Based on observation, interview, and record review the facility failed to ensure accurate care planning of antipsychotic medication on the comprehensive Care Plan and failed to ensure the comprehensive Care Plan addressed wandering behavior for 1 of 13 residents reviewed for Care Plans (Resident #3). The facility reported a census of 32 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #3 dated 6/25/24 revealed the resident scored 3 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment the resident took antipsychotic medication and wandered 1 to 3 days during the 7-day look-back period. Review of Resident #3's clinical record revealed an admission date to the facility on 5/22/24. a. Review of Resident #3's Care Plan for psychotropic medication use dated 6/4/24 revealed the following: I use psychotropic medications (Haloperidol) r/t (related to) anxiety/Depression and Paranoid Schizophrenia. Review of the resident's Medication Administration Record (MAR) dated May, June, and July 2024 lacked administration of Haloperidol for this resident. Review of the resident's physician orders lacked an order for Haloperidol. b. Review of Resident #3's comprehensive Care Plan lacked a focus area to address wandering/elopement. The Baseline Care Plan Summary dated 5/22/24 revealed, Resident had an elevated risk for wandering and elopement. The Progress Note dated 6/5/24 at 3:18 AM revealed, Before supper last evening, resident was walking in the halls and alarm sounded when she went out of the end door on 200 hall. Resident just made it outside the door a little ways and staff was following her. Returned inside the building. The Progress Note dated 6/6/24 at 1:31 AM revealed, Pt (patient) after dinner went to the front door of the building and was trying to leave. Pt was easily redirected. Will report to oncoming of patient exit seeking The Progress Note dated 6/8/24 at 9:30 PM revealed, Resident attempted to leave facility by exiting doors alone on 400 hall. Resident cooperative as staff assisted her back into facility. Resident voices no c/o and is unable to state why she attempted to leave. The Orders-Administration Note dated 6/24/24 at 3:34 PM revealed, in part, res (resident) is wandering a lot today. will not sit down to allow this writer to change dressing. Review of the Wandering Risk Scale assessments dated 5/27/24 and 6/25/24 identified the resident at high risk to wander with a score of 11, then 12 on the assessment. Observation conducted 7/30/24 at 1:29 PM revealed Resident #3 walked with a walker down the hallway where the resident resided, then turned and walked back. Observation revealed a staff member asked Resident #3 where they were going, and Resident #3 responded, I don't know. On 8/1/24 at 3:52 PM, the MDS Coordinator queried about Haldol (Haloperidol), as was observed on the resident's Care Plan. The MDS Coordinator explained she did see the resident had Risperdal (a different antipsychotic medication). The MDS Coordinator explained she was going to take out the Haldol and put in psychotropic medication so did not happen again. When queried about wandering/elopement, the MDS Coordinator explained she saw the resident had a behavior Care Plan but did not have specifics. The MDS Coordinator explained she would update it. On 8/1/24 at 4:55 PM during an interview with Staff B, Registered Nurse (RN), Staff B explained the resident wandered a little bit, and was easily redirected. On 8/1/24 at 4:19 PM, a Facility Policy which addressed care plans, both comprehensive and revision, was requested from the facility. The policy was not provided prior to the exit of the survey.

Based on interviews, clinical record review, and facility policy review, the facility failed to include person center care needs or identify interventions related to seizure disorders and medications taken to prevent seizures within the Care Plan for 2 of 5 residents (Resident #12 and #26) reviewed for medication regimen. The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #12, dated 6/11/24, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating moderate cognitive impairment. Diagnoses included: Parkinson's Disease, non-Alzheimer's dementia, anxiety disorder, and depression. The Care Plan, revised 7/09/24, lacked identification of seizure disorder or anticonvulsant medications administered on a routine basis. The Medication Administration Record (MAR), dated August 2024, revealed medications ordered included: 1. Levetiracetam 500 milligrams (mg), given one and a half tablets by mouth every day and evening shift for Altered Mental Status (AMS), started on 3/27/24. 2. Carbamazepine 200 mg, given 1 tablet by mouth every day and evening shift for anticonvulsant, started on 3/27/24. A Hospital Inpatient Note, dated 12/22/23, revealed Resident #12's Past Medical History (PMH) had episode concerning for seizure 7/2023. Resident #12 taking Levetiracetam and Carbamazepine. A Hospital Inpatient Note, dated 12/30/23, revealed Resident #12's medical history included seizures. 2. The Minimum Data Set (MDS) for Resident #26, dated 5/28/24, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive impairment. Diagnoses lacked seizure disorder at time of assessment. The Care Plan, revised 7/25/24, lacked identification of seizure disorder or administration of anticonvulsant medications. The Medication Administration Record (MAR), dated July 2024, revealed an order for Levetiracetam 500 milligrams (mg) twice per day for seizure activity, started on 7/12/24 and discontinued on 7/26/24. The Order Summary dated August 2024, revealed an order for Ativan 2 milligrams (mg) per milliliter (mL), give 1 mg as needed intramuscularly for active seizure. The order start date on 6/19/24 with no discontinue date. The Hospital Note, dated 6/12/24, revealed a Principle Diagnosis of subdural hematoma (bleed in the brain membrane) status post fall. Resident #26 had been given Levetiracetam (Keppra) intravenously with recommendation from Neurosurgery to start Keppra 500 mg twice per day. A Nursing Progress Note, dated 6/12/24 at 1:22 PM, revealed nursing received communication from the Hospital that Resident #26 sustained a large subdural hematoma in which family had declined treatment and would discharge back to facility. Resident #26 returned to the facility with new medication order Keppra for seizure activity. On 6/19/24 at 2:00 PM, a Nursing Progress note revealed that the Provider ordered many oral medication to be discontinued per family request, including Keppra, and an as needed order for Ativan Intramuscular injection to be given for active seizure. At 3:24 PM, the facility additionally initiated seizure pads to be placed on Resident #26's bed as safety intervention. On 8/01/24 at 3:52 PM, Staff D, MDS Registered Nurse (RN), revealed that she had recently become responsible for updating the facility's Care Plans and worked offsite, communication regarding changes received from the facility in a weekly meeting and as needed. Staff D informed that if a resident has a diagnosis of seizure disorder whatever the facility's goal and interventions should be included in the resident's Care Plan. On 8/01/24 at 4:55 PM, Staff B, Registered Nurse (RN) revealed she had been responsible for updating fall related interventions in resident Care Plans but believed seizure disorders would be in resident Care Plans. Staff B informed that Resident #26 continued to have the seizure pads on bed intervention in place. On 8/1/24 at 4:19 PM, a Facility Policy which addressed Care Plans, both comprehensive and revision, was requested from the facility. The policy was not provided prior to the exit of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and clinical record review, the facility failed to ensure interventions had been effective to prevent recurring falls in 1 of 5 residents reviewed for accidents (Resident #19). The facility reported a census of 32 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating moderate cognitive impairment. The MDS revealed Resident #19 required partial to moderate amount of staff assistance to transfer and ambulate. Diagnoses included Parkinson's Disease, non-Alzheimer's dementia, anxiety disorder, asthma, and muscle weakness. The MDS revealed Resident #19 had 2 or more falls since the last assessment date. The Care Plan, dated 5/08/24, revealed Resident #19 had been at high risk of falls with a history of multiple falls and listed the following dates in which a fall occurred: 2/18/24, 2/25/24, 3/21/24, 4/21/24, 4/22/24, 4/29/24, 5/01/24, 5/24/24, 5/25/24, 5/28/24, 5/30/24, 6/04/24, 6/18/24, 6/21/24, 7/30/24. The Care Plan revealed Resident #19 required the assistance of one staff for transfers, ambulation, and toileting needs using a walker and gait belt. Additionally the Care Plan revealed Resident #19 had impaired cognitive function and impaired thought processes related to delirium with impaired decision making and behavioral problems such as verbal aggression and refusal of cares. Review of Resident #19's Incident Reports, revealed 8 of 18 falls had intervention to remind resident to use call light or call for help. A review of incident reports indicated the following interventions implemented: 1. On 02/16/24 at 3:50 PM, unwitnessed fall in resident's room, reminder for staff to look and make sure belongings are off the floor. 2. On 02/25/24 at 8:30 PM, unwitnessed fall in resident's room, intervention for staff to assist resident to get ready for bed at 8 PM per her request. 3. On 3/23/24 at 3:45 AM, unwitnessed fall in resident's bathroom, intervention for staff to leave her door open or cracked at night. 4. On 4/11/24 at 7:00 PM, unwitnessed fall in resident's room, intervention for staff to frequently check on resident and encourage use of call light. 5. On 4/21/24 at 9:00 PM, unwitnessed fall in resident's room with door closed, intervention for staff to leave door open or cracked for closer supervision. 6. On 4/22/24 at 8:00 AM, unwitnessed fall in resident's room, intervention for staff to open curtains once resident is ready for the day. 7. On 4/29/24 at 2:30 PM, unwitnessed fall in resident's room, intervention to place non slip strips next to the bed. 8. On 4/30/24 at 7:00 PM, unwitnessed fall in resident's room, intervention to encourage resident to use call light and staff continue with frequent checks. 9. On 5/24/24 at 6:06 PM, unwitnessed fall in resident's room, staff to continue to remind resident to not get up without assistance as resident does not remember. 10. On 5/25/24 at 12:50 PM, unwitnessed fall in resident's room, staff remind resident to use controls for recliner and call for help. 11. On 5/28/24 at 8:50 AM, unwitnessed fall in resident's room, staff continuously remind resident to call for help. 12. On 6/04/24 at 8:15 PM, witnessed fall in bathroom when handrail moved, intervention to replace or repair bathroom handrail. 13. On 6/12/24 at 2:00 PM, unwitnessed fall in resident's room, intervention to place bed in lowest position when the bed is made. 14. On 6/12/24 at 3:30 PM, unwitnessed fall in resident's room, intervention to place reminder sign on walker and in room. 15. On 6/18/24 at 1:50 PM, unwitnessed fall in resident's room, staff continue to work with resident to call for help. 16. On 6/21/24 at 9:15 PM, unwitnessed fall in resident's room, staff re-educated on getting resident ready for bed at 8 PM per her request. 17. On 6/26/24 at 5:45 AM, unwitnessed fall in resident's room, shorten oxygen tubing, resident continues to get up without assistance. 18. On 7/17/24 at 9:30 AM, unwitnessed fall in resident's room, Resident #19 found with eyes open, not responding, had a laceration to back of head and pain in right hip. Incident report indicated last time resident toileted is unknown, resident transferred to the hospital and returned without fracture sustained. Intervention for all departments to spend one on one time with resident when able and continue to encourage resident to call for assistance. The Transfer Assessment Form, dated 7/17/24, revealed Resident #19 had been sent to the Hospital due to fall and informed that resident had frequent falls due to resident ambulation in room without assistance. Injuries included left hip pain and head laceration. Head pain rated 7-8 out of 10. A Primary Care Provider Note, dated 7/19/24, revealed Resident #19 had fall on 7/17/24 that required a trip to the Emergency Department as a result of laceration to head, that required 2 staples. On 7/29/24 at 1:29 PM, Resident #19 ambulated in room without walker, noted non gripper socks on her feet, a Certified Nursing Assistant (CNA) passed by and asked Resident #19 to sit back down in her recliner. On 7/29/24 at 1:38 PM, Resident #19 walked around room without walker, attempted to move a wheelchair to get into drawers. Resident #19's gait unsteady as she moved about room. On 7/30/24 at 1:09 PM, Resident #19 walked around in room, CNA passed by and asked to sit down. On 7/30/24 at 1:25 PM, Resident #19 walked around room, Nurse passed by and tried to get Resident #19 to sit down. Resident #19 stated, she is tired of sitting and needed something to do, Nurse called activity director to get resident a puzzle. On 8/01/24 at 10:10 AM, Staff B, Registered Nurse (RN), revealed that Resident #19 is non-complaint with waiting for help and has had repeated falls. Staff B stated the staff try to keep an eye on Resident #19 and try to keep her door open. Staff B informed that interventions in place to prevent falls include one on one with resident, inviting her to activities, and frequent checks. Staff B revealed Resident #19 had confusion and sometimes understood use of call light. On 8/01/24 at 1:22 PM, Staff A, Certified Medication Assistant (CMA) informed that fall interventions for Resident #19 included frequent checks, sign placed on wall to remind her to call, and keep resident items close to her. Staff A revealed that Resident #19 will sometimes push call light but not always. On 8/01/24 at 4:28 PM, Staff C, Registered Nurse (RN), informed that Resident #19 often is non-compliant with calling for help and stated staff constantly help her back to chair. Staff C revealed interventions to prevent Resident #19 falls included give resident her call light, offer a snack, bring to nurses station, and frequent checks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, hospital record review, and clinical record review, the facility failed to include self harm monitoring, triggers, and safety interventions in the plan of care following attempted suicide for 1 of 2 residents reviewed for behavioral health needs (Resident #12). The facility reported a census of 32 residents. Findings include: The Minimum Data Set (MDS) assessment, dated 6/11/24, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. The MDS indicated Resident #12 had verbal behaviors directed at others and rejection of cares reported during the review period. Diagnoses included Parkinson's Disease without dyskinesia, non-Alzheimer's dementia, anxiety disorder, depression, and adjustment disorder with depressed mood. The MDS revealed Resident #12 required antidepressant and antipsychotic medications. The Care Plan, revised on 7/09/24, revealed Resident #12 had impaired cognitive function, verbal aggression, and inappropriate behaviors at times with staff. The Care Plan listed the goal that resident's behaviors will not interfere with other residents. Behavioral interventions included: 1. Administration of medications as ordered, monitor for side effects and effectiveness 2. Provide opportunity for positive interaction with resident, stop and talk with him as passing by. 3. Psychiatric services initiated. 4. If reasonable, discuss resident's behavior and explain why it is inappropriate or unacceptable to the resident. 5. Intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, remove from situation and take to alternate location as needed. 6. Monitor behavior episodes and attempt to determine underlying cause, document behavior and potential causes. 7. Praise any indication of resident's progress or improvement in behavior. 8. Provide a program of activities of interest and accommodate resident's status. Review of Hospital Adult Psychiatric Inpatient Note, dated 12/22/23, revealed a transfer and admission to the Hospital related to suicide attempt, increasing depressive symptoms, and agitation. The Hospital Note revealed that on 12/20/23, Resident #12 was found at the facility, in his closet, with a belt wrapped around his neck, attempting to tie the belt to the rod in the closet. Resident #12 had stated he was trying to hurt himself and that he does attempt to hurt self everyday. Note revealed accompanying documentation from facility included several communications from Resident #12 to his children that appeared to be suicide notes. Hospital Note additionally revealed past trauma related to abuse. Hospital completed suicide risk assessment, Resident #12 determined to be at moderate to high risk. Review of Nursing Progress Notes, revealed the following entries: a. On 11/27/23 at 4:09 PM, family discussed concern about Resident #12 increase in odd behaviors and requested dementia testing be done. b. On 12/01/23 at 7:10 PM, another call from family regarding concern about increase in Resident #12's odd behaviors, again requesting dementia testing be done. Nursing charted they would notify Director of Nursing and Primary Care Provider. c. On 12/06/23 at 10: 32 AM, nursing staff report increased verbal and sexual behaviors with staff that had not improved since initiation of Sertraline on 10/29/23. Update sent to Psychiatric Provider to report concerns and schedule appointment. d. On 12/18/23 at 1:09 PM, Resident #12 refused to eat, spoke only minimally and appeared upset, quietly declined cares. e. On 12/20/23 at 6:22 PM, Resident #12 sat on footrest of recliner, did not know where he was going or what he was doing. Resident #12 had eyes very wide open and appeared mixed up. Nursing had suggested to day shift to get a hold of Psychiatric Provider to discuss recent behaviors and possible medication change. f. On 12/20/23 at 6:41 PM, Resident #12 requested a sheet of paper and a pen to write a letter, staff gave him a sheet of blank computer paper and a pen. g. On 12/20/23 at 9:51 PM, staff went into Resident #12's room when he was not seen in bed or chair, found Resident #12 in the closet with belt around his neck attempting to hang himself. Nursing noted resident had been in a tormented state all shift, called people constantly and wrote letters. Nurse called Director of Nursing who text Resident #12's Psychiatric Provider, order to transfer Resident #12 to Emergency Department for psychiatric evaluation. h. On 3/27/24 at 2:30 PM, Resident #12 returned to facility from Hospital, mildly aggressive mood during admission assessment, refused to have weight checked. i. On 4/04/24 at 9:17 PM, Nursing noted after evening meal, Resident #12 started verbalizing that he would die tonight, stated he was not going to do anything to cause it, but he just had the feeling. Resident went around to tell other residents that this was his last night. 15 minute checks initiated on Resident #12 through the evening and night. Primary Care Provider at facility, talked to resident and made aware of the situation. DON also made aware. j. On 4/18/24 at 12:04 AM, Resident #12 asked staff if he could have his belt back, belt had been removed from room due to history of suicide attempt. Belt remained at nurses station. k. On 4/21/24 at 5:57 PM, Resident #12 asked if he could have the Certified Nursing Assistant's (CNA) gait belt, CNA told him no. l. On 4/21/24 at 8:38 PM, Resident #12 worked at over bed table all evening writing notes, nursing informed staff would continue to monitor him closely. m. On 7/07/24 at 10:40 AM, Resident #12 in his room taking razor apart and trying to put back together. Resident #12 threw the wheelchair foot pedals at staff's feet who entered room. n. On 7/08/24 at 5:23 PM, Resident #12 found on floor knelt in front of bed with head pressed down in a blanket, told staff he wanted to die and did not want to be here. On 7/29/24 at 1:46 PM, Resident #12 sat in recliner in room, only provided a nod in response, offered no verbal responses. On 8/01/24 at 4:04 PM, Staff D, MDS Registered Nurse (RN), revealed that any self harm or suicide attempts would be included in the Care Plan under the behaviors and safety sections. Staff D worked offsite and received information from the facility through communication with Interdisciplinary Team during weekly meetings. Staff D revealed other disciplines should update their areas such as sections specific to Social Work, Dietary, and Activity staff. On 8/01/24 at 4:28 PM, Staff C, RN, reported Resident #12 would put himself on the floor at times and had agitated behaviors. Staff C recalled Resident #12 recently stated he felt he would die one evening, but informed he wasn't going to do anything to harm self. In response, Staff C stated Resident #12 had been put on suicide watch, notified Director of Nursing, and had staff sit outside resident's door overnight to watch him. Staff C recalled Resident #12's belt had been at the Nurse's Station, unable to recall additional items Resident #12 was not allowed to keep in room for safety reasons. On 8/01/24 at 4:40 PM, Staff E, Social Services staff, revealed Resident #12 often had behaviors such as putting self on the floor, making calls to 911, and destroying phones. Staff E stated Resident #12 had not attempted to harm self since prior suicide attempt at facility. Staff E informed that when Resident #12 had admitted to facility he said he would rather die than stay at facility. Staff E revealed that everything cord like had been taken out of room such as strings and belts. On 8/01/24 at 4:55 PM, Staff B, Registered Nurse (RN) informed that Resident #12 had no additional suicidal ideation since he returned to the facility from hospital. Staff B stated if Resident #12 had indication to harm self, he would tell someone. Staff B reported interventions to prevent harm included removal of the closet bar from Resident #12's room and no gait belts in room. Staff B revealed Resident #12 did still have call light cord in room. Staff B stated Certified Nursing Assistants (CNAs) could check for safety interventions on Resident #12's Care Plan/[NAME]. On 8/01/24 at 5:17 PM, Facility Administrator, indicated there had no longer been a concern with Resident #12's safety related to self harm or re-attempted suicide. Administrator reported Resident #12 had changed since Hospitalization, and that Resident #12 stated he would not do that again. Administrator informed that staff had in-service training on trauma informed care, but denied use of screening assessment for Post Traumatic Stress Disorder (PTSD).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy review the facility failed to notify the physician when a resident's weight increased by two pounds in a day per the physician order for 1 of 12 residents reviewed for notification of changes (Resident #2). The facility reported a census of 30. Finding include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS documented the resident had medical diagnoses including heart failure, unspecified, chronic obstructive pulmonary disease, unspecified, lung transplant status, and Type II diabetes mellitus with hyperglycemia. The MDS documented resident received insulin injections and a diuretic 7 out of 7 days. The Care Plan revealed a focus problem for Congestive Heart Failure (CHF) with initiated date 1/01/22. The Care Plan document an intervention dated 4/6/22 as follows; resident on diuretic therapy for CHF. The interventions dated 3/21/22 directed staff to monitor weight daily and reported concerns of weight gain to the provider. The Electronic Medical Record (EMR) documented the following medical diagnosis: a. heart failure, unspecified The Physician Orders revealed the following orders: a. ordered 12/4/22- Check weight daily ****CALL DR IF UP MORE THAN 2 LB IN ONE DAY**** in the morning for monitoring b. ordered 1/6/22- furosemide tablet 20 mg (milligrams) by mouth every day shift for CHF The Weights Summary Report revealed the following dates that documented dates the weight increased over 2 pounds in one day: a. 7/25/23 at 9:11 AM: 199.0 Lbs (pounds) b. 7/26/23 at 1:28 PM: 202.2 Lbs c. 8/7/23 at 10:16 AM: 193.8 Lbs d. 8/8/23 at 11:03 AM: 196.8 Lbs e. 9/14/23 at 11:22 AM: 191.4 Lbs f. 9/15/23 at 3:29 PM: 194.2 Lbs g. 10/7/23 at 11:39 AM: 183.9 Lbs h. 10/8/23 at 11:54 AM: 190.0 Lbs i. 10/20/23 at 11:26 AM: 178.4 Lbs j. 10/23/23 at 1:11 PM: 181.2 Lbs k. 10/30/23 at 6:57 AM: 176.6 Lbs l. 10/31/23 at 11:35 AM: 179.4 Lbs The EMR lacked documentation of the physician notification for the weight increases on 7/26; 8/8; 9/15; 10/8; 10/23; and 10/31. During an observation on 11/1/23 at 10:24 AM, the resident sat in her recliner with blankets over her. She wore a Nasal Cannula (NC) and the oxygen concentrator set at 3.5 Litters. During an interview on 11/2/23 at 12:07 PM, the Director of Nursing (DON) queried on the check weight order and notification to the provider if resident gained over 2 pounds and she stated if the Medication Administration Record (MAR) didn't document the provider notified she expected a progress note documented of the notification. The Notification of Physician by Facsimile of Non-Emergent Change of Condition Policy dated 9/13/10 revealed the following information: a. Purpose: 1. To provide the facility with another means of communication with attending physician. The use of facsimile for notification of change of condition of a resident's status not intended to circumvent telephone or personal contact between facility staff and attending physician. b. Procedure: 1. When utilizing facsimile to contact a physician, resident condition must be non-emergent, and facsimile intended to inform only. 2. In the event the facility attempted to contact the physician for an urgent or emergent condition change, the facility phoned to consult the physician. The facility won't use facsimile in the event of an emergency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review the facility failed to consistently notify the ombudsman of a resident's transfer to the hospital for one of two residents reviewed for hospitalization (Resident #4). The facility reported a census of 30 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #4 dated 8/29/23 revealed the resident scored 7 out of 15 on a Brief Interview for Mental Status exam, which indicated severely impaired cognition. The Progress Note for Resident #4 dated 9/20/23 at 4:17 AM documented, in part, Called to 200 hall by staff. Observed resident sitting on floor in front of room [ROOM NUMBER]. Resident in [room number redacted] heard her shout for help and put call light on. Copious amounts of blood was on gown front and back. Hair was covered with blood. Observed hole in back of head about size of nickel. Resident does not remember falling. States she woke up on the floor and scooted out to hall way on her bottom to get help. Back or her gown was wet and a blood trail led to her bathroom. Blood was on radiator. Called 911 for transport to [hospital name redacted]. On-call provider, Dr. [name redacted] notified and gave order to send out. The Progress Note dated 9/20/23 at 11:15 AM documented, in part, Call received from [hospital name redacted] ER (emergency room) nurse to give report for resident to return to facility. Review of Ombudsman Notification provided by the facility did not include notification for Resident #4's hospitalization described in the resident's progress notes. On 11/02/23 at 11:34 AM when queried who would go on the ombudsman report, the Director of Nursing (DON) explained anyone who transfers would be on that notification. The Facility Policy titled Policy on Transfers reporting to Iowa State Ombudsman's Office, undated, documented the following: Monthly Reporting shall include: Information on Transfers: -Hospitalization, 2-Discharge/Home, 3-Transfer to another facility, 4-Theraputic Leave, 5-Other-Including emergency room visits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS 9/14/23 assessment dated [DATE] revealed Resident #2 scored 15 out of 15 on a BIMS exam, which indicated cognition intact. The MDS revealed medical diagnosis of unspecified mood disorder and generalized anxiety disorder. The MDS documented the resident received an antidepressant 7 out 7 days. The Care Plan revealed a focus area for an order for antidepressant medication citalopram related to depression with an updated upon admission from the hospital on 5/26/23, resident received orders for Mirtazapine also for anxiety and depression initiated on 6/10/21 and revised on 5/26/23. The interventions dated 6/10/21 documented administration of antidepressant medications as ordered by the physician and monitored and documented side effects and effectiveness as needed. The Care Plan lacked documentation that the resident took Trazadone HCL (hydrochloride), and failed to update that Mirtazapine was discontinued one 6/9/23. The Physician Orders revealed the following orders: a. ordered on 7/10/23- Trazadone HCL (hydrochloride) oral tablet- give 25 mg by mouth every evening shift for depression b. ordered 5/26/23 and discontinued on 6/9/23 - Mirtazapine oral tablet 15 mg - give 15 mg by mouth at bedtime for anxiety 3. The MDS assessment dated [DATE] revealed Resident #19 didn't complete a BIMS exam, which indicated severely impaired cognition. The Care Plan revealed a focus area for use of psychotropic medication of olanzapine related to depression, anxiety, and dementia dated 12/1/20. The interventions dated 6/10/21 documented an order for olanzapine related to depression, anxiety, and dementia and administration as ordered by the physician. The Care Plan failed to document that the Olanzapine was discontinued on 7/8/23. The Care Plan revealed a focus area for antidepressant medication of Trazadone related to depression and dementia dated 12/1/20. The interventions dated 2/14/22 administration of antidepressants medications as ordered by provider. The Care Plan failed to document on 7/8/23 that the Trazadone was discontinued. The Physician Orders documented the following orders: a. olanzapine ordered 3/30/23 and discontinued on 7/8/23- olanzapine tablet 10 mg (milligrams)- give 10 tablet by mouth three times a day b. Trazadone HCl (hydrochloride) ordered on 3/30/23 and discontinued on 7/8/23- give 100 mg by mouth three times a day The Progress Note dated 7/10/2023 at 3:26 PM documented a faxed verbal order received from hospice to discontinue all oral non liquid medications. During an observation on 10/30/23 at 1:21 PM, Resident #19 sat in his recliner in his room and rested. A blanket covered his lower half. During an interview on 11/2/23 at 11:53 AM, the MDS Coordinator queried on when a care plan needed to be updated and she stated on a daily basis because things change. She stated at least quarterly. The MDS Coordinator asked what warranted a change and she stated medications, health status, new providers, or anything to follow up to an existing condition. The MDS Coordinator queried on concerns with Resident #2 care plan and she stated she needed to update it and remove the Mirtazapine and citalopram from the care plan. The MDS Coordinator queried on concerns with Resident #19 care plan and she stated his medications were recently discontinued and the care plan needed updated. During an interview on 11/2/23 at 12:07 PM, the Director of Nursing (DON) queried on when care plans needed updated and she stated frequently, minimally quarterly, significant changes, admission, and they always worked on it. The DON queried on Resident #2 care plan and her expectations and she stated she expected the care plan updated by now. The DON asked about Resident #19 care plan and she stated yes, it definitely needed updated on the quarterly. Based on observation, interview, and record review the facility failed to revise the Care Plan to address use of antidepressant medication and/or reflect current antidepressant medications ordered, and update following discontinuation of antidepressant medication for three of twelve residents reviewed for care plans (Resident #2, Resident #19, Resident#27). The facility reported a census of 30 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #27 dated 9/20/23 revealed the resident scored 3 out of 15 on a Brief Interview for Mental Status exam, which indicated severely impaired cognition. Per this assessment, the resident received antidepressant medication for seven of the last seven days. The Physician Order dated 6/24/23 documented, Sertraline HCl Oral Tablet 25 MG (milligram) with directions to give 25 mg by mouth every day shift for dementia. On 11/1/23, review of the Care Plan for Resident #27 did not address receipt of antidepressant medication for Resident #27. Observation on 10/30/23 at 1:09 PM revealed Resident #27 in their room in bed. On 11/2/23 at 11:51 AM, the Director of Nursing (DON) acknowledged antidepressant should be on the care plan, and acknowledged it was missed. The Facility Policy titled Resident Assessment Instrument and Care Planning, undated, docuemnted, Assessments and care plans scheduled will be completed via CMS (Centers for Medicare and Medicaid Services)/RAI (Resident Assessment Instrument) guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The MDS 9/14/23 assessment dated [DATE] revealed Resident #2 scored 15 out of 15 on a BIMS exam, which indicated cognition intact. The MDS revealed medical diagnosis for unspecified, chronic obstructive pulmonary disease, unspecified, lung transplant status, and Type II diabetes mellitus with hyperglycemia. The MDS documented resident received insulin injections 7 out of 7 days. The MDS documented the resident wore oxygen while a resident. The Care Plan revealed a focus area for oxygen therapy related to impaired respiratory function initiated on 6/10/21 and revised on 3/20/22. The interventions dated 6/10/21 documented oxygen settings of 2 Liters (L) for comfort or shortness of breath via nasal cannula. The Care Plan revealed a focus area for a diagnosis of Type II Diabetes Mellitus dated 6/10/21. The interventions dated 3/20/22 documented administration of diabetes medication as ordered by the medical providers. The resident had scheduled and sliding scale insulin. Please review the Medication Administration Record (MAR) or order summary for the most up to date orders, and administration as ordered and appropriate. The EMR (Electronic Medical Record) revealed the following medical diagnoses: a. Chronic Obstructive Pulmonary Disease (COPD), unspecified b. shortness of breath c. lung transplant status d. Type II DM (diabetes mellitus) with hyperglycemia The Physician Orders revealed the following orders: a. ordered 6/7/23- Humalog KwikPen solution Pen-injector 100 UNIT/ML (milliliter) (Insulin Lispro (1 Unit Dial))- Inject as per sliding scale: if 150 - 199 = 1; 200 - 249 = 2; 250 - 299 = 3; 300 - 349 = 4; 350+ = 5, subcutaneously before meals and inject 7 unit subcutaneously before meals for diabetes mellitus (DM) II and hold if blood sugar is below 130 b. ordered 6/7/23- Lantus SoloStar subcutaneous solution Pen-injector 100 UNIT/ML (Insulin Glargine)- inject 24 unit subcutaneously at bedtime for DM II c. ordered 7/17/21- blood sugar finger sticks QID (before meals and hs(bedtime)) if unable to use continuous blood sugar monitor.- as needed for DM II check blood sugar, via continuous glucose monitoring device, QID (before meals and at HS), and as needed before meals and at bedtime for DM II. d. ordered 8/2/23- continuous oxygen 2 L per NC (nasal cannula) The MAR/TAR (Medication Administration Record/Treatment Administration Record) for October showed the following dates the resident received the physician scheduled order of Humalog KwikPen 7 units when the blood glucose below 130: a. 10/7/23 at 7:30 AM dose- blood glucose 115 b. 10/8/23 at 4:30 PM dose- blood glucose 125 c. 10/11/23 at 7:30 AM dose- blood glucose 121 d. 10/12/23 at 7:30 AM dose- blood glucose 88 e. 10/15/23 at 4:30 PM dose- blood glucose 86 f. 10/22/23 at 4:30 PM dose - blood glucose 113 g. 10/26/23 at 7:30 AM dose- blood glucose 105 The Progress Note dated 10/4/23 at 3:18 PM documented portable oxygenator delivered for use as requested by resident, following each use the batteries required charging so there will be 5 hours of total use with both batteries next time she wanted to use it. Tubing changes will be required for both the large concentrator and the portable per facility monthly schedule. Resident preferred continuous 2 L versus pulse setting on portable unit. During an observation on 10/30/23 at 1:45 PM, the resident sat in her recliner with a NC in her nostrils and the oxygen concentrator set at 3.5 L. During an observation on 11/1/23 at 10:24 AM, the resident sat in her recliner with blankets over her. She wore a NC and the oxygen concentrator set at 3.5 L. During an observation on 11/1/23 at 12:00 PM, resident sat in her wheelchair in the dining room and had her NC in her nostrils and the portable oxygen set at 3 L. During an observation on 11/2/23 at 8:02 AM, resident sat in her wheelchair in the dining room and ate breakfast. NC in her nostrils and portable oxygen set at 3 L. During an interview on 11/02/23 11:45 AM, Staff B queried on what Resident #2 oxygen needed set at and she stated it currently set at 3 liters and the resident's order could be titrated. She stated 3 liters seemed to hold her at 93% to 94%. Staff B looked up the resident's order and stated she the resident's order wasn't a titrated order. Staff B queried on Resident #2 insulin order and she stated the insulin order documented to hold if blood glucose below 125 mg/dl (milligrams per deciliter) and the resident also had an order for sliding scale. She stated she expected the order held when her blood glucose below 125 mg/dl. Insulin order- unless it below 125 and then sliding scale. Yes, I would expect it to be held. I use 9. During an interview on 11/02/23 at 12:07 PM, the DON (Director of Nursing) queried on Resident #2 insulin order and her expectation of the insulin held if the blood glucose below 130 mg/dl and she stated she expected the insulin held as ordered. The DON queried on Resident #2 oxygen order and the setting on the oxygen concentrators and she stated when the order changed to continuous the nurses needed to follow the order and follow up with the provider if they felt the order not appropriate. She stated they didn't normally have continuous orders and the orders generally documented a titration order. Based on observation, interview, record review, and facility policy review the facility failed to ensure insulin held per physician ordered parameters and failed to set oxygen at the physician ordered rate for three of twelve residents reviewed for professional standards (Resident #2, Resident #13, Resident #27). The facility reported a census of 30 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #13 dated 10/14/23 revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severe cognitive impairment. Per this assessment, the resident received insulin injections for seven of the last seven days. The Care Plan for Resident #13 dated 5/10/19 documented, I a diagnoses of type 2 Diabetes Mellitus. The Physician Order dated 7/31/23 documented, NovoLOG Solution 100 UNIT/ML (Unit/Milliliter) with directions to inject 10 unit subcutaneously in the evening for DM II Administer with supper. Hold if BS (blood sugar) if below 125. Review of the resident's Medication Administration Record (MAR) dated October 2023 revealed Novalog 10 Units administered on the following dates when blood sugar level outside parameters: a. 10/11/23: BS level 107 b. 10/17/23: BS level 124 c. 10/23/23: BS level 123 The Physician Order dated 8/1/23 documented, NovoLOG Solution 100 UNIT/ML (Insulin Aspart) with directions to inject 12 unit subcutaneously in the morning for DM II related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS .Administer with breakfast. Hold if Blood Sugar is less than 125. Review of the resident's MAR dated October 2023 revealed Novalog 12 Units administered on the following dates when blood sugar level outside parameters: a. 10/16/23: BS level 119 The Physician Order dated 8/1/23 revealed, NovoLOG Solution 100 UNIT/ML (Insulin Aspart) with directions to inject 8 unit subcutaneously in the afternoon for DM II Administer with lunch. Hold if BS if below 125. Review of the resident's MAR revealed Novalog 8 units administered on the following dates when BS levels outside parameters: a. 10/16/23: BS level 122 b. 10/17/23: BS level 122 2. The Minimum Data Set (MDS) assessment for Resident #27 dated 9/20/23 revealed the resident scored 3 out of 15 on a Brief Interview for Mental Status exam, which indicated severely impaired cognition. Per this assessment, the resident received antidepressant medication for seven of the last seven days. The Care Plan dated 6/8/23 documented, I have Diabetes Mellitus II. The Intervention dated 6/8/23 documented, Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. The Physician Order dated 9/27/23 documented, Hold Humalog if blood sugar is less than 100. Notify provider if held. with meals for DM (Diabetes Mellitus) II. The Physician Order dated 9/27/23 documented, HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Unit/milliter) with directions to inject 14 unit subcutaneously two times a day for diabetes. Review of documentation on the resident's Medication Administration Record (MAR) dated 10/26/23 documented 14 units of insulin administered on 10/26/23 when blood sugar documented on MAR as 99. Observation on 10/30/23 at 1:09 PM revealed Resident #27 in their room in bed. On 11/2/23 at 11:16 AM upon review of the above information, the Director of Nursing (DON) explained she would add a prompt and acknowledged education needed. The Facility Policy titled Medication Administration dated 1/16/12, revision date 4/12/19, documented, Each Resident will receive the medications and treatments that they and their physician agree are necessary. These medications and treatments require a physician's order or an order from an alternate provider who is legally able to write orders. Medications are administered by licensed nurses or certified medication aides.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure care planned diet recommendations from the Registered Dietician were consistently implemented for one of one resident reviewed for nutrition (Resident #6). The facility reported a census of 30 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] 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 6/1/20, revised 10/10/23, documented, I am at risk for nutrition alteration due to: Schizoaffective disorder, ASHD, constipation, depression, hx (history) of TIA (Transient Ischemic Attack), adult failure to thrive. I would like to have a gradual wt (weight) loss. Hx of covid 19. Swallow concerns. I have a mass on thyroid which affects my swallowing. The Intervention dated 6/1/20, revised 10/10/23, documented, I will receive a Gen (general) diet to meet by nutrition needs. I will be offered alternatives as requested and these requests will be honored. I am receiving 206 nutrition drink due to decrease appetite while ill. I am receiving a Mech (mechanical) soft diet with yogurt or magic cup at each meal to assist with swallowing and wt maintenance. The Nutrition/Dietary Note dated 10/25/23 at 5:56 PM documented, in part, Sign (significant) wt change/Sign change Res' wt-165.6#, IBW (ideal body weight)-160-196#, BMI (body mass index)-22.5 (normal) .Res feeds self and consumes 25-100% of the food/meal fluids. Swallowing problem due to mass on thyroid. Mech soft to assist with chewing/swallowing. Also send [Brand Name supplement] or yogurt to follow bites of food to assist with swallow . A: Meet needs for comfort with food/fluids as desired. P: Mech soft with [Brand Name supplement] or yogurt after each bite to assist with swallowing. The Physician Order dated 7/11/23 documented, Regular diet, Minced texture, Regular consistency mechanical soft for diet order. Review of documentation provided with information for the kitchen documented the following diet order for Resident #6: General diet with Mech (mechanical) soft and yogurt or [Brand Name supplement] with meals. Observation of the resident on 11/1/23 at 12:20 PM during the lunch meal revealed the resident did not have yogurt or the supplement present with his food at the table. The resident coughed at time of observation. The Dietary Manager was notified of the observation, went to the container where drinks were located on ice, obtained the missing item, and provided it to the resident. On 11/02/23 at 11:38 AM, the Director of Nursing (DON) explained it should have been on the tray instead of the ice bin. The Facility Policy titled Dietary Policy No. 3.4 dated 12/14/99, revised 2/16/21, documented, in part, It is the policy of [Facility Name Redacted] that resident receive diets as ordered by their attending physicians.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, and facility policy review the facility failed to ensure residents who received a pureed diet were served all foods included on the menu for four of four residents who received a pureed diet (Resident #3, Resident #7, Resident #19, Resident #22). The facility reported a census of 30 residents. Findings include: On 10/31/23 at approximately 11:15 AM an observation of the puree process was completed with Staff A, Dietary. Observation revealed pureed food items did not include bread for the lunch meal. Review of the general menu at the time of survey revealed the following for Tuesday: country fried steak, mashed potatoes, country gravy, vegetable blend, bread/[NAME], ambrosia dessert, and milk. Review of the pureed menu for Tuesday revealed the meal included 1 serving of puree bread/[NAME]. On 11/1/23 at approximately 1:14 PM, the Dietary Manager notified of the observation with additional information requested. On 11/1/23 at 1:14 PM, the Dietary Manager returned and explained, she said she missed it. The Facility Policy titled Pureed Foods, undated, documented the following per the Supplies section: 1. Menu, 2. Blender, 3. Food items to be pureed and appropriate liquid, 4. Storage containers.