**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure signs of a potential gastrointestinal (GI) bleed were acted upon or evaluated timely and, if needed, referred for care or treatment to reduce the risk of complication for 1 of 1 residents (R1) reviewed who was hospitalized with GI complications. Findings include: R1's Entry Minimum Data Set (MDS), dated [DATE], identified R1 admitted to the care center on 9/15/25 from the acute care hospital. R1's initial Medicare/5-Day MDS remained, In Progress, at the time of survey.R1's Interagency Transfer Form, dated 9/10/25, was completed by the admitting hospital and outlined R1 as having a past medical history significant for colon cancer and chronic kidney disease (CKD). The report outlined R1 admitted to the hospital on [DATE] after a mechanical fall with a resulted odontoid fracture (i.e., a form of cervical fracture). R1's medical history was detailed which included a history of right hemicolectomy (a surgical procedure that involves removing the right side of the colon) in June 2025; however, the completed report lacked any evidence R1 had a current or active GI bleed which was being treated or monitored while he had been hospitalized . R1's progress note, dated 9/15/25, identified R1 admitted to the care center via a transport service. R1's vital signs were listed as being within normal limits and he rated his pain at three (out of ten). R1 had no skin issues present aside from a scab on his head. The note concluded with, . no other area of concern noted at this time. R1's corresponding Admission/re-admission Summary - V6, dated 9/15/25, identified an evaluation completed by the care center' staff which detailed a brief review of systems. The evaluation included a section labeled, A4. Elimination, which outlined R1 as having urinary and bowel incontinence, having a last bowel movement on 9/15/25, and having hypoactive bowel sounds in all four quadrants. The completed summary lacked any concern or indication of R1 having an active or monitored GI bleed. R1's POC (Point of Care) Response History, dated 9/22/25, outlined a task labeled, B&B - Bowel and Bladder Elimination, and recorded responses from the staff members for the previous 14 day period. This recorded R1 as having a large bowel movement (BM) on 9/16/25 at 4:30 p.m., and another large bowel movement on 9/17/25 at 12:00 p.m. The report continued and identified both of these BM(s) were, Formed/Normal, in consistency. However, R1's progress note, dated 9/17/25 at 12:19 p.m., identified R1 was being transferred to the hospital [due to prior complaints of head pain after a fall]. The note outlined, EMTS [sic] just came in to pick up resident . staff stood resident up to move to gurney [and] a large amount of very bloody black stool come [sic] down his leg . [EMT] stated it smells like a GI bleed . placed on the gurney and left the building to ED . The note was authored by licensed practical nurse (LPN)-A. When interviewed on 9/22/25 at 10:06 a.m., nursing assistant (NA)-A explained they had worked with R1 during his few days at the care center and recalled him as often saying he feels dizzy with ambulation. NA-A stated R1 needed help with dressing and most cares. NA-A explained they were assisting R1 with ambulation on 9/17/25 when he, again, reported being dizzy and was lowered to the floor. NA-A stated they did not recall ever helping R1 after a BM, however, then expressed everyone was complaining about the smell in the room. NA-A explained they had noticed a foul odor in R1's wash room the morning of 9/17/25 before the breakfast meal (i.e., approx. 7:30 a.m.) which NA-A described as the same smell as happened when R1 evacuated his bowels with the EMT present later in the day. NA-A stated they had not always noticed that odor but felt it was because R1 had just used the bathroom. NA-A stated they did not report this odor to the nurse as someone from a previous overnight shift had told them R1's room sometimes smells, so they assumed it had been addressed. NA-A stated they didn't recall ever seeing any active bleeding from R1, however, verified the odor they noticed in the early morning hours on 9/17/25 was the same one they smelled later in the afternoon when R1 was transferred to the hospital adding, It's not a normal smell. NA-A expressed further the odor was, Not a [typical] poop smell.When interviewed on 9/22/25 at 11:04 a.m., LPN-A verified they were assigned care for R1 on 9/17/25 and helped transfer him to the hospital. LPN-A explained R1 had been lowered to the ground earlier on 9/17/25, and he had complained of severe head or neck pain afterward which was the reason for the hospital transfer. LPN-A recalled that day and expressed R1 had gotten up for the day per usual and had said he was fine. Then while being prepared for the hospital transfer, the NA staff called her back into the room as they had noticed a large amount of blood in R1's incontinence product. LPN-A stated this happened between the time EMS was contacted and when they arrived. LPN-A stated R1 was visibly uncomfortable at this time. The EMS then arrived and R1 was assisted to stand to transfer to their stretcher and, at that time, R1 became incontinent of bowel and it had just flooded down his pants leg. LPN-A stated the stool was loose and had lots of blood in it with an evident odor. The EMT present then responded aloud, [He] has a GI bleed, I can smell it. R1 was then transferred to the hospital. LPN-A acknowledged the odor of a GI bleed as being a mixture of rotten egg and metallic smell adding aloud, I think you [surveyor] did a really good job [describing it]. LPN-A verified nobody had reported any concerns about the same odor being present in his room earlier that day adding, Nobody reported nothing. LPN-A stated if it had been reported, they would have started monitoring R1's vital signs and updated the physician immediately with that information adding, I would call right away just because I don't know what it is. R1's medical record was reviewed and lacked evidence the odor identified by the direct care staff had been evaluated timely to determine what, if any, potential causative factors existed. Further, the record lacked evidence staff had reviewed R1 on 9/17/25 prior to the EMT arrival for what, if any, other symptoms of a potential GI bleed were present or needed to be addressed, including potentially emergently, despite the direct care staff smelling the potential distinctive odor of a GI bleed several hours prior. On 9/22/25 at 1:26 p.m., the assistant director of nursing (ADON) and director of nursing (DON) were interviewed, and both verified they had an opportunity to review R1's medical record. ADON explained R1 had previously been at the care center a few months prior after having bowel surgery. He re-admitted to the center on 9/15/25 after having a fall and was in a cervical collar for his fracture. ADON stated the medical record showed R1 having a formed stool the day prior and R1 consuming some bowel-related medications; however, both the ADON and DON expressed nobody had reported any concerns about R1 having a potential GI bleed smell in their room on the morning of 9/17/25. ADON stated R1 consumed an iron supplement with their medications, however, acknowledged that would not cause the same, distinct odor a GI bleed causes. ADON stated if the NA staff had smelled such an odor, then it should be reported to the nurse right away to be addressed adding a GI bleed needs to be handled pretty quick to help improve the outcome to the patient. Further, ADON stated they typically complete a hospitalization review for each hospitalized resident as part of their overall quality assurance (QA) process, which may have helped them to identify the potential delay in care; however, they had not completed it yet as R1 remained hospitalized . The facility' Change of Condition policy, dated 3/2025, identified the facility would consult with the resident and notify their physician if a significant change in status was identified. A procedure was outlined which included evaluation of the changes through observations, obtaining a set of vital signs at the onset of the change, and obtain other relevant data, as needed, for a complete evaluation. Then, if needed, notify the physician and ensure the events are recorded in the medical record. Further, the policy outlined examples of situations which required immediate physician notification or situations which could be notified to them within 8 hours. The examples of an eight (8) hour notification included abdominal pain with emesis, seizure activity, med errors (non life-threatening), increased behaviors, and respiratory changes (i.e., cough, congestion). However, the policy lacked an example of a potential GI bleed (i.e., odor with stool, black stools) under either example base.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASARR) were completed, retained in the medical record, and readily available to ensure continuity of care with mental health needs for 1 of 1 resident (R30) reviewed for PASARR. Findings include:R30's significant change Minimum Data Set (MDS) dated [DATE], indicated R30 had moderate cognitive impairment, did not have delusions, hallucinations or behaviors.R30's Clinical Diagnosis Report printed 7/23/25, indicated R30 was admitted on [DATE] and indicated diagnoses of paranoid schizophrenia (a chronic mental health disorder characterized by significant disturbances in thought, perception, and behavior, primarily marked by paranoid, delusions and hallucinations), cerebral infarction (area of damaged tissue on the brain), muscle weakness, drug induced dyskinesia (uncontrolled, involuntary muscle movement), diabetes, and hypertension.An attached Fax from Senior LinkAge Line, dated 4/5/23, included R30's Preadmission Screening (PAS) which stated Based on the information provided for this nursing home admission, it appears this consumer MEETS Level of Care for purposes of MA payment. The Fax from senior LinkAge Line also included a letter which indicated the Senior LinkAge Line forwarded the PAS to the county/manage care organization for processing. The PAS is not final until the lead agency sends documentation to the nursing facility. R30's entire medical record was reviewed and lacked evidence the facility followed up with the Senior LinkAge Line to find out if further assessment was needed.During interview on 7/22/25 at 11:03 a.m., the administrator stated when a new resident was admitted from a hospital the hospital' social workers sent the PAS screening. The facility usually received the PAS screening upon new residents' admission. In the event a new resident was admitted from home, the facility completed PAS screening. Administrator stated once a PAS screening was received, it was immediately filed on residents' medical record. The administrator reviewed R30's record and verified the medical record lacked documentation of any further assessment done by the Senior LinkAge Line or a letter to confirm R30 did not meet the requirements to be evaluated for a level II screening. Administrator stated she was not aware the facility needed to follow up and obtain a document stating whether a resident needed an OBRA Level II referral.On 7/23/25 at 1:54 p.m., the facility provided a document via e-mail. The document was titled OBRA Level I Criteria Screening for Developmental Disabilities or Mental Illness and was dated 1/11/23. This document indicated R30 had cognitive or behavioral signs that would lead someone to suspect the presence of developmental disabilities or related conditions. This document also indicated R30 had a diagnosis or symptoms of mental illness that significantly interfered with functioning in life activities or caused significant distress the past six months. In addition, the document indicated R30 needed supportive services or interventions due to mental illness to maintain functioning within the past two years, and indicated an OBRA Level II referral was needed.During interview on 7/23/25 at 8:50 a.m., administrator stated she oversaw the PAS screenings and before the interview on 7/22/25 she was not aware a follow up was necessary. Administrator stated the purpose to complete a PASSAR screening was to know the residents' level of care and services needed. A PASARR policy was requested but was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, intervention, and document review, the facility failed to develop a comprehensive care plan to ensure safety with wandering behaviors for 1 of 1 residents (R9) reviewed who had a history of wandering. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], identified R47 had severe cognitive impairment and was dependent on staff during the lookback period (LBP) to use her manual wheelchair. The MDS indicated R9 had not wandered during the LBP. R9's progress note dated:-3/24/25 at 10:14 p.m., indicated R9 had been wandering trying to find the doctor's office. -4/1/25 at 9:36 p.m., indicated R9 was often wandering down halls and 1:1 and redirection had been effective interventions. -4/2/25 at 3:25 p.m., indicated R9 was wheeling herself into other residents' rooms and attempting to push a wheelchair that was in the hallway. -4/7/25 at 3:01 p.m., indicated R9 was wheeling herself in her wheelchair around the unit and yelling at the laundry lady to come back here. The note indicated staff would continue to redirect the resident. -4/11/25 at 2:48 p.m., indicated R9 was restless and wandering that shift.-4/17/25 at 1:51 p.m., indicated R9 was very anxious and wheeling herself around the unit, asking for help leaving. -5/28/25 at 2:58 p.m., indicated R9 continued to wander up and down both the long and short hall, and staff were able to redirect the resident. -5/28/25 at 3:18 p.m., indicated R9 had been wandering and getting into other residents' rooms. R9's Wandering Risk assessment dated [DATE], indicated R9 was disoriented, forgetful/short attention span, independent with mobility with a mobility aide, had Alzheimer's disease, and was taking antipsychotics and antidepressants. The assessment indicated R9 had a known history of wandering and indicated R9 had a high risk for wandering.R9's Wandering Risk Scale dated 4/17/25, indicated R9 was able to follow instructions, could move without assistance while in the wheelchair, and had no history of wandering. The assessment indicated R9 was a low risk for wandering. R9's Wandering Risk assessment dated [DATE], indicated R9 was disoriented, did not understand surroundings or what was being said, and exhibited fear and anxiety. The assessment indicated R9 had Alzheimer's disease and was taking antipsychotics and antidepressants. The assessment indicated R9 had a known history of wandering and indicated R9 had a high risk for wandering.R9's Order Summary Report dated 7/17/25, indicated R9 was a wander risk as well as a fall risk, so red and yellow squares were placed on the outside of the door, and staff were to complete frequent checks on the resident. R9's Follow Up Question Report dated 6/23/25 to 7/22/25, indicated R9 wandered in the hallway on 7/5/25 and 7/21/25 and into other rooms/unsafe areas on 7/6/25, 7/11/25, and 7/21/25.R9's care plan was reviewed and did not include any behavioral interventions for R9 when wandering behaviors were observed. During an observation on 7/21/25 at 1:52 p.m., R9 was observed sitting in a recliner in her room with her eyes open. R9 did not respond or make eye contact to questions. During an interview on 7/22/25 at 1:20 p.m. with licensed practical nurse (LPN)-B and trained medication assistant (TMA)-A, LPN-B stated R9 was able to wheel herself around independently in her wheelchair and did have a history of wandering down the halls and into other resident rooms. LPN-B and TMA-A agreed that they had both attempted redirecting R9 and giving her an activity to do, and that had been a helpful intervention when R9 was wandering. During an interview on 7/23/25 at 9:21 a.m. with the director of nursing (DON) and assistant director of nursing (ADON), a registered nurse (RN), the ADON stated she would expect staff to redirect R9 if she were found wandering. The ADON stated she would expect R9's wandering behaviors to be care planned as soon as the behaviors started, including personalized interventions, so staff could be aware, as they did utilize agency staff. The ADON stated wandering was not a new behavior for R9, and it was kind of her baseline, so she was unsure why this had not made it on the care plan. The facility's Care Planning Policy dated 4/9/25, indicated the facility would develop a comprehensive care plan to reflect each resident's objective goals and include services that would be given to maintain the resident's highest practicable physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure a change with hearing ability was acted upon, fully evaluated and, if needed, treated or referred to the audiologist for 1 of 1 residents (R1) reviewed who complained about worsening hearing. Findings include: R1's annual Minimum Data Set (MDS), dated [DATE], identified R1 had severe cognitive impairment but demonstrated no delusional thinking. Further, the MDS recorded R1 as having, Adequate, hearing with no hearing aid use.On 7/21/25 at 1:43 p.m., R1 was observed seated in a recliner chair while in her room. R1 did not have any hearing aids or audio devices present on her at this time. R1 was interviewed and stated her hearing in the left ear had been getting worse which concerned her. R1 was asked if they'd been seen by the audiologist for this and abruptly laughed stating, I can't afford it. R1 was hard-of-hearing during the interview and would often times turn her head to the left side and respond, Say again[?], to the surveyor's questions. R1 stated she did not wear hearing aids and, again, responded, I can't afford it. R1 stated she thought staff were aware of her hearing concerns but was unsure what, if anything, was being done about it. Further, R1 stated she had her ears checked and flushed (i.e., wax removal) before, however, it was in a clinic setting prior to her admitting to the care center. R1's Nursing Summary(s), dated 10/2024 to 4/2025, were reviewed. These each contained a section labeled, A. Hearing and Hearing Aids, which had two questions to be answered by the evaluator. These identified: On 10/24/24, R1's hearing was recorded as, Adequate, and no hearing devices were used. On 1/13/25, R1's hearing was recorded as, Moderate difficulty, and no hearing devices were used. On 4/14/25, R1's hearing was recorded as, Adequate, and no hearing devices were used.On 7/15/25, R1's hearing was recorded as, Minimal difficulty, and no hearing devices were used. When interviewed on 7/22/25 at 8:56 a.m., nursing assistant (NA)-A stated they had helped R1 multiple times with various cares. NA-A stated R1 was hard-of-hearing and one ear seemed to be worse than the other adding, I'm not sure which ear it is but she is [hard-of-hearing]. NA-A stated R1 had been hard-of-hearing for awhile now and staff would, at times, have to repeat words to her for her to hear them. NA-A stated the believed the nurses were aware of R1's hearing difficulties adding, They take care of it.However, R1's medical record was reviewed and lacked evidence the potential changes in hearing ability (i.e., adequate to moderate/minimal difficulty) had been comprehensively evaluated to determine what, if any, interventions or potential treatment was needed such as irrigation, flushing, or referral to the audiologist, despite the documented changes on the completed nursing summary(s) and direct care staff being aware of R1's hearing difficulty. When interviewed on 7/22/25 at 10:28 a.m., licensed practical nurse (LPN)-A stated they had worked with R1 only a handful of times. LPN-A stated they didn't feel R1 had too much difficult with hearing but added, I tend to raise my voice a little louder [when conversing with elderly]. LPN-A stated nobody had reported concerns with R1's hearing to their recall, however, expressed any changes with hearing should be evaluated using a visual inspection to check for wax build-up and then doing treatment, if needed. LPN-A stated if an audiologist referral was needed, then family could be asked and that could be arranged. LPN-A stated this process, including evaluation and treatment, should be recorded in the progress notes.On 7/22/25 at 12:37 p.m., the assistant director of nursing (ADON) was interviewed, and verified they had an opportunity to review R1's medical record. ADON explained all residents were asked upon admission what, if any, ancillary services they wished for which included audiology and R1's family had only consented to podiatry back then. ADON stated the medical records personnel had since visited with R1's family about other services, however, it was not documented. ADON stated they were going to have the nurse working that day (7/22) go check in R1's ears and see if there was any wax build-up which could be addressed. ADON acknowledged the completed 'Nursing Summary(s)' which documented R1's potential hearing difficulties on some of them and expressed if a change was noticed, then staff should let the nurse or management know so it could be acted upon. ADON stated they were unaware the direct care staff had noticed R1 to be hard-of-hearing, too, and explained audiology was currently not one of the 'prompted' questions being asked at care conferences, either, so it could potentially be added to that and evaluated more often with residents adding, That's another opportunity to improve. ADON verified any changes with hearing should be evaluated and acted upon adding it was important for a resident's quality of life.A facility' policy on hearing evaluations and/or treatment was requested, however, none was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure recorded complaints of pain or discomfort were comprehensively assessed and, if needed, interventions developed to ensure adequate comfort for 1 of 2 residents (R12) reviewed for pain management. Findings include: R12's quarterly Minimum Data Set (MDS), dated [DATE], identified R12 had moderate cognitive impairment but demonstrated no delusional thinking. The MDS recorded R12 as consuming scheduled pain medication, but having no as-needed (i.e., PRN) medications or non-pharmacological interventions done for pain. Further, the MDS recorded R12 as, Frequently, having pain with a moderate intensity recorded. On 7/21/25 at 1:57 p.m., R12 was observed seated in her wheelchair while in her room. R12 demonstrated no obvious physical symptoms of pain at this time (i.e., grimacing, moaning), however, when interviewed she expressed having pain in her legs and knees due to a fall which happened awhile ago. R12 explained she was currently working with physical therapy (PT) but it was not doing good to help the pain and she continued to have troubles with walking. R12 described the pain as a sore and expressed aloud, It's terrible. R12 stated the staff were aware of her pain as they just add another pain pill, and another, and another, however, it remained ineffective to adequately control her pain. R12 was asked if she'd ever had ice or heat applied to her knees and abruptly responded, That don't help. R12 stated she had been using some knee patches while working with therapy and those did help some, however, she only used them when working with therapy and expressed maybe wearing those more often would help her pain.R12's care plan, dated 2/18/25, identified R12 was on pain medication and listed a goal which read, [R12] will be free of any discomfort or adverse side effects from pain medication through the review date, along with several interventions to help R12 meet this goal. The interventions included providing pain medication as ordered, allowing her to rest to facilitate relief, completing a pain flow sheet per protocol, using non-medication techniques to help relieve pain and, Review pain medication efficacy. [A]ssess whether pain intensity acceptable to resident, no treatment regimen or change in regimen required; Controlled adequately by therapeutic regimen[,] no treatment regimen or change in regimen required but continue to monitor closely . Therapeutic regimen followed, but pain control ot adequate, changes required. R12's Pain Assessment, dated 2/13/25, identified R12 was evaluated for pain using the MDS questions (i.e., Have you had pain or hurting at any time in the last 5 days?) with R12 being recorded as having no pain or hurting during the last five days.R12's most recent Pain Assessment, dated 5/11/25, identified R12 was again evaluated using the MDS questions but now R12 endorsed having pain or hurting with a recorded frequency of, Frequently. The pain was listed as not having much, if any, effect on R12's sleep but did have interference with her day-to-day activities recorded as, Occasionally. The intensity of the pain was recorded as, 2. Moderate. However, the evaluation lacked any comprehensive assessment of the pain including the pain' characteristics, history of the pain, items which worsened or improved it, or R12's goals for pain management; nor did the evaluation outlined what, if any, changes to R12's pain control regimen (i.e., medication adjustment, non-pharmacological interventions) would be considered or implemented to help reduce the pain. R12's progress note(s), dated 5/21/25 and 6/27/25, respectively, identified R12 had a care conference held where R12's pain medications were reviewed. However, on 6/27/25, a note recorded R12 as sitting on the bedside in the morning and, . complaining of knee pain and noted to be short tempered. R12 was provided her scheduled pain medications and had no further complaints recorded. R12's POC (Point of Care) Response History, dated 7/22/25, identified a look-back period of 21 days with recorded nursing assistant (NA) data asking, Resident complained of pain? This recorded the staff marking R12 as having complained of pain on 7/13/25, 7/15/25, 7/18/25, and 7/19/25.R12's Medication Administration Record (MAR), dated 7/2025, identified R12's current medications along with spacing to record their respective administration. The MAR outlined R12 had orders including:- Muscle Rub Cream 10-15% applied once daily which was ; - Tramadol (a narcotic) 25 milligrams (mg) twice a day with a, Pain Level, recorded for each administration. These levels ranged from 0 to 3 (i.e., mild) on the scale; - Tylenol 1000 mg three times daily with a, Pain Level, recorded for each administration. These levels ranged from 0 to 3 on the scale. R12's Treatment Administration Record (TAR), dated 7/2025, identified R12's current treatments along with spacing to record their respective administration. The TAR outlined ta treatment for non-pharmacological pain interventions (i.e., massage, warm pack, cold pack) along with a number to represent which intervention was done and spacing to record which was used and if it improved the pain. This identified only a single non-pharmacological intervention of, Cold Pack, as being done on 7/8/25 with the pain being recorded as improved. The TAR lacked any other recorded non-pharmacological interventions being done despite R12 having documented pain on 7/13/25, 7/15/25, 7/18/25, and 7/19/25, per the POC Response charting.When interviewed on 7/22/25 at 8:52 a.m., NA-A stated they had worked with R12 in helping with her with transfers, and expressed needed extensive assistance for many activities of daily living (ADLs). NA-A stated R12 used to complain of knee pain but they had not heard her voice complaints for awhile. NA-A stated the nurses did a muscle rub on R12 and reiterated they had not heard complaints of pain from R12 for awhile adding, Me, personally [hadn't heard any]. R12's medical record was reviewed and lacked evidence R12's pain had been comprehensively evaluated to determine what, if any, additional interventions were needed to ensure comfort for R12 despite a potential change in her reported pain (i.e., Pain Assessments) and direct care staff charting R12 as having pain. The record lacked a comprehensive assessment of the pain including the pain' characteristics, history of the pain, items which worsened or improved it, or R12's goals for pain management. When interviewed on 7/22/25 at 10:26 a.m., licensed practical nurse (LPN)-A stated they had not worked closely with R12 but were aware of her care needs. LPN-A stated they had not heard R12 complain of pain themselves but explained the Pain Assessment(s) were the only documented evaluation of pain the nurses' completed to their knowledge. LPN-A stated if a resident started complaining of pain, the staff could repeat the evaluation or place a progress note with their evaluation and implement condition monitoring on the resident. LPN-A verified the POC Response History documentation was charted by the NA staff and verified R12 had recorded pain on several dates in July 2025. LPN-A stated there was no documented comprehensive assessment in the medical record per se but expressed complaints of pain should be evaluated adding it was more a verbal process than documented process. On 7/22/25 at 12:25 p.m., the assistant director of nursing (ADON) and director of nursing (DON) were interviewed. ADON verified they had been able to review R12's medical record, and explained the 'Pain Assessment(s)' were done on admission and with the MDS' cycle thereafter. ADON stated pain was tracked and monitored using the 'Pain Level' on the MAR and TAR, too, explaining R12 had dementia and was occasionally confused or forgetful so staff could also use the Pain AD scale then (uses physical signs to equate pain levels). ADON stated the charted pain for R12 was mild in nature but expressed the assessments needed more detail and evaluation recorded adding, I would agree with your [surveyor] point. ADON added, There is room for improvement. ADON verified the only comprehensive evaluation documented within the medical record for pain was via the annual MDS if a Care Area Assessment (CAA) triggered for the person. ADON stated it was important to ensure complaints of pain were evaluated to provide good quality of life. A facility' provided Pain Management Policy and Procedure, dated 4/2025, identified a pain level of 1 to 3 was considered, Mild Pain, and listed a procedure which included each resident having an initial pain interview completed and having that reassessed on readmission, annually, quarterly and with a significant change in condition. The policy outlined, Resident experiencing pain should be treated with non-pharmacological and pharmacological methods to help relieve pain and re-evaluate for effectiveness of interventions used. The policy outlined a section on how to evaluate and record pain for severely cognitively impaired residents, which included a progress note and review of interventions, however, the policy did not outline how or what would be included in an assessment for non-severely impaired residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure a comprehensive care plan was developed, and maintained to ensure appropriate care was provided for 1 of 1 residents (R29) reviewed for dignity. Findings include: R29's significant change in status Minimum Data Set (MDS), dated [DATE], indicated R29 was admitted in 2/26/24, had intact cognition and required maximum assistance for toileting, dressing lower part of body, footwear. R7 required moderate assistance from staff for personal hygiene, dressing upper part of body, shower/bathing. MDS further identified, R7 was dependent on staff for sitting to standing and transfers. Noted for toilet transfer, resident refused. R29's MDS indicated no behaviors were present, and no rejection of care exhibited. Section V: Care Area Assessment (CAA) summary, the following care areas were triggered and marked as addressed in care plan: communication; ADL function/rehabilitation potential; urinary incontinence and indwelling catheter; psychosocial well-being; activities; nutritional status; dental care; pressure ulcer; and pain. Section 0: Special Treatments and Programs identified R29 had occupational therapy from 2/27/24 to 3/27/24 and physical therapy from 2/27/24 to 3/27/24. R29's diagnosis report, printed 6/5/24, included the following diagnoses: atrial fibrillation (irregular heart beat), mild cognitive impairment (condition in which people have more memory or thinking problems than other people their age), muscle weakness, repeated falls, weakness, cardiomyopathy (disease of heart muscle), chronic kidney disease (kidneys not filtering waste properly), hypertension (high blood pressure), pain in left leg, congestive heart failure. R29's care plan, printed on 6/5/24, had the following focus areas: - [R29] past meaningful activities to help identify her likes and experiences to better identify her likes and experiences to better care for her with a date initiated of 2/28/24 - The resident is independent for meeting emotional, intellectual, physical, and social needs with a date initiated of 3/1/24 - the resident has potential nutritional problem r/t CHF [congestive heart failure], HTN [hypertension], CKD [chronic kidney disease], elevated BMI [body mass index] with a date initiated of 3/2/24. The care plan lacked evidence of assistance needed for activities of daily (ADLs), cognitive concerns, behavioral symptoms, falls, pressure ulcers, communication, bowel and bladder, dental care, skin integrity, medication needs/monitoring, and pain, which were identified in the CAA. The care plan lacked evidence of preference and potential for future discharge. The care plan lacked evidence of rehab potential as care plan identified working with PT [physical therapy] and lacked identification of discharging from PT and occupational therapy (OT) services. During interview on 6/03/24 at 1:51 p.m., R29 stated I am here because I can't care for myself anymore. I can't change my own depends, I can't walk anymore, and I must have staff help me with all that. R29 stated, they even have to help me sit up in bed. R29 indicated throughout the interview that she prefers only female staff. On 6/04/24 at 9:52 a.m., nursing assistant (NA)-H stated if they are working with a resident that they don't currently with, they would look at the care plan and [NAME] for information needed to help care for the resident. NA-H stated they would also get information from the previous nursing assistant working, nurse working and the nursing assignment sheets. On 6/05/24 at 8:27 a.m., NA-C verified that they are familiar with R29. NA-C stated that R29 is an assist of one with transfers, uses a wheelchair for mobility, is able to pivot transfer and doesn't ambulate for more than a couple of steps. NA-C stated R29 has has made some accusations, so there need to be two in the room at all times. NA-C verified nursing assistants have access to the [NAME] which is a shorter version of the full care plan. NA-C verified R29's [NAME] did not indicate how R29 transfers, care needs, the preference for female only caregivers and the need for two staff being present. NA-C stated they would refer to the nurse and nursing assistant assignment sheet for any questions. On 6/05/24 at 8:32 a.m., NA-B verified they have worked with R29 previously but did work with her often. NA-B stated that if they are assigned to work with a resident they are not familiar with, they will refer to the [NAME], care sheet and ask the nurse any questions. On 6/05/24 at 8:39 a.m., registered nurse (RN)-A verified they are familiar with and currently work with R29. RN-A stated R29 is particular about needs and knowing her routine is the best intervention to reduce behaviors. RN-A verified R29 does have behaviors at times. RN-A verified R29 prefers only female staff and requests a check and change at night. RN-A stated the staff on the floor do not add to the care plan as the MDS coordinator does this. RN-A stated when an intervention is put in place, the MDS coordinator is notified, and it is then added to the care plan. On 6/05/24 at 8:47 a.m., MDS coordinator (MDS)-C verified they complete the MDS assessment and initiate/update the care plan for the facility. After reviewing R29's care plan, MDS-C stated, it's incomplete. MDS-C verified the only sections in the care plan are nutrition and activities. MDS-C verified a comprehensive care plan should be completed and include ADLs (activities of daily living), bowel and bladder, behaviors, medication, diagnosis, everything. MDS-C verified a care plan identified how she is taken care of, assistance she needs, care to be provided in a consistent manner, and can reduce behaviors. On 6/05/24 at 10:35 a.m., assistant director of nursing (ADON) stated a comprehensive care plan is important so that we can provide the best quality care for each individual resident. ADON verified R29's care plan was incomplete. On 6/05/24 at 1:33 p.m., administrator stated a comprehensive care plan is important so we know how to best care for our residents, know their limitations and what they need. A facility policy titled Care Planning Policy, revision date 2/16/24, was provided. The policy indicated the facility will develop an individualized plan of care that is designed to address the resident's specific problems, risk factors, and complications. Care plans are developed upon admission to the facility, and then reviewed quarterly, annually, and upon significant change in status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to implement and maintain enhanced barrier precautions (EBP) for 1 of 1 residents (R22) reviewed for transmission based precautions. Findings include: R22's quarterly Minimum Data Set (MDS) dated [DATE], indicated R22 was admitted to the facility on [DATE], had intact cognition and diagnoses of hemiplegia (paralysis) affecting right dominant side and rhabdomyolysis (condition where damaged muscle fibers leak into the blood, causing kidney and heart problems). R22's progress note (PN) dated 5/22/24, indicated R22 was sent to emergency room for urinary retention and returned to facility with a foley catheter in place. R22's physician note dated 5/30/24, documented R22 was transferred to the ER on [DATE], with symptoms of urinary retention and a catheter was placed and, Will be discharged home with a leg bag. R22's care plan (CP), physician orders (PO) and [NAME] (nursing assistant care sheet) downloaded on 6/4/24, lacked mention of a foley catheter in place and EBP precautions. During observation and interview on 6/3/24 at 2:50 p.m., R22's room was observed with EBP signage posted outside door in the hallway. Nursing assistant (NA)-A was observed to be in R22 bathroom with water running rinsing out a graduated cylinder used for foley catheter drainage. NA-A not wearing personal protective equipment (PPE) gown. NA-A left the room and R22 stated, [I] have catheter or whatever its called. R22 stated, [NA-A] did not wear a gown. During interview with NA-A at 3:01 p.m., NA-A stated there was EBP signage posted outside R22's doorway, and that R22, has catheter, and staff, supposed to wear gloves and should have had a gown on. R22 stated she, Spaced it right off just now helping him and verified she did not wear a PPE gown when emptying R22's catheter contents (urine) into graduated cylinder from bedside to the bathroom. NA-A stated, [I] totally spaced the gown and should have had one on. During interview with NA-B on 6/4/24 at 10:45 a.m., NA-B stated, anyone with an open wound, catheter and bags, we wear PPE gown and gloves. During interview with NA-C on 6/5/24 at 12:49 p.m., NA-C stated for residents with EBP signage posted on the outside of the room, we put on gown and gloves in case of spills or liquid gets on us. I put it on every time for hands on care. During interview with NA-D on 6/5/24 at 12:58 p.m., NA-D stated the expectation of EBP care is, we have gowns and gloves. We wear them when entering room and doing hands on care only like catheter cares, wounds. It is posted outside the door. Everyone with a catheter we should always wear gown and gloves when caring for them hands on. During interview with licensed practical nurse (LPN)-A on 6/4/24 at 10:30 a.m., LPN-A stated resident rooms with EBP signage posted on the outside of the room, if we go in for emptying catheter, we wear gloves and gown. During interview registered nurse (RN)-A on 6/5/24 at 12:56 p.m., RN-A stated the nursing assistants are to, ask if they have questions about any type of care they are to provide, including EBP. During interview with infection control preventionist (IP) on 6/4/24 at 1:32 p.m., IP stated she had placed R22 in EBP when he returned from the ER on [DATE], with a foley catheter. IP stated the expectation for EBP care is for staff who are providing hands on care, including catheter care, should be hand sanitizing [before entering resident room], put on gown and gloves. During interview with both IP and the assistant director of nursing (ADON) on 6/4/24 at 2:06 p.m., IP and ADON looked at R22's EMR and stated the EMR lacked mention of EBP on the orders, care plan, and [NAME], which is where it should be. Facility policy titled Friendship Manor Health Care Center Enhanced Barrier Precautions dated 3/10/2023 direct, it is with the recommendation of the CDC (Centers for Disease Control) that any resident who meets the following requirements will have EBPs initiated: -Any resident with an indwelling medical device such as a urinary catheter, port, ostomy, G tube, PICC or central line. Furthermore policy stated, At the minimum, the nurse or nursing assistant performing cares will be wearing a contact gown and gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to comprehensively assess and monitor bruises for 1 of 1 resident (R22) reviewed for non-pressure related skin conditions. Findings include: R22 was admitted to the facility on [DATE]. Diagnosis listed on the Physician Order sheet dated 5/16/23, located in the medical record included; osteoporosis (bones become week and brittle), Alzheimer's disease (a progressive disease that destroys memory and other mental functions), macular degeneration (eye disease that causes vision loss), and mood and anxiety disturbance (mental health disorder characterized by feelings of worry, and fear that interfere in ones daily activities). During observation and interview on 5/15/23 at 1:59 p.m., R22 was noted to have a large dark bluish bruise on the top of the right hand. The bruise covered the entire top of the hand. R22 indicated she was not sure how she got the bruise, and unsure if they were improving or worsening. R22's quarterly Minimum Data Set (MDS) assessment, dated 4/6/23, identified R22 as having a brief interview for mental status (BIMS) score of 8 indicating impairment in cognition. The MDS indicated R22 required extensive staff assistance with activities of daily living (ADL's). Review of the current physicians orders included a weekly skin check on bath day. Review of the current skin assessment dated [DATE], indicated the resident is at risk for skin breakdown that included bruises. No other documentation was found in the medical record, addressing R22's weekly skin checks or condition of skin since 4/16/23. R22's current care plan dated 8/20/20, identified the resident as having potential for impairment to skin integrity, related to cognitive impairment and being at risk for bruising and skin tears due to fragile skin. Interventions included; daily skin check with cares, follow facility protocols for treatment of injury, skin check weekly on bath day and document and cover arms with long sleeved shirts. Review of the progress notes, did not include any bruising over the past 2 months. During interview on 5/16/23 at 10:30 a.m., licensed practical nurse (LPN)-B indicated she had not been aware of R22's bruise on the right hand. LPN-B stated R22 is at risk for bruising and should be monitored daily. LPN-B further indicated R22 does wheel herself in the hallway and could possibly bump herself on something, but was unsure how she got the bruise or for how long she had it. During interview on 5/16/23 at 11:00 a.m., nursing assistant (NA)-A indicated he had been aware of R22's bruise on the top of the right hand for at least a week. NA-A stated R22 usually always has a bruise on her hands, but was unsure how she gets them. NA-A further indicated R22 wheels herself around in her wheelchair and could possible bump her hands, but had not witnessed. During interview on 5/17/23 at 9:15 a.m., the assistant director of nursing (ADON) indicated she had not been aware of R22's bruise on the top of the right hand. The ADON stated staff should be reporting skin concerns to the charge nurse when identified, and then monitored as well as completing a incident report. The ADON confirmed this had not been done. A policy related to non-pressure related skin concerns was requested, but not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to comprehensively assess and implement interventions for 1 of 1 resident (R1) who was at risk for pressure ulcers (PU) and currently had a pressure ulcer. Findings include: R1 was admitted to the facility on [DATE], with diagnoses identified on the active physician order sheet, dated 5/17/23, including; fracture of the vertebrae (dislocation/fracture of the backbone), muscle weakness (decreased strength in the muscles), osteoarthritis (tissue at the ends of the bone wears down) and pain in the thoracic spine. R1's admission minimum data set (MDS) dated [DATE], identified R1 as having a baseline interview for mental status (BIMS) of 12 (moderately impaired cognition). R1 required extensive assistance with activities of daily living (ADL's) that included bed mobility. The MDS identified R1 as being at risk for PU's and identified a unhealed stage 2 pressure ulcer. Review of the admission data collection form dated 4/19/23, identified R1 as having a pressure ulcer (PU) on the coccyx (tail bone). There was no documentation related to the description of the PU or interventions. Review of the current Braden scale dated 5/11/23, indicated a score of 16 meaning at risk for PU. Review of the nursing progress notes dated 4/26/23 at 2:45 a.m. and 6:23 a.m., identified R1 with a open sore on the coccyx that measures 1.2 cemtimers (cm) The note indicated there was redness on the testes and around rectum with an intervention of buttpaste (barrier cream) applied. Review of the current physicians orders dated 5/17/23, included orders for a pressure reduction cushion in wheelchair and on bed, butt paste to buttocks/coccyx every 4 hours and check skin weekly on bath days. Review of the care plan, reviewed on 5/4/23, identified R1 as having a ADL self-care deficit and potential impairment to skin integrity related to a fracture, vertebrae pain, incontinence weakness and limited physical mobility. Interventions included; reposition every 2 hours, daily skin check with cares over bony areas, follow facility protocols related to treatment of injury, document causal factors to eliminate and resolve, pressure reducing mattress and to wheelchair, weekly skin audit on bath day, weekly treatment documentation to include measurements of each skin breakdown and check and change every 2 hours for incontinence. During observation and interview with the resident on 5/16/23 at 12:30 p.m., R1 was laying in bed on his back. Nursing assistant (NA)-A turned the resident on his side, when the surveyor asked to see the residents skin condition on the coccyx. R1 was noted with a 7 inch unblanchable area of redness on the coccyx. There were no open areas noted. During interview with NA-A during this time, NA-A stated the resident did have an open area on the coccyx, but had healed about a couple of weeks ago. NA-A indicated R1's coccyx is always red and butt past is applied. NA-A further indicated R1 will reposition himself, and staff will remind him at times when he forgets. During interview on 5/16/23 at 1:30 p.m., licensed practical nurse (LPN)-B, indicated she had not been aware of R1's skin condition on the coccyx and confirmed weekly skin assessments had not been implemented. During observation on 5/17/23 at 8:15 a.m., the R1 was assisted into bed for a nap and positioned on his back. R1 was not repositioned until he was gotten up at 11:00 a.m. (2 hours 45 min). R1 remained on his back during this time. During interview with R1 at this time, R1 confirmed he had not been repositioned while in bed. R1 stated he attempts to lift his buttocks up while in bed independently, but that he is unable to do for very long. R1 further stated he prefers to lay on his back, because he has a lot of pain when moving. During interview on 5/17/23 at 9:00 a.m., the assistant director of nursing (ADON) indicated she had not been aware of the PU on the residents coccyx on admission, but stated when the PU was identified it should have been assessed and monitored weekly to prevent further breakdown. Review of the facility policy titled Pressure Injury Prevention and Managing Skin Integrity reviewed on 5/1/23, indicated the purpose of the policy is for nursing to assess and manage skin integrity for all residents and to heal pressure injuries. The procedure included; skin audit on admission and re-admission, daily skin checks during ADL's daily by the NA and weekly by a nurse, residents who are at risk for skin breakdown per risk assessment results will have pressure reduction interventions, preventive skin care treatments, education and prevention of skin breakdown for resident and medical records and MDS nurse will review and complete audits to ensure prevention and promote healing of PU's.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to comprehensively assess and develop interventions to proactively provide comfort and ensure adequate pain-relief measures were in place for 1 of 1 resident (R29) reviewed who was non-verbal and demonstrated potential physical signs of pain (i.e., teeth grinding, grimacing). Findings include: R29's significant change Minimum Data Set (MDS), dated [DATE], identified R29 had severely impaired decision-making but demonstrated no rejection of care behaviors. In addition, the MDS outlined R29 was totally dependent on staff for their activities of daily living (ADLs), consumed scheduled pain medication only, and demonstrated no indicators of pain or possible pain in the last five (5) days. Further, the Care Area Assessment (CAA) for pain did not trigger to be completed. R29's most recent Pain Interview (3.0) - V3, dated 4/21/23, identified instructions to complete the evaluation if the resident was able to communicate properly. If they were not, then the evaluation directed to, . skip to Section E. The first question on the evaluation outlined, Should Pain Assessment Interview be Conducted? This was answered by staff as, 0. No, and the remainder of the pain evaluation was left blank and not completed. R29's care plan, dated 5/15/23, identified R29 was non-verbal and consumed pain medication and listed a goal for R29 to be free of any discomfort or adverse side effects from the pain medication. The care plan listed several interventions to help R29 meet this goal, including one-to-one visits using distraction, providing analgesic medications as ordered, and completion of the Pain flow sheet per protocol. On 5/15/23 at 2:37 p.m., R29 was observed laying in bed while in their room with their jaw line visibly moving in a slight side-to-side manner. R29's eyes were closed and they did not respond to verbal interaction by the surveyor; however, R29's mouth made an audible grinding-like noise which could be heard from the doorway to the room. Later, on 5/15/23 at 3:24 p.m., R29 remained in bed but now had their eyes open but still did not respond to the surveyor' interactions. R29 continued to have audible, grinding-like noises coming from their mouth with no visible mouth guards or protectors in place. A telephone call was placed to R29's family member (FM) on 5/15/23, with a request to be called back to discuss R29's care while at the nursing home; however, a return call was never received. During subsequent observation, on 5/16/23 at 11:23 a.m., R29 was seated in a high-back wheelchair in the main dining room at the table. R29's eyes were open and, again, they had audible grinding-like noise coming from their mouth which stopped as R29 yawned, and then resumed when their mouth closed. R29 had no other physical signs of pain (i.e., grimacing), however, remained non-verbal with interaction. R29's progress note(s), dated 4/21/23 to 5/17/23, were reviewed and identified: On 5/5/23, R29 had range of motion performed and the staff recorded, . showed signs of discomfort with facial wincing . cream [muscle] was applied and wrist brace was placed back one, no signs of discomfort noted . continue to monitor. On 5/11/23, R29 had . occ[asional] teeth grinding this morning . Pain meds given as ordered, no s/s [signs or symptoms] of pain. R29's Medication Administration Record (MAR), dated 4/2023, identified R29's current physician-order medications and treatments along with their respective administration dates and/or times. This identified R29 had orders for tramadol (a non-narcotic pain medication) 25 milligrams (mg) twice a day for pain with a corresponding, Pain Level, being recorded. This identified ratings of two (2) recorded on 4/13/23 and 4/26/23. In addition, the MAR included orders for, Muscle Rub Cream 10-15%, to be applied twice a day, and Tylenol 650 mg three times daily with another corresponding, Pain Level, being recorded. This identified a rating of three (3) on 4/1/23. R29's current MAR, dated 5/2023, identified these same orders remained in place and were being administered to R29; with recorded pain levels of two (2) on 5/12/23, four (4) on 5/5/23, five (5) on 5/8/23, and two (2) on 5/12/23. Further, neither MAR outlined specific start or stop dates for these medications. When interviewed on 5/16/23 at 1:16 p.m., nursing assistant (NA)-B explained they had worked with R29 and described them as needing total help for cares. NA-B stated R29 was almost always non-verbal and would very rarely speak and, when they did, it was typically just an isolated curse word. NA-B stated they had noticed R29 to be grinding their teeth which had been happening for at least six months, and expressed it had been reviewed with R29's family and the medical provider to their knowledge. NA-B stated R29 did occasionally have physical symptoms of pain, like a grimace with care, but felt it was observed not very often but added it happened with no mobility and with R29 just kind of sitting there. NA-B stated they did not feel R29 was in significant pain, overall, and expressed they would report such concerns to the nurse if they noticed them. R29's medical record was reviewed and lacked evidence R29 had been comprehensively assessed for pain and comfort needs, or subsequent interventions and efficacy of the current medication regimen, despite having several recorded episodes of pain since 4/21/23 (the most recent pain interview) in the progress notes and MAR, and direct care staff observing signs of potential physical pain during periods of rest. On 5/17/23 at 9:03 a.m., licensed practical nurse (LPN)-C was interviewed and explained R29 consumed Tylenol and tramadol for pain, and they had a topical application of muscle rub applied to the wrist twice a day. LPN-C stated they monitored R29 for pain using the PainAD scale which is used for non-verbal persons and to record the pain levels in the MAR using the same tool. LPN-C expressed there was not a comprehensive pain evaluation in the EMR to their knowledge, rather they would start short term condition charting if they observed or witnessed an issue, including pain, with a non-verbal person. LPN-C verified R29 was not currently on such charting for pain, and they explained there had been some days they noticed R29 to grimace with range-of-motion or the application of their wrist splint; however, the pain seemed to kind of resolve after the application of the device. LPN-C reiterated there was no formal comprehensive pain assessment or evaluation, to their knowledge, in the medical record and reiterated just day-to-day charting and the condition monitoring would be used for such. On 5/17/23 at 1:08 p.m., the assistant director of nursing (ADON) was interviewed. ADON explained non-verbal residents should be evaluated for pain using the PainAD scale along with a review of progress notes, and vital signs, and this was done in a day to day manner. However, there was no formal comprehensive assessment process to review pain and the subsequent interventions; rather the MDS was the evaluation process the facility used. ADON stated if staff were seeing signs of potential pain, then pain monitoring in the MAR could be implemented and the medical provider updated to readdress the situation. ADON reviewed R29's medical record and stated there had been no adjustments to R29's consumed pain medication orders since October 2022 (seven months prior), and reiterated there was no comprehensive assessment process documented in the medical record aside from the completed MDS adding, Not to my knowledge. A provided Pain Management Policy and Procedure, dated 2/2023, identified each resident would have an initial pain interview completed upon admission and then be reassessed on readmission, annually, quarterly, and with a significant change in condition. The policy outlined pain monitoring would be completed quarterly on every shift, and such monitoring could be stated . when resident is verbally or physically showing signs and symptoms of increase [sic] pain, and the medical provider updated. Further, the policy outlined the PAINAD would be completed for residents with cognitive impairment or whom were unable to answer if having pain; however, lacked direction on what, if any, other indicators or assessment process would be completed to ensure a comprehensive evaluation of a non-verbal resident' pain symptoms and interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility consulting pharmacist failed to address the continued use of psychoactive medications for 1 of 5 residents (R19) reviewed for unnecessary medications. Findings include: R19 was admitted on [DATE]. R19's diagnoses (identified on the physician order sheet in the medical record) dated 5/16/23, included delusional disorders (mental health condition in which a person can't tell what's real from what is imagined), anxiety disorder (a mental heath disorder characterized by feelings of worry or fear in ones daily activities), cerebral infarction (disrupted blood flow to the brain) major depressive disorder ( mood disorder that causes persistent feeling of sadness or loss in daily life), epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures) and psychotic disturbance (mental disorder that cause abnormal thinking and perceptions from reality). R19's quarterly Minimum Data Set (MDS) dated [DATE], identified R19 as having a brief interview for mental status (BIMS) score of 3 (severe cognition impairment). The assessment indicated R19 received seven days of antipsychotic medications, seven days of antianxiety medications and seven days of antidepressant medications. R19 did not exhibit any mood or behaviors during the assessment period. The MDS indicated a gradual dose reduction (GDR) had not been done but a clinical contraindication had been documented for continued use. Review of the current physicians orders dated 5/16/23, included Ativan (used for anxiety) 0.5 milligrams (mg) bid (twice a day)order date 12/4/19, Celexa (used for depression) 10 mg daily, order date 4/29/21 and Zyprexa (used to treat mental disorders) 5 mg tid (three times a day), order date 4/14/12/21. Review of a consultant pharmacist medication review note dated 8/1/22, included a recommendation to the provider to evaluate continued use of the Celexa and if a dose change is not indicated at th the time to provide a clinical rationale for continued use. A comment from the provider included a rejection to the recommendation and indicated R19 exhibits persistent depressive symptoms and continue same plan and re-evaluate in 90 days. No further recommendations had been done after the 90 days and the medication did not get evaluated by the provider for the Celexa. Review of a provider progress note dated 3/5/23, included a review and justification for continued use of the Zyprexa without a GDR. The progress note did not address the Ativan or the Celexa. Review of the mood and behavior monitoring for the past 3 months did not include any exhibited behaviors on the tracking form. During interview on 5/17/23 at 1:30 p.m., the assistant director of nursing (ADON) confirmed minimal documentation of R19's target behaviors. The ADON also verified R19's Celexa and Ativan had not been addressed for continued use in the past year. During interview on 5/18/23 at 11:20 a.m., the facility contracted pharmacist confirmed he had not addressed R19's Ativan in the past year and did not follow up with the recommendation for continue use of the Celexa when the provider addressed continued use for 90 days and then evaluate. The consulting pharmacist did confirm R19 had been on Celexa and Ativan for over a year without a GDR. The consulting pharmacist also confirmed he would expect a justification from the physician annually for continued use of the medication, but he does not follow up unless it has been a year. A policy was requested, but not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure a gradual dose reduction (GDR) was attempted or an adequate medical justification for the use of psychoactive medications for 1 of 5 residents (R19) who was reviewed for unnecessary medications. Findings include: R19 was admitted on [DATE]. R19's diagnosis (identified on the physician order sheet in the medical record) dated 5/16/23, included; delusional disorders (mental health condition in which a person can't tell what's real from what is imagined), anxiety disorder (a mental heath disorder characterized by feelings of worry or fear in ones daily activities), cerebral infarction (disrupted blood flow to the brain), major depressive disorder ( mood disorder that causes persistent feeling of sadness or loss in daily life), epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures) and psychotic disturbance (mental disorder that cause abnormal thinking and perceptions from reality). R19's quarterly Minimum Data Set (MDS) dated [DATE], identified R19 as having a brief interview for mental status (BIMS) score of 3 (severe cognition impairment). The assessment indicated R19 received seven days of antipsychotic medications, seven days of antianxiety medications and seven days of antidepressant medications. R19 did not exhibit any mood or behaviors during the assessment period. The MDS indicated a gradual dose reduction (GDR) had not been done, but a clinical contraindication had been documented for continued use. Review of the current physicians orders dated 5/16/23, included Ativan (used for anxiety) 0.5 milligrams (mg) bid (twice a day)order date 12/4/19, Celexa (used for depression) 10 mg daily, order date 4/29/21 and Zyprexa (used to treat mental disorders) 5 mg tid (three times a day), order date 4/14/12/21. Review of a consultant pharmacist medication review note dated 8/1/22, included a recommendation to the provider to evaluate continued use of the Celexa, and if a dose change is not indicated at the time to provide a clinical rationale for continued use. A comment from the provider included a rejection to the recommendation and indicated R19 exhibits persistent depressive symptoms, and continue same plan and re-evaluate in 90 days. No further recommendations had been done after the 90 days and the medication did not get evaluated by the provider for the Celexa. The pharmacy consultant did not include a recommendation for Ativan. Review of a provider progress note dated 3/5/23, included a review and justification for continued use of the Zyprexa without a GDR. The progress note did not address the Ativan or the Celexa. Review of the mood and behavior tracking form for the past 3 months, did not include any exhibited target behaviors. R19's care plan reviewed on 3/1/22, identified R19 as having physical and verbal aggression that included vulgar language, hitting out at staff with cares and inappropriate sexual comments towards staff. Interventions included; administer medications and document effectiveness, allow time to express self, monitor behaviors/interventions and document when occur, engage in calm conversation, anticipate needs and intervene before agitation occurs During observation and interview on 5/17/23 from 8:30 a.m. to 10:00 a.m., R19 was sitting in the lounge calmly. R19 yelled out a swear word during this time, but was not directed towards anyone. No other behaviors were observed. During observation on 5/17/23 from 12:30 p.m. to 1:30 p.m., R19 was observed being assisted with activities of daily living (ADL's) and was cooperative and calm during this time. No other behaviors were observed. The resident was calm and cooperative throughout random observations during the survey. R19 was not able to be interviewed due to decline in cognition. During interview on 5/16/23 at 2:30 p.m., nursing assistant (NA)-A indicated R19 exhibits behaviors of physical abuse towards staff when providing cares. NA-A indicated this happens several times during the week, and the resident does not always respond to re-direction. During interview on 5/17/23 at 9:00 a.m., licensed practical nurse (LPN)-B indicated R19 exhibits behaviors of physical aggression and will hit out at staff with cares, LPN-B further indicated not all behaviors get documented like they should. During interview on 5/17/23 at 1:30 p.m., the assistant director of nursing (ADON) confirmed minimal documentation of R19's target behaviors. The ADON also verified R19's Celexa and Ativan had not been addressed for continued use in the past year. A policy was requested, but not provided .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R5's quarterly MDS, dated [DATE], identified R5 was cognitively intact, demonstrated no delusional behaviors, and required extensive assistance with personal hygiene (i.e., combing her hair, teeth brushing, washing hands and face.) In addition, the Residents Rate Report identified R5's current payer as, Medicaid. During interview on 5/15/23 at 4:15 p.m., R5 stated food at the nursing home was not good and there is a lot of food I cannot eat because I only have two teeth. I wish I could eat a steak. R5 stated the dentist had removed multiple teeth in December (2022) and, as a result, they only had a few teeth left on the bottom palate. R5 expressed they were unsure what, if any, actions to replace the teeth with dentures were in process as the nursing home staff had never offered or discussed it with them. R5 stated they wanted to seek getting dentures, if able, so they could eat a steak again. During follow-up interview, on 5/16/23 at 12:24 p.m., R5 stated last evening (dinner) and today (lunch) they ate soup for the meals as there was no options offered they would be able to chew without teeth. Review of R5's care conference dated 4/6/23, included a therapy note which indicated R5 had speech therapy three times a week, received a regular diet with thin liquids and it also indicated R5 needed minimal cues to chew thoroughly and swallow. Care conference had no documentation of R5's dental status. On 5/16/23 at 1:10 p.m., a voice mail was left for R5's family member which included call back information. However, family member did not return the call. During interview on 5/16/23 at 12:32 p.m., licensed practical nurse (LPN)-A stated R5 won't wear her teeth (dentures). LPN-A checked with medical record staff, who coordinated appointments, and LPN-A was informed R5 only had two teeth on the bottom and actually didn't have any dentures. Further, LPN-A stated all residents should go to the dentist once a year for cleaning appointments and as needed. During a follow-up interview on 5/17/23 at 7:59 a.m., LPN-A verified R5 had only a few teeth on the bottom palate, and LPN-A stated they were unaware R5 had expressed the desire to have dentures. LPN-A stated nursing should have assessed R5 dental status to help determine such. When interviewed on 5/17/23 at 7:44 a.m., registered nurse (RN)-A stated R5 lost a lot of teeth and family knew about her status. RN-A stated R5 had a choking/coughing episode while eating resulting in nursing staff obtaining an order for speech therapy. RN-A confirmed R5 had a regular diet and expressed, after R5 had her teeth removed, the nurses and family should have follow up about R5's dental status and need to get dentures. During an interview on 5/16/23 at 2:33 p.m., the assistant director of nursing (ADON) stated R5 had two teeth left on the bottom. ADON stated R5 received a regular diet with regular texture. The ADON stated she was not aware R5 had problems chewing. The ADON also stated it was a problem if R5 was not able to eat what she wanted to eat, due to lack of teeth. ADON stated the nurses should have been able to capture the fact R5 cannot chew, and they expected R5's primary nurses to contact the person in charge to set up an appointment with the dentist. ADON verified there was no follow up plan at this time for R5's dental status and getting dentures. Facility's Oral Care Management Policy dated 5/1/23, indicated facility will meet dental needs of each resident, as each resident and family allows, to ensure quality of life, adequate nutrition, and comfort. FYI: Each resident should undergo a dental evaluation, upon admission, re-admission, quarterly, yearly and with significant change. Based on observation, interview, and document review, the facility failed to ensure dental needs were comprehensively assessed and appropriately acted upon (i.e., referred to a dental provider) for 2 of 2 residents (R33, R5) reviewed who voiced dental concerns. Findings include: R33's quarterly Minimum Data Set (MDS), dated [DATE], identified R33 had moderate cognitive impairment, demonstrated no delusional behavior or rejection of care, and required extensive assistance with personal hygiene (i.e., combing hair, teeth brushing). Further, R33's Census listing, printed 5/18/23, identified R33's current payer as, Medicaid. R33's care plan, dated 3/2023, identified R33 had an activities of daily living (ADL) self-care deficit and listed several interventions for R33 including, ORAL CARE: Limit assist with oral cares, and, Oral examination per protocol and for complaints of mouth pain/discomfort by staff nurse. On 5/15/23 at 3:51 p.m., R33 was observed while seated in their wheelchair. R33 was interviewed at this time, and they expressed a desire to see a dentist as their last appointment had been over six months ago adding they wanted to go for an evaluation at least every six months. R33 stated they had never been asked about scheduling an appointment and nobody from the nursing home and addressed it, including how-to do so, with them to their recall. R33 denied issues with chewing or oral pain when asked. R33's Oral Health and Overall Health questionnaire, dated 2/2020 (over three years prior), identified residents would have an initial dental appointment within the first 90 days of admission to the nursing home, then annually as needed. This included two questions to be completed by the resident and/or family member including, I have seen a dentist in the past 6 months, which was answered, Yes, using a written X marking; and, I would like . making a dental appointment for myself within the first 90 days after admission, which was answered, No. R33's most recent Oral Health Examination - V2, dated 4/26/23, identified a section labeled, Date of Last Dental Examination, which was responded, Unknown. The evaluation outlined R33 had their own teeth along with, Obvious or likely cavity or broken natural teeth. A section was provided labeled, FOLLOW UP ACTION, which had several options to demonstrate what, if any, actions or interventions would be taken. This was answered with a soft regular toothbrush, fluoride toothpaste, and mouth wash would be used. The option for a dental examination referral was left unchecked. Further, the evaluation lacked evidence R33 had been asked or queried on the need or desire for a dental examination despite being recorded with broken teeth and/or likely cavities on the evaluation. When interviewed on 5/16/23 at 1:20 p.m., nursing assistant (NA)-B stated they had worked with R33 and described them as needing extensive assistance with many personal cares. NA-B explained R33 would often want or attempt to do oral care themselves, however, would usually miss several teeth or areas of the mouth without guidance and oversight. NA-B stated R33 had their own teeth and several were missing from the bottom palate adding, [R33] does complain occasionally about [their] teeth, with repeated cold sensitivity comments. NA-B stated they last heard these complaints or comments several weeks prior and the nurse was aware. Further, NA-B stated they believed R33 had been to the dentist at some point in the last calendar year, but were unsure and directed the surveyor to the medical records personnel for more information. On 5/17/23 at 8:12 a.m., the medical records coordinator (MRC) was interviewed, and they verified there were no current dental appointments set-up for R33. MRC explained R33 was listed on the refusal list, and explained the listing was developed when someone admitted and completed the Oral Health and Overall Health questionnaire on seeing a dentist within the first 90 days of admission. MRC then tried to offer an examination on an annual basis thereafter and, if they refused again, the person remained on the refusal list. MRC stated they could not recall asking R33 or their family about a subsequent dental appointment after admission and added, [R33] probably hasn't gone. MRC stated they tried to send a Plan of Care Refusal Form to family annually, however, were a little behind, and there was no evidence R33 had ever been sent or offered once since admission in 2020. Further, MRC stated they had not been asked or told by nursing to make an appointment for R33 in the recent months. R33's medical record was reviewed and lacked evidence R33 had been offered or referred to a dental provider since 2020 when they admitted ; despite R33 being assessed on 4/21/23 as having obvious broken teeth or cavities, and direct care staff having knowledge R33 had been complaining about teeth cold sensitivity for an extended period of time. On 5/17/23 at 12:59 p.m., the assistant director of nursing (ADON) was interviewed, and they verified they had reviewed the medical record. ADON explained the spoke with MRC and they were, right then, following up with the family to determine if a dental appointment was needed or wanted. ADON acknowledged R33's medical record lacked evidence a dental appointment had been offered or completed since their admission several years prior. ADON expressed they were unaware R33 had been reporting cold sensitivity with their teeth, and stated the nurses' should be asking if a dental appointment was desired when they completed the Oral Health Examination (dated 4/26/23); however, it was not asked or offered to their knowledge. ADON stated they would be revising the examination form to ensure such information was asked and not overlooked in the future. Further, ADON stated it was important to ensure dental appointments were offered and completed, including with new complaints of pain or cold sensitivity, to promote the quality of life for the resident. ADON added, The ball was dropped.