**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and interviews, the facility failed to ensure notifications of changes in resident conditions were made, as evidenced by the facility failing to ensure the resident's physician was notified of an incident for 1 (#1) of 3 (#1, #2, and #4) residents reviewed for notification of change. Findings: Review of the facility's Change in a Resident's Condition or Status Policy undated revealed: Policy Statement Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc). Review of the medical record for resident #1 revealed an admission date of 10/24/2024 with diagnoses including unspecified dementia with other behavioral disturbance, depression, and hypothyroidism. Review of the resident #1's medical record revealed no documentation of an Admit Minimum Data Set Assessment (MDS) due to the resident was transferred to the emergency room on [DATE]. Resident #1 was discharged from the facility on 10/26/2024 before the Admit MDS assessment could be completed. Review of resident #1's Baseline Care Plan revealed she was confused, nonverbal, and required 1 person assistance with all activities of daily living. Review of the Incident/Accident (IA) Reporting Form dated 10/26/2024 at 10:15 a.m., revealed S4Licensed Practical Nurse (LPN) was summoned to the locked unit by S3Certified Nursing Assistant (CNA). S3CNA reported that resident #1 sat on the floor and when she got up she hit the left side of her head on a chair. S4LPN found the resident sitting on buttocks with legs extended out in front of her. Resident #1 was assessed for injuries and she had a knot on the side of her head (left side per diagram). There was no bleeding or any other visible injuries. Resident #1 was moving her extremities continuously. Further review of the IA report revealed the resident's physician was notified on 10/26/2024 at 10:20 a.m. However, there was no time documented for time the physician responded. An interview with S3CNA on 12/04/2024 at 12:15 p.m., revealed she witnessed the above incident. She reported the object that resident #1 bumped her head on was the table in the day room in the locked unit. S4LPN documented in the above IA Report that the object was a chair, which was incorrect. A phone interview with S4LPN was conducted on 12/03/2024 at 9:35 a.m. S4LPN revealed she tried to contact the resident's physician regarding the above incident on 10/26/2024 at 10:20 a.m but the physician's phone number in the computer was not up to date. She called the phone number but it had been disconnected. S4LPN revealed she tried to look up the physician's new number on her phone but couldn't find it. S4LPN confirmed she failed to find out the physician's new number at that time and resident #1's physician was not notified of the incident on 10/26/2024 at 10:20 a.m. An interview with S2Interim Director of Nursing on 12/04/2024 at 10:00 a.m. confirmed S4LPN should have notified resident #1's physician regarding the above incident that occurred on 10/26/2024 at 10:15 a.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #6 Review of the medical record revealed resident #6 was admitted to the facility on [DATE]. Further review revealed her diagnoses included in part, dementia without behavioral disturbance and a history of pressure ulcers. Review of the annual MDS assessment dated [DATE] revealed resident #6 had a BIMS score of 09. A score of 08-12 indicated resident #6 had moderately impaired cognitive skills for daily decision making. On 10/14/2024 at 2:30 p.m., an observation revealed resident #6 in her room and resting in bed. Further observation revealed the resident's feet were both pressed against the footboard of the bed. Further observation revealed resident #6 had purple colored bruising to the top of her left foot between the resident's great toe and the distal interphalangeal joints. There was further bruising observed to the outer, lateral part of the left foot. S9LPN was notified of the bruising. On 10/16/2024 at 12:00 p.m., S2ADON and S8ADON were notified of resident #6 having bruising observed to the top of her left foot. S2ADON and S8ADON performed an inspection of resident #6's skin. Observation revealed two dime sized areas of greenish-yellow bruising to the resident's outer biceps of her right arm. Further observation revealed one small area of bruising to the back of the resident's inner, lateral part of the right knee and a second area that was approximately dime sized to the back of her left leg, below the bend of the knee. During an interview with resident #6, resident #6 revealed she could not recall exactly how the bruising had occurred. Both S2ADON and S8ADON confirmed they were not aware of resident #6's bruises. They further confirmed that staff were to notify them upon discovery of any injury of unknown origin. On 10/16/2024 at approximately 5:45 p.m., S7Corporate Administrator and S1Administrator were notified of the above findings. Based on record reviews, and interviews, the facility failed to ensure notifications of changes in resident conditions were made, as evidenced by the facility failing to ensure 1) the resident's representative was notified after resident #69 had a fall, and 2) staff notified the nurse when resident #6 was found to have bruises for 2 (#6 and #69) of 2 residents reviewed for notification of change. Findings: Review of the facility's Change in a Resident's Condition or Status Policy undated revealed: Policy Statement Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc). Resident #69 Review of the medical record for resident #69 revealed an admission date of 06/25/2024 with diagnoses including pulmonary edema, hypertension, dementia, muscle weakness, and cerebral infarction. Review of the current Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment for daily decision making. Further review of the MDS revealed resident #69 required assistance with activities of daily living. Review of the Incident/Accident Reporting Form dated 10/14/2024 revealed resident #69 was found lying in the supine position on the floor mat. Further review of the report revealed there was no documented evidence that S4Licensed Practical Nurse (LPN) notified the family of the fall. On 10/15/2024 at 1:50 p.m., an interview with S4LPN confirmed she did not inform the family that the resident had a fall on 10/14/2024. On 10/16/2024 at 2:45 p.m., an interview with S2Assistant Director of Nursing (ADON) confirmed S4LPN should have notified the responsible party on 10/14/2024 that #69 had a fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #25 Review of the medical record for resident #25 revealed an admission date of 09/01/2017 with diagnoses including vascular dementia unspecified severity with other behavioral disturbance, cerebrovascular disease, Alzheimer's disease early onset, pseudobulbar affect, anxiety disorder, type 2 diabetes mellitus, hypotension, and major depressive disorder. Review of resident #25's October 2024 Physician's Orders revealed there was no order for the use of a geri chair or a lap tray. Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 2 indicating severe cognitive impairment. Further review of the MDS revealed dependence on staff for all activities of daily living and no physical restraint was marked on the MDS. Observations on 10/14/2024 at 9:25 a.m. and 10/15/2024 at 12:42 p.m. revealed resident #25 was in a geri chair with lap tray in his room. Observation of resident #25 on 10/16/2024 at 11:10 a.m. revealed resident was up in a geri chair with a lap tray in the dayroom. An interview on 10/16/2024 at 8:15 a.m. with S3Certified Nursing Aid (CNA) revealed resident #25 was not able to release the lap tray on his geri chair. Review of resident #25's Pre-Restraining assessment dated [DATE] revealed resident had a geri chair for poor trunk control, but did not identify the use of a lap tray while in the geri chair. Review of the Informed Consent for Use of Physical Restraint dated 09/01/2024 for resident #25 revealed use of a geri chair with lap tray, physical restraint, purpose- poor trunk control, to be applied when out of bed. Review of the record revealed no documentation of monitoring the release of the lap tray at least every 2 hours for resident #25. An interview on 10/16/2024 at 1:55 p.m. with S2ADON confirmed resident #25 was not able to release the lap tray on his geri chair. S2ADON confirmed resident #25 did not have a physician's order for the use of a geri chair or a lap tray. S2ADON further confirmed resident #25 did not have any documentation of monitoring the release of the lap tray for resident #25. Resident #52 Review of the medical record revealed resident #52 was admitted to the facility on [DATE] with diagnoses including in part, dementia without behavioral disturbance and a history of falls. Review of the Significant Change in Status MDS assessment dated [DATE] revealed resident #52 had a BIMS score of 99 which indicated the resident had severe cognitive impairment with daily decision making skills. Further review revealed resident #52 was dependent upon staff for all activities of daily living. Review of resident #52's Pre-Restraining Evaluation form dated 09/18/2024 revealed an interdisciplinary team evaluation revealed a recommendation for resident #52 to have a geri chair with a lap tray to assist with poor trunk control and forward leaning. Review of the Informed Consent for Use of Physical Restraint dated 09/01/2024 for resident #52 revealed use of a geri chair with lap tray for trunk control. Review of the medical record revealed there was no documented evidence of monitoring for the release of the lap tray at least every two hours for resident #52. On 10/14/2024 at 10:22 a.m., an observation in the dayroom revealed resident #52 sitting up in a geri chair. Further observation revealed a lap tray was intact to the geri chair. Further observation revealed the resident's hand were closed and contracted. On 10/16/2024 at 11:45 a.m., an interview with S2ADON confirmed there was no documented evidence in the medical record to address monitoring for the release of resident #52's lap tray. She further confirmed resident #52 had contractures to both hands and could not remove the lap tray. On 10/16/2024 at approximately 5:45 p.m., S7Corporate Administrator and S1Administrator were notified of the above findings. Based on observations, record reviews, and interviews, the facility failed to ensure residents were free from physical restraints imposed for the purpose of discipline or convenience for 3 (#25, #52 and #70) of 3 residents reviewed for restraints. The facility failed to have documented evidence of monitoring the release of the lap trays for residents #25, #52 and #70 and failed to have physician orders for the lap trays for residents #25 and #70. Findings: Review of the facility's Use of Restraints policy and procedure, revised December 2007, revealed the following, in part: Policy Interpretation and Implementation 2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which staff applied it given that resident's physical condition (i.e., side rails put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. 3. Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, geri-chairs, and lap cushions and trays that the resident cannot remove. 9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. the specific reason for the restraint (as it relates to the resident's medical condition) b. how the restraint will be used to benefit the resident's medical condition; and c. the type of restraint, and period of time for the use of the restraint. 17. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom, but the underlying problems that may be causing the symptom. 18. Care plans shall also include the measures taken to systemically reduce or eliminate the need for restraint use. Review of the facility's undated Informed Consent for Use of Physical Restraint revealed the following, in part: a staff member shall assess restrained residents every 30 minutes, for physical needs and comfort, and release the restraint for 10 minutes at least every 2 hours, changing position, toileting, and performing range of motion exercises to all extremities, as part of the resident's plan of care. Resident #70 Review of the medical record for resident #70 revealed an admission date of 07/24/2024 with diagnoses of edema, depression, muscle weakness, seizures, hypertension and lack of coordination. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #70 had a Brief Interview for Mental Status (BIMS) score of 2 which indicated severe cognitive impairment for daily decision making and the resident required assistance with activities of daily living (ADLs). Review of resident #70's October 2024 physician's orders revealed a physician's order dated 10/05/2024 to use a geri chair when the resident was out of the bed. Further review of the physician's orders revealed no order for the use of a lap tray. Review of the current careplan revealed resident #70 was at high risk for injury due to the resident used a geri chair with a lap tray. On 10/14/2024 at 10:00 a.m. and 2:10 p.m., observations of resident #70 revealed he was sitting in a geri chair with a lap tray. On 10/15/2024 at 9:18 a.m. and 10/16/2024 at 9:00 a.m., observations of resident #70 revealed he was sitting in a geri chair with a lap tray. Review of resident #70's Pre-Restraining assessment dated [DATE] revealed the resident had a geri chair with a lap tray to assist with trunk control. Review of the Informed Consent for Use of Physical Restraint dated 09/01/2024 for resident #70 revealed use of a geri chair with lap tray, physical restraint for trunk control. Review of the record revealed no documentation of monitoring the release of the lap tray at least every 2 hours for resident #70. On 10/16/2024 at 1:55 p.m., an interview with S2Assistant Director of Nursing (ADON) confirmed resident #70 did not have a physician's order for use of a lap tray. S2ADON confirmed resident #70 did not have any documentation of monitoring the release of the lap tray for resident #70.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and send a copy of the notice to a representative at the Office of the State Long-Term Care Ombudsman for 1 (#12) of 1 (#12) reviewed for hospitalizations. Findings: Review of the Emergency Transfer Logs for June 2024 and July 2024 revealed resident #12 was discharged to the hospital on the dates of 06/23/2024 and 07/17/2024. Further review revealed there was no documented evidence of the Ombudsman being notified of resident #12 being transferred to the hospital on [DATE] and 07/17/2024. On 10/16/2024 at 5:12 p.m., during a telephone interview with the local Ombudsman assigned to the nursing facility, she confirmed that she had not been notified of resident #12's transfers to the hospital on the dates of 06/23/2024 and 07/17/2024. On 10/16/2024 at approximately 5:45 p.m., S7Corporate Administrator and S1Administrator were notified of the above findings.

Based on record reviews and interview, the facility failed to assess residents using the quarterly review instrument specified by the State and approved by Centers for Medicare and Medicaid Services (CMS) not less frequently than once every 3 months for 2 (#25 and #27) of 2 residents sampled for Minimum Data Set (MDS) Assessments. Findings: Resident #25 Review of resident #25's record revealed an admission date of 09/01/2017. Further review of the record revealed the resident's last Quarterly MDS Assessment with an Assessment Reference Date (ARD) of 06/25/2024 and no documented Quarterly MDS for resident #25. Resident #27 Review of resident #27's record revealed an admission date of 08/31/2021. Further review of the record revealed the resident's last Quarterly MDS Assessment with ARD of 06/04/2024 and no documented Quarterly MDS for resident #27. An interview on 10/16/2024 at 7:45 a.m. with S2Assistant Director of Nursing (ADON) confirmed that the Quarterly MDS Assessments for resident #25 and resident #27 were not completed within 3 months of the previous Quarterly MDS Assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the resident's status for 1 (#72) of 3 (#72, 73, 74) residents selected for closed record reviews. Findings: Review of the discharge Minimum Data Set (MDS) assessment for resident #72 revealed the resident was discharged to the hospital on [DATE]. Review of the nurse's notes revealed resident #72 was discharged to home. On 10/16/2024 at 4:05 p.m., an interview with S2Assistant Director or Nursing confirmed the resident was discharged home. On 10/16/24 at 4:15 p.m., an interview with S6Licensed Practical Nurse confirmed the MDS incorrectly indicated resident #72 was discharged to the hospital rather than to home.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet the resident's needs by not having documentation of the character of urine every shift for 1 (#18) of 1 residents reviewed for urinary catheters. Findings: Review of the Catheter Care Urinary Policy and Procedure updated 01/12/2024 revealed the following in part: Documentation The following information should be recorded in the resident's medical record: 1. Date and time catheter care was given. 2. The name and title of the individual giving the catheter care. 3. All assessment data obtained when giving catheter care. 4. Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor. Review of resident #18's medical record revealed an admission date of 09/03/2024 with diagnoses including urinary retention, fibromyalgia, hypertension, paroxysmal atrial fibrillation, hypothyroidism, and urinary tract infection. Review of resident #18's October 2024 Physician's Orders revealed the following orders: 09/04/2024- Foley catheter care every shift, clean with soap and water every shift 3 times per day and 18 French Foley catheter, change every month on the 4th of the month and as needed for dislodgement, diagnoses urinary retention; and 09/21/2024- enhanced barrier precautions during high contact; resident care activities every shift 2 times per day. Review of resident #18's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 indicating cognitively intact. Further review of the MDS revealed resident #18 required substantial/maximal assistance with activities of daily living and had an indwelling urinary catheter. Observations on 10/14/2024 at 10:30 a.m. and 10/15/2024 at 12:45 p.m. revealed resident #18 had an indwelling urinary catheter. Review of resident #18's careplan dated 09/05/2024 revealed urinary catheter: indwelling urine retention chronic urinary tract infection with an intervention to assess color, clarity, and character of the urine and catheter care every shift. Review of resident #18's September and October 2024 Medication Administration Record (MAR) revealed no documented evidence of staff assessing the color, clarity, and character of resident's urine. An interview on 10/15/2024 at 12:58 p.m. with S2Assistant Director of Nursing confirmed the facility failed to implement the careplan for resident #18, by failing to document the color, clarity, and character of the resident's urine every shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 (#52) of 5 (#6, #28, #30, #52, and #67) residents investigated for activities of daily living. The facility failed to ensure resident #52's fingernails were kept trimmed. Findings: Review of the Care of Fingernails/Toenails Policy (Undated), included the following, in part: General Guidelines: 1. Nail care includes daily cleaning and regular trimming. Documentation: The following information should be recorded in the resident's medical record: 1. The date and time that nail care was given 2. The name and title of the individual(s) who administered the nail care 3. The condition of the resident's nails and nail bed, including: a. Redness or irritation of skin of hands and feet 6. If the resident refused the treatment, the reason(s) why and the intervention taken 7. The signature and title of the person recording the data. Review of the medical record revealed resident #52 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance, schizophrenia, mood affective disorder, anxiety disorder, and pseudobulbar affect. Review of the Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed resident #52 had a documented brief interview for mental status score of 99 which indicated the resident had severe cognitive impairment with daily decision making skills. Further review of the MDS revealed that resident #52 had limitation in range of motion to her upper extremity and impairment on one side and she was dependent upon staff for all activities of daily living including personal hygiene. Review of the medical record revealed a section noted as Tasks: Nails cleaned daily. Further review revealed there was no documented evidence of nail care being provided for resident #52 during the look back period of 30 days. Further review of the tasks revealed there was no documented evidence of nail care that included the trimming of the resident's fingernails. On 10/14/2024 at 10:22 a.m., an observation revealed resident #52 sitting up in a geri chair, in the dayroom. Further observation revealed the resident had contractures and long and untrimmed fingernails to both hands. On 10/14/2024 at 11:00 a.m., an observation revealed S11Activity Director pushing resident #52 out of the activity room in the resident's geri chair. The resident's fingernails had been trimmed. An interview with S11Activity Director revealed she had trimmed resident #52's fingernails. She was notified of the observation on 10/14/2024 at 10:22 a.m. of the resident's nails being long and untrimmed. S11Activity Director confirmed that the resident's fingernail had needed trimming. On 10/16/2024 at approximately 5:45 p.m., S7Corporate Administrator and S1Administrator were notified of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure that a resident with limited range of motion receives appropriate treament and services to increase range of motion and /or to prevent further decrease in range of motion for 1 (#52) of 1 residents reviewed for Position/Mobility. The facility failed to ensure hand rolls were provided for resident #52's hand contractures. Findings: Review of the medical record revealed resident #52 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance, schizophrenia, mood affective disorder, anxiety disorder, and pseudobulbar affect. Review of the Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed resident #52 had a documented brief interview for mental status score of 99 which indicated the resident had severe cognitive impairment with daily decision making skills. Further review of the MDS revealed that resident #52 had limitation in range of motion to her upper extremity and impairment on one side and she was dependent upon staff for all activities of daily living including personal hygiene. On 10/14/2024 at 10:22 a.m., an observation revealed resident #52 was sitting up in a geri chair in the dayroom. Further observation revealed the resident's hands were both contracted and closed. Further observation revealed the resident did not have any type of hand roll present to either hand. On 10/14/2024 at 11:00 a.m., S9Licenced Practical Nurse (LPN) was notified of the above findings. She revealed that she was not aware of the resident not having hand rolls in place. S9LPN confirmed that resident #52 was supposed to have a hand roll placed in each hand at all times. Review of the medical record revealed there was no documented evidence in the plan of care to address resident #52's hand contractures. On 10/16/2024 at approximately 5:45 p.m., S7Corporate Administrator and S1Administrator were notified of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to monitor edema for a resident who received a diuretic for 1 (#17) of 5 (#17, #35, #38, #52, and #68) residents reviewed for unnecessary medications. Findings: Review of the medical record for resident #17 revealed an admit date of 08/26/2022 with diagnoses including depression, hypotension, edema, hypokalemia, muscle weakness and anemia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident #17's Brief Interview for Mental Status (BIMS) score was 15 which indicated intact cognition for daily decision making. Resident #17 required assistance with activities of daily living. Review of the current care plan revealed the resident had the potential for hypertension /hypotension related to medication use. The interventions were to monitor blood pressure, administer medications as ordered and obtain labs and diagnostic tests as ordered. Review of the physician's orders revealed an order dated 10/04/2024 for Lasix (diuretic) 40 milligrams, give one tablet orally every other day related to edema. Review of the record for resident #17 revealed no documented evidence of edema checks being performed. On 10/16/2024 at 11:50 a.m., an interview with S2Assistant Director of Nursing (ADON) confirmed resident #17 received Lasix and there was no documentation of edema checks performed for resident #17.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure a resident with pressure ulcers recieved the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 2 (#6 and #52) of 5 (#5, #6, #18, #52, and #125) residents investigated for pressure ulcers. The facility failed to ensure that a pressure relieving device was implemented for resident #52, who currently had a new, unidentified pressure to her left heel. Findings: Resident #6 Review of the medical record revealed resident #6 was admitted to the facility on [DATE]. Further review revealed her diagnoses included in part, dementia without behavioral disturbance and a history of pressure ulcers. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident #6 had a brief interview for mental status (BIMS) score of 09. A score of 08-12 indicated resident #6 had moderate cognitive impaired with daily decision making skills. On 10/14/2024 at 2:35 p.m., an observation revealed resident #6 lying in bed in her room. Further observation revealed the resident's feet were both pressed against the footboard of the bed. Resident #6 reported that her feet were hurting and that she had requested a pillow to go underneath her ankles and legs to keep her feet from touching the mattress. S12Certified Nursing Assistant (CNA) was notified of the residents' request for a pillow. While S12CNA was positioning the resident's lower extremities, an observation revealed some brownish-yellow colored areas of drainage on the bedsheet located underneath the left heel. A visual skin inspection of the left heel with S12CNA revealed an open area to the ball of resident #6's left heel. Further observation revealed the skin had separated from the heel. S12CNA left the resident's room to notify the nurse of the findings. On 10/14/2024 at approximately 2:40 p.m., S9Licensed Practical Nurse (LPN) arrived to the room. She was notified of the findings regarding the drainage and open area to resident #6's left heel. S9LPN observed the heel and revealed that resident #6 had previously had skin breakdown to her heels approximately one to two months ago, but they had since heeled. S9LPN was further notified of the residents' request for a pillow to be positioned underneath her lower extremities due to her complaints of pain. S9LPN revealed that resident #6 had previously complained of pain in her feet, but she (S9LPN) had not assessed the resident's feet at that time as the resident was already taking medication for pain. S9LPN confirmed there was no type of pressure relieving device underneath resident #6's lower extremities to help keep the resident's feet off of the bed mattress and to aide in the prevention of further skin breakdown. On 10/16/2024 at approximately 5:45 p.m., S7Corporate Administrator and S1Administrator were notified of the above findings. Resident #52 Review of the medical record revealed resident #52 was admitted to the facility on [DATE] with diagnoses including in part, dementia without behavioral disturbance and a history of pressure ulcers. Review of the MDS assessment dated [DATE] revealed resident #52 had a documented BIMS score of 99 which indicated that she had severe cognitive impairment with daily decision making skills. Further review revealed resident #52 was dependent upon staff for all activities of daily living. On 10/14/2024 at 10:22 a.m., an observation revealed resident #52 sitting up in a geri chair, in the dayroom. Further observation revealed there was no type of pressure relieving device in the seat of the geri chair. On 10/16/2024 at approximately 5:30 p.m., resident #52 was observed sitting in her geri chair, in the main dining room. Observation revealed there was not any type of pressure relieving device in the seat of the geri chair. S2Assistant Director of Nursing (ADON) was present during the observation. S2ADON revealed that resident #52 currently had a Stage II facility acquired pressure ulcer to the right hip. S2ADON confirmed there was no type of pressure relieving device in the seat of the geri chair to help prevent further skin breakdown. On 10/16/2024 at approximately 5:45 p.m., S7Corporate Administrator and S1Administrator were notified of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #25 Review of the medical record for resident #25 revealed an admission date of 09/01/2017 with diagnoses including vascular dementia unspecified severity with other behavioral disturbance, cerebrovascular disease, Alzheimer's disease early onset, pseudobulbar affect, anxiety disorder, type 2 diabetes mellitus, hypotension, and major depressive disorder. Review of the Quarterly MDS assessment dated [DATE] revealed resident #25 had a BIMS score of 2 indicating severe cognitive impairment. Further review of the MDS revealed he was dependent on staff for all activities of daily living. Observations on 10/14/2024 at 9:25 a.m. and 10/15/2024 at 12:42 p.m. revealed resident #25 was in a geri chair with lap tray, in his room. Observation of resident #25 on 10/16/2024 at 11:10 a.m. revealed resident was up in his geri chair with a lap tray in the dayroom. Review of resident #25's nurses' notes dated 08/11/2024 at 11:28 a.m. revealed nurse was summoned to resident's room per certified nursing aide (CNA) that stated resident broke his lap tray and slid on the floor. Resident was found sitting on buttocks in front of his geri chair with legs drawn toward his chest and resident was unable to say what happened. Treatment to skin tear to left elbow and assisted back to bed. Review of the medical record revealed no incident/accident report was done for this incident on 08/11/2024. Review of resident #25's careplan dated 02/07/2022 revealed resident at risk for fall. Further review revealed the careplan was not updated with a fall on 08/11/2024. An interview on 10/16/2024 at 2:50 p.m. with S2ADON confirmed that an incident/accident report was not completed on 08/11/2024 on resident #25, and should have been completed on 08/11/2024 when resident #25 broke his lap tray and slid onto the floor. Based on observations, record reviews and interviews, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 (#25 and #70) of 9 (#5, #12, #17, #25, #38, #52, #69, #70 and #175) residents reviewed for accident hazards. The facility failed to 1) complete an Incident/Accident report after residents #25 and #70 had an incident, and 2) assess resident #70 to determine if the lap tray was appropriate after he slid under the lap tray. Findings: Resident #70 Review of the medical record for resident #70 revealed an admission date of 07/24/2024 with diagnoses of edema, depression, muscle weakness, seizures, hypertension and lack of coordination. Review of the physician's orders dated 10/05/2024 for resident #70 revealed an order to use a geri chair when the resident was out of the bed. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #70 had a Brief Interview for Mental Status (BIMS) score of 2 which indicated severe cognitive impairment for daily decision making and he required assistance with activities of daily living (ADLs). Review of the current careplan revealed resident #70 was at high risk for injury due to the resident uses a geri chair with a lap tray. On 10/14/2024 at 10:00 a.m. and 2:10 p.m., observations of resident #70 revealed he was sitting in a geri chair with a lap tray. On 10/15/2024 at 9:18 a.m., and on 10/16/2024 at 9:00 a.m., observations of resident #70 revealed he was sitting in a geri chair with a lap tray. Review of the nurses' notes dated 10/06/2024 at 10:04 p.m. revealed resident #70 had behaviors throughout the entire weekend. Resident #70 was yelling, screaming, cursing at staff, and undressing in the day room and in his room. The resident slides down in the geri chair under the lap tray and gets on the floor, banging on the lap tray with his fist, and bumping his knee on the tray attempting to remove the tray. Review of the record revealed no documented evidence that an Incident/Accident Reporting form was completed on 10/06/2024 when the resident was noted sliding down in the geri chair under the lap tray and getting on the floor. Further review of the record revealed no documented evidence that resident #70 was assessed for the use of a lap tray to ensure the assistive device was appropriate after the incident on 10/06/2024 when he slid under the lap tray. On 10/16/2024 at 11:50 a.m., an interview with S2Assistant Director of Nursing (ADON) revealed she was unaware that resident #70 slid under the lap tray on 10/06/2024 as stated in the nurses' notes. . On 10/16/2024 at 1:55 p.m. interview with S2ADON confirmed an Incident/Accident Report Form should have been completed for resident #70 for the incident noted in the nurses' notes dated 10/06/2024 when he slid under the lap tray. S2ADON further confirmed the resident should have been assessed for the need of the lap tray to determine if the lap tray was an appropriate assistive device.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a resident who required dialysis received services consistent with professional standards of practice by failing to ensure fluid restrictions were followed and implemented as ordered for 1 (#3) of 1 sampled residents who were reviewed for dialysis. Findings: Review of the medical record revealed resident #3 was admitted on [DATE]. Her diagnoses included end stage renal disease, hypertensive heart disease and unspecified psychosis. Review of the October 2024 physician orders revealed the resident received dialysis on Monday, Wednesday and Friday and had a 1000 cc fluid restriction. There was no documentation in the medical record that resident #3's fluid intake was being monitored. On 10/15/2024 at 1:55 p.m., interview with S5Certified Nurse Aid (CNA) revealed she worked in the memory care unit where resident #3 resided. S5CNA reported they did not keep a fluid intake log for resident #3. On 10/25/2024 at 2:15 p.m., interview with S2Assistant Director or Nursing (ADON) confirmed the staff were not documenting resident #3's fluid intake to ensure it stayed within the fluid restriction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #5 Review of the medical record for resident #5 revealed an admission date of 02/10/2017 with diagnoses of mononeuropathy, hypertension, type 2 diabetes mellitus without complications, pressure ulcer, and hyperlipidemia. Review of resident #5's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 6 indicating severe cognitive impairment. Further review of the MDS revealed resident required substantial/maximal assistance with activities of daily living. Observations of resident #5 on 10/14/2024 at 11:45 a.m. and 10/16/2024 at 8:22 a.m. revealed resident #5 was lying in bed with bilateral bed rails in the up position. Review of resident #5's October 2024 Physician's Orders revealed an order dated 04/12/2023 for siderails (bed rails) up while in bed to assist with bed mobility. Review of the medical record revealed no documented bed rail assessment for the risk of entrapment for resident #5. An interview on 10/16/2024 at 11:50 a.m. with S2ADON confirmed there was no documented assessment for the risk of entrapment with bed rail use for resident #5. Resident #12 Review of the medical record revealed resident #12 was re-admitted to the facility on [DATE] with diagnoses including in part, generalized muscle weakness, heart failure, intervertebral disc, dementia with behavioral disturbance, and repeated falls. Review of the medical record revealed a pre-restraining evaluation dated 09/01/2024. Review of the evaluation revealed the interdisciplinary team's recommendations was for resident #12 to have a turning bar to assist with turning and repositioning. Further review revealed resident #12 had a documented BIMS score of 09. A score of 08-12 revealed the resident had moderate cognitive impairment with daily decision making skills. Review of the annual MDS assessment dated [DATE] revealed resident #12 required partial to moderate assistance with rolling from left to right, sitting to lying, lying to sitting, sitting to standing, and from a chair to the bed. On 10/14/2024 at 11:22 a.m., an observation revealed resident #12 in her room and lying in bed. Further observation revealed there were two bed rails intact, one to each side of the resident's bed. The bed rails were up and in a locked position. On 10/15/2024 at 8:52 a.m., resident #12 was observed in her room and was resting in bed. Further observation revealed the bed rails remained up and in a locked position. Review of the medical record revealed there was no documented evidence of resident #12 being assessed for entrapment regarding the use of the bed rails. On 10/16/2024 at 5:00 p.m., an interview with S2ADON confirmed there was no documented evidence of resident #12 being assessed for the risk of entrapment regarding the use of the bed rails. On 10/16/2024 at approximately 5:45 p.m., S7Corporate Administrator and S1Administrator notified of the above findings. Based on observations, record reviews and interviews, the facility failed to ensure residents were assessed for the risk of entrapment from bed rails prior to the installation of bed rails for 4 (#5, #12, #17, and #38) of 5 (#5, #12, #17, #38 and #52) residents reviewed for bed rails. Findings: Review of the facility's undated Physical Restraints, Side Rails policy revealed: Purpose The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. General Guidelines 3. As assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails, when used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. Resident #17 Review of the medical record for resident #17 revealed an admit date of 08/26/2022 with diagnoses including depression, hypotension, edema, hypokalemia, muscle weakness and anemia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident #17's Brief Interview for Mental Status (BIMS) score was 15 which indicated intact cognition for daily decision making. Resident #17 required assistance with activities of daily living. Observations on 10/14/2024 at 11:05 a.m. and 10/15/2024 at 11:00 a.m. of resident #17's room revealed the bed rails were raised on both sides of the bed. On 10/16/2024 at 8:10 a.m., an observation of the resident revealed she was in the bed with bed rails raised on both sides of the bed. Review of the record revealed no documented evidence of an assessment for the risk of entrapment for the bed rails. On 10/16/2024 at 11:45 a.m., an interview with S2Assistant Director of Nursing (ADON) revealed the facility did not assess for the risk of entrapment for the use of bed rails for resident #17. Resident #38 Review of the medical record for resident #38 revealed an admission date of 06/10/2024 with diagnoses including diabetes mellitus, depression, history of falling, vascular dementia, pseudobulbar affect, hemiplegia following cerebral infarction, and osteoarthritis. Review of the quarterly MDS assessment dated [DATE] revealed resident #38 had a BIMS score of 12 which indicated the resident had moderate cognitive impairment for daily decision making. Resident #38 required assistance with activities of daily living. On 10/14/2024 at 2:47 p.m., 10/15/2024 at 1:35 p.m. and 10/16/2024 at 7:30 a.m., observations of resident #38's room revealed bed rails were in the raised position on both sides of the bed. Review of the care plan dated 10/28/2022 revealed resident #38 had impaired mobility related to hemiplegia. Further review of the care plan revealed the interventions were to provide assistive devices as needed for transfers/mobility and to have turning bars to assist with bed mobility. Review of the record revealed no documented evidence of an assessment for the risk of entrapment for the bed rails. On 10/16/2024 at 11:45 a.m., an interview with S2ADON revealed the facility did not assess for the risk of entrapment for the use of bed rails for resident #38.

Based on observations of medication administration, record review, and interview, the facility failed to ensure that it was free from a medication error rate of 5% or greater. The facility had a 10.71% medication error rate with 3 medication errors out of 28 opportunities. Findings: Resident #43 An observation of the medication administration for resident #43 on 10/15/2024 at 8:33 a.m. with S4Licensed Practical Nurse (LPN) revealed S4LPN administered Furosemide 20 milligrams (mg) 1 tablet by mouth and administered Gabapentin 100 mg 1 capsule by mouth. Review of the October 2024 Physician's orders for resident #43 revealed the following orders: 02/13/2024 Gabapentin 300 mg capsule by mouth 2 times per day (BID) at 9:00 a.m. and 5:00 p.m; and 09/23/2024 Furosemide 40 mg tablet: take 1 tablet by mouth (40 milligrams total dose) at 8:00 a.m. every Tuesday, Thursday, Saturday, and Sunday. An interview on 10/15/2024 at 1:30 p.m. with S2Assistant Director of Nursing (ADON) confirmed that S4LPN should have administered Furosemide 40 mg by mouth and Gabapentin 300 mg by mouth to resident #43 during the morning medication pass on 10/15/2024. Resident #44 An observation of the medication administration for resident #44 on 10/15/2024 at 8:15 a.m. with S4LPN revealed S4LPN administered Fludrocortisone 0.1 mg 1 tablet by mouth. Review of the October 2024 Physician's Orders for resident #44 revealed an order dated 09/10/2024 for Fludrocortisone 0.1 mg tablet: take 2 tablets by mouth (0.2 mg total dose) at 8:00 a.m. every day. An interview on 10/15/2024 at 1:30 p.m. with S2ADON confirmed that S4LPN should have administered Fludrocortisone 0.1mg, 2 tablets by mouth to resident #44 during the morning medication pass on 10/15/2024. S2ADON further confirmed that 3 medication errors occurred on the morning medication pass and the medication error rate was greater than 5%.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to implement policies and procedures for enhanced barrier precautions (EBP) for 3 (#18, #28, and #35) of 3 (#18, #28, and #35) residents reviewed for enhanced barrier precautions. Findings: Review of the Enhanced Barrier Precautions (EBP) policy and procedure dated 04/01/2024 revealed the following in part: Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with any of the following: -colonization with a Center for Disease Control and Prevention (CDC)- targeted Multidrug-resistant organism (MDRO) when Contact Precautions do not otherwise apply; or -wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO. Indwelling medical devices examples include central lines, urinary catheters, feeding tubes, and tracheostomies. Communication to Staff The facility will utilize postings outside the room and Point Click Care to communicate to staff if a resident requires EBP. Resident #18 Review of resident #18's record revealed an admission date of 09/03/2024 with diagnoses including urinary retention, fibromyalgia, hypertension, paroxysmal atrial fibrillation, hypothyroidism, and urinary tract infection. Review of resident #18's October 2024 Physician's Orders revealed the following orders: 09/04/2024- Foley catheter care every shift, clean with soap and water every shift 3 times per day and 18 French Foley catheter, change every month on the 4th of the month and as needed for dislodgement, diagnoses urinary retention; and 09/21/2024- enhanced barrier precautions during high contact-resident care activities every shift 2 times per day. Review of resident #18's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating cognitively intact. Further review of the MDS revealed the resident required substantial/maximal assistance with activities of daily living and has an indwelling urinary catheter. Observations on 10/14/2024 at 10:30 a.m. and 10/15/2024 at 12:45 p.m. revealed resident #18 had an indwelling urinary catheter and did not have an EBP sign posted on her door. An interview on 10/15/2024 at 12:58 p.m. with S2Assistant Director of Nursing (ADON) confirmed that the facility failed to post the EBP sign on resident #18's door and should have EBP due to resident #18 having a urinary catheter. Resident #28 Review of resident #28's record revealed an admission date of 02/13/2024 with diagnoses including unqualified visual loss both eyes, benign prostate hypertrophy, glaucoma, chronic kidney failure, hypertension, unspecified dementia, and alcohol abuse. Review of the Quarterly MDS assessment dated [DATE] revealed BIMS score of 14 indicating cognitively intact. Further review of the MDS revealed the resident required substantial/maximal assistance with activities of daily living and has dialysis. Review of resident #28's October 2024 Physician's Orders revealed an order dated 08/02/2024 for dialysis every Tuesday, Thursday, and Saturday. Observation on 10/14/2024 at 9:35 a.m. and 10/15/2024 at 12:58 a.m. revealed resident #28's door did not have an EBP sign posted. Interview on 10/15/2024 at 12:58 p.m. with S2ADON confirmed resident #28's door did not have an EBP sign posted and confirmed resident #28 had a dialysis access to right chest wall and required EBP while he has an indwelling medical device. Resident #35 Review of the medical record for resident #35 revealed an admission date of 02/16/2024 with diagnoses of insomnia, anxiety, dementia, enlarged prostate, hyperlipidemia, and osteoarthritis. Review of the quarterly MDS assessment dated [DATE] revealed resident #35's BIMS score was 14 which indicated intact cognition for daily decision making. Resident #35 required assistance with activities of daily living. Review of the current care plan revealed resident #35 had an indwelling catheter and to use EBP as ordered. Review of the physician's orders dated 10/03/2024 revealed EBP during high contact resident care activities every shift. On 10/15/2024 at 8:35 a.m., 10:15 a.m., and 11:00 a.m., observations of resident #35 revealed he had an indwelling catheter and observation of the resident's door revealed the door did not have signage indicating that the resident required EBP. On 10/15/2024 at 1:10 p.m., observation of #35's door with S2ADON revealed the resident had an indwelling catheter. S2ADON confirmed the door should have signage that indicated EBP should be taken when providing high contact care to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (#18) of 2 (#8, #18) residents reviewed for limited range of motion. The facility failed to ensure staff placed a splint device to resident #18's contracted right hand. Findings: Review of the medical record for sampled resident #18 revealed an admission date of 06/08/2022 with diagnoses of diabetes mellitus, hypertension, spastic hemiplegia, right hand contracture and cerebral infarction. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively impaired and needed assistance with activities of daily living. Further review of the Minimum Data Set revealed documentation of functional limitation of upper extremity on one side. On 10/09/2023 at 1:10 p.m., observation revealed resident #18 had a contracture to the right hand and did not have a brace or hand roll in place. On 10/10/2023 at 9:50 a.m., observation revealed resident #18 had a contracture to the right hand and did not have a hand roll or splint in place. On 10/10/2023 at 4:10 p.m., observation revealed resident #18 had a contracture to the right hand and did not have a hand roll or splint in place. On 10/11/2023 at 8:15 a.m., observation revealed resident #18 had a contracture to the right hand and did not have a hand roll or splint in place. Interview on 10/11/2023 at 8:30 a.m. with S5Certified Nursing Assistant (CNA) confirmed resident #18 should have a hand roll in his right hand, but has not had one. Interview on 10/11/2023 at 9:00 a.m., with S2 Director of Nurses confirmed resident #18 should have a hand roll in the right hand due to the contracture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure the pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing for 5 (#4, #49, #57, #80 and #82) of 6 (#4, #7, #49, #57, #80, and #82) residents reviewed for unnecessary medications. The pharmacist failed to address no monitoring for side effects for residents #4, #49, #57, #80 and #82 while receiving psychotropic medications. Findings: Resident #4 Review of the Facility's Behavioral Assessment, Intervention and Monitoring Policy revealed in part: The nursing staff and the physician will monitor for side effects and complications related to psychoactive medications; for example, lethargy, abnormal involuntary movements, anorexia, and or recurrent falling. Review of the facility's Pharmacy Services: Medication Regimen Review (MRR) Policy and Procedure revealed in part: 5. The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example: inadequate monitoring for adverse consequences. Review of the record revealed resident #4 was admitted on [DATE] with diagnoses including other seizures, bipolar disorder, depression, unspecified dementia, blindness both eyes, and metabolic encephalopathy. Review of the current Physician's Orders for resident #4 revealed the following: -09/02/2022- Celexa (antidepressant) 20 milligram tablet give 1 tab by mouth daily; and -12/06/2022- Seroquel (antipsychotic) 200 milligram tablet give 1 tab with 1 Seroquel 50 milligram tablet to equal 250 milligrams by mouth every hour of sleep Review of the current care plan for resident #4 revealed resident at risk for side effects from antidepressant and antidepressant medication use. Review of the August 2023, September 2023, and October 2023 Medication Administration Record (MAR) revealed no documented evidence of monitoring for side effects of psychotropic medications. An interview on 10/11/2023 at 11:55 a.m. with S2Director of Nursing (DON) revealed: -all residents on psychotropic medications should have monitoring every shift for mood and behaviors, and side effects; and -confirmed that resident #4 did not have monitoring of side effects of psychotropic medications every shift. Review of the Pharmacy Consultant Review dated 09/20/2023 revealed no recommendations from the pharmacist for resident #4 regarding the facility not monitoring for side effects of psychotropic medications. An interview on 10/11/2023 at 2:15 p.m. with S2DON confirmed the following: -Resident #4 should have had monitoring of side effects for psychotropic meds -Pharmacy did not identify that facility was not monitoring for side effects of psychotropic meds. Resident #49 Review of resident #49's medical record revealed the resident was originally admitted to the facility on [DATE] and re-admitted from an acute hospital on [DATE] with diagnoses that included in part, dementia with unspecified severe behavioral disturbances. Review of the October 2023 physician's orders revealed an order dated 08/20/2023 for resident #49 to have Quetiapine Fumarate 25 (Anti-Psychotic) milligrams by mouth every day at 8:00 p.m. Review of the September 2023 and October 2023 medication administration records (MAR) and nurse's notes revealed that resident #49 had received the medication Quetiapine Fumarate 20 milligrams by mouth every day at 8:00 p.m. Further review of the MAR and nurse's notes revealed there was no documented evidence of resident #49 being monitored for any potential side effects for the medication. On 10/11/2023 at 2:35 p.m., S6Licensed Practical Nurse (LPN) was notified of the above findings. After a review resident #49's October 2023 MAR and nurse's notes, S6LPN confirmed that she had not been recording in the records if resident #49 had any side effects of the medication Quetiapine Fumarate during her shift. On 10/11/2023 at 3:22 p.m., S2Director of Nursing (DON) was notified of the findings regarding there being no documented evidence of side effect monitoring. S2DON confirmed that resident #49 had received the medication Quetiapine Fumarate for behaviors and should have been monitored for side effects of the medication every shift. S2DON further confirmed there was no documented evidence monitoring for side effects of the psychotropic medication for resident #49. An interview on 10/11/2023 at 2:33 p.m. with S2DON confirmed the Pharmacist did not identify that the facility was not monitoring for side effects of psychotropic medications for resident #94. On 10/11/2023 at 1:00 p.m., S1Administrator was notified of the above findings. Resident #80 Review of resident #80's medical record revealed that she was admitted to the facility on [DATE] with diagnoses that included, in part, essential (primary) hypertension, personal history of transient ischemic attacks, and chronic kidney disease. On 10/09/2023 at 10:41 a.m., resident #80 was observed in her room and sitting up in her wheelchair. Further observation revealed both of the resident's feet were slightly edematous. Resident #80 reported that she took a fluid pill for the edema. 10/11/2023 at 8:25 a.m. resident #80 was sitting up in her room in her wheelchair. Further observation revealed resident #80 had puffiness with slight edema observed to both feet. Review of the October 2023 physician's orders revealed an order dated 08/30/2023 for resident #80 to have Bumetanide (Diurectic) 1 milligram tablet by mouth every day at 8:00 a.m. Review of the September 2023 and October 2023 MARS revealed resident #80 was being administered the medication Bumetanide 1 milligram tablet by mouth every day at 8:00 a.m. Further review revealed there was documented evidence of resident #80 being monitored for edema checks. Review of the progress notes dated September 2023 and October 2023 nurses' notes revealed there was no documented evidence of consistent monitoring of edema checks for resident #80. On 10/11/2023 at 12:50 p.m., S2DON was notified of there being no documented evidence of monitoring for edema on the September 2023 and October 2023 MARs and the nurses' notes for each shift. S2DON confirmed there was no documented evidence of edema monitoring every shift for the diuretic medication for resident #80 An interview on 10/11/2023 at 2:33 p.m. with S2DON confirmed the Pharmacist did not identify that the facility was not monitoring edema for dieuretic medications for resident #80. On 10/11/2023 at 1:00 p.m., S1Administrator was notified of the above findings. Resident #57 Review of the medical record for sample resident #57 revealed an admission date of 01/17/2022 with diagnosis of major depressive disorder, peripheral vascular disease, anxiety, mood disorder, hypotension, type 2 diabetes mellitus and lack of coordination. Review of the quarterly Minimum Data Set, dated [DATE] revealed the resident has a brief interview of mental status (BIMS) score of 14 which indicated the resident was cognitively aware and able to make daily decisions. Further review revealed the resident needs assistance with activities of daily living. Review of the October 2023 physician's orders revealed the resident is taking the following medications: Abilify (psychotropic) 5 milligrams (mg) tablet by mouth each day with a start date of 04/14/2023 Tranzodone (antidepressant) 50mg tablet by mouth each night with a start date 04/14/2032 Review of the Drug Regimen review dated 09/20/2023 revealed the pharmacist failed to notify the facility regarding the need for side effect monitoring for residents receiving the psychotropic medications. Review of the current care plan for resident #57 revealed resident was at risk for side effects from psychotropic medication use. Review of the August 2023, September 2023, and October 2023 Medication Administration Record (MAR) revealed no documented evidence of monitoring for side effects of psychotropic medications. An interview on 10/11/2023 at 11:55 a.m. with S2Director of Nursing (DON) revealed: -all residents on psychotropic medications should have monitoring every shift for mood and behaviors, and side effects; and confirmed that resident #57 did not have monitoring of side effects of psychotropic medications every shift. Resident #82 Review of the medical record for resident #82 revealed an admission date of 04/27/2023 with diagnoses including vascular dementia, encephapathy, hypertension, depression, Alzheimer's disease, heart disease, hyperlipidemia, and hypothyroidism. Review of the current Physician's Orders for resident #82 revealed an order dated 05/19/2023 for Risperdal (antipsychotic) .5 milligrams (mg) take 1 table by mouth every day, 05/19/2023 for Risperdal 1 mg every hour of sleep, 04/27/2023 for Zoloft (antidepressant) 50 mg every morning, and 04/27/202 for Trazadone (antidepressant) 50 mg every day. Review of the careplan revealed the resident was at risk for side effects from antidepressant medication use and to observe for adverse side effects. Review of the August 2023 Medication Administration Record (MAR) for resident #82 revealed there was no documented evidence of monitoring for side effects for the psychotropic medications. Review of the Pharmacy Consultant Review dated 09/20/2023 revealed no recommendations from the pharmacist for resident #82 regarding the facility not monitoring for side effects of the psychotropic medications. An interview on 10/11/2023 at 11:55 a.m. with S2Director of Nursing (DON) revealed all residents on psychotropic medications should have monitoring for side effects every shift. Further interview with S2DON revealed resident #82 did not have monitoring of side effects of the psychotropic medications every shift. An interview on 10/11/2023 at 2:15 p.m. with S2DON confirmed the Pharmacist did not identify that the facility was not monitoring for side effects of psychotropic medications for resident #82.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure that resident's drug regimen was free from unnecessary drugs for 2 (#4 and #80) of 6 (#4, #7, #49, #57, #80, and #82) sampled residents reviewed for unnecessary medications. The facility failed to monitor resident #80 for edema while receiving a diuretic and failed to monitor lab for resident #4 while taking Keppra and Divalproex. Findings: Resident #4 Review of the record for resident #4 revealed an admission date of 06/24/2022 with diagnoses including other seizures, bipolar disorder, hypertension, hyperlipidemia, depression, unspecified dementia, blindness both eyes, and metabolic encephalopathy. Review of the current Physician's Orders for resident #4 revealed the following: 08/29/2022- Divalproex Sodium DR 250 milligram tablet give 1 tablet by mouth 3 times per day (seizures) 09/02/2022- Keppra 500 milligram tablet give 1 tablet by mouth 2 times per day (seizures) Further review of the Physician's Orders revealed no order for monitoring of lab for Divalproex and Keppra. Review of the September 2023 and October 2023 Medication Administration Record for resident #4 revealed Divalproex and Keppra administered as ordered. An interview on 10/11/2023 at 11:55 a.m. with S2Director of Nursing (DON) revealed resident #4 taking Keppra and Divalproex and did not have an order to monitor lab. An interview on 10/11/23 at 2:15 p.m. with S2DON confirmed resident #4 did not have lab monitoring while taking Keppra and Divalproex. Resident #80 Review of resident #80's medical record revealed that she was admitted to the facility on [DATE] with diagnoses that included, in part, essential (primary) hypertension, personal history of transient ischemic attacks, and chronic kidney disease. On 10/09/2023 at 10:41 a.m., resident #80 was observed in her room and sitting up in her wheelchair. Further observation revealed both of the resident's feet were slightly edematous. Resident #80 reported that she took a fluid pill for the edema. 10/11/2023 at 8:25 a.m., resident #80 was sitting in her room in her wheelchair. Further observation revealed resident #80 had puffiness with slight edema observed to both feet. Review of the October 2023 physician's orders revealed an order dated 08/30/2023 for resident #80 to have Bumetanide (Diuretic) 1 milligram tablet by mouth every day at 8:00 a.m. Review of the September 2023 and October 2023 Medication Administration Record revealed resident #80 was being administered the medication Bumetanide 1 milligram tablet by mouth every day at 8:00 a.m. Further review revealed there was no documented evidence of resident #80 being monitored for edema checks. Review of the progress notes dated September 2023 and October 2023 nurses' notes revealed there was no documented evidence of consistent monitoring of edema checks for resident #80. On 10/11/2023 at 12:50 p.m., S2DON was notified of there being no documented evidence of monitoring for edema on the September 2023 and October 2023 MARs and the nurses' notes for each shift. S2DON confirmed there was no documented evidence of edema monitoring every shift for the diuretic medication for resident #80. On 10/11/2023 at 1:00 p.m., S1Administrator was notified of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #4 Review of the record revealed resident #4 had an admission date of 06/24/2022 with diagnoses including bipolar disorder, depression, and unspecified dementia. Review of the current Physician's Orders for resident #4 revealed the following: -09/02/2022- Celexa (antidepressant) 20 milligram tablet give 1 tab by mouth daily; and -12/06/2022- Seroquel (antipsychotic) 200 milligram tablet give 1 tab with 1 Seroquel 50 milligram tablet to equal 250 milligrams by mouth every hour of sleep Review of the current care plan for resident #4 revealed resident at risk for side effects from antidepressant and antidepressant medication use. Review of the August 2023, September 2023, and October 2023 Medication Administration Record (MAR) revealed no documented evidence of monitoring for side effects of psychotropic medications. An interview on 10/11/2023 at 11:55 a.m. with S2Director of Nursing (DON) revealed: -all residents on psychotropic medications should have monitoring every shift for mood and behaviors, and side effects; and -confirmed that resident #4 did not have monitoring of side effects of psychotropic medications every shift. An interview on 10/11/2023 at 2:15 p.m. with S2DON confirmed resident #4 should have had monitoring of side effects for psychotropic meds. Resident #49 Review of resident #49's medical record revealed the resident was originally admitted to the facility on [DATE] and re-admitted from an acute hospital on [DATE] with diagnoses that included in part, dementia with unspecified severe behavioral disturbances. Review of the October 2023 physician's orders revealed an order dated 08/20/2023 for resident #49 to have Quetiapine Fumarate 25 (Anit-Psychotic) milligrams by mouth every day at 8:00 p.m. Review of the September 2023 and October 2023 medication administrationv records (MAR) and nurse's notes revealed that resident #49 had received the medication Quetiapine Fumarate 20 milligrams by mouth every day at 8:00 p.m. Further review of the MAR and nurse's notes revealed there was no documented evidence of resident #49 being monitored for any potential side effects for the medication. On 10/11/2023 at 2:35 p.m., S6 Licensed Practical Nurse (LPN) was notified of the above findings. After a review resident #49's October 2023 MAR and nurse's notes, S6LPN confirmed that she had not been recording in the records if resident #49 had any side effects of the medication Quetiapine Fumarate during her shift. On 10/11/2023 at 3:22 p.m., S2 Director of Nursing (DON) was notified of the findings regarding there being no documented evidence of side effect monitoring. S2DON confirmed that resident #49 had received the medication Quetiapine Fumarate for behaviors and should have been monitored for side effects of the medication every shift. S2DON further confirmed there was no documented evidence monitoring for side effects of the psychotropic medication for resident #49. On 10/11/2023 at 1:00 p.m., S1Administrator was notified of the above findings. Resident #57 Review of the medical record for sample resident #57 revealed an admission date of 01/17/2022 with diagnosis of major depressive disorder, peripheral vascular disease, anxiety, mood disorder, hypotension, type 2 diabetes mellitus and lack of coordination. Review of the quarterly Minimum Data Set, dated [DATE] revealed the resident has a brief interview of mental status (BIMS) score of 14 which indicated the resident was cognitively aware and able to make daily decisions. Further review revealed the resident needed assistance with activities of daily living. Review of the October 2023 physician's orders revealed the resident was taking the following medications: Abilify ( psychotropic ) 5 milligrams (mg) tablet by mouth each day -start date 04/14/2023 Tranzodone (antidepressant) 50 mg tablet by mouth each night-start date 04/14/2032 Review of the August, September and October Medication administration record (MAR) revealed there was no documentation for monitoring the side effects of the psychotropic medications. An interview on 10/11/2023 at 11:55 a.m. with S2Director of Nursing (DON) revealed all residents on psychotropic medications should havebeen monitored for side effects every shift. Further interview with S2DON revealed resident #57 did not have monitoring of side effects of the psychotropic medications every shift. Based on record reviews and interviews the facility failed to ensure that each resident was free from unnecessary medication use for 5 (#4, #49, #57, #80 and #82) of 6 (#4, #7, #49, #57, #80, and #82) residents reviewed for unnecessary medications. The facility failed to monitor side effects for residents #4, #49, #57, #80 and #82 that received psychotropic medications. Findings Resident #82 Review of the Facility's Behavioral Assessment, Intervention and Monitoring Policy revealed in part: The nursing staff and the physician will monitor for side effects and complications related to psychoactive medications; for example, lethargy, abnormal involuntary movements, anorexia, and or recurrent falling. Review of the medical record for resident #82 revealed an admission date of 04/27/2023 with diagnoses including vascular dementia, encephapathy, hypertension, depression, Alzheimer's disease, heart disease, hyperlipidemia, and hypothyroidism. Review of the current Physician's Orders for resident #82 revealed an order dated 05/19/2023 for Risperdal (antipsychotic) .5 milligrams (mg) take 1 table by mouth every day, 05/19/2023 for Risperdal 1 mg every hour of sleep, 04/27/2023 for Zoloft (antidepressant) 50 mg every morning, and 04/27/202 for Trazadone (antidepressant) 50 mg every day. Review of the careplan revealed the resident was at risk for side effects from antidepressant medication use and to observe for adverse side effects. Review of the August 2023, Septemeber 2023 and October 2023 Medication Administration Record (MAR) for resident #82 revealed there was no documented evidence of monitoring for side effects for the psychotropic medications. An interview on 10/11/2023 at 11:55 a.m. with S2Director of Nursing (DON) revealed all residents on psychotropic medications should have monitoring for side effects every shift. Further interview with S2DON revealed resident #82 did not have monitoring of side effects of the psychotropic medications every shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance wtih professional standards for food service safety by storing resident and staff's personal belonging in the kitchen food preparation and supply storage areas. Findings: During a tour of the kitchen on 10/09/2023 at 8:15 a.m., an observation revealed one large rolling cart that was located near to 7DM (Dietary Manager's) office. Observation of the inside of the cart revealed there a Christmas [NAME], 3 individual packages of table clothes, one thirty ounce bottle of old spice body wash, three bars of old spice soap, one ten ounce bottle of men's care exfoliating deep cleanser, and one seven ounce can of equate shaving gel. Further observation revealed one pair of tennis shoes and one cell phone that were sitting the tops of storage containers that was located in a small section of the kitchen and was designated supplies for food services. S7DM confirmed the items should not have been strored in the kitchen. On 10/11/2023 at approximately 9:30 a.m., S1Administrator was notified of the findings.

Based on record review and interview the facility failed to coordinate and evaluate activities under the Quality Assessment and Assurance QAA / Quality Assurance Performance Improvement (QAPI) program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary. Findings: Review of the facility's Quality Assurance binder revealed there was no documented evidence the facility addressed issues or concerns identified on a quarterly basis. Further review of the binder revealed no documented evidence of minutes from the April, July and October 2023 quarterly meetings. On 10/11/2023 at 4:15 p.m., an interview with S1Administrator revealed he only had sign in sheets for the April, July, and October 2023 QA (Quality Assurance) meetings and did not have any meeting minutes or any documentation of tracking, trending or QAPI issues the facility addressed during the April, July, and October quarterly meetings.

Based on observation and interviews, the facility failed to maintain all mechanical and electrical equipment in safe operating condition, by having a grease build-up on the internal components of the deep fryer. Findings: On 10/09/2023 at 8:15 a.m., an observation revealed one large gas deep fryer located in the kitchen. Observation of the deep fryer revealed a grease build-up on the internal components that were housed inside of the fryer's lower compartment. S7Dietary Manager was present during the observation and confirmed that the fryer was a gas operated fryer. She further confirmed the deep fryer was not in safe operating condition due to the grease build-up on the internal components of the fryer. On 10/11/2023 at approximately 9:40 a.m., S1Administrator was notified of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the provider failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical specialist of laboratory results that fall outside of clinical reference ranges for 1 (#1) of 1 (#1) residents who received seizure medications. Findings: Review of resident #1's medical record revealed a physician's order dated 05/13/2023 for Dilantin 100 milligrams; give one capsule by mouth every a.m. at 9:00 a.m. Further review revealed a second order dated of 05/13/2023 for Phenytoin (Dilantin) 100 milligrams; give one capsule by mouth at bedtime every day at 9:00 p.m. Review of a hand written physician's order dated 09/26/2023 revealed an order to increase Dilantin to 200 milligrams every p.m. and 100 milligrams every a.m. Further review revealed a second order to check a Dilantin level in one week. Review revealed diagnosis as history of seizures and recent seizure activity. Review of the medical record further revealed a laboratory final report status. Review of the report revealed a sample was collected on 09/08/2023 at 8:58 a.m. and the results were reported to the facility on [DATE] at 8:45 a.m. Review of the laboratory report revealed resident #1 had a Phenytoin (Dilantin) level of 6.3 L (Low) ug/ml (micrograms per milliliter). Further review revealed the clinical reference range for the medication Dilantin was 10.0 ug/ml to 20.0 un/ml. Review of the laboratory report further revealed a hand written note on the bottom of the report that read: see orders written during round today, it was signed by the physician, and dated 09/26/2023. Review of resident #1's medical record revealed there was no documented evidence of the physician being notified of the low Dilantin results prior to the date of 09/26/2023. On 09/27/2023 at 3:00 p.m., after a review of the laboratory report was completed with S2DON (Director of Nursing), she reported that laboratory technician comes to the facility and collects laboratory specimens, the collected specimens would be returned to the laboratory, and the final resulted report would then be faxed to the nursing facility. S2DON further reported the final reported results would be distributed to the nursing staff in charge of the resident at that time for review and then immediately fax the final reported results to the physician. S2DON confirmed the physician had not been promptly notified of resident #1's Dilantin level that was low and had fallen out of clinical reference ranges. On 09/27/2023 at 3:35 p.m., S1Administrator was notified of the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure a resident with an injury of unknown origin was reported to the State Survey Agency in accordance with State law for 1 of 1 (#107) residents with an injury of unknown origin. Findings: Review of the facility current abuse policy and procedure that was reviewed and approved by S1 Administrator on 8/23/22 in part revealed: Identification: 1. All incidents/accidents including injuries of unknown source shall be recorded on the Incident/Accident Report form by the licensed nurse and reported to the resident's physician and responsible party upon occurrence. Injuries of unknown source must be reported to the Administrator and DON (Director of Nurses) immediately. The Administrator or his/her designee will complete an investigation of all injuries of unknown source. 2. Any suspicious bruising or injury to the resident must be reported immediately to the Administrator and DON. Investigation: The facility will report such allegations to the state, as per regulation. On 11/28/22 review of the record for resident #107 revealed diagnoses of unspecified protein calorie malnutrition, chronic pancreatitis, anemia, hyperkalemia, unspecified convulsions, alcohol abuse, type 2 diabetes, and cerebral infarct. Review of the MDS (Minimum Data Sets) dated 8/5/22 revealed a BIMS (Brief Interview for Mental Status) of 5 (severe cognitive impairment). Further review of the MDS dated [DATE] revealed resident #107 was total dependence for bed mobility, dressing, eating, toileting, personal hygiene, bathing, and transferring. Resident #107 was unable to walk and uses a wheelchair for locomotion. Review of section J- Health Conditions for falls since admit/reentry/prior assessment revealed resident #107 had no falls. Review of the fall risk assessment dated [DATE] revealed resident #107 was high risk for falls. Review of the current plan of care revealed no indication resident #107 had any falls. On 11/28/22 at 3:38 p.m. review of the nurses' notes dated 8/30/22 at 4:15 p.m. by S9 LPN revealed: upon entering room resident sitting up in wheelchair noted scratch to right nares and right eye with bruising and swelling. Asked resident had she fallen and she stated no. Asked if she knew what happened to face and she said no. Denies pain. ADON (Assistant Director of Nurses) notified. Further review of the nurses' notes revealed the next written nurses' note was dated 9/29/22 that was for a new order for house supplement and weekly weights. There was no further documentation in the record regarding the bruising and swelling to right eye and scratch to nose. On 11/28/22 review of the incident logs for June, July, August 2022 revealed no documentation of any incidents involving resident #107. On 11/29/22 1:30 p.m. interview with S4 ADON revealed she did not remember being told about the scratch to the nose and the bruising and swelling to right eye. On 11/29/22 1:45 p.m. interview with S2 DON (Director of Nurses) (who was previously an ADON on 8/30/22) revealed she did not remember this incident. At that time requested an incident accident investigation report for the 3rd time from S2 DON. On 11/29/22 1:50 p.m. interview with S1 Administrator revealed he checked for a SIMS (State Incident Management System) report for resident #107 while the surveyor was in the office. S1 Administrator confirmed at that time there was no SIMS report completed for this resident on 8/30/22. He further said there was no investigation regarding the scratch to the nares and the bruising and swelling to resident #107 right eye. 11/29/22 2:30 p.m. interview with S5 LPN revealed the resident #107 gets fidgety in the wheelchair but has never actually stood up out of wheelchair and has never had a fall that she was aware of. S5 LPN further said she did remember Hospice asking about the bruising, but doesn't remember much else because she was still in training. S5 LPN also said that if a resident had bruising to eye or injury to the head they are supposed to perform neuro checks for 72 hours and an incident and accident report should be completed and reported to the DON. On 11/29/22 at 3:17 p.m. interview with S8 Corporate Director revealed he said an incident/accident report should have been done so the facility could perform an investigation of the bruising and scratches and complete a SIMS report if indicated. On 11/30/22 at 12:57 p.m. interview with resident #107 regarding having a black eye in August 2022 revealed she could not remember anything about it. She did not even remember having a black, swollen eye or a scratch to her nose.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to initiate an investigation of an injury of unknown origin for 1of 1(#107) resident with an injury of unknown origin. Findings: Review of the facility current abuse policy and procedure that was reviewed and approved by S1 Administrator on 8/23/22 in part revealed: Identification: 1. All incidents/accidents including injuries of unknown source shall be recorded on the Incident/Accident Report form by the licensed nurse and reported to the resident's physician and responsible party upon occurrence. Injuries of unknown source must be reported to the Administrator and DON (Director of Nurses) immediately. The Administrator or his/her designee will complete an investigation of all injuries of unknown source. 2. Any suspicious bruising or injury to the resident must be reported immediately to the Administrator and DON. On 11/28/22 review of the record for resident #107 revealed diagnoses of unspecified protein calorie malnutrition, chronic pancreatitis, anemia, hyperkalemia, unspecified convulsions, alcohol abuse, type 2 diabetes, and cerebral infarct. Review of the MDS (Minimum Data Sets) dated 8/5/22 revealed a BIMS (Brief Interview for Mental Status) of 5 (severe cognitive impairment). Further review of the MDS dated [DATE] revealed resident #107 was total dependence for bed mobility, dressing, eating, toileting, personal hygiene, bathing, and transferring. Resident #107 was unable to walk and uses a wheelchair for locomotion. Review of section J- Health Conditions for falls since admit/reentry/prior assessment revealed resident #107 had no falls. Review of the fall risk assessment dated [DATE] revealed resident #107 was high risk for falls. Review of the current plan of care revealed no indication resident #107 had any falls. On 11/28/22 at 3:38 p.m. review of the nurses' notes dated 8/30/22 at 4:15 p.m. by S9 LPN revealed: upon entering room resident sitting up in wheelchair noted scratch to right nares and right eye with bruising and swelling. Asked resident had she fallen and she stated no. Asked if she knew what happened to face and she said no. Denies pain. ADON (Assistant Director of Nurses) notified. Further review of the nurses' notes revealed the next written nurses' note was dated 9/29/22 that was for a new order for house supplement and weekly weights. There was no further documentation in the record regarding the bruising and swelling to right eye and scratch to nose. On 11/28/22 review of the incident logs for June, July, August 2022 revealed no documentation of any incidents involving resident #107. On 11/29/22 1:30 p.m. interview with S4 ADON revealed she did not remember being told about the scratch to the nose and the bruising and swelling to right eye. On 11/29/22 1:45 p.m. interview with S2 DON (Director of Nurses) (who was previously an ADON on 8/30/22) revealed she did not remember this incident. At that time requested an incident accident investigation report for the 3rd time from S2 DON. On 11/29/22 1:50 p.m. interview with S1 Administrator revealed he checked for a SIMS (State Incident Management System) report for resident #107 while the surveyor was in the office. S1 Administrator confirmed at that time there was no SIMS report completed for this resident on 8/30/22. He further said there was no investigation regarding the scratch to the nares and the bruising and swelling to resident #107 right eye. On 11/29/22 at 2:00 p.m. further interview with S2 DON revealed she just spoke to S9 LPN on the phone and S9 LPN (Licensed Practical Nurse) said she did not do an incident/accident report because the bruise was already there. S2 DON did not have an incident accident report for the bruising and swelling to right eye and scratches to right nose. On 11/29/22 02:01 p.m. attempted to contact S9 LPN X 2 who documented the bruising and swelling to the right eye and the scratch to the nare with no answer. 11/29/22 2:30 p.m. interview with S5 LPN revealed the resident #107 gets fidgety in the wheelchair but has never actually stood up out of wheelchair and has never had a fall that she was aware of. S5 LPN further said she did remember Hospice asking about the bruising, but doesn't remember much else because she was still in training. S5 LPN also said that if a resident had bruising to eye or injury to the head they are supposed to perform neuro checks for 72 hours and an incident and accident report should be completed and reported to the DON. On 11/29/22 2:45 p.m. interview with S6 CNA (Certified Nurses Assistant) revealed resident #107 will try to reach over to her snack cart next to the bed but she is not able to get out of the bed alone without falling. If resident #107 were to get out of the bed alone and fall she would not be able to get back up in the bed by herself. She also said if the resident had bruising to the face or a fall it would be reported to the nurse immediately. On 11/29/22 at 2:50 p.m. interview with S7 CNA revealed resident #107 will attempt to get to her snack cart next to her bed and she will fidget in her wheelchair and try to get up but if she were to get up she would fall and she would not be able to get back in the wheelchair or the bed by herself. If the resident were to have a fall or bruising to the face she would report to nurse immediately. On 11/29/22 at 3:17 p.m. interview with S8 Corporate Director revealed he said an incident/accident report should have been done so the facility could perform an investigation of the bruising and scratches and complete a SIMS report if indicated. On 11/30/22 at 12:57 p.m. interview with resident #107 regarding having a black eye in August 2022 revealed she could not remember anything about it. She did not even remember having a black, swollen eye or a scratch to her nose. On 11/30/22 at 1:02 p.m. another attempt was made to call S9 LPN but again there was no answer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure respiratory care was consistent with professional standards of practice by failing to properly store the BiPap (Bi-level positive airway pressure) mask for 1 of 1 (#331) resident receiving BiPap therapy. Findings: On 11/30/22 at 10:16 a.m. record review revealed orders for BiPap every evening with inspiratory pressure of 10 and expiratory pressure of 6. Review of the November 2022 medication administration record revealed documentation the resident received BiPap therapy every night. Review of the MDS dated [DATE] revealed a BIMS of 10 indicating moderate cognitive impairment. Review of the plan of care revealed to use BiPap as ordered, change BiPap mask/tubing per facility protocol and as needed. On 11/28/22 at 8:59 a.m. observation of resident #331 room revealed a BiPap machine and mask. Observation of the nightstand revealed there was a large plastic bag on the table but the BiPap mask was not inside of the bag and the mask was laying on the table. On 11/29/22 at 10:59 a.m. observation of resident #331 room revealed a BiPap machine and mask. Observation of the nightstand revealed there was a large plastic bag on the table but the BiPap mask was not inside of the bag and again the mask was laying on the table. On 11/30/22 at 10:10 a.m. interview with S2 DON revealed there currently was no written policy and procedure regarding the storage and cleaning of the BiPap mask. She further said the staff are supposed to store the mask in the large plastic bag that is at the bedside after the resident is taken off in the morning. She also said the mask is supposed to be cleaned on a weekly basis. At that same time observation in the room with S2 DON revealed the BiPap mask was again laying on the nightstand without being stored in the plastic bag that was laying on the table next to it. Interview with the S2 DON confirmed the BiPap mask was not stored correctly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews the facility failed to ensure each resident's drug regimen was free from unnecessary medication by failing to adequately monitor the resident for signs and symptoms of bleeding for resident receiving anticoagulant medication for 1 (#17) of 6 (#9, #17, #18, #32, #78, #92) residents reviewed for unnecessary medications. Finding: Record review revealed Resident #17 was admitted to the facility on [DATE] with diagnoses that include but not limited to the following: Unspecified atrial fibrillation, bradycardia, history of pulmonary embolism, long term current use of anticoagulants, age related physical disability, history of bariatric surgery, iron deficiency anemia, abnormal weight loss, vitamin D deficiency, gastroesophageal reflux disease, disorders of electrolyte and fluid balance, edema unspecified, and polyneuropathy. Further review of the medical record revealed Resident #17 was readmitted to the facility on [DATE] with the following diagnoses adult failure to thrive, chronic diarrhea, and malabsorption. Review of the admission physician orders dated 10/06/2022 revealed an order for Coumadin 1 mg (milligram) by mouth every day. Review of the readmission physician orders dated 11/26/2022 revealed an order for Coumadin 1 mg by mouth every day. Review of the October and November 2022 MAR (Medication Administration Record) revealed documentation Resident #17 received Coumadin 1 mg by mouth every day while at the facility. There was no documentation of the monitoring for signs and symptoms of bruising and bleeding noted. Further record review revealed there was no documentation for the monitoring for signs and symptoms of bruising or bleeding every shift. Review of Resident #17's care plan revealed the following: At risk for bleeding due to anticoagulant therapy currently on warfarin (Coumadin) related to personal history of venous thrombus and emboli. Interventions included: administer anticoagulant as ordered by physician, monitor for S/S (signs/symptoms) of bleeding every shift; chart (-) No S/S present or (+) S/S present (nausea; cold clammy skin; trouble breathing after an injury; abdominal pain/tenderness; spitting/coughing blood; bloody vomit or diarrhea; coffee grained vomit; loss of consciousness) and notify Physician. On 11/28/2022 at 10:30 a.m. an observation and interview conducted with Resident #17 revealed superficial bruising to bilateral forearms and hands. Resident #17 reported that she bruises easily because she takes Coumadin every day. On 11/29/2022 at 3:00 p.m. an interview conducted with S2DON (Director of Nursing) was informed of the findings regarding no documentation of Resident #17 being monitored for signs or symptoms of bruising and bleeding every shift. S2DON revealed there was no documentation of the monitoring of bruising or bleeding for Resident # 17 on the October or November 2022 MAR. S2DON confirmed that Resident #17 should be monitored for bruising and bleeding every shift while receiving anticoagulant medication. S2DON reported that the monitoring for bruising and bleeding every shift was not entered correctly to allow staff to document their finding. On 11/29/2022 at 3:30 p.m. an interview conducted with S3LPN (Licensed Practical Nurse) confirmed there was not a spot on Resident #17's MAR to document the monitoring of bruising or bleeding every shift. S3LPN further confirmed Resident #17 should be monitored for bruising and bleeding every shift.