Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good grooming and personal hygiene for one (1) of eighteen (18) sampled residents, Resident #34. Findings include: A review of the facility's policy titled Resident Rights, undated, revealed, . Residents' rights, policies, and procedures shall insure that each resident admitted to the center . 9. Is treated with consideration, respect, and full recognition of his dignity and individuality, . in care of his personal needs . On 6/30/25 at 10:55 AM, Resident #34 was observed to have noticeable long, white hairs on her chin. During the initial interview, she shared that she would like them shaved but mentioned it had not been done in quite some time. On 7/1/25 at 11:01 AM, in a follow-up observation and interview, Resident #34 still had long gray hair on her chin. The resident expressed that she wished to have it removed and shared that her Certified Nurse Aide (CNA) had not offered to assist with grooming during the earlier care visit. On 7/1/25 at 11:19 AM, during an interview with CNA #1, she confirmed she was currently assigned to Resident #34 and acknowledged seeing the gray hair on the resident's chin. She stated she would return to take care of it. CNA #1 explained that when helping female residents with their ADLs, it is important to include trimming facial hair to help maintain their dignity. On 7/1/25 at 1:46 PM, during an interview with the Director of Nursing (DON), she stated it is the CNA's responsibility to trim their assigned residents' facial hair when providing ADL care. She added that when CNA #1 saw Resident #34 had hair on her face, she should have trimmed it immediately. A record review of Resident #34's admission Record revealed the facility admitted her on 7/25/23 with diagnoses including Muscle Weakness and Unspecified Lack of Coordination. A record review of Resident #34's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/8/25 revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident's cognition was moderately impaired.

Based on interview, record review, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) to reflect residents' assessments for anticoagulant and hypnotic medications for six (6) of eighteen (18) MDS assessments reviewed, Resident #5, Resident #14, Resident #21, Resident #38, Resident #44, and Resident #53. Findings included: A review of the facility's policy titled MDS Assessments, dated 5/2006, revealed, . It is the policy of this facility to follow the RAI (Resident Assessment Instrument) process as set forth by CMS (Centers for Medicare and Medicaid Services) protocol . The facility will follow direction per federal and state guidelines for resident assessment protocol and will refer to the MDS RAI manual. A review of the RAI Manual 3.0 Version 1.19.1, dated October 2024, revealed, . N0415: High-Risk Drug Classes: . N0415D1. Hypnotic: Check if a hypnotic medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) . N0415D2. Hypnotic: Check if there is an indication noted for all hypnotic medications taken by the resident any time during the observation period . N0415E1. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken . N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g., aspirin/extended release, dipyridamole, clopidogrel) was taken by the resident at any time during the 7-day observation period (or since admission/entry or reentry if less than 7 days) . Do not code antiplatelet medications such as aspirin . A record review of the Drugs.com package insert for Temazepam (Restoril), updated 3/19/25, revealed the drug classification is Benzodiazepines and indicated that Temazepam is a benzodiazepine hypnotic agent . A record review of the Drugs.com package insert for clopidogrel bisulfa (Plavix), updated 6/12/25, revealed the drug classification is Platelet aggregation inhibitors . A record review of the Drugs.com package insert for aspirin, updated 3/1/24, revealed the drug classification is Platelet aggregation inhibitors . Resident #5 A record review of Resident #5's admission Record revealed the facility admitted the resident on 4/26/22 with diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction. A record review of Resident #5's Quarterly MDS with an Assessment Reference Date (ARD) of 6/5/25 revealed Section N0415 indicated the resident received an anticoagulant medication and no antiplatelet medications during the seven-day look-back period. A record review of Resident #5's Order Summary Report with active orders as of 5/1/25 and 6/1/25 revealed no orders for anticoagulant medications. Physician's orders included Plavix (dated 4/26/22) and Aspirin (dated 9/18/24). A record review of the Medication Administration Records (MARs) for May and June 2025 revealed no anticoagulant medications were administered, however, antiplatelet medications were administered. Resident #14 A record review of Resident #14's admission Record revealed the facility admitted the resident on 1/7/25 with diagnoses including Congestive Heart Failure. A record review of Resident #14's Quarterly MDS with an ARD of 4/11/25 revealed Section N0415 indicated the resident received an anticoagulant medication during the seven-day look-back period and did not receive an antiplatelet. A record review of the Order Summary Report with active orders as of 4/1/25 revealed an order dated 1/7/25 for Plavix. There were no anticoagulant medications listed. A record review of the MAR for April 2025 revealed Plavix was administered daily and there were no anticoagulant medications administered. Resident #21 A record review of Resident #21's admission Record revealed the facility admitted the resident on 4/2/25 with diagnoses including Cerebral Infarction. A record review of the admission MDS with an ARD of 4/8/25 revealed Section N0415 indicated the resident received an anticoagulant medication during the seven-day look-back period. Antiplatelet was not marked as administered. A record review of the Order Summary Report with active orders as of 4/2/25 revealed there were no orders for anticoagulant medications, however, there were physician's orders dated 4/2/25 for Aspirin and Clopidogrel Bisulfate. A record review of the MAR for April 2025 revealed there were no anticoagulant medications administered, and Clopidogrel Bisulfate was administered. Resident #38 A record review of Resident #38's admission Record revealed the facility admitted the resident on 1/10/24 with diagnoses including Cerebrovascular Disease and Insomnia. A record review of the Quarterly MDS with an ARD of 6/26/25 revealed Section N0415 indicated the resident received an anticoagulant medication, however, there was no indication that the resident received an antiplatelet or a hypnotic medication during the seven day look back period. A record review of the Order Summary Report with active orders as of 6/1/25 revealed there were physician's orders for Aspirin (dated 1/10/24) and Restoril (Temazepam) (dated 4/8/25). There were no orders for anticoagulant medications. A record review of the MAR for June 2025 revealed there was no anticoagulant administered, but antiplatelet and hypnotic medications were administered. Resident #44 A record review of Resident #44's admission Record revealed the facility admitted the resident on 6/9/25 with diagnoses including Peripheral Vascular Disease. A record review of the admission MDS with an ARD of 6/16/25 revealed Section N0415 indicated the resident received an anticoagulant medication and did not receive an antiplatelet medication during the seven-day look-back period. A record review of the Order Summary Report with active orders as of 6/9/25 revealed there were no physician orders for anticoagulant medications, but there were orders for Clopidogrel Bisulfate (dated 6/9/25). A record review of the MAR for June 2025 revealed no anticoagulant medications were administered; however, an antiplatelet medication was administered. Resident #53 A record review of Resident #53's admission Record revealed the facility admitted the resident on 3/7/25 with a diagnosis of Cerebral Infarction. A record review of the Quarterly MDS with an ARD of 6/10/25 revealed Section N0415 indicated the resident received an anticoagulant medication during the seven-day look-back period and did not receive an antiplatelet medication. A record review of the Order Summary Report with active orders as of 6/1/25 revealed there were no anticoagulant medications ordered, however there was a physician's order for Plavix (dated 3/7/25). A record review of the MAR for June 2025 revealed there were no anticoagulant medications administered; however, an antiplatelet medication was administered. On 7/2/25 at 10:29 AM, during an interview with Registered Nurse (RN) #1, she explained that different staff members complete each section of the MDS, but she completes Section N for medications. She stated that information is gathered by reviewing residents' medical records. RN #1 confirmed Plavix and Aspirin are classified as antiplatelet medications and Restoril is classified as a hypnotic. After reviewing the MDS and physician orders for Residents #5, #14, #21, #38, #44, and #53, she confirmed the MDS assessments were coded in error. She stated that while staff are responsible for the accuracy of their own sections, she reviews assessments before submission and acknowledges these errors. On 7/2/25 at 10:45 AM, during interviews with the Director of Nursing (DON) and Administrator, both confirmed they were made aware of the inaccurate MDS coding. They acknowledged the facility does not have a triple-check system for accuracy but stated their expectation is for staff to code the MDS accurately to reflect each resident's clinical status.

Based on observation, staff interview, record review, and facility policy review, the facility failed to maintain food quality in accordance with professional standards for food safety related to overly ripe produce, exposed foods, undated and unlabeled foods, and expired foods and unsanitary meal preparation for two (2) of three (3) days of survey. Findings included: A review of the facility's policy titled, Food Storage Labeling, dated 3/24, revealed, .The facility will ensure the safety and quality of food by following good storage and labeling procedures .Procedure .2. All food items that are not in their original containers must be labeled with the common name of the food and the use by date. 3. Foods that are prepared and stored for later service must be labeled and dated .8. Rotation a . iv. Foods stored in storage units will be surveyed routinely to identify and discard foods that have passed its manufacturer use-by date or expiration date .10. Product Placement Food is stored in containers .that are .tightly sealed or covered and labeled . On 6/30/25 at 10:06 AM, during an observation and interview in the kitchen with the Certified Dietary Manager (CDM), in Refrigerator #1 there were two (2) beverage cups with sippy lids attached, containing a clear liquid and a brown liquid, without date labels or identifying information. The CDM identified them as thickened water and thickened tea. Refrigerator #2 contained two (2) unopened bags of chopped cabbage showing browning and liquefaction with manufacturer use-by dates of 6/22/25 and 6/24/25. Freezer #2 contained one personal-sized bowl of food covered with plastic wrap, lacking a label or date, and the CDM could not identify its contents. In the pantry, 19 overly ripe bananas with open skins and five (5) bottles of dry seasoning with open lids were observed. The CDM acknowledged the presence of expired, undated, and exposed food items and stated he was responsible for food quality and safety. He reported he conducts regular in-services on food safety and planned to begin making daily rounds to ensure compliance. On 7/1/25 at 11:17 AM, during an observation and interviews with the CDM, [NAME] #1, and [NAME] #2, [NAME] #1 was observed preparing food trays while placing the scoop for pureed bread flat into the food, with the scoop handle touching the food item and then repeatedly using it. During this process, [NAME] #1 asked [NAME] #2-who was actively washing pots in the three-compartment sink-to use a towel to wipe a spill on a resident's plate. The plate was then placed on the food cart. [NAME] #2 acknowledged she used a soapy towel from the dishwashing area and confirmed that dish soap is a chemical. [NAME] #1 acknowledged the entire scoop, including the scoop handle, was touching the food while preparing meals. She also confirmed she had asked [NAME] #2 to wipe a plate with a soapy towel, which was inappropriate. She affirmed her responsibility for food prep sanitation. The CDM acknowledged observing both infractions and stated he would conduct additional in-service training on food safety, noting that he typically oversees tray preparation to ensure food handling standards are met. On 7/2/25 at 9:08 AM, during an interview with the Administrator, he acknowledged he was made aware of the issues involving undated and unlabeled food, overly ripe and expired produce, and the unsanitary practices observed. He stated that the CDM is responsible for kitchen sanitation and food quality and noted his own expectation is for food safety to be maintained.

Based on observation, interviews, record review, and facility policy review, the facility failed to honor residents' rights or choices, as evidenced by the resident having to remain in her room despite her request to get up and interact with other residents for one (1) of fifteen (15) sampled residents. Resident #13 Findings include: Record review of the fcility's Resident Rights dated 4/2012, revealed, . Residents' rights, policies, and procedures shall insure that each resident admitted to the center . 5. Is encouraged and assisted throughout the resident period of stay .9. Is treated with consideration, respect, and full recognition of his dignity and individuality .12.May .participate in activities .at his discretion . On 1/08/24 at 12:42 PM, during an observation and interview of Resident #13 revealed the resident was lying in bed with her head elevated watching television. In the interview, the resident stated that she wishes she could get out of her room every day, but staff do not get her up as often as she would like. On 1/9/24 at 8:54 AM, in an interview with Certified Nursing Assistant (CNA) #1, while in the room with Resident #13, she stated that she gets the resident out of her room every other day. CNA #1 stated that today is her shower day therefore, she will be up to attend bingo, which is good because the resident enjoyed playing bingo. CNA #1 confirmed that the resident has no physical constraints that would prohibit her from getting up daily. On 1/9/24 at 9:03 AM, during an interview with Resident #13, she stated that CNA #1 was lying. She says they do not take her out of her room every other day. She claims she wants to get up daily, but they rarely do that and that they only occasionally take her to play bingo. Resident #13 said she wants to get up daily and go to Bingo whenever they have it. On 1/9/24 at 9:34 AM, in an interview with Registered Nurse (RN) #1, she stated that CNAs must get all residents out of their rooms daily unless their acuity level forbids it. As a result, there is no need for a written system to determine if a person wishes to get up or refuses. She stated that she believed the CNA and that if they could not get a resident up, the resident had refused to do so. She added that, based on what she knows, all residents who want to leave their rooms on a daily basis are doing so. On 1/10/24 at 9:04 AM, in an interview with the Activities Director (AD), she stated that there is no resident get-up list or any other documented procedure in place to notify staff of residents who wish to get up on a daily basis. She stated that after her rounds with the residents, she notifies the CNAs of the residents who had indicated that they want to get up for activities. The AD stated that she does not recall and is unsure whether Resident #13 requested to be out of her room daily. On 1/10/24 at 11:57 AM, in an interview with Resident #13's daughter, she indicated that she frequently saw her mother in bed while other residents were up and out of their rooms during her visits. She revealed she had asked the CNA assigned to her mother, Why is my mother in bed? She stated the CNA informed her that her mother could only get up every other day, and today was not that day. The daughter said she did not like that response but assumed it was how things were done at the facility. On 1/10/24, at 12:31 PM, in an interview with the Director of Nursing (DON), she indicated that all residents are permitted to leave their rooms on a daily basis. If a resident refuses to get up, CNAs should report it to the nurse, who should document it in their progress notes. She further stated that regardless of whether the Resident is completely dependent, they should be free to leave their rooms daily, unless the Resident declines. She says denying residents the freedom to get up and out of their rooms violates their rights. On 1/11/24 at 12:52 PM, in an interview with the Administrator, he indicated his expectation of staff is to daily check with the residents and ask in an assumptive tone, Let's get you up today! He added that when staff refuses the request of the resident to get up, it violates their rights. A record review of the admission Record revealed the facility admitted Resident #13 on 4/30/21. Her diagnoses included Cerebral Aneurysm, Epilepsy, Type 2 Diabetes, and Hypertension. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/09/23, revealed a Brief Interview for Mental Status (BIMS) score of 6, indicating the resident had severe cognitive impairment. However, the interview with the daughter corroborates the resident's account of being left in bed and the resident not being gotten up as she desired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and facility policy review, the facility failed to ensure the shower room was at a comfortable temperature while providing showers for three (3) of fifteen (15) sampled residents. Residents #8, #9, and #23. Findings Include: A record review of the facility policy titled, Resident Rights, dated 4/2012, revealed, Policy Statement: Employees shall treat all residents with kindness, respect, and dignity . Policy Interpretation and Implementation .3. Our facility will make every effort to assist each resident .is always treated with respect, kindness, and dignity .9. Is treated with consideration .in treatment and in care for his personal needs . Resident #8 Observation on 1/8/23 at 1:00 PM, revealed Resident #8 lying in bed with the head of her bed elevated. The resident was alert and oriented, and able to make her needs known. During an interview with Resident #8 on 1/8/23 at 1:15 PM, revealed she doesn't go to the shower because it's cold in there. Resident #8 said the staff told her the heater does not work in the shower room. Resident #8 said she feels better when she gets a shower, but it's too cold to bathe without heat. The resident said she had talked to the Certified Nursing Assistance (CNA) that assists her with a shower about the room being cold. During an interview on 1/8/23 at 6:15 PM, with Resident #8's daughter, she stated that her mother complains, as well as other residents, that the shower room is cold during their showers. The daughter also said her mother complains that the facility does not dry her hair after shampooing it. The daughter said the facility towel dries the resident's head, which could cause her to get sick. The daughter said she has discussed her complaints with several staff members. A record review of the admission Record for Resident #8 revealed the resident was admitted to the facility on [DATE], with diagnoses that included Anemia, Essential (Primary) Hypertension, and Chronic Systolic (Congestive) Heart Failure. A record review of the MDS (Minimum Data Set), with an Assessment Reference Date (ARD) 1/5/24, revealed a Brief Interview for Mental Status of 12, which indicated the resident had moderate cognitive impairment. Resident #9 On 1/9/23 at 10:00 AM, the State Agency (SA) observed Resident #9 taking a shower. The resident was shivering during the shower. The shower room did not have any heat blowing during her shower. CNA #1 bathed the resident, using warm water, then dried the resident and put clean clothes on her. The resident shivered during the whole process. During an interview on 1/9/23 at 10:45 AM, with Resident #9, she confirmed the shower room was cold. The resident said she likes to be clean, but she doesn't like the room being cold. The resident revealed she doesn't complain because she needs her showers. Resident #9 stated the shower room is always cold and she is concerned she might get sick from being so cold, however, she added, I just take a chance. During an interview on 1/9/23 at 2:00 PM, CNA #1 revealed she wasn't cold in the shower room because she was working and had not noticed that Resident #9 was shivering and had not complained about being cold. CNA #1 said the heater inside the shower room has not worked since she began employment at the facility. CNA #1 said she had turned the main heater on earlier this morning, but somebody must have turned it off. CNA #1 also stated she towel dried the resident's hair because the shower room does not have an electrical plug and it is the responsibility of the floor CNA to blow dry the resident's hair. A record Review of Resident #9's admission Record revealed the facility admitted the resident to the facility on 4/26/22, with diagnoses that included Diabetes Mellitus, Hypertension, Hemiplegia, and Hemiparesis. A record review of the Quarterly Minimum Data Set (MDS), with Assessment Reference Date (ARD) 12/22/23, revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. Resident #23 On 1/9/23 at 11:00 AM, the State Agency (SA) observed Resident #23 taking a shower. The resident was shivering during the shower. The shower room did not have any heat blowing during her shower. CNA #2 bathed the resident, using warm water, then dried the resident and put clean clothes on her. The resident shivered during the whole process. The State Agency (SA) asked Resident #23 if she was cold while in the shower. The resident stated, Yes, it's cold in here. During an interview on 1/9/23 at 11:45 AM, Resident #23 confirmed she was cold during her shower. The resident said it is always cold. Resident #23 revealed the staff told her the heater does not work. The resident also said the staff does not dry her hair. She said her head is only dried with a towel. She commented she is cold most of the day because her hair is wet, however, she doesn't complain because she doesn't want to cause problems with the staff. During an interview on 1/9/23 at 2:30 PM, CNA #2 confirmed Resident #23 said she was cold. CNA #2 also said the heater in the shower room has not worked for over a year, however, she thought the main heating unit for the shower was on. CNA #2 stated she didn't realize it was cold in the shower room. A record review the admission Record for Resident #23 revealed the facility admitted the resident to the facility on 6/24/22, with diagnoses that included Diabetes Mellitus, Hypertension, and Chronic Kidney Disease. A record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) 11/17/23, revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. During an interview on 1/9/23 at 2:45 PM, with the Maintenance Director, he confirmed the heater was not on. The Maintenance Director confirmed he turned on the thermostat that is located outside of the shower room on the wall, after the State Agency (SA) inquired about the heat. The Maintenance Director revealed that thermostat only regulates the shower room and the storage room and does not regulate the temperature in the hallway or at the nurse's station. The Maintenance Director also confirmed he had not realized that the knob on the electric heater located in the shower room was broken, but that it has now been replaced. During an interview on 1/9/23 at 3:00 PM, with the Director of Nursing (DON), she stated she did not know the staff were showering the residents without turning on the heater. The DON confirmed the residents could get sick without heat. The DON said the staff will be in-serviced today on making sure the heater is on and that the residents' hair is dried when they are showered. An interview with the Administrator on 1/9/23 at 3:30 PM, revealed he unaware the staff were not using the heater in the shower and that the electric heater located inside the shower room was not working. The Administrator stated the staff know how to regulate the heater by turning regulating the thermostat in the hallway outside the shower door.

Based on record review, interviews, and facility policy review, the facility failed to ensure PRN (as needed) psychotropic medications were discontinued or limited to a 14 day duration without adequate clinical rationale for continued use for one (1) of five (5) residents reviewed for unnecessary medications. Resident #42 Findings include: A record review of the facility's policy Monitoring of Antipsychotic Medication Therapy with revised date 06/2015 revealed . It is the policy of this facility to monitor the effectiveness and side effects for any resident that is taking an antipsychotic medication . The Pharmacy consultant will review these meds monthly and make dose reduction recommendations as indicated per CMS (Center for Medicare and Medicaid Services) guidelines. These recommendations will be forwarded to the physicians for their response within 7 days . Record review of a statement on facility letterhead dated 1/12/24 and signed by the Administrator revealed, (Proper Name) Nursing Home does not have a specific policy that sites the 14 day rule for the new guidelines on Monitoring of Antipsychotic Medications Therapy. We do however follow the federal guidelines on the 14 day psychotropic rule . A record review of Resident #42's admission Record, revealed the facility admitted the resident on 09/01/2023, with an original admission date of 10/22/2020. Resident #42 was admitted with diagnoses that included Unspecified Psychosis Not Due to A Substance or Known Physiological Condition, Anxiety, Unspecified, and Insomnia, Unspecified. Diagnoses of Unspecified Dementia, Unspecified Severity, With Other Behavioral Disturbance, and Paranoid Schizophrenia was added after the original admission date. A record review of Resident #42's Order Summary Report, with active orders as of 01/11/2024, revealed orders for Klonopin Tablet 0.5 MG (milligrams) (Clonazepam) Give 0.5 mg by mouth every 8 (eight) hours as needed for agitation, with order date and start date of 03/18/2022. A record review of Resident #42's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/26/2023, revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. Further review of the MDS revealed that in the look back period, the resident had no behavioral symptoms and had received antipsychotic and antianxiety medications. A record review of Resident #42's Pharmaceutical Consultant Report (PCSA) Psychoactive Gradual Dose Reduction, dated 07/26/2023 revealed the Nurse Practitioner's (NP) signature and date of 10/02/2023 revealed . This resident is prescribed the following psychotic medications: . 3. Klonopin 0.5 mg QD (every day), 0.5 mg Q8H (every eight hours) PRN (as needed) . Clinical Rationale for continuance . mood instability .multiple GPU (Geripsych Unit) stays . The document has no duration time or stop date for the PRN Klonopin 0.5 mg. A record review of the facility's Interdisciplinary Team Psychotropic Dashboard December 2023 revealed Resident #42 had an order for Klonopin 0.5 mg Q8H prn with no mention of duration of the medication. A record review of Resident #42's MAR for 11/01/2023 - 11/30/2023 revealed that resident received three (3) doses of Klonopin 0.5 mg for agitation but no documented behaviors. A record review of Resident #42's MAR for 12/01/2023 - 12/31/2023 revealed that resident received seven (7) doses of Klonopin 0.5 mg for agitation. Documented behaviors of agitation and yelling for resident on 12/14/2023, 12/15/2023, and 12/16/2023. A record review of Resident #42's Medication Administration Record (MAR) for 01/01/2024 - 01/31/2024 revealed no doses of Klonopin 0.5 mg PRN were given and resident had no behavioral issues. On 01/10/2024 at 2:15 PM, during an interview with Licensed Practical Nurse (LPN) #2, she explained Resident #42 used to have behaviors and would yell out and holler and has been in and out of Geri-psych several times, but her medications have been working and the resident has been much calmer and cooperative. LPN #2 revealed it has been a while since Resident #42 has had any problems with behaviors and has not had any PRN medications for behaviors. LPN #2 further revealed that Resident #42 is very cooperative with medication and care and never refuses. At 2:35 PM on 1/10/24, during an interview with Certified Nurse Aide (CNA) #2, she explained Resident #42 is confused at times, but cooperative with care and has never refused care. On 1/11/24 at 10:09 AM, during an interview with the Director of Nursing (DON), she explained she has been reviewing all residents' records regarding the psychotropic medications and is aware of 14-day period and has interacted with the facility's Advanced Registered Nurse Practitioner (APRN) to discontinue all PRN medications if possible or to have a stop date. The DON stated that Resident #42 has been seeing behavioral health services and has been out to Geri-psych in the past and is doing much better since her last visit. She stated Resident #42 currently has not had any recent behaviors and has adjusted to the medications. She confirmed the resident continues to have an order for Klonopin 0.5 mg Q 8 hours PRN. The DON mentioned that the pharmacy consultant is aware of the regulations because she informed her via an email at an earlier date. On 1/11/23 at 12:00 PM, during a phone interview with the facility's APRN, she explained she understood if a psychotropic medication was used as PRN and still needed after the 14-day period all that was needed was a rationale why but was not aware there was to be a duration of time or stop date for the PRN medication. At 12:20 PM on 1/11/23, during an interview with the facility's Pharmacy Consultant, she explained she is aware of the of the time limit duration for PRN psychotropic medications and informs the facility of the regulations on a monthly basis. She explained she has asked for a stop date monthly when she continues to see a medication with no duration or stop date. She stated the facility has access to her monthly recommendations. The Pharmacy Consultant revealed that she would expect the facility to follow her expectations. On 1/11/24 at 12:52 PM, during an interview with the Administrator, he explained he expected the APRN to know the regulations or requirements for psychotropic medications and to follow the requirements for all residents. He would expect the facility, including the pharmacist consultant, to follow all CMS guidelines to provide appropriate care for all residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to notify the Resident Representative (RR) in writing the reason for a transfer to an acute care hospital for one (1) of one (1) sampled residents for hospitalizations. Resident #35 Findings include: Record review of the facility's Transfers and Documentation policy with a revised date of 11/2017, revealed . E. Documentation- . The documentation for all discharges and transfers, must include, as a minimum, and as they may apply: 1. The reason(s) for the discharge or transfer. 2. That an appropriate notice was provided to the resident and/or resident representative . On 07/18/22 at 01:45 PM, during an interview with the Director of Nursing (DON), she explained Resident #35 is currently in the hospital and is on bed hold with plans to return to the facility. Resident #35's son was at the facility when she was transferred to the hospital and was aware of the transfer. The Social Worker is responsible for mailing transfer and bed hold letters to the family. On 07/18/22 at 02:50 PM, during a phone interview with Resident #35's son, who is the RR, he explained his mother has been in the hospital since 6/24/2022 and plans to return to the facility. He reported he did not receive a letter regarding the hospitalization transfer but did talk on the phone with the Social Worker regarding bed hold. A record review of Resident #35's admission Record revealed the facility initially admitted her on 02/08/2013 and she was readmitted on [DATE] with diagnoses including Chronic Stage 3 Kidney Disease and Blister Right Thigh Initial Encounter. A record review of Resident #35's Physicians Orders dated 6/24/22, revealed .To (Proper Name of Physician and Nurse Practitioner) Transport resident via (Proper Name of Transport Service) to (Proper Name of Acute Care Hospital) for further evaluation . Record review of the Notice of Hospital Transfer/Therapeutic Leave for Medicaid-Eligible Residents letter revealed (Proper Name of Resident #35) .Notice is hereby given Resident Representative that (Proper Name of Resident #35) transferred to (Proper Name of Acute Hospital) at 10:00 PM on 6/24/22 . A record review of Resident #35's (Proper Name of Acute Care Hospital) Hospitalist Daily Progress Note revealed Resident #35 . admit date [DATE] . On 07/18/22 at 03:05 PM, during an interview with the DON, she explained the current notification to the RR is a letter mailed for bed hold and hospital transfer/therapeutic leave. She confirmed this letter does not include the reason for the transfer and she did not know that the reason for transfer was required to be included on the notification letter. On 07/18/22 at 03:30 PM, during an interview with the Corporate Nurse, she explained the facility does not have a hospital transfer letter explaining in writing the reason the resident was transferred to the hospital and the facility did not mail a hospital transfer letter to Resident #35's RR detailing the reason for the transfer. On 07/19/22 at 09:30 AM, during an interview with the facility's Social Worker, she explained she was not aware the letter mailed to Resident #35's RR should have included the reason for transfer. She confirmed she had only mailed bed hold letters to the RR's and she had not mailed any notifications of transfers that included the reason for the transfer. On 07/19/22 at 09:45 AM, during an interview with the Administrator, he explained he was not aware the resident transfer letters mailed to the RR's must include the reason for the transfer.

Based on interviews, record review and facility policy review the facility failed to conduct a Level I Pre-admission Screening prior to the resident's admission to the facility to determine if the resident has a mental, intellectual disorder, or related condition for five (5) of 17 sampled residents. Resident # 3, Resident #5, Resident #12, Resident #22, and Resident #25 Findings include: A review of the facility's policy PASRR (Pre-admission Screen and Resident Review), revised 2012, revealed, It is the policy of this facility to do the Pre-admission Screening process .All persons requiring nursing facility level of care must have a PAS completed for admission to a Medicaid certified nursing facility . Resident #3 A record review of Resident #3's clinical record revealed no Pre-admission Screening (PAS) had been completed. A record review of the admission Record for Resident #3 revealed the facility admitted her on 7/29/21 with a diagnosis of Unspecified Dementia. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/14/22 revealed a Brief Interview for Mental Status (BIMS) score of seven (7) which indicated Resident #3 had severe cognitive impairment. Resident #5 A record review of Resident #5's clinical record revealed no PAS had been completed. A record review of Resident #5's admission Record revealed the facility admitted her on 4/23/21 with diagnoses including Type II Diabetes Mellitus and Schizophrenia. A record review of the Quarterly MDS with an ARD of 4/08/22 revealed Resident #5 had a BIMS score of 15 which indicated she is cognitively intact. Resident #12 A record review of Resident #12's clinical record revealed no PAS had been completed. A record review of Resident #12's admission Record revealed the facility admitted her on 5/19/21 with diagnoses including Major Depressive Disorder and Schizoaffective Disorder. A record review of the Quarterly MDS with an ARD of 4/22/22 revealed Resident #12 had a BIMS score of 00, which indicated she had severe cognitive impairment. Resident #22 A record review of Resident #22's clinical record revealed no PAS had been completed. A record review of the admission Record for Resident #22 revealed an original admission date of 6/8/21 and a readmission date of 9/22/21 with diagnoses of Unspecified Dementia in other Diseases classified elsewhere with behavioral disturbance. A record review of the Comprehensive MDS with an ARD of 5/20/22 revealed a BIMS score of 15, which indicated Resident #22 is cognitively intact. Resident #25 Record review of Resident #25's clinical record revealed no PAS had been completed Record review of the admission Record for Resident #25 revealed an admission date of 12/6/21 with diagnoses of Schizophrenia and Major Depressive Disorder. Record review of the Quarterly MDS with an ARD of 5/31/22 revealed a BIMS score of 15, which indicated Resident #25 is cognitively intact. On 7/18/22 at 12:12 PM, in an interview with the Director of Nursing (DON), she confirmed the Pre-admission Screenings (PAS) for Resident #3, Resident #5, Resident #12, Resident #22, and Resident #25 were not completed. She stated the Social Worker (SW) is responsible for making sure it is completed upon admission, but she is responsible for ensuring they are completed. She confirmed the PAS should have been completed before the residents were admitted to the facility to make sure that the facility could meet the needs of the residents. On 7/18/22 at 2:10 PM, in an interview with the SW, she stated that she is responsible for making sure the PAS is completed for the residents and it is her responsibility to make sure it is done. On 7/18/22 at 3:01 PM, in an interview with the Administrator, he stated that it is the responsibility of himself and the SW to complete the PAS. He stated that it is a team effort, and the DON is responsible for conducting a final check of the records to make sure everything is completed. He stated a PAS is completed for residents to make sure that the facility can provide for the resident's needs, and a PAS should have been completed prior to the residents' admission to the facility.