**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure MDS (Minimum Data Set) assessments accurately reflected the resident's status for 1 (#24) of 20 (#3, #5, #6, #9, #19, #24, #26, #28, #30, #41, #51, #52, #58, #59, #72, #77, #78, #90, #94, #95) sampled residents reviewed. The facility failed to ensure for Resident #24's most recent MDS assessment dated [DATE] accurately reflected Resident #24's functional ability. Findings: Review of Resident #24's medical record revealed an admit date of 01/16/2023 with diagnoses that included, in part, hemiplegia following cerebral infarction affecting right dominate side, hemiplegia following cerebral infarction affecting left non-dominate side, and generalized muscle weakness. Review of Resident #24's May 2025 physician orders revealed an order dated 09/04/2024 for full range of motion performed to all extremities with morning and bedtime care for hemiplegia. Review of Resident #24's most recent MDS assessment dated [DATE] revealed no functional impairment in range of motion to bilateral upper and lower extremities. During an interview on 05/13/2025 at 2:38 p.m. S5 Medicare Nurse reported Resident #24 was paralyzed and unable to move her extremities. S5 Medicare Nurse reviewed Resident #24's record and acknowledged the MDS assessment on 02/18/2025 indicated Resident #24 had no functional range of motion impairment in bilateral upper and lower extremities and was not accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 (#30, #52, and #78) of 5 (#9, #30, #41, #52, and #78) residents reviewed for restraints. The facility failed to ensure: 1) Consent was obtained for the use of a gerichair with lap tray for Resident #30; 2) The facility failed to have documented evidence of monitoring of resident condition when lap trays were in use for Resident #30 and Resident #78; 3) Resident care plans were developed with problems and approaches related to the use of a gerichair with lap tray for Resident #30 and Resident #78 and; 4) Quarterly restraint assessments were conducted for the use of bed and chair alarms for Resident #52. Findings: Review of the facility's Physical Restraints policy dated reviewed/revised July 2024 revealed in part: Policy and Purpose: The facility is committed to maintaining a restraint-free environment. Physical restraints will only be used to treat a resident's medical symptoms and only after other alternatives have been tried unsuccessfully. In such circumstances that a physical restraint is indicated for treatment of medical symptoms, the facility will use the least restrictive alternative for the least amount of time necessary, and the on-going need for restraints will be documented. Restraints will never be used for discipline, staff convenience or solely for prevention of falls. Procedure: 1. Physical restraints are defined as any manual method or physical or mechanical device, equipment or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his or her body. 2. The definition of a restraint is based on the cognitive functional status of the resident and not the intent of the device. If the resident cannot intentionally remove the device in the same manner in which staff applied it given the resident's cognitive or physical condition, and this restricts his/her typical ability to change position or place, the device is considered a restraint. 8. Consent of the resident and/or resident representative is required . 10. Physical restraints should be used for the shortest duration indicated. Restraint use should be re-evaluated at least quarterly or upon significant change. Evaluations should address the medical symptoms, documentation of benefit versus risk to any physical or psychosocial impacts of restraint use present during the resident's evaluation, recommendations for least restrictive interventions, and recommendations for continuation of restraint use. Evaluations are to be completed by a licensed nurse. 14. Specific direct monitoring and supervision will be documented during the use of the restraint. Documentation will include (no inclusions were in the policy after this statement). 17. Position change alarms may be used initially as the least restrictive measure to reduce fall risk. 18. Use of alarm requires documentation of an identified medical symptom requiring treatment by a licensed nurse. 19. The goal of position change alarms may be, but are not limited to, determine the frequency of unassisted attempts to rise, determine a pattern of unassisted mobility placing a resident at risk, or alert staff of prolonged attempts to rise unassisted in the absence of safety awareness. Alarm use is intended to be short term until the least restrictive fall prevention measures can be identified. 20. Alarm use should be reassessed at minimum of quarterly. Alarm use should be reassessed immediately when resident meets potential criteria for alarm to be discontinued. 21. Position change alarms are any physical or electronic device that monitors resident movement and alerts the staff when movement is detected. Types of position change alarms include chair and bed sensor pads, bedside alarmed mats, alarms clipped to a resident's clothing, self release seatbelt alarms, and infrared beam motion detectors . Further Review of the facility's Physical Restraints policy revealed additional policy titled Use of Restraints dated April 2017 (from ____, Inc.) which revealed in part: 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, gerichairs, 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 . 12. The following safety guidelines shall be implemented and documented while a resident is in restraints: c. A resident placed in a restraint will be observed at least every thirty (30) minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident's medical record. d. The opportunity for motion and exercise is provided for a period of not less than ten (10) minutes during each two (2) hours in which restraints are employed. e. Restrained residents must be repositioned at least every two (2) hours on all shifts. 16. Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. 17. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s). 18. Care plans shall also include the measures taken to systemically reduce or eliminate the need for restraint use. 19. Documentation regarding the use of restraints shall include: f. observation, range of motion and repositioning flow sheets. During an interview on 05/14/2025 at 9:23 a.m. S1 Administrator reported the facility utilized _____, Inc. for nursing policies from Nursing Services Policy and Procedure Manual for Long-Term Care. S1 Administrator reported the facility's policy regarding restraints included both the Physical Restraints policy and the Use of Restraints Med-Pass Policy. S1 Administrator reported both components were the facility policy. Resident #30 Review of Resident #30's medical records revealed an admit date of 12/21/2021 with the following diagnoses, including in part: Alzheimer's disease with late onset, wandering in diseases classified elsewhere, unspecified dementia moderate with mood disturbance, weakness, unsteadiness on feet, and muscle weakness (generalized). Review of Resident #30's Physician's Orders revealed an order dated 11/07/2024 for gerichair with lap tray when out of bed; medical symptom (s) poor trunk support, impaired gait and balance, impulsive, cognitive deficit, lack of judgement, lap tray for activities and meal times. Review of Resident #30's Comprehensive Care Plan failed to reveal a problem and approach for gerichair with lap tray. Review of Resident #30's medical record failed to reveal a consent for lap tray. Review of Resident #30's medical record failed to reveal monitoring of lap tray use. Observation on 05/13/2025 at 2:15 p.m. revealed Resident #30 sitting upright in common area in a gerichair with lap tray in place. Further observation revealed lap tray with nothing on it. Observation on 05/14/2025 at 10:10 a.m. revealed Resident #30 sitting up in gerichair with lap tray in place in common area in front of tray. Further observation revealed lap tray with nothing on it. During an interview on 05/14/2025 at 1:10 p.m. S4 RN (Registered Nurse)/Director of Quality and Compliance reported the facility did not use restraints, no resident devices were classified as restraints. S4 RN/Director of Quality and Compliance reported if a resident has a lap tray with nothing on it, the lap tray should not be in place. S4 RN/Director of Quality and Compliance further reported a lap tray is placed on a gerichair for activities and meals only. Observation on 05/14/2025 at 1:20 p.m. revealed Resident #30 sitting up in gerichair with lap tray in place in common area. Further observation revealed lap tray with nothing on it. During an interview on 05/14/2025 at 1:50 p.m. S1 Administrator reported residents should not have lap trays on unless they are receiving meals or having activities. Administrator further reported if there is nothing on the lap tray, the tray should not be in place. During an interview on 05/14/2025 at 2:20 p.m. S6 LPN (Licensed Practical Nurse) reported Resident #30 had the lap tray on because she would jump up out of the chair. S6 LPN further reported the staff will remove the tray at certain times but there is no documentation of the monitoring of the lap tray. During an interview on 05/14/2025 at 3:30 p.m. S4 RN/Director of Quality and Compliance acknowledged Resident #30 did not have an informed consent for a lap tray and should have. Resident #52 Review of Resident #52's medical record revealed an admit date of 03/02/2022 with diagnoses that included in part congestive heart failure, chronic respiratory failure, idiopathic gout, paroxysmal atrial fibrillation, generalized muscle weakness, and unsteadiness on feet. Review of Resident #52's May 2025 Physician Orders included the following orders dated 09/03/2024: -Bed alarm when in bed every shift-staff to ensure it is on and working properly -Chair alarm when in recliner every shift-staff to ensure it is on and working properly Review of Resident #52's most recent MDS (Minimum Data Set) assessment dated [DATE] revealed Resident #52 had a BIMS (Brief Interview for Mental Status) of 9 which indicated moderately impaired cognition. Further review of Resident #52's MDS revealed Resident #52 required one person extensive assistance with transfers. Review of Resident #52's medical record revealed documentation of a pre-restraining assessment dated [DATE] for use of bed and chair alarms. Further review of Resident #52's medical record failed to reveal further quarterly assessments for use of bed and chair alarms. Observation on 05/12/2025 at 9:25 a.m. revealed Resident #52 asleep in his bed with bed alarm noted to bed. Observation on 05/12/2025 at 3:09 p.m. revealed Resident #52 sitting in his wheelchair next to his bed with bed alarm noted to Resident #52 bed. During an interview on 05/14/2025 at 3:57 p.m. S4 RN/Director of Quality and Compliance reviewed Resident #52's record and acknowledged there was no documentation of further quarterly assessments for use of bed and chair alarms after the pre-restraining assessment dated [DATE]. Resident #78 Review of Resident #78's record revealed an admit date of 10/04/2024 with diagnoses including: Alzheimer's disease, dementia, cerebral infarction, generalized muscle weakness, repeated falls, other frontotemporal neurocognitive disorders, and epilepsy. Review of Resident #78's current physician orders revealed an order dated 01/17/2025 for a gerichair with lap tray when out of bed for impaired gait, impaired balance, impaired mobility, lack of coordination, impulsive poor judgement, and cognitive deficit. Review of Resident #78's most recently completed MDS assessment dated [DATE] revealed the resident's BIMS (Brief Interview for Mental Status) was not completed due the resident being rarely/never understood. Further review revealed the resident had short-term and long-term memory problems and severely impaired cognitive skills for daily decision making. Further review revealed the resident required extensive assistance with two-plus person physical assist for bed mobility, total dependence with one person assist for eating, total dependence with two-plus person assist for transfers and toileting. Review of Resident #78's comprehensive care plan revealed a problem related to falls with a nursing intervention initiated 10/14/2024 for gerichair with lap tray. Further review revealed no problems or approaches related to the use of the gerichair with lap tray per facility policy. Review of Resident #78's record failed to reveal documentation of the resident's condition during times the lap tray was in use. Observation on 05/12/2025 at 10:42 a.m. revealed Resident #78 seated in a gerichair in the day room of the facility's secure memory care unit with his feet elevated. There was a lap tray in place attached to the chair in front of Resident #78 with nothing on the tray. During an interview on 05/12/2025 at 10:42 a.m. S9 CNA (Certified Nursing Assistant) reported Resident #78 had the lap tray because he could scoot and would try to stand. S9 CNA further reported Resident #78 could not release the lap tray by himself. Observation on 05/13/2025 at 4:00 p.m. revealed Resident #78 awake, sitting upright in gerichair in the day room of the secure dementia care unit. Lap tray in place to front of chair with nothing on the tray. During an interview on 05/13/2025 at 4:00 p.m. S10 LPN reported the resident had a lap tray in use because they were getting ready for the evening meal and the meal would be placed on the lap tray for staff to feed the resident. Further indicated the lap tray was used to keep him from leaning too far forward when he was sitting upright in the chair. S10 LPN reported Resident #78 was unable to remove the lap tray by himself. During an interview on 05/14/2025 at 1:10 p.m. S4 RN/Director of Quality and Compliance reported the facility did not use restraints, no resident devices were classified as restraints. S4 RN/Director of Quality and Compliance reported if a resident has a lap tray with nothing on it, the lap tray should not be in place. S4 RN/Director of Quality and Compliance further reported a lap tray is placed on a gerichair for activities and meals only. During an interview on 05/14/2025 at 1:50 p.m. S1 Administrator reported residents should not have lap trays on unless they are receiving meals or having activities. Administrator further reported if there is nothing on the lap tray, the tray should not be in place. During an interview on 05/15/2025 at 10:15 a.m. S2 DON (Director of Nursing) reviewed Resident #78's care plan and confirmed there were no problems or approaches related to the use of the gerichair with lap tray, and she didn't know there should be.

Based on record reviews and interview, the facility failed to ensure residents receiving a psychotropic medication had a Gradual Dose Review (GDR) attempted for 1 (#30) of 5 (#4, #5, #30, #51, #77) residents reviewed for unnecessary medications. Findings: Review of Resident #30's medical records revealed an admit date of 12/21/2021 with the following diagnoses, including in part: Alzheimer's disease with late onset, wandering in diseases classified elsewhere, depression unspecified, unspecified dementia moderate with mood disturbance, MDD (major depressive disorder) recurrent in partial remission, and generalized anxiety disorder. Review of Resident #30's Physician's Orders revealed an order dated 10/19/2023 for Trazadone 50mg (milligram) tablet by mouth at bedtime for MDD. Review of Resident #30's GDR dated 11/24/2024 failed to reveal Trazadone 50mg was reviewed for an attempted GDR and a rationale was provided for continuing psychoactive medication at current dose by the Physician/Nurse Practitioner. During an interview on 05/14/2025 at 2:15 p.m. S2 DON (Director of Nursing) acknowledged Resident #30's GDR for Trazadone 50mg reviewed for an attempted and a rationale was not provided for continuing psychoactive medication at current dose by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to develop and implement resident's comprehensive person-centered care plans by: 1. The facility failed to develop a care plan with a focus and appropriate approaches on bed rails/side rails for 2 (#9, #41) of 5 (#9, #30, #41, #52, #78) residents reviewed for restraints. 2. The facility failed to implement 1 (#24) of 3 (#19, #24, #90) residents reviewed for nutrition. The facility failed to ensure Resident #24 was weighed weekly as per the physician order. Findings: Resident #9 Review of Resident #9's May 2025 physician orders dated 09/17/2024 revealed 1/3 length assist rail up times one on left when in bed to facilitate bed mobility. Review of Quarterly MDS (Minimum Data Sets) assessment dated [DATE] revealed a BIMS (Brief Interview on Mental Status) of 12 out of 15 indicating moderately impaired cognition. Review of Resident #9's care plan failed to reveal a care plan had been developed with a focus and appropriate approaches for use of bed rails/side rails. Observation on 05/12/2025 at 9:30 a.m. revealed Resident #9 in bed with 1/3 side rail raised to left side of the bed. During an interview on 05/12/2025 at 9:30 a.m. Resident #9 reported 1/3 side rail was used to assist with turning and repositioning while in bed. Resident #41 Review of Resident #41's MDS assessment dated [DATE] a BIMS of 14 out of 15 indicating intact cognition. Review of Resident #41's May 2025 physician orders dated 03/27/2025 revealed 1/3 length assist rail up times two on left when in bed to facilitate bed mobility Review of Resident #41's care plan failed to reveal a care plan had been developed with a focus and appropriate approaches for use of bed rails/side rails. Observation on 05/12/2025 at 9:00 a.m. revealed Resident #41 in bed with side rails raised to both sides of the bed. During an interview on 05/12/2025 at 9:00 a.m. Resident #41 reported side rails were used to assist with turning and repositioning while in bed. During an interview on 05/15/2025 at 9:00 a.m. S4 RN (Registered Nurse)/Director Quality and Compliance reviewed care plans for Resident 9 and Resident #41 and confirmed Resident # 9 and #41 did not have a focus on bed rails with appropriate approaches. During an interview on 05/15/2025 at 9:15 a.m. S1 Administrator reported Resident #9 and Resident #41's care plan did not have a focus on bed rails with appropriate approaches. Resident #24 Review of Resident #24's medical record revealed an admit date of 01/16/2023 with diagnoses that included, in part, hemiplegia following cerebral infarction affecting right dominate side, hemiplegia following cerebral infarction affecting left non-dominate side, gastrostomy status, dysphagia following cerebral infarction, other complications of gastrostomy, and gastroparesis. Review of Resident #24's May 2025 Physician Orders revealed an order dated 12/05/2024 for weekly weights on Wednesday via arm circumference: use conversion table and enter weight every week. Review of Resident #24's April 2025 and May 2025 MARs (Medication Administration Records) failed to reveal documentation of weekly weights as ordered. Review of Resident #24's EHR (Electronic Health Record) Weight Log failed to reveal documentation of weekly weights as ordered. During an interview on 05/13/2025 at 1:35 p.m. S6 LPN (Licensed Practical Nurse) reviewed Resident #24's April 2025 and May 2025 MARs and acknowledged there was no documentation of weekly weights as ordered. S6 LPN reviewed Resident #24's EHR Weight Log and acknowledged there was not documentation of weekly weights as ordered. S6 LPN reported she documented N/A (not applicable) in Resident #24 weight area when she documented because she just learned of the arm circumference conversion table yesterday. During an interview on 05/13/2025 at 2:45 p.m. S2 DON (Director of Nursing) reviewed Resident #24's record and reported weekly weights should be documented on Resident #24's MAR via arm circumference using the conversion table. S2 DON provided a copy of the conversion table utilized in converting arm circumference to pounds for weights. S2 DON reviewed Resident #24's April 2025 and May 2025 MARs and acknowledged there was no documentation of weekly weights as ordered.

Based on record reviews, observation and interviews, the facility failed to ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing for 1 (#6) of 2 (#6, #24) residents reviewed for pressure ulcers. The facility failed to identify, assess, and treat pressure wounds for Resident #6. Findings: Review of Resident #6's medical records revealed an admit date of 10/02/2020 with the following diagnoses, including in part: moderate protein-calorie malnutrition, muscle wasting and atrophy multiple sites, Alzheimer's disease unspecified, neuromuscular dysfunction of bladder unspecified and cognitive communication deficit. Review of Resident #6's Comprehensive Care Plan revealed problems and approaches for: at increased risk for pressure ulcer - investigate causes of injury/bruise/skin tear, treatment as ordered .has fragile skin with history of prone to bruising and/or skin tear - assess new areas for size and injury .Further review failed to reveal current wounds on right foot and right heel with treatment and interventions noted. Review of Resident #6's Physician's Orders revealed an order dated 12/14/2022 for weekly skin assessment on Thursday. Review of Resident #6's Medication Administration Record/Treatment Administration Record failed to reveal skin assessments were completed weekly since January 2025. Review of Resident #6's Braden Scale for Predicting Pressure Sore Risk dated 05/09/2025 revealed a total score of 12 (if score is 18 or less, consider him/her high risk for pressure ulcer development). Review of Resident #6's Skin Evaluation Records revealed no assessments were completed since January 2025 indicating if skin was intact or not intact. Further review failed to reveal documentation of two black areas to right foot and right heel. Review of Resident #6's Skin Evaluation Form dated 05/14/2025 following S3 ADON (Assistant Director of Nursing) becoming aware of wounds revealed: Pressure injury to right bunion area, length 2cm (centimeter) x width 2cm, necrotic/eschar, no exudate, deep tissue injury. Pressure area to right outer heel, length 2cm x width 2.5cm, necrotic/eschar, no exudate. Review of Resident #6's ID (Interdisciplinary) Notes revealed the following entries: 05/08/2025 1230 - . black spots found on right foot .informed S7 NP (Nurse Practitioner) of right foot . 05/09/2025 0800 - .2 black areas noted on right foot. 1 near great toe and the other on the heel. Both blackened areas approx. ½ inch in diameter. No redness, edema or drainage noted Review of Resident #6's S7 NP Progress Notes failed to reveal documentation about wounds to right foot and right heel. During an interview on 05/14/2025 at 8:05 a.m. S6 LPN (Licensed Practical Nurse) reported she did not know Resident #6 had a wound on her right foot. During an interview on 05/14/2025 at 8:40 a.m. S3 ADON reported there were no wound assessments for Resident #6 because she had no wounds. S3 ADON further reported no one had notified her Resident #6 had wounds on her right foot and right heel. S3 ADON reported the nurses complete the weekly skin assessments. Observation on 05/14/2025 at 8:45 a.m. accompanied by S3 ADON revealed Resident #6's right foot with a half dollar sized blackened area surrounded by a 1/2 inch reddened area on the ball of the foot below the great toe. Further observation revealed a half dollar sized blackened area on the bottom right of the heel. During an interview on 05/14/2025 at 9:00 a.m. S7 NP reported she remembered being notified about Resident #6's wounds. During an interview on 05/14/2025 at 10:20 a.m. S3 ADON acknowledged the weekly skin assessments were not completed by the nurse since January 2025. S3 ADON further confirmed there should be documentation indicating if the skin was intact or not intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews the facility failed to provide respiratory care consistent with professional standards for 1 (#72) of 1 resident reviewed for respiratory care. The facility failed to ensure Resident #72's nebulizer mask and tubing were labeled, dated and stored properly when not in use, and failed to develop a care plan for respiratory treatments with appropriate approaches. Findings: Review of Facility's Policy on Administering Medications through a small volume (handheld) nebulizer with a revision date October 2010 revealed: Purpose: The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Preparation: 2. Review the resident's care plan, current orders, and diagnoses to determine resident needs. Steps in Procedure: 29. when equipment is completely dry, store in a plastic bag with the resident's name and the date on it. 30. Change equipment and tubing every seven days, or according to facility protocol. Review of Resident #72's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) of 15 indicating cognition intact. Further review of Resident #72's MDS revealed the following active diagnoses but not limited to: debility, cardiorespiratory conditions, heart failure, hypertension, anxiety disorder, atherosclerotic heart disease, and bradycardia. Review of Resident #72's May 2025 Physician Orders dated 05/02/2025 revealed Albuterol sulfate 2.5 mg (milligram)/3 ml (milliliters) (0.083%) solution for nebulization; 1 vial inhalation every 4 hours as needed for wheezing if ineffective times two consecutive doses notify physician. Review of Resident #72's Care Plan failed to reveal a care plan for nebulizer treatments. Observation on 05/12/2025 at 9:30 a.m. revealed nebulizer and unlabeled/undated mask and tubing on Resident #72's bed side not stored in a plastic storage bag. Observation on 05/12/2025 at 4:06 p.m. revealed nebulizer and unlabeled/undated mask and tubing on Resident #72's bed side not stored in a plastic storage bag. Observation on 05/13/2025 at 8:40 a.m. revealed nebulizer and unlabeled/undated mask and tubing on Resident #72's bed side not stored in a plastic storage bag. Observation on 05/14/2025 at 8:45 a.m. revealed nebulizer and unlabeled/undated mask and tubing on Resident #72's bed side not stored in a plastic storage bag. During an interview on 05/14/2025 at 8:45 a.m. S8 LPN (Licensed Practical Nurse) reported Resident #72's nebulizer mask and tubing for the breathing treatments should have been labeled, dated and stored in a plastic bag and was not. During an interview on 5/14/2025 at 9:20 a.m. S2 DON (Director of Nursing) reported when resident's nebulizer mask and tubing was not in use the nebulizer mask and tubing should be labeled, dated and stored in a zip lock bag. During an interview on 05/14/2025 at 10:54 a.m. S1 Administrator reviewed Resident #72's care plan and confirmed Resident #72 was not care planned for nebulizer treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews the facility failed to ensure medications (inhalations vials) for nebulizer treatments were stored properly for 1 (#72) of 1 resident reviewed for respiratory. Findings: Review of Facility's Resident Rights Policy with a revision date of November 2016 revealed in part: Policy and Purpose: Each and every resident in this facility has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. To meet this requirement residents have rights guaranteed to them under State and Federal Law. Resident of the facility have the right to: Procedures: 24. Self-administer medications when the interdisciplinary team has determined this practice is clinically appropriate. Medications, including over-the-counter medications, should be provided to the nursing staff and are not to be stored in the resident's room unless the requirements are met. Review of Resident #72's May 2025 Physician Orders dated 05/02/2025 revealed Albuterol sulfate 2.5 mg (milligram)/3 ml (milliliters) (0.083%) solution for nebulization; 1 vial inhalation every 4 hours as needed for wheezing if ineffective times two consecutive doses notify physician. Review of Resident #72's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) of 15 out of 15 indicating cognition intact. Further review of Resident #72's MDS revealed the following active diagnoses but not limited to: debility, cardiorespiratory conditions, heart failure, hypertension, anxiety disorder, atherosclerotic heart disease, bradycardia. Observation on 05/12/2025 at 9:30 a.m. revealed Resident #72's nebulizer inhalant medication at bed side. Observation on 05/12/2025 at 4:06 p.m. revealed Resident #72's nebulizer inhalant medication at bed side. Observation on 05/13/2025 at 8:40 a.m. revealed Resident #72's nebulizer inhalant medication at bed side. Observation on 05/14/2025 at 8:45 a.m. revealed Resident #72's nebulizer inhalant medication at bed side. During an interview on 05/14/2025 at 9:20 a.m. S2 DON (Director of Nursing) reviewed Resident #72's medication self-administration assessment dated [DATE] form completed by S4 RN (Registered Nurse)/ Director of Quality of Compliance and confirmed Resident #72's nebulizer treatments were not ordered at the time of medication self-administration assessment and Resident #72 was not able to self-administer nebulizer treatments. S2 DON reported Resident #72's nebulizer treatments should not have been left at the bedside.

Based on record reviews and interviews, the facility failed to ensure equipment was in safe operating condition. The facility failed to perform glucometer control checks for 2 Households (X and Z) according to the facility's policy and procedures.This deficiency has the potential to effect 6 residents (#74, #43, #5, #31, #7, #41) residing in Household X and 3 residents (#14, #21, #346) residing in Household Z. Findings: Household X Review of Facility's Glucometer-Disinfecting and Quality Control Procedures Policy with an effective date of November 1, 2019 revealed: Policy and Purpose - To ensure proper disinfection and operation of glucometers in use by facility staff. Procedure: 3. At a minimum quality control checks on the glucometer will be performed daily. Results of quality control checks will be recorded on the glucometer log. Review of Facility's Blood Glucose Monitoring System Daily Quality Control Record for Household X failed to reveal glucometer controls were checked during the month of May 2025. During an interview on 05/14/2025 at 10:20 a.m. S8LPN (Licensed Practical Nurse) acknowledged the glucometer controls for Household X were not checked for the month of May 2025 and from April 19 through 22nd 2025. During an interview on 05/14/2025 at 2:30 p.m. S2 DON (Director of Nursing) acknowledged she was unable to produce documentation a Blood Glucose Monitoring System Daily Quality Control Record for Household X was completed for May 2025. Household Z Review of Facility's Blood Glucose Monitoring System Daily Quality Control Record for Household Z failed to reveal glucometer controls were checked from May 1 through 8th 2025. During an interview on 05/14/2025 at 3:25 p.m. S3 ADON (Assistant Director of Nursing) acknowledged the Blood Glucose Monitoring System Daily Quality Control Record for for Household Z failed to reveal glucometer controls were checked from May 1 through 8th 2025.

Based on record review and interview, the facility failed to ensure residents' environment was as free of accident hazards as possible by failing to evaluate residents' fall risk and implement interventions to reduce fall risk for 1 (#4) of 4 (#1, #2, #3, #4) sampled residents. Findings: Review of Resident #4's medical record revealed an admission date of 01/31/2025 with diagnoses that included, in part, coronary artery disease, atherosclerotic heart disease of the native coronary artery without angina pectoris, unspecified anemia, hypertension, macular degeneration, hyperlipidemia, and major depressive disorder. Review of Resident #4's medical record revealed a Fall Risk Assessment had been conducted on 02/10/2025 with a total score of 23. The Fall Risk Assessment form indicated a score of 10 or more indicates a high risk for falls. Further review of Resident #4's medical record failed to reveal any Fall Risk Assessment had been conducted on admission or prior to the 02/10/2025 Fall Risk Assessment. Review of Incident Logs revealed Resident #4 had unwitnessed falls on 02/01/2025, 02/05/2025, 02/09/2025, and 02/10/2025. Review of Resident #4's Baseline Care Plan with start date of 01/31/2025 revealed Resident #4 had safety concerns of fall risk, skin impairment, infection with approaches that included only that Resident #4 needed a pressure reducing mattress and alarms were not applicable. No approaches in regard to fall risk were included in the Baseline Care Plan. During an interview on 02/12/2025 at 12:50 p.m. S2 DON (Director of Nursing) reviewed Resident #4's Baseline Care Plan and reported there were no interventions in regard to Resident #4's fall risk and should have been. During an interview on 02/12/2025 at 12:53 p.m. S3 ADON (Assistant Director of Nursing) reported a fall risk assessment had not been conducted for Resident #4 on admission and should have been. During an interview on 02/12/2025 at 1:15 p.m. S1 Administrator reviewed Resident #4's Baseline Care Plan and reported fall risk interventions should have been included for Resident #4's risk of falls and was not. S1 Administrator further reported a fall risk assessment should have been conducted on admission for Resident #4 who was at risk for falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review the facility failed to ensure 1 (#3) of 3 sampled resident's environment remains as free of accident hazards as possible. The facility failed to have Resident #3's fall mats in place as ordered to prevent injuries. Findings: Observation on 09/04/2024 at 9:00 a.m. revealed 1 fall mat positioned along the floor on the right side of Resident #3's bed. Observation on 09/04/2024 at 10:30 a.m. revealed 1 fall mat positioned along the floor on the right side of Resident #3's bed. During an interview on 09/04/2024 at 10:30 a.m. S2 CNA (Certified Nurse Assistant) reported there should have been 2 fall mats on the floor along each side of Resident #3's bed. Review of Resident #3's Physician's Orders revealed an order dated 08/31/2024 for a low bed with fall mats times 2 to be applied when in bed. Review of Resident #3's Medical Records revealed an admit date of 04/25/2024. Diagnoses include Alzheimer's disease, impaired balance, impaired mobility, muscle weakness, essential hypertension, extrapyramidal and movement disorder unspecified. Review of Resident #3's Fall Risk assessment dated [DATE] revealed level of consciousness is disoriented times three at all times and a history of 3 or more falls. Further review revealed a total score of 18 which indicates resident is a high risk for falls. Review of Resident #3's MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) of 3 which indicates severe cognitive impairment. Further review revealed resident requires one person physical assist with bed mobility, transfers, eating, and toilet use. Review of Resident #3's Care Plan revealed risk factors that require monitoring and interventions to reduce potential for self-injury for falls. Further review revealed approaches are resident will follow safety suggestions and limitations with supervision and verbal reminders for better control of risk factors through next review decreasing fall or fall risk to resident.

Based on record reviews, observations and interview the facility failed to ensure each resident received the care and treatment in accordance with professional standards of practice for 2 (#1, #3) of 3 sampled residents. The facility failed to ensure medications were administered for Resident's #1 and #3 in accordance with the physician's orders and /or within their liberalized medication time blocks. Findings: Review of the facility's Medication Administration Schedule Healthcare Policy and Procedures revealed in part, the following. Effective Date: 03/01/2012. Reviewed /Revised: 06/12/2023. Policy and Purpose: To administer medications and treatments in a liberalized manner in accordance with resident preferences. To facilitate medications compliance, schedule medical care around natural life patterns, and promote continued quality of life through honoring principals of natural awakenings and resident choice. Procedures: 1. Liberalized medication time blocks have been established. Liberalized Time Code Blocks: AM medications administered (7AM - 10:30AM) 7. Medications/treatments should be administered in accordance with physician's order and manufacturer specifications. Medications may be scheduled without regard to manufacturer recommendations based on resident preferences with MD (medical doctor) approval. Rationale must be documented in resident's clinical record. 8. Medication Administration is documented on the Medication Administration record. Each dose is documented as administered. 9. A physician's order for specified times supersedes any liberalized schedule.14. If the liberalized medication pass time blocks do not address medications with multiple dosing schedules, these medications will continue to be scheduled at specific times based on MD order and /or resident preference. Review of Resident #3's September 2024 MAR (Medication Administration Record) on 09/04/2024 at 9:30 a.m. failed to reveal morning medications had been initialed as being administered. Resident #1 Review of Resident #1's Physician's orders revealed the following medication orders were not administered between the liberalized hours of 7:00 a.m. and 10:30 a.m.: 08/28/2024 - Folic acid 1mg (milligram) tablet 1 tab by mouth once daily (given at 10:51 a.m.) 08/22/2024 - Vitamin C 500mg tablet by mouth once daily for wound healing (given at 10:55 am.) 08/22/2024 - Ferrous Sulfate 325mg tablet 1 tab by mouth once daily for iron deficiency (given at 10:54 a.m.) 08/14/2024 - Colace 100mg capsule 1 capsule by mouth twice daily (given at 10:54 a.m.) 08/14/2024 - Ventolin HFA (hydrofluoroalkane) 90 mcg (microgram)/actuation aerosol inhaler 2 puffs inhalation once daily (given at 10:51 a.m.) 08/14/2024 - Pantoprazole 40mg tablet delayed release 1 tab by mouth once daily (given at 10:51 a.m.) 08/14/2024 - Miralax 17 gram/dose oral powder 1 capful by mouth 3 times a week (given at 10:51 a.m.) 08/14/2024 - Asmanex HFA 100 mcg/actuation aerosol inhaler 1 inhalation once daily (given at 10:45 a.m.) 08/13/2024 -Memantine 10 mg tablet 1 tab by mouth twice daily (given at 10:51 a.m.) 08/13/2024 - Eliquis 2.5mg tablet 1 tab by mouth twice daily (given at 10:45 a.m.) 08/13/2024 - Dorzolamide 2% eye drops 1 drop right eye twice daily (given at 10:53 a.m.) 08/13/2024 - Cetirizine 10mg tablet 1 tab by mouth once daily (given at 10:51 a.m.) 08/13/2024 - Brimonidine 0.1% eye drops 1 drop right eye twice daily (given at 10:53 a.m.) Review of Resident #1's September 04, 2024 MAR revealed all morning medications with times to be administered at 07:00 a.m. were initialed being administered between 10:45 a.m. and 10:55 a.m. Resident #3 Review of Resident #3's September 2024 MAR on 09/04/2024 at 10:40 a.m. with S1 LPN (Licensed Practical Nurse) failed to reveal she had initialed Resident #1's morning medications had been administered. Review of Resident #3's September 2024 Physician's orders revealed the following orders: 08/28/2024 Lexapro 10 mg by mouth once daily. Times 7:00. 08/27/2024 Bupropion HCL XL 150 MG 24 hour tablet, extended release by mouth once a day. Times: 07:00. 08/23/2024 Hydralazine 50 mg tablet 1 tablet by mouth 3 times a day. Times 0700, 13:00, 19:00. 08/14/2024 Cranberry Concentrate 500 mg capsules by mouth once daily. Times 07:00. 06/19/2024 Prevacid Solutab 30 mg delayed release, disintegrating tablet by mouth once daily. Times 07:00. 06/29/2024 Losartan 100 mg tablet 1 tablet by mouth daily. Times 0700. 04/25/2024 Potassium chloride extended release 10 meq (milliquivalent) tablet extended release -1 tab by mouth once daily. Times 07:00. 04/26/2024 Furosemide 20 mg 1 tab by mouth once daily. Times 07:00. Review of Resident #3's September 04, 2024 MAR revealed all morning medications with times to be administered at 07:00 a.m. were initialed as not being administered until 11:17 a.m. Medications were not administered according to the physician's orders or within the facility's liberalized medication time blocks. During an interview on 9/04/2024 at 10:45 a.m. S1 LPN reported there was no set time to administer medications. S1 LPN acknowledged she had not administered Resident #3's morning medications and reported the facility had liberalized times to administer medications at any time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interview, the facility failed to ensure correct use and maintenance of bed rails by ensuring residents were assessed for the risk of entrapment from bed rails, obtaining a written order from the physician for bed rails and an informed consent from resident or resident representative prior to installation for 2 (#1, #2) out of 3 (#1, #2, #3) residents reviewed for falls. Findings: Resident #1 Review of Resident #1's medical record revealed an admit date of 03/13/2023 with the following diagnoses, including but not limited to: Parkinson's disease without dyskinesia/without mention of fluctuations, dementia in other disease classified elsewhere/unspecified severity without behavior/psychosis/mood/anxiety, schizoaffective disorder, weakness, unspecified lack of coordination, muscle weakness (generalized), and cognitive communication deficit. Review of Resident #1's MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 06 indicating severely impaired cognition and functional status requiring extensive assistance with one person for bed mobility and transfer. Review of Resident #1's Physician's Orders failed to reveal an order for bed rails. Review of Resident #1's medical records failed to reveal a risk assessment for entrapment from bed rails and a signed consent for bed rails prior to installation. Observation on 08/06/2024 at 8:05 a.m. revealed Resident #1 asleep in bed with two upper bed rails in the raised position. Observation on 08/06/2024 at 2:55 p.m. revealed Resident #1 lying in bed with two upper bed rails in the raised position. Observation on 08/07/2024 at 7:45 a.m. revealed Resident #1 asleep in bed with two upper bed rails in the raised position. Resident #2 Review of Resident #2's medical record revealed an admit date of 06/21/2024 with the following diagnoses, including , m but not limited to: spondylosis/unspecified, dementia in other disease classified elsewhere/moderate without behavior/psychosis/mood/anxiety, unspecified osteoarthritis/unspecified site, muscle weakness (generalized), and unsteadiness on feet. Review of Resident #2's MDS assessment dated [DATE] revealed a BIMS of 07 indicating severely impaired cognition. Further review revealed functional status requiring extensive assistance with one person for bed mobility and extensive assistance with two person for transfers. Review of Resident #2's Physician's Orders failed to reveal an order for bed rails. Review of Resident #2's medical records failed to reveal a risk assessment for entrapment from bed rails and a signed consent for bed rails prior to installation. Observation on 08/06/2024 at 9:00 a.m. revealed Resident #2 lying in bed with both upper bed rails in the raised position. Observation on 08/06/2024 at 3:50 p.m. revealed Resident #2 lying in bed with both upper bed rails in the raised position. Observation on 08/07/2024 at 7:50 a.m. revealed Resident #2 lying in bed with both upper bed rails in the raised position. During an interview on 08/07/2024 at 9:15 a.m. S1 Administrator reported Resident #1 and Resident #2 have assist rails for positioning. During an interview on 08/07/2024 at 12:15 p.m. S1 Administrator acknowledged Resident #1 and Resident #2 did not have an assessment for entrapment of bed rails, a physician order for bed rails or a signed consent from resident or resident representative for placement of bed rails and should.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. The facility failed to ensure Resident #1 had a written consent for a self-releasing seatbelt and was able to intentionally remove the self-releasing seatbelt in the same manner as it was applied by the staff. Findings: Review of Facility's Chemical & Physical Restraints Policy and Procedure (Reviewed/revised April 2017) revealed: - Policy and purpose: It is the policy of the ___Retirement System to maintain a restraint free environment . - Procedure: 1. Physical restraints are defines as any manual method or physical or mechanical device attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove the device in the same manner in which staff applied it given the resident's physical condition, and this restricts his/her typical ability to change position or place, the device may be a restraint. 10. Consent of the resident and/or responsible party is required. 14. Physical restraint use is to be reassessed when the emergent situation has been addressed, at least quarterly, and more frequently if condition changes. Review of Resident #1's Medical Records revealed an admit date of 05/08/2024 with the following diagnoses, in part: unspecified dementia/severe with mood disturbance, unspecified dementia/severe with other behavioral disturbance and muscle weakness. Review of Resident #1's Restraint Determination form dated 06/05/2024 revealed: - Physical Restraints: Self-Release alarm seat belt. Intent - To assist the assessor to evaluate whether or not a device meets the definition of a physical restraint, and then code only those items in section P4 that has the effect of restraining the resident. - - Definition - C. Trunk restraint - includes any device or equipment or material that the resident cannot easily remove {e.g. vest or waist restraint, belts used in w/c (wheelchair)}. Process - The assessor should not focus on the intent or the reason behind the use of the device, but on the effect the device has on the resident. - Assessment: 1) Does the resident utilize any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body? YES - self-release alarm seat belt. 2) Can the individual easily remove the device? Consider can the device be removed by the resident in the same fashion it was applied by the staff. YES - Resident #1 cannot release the device on command due to cognition. Assessor: S1 Administrator. Review of Resident #1's Physician's Orders revealed an order dated 06/17/2024 for fall intervention: self-release belt on while in chair every shift. Review of Resident #1's MDS (Minimum Data Set) assessment dated [DATE] revealed BIMS (Brief Interview of Mental Status) 99 - resident was unable to complete the interview. Cognitive skills for daily decision making are moderately impaired. Observation on 06/18/2024 at 3:00 p.m. revealed Resident #1 sitting up in high back wheelchair in living area with self-releasing seatbelt in place. Observation on 06/24/2024 at 7:55 a.m. revealed Resident #1 sitting up in high back wheelchair with self-releasing seatbelt in place. During an interview on 06/24/2024 at 8:00 a.m. S3 LPN (Licensed Practical Nurse) reported she doesn't know if Resident #1 can remove her self-releasing seatbelt. S3 LPN asked Resident #1 to take her seat belt off several times, but resident did not attempt and did not appear to understand what the nurse was asking her to do. During an interview on 06/24/2024 at 11:05 a.m. S2 DON (Director of Nursing) acknowledged she has no written consent or documentation for Resident #1's self-releasing seatbelt restraint use as required by the facility's restraint policy. S2 DON the nurse's should communicate when resident is no longer able to release self-releasing seatbelt restraint. During an interview on 06/24/2024 at 12:55 p.m. S1 Administrator reported they did obtain a consent for the restraint because they did not see it as a restraint. S1 Administrator further reported they were trying to address the resident getting up unassisted.

Based on record review and interviews the facility failed to ensure pain management is provided to residents who may require such services consistent with professional standards of practice for 1 (#1) of 3 (#1, #2, and #3) sample residents reviewed for pain management after a fall/injury. The facility failed to ensure an initial assessment for pain was completed for resident #1 after a fall/injury. Findings: Review of the facility's Fall - Clinical Protocol (Revised March, 2018) presented by S3 Director of Quality and Compliance RN (Registered Nurse) revealed in part the following: Assessment and Recognition 2. In addition, the nurse shall assess and document/report the following: f. Pain; Review of resident #1's ID (Interdisciplinary) Notes dated 04/15/2024 S5 LPN (Licensed Practical Nurse) documented at 5:20 a.m. writer on hall during morning med pass hear resident calling out for help. Writer entered room resident noted awake and alert lying on back on floor next to bathroom. Left side quarter size knot to back of head. Right hand thumb cut, left knee side cut, left skin tear to front to leg. Slightly red area to upper back. Assisted up X2 to wheelchair. Vital signs 108/62, 69, 18, 95%. Wound to thumb and knee clean and dressed. Neuro checks started. Resident sitting at breakfast table with wheels locked. NP (Nurse Practitioner) notified. No new orders noted. Responsible party notified. Review of the initial ID Notes dated 04/15/2024 failed to reveal an assessment of pain was done. Review of the facility's Incident Report for fall/injury dated 04/15/2024 failed to reveal any documentation that assessment of resident #1's pain had been done. Review of the Neurological Evaluation Flow Sheet beginning date 04/15/2024 beginning at 05:20 a.m. and documented checks every 15 minutes times one hour, then every 30 minutes times 2 hours, this form failed to reveal a pain assessment. Review of NP's Progress Notes dated 04/16/2024 revealed resident #1's diagnosis of displaced fracture of left femoral neck. Plan: Displaced left femoral neck fracture with intertrochanteric extension: Acute unwitnessed, fall at 05:20 a.m. on 04/15/2024. Resident grimaces in pain with manipulation of left lower extremity. Reviewed left tibia-fibula x-ray, left ankle x-ray, and left foot x-ray (unremarkable with the exception of arthrosis and osteopenia). Left hip and pelvis x-ray, findings concerning for minimally displaced left femoral neck fraction with intertrochanteric extension. Non contrast CT (computer tomography) scan of the left hip recommended for further evaluation, per radiology report. Ordered send to emergency department to rule out emergent conditions, possible need for surgery, and pain control. During an interview on 05/07/2024 at 12:22 p.m. S2 DON (Director of Nursing) acknowledged there should be some type of pain assessment completed for resident #1. She reported there should be a Pain Assessment form in the Matrix (their computer system). S2 DON reported she could not locate in the Matrix that a Pain Assessment form was completed for the fall/injury resident #1 had on 04/15/2024. S2 DON reviewed the Incident Report dated 04/15/2024 for resident #1's fall/injury and acknowledged there was no pain assessment completed. During an interview on 05/08/2024 at 12:10 p.m. S4 LPN reported when a resident has a fall/injury the nurses document in the ID Notes a head to toe assessment and if they have any pain. S4 LPN reported we ask the residents that are able to respond what is their level of pain 1-10. S4 LPN reported we touch or palpate the affected areas if they are not able to respond due to poor cognition and observe their response if they grimace, how they are moving are they guarding the area. Review the ID notes of the fall/injury dated 04/15/2024 at 5:30 a.m. with S4 LPN. S4 LPN agreed there was no documentation of resident #1's assessment of pain. During an interview on 05/08/2024 at 1:00 p.m. S3 Director of Quality and Compliance RN acknowledged the nurse that discovered resident #1 after her fall should have completed an initial assessment including if she had any pain and nurse did not.

Based on record reviews and interviews, the facility failed to ensure that 1 (#82) resident out of 35 sampled residents reviewed for a significant change in status was comprehensively assessed using the CMS (Center for Medicare & Medicaid Services) specified Resident Assessment Instrument after Resident #82 was hospitalized following a cerebral infarction and right femoral head fracture on 02/10/2024. Findings: Review of Resident #82's diagnosis revealed hemiplegia following cerebral infarction affecting left non-dominant side, right femoral head fracture. Review of Resident #82's nurse's note dated 02/10/2024 revealed Resident #82 was found lying supine on the floor with no movement to her right lower extremity and tremors to the left side of her body. Resident #82 was assessed by the nurse and 3 staff members assisted Resident #82 into her wheelchair. The Nurse Practitioner was notified and Resident #82 was transferred to the emergency room for evaluation. Review of Resident #82's hospital records revealed the following, in part: Hospital admit date of 02/10/2024 and discharge date of 02/19/2024. Final active diagnosis included acute ischemic left MCA (Middle Cerebral Artery) stroke, cytotoxic cerebral edema, fracture of neck of right femur, femur fracture, right hemiparesis . X-ray hip two or three views right (with pelvis when performed) result on 02/10/2024 findings were right complete femoral head fracture, displaced. Review of Resident #82's MDS (Minimum Data Set) for the following dates of 02/10/2024, 02/21/2024, and 02/27/2024 failed to reveal a significant change assessment was completed. During an interview on 04/11/2024 at 4:20 p.m., S2 Medicare Case Manager verified she did not complete a significant change MDS after Resident #82 suffered a cerebral infarction and a right femoral head fracture on 02/10/2024. During an interview on 04/11/2024 at 4:30 p.m., S1 Administrator verified a significant change MDS should have been completed by S2 Medicare Case Manager after Resident #82 suffered a cerebral infarction and a right femoral head fracture on 02/10/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure resident assessments were transmitted within the required timeframe for 10 (#3, #41, #47, #61, #76, #50, #51, #72, #34, #62) of 10 residents reviewed for assessments out of a total of 35 sampled residents. Findings: Review of Resident #3's MDS (Minimum Data Set) assessments revealed an Other State Assessment MDS dated [DATE] with a status of completed on 02/15/2024 and submitted and accepted on 03/21/2024. Further review of Resident #3's MDS revealed a Quarterly MDS dated [DATE] with a status of completed 02/15/2024 and submitted 03/20/2024 and not accepted. Review of Resident #41's MDS assessments revealed a Quarterly MDS dated [DATE] with a status of not completed, not submitted, and not accepted. Review of Resident #47's MDS assessments revealed an Other State Assessment MDS dated [DATE] with a status of completed on 02/22/2024 and submitted and accepted on 03/21/2024. Further review of Resident #47's MDS revealed a 5-Day MDS dated [DATE] with a status of completed 02/22/2024 and submitted 03/20/2024 and not accepted. Review of Resident #61's MDS assessments revealed a Discharge MDS dated [DATE] with a status of not completed, not submitted, and not accepted. Review of Resident #76's MDS assessments revealed an Other State Assessment MDS dated [DATE] with a status of completed 11/16/2023, submitted 02/21/2024, and accepted 02/21/2024. Review of Resident #50's MDS assessments revealed an Entry MDS dated [DATE] with a status of completed 02/15/2024, submitted 03/20/2024, and not accepted. Review of Resident #51's MDS assessments revealed a Quarterly MDS dated [DATE] with a status of not completed, not submitted, and not accepted. Further review of Resident #51's MDS assessments revealed an Other State assessment dated [DATE] with a status of completed 12/08/2023, submitted 12/20/2023, and not accepted. Review of Resident #72's MDS assessments revealed an Other State Assessment MDS dated [DATE] with a status of completed 02/15/2024 and submitted and accepted on 03/21/2023. Review of Resident #34's MDS assessments revealed an Other State Assessment MDS dated [DATE] with a status of completed 02/15/2024 and submitted and accepted on 03/21/2024. Further review of Resident #34's MDS assessments revealed a Quarterly MDS dated [DATE] with a status of completed 02/15/2024 and submitted 03/20/2024, and not accepted. Review of Resident #62's MDS assessments revealed Other State Assessment MDS dated [DATE] with a status of completed 02/22/2024 and submitted and accepted 03/21/2024. Further review of Resident #62's MDS assessments revealed a Quarterly MDS dated [DATE] with a status of completed 02/22/2024, submitted 03/20/2024, and not accepted. During an interview on 04/11/2024 at 3:15 p.m. S2 Medicare Case Manager reviewed Resident #3, #41, #47, #61, #76, #50, #51, #72, #34, and #62's MDS assessments and acknowledged their MDS assessments had not been completed and transmitted to CMS (Centers for Medicare and Medicaid Services) within the required time frame.

Based on observations and interviews the facility failed to store, prepare, distribute and serve food under sanitary conditions. This had the potential to affect 12 residents who received trays out of the main kitchen on 04/08/2024. Findings: Review of the facility's Basic Standards-Food Services -Health Care Policy (revised March 2022) revealed the following: Sanitation: 7. Effective methods of cleaning all equipment and work areas are followed as outlined in individual assignment procedures. 9. Food is stored following sanitary code. All open containers are dated and labeled with first use date and discarded prior to expiration. All food items removed from original containers are properly packaged, dated and labeled prior to being stored. Observation on 04/08/2024 at 8:30 a.m. of the main kitchen revealed the following: 1. Meat covered in ice with frost bitten appearance inside a plastic bag without a label inside the freezer. 2. An opened, unlabeled jar of jalapenos, tartar sauce, and pepperoncini's and lime juice inside the walk in refrigerator. 3. Stand Mixer was unclean with yellow and white food residue on the top and underneath the hood of the mixer. 4. Grease and food residue noted on the outside of both fryers and on the floor between the stove and fryers. The pipes and the wall behind the fryer and stove had grease and food residue present. 5. Walk-in refrigerator with food and debris on the floor. During an interview on 04/08/2024 at 8:30 a.m. S3 [NAME] reported the meat should have been removed from the refrigerator before going bad and the opened, unlabeled items in the refrigerator should have been labeled with an opened date. S3 [NAME] further confirmed the walk in refrigerator's floor, the stand mixer, the fryer, and the floors and walls behind the fryers should have been cleaned. During an interview on 04/09/2024 at 10:15 a.m. S4 Chef reported the morning and evening kitchen staff have assignments to clean the main kitchen and the equipment daily. S4 Chef confirmed the kitchen and equipment should have been cleaned daily. S4 Chef further confirmed the the meat should have been removed from the refrigerator before going bad and the opened, unlabeled items in the refrigerator should have been labeled with an opened date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure an allegation of physical abuse was reported immediately, but not later than 2 hours after the allegation was made, to the State Survey agency for 1 (#1) of 3 (#1, #2, & #3) residents reviewed for abuse. Findings: Review of facility's Resident Abuse and Neglect Prevention and Detection policy with a revision date of November 2022 revealed in part: G. Reporting: 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injures of unknown origin and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is made or discovered, to the administrator of the facility and to other officials . if the events that caused the allegation involve abuse or result in a serious bodily injury . Resident #1 was admitted to the facility on [DATE] with diagnoses including in part, Alzheimer's disease, dementia, anxiety disorder, cognitive communication deficit and age-related osteoporosis. Review of Resident #1's Quarterly MDS (Minimum Data Set) dated 12/07/2023 revealed in part a BIMS (Brief Interview of Mental Status) score of 99, indicating Resident #1 was unable to complete interview. Review of Resident #1's interdisciplinary notes revealed in part, on 12/09/2023 at 9:40 a.m. S2CNA (Certified Nursing Assistant) reported to S3LPN (Licensed Practical Nurse) Resident #1 became combative during bath and swung her right arm at S2CNA. S2CNA held her arm up to block the hit and Resident #1's wrist and lower forearm made contact with S2CNA's arm. S2CNA heard a pop and immediately reported to S3LPN. S3LPN arrived in room at 10:00 a.m. and documented Resident #1 was up in Geri chair and appeared in no discomfort. S3LPN further documented when Resident #1 was asked to move right arm, she was hesitant in doing so, otherwise, no apparent injuries, redness or swelling at this time. Further review of Resident #1's interdisciplinary notes revealed in part, on 12/09/2023 at 9:00 p.m., S4CNA reported to S5LPN Resident #1 exhibited pain to right arm while providing care. S5LPN immediately assessed Resident #1's right arm and documented no swelling or discoloration. S5LPN further documented Resident #1 was able to move her right arm and fingers on command and did not grimace or moan in pain during assessment. S5LPN documented no abnormalities were found upon palpating Resident #1's arm. Further review of Resident #1's interdisciplinary notes revealed in part, on 12/10/2023 at 9:45 a.m. S6CNA reported to S3LPN Resident #1 exhibited signs of pain to right arm with movement. S3LPN observed edema with light bruising from just above elbow and extending half way down Resident #1's right forearm. S3LPN notified S7Nurse Practitioner of findings and received an order for an x-ray to right elbow. During an interview on 12/19/2023 at 8:40 a.m., S8Director of Quality and Compliance reported S3LPN called S8Director of Quality and Compliance on 12/10/2023 at 4:45 p.m. and reported an x-ray had been performed on Resident' #1's right elbow, upon discovery of pain and swelling. S3LPN reported imaging company had just called to confirm a right elbow fracture for Resident #1. S8Director of Quality and Compliance further reported S1Admininistrator was notified of findings on 12/10/2023 at 5:30 p.m. Review of the facility's State incident report revealed in part, the incident occurred on 12/09/2023 at 10:00 a.m. The incident was discovered on 12/10/2023 at 10:30 a.m. and an allegation of physical abuse was entered into the system on 12/11/2023 at 9:06 a.m., by S1Administrator. During an interview on 12/19/2023 at 1:45 p.m., S1Administrator acknowledged the allegation of physical abuse had not been reported to State Survey agency within 2 hours of discovery and should have been.

Based on record reviews, observation and interviews, the facility failed to provide services that met professional standards for 1 (#371) of 24 sampled residents reviewed. The facility failed to ensure safe medication administration practices by leaving medication at the bedside. Findings: Review of facility policy and procedure with subject line of Pharmaceutical Services and a revision date of February 2018 revealed in part, Provision for Medications: 5. Self-administration of medication by residents is permitted only on order of the residents' physician and with the approval of the interdisciplinary team. Review of facility policy and procedure entitled Self-Administration of Medications with revision date of February 2021, revealed in part: 8. Self-administered medications are stored in a safe & secure place, which is not accessible by other residents. Review of Resident #371's medical record revealed an admit date of 04/18/2023 with diagnoses including, but not limited to, chronic respiratory failure with hypoxia and pneumonitis. Review of Resident #371's admit MDS (Minimum Data Set) revealed a BIMS (Brief Interview for Mental Status) score of 15 out of 15 which indicated the resident had intact cognition. Review of Resident #371's current physician orders failed to reveal an order for resident to self-administer her medication. During an observation on 05/08/2023 at 8:50 a.m. a bottle of Tussin DM (Dextromethorhan) medication was observed sitting on Resident #371's bedside table. During an interview on 05/08/2023 at 8:50 a.m. Resident #371 reported a nurse told her the medication should be in a locked cabinet. During an interview on 05/08/2023 at 9:00 a.m. S1 DON (Director of Nursing) confirmed a medication bottle of Tussin DM was left sitting out on Resident #371's bedside table and should not have been. During an interview on 05/09/2023 at 3:45 p.m. S2 LPN (Licensed Practical Nurse) confirmed Resident #371 did not have an order to self-administer medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure resident's medical records reflected the resident's wishes for 1 (#36) of 1 (#36) resident reviewed for advanced directives out of a total sample of 29. The facility failed to ensure the physician's orders were consistent with the resident's wishes for Do Not Resuscitate (DNR). Findings: Review of facility's Emergency Procedure - Cardiopulmonary Resuscitation (CPR) revealed in part: 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified CPR/BSL (Basic Life Support) shall initiate CPR unless: a. it is known that a Do Not Resuscitate order that specifically prohibits CPR and/or external defibrillation exists for that individual . 7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer. Review of Resident #36's LaPOST (Louisiana Physician Orders for Scope of Treatment) order signed and dated on [DATE] by Resident #36 and Resident #36's physician revealed Resident #36's wish for Cardio Pulmonary Resuscitation (CPR) was marked DNR - Allow Natural Death. Review of Resident #36's current physician's orders revealed an order dated [DATE], which read, Resuscitate: Yes; Full Code. During an interview on [DATE] at 1:40 p.m., S3 LPN (Licensed Practical Nurse) acknowledged Resident #36 had a current physician's order for Full Code and a LaPOST order for DNR. S3 LPN acknowledged physician's order did not match Resident #36's wish for DNR and should have.