**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive, person centered care plan for two residents (Resident #35 and #89), in a review of 15 sampled residents. The facility census was 36. Review of the facility's undated policy Care Plan Comprehensive, showed the following: -An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental and psychosocial well-being; -Assessment of each resident is ongoing and the care plan will be revised as changes occur in the resident's condition; -The comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment; -Periodic review and updating of care plans will occur: a. When a significant change in the resident's condition has occurred; b. At least quarterly; c. when changes occur that impact the resident's care (i.e. change in diet, change in care areas). 1. Review of Resident #35's face sheet showed the following: -He/She admitted to the facility on [DATE]; -Diagnoses included unspecified dementia, unspecified severity, with agitation (a type of dementia-a progressive decline in cognitive function, including memory, thinking, and reasoning, severe enough to affect a person's daily life-where the specific cause is unknown or unspecified, and where the individual experiences agitation) and unspecified atrial fibrillation (an irregular heartbeat that can be intermittent or persistent, whose cause is unknown). Review of the resident's Continuity of Care Document (CCD), showed the following medication orders: -Citalopram (an antidepressant medication), 20 milligrams (mg) by mouth daily for a diagnosis of unspecified dementia, start date 12/04/24; -Eliquis (a blood thinner used to help prevent blood clots and stroke), 2.5 mg by mouth two times daily, for a diagnosis of unspecified atrial fibrillation, start date 11/04/24; -Seroquel (an antipsychotic medication used to treat several kinds of mental health conditions), 25 mg by mouth daily in the evening, for a diagnosis of unspecified dementia, start date 12/17/24. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/07/25, showed the following: -The resident was rarely understood; -Dependent for toileting; -Substantial to maximum assistance for mobility; -Received an antipsychotic and an antidepressant medication routinely; -No evidence facility staff documented the resident received an anticoagulant medication routinely. Review of the resident's care plan, last reviewed/revised on 04/14/25, showed the following: -Problem: Cognitive loss/dementia: impaired neurological status related to dementia; -Long-term goal: the resident will maintain activities of daily living (ADL's) through the next review on 07/31/25; -No evidence facility staff identified the problem, long-term goals, or interventions related to the resident's use of an antidepressant for a diagnosis of unspecified dementia in the resident's care plan; -No evidence facility staff identified the problem, long-term goals, or interventions related to the resident's diagnosis of unspecified atrial fibrillation and the use of an anticoagulant medication in the resident's care plan; -No evidence facility staff identified the problem, long-term goals, or interventions related to the resident's use of an antipsychotic medication for a diagnosis of unspecified dementia in the resident's care plan. Observation on 04/14/25 at 2:50 P.M. showed the following: -The resident moved himself/herself about the facility in his/her wheelchair using his/her feet; -The resident did not answer verbal questions; -The resident was calm. During an interview on 04/15/25 at 9:05 A.M., the resident's family member said the following: -The resident had a lot of behaviors when he/she first arrived at the facility, but was better the last few months; -He/She knew the facility had used some medications to help with the behaviors, but he/she wasn't sure what they were. During an interview on 04/16/25 at 10:55 A.M., the Director of Nursing (DON) said the following: -The resident was placed on an antipsychotic when he/she first arrived due to behaviors such as wandering in and out of certain rooms, urinating in the hall, being aggressive towards staff and difficult to redirect; -The resident had a diagnosis of dementia with agitation; -She was responsible for the residents' care plans; -She was not aware Resident #35's care plan did not reflect the use of an antipsychotic or anticoagulant; she may have just forgotten to add it; -The resident has had pharmaceutical evaluation of the antipsychotic medication with dose changes made based on behaviors; -The MDS should indicate the resident's use of an antipsychotic medication. 2. Review of Resident #89's Face Sheet showed following: -He/She admitted to the facility on [DATE]; -Diagnoses included dyspnea (shortness of breath). Review of the resident's Physician's Order, dated 03/28/25, showed to administer oxygen via nasal cannula at bedtime as needed for oxygen saturation level (measures oxygen level in) below 90%. Review of the facility's undated list of residents who smoke showed the resident was a smoker. Review of the resident's smoking assessment, dated 04/11/25, showed he/she was to be supervised while smoking. Observation on 04/14/25 at 1:15 P.M. showed the resident smoked with supervision. Review of resident's Care Plan, last reviewed/revised on 04/14/25, showed the following: -The care plan did not include documentation to show the resident may require oxygen as needed to maintain oxygen saturation levels above 90%; -The care plan did not include documentation to show the resident smoked and required supervision while smoking. During an interview 4/16/25 at 2:06 P.M., the DON said the following: -The resident was a smoker; -The resident had orders for PRN oxygen; -The resident's smoking status and oxygen use should be documented on the resident's care plan; -She was responsible for developing the care plans and missed adding smoking and oxygen use to the resident's care plan; -She found it difficult at times to complete/update care plans as needed as she had several duties. During an interview on 04/17/25 at 3:30 P.M., the Administrator said the care plans should reflect all of a resident's care areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete or maintain documentation of a two-step or prior two step Tuberculin Skin Tests (TST), or a chest x-ray in the last year, as required to rule out Tuberculosis (TB) (a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing), and failed to complete annual TB screening as required for three residents (Resident #17, #239, and #15), in a review of five sampled residents evaluated for immunization status. The facility failed to ensure there was a complete water management program in place to reduce the risk of legionellosis (any disease caused by Legionella (a bacteria which people can breathe in without knowing, sometimes causing infection in the lungs)) in the facility. The facility census was 36. Review of the facility's Tuberculosis Control Plan, dated May 2015, showed the following: -All residents new to long-term care who do not have documentation of a previous skin reaction less than 10 millimeter (mm) or a history of adequate treatment of tuberculosis infection or disease, should have the initial test of a Mantoux PPD two-step test to rule out tuberculosis within one month prior to or one week after admission. If the initial result is 0-9 mm, the second test, which can be given after admission, should be given at least one week and no more than three weeks after the first test. The results of the second test should be used as the baseline; -Documentation of a chest x-ray ruling out active pulmonary tuberculosis within one month prior to admission along with an evaluation to rule out signs and symptoms of tuberculosis, may be acceptable by the facility on an interim basis until the Mantoux PPD two-step test is completed; -Annual skin tests for residents with documented results greater than 10 mm are not required nor annual chest x-rays for residents with documented skin tests results greater than 10 mm; (The policy did not identify how staff were to routinely monitor residents for signs and symptoms of TB (i.e. annual evaluation).) Review of the TB Screening for Long-Term Care Residents (a document provided by the Department of Health and Senior Services to long-term care facilities), updated 3/11/24, showed to conduct an annual evaluation to rule out signs/symptoms of TB. 1. Review of Resident #17's undated face sheet showed the following: -He/She admitted on [DATE]; -He/She was not his/her own responsible party for decision making. Review of the resident's Medication Administration Record (MAR), dated June 2024, showed the following: -A first-step TST administered on 6/3/24, and the results read on 6/6/24; -The resident refused the second-step TST on 6/13/25. Review of the resident's medical record showed no documentation staff attempted to administer the second-step TST at another time or notified the resident's responsible party or physician of the resident's refusal. During an interview on 4/17/25 at 10:18 A.M., the Director of Nursing (DON) said the following: -The resident refused the second-step TST; -Staff should have tried again and contacted the responsible party; -If the resident continued to refuse the TST, staff should have documented the refusal and notified the physician for an order for a chest x-ray. During an interview on 4/17/25 at 11:11 A.M., the facility Nurse Practitioner said she was not notified of the resident refusing to complete the two-step TST. 2. Review of Resident #239's undated face sheet showed the following: -The resident admitted on [DATE]; -The resident was his/her own responsible party; -The resident was unable to have TB testing due to receiving Bacillus Calmette-Guerin (BCG) treatment (an immunotherapy used to treat bladder cancer) related to history of bladder cancer. Review of the resident's electronic medical record showed no documentation of a chest x-ray completed in the last year. During an interview on 4/17/25 at 9:56 A.M., the resident's family member said the following: -The resident could not have TB testing due to his/her history of bladder cancer and the treatment the resident received; -The facility did not ask about obtaining a copy of a chest x-ray or getting a new chest x-ray. During an interview on 4/17/25 at 10:18 A.M., the DON said the following: -The resident was unable to receive TB testing; -A chest x-ray should have been obtained through records, if possible, or a new chest x-ray should have been requested, ordered, and completed. 3. Review of Resident #15's undated face sheet showed the following: -He/She admitted on [DATE]; -He/She was not his/her own responsible party for decision making. Review of the resident's electronic medical record showed no documentation staff completed an annual TB signs and symptoms evaluation on the resident's anniversary of admission. During an interview on 4/17/25 at 10:18 A.M., the DON said the resident should have received an annual evaluation to rule out signs and symptoms of TB on the anniversary of his/her admission and did not not. 4. During an interview on 4/17/25 at 11:11 A.M., the facility Nurse Practitioner said the following: -The facility was responsible for the admission TB testing as well as the annual signs and symptoms evaluation; -If a resident had a positive TST result, refused, or was unable to have the TB testing for any reason, the facility should notify the medical team and they could order an x-ray. During an interview on 4/17/25 at 3:30 P.M., the Administrator said the following: -The two-step TST should be started on admission, unless contraindicated; -Staff should complete an evaluation to rule out signs and symptoms of TB every year on the resident's anniversary of admission; -The charge nurse should complete both the two-step TST and the annual evaluation to rule out signs and symptoms of TB. 5. Review of the facility's undated policy, Water Management Program to Reduce Legionella Growth, showed the following: -Our facility will develop and implement a Water Management Program to inhibit microbial growth in building water systems that reduce the risk of growth and spread of legionella and other opportunistic pathogens in water; -Legionella Infections: the bacterium Legionella can cause a serious type of pneumonia called Legionnaires' Disease in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devises such as showerheads, cooling towers, hot tubs, and decorative fountains; -Purpose: to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections; -The facility will create a water management committee which will consist of the Administrator, Director of Nursing, and the Maintenance Director; -The water management committee will conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system; -The water management commit will implement a water management program that considers the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard and the Centers for Disease Control and Prevention (CDC) toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -The water management committee will specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the facility's undated Annual Water Management Checklist, showed the following: -Acceptable hot water range of 110 to 120 degrees Fahrenheit; -Acceptable cold water range of 50 to 68 degrees Fahrenheit. Review of the Centers for Disease Control and Prevention Legionella Environmental Assessment Form, undated, showed Legionella generally grow well between 77 degrees Fahrenheit (F) and 113 degrees F. The optimal growth range for Legionella is between 85 degrees F and 108 degrees F. Growth slows between 113 degrees F and 120 degrees F, and Legionella begin to die above 120 degrees F. Growth also slows between 68 degrees F and 77 degrees F, and Legionella become dormant below 68 degrees F. 6. Review of the facility's water management program binder on 4/16/25, showed the facility only checked and documented the temperature of the hot water temperatures weekly. There was no documentation to show the facility checked the temperature of the cold water temperatures in the facility. During an interview on 4/17/25 at 11:57 A.M., the Maintenance Director said the following: -He was on the water management committee, but did not know who else was on the committee; -He checked the temperature of the hot water weekly on Mondays. He did not check the temperature of the cold water; -He checked the water temperature in the kitchen, laundry and two resident rooms on each hall. He had not checked the temperature in either shower room; -He did not keep track of when a room sat empty for a period of time to know if the water fixtures needed to be flushed prior to using the room again. During an interview on 4/17/25 at 3:30 P.M., the Administrator said the following: -She expected the facility's water management program to follow the ASHRAE guidelines; -She expected maintenance staff to complete water temperature checks, flush the lines, and check for leaks every month; -She was not aware staff should check and monitor the temperature of the cold water.

Based on interview and record review, the facility staff failed to follow the facility's policy for the antibiotic stewardship program by not reporting infections to the infection preventionist as directed in policy, and failed to timely track infections and review antibiotic use following initiation of the medications. The facility census was 36. Review of the facility's undated policy, Surveillance: Antibiotic Stewardship Program, showed the following: -Measures of Antibiotic Prescribing, Use, and Clinical Outcomes: -The Infection Preventionist/designee will be responsible to audit the clinical assessment documentation at the time of the antibiotic prescription; -The Infection Preventions/designee will be responsible for auditing the completeness of antibiotic prescribing documentation to include dose, route, start date, end date, days of therapy, and indication; -The Infection Preventionist/designee will monitor antibiotic imitation. This is done by taking the number of new antibiotic starts for a single indication (Urinary Tract Infection, etc), dividing by total number of resident-days, and multiplying by 1,000; -The infection Preventionist/designee will track C. difficile and antibiotic resistant infections. The facility will work with the consultant laboratory personnel to develop a quarterly report of any instances of C. difficile or antibiotic resistant infections, such as methicillin-resistant staphylococcus aureus (MRSA) or E. coli. This report will be discussed with the Medical Director, Pharmacist Consultant, and Lab Consultant during the quarterly Quality Assurance meeting; -Antibiotic Utilization: All residents transferred to or from the facility who are on an antibiotic will have adequate documentation of dose, duration, and indication for the antibiotic. This will aid in determining the appropriateness of treatment based on additional laboratory/clinical data and resident response to treatment. This will also ensure discontinuation in a timely manner; -Broad Interventions to Improve Antibiotic Use: -Residents with a change in condition (symptoms of infection) should be identified with the Stop and Watch Tool; -Licensed nurses should complete the Situation-Background-Assessment-Recommendation (SBAR) to ensure a comprehensive assessment of the resident suspected of having an infection; -The Infection Preventionist/designee will initiate an antibiotic time-out three days after an antibiotic is initiated. The team will review all clinical findings, diagnostic findings, and resident response to answer the following questions: 1. Does the resident have a bacterial infection that will respond to antibiotic treatment? 2. Is the resident on the most appropriate antibiotic, including dose and route of administration? 3. Can the spectrum of the antibiotic be narrowed of the during of therapy be shortened? 4. Does the resident need additional infectious disease expertise to ensure optimal treatment? -The facility will reduce prolonged antibiotic treatment courses for common infections by requesting the shortest duration of efficacy or the specific infection. Best evidence has shown that short courses of antibiotics are effective for common infections and may reduce adverse events and complications associated with antibiotic use; Review of the facility's undated policy, Antibiotic Stewardship Program, showed the following: -The antibiotic stewardship program is designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use; -The goal of the facility will be to monitor infections and antibiotic usage by having a designated individual to track, monitor, trend and evaluate the monthly infections This individual will be known as the infection prevention coordinator; -The Director of Nursing (DON) will set the standard for assessment, monitoring and communication changes in a resident's condition to the front-line nursing staff; -The leadership team will include the charge nurses and the nursing assistants in the decision-making process for stating an antibiotic; -The infection prevention coordinator will play a key role in the stewardship program by performing the tracking, monitoring, trending and evaluating of antibiotic usage. The infection prevention coordinator will identify education needs of the facility staff and will communicate needs with the DON, medical director and charge nurses as needed; -The nursing home will utilize specific forms to identify the three most common infections: 1. Urinary tract infection (UTI) 2. Skin and soft tissue 3. Respiratory; -The facility will utilize the SBAR forms available in the electronic medical record (EMR) system for suspected UTI, suspected lower respiratory and suspected soft skin tissue prior to calling the attending physician; -The facility will utilize the Event-Infection Report in EMR system; -The facility will attach the nursing progress note to the event form; -The facility will utilize the following reports in the EMR system for review and monitoring of infections: 1. Antibiotic Medication Report - Utilization Report 2. Infection Summary Report 3. Current Resident Infection by infection type 4. Resolved Resident Infection by infection type; -The infection prevention coordinator will track the adverse outcomes and costs from antibiotic usage including: C. difficile infections, antibiotic-resistant organisms or adverse drug events to analyze whether or not the stewardship is successful in improving resident outcomes; -The facility will provide reporting related to antibiotic usage, tracking, and trending trough the Quality Assurance and Performance Improvement and Quality Assurance Agency process; -The facility will provide antibiotic stewardship education to clinicals, nursing staff, residents and families; -There should be a minimum of two individuals to serves as the champions of the facility infection prevention plan. There should be a designated Infection Prevention Coordinator as well as team members to assist with the infection program. 1. Review of Resident #35's Physician Order Sheet, dated April 2025, showed the following: -An order for Bactrim DS (an antibiotic) 800-160 milligrams (mg), one tablet twice a day, for a diagnosis of urinary tract infection (order dated for 3/31/25 to 4/3/25); -An order for cefuroxime axetil (an antibiotic) 250 mg, one tablet twice a day, for a diagnosis of urinary tract infection (order dated for 4/3/25 to 4/8/25). 2. Review of Resident #26's Physician Order Sheet, dated January 2025, showed the following: -An order for azithromycin (an antibiotic) 250 mg, one tablet daily, for a diagnosis of bacterial pneumonia (order dated for 1/24/25 to 1/29/25); -An order for amoxicillin-potassium clavulanate (an antibiotic) 875-125 mg, one tablet twice a day, for a diagnosis of bacterial pneumonia (order dated for 1/24/25 to 1/30/25). 3. Review of the resident's progress note, dated 12/31/24 at 9:06 A.M., showed physician orders were received to start amoxicillin (oral antibiotic) 875 milligrams (mg)/125 mg for treatment of pneumonia. Review of resident's progress notes, dated 01/27/25 at 3:38 P.M., showed new orders were received to start Augmentin (oral antibiotic) 875 mg/125 mg due to abnormal CT scan (a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) with diagnosis of possible pneumonia. 4. During interviews on 4/16/25 at 9:11 A.M. and 1:57 P.M. and 4/17/25 at 10:18 A.M. the Director of Nursing (DON) said the following: -She was the Infection Preventionist and was responsible for the antibiotic stewardship program; -She completed the tracking and trending reports for infections and antibiotics at the end of every month; -She tried to complete the tracking and trending reports in real time, but due to staffing, hours worked, and other assigned duties, she was not able to do that; -The nurses did not notify her when a resident had signs/symptoms of infections; -The charge nurses did not use the SBAR or event infection reports; -She tried to review progress notes and new orders daily; this is how she was made aware of new infections and antibiotics; -She tried to use McGreer criteria (a set of clinical and laboratory findings used to define and track infections in long-term care facilities) if she could capture the symptoms in the nursing progress notes. During an interview on 4/17/25 at 11:11 A.M., the facility Nurse Practitioner said she expected the facility to use and follow the McGreer criteria as much as possible. During an interview on 4/17/25 at 3:30 P.M., the Administrator said the following: -She expected the DON to track and monitor all infections and antibiotics; -She expected the DON to follow the McGreer criteria; -She expected for all nurses to use the SBAR and event infection reports in the resident's chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the pneumococcal vaccinations (a vaccine that can protect against pneumococcal disease) as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines for four residents (Residents #15, #25, #6, and #34), of five five residents reviewed for immunization status. The facility census was 36. Review of the facility's undated policy, Immunization, showed the following: -Pneumococcal vaccination in persons age [AGE] and older years, unless contraindicated, would be administered according to the following guidelines when determining the vaccination status; -Adults 65 years or older who have not already received a pneumococcal conjugate vaccine should receive either a single dose of PCV15 followed by a dose of PPSV23 one year later, or a single dose of PVC20. If PCV20 is administered, a dose of PPSV23 is not indicated; -Adults 65 or older who have only received PPSV23 should receive a single dose of PCV15 or PCV20. The PCV 15 OR PVC20 dose should be administered at least one year after the most recent PPSV23. Regardless whether PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it; Review of the CDC's Pneumococcal Vaccine Timing for Adults, updated October 2024, showed the following: -For adults 50 years or older who have never received any pneumococcal vaccine or whose previous vaccination history is unknown, administer PCV15, PCV20, or PCV21; -If PCV15 is administered, administer a dose of PPSV23 at least one year after the dose of PCV15. If the PPSV23 is not available, the PCV20 or PCV21 may be used; -If PCV20 or PCV21 is administered, regardless of which vaccine is used, their pneumococcal vaccinations are complete; -For adults 50 years or older who received the PPSV23 only at any age, administer the PCV15, PCV20 or the PCV 21 at least one year after the PPSV23 was administered; -For adults 50 years or older who received the PCV13 only at any age, administer the PCV20 or PCV21 at least one year after the PCV13 was administered; -For adults 50 years or older who received the PCV13 at any age and the PPSV23 when less than [AGE] years of age, administer the PCV20 or PCV21 after at least five years after the last pneumococcal vaccine dose; -For adults 65 years or older who received the PCV13 at any age and the PPSV23 at 65 years or older, the individual and their vaccination provider may choose to administer the PCV20 or PCV21 after at least five years after the last pneumococcal vaccine dose. (Refer to the CDC's Shared Clinical Decision-Making PCV20 or PVC21 Vaccination for Adults 65 Years or Older for additional information on clinical decision making.) 1. Review of Resident #15's undated face sheet showed the following: -He/She was greater than [AGE] years of age; -He/She admitted on [DATE]; -He/She was not his/her own responsible party for decision making. Review of the resident's admission packet, dated 3/14/23, showed the resident's pneumococcal vaccination consent was left blank. Review of the resident's significant change MDS, dated [DATE], showed he/she was up to date with pneumococcal vaccinations. Review of the resident's medical record showed no documentation the resident received or declined any pneumococcal vaccinations prior to admission or while a resident at the facility. (The resident's vaccination status was not up to date in accordance with the CDC guidelines and recommendations.) During an interview on 4/23/25 at 11:11 A.M., the resident's responsible party said he/she wanted the resident to be up to date on vaccinations, including the pneumococcal vaccination. He/She would consent to the pneumococcal vaccination if it was offered. 2. Review of Resident #25's face sheet showed the following: -He/She was greater than [AGE] years of age; -He/She admitted to the facility on [DATE]; -He/She had a power of attorney (POA) for health care; -Diagnoses included congestive heart failure (a condition where the heart muscle is weakened and can't pump enough blood to meet the body's needs; this lead to buildup of fluid in the lungs, legs, and other parts of the body), cough and dyspnea (shortness of breath). Review of the resident's admission packet, dated 11/01/23, showed the resident provided consent for the pneumococcal vaccinations on 11/01/23. Review of the resident's quarterly MDS, dated [DATE], showed he/she was up to date with pneumococcal vaccinations. Review of the resident's Continuity of Care Documentation (CCD), dated 04/16/25, showed no documentation the resident received any pneumococcal vaccinations prior to or after admission. 3. Review of Resident #6's immunization record showed the resident received the PPSV 23 vaccination on 06/14/17. Review of the resident's undated face sheet showed the following: -He/She was greater than [AGE] years of age; -He/She admitted on [DATE]; -He/She had a guardian. Review of the resident's admission packet, dated 11/17/22, showed the resident's guardian consented to the pneumococcal vaccinations on 11/17/22. Review of the resident's quarterly MDS, dated [DATE], showed the resident's pneumococcal vaccine was up to date. Review of the resident's Continuity of Care Document, dated 04/17/25, showed no documentation the resident received any pneumococcal vaccinations after admission. (The resident's vaccination status was not up to date in accordance with the CDC guidelines and recommendations.) 4. Review of Resident #34's face sheet showed the following: -He/She was greater than [AGE] years of age; -He/She admitted to the facility on [DATE]; -He/She was not his/her own responsible party for decision making. Review of the resident's admission packet, dated 11/02/23, showed the resident's responsible party consented to the pneumococcal vaccinations on 11/02/23. Review of the resident's quarterly MDS, dated [DATE], showed he/she was up to date with pneumococcal vaccinations. Review of the resident's Continuity of Care Document, dated 04/17/25, showed no documentation the resident received any pneumococcal vaccinations prior to or after admission. 5. During an interview on 4/16/25 at 9:11 A.M. and 1:57 P.M. the Director of Nursing (DON) said the following: -The facility gave the immunization consents to the resident/responsible party upon admission. These should be completely filled out; -With the new regulations and changes in pneumococcal vaccinations, it was confusing to determine which pneumococcal vaccinations the residents needed; -She and the medical director worked together to determine which pneumococcal vaccination to order; -She or the charge nurses were responsible for administering the pneumococcal vaccinations as ordered; -Most of the residents were not up to date with their pneumococcal vaccinations. During an interview on 4/17/25 at 3:30 P.M., the Administrator said the following: -It could be difficult to obtain a resident's vaccination history on admission; -She was aware of the issues with the residents' pneumococcal immunizations. The process was overwhelming but needed more attention; -She expected the pneumococcal vaccinations to be given following the CDC guidelines.

Based on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. This had the potential to affect all residents. The facility census was 36. Review of the facility's policy, Staff Scheduling, dated April 2015, showed an RN must work eight consecutive hours on the day shift every day, seven days a week. 1. Review of the facility's RN daily staffing sheets and time-clock data, dated December 2024, showed the facility did not have documentation to show an RN (including the Director of Nursing (DON)) worked on 12/01/24, 12/07/24, 12/13/24, and 12/26/24. Review of the facility's RN daily staffing sheets and time-clock data, dated January 2025, showed the facility did not have documentation to show an RN (including the DON) worked on 01/13/25, 01/19/25, and 01/27/25. Review of the facility's RN daily staffing sheets and time-clock data, dated March 2025, showed the facility did not have documentation to show an RN (including the DON) worked on 03/23/25. During an interview on 04/17/25 at 9:50 A.M., the Director of Nursing (DON) said the following: -There were some days when there was no RN coverage in the facility; -She was the only full-time RN employed at the facility; -The facility had advertised to hire another RN for several months but had not found anyone to fill this role; -When she was working as the facility RN, it took her away from her administrative duties. During an interview on 04/17/25 at 3:30 P.M., the Administrator said the following: -The DON was the only full-time RN at the facility; -The facility had advertised for several months to hire another RN but was unable to fill this role; -The facility used agency staff in the past, but they were not available for the facility's needs and were not reliable; -The corporate office was aware of this issue but had not offered any solutions.

Based on interviews, record review, and document review, the facility failed to complete a significant change Minimum Data Set (MDS) assessment as required for 2 (Resident #26 and Resident #8) of 19 sampled residents. Specifically, the facility failed to conduct a significant change MDS when Resident #26 had a decline in two areas of activities of daily living (ADL) and when Resident #8 was admitted to hospice services. Findings included: On 08/23/2023 at 2:40 PM, the Administrator stated the facility did not have a policy for MDS assessments and indicated they used the Resident Assessment Instrument (RAI) manual for MDS information. 1. A review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019 (Version 1.17.11), revealed, The MDS completion date (item Z0500B) must be no later than 14 days from the ARD [Assessment Reference Date] (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for an SCSA [Significant Change in Status Assessment] were met. The manual also indicated, The final decision regarding what constitutes a significant change in status must be based upon the judgment of the IDT [Interdisciplinary Team]. The manual revealed, Some Guidelines to Assist in Deciding If a Change is Significant or Not: included a Decline in two or more of the following: which included Any decline in an ADL physical functioning area (at least 1) where a resident is newly coded as Extensive assistance, Total dependence, or Activity did not occur since last assessment and does not reflect normal fluctuations in that individual's functioning. A review of a Resident Face Sheet indicated the facility admitted Resident #26 on 03/22/2023 with diagnoses that included dementia, restlessness and agitation, scoliosis of the lumbar region, reduced mobility, and muscle weakness. A review of Resident #26's quarterly MDS, with an ARD of 03/05/2023, revealed the resident required supervision of one staff member with bed mobility, transfers, and locomotion on the unit and supervision/set-up help for locomotion off the unit. A review of Resident #26's Care Plan, dated 10/04/2019, indicated the resident had a physical functioning deficit related to a self-care impairment. The facility developed interventions that required staff to assist with ADLs as needed and provide frequent cueing to complete ADLs, and to monitor and report changes in physical functioning. A review of the quarterly MDS assessment, with an ARD of 06/02/2023, indicated Resident #26 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident had severe cognitive impairment. The MDS indicated the resident's activities of daily living had declined from the previous MDS with an ARD of 03/05/2023. The resident required extensive assistance of one person for bed mobility and locomotion on and off the unit, and extensive assistance of two or more staff for transfers. During an interview on 08/23/2023 at 9:50 AM, the Interim Director of Nursing/Assistant Director of Nursing (IDON/ADON) stated she was the person that completed MDS assessments for the facility. She stated she knew the resident had a gradual decline but could not say specifically when it occurred without reviewing the record. She stated a significant change MDS should have been completed, but she had not been able to get to it. During an interview on 08/23/2023 at 1:50 PM, the IDON/ADON stated a significant change MDS should be done when a change was identified, which included a change in two different ADL areas. The IDON/ADON stated a significant change assessment should be done within 14 days of the change. During an interview on 08/23/2023 at 2:02 PM, the Administrator stated a significant change MDS should be done when a resident had a significant change. She stated the IDON/ADON completed MDS assessments. 2. A review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019 (Version 1.17.11), revealed, A SCSA [Significant Change in Status Assessment] is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD [Assessment Reference Date] must be within 14 days from the effective date of the hospice election (which can be the same date or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. A review of Resident #8's Care Plan, dated 08/10/2023 revealed the resident had a diagnosis that included immune thrombocytopenic purpura (abnormally low levels of platelets, which are blood cells that control bleeding). A review of the quarterly MDS, with an ARD of 03/03/2023, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. According to the MDS, Resident #8 was not receiving hospice care. A review of a Hospice Certification Form revealed Resident #8 was referred to hospice on 04/07/2023 due to not eating well and losing weight and a long-time diagnosis of thrombocytopenia with a drop in platelets in the last few weeks. The medical director signed the certification on 04/11/2023. A review of Physician's Orders/Plan of Care as of 04/11/2023 revealed Resident #8 was admitted to the hospice program on 04/11/2023. A review of a significant change in status MDS, with an ARD of 06/02/2023, approximately two months after admission to hospice care, revealed the facility completed an MDS that indicated Resident #8 was receiving hospice care. During an interview on 08/23/2023 at 1:50 PM, the Interim Director of Nursing/Assistant Director of Nursing (IDON/ADON) stated a significant change MDS should be done when a change was identified, which included admission or discharge from hospice. The IDON/ADON stated the significant change assessment should be completed within 14 days of the change. During an interview on 08/23/2023 at 2:02 PM, the Administrator stated a significant change MDS should be done when a resident experienced a significant change. She stated the IDON/ADON was responsible for completing MDS assessments.

Based on record review, interviews, and facility policy review, the facility failed to revise a care plan for 1 (Resident #24) of 19 residents reviewed for care plans. Specifically, the facility failed to ensure Resident #24's care plan was appropriately revised when the resident's diet status changed by removing the portions of the care plan that were no longer pertinent. Findings included: A review of an undated facility policy titled, Care Plan Comprehensive, revealed, Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition. The policy further revealed, The interdisciplinary care plan team is responsible for the periodic review and updating of care plans: c. When changes occur that impact the resident's care (i.e., change in diet, discontinuation of therapy, changesin [sic] care areas that do not require a significant change assessment). A review of the Resident Face Sheet indicated the facility readmitted Resident #24 on 06/26/2023 with diagnoses that included abnormal weight loss and dysphagia (difficulty swallowing). The significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/07/2023, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated Resident #24 was totally dependent on one staff for eating, had a feeding tube, and received 51% or more of their total calories through tube feeding and 501 cubic centimeters (cc) of fluid by tube feeding. A review of Resident #24's Care Plan, with a start date of 06/26/2023, indicated the resident was to receive nothing by mouth (NPO) and had a gastric (G) tube in place to receive nutritional requirements. Interventions directed staff to administer tube feeding per orders, record intake and output every shift, and to educate the resident on the importance of allowing the tube feeding to run while out of bed and in their wheelchair due to the resident declining to take the tube feeding out of the room, despite being aware of and having portable means for the tube feeding. A review of Resident #24's Orders revealed physician orders included: - NPO (nothing by mouth) diet, ordered 06/26/2023. - Check J-G tube placement every shift, ordered 06/27/2023. - Flush G-tube with 100 milliliters (mls) of water four times a day, ordered 06/27/2023. - Flush with 20 mls of water after medication pass, ordered 06/26/2023. - Osmolite 1.2 at 65 ml per hour continuous using the J-port, ordered 06/27/2023. A further review of Resident #24's Care Plan revealed it continued to include problem areas and interventions that did not reflect the resident's current status. The Care Plan, with a problem start date of 03/07/2023, indicated the resident required a mechanically altered diet with interventions that included an easy-to-chew diet with ground meat, encourage oral intake of food and fluids, and monitor and record intake of food. The Care Plan, with a problem start date of 03/29/2021, indicated the resident had impaired swallowing with interventions that directed staff to monitor and record intake of food, offer available substitutes if the resident had problems with the food being served, and provide adequate time for the resident to feed self, assist the resident as needed, provide supplements per order, and pureed diet per the resident's request. During an interview on 08/23/2023 at 1:50 PM, the Interim Director of Nursing/Assistant Director of Nursing (IDON/ADON) stated she was responsible for updating the care plans and the care plan should have been updated with diet changes. She confirmed she missed updating Resident #24's care plan when they became NPO to remove the other portions of the care plan that were no longer pertinent. During an interview on 08/23/2023 at 2:02 PM, the Administrator stated the care plan should reflect the resident's current status.

Based on observation, record review, interviews, and facility policy review, the facility failed to assess an open wound for 1 (Resident #8) of 13 sampled residents after hospice staff identified superficial areas to Resident #8's buttocks on 08/04/2023. Findings included: A review of a facility policy titled, Wound Care and Treatment, undated, indicated the guidelines for treatment included, 1. There must be a specific order for the treatment and 22. The care plan should reflect the current status of the wound and appropriate goals and approaches. Prevention strategies included, 1. On-going skin assessment with weekly documentation of status. A review of a significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/02/2023, revealed the facility admitted Resident #8 on 08/31/2019. Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Resident #8 required extensive staff assistance for transfers, bed mobility, locomotion, and toilet use. The MDS indicated Resident #8 had no skin conditions/wounds during the assessment period but was at risk of developing pressure ulcers/injuries. The MDS revealed Resident #8 had a pressure-reducing device for the chair and bed. A review of Resident #8's Care Plan, dated 08/10/2023, revealed the resident had diagnoses that included immune thrombocytopenic purpura (abnormally low levels of platelets, blood cells that control bleeding, causing easy bruising and bleeding), protein-calorie malnutrition, and adult failure to thrive. A Care Plan problem, dated 03/11/2023, for activities of daily living deficits revealed an intervention that directed staff to inspect skin with care, and report reddened areas, rashes, bruising, or open areas to the charge nurse. An interview with Resident #8 on 08/21/2023 at 10:37 AM revealed the resident had a tiny sore on their bottom and the staff were taking care of it. A review of Hospice Staff Facility Chart Documentation, dated 08/03/2023, revealed Resident #8 had superficial skin breakdown/abrasion to the bilateral buttocks and a foam dressing was applied. The note indicated the foam dressing would be changed every three days and as needed. A review of an email from the hospice facility, dated 08/23/2023 at 12:54 PM, revealed on 08/03/2023, Resident #8 had skin abrasions to the left buttock. The area was a purple, moist, fragile area of skin measuring 5.5 centimeters (cm) by (x) 5.5 cm. In the center of the area, was two small abrasions. The top one measured 1 cm x 0.5 cm and the bottom one measured 1 cm x 1 cm. A review of the Long Term Care/Hospice - Coordination of Care Form revealed on 08/03/2023, hospice staff noted that facility staff would treat the sacrum (at the base of the spine, above the tailbone) with foam border foam every three days and as needed until healed. During a telephone interview on 08/23/2023 at 9:16 AM, the Hospice Registered Nurse (RN) stated the resident's buttocks had some very superficial areas. She stated she contacted the nurse practitioner (NP) and obtained an order for a foam border. The Hospice RN did not discuss the specific type of wound but felt it was probably due to incontinence and sitting in a wheelchair much more often. Review of facility Resident Progress Notes for Resident #8, dated 08/03/2023 at 8:49 AM, revealed per the hospice nurse, staff were to apply a dry dressing to the open areas on Resident #8's buttocks every three days and as needed until the areas were healed. A review of an Observation Detail List Report [Weekly Skin Assessment], dated 08/04/2023 at 3:46 PM, revealed RN #3 documented that Resident #8 had an open area on buttocks with treatment plan. There was no description of the wound, the wound size, color of the wound, nor whether there was drainage. A review of Resident Progress Notes, dated 08/12/2023 at 4:09 PM, revealed RN #3 documented there appears to be three very small areas of open skin that appears to be related to shearing. There was no evidence of further assessment of the wounds, including a description of the color, size, nor drainage. A review of an Observation Detail List Report [Weekly Skin Assessment] revealed there was no documented evidence the facility completed another weekly skin assessment until 08/18/2023 (14 days between weekly skin assessments). A review of the skin assessment completed by RN #3 on 08/18/2023 at 4:31 PM revealed the resident's skin was intact; however, the comments section indicated Resident #8 had an open wound to the buttocks area and a treatment was in place. There was no description of the wound to include the size, color, nor whether the wound was draining. During an interview on 08/23/2023 at 9:41 AM, RN #3 stated Resident #8's skin assessment was documented in the computer health record. RN #3 stated that the wound areas were very pinpoint in size, approximately 0.5 to 1 cm. An observation of the Interim Director of Nursing/Assistant Director of Nursing (IDON/ADON) providing wound care to Resident #8 on 08/22/2023 at 11:35 AM, revealed an open area to the left buttock, measuring approximately 0.2 centimeters (cm) by 0.2 cm. The area was pink with no drainage. An interview with the IDON/ADON on 08/22/2023 at 3:36 PM, revealed Resident #8's skin area had not been classified nor measured. She and the Hospice RN had discussed it and felt it was most likely moisture related. The IDON/ADON stated if the wound were classified as a pressure ulcer, the facility would have weekly documented assessments, including the stage and tissue appearance. An interview with the NP on 08/23/2023 at 11:31 AM revealed Resident #8 had a red 5 cm area that was moisture based with two small openings. Due to chronic hip pain, the resident refused to off load. The NP stated the open area was not over a bony prominence on the left buttock and was moisture associated. The NP stated that Resident #8 had slept in the recliner for five years and refused to get in bed. The NP stated that due to thrombocytopenia, the resident would continue to decline. The Administrator stated on 08/23/2023 at 2:13 PM that a skin assessment should be completed, and the care plan should be updated for any wound.

Based on observations, record reviews, facility policy review, and interviews, it was determined that the facility failed to perform assessments and obtain consents for bed rails for 3 (Residents #19, #24, and #26) of 3 residents reviewed for the use of bed rails. This affected 27 residents that had bed rails on their bed. Findings included: A review of an undated facility policy titled, Bed Rails, indicated, Once the Bed Rail observation is completed, the facility will print the observation and review associated risks and benefits with the resident and/or resident representative. After the review is complete, the resident and/or resident representative will sign the consent line and the nurse will sign as well. The policy further indicated, Educate the resident/legal representative on the benefits and risks of bed rail use. Develop a care plan that outlines the medical factors necessitating bed rails and an explanation of how the use of a bed rail is intended to treat the specific resident's condition. 1. A review of a Resident Face Sheet indicated the facility admitted Resident #19 on 05/11/2023 with diagnoses that included cerebral infarction (stroke) with hemiplegia and hemiparesis (one-sided muscle paralysis or weakness) following unspecified cerebrovascular diseases affecting the left non-dominant side, reduced mobility, weakness, unsteadiness on feet, and abnormalities of gait and mobility. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/18/2023, revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required limited assistance from staff with bed mobility and transfers and indicated bed rails were not used as a restraint. A review of Resident #19's Care Plan, with a problem start date of 03/14/2023, indicated the resident had a physical functioning deficit related to self-care impairment. Interventions included assistive devices as needed and assist rails on bed to aid with bed mobility and transfers. Observation on 08/22/2023 at 3:20 PM revealed the bed in Resident #19's room had one bed rail on the outside, with the bed pushed up against the wall. During an interview on 08/22/2023 at 4:22 PM, Resident #19 stated they used the bed rail every day to get out of bed. The resident stated the rail was loose, but they kept forgetting to tell anyone. A review of Resident #19's electronic health record (EHR) and paper chart revealed no consent or assessment for the use of the bed rail. During an interview on 08/23/2023 at 11:20 AM, Certified Nursing Assistant (CNA) #2 stated she did not know if bed rail assessments were completed or by whom. She stated maintenance would put the bed rails on if the resident needed them. CNA #2 stated Resident #19 used their bed rails for transfers. During an interview on 08/23/2023 at 11:33 AM, Certified Medication Tech (CMT) #1 stated the nurse did the bed rail assessments but she was not sure when or how often they were completed. She stated the bed rails were used for bed mobility and transfers and were not restraints. During an interview on 08/23/2023 at 11:52 AM, CNA #4 stated bed rails were used for positioning and transferring. CNA #4 stated Resident #19 used their bed rails for transferring. 2. A review of a Resident Face Sheet indicated the facility admitted Resident #24 on 03/06/2020 with diagnoses that included a non-displaced fractur of the fourth cervical vertebra, abnormalities of gait and mobility, and generalized muscle weakness. The significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/07/2023, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident required supervision for bed mobility and was independent with transfers and indicated bed rails were not used as a restraint. A review of Resident #24's Care Plan, with a problem start date of 03/06/2020, indicated the resident had a physical functioning deficit related to requiring assistance with activities of daily living (ADLs). Interventions included assistive devices as needed and assist rails on bed to aid with bed mobility and transfers. Observation on 08/21/2023 at 10:30 AM revealed Resident #24 had a quarter rail at the top of the bed on the resident's left-hand side. Observation on 08/23/2023 at 12:16 PM revealed Resident #24 lying in bed, and the bed had a quarter rail at the top of the bed on the resident's left-hand side with the call light, oxygen cannula, and urinal hanging on it. During an interview at that time, Resident #24 stated they used the rail to roll over in the bed and put their stuff on, so they did not lose it. A review of Resident #24's electronic health record (HER) and paper chart revealed no consent or assessment for the use of the bed rail. During an interview on 08/23/2023 at 11:20 AM, Certified Nursing Assistant (CNA) #2 stated she did not know if bed rail assessments were completed or by whom. She stated maintenance would put the bed rails on if the resident needed them. CNA #2 stated Resident #24 used their bed rails for bed mobility and would put their call light and urinal on the rail. During an interview on 08/23/2023 at 11:33 AM, Certified Medication Tech (CMT) #1 stated the nurse did the bed rail assessments but she was not sure when or how often they were completed. She stated the bed rails were used for bed mobility and transfers and were not restraints. During an interview on 08/23/2023 at 11:52 AM, CNA #4 stated bed rails were used for positioning and transferring. CNA #4 stated Resident #24 used their bed rails for positioning and to hold their personal items. 3. A review of a Resident Face Sheet indicated the facility admitted Resident #26 on 08/30/2021 with diagnoses that included dementia, reduced mobility, unsteadiness on feet, generalized muscle weakness, and abnormalities of gait and mobility. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/02/2023, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required extensive assistance from staff for bed mobility and transfers and indicated bed rails were not used as a restraint. A review of Resident #26's Care Plan, with a problem start date of 10/04/2019, indicated the resident had a physical functioning deficit related to self-care impairment and dementia. Interventions included assistive devices as needed and assist rails on bed to aid with bed mobility and transfers. Observation on 08/21/2023 at 11:23 AM revealed Resident #26's bed had a quarter rail at the top of the bed with the bed and rail pushed up against the wall. A review of Resident #26's electronic health record (EHR) and paper chart revealed no consent or assessment for the use of the bed rail. During an interview on 08/23/2023 at 11:20 AM, Certified Nursing Assistant (CNA) #2 stated she did not know if bed rail assessments were completed or by whom. She stated maintenance would put the bed rails on if the resident needed them. CNA #2 stated Resident #26 used their bed rails to assist in holding themself over in bed while care was being provided. During an interview on 08/23/2023 at 11:33 AM, Certified Medication Tech (CMT) #1 stated the nurse did the bed rail assessments but she was not sure when or how often they were completed. She stated the bed rails were used for bed mobility and transfers and were not restraints. During an interview on 08/23/2023 at 11:52 AM, CNA #4 stated bed rails were used for positioning and transferring. CNA #4 stated Resident #26 used their bed rails for positioning in bed. During an interview on 08/22/2023 at 3:01 PM, the Interim Director of Nursing/Assistant Director of Nursing (IDON/ADON) stated she had not completed any bed rail assessments in a couple of years. She stated they used to be completed on paper and she just stopped doing them. She stated none of the residents with bed rails had consents or assessments. She was not able to say why the assessments were not completed; it was just something that fell off the radar of things that needed to be done. During an interview on 08/23/2023 at 1:50 PM, the IDON/ADON stated they needed to have a consent for bed rails and was unsure how often assessments should be completed without looking at the policy but thought the assessments should be done quarterly by the MDS nurse, which was the IDON/ADON. She stated the bed rail assessments were not completed because she prioritized other things over the bed rail assessments. She indicated Resident #19 and Resident #24 used their bed rails for bed mobility and positioning and that she would have to assess Resident #26's need for bed rails, but at one time the resident used them for bed mobility. During an interview on 08/23/2023 at 2:02 PM, the Administrator stated the facility should have consents for the use of bed rails, and bed rail assessments should be completed annually or depending on if the resident had a change, then they should be reassessed. She stated the IDON/ADON was responsible for doing the assessments and she did not know why the assessments were not done but was aware that they were not completed. She stated the facility considered the bed rails an enabler bar and not a bed rail and did not think it required all the paperwork and assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and facility document and policy review, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 36 out of 59 beds in the facility with bed rails. Findings included: Review of an undated policy titled, Bed Rails, revealed, Staff will conduct regular inspections of all bedframes, mattresses, and bed rails, to identify areas of possible entrapment. On 08/22/2023 at 3:11 PM, the Administrator provided a handwritten list of residents titled Assit [sic] Rails that listed 27 beds with rails (16 beds with two bed rails and 11 beds with one bed rail). Observations on 08/22/2023 between 3:20 PM and 3:31 PM revealed 31 occupied beds in the facility had either one or two bed rails. The facility census was 38. During an interview on 08/22/2023 at 3:11 PM with the Administrator and the Maintenance Director after maintenance logs for the beds and rails had been requested, the Maintenance Director stated she had not done bed checks or bed rail checks in over two years and, therefore, could not provide any maintenance logs. The Maintenance Director stated she knew how to perform the checks and check for areas of potential entrapment. The Maintenance Director was unable to explain why the checks had not been completed. During an interview on 08/22/2023 at 4:36 PM, after inspection of the bed rail on the bed in room [ROOM NUMBER] revealed the rail was loose, the Maintenance Director stated she would tighten the rail and check all the beds with rails to ensure they were tight. On 08/23/2023, the facility provided a document titled Midnight Census Worksheet containing an updated list of all beds in the facility and denoting whether the bed had one rail, two rails (indicating one on each side of the bed), or no rails. Out of 59 beds in the facility, 36 beds had rails (including unoccupied beds). Specifically, the document indicated 15 beds had one rail, and 21 beds had two rails. During an interview on 08/23/2023 at 1:50 PM, the Interim Director of Nursing (IDON) stated the maintenance department was responsible for bed inspections. During an interview on 08/23/2023 at 2:02 PM, the Administrator stated bed rails should be inspected monthly by maintenance staff. The Administrator stated she did not know why the inspections had not been completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop, implement and revise comprehensive, person centered care plans for two residents (Resident #10 and #32) in a review of 12 sampled residents. The facility census was 34. Review of the Resident Assessment Instrument (RAI) Manual, dated 10/1/19, showed the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan is an interdisciplinary communication tool. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and any services that would otherwise be required but are not provided due to the resident's exercise of rights including the right to refuse treatment. The Care Area Assessments (CAA)'s provide a link between the Minimum Data Set (MDS), a federally mandated assessment tool, completed by the facility staff, and care planning . The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving. Review of the facility's policy Care Plan Comprehensive, dated March 2015, showed the following: -An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental and psychosocial well-being; -Assessment of each resident is ongoing and the care plan will be revised as changes occur in the resident's condition; -The comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment; -Periodic review and updating of care plans will occur: a. When a significant change in the resident's condition has occurred; b. At least quarterly; c. when changes occur that impact the resident's care (i.e. change in diet, change in care areas). 1. Review of Resident #10 admission MDS, dated [DATE], showed the following: -Severe cognitive impairment; -No hallucinations, delusions, or behaviors; -Requires limited assistance of one staff member for eating; -Requires extensive assistance of two or more staff members for bed mobility, toilet use, and transfers; -Frequently incontinent of bladder occasional bowel; -At risk for pressure ulcers; -Antipsychotics, antidepressants received everyday; -Section V triggered care areas of concern: cognitive loss/dementia, urinary incontinence, falls, nutritional status, pressure ulcer, and psychotropic drug use; -Facility staff documented all care areas of concern would be addressed in the care plan. Review of the resident's care plan, dated 11/17/19, showed the following: -Discharge plans; -Activities; The care plan did not include instruction to the staff to address cognitive loss/dementia, urinary incontinence, falls, nutritional status, pressure ulcer, or psychotropic drug use. During an interview on 1/15/20, at 3:31 P.M., the assistant director of nursing (ADON) said: -She was responsible to ensure the care plan is complete; -The comprehensive care plan should be completed within 21 days of admission; -The resident's care plan was not completed; -It was overlooked. 2. Review of Resident # 32's annual MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Weight 188 pounds (lbs.); -Supervision of a staff member for bed mobility; -Limited assistance of one staff member for bed mobility, transfers, and toilet use. Review of the resident's quarterly MDS, dated [DATE] showed the following: -Moderate cognitive impairment; -Weight 188 pounds; -Requires extensive assistance of one staff member for bed mobility, transfers, and toilet use. Review of the resident's quarterly MDS, dated [DATE] showed the following: -Moderate cognitive impairment; -Weight 168 pounds (10.6% weight loss); -Significant weight loss not prescribed by the physician; -Requires extensive assistance of two or more staff members for bed mobility, transfers, and toilet use. Review of the resident's wound assessment, showed the resident returned from the hospital on 1/3/20 with two pressure ulcers. Review of the resident's care plan, last updated 1/14/20, showed the following: -At risk for weight loss with interventions dated 11/4/16; -At risk for pressure ulcers with interventions last updated 1/7/20; -Offer assistance with transfers as the resident will allow and use a gait belt last updated 11/10/18; -Assist with bed mobility dated 11/4/16; -Provide incontinence care after each incontinent episode dated 11/4/16. Observation on 1/13/20, at 12:30 P.M., showed the resident had a protective boot on his/her right foot to below his/her knee. Observation on 1/14/20, at 7:59 A.M., showed the resident had a protective boot on his/her right foot to below his/her knee. Observation on 1/14/20, at 9:10 A.M., showed the following: -The resident had a protective boot on his/her right leg; -The director of nursing (DON) provided wound care to the resident's pressure ulcer on the right heel, a diabetic ulcer on the right ankle, and a pressure ulcer on the resident's left heel; -After wound care the DON placed a protective boot to each of the resident's legs, from the resident's foot to below the knee. Observation on 1/15/20, at 9:56 A.M., showed the resident had a protective boot on his/her right foot to below his/her knee. Review of the resident's care plan did not include an update of the increased assistance or staff needed with the MDS reviews in September 2019 and December 2019, or updates and evaluation of interventions or added interventions with the resident's significant weight loss identified in the December 2019 MDS, updates and interventions when the resident returned from the hospital with two new pressure ulcers on 1/3/20, or the use of pressure relieving boots. During an interview on 1/16/20, at 11:15 A.M., the ADON said the comprehensive care plans should be updated quarterly with the MDS and with changes to the resident's care. She was out on leave and may be behind on some updates. During an interview on 1/16/20, at 3:21 P.M., the DON said the following: -She and the ADON update the care plans; -The ADON updates the care plan with the quarterly MDS; -Both she and the ADON update the care plan with changes to the resident's care like new wounds, falls, weight loss as they occur; -She was not sure how they missed the updates to the resident's care plan.

Based on observation, interview, and record review, the facility failed to follow physician's orders and obtain medication timely for a yeast infection for one resident (Resident #21) in a review of 12 sampled residents. The facility census was 34. 1. During interview on 1/16/2020 at 2:55 P.M., the associate director of nursing (ADON) said the facility did not have a policy regarding following physician's orders. 2. Review of Resident #21's physician's orders dated 12/14/19-12/20/19, showed the resident's diagnoses included candidiasis (yeast infection), type 2 diabetes mellitus with diabetic chronic kidney disease. Review of the resident's progress notes dated 1/13/2020 at 7:07 P.M., showed the following: -The resident's family member called the charge nurses in the later afternoon and requested the resident called him/her and wanted the Monistat (antifungal medication) back like he/she had before; -The family member requested the charge nurse check if the resident had any concerns in the perineum and genitalia; -The charge nurse assessed the area with no redness, rash, or irritation noted and called the family member to let them know. During interview on 1/13/2020 at 10:10 A.M., and on 1/14/2020 at 5:53 A.M., the resident said when he/she urinates, it itches and bothers him/her in the perineal area. His/Her perineal area had a rash, it was itchy and hurt down in his/her bottom. He/She had used cream before for the itching and burning twice a day and only got it put on once a day and needed it again. He/She had told different staff but it had not been ordered. Review of the resident's progress notes dated 1/14/2020 at 5:18 P.M., showed the facility received a physician's order for Monistat one tube every day for three days. Review of the resident's medical record showed a new order for Monistat cream 3- 200 milligrams (mg)/5 grams (gm) 1 tube once a day and ordered on 1/14/20. During interview on 1/15/2020 at 10:15 A.M., the resident said he/she was waiting for the Monistat cream to come from the pharmacy today. He/she was itching and burning in his/her perineal area. During interview on 1/16/2020 at 11:05 A.M., the resident said the pharmacy did not bring the Monistat cream yesterday, and he/she was going to call his/her family member again to call the physician. During interview on 1/16/2020 at 11:16 A.M., Registered Nurse (RN) C said the resident hadn't got the Monistat cream yet. He/She checked the medication room and the medication cart and it was not there. He/She said the pharmacy delivered once a day and it may not come until the next day if ordered in afternoon from the local pharmacy in town. He/She called the facility pharmacy and they had received the physician's order but had not sent the Monistat cream. The Monistat cream was order on 1/14/20 (two days ago.) During interview on 1/16/2020 at 3:18 P.M., the resident said the itching and burning was in his/her genitalia. During interview on 1/16/2020 at 3:22 P.M., the Director of Nursing said the following: -The order for the Monistat cream did not come in until after 5:00 P.M. on 1/14/2020 and the local pharmacy was closed; -Staff faxed the physician's order to the local pharmacy, but they did not bring it on the 15th to the facility; -The local pharmacy sent this on to the facility pharmacy since they did not know who to bill the medication for; -The facility pharmacy will not deliver over-the-counter medication such as Monistat cream to the facility; -Staff should have gone to pick the medication up from the pharmacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain housekeeping and maintenance services to maintain a clean, comfortable and homelike environment for the residents. The facility census was 34. Observation on 1/13/20, at 10:24 A.M., on the 100 hallway showed the following: -Each residents' room door was scratched the entire width, in several places from the middle of the door to the bottom of the door; -A piece of handrail was missing at the beginning of the 100 hall by room [ROOM NUMBER]; -The doors to storage areas and offices on the 100 hallway were scratched and marred; -The door to the shower room had deep scratches and chips to the exterior, exposing the particles inside the door; -The shower room wall, located to the right of entrance to the shower room, was scratches and marred. The lower trim board was missing paint and the wood underneath was exposed; -The shower room wall, located next to shower and heater control, had an area where the dry wall was patched and had not been sanded or painted; -The walls in the storage area, located in the shower room, had areas where the drywall was patched and was not sanded or painted; -The mirror in the shower room mirror was propped up on the sink behind the faucet and was not mounted to the wall; -The tile floor at the threshold to the shower room was cracked; -In room [ROOM NUMBER] B, the wall behind the resident's recliner was patched and not painted; -In the bathroom in room [ROOM NUMBER], the baseboard was not attached to the wall; -In room [ROOM NUMBER], the wall by bed A was patched with drywall compound but was not painted, and the wall by the window was scratched which exposed dry wall; -In the bathroom in room [ROOM NUMBER], an approximately 2 inch wide area of the drywall surrounding the soap dispenser was exposed; -In room [ROOM NUMBER], the floor tile at the entrance to the room was chipped; -In room [ROOM NUMBER] B, the floor tiles right inside the room had chipped corners, and the area between the tiles behind the door was dark and discolored; -The finish on the door to the medication room, located at the nurses station, was coming off the door; -In the nurses station, the cabinets and counters had exposed particle board, the cabinet doors were broken off at the hinges, and edge trim was missing off the counter; -The floor tiles, located in the area of the 200 hall and the back hall to the employee entrance, were discolored; -Floor tiles behind the nurses station were broken in half and exposed the sub-floor. Observation on 1/15/20 at 11:30 A.M. on the 200 hall, showed the following: -Each handrail was scratched and marred the full length of the rails; -Each resident's room door was scratched the entire width of the door in several places from the middle of the door to the bottom of the door; -In room [ROOM NUMBER], the mini blinds at the window were crinkled, twisted, and bent in several places. The trim around the bathroom door was scratched and marred. The flooring behind the toilet and the sink had dark staining, and the cove base along the floor had dark grime at the floor level; -In room [ROOM NUMBER], the resident's door was gouged at the bottom of the door. The wall cove base by the resident's bathroom was chipped to the dry wall. The dresser edges were chipped and rough. There was a dark stain in the toilet and no roller to hold the toilet paper. The flooring in the bathroom was cracked against the wall by the toilet. Observation on 1/16/20 at 10:55 A.M. showed the following: -In room [ROOM NUMBER], the walls were scuffed and the resident's closet was gouged and chipped on the side which measured approximately 2 inches by 2.5 inches. The resident's room door was gouged and scratched across the entire width in several places on the lower half of the door. The door frame was gouged in places. The wall surrounding the soap dispenser was pulled out, torn, and exposed the dry wall. The linoleum in the bathroom was loose behind the toilet, the sink, and beside the toilet on the wall below the cove base. The dresser next to bed A was scuffed, scratched, and marred on the sides. The small dark dresser top was scratched and marred. The curtain rod screws were loose at the top and the rod was falling down; -In room [ROOM NUMBER], the lower half of the room door was scratched the width of the door in several places to the bottom of the door. In front of the baseboard heater under the window, the tile was dark and had a dirty appearance. The top of the brown dresser next to the resident's closet was marred and chipped. The cove base next to the bathroom was missing. The linoleum in the bathroom was stained behind the toilet. The wall surrounding the soap dispenser was pulled out, torn, and exposed the drywall; -In room [ROOM NUMBER], the room door was scratched the full width of the door in several places from the middle of the door down to the bottom of the door; -In room [ROOM NUMBER], the room door was scratched the full width of the door in several places from the middle of the door down to the bottom of the door and gouged on the side of the door frame. The wall surrounding the wall soap dispenser was torn to the dry wall and was not painted. During an interview on 1/16/20 at 8:15 A.M., the maintenance director said staff made environmental rounds monthly. Most of the problems discussed had been identified. It was difficult to find matching tiles to replace the broken tiles, and the painting and repairs were not done due to time and budget issues. During an interview on 1/29/20, at 2:00 P.M., the administrator said the maintenance director was behind on maintenance repairs because has been assisting to cover transportation of the resident's to physician appointments, from the hospital, and other task as needed because of the employee that usually does the bulk of the transportation has been on medical leave.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, for three residents ( Residents #8, #14, and #32) in a review of 12 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 34. 1. Review of the Long Term Care Facility RAI User's Manual, version 3.0 showed a significant change is a decline or improvement in a resident's status that: -Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting; -Impacts more than one area of the resident's health status; -Requires interdisciplinary review and/or revision the care plan. The manual also showed a SCSA was appropriate if there was a consistent pattern of changes, with either two or more areas of decline, or two or more areas of improvement. This may include two changes within a particular domain (e.g., two areas of activities of daily living (ADL) decline or improvement). 2. Review of Resident #8's admission MDS dated [DATE], showed the following: -Supervision with one staff assistance for bed mobility; -Limited assistance of one staff for transfers; -Supervision with one staff assistance for dressing and personal hygiene; -Limited assistance of one staff to use the toilet Review of the resident's quarterly MDS dated [DATE], showed the following: -Independent in bed mobility; -Independent in transfers; -Independent in dressing and personal hygiene; -Independent in using the toilet. Review of the resident's quarterly MDS dated [DATE], showed the following: -Improvement from supervision of one staff assistance to independent in bed mobility; -Improvement from limited assistance of one staff to independent in transfers; -Improvement from supervision of one staff assistance to independent in dressing and personal hygiene; -Improvement from limited assistance of one staff to independent in using the toilet. During interview on 1/13/2020 at 10:25 A.M., the resident said he/she was pretty much independent in all activities of daily living and planned to discharge soon to an assisted living facility as soon as a room became available. Observation on 1/15/2020 at 10:05 A.M. showed the resident transferred him/herself from the bed to the wheelchair and then wheeled down the hall to the dining room for activities. During interview on 1/16/2020 at 2:55 P.M., the Assistant Director of Nursing (ADON) who completed the MDS process, said the resident had an amputation (removal) of his/her left lower leg but had improved in his/her activities of daily living and should have had a significant change assessment completed. 3. Review of Resident #14's annual MDS dated [DATE], showed the following: -No mood or behaviors noted; -Supervision with one staff assistance for bed mobility; -Limited assistance of one staff to transfers, dressing, and using the toilet; -Complete dependence on one staff for bathing; -Occasionally incontinent of bladder. Review of the resident's quarterly MDS dated [DATE], showed the following: -Feeling tired and having little energy from two to six days a week; -Verbal behaviors occurred one to three days per week; -Limited assistance of one staff for bed mobility; -Extensive assistance of one staff to transfer; -Extensive assistance of one staff for dressing; -Extensive assistance of one staff to use the toilet; -Extensive assistance of one staff for bathing; -Frequently incontinent of bladder. Observation on 1/14/2020 at 6:17 A.M., showed Certified Nurse Assistant (CNA) A assisted the resident to sit up on the side of the bed and put socks on the resident; -CNA A removed the resident's oxygen per nasal cannula, put underclothing on the resident, and then the resident's shirt before placing the oxygen nasal cannula back on the resident; -CNA A transferred the resident from the bed to the wheelchair with the gait belt; -The resident wheeled self to the bathroom as CNA A pulled the oxygen concentrator behind the resident; -The resident reached for the grab bar next to the toilet, and CNA A assisted the resident to the toilet; -CNA A removed the resident's incontinence brief which was dampened with urine; -While the resident was sitting on the toilet, CNA A cleaned the resident's top dentures at the sink and gave them to the resident who put them in; -CNA A assisted the resident to stand, and then provided pericare as the resident held on to the grab bar; -CNA A transferred the resident back into the wheelchair and pushed the resident in the wheelchair to the dining room. The facility did not complete a significant change in status assessment when the resident had new verbal behaviors, required limited assistance of one staff for bed mobility, and extensive assistance of one staff to transfer, dress, and use the toilet. The resident's occasional bladder incontinence worsened to frequently incontinent of bladder. During interview on 1/16/2020 at 2:55 P.M., the ADON who completed the MDS process, said the resident's activities of daily living had been declining. The resident was on hospice care for the high levels of oxygen the resident required and needed a significant change MDS. 4. Review of Resident #32's annual MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Weight 188 pounds (lbs.); -Supervision of a staff member for bed mobility; -Limited assistance of one staff member for bed mobility, transfers, and toilet use. Review of the resident's quarterly MDS, dated [DATE] showed the following: -Moderate cognitive impairment; -Weight 188 pounds; -Requires extensive assistance of one staff member for bed mobility, transfers, and toilet use Review of the resident's quarterly MDS, dated [DATE] showed the following: -Moderate cognitive impairment; -Weight 168 pounds (10.6% weight loss); -Significant weight loss not prescribed by the physician; -Requires extensive assistance of two or more staff members for bed mobility, transfers, and toilet use. Review of the resident's medical record showed a SCSA were not completed in September 2019 with two or more changes in the resident's ADL's, or in December with the same ADL changes and a significant weight loss. During an interview on 1/15/20, at 9:45 A.M., CNA D said the following: -The resident has declined over the past few months and needs more assistance; -He/She doesn't eat well, and he/she has lost weight; -The resident was a lot weaker since he/she came back from the hospital. During interview on 1/16/2020 at 2:55 P.M., the ADON said the resident should have had a significant change assessment completed. 5. During an interview on 1/16/20, at 3:21 P.M., the director of nursing (DON) said the ADON completes a SCSA when there is a significant decline or improvement in the resident. A significant change would be two or more changes in the resident's ADL's or two or more areas of the resident's care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan consistent with the resident's specific condition, needs and risks to provide person centered care that met professional standards of quality care, and reviewed or provided a printed copy to the resident/responsible party for four residents ( Resident #8, #137, #6,and #10) in a review of 12 sampled residents, and one additional resident (Resident #187). The facility census was 34. 1. Review of Resident #8's Electronic Medical Record (EMR) showed the following: -Admit 7/1/2019; -Diagnoses of chronic pain, stress fracture of left tibia (lower leg bone), depression, acquired absence of left leg below knee, and edema. Review of the resident's EMR showed no interim care plan to meet the resident's immediate needs completed within 48 hours of facility admission. 2. Review of Resident #137's EMR showed the following: -Admit 5/21/2019; -Diagnoses of heart failure, hyperkalemia (low potassium level), urinary tract infection (bladder infection),chronic venous hypertension with ulcer of left lower extremity (left ankle open wound), muscle weakness, fracture of right fibula (lower leg bone), pain, depression, and muscle spasm. Review of the resident's EMR showed no interim care plan to meet the resident's immediate needs completed within 48 hours of facility admission. During interview on 1/15/2020 at 3:30 P.M., the Director of Nursing (DON) said staff did not complete a baseline care plan for either Resident #8 and Resident #137. Staff should have completed one within 72 hours of admission and then went over this information on the telephone with the resident and/or family. 3. Review of Resident #6's EMR showed the following: -Admit 7/22/2019; -Diagnoses of cervicalgia (neck pain), edema (swelling), pain in right and left legs, myalgia (muscle pain), hypoxemia (low oxygen level), cognitive communication deficit, dysphagia (difficulty swallowing), corneal ulcer (eye ulcer), dizziness and giddiness, and anxiety. Review of the resident's baseline care plan dated 7/24/2019 showed the baseline care plan had no completion signature and no evidence staff reviewed the care plan with the resident and/or family. During interview on 1/15/2020 at 4:08 P.M., the DON said she went over the base line care plan over the telephone with the family and did not give a copy of the baseline care plan to the resident and family unless they requested a copy. The resident's family only comes to the facility once in a while. 4. Review of Resident #10's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses include dementia, delusional disorder (believing things than are not objectively true), depression, abnormal gait, and chronic pain. Review of the resident's baseline care plan, dated 11/5/19, showed the following: -The baseline care plan was not completed within 48 hours of admission; -Work history showed staff completed on 11/5/19 (resident admitted on [DATE]); The baseline care plan did not contain signature or date of review with the resident/responsible party, or that a printed copy was given to the resident/responsible party 5. Review of Resident #187's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses include: congestive heart failure, chronic kidney disease, pain, and diabetes (inability to regulate blood sugar). Review of the resident's baseline care plan, undated, showed the following: -The baseline care plan was not completed within 48 hours of admission; -Work history showed information added to the blank document on 1/11/20; -Not completed. The baseline care plan did not contain signature or date of review with the resident/responsible party, or that a printed copy was given to the resident/responsible party. 6. During an interview on 1/15/20, at 3:31 P.M., the assistant director of nursing (ADON) said the following: -The charge nurse that admits a resident starts the baseline care plan; -She reviews and completes the baseline care plan; -The care plan is reviewed with the resident/responsible party; -The resident/responsible party signs the baseline care plan, then; -She scans the baseline care plan into the electronic medical record; -The baseline care plan must be completed within 72 hours. During interview on 1/15/2020 at 4:08 P.M., the DON said the baseline care plan was to be completed within 72 hours of the resident's admission to the facility. The facility had no policy for baseline care plans. Baseline care plan items are generally discussed with the resident/responsible party. A copy is not given to the resident/responsible party unless requested.