Based on clinical record review, staff interviews, and facility policy review, the facility failed to ensure the admission Minimum Data Set (MDS) Assessment submitted in a timely manner for 1 of 12 residents reviewed for MDS. (Resident #9). The facility reported a census of 36. Findings include: The admission MDS, Assessment Reference Date (ARD) 12/27/22 reviewed for Resident #9. The assessment completed on 2/6/23, and submitted on 2/7/23. During an interview on 6/29/23 10:08 AM, the admission Coordinator queried when an admission MDS needed completed and he stated he believed 14 days after admission and he knew some of them were late because of all the transitioning of job positions. During an interview on 6/29/23 at 2:41 PM, the Director of Nursing (DON) queried on the expectation of MDS being completed on time and she stated the expectation was for them to be completed on time and when changes occurred. The Facility MDS Completion and Submission Timeframes Policy dated July 2023 revealed the facility conducted and submitted Resident Assessments in accordance with current federal and state submission timeframes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS assessment dated [DATE] revealed Resident #9 scored 7 out 15 on the BIMS exam, which indicated severe cognitive impairment. The MDS revealed medical diagnosis of age-related cognitive decline. The MDS identified the resident with an unstageable pressure ulcer not present upon admission. The MDS revealed the resident received an antidepressant 7 out of 7 days. The Care Plan entry dated 12/21/22 documented a focus area of risk for skin breakdown. The interventions dated 12/21/22 included to administer treatments to the wounds as ordered and monitor for effectiveness. The interventions dated 2/9/23 revealed resident wore heel boots in bed. The Care Plan lacked documentation of the presence of an unstageable pressure ulcer prior to 6/29/23. The Clinical admission Evaluation dated 12/20/22 at 3:44 PM, revealed Resident #9 received lower extremities Range of Motion (ROM) as impaired on both sides. The Progress Note dated 12/31/2022 at 3:13 PM, identified a deep large black area with loose gray skin around a firm black wound. The wound measured 5.2 centimeter (cm) long x 6.5 cm wide x 0 cm deep. The Physician Orders dated 2/15/23 shown an order for Remeron oral tablet (mirtazapine)- Give 7.5 milligrams (mg) by mouth one time a day for depression and appetite related to age related cognitive decline. The Care Plan entry dated 5/15/23 revealed a focus area that resident took an antidepressant medication. The record lacked a focus area to address an antidepressant medication prior to 6/29/22. During an observation on 6/26/23 at 10:00 AM , Resident #9 sat in his wheelchair and wore a heel boot on his left foot. During an interview on 6/29/23 10:08 AM, the admission Coordinator queried when a resident's Care Plan changed such as started antidepressant medications or acquired a pressure sore if it needed addressed on the Care Plan and within what time period and he stated yes, it should be addressed on their Care Plan and it should be added in 24 hours unless it happened over the weekend and then it should be addressed that following week. The admission Coordinator stated Resident #9's pressure ulcer should have been addressed and it was his error. Based on clinical record review, staff interviews, observation and facility policy review, the facility failed to update the Care Plan to accurately reflect code status, antidepressant use, and an actual pressure ulcer for two of twelve residents reviewed for Care Plans (Resident #9, Resident #14). The facility reported a census of 36 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #14 dated 6/15/23 revealed the resident scored 12 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated moderately impaired cognition. The Care Plan dated 12/6/22 documented, I have Advanced Directives in place: My Code Status is FULL CODE. The Profile Section in Resident #14's Electronic Health Record documented a code status of Do Not Resuscitate (DNR). The Health Status Note dated 4/24/23 at 2:21 PM, documented, in part, a change in the Iowa Physician Orders for Scope of Treatment (IPOST) and code status now DNR. The Physician Order dated 4/24/23 documented DNR status for the resident. On 6/29/23 at 10:58 AM, the Admissions Coordinator shown the conflicting information in the resident's electronic profile and order versus the resident's Care Plan, and acknowledged the Care Plan should reflect current status. Per the Admissions Coordinator, he explained he would go change that now. On 6/29/23 at 2:28 PM, the Director of Nursing (DON) explained Care Plans needed to be reviewed quarterly and as needed and with a significant change. The Facility Policy dated January 2023 documented, in part, the following: Assessments of residents are ongoing and Care Plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility video review, staff interviews, and facility policy review, the facility staff failed to assess a change of condition and intervene appropriately following an accident during a wheelchair transport for 1 of 12 residents reviewed for assessment and interventions. (Resident #7). The facility reported a census of 36. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #7 scored 00 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severe cognition impairment. The MDS revealed the resident required extensive assistance with 2 plus person physical assistance for bed mobility and transfers and used a wheelchair. The MDS identified the medical diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; and age-related osteoporosis with current pathological fracture, right lower leg, subsequent encounter for fracture with routine healing. The Care Plan entry dated 1/10/22 revealed a focus problem of deficit Activities of Daily Living (ADL) self-care performance related to impaired mobility, vascular dementia, osteoarthritis, compression fractures of vertebra, knee arthroplasty and periprosthetic fracture. The interventions dated 1/10/22 identified a wheelchair for mobility the resident self propelled or pushed by staff. The Care Plan entry dated 1/10/22 documented a focus area of pain related to a non-displaced fracture of the right distal tibial and fibula metadiaphysis, healed proximal right tibia/fibula fracture, compression fractures of vertebra, osteoarthritis, osteoporosis, and history of right knee arthroplasty and periprosthetic fracture. The interventions dated 1/10/22 indicated to notify the Physician for interventions unsuccessful or if current complaint was a significant change from the resident's past experience of pain. Review of a facility video provided the following information: a. On 7/9/22 at 9:32 PM, the resident pushed down the hallway by a staff member and visualized her right foot not placed on the right foot pedal and positioned between the foot pedals. b. At 9:33 PM, observed the resident's body lifting up in her wheelchair and turning towards staff member with a visual change in her facial expression and the right foot under the wheelchair. The staff member stopped the wheelchair and went around to the front of the wheelchair and removed her foot from under the wheelchair and placed it on the foot pedal. The right foot visualized facing outward and the knee straight. The staff member turned wheelchair around in the hallway and escorted resident to the outside of the Nurse's Station and another staff member came outside and saw the resident. The Health Status Note dated 7/9/22 at 9:40 PM, Staff G, Registered Nurse (RN) was called into Resident #7's room by a Certified Nurse Aide (CNA) because the resident not letting them get her into bed because she was in pain. Upon entering the room, the resident sat in her wheel chair. This nurse talked to resident and asked her where her pain was located. She appeared quite upset, but did not give an answer at first. She was tremoring off and on and when asked again, she started grabbing below her abdomen, then pointed at her hips and legs, but did not give a specific place and would just kind of flail her hands around. She would go from mumbling incoherent things to making direct statements. Staff G attempted to give Resident #7 pain medication, but she refused to take it, turning her head away each time. Attempted to explain to her that the medication would help her pain, but she continued to refuse. Staff G explained to her that staff needed to put the brace on her leg and get her into bed so she could rest as resting might help her pain. She began swinging her arms at us as we put the brace on her right leg. She was then assisted into bed with assist x 2, gait belt and pivot disk. She pushed against us the whole time. Once in bed, this nurse removed the Thrombo-Embolic Deterrent (TED) Hose from her right leg and pulled her pant leg down. She then kicked her left leg at this nurse. The brace on right leg was left on since she was so agitated. Explained to resident that we were going to leave her to rest for a while and would check back on her. Bed was placed in lowest position, call light within reach. The Health Status Note dated 7/10/22 3:30 AM, revealed Staff I, CNA notified this nurse that while she changed the resident, the resident yelled out in pain and started crying. Staff I reported that when asked where her pain was, resident pointed to her waist and then down her legs. Staff I also reported a bruise to the inside of her lower right leg. This nurse went in to assess the resident and talked with her about her pain. Resident #7 did not clearly show where her pain was, so this nurse started up around her waist, lightly touching her and asking if she had pain where she was being touched. This nurse touched her waist, abdomen, left hip, left upper leg, left knee, left lower leg and right hip and right upper leg. Resident denied pain at each of those locations. Upon touching her right knee, the resident grimaced. Lightly touched below her right knee to the upper portion of her right lower leg and she started to say ow, ow, ow over and over. Attempted to touch lower on her right leg and she yelled at this nurse to leave her alone and to not touch her there. While attempting to measure the bruise on her lower right leg, when not even touching her leg, resident was yelling to stop touching her there and said that was where it was hurting the most. Asked resident what she was wanting to do to help with the pain. She stated I want to die. Tried to comfort resident and direct her away from those thoughts. This nurse explained to resident that pain medication would help with her pain and hopefully make her feel a little better. After a few attempts, resident finally took a pain pill. Sat with resident for a little while longer and continued to comfort her as best as possible. Left bed in lowest position, call light within reach. The Progress Note dated 7/10/2022 at 8:03 AM revealed a new bruise to resident's inner right lower leg noted. It was light purple in color and measures 5.6 centimeters (cm) in length x 3.1 cm in width. Also, the resident had severe pain to this area of her leg. It been difficult to get her to take her medications at times, especially when she was agitated. Could we change her Tylenol from tablet form to liquid form, keeping the same dosing and schedule of 650 milligram (mg) four times a day (QID) ? Also, she currently has an order for Lortab (Hydrocodone-acetaminophen) 5/325 mg every 6 hours as needed for pain. Since it was difficult to get her to take pills at times, even when crushed, could we have an order for something similar, only in a liquid form? The Progress Note dated 7/10/22 at 8:15 AM, revealed a Progress Note faxed to the physician for review and awaiting response. The Health Status Note dated 7/10/2022 at 10:31 AM, documented a follow up assessment due to increased pain to right lower extremity (RLE). Bruise continued to RLE with swelling. Painful to touch. Resident yelled out just removing the blanket from legs. Able to get resident to take scheduled medications. Resident stated she was tired, kept in bed from breakfast and offered room tray 2 times. Placed call to daughter and left voicemail due to increased pain. Resident rested in bed with eyes closed and even respirations, appeared comfortable. The Health Status Note dated 7/10/2022 at 10:35 AM, revealed a call placed to the Director of Nursing (DON), Manager on Duty ( MOD) and Executive Director after 10 am assessment. Voicemail left for daughter. The Health Status Note dated 7/10/2022 at 1:16 PM, documented the resident's daughter visited the resident. Explained to the daughter that the Night Nurse noted redness, bruising and edema to right ankle and increased discomforts this AM. Hydrocodone appeared effective. Took scheduled acetaminophen today. Resident remained in bed this AM for breakfast due to increased tiredness. Daughter requested to send resident to the emergency room (ER). The area ambulance notified and papers sent to hospital with resident. The ambulance transported her to the ER. The DON and MOD notified of transfer. The X-Ray of the Tibia and Fibula Right Anterior/Posterior and Lateral Final Result dated 7/10/22 at 2:57 PM, revealed a comparison of right tibia and fibula dated 1/9/22 with the findings of the following: a. There were healed fracture deformities of the proximal tibial and fibular fractures. New acute fracture of the distal tibial metadiaphysis without displacement. New acute nondisplaced fracture of the distal fibular metadiaphysis. Soft tissue swelling is present. The Health Status Note dated 7/10/22 at 5:09 PM, revealed the nurse spoke with daughter. Resident will return to the facility with new orders to schedule Hydrocodone. The daughter stated 2 fractures to the RLE. The resident returned with a boot and follow up appointment with ortho. The Health Status Note dated 7/10/22 at 6:40 PM, documented the resident returned to facility with daughter. The resident sat in her wheel chair with a boot to her right foot that goes up to just below her knee. The Health Status Note dated 7/10/22 at 7:00 PM, revealed the After Visit Summary from resident's trip to the hospital listed diagnoses as mild anemia and closed fracture of distal end of right tibia, unspecified fracture morphology, initial encounter. It also included the following instructions: No weight bearing on the right leg. Ice, elevation, Lortab as needed for pain. Follow-up with orthopedic surgery this week for further treatment advice. The Investigation Notes dated 7/20/22 revealed Staff G, RN stated to the DON that no one informed her of what the CNA reported happened earlier in the evening with Resident #7 when she was taken back to her room and she had no idea of a possible mechanism of injury to assess. Staff G stated the resident was agitated when she arrived in the room at 9:40 PM and it appeared as if it was related to pain. Staff G stated after talking with Staff H, Licensed Practical Nurse (LPN), the pain was because of the resident using her right leg more in the last year or so. Staff G stated they attempted pain medications and the resident refused so they decided to put her to bed to rest in hopes of her agitation calming down. Staff G stated it was because of not knowing there was a possible mechanism of injury to her right leg that she did not proceeded further, beyond assessment, and checking on resident later, by contacting the On-Call Nurse Manager, On-Call Doctor or resident's daughter immediately and also why Staff G did not request to have her sent out to be evaluated right away. This all happened at the end of the other nurse's shift, as well as the CNA's shift, so they both left shortly after it happened. Even during report, Staff H the other nurse did not notify me of what had happened earlier in the shift, in regards to a possible injury that may have happened prior to my arrival in resident's room. Staff G stated in the Morning Report, she passed on to Staff F, RN, the oncoming nurse, what she knew. Staff G stated at that time she did not know there was an actual mechanism of injury that was most likely contributed to resident's distress. Staff G asked Staff F to notify resident's daughter of the bruise and pain. Staff G stated she also mentioned that Staff H (the nurse working on the front hall the night before) and herself discussed the possibility of resident's pain being related to the resident use of her right leg more recently. Staff H, LPN statement (no date of when statement taken) of the incident on 7/9/22 around 9:20 PM, Staff J, CNA reported while wheeling resident to room the resident's right foot came off the foot pedal on wheelchair. Resident expressed that it hurt and didn't want it touched but wasn't in tears. Staff H noticed the right foot angled outward and not being familiar with what was normal for Resident #7, Staff H asked the other nurse on duty and it was. Staff G, RN assured Staff H it was normal and would look at it soon. Staff H assessed the leg by rotating the ankle and bent the knee and resident became increasingly agitated. Resident insisted it was her right hip. The resident wheeled to her room and was assessed again by Staff G and resident became more agitated and upset as being questioned again where it hurts. The leg brace applied and assisted x 2 with gait belt to bed where resident insisted on being left alone in tears and swatted with hands. As needed Lortab crushed in choc pudding and offered, resident refused by resident shaking her head, crying out and swatted Staff H. Staff G and Staff H agreed that it would be best for the resident to have some time to relax and reassessed in a bit due to all the commotion and simulation. During an interview on 6/28/23 at 5:16 PM, Staff F, RN stated she wasn't present for the incident and took the resident over at the start of her shift. She stated she called the daughter and asked if she wanted X-rays and informed the DON to start the investigation. Staff F stated the resident had pain in leg and couldn't use her leg. During an interview on 6/29/23 at 9:33 AM, Staff C, RN queried on how report given to the next shift and she stated verbally and they used a 24 hour report. She stated they discussed each resident and if they received new orders, went to the hospital, or any pertinent changes. Staff C asked if an accident would be expected to be reported and she stated yes. Staff C queried what she did if a resident presented with pain not aware of the cause and she stated she got a set of vitals, asked another nurse if they knew something, informed the DON (Director of Nursing) and informed the physician. Staff C queried if a resident cried out in pain and a new bruise found, what interventions she did and she stated she called the on-call instantly, and let the doctor and family now. During an interview on 6/29/23 at 10:24 AM, Staff D, RN asked what is considered emergent to call the physician and she stated anything with falls with fracture or possible fracture. During an interview on 6/29/23 at 2:41 PM, the DON queried on the expectation when a resident cried out in pain and a new bruise observed and the DON responded she expected more of an investigation started. The DON stated if the nurses thought there was something and Resident #7 needed to be sent out, they would of called and sent the resident out but they treated her and the resident went to sleep. The Facility Change in a Resident's Condition or Status Policy dated February 2021 revealed the following: a. The nurse will notify the resident's attending physician or physician on call when there has been: a. An accident or incident involving the resident. b. Discovery of injuries of an unknown source. c. Significant change in the resident's physical/emotional/mental condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and staff interview, the facility failed to complete a follow-up Preadmission Screening and Resident Review (PASRR) for one of one residents reviewed in the current sample who had a change in mental health diagnoses and psychotropic medication (Resident #11). The facility reported a census of 30 residents. Findings Include: The Significant Change Minimum Data Set (MDS) assessment dated [DATE] recorded Resident #11 had diagnoses that included non-Alzheimer's dementia, depression and psychotic disorder. The MDS indicated the resident with no serious mental illness and had not met criteria for a Level 2 PASRR. The assessment documented Resident #11 re-entered the facility on 9/23/20. The MDS further documented Resident #11 had a Brief Interview for Mental Status (BIMS) of 5 indicating severely impaired decision making skills. The MDS indicated Resident #11 received antipsychotic and antidepressant medications for 7 of 7 days during the look-back period. The Care Plan with a revision date 3/15/21 revealed Resident #11 with diagnoses of Lewy body dementia, delusional disorder, psychosis and major depressive disorder and had hallucination and delusions that caused her to become agitated and fearful. The Care Plan directives for staff included monitoring mood/behaviors/cognition and side effects of antidepressant, anti-convulsant and antipsychotic medications. The Medication Administration Record (MAR) dated 4/2022 revealed Resident #11 took the following medications: a. Depakote (anticonvulsant) for major depressive disorder. b. Lexapro (antidepressant) for major depressive disorder. c. Seroquel (antipsychotic) for delusional disorder and unspecified dementia with behavioral disturbance. d. Seroquel (antipsychotic) as needed for hallucinations. The medical record revealed a negative Level 1 PASRR dated 8/5/19 completed by Ascend Management Innovation under contract with the Iowa Department of Human Services to perform Level 1 screens and Level 2 evaluations. The Level 1 PASRR screening documented Resident #11 did not have a diagnoses of major depression, psychotic/delusional disorder or dementia and did not exhibit hallucinations or delusions at the time of the screening. Observation 4/25/22 at 1:11 PM, revealed Resident #11 in the hallway of the health care center with a visitor present inquiring about people in the hallway that are coming through the door. At the time of the observation, there were not people in the hallway nor people coming through the door. During an interview 04/27/22 at 11:10 AM the Director of Nursing (DON) acknowledged a Level 2 evaluation had not been submitted as it should have been since Resident #11 diagnosed with a new mental health diagnosis since the Level 1 PASRR had been completed. On 5/3/22 at 3:37 PM the DON reported they do not have a policy in place for PASRR completion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and facility policy review the facility failed to include a fall risk concern on the Comprehensive Care Plan for a resident with a recent fall with fracture for 1 of 3 residents reviewed for falls (Resident #22). The facility reported a census of 30 residents. Findings Include: The admission Minimum Data Assessment (MDS) dated [DATE] identified diagnoses of Alzheimer's disease, dementia, anxiety disorder, hypertrophic osteoarthropathy and gastro-esophageal reflux disease (GERD) for the resident. A Brief Interview for Mental Status (BIMS) score of 10 indicated moderate cognitive impairment. Resident #22 required limited assistance of one staff for bed mobility, transfers and personal hygiene, extensive assistance of one for toileting and supervision for eating. The MDS indicated the resident unsteady from seated to standing position, walking, turning around and facing the opposite direction while walking, moving on and off the toilet and with surface to surface transfers. Resident #22 utilized a walker and wheelchair for mobility. The MDS revealed a fall in the month prior to admission, a fall in the previous 2-4 months prior to admission, a fall in the previous 2-6 months prior to admission and a fracture related to a fall in the previous 6 months prior to admission. The MDS also revealed 2 or more falls without injury since admission. Per the MDS instructions in section V under the Care Area Assessment (CAA) Summary instructed for each triggered Care Area, staff are to indicate whether a new Care Plan, Care Plan revision, or continuation of current Care Plan is necessary to address the problem(s) identified in the assessment of the care area. Per the MDS dated [DATE], falls triggered as a problem and per the CAA Trigger Summary it was to be addressed on the Care Plan. The CAA worksheet revealed the following: I will be free of falls and need assistance with transfers and ambulation, however not added to the Comprehensive Care Plan. The Baseline Care Plan on admission to the facility dated 7/27/20 indicated the resident at risk for falls, and the resident had a fall in the last 30 days with a fracture of the pubis in the last 6 months. A goal was set not to fall through the next review date. The Initial Comprehensive Care Plan dated 9/21/20, revealed Focus Areas for alteration in nutrition, acute pain, disease management, impaired physical mobility, impaired social interaction, medication management, personalized care, risk for self-harm, risk for impaired urinary elimination, risk for insomnia, risk for self-care deficit, safety, assistance with meeting emotional, spiritual, intellectual, physical and social needs, activity of daily living assistance, and dementia. The Care Plan lacked a focus area addressing resident being a fall risk and no interventions in place for staff to monitor, evaluate or assist resident in preventing further falls. The Fall Risk assessment dated [DATE], revealed Resident #22 to be disoriented times 3, 1-2 falls in the previous 3 months, required regular assistance with elimination, balance problems with standing and walking, required the use of assistive devices and carried a diagnosis of dementia. The Incident Report dated 8/2/20, indicated Resident #22 found on the floor in the hallway at 6:40 PM, sitting on buttocks with legs straight out in front of her and hands at her side. Resident had been ambulating alone and unattended. The report indicated resident confused and looking for an Uber to go home and this was baseline mental status for the resident. Resident had shoes on and not using an assistive device for ambulation. Root cause felt to be Resident #22 left in room alone and attempted to transfer. Intervention placed to not leave resident alone in room. Progress Note dated 8/2/20 at 9:33 PM, indicated Resident #22 was found sitting on her buttocks on the floor outside her room with legs stretched out in front of her. The wheelchair and walker were next to her. Resident unable to recall what happened. Resident #22 denied pain, moved all extremities well, pupils were equal and reactive to light, grips equal and no change in mental status noted. Two staff assisted resident into wheelchair and resident was able to propel the wheelchair without difficulty or complaints of pain. Progress Note dated 8/3/20 at 5:24 AM, indicated the granddaughter updated regarding the fall and the medical provider faxed regarding the fall. Progress Note dated 8/3/20 at 12:53 PM, indicated the granddaughter concerned with the fall. Care plan reviewed with her. Resident #22 to be assisted by one staff and granddaughter had no further questions or concerns. In an interview on 4/28/22 at 2:00 PM, the Director of Nursing (DON) stated it is his expectation that there be a fall risk concern on the Comprehensive Care Plan for a resident that came to the facility after a fall with fracture. In an interview on 5/2/22 at 10:10 AM, Staff C, MDS Coordinator reported she had been in the position for 7 months. She stated it was an expectation a fall risk concern be put in place for a resident admitted to the facility after a fall with fracture. Staff C stated a fall problem, goal and interventions would be put in place to help prevent the resident from further falls or injuries. Staff C indicated Interventions on the Care Plan were instrumental in educating the staff on how to care for the resident. The facility provided a policy titled Care Plans, Comprehensive Person-Centered dated December 2016. The policy stated the Interdisciplinary Team (IDT) and resident were to incorporate identified problem areas and risk factors associated with the identified problems into the Comprehensive Care Plan. The Comprehensive Care Plan was to reflect treatment goals, timetables and objectives in measurable outcomes. Identifying problem areas and their causes, and developing interventions that were targeted and meaningful to the resident was the endpoint of an interdisciplinary process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, family and staff interviews, the facility failed to treat constipation in accordance with facility policy and professional standards (Resident #1) and failed to follow physician's orders for wound treatment (Resident #5) for 2 of 12 residents reviewed. The facility reported a census of 30 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 with diagnoses that included non-Alzheimer's dementia, anxiety and depression. The MDS documented a Brief Interview for Mental Status (BIMS) score of 1 indicating severely impaired cognition. The MDS further documented Resident #1 required total dependence of 2 staff for transfers and extensive assistance of 2 staff for toilet use and was always continent regarding bowel movements (BM). The Care Plan initiated with a Focus Area initiated 1/10/22 revealed Resident #1 had an activities of daily living (ADL) self-care performance deficit related to impaired mobility, dementia and compression fractures of the vertebra. The Care Plan directed staff to check and change Resident #1 before and after meals, at bedtime and as needed. The Progress Notes for 4/2022 contained the following entries: a. On 4/3/22 at 9:42 AM, staff documented an Orders-Administration Note that showed they administered Milk of Magnesia Suspension (MOM) 1200 Milligrams (mg)/15 Milliliters (ml) by mouth as needed for constipation. b. On 4/3/22 at 5:14 PM, staff documented an Orders-Administration Note that verified the administered MOM 1200 MG/15 ML as needed for constipation was ineffective. Additional review of the Progress Notes revealed a lack of documentation to indicate staff administered Resident #1 MOM as needed. The BM Record for 4/2022 revealed Resident #1 had a BM on the following dates: a. On 4/3/22. b. On 4/4/22. c. On 4/9/22. d. On 4/22/22. e. On 4/23/22. f. On 4/27/22. Review of the Medication Administration Record (MAR) dated 4/2022 revealed the physician ordered Resident #1 the following with directives to staff related to constipation management: a. MOM 1200 mg/15 ml Give 30 ml's by mouth every 24 hours as needed for constipation with a start date of 1/26/21. The undated Bowel Movement Monitoring/Protocol directed the Night Nurse to review BM records daily by running the Look Back Report and communicate in morning report any resident without BM's for 2 days or more and implement the following protocol: a. Day 0-Day 2= no interventions b. Day 3 = Day shift administer as needed MOM/Miralax dose and document acceptance or refusals/results c. Day 4 = Day shift administer as needed Bisacodyl suppository dose and document acceptance or refusal/results d. Day 5 and every day thereafter = Check bowel sounds, abdominal status - any distention or pain and call Primary Care Physician for further directives. e. Document completion and further interventions and results. During an interview 4/26/22 at 3:28 PM, a family member revealed Resident #1's BMs were as big as a horse. During an interview 5/02/22 at 9:05 AM, the Director of Nursing (DON) revealed the bowel protocol not followed for Resident #1 as expected. The DON further revealed the only intervention that had been implemented as part of the bowel program for 4/2022 was when Resident #1 received MOM on 4/3/22. 2. The MDS assessment dated [DATE] documented Resident #5 with diagnoses of peripheral vascular disease, heart failure and malnutrition. The MDS further revealed Resident #5 had a BIMS of 10 indicating moderate cognitive impairment. During a wound treatment observation on 4/27/22 at 10:55 AM, noted Resident #5's right lateral distal foot wound with a scab. Staff D, Registered Nurse (RN), stated the current treatment for the distal wound is to keep it open to air since it is scabbed over and did not complete the treatment as ordered. Review of Resident #5's current Treatment Administration Record (TAR) for 4/2022 indicated the following Treatment Order with a Start Date of 2/16/22: a. Right lateral proximal foot and right lateral distal foot wounds: Cleanse with normal saline and pat dry. b. Paint with Betadine and allow to dry. c. Cover with silicone bordered foam dressing (Mepilex). d. Change Monday, Wednesday, Friday and as needed for soiling every day shift Monday, Wednesday and Friday for wound care. During an interview 4/27/22 at 3:35 PM, the DON revealed it is an expectation Physician's Orders are followed as written.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review, staff and provider interviews. the facility failed to ensure as needed (PRN) psychotropic medication orders are limited to fourteen days, and residents have an in person evaluation prior to the prescription renewal for 1 of 5 residents (Resident #11) The facility reported a census of 30 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE], listed diagnoses for Resident #11 that included: non Alzheimer's dementia, depression and psychotic disorder other then schizophrenia. The MDS indicated the resident required total assistance with bathing; extensive assistance of two staff for bed mobility, transfer, dressing, toilet use, and personal hygiene; and the supervision of one for eating. The MDS listed the resident's Brief Interview for Mental Status) score as 5 out of 15, indicating severely impaired cognition. A 4/15/22 Monthly Medication Review (MMR) completed by the Consulting Pharmacy recommended an order for quetiapine (a psychotropic medication) 12.5 milligrams (mg) every 4 hours PRN for hallucinations be updated with a 14 day expiration date (4/28/22), and at the end of the 14 days the resident be evaluated in person by the physician and another 14 day PRN can be written. On 4/18/22 the provider directed staff to administer quetiapine fumarate tablet 12.5 mg's by mouth every 4 hours as needed for hallucinations, delusions, and sun downing (a change that occurs after the sun has set for the day) that can cause behavioral concerns related to delusional disorders for 90 Days. A review of the clinical record identified the resident last had an in person evaluation the provider on 4/9/22. During an interview on 5/02/22 at 9:29 AM, the Consulting Pharmacist stated the recommendation on 4/15/22 was to change the expiration date for the PRN quetiapine fumarate tablet 12.5 mg by mouth every 4 hours to be changed to 4/28/22 so the requirement for a 14 day limit to the prescription met. The Consulting Pharmacist explained a new PRN order should not be written until the resident evaluated in person by the prescribing physician. During an interview on 5/2/22 at 2:40 PM, the Director of Nursing (DON) stated he reviews MMR's when they are received, and if changes are recommended he would make a notations regarding what has been attempted in the past and the outcome. The DON explained the MMR's are then sent to the resident's physician for agreement, declination or other orders. The DON stated the MMR completed on 4/15/22 for Resident #11 was sent to the provider, but the facility did not follow up on the need for the provider to adhere to the 14 day limit on psychotropic PRN orders; or request an in person evaluation. During an interview on 5/2/22 at 3:07 PM, the resident's provider stated she was not informed by the facility that a PRN order for quetiapine needed to be limited to 14 days at a time, and she was not informed of the need for a face to face evaluation prior to a renewed PRN order. The facility policy, dated October 2019, titled Consultant Pharmacist Reports directed the facility to limit as needed psychotropic drugs to 14 days, and cannot be continued without a provider evaluation.

Based on observation, policy review and staff interview, the facility failed to ensure they were not serving expired food items and failed to label and date food items when opened to reduce the risk of contamination and food-borne illness. The facility also failed to ensure food preparation equipment were clean and failed to maintain sanitary conditions in the kitchen. The facility reported a census of 30 residents. Findings Include: On 4/25/22 at 11:30 AM, during the initial tour of the facility kitchen with the Culinary Director, the following spice or seasoning containers noted opened with no dates when opened: a. Cumin. b. Lemon Pepper. c. Everything But Salt. d. Garlic Powder. e. Coriander. f. Greek Seasoning. g. Classic Herb Seasoning. h. Season Well Herbs and Spices dated as opened 6/29/20 (Culinary Director stated the facility discards spices after 6 months) i. Mojito Lime. j. Cinnamon. k. Thyme. l. Curry Powder dated as opened 9/16/21 (Culinary Director stated the facility discards spices after 6 months) m. Cajun Spice. n. Poultry Seasoning. o. Southwest Chipotle. p. Poultry Seasoning. q. Lemon Pepper. r. Sesame Seed. s. Mr. Dash. t. Bay Leafs. Also found during the initial tour, other undated food products opened or undated already prepared foods with no expiration dates: a. Shredded Cheddar Cheese. b. Mixed fruit in a bowl. c. Spinach salad in a container. d. Egg salad in a container that had a use by date of 4/23/22. e. Carrot raisin salad in a container. f. Chili in a container. g. Sauerkraut in a container. h. Marinara sauce in a container with an expiration date of 4/18/22 i. BBQ sauce in a container. j. Ranch dressing in a container. k. Mashed potatoes in a large bowl. l. Cheddar Cheese slices. m. Loaf of bread not labeled when opened and with an expiration date of 4/17/22. n. 4 loaves of bread with expiration date of 4/18/22. o. Elbow macaroni bag. p. Spaghetti bag. q. Biscuit Gravy Mix. r. Granola cereal bag. s. Nilla Wafers box. t. Yellow cake mix. On 4/25/22 at 11:30 AM, during the initial tour of the facility kitchen with the Culinary Director, the following issues were noted with cleanliness of the area: a. The floors noted to have debris and food particles on them. b. The 6 burners on the gas stove noted to have debris on them. c. The griddle located on the stove top dirty with food debris and very black in color. d. The outside of the oven and the handle noted to have debris on them. e. The inside of the oven noted to have some debris in it. f. The vegetable freezer noted to have debris in the bottom of it. On 4/26/22 at 9:15 AM, on a revisit of the facility kitchen, the following issues were noted: a. The floors noted to have debris and food particles on them. b. The chemical jug for the dishwasher noted to have a lot of grime/dirt debris on top of it. c. The griddle on the stove top very dirty and black in color. d. Handle on the black milk refrigerator dirty with debris noted. e. The vegetable freezer handle and outside door dirty with debris noted. f. The inside bottom of the vegetable freezer with debris noted. On 4/28/22 at 1:35 PM, on a revisit with the Culinary Director present the following was noted: a. Griddle on stove top noted to be very dirty. Staff reported they scrambled eggs on it at breakfast and fried hamburgers on it at lunch. Noted scrambled egg and hamburger remnants on and around the griddle. b. Debris noted on burners on the stove top. c. Outside of oven doors dirty as well as the outside of the oven not currently working were dirty and noted debris on them. d. The milk refrigerator handle dirty with debris noted. e. The inside of the milk refrigerator with debris on the bottom of it. f. Chocolate milk splattered on the inside of the door. g. The vegetable freezer handle dirty with debris noted. h. The vegetable freezer noted to have debris in the bottom of the freezer. The Culinary Director provided daily and weekly cleaning schedule for the month of April. They revealed the cleaning completed as directed. On 4/27/22 at 2:00 PM, the Culinary Director stated he expected all items be labeled and dated when opened and prior to putting the items away. He also stated he expected the staff go through the coolers and dry food supplies daily to check for outdated food items. On 4/28/22 at 1:35 PM, the Culinary Director stated he expected the entire kitchen area be kept clean. He expected the staff be responsible to ensure all areas of the kitchen be kept clean and stated the cleaning schedules will need to be expanded. The facility provided a policy, titled Food Receiving and Storage dated 10/18, revealed staff were to maintain clean food storage areas at all times, dry foods were to be labeled and dated (use by date), all food stored in the refrigerator or freezer were to be covered, labeled and dated (use by date) and open containers dated and sealed or covered during storage. The facility provided policy, titled Refrigerators and Freezers dated 10/18, revealed all food to be appropriately dated to ensure proper rotation by expiration dates. Use by dates were to be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food was to be observed and use by dates indicated once food was opened. Supervisors were responsible for ensuring food items in pantry, refrigerator, and freezers were not expired or past perish dates. Refrigerators and freezers were to be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary.