The facility had a census of 151 residents. The sample included 31 residents with one reviewed for dignity. Based on observation, record review, and interview the facility failed to treat Resident (R) 115 with dignity in one of five dining rooms, during the noon meal when staff stood over R115 while assisting him to eat. This placed the resident at risk for an undignified experience. Findings included: - On 03/25/24 at 11:39 AM, observation in the 300-hall dining room revealed Certified Nurse Aide (CNA) M served R115 a plate of food. CNA M stood over R115 and gave the resident bites of food. CNA M left the table several times during the noon meal to do other tasks and then returned to R115's table, stood over him, and gave him bites of food. On 03/25/24 at 12:05 PM, Certified Dietary Manager (CDM) BB stated staff should sit in a chair next to R115 when assisting him with eating, not stand over him. On 03/26/24 at 04:30 PM, Administrative Nurse D stated she expected staff to sit by the resident face to face when assisting the resident to eat. Administrative Nurse D stated staff should try to converse with the resident and that staff should not leave the table to go do other tasks until the resident was finished eating. The facility's Resident Rights Policy, undated, documented the right to be treated with dignity and respect was the foundation on which all other resident rights and responsibilities were based. The facility failed to treat R115 with dignity when staff stood over him at the 300-hall dining room table during assisted dining. This placed the resident at risk for an undignified experience.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R75's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough sepsis made, or the body cannot respond to the insulin), heart failure, hypertension (high blood pressure), and iron deficiency (too little iron in the body). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R75 had severely impaired cognition and required substantial/maximum assistance for dressing, transfer, toileting, and partial/moderate assistance for personal hygiene. R75's Care Plan, dated 03/12/24 and initiated on 04/12/23, documented R75 had a potential for cardiovascular problems and directed staff to administer medications as ordered, monitor vital signs as ordered, and notify the physician of any abnormal readings. The Nurse's Note, dated 08/21/23 at 09:39 PM, documented R75 was admitted to the hospital on [DATE]. A review of R75's clinical record lacked evidence the resident or representative was provided written notice when she was transferred to the hospital. On 03/26/24 at 08:55 AM, observation revealed R75 sat in her wheelchair and talked on the telephone in her room. On 03/26/24 at 10:45 AM, Licensed Nurse (LN) G stated the nurse sent the bed hold policy with the resident when they went to the hospital. LN G said the staff called the resident's representative but would not send a written notice. On 03/26/24 at 10:39 AM, Administrative Staff B stated the nurse sent the bed hold policy with transfer papers to the hospital. On 03/26/24 at 10:45 AM, Administrative Nurse D stated the nurse sent a bed hold with residents when they were transferred to the hospital; medical records were responsible for receiving it back. Administrative Nurse D verified the facility did not notify the resident's representative in writing regarding transfers to the hospital and the reason for the transfer. The facility's Bed Hold policy, undated, documented the facility notified the resident and/or representative of the bed hold policy in writing at the time of admission when transferred to the hospital or during therapeutic leave, as well as the intent for readmission according to state and federal regulations. The facility failed to provide R75 or her representative written notice regarding R75's facility-initiated transfer to the hospital. This placed the resident and/or her representative at risk for uninformed care choices. The facility had a census of 151 residents. The sample included 31 residents with four reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to provide written notice for facility-initiated transfer to Resident (R) 68, R347, and R75 or their representatives, when they were transferred to the hospital. This placed the residents at risk for uninformed care choices. Findings included: - R68's Electronic Medical Record (EMR) documented R68 had a diagnosis of benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections) R68's admission Minimum Data Set (MDS), dated [DATE], documented R68 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented the resident required substantial to maximal staff assistance with toileting and personal hygiene. The Urinary Incontinence Care Area Assessment (CAA), dated 10/18/23, documented R68 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag) and instructed staff to monitor R68 for urinary tract infections (UTI-an infection in any part of the urinary system). R68's Care Plan, revised 10/18/23, documented R68 had an indwelling catheter and instructed staff to provide catheter care as needed (PRN) and encourage R68 to drink fluids to reduce UTI risks. The Progress Note, dated 03/04/2024 at 05:10 PM, documented R68 was admitted to the hospital. A review of R68's clinical record lacked evidence the resident or representative was provided written notice when he was transferred to the hospital. On 03/25/24 at 04:22 PM, observation revealed R68 sat quietly in a wheelchair in his room. His indwelling foley catheter was in a privacy bag hooked on the wheelchair and the urine in the tubing had clear yellow urine. On 03/26/24 at 10:39 AM, Administrative Staff B verified the facility lacked documentation R68 or his representative was provided written notice when the resident was transferred to the hospital. Administrative Staff B stated nursing was responsible for sending the bed hold policy with transfer papers to the hospital and she did not follow up on obtaining the signed notice. On 03/26/24 at 10:45 AM, Administrative Nurse D stated verified the facility lacked documentation R68, or their representative was provided a written notice when the resident was transferred to the hospital. Upon request, the facility failed to provide a policy regarding facility-initiated transfers to the hospital. The facility failed to provide R68 or his representative written notice regarding R68's facility-initiated transfer to the hospital. This placed the resident and/or her representative at risk of uninformed care choices. - R347's Electronic Medical Record (EMR) documented R347 had a diagnosis of disorders of the lungs, R347's admission Minimum Data Set (MDS), dated [DATE], documented R347 had a Brief Interview of Mental Status score of 15, which indicated intact cognition. The MDS documented R347 was dependent on staff for toileting, showering, lower body dressing, putting on and taking off footwear, and transfers. R347 required partial to moderate staff assistance with oral care and personal hygiene; R347 required substantial to maximal staff assistance with upper body dressing and bed mobility. R347's Care Plan, revised 01/05/24, instructed staff to change the oxygen tubing and water reservoir per facility protocol and administer oxygen as the physician ordered. Staff monitored R347's oxygen saturation as the physician ordered and notified the physician of abnormal readings. The care plan instructed staff to monitor R347 for shortness of breath during activity participation. The Progress Note, dated 03/08/24 at 07:12 AM, documented R347 was admitted to the hospital. A review of R347 's clinical record lacked evidence the resident or representative was provided written notice when R347 was transferred to the hospital. On 03/25/24 at 03:46 PM, observation revealed R347 sat in bed with oxygen on per nasal cannula. On 03/26/24 at 10:39 AM, Administrative Staff B verified the facility lacked documentation R347 or his representative was provided written notice of the transfer to the hospital. On 03/26/24 at 10:45 AM, Administrative Nurse D verified the facility lacked documentation R347, or the representative was provided a written notice when R347 was transferred to the hospital. Upon request, the facility failed to provide a policy for facility-initiated transfer to the hospital. The facility failed to provide R347 or his representative written notice regarding R347's facility-initiated transfer to the hospital. This placed the resident and/or her representative at risk of uninformed care choices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R75's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough sepsis made, or the body cannot respond to the insulin), heart failure, hypertension (high blood pressure), and iron deficiency (too little iron in the body). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R75 had severely impaired cognition and required substantial/maximum assistance for dressing, transfer, toileting, and partial/moderate assistance for personal hygiene. R75's Care Plan, dated 03/12/24 and initiated on 04/12/23, documented R75 had a potential for cardiovascular problems and directed staff to administer medications as ordered, monitor vital signs as ordered, and notify the physician of any abnormal readings. The Nurse's Note, dated 08/21/23 at 09:39 PM, documented R75 was admitted to the hospital on [DATE]. A review of R75's clinical record lacked evidence the resident or representative was provided the facility's bed hold policy when R75 went to the hospital. On 03/26/24 at 08:55 AM, observation revealed R75 sat in her wheelchair and talked on the telephone in her room. On 03/26/24 at 10:45 AM, Licensed Nurse (LN) G stated the nurse sent the bed hold policy with the resident when they went to the hospital. LN G said the staff called the resident's representative but would not send a written notice. On 03/26/24 at 10:39 AM, Administrative Staff B stated the nurse sent the bed hold policy with transfer papers to the hospital. On 03/26/24 at 10:45 AM, Administrative Nurse D stated the nurse sent a bed hold with residents when they were transferred to the hospital; medical records were responsible for receiving it back. Administrative Nurse D verified the facility did not notify the resident's representative in writing regarding transfers to the hospital and the reason for the transfer. The facility's Bed Hold policy, undated, documented the facility permits residents to return to the facility after they are hospitalized or placed on therapeutic leave and if a resident who was hospitalized exceeds the bed-hold period under the State plan, may return to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident requires the services provided by the facility and was eligible for Medicare/Managed Care skilled nursing services or Medicaid. The facility failed to provide R75 or his representatives with the bed hold policy when they were transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility. The facility had a census of 151 residents. The sample included 31 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 68, R347, and R75 or their representative with written information regarding the facility bed hold policy when they were transferred to the hospital. This placed the residents at risk of not being permitted to return and resume residence in the nursing facility. Findings included: - R68's Electronic Medical Record (EMR) documented R68 had a diagnosis of benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections) R68's admission Minimum Data Set (MDS), dated [DATE], documented R68 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented the resident required substantial to maximal staff assistance with toileting and personal hygiene. The Urinary Incontinence Care Area Assessment (CAA), dated 10/18/23, documented R68 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag) and instructed staff to monitor R68 for urinary tract infections (UTI-an infection in any part of the urinary system). R68's Care Plan, revised 10/18/23, documented R68 had an indwelling catheter and instructed staff to provide catheter care as needed (PRN) and encourage R68 to drink fluids to reduce UTI risks. The Progress Note, dated 03/04/2024 at 05:10 PM, documented R68 was admitted to the hospital. A review of R68's clinical record lacked evidence the resident or representative was provided the bed hold policy when he was transferred to the hospital. On 03/25/24 at 04:22 PM, observation revealed R68 sat quietly in a wheelchair in his room. His indwelling foley catheter was in a privacy bag hooked on the wheelchair and the urine in the tubing had clear yellow urine. On 03/26/24 at 10:39 AM, Administrative Staff B verified the facility lacked documentation R68, or his representative was provided the bed hold policy when R68 was transferred to the hospital. Administrative Staff B stated nursing was responsible for sending the bed hold policy with transfer papers to the hospital and she did not follow up on obtaining the signed notice. On 03/26/24 at 10:45 AM, Administrative Nurse D verified the facility lacked documentation R68, or their representative was provided the bed hold policy when the resident was transferred to the hospital. The facility's Bed Hold Policy, undated, documented the facility would inform and give a written copy of this policy to the resident and/or representative upon admission and if transferred to a hospital or during therapeutic leave. The facility failed to provide R68 or his representative with the bed hold policy when R68 was transferred to the hospital. This placed the resident and/or her representative at risk of uninformed care choices. - R347's Electronic Medical Record (EMR) documented R347 had a diagnosis of disorders of the lungs. R347's admission Minimum Data Set (MDS), dated [DATE], documented R347 had a Brief Interview of Mental Status score of 15, which indicated intact cognition. The MDS documented R347 was dependent on staff for toileting, showering, lower body dressing, putting on and taking off footwear, and transfers. R347 required partial to moderate staff assistance with oral care and personal hygiene; R347 required substantial to maximal staff assistance with upper body dressing and bed mobility. R347's Care Plan, revised 01/05/24, instructed staff to change the oxygen tubing and water reservoir per facility protocol and administer oxygen as the physician ordered. Staff monitored R347's oxygen saturation as the physician ordered and notified the physician of abnormal readings. The care plan instructed staff to monitor R347 for shortness of breath during activity participation. The Progress Note, dated 03/08/24 at 07:12 AM, documented R347 was admitted to the hospital. A review of R347s clinical record lacked evidence the resident or representative was provided the bed hold policy when R347 was transferred to the hospital. On 03/25/24 at 03:46 PM, observation revealed R347 sat in bed with oxygen on per nasal cannula. On 03/26/24 at 10:39 AM, Administrative Staff B verified the facility lacked documentation R347, or his representative was provided the bed hold policy when R347 was transferred to the hospital. On 03/26/24 at 10:45 AM, Administrative Nurse D verified the facility lacked documentation R347, or the representative was provided the bed hold policy when R347 was transferred to the hospital. The facility's Bed Hold Policy, undated, documented the facility would inform and give a written copy of this policy to the resident and/or representative upon admission and if transferred to a hospital or during therapeutic leave. The facility failed to provide R347 or his representative with the bed hold policy when R347 was transferred to the hospital. This placed the resident and/or her representative at risk of uninformed care choices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R68's Electronic Medical Record (EMR) documented diagnoses of benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections) and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). R68's admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R68 had no mood or behaviors during the observation period. The MDS documented R68 required substantial to maximal staff assistance with activities of daily living (ADLs). R68's Care Plan, revised 09/12/23, documented R68 preferred privacy when staff provided care as well as when discussing personal issues and instructed staff to provide care in a calm, patient, non-judgmental manner. Staff were to explain what task was to be done before beginning the task. R68's clinical record lacked evidence a PASRR was completed. On 03/25/24 at 04:22 PM, observation revealed R68 sat quietly in a wheelchair in his room. On 3/26/24 at 08:20 AM, Administrative Staff A stated the resident was admitted from the Veteran's Administration (VA) and the VA did not perform a PASRR. Upon request, the facility did not provide a policy. The facility failed to ensure a PASRR was completed for R68 before admission. This placed the residents at risk for unidentified needs and inadequate care. - R110 was admitted to the facility on [DATE]. R110's Electronic Health Record (EHR), recorded the diagnoses of posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress,) and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear.) R110's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 14, with intact cognition. The MDS documented the resident had verbal behaviors directed towards others. R110's Care Plan, dated 03/21/24, indicated R110 had a history of behavioral symptoms and had a history of being manipulative, making statements that were exaggerated or false about events, care, and medications, and often wanting to manipulate staff's time. R110's EHR lacked evidence a PASRR assessment was completed as required. The facility was unable to provide a PASRR screening for R110 upon request. On 03/25/24 at 02:10 PM, observation revealed R110 sat in a recliner in his room watching TV. On 03/26/24 at 08:20 AM, Administrative Staff A verified R110 lacked a PASRR assessment before admission to the facility. Administrative Nurse D stated the resident was from the Veterans Hospital (VA) and the VA did not assess for PASRR upon admission. Upon request, the facility did not provide a policy. The facility failed to adequately assess the resident for placement in the facility by obtaining a PASRR screening as required. This placed R110 at risk for inadequate facility care and unidentified needs. The facility had a census of 151 residents. The sample included 31 residents. Based on observation, interview, and record review the facility failed to ensure Residents (R) 87, R68, and R110 received a Preadmission Screening and Resident Review (PASRR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) to identify potential care needs related to a mental disorder (MD) or intellectual disability (ID). This placed the residents at risk for unidentified needs and inadequate care. Findings included: - R87's Electronic Medical Record (EMR) documented diagnoses of atrial fibrillation (rapid, irregular heartbeat), asthma (a disorder of narrowed airways that caused wheezing and shortness of breath), and bipolar disorder (a major mental illness that caused people to have episodes of severe high and low moods). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R87 had no mood or behaviors during the observation period. R87 required set up for eating, verbal cues for bathing, and dressing, and moderate assistance for toileting, and transfers. R87's Care Plan, dated 3/16/24, stated he preferred to stay in his room and was most comfortable when around familiar people. He would occasionally attend the group setting although he tended to leave early related to emotional comfort as big groups made him anxious. R87's clinical record lacked evidence a PASRR was completed. On 03/26/24 at 07:40 AM, observation revealed R87 independently ate hot cereal while holding the bowl in his lap. On 3/26/24 at 08:20 AM, Administrative Staff A stated the resident was admitted from the Veteran's Administration (VA) and the VA did not perform a PASRR. Upon request, the facility did not provide a policy. The facility failed to ensure a PASRR was completed for R87 before admission. This placed the residents at risk for unidentified needs and inadequate care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 151 residents. The sample included 31 residents. Based on observation, record review, and interview, the facility failed to revise the care plan with trauma triggers and coping strategies for Resident (R)50 who had post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) which placed the resident at risk for impaired care due to uncommunicated care needs. Findings included: - Resident (R) 50's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), aphasia (a language disorder that affects ability to communicate), post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), major depressive disorder (major mood disorder which causes persistent feelings of sadness), Wernicke's encephalopathy (impaired coordination movement and eye dilated veins). R50's Quarterly Minimum Data Set (MDS), dated [DATE], documented that staff assessed R50's cognition as moderately impaired. R50 rejected care one to three days of the look-back period. R50 received an antidepressant (medication used to treat mood disorders) and was independent with most activities of daily living. The Behavioral Symptoms Care Area Assessment (CAA), dated 08/21/23, documented R50 had multiple episodes of refusing care such as showers. R50's family was very involved and encouraged R50 to participate. R50's Care Plan, dated 02/27/24, documented R50 had problems with short-term memory due to the diagnosis of dementia. The care plan directed staff always to tell R50 what staff were going to do before initiating nursing care and to encourage R50 to talk about her life, past experiences, career, and family. R50's admission information documented R50 had a 70 percent (%) disability through the Veteran Administration (VA). The facility's Social Service Quarterly Long-Term Observation, dated 11/17/22, documented a trauma screening which recorded R50 answered No when asked about a history of traumatic events. The Progress Note dated 12/27/23 at 01:49 PM, documented R50's family called the facility regarding R50 being upset. R50 indicated that someone had spoken mean to her, and she wanted someone to pick her up from the facility. The note further documented R50's roommate had been using profanities toward staff and R50's family inquired about a private room. On 03/26/24 at 08:17 AM, observation revealed R50 remained in bed, covered with several blankets. She had a breakfast tray sitting on her overbed table. On 03/26/24 at 02:20 PM, Social Service X stated most of the facility's residents were admitted from Veteran Administration (VA) referrals and usually had PTSD. Social Service X had not assessed or gathered information related to R50's triggers of past trauma nor had she spoken to R50's family about possible triggers to prevent re-traumatization. On 03/26/24 at 02:20 PM, Administrative Staff Nurse E verified that R50's Care Plan had behaviors of obsessive cleaning noted but did not specifically address R50's trauma issues. On 03/26/24 at 04:29 PM, Administrative Nurse D stated residents with a diagnosis of PTSD were not assessed for triggers on admission, only when the residents showed some sort of symptoms such as depression, flashbacks, or anxiety. Administrative Nurse D said if those symptoms occurred, she expected her staff to conduct a PTSD assessment. The facility's Trauma Informed Care and Behavioral Health Management policy, dated 09/2019, documented it is the philosophy of the facility to assist in the early identification of residents' past traumatic events/behaviors and to develop and implement interventions to manage or de-escalate those behaviors. Any actual or potential areas of concern identified by the social worker based on the interview will be documented and communicated with the nurse, nursing administration, behavior management committee, and care planned. Care Plans will be communicated to all direct caregivers to avoid triggers for the residents and promote their mental and psychological well-being. The facility failed to identify and implement interventions for R50's diagnosed PTSD, which placed the resident at risk of uncommunicated care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 151 residents. The sample included 31 residents, of which one was reviewed for mobility and positioning. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 53 received appropriate treatment and services to maintain and prevent a decline in mobility and ambulation. This placed the resident at risk for a decline in mobility and impaired independence. Findings included: - R53's Electronic Health Record (EHR), recorded the diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R53's admission Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The assessment revealed the resident required partial to moderate assistance with activities of daily living (ADLs) and supervision to walk 50 to 150 feet. R53's Care Plan, dated 12/07/23, directed staff to assist the resident with dressing but lacked any direction for therapy or restorative assistance. R53's Restorative Therapy Plan of Care, dated 03/09/24, documented the restorative aide would assist the resident to walk two to three times a week using the platform walker in the therapy gym with a gait belt for 100 feet, twice with stand-by assistance. A review of the Restorative Flowsheet documentation revealed the resident refused to walk on 03/26/24 and lacked documentation the resident was provided or asked to participate in ambulation from 03/09/24 until 03/26/24. On 03/25/24 at 11:00 AM, observation revealed the resident sat in a recliner in her room. She was dressed in street clothes and had her feet elevated. On 03/26/24 at 07:30 AM, Physical Therapist (PT) HH stated the resident received physical therapy from admission [DATE] until 03/09/24. PT HH stated the therapists developed a restorative program for R53 on 03/09/24 and the restorative aide would continue the resident's restorative program 2-3 times a week. PT HH stated the facility had one restorative aide to complete restorative on all the residents in the facility who required restorative services. On 03/26/24 at 02:10 PM, Administrative Nurse E verified the physical therapists completed the resident's therapy and then the therapist developed a restorative program. Administrative Nurse E stated the restorative aide would document the restorative services in the EHR. Administrative Nurse E verified the resident had not received any of the directed restorative services since 03/09/24 when the therapist developed the restorative program for the resident. The facility's Restorative Therapy Program policy, dated May 2021, documented the facility would assist each resident to attain and or maintain their individual highest most practicable functional level of independence and well-being, in accordance with State and Federal regulations. Each resident would be screened and evaluated by the nurse or therapist designated to oversee the restorative nursing process for inclusion into the appropriate facility restorative nursing program when it has been identified by the interdisciplinary team that the resident is in need or may benefit from such program. The facility's restorative nursing program would include, but not be limited to hygiene, mobility including ambulation, dining, and communication. The restorative program would be documented on the facility-designated restorative care form and tools in the resident's electronic medical record. The designated nurse would be responsible for obtaining orders for the resident's restorative program and documentation every month. The therapist would be responsible for initiating and updating restorative care plans and the designated nurse or therapist would continue to monitor the resident's progress. The designated nurse would evaluate the restorative documentation monthly to determine if there are any changes needed to the existing program and make a monthly progress note, in the resident's electronic medical record. The policy documented some residents may not wish to participate in restorative care programming which will be respected as an election of choice and documented accordingly. The facility failed to ensure R53 received appropriate restorative treatment and services to increase or prevent further deterioration for the resident. This placed the resident at risk for a decline in mobility and impaired independence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 151 residents. The sample included 31 residents. The facility had six medication carts. Based on observation, interview, and record review, the facility failed to date Resident (R)53's insulin (a hormone which allows cells throughout the body to uptake glucose) flex pen when opened and failed to discard R15 and R346's insulin flex pen and R01's insulin vial when outdated. The facility further failed to discard expired stock medications. This deficient practice placed the affected residents at risk for ineffective medications. Findings included: - On [DATE] at 08:15 AM, observation of the facility's 500 Nurse medication cart revealed the following: R53's Lantus (long-acting insulin) flex pen lacked an open date and discard date. R15 s Lantus flex pen opened date of [DATE] and discard date of [DATE]. On [DATE] at 08:20 AM, observation of the facility's 600 Nurse medication cart revealed the following: R346's Levemir (long-acting insulin) flex pen lacked an open and discard date. R01's Lantus vial had an opened date of [DATE], and a discard date of [DATE]. On [DATE] at 08:25 AM, observation of the facility's 600 medication cart revealed the following: [NAME]-Tussin DM (cold and cough medication) 16 fluid ounces expired [DATE]. On [DATE] at 10:30 AM, Administrative Nurse E verified the nurses were to date the insulin when opened and discard the outdated insulin, Administrative Nurse E said staff were to discard expired stock medications. Medlineplus.gov directs open, unrefrigerated Levemir vials and pens that can be used within 42 days, but after that time they must be discarded. Unrefrigerated vials or pens of Lantus can be used within 28 days but after that time they must be discarded. The facility's Insulin Administration policy dated [DATE], documented the staff would administer insulin via pen device according to the physician's orders and the facility's policy and procedures. Insulin pens should be clearly labeled with the person's name. The label on the pen and make sure it is the correct ordered insulin for the resident, check the expiration date, if the pen is being used for the first time, date the on the label. Refer to the chart for pen expiration dates. Verify the insulin is being given at the correct time in relation to meals. The facility's Storage of Drugs policy, dated [DATE], documented the facility would store in the original container in which they were received. The refrigerator, freezer, and control room would be available in the pharmacy medications requiring specific storage. No discontinued, outdated, or deteriorated drugs or medications are stored in the facility over thirty (30) days. The facility failed to date R53's flex pen insulin with the date opened and discard date, and failed to discard R01's, R15's, and R346's outdated insulin vial. The facility also failed to discard expired stock medications placing the residents at risk for ineffective medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 118 residents. The sample included 25 residents, with one reviewed for smoking. Based on observation, record review and interview, the facility failed to develop a comprehensive care plan for smoking for Resident (R) 72. This placed the resident at risk for smoking related injury. Findings included: - The Electronic Medical Record (EMR) for R72 documented diagnoses of hemiplegia (paralysis of one side of the body), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), diabetes mellites type 2 (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R72 had moderately impaired cognition and required extensive assistance with one staff for transfers, toileting, and personal hygiene, and limited assistance of one staff for bed mobility and dressing. The MDS further documented R72 did not ambulate. The Smoking Assessment dated 04/07/22 documented R72 was not cognitively impaired, was able to call for help is a lit cigarette fell, was supervised by staff in a designated area, and had been instructed in the facility's smoking policy. R72's EMR lacked documentation of a smoking care plan. On 10/18/22 at 04:10 PM, observation revealed R72 sat outside in the designated smoking area, with other residents and staff, smoking. On 10/24/22 at 10:05 AM, Administrative Nurse E verified R72 did not have a care plan for smoking. On 10/24/22 at 01:00 PM, Administrative Nurse D stated R72 should have a care plan for smoking. The facility's Care Management policy, dated December 2020, documented a comprehensive plan of care, based on interdisciplinary assessments, are developed and implemented within 21 days of admission for permanent residents. The facility failed to develop a comprehensive care plan for smoking for R72. This placed the resident at risk for smoking related injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 118 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed to update the care plan with interventions for Resident (R) 51, and R111's falls, and R35 for behaviors. This practice placed the residents at risk for injury from falls and unmet care needs. Findings included: - The Electronic Medical Record (EMR) for R51 documented diagnoses of astrocytoma (brain cancer), epilepsy (brain disorder characterized by repeated seizures), and hypokalemia (deficiency of potassium in the bloodstream). The admission Minimum Data Set, (MDS), dated [DATE], documented R51 had severely impaired cognition and required extensive assistance of two staff for transfers, toileting, and extensive assistance of one for bed mobility, personal hygiene, and locomotion on and off the unit. The assessment further documented R51 had unsteady balance, no upper or lower functional impairment, and had no falls. The Quarterly MDS, dated 09/11/22, documented R51 had moderately impaired cognition and required extensive assistance of two staff for transfers, toileting, and extensive assistance of one staff for bed mobility, personal hygiene, and locomotion on and off the unit. The MDS further documented R51 had unsteady balance, no upper or lower functional impairment, and had no falls. The Fall Risk Assessments, dated 06/08/22, and 09/15/22 documented R51 was a high risk for falls and on 10/17/22, a low risk for falls. The Care Plan, originally dated 10/27/21, documented R51 was a high risk for falls and directed staff to minimize the risk of falls and encouraged R51 to wait for assistance and not transfer herself, ensure the call light was within reach and educate on the use of the call light, and physical therapy to evaluate and treat. The update, dated 12/29/21, directed staff to ensure her plant was within reach to enable her to care for her plant in a safe way. The update, dated 01/29/22, directed staff to provide frequent checks on the resident. The update, dated 03/17/22, documented R51 was on therapy caseload, and directed staff to encourage or offer toileting more frequently. The update, dated 05/22/22, directed staff to obtain therapy screen to assess for safety with adaptive equipment use. The update, dated 06/11/22, documented R51 was on therapy caseload and assess the ability to use a reacher tool (an adaptive device for people with limited range of motion grab out of reach items). The Post -Fall Assessment, dated 12/29/21 at 07:45 AM, documented R51 rolled out of bed while she reached for her plant to water it. The plant had been on her heater unit and R51 was unable to reach it. The assessment further documented staff reeducated R51 to utilize her call light for assistance and moved the resident's plant within reach. The Post-Fall Assessment, dated 01/29/22 at 11:00 PM, documented R51 was unable to communicate what had occurred but the nurse anticipated the resident tried to pick up something off the floor and fell. The assessment further documented staff reeducated R51 to call for assistance and to provide frequent checks related to unsafe behavior. The Post-Fall Assessment, dated 03/07/22 at 10:43 AM, documented R51 stated she fell while taking herself to the bathroom. The assessment further documented the resident was on therapy caseload and directed staff to encourage or offer toileting more often. The Post-Fall Assessment, dated 05/22/22 at 10:00 PM, documented R51 was in her room on the floor, and stated she had dropped her ipad (a touchscreen electronic device) under her bed and tried to pick it up. The assessment documented staff reeducated R51 to call for assistance and the resident was on therapy caseload and have therapy assess for safety with adaptive equipment use. The Post-Fall Assessment, dated 06/11/22 at 01:30 PM, documented R51 was in her room on the floor and she did not know what had happened. The assessment further documented R51 was uninjured and R51 was on therapy caseload and would have therapy assess R51 to use a reacher tool. On 10/20/22 at 10:00 AM, observation revealed Certified Nurse Aide (CNA) N placed a gait belt around R51's waist, slowly stood the resident up, and held onto her gait belt as she did not have good balance and CNA N had to slowly assist her to sit in the wheelchair. On 10/20/22 at 10:00 AM, CNA N stated R51 had previous falls from transferring without calling for assistance and physical therapy was working with her to assist with balance and ambulation. On 10/24/22 at 10:15 AM, Licensed Nurse (LN) G stated R51 was unable to ambulate and received therapy to assist with balance and ambulation. LN G further stated nurses were able to assist with new interventions after a resident fell but did not remember any of R51 falls or any of her current fall interventions. On 10/24/22 at 01:00 AM, Administrative Nurse D stated, there were new interventions for each fall and any resident with cognitive impairment should have new interventions on their care plans. The facility's Care Management policy, dated December 2020, documented a plan of care was continually updated to reflect current residents needs at all times. The facility failed to revise the care plan with interventions to prevent further falls for cognitively impaired R51. This placed the resident at risk for further falls. - The Electronic Medical Record (EMR) for R111 documented diagnoses of diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypertension (high blood pressure), chronic kidney disease (disease of the kidneys leading to renal failure), and chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set, (MDS), dated [DATE], documented R111 had moderately impaired cognition and required supervision and one staff assistance for dressing, toileting, and supervision with set up assistance for bed mobility and transfers. The MDS further documented R111 had unsteady balance, independent with set up assistance for ambulation, no functional impairment, and one non-injury fall since the prior assessment. The Quarterly MDS, dated 09/23/22, documented R111's cognition was not assessed and required extensive assistance of two staff for bed mobility, transfers, toileting, and did not ambulate. The assessment further documented R111 had unsteady balance, no functional impairment, had no falls, and received physical, occupational, and speech therapy services three to five days per week. The Fall Risk Assessments, dated 05/16/22, 08/15/22, 09/15/22, documented R111 was a high risk for falls. The Fall Care Plan, originally dated, 05/29/21, documented R111 may forget to use her call light, so check on the resident frequently, ensure R111 had nonskid footwear one and assist with keeping room clutter free, wear nonskid socks, educate the resident to use her call light, and monitor and remind the resident not to sit or lay on top of her bedding near the edge of the bed or she was at risk to slip off the bed, The update, dated 01/09/22, directed staff to check on the resident every two hours for bathroom needs, and obtain a therapy screen for balance and gait training. The update, dated 01/15/22, directed staff to ensure non-skid footwear/socks are on the resident. The update, dated 01/18/22, directed staff to obtain therapy screen for balance and strength for safe ambulation. The update, dated 05/18/22, directed staff to use a hoyer lift (a full body lift that allows a person to be lifted and transferred with a minimum of physical effort) for transfers. The update, dated 07/23/22, directed staff to encourage non skid socks, reeducate to use the call light and ask for assistance. The update, dated 07/28/22, directed staff to ensure personal items are within reach. The Post -Fall Assessment, dated 01/09/22 at 07:12 PM, documented R111 felt weak and fell while attempting to take herself to the bathroom. The resident had poor safety awareness, forgetful, and had a history of falls. The assessment directed staff to obtain a therapy screen for gait training. The Post -Fall Assessment, dated 01/15/22 at 03:24 PM, documented R111 ambulated without nonskid sock on by her bathroom sink. The resident had poor safety awareness and were directed to ensure nonskid footwear or socks were on the resident. The Post -Fall Assessment, dated 01/18/22 at 10:03 PM, documented R111 was fully dressed, lying on the floor with a blanker under her head. The resident did not have non skid socks on, with the walker lying beside her. The assessment further documented R111 stated she was walking to the bathroom, slipped, and landed on her left knee. The assessment documented R111 obtained a small abrasion (scrape) which measured one-centimeter (cm) x one cm. The resident was reeducated to use her call light for assistance. The assessment directed staff to obtain a therapy screen to continue to work on balance and strengthening and to assist R111 to wear non skid socks. The Post -Fall Assessment, dated 03/18/22 at 08:09 PM, documented R111 stated she sat on the edge of her bed and thought she slid off. The resident did not have non skid socks on. The assessment directed staff to ensure R111 had non skid socks on and non skid strips were placed on the floor at the bedside. The Post -Fall Assessment, dated 04/21/22 at 02:30 AM, documented R111 slid off the bed onto the floor while she attempted to transfer herself to go to the bathroom. The assessment directed staff to continue to provide frequent checks on the resident. The Post -Fall Assessment, dated 04/25/22 at 01:31 PM, documented R111 slid out of bed onto the floor while she attempted to take herself to the bathroom. the assessment directed staff to obtain a therapy screen for bed safety training. The Post -Fall Assessment, dated 05/18/22 at 10:40 AM, documented R111 fell while staff assisted her with a transfer. The assessment documented R111 obtained a small abrasion to her left knee which measured one cm x a half cm. The assessment further documented staff were educated on R111 increased weakness and weight bearing status and she was assisted to bed with three staff assistance. The Post -Fall Assessment, dated 06/04/22 at 11:14 AM, documented R111 stated she fell while she tried to get out of bed. R111 was dressed in her night gown, was incontinent, and had no shoes or socks on. The staff reeducated R111 on the importance to use her call light and to put on non skid socks. The assessment documented R111 was non-compliant with all previous fall interventions and a medical evaluation would be completed. The Post -Fall Assessment, dated 07/23/22 at 01:36 PM, documented R111 stated she tried to shut off her light and fell. The assessment documented staff reeducated R111 on the use of non skid socks and call for assistance. The assessment directed staff to continue current plan of care. The Post -Fall Assessment, dated 07/28/2 at 04:17 PM, documented R111 stated she leaned over to grab an envelope, lost control and fell. The assessment documented R111 obtained rug burns to both of her knees. The assessment directed staff to continue current plan of care. On 10/20/22 at 08:45 AM, observation revealed R111 in bed with pressure reducing boots on both feet. Further observation revealed Certified Nurse Aide (CNA) O and CNA QQ in room to assist with a transfer out of bed and into her wheelchair. Further observation revealed the sling for the lift was already under R111 and CNA O attached it to the lift. Continued observation revealed R111 was raised up off the bed with the lift and taken to her wheelchair and lowered into the seat as CNA QQ tilted the wheelchair back so the resident would sit comfortably in the wheelchair. Observation revealed there were no non skid strips beside the resident's bed. On 10/20/22 at 08:45 AM, CNA O stated R111 had a lot of falls because she did not use her call light and they always tell her she needs to use her call lights. On 10/24/22 at 10:15 AM, Licensed Nurse G stated they reeducate her to call, check on her hourly, and tell her not to get up by herself. LN G further stated R111 thinks she can get up by herself but her functional status has changed, staff put non skid socks are her, lower her bed, and she is a two person mechanical lift. On 10/24/22 at 01:00 PM, Administrative Nurse D stated all falls should have new interventions after review of the fall. Administrative Nurse D further stated, all falls are reviewed weekly during fall huddle. The facility's Care Management policy, dated December 2020, documented a plan of care was continually updated to reflect current residents needs at all times. The facility failed to revise the care plan with interventions to prevent further falls for R111. This placed the resident at risk for further falls. - The Electronic Medical Record (EMR) documented R35 had diagnoses of dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), psychosis (any major mental disorder characterized by a gross impairment in reality testing), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R35 had moderately impaired cognition and required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS further documented R35 had no behaviors and received an antidepressant (a class of medication used to treat mood disorders and relieve symptoms of depression) six days during the look back period. The Care Plan, dated 09/06/22, directed staff to administer medications as ordered, when agitated ask R35 about his pain level, and if he would like a snack, encourage him to talk about his past life, and experiences. The care plan lacked interventions related to R35's repeated calls to 911 (a phone number used to contact the emergency services). The Nurse's Note, dated 01/05/22 at 06:14 AM, documented R35 continued to call 911 from a phone in his room, four times in 10 minutes, and about 20 times in total. The nurse's note further documented R35 had delusions that the hospital, his former employer, tried to reach him. The note documented staff attempted to explain to him that he was retired but R35 was non receptive and continued to yell and scream at staff. The Nurse's Note, dated 05/02/22 at 09:51 PM, documented the facility received a call from the local police department and stated R35 had called and requested assistance in his room. The note further documented staff asked R35 not to call police. The Nurse's Note, dated 05/19/22 at 10:47 PM, documented R35 called 911 and told them someone was on the floor. The note further documented R35 told nursing staff he had been on the floor. The Nurse's Note, dated 08/16/22 at 11:42 PM, documented the facility received a call from 911 twice and were told R35 had called 911 ten times for assistance into his wheelchair. The Nurse's Note, dated 09:32 AM, documented R35 called 911 because his roommate yelled for help. The note further documented R35 was agitated and wanted his roommate removed from the room. On 10/18/22 at 03:50 PM, observation revealed R35 in bed watching television. On 10/20/22 at 11:44 AM, Certified Nurse Aide (CNA) M stated R35 had always been pleasant with her and had never called 911 when she had been there. CNA M further stated R35 did not like his roommate and would often get mad at him but they moved the resident to a different room. On 10/24/22 at 10:05 AM, Administrative Nurse E verified there was not an intervention for when R35 called 911. On 10/24/22 at 10:15 AM, Licensed Nurse (LN) G stated she would not know if R35 called 911 unless other staff hear him and informed her. The facility's Care Management policy, dated December 2020, documented a plan of care was continually updated to reflect current residents needs at all times. The facility failed to revise the care plan with interventions to address R35's behavior of placing multiple calls to 911 placing the resident at risk for further distress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 118 residents. The sample included 25 residents with one reviewed for positioning. Based on observation, interview and record review the facility failed to ensure proper positioning and utilize a neck pillow or collar as care planned for sampled Resident (R) 101. This deficient practice placed the resident at risk for further decrease in range of motion. Findings included: - R101's Electronic Medical Record (EMR) included diagnoses of Alzheimer's disease (type of dementia that affects memory, thinking and behavior). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R101 had severe cognitive impairment, impaired range of motion (ROM) in all extremities, and required extensive staff assistance with eating, dressing, bed mobility and total staff assistance with transfers, locomotion, toileting, and hygiene. The Skin Care Area Assessment (CAA), dated 09/26/22, documented R101 was at risk of skin breakdown due to decreased mobility and incontinence. The Skin Care Plan, dated 09/20/22, directed staff to transfer R101 with a total lift for meals only, and plan for her to be the last resident up and first down (to bed) to limit daily transfers and limit time in her wheelchair due to fragile skin. The care plan directed staff to utilize a neck collar or pillow while in her wheelchair, assist her with repositioning frequently, and use positioning devices as needed. The 08/03/22 Event Investigation documented R101 had bruising due to the total lift pad cradling her during transfers. She had contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and fragile skin and the yellowish/green bruise to her left neck, right cheek and eye area were consistent with where the resident positioned her hand. The investigation stated the schedule was changed so she was last up and first down for meals and activities. The 08/30/22 Hospice Note documented the nurse provided a bed bath and found redness and yeast under R101's chin and neck. The hospice nurse notified the physician who ordered antifungal treatment to the area. The 10/15/22 Occupational Therapy (OT) Assessment documented R101 had a long-standing history of contractures though they appear to have increased with potential for decreased skin integrity and increased assistance during care. Contractures were severe and R101 presented with hypertonicity (resistance to passive movement), and severe contractures of both upper extremities. The OT assessment documented R101 required skilled therapy services to address the following: develop/train/educate caregivers in techniques and strategies, facilitate sitting tolerance and postural control, decrease painful condition of upper extremities and improve range of motion in order to enhance this patient's quality of life by improving the ability to relieve pressure for decreased risk of skin breakdown and preserve skin integrity. The assessment documented the resident was at risk for further decline in function, decreased skin integrity and contractures. On 10/18/22 at 04:05 PM, observation revealed R101 in her wheelchair in her room. Her right hand was by her cheek, in a fist shape. R101 had no neck collar or pillow. The lift sling was under her, and she had thick bootie socks on her feet. On 10/19/22 at 08:45 AM, observation revealed R101 in her wheelchair in the dining room, facing the windows, with her arms folded across tummy and her neck tilted to the right without a neck pillow or collar. Further observation revealed at 08:50 AM, Nurse Aide (NA) Q took R101 to her room and left her in the wheelchair with her head tilted to the right and no neck pillow placed. Continued observations at 09:40 AM, 10:38 AM, and 11:15 AM, revealed the resident had not been moved or cares provided. At 11:30 AM, NA P wheeled the resident in the wheelchair to the dining room without providing any cares. After staff fed the resident, R101 sat in the wheelchair in the dining room with her head tilted down and to the right side, resting on her right shoulder. At 12:25 PM, NA P fed R101 ice cream and a shake. At 12:35 PM, observation revealed NA P took the resident to her room, and with NA Q assisted to transfer R101 with a total lift from her wheelchair to her bed. The aides provided incontinent care, placed a pillow between R101's knees, and positioned the resident on her right side with a pillow under head. On 10/20/22 at 07:50 AM, observation revealed R101 in her wheelchair at the dining table. She had her legs drawn up partially, her hands clenched, and she had no neck pillow or collar. On 10/24/22 at 09:22 AM, observation revealed R101 sat in her wheelchair in the hall outside her room with her eyes closed, and her knees drawn up. Her head lay to her right, resting on her shoulder without a neck pillow or collar. At 09:23 AM, NA PP wheeled R101 into her room, attempted to wash her face but R101 refused to allow her. NA PP left R101 in her wheelchair in her room. At 10:00 AM, observation revealed NA OO and NA PP used the total lift to transfer R101 from her wheelchair to her bed. After providing incontinence cares the aides used the total lift to transfer R101 back into her wheelchair. R101 leaned to her right side, legs pulled up, right hand in a fist under her right chin. When asked if R101 had a neck pillow, NA PP replied, she does need one and she looked and found a hand splint, but no neck pillow in the resident's room. On 10/19/22 at 10:25 AM, Licensed Nurse (LN) H stated R101's skin became reddened occasionally but she had no open areas. LN H stated staff toileted the resident after lunch. On 10/19/22 at 1:00 PM, NA Q stated R101's next care would be provided around 03:00 PM for incontinent care and then staff would get R101 up in her wheelchair about 04:30 PM. On 10/20/22 at 07:55 AM NA P stated she did not provide restorative exercises for R101 or any resident on the hall. She stated she did not know if any staff did. On 10/20/22 at 09:30 AM, Administrative Nurse D stated the facility provided restorative for some residents, but they tried to use Medicare Part B if needed. She did not provide further information. On 10/24/22 at 10:35 AM, Administrative Nurse E stated R101's family brought a neck pillow in for the resident for positioning and that was placed on the care plan. She stated the hand splint was on the care plan and then verified it was not in the current care plan. Administrative Nurse E stated staff were to take R101 to the dining room right before meals and back to bed right after the meals. Administrative Nurse E stated nurses and aides can see the care plan and verified staff were to follow care plan. On 10/24/22 at 11:17 AM, LN I stated staff were to get R101 up into her wheelchair one hour before lunch. He was unsure if R101 had a neck pillow or collar and looked it up on the Medication Administration Record (MAR) but was unable to find it. He looked in R101's room and did not find a neck pillow or collar. He concluded the regular bed pillow was used for support. On 10/24/22 at 01:47 PM, Administrative Nurse D stated staff were to follow the care plan and place a neck pillow or collar on R101 when she is up in her wheelchair. The facility's Positioning Resident policy, date May 2021, documented residents must be repositioned at least every two hours to maintain good body alignment and reduce excessive pressure on any one area of the body. The policy documented good positioning along with range of motion exercises would go a long way to prevent deformities and if not done it becomes difficult to wash the contracted areas and sores may develop. The facility failed to ensure proper positioning and utilize a neck pillow or collar as care planned for R101, placing the resident at risk for further decrease in range of motion to her neck.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 118 residents. The sample included 25 residents, with seven reviewed for accidents. Based on observation, record review, and interview, the facility failed to indentify and /or implement resident centered interventions to prevent falls for Resident (R) 51, and R111. This placed the residents at risk for further falls and injury. Findings included: - The Electronic Medical Record (EMR) for R51 documented diagnoses of astrocytoma (brain cancer), epilepsy (brain disorder characterized by repeated seizures), and hypokalemia (deficiency of potassium in the bloodstream). The admission Minimum Data Set, (MDS), dated [DATE], documented R51 had severely impaired cognition and required extensive assistance of two staff for transfers, toileting, and extensive assistance of one for bed mobility, personal hygiene, and locomotion on and off the unit. The assessment further documented R51 had unsteady balance, no upper or lower functional impairment, and had no falls. The Quarterly MDS, dated 09/11/22, documented R51 had moderately impaired cognition and required extensive assistance of two staff for transfers, toileting, and extensive assistance of one staff for bed mobility, personal hygiene, and locomotion on and off the unit. The MDS further documented R51 had unsteady balance, no upper or lower functional impairment, and had no falls. The Fall Risk Assessments, dated 06/08/22, and 09/15/22 documented R51 was a high risk for falls and on 10/17/22, a low risk for falls. The Care Plan, originally dated 10/27/21, documented R51 was a high risk for falls and directed staff to minimize the risk of falls and encouraged R51 to wait for assistance and not transfer herself, ensure the call light was within reach and educate on the use of the call light, and physical therapy to evaluate and treat. The update, dated 12/29/21, directed staff to ensure her plant was within reach to enable her to care for her plant in a safe way. The update, dated 01/29/22, directed staff to provide frequent checks on the resident. The update, dated 03/17/22, documented R51 was on therapy caseload, and directed staff to encourage or offer toileting more frequently. The update, dated 05/22/22, directed staff to obtain therapy screen to assess for safety with adaptive equipment use. The update, dated 06/11/22, documented R51 was on therapy caseload and assess the ability to use a reacher tool (an adaptive device for people with limited range of motion grab out of reach items). The Post -Fall Assessment, dated 12/29/21 at 07:45 AM, documented R51 rolled out of bed while she reached for her plant to water it. The plant had been on her heater unit and R51 was unable to reach it. The assessment further documented staff reeducated R51 to utilize her call light for assistance and moved the resident's plant within reach. The Post-Fall Assessment, dated 01/29/22 at 11:00 PM, documented R51 was unable to communicate what had occurred but the nurse anticipated the resident tried to pick up something off the floor and fell. The assessment further documented staff reeducated R51 to call for assistance and to provide frequent checks related to unsafe behavior. The Post-Fall Assessment, dated 03/07/22 at 10:43 AM, documented R51 stated she fell while taking herself to the bathroom. The assessment further documented the resident was on therapy caseload and directed staff to encourage or offer toileting more often. The Post-Fall Assessment, dated 05/22/22 at 10:00 PM, documented R51 was in her room on the floor, and stated she had dropped her ipad (a touchscreen electronic device) under her bed and tried to pick it up. The assessment documented staff reeducated R51 to call for assistance and the resident was on therapy caseload and have therapy assess for safety with adaptive equipment use. The Post-Fall Assessment, dated 06/11/22 at 01:30 PM, documented R51 was in her room on the floor and she did not know what had happened. The assessment further documented R51 was uninjured and R51 was on therapy caseload and would have therapy assess R51 to use a reacher tool. On 10/20/22 at 10:00 AM, observation revealed Certified Nurse Aide (CNA) N placed a gait belt around R51's waist, slowly stood the resident up, and held onto her gait belt as she did not have good balance and CNA N had to slowly assist her to sit in the wheelchair. On 10/20/22 at 10:00 AM, CNA N stated R51 had previous falls from transferring without calling for assistance and physical therapy was working with her to assist with balance and ambulation. On 10/24/22 at 10:15 AM, Licensed Nurse (LN) G stated R51 was unable to ambulate and received therapy to assist with balance and ambulation. LN G further stated nurses were able to assist with new interventions after a resident fell but did not remember any of R51 falls or any of her current fall interventions. On 10/24/22 at 01:00 AM, Administrative Nurse D stated, there were new interventions for each fall and any resident with cognitive impairment should have new interventions on their care plans. The facility Fall Risk/Prevention policy, dated April 2021, documented the interdisciplinary fall review team would meet at least weekly and formally address each resident that had fallen during the previous week. The discussion would focus on interventions that have been implemented and other interventions that may be required to reduce falls and meet the resident's needs. The policy further documented, interventions are to be updated on the resident care plan. The facility failed to implement interventions to prevent or reduce falls for cognitively impaired R51, placing the resident at risk for further falls and injury. - The Electronic Medical Record (EMR) for R111 documented diagnoses of diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypertension (high blood pressure), chronic kidney disease (disease of the kidneys leading to renal failure), and chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set, (MDS), dated [DATE], documented R111 had moderately impaired cognition and required supervision and one staff assistance for dressing, toileting, and supervision with set up assistance for bed mobility and transfers. The MDS further documented R111 had unsteady balance, independent with set up assistance for ambulation, no functional impairment, and one non-injury fall since the prior assessment. The Quarterly MDS, dated 09/23/22, documented R111's cognition was not assessed and required extensive assistance of two staff for bed mobility, transfers, toileting, and did not ambulate. The assessment further documented R111 had unsteady balance, no functional impairment, had no falls, and received physical, occupational, and speech therapy services three to five days per week. The Fall Risk Assessments, dated 05/16/22, 08/15/22, 09/15/22, documented R111 was a high risk for falls. The Fall Care Plan, originally dated, 05/29/21, documented R111 may forget to use her call light, so check on the resident frequently, ensure R111 had nonskid footwear one and assist with keeping room clutter free, wear nonskid socks, educate the resident to use her call light, and monitor and remind the resident not to sit or lay on top of her bedding near the edge of the bed or she was at risk to slip off the bed, The update, dated 01/09/22, directed staff to check on the resident every two hours for bathroom needs, and obtain a therapy screen for balance and gait training. The update, dated 01/15/22, directed staff to ensure non-skid footwear/socks are on the resident. The update, dated 01/18/22, directed staff to obtain therapy screen for balance and strength for safe ambulation. The update, dated 05/18/22, directed staff to use a hoyer lift (a full body lift that allows a person to be lifted and transferred with a minimum of physical effort) for transfers. The update, dated 07/23/22, directed staff to encourage non skid socks, reeducate to use the call light and ask for assistance. The update, dated 07/28/22, directed staff to ensure personal items are within reach. The Post -Fall Assessment, dated 01/09/22 at 07:12 PM, documented R111 felt weak and fell while attempting to take herself to the bathroom. The resident had poor safety awareness, forgetful, and had a history of falls. The assessment directed staff to obtain a therapy screen for gait training. The Post -Fall Assessment, dated 01/15/22 at 03:24 PM, documented R111 ambulated without nonskid sock on by her bathroom sink. The resident had poor safety awareness and were directed to ensure nonskid footwear or socks were on the resident. The Post -Fall Assessment, dated 01/18/22 at 10:03 PM, documented R111 was fully dressed, lying on the floor with a blanker under her head. The resident did not have nonskid socks on, with the walker lying beside her. The assessment further documented R111 stated she was walking to the bathroom, slipped, and landed on her left knee. The assessment documented R111 obtained a small abrasion (scrape) which measured one-centimeter (cm) x one cm. The resident was reeducated to use her call light for assistance. The assessment directed staff to obtain a therapy screen to continue to work on balance and strengthening and to assist R111 to wear non skid socks. The Post -Fall Assessment, dated 03/18/22 at 08:09 PM, documented R111 stated she sat on the edge of her bed and thought she slid off. The resident did not have non skid socks on. The assessment directed staff to ensure R111 had non skid socks on and non skid strips were placed on the floor at the bedside. The Post -Fall Assessment, dated 04/21/22 at 02:30 AM, documented R111 slid off the bed onto the floor while she attempted to transfer herself to go to the bathroom. The assessment directed staff to continue to provide frequent checks on the resident. The Post -Fall Assessment, dated 04/25/22 at 01:31 PM, documented R111 slid out of bed onto the floor while she attempted to take herself to the bathroom. the assessment directed staff to obtain a therapy screen for bed safety training. The Post -Fall Assessment, dated 05/18/22 at 10:40 AM, documented R111 fell while staff assisted her with a transfer. The assessment documented R111 obtained a small abrasion to her left knee which measured one cm x a half cm. The assessment further documented staff were educated on R111 increased weakness and weight bearing status and she was assisted to bed with three staff assistance. The Post -Fall Assessment, dated 06/04/22 at 11:14 AM, documented R111 stated she fell while she tried to get out of bed. R111 was dressed in her night gown, was incontinent, and had no shoes or socks on. The staff reeducated R111 on the importance to use her call light and to put on non skid socks. The assessment documented R111 was non-compliant with all previous fall interventions and a medical evaluation would be completed. The Post -Fall Assessment, dated 07/23/22 at 01:36 PM, documented R111 stated she tried to shut off her light and fell. The assessment documented staff reeducated R111 on the use of non skid socks and call for assistance. The assessment directed staff to continue current plan of care. The Post -Fall Assessment, dated 07/28/2 at 04:17 PM, documented R111 stated she leaned over to grab an envelope, lost control and fell. The assessment documented R111 obtained rug burns to both of her knees. The assessment directed staff to continue current plan of care. On 10/20/22 at 08:45 AM, observation revealed R111 in bed with pressure reducing boots on both feet. Further observation revealed Certified Nurse Aide (CNA) O and CNA QQ in room to assist with a transfer out of bed and into her wheelchair. Further observation revealed the sling for the lift was already under R111 and CNA O attached it to the lift. Continued observation revealed R111 was raised up off the bed with the lift and taken to her wheelchair and lowered into the seat as CNA QQ tilted the wheelchair back so the resident would sit comfortably in the wheelchair. Observation revealed there were no nonskid strips beside the resident's bed. On 10/20/22 at 08:45 AM, CNA O stated R111 had a lot of falls because she did not use her call light and they always tell her she needs to use her call lights. On 10/24/22 at 10:15 AM, Licensed Nurse G stated they reeducate her to call, check on her hourly, and tell her not to get up by herself. LN G further stated R111 thinks she can get up by herself but her functional status has changed, staff put nonskid socks are her, lower her bed, and she was a two person mechanical lift. On 10/24/22 at 01:00 PM, Administrative Nurse D stated all falls should have new interventions after review of the fall. Administrative Nurse D further stated, all falls are reviewed weekly during fall huddle. The facility Fall Risk/Prevention policy, dated April 2021, documented the interdisciplinary fall review team would meet at least weekly and formally address each resident that had fallen during the previous week. The discussion would focus on interventions that have been implemented and other interventions that may be required to reduce falls and meet the resident's needs. The policy further documented, interventions are to be updated on the resident care plan. The facility failed to implement interventions to prevent or reduce falls for R111, placing the resident at risk for further falls and injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 118 residents. The sample included 25 residents with one reviewed for medically related social service needs. Based on observation, interview and record review the facility failed to provide routine social services visits as care planned for Resident (R) 13. This deficient practice placed her at risk for further behavior and potential for rehospitalization. Findings included: - Resident (R) 13's Electronic Medical Record included diagnoses of stroke, hemiparesis (paralysis of one side of the body), diabetes mellitus (an impairment in the way the body regulates and uses sugar (glucose), chronic pain, bipolar disorder (mental illness that causes unusual shifts in mood, energy), post traumatic stress disorder (PTSD- disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R13 had moderate cognitive impairment and behaviors including physical, verbal and rejection of care every one to three days of the lookback period. The MDS documented the behaviors placed the resident at risk for illness or injury. R13 required limited staff assistance with eating and extensive staff assistance for all other activities of daily living (ADL). R13 had range of motion (ROM) impairment in one upper and one lower extremity, was always incontinent, no pain management, and received antianxiety ( medication used to treat anxiety), antidepressant ( medication used to treat mood disorders), antibiotic (medication used to treat bacterial infections), diuretic (substance that promotes diuresis, the increased production of urine, opioids (narcotic pain medication) and insulin (hormone that helps control your body's blood sugar level and metabolism). The ADL Care Area Assessment (CAA), dated 07/17/22, recorded a history of a stroke with left hemiparesis. R13 needed extensive assist of two staff members to complete all ADL tasks. She was bedbound by choice and refused to be transferred (out of bed) despite being educated regarding skin breakdown. She has had episodes of incontinence with staff assisting with incontinence care as needed. Staff will continue to assist with ADL completion and mobility. She was recently hospitalized for altered mental status and urinary tract infection. The Behavior Care Plan, dated 07/19/22, documented R13 resisted care such as bathing, linen changes, up/down schedule, position changes, and other cares. R13 has anxiety which could manifest as clinical symptoms. She had multiple hospitalizations possibly due to high anxiety. The care plan directed staff to ensure routine visits from the Social Worker. The Psychiatric Practitioner Visit Note, dated 07/25/22, documented R13 had a history of wanting to go to the emergency room multiple times. At that time, she was calm, without pain, and no acute nursing concerns. Psychological services were provided via telehealth. R13's medical record contained only two social services notes for 2022. The March 2022 note was related to a snack issue and the August 2022 note was related to a room change. The medical record contained no documentation of social services visits provided by the facility for psychosocial concerns. On 10/19/22 at 09:21 AM, observation revealed R13 in bed using an iPad device. Staff provided incontinence care and noted numerous bloody scratch marks on her left hip and bloody area on left upper buttock. On 10/19/22 at 10:25 AM, Licensed Nurse (LN) H stated R13 was not very cooperative with the skin treatment and yelled. She stated she washed R13's hands and trimmed her fingernails. She stated staff were to provide care for R13 with two present due to R13's behaviors. On 10/24/22 at 01:23 PM, Social Services X verified she discussed R13 at the care plan meeting, but the resident was not present. She stated R13 refused psychosocial services from a provider and stated R13's spouse relayed any concerns the resident had. Social Services Staff X verified she had not performed routine visits to R13 for psychosocial or mental health. On 10/24/22 at 01:24 PM, Social Services Y verified she had not performed routine visits to R13 for psychosocial or mental health and asked if she was supposed to document any interaction she had with R13. On 10/24/22 at 01:30 PM, Administrative Nurse D stated the social services staff should have visited R13 routinely, as care planned, for mental health and well-being. The facility's Care Management policy, dated May 2021, documented responses to therapeutic interventions would be recorded in the progress notes. The facility failed to provide routine social services visits as care planned for R13, placing her at risk for further behavior and potential for hospitalization.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 118 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed to ensure consistent reconciliation of controlled drugs at the end of daily worked shifts for two of six medication carts and failed to ensure availability of physician ordered medication for two days for Resident (R) 70, which placed residents at risk for misappropriation of medications by staff and unmet therapeutic medication regimen. Findings included: - On 10/18/22 at 10:26 AM, observation on the 200-hall medication cart revealed a lack of staff signatures on the Controlled Drug Record at the beginning of the day shift 10/04/22 through 10/07/22 (four days). Certified Medication Aide (CMA) S verified the lack of signatures and stated the Controlled Drug Record should have been signed to indicate the reconciliation was completed. On 10/18/22 at 04:11 PM, observation on the 700-hall medication cart lacked staff signatures on the Controlled Drug Record on day shift 10/02/22, 10/10/22, 10/16/22 and evening shift 10/07/22, 10/11/22, and 10/17/22. CMA R verified lack of signatures the Controlled Drug Record. On 10/18/22 at 04:20 PM, Administrative Nurse D verified staff should complete a reconciliations and sign the Controlled Drug Record at the end of each shift to show the count was completed. The facility's Medications, Controlled Drugs policy, dated 06/2021, documented when controlled keys change hands during a shift, controlled drugs are recounted and the counted record is signed by nurse/certified medication aide. Monitoring of accuracy will be completed routinely by Nursing Administration and Pharmacy. The facility failed to ensure consistent reconciliation of controlled drugs for two of six medication carts which placed residents at risk for misappropriation of medications by staff. - R70's Electronic Medical Record, (EMR) documented the resident had a diagnosis of hyperkalemia (greater than normal amount of potassium in the blood). R70's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) of 13, which indicated intact cognition. The MDS documented R70 required staff supervision with activities of daily living (ADLs). R70's Medication Care Plan, revised 10/02/22, instructed staff to administer her medications as the physician ordered. R70's EMR documented her potassium level was out of normal range (3.5-5.1millimoles per liter (mmol/L) of blood) on the following dates: 04/22/22-6.2 mmol/L 05/31/22-5.4 mmol/L The Physician Order, dated 06/09/2022, instructed staff to administer to R70 Lokelma (medication used to treat high levels of potassium in the blood) 5 gram (g) packet, daily. The Nurse's Note, dated 09/19/2022 at 01:50 PM, documented R70 did not receive the physician ordered Lokelma, 5g daily, for the last two days related to the pharmacy failed to deliver it. On 10/24/22 at 8:00 AM, observation revealed R70 sat in a wheelchair at the nurse's station. On 10/24/22 at 12:19 PM, Licensed Nurse (LN) G stated she reordered residents' medication seven to 10 days before it ran out. LN G stated if a resident was out of a medication, she called the pharmacy and asked the pharmacy to send it stat (right away). LN G stated the facility had been having trouble with the pharmacy failing to send residents medications on time; the medications were often sent to a sister facility or not sent at all. On 10/24/22 at 01:29 PM, Administrative Nurse D stated if a resident was out of a medication, she expected staff to call the physician, family and pharmacy. If the medication continued to be unavailable, she expected staff to keep calling the physician and pharmacy. Administrative Staff D stated the facility had been having trouble with the pharmacy delivering R70's Lokelma; first it was trouble with insurance, then they were not stocking it. The undated Pharmacy Services Policy, documented the facility would provide routine and emergency medications and biologicals (medications developed from blood, proteins, viruses, or living organisms) to its residents through an agreement with United Scripts Pharmacy. The facility failed to ensure availability of physician ordered medications for R70, which placed the resident at risk for ineffective medication management.

The facility had a census of 124 residents. The sample included 24 residents with three reviewed for incontinence care and urinary tract infections (UTI - infection that occurs when bacteria enters into any part of the urinary tract). Based on observation, interview, and record review, the facility failed to provide care and services to prevent urinary tract infections for one sampled resident, Resident (R) 76 when providing incontinence care. Findings included: - R76's Physician Order Sheet (POS) dated 03/22/21, documented a diagnosis of nondisplaced comminuted (producing multiple bone splinters) fracture of shaft of right tibia (front bone in the lower leg). The admission Minimum Data Set (MDS) dated 03/29/21 documented the resident had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of nine. The MDS documented the resident required extensive assistance of one to two staff with toileting. The Urinary Care Assessment (CAA), dated 03/29/21, documented the resident admitted with a urinary catheter (a closed urinary drainage system inserted into the bladder) for difficulty with retention of urine when in the hospital. The urinary catheter would be discontinued on 03/29/21 and staff would provide toileting assistance with incontinence care. The Urinary Incontinence Care Plan, dated 05/17/21, directed the staff to offer, remind, or assist R76 to use the bathroom in the morning, before meals, after meals, before bed, and as needed. Staff were directed to provide peri care after any incontinence episode. The Urinary Analysis, dated 05/06/21, documented the need for a culture and the bacteria identified was susceptible to amoxicillin (antibiotic). The Electronic Medical Record (EMR) documented amoxicillin 500 milligrams (mg) three times a day for seven days started on 05/10/21 The Nurses Note, dated 05/10/21, documented amoxicillin given for UTI and urine tea colored with no blood in the catheter bag. The Physician Order, dated 05/12/21, directed staff to remove the catheter tomorrow in the morning. The Nurses Note, dated 05/13/21, documented R76 returned from her appointment and had a large amount of output and was incontinent of urine. On 05/19/21 at 02:15 PM, Certified Nurse Aide (CNA) M provided perineal care for R76. The resident was lying in bed and with urine soaked pants. CNA M stated the resident refused perineal care earlier that morning. CNA M washed her hands, donned gloves, and took off the resident's soiled pants and brief. CNA M provided perineal care from front to back using different wipes. CNA M did not change her gloves and proceeded to apply a new brief and new pants with soiled gloves. After completion of incontinence care, CNA M threw her gloves away and washed her hands. On 05/20/21 at 02:30 PM CNA N assisted R76 with perineal care. The resident's pants were soiled with urine in the front. CNA N stated the resident refused perineal care earlier this morning. CNA N washed her hands, donned gloves, and assisted the resident with removal of the soiled pants and brief. CNA N provided perineal care using different wipes, wiped front to back, assisted the resident with soiled gloves to turn on to her side, and cleaned the resident's buttocks. CNA N placed the clean brief under the resident using soiled gloves. She then threw the gloves away, washed her hands, and donned new gloves to assist the resident into clean pants. On 05/19/21 at 02:15 PM, CNA M stated she did not know how often staff should provide perineal care on the resident, but should be several times a shift. The resident refused incontinence care because she just wanted to stay up in her chair and not have to get back into bed for the care. CNA M stated the resident was incontinent of urine all of the time when she provided perineal care, and she failed to change her gloves or wash her hands after cleaning the resident. On 05/20/21 at 02:30 PM, CNA N stated that she was unsure how often perineal care should be performed, but should be several times throughout the shift. On 05/24/21 at 01:30 PM, Administrative Nurse D stated that she would expect the CNAs to perform hand hygiene after providing the incontinence care and should change gloves before touching anything that was clean. The Hand Washing policy, revised January 2017, stated handwashing should be completed after handling any contaminated items (linens, soiled diapers, garbage, etc). The facility failed to provide incontinence care in a sanitary manner for R76, placing her at risk for development of UTIs.