**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, record review, and facility policy review, the facility failed to honor a resident's expressed preference for care and provide services in a manner that maintained and promoted dignity. This failure resulted in Resident #1 not receiving care as requested, leaving her wet and uncomfortable, for one (1) of four (4) residents reviewed for dignity concerns (Resident #1).Findings include: Review of the facility policy titled, “Resident Rights,” last revised November 28, 2016, revealed: “(a) The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. … (1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident’s individuality. … The facility must protect and promote the rights of the residents . An interview with Resident #1 on 8/19/25 at 3:35 PM revealed that on the night of 6/23/25, she requested that Certified Nurse Assistant (CNA) #1 clean her back with a washcloth. She stated CNA #1 refused and attempted to use cleansing wipes instead. Resident #1 stated she told CNA #1 to leave if she would not do it the way she asked. She further stated that Licensed Practical Nurse (LPN) #1 came into her room and told her that if she did not allow CNA #1 to change her, she would have to wait until staff were finished with other residents. An interview with CNA #1 on 8/19/25 at 5:23 PM she stated that the night of 6/23/25 Resident #1 asked her to clean her back with a warm wet washcloth, but what she had on hand was wet wipes. CNA #1 stated she did not think at the time of just going get a washcloth as the resident asked and confirmed there were washcloths on the linen cart. Review of a Resident Investigation Report Form related to Resident #1 revealed an Interview Summary dated 6/24/25 conducted by the Administrator. CNA #1 stated: “I went in to dry her, and while I had the resident turned over on her side, she asked me to rinse her back off with a washcloth because they had left soap on her during her bath that day. I explained to Resident #1 I had wipes with me, so I wiped her back with a wipe and then started to change her. Resident #1 stated, ‘Well, they did not get all the soap off of me.’ I told her again that I had cleansing wipes with me but did not have a washcloth at the time.” Further review of the same Resident Investigation Report Form revealed an Interview Summary dated 6/26/25 conducted by the Director of Nursing. LPN #1 stated CNA #1 reported Resident #1 was refusing care because she had been cleaned with wipes instead of a washcloth. LPN #1 stated she told the resident it was her right to refuse, but if she did not allow staff to finish, “she would have to lay there wet until the staff finished with the other residents, and that could be a while.” In an interview with the Administrator on 8/19/25 at 6:34 PM, she confirmed the incident was a dignity concern. She stated CNA #1 should have provided care using a washcloth as the resident requested. She acknowledged that failing to do so could have made the resident feel her voice was not heard. Record review of the “admission Record” revealed Resident #1 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease. Record review of the Quarterly Minimum Data Set (MDS) for Resident #1 with an Assessment Reference Date (ARD) of 6/26/25 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident was moderately cognitively impaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and facility policy review, the facility failed to ensure allegations of abuse/neglect were reported to the State Agency within the required timeframe for one (1) of three (3) residents reviewed for reporting. (Resident #1) Findings include: Review of the facility policy titled, “Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Policy,” dated January 2019, revealed: “…7. Reporting/Response: …Immediately reporting all alleged violations to the …state agency, adult protective services and to all other required agencies within specified timeframes…” A phone interview with the Ombudsman on 8/19/25 at 10:00 AM revealed that she was at the facility on 6/24/25 when Resident #1 made allegations of verbal abuse and neglect involving a Certified Nurse Assistant (CNA) #1 and Licensed Practical Nurse (LPN) #1. The Ombudsman stated she immediately reported the allegations to the Administrator. She further stated that when she followed up with the Administrator on 7/8/25, she discovered the allegation had not been reported to the State Agency and subsequently reported it herself. During an interview with the Administrator on 8/19/25 at 4:39 PM, she confirmed the Ombudsman informed her on 6/24/25 of Resident #1’s allegations of verbal abuse and neglect. She acknowledged she did not notify the State Agency within the required timeframe and confirmed she should have. She stated the importance of reporting is that it is part of the investigation process and serves to keep residents safe. Review of the Investigation Report for Resident #1 revealed: “Date of Incident: 6/23/25. Date Incident Reported: 6/24/25 Ombudsman asked facility to investigate.” … Results reported to State Licensing Agency: 7/8/25. Review of the “admission Record” revealed Resident #1 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure call lights and frequently used items were maintained within residents' reach for three (3) of four (4) residents observed (Residents #1, #2, and #3).Findings include: Review of the facility policy titled, “Call Light, Use Of,” last revised August 2014, revealed: “ .Procedure: When providing care to residents be sure to position the call light conveniently for the resident to use . Resident #1During an observation and interview with Resident #1 on 8/19/25 at 3:35 PM, she stated that on the evening of 6/23/25 her call light and phone were not within her reach. She explained that her call light was often on the floor and her phone was also on the floor, leaving her unable to call for assistance when she needed help. An observation revealed Resident #1’s call light lying on the floor under the bed, with no clip observed on the cord to keep it accessible. An observation of Resident #1’s room on 8/19/25 at 5:30 PM with Certified Nurse Assistant (CNA) #1 confirmed the call light was not in reach and was located on the floor under the bed. Review of the “admission Record” revealed Resident #1 was admitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease. Review of the Quarterly Minimum Data Set (MDS) for Resident #1 with an Assessment Reference Date (ARD ) of 6/26/25 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident was moderately cognitively impaired. Resident #2An observation of Resident #2 on 8/19/25 at 3:32 PM revealed she needed to be changed. When asked if she called for someone to help her, she stated she could not reach her call light. She was observed attempting to reach the call light, which was attached to the top of the upper side rail, and not accessible. An observation of Resident #2 on 8/19/25 at 4:34 PM with CNA #2 confirmed the resident’s call light was not in reach. CNA #2 stated that concerns with call lights being out of reach include residents missing needed care. Review of the “admission Record” revealed Resident #2 was admitted on [DATE] with a diagnosis of bilateral primary osteoarthritis of first carpometacarpal joints. Review of the Quarterly MDS for Resident #2 dated 7/17/25, Section C, revealed a BIMS score of 12, indicating the resident was moderately cognitively impaired. Resident #3An observation of Resident #3 on 8/19/25 at 3:48 PM revealed the resident’s call light lying on his nightstand across the room. During an interview, he stated he could not reach his call light. He explained that if he needed it, he would either climb across the bed or get in his wheelchair and roll out to the hallway for help but stated “that was hard to do.” An observation of Resident #3 on 8/19/25 at 5:36 PM with CNA #1 confirmed the call light was across the room and out of the resident’s reach. She stated concerns included the resident being unable to call for help, attempting to get the call light and risking a fall, or having unmet needs. Review of the “admission Record” revealed Resident #3 was admitted on [DATE] with a diagnosis of cerebral infarction. Review of the Quarterly MDS for Resident #3 dated 6/24/25, Section C, revealed a BIMS score of 15, indicating the resident was cognitively intact. An interview with Licensed Practical Nurse (LPN) #2 on 8/19/25 at 5:37 PM revealed if a resident’s call light was not in reach and the resident experienced a medical emergency, they would not be able to call for help. An interview with the Administrator on 8/19/25 at 6:34 PM confirmed that frequently used items such as call lights and phones should always be within residents’ reach. She stated concerns with items being out of reach, included residents being unable to call staff if needed, potentially delaying care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interviews, record review, and facility policy review, the facility failed to consult with a cognitively intact resident about his Advance Directives, which resulted in a conflict between his documented preferences and his actual wishes for one (1) of sixteen (16) residents reviewed. Resident #6. Findings Included: Record review of the facility policy with reviewed date of 11/2022 and titled, Advance Directives revealed The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so 5. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative An interview on [DATE] at 10:50 AM, with Resident #6 revealed that his brother signed the admission paperwork. He revealed that he didn't remember anyone discussing Cardiopulmonary Resuscitation (CPR) with him or asking him what his wishes were regarding resuscitation if he stopped breathing. Resident #6 confirmed that he did not know that his brother signed for him to be a DNR (Do Not Resuscitate). He confirmed that if he quit breathing, he wanted them to do CPR and everything they could to save him. An interview on [DATE] at 8:40 AM, with the Social Services Director (SSD) stated that Resident #6's representative signed the Code Status form marked DNR at the time of admission and confirmed that she did not discuss CPR options with Resident #6. The SSD revealed that Resident #6 was cognitively intact and should have been asked about his wishes. He should have made the choice and signed his own Advanced Directive. An interview on [DATE] at 8:45 AM, with the Administrator (ADM) confirmed that they were supposed to ask the residents about their code status choice and get them to sign if they were cognitively intact. She confirmed that Resident #6 was cognitively intact and capable of making his own decisions. ADM revealed that Resident #6 should have been asked about this choice and should have signed his own advanced directive on admission. Record review of Resident #6's Code Status form revealed that his representative initialed the Do Not Attempt Resuscitation choice and signed it on [DATE]. Record review of Resident #6's Physician Orders revealed an order effective [DATE] which revealed, Do Not Resuscitate in case of Arrest Record review of Resident #6's admission Record revealed an admission date of [DATE] with diagnoses that included Syncope and Collapse, End Stage Renal Disease, and Anemia. Record review of Resident #6's Care Plan revealed I am a DNR (Do Not Resuscitate) Record review of Resident #6's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] under Section C revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated that he was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy review, the facility failed to provide written notification of discharge/transfer to the resident and/or resident representative (RR) upon transfer to the hospital for two (2) of two (2) residents reviewed for hospitalization. Resident #15 and Resident #30. Findings include: Review of the facility policy titled Notice of a Transfer and/or Discharge dated February 26, 2003, revealed .3. The resident, and/or representative (sponsor) will be provided with the following information: a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged . Resident #15 Record review of Resident #15's Progress Notes dated 8/2/24 revealed the resident was transported to the emergency room accompanied by two facility staff members. Record review revealed there was no transfer/discharge notification for Resident #15's transfer to the emergency room on 8/2/24. Record review of Resident #15's admission Record revealed that he was admitted to the facility on [DATE] with diagnoses that included a Personal History of Traumatic Brain Injury, and Hydrocephalus. Resident #30 Record review of the Progress Notes for Resident #30 revealed on 8/6/24 that the resident was transferred to the Emergency Room. Record review revealed there was no transfer/discharge notification for Resident #30's transfer to the emergency room on 8/6/24. On 10/29/24 at 11:37 AM, an interview with the Administrator (ADM) revealed that the facility failed to mail a written transfer/discharge notification to the Resident Representative (RR) for both Resident #15 and Resident #30 when they were transferred to the hospital. An interview on 10/29/24 at 3:00 PM, the Social Services Director (SSD) confirmed she was unaware that a copy of the transfer/discharge notification was supposed to be mailed to the Resident's RRs, but she would make sure to get them sent out from now on. Record review of the admission Record revealed the facility admitted Resident #30 on 07/25/24 with medical diagnoses that included Aphasia and Metabolic Encephalopathy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review, and facility policy review the facility failed to implement a comprehensive care plan for residents who required assistance with Activities of Daily Living (ADL) for two (2) of thirteen sampled residents. Resident #3 and Resident #4. Findings include: Review of the facility policy titled Care Plan - Comprehensive undated, revealed, Policy Statement: It is the policy of this facility to develop comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs .Procedure: 1. An interdisciplinary team, in coordination with the resident and his/her family or representative, develops and maintains a comprehensive care plan for each resident. Resident #3 A record review of Resident #3's care plan revealed, I have an ADL self-care performance deficit .Interventions/Tasks . Please shave when needed per my request . Check nail length and trim and clean on bath day and as necessary. On 10/28/24 at 10:50 AM, observation of Resident #3 revealed sporadic facial hair approximately one-half (1/2) inch long to the chin and above the upper lip and sides of her mouth. Fingernails on bilateral hands were approximately one-fourth (1/4) inch long and jagged past the tips of her fingers with a brown substance under the fingernails. On 10/28/24 at 4:40 PM, an interview and observation Registered Nurse (RN) #1 confirmed Resident #3's facial hair needed to be shaved, and her fingernails needed to be cleaned and filed. She confirmed the resident's ADL care plan was not being followed, and it should have been. In an interview on 10/29/24 at 10:10 AM, the Director of Nurses (DON) confirmed that Resident #3's ADL care plan was not being followed, and it should have been. During an interview on 10/30/24 at 11:46 AM, the Minimum Data Set (MDS) Coordinator revealed she and the team are responsible for developing the resident's individualized person-centered care plan. She revealed that when the residents were not being shaven and their nails cleaned and trimmed, then their ADL care plan was not being followed. She also revealed that everyone wants to look nice and neat, and the facility is responsible for ensuring this is being done. Record review of Resident #3's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Chronic Obstructive Pulmonary Disease, Osteoporosis with current pathological fracture, and Paroxysmal Atrial fibrillation. Resident #4 Record review of Resident #4's Care Plan revealed that she had an ADL self-care performance deficit with interventions that included checking nail length and trim and clean on bath day and as necessary. On 10/28/24 at 10:45 AM, observation and interview revealed Resident #4 lying in bed with long, jagged fingernails approximately one-half inch long past the tips of her fingers bilaterally with a brown substance underneath. Resident #4 also had two dime size patches of white curly hair on her left and right lower jaw area. On 10/28/24 at 4:35 PM, observation and interview with RN #1 confirmed that Resident #4's fingernails were long and jagged with a brown substance underneath and that she had facial hair. RN #1 revealed that nail care, shaving and oral care were all included in personal hygiene provided in the Care Plan and confirmed that since it was not done, then they did not follow the care plan. Record review of Resident #4's admission Record revealed an original admission date of 09/28/23 and diagnoses that included Peripheral Vascular Disease and Muscle Weakness. Record review of Resident #4's MDS with Assessment Reference Date (ARD) of 10/10/24 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 03 which indicated that she had severe cognitive deficits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident/family and staff interviews, record review, and facility policy review, the facility failed to provide care to maintain hygiene, as evidenced by the failure to provide shaving and nail care for two (2) of the 27 residents reviewed. Resident #3 and Resident #4. Findings include: Review of the facility policy titled Shaving the Resident, with a revised date of August 25, 2014, revealed, The purpose of this procedure is to promote cleanliness and to provide skin care. Review of the facility policy titled A.M. Care (Day Tour of Duty) dated August 25, 2014, revealed Purpose: 1. To refresh the resident. 2. To provide cleanliness, comfort, and neatness. Resident #3 An observation of Resident #3 on 10/28/24 at 10:50 AM, revealed sporadic facial hair approximately one-half (1/2) inch long to the chin and above the upper lip and sides of her mouth. Fingernails on bilateral hands were approximately one-fourth (1/4) inch long and jagged past the tips of her fingers with a brown substance under the fingernails. During an observation and interview on 10/28/24 at 3:35 PM, Resident #3 was lying in bed with no change in appearance. Resident #3's sister was present in the room and revealed that she was sure her sister would like to have those facial hairs removed. An interview and observation on 10/28/24 at 4:20 PM, with the Certified Nurse Aide (CNA) #2 revealed hospice bathes the resident three days a week and the facility CNAs are responsible for the other days. She confirmed the resident's facial hair should have been shaven and her nails cleaned. In an interview and observation on 10/28/24 at 4:30 PM, with Licensed Practical Nurse (LPN) #1 revealed we've talked to the hospice staff several times about ensuring Resident #3's facial hair is shaved when they bathe her. She confirmed that the resident had long facial hair and her fingernails were jagged with a brown substance under them. She revealed that she was unsure how long it had been since the resident's facial hair had been shaved and stated, The resident needs to be cleaned up. In an interview and observation on 10/28/24 at 4:40 PM, Registered Nurse (RN) #1 revealed we are all responsible for making sure the resident is properly groomed; even though she is on hospice services. She stated they are ultimately responsible for ensuring the resident's facial hair is shaved, and her fingernails are clean and trimmed. RN #1 confirmed Resident #3's facial hair needed to be shaved, and her fingernails needed to be cleaned and filed. Record review of Resident #3's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Chronic Obstructive Pulmonary Disease, Osteoporosis with current pathological fracture, and Paroxysmal Atrial Fibrillation. Resident #4 An observation and interview on 10/28/24 at 10:45 AM, revealed Resident #4 lying in her bed with long, jagged fingernails, approximately one-half inch long past the fingertips bilaterally with brown substance underneath. Resident #4 also had two dime size patches of white curly hair on her left and right lower jaw area. She was pleasant and was fidgeting with her hair bonnet she held in her hands and when she was asked if she would like to have her facial hair removed, she stated, I think I would. An observation and interview with CNA #1 on 10/28/24 at 4:25 PM, revealed Resident #4 sitting up in her wheelchair across from the nurse's desk. CNA #1 confirmed that Resident #4 had long jagged fingernails with a brown substance underneath. CNA #1 also confirmed that Resident #4 had facial hair on both sides of her face that needed to be removed. CNA #1 revealed that it was the nurses' job to cut the fingernails, and the CNAs cleaned out from under the nails and took care of the facial hair. She revealed that Resident #4 was not assigned to her, but her nails should have been cleaned and her facial hair should have been removed during her bath or shower. CNA #1 revealed that long, jagged, dirty fingernails could cause infection if she scratched herself and stated, We can get that facial hair off. An interview on 10/28/24 at 4:35 PM with RN#1, confirmed that the nurses clipped resident fingernails, and the CNAs cleaned fingernails and shaved residents during their bath or shower time. RN #1 confirmed Resident #4 had long, jagged fingernails with a brown substance underneath and they should have been taken care of. She also confirmed the two patches of facial hair on both sides of Resident #4's face and agreed that this needed to be shaved. A phone interview with Resident #4's Resident Representative (RR) on 10/29/24 at 9:23 AM, revealed that he came to the facility and visited often. He revealed that the facility needed to do better about keeping her nails clipped. He also stated that he had noticed some facial hair and that she would want it to be removed. An interview on 10/29/24 at 10:20 AM, with the Director of Nursing (DON), revealed that seeing facial hair on ladies was one of her pet peeves and agreed that facial hair on ladies should be removed. She also confirmed that resident fingernails should be clipped and kept clean. Record review of Resident #4's admission Record revealed an original admission date of 09/28/23 and diagnoses that included Peripheral Vascular Disease and Muscle Weakness,. Record review of Resident #4's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/10/24 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 03 which indicated that she had severe cognitive deficits. Section GG revealed that she required substantial to maximal assistance with her personal hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #4 Record review of Physician Orders documented order for Resident #4 dated [DATE] for DNR and signed by physician. Record review of Resident #4's Scanned Electronic Medical Records revealed that there was no signed consent for DNR (Do Not Resuscitate) status or Advanced Directive. An interview with the Administrator on [DATE] at 8:18 AM, revealed the facility failed to have a signed code status or advance directive for Resident #4 to indicate the resident's or the resident representative's wishes for end of life care. She stated the facility had been in the process of developing a new form that would be consistent throughout the facility, but they realized several residents did not have a signed consent to indicate the resident's or the representative's wishes, only the electronic order and the signed physician order. She confirmed the residents' and the representatives' wishes needed to be honored and the code status needed to be discussed and verified by a signed consent to ensure proper care was given. Record review of Resident #4's admission Record documented admission Date of [DATE] with the following diagnoses to include: Peripheral Vascular Disease, Cognitive Communication Deficit, Gout, Benign Neoplasm of Unspecified Adrenal Gland, and History of Falling. Record review of the MDS with an ARD of [DATE] revealed Resident #4 had a BIMS score of 03 indicating the resident was severely cognitively impaired. Based on staff interviews, record review, and facility policy review, the facility failed to have an informed consent for code status signed for two (2) of 16 sampled residents reviewed. Resident #3 and Resident #4 Findings include: Record review of facility policy titled, Advance Directives, dated 11/22, revealed, The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. The policy also revealed, Do Not Resuscitate (DNR) - indicates that, in case of respiratory or cardiac failure, the resident or legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used. Resident #3 Record review of Resident #3's electronic Order Summary Report revealed an order dated [DATE] for DNR. Record review of Resident #3's handwritten Physician Orders dated [DATE], revealed an order for DNR. Record review of Resident #3's medical records revealed there was no signed consent by Resident #3 or Resident #3's Resident Representative that indicated the ordered DNR status was consented to. An interview with the Administrator on [DATE] at 8:15 AM, revealed the facility failed to have a signed code status or advance directive for Resident #3 to indicate the resident's or the resident representative's wishes for end-of-life care. She stated the facility had been in the process of developing a new form that would be consistent throughout the facility, but they realized several residents did not have a signed consent to indicate the resident's or the representative's wishes, only the electronic order and the signed physician order. She confirmed the residents' and the representatives' wishes needed to be honored and the code status needed to be discussed and verified by a signed consent to ensure proper care was given. An interview with the Social Services Coordinator on [DATE] at 3:05 PM, revealed she was responsible for having the advance directive and/or code status filled out on admission, as well as reviewing during each care plan meeting. She confirmed that Resident #3's code status form just slipped through the cracks, and therefore, it was not done. She confirmed the facility failed to have a consent signed to ensure the resident and family wishes were honored. Record review of Resident #3's admission Record revealed the resident was originally admitted to the facility on [DATE] and the most recent admission was [DATE]. Resident #3's diagnoses included Chronic Obstructive Pulmonary Disease, Cognitive Communication Deficit, Hypertension, and Paroxysmal Atrial Fibrillation. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] indicated a Brief Interview for Mental Status (BIMS) of 0, which indicated the resident was severely cognitively impaired.

Based on staff interview, record review, and Resident Assessment Instrument (RAI) review, the facility failed to ensure that Minimum Data Set (MDS) was coded accurately for one (1) of 16 sampled residents. Resident #4. Findings Include: Record review of typed statement on company letterhead documented: The facility utilizes the MDS 3.0 Resident Assessment Instrument (RAI) Manual as the guide to complete the MDS. This document was signed by the Administrator but not dated. Record review of Resident Assessment Instrument (RAI) Version 3.0 Manual on page J-38 was documented under revealed, Coding Instructions for J1900C, Major Injury Code 0, none: if the resident had no major injurious fall since admission/entry or reentry or prior assessment Code 1, one: if the resident had one major injurious fall since admission/entry or reentry or prior assessment Record review of Resident #4's MDS with Assessment Reference Date (ARD) of 11/03/2023 Section J1900 question relating to number of falls since admission entry was answered 1 under B. Injury (except major). Under C. Major Injury, which included bone fractures was answered 0 which indicated that resident had no fall with a major injury. On 12/13/23 at 9:54 AM, an interview with Registered Nurse (RN) #1, revealed that Resident #4 had a fall on 09/17/23 and was sent out to the emergency room (ER) with fractured ribs. On 12/13/23 at 9:40 AM, an interview with MDS Coordinator revealed that she was aware of Resident #4's fall in September, and she was also aware the resident had a major injury from the fall. The MDS Coordinator revealed that she and the Administrator had discussed the fall with the injury. She revealed that when she did the MDS assessment in November, she mistakenly entered the fall as a fall with injury and not as a fall with a major injury. She stated that this was a mistake on her part when entering the information into the MDS system. She confirmed she would make a modification to ensure the entered information was accurate. On 12/13/23 at 9:42 AM, an interview with the Administrator (ADM) revealed she was aware of the fall with a major injury, and this was discussed with the MDS coordinator as well during the stand-up morning meetings. ADM confirmed the facility failed to accurately enter the information into the system and the information entered should be accurate since it reflects the resident's condition. Record review of Resident #4's After Visit Summary report from the hospital dated 09/18/2023 documented under Narrative .Impression: Minimally displaced left posterior ninth and 10th rib fractures. Record review of Resident #4's admission Record documented admission date of 09/28/2022 with the following diagnoses to include: Peripheral Vascular Disease, Cognitive Communication Deficit, and History of Falling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy review, the facility failed to ensure that an as-needed (prn) psychotropic drug was limited to14 days for one (1) of six (6) residents reviewed for psychotropic medication use. Resident #9 A review of the facility policy titled Psychotropic Medications, dated 02/15/2018, revealed, PRN psychotropic medications will have a 14-day period of administration time. If the prescribing MD/NP orders to continue the medication beyond 14 days, the MD/NP will document rationale and the duration for the medication in the clinical record. Record review of Resident #9's Order Summary Report for Order Date Range: 06/01/2022-08/31/2022 page 3, revealed an order for Lorazepam Concentrate 2 MG/ML Give 0.5 ml by mouth every 4 hours as needed for restlessness and anxiety. Order start date 06/13/2022, and no end date. Record review of Resident #9's Order Summary Report for Order Date Range: 06/01/2022-08/31/2022 page 3, revealed an order for Lorazepam Concentrate 2 MG/ML Give 0.5 ml by mouth every 4 hours as needed for restlessness and anxiety for 4 weeks. Start date 07/25/2022 and end date 08/22/2022. Record review of consultant pharmacist communication to the physician dated 06/29/22 revealed to continue therapy for 4 weeks then discontinue. No rationale by the physician was noted as to why the medication exceeded the 14 day duration. An interview on 09/22/22 at 12:12 PM with the Medical Records nurse confirmed that the PRN psychotropic medication written on 06/13/22 did not have an end date. An interview on 09/22/22 at 12:37 PM with the Pharmacy consultant confirmed the PRN psychotropic medication must be re-evaluated every 14 days unless the clinician determines that it is needed, and the physician must write a rationale to continue it beyond the 14 day requirement. He revealed that he gave the recommendation to either discontinue the Ativan (Lorazepam) or continue medication therapy and that he leaves the number of weeks or days blank for the Physician to fill in. He revealed that the pharmacy recommendation form dated 06/29/22 had a blank for the week or days to be specified by the Physician but that the physician filling out the form left that area blank. An interview on 09/21/22 at 10:15 AM, with the Director of Nurses (DON) revealed any resident that is on a psychotropic as-needed (PRN) is supposed to be on the medication for fourteen (14) days and then re-evaluated by the physician to continue the medication. An interview on 09/22/22 at 12:48 PM with the DON confirmed the Consultant Pharmacist's communication to the Physician dated 06/29/22 with the recommendation to continue PRN Ativan for four weeks does not have a rationale from the physician and there should be. An interview on 09/22/22 at 12:20 PM, with Resident #9's Attending physician revealed we try not to do any PRN psychotropic medications and the order for the medication came from the hospice doctor, but I do co-sign everything. He revealed the resident, has been agitated ever since she came into the facility. She went on hospice a while back and all her medications were discontinued except for comfort medications from hospice. He confirmed the medication is supposed to be for 14 days and then the resident can be re-evaluated for further usage. He confirmed the PRN Ativan did not have an end date on it when the order was written for hospice. He revealed that he told the DON today to make the Ativan a scheduled medication because the resident is requiring it more. Record review of Resident #9's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses that included, Alzheimer's disease, dementia with behavioral disturbance, anxiety disorder, other specified depressive episodes, and brief psychotic disorder. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of June 24, 2022, revealed Resident #9 is rarely/never understood indicating resident is Severely impaired.