**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility failed to ensure residents were notified of changes to services covered by Medicare and/or Medicaid as soon as possible for one of three sampled residents reviewed for appeal writes (Resident (R)38). R38 received therapeutic services; however, the facility failed to inform the resident in writing of the end date to services or of their right to appeal. The findings include: During the task of Beneficiary Notification Review, the State Survey Agency (SSA) determined for the three residents selected, there was no documented evidence one of the residents received form CMS 10055 (Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage) or form CMS 10123 (Notice of Medicare Non-Coverage). Continued review revealed, of the three residents, one resident was voluntarily discharged from services as family elected hospice services (R125). Per review, a second resident opted to discharge from services and returned home with home health with almost two weeks remaining (R126). Further review revealed one resident (R38) should have received both the CMS 10055 and CMS 10123; however, did not receive that documentation. Review of R38's medical record revealed the facility readmitted the resident from the hospital on [DATE]. Continued record review revealed R38 was scheduled to receive Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) under Medicare Part A payment. Review of the resident census revealed R38's last covered day under Medicare Part A was 10/25/2024. However, further record review and review of facility documentation revealed no evidence the facility issued or resident representative was provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) or form CMS 10123 Notice of Medicare Non-Coverage (NOMNC) form. In interview on 11/20/2024 at 9:24 AM, the facility's Admissions Coordinator (AC) stated R38 was not given a SNF ABN or NOMNC as she had not been informed or included in the email which was how she was notified of that information. She said since she had not received the email, she had no idea the resident or family should have received the SNF ABN and NOMNC letters. The AC reported it was important the letter(s) were available for informing both staff and the resident of the end date of the resident's skilled services. She further stated it was also important as well for providing residents or families other billing options for continued services or the opportunity to appeal if they desired to do that. In interview on 11/21/2024 at 1:09 PM, the Interim DON stated the SNF ABN and NOMNC were forms the facility completed. She stated she expected those forms to be discussing the resident's progress in morning meeting prior to the end of services for the resident receiving services. The Interim DON said the SNF ABN and NOMNC were important for payment of care residents were receiving, so that residents or family members could file an appeal if they felt services were still needed. She further stated the expectation was for residents or their responsible parties to be alerted in a timely manner so they had opportunity to respond. In interview on 11/21/2024 at 2:09 PM, the Interim Administrator stated the NOMNC should be issued to the resident or responsible party as appropriate, and should be issued prior to the cut off date. She stated the NOMNC was to be provided in order for the resident or responsible party to have time to respond and to have a plan for a safe discharge or to appeal. The Interim Administrator said she had only been at the facility four or five days, and did not know the facility's process for beneficiary notification. She further stated her expectation was for it to be issued timely, with the facility maintaining a copy, in addition to, those provided to the resident or responsible party. The Interim Administrator additionally stated the AC would be receiving training on her role in the SNF ABN/NOMNC process.

Based on interview, record review, and facility policy review, the facility failed to ensure residents requiring dialysis services, received those services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one of one residents sampled for dialysis services, out of the total sample of 26 residents, (Resident (R)425). The facility failed to ensure there was documented evidence of ongoing assessments of R425's condition and monitoring for complications before and after dialysis treatments was done. The facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding R425's dialysis care and services was completed. The findings include: Review of the facility's policy titled, Dialysis Policy, undated, revealed, pre and post dialysis assessments will be completed for each visit. Continued policy review revealed the thrill and bruit were to be monitored and documented per the dialysis assessment and as needed. Further review revealed the dialysis shunt/fistula was to be monitored on a regular basis by nursing staff. Review of the facility document, Dialysis Communication Form, for R425's dialysis, revealed there were only four forms located. Further review revealed no documented evidence of post dialysis assessments completed. Review of R425's face sheet, located in the electronic health record (EHR) revealed the facility admitted the resident on 11/08/2024, with diagnoses of Congestive Heart Failure. Continued review of the EHR revealed End Stage Renal Disease with Hemodialysis was listed in R425's medical diagnosis list. Review of R425's Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 11/19/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine out of 15, indicating moderate cognitive impairment. Review of R425's comprehensive care plan 11/13/2024, revealed the facility care planned the resident for dialysis with a goal of no signs/symptoms of complications from dialysis through the next review date of 02/06/2025. Continued review revealed the interventions included checking the arteriovenous (AV) fistula for thrill and bruit which was added on 11/15/2024. Review of R425's physician orders revealed an order dated 11/15/2024, to obtain a full set of vital signs every day with parameters to notify the physician for a systolic blood pressure (B/P) greater than 170 or less than 90 and a pulse greater than 120 or less than 50. Continued review revealed a physician's order dated 11/21/2024, for the dialysis shunt in the resident's left upper arm to be assessed for thrill and bruit every day and night. Further review revealed a physician's order also dated 11/21/2024, to obtain R425's weight prior to dialysis and document on the dialysis communication form to send to dialysis with the resident on day shift every Monday, Wednesday, and Friday. Review of R425's progress notes dated: 11/11/2024, 11/13/2024, 11/15/2024, 11/18/2024, and 11/20/2024, revealed the only date that post dialysis vital signs were completed was on 11/15/2024. Further review of the 11/15/2024 note revealed no documentation addressing the resident's dialysis fistula site. The State Survey Agency (SSA) Surveyor requested pre/during/post dialysis assessment communication information, but the facility was unable to produce all the dialysis pre/during/post dialysis assessment communications. The SSA Surveyor received five communication forms of which four were not completed. (According to R425's dialysis schedule, the resident should have received five dialysis treatments before the SSA exited on 11/22/2024.) During interview on 11/20/2024 at 8:20 AM, Licensed Practical Nurse (LPN) 5 stated she assessed the fistula sites on dialysis residents when they left for dialysis and when they returned to the facility. However, additional review of R425's EHR revealed no documented evidence of assessment of the resident's fistula for 11/11/2024, 11/13/2024, and 11/18/2024. Further review of R425's EHR review, after the interview with LPN5 on 11/20/2024, revealed the LPN had documented an assessment of the resident's fistula in a progress note for that date. During interview on 11/20/2024 at 11:53 AM, Registered Nurse (RN) 4 stated the dialysis communication forms and reassessments were not done consistently. RN4 said the form did not appear for use until the end of October after she brought it to the facility's leadership's attention. She stated the front desk let the nurses know when a resident returned from dialysis. The RN reported after a dialysis resident returned she obtained a set of vitals (vital signs); checked the resident's fistula site and glucose; provided food if the resident had not eaten; and asked if the resident wanted to do activities. She said R425 never wanted to participate in activities after his dialysis. RN4 stated R425 was always confused after dialysis and would not take his medications until he spoke to his daughter. She reported R425 would also get aggressive, and staff would have to stay with him for about 30 minutes. The RN stated the parameters for residents' vitals were not listed in their care plan. She said however, with her history of working with dialysis residents, she felt the parameters should be on the care plans. RN4 further stated she had not received any training by the facility, but had received training at her previous place of employment. In interview on 11/20/2024 at 2:06 PM, LPN5 stated she received dialysis training/CEU's through the agency she worked for. She further stated she had not received any training by the facility. In interview on 11/21/2024 at 9:07 AM, State Registered Nurse Aide (SRNA) 5 stated she had not worked with a lot of dialysis residents, and said, most of what I would do is get them ready for dialysis. SRNA5 said she got the dialysis residents dressed and in a wheelchair and took them to the front of the building to wait for their transportation. She stated she had not received any training and that every resident got a full set of vitals taken on Tuesdays. The SRNA reported she knew not to get a B/P in the arms residents had any implantable device in. She further stated, the nurse would let us know if we couldn't use a side. During interview on 11/21/2024 at 9:14 AM, LPN6 stated she had only taken care of R425 once in the past. She said for dialysis residents she would check their vitals, glucose, and fistula site every day. The LPN stated she had not received any recent education; however, looked things up herself when she got something she had not had in a while. She stated she looked at resident's care plans for their parameters. LPN6 reported she obtained all her residents' vitals herself because we don't have full time staff. She said she did not know the SRNA's and said, they could go in there and tell me anything. The LPN stated if a resident's vital signs were saved incorrectly, the system would not let you undo the charting. She further stated when R425 returned from dialysis I would write a nurse's note because the Dialysis Communication Form was just a piece of paper that could get lost. In interview on 11/21/2024 at 9:42 AM, the MDS Nurse stated the parameters for vitals being in dialysis residents' care plans was important in order for staff to know the resident's normal/baseline and when any changes were going on. She stated the communication forms between the dialysis clinic and the facility were not being completed as required. The MDS Nurse further stated however, the communication form was important because it was a good tool for communication between the clinic and facility. During interview on 11/21/2024 at 10:05 AM, the Quality Assurance (QA) Nurse stated the facility rarely has dialysis residents and that all of our staff are certified and should know how to care for dialysis residents. When the State Survey Agency (SSA) Surveyor asked the QA Nurse about what education staff had received from the facility regarding dialysis, she indicated she was unable to answer that question and the facility had no process in place to ensue that. She stated she did not provide any education or training to staff; however, when asked who provided education she said Probably me . When asked why having trained, qualified staff was important she stated, Dialysis residents are fragile and definitely need to be monitored closely. The QA Nurse further stated the issue would be addressed in clinical meetings going forward. In interview on 11/21/2024 at 10:45 AM, the Interim Director of Nursing (DON) stated the parameters for vitals should be included on residents' care plans. She stated a new process was being put into place for dialysis residents. The DON reported the communication between the dialysis clinics and the facility was not being done; however, a new form had been created and was awaiting the board's approval for use. She further stated communication between dialysis and the facility was important, Because it tells you everything you need to know and if there are any new issues. During interview on 11/21/2024 at 10:45 AM, the Interim Administrator stated residents should be care planned appropriately to include whatever parameters the provider wanted for that (dialysis) resident. The Interim Administrator said a new process was being worked on currently. She stated communication between the dialysis clinics and the facility should be done consistently for resident safety. The Interim Administrator further stated a new communication form had been created and she was awaiting the board's approval for its use.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure all drugs used in the facility were labeled in accordance with professional standards. Observation revealed undated, opened medications, found in one of four medication carts, which included laxatives, cough medication, and nasal sprays. The findings include: Review of the facility's policy titled, General Dose Preparation and Medication Administration, dated 12/01/2007, and revised 01/01/2013, revealed, Once any medication or biological package is opened . the facility was to follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Per policy review, facility staff were to record the date opened on the primary medication container (i.e., vial, bottle, inhaler) when the medication had a shortened expiration date once opened. Further review revealed facility staff were to also comply with applicable law and the State Operations Manual when administering medications. Observation on 11/20/2024 at 3:30 PM, revealed the Unit 3 medication cart contained opened, undated medications. Per observation the medications included: Flonase (steroid) inhalers Resident (R)5, R12, and R29; Ipratropium Bromide nasal spray for R12; Milk of Magnesia (laxative) and Geri-Tussin (cough syrup) for R56, Keppra (seizure medication) for R33, and Guaifenosorb (used to treat chest congestion) for R29. During interview on 11/20/2024 at 3:30 PM, Kentucky Medication Aide (KMA) 2 stated she did not know the actual medication container needed to be dated. During an interview on 11/21/2024 at 9:14 AM with Licensed Practical Nurse (LPN) 6, she stated medications should be dated when they are opened to ensure they are not used after expiration date. She revealed that any opened medication that was undated should be discharged and reordered by the pharmacy. During interview on 11/21/2024 at 10:45 AM, the Interim Director of Nursing (DON) stated it was her expectation of staff to date any opened medication. She further stated that was so staff would know when the medication expired. During interview on 11/21/2024 at 10:50 AM, the Interim Administrator stated it was her expectation that staff would follow the facility's medication policy and date medications when they were opened for residents' safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of facility policy, the facility failed to have systems in place to ensure there were an adequate number of staff always present who were properly trained and/or certified in Cardiopulmonary Resuscitation (CPR) for Healthcare Providers to be able to provide CPR until emergency medical services arrived. The deficient practice had the potential to affect all facility residents who required CPR. The findings include: Review of the facility's policy titled, CPR Certification, dated 01/2020, revealed all licensed nurses were responsible for obtaining a Basic Life Support (BLS) CPR certification from an accredited licensing agency. Per review, all Kentucky Medication Aides (KMA) were also responsible for obtaining a Basic Life Support (BLS) CPR certification from an accredited licensing agency. Review of the facility's list of all its nurses and KMA's with CPR certification, provided by the Interim Director of Nursing (DON), revealed eight nurses currently employed had expired CPR certifications. Per review of the list, two of the nurses, Licensed Practical Nurse (LPN) 2 and LPN6, were being staffed as charge nurses on [DATE]. During interview on [DATE] at 11:53 AM, Registered Nurse (RN) 4 stated several staff members in the building had expired CPR certification. She stated she knew that because her license had recently expired. RN4 reported prior to her CPR certification expiring, she went to Infection Preventionist (IP) Nurse to let her know. She stated the IP told her she had to get a class together because several employees' CPR certification had expired. RN4 stated however, a CPR class was never offered and her CPR certification expired. She further stated she ended up going to an outside company to renew her CPR certification, but she had worked as a charge nurse for one week with it expired. During interview on [DATE] at 2:00 PM, the IP Nurse stated she provided classes for CPR certification; however, it was not part of her job duties to keep up with who had expiring certification. During interview on [DATE] at 9:14 AM, LPN4 stated she did not know her CPR certification had expired. She stated she was attending a CPR class on that date provided by the IP Nurse. During interview on [DATE] at 10:05 AM, the Quality Assurance (QA) Nurse stated she was not the one responsible for keeping a record of CPR certifications for staff. She further stated she was not sure whose responsibility it was to do that. During interview on [DATE] at 10:34 AM, the Scheduler/Staff Coordinator stated, I do not keep up with CPR certifications of full-time staff. Agency staff falls on me. I would assume it would be the IP because she does the classes. She stated, I check agency and keep up with agency [staff]. The Scheduler/Staff Coordinator further stated it was important to have staff qualified with active CPR certification, Because when you have a code you need to know how to respond, it's good to be up to date with what studies show works best. During interview on [DATE] at 10:45 AM, the Interim DON stated the two nurses currently working today (LPN2 and LPN6) with expired CPR certifications now had active CPR certifications. She said the IP Nurse taught a class and got them re-certified. The Interim DON further stated the IP Nurse would now be the person responsible for keeping up with staff's CPR certifications and the expiration dates. During interview on [DATE] at 10:50 AM, the Interim Administrator stated it was her expectation that all nurses had active CPR certifications for the safety of all the residents.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure each resident received food and drinks which were palatable, attractive, and at a safe and appetizing temperature for five of nine sampled residents reviewed for food temperatures (Residents (R)68, R29, R9, R65, and R58). During resident council, residents expressed concerns of their food being served cold when the aides passed their trays. Observation of the lunch meal on 11/20/2024, revealed the beef and noodle entree and vegetable medley were not at an appetizing and acceptable temperature. The findings include: Review of the facility's policy titled, Food Temperatures, dated 2003-2004, revealed the appropriate serving temperature (temp) of hot foods was for the food to be over 140 degrees (140°) Fahrenheit (F) for hot foods. Review of the facility's Room Test Tray Evaluation Form, undated, noted the acceptable point of service (POS) temp for hot foods was 135° to 160° F. Review of the facility's form titled, Food Temperatures, undated, revealed the POS temp for hot foods was 115 to 125 degrees F. Review of the Test Tray Report Form, undated, (provided after review of the Room Test Tray Evaluation Form) noted the acceptable POS temp was greater than 120° F for hot foods, and less than 45° F for cold foods. Review of the facility's Resident Council Meeting Minutes, dated 08/05/2024, revealed a resident (R68) complained about the food being cold when the aides passed out trays. Per review, the resident who complained resided on the facility's Unit 2. Review of the Resident Council Meeting minutes dated 10/07/2024, revealed two residents (R68 and R29), who both resided on Unit 2, complained of their food being cold when it was delivered to their rooms. Review of the Resident Council Meeting minutes dated 11/04/2024, revealed R68 and R29 both reported their concerns regarding cold food. Continued review of the 11/04/2024 minutes revealed it was noted the residents' concerns had not been resolved and was an ongoing issue. During the Resident Group meeting held on 11/18/2024 at 3:30 PM, with nine residents in attendance, four residents complained about cold food. R9, from Unit 2, stated during the meeting the food was always cold, because it sits out in the hallway and gets cold. R9 additionally stated staff said they could not reheat the food. R29 also stated during the meeting, the food was always cold and R65, from Unit 1, agreed the food was always cold. R58, from Unit 2, also stated the food was only ever warm at best. Observation on 11/20/2024 at 11:30 AM of the steam table temperatures taken for food for the Unit 1, Cart 1 revealed: beef entrée temp was 192° F; starch temp (noodles) was 186° F; and vegetable temp was 191° F. The Unit 1, Cart 1 was observed to leave the kitchen at 11:48 AM, and arrived on the unit at 11:52 AM. Observation revealed the last tray was delivered at 12:04 PM. The SSA Surveyor checked the palatability of the test tray at 12:04 PM, and determined both the entrée/starch (beef and noodles) and vegetable medley had cool temperatures. Observation of the temp checks for the test tray food at POS was: 125° F for both the entrée and starch, and 120° F for the vegetable medley. In interview on 11/20/2024 at 12:43 PM, the Dietary Manager (DM), when asked about the large drop in food temps from the tray line to the POS, she stated staff were up and down the hall multiple times opening and closing the food cart. The DM reported however, she was not certain that caused the food temps to drop. She stated she would have another test tray on Unit 1 tomorrow at lunch to see if the issue was isolated. Review of the Test Tray Report Form for lunch service on 11/21/2024, revealed the Unit 1, Cart 1 was loaded at 11:33 AM, was on the unit at 11:37 AM, and the last tray was delivered from the cart at 11:54 AM. Review revealed it was a total of 17 minutes on the unit or 21 minutes from the time the cart was prepped until the time the last tray was delivered. Review of the food temps on the Report form revealed: the starch (potato wedges) was 182° F on the steam table, but was 120° F at the POS; milk was 37° F on ice in the kitchen, but was temping at 47° F at POS. In follow up interview on 11/21/2024 at 10:54 AM, the DM stated she had used the wrong form yesterday, which was the Room Test Tray Evaluation Form. She stated the correct form was the Test Tray Report Form. The DM reported that, according to measures on the correct form, the entree yesterday had been in an acceptable range at 120° F, and the vegetable had been bordering on acceptable range. When asked by the SSA Surveyor if the DM had been able to determine why the food temps dropped so greatly yesterday from the steam table to POS, she said she was uncertain. In additional interview on 11/21/2024 at 12:42 PM, with the DM following the lunch service, she reported the entree (fish) temp was 136° F; the vegetable (potato wedges) at 120° F; cole slaw at 41° F; coffee at 130° F; and milk at 47° at POS. When the DM was asked about the vegetable being below the desired temp of greater than 120° F, she stated they were not as dense and tended to lose their temp a lot faster. She stated there was only one aide and one nurse delivering trays on the floor at lunch service on Unit 1, as both other aides had been providing resident care at the time. The DM stated she was going to have maintenance look at the plate warmer to see if the temp could be increased, as a hotter plate might make a difference. When the DM was asked about the residents' complaints brought up in resident council meetings, the DM said those were reported to the dietician, who did test trays and had not noted any food temp concerns. In interview on 11/21/2024 at 1:02 PM, the Interim Director of Nursing (DON) stated she had not heard any concerns about cold food in her eight (8) days at the facility. She stated her expectation was that residents be satisfied with their food and the temperature of it. The Interim DON further stated she expected residents' food to be delivered to them warm. In interview on 11/21/2024 at 2:16 PM, the Interim Administrator stated in the short time she had been in the facility, no one had expressed concern to her regarding food temps. When the SSA Surveyor shared with her the various conflicting standards for expected food temps at POS, she stated her expectation was for there to be consistency in policy on what the facility's expectations were. She further stated the food temperatures should be acceptable to residents, with residents never getting cold food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, the facility failed to treat each resident with respect and dignity, and care for each resident in a manner and environment that promoted maintenance or enhancement of his/her quality of life, recognizing each resident's individuality for the total census of 74 residents, which included (Resident (R)3, R6, R9, R21, R41, R55, and R67). On 08/29/2024, and 09/04/2024, the sample result for the Unit 2 shower showed legionella non-pneumophila at poorly controlled growth levels. Staff interviews revealed the facility failed to provide showers for residents starting in early September 2024, due to the showers on Unit 1, Unit 2, and Unit 3 being closed. During that timeframe residents were only offered bed baths. Recommendations were made by the independent water systems company (IWSC) and the certified water safety and management expert (CLWSE) to bring in portable showers as a temporary measure in order for residents to have the opportunity to shower; however, the facility declined to do that. Review of an electronic mail (e-mail) sent on 09/18/2024, from the facility's Infection Preventionist (IP) to the Director of the Local Health Department (LHD), revealed the facility inquired about reopening the showers on Units 1 and Unit 3 for resident use as those showers no longer showed detectable levels of Legionella pneumophilia bacteria. Per the email, the LHD Director noted if there was no detection of legionella in those showers, there was no reason residents could not use them. However, the showers on Units 1 and Unit 3 were not opened for resident use until October 2024. Resident interviews revealed they were not sure why they could not take showers as they had not been informed of any water concerns. The resident interviews revealed they missed taking their showers as bed baths only made them feel partially clean. Refer to F880 The findings include: Review of the facility's policy titled, Resident Rights, undated, revealed the resident had a right to a dignified existence with access to services inside the facility. Per review, the resident had the right to receive care in a manner and in an environment that promoted the maintenance or enhancement of his or her quality of life. Further policy review revealed the resident had the right to receive services in the facility with reasonable accommodation of resident needs and preferences. Review of the facility's policy titled, Complete and Partial Bed Bath, undated, revealed all residents were bathed as often as necessary to maintain cleanliness, refresh, stimulate circulation, and prevent disease and infection. Continued review revealed a bed bath was to be given to residents who were unable to bathe themselves. Further review revealed a bed bath was given daily and/or as needed depending upon the condition and desires of the resident. Review of the microbiology analysis report dated 08/29/2024, performed by a third party IWSC to test for legionella, revealed the Unit 2 shower showed legionella non-pneumophila at 1.0 colony forming units per milliliter (CFUs/ml) with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth. Continued review of the microbiology report dated 09/04/2024, revealed the sample result from the Unit 2 shower showed legionella non-pneumophila at 1.0 CFUs/ml with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth. 1. Review of R55's Face Sheet located in the resident's electronic medical record (EMR) revealed the facility admitted the resident on 12/16/2022 with diagnoses to chronic obstructive pulmonary disease (COPD), acute respiratory failure, and unspecified osteoarthritis. Review of the Annual Minimum Data Set (MDS) Assessment for R55, with an Assessment Reference Date (ARD), of 09/13/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of eight out of 15, which indicated moderate cognitive impairment. Continued review revealed the facility also assessed R55 to require partial to moderate assistance (helper doing less than half the effort) with bed baths/showers. Review of R55's Comprehensive Care Plan (CCP), dated 08/20/2024, revealed the facility identified the resident as having an activities of daily living (ADL) self-care performance deficit. Per review, interventions included R55 needed a weekly shower and partial bed baths all other days with the assistance of one staff. Further review revealed interventions initiated on 11/14/2022, included R55 was able to specify her preference for bathing or showering. During interview with R55's Family (F)1, on 10/03/2024 at 10:32 AM, he stated there had been ongoing water contamination at the facility for at least four weeks. He stated however, he had not been notified of the water situation and only became aware of it after asking the Administrator about it directly. F1 stated showers were not available, and the Administrator told him the Local Health Department (LHD) and the Kentucky Department for Public Health (KDPH) had been discussing when the facility could resume shower usage for residents. He stated the Administrator informed him legionella bacteria had been detected in Unit 2's shower during a test. He reported the Administrator told him the issue of whether there was a risk to residents if they used the shower on the second floor was being discussed. F1 stated according to what the Administrator told him, neither the LHD nor the KDPH had provided the facility with a clear answer on whether to open the showers. He further stated he purchased water for R55, so she would have clean water to wash her hands and face and use it to brush her teeth, as the facility only provided water for drinking. During interview on 10/09/2024 at 3:43 PM, R55 stated she did not realize how mentally and physically refreshing a shower was and how much she missed getting her showers over the past month. She stated, I had my shower on Sunday, and it was wonderful. Additionally, R55 stated the bed baths had never made her feel completely clean. 2. Review of R41's Face Sheet located in the EMR, revealed the facility admitted the resident on 05/26/2023, with diagnoses to include chronic obstructive pulmonary disease, anxiety disorder, and other specified depressive episodes. Review of the Quarterly MDS Assessment for R41, with an ARD of 09/18/2024, revealed the resident had not been assessed for mental status. Continued review revealed the facility assessed R41 to require partial to moderate assistance with bed baths/showers. Review of R41's CCP, dated 09/12/2024, revealed the facility identified R2 as having an Activities of Daily Living (ADL) self-care performance deficit and to require the assist of one staff for help with bathing/showering. Further review revealed no documented evidence of interventions in place related to the resident's preference for bathing or showering. During interview on 10/03/2024 at 1:20 PM, with R41's F2, she stated she was not aware the resident had not received showers in over a month. She stated the facility should have contacted her about the resident not getting showers. F2 further stated, It makes me upset that they did not communicate that to me. Additionally, F2 stated, it was not right that the residents were not provided showers for weeks. 3. Review of R9's Face Sheet located in the EMR revealed the facility admitted the resident on 11/19/2014, with diagnoses to include cerebral infarction, type 2 diabetes mellitus, and frequency of micturition (process of expelling urine from the bladder). Review of the Quarterly MDS Assessment for R9, with an ARD of 09/18/2024, revealed the facility assessed the resident to have a BIMS score of 11 out of 15, which indicated moderate cognitive impairment. Continued review revealed the facility also assessed R9 to require partial to moderate assistance with bed baths/showers. Review of R9's CCP, dated 08/20/2024, revealed the facility identified R9 as having ADL self-care performance deficit, and was totally dependent on one staff to provide showers weekly and bed baths all other days. Further review revealed no documented evidence of interventions in place related to the resident's preference for bathing or showering. During interview on 10/03/2024 at 12:11 PM, R9 stated it had been a while since she had received a shower. She stated, They have had trouble with the showers and the water isn't okay. R9 stated staff currently assisted her with a partial bed bath. The resident said she missed taking her showers and, You just don't get clean [with a bed bath]. Additionally, R9 stated she had been told the facility was not to blame, but the Local Health Department (LHD), was the cause of the resident's shower closure. 4. Review of R21's Face Sheet located in the EMR revealed the facility admitted the resident on 09/12/2024, with diagnoses to include sciatica, morbid obesity, and type 2 diabetes mellitus. Review of the admission MDS Assessment, with an ARD of 09/18/2024, revealed the facility assessed the resident as having a BIMS score of 12 out of 15, which indicated moderate cognitive impairment. Continued review revealed the facility additionally assessed R21 to require substantial/maximal assistance (helper doing more than half the effort) with bed baths/showers. Review of R21's CCP, dated 09/13/2024, revealed the facility identified the resident as having an ADL self-care performance deficit and required assistance of one staff for bathing/showering. Further review revealed no documented evidence of interventions in place related to the resident's preference for bathing or showering. During interview on 10/03/2024 at 11:58 AM, R21 stated she had no idea what was wrong with the facility's water. R21 stated someone had mentioned weeks ago residents could not use the showers, and they had to start getting bed baths. She stated staff assisted her with her bed baths; however, she did not like taking bed baths. R21 stated she missed taking showers, and You just don't get clean with a bed bath. I felt like I smelled. Additionally, R21 stated she had been informed the facility was not to blame for the shower closures; rather, it was the LHD that was responsible. 5. Review of R67's Face Sheet located in the EMR revealed the facility admitted the resident on 04/28/2024, with diagnoses to include type 2 diabetes mellitus, dementia, and personal history of urinary tract infections. Review of the Quarterly MDS Assessment for R67, with an ARD of 09/11/2024, revealed the facility assessed the resident to have a BIMS score of six out of 15, which indicated severe cognitive impairment. Continued review revealed the facility also assessed R67 as independent with bed baths/showers. Review of R67's CCP, dated 08/20/2024, revealed the facility identified R67 as having an ADL self-care performance deficit and required the assistance of one staff for bathing/showering. Review further revealed no documented evidence of interventions in place related to the resident's preference for bathing or showering. During interview on 10/09/2024 at 3:21 PM, R67 stated, the facility's shower system was down and she was not sure why she could not take a shower. Additionally, R67 stated she liked her showers and bed baths only made her feel partially clean and not refreshed. 6. Review of R3's Face Sheet located in the resident's EMR, revealed the facility admitted the resident on 11/21/2022, with diagnoses to include type 2 diabetes mellitus, Alzheimer's disease, and paroxysmal atrial fibrillation. Review of the Quarterly MDS Assessment for R3, with an ARD of 08/22/2024, revealed the facility assessed the resident as having a BIMS score of eight out of 15, which indicated moderate cognitive impairment. Further review revealed the facility also assessed R3 as requiring substantial/maximal assistance with bed baths/showers. Review of R3's CCP, dated 07/15/2024, revealed the facility identified the resident as having an ADL self-care performance deficit, and as totally dependent on one staff to provide a shower at least weekly with partial bed baths all other days as necessary. Further review revealed no documented evidence of interventions in place related to the resident's preference for bathing or showering. During interview on 10/09/2024 at 3:30 PM, R3 stated he was not sure why he could not take a shower, and he had gone a long time without one. Additionally, R3 stated he missed taking showers, and said, I just feel dirty without a shower. 7. Review of R6's Face Sheet located in the resident's EMR, revealed the facility admitted the resident on 03/15/2023, with diagnoses to include cerebral palsy, Hemiplegia right side, and type 2 diabetes mellitus. Review of the Quarterly MDS Assessment with an ARD of 09/09/2024, revealed the facility assessed the resident as having a BIMS score of nine out of 15, which indicated moderate cognitive impairment. Continued review revealed the facility also assessed R6 as dependent (helper doing all of the effort) with bed baths/showers. Review of R6's CCP, dated 08/20/2024, revealed the facility identified the resident as having an ADL self-care performance deficit, and to require the assistance of one staff to provide a shower at least weekly with partial bed baths all other days as necessary. Continued review revealed no documented evidence of interventions in place related to the resident's preference for bathing or showering. During interview on 10/09/2024 at 3:50 PM, R6 stated she did not know what was wrong with the facility's water, but residents had been told they could not use the showers and had to receive bed baths, which she disliked. R6 stated she missed taking showers, and said, You just don't get clean with a bed bath, and I miss getting my hair washed in the shower. I felt dirty. She further stated she had been told the LHD, not the facility, was responsible for the shower closures. Review of an e-mail sent on 09/18/2024 at 7:18 AM, from the facility's Infection Preventionist (IP) to the Director of the LHD, revealed the facility was inquiring about reopening the showers in Units 1 and Unit 3 for resident use as those showers showed no detectable levels of Legionella pneumophilia bacteria. Per review of the email, the LHD Director replied to the facility's IP: if there was no detection of legionella in those showers, there was no reason the residents could not use them. During interview with Licensed Practical Nurse (LPN) 1, on 10/03/2024 at 10:15 AM, she stated there had been no showers for residents for a while. She stated staff used spring water from gallon jugs for both hydration and medication administration. She additionally stated residents and staff were allowed to use water from the faucets for ADL care, such as bed baths, handwashing, and oral care. During interview with Kentucky Medication Aide (KMA) 1, on 10/03/2024 at 11:10 AM, she stated there had been no showers available for residents since September 2024. She stated the facility supplied jugs of spring water for drinking and medication administration. KMA 1 further stated staff used water from the faucets in resident rooms to provide bed baths, washing hands, and oral care. During interview with Registered Nurse (RN) 1 (an agency nurse), on 10/03/2024 at 11:35 AM, he stated he wasn't quite sure why there had been no showers for residents in over a month. He stated he believed the facility provided water for drinking and medication administration. RN1 further stated residents could use water from the faucets in their rooms for bed baths, handwashing, and oral care. During interview, with State Registered Nurse Aide (SRNA) 1, on 10/03/2024 at 11:45 AM, she stated the facility had closed the showers on all units sometime in September 2024. She stated since then residents had not been allowed to take showers, and staff had been providing them bed baths. She further stated the residents were upset they did not get showers. During interview with SRNA5, on 10/03/2024 at 11:49 AM, she stated there had been no showers available for residents since September 2024 due to legionella being in the water. She stated the facility provided water for drinking and medication administration. SRNA5 further stated residents and staff used water from the faucets for bed baths, washing hands, and oral care. During interview with the Quality Assurance (QA) Nurse, on 10/09/2024 at 10:59 AM, she stated she was a member of the facility's water management plan (WMP) team and attended those meetings regularly. She stated the WMP team discussed the water contamination issues and shower use. The QA nurse reported Unit 2's shower was closed and had been closed for about a month to keep residents safe due to the legionella bacteria in the water supply for that shower. She further stated however, she did not know why the Unit 1 and Unit 3 showers were not being used. The QA Nurse additionally stated the showers on Unit 1 and Unit 3 were now open, and residents residing on Unit 2 could use either shower. During interview with the Infection Preventionist (IP), on 10/03/2024 at 3:16 PM, she stated the control measures the facility was taking to protect the residents included providing bed baths instead of showers. She stated since February 2024, the facility had intermittently stopped and started using the showers due to the increased risk to residents. The IP said however, she could not explain why the facility did not utilize the showers on Unit 1 and Unit 3, as those units had no detectable bacteria. She stated recommendations the facility received from the LHD and the KDPH included closing Unit 2's shower while continuing testing and flushing. The IP reported the water was safe to drink, but out of an abundance of caution the facility provided gallon jugs of spring water to use for hydration and medication administration on all units. She said residents, and their families were frequently being updated on the results of the legionella testing, although she could not recall when the facility last notified them of the results. The IP further stated the last communication to staff on the results of legionella testing occurred through a telephone notification in June 2024. During telephone interview with an independent water systems company (IWSC) representative, on 10/11/2024 at 9:58 AM, he stated he had provided third-party water testing and treatment services for the facility. The IWSC representative stated the facility had been seeking guidance from the various health departments to make decisions for them. He stated, after the CLWSE's onsite assessment in September 2024, the facility awaited recommendations and repeatedly inquired about reopening the showers. The IWSC stated the CLWSE sent recommendations to the facility on [DATE], which stated it was the facility's responsibility to make decisions based on their own due diligence. The IWSC said he had suggested the facility bring in portable showers, but the facility opted not to do that. He stated not doing that he believed was detrimental to their situation, as it demonstrated a lack of responsibility for a temporary solution to the problem. The IWSC representative further stated, You can't have a nursing home without showers. During telephone interview with the CLWSE, on 10/04/2024 at 2:42 PM, he stated he had discussed the possibility of using temporary showers; however, the facility opted not to implement that solution. The CLWSE further stated he was unaware of any plans by the facility to manage the future use of its showers. He additionally stated there was no scientific reason not to use the showers based on the recent test results, but the facility still chose not to use the showers. During interview with the Director of Nursing (DON), on 10/08/2024 at 9:21 AM, she stated residents last received showers at the beginning of September 2024, and had since been receiving bed baths. The DON said the facility had waited for confirmation from the LHD regarding the safety of using the showers with no detectable bacteria levels. According to the DON in interview, no detectable levels of Legionella pneumophila were found in the showers on Units 1 and 3, while Legionella pneumophila was detected in the Unit 2 shower. When the State Survey Agency (SSA) Surveyor asked her why residents on Unit 2 were not taken to use the other showers, the DON stated all three shower rooms were closed out of extra precautions. She said the IP emailed the LHD in September 2024 asking if residents could use Units 1 and 3 showers. The DON reported however, the facility had yet to receive definitive instructions about using the showers from the LHD. She further stated she expected staff to follow facility policies in order to protect resident rights, as it was important for their quality of life and well-being. During interview with the Administrator on 10/03/2024 at 10:50 AM, he stated the facility closed all showers in early September 2024 due to positive results for Legionella pneumophila in the water testing. He stated after that, staff provided residents with bed baths instead of showers. The Administrator said it was safe for residents to use water from the faucets in their rooms for washing hands, face, and oral care. He reported although the Unit 1 and Unit 3 showers tested negative for any bacterial contaminants based on the microbiology analysis report dated 09/13/2024, the facility was awaiting the LHD and the CLWSE to confirm all showers were safe for resident use. Review of the microbiology analysis report, performed by a third party IWSC to test for legionella, dated 09/13/2024, revealed testing for the Unit 2 shower showed Legionella non-pneumophila 0.1 CFUs/ml with a detection limit of 0.1 CFU/ml, indicating well-controlled growth. Additionally, review of the microbiology analysis report, performed by a third party IWSC to test for legionella, dated 09/18/2024, revealed testing for the Unit 2 shower showed Legionella non-pneumophila SG1 at 0.4 CFUs/ml with a detection limit of 0.1 CFU/ml, indicating well-controlled growth. During a follow up interview with the Administrator on 10/25/2024 at 12:45 PM, he stated it was his expectation for all staff to adhere to the facility's Resident Rights policy to protect residents' rights to ensure their quality of life. During telephone interview with the Medical Director on 10/25/2024 at 11:01 AM, he stated the facility decided to close the showers until no legionella growth was detected to ensure the residents' safety. He stated further decision that it was his expectation all staff members adhered to the facility's policies and procedures regarding resident rights. The Medical Director further stated protecting resident rights was important to maintaining a high standard of quality of life. During interview with the SSW on 11/19/2024 at 8:01 AM, she stated the issue regarding legionella contamination was brought up by residents who attended the facility's Resident Council Meeting. She stated those residents in attendance were informed about the ongoing issues with contaminated water. The SSW reported she could not recall the specifics of what was discussed or the questions that were asked at those meetings, but she said the residents expressed their understanding of the situation. She stated however, the residents were not informed about the extent of the contamination. When asked by the SSA Surveyor whether all residents had the right to know about the extent of the contamination and what the facility was doing to address it, she responded, I guess. When questioned further about whether the facility had a duty to be transparent with its residents, she stated, Sure. During interview with the Interim Director of Nursing (DON) on 11/21/2024 at 3:45 PM, she stated it was her expectation that all nursing staff follow facility policies and procedures regarding resident rights. She stated protecting residents' rights was important to maintaining a high standard of quality of life. During interview with the Interim Administrator on 11/22/2024 at 2:02 PM, she stated it was her expectation all staff followed the facility's Resident Rights policy to ensure the well-being of all residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, poilcy review, and the facility assessment the facility failed to ensure the licensed nurses and other nursing personnel had the knowledge, competencies and skill sets to provide care and respond to each resident's individualized needs as identified in his/her assessment and care plan. In interview agency staff stated they had not received training or education prior to being assigned to residents' care. The findings include: Review of the facility's policy titled, Resident Rights, undated, revealed residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety to the resident or other residents. Review of the facility document titled, Facility Assessment Tool: [Facility Name], Inc. undated, revealed there was no accommodation for agency staffing in the assessment. Per review of the Assessment, in the section titled, Table 3.1: Staff Competencies and Skills Based in Resident Population, the categories for training/assessment, competency approach, and competency listed licensed nurses, nursing assistants, dietary, environmental services, administration, therapy. However, continued review revealed no categories regarding agency staffing's training/assessment, competency approach, and competency. Continued review of the facility document titled, Facility Assessment Tool: [Facility Name], Inc. undated, regarding Table 3.1 revealed it identified competencies for licensed nurse and nursing assistants were to be assessed during orientation, annually, and pre/post test. During interview on 11/20/2024 at 10:07 AM, the Schedule Coordinator (SC) stated she had been in her position since 08/14/2024, and was also a State Registered Nurse Aide (SRNA) and Kentucky Medication Aide (KMA). She stated her duties at the facility included employee onboarding and orientation. The SC said she had previously worked for a staffing agency and was familiar with the process for using agency staff. Per the SC in interview, for Unit 1, there were four nurse aides staffed, and during breakfast and lunch two of the aides went to the dining room and two stayed on the unit for resident care. She reported there was one Registered Nurse (RN) to cover the residents' needs and one Licensed Practical Nurse (LPN) who strictly passed medications. In continued interview on 11/20/2024 at 10:07 AM, the SC stated staff rotated through on the weekends with in-house and agency staff. She said having agency made things harder because the agency staff might not know the residents as well as facility staff. The SC stated having in-house staff made a difference with residents, and she was working with the Administrator to understand the facility's assessment and how to determine the Hours Per Resident Day (HPRD). She stated she was not currently familiar with the facility's assessment and its purpose. The SC reported when an agency employee started working at the facility, she set them up with a login for the facility's computer system, and agency staff could not pick up a shift if they were out of compliance with their trainings. She stated no one tracked the agency staff, but they were not allowed to provide care to residents if their online training was not current. She said when she was working for an agency, notifications were sent to her to complete necessary trainings or additional education before she was able to pick up shifts. In further interview on 11/20/2024 at 10:07 AM, the SC stated all agency staff were trained by their agency through a computerized training program which incorporated online videos and posttests to determine staffs' competency. She said once agency staff arrived for work at the facility all their training and certifications had already been imported from their agency. The SC reported agency personnel shadowed facility staff to become familiar with the resident, the charting system, and layout of the facility. She further stated agency staff competencies were completed prior to providing resident care, and they were not allowed to care for residents without passing their competencies. The SC also stated the agencies who supplied staffing for the facility were required to validate the credentials of staff who were to work at the facility. During interview on 11/22/2024 at 9:39 AM, LPN3 stated she was and agency nurse and had worked at the facility for a month. She stated the nurse aides who worked on the unit she did were mostly agency, but as they had worked at the facility for a long time, she felt like the aides knew the residents. The LPN said she received no education or training when she started working at the facility, and had not received any competency assessments since she started working. She stated her staffing agency made sure we have all of our trainings up to date. LPN3 reported she had not worked at the facility long enough to know if they provided check offs or had competency trainings. During interview on 11/22/2024 at 12:43 PM, R25 stated the agency staff did not know him or his preferences. He stated agency had to be told what to do, especially at night and on the weekends. R25 further stated, They don't know nothin, I have to tell them everything to do. During interview on 11/22/2024 at 12:51 PM, RN 2 (an agency nurse) stated when R425 came back from the hospital on [DATE], they just dropped him off, and no one told him the resident was being admitted to skilled nursing from where he previously resided on the facility's personal care unit. He reported he texted the former Director of Nursing (DON) and received no response from her, so he called the house supervisor who assisted him. RN2 stated They didn't tell me I needed to do an initial assessment, I thought it was a transfer. He further stated when he told the former DON, she told him nothing, and said, You're basically left on your own. During an interview on 11/22/2024 at 2:01 PM, with RN1 (an agency nurse) he stated he worked on the facility's Unit 2. He stated he was the only nurse working on the unit and must pass medication, do treatments, assessments, discharges and admissions. The RN stated he felt overwhelmed at times, and said the nurse aides on his unit did not know the residents' needs and preferences. He said he was unsure if agency staff knew anything about the residents they were caring for. The RN reported he had not received any training from the facility or the agency he worked fro on competencies. He said when he was hired to work, there had been no education or skills check off, and the facility had not provided any additional skills or assessment verification. RN1 stated agency staff did not ensure continuity of care because some were not qualified or had not received proper training. He further stated he obtained his residents' vital signs because he did not trust the aides to accurately obtain them for him. During interview on 11/22/2024 at 1:15 PM, RN7 stated she had not received any training from the facility when she started. She stated there were a lot of new aides and it was hard to know if they were doing their jobs. The RN stated she had not received training from the agency she worked for; however, had been required to do online education. She further stated the facility had not provided her any skills check off or testing. During interview on 11/22/2024 at 2:04 PM, SRNA21 stated it was her sixth shift working at the facility, two shifts at night and the rest of the shifts during the day. She stated she was just placed on the floor to work with no training or had not been able to shadow another STNA. SRNA21 said she got report from the previous SRNA about her residents and that was it. She stated she completed some computer modules at the agency she worked for, and had been trained on Enhanced Barrier Precautions (EBP). During interview on 11/21/2024 at 1:19 PM, the Interim DON stated there was a huge problem with staffing from an agency stand point. She said she and the Interim Administrator figured the staffing was at 4.25 PPD which was high for the facility with the acuity level of the residents currently. The Interim DON reported we have a lot of agency staff currently, and when she looked at the staffing ratio for the last two days it revealed 68% of the facility's staffing was agency filled. She stated she and the Interim Administrator had presented their concerns to the facility's board of directors as recently as 11/20/2024. The Interim DON further stated with all the agency staff currently, there could not be continuity of care, and the residents needed to know who was going to be taking care of them consistently. During interview on 11/21/2024 at 2:09 PM, the Interim Administrator stated my role in developing the staffing schedule covered working with the Schedule Coordinator to ensure we have enough staffing to provide for the residents' needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility documentation and it 2024 Facility Assessment, it was determined the facility failed to conduct and document a facility-wide assessment to determine the necessary resources for addressing the the ongoing legionella bacterial contamination in the facility's water system. Additionally, the facility failed to address the volume of agency staffing in its assessment to evaluate its resident population and identify resources essential for provision of the necessary care and services of those residents during day-to-day operations and emergencies. Refer to F880 and F726 The findings include: Review of the facility document titled, Facility Assessment Tool: [Facility Name], Inc., dated 06/01/2024, revealed under the Infection Control Risk Assessment section a requirement for a discussion on how the facility evaluated the effectiveness of its infection prevention and control program in identifying, reporting, investigating, and controlling infections and communicable diseases according to accepted national standards. However, continued review of the Infection Control Risk Assessment section revealed it had not been completed, and the facility's leadership failed to address or include legionella under that section of the Assessment when the legionella was first discovered in its water system in January 2024. Continued review of the facility's document titled, Facility Assessment [Facility Name], revealed the facility failed to update its Assessment to reflect the ongoing issues with legionella water contamination. Per review of the Additional Information section of the Assessment, the facility diminished the extent of legionella contamination in its water system, noting the contamination was only at traceable levels. (However, review of the testing documentation confirmed there was poorly controlled and uncontrolled levels of legionella bacteria found throughout the building). Further review of the Assessment revealed the facility noted it was following a Water Management Plan (WMP), (However, the facility's WMP had been determined as insufficient in the State's Division of Epidemiology and Health Planning's (DEHP) recommendations dated 07/26/2024, and communicated by the Local Health Department (LHD) to the facility on [DATE]). Additionally, review of the Assessment revealed the facility noted, The efforts to maintain legionella is ongoing and a collaborative approach with facility staff, contractors, [and the] state and local health department. Review of the DEHP recommendations dated 07/26/2024, revealed the recommendations included the facility needing to continue enhanced surveillance for new cases of legionellosis; to require an on-site water treatment consultant; complete the Water Infection Control Risk Assessment (WICRA); and complete a WMP, which incorporated the Centers for Disease Control and Prevention's (CDC) recommendations with a detailed plumbing diagram. In addition, the recommendations included the requirement for the facility to complete the CDC's course titled, Prevent Legionnaires' Disease, and follow accepted environmental sample protocols. During interview with the Director of Maintenance (DOM) on 11/20/2024 at 10:45 AM, he stated he was not familiar with the facility's Assessment or requirements. During interview with the Infection Preventionist (IP) on 11/21/2024 at 10:10 AM, she stated she was familiar with the facility's Assessment. She stated however, she was not involved in the process of determining its composition regarding infection control and prevention or the Infection Control Risk Assessment. During interview with the Interim Director of Nursing (DON) on 11/21/2024 at 3:45 PM, she stated she did not know why the former administration had not completed the Facility Assessment as required. She further stated in her review of the facility and its operations to date had revealed that there were no systems in place to ensure proper administration of the facility. During interview with the Interim Administrator on 11/22/2024 at 2:02 PM, she stated she did not know why the former administration had not completed the Facility Assessment as required. She stated the Infection Control Risk Assessment section should have been completed to describe the facility's current infection control risks, to include the ongoing legionella bacterial contamination in the facility's water system. The Interim Administrator further emphasized the need for a comprehensive assessment of the facility to adequately address the needs of the resident population and ensure the necessary resources for providing care and services. 2. Review of the facility's document titled, Facility Assessment Tool: [Facility Name] Inc dated 06/01/2024, revealed no documented evidence of an accounting for agency staffing located in the Assessment. Per review of the Assessment, it only addressed staff positions such as Registered Nurse (RN), Licensed Practical Nurse (LPN), and State Registered Nurse Aides (SRNA's)are direct care providers. Review of the facility's staffing sheets for the week of 11/18/2024 to 11/22/2024, revealed agency staffing personnel comprised 68% of the 24-hour staffing assignments for the facility. During interview on 11/20/2024 at 8:54 AM, Registered Nurse (RN) 4 stated the continuity of care for residents was not being addressed by the facility. She reported some of the agency SRNAs were not properly trained and the facility did not provide training for the agency staff before they started working on the floor. During interview on 11/20/2024 at 10:18 AM, the Schedule Coordinator (SC) stated agency staff received onboarding and orientation training from their staffing agencies before starting to work on the floor at the facility. She stated having agency staff made it harder because agency might not know the residents as well as staff employed by the facility. The SC reported a staff member called out (not reporting for work) that morning and she was able to fill the position with another in-house staff person. She further stated having in-house staff made a difference with residents and continuity of care. In interview on 11/22/2024 at 9:39 AM, LPN3 stated she was an agency nurse and had worked at the facility for a month. She stated she and the nurse got report from the previous shift nurses every morning on their residents. LPN3 stated the nurse aides who worked on the unit were mostly agency, but because they had been working here for a long time, she felt like they knew the residents. She reported she had received no education or training when she started at the facility. The LPN said she had not received any competency assessments from the facility since she started working there. She stated the staffing agency made sure we have all of our training up to date. Per LPN3 in interview, she had not worked at the facility long enough to know if they provided check offs or had any competency training. In interview on 11/22/2024 at 12:43 PM, Resident (R)25 stated agency staff did not know him or his preferences. He stated especially at night and on weekends agency staff had to be told what to do. R25 reported, They don't know nothin, I have to tell them everything to do. He further stated he had to tell a nurse aide everything he needed. In interview on 11/22/2024 at 1:15 PM, RN7 (an agency nurse) stated she had not received any training from the facility when she started. She stated there were a lot of new aides and it was hard to know if they were doing their job. The RN reported her agency required her to do online education. She further stated the facility had not provided any skills check off or testing. In interview on 11/22/2024 at 1:29 PM, State Registered Nurse Aide (SRNA) 16/Kentucky Medication Aide (KMA) 5 stated we have a few agency SRNA's who knew the residents; however, there were some SRNA's she did not know how they ever got their license. She reported there was no continuity of care, and they used to have education on every payday, but since the former DON came we got nothing. In interview on 11/21/2024 at 1:19 PM, the Interim DON stated there was a huge problem with the stand point of using staffing from an agency. She said she and the Interim Administrator figured the staffing was at 4.25 PPD which for the acuity level of the residents currently in the facility was high. The Interim DON stated We have a lot of agency staff currently. She reported she looked at the staffing ratio for the last two days and review revealed 68% of the staffing for the facility was agency filled. Per the Interim DON in interview, she and the Interim Administrator had presented their concerns to the facility's board of directors as recently as 11/20/2024. She further stated with all the agency staff currently, there could not be continuity of care for the residents. The Interim DON additionally stated residents needed to know who was going to be taking care of them.

Based on interview, record review, and review of facility's policy, it was determined the facility failed to ensure residents were free from abuse for four of 24 sampled residents (Residents (R) 3, 4, 5, and 6). 1) On 06/04/2023, staff witnessed R3 strike R4 on the right side while shouting, I told you to move. 2) On 09/05/2023, R4 struck R5 on the cheek while sitting in the lobby, having a conversation. 3) On 10/24/2023, R6 struck R3 on the neck while trying to enter through the door to his room. The findings include: Review of the facility's policy titled, Abuse, Neglect, and Exploitation Policy and Procedure, undated, revealed residents in the long-term care facility had the right to be free from physical abuse, and the willful infliction of injury of any kind was prohibited. 1) Review of the facility's Incident Report, dated 06/09/2023 and signed by the Social Services Director (SSD), revealed on 06/04/2023 at approximately 6:15 PM, R3 slapped R4 for not moving out of his way. As reported by State Registered Nurse Aide (SRNA) 12, R3 stated, I told you to move. It was noted both residents were in the hallway outside of their shared room on Unit 1. Per the report, neither resident sustained any injury. Review of R3's Face Sheet revealed the facility admitted the resident on 02/28/2022 with diagnoses that included atrial fibrillation, unspecified dementia, and congestive heart failure. Review of R3's annual Minimum Data Set (MDS), with an assessment reference date (ARD) of 05/31/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of eight out of 15. This score indicated severe cognitive impairment. Further review of the MDS and goals revealed once seated in a wheelchair the resident could ambulate 50 feet and turn with supervision or touching assistance. No behaviors were exhibited. Review of R3's Comprehensive Care Plan (CCP), undated, revealed a focus of the resident having the potential to be physically aggressive. The goal, with a target date of 09/27/2023, stated the resident would have no decline in mood state. Interventions initiated on 03/25/2024, included a psychiatric consult; and, when the resident became agitated, staff should intervene before agitation escalated. Additionally, interventions included guiding the resident away from the source of distress and engaging calmly in conversation; and if the response was aggressive, staff was to walk calmly away and approach the resident later. Review of R3's Incident Note, dated 06/04/2023 at 4:15 PM, revealed SRNA12 witnessed R3 slap R4 on his right side with moderate force. Further review revealed R3 stated, I told you to move to R4. Per the note, the residents were sitting in their wheelchairs in the doorway of their room. Both residents were separated immediately, and skin assessments were completed with no injuries visualized on either resident. The note stated both residents were placed on 15 minute checks. The facility moved R3 to another room to ensure R4's safety. Further review revealed the note was not signed. Review of R3's Psychiatric Consult, dated 06/05/2023, revealed the resident was interviewed via telehealth by an Advanced Practice Registered Nurse (APRN). Per the report, R3 stated he did get angry and admitted to hitting R4. However, the consult stated he denied any intention to harm his roommate [R4]. Further review of the consult revealed R3 had no previous behaviors, but R3 had been treated recently for a urinary tract infection (UTI). Per the consult, there was no evidence of acute risk of harm to self or others. The APRN recommended R3 be monitored for behaviors and mood changes. During an interview with R3 on 04/04/2024 at 10:12 AM, the resident stated he did not remember hitting anyone. R3 stated he liked his roommates, and there were no problems between himself and R4. The resident stated he felt safe in the facility. R3 stated he liked the room he was in now. Review of R4's Face Sheet revealed the facility admitted the resident on 03/01/2021 with diagnoses that included dementia with behavioral disturbances, type 2 diabetes mellitus, and cerebral infarction. Review of R4's Quarterly MDS Assessment, with an ARD of 03/13/2023, revealed the facility assessed the resident to have a BIMS' score of six out of 15. This score indicated severe cognitive impairment. The MDS also revealed, once seated in a wheelchair, the resident could ambulate 50 feet and turn with partial/moderate assistance to complete the activity. No behaviors were exhibited. Review of R4's CCP, revealed nursing staff care planned the resident on 06/05/2023 for being at risk for a decline in mood related to a resident-to-resident altercation on 06/04/2023 with his roommate. Interventions included a psychiatric consult, observing, reporting, and documenting any changes in behavior. During an interview with R4 on 04/04/2024 at 10:54 AM, R4 stated he did not remember being hit by anyone. R4 further stated he felt safe in the facility. R4 denied any concerns or complaints and stated he liked to ambulate through the facility and talk to people The State Survey Agency (SSA) Surveyor attempted a telephone interview with SRNA12, on 04/04/2024 at 9:52 AM, but was unable to leave a voicemail message. During an interview with SRNA14 on 04/05/2024 at 12:35 PM, she stated R3 continually ambulated in a wheelchair throughout the facility during the day while he was out of his room. However, she stated R3 could sometimes get impatient with staff and other residents if they obstructed his way while he was moving around. She further stated all staff members were aware of this and would redirect R3 if they witnessed any potential conflicts. SRNA14 stated R3 liked to spend his time in the front lobby looking out the windows. During an interview with the Social Services Director (SSD) on 04/01/2024 at 10:35 AM, she stated SRNA12 witnessed R3 hit R4, while both were seated in their wheelchairs, in the hallway beside their shared room. She stated the residents' families and physicians were notified immediately, and the residents were separated. She further stated after a psychiatric evaluation, R3 was cleared to return to his room with R4. She stated a full investigation began, and she interviewed both residents. She stated R3 claimed not to know what happened, and R4 had no recollection of the event. The SSD stated R3 was moved to another room temporarily and placed on 15-minute monitoring. The SSD stated she received permission from both residents and their families before placing R3 back in the room with R4. 2) Review of the R4's Incident Report, dated 09/11/2023 and signed by the SSD, revealed on 09/05/2023 at approximately 6:45 PM, the receptionist witnessed R4 slap R5 on the cheek while the two residents were engaged in a conversation in the front lobby. The report stated there were no injuries, and both residents were placed on 15-minute checks. Review of R4's Incident Statement, dated 09/05/2023 at 6:45 PM and entered by Licensed Practical Nurse (LPN) 7, revealed LPN7 was called to the lobby by the Receptionist because R4 was upset and yelling at staff. LPN7 stated when she arrived, R4 was not yelling. She stated when she asked R4 if he was okay, he smiled. LPN7 stated she took R4 back to the nurse's station on Unit 1. Per the statement, R4 did not exhibit any other behaviors. Review of R4's CCP, undated, revealed there was an additional focus of behavior problems related to not being able to go outside and being involved in a resident-to-resident altercation on 09/05/2023, when he struck another resident. Interventions again included a psychiatric consult, observing, reporting, and documenting any changes in behavior. Review of two 15 Minute Monitoring forms, dated 09/05/2023 and 09/06/2023, revealed staff began 15-minute checks for R4 beginning on 09/05/2023 at 7:30 PM and ended on 09/07/2023 at 6:45 AM. Review of R5's Face Sheet revealed the facility admitted the resident on 09/24/2012 with diagnoses to include cerebral palsy, unspecified intellectual disabilities, and generalized muscle weakness. Review of R5's CCP, revealed a focus of communication problems related to difficulty in making himself understood, initiated on 08/30/2016. Interventions included the staff being conscious of the resident's position during group activities and communication with others, and ensuring and providing a safe environment. Review of R5's quarterly MDS, with an ARD of 07/16/2023, revealed the facility assessed the resident to have a BIMS score of 12 out of 15, indicating moderate cognitive impairment. The MDS also assessed that the resident could ambulate 50 feet and turn independently. No behaviors were exhibited. Review of R5's Psychiatric Consult, dated 09/05/2023 at 3:30 PM, revealed the resident was interviewed by an APRN as a follow-up to R5's involvement in an altercation with another resident. According to the consult, R5 re-enacted the incident and described the other resident striking him in the face. The consult stated he denied pain or feeling sad, giving a thumbs up sign when asked how he was doing. Per the consult, the APRN discontinued the 15-minute monitoring. Review of R5's Nursing Health Status Note, dated 09/05/2023 at 8:59 PM, revealed the Unit Nurse (UN) was notified by the Receptionist at 6:50 PM that R4 was exhibiting aggressive behavior in the lobby. The UN went to the lobby and returned with R4. Per the note, R4 hit R5 on the cheek with his hand. Further review revealed R4 and R5 were assessed and placed on 15-minute monitoring. The provider, SSD, and the resident's responsible party were notified. An x-ray of the face was ordered for R5, and no injuries were noted. During an interview with R5 on 04/02/2024 at 8:50 AM, the resident nodded yes when asked if another resident hit him in the face. He also gave a thumbs up when asked if he was okay. In a telephone interview with the Receptionist on 04/04/2024 at 9:28 AM, she stated R4 and R5 usually socialized together, and there had not been any prior incidents between them. She stated before the incident, both residents were engaged in a conversation, laughing and getting along, until she saw R4 hit R5 in the face as R5 got up to walk away. She stated there were no injuries, the residents were separated, and nursing staff took the residents back to their rooms. During an interview with the SSD on 04/01/2024 at 10:35 AM, she stated the Receptionist witnessed R4 hit R5 in the face while both were seated in the front lobby. The SSD stated nursing staff initiated 15-minute monitoring for both residents. She stated the residents were under the care of psychiatric services at the time of the incident, which continued to follow the residents. 3) Review of the facility's Incident Report, dated 10/25/2023 and signed by the SSD, revealed on 10/24/2023 at 1:15 PM, SRNA14 witnessed R6 hit R3 on the neck. Per the report, R3 was sitting in his wheelchair at the entrance to his room because housekeeping staff was cleaning the room. The report stated, while R3 was waiting, R6 went behind R3, hit him on the back of his neck, and instructed him to go inside his room. Per the report, the residents were separated and neither of them was injured. Review of another R3 Psychiatric Consult, dated 10/24/2023 at 3:25 PM, revealed R3 was interviewed via telehealth by an APRN as a follow-up to being involved in an altercation with another resident, and there was no evidence of risk to self or others. The consult documented 15-minute monitoring of the resident was discontinued. Review of R6's Face Sheet revealed the facility admitted the resident on 08/27/2019 with diagnoses to include dementia with agitation, congestive heart failure, and type 2 diabetes. Review of R6's Quarterly MDS, with an ARD of 03/11/2023, revealed the facility assessed the resident as having a BIMS' score of three out of 15, indicating severe cognitive impairment. Further review revealed, once seated in a wheelchair, the resident could ambulate 50 feet and turn with substantial assistance to complete the activity. No behaviors were exhibited. Review of R6's CCP, revealed a focus of behaviors related to the resident hitting another resident, initiated on 10/24/2023. Interventions initiated 10/24/2023 included allowing the resident to express feelings and redirecting the resident when behaviors occurred; monitoring and documenting any mood or behavior changes; and the resident was to be seen by psychiatric services. Review of R6's Psychiatric Consult, dated 10/24/2023 at 3:00 PM, revealed the resident was interviewed via telehealth by an APRN as a follow-up to an altercation with another resident. The consult stated R6 admitted to the physical altercation and denied any further intent to harm another person or self. Per the consult, a plan to continue the current medication regimen, order labs, and continue behavior monitoring for mood changes was ordered. During an interview with R6 on 04/04/2024 at 10:38 AM, he stated he had not been involved in an altercation with any resident in the facility. He further stated staff treated him well, and he felt safe. During an interview with SRNA14 on 04/05/2024 at 12:38 PM, she stated R6 came up from behind R3 and hit him in the back of the neck. She stated R3 and R6 were roommates, and R6 wanted to go into his bedroom, but R3 was in the way. The SRNA stated, when R3 did not move, R6 struck him. SRNA14 stated she separated the residents and notified the charge nurse of the incident, and neither resident was injured. During an interview with the SSD on 04/01/2024 at 10:35 AM, she stated she interviewed R3 and R6, and neither resident recalled the incident. She further stated no harm occurred, and neither showed any mental or physical distress. The SSD stated psychiatric services evaluated both residents via online appointments. Further, the SSD stated the APRN scheduled both residents for a follow-up evaluation on 11/02/2023. During an interview with the Director of Nursing (DON) on 04/05/2024 at 12:54 PM, she stated the facility's abuse policy prohibited abuse of any type including resident-to-resident abuse. She stated staff was trained upon hire, yearly, and as needed on the facility's abuse policy, which included all types of abuse. The DON stated the quality assurance (QA) nurse was responsible for documentation of abuse training for staff, the QA Nurse was on vacation, and she did not have access to that information. Per the interview, the DON stated the facility monitored residents for behaviors and implemented actions according to the behaviors. She stated it was important to follow facility policies to ensure the safety and well-being of the residents and staff. During an interview with the Medical Director on 04/04/2024 at 9:26 AM, he stated the facility's abuse policy prohibited abuse of any type, including resident-to-resident abuse. He stated it was his expectation that staff members notified their immediate supervisors and the on-call provider of any allegation of abuse or suspected abuse, or any change in a resident's behavior to ensure the well-being and safety of the residents. During an interview with the Administrator on 04/05/2024 at 3:40 PM, he stated the facility's abuse policy prohibited abuse of any type, including resident-to-resident abuse. He stated the SSD educated staff regarding the facility's abuse policy upon hire, and staff received a refresher training every year and as needed.

Based on interview, record review, review of the facility's initial report of abuse and review of the facility's policy, it was determined the facility failed to immediately report alleged abuse to the Administrator and State Agencies within specified timeframes for one of 24 sampled residents (Resident 1 (R1)). R1 reported sexual abuse to staff on 03/19/2024 at 2:48 AM. Staff failed to report the allegation to Administration. Resident #1 again reported sexual abuse to staff on 03/20/2024 at 1:15 PM, and Administration was notified on 03/20/2024 at 2:00 PM. The findings include: Review of the facility's policy titled, Abuse, Neglect, and Exploitation, dated 11/2016, revealed staff was to report all alleged violations involving abuse immediately, but not more than two hours after the occurrence to the Administrator or designee of the facility, and they would in turn immediately report the complaint to Adult Protective Services (APS), Office of Inspector General/State Survey Agency (OIG/SSA), and law enforcement if appropriate. Additional review of the policy revealed all employees received training at orientation and through on-going in-services on how to report incidents of abuse. Review of R1's Face Sheet revealed the facility admitted the resident on 04/28/2023 with diagnoses including dementia, cerebral atherosclerosis (arteries in the brain become hard and narrow due to fatty buildup, decreases the amount of blood to certain areas of the brain), and psychophysiological insomnia (difficulty falling asleep or staying asleep due to heightened body and brain activity). Review of R1's Quarterly Minimum Data Set (MDS), dated 03/11/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of six out of 15, indicating severe cognitive impairment. Review of R1's Progress Note, dated 03/19/2024 at 2:48 AM, entered by LPN2, revealed R1 informed a State Registered Nurse Aide (SRNA) (unidentified) she was molested. Further review revealed LPN2 went to R1's room to ask her about the allegation and observed the resident as being sleepy and confused. Continued review of the note, revealed R1 requested to go back to sleep and slept without any further issues. In addition, the review revealed LPN2 entered the note for 03/19/2024 at 2:48 AM on 03/21/2024 at 8:53 PM as a late entry. Review of R1's Progress Note, dated 03/20/2024 at 1:15 PM, entered by LPN6, revealed the SRNA (unidentified) reported R1 stated she was raped. Further review revealed LPN6 spoke with R1, who stated a man had raped her the night prior. Per the note, LPN6 reported the incident to the Director of Nursing (DON), Advanced Practice Registered Nurse (APRN), and the Social Services Director (SSD). In addition, review of the note revealed LPN6 entered the progress note for 03/20/2024 at 1:15 PM on 03/22/2024 at 6:12 PM as a late entry. Review of the facility's initial report of abuse to the SSA, revealed the incident date and time of the allegation was documented as 03/19/2024, time uncertain. Further review revealed the Administrator notification date and time was 03/20/2024 at 2:00 PM. The notification form was faxed to SSA on 03/20/2024 at 4:29 PM. In an interview with R1 on 03/25/2024 at 3:50 PM, she stated she could not recall an exact date or time of the incident, but recalled being asleep. R1 stated she believed a male came into her room and rubbed her groin area. R1 stated she could not recall who she told initially. However, she stated the next morning, while being bathed, she recalled the incident and reported it to the person giving her a bath. In addition, R1 stated after she told the person giving her a bath, people came in and started asking questions. R1 stated she went to the hospital for an examination (exam). In an interview with R1's family member on 03/26/2024 at 9:10 AM, he stated the SSD contacted him on 03/20/2024 around 2:00 PM informing him of the allegation. He stated he was told the police had been notified, and his parent was being sent out to the hospital for an exam. In an interview with SRNA2 on 03/28/2024 at 1:52 PM, she stated she worked through an agency and usually on the first shift. However, SRNA2 stated she worked the night shift on 03/19/2024 and was assigned to Unit 1, where R1 resided. SRNA2 stated R1 had gone to bed, and at an unknown time, the call light went off. She stated she entered R1's room, and R1 told her she [R1] had been raped. SRNA2 stated she left the room, went to the nurse's station, reported the incident to the assigned nurse, and the nurse made a comment that R1 was often confused. SRNA2 stated she could not recall the nurse's name and did not know what the nurse did after being told. In an interview with SRNA1 on 03/26/2024 at 9:58 AM, she stated she worked the day shift on 03/20/2024 and was assigned to Unit 1, where R1 resided. SRNA1 stated while assisting R1 to the bedside commode, R1 told her she [R1] had been drugged and raped the previous night and complained of hurting and burning. SRNA1 stated she reported the incident to the nurse, but could not recall her name and believed she came from an agency. SRNA1 further stated, shortly after notifying the nurse, she saw the SSD and informed her of the incident. In an interview with LPN2 on 03/26/2024 at 7:21 PM, she stated SRNA3 reported R1 had called out and told her someone had touched her inappropriately. LPN2 stated she went to R1's room and woke R1 from sleeping. LPN2 stated when questioned, R1 appeared confused and denied the incident. LPN2 stated she did not report the incident because she felt R1 had experienced a bad dream, and no abuse had occurred. In addition, LPN2 stated the facility's policy was to report the incident immediately to the Director of Nursing (DON), and she should have reported it despite not believing it occurred. Further, LPN2 stated the DON contacted her to enter a progress note, and she mistakenly documented the wrong date because of confusion over working the night shift. She stated the actual date of the incident took place on 03/20/2024, not 03/19/2024. The State Survey Agency (SSA) Surveyor twice attempted a telephone interview with LPN6. A voicemail was left on her phone on 03/26/2024 at 9:08 AM and on 03/28/2024 at 3:10 PM, with no response. In an interview with the SSD on 03/26/2024 at 12:47 PM, she stated SRNA1 told her of the allegation of abuse on 03/20/2024 between 1:00 PM and 1:30 PM. Further, she stated she immediately went to Unit 1 and started an investigation. She stated every nurse's station had a flow sheet posted with the reporting procedures. She further stated all staff members were educated on abuse and reporting on hire and received in-service training every three to six months. The SSD stated she was responsible for 90 percent of all abuse investigations. In an interview with the DON on 03/26/2024 at 2:00 PM, she stated all staff members including agency staff were educated on abuse upon hire, and in-services were conducted throughout the year. The DON further stated it was her expectation abuse of any kind be reported immediately to the SSD, DON, or Administrator after it was reported to staff, as per the facility's policy. In addition, she stated immediate reporting was important for evidence preservation, and delayed reporting could cause evidence to be lost. In an interview with the Administrator on 03/29/2024 at 7:48 AM, he stated it was his expectation an allegation of any type of abuse be reported immediately to the Administrator and to State Agencies as per policy and regulation. In addition, he stated any delay in reporting to Administration led to delays in activating an investigation and notifying other required agencies. The Administrator further stated important evidence could be lost when there was a delay in reporting.

Based on observation, interview, record review and review of the facility's Policy, it was determined the facility failed to ensure residents were free from physical restraints imposed for purposes of discipline or staff convenience and that are not required to treat resident's medical symptoms for three (3) of three (3) sampled residents reviewed for physical restraints out of a total of twenty (20) sampled residents (Resident #39, Resident #70 and Resident #85). 1. Resident #39 had current Monthly January 2020 Physician's Orders, for a Lap Buddy when in the wheelchair, which was ordered 12/26/19. However, there was no documented evidence the order included the presence of a medical symptom and how the chair alarm would treat the medical symptom and protect the resident. Additionally, there was no documented evidence the Physical Restraint Consent was signed by the Resident Representative. Further, the Compressive Care Plan (CCP) was not revised to include the medical symptoms being treated when using the Lap Buddy, ongoing monitoring, or period use for the Lap Buddy. 2. Resident #70 had a current Monthly January 2020 Physician's Orders, for a lap buddy in the wheelchair to aide in preventing falls, which was ordered 01/12/17. However, there was no documented evidence the order included the presence of a medical symptom and how the lap buddy would treat a medical symptom, or specify the duration of time the lap buddy would beb used. Resident #70 had a Physician's order for a mat alarm while in bed and chair, which was ordered 11/29/17. However, there was no documented evidence the order included the presence of a medical symptom, how the mat alarm would treat a medical symptom or protect the safety of the resident, or duration of time the mat alarm would be used. 3. Resident #85 had current Monthly January 2020 Physician's Orders, for a Velcro Seatbelt while up in the wheelchair, which was ordered 11/18/16. However, there was no documented evidence the order included the presence of a medical symptom and how the chair alarm would treat the medical symptom and protect the resident. Further, the CCP was not revised to include the medical symptoms being treated when using the Velcro Seatbelt. The findings include: Review of the facility's Policy, titled Restraint Use, dated as revised on 11/2014; revealed restraints should only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. Further Policy review revealed restraints were only to be used under the written order of the physician and after obtaining consent from the resident/responsible party. The Policy further stated the order shall include the following: the specific reason for the restraint (as it related to the resident's medical symptom); how the restraint would be used to improve/treat the resident's medical symptom; and type of restraint and period of time for use of the restraint. Per policy, restrained individuals shall be reviewed routinely (at least quarterly) and as needed to determine whether they were candidates for restraint reduction, less restrictive methods of restraint, or total restraint elimination and Care Plans would include measures taken to systematically reduce or eliminate the need for restraint use. Continued review of the Policy revealed clinical notes regarding the use of restraints would be documented in the clinical record and include the type of physical restraint being used, the resident's medical symptoms being treated, observations of the resident and resident's tolerance to the restraint every shift. Additional review revealed restraints would be checked every thirty (30) minutes and released every two (2) hours to permit restrained individuals range of motion, ambulation and other activities. 1. Review of Resident #39's medical record, revealed the facility admitted the resident on 06/19/17 with diagnoses including, but not limited to Tuberous Sclerosis, and Congenital Malformations. Review of the Physical Restraint Consent, dated 07/31/17, revealed a change in wheelchair was a less restrictive, alternative non-restraint approach that was proven ineffective. Additionally, a Lap Buddy was a recommended restraint intervention for a specific target behavior of attempts to get up without assistance, secondary to the medical symptom of poor upper body control and seizure disorder. Further, potential benefits and risks of restraint use was provided; however, there was no documented evidence the resident representative signed the acknowledgement. Review of the Comprehensive Care Plan (CCP), initiated on 06/09/17, revealed Resident #39 had the potential for injury related to impaired safety awareness, impaired mobility, non-ambulatory, seizure disorder, history of falls, and use of a restraint. The goal revealed staff would work with the resident to minimize falls through the next review date, 02/15/20. Interventions included, but were not limited to: lap buddy while in wheelchair; fall risk assessment quarterly and as needed; use wheelchair for long distance mobility; and educate the family on potential consequences related to falls (There were no dates on the CCP to indicate when each intervention was implemented); however, the medical symptoms being treated when using the Lap Buddy, ongoing monitoring, or period use for the Lap Buddy was not included in the CCP. Review of Resident #39's Monthly January 2020 Physician's Orders, revealed orders for a Lap Buddy when up in the wheelchair, dated 12/26/19. However, there was no documented evidence the order included the presence of a medical symptom and how the Lap Buddy would treat the medical symptom and protect the resident. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 11/13/19 revealed Resident #39 had impaired vision, no speech, and adequate hearing. Additionally, the Residents Brief Interview of Mental Status (BIMS) score was ninety-nine (99) indicating the resident was unable to complete the Assessment. Per Assessment, psychosis was present and the resident required extensive to total assistance with Activities of Daily Living (ADLs). Continued review of the Assessment revealed the resident had no pain and had one (1) non-injury fall during the Assessment period. Further, the resident used a daily trunk restraint in chair/out of bed. Review of Resident #39's Restraint Elimination Assessment, dated 11/15/19 revealed the resident was chair bound and non-weight bearing. Additionally, the resident required assistance of one (1) staff for position and had a leaning sitting balance. Per assessment, the resident was disoriented and had a history of seizures. Further, the total score of fifteen (15) indicated the resident was a poor candidate for restraint elimination. Continued review revealed a consent had been signed for the Lap Buddy when up in the wheelchair for the medical symptom or target behaviors of poor upper body/trunk support. Observation on 01/07/2020, at 2:33 PM, revealed Resident #39 lying flat in bed with his/her eyes open. Additionally, the resident was holding a ball with his/her right hand, at their side, and their left hand was wrapped in a kerlix. Further observation revealed when State Inspector spoke to the resident he/she sat up straight up in bed without using his/her hands and looked towards State Inspector; the resident was non-verbal. Observation on 01/09/2020, at 3:00 PM, revealed Resident #39 sitting in the wheelchair in the hallways by his/her room. Additionally, the Lap Buddy was across the resident's lap and his/her hands were resting on the Lap Buddy. Further, the resident was non-verbal and his/her feet were resting on the wheelchair foot pedals and his/her trunk was upright and not leaning. Interview with State Registered Nursing Assistant (SRNA) #1, on 01/10/2020 at 11:20 AM, revealed Resident #39's Lap Buddy to the wheelchair was used to keep the resident in the chair when he/she had a seizure, because he/she could not remove it from the wheelchair. Continued interview revealed the resident was up in the wheelchair daily for approximately two (2) hours for each meal. Further, she checked on the resident while he/she was up in the wheelchair every time she walked past them to make sure the Lap Buddy was in the right position. Interview with Licensed Practical Nurse (LPN) #2, on 01/10/2020 at 11:35 AM, revealed the Lap Buddy for Resident #39 was used to keep the resident from falling out of the wheelchair because the resident had seizures and leaned forward. Additional interview revealed the she was not aware of other interventions used to keep the resident safe and to reduce the risk for falls out of the wheelchair prior to the Lap Buddy being placed on the wheelchair. Per interview, the facility policy for restraints was to check them every two (2) hours to ensure the restraint was on the resident correctly and to reposition the resident in the chair; which was documented on the Treatment Administration Record (TAR) each shift. Further, the Physician's Order, for restraints should include the medical symptom the restraint was used for. Continued interview revealed the facility policy ensured resident safety. 2. Review of the clinical record revealed the facility admitted Resident #70 on 10/03/16 with diagnoses to include Alzheimer's Disease, Dementia without Behavioral Disturbance, Unspecified Atrial Fibrillation, Essential Primary Hypertension and Benign Prostatic Hyperplasia. Review of Resident #70's Quarterly Minimum Data Set (MDS) Assessment, dated 12/11/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), indicating the resident to be severely cognitively impaired. Continued review revealed the facility assessed Resident #70 as requiring extensive physical assistance of one (1) staff member for bed mobility, dressing, toileting and personal hygiene. Further MDS review revealed the facility assessed Resident #70 as requiring limited assistance of one (1) staff member for transfers and as ambulating once or twice with limited assistance of one (1) staff member during the review period. Continued review of MDS revealed the facility assessed Resident #70 as having no limitations in functional range of motion (ROM) to upper or lower extremities, and as having no trunk or limb restraints. Additional MDS review revealed the facility assessed the resident as requiring a bed alarm and a chair alarm use daily. Review of Resident #70's Comprehensive Care Plan, initiated 10/20/16, last revised on 11/02/19, revealed the resident was at risk for falls due to a history of falls related to weakness due to diagnoses of Atrial Fibrillation, Hypertension and Severe Cognitive Impairment. The goal stated the facility would attempt to minimize injuries related to high fall risk daily through the next review date of 03/18/20. Interventions included the following: Reminding Resident #70 to request assistance for ambulation; assistance of two (2) staff members for all ambulation of short distances; and monitoring resident for changes in condition that may warrant increased supervision/assistance and notification of physician. Additional Care Plan review revealed interventions that included, but were not limited to the following: Completing a Fall Risk Assessment upon admission and quarterly; utilizing a mat alarm while in bed and in a chair as of 11/29/17; referring to therapy for wheelchair management a for lap trap/lap buddy; if the resident becomes fidgety/wandering, attempt to occupy with busy board; closer supervision at nurse's station; one on one discussions or attempt to toilet; keeping resident in the hallway until staff were ready to lay in bed; and ensuring application of lap tray/lap buddy after lunch and prior to resident leaving dining room. Further review of Resident #70's Comprehensive Care Plan, initiated 03/24/17, revealed a focus for resident at risk for fall prevention devices becoming a restraint. The goal stated Resident #70 would continue to have the ability to remove the lap tray/lap buddy through the next review date of 03/18/20. Interventions included the following: Staff completing Restraint Necessity Assessment when considering any restraint; completing Restraint Elimination Assessment quarterly; observing resident with restraint in use; removing resident's lap tray/lap buddy at meal times to enable him/her to eat at table; replacing lap tray/lap buddy after meal; periodically asking resident to remove lap tray/lap buddy (if unable to do so, will be considered a restraint); documenting resident ability or inability to remove; and ensuring mat pressure alarm in use when resident in bed or in chair. Review of Resident #70's January 2020 Physician's Orders revealed an active order with a start date of 01/12/17 for a lap buddy in the wheelchair to aide in preventing falls. There was no documented evidence the order included the presence of a medical symptom, how the lap buddy would treat a medical symptom, or specify the duration of time the lap buddy would be used. Further review of Resident #70's Physician's Orders revealed an active order with a start date of 11/29/17, for a mat alarm while in bed and chair. There was no documented evidence the order included the presence of a medical symptom, how the mat alarm would treat a medical symptom or protect the safety of the resident, or duration of time the mat alarm would be used. Continued Physician's Order review revealed an active order with a start date of 02/08/18 to try a different lap buddy. There was no documented evidence the order included the presence of a medical symptom, how a different lap buddy would treat a medical symptom or protect the safety of the resident or duration of time a different lap buddy would be used or the indication for use. Review of Resident #70's January 2020 Treatment Administration Record (TAR) revealed no documented evidence staff were checking/releasing lap tray/lap buddy. Further review of Resident #70's TAR revealed no documented evidence staff were utilizing a mat alarm on the bed/chair or lap tray/lap buddy for Resident #70. Continued TAR review revealed no documented evidence staff were checking for functioning of Resident #70's mat alarm on bed and/or on chair. Further review of the clinical record revealed no documented evidence of an initial restraint evaluation for the mat alarm to Resident #70's wheelchair and bed in order to assess if the mat alarm was the least restrictive device, nor was there documented evidence of the reasons the device was appropriate or effective for this resident to prevent further fall accidents/incidents. Furthermore, there was no documented evidence of ongoing evaluations of the mat alarm to assess the effectiveness of this intervention, to assess if this was the least restrictive device, or to ensure the device was not a restraint. In addition, there was no documented evidence of risks verses benefits was explained to the resident/responsible party nor was there a consent signed for the mat alarm for wheelchair and bed. Continued review of Resident #70's clinical record revealed no documented evidence of an initial restraint evaluation for the lap tray/lap buddy to assess for least restrictive device, nor was there documented evidence of the reasons the device was appropriate or effective for the resident to prevent further fall accidents/incidents. Furthermore, there was no documented evidence of risks verses benefits explained to the resident/responsible party nor was there a consent signed for the mat alarm for wheelchair and bed. Review of the Restraint Elimination Assessments, dated 09/18/19 and 12/18/19, revealed Resident #70 with grand score totaling between zero (0) and ten (10), indicating resident was a good candidate for restraint reduction or elimination program, based on physical functioning and behavioral/social functioning assessment. However, the facility documented the resident was not a candidate for a restraint reduction or elimination due to his/her ability to remove lap tray/lap buddy upon request. Additionally, the facility documented the mat alarm does not restrict and no documented evidence of ongoing assessments for reduction or elimination were provided for the mat alarm. Observation of Resident #70 with Licensed Practical Nurse (LPN) #3, on 01/09/2020 at 1:20 PM, revealed the resident in the room, sitting up in a wheelchair with a mat alarm and lap tray/lap buddy in place. Further observation revealed Resident #70 alert, awake and talking in confused mixture of random words as LPN #3 interacted/engaged with the resident. Resident #70 made eye contact when his/her name was called but was unable to respond appropriately due to his/her cognition. Continued observations revealed a bedside table with a hand-made picture book of cows and other farm animals. LPN #3 advised Resident #70 enjoyed these pictures as they often provided him/her comfort and provided the book to the resident. Additional observations revealed the resident pointed to the picture book, showing it to LPN #3 smiling and attempted to explain what was in book. Interview with LPN #3 (nurse assigned to provide care to Resident #70 daily), on 01/09/2020 at 1:30 PM, revealed she was responsible for performing the initial restraint assessments and quarterly restraint elimination assessments. Further interview revealed the MDS nurses reviewed initial and quarterly restraint assessments and other resident assessments performed by each of the unit's floor nurses and formulated comprehensive care plans and implemented restraint devices based upon those assessments. Continued interview with LPN #3 revealed the MDS nurses revised the comprehensive care plan as LPN #3 and other floor nurses were not permitted to do so. LPN #3 advised the unit's floor nurses could temporarily revise the nursing assistants care plans/care tasks by utilizing the Care Plan update form attached to the Physician's Orders located in the resident's paper chart. LPN #3 advised this form was utilized as a temporary Care Plan intervention until reviewed and approved by MDS nurse. Per interview, once completed by the floor nurse, the Care Plan update form would be placed in the unit's communication box (with the Physician's Orders) and would then be picked up each morning by the Director of Nursing (DON) or her designee. Further interview with LPN #3 revealed the MDS nurse would place the new intervention on the resident's comprehensive care plan if the Interdisciplinary Team (IDT) deemed the intervention (Care Plan update) as appropriate, following the IDT morning meeting. Continued interview with LPN #3 revealed the Physician's Order should include specific type of restraint, medical symptom treated, duration of use and how use of the restraint would protect the safety of the resident. Review of Resident #70's Occupational Therapy (OT) Plan of Care, Initial Assessment, dated 08/11/17, revealed reason for referral was short-term rehabilitation related to functional decline due to confusion and resistance. Further review of the assessment revealed Resident #70 required assistance of two (2) staff members for functional transfers and bed mobility and required modified independence with wheelchair mobility. There was no documented evidence of an evaluation for the need for the lap tray/lap buddy by OT. Further, there was no documentation of on-going assessments by OT for continued use of lap tray/lap buddy. Interview with State Registered Nurse Aide (SRNA) #5, on 01/09/2020 at 1:51 PM, revealed she was routinely assigned to provide direct care to Resident #70 and was familiar with the resident's care needs. Further interview revealed Resident #70 had a mat alarm to his/her wheelchair and bed as well as a lap tray/lap buddy on his/her wheelchair due to falls sustained in the past from apparent attempts to self-transfers. Continued interview with SRNA #5 revealed she had observed Resident #70 remove the lap tray/lap buddy in the past but had not observed the resident removing it recently. Additional interview with SRNA #5 revealed Resident #70 had an inability to follow commands and had difficulty communicating needs related to severe cognitive impairment. SRNA #5 advised staff anticipated resident needs and had never been advised to check the resident's lap tray/lap buddy every thirty (30) minutes and release every two (2) hours. Continued interview with SRNA #5 revealed the only instructions she had received were those located on Resident #70's care tasks, which included removing lap tray/lap buddy at meal times and replacing lap tray/lap buddy prior to resident leaving dining room. SRNA #5 reported no other instructions regarding Resident #70's lap tray/lap buddy had been provided to her. Interview on 01/10/2020 at 9:41 AM with Registered Nurse/MDS Coordinator (MDS) #1, employed with facility for thirteen (13) years, revealed her assessment of Resident #70 on 12/11/19 revealed the facility assessed the resident to have a BIMS of three (3) with observation of resident as having the ability to remove lap tray/lap buddy at any given time upon request. Further interview with MDS #1 revealed lap tray/lap buddy would be considered a restraint if he/she were unable to remove it upon command. Continued MDS #1 interview revealed a mat alarm to the wheelchair and bed would not be considered a restraint and wasn't sure how she should have coded the wheelchair and mat alarms on 12/11/19 Quarterly MDS Assessment. Additional interview revealed MDS #1 collected resident data for assessments by reviewing the clinical record for any falls or other incidents. MDS #1 added she gathered data for MDS assessments by reviewing Physician's Orders, monthly summaries, restraint assessments and pain interviews performed by unit floor nurses. Further interview revealed another source of information for MDS #1 was talking with floor nurses providing care for the residents. Continued interview with MDS #1 revealed her only physical assessment of residents was during their BIMS interviews. Observation of Resident #70, on 01/10/2020 at 10:28 AM with MDS #1 present revealed resident in room, sitting in wheelchair with a mat alarm and lap tray/lap buddy in place. Resident #70 was alone, facing the doorway with a picture book on the bedside table at the resident's right side and not within reach. Further observation revealed MDS #1 talking with the resident and explained the purpose of the visit as resident responded back in a word salad (confused unintelligible mixture of words and phrases). Further observation revealed MDS #1 requested Resident #70 to remove lap tray/lap buddy several times with resident repeating word salad and unable to process request. Continued observations revealed MDS #1 pointed to lap tray/lap buddy, making a tapping sound with fingernails, drawing Resident #70's attention to lap tray/lap buddy. Additional observations revealed Resident #70 picked up lap tray/lap buddy from the left side arm of wheelchair and held it up to MDS #1. Continued observations revealed Resident #70 asked MDS #1 Is this it, is this what you want from me? Further observations revealed Resident #70 continued to speak in word salad as MDS #1 re-applied lap tray/lap buddy before exiting resident room. Interview with MDS #1, on 01/10/2020 at 11:00 AM, revealed all Physician's Orders for restraints should include specific type of restraint, medical symptom(s) restraint would treat, how the restraint would protect the safety of the resident and how long the restraint would be in use. Further interview with MDS #1 revealed all Physician's Orders, including those written for restraints, were reviewed by the IDT Team during daily morning meetings and had no explanation for missing regulatory specifications in Resident #70's Physician's Orders for lap tray/lap buddy and mat alarm. Continued interview revealed it was the MDS nurse's responsibility to ensure all Physician's Orders were correct and placed on resident's care plans. MDS #1 reported she did not know Resident #70's mat alarm to wheelchair and bed or lap tray/lap buddy to wheelchair were considered restraints therefore, did not obtain necessary assessment data, restraint necessity form, consent, perform on-going evaluations nor did she revise the resident's care plan to include any new interventions for possible reduction or elimination of the restraints as per the facility's Restraint Use Policy. Additional interview revealed MDS #1 should have care planned the restraints to ensure staff caring for Resident #70 checked the restraint every thirty (30) minutes and released the restraint every two (2) hours to allow the resident rest periods from the restraint. 3. Review of Resident #85's medical record, revealed the facility admitted the resident on 10/11/16 with diagnoses including, but not limited to Alzheimer's Disease, Major Depressive Disorder, and Psychophysiological Insomnia. Review of the Physical Restraint Consent, dated 09/10/17, revealed re-direction was a less restrictive, alternative non-restraint approach that was proven ineffective. Additionally, a Velcro Seatbelt was a recommended restraint intervention for a specific target behavior of attempts to decrease fall risk, secondary to the medical symptom of dementia and poor safety awareness. Further, potential benefits and risks of restraint use was provided. Review of the Comprehensive Care Plan (CCP), initiated on 10/19/17, revealed Resident #89 had the potential for discomfort, injury and loss of autonomy related to use of physical restraint/Velcro seatbelt due to attempts to get up without assistance, poor safety awareness related to dementia. Redirection supervision unsuccessful. The goal revealed the resident would be free from discomfort and injury and autonomy will be maintained at the highest possible level through the next review date, 03/23/20. Interventions included, but were not limited to: check the resident frequently; attempt reduction or removal of restraint quarterly and as needed; observer for potential negative outcomes; continue to asses for possible elimination or restraint quarterly and as needed; explain risk and benefits; Velcro seat belt while up in wheelchair to remind resident not to get up without assistance, check every thirty (30) minutes and release every two (2) hours, dated 06/20/17. However, the medical symptoms being treated when using the Velcro Seatbelt was not included in the CCP. Review of Resident #39's Monthly January 2020 Physician's Orders, revealed orders for a Velcro Seat belt while up in wheelchair to remind resident not to get up without assistance; check every thirty (30) minutes and release every two (2) hours, dated 12/26/19. However, there was no documented evidence the order included the presence of a medical symptom and how the Velcro Seat belt would treat the medical symptom and protect the resident. Review of the Quarterly MDS Assessment, dated 12/18/19 revealed Resident #89 had BIMS score of two (2) out of fifteen (15), indicating severe cognitive impairment. Per Assessment, the Resident had no behaviors and required extensive assistance with ADLs. Continued review of the Assessment revealed the Resident had no pain and no falls during the Assessment period. Further, the Resident used a daily trunk restraint in chair/out of bed. Review of Resident #89's Restraint Elimination Assessment, dated 12/18/19 revealed the resident was chair bound and non-weight bearing. Additionally, the resident required assistance of one (1) staff for position and had a leaning sitting balance. Per assessment, the resident was disoriented and had a history of falls. Further, the total score of fifteen (15) indicated the resident was a poor candidate for restraint elimination. Continued review revealed a consent had been signed for the Velcro Seatbelt when up in the wheelchair for the medical symptom or target behaviors of poor safety awareness and history of falls. Observation on 01/07/20, at 2:45 PM, revealed Resident #89 lying flat in bed with his/her eyes closed. Additionally, the resident did not respond to verbal stimuli. Further observation revealed a wheelchair at the foot of the bed with a Velcro Seatbelt crisscrossed behind and attached to the anti-tipper bars. Observation on 01/08/20, at 3:00 PM, revealed Resident #89 lying flat in bed with his/her eyes open. Further observation revealed the resident was non-verbal. Additional interview with SRNA #1, on 01/10/20 at 11:20 AM, revealed Resident #89's Velcro Seatbelt to the wheel chair was used to keep the resident from falling out of the chair, because he/she could not remove it from the wheelchair. Continued interview revealed the resident was up daily for about three (3) hours in the wheelchair. Further, she checked on the resident while he/she was up in the wheelchair each time she walked past them to make sure the Velcro Seatbelt was on right. Additional interview with LPN #2, on 01/10/20 at 11:45 AM, revealed the Velcro Seatbelt for Resident #89 was used to reminder the resident to not try to get up unassisted. Per interview, Resident #89 was nonverbal, staff had to anticipate his /her needs, and the resident could not remove the Velcro Seatbelt. Interview with Quality Assurance Registered Nurse (QA) #1, on 01/10/2020 at 12:43 PM, revealed each of the unit's floor (direct care) nurses were responsible for utilizing the Care Plan update form attached to Physician's Orders located in each resident's paper chart for temporarily updating resident's care plans with new interventions. Further interview revealed the Care Plan update form was then placed in the unit communication box along with Physician's Orders (copy kept in chart) and be picked up each morning by the DON or designee and taken to IDT Team morning meeting. Continued interview revealed once the Care Plan update was deemed appropriate for resident, the MDS nurse was responsible for ensuring the resident's care plan was revised and staff providing resident care were made aware of new intervention(s). QA #1 reported MDS nurse's revision of care plan and communication to staff was important to ensure staff provided the proper care and services to the resident across all shifts. Additional QA #1 interview revealed all restraint orders should include specific restraint type, medical symptom restraint would be treating, the duration of restraint use and how restraint use would protect the safety of the resident. Further, QA #1 revealed the resident should be assessed and re-assessed quarterly and as needed, if possible, by the nurse implementing the restraint to ensure continuity of care provided to the resident requiring the restraint. Continued QA #1 interview, revealed she expected the Resident Assessment Instrument (RAI) Manual to be followed during formulation of a restraint care plan and should include regulatory criteria for staff to check the restraints every thirty (30) minutes and to release the restraints every two (2) hours to allow the resident rest periods for toileting, eating, and exercise. Additional interview revealed QA #1 was responsible for auditing resident clinical records to ensure pharmacy consults were completed, fall risk assessments were performed, behavior-monitoring assessments were in place and completed and she reviewed provider notes to ensure medications ordered included resident's diagnosis. QA #1 reported she was aware Physician's Orders for restraints were not correct but she was not responsible for auditing the MDS nurse. Additional Interview with MDS #1, on 01/10/2020 at 01:36 PM, revealed the responsible party/power of attorney restraint consent was not obtained for mat alarm to wheelchair and bed or for lap tray/buddy related to not considered restraint at time of initial restraint assessment. Further interview revealed MDS #1 would be mailing restraint consent form this day to request signature for continued use of lap tray/lap buddy. Continued interview revealed MDS #1 unable to locate requested Resident #70's therapy clinical notes due to facility's change of companies in 2019. MDS #1 advi[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Minimum Data Set (MDS) Assessment accurately reflected the resident's status for one (1) of three (3) sampled residents for restraints out of a total of twenty (20) sampled residents, (Resident # 70). Review of the Quarterly Minimum Data Set (MDS) Assessment, Section P, dated 12/11/19, revealed the facility assessed Resident #70 as not requiring the daily use of a restraint. However, observations of Resident #70 throughout the survey process revealed daily use of a lap tray/lap buddy that Resident #70 was unable to release/remove without staff intervention. The findings included: Interview with Registered Nurse/MDS Coordinator (MDS) #1, on 01/10/2020 at 09:41 AM, revealed the facility utilized the Resident Assessment Instrument (RAI) Manual 3.0, as a guideline for accuracy of resident assessments. Further interview revealed MDS #1 was responsible for ensuring MDS Assessments were accurately performed. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, revised October 2019, Section P: Restraints, revealed the intent of this section was to record the frequency the resident was restrained by any of the listed devices or an alarm was used, at any given time during the day or night, during the seven (7)-day look-back period. Further RAI Manual 3.0 review revealed the facility was to evaluate whether or not a device (including an alarm) met the definition of being a physical restraint and were required to code only those devices that met the definition in the appropriate categories. Continued review revealed the Centers for Medicare and Medicaid Services definition of physical restraint was any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that he/she cannot easily remove and restricted freedom of movement and/or normal access to one's body. Review of the clinical record revealed the facility admitted Resident #70, on 10/03/16 with diagnoses to include Alzheimer's Disease, Dementia without Behavioral Disturbance, Unspecified Atrial Fibrillation, Essential Primary Hypertension and Benign Prostatic Hyperplasia. Review of Resident #70's Quarterly Minimum Data Set (MDS) Assessment, dated 12/11/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), indicating the resident to have severe cognitive impairment. Continued review revealed the facility assessed Resident #70 as requiring extensive physical assistance of one (1) staff member for bed mobility, dressing, toileting and personal hygiene. Further MDS review revealed the facility assessed Resident #70 as requiring limited assistance of one (1) staff member for transfers and as ambulating once or twice with limited assistance of one (1) staff member during the review period. Continued review of MDS revealed the facility assessed Resident #70 as having no limitations in functional range of motion (ROM) to upper or lower extremities, and as having no bed rails, no trunk or limb restraints when in bed or when out of bed or when in chair. Additional 12/11/19 MDS review revealed the facility assessed Resident #70 as requiring bed alarm and chair alarm use daily during the review period. Review of Resident #70's January 2020 Physician's Orders revealed an active order with a start date of 01/12/17 for lap buddy in wheelchair to aide in preventing falls. There was no documented evidence the order included the presence of a medical symptom, how the lap buddy would treat a medical symptom, nor did the order specify the duration of time the lap buddy would be used. Further review of Resident #70's Physician's Orders revealed an active order, with a start date of 11/29/17, for a mat alarm while in bed and chair. There was no documented evidence the order included the presence of a medical symptom, how the mat alarm would treat a medical symptom or protect the safety of the resident, nor did the order include the duration of time the mat alarm would be used. Continued Physician's Order review revealed an active order with a start date of 02/08/18 to try a different lap buddy. There was no documented evidence the order included the presence of a medical symptom, how a different lap buddy would treat a medical symptom or protect the safety of the resident nor did the order specify the duration of time a different lap buddy would be used nor was an indication for use included in the Physician's Order. Observation of Resident #70, on 01/10/2020 at 10:28 AM with MDS #1 present, revealed the resident in the room, sitting in a wheelchair with a mat alarm and lap tray/lap buddy in place. Continued observation revealed Resident #70 was alone, facing the doorway with a picture book on the bedside table at the resident's right side and not within reach. Further observation revealed MDS #1 spoke with the resident and explained the purpose of the visit as resident responded back in an unintelligible mixture of words and phrases. Further observation revealed MDS #1 requested Resident #70 to remove the lap tray/lap buddy several times with the resident unable to process her request. Continued observations revealed MDS #1 pointed to the lap tray/lap buddy, making a tapping sound with fingernails, drawing Resident #70's attention to lap tray/lap buddy. Additional observations revealed Resident #70 picked up the lap tray/lap buddy from the left side arm of the wheelchair and held it up to MDS #1. Continued observations revealed Resident #70 asked MDS #1 Is this it, is this what you want from me? Further observations revealed Resident #70 continued to speak in an unintelligible mixture of words and phrases as MDS #1 re-applied lap tray/lap buddy before exiting resident room. Interview with the MDS #1, on 01/10/2020 at 11:00 AM, revealed she was responsible for completing the MDS Assessments, including Section P as it related to Restraints. Further interview revealed MDS #1 did not realize Resident #70 was unable to independently remove the lap tray/lap buddy and did not believe it to be a restraint, therefore not coding it as such on Resident #70's 12/11/19 MDS. Continued interview revealed MDS #1 was unfamiliar with restraint regulations and was unaware of the need to re-assess resident(s) for restraint reductions for the least restrictive device and possible restraint elimination although she had directed the unit's floor nurses (direct care) to perform those assessments for her review. MDS #1 was unable to explain the reason the MDS dated [DATE] was coded incorrectly. Per interview, MDS #1 revealed it was important to ensure proper MDS coding to provide proper care and services to each of the residents. Additional interview revealed it was important to ensure the MDS Assessment was completed accurately because information on the Assessment drove the development and revision of the Comprehensive Care Plan and ensured care provided was the best care to meet the individual residents' needs. Interview with the Director of Nursing (DON), employed with the facility for seventeen (17) years, on 01/10/2020 at 1:48 PM, revealed the Resident Assessment Instrument (RAI) Manual was the guideline used by the facility to ensure accurate assessments were performed for each resident. Further interview revealed the MDS Assessment for Resident #70 should have been accurate related to use of lap tray/lap buddy as well as his/her use of a mat alarm because this was the assessment information documented in the resident's clinical record during the Assessment look-back period. Continued DON interview revealed the MDS Assessment guided the development of the resident's Comprehensive Care Plan and therefore, the MDS Assessment should be an accurate reflection of the resident's status to ensure the resident received appropriate, individualized care and services. Additional interview with the DON revealed it was ultimately the MDS nurse's responsibility to ensure the MDS Assessments were performed accurately and timely in order to formulate a Comprehensive Care Plan individualized to each resident. The DON added it would not be possible to properly develop or revise a Comprehensive, Individualized Plan of Care if the MDS Assessments were not accurate. The Licensed Nursing Home Administrator was not present during the survey process nor was she present for interview on 01/10/2020.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure each resident had a person-centered Comprehensive Care Plan (CCP) developed and implemented to address the resident's medical, physical, mental and psychosocial needs related to use of restraints for two (2) residents of twenty (20); (Resident #19 and Residents # 70). Resident #19's Comprehensive Care Plan was not developed to include the use of Buspar (anti-anxiety medication). Resident #70 Comprehensive Care Plans were not developed to include interventions for restraint potential negative outcomes, potential benefits of restraint use, or assess/attempt reduction or removal of restraints when no longer required to treat the resident's medical symptoms. The findings included: Review of the facility's policy titled, Electronic Health Record-Care Plans, dated 12/2014, revealed the purpose of the policy was to ensure staff communication of all resident care needs for continuity of care. Further review revealed Care Plans ensured all persons involved in resident care would be made aware of resident care needs and were encouraged to make changes to the Care Plan as resident changes occurred. Continued policy review revealed all resident problems with interventions in place would be included on each resident Care Plan. Additional Policy review revealed Care Plans should be accurate to reflect resident current conditions and should change as resident changes. 1. Review of Resident #19's medical record revealed the facility admitted the resident on 11/23/15 with diagnoses to include Acute Kidney Failure, Type 2 Diabetes, Generalized Anxiety Disorder, and Age-Related Physical Debility. Review of Annual Resident's Minimum Data Set, dated [DATE] revealed the facility assessed resident to have a Brief Interview for Mental Status (BIMS) score of four (04) out of fifteen (15) indicating severe cognitive impairment. Review of Resident #19's Active Physician's Orders revealed a current order for Buspirone HCL 7.5 milligram (mg) tablet by mouth twice daily with a start date of 07/10/19. Continued review revealed an active current order for Lorazepam 0.5 mg tablet, take one (1) tablet by mouth once daily at 4:00PM, with a start date of 07/26/18. Continued review revealed a current active treatment order to Observe Resident for Behaviors Related to Psychotropic Drug Usage with a start date of 10/16/18. Review of Resident #19's Care Plan, with problem onset of 07/29/16 revealed resident is at risk for side effects from antianxiety medication: use of Lorazepam 0.5mg at bedtime for anxiety disorder. The Goal states resident will have no injury related to medication usage/side effects through the next ninety (90) days, and resident will be free of any discomfort or adverse side effects of Lorazepam through the next ninety (90) days. The Approaches state to administer medication as ordered by the physician. Observe resident for adverse side effects, document and report to physician. Observe resident to signs and symptoms of extrapyramidal symptoms and document. Assess for fall risk. Pharmacy consultant review of medication monthly for need of trial dose reduction, labs as needed for possible interactions with other medications with recommendations to be faxed to physician and flagged and placed in the chart. Observe for side effects of Lorazepam: drowsiness, sedation, agitation, dizziness, nasal congestion, nausea, change in appetite; if observed report to charge nurse promptly. Gradual Dose Reduction on 11/16/17 declined by physician. However, continued review of the care plan revealed no documented evidence a problem was identified related to resident #19's use of the antianxiety medication Buspirone. 2. Review of the clinical record revealed the facility admitted Resident #70 on 10/03/16 with diagnoses to include Alzheimer's Disease, Dementia without Behavioral Disturbance, Unspecified Atrial Fibrillation, Essential Primary Hypertension and Benign Prostatic Hyperplasia. Review of Resident #70's Quarterly Minimum Data Set (MDS) Assessment, dated 12/11/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), indicating the resident had severe cognitive impairment. Review of Resident #70's January 2020 Physician's Orders revealed an active order with a start date of 01/12/17 for lap buddy in wheelchair to aide in preventing falls. Further review of Resident #70's January 2020 Physician's Orders revealed an active order with a start date of 11/29/17, for a mat alarm while in bed and chair. Review of Resident #70's Comprehensive Care Plan, initiated 03/24/17, revealed the resident at risk for fall prevention devices becoming a restraint. The goal stated Resident #70 would continue to have ability to remove the lap tray/lap buddy through next review date of 03/18/20. Interventions included the following: Staff completing Restraint Necessity Assessment when considering any restraint; Completing Restraint Elimination Assessment quarterly; Observing resident with restraint in use; Removing resident's lap tray/lap buddy at meal times to enable him/her to eat at table; Replacing lap tray/lap buddy after meals; Periodically asking resident to remove lap tray/lap buddy (if unable to do so, will be considered a restraint); Documenting resident ability or inability to remove; and ensuring mat pressure alarm in use when resident in bed or in chair. Further review of Comprehensive Care Plan revealed no documented evidence of initial restraint necessity assessment, medical symptom treating, on-going restraint assessments for possible restraint reduction or elimination or interventions individualized to resident's specific needs related to restraint use. Continued Care Plan review revealed no documented evidence of duration of restraint use or when staff were to check the resident's restraint for monitoring every thirty (30) minutes and release every two (2) hours. Interview with State Registered Nurse Aide (SRNA) #5, on 01/09/2020 at 1:51 PM, revealed she was routinely assigned to provide direct care to Resident #70 and was familiar with the resident's care needs. Further interview revealed Resident #70 had a mat alarm to his/her wheelchair and bed as well as a lap tray/lap buddy on his/her wheelchair due to falls sustained in the past from apparent attempts to self-transfers. Continued interview with SRNA #5 revealed she had observed Resident #70 remove the lap tray/lap buddy in the past but had not observed resident removing it recently. Additional interview with SRNA #5 revealed Resident #70 did not have the ability to follow commands and had difficulty communicating needs related to severe cognitive impairment. SRNA #5 advised staff anticipated resident needs and had never been advised to check resident's lap tray/lap buddy every thirty (30) minutes and release the lap tray/lap buddy every two (2) hours. Continued interview with SRNA #5 revealed the only instructions she had received regarding the lap tray/lap buddy were those located on Resident #70's care tasks, which included removing the lap tray/lap buddy at meal times and replacing lap tray/lap buddy prior to resident leaving dining room. SRNA #5 added no additional instructions regarding Resident #70's lap tray/lap buddy had been provided to her. Interview with Licensed Practical Nurse (LPN) #3 (nurse assigned to provide care to Resident #70 daily), on 01/09/2020 at 1:30 PM, revealed she was responsible for performing the initial restraint assessments and quarterly restraint elimination assessments. Further interview revealed the MDS nurses reviewed initial and quarterly restraint assessments and other resident assessments performed by each of the unit's floor nurses and formulated comprehensive care plans and implemented restraint devices based upon those assessments. Interview on 01/10/2020 at 09:41 AM with Registered Nurse/MDS Coordinator (MDS) #1, employed with facility for thirteen (13) years, revealed her assessment of Resident #70 on 12/11/19 revealed a BIMS score of three (3) out of fifteen (15), indicating severe cognitive impairment but, her observation of resident, during that time, was the resident had the ability to remove lap tray/lap buddy at any given time upon request. Further interview with MDS #1 revealed lap tray/lap buddy would be considered a restraint if resident was unable to remove it upon command. Continued MDS #1 interview revealed mat alarm to wheelchair and bed would not be considered a restraint and wasn't sure how she should have coded the wheelchair and mat alarms on 12/11/19 Quarterly MDS Assessment. Additional interview revealed MDS #1 collected resident data for MDS assessments by reviewing the clinical record for any falls or other unusual incidents. MDS #1 added she gathered data for MDS assessments by reviewing Physician's Orders, monthly summaries, restraint assessments and pain interviews performed by the unit floor nurses. Further interview revealed another source of information for MDS #1 was talking with the unit floor nurses providing care for the residents. Additional interview revealed the only physical assessment of residents performed by MDS #1 was those completed during the resident BIMS interviews. MDS #1 relied on other staff member's assessments to complete resident's Annual and Quarterly Assessments. MDS #1 revealed accurate MDS Assessments were important to ensure proper care was provided to each resident. Interview with Director of Nursing (DON), employed with facility for seventeen (17) years, on 01/10/2020 at 1:48 PM, revealed the Resident Assessment Instrument (RAI) Manual was the guideline used by the facility to ensure accurate assessments were performed for each resident. Further interview revealed the facility also followed their Care Plan Policy to ensure Comprehensive Care Plans were developed, implemented and revised with resident changes to ensure individualized care was provided. Continued interview revealed the 12/11/19 MDS Assessment for Resident #70 should have been accurate related to use of lap tray/lap buddy as a restraint because this was the assessment information documented in the resident's clinical record during the Assessment look-back period. Continued DON interview revealed the MDS Assessment guided the development of the resident's Comprehensive Care Plan and therefore, the MDS Assessment should be an accurate reflection of the resident's status to ensure the resident received appropriate, individualized care and services. Additional interview with the DON revealed it was ultimately the MDS nurse's responsibility to ensure the MDS Assessments were performed accurately in order to formulate/develop a Comprehensive Care Plan individualized to each specific resident. DON added it would not be possible to properly develop or revise a Comprehensive, individualized Plan of Care if the MDS Assessments were not accurate. The Licensed Nursing Home Administrator was not present during the survey process and was not available for interview.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of facility Policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for five (05) of twenty (20) residents. (Resident #9 and Resident#10). Resident #9 had fall events on 06/04/19 and 08/15/19; however the CCP was not revised to include interventions status post fall to prevent falls of the same nature based on the facility's investigation. Resident #10, had current Monthly January 2020 Physician's Orders, for Celexa (anti-depressant), dated 10/30/19. Additionally the Quarterly Minimum Data Set (MDS) Assessment, dated 10/09/19, revealed the Resident received six (6) days of anti-depressant medication; however, the CCP was not revised to include the use of anti-depressants. The findings include: Review of the facility Care Plans Policy, effective 12/2014, revealed the Care Plan (CP) was a communication tool containing information about the resident so there would be continuity of care. Additionally, CPs are utilized to inform all staff of the needs and changes for all the residents. Continued review revealed all problems with interventions in place should be included on the CP. Per policy, CP should be updated immediately upon discovering (including but not limited to) a change in condition, any intervention put into place, and incidents. Further, CPs should be an accurate reflection of residents' current conditions and changes. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the care plan must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written plan of care. Continued review revealed the care plan was driven not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a care plan based on a thorough assessment and effective clinical decision making, was compatible with current standards of clinical practice that provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. A well developed and executed assessment and care plan: re-evaluates the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary. 1. Review of Resident #9's clinical record revealed the facility admitted the resident on 01/10/2012 with diagnoses including, but not limited to Dementia without behavioral disturbance, Chronic Obstructive Pulmonary disease, Polyarthritis, Anxiety Disorder, and history of falls. Review of Resident #9's Occupational Therapy (OT) Discharge, dated 03/07/2019 revealed the Resident was seen for short term rehabilitation for assessment/adaptation of the wheelchair in order to eliminate fall risk out of the wheelchair. Additionally, the Resident had received recent OT skilled services from 02/26/2019-02/28/2019 for wheelchair management training. Further, the Resident had improved anatomical positioning and no falls out of the wheelchair since OT Plan of Care. Review of Resident #9's Progress Note, dated 06/04/2019 at 9:08 PM, revealed the resident had an unwitnessed fall even in their room from their wheelchair. Additionally, the Resident had no obvious injuries and denied discomfort. Further, the Resident was wearing shoes at the time of the fall event. Review of Resident #9's Annual Minimum Data Set (MDS) Assessment, dated 07/17/2019, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (03) out of fifteen (15) indicating severe cognitive impairment. Additionally, the facility assessed the resident as requiring extensive assistance of two (02) staff for transfers and ambulation did not occur. Per the Assessment, the resident had unsteady balance, was only able to stabilize with staff assistance during transition from surface to surface. Continued review revealed the resident had no falls since prior Assessment. Further review revealed a chair and bed alarm was used daily and the resident used no physical restraints. Review of Resident #9's Progress Note, dated 08/15/2019 at 12:05 PM, revealed the resident had a fall event in the hallway from his/her wheelchair. Additionally, the resident had a bloody nose. Further, the resident was sent to the emergency room for evaluation and treatment. Review of Resident #9's Comprehensive Care Plan (CCP), revised 09/09/19, revealed the resident was at risk for falls related to use of antipsychotic medication, Alzheimer's Dementia. The goal was to minimize injuries related to fall risk. The interventions included, but were not limited to: fall risk per policy; fall follow up documentation seventy-two (72) hours; and assessment for different wheelchair related to leaning forward in chair (02/24/2019). However, further review of the CCP, revealed it was not revised to include keeping the Resident in the hallway when up in the wheelchair, on 06/04/2019. Additionally, the CCP was not revised to include reclining the wheelchair, on 08/15/2019. Interview with Quality Assurance Director (QAD), 01/09/2020 at 3:19 PM, revealed after review of the Incident Report (IR) and Quality Review (QR) for Resident #9's Fall Investigation, dated 06/04/2019 revealed the Root Cause Analysis (RCA) of the fall event was the resident was in his/her wheelchair alone in their room and leaned forward from the wheelchair. Additionally, the intervention to prevent future falls of the same natures was to educate the staff to keep the resident in the hallway when in the wheelchair. Further, after review of the IR and QR for Resident #9's Fall Investigation, dated 08/15/2019, revealed the RCA of the fall event was the resident leaned forward from the wheelchair. The intervention to prevent further falls of the same nature was to place the wheelchair positioning into a reclined position when the resident was in the wheelchair. Continued interview with the QAD, revealed the Minimum Data Set (MDS) nurse was responsible to revise the CCP, after resident fall events with interventions determined by the interdisciplinary team (IDT) to ensure resident were provided safe care and to decrease the risk for similar falls. Additional interview revealed fall events were reviewed each morning and each Wednesday, in the Quality Assurance and IDT Meeting, by the Administrator, Director of Nursing, QAD, Therapy, MDS nurse, Restorative Nursing Nurse, Unit Coordinators, and Social Services, to ensure documentation was in place, interventions were implemented and effective status post fall event. Further, the CCP for Resident #9 should have been revised to include interventions status post falls on 06/04/2019 of keeping the resident in the hall when up in the wheel chair and 08/15/2019 with the intervention reclining the wheel chair as determined by the IDT. Interview with MDS Coordinator, on 01/09/2019 at 3:45 PM, revealed he/she utilized the Resident Assessment Instrument (RAI) as guidelines to revise the CCP. Additionally, the CCP was revised with an intervention status post all resident fall events. Continued interview revealed after Resident #9's fall event, on 06/04/2019, revealed the CCP was not revised to include the intervention, determined by the IDT, to keep the resident in the hallways when in his/her wheelchair. Further, the CCP was not revised after Resident #9's fall event on 08/15/2019 in include reclining the wheelchair positioning. Continued interview revealed revision of the CCP was important to ensure direct care staff were provided with information to keep a resident safe and meet their care needs. 2. Review of Resident #10's clinical record revealed the Resident was admitted to the facility on [DATE] with diagnosis including but not limited to: Bipolar Disorder, Insomnia, and Anxiety. Review of the Quarterly MDS Assessment, dated 10/09/2019, revealed the Resident had a BIMS of ten (10) out of fifteen (15) indicating moderate cognitive impairment. Additionally, the Resident had no symptoms of depression. Further, the Resident received six (6) days of anti-depressant medication during the look back period. Review of Resident #10's Monthly Physician's Orders, dated January 2020, revealed an order for Celexa (anti-depressant) twenty (20) milligrams (mg) daily. Review of the CCP, initiated on 02/07/2017, revealed the Resident used psychotropic medication, anti-depressants, secondary to a diagnosis of Bipolar disorder and currently received Cymbalta. The goal was the Resident would have no injury related to medication use/side effects undetected. However, the Goal was achieved on 11/27/2018. Further, review of the CCP, revealed no documented evidence of a CCP to address Resident #10's use of anti-depressant medications. Interview with MDS Coordinator, on 01/10/2020 at 12:27 PM, he/she utilized the RAI as guidelines to revise the CCP. Additionally, the CCP should be revised with a Physician orders, for anti-depressant medication. Per interview, when an order for medication was received, the MDS Nurse was responsible to revise the CCP for the use of the medication and interventions to ensure safe/therapeutic use of the medication. Further, interview revealed Resident #10's CCP should have been revised when the anti-depressant medication was changed and/or the MDS Assessment was completed. Per interview, the revision to the CCP was missed because the MDS Assistant was off work when the order changed and the MDS Coordinator missed the change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of facility Policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident, with measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for two (2) of twenty-four (24) sampled residents (Resident #33, and #71). There was no documented evidence the facility developed and implemented Comprehensive Care Plans for Resident #33 and #71 based on the comprehensive assessment, and the preferences of each resident related to Activities. The findings include: Review of the facility Policy titled, Care Plan Development undated, revealed the facility must develop and implement a comprehensive person-centered care plan for each resident. Further review revealed the purpose of the Care Plan was to attain or maintain the resident's highest practicable physical, mental, and psychological well-being. Review of the facility Policy titled, Activities dated 11/2016, revealed the facility must provide, based on the comprehensive assessment, care plan, and the preferences of each resident, an ongoing program to support residents in their choice of activities. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. 1. Review of Resident #33's medical record revealed the facility admitted the resident on 03/14/13 with diagnoses to include Adult Failure to Thrive, Chronic Ischemic Heart Disease, and Major Depressive Disorder. Review of the Annual Minimum Data Set (MDS) Assessment, dated 12/06/17, revealed the facility assessed Resident #33 as not exhibiting speech and as rarely understood. The Assessment further revealed the family provided information and stated it was very important to the resident to participate in favorite activities. Review of the Quarterly MDS Assessment, dated 08/15/18, revealed the facility assessed Resident #33 as being unable to answer questions in order to determine a Brief Interview for Mental Status (BIMS) score. Further review revealed the facility assessed the resident as having no change from the Annual MDS assessment dated [DATE], in speech patterns or the desire to participate in favorite activities. Review of Resident #33's Care Plan, with problem onset of 09/12/16, revealed the resident had the potential for social isolation. Per the Care Plan, no specific activity preferences were identified despite the importance for Resident #33 to participation in favorite activities identified per the Annual and Quarterly MDS Assessments. The identified Care Plan goal stated the resident would socialize with staff and roommates to the extent possible, through target date 11/17/18. However, this Care Plan was not developed with an attainable goal as Resident #33 was aphasic and was rarely understood according to the MDS Assessments. Care Plan Approaches included assistance to and from activities; activity calendar in the room; and visits to determine appropriate in-room activities, which were not consistent with the resident's communication limitations. Observation of Resident #33, on 10/24/18 at 9:33 AM, revealed the resident was up in a Geri chair in his/her room with his/her eyes closed. Observation of Resident #33 on 10/24/18 at 1:10 PM, revealed the resident was in the dining area and was dependent for feeding assistance. The resident was not observed to interact with any other residents or staff. Observation on 10/25/18 at 10:11 AM, revealed the resident was dressed, up in the Geri chair in his/her room with eyes closed. The resident was unresponsive to the State Agency Representative when questioned during this observation. Review of the Activity Participation Roster, dated 09/01/18 through 10/24/18, revealed the Care Plan was not implemented related to activities as there was no documented evidence the resident had participated in any activities during this timeframe. Although requested, the facility was unable to submit any documented evidence Resident #33 participated in any Activities for the months of September 2018 and October 2018. There was no documented evidence the Care Plan approaches to assist the resident to activities and to visit the resident to ascertain in-room activities were implemented. Interview with the Interim Activity Director on 10/25/18 at 9:50 AM, revealed Resident #33 was less responsive at this time. She stated she could not recall any information related to this resident's activities preferences, and could not locate any documentation to indicate the resident had participated in activities, as per the Care Plan. 2. Review of Resident #71's medical record revealed the facility admitted the resident on 06/25/15 with diagnoses to include Chronic Obstructive Pulmonary Disease, Heart Failure, Osteoarthritis of the Hip, and Type ll Diabetes. Review of the Annual MDS Assessment, dated 6/13/18, Section B, revealed the facility assessed the resident as having impaired vision and as requiring large print to be able to read. Section F, revealed it was very important to the resident to be able to participate in his/her favorite activities. Review of the Quarterly MDS Assessment, dated 09/05/18, revealed the facility assessed the resident as having a BIMS score of eleven (11) out of fifteen (15) indicating moderate cognitive impairment. Further review of the MDS, revealed the facility assessed the resident as having no visual changes nor changes in the importance of activities (Sections B and F) since completion of the Annual MDS assessment dated [DATE]. Review of Resident #71's Care Plan revealed a problem onset date of 09/27/16, related to decreased socialization. Per the Care Plan, Resident #71 preferred to stay in his/her room to watch television, read the Bible as well as other books, and visit with family and friends. The resident's visual impairment identified on the MDS assessment was not included in the Care Plan problem. Identified Care Plan goals included: group activity attendance; staff, family and volunteer visits; and daily self-directed activities with a target date of 01/12/19. Approaches included: provide monthly newsletters and calendars, provide supplies for self-directed activities upon resident request, encourage to attend group activities; family visits; and monitor for changes in activity. However, the Care Plan approaches did not include large print reading material to enable the resident to participate in his/her favorite activity of reading. Review of the Activity Participation Roster dated 09/01/18 through 10/24/18, revealed the Care Plan was not implemented as there was only one (1) sensory activity offered on 09/24/18 at 1:26 PM, with no documented evidence the resident participated in any other activities during this timeframe. Review of facility Activities Minutes Total Roster dated 09/01/18 through 10/24/18 revealed one (1) minute of resident activity minutes was recorded for the date of 09/24/18. The Interim Activity Director stated the time recorded for the activity on 09/24/18 was incorrect; however, she was not sure of the actual length of time for the 09/24/18 activity. Observation of Resident #71 on 10/24/18 at 9:16 AM revealed the resident was in his/her room. The resident was not observed out of his/her room on 10/24/18 during observations conducted every thirty (30) minutes until noon on that date. Observation on 10/25/18 at 10:29 AM, revealed Resident #71 was again observed in his/her room. Interview with the resident during this observation, revealed he/she loved books and preferred to read; however, his/ her eyesight had declined and it was now difficult to read. The resident stated he/she was not up to attending group activities, but enjoyed activities in the room. Although Resident #71 stated he/she loved to read, but found his/her vision to be an impairment to achieving his/her reading preference, neither the Care Plan nor the Activity Participation Roster reflected approaches to address visual limitations. Interview with the Interim Activity Director, on 10/25/18 at 9:50 AM, revealed she had no documentation of participation in any group or individual activities for Resident #71 other than on 09/24/18, and therefore the Care Plan was not implemented. She further stated the general practice was for activity staff to go to the resident's room to offer individual activities. She could not recall any specific activities provided for this resident, nor was the Care Plan developed with interventions in place for the resident's visual challenges. Further interview with the Interim Activity Director, on 10/25/18 at 9:50 AM, revealed she was new to the role. She stated she was working on a better process for providing and documenting individual activities consistent with the comprehensive assessment and Care Plan. The Interim Activity Director stated the former Director of Activities did not have a system for documentation of individual activities and thus, this was a focus for her going forward. She stated individual one to one (1:1) activities were not scheduled for specific residents who needed needed the one to one (1:1) activities. Per interview, efforts were in progress to obtain more tools to provide one to one (1:1) activities for residents. The Interim Activity Director stated the purpose of providing person-centered activities was to give residents a sense of purpose, improve social skills, and for their overall well-being. Interview with the Minimum Data Set (MDS) Coordinator, on 10/25/18 at 4:58 PM, revealed the MDS staff completed MDS assessments and coordinated Care Plans, but relied on each department to develop and implement person-centered care pertinent to their areas of expertise. Continued interview revealed the activity staff was responsible for creating and entering the Activity Care Plan goals and approaches for each resident, and Activities staff was responsible for implementing the Activities Care Plan. Interview with the Administrator, on 10/25/18 at 3:54 PM, revealed it was her expectation for the Activity Staff to develop the Care Plan with identified meaningful activities for each resident in collaboration with MDS staff. Per interview, it was also her expectation for the Care Plan to be implemented to ensure residents participate in meaningful activities. She stated the Interim Activity Director was new to the role and was working on improving the department and ensuring activities met identified MDS needs and Care Plan goals. The Administrator stated the importance of person-centered activities was to ensure the highest quality of life for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of facility Policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure services were provided or arranged by the facility, as outlined by the comprehensive care plan for three (3) of twenty-four (24) sampled residents (Resident #14, #16, and #27). Activities were not provided for Resident #14, #16, and #27, as per their Comprehensive Care Plans. The findings include: Review of facility Policy titled Care Plan Development undated, revealed the purpose of the Care Plan was to attain or maintain the resident's highest practicable physical, mental, and psychological well-being. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. 1. Review of Resident #14's medical record revealed the facility admitted the resident on 01/25/18 with diagnoses to include Intrahepatic Bile Duct Carcinoma, and Cirrhosis of the Liver. Review of Resident #14's Comprehensive Care Plan dated 01/25/18, identified decreased participation in activities as a problem. The Care Plan further identified the resident's enjoyment of interactions with staff. Goals included: activities staff to provide items for self-directed activities; resident to be out of the room for activities of interest; regular visits with staff; and church visits at least weekly. Approaches to accomplish goals included: providing the resident with calendars and newsletters; checking with the resident to ensure in-room needs were met; and encouraging the resident to attend activities. The Comprehensive Care Plan further identified the resident's feeling of fatigue with little energy as a problem on 08/01/18. Goals included: an increase in the mood score and resolution of depression by target date 01/25/19. Approaches included: family visits; resident expression of feelings; out of room activities; socialization; monitoring for negative statements; encouragement for resident to leave room; one on one (1:1) individual visits; medications; and clergy visits. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 08/01/18, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of fourteen (14) out of fifteen (15) indicating the resident was cognitively intact. Review of the Activity Participation Roster dated 09/01/18 through 10/24/18, revealed the resident received four (4) activity/socialization interactions during the fifty-four (54) day report period. The activities included three (3) group activities and one (1) outdoor activity. There was no documentation of church visits nor were any individual activities for the resident implemented in accordance with Care Plan approaches. Although the Care Plan identified the resident's fatigue and included one on one (1:1) approaches, the facility provided only group activities. Review of Departmental Notes, written by the Interim Activity Director, dated 10/22/18 at 2:23 PM, revealed the resident liked to watch television and have one to one (1:1) conversations. The Activity Participation Roster dated 09/01/18 through 10/24/18, did not support provision of activities in accordance with the Departmental Notes. Observation of Resident #14 on 10/24/18 at 8:43 AM and 10/25/18 at 9:54 AM, revealed the resident was in bed with no one present and no items visible for self-directed activity. Interview with the resident on 10/25/18 at 9:54 AM, revealed he/she preferred to have one on one (1:1) activities in the room due to his/her progressive illness. Resident #14 further stated he/she missed socialization with others. Interview with the Interim Activity Director on 10/25/18 at 9:34 AM, revealed Resident #14 had experienced a decline in overall health due to his/her diagnoses. The Interim Director stated although the resident was very social; the last activity provided was a group activity on 10/03/18. Further interview revealed the resident was not provided activities in accordance with his/her Care Plan. 2. Review of Resident #16's medical record revealed the facility admitted the resident on 04/27/16 with diagnoses to include Myocardial Infarction, Obstructive Sleep Apnea, Osteoarthritis, and Osteoporosis, and Unspecified Dementia without Behavioral Disturbance. Observation on 10/25/18 at 10:33 AM, revealed Resident #16 interacted with others with a smile and pleasantly confused conversation. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of six (6) out of fifteen (15) indicating severe cognitive impairment. Review of Resident #16's Comprehensive Care Plan with admission date of 04/25/16, revealed decreased participation in activities was identified as a problem on 09/28/16. The Goal stated the resident would have visits from staff several times each week through the next review date of 01/12/19. Care Plan interventions included: staff assistance to and from activities; room visits; one to one (1:1) activities as needed; encouragement to attend activities; and provision of the monthly newsletter and calendar. A second Goal for the resident to receive family visits several times each week was documented as achieved on 10/25/18. Review of Department Notes written by the Interim Activity Director, dated 10/15/18 at 4:00 PM, revealed the resident was bedridden; however, he/she was up in a Geri chair and liked to sit in the hall or watch television. The facility had no activities documented on the Activity Participation Roster from 09/01/18 through 10/24/18 to support implementation of the Care Plan activity Goals and Approaches, or to substantiate achievement of the Goal for the resident to receive family visits several times each week Interview with the Interim Activity Director on 10/25/18 at 9:40 AM, revealed Resident #16 was able to be up in a chair. She stated no documentation was available to support ongoing activities for the resident in the last fifty-four (54) days; and therefore the resident's Activities Care Plan was not implemented. 3. Review of Resident #27's medical record revealed the facility admitted the resident on 01/06/15 with diagnoses to include Cerebral Infarction due to Unspecified Occlusion or Stenosis of Unspecified Cerebral Artery, Chronic Ischemic Heart Disease, Osteoarthritis, and Pain in Unspecified Limb. Review of Resident #27's Comprehensive Care Plan, revealed the onset of a socialization problem on 08/26/16. The Goal included: interaction with staff and others through the next review date of 11/16/18. Approaches included: encouragement and assistance to attend meals and group activities and individual one on one (1:1) visits as needed. Further review of the Comprehensive Care Plan, revealed a problem with onset date of 08/29/16, related to the resident's isolation in the room and lack of participation in activities, although per the Care Plan, the resident had a love of music. The Goal included: self -directed activities in the room; daily visits with staff; and weekly family visits through 11/13/18. Approaches included: family visits; provision of the monthly newsletter and calendar; escorting to group activities; room visits from staff and volunteer;, assistance with television; and monitoring for a change in activity levels. Review of the Quarterly MDS Assessment, dated 08/08/18, revealed the facility assessed the resident as having a BIMS of thirteen (13) out of fifteen (15) indicating the resident was cognitively intact. There was no documented evidence Resident #27 participated in any activities from 09/01/18 through 10/24/18 per the Activity Participation Roster. No approaches detailed in the Care Plan were implemented to support goal achievement for the resident. Observation of Resident #27 on 10/24/18 at 9:46 AM, revealed a talkative resident; however, the resident was not observed to be out of the room. On 10/24/18 at 1:02 PM, Resident #27 ate lunch in the dining area and then returned to the room. On 10/25/18 at 10:31 AM, Resident #27 was in bed with eyes closed in the room. Interview with the Interim Activity Director on 10/25/18 at 9:45 AM, revealed she could not recall any activities provided for the resident. She further stated she reviewed the Activity Participation Roster for the last two (2) months and found no activities recorded for the resident. Per interview, the resident's Care Plan related to Activities was not followed. Further interview with the Interim Activity Director on 10/25/18 at 9:50 AM, revealed she was new to the role. She stated she was working on a better process for providing and documenting individual and group activities. Per interview, the former the Activity Director did not have a system for documentation of individual activities and thus, this was a focus for her going forward. The Interim Activity Director stated the purpose of providing regular person-centered activities was to give residents a sense of purpose and to improve social skills. Interview with the Minimum Data Set (MDS) Coordinator, on 10/25/18 at 4:58 PM, revealed the activity staff created and entered the Activity Care Plan goals and approaches for each resident. Per interview, Activities staff was to ensure the Activities Care Plans were followed. Interview with the Administrator, on 10/25/18 at 3:54 PM, revealed it was her expectation for the Activity Staff to plan, coordinate, and document meaningful activities for each resident. She stated the Interim Director was new to the role and was working on improving the department. The Administrator stated the importance of person-centered activities was to ensure the highest quality of life for each resident, and it was her expectation Activities Care Plans be implemented,

Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure initial PRN (as needed) psychotropic drug orders were limited to fourteen (14) days for two (2) of twenty-four (24) sampled residents (Resident #16 and #83). Resident #16's Physician's Orders dated 08/17/18, revealed orders for Ativan (Lorazepam) 0.5 milligrams (mg) (anti-anxiety medication) by mouth every six (6) hours as needed (PRN) for agitation, with no stop date written for the medication. Based on the Consultant Pharmacist recommendations, Physician's Orders were obtained on 08/26/18 to stop Ativan on 09/01/18 (fourteen (14) days after the initial order). However, review of the Medication Administration Record (MAR) revealed the resident received the medication on 09/04/18, after the medication had been discontinued. In addition, Resident #83's Physician's Orders, dated 06/13/18, revealed orders for Ativan 0.5 mg, one (1) tablet every six (6) hours PRN, with no stop date for the medication. The Consultant Pharmacist made recommendations on 06/14/18, for the PRN Psychotropic medication to be limited to fourteen (14 days). The Physician documented rationale for continuing the medication on 07/12/18; however, failed to document the determined duration of time for the medication. There was no documented evidence the Consultant Pharmacist made another recommendation related to the PRN Ativan for the determined duration of time for the medication until 10/17/18, more than three (3) months later. The original Ativan order dated 06/13/18 continued without a determined duration of time for the Ativan until the medication was discontinued on 10/31/18. The findings include: Review of the facility Policy titled, How to Administer a PRN Medication dated 04/03/15, revealed general instructions for use of the EMAR (Electronic Medication Administration Record) when administering a PRN medication. The policy was not specific related to PRN administration of psychotropic medications. Review of the Center for Medicare Advocacy, Reducing Antipsychotic Use in Nursing Homes: Save Residents' Lives, Save Medicare Billions of Dollars undated, revealed better care was less costly than poor care. Reduction of antipsychotic drug use in residents without psychosis provided better care at reduced cost. The review noted the Food and Drug Administration (FDA) found use of antipsychotic drugs in the elderly who did not need them was extremely dangerous. 1. Review of Resident #16's medical record revealed the facility admitted the resident on 04/27/16 with diagnoses including Myocardial Infarction, Obstructive Sleep Apnea, Osteoarthritis, Osteoporosis, and Unspecified Dementia without Behavioral Disturbance. On 07/07/18, the resident was placed under Hospice care with a diagnosis of Senile Degeneration of the Brain. Review of the Physician's Orders dated 08/17/18, revealed orders for Ativan (Lorazepam) 0.5 milligrams (mg) by mouth every six (6) hours as needed (PRN) for agitation, without a discontinue date. Review of the Consultant Pharmacist Communication to Physician Form dated 08/20/18, revealed the pharmacist recommended limiting the use of PRN Ativan ordered on 08/17/18, to fourteen (14) days. The pharmacist cited the Centers for Medicare/Medicaid Services (CMS) guidelines requiring documented rationale for use of the psychotropic beyond fourteen (14) days. On 08/26/18, the Attending Physician reviewed and signed the Form as agreeing with the recommendation. Review of Resident #16's Physician's Orders dated 08/26/18 at 8:15 AM, revealed orders to stop Ativan on 09/01/18 (fourteen (14) days after the initial order). Review of the Medication Administration Record (MAR) dated September 2018, revealed an order for Ativan (Lorazepam) 0.5 milligrams (mg) tablet, one (1) tablet by mouth every six (6) hours as needed for agitation. The MAR was marked with an order date and start date of 08/17/18. However, per the MAR, Ativan was marked to be discontinued on 09/09/18, which exceeded the fourteen (14) day limitation. Further review of the MAR, revealed Ativan was administered to Resident #16 on 09/04/18 at 3:11 AM, and was therefore administered after the medication was discontinued per Physician's Orders. Interview with the Consultant Pharmacist on 10/24/18 at 3:11 PM, revealed she performed monthly medication reviews for each resident. She stated a recommendation for a fourteen (14) day stop date was made to the physician for Resident #16's PRN Ativan, on 08/20/18. Per interview, the expected date to discontinue the medication was 09/01/18, based on the initial medication order date of 08/17/18. Interview with Resident #16's Attending Physician on 10/29/18 at 2:02 PM, revealed he relied on pharmacy recommendations and expertise in the care of facility residents. The Physician stated he agreed with the Pharmacist recommendation for Resident #16 to discontinue Ativan fourteen (14) days after the initial order to allow for continued evaluation of this hospice resident. Per interview, he was aware of the regulation to limit PRN psychotropic use and further stated the regulation was somewhat new. The Attending Physician stated it was his expectation for the facility to follow the discontinue order for Ativan PRN for Resident #16, and not exceed the fourteen (14) day limit without additional orders to support medication administration. The Physician stated the reason for limiting psychotropic drug use was to ensure residents received only necessary medications to maintain quality of life. Interview with the Director of Nursing (DON), on 10/24/18 at 3:53 PM, revealed medications were to be administered based upon Physician's orders. Per interview, Resident #16's PRN Ativan was to be discontinued on 09/01/18 as per Physician's Orders. Further interview revealed she could not explain the administration of PRN Ativan on 09/04/18, after the medication had been discontinued. 2. Review of Resident #83's medical record revealed the facility admitted the resident on 03/23/12 with diagnoses including Parkinson's Disease, Anxiety, and Gastro-esophageal reflux disease. Review of Resident # 83's Physician's Orders, revealed orders with a start date of 06/13/18, for Ativan 0.5 mg, one (1) tablet every six (6) hours PRN, with no stop date for the medication. Review of the Consultant Pharmacist Communication to Physician Form, dated 06/14/18, revealed communication to the Physician concerning the change in the Center for Medicare Services (CMS) guidelines requiring documented rationale for use of the psychotropic beyond fourteen (14) days and determined duration documented by the prescriber in the medical record. Further review of the Form, revealed the Physician reviewed the Form on 07/12/18, indicating the rationale for continuing the medication included episodes of agitation and hallucinations. However, further review revealed the Physician did not indicate a determined duration of time for the Psychotropic PRN medication. The Form was signed on 07/12/18, by the Physician. Review of the MAR, dated October 2018, revealed orders for Ativan 0.5 mg, one (1) tablet every six (6) hours PRN continued with no stop date. Continued review of the MAR, revealed two (2) PRN doses of Ativan were administered on 10/16/18 at 10:14 AM and on 10/23/18 at 2:09 PM. There was no documented evidence the Consultant Pharmacist made another recommendation related to the PRN Ativan related to the need for the determined duration of time for the medication until 10/17/18, more than three (3) months later. Review of the Consultant Pharmacist Communication to Physician Form, dated 10/17/18, revealed communication to the Physician concerning the change in the Center for Medicare Services (CMS) guidelines for Psychotropic medications to be limited to fourteen (14 days). Per the Form, use beyond fourteen (14) days required a documented rationale and determined duration documented by the prescriber in the medical record. This Form was faxed to the Physician on 10/23/17, and the Physician marked the Form in agreement and signed the Form on 10/31/17. Review of Physician's Orders dated 10/31/18, revealed orders to discontinue the PRN Ativan. Further interview on 10/24/18 at 3:00 PM, with the Consultant Pharmacist, revealed the reason for the initial fourteen (14) day stop date for psychotropic medications was to ensure the medications were not being given without evaluation of the reason(s) for resident behaviors. Continued interview revealed it was her understanding a psychotropic medication order could extend beyond fourteen (14) days if there was a determined duration with rationale for the medication. Further interview revealed she did not realize a determined duration date for the PRN psychotropic drug was needed once the rationale for the medication was documented. Continued interview with the Director of Nursing (DON), on 10/24/18 at 3:53 PM, revealed PRN psychotropic medications had a fourteen (14) day limitation to ensure behaviors were carefully evaluated prior to continued use. Per interview, this process prevented medications from being administered for behavioral control use, without consideration of behavioral causation. The DON agreed if a PRN psychotropic medication was to be ordered past the fourteen (14) days, there needed to be a rationale and determined duration of time for the medication as per regulation. Interview with the Administrator on 10/24/18 at 3:54 PM, revealed it was her expectation Physician's Orders were followed related to discontinuing medications as per orders. Further interview revealed it was her expectation for the pharmacist to monitor all resident medications in collaboration with the attending physician or provider. She stated the reason for medication reviews and limitations for psychotropic drugs was to determine the root cause of resident behaviors and to first address identified behaviors with methods other than medications. Continued interview revealed the process of identifying behavior and implementing non-pharmacological resolutions when possible ensured the best person-centered, resident outcomes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure an ongoing program to support the residents in their choice of activities, both facility sponsored group and individual activities and independent activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for five (5) twenty-four (24) sampled residents (Resident #14, #16, #27, #33, and #71). There was no documented evidence the facility ensured an ongoing program of Activities for Residents #14, #16, #27, #33, and #71. The findings include: Review of the facility Policy titled, Activities dated 11/2016, revealed the facility must provide, based on the comprehensive assessment, care plan, and the preferences of each resident, an ongoing program to support residents in their choice of activities. Review of the facility Policy titled, Patient Activity Therapy Program, undated, revealed the Activity Director would complete an Activity Assessment on each resident and make progress notes for each resident in the chart. Individual activities were to be provided on an individual, one to one (1:1) basis, as well as large group activities. The Policy further stated, residents could choose to follow a plan of self-directed activities if the resident desired. Review of facility Policy titled, Activity Assessments dated 12/2014, revealed activity assessments should use a variety of information sources. The assessments should follow the Minimum Data Set (MDS) Assessments and be completed at least yearly. 1. Review of Resident #14's medical record revealed the facility admitted the resident on 01/25/18 with diagnoses to include Gastrointestinal Hemorrhage, Unspecified, Intrahepatic Bile Duct Carcinoma, and Cirrhosis of the Liver. Review of Resident #14's Comprehensive Plan of Care, dated 01/25/18, revealed a focus area of decreased participation in activities; and further stated the resident enjoyed interactions with staff. The Goals included: activities staff to provide items for self-directed activities, resident to be out of room for activities of interest, regular visits with staff, and church visits at least weekly. Approaches to accomplish the goals included providing the resident with calendars and newsletters; checking with the resident to ensure in-room needs were met; and encouraging the resident to attend activities. Review of the Quarterly Minimum Data (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) indicating the resident was cognitively intact. Review of Resident #14's Activity Participation Roster, dated 09/01/18 through 10/24/18, revealed the resident received four (4) activity/socialization interactions during the fifty- four (54) day report period. The activities included three (3) group activities and one (1) outdoor activity. Review of the Activities Minutes Total Roster dated 09/01/18 through 10/24/18, revealed the group activities lasted one hundred fifty (150) minutes and the outdoor activity was twenty-five (25) minutes. There was no documentation of church visits nor any individual activities for the resident, as per the Care Plan. Review of the Departmental Notes, written by the Interim Activity Director, dated 10/22/18 at 2:23 PM, revealed Resident #14 liked to watch television and have one to one (1:1) conversations. The Activity Participation Roster did not support provision of activities in accordance with these Departmental Notes. Observation of Resident #14, on 10/24/18 at 8:43 AM, revealed the resident was in bed with no one present and no items for self-directed activity. Observation of Resident #14 on 10/25/18 at 9:54 AM, revealed the resident was in bed with no one present and no items for self-directed activity. Interview with the resident during this observation, revealed he/she preferred to have one to one (1:1) activities in the room due to his/her progressive illness. Resident #14 further stated he/she missed socialization with others. Interview with the Interim Activity Director, on 10/25/18 at 9:34 AM, revealed she was unable to submit an Activities Assessment for review for Resident #14. Per interview, Resident #14 experienced a decline in overall health due to his/her diagnoses. The Interim Director stated the resident was very social; however, the last activity provided for Resident #14 was on 10/03/18. She stated she planned to focus more on individual one to one (1:1) activities for Resident #14 in accordance with the Care Plan. 2. Review of Resident #16 medical record revealed the facility admitted the resident on 04/27/16 with diagnoses to include Myocardial Infarction, and Unspecified Dementia without Behavioral Disturbance. Review of Resident #16's Comprehensive Plan of Care, dated 09/28/16, revealed decreased participation in activities was identified as a focus problem. The Goal stated the resident would receive visits from staff several times each week through the next review date of 01/12/19. Interventions included: staff assistance to and from activities; room visits; one to one (1:1) activities as needed; encouragement to attend activities; and provision of the monthly newsletter and calendar. Review of the Significant Change MDS Assessment, dated 07/19/18, revealed the facility assessed the resident as having a BIMS score of three (3) out of fifteen (15) indicating the resident was severely cognitively impaired. Observation of Resident #16 on 10/25/18 at 10:33 AM, revealed he/she interacted with others with a smile and was pleasantly confused with conversation. Review of the Activity Participation Roster from 09/01/18 through 10/24/18, revealed no documented evidence the resident participated in either one on one (1:1) or group activities. The facility was unable to submit any documented evidence of the resident participating in activities for this timeframe. Review of the Department Notes written by the Interim Activity Director, dated 10/15/18 at 4:00 PM, revealed the resident was bedridden; however, he/she like to sit in the hall in the Geri chair and or watch television. Interview with the Interim Activity Director, on 10/25/18 at 9:40 AM, revealed she could not locate an Activities Assessment completed for Resident #16 to submit for review. Further interview revealed although Resident #16 was able to be up in a chair and could therefore attend group activities; there was no documented evidence to support ongoing activities for the resident in the last fifty-four (54) days. 3. Review of Resident #27's medical record revealed the facility admitted the resident on 01/06/15 with diagnoses to include Cerebral Infarction, Chronic Ischemic Heart Disease, Osteoarthritis, and Pain in Unspecified Limb. Review of Resident #27's Comprehensive Plan of Care, dated 08/26/16 revealed socialization was a focus problem. The goal stated the resident would have interaction with staff and others through the next review date of 11/16/18. Interventions included: encouragement and assistance to attend meals and group activities and individual 1:1 visits as needed. Further review of the Comprehensive Plan of Care, revealed a focus problem initiated on 08/29/16, revealing the resident was isolated in the room and there was a lack of resident's participation in activities, although the resident loved music. The goal stated the resident would participate in self -directed activities in the room, participate in daily visits with staff, and participate in weekly family visits through 11/13/18. Interventions included: family visits; provision of the monthly newsletter and calendar; escorting the resident to group activities; room visits from staff and volunteers; assistance with television; and monitoring for a change in activity levels. Review of the Quarterly MDS Assessment, dated 08/08/18, revealed the facility assessed the resident as having a BIM score of thirteen (13) out of fifteen (15) indicating the resident was cognitively intact. Section F of the MDS reflected it was somewhat important to the resident to participate in activities of his/her preference. Review of the Activity Participation Roster, from 09/01/18 through 10/24/18, revealed there was no documented evidence Resident #27 participated in either one on one (1:1) or group activities. The facility was unable to submit any documentation to indicate Resident #27 participated in activities for this timeframe. Observation of Resident #27 on 10/24/18 at 9:46 AM, revealed a talkative resident; however, the resident was not observed to be out of the room. On 10/24/18 at 1:02 PM, Resident #27 ate lunch in the dining area and then returned to the room. On 10/25/18 at 10:31 AM, Resident #27 was in bed with eyes closed in his/her room. Interview with the Interim Activity Director, on 10/25/18 at 9:45 AM, revealed she was unable to find or submit an Activities Assessment completed for Resident #27. She further stated she could not recall any activities provided for Resident #27. Per interview, the Activity Participation Roster for the last two (2) months revealed no activities were recorded for this resident. 4. Review of Resident #33's medical record revealed the facility admitted the resident on 03/14/13 with diagnoses to include Adult Failure to Thrive, Chronic Ischemic Heart Disease, and Major Depressive Disorder. Review of Resident #33's Care Plan revealed a focus problem initiated 09/12/16, which stated the resident had the potential for social isolation, although per the Care Plan the resident enjoyed room visits from staff and volunteers, watching television, and eating meals with others on the unit. The goal stated the resident would socialize with staff and roommates, to the extent possible, and eat meals with other residents on the unit through target date of 11/17/18. The interventions included: assist to and from activities; activity calendar in the room; and visits with the resident to determine appropriate in-room activities. Review of the Quarterly MDS Assessment, dated 08/15/18, revealed the facility assessed the resident as not responsive to any of the questions in the BIMS assessment section. Observation of Resident #33, on 10/24/18 at 9:33 AM, revealed the resident was sitting up in a Geri chair in the room with eyes closed. Further observation of Resident #33, on 10/25/18 at 10:11 AM, revealed the resident was dressed, up in the Geri chair in the room, with eyes closed. The resident did not respond to the State Agency Representative when questioned. Review of the Activity Participation Roster, from 09/01/18 through 10/24/18, revealed there was no documented evidence Resident #33 participated in either one on one (1:1) or group activities. The facility was unable to submit any documentation to indicate Resident #33 participated in activities for this timeframe. Interview with the Interim Activity Director on 10/25/18 at 9:50 AM, revealed she was unable to locate an Activities Assessment for Resident #33 to submit for review. She stated she could not locate any documentation of activities for this resident and could not recall any specific information related to activities for Resident #33. 5. Review of Resident #71's medical record revealed the facility admitted the resident on 06/25/15 with diagnoses to include Chronic Obstructive Pulmonary Disease, Heart Failure, and Type ll Diabetes. Review of Resident #71's Comprehensive Plan of Care with onset date of 09/27/16, revealed a focus problem of social isolation. Further, the Care Plan revealed the resident preferred to stay in his/her room to watch television, read the Bible and other books, and visit with family and friends; enjoyed going outside on warm days; and enjoyed attending large group social activities. The goal stated the resident would participate in group activities; have visits from family and volunteers; and participate in daily self-directed activities with a target date of 01/12/19. Interventions included: provide monthly newsletters and calendars; provide supplies for self-directed activities upon resident request; encourage to attend group activities; family visits; and monitor for changes in activity. Review of the Quarterly MDS Assessment, dated 09/05/18, revealed the facility assessed the resident as having a BIMS score of eleven (11) out of fifteen (15) indicating moderate cognitive impairment. Review of the Activity Participation Roster dated 09/01/18 through 10/24/18, revealed the resident participated in one (1) sensory activity on 09/24/18 at 1:26 PM. There was no documented evidence the resident participated in any other activities during this timeframe. Review of facility Activities Minutes Total Roster dated 09/01/18 through 10/24/18, revealed the one (1) sensory activity on 09/24/18 at 1:26 PM lasted for one (1) minute. Interview with the Interim Activity Director on 10/25/18 at 9:30 AM, revealed this time was incorrect; however, she was not sure of the actual length of time of the 09/24/18 activity. Observation of Resident #71, on 10/24/18 at 9:16 AM, revealed the resident was in his/her room, and further observations of the resident on that date revealed the resident stayed in his/her room. On 10/25/18 at 10:29 AM, the resident was again observed in his/her room. Interview with the resident during this observation revealed he/she loved books and preferred to read; however, his/ her eyesight had declined and it was now difficult to read. The resident stated he/she was not up to attending group activities, but enjoyed activities in his/her room. Interview with the Interim Activity Director, on 10/25/18 at 9:30 AM, revealed she was unable to locate or submit for review any Activities Assessment for Resident #71. Continued interview revealed she had no documentation of Resident #71 participating in any group or individual activities other than on 09/24/18. She further stated general practice was for activity staff to go to the resident's room to offer individual activities. She could not recall any specific activities provided for the resident. Further interview with the Interim Activity Director on 10/25/18 at 9:50 AM, revealed she was new to the role. She stated she was working on a better process for providing and documenting one to one (1:1) activities as well as group activities. Per interview, the Activities staff needed to ensure residents who could not attend group activities or preferred individual one to one (1:1) individual activities participated in meaningful individualized activities and at the present time one on one (1) activities were not scheduled for specific residents. Per interview, the former Activity Director did not have a system for documentation of individual activities and thus, this was a focus for her going forward. Continued interview revealed efforts were in progress to obtain more tools to provide one on one (1:1) activities for residents. The Interim Activity Director stated the purpose of providing regular person-centered activities was to give residents a sense of purpose and to improve social skills. Interview with the Administrator, on 10/25/18 at 3:54 PM, revealed it was her expectation for the Activity Staff to plan, coordinate, and document meaningful activities for each resident. She stated the Interim Director was new to the role and was working on improving the department. The Administrator stated the importance of person-centered activities was to ensure the highest quality of life for each resident.