**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the Care Plan reflected a resident's current liquid consistency order for one of twenty-one residents reviewed for care plan revision (Resident #17). The facility reported a census of 63 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #17 revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. The Care Plan, dated 3/23/21, revealed a focus area to address I am at risk for choking and swallowing difficulty. The Intervention dated 3/14/24 revealed, Diet as ordered House Diabetic mechanical soft thicken liquids to nectar small portions. The Diet Order and Communication Form dated 2/27/24 revealed mechanical soft texture for foods and thin drinks. The Physician Order dated 2/29/24 to 4/26/24 revealed, House diabetic diet/mechanical soft texture/thin liquids. The Physician Order dated 4/26/24 revealed, House diabetic diet/mechanical soft texture/thin liquids. On 6/5/24 at 12:14 PM, observation of Resident #17 during the lunch meal revealed Resident #17 in their wheelchair in the dining room. The resident observed to drink from a cup which had a lid and straw. On 6/6/24 at 1:40 PM when queried about the fluid thickness included in the resident's Care Plan, the MDS Coordinator acknowledged she missed it and needed to take it out. On 6/6/24 at 2:10 PM, the facility's Director of Nursing (DON) explained the facility did not have a policy on care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to trim and clean fingernails for 1 of 3 residents reviewed (Resident #62) The facility reported a census of 63 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed Resident #62 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. The MDS revealed resident dependent with personal hygiene and shower/bathing. The MDS listed diagnoses for acute and chronic respiratory failure with hypoxia. The Care Plan, dated 3/28/24, included a focus area for staff assistance with Activities of Daily Living (ADL's). The plan included an intervention for total staff assistance with all ADLs. During an interview on 6/3/24 at 11:02 AM, Resident #62 stated he received a bed bath once a week. He stated he would like them to trim his nails. During an observation on 6/3/24 at 11:02 AM, the fingernails on Resident #62 left hand appeared long with dirt under the nail bed. During an interview on 6/4/24 at 1:22 PM, Resident #62 stated he received a bed bath today but they didn't clean or trim his nails. During an observation on 6/4/24 at 1:22 PM, resident's left fingernails appeared dirty and long. During an interview on 6/5/24 at 12:15 PM, the resident stated they trimmed his nails twice since he had been admitted . During an observation on 6/5/24 at 12:15 PM, fingernails on the Resident #62 left and right hand appeared to be long with dirt under the nail bed. During an interview on 6/6/24 at 9:21 AM, Staff D, Certified Nursing Assistant (CNA) stated they completed bed baths with Resident #62 for his comfort due to his pain. Staff D stated the CNA didn't cut fingernails because the nurses completed that task. During an interview on 6/6/24 at 10:01 AM, Staff A, CNA stated Resident #62 experienced a lot of pain so they only gave him bed baths. She stated she noticed Resident #62 fingernails and they cleaned them when they gave him a bed bath but he scratched his skin so he always had skin under his nails. She stated the bed baths didn't get him as clean but he refused to get into the shower chair. She stated the house supervisor would go to the resident's rooms and trim their nails. During an interview on 6/6/24 at 9:36 AM, Staff E, RN (Registered Nurse) stated the nurses trimmed the nails when they had time. She stated the house supervisor would go to the resident's room and trim them once a month. Staff E stated Resident #62 nails needed done and she didn't have time to get to them but hoped she had time today to do them. Staff E stated she didn't know if Resident #62 fingernails had been trimmed since he arrived to the facility. During an interview on 6/6/24 at 10:32 AM, the Director of Nursing (DON) stated she expected Resident #62 fingernails to be trimmed and cleaned especially because he mainly received bed baths and not showers. The DON stated the house supervisor trimmed nails monthly but last month she took time off and the resident probably missed but she still expected the floor nurses to look and trim and clean his nails if needed. During an interview on 6/6/24 at 2:10 PM, the DON stated they didn't have a policy for nail care. They followed the standard of practice for nail care. During an interview on 6/6/24 at 3:28 PM, Staff F, RN stated she conducted monthly spot audits on the residents for nail care. She stated Resident #62 got his toenails and fingernails cut on the day of admission and again on 4/11/24 and he did not get done in May or audited in May.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure catheter drainage bags were maintained off of the floor for three of three residents reviewed for catheters (Resident #17, Resident #30, Resident #41). The facility reported a census of 63 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #17 revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. The assessment revealed the resident had an indwelling catheter. The Care Plan dated 3/22/21 revealed, I require a suprapubic urinary catheter. Observation on 6/6/24 at 9:52AM revealed Resident #17 in their room in bed. The resident's catheter drainage bag present to the side of the resident's bed, and the catheter drainage bag touched the floor in the resident's room. 2. The MDS assessment for Resident #30 dated 5/23/24 revealed Resident #30 was rarely to never understood, and further revealed the resident had an indwelling catheter. The Care Plan dated 9/4/19 revealed, Indwelling Catheter I require an indwelling urinary catheter. Observation on 6/03/24 at approximately 2:30 PM revealed Resident #30 in bed. The resident's catheter bag observed on the floor. 3. The MDS assessment for Resident #41 dated 5/23/24 revealed Resident #41 was rarely to never understood, and further revealed the resident had an indwelling catheter. The Care Plan dated 10/13/20 revealed, I have a catheter. Observation on 6/04/24 at approximately 2:54 PM revealed the resident in bed, and the resident's urinary catheter drainage bag and call light were on the floor to the right side of the resident's bed. On 6/6/24 at 10:12 AM during an interview with Staff A, Certified Nursing Assistant (CNA), Staff A acknowledged the catheter bag should be on the bed railing, positioned to not touch the floor, with catheter tubing going down flow. On 6/6/24 at 2:19 PM when queried about catheter bags on the floor, the DON acknowledged the concern, acknowledged it should not happen, and explained it was an infection control issue. The Facility Policy titled Catheter, dated 11/19, did not address the area of concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident remained free from unnecessary medication when a resident who experienced loose stools was administered a laxative and stool medication for one of six residents reviewed for unnecessary medications (Resident #17). The facility reported a census of 63 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #17 revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. The Care Plan dated 9/29/21 revealed, I am incontinent of bowel. Review of Physician Orders for Resident #17 revealed the following: a. 4/26/24: Docusate sodium liquid; 50 mg (milligram)/5 mL (milliliter); amt: 20 mL; oral Once A Day. (This was noted to be a stool softener medication) b. 4/26/24: Gavilax (polyethylene glycol 3350) powder; 17 gram/dose; amout: 17 grams; gastric tube Once A Day. (This was noted to be a laxative medication). c. 5/1/24: Imodium A-D (loperamide) . tablet; 2 mg; amount: 2 1st loose stool then 1; oral Special Instructions: 1st loose stool give 2 then give 1 for each loose after that do not exceed over 8 in 24 hours As Needed. The Progress Note dated 4/28/24 at 1:40 PM documented, Incontinent of bowel. Several loose stools this shift. The Progress Note dated 4/29/24 at 11:20 PM documented, Incontinent of bowel with recent HX (history) of diarrhea. No hand off report to this nurse about diarrhea thus far today. The Progress Note dated 4/30/24 at 7:43 PM documented, Resident had a large projectile emesis and a large foul loose bm (bowel movement) twice. Resident cleaned up small sips liquids given and doctor notified awaiting orders. Head of bed up 35 degrees. Held meds due to condition .Very active bowel sounds through out. The Progress Note dated 5/1/24 at 12:10 AM revealed, Notified DON (Director of Nursing) and HCP (Health Care Provider) on res.(resident) current illness with diarrhea and not eating. HCP ordered 100 mL/hr (milliliter/hour) of fluids through peg tube for 10 hours and to continue the loperamide (Imodium). Advised the DON (Director of Nursing)and put in order. The Progress Note dated 5/1/24 at 1:16 AM revealed, Res. (resident) this shift (early in shift) had projectile vomiting that was reported to his nurse with diarrhea. Res. assessed by myself and other nurse. HCP notified and gave N.O (new order) for loperamide for res. Loperamide was started and was found to not be working. DON and HCP notified for further instructions d/t (due to) res. heart rate increased to 128 bpm (beats per minute). RR (respiratory rate) 22, spo2 (oxygen saturation) 92%. Felt needed treated for dehydration. HCP N.O (new order) for 100 ml/hour of fluids through peg tube for 10 hours and to continue loperamide .continued water hydration 100 ml/hr. resting at this time with loperamide continued for diarrhea. The Progress Note dated 5/01/24 at 6:26 AM revealed, Res. continues to have loose stools, a couple thru the night were small liquidly light brown stools the rest have been large liquidly stools. Loperamide given with no changes in stools. Held res. mirilax and docusate this a.m. med pass. No more emesis just loose stools. The Progress Note dated 5/01/24 at 6:28 AM revealed, total of 5 loperamide has been given and advised nurses on day shift hand off report of this and that res. continues to have loose stools. Review of the resident's Medication Administration Record (MAR) dated Apil 2024 revealed Docusate Sodium 20 ml and Gavilax powder 17 grams administered to the resident daily on 4/28/24 through 4/30/24. On 6/6/24 at 2:20 PM, the DON explained she would have held the medications, called the doctor/ordering provider, explained the resident having diarrhea, and see how they wanted to proceed. The Facility Policy titled Medication Administration, dated 9/17 and reviewed 2/24, did not address holding medications.

Based on clinical record review, resident and staff interviews, the facility failed to provide sufficient staff to meet the needs (bathing)for 4 of 4 residents reviewed. (Residents #1, #2, #3, #4) The facility census was 58. Findings include: In an interview on 12/5/23 at 3:20 p.m. the Director of Nursing (DON) stated staff scheduling is based on census, but notes there is no specific criteria established. The DON stated she would not like to see anything more than a 1:12 to 1:15 aide to resident ratio. Currently with 34 residents on [NAME] they would minimally schedule 2 nurses, 3 aides and 1 shower aide as adequate to meet resident needs on day and evening shifts. In an interview on 12/5/23 at 1:00 p.m. Staff E, staff scheduler, stated staff numbers are dependent on the census. Currently (census 34) they schedule 2 nurses, 4 aides and 1 or 2 shower aides during day and evening shifts. According to daily assignments sheets for October 2023 on [NAME] halls, no shower aide was scheduled on either day or evening shift on the 4th, 8th, 9th, 14th, 15th, 16th, 18th, 19th, 20th, 21st, 22nd and 29th. Additionally there were 10 day shifts (1st, 2nd, 6th, 10th, 11th, 24th, 25th, 27th, 28th and 31st) and 5 evening shifts (3rd, 6th, 11th, 12th and 31st) in which staff scheduling fell below the minimum standard of 2 nurses, 3 aides and 1 shower aide. According to daily assignments sheets for November 2023 on [NAME] halls, no shower aide was scheduled on either day or evening shift on the 4th, 5th, 15th, 25th, 26th and 27th. Additionally there were 12 day shifts (1st, 2nd, 7th, 11th, 12th, 13th, 14th, 16th, 18th 19th, 20th and 30th) and 6 evening shifts (6th, 8th, 9th, 16th, 22nd and 29th) in which staff scheduling fell below the minimum standard of 2 nurses, 3 aides and 1 shower aide. According to a Quarterly Minimum Data Set (MDS) with a reference date of 11/30/23, Resident #1 had a Brief Mental Status (BIMS) score of 14 indicating an intact cognitive status. Resident #1 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #1's diagnosis included acute and chronic respiratory failure with hypoxia, morbid obesity, coronary artery disease, congestive heart failure, diabetes mellitus, ventilator dependent and sleep apnea. In an interview on 12/6/23 at 1:00 p.m. Resident #1 indicated frustration with staff not responding to call lights timely, causing him to be incontinent of bowel and bladder and having to sit in his own excrement for lengthy periods of time. Resident #1 attributes the slow response to call lights to insufficient staffing. Resident #1 stated short staffing has also caused missed shower opportunist, noting there was a period of time a month or so ago in which he only got a shower one time a week for four weeks. According to bathing records, Resident #1 was to receive showers on Mondays and Thursdays. In October 2023, Resident #1 received a shower on October 5th and did not receive another shower until the 20th. Resident #1 did not receive scheduled bathing opportunities on October 9th, 12th, 16th and 23rd. According to a Quarterly Minimum Data Set (MDS) with a reference date of 10/12/23, Resident #2 had a Brief Mental Status (BIMS) score of 15 indicating an intact cognitive status. Resident #2 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #2's diagnosis included chronic obstructive pulmonary disease, respiratory failure, coronary artery disease, acute myocardial infarction, congestive heart failure and gastroesophageal reflux disease. According to bathing records, Resident #2 was to receive showers on Wednesdays and Saturdays. During September 2023, he received showers a week apart on 1st, 8th, and 15th, missing scheduled showers on 6th, 13th, 23rd and 30th. In October 2023 Resident #2 missed scheduled showers on the 4th, 11th, 18th, 21st and 28th and in November 2023 he missed scheduled showers on the 1st, 4th, 8th, 15th, 18th, 25th and 29th. According to a Quarterly Minimum Data Set (MDS) with a reference date of 11/2/23, Resident #3 had a Brief Mental Status (BIMS) score of 14 indicating an intact cognitive status. Resident #3 required limited assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #3's diagnosis included chronic obstructive pulmonary disease, respiratory failure, coronary artery disease, renal insufficiency, congestive heart failure and gastroesophageal reflux disease. According to bathing records, Resident #3 was to receive showers on Mondays and Thursdays. During September 2023, she missed scheduled showers on the 14th and 25th. In October 2023 she received a shower on the 2nd and not again until the 23rd. Missing scheduled showers on the 5th, 9th, 12th, 16th, 19th, 26th and 30th. In November 2023 Resident #3 missed scheduled shower opportunities on the 16th, 23rd, 27th and 30th. According to a Quarterly Minimum Data Set (MDS) with a reference date of 11/30/23, Resident #4 had a Brief Mental Status (BIMS) score of 11 indicating a moderately impaired cognitive status. Resident #4 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #4's diagnosis included Displaced comminuted fracture shaft right tibia, diabetes mellitus, cerebrovascular accident (stroke) with hemiplegia, Non-Alzheimer's dementia. According to bathing records, Resident #4 was to receive showers on Mondays and Thursdays. During September 2023, she missed scheduled showers on the 11th and 25th. In October 2023 she received a shower on the 2nd and not again until the 23rd. Missing scheduled showers on the 5th, 9th, 12th, 16th, 19th and 30th. In November 2023 Resident #4 missed scheduled shower opportunities on the 16th, 23rd and 27th. In an interview on 12/4/23 at 1:00 p.m. Staff A, Certified Nurse Aide, stated she doesn't believe resident needs can be adequately met with just three aides on the [NAME] hall. Staff A stated three aides on days is typical, but notes they are only able to get the bare minimum done. Staff A stated they are able to get to most call lights promptly. Staff A stated she believes 5 aides would be more appropriate in meeting quality care standards for residents. In an interview on 12/4/23 at 3:50 p.m. Staff B, Certified Nurse Aide, (CNA) stated they currently have three aides and one shower aide working this evening. Staff B stated that was sufficient to meet resident needs if they have quality aides working and if the day shift were able to get their showers completed. Staff B stated the Director of Nursing and CNA trainer do a good job of trying to educate aides to become better aides on the floor and are aware of some of the aides limitations. In an interview on 12/5/23 at 11:45 a.m. Staff C, Certified Nurse aide, stated today with two nurses, three aides and two shower aides on West, they have adequate staff to meet resident needs. However, Staff C stated the staffing today is often not the case, citing it is often two nurses and two or three aides without shower aides. Staff C stated she was hired as a shower aide and will often get pulled to the floor, leaving showers undone. Staff C recalled on September 10th through the 16th she worked with only one other aide and no shower aides. Staff C stated ideally having two aides on each hall (6) and two shower aides would provide the best coverage to meet resident needs. In an interview on 12/5/23 at 12:00 p.m. Staff D, CNA, stated she was hired as a shower aide and works Monday through Friday with days off for school during the week. Staff D stated she often gets pulled to the floor leaving showers undone. Staff D stated they need at least four aides with one to two shower aides during the day to meet resident needs. Staff D stated they have staff scheduled, but often have call-ins. Staff are working a lot of hours and it is sometimes hard to find staff to come in. In an interview on 12/6/23 at 2:15 p.m., Staff F, CNA, stated she was a shower aide from 6:00 a.m. to 2:00 p.m. today and stated sometimes depending on their staffing she may only work until 9:00 a.m. before being pulled to the floor. Staff F stated [NAME] hall is usually staffed with 3 to 4 aides during the day and evening. When they have 4 aides, there is usually a shower aide, but with only 3 aides there is no shower aide. Staff F stated she believes 5 to 6 aides would be ideal to meet resident needs which would include 1 to 2 shower aides during the week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to determine if self-administration of medication was safe and clinically appropriate for two (Resident (R) 11 and R37) of 27 sampled residents. Findings include: Review of a facility policy titled, Self-Administration of Medication, revised 02/2013, indicated, The facility, in conjunction with the interdisciplinary team, should assess and determine, with respect to each resident, whether self-administration of drugs is safe and appropriate. 1. a. During an observation on 02/20/23 at 1:47 PM, R11 was in her room performing her nebulizer treatment. There were no staff present during this observation. At 1:49 PM, R11 was observed turning off the nebulizer. During an interview on 02/21/23 at 9:09 AM, R11 stated that she does her nebulizer treatment three times a day. R11 stated, The nurse put the solution in and then I do the treatment for about 10 minutes. When asked if she had been assessed by staff to self-administer her nebulizer, R11 stated, No, but I know how to do it. b. During a continuous observation on 02/21/23 at 2:03 PM, R11 was in her room performing her nebulizer treatment. There were no staff present during this observation. At 2:17 PM, R11 was observed turning off the nebulizer. Review of R11's undated Resident Face Sheet, located in the resident's electronic medical record (EMR) under the Resident tab revealed the resident was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease and asthma. Review of R11's quarterly Minimum Data Set (MDS), located in the resident's EMR under the RAI (Resident Assessment Instrument) tab with an Assessment Reference Date (ARD) of 01/19/23, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R11 was cognitively intact. Review of R11's Prescription Order, dated 11/07/22, located in the resident's EMR under the Orders tab revealed, Ipratropium-albuterol solution for nebulization; 0.5 mg [milligrams]-3 mg (2.5 mg base)/3 mL [milliliters]; amt[amount]: 3 mL (one vial); inhalation. Three times a day. Continued review of R11's EMR revealed the absence of an order for self-administration of medication and no evidence that the facility had completed an assessment for self-administration of medication. Review of R11's January 2023 - February 2023 Medication Administration Record, located in the resident's EMR under the Resident tab revealed R11 received the ipratropium-albuterol solution as ordered. During an interview on 02/22/23 at 8:36 AM, when asked about R11's nebulizer treatments, Certified Medication Aide (CMA)1 stated, I set the medicine up into the canister and then she likes to do them after breakfast. So, I have it already prepared in the canister. When she returns to her room, she flips on the nebulizer and does her treatment. It takes about ten minutes complete the treatment. Later, I check on her and look at canister to verify that it is empty. 2. a. During an observation on 02/20/23 at 11:02 AM, R37 was observed seated upright on the edge of her bed with a nebulizer on the bed with the resident. b. During an observation and concurrent interview on 02/21/23 at 2:00 PM, R37 was observed seated upright on the edge of her bed with a nebulizer on the bed with the resident. When asked about the nebulizer, R37 stated, I do it myself. The staff does the medicine and I take it off when the medicine runs out and I turn off the machine. Well, yeah, sometimes they turn it on and sometimes I do, and I always turn it off. When asked how often she is scheduled to receive the nebulizer treatment, R37 stated, A couple of times a day. When asked if staff watched to ensure the treatment was done correctly, R37 stated, No. When asked if staff educated her on the nebulizer treatment, R37 stated, No, they just put in on my bed to make sure that I can reach it and they put the medicine in. c. During an observation on 02/22/23 at 11:12 AM, CMA1 administered R37's nebulizer medication and the treatment began at 11:17 AM. CMA1 proceed to administer medication to R37's roommate and then left the room at 11:17 AM. At 11:27 AM, R37 removed the nebulizer from her mouth, looked at the remaining medication in the holder, and placed the nebulizer back in her mouth. At 11:32 AM, R37 checked the remaining medication, laid the nebulizer on the bed, and turned the machine off. R37 stated she always self-administered her nebulizer treatment. R37 further stated she had not been assessed by the staff to determine if she could self-administer. Review of R37's undated Resident Face Sheet, located in the resident's EMR under the Resident tab revealed the resident was admitted to the facility on [DATE] with diagnoses of congestive heart failure and chronic respiratory failure with hypoxia. Review of R37's quarterly MDS, located in the resident's EMR under the RAI tab with an ARD of 12/29/22, revealed a BIMS score of 15 out of 15, indicating R37 was cognitively intact. Review of R37's Prescription Order, dated 11/07/22, located in the resident's EMR under the Orders tab revealed, Ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg (2.5 mg base)/3 mL; amt: 1 vial; inhalation. Four times a day. Continued review of R37's EMR revealed the absence of an order for self-administration of medication and no evidence of an assessment for self-administration of medication. Review of R37's November 2022 - February 2023 Medication Administration Record, located in the resident's EMR under the Resident tab revealed R37 received the ipratropium-albuterol solution as ordered. During an interview on 02/22/23 at 8:36 AM, when asked about R37's nebulizer treatments, CMA1 stated, I go into the room, put the medicine into the canister, I start the machine for her or sometimes she starts the machine, she does her treatment, and turns it off when she is done. I go back in later and verify the medicine has been completed. When asked about a self-administration assessment, the CMA stated, I don't know if she has been assessed to do the medication. I think that respiratory therapy would do something with that. I have witnessed her do her treatment before. During an interview on 02/22/23 at 12:07 PM, the Director of Nursing (DON) stated, There are not any self-administration assessments for these residents [R11 and R37]. The DON further stated that she was unaware R37 and R11 were self-administering their nebulizer treatment. The DON confirmed there were no physician orders for R37 or R11 to self-administer medications. During an interview on 02/22/23 at 12:09 PM, the Infection Preventionist (IP) and previous DON stated, I have seen the self-administration assessments before, but we don't do those. The IP also stated she was unaware that R37 and R11 were self-administering their nebulizers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to promote self determination to support and honor a resident's expressed desire to lose weight for one (Resident (R) 56) of five residents reviewed for nutrition out of a total sample of 27 residents. Findings include: Review of R56's undated Resident Face Sheet, located in the resident's electronic medical record (EMR) under the Resident tab revealed the resident was admitted to the facility on [DATE] with diagnoses including diabetes. The resident was listed as his own responsible party. Review of R56's quarterly Minimum Data Set (MDS), located in the resident's EMR under the RAI (Resident Assessment Instrument) tab with an Assessment Reference Date (ARD) of 08/09/22, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R56 was cognitively intact. Review of R56's Weights, located in the resident's EMR under the Resident tab revealed R56 weighed 251 pounds 08/05/2022 and 208 pounds on 02/05/2023, which was a 17.13 % (percent) weight loss in six months. Review of R56's Physician Orders, located in the resident's EMR under the Resident tab revealed the following order dated 01/28/23: Ensure Plus Protein 1 carton Twice A Day. Review of R56's Progress Notes, located in the resident's EMR under the Resident tab revealed the following notes: a. 02/03/23: assessment completed. BMI [body mass index] is 34.9 and is obese. receives a house diabetic diet with regular texture. Wts [weights] stable this quarter. also receives Ensure Pro for healing and hx [history] of wt loss. has 4 wound sites. albumin is mildly depleted. monitor wts monthly and reassess quarterly. b. 02/08/23: has had a significant weight loss in 180 days weight is stable weight 208 BMI 34.61 he is fed by staff started on ensure plus protein for wound care and when not eating as well at time chooses to eat soup at meals will cont [continue] to encourage at meals. c. 02/10/23: wt loss at 180 days. wt is stable for last 30 days. approaches for wound healing and wt loss are liquacell (100 cal[calories]/ and 16 GR [gram] protein/srvg [serving]), Ensure Plus protein (360 calories and protein per srvg). receives a house diabetic diet with regular texture. d. 02/18/23: Noted and Dr. aware of 43# [pound] weight loss in 6 months. Res continues on House Diabetic. Appetite has been good. Meals in dining room. Weight loss had happen [sic] when res was sick and in hospital. Res aware of weight loss. During an interview on 02/22/23 at 8:49 AM, when asked about his recent weight loss, R56 stated, I was 250 pounds. I didn't want to be 250 pounds, so I started eating less. During an interview on 02/22/23 at 8:44 AM, when asked about R56's weight loss, Certified Medication Aide (CMA)1 stated, He had COVID for a while and had weight loss then. He is on Ensure twice a day and he started that on 01/28/23. Sometimes he doesn't eat his entire meal. During an interview on 02/22/23 at 10:33 AM, the Social Services Director (SSD) stated, He always says that he wants to lose weight. I would tell him that he was good as he was. I thought he was teasing and just talking, you know. He didn't say it aggressively but stated he wanted to lose weight, but we were worried with his wounds and the extra protein needs. The SSD stated that she did not document R56's expressed desire to lose weight. The SSD further confirmed she did not inform the nursing staff or the dietary manager (DM) of R56's desire to lose weight. During a follow-up interview on 02/23/23 at 10:01 AM, R56 stated he told the SSD I wanted to lose weight. She told me that I was OK like I was, but I don't want to weigh 250 pounds, so I decided to cut back some. Now I eat soup and eggs and fruit. I lost my leg and decided I needed to do better with eating so I can get well. I don't want to be sick, and I don't want to weigh too much. During an interview on 02/23/23 at 10:16 AM, when asked about R56's weight loss, the Administrator stated, Yes, he has lost weight. He used to eat a lot of sweets, but I noticed that he has been eating more soups and peaches. The Administrator further stated, I was not aware that he wanted to lose weight. I would expect that if he told someone that he wanted to lose weight, it should be documented, and we should assist him in losing weight. He should not have been brushed off. It should have been documented and taken seriously. During an interview 02/23/23 at 10:48 AM, the Dietary Manager (DM) stated, I did not know that he wanted to lose weight. That was not communicated with me. I documented that he was sick and lost a limb and that attributed to his weight loss. I talked with the dietician, and she added the ensure to add the extra calories. He used to love sugar and always ate his desert first. He was always asking for honey buns and such. I would always educate him but that was still his choice. The DM further stated, After he lost his leg, I started noticing that he was asking for different foods and wasn't eating the sweets anymore. I think that, when he had the amputation, that scared him. I saw him eating less sweets but I didn't know that he wanted to lose weight. If I had known, I would have assisted him with his weight loss. During an interview on 02/23/23 at 10:57 AM, the Registered Dietitian (RD) stated, The resident has had a weight loss of over 40 pounds in the last 180 days but stabilized back in November. We have him on Ensure Pro Plus Protein twice per day which adds 720 calories a day. For his wounds, we have him on Liquacel which adds 100 calories per day. The RD further stated, I was not aware that he wanted to lose weight. If I had known, I would not have started him on the Ensure Plus but would have kept him on the Liquacel. The Ensure Plus adds an extra 720 calories. I would have addressed his weight loss differently if I had known that he wanted to lose weight. It's like a catch 22 because we are adding calories and he is eating less trying to lose the weight. During an interview on 02/23/23 at 11:27 AM, the Director of Nursing (DON) stated she was aware of R56's weight loss but was unaware that he wanted to lose weight. The DON stated, When a resident desires to lose weight, I expect this information to be documented and for the dietary department to come up with healthy food choices, taking his wounds into account. I fully expect the facility to assist him in losing weight. I feel like if a resident took the time to speak up for himself and tell someone that he wanted to lose weight, staff should have listened to him. I personally would have been upset if I approached someone with the want to lose weight and they didn't listen to me because apparently I wanted to lose weight and feel better about myself and went to someone expecting them to support me.

Based on interview, record review, and facility policy review, the facility failed to report an allegation of abuse to the State Survey Agency (SSA - Iowa Department of Inspections and Appeals) within two hours for one (Resident (R) 42) of one residents reviewed for abuse out of 27 sampled residents. Findings include: Review of the facility's policy titled, Abuse Prevention, Identification, Investigation and Reporting, dated 10/2022, indicated, All allegations of Resident abuse shall be reported to the Iowa Department of Inspections and Appeals not later than two (2) hours after the allegation is made. Review of R42's Face Sheet, located under the Resident tab of the electronic medical record (EMR), indicated R42 was admitted with diagnoses that included adjustment disorder. During an interview on 02/21/23 at 1:32 PM, R42 stated that Certified Nurse Aide (CNA) 4 and CNA5 had assisted her with personal care at some time during 12/2022 or 01/2023 and, during that care, CNA5 told CNA4 that R42 just wanted CNA4 in her pants. R42 stated this was mental abuse. R42 stated she had informed the Director of Nursing (DON) and nothing was done. During an interview on 02/21/23 at 1:38 PM, the DON denied any knowledge of the allegation. During an interview on 02/21/22 at 2:23 PM, the Administrator stated she was responsible for reporting allegations of abuse at the facility. At this time, the Administrator was notified of R42's allegation of mental abuse. During an interview on 02/22/23 at 9:51 AM, the Administrator provided a Summary Report of her investigation of the allegation of mental abuse that was reported to her, over 19 hours earlier. on 02/21/23 at 2:23 PM. The Administrator stated there was lack of evidence to support the allegation and, since the allegation was disproven within two hours, it did not have to be reported per Iowa state law. The Administrator confirmed the allegation of mental abuse had not been reported to the Iowa Department of Inspections and Appeals within two hours. The Administrator stated that the facility followed Iowa law and she did not know what the federal regulation was regarding reporting allegations of abuse. During an additional interview on 02/22/23 at 12:49 PM, the Administrator stated she had reviewed the federal regulation. The Administrator stated that the allegation (which alleged abuse and therefore required reporting within no more than two hours) was reported within 24 hours since it did not involve serious injury.

Based on interview, record review, and facility policy review, the facility failed to conduct a thorough investigation of an allegation of mental abuse for one (Resident (R) 42) of one residents reviewed for abuse out of 27 sampled residents. The facility failed to interview or attempt to obtain a witness statement from the alleged victim. Findings include: Review of the facility's policy titled, Abuse Prevention, Identification, Investigation and Reporting, dated 10/2022, revealed, Should an incident or suspected incident of Resident abuse . be reported . The administrator or designee will . Attempt to obtain witness statements . from all known witnesses. Review of R42's Face Sheet, located under the Resident tab of the electronic medical record (EMR), indicated R42 was admitted with diagnoses that included adjustment disorder. During an interview on 02/21/23 at 1:32 PM, R42 stated that Certified Nurse Aides (CNA) 4 and 5 had assisted her with personal care at some time during 12/2022 or 01/2023 and during that care, CNA5 told CNA4 that R42 just wanted CNA4 in her pants. R42 stated this was mental abuse. R42 stated she had informed the Director of Nursing (DON) and nothing was done. During an interview on 02/21/23 at 1:38 PM, the DON denied any knowledge of the incident. During an interview on 02/21/23 at 2:23 PM, the Administrator stated she was responsible for investigating allegations of abuse at the facility. At this time, the Administrator was notified of R42's allegation of mental abuse. During an interview on 02/22/23 at 9:51 AM, the Administrator provided a Summary Report of her investigation of R42's allegation of mental abuse. Review of the Summary Report indicated R42, the alleged victim, was not interviewed during the investigation. During an interview on 02/22/23 at 10:26 AM, R42 stated she had not been interviewed by any staff member regarding her allegation of mental abuse. During an additional interview on 02/22/23 at 12:58 PM, the Administrator stated she was finished with the investigation and confirmed she had not interviewed R42. The Administrator stated she did not interview R42 since the allegation of mental abuse was reported by the survey team.

Based on interview and record review, the facility failed to complete a significant change assessment for one (Resident (R) 42) of one sampled resident who experienced a significant change in status out of 27 sampled residents. A significant change (comprehensive) assessment was not completed after R42 was hospitalized for suicidal ideation and assessed as requiring specialized services. Findings include: Review of R42's Face Sheet, located under the Resident tab of the electronic medical record (EMR), indicated R42 was admitted with diagnoses that included adjustment disorder. Review of R42's Progress Note, dated 09/22/22 and located under the Resident tab of the EMR, indicated R42 was hospitalized for psychiatric care after verbalizing suicidal ideations. Review of R42's PASRR [Preadmission Screening and Resident Review] Level II Outcome Explanation, dated 10/13/22 and located under the Resident tab of the EMR, indicated R42 required specialized services due to her behavioral health conditions. Review of R42's Minimum Data Set (MDS) assessments indicated the facility completed a quarterly MDS assessment with an Assessment Reference Date (ARD) of 10/13/22. Review of this quarterly MDS, as well as the resident's MDS assessment history, revealed the facility did not complete a significant change assessment for R42 following her 09/22/22 hospitalization for suicidal ideations and PASRR Level II assessment which indicated the need for specialized services. During an interview on 02/23/23 at 4:05 PM, the MDS Coordinator (MDSC) stated R42's hospitalization and need for specialized services was a significant event that qualified for a significant change (comprehensive) assessment and confirmed one was not done. The MDSC stated the facility's policy on significant change assessments was to follow the regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a behavioral health comprehensive care plan for one (Resident (R) 42) of one residents reviewed for behavioral health concerns out of 27 sampled residents. Findings include: Review of R42's Face Sheet, located under the Resident tab of the electronic medical record (EMR), indicated R42 was admitted with diagnoses that included adjustment disorder. Review of R42's Progress Note, dated 09/22/22 and located under the Resident tab of the EMR, indicated R42 was hospitalized for psychiatric care after verbalizing suicidal ideations. Review of R42's Notice of PASRR [Preadmission Screening and Resident Review] Level II Outcome, dated 10/13/22 and located under the Resident tab of the EMR, indicated, The nursing facility will be required to Care Plan in a PASRR compliant fashion for all identified services including Specialized Services . you have a mental health diagnosis of recurrent, severe major depressive disorder . you have a history of self-harm . you shared that you are lonely, you spend most of your time in bed in your room, you miss the one-to-one interaction you had when you lived with your family, you get anxious and depressed due to your ongoing medical conditions and being in a nursing facility . Staff arguing with you . You stop doing the things you like to do and get angry very easily when you are not doing well. Going outside or having someone to talk with helps you feel better when you are having a hard time . We learned that the following things are important to and for you: You shared that you enjoy arts, crafts, drawing, drinking liquor, being outside, getting out of the nursing facility, listening to music, playing games on your phone, shopping, and watching Netflix . A good day is a day spent watching Netflix and talking with people . Going outside or talking with someone [NAME] you up when you feel down . Staff at Mississippi Valley Healthcare & Rehabilitation Center are encouraged to continue to learn about what you do and do not like, what your hobbies are, and how you like to spend your time . You will need to be provided . Development by the nursing facility in conjunction with the individual and behavioral health providers of a Crisis Intervention/Safety Plan to identify triggers and symptoms, best methods for management of challenges, action steps to be taken by all parties in order to reduce risk of hospitalization . Socialization/leisure/recreation activities appropriate to current skills or adapted to facilitate optimal participation . Supportive counseling from NF [nursing facility] staff . Because you get lonely and you have been anxious and depressed, will benefit from the support of staff to help . you manage your behavioral symptoms. Review of R42's Care Plan, revised 01/23/23 and located under the RAI (Resident Assessment Instrument) tab of the EMR, indicated R42 had a problem related to adjustment disorder. The goal was listed as learning to cope with stressful situations in a healthy manner and interventions were to monitor for hopelessness, insomnia, anxiety, anger, disruptive behavior, depressed mood, headaches, loss of appetite, withdrawing from social environment, and suicidal thoughts. There were no individualized interventions listed for R42. The care plan did not address the PASRR requirements or R42's need for specialized services, crisis plan, interventions to assist R42 in managing any behavioral symptoms, the episode of suicidal ideation requiring hospitalization, or previous attempts at self-harm. During an interview on 02/23/23 at 10:48 AM, the MDS Coordinator (MDSC) stated the Social Services Director (SSD) was responsible for ensuring behavioral concerns were addressed on the care plan. The MDSC confirmed R42's care plan did not address behaviors, specialized services, past mental health issues, crisis plan, or contain interventions related to R42's behavioral health. The MDSC confirmed the behavioral care plan should have been included in R42's plan of care. During an interview on 02/23/23 at 9:43 AM, the Social Services Director (SSD) confirmed R42's care plan did not address behaviors, specialized services, past mental health issues, crisis plan, or contain interventions related to R42's behavioral health. The SSD stated she had focused on R42's crisis plan but confirmed R42's care plan should have addressed her behavioral health concerns. During an interview on 02/23/23 at 4:16 PM, the Administrator stated the facility's policy on developing comprehensive care plans was to follow the regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to ensure appropriate treatment and services to maintain or prevent a decline in range of motion for one (Resident (R) 41) of two residents sampled for limited range of motion (ROM) in a total sample of 27 residents. R41 was not consistently provided a splint in accordance with physician orders and her restorative program. This failure had the potential for the resident's contracted hand to have a decline in range of motion. Findings include: Review of a facility policy titled, Restorative Nursing Services, dated 03/2016, indicated, Under the guidance of the Director of Nursing (DON) or designee, the facility shall provide restorative nursing services that assist residents in achieving and/or maintaining the highest possible degree of functioning, self-care, and. independence and shall be based upon resident choice, where practicable. During an observation and concurrent interview on 02/20/23 at 11:05 AM, R41 was observed seated in her room. The resident's right hand was contracted. R41 stated she had four strokes and normally wears a splint. R41 stated, I haven't worn it in two weeks. R41 further stated the restorative aide usually puts the splint on daily for her but had not done so lately. When asked if her contracted had gotten worse, R41 stated that it had not. R41 stated, Because of all the straps, I can't put in on by myself and I need to wear it because I can't open this hand on my own. R41's splint was observed near her windowsill at this time. During observations on 02/20/23 at 1:50 PM, 02/21/23 at 9:15 AM, and 02/21/23 1:59 PM, R41's splint remained in the same location near her windowsill and was not in use on the resident's contracted hand. Review of R41's undated Resident Face Sheet located in the EMR under the Resident tab, revealed R41 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction. Review of R41's quarterly MDS (Minimum Data Set) located in EMR under the RAI (Resident Assessment Instrument) tab with an Assessment Reference Date (ARD) of 01/05/23 revealed R41's a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R41 was cognitively intact. Review of R41's Physician Order Report located in the resident's electronic medical record (EMR) under the Resident tab, revealed the following order dated 02/19/21: Nursing order - Heat application w [with]/ RUE [right upper extremity] PROM [passive range of motion] & prior to splint application w/ Restorative Therapy. During an interview and concurrent review of R41's Restorative Programs log, on 02/21/23 at 10:49 AM, Restorative Licensed Practical Nurse (LPN) 3 confirmed R41's participation in the restorative nursing program. Restorative LPN3 stated, We are to see her three times a week. The splint should be placed every day but a minimum of three times a week. Restorative LPN3 confirmed that R41 was unable to put on her splint independently. When reviewing the Restorative Programs weekly logs from 12/26/22 through 2/17/23, Restorative LPN3 identified that R41 had 24 opportunities to receive restorative nursing and splint placement as ordered, but only received these services nine times. Restorative LPN3 confirmed that R41 never refused restorative nursing assistance and the biggest gap in care was from 01/09/23 - 01/31/23, where R41 did not receive restorative nursing and splint placement during that time. During an interview on 02/21/23 at 12:31 PM, the Certified Occupational Therapist Aide (COTA) stated, It looks as if she had the splint before she came to us. Since she has had it for so long, I would expect it to be worn two hours per shift, every day. During an interview on 02/23/23 at 10:16 AM, the Administrator stated, I expect for a resident that is on the restorative nursing program to receive the required services. During an interview on 02/23/23 at 11:27 AM, the Director of Nursing (DON) stated, I expect residents to get restorative as scheduled. The DON confirmed Restorative LPN3 was the lead on the restorative nursing program and that the program fell under her overall umbrella. The DON further stated, I wasn't aware that the resident had a splint until it was mentioned to me on yesterday. Since she has the splint, she should be wearing it for her contracture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to develop and implement individualized care plans for behavioral health concerns for one (Resident (R) 42) of one sampled resident reviewed for behavioral health concerns out of 27 sampled residents. The facility failed to thoroughly assess the resident's mood/cognition and care plan related to R42's behavioral health needs. Level II Preadmission Screening and Resident Review (PASRR) recommendations were not acted on. A crisis plan for R42, who had verbalized suicidal ideation, was not available for staff use. Staff were unaware and/or did not implement actions designed to improve the resident's mood/mental health. Findings include: Review of the facility's policy titled, Suicide Threats, revised 03/2013, indicated, Positive Helping Relationships . Be available, be there and willing to listen. Many individuals in a suicide dilemma have never encountered anyone who really wanted to hear them and understand what they really feel . Encourage talking: As frequently as possible; not necessary for these periods to be lengthy but they should provide the person an opportunity for ventilation . Provide positive human contact: Human relating that alleviates distress builds or rebuilds the hopeful expectation that other human relationships may also be helpful and fulfilling. Review of R42's Face Sheet, located under the Resident tab of the electronic medical record (EMR), indicated R42 was admitted with diagnoses that included adjustment disorder. Review of R42's Progress Note, dated 09/22/22 and located under the Resident tab of the EMR, indicated R42 was hospitalized for psychiatric care after verbalizing suicidal ideations. Review of R42's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/13/22 revealed staff failed to conduct the Brief Interview for Mental Status in the Cognitive Patterns section of the MDS or the Resident Mood Interview in the Mood section of the MDS. Although the resident could communicate/answer questions, staff instead conducted the Staff Assessment for Mental Status and Staff Assessment of Resident Mood. (Cross -reference F641 for failure to complete MDS in accordance with assessment instructions.) Staff coded R42 as having modified independence in cognitive skills for daily decision making, and diagnoses of anxiety and depression. Review of R42's Notice of PASRR [Preadmission Screening and Resident Review] Level II Outcome, dated 10/13/22 and located under the Resident tab of the EMR, indicated, The nursing facility will be required to Care Plan in a PASRR compliant fashion for all identified services including Specialized Services . you have a mental health diagnosis of recurrent, severe major depressive disorder . you have a history of self-harm . you shared that you are lonely, you spend most of your time in bed in your room, you miss the one-to-one interaction you had when you lived with your family, you get anxious and depressed due to your ongoing medical conditions and being in a nursing facility . Staff arguing with you . You stop doing the things you like to do and get angry very easily when you are not doing well. Going outside or having someone to talk with helps you feel better when you are having a hard time . We learned that the following things are important to and for you: You shared that you enjoy arts, crafts, drawing, drinking liquor, being outside, getting out of the nursing facility, listening to music, playing games on your phone, shopping, and watching Netflix . A good day is a day spent watching Netflix and talking with people . Going outside or talking with someone [NAME] you up when you feel down . Staff at Mississippi Valley Healthcare & Rehabilitation Center are encouraged to continue to learn about what you do and do not like, what your hobbies are, and how you like to spend your time . You will need to be provided . Development by the nursing facility in conjunction with the individual and behavioral health providers of a Crisis Intervention/Safety Plan to identify triggers and symptoms, best methods for management of challenges, action steps to be taken by all parties in order to reduce risk of hospitalization . Socialization/leisure/recreation activities appropriate to current skills or adapted to facilitate optimal participation . Supportive counseling from NF [nursing facility] staff . Because you get lonely and you have been anxious and depressed, will benefit from the support of staff to help . you manage your behavioral symptoms. Review of R42's Care Plan, revised 01/23/23 and located under the RAI (Resident Assessment Instrument) tab of the EMR, indicated R42 had a problem related to adjustment disorder. The goal was listed as learning to cope with stressful situations in a healthy manner and interventions were to monitor for hopelessness, insomnia, anxiety, anger, disruptive behavior, depressed mood, headaches, loss of appetite, withdrawing from social environment, and suicidal thoughts. There were no individualized interventions listed for R42. The care plan did not address R42's PASRR recommendations, the need for specialized services, crisis plan, or interventions to assist R42 in managing any behavioral symptoms. The care plan had not been updated to include the episode of suicidal ideation requiring hospitalization or previous attempts at self-harm. During an observation on 02/20/23 at 12:25 PM, Licensed Practical Nurse (LPN) 2 entered R42's room, provided education to R42 on the importance of repositioning, and left the room. LPN2 did not attempt to converse with R42 except to educate her on repositioning. During an observation on 02/20/23 at 12:28 PM, an unidentified staff member entered R42's room, placed R42's noon meal on the bed, and left the room. The staff member did not attempt to converse with R42. During an interview on 02/21/23 at 1:32 PM, R42 stated she did not like living at the facility, it was depressing, and it had caused her to be hospitalized at the psychiatric hospital. R42 stated staff argued with her and no one came just to talk with her. During an interview on 02/23/23 at 9:32 AM, Certified Nurse Aide (CNA) 3 stated R42 had continuous verbal behaviors, refused care, and boycotted sleeping in her bed. CNA3 stated she would continue to ask R42 if she wanted care, attempt to direct her to other things and reapproach her in a different way when she was having behaviors. CNA3 stated she had not received any training or direction from her supervisor on how to care for R42 related to R42's behavioral health. During an interview on 02/23/23 at 9:37 AM, Registered Nurse (RN)1 stated R42 had verbalized in the past that she wanted to die, and the main problem now was R42 did not want to get out of her wheelchair and sleep in her bed. RN1 stated staff was supposed to educate R42, document her behaviors, and continue to educate her. RN1 stated she instructed the CNAs to check on R42 at least every two hours and ask R42 if she wanted to lie down. RN1 stated she did not attend R42's care plan meetings and had not been asked to provide any input into R42's treatment plan. RN1 stated she had not received any direction on interventions related to R42's behavioral health. During an interview on 02/23/23 at 10:48 AM, the MDS Coordinator (MDSC) stated the Social Services Director (SSD) was responsible for ensuring behavior items were addressed on the care plan. The MDSC confirmed R42's care plan did not address behaviors, specialized services, past mental health issues, crisis plan, or contain interventions related to R42's behavioral health. The MDSC confirmed the behavioral care plan should have been included in R42's plan of care. Continuing with the interview, the MDSC stated the interdisciplinary group talked about R42's behaviors during morning meetings and R42's progress notes were reviewed at that time. The MDSC stated they had been focusing on the documentation in the progress notes. The MDSC confirmed she should have made sure there was a behavioral care plan. The MDSC stated staff was verbally informed of any interventions that were identified for R42. The MDSC stated that she and representatives from the dietary, activities, social services, and restorative departments were involved in the care planning process. The MDSC stated the floor nurses and aides were not involved in this process During an interview on 02/23/23 at 9:43 AM, the Social Services Director (SSD) stated when the results of R42's Level II PASRR were received, R42 was referred to a psychiatrist and counseling. The SSD stated other recommendations were to develop a crisis plan, obtain past medical records related to R42's mental health, staff was to provide supportive counseling, and assist in pursuing community placement. The SSD attempted to open the electronic copy of the crisis plan and stated, It's blank. It doesn't even show. The SSD stated a paper copy of the crisis plan was kept in a notebook at each nurses' station. The SSD stated she obtained R42's mental health records when R42 was admitted to the facility and with each psychiatrist and counselor visit. The SSD stated the staff was providing supportive counseling through interaction and encouraging R42 to take care of herself. The SSD stated the only individualized information the staff received about R42 was the crisis plan. The SSD stated the staff was educated on behavioral health in general during staff meetings but no education specific to R42 had been delivered. The SSD stated she had reviewed R42's mental health records and determined some interventions were to let R42 speak and to not be argumentative with R42. The SSD stated she had only talked with supervisory staff about these interventions, and the interventions were listed on R42's crisis plan. Continuing with the interview, the SSD stated any staff who was caring for R42 had access to the paper copy of the crisis plan located at the nurses' station and they would know there was a crisis plan if their supervisors had informed them of such. The SSD stated the crisis plan was not included in R42's care plan, confirmed that it should have been, and stated it was her responsibility to ensure it was. The SSD stated the crisis plan had been discussed at R42's care plan meeting but that nurses and CNAs were never at the care plan meetings. During an observation on 02/23/23 at 10:24 AM with the SSD, no copy of R42's crisis plan was observed in the Behavior Crisis/PASRR Plans notebook at the nurses' station for R42. The SSD stated R42's crisis plan was supposed to be in the notebook. During an interview on 02/23/23 at 11:19 AM, the Director of Nursing (DON) stated R42 had verbal behaviors, resisted care, and lashed out at staff. The DON stated there were multiple problems with R42 even though education had been provided. The DON stated staff was verbally educated to not argue with R42 and to follow their chain of command if problems were encountered with R42.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure medication regimen reviews addressed gradual dose reductions for psychotropic medications and/or as needed (PRN) anti-anxiety medications ordered for longer than 14 days for two (Resident (R) 11 and 49) of five sampled residents reviewed for unnecessary medications. Findings include: 1. Review of the facility's policy titled, Anxiolytic [anti-anxiety] Medication Renewal, revised 01/2022, revealed PRN anxiolytic medication orders must be limited to 14 days unless prescriber believes it is necessary for a longer duration and documents the clinical rationale and duration . Consultant Pharmacist will monitor compliance with monthly chart review of the resident's records. Review of R49's Face Sheet, located under the Resident tab of the electronic medical record (EMR), indicated R49 was admitted with diagnoses that included ventilator dependence and chronic kidney disease. Review of R49's Physician Order, dated 12/13/22 and located under the Resident tab of the EMR, indicated R49 was to receive lorazepam, an anti-anxiety medication, 0.5 milligrams (mg) every eight hours as needed for anxiety through 03/12/23. This was for longer than 14 days after the order was written. Review of R49's Progress Notes, dated 12/13/22 through 02/20/23 and located under the Resident tab of the EMR, revealed no documentation the Consultant Pharmacist identified the discrepancy or made a recommendation related to R49's PRN lorazepam order exceeding 14 days. On 02/23/23 at 12:30 PM, the Consultant Pharmacist confirmed she had not sent a recommendation to the physician regarding R9's lorazepam order. The Consultant Pharmacist stated she checked the orders to ensure there was a stop date and if so, she did not make a recommendation, even if the order lasted more than 14 days. 2. Review of facility policy titled, Consultant Pharmacist/Medication Review Policy, dated 05/2017, indicated, The consultant pharmacist documents activities performed and services provided on behalf of the residents and the facility. Resident-specific recommendations are documented and provided to the director of nursing to review and forward to the appropriate physician. Review of R11's undated Resident Face Sheet, located in the resident's EMR under the Resident tab revealed the resident was admitted to the facility on [DATE] with diagnoses of anxiety disorder and major depressive disorder. Review of R11's Prescription Order, dated 11/07/22, located in the resident's EMR under the Orders tab revealed the following orders dated 06/29/21 and 11/18/21, respectively: Venlafaxine [antidepressant] 225 mg [milligrams]; Ativan [lorazepam - an antianxiety medication] - 0.5 mg; amt [amount]: 1/2 tab [tablet] Review of R11's Physician Recommendation, dated 10/19/21, located in the resident's EMR under the Resident tab revealed a gradual dose reduction (GDR) for Ativan was agreed upon by the physician on 10/29/21. Review of Physician Recommendation, dated 11/29/21 revealed a GDR for Venlafaxine was agreed upon by the physician on 12/01/21. Review of R11's complete medical record showed no additional pharmacy recommendations for R11's Venlafaxine or Ativan since 2021. During an interview on 02/22/23 at 12:07 PM, the Director of Nursing (DON) stated, We do not have the pharmacy recommendations for the Ativan and Venlafaxine. The DON confirmed, The last pharmacy recommendation for those medications are from 2021. During an interview on 02/22/23 at 12:09 PM, the Infection Preventionist (IP) and previous DON stated, We do not have any more recent pharm recommendations. I talked to the pharmacist, and she stated that she did not have to send those. She stated that is not what the regulations state. During an interview on 02/22/23 at 11:28 AM, the Consultant Pharmacist stated, There are no pharmacy recommendations for the Ativan or the Venlafaxine for 2022. I haven't sent those because the regulation states as long as the resident is assessed, I don't have to send the recommendation over. She sees a psychiatrist regularly and I've been reading the notes and the psychiatrist stated she was stable on her medication. There were notes from 10/07/22 and 06/02/22 and that is why I didn't send the recommendations. Review of R11's psychiatric notes revealed no evidence that a further attempt at a GDR was contraindicated. The psychiatric note dated 06/02/22, located in the resident's EMR under the Resident tab revealed, Discussed current medication regimen and options for depression, anxiety, and insomnia. Continue the . venlafaxine . as prescribed. Indications and side effects reviewed and discussed. She [R11] is agreeable to this medication regimen. Review of a psychiatric note dated 10/07/22 revealed, Moods is improving. Remains with depressed moods at times. Appetite decreased. Sleep good. Decreased anxious and irritable moods. Plan adjust medication. (Cross-reference F758.)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure that one (Resident (R) 11) of five sampled residents reviewed for unnecessary medications received ongoing gradual dose reductions of psychotropic medications. In addition, one (R49) of the five sampled residents reviewed for unnecessary medications had an order for an as needed (PRN) anti-anxiety (anxiolytic) medication for longer than 14 days without a documented rationale. Findings include: 1. Review of the facility's policy titled, Anxiolytic Medication Renewal, revised 01/2022, indicated, PRN anxiolytic medication orders must be limited to 14 days unless prescriber believes it is necessary for a longer duration and documents the clinical rationale and duration. Review of R49's Face Sheet, located under the Resident tab of the electronic medical record (EMR), indicated R49 was admitted with diagnoses that included ventilator dependence and chronic kidney disease. Review of R49's Physician Order, dated 12/13/22 and located under the Resident tab of the EMR, indicated R49 was to receive lorazepam, an anti-anxiety medication, 0.5 milligrams (mg) every eight hours as needed for anxiety through 03/12/23. This was for longer than 14 days after the order was written. Review of R49's Progress Notes and Physician Progress Notes, dated 12/13/22 through 02/20/23 and located under the Resident tab of the EMR, revealed no documentation of the physician's rationale for the PRN anti-anxiety medication order to last longer than 14 days. During an interview on 02/23/23 at 11:15 AM, the Director of Nursing (DON) stated the facility's policy on the use of PRN anti-anxiety medications was that the order could not be for more than 14 days without a rationale documented by the physician. The DON confirmed there was no rationale documented to explain why R49 required the PRN medication longer than 14 days. During an interview on 02/23/23 at 12:30 PM, the Consultant Pharmacist stated it was the nursing staff's responsibility to ensure a rationale was documented related to an as need anti-anxiety medication order lasting longer than 14 days. The Consultant Pharmacist stated she did not look for a documented rationale for the PRN psychotropic medication to exceed 14 days. (Cross- reference F756 regarding identifying and acting upon irregularities.) 2. Review of R11's undated Resident Face Sheet, located in the resident's EMR under the Resident tab revealed the resident was admitted to the facility on [DATE] with diagnoses of anxiety disorder and major depressive disorder. Review of R11's Prescription Order, dated 11/07/22, located in the resident's EMR under the Orders tab revealed the following orders dated 06/29/21 and 11/18/21, respectively: Venlafaxine [antidepressant] 225 mg [milligrams]; Ativan (lorazepam - anti-anxiety medication] - 0.5 mg; amt [amount]: 1/2 tab [tablet] Review of R11's December 2022 - February 2023 Medication Admin[stration Record, located in the resident's EMR under the Resident tab revealed the nursing staff administered the above-mentioned medication as ordered by the physician. Review of R11's Physician Recommendation, dated 10/19/21, located in the resident's EMR under the Resident tab revealed a gradual dose reduction (GDR) for Ativan was agreed upon by the physician on 10/29/21. Review of Physician Recommendation, dated 11/29/21 revealed a GDR for Venlafaxine was agreed upon by the physician on 12/01/21. Review of R11's complete medical record showed no additional attempts at a GDR since 2021 or evidence of a clinical rationale documenting the reasoning further GDRs should not be attempted for R11's Venlafaxine or Ativan. Review of R11's psychiatric notes for 10/07/22 revealed, Moods is improving. Remains with depressed moods at times. Appetite decreased. Sleep good. Decreased anxious and irritable moods. Plan adjust medication. However, review of R11's complete medical record revealed no evidence of a medication adjustment. During an interview on 02/22/23 at 12:07 PM, the DON confirmed the facility did not have evidence of an attempted GDR since 2021 or a clinical rationale documenting the reasoning a GDR should not be attempted for R11's Venlafaxine or Ativan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the appropriate coordination of hospice care by specifically failing to maintain hospice orders and/or hospice election forms for two (Resident (R) 6 and R19) of two residents sampled for hospice. This failure had the potential result in the interruption of the residents' coordination of care. Findings include: Review of the hospice agreement titled Patient/Resident Services Agreement, dated 08/20/20, indicated EveryStep will provide the following information to Contractor: The most recent hospice plan of care specific to each patient; Hospice election form and any advance directives specific to each patient; Physician certification and recertification of the terminal illness specific to each patient; Names and contact information for hospice personnel involved in hospice care of each patient; Instructions on how to access the hospice's 24-hour on-call system; Hospice medication information specific to each patient; and Hospice physician and attending physician orders specific to each patient. 1. Review of R6's undated Resident Face Sheet, located in the resident's electronic medical record (EMR) under the Resident tab revealed the resident was admitted to the facility on [DATE]. Review of R6's Resident Progress Notes, dated 01/11/23, located in the resident's EMR under the Resident tab revealed the resident was admitted to hospice on 01/11/23. Review of R6's complete medical record, revealed the absence of hospice orders and a hospice election form. During an interview on 02/21/23 at 9:38 AM, the Director of Nursing (DON) reviewed R6's EMR and hospice binder. The DON confirmed there were no hospice orders or a hospice election form for R6. When asked why the resident was on hospice, the DON stated, because she had an overall decline in condition. The DON stated the hospice orders and hospice election form should be maintained at the facility. During an interview on 02/21/23 at 10:13 AM, Hospice Registered Nurse (RN) stated R6 started on hospice in January for her rapid decline with dementia. The Hospice RN confirmed the hospice order and hospice election form should be maintained on file at the facility. The Hospice RN stated, That's just our normal standard of practice. We provide the facility with that information plus the care plan when a resident is admitted to hospice. 2. Review of the facility's Nursing Facility Hospice and Respite Care Services Agreement. dated 03/22/18, revealed in Part II, Section At2: The Plan of Care will be established by the Attending Physician, the Medical Director, or physician-in-charge and the Interdisciplinary Team prior to the provision of hospice services and will be established and maintained in consultation with Facility's representatives. The Plan of Care will identify the care and services that are needed and will specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the Plan of Care. During the initial tour on 02/20/23 at 10:35 AM, R19 stated that she is receiving hospice services as of 01/26/23. Review of R19's Hospice and Coordinated Plan of Care, dated 01/26/23, revealed there were no times or dates for services performed. There were no sheets available to show the routine care interventions. Further review of the resident's record revealed no physician's orders for hospice services, and no evidence of coordination by the Hospice Nurse and the Facility Nurse. During an interview on 02/2/123 at 11:35AM, the DON stated that the facility could not find the Hospice contact, care coordination notes or schedule for when services were to be provided. Further interview with the DON revealed it should be there. During an interview on 02/21/23 at 12:15 PM, the Administrator stated that the resident was transferred from the hospital with orders for hospice care. The Administrator confirmed that there were no physician's orders at the facility to continue hospice care, stating that because of the discharge summary for hospice care, there was no need for a doctor's order. Review of the Hospice Agreement between Southeast Iowa Regional Medical Center and Mississippi Valley Healthcare & Rehabilitation Center dated January 26, 2023, revealed in Appendix A Hospice admission Criteria Section 1B: The Attending Physician agrees to patient admission and is willing to remain actively involved in provision of medical care to the patient.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, the facility failed to provide a written notice of transfer to the resident and/or resident's representative for four (Resident (R) 30, R32, R61 and R116) of four residents reviewed for hospitalization to ensure that the resident and/or their representative were informed of all pertinent information regarding their transfer to another health facility. Findings include: 1. Review of R30's Face Sheet, found under the resident tab in the Electronic Medical Record (EMR), revealed an admission date of 11/28/22, with medical diagnoses that included respiratory failure and dependence on a respirator. Review of the Progress Notes under the resident tab in the EMR, dated 11/25/22 at 12:34 AM, revealed, While performing this resident's vent check, this RT [respiratory therapist] noticed an absence in lung sounds throughout. When asked if he [R30] had any difficulty breathing he said yes. RT called his nurse in to assess . His nurse was unable to detect any breath sounds throughout . Resident appears ashen in skin tone and lethargic. He was sent to the hospital to be further evaluated. Review of the resident's clinical record revealed no evidence that a written notice, which contained all required information including the reason and effective date for the transfer, the location to which the resident was transferred, and information about the resident's appeal rights and how to contact the Long-Term Care Ombudsman, was provided to either the resident and/or their representative. 2. Review of R32's Face Sheet, found under the resident tab in the EMR, revealed an admission date of 12/14/22 with medical diagnoses that included chronic kidney disease (stage 4) and anxiety. Review of the Progress Notes under the resident tab in the EMR, dated 02/20/23 at 4:13 AM revealed the resident was transferred to the hospital for vaginal bleeding. Review of the resident's clinical record revealed no evidence that a written notice, which contained all required information including the reason and effective date for the transfer, the location to which the resident was transferred, and information about the resident's appeal rights and how to contact the Long-Term Care Ombudsman, was provided to either the resident and/or their representative. 3. Review of R61's Face Sheet, found under the resident tab in the EMR, revealed an admission date of 01/13/23 with medical diagnoses that included dependence on a respirator and chronic disease. Review of the Hospital Notes under the resident tab in the EMR, dated 01/23/23, revealed, pt [patient] admitted to hospital from [facility name] pt with hx [history] of anoxic brain injury - vent dependent. She presented with tachypnea pt with sepsis - looking into antibiotics and then may be able to d/c [discharge] back. Review of the resident's clinical record revealed no evidence that a written notice, which contained all required information including the reason and effective date for the transfer, the location to which the resident was transferred, and information about the resident's appeal rights and how to contact the Long-Term Care Ombudsman, was provided to either the resident and/or their representative. 4. Review of R116's undated Resident Face Sheet, located in the resident's EMR under the Resident tab revealed the resident was admitted to the facility on [DATE]. Review of R116's Census Report, located in the EMR under the Resident tab, revealed R116 was transferred to the hospital on [DATE]. Review of R116's medical record revealed no evidence of a written notice of transfer to the resident and/or the resident's representative. During an interview with Registered Nurse (RN) 2, on 02/22/23 at 10:58 AM, she stated when a resident needed to go to the hospital, the resident's doctor and the resident's responsible party would be notified verbally. RN2 stated she was not aware of any paperwork that was provided to the resident or their responsible party when the resident was sent to the hospital that explained the reason for the transfer to the hospital. During an interview with the Director of Nursing (DON), on 02/22/23 at 11:30 AM, she stated the facility did not complete a discharge or transfer form and was unaware one was required per regulation. During an interview with the Administrator, on 02/22/23 at 12:07 PM, she stated the facility did not use a transfer form when a resident was sent to the hospital and was not aware one was needed. The Administrator stated the facility did not have a policy for this requirement but would be implementing one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that four (Resident (R) 30, 42, 56 and 21) of 31 residents (27 sampled and four supplemental residents) had Minimum Data Set (MDS) assessments completed in accordance with instructions from the Resident Assessment Instrument (RAI) 3.0 User's Manual. Residents who could communicate and answer questions were not interviewed by facility staff to determine their cognitive and/or mood status. Staff made their own determination in these areas, and inaccurately reflected residents' cognitive status. Findings include: Review of the RAI 3.0 User's manual, dated 10/2019, revealed the following instructions related to Section C (Cognitive Patterns), The RAI assessment process is the basis for the accurate assessment of each resident .Most residents are able to attempt the Brief Interview for Mental Status. A structured cognitive test is more accurate and reliable than observation alone for observing cognitive performance. Without an attempted structured cognitive interview, a resident might be mislabeled based on his or her appearance or assumed diagnosis. Instructions for C0100 included the statement, Should Brief Interview for Mental Status be conducted? Attempt to conduct interview with all residents. Further instructions for Section C revealed the instruction, Do not complete the Staff Assessment for Mental Status items (C0700-C1000) if the resident interview should have been conducted, but was not done. Instructions for Section D (Mood) revealed the following information: Should Resident Mood Interview be conducted? Attempt to conduct interview with all residents Do not complete the Staff Assessment of Resident Mood items (D0500) if the resident interview should have been conducted, but was not done. 1. Review of R42's Face Sheet, located under the Resident tab of the electronic medical record (EMR), indicated R42 was admitted with diagnoses that included adjustment disorder. a. Review of R42's Progress Notes, dated 10/01/22 through 10/12/22 and located under the Resident tab of the electronic medical record (EMR), indicated R42 was alert, oriented, and capable of answering questions related to mental status and mood. Review of R42's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/13/22 and located under the RAI (Resident Assessment Instrument) tab of the EMR indicated staff did not conduct the Brief Interview for Mental Status in the Cognitive Patterns section of the MDS. Although the resident was capable of answering questions, staff instead conducted the Staff Assessment for Mental Status and coded R42 as having modified independence in cognitive skills for daily decision making. In addition, staff failed to conduct the Resident Mood Interview in the Mood section of the MDS, and instead completed the Staff Assessment of Resident Mood instead. b. Review of R42's Progress Notes, dated 01/01/23 through 01/11/23 and located under the Resident tab of the EMR, indicated R42 was alert, oriented, and capable of answering questions related to mental status and mood. Review of R42's quarterly MDS with an ARD of 01/12/23 and located under the RAI tab of the EMR revealed staff did not conduct the Brief Interview for Mental Status in the Cognitive Patterns section of the MDS. Instead, staff completed the Staff Assessment for Mental Status and coded R42 as being moderately impaired in cognitive skills for daily decision making. In addition, it was indicated that staff did not conduct the Resident Mood Interview in the Mood section of the MDS but conducted the Staff Assessment of Resident Mood instead. Review of R42's Progress Note, dated 01/16/23 at 12:33 PM and located under the Resident tab of the EMR, indicated, SS [Social Services] completed MDS based off of Resident progress notes, observations and documentation. During an interview on 02/22/23 at 10:31 AM, the MDS Coordinator (MDSC) stated, Section C is handled by our Social Services Director (SSD). She is the one that actually inputs the cognition data into the system. During an interview on 02/23/23 at 3:39 PM, the SSD confirmed R42 was capable of answering the cognitive and mood interview questions on the 10/13/22 MDS. The SSD stated she attempted to interview R42 and R42 had asked her to come back at a different time, but she could not as the assessment was due on that day. Further interview with the SSD confirmed that R42 was also capable of answering the cognitive and mood interview questions on the 01/12/23 MDS. However, the SSD had completed the staff assessment instead, based on progress notes, observations, and documentation. The SSD stated she did not remember if R42 had been sleeping but she did not document that R42 refused the interview. The SSD stated it was best practice for residents to participate in the interviews and she had not been reporting when residents did not participate in the interviews. During an interview on 02/23/23 at 4:05 PM, the MDS Coordinator (MDSC) confirmed it was her job to monitor the accuracy of the MDS and it was the facility's policy to follow regulations related to MDS accuracy. The MDSC stated staff had six to eight days to complete their sections of the MDS and that allowed ample to conduct resident interviews. 2. Review of R56's undated Resident Face Sheet, located in the resident's EMR under the Resident tab revealed the resident was admitted to the facility on [DATE]. Review of R56's quarterly MDS, located in the resident's EMR under the RAI tab with an ARD of 08/09/22, revealed a BIMS score of 14 out of 15, indicating R56 was cognitively intact. Review of R56's quarterly MDS assessments, with ARDs of 11/03/22 and 02/02/23, revealed these two assessments were not conducted in accordance with instructions from the RAI manual. Although the resident was able to communicate and answer questions, staff failed to conduct the resident interview to determine the BIMS score of this resident. Instead, for these MDS assessments, staff completed their own determination of the resident's mental status. Further review of these MDS, revealed that although the resident had previously been identified as cognitively intact, on both the 11/03/22 and 02/02/23 MDS, staff now documented the resident was moderately cognitively impaired. Review of R56's Resident Progress Notes, dated 11/03/22, written by the SSD, located in the resident's EMR under the Resident tab revealed the following: SS [Social Services] completed MDS based off of Documentation and interactions. Res [resident] was presently unavailable due to an appointment. During an interview on 02/22/23 10:33 AM, the SSD stated that R56 was very talkative and had good memory recall. The SSD further stated that R56 was alert and oriented times three except when he is sick and his cognition lowers. When asked if R56 was sick during the time of the 02/02/23 MDS assessment, the SSD stated R56 was not sick. When asked why R56's BIMS was not assessed on the MDS assessment, the SSD stated, I put 'not assessed/no information' and I did the staff assessment portion. That's what I put in if I didn't get a chance to do the cognitive questions, like if he was asleep or not able to participate. I should have documented how many attempts I made to talk to him so that we could have the BIMS score reflect accurately. I usually attempt three times. The SSD further stated, It [BIMS] should have been completed on him. I didn't document why so not sure why I didn't do it that day. When asked about the 11/03/22 MDS assessment, the SSD stated, That one should have been done also. I put a note in for November that he was at doctor's appointment. The SSD further stated that when the MDSC opens the assessment, they are open for a day or two and that is our timeframe to put in the information. The SSD stated, Just because he was not in the facility at that moment, I should have went [sic] back and checked again in order to complete his BIMS. When asked why the staff assessment portion that the SSD completed reflected R56's cognition to be moderately impaired, (equivalent to a BIMS score of between eight through 12,) the SSD stated, I should have put that he was cognitively intact. His BIMS score is normally a 14 or 15. During an interview on 02/22/23 at 2:13 PM, the MDSC stated, When staff are to assess the residents, I leave the MDS open from Monday - Friday or from Friday - Friday so that the staff can have time to input the data. I expect the sections to be completed accurately and I expect the staff to attempt to see resident at least three to four times in order to get the assessment completed accurately. 3. Review of R21's undated Resident Face Sheet, located in the resident's EMR under the Resident tab revealed the resident was admitted to the facility on [DATE]. Review of R21's quarterly MDS, located in the resident's EMR under the RAI tab with an ARD of 11/03/22, revealed a BIMS score of 15 out of 15, indicating R21 was cognitively intact. Review of R21's annual MDS, with an ARD of 02/02/23, revealed this assessment was not conducted in accordance with instructions from the RAI manual. Staff failed to conduct the resident interview to determine the BIMS score of this resident, who was able to communicate and answer questions. Instead, staff completed their own determination of the resident's mental status. Further review of this MDS revealed that although the resident was previously assessed as cognitively intact on the 11/03/22 MDS, the resident was now documented as being moderately cognitively impaired During an interview 02/23/23 at 3:26 PM, the SSD stated that R21 was alert and oriented times three. When asked why R21's BIMS was not assessed on the MDS assessment, the SSD stated, I didn't put a note why it wasn't done. The SSD confirmed R21 was available at the facility during the time the MDS was due and had no answer as to why the BIMS was not completed. When asked why the staff assessment portion that the SSD completed reflected R21's cognition to be moderately impaired (reflecting an equivalent BIMS score of between eight through 12), the SSD stated, Her BIMS score is normally 15. The SSD stated that although there was no change in the resident's cognition, she scored it lower when she completed her assessment. The SSD was unable to answer why she reflected R21's BIMS inaccurately. 4. Review of R30's Face Sheet, found under the resident tab in the EMR, revealed an admission date of 11/28/22 with medical diagnoses that included respiratory failure and dependence on a respirator. Review of R30's quarterly MDS, provided by the facility, with an ARD of 10/27/22, revealed a BIMS score of 15 out of 15, indicating R30 was cognitively intact. Review of the most recent MDS, with an ARD of 01/26/23, revealed that although the resident could communicate and answer questions, staff failed to interview the resident to complete the BIMS score or mood assessment. Instead, review of the 01/26/23 MDS revealed that staff completed the assessment of these areas with no staff interview. During an interview with the social services director (SSD), on 02/23/23 at 1:47 PM, she stated she was responsible for completing section C, D, E, Q, and Z of the MDS. The SSD stated she would be notified when the MDS needed to be completed, based on the weekly list provided by the MDSC. She stated she would typically try three times to interview the resident in case they were out at an appointment or asleep. She stated she would document in the progress note if the resident was not available for the interview. The SSD confirmed the resident interviews for section C (Cognitive) and Section D Mood) were not completed for the ARD of 01/26/23 and there was no documentation indicating why these portions of the MDS were not completed. She stated R30's cognition had not changed and R30 was interviewable. During an interview with the MDS Coordinator (MDSC), on 02/23/23 at 2:15 PM, she stated she would send out a weekly list indicating which MDS were due the following week. She stated she would leave the MDS open for seven days and would verify all departments had completed their portion of the MDS. She stated she expected the MDS to be accurate but did not verify accuracy of sections that were completed by other staff During an interview with the Administrator and the Director of Nursing, on 02/23/23 at 2:29 PM, they stated they expected all sections of the MDS to be completed accurately. During an interview 02/23/23 at 2:40 PM, the Administrator stated, We do not have a MDS policy. We follow the RAI manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Registered Nurses (RN) and/or Certified Nurse Aides (CNAs) with resident responsibilities were involved in the care planning process for three (Resident (R) 42, 56, and 30) of 27 sampled residents. Findings include: 1. Review of R42's Face Sheet, located under the Resident tab of the electronic medical record (EMR), indicated R42 was admitted with diagnoses that included adjustment disorder. Review of R42's Care Plan, last reviewed and revised 01/23/23 and located under the RAI (Resident Assessment Instrument) tab of the EMR, revealed no evidence that an RN or CNA with responsibility for the resident was involved in the care planning process. During an interview on 02/23/23 at 9:32 AM, CNA3 stated she worked with R42 frequently. CNA3 stated the CNAs did not attend care plan meetings for R42 or any resident and had never been asked for input into any resident's care. During an interview on 02/23/23 at 9:37 AM, RN1 stated she had been responsible for R42 since 10/2022. RN1 stated she did not attend care plan meetings for R42 or any resident and had not been asked to provide input into the care planning process for any resident. RN1 stated the floor nurses did not attend care plan meetings. 2. Review of R56's undated Resident Face Sheet, located in the resident's EMR under the Resident tab revealed the resident was admitted to the facility on [DATE]. Review of R56's Care Plan, dated 01/20/23 located in the resident's EMR under the RAI tab revealed R56's most recent care conference was on 02/14/23. Review of R56's care plan information revealed no evidence that a CNA or RN participated in the resident's care planning process. 3. Review of R30's Face Sheet found under the resident tab in the Electronic Medical Record (EMR), revealed an admission date of 11/28/22, with medical diagnoses that included respiratory failure and dependence on a respirator. Review of R30's Care Plan, found under the resident tab in the EMR, revealed it was last revised on 01/23/23 by the Minimum Data Set Coordinator (MDSC). Further review of the care plan information revealed no evidence that a CNA was involved as part of the interdisciplinary team who developed/revised the care plan. During an interview on 02/23/23 at 10:48 AM, the MDSC stated the facility held weekly care plan meetings where she and representatives from the activities, dietary, restorative, and social services departments met to review and revise the residents' care plans. The MDSC stated she tried to talk with the CNAs before any care plan meeting, but confirmed the floor nurses and CNAs were not involved in the care planning process for any resident. On 02/23/23 at 4:16 PM, the Administrator stated the facility's policy for the care planning process was to follow the regulations.

Based on observation, interview, record review, and review of facility policy, the facility failed to provide food storage in a safe and consistent manner. Frozen food was not stored at a temperature to ensure that the food remained frozen. Expired perishables were available for use. Opened foods were not securely closed, labeled, and dated. This had the potential to affect 45 of 62 residents who consumed food from the kitchen. Findings include: Review the of facility's undated policy titled, Food Storage (Dry, Refrigerated, and Frozen) indicated, Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. This policy also indicated, General storage guidelines to be followed: a. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded; c. Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration. Review the of facility's undated policy titled, Refrigerator and Freezer Temperatures indicated, 2. The employee ensures that all cold storage units are 41F [degrees Fahrenheit] or below for refrigeration or 0 F or below for freezers. This policy further indicated, 3. The temperature of each refrigeration and freezer unit is checked by the staff member who is closing the department for the day. The temperature is verified to be in the correct range as listed in #2 above. If the unit is not in the correct operating range, the staff member alerts management per facility policy. 1. During an initial kitchen walkthrough with the Dietary Manager (DM) on 02/20/23 beginning at 9:00 AM, the following was observed: a. The ice machine had some black buildup on the right interior and on edge. The DM stated, The ice machine is cleaned monthly by kitchen staff or as needed. A quarterly flushing/sanitation is completed by an outside company. The DM stated that she would clean the black substance right away. b. In the stand-up meat freezer, immediately upon opening freezer, the temperature gauge read 10 degrees. The temperature affixed to the side of the stand-up meat freezer revealed the most recent temperature of -10 degrees on 02/20/23. The DM stated that Dietary Aide (DA) documented the freezer temps this morning. An interview was conducted with the DA at this time. The DA stated, The temperature was 10 degrees, not -10 degrees. I put that number down by mistake. Further review of the temperature log showed the temperature was documented as above 0 degrees for 18 of 19 days in the month of February 2023, with one additional day not being documented. The DM stated she was unaware that there were any issues with the freezer. The DM further stated The freezer temp should be 0 degrees and below. The staff should have informed me of the freezer issue. c. In the stand-up meat freezer, there were 12 packs of Hillshire Farm smoked ham, 32-ounce packages, starting to thaw as evidenced by water droplets in the packages. The DM stated, We are going to remove these immediately and figure out what is going on with the freezer. d. In the dry storage room, there was a 16-ounce carton of corn starch, opened, undated, and unlabeled. The DM stated this item should be dated and labeled. e. In the dry storage room, there was a six-pound carton of rainbow sprinkles opened to air, undated and labeled. The DM stated, I'm going to discard this. f. In the dry storage room, there was a 16-ounce bag of marshmallows, open to air, undated and unlabeled. The DM stated the food should not be opened to air and should also be dated labeled. g. In the dry storage room, there were four bags of coconut flakes with a date printed on each bag of 8/4/21 and a written date on each bag of 9/11/21. The DM stated I am unsure of the dates but the items should be thrown out. h. In the walk-in cooler, there was a container of what the DM stated was icing. The icing was undated and unlabeled. The DM stated the item is required to be dated and labeled. i. In the walk-in cooler, there was a container with an onion and pepper, both cut in half, undated and unlabeled. The DM stated the items is required to be dated and labeled. j. Near the cook's area, there were two 25-pound containers of flour and sugar, undated and unlabeled. The DM stated the items should be dated and labeled. 2. During a tour of the refrigerators outside of the kitchen with the DM on 02/20/23 beginning at 9:37 AM, there were three eight-ounce cartons of milk with an expiration date of 02/17/23 in the refrigerator on the [NAME] unit. The DM stated, Staff gets all of the items from the kitchen and these should have been disposed of. During an interview on 02/20/23 at 9:45 AM, the DM stated she expected all foods to be stored properly, including being dated and labeled as required. The DM stated that she expected the staff to check as needed for expired foods. During an interview on 02/23/23 at 10:16 AM, the Administrator stated she expected the freezer to be in working order, food to be stored appropriately and expired foods to be discarded.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during meal service so as to potentially prevent the development and transmission of communicable diseases for two of two dining observations in the main dining room. Findings include: During a continuous dining observation on 02/20/23 at 12:05 PM through 12:35 PM, the following was observed: 1. Certified Nursing Assistant (CNA)2, Dietary Aide (DA)5, Activity Assistant (AA), Dietary Manager (DM), DA3, and DA4 were observed serving meal trays to residents. These staff were observed to do the following: Remove meal trays from the steam table area. Serve the meal tray to the resident. Set up resident's meal, which included opening creamers, straws, setting up utensils, stirring in creamers. Adjust resident's chairs, wheelchairs, don clothing protectors, and adjust resident's clothing. Return to the steam table area to get another resident's tray and repeat the above steps. During this time, DA4 was also loading the cart for hallway meal trays. a. Throughout the meal process. CNA2, DA5, AA, DM, DA3, and DA4 failed to perform hand hygiene during the above process, as they passed trays and made contact with multiple residents. b. After passing meal trays, CNA2 was observed to begin feeding Resident (R) 31. CNA2 failed to perform hand hygiene between passing meal trays and assisting R31 with eating. c. DA5 was observed serving and setting up meal trays, pouring drinks, and going back and forth between the dining room and the kitchen, bringing resident food from the kitchen, and delivering to the resident. DA5 failed to perform hand hygiene during this observation. d. After passing meal trays, AA was observed to begin feed R27. AA was observed to put on gloves before she began assisting R27 to eat. AA was then observed to remove her gloves, open a condiment packet, and put the condiment on R27's food. AA then began cutting up food for R27's tablemate and went directly back to feeding R27. AA used the same silver to cut up the tablemate's food that the tablemate was already using. AA did not perform hand hygiene prior to feeding R27, after removing her gloves, or after touching the tablemate's silverware. During an interview on 02/20/23 at 12:35 PM, CNA2 stated she was taught to wash hands before serving meals in the dining room. During an interview on 02/20/23 at 12:36 PM, AA stated she taught to wash her hands before serving meals and to wear gloves while feeding. 2. During a second continuous dining observation on 02/21/23 at 8:07 AM through 8:22 AM, the following was observed: 1. DA2, DA4, Restorative Licensed Practical Nurse (LPN)3, and CNA7 were observed serving meal trays to residents. These staff were observed to do the following: Remove meal trays from the steam table area. Serve the meal tray to the resident. Set up resident's meal, which included opening creamers, straws, setting up utensils, stirring in creamers. Adjust resident's chairs, wheelchairs, don clothing protectors, and adjust resident's clothing. Return to the steam table area to get another resident's tray and repeat the above steps. During this time, DA4 was also loading the cart for hallway meal trays. Throughout the above process, DA2, DA4, Restorative LPN3, and CNA7 failed to perform hand hygiene as they touched multiple residents, as well as items such as silverware and glasses used by residents. During an interview on 02/21/23 at 8:22 AM, DA2 stated she was trained to wash hands at the sink before serving meals. During an interview on 02/21/23 at 8:23 AM, CNA7 stated, I was trained to sanitize hands before meal pass and put on gloves when sitting to feed resident. During an interview on 02/21/23 at 8:24 AM, DA4 stated he was trained to sanitize hands before meals. During an interview on 02/23/23 at 10:16 AM, the Administrator stated, I expect hands to be cleaned prior to walking into dining and between contact with residents. Also, after staff take their gloves off, they are supposed to wash their hands. During an interview on 02/23/23 at 10:40 AM, the Infection Preventionist (IP) stated, Staff are to wash or sanitize hands before serving and after contact with residents. Staff are also to wash hands after removing gloves. During an interview on 02/23/23 at 10:48 AM, the DM stated, I expect hand hygiene before coming to serve in the dining room and contact with residents. I also have told them not to wear gloves if they are not touching food because if they put gloves on and touch everything, the gloves are no longer clean. During an interview on 02/23/23 at 11:27 AM, the Director of Nursing (DON) stated, I expect hands to be sanitized before feeding a resident. The staff should have gloves on also. Hands should be sanitized between contact with residents. I worry about that because we have so many residents with MDRO (multi-drug resistant organism) and don't want the organisms to spread.