note was to be completed and include an assessment. There was no skin impairment assessment completed for Resident 105's right heel upon admission. A pressure ulcer risk assessment, dated 10/4/2024, indicated Resident 105 was a low to moderate risk to develop pressure injuries. A Baseline Care Plan, dated 10/4/2024, indicated a goal for the resident not to develop a pressure ulcer, or if a pressure ulcer was present, the wound would not worsen. Interventions included, but were not limited to, turn and reposition for care and use devices to optimize independent repositioning and transfers. There were no interventions to provide pressure relief to the resident's heels. A Wound Management Detail Report, dated 10/4/2024, indicated Resident 105 had a DTI (deep tissue injury, damage to the soft tissue beneath the skin caused by pressure or shear forces) to the right heel that was present on admission. The wound measured 5 cm (centimeter) length x 5 cm width. There was no other description of the wound. Physician's Orders, dated 10/4/2024, included: Skin prep (fast drying protective dressing) to the right heel 3 times a day as a preventative measure. There was also an order for a preventative foam dressing to the right heel and it was to be changed every 3 days. The orders included instructions to provide pressure relief to the resident's right heel. A Care Plan, initiated on 10/6/2024, indicated Resident 105 was at risk for skin breakdown related to: (the area to indicate where the area was located was left blank). Interventions included, but were not limited to, avoid shearing skin during positioning, turning, and transferring, conduct weekly skin assessments, pay particular attention to resident's bony prominences, encourage and assist the resident to turn and reposition for comfort and as needed and to keep bed linens clean and dry. The plan did not specifically include interventions to prevent pressure on the resident's heels. A Care Plan, initiated on 10/10/2024, indicated the resident had a pressure ulcer, DTI, to the right heel. Interventions included, but were not limited to: Assess and record the condition of the skin surrounding the pressure ulcer, administer analgesics per physicians order, observe and report signs of infection (e.g., localized pain, redness, swelling, tenderness, drainage, odor, and fever), observe for and report signs of pain related to the pressure ulcer, pressure reducing cushion to the wheelchair, treatment per physicians order, notify physician if treatment is not effective, weekly skin assessment, measurement and observation of the pressure ulcer and record, keep the resident as clean and dry as possible, minimize skin exposure to moisture and use a lifting device as needed for bed mobility (e.g. lift sheet, etc.) There were no specific interventions to ensure pressure relief to the resident's right heel. An NP Progress Note, dated 10/11/2024, indicated the resident had undergone a right hip replacement on 9/28/2024. The facility's wound nurse had called and discussed concerns regarding a possible DTI for Resident 105 on 10/6/2024. The wound NP indicated she had given the facility's wound nurse recommendations for the skin prep treatment and routine offloading procedures. The note indicated when she had assessed the resident on 10/11/2024, she noted a stage II pressure ulcer to the resident's right heel. She wrote treatment orders and recommended off-loading heel booties. During an observation, on 10/11/2024 at 9:32 A.M., Resident 105 was observed with shoes on both feet, seated in his wheelchair. The resident's shoes were positioned on the footrest pedals of the wheelchair. During an observation, on 10/11/2024 at 10:40 A.M. with the Wound Nurse Practitioner (NP) and the facility wound nurse, the following was observed on Resident 105's right heel: an opened wound approximately 5 cm (length) x 5 cm (width) with red granulation tissue and specs of a dark purple/black color in the middle and along the right side of the wound bed. The open wound had a white ring around the outside edge of the wound. The Wound NP indicated the area did not have any dead/necrotic tissue and staged it as a stage II pressure ulcer (an open sore or blister that indicated partial thickness loss of the skin). During an interview, on 10/11/2024 at 1:25 P.M., the Director of Nursing (DON) indicated the pressure area to the heel was not present on admission. The nurse had made a mistake when she documented it as present on admission as an ulcer. There was no other documentation in the chart that indicated the DTI was found on admission. The DON indicated the nurse realized she had coded the wound incorrectly on the Wound Management Detail Report, completed on 10/4/2024. The nurse had contacted the Wound NP and the wound should have been identified as in-house acquired. When questioned as to why the current care plan for the foot ulcer did not include specific interventions to prevent pressure on the resident's heels, such as floating his heels, the DON indicated the resident's mattresses were pressure relieving. During an observation, on 10/15/2024 at 12:02 P.M., Resident 105 was seated in the dining room with his feet covered with regular socks and his heels/feet resting on the floor. During an interview, on 10/15/2024 at 1:47 P.M., Resident 105 indicated he wore socks on his feet when he went to bed, but did not wear anything else on his feet. Resident 105 did not indicate staff ever placed a pillow underneath his lower legs to elevate his heels or staff placed booties on his feet. During an observation, on 10/16/2024 at 9:03 A.M., Resident 105 was observed in his wheelchair. His right foot was resting on the floor with a foam dressing adhered to the middle of his foot and his heel exposed. There were no offloading booties in his room, even though the NP had recommended them on 10/11/2024. During an interview, on 10/16/2024 at 9:05 A.M., RN 5 indicated there were no booties located in the room and the resident should have had a bootie on his right foot. On 10/11/2024 at 2:45 P.M., the Director of Nursing provided the policy titled, Guidelines for Pressure Prevention, dated 12/31/2023, and indicated the policy was the one currently used by the facility. The policy indicated . To maintain good skin integrity and avoid development of pressure ulcers. Care plan interventions shall be implemented based on risk factors identified in the nursing assessment. Interventions may include, but not be limited to: .float heels as needed .Elevate heels off the bed- avoid use of heel protectors On 10/11/2024 at 2:45 P.M., the Director of Nursing provided the policy titled, Guidelines for General Wound and Skin Care, dated 12/31/2023, and indicated the policy was the one currently used by the facility. The policy indicated .5. Evaluate the need for a pressure reduction surface for bed/chair .or float heels/boots 3.1-40

Based on record review and interview, the facility failed to administer a physician ordered medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 12) Finding includes: The record for Resident 12 was reviewed on 10/11/2024 at 10:17 A.M. Diagnoses included, but were not limited to: heart failure, dementia, anxiety, depression and Bipolar disorder. The current Physician's orders for Resident 12 included an order for the resident to receive Lorazepam 0.5 mg daily for anxiety and agitation. The Medication Administration Record (MAR), dated August 2024, indicated the resident was to receive Lorazepam 0.5 mg daily for anxiety and agitation. The MAR indicated the resident did not receive the ordered Lorazepam from 8/4/2024 through 8/12/2024. On the section labeled Reasons/Comments was documented Med Not Available, from 8/4/2024 to 8/12/2024, for the Lorazepam. During an interview, on 10/15/2024 at 10:26 A.M., the Director of Nursing indicated the physician should have been notified of the missed doses. During an interview, on 10/15/2024 at 1:38 P.M., the Director of Nursing indicated the nurse should have obtained the medication from the facility's Emergency Drug Kit (EDK) and called the Pharmacy. During an interview, on 10/15/24 at 1:49 P.M., LPN 11 indicated if a medication was not available in the medication cart, she would get in the EDK (emergency drug kit) to get the medications or call the pharmacy. On 10/15/2024 at 4:05 P.M., the Director of Nursing provided the policy titled, Unavailable Medications, undated, and indicated the policy was the one currently use by the facility. The policy indicated .The facility must make every effort to ensure that medications are available to meet the needs of each resident .B. Facility personnel shall: 1). Notify the attending physician of the situation and explain circumstances, expected availability and optional therapy(ies) that are available . 2). Obtain a new order and cancel/discontinue the order for the non-available medication. 3). Notify the pharmacy of the replacement order 3.1-25(a)

Based on observation, interview and record review, the facility failed to ensure infection control practices were followed related to lack of changing gloves and handwashing during perineal care and when administering insulin for 1 of 1 resident observed for incontinence care and 1 of 1 resident observed for insulin injection. (Resident 15) Findings include: 1. During an observation, on 10/10/2024 at 7:25 A.M. Certified Nursing Assistant (CNA) 7 was observed to provide incontinence/catheter care to Resident 15. She washed her hands and donned gloves. She used a washcloth and cleaned the catheter. CNA 7 turned the resident over to her right side, and with wet wipes, she washed the residents' buttocks. There was a smear of feces around the resident's rectum. She then placed the dirty wipes on the soiled brief and removed the brief. Lastly, the aide applied a clean brief and pulled up the resident's pants. CNA 7 then removed her gloves and placed them in the trash can and washed her hands. During an interview, CNA 7 indicated she should have removed her gloves and washed her hands after washing the resident's buttocks. 2. During an observation on 10/10/2024 at 8:55 A.M., QMA 8 washed her hands and donned gloves. She cleansed an area on the resident's right lower abdomen with an alcohol pad and with an opened hand, she fanned the area she had just cleansed During an interview, on 10/10/2024 at 8:56 A.M., QMA 8 indicated she should not have fanned the area. On 10/25/2024 at 4:05 P.M., the Director of Nursing provided the policy titled, Perineal Care for Incontinence, dated 12/31/2023, and indicated the policy was the one currently used by the facility. The policy indicated .7. Pay particular attention to infection prevention and control techniques when performing pericare, to prevent the introduction of contamination that may lead to a urinary tract infection A policy for glove use was requested but none was not provided prior to the survey exit. On 10/15/2024 at 4:05 P.M., the Director of Nursing provided a policy titled, Injectable Medication Administration, with a revision date of 11/2018, and indicated the policy was the one currently used by the facility. The policy indicated: .Expose the area to be injected and clean with an alcohol wipe 3.1-18(b)(1)

Based on interview and record review the facility failed to ensure comprehensive mental health services twere obtained for 1 of 1 resident reviewed. (Resident 29) Findings include: Resident 29's record review, began on 7/20/22 at 1:16PM. Diagnoses included schizo affective disorder, major depressive disorder and bipolar disorder with psychotic features. The most recent MDS (minimal data set) indicated the resident's brief interview for mental status score was 15. The score of 15 indicated there was no cognitive deficit. The MDS (minimal data set) dated May, 30, 2022 indicated under mood his mood severity was 15.The section for behavior the residnet had no hallucinations or delusions In the asseessment dated July 11, 2022, the score for mood severity was documented as 17 and the residnet had hallucinations, delusions and increased rejection of care. The facility indicated in a resident interviewable list Resident 29 was interviewable. Resident 29's current care plan had problems listed related to mental health including: Resident may experience signs and symptoms of depression including tearfulness, isolating himself to room, staying in bed all day, etc. This problem was dated 7/21/22. Interventions included; Refer to psych services as needed dated 7/18/22. Resident was at risk for adverse consequences related to receiving antipsychotic medications for schizoaffective disorder, dated 2/2/22. Resident demonstrates altered behaviors including hallucinations and or delusions, dated 1/5/22. interventions included; record triggers for hallucinations in resident's medical record. Resident met PASRR inclusion criteria because he had a diagnosis of bipolar disorder, major depressive disorder with psychotic features dated 3/10/20 with a goal date 11/1/22. The goal was stated as the resident's needs will be met through the necessary rehabilitation services. Interventions iincluded provide resident with supportive counseling to help resident through hard moments, support well being, and refer for individual therapy dated 3/10/20. Resident may demonstrate non compliance with physician orders and or plan of care as evidenced by refusing activity of daily living care, showers, meals, refusing physician orders and or medication, treatments or therapy diet order, fluid restriction orders, refusing diabetic shoes, wearing 2 pairs of socks at a time, and tying shoes too tight after being educated on consequences; dated 4/22/20. The problems, goals, and interventions did not include refusals of appointments. A review of Resident 29's physician order report from 1/22/22 to 7/23/22 indicated the following orders without any documentation of refused or missed appointments: 2/12/22 Resident to be evaluated and treated by mental health services. 4/23/22 Resident has an appt with hospital heart pavilion please have ready for transport 4/30/22 Resident has an appointment with NP please have ready for transport 6/8/22 Resident has an appoint with Dr. please have ready for transport 7/17/22 Resident has an appointment with NP please have ready for transport. A review of Resident 29's behavior analysis report from certified nurse aids charting dated from 1/1/22 to 7/25/22 indicated 3 shifts daily indicated no behavior occurred, not applicable for the intervention, not applicable for the intervention effectiveness, and no comments. Except for rejection of care documented consistently by one staff member as follows: 1/3/22 on 2nd shift with intervention of offering food or fluids, intervention not effective and with a comment refused x3. 1/6/22 on 2nd shift intervention redirection, intervention not effective, and comment of refused x3. 3/7/22 on 2nd shift intervention redirection, intervention not effective, and comment refused shower x3 and refused to sign shower sheet. 6/27/22 on 2nd shift intervention redirection, intervention not effective and comment refused shower x3 nurse witnessed. 7/4/22 on 2nd shift intervention redirection, intervention not effective, and comment refused shower and dressing x3 nurse witnessed. No other refusals or behaviors were documented. A review of the event reports and observation reports indicated the following reports: An event report on 1/21/22 regarding hallucinations and delusions, possible triggers recent med change, intervention provide snack, and intervention refused. An observation detail list report on 2/2/22 was a discussion of recent psychotropic medication changes and no referrals. An event report dated 4/13/22 regarding picking at skin due to bugs, no possible triggers determined, one on one care for intervention, and not applicable of intervention successful. An even report dated 6/27/22 regarding delusions and hallucinations, with triggers of recent med changes, intervention one on one support, and the intervention successful indicated offer validations and reassurance. No other events or observations were noted. Resident 29 was hospitalized for psychiatric illness in late January and discharged early February. A thorough review of Resident 29's progress notes from February 1, 2022 to present indicated; 2/1/22 Resident was tearful and wanted to know if there was anyone who could help him decide where to go with his life. He was tired of sitting in that room. No event was triggered. 3/4/22 Resident had recent hospital stay and had been isolating to his room. No event was triggered. 3/30/22 Resident stated he was seeing bugs in his room at this time. Staff checked no bugs noted. No event was triggered. 4/13/22 Resident noted picking at scabs to arms and leg stating they are bugs that keep growing back. Resident indicated the bugs are living under his skin. 4/15/22 Resident reported he had small crab like bug crawling in and out of his skin. 4/22/22, 4/28/22, and 5/12/22 team meeting regarding medication changes. 5/13/22 Resident said to nurse, I am feeling a little down 5/22/22 Resident asked, what is going on next door and expressed that he could hear several men talking about him. No event was triggered. 6/9/22 team meeting regarding psych medication changes. 6/23/22 team meeting regarding recent decline and has been refusing to eat or get out of bed. 6/24/22 Resident continues to refuse oral medications related to nausea. Resident stated There are two men in the vents above my bed and I do not know what they want or what they are doing here. Resident indicated he feels safe. 6/28/22 effect is flat. Reports I am not doing well. Resident reports concerns about medical and mental health. 7/5/22 Reports visual hallucinations, I seen a cat and a dog. No event was triggered. 7/5/22 Resident declined shower x3. Strong body odor was noted. No event was triggered. 7/7/22 Resident is exit seeking. Resident voiced a man was standing behind my bed and just stared at him. He is able to go thru the wall and I think he stays in the room behind me. He can see me and talk to you thru the call lights and vents in the ceiling. I know you think I am crazy, maybe you are crazy. Resident stated Call the police, ok if not just let hm go and keep doing what he is doing. No event was triggered. 7/7/22 team meeting resident refusing care and has been withdrawing to room. 7/7/22 still has not showered. 7/8/22 Resident stated, do you see those bugs on the floor and the wall over there. Did not see any bugs in residents room. No event was triggered. 7/8/22 told staff, there are cats. Nursing trapped them in that oxygen machine. No event report triggered. 7/11/22 Resident has been having delusions and hallucinations. Resident has also refused care. 7/12/22 Resident put on call light and when entered room resident was tying his bed sheet to the handle of his closet and could not explain what he was in the process of doing. No event report was triggered. In an interview on 7/20/22 at 9:59AM, Resident 29 indicated he went to a psych hospital and did not like it there. Resident 29 indicated he had asked nursing and social services three times since discharge to speak with someone; a therapist or counselor about his life. Resident 29 indicated he had not seen any mental health advocates, counselors, or therapists. Resident 29 indicated he frequently saw the psych nurse doctor to change his meds. Resident 29 indicated he had frequent med changes, was unsure which ones worked, and which ones caused more issues. Resident 29 indicated he had not refused any therapy appointments either in house or in community. In an interview on 7/22/22 at 3:16 PM the Director of Health Services indicated Resident 29 refused many appointments and had been fired from pain management in the past. During an interview on 7/25/22 at 9:46AM the Director of Social Services (DSS) indicated Resident 29's behaviors were tracked during morning meeting, weekly team meetings, care notes, and progress notes. The DSS indicated Resident 29's psych medications had been changed frequently lately due to hospitalization, pharmacy suggestion secondary to genetic testing, and symptom management. The DSS indicated Resident 29 was set up with counseling services with a provider to come to facility. The provider came once, did not leave any session notes, did not return, and the company had not followed through on getting another therapist to come to facility. The DSS indicated she had no record of when that one session occurred due to lack of documentation. The DSS indicated she had attempted to contract with another provider. The DSS indicated Resident 29 frequently was seen by a psych provider and they had a good relationship. The DSS indicated they had not discussed Resident 29 going out for therapy. A letter provided by the Director of Health Services on 7/25/22 at 12:48PM from a psych nurse practioner, indicated .had may times been referred to and appointments made, for outpatient therapy and he continually refused to go At time of exit there was no further documentation provided of the therapy appointments made or refused by Resident 29. A policy, titled Guideline for Mental Health Wellness Program provided by Director of Health services on 7/22/22 at 1:12 PM, indicated .1.Behaviors that required interventions shall be defined as: a b. A behavior that negatively affects the resident's quality of life 8. The social services director or nursing staff shall initiate a Mental Health Event that will include a 72 hour follow-up.9. The Social Services Director shall review the documentation to determine if the behavior is isolated, causative factor identified, and if re-direction is successful. 3.1-37