**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility provided document, staff interview, and policy review the facility failed to notify a Resident's Representative and the Long Term Care Ombudsman of discharge/transfer of residents as required for 2 of 4 residents reviewed who were discharged /transferred from the facility (Residents #3, #20). The facility reported a census of 26 residents. Findings include: 1. Review of the facility's Census Report, Resident #3 was transferred and hospitalized on [DATE] until he reentered the facility on 10/11/24. The clinical record lacked documentation of notification to Resident #3's Representative and the Long Term Care Ombudsman that Resident #3 had been discharged to the hospital as required by federal regulation. Facility provided document, Notice of Transfer Form to Long Term Care Ombudsman dated 9/27/24-10/27/24 failed to indicated Resident #3's hospital transfer. Review of Resident #3's clinical record documented on 10/7/24, Resident #3's Guardian had called the facility and had expressed concern of not being notified of Resident #3 being sent and admitted to the hospital on [DATE]. 2. Review of facility's Census Report, Resident #20 was transferred and hospitalized on [DATE] until he reentered the facility on 8/17/24. The clinical record lacked documentation of notification to the Long Term Care Ombudsman that Resident #20 had been discharged to the hospital as required by federal regulation. Email communication with the facility's Administrator dated 11/7/24 at 11:07 AM stated August does not have a report (Notification to the Long Term Care Ombudsman) as there were no transfers or discharges. During an interview on 11/7/24 at 3:26 PM the facility's Administrator, acknowledged the facility's failure to notify the Ombudsman of transfer for Residents #3 and #20 and notification to Resident #3's Guardian. The Administrator stated her expectations of accurate notification of resident transfers to the Ombudsman and notification to resident's representative at the time of a resident's transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and policy, the facility failed to submit for an updated Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 1 resident reviewed with a new mental health diagnosis (Resident #7). The facility reported a census of 26 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #7 had a Brief Interview for Mental Status (BIMS) score 15 out of 15 indicating intact cognition. The MDS further documented diagnoses of mood disorders, anxiety, depression, and psychotic disorder. The Care Plan for Resident #7 initiated 1/3/23 revealed the Resident #7 used psychotropic medications that included, antipsychotics, antidepressants, and anxiolytics related to delusional disorder. The PASRR dated 12/1/22 for Resident #7's nursing facility admission revealed diagnoses of anxiety disorder and depressive disorder. The Clinical Record for Resident #7 revealed an updated mental health diagnosis on 3/9/23 of delusional disorder. The clinical record further revealed an updated PASRR had not been submitted following the new diagnosis. In an interview on 11/05/24 at 12:29 PM the Assistant Director of Nurses (ADON) relayed they were familiar with PASRR requirements, must have it prior to nursing facility admit and another screening with changes including a new mental health diagnosis. The ADON acknowledged Resident #7 received a new mental health diagnosis of delusional disorder on 3/9/23 and there should have been a request for an updated PASRR evaluation. In an interview on 11/05/24 at 12:29 PM the Director of Nurses (DON) agreed a new PASRR should have been completed when Resident #7 was diagnosed with delusional disorder. Policy titled Behavioral Assessment, Intervention, and Monitoring, dated 2001 directed new onset or changes in behavior that indicate newly evident or possible serious mental disorder or related disorder should be referred for a Level II (two) PASRR evaluation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review the facility failed to follow professional standards regarding following facility policy, following physician's orders, and failing to notify physician for 2 of 12 residents reviewed (Residents #3 and #23). The facility reported a census of 26 residents. Findings include: 1. While interviewing a resident on 11/04/24 at 11:12 AM, an observation of a medication cup with pills sitting on the resident's bedside table, during conversation the resident picked up the medication cup and took the pills with water also sitting on her bedside table. The Resident's medications were delivered by the nurse, the nurse failed to provide supervision while the resident took the medications. During an interview on 11/07/24 at 3:14 PM, Facility Administrator stated the expectations are for Nurses and/or Certified Medication Aides to be present with residents until the medications have been administered and not leave the medications unattended. 2. Review of Resident #3's Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment. Resident #3 had diagnoses of Stroke, Diabetes Mellitus, and Benign Prostatic Hyperplasia. Review of Consultant Pharmacist Recommendation to Physician document dated 7/31/24 indicated Resident #3 was receiving two drugs with very similar therapeutic activity: Oxybutynin ER 15 mg daily for Overactive Bladder Oxybutynin ER 20 mg daily for Urinary Frequency The facility Physician noted to discontinue the Oxybutynin ER 20 mg dosage and signed on 9/16/24. Notation by a nurse dated 9/19/24 indicated this notation was documented in a Progress Note and the Medication Administration Record (MAR). Review of Resident #3's Progress Notes dated 9/19/24 at 11:23 AM stated, Per pharmacy recommendations discontinue Oxybutynin 20 mg as resident is receiving 2 drugs with very similar therapeutic activity. Reviewed by physician and signed order discontinued. Review of Resident #3 ' s MAR indicated in September: 1. Ditropan (Oxybutynin) XL 10 mg tablet, give 2 tablets by mouth one time a day for urinary frequency in the morning. Order Date 7/24/24, Discontinue date 10/10/24 was administered to Resident #3 every day in September. 2. Oxybutynin Chloride ER 15 mg tablet, give 1 tablet by mouth one time a day in the morning related to Benign Prostatic Hyperplasia. Order date 8/1/24, Discontinue date 10/10/24 was administered to Resident #3 every day in September. Review of Resident #3's MAR indicated in October: 1. Ditropan (Oxybutynin) XL 10 mg tablet, give 2 tablets by mouth one time a day for urinary frequency in the morning. Order Date 7/24/24, Discontinue date 10/10/24 was administered to Resident #3 on 10/1, 10/2, 10/3, 10/5 and discontinued on 10/10/24 2. Oxybutynin Chloride ER 15 mg tablet, give 1 tablet by mouth one time a day in the morning related to Benign Prostatic Hyperplasia. Order date 8/1/24, Discontinue date 10/10/24 was administered to Resident #3 on 10/1, 10/2, 10/3, 10/5 and discontinued on 10/10/24 During an interview on 11/07/24 at 3:14 PM, the Facility Administrator acknowledged the discontinued Oxybutynin order was not accurately processed. The Administrator stated expectations to accurately follow physician's orders and process in a timely manner. 3. The Minimum Data Set (MDS) annual assessment, dated 8/23/24 for Resident #23 listed diagnoses that included diabetes mellitus, coronary artery disease, heart failure, and peripheral vascular disease. The Care Plan focus initiated 3/23/24 documented Resident #23 had Diabetes Mellitus. Interventions included, administer diabetes medication as ordered by doctor, monitor, document for side effects and effectiveness. Review of the October 2024 Medication Administration Record (MAR) for Resident #23 revealed on 10/13/24 at HS (hours of sleep), blood sugar was 461. The Medication Administration Record (MAR) October 2024 for Resident #23 revealed a physician order for Insulin and directed amounts of insulin to be administered based on sliding scale (blood glucose results) directed staff to notify the provider if Blood Glucose (BG) is greater than 400. The clinical record for Resident #23 lacked documentation of physician notification as directed for hyperglycemia (high blood glucose). On 11/06/24 at 11:07 AM the Administrator (interim) relayed they would expect the nurse to inform the physician as the order directed, in addition they relayed could not locate documentation of the provider notification. Facility policy provided titled Acute Change in Condition, Revised February 2022 documented the nurse will notify the residents attending physician or physician on call when there has been specific instruction to notify the physician of changes in the resident's condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #20's MDS dated [DATE] revealed a BIMS score of 00, indicating severe cognitive impairment and diagnoses of Stroke, Aphasia (inability to understand and express language), Gastrostomy status (feeding tube), Tracheostomy status, and Persistent Vegetative state. Review of Resident #20's Care Plan dated 9/19/24 indicated the resident required tube feedings, had a tracheostomy, had a communication deficit with interventions including anticipating and meeting resident's needs. Resident #20 was at risk for skin impairment related to limited physical mobility, need for assistance with ADLs and incontinence with interventions to avoid scratching and keeping resident's hands and body parts from excessive moisture. Keep skin clean and dry. Monitor and document location, size, and treatment of skin injury. Resident #20 had a colostomy and was incontinent of bladder with interventions including use of disposable briefs, check Resident #20 at regular intervals and as required for incontinence. Wash, rinse, and dry perineum and change clothing as needed after incontinence episodes. Resident #20 had an ADL self care performance deficit requiring full assistance of two with all cares, transfers with a mechanical lift, and total dependence on staff for repositioning and turning. Observations on 11/05/24 revealed the following: At 9:02 AM, Resident #20 was observed sitting in a recliner, leaning to the right side with a chuck (absorbent pad) and mechanical lift sling under him. The sling was draped over bilateral shoulders. At 12:02 PM, Resident observed sitting in the same position in the recliner, asleep, tube feeding running. Incontinence chuck and mechanical lift sling under resident with sling draped over bilateral shoulders. At 3:06 PM, Resident #20 observed in the same position, leaning on the right side in the recliner, asleep, tube feeding running. At 3:24 PM, CNA's entered Resident #20's room with a mechanical lift, after completing care a CNA observed exiting with a visibly wet soiled chuck. Observations on 11/06/24 revealed the following: At 9:28 AM, Resident #20 was observed in a recliner with a blanket draped over his lap, mechanical lift sling under resident with left side strap up above shoulder and behind head and the right side strap draped behind his right shoulder. Resident #20 was leaning to the right side. At 11:19 AM Resident #20 observed in the recliner, leaning to the right side, blanket draped over his lap with mechanical lift sling under resident, left side up above left shoulder and behind his head, right strap continued to be draped behind his right shoulder. Resident #20 did not appear to have been moved since the previous observation. Review of Resident #20's Point of Care Report of documented incontinence cares and rolling/repositioning Resident #20, revealed incontinence cares and rolling/repositioning being completed three times a day, once each shift. Review of facility provided Repositioning Policy revision date May 2013 stated residents who are in bed should be on at least an every two hour repositioning schedule. Residents who are in a chair should be on an every hour repositioning schedule. Based on observations, clinical record review, and staff interviews, the facility failed to ensure repositioning for 2 of 3 residents reviewed for positioning and skin care (Residents #4 & #20). The facility reported a census of 26 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #4 documented a Brief Interview for Mental Status (BIMS) of 4 out of 15 indicating severe cognition impairment. The MDS also documented the resident had Moisture Associated Skin Damage (MASD). The MDS coded the resident was dependent for assistance of two (2) or more for toileting, personal hygiene, dressing, and transfers. The Care Plan focus initiated 11/01/20 documented Resident #4 had an alteration in elimination related to decreased mobility and frequent episodes of incontinence and potential for impaired skin integrity. Interventions included to complete peri-care after any incontinent episodes. The Care Plan also documented Resident #4 had self-care deficits, required two assist for transfers, to reposition side to side when in bed and to keep pressure off buttocks as allowed. An observation on 11/06/24 at 08:45 AM, Resident #4 sat in their room in a recliner with a breakfast room tray. An observation on 11/06/24 at 11:24 AM Resident #4 remained in the recliner, stated they needed to go to the bathroom, nursing staff summoned. An observation on 11/6/24 at 11:35 AM, Certified Nursing Assistant (CNA) Staff A and CNA Staff B assisted the resident up from the chair with a lift, that revealed on the chair pad a brownish fluid, appearance of a brown wet stain on the white pad. Further observation on 11/06/24 at 11:40, following transfer of Resident #4 from the chair to the bed via lift, CNA, Staff A and CNA Staff B along with the Director of Nurses, interim (DON) present, proceeded and removed the residents pants after he laid down, liquid bowel movement observed outside of the brief on the side of both legs and residents upper back. Disposable brief removed, resident's skin was cleansed to remove the bowel movement. Resident #4 moaned, appeared uncomfortable, vocal moan each time he was cleansed with each wipe. Following cleanse, Resident #4 buttocks was severely excoriated, multiple areas of bleeding and dark redness. At 11:50 AM CNA Staff B voiced Resident #4 bleeds all the time. On 11/06/24 at 11:50 AM the Director of Nursing (interim) acknowledged Resident #4 excoriated buttocks, asked the CNA, Staff B, how long has resident bottom been like that. The DON applied additional coating of skin cream and relayed it was to soothe Resident #4's discomfort. CNA, Staff B responded, can only do what I can. In an interview on 11/06/24 at 11:51 AM CNA, Staff A and CNA, Staff B acknowledged Resident #4 had not been repositioned in the chair since he got out of bed to the recliner for breakfast. The DON asked at this time if the CNA's had asked if the resident wanted to lie down and Staff B replied could not get to that, indicated they were busy with other residents. CNA, Staff B relayed there was no reposition schedule, stated Resident #4 required a lift with two staff and stated we transfer when we can. In an interview on 11/06/24 at 12:08 PM the DON relayed it is the expectation that dependent residents be encouraged and repositioned every few hours along with routine skin assessments. In an interview on 11/06/24 at 12:19 PM the Assistant Director of Nursing (ADON) relayed the expectation was to reposition every two (2) hours, relayed they had completed a skin assessment on Wednesday and documented as healed. The ADON relayed Resident #4 had chronic skin breakdown and the expectation was resident to be moved by staff from the wheel chair, to bed and to the recliner. The ADON stated standard practice was for staff to reposition Resident #4 every two hours. Policy titled Repositioning, revised May 2013 documented repositioning for preventing skin breakdown, promoting circulation and providing pressure relief, critical for a resident who is dependent upon staff for repositioning. Residents who are in bed should be on at least every two-hour repositioning schedule. Residents who are in a chair should be on every hour repositioning schedule.

Based on staff interview, resident interview, clinical record review, observations, and policy review the facility failed to provide appropriate interventions to minimize or prevent complications of infections for 1 of 2 residents reviewed for urinary conditions (Residents #10). The facility reported a census of 26 residents. Findings include: The Minimum Data Set (MDS) for Resident #10 dated 8/7/24 relayed Resident #10's BIMS score of 10 out of 15 that indicated moderate cognitive impairment. Diagnoses included diabetes, anxiety, depression, lung disease, and renal insufficiency. The Care Plan focus initiated 10/1/24 for Resident #10 documented, had an indwelling catheter related to diagnoses of obstructive uropathy and urinary retention. Interventions included to monitor, record, and report to the provider signs and symptoms of urinary tract infection An Emergency Department Report dated 10/3/24 documented Resident #10 urinalysis report findings included bacteria and included a diagnoses of a urinary tract infection associated with indwelling urethral catheter. A new prescription for Cephalexin (antibiotic) one 500 milligram capsule two times a day for ten days was prescribed. During an observation on 11/04/24 at 12:35 PM Resident #10 walked down the hall with Staff A, Certified Nursing Assistant (CNA). Staff A held on to the resident's gait belt secured around the resident's waist. The catheter tubing dragged on the floor as the resident walked. In an interview on 11/04/24 at 12:36 PM, Staff A, CNA acknowledged the catheter tubing dragged on the floor and stated last week he had a shorter tube so did not realize the tubing dragged. In an interview on 11/05/24 at 01:38 PM, Resident #10 revealed the catheter was put in on 9/20/24 due to the bladder not emptying as it should. Resident #10 reported he had developed a urinary tract infection (UTI) shortly after and required antibiotics to clear up the infection. In an interview on 11/7/24 at 10:04 AM with The Director of Nursing (DON) and the Assistant Director of Nursing (ADON), both relayed and agreed for infection control purposes and to avoid a possibility of a fall, Resident #10 should not have walked as the catheter tubing dragged on the floor. A policy titled Catheter Care, Urinary dated 2009 documented to prevent catheter associated urinary tract infections to be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, staff interviews, and policy review, the facility failed to ensure the medication and treatment cart remained locked in a resident care area when not under staff supervision. The facility reported a census of 26 residents. Findings include: During an observation 11/4/24 at 9:24 AM, the medication cart in the central hallway next to the nurses station was noted to be unlocked with no staff present. During an observation 11/4/24 at 10:38 AM, the treatment cart in the central hallway next to the nurses station was noted to be unlocked with no staff present. Further observations revealed the following: a. 10:38 AM Housekeeper cleaning the dining room floor across from the unlocked treatment cart. b. 10:39 AM a resident self propelled in a wheelchair past the unlocked treatment cart. c. 10:40 AM a staff member walked into the nurses station, another resident self propelled in a wheelchair past the unlocked treatment cart, and a staff member walked passed going down the west hall. d. 10:42 AM 2 staff members exited the nurses station and walked past the unlocked treatment cart. e. 10:44 AM a staff member walked past the unlocked treatment cart. f. 10:45 AM a staff member walking with a resident using a walker, walked past the unlocked treatment cart. g. 10:45 AM 2 staff members walked past the unlocked treatment cart. h. 10:46 AM, Staff D, RN, pulled supplies from the treatment cart, locked it and walked away. Observation on 11/4/24 at 10:56 AM, treatment cart noted to be unlocked and unattended again. Residents and staff continue to pass the unlocked treatment cart. At 11:06 AM Staff D, RN removed 6 individual containers (holding insulin pens) from the treatment cart and placed them on top of the medication cart. Staff D, locked the treatment cart and continued with the medication cart down the west hall. Staff D, entered a resident's room leaving 5 containers (holding insulin pens) unattended on top of the medication cart with staff and residents passing the medication cart. During an interview on 11/07/24 at 3:14 PM, the Facility Administrator, stated her expectations are medication and treatment carts remain locked when not in use or supervised and all medications are to be locked in medication or treatment carts when not being used or supervised. Review of facility provided Medication Labeling and Storage revision date February 2023, stated Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on observation, staff interview, and policy review, the facility failed to store food in accordance with professional standards for food service safety. The facility reported a census of 26 residents. Findings include: On 11/04/24 at 10:46 AM, Initial observation of the kitchen's refrigerators and freezers revealed opened items that were unsealed (open to air), and lacked labeling to identify product, open date, and use by date. During an interview 11/6/24 at 3:39 PM, Dietary Manager acknowledged these items should have been sealed, labeled, and dated when opened. During an interview on 11/7/24 at 3:26 PM the facility's Administrator, stated expectations that all opened and stored foods are to be labeled with identification of product, open date, and expiration date. Review of policy titled Food Receiving and Storage revised November 2022 indicated, all foods stored in the refrigerator or freezer are covered, labeled and dated.

Based on record review, observation, and staff interviews the facility failed to effectively and efficiently maintain the highest well-being of each resident. The facility failed to sustain their Plan of Correction (POC) dated 9/12/23, to ensure required members were present at the quarterly Quality Assurance and Performance Improvement (QAPI) meetings. The facility reported a census of 26 residents. Findings include: Review of the facility citations from their annual recertification survey dated 8/17/23, the facility failed to have the required members present for the quarterly QAPI meetings. The facility put a POC in place on 9/12/23 and failed to sustain it. The attendance sheets for the QAPI meetings held on 12/12/23, 4/18/24, 7/29/24, and 10/8/24 revealed the Director of Nursing (DON) was not in attendance. The attendance sheets for the QAPI meetings held on 12/12/23, 3/22/24, 4/18/24, and 7/29/24 revealed the Infection Preventionist (IP) was not in attendance. In an interview on 11/7/24 at 1:20 PM, the Interim Administrator stated it was the expectation the QAPI committee meet at least quarterly. It was expected that all department heads, the Medical Director and any other staff that wanted to join be present for the meetings. Going forward the meetings would be communicated via outlook calendar and the facility would follow the employee discipline process if the required employees were not in attendance.

Based on record review, staff interview, and policy review the facility failed to have the required members present at their Quality Assurance and Performance Improvement (QAPI) meetings. The facility did not have the Director of Nursing (DON) or the Infection Preventionist (IP) in attendance at all quarterly meetings. The facility reported a census of 26 residents. Findings include: Review of the attendance sheets for the QAPI meetings revealed the required members attended on 9/12/23. The attendance sheets for the QAPI meetings held on 12/12/23, 4/18/24, 7/29/24, and 10/8/24 revealed the DON was not in attendance. The attendance sheets for the QAPI meetings held on 12/12/23, 3/22/24, 4/18/24, and 7/29/24 revealed the IP was not in attendance. In an interview on 11/5/24 at 11:04 AM, the Interim Administrator stated she would look at the attendance sheets and see if she could figure out who the IP was for the listed meetings and if the DON was present but the DON was most likely not in attendance. In an interview on 11/7/24 at 1:20 PM, the Interim Administrator stated it was the expectation the QAPI committee meet at least quarterly. It was expected that all department heads, the Medical Director and any other staff that wanted to join be present for the meetings. Going forward the meetings would be communicated via outlook calendar and the facility would follow the employee discipline process if the required employees were not in attendance. Per a facility provided policy titled QAPI Meeting Management, last revised 8/19, the Risk Management/QAPI committee was to consist of no less than 5 members. Members were to be appointed by the Administrator and would include, but not limited to: Administrator, Director of Nursing, Infection Preventionist, Medical Director or Physician designee, and at least two additional facility staff.

Based on record review, staff interview, and policy review the facility failed to provide licensed nurse coverage 24 hours a day 7 days a week. Review of the Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 3 2024 (April 1 through June 30) revealed the facility failed to provide licensed nurse coverage 24 hours per day on 5/7/24, 5/11/24, 5/13/24, 5/19/24, 6/15/24, 6/29/24, and 6/30/24. Findings include: In an interview on 11/6/14 at 1:49 PM, the Interim Administrator stated they had their time cards through another company at the time of the reported dates on the PBJ Staffing Data Report and she would try to obtain the information from them. In an interview on 11/7/24 at 10:55 AM, the Interim Administrator stated the facility would not be able to get the information for licensed nurse coverage until 11/8/24 at the earliest. On 11/7/24 at 10:56 AM, Staff C, Certified Medical Assistant (CMA)/Scheduler provided a list of licensed nurse coverage staff for the dates the facility was reportedly missing licensed coverage. Staff C reported per the facility records the coverage was provided by the following staff but they were waiting on verification of punch details for the facility staff. The list revealed the following: 5/7/24 - 6:30 AM - 6:45 PM Licensed Practical Nurse (LPN) (agency) and 4:15 PM - 6:15 AM Registered Nurse (RN) (agency) 5/11/24 - 6:00 AM - 6:30 PM RN (agency) and 6:00 PM - 6:00 AM RN (facility) 5/13/24 - 6:00 AM - 6:30 PM RN (facility), 6:00 PM - 10:00 PM RN (facility), and 10:00 PM - 6 AM LPN (facility) 5/19/24 - 6:00 AM - 6:00 PM LPN (facility), 6:00 PM - 6:15 AM LPN (agency) 6/15/24 - No information provided 6/29/24 - 6:00 AM - 6:15 PM RN (agency) and 5:34 PM - 6:00 AM RN (agency) 6/30/24 - 4:00 AM - 6:00 PM RN (agency) and 5:45 PM - 7:15 AM RN (agency) In an interview on 11/7/24 at 1:25 PM, the Interim Administrator stated it was the expectation the facility provides 24 hours licensed nurse coverage daily. The facility did provide time cards from the staffing agency to verify the shifts that agency nurses worked for the above dates. In a facility provided policy titled Departmental Supervision, Nursing, revised 8/22, stated a licensed nurse (registered nurse (RN)/licensed practical nurse (LPN)/licensed vocational nurse (LVN)) was to be on duty twenty-four hours per day, seven days per week, to provide resident care services and supervise the nursing services activities provided by unlicensed staff. A licensed nurse was to be designated as a charge nurse on each shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, policy review, Facility Assessment and Payroll Based Journal (PBJ) review the facility failed to ensure appropriate staffing, lacked Registered Nursing (RN) coverage and lacked a Director of Nursing (DON) on four days. The facility reported as census of 26 residents. Findings include: 1. On 11/04/24 at 10:00 AM upon entrance to the facility , the Assistant Director of Nursing (ADON) relayed the Director of Nurses (DON) left last Wednesday 10/30/24 without notice and there was no DON covering as of yet. The Minimum Data Set (MDS) dated [DATE] documented Resident #7 had a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating intact cognition. On 11/04/24 at 11:14 AM Staff #7 relayed, they definitely needed more staff. The DON just up and quit and the Administrator quit, there are many temporary staff and definitely needed staff improvements. The Facility Assessment updated 8/5/24 documented the resources needed to provide competent support and care for resident population every day and during emergencies. It included a general staffing plan to ensure sufficient staff to meet the needs of the residents at any given time is as follows, DON, RN full-time Days. The type of staff members, health care professionals, and medical practitioners needed to provide support and care for residents included Administrator and DON. 2. The Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 3 2024 (April 1- June 30) reported the facility lacked 8 hours of Registered Nurse (RN) coverage on the following dates: 4/20/24, 5/4/24, 5/5/24, 6/1/24, and 6/2/24. In an interview on 11/6/14 at 1:49 PM, the Interim Administrator stated they had their time cards through another company at the time of the reported dates on the PBJ Staffing Data Report and she would try to obtain the information from them. In an interview on 11/7/24 at 10:55 AM, the Interim Administrator stated the facility would not be able to get the information for RN coverage until 11/8/24 at the earliest. The facility failed to provide any information or verification of RN coverage for 4/20/24, 5/4/24, 5/5/24, 6/1/24 or 6/2/24. Review of the facility provided nursing schedules for the time period of 10/1/24 through 11/7/24, the facility reported the contracted Director of Nursing (DON) provided the RN coverage for 17 days in October, but on 9 of those days the DON was either not present in the facility or did not work 8 hours. The punch detail revealed the following: 10/6/24 - No RN coverage in house 10/7/24 - RN coverage for 7.5 hours 10/9/24 - RN coverage for 7.5 hours 10/10/24 - RN coverage for 6.5 hours 10/15/24 - RN coverage for 7.5 hours 10/19/24 - RN coverage for 5.5 hours 10/20/24 - RN coverage for 4.3 hours 10/28/24 - No RN coverage 10/29/24 - No RN coverage In an interview on 11/7/24 at 1:25 PM, the Interim Administrator stated it was the expectation the facility provides a minimum of 8 hours RN coverage daily. In a facility provided policy titled Departmental Supervision, Nursing, last revised 8/22 stated a registered nurse provides services at least eight consecutive hours every 24 hours, seven days a week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to accurately document pressure ulcers for 1 of 3 residents reviewed (Resident #1). During the record review of Resident #1's record, the assessments revealed inconsistent documentation related to their wound on their right buttock. As the wound declined, the facility failed to update the stages of the pressure ulcer with worsening changes. The facility reported a census of 27 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Regardless of the staging system or wound definitions used by the facility, the facility is responsible for completing the MDS utilizing the staging guidelines found in the RAI (Resident Assessment Instrument) Manual. Stage 1 Pressure Injury: Non blanchable erythema of intact skin Intact skin with a localized area of non blanchable erythema (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes of intact skin may also indicate a deep tissue PI (see below). Stage 2 Pressure Ulcer: Partial thickness skin loss with exposed dermis Partial thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage including incontinence associated dermatitis, intertriginous dermatitis (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Ulcer: Full thickness skin loss Full thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. Stage 4 Pressure Ulcer: Full thickness skin and tissue loss Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI. Unstageable Pressure Ulcer: Obscured full thickness skin and tissue loss Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur. Other staging considerations include: o Deep Tissue Pressure Injury (DTPI): Persistent non blanchable deep red, maroon or purple discoloration Intact skin with localized area of persistent non blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure ulcer. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. Resident #1's Minimum Data Set (MDS) assessment dated [DATE], reflected they had no pressure ulcers during the assessment lookback period. The History And Physical dated 8/5/24 documented Resident #1 saw the wound clinic for a furuncle (also known as a boil, is a painful, pus filled bump on the skin that results from a bacterial infection of the hair follicle). The Weekly Skin Assessment - V5 dated 7/24/24 reflected Resident #1 had an abscess to his right buttock that measured 1.8-centimeter (cm) length by (x) 0.6 cm width x 0 depth, no stage. The Weekly Skin Assessment - V5 dated 7/30/24 indicated Resident #1 had an abscess to his right buttock that measured 2.1 cm length x 0.6 cm width x 0 depth, no stage. The Weekly Skin Assessment - V5 dated 8/6/24 indicated Resident #1 had a abscess to his right buttock that measured 2.4 cm length x 1.8 cm width x 0 depth, stage I. In addition, he had a skin tear to his buttock that measured 1.7 cm length x 0.4 cm width x 0.1 cm depth, stage II. The buttock had thin, watery, clear drainage. The Weekly Skin Assessment - V5 dated 8/13/24 indicated Resident #1 had an abscess to his right buttock that measured 3.8 cm length x 3.5 cm width x 0 depth, stage I. In addition, he had a skin tear to his buttock that measured 1 cm length x 0.4 cm width x 0.1 cm depth, stage II. The right buttock had thin, watery, pale, red/pink drainage. The Weekly Skin Assessment - V5 dated 8/20/24 indicated Resident #1 had three abscesses to his right buttock. a. Type: Redness - Abscess that measured 10.5 cm length x 18 cm width x 0 depth, Not Applicable (N/A) stage. b. Type: Blackened - Abscess that measured 6.8 cm length x 7.7 cm width x 0 depth, N/A stage. c. Type: Abscess that measured 1.1 cm length x 1.1 cm length x 0.1 cm, stage II. i. The 2 abscesses on the right buttock had a scant amount of purulent drainage (a thick, milky consistency, with a green or yellow appearance indicating an infection) with hardness noted to the surrounding skin/wound edges. During an interview on 8/26/24 at 2:25 PM Staff A, Registered Nurse, reported it is different each week who did the skin assessments, as it is the nurses on the floor who complete them each week. When asked if they had any training on skin assessments she reported the facility didn't have special training. She reported each nurse may measure and document things differently. She reported Resident #1 had a boil that turned into an open pressure area. During an interview on 8/26/24 at 3:07 PM, the Advanced Registered Nurse Practitioner (ARNP) reported it changed very quickly. She voiced she didn't like the inconsistency in documentation for the wounds because it made it hard to determine what it looked like until she saw it on rounds. She saw Resident #1 the day the facility sent him to the hospital. That is why they ordered labs and did the creatinine level, he was sent out. He had black necrotic tissue over a pressure area. During an interview on 8/26/24 at 3:25 PM the Nurse Consultant reported the facility had inconsistency in their skin assessments. She reported that she didn't know why they staged Resident #1's skin tear if it wasn't a pressure ulcer. She added the facility didn't have consistent staging with each assessment. The Skin Care and Wound Management policy dated June 2015 defined a pressure ulcer as a localized injury to skin and/ or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction. Monitor for consistent implementation of interventions and effectiveness of the interventions

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, document review and staff interview, the facility failed to ensure licensed nurse coverage 24 hours a day. On 6/15/24 the night nurse clocked out at 6:45 AM and the day nurse clocked in at 8:41 AM The facility did not have a licensed nurse on duty, in house during that time frame. The facility staff contacted the Director of Nursing (DON) and the Administrator who failed to act to immediately to provide licensed coverage. The facility identified 15 diabetic residents, 8 of whom are insulin dependent with one resident (Resident #7) who had a blood glucose reading of 65, during the time the facility didn't have no licensed nurse coverage. In addition, the facility had one resident (Resident #2) had a tracheostomy that required suctioning three times a day (TID) and as needed. The facility identified a census of 28 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] reflected they sometimes could make themselves understood and sometimes understood others. The MDS identified Resident #2 had severely impaired cognitive skills for decision making. Resident #2 required total assistance with rolling side to side and transfers. The MDS included diagnoses of stroke, aphasia (inability to speak), and a tracheostomy. Resident #2's June 2024 Treatment Administration Record (TAR) included the following orders: a. Suction free of mucus and crusting at least 3 times a day with application of sterile saline suctioning as needed. b. Use humidified air to the tracheostomy as much as possible. c. Keep the area around the stoma area free of crusting and debris with gentle cleansing with half strength hydrogen peroxide solution every hour as needed. d. Provide trach cares, including removing and cleaning of the inner cannula. On 7/31/24 at 12:15 PM Staff B, Registered Nurse (RN), demonstrated the emergency tracheostomy supplies and suction equipment located in Resident #2's bedside stand. Resident #2 required total assistance of 2 staff for repositioning and couldn't respond to verbal instructions. Staff B reported only a licensed nurse could provide suctioning and care of the tracheostomy and if the tracheostomy became dislodged or pulled out, the resident would need immediate intervention and transfer to the hospital. 2. Resident #7's MDS assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 4, indicating severely impaired cognitive skills for decision making. The MDS listed Resident #7 as independent with sit to stand and chair to bed transfer. The MDS included diagnoses of stroke, intellectual disability, and diabetes mellitus. The Care Plan Focus revised 2/20/24 indicated Resident #7 had diabetes mellitus type 2. The Interventions directed staff the following: a. Provide diabetic medication as ordered. b. Monitor and document for side effects and effectiveness. c. Monitor, document, report to provider signs and symptoms of hypoglycemia (low blood sugar less than 80) and hyperglycemia (elevated blood sugar greater than 150). Resident #7's June 2024 TAR included an order for Fiasp FlexTouch 100 unit/ml (insulin) pen injector, inject as per sliding scale three times a day dated as ordered 3/6/24. The TAR included the following blood sugar readings in the AM (morning) and insulin units injected: 6/14/24 Blood sugar 533 required 15 units of insulin, 6/15/24 65 required no insulin. During an interview on 7/30/24 at 2:28 PM, Staff C, Licensed Practical Nurse (LPN), stated on 6/15/24 she called and reported to the DON she would be late. Staff C responded when she arrived at the facility the other nurse had already left. The facility didn't have a nurse at the facility during that time. She reported being very surprised that the nurse left, leaving the facility without a licensed nurse. She expected the facility have a licensed nurse on duty at all times. In an interview on 7/31/24 at 11:25 AM Staff D, Certified Medication Aide (CMA), said on 6/15/24 Staff E, Agency Registered Nurse (RN), informed her about Staff C being on her way and then she left, leaving the facility without a nurse. Staff D recalled that Staff E left at approximately 6:45 AM and Staff C didn't arrive for a couple of hours. Staff D stated she got the residents' blood sugars because it was in her scope of practice, however, she wouldn't be in her scope of practice to administer insulin or assess a resident with a low blood sugar. Staff D recalled having concern with Resident #7's low blood sugar reading as his blood sugar varies a lot from day to day. She recalled that he didn't show symptoms when really low or really high blood sugars. Staff D added she would have referred the blood sugar reading of 65 to the nurse to assess and direct interventions or monitoring. Staff D reflected being nervous about a fall, Resident #2's tracheostomy, and the diabetic residents. She added if Resident #2's tracheostomy came out she couldn't reinsert it, because not within her scope of practice. Staff D stated the expectation is to have a nurse present in the facility at all times. During an interview on 7/31/24 at 11:45 AM Staff F, CMA, stated she worked the day shift on 6/15/24. She saw Staff E leave the facility and get in a car in the parking lot at 6:45 AM. Staff D informed her they didn't have a nurse in the facility. She took Resident #7's blood sugar and if she had a nurse in the building, she would have notified them of a reading of 65. Then she would give orange juice or whatever the nurse directed her to do. Staff F stated she called the Director of Nursing (DON), however, she didn't answer the phone or respond to the multiple text messages sent. In an interview on 7/31/24 at 11:53 AM Staff G, Housekeeper, stated on 6/15/24 when she arrived to work around 8:00 AM, she learned the night nurse left and the day nurse hadn't arrived yet. So, she notified the Administrator that the facility still didn't have a nurse. Staff G provided a screenshot of the text she sent to the Administrator at 8:25 AM that included: the nurse left at 6:45 AM and so it's been almost two hours without a nurse in the building. At 8:32 AM the Administrator responded: Yes, we already spoke with her. She understood, the facility should always be a nurse on duty 24/7. In an interview on 8/1/24 at 10:53 AM Staff E stated on 6/15/23 she worked a 12-hour shift. At 6:15 AM she called Staff C who told her she overslept and was on her way. Staff E stated Staff C told her to just go ahead and go because she would be in soon. Staff E added she called the DON who also instructed to go ahead and go because Staff C would be in soon, and she, would also be at the facility soon. Staff E responded the expectation is to have a licensed nurse at the facility at all times. During an interview on 7/31/4 at 8:10 AM the Interim Administrator provided documentation that Staff C arrived at the facility on Saturday 6/15/24 at 8:41 AM and the night nurse, Staff E clocked out at 6:45 AM. The review of the staffing sheet documented the facility didn't have a nurse on duty during that time. The Interim Administrator stated she didn't know the facility didn't have a nurse on 6/15/24. She added she would have expected the Agency Nurse to stay and the DON come in when she became aware the facility didn't have licensed nurse coverage. She expected the facility have a licensed nurse in the facility at all times. The Interim Administrator responded the facility didn't have a formal policy regarding nursing staffing, as the facility would follow regulations. Further interview on 8/1/24 at 12:57 PM the Interim Administrator reported the facility did not have a medication administration policy nor a policy on tracheostomy care, but expected a licensed nurse would administer insulin and perform tracheostomy care and suctioning. Review of the staffing agency invoice revealed Staff E clocked out at 6:45 AM on 6/15/24. Review of an Employee Timesheet for Staff C revealed on 6/15/24 Staff C clocked in at 8:41 AM. A facility document titled Nursing Staffing Information revealed on 6/14/24 listed Staff E as the nurse on duty from 6:00 PM until 6:00 AM on 6/15/24. The form listed Staff C as scheduled for the 6:00 AM to 6:00 PM shift on 6/15/24. The form didn't have other nurses on the schedule. The facility provided a typed document that identified 15 residents with a diagnosis of diabetes, with 8 insulin dependent.

Based on observations, document review, menu review, and staff interview the facility failed to follow the planned menu for residents on all diet types. The facility identified a census of 28 residents. Findings include: Observation of lunch meal service on 7/30/24 from 11:15 AM through 12:20 PM revealed the unsigned dietary menu intended for Tuesday 7/30/24 lunch listed: cheeseburger on a bun, French fries, creamy coleslaw, scotcheroo bars, and milk. The meal observed to the residents included: Ham salad sandwich, French fries, beets, a cookie and milk. Review of the unsigned Week 1, Regular NAS (no added salt) Tuesday menu for the facility dated for the week that started on Sunday 7/28/24 directed: cheeseburger on a bun, French fries, creamy coleslaw, scotcheroo, and milk. Interview on 7/30/24 at 3:30 PM the Dietary Manager said she didn't know the Dietitian didn't sign the current menu and couldn't locate a signed menu. The Dietary Manager added they made some last-minute changes to the menu and didn't have the Dietitian approve. In addition, she didn't know the Dietitian had to approve the change prior to implementation. Interview on 7/30/4 at 3:30 PM the Corporate Dietitian stated she usually signed the approved menus and if the menu didn't have a signature, then she must have missed it. The Dietitian further stated she expected the facility staff to follow the menu and if they had changes she would review, approve and sign off before they served the meal. She responded no one told her about the changes to that day's menu. Interview on 7/30/24 at 11:15 AM Staff A, Cook, reported they couldn't always to follow the menu, so, sometimes they had to improvise. She said they had to improvise that day because the facility didn't have the items on the menu, so they had to improvise with what the facility had available.

Based on observation and staff interview, the facility failed to protect food from contamination during meal service. The facility reported a census of 28 residents. Findings include: During lunch service observation on 7/30/24 at 11:22 AM, Staff A, Cook, served ham salad sandwiches, French fries, beets and cookies. Under constant observation Staff A repeatedly touched the ham salad sandwiches with a gloved hand to steady the sandwich while cutting. The continued observation revealed Staff A touched a variety of surfaces with gloved hands including, but not limited to: the outside of the hamburger bun bag, the surface of the counter, the scoop handle, tong handle, serving lids, and her cheek. She repeatedly handled the ready to eat ham salad sandwiches and French fries with the contaminated gloves. The staff directly served the ham salad sandwiches and French fries to the residents. During an interview on 7/30/24 at 3:30 PM, the Dietary Supervisor stated she noticed Staff A repeatedly touch the ready to eat food with contaminated gloves during the meal service. The Dietary Supervisor stated she expected the staff to handle food to prevent food borne illness and not to touch ready to eat food with bare hands or contaminated gloves. The Food Code version 1/18/23 directed that food employees must not touch ready to eat food with their bare hands and must use suitable utensils such as deli tissue, spatulas, tongs, single use gloves or dispensing equipment. The Food Code further required food employees to clean their hands immediately before engaging in food preparation, including before donning gloves for working with food, and as often as necessary to remove soil and contamination in order to prevent cross contamination when changing tasks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to have accurate code status directives available to their staff for 2 of 16 residents reviewed (Residents #17 and #33). Resident #17 had a Do Not Resuscitate (DNR) directive in the front book and a full code/CPR directive in her electronic record. Resident #33 did not have any code status direction in the book. The facility reported a census of 32 residents. Findings include: On [DATE] at 12:41 PM, Staff O, Certified Medication Aide (CMA), stated that Code Status was found in the front book and in PCC (Point Click Care-electronic health record). Staff O stated that if there was an emergency that she would look in the computer because she is typically on the computer. Staff O stated that if she wasn't in the computer, she would look in the book to find the code status direction. During record review on [DATE] at 12:54 PM, it was found that Resident #17 had a DNR IPOST (Iowa Physician Orders for Scope of Treatment) dated [DATE] in the book and in the electronic health record (PCC) it documented Resident #17 was to be a Full Code/CPR. On [DATE] at 12:54 PM , Resident #33 had No IPOST (or any other code status direction) in book, it documented DNR in PCC. On [DATE] at 1:18 PM, the Administrator, Acting Director of Nursing, and Staff N, Clinical Regional Nurse, all stated Resident #17's conflicting code status directives was an issue. They were going to take care of it right away. The Acting DON thought that Resident #33's IPOST was placed in the book, but they must have forgotten to do it. The Acting DON stated she had looked that one up herself. An Emergency Care/CPR Policy revised on 6/2023, directed staff that: the facility provides Basic Life Support (BLS) CPR only. The physician's order for full code or Do Not Resuscitate is written based on the wishes of the resident/resident representative or legally authorized party. Advanced Directives will be honored during the code process. A Do Nor Resuscitate (DNR) order- Cardiopulmonary resuscitation will not be initiated in the absence of pulse or respirations. Code status physician's order (DNR or Full Code) will be filed as the first document within the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure that residents had the right to be free from abuse, and exploitation for 4 out of 4 residents reviewed (Resident #17, #20, #136, and #187). The facility must not allow verbal, mental, physical or sexual abuse. Resident #18 was found kissing resident #20 and inappropriately touched Residents #136 & #187. These residents had diminished cognitive functioning. Resident #18 was found sitting in Resident #17's doorway and would not leave when she asked him to, causing Resident #17 fear. The facility was aware of these and other incidents but failed to put interventions into place that would prevent Resident #18 from further exploiting female residents. The facility reported a census of 32. Findings include: 1. Minimum Data Set (MDS) dated [DATE], documented that diagnoses for Resident #136 included non-Alzheimer's dementia. A Brief Interview for Mental Status (BIMS) documented that Resident #136 scored an 8 out of 15, which indicated Resident #136 had moderately impaired cognition. Resident #136 required extensive assist of 1 for transfers, ambulation, and dressing. A Progress Note for Resident #136 dated 6/25/22 at 1:54 PM, documented the following: Notified at this time by staff that resident had been touched by another resident in her genital area over her clothing. Assessed resident to ensure no injury was done to her person, no injuries observed, resident denies pain or discomfort. Resident alert and oriented to self only per usual, very smiley and pleasant at this time. Resident's family notified of incident and precautions taken to prevent future incidents, stated thank you for letting us know. Notified physician via phone, no new orders given. 2. A Minimum Data Set (MDS) dated [DATE], documented that diagnoses for Resident #17 included Post Traumatic Stress Disorder (PTSD). It documented that this resident admitted to the facility on [DATE]. A Brief Interview for Mental Status (BIMS) documented that Resident #17's BIMS score was 7, which indicated Resident 17's cognition was severely impaired. Resident required extensive assist of 2 for transfers, bed mobility, and locomotion. A Minimum Data Set (MDS) dated [DATE], documented that this resident's BIMS score had increase to 15 out of 15 which indicated intact cognition. On 5/18/2023 at 5:24 AM, a Progress Note from Resident #18's chart documented the following: Resident #18 was sitting in the doorway of room [ROOM NUMBER] (Resident #17's room). When CNA asked what he was doing he said, just watching. CNA told him he cannot be sitting in people's doorways watching them, he went back to his room. When CNA asked resident in room [ROOM NUMBER] what he was doing or if he said anything she said No, he was just sitting there watching me. There was no documentation of this incident in Resident #17's Progress Notes. On 8/10/23 at 8:44 AM, Resident #17, when asked about a resident watching her from the doorway in the middle of the night, she stated 'you mean (Resident #18's name)?, Oh yes.' Resident #17 stated she told him not to come into her room. She said she was scared at the time. She stated she was really sick at the time and just wanted him to go away. She stated he hasn't done that since. Resident #17 said she's much better now and she thinks he knows better. She said if a resident would try to fondle her, she would tell them to stop and to get away from her. 3. A MDS dated [DATE], documented that Resident #20's diagnoses included Alzheimer's disease. It documented that this resident admitted to the facility on [DATE]. A BIMS documented a score of 9 out of 15, which indicated Resident #20's cognition was moderately impaired. This resident required supervision for transfers and ambulation. A MDS dated [DATE], documented that this Resident's BIMS score had decreased to 3 out of 15, which indicated severely impaired cognition. This resident required an extensive assist of 1 for transfers, ambulation, and locomotion. A Progress Note for Resident #20 documented the following: Staff witnessed in the Dining room prior to supper a male resident (Resident #18) kiss a resident on the lips as if they were making out with only lips touching lips and no other physical contact noted. Immediately removed residents from each other. Placed male resident on watch for 1on1 with staff. Call placed to make admin., DON, provider, and brother aware. 4. A MDS dated [DATE], documented that Resident #187's diagnoses included Alzheimer's. It documented that this resident admitted to the facility on [DATE]. The facility showed no score for the BIMS for this resident. This MDS documented that Resident #187 had hallucinations and delusions. This resident required assistance of 1 for transfers and ambulation. A Progress Note for Resident #187 dated 5/7/23 at 8:01 PM, documented that Resident was observed being touched by another Resident (Resident #18). When this writer approached Resident, she stated that this other Resident is her husband then also her son. Tried to have the Resident walk up to lobby but was followed. Resident is extremely agitated at this point. States she is going home and that her husband/son is going with her. A Progress Note for Resident #187 dated 7/4/23 at 12:35 AM, documented: a CNA was yelling down the hall for a nurse. When the nurse got to the room, she found Resident #18 in Resident #187's room and the CNA was telling Resident #18 that he cannot be in other residents' rooms. Resident #18 was upset and mad that he was told to get out of female residents' room, he would not tell us why he was in her room or what he was doing. Resident #18 was removed from Resident #187's room. Nurse did assessment on Resident #187, who was upset and startled from being woken up. ADON (Assistant Director of Nursing) notified, and Administrator notified - (administrator is reporting incident). 5. A MDS dated [DATE], documented that Resident #18's diagnoses included dehydration and alcohol dependence in remission. It documented that this resident admitted to the facility on [DATE]. This Resident had a BIMS of 9 out of 15, which indicated moderately impaired cognition. This resident required supervision for transfers and was independent with ambulation. A MDS dated [DATE], documented that this resident's BIMS remained at a 9 out of 15. It documented that this resident did not ambulate during the assessment period. It documented that this resident was independent for locomotion in his room and adjacent hallway to his room and required supervision for locomotion to the dining room and other areas in the facility. This assessment documented that this resident had a diagnosis of mood disorder. A MDS dated [DATE], documented that this resident's BIMS score was 5 out of 15, which indicated severely impaired cognition. The following entries were documented in Resident #18's progress notes: -On 6/25/22 t 3:01 PM: Staff found resident touching another resident's (female) groin area over her clothes. Staff had to intervene and asked resident to go to room. Resident complied. -On 6/25/22 at 3:19 PM: Staff notified the nurse. The staff notified this nurse that they found resident in dining room with a female resident, whom was confused, and noted his hand on her groin/perineal area outside of her pants and making a rubbing motion. Staff told resident we will have none of that. Resident removed via wheelchair from dining area and asked to go to room, he complied. He stated I was touching her leg. Resident removed from situation. Other resident assessed, no injuries/harm observed. Notified DON (Director of Nursing), notified family. Thirty minute checks initiated. Resident not allowed to be in the dining room unsupervised if female residents present. -On 6/30/22 at 12:59 PM, Staff informed the nurse that resident had moved his dinner to a different table in the dining room, this table was only ladies. Due to recent incidents resident is to be away from any female residents. Resident was asked by staff to move back to his table and he refused. The Director of Nursing (DON) was asked to step in due to resident not cooperating. When DON asked resident to move tables, he stated that he didn't want to, and when he was informed that he could not sit at this particular table. The resident stated he was done and left the dining area. -On 7/2/22 at 2:08 PM, Staff reported resident respectful with staff and residents. Asked to distance himself from female resident at mealtime and did so quickly and kindly. -On 7/24/22 at 3:48 PM, Resident told multiple times today to keep hands to himself and not touch the female residents. Resident (was) finally asked to either keep hands to himself or go to his room. Resident began to get angry and resident told staff to mind their own business or call the cops as he was allowed to touch whoever he wanted and staff didn't need to be concerned with what he was doing. -On 8/4/22 at 2:01 PM, Resident was seen by the Advanced Registered Nurse Practitioner (ARNP), today and received a new diagnosis of mood disorder and hypersexuality. Also received a new order to start taking paroxetine (an anti-depressant) 10 mg PO daily x 7 days then increase to 20 mg PO daily. Resident is aware and pharmacy has been notified. -On 11/12/22 at 12:00 PM, The resident was witnessed laughing and making fun of another resident and then yelling at other resident to shut up. When redirected resident became angry with writer and told writer to shut the hell up and go away. Resident encouraged to go to his room if he could not be appropriate in the common area with other residents and if other residents were irritating him. Res continues to yell at writer and become angry. Writer walked away and resident continued with his dinner without any further behaviors towards other residents. -On 12/4/22 at 8:28 AM, Resident was yelling and cussing at staff related to another resident screaming in her room. Resident was educated and still unsuccessful and was upset. Offered resident to sleep for the night in a room on another hall and this made resident happy. -On 1/7/23 at 7:34 AM, Resident came out to dining area last night when he heard a resident yelling, he started yelling at the staff to do their jobs. Nurse tried to explain to resident that the resident yelling had just been checked on and he was still mad telling the nurse to do her job. He then went down the hall and looked into other residents' room and came back to nurses' station and was yelling at the nurse again. Nurse told Resident that he needs to go to his room to calm down. Resident stayed in his room the rest of the night -On 1/17/23 at 2:49 AM, Certified Nurse Aide (CNA) informed nurse that he found resident in a female resident's room. CNA told resident that he was not allowed to be in her room, and he got mad and said that he was in her room because no one takes care of her. Female resident was sleeping at the time and this nurse had just checked on her 10 minutes before this incident happened. CNA also informed nurse at 10:00 PM that the resident got in an argument with roommate. Roommate told CNA that resident tried to unplug his TV because he was watching something resident didn't like. CNA told resident that he can't be doing that. Resident was mad and went to dining area to get coffee and a snack. Nurse went in room at 10:30 PM to check on them and they were watching TV together. -On 1/19/23 at 4:50 AM, Resident was sitting in his wheelchair in front of door to room [ROOM NUMBER]. Resident informed that he does not need to be sitting in front of that door and resident asked to return to his room. Resident states she is yelling for help and you all aren't doing anything for her. Resident informed that other resident is fine and that her yelling is not his concern. Resident again asked to return to his room, resident states that's where I was going. Resident also told staff you aren't going to tell me what to do and then proceeded to sit in his wheelchair in the hallway. Resident asked by both nurse and CNA to return to his room, resident loudly stated if you would shut the hell up maybe I would. Resident asked to lower his voice as other residents are sleeping and was again asked to return to his room. Resident did finally return to his room. -On 2/5/23 at 2:06 PM, At approximately 1:30 PM, It was brought to the nurse's attention by another resident that resident was reaching out to touch a nonverbal resident yesterday, but did not actually touch the resident. This nurse educated resident that he can not touch other residents without consent. Resident stated I know, I keep my hands right where they belong and that is to myself. DON aware. -On 2/9/23 at 5:58 PM, Resident was in dining area and was constantly messing with a female resident after staff asked him several times to please leave her alone so she could sleep. Staff decided to move female resident to her room to allow her more privacy and quiet space to try and sleep. Female resident was very anxious and kept yelling, the CNAs and nurse were doing checks between helping other residents get to bed and giving medications. Resident kept going past her door and would yell at the staff to check on her and help her. He said we weren't doing our jobs. Nurse tried to explain to resident that the resident was fine and that she was just checked on, he said the nurse was lying and was yelling even louder. Male CNA got up to go into female resident's room and resident tried to hit him when he was walking by. Resident was told that it is not ok to hit people and was sent back to his room. He has been in his room the rest of the night. -On 3/24/23 at 4:59 AM, Resident kept coming down the hall to tell the CNAs to do their job when he heard a resident say hello. The resident that was saying Hello had just woken up and CNAs had been in her room several times to sit with her. The resident fell back to sleep and Resident #18 came back down the hall yelling at CNAs and when they tried to tell him that she was sleeping he got mad and called CNA a bitch and was yelling and woke up the sleeping resident. Nurse told him that he needs to go to his room if he was going to be yelling at staff and be disruptive to other residents. After a few minutes he went back to his room. -On 5/7/23 at 7:53 PM, Resident caught touching another Resident in the hallway. When asked to stop touching other Resident states, I do not have to. She likes me. Tried to explain to Resident that this other Resident was confused and thought he was her brother or her husband. Resident laughs at this and tries approaching Resident again. When this writer tried to remove the other Resident from the area, he started following. Asked this Resident to go to his room and he stated he didn't have to. At this time he tried grabbing the other Resident's walker and put his foot in front of her walker to stop her from walking. This writer tried to move his wheelchair and Resident threw his coffee at this writer and started running his wheelchair into this writer's leg. His roommate came into the hallway and asked Resident to stop. At this distraction, walked other Resident up to front lobby. Resident followed up and is up in front lobby as well at this time. Observing interaction. -On 5/7/23 at 8:57 PM, Nurse spoke with on-call ARNP, regarding resident touching a female resident, throwing coffee on staff, running his wheelchair into staff, grabbing another resident's walker, and putting himself in front of resident's walker. Received phone order for Lorazepam 0.5 mg PO prn (as needed)1 time only dose for restlessness or anxiety for 24 hours only. ARNP also suggested staff contact another provider on 5/8/23 to update on resident's behaviors. -On 5/8/23 at 6:38 AM, Resident has been on 1:1 supervision since 2145 last evening. Resident came out of room x 3 during the night, 2 times he sat at end of west hallway looking out the window, and 1 time he came down to dining room. Before going to bed last night resident was redirected away from another resident multiple times, as this resident followed other resident down hallway, into lobby, into dining room, and was encouraging other resident to sit with him at a dining room table. When other resident would refer to this resident as her husband/son, this resident did not state he was not those people. When resident was redirected away from other resident, this resident stated call the cops and see what they have to say about it. Resident was asking the resident (Resident #187) what room she was in as she wanted this resident to come to her room. Resident has not been in room [ROOM NUMBER] and they were monitoring his location. -On 5/11/23 at 1:29 AM, CNA just informed this nurse that resident was sitting in the doorway of a female resident's room. Female resident was sleeping at this time. CNA asked if he needed anything, resident said no. CNA then asked what he was doing sitting in her doorway, he replied that he was just sitting here, watching her. CNA told him he needed to move, he cannot just sit in a resident's doorway watching her. Resident was easily redirected and went back to his room. The other resident remains asleep. -On 5/12/23 at 6:41 PM, Resident noted to be sitting in his wheelchair in dining room behind female resident with his right hand on left shoulder and attempting to snap her cloth bib. This resident made aware that he cannot be touching another resident at any time. This resident states I'm not touching her, this resident informed this nurse can see him touching the other resident's shoulder and trying to snap the bib. This resident stopped touching other resident's shoulder and trying to snap cloth bib, this nurse then snapped resident's cloth bib. -On 5/17/23 at 12:25 AM, at 11:20 PM on 5/16/23 CNA found this resident in his wheelchair in room [ROOM NUMBER] near resident's nightstand, was asleep and other resident in room [ROOM NUMBER], couldn't see this resident as privacy curtain was pulled. CNA removed this resident from room [ROOM NUMBER] and asked this resident what he was doing, this resident stated just hanging out. CNA educated this resident that he is not allowed to be in other resident's rooms. Both CNAs then went back into room [ROOM NUMBER] and saw that resident's wallet was opened and money was scattered on the nightstand. -On 5/17/23 at 3:41, At 3:00 AM this resident came up to 2 CNAs to tell them room [ROOM NUMBER] call light was on and that resident wanted help. CNA went down to room [ROOM NUMBER] and answered call light, stated that he accidentally bumped his light and didn't need anything. Resident was informed about this resident being in room last night and that this resident had potentially went thru resident wallet. Resident stated he knew exactly how much was in and counted in front of CNA, $139 was counted and resident stated that was the correct amount. Resident stated he told this resident (Resident #18) to leave his room when call light was on and this resident was asking him what he needed. Resident states when he told this resident to leave this resident said no. -On 5/18/23 at 5:24 AM, Resident was sitting in the doorway of room [ROOM NUMBER]. When CNA asked what he was doing he said, just watching. CNA told him he cannot be sitting in people's doorways watching them, he went back to his room. When CNA asked resident in room [ROOM NUMBER] what he was doing or if he said anything she said No, he was just sitting there watching me. -On 5/19/23 at 3:01 AM, Resident came down the hall when another resident was yelling. Nurse and CNA have been in and out of this resident's room several times for the past few hours because of the yelling. Resident #18 came down the hall and was telling the CNA and nurse to get up and do their job. When nurse tried to comfort Resident #18 said, You shut up I am not talking to you. The nurse said, I understand you are not talking to me, but you are talking to the CNA and being very disrespectful. The nurse explained to Resident #18 that they were taking care of the other resident and he needs to either go back to his room or go to the dining area. He cannot sit in the hall by her door. He got very mad and was yelling at this nurse. Nurse went into the other resident's room and shut the door. After about ten minutes Resident #18 went back to his room. -On 5/19/23 at 8:49 AM, A CNA told the Activity Director that Resident #18 was yelling at another resident that she needs to move out of his spot. The Activity Director went out to the dining room to deescalate the situation and separate the two residents away from each other. -On 5/20/23 at 5:04 AM, Around 2400 (midnight) last night this resident was noted to be following female resident (Resident #187) as resident was stating for this resident to come down to her room and go to sleep, resident #187 thought this Resident #18 was her son and he needed to go to sleep. When this resident and Resident #187 were in lobby and staff was trying to walk Resident #187 down to her room, this resident (#18) stopped his wheelchair in front of Resident #187 so she could not walk forward. This resident was asked multiple times by staff to please go down to his room or back to the dining room so staff could get resident down to her room. This resident proceeded to follow staff and Resident #187 down the hallway, this resident would stop in his wheelchair every time Resident #187 and staff stopped in the hallway. When staff and Resident #187 were stopped outside of room [ROOM NUMBER], this resident ran his wheelchair into the CNA and then hit the CNA on the back. This resident was informed that he cannot run into staff with his wheelchair nor can he hit staff, and resident was again asked to go to his room or back to the dining room. Resident refused to go to his room or back to dining room. Resident continued to follow staff and Resident #187 down the hallway. Resident did go into his room around 12:30 AM after sitting in the doorway of his room watching staff and Resident #187. -On 6/5/23 at 10:00 AM, Resident was trying to take a female resident into the back room with him. The resident from room [ROOM NUMBER] was in a wheelchair at church and he was trying to pull her away. Several staff members tried to redirect resident and he began yelling at staff, kicking at staff and making fists at staff members. Removed the female resident from the dining room and eventually she was brought back and sat with a staff member to enjoy the service and this resident sat alone at a table without further incident. -On 6/5/23 at 10:29 AM, As soon as the facility's staff member left the church service, this resident approached the female resident from room [ROOM NUMBER] and tried pulling her in her wheelchair away from the table with him. The resident from room [ROOM NUMBER]'s wife asked resident to please leave resident from room [ROOM NUMBER] alone and he began yelling at the visitor and hit her on her arm 3 times. The visitor has no injuries and filled out a statement of this event. -On 6/5/23 at 10:28 AM, About ten minutes after this progress note was made, Resident attempted to get to other Resident again. Called providers, and notified them of this situation. Notified DON and administrator. Resident's Vital Signs (VS) assessed and stable. No signs or symptoms of infection noted. Denies N/V/D/C nausea/vomiting/diarrhea/constipation). Denies back pain, suprapubic pain (above pelvis), dysuria (difficulty urinating), or polyuria (frequent urination). Has not had any recent medication changes and was treated for a UTI (Urinary Tract Infection) last month. No recent falls or injuries noted. Will continue to monitor for further behaviors. -On 6/8/23 at 8:50 AM, Resident was sitting in west hallway in front of room [ROOM NUMBER]. Nurse entered room [ROOM NUMBER] and asked resident if she is ok and needing anything. When nurse exited room [ROOM NUMBER] this resident stuck his leg out in front of nurse causing nurse to stumble. When this resident informed that behavior was inappropriate, this resident laughed. This resident then went down to his room. -On 6/20/23 at 9:34 AM, resident was yelling at a CNA about helping another resident that was sitting in the dayroom. This writer asked him to back off and let it go that someone would take care of it and he need not concern himself. He proceeded to tell staff that he was going to continue to interfere because no one was doing their job. Staff removed Resident #20 and asked Resident #18 to go back to the table and let it alone. -On 6/20/23 at 10:35 AM, Received an order to start Carbamepine (anti convulsant also used for bipolar) 50mg at HS (hour of sleep) for impulsive behavior and aggression.with follow up in 1 month. Orders updated. Communications updated. -On 6/24/23 at 6:05 PM, Staff witnessed in the dining room prior to supper resident kissing a female resident on the lips as if they were making out with only lips touching lips and no other physical contact noted. Immediately removed residents from each other. Placed resident on watch for 1 on 1 with staff. call placed to make administrator, DON, and provider service aware. Left message for brother to return call. -On 6/24/23 at 9:00 AM, Late entry, Dietary aide and Social Worker reported to this nurse when she was walking the halls passing bedtime snacks, resident #187 was looking for Jane, and when dietary aide and Resident #187 were going by this resident's (#18) room, dietary aide heard this resident say Jane's in here to Resident #187. -On 6/26/23 at 12:52 PM, No other behaviors noted so far besides verbal aggression when Resident told he has to be with a staff member if he's out of his room. Gets upset and states to this writer, stop following me around, I can be out here -On 7/04/23 at 12:35 AM, CNA was yelling down the hall for a nurse. When nurse got to room, she found Resident #18 in Resident #187's room and CNA was telling Resident #18 that he cannot be in other residents' rooms. Resident was upset and mad that he was told to get out of female residents' room, he would not tell us why he was in her room or what he was doing. Resident was removed from room. Nurse did assessment on female resident, who was upset and startled from being woken up. ADON (Assistant Director of Nursing) notified, and Administrator notified - (administrator is reporting incident) In an observation on 8/9/23 at 12:30 PM, Resident #18 was sitting in the dining room at table with other men. Staff were present in dining room. On 8/9/23 at 3:05 PM, the Administrator acknowledged that there have been a lot of incidents with Resident #18 and female residents. When asked what the facility has done to prevent incidents, she stated they had involved providers and tried to stay vigilant. A Timeline of Interventions the facility put in place was provided by the Administrator and documented the following: -March 2023 Moved to a men's only table -Change of medications-multiple different types of medications -Psych consultation with monthly visits 4/26/23 -Observation when out of room -Redirected if going near females -1:1 during main behaviors 6/24-6/25 went to ER, 1:1 with Female Resident #20 -Police officer conversation regarding aggressive behavior on 6/5/23. -Sent out to ER for behavior observation -Behavior occurred, labs and tests. UTI found. 1:1 continued until antibiotic was complete due to assumed cause of initial behavior. Resident #187 was also encouraging and okay with touches. She didn't understand why touches couldn't happen. 5/7 one on one started. 5/11 antibiotic UTI start. 5/16 end of antibiotic. No behavior since 5/7. 1:1 ended 5/12. -6/24 1:1 with Resident #20 and eyes on Resident #18 when out of room. Behavior, ER on 6/25. No changes or orders and psych consult set up for 7/6 plus medication increase. 7/4 behavior med changes. No other focus on females at this time. An observation on 8/10/23 at 8:16 AM, revealed Resident #18 was sitting at a dining table with 3 other male residents. He wheeled himself into the smaller dining room and grabbed a box of tissues. He then wheeled back into the main dining room and went to Resident #20. Resident #18 handed Resident #20 a tissue, leaning close into her space. No staff were present in dining room. Resident was aware that a surveyor was in the room and looked at the surveyor several times when he handed Resident #20 the tissue. He then patted Resident #20's back then backed away from her and went back to the men's table. On 8/10/23 at 8:30 AM, A Certified Medication Aide (CMA) brought the medication cart in to the dining room. No other staff were in the dining room until the CMA came in with the medication cart. On 8/10/23, 2 Immediate Jeopardies (IJs) were given to the facility related to sexual exploitation and inadequate supervision. On 8/10/23 at 4:00 PM, Staff N, Clinical Regional Nurse and the Administrator stated the abatement plan for the 2 IJs included all staff education with agency staff being educated when they worked, they were looking at discharging this resident to another facility. They had contacted 3 facilities with 1 of the facilities having an all-male unit. Staff N stated they moved this resident closer to the nurses' station and a door alarm was placed on his door. When asked how staff would keep track of him after he left the room, she stated they would put a 1:1 on him when he was out of the room and they had contacted the psych ARNP to evaluate the need for this. On 8/14/23 at 12:23 PM, Resident #18 was sitting at the male table in the dining room. His door alarm sounded when housekeeping came out of it. Staff started toward the door and then saw the housekeeper. Staff present in dining room. On 8/14/23 at 4:35 PM, Resident #18's brother and emergency contact stated he was aware of his brother's inappropriate behavior with females. He stated the facility lets him know when his brother does things like that. Resident #18's brother stated that all the facility needs to do is tell his brother not to do those things, and his brother will stop doing them. Resident #18's brother stated the last time he visited his brother, he told his brother to not do those things anymore and Resident #18 stated he would stop. On 8/14/23 at 9:00 AM, Staff A, Registered Nurse (RN), stated that this resident's behaviors vary from day to day. Staff A stated that Resident #18 not only can be inappropriate with some of the ladies, he also has fits of anger. She stated Resident #18 and another resident did yell at each other but then shook hands right after and have been fine ever since. Staff A stated Resident #18 preys on the ladies that he knows can't tell on him or don't understand what he is doing. He also preys on the ones that really can't move themselves. She said Resident #18 was sneaky and that other residents watch out for him too. She said that one time Resident #18 was putting a blanket on Resident #20 and another resident wheeled by and told staff to watch Resident #18's hands, implying that this resident would try to touch Resident #20. Staff A stated that having a 1:1 on him was hard. She said they are responding when his door alarm goes off. She added they have the rest of the residents to take care of and it is difficult to get the workload done. She said because he is mobile, they have to stay with him because he is sneaky. She said he knows what he is doing and he stays aware of his surroundings. This RN said that he is one that would wait for staff to clear the room, and then he would prey on female residents who are not able to say no and are not able to get away from him. On 8/14/23 at 11:45 AM Resident #187's son stated that his mother was deteriorating every day. Her memory wasn't good she couldn't remember more than 15 minutes. When asked if he was alerted regarding a resident entering his mother's room he said yes. He stated he told the facility that the guy needed his ass kicked. When asked if the facility told him what the plan would be to keep his mother safe. He said no, they didn't say nothing. He then asked how many questions he was going to be asked. He stated he was busy and didn't feel like answering any more que[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and policy review, the facility failed to develop a comprehensive person centered care plan for 3 of 16 residents reviewed (Resident #7, #17, #26). The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #7 had diagnoses that included osteoporosis, Parkinson's disease, anxiety disorder, depression, schizophrenia, and lobar pneumonia. The resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Resident #7 required supervision of one staff for bed mobility, transfers, and toilet use and supervision with set up assistance for eating. The MDS indicated the resident received antipsychotic, antianxiety, and antidepressant medications daily. The Care Plan date 7/9/23 revealed focus areas for Resident #7 which included a potential nutritional problem, antibiotic therapy related to pneumonia, activities of daily living deficit, dependency on staff for activities, PASRR/Level 2 determination, and advanced directive for full code status. The Care Plan lacked information related to the need for psychotropic medications, resident behaviors, and potential side effects of the medications. Review of current Physician Orders on the August 2023 Medication Administration Record (MAR) for Resident #7 revealed resident received the following psychotropic medications: a. Clomipramine Hydrogen Chloride (HCl) Oral Capsule 25 milligrams (MG), give 1 capsule by mouth one time a day related to depression in the morning (order date 06/29/2023) b. Clomipramine HCl Oral Capsule 50 MG, give 1 capsule by mouth one time a day related to depression at bedtime (order date 07/28/2023) c. Lorazepam Oral Tablet 0.5 MG, give 1 tablet by mouth one time a day related to anxiety disorder (order date 07/28/2023) d. Quetiapine Fumarate Oral Tablet 25 MG, give 1 tablet by mouth one time a day related to schizophrenia in the morning (order date 06/29/2023) e. Quetiapine Fumarate Oral Tablet 400 MG, give 1 tablet by mouth one time a day related to schizophrenia at bedtime (order date 07/28/2023) f. Trazodone HCl Oral Tablet 150 MG, give 1 tablet by mouth one time a day related to depression (order date 07/28/2023) g. Citalopram Hydrobromide Oral Tablet 40 MG, give 40 mg by mouth two times a day related to depression (order date 06/29/2023) 2. A Medication Administration Record for August 2023, revealed that Resident #17 was administered Oxycodone-acetaminophen (opioid pain medication) 5 mg-325 administer 2 tabs every 6 hours for pain. This resident was administered 15 doses between 8/1/23 to 8/14/23. Review of Resident #17's care plan revealed that she was not care planned for pain medication or pain. 3. A Medication Administration Record for August 2023, revealed that Resident #23 was administered furosemide (a diuretic) 40 mg 1 tab daily. Review of Resident #23's care plan revealed that he was not care planned for being on this medication. In an interview on 8/15/23 at 5:12 PM, the Administrator stated it was the expectation that if a resident was prescribed a psychotropic, anticoagulant, diuretic, or opioid medication, it would be addressed on the resident's Care Plan. Review of the facility provided policy titled Care Plan Development dated August 2015 revealed the comprehensive care plans are designed to: include identified resident needs and strengths, include risk factors associated with needs, and indicate goals and objectives that are measurable and obtainable and are derived from information supplied by resident/family/legal guardian and the MDS data. The Care Plan will be reviewed and revised as needed when a significant change in condition is noted, when outcomes were not achieved, or when outcomes are complete and at least every 92 days.

Based on observation, record review, staff interviews and manufacturer's insert, the facility failed to provide services that met professional standards regarding medication administration for 1 of 6 residents observed (Resident #16) who did not have their insulin flex pen primed prior to administering insulin (to ensure the proper amount of insulin administered) and did not leave the needle injected in the skin for the recommended period of time to ensure the full dose of medication was given. The facility reported a census of 32 residents. Findings include: 1. During the Medication Pass Task, an observation on 8/9/23 at 7:53 AM revealed Staff, A, Registered Nurse (RN) administered Resident #16's insulin. Staff A, RN obtained a Novolog (insulin) FlexPen from the medication cart, put a needle on the tip of the pen, dialed up to 5 units and proceeded to administer the insulin into resident's right lower quadrant of the abdomen. Staff A, RN failed to prime the insulin pen prior to administration. Staff A, RN further failed to keep the needle under the skin for a full count of 6 to make sure the full dose was injected before removing. Resident #16 had a physician order on the Treatment Administration Record (TAR) for August 2023 for Novolog FlexPen Subcutaneous Solution Pen-injector 100 units per milliliter (ML). Inject 5 units subcutaneously with meals. On 8/9/23 at 10:58 AM, Staff A, RN administered Novolog 5 units to Resident #16. Staff A gave the shot in the back of the left thigh. She did not prime the pen prior to administration of the insulin. In an interview on 8/9/23 at 4:45 PM, the Administrator and acting Director of Nursing (DON) acknowledged the concerns of staff not priming the FlexPen prior to administering the insulin and not following manufacturer's recommendation of leaving the needle under the skin for a count of 6 to ensure all medication was given. Review of facility provided policy on Medication Administration: Insulin Injections dated January 2013, did not have information regarding the use of a FlexPen for insulin administration. Review of the manufacturer insert for Novolog FlexPen stated small amounts of air may collect in the cartridge during normal use. An airshot must be done before each injection to avoid injecting air and to make sure the prescribed dose of the medicine is received. Do the airshot as described in the instruction manual that comes with the device. It also stated to insert the needle into the skin. Press and hold down the dose button until the dose counter shows 0. Continue to keep the dose button pressed and keep the needle in the skin and slowly count to 6.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, resident and staff interviews, and policy review, the facility failed to provide interventions specific enough to guide the staff to provide services and treatment for an indwelling catheter with interventions to maintain the resident and catheter cleanliness for 2 of 2 residents reviewed for catheter care (Resident #14 and #28). The facility reported a census of 32 residents. The Minimum Data Set (MDS) dated [DATE] for Resident #14 revealed a diagnosis of obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow) and identified an indwelling catheter that required the assistance of 1 person to provide care. The Care Plan dated 6/30/23 for Resident #14 failed to address cleaning care for the indwelling catheter. Clinical record titled Point of Care-Catheter Output of Resident #14 revealed a lack of documentation on 8/7/23 and 8/9/23 between 1 PM and 3 PM. During observations on 8/7/23 and 8/9/23, the indwelling catheter for Resident #14 was not cleaned nor emptied by the day shift. On 8/8/23 the indwelling catheter for Resident #14 was not cleaned. During an interview on 8/07/23 at 1:32 PM, Resident #14 stated the staff empty the catheter bag but do not clean the catheter. The MDS dated [DATE] for Resident #28 revealed a diagnosis of respiratory failure, obesity, heart failure, required extensive assist for toilet use and personal hygiene of two persons and identified an indwelling catheter. The Care Plan dated 7/7/23 for Resident #28 identified a size 16 French, Foley catheter but lacked direction for staff to provide cleaning care. During an observation on 8/08/23 at 9:45 AM, Resident #28 was sitting in a high back wheel chair gown high on legs, can see the strap around left leg to secure an indwelling catheter with the Foley collection bag in a dignity bag. During an observation on 8/9/23 at 2:10 PM, Staff C, Certified Nursing Assistant (CNA) emptied Resident #28's catheter drainage bag. During an interview on 8/9/23 at 2:10 PM Staff C, CNA stated the CNA's check and change the residents and empties the catheter bag, the nurse completes the indwelling catheter cares. During an interview on 8/9/23 at 2:15 PM, Staff A, Registered Nurse (RN) stated the CNA's provide indwelling catheter care. The policy titled Indwelling Catheter Evaluation & Management dated 5/14 revealed a lack of procedure for the cleaning and care of an indwelling catheter. During an interview on 8/9/23 at 3:15 PM Staff B, RN stated the expectation was for the indwelling catheter care to be completed at the end of each shift. Staff B stated the CNA's are responsible for the indwelling catheter care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide a sterile field for tracheotomy care for 1 of 1 resident's observed (Resident #29). Staff A, Registered Nurse (RN), performed tracheostomy care on Resident #29 and broke the sterile field when she touched the objects in the sterile tray with her bare hands. The facility reported a census of 32. Findings include: A Minimum Data Set, dated [DATE], documented that Resident #29's diagnoses included tracheostomy status, and persistent vegetative state. It documented that this resident's cognition was severely impaired. This resident required extensive assist of 2 for bed mobility, transfers, eating, personal hygiene, and toileting. This resident had a feeding tube. A Care Plan with a revision date of 5/8/23, directed staff that Resident #29 had a tracheostomy related to impaired breathing mechanics. It directed that Resident #29 will have no abnormal drainage around the trach site. It directed that Resident #29 will have no signs or symptoms of infection related to tracheostomy. A Treatment Administration Record for August 2023, directed staff to provide trach (tracheostomy) cares to Resident #29, to include removing and cleaning of inner cannula every shift related to tracheostomy status. On 8/9/23 at 3:57 PM, Staff A washed her hands. Staff A had supplies sitting on tray table. She opened up the sterile trach kit and took the sterile barrier out. Staff A used bare hands to open up barrier cloth and spread it out on the table. Staff A then proceeded to take out a sterile brush, pipe cleaners, 4X4's (sterile gauze pads), and other sterile items from the sterile package with her bare hands and placed them on the barrier surface. She then put on sterile gloves. Staff A opened cup with sterile water and poured hydrogen peroxide into sterile container. Staff A then removed this resident's steel inner cannula, and held onto it with gloved hands. Staff A cleaned the inside of the inner cannula with the long brush, 4X4's, and the pipe cleaners. Staff A then took a package of wipes off of a counter in the resident's room and pulled one out while holding the inner cannula in the other hand. Staff A wiped around outer cannula with a wipe and placed the inner cannula back into the outer cannula. Staff A then opened up the sterile suctioning kit. She pulled out the suctioning cannula, hooked it up to the suction machine, then suctioned the inner cannula. This resident coughed up some phlegm, she suctioned again, then turned off the machine and disposed of supplies. When asked if she felt she kept the procedure sterile, she said yes except for grabbing the wipes. When asked if she should have touched the sterile supplies with her bare hands. She said no. This RN acknowledged she broke the sterile field. On 8/9/23 at approximately 4:45, reviewed above concerns with trach care and infection control issues seen earlier as well with the acting DON and Administrator. They both acknowledged the concerns. The acting DON stated she had been working with Staff A regarding infection control technique as well as some other things. The facility did not have a policy on sterile trach cleaning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, observation, and policy review, the facility failed to provide pain management for 1 of 3 residents reviewed (Resident #186). The facility failed to pre-medicate Resident #186 before Physical and Occupational Therapy was initiated as per the resident's request and policy directive. The Minimum Data Set (MDS) dated [DATE] for Resident #186 revealed she was admitted to the facility on [DATE] with a diagnosis of post-surgical of a nondisplaced fracture of the left humerus (upper arm), fracture of pelvis and had the ability to express her ideas and wants. The Care Plan dated 8/8/23 for Resident #186 identified the need for assistance for activities of daily living, non-weight bearing to left side, keep left arm immobilizer in place except for showering, required substantial assistance of 1 to dress, 2 person assist for bathing and toilet use. The Care Plan failed to address pain management to include pre-medication before physical and occupational therapy. During an interview on 8/08/23 at 8:58 AM, Resident #186 stated, I fell out of my truck and fractured my pelvis and my left arm, it hurts to use my left leg, and I just seen the therapist, she talks so fast and does not listen to me, I have to protect myself from the excruciating pain. Observation on 8/8/23 at 8:58 AM revealed Resident #186's left arm had a large amount of purple and yellow bruising; a shoulder immobilizer was in place. The Physician Order on 8/7/23 for Hydrocodone-Acetaminophen Tablet 5-325 MG. Give 1 tablet by mouth every 4 hours as needed for Moderate Pain. During an observation on 8/9/23 at 8:03 AM, Staff I, Physical Therapy and Staff J, Occupational Therapy were attempting to assist Resident #186 out of bed to a chair. Resident #186 stated she did not want to, she was in so much pain, It's scary and painful. Resident #186 had tears in her eyes. Staff J told Resident #186 she needs to get up. Resident #186 reported to the therapists that she told the CNA she needed a pain pill first around 7 :30 AM. Staff I and Staff J continued to sit Resident #186 up on the side of the bed. Resident #186 was moving very slowly and gritting her teeth and making hissing noises. Staff A, Registered Nurse (RN) entered the room and stated she was unaware Resident #186 needed pain medication, though the medication aide may know. During the continued observation on 8/9/23 at 8:12 AM, Staff G, Certified Medication Aide (CMA) entered the room and administered the pain medication to Resident #186 who was dangling off the bed and took the medication offered. Resident #186 told therapy she did not want to stand but agreed to pivot to the wheel chair. During an interview on 8/9/23 at 8:16 AM Staff G, CMA stated, I was down the other hall and they told me she (Resident #186) needed pain medication, but I forgot. During an interview on 8/9/23 at 8:10 AM Resident #186 stated her pain was a 10/10 and she had not had anything all night for pain. A Surveyor who was watching the medication pass on 8/9/23 7:30 AM stated a CNA had told Staff G, CMA that Resident #186 was in pain and needed pain medication, Staff G wrote it down and stated, so I don't forget. The document titled Medication Administration Record (MAR) revealed: a. Hydrocodone-Acetaminophen 5-325 milligram (mg) give 1 tablet every 4 hours as needed for pain. b. On 8/8/23 at 9:14 AM received 1 tablet for pain of 8/10. c. On 8/8/23 at 7:25 PM received 1 tablet for pain 7/10. d. On 8/9/23 at 8:08 AM received 1 tablet for pain 8/10. The policy titled Pain Management dated 4/2013 revealed: a. The interdisciplinary team recognizes that a resident/patient's response to pain is subjective and individual; therefore, pain is whatever the resident expresses as pain. b. The team works with the resident/patient and family/responsible party to identify and implement appropriate interventions to improve comfort and minimize pain. c. Identification of current discomfort and pain levels, potential for pain and circumstances in which to anticipate pain. d. Implementation of individualized interventions to improve comfort and minimize pain. e. Monitor and document resident/patient response to comfort promotion and pain management interventions. During an interview on 8/9/23 at 8:26 AM, Staff B, Assistant Director of Nursing (ADON) stated My expectation is for the staff to communicate, if a resident stated they are in pain, they only wait 15 minutes, 30 minutes tops to get the pain medication. Staff B stated, The residents are to be premedicated before wound changes and before therapy and the Care Plan should reflect this.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure nursing agency staff received orientation and direction prior to providing care to the residents of the facility. The facility reported a census of 32 residents, Findings include: Per documentation on [DATE] at 9:29 AM, Staff Q, certified nurse aide (CNA) with nursing agency, stated, The facility does not give any training here to agency, you just figure it out as you go. Staff Q, CNA stated she saw heel protectors for Resident #10 in the room but no staff told her the resident used them. Staff Q, CNA stated, There are no care plans on the wall, so I don't know what they need because I do not have access to the computer to chart. The staff chart for us. In an interview on [DATE] at 11:10 AM, the Administrator reported the agency staff did not get an official orientation per say. They were to do rounds at the beginning of their shift with a staff person from the previous shift and a regular facility staff person from the shift they are working. The facility staff person was to write down important information on a sheet of paper and give it to the agency staff as a quick reference when assisting the residents. She stated the lists were normally hand written by the regular facility CNA on duty. The computers have Point of Care (POC) on them that has a [NAME] on it to give them more specifics on how to care for the residents. She stated the agency staff were given a user name and password so they had access to POC for this information and be able to document cares provided. In an interview on [DATE] at 11:20 AM, Staff D, CNA with nursing agency, reported it to be her 4th day working at the facility. She reported she was not given anything in writing by the facility CNA's. She stated she just buddied up with regular staff so they could show her what to do. She stated she does not have a user name or password for POC and has had no access to the [NAME] or the ability to document in POC. She reported she had been telling the facility staff things that needed to be documented and they had been documenting for her. In an interview on [DATE] at 8:25 AM, Staff P, CNA with nursing agency, reported this was her first day at the facility. She stated she was a little late getting to work this morning and was not present for the walk through report from the night shift. She reported Staff D, CNA (also agency staff) had helped her with the routine of the facility and how to care for the residents. She stated when she got to work a staff person in the office gave her a couple of lists that had the resident's name and specifics, like how they transfer and toilet on them. She stated she did not have a user name or password or access to POC to look at the [NAME]'s or to document at that time. In an interview on [DATE] at 8:28 AM, Staff D, CNA with nursing agency, stated she did receive a user name and password to POC yesterday afternoon. She stated she had never received the paper the Staff P, CNA had in her possession at any time. She stated she was the one showing Staff P, CNA around, not a regular facility CNA. In an interview on [DATE] at 5:10 PM, the Administrator reported the facility does not have a policy for nursing agency staff orientation. In an interview on [DATE] at 5:10 PM, the Administrator acknowledged there was not a good orientation process put in place for nursing agency staff that come to work at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and policy review, the facility failed to ensure antipsychotic medications were re-assessed or included a clinical rational to continue the medication for 3 of 5 residents reviewed (Resident 26, #28, #30). The facility reported a census of 32 residents. Finding include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #28 with diagnoses that included: heart failure, respiratory failure, pulmonary hypertension, depression, anxiety disorder, and diabetes mellitus. The MDS documented a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS identified the resident with inattention, disorganized thinking, with verbal behavioral symptoms directed toward others daily during the assessment period. The MDS recorded the resident received antipsychotic, antianxiety, antidepressant, and hypnotic medications during the seven day look-back period. The MDS identified resident as under hospice care. The Care Plan updated on 8/14/23 revealed focus areas that included: the use of antianxiety medications related to adjustment issues, behavior problems related to attention seeking and crying, and depression related to mood disorders. The staff directives included giving medications ordered by physician, monitor/document medication side effects and effectiveness, behavioral health consults as needed and monitor/record/report mood patterns signs and symptoms of depression, anxiety, and sad mood as per facility behavioral monitoring protocols. The Medication Administration Record for August 2023 for resident #28 revealed resident had orders to receive the following psychotropic medications: (Resident passed away on 8/10/23 under hospice care) a. Ambien tablet 5 milligrams (MG) give 1 tablet by mouth one time a day for sleep. Order Date- 08/01/2022, Discontinue (D/C) Date-08/09/2023 b. Effexor extended release (XR) capsule 37.5 MG give 1 capsule by mouth one time a day for mood stabilizer. Order Date-07/08/2022 -D/C Date-08/09/2023 c. Haloperidol tablet 5 MG give 1 tablet by mouth one time a day related to generalized anxiety disorder. Order Date-06/28/2023 D/C Date-08/09/2023 d. Lorazepam oral concentrate 2 MG/milliliter (ML) give 0.25 ml by mouth three times a day related to generalized anxiety disorder. Order Date-06/28/2023 D/C Date-08/10/2023 e. Haloperidol oral tablet 5 MG (Haloperidol) give 1 tablet by mouth every 6 hours as needed for anxiousness for 14 days. Order Date-07/25/2023 f. Lorazepam intensol oral concentrate 2 MG/ML give 0.5 ml by mouth every 2 hours as needed for anxiousness for 14 days. Order Date-07/25/2023 In the Consultant Pharmacist Recommendation to Physician form dated 12/31/22, pharmacy recommended discontinuing pro re nata (PRN) (as needed) Haloperidol 5 mg for agitation. Response from provider: None In the Consultant Pharmacist Recommendation to Physician form dated 1/29/23, pharmacy recommended the following: a. Discontinuing PRN Haloperidol 5 mg for agitation. Response from provider: None b. A trail dose reduction of Venlafaxine extended release (ER) 37.5 mg daily (resident had been on since 7/9/22). Response from provider: None c. Provider provide a duration of use for Lorazepam 2 mg/ml stating psychotropic drugs PRN are limited to 14 days, except when attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. Response from provider: None In the Consultant Pharmacist Recommendation to Physician form dated 2/28/23, pharmacy recommended the following: a. Provider provide a duration of use for Lorazepam 2 mg/ml - psychotropic drugs PRN are limited to 14 days, except when attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. Response from provider: None b. Discontinuing PRN Haloperidol 5 mg for agitation. Response from provider: None In the Consultant Pharmacist Recommendation to Physician form dated 4/30/23, pharmacy recommended the following: a. Discontinuing PRN Haloperidol 5 mg for agitation. Pharmacy noting Hospice patients are not exempt from this rule; PRN psychotropic medications require a stop date irrespective of indication. Response from provider: None b. Provider provide a duration of use for Lorazepam 2 mg/ml - psychotropic drugs PRN are limited to 14 days, except when attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. Pharmacy noting Hospice patients are not exempt from this rule; PRN psychotropic medications require a stop date irrespective of indication. Response from provider: None c. Resident has been using Venlafaxine extended release (ER) 37.5 mg daily since 7/9/22. Pharmacy questioned if a trial dose reduction would be reasonable at this time. If this therapy is required to prevent future depressive episode, please document to that effect in your progress notes. Response from provider: None In the Consultant Pharmacist Recommendation to Physician form dated 5/26/23, pharmacy recommended the following: a. Pharmacy recommended discontinuing PRN Haloperidol 5 mg for agitation. Pharmacy noting Hospice patients are not exempt from this rule; PRN psychotropic medications require a stop date irrespective of indication. Response from provider on 6/30/23: Resident received a consultation pharmacist recommendation to physician form regarding her Venlafaxine, Lorazepam and Haloperidol. Provider responded to not change, resident is hospice level of care and these are comfort medications. The Haloperidol request was on 5/26/23 and Venlafaxine and Lorazepam request was on 4/30/23. The records lacked provider follow up on pharmacy recommendations for gradual dose reductions. 2. Record review done on 8/15/23 at 1:56 PM, revealed that the following Consultant Pharmacist Recommendation to Physician sheets for Resident #26 were sent to the physician from the pharmacist with recommendations to look at medications and determine if they should be discontinued, continued related to the benefits outweighing the risk, or have a gradual dosage reduction (GDR), went without a response from the physician: 1/29/23 Lorazepam (antianxiety) 0.5 mg limited to 14 day (PRN-as needed), and a GDR for elation (sedative/hypnotic) mg; 4/30/23 GDR for melatonin 5 mg; 5/26/23 GDR Mirtazapine (antidepressant) 30 mg; and 6/30/23 GDR lithium 150 mg. A Medication Administration Record for August 2023, revealed Resident #26 was being administered melatonin at 5 mg. He no longer had a PRN Lorazepam. Resident #26 remained on Mirtazapine at 30 mg and lithium at 150 mg. 3. Record review done on 8/15/23 at 3:56 PM, revealed that the following Consultant Pharmacist Recommendation to Physician sheets for Resident #30 were sent to the physician from the pharmacist with recommendations to look at medications and determine if they should be discontinued, continued related to the benefits outweighing the risk, or have a gradual dosage reduction (GDR), went without a response from the physician: 12/31/22, 1/29/23, and 2/28/23 lorazepam (antianxiety) 0.5 mg limited to 14 day; and 6/30/23 GDR Mirtazapine (antidepressant) 30 mg. A Medication Administration Record for August 2023, revealed the Mirtazapine was being administered at 15 mg daily. Resident no longer had an as needed dose for Lorazepam. On 8/15/23 at 2:00 PM, the Administrator provided the pharmacist number. She also provided all of the provider responses to recommendations, sent to her by the pharmacist, for the 5 residents that were selected. She acknowledged that there were many missing responses, and that the pharmacist stated that he sent her everything that the provider had responded to. On 8/15/23 at 4:36 PM, the Consultant Pharmacist, stated that he reviewed all the residents' medications monthly. He then sends the Consultant Pharmacist Recommendation Physician sheets to the physician with the pharmacists recommendations. This Pharmacist acknowledged that he did not always get a response from the provider. He stated that when he does not receive a response, he commonly waits until the next month to write the recommendation again during his review. He stated PRN psychotropics without a stop date and antibiotics without a stop date are ones that he has needed to repeat. He stated if it is something like a routine psychotropic recommendation, he will wait a month and repeat the recommendation again. He stated he will then on the second month of no response put a note in the computer that the recommendation was not responded to. He stated he hasn't called the physician, he doesn't have the contact information to call the physician. He said at this facility there hasn't been anything that he has seen or a recommendation that the physician didn't respond to, that this pharmacist felt was an emergency or rose to an urgent level. He said if that did happen he would contact the Director of Nursing (DON) or the Minimum Data Set (MDS) nurse so they could follow up on it promptly. Review of a facility provided policy titled Behavioral Management - Psychoactive Medication Management dated 5/2014 documented there was to be attempted gradual dose reductions and elimination as ordered by the physician and appropriate for the resident.

Based on observation, interview, record review, and manufacturer's package insert review, the facility failed to keep their medication error rate less than 5 percent for 1 of 1 residents (Resident #16) observed. An observation of 25 medications being passed was completed with 2 medication errors noted giving the facility an 8% medication error rate. The facility reported a census of 32 residents. Finding Include: In an observation on 8/9/23 at 7:52 AM, Staff A, RN prepared a Novolog FlexPen by placing a needle on the pen and then dialed it to 5 units and administered the insulin in Resident #16's right lower quadrant (RLQ) of her abdomen holding the syringe in the abdomen for no more than a count of 2. Staff A, RN failed to prime the insulin FlexPen with 2 units prior to setting and administering the insulin and failed to leave the FlexPen needle injected under the skin for a count of 6. In an observation on 8/9/23 at 10:58 AM, Staff A, RN prepped a Novolog FlexPen by placing a needle on the pen and then dialed it to 5 units and administered the insulin in Resident #16's backside of the left thigh. Staff A, RN failed to prime the insulin FlexPen with 2 units prior to setting and administering the insulin. Review of current physician orders on the August 2023 Medication Administration Record/Treatment Administration Record (MAR/TAR) for Resident #16 revealed resident was to receive the following: a. Novolog FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 5 unit subcutaneously with meals. In an interview on 8/9/23 at 4:45 PM, the Administrator and acting Director of Nursing (DON) acknowledged the concerns of staff not priming the FlexPen prior to administering the insulin and not following manufacturer's recommendation of leaving the needle under the skin for a count of 6 to ensure all medication was given. Review of facility provided policy on Medication Administration: Insulin Injections dated January 2013, did not have information regarding the use of a FlexPen for insulin administration. Review of the Novolog FlexPen Manufacturer's Package Insert stated small amounts of air may collect in the cartridge during normal use. An airshot must be done before each injection to avoid injecting air and to make sure the prescribed dose of the medicine is received. Do the airshot as described in the instruction manual that comes with the device. It also stated to insert the needle into the skin. Press and hold down the dose button until the dose counter shows 0. Continue to keep the dose button pressed and keep the needle in the skin and slowly count to 6.

Based on record review, staff interview, and policy review the facility failed to have the required members present at their quarterly Quality Assurance and Performance Improvement (QAPI) meeting. The facility did not have the Director of Nursing (DON) or the Infection Preventionist (IP) in attendance at the November 29, 2022 quarterly meeting. The facility reported a census of 32 residents. Findings include: Review of the attendance sheets for the QAPI meetings revealed the required members attended the QAPI meetings on 5/18/22, 8/27/22, 2/22/23, and 6/6/23. The attendance sheet for the QAPI meeting held on 11/29/22 revealed the DON and IP were not in attendance. The Administrator reported Staff N, Regional Clinical Director was the acting DON at that time related to the previous DON and IP quitting without notice. Staff N, Regional Clinical Director was not able to attend as she was needed in another facility on the day of the QAPI meeting. In an interview on 8/17/23 at 2:04 PM, the Administrator stated it was the expectation that all required members be present for the quarterly QAPI meetings. Per a facility provided policy titled QAPI Meeting Management, last revised 8/19, the Risk Management/QAPI committee was to consist of no less than five members. Members were to be appointed by the Administrator and would include, but not be limited to: Administrator, Director of Nursing, Infection Preventionist, Medical Director or Physician designee, and at least two additional facility staff.

Based on clinical record review, observation, staff interview, and facility policy review, the facility failed to maintain proper infection control practices to prevent cross contamination and potential infection of residents when providing cares and treatments. The facility reported a census of 32 residents. Findings include: 1. In an observation of medication pass on 8/9/23 at 7:35 AM, Staff G, Certified Medication Aide (CMA) was observed to drop Resident #26's bupropion tablet on the top of the medication cart. She picked the tablet up with her ungloved hand and placed it into the medication cup with the resident's other medications and administered them to the resident. She failed to discard the tablet and obtain a new one for the resident. 2. In an observation of a blood glucose check on 8/9/23 at 7:53 AM, Staff A, Registered Nurse (RN) washed her hands and took the glucometer and a lancet with alcohol swab into Resident #16's room. She sat the glucometer on the resident's bed with no barrier under it. She gloved her hands and picked up the glucometer to put the blood from the residents left index finger onto the strip. Staff A, RN then sat the glucometer machine back down on the bed with no barrier. She then returned the glucometer to the medication cart and did not sanitize the machine when she was done. On 8/9/23 at 10:58 AM, Staff A provided medication and/or obtained a blood glucose reading from the following residents: 3. Resident #3, Staff A placed her gloves on and administered insulin in the hallway. Staff A wiped the insulin bottle top with an alcohol swab, drew up 4 units of Humalog, wiped the back of left arm with an alcohol swab and then administered the shot of insulin with a safety syringe into the back of this resident's left arm. Staff A did not perform hand hygiene prior to the application of gloves. Staff A removed her gloves and threw them in the trash, she then proceeded to get the medication out of the medication cart for a different resident without performing hand hygiene. Staff A then walked into Resident #17's room carrying the IV bag that she was going to administer to Resident #17. 4. Resident #17, Staff A carried in the antibiotic Vancomycin 750 mg in a 250 ml Normal Saline (NS) bag. Staff A opened up new tubing. She then removed the cap off of Resident #17's PICC (peripherally inserted central catheter) line, flushed the PICC line with 10 cc's NS and after priming the syringe (removing the air out). Staff A spiked the IV bag with the new tubing and primed the IV line. Staff A then turned on the IV pump and the pump beeped. Staff A disconnected the tubing from Resident #17's PICC line, primed the tubing again, then reattached the IV line to the PICC port and turned the IV pump back on. She did not use alcohol wipes to sterilized the PICC port after removing the cap, nor when she disconnected and reconnected the IV line. Staff A did not perform hand hygiene before entering the room, when in the room, nor after she left the room. Staff A then went into Resident #29's room without performing hand hygiene. 5. Resident #29, Staff A carried the glucometer into Resident #29's room. She did not use a barrier and set the glucometer directly on to his bed. Staff A wore gloves. She obtained the blood sample and obtained the blood sugar level. Staff A then left the room carrying the glucometer and placed the glucometer on top of the medication cart. Staff A then opened the medication cart and grabbed an insulin pen out. She did not sanitize her hands. She applied new gloves. She left the glucometer with blood on the strip sitting on top of med cart. Staff A then walked into Resident #16's room. (refer to 2.) Resident #16, Staff A carried the Novolog pen dialed to 5 units and gave the insulin in the back of her left thigh. Staff A then removed her gloves. Staff A did not sanitize her hands and held the gloves she had just removed in her left hand. She placed the insulin pen back in the bag it was in. The gloves were still in Staff A's left hand as she was pushing everything down in the top medication drawer. Staff A then removed the strip from the glucometer that had a droplet of Resident #29's blood on it with her bare hand and threw it into the garbage not the sharps container on the side of the medication cart. Staff A left the glucometer on top of the medication cart (without disinfecting it). She closed her book that she was keeping notes in, shut off the screen on the medication cart laptop and walked away after locking the cart. Staff A did not perform hand hygiene at anytime during these observations. On 8/9/23 at 3:57 PM, Staff A, when asked about the medication administration from earlier this day, she acknowledged she did not sanitize or wash hands in between the 4 residents she provided medications or interventions to during the 11:00 AM medication administration time frame observation. She acknowledged that she did not place a barrier down under the glucometer when getting a blood sugar reading and that she had set it down on the bed for both observations seen on this day. She acknowledged she didn't sterilize the PICC port before flushing and attaching the IV line and after removing the IV line and reinserting it again in the PICC port. She acknowledged that she didn't prime the insulin pen prior to injection both at this time and earlier. She acknowledged she did not clean the glucometer after the blood sugar reading and left it set on the top of her medication cart for both observations seen on this day. She acknowledged she had taken off her gloves and opened the drawer, then moved things around with both hands while her used gloves remained in her left hand while she was putting the insulin pen back into a baggie in the drawer of her medication cart. She acknowledged she removed the strip from the glucometer with bare hands and disposed of it in the trash on her cart. On 8/9/23 at approximately 4:45, reviewed all of the above concerns with infection control issues seen earlier with the acting Director of Nursing (DON) and the Administrator. They both acknowledged the concerns. The DON stated she had been working with Staff A regarding infection control technique as well as some other things. This acting DON acknowledged that she should have wiped the port with an alcohol swab before attaching the IV line to the PICC line. The acting DON stated that Resident #17 has had a major infection and did not need any further infections. They acknowledged that the pill dropped earlier should have been thrown away and not given to the resident. Review of a facility provided policy titled Medication Administration dated 1/2013 did not address what staff were to do if dropping a medication. Review of a facility provided policy titled Glucometer Cleaning - Finger Stick Procedure dated 8/2015 stated staff were directed to wear gloves while cleaning the device thoroughly after each use and disinfecting it according to manufacturers' recommendations with an Environmental Protection Agency (EPA)-approved disinfectant. The device was to remain wet for a minimum of 2 minutes after cleaning and disinfecting. The policy also directed staff to place a barrier on the surface before placing the glucometer on any surface in resident care areas. Review of facility provided policy titled Hand Hygiene last reviewed 3/2022 stated healthcare providers must perform hand hygiene for the following; · Immediately before touching a resident or the resident's immediate environment · Before performing an aseptic task (e.g., placing an indwelling device), handling invasive medical devices etc. · Before moving from work on a soiled body site to a clean body site on the same patient · After contact with blood, body fluids, or contaminated surfaces · Immediately after glove removal Review of facility provided information from Manual Section II for Infusion Therapy Procedures, stated when starting an infusion staff are to cleanse the resident ' s catheter injection site/IV (intravenous) access device.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of policy and procedures, the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse of a resident and/or residents are reported immediately to management staff per facility policy and to the Iowa Department of Inspection and Appeals for 1 of 4 residents reviewed (Resident #2). The facility reported a census of 34 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE], documented Resident #2 with a Brief Interview for Mental Status (BIMS) score of 14 which indicated no impaired decision making abilities, and they demonstrated verbal behavior symptoms directed towards others. The MDS also documented the resident required extensive assistance with all activities of daily living and diagnoses which included Hypertension, Diabetes Mellitus, Depression, Psychotic Disorder, and Schizophrenia. The plan of care with an initiated date of 11/21/2022, stated the resident has potential to demonstrate verbally abusive behaviors, Interventions include: *Provide positive feedback for good behavior. Emphasize the positive aspects of compliance. *When resident becomes agitate, Intervene before agitation escalates, guide away from source of distress, *Engage calmly in conversation, If response is aggressive, staff to walk calmly away and approach later. *Staff to converse with me during cares. Review of Form #1171, on 2/28/23 at 10:00 p.m., documented, Staff B, CNA (certified nursing assistant) reported that Staff C, CNA (certified nursing assistant) raised his voice at Resident #2 being verbally aggressive and told her to shut up. That man was mean to me. He was pissed off about something but I don't think it was me. I was scared. He used a loud voice, but we are human and that happens when someone is upset. He got close to my face and moved around like he was angry. The Self Report dated 3/1/23 at 11:04 a.m., documented the allegation of abuse approximated date/time occurred: 2/28/23 at 10:00 p.m., that Staff B, reported that Staff B and Staff C were putting Resident #2 to bed. The resident would not turn or move because she wanted a magazine while were were doing cares. Staff C raised his voice and got close to the resident face and told her no we are not giving you a magazine. In an interview on 4/3/23 at 12:18 p.m., Staff B, confirmed and verified that Staff C raised his voice to Resident #2 and told the resident to shut up. In an interview on 4/3/23 at 2:15 p.m Staff C, confirmed and verified that he raised his voice at Resident #2 and told the resident I don't deserve to be treated like this and to stop yelling and screaming. Staff C explained that he raised his voice to the resident. In an interview on 4/5/23 at 11:11 a.m., the facility Administrator confirmed and verified that they failed to report the incident within the 2 hour time frame that the facility policy and procedure stated. The Abuse Prevention Program and Reporting Policy with a revise date 08/2019, documented Reporting: *Report the incident immediately to the Administrator, and Director of Nursing. *Notify the appropriate State Agency immediately by fax or telephone after identification of alleged/suspected incident. Initiate process according to State-specified regulations. *Notify the legal guardians, spouses, or responsible family members/significant others of the alleged or suspected resident abuse immediately. *Report results of investigation to the proper authorities as required by State law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident, and staff interviews, the facility failed to provide care and services according to accepted standards of clinical practice for 1 of 4 residents reviewed (Resident #1). The facility failed to provide breakfast and administer medications. The facility also failed to offer or provide a snack for an insulin dependent diabetic resident going to an out of town appointment. The facility reported a census of 34 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 15, indicating intact cognition. The MDS identified Resident #1 was independent with bed mobility and walking in the corridor. The MDS identified Resident #1 required supervision and assistance of one person with transfers and limited assistance of one person with toilet use. The MDS included diagnoses of Type 2 Diabetes Mellitus with Hyperglycemia, Chronic Lung Disease, Anxiety Disorder, Depression, and Hypertension (high blood pressure). The Progress Note dated 11/8/22 at 6:14 a.m. revealed Resident #1 went to Iowa City for a dental appointment. The Progress Notes on 11/8/22 lacked documentation on when Resident #1 returned from the appointment. Resident #1's November 2022 Medication Administration Records (MAR) and Treatment Administration Records (TAR) revealed morning (AM) medications, blood sugar (AM and lunch) and insulin (routine and sliding scale) were not administered. The MAR and TAR documented a 3 for the AM medications which indicated Resident #1 was not in the facility and medications were not administered. The noon blood sugar and sliding scale insulin lacked documentation and was blank which indicated the blood sugar check and insulin were not completed. The November 2022 MAR and TAR included the following orders to be administered on 11/8/22 in the AM: a. Calcium Carbonate-Vit D-Min Tablet 600-400 MG-Unit (milligram) b. Cetirizine HCL 10 mg c. Januvia Tablet 100 mg d. Lasix Tablet 60 mg e. Lisinopril Tablet 10 mg f. Omeprazole Capsule Delayed Release 20 mg g. Vitamin D3 Tablet 25 MCG (microgram) h. Zoloft Tablet 50 mg i. Budesonide-Formoterol Fumarate Aerosol 160-4.5 MCG/ACT 2 inhalations j. FiberCon Tablet 623 mg k. Metoprolol Tartrate Tablet 25 mg l. Refresh Tears Solution 0.5% One drop in both eyes m. Insulin glargine- inject 88 units subcutaneously (beneath the skin) n. Novolog (insulin) solution- 100 units/ml (milliliter) per sliding scale (varied dose of insulin based on blood sugar levels). (AM and Lunch) During an interview on 4/03/23 at 3:15 p.m., Resident #1 reported he went to an early morning dental appointment in Iowa City a couple months ago. He stated the facility did not arrange for a staff member to go with him. He reported he did not have breakfast, medications, or insulin before he left for the appointment. He stated the facility did not send any food with him. He reported he did not eat until he returned to the facility around 1 PM. During an interview on 4/4/23 at 12:23 p.m., the Administrator reported residents are able to go to appointments unaccompanied depending on their BIMs score, physical needs, and behaviors. The Administrator reported the facility did not have a policy or procedure regarding transportation. During an interview on 4/4/23 at 1:00 p.m., Staff A, Licensed Practical Nurse (LPN) reported if Resident #1 had an early morning appointment, she would expect the overnight nurse to provide breakfast and administer medications prior to leaving. Staff A, LPN reported Resident #1 is a brittle diabetic and would need to eat before he went to the appointment. During an interview on 4/4/23 at 3:00 p.m., the Director of Nursing verified she would expect staff members to provide breakfast, administer medications per physician orders, and send a snack when going to out of town appointments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility investigation, facility policy/procedures, and staff interviews the facility failed to conduct a thorough investigation of an allegation of abuse. On 2/28/23, the facility staff learned of a Certified Nurse Aide (CNA) raising their voice with verbal aggression and told Resident #2 to shut up. After learning of this allegation of abuse, the facility staff told the CNA not to help Resident #2, but allowed them to work with supervision with other residents. The facility identified a census of 34 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE], documented Resident #2 with a Brief Interview for Mental Status (BIMS) score of 14 for which indicated no impaired decision making abilities with verbal behavior symptoms directed towards others. The MDS also documented the resident as required extensive assistance of two staff with all activities of daily living and diagnoses for which included Hypertension, Diabetes Mellitus, Depression, Psychotic Disorder, and Schizophrenia. The plan of care with an initiated date of 11/21/2022, stated the resident has potential to demonstrate verbally abusive behaviors, Interventions include: *Provide positive feedback for good behavior. Emphasize the positive aspects of compliance. *When resident becomes agitate, Intervene before agitation escalates, guide away from source of distress, *Engage calmly in conversation, If response is aggressive, staff to walk calmly away and approach later. *Staff to converse with me during cares. Review of Form #1171, on 2/28/23 at 10:00 p.m., documented, Staff B, CNA (certified nursing assistant) reported that Staff C, CNA (certified nursing assistant) raised his voice at Resident #2 being verbally aggressive and told her to shut up. That man was mean to me. He was pissed off about something but I don't think it was me. I was scared. He used a loud voice, but we are human and that happens when someone is upset. He got close to my face and moved around like he was angry. Staff C left the building and took a break. Staff C did not do any cares with Resident #2. The Self Report dated 3/1/23 at 11:04 a.m., documented the allegation of abuse approximated date time occurred: 2/28/23 at 10:00 p.m., that Staff B, reported that Staff B and Staff C were putting Resident #2 to bed. The resident would not turn or move because she wanted a magazine while we were doing cares. Staff C raised his voice and got close to the resident face and told her no we are not giving you a magazine. The Summary stated that Staff C did yell at the resident because she was yelling at me. I don't deserve to be yelled at. Resident #2 was screaming at us. Resident is not rolling for us. Staff C, commented I did yell at the resident and told the resident to shut up last night. Staff C stated I am tired of being abused and quit. Review of the Time Entries Audit Trail Report dated 4/6/23 at 11:15 a.m., revealed Staff C worked on 2/28/23 from 6:44 p.m., through 3/1/23 at 5:39 a.m. In an interview on 4/4/23 at 5:24 p.m., Staff D, LPN (licensed practical nurse) stated she helped do rounds the rest of the shift and made sure Staff D did not work with Resident #2 and was not alone with the other residents. In an interview 4/5/23 at 12:25 p.m., the facility Director of Nursing, confirmed and verified that the directive to Staff D, was to not allow Staff C into Resident #2 room and to supervise Staff C through out the entire shift. The facility Director of Nursing acknowledged that a directive to remove Staff C from the facility according to the facility Abuse policy/procedures was not followed. In an interview on 4/5/23 at 11:11 a.m., the facility Administrator confirmed and verified that they failed to give any directives to the facility staff to remove Staff C from the facility according to the Abuse policy/procedures. The Abuse Prevention Program and Reporting Policy with a revise date 08/2019, documented the facility prohibits the mistreatment, neglect, and abuse of residents by anyone including but not limited to staff, family, or friends. The policy further documented the facility must provide for the immediate safety of the resident upon identification of suspected abuse, neglect, mistreatment, and/or misappropriation of property. The policy documented in the case a direct caregiver being suspended for allegedly abusing, neglecting, or mistreating a resident, the Administrator (in their absence the Director of Nursing, Assistant Director of Nursing, Charge Nurse, in that order) must immediately relieve the individual of their duties without pay (suspend) until the investigation is complete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to complete a significant change Minimum Data Set (MDS) for 1 of 16 (Resident #5) residents reviewed. Resident #5 no longer required Hospice services, a Significant Change MDS was initiated at the time but was not completed. A Significant Change in Status MDS was required when this resident came off of hospice. The facility reported a census of 28. Findings include: The Census sheet from Resident #5's electronic health record showed the following changes, which revealed this resident came out of Hospice status on 5/31/22: 7/4/2022 Medicaid IA - Total Care N Active TI LL South 1 15-A Private 7/3/2022 Medicaid IA - Total Care N Unpaid Hospital Leave TO [NAME] South 1 15-A Private 6/12/2022 Medicaid IA - Total Care N Active RL LL South 1 15-A Private 6/12/2022 Medicaid IA - Total Care N Unpaid Hospital Leave TO LL South 1 15-A Private 5/31/2022 Medicaid IA - Total Care Y Active PC LL South 1 15-A Private 4/1/2022 Hospice Medicaid IA Y Active LC LL South 1 15-A Private 3/22/2022 Hospice Medicaid IA Y Active PC LL South 1 15-A Private 3/19/2022 Medicaid IA - Total Care Y Active AA LL South 1 15-A Private Review of records on 7/6/22 at 8:55 AM, revealed Resident #5 came off of Hospice and a Significant Change MDS Review with a date of 6/8/22, was initiated but not completed. The Significant Change at that time showed in this resident's chart as in progress. A Quarterly MDS Review was initiated after this on 6/30/22 and was not completed. Both of these reviews showed they were in progress. On 7/6/22 at 11:06 AM, the Administrator stated the Significant Change dated 6/6/22, for Resident #5, should have been completed. She stated they are removing the Quarterly Review as that had been set up prior to the Significant Change Review. She stated they will finish the Significant Change on this day. The Nursing Home Administrator stated she understood this was a concern. A MDS for Resident #5 and dated 6/8/22, documented the reason for the assessment was a Significant Change. The MDS was partially completed when reviewed on 7/6/22. Review of the list of MDS on 7/6/22 at 12:41 PM, revealed the Significant Change had changed from In Progress to Export Ready: 6/30/2022 Quarterly - None PPS / In Progress 6/8/2022 Significant Change - None PPS / Export Ready 3/28/2022 admission - None PPS / Accepted 3/26/2022 Medicare - 5 Day / Completed 3/19/2022 Entry / Accepted The facility did not provide a MDS Significant Change Review policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to fill out a Minimum Data Set (MDS) accurately for 1 of 16 residents (Resident #6) reviewed. The MDS for Resident #6 did not reflect multiple falls for this resident. The facility reported a census of 28 residents. Findings include: A MDS dated [DATE], documented Resident #6's diagnoses included non-Alzheimer's dementia and degenerative disease of the nervous system. A Brief Interview for Mental Status (BIMS) for this resident showed a score of 7 out of 15. This indicated severely impaired cognition. The MDS revealed the facility did not answer the questions regarding falls for this resident, they were left blank. The MDS showed an admission date of 2/3/22. Review of Progress Notes on 6/29/22 at 12:10 PM, documented Resident #2 had 10 falls since his admission on [DATE] and one of the falls resulted in broken ribs. The dates of the falls were as follows: 3/5/22, 3/12/22 (rib fractures), 3/16/22, 3/23/22, 3/26/22 (2 falls on this day), 6/1/22, 6/18/22, 6/21/22, and 6/25/22. The Care Plan for this resident was reviewed on 6/29/22. The Care Plan was updated after the fall with the broken ribs, no other revisions or interventions were made to this resident's Care Plan. On 7/7/22 at 12:50 PM , the Nursing Home Administrator (NHA), stated she was unaware that Resident #6's fall questions were left unanswered on his last MDS. She acknowledged that they should have been answered. A Care Plan Development policy dated 8/15, documented an individualized, comprehensive care plan would be developed for each resident using the MDS assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interviews, observations, and record review, the facility failed to ensure services were provided to maintain a resident's abilities to carry out activities of daily living for 1 of 24 residents reviewed, (Resident #3). Physical Therapy recommended a restorative ambulation program for this resident and it did not get added to this resident's plan of care, therefore staff were not able to provide the assistance recommended. The facility reported a census of 28. Findings include: A Minimum Data Set (MDS) dated [DATE], documented diagnoses for Resident #3 included seizures, history of TIAs (transient ischemic attacks) and CVA (cerebrovascular accident (stroke)). The Brief Review for Mental Status (BIMS) revealed a score of 14 out of 15. This indicated Resident #3's cognition was intact. This resident required extensive assist of 2 for transfers and ambulation. This resident admitted to the facility on [DATE]. On 6/27/22 at 11:07 AM, Resident #3 was lying in bed. The head of his bed was up and his covers were up to his chin. There were 2 urinals on the garbage next to his bed. This resident appeared to be sleeping. On 6/28/22 at 3:01 PM, Resident #3 stated he was being seen in therapy. This resident was lying in bed. When asked if lying in bed was by choice, he stated that's all he can do. This resident did not expound on what he meant by that. On 7/6/22 at 10:35 AM, Staff D, Physical Therapy Assistant (PTA), stated this resident had been on their case load before. When asked how nursing knows Physical Therapy's recommendations, Staff D stated he normally hands the Therapy Status Communication plan as his communication, both during therapy treatment and after discharge (the restorative plan), to the Director of Nursing (DON). Staff D stated he just recently had nursing start signing the notes, when Staff D gave the Therapy Status Communication to nursing. Staff D said he also had, in the past, given copies to the nurses, so they could relay the information to the certified nursing assistants (CNAs). Staff D stated Resident #3 had recently finished his therapy the week prior. A Therapy Status Communication dated 6/28/22, was provided by Staff D for Resident #3. The instructions included: 1. Physical therapy was discontinuing. 2. FMP/RMP (functional maintenance program/Risk Management Plan) consisted of ambulating with patient using a hemi-walker in right upper extremity and left KAFO (knee ankle foot orthosis) locked, gait belt and wheel chair following. 3. Ambulate as patient tolerates. This Therapy Status Communication was signed by Staff D and the DON. A review of Resident #3's Care Plan on 7/6/22 at 2:11 PM, revealed the recommendations from Staff D the prior week were not added. This resident had a focus area initiated on 7/2/21, of alteration in musculoskeletal status related to a history of stroke with left sided weakness. The goal initiated on 10/5/21 was this resident's mobility will be improved by participating in a restorative therapy program. This focus area directed staff Resident #3 would stand by his bedside or transfer to his chair/bed 6 times a day for strengthening. The Tasks (list of individualized care that CNA's sign for when they provide care for a resident) for Resident #3 was reviewed on 7/6/22 at 2:19 PM. The Task for nursing rehab directed staff to stand or transfer this resident 6 times a day for strengthening. No further direction was found regarding ambulation. On 7/6/22 at 5:00 PM, the DON, stated the restorative communication never made it to the Tasks, so the CNA's that take care of this resident would know what the recommendations were. She stated the recommendations did not get added to his care plan either. She stated the current activities director was going to take over the restorative program 2 months ago. She said unfortunately, they did not get it going. The DON acknowledged the restorative recommendations from PT have not been implemented for this resident. She acknowledged understanding that processes were not being carried through for restorative orders. She stated they are working on all of this. A Restorative Nursing Policy dated 5/14, had directions that included: the facility strives to enable residents/patients to attain and maintain their highest practicable level of physical, mental, and psychosocial functioning. The works with interdisciplinary team the resident/patient and family/responsible party to identify measurable restorative goals and practical interventions that can be implemented and achieved with nursing support. A licensed nurse manages the restorative nursing process with assistance of assistants trained in nursing providing restorative care. Components of the restorative nursing program include, but are not limited to, the following: -Interdisciplinary process to identify residents/patients who would benefit from a restorative nursing program -Development of measurable goals and individualized interventions for a specific restorative program -Evaluation of progress towards goals and effectiveness of interventions -Interdisciplinary process to identify when a resident/patient is appropriate to discharge from restorative nursing Identify restorative goals and interventions with input from the interdisciplinary team and the resident/ patient and family/responsible party. Document individualized restorative goals and interventions. Document resident/patient daisy participation and actual number of minutes Communicate interventions and goals to the caregiving team, Monitor and document resident/patient progress towards goals weekly. Evaluate effectiveness of interventions and progress toward goals during Care Management meeting. Modify and document goals and interventions as indicated. Communicate changes to the caregiving team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure respiratory care was provided in accordance to professional standards for 1 out of 2 residents reviewed, (Resident #8). The facility did not set up a titration of oxygen (O2) order along with a pulse oximeter check to determine if this resident required supplemental oxygen. The facility reported a census of 28 residents. Findings include: A Minimum Data Set (MDS) dated [DATE], documented diagnoses for Resident #8 included psychotic disorder. This resident's Brief Interview for Mental Status (BIMS) showed a score of 15 out of 15. This indicated intact cognition. The MDS showed this resident used oxygen. An observation on 6/27/22 at 2:51 PM, revealed Resident #8 was wearing oxygen tubing per nasal cannula (nc). The liter(L) flow was on 0 (no O2 was flowing). Resident #8 stated she is on O2 all of the time. Resident #8 stated she had asthma. An observation on 6/28/22 at 3:07 PM, revealed O2 was on at 2L per nc. Resident was sleeping at that time. A review of this resident's Care Plan on 6/29/22 at 8:43 AM, revealed this resident did not have O2 use Care Planned. A Physician's Order dated 1/28/21, directed staff 02 was to be applied via nc if 02 saturations (level of O2 in the blood) were <90% on room air (RA). A review of this resident's record on 6/28/22, revealed there was not an O2 titrate order on the June 2022 Medication Administration Record/Treatment Administration Record (MAR/TAR). A change O2 tubing weekly every Sunday was on the TAR with an order date of 11/8/21. When told about the lack of an O2 order at that time on the MAR, the Nursing Home Administrator (NHA) stated she would look into it. On 6/28/22 at 5:38 PM, the Director of Nursing (DON) stated she thought the nurses did not put the doctor's order in the right way and that is why it was not showing up on the MAR. When observations were shared with the DON of O2 tubing on with the liter flow at 0 one day and then at 2L the next, the DON acknowledged the O2 titration order should be on the MAR/TAR to show the reason to administer the O2. The NHA was with the DON during this conversation and concurred. The DON stated Resident #8 started using O2 when she had Covid and had kind of kept using it since then. On 6/29/22 at 8:31 AM, the DON stated she hadn't done anything with this resident's O2 yet as she hadn't had time. She stated it was on her list of things to do. On 6/29/22 at 8:43 AM, Resident #8 was not in her room. O2 concentrator was in room with tubing on top of it. A resident coming down the hall stated that Resident #8 had went to a doctor's appointment outside of the facility. On 6/29/22 at 11:30 AM the DON stated she obtained a new O2 order for Resident #8 as the liter flow was not specified on the old order. A Doctor's Order on 6/29/22 at 11:25 AM, directed O2 be used PRN (as needed) to keep O2 saturations equal to or greater than 90%. Check O2 level every shift. Contact provider if there is no improvement in O2 saturations or if this resident has shortness of breath. On 6/29/22 at 11:09 AM, the NHA acknowledged there are concerns with Resident # 8's titrate order for O2 not being on MAR with resident using O2 anyway. An Oxygen Administration Policy/Procedure revised on 6/15/21, directed: 1. Verify physician's order to include, but not be limited to: · Flow rate · Duration of use (PRN, continuous, etc.) · Parameters for monitoring O2 saturation, as indicated 2. Identify resident/patient, explain procedure, and provide privacy. 3. Assemble equipment in the resident/patient room. 4. Wash hands. 5. Connect nasal cannula to oxygen source and set the prescribed flow rate. · Humidification is required for O2 flow rate greater than 4Lpm · O2 rates of 6Lpm or less may be delivered per nasal cannula 6. Adjust cannula to assure optimal fit and resident/patient comfort. 7. Date disposable supplies upon opening. · Change disposable equipment as indicated; refer to Respiratory Equipment Change guide in this manual. 8. Place Oxygen in Use signs on the resident/patient's door when required per life safety code. 9. Assist resident/patient to a comfortable position with call light in reach. 10. Wash hands. 11. Instruct resident/patient to notify nursing staff of discomfort or concerns. 12. Document the following: · Date and time · O2 concentration · Flow rate · O2 saturation, as ordered · Resident/patient response to procedure · Education completed, as indicated 13. Observe resident/patient for complaints or changes in condition. 14. Monitor O2 flow rate and O2 saturation, as ordered. 15. Notify the physician of any changes or concerns. 16. Review and revise treatment plan, as indicated and per physician order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure follow up on Monthly Medication Review (MRR) recommendations by the pharmacist were addressed for 3 out of 6 residents reviewed (Resident #1, #6 and #14). Residents #1 and #14 had orders for PRN (as needed) anti-psychotic medications for longer than 14 days and Resident #6 had an order for an as needed anxiolitic that did not have a discontinuation date on it. The facility reported a census of 28. Findings include: 1. Minimum Data Set (MDS) dated [DATE], documented Resident #1's diagnoses included non-Alzheimer's dementia and psychotic disorder. A Brief Interview for Mental Status (BIMS) for Resident #1, showed a score of 13 out of 15. This indicated Resident #1's cognition was intact. His admission date was on 9/23/20. A Physician's Order dated on 2/19/21, directed Seroquel (anti-psychotic) 12.5 mg to be given every 12 hours as needed for anxiousness. This order was discontinued on 4/15/21, exceeding the 14 day limit. A Monthly Regimen Review (MMR) done by a pharmacist and issued on 3/31/21, documented this was a REPEATED RECOMMENDATION (in all capital letters) from 2/26/21 and was addressed to the physician and the Director of Nursing (DON). It recommended the following: Please respond promptly to assure facility compliance with Federal regulations. Please make sure proper protocol is being followed to prevent from getting a tag. A new script is needed for this order to continue after being examined by his provider. This resident has a PRN order for an antipsychotic: Seroquel 12.5 mg BID anxiousness. Recommendation: This PRN antipsychotic was to be discontinued (d/c'd) after 14 days from 2/19/21. If this PRN antipsychotic is to continue, current regulations require that the prescriber directly examine the resident to determine if the antipsychotic is still needed and document the specific condition being treated prior to issuing a new PRN order. Rationale for Recommendation: Centers for Medicare and Medicaid Services (CMS) requires that PRN orders for antipsychotic drugs be limited to 14 days. A new order should not be written without the prescriber directly examining the resident and assessing the resident's condition and progress to determine if the PRN antipsychotic is still needed. Report of the resident's condition from facility staff to the prescriber does not meet the criteria for an evaluation. References: 42 CFR 483, Subpart B - Requirements for Long Term Care Facilities. 2. A MDS dated [DATE], documented Resident #14's diagnoses included non-Alzheimer's dementia and anxiety. A BIMS for Resident #14, showed a score of 5 out of 15. This indicated severely impaired cognition. Her admission date from an acute hospital visit was on 2/24/22. A Physician Order with a start date of 3/2/22, directed Resident #14 could have Haldol Solution 5 MG/ML (anti-psychotic) Injection 5 mg intramuscularly every 24 hours as needed for agitation, exit seeking, combative behavior. This medication was discontinued on 4/28/22, exceeding the 14 day limit. A Monthly Regimen Review done by a pharmacist for this resident and issued on 4/26/22, documented this was a REPEATED RECOMMENDATION (in all capital letters) from 3/31/22 and was addressed to the physician and the Director of Nursing (DON). It recommended the following: Please respond promptly to assure facility compliance with Federal regulations. Resident #14 has a PRN order for an antipsychotic without a stop date: haloperidol 5 mg lM once daily as needed. Recommendation: Please discontinue PRN haloperidol or add a stop date that does not exceed 14 days from initiation. If this PRN antipsychotic cannot be discontinued at this time, current regulations require that the prescriber directly examine the resident to determine if the antipsychotic is still needed and document the specific condition being treated prior to issuing a new PRN order. Rationale for Recommendation: CMS requires that PRN orders for antipsychotic drugs be limited to 14 days. A new order should not be written without the prescriber directly examining the resident and assessing the resident's condition and progress to determine the PRN antipsychotic is still needed. Report of the resident's condition from facility staff to the prescriber does not meet the criteria for an evaluation. 3. A MDS dated [DATE], documented Resident #6's diagnoses included non-Alzheimer's dementia and degenerative disease of the nervous system. A BIMS for this resident showed a score of 7 out of 15. This indicated severely impaired cognition. The MDS showed an admission date of 2/3/22. A Physician Order with a start date of 3/26/22, directed Resident #14 could have Lorazepam 0.5-1 ml orally every 2 hours as needed for restlessness and agitation. This medication was discontinued on 4/28/22. A MMR done by a pharmacist and issued on 4/26/22, documented this was a REPEATED RECOMMENDATION (in all capital letters) from 3/31/22 and was addressed to the physician and the Director of Nursing (DON). It recommended the following: Please respond promptly to assure facility compliance with Federal regulations. It documented that this resident had a PRN order for an anxiolytic, without a stop date: Lorazepam 0.5 every 2 hours as needed. Recommendation: Please add a stop date to this medication such as 90 days and re-evaluate use. Current regulations require that the prescriber document the indication for use, the intended duration of therapy, and the rationale for the extended time period. Rationale for Recommendation: CMS requires that PRN orders for non-antipsychotic psychotropic drugs be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rationale for the extended time period, and the duration for the PRN order. On 7/7/22 12:50 PM , the Nursing Home Administrator (NHA), stated she was not aware that multiple recommendations for a decrease in as needed psychotropic medications were made on the MRR's. She stated there is a process error and it needed improvement. She stated understanding that the pharmacists were required to do a MRR and every month there needed to be a response to the pharmacist recommendations from the physician and or nursing department, depending on to whom the recommendation is being made. The NHA stated she is aware a PRN anti-psychotic should only be ordered for no more than 14 days. A LTC (long term care) Facility's Services and Procedures Manual-9.1 Medication Regimen Review with a revision date of 3/20/20, directed the consultant pharmacist will conduct MRR's and will make recommendations based on the information available in the residents' health record. The pharmacist will address copies of residents' MRR's to the Director of Nursing (DON) and/or the attending physician, and the Medical Director. The facility should ensure the attending physician, the Medical Director and the DON are provided copies. The facility should encourage the Physician/prescriber and the DON to act upon the recommendations. For issues that require Physician/Prescriber intervention, the facility should encourage the Physician/Prescriber to either accept and act upon the recommendations contained within the MRR, or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If the attending physician has decided to make no change in the medication, the attending physician should document the rationale in the residents' health care record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure as needed (PRN) orders for anti-psychotic drugs were limited to 14 days for 2 out of 6 (Resident #1 and #14) residents and a PRN anxiolytic drug had a stop date on it for 1 out of 6 (Resident #6) residents reviewed. Residents #1 and #14 had orders for PRN anti-psychotic medications for longer than 14 days without a physician's assessment and Resident #6 had an order for an as needed anxiolitic that did not have a discontinuation date on it. The facility reported a census of 28. Findings include: 1. Minimum Data Set (MDS) dated [DATE], documented Resident #1's diagnoses included non-Alzheimer's dementia and psychotic disorder. A Brief Interview for Mental Status (BIMS) for Resident #1, showed a score of 13 out of 15. This indicated Resident #1's cognition was intact. His admission date was on 9/23/20. A Physician's Order dated on 2/19/21, directed Seroquel (anti-psychotic) 12.5 mg to be given every 12 hours as needed for anxiousness. This order was discontinued on 4/15/21, exceeding the 14 day limit. A Monthly Regimen Review (MMR) done by a pharmacist and issued on 3/31/21, documented that this was a REPEATED RECOMMENDATION (in all capital letters) from 2/26/21 and was addressed to the physician and the Director of Nursing (DON). It recommended the following: Please respond promptly to assure facility compliance with Federal regulations. Please make sure proper protocol is being followed to prevent from getting a tag. A new script is needed for this order to continue after being examined by his provider. This resident has a PRN (as needed) order for an antipsychotic: Seroquel 12.5 mg BID anxiousness. Recommendation: This PRN antipsychotic was to be discontinued (d/c'd) after 14 days from 2/19/21. If this PRN antipsychotic is to continue, current regulations require that the prescriber directly examine the resident to determine if the antipsychotic is still needed and document the specific condition being treated prior to issuing a new PRN order. Rationale for Recommendation: CMS requires that PRN orders for antipsychotic drugs be limited to 14 days. A new order should not be written without the prescriber directly examining the resident and assessing the resident's condition and progress to determine if the PRN antipsychotic is still needed. Report of the resident's condition from facility staff to the prescriber does not meet the criteria for an evaluation. References: 42 CFR 483, Subpart B - Requirements for Long Term Care Facilities. 2. A MDS dated [DATE], documented Resident #14's diagnoses included non-Alzheimer's dementia and anxiety. A BIMS for Resident #14, showed a score of 5 out of 15. This indicated severely impaired cognition. Her admission date from an acute hospital visit was on 2/24/22. A Physician order with a start date of 3/2/22, directed that Resident #14 could have Haldol Solution 5 MG/ML (anti-psychotic) Injection 5 mg intramuscularly every 24 hours as needed for agitation, exit seeking, combative behavior. This medication was discontinued on 4/28/22, exceeding the 14 day limit. A Monthly Regimen Review done by a pharmacist and issued on 4/26/22, documented that this was a REPEATED RECOMMENDATION (in all capital letters) from 3/31/22 and was addressed to the physician and the Director of Nursing (DON). It recommended the following: Please respond promptly to assure facility compliance with Federal regulations. Resident #14 has a PRN order for an antipsychotic without a stop date: haloperidol 5 mg lM once daily as needed. Recommendation: Please discontinue PRN haloperidol or add a stop date that does not exceed 14 days from initiation. If this PRN antipsychotic cannot be discontinued at this time, current regulations require that the prescriber directly examine the resident to determine if the antipsychotic is still needed and document the specific condition being treated prior to issuing a new PRN order. Rationale for Recommendation: Centers for Medicare and Medicaid Services (CMS) requires that PRN orders for antipsychotic drugs be limited to 14 days. A new order should not be written without the prescriber directly examining the resident and assessing the resident's condition and progress to determine the PRN antipsychotic is still needed. Report of the resident's condition from facility staff to the prescriber does not meet the criteria for an evaluation. 3. A MDS dated [DATE], documented that Resident #6's diagnoses included non-Alzheimer's dementia and degenerative disease of the nervous system. A BIMS for this resident showed a score of 7 out of 15. This indicated severely impaired cognition. The MDS showed an admission date of 2/3/22. A Physician Order with a start date of 3/26/22, directed that Resident #14 could have Lorazepam 0.5-1 ml orally every 2 hours as needed for restlessness and agitation. This medication was discontinued on 4/28/22. A Monthly Regimen Review (MMR) done by a pharmacist and issued on 4/26/22, documented that this was a REPEATED RECOMMENDATION (in all capital letters) from 3/31/22 and was addressed to the physician and the Director of Nursing (DON). It recommended the following: Please respond promptly to assure facility compliance with Federal regulations. It documented that this resident had a PRN order for an anxiolytic, without a stop date: Lorazepam 0.5 every 2 hours as needed. Recommendation: Please add a stop date to this medication such as 90 days and re-evaluate use. Current regulations require that the prescriber document the indication for use, the intended duration of therapy, and the rationale for the extended time period. Rationale for Recommendation: CMS requires that PRN orders for non-antipsychotic psychotropic drugs be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rationale for the extended time period, and the duration for the PRN order. On 7/7/22 12:50 PM , the Nursing Home Administrator (NHA), stated she was not aware that multiple recommendations for a decrease in psychotropic medications were made on the MRR's. She stated there is a process error and it needed improvement. She stated understanding that the pharmacists were required to do a MRR and every month there needed to be a response to the pharmacist recommendations from the physician and or nursing department, depending on to whom the recommendation is being made. The NHA stated she is aware a PRN anti-psychotic should only be ordered for no more than 14 days. A LTC (long term care) Facility's Services and Procedures Manual-9.1 Medication Regimen Review with a revision date of 3/20/20, directed that the consultant pharmacist will conduct MRR's and will make recommendations based on the information available in the residents' health record. The pharmacist will address copies of residents' MRR's to the DON and/or the attending physician, and the Medical Director. The facility should ensure that the attending physician, the Medical Director and the DON are provided copies. The facility should encourage the Physician/prescriber and the DON to act upon the recommendations. For issues that require Physician/Prescriber intervention, the facility should encourage the Physician/Prescriber to either accept and act upon the recommendations contained within the MRR, or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If the attending physician has decided to make no change in the medication, the attending physician should document the rationale in the residents' health care record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure participation of residents and/or their representatives in the residents' plan of care for 4 out of 4 residents (Residents #2, #8, #9, and #14) reviewed. The facility failed to include residents and/or their representatives to take part in the residents' care planning and were not able to provide documentation of invitations to care planning meetings or attendance at the care planning meetings. The facility failed to revise residents' care plans with changes and updates for 5 out of 16 residents reviewed, (Residents #3, #6, #8, #14 and #129) . The facility reported a census of 28 residents. Findings include: 1. A Minimum Data Set (MDS) dated [DATE], documented Resident #2's diagnoses included anxiety and chronic obstructive pulmonary disease (COPD). A Brief Interview for Mental Status (BIMS) for Resident #2, showed a score of 15 out of 15. This indicated intact cognition. In an interview on 6/27/22 at 3:45 PM, Resident #2 stated he was not invited to care plan meetings. 2. A MDS dated [DATE], documented diagnoses for Resident #3 included seizures, history of TIAs (transient ischemic attacks) and CVA (cerebrovascular accident (stroke)). The BIMS revealed a score of 14 out of 15. This indicated Resident #3's cognition was intact. This resident required extensive assist of 2 for transfers and ambulation. This resident admitted to the facility on [DATE]. A Therapy Status Communication dated 6/28/22, was provided by Staff D for Resident #3. The instructions included: a. Physical therapy was discontinuing. b. FMP/RMP (functional maintenance program/Risk Management Plan) consisted of ambulating with patient using a hemi-walker in right upper extremity and left KAFO (knee ankle foot orthosis) locked, gait belt and wheel chair following. c. Ambulate as patient tolerates. This Therapy Status Communication was signed by Staff D and the Director of Nursing. A review of Resident #3's Care Plan on 7/6/22 at 2:11 PM, revealed the recommendations from Staff D the prior week were not added. This resident had a focus area initiated on 7/2/21, of alteration in musculoskeletal status related to a history of stroke with left sided weakness. The goal initiated on 10/5/21 was this resident's mobility will be improved by participating in a restorative therapy program. This focus area directed staff Resident #3 would stand by his bedside or transfer to his chair/bed 6 times a day for strengthening. On 7/6/22 at 5:00 PM, the Director of Nursing (DON), stated the restorative recommendations did not get added to Resident #8's Care Plan. 3. A MDS dated [DATE], documented Resident #6's diagnoses included non-Alzheimer's dementia and degenerative disease of the nervous system. A BIMS for this resident showed a score of 7 out of 15. This indicated severely impaired cognition. The MDS revealed the facility did not answer the questions regarding falls for this resident. The MDS showed an admission date of 2/3/22. Review of Progress Notes on 6/29/22 at 12:10 PM, documented Resident #2 had 10 falls since his admission on [DATE] and one of the falls resulted in broken ribs. The dates of the falls were as follows: 3/5/22, 3/12/22 (rib fractures), 3/16/22, 3/23/22, 3/26/22 (2 falls on this day), 6/1/22, 6/18/22, 6/21/22, and 6/25/22. The Care Plan for this resident was reviewed on 6/29/22. The Care Plan was updated after the fall with the broken ribs, no other revisions or interventions were made to this resident's Care Plan. Physician's Orders on reviewed on 7/6/22 at 11:59 PM showed Seroquel 25 mg was to be given 2 times a day and had a start date of 5/23/33. Review of Care Plan for this resident on 7/6/22 at 12:23 PM, revealed Seroquel, an antipsychotic, was not care planned 4. A MDS dated [DATE], documented diagnoses for Resident #8 included psychotic disorder. This resident's BIMS showed a score of 15 out of 15. This indicated intact cognition. The MDS showed this resident used oxygen. On 6/27/22 at 11:53 AM, when asked about her participation in her plan of care and her attendance at meetings, Resident #8 responded that they don't tell her about anything. She stated she had not been invited to a meeting, nor had she been involved in her plan of care. An observation on 6/27/22 at 2:51 PM, revealed Resident #8 was wearing oxygen (O2) per nasal cannula (nc). The liter(L) flow was on 0 (no O2 was flowing). Resident #8 stated she is on O2 all of the time. Resident #8 stated she had asthma. A review of this resident's Care Plan on 6/29/22 at 8:43 AM, revealed this resident did not have oxygen use care planned. 5. A Minimum Data Set (MDS) dated [DATE], documented Resident #9's diagnoses included COPD and diabetes. A Brief Interview for Mental Status (BIMS) for Resident #9, showed a score of 11 out of 15. This indicated moderately impaired cognition. The admission date was documented as 2/24/22. Review of Resident #9's Physician's Orders on 7/6/22, revealed this resident received Seroquel (antipsychotic) at that time and was started on Seroquel on 2/28/22. Review of Resident #9's Care Plan on 7/6/22 revealed psychotropic medications were not included in this residents plan of care. 6. A Minimum Data Set (MDS) dated [DATE], documented Resident #14's diagnoses included non-Alzheimer's dementia and anxiety. A BIMS for Resident #14, showed a score of 5 out of 15. This indicated severely impaired cognition. Her admission date from an acute hospital visit was on 2/24/22. In an interview on 6/27/22 at 1:22 PM, the Responsible Party and Emergency Contact (Resident's Representative) for both Resident #9 and Resident #14 stated she had not been invited to a care plan meeting nor had she participated in care planning. She stated she did not know what that was, but she would like to be a part of it. 7. A MDS dated [DATE], documented Resident #129's diagnoses included quadriplegia and a disorder of central nervous system. A Brief Interview for BIMS for Resident #129, showed a score of 15 out of 15. This indicated intact cognition. On 6/29/22 at 12:33 PM, a review of Resident #129's Care Plan revealed the facility failed to update the resident's Care Plan upon return to the facility with focus area on a new tracheotomy. On 6/29/22 at 8:43 AM, the Social Services Director (SSD), stated she notified family by letters of upcoming care plan meetings. She grabbed the care plan book that held the letters, and said oh this isn't for this year. When asked for copies she said she could not produce any. When asked how she notifies residents who are their own decision makers of care plan meetings she stated she just tells them. When asked about notifying Resident #8 of the meetings, she stated they just go over it with her. She then said they are seeking guardianship for #8. She stated she does not have documentation of providing information of care plan meetings or her going over the care plan with residents or their families. She provided a blank letter. She acknowledged understanding that concerns were voiced by resident representatives and residents that they have not been notified or invited to care plan meetings. She was unable to provide any information of notification or invitation to care plan meetings or discussion of individualized care plans for Residents #2, #8, #9, and #14. On 6/29/22 at 11:09 AM, the Nursing Home Administrator (NHA), acknowledged there are concerns with invitations/participation in care planning for Resident #2, Resident #8, Resident # 9, and Resident #14. The NHA acknowledged that O2 had not been updated on a care plan for Resident # 8. On 7/6/22 at 11:06 AM, the NHA stated that falls for Resident #6 were this resident purposefully placing himself on the ground, and staff submitting these as falls. The NHA stated they actually were not falls. The NHA stated this should be care planned. When she was told interventions for the reported falls were not added with the exception of the fall with fracture, nor was the resident crawling on the ground care planned, she stated it should have been and acknowledged this was a concern. The NHA also acknowledged that Resident #14's psychotropic's should have been care planned and Resident #129's new tracheostomy should have been care planned as well. On 7/6/22 at 12:28 PM, the NHA stated Resident #6 should have had Seroquel care planned. A Care Plan Development policy dated 8/15, directed staff that an individualized, comprehensive care plan using the results of the MDS assessment, resident/family/representative and interdisciplinary input will be developed for each resident in the facility. The resident and or family/legal guardian have the right to decline participation in the development of the care plan or decline treatment. The care plan is integral to the provision of care to the resident and will be available to team members who are responsible for providing care and services. All team members are responsible for reporting any changes to the resident's condition to the primary/charge nurse and of any goals/objectives not being met. Any changes must be reported to the MDS coordinator for review. Documentation must be consistent with the resident's plan of care and revisions will be done on an as needed basis and can be done by any member of the interdisciplinary team. The resident's/family/legal guardians are encouraged to attend care plan meeting and will be notified in writing via postal service of date and time of meeting. Accommodations for scheduling will be made according to residents/family/legal guardian availability or needs as necessary.