**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure a resident taking an anticoagulant medication was monitored for bruising and/or bleeding for 1 (#1) out of 3 (#1, #2 and #3) residents reviewed for unnecessary medications. Findings: On 02/18/2025, a review of the facility's undated policy entitled, Anticoagulant Therapy Bruising Bleeding Policy and Procedure revealed, in part, Purpose: 1. To monitor for possible bruising and/or bleeding due to anticoagulant medication therapy. Policy: It is the policy of this facility to have a special requirement or monitoring tool in place to monitor for possible side effects of anticoagulant therapy such as bruising and/or bleeding. Procedure: 1. Implement supplementary documentation or monitoring tool upon implementation of anticoagulant therapy. 2. The nurse is to assess the resident for any possible side effects such as bruising and/or bleeding daily or as needed. Review of Resident #1's admission Record revealed the resident was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, atrial fibrillation and heart failure. Review of Resident #1's admission MDS (Minimum Data Set) assessment dated [DATE] revealed in part, Section N - Medications: the resident was taking an anticoagulant. Review of Resident #1's Order Recap Report, revealed a physician's order with a start date of 02/13/2025 Dabigatran Etexilate Mesylate Oral Capsule 150 mg (milligram); give 1 capsule by mouth one time a day. Review of Resident #1's MAR (Medication Administration Record), from February 2025 revealed the resident was administered Dabigatran Etexilate Mesylate Oral Capsule 150 mg on 02/13/2025, 02/14/2025, 02/15/2025, 02/16/2025, 02/17/2025, and 02/18/2025. Further review of the February 2025 MAR revealed the resident was not monitored for bruising and/or bleeding from 02/13/2025 to 02/18/2025. Review of Resident #1's physician orders and comprehensive plan of care failed to reveal an order for monitoring for bruising and/or bleeding of Dabigatran Etexilate Mesylate. Further review revealed no other evidence in Resident #1's record of adequate monitoring for the administration of Dabigatran Etexilate Mesylate from 02/13/2025 to 02/18/2025. On 02/18/2025 at 10:49 AM, an interview and record review was conducted with S2LPN (Licensed Practical Nurse). She confirmed that Resident #1 was receiving Dabigatran Etexilate Mesylate and residents who receive anticoagulants should be monitored for bleeding and/or bruising and a yes or no should be documented in the MAR. She reviewed Resident #1's February 2025 MAR and confirmed the resident was not monitored for signs and symptoms of bruising and/or bleeding from 02/13/2025 to 02/18/2025, and should have been. On 02/18/2025 at 12:52 PM, an interview and record review was conducted with S1DON (Director of Nursing) who confirmed that Resident #1 was taking Dabigatran Etexilate Mesylate and it is an anticoagulant. She stated that the nurses should monitor the resident for bruising and/or bleeding and document the findings on the MAR. S1DON reviewed Resident #1's MAR from February 2025 and confirmed the nurses did not monitor Resident #1 for signs and symptoms bruising and/or bleeding from 02/13/2025 to 02/18/2025, and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure a resident was free from verbal and physical abuse for 1 (Resident #R1) out of 4 (Resident #1, Resident #2, Resident #3, and Resident #R1) sampled residents. Findings: On 12/26/2024, a review of the facility's policy titled, Abuse and Neglect Policy and Procedure with a last revision date of 12/19/2024, read in part: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Examples of verbal abuse may include but are not limited to: Yelling or hovering over a resident, with the intent to intimidate. Physical Abuse includes hitting, slapping, pinching, biting, shoving, and kicking. Resident #R1 Review of Resident #R1's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and Alzheimer's Disease. Review of the Quarterly MDS (Minimum Data Set) with and ARD (Assessment Reference Date) of 10/16/2024 revealed Resident #R1 had a BIMS (Brief Interview of Mental Status) score of 8, which indicated she was moderately cognitively impaired. Resident #3 Review of Resident #3's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, unspecified dementia, unspecified severity, with other behavioral disturbance, depression, and anxiety disorder. Review of the Discharge MDS with ARD of 12/10/2024 revealed Resident #3 had a BIMS score of 6, which indicated she was severely cognitively impaired. A review of facility's incident report, dated 12/10/2024 at 7:20 PM, included a note by S2DON (Director of Nursing) that revealed in part: Staff reported they over heard yelling coming from the dining room. Upon entering, Resident #3 noted sitting in her wheelchair, directly in front of Resident #R1, blocking her in. Both residents were arguing at this time. Resident #3 was immediately removed from the area. Family members of another resident stated that Resident #3 went up to Resident #R1, started arguing with Resident #3, pushing Resident #R1 with Resident #3's wheelchair, told Resident #R1 to shut up, and hit Resident #R1 in the face. A review of a facility incident report, dated 12/10/2024, included a statement by S4VIS (Visitor) that revealed in part: Resident #3 went up to Resident #R1 and started arguing and pushed Resident #R1 with her wheelchair. Resident #3 told Resident #R1 that she was going to hit her. Resident #3 hit Resident #R1. A review of a facility incident report, dated 12/10/2024, included a statement by S5VIS (Visitor) that revealed in part: Resident #3 came rolling in the wheelchair and was pushing Resident #R1 with her wheelchair and told Resident #R1 to shut up, and Resident #R1 said she did not have to. Resident #3 then slapped Resident #R1. On 12/23/2024 at 3:54 PM a phone interview was conducted with S4VIS regarding the incident on 12/10/2024 between Resident #3 and Resident #R1. S4VIS stated that Resident #3 was arguing with Resident #R1 because Resident #3 did not want the lady to be in that spot. Resident #3 raised her fist and threatened to hit Resident #R1. Resident #R1 stated she was not going to move and Resident #3 slapped Resident #R1 in the face. On 12/23/24 at 4:28 PM, a phone interview was conducted with S5VIS regarding the incident on 12/10/2024 between Resident #3 and Resident #R1. She stated that Resident #R1 was sitting by the wall, and Resident #3 told Resident #R1 to move, and when Resident #R1 said she would not, Resident #3 raised her fist. S5VIS stated that Resident #R1 could not move because she was stuck. The next thing S5VIS remembers is that Resident #R1's glasses flew off. S5VIS stated that Resident #R1 was minding her own business before the argument. On 12/26/2024 at 12:08 PM, a joint interview was conducted with S1ADM (Administrator) and SDON. Both confirmed that an argument was held between Resident #3 and Resident #R1 on 12/10/2024. Both confirmed that this incident resulted in Resident #3 hitting Resident #R1 in the face and resulted in no injury to either resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and facility policy review, the facility failed to ensure an allegation of physical and verbal abuse was reported to the state survey agency no later than 2 hours after the allegation was made for 1 (Resident #R1) out of 4 (#1, #2, #3 and #R1) residents investigated for abuse. Findings: On 12/26/2024, a review of the facility's policy titled, Abuse and Neglect Policy and Procedure with a last revision date of 12/19/2024, read in part: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Examples of verbal abuse may include but are not limited to: Yelling or hovering over a resident, with the intent to intimidate. Physical Abuse includes hitting, slapping, pinching, biting, shoving, and kicking. 7. Reporting/Response: The facility administrator or designee shall complete a report to be made to the mandated state agency according to state guidelines upon notification of an alleged abuse. Resident #R1 Review of Resident #R1's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and Alzheimer's Disease. Review of the Quarterly MDS (Minimum Data Set) with and ARD (Assessment Reference Date) of 10/16/2024 revealed Resident #R1 had a BIMS (Brief Interview of Mental Status) score of 8, which indicated she was moderately cognitively impaired. Resident #3 Review of Resident #3's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, unspecified dementia, unspecified severity, with other behavioral disturbance, depression, and anxiety disorder. Review of the Discharge MDS with ARD of 12/10/2024 revealed Resident #3 had a BIMS score of 6, which indicated she was severely cognitively impaired. A review of facility's incident report, dated 12/10/2024 at 7:20 PM, included a note by S2DON (Director of Nursing) that revealed in part: Staff reported they over heard yelling coming from the dining room. Upon entering, Resident #3 noted sitting in her wheelchair, directly in front of Resident #R1, blocking her in. Both residents were arguing at this time. Resident #3 was immediately removed from the area. Family members of another resident stated that Resident #3 went up to Resident #R1, started arguing with Resident #3, pushing Resident #R1 with Resident #3's wheelchair, told Resident #R1 to shut up, and hit Resident #R1 in the face. On 12/26/2024 at 12:08 PM, a joint interview was conducted with S1ADM (Administrator) and SDON. Both confirmed that an argument was held between Resident #3 and Resident #R1 on 12/10/2024 and was not reported to the state survey agency. Both confirmed that this incident resulted in Resident #3 hitting Resident #R1 in the face and resulted in no injury to either resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to provide reasonable accommodations of the resident's needs by failing to ensure the call bell in the resident's room was in reach for 1 (#88) resident. The deficient practice had the potential to effect a census of 101. Findings: Review of facility's policy titled Call lights-use of, with a review date of 04/06/2024, read in part, Purpose: to provide the resident with a call light to notify staff to meet the need of the resident. Procedure: 10. Be sure all call lights are placed in reach. Resident #88 was admitted to the facility on [DATE] with diagnoses including: Dysphagia, Shortness Of Breath, Protein-Calorie Malnutrition, Major Depressive Disorder, Anxiety, Dependent on Dialysis, Cervical Disc Disorder at C4 (Cervical) - C5 with Myelopathy, Fracture at 1st Lumbar Vertebra, Encephalopathy and Pain. Review of Resident #88's Quarterly MDS (Minimum Data Set) dated 07/18/2024 revealed the resident had a BIMS (Brief Interview of Mental Status) score of 08, indicating a moderately impaired cognition. Section G revealed the resident requires Extensive Assistance with 2 person assist for bed mobility and toileting and total dependence with two person assist for transfers. On 10/14/2024 at 11:15 a.m., during an interview with Resident #88 he stated the staff puts his call bell too far for him to reach. An observation was made of the resident at the same time, and he was sitting up in his geri-chair. His call bell was laying across his bed, which was behind him, under the incontinent pad. Resident then attempted to reach the call light and was unable to. On 10/14/2024 at 11:36 a.m., an interview was conducted with S9LPN (Licensed Practical Nurse),. She observed Resident #88 reaching for his call light, as it was laying across his bed, which was behind him, under the incontinent pad and confirmed the call light was not in reach for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure all areas or equipment were in good repair as evidenced by failing to ensure a resident's toilet was secured to the floor for 1 (#305) out of 8 (#13, #53, #61, #69, #83, #88, #100, #305) residents investigated for environment. Findings: On 10/16/2024 a review of the facility's policy titled Preventive Maintenance of Resident Equipment with a review date of 4/06/2024 was done. The policy read in part, Purpose: To provide a safe environment for residents and to meet safety guidelines. Policy: It is the job of all staff to identify areas of concern regarding the maintenance of resident equipment and building. Procedure: Preventive maintenance will occur throughout the year. Review of Resident #305's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to Shortness of Breath, Bipolar Disorder, Hypertensive Heart Disease Without Heart Failure and Anxiety. Review of Resident #305's quarterly MDS (Minimum Data Set) with an ARD (Assessment Review Date) of 09/12/2024 revealed she had a BIMS (Brief Interview for Mental Status) of 13 which indicated she was cognitively intact. Further review of her MDS revealed she required supervision or touching assistance for toilet transfer. On 10/14/2024 at 08:14 a.m., an observation was made of Resident # 305's bathroom. Resident # 305's toilet bowl was loose and moved easily with a gentle nudge. Resident #305 stated that she went to the bathroom without assistance. On 10/15/2024 at 1:15 p.m., a second observation was made of Resident #305's toilet bowl. It was still loose and moved easily. On 10/15/2024 at 1:34 p.m., an interview was conducted with S7Maint (Maintenance Supervisor) and he stated that maintenance checks were done on rooms monthly. He stated that maintenance in residents' rooms were also done when he was notified by the residents and/or staff. S7Maint stated that he was not aware of a loose toilet in Resident #305's room. On 10/15/2024 at 1:40 p.m., an interview and record review was conducted with S1ADM (Administrator). He stated daily QA (Quality Assurance) were done throughout the facility by designated staff, which included checking the residents' rooms. A review was conducted with S1ADM of the QA document for 10/15/2024 revealed there were maintenance issues that included loose toilets. S1ADM confirmed that a QA was not conducted on 10/14/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to develop and implement a person centered care plan for 1 (#100) out of 34 sampled residents, by failing to ensure Resident #100 was care planned for repeatedly pulling her call bell station off the wall. The facility's census was 101. Findings: On 10/16/2024, a review of the facility's policy titled Care Plan Policy and Procedure with a review date of 04/08/2024, revealed in part, Purpose: To provide a comprehensive person-centered plan of care addressing resident's needs, strengths, goals and approaches. Policy: each resident's care plan will remain current and inform staff of resident's needs, strengths, goals and approaches . A review of Resident #100's medical records revealed that she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Diabetes and Gastroesophageal Reflux Disease. Further review of the recent Quarterly Set (MDS) dated [DATE], revealed the resident had a BIMS (Brief Interview for Mental Status) of 8, which indicated moderate cognitive impairment. On 10/15/2024 at 9:10 a.m., an observation was made of the resident in her bed. The resident's call bell bed station was observed dislodged and hanging off the wall. The resident was not able to reach the wall station from her bed. The resident stated that the bed station kept falling off the wall. On 10/15/2024 at 9:10 a.m., S3DON (Director of Nursing) came to Resident # 100's room and confirmed the resident's call bell bed station was hanging off the wall and stated it should not be like that. The resident stated it was always like that and staff came in to put it back on the wall but did not fix it. She also stated that her call bell works and she was able to call for help but unable to reach the wall station to put it back on when it fell off. On 10/15/2024 at 9:15 a.m., S4RNSup (Registered Nurse Supervisor) confirmed the resident's call bell bed station was hanging off the wall. He stated that there was a proper way to place the bed station on the wall and if it was not placed properly it will keep falling off. On 10/15/2024 at 9:18 a.m., S1ADM (Administrator) walked in Resident #100's room and confirmed the call bell bed station was off the wall. He stated they have been having trouble with the resident pulling off the bed station, and it had been an ongoing problem. S1ADM also stated that the resident should be care planned for frequently pulling her call bell bed station from the wall. On 10/15/2024 at 12:36 p.m., an interview was conducted with S7Maint (Maintenance). He stated he was in-charge of maintenance and was aware that Resident #100 had been pulling her call bell bed station off the wall. He stated that the company showed him how to reapply it to the wall if she pulled it off. He stated that the company replaced the whole thing before but she pulled it off again. He stated he showed S4RNSup how to reapply it but preferred staff calling him when S4RNsup was not there because it had to be placed properly. A review of Resident's #100 medical record revealed she was not care planned for frequently pulling her call bell station from the wall. On 10/15/2024, at 1:14 p.m., an interview was conducted with S2RNCorp (Corporate Nurse) who confirmed Resident #100 was never care planned for frequently pulling her call bell off the wall until surveyors brought it to staff's attention.

Based on observation and interview, the facility failed to properly store drugs as evidenced by loose pills found in the bottom of the medication cart drawers for 1 (Cart #4) of 2 (Cart #1, #4) medication carts observed. The facility had a total of four medication carts. Findings: Review of the facility's policy on 10/16/2024 titled Medication Storage Policy and Procedure dated 06/18/2024 read, in part, Purpose: To properly secure medications and biologicals according to CMS (Centers for Medicare & Medicaid Services) guidelines. Procedure: 2. Medication carts will be checked weekly for expired medications, loose pills, cleanliness and compliance with storage guidelines. a. Any expired medications or loose pills will be destroyed according to the standard guidelines. On 10/16/2024 at 11:08 a.m., Cart #4 was inspected with S9LPN (Licensed Practical Nurse). Two yellow oblong pills were observed loose on the bottom of the second drawer on the left side of the cart, one white oblong pill and a half of a white pill were observed loose on the bottom of the second to last drawer on the right side of the cart. The pills were observed underneath resident medication blister packages. S9LPN confirmed the loose pills at the bottom of the drawers. S9LPN stated these loose pills should not have been in the bottom of the medication cart. On 10/16/2024 at 11:15 a.m., S3DON (Director of Nursing) confirmed the loose pills in the bottom of the drawers of the medication cart 4. She stated these loose pills should not have been in the bottom of the medication cart.

Based on observations, interviews, and record reviews, the facility failed to ensure the provided diet met the nutritional needs of each resident as evidenced by failing to ensure dietary staff provided the appropriate portion sizes according to the recipe for 2 (#33, #97) out of 7 residents who received pureed meals. Findings: Review of the facility's policy titled Accuracy and Quality of Tray Line Service Policy and Procedure, with a last reviewed date of 05/09/2024, read in part: 7. Each meal will be checked for: .Proper portion sizes. On 10/14/2024 at 11:40 a.m., an observation was made of the food service line during lunch. Pureed food items (rice, turnip greens, beans and sausage, cornbread) were being served with a 1/2 cup scoop. Review of the recipe and diet spread sheet revealed pureed beans and sausage were to be served with a 3/4 cup or 6 oz (ounce) spoodle. S10Cook stated that she was instructed to serve all pureed food items with a half cup scoop. S8DM (Dietary Manager) was asked how the staff knew which serving scoops to use, and she stated the staff should have followed the recipes and recipe spreadsheets that lists the appropriate serving sizes. S8DM confirmed the wrong scoop size was being used to serve the pureed beans and sausage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #76 A review of Resident #76's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to Depression and Wernicke's Encephalopathy. Further review of Resident #76's medical record revealed she was diagnosed with Bipolar Disorder on 10/05/2022. There was no written evidence a resident review had been submitted for a Level II PASARR evaluation and determination. On 10/15/2024 at 4:08 p.m., an interview was conducted with S13SSD who confirmed that she was responsible for submitting reviews to the OBH when a resident had a newly qualifying mental illness. S13SSD confirmed that Resident #76 on 10/05/2022 had a new diagnosis of Bipolar Disorder. She confirmed that she did not submit a Level II PASARR evaluation and determination review to OBH for Resident #76 and that she should have. Based on record review and interview, the facility failed to ensure a resident identified with a qualified mental disorder was referred to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 2(#6, and #76) of 5 (#6, #8, #66, #76, and #81) residents sampled for PASARR, out of a total sample of 34 residents. Findings: On 10/16/2024, a review of the facility's policy titled, Pre-admission Screening and Resident Review, reviewed date of 07/05/2024, read in part, . The facility is to review resident diagnosis and medications upon admission and throughout the resident stay to determine if a Level II request for resident review is to be completed. Resident #6 A review of Resident #6's medical record revealed that she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Depression, and Unspecified Psychosis. Further review of the resident's medical record revealed she was diagnosed with Unspecified Psychosis Disorder on 04/10/2024 and there was no written evidence a resident review had been submitted for a Level II PASARR evaluation and determination. On 10/15/2024 at 1:51 p.m., an interview conducted with S13SSD (Social Service Director) who confirmed she was responsible for submitting reviews to the OBH (Office of Behavioral Health) when a resident had a new qualifying mental illness. S13SSD confirmed that on 04/10/2024 Resident #6 had a new diagnosis of Unspecified Psychosis. She confirmed that she did not submit a Level II PASARR evaluation and determination review to OBH for Resident #6 and that she should have.

Based on observation and interview, the facility failed to ensure food was prepared and served in a form to meet individual needs for residents who received pureed diets as evidenced by: 1. Failing to ensure food items were pureed to the appropriate consistency; 2. failing to ensure rice was pureed according to recipe, and 3. failing to ensure regular textured beans and sausage were not placed on Resident #33's meal tray. This deficient practice had the potential to effect the 7 residents who received pureed diets. Findings: Review of the facility's policy titled Accuracy and Quality of Tray Line Service Policy and Procedure, with a last reviewed date of 05/09/2024, read in part: 5. Staff will refer to the meal identification (ID) card/ticket for food dislikes, allergies, and other details and substitute appropriately for those items .7. Each meal will be checked for: Accuracy of following the therapeutic diet extension. On 10/14/2024 at 10:17 a.m., an observation was made of S10Cook puree parboiled rice for the 7 residents who received pureed diets. S10Cook added 5 and 3/4 cup of rice and 1 and 2/3 cups of milk to the food processor. S10Cook was asked how she knew she was pureeing the correct amount of rice. She stated that she followed the recipe for 10 servings. Review of the recipe for pureed rice revealed the following: Ingredients- Pureed rice instant, 10 servings, 1 and 2/3 cup. Instructions: Bring water and salt (if desired) to a boil, whisk in pureed rice mix according to the product chart, whisk in butter, margarine, or oil if desired. Cover and place on steam table for 30 to 45 minutes. S10Cook stated that they did not use instant rice mix, but use parboiled rice and pureed it with milk instead. S10Cook proceed to puree the parboiled rice with milk and placed the finished product in a pan. Whole grains of rice were observed, and the rice had a sticky texture. S10Cook then covered the pan and placed in the holding oven. On 10/14/2024 at 10:30 a.m., an observation was made of S10Cook puree turnip greens with added bacon bits. At 10:36 a.m., an observation was made of the pureed turnip greens. Bacon bits and stems were visible in the pureed greens. S10Cook stated that she was finished pureeing the turnip greens. On 10/14/2024 at 11:07 a.m., an observation was made of the pureed turnip greens and pureed rice with S8DM (Dietary Manager). She confirmed that there were still grains of rice in the pureed rice and it was not smooth or pureed to the appropriate consistency. She also confirmed that bacon bits and stems were visible in the turnip greens and was not pureed to the appropriate consistency. On 10/14/2024 at 11:34 a.m., the recipe for pureed rice was reviewed with S8DM. She stated that the facility did not have instant rice mix although the recipe for pureed rice using instant rice mix was followed. She confirmed S10Cook did not use the correct recipe to puree parboiled rice, and the recipe for instant rice mix was not equivalent. On 10/14/2024 at 12:00 p.m., an observation was made of dietary staff prepare Resident # 33's lunch meal tray. The resident's meal ticket read: regular/puree, indicating the resident had a regular pureed texture diet. Pureed beans and sausage, turnip greens, rice, and cornbread were observed on the resident's plate. S11Dietary proceeded to scoop regular textured beans and sausage and placed on top of the resident's pureed beans and sausage. S11Dietary was asked what kind of diet the resident was on, and she stated pureed. She was then asked if there was a reason she placed regular textured beans and sausage on top of Resident #33's pureed beans and sausage, and she stated because the resident wanted extra juice/gravy from the regular textured beans. S8DM confirmed that the staff member should not have placed the regular textured beans and sausage on the resident's plate as the resident was on a pureed diet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to obtain the recertification of terminal illness for 3 (Resident #1, #2, and #3) out of 6 (Resident #1, #2, #3, #R1, #R2, and #R3) sampled residents reviewed for hospice. Findings: On 06/11/2024, a review of the facility's agreement with the Contracted Hospice Agency dated 12/21/2022 read in the part, the following V. Records (a) Nursing facility . shall prepare and maintain complete and detailed clinicals records . Each clinical record shall completely, promptly and accurately documents all services provided to, and events concerning each Residential Hospice Patient . Resident #1 Review of Resident #1's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Senile Degeneration of Brain and Encounter for Palliative Care. Review of Resident #1's Quarterly MDS (Minimum Data Set) dated 03/19/2024 revealed the Brief Interview for Mental Status (BIMS) of 3, indicating her cognition was severely impaired. Under Section O: Special Treatments revealed the resident was admitted to hospice. Review of Resident #1's physician's orders revealed an order entry with a start date of 07/07/2023 read in part, Admit to Contracted Hospice for Terminal dx (diagnosis) of Senile Degeneration of Brain. Review of Resident #1's person-centered plan of care, revealed in part, a focus of I have chosen to receive hospice care r/t (related to) dx Senile Degeneration of Brain. Review of Resident #1's hospice documents in the EHR (Electronic Health Record) revealed, in part, the most recent recertification of terminal illness by the Contracted Hospice Agency's physician was signed on 03/04/2024 for the recertification period of 03/03/2024 through 05/01/2024. Resident #2 Review of Resident #2's record revealed she was re-admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Parkinsonism and Encounter for Palliative Care. Review of Resident #2's Quarterly MDS (Minimum Data Set) dated 05/14/2024 revealed the Brief Interview for Mental Status (BIMS) of 3, indicating her cognition was severely impaired. Under Section O: Special Treatments revealed the resident was admitted to hospice. Review of Resident #2's physician's orders revealed an order entry with a start date of 09/01/2023 read in part, Admit to Contracted Hospice for Terminal dx (diagnosis) of end stage Parkinson's . Review of Resident #2's person-centered plan of care, revealed in part, a focus of I have chosen to receive hospice care admitted with dx of Parkinson's. Review of Resident #2's hospice documents in the EHR revealed, in part, the most recent recertification of terminal illness by the Contracted Hospice Agency's physician was signed on 09/01/2023 for the initial certification period of 09/01/2023 through 11/29/2023. No recertification's noted in Resident #2's EHR. Resident #3 Review of Resident #3's record revealed she was re-admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Hypertension and Hyperlipidemia. Review of Resident #3's Quarterly MDS (Minimum Data Set) dated 03/03/2024 revealed the Brief Interview for Mental Status (BIMS) of 00, indicating the resident was unable to complete the assessment. Under Section O: Special Treatments revealed the resident was admitted to hospice. Review of Resident #3's physician's orders revealed an order entry with a start date of 11/22/2023 read in part, Admit to Contracted Hospice for Terminal dx of CVD (Cardiovascular Disease) . Review of Resident #3's person-centered plan of care, revealed in part, a focus of I have chosen to receive hospice care r/t diagnosis of CVD . Review of Resident #3's hospice documents in the EHR revealed, in part, the most recent recertification of terminal illness by the Contracted Hospice Agency's physician was signed on 02/16/2024 for the recertification period of 02/20/2024 through 05/19/2024. On 06/11/2024 at 2:20 p.m., an interview was conducted with S1DON (Director of Nursing). S1DON confirmed she was the designated team member for ensuring all hospice documents were current and scanned into the EHR. She stated the hospice documents are only in the EHR they are not in hospice binders or anywhere else. Review of Resident #1, #2 and #3's hospice documents in the EHR was conducted with S1DON. She confirmed Resident #1's last recertification period that was scanned into the EHR was from 03/03/2024 - 05/01/2024. She confirmed Resident #2's initial certification period that was scanned into the EHR was from 09/01/2023 - 11/29/2023 and there are no recertification's scanned into Resident #2's EHR. She confirmed Resident #3's last recertification period that was scanned into the EHR is from 02/20/2024 - 05/19/2024. S1DON confirmed there were not any current recertification statements for hospice for Resident #1, #2 and #3 and there should have been a current and updated recertification statement scanned into each resident's EHR that was obtained from the resident's contracted hospice facility. She stated she also checked her emails and was unable to locate current recertifications for Resident #1, #2, and #3.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that a resident's physician and resident representative (RP) were immediately notified of a change in the resident's condition for 1(#1) of 3 (#1, #2, and #3) sampled residents by failing to notify the physician and RP that the resident had nausea and refused to take her medications in two days. Findings: On 05/07/2024, a review of the facility's undated policy titled Medication Administration - General Guidelines .Policy: Medications are administered in accordance with good nursing principles and practices .Refusals of Medication b. Medication refusal must be reported to the prescriber . Resident #1 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Constipation, Nausea with Vomiting, Dementia, Overactive Bladder, Muscle Weakness, Protein Calorie Malnutrition, and Atrial Flutter. A review of the resident's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/30/2024 revealed she had a BIMS (Brief Interview for mental Status) of 5, indicating severe cognitive impairment. A review of Physician's Orders revealed an order for the following medications ordered on the specified date: 11/27/2023 Levothyroxine 88 MCG (microgram) tablet 1 (PO) (by mouth) Q (every) day 11/27/2023 Metolazone 2.5 mg (milligram) tablet 1 (PO) Q day 11/27/2023 Potassium CL (chloride) ER (extended release) 20 MEQ (mill equivalent) tablet 1 (PO) Q day 11/27/2023 Diltiazem 24H ER (Hydrochloride extended release) (CD) (controlled delivery) 300 MG CP (capsule) 1 (PO) Q day 11/27/2023 Rivastigmine 4.6 mg/24 hr. (hour) patch - apply 1 patch topically Q day 03/25/2024 Celexa 20 mg tablet 1 tab PO Q day. 04/16/2024 Mighty Shake supplement with meals. 12/14/2023 Pantroprazole SOD DR (Sodium delayed release) 40 mg tab 1 PO Q day. 11/27/2023 Ditropan XL (long acting) 5 mg tablet 1 PO Q day for overactive bladder. A review of the resident's April MAR (Medication Administration record) revealed the following medications and supplements were marked N (not given) on the specified dates: -Mighty shake supplement on 04/20/2024 at 7:00 a.m. and 5:00 p.m. and on 04/21/2024 at 11:00 a.m. and 5:00 p.m. -Macrobid 100 mg (milligram) capsule on 04/21/2024 at 7:00 a.m. -Celexa 20 mg tablet on 04/20/2024 at 7:00 a.m. and 04/21/2024 at 7:00 a.m. -Levothyroxine 88 MCG on 04/20/2024 and 04/21/2024 at 6:00 a.m. -Pantoprazole SOD DR 40 mg tablet on 04/20/2024 and 04/21/2024 at 6:00 a.m. -Multivitamin tablet on 04/20/2024 and 04/21/2024 at 8:00 a.m. -Clonidine HCL (Hydrochloride) 0.1 mg tablet on 04/20/2024 at 7:00 a.m. and 04/21/2024 at 7:00 a.m. and 3:00 p.m. -Diltiazem 24 H ER (CD) 300 mg CP on 04/20/2024 at 7:00 a.m. and 04/21/2024 at 7:00 a.m. -Potassium CL ER 20 MEQ tablet on 04/20/2024 at 7:00 a.m. and 04/21/2024 at 7:00 a.m. -Ditropan XL 5 mg tablet on 04/20/2024 at 7:00 a.m. and 04/21/2024 at 7:00 a.m. -Metolazone 2.5 mg tablet on 04/20/2024 at 7:00 a.m. and 04/21/2024 at 7:00 a.m. -Lisinopril 10 mg tablet on 04/20/2024 at 7:00 a.m. and 04/21/2024 at 7:00 a.m. -Rivastigmine 4.6 mg/24 hr. patch on 04/20/2024 and 04/21/2024 at 7:00 a.m. A review of the resident's medication administration record notes revealed the above medications were refused by the resident. A review of the resident's progress notes revealed three entries by S2LPN (Licensed Practical Nurse) that were summarized below: On 04/20/2024 at 12:34 p.m. - The resident continued to have bouts of nausea but no vomiting. She was served a clear liquid diet. On 04/21/2024 at 11:09 a.m. - The resident continued to complain of nausea. On 04/21/2024 at 6:38 p.m. - Gave the resident an 8 ounce cup of water at 5:15p.m. At 5:30 p.m. the resident's daughter is at her bedside and requested her mother sent to the ER for evaluation and treatment because she doesn't see she has improved since her visit on Friday. NP (nurse practitioner) advised order noted to send to ER. Resident was transported to ER at 6:15 p.m. There were no notes in the resident's administration record or progress notes on 04/20/2024 or on 04/21/2024 to indicate that the resident's physician or RP were notified that the resident had not taken her medications in two days. On 04/30/2024 at 4:27 p.m., a phone interview was conducted with the resident's RP. She stated that on 04/21/2024, her daughter went to the nursing home to visit her grandmother and called to let her know that the resident was not feeling well. She stated that when she got there S2LPN informed her that she didn't give the resident her medicines in a couple of days because she was nauseated. The RP stated that no one at the facility had notified her that her mother was nauseated and was refusing her medicines. She stated that her mother was transferred to the hospital and was there for four days then transferred back to the facility. On 05/06/2024 at 3:30 p.m., a phone interview was conducted with S2LPN. She stated that she had been working at the facility for over 30 years. She stated that on the 04/20/2024 and 04/21/2024 the resident refused her medications. S2LPN confirmed that she did not call the resident's representative or physician/nurse practitioner to make them aware the resident had nausea and refused her medications. On 05/07/2024 at 9:31 a.m., an interview was conducted with S3NP (Nurse Practitioner). He stated he was not notified that the resident had not taken her medications on 04/20/2024 and on 04/21/2024. He stated if the medications were refused or not taken he probably wouldn't do anything about it, but by noon and evening of 04/20/2024 there was a problem of which he should be notified. S3NP stated that if he had known that the resident did not take her medications for two days, he would have done something sooner. On 05/07/2024 at 10:00 a.m., an interview was conducted with S1DON (Director of Nursing) and S4RN (Regional nurse) who reviewed Resident #1's MAR and administration notes. They both stated a resident should not miss a full day of medications and especially two days. They both confirmed the RP and NP should have been notified of the resident's change in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assess 1 (#59) resident investigated to self -administer medication out of a finalized sample of 38 residents. The right to self-administer medications is the responsibility of the interdisciplinary team to assess and determine that this practice is clinically appropriate. Findings: Review of the facility's policy titled, Medications-Self Administration Policy and Procedure, revealed in part: If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility during the care planning process, A. Complete Self Administration Assessment . Resident #59 was admitted to the facility on [DATE] with diagnoses that included, Lack of Coordination, Generalized Muscle Weakness, Allergic Rhinitis, and Essential Hypertension. Review of Resident #59's September 2023 Medication Administration Record (MAR) revealed Resident #59 had been administered Mometasone Furoate 50 mcg (micrograms) 2 sprays to each nostril on the morning of 09/18/2023 by S7LPN. Review of Resident #59's (Electronic Medical Record) EMR revealed no documented evidence that the resident was assessed to self-administer medication. On 09/18/2023 at 10:25 a.m., an interview and observation was made with Resident #59 of a prescription nasal spray on her nightstand. Resident #59 confirmed she's always kept this nasal spray at her bedside so that she can administer it to herself. On 09/18/2023 at 10:45 a.m., an interview was conducted with S7LPN (Licensed Practical Nurse). S7LPN confirmed the resident's prescription nasal spray (Mometasone Furoate) was on the nightstand of Resident #59 and confirmed it should not be. On 09/20/2023 at 2:00 p.m., an interview was conducted with S15CN (Corporate Nurse) who stated residents who self-administer medications should have a Medications Self-Administration assessment that should be in the resident's EMR. S15CN confirmed that Resident #59 did not have a Medication self-Administration assessment. S15CN also confirmed the resident should have a Medication Self-Administration assessment in order to keep her medication at her bedside to self-administer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records reviewed and interviews the provider failed to ensure that a resident's assessment accurately reflected the resident's status for 2 (#16 and #69) residents investigated out of a finalized sample of 38 residents as evidenced by: 1. Failing to ensure that Resident # 16's MDS (Minimum Data Set) assessment reflected recent falls and the presence of a wander guard (monitoring device) and 2. Failing to identify a PASARR (Preadmission Screening and Resident Review) Level II for Resident #69. Findings: Resident # 16 Resident #16 was admitted to the facility on [DATE] with diagnoses that included, Aphasia, Anxiety Disorder, Major Depressive Disorder, and Tobacco Use. Record review of Resident #16's Care Plan, dated 04/10/2023, read in part, Place monitoring device on me that sounds alarms when I leave building. Further review of Resident #16's Care Plan dated 04/10/2023, read in part a fall on 05/02/2023 and on 05/20/2023. Record review of Resident #16's MDS (Minimum Data Set), dated 07/26/2023, under Section J, Any Falls Since Prior Assessment, coded 0 which indicated No. Further review of Resident #16's MDS dated [DATE], under Section P, Wander/elopement alarm was coded as 0 which indicated Not Used. On 09/19/2023 at 10:00 a.m., an observation was made of Resident #16 sitting in his wheelchair on the secured patio. A wander guard (monitoring device) was noted to Resident #16's left ankle. On 09/19/2023 at 1:00 p.m., an interview was conducted with S6LPN (Licensed Practical Nurse). S6LPN confirmed Resident #16 had 2 falls, dated 05/02/2023 and 05/20/2023. S6LPN also confirmed that the resident used a wander guard. S6LPN then confirmed that the 07/26/2023 MDS assessment for both falls and wander guard were not coded accurately to reflect Resident #16's status and confirmed they both should be coded. Resident #69 Resident #69 was admitted to the facility on [DATE] with diagnoses that included, Schizophrenia and Major Depressive Disorder. Record review of Resident #69's Care Plan, dated 11/19/2023, read in part, I have a Level II PASARR (Preadmission Screening and Resident Review). Record review of Resident #69's MDS dated [DATE], under Section A, Resident evaluated by PASRR, coded 0 indicating No. On 09/19/2023 at 1:00 p.m., an interview was conducted with S6LPN. S6LPN confirmed Resident #69 had a PASRR Level II. S6LPN then confirmed the 07/19/2023 MDS assessment was not coded accurately to reflect Resident #69's status and confirmed it should have been coded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents identified with Mental Disorder and/or Intellectual Disability had an accurately completed PASARR (Pre-admission Screening and Resident Review ) Level I and/or Level II for 1 (#45) of 5 (#34, #37, 45 #77, #95) residents reviewed for PASARR screening out of a total sample of 38 residents. Findings: Review of the facility's policy titled Pre-admission Screening and Resident Review (PASARR) Policy and Procedure read in part .Policy: The facility is to review resident diagnosis and medications upon admission and throughout the resident staty to deterine if a level two request for resident review is to be completed. Resident #45 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder. Review of Resident #45's medical record revealed a Level I PASARR screening dated 09/13/2021. Further review of the PASARR screening revealed, in part, Major Depressive Disorder was not documented. On 09/19/2023 at 10:53 a.m., an interview was conducted with S3SSD (Social Services Director) who stated that she was responsible for completing and reviewing PASARRs when residents were admitted to the facility. A review of Resident #45's Level 1 PASARR screening dated 09/13/2021 was conducted with S3SSD, who stated the Resident's Level 1 screening was completed at the hospital before the resident was admitted . Section III: Mental Illness was reviewed, and there was no response to the question asking if the applicant had or had the applicant ever been diagnosed as having a mental illness. When asked if there should have been a check mark next to Major Depressive Disorder since the resident had the diagnosis, S3SSD stated she did not know, but would find out. On 09/19/2023 at 11:42 a.m., a follow up interview was conducted with S3SSD who stated that documenting that Resident #45 was diagnosed with Major Depressive Disorder on the Level I PASARR screening would have triggered a resident review for Level II evaluation. She stated she should have completed another PASARR screening reflecting the resident's diagnosis of Major Depressive Disorder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to facilitate the resident's, and if applicable, the resident representatives' participation in the care planning process for 3 (#2, #34, #46) of 5 (#1-#5) residents investigated for care planning out of a total sample of 8 residents. Findings: Resident #2 Review of Resident #2's medical records revealed she was admitted on [DATE]. Review of the resident's MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, indicating she was cognitively intact. On 09/18/2023 at 2:30 p.m., during an interview with Resident #2, the resident stated that she was not sure what a care plan meeting was and that she had not been invited to attend. On 09/19/2023 at 1:41 p.m., a telephone interview was conducted with Resident #2's Responsible Party (RP), he stated that he was not aware of a care plan meeting for 08/23/2023. On 09/19/2023 at 2:27 p.m., an interview was conducted with Resident #2 and S3SSD (Social Service Director). Resident #2 was asked if she had been invited to her care plan meeting. She stated no she had not been invited. S3SSD was asked if she had invited the resident to the care plan meeting. S3SSD looked at the resident and did not voice any response Resident #34 Review of Resident #34's medical records revealed she was admitted on [DATE]. Review of the resident's MDS dated [DATE] revealed the resident had a BIMS score of 07, which indicated severe cognitive impairment. On 09/18/2023 at 10:18 a.m., an interview was conducted with Resident #34 who stated that she did not know anything about care plan meetings, and that she has never been invited. Resident #46 Review of Resident #46 medical record revealed she was admitted on [DATE]. Review of the MDS dated [DATE] and had a BIMS score of 12, which indicated moderate cognitive impairment. 09/19/2023 at 1:47 p.m., a telephone interview was conducted with Resident #46's RP who stated he did not know anything about a care plan meeting. He stated that the facility had not invited him to any such meeting. 09/19/23 at 2:20 p.m., an interview was conducted with S3SSD, and Resident #46. Resident #46 stated that she doesn't know what that is and has not been invited to such a meeting. Resident added that she doesn't know what that is. S3SSD did not respond but shrugged her shoulders. 09/19/23 at 2:30 p.m., S3SSD was asked if she invited Resident #2, #34, and #46 to attend their quarterly care plan meetings. S3SSD stated that she didn't know what to say.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident received the necessary treatment and services to promote healing and prevent new ulcers from developing by failing to turn a resident every two hours to prevent development or worsening of pressure ulcers for 1 (#56) out of 3 (#56, #90, #101) residents investigated for pressure ulcers out of a total sample of 38 residents. Findings: Review of the facility's policy titled Physician's Orders Policy and Procedure read in part .1. Nurse is to follow physician's order according to the order. Resident #56 was admitted to the facility on [DATE] with diagnoses that included Gastrostomy Status, [NAME] Syndrome, Abnormal Weight Loss, and Major Depressive Disorder. Review of the facility's wound log revealed Resident #56 had an Unstageable/Suspected DTI (Deep Tissue Injury) to her right buttock. Review of Resident #56's September 2023 current Physician's Orders revealed an order dated 07/20/2023 that read Turn/reposition q 2 hours (every 2 hours) or as appropriate. Further review of current Physician's Orders revealed an order dated 08/24/2023 that read Comfort cushion to geri-chair -monitor every shift. On 09/18/2023 at 9:00 a.m., an observation was made of Resident #56's room. The resident was observed in bed, laying on her back. There were no pressure relieving devices in the resident's room. On 09/20/2023 at 8:30 a.m., Resident #56 was observed in her room. She was slightly reclined in the geri-chair, and laying on her back. There was no pillow, turning wedge, or pressure relieving device in the resident's chair or in her room. On 09/20/2023 at 10:30 a.m., a second observation was made of Resident #56 in her room. She was in the same position, slightly reclined in the geri-chair, and laying on her back. There was no pillow, turning wedge, or pressure relieving device in the resident's chair or in her room. On 09/20/2023 at 12:32 p.m., a third observation was made of Resident #56 in her room. She remained in the same position, slightly reclined in the geri-chair, and laying on her back. There was no pillow, turning wedge, or pressure relieving device in the resident's chair or in her room. On 09/20/2023 at 12:34 p.m., an interview was conducted with S5CNA (Certified Nursing Assistant). She stated that Resident #56 had been in the geri- chair since this morning. She stated that she could not really turn the resident because she was in the geri chair, but the staff used a cushion to put under residents in the geri chair. S5CNA proceeded to go to the supply room to show the surveyor the cushion, but there were none in the supply room. An observation was then made of Resident #56's room with S5CNA. S5CNA stated there was no cushion in the resident's room because it was wet and she did not get her another one. S5CNA confirmed that she had not repositioned Resident #56 since she was put in the geri- chair this morning. 09/20/2023 at 12:41 p.m., an interview was conducted with S4LPNTN (Treatment Nurse) who stated that Resident #56 could be in the geri- chair as tolerated. She stated there was to be a pillow or wedge under the resident to relieve pressure from the resident's pressure points while she was in the geri - chair. S4LPNTN confirmed Resident #56 was supposed to be repositioned every 2 hours, even while in the geri chair. An observation was then made of Resident #56's room with S4LPNTN, and confirmed there was no pressure relieving pillow or wedge in the resident's geri chair or room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed, interviews, and observations, the facility failed to ensure the resident's care plan and physician's orders were followed for 1 (#34) of 38 sampled residents. This was evidenced when: 1. Facility staff failed to apply compression stockings. 2. Facility staff failed to place a hand roll in Resident #34's left hand to prevent further contractures; and 3. Failed to apply pneumatic compression device to left leg daily for one hour a day. Findings: Review of Resident #34's electronic clinical record revealed an admit date of 07/08/2013 with diagnoses that included Hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, Age related osteoporosis, Contracture left elbow, Glaucoma, Dementia without behavioral disturbance, Peripheral vascular disease, and Contracture left hand. Review of physician orders dated September 2023 revealed the following orders: Calf compression stocking to left lower extremity-apply in the morning and remove at night .Hand roll to left hand .Pneumatic compression boots to bilateral lower extremities for one hour daily .Document any refusals. Review of resident's care plan dated 02/23/2022 read in part, apply hand rolls to left hand at all times except bathing and hygiene. On 05/10/2022, apply pneumatic compression boots to bilateral lower extremities was ordered. On 06/15/2019, compression stockings worn as ordered. Review of Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 07, which indicate severe cognitive impairment. Review of the EMAR (Electronic Medication Administration Record) dated July 2023 - September 18, 2023 revealed the following: On 07/02/2023, 07/04/2023, 07/05/2023, 07/06/2023, 07/07/2023, 07/09/2023, 07/10/2023, 07/12/2023, 07/14/2023, 07/19 - 07/24/2023, 8/05/2023, 08/06/202, 09/11/2023, 09/13/2023, 09/16/2023, and 09/17/2023, an N was documented indicating that the resident's pneumatic compression boots were not applied; On 08/06/2023, 08/14/2023, 08/15/2023, 08/17/2023, 08/28/2023, 09/06/2023, 09/12/2023, 09/15/2023, 09/17/2023, and 09/18/2023, an N was documented indicating that the resident's hand roll to left hand was not applied; On 09/18/2023, an N was documented indicating that the resident's calf compression stocking to left lower extremity was not applied. Review of Nurses Notes, EMAR and TAR (Treatment Administration Record) dated 07/03/2023 through 09/18/2023 revealed no documented evidence that Resident #34 had refused for staff to apply her hand roll, compression stockings, and/or pneumatic compression boots. On 09/18/2023 at 10:23 a.m., an observation was conducted in Resident #34's room. The resident was lying in bed awake and alert. Her left hand was contacted, and observed without a hand roll. Further observation revealed that the resident had bilateral blue non- skid socks and no compression stockings applied. There was no pneumatic compression device or sleeves observed inside of the resident's room. On 09/18/2023 at 2:05 p.m., an interview was conducted with Resident #34's Responsible Party (RP) who stated that he had not observed his mother wearing compression stockings or a hand roll in her left hand for months. He added that the pneumatic compression boots are usually observed on the chair, but he had not observed the machine that goes to the boots inside the room for months. On 09/18/2023 at 2:15 p.m., S4LPN (Licensed Practical Nurse) entered Resident #34's room. She stated that she was there to apply the pneumatic compression boots to the resident's left leg. S4LPN stated that as the treatment nurse, she was responsible for applying the resident's pneumatic compression boots. S4LPN was not able to locate the pneumatic compression boots or the machine inside of the resident's room. S4LPN confirmed that the resident was supposed to have a hand roll placed in her left hand and bilateral compression stockings applied daily. She also stated that the resident should have her pneumatic compression boots applied for one hour daily. On 09/18/2023 at 3:00 p.m., S4LPN returned to the residents room with S14IPQA (Infection Preventionists Quality Assurance). S14IPQA was holding a pneumatic compression sleeve and machine. S14IPQA stated that the attachment on the sleeve was broken and the machine had been taken out of the room. On 09/19/2023 at 9:00 a.m., an observation was conducted of the Resident #34's room. The resident's pneumatic compression sleeves or the machine that connects to the sleeves were not observed inside the resident's room. On 09/19/2023 at 9:05 a.m., Resident #34 was observed sitting in a wheelchair in the television room. Further observation revealed that the resident was not wearing bilateral compression stockings. The resident was observed with bilateral blue non-skid socks. On 09/19/2023 at 9:07 a.m., an interview was conducted with S7LPN. S7LPN stated that the resident's pneumatic compression boot are applied for one hour while the resident is in bed. S7LPN confirmed that the resident's compression stocking are to be applied daily in the morning and removed at night. An observation was conducted with S7LPN of the Resident #34 sitting in her wheelchair in the television room. She confirmed that the resident did not have her compression stockings applied. She added that if the resident refused to have her hand roll, compression stockings or the pneumatic compression stockings applied, the nurses are to document the refusals. On 09/19/2023 at 3:40 p.m., an interview was conducted with S8CNA (Certified Nursing Assistant), who stated that she has been working with Resident #34 for years. S8CNA confirmed that she had not seen or applied compression stockings to the resident's bilateral legs for over 3 months.

Based on observation and interview, the facility failed to properly store drugs as evidenced by loose pills found in the bottom of the medication cart drawers for 2 (Cart A, B) of 2 (Cart A, B) medication carts observed. The facility had a census of 105 residents. Findings: Review of the facility's policy titled Medication Storage Policy and Procedure read, in part, Purpose: To properly secure medications and biologicals according to CMS (Centers for Medicare & Medicaid Services) guidelines. Procedure: 1. Medication carts will be checked weekly for expired medications, loose pills, cleanliness and compliance with storage guidelines. a. Any expired medications or loose pills will be destroyed according to the standard guidelines. On 09/20/2023 at 9:23 a.m., Cart A was inspected with S14IPQA(Infection Preventionist, Quality Assurance) and S2DON (Director of Nursing). 1 white oblong pill, 2 small oblong white pills, 1 round white pill, 1/2 of a white pill, and 1 yellow oblong pill were observed loose on the bottom of the first and second drawer. The pills were observed underneath resident medication blister packages. S14IPQA, and S2DON confirmed the loose pills in the bottom of the drawers. S14IPQA stated these loose pills should not be in the bottom of the medication cart. On 09/20/2023 at 9:31 a.m., Cart B was inspected with S14IPQA. 3 round white pills, 1 round red pill, 2 round yellow pills, 1 oblong white pill, and 1/2 of an oblong white pill were observed loose on the bottom of the second and third drawer. The pills were observed underneath resident medication blister packages. S14IPQA confirmed the loose pills in the bottom of the drawers. She stated these loose pills should not be in the bottom of the medication cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #2 Review of facility's policy titled, Resident Elopement Wanderguard Policy and Procedure read in part: Wandering Resident or Resident Missing From Designated Area of Facility: 1. Any staff member who becomes aware of a resident not being at the designated area or activity shall proceed to notify the charge nurse, director of nurse and/or administrator 8. Document incident using guidelines on documentation. Review of Resident #2's record revealed he was admitted to the facility on [DATE] with diagnoses that included in part: Alcohol Abuse, Neurosyphilis, Unspecified Convulsions, Weakness, Dementia, Encephalopathy, and Personal History of Traumatic Brain Injury. Review of his significant change MDS (Minimum Data Set), dated 12/14/2022 revealed a BIMS (Brief Interview for Mental Status) of 6, severe impaired cognition. Review of the resident's care plan revealed that the resident was care planned for Dementia on 10/27/2022. Review of Resident #2's Wander Data Collection Tool dated 12/14/2022, under the Summary/Comments for Wander Assessment read, Resident often looks for his bike to go home and often asks when can I leave to go to work. Resident is an elopement risk. Wanderguard device implemented and to be worn at all times. Will re-evaluate quarterly and as needed. Review of the resident's nurse's notes by S4LPN on 12/24/2022 at 3:12 p.m. read, Resident observed propelling himself up driveway in wheelchair. When approached by staff, he is easily redirected to facility states he was looking for his mom who lives up the street. Resident brought back into facility and reoriented to room. Oriented to self. Confused most days. Will closely monitor. In a phone interview on 04/03/2023 at 4:13 p.m. with S4LPN, she stated that she worked at the facility as an agency nurse and recalled working with Resident #2. She stated that Resident #2 was confused at times and his conversations were off. She stated that on 12/24/2023 Resident #2 left out of the facility. He was found in front of the facility in the circle driveway where the facility vans travel. She stated that Resident #2 stated that he was looking for his mom. She stated that she reported the incident to the on-call staff. S4LPN later stated that she was unsure if she had reported it. In an interview on 04/04/2023 at 9:20 a.m. with S2DON, she stated that she was not notified that Resident #2 had attempted to leave the facility on 12/24/2022. When asked if a resident tried to leave the facility on a weekend, could nurses put a wandering bracelet on the resident to ensure that the resident didn't leave the facility again? She replied, the nurses had access to the wandering bracelets that are kept in her office but did not place one on the resident until 12/14/2022. In a second interview on 04/04/2023 at 11:24 a.m. with S2DON, she stated that the nurse should have notified herself or the Administrator and completed an incident report when Resident #2 left the faciity on [DATE]. Based on interviews and record reviews, the facility failed to provide the necessary monitoring and supervision of residents to prevent elopement for 3 (#1, #2 and #3) out of 3 sampled residents investigated for elopement out of 5 sampled residents. The facility failed to: 1. ensure adequate monitoring of the facility's front door which remained unlocked at all times and; 2. ensure staff reported Resident #1's expressed desire to leave the facility while she was in an angry state which resulted in no immediate interventions put in place to prevent elopement. The facility had a census of 105. Findings: Review of the facility's policy titled, Resident Elopement Wanderguard Policy and Procedure revealed the following in part, For the purpose of this policy, missing resident shall be defined to mean resident who has left the facility grounds without signing him/herself out of the facility. Resident #1 Resident #1 was admitted to the facility on [DATE]. Her diagnoses include in part, Alzheimer's Disease, Anxiety Disorder and Unspecified Psychoses. Resident #1 was discharged from the facility on 03/09/2023. Review of the resident's quarterly MDS (Minimum Data Set) dated 2/16/2023 revealed a BIMS (Brief Interview of Mental Status) score of 8, moderate impaired cognition. Under Section G: Functional Status, the resident required the use of walker while ambulating. Review of the nurse's note by S3LPN (Licensed Practical Nurse) dated 03/08/2023 at 2:02 p.m. read in part, Resident upset this a.m. because a blanket was sent to laundry for washing. She was standing at desk cursing and referring to staff member that took laundry as fat *ss. Stating I can't wait to get out of this hell hole. Resident requested to speak with the boss to report blanket missing. This nurse walked resident to Administrator's office as requested. Review of the nurse's note by S3LPN dated 03/08/2023 at 4:01 p.m. read in part, At approximately 2:15 p.m., someone called the facility stating they seen an elderly person walking on side of road. All staff preformed a resident check entering every room to account for all residents, it was noted that this resident was not present. Review of the incident report completed by S2DON dated 03/08/2023 at 3:30 p.m. read in part, Resident walked out of facility and to a neighboring house next to the facility. Resident of the home asked resident where she was going. She responded that she was going to her sister's house. The occupant of the house knew resident so they brought resident to her sister's house where she safely remained until the son notified facility approximately 30 min (minutes) later where she was . On 04/03/2023 at 12:30 p.m. to 12:45 p.m., an observation was conducted of the area from the nursing home to the nearby hospital where Resident #1 was reported as being seen. The driveway leading from the nursing home to the highway was long and at the end of the driveway, near the highway, was an assisted living facility with a pond in the front. The nursing home was calculated at 0.4 miles from the hospital. The highway was a two-lane road with a shoulder on each side but there were no sidewalks adjacent to either side of the highway. There were several homes and businesses on the side of the highway opposite of the nursing home. The highway was observed very busy with traffic at times. The posted speed limit was 35 mph (miles per hour). On 04/30/2023 at 1:45 p.m., a phone interview was conducted with Resident #1's son. He stated that his mother's blanket was missing. He stated that S1ADM called him on 03/08/2023 to let him know that his mother had left the facility. He stated that he called his mother's phone and she answered and told him she was at her sister's house. He stated that a lady, who knows his mother and lives by the hospital near the facility, saw the resident walking with her walker on the side of the highway and gave her a ride to her sister's house who lives miles away from the facility. On 04/03/2023 at 3:30 p.m., an interview was conducted with S7CNA (Certified Nursing Assistant). S7CNA stated on 03/08/2023, between 1:45 p.m. to 2:00 p.m., he made rounds with S8CNA and another unnamed CNA. After they made rounds, they were standing by the linen closet on the hall when Resident #1 came out of her room upset about her blanket. The resident walked by them and cursed S8CNA and then turned and ran her walker into S8CNA He stated the resident stated that she wanted her son to come get her out of the facility and if he didn't come get her, she was going to leave. The resident then went to the front lobby. He stated that he did not tell anyone that the resident had stated that she was going to leave. He stated that residents say things all the time and didn't think that Resident #1 really meant that she was going to leave the facility. On 04/03/23023 at 3:55 p.m., an interview was conducted with S3LPN (Licensed Practical Nurse). S3LPN stated on 04/08/2023, the resident was very irritated since 6 a.m. that morning. The resident was upset with S8CNA because she had stripped her bed and her blanket was missing. She stated that at shift change, between 1:45 p.m. to 1:50 p.m., Resident #1 came out of her room and cursed at S8CNA and took her walker and pushed it into the CNA. She confirmed that the resident stated that she wanted to leave the facility. S3LPN stated that she walked with the resident to the front lobby of the facility to speak with the Administrator. She stated that after the resident talked with the Administrator, she sat in one of the chairs in the lobby and started talking with another resident. She stated that this was about 2:00 p.m. She stated that 15 minutes later, S10WC reported that someone had called the nursing to report that they had seen an elderly person with a walker walking on the highway that ran in front of the facility. She confirmed that it was a busy highway. She stated a search of the facility was conducted and it was determined that Resident #1 was missing. On 04/03/2023 at 4:15 p.m., a phone interview was conducted with S8CNA. She stated on 03/09/2023 she worked the 6:00 a.m. to 2:00 p.m. shift. She stated that on 03/07/2023, she accidentally sent the resident's blanket to the laundry when she stripped her bed. She stated that she informed the resident that she would go find her blanket but by the end of day she was not able to find it. She looked again the next day (03/08/2023) when she came back to work. She stated that she found the resident's blanket but the resident stated that it was not her blanket. The resident was very upset and she could not calm her down. She gave the blanket to S1ADM. She stated that she switched room assignments with another CNA because she did not want to upset the resident further. At shift change at 2:00 p.m., she and S7CNA made rounds on the hall where the resident resided. The resident came up behind her, cursed at her and then hit her with the walker. She stated that she reported it to the nurse, clocked out, and went home. She stated she did not recall the resident stating that she wanted to leave the facility. On 04/04/2024 at 10:00 a.m., an interview was conducted with S1ADM. S11CN was present. S1ADM stated that after lunch on 03/08/2023, he talked to the resident about her blanket and had seen the resident sitting in the lobby area of the facility. He stated that he left his office to go to the kitchen and the DON's (Director Of Nursing) office. He stated moments after that, he was informed that someone (ambulance personnel) had called saying they had seen a resident walking with a walker on the highway that ran in front of the nursing home. Staff then searched the facility and the facility grounds for the resident and determined that Resident #1 was missing. He stated he got in his truck and rode down the highway but he did not see the resident. He called the resident's son and he called back later to let him know that the resident at her sister's home. S1ADM and S11CN stated that the facility's front door was unlocked at the time of the incident. S1ADM stated that the facility's front door was never locked before until they installed the automatic lock on 03/22/2023. S1ADM stated that the facility was in the process of installing an automatic door lock that required a code to open the door at the time the resident eloped. He confirmed that the lock was not activated and fully functional until 03/22/2023. When asked if staff had reported to him that the resident had expressed the desire to leave on the facility that day. He stated No one had informed him. S1AADM and the Corporate Nurse agreed that the staff should have reported this to the DON or the Administrator. Resident # 3 Resident #3 was admitted to the facility on [DATE]. His diagnoses included in part, Unspecified Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. Review of the resident's MDS (Minimum Data Set) dated 01/11/2023 revealed a BIMS (Brief Interview of Mental Status) of 8, indicating Resident #3 had moderate impaired cognition. Review of the resident's care plan revealed that he was care planned for risk for falls and Dementia. Review of the Wander Data Collection Tool completed by S13MDS Coordinator dated 1/11/2023 under the Summary/Comments for Wander Assessment read, 1/4/23 resident was found in parking lot stating he was going to the MD (medical doctor) . Review of the resident's January 2023 nurses notes revealed no documentation related to the incident on 01/04/2023. On 04/04/2023 at 2:21 p.m., an interview was conducted with S12SSD. S12SSD stated that she found the resident outside on the front porch of the facility stating that he was going to a doctor's appointment. On 04/04/2023 at 2:30 p.m., an interview was conducted with S13MDS Coordinator. S13MD Coordinator confirmed that she completed the Wander Data Collection Tool on 01/11/2023 for the resident. She stated that it was reported to her by S13SSD that the resident was found in the parking lot stating that he was going to his doctor's appointment. On 04/04/2023 at 2:40 p.m., a phone interview was conducted with S14LPN. S14LPN confirmed that she was the resident's nurse on 01/4/2023. She stated on 01/04/2023, S12SSD informed her that she found the resident on the front porch stating he was going to the doctor. S14LPN was informed that the Wander Data Collection Tool dated 01/11/2023 indicated that the resident was found in the parking lot. S14LPN stated that she didn't see the resident outside but now remembered that she was informed by one of the CNAs that the resident was in the parking lot. When asked if she completed an incident report, she stated that she was not aware that an incident report needed to be completed. On 04/04/2023 at 10 a.m., an interview was conducted with S1ADM. S11CN was present. S1ADM was asked the facility's definition of elopement. He replied, when someone who goes out the building and off the premises and not seen on the porch or walking in the front of the facility. When asked what he considered the safest place for the resident, he stated the facility. S1AD and S11CN agreed that a cognitively impaired resident should be supervised.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #2 Review of facility's policy titled, Resident Elopement Wanderguard Policy and Procedure read in part: Wandering Resident or Resident Missing From Designated Area of Facility: 1. Any staff member who becomes aware of a resident not being at the designated area or activity shall proceed to notify the charge nurse, director of nurse and/or administrator 8. Document incident using guidelines on documentation. Review of Resident #2's record revealed he was admitted to the facility on [DATE] with diagnoses that included in part: Alcohol Abuse, Neurosyphilis, Unspecified Convulsions, Weakness, Dementia, Encephalopathy, and Personal History of Traumatic Brain Injury. A review of his significant change MDS (Minimum Data Set), dated 12/14/2022 revealed a BIMS (Brief Interview for Mental Status) of 6, severe impaired cognition. Review of the resident's care plan revealed that the resident was care planned for Dementia on 10/27/2022. Review of Resident #2's Wander Data Collection Tool dated 12/14/2022, under the Summary/Comments for Wander Assessment read, Resident often looks for his bike to go home and often asks when can I leave to go to work. Resident is an elopement risk. Wanderguard device implemented and to be worn at all times. Will re-evaluate quarterly and as needed. Review of the resident's nurse's notes by S4LPN on 12/24/2022 at 3:12 p.m. read, Resident observed propelling himself up driveway in wheelchair. When approached by staff, he is easily redirected to facility states he was looking for his mom who lives up the street. Resident brought back into facility and reoriented to room. Oriented to self. Confused most days. Will closely monitor. In a phone interview on 04/03/2023 at 4:13 p.m. with S4LPN, she stated that she worked at the facility as an agency nurse and recalled working with Resident #2. She stated that Resident #2 was confused at times and his conversations were off. She stated that on 12/24/2023 Resident #2 left out of the facility. He was found in front of the facility in the circle driveway where the facility vans travel. She stated that Resident #2 stated that he was looking for his mom. She stated that she reported the incident to the on-call staff. S4LPN later stated that she was unsure if she had reported it. In an interview on 04/04/2023 at 9:10 a.m. with S5MDS Coordinator, he stated that a wander assessment was conducted on every resident on admission, quarterly and if there was an episode where the resident who is confused attempt to leave the facility. He stated that if a resident who was confused attempted to leave the facility, the nurse should contact the NP (Nurse Practitioner) or doctor for recommendations and perform a census check of the residents in the facility. He stated that the nurse should also notify the Administrator or the DON (Director of Nurse). In an interview on 04/04/2023 at 9:20 a.m. with S2DON, she stated that she was not notified that Resident #2 had attempted to leave the facility on 12/24/2022. When asked if a resident tried to leave the facility on a weekend, could the nurse put a wandering bracelet on the resident to ensure that the resident didn't leave the facility again, she replied that the nurses had access to the wandering bracelets that are kept in her office. In a second interview on 04/04/2023 at 11:24 a.m. with S2DON, she stated that the nurse should have notified herself or the Administrator and completed an incident report when Resident #2 left the faciity on [DATE]. Based on interviews and record reviews, the facility failed to ensure nurses demonstrate competencies necessary to care for residents' needs for 4 (#1, #2, #3, #4) of 5 (#1, #2, #3, #4, #5) sampled residents by: 1. Failing to assess a resident after a fall (#4); 2. Failing to report to Director of Nursing or Administrator when a resident expresses the desire to leave the facility (#1); and by 3. Failing to complete an incident report (#2, #3). The facility had a census of 105 residents. Findings: 1. Resident #4 Review of the policy titled Incident and Accident Policy and Procedure revealed the following in part: Policy: Incident and accidents are to be reported, investigated, and followed up in a timely manner. Procedure: 1) Reporting of Incidents and Accidents: a) The incident and accident must be reported to the designated departmental supervisor. 2) Assisting Incident and Accident Victims: a) Provide immediate assistance. 3) Medical attention: a) Assess all Incident and Accident victims. C) Documentation in the nurse's notes must clearly define the incident along with vital signs. Resident #4 admitted to the facility on [DATE] with diagnoses that included Osteoarthritis and History of Falling A review of the Quarterly Minimum Data Set (MDS) Assessment on 02/23/2023 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 10 that indicated moderately impaired cognition. Further review, revealed Resident #4 required extensive assistance with two persons for transfers. The review revealed Resident #4 has had one fall with a major injury since the prior assessment. A review of Resident #4's plan of care revealed the resident was at risk for falls related to a history of falls, muscle weakness and dizziness. Resident #4 had diagnoses of severe osteoarthritis to bilateral lower extremities and osteoporosis. Further review revealed Resident #4 required assistance with transfers. Review of the facility's report to the State Survey Agency revealed an incident for Resident #4 was discovered on 03/15/2023 at 4:10 p.m. and reported by S1ADM. On the morning of 03/15/2023, the staff noted Resident #4 had swelling to right leg and knee. Resident #4 was evaluated by the physician and x-rays revealed a distal right femur fracture. An investigation was completed that revealed Resident #4 had a fall on 03/13/2023. S15LPN failed to assess Resident #4 . Review of Disciplinary Action for S15LPN, dated 03/16/2023, revealed Termination related to Resident #4's incident on 03/13/2023. S15LPN failed to complete an assessment of Resident #4 following incident, . S15LPN should have completed an assessment, . Signed by S15LPN and S1ADM on 03/16/2023. A review of Resident #4's nurse's notes revealed no documentation of any fall on 03/13/2023 or 03/14/2023. On 04/03/2023 at 2:54 p.m., an interview was conducted with Resident #4 that revealed she fell in the shower room when she was transferred by two Certified Nursing Assistants (C.N.A.). Resident #4 stated she was assisted by two C.N.A.s from the floor to her wheelchair and brought back to her room. On 04/03/2023 at 3:49 p.m., a telephone interview with S9CNA was conducted that revealed Resident #4 required assistance of two persons for transfers. S9CNA stated on 03/13/2023, Resident #4 had a fall in the shower room during transfer from shower chair to wheelchair. S9CNA assisted S16CNA and S17CNA with the transfer of Resident #4. S9CNA stated that Resident #4's legs buckled and was lowered to the floor. S9CNA stated Resident #4 was assisted back to wheelchair and did not complain of pain. On 04/04/2023 at 10:45 a.m., an interview was conducted with S17CNA that revealed Resident #4 had a fall on 03/13/2023 at approximately 6:30 a.m. in the shower room. S17CNA stated she was assisted by S9CNA with the transfer of Resident #4 from the shower chair to the wheelchair. S17CNA stated Resident #4's legs got weak and was placed in sitting position on the floor with her legs out in front of her. Resident #4 was assisted by S17CNA, S16CNA, and S9CNA from floor to wheelchair. S17CNA stated she notified S15LPN of Resident #4's fall. On 04/04/2023 at 12:30 p.m. an interview was conducted with S1ADM and S2DON that confirmed that S15LPN failed to complete an assessment of Resident #4 following incident and should have. On 04/04/2023 at 2:40 p.m., called S16CNA with no answer, unable to obtain an interview. On 04/04/2023 at 2:45 p.m., called S15LPN with no answer, unable to obtain an interview. 2. Resident #1 Resident #1 was admitted to the facility on [DATE]. Her diagnoses include in part, Alzheimer's Disease, Anxiety Disorder and Unspecified Psychoses. Review of the resident's quarterly MDS (Minimum Data Set) dated 2/16/2023 revealed a BIMS (Brief Interview of Mental Status) score of 8, moderate impaired cognition. Under Section G: Functional Status, the resident required the use of walker while ambulating. Review of the nurse's note dated 03/8/2023 at 2:02 p.m. read in part, Resident upset this a.m. because a blanket was sent to laundry for washing. She was standing at desk cursing and referring to staff member that took laundry as fat ass. Stating I can't wait to get out of this hell hole. Res requested to speak with the boss to report blanket missing. This nurse walked resident to Administrators office as requested. On 04/03/2023 at 3:55 p.m., an interview was conducted with S3LPN (Licensed Practical Nurse). S3LPN stated on 03/08/2023, the resident was very irritated since 6:00 a.m. that morning. The resident was upset with the S8CNA because she had stripped her bed and her blanket was missing. S3LPN stated that she walked with the resident to the front lobby of the facility to speak with the Administrator. She stated that she didn't inform the DON (Director of Nurses) or the Administrator that the resident stated that she wanted to leave the facility. On 04/03/2023 at 3:30 p.m., an interview was conducted with S7CNA (Certified Nursing Assistant). S7CNA stated on 03/08/2023, between 1:45 p.m. to 2:00 p.m., he made rounds with S8CNA and another CNA. After they made rounds, they were standing by the linen closet on the hall when Resident #1 came out of her room upset about her blanket. The resident walked by them and cursed S8CNA and then turned and ran her walker into S8CNA. He stated the resident stated that she wanted her son to come get her out of the facility and if he didn't come get her, she was going to leave. The resident then went to the front lobby. He stated that he did not tell anyone that the resident had stated that she was going to leave. He stated that residents said things all the time and didn't think that Resident #1 really meant that she was going to leave the facility. On 04/04/2023 at 10:00 a.m., an interview was conducted with S1ADM. The facility's Corporate Nurse was present. When asked if staff had reported to him that the resident had expressed the desire to leave on the facility that day, he stated No one had informed him. S1AADM and the Corporate Nurse agreed that the staff should have reported this to the DON or the Administrator. Resident #3 Resident #3 was admitted to the facility on [DATE]. His diagnoses included in part, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. Review of the resident's MDS (Minimum Data Set) dated 01/11/2023 revealed a BIM (Brief Interview of Mental Status) of 8, moderate impaired cognition. Review of the resident's care plan revealed that he was care planned for risk for falls and Dementia. Review of the Wander Data Collection Tool completed by S13MDS Coordinator dated 1/11/2023 under the Summary/Comments for Wander Assessment read, 01/4/2023 resident was found in parking lot stating he was going to the MD (medical doctor) . On 04/04/2023 at 2:40 p.m., a phone interview was conducted with S14LPN. S14LPN confirmed that she was the resident's nurse on 01/4/2023. She stated on 01/04/2023 S12SSD informed her that she found the resident on the front porch stating he was going to the doctor. S14LPN was informed that the Wander Data Collection Tool dated 01/11/2023 indicated that the resident was found in the parking lot. S14LPN stated that she didn't see the resident outside but now remembered that she was informed by one of the CNAs that the resident was in the parking lot. Asked if she completed an incident report. She stated that she was not aware that an incident report needed to be completed. On 04/04/2023 at 2:50 p.m., an interview was conducted with S11CN. S11CN stated there was no incident report completed for the incident on 01/04/2023 when the resident was found outside in the facility's parking lot. She confirmed that an incident report should have been done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to implement the plan of care by failing to ensure the seatbelt alarm was functioning properly for 1 (#77) out of 3 (#35, #43, #77) residents investigated for falls out of a total sample of 23 residents. Findings: 1. Resident #77. Review of the resident's electronic clinical record revealed that the resident was admitted to the facility on [DATE]. The resident's admitting diagnoses included Parkinson's Disease, Chronic Kidney Disease, Dysphagia following other Cerebrovascular Disease, and Repeated Falls. Review of the resident's admission MDS (Minimum Data Set) dated 7/21/2022 revealed that the resident's BIMS (Brief Interview for Mental Status) score was 3, for being severely impaired for cognition. Review of the resident's care plan revealed that it addressed that the resident was at risk for falls. Review of the interventions included ensure alarming seatbelt working properly. Review of the resident's care plan revealed that the resident had falls on 7/14/2022, 7/15/2022, 7/19/2022, 7/20/2022, 7/26/2022, 7/31/2022, 8/3/2022, 8/10/2022, 8/13/2022, and on 8/20/2022. On 8/23/2022 at 10:12 am, an observation of the resident was made. The resident was observed sitting up wheelchair in the therapy room. During this observation, the therapist were not providing services to the resident at this time. The resident was observed to have a seatbelt alarm in place that was attached to the wheelchair. S6CNA (Certified Nursing Assistant) was present and demonstrated how the seatbelt with the alarm functioned. S6CNA was observed to release the seatbelt and the alarm did not ring. S6CNA stated that she did not know why the alarm was not functioning and went to get the nurse to check the alarm. At 10:15 am, S7LPN (Licensed Practical Nurse) checked the alarm and discovered and confirmed that the alarm was turned off. On 8/23/2022 at 10:20 am, the therapy staff was interviewed. S8OT (Occupational Therapist, S9ST (Speech Therapist), S10PT (Physical Therapist), and S11RD (Rehab Director) all stated that they did not touch the resident's seatbelt alarm or turned it off. On 8/24/2022 at 11:15 am, S4DON (Director of Nursing) stated that she was informed that the resident's seatbelt alarm attached to her wheelchair was not turned on while she was in the therapy room and that it should have been on.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure the resident receive the treatment and care to support and maintain an upright position while sitting up in a gerichair for 1 (#35) out 4 (#35, #37, #65, #152) residents investigated for positioning and mobility out of a total sample of 23 residents. Findings: 1. Resident #35. Review of the resident's electronic clinical record revealed that the resident was admitted to the facility on [DATE]. The resident's diagnoses included Dementia without Behavioral Disturbance, History of Falling, Muscle Weakness, and Primary Osteoarthritis. Review of the resident's care plan revealed, May use gerichair for proper positioning . Review of the resident's quarterly MDS (Minimum Data Set) dated 6/28/2022 revealed that the resident's BIMS (Brief Interview for Mental Status) score was 3, for being severely impaired for cognition. On 8/22/2022 at 10:12 am, the resident was observed sitting up in gerichair in her room. The resident's body was observed leaning towards the ride side of the gerichair without support to maintain the resident's body in an upright position. The resident's right arm was observed hanging over the armrest of the gerichair reaching towards the floor. On 8/23/2022 at 10:00 am, the resident was observed sitting up in gerichair in her room. The resident's body was observed leaning toward the right side of the gerichair without support to maintain the resident's body in an upright position. The resident's right arm was observed hanging over the armrest of the gerichair during this observation. On 8/23/2022 at 11:30 am, the resident was observed sitting up in gerichair at the dining room table. The resident's body was observed leaning on the side of the gerichair without support to maintain body in an upright position. On 8/23/2022 at 1:00 pm, the resident was observed in her room sitting up in gerichair. The resident's body was observed leaning to the right side of the gerichair without support to maintain body in an upright position. On 8/24/2022 at 9:00 am, the resident was observed in the dayroom across from the nurse's station and therapy room. The resident was sitting up in gerichair and her body was leaning on the right side of the gerichair without support to maintain body in an upright position. On 8/24/2022 at 8:40 am, S12CNA (Certified Nursing Assistant) stated that the resident's body does lean to the right side while sitting up in the gerichair and confirmed that there were no supportive devices used to maintain the resident in an upright position. On 8/24/2022 at 9:50 am, S13CNA stated that the resident's body does lean to the right side while she is in the gerichair and that there were no devices used to maintain the resident in an upright position while up in the gerichair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with a hospice agency to ensure a resident had a Hospice Plan of Care for 1 (#252) out of 1 residents investigated for hospice services in a total investigative sample of 24 residents. The deficient practice had the potential to affect any of the 6 residents receiving hospice services as documented on the facility's Resident Census and Conditions form (CMS-672). Findings: Review of Resident #252's clinical record revealed he was admitted on [DATE]. Further review of the record revealed a physician's order dated 8/8/22 to admit to hospice with the following diagnoses of Cerebral Palsy, Down Syndrome, and Spina Bifida Occulta. Review of the facility's Hospice Care Policy and Procedure revealed, in part, 3. Hospice will maintain all documentation in the clinical record. Review of the facility and hospice agency's contract titled Hospice Routine Care/Patient Specific-Service Agreement dated 8/4/22 read in part, Hospice will provide the Nursing Center: most recent Hospice Plan of Care that is patient specific . Further review read in part, Hospice and Nursing Center shall coordinate, establish, and agree upon a coordinated plan of care for Hospice patients residing in Nursing Center . Review of Resident #252's clinical record revealed no Hospice Plan of Care and/or a separate hospice record. In an interview on 8/23/22 at 3:35 p.m., S15LPN was asked if Resident #252 had a hospice chart. She stated that she was not sure if the resident had a hospice chart. She stated that this was the first time the resident's hospice agency had patients in the facility and she did not think that they provided a chart. When asked if there were any documents provided by the hospice agency and if she knew where they were, S16LPN replied she was not sure where those documents would be. On 8/23/22 at 3:50 p.m., a review of the resident's clinical record was conducted with S14CN. After review of the record, S14CN confirmed that there were no hospice documents in the record, including a hospice plan of care. She stated that the facility should a have a hospice chart on every hospice resident. S14CN stated that the hospice agency should scan the documents to the facility and that it was the responsibility of the ward clerk to scan the documents in the resident's clinical record. On 8/23/22 at 4:00 p.m., S14CN stated the resident's hospice documentation was found in the To be scanned folder at the nurse's station and had not been scanned in the resident's clinical record. A review of the documents revealed no hospice plan of care. She confirmed the documents should have been scanned in the resident's clinical record. She also confirmed that a plan of care should be in the resident's clinical record to ensure coordination of Resident #252's care with the hospice agency.