**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on electronic record review (EHR), staff interview, and policy review the facility failed to develop a comprehensive care plan that included problems, goals, or approaches for the implementation of Enhanced Barrier Precautions for 1 of 3 residents reviewed (Resident #26). The facility reported a census of 49 residents. Findings include: Review of Resident #26's Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was admitted to the facility on [DATE] from a short term hospital stay. The MDS further revealed that Resident #26 utilized the use of an indwelling catheter. Review of a document titled, Order Summary Report revealed a physician's order for a 16 french indwelling Foley catheter to be changed on the 15th of every month in the evening starting on the 15th and ending on the 15th every month for catheter change. This document further revealed that this order had an order dated of 1/8/25 and a start date of 1/15/25. Review of a document titled, Baseline Care Plan with a signed date of 2/7/25 revealed that Resident #26 does utilize an indwelling catheter. The Care Plan lacked staff directive to use Enhanced Barrier Precautions. During an interview on 2/11/25 at 2:52 PM with the Director of Nursing (DON) revealed the facility did not have a policy on accuracy of care plans. The DON further revealed the facility followed professional standards, and the Resident Assessment Instrument (RAI) when care plans are completed.

Based on observation, staff interviews, and policy review the facility failed to properly secure and store medications to minimize loss or access for 1 of 1 medication carts. The facility reported a census of 49 residents. Findings include: During a continuous observation 2/10/25 at 2:20 PM the medication (med) cart on the east hall of the facility was left unlocked and unattended for 5 minutes by Staff C Licensed Practical Nurse (LPN). In this time a Resident (Resident #29) at the facility rolled by in a wheelchair past the unlocked medication cart. At 2:25 PM Staff D Registered Nurse (RN) came from the south hallway and came to the unlocked med cart and locked it. Interview 2/10/25 at 2:36 PM with Staff E RN revealed the med cart should be locked when not working with it. Interview 2/10/25 at 3:31 PM with the Director of Nursing (DON) revealed that the facility's expectation would be for med carts to be locked when not in use or out of eyesight of the nurse using it. The DON further revealed that the facility does not have a policy for this as the facility follows standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and clinical record review the facility failed to implement Enhanced Barrier Precautions (EBP) to prevent the spread of pathogens for 3 of 3 residents reviewed. (Residents #103, #47 and #26.) Residents #103 and #47 required enteral nutrition and medication administration (directly into the gastrointestinal tract through feeding tube.) Resident #26 had a urinary catheter. Staff failed to wear all of the required Personal Protective Equipment (PPE) when administering cares to these three residents. The Facility reported a census of 49 residents. Findings include: 1) According to the Baseline Care Plan dated 2/5/25 at 3:28 PM, Resident #103 required special treatments including suctioning, tube feedings and a suprapubic catheter. The resident was non-verbal and did not understand staff. An order dated 2/5/25 at 1:31 PM, showed that Resident #103 had continuous nutrition through enteral feedings. 2) The Profile page for Resident #47, showed special instructions for staff to use Enhanced Barrier Precautions. (infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes) An order dated 2/10/25 at 6:44 PM, showed that all medications for Resident #47 should be administered via PEG (Percutaneous Endoscopic Gastrostomy, used for long-term enteral feeding) tube. The Care Plan updated on 1/20/25, showed that Resident #47 had severe limited physical mobility related to cerebral palsy and was totally dependent on staff for all Activities of Daily Living. The residents' main source of nutritional intake was through PEG tube feedings. On 2/11/25 from 9:13-9:30 AM, Staff A Licensed Practical Nurse (LPN) provided medication administration and enteral feeding set-up via Kangaroo Pump (used to deliver enteral nutrition and hydration.) Residents #103 and #47 resided in the same room. Staff A failed to wear a gown throughout the process. On 2/13/25 at 9:00 AM, the Director of Nursing (DON) acknowledged that staff were expected to use EBP when administering tube feedings and medications through the PEG tube. 3. Review of Resident #26's MDS dated [DATE] revealed Resident #26 requires the use of an indwelling catheter. The MDS further revealed that Resident #26 has a diagnosis of chronic kidney disease. Review of a document titled, Order Summary Report revealed a physician's order for a 16 french indwelling Foley catheter to be changed on the 15th of every month in the evening starting on the 15th and ending on the 15th every month for catheter change. This document further revealed that this order had an order dated of 1/8/25 and a start date of 1/15/25. On 2/11/25 at 9:51 AM observed Staff E Certified Nurses Aide (CNA) and Staff F CNA complete hand hygiene and donn gloves. Staff E and Staff F then proceeded to drain Resident #26's catheter drainage bag. Hand hygiene was completed after the procedure. No gown was worn during the process. Interview on 2/11/25 at 10:03 AM Staff F revealed that she and Staff E should have worn gowns during catheter drainage for Resident #26 as this is part of Enhanced Barrier Precautions. Interview on 2/11/25 at 2:52 PM with the Director of Nursing (DON) stated the facility's expectation was for Personal Protective Equipment (PPE) to be worn appropriately when caring for residents with enhanced barrier precautions in place. Review of a facility provided policy titled, Enhanced Barrier Precautions with a date of 7/2022 and updated date of 3/21/24 revealed: EBP should be applied to residents with any of the following: 1. Chronic wounds 2. Indwelling medical devices, regardless of MDRO (Multi-drug resistant organisms) colonization status. (Indwelling device examples include central/PICC lines, urinary catheters, feeding tubes and tracheostomies).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Electronic Record Review (EHR), document review, and staff interviews the facility failed to provide a Comprehensive Care Plan including goals and interventions for pain, with the use of opioids for 1of 5 residents reviewed (Resident #7). The facility reported a census of 37 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #7 had a Brief Interview for Mental Status (BIMS) of 14 indicating no cognitive impairment. MDS revealed a diagnosis of pain. Review of Resident #7 Physician Orders documented an order for Tramadol 50mg PRN every 6 hours with a start date of 12/23/22. Review of Resident #7 Care Plan revealed a lack of goals with interventions related to pain, and the use of opioids. On 5/8/24 at 3:25 PM the DON (Director of Nursing) stated the facility's expectation was Resident #7 ' s Care Plan would have goals and interventions in place for pain with the use of opiods. The DON stated the goals and interventions were not present in the Care Plan for Resident #7. The DON stated the facility has no policy for Care Plans. The DON stated the facility follows the Centers for Medicaid and Medicare Services (CMS) Resident Assessment Instrument (RAI) for Care Plan completion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinicial record review, and staff interviews the facility failed to update the Care Plan when a resident had a change in condition for 1 of 15 residents. Resident #35 experienced some increased weakness, loss of appetite and was diagnosed with the COVID-19 virus. The Care Plan lacked interventions or increased monitoring related to the residents needs. The facility reported a census of 37 residents Findings include: According to the Minimum Data Set (MDS), dated [DATE], Resident #35 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating a severely impaired cognition. Diagnosis included heart failure, non-Alzheimer's Dementia, malnutrition, and retention of urine. The Physician Order's for Resident #35 included an order dated 11/6/23 for COVID-19 screening as needed. A Nursing Note, dated 2/3/24 at 8:16 AM, revealed the resident reported not feeling well that morning and presented with nasal congestion, shortness of breath and a sore throat. Staff administered a COVID-19 test, and the residetn tested postive. The Care Plan included a note dated 2/3/24 indicating the resident was started on an antibiotic and steroid for COVID-19, but lacked direction to staff on interventions or monitoring goals. On 5/9/24 at 7:48 AM, The Director of Nursing (DON) stated the facilty did not have a specific policy related to Care Plan updates and follow the standards of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to provide appropriate infection prevention practices when securing a catheter drainage bag to a trash can for 1 of 1 residents reviewed (Resident #33).The facility reported a census of 37 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #33 had a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. The MDS documented Resident #33 had an indwelling catheter. On 5/6/24 at 10:31 AM an observation of Resident #33's catheter bag hanging on her garbage can, with trash in the garbage can. Resident #33's catheter bag lacked a dignity cover. On 5/8/24 at 12:25 PM Staff A, Certified Nursing Assistant (CNA) stated [catheter] either laying on a barrier on the floor or hanging from Resident #33 garbage can. Stated dignity bags are not utilized in the residents room. On 5/8/24 at 12:36 PM the Director of Nursing (DON) stated the facility's expectation is that it [catheter] would be placed on a barrier on the ground. The DON stated she would not expect the catheter bag to be hanging on the garbage can. The DON stated the facility had no policy on catheter placement. The DON stated the facility follows professional standards of practice.

Based on observation, interviews and policy review the facility failed to ensure that all food items were replaced before the recommended past due date. On 5/6/24 it was discovered that a bin of flour had an open date of October of 2023. The facility reported a census of 37 residents. Findings include: During an observation of the facility kitchen on 5/6/24 at 9:25 AM it was discovered that on the lid on a bin of flour, there was a piece of brown tape with a date of 10/16/23. The Certified Dietary Manager (CDM) said that would have been the date that the bin was last filled with flour. She was not sure of the recommended shelf life for flour. On 5/7/24 at 10:15 AM, the CDM said that she talked to the dietician about the flour and was told that in those containers, the flour would be good for 6 months. The CDM said that she had emptied the flour bin and cleaned it out and would refill it with fresh flour. On 5/8/24 at 2:30 PM, the facility Dietician said that she expected the staff to date the items when they are first opened. The flour should not be kept in the bin for more than 6 months. An undated policy titled: Safety in Food Products and Storage, indicated that all food products would be rotated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The MDS dated [DATE] for Resident #10 listed an admission date of 1/27/22. The MDS identified a BIMS score of 13, indicating no cognitive impairment. The MDS included diagnoses of unspecified fracture shaft of humerus, unspecified fracture upper end of humerus, and age related osteoporosis. Resident #10 had a scheduled pain medication regimen, PRN pain medication, and rated her pain at a 5/10, indicating moderate pain within the five days of the lookback period. The Care Plan Problem dated 1/20/23 indicated that Resident #10 had a humerus fracture that required her to need assistance with her activities of daily living (ADL's) while healing. The record review completed on 2/21/23 at 4:44 PM revealed for Resident #10's Comprehensive Care Plan lacked information related to pain. Based on clinical record review, staff interview, and facility policy review, the facility failed to develop Care Plans to address psychotropic medication usage, opioid medication, pain management, elopement risk, and dementia for 4 out of 14 residents reviewed (Residents #3, #10, #30, and #140). The facility reported a census of 36. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #30 identified a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Resident #30 had a PHQ-9 (9-question depression scale of PHQ) score of 21, indicating severe depression. The MDS included diagnoses of non-Alzheimer's dementia, restlessness, and agitation. Resident #30 used antianxiety and antidepressant medications for seven out of seven days in the lookback period. The Physician's Order List included the following psychotropic medications: a. 9/15/22 Ativan 0.5 milligrams (mg) tablet ordered twice a day at noon and bedtime. b. 1/20/22 Ativan 0.5 mg tablet ordered every 4 hours as needed (PRN) for agitation and restlessness. Interdisciplinary Notes Review 2/6/23 at 10:53 AM - At the beginning of the shift, Resident #30 paced and attempted to exit the building out the back door as another staff member left. The staff redirected Resident #30 and he continued to walk around the building multiple times asking what he could or should be doing. 2/13/23 at 5:22 AM - As Resident #30 wandered in the hallway, he entered room [ROOM NUMBER] and scared the resident in that room. It took two staff members to redirect him back into his room to get dressed. Resident #30 got back up and across the hall attempting to go into room [ROOM NUMBER] again. 2/21/23 at 6:37 AM - At 5:30 am this morning a Certified Nursing Assistant (CNA) reported that Resident #30 roamed the halls. The Care Plan reviewed on 2/21/22 at 9:53 AM for Resident #30 showed the facility failed to monitor the resident's usage and side effects to watch for psychotic medication usage. The Care Plan also lacked documentation for the facility to safely monitor Resident #30's wandering and exit seeking behaviors to prevent a possible elopement. In an interview on 2/21/23 at 2:11 PM, the Director of Nursing (DON) revealed that she expected psychotropic medication, usage, and side effects to be on the care plan. In an interview on 2/21/23 at 6:07 PM, Staff K, CNA, reported that he observed Resident #30 wander into other resident rooms on occasion. Staff K stated, I only know of a couple of times he has tried to get outside but we were there and he is easily redirected. In an interview on 2/22/23 at 11:42 PM, the DON reported that she added psychotropic medications to Resident #30's Care Plan. When asked about Residents #30's elopement and wandering risk she responded, we don't have a locked unit. We would also talk with family about different placements but he doesn't really wander and doesn't seek. The DON reported the facility lacked a psychotropic medication and Care Plan policy. 2. The Minimum Data Set (MDS) dated [DATE] for Resident #140 identified a Brief Interview for Mental Status (BIMS) score of 14, which indicated cognition intact. The MDS showed Resident #140 prescribed opioids. The MDS diagnosis showed post shoulder surgery, fractures or other trauma and polyneuropathy. In an interview on 2/20/23 at 1:31 PM, Resident #140 reported that she had severe pain in her right hand and shoulder area at times due to a recent fall that required shoulder surgery. Resident #140 observed with a shoulder immobilizer applied to her right shoulder. Resident #140 reported she is prescribed regular pain medication and could have extra pain medication and ice packs if needed. Resident #140 stated, the pain can get severe sometimes, right now it happens more in her right hand. Resident #140 stated that she didn't know when asked if the pain medication and packs worked for her. The Physician's Order List Review included the following pain medications: a. Acetaminophen 325 mg 2 tabs every 4 hours PRN for pain. b. Tramadol 50 mg twice a day PRN for pain. c. Tramadol 40 mg 3 times a day for pain. d. Physical Therapy for pain management On 2/21/22 at 3:00 PM witnessed Staff B, Licensed Practical Nurse (LPN), applied 2 ice packs to Resident #140's right arm and hand due to pain. The Initial Care plan dated 2/6/23 for Resident #140 lacked mention of pain, pain management, and failed to contain a plan of care for pain. In an interview on 2/22/23 at 11:42 AM, the DON confirmed that the Care Plan did not address pain management, however the facility's practice is to locate orders with the Care Plan. When more information or clarification is needed, staff can refer to the orders. The DON stated, I would be chasing my tail if I had to write all those orders on the Care Plan when staff can just look at the orders, the Care Plan and orders are together on the chart. When asked about the plan of pain management versus looking at a list of orders, the DON stated, I can see where you're coming from, but staff can see that by looking at the orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement safe transfer practices to prevent accidents and hazards for 1 of 3 residents reviewed (Resident #7). As the staff transferred Resident #7 with the use of a sit to stand mechanical lift, he could not hold onto the left handle, and the sling supported most of his weight. The facility reported a census of 36 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE] Resident #7 had a Brief Interview for Mental Status (BIMS) score of 9 (moderate cognitive deficit). The resident required extensive assistance with the help of one staff member for transfers, dressing and toilet use. The MDS included diagnoses of hemiplegia affecting the left side, aphasia, contracture of the left hand, and contracture of the left ankle. The Care Plan dated 10/4/22 showed that Resident #7 needed assistance with Activities of Daily Living (ADL) due to left-sided paralysis. He required extensive assistance with transfers and toilet use. The Care Plan instructed the staff to use the EZ lift mechanical lift. The paper copy of the care plan had the word lift crossed out and stand was added. The written changes did not include a date. On 2/19/23 an addition was made that indicated that the resident had tested positive for the COVID-19 virus. In an observation on 2/20/23 at 12:52 PM Staff A, Certified Nursing Assistant (CNA), moved the sit to stand mechanical lift into the room of Resident #7. She assisted the resident to put his feet on the platform. After getting his feet on the platform, his left foot did not lay flat and his toes were up on the rim of the platform. The resident wore a lower leg brace on his left leg. Staff A failed to strap his legs onto the stand for support and his shins did not rest against the shin padding. The resident moaned as she raised him up out of the chair and pushed him to the bathroom. The resident's left arm hung over the side of the sling, and the sling was up into his armpits. The sling supported a majority of his weight as evidenced by his slumped body and the sling that slid higher up his arm as staff transferred him. On 2/21/23 at 8:32 AM, Staff J, Physical Therapist (PT), reported being familiar with Resident #7 and knew that he had left-sided weakness but it had been several months since PT worked with him. She said at that time he could walk but he mostly dragged his left leg behind him. She said that if he wasn't bearing weight on the stand, the staff should not be using the EZ stand but should use the EZ lift. On 2/21/23 at 9:07 AM Staff C, CNA, said that at times Resident #7 would not bear weight on his legs as he should in order to use the EZ stand. She said he could no longer walk because his right knee would give out. She explained that she would always strap his legs on the EZ stand when transferring with the mechanical lift because he could be unstable. On 2/21/23 at 5:32 PM, the Director of Nursing (DON) said that Resident #7 went back and forth on his level of ability related to use of EZ lift or stand. She said that nursing should evaluate him for mechanical lift use if he had a decline in ability. On 2/22/23 at 10:46 AM, Staff A said that Resident #7 had his good and bad days. Some days he would have a lot of pain in his hips and then he would be unable to bear weight on either side. She said that sometimes the resident would take his right hand and hold his left arm while they transferred him, therefore, he would not be holding onto either handle. She said that she would use the lift rather than the stand if he wasn't bearing weight on his legs. According to the EZ Way Stand owner's manual dated 2007, page 2 instructed staff to apply the harness 4-5 inches below the underarm, place the feet on footplate, and position shins into shin pads. If necessary to keep patients shins or feet on foot plates, secure shin straps around the legs. Page 3 instructed staff to place the patients' hands on the padded handles. On 2/23/23 at 7:48 AM, the DON said that she knew Resident #7 had moments of instability on his feet and she would expect the staff to strap his legs into the sit to stand when transferring him.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview the facility failed to limit the timeframe for PRN (as needed) a psychotropic medication to 14 days, unless the physician deemed a longer timeframe appropriate, for 1 of 5 residents reviewed for unnecessary medications (Resident #30). The facility reported a census of 36 residents. Findings Included: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #30 identified a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Resident #30 had a PHQ-9 (9-question depression scale of PHQ) score of 21, indicating severe depression. The MDS included diagnoses of non-Alzheimer's dementia, restlessness, and agitation. Resident #30 used antianxiety and antidepressant medications for seven out of seven days in the lookback period. The Physician's Order List included the following psychotropic medications: a. Start date of 1/20/22 without a stop date: Ativan 0.5 mg tablet ordered every 4 hours as needed (PRN) for agitation and restlessness. The Medication Administration Records (MAR) for Resident #30 showed the administration dates for Ativan 0.5 mg tablet ordered every 4 hours PRN for agitation and restlessness: a. January 24, 2022 b. February 8, 2022 c. February 9, 2022 d. March 31, 2022 e. April 31, 2022 f. June 4, 2022 g. July 4, 2022 h. August 15, 2022 i. October 8, 2022 j. November 16, 2022 k. December 17, 2022 l. January 14, 2023 The Care Plan reviewed on 2/21/22 at 9:53 AM for Resident #30 showed the facility failed to monitor the resident's usage and side effects to watch for psychotic medication usage. In an interview on 2/22/23 at 1:45 PM, the Director of Nursing (DON), reported that she knew about the psychotropic medication PRN requirement. The DON reported that she taught the staff that PRN psychotropic medications required a 14 day stop date otherwise a written review is required by the physician. In an interview on 2/22/23 at 2:11 PM, the DON acknowledged that the facility failed to limit the PRN Ativan order to 14 days and that the facility lacked a documented rationale by the prescribing physician for the PRN Ativan order that extended beyond 14 days. The DON stated, I know we should be doing that, but we didn't for this one. The DON reported that the facility lacked a policy for psychotropic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The Minimum Data Set (MDS) dated [DATE] for Resident #29, identified a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The Care Plan last revised on 2/21/23 revealed Resident #29 tested positive for COVID-19 on 2/12/23. The Care Plan instructed staff to wear personal protective equipment (PPE) when entering his room. On 2/21/23 at 9:27 AM observed a sign posted outside of Resident #29's room that instructed the staff to apply PPE before entering his room, including a N95 mask. On 2/20/23 at 1:43 PM watched Staff D, Certified Nurse Assistant (CNA), entered Resident #37's wearing personal protective equipment (PPE) of a surgical mask, face shield, gown, and gloves for transmission based droplet precautions related to COVID-19. Staff C assisted Resident #29 with a transfer from the wheelchair to their recliner using an EZ Stand. After exiting the resident's room, Staff C stated, I was told that I didn't have to wear a N95 in COVID positive rooms because I just got over COVID last week. In an interview on 2/21/23 at 5:17 PM, the Director of Nursing reported that she expected staff to wear PPE and a N95 mask, not a surgical mask, when staff entered a resident's room that is infected with COVID-19. The Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last updated Sept. 23, 2022, revealed Health Care Personnel are required to wear a N95 mask or higher respirator during care of a resident infected with COVID-19. Based on observations, interviews, and record review the facility failed to implement adequate infection control measures to prevent the spread of infection. On three separate observations the staff failed to use the recommended Personal Protective Equipment (PPE) and social distancing when interacting with residents that were positive for Covid-19. The facility reported a census of 36 residents. Findings include: 1. On 2/20/23 at 12:40 PM, observed that room [ROOM NUMBER] had contact precaution signage on the door frame. At the time witnessed Staff D, Licensed Practical Nurse (LPN), in the room with Resident #15 trying to calm them during a coughing spell. The observation revealed Resident #15's room door open and Staff D not wearing a gown or gloves. She held a package of disposable gowns. When she left the room, she went to a cart at the end of the hall, without hand hygiene, she opened a drawer on the cart and put the gowns in the drawer. Without completing hand hygiene, she then donned a gown and gloves before she helped the resident and closed the door. According to the census report, Resident #15 resided in that room and she tested positive for COVID-19 on 2/13/23. 2. On 2/20/23 at 11:07 AM, observed that room [ROOM NUMBER] had contact precaution signage outside the door. Resident #1 sat in a wheelchair just inside their room with her door open. Staff I, Housekeeping, stopped in the doorway and visited with the resident for a couple of minutes. The staff member wore a surgical mask and no gloves. As she talked to the resident, Staff I rested her bare hand on the doorframe and the two of them were just a couple of feet apart. Staff I then proceeded down the hallway and failed to use hand sanitizer. According to the census report Resident #1 resided in that room and she had tested positive for Covid-19 on 2/13/23.

Based on electronic record review, document review, and staff interview the facility failed to develop and implement policies and procedures, to ensure a resident's medical record included documentation that a resident refused the influenza or pneumococcal immunizations for 1 of 5 residents reviewed (Resident #27). The facility reported a census of 36 residents. Findings included: The Minimum Data Set (MDS) for Resident #27 documented she entered the facility on 5/26/21. The MDS also documented a Brief Interview of Mental Status (BIMS) of 3, indicating severe cognitive impairment. In an interview on 2/21/23 at 11:26 AM, Staff F, Licensed Practical Nurse (LPN), stated on the day of admission residents are offered vaccines and their history of vaccines are discussed. Staff F explained that the chart had notes about vaccines in the nurses notes on the day of admission as well. The electronic and paper record review conducted on 2/21/23 at 1:30 PM revealed Resident #27 did not have documentation of a declination of the COVID-19 immunization. In an interview on 2/21/23 at 11:15 AM, Staff H, Director of Nursing (DON), verified that Resident #27 did not have a declination of immunization completed. Staff H stated Resident #27 refuses all immunizations. Staff H reported that the facility's expectation is that a declination form is filled out or charted in medical records for any immunizations that are declined or refused by residents.

Based on electronic record review, document review, and staff interview the facility failed to develop and implement policies and procedures, to ensure the resident's medical record included documentation that the resident did not receive COVID-19 immunizations due to refusal for 2 of 5 residents reviewed (Resident #141 and Resident #27). The facility reported a census of 36 residents. Findings included: 1. The Minimum Data Set (MDS) for Resident #27 documented she entered the facility on 5/26/21. The MDS also documented a Brief Interview of Mental Status (BIMS) of 03 indicating severe cognitive impairment. The electronic and paper record review conducted on 2/21/23 at 1:30 PM revealed Resident #27 did not have documentation of a declination of the COVID-19 immunization. 2. The Minimum Data Set (MDS) for Resident #141 documented she entered the facility on 6/27/22. The MDS also documented a Brief Interview of Mental Status (BIMS) of 13 indicating no cognitive impairment. In an interview on 2/21/23 at 11:26 AM, Staff F, stated on the day of admission residents are offered vaccines and their history of vaccines are discussed. STaff F stated notes about vaccines are in the nurses notes on the day of admission as well. The electronic and paper record review conducted on 2/21/23 at 1:12 PM revealed that Resident #141 did not have documentation of a declination of the COVID-19 immunization. In an interview on 2/21/23 at 11:15 AM, Staff H, stated no declination of immunization refusal was completed for Resident #27. Staff H stated Resident #27 refuses all immunizations. Staff H stated the facility expectation is that declination form is filled out or charted in medical records for any immunizations that are declined or refused by residents. Staff H stated Resident #141 probably doesn't have a declination form either. Staff H stated Resident 141 might have refusal of immunization charted from the admission.