**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 #10). This deficient practice had the potential for the care plan to omit current needs, services, and monitoring for residents. Findings include: Resident #10 Resident #10 was admitted to the facility on [DATE], with diagnoses including depression, hypertension, hyperlipidemia, and type two diabetes mellitus. A Physician Progress Note dated 10/14/2024, documented Resident #10 had a diagnosis of depression. The resident was not receiving any medication for depression and the physician recommended follow-up with behavioral health if the resident showed any overt signs of depression. A quarterly MDS assessment dated [DATE], Section I - Active Diagnoses, included instructions to check all that apply. Diagnoses of hypertension, hyperlipidemia, and diabetes mellitus were checked with an X. Item I5800 - Depression lacked a checkmark, X, or any other indication the resident had the diagnosis. Section Z, item Z0400, included a signature indicating the facility's MDS Coordinator completed Section I of the MDS assessment. On 02/05/2025 at 1:52 PM, a Licensed Practical Nurse (LPN) confirmed Resident #10 had a diagnosis of depression. The LPN explained Resident #10 was not currently taking any medication for depression and staff were monitoring the resident for any changes in behavior such as being tearful or not wanting to get out of bed. The LPN verbalized Resident #10 had some days when the resident did not want to get out of bed and had to be encouraged by staff to get up. If the resident exhibited any signs or symptoms of depression or changes in behavior, staff would notify the physician. On 02/06/2025 at 11:34 AM, the MDS Coordinator verbalized residents' diagnoses were recorded in section I of the MDS assessment. The MDS Coordinator explained the MDS Coordinator included diagnoses in section I of the assessment based on physician notes completed in the 60 days prior to the assessment date. The MDS Coordinator verbalized Resident #10 had a diagnosis of depression, and the resident had been gradually reduced off of psychiatric medications. The MDS Coordinator reviewed the Physician Progress Note dated 10/14/2024, and confirmed the note documented Resident #10 had a diagnosis of depression. The MDS Coordinator confirmed the MDS assessment dated [DATE], did not document the resident's diagnosis of depression and was inaccurate. The facility policy titled Resident Assessment Process, reviewed 01/14/2025, documented it was the responsibility of each member of the Interdisciplinary Team (IDT) to document all information gathered into the resident's clinical record during the lookback period, so it was a comprehensive, accurate, standardized, and reproducible assessment of the resident's status. The information was then entered into the MDS. Each person completing a section of the MDS attested to its accuracy by electronically affixing a signature to the section. The comprehensive care plan must address all care issues relevant to the individual.

Based on interview, personnel record review, and document review, the facility failed to employ a trained Activity Coordinator. This deficient practice had the potential to affect resident safety and satisfaction for the entire facility census. Findings include: The personnel roster provided to the State Agency lacked documentation of an Activity Coordinator. On 02/03/2025 at 1:10 PM, the Infection Preventionist/Registered Nurse verbalized the facility did not have a certified Activity Coordinator. An Activity Aide was acting in the Activity Coordinator role and working to complete the required credentials. On 02/06/2025 at 10:35 AM, the Resident Care Coordinator verbalized the previous Activity Coordinator stopped working at the facility around the end of September 2024, and the Activity Aide took on the Activity Coordinator role as soon as the Activity Coordinator left. The Resident Care Coordinator explained since the Activity Coordinator left, the facility had received an elevated number of complaints regarding the activities program. On 02/06/2025 at 11:21 AM, the Human Resources (HR) Manager verbalized the previous Activity Coordinator moved to a new position on 09/09/2024. As a result, the facility hired a Certified Activity Consultant and would be working with the facility remotely. The HR Manager verbalized responsibilities of the Activity Coordinator included attending care plan conferences, organizing and maintaining a safe environment, transporting residents to local appointments, and compiling the monthly program calendar. The HR Manager believed the Activity Consultant acted as the Activity Coordinator; however, the HR Manager verbalized the Consultant had not signed the Activity Coordinator position description, was unsure how the consultant would be aware of the expectations without a signed position description, was unsure whether the Consultant fulfilled the job duties of the Activity Coordinator and confirmed it would be difficult to perform those responsibilities while working remotely. The HR Manager confirmed the Agreement for Activity Consultant referred to the Activity Coordinator as a separate person to receive guidance from the Consultant. The HR Manager also verbalized the Activity Aide was not the Activity Coordinator. An Agreement for Activity Consultant dated 09/06/2024, documented the Activity Consultant would provide the Activity Coordinator with information regarding existing community resources, literature and services which would enhance activity programming. An unsigned facility position description titled, Activity Coordinator, revised 02/16/2024, documented the Activity Coordinator was responsible for all aspects of the activities program including the development and implementation of recreation programs, assessment of resident abilities and needs, compilation of a social program calendar, and transportation of residents to local appointments. The position description lacked language to include the role and responsibilities of a certified Activity Consultant to direct the facility's activities program during the period a new Activity Coordinator was obtaining certification. The Activity Aide and Activity Consultant's personnel records lacked a signed position description for Activity Coordinator. On 02/06/2025 at 12:15 PM, the Activity Consultant explained the Consultant was responsible for reviewing the activity calendar, updating resident care plans, and training and certifying employees for the Activity Coordinator position. The Consultant verbalized the Activity Aide had not completed the required training to be in the Activity Coordinator position and had only begun the training in January 2025, despite being in the role since September 2024. Additionally, the Activities Aide did not have two years of experience in an activities program as required to be a qualified Activity Coordinator. The Consultant verbalized neither the Consultant nor the Activity Aide were the facility's Activity Coordinator and confirmed the Activity Coordinator position remained vacant. An Education Reimbursement Request form dated 11/05/2024, documented the Activity Aide needed the certification to hold the Activity Coordinator position.

Based on observation, interview, and document review, the facility failed to ensure resident information was not visible on an unattended computer screen. This deficient practice had the potential for unauthorized access to residents' protected health information. Findings include: On 02/05/2025 at 7:49 AM, a Licensed Practical Nurse (LPN) was preparing medications for a resident. The LPN was utilizing a stationary (desktop) computer next to the facility's medication dispensing system. The computer and medication dispensing system were in a common area, near the nurses' station, and the computer screen was facing the hallway. The LPN verbalized one of the medications was required to be cut in half and the half tablet not being used was to be discarded in the medication storage room. The LPN took the half tablet, walked away from the computer and entered the medication storage room to dispose of the half tablet. The computer screen was left on and unlocked; resident information was visible on the screen. On 02/05/2025 at 8:05 AM, the LPN began preparing medication for a resident. One of the resident's medications required the tablet to be cut in half. The LPN cut the tablet in half, walked away from the computer and entered the medication storage room to dispose of the half tablet. The computer screen was left on and unlocked; resident information was visible on the screen. On 02/05/2025 at 8:36 AM, the LPN verbalized the LPN usually minimized the window on the computer screen prior to walking away from the workstation. The LPN acknowledged the computer screen was left on and unlocked, with resident information visible, while the LPN went into the medication storage room. The LPN verbalized protected resident health information should always be hidden from view prior to staff walking away from a workstation. On 02/06/2025 at 10:05 AM, the Infection Preventionist/Registered Nurse (IP/RN) verbalized private health information should not be visible when staff walked away from a workstation. The IP/RN explained if a computer screen was left on and unlocked without staff present, residents' private health information was not protected. The IP/RN verbalized private health information was anything showing on the screen when a resident's chart was open. The facility policy titled Workstation Use, reviewed 04/04/2024, documented the facility ensured the security of all electronic protected health information by structuring the access to electronic information through workstations. A workstation was an electronic computing device such as a laptop or desktop computer. Employees found to leave any computer workstation unattended after logging in would be subject to the facility's disciplinary process for suspected breach of patient protected health information.

Based on observation, interview, and document review, the facility failed to ensure a Licensed Practical Nurse (LPN) donned gloves, according to the facility's policy, prior to removal and placement of transdermal patches. This deficient practice had the potential to transfer bacteria, germs, and residual medication between residents. Findings include: On 02/05/2025 at 8:30 AM, during the morning medication pass, an LPN removed a transdermal patch from a resident's chest. The LPN was not wearing gloves during the removal of the patch and did not perform hand hygiene after removing the patch. On 02/05/2025 at 8:31 AM, the LPN placed a new transdermal patch on the resident's right arm. The LPN was not wearing gloves. On 02/05/2025 at 8:37 AM, the LPN confirmed the LPN was not wearing gloves during the removal and placement of transdermal patches while completing the morning medication pass. The LPN verbalized the LPN should have been wearing gloves since the removed patch had been in contact with the resident's skin and to prevent potential transfer of medication from the patches to the LPN's hands. On 02/06/2025 at 10:05 AM, the Infection Preventionist/Registered Nurse (IP/RN) confirmed nursing staff were expected to perform hand hygiene and wear gloves when removing transdermal patches and when administering topical or transdermal medications to residents. The IP/RN verbalized hand hygiene was required to be performed prior to donning and after doffing gloves. The facility policy titled Transdermal Patch Application, revised 05/19/2024, documented staff were to perform hand hygiene and put on gloves prior to the removal of previously applied transdermal patches and application of new patches. The facility policy titled Hand Hygiene, reviewed 08/13/2024, documented hand hygiene was the single most important strategy to reduce the risk of transmitting organisms from one person to another or from one site to another on the same resident. All staff were to perform hand hygiene before each patient encounter including before donning gloves, after contact with a resident's intact skin, and when moving from a contaminated body site to a clean body site during resident care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, document review, and interview, the facility failed to ensure a care plan was developed and implemented related to a resident's hearing deficit and the use of a hearing device for 1 of 12 sampled residents. Findings include: Resident #11 Resident #11 was admitted to the facility on [DATE], and re-admitted [DATE], with diagnoses including ceruminosis, vertigo, and head injury. A Physician Office Clinic Note dated 02/07/2024, documented the resident was severely hard of hearing and even with his hearing aids in place, the resident could not hear what was being said. On 04/01/2024 at 4:37 PM, Resident #11 verbalized the resident could not hear very well and had hearing aids. The resident verbalized the hearing aids did not work very well when the resident placed them in the resident's ear. On 04/02/2024 at 11:25 AM, the Certified Nursing Assistant (CNA) assisted Resident #11 place the resident's hearing aids in the resident's ears and verbalized the hearing aids did not work well. The CNA verbalized previously the resident had another pair which worked better but lost one of them and was using a cheaper pair of hearing aids now which did not work as well. On 04/02/2024 at 11:32 AM, the CNA verbalized sometimes the CNAs had to use a white board to communicate with Resident #11. Resident #11's Care Plan dated 03/25/2024, lacked documented evidence of a care plan for a hearing deficit and the use of hearing devices. On 04/04/2024 at 9:26 AM, the CNA verbalized assisting the resident with the resident's hearing aids and confirmed if the resident did not have the hearing aids in use, the resident could not hear. The CNA verbalized the current devices were hit and miss for working and had been cleaned. On 04/04/2024 at 9:53, the Resident Advocate (RA) confirmed the facility was aware of the current issue with the resident's hearing devices not working properly and the resident's hearing deficit. The RA verbalized the facility lacked transportation for the resident to travel to an appointment for the resident to receive a hearing test and new hearing devices. On 04/04/2024 at 10:40 AM, the Minimum Data Set Coordinator confirmed Resident #11's Comprehensive Care Plan lacked care planning for the resident's hearing deficit and use of hearing aids and verbalized Resident #11 should have a care plan with a communication focus area to address the resident's hearing deficit. The facility's policy titled Care Plan Development Process, reviewed 11/03/2023, documented the care plan guided the care and treatment provided to each resident. The care plan was individualized and addressed the resident's medical, nutritional, psychological, physical, functional, social, educational, and spiritual needs, and the severity of the resident's condition, impairments, disability or disease as indicated.

**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 of 12 residents (Resident #10) had an active order for the use and monitoring of a urinary catheter and failed to ensure the resident urinary drainage bag was maintained at a safe and appropriate level. The failure to maintain the urine collection bag at the appropriate level could have resulted in urine flowing back into the residents bladder, placing the resident at increased risk for infection. Findings include: Resident #10 Resident #10 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including history of cerebral vascular accident (CVA) with residual deficit, left sided weakness, type II diabetes mellitus, complicated urinary tract infection (UTI), frequent urinary tract infections, voiding dysfunction, urinary retention with incomplete bladder emptying. On 04/01/2024 at 2:54 PM, Resident #10 was lying in bed, a urinary collection bag was covered with a dignity bag, and the bag was lying on the floor. On 04/03/2024 at 4:09 PM, the Minimum Data Set (MDS) Coordinator/Registered Nurse (RN) Confirmed Resident #10's clinical record did not include an order for the use and monitoring of a urinary catheter. The MDS RN explained when Resident #10 was readmitted from an acute care stay on 03/26/2024, the facility failed to ensure the order was entered into the resident's clinical record. Resident #10's Urinary Catheter Flow Sheet, utilized to monitor and document observations of the resident's urinary catheter, lacked documented evidence the catheter was monitored from 03/22/2024 - 04/04/2024. The flow sheet was repopulated on 04/04/2024 at 11:30 AM. On 04/04/2024 at 9:00 AM, Resident #10 was lying in bed in preparation for wound care. The resident's urinary drainage bag was not visible and appeared to be in the resident's bed beneath the blankets. On 04/04/2024 at 9:57 AM, a Certified Nursing Assistant (CNA) located Resident #10's urinary drainage bag lying next to the resident, in the residents bed. The CNA verbalized it was important to keep urinary drainage bags below the level of a resident's bladder and confirmed Resident #10's urinary drainage bag was not below the resident's bladder when lying next to the resident in the resident's bed. On 04/04/2024 at 10:00 AM, the Director of Nursing (DON) verbalized the expectation was urinary drainage bags would not be left lying next to residents and would be kept below the level of a resident's bladder. The DON confirmed Resident #10's urinary drainage bag should have been hooked to the side of the resident's bed to allow urine to flow to gravity. On 04/04/2024 at 11:03 AM, the DON verbalized the facility did not have a policy related to the care of urinary catheters. The DON verbalized [NAME] online was the facility's Standard of Practice (SOP). On 04/04/2024 at 11:30 AM, the DON explained when the Resident #10 returned to the facility following an acute care stay, the facility failed to re-enter the resident's urinary catheter orders. The failure to enter the orders led to the monitoring flow sheet not being populated. The monitoring flow sheet triggered staff to monitor and document observations of the urinary catheter and collection bag. The DON confirmed not entering the orders led to the lack of monitoring and documenting observations of Resident #10's urinary catheter and drainage bag. A [NAME] online document titled Indwelling Urinary Catheter (Foley) Care and Management, dated 12/10/2023, printed by the facility on 04/04/2024, documented to monitor for intake and output, changes in urinary output, including volume and color. Keep the drainage bag below the level of the bladder to prevent backflow of urine into the bladder. Backflow of urine into the bladder increased the risk for catheter associated urinary tract infections (CAUTI).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #12 Resident #12 was admitted to the facility on [DATE], with diagnoses including depression, type 2 diabetes mellitus, hypothyroidism, hypertension, and kidney disease, chronic stage III. Resident #12's order was as followed: -citalopram 20 mg oral tablet, one tablet, by mouth, daily, start date of 09/16/2022, for depression. The Psychiatric Nurse Practitioner Note dated 04/03/2023, documented the provider did not recommend a GDR attempt at this time due to the stability of resident's behavior. On 04/03/2024 at 4:10 PM, the MDS Coordinator verbalized there was not a second GDR attempt for citalopram within the first year of use of Resident #12's antidepressant medication. The facility policy titled Psychotropic Medication Use In Long Term Care, reviewed 12/29/2023, documented within the first year a resident was admitted on psychopharmacological medication or after the facility had initiated such medication, dose reduction should be attempted twice in two separate quarters with at least one month in between attempts. Based on interview, clinical record review, and document review, the facility failed to ensure a resident on a psychotropic medication had a gradual dose reduction (GDR) for 2 of 12 sampled residents (Resident #28 and #12). Findings include: Resident #28 was admitted to the facility on [DATE], with diagnoses including atypical psychosis, schizophrenia, auditory hallucinations, and depression. Resident #28's orders were as follows: - Depakote extended release 750 milligrams (mg) = 3 tablets, by mouth, every night before bedtime, with original start date of 11/01/2022, for atypical psychosis, schizophrenia, and history of auditory hallucinations. - olanzapine 15 mg = 3 tablets, by mouth, every night at bedtime, with original start date of 11/01/2022, for atypical psychosis, schizophrenia, and history of auditory hallucinations. The Monthly Medication Review dated April 2023, documented the Pharmacist's recommendation to try a GDR for sertraline and Depakote. The Psychiatric Nurse Practitioner Note dated 04/17/2023, documented the provider did not recommend a GDR attempt at this time due to the stability of resident's behavior. On 04/03/2024 at 4:10 PM, the Minimum Data Set (MDS) Coordinator verbalized there was not a GDR recommendation for olanzapine and there was not a second GDR attempt for Depakote within the first year of use of Resident #28's two antipsychotic medications.

Based on interview and document review, the facility failed to accurately report 24-hour licensed nursing coverage documented on the payroll-based staffing (PBJ) requirements submitted to the Center for Medicare and Medicaid Services (CMS). Findings include: Review of the facility's Certification and Survey Provider Enhanced Reporting System (CASPER) Report revealed the facility lacked 24-hour licensed nursing coverage on 10/01/2023, 10/02/2023, 10/03/2023, 10/04/2023, 10/05/2023, 10/06/2023, 10/07/2023, 10/08/2023, 10/09/2023, 10/10/2023, 10/11/2023, 10/12/2023, 10/13/2023, 10/14/2023, and 10/15/2023. Facility nursing schedules and timesheets indicated 24-hour licensed nursing coverage for 10/01/2023, 10/02/2023, 10/03/2023, 10/04/2023, 10/05/2023, 10/06/2023, 10/07/2023, 10/08/2023, 10/09/2023, 10/10/2023, 10/11/2023, 10/12/2023, 10/13/2023, 10/14/2023, and 10/15/2023. The PBJ reports submitted to CMS lacked documentation of 24-hour licensed nursing coverage for 10/01/2023, 10/02/2023, 10/03/2023, 10/04/2023, 10/05/2023, 10/06/2023, 10/07/2023, 10/08/2023, 10/09/2023, 10/10/2023, 10/11/2023, 10/12/2023, 10/13/2023, 10/14/2023, and 10/15/2023. On 04/03/2024 at 4:35 PM, the Director of Nursing (DON) indicated the facility had been submitting PBJ data. The DON confirmed the PBJ reports submitted to CMS were inaccurate and the facility did have 24-hour licensed nursing coverage on 10/01/2023, 10/02/2023, 10/03/2023, 10/04/2023, 10/05/2023, 10/06/2023, 10/07/2023, 10/08/2023, 10/09/2023, 10/10/2023, 10/11/2023, 10/12/2023, 10/13/2023, 10/14/2023, and 10/15/2023.

Based on observation, interview, and document review, the facility failed to ensure the Quality Assurance and Process Improvement (QAPI) committee had the required members. Findings include: The facility provided a list of QAPI Committee members. The list documented the QAPI committee was comprised of the Administrator, the Director of Nursing (DON), Medical Director or designee, and the Infection Preventionist (IP). On 04/04/2024 at 11:56 AM, the DON verbalized the QAPI committee required at a minimum the Administrator, the DON, Medical Director or designee, the IP and two other staff members. The DON confirmed on the QAPI sign in sheet dated 12/28/2023 lack the signature of the DON attending the QAPI meeting on 12/28/2023. The facility document titled Quality Assurance and Performance Improvement (QAPI) Plan for Humboldt General Hospital, Harmony Manor Skilled Nursing Facility and Quail Corner Life Enrichment Community, undated, documented the Director of Nursing would provide QAPI leadership by being on the Quality Assessment and Assurance Committee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview, and document review the facility failed to ensure 1 of 5 residents sampled for vaccinations (Resident #31) was screened for eligibility to receive an influenza vaccine, education regarding the vaccine was provided to the resident and/or the Resident Representative, and the vaccine was offered and either administered or declined. Findings include: Resident #31 Resident #31 was admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus without complication, and malignant neoplasm of stomach, unspecified. Resident #31's clinical record lacked documented evidence the resident was screened for eligibility to receive pneumococcal vaccines, education regarding the vaccines was provided to Resident #31 and/or the resident's representative, and a vaccine was either administered or declined. The Resident was [AGE] years old. Resident #31's state immunization record downloaded and printed by the facility on 04/02/2024, documented the resident received the following pneumococcal vaccines: -One dose of pneumococcal polysaccharide vaccine (PPSV) 23 was administered on 01/27/2014, the resident was [AGE] years old at the time of administration. -PPSV23 was administered on 10/27/2015, the resident was [AGE] years old at the time of administration. The facility was not able to provide documented evidence the resident was screened for eligibility to receive a pneumococcal vaccine, education related to the vaccine was provided, and the resident either received or declined the vaccine. On 04/03/2024 at 12:14 PM, an Infection Preventionist (IP) confirmed Resident #31 was administered two doses of PPSV23 prior to admission to the facility, and was not screened for eligibility to receive additional updated/booster doses of a pneumococcal vaccine, was not provided education regarding pneumococcal vaccines, and was not offered the opportunity to receive or decline pneumococcal vaccines. The IP confirmed Resident #31 was eligible to receive either pneumococcal conjugate vaccine (PCV)15 or PCV20, and was not screened for eligibility to receive either of the vaccines, was not provided education regarding the vaccine, and was not given the opportunity to receive or decline the vaccine. The facility policy titled Administering Pneumococcal Vaccines (PCV15, PCV20, and PPSV23) to Adults, dated 04/28/2023, documented screening residents for vaccination with a pneumococcal vaccine included the following: -Screening residents for need of vaccination against Streptococcus pneumoniae (pneumococcus) infection, -Screening residents for contraindications and precautions, -Educating by providing the Vaccine Information Statement (VIS). The provision of the VIS was documented, and -Administration of pneumococcal vaccines as indicated. Residents who were over the age of 65, and previously vaccinated with PPSV23, were to be offered vaccination with either PCV15 or PCV20 at least one year after vaccination with PPSV23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview, and document review the facility failed to ensure 1 of 5 residents sampled for vaccinations (Resident #30) was screened for eligibility to receive an updated/booster dose of COVID-19 (COVID) vaccine, education regarding the vaccine was provided to the resident and/or the Resident Representative, and the vaccine was offered and either administered or declined. Findings include: Resident #30 Resident #30 was admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus, chronic anticoagulation, vitamin D deficiency, history of deep vein thrombosis (DVT), and chronic kidney disease. Resident #30's COVID Vaccination Record documented the resident was administered a COVID vaccine on 12/30/2022, and 10/24/2023. Resident #30's clinical record lacked documented evidence the resident was administered any additional doses of a COVID vaccine. Resident #30's clinical record lacked documented evidence the resident was screened for eligibility to receive a booster dose of COVID vaccine, education regarding the vaccine was provided to Resident #30 and/or the Resident's Representative, and the vaccine was either administered or declined. On 04/03/2024 at 12:24 PM, an Infection Preventionist (IP) confirmed Resident #30's clinical record lacked documented evidence the resident was screened for eligibility to receive a COVID booster vaccine, the resident and/or the resident's representative were provided education regarding booster doses of the vaccine, and the resident had either received or declined a booster dose of a COVID vaccine. The IP verbalized two doses of a 2023 or 2024 COVID vaccine were needed to be up to date with COVID vaccination and confirmed Resident #30's clinical record lacked documented evidence of screening, education, and administration or declination of a second dose of a 2023 or 2024 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 Respiratory Illnesses in Long Term Care, reviewed on 01/04/2024, documented residents were offered COVID vaccines in accordance with CDC recommendations unless medically contraindicated. Residents were provided education regarding the risk, benefits, and potential side effects of the vaccine. The resident or the resident representative were given the opportunity to accept or refuse vaccination. The resident's clinical record included the following documentation: -Education provided to the resident and/or representative -Each dose of the vaccine administered to the resident -The vaccine was either accepted and received, was not received if medically contraindicated or already vaccinated, or was declined.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #12 Resident #12 was admitted to the facility on [DATE], with diagnoses including depression, type 2 diabetes mellitus, hypothyroidism, hypertension, and kidney disease, chronic stage III. On 04/03/2024 at 4:10 PM, the DON confirmed the MMRs were not completed within thirty (30) days of the prior MMR for June 2023, completed 07/12/2023 and September 2023, completed 10/03/2023, and November 2023, completed 12/23/2023 for Resident #11, #14, #30, and #12. The DON explained there was no policy related to Monthly Medication Reviews. Resident #30 Resident #30 was admitted to the facility on [DATE], with diagnoses including chronic neck pain, sciatic pain, hip pain, right, chronic anticoagulation, history of deep vein thrombosis (DVT) of lower extremity, major depressive disorder, neurocognitive disorder, and post-traumatic stress disorder. Based on interview and document review, the facility failed to ensure Monthly Medication Reviews (MMR) were completed monthly for 4 of 5 residents reviewed for unnecessary medications (Resident #11, #14, #30, and #12). Findings include: On 04/03/2024 at 3:12 PM, the Director of Nursing (DON) verbalized all psychotropic medications were reviewed monthly by the consulting Pharmacist for appropriateness and recommendations for dose reduction. The DON confirmed monthly was defined as no later than the first Monday of the month for the proceeding month of use. The following residents lacked an MMR completed within thirty (30) days of the prior MMR for June 2023, completed 07/12/2023 and September 2023, completed 10/03/2023, and November 2023, completed 12/23/2023: Resident #11 Resident #11 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses including benign prostatic hyperplasia without urinary obstruction, congestive heart failure, shoulder pain, bilateral, atrial fibrillation, controlled, essential (primary) hypertension, gastro-esophageal reflux disease, depression, hyperlipidemia, depression, glaucoma, hypothyroidism, chronic low back pain, right knee pain, left knee pain, osteoarthritis of multiple joints, and chronic pain. Resident #14 Resident #14 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses including syncope, bladder spasms, chronic obstructive pulmonary disease without exacerbation, oxygen dependent, anemia, chronic leg pain, right shoulder pain and chronic pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #2 (R2) Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of psychotic disorder. A hospital discharge summary report dated 06/13/22, documented Resident #2 had a diagnosis of psychotic disorder. A physician's order dated 11/14/22, documented divalproex sodium capsule, 500 milligrams (mg), give four capsules by mouth daily for unspecified psychotic disorder. A physician's order dated 02/15/23, documented risperidone tablet, 0.5 milligrams, give one tablet by mouth twice a day for unspecified psychotic disorder. R2's care plan dated 10/28/22, documented the resident used antipsychotic medications to prevent unwanted behaviors including risperidone and divalproex sodium. R2's quarterly MDS assessment dated [DATE], Section N, Medications, documented the resident had been administered an antipsychotic within the previous seven days. R2's annual MDS assessment dated [DATE], Section N, Medications, documented the resident had been administered an antipsychotic within the previous seven days. Behavioral management evaluations dated 10/03/22, 12/05/22, 02/09/23, and 03/16/23, documented R2 had a diagnosis of psychotic disorder and medication treatment included risperidone and divalproex sodium. A PASARR Level I Determination dated 01/11/08 documented R2 met placement for nursing facility and did not need specialized services. R2's clinical record lacked documented evidence a PASARR Level II review had been submitted for determination. On 04/19/23 at 3:35 PM, the Director of Nursing (DON) confirmed the DON was responsible for submission to the State agency for review of necessary services for residents diagnosed with mood or psychotic disorders. The DON confirmed R1 was diagnosed with a mood disorder and R2 with a psychotic disorder, and both had been receiving behavioral health services and medication treatments for those diagnoses. The DON confirmed R1 and R2 each had a change of condition in mental status and had not been resubmitted to the State agency for PASARR review for any necessary services but should have been. Based on interview, record review and document review, the facility failed to notify the state designated authority to re-evaluate the Pre-admission Screening and Annual Resident Review (PASARR) for 2 of 12 sampled residents who had changes in mental status (Resident #1 and Resident #2). The failure had the potential to deprive the residents of the care and services necessary to meet their mental health needs. Finding include: The facility policy titled Preadmission Screening and Resident Review (PASRR), dated 11/05/2021 and reviewed on 10/27/2022, documented residents would be assessed on an ongoing basis to identify if a resident (1) develops mental illness, or (2) a resident who was not previously identified through the Level Identification screening as having indicators of mental illness (MI), intellectual disabilities (ID), developmental disabilities (DD) or related condition (RC) and was displaying Indicators, or (3) the facility had identified the need for a Significant Change in Status. The policy indicated any of these conditions may indicate the need for a PASRR Level II screening. The policy documented that within 14 days of the identification of a significant change in status, the facility must complete and submit a Level identification screening to the PASRR clinical reviewers. The clinical reviewers would review the information to determine if a PASRR Level II screening was indicated. The policy revealed a pre-admission screening was not required for residents being readmitted after a hospital stay unless the resident was transferred to a Psychiatric facility or hospital for reasons related to Ml, ID, DD, or RC. Resident #1 (R1) R1 was admitted to the facility on [DATE], with diagnoses including alcohol disorder and amphetamine substance use in remission, anxiety, depression, and post-traumatic brain syndrome. PASSAR level 1 dated 10/01/2007, revealed Organic Brain Syndrome as IB (appropriate to be admitted ) determination for admission in nursing facility. R1's medical record revealed R1 was discharged on 04/12/2022 and admitted in a psychiatric hospital due to increased behaviors. Discharge summary from the behavioral health facility dated 04/22/2022, documented R1 was admitted to the facility for exhibiting sexual behaviors in public, and inappropriate touching of a female resident. The resident discharge diagnoses included mood disorder. The transfer orders included valproic acid for bipolar disorder. Minimum Data Set (MDS) Quarterly assessment dated [DATE], and the MDS discharge assessment dated [DATE] revealed R1 had diagnoses including traumatic brain dysfunction, anxiety, depression, and antisocial personality as medical conditions. The resident was transferred to a behavioral care facility for inpatient evaluation and treatment on 04/12/2022. The MDS Quarterly assessment dated [DATE], documented bipolar disorder as a psychiatric and mood disorder new diagnoses. Behavioral management evaluation dated 04/09/2022, revealed R1 was displaying inappropriate sexual behaviors in the dining room. Discharge note dated 04/12/2022, documented R1 was referred to a behavioral health facility for further evaluation and treatment due to recent sexual behaviors and accumulative behaviors displayed in the past several months. History and Physical Evaluation dated 04/22/2022, revealed R1 was transferred to an acute behavioral health facility on 4/12/2022, for the need of inpatient acute psychiatric evaluation after a series of psychiatric problems experienced at the Skilled Nursing Facility. Over the course of a few months, R1 became more aggressive both physically and verbally, mostly directed towards staff, and was increasingly harder to care for in this setting. The History and Physical Evaluation indicated R1 also was having some sexually inappropriate behaviors. Nursing administration along with medical staff felt as though R1 would benefit from inpatient psychiatric evaluation. The History and Physical Evaluation documented while in the acute behavioral health facility, psychiatric staff did make the following new diagnoses: bipolar disorder most recent episode mixed phase, cognitive disorder secondary to history of head trauma and substance use disorder, alcohol use disorder in remission, amphetamine disorder in remission, and rule out antisocial personality disorder. R1 returned to the SNF on 04/21/2022. The facility MDS Coordinator confirmed R1 did not have a PASSR 2 assessment performed after being transferred and admitted in a psychiatric facility for increased behaviors affecting others. The MDS Coordinator acknowledged a PASSR 2 should have been done to determine eligibility for nursing facility admission.