**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 1 of 12 sampled residents (Resident #1). This deficient practice had the potential to deprive the resident of a person-centered care plan and the associated interventions relative to their current health management needs. Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of generalized anxiety disorder. A physician's order dated 10/15/2024, documented Buspirone Hydrochloride (HCl) oral tablet 10 milligrams (mg). Give 10 mg by mouth three times a day related to generalized anxiety disorder. Resident #1's physician orders lacked documentation of an antipsychotic medication. A quarterly MDS assessment dated [DATE], Section N0415 (Medications - High-risk Drug Classes: Use and Indication), documented Resident #1 took antipsychotic medications during the seven-day look-back period. The MDS assessment lacked documentation Resident #1 took antianxiety medications during the seven-day look-back period. Resident #1's February 2025 Medication Administration Record (MAR), documented Buspirone HCl was administered daily 02/01/2025-02/28/2025. The MAR lacked documented evidence an antipsychotic was administered to Resident #1. On 04/10/2025 at 9:20 AM, the Assistant Director of Nursing/MDS Coordinator verbalized Resident #1 did receive Buspirone HCl and did not receive an antipsychotic medication during the MDS assessment's seven-day look-back period. The MDS Coordinator confirmed Resident #1's MDS assessment did not indicate an antianxiety medication was received but should have, and documented an antipsychotic medication was received but should not have. The facility policy titled, MDS Process, dated 08/11/2003, documented if a revision was needed, the MDS Coordinator would be notified, and the revision would be made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #14 Resident #14 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type II diabetes mellitus without complications, hyperglycemia, unspecified, and irritable bowel syndrome with diarrhea. On 04/07/2025 at 10:30 AM, Resident #14 verbalized the resident had been hospitalized for a low sodium level and was still experiencing frequent nausea from low sodium levels. A Progress Note, dated 12/09/2024, documented the resident was transferred to the Emergency Department (ED) for evaluation and subsequent admission for observation due to hyponatremia (low sodium levels). A Progress Note, dated 12/24/2024, documented the resident was sent to the ED for a critical low sodium level of 108 (the laboratory documented a reference range for a normal sodium level would be between 136 to 145 millimoles per liter (mmol/L). A Laboratory Report for Resident #14 documented the resident had a low sodium level of 129 mmol/L on 03/05/2025, a low sodium level of 133 mmol/L on 03/12/2025, and a low sodium level of 131 mmol/L on 03/19/2025. The Care Plan for Resident #14 did not include a care plan to address the ongoing concern of low sodium levels or symptoms of low sodium levels for the resident. On 04/09/2025 at 11:14 AM, the Registered Nurse (RN) for Resident #14 verbalized the Director of Nursing (DON) was responsible for updating the care plan. The RN verbalized the resident's low sodium levels had resulted in the resident experiencing symptoms of nausea, altered mental status, and changes in eating and drinking habits. The RN verbalized the cause of the low sodium levels had not yet been determined. The RN confirmed the resident did not have a care plan addressing the concerns of low sodium levels and the symptoms and interventions to alleviate symptoms should have been care planned. On 04/09/2025 at 2:45 PM, the DON confirmed the DON would frequently document the care plans but any nurse caring for a resident could document in the care plan. The DON confirmed Resident #14 did not have a care plan related to the resident's low sodium levels and verbalized a care plan would have been helpful to the nurses managing the resident's symptoms. The facility policy titled Care Plans, revised 03/22/2017, documented each resident would have a comprehensive person-centered care plan developed by the interdisciplinary team. The care plans would be updated as the needs of the resident changed. Comprehensive person-centered care plans must include measurable objectives and timeframes to meet a resident's mental and psychosocial needs. Comprehensive care plans must meet the requirements of the baseline care plans to incorporate physician orders. Based on interview, clinical record review, and document review, the facility failed to 1) develop a person-centered Comprehensive Care Plan for the use of psychotropic medications for 1 of 12 sampled residents (Resident #18), and 2) ensure a resident's persistent symptoms associated with an ongoing concern of a low sodium level were care planned for 1 of 12 sampled residents (Resident #14). These deficient practices had the potential to result in health management concerns to remain unidentified and unaddressed. Findings include: Resident #18 Resident #18 was admitted to the facility on [DATE], with a primary diagnosis of disorder of brain, unspecified. A physician's order dated 04/03/2025, documented Lorazepam oral concentrate 2 milligrams (mg) per milliliter (ml), give 0.5 ml by mouth every four hours as needed for terminal agitation for 14 days. Resident #18's health record lacked documented evidence a care plan had been developed to include Resident #18's Lorazepam. On 04/10/2025 at 9:23 AM, the Assistant Director of Nursing (ADON) verbalized it was important for care plans to include psychotropics to facilitate communication across shifts and to ensure residents received needed care. The ADON confirmed the Lorazepam was not addressed in Resident #18's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to 1) ensure a resident's nutrition care plan was updated after the resident had a significant weight loss for 1 of 12 sampled residents (Resident #11). This deficient practice had the potential to result in a resident with significant weight loss not receiving interventions to correct the weight loss or prevent further weight loss; and 2) to ensure a resident's activity care plan included interventions related to activity preferences and services for 1 of 12 sampled residents (Resident #21). This deficient practice had the potential to result in a resident with activity preferences not receiving the activity, care, and services for the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #11 Resident #11 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type II diabetes mellitus without complications, pressure-induced deep tissue damage of right heel, and chronic obstructive pulmonary disease, unspecified. On 04/07/2025 at 1:22 PM, the resident was lying in bed and the resident's face appeared gaunt with a sunken appearance around the resident's eyes and cheeks. The resident verbalized the resident had been eating less due to a decreased appetite and the resident did not like the food served by the facility. The resident verbalized the resident felt the resident had lost weight because of not eating. The Weights and Vitals Summary for Resident #11 documented the following: - On 02/02/2025, the resident's weight was 156.8 pounds (lbs). A 10.25 percent (%) weight loss over five months from the resident's weight of 174.7 lbs on 09/01/2024. - On 04/06/2025, the resident's weight was 154.6 lbs. A 15.01% weight loss over three months from the resident's weight of 181.9 lbs on 01/06/2025. The Care Plan for Resident #11 included a care plan for altered nutrition status. The care plan had last been revised on 09/08/2024, prior to the resident's significant weight loss recorded on 02/02/2025, and 04/06/2025. On 04/09/2025 at 2:48 PM, the Director of Nursing (DON) verbalized the nutrition care plan for Resident #11 should have been updated when significant weight loss was identified. On 04/10/2025 at 9:06 AM, the Registered Dietitian (RD) verbalized interventions to implement after significant weight loss would include evaluating meal intake and percentage of meals eaten, assessing skin integrity, encouraging protein intake, and ensuring the resident was turned every two hours to prevent skin breakdown. Cross reference with F692 Resident #21 Resident #21 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus without complications, failure to thrive, and acquired absence of unspecified leg below knee. Resident #21's Care Plan documented the following activities care plan focus on 02/18/2025: The resident partially depended on staff for activities due to physical limitations of using a wheelchair and requiring staff to assist with transfers. The goal documented Resident #21 wanted to go on a nature adventure within the review period and was dated 02/18/2025. The goal was revised on 03/29/2025, to include a target date of 05/16/2025. Resident #21's Care Plan lacked interventions related to the documented activities focus and goals. On 04/09/2025 at 2:21 PM, the DON explained the Activities Director (AD) would fill out the activities portion of the care plan for all residents. The DON verbalized an expectation the AD would accurately and completely document the resident's preferred activities focus, goals, and interventions on the care plan. The DON confirmed Resident #21's Care Plan lacked interventions related to the residents' preferred facility activities and services. On 04/09/2025 at 4:07 PM, the AD explained the activities portion of Resident #21's Care Plan was created by the AD during the resident interview. The AD explained the AD was not aware the interventions were missing from the care plan and would be necessary to provide activities in a manner the resident preferred. The AD confirmed the activities interventions were the AD's responsibility to document and implement and were not documented on Resident #21's Care Plan. The facility policy titled Care Plans, revised 03/22/2017, documented each resident would have a comprehensive person-centered care plan developed by the interdisciplinary team. The care plans would be updated as the needs of the resident changed and would include any updated information based on details of the comprehensive assessment. The care plan included the instructions needed to provide effective person-centered care of the resident that met professional standards of quality care. The comprehensive person-centered care plan was consistent with resident's rights and included measurable objectives and timeframes to meet the resident's medical, nursing, and psychosocial needs that are identified in the comprehensive assessment and included the description of any services that were furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure 1) a resident did not have a wooden trap (a trap using a spring-loaded mechanism with a metal bar designed to snap shut with sufficient force to trap and kill a rodent when the trap was triggered) set and baited with peanut butter in a resident's bathroom for 1 of 12 sampled residents (Resident #15). This deficient practice had the potential to result in a resident accidentally triggering the trap when entering the bathroom and sustaining injury to the resident's foot; and 2) unsecured medications prescribed to facility staff were not left unattended at the Nurse's Station. This deficient practice had the potential to cause harm by ingestion of unsecured medications by residents residing in the Long Term Care Unit. Findings include: Resident #15 Resident #15 was admitted to the facility on [DATE], with diagnoses including chronic atrial fibrillation, unspecified and adult failure to thrive. On 04/07/2025 at 11:50 AM, there was a wooden rodent trap set and baited in the resident's bathroom. The resident verbalized the resident had woken up one night and saw a mouse near the entrance to the bathroom. The resident verbalized the resident told staff and staff's solution was to put the rodent trap in the resident's bathroom. On 04/08/2025 at 2:36 PM, the Director of Nursing (DON) verbalized the facility had found no evidence of mice in resident rooms and the trap in the resident's bathroom could have been a safety hazard if the resident accidentally triggered the trap with the resident's foot. Unsecured Medications On 04/09/2025 at 5:02 PM, a duffle bag was observed at the Nurse's station to be open, unsecured, and unattended with four medication bottles in view. On 04/09/2025 at 5:42 PM, a Registered Nurse (RN) explained the open duffle bag belonged to staff and was left unattended at the Nurse's Station with four medication bottles in view. The RN confirmed there were four medication bottles that were prescribed to a staff member in the duffle bag and were left unsecured and available to residents for an unknown amount of time. The RN explained the RN had moved the duffle bag into the DON's office once the unsecured bag was discovered. The RN confirmed the labeled contents of the four unsecured medication bottles were as follows: -Hydrochlorothiazide 25 milligrams (mg), -Lisinopril 10 mg, -Losartan potassium 100 mg, and -Losartan potassium 50 mg. The RN confirmed the medications could have caused a resident's blood pressure to bottom out, which meant a resident's blood pressure could be rendered low enough to cause a medical emergency. On 04/09/2025 at 5:46 PM, the DON confirmed the staff duffle bag was left unsecured and contained a staff member's personal medications. The DON explained the expectation of staff was to secure any personal belongings and not allow resident access to unprescribed medications for safety concerns. The facility document, titled Resident Rights, revised 08/2018, documented the resident had the right to a safe environment. This included ensuring the physical layout of the facility maximized resident independence and did not pose a safety risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure the facility policy for weight loss was followed when a resident experienced a significant weight loss for 1 of 12 sampled residents (Resident #11). This deficient practice had the potential to result in a resident experiencing adverse outcomes from a significant weight loss not identified by the facility and a delay in care from the Registered Dietitian (RD) not being notified of the resident's weight loss. Findings include: Resident #11 Resident #11 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type II diabetes mellitus without complications, pressure-induced deep tissue damage of right heel, and chronic obstructive pulmonary disease, unspecified. On 04/07/2025 at 1:22 PM, the resident was lying in bed and the resident's face appeared gaunt with a sunken appearance around the resident's eyes and cheeks. The resident verbalized the resident had been eating less due to a decreased appetite and the resident did not like the food served by the facility. The resident verbalized the resident felt the resident had lost weight because of not eating. The Weights and Vitals Summary for Resident #11 documented the following: - On 04/06/2025, the resident's weight was 154.6 lbs. A 15.01% weight loss over three months from the resident's weight of 181.9 lbs on 01/06/2025. The Weights and Vitals Summary for Resident #11 did not include documentation of a weight taken on 04/07/2025 to verify the significant weight loss. The clinical record for Resident #11 did not include documentation of notification of the significant weight loss to the RD. On 04/09/2025 at 11:19 AM, the Registered Nurse (RN) for Resident #11 verbalized a resident with a significant weight loss would be reweighed the following day to verify the findings. The RN verbalized the RN would not contact the RD to notify of the significant weight loss. On 04/09/2025 at 2:46 PM, the Director of Nursing (DON) confirmed Resident #11 did have significant weight loss based on the weight recorded from 04/06/2025. The DON verbalized the process for reviewing significant weight loss was for staff to discuss resident weights during an interdisciplinary team (IDT) meeting on Monday mornings and the RD would attend the IDT meeting once a month. The DON verbalized a resident with a significant weight loss would be reweighed the following day to verify the weight loss and the RD would be notified. The DON confirmed Resident #11 had not been reweighed and the RD had not been notified. On 04/10/2025 at 9:06 AM, the RD verbalized the RD was sent an email from the facility on Monday mornings notifying the RD if a resident has a nutrition concern or significant weight loss. The RD verbalized the RD reviewed the communication the RD was sent by the facility on Monday, 04/07/2025, and Resident #11 was not discussed in the email. The RD confirmed the RD had not been informed of Resident #11's most recent significant weight loss. The RD confirmed a 15% weight loss over three months was considered a significant weight loss. The RD verbalized the RD would expect the facility to reweigh the resident to verify the weight change and would then review the resident's recent meal intake and percentage of meals eaten. The RD discussed possible interventions the RD would initiate included adding a nutritional supplement, increasing protein due to the increased risk of skin breakdown, reinforcing the importance of turning the resident every two hours, and requesting bloodwork. The facility policy titled Weight Loss, revised 09/06/2012, documented residents would be evaluated for weight loss. Residents with a weight change of five pounds would be reweighed the next day. Significant changes in weights would initiate a nutrition meeting and weekly weights until weights were stable. Cross reference with F657

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure nursing staff responsible for administering vaccinations had been trained according to accurate vaccination guidelines and were not instructed to follow a facility policy containing outdated and inaccurate information affecting 21 of 21 residents residing in the facility. Findings include: On 04/09/2025 at 6:08 PM, the Director of Nursing (DON) verbalized the facility would follow the Centers for Disease Control and Prevention (CDC) guidelines for vaccine schedules. The DON confirmed none of the 21 residents in the facility had completed a pneumococcal vaccine series per the CDC pneumococcal vaccine schedule. On 04/10/2025 at 9:38 AM, the Infection Preventionist (IP) verbalized the immunization program for residents was the responsibility of the IP. The IP confirmed the IP was responsible for providing the orientation and training to facility staff on the immunization program. The IP verbalized the facility was following CDC guidelines. The IP verbalized the IP's understanding of pneumococcal vaccines was for a resident to receive one vaccine before age [AGE] and one vaccine after age [AGE]. The IP confirmed the IP was unaware of the most current CDC schedule for pneumococcal immunizations and confirmed the facility was not following the CDC guidelines for pneumococcal vaccinations when presented with the CDC's guidelines on pneumococcal vaccine timing for adults. On 04/10/2025 at 4:11 PM, the Risk Manager confirmed the facility policy for Immunizations was not up to date or accurate and the facility was not vaccinating residents for pneumonia per current CDC guidelines. The facility policy titled Immunizations, revised 04/06/2012, documented all residents would be offered influenza or pneumococcal immunizations unless medically contraindicated. The facility would follow current CDC guidelines for immunization schedules. Influenza immunizations would be offered as soon as the vaccination was available in the fall and continued until March 31st yearly. Pneumococcal immunizations would be offered once before the age of 65 and once after the age of 65. Cross reference with F883

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure side effects and behaviors were monitored related to an ordered psychotropic medication for 1 of 12 sampled residents (Resident #18). This deficient practice had the potential to result in an unmanaged medication regimen, missed signs of worsening condition, and compromised resident safety. Findings include: Resident #18 Resident #18 was admitted to the facility on [DATE], with a primary diagnosis of disorder of brain, unspecified. A physician's order dated 04/03/2025, documented Lorazepam oral concentrate 2 milligrams (mg) per milliliter (ml), give 0.5 ml by mouth every four hours as needed for terminal agitation for 14 days. The behavior and side effect monitoring binder lacked psychotropic monitoring for Resident #18. On 04/10/2025 at 9:23 AM, the Assistant Director of Nursing (ADON) explained all residents on psychotropic medications required behavior and side effect monitoring. Monitoring was done in a binder at the nurse's station. The ADON confirmed the binder lacked side effect and behavior monitoring for Resident #18's Lorazepam. On 04/10/2025 at 10:31 AM, the Director of Nursing (DON) verbalized behavior and side effect monitoring for Resident #18's Lorazepam had not yet begun. On 04/10/2025 at 1:28 PM, the Director of Nursing (DON) explained Lorazepam was being used to treat Resident #18's terminal agitation. In December of 2024, Resident #18 began to have terminal agitation exhibited by hallucinations, decreased communication, decreased appetite, sleeping more often, and sensitivity to light. The facility policy titled Psychotropic Medication Use, revised 04/20/2023, documented psychotropic medications included hypnotics, antipsychotics, benzodiazepines, sedatives, and antidepressants. Licensed nurses would be aware of potential side effects of psychotropic medications and all medical and nursing staff would evaluate the effectiveness of as needed psychotropic drugs to manage behavior.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure the Facility Assessment (FA) was accurate and included nicotine dependence and addiction with the facility's common diagnoses and conditions. This deficient practice had the potential to result in facility staff not receiving adequate training on the care of residents with nicotine dependence and addiction diagnoses and the needs of those residents not being met. Findings include: During the entrance conference with the facility on 04/07/2025, a list of cigarette smokers (smokers) residing in the facility and the FA was provided by the facility. The list of smokers in the facility included six residents. Three residents were able to smoke unsupervised and three residents required supervision during the designated smoking times of every two hours between 7:00 AM and 11:00 PM. The smoking location was designated as the smoke shack off the outside patio accessed through the facility dining room. The facility document titled Facility Assessment, reviewed 01/15/2025, did not include nicotine abuse or addiction under the list of common diagnoses and listed the number of active or current substance abuse disorders among residents as zero. On 04/10/2025 at 2:09 PM, the Director of Nursing (DON) verbalized the DON assisted with reviewing and completing the FA. The DON confirmed nicotine addiction was not identified on the FA as a diagnosis in the facility and the FA documented the number of residents with active or current substance use disorders was zero. The DON verbalized the DON did not consider nicotine addiction to be a substance use disorder. The DON confirmed six residents in the facility were current cigarette smokers. The Centers for Disease Control and Prevention article titled Treatment of Substance Use Disorders, dated 04/25/2024, documented a substance use disorder was a treatable, chronic disease and could range in severity from moderate to severe. A substance use disorder could be applied to many types of drugs including tobacco (nicotine). The facility document titled Facility Assessment Tool, undated, documented the FA would include the care required by the resident population considering the types of diseases and other pertinent facts present within the population.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure the Infection Prevention and Control Plan included a method of ongoing surveillance of active infections in the facility. This deficient practice had the potential to result in a delay in recognition of infection outbreaks and reversible trends going unrecognized leading to missed opportunities for staff education and infection spreading among residents and staff in the facility. Findings include: On 04/10/2025 at 9:24 AM, the Infection Preventionist (IP) verbalized the IP would compile a spreadsheet at the end of every month for residents in long term care with culture results and antibiotic orders. The IP was unable to provide an ongoing surveillance tool with locations of infections within the facility and verbalized the IP did not have a tool to monitor trends including location of infections, staff providing care to infected residents, residents colonized with multi drug resistant organisms, or infections not requiring antibiotics. The IP verbalized the facility was small so the IP would know if there was a concern with multiple infections but was unable to provide documentation of infection surveillance. The facility policy titled Surveillance Plan, revised 10/06/2024, documented the plan would assess the magnitude of healthcare associated infections within the facility, recognition of trends in infections rates, antimicrobial resistance, and healthcare associated pathogens.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure resident consents for the COVID-19 (Covid) vaccination were offered or completed correctly for 2 of 5 residents sampled for vaccinations (Resident #18 and #21). This deficient practice had the potential to result in residents wishing to receive a Covid vaccination not receiving the vaccine and experiencing severe or prolonged illness, hospitalization, or death as the result of infection with the Covid virus. Findings include: Resident #18 Resident #18 was admitted to the facility on [DATE], with diagnoses including adult failure to thrive and personal history of benign neoplasm of the brain. A Covid vaccine consent and declination form for Resident #18 had both the checkboxes for consent and declination completed and was signed by the resident and a facility employee on 10/29/2024. The Immunization Record for Resident #18 documented the resident's most recent dose of the Covid vaccine was administered on 04/21/2022. On 04/09/2024 at 9:24 AM, the Infection Preventionist (IP) confirmed Resident #18's consent form for the Covid vaccine indicated the resident both wanted the vaccine and was declining the vaccine. The IP verbalized the consent should have been clarified and corrected to indicate the resident's choice. Resident #21 Resident #21 was admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus without complications and adult failure to thrive. The clinical record for Resident #21 lacked a consent or declination form for the Covid vaccine. The Immunization Record for Resident #21 documented the resident had not received any doses of the Covid vaccine. On 04/09/2025 at 10:42 AM, the Director of Nursing (DON) verbalized a consent or declination form for the Covid vaccine had not been completed for Resident #21. The facility policy titled COVID-19 Voluntary Vaccination Policy, revised 02/20/2024, documented the facility would provide education and resources to promote the benefits and safety of COVID-19 vaccination. Regular communication efforts would be made to inform individuals about the availability, benefits, and recommended guidelines for COVID-19 vaccination.

Based on interview, personnel record review, and document review, the facility failed to ensure initial communications training was completed timely per facility policy for 1 of 18 sampled employees (Employee #4). This deficient practice had the potential to prevent residents with communication needs from attaining or maintaining their highest practicable physical, mental and psychosocial well-being. Findings include Employee #4 Employee #4 was hired as the Registered Dietician on 10/21/2024. Employee #4's personnel record documented communication training completed on 11/30/2024, 40 days after hire. On 04/10/2025 at 2:39 PM, the Human Resources (HR) Generalist confirmed communication training was required for all employees and to be completed prior to working on the floor. The HR Generalist explained employee orientation lasted two to three days after hire. After completion of orientation, the employee would be released to work on the floor. On 04/10/2025 at 3:01 PM, the HR Manager confirmed Employee #4's personnel record lacked documented evidence of communication training completed prior to 11/30/2024. The facility policy titled, Training Policy, revised 02/06/2024, documented new employees were required to complete communication training prior to beginning work on the floor.

Based on interview, personnel record review, and document review, the facility failed to ensure initial resident rights training was completed timely per facility policy for 2 of 18 sampled employees (Employee #4 and #10). This deficient practice had the potential to prevent residents from being able and encouraged to practice their rights as residents. Findings include Employee #4 Employee #4 was hired as the Registered Dietician on 10/21/2024. Employee #4's personnel record documented resident rights training completed on 01/11/2025, 82 days after hire. Employee #10 Employee #10 was hired as a Registered Nurse on 10/21/2024. Employee #10's personnel record documented resident rights training completed on 11/23/2024, 33 days after hire. On 04/10/2025 at 2:39 PM, the Human Resources (HR) Generalist confirmed resident rights training was required for all employees and to be completed prior to working on the floor. The HR Generalist explained employee orientation lasted two to three days after hire. After completion of orientation, the employee would be released to work on the floor. On 04/10/2025 at 3:04 PM, the HR Manager confirmed Employee #4's personnel record lacked documented evidence of resident rights training completed prior to 01/11/2025, and Employee #10's personnel record lacked documented evidence of resident rights training completed prior to 11/23/2024. The facility policy titled, Training Policy, revised 02/06/2024, documented new employees were required to complete resident rights training prior to beginning work on the floor.

Based on interview, personnel record review, and document review, the facility failed to ensure elder abuse prevention training was completed timely per facility policy for 2 of 18 sampled employees (Employee #4 and #8). This deficient practice had the potential to place all residents at risk for abuse and neglect. Findings include Employee #4 Employee #4 was hired as the Registered Dietician on 10/21/2024. Employee #4's personnel record documented elder abuse prevention training completed on 12/07/2024, 47 days late. Employee #8 Employee #8 was hired as a Certified Nursing Assistant on 04/27/2023. Employee #8's personnel record documented elder abuse prevention training completed on 01/02/2024, and annual elder abuse prevention training completed on 01/24/2025, 22 days late. On 04/09/2025 at 2:27 PM, the Human Resources (HR) Manager verbalized all staff were required to take elder abuse prevention training before stepping foot on the floor and annually. The HR Manager verbalized Employee #4's personnel record lacked elder abuse prevention training completed prior to 12/07/2024, and Employee #8's personnel record lacked elder abuse prevention training completed prior to 01/24/2025. The facility policy titled, Training Policy, revised 02/06/2024, documented new employees were required to complete elder abuse prevention training prior to beginning work on the floor and annually.

Based on interview, personnel record review, and document review, the facility failed to ensure initial infection control training was completed timely per facility policy for 2 of 18 sampled employees (Employee #4 and #10). This deficient practice had the potential to put residents at risk of contracting avoidable infections and diseases. Findings include Employee #4 Employee #4 was hired as the Registered Dietician on 10/21/2024. Employee #4's personnel record documented infection control training completed on 11/30/2024, 40 days after hire. Employee #10 Employee #10 was hired as a Registered Nurse on 10/21/2024. Employee #10's personnel record documented infection control training completed on 11/21/2024, 31 days after hire. On 04/10/2025 at 2:39 PM, the Human Resources (HR) Generalist confirmed infection control training was required for all employees and to be completed prior to working on the floor. The HR Generalist explained employee orientation lasted two to three days after hire. After completion of orientation, the employee would be released to work on the floor. On 04/10/2025 at 3:15 PM, the HR Manager confirmed Employee #4's personnel record lacked documented evidence of infection control training completed prior to 11/30/2024, and Employee #10's personnel record lacked documented evidence of infection control training completed prior to 11/21/2024. The facility policy titled, Training Policy, revised 02/06/2024, documented new employees were required to complete infection control training prior to beginning work on the floor.

Based on interview, personnel record review, and document review, the facility failed to ensure initial compliance and ethics training was completed timely per facility policy for 2 of 18 sampled employees (Employee #4 and #10). This deficient practice had the potential to put residents at risk of receiving care from employees unaware of facility regulations. Findings include Employee #4 Employee #4 was hired as the Registered Dietician on 10/21/2024. Employee #4's personnel record documented compliance and ethics training completed on 11/30/2024, 40 days after hire. Employee #10 Employee #10 was hired as a Registered Nurse on 10/21/2024. Employee #10's personnel record documented compliance and ethics training completed on 11/23/2024, 33 days after hire. On 04/10/2025 at 2:39 PM, the Human Resources (HR) Generalist confirmed compliance and ethics training was required for all employees and to be completed prior to working on the floor. The HR Generalist explained employee orientation lasted two to three days after hire. After completion of orientation, the employee would be released to work on the floor. On 04/10/2025 at 3:26 PM, the HR Manager confirmed Employee #4's personnel record lacked documented evidence of compliance and ethics training completed prior to 11/30/2024, and Employee #10's personnel record lacked documented evidence of compliance and ethics training completed prior to 11/23/2024. The facility policy titled, Training Policy, revised 02/06/2024, documented new employees were required to complete compliance and ethics training prior to beginning work on the floor.

Based on interview, personnel record review, and document review, the facility failed to ensure initial behavioral health care training was completed timely per facility policy for 1 of 18 sampled employees (Employee #4). This deficient practice had the potential to prevent residents with behavioral health care needs from attaining or maintaining their highest practicable physical, mental and psychosocial well-being. Findings include Employee #4 Employee #4 was hired as the Registered Dietician on 10/21/2024. Employee #4's personnel record documented behavioral health care training completed on 12/23/2024, 63 days after hire. On 04/10/2025 at 2:39 PM, the Human Resources (HR) Generalist confirmed behavioral health care training was required for all employees and to be completed prior to working on the floor. The HR Generalist explained employee orientation lasted two to three days after hire. After completion of orientation, the employee would be released to work on the floor. On 04/10/2025 at 2:56 PM, the HR Manager confirmed Employee #4's personnel record lacked documented evidence of behavioral health care training completed prior to 12/23/2024. The facility policy titled, Training Policy, revised 02/06/2024, documented new employees were required to complete behavioral health training prior to beginning work on the floor.

Based on interview, clinical record review, and document review, the facility failed to ensure the facility's Quality Assurance and Performance Improvement Program identified areas of concern with the facility's Infection Prevention and Control Plan including concerns with pneumococcal immunizations and the immunization policy affecting 21 of 21 residents residing in the facility. This deficient practice had the potential to result in high-risk areas of concern and deficient infection control practices not being corrected and leading to infectious disease outbreaks and residents suffering severe illness or death from lack of vaccinations. Findings include: The facility document titled Infection Prevention and Control Annual Plan 2024/2025, documented a surveillance activity from the prior year was Prevention and Reduction of Pneumonia in long term care residents. The 2024 outcome of the surveillance activity was five residents had pneumonia in 2024. The effectiveness of the surveillance activity was documented as goal not met. The surveillance activity was not carried over to the 2024/2025 Infection Prevention Plan. The facility policy titled Immunizations, revised 04/06/2012, documented all residents would be offered influenza or pneumococcal immunizations unless medically contraindicated. The facility would follow current CDC guidelines for immunization schedules. Influenza immunizations would be offered as soon as the vaccination was available in the fall and continued until March 31st yearly. Pneumococcal immunizations would be offered once before the age of 65 and once after the age of 65. On 04/10/2025 at 9:43 AM, the Infection Preventionist (IP) verbalized the IP did present information during the QAPI committee meetings, but did not review the vaccination status of the residents and the Infection Prevention and Control Annual Plan was not presented to the QAPI committee for review. On 04/10/2025 at 4:11 PM, the Risk Manager verbalized the Infection Prevention Plan should have been reviewed by the QAPI committee and an unmet goal for a surveillance activity should have been reevaluated and carried over to the current plan. The Risk Manager confirmed the facility policy for Immunizations was not up to date or accurate and the facility was not vaccinating residents for pneumonia per current CDC guidelines. Cross reference with 883

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure the facility's immunization policy was accurate and included correct, up to date information for vaccinations, resident's were provided vaccinations when the resident's consented to receive pneumococcal vaccines, and staff were training on accurate and correct information related to pneumococcal vaccinations affecting 21 of 21 residents residing in the facility (Residents #12, #17, #14, #8, #6, #20, #13, #2, #4, #5, #16, #19, #15, #11, #7, #10, #21, #3, #18, #1, and #9). This deficient practice had the potential to result in staff providing inaccurate education and information to residents based on the facility policy and training provided and residents experiencing severe or life-threatening illness from infection with pneumococcal bacteria due to lack of completing a pneumococcal vaccination series. Resident #12 Resident #12 was admitted to the facility on [DATE], with diagnoses including obesity, unspecified and personal history of COVID-19. A Pneumonia Vaccination Administration consent for Resident #12, dated 04/05/2017, documented the resident's responsible party had consented to the resident receiving the vaccine as recommended by the Centers for Disease Control and Prevention (CDC). The Immunization Record for Resident #12 documented the resident had received the following pneumococcal vaccines: - Pneumococcal conjugate vaccine to protect against 13 strains of streptococcus pneumoniae bacteria (PCV-13) administered 02/09/2017. - Pneumococcal polysaccharide vaccine to protect against 23 serotypes of streptococcus pneumoniae bacteria (PPSV23) administered 09/21/2018. Resident #17 Resident #17 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease and chronic systolic (congestive) heart failure. The clinical record for Resident #17 lacked a consent or education regarding the influenza vaccination. The facility was unable to provide an immunization record for Resident #17. Resident #14 Resident #14 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified, acute bronchitis, unspecified, and nicotine dependence, cigarettes, with unspecified nicotine-induced disorders. A Pneumonia Vaccination Administration consent for Resident #14 documented the resident had consented to receiving the vaccine on 12/16/2024. An Influenza Vaccine Administration consent for Resident #14 documented the resident had consented to receiving the vaccine on 12/16/2024. The Immunization Record for Resident #14 documented the resident had last received an influenza vaccine on 10/03/2023, and had received the following pneumococcal vaccines: - PCV-13 on 06/05/2019. - PPSV23 on 03/17/2020. Resident #8 Resident #8 was admitted to the facility on [DATE], with diagnoses including cerebral infarction, unspecified and nicotine dependence, cigarettes, with unspecified nicotine-induced disorders. A Pneumonia Vaccination Administration consent for Resident #8 documented the resident had consented to receiving the vaccine on 07/22/2021. The clinical record for Resident #8 lacked an Influenza Vaccination Administration consent for the 2024/2025 influenza season. The Immunization Record for Resident #8 documented the resident had last received an influenza vaccine on 09/28/2021, and had not received a pneumococcal vaccine. Resident #6 Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including shortness of breath and chronic obstructive pulmonary disease, unspecified. A Pneumonia Vaccine Administration consent for Resident #6, dated 10/31/2022, was signed by the resident and witnessed by a Licensed Practical Nurse (LPN) under both the section consenting to administration of the vaccine and the section declining administration of the vaccine. The Immunization Record for Resident #6 documented the resident had received the following pneumococcal vaccines: - PPSV23 on 11/05/2015. - PPSV23 on 01/15/2021. Resident #20 Resident #20 was admitted to the facility on [DATE], with diagnoses including hypothyroidism, unspecified and atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. The clinical record for Resident #20 lacked a Pneumonia Vaccine Administration consent or declination. The Immunization Record for Resident #20 documented the resident had received the following pneumococcal vaccines: - PPSV23 on 12/11/2009. - PCV-13 on 05/11/2017. - PPSV23 on 09/27/2019. Resident #13 Resident #13 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including pneumonia, unspecified organism and chronic obstructive pulmonary disease. A Pneumonia Vaccine Administration consent for Resident #13 documented the resident's representative had consented to the resident receiving the vaccination on 07/31/2023. The Immunization Record for Resident #13 documented the resident had received the following pneumococcal vaccines: - PCV-13 on 11/01/2018. - PPSV23 on 02/04/2020. Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type II diabetes mellitus without complications, nicotine dependence, cigarettes, with unspecified nicotine-induced disorders, and morbid (severe) obesity due to excess calories. A Pneumonia Vaccine Administration consent for Resident #2 documented the resident had consented to receiving the vaccine on 02/06/2020. The Immunization Record for Resident #2 documented the resident had received the PPSV23 vaccine on 12/24/2019. Resident #4 Resident #4 was admitted to the facility on [DATE], with diagnoses including spastic quadriplegic cerebral palsy, acute cough, and wheezing. The clinical record for Resident #4 lacked a Pneumonia Vaccine Administration consent or declination. The facility was unable to provide an immunization record for Resident #4. Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus without complications and adult failure to thrive. A Pneumonia Vaccination Administration consent for Resident #5 documented the resident had consented to receiving the vaccine on 06/30/2020. The Immunization Record for Resident #5 documented the resident had received the PPSV23 vaccine on 07/03/2013. Resident #16 Resident #16 was admitted to the facility on [DATE], with diagnoses including heart failure, unspecified and chronic kidney disease, unspecified. A Pneumonia Vaccination Administration consent for Resident #16 documented the resident had consented to receiving the vaccine on 04/27/2023. The Immunization Record for Resident #16 documented the resident had received the PCV-13 vaccine on 10/05/2016. Resident #19 Resident #19 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified and congenital pneumonia, unspecified. An Influenza Vaccine Administration consent for Resident #19 documented the resident had consented to receiving the vaccine on 01/02/2025. A Pneumonia Vaccination Administration consent for Resident #19 documented the resident had consented to receiving the vaccine on 01/02/2025. The Immunization Record for Resident #19 documented the resident had not received a pneumococcal or influenza vaccine. Resident #15 Resident #15 was admitted to the facility on [DATE], with diagnoses including chronic atrial fibrillation, unspecified, lobar pneumonia, unspecified organism, and contact with and (suspected) exposure to other viral communicable diseases. The clinical record for Resident #15 lacked a consent or declination for an influenza vaccine for the 2024/2025 influenza season. The most recent consent/declination forms for both influenza and pneumococcal vaccines available in the resident's record were dated 09/28/2021. The Immunization Record for Resident #15 documented the resident had last received an Influenza vaccine on 10/23/2023, and the resident had not received any pneumococcal vaccines. Resident #11 Resident #11 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including heart failure, unspecified and chronic obstructive pulmonary disease, unspecified. A Pneumonia Vaccination Administration consent for Resident #11 documented the resident had consented to receiving the vaccine. The consent was undated. The Immunization Record for Resident #11 documented the resident had not received any pneumococcal vaccines. Resident #7 Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type II diabetes mellitus without complications and essential (primary) hypertension. A Pneumonia Vaccination Administration consent for Resident #7 documented the resident's representative had consented to the resident receiving the vaccine on 07/27/2023. The Immunization Record for Resident #7 documented the resident had received the PCV-13 vaccine on 01/16/2020. Resident #10 Resident #10 was admitted to the facility on [DATE], and readmitted on [DATE], and 06/28/2024, with diagnoses including chronic obstructive pulmonary disease, unspecified and pneumonia, unspecified organism. A Pneumonia Vaccination Administration consent for Resident #10 documented the resident had consented to receiving the vaccine on 03/22/2023. The Immunization Record for Resident #10 documented the resident had received the following pneumococcal vaccinations: - PPSV23 on 09/26/2014. - PCV-13 on 02/15/2016. - Pneumococcal, UF (unspecified vaccine) on 02/15/2016. - PCV-13 on 02/08/2017. Resident #21 Resident #21 was admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus without complications and adult failure to thrive. A Pneumonia Vaccination Administration consent for Resident #21 documented the resident had consented to receiving the vaccine on 02/10/2025. The Immunization Record for Resident #21 documented the resident had received the following pneumococcal vaccinations: - PPSV23 on 02/16/2010. - PCV-13 on 08/12/2015. - PPSV23 on 04/05/2018. Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], and 07/03/2023, with diagnoses including chronic obstructive pulmonary disease, unspecified and type II diabetes mellitus without complications. A Pneumonia Vaccination Administration consent for Resident #3 documented the resident's representative had consented for the resident to receive the vaccine on 07/05/2023. The Immunization Record for Resident #3 documented the resident had received the following pneumococcal vaccinations: - PPSV23 on 12/04/2008. - PCV-13 on 01/31/2016. Resident #18 Resident #18 was admitted to the facility on [DATE], with diagnoses including adult failure to thrive and personal history of benign neoplasm of the brain. A Pneumonia Vaccination Administration consent for Resident #18 documented the resident had consented to receive the vaccine on 05/28/2024. The Immunization Record for Resident #18 documented the resident had not received a pneumococcal vaccine. Resident #1 Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including epilepsy, unspecified, not intractable, without status epilepticus and hydrocephalus, unspecified. A Pneumonia Vaccination Administration consent for Resident #1 documented the resident had received a pneumococcal vaccine on 04/10/2013. The consent was not signed by the resident and was signed by an LPN on 04/19/2022. The Immunization Record for Resident #1 documented the resident had received the PPSV23 vaccine on 04/10/2013. Resident #9 Resident #9 was admitted to the facility on [DATE], with diagnoses including other myeloid leukemia not having achieved remission, acute cough, and type II diabetes mellitus with diabetic neuropathy, unspecified. A Pneumonia Vaccination Administration consent for Resident #9 documented the resident had consented to receive the vaccine on 08/15/2023. The Immunization Record for Resident #9 documented the resident had received the following pneumococcal vaccinations: - PPSV23 on 03/04/2013. - PCV-13 on 02/01/2016. - PPSV23 on 03/04/2017. On 04/09/2025 at 10:25 AM, the Director of Nursing (DON) verbalized Resident #19 had not received the influenza or pneumococcal vaccination the resident had consented to because the facility was waiting until the resident was well enough to receive the vaccine. The DON verbalized the resident did not have fevers but the resident just wasn't themselves. The DON confirmed the resident had not been given further education on delaying the vaccinations and the resident's clinical record lacked documentation of a clinically indicated reason for the delay in vaccination. On 04/09/2025 at 10:27 AM, the Infection Preventionist (IP) verbalized the facility followed CDC guidelines for vaccination and would follow the CDC recommendations for vaccine schedules. The IP confirmed Resident #11 had consented to receive the pneumonia vaccine, but a pneumonia vaccine had not been administered to the resident. On 04/09/2025 at 6:08 PM, the DON verbalized the facility followed CDC guidelines for vaccine schedules. The DON confirmed none of the 21 residents in the facility had completed a pneumococcal vaccine series per the CDC pneumococcal vaccine schedule. On 04/10/2025 at 9:38 AM, the IP verbalized the immunization program for residents was the responsibility of the IP. The IP confirmed the IP was responsible for providing the orientation and training to facility staff on the immunization program. The IP verbalized the facility was following CDC guidelines. The IP verbalized the IP's understanding of pneumococcal vaccines was for a resident to receive one vaccine before age [AGE] and one vaccine after age [AGE]. The IP confirmed the IP was unaware of the most current CDC schedule for pneumococcal immunizations. The IP confirmed residents in the facility had only received either the PPSV23 or PCV-13 vaccine. When shown the current CDC complete pneumococcal vaccine schedule for adults the IP confirmed PPSV23 and PCV-13 did not complete a pneumococcal vaccine series. The IP confirmed the facility had not administered the pneumococcal conjugate vaccine to protect against 20 strains of the bacteria streptococcus pneumoniae (PCV20), the pneumococcal conjugate vaccine to protect against 21 strains of the bacteria streptococcus pneumoniae (PCV21), or the 15-valent pneumococcal conjugate vaccine (PCV15). The facility document titled Infection Prevention and Control Annual Plan 2024/2025, documented a surveillance activity from the prior year was Prevention and Reduction of Pneumonia in long term care residents. The 2024 outcome of the surveillance activity was five residents had pneumonia in 2024. The effectiveness of the surveillance activity was documented as goal not met. The surveillance activity was not carried over to the 2024/2025 Infection Prevention Plan. On 04/10/2025 at 4:11 PM, the Risk Manager verbalized the Infection Prevention Plan should have been reviewed with the Quality Assurance and Performance Improvement committee and an unmet goal for a surveillance activity should have been reevaluated and carried over to the current plan. The Risk Manager confirmed the facility policy for Immunizations was not up to date or accurate and the facility was not vaccinating residents for pneumonia per current CDC guidelines. The CDC guideline titled Pneumococcal Vaccine Timing for Adults, dated 10/2024, documented adults 50 years or older had the following options to complete a pneumococcal vaccine schedule: - Those with no prior vaccine had the option to receive either the PCV20 or PCV21 or the option to receive the PCV15 and then the PPSV23 a year later. - Those who received the PPSV23 at any age had the option to receive either the PCV20 or PCV21 at least one year later or the option to receive the PCV15 at least one year later. - Those who received the PCV13 at any age would receive the PCV20 or PCV21 at least one year later. - Those that received the PCV13 at any age and the PPSV23 after [AGE] years of age would receive the PCV20 or PCV21 after at least five years. The schedule for adults 19 to [AGE] years old with chronic health conditions included offering those with no prior vaccines either the option of receiving the PCV20 or PCV21 or the option of receiving the PCV15 and then the PPSV23 after one year. The facility policy titled Immunizations, revised 04/06/2012, documented all residents would be offered influenza or pneumococcal immunizations unless medically contraindicated. The facility would follow current CDC guidelines for immunization schedules. Influenza immunizations would be offered as soon as the vaccination was available in the fall and continued until March 31st yearly. Pneumococcal immunizations would be offered once before the age of 65 and once after the age of 65. Cross reference with F726 and F867

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and document review, the facility failed to obtain informed consent prior to placing the resident in a scoop mattress for 1 of 12 sampled residents (Resident #14). Findings include: Resident #14 Resident #14 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, with anxiety, and pain. On 05/20/2024 at 11:20 AM, Resident #14 was in bed sleeping in a mattress that came up around the edges like a scoop. On 05/21/2024 at 8:04 AM, Resident #14 verbalized the resident had a weird mattress and did not know why. The resident explained the mattress was what the facility had and did not recall an explanation for use or signing documents regarding the mattress. Resident #14's clinical record lacked a care plan for the use of a scoop mattress. Resident #14's clinical record lacked documented evidence the risk and benefits were explained to the resident's Guardian and the resident had been assessed for the risk of entrapment and restraint. On 05/23/2024 at 7:26 AM, the Director of Nursing (DON) verbalized Resident #14 did not have a medical need for a scoop mattress. The DON explained the resident had a scoop mattress because there were no other mattresses available. The DON confirmed the resident did not have a care plan for the mattress, an assessment for entrapment was not completed, and an informed consent explaining the risks and benefits had not been signed for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview, the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 2 of 12 sampled residents (Resident #17 and #2). Findings include: Resident #17 Resident #17 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including pain unspecified, edema unspecified, and acute embolism and thrombosis of other specified deep vein of left lower extremity. Anticoagulant A physician's order dated 02/26/2024, with a start date of 03/04/2024, documented Eliquis oral tablet five milligrams (mg). Give five mg by mouth two times a day related to acute embolism and thrombosis of other specified deep vein of left lower extremity. Resident #17's care plan, with a focus initiated on 02/29/2024, documented the resident was prescribed Eliquis 5 mg twice a day. Resident #17's April 2024 Electronic Medication Administration Record (EMAR) documented Eliquis oral tablet 5 mg, was administered to the resident twice daily 04/14/2024-04/21/2024. Resident #17's last quarterly MDS assessment dated [DATE], section N0415 (Medications - High-Risk Drug Classes: Use and Indication) documented the resident was not taking an anticoagulant medication in the seven day look back period. Diuretic A physician's order dated 04/04/2024, with a start date of 04/05/2024, documented Bumex oral tablet 1 mg. Give one tablet by mouth one time a day related to edema unspecified. Resident #17's April 2024 EMAR documented Bumex oral tablet 1 mg was administered to the resident once daily 04/14/2024-04/21/2024. Resident #17's last quarterly MDS assessment dated [DATE], section N0415 (Medications - High-Risk Drug Classes: Use and Indication) documented the resident was not taking a diuretic in the seven day look back period. Opioid A physician's order dated 03/08/2024, documented Tramadol Hydrochloride (HCl) oral tablet 50 mg. Give one tablet by mouth every 12 hours as needed for pain. Resident #17's care plan with a focus initiated on 04/17/2024, documented the resident was prescribed Tramadol 50 mg as needed every 12 hours for pain relief. Resident #17's April 2024 EMAR documented Tramadol HCl 50 mg was administered on the following dates: -On 04/14/2024, at 9:10 PM -On 04/16/2024, at 9:04 AM and 11:33 PM -On 04/18/2024, at 9:55 AM and 10:03 PM -On 04/20/2024, at 8:52 PM -On 04/21/2024, at 9:21 PM Resident #17's last quarterly MDS assessment dated [DATE], section N0415 (Medications - High-Risk Drug Classes: Use and Indication) documented the resident was not taking an opioid in the seven day look back period. Hypoglycemic Resident #17's last quarterly MDS assessment dated [DATE], section N0415 (Medications - High-Risk Drug Classes: Use and Indication) documented the resident was taking a hypoglycemic medication. Resident #17's clinical record lacked any other documented evidence of a hypoglycemic being ordered or administered. On 05/23/2024 at 9:58 AM, the MDS Coordinator confirmed Resident #17's MDS assessment documented the resident was not taking an anticoagulant, opioid, or diuretic. The MDS Coordinator confirmed Eliquis was an anticoagulant, Tramadol HCl was an opioid, and Bumex was a diuretic. The three medications should have been accurately reflected on the MDS assessment. The MDS Coordinator confirmed Resident #17's MDS assessment documented the resident was on a hypoglycemic. The MDS Coordinator verbalized the resident was not on a hypoglycemic and confirmed the MDS assessment should not have indicated the resident was taking a hypoglycemic. Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including multiple sclerosis and acute cholecystitis. The Facility Resident Matrix (802) received from the facility on 05/20/2024, documented Resident #2 had physical restraints. Resident #2's last quarterly MDS assessment dated [DATE], Section P0100 (Restraints) documented the resident had bed rails and were used daily. On 05/20/2024 at 9:28 AM, Resident #2's bed did not have bedrails or a Halo Safety Ring affixed to the bed. On 05/23/2024 at 9:13 AM, Resident #2's bed did not have bedrails or a Halo Safety Ring affixed to the bed. On 05/23/2024 at 9:39 AM, the MDS Coordinator confirmed the 802 indicated Resident #2 had physical restraints. The MDS Coordinator explained Resident #2 used to have bedrails but did not have them any longer. The MDS Coordinator confirmed the resident's bed rails were removed in June 2023, and the MDS was not accurate for Resident #2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and document review the facility failed to update a fall care plan with new interventions for 2 of 12 sampled residents (Resident #1, and #5) and to include the use of a scoop mattress in a resident's care plan for 1 of 12 sampled residents (Resident #14). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and epilepsy, unspecified, not intractable, without status epilepticus. On 05/21/2024 at 7:20 AM, Resident #1 was in bed asleep with a fall mat on the floor on the right side of the bed. A pressure alarm was on the floor mat. A Personal Care Technician (PCT) was seated next the resident's room. On 05/21/2024 at 7:21 AM, the PCT verbalized the PCT was stationed outside of Resident #1's room because Resident #1 was a fall risk. The PCT explained the resident had a position change alarm on the resident's bed and floor mat. If the resident got up from the bed or rolled onto the floor mat, the position change alarms would sound, alerting the staff. A Facility Reported Incident documented on 04/11/2024, Resident #1 was heard yelling out and was found sitting on the floor. The resident was determined to be ambulating in their room without assistance and fell. The facility would provide one to one supervision to prevent future occurrences. On 05/22/2024 at 11:15 AM, a Licensed Practical Nurse verbalized Resident #1 had falls and was very unstable. The LPN explained interventions to prevent falls for Resident #1 included one to one supervision, fall mats at the bedside, and a position change alarm on the floor mat and on the resident's bed. The LPN would expect to find those interventions on the resident's care plan. The LPN confirmed the care plan did not include one to one supervision until 05/20/2024. The LPN confirmed the care plan lacked floor mats and position change alarms. Resident #1's Comprehensive Care Plan documented Resident #1 had incidents of falling the past several months due to lack of safety awareness. Interventions were documented as follows: -resident to use a wheelchair for ambulating in the facility while their arm heals from a recent fall on 04/11/2024 -resident to be encouraged to sit out in day room and watch television to receive additional assistance when required An intervention initiated 05/20/2024, documented resident to have daily supervision and line of sight monitoring related to impulsivity and poor safety awareness. The care plan lacked an intervention for falls mats at the bedside and position change alarms on the resident's bed and bedside. On 05/22/2024 at 4:04 PM, the Director of Nursing (DON) verbalized Resident #1 had falls and overestimated their abilities. The DON explained Resident #1 fell and broke their wrist on 04/11/2024. The staff was made aware of the fall due to position change alarm on the floor mat. The intervention to prevent future falls was to implement one to one supervision of the resident. The DON confirmed fall mats and position change alarms were not on the resident's care plan and the care plan was updated on 05/20/2024 to include one to one supervision. The DON confirmed the interventions should have been updated on the care plan when they were implemented. Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including adult failure to thrive, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter. On 05/20/2024 at 11:08 AM, Resident #5 was in bed with a fall mat at the bedside. On 05/20/2024 at 11:09 AM, Resident #5 verbalized they have had falls in the past. On 05/23/24 at 8:21 AM, a Certified Nursing Assistant (CNA) verbalized Resident #5 was a fall risk and could get out of bed by themselves with a standby assist. The CNA explained the resident overestimated their abilities and would try to get out of bed without calling for assistance. The resident had fall mats and a position change alarm. On 05/23/2024 at 8:32 AM, an LPN verbalized Resident #5 was a fall risk and had fall prevention interventions to include a floor mat and a position change alarm. A Fall Risk assessment dated [DATE], documented Resident #5 was a moderate fall risk. Resident #5's Comprehensive Care Plan documented Resident #5 was at risk for falls characterized by history of falls/injury, multiple risk factors related to impaired balance and pain. Interventions were documented as follows: -ensure environment was free of clutter -transfer and change positions slowly An intervention initiated 05/22/2024, documented resident would have a bed alarm in place to alert staff of resident movement due to poor safety awareness, unsteady gait and non-use of the call light for requesting assistance. The care plan lacked an intervention for falls mats at the bedside. On 05/23/2024 at 10:32 AM, the DON verbalized Resident #5 had falls and a care plan for falls. The DON confirmed the intervention for position change alarms was not updated on the care plan until 05/22/2024, and the care plan lacked floor mats as an intervention. Resident #14 Resident #14 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, with anxiety, and pain. On 05/20/2024 at 11:20 AM, Resident #14 was in bed sleeping in a mattress that came up around the edges like a scoop. On 05/21/2024 at 8:04 AM, Resident #14 verbalized the resident had a weird mattress and did not know why. Resident #14's clinical record lacked a care plan addressing the scoop mattress. On 05/23/2024 at 7:26 AM, the DON verbalized Resident #14 did not have a medical need for a scoop mattress. The DON explained the resident had a scoop mattress because there were no other mattresses available. The DON confirmed the resident did not have a care plan for the mattress. The facility policy titled Fall Prevention, dated 04/01/2003, documented the resident's plan of care would be updated with the plan being used to prevent falls. The facility policy titled Care Plans, revised 03/22/2017, documented each resident would have a comprehensive person-centered care plan developed by the interdisciplinary team. The care plan must include the instructions needed for proved effective person-centered care of the resident to meet professional standards of quality of care. The comprehensive care plan would include a description of services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, interview and document review, the facility failed to remove floor mats from the bedside when residents were not in bed for 1 of 12 sampled residents (Resident #5), and assess a resident with a scoop mattress for risk of entrapment for 1 of 12 sampled residents (Resident #14). The deficient practices had the potential to increase falls and injury in the facility. Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including adult failure to thrive, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter. On 05/20/2024 at 11:08 AM, Resident #5 was in bed with a fall mat at the bedside. The resident's walker was up against the resident's bed, with the back half on the floor mat and the front half on the tile floor. On 05/20/2024 at 11:09 AM, Resident #5 verbalized they have had falls in the past and had tripped on the mat while walking. On 05/22/2024 at 11:15 AM, a Licensed Practical Nurse (LPN) verbalized residents who were fall risks had floor mats at the bedside. The LPN explained the fall mats were always at the bedside, even when the resident was out of bed. The LPN confirmed floor mats at the bedside could pose a tripping hazard to ambulatory residents. On 05/22/2024 at 11:42 AM, a Housekeeping Lead verbalized floor mats were at the bedside of residents who had falls or were fall risks. The Housekeeping Lead explained floor mats were cleaned daily by Housekeeping. The floor mats were taken out of the resident rooms, preferably while the resident was out of the room, cleaned, dried, and placed back at the resident bedside. The Housekeeper confirmed the floor mats were always at the resident's bedside unless they were being cleaned. On 05/22/2024 at 1:58 PM, the Director of Nursing (DON) verbalized all floor mats had been picked up and would no longer be at the resident's bedside when the residents were out of bed. The DON confirmed floor mats at the bedside could be a tripping hazard for residents that were ambulatory. On 05/23/2024 at 8:21 AM, a Certified Nursing Assistant (CNA) verbalized Resident #5 was a fall risk and could get out of bed by themselves with a standby assist. The CNA explained the resident overestimated their abilities and would try to get out of bed without calling for assistance. The resident had fall mats and a position change alarm. The CNA explained the fall mats were always down in the resident's room. On 05/23/2024 at 8:32 AM, the LPN verbalized Resident #5 was a fall risk and had fall prevention interventions to include a floor mat and a position change alarm. The LPN explained the resident was able to ambulate from their bed to the bathroom and back with a walker. A Fall Risk assessment dated [DATE], documented Resident #5 was a moderate fall risk. Resident #5's Comprehensive Care Plan documented Resident #5 was at risk for falls characterized by history of falls/injury, multiple risk factors related to impaired balance and pain. Interventions were documented as follows: -ensure environment was free of clutter -transfer and change positions slowly The care plan lacked an intervention for fall mats at the bedside. On 05/23/2024 at 10:32 AM, the DON verbalized Resident #5 had falls and a care plan for falls. The DON confirmed the intervention for position change alarms was not updated on the care plan until 05/22/2024, and the care plan lacked floor mats as an intervention. Resident #14 Resident #14 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, with anxiety, and pain. On 05/20/2024 at 11:20 AM, Resident #14 was in bed sleeping in a mattress that came up around the edges like a scoop. On 05/21/2024 at 8:04 AM, Resident #14 verbalized the resident had a weird mattress and did not know why. The resident explained the mattress was what the facility had and did not recall an explanation for use or signing documents regarding the mattress. The resident verbalized they were able to get in and out of the bed and the scoop mattress did not restrict their movement. Resident #14's clinical record lacked a care plan addressing the scoop mattress. Resident #14's clinical record lacked documented evidence the risk and benefits were explained to the resident's Guardian and the resident had been assessed for the risk of entrapment. On 05/23/2024 at 7:26 AM, the DON verbalized Resident #14 did not have a medical need for a scoop mattress. The DON explained the resident was able to get in and out of bed and had a scoop mattress because there were no other mattresses available. The DON confirmed the resident did not have a care plan for the mattress and had not been assessed for risk of entrapment. The facility policy titled Safe Environment, undated, documented residents had a right to a safe, clean, comfortable and homelike environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure cognitive assessments for the use of a grab bar device (Halo Safety Ring) were completed quarterly for 1 of 20 residents residing in the facility (Resident #12). Findings include: Resident #12 Resident #12 was admitted to the facility on [DATE], with diagnoses including heart failure, unspecified, hereditary and idiopathic neuropathy, unspecified, and peripheral vascular disease, unspecified. On 05/20/2024 at 4:08 PM, Resident #12's bed had a Halo Safety Ring on both upper sides of the bed. On 05/21/2024 at 12:47 PM, Resident #12's bed had a Halo Safety Ring on both upper sides of the bed. Resident #12's physician order dated 10/13/2023, documented: May have Halo Safety Ring for bed mobility and maintain functional capabilities during perineal care. Resident #12's care plan intervention dated 10/13/2023, documented the resident would receive a cognitive assessment completed quarterly to determine safe and responsible use of the Halo Safety Ring. Resident #12's clinical record lacked documented evidence of a Halo Safety Ring cognitive assessment since the installation of the Halo Ring Safety device to both upper sides of the resident's bed on 10/13/2023. On 05/23/2024 at 10:15 AM, the Skilled Nursing Facility (SNF) Manager confirmed the requirement of quarterly cognitive assessments for residents using Halo Safety Rings to ensure the resident understood how to use the device. The cognitive assessment would also be completed with any changes in condition and were done on paper and kept at the Nurse's station. The SNF Manager confirmed Resident #12's clinical record lacked a quarterly cognitive assessment and could not provide a paper copy of a quarterly assessment for January 2024 or April 2024. The facility policy titled Halo Safety Ring Device Policy, undated, documented the primary objective of the safety evaluation included safety risks associated with Halo Safety Rings and ensured the safe and appropriate use of the Halo Safety Rings. Before installing the device, a registered nurse would complete the comprehensive cognitive assessment to evaluate the resident's capacity to use the device safely. Quarterly cognitive assessments would be completed to evaluate the resident's ability to safely utilize the device. Physical Therapy would re-evaluate the resident for continued use following major changes in mobility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and document review the facility failed to ensure medication was administered with an error rate less than 5 percent (%). There were 35 opportunities and two medication errors. The medication error rate was 5.71%. Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type two diabetes mellitus without complications and mixed hyperlipidemia. Resident #3's physician's order documented Niacin Extended Release tablet 500 milligrams (mg) give two tablets by mouth one time a day related to hyperlipidemia, unspecified. On 05/22/2024 at 7:41 AM, during medication pass observation, a Licensed Practical Nurse (LPN) administered one tablet of Niacin 500 mg to Resident #3. On 05/22/2024 at 12:44 PM, the LPN confirmed Resident #3 was prescribed two tablets of Niacin 500 mg and the LPN administered one tablet of the medication. Resident #15 Resident #15 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified, cramp and spasm, and other fatigue. Resident #15's physician order documented Vitamin D3 25 micrograms (mcg) give two tablets by mouth one time a day for vitamin supplement. On 05/22/2024 at 8:07 AM, during medication pass observation, the LPN administered one tablet of Vitamin D3 25 mcg to Resident #15. On 05/22/2024 at 12:45 PM, the LPN confirmed Resident #15 was prescribed two tablets of Vitamin D3 25 mcg and the LPN administered one tablet of the medication. The LPN explained the resident could have a vitamin or supplement deficiency if the resident did not receive the ordered dose of the vitamin or supplement. On 05/22/2024 at 12:49 PM, the Director of Nursing (DON) explained a resident could encounter an adverse effect if the ordered supplement or vitamin was not administered according to the physician's order. On 05/23/2024 at 8:37 AM, the DON communicated the expectation of nursing staff to follow the physician's order 100 % of the time. The facility policy titled Medication Administration Policy, dated 03/14/2024, documented medication administration procedures would include the Five Rights of medication administration: right patient, right medication, right dose, right route, and right time. Medications shall be administered strictly according to the prescriber's orders.

On 05/23/2024 at 10:51 AM, the Quality Assurance and Risk Manager verbalized the QAPI Committee had not initiated a Performance Improvement Project (PIP) related to the lack of residents being screened, offered, or provided education for COVID booster vaccinations. The QAPI Committee had not been aware the facility lacked the COVID booster vaccination for 2023-2024. The facility policy titled QAPI Plan, undated, documented the facility used QAPI to make decisions and guide their day-to-day operations. The QAPI Plan addresses care areas to include infection control, and focused on systems and processes, rather than individuals. The emphasis was on identifying opportunities for systemic improvement, and to educate individuals in facility processes and systems. Based on interview and document review, the Quality Assessment Performance Improvement (QAPI) Committee failed to identify the lack of COVID-19 (COVID) booster vaccinations offered to residents with the potential to affect the entire facility census. Findings include: On 05/22/2024 at 2:35 PM, the Skilled Nursing Facility (SNF) Manager confirmed COVID vaccinations and boosters were not provided to the residents for 2023 and 2024, as the facility had not put anything in place for the resident vaccinations. On 05/23/2024 at 9:51 AM, the Infection Preventionist confirmed the IP was responsible for all resident vaccinations and the Infection Control Program. The IP verbalized the IP was not involved with COVID vaccinations for the residents. The IP had depended on the Director of Nursing (DON) and the SNF Manager to order the COVID vaccine and the DON and SNF Manager would arrange consent, administration, and documentation. The IP confirmed the IP did not follow up on COVID vaccinations to ensure the vaccine was ordered or if each resident was screened for eligibility to receive the vaccine, education regarding the vaccine was provided to the residents/resident's representative, and if the vaccine was offered and either administered or declined for the years 2023 and 2024. On 05/23/24 at 10:03 AM, the SNF Manager confirmed COVID vaccinations were not ordered for the residents for the years of 2023 and 2024, because the SNF Manager and DON were focused on the resident influenza and pneumococcal vaccines. The SNF Manager confirmed the DON and the SNF Manager were responsible to order the resident COVID vaccines for 2023 and 2024, and did not order the vaccines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, interview, and document review the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented for 1 of 12 sampled residents (Resident #12). Findings include: Resident #12 Resident #12 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including peripheral vascular disease, unspecified, type II diabetes mellitus without complications, hereditary and idiopathic neuropathy, unspecified, and left lower extremity amputation. A physician's order for Resident #12 dated 04/22/2024, documented cleanse right second toe on right foot with wound cleanser. Apply medi (medical)-honey and cover with band aid every 48 hours for wound care. Resident #12's physician order dated 04/23/2024, documented apply pressure boot to resident's right foot every day and night shift for open sore on right second toe. A Nursing Progress Note dated 05/08/2024, documented Resident #12 had a small scabbed area on second toe which had been slow to resolve despite best efforts to treat. On 05/20/2024, in the morning, Resident #12's room lacked signage for EBP and did not have a Personal Protective Equipment (PPE) cart available at or near the room. On 05/21/2024 at 12:47 PM, Resident #12 was provided wound care by a Licensed Practical Nurse (LPN) who was also the Wound Care Nurse. Resident #12's room lacked signage for EBP or a PPE cart outside the room. On 05/22/2024 at 8:34 AM, the Wound Care Nurse confirmed Resident #12 received wound care every other day and the resident's room did not have EBP signage or PPE available outside the room. The Wound Care Nurse confirmed a resident receiving wound care would require EBP with a PPE hanging organizer affixed to the wall outside the resident's room. The Wound Care Nurse considered the wound unstageable. On 05/22/2024 at 12:57 PM, the Director of Nursing (DON) explained a resident with a wound should be on EBP and a PPE organizer was required to be placed outside the resident's room. The purpose of the PPE was to provide protection from potential materials that could pose an infection risk to the other residents. The DON confirmed Resident #12 had a chronic wound of the right second toe and should have been placed on EBP, however did not question this as the wound was scabbed over and not draining. On 05/22/2024 at 1:18 PM, the Infection Preventionist (IP) confirmed the facility used CDC guidelines for the Infection Control Program. A resident on EBP would have a PPE cart or hanging organizer which included gowns, gloves, garbage bags, and masks and signage would be on the resident's door. The IP confirmed Resident #12 was not on EBP, did not have a PPE organizer at or near the resident's room, did not have signage, and received every other day wound care for a right second toe wound. The IP was not able to describe how individuals entering the room would be queued to don PPE prior to providing care. On 05/22/2024 at 1:50 PM, the IP explained any resident with a wound needed to be on EBP. A consequence to the resident not identified as requiring EBP was the wound/infection could be spread around to the staff and other residents. The other residents would be at risk for contamination or developing an infection. On 05/23/2024 at 10:10 AM, the Skilled Nursing Facility (SNF) Manager verbalized the expectation for a resident receiving wound care would be placed on EBP and have PPE available outside the room. Nursing and Certified Nursing Assistants (CNA) staff should use the PPE stored in the PPE organizer to impede bacteria transmission from resident to resident during direct care. The SNF Manager was not able to explain how staff would know to don PPE prior to entry without signage and a PPE organizer and would most likely rely on verbal communication. A Centers for Medicare and Medicaid Services (CMS) Memo QSO-24-08-NH, dated 03/20/2024, documented EBP as an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employed targeted gown and glove use during high contact resident care activities. EBP were indicated for residents with wounds and/or indwelling medical devices even if the resident was not known to be infected or colonized with a MDRO. Wounds included chronic wounds, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Wound care was defined as any skin opening requiring a dressing. The facility policy titled Infection Prevention and Control Annual Plan, dated 2024, documented the purpose of the plan was to facilitate participation of each healthcare worker in infection prevention strategies at the user level and to limit unprotected exposure to pathogens.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to provide a comfortable, homelike environment when the facility utilized an overhead paging system to communicate with the adjoining hospital staff and temperatures in the facility were below 71 degrees. The overhead paging system and the temperature had the potential to affect the entire facility census. Findings include: Overhead Paging System On 05/22/2024 at 11:12 AM, an overhead page was heard calling a Code Gray in room [ROOM NUMBER]. On 05/22/2024 at 11:12 AM, the Director of Nursing (DON) verbalized the code was called for room [ROOM NUMBER] of the adjoining hospital. The DON explained hospital pages were heard on the skilled nursing home side of the facility because the intercom system was for the entire building. The DON confirmed overhead pages from the hospital did not contribute to a homelike environment for residents residing in the skilled nursing facility. On 05/22/2024 at 11:20 AM, an overhead page was heard announcing a hospital staff meeting. On 05/22/2024 at 11:20 AM, a Licensed Practical Nurse (LPN) verbalized overhead hospital pages were heard all the time on the skilled nursing side of the facility. The LPN explained residents on the skilled nursing side of the facility had a homelike environment which included rooms designed to be like their homes and decorations and belongings personalized to the individual which extended to the common areas. The LPN confirmed the overhead hospital pages did not contribute to a homelike environment. On 05/23/2024 at 9:22 AM, a business office meeting for the hospital was announced on the overhead paging system. Temperature in the Facility Resident #7 Resident #7 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus without complications, and hypo-osmolality and hyponatremia. Resident #8 Resident #8 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, with agitation, and pain. Resident #9 Resident #9 was admitted to the facility on [DATE] with diagnoses including cerebral infarction and adult failure to thrive. Resident #10 Resident #10 was admitted to the facility on [DATE], with diagnoses including primary osteoarthritis, unspecified site, and type two diabetes mellitus with diabetic neuropathy, unspecified. Resident #11 Resident #11 was admitted to the facility on [DATE], with diagnoses including epilepsy, unspecified, not intractable, without status epilepticus and chronic obstructive pulmonary disease. Resident #15 Resident #15 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic kidney disease, stage three, unspecified, and acute bronchitis, unspecified. Resident #20 Resident #20 was admitted to the facility on [DATE], with diagnoses including congestive heart failure and chronic atrial fibrillation. On 05/20/2024 at 11:17 AM, residents were in the common areas of the facility in heavy sweaters and long sleeves. On 05/20/2024 at 11:18 AM, Resident #7 verbalized it was cold in the facility and the resident did not like it, but the staff were moving around so much, it was probably better for them. On 05/20/2024 at 12:14 PM, Resident #20 was wearing a long sleeve flannel shirt, pants, and shoes. On 05/20/2024 at 12:15 PM, Resident #20 verbalized the resident did not like to shower because it was cold. On 05/21/2024 at 9:28 AM, Resident #11 was in the common area during exercise time wearing a long sleeve, fluffy jacket. On 05/21/2024 at 9:31 AM, Resident #7 was in the common area using a stationary bike pedal machine with a long sleeve sweater on their lap. On 05/21/2024 at 9:32 AM, Resident #7 verbalized they were wearing the sweater, but warmed up a little with exercise and took it off. On 05/21/2024 at 9:45 AM, Resident #9 was sitting in the common area in a fluffy pink sweater. On 05/21/2024 at 9:46 AM, Resident #9 verbalized they were not cold because they were wearing a sweater. On 05/21/2024 at 11:55 AM, a Certified Nursing Assistant (CNA) walked into the dining area and verbalized it was cold. On 05/21/2024 at 12:00 PM, Resident #20 verbalized they were not cold in the common areas because they were always prepared with a sweater. On 05/21/2024 at 12:01 PM, Resident #10 was seated at the dining room table waiting for lunch in a thick sweater. On 05/21/2024 at 12:02 PM, Resident #10 verbalized it was cold in the dining area. The resident explained it was too cold and the staff always kept it cold. Sometimes the staff would open the doors to the facility when it was raining or was windy and the residents would freeze. The resident verbalized They think when the temperature goes up outside, it needs to go down inside. On 05/21/2024 at 12:04 PM, Resident #11 verbalized they wore a sweater at the dining room table because they were cold and the staff kept it cold in the facility. The resident explained residents have told staff they were cold and staff informed maintenance. Maintenance would come look at the thermostat and would say it was comfortable but the resident exclaimed it was not comfortable for the residents. CNAs told the residents well, we're not cold, when the residents complained of the temperature. On 05/21/2024 at 12:10 PM, Resident #15 was eating lunch at the dining room table in a large, heavy jacket. On 05/21/2024 at 12:11 PM, Resident #15 verbalized it was cold and explained they always keep it cold in the hospital. The resident wore a heavy jacket because they were cold and preferred to be warm. On 05/21/2024, during the resident council interview, six out of ten residents verbalized it was too cold in the dining room and the room where exercise and karaoke took place. Six out of ten residents verbalized they have told staff it was too cold. One resident stated when they have complained of being cold, staff have responded by saying they were hot. Two residents verbalized they felt the staff's comfort was more important than the residents. Another resident verbalized one staff member informed them the staff member was going through menopause and took bipolar medication that made them hot. Temperatures at the nurse's station were as follows on: 05/21/2024 at 7:20 AM 69.1 degrees Fahrenheit (F) 05/21/2024 at 9:18 AM 69.4 F 05/21/2024 at 11:26 AM 69.4 F 05/21/2024 at 11:59 AM 69.6 F 05/21/2024 at 2:36 PM 70.0 F 05/22/2024 at 7:37 AM 69.6 F 05/22/2024 at 8:11 AM 70.0 F 05/22/2024 at 11:11 AM 69.6 F On 05/22/2024 at 8:11 AM, the Unit Clerk verbalized the temperature had been low in the facility due to inconsistent weather. The Unit Clerk explained the previous week, temperatures where high outside and the temperature in the facility was reaching 80 F. Maintenance adjusted the thermostat to a cooler temperature and then the weather changed outside and became cool. Maintenance had not adjusted the temperature in the facility to accommodate for the drop in temperature outside. The staff made sure the residents stayed warm by having the residents dressed in sweaters and giving them blankets. On 05/22/2024 at 8:12 AM, a CNA verbalized residents have stated they were cold and when they do, the staff provide blankets and sweaters to the residents. The CNA explained it was cold in the facility today and maintenance was slow to adjust the temperature in the facility. On 05/22/2024 at 8:17 AM, Resident #8 was in the TV room in a recliner. A CNA provided a blanket to Resident #8. The resident yelled out they were cold and wanted another blanket. The CNA put another blanket on the resident and remarked to the resident it was a bit cooler than usual in the facility. On 05/22/2024 at 9:30 AM, a CNA verbalized ooh, it's cold up in here! On 05/22/2024 at 9:31 AM, a Personal Care Technician (PCT) verbalized they personally felt it was cold in the facility the last few days. The PCT made sure residents were warm by ensuring they were dressed appropriately and provided blankets. On 05/22/2024 at 10:44 AM, the Activities Director verbalized the cooling system was new and facility staff were trying to regulate the temperature in the facility. Requests to change the temperature would be sent from the Skilled Nursing Facility (SNF) Manager and the DON to maintenance. Until the temperature was adjusted, the Activities Director explained the staff would offer blankets and sweaters to the residents if they were cold. On 05/22/2024 at 11:00 AM, the Activities Director confirmed the temperature at the nurses station, in the resident dining area, was 69.6 F. The Activities Director explained it was extremely hot last week and they believe there was an overcorrection to the thermostat. The Activities Director was unaware of the regulatory requirement of the temperature to be set at 71 F and confirmed each resident was different, but overall did not feel temperatures below 70 F were a comfortable homelike environment. Facility policy titled Safe Environment, undated, documented residents had a right to a safe, clean, comfortable and homelike environment. The facility must provide comfortable and safe temperatures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview, and document review the facility failed to ensure residents were screened for eligibility to receive a COVID-19 (COVID) vaccine, education regarding the vaccine was provided to the resident or resident representative, and if the vaccine was offered and either administered or declined 19 of 20 residents sampled for immunizations (Resident #17, #2, #13, #19, #15, #9, #6, #8, #14, #3, #5, #18, #16, #12, #7, #11, #4, #1, and #10). Findings include: Resident #17 Resident #17 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including pain unspecified, edema unspecified, and acute embolism and thrombosis of other specified deep vein of left lower extremity. Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including multiple sclerosis and acute cholecystitis. Resident #13 Resident #13 was admitted to the facility on [DATE], with diagnoses including adult failure to thrive, personal history of COVID-19, and hemiplegia, unspecified affecting unspecified side. Resident #19 Resident #19 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease, chronic systolic heart failure, ventricular tachycardia, unspecified. Resident #15 Resident #15 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified, cramp and spasm, and other fatigue. Resident #9 Resident #9 was admitted to the facility on [DATE], with diagnoses including cerebral infarction, unspecified and type two diabetes mellitus. Resident #6 Resident #6 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses including shortness of breath, personal history of COVID-19, chronic obstructive pulmonary disease, unspecified. Resident #8 Resident #8 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, with agitation, anemia, unspecified, and long term use of anticoagulants. Resident #14 Resident #14 was admitted to the facility on [DATE], with diagnoses including chronic atrial fibrillation, unspecified, pneumonia, unspecified organism, and shortness of breath. Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type two diabetes mellitus without complications and personal history of COVID-19. Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus without complications, adult failure to thrive, and personal history of COVID-19. Resident #18 Resident #18 was admitted to the facility on [DATE], with diagnoses including heart failure, unspecified, adult failure to thrive, and chronic kidney disease, unspecified. Resident #16 Resident #16 was admitted to the facility on [DATE], with diagnoses including chronic atrial fibrillation, lobar pneumonia, unspecified organism, and contact with and exposure to other viral communicable diseases. Resident #12 Resident #12 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus without complications, personal history of COVID-19, and heart failure, unspecified. Resident #7 Resident #7 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus without complications, hypothyroidism, unspecified, and deficiency of other specified B group vitamins. Resident #11 Resident #11 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including epilepsy, unspecified, chronic obstructive pulmonary disease, and unspecified asthma, uncomplicated. Resident #4 Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting unspecified side, personal history of COVID-19, and type two diabetes mellitus without complications. Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including epilepsy, unspecified, not intractable, without status epilepticus, personal history of COVID-19, and hyperkalemia. Resident #10 Resident #10 was admitted to the facility on [DATE], with diagnoses including acute cough, other myeloid leukemia not having achieved remission, and type two diabetes mellitus with diabetic neuropathy, unspecified. Resident #19's clinical record lacked documented evidence the resident was screened for eligibility to receive a COVID vaccine, education regarding the vaccine was provided to the resident or resident representative, and if the vaccine was offered and either administered or declined for 2024. Resident #17, #2, #13, #15, #9, #6, #8, #14, #3, #5, #18, #16, #12, #7, #11, #4, #1, and #10's clinical records lacked documented evidence the residents were screened for eligibility to receive the COVID vaccine, education regarding the vaccine was provided to the resident or resident representative, and if the vaccine was offered and either administered or declined for the years 2023 and 2024. On 05/22/2024 at 2:12 PM, the Infection Preventionist (IP) verbalized a consequence to a resident not receiving an up-to-date COVID vaccination could cause the resident to contract COVID and die. The IP communicated the resident's clinical documentation for immunizations were not monitored or updated and the facility was not sure how up-to-date the vaccinations were for each resident. On 05/22/2024 at 2:35 PM, the Skilled Nursing Facility (SNF) Manager confirmed COVID vaccinations and boosters were not provided to the residents for 2023 and 2024, as the facility had not put anything in place for the resident vaccinations. On 05/23/2024 at 9:51 AM, the IP confirmed the IP was responsible for all resident vaccinations and the Infection Control Program. The IP verbalized the IP was not involved with COVID vaccinations for the residents. The IP had depended on the Director of Nursing (DON) and the SNF Manager to order the COVID vaccine and the DON and SNF Manager would arrange consent, administration, and documentation. The IP confirmed the IP did not follow up on COVID vaccinations to ensure the vaccine was ordered or if each resident was screened for eligibility to receive the vaccine, education regarding the vaccine was provided to the resident or resident representative, and if the vaccine was offered and either administered or declined for the years 2023 and 2024. On 05/23/2024 at 10:03 AM, the SNF Manager confirmed COVID vaccinations were not ordered for the residents for the years of 2023 and 2024 because the SNF Manager and DON were focused on the resident influenza and pneumococcal vaccines. The SNF Manager confirmed the DON and the SNF Manager were responsible to order the resident COVID vaccines for 2023 and 2024, and did not order the vaccines. On 05/23/2024 at 11:22 AM, the DON confirmed the facility's COVID policies lacked guidance regarding resident COVID vaccinations. The DON provided an immunization policy which did not include the administration of the COVID vaccine. A Centers for Disease Control and Prevention (CDC) document titled Stay Up to Date with COVID-19 Vaccines, updated 03/07/2024, documented people aged 65 years and older were considered up to date with COVID vaccinations when two updated 2023-2024 COVID vaccines were administered. People 65 and older who had received one dose of an updated 2023-2024 vaccine, should receive one additional dose of an updated COVID vaccine at least four months after the previous updated dose. The facility policy titled Immunizations, revised 04/06/2012, documented the immunization schedule would follow current CDC recommendations for immunizations. The resident medical record would include documented education to the resident/representative, the opportunity to refuse immunization, the consent/refusal form and date, and if administered, would document the vaccine manufacturer, lot number, and expiration date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and document review, the facility failed to ensure a resident gave informed consent prior to administration of a psychotropic medication for 4 of 12 sampled residents (Resident #5, #6, #14 and #12). Findings include: Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including major depressive disorder, single episode, unspecified and major depressive disorder, recurrent severe without psych features. Resident #5's psychotropic physician orders included the following: -02/23/23 citalopram hydrobromide (brand name Celexa) Oral Tablet 20 milligrams (mg), give 20 mg by mouth one time a day related to major depressive disorder, recurrent severe without psychotic features. Resident #4's informed consent for Celexa, signed 10/10/22, lacked evidence the resident was informed on the indication for use. In a blank space intended for the diagnosis was the resident's first name. On 08/10/23 at 3:10 PM, the Minimum Data Set (MDS) Coordinator explained Celexa was the brand name for citalopram hydrobromide, and the resident signed the consent without evidence the resident was informed of the indication for use. Resident #6 Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including insomnia, unspecified, anxiety disorder, unspecified, and major depressive disorder, recurrent, unspecified. Resident #6's psychotropic physician orders included the following: -07/06/23 trazodone HCl Oral Tablet 150 mg, give 150 mg by mouth at bedtime for sleep. A consent for Trazadone was for 100 mg and signed 11/01/22. On 08/02/23 at 3:49 PM, the Skilled Nursing Facility (SNF) Manager confirmed the informed consent for Trazadone should have been updated upon readmit and when it was increased. A facility policy titled Resident Rights, dated 11/2016, documented the resident had the right to be informed of their treatment. Resident #14 Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including major depressive disorder, single episode, unspecified and insomnia, unspecified. Resident #14's psychotropic physician orders documented the following: -06/09/22 traZODone HCl Tablet 100 MG, give 1 tablet by mouth one time a day related to major depressive disorder, single episode, unspecified. Resident #14's informed consent, signed 06/09/23, indicated the resident was administered tazadone for insomnia. On 08/10/23 at 2:05 PM, the Minimum Data Set (MDS) Coordinator verbalized the physician order for Trazadone indicated major depressive disorder was the indication for use. On 08/10/23 at 2:17 PM, the MDS Coordinator confirmed the consent was given to administer arazadone for insomnia and it did not match the order, therefore, informed consent was not given or obtained for the administration of Trazadone. Resident #12 Resident #12 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavior/psychosis/mood/anxiety, major depressive disorder, single episode, unspecified, anxiety disorder, unspecified, and insomnia, unspecified. Resident #12's psychotropic physician orders documented the following: -07/24/23 LORazepam Oral Concentrate 1 mg/0.5ml (Lorazepam), give 0.5 ml by mouth every six hours as needed (PRN) for anxiety. Resident #12's Medication Administration Records documented the resident recieved lorazepam on the following dates: -07/25/23 -07/31/23 -08/01/23 -08/02/23 -08/04/23 -08/05/23 -08/06/23 On 08/10/23 at 2:50 PM, the MDS Coordinator verbalized the resident had recieved Lorazepam two times in July and five times in August. On 08/10/23 at 2:48 PM, the MDS Coordinator confirmed Resident #12 had not signed an informed consent for the administration of lorazepam and verbalized it was required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review the facility failed to honor a resident's choice to smoke for 1 of 12 sampled residents (Resident #4). Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified site, anxiety disorder, unspecified, and unspecified dementia, unspecified severity, with psychotic disturbance. A Unit Secretary Note dated 11/23/22, documented Resident #4 wanted to go out and smoke and was told by the resident's Public Guardian the resident could not smoke until 12/01/22 due to past actions. A Nursing Progress Note dated 12/17/22, documented the CNA had informed the Nurse of Resident #4's cigarette case and blanket being burned. No burns noted to resident's skin. The Director of Nursing was informed, and the cigarette breaks for the resident were discontinued for the time being. A Behavioral Health Services Physician Progress Note dated 06/07/23, documented Resident #4's chief complaint was I want to smoke, and verbalized the resident felt the resident's needs were not met in regard to smoking. On 07/31/23 at 4:58 PM, Resident #4 explained the facility staff used to take the resident out to the smoking area at certain times of the day to smoke with the other residents. Resident #4 verbalized the facility staff would not allow the resident to smoke, even if the resident was supervised, because the resident had been caught smoking in the resident's room. Resident #4 expressed the resident felt bad because the resident watched the other residents go out and smoke when the resident was not allowed. On 08/01/23 at 10:12 AM, a Licensed Practical Nurse (LPN1) explained Resident #4 asked to go out and smoke frequently but did not know if the resident had a Smoking Assessment completed. The Smoking Assessment evaluated if the resident required adaptive equipment, supervision, and assistance to light the cigarette. LPN1 verbalized one or two staff supervised the smoking area at any time and there were two cameras which had monitors displayed at the Long-Term Care Nurses' Station for additional monitoring. On 08/01/23 at 4:10 PM, a Social Worker (SW) explained the SW was aware Resident #4 wished to smoke but was not allowed because the resident had been found smoking in the resident's room on 10/29/22 and had burned a hole in the resident's own blanket and cigarette case while smoking in the dedicated smoking area on 12/17/22. The SW confirmed the Smoking Assessment in the resident's chart was dated 07/12/22 and had not been re-assessed after the two incidents had occurred. The SW explained the SW was responsible to follow up on the enforced smoking restriction and did not. On 08/02/22 at 12:53 PM, LPN2 explained Resident #4 was required to have supervision when smoking. LPN2 verbalized the resident's Public Guardian decided the resident was not safe to smoke in the smoking area and the Resident was not allowed out to the smoking area or to smoke. On 08/02/23 at 1:35 PM, the Minimum Data Set (MDS) Coordinator explained a Smoking Assessment was to be completed quarterly after the initial assessment completed on 07/12/22. The MDS Coordinator confirmed responsibility for completing the Smoking Assessment and failed to complete a quarterly Smoking Assessment for Resident #4. On 08/02/23 at 3:47 PM, the Skilled Nursing Facility (SNF) Manager explained Resident #4 was not allowed to smoke because the resident was a safety risk due to requiring total care assistance. The SNF Manager verbalized Resident #4 had required supervision when smoking because the resident needed assistance to get out to the smoking area and light a cigarette. The SNF Manager explained the facility had discussed purchasing a smoking apron for safety and never followed up. On 08/02/23 at 4:02 PM, the SNF Manager verbalized Resident #4 had the right to smoke and it was wrong for the facility to take the choice away from the resident. On 08/09/23 at 5:08 PM, Resident #4's Public Guardian confirmed making the decision to restrict the resident from smoking. The Public Guardian explained if the resident had a guardian, it meant the resident was not competent and could not make their own decisions. The Public Guardian explained facility staff had asked the Public Guardian to stop the resident from smoking because the resident had smoked in the bedroom on one occasion and had burned a blanket on another occasion. The Public Guardian verbalized having the authority to prevent the resident from exercising resident rights. On 08/10/23 at 2:50 PM, Resident #4 verbalized the resident did not understand why the SNF Manager and the Public Guardian would not allow the resident to smoke. Resident #4 verbalized the resident had smoked for forty years, did not want to stop, was not offered smoking cessation products, and did not think the facility should force the resident to quit smoking. A facility policy titled Fire Safety-Smoking Policy, revised 03/24/22, documented patients and residents who are not mentally competent may smoke only if accompanied by staff that is capable and assigned to accompany that resident/patient. Patients that are too ill to get out of bed to smoke would be offered a nicotine patch for comfort. The patient and family would be provided with education about the health risks connected with smoking and the patient would be encouraged not to smoke. The patient would be provided with education assistance programs about smoking cessation if a desire to quit was expressed. A facility policy titled Resident Rights, dated 11/2016, documented the facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. The resident had the right to make choices about aspects of his or her life in the facility that are significant to the resident. The resident had a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility. A facility policy titled Resident Rights Introduction, revised 08/15/11, documented the facility upheld the resident's right to act as a partner in his/her own care processes. Cross refence with tag 657, and F689.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility was out of compliance due to late completion and/or transmission of Minimum Data Set (MDS) assessments, Care Area Assessments (CAA) and/or care plans for 8 of 12 months, starting July, 2022. Findings include: [DATE]: 10.00% of admission assessments were submitted late (1 of 10) 10.00% of admission care plans were completed late Sep 2022: 54.55% of assessments were transmitted late (6 of 11) [DATE]: 42.86% of assessments were transmitted late (3 of 7) 14.29% of comprehensive assessments were transmitted late (1 of 7) 14.29% of entry tracking records were transmitted late 14.29% of death in facility tracking records were submitted late [DATE]: 28.57% of assessments were transmitted late (4 of 14) 14.29% of entry tracking records were transmitted late (2 of 14) [DATE]: 47.06% of comprehensive assessments were transmitted late (8 of 17) 35.29% of assessments were transmitted late (6 of 17) 23.53% of care areas assessments were completed late (4 of 17) [DATE]: 13.33% of assessments were completed late (2 of 15) 13.33% of admission assessments were completed late 13.33% of admission care plans were completed late 13.33% of entry tracking records were transmitted late [DATE]: 20.00% of assessments were completed late (2 of 10) [DATE]: 46.67% of assessments were transmitted late (7 of 15) 20.00% of comprehensive assessments were transmitted late (3 of 15) 20.00% of admission assessments were completed late 20.00% of admission care plans were completed late 13.33% of entry tracking records were transmitted late (2 of 15) On 08/10/23 at 1:45 PM, the Minimum Data Set (MDS) Registered Nurse confirmed the MDS transmissions were submitted late.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview, and document review the facility failed to ensure a care plan was developed related to 1) wound care for a resident with pressure ulcers for 1 of 12 sampled residents (Resident #17), 2) the use and monitoring of high-risk medications for 1 of 12 sampled residents (Resident #4), 3) the administration of psychotropic medications to include specific behaviors associated with the administration for 4 of 11 residents (Resident #4, #12, #3, and #6) reviewed for unnecessary medications, and 4) a resident requiring pain management for 1 of 12 sampled residents (Resident #10). Findings include: Pressure Ulcers Resident #17 Resident #17 was admitted to the facility on [DATE], with diagnoses including moderate protein-calorie malnutrition, multiple sclerosis, and pressure ulcer of sacral region, stage I. Resident #17's physician order for Vitamin C documented the following: -4/21/23, Vitamin C 500 milligrams (mg), give 500 mg by mouth two times a day to aid in wound healing for 14 days, discontinued 05/05/23. -06/23/23, Vitamin C 500 mg, give 500 mg by mouth two times a day to aid in wound healing for 14 days, discontinued 07/07/23. -07/17/23, Vitamin C 500 milligrams mg, give 500 mg by mouth two times a day to aid in wound healing for 14 days. Resident #17's physician order dated 05/18/23, documented Zinc oral tablet 50 mg, give one tablet by mouth one time a day for skin integrity. Resident #17's physician order dated 07/13/23, documented to encourage resident to change positions frequently to keep pressure off, monitor sacral area, and offer warm, moist compresses twice daily for 15 minutes to raised boggy area on sacral area. A Resident Skin Evaluation dated 07/20/23, documented Resident #17 had two small open holes in the left gluteal fold. A Resident Skin Evaluation dated 07/27/23, documented open area on coccyx, wound nurse aware. A Minimum Data Set Assessment (MDS) 3.0 dated 04/21/23, Section M0210, documented Resident #17 had one or more unhealed pressure ulcers/injuries. Section M0300, documented the resident had a stage I pressure injury and defined stage I as intact skin with non-blanchable redness of a localized area, usually over a bony prominence. Resident #17's Comprehensive Care Plan lacked identification, care, and treatment of wounds or pressure ulcers. On 08/01/23 at 10:54 AM, a Registered Nurse (RN) verbalized Resident #17's pressure ulcer started as redness and was now an open wound. The RN explained the resident received wound care from a wound care nurse. ON 08/02/23 at 3:07 PM, a Licensed Practical Nurse (LPN), who was also the wound care nurse, explained Resident #17 's care plan did not include wound care, pressure ulcers, or the interventions used for either skin condition. The LPN verbalized the risk of skin breakdown/impairment and wound care should have been on the resident's care plan and was not. The LPN defined the purpose of the care plan was a document which laid out the residents' care. The residents' care and anything that may have happened to the resident should be on the care plan. On 08/02/23 at 3:15 PM, the Skilled Nursing Facility (SNF) Manager explained Resident #17's care plan lacked pressure ulcer prevention and treatment and should have been included on the care plan. The SNF Manager defined the purpose of the care plan was to be a guide for resident care and it was to be person-centered regarding the resident's likes/dislikes. High Risk Medications Resident #4 Resident #4 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified site, anxiety disorder, unspecified, and unspecified dementia, unspecified severity, with psychotic disturbance. Resident #4's clinical record documented the following physician orders: -07/04/23, Novolin R (insulin regular human) injection solution 100 unit per milliliter (ml), inject as per sliding scale subcutaneously two times a day related to type II diabetes mellitus, without complications. -07/06/23, Lantus Solostar subcutaneous solution pen-injector 100 unit/ml, inject 21 unit subcutaneously one time a day related to type II diabetes mellitus, without complications. On 08/03/23 at 10:01 AM, a Licensed Practical Nurse (LPN) verbalized the expectation for insulin medications was to be included on the resident's care plan and should have included interventions, signs and symptoms monitoring, side effect monitoring, and medication efficacy for specific symptoms. The medications should be care planned to provide guidance for each specific medication that required monitoring for each type of insulin used. The LPN confirmed Resident #4 did not have a care plan specific to the use of insulin and should have. On 08/10/23 at 2:34 PM, the Assistant Director of Nursing (ADON) verbalized the resident's care plan should identify medications by name and include the diagnosis the medications treated. The ADON explained the facility care plans were general and not resident or medication specific. Psychotropic medications Resident #4 Resident #4's clinical record documented the following psychotropic order: -07/03/23, Mirtazapine oral tablet 7.5 mg, give 7.5 mg by mouth at bedtime related to insomnia, unspecified. Resident #4's clinical record lacked documented evidence of a resident-centered care plan for the diagnosis of insomnia, unspecified, the use of a psychotropic to treat the diagnosis, or monitoring for specific behaviors or adverse effects related to the medication. On 08/03/23 at 10:03 AM, an LPN confirmed Resident #4 did not have a care plan specific to the diagnosis of insomnia, the specific medication prescribed, interventions used, behavior monitoring, and signs and symptoms monitoring related to the use of a psychotropic medication and should have. Resident #12 Resident #12 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, single episode, unspecified, and anxiety disorder, unspecified. Resident #12's psychotropic physician orders included the following: -Lorazepam oral concentrate 1 mg/0.5 ml, give 0.5 ml by mouth every 6 hours as needed for anxiety. -10/04/22, Zoloft tablet 25 mg, give 1 tablet by mouth one time a day related to major depressive disorder, single episode, unspecified and anxiety disorder, unspecified. Resident #12's care plan for psychotropic medications related to depression, initiated on 06/16/23, documented the following: -Resident #12 was prescribed an antidepressant. -Any pharmacy recommendations be given to provider to make determinations. -Resident #12 continued to be monitored by Behavior Health Services (BHS) psychiatry. -Resident #12 was given medication as prescribed. -Non-medication interventions were continued to be provided. Resident #12's care plan for the diagnosis of anxiety disorder, initiated 05/04/22, included the following: -Assist with verbalization of feelings. -Continue to encourage normal daily routines -Resident #12 continue counseling through BHS. -Encourage to engage in conversation with fellow residents. -Offer a cold damp wash cloth for resident #12 to wipe their face. -Per conversation with counselor, offer Resident #12 a piece of ice to hold in their hand for 10 seconds. -Staff support resident #12 through active listening skills. On 08/10/23 at 11:24 AM, an LPN explained behavior monitoring included breathing, hypotension, alertness, and anything to do with the central nervous system. The LPN verbalized behavior monitoring, and documentation was not medication specific and only documented an observed behavior and interventions used for that behavior. The LPN confirmed the electronic health record did not include medication specific behavior monitoring. On 08/10/23 at 2:36 PM, the ADON verbalized behavior monitoring was generalized for all residents. The ADON explained the staff knew the residents well and knew what to watch for, however the staff did not document very well in the clinical record. Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnoses including bipolar disorder, unspecified, major depressive disorder, single episode, unspecified, other specified mental disorders due to known physiological condition, and other specified problems related to psychosocial circumstances. Resident #3's psychotropic physician orders include the following: -10/27/22 Effexor XR Capsule Extended Release 24 Hour 75 mg, give three capsules by mouth one time a day related to bipolar disorder, unspecified. -10/27/22 Mirtazapine Tablet 15 mg, give one tablet by mouth at bedtime related to major depressive disorder, single episode, unspecified. -10/27/22 Aripiprazole Tablet 2 mg, give one tablet by mouth at bedtime related to bipolar disorder, unspecified. Resident #3's care plan for the psychotropic medications, initiated on 11/03/22, and revised on 06/16/23, documented the following: Resident #3 was prescribed Effexor, Aripiprazole, and Mirtazapine to help. alleviate signs and symptoms of bipolar and major depression disorder. -Resident #3 took medications as prescribed. -Medications taken to provide a therapeutic affect. -Blood levels were within normal range. -Resident #3's provider/Medical Director (MD) was to be given pharmacy recommendations and make following determination. -Maintain overall good mood/behavior. -Medications were to be monitored and assessed by the pharmacist, provider, and BHS psychiatry. -Monitor and report if any side effects or physical conditions occurred as a result of long-term use. Resident #3's care plan for Bipolar and Major Depression Disorder, initiated on 11/03/22, documented the following: -Resident #3 utilized coping skills. -Resident #3 was able to socialize and communicate thoughts and feelings. -Resident #3 expressed overall having a positive mental wellbeing. -Resident #3 continued to be monitored by the resident's provider and BHS psychiatry. -Resident #3 was aware of BHS counseling services and agreed to notify staff if the resident would like to receive additional support. -Resident #3 was encouraged to express thoughts and feelings. -Resident #3 participated in activities such as bingo and outings as well as provided individual activities based on her preferences such as puzzles, crossword puzzles, etc. -Resident #3 socialized with fellow residents. -Resident #3 understood counseling services were available with BHS. -Encourage and support Resident #3 to continue daily exercise routine. On 08/02/23 at 4:06 PM, the Skilled Nursing Facility (SNF) Manager verbalized there were no specific behaviors indicated on Care Plans or physician orders, related to psychotropics. Physicians wrote orders for diagnosis only. Nurses were responsible for identifying behaviors but did not associate the specific behavior with a specific diagnosis in conjunction with a psychotropic medication. Resident #6 Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including insomnia, unspecified, anxiety disorder, unspecified, and major depressive disorder, recurrent, unspecified. Resident #6's psychotropic physician orders included the following: -07/16/23 Duloxetine HCl Oral Capsule Delayed Release Particles 60 mg, give one capsule by mouth two times a day related to major depressive disorder, recurrent, unspecified. -07/25/23 busPIRone HCl Oral Tablet 15 mg, give one tablet by mouth every six hours related to major depressive disorder, recurrent, unspecified. -07/06/23 Abilify Oral Tablet 5 mg, give 2.5 mg by mouth one time a day related to major depressive disorder, recurrent, unspecified. -07/06/23 trazodone HCl Oral Tablet 150 mg, give 150 mg by mouth at bedtime for sleep. Resident #6's care plan for the psychotropic medications, initiated on 08/06/21, documented the following: -Resident #6 took prescribed antidepressant and anxiety medications Buspirone, Abilify, and duloxetine medications for depression and anxiety. -Monitor drug blood levels as per orders. -Monitor interaction or resident with others for appropriateness. -Monitor resident's mental status on ongoing basis. -Monitor Resident #6's mood, state, and behavior. Resident #6 care plan for diagnosis of insomnia reporting not sleeping well at night. initiated 06/16/23, documented the following interventions: -Resident #6 was to be provided non-medication interventions to help provide quality of sleep. -Continue to encourage Resident #6 with activities during the day with preferred independent activities or when there are outings in the community. -Encourage Resident #6 to do exercises. -Resident #6 preferred to sleep with the TV on in a darkened room at night. -Resident #6 took medication to help with sleeping at night. On 08/02/23 at 4:05 PM, the SNF Manager verbalized Resident #6's specific non-medication interventions included headphones and tablet. The specific interventions should have been listed on the care plan for sleeping but were not. The specific medication for sleep was not listed. On 08/02/23 at 4:06 PM, the SNF Manager confirmed the psychotropic medications listed on Resident #6's care plan did not reflect which medication was administered for a specific diagnosis and the behavior associated with the diagnosis. Pain management Resident #10 Resident #10 was admitted to the facility 09/01/21, and readmitted on [DATE], with diagnoses including type 2 diabetes mellitus without complications. On 07/31/23 at 12:24 PM, Resident #10 verbalized having had pain in the resident's right hand. The resident requested to end the interview due to the pain. On 07/31/23 at 2:07 PM, the resident verbalized having been in extreme pain in the right hand and was awaiting an X-ray. The resident was repeatedly pressing the call bell. The nursing progress note, dated 07/31/23, documented the resident complained of right-hand pain. The Supervisor assessed the resident. The area of concern was noted to right hand thumb where the resident propped up the resident's weight while in bed. X-ray was ordered and the results were pending. The Medication Regimen Review (Pharmacist's Review), dated 7/31/23, documented the resident complained of right-hand pain, X-ray ordered, results were pending. Provider started the resident on Norco PRN (as needed.) Resident #10's physician orders for pain were as follows: -01/04/23 Voltaren Gel 1 % (Diclofenac Sodium) apply to shoulders topically every 24 hours as needed for arthritic shoulder pain. -11/14/22 Tylenol tablet 325 mg (Acetaminophen), give one tablet by mouth every four hours as needed for pain. -07/31/23 Norco Oral tablet 5-325 mg, give one tablet by mouth every eight hours as needed for pain related to hereditary and idiopathic neuropathy, unspecified for two days. On 08/03/23 at 10:51 AM, a Licensed Practical Nurse (LPN) confirmed pain required a care plan. The care plan would indicate the required medications and side effects, evaluation of pain level, what would increase the pain or what decreased the pain, and any comfort measures such as ice packs prior to administering meds. The LPN confirmed Resident #10 exhibited pain and explained the pain was currently located in the resident's right thumb. The X-ray and Norco were ordered. The resident also had an order for Voltaren gel for shoulder pain. The resident sometimes had headaches. On 08/03/23 at 10:57 AM. the LPN confirmed the location of Resident #10's pain and management of the pain had not been identified in the resident's care plan. On 08/03/23 at 11:15 AM, the SNF Manager verbalized pain management should be care planned. The care plan would include location of pain, type of pain, non-pharmacological strategies to alleviate pain and the prescribed medications. The SNF Manager explained Resident #10 had increased pain in the past week to the right thumb and previously had pain in left shoulder. On 08/03/23 at 11:19 AM, the SNF Manager confirmed Resident #10 did not have a care plan specific for pain management. The facility policy titled Care Plans, revised 03/22/17, documented the care plan must include the instructions needed to provide effective person-centered care of the resident that met professional standards of quality care. The comprehensive person-centered care plan was consistent with the resident's rights that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment, and a description of services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #4 Resident #4 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified site, anxiety disorder, unspecified, and unspecified dementia, unspecified severity, with psychotic disturbance. A Smoking assessment dated [DATE], documented Resident #4 had cognitive loss, had a dexterity problem, did not require supervision or assistance, and the plan of care was used to assure the resident was safe while smoking. Resident #4's care plan lacked documentation of the Smoking Assessment completion, results, or interventions identified from the assessment. On 08/01/23 at 4:10 PM, a Social Worker (SW) confirmed Resident #4's Smoking Assessment was dated 07/12/22 and had not been re-assessed since then or upon re-admission. On 08/02/23 at 1:36 PM, the MDS Coordinator explained a Smoking Assessment was supposed to be completed quarterly, after the initial assessment was completed on 07/12/22, for Resident #4. The MDS Coordinator confirmed responsibility for completing the Smoking Assessment and verbalized a quarterly Smoking Assessment was not completed upon Resident #4's readmission. On 08/02/23 at 3:48 PM, the SNF Manager verbalized Resident #4 required supervision when smoking because the resident needed assistance to ambulate to the smoking area, and to light a cigarette. The SNF Manager explained Resident #4 was not allowed to smoke because the resident's safety was at risk. The resident's safety risk assessment and assistance requirement were not documented or updated on the care plan. The SNF Manager confirmed Resident #4 had not received another Smoking Assessment upon re-admission and should have. On 08/09/23 at 4:06 PM, the SW verbalized the care plan for smoking had been removed from Resident #4's care plan completely. The SW communicated the care plan for smoking should have been updated and did not know why it had been removed. The SW explained the MDS Coordinator was responsible to update the care plan with Smoking Assessment. On 08/09/23 at 4:22 PM, the MDS Coordinator confirmed the Smoking Assessment did not identify the resident as a safety risk, was not added to the care plan, and had not been completed in a timely manner. The MDS Coordinator verbalized the MDS Coordinator was responsible to perform the Smoking Assessment and to update the care plan with the results. On 08/09/23 at 4:24 PM, the MDS Coordinator confirmed smoking was removed from Resident #4's care plan. The MDS Coordinator explained having determined the Smoking Assessment required improvement and therefore removed the entire section from Resident #4's care plan. The MDS Coordinator verbalized the resident was not allowed to smoke until smoking safety could be determined and was not in a position to make the determination of the resident's smoking status until the SNF Manager returned. Resident #4's care plan lacked revision and updates upon readmission and documentation of the smoking assessment, to include the evaluation of cognitive ability, judgement, manual dexterity, and mobility. Resident #4's care plan initiated on 11/02/22, and revised on 02/02/23, documented: -10/29/22, the resident was caught smoking in the resident's room by staff. -12/17/22, the resident was found with cigarette burns on their blanket, which was on the resident's lap, along with cigarette burns on the resident's cigarette case. Therefore, it was determined and agreed upon by the Skilled Nursing Facility and the resident's guardian, the resident was unsafe to smoke. Smoking privileges were revoked at this time. Interventions for Resident #4 were documented as follows: -11/03/22, Resident #4 followed smoking policy by keeping cigarettes and lighters behind the CNA desk. -11/03/22, Smoking restriction would be lifted if the resident met the smoking safety assessment. Staff would use active measures to assist with monitoring cigarettes and ensure lighters were kept at the CNA desk. -11/03/22, and revised 05/03/23, while the resident was on smoking restriction, the resident was informed of reasoning due to safety risks of self and others being unable to follow smoking policies. Resident #4's care plan lacked documentation of an update or outcome of the imposed smoking restriction on the previous admission. On 08/02/23 at 1:02 PM, the SW verbalized Resident #4 had been on a 30 day smoking restriction for not following the facility smoking policy last year. The SW confirmed the SW did not follow up on the resident's smoking restriction after the 30 days had passed, the smoking restriction was not lifted, and another Smoking Assessment was not completed after the smoking restriction was initiated or upon readmission. The SW verbalized the SW had forgotten to update the care plan to include the resident's choice to smoke, interventions in place to facilitate the resident's choice to safely smoke, and an updated outcome to the smoking restriction. On 08/09/23 at 4:07 PM, the SW verbalized the care plan for smoking had been removed from Resident #4's care plan completely. The SW communicated the care plan for smoking should have been updated and did not know why it had been removed. The SW explained the MDS Coordinator was responsible to update the care plan with Smoking Assessment results. On 08/09/23 at 4:23 PM, the MDS Coordinator confirmed smoking was removed from Resident #4's care plan due to inaccuracies. The MDS Coordinator explained having determined the Smoking Assessment required improvement and therefore removed the entire smoking section from Resident #4's care plan. The MDS Coordinator verbalized the resident was not allowed to smoke until smoking safety could be determined and was not able to make the determination of the resident's smoking status until the SNF Manager returned. The facility policy titled Care Plans, revised 03/22/17, documented the comprehensive person-centered care plan was consistent with the resident's rights that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment, and a description of services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plans would be updated as the needs of the resident changed and reviewed at least every 92 days by the interdisciplinary team. The facility policy titled Interdisciplinary Team Plan of Care, dated 04/01/03, documented care plans would be updated at the time of the care conference or on the shift immediately following the conference. Responsibility for each intervention conducted and documentation of resident response and progress toward the goal is decided and designated by the interdisciplinary team. Based on interview, observation, clinical record review, and document review, the facility failed to ensure a comprehensive care plan for smoking included revisions or updates upon readmission and included documentation of the smoking assessment with evaluation of cognitive ability, judgement, manual dexterity, and mobility for 2 of 12 sampled residents (Resident #6 and #4), a comprehensive care plan for smoking was revised to include an update for an imposed smoking restriction for 1 of 12 sampled residents (Resident #4), and a comprehensive care plan was updated to include interventions for residents' nutrition status for 1 of 12 residents (Resident #5). Findings include: Resident #6 Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including nicotine dependence, unspecified, uncomplicated, and personal history of nicotine dependence. On 07/31/23 at 2:01 PM, Resident #6 verbalized the resident was able to smoke when the resident wanted to, and staff did not supervise the resident's smoking. On 08/01/23 at 4:09 PM, Resident #6 was outside smoking without supervision. Resident #6's last Smoking Assessment was completed 05/31/22, prior to most recent admission. The following areas were assessed: -Cognitive -Vision -Dexterity -Frequency -Safety Resident #6's comprehensive care plan, initiated 08/06/21 and last revised 11/03/21, for smoking, indicated the following interventions: -created 08/23/21, a quarterly smoking assessment was to be completed quarterly. -created 08/06/21, staff to monitor for continued safety. -created 07/12/22, Resident #6 was able to sustain the resident's nicotine needs using chewing tobacco while unable to go outside to smoke during isolation. -last revised 05/11/23, Resident #6 understood cigarettes and lighter needed to be kept at the Certified Nursing Assistant desk. On 08/01/23 at 4:45 PM, the Minimum Data Set (MDS) Coordinator verbalized a smoking assessment was completed annually or if the resident expressed interest in starting to smoke. The SNF Manager verbalized smoking assessments were completed only upon admission or on onset of a resident's desire to smoke. On 08/01/23 at 4:51 PM, the SNF Manager verbalized Resident #6's last smoking assessment was completed 05/31/22, prior to most recent admission of 01/23/23 and confirmed the assessment was without quantifying data to determine safety interventions. The data collected on the assessment did not have criteria to determine needed interventions. On 08/01/23 at 4:48 PM, the MDS Coordinator verbalized the data collected on the smoking assessment did not equate to a score to determine a resident's safety level of smoking. The facility policy titled, Smoking by Residents, effective 07/01/12, documented all smoking residents were to be evaluated by the medical and nursing staff for the capability of handling their own smoking materials. Assessment shall be documented in the medical record in the resident's care plan and include the evaluation of cognitive ability, judgement, manual dexterity, and mobility. Resident smoking safety was to be reassessed upon change in resident clinical condition. Resident #6's smoking assessment lacked assessment of mobility. Resident #6's care plan for smoking lacked revision and updates upon readmission and documentation of the smoking assessment, to include the evaluation of cognitive ability, judgement, manual dexterity, and mobility. Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnosis including adult failure to thrive, vitamin deficiency, unspecified, and type two diabetes mellitus without complications. On 07/31/23 at 12:27 PM, Resident #5's lunch tray contained a whole pork chop. The resident verbalized the resident did not have any teeth and would not be able to eat the whole pork chop but was going to try. The resident did not recall if staff normally cut up meat, however the resident would prefer the meat to be cut up. Resident #5's tray card documented regular, soft texture: smothered pork cutlet with onions, rice pilaf, green beans, wheat dinner roll, and ice cream. On 07/31/23 at 12:30 PM, a Licensed Practical Nurse (LPN) verbalized a soft diet would contain chopped or ground meat. The LPN confirmed the residents tray card documented the resident would receive a soft texture diet and the resident had received a whole pork chop. The whole pork chop was not part of a soft diet and would be difficult to eat for a resident that did not have teeth. On 08/03/23 at 10:38 AM, the SNF Manager verbalized Resident #5 was on a soft diet. The SNF Manager confirmed the resident's care plan did not document the resident's diet type and should have. An Annual Nutrition Assessment date 07/15/23, documented Resident #5 received a regular diet, soft texture. A physician's order dated 03/17/22, documented diet type: regular, diet type: soft. Resident #5's Comprehensive Care Plan included a care plan for altered nutritional status. The care plan documented provide and serve diet as ordered. The care plan did not specify the type of diet the resident should have received. The facility policy Care Plans, revised 03/22/17, documented each resident would have a comprehensive person-centered care plan which would be based on the findings of the comprehensive assessment, include measurable objectives, timeframes to meet a residents' needs, and the care plan would be updated as the residents needs changed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observations, clinical record review and document review, the facility failed to ensure a resident received supervision and assistance to prevent a resident from burning a blanket and cigarette case on the resident's person for 1 of 12 sampled residents (Resident #4), and ensure a smoking resident had a smoking assessment completed quarterly for safety and the assessment determined safety interventions resulting from information gathered on the assessment for 2 of 12 sampled residents (Resident #4 and #6). Findings include: Supervision and Assistance and Smoking Assessment Resident #4 Resident #4 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified site, anxiety disorder, unspecified, and unspecified dementia, unspecified severity, with psychotic disturbance. A Certified Nursing Assistant (CNA) Progress Note dated 10/18/22, documented Resident #4 was found outside at 7:30 PM and hollering about wanting to come inside. The CNA was told upon shift change the resident had been outside since noon that day. A CNA Progress Note dated 10/28/22, documented Resident #4 was found laying in bed and smoking a cigarette in the resident's room while wearing oxygen. The cigarette and lighter were removed from the resident. A CNA Progress Note dated 12/03/22, documented Resident #4 was taken to the smoking shed at 2:30 PM, left with two cigarettes, and the resident returned at 4:30 PM. A CNA Progress Note dated 12/17/22, documented the resident was taken to smoke at 10:22 AM and left in the smoke shack. The resident was brought back in at 11:15 AM and was found to have melted a hole in their blanket and cigarette case. The situation was reported to the nurse, Activities Dept, and the Director of Nursing (DON). A Nursing Progress Note dated 12/17/22, documented the LPN was informed by a CNA the resident had burned their cigarette case and blanket. No burns noted to the resident's skin. The LPN informed the DON and cigarette breaks were discontinued. On 07/31/23 at 4:57 PM, Resident #4 explained the facility staff used to take the resident out to the smoking area to smoke with the other residents. Resident #4 verbalized the facility staff would not allow the resident to smoke, even if the resident was supervised, because the resident had been caught smoking in the resident's room last year. Resident #4 expressed the resident felt bad because the resident watched the other residents go out and smoke when the resident was not allowed. On 08/02/22 at 12:53 PM, a Licensed Practical Nurse (LPN) explained Resident #4 was required to have supervision when smoking. On 08/02/23 at 3:48 PM, the Skilled Nursing Facility (SNF) Manager verbalized Resident #4 was supposed to be supervised in the smoking area because the resident required total care assistance and help to get out to the smoking area and light a cigarette. The resident had verbalized the resident did not want staff to babysit the resident in the smoking area. The SNF Manager explained staff tried leaving the resident outside without supervision and the resident burned their cigarette case and blanket. The SNF Manager verbalized the facility was looking into obtaining a smoking apron for safety and did not purchase the apron. On 07/31/23 at 4:59 PM, Resident #4 verbalized the resident wanted to smoke but was not allowed to smoke outside and with the other residents. Resident #4 explained facility staff did not allow the resident to smoke since last year because the resident had been caught smoking in the resident's room once and at another time had burned the resident's blanket while smoking. Resident #4's last Smoking Assessment was completed 07/12/22, prior to the resident's most recent admission, assessed the following: -Cognitive -Vision -Dexterity -Frequency -Safety Resident #4's care plan for smoking, initiated on 11/03/22, documented the resident was caught smoking in the resident's room on 10/29/22 and burned the resident's lap blanket and cigarette case on 12/17/22. An intervention, dated 11/03/22, documented when the smoking restriction was lifted, and if the resident met the Smoking Safety Assessment, staff would use active measures to assist with monitoring cigarettes and ensure lighters were kept at the Certified Nursing Assistant (CNA) desk. On 08/02/23 at 1:36 PM, the Minimum Data Set (MDS) Coordinator verbalized being responsible to complete the Smoking Assessments on admission, quarterly, and when a resident indicated an interest to start smoking. The MDS Coordinator confirmed Resident #4's last Smoking Assessment was performed on 07/12/22 and should have been completed after the resident had smoked in the resident's room on 10/29/22, after the resident burned holes in their blanket and cigarette case on 12/17/22, quarterly, and upon re-admission and was not done. On 08/02/23 at 3:51 PM, the SNF Manager verbalized the facility had not performed a Smoking Assessment since 07/12/22 and should have re-assessed the resident for safety after the two incidents last year and upon re-admission. On 08/09/23 at 4:21 PM, the MDS Coordinator confirmed the Smoking Assessment did not identify the resident as a safety risk and had not been completed in a timely manner. Resident #4's Smoking Assessment lacked assessment of mobility. The facility policy titled Resident Rights, dated 11/2016, documented the resident had the right to a safe, clean, comfortable, and homelike environment, including receiving treatment and support for daily living safely. Cross Reference with tag F561. Resident #6 Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including nicotine dependence, unspecified, uncomplicated, and personal history of nicotine dependence. On 07/31/23 at 2:01 PM, Resident #6 verbalized the resident was able to smoke when the resident wanted to, and staff did not supervise the resident's smoking. On 08/01/23 at 4:09 PM, Resident #6 was outside smoking without supervision. Resident #6's last Smoking Assessment was completed 05/31/22, prior to most recent admission. The following areas were assessed: -Cognitive -Vision -Dexterity -Frequency -Safety Resident #6's comprehensive care plan, initiated 08/06/21, for smoking, indicated an intervention created 08/23/21, a quarterly smoking assessment was to be completed quarterly and staff monitor for continued safety. On 08/01/23 at 4:45 PM, the SNF Manager explained smoking assessments were completed to make sure residents were safe to smoke. The Minimum Data Set (MDS) Coordinator verbalized a smoking assessment was completed annually or if the resident expressed interest in starting to smoke. The SNF Manager verbalized smoking assessments were completed only upon admission or on onset of a resident's desire to smoke. On 08/01/23 at 4:51 PM, the SNF Manager verbalized Resident #6's last smoking assessment was completed 05/31/22, prior to most recent admission of 01/23/23 and confirmed the assessment was without quantifying data to determine safety interventions. The data collected on the assessment did not have criteria to determine needed interventions. The SNF Manager verbalized the SNF Manager tracked the timeliness of other assessments but there had been no need to track the timeliness of smoking assessments. On 08/01/23 at 4:48 PM, the MDS Coordinator verbalized the data collected on the smoking assessment did not equate to a score to determine a resident's safety level of smoking. On 08/01/23 at 4:50 PM, the MDS Coordinator verbalized the smoking assessments should have been tracked to be completed quarterly. The facility policy titled, Smoking by Residents, effective 07/01/12, documented all smoking residents were to be evaluated by the medical and nursing staff for the capability of handling their own smoking materials. Assessment shall be documented in the medical record in the resident's care plan and include the evaluation of cognitive ability, judgement, manual dexterity, and mobility. Resident #6's smoking assessment lacked assessment of mobility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to provide a therapeutic diet for an edentulous resident for 1 of 12 sampled residents (Resident #5). Findings include: Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including adult failure to thrive, vitamin deficiency, unspecified, and type two diabetes mellitus without complications. On 07/31/23 at 12:27 PM, Resident #5's lunch tray contained a whole pork chop. The resident verbalized the resident did not have any teeth and would not be able to eat the whole pork chop but was going to try. The resident did not recall if staff normally cut up meat, however the resident would prefer the meat to be cut up. Resident #5's tray card documented regular, soft texture: smothered pork cutlet with onions, rice pilaf, green beans, wheat dinner roll, and ice cream. On 07/31/23 at 12:30 PM, a Licensed Practical Nurse (LPN) verbalized a soft diet would contain chopped or ground meat. The LPN confirmed the resident's tray card documented the resident would receive a soft texture diet and the resident had received a whole pork chop. The whole pork chop was not part of a soft diet and would be difficult to eat for a resident that did not have teeth. On 08/01/23 at 3:55 PM, a Personal Care Technician (PCT) verbalized Resident #5 had problems eating due to not having teeth. The PCT explained the resident usually received whole pieces of meat and the PCT would chop the meat when the resident asked. On 08/02/23 at 8:51 AM, the Dietary Manager (DM) verbalized a soft diet consisted of soft textured foods such as chopped meats. The DM explained dry meats such as chicken or pork should be chopped with gravy for a resident on a soft diet. The DM confirmed Resident #5 was to receive a soft diet. The DM verbalized a whole pork chop would not meet the criteria for a soft diet. On 08/03/23 at 10:38 AM, the Registered Dietician (RD) explained a soft diet was a texture modified diet with chopped or ground meats and soft mushy vegetables. A resident on soft diet should never receive a whole piece of pork loin. The RD confirmed Resident #5 had poor dentition and should receive meats chopped up or ground. An Annual Nutrition assessment dated [DATE], documented Resident #5 received a regular diet, soft texture. A physician's order dated 03/17/22 documented diet type: regular, diet type: soft. The facility policy titled Texture Consistency, dated 10/05/17, documented the food and nutrition services department would be responsible for preparing and serving diet textures as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, clinical record review and document review, the facility failed to ensure a resident's pain was managed with care planned interventions, pain was evaluated per a physician order, and appropriate administration of pain medication for 1 of 12 sampled residents (Resident #10). Findings include: Resident #10 Resident #10 was admitted to the facility 09/01/21, and readmitted on [DATE], with diagnoses including type 2 diabetes mellitus without complications. On 07/31/23 at 12:24 PM, Resident #10 verbalized having had pain in the resident's right hand. The resident had requested Voltaren gel for the resident's right hand. The resident requested to end the interview due to the pain. A Registered Nurse entered the resident's room and applied the Voltaren gel to the resident's right hand. On 07/31/23 at 2:07 PM, the resident verbalized having extreme pain in the right hand and was awaiting an X-ray. The resident was repeatedly pressing the call bell. The nursing progress note, dated 07/31/23, documented the resident complained of right hand pain. The Supervisor assessed the resident. The area of concern was noted to right hand thumb where the resident propped up the resident's weight while in bed. X-ray was ordered and the results were pending. The Medication Regimen Review (Pharmacist's Review), dated 07/31/23, documented the resident complained of right hand pain, X-ray ordered, results were pending. Provider started the resident on Norco PRN (as needed.) Resident #10's physician orders for pain were as follows: -01/04/23 Voltaren Gel 1 % (Diclofenac Sodium) apply to shoulders topically every 24 hours as needed for arthritic shoulder pain. -11/14/22 Tylenol tablet 325 mg (Acetaminophen), give one tablet by mouth every four hours as needed for pain. -11/14/22 Evaluate level of pain using 0-10 scale -07/31/23 Norco Oral tablet 5-325 mg, give one tablet by mouth every eight hours as needed for pain related to hereditary and idiopathic neuropathy, unspecified for two days. On 08/03/23 at 10:51 AM, a Licensed Practical Nurse (LPN) confirmed pain required a care plan. The care plan would indicate the required medications and side effects, evaluation of pain level, what would increase the pain or what decreased the pain, and any comfort measures such as ice packs prior to administering meds. The LPN confirmed Resident #10 exhibited pain and explained the pain was currently located in the resident's right thumb. The X-ray and Norco were ordered. The resident also had an order for Voltaren gel for shoulder pain. The resident sometimes had headaches. On 08/03/23 at 10:57 AM, the LPN confirmed the location of Resident #10's pain and management of the pain had not been identified in the resident's care plan. On 08/03/23 at 11:01 AM, the LPN confirmed the resident had an active order to evaluate pain but explained it was only evaluated if staff were administering a pain medication. On 08/03/23 at 11:07 AM, the LPN confirmed the resident received Voltaren gel on 07/31/23 at 12:47 PM, and verbalized it was coded as a five for location, indicative administration of the medication was due to pain in the hand. On 08/03/23 at 11:11 AM, the LPN verbalized the Voltaren gel was ordered for pain in the resident's shoulder. The LPN verbalized it was administered incorrectly. On 08/03/23 at 11:15 AM, the SNF Manager verbalized pain management should be care planned. The care plan would include location of pain, type of pain, non-pharmacological strategies to alleviate pain and the prescribed medications. The SNF Manager explained Resident #10 had increased pain in the past week to the right thumb and previously had pain in left shoulder. On 08/03/23 at 11:19 AM, the SNF Manager confirmed Resident #10 did not have a care plan specific for pain management. On 08/03/23 at 11:20 AM, the SNF Manager confirmed Resident #10 had an order for evaluation of pain. The SNF Manager verbalized the evaluation of pain was not documented unless the resident requested a PRN pain medication. The order for evaluation of the resident's pain should have been scheduled and documented on the resident's Treatment Administration Record (TAR). The nurse did not input the order correctly to ensure it was evaluated on a schedule. It should have been scheduled for morning and night in addition to the evaluation during a PRN pain medication administration. On 08/03/23 at 11:25 AM, the SNF Manager admitted the resident had received Voltaren gel for thumb pain on 07/31/23 at 12:47 PM, and it should have only been administered for shoulder pain. A nurse cannot administer medication to a different location then where it was specified on an order. The facility policy titled Pain Assessment, Treatment and Documentation, revised 01/01/19, documented administration of pain relieving care or medications and their effectiveness were to be accurately and completely documented. A medical provider was to specify the type of pain a medication was intended to treat when more that one pain medication was ordered. The facility policy titled Pain Management, effective 01/02/19, documented the physician was to be contacted regarding pain or pain indicators, an individualized care plan was to be developed and implemented, and in the event there were no new orders for the pain, licensed staff were to continue to monitor the resident's condition. Alternative methods of pain control were to be attempted.

Based on interview and document review the facility failed to ensure the facility had a full-time Director of Nursing (DON). Findings include: On 07/31/23 at 11:03 AM, the Administrator verbalized the facility did not have a DON, however the facility had a Licensed Practical Nurse (LPN) functioning as the Skilled Nursing Facility (SNF) Manager. On 08/03/23 at 1:28 PM, the Human Resources Director verbalized the facility did not have a DON and the DON position was vacant. The Facility Assessment Tool, revised 07/19/23, documented to ensure sufficient staff to meet the needs of the residents at any given time one Skilled Nursing Manager, License Practical Nurse (LPN), was to be full-time on days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and clinical record review, the facility failed to ensure a physician responded to a pharmacist recommendation to add an end date to a psychotropic as needed (PRN) physician's order for 1 of 11 residents receiving psychotropic medications (Resident #12) Findings include: Resident #12 Resident #12 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavior/psychosis/mood/anxiety, major depressive disorder, single episode, unspecified, anxiety disorder, unspecified, and insomnia, unspecified. Resident #12's psychotropic physician orders documented the following: -07/24/23 Lorazepam Oral Concentrate 1 milligram (mg)/0.5 milliliter (ml) (Lorazepam), give 0.5 ml by mouth every six hours as needed for anxiety. Resident #12's Medication Regimen Review note, dated 07/31/23, completed by the pharmacist, documented consideration to add duration to PRN lorazepam had been made to the psychotropic medication review form. On 08/10/23 at 2:40 PM, the Minimum Data Set (MDS) Coordinator verbalized the Lorazepam order should have had a 14 day stop date because it was ordered as needed. On 08/10/23 at 2:49 PM, the MDS Coordinator explained the physician signed the psychotropic medication review form acknowledging the pharmacist had read the recommendation from the pharmacist to add the end date to the PRN lorazepam. However, the physician did not respond or document a clinical rationale to the pharmacist recommendation. Nursing was not directed to add an end date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, clinical record review and document review, the facility failed to ensure a resident did not receive an unnecessary pain medication when a nurse administered Voltaren gel for a different location of pain than indicated in a physician order for 1 of 12 sampled residents (Resident #10). Findings include: Resident #10 Resident #10 was admitted to the facility 09/01/21, and readmitted on [DATE], with diagnoses including type 2 diabetes mellitus without complications. On 07/31/23 at 12:24 PM, Resident #10 verbalized having had pain in the resident's right hand. The resident had requested Voltaren gel for the resident's right hand. The resident requested to end the interview due to the pain. The Registered Nurse entered the resident's room and applied the Voltaren gel to the resident's right hand. The nursing progress note, dated 07/31/23, documented the resident complained of right hand pain. The Supervisor assessed the resident. The area of concern was noted to right hand thumb where the resident propped up the resident's weight while in bed. X-ray was ordered and the results were pending. Resident #10's physician order dated 01/04/23, documented Voltaren Gel 1 % (Diclofenac Sodium) apply to shoulders topically every 24 hours as needed for arthritic shoulder pain. On 08/03/23 at 10:51 AM, a Licensed Practical Nurse (LPN) confirmed Resident #10 exhibited pain and explained the pain was currently located in the resident's right thumb. The resident also had an order for Voltaren gel for shoulder pain. On 08/03/23 at 11:07 AM, the LPN confirmed the resident received Voltaren gel on 07/31/23 at 12:47 PM, and verbalized it was coded as a five for location, indicative of administration of the gel due to pain in the hand. On 08/03/23 at 11:11 AM, the LPN verbalized the Voltaren gel was ordered for pain in the resident's shoulder. The LPN verbalized it was administered incorrectly. On 08/03/23 at 11:15 AM, the SNF Manager verbalized Resident #10 had increased pain in the past week to the right thumb and previously had pain in left shoulder. On 08/03/23 at 11:25 AM, the SNF Manager admitted the resident had received Voltaren gel for thumb pain on 07/31/23 at 12:47 PM, and it should have only been administered for shoulder pain. A nurse cannot administer medication to a different location then where the pain was specified on an order.

Based on interview and document review the facility failed to ensure the facility had a full-time Director of Nursing (DON), resulting in a lack of clinical oversight for safe bedrail implementation, and psychotropic medications. Findings include: Full-time DON On 07/31/23 at 11:03 AM, the Administrator verbalized the facility did not have a DON, however the facility had a Licensed Practical Nurse (LPN) functioning as the Skilled Nursing Facility (SNF) Manager. The Administrator explained the SNF Manager was in a nursing program and would become a Registered Nurse in May of 2024. On 08/01/23 at 9:36 AM, a Registered Nurse (RN) verbalized the SNF Manager was the charge nurse. On 08/03/23 at 1:28 PM, the Human Resources Director verbalized the facility did not have a DON and the DON position was vacant. On 08/09/23 at 3:59 PM, an RN verbalized the SNF Manager was the Charge Nurse and the RN took clinical direction from the SNF Manager. On 08/09/23 at 4:20 PM, the Assistant Director of Nursing (ADON)/RN verbalized the Charge Nurse supervised the care of residents and ensured policies and procedures were followed. The Charge Nurse supervised and provided clinical guidance to the staff. The ADON confirmed the SNF Manager was the Charge Nurse and was an LPN. The ADON confirmed an LPN cannot clinically supervise an RN. On 08/09/23 at 4:45 PM, the Minimum Data Set (MDS) Nurse/RN verbalized the SNF Manager was an LPN. The MDS RN confirmed the SNF Manager was the Charge Nurse and the MDS RN's direct supervisor. The SNF Manager job description, revised 04/28/22, documented the SNF Manager performed duties such as completing care plans, supervising all SNF staff, and providing coverage on the floor as the Charge Nurse. Practical Nurses NAC 632.230 to 632.242, inclusive (Added to NAC by Board of Nursing, effective 11/02/87) NAC 632.230 Limitations on performance of tasks; supervision of others; delegation of duties. A licensed practical nurse may not independently carry out those duties which require the substantial judgment, knowledge and skill of a registered nurse. Bedrails On 08/02/23 at 9:18 AM, the Skilled Nursing Facility (SNF) Manager verbalized upon admission, if a resident had issues with mobility, the facility would obtain an order from the physician for a halo and have the halo installed. The SNF Manager confirmed the facility did not attempt alternatives prior to installation. On 08/02/23 at 10:05 AM, the SNF Manager verbalized the Halo Mobility Ring Assessment did not contain an assessment for entrapment. The SNF Manager explained the Halo Mobility Ring Assessment assesses if the resident's head could get stuck but did not assess for overall risk of entrapment. On 08/02/23 at 10:42 AM, the SNF Manager verbalized the Halo Mobility Ring Assessment had a section of questions, when answered yes, would prompt the facility to complete a restraint assessment, a restraint care plan, and a restraint reduction plan initiated. The SNF Manager confirmed for residents whose assessments indicted a yes as an answer to those questions, restraint assessments and restraint care plans were not completed and restraint reduction plans were not initiated. On 08/03/23 at 10:55 AM, the SNF Manager verbalized alternatives were not attempted prior to installing bed rails. The SNF Manager explained upon admission, if the resident was unable to get in and out of bed independently, the facility would get an order from the physician for a halo device to be installed. The SNF Manager confirmed residents were given Halo Mobility Rings upon admission, prior to attempting alternatives. The SNF Manager verbalized residents with Halo Mobility Rings and side rails should have consents explaining the risks and benefits, a physician's order, and care plans for mobility that include the Halo ring. The SNF Manager confirmed not all residents had Halo Mobility Assessments completed, consents that explained the risks and benefits, and care plans for mobility that included the Halo Mobility Ring. Psychotropic Medications On 08/02/23 at 1:49 PM, the LPN explained in April 2023, the facility transitioned from monitoring behaviors and side effects on hardcopy flowsheets to monitoring all behaviors electronically. Adverse side effects for psychotropic medications were no longer monitored. On 08/02/23 at 1:53 PM, the SNF Manager verbalized behavior monitoring was conducted under the behavior tab in the Electronic Medical Record (EMR). On 08/02/23 at 2:15 PM, the SNF Manager verbalized behavior monitoring was not medication specific since the facility transitioned to documenting behaviors in the EMR. All residents were monitored for all the same behaviors regardless of medications ordered. On 08/02/23 at 4:06 PM, the Skilled Nursing Facility (SNF) Manager verbalized there were no specific behaviors indicated on Care Plans or physician orders, related to psychotropics. Physicians wrote orders for diagnosis only. Nurses were responsible for identifying behaviors but did not associate the specific behavior with a specific diagnosis in conjunction with a psychotropic medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure the last revised Facility Assessment reflected an open Director of Nursing (DON) position. Findings include: The Facility assessment dated [DATE], did not include the open DON position on the facility's staffing plan. On 08/10/23 at 11:27 AM, the Administrator confirmed the Facility Assessment's staffing plan did not include the open DON position. The Administrator confirmed the Facility Assessment staffing plan should indicate all open positions.

Based on interview and document review, the facility failed to ensure the Quality Assessment Performance Improvement (QAPI) Committee identified areas of concern related to use of widespread implementation of bedside rails and unnecessary psychotropic medications and implemented Performance Improvement Projects (PIPs) to reduce the risk of Substandard Quality of Care (Cross-reference tags F700 and F758). Findings include: The facility's Quality Assessment Performance Improvement (QAPI) Plan, undated, documented the QAPI plan addressed clinical care by monitoring existing quality indicator and quality monitor results, internal monitors for falls, medication errors, pressure ulcers, incident reports, infection reports, and adverse events. The QAPI committee was to prioritize topics for PIPs based on the current needs of the residents and the organization. Priority would be given to areas defined as high risk to residents and staff, high prevalence, or high-volume areas, and areas problem prone. Potential topics for PIPs were identified through a prioritization process by the QAPI committee. Review of State/National and past facility measures were to be used to benchmark for improvement in all areas. These benchmarks will be reviewed at least monthly and reported to the QA committee on a quarterly basis. The QA committee monitored progress to ensure interventions or actions were implemented and effective in making and sustaining improvements. The facility's Minimum Data Set (MDS) 3.0 Facility Level Quality Measure Report dated 01/01/23-06/30/23, indicated antianxiety/hypnotic percentage for use with long-term residents for the Comparison Group National Percentile was flagged at 82 percent and antipsychotic use for long term residents was flagged at 88 percent. CASPER Report 0004D F133-Number of Residents receiving Psychoactive Drugs, last updated 07/26/23, documented usage at 13 residents at 56.5 percent for the facility. On 08/10/23 at 3:14 PM, the Risk Manager verbalized the role of Risk Manager was also the Quality Assurance Coordinator for the QAPI committee. The QAPI meeting was conducted monthly. The QAPI committee did not review CASPER reports to determine issues needing PIPs and monitoring. Significant weight loss, falls, psychotropic drug usage, implementation of bed rails/halo rings were not areas reviewed monthly for consideration for improvement. On 08/10/23 at 3:26 PM, the Risk Manager verbalized having been in the role for about a year and was not familiar with psychotropic drugs or the implementation of bed rails/halo rings.

Based on observation, interview and document review, the facility failed to ensure signage regarding COVID-19 (COVID) was present at the facility's point of entry and at the internal and external entrance doors of the Long-Term Care (LTC) Unit. Findings include: On 07/31/23, 08/01/23, 08/02/23, 08/03/23, 08/09/23, and 08/10/23, the dates of the facility's annual recertification survey, signage related to COVID was not posted at or near the facility's point of entry, the internal LTC Unit entrance, and the LTC Unit external entrance door. On 08/03/23 at 10:42 AM, the Infection Preventionist (IP) explained the IP was not aware signage related to COVID was needed when the facility was not experiencing an outbreak. The IP verbalized the facility did not have signage related to COVID at the facility's point of entry, at the internal entrance double doors leading to the LTC unit, or at the external entrance door of the LTC unit. The IP explained visitors were verbally educated on self-monitoring for signs and symptoms of COVID, but this occurred after the visitor entered the facility. The IP confirmed the facility followed the Center for Disease Control and Prevention (CDC) infection control guidelines. The Centers for Medicare and Medicaid Services (CMS) Memo titled QSO-20-39-NH, revised 05/08/23, documented core principles and best practices to reduce the risk of COVID-19 transmission included facility provided guidance (e.g., posted signs at entrances) about recommended actions for visitors who have a positive viral test for COVID-19, symptoms of COVID-19, or have had close contact with someone with COVID-19. Visual alerts (e.g., signs, posters) were posted at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias). The alerts should include instructions about current Infection Prevention and Control (IPC) recommendations, source control, cleaning and disinfection of frequently touched surfaces, designated visitation areas, appropriate staff use of Personal Protective Equipment (PPE), and effective cohorting of residents in separate areas dedicated to COVID-19 care. The core principles were consistent with the CDC guidance for nursing homes and should be adhered to at all times. The facility policy titled Covid-19 Facility Testing Policy, revised 05/31/23, documented all areas with direct patient care would follow the appropriate CDC/CMS recommendations. Visitors, patients, and employees were asked to self-screen and monitor for symptoms prior to entry. Patient management strategies would be implemented in accordance with the CDC's recommendations. The facility policy titled Infection and Prevention Control Annual Plan 2023, dated 2023, documented policies would reflect current accepted and approved infection prevention practices based on regulatory recommendations, standards, and guidelines. Education was provided to patients, visitors, and families with fact sheets and signage.

Based on personnel record review, interview and document review, the facility failed to ensure resident rights training was completed by staff for 7 of 20 sampled employees (Employee #1, #6, #10, #11, #13, #14, and #16. Findings include: Employee #1 Employee #1 was hired as the Administrator on 06/15/22. Employee #1's personnel record lacked documented evidence of resident rights training. Employee #6 Employee #6 was hired as the Nutrition Services Supervisor on 11/28/21. Employee #6's personnel record documented lacked documented evidence resident rights training was completed since hiring date. Employee #10 Employee #10 was hired as a CNA on 06/01/23. Employee #10's personnel record lacked documented evidence resident rights training was completed. Employee #11 Employee #11 was hired as the CNA on 02/20/23. Employee #11's personnel record lacked documented evidence resident rights training was completed. Employee #13 Employee #13 was hired as a RN on 06/12/23. Employee #13's personnel record lacked documented evidence resident rights training had been completed. Employee #14 Employee #14 was hired as a Licensed Practical Nurse (LPN) on 03/08/23. Employee #14's personnel record lacked documented evidence resident rights training had been completed. Employee #16 Employee #16 was hired as a CNA on 07/24/23. Employee #16's personnel record lacked documented evidence resident rights training had been completed. On 08/10/23 at 2:53 PM, the Human Resources (HR) Director verbalized all staff were required to complete resident rights training upon hire and annually thereafter. The Business Office Manager confirmed Employees #1, #6, #10, #11, #13, #14, and #16 had not completed timely resident rights training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure the alternatives were attempted, risks and benefits were explained, consents were obtained prior to installation of bedrails or grab bar (Halo ring) and mobility assessments were completed for 15 of 21 residents residing in the facility (Resident #1, #2, #3, #4, #5, #7, #9, #10, #12, #14, #15, #16, #17, #171, and #172). Resident #1 Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and falls. On 07/31/23, Resident #1's bed had a Halo ring on the left side. Resident #1's physician's order dated 04/19/22, documented may use Halo for bed mobility. Resident #1's clinical record lacked documented evidence of a Halo Mobility Ring Assessment, an assessment for entrapment, a signed consent with risks and benefits, and alternatives were tried prior to installation. Resident #2 Resident #2 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis and other seizures. On 07/31/23, Resident #2's bed had two quarter rails in the up position. Resident #2's physician's order dated 07/05/23, documented may use side rails for safety. Resident #2's Bedrail Consent, dated 07/05/23, lacked an explanation of risks and benefits. Resident #2's Restraint vs Enabling Device Bed Rail Safety Resident Assessment and Need for Side Rails dated 05/05/23, lacked documented evidence of an assessment for entrapment. Resident #2's clinical record lacked documented evidence alternatives were tried prior to installation. Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnoses including adult failure to thrive and pain in left shoulder. On 07/31/23, Resident #3's bed had two Halo rings on both sides. Resident #3's physician's order dated 10/27/22, documented may use Halo for bed mobility. Resident #3's Halo Mobility Ring assessment dated [DATE], lacked documented evidence of an assessment for entrapment. Resident #3's Bedrail Consent, dated 07/05/23, lacked an explanation of risks and benefits. Resident #3's clinical record lacked documented evidence alternatives were tried prior to installation. Resident #3's Comprehensive Care Plan lacked a care plan for side rails and/or Halos. Resident #4 Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including unspecified dementia, unspecified severity, with psychotic disturbance and hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side. On 07/31/23, Resident #4's bed had a Halo ring on each side of the bed. Resident #4's physician's order, dated 07/03/23, documented may use Halo for bed mobility, the same day as readmission. Resident #4's clinical record lacked documented evidence alternatives were tried prior to installation. Resident #4's Restraint vs Enabling Device Bed Rail Safety Resident Assessment and Need for Side Rails was dated 05/27/21. The assessment indicated the resident had a diagnosis of dementia, required a low bed or bed alarm for safety from falls and therefore, the device was a restraint. The assessment was utilized in determining if the device was a restraint. The assessment did not have a determination if the resident was at risk for entrapment. Resident #4's Bedrail Consent, dated 07/03/23, lacked an explanation of risks and benefits. Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnosis including adult failure to thrive and fall on same level from slipping, tripping, and stumbling without subsequent striking against object, initial encounter. On 07/31/23, Resident #5's bed had a Halo ring on each side of the bed. Resident #5's physician's order dated 08/02/23, documented may use Halo for bed mobility. Resident #5's Restraint vs Enabling Device Bed Rail Safety Resident Assessment and Need for Side Rails was dated 08/26/22 and lacked the option to document the answers to the questions for the Restraint vs Activities of Daily Living (ADL) Enabling Device assessment. Resident #5's clinical record lacked documented evidence of a signed consent that explained the risks and benefits. Resident #5's clinical record lacked documented evidence alternatives were tried prior to installation. Resident #5's Comprehensive Care Plan lacked a care plan for side rails and/or Halos. Resident #7 Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including dementia and altered mental status. On 07/31/23, Resident #7's bed one Halo up on the side. Resident #7's physician's order dated 08/02/23, documented may use Halo for bed mobility. Resident #7's Restraint vs Enabling Device Bed Rail Safety Resident Assessment and Need for Side Rails was dated 10/07/22. The assessment indicated the resident had a diagnosis of and therefore, the device was a restraint. Resident #7's clinical record lacked documented evidence of a Restraint Assessment, a restraint care plan, or a restraint reduction plan initiation. Resident #7's clinical record lacked documented evidence of a signed consent that explained the risks and benefits. Resident #7's clinical record lacked documented evidence alternatives were tried prior to installation. Resident #7's Comprehensive Care Plan lacked a care plan for side rails and/or Halos. Resident #9 Resident #9 was admitted to the facility on [DATE], with a diagnosis of epilepsy. On 07/31/23, Resident #9's bed had a Halo ring on each side of the bed. Resident #9's physician's order dated 03/22/23, documented may use Halo for bed mobility. Resident #9's clinical record lacked documented evidence of a Halo Mobility Ring Assessment, a signed consent that explained risks and benefits, alternatives were tried prior to installation, and a care plan for side rails and/or Halos. Resident #10 Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of muscle weakness. On 07/31/23, Resident #10's bed had a Halo on the left side. Resident #10's physician's order dated 11/14/22, documented may use Halo for bed mobility. Resident #10's clinical record lacked documented evidence of a Halo Mobility Ring Assessment, a signed consent that explained risks and benefits, alternatives were tried prior to installation, and a care plan for side rails and/or Halos. Resident #12 Resident #12 was admitted to the facility 12/02/20 and readmitted on [DATE], with a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, mood disturbance, and anxiety. On 07/31/23, Resident #12's bed had a Halo ring on one side. Resident #12's physician's order dated 03/12/22, documented may use Halo for bed mobility. Resident #12's Restraint vs Enabling Device Bed Rail Safety Resident Assessment and Need for Side Rails was dated 09/22/22. The assessment indicated the resident had falls, dementia or decreased cognition or delirium, and the resident required a low bed or bed alarm for safety from falls and therefore, the device was a restraint. Resident #12's clinical record lacked documented evidence of a Restraint Assessment, a restraint care plan, or a restraint reduction plan initiation. Resident #12's clinical record lacked documented alternatives were tried prior to installation, and a care plan for side rails and/or Halos. Resident #12's Bedrail Consent, dated 07/26/21, lacked an explanation of risks and benefits. Resident #14 Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including dementia, and overactive bladder. On 07/31/23, Resident #14's bed had a Halo on the right side. Resident #14's physician's order dated 08/02/23, documented may have Halo for bed mobility. Resident #14's Restraint vs Enabling Device Bed Rail Safety Resident Assessment and Need for Side Rails was dated 06/17/23. The assessment indicated the resident had dementia or decreased cognition or delirium and therefore, the device was a restraint. Resident #14's clinical record lacked documented evidence of a Restraint Assessment, a restraint care plan, or a restraint reduction plan initiation. Resident #14's clinical record lacked documented alternatives were tried prior to installation, and a care plan for side rails and/or Halo s. Resident #15 Resident #15 was admitted to the facility on [DATE] with a diagnosis of adult failure to thrive. On 07/31/23, Resident #15's bed had a Halo on the side. Resident #15's physician's order dated 08/02/23, documented may have Halo ring for bed mobility. Resident #15's clinical record lacked documented evidence of a Halo Mobility Ring Assessment, a signed consent that explained risks and benefits, alternatives were tried prior to installation, and a care plan for side rails and/or Halos. Resident #16 Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbances and multiple falls. On 07/31/23, Resident #16's bed had a Halo on the left side. Resident #16's physician's order dated 08/02/23, documented may have Halo for bed mobility. Resident #16's Restraint vs Enabling Device Bed Rail Safety Resident Assessment and Need for Side Rails was dated 08/05/22. The assessment indicated the resident had dementia or decreased cognition or delirium and history of falls and therefore, the device was a restraint. Resident #16's clinical record lacked documented evidence of a Restraint Assessment, a restraint care plan, or a restraint reduction plan initiation. Resident #16's Bedrail Consent, dated 10/31/22, lacked an explanation of risks and benefits. Resident #16's clinical record lacked documented alternatives were tried prior to installation, and a care plan for side rails and/or Halos. Resident #17 Resident #17 was admitted to facility on 04/10/23, with a diagnosis of dementia in other diseases classified elsewhere, unspecified severity, with mood disturbance. On 07/31/23, Resident #17's bed had Halo s on each side of the bed. Resident #17 physician's order dated 04/10/23, documented may use Halo for bed mobility. Resident #17's clinical record lacked documented evidence of a Halo Mobility Ring Assessment, a signed consent that explained risks and benefits, alternatives were tried prior to installation, and a care plan for side rails and/or Halos. Resident #171 Resident #171 was admitted to the facility on [DATE], with a diagnosis of dementia. On 07/31/23, Resident #171's bed had Halo s on each side of the bed. Resident #171 physician's order dated 08/02/23, documented may use Halo for bed mobility. Resident #171's Restraint vs Enabling Device Bed Rail Safety Resident Assessment and Need for Side Rails was dated 06/27/23. The assessment indicated the resident had a history of falls and therefore, the device was a restraint. The assessment lacked documentation the resident had a diagnosis of dementia. Resident #171's clinical record lacked documented evidence of a Restraint Assessment, a restraint care plan, or a restraint reduction plan initiation. Resident #171's clinical record lacked documented evidence a signed consent that explained risks and benefits, alternatives were tried prior to installation, and a care plan for side rails and/or Halos. Resident #172 Resident #172 was admitted to the facility on [DATE], with a diagnosis of Parkinson's disease. On 07/31/23, Resident #172's bed had Halo s on each side of the bed. Resident #172 physician's order dated 06/22/23, documented may use Halo for bed mobility. Resident #172's Restraint vs Enabling Device Bed Rail Safety Resident Assessment and Need for Side Rails was dated 06/22/23. The assessment indicated the resident had a history of falls and therefore, the device was a restraint. Resident #172's clinical record lacked documented evidence of a Restraint Assessment, a restraint care plan, or a restraint reduction plan initiation. Resident #172's clinical record lacked documented evidence a signed consent that explained risks and benefits, alternatives were tried prior to installation, and a care plan for side rails and/or Halo s. On 08/02/23 at 9:18 AM, the Skilled Nursing Facility (SNF) Manager verbalized upon admission, if a resident had issues with mobility, the facility would obtain an order from the physician for a Halo ring and have the Halo ring installed. The SNF Manager confirmed the facility did not attempt alternatives prior to installation. On 08/02/23 at 10:05 AM, the SNF Manager verbalized the Halo Mobility Ring Assessment did not contain an assessment for entrapment. The SNF Manager explained the Halo Mobility Ring Assessment assesses if the resident's head could get stuck but did not assess for overall risk of entrapment. On 08/02/23 at 10:42 AM, the SNF Manager verbalized the Halo Mobility Ring Assessment had a section of questions, when answered yes, would prompt the facility to complete a restraint assessment, a restraint care plan, and a restraint reduction plan initiated. The SNF Manager confirmed for residents whose assessments indicated a yes as an answer to those questions, restraint assessments and restraint care plans were not completed, and restraint reduction plans were not initiated. On 08/03/23 at 10:55 AM, the SNF Manager verbalized alternatives were not attempted prior to installing bed rails. The SNF Manager explained upon admission, if the resident was unable to get in and out of bed independently, the facility would get an order from the physician for a Halo device to be installed. The SNF Manager confirmed residents were given Halo Mobility Rings upon admission, prior to attempting alternatives. The SNF Manager verbalized residents with Halo Mobility Rings and side rails should have consents explaining the risks and benefits, a physician's order, and care plans for mobility that include the Halo ring. The SNF Manager confirmed not all residents had Halo Mobility Assessments completed, physician's orders, consents that explained the risks and benefits, and care plans for mobility that included the Halo Mobility Ring. The facility policy titled Restraints, revised 10/31/18, documented all residents had the right to be free from physical restraints. Restraints should only be used where alternative methods were not sufficient to protect residents from injury and are not a substitute for less restrictive forms of protective restraint. All residents would have an assessment performed to determine the safety and protective needs of the resident prior to the application of restraints or medical protective device and at least every 90 days. Bedrail Assessment - All residents will be assessed for safe use, the need for side rails, and determination of their use being a restraint or one that enhances the resident's independence and mobility, prior to adding bedrails to the bed and before use, using the Restraints vs Enabling Device Bed Rail Safety and Need for Side Rails Assessment admission and quarterly. - Competent residents desiring side rails for mobility may have them after assessment and completion of the Bed Rail Safety Guidelines and Need for Side Rails Assessment. - All side rail use must be care planned, have a physician's order, and address reduction and monitoring of residents during use and an informed consent outlining the advantages and disadvantages of side rails. - Reduction of bed rail use using alternative methods must be attempted prior to use and assessed quarterly when the resident Minimum Data Set was completed. Medical conditions that warrant the use of restraints must be documented in the resident's medical record, ongoing assessments, and care plans. The physician's order alone was not sufficient to warrant the use of the restraint. For those residents whose care plans indicate the need for restraints, there would be a systematic and gradual process toward reducing restraints. This systematic process would also apply to recently admitted from who restraints were used in the previous setting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #4 Resident #4 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including unspecified dementia, unspecified severity, with psychotic disturbance, and major depressive disorder, recurrent, in remission, unspecified. Resident #4's clinical record documented the following psychotropic orders: -[DATE], Mirtazapine oral tablet 7.5 mg, give 7.5 mg by mouth at bedtime related to insomnia, unspecified. -[DATE], duloxetine hcl oral capsule delayed release sprinkle 30 mg, give 1 capsule by mouth one time a day related to major depressive disorder, recurrent, in remission, unspecified. Resident #4's care plan for the antidepressant medication, initiated on [DATE], included the following interventions: -Educate Resident #4 and guardian about risks, benefits, and the side effects and/or toxic symptoms of duloxetine. -Give antidepressant as ordered by physician. -Monitor/document side effects and effectiveness. Antidepressant side effects: dry mouth, dry eyes, constipation, urinary retention, suicidal ideations. -Monitor/document/report to physician ongoing signs/symptoms of depression unaltered by antidepressant meds: sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, negative mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. Resident #4's care plan for the antidepressant medication, initiated on [DATE], and revised on [DATE], documented the following interventions: -Resident #4 took prescribed antidepressant and anxiety medication duloxetine related to depression. -Monitor for signs and symptoms of anxiety: irritability, restlessness, uncontrolled worrying, difficulty sleeping, fatigue, etc. -Monitor/document/report to physician ongoing signs/symptoms of depression unaltered by antidepressant meds: sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, negative mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. Resident #4's clinical record lacked documented evidence of a resident-centered care plan for the diagnosis of insomnia, unspecified, the use of a psychotropic to treat the diagnosis, or monitoring for specific behaviors or adverse affects related to the medication. On [DATE] at 10:03 AM, an LPN confirmed Resident #4 did not have a care plan specific to the diagnosis of insomnia, unspecified, the specific medication prescribed, interventions used, behavior monitoring, and signs and symptoms monitoring related to the use of a psychotropic medication and should have. On [DATE] at 2:36 PM, the ADON verbalized behavior monitoring was general and was not specific to a prescribed medication. Based on interview, clinical record review, and document review, the facility failed to ensure residents did not receive unnecessary psychotropic medications when the facility lacked specific indications for use, monitoring of the behaviors associated with the psychotropic medications, and monitoring for adverse side effects for 11 of 11 residents receiving psychotropic medications (Resident #1, #3, #5, #6, #7, #9, #12, #14, #4, #13, and #16), residents did not receive an increase in a hypnotic medication related to environmental factors and resident request and a gradual dose reduction was attempted despite resident request to continue all psychotropic medications for 2 of 11 residents receiving psychotropic medications (Resident #14 and #16), and as needed (PRN) physician ordered psychotropics had a 14 day stop date for 1 of 11 residents receiving psychotropic medications (Resident #12). Findings include: Resident # 1 Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavior/psychosis/mood/anxiety and major depressive disorder, single episode, unspecified. Resident #1's physician orders for psychotropic medications were as follows: -[DATE] buspirone (hydrochloric acid) HCl oral tablet, give 5 milligrams (mg) by mouth one time a day for anxiety related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and give 5 mg by mouth at bedtime for anxiety. -[DATE] sertraline HCl oral tablet 25 mg, give 25 mg by mouth at bedtime related to major depressive disorder, single episode, unspecified. -[DATE] sertraline HCl tablet 100 mg, give 100 mg by mouth at bedtime related to major depressive disorder, single episode, unspecified. Resident #1's physician's orders lacked identified behaviors associated with the administration of buspirone, and sertraline, and adverse side effects to be monitored. Resident #1's comprehensive care plans included the following related to psychotropic medications: Initiated [DATE], Resident #1 was prescribed sertraline and buspirone for anxiety/agitation due to evening behaviors and anxiety through the early morning verbal/physical aggressive behaviors. The care plan documented the following interventions: -Resident #1 was to take the medications as prescribed. -Nursing staff to monitor and assess for any side effects. Initiated [DATE], Resident #1 was prescribed sertraline and alprazolam for depression and Depakote for Seizures. The care plan documented the following interventions: -Decrease dosage of psychotropic drugs as per orders until signs or tardive dyskinesia disappears. -Monitor drug blood levels as per orders. -Monitor for signs of tremor. -Monitor interaction or resident with others for appropriateness. -Monitor resident's mental status functioning on ongoing basis. The care plans did not differentiate the behaviors associated with sertraline, buspirone and alprazolam. The resident did not have an active order for alprazolam. The care plan lacked the specific adverse side effects to be monitored for buspirone HCl, and sertraline HCl. Resident #1's Progress Notes documented the following Black Box warnings for psychotropic medications: -[DATE] The system identified a black box warning for the following order: Sertraline HCl oral tablet 25 mg Warning: Closely monitor all antidepressant-treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors. The facility lacked documented evidence the Black Box warnings for adverse side effects were monitored for Resident #1. The facility lacked adequate monitoring for efficacy and adverse consequences for the four physician ordered psychotropic medications. Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnoses including bipolar disorder, unspecified, major depressive disorder, single episode, unspecified, other specified mental disorders due to known physiological condition, and other specified problems related to psychosocial circumstances. Resident #3's psychotropic physician orders included the following: -[DATE] Effexor XR Capsule Extended Release 24 Hour 75 mg, give three capsules by mouth one time a day related to bipolar disorder, unspecified. -[DATE] Mirtazapine tablet 15 mg, give one tablet by mouth at bedtime related to major depressive disorder, single episode, unspecified. -[DATE] aripiprazole tablet 2 mg, give one tablet by mouth at bedtime related to bipolar disorder, unspecified. Resident #3's physician's orders lacked identified behaviors associated with the administration of Effexor XR, Mirtazapine, and aripiprazole and adverse side effects to be monitored. Resident #3's comprehensive care plans included the following related to psychotropic medications: Initiated on [DATE], Resident #3 was prescribed Effexor, Aripiprazole, and Mirtazapine to help alleviate signs and symptoms of bipolar and major depression disorder. The care plan documented the following interventions: -Blood levels were within normal range. -Resident #3's provider/Medical Director (MD) was to be given pharmacy recommendations and make following determination. -Maintain overall good mood/behavior. -Medications were to be monitored and assessed by the pharmacist, provider, and Behavioral Health Services (BHS) psychiatry. -Monitor and report if any side effects or physical conditions occurred as a result of long-term use. The care plan lacked identified behaviors associated with the administration of Effexor, Aripiprazole, and Mirtazapine and the specific adverse side effects to be monitored. Resident #3's Progress Notes documented the following black box warnings for psychotropic medications: -[DATE] The system identified a black box warning for the following order: Mirtazapine Tablet 15 mg Warning: Closely monitor all antidepressant-treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors. -[DATE] The system has identified a black box warning for the following order: Effexor XR Capsule Extended Release 24 Hour 75 mg Warning: Patients of all ages who are started on antidepressant therapy should be monitored appropriately and observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber. -[DATE] The system has identified a black box warning for the following order: aripiprazole tablet 2 mg Warning: Increased mortality in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Aripiprazole is not approved for the treatment of patients with dementia-related psychosis. Closely monitor all antidepressant-treated patients for clinical worsening and for the emergence of suicidal thoughts and behaviors. Advise families and caregivers of the need for close observation and communication with the prescriber. The facility lacked documented evidence the Black Box warnings for adverse side effects were monitored for Resident #3. The facility lacked adequate monitoring for efficacy and adverse consequences for the three physician ordered psychotropic medications. Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including major depressive disorder, single episode, unspecified and major depressive disorder, recurrent severe without psych features. Resident #5's psychotropic physician orders included the following: -[DATE] citalopram hydrobromide oral tablet 20 mg, give 20 mg by mouth one time a day related to major depressive disorder, recurrent severe without psychotic features. Resident #5's physician's order lacked identified behaviors associated with the administration of citalopram hydrobromide and adverse side effects to be monitored. Resident #5's comprehensive care plans included the following related to psychotropic medications: Initiated [DATE], Resident #5 was prescribed an anti-depressant medication. The care plan documented the following interventions: -Inform Guardian's office of any medication recommendations and for consent. -Nursing staff monitor for side effects. -Pharmaceutical recommendations be provided and assessed by Doctor/Provider. -Staff to continue to provide non-medication interventions to help with mental/emotional wellbeing. The care plan lacked identified behaviors associated with the administration of citalopram hydrobromide and adverse side effects for monitoring. The facility lacked adequate monitoring for efficacy and adverse consequences for the physician ordered psychotropic medication. Resident #6 Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including insomnia, unspecified, anxiety disorder, unspecified, and major depressive disorder, recurrent, unspecified. Resident #6's psychotropic physician orders included the following: -[DATE] duloxetine HCl oral capsule delayed release particles 60 mg, give one capsule by mouth two times a day related to major depressive disorder, recurrent, unspecified. -[DATE] buspirone HCl oral tablet 15 mg, give one tablet by mouth every six hours related to major depressive disorder, recurrent, unspecified. -[DATE] Abilify oral tablet 5 mg, give 2.5 mg by mouth one time a day related to major depressive disorder, recurrent, unspecified. -[DATE] trazodone HCl oral tablet 150 mg, give 150 mg by mouth at bedtime for sleep. Resident #6's physician's order lacked identified behaviors associated with the administration of buspirone, Abilify, and duloxetine and adverse side effects to be monitored for buspirone, Abilify, duloxetine and trazadone. Resident #6's care plans for the psychotropic medications, initiated on [DATE], documented the following: -Resident #6 took prescribed antidepressant and anxiety medications buspirone, Abilify, and duloxetine medications for depression and anxiety. The care plan documented the following interventions: -Monitor drug blood levels as per orders. -Monitor interaction or resident with others for appropriateness. -Monitor resident's mental status on an ongoing basis. -Monitor Resident #6's mood, state, and behavior. Resident #6 care plan for diagnosis of insomnia reported not sleeping well at night, initiated on [DATE], documented the following interventions: -Resident #6 was to be provided non-medication interventions to help provide quality of sleep. -Continue to encourage Resident #6 with activities during the day with preferred independent activities or when there are outings in the community. -Encourage Resident #6 to do exercises. -Resident #6 preferred to sleep with the TV on in a darkened room at night. -Resident #6 took medication to help with sleeping at night. The care plans lacked identified behaviors associated with the administration of buspirone, Abilify, and duloxetine and the specific adverse side effects to be monitored for buspirone, Abilify, duloxetine and trazadone. Resident #6's psychotropic medications had the following Black Box warnings for adverse side effects: -[DATE] trazodone HCl oral tablet 150 mg has triggered the following drug protocol alerts/warning(s): The system has identified a possible drug interaction with the following orders: buspirone HCl oral tablet 15 mg Severity: Severe Interaction: Additive serotonergic effects may occur during coadministration of buspirone and duloxetine HCl oral capsule delayed release particles 60 mg, fentaNYL Transdermal Patch 72 Hour 100 micrograms (MCG)/hour, and trazodone HCl Oral Tablet 150 mg, and the risk of developing serotonin syndrome may be increased. duloxetine HCl oral capsule delayed release particles 60 mg Severity: Severe Interaction: Serotonergic effects of trazodone and serotonin/norepinephrine reuptake inhibitors (SNRIs) may be additive. The risk of serotonin syndrome/toxicity may be increased. The system has identified a black box warning for the following order: trazodone HCl oral tablet 150 mg Warning: Suicidal thoughts and behaviors. Closely monitor all antidepressant-treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors. The facility lacked documented evidence the Black Box warnings for adverse side effects were monitored for Resident #6. Resident #6's Electronic Medical Record (EMR) lacked documented evidence the resident had experienced insomnia in [DATE] and indicated No Behaviors Observed from [DATE]-[DATE]. Resident #6's Behavior Progress Notes lacked documented evidence of insomnia related behaviors for [DATE]. Resident #6's Psychoactive Medication Review Progress Note, dated [DATE], documented the resident endorsed fatigue and irritability secondary to frustration with roommate .Trazodone was increased from 100 mg at night (HS) to 150 mg HS due to ongoing sleep issue. On [DATE] at 3:49 PM, the Skilled Nursing Facility (SNF) Manager explained trazadone was increased per the resident request in [DATE] from 100 mg to 150 mg. There should have been tracking and monitoring for insomnia. There should have been behavior notes on the insomnia. The March behavior flow sheets and the April behavior tracking in the EMR did not reflect an issue with insomnia. On [DATE] at 4:06 PM, the SNF Manager confirmed the psychotropic medications listed on Resident #6's care plan did not reflect a specific diagnosis and behavior associated with the specific medication. The care plan did not specify if Buspirone, Abilify, and duloxetine were administered for depression or anxiety. Anxiety and depression did not have documented signs and symptoms from the physician associated with the medication. The facility lacked adequate monitoring for efficacy and adverse consequences for the four physician ordered psychotropic medication. Resident #7 Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including major depressive disorder, single episode, unspecified and altered mental status, unspecified. Resident #7's psychotropic physician orders documented the following: -[DATE] Seroquel Tablet 25 mg (quetiapine fumarate), give one tablet by mouth two times a day related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Resident #7's physician's orders lacked identified behaviors associated with the administration of Seroquel and adverse side effects. Resident #7's care plan for the psychotropic medications, initiated on [DATE], documented the following: -Resident #7 was prescribed Seroquel for depression, at times maybe prescribed short term medications such as Ativan or other psychotropic medications dependent upon changes in mood/behavior. The care plan documented the following interventions: Administer medications as ordered. Document changes in moods and behaviors. Gradual dose reduction as per policy. Monitor and record adverse effects of medication every shift. Monitor and record behaviors every shift. Notify physician of increase in agitation, mood, or behaviors. Obtain and maintain consents from her guardian. Pharmacy review of medications every month. Staff assist with mental/emotional wellbeing through encouragement to participate in group and/or 1:1 activities and assist if needed to a less stimulating environment. The care plan lacked identified behaviors associated with the administration of Seroquel and adverse side effects to be monitored. Resident #7's psychotropic medications had the following Black Box warnings for adverse side effects: Note Text: The system identified a black box warning for the following order: Seroquel Tablet 25 MG (quetiapine fumarate) Warning: Increased mortality in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Quetiapine is not approved for the treatment of patients with dementia-related psychosis. Suicidal thoughts and behavior. In patients of all ages who have started on antidepressant therapy, monitor closely for clinical worsening and for emergence of suicidal thoughts and behaviors. Advise families and caregivers of the need for close observation and communication with the prescriber. The facility lacked documented evidence the Black Box warnings for adverse side effects were monitored for Resident #7. On [DATE] at 2:27 PM, the SNF Manager explained Resident #7 had a behavior of calling out frequently. The SNF Manager reviewed Resident #7's physician's order for Seroquel and confirmed the behavior was not identified for the purpose of administering the medication. On [DATE] at 2:30 PM, the SNF Manager explained Resident #7's Seroquel was increased to two times a day due to increased agitation. Agitation was exhibited by calling out. Calling out was part of the behavior of dementia. On [DATE] at 2:37 PM, the SNF Manager confirmed Resident #7 was not monitored for specific behaviors or adverse side effects associated with Seroquel. Agitation as evidence by calling out had not been identified by the physician as indication for use of Seroquel, monitored as the identified behavior, and Black Box warnings of adverse side effects were not monitored. The facility lacked adequate monitoring for efficacy and adverse consequences for the physician ordered psychotropic medication. Resident #9 Resident #9 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including major depressive disorder, single episode, unspecified. Resident #9's psychotropic physician orders documented the following: -[DATE] citalopram hydrobromide oral tablet 20 mg, give one tablet by mouth one time a day related to major depressive disorder, single episode, unspecified. -[DATE] bupropion HCl oral tablet 75 mg, give 75 mg by mouth one time a day related to major depressive disorder, single episode, unspecified. Resident #9's physician's orders lacked identified behaviors associated with the administration of citalopram hydrobromide and bupropion HCI and adverse side effects associated with the medications. Resident #9's care plan for the psychotropic medications, initiated on [DATE], documented the following: Resident #9 was prescribed anti-depressant medication for treatment of depression. The care plan documented the following interventions: Resident #9 was to attend BHS psychiatry appointments to assess and provide recommendations to provider. Evaluate effectiveness and side effects of medications for possible decease/ elimination of psychotropic drugs. Monitor drug blood levels as per orders. Monitor resident mood state/ behavior. Monitor resident's mental status functioning on ongoing basis. Non-medication related interventions continue to be implemented such as counseling services and offering/providing activities, etc. The care plan lacked specific anti-depressant medications and the identified behaviors associated with the administration of the medications and adverse side effects to be monitored. Resident #9's psychotropic medications had the following Black Box warnings for adverse side effects: -[DATE] bupropion HCl Oral Tablet 75 mg (Bupropion HCl) Warning: Suicidality and antidepressant drugs. In patients of all ages who are started on antidepressant therapy, monitor closely for worsening and for emergence of suicidal thoughts and behaviors. Advise families and caregivers of the need for close observation and communication with the prescriber. -[DATE] bupropion HCl oral tablet 75 mg (Bupropion HCl) has triggered the following drug protocol alerts/warning(s): The system has identified a possible drug interaction with the following orders: citalopram hydrobromide oral tablet 20 mg Severity: Severe Interaction: Plasma concentrations and pharmacologic effects of citalopram hydrobromide oral tablet 20 mg may be increased by bupropion HCl oral tablet 75 mg. -[DATE] citalopram hydrobromide oral tablet 20 mg Warning: Suicidal thoughts and behaviors. Closely monitor all antidepressant-treated patients for clinical worsening, and for emergence of suicidal thoughts and behaviors. Resident #9's clinical record lacked evidence the Black Box warnings of adverse side effects were monitored. The facility lacked adequate monitoring for efficacy and adverse consequences for the two physician ordered psychotropic medication. Resident #12 Resident #12 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavior/psychosis/mood/anxiety, major depressive disorder, single episode, unspecified, anxiety disorder, unspecified, and insomnia, unspecified. Resident #12's psychotropic physician orders documented the following: -[DATE] lorazepam oral concentrate 1 mg/0.5 ml, give 0.5 ml by mouth every six hours as needed (PRN) for anxiety. Resident #12's Medication Regimen Review note, dated [DATE], completed by the Pharmacist, documented consideration to add duration to PRN lorazepam had been made to the psychotropic medication review form. Resident #12's physician's orders lacked identified behaviors associated with the administration of lorazepam and adverse side effects associated with the medication. Resident #12's care plan for anxiety disorder, initiated on [DATE], documented the following: Resident #12 was diagnosed with anxiety disorder with signs and symptoms of continual fears/worries, irritability, fatigued, restlessness, difficulty concentrating, etc. The care plan documented the following interventions: Assist with verbalization of feelings. Continue to encourage normal daily routines. Resident #12 continues with counseling services through BHS. Encourage to engage in conversation with fellow residents. Offer a cold damp wash cloth for Resident #12 to wipe face. Per resident's conversation with counselor, offer Resident #12 a piece of ice to hold in the resident's hand for 10 seconds. Staff support Resident #12 through active listening skills. Resident #12's care plans lacked a care plan for the psychotropic medication ordered for anxiety and the anxiety disorder care plan lacked evidence of a pharmacological intervention associated with behaviors. Resident #12's psychotropic medications had the following Black Box warnings for adverse side effects: -[DATE] The system identified a black box warning for the following order: lorazepam oral concentrate 1 mg/0.5 ml Risks from concomitant use with opioids. Concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. Follow patients for signs and symptoms of respiratory depression and sedation. Resident #12's clinical record lacked evidence the Black Box warnings of adverse side effects were monitored. Resident #12's Medication Administration Records documented the resident received lorazepam on the following dates: -[DATE] -[DATE] -[DATE] -[DATE] -[DATE] -[DATE] -[DATE] On [DATE] at 2:40 PM, the MDS Coordinator verbalized the Lorazepam order should have had a 14 day stop date because it was ordered as needed. On [DATE] at 2:46 PM, the MDS Coordinator confirmed the resident did not have a care plan for the use of lorazepam specifically. On [DATE] at 2:50 PM, the MDS Coordinator verbalized the resident had received Lorazepam two times in July and five times in August. On [DATE] at 2:49 PM, the MDS Coordinator explained the physician signed the psychotropic medication review form acknowledging the pharmacist had read the recommendation from the pharmacist to add the end date to the PRN lorazepam. However, the physician did not respond or document a clinical rationale to the Pharmacist recommendation. Nursing was not directed to add an end date. On [DATE] at 2:53 PM, the MDS Coordinator explained Resident #12 became anxious by exhibiting restlessness and confirmed the physician's order did not reflect the specific indication for use related to the behavior. The facility lacked adequate monitoring for efficacy and adverse consequences for the physician ordered psychotropic medication. Resident #14 Resident #14 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including major depressive disorder, single episode, unspecified and insomnia, unspecified. Resident #14's psychotropic physician orders documented the following: -[DATE] duloxetine HCl oral capsule delayed release sprinkle 60 mg, give one capsule by mouth one time a day for major depressive disorder related to major depressive disorder, single episode, unspecified. -[DATE] Cymbalta Oral Capsule Delayed Release Particles 30 mg (duloxetine HCl), give 1 capsule by mouth at bedtime for major depressive disorder related to major depressive disorder, single episode, unspecified. -[DATE] haloperidol decanoate intramuscular solution 50 mg/ml, inject one vial intramuscularly starting on the 14th and ending on the 14th every month related to major depressive disorder, single episode, unspecified. -[DATE] buspirone HCl tablet 15 mg, give 0.5 tablet by mouth three times a day related to major depressive disorder, single episode, unspecified, give 1/2 tab to = 7.5 mg. -[DATE] trazodone HCl tablet 100 mg, give one tablet by mouth one time a day related to major depressive disorder, single episode, unspecified. -[DATE] Abilify Tablet 5 mg (aripiprazole), give one tablet by mouth one time a day related to major depressive disorder, single episode, unspecified. Resident #14's physician's orders lacked identified behaviors associated with the administration of the psychotropics and adverse side effects associated with the medication. Resident #14's care plan for the psychotropic medications, initiated on [DATE], documented the following: Resident #14 was prescribed anti-depressant and antipsychotic medications: trazadone, Abilify, and Cymbalta, buspirone, and Haldol injections related to depression. The care plan documented the following interventions: Educate Resident #14 and caregivers about risks, benefits, and the side effects and/or toxic symptoms of medications prescribed. Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness. ANTIANXIETY SIDE EFFECTS: Drowsiness, lack of energy, Clumsiness, slow reflexes, Slurred speech, Confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Paradoxical side effects: Mania, hostility, and rage, aggressive or impulsive behavior, hallucinations. Monitor/record occurrence of for target behavior symptoms such as wandering and document per facility protocol. Non-medication interventions be done such as attend counseling, encouraging to participate in activities, outings, or activities that help provide coping skills for Resident #14. Resident #14 is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, falls, broken hips and legs. Monitor for safety. When exhibiting or reporting signs and symptoms of anxiety or mood symptoms/behaviors, Resident #14 is assisted by staff to help strengthen coping skills. Resident #14's care plan identified the psychotropic medications as antianxiety medications. Duloxetine HCl oral capsule delayed release sprinkle, Cymbalta Oral Capsule Delayed Release Particles, haloperidol decanoate intramuscular solution, buspirone HCl, trazodone HCl, and Abilify were all physician ordered for a diagnosis of major depressive disorder, single episode, unspecified. Resident #14's clinical record lacked a diagnosis of anxiety on the admission Record date [DATE]. Resident #14's MDS 3.0 assessment dated [DATE], Section I5700, lacked indication of anxiety disorder. On [DATE] at 2:07 PM, The MDS Coordinator verified Resident #14 was not ordered medications for anxiety as an indication for use and confirmed anxiety was not indicated as a diagnosis for the resident. On [DATE] at 2:09 PM, the MDS[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure a facility staff member did not steal a resident's debit card and attempt to transfer money from the resident's banking account for 1 of 5 sampled residents (Resident #2). Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including heart failure, unspecified, peripheral vascular disease, unspecified, and chronic obstructive pulmonary disease, unspecified. A Facility Reported Incident (FRI) final report, documented on 01/21/23, Resident #2's wallet was reported missing by a staff member. On 01/23/23, a staff member provided copies of a text message from a different staff member, with proof of two money transfer application transactions for $1000.00 and $850.00, matching the resident's bank statements. The police were notified of the attempted theft and the employee was terminated. A Certified Nursing Assistant's (CNA) statement documented the CNA had entered Resident #2's room with another CNA on 01/21/23 and noticed the resident's wallet was missing. A CNA was texted pictures of screenshots between a Patient Care Technician (PCT) employed by the facility and a member of the community. The PCT was requesting to send money through a money transfer application to the community member so the community member could then give the money to the PCT. The CNA informed the Skilled Nursing Facility (SNF) Manager. A text message screenshot provided by the facility, undated, documented two payments were requested through a money transfer application in the amounts of $1000.00 and $850.00 from an individual with the same name as Resident #2. A copy of pending charges for the checking account of Resident #2, dated 01/22/23, documented the money transfer application had two pending charges for $1000.00 and $850.00. On 04/05/23 at 1:37 PM, the SNF Manager verbalized Resident #2 had received a notification about a withdrawal from the resident's bank when the resident's debit card was missing. The SNF Manager verbalized the resident's bank statement matched the amounts requested from the money transfer application and the resident's name was the same as the name on the screenshots provided from the money transfer application. The SNF Manager verbalized the PCT had attempted to send the funds to a friend so the friend could then give the money to the PCT. The facility policy titled Abuse: Suspected Abuse and Reporting Unwitnessed Injuries and Abuse Prevention, revised 11/13/14, documented it was the policy of the facility for residents to be free from exploitation of person or property. Exploitation was defined as any act taken by a person having the trust or confidence of a resident to obtain control, through deception, intimidation, or undue influence, over the resident's money, assets, or property. FRI #NV00067824

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident had interventions in place and was monitored to prevent a fall with injury for 1 of 5 sampled residents (Resident #1). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including adult failure to thrive, muscle weakness (generalized), and unspecified dementia with behavioral disturbance. A Facility Reported Incident (FRI), dated 02/18/23, documented on 02/17/23, at approximately 7:25 PM, Resident #1 was found on the resident's left side on the floor of the dining room. The resident was found lying next to the resident's wheelchair and had a laceration above the resident's left eye and a skin tear to the left arm. A Fall Risk Assessment for Resident #1, dated 12/20/22, documented the resident was confined to a chair and disoriented. The resident's fall risk score was 23, indicating the resident was a high risk for falls. A care plan for Resident #1, initiated on 09/26/22, documented the resident had a risk for falls related to a history of falls with injury, multiple risk factors related to impaired balance, poor coordination, and unsteady gait. A Nursing Narrative Note, dated 02/17/23, documented Resident #1 was found on the resident's left side next to the resident's wheelchair in the dayroom at approximately 7:25 PM. Resident #1 had a cut on the resident's eyebrow and the cut was bleeding. On 04/05/23 at 11:51 AM, Resident #1 was sitting at a table in the dining room in a wheelchair pushed up close to the table. The resident's representative was sitting beside the resident. The resident's representative verbalized the representative was told the resident had pushed back from the table prior to the fall and the representative believed the resident was able to push back from the table because the wheels of the chair were left unlocked, and the resident was unattended. On 04/05/23 at 1:32 PM, the Risk Manager verbalized the Risk Manager had reviewed footage from the incident in the dining room. The Risk Manager verbalized the resident had scooted back from the table by rocking back and forth in the resident's chair. The Risk Manager verbalized staff had left the area to see to other resident needs and had left the resident unattended in the dining room. On 04/05/23 at 1:58 PM, the Administrator verbalized the facility should always have a staff member available to monitor a high fall risk resident. The Administrator verbalized the wheel locks were not engaged on the wheelchair and the resident was able to push back from the table. The Administrator verbalized the staff had left the resident unattended and the Administrator's expectation was there would always be at least one staff member monitoring the common area when residents were present. The facility policy titled Fall Prevention, effective 04/01/03, documented residents with high risk factors of falling would be identified to prevent falls. Residents at risk for falls would be placed as close as possible to the nursing station. Residents in the fall prevention program would be monitored closely. FRI #NV00068021