Based on record review and interview, the facility failed to ensure residents and/or their representatives were informed in advance of what medications they received and understood the reasons, risks, and benefits of the medications for 2 (R #119 and R #130) of 7 (R #1, R #9, R #10, R #11, R #118, R #119, and R #130) residents reviewed for unnecessary medications. If the residents or their representatives are not informed of the risks and benefits of the medication or treatment alternatives, they are not able to make informed decisions regarding residents' care. The findings are: R #119 A. Record review of R #119's physician's orders revealed an order dated 04/29/25 for trazadone (antidepressant medication) 25 mg as needed for sleep related to systolic (congestive) heart failure (occurs when the heart's left ventricle cannot contract effectively, leading to insufficient blood being pumped to the body). B. Record review of R #119's medical record revealed staff did not document consent for trazadone. C. On 05/19/25 at 2:12 PM, during an interview, the Director of Nursing (DON) confirmed that staff did not obtain the consent form for the trazadone for R #119. The DON confirmed that staff are expected to complete the psychotropic medication consent form prior to the resident starting psychotropic medications. R #130 D. Record review of R #130's physician's orders revealed the following: 1. 04/19/25 An order for hydroxyzine tablet (prescription-only antihistamine [medication with sedating and calming effect] that is used to treat anxiety) 25 mg, give one tablet by mouth two times daily related to anxiety. 2. 05/13/25 An order for trazodone tablet (antidepressant medication that is sometimes prescribed as a sleep aid) 50 mg, give one tablet by mouth in the evening for insomnia (common sleep disorder that makes it hard to fall asleep or stay asleep). E. Record review of R #130's medical record revealed staff did not document consent for hydroxyzine or trazodone. F. On 05/19/25 at 3:06 PM, during an interview, DON confirmed that staff did not obtain the consent form for hydroxyzine and trazodone for R #130. The DON confirmed that staff are expected to complete the psychotropic medication consent form prior to the resident starting psychotropic medications. The DON stated that the nurse should initially obtain verbal consent prior to administration of the first dose of the medications and then follow up with the written consent that is signed by the power of attorney (POA; legal document that appoints someone as a representative and allows them to act on one's behalf).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Recite from 05/22/24 Based on record review and interview, the facility failed to ensure a comprehensive MDS was completed within 14 calendar days after admission for 1 (R #12) of 9 (R #1, R #2, R #3, R #4, R #5, R #6, R #9, R #11, and R #12) residents reviewed for MDS. This deficient practice could likely result in residents' care needs not being met. The findings are: A. Record review of R #12's admission record no date revealed an admission date of 12/17/24. B. Record review of R #12's admission MDS assessment dated [DATE] revealed the admission MDS assessment was accepted on 01/06/25. C. On 05/19/25 at 1:21 PM, during an interview with the MDS Coordinator, she confirmed R #12's admission MDS assessment was not completed within 14 days of admission. The MDS Coordinator confirmed that the admission MDS assessments should be completed within 14 days of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a significant change (major decline or improvement in the patient's health status) MDS Set assessment within 14 days after the facility determined a significant change in the resident's physical or mental condition for 1 (R #3) of 9 (R #1, R #2, R #3, R #4, R #5, R #6, R # 9, R #11, and R #12) resident reviewed for MDS. This deficient practice could likely result in the residents not receiving the appropriate care and services they need. The findings are: A. Record review of R #3's admission record no date revealed an admission date of 03/24/25. B. Record review of R #3's physician orders dated 03/26/25 revealed an order for palliative care (an interdisciplinary medical care-giving approach aimed at optimizing quality of life and mitigating or reducing suffering among people with serious, complex, and often terminal illnesses). C. Record review of R #3's nursing progress note dated 03/26/25 revealed R #3 was placed on Palliative Care due to R #3 declining and failure to thrive. D. Record review of R #3's significant change of condition MDS assessment dated [DATE], revealed the MDS assessment was not completed and signed off by the RN until 04/10/25, and accepted on 04/21/25. E On 05/19/25 at 1:21 PM, during an interview with the MDS coordinator, she confirmed R #3's physicians orders for palliative care on 03/26/25, and the significant change MDS assessment for R #3 was not completed within 14 days from the determination date of 03/26/25 when resident was placed on palliative care. The MDS Coordinator confirmed that the significant change MDS assessments should be completed within 14 days of change of condition.

Based on record review and interview, the facility failed to ensure that an MDS was completed every three months for 2 (R #1, and R #9) of 9 (R #1, R #2, R #3, R #4, R #5, R #6, R #9, R #11, and R #12) resident reviewed for MDS assessments, when they failed to complete quarterly MDS assessments timely (completed 92 days after the previous assessment reference date (ARD)). This failed practice could result in residents' assessments being outdated and residents not receiving care and treatment that meets their current needs. The findings are: A. Record review of R #1's quarterly MDS assessments revealed the following: 1. Quarterly MDS accepted 01/06/25. 2. Quarterly MDS accepted 04/07/25. B. Record review of R #9's quarterly MDS assessments revealed the following: 1. Quarterly MDS accepted 01/06/25. 2. Quarterly MDS accepted 04/13/25. D. On 05/19/25 at 1:21 PM, during an interview with the MDS Coordinator confirmed that R #1's, and R #9's, Quarterly MDS assessments were not completed on time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to have MDS assessments completed, submitted, and finalized in a timely manner (within 14 days of completion) for 9 (R #1, R #2, R #3, R #4, R #5, R #6, R #9, R #11, and R #12) of 9 (R #1, R #2, R #3, R #4, R #5, R #6, R #9, R #11, and R #12) residents reviewed for MDS assessments. If MDS assessments are not completed, submitted, and finalized in a timely manner, it is likely that residents will receive less than optimal care. The findings are: R #1 A. Record review of R #1's admission record revealed that R #1 was admitted on [DATE]. B. Record review of the MDS 3.0 Missing OBRA Assessment Report for R #1 revealed R #1 MDS target date (Assessment Reference Date) on 12/25/24 and was not received. R #2 C. Record review of R #2's admission record revealed that R #2 was admitted on [DATE]. D. Record review of the MDS 3.0 Missing OBRA Assessment Report for R #2 revealed R #2 MDS target date on 01/01/25 and was not received. R #3 E. Record review of R #3's admission record revealed that R #3 was admitted on [DATE]. F. Record review of the MDS 3.0 Missing OBRA Assessment Report for R #3 revealed R #3 MDS target date on 08/28/24 and was not received. R #4 G. Record review of R #4's admission record revealed that R #4 was admitted on [DATE]. H. Record review of the MDS 3.0 Missing OBRA Assessment Report for R #4 revealed R #4 MDS target date on 12/18/24 and was not received. R #5 I. Record review of R #5's admission record revealed that R #5 was admitted on [DATE]. J. Record review of the MDS 3.0 Missing OBRA Assessment Report for R #5 revealed R #5 MDS target date on 12/18/24 and was not received. R #6 K. Record review of R #6's admission record revealed that R #6 was admitted on [DATE]. L. Record review of the MDS 3.0 Missing OBRA Assessment Report R #6 revealed R #6 MDS target date on 12/18/24 and was not received. R #9 M. Record review of R #9's admission record revealed that R #9 was admitted on [DATE]. N. Record review of the MDS 3.0 Missing OBRA Assessment Report for R #9 revealed R #9 MDS target date on 12/18/24 and was not received. R #11 O. Record review of R #11's admission record revealed that R #11 was admitted on [DATE]. P. Record review of the MDS 3.0 Missing OBRA Assessment Report for R #11 revealed R #11 MDS target date on 01/01/25 and was not received. R #12 Q. Record review of R #12's admission record revealed that R #12 was admitted on [DATE]. R. Record review of the MDS 3.0 Missing OBRA Assessment Report for R #12 revealed R #12 MDS target date on 12/24/24 and was not received. S. On 05/19/25 at 1:21 PM, during an interview with the MDS coordinator, she confirmed that she wasn't sure why the MDS Assessments were not being submitted on time, and stated she would consult the facilities MDS Consultant for directions. T. On 05/22/25 at 9:52 AM, during an interview with the State Agency MDS Coordinator, she confirmed that the MDS 3.0 Missing OBRA Assessment Report showed that the MDS Assessments have not been received from the facility and the facility was sent error messages related to the assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) for 1 (R #119) of 1 (R #119) resident reviewed for unnecessary medication use. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission. The findings are: A. Record review of R #119's admission Record, no date, revealed R #119 was admitted into the facility on [DATE]. B. Record review of R #119's medication list from the hospital, no date, revealed an order for trazadone (antidepressant medication) 50 mg, give 0.5 mg as needed for sleep. C. Record review of R #119's physician's order, dated 04/29/25, revealed an order for trazadone 25 mg by mouth as needed for sleep related to systolic (congestive) heart failure (occurs when the heart's left ventricle cannot contract effectively, leading to insufficient blood being pumped to the body). D. Record review of R #119's baseline care plan, dated 04/29/25, revealed R #119's baseline care plan did not include R #119's order the antidepressant medication trazadone. E. On 05/19/25 at 2:12 PM, during an interview, the DON confirmed the following: 1. R #119 had an order for the antidepressant medication trazadone. 2. Antidepressant medication is a high-risk medication drug classification (medications that have a heightened risk of causing significant patient harm when they are used in error). 3. R #119's baseline care plan did not include R #119's order for trazadone. 4. Baseline care plan should include all high-risk medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Recite from 05/22/24 Based on record review and interview, the facility failed to develop an accurate, person-centered comprehensive care plan for 2 (R #4 and R #9) of 12 (R #1, R #4, R #9, R #10, R #11, R #118, R #121, R #122, R #123, R #124, R #130 and R #131) residents reviewed for comprehensive care plans (plan that has measurable goals and timeframes to meet a resident's medical, nursing, mental health and psychosocial needs). This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are: R #4 A. Record review of R #4's admission record no date revealed an admission date of 09/05/23. B. Record review of R #4's MDS Assessment revealed the Annual MDS Assessment was completed on 09/18/24. The MDS included R #4's personal preferences for activities. C. Record review of R #4's care plan dated 09/30/24 revealed staff did not document on the care plan R #4's personal preferences for activities. D. On 05/14/25 at 9:26 AM, during an interview with the Activities Director, she confirmed R #4's Annual MDS assessment dated [DATE] is accurate and reflects the resident's personal preferences, and R #4's care plan does not include personal preferences from the Annual MDS Assessment. R #9 E. On 05/12/25 at 2:08 PM, during an interview, R #9 stated, I'm a Jehovah's witness so I can't participate in all the activities, but I do some. F. Record review of R #9's admission record (no date) revealed an admission date of 09/16/2024. G. Record review of R #9's Activities Initial Review dated 09/17/24 revealed the following: 1. R #9 enjoys reading her spiritual books. 2. R #9 is a Jehovah Witness (Christian based religious movement known for their distinct beliefs and practices) 3. R #9 is looking forward to visit from her church group. H. Record review of R #9's admission MDS assessment completed (signed by the RN/MDS Coordinator) on 10/01/24, revealed the following. 1. Section F - Preferences for Customary Routine and Activities. a. Question F0500, interview for activity preferences. How important is it to you to participate in religious services or practices? staff documented 1, very important I. Record review of R #9's care plan, initiated on 09/23/24, revealed staff did not document the following: 1. R #9's religion to include information on her distinct beliefs and practices. 2. Religious services and practices are very important to R #9. J. On 05/19/25 at 2:49 PM, during an interview, the MDS Coordinator confirmed the following: 1. Per documentation of the Activities Review and MDS Activities section R #9 did inform facility staff regarding the importance of her religion and religious practices. 2. R #9's care plan did not include her religion and religious preference or what specific activities R #9 could and could not participate in. 3. R #9's religious information should be included in her comprehensive care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to keep residents free from accidents for 1 (R #118) of 3 (R #11, R #118, and R #119) resident reviewed for accidents, when staff failed to ensure that ordered fall mats were in place when R #118 was in bed. This deficient practice could likely result in residents getting injured if they fall from their bed. The findings are: A. Record review of R #118's admission documents, no date, revealed the following: 1. R #118 was admitted to the facility on [DATE]. 2. R #118 had the following diagnoses: a. History of falling. b. Dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities). B. On 05/12/25 at 3:47 PM during an interview with R #118's family member (FM) #1 the following was revealed: 1. R #118 fell approximately four weeks prior to the interview (FM #1 was unsure of the date). 2. R #118 tried to get out of bed on her own. 3. The facility placed a fall mat and R #118's bed in lowest position when she is in bed after the fall. C. Record review of R #118's physician's order, dated 03/15/25, for a fall mat and bed to be in lowest position when R #118 is in bed. D. On 05/12/25 at 2:15 PM during observation of R #118 in her room, revealed the following: 1. R #118 laid in her bed. 2. The bed was at the lowest position with the head elevated. 3. A fall mat was folded up next to R #118's bathroom. 4. A fall mat was not next to R #118's bed. E. On 05/13/25 at 2:25 PM during observation of R #118 in her room, revealed the following: 1. R #118 laid in her bed. 2. The bed was at the lowest position with the head elevated. 3. A fall mat was folded up next to R #118's bathroom. 4. A fall mat was not next to R #118's bed. F. On 05/13/25 at 2:33 PM during an observation of R 118's room and interview with LPN #16, the following was confirmed: 1. She confirmed that R #118 was in bed and her fall mat was not next to the bed. 2. R #118's fall mat was supposed to be next to her bed when R #118 was in bed. G. On 05/13/25 at 2:35 PM during an interview, the DON confirmed the following: 1. R #118 had a history of falls. 2. R #118 had an order to have a fall mat next to her bed when she was in bed. 3. Staff were expected to put R #118's fall mat next to her bed when she was in bed.

Based on record review and interview, the facility failed to provide abuse, neglect, and exploitation training to 1 staff (RN #24) of 5 (RN #24, LPN #25, CNA #26, RN #27 and CNA #28) staff sampled for training. This deficient practice could likely result in staff not knowing who, what, and when to report abuse, neglect, and exploitation. The findings are: A. Record review of RN #24's training transcript, no date, revealed that abuse, neglect, and exploitation training was last completed 12/31/23. B. On 05/19/25 at 2:48 PM, during an interview, the Human Resource Manager (HRM) confirmed that RN #24 did not complete the required training since 2023. The HRM confirmed that the training should be completed annually.

Recite from 05/22/24 Based on record review and interview, the facility failed to provide behavioral health training (training that helps staff recognize and respond to various behavioral and mental health issues that residents may present with) for 1 (CNA #26) of 5 (RN #24, LPN #25, CNA #26, RN #27 and CNA # 28) staff sampled for training. This deficient practice could likely result in residents not receiving the services necessary to attain or maintain their physical, mental, and psychosocial (involving both psychological and social aspects) well-being. The findings are: A. Record review of the staff training records revealed CNA #26 did not complete training for behavioral health needs. B. On 05/19/25 at 2:48 PM, during an interview, the Human Resource Manager (HRM) confirmed that CNA #26 did not complete the training for the year 2025. The HRM confirmed that the training should be completed annually.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the provider of abnormal vital signs (blood pressure and heart rate outside of set parameters) for 1 (R #1) of 7 (R #1, R #9, R #10, R #11, R #118, R #119, and R #130) residents reviewed for unnecessary medications, when staff failed to notify the provider that R #1's blood pressure was high and R #1's pulse was low. This deficient practice could likely result in residents not receiving necessary care or worsening medical conditions due to lack of or changes in treatment. The findings are: A. Record review of R #1's admission record (no date) revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 had a diagnosis of essential (primary) hypertension (common form of high blood pressure that does not have a known secondary cause and is influenced by various lifestyle and genetic factors). B. Record review of R #1's physician orders revealed the following: 1. Amlodipine (high blood pressure primarily used to treat high blood pressure and chest pain by relaxing blood vessels which lowers blood pressure and decreases the hears workload) tablet 10 mg, give 1 tablet by mouth in the morning for high blood pressure (HTN; hypertension medical term for high blood pressure) hold (do not give medication) and call doctor if systolic blood pressure (SBP, top number of blood pressure reading ) is less than 100, diastolic blood pressure (DBP, bottom number of blood pressure reading) is less than 50 and/or pulse (heart rate, beats per minute) is less than 50. Administer (give medication) and call doctor if SBP is greater than 180, DBP is greater than 100 and/or Pulse is greater than 100. C. Record review of R #1's Medication Administration Record (MAR; a form used to document medication administration), dated April 2025, revealed staff documented the following: 1. On 04/01/25 staff documented bp 195/63 and administered amlodipine. 2. On 04/05/25 staff documented bp 181/64 and administered amlodipine. 3. On 04/08/25 staff documented pulse 47 and administered amlodipine. 4. On 04/08/25 staff documented pulse 43 and administered amlodipine. 5. On 04/09/25 staff documented bp 184/81 and administered amlodipine. 6. On 04/12/25 staff documented bp 189/78 and administered amlodipine. D. Record review of R #1's MAR dated May 2025, revealed staff documented the following: 1. On 05/04/25 staff documented bp 190/82 and administered amlodipine. 2. On 05/05/25 staff documented bp 198/74 and administered amlodipine. 3. On 05/06/25 staff documented bp 189/73 and administered amlodipine. 4. On 05/07/25 staff documented bp 185/76 and administered amlodipine. 5. On 05/10/25 staff documented bp 185/79 and administered amlodipine. 6. On 05/11/25 staff documented bp 217/92 and administered amlodipine. 7. On 05/13/25 staff documented bp 185/79 and administered amlodipine. 8. On 05/14/25 staff documented bp 182/70 and administered amlodipine. 9. On 05/15/25 staff documented bp 215/74 and administered amlodipine. E. Record review of R #1's progress notes for March and April 2025, revealed staff did not notify the physician of R #1's elevated blood pressure (SBP higher than 180) or low pulse (heart rate less than 50). F. On 05/19/25 at 3:19 PM, during an interview, the DON confirmed the following: 1. R #1's blood pressure was elevated, and her pulse was low. 2. R #1's order indicated that staff are to call physician when blood pressure is greater than 180 and heart rate is less than 50. 3. Facility staff did not call the physician as indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception. They are used to treat a variety of conditions including anxiety, depression, bipolar disorder, and schizophrenia) unless the medication was medically necessary for 6 (R #9, R #10, R #11, R #118, R #119, and R #130) of 7 (R #1, R #9, R #10, R #11, R #118, R #119, and R #130) residents reviewed for unnecessary medications, when staff failed to: 1. Psychotropic medications for R #118 and R #119 were prescribed to treat a specific psychiatric diagnosis (mental illness, symptoms or condition that greatly disturbs your thinking, moods, and/or behavior). 2. Psychotropic medications that were ordered to be given as needed (PRN) for R #119 were not prescribed for longer than 14 days without a rationale from the provider for why the medication was needed for longer than 14 days. 3. Carry out a gradual dose reduction (GDR; stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued). 4. R #130 received psychotropic medications causing excessive sedation (state of calm or sleep induced by the administration of medication). These deficient practices could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: Diagnosis and PRN Orders R #118 A. Record review of R #118's admission record, no date, revealed R #118 was admitted to the facility on [DATE]. B. Record review of R #118's physician's orders revealed an order dated 04/03/25 for hydroxyzine (medication that can be used to treat anxiety) 25 mg at bedtime for restlessness or anxiety. C. Record review of R #118's MAR, dated 05/01/25 through 05/12/25, revealed the following: 1. On 05/01/25, R #118 received hydroxyzine 25 mg in the evening. 2. On 05/02/25, R #118 received hydroxyzine 25 mg in the evening. 3. On 05/03/25, R #118 refused hydroxyzine 25 in the evening. 4. On 05/04/25, R #118 refused hydroxyzine 25 mg in the evening. 5. On 05/05/25, R #118 received hydroxyzine 25 mg in the evening. 6. On 05/06/25, R #118 received hydroxyzine 25 mg in the evening. 7. On 05/07/25, R #118 received hydroxyzine 25 mg in the evening. 8. On 05/08/25, R #118 received hydroxyzine 25 mg in the evening. 9. On 05/09/25, R #118 received hydroxyzine 25 mg in the evening. 10. On 05/10/25, R #118 received hydroxyzine 25 mg in the evening. 11. On 05/11/25, R #118 received hydroxyzine 25 mg in the evening. 12. On 05/12/25, R #118 refused hydroxyzine 25 mg in the evening. D. Record review of R #118's entire medical record, no date, revealed R #118 did not have a diagnosis of anxiety. E. On 05/19/25 at 2:16 PM, during an interview, the DON confirmed the following: 1. R #118 had an order for hydroxyzine for restlessness or anxiety. 2. R #118 did not have a diagnosis of anxiety. 3. Staff are expected to ensure that medications are ordered to treat a diagnosed condition. R #119 F. Record review of R #119's admission record, no date, revealed the following: 1. R #119 was admitted to the facility on [DATE]. 2. R #119 did not have a psychiatric diagnosis. G. Record review of R #119's physician's orders revealed an order dated 04/29/25, for trazadone (antidepressant medication) 25 mg as needed (PRN) for sleep related to systolic (congestive) heart failure (CHF, occurs when the heart's left ventricle cannot contract effectively, leading to insufficient blood being pumped to the body), ordered for indefinite time period (no end date). H. Record review of R #119's MAR's, dated April and May 2025, revealed that R #119 received PRN trazadone on 05/07/25 at 9:34 PM. I. Record review of R #119's entire medical record, no date, revealed the provider did not document a rationale for why R #119 needed to have a PRN order for trazadone for longer than 14 days. J. On 05/19/25 at 2:12 PM, during an interview, the DON confirmed the following: 1. R #119 had an order for trazadone for sleep related to CHF. 2. R #119 did not have a psychiatric diagnosis for the use of trazadone. 3. R #119's PRN order for trazadone was ordered indefinitely. 4. Staff are expected to ensure there is a psychiatric diagnosis for the psychotropic medications that are ordered. 5. PRN psychotropic medications are not supposed to be ordered for longer than 14 days without a rationale for why it is needed. Gradual Dose Reduction R #9 K. Record review of R #9's admission record, no date revealed the following: 1. R #9 was admitted to the facility on [DATE]. 2. R #9 had a diagnosis of Anxiety disorder (mental health condition characterized by excessive fear, worry, and anxiety that interfere with daily life). L. Record review of R #9's physician's orders revealed an order for sertraline tablet (antidepressant medication used to treat anxiety and depression disorders) give 50 mg by mouth one time a day for anxiety. Start date: 09/16/24. M. Record review of R #9's MAR, dated 05/01/25 through 05/19/25, revealed the following: 1. On 05/01/25, R #9 received sertraline 50 mg in the morning. 2. On 05/02/25, R #9 received sertraline 50 mg in the morning. 3. On 05/03/25, R #9 received sertraline 50 mg in the morning 4. On 05/04/25, R #9 received sertraline 50 mg in the morning. 5. On 05/05/25, R #9 received sertraline 50 mg in the morning. 6. On 05/06/25, R #9 received sertraline 50 mg in the morning. 7. On 05/07/25, R #9 received sertraline 50 mg in the morning. 8. On 05/08/25, R #9 received sertraline 50 mg in the morning. 9. On 05/09/25, R #9 received sertraline 50 mg in the morning. 10. On 05/10/25, R #9 received sertraline 50 mg in the morning. 11. On 05/11/25, R #9 received sertraline 50 mg in the morning. 12. On 05/12/25, R #9 received sertraline 50 mg in the morning. 13. On 05/13/25, R #9 received sertraline 50 mg in the morning. 14. On 05/14/25, R #9 received sertraline 50 mg in the morning. 15. On 05/15/25, R #9 received sertraline 50 mg in the morning. 16. On 05/16/25, R #9 received sertraline 50 mg in the morning. 17. On 05/17/25, R #9 received sertraline 50 mg in the morning. 18. On 05/18/25, R #9 received sertraline 50 mg in the morning. 19. On 05/19/25, R #9 received sertraline 50 mg in the morning. N. Record review of R #9's Note to attending physician/prescriber (form that documents pharmacist recommendation regarding residents' medication(s)) to the physician/prescriber dated 03/03/25, revealed the following: 1. R #9 has been taking the antidepressant sertraline 50 mg once daily for anxiety since 09/17/24. Please evaluate the current dose and consider a dose reduction (GDR). 2. The form had Resident with good response, maintain the current dose and Disagree marked. 3. The medical director (clinician who oversees and guides the care provider to nursing home residents) did not provide rationale with patient specific information as to why R #10 needed to remain on the medication. 4. The form was signed by the medical director and dated 03/23/25. O. On 05/19/25 at 3:50 PM during an interview, the DON confirmed the following: 1. R #9 has not had a GDR for sertraline. 2. The medical director did not provide a rationale for not performing a GDR for R #9's sertraline. R #10 P. Record review of R #10's admission record, no date, revealed the following: 1. R #10 was admitted to the facility on [DATE]. 2. R #10 had the following psychiatric diagnoses: a. Depression (mood disorder that causes a persistent feeling of sadness and loss of interest). b. Restlessness and agitation (feelings of irritability, nervousness and mental distress). Q. Record review of R #10's physician's orders, multiple dates, revealed the following: 1. Order dated 04/11/24 and discontinued 11/26/24, for sertraline tablet (antidepressant medication used to treat anxiety and depression disorders) 50 mg, give 1 tablet by mouth in the morning related to depression. 2. Order dated 11/27/24 for sertraline tablet 50 mg, give 1 tablet by mouth in the morning for depression as evidenced by sadness. 3. Order dated 04/08/24 and discontinued 11/26/24, for trazodone tablet give 50 mg by mouth at bedtime for insomnia (common sleep disorder that makes it hard to fall asleep or stay asleep). 4. Order dated 11/27/24 for trazodone tablet give 50 mg by mouth at bedtime for insomnia. 5. Order dated 06/09/24 and discontinued 11/26/24, for escitalopram tablet (antidepressant medication used to treat anxiety and depression disorders) 10 mg, give 2 tablets by mouth in the morning for depression. 6. Order dated 11/27/24 for escitalopram tablet 10 mg, give 2 tablets by mouth in the morning for depression as evidenced by social isolation. 7. Order dated 04/22/24 and discontinued 11/26/24, hydroxyzine tablet (prescription-only antihistamine [medication with sedating and calming effect] that is used to treat anxiety) 10 mg, give 1 tablet by mouth two times a day for anxiety related to restlessness and agitation. 8. Order dated 11/27/24 hydroxyzine tablet 10 mg, give 1 tablet by mouth two times a day for anxiety as evidenced by restlessness and agitation. R. Record review of R #10's MAR, dated 05/01/25 through 05/19/25, revealed the following: Sertraline 1. On 05/01/25, R #10 received sertraline 50 mg in the morning. 2. On 05/02/25, R #10 received sertraline 50 mg in the morning. 3. On 05/03/25, R #10 received sertraline 50 mg in the morning 4. On 05/04/25, R #10 received sertraline 50 mg in the morning. 5. On 05/05/25, R #10 received sertraline 50 mg in the morning. 6. On 05/06/25, R #10 received sertraline 50 mg in the morning. 7. On 05/07/25, R #10 received sertraline 50 mg in the morning. 8. On 05/08/25, R #10 received sertraline 50 mg in the morning. 9. On 05/09/25, R #10 received sertraline 50 mg in the morning. 10. On 05/10/25, R #10 received sertraline 50 mg in the morning. 11. On 05/11/25, R #10 received sertraline 50 mg in the morning. 12. On 05/12/25, R #10 received sertraline 50 mg in the morning. 13. On 05/13/25 R #10 received sertraline 50 mg in the morning. 14. On 05/14/25, R #10 received sertraline 50 mg in the morning. 15. On 05/15/25, R #10 received sertraline 50 mg in the morning. 16. On 05/16/25, R #10 received sertraline 50 mg in the morning. 17. On 05/17/25, R #10 received sertraline 50 mg in the morning. 18. On 05/18/25, R #10 received sertraline 50 mg in the morning. 19. On 05/19/25, R #10 received sertraline 50 mg in the morning. Trazodone 20. On 05/01/25, R #10 received trazodone 50 mg in the evening. 21. On 05/02/25, R #10 received trazodone 50 mg in the evening. 22. On 05/03/25, R #10 received trazodone 50 mg in the evening. 23. On 05/04/25, R #10 received trazodone 50 mg in the evening. 24. On 05/04/25, R #10 received trazodone 50 mg in the evening. 25. On 05/06/25, R #10 received trazodone 50 mg in the evening. 26. On 05/07/25, R #10 received trazodone 50 mg in the evening. 27. On 05/08/25, R #10 received trazodone 50 mg in the evening. 28. On 05/09/25, R #10 received trazodone 50 mg in the evening. 29. On 05/10/25, R #10 received trazodone 50 mg in the evening. . 30. On 05/11/25, R #10 received trazodone 50 mg in the evening. 31. On 05/12/25 R #10 received trazodone 50 mg in the evening. 32. On 05/13/25, R #10 received trazodone 50 mg in the evening. 33. On 05/14/25, R #10 received trazodone 50 mg in the evening. 34. On 05/15/25, R #10 received trazodone 50 mg in the evening. 35. On 05/16/25, R #10 received trazodone 50 mg in the evening. 36. On 05/17/25, R #10 received trazodone 50 mg in the evening. 37. On 05/18/25, R #10 received trazodone 50 mg in the evening. Escitalopram 38. On 05/01/25, R #10 received escitalopram 20 mg in the morning. 39. On 05/02/25, R #10 received escitalopram 20 mg in the morning. 40. On 05/03/25, R #10 received escitalopram 20 mg in the morning. 41. On 05/04/25, R #10 received escitalopram 20 mg in the morning. 42. On 05/05/25, R #10 received escitalopram 20 mg in the morning. 43. On 05/06/25, R #10 received escitalopram 20 mg in the morning. 44. On 05/07/25, R #10 received escitalopram 20 mg in the morning. 45. On 05/08/25, R #10 received escitalopram 20 mg in the morning. 46. On 05/09/25, R #10 received escitalopram 20 mg in the morning. 47. On 05/10/25, R #10 received escitalopram 20 mg in the morning. 48. On 05/11/25, R #10 received escitalopram 20 mg in the morning. 49. On 05/12/25, R #10 received escitalopram 20 mg in the morning. 50. On 05/13/25 R #10 received escitalopram 20 mg in the morning. 51. On 05/14/25, R #10 received escitalopram 20 mg in the morning. 52. On 05/15/25, R #10 received escitalopram 20 mg in the morning. 53. On 05/16/25, R #10 received escitalopram 20 mg in the morning. 54. On 05/17/25, R #10 received escitalopram 20 mg in the morning. 55. On 05/18/25, R #10 received escitalopram 20 mg in the morning. 56. On 05/19/25, R #10 received escitalopram 20 mg in the morning. Hydroxyzine 57. On 05/01/25, R #10 received hydroxyzine 10 mg twice daily. 58. On 05/02/25, R #10 received hydroxyzine 10 mg twice daily. 59. On 05/03/25, R #10 received hydroxyzine 10 mg twice daily. 60. On 05/04/25, R #10 received hydroxyzine 10 mg twice daily. 61. On 05/05/25, R #10 received hydroxyzine 10 mg twice daily. 62. On 05/06/25, R #10 received hydroxyzine 10 mg twice daily. 63. On 05/07/25, R #10 received hydroxyzine 10 mg twice daily. 64. On 05/08/25, R #10 received hydroxyzine 10 mg twice daily. 65. On 05/09/25, R #10 received hydroxyzine 10 mg twice daily. 66. On 05/10/25, R #10 received hydroxyzine 10 mg twice daily. 67. On 05/11/25, R #10 received hydroxyzine 10 mg twice daily. 68. On 05/12/25, R #10 received hydroxyzine 10 mg twice daily. 69. On 05/13/25, R #10 received hydroxyzine 10 mg twice daily. 70. On 05/14/25, R #10 received hydroxyzine 10 mg twice daily. 71. On 05/15/25, R #10 received hydroxyzine 10 mg twice daily. 72. On 05/16/25, R #10 received hydroxyzine 10 mg twice daily. 73. On 05/17/25, R #10 received hydroxyzine 10 mg twice daily. 74. On 05/18/25, R #10 received hydroxyzine 10 mg twice daily. S. Record review of R #10's Recommendation Summary for DON and medical director dated 02/03/25, revealed the following: 1. R #10 has a history of chronic depression and has been receiving the current dose sertraline 50 mg every morning since 04/11/24, trazodone 50 mg at bedtime since 04/08/24, and escitalopram 20 mg every morning since 06/09/24 2. Federal guidelines require assessment of medication therapy showing benefit to risk for continuing therapy and periodic dose reduction trials when medications may no longer be necessary. Please check the appropriate response and add additional information as requested. 3. The form had Patient has had good response to treatment and requires this dose for condition stability. Dose reduction is contraindicated because benefits outweigh risks for this patient at this time and a reduction is likely to impair the residents function and or cause psychiatric instability. Please elaborate with patient specific information marked. 4. The medical director did not provide rationale with patient specific information as to why R #10 needed to remain on the medications. 5. The form was signed by the medial director and dated 03/23/25. T. Record review of R #10's Note to attending physician/prescriber dated 04/01/25, revealed the following: 1. R #10 has been taking the anxiolytic (class of medications used to prevent or treat anxiety symptoms or disorders) hydroxyzine 10 mg twice daily for anxiety since 04/22/24. Please evaluate the current dose and consider a dose reduction. 2. The form had Resident with good response, maintain the current dose marked. 3. The medical director did not provide rationale with patient specific information as to why R #10 needed to remain on the same dose of hydroxyzine. 4. The form was signed by the medical director and dated 04/03/25. U. On 05/19/25 at 3:57 PM, during an interview, the DON confirmed the following: 1. R #10 has not had a GDR for sertraline, trazodone, escitalopram, and hydroxyzine. 2. The medical director did not provide a rationale for not performing GDR's for R #10's medications. R #11 V. Record review of R #11's admission record, no date, revealed the following: 1. R #11 was admitted to the facility on [DATE]. 2. R #11 had the following psychiatric diagnoses: a. Major Depressive Disorder (MDD, mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) b. Panic disorder [Episodic Paroxysmal Anxiety] (mental and behavioral disorder, specifically an anxiety disorder characterized by recurring unexpected panic attacks). c. Psychotic Disorder with Hallucinations due to known physiological condition (a condition when people lose some contact with reality. This might involve seeing or hearing things that other people cannot see or hear (hallucinations) and believing things that are not actually true (delusions)). d. Insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep). W. Record review of R #11's physician's orders, multiple dates, revealed the following: 1. Order dated 04/29/24 and discontinued 11/26/24, for buspirone (medication that can treat anxiety) 5 mg tablet, one tablet twice a day for anxiety. 2. Order dated 11/26/24, for buspirone 5 mg tablet, one tablet twice a day for anxiety. 3. Order dated 09/29/23 and discontinued 11/26/24, for lorazepam 0.5 mg tablet, one tablet twice a day for anxiety. 4. Order dated 11/26/24, for lorazepam (medication that can treat anxiety) 0.5 mg tablet, one tablet twice a day for anxiety. 5. Order dated 07/07/23 and discontinued 10/01/23, for trazadone 50 mg, one tablet in the evening for insomnia. 6. Order dated 10/01/23 and discontinued 11/26/24, for trazadone 50 mg, one tablet in the evening for depression, MDD, insomnia. 7. Order dated 11/26/24, for trazadone 50 mg tablet, one tablet in the evening for depression, MDD, insomnia. 8. Order dated 08/03/23 and discontinued 11/26/24, for mirtazapine 7.5 mg, give ½ of 15 mg tablet in the evening for depression. 9. Order dated 11/26/24, for mirtazapine 7.5 mg, give ½ of 15 mg tablet in the evening for depression. 10. Order dated 06/30/23, for Nuplazid 34 mg, give one capsule at bedtime for hallucinations related to Parkinson's disease (psychotic disorder with hallucinations due to known physiological condition). X. Record review of R #11's MAR, dated May 2025, revealed the following: 1. R #11 received Lorazepam 0.5 mg twice a day as ordered. 2. R #11 received buspirone 5 mg twice a day as ordered. 3. R #11 received trazadone 50 mg in the evening as ordered. 4. R #11 received mirtazapine 7.5 mg in the evening as ordered. 5. R #11 received Nuplazid 34 mg in the evening as ordered. Y. Record review of of the Psychotropic & Sedative/Hypnotic Utilization By Resident report (pharmacist spreadsheet that includes information about the use of psychotropic, sedative, and hypnotic medications), dated 05/02/25, revealed the following: 1. R #11 had an order for buspirone 5 mg twice a day since 04/29/24, and a GDR was declined in February 2025. 2. R #11 had an order for lorazepam 0.5 mg twice a day since 09/29/23, and a GDR was declined in September 2024. 3. R #11 had an order for mirtazapine (antidepressant medication) 7.5 mg in the evening for depression since 08/03/23, and a GDR was declined in September 2024. 4. R #11 had an order for Nuplazid 34 mg at bedtime since 06/30/23, and a GDR was recommended in April 2025. 5. R #11 had an order for trazadone 50 mg at bedtime since 10/01/23, and a GDR was declined in October 2024. Z. Record review of R #11's pharmacist recommendation, dated 08/03/24, revealed the following: 1. R #11 has a history of chronic depression and has been receiving the current dose of mirtazapine 7.5 mg in the evening for depression since 08/03/23. Federal guidelines require assessment of medication therapy showing benefit to risk for continuing therapy and periodic dose reduction trials when medications may no longer be necessary. Please check the appropriate response and add additional information as requested: 2. The form had Patient has had a good response to treatment and requires this dose for condition stability. Dose reduction is contraindicated because benefits outweigh risks for this patient at this time and a reduction is likely to impair the resident's function and/or cause psychiatric instability. (Please elaborate with patient specific information) selected. 3. The form had agree selected with a provider signature and date of 09/15/24. 4. R #11's physician did not provide rationale with patient specific information as to why resident needed to remain on medication. AA. Record review of R #11's pharmacist recommendation, dated 09/03/24, revealed the following: 1. R #11 has been taking the anxiolytic lorazepam 0.5 mg twice daily since 09/28/23. Please evaluate the current dose and consider a dose reduction. 2. The form had agree selected with a signature and date of 09/09/24. 3. The form had a note dated 09/16/24, verbal order to continue med. Per order by [Doctor Name]. 4. R #11's physician did not provide rationale with patient specific information as to why resident needed to remain on medication. BB. Record review of R #11's pharmacist recommendation, dated 10/04/24, revealed the following: 1. R #11 has a history of chronic depression and h

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide the required discharge or transfer information to the resident and the resident's representative(s) in writing for 3 (R #8, R #11, and R #119) of 3 (R #8, R #11, and R #119) residents sampled for hospitalizations or discharge when staff failed to: 1. Notify the resident and the resident's representative of the plan to discharge the resident from the facility in writing and in a language and manner they understand for R #8. 2. Complete a discharge summary for R #8 that included the following: a. A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. b. A final summary of the resident's status including an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions, to ensure that care is coordinated and the resident transitions safely from one setting to another. c. A reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter) 3. Notify the residents and resident's representative(s) of the resident's transfer to the hospital in writing and in a language and manner they understand for R #11 and R #119. 4. Ensure the transfer or discharge notice for R #8, R #11, and R #119 included: a. A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. b. The name, phone number, and address (mailing and email) of the Office of the State Long-Term Care Ombudsman. 5. Send a written copy of the Discharge or Transfer Notices to the Ombudsman for R #8, R #11, and R #119. 6. Ensure R #119 or his representative received a written notice of the bed hold policy which indicated the duration the bed would be held. These deficient practices could likely result in the resident and/or their representative not knowing the reason for a transfer or discharge, the location of the transfer or discharge their rights to advocate and make informed decisions regarding the resident's healthcare, the services that the resident received while at the facility, the resident's current health status, or the resident's current medications leading to adverse outcomes for the resident. The findings are: Discharge Notices R #8 A. Record review of R #8's medical record, no date, revealed the following: 1. R #8 was admitted to the facility on [DATE]. 2. R #8 was discharged from the facility on 03/14/25. B. Record review of R #8's progress note, dated 03/14/25, revealed the following: 1. R #8 was discharged home with family. 2. R #8 was given her medications and copies of her paperwork. 3. R #8 and her family were educated on how to take her medications and what they were for. 4. R #8's vital signs were normal and she had no pain. C. Record review of R #8's entire medical record, no date, revealed staff did not document the following: 1. A discharge notice for R #8's discharge from the facility on 03/14/25. 2. A discharge summary for R #8. D. On 05/15/25 at 2:40 PM, during an interview, RN #16 stated the following regarding discharging residents: 1. They complete an assessment on the resident. 2. She stated they do not complete a discharge summary or a recapitulation of the resident's stay. 3. The nurses educate the resident and their family about medications that the resident was taking in the facility and give them a printout of facility medications. 4. They educate the resident and family about any upcoming appointments. E. On 05/15/25 at 3:14 PM, during an interview, the Ombudsman stated that she did not receive a discharge notice for R #8's discharge on [DATE]. F. On 05/19/25 at 2:27 PM, during an interview, the DON confirmed the following: 1. R #8 discharged to her home on 3/14/25. 2. R #8's medical record did not contain documentation of discharge summary, discharge notification, recapitulation of stay, or medication reconciliation. 3. The facility did not send a written copy of a discharge notification for R #8 to the Ombudsman. Transfer and Behold Notices R #11 G. Record review of R #11's medical record revealed the following: 1. On 04/16/25, R #11 was sent to the hospital after a fall. 2. The medical record did not contain a written transfer notice for R #11's transfer to the hospital on [DATE]. R #119 H. Record review of R #119's medical record revealed the following: 1. On 05/08/25, R #119 was sent to the hospital after a fall. 2. The medical record did not contain a written transfer notification for R #119's transfer to the hospital on [DATE]. 3. The medical record did not contain a written bed hold notification for R #119's transfer to the hospital on [DATE]. I. On 05/16/25 at 10:34 AM, during an interview, the Business Office Manager (BOM), stated the following: 1. She does not complete transfer notices. 2. She is responsible for completing bed hold notifications for residents. 3. She did not complete a bed hold notification for R #119's transfer to the hospital on [DATE]. J. On 05/16/25 at 10:58 AM, during an interview, the DON confirmed the following: 1. Staff were not completing written transfer or discharge notices when residents transfer or discharge from the facility. 2. Staff were not providing a copy of written transfer or discharge notices to the ombudsman. 3. The BOM is expected to complete bed hold notifications when residents are transferred to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set Assessment were accurate for 3 (R #9, R #118 and R #121) of 9 (R #1, R #4, R #9, R #10, R #118, R #119, R #121, R #130 and R #131) residents reviewed for accurate MDS assessments. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are: R #9 A. Record review of R #9's admission record revealed R #9 was admitted on [DATE]. B. Record review of R #9's physician's orders revealed an order for Smaglutide (non-insulin medication used to help improve blood sugar control) subcutaneous (fatty tissue layer just beneath the skin) solution, inject 1 mg every Sunday for diabetes mellitus type 2 (DM 2; chronic disease characterized by high levels of sugar in the blood). Start date: 12/08/24. C. Record review of R #9's Quarterly MDS dated [DATE] revealed the following: 1. Section N0350, Insulin (hormone that helps lower blood sugar levels) a. Staff documented R #9 received 1 insulin injection in the last 7 days. D. Record review of R #9's MAR for March 2025 revealed the following: 1. R #9 received semaglutide injection on 03/09/25 2. R #9 did not receive any insulin injections. E. On 05/19/25 at 2:27 PM, during an interview, the MDS Coordinator confirmed that R #9 did receive semaglutide injection but did not receive any insulin injections. The MDS coordinator confirmed that R #9's Quarterly MDS was not accurate because R #9 did not receive any insulin injections. R #118 F. Record review of R #118's admission documents revealed the following: 1. R #118 was admitted to the facility on [DATE]. 2. R #118 had a diagnosis of muscle weakness. G. Record review of R #118's physician's order, dated 12/06/24, revealed R #118 had an order for Restorative Nursing Program (RNP), for bilateral (right and left side) arm and leg strengthening exercises once a day five days a week as tolerated. H. Record review of R #118's quarterly MDS assessment, dated 02/19/25, revealed staff documented the following: 1. Section O- Special Treatments, Procedures, and Programs. O0500. Restorative Nursing Programs Record the number of days each of the following restorative programs was performed for at least 15 minutes a day) in the last 7 calendar days (enter 0 if none or less than 15 minutes daily): a. Range of Motion (passive)- 0 bragged of Motion (active)- 0 c. Splint of brace assistance- 0 I. Record review of R #118's survey documentation report (report that includes documentation regarding activities of daily living, RNP, and other care areas provided for residents), dated February 2025, revealed R #118 received active range of motion (AROM, resident moves joints on their own) and passive range of motion (PROM, resident receives assistance with moving joints) as follows: 1. 02/01/25, 5 minutes of AROM and 5 minutes of PROM. 2. 02/02/25, 5 minutes of AROM and 5 minutes of PROM. 3. 02/03/25, 10 minutes of AROM and 10 minutes of PROM. 4. 02/04/25, 10 minutes of AROM and 10 minutes of PROM. 5. 02/05/25, 15 minutes of AROM and 15 minutes of PROM. 6. 02/06/25, 15 minutes of AROM and 15 minutes of PROM. 7. 02/07/25, 10 minutes of AROM and 10 minutes of PROM. 8. 02/08/25, 5 minutes of AROM and 5 minutes of PROM. 9. 02/09/25, 5 minutes of AROM and 5 minutes of PROM. 10. 02/10/25, 5 minutes of AROM and 5 minutes of PROM. 11. 02/11/25, 15 minutes of AROM and 15 minutes of PROM. 12. 02/12/25, 15 minutes of AROM and 15 minutes of PROM. 13. 02/13/25, 0 minutes of AROM and 15 minutes of PROM. 14. 02/14/25, 5 minutes of AROM and 5 minutes of PROM. 15. 02/17/25, 15 minutes of AROM and 15 minutes of PROM. 16. 02/18/25, 15 minutes of AROM and 15 minutes of PROM. 17. 02/19/25, 5 minutes of AROM and 5 minutes of PROM. J. On 05/19/25 at 12:50 PM, during an interview, the MDS coordinator confirmed the following: 1. R #118 had received RNP services within the 7 days prior to the MDS assessment. 2. R #118's quarterly MDS, dated [DATE], showed that R #119 did not receive RNP services during the 7 days prior to the MDS assessment. 3. She should have included R #118's RNP services on the MDS assessment. R #121 K. Record review of R #121's admission documents revealed the following: 1. R #121 was admitted to the facility on [DATE]. 2. R #121 had a diagnosis of cellulitis (a common and potentially serious bacterial skin infection) of unspecified toe. L. Record review of R #121's skin assessment, dated 04/16/25, revealed the following: 1. R #121 had an open blister on her lower left leg. 2. R #121 had newly diagnosed cellulitis and was taking antibiotics. 3. R #121 had wound care orders. 4. R #121 did not have any pressure wounds. M. Record review of R #121's physician's orders, dated 04/16/25, revealed an order for wound care to left lower leg blister every day and as needed until healed. N. Record review of R #121's quarterly MDS assessment, dated 04/17/25, revealed Section M- Skin Conditions: M0300- Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage- B. Stage 2 Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister, staff documented that R #121 had one stage 2 pressure ulcer. O. On 05/19/25 at 12:39 PM, during an interview, the MDS Coordinator confirmed the following: 1. R #121 did not have any pressure ulcers. 2. R #121's quarterly MDS, dated [DATE], indicated that R #121 had a stage 2 pressure ulcer. 3. R #121's quarterly MDS was inaccurate because she did not have a pressure wound.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Recite from 05/22/24 Based on record review and interview, the facility failed to ensure care plan revisions occurred for 4 (R #9, R #11, R #118, and R #130) of 6 (R #9, R #11, R #118, R #119, R #121, and R #130) residents when the staff failed to revise the care plan with the most current resident information. These deficient practices could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: R #9 A. Record review of R #9's admission Record (no date) revealed R #9 was admitted to the facility on [DATE]. B. Record review of R #9's CNA shower review forms dated 02/03/25 through 05/15/25 revealed the following: 1. R #9 was offered showers twenty-three times. 2. R #9 refused her showers eleven of the twenty-three times showers were offered to her. C. Record review of R #9's care plan dated 09/17/24 revealed the following: 1. R #9 requires partial/limited assistance with bathing/showering. 2. R #9's care plan was not revised to include residents refusal of showers and what actions staff could take to encourage her to shower. D. On 05/19/25 at 4:19 PM, during an interview, the MDS Coordinator confirmed that R #9's care plan was not revised to include her refusal of care (refusing to shower) and actions that staff could take to assist her to agree to shower. R #11 E. Record review of R #11's admission documents, no date, revealed the following: 1. R #11 was admitted to the facility on [DATE]. 2. R #11 had the following diagnoses: a. Lack of coordination. b. Muscle weakness. c. History of falling. F. Record review of R #16's progress note dated 04/16/25 revealed R #11 fell and was sent to the hospital. G. Record review of the facility's follow-up report, dated 04/18/24, revealed the facility implemented increased monitoring and redirection as interventions to prevent R #11 from falling again. H. Record review of R #11 care plan, revised 04/02/25, revealed staff did not revise R #11's care plan after she fell on [DATE]. I. On 05/19/25 at 2:31 PM, during an interview, the DON confirmed the following: 1. R #11 fell on [DATE]. 2. Close monitoring and redirection are interventions that are in place to prevent R #11 from falling. 3. R #11's care plan was not revised to include these interventions. 4. R #11's care plan should have been revised to include these interventions. R #118 J. Record review of R #118's admission documents, no date, revealed the following: 1. R #118 was admitted to the facility on [DATE]. 2. R #118 had the following diagnoses: a. History of falling. b. Dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities). K. On 05/12/25 at 3:47 PM, during an interview with R #118's family member (FM) #1 the following was revealed: 1. R #118 fell approximately four weeks prior to the interview (FM #1 was unsure of the date). 2. R #118 tried to get out of bed on her own. 3. The facility placed a fall mat and R #118's bed in lowest position when she is in bed. 4. The provider ordered hydroxyzine to be added to R #118's medications to help with anxiety. L. Record review of R #118's physician's orders, multiple dates, revealed the following: 1. An order dated 03/15/25, for a fall mat and bed to be in lowest position when R #118 is in bed. 2. An order dated 04/03/25, for hydroxyzine 25 mg at bedtime for anxiety and restlessness. M. Record review of R #118's care plan, revised 03/24/25, revealed the following: 1. R #118's care plan was not revised to include a fall mat next to her bed or the bed to be in lowest position when she is in bed. 2. R #118's care plan was not revised to include R #118's order for hydroxyzine for anxiety or restlessness. N. On 05/14/25 at 10:27 AM, during an interview, the DON confirmed the following: 1. R #118's care plan was not revised to include a fall mat next to R #118's bed and the bed to be in lowest position when she was in bed. 2. She confirmed that resident care plans are expected to be revised with any interventions in place to prevent them from falling. R #130 O. Record review of R #130's admission Record (no date) revealed R #130 was admitted to the facility on [DATE]. P. Record review of R #130's physician's orders revealed the following: 1. Alprazolam (generic for Xanax; medication primarily used to treat anxiety disorders and anxiety associated with depression) 0.25 mg, give 1 tablet by mouth three times daily for anxiety (mental health condition characterized by excessive fear, and worry that interfere with daily life) and restlessness (feelings of irritability, nervousness and mental distress). Start date 04/16/25. 2. Hydroxyzine tablet (prescription-only antihistamine [medication with sedating and calming effect] that is used to treat anxiety) 25 mg, give one tablet by mouth two times daily related to anxiety. Start date: 04/19/25. Q. Record review of R #130's care plan revised on 04/30/25 revealed the following: 1. R #130 uses anti-anxiety medications (Xanax) related to anxiety disorder. 2. R #130's care plan was not revised to include that R #130 also takes hydroxyzine for anxiety. R. On 05/19/25 at 2:20 PM, during an interview, the MDS Coordinator confirmed that R #130's care plan was not revised to include that R #130 also takes hydroxyzine for anxiety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to meet professional standards of practice (established guidelines and expectations that ensure the delivery of high-quality care to residents) for 2 (R #1 and R #121) of 2 (R #1 and R #121) residents reviewed for unnecessary medication use and wound care when staff failed to: 1. Notify the physician about R #1's elevated blood pressure as indicated on physician's order. 2. Obtain wound care orders prior to performing wound care on R #121's right leg. If the facility is not providing care per physician's orders and care that meets professional standards of practice, then residents are likely to experience adverse effects, worsening of their condition, and potential complications from not receiving the care ordered by the physician. The findings are: R #1 A. Record review of R #1's admission record (no date) revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 had a diagnosis of essential (primary) hypertension (common form of high blood pressure that does not have a known secondary cause and is influenced by various lifestyle and genetic factors). B. Record review of R #1's physician orders revealed an order for Amlodipine (high blood pressure primarily used to treat high blood pressure and chest pain by relaxing blood vessels which lowers blood pressure and decreases the hears workload) tablet 10 mg, give 1 tablet by mouth in the morning for high blood pressure (HTN; hypertension medical term for high blood pressure) hold (do not give medication) and call doctor if systolic blood pressure (SBP, top number of blood pressure reading ) is less than 100, diastolic blood pressure (DBP, bottom number of blood pressure reading) is less than 50 and/or pulse (heart rate, beats per minute) is less than 50. Administer (give medication) and call doctor if SBP is greater than 180, DBP is greater than 100 and/or Pulse is greater than 100. C. Record review of R #1's medication administration record (MAR; a form used to document medication administration), dated April 2025, revealed staff documented the following: 1. On 04/01/25 staff documented bp 195/63 and administered amlodipine. 2. On 04/05/25 staff documented bp 181/64 and administered amlodipine. 3. On 04/08/25 staff documented pulse 47 and administered amlodipine. 4. On 04/08/25 staff documented pulse 43 and administered amlodipine. 5. On 04/09/25 staff documented bp 184/81 and administered amlodipine. 6. On 04/12/25 staff documented bp 189/78 and administered amlodipine. D. Record review of R #1's MAR dated May 2025, revealed staff documented the following: 1. On 05/04/25 staff documented bp 190/82 and administered amlodipine. 2. On 05/05/25 staff documented bp 198/74 and administered amlodipine. 3. On 05/06/25 staff documented bp 189/73 and administered amlodipine. 4. On 05/07/25 staff documented bp 185/76 and administered amlodipine. 5. On 05/10/25 staff documented bp 185/79 and administered amlodipine. 6. On 05/11/25 staff documented bp 217/92 and administered amlodipine. 7. On 05/13/25 staff documented bp 185/79 and administered amlodipine. 8. On 05/14/25 staff documented bp 182/70 and administered amlodipine. 9. On 05/15/25 staff documented bp 215/74 and administered amlodipine. E. Record review of R #1's progress notes for March and April 2025, revealed staff did not document that they notified the physician of R #1's elevated blood pressure (SBP higher than 180) or low pulse (heart rate less than 50). F. On 05/19/25 at 3:19 PM, during an interview, the DON confirmed the following: 1. R #1's blood pressure was elevated, and her pulse was low. 2. R #1's order indicates that staff are to call physician when blood pressure is greater than 180 and heart rate is less than 50. 3. Facility staff did not call the physician as indicated on the order and staff are expected to follow the physician's order. R #121 G. Record review of R #121's admission record (no date) revealed the following: 1. R #121 was admitted to the facility on [DATE]. 2. R # 121 had a diagnosis of cellulitis (a common and potentially serious bacterial skin infection) of unspecified toe. H. On 05/12/25 at 2:18 PM, during an interview and observation of R #121, the following was revealed: 1. R #121 stated she had cellulitis in both legs. 2. Her right leg was worse than her left leg. 3. She stated that the nurses were performing wound care on both of her legs. 4. She had bandages to both legs. 5. She stated she was on antibiotics for the cellulitis. 6. The provider ordered for her to see the wound care specialist, but she didn't know the date of the scheduled appointment. I. Record review of R #121's physician orders, multiple dates, revealed the following: 1. An order dated 04/16/25, for dry dressing and kerlix (bandage roll that provides absorbency and aeration) wrap to left lower leg blister every day and as needed until healed. 2. R #121's medical record did not have orders for wound care for R #121's right leg. J. Record review of R #121's TAR for May 2025 revealed the following: 1. dry dressing and kerlix wrap to left lower leg blister every day and as needed until healed. 2. Staff documented treatment was administered as ordered. K. On 05/15/25 at 12:27 PM, during an interview with RN #17, the following was revealed: 1. R #121 has wounds on both of her legs. 2. R #121's right leg wounds were worse than her left. 3. She performed wound care on both of R #121's legs. 4. For wound care, she washed R #121's wounds with wound care solution or normal saline (a mixture of water and salt with a salt concentration of .9%). Then put a non-adhesive (non-stick) dressing over the wounds and wrapped with kerlix. 5. She confirmed that R #121 had wound care orders for her left leg. 6. She confirmed that R #121 did not have orders for wound care to her right leg. 7. She stated that R #121's wounds on both legs were healing. 8. She confirmed R #121 had an appointment scheduled with the wound care specialist on 05/19/25. L. On 05/19/25 at 2:24 PM, during an interview, the DON confirmed the following: 1. R #121 had cellulitis in both legs. 2. Staff were performing wound care on both of R #121's legs. 3. R #121 did not have physician's orders for wound care for R #121's right leg. 4. Staff were expected to get orders for wound care for R #121's right leg prior to performing wound care on the right leg.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide an ongoing activity program to support residents in their choice of activities designed to support their physical, mental, and psychosocial well-being for 1 (R #4) of 1 (R #4) resident reviewed for activities. If the facility does not ensure that all residents are receiving an ongoing activity program, documenting resident refusals, and making in-room activity accommodations, then residents are likely to demonstrate an increase in isolation and depression and could likely experience a decline in independence. The findings are: A. Record review of R #4's admission record no date revealed an admission date of 09/05/23. B. Record review of R #4's Annual MDS assessment dated [DATE] revealed R #4's personal preferences for activities. C. Record review of R #4's care plan dated 09/30/24 revealed R #4's care plan did not include her personal preferences from the MDS Annual Assessment. D. Record review of R #4's Activity Individual Participation Record dated March 2025 revealed staff did not document that activities occurred for the following personal preferences: 1. Spiritual/religious activities. 2. Music. 3. Books, newspapers, and magazines to read. E. Record review of R #4's Activity Individual Participation Record dated April 2025 revealed staff did not document that activities occurred for the following personal preferences: 1. Spiritual/religious activities. 2. Music. 3. Books, newspapers, and magazines to read. F. Record review of R #4's Activity Individual Participation Record dated May 2025 revealed staff did not document that activities occurred for the following personal preferences: 1. Spiritual/religious activities. 2. Music. 3. Books, newspapers, and magazines to read. G. On 05/14/25 at 9:12 AM, during an interview, R #4 stated she was not offered activities in her room. R #4 stated no one comes in and watches tv with me, no talking or conversing. R #4 stated she would like a prayer, or bible study regarding Catholic religion, and likes all music, games, arts/crafts, gardening, any activity would be nice because she was not offered them by staff. H. On 05/14/25 at 9:26 AM, during an interview with the Activities Director, she confirmed the following: 1. R #4's Annual MDS assessment dated [DATE] is accurate and reflects resident's personal preferences for activities. 2. The Activities Director (AD) confirmed that she doesn't document everything for R #4 in the chart but is offering R #4 activities (contradicting R #4's statement). The AD will start documenting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Recite from 05/22/24 Based on record review and interview, the facility failed to ensure that residents had a physician visit at least every 60 days for 4 (R #1, R #9, R #10, and R #118) of 5 (R #1, R #9, R #10, R #118, and R #130) residents reviewed for physician's visits. This deficient practice could likely result in residents not receiving the required medical assessment which could cause a delay in care and treatment of medical conditions. The findings are: R #1 A. Record review of R #1's Electronic Medical Record (EMR) revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 was seen by the Medical Director (clinician who oversees and guides the care provider to nursing home residents) on 12/29/24. 3. R #1 was seen by the Medical Director on 05/10/25. B. On 05/19/25 at 3:13 PM, during an interview, the DON confirmed that R #1 was not seen by the provider every 60 days. R #9 C. Record review of R #9's EMR revealed the following: 1. R #9 was admitted to the facility on [DATE]. 2. R #9 was seen by the Medical Director on 09/24/24. 3. R #9 was seen by the Medical Director on 05/02/25. D. On 05/19/25 at 3:44 PM during an interview, the DON confirmed that R #1 was not seen by the provider every 60 days. R #10 E. Record review of R #10's EMR revealed the following: 1. R #10 was admitted to the facility on [DATE]. 2. R #10 was seen at the local medical clinic on 07/24/24. 3. R #10 was seen by the Medical Director on 04/03/25. F. On 05/19/25 at 3:52 PM during an interview, the DON confirmed that R #10 was not seen by the provider every 60 days. R #118 G. Record review of R #118's EMR revealed the following: 1. R #118 was admitted to the facility on [DATE]. 2. Last physician visit was on 07/12/24. H. On 05/14/25 at 12:42 PM, during an interview, the DON stated the following: 1. The physician went to the facility weekly. 2. The physician saw all new residents during her weekly visits. 3. The physician saw all residents receiving skilled services weekly. 4. The physician saw any resident who had a specific need to be seen. 5. The physician saw all residents annually. 6. The DON confirmed that R #118 had not been seen by the physician since 07/12/24.

Based on interview and record review, the facility failed to complete performance reviews at least every 12 months for 1 (CNA #26) of 2 (CNA #26 and CNA #28), CNAs sampled for 12 hours of annual training. This deficient practice could likely result in staff being undertrained and providing inadequate care. The findings are: A. Record review of CNA #26's employee files revealed the following: 1. CNA #26's hire date was 07/18/11. 2. CNA #26's last performance review was 02/20/24. B. On 05/19/25 at 2:48 PM during an interview, the Human Resource Manager confirmed that the last performance evaluation for CNA #26 was 02/20/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician and/or the physician provided documentation of a rationale (a set of reasons or a logical basis for a course of action or a particular belief) for not following the consultant pharmacist's recommendation in the residents' medical record for 4 (R #9, R #10, R #11 and R #118) of 7 (R #1, R #9, R #10, R #11, R #118, R #119, and R #130) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication). The findings are: R #9 A. Record review of R #9's admission record, no date, revealed the following: 1. R #9 was admitted to the facility on [DATE]. 2. R #9 had the following psychiatric diagnoses: a. Anxiety disorder (mental health condition characterized by excessive fear, worry, and anxiety that interfere with daily life). B. Record review of R #9's physician's orders revealed an order for sertraline tablet (antidepressant medication used to treat anxiety and depression disorders) give 50 mg by mouth one time a day for anxiety. Start date: 09/16/24. C. Record review of R #9's MAR, dated 05/01/25 through 05/19/25, revealed the following: 1. On 05/01/25, R #9 received sertraline 50 mg in the morning. 2. On 05/02/25, R #9 received sertraline 50 mg in the morning. 3. On 05/03/25, R #9 received sertraline 50 mg in the morning 4. On 05/04/25, R #9 received sertraline 50 mg in the morning. 5. On 05/05/25, R #9 received sertraline 50 mg in the morning. 6. On 05/06/25, R #9 received sertraline 50 mg in the morning. 7. On 05/07/25, R #9 received sertraline 50 mg in the morning. 8. On 05/08/25, R #9 received sertraline 50 mg in the morning. 9. On 05/09/25, R #9 received sertraline 50 mg in the morning. 10. On 05/10/25, R #9 received sertraline 50 mg in the morning. 11. On 05/11/25, R #9 received sertraline 50 mg in the morning. 12. On 05/12/25, R #9 received sertraline 50 mg in the morning. 13. On 05/13/25, R #9 received sertraline 50 mg in the morning. 14. On 05/14/25, R #9 received sertraline 50 mg in the morning. 15. On 05/15/25, R #9 received sertraline 50 mg in the morning. 16. On 05/16/25, R #9 received sertraline 50 mg in the morning. 17. On 05/17/25, R #9 received sertraline 50 mg in the morning. 18. On 05/18/25, R #9 received sertraline 50 mg in the morning. 19. On 05/19/25, R #9 received sertraline 50 mg in the morning. D. Record review of R #9's Note to attending physician/prescriber (form that documents pharmacist recommendation regarding residents' medication(s) to the physician/prescriber dated 03/03/25 revealed the following: 1. R #9 has been taking the antidepressant sertraline 50 mg once daily for anxiety since 09/17/24. Please evaluate the current dose and consider a dose reduction (GDR). 2. The form had Resident with good response, maintain the current dose and Disagree marked. 3. The medical director (clinician who oversees and guides the care provider to nursing home residents) did not provide rationale with patient specific information as to why R #10 needed to remain on the medication. 4. The form was signed by the medical director and dated 03/23/25. E. On 05/19/25 at 3:50 PM, during an interview, the DON confirmed the following: 1. The pharmacist recommendation for R #9 was not implemented by the medical director. 2. The medical director did not provide a rationale for not performing a GDR for R #9's sertraline. R #10 F. Record review of R #10's admission record, no date, revealed the following: 1. R #10 was admitted to the facility on [DATE]. 2. R #10 had the following psychiatric diagnoses: a. Depression (mood disorder that causes a persistent feeling of sadness and loss of interest). b. Restlessness and agitation (feelings of irritability, nervousness and mental distress). G. Record review of R #10's physician's orders, multiple dates, revealed the following: 1. Order dated 04/11/24 and discontinued 11/26/24, for sertraline tablet (antidepressant medication used to treat anxiety and depression disorders) 50 mg, give 1 tablet by mouth in the morning related to depression. 2. Order dated 11/27/24, for sertraline tablet 50 mg, give 1 tablet by mouth in the morning for depression as evidenced by sadness. 3. Order dated 04/08/24 and discontinued 11/26/24, for trazodone tablet give 50 mg by mouth at bedtime for insomnia (common sleep disorder that makes it hard to fall asleep or stay asleep). 4. Order dated 11/27/24, for trazodone tablet give 50 mg by mouth at bedtime for insomnia. 5. Order dated 06/09/24 and discontinued 11/26/24, for escitalopram tablet (antidepressant medication used to treat anxiety and depression disorders) 10 mg, give 2 tablets by mouth in the morning for depression. 6. Order dated 11/27/24, for escitalopram tablet 10 mg, give 2 tablets by mouth in the morning for depression as evidenced by social isolation. 7. Order dated 04/22/24 and discontinued 11/26/24, hydroxyzine tablet (prescription-only antihistamine [medication with sedating and calming effect] that is used to treat anxiety) 10 mg, give 1 tablet by mouth two times a day for anxiety related to restlessness and agitation. 8. Order dated 11/27/24, hydroxyzine tablet 10 mg, give 1 tablet by mouth two times a day for anxiety as evidenced by restlessness and agitation. H. Record review of R #10's MAR, dated 05/01/25 through 05/19/25, revealed the following: Sertraline 1. On 05/01/25, R #10 received sertraline 50 mg in the morning. 2. On 05/02/25, R #10 received sertraline 50 mg in the morning. 3. On 05/03/25, R #10 received sertraline 50 mg in the morning 4. On 05/04/25, R #10 received sertraline 50 mg in the morning. 5. On 05/05/25, R #10 received sertraline 50 mg in the morning. 6. On 05/06/25, R #10 received sertraline 50 mg in the morning. 7. On 05/07/25, R #10 received sertraline 50 mg in the morning. 8. On 05/08/25, R #10 received sertraline 50 mg in the morning. 9. On 05/09/25, R #10 received sertraline 50 mg in the morning. 10. On 05/10/25, R #10 received sertraline 50 mg in the morning. 11. On 05/11/25, R #10 received sertraline 50 mg in the morning. 12. On 05/12/25, R #10 received sertraline 50 mg in the morning. 13. On 05/13/25 R #10 received sertraline 50 mg in the morning. 14. On 05/14/25, R #10 received sertraline 50 mg in the morning. 15. On 05/15/25, R #10 received sertraline 50 mg in the morning. 16. On 05/16/25, R #10 received sertraline 50 mg in the morning. 17. On 05/17/25, R #10 received sertraline 50 mg in the morning. 18. On 05/18/25, R #10 received sertraline 50 mg in the morning. 19. On 05/19/25, R #10 received sertraline 50 mg in the morning. Trazodone 20. On 05/01/25, R #10 received trazodone 50 mg in the evening. 21. On 05/02/25, R #10 received trazodone 50 mg in the evening. 22. On 05/03/25, R #10 received trazodone 50 mg in the evening. 23. On 05/04/25, R #10 received trazodone 50 mg in the evening. 24. On 05/04/25, R #10 received trazodone 50 mg in the evening. 25. On 05/06/25, R #10 received trazodone 50 mg in the evening. 26. On 05/07/25, R #10 received trazodone 50 mg in the evening. 27. On 05/08/25, R #10 received trazodone 50 mg in the evening. 28. On 05/09/25, R #10 received trazodone 50 mg in the evening. 29. On 05/10/25, R #10 received trazodone 50 mg in the evening. . 30. On 05/11/25, R #10 received trazodone 50 mg in the evening. 31. On 05/12/25 R #10 received trazodone 50 mg in the evening. 32. On 05/13/25, R #10 received trazodone 50 mg in the evening. 33. On 05/14/25, R #10 received trazodone 50 mg in the evening. 34. On 05/15/25, R #10 received trazodone 50 mg in the evening. 35. On 05/16/25, R #10 received trazodone 50 mg in the evening. 36. On 05/17/25, R #10 received trazodone 50 mg in the evening. 37. On 05/18/25, R #10 received trazodone 50 mg in the evening. Escitalopram 38. On 05/01/25, R #10 received escitalopram 20 mg in the morning. 39. On 05/02/25, R #10 received escitalopram 20 mg in the morning. 40. On 05/03/25, R #10 received escitalopram 20 mg in the morning. 41. On 05/04/25, R #10 received escitalopram 20 mg in the morning. 42. On 05/05/25, R #10 received escitalopram 20 mg in the morning. 43. On 05/06/25, R #10 received escitalopram 20 mg in the morning. 44. On 05/07/25, R #10 received escitalopram 20 mg in the morning. 45. On 05/08/25, R #10 received escitalopram 20 mg in the morning. 46. On 05/09/25, R #10 received escitalopram 20 mg in the morning. 47. On 05/10/25, R #10 received escitalopram 20 mg in the morning. 48. On 05/11/25, R #10 received escitalopram 20 mg in the morning. 49. On 05/12/25, R #10 received escitalopram 20 mg in the morning. 50. On 05/13/25 R #10 received escitalopram 20 mg in the morning. 51. On 05/14/25, R #10 received escitalopram 20 mg in the morning. 52. On 05/15/25, R #10 received escitalopram 20 mg in the morning. 53. On 05/16/25, R #10 received escitalopram 20 mg in the morning. 54. On 05/17/25, R #10 received escitalopram 20 mg in the morning. 55. On 05/18/25, R #10 received escitalopram 20 mg in the morning. 56. On 05/19/25, R #10 received escitalopram 20 mg in the morning. Hydroxyzine 57. On 05/01/25, R #10 received hydroxyzine 10 mg twice daily. 58. On 05/02/25, R #10 received hydroxyzine 10 mg twice daily. 59. On 05/03/25, R #10 received hydroxyzine 10 mg twice daily. 60. On 05/04/25, R #10 received hydroxyzine 10 mg twice daily. 61. On 05/05/25, R #10 received hydroxyzine 10 mg twice daily. 62. On 05/06/25, R #10 received hydroxyzine 10 mg twice daily. 63. On 05/07/25, R #10 received hydroxyzine 10 mg twice daily. 64. On 05/08/25, R #10 received hydroxyzine 10 mg twice daily. 65. On 05/09/25, R #10 received hydroxyzine 10 mg twice daily. 66. On 05/10/25, R #10 received hydroxyzine 10 mg twice daily. 67. On 05/11/25, R #10 received hydroxyzine 10 mg twice daily. 68. On 05/12/25, R #10 received hydroxyzine 10 mg twice daily. 69. On 05/13/25, R #10 received hydroxyzine 10 mg twice daily. 70. On 05/14/25, R #10 received hydroxyzine 10 mg twice daily. 71. On 05/15/25, R #10 received hydroxyzine 10 mg twice daily. 72. On 05/16/25, R #10 received hydroxyzine 10 mg twice daily. 73. On 05/17/25, R #10 received hydroxyzine 10 mg twice daily. 74. On 05/18/25, R #10 received hydroxyzine 10 mg twice daily. I. Record review of R #10's Recommendation Summary for DON and medical director (pharmacist recommendation to the DON and medical director regarding residents' medications) dated 02/03/25, revealed the following: 1. R #10 has a history of chronic depression and has been receiving the current dose sertraline 50 mg every morning since 04/11/24, trazodone 50 mg at bedtime since 04/08/24, and escitalopram 20 mg every morning since 06/09/24 2. Federal guidelines require assessment of medication therapy showing benefit to risk for continuing therapy and periodic dose reduction trials when medications may no longer be necessary. Please check the appropriate response and add additional information as requested. 3. The form had Patient has had good response to treatment and requires this dose for condition stability. Dose reduction is contraindicated because benefits outweigh risks for this patient at this time and a reduction is likely to impair the residents function and or cause psychiatric instability. (Please elaborate with patient specific information marked. 4. The medical director did not provide rationale with patient specific information as to why R #10 needed to remain on the medications. 5. The form was signed by the medial director and dated 03/23/25. J. Record review of R #10's Note to attending physician (form that documents pharmacist recommendation regarding residents' medication(s) to the physician/prescriber dated 04/01/25, revealed the following: 1. R #10 has been taking the anxiolytic (class of medications used to prevent or treat anxiety symptoms or disorders) hydroxyzine 10 mg twice daily for anxiety since 04/22/24. Please evaluate the current dose and consider a dose reduction. 2. The form had Resident with good response, maintain the current dose marked. 3. The medical director did not provide rationale with patient specific information as to why R #10 needed to remain on the same dose of hydroxyzine. 4. The form was signed by the medical director and dated 04/03/25. K. On 05/19/25 at 3:57 PM, during an interview, the DON confirmed the following: 1. The pharmacist recommendation for R #10 was not implemented by the medical director. 2. The medical director did not provide a rationale for not performing GDR's for R #10's medications. R #11 L. Record review of R #11's admission record, no date, revealed the following: 1. R #11 was admitted to the facility on [DATE]. 2. R #11 had the following psychiatric diagnoses: a. Major Depressive Disorder (MDD, mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) b. Panic disorder [Episodic Paroxysmal Anxiety] (mental and behavioral disorder, specifically an anxiety disorder characterized by recurring unexpected panic attacks). c. Psychotic Disorder with Hallucinations due to known physiological condition (a condition when people lose some contact with reality. This might involve seeing or hearing things that other people cannot see or hear (hallucinations) and believing things that are not actually true (delusions)). d. Insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep). M. Record review of R #11's physician's orders, multiple dates, revealed the following: 1. Order dated 04/29/24, and discontinued 11/26/24, for buspirone (medication that can treat anxiety) 5 mg tablet, one tablet twice a day for anxiety. 2. Order dated 11/26/24, for buspirone 5 mg tablet, one tablet twice a day for anxiety. 3. Order dated 09/29/23 and discontinued 11/26/24, for lorazepam 0.5 mg tablet, one tablet twice a day for anxiety. 4. Order dated 11/26/24, for lorazepam (medication that can treat anxiety) 0.5 mg tablet, one tablet twice a day for anxiety. 5. Order dated 07/07/23 and discontinued 10/01/23, for trazadone 50 mg, one tablet in the evening for insomnia. 6. Order dated 10/01/23 and discontinued 11/26/24, for trazadone 50 mg, one tablet in the evening for depression, MDD, insomnia. 7. Order dated 11/26/24, for trazadone 50 mg tablet, one tablet in the evening for depression, MDD, insomnia. 8. Order dated 08/03/23 and discontinued 11/26/24, for mirtazapine 7.5 mg, give ½ of 15 mg tablet in the evening for depression. 9. Order dated 11/26/24, for mirtazapine 7.5 mg, give ½ of 15 mg tablet in the evening for depression. 10. Order dated 06/30/23, for Nuplazid 34 mg, give one capsule at bedtime for hallucinations related to Parkinson's disease, psychotic disorder with hallucinations due to known physiological condition. N. Record review of R #11's MAR, dated May 2025, revealed the following: 1. R #11 received Lorazepam 0.5 mg twice a day as ordered. 2. R #11 received buspirone 5 mg twice a day as ordered. 3. R #11 received trazadone 50 mg in the evening as ordered. 4. R #11 received mirtazapine 7.5 mg in the evening as ordered. 5. R #11 received Nuplazid 34 mg in the evening as ordered. O. Record review of the Psychotropic & Sedative/Hypnotic Utilization By Resident report (pharmacist spreadsheet that includes information about the use of psychotropic, sedative, and hypnotic medications), dated 05/02/25, revealed the following: 1. R #11 had an order for buspirone 5 mg twice a day since 04/29/24, and a GDR was declined in February 2025. 2. R #11 had an order for lorazepam 0.5 mg twice a day since 09/29/23, and a GDR was declined in September 2024. 3. R #11 had an order for mirtazapine (antidepressant medication) 7.5 mg in the evening for depression since 08/03/23, and a GDR was declined in September 2024. 4. R #11 had an order for Nuplazid 34 mg at bedtime since 06/30/23, and a GDR was recommended in April 2025. 5. R #11 had an order for trazadone 50 mg at bedtime since 10/01/23, and a GDR was declined in October 2024. P. Record review of R #11's pharmacist recommendation, dated 08/03/24, revealed the following: 1. R #11 has a history of chronic depression and has been receiving the current dose of mirtazapine 7.5 mg in the evening for depression since 08/03/23. Federal guidelines require assessment of medication therapy showing benefit to risk for continuing therapy and periodic dose reduction trials when medications may no longer be necessary. Please check the appropriate response and add additional information as requested: 2. The form had Patient has had a good response to treatment and requires this dose for condition stability. Dose reduction is contraindicated because benefits outweigh risks for this patient at this time and a reduction is likely to impair the resident's function and/or cause psychiatric instability. (Please elaborate with patient specific information) selected. 3. The form had agree selected with a provider signature and date of 09/15/24. 4. R #11's physician did not provide rationale with patient specific information as to why resident needed to remain on medication. Q. Record review of R #11's pharmacist recommendation, dated 09/03/24, revealed the following: 1. R #11 has been taking the anxiolytic lorazepam 0.5 mg twice daily since 09/28/23. Please evaluate the current dose and consider a dose reduction. 2. The form had agree selected with a signature and date of 09/09/24. 3. The form had a note dated 09/16/24, verbal order to continue med. Per order by [Doctor Name]. 4. R #11's physician did not provide rationale with patient specific information as to why resident needed to remain on medication. R. Record review of R #11's pharmacist recommendation, dated 10/04/24, revealed the following: 1. R #11 has a history of chronic depression and has been receiving the current dose of trazadone 50 mg at bedtime for depression since 10/01/23. Federal guidelines require assessment of medication therapy showing benefit to risk for continuing therapy and periodic dose reduction trials when medications may no longer be necessary. Please check the appropriate response and add additional information as requested: 2. The form had Patient has had a good response to treatment and requires this dose for condition stability. Dose reduction is contraindicated because benefits outweigh risks for this patient at this time and a reduction is likely to impair the resident's function and/or cause psychiatric instability. (Please elaborate with patient specific information) selected. 3. R #11's physician did not provide rationale with patient specific information as to why resident needed to remain on medication. 4. The form had a note, dated 10/14/24, [Name of nurse practitioner] verbal continue of this dose. S. Record review of R #11's pharmacist recommendation, dated 02/03/25, revealed the following: 1. R #11 has been taking the anxiolytic buspirone 5 mg since 04/29/24. Please evaluate the current dose and consider a dose reduction (GDR). 2. The form had Condition stable: Attempt dose reduction to discontinue this medication, Resident with good response, maintain the current dose, and Disagree marked. 3. R #11's physician did not provide rationale with patient specific information as to why resident needed to remain on medication. 4. The form had a comment dated 02/19/25, MD intended to keep resident on current dose, verified by [DON signature]. T. Record review of R #11's pharmacist recommendation, dated 04/05/25, revealed the following: 1. R #11 has been taking the antipsychotic Nuplazid 34 mg at bedtime for psychotic disorder with hallucinations related to Parkinson's Disease since 06/30/23. Please evaluate the current dose and consider a dose reduction. 2. The form had Resident with good response, maintain the current dose. 3. The form had agree selected with a signature and date of 05/09/25. 4. R #11's physician did not provide rationale with patient specific information as to why resident needed to remain on medication. U. On 05/19/25 at 2:34 PM, during an interview, the DON confirmed the following: 1. R #11 has not had a GDR for buspirone, lorazepam, mirtazapine, trazadone, or Nuplazid. 2. The provider did not provide a rationale for why she did not perform a GDR for R #11 for buspirone, lorazepam, mirtazapine, trazadone, or Nuplazid. R #118 V. Record review of R #118's physician's orders, multiple dates, revealed the following: 1. An order, dated 07/15/24 and discontinued on 05/13/25, for Mirtazapine 7.5 mg in the evening for appetite and depression. 2. An order, dated 05/13/25, for Mirtazapine 7.5 mg in the evening for appetite and depression. W. Record review of R #118's MAR, dated 05/01/25 to 05/12/25, revealed the following: 1. On 05/01/25, R #118 received mirtazapine 7.5 mg in the evening. 2. On 05/02/25, R #118 received mirtazapine 7.5 mg in the evening. 3. On 05/03/25, R #118 refused mirtazapine 7.5 mg in the evening. 4. On 05/04/25, R #118 refused mirtazapine 7.5 mg in the evening. 5. On 05/05/25, R #118 received mirtazapine 7.5 mg in the evening. 6. On 05/06/25, R #118 received mirtazapine 7.5 mg in the evening. 7. On 05/07/25, R #118 received mirtazapine 7.5 mg in the evening. 8. On 05/08/25, R #118 received mirtazapine 7.5 mg in the evening. 9. On 05/09/25, R #118 received mirta

Recite from 05/22/24 Based on record review and interview the facility failed to ensure residents obtained dental services for 3 (R #9, R #10 and R #123) of 4 (R #9, R #10, R #121 and R #123) residents sampled for dental services, when staff failed to ensure residents receive routine dental care to include an annual inspection of the mouth for signs of disease, dental cleaning, fillings, or minor partial or full denture adjustments. This deficient practice is likely to cause the resident unnecessary pain, embarrassment over the condition/appearance of teeth, and potential dental or oral complications. The findings are: R #9 A. On 05/12/25 at 2:15 PM, during an interview, R #9 stated that she needed to have her dentures checked because they were loose. B. Record review of R #9's admission Record, no date, revealed an admission date of 09/16/24. C. Record review of R #9's physician's order dated 09/16/24 revealed Dental consult as needed. D. On 05/15/25 at 1:58 PM, during an interview with Medical Records staff, she confirmed R #9 had not been seen by a dentist since her admission. R #10 E. On 05/13/25 at 10:22 AM, during an interview, R #10's Power of Attorney (POA; legal document that appoints someone as a representative and allows them to act on one's behalf) stated that R #10 had a dental filling that fell out approximately 6 months ago. R #10's POA stated she asked for the facility to schedule an appointment, but she is unsure if she was seen by a dentist. F. Record review of R #10's physician's order dated 05/20/24 revealed Dental consult as needed. G. Record review of R #10's Weekly Oral/Dental Assessment, dated 11/29/24 revealed Upper gums red, irritated. Currently using medicated mouthwash for treatment. Resident broke her silver cap off a tooth yesterday 11/28/24. Transportation noted to make resident dentist appointment. Passed on in nursing report and nursing staff. H. Record review of R #10's progress notes revealed Social Service Note dated 12/13/24 at 1:57 PM: POA reported that her filling fell out of her mouth, she did report it to nurse. POA request that she needs to be taken to a dentist. I. On 05/15/25 at 1:58 PM, during an interview with Medical Records staff, she confirmed R #10 had not been seen by a dentist after 11/28/24. R #123 J. Record review of R #123's face sheet, no date, revealed an admission date of 05/06/2024. K. On 05/13/25 at 2:23 PM, during an interview, R #123 stated he had toothache, and he has not been to the dentist since his admission to the facility. L. Record review of R #123's treatment administration record dated 05/01/25 revealed dental consultation as needed. M. On 05/14/25 11:19 AM during an interview, DON stated she did not know that R #123 had a tooth ache. DON confirmed that R #123 did not have a monthly dental assessment in his record, and R #123 has been at the facility since 05/06/25 and has not seen a dentist in this time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Recite from 05/22/24 Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 2 (R #9 and R #118) of 6 (R #1, R #9, R #10, R #118, R #130 and R #131) residents reviewed for documentation accuracy. This deficient practice has the potential to negatively impact on the care staff provide to meet residents' needs due to missing or inaccurate records and resident information. The findings are: R #9 A. Record review of R #9's physician orders revealed the following: 1. An order dated 11/25/24 for acetaminophen (Tylenol; analgesic medication used to treat mild to moderate pain) tablet 325 mg, give 2 tablets by mouth every 4 hours as needed for pain. B. Record review of R #9's medication administration record (MAR; a form used to document medication administration), dated April 2025, revealed staff documented the following: 1. On 04/06/25 at 3:01 AM, staff documented acetaminophen was given for a pain level of 5 (pain scale 1-10, 10 highest). 2. On 04/08/25 at 1:30 PM, staff documented acetaminophen was given for a pain level of 4. 3. On 04/16/25 at 11:15 PM, staff documented acetaminophen was given for a pain level of 4. 4. On 04/30/25 at 4:25 AM, staff documented acetaminophen was given for a pain level of 6. C. Record review of R #9's MAR dated May 2025, revealed staff documented the following: 1. On 05/09/25 at 4:54 AM, staff documented acetaminophen was given for a pain level of 6. 2. On 05/09/25 at 9:46 PM, staff documented acetaminophen was given for a pain level of 5. 3. On 05/13/25 at 2:45 AM, staff documented acetaminophen was given for a pain level of 3. 4. On 05/14/25 at 3:00 AM, staff documented acetaminophen was given for a pain level of 5. 5. On 05/16/25 at 5:46 AM, staff documented acetaminophen was given for a pain level of 5. 6. On 05/17/25 at 5:45 AM, staff documented acetaminophen was given for a pain level of 5. 7. On 05/17/25 at 5:08 PM, staff documented acetaminophen was given for a pain level of 5. 8. On 05/18/25 at 3:33 AM, staff documented acetaminophen was given for a pain level of 5. D. Record review of R #9's progress notes dated April 2025 and May 2025 revealed the following: 1. On 04/08/25 staff documented acetaminophen was given for throat pain. 2. Staff did not document the reason acetaminophen was given for any other dates in April or May. E. On 05/19/25 at 3:47 PM, during an interview with the DON, she confirmed the following: 1. Facility staff did not document the reason R #9 was given acetaminophen. 2. Facility staff did not document whether the acetaminophen was effective in treating R #9's complaints of pain. 3. She expects staff to document the location of the pain and whether the pain medication helped relieve the pain. 4. Documenting the pain location and effectiveness helps the facility staff and physician know if there needs to be additional treatment for complaints of pain or if medication changes are necessary. R #118 F. Record review of R #118's admission record, no date, revealed the following: 1. R #118 was admitted to the facility on [DATE]. 2. R #118 did not have any mental health diagnoses. G. Record review of R #118's physician's orders, multiple dates, revealed the following: 1. An order dated 07/15/24 and discontinued on 05/13/25, for Mirtazapine (antidepressant to treat major depressive disorder) 7.5 mg in the evening for appetite and depression. 2. An order dated 05/13/25, for Mirtazapine 7.5 mg in the evening for appetite and depression. H. Record review of R #118's provider's progress note, dated 07/12/24, revealed R #118 had a diagnosis of major depressive disorder (MDD, mood disorder that causes a persistent feeling of sadness and loss of interest). I. Record review of R #118's medical record, no date, revealed staff did not update R #118's medical diagnoses to include her diagnosis of MDD. J. On 05/19/25 at 2:16 PM, during an interview, the DON confirmed the following: 1. R #118's did not have a diagnosis of depression in her list of diagnoses in the medical record. 2. R #118's provider progress note, dated 07/12/24, listed MDD as one of R #118's diagnoses. 3. Staff did not update R #118's electronic medical record (EMR) with the diagnosis of MDD. 4. Staff were expected to update resident EMR's with all new diagnoses

Based on record review and interview, the facility failed to ensure that nursing staff have completed the mandatory Effective Communication training for 3 (RN #24, LPN #25, CNA #26) of 5 (RN #24, LPN #25, CNA #26, RN #27 and CNA # 28) staff randomly sampled for staffing. This deficient practice could likely result in staff being unable to inform residents of their total health status and to provide notice of rights and services. The findings are: A. Record review of RN #24's Online Training Transcript, no date revealed effective communication training was not completed. B. Record review of LPN #25's Online Training Transcript, no date revealed effective communication training was not completed. C. Record review of CNA #26's Online Training Transcript, no date revealed effective communication training was not completed. D. On 05/19/25 at 2:48 PM, during an interview, the Human Resource Manager confirmed that Effective Communication Training has not been completed for RN #24, LPN #25, and CNA #26.

Based on record review and interview, the facility failed to provide resident rights training (training that helps staff promote and protect the rights of each resident and places a strong emphasis on individual dignity and self-determination) for 4 staff (RN #24, LPN #25, CNA #26, and RN #27) of 5 (RN #24, LPN #25, CNA #26, RN #27 and CNA # 28) staff sampled for training. This deficient practice could likely result in staff being unaware of residents rights resulting in negative psychosocial well-being for residents. The findings are: A. Record review of staff training records revealed RN #24 did not complete training for resident rights. B. Record review of staff training records revealed LPN #25 did not complete training for resident rights. C. Record review of staff training records revealed CNA #26 did not complete training for resident rights. D. Record review of staff training records revealed RN #27 did not complete training for resident rights. E. On 05/19/25 at 2:48 PM, during an interview, the Human Resource Manager confirmed that RN #24, LPN #25, CNA #26, and RN #27 did not complete the training.

Based on record review and interview, the facility failed to ensure that nursing staff have completed the mandatory QAPI (Quality Assurance/Performance Improvement) training for 3 (RN #24, LPN #25, CNA #26) of 5 (RN #24, LPN #25, CNA #26, RN #27 and CNA #28) staff randomly sampled for staffing. This deficient practice could likely result in staff being unable to identify opportunities for improvement, address gaps in systems or processes, develop and implement an improvement or corrective plan, and continuously monitor the effectiveness of interventions. The findings are: A. Record review of the employee training transcript, no date, revealed RN #24 did not complete QAPI training. B. Record review of the employee training transcript, no date, revealed LPN #25 did not complete QAPI training. C. Record review of the employee training transcript, no date, revealed CNA #26 did not complete QAPI training. D. On 05/19/25 2:48 PM, during an interview, the Human Resource Manager confirmed that the QAPI training has not been completed for RN #24, LPN #25, and CNA #26.

Based on record review and interview, the facility failed to provide infection control training (training that helps staff recognize various infection control prevention to help stop the spread of infections) for 2 (RN #24 and CNA #26) of 5 (RN #24, LPN #25, CNA #26, RN #27 and CNA #28) staff sampled for training. This deficient practice could likely result in inadequate infection control, and can lead to increased spread of resistant organisms, and risk of infections among residents and staff. The findings are: A. Record review of staff training records revealed CNA #26 completed training for infection control on 11/11/22. B. Record review of staff training records revealed RN #24 completed training for infection control on 12/31/23. B. On 05/19/25 at 2:48 PM, during an interview, the Human Resource Manager (HRM) confirmed that CNA #26 and RN #24 did not complete the training for the year 2025. The HRM confirmed that the training should be completed annually.

Based on record review and interview, the facility failed to ensure that each CNA received a minimum of 12 in-service hours a year based on hire date for 1 (CNA #26) of 2 (CNA #26, and CNA #28) CNAs sampled for training. If CNAs are not adequately trained, they are unable to provide the necessary care and services to residents. The findings are: A. Record review of the facility's CNA training records revealed the following: 1. CNA #26 hire date was 07/18/11. 2. CNA #26 had 1 training in-service hour taken on 11/22/24. B. On 05/19/25 at 2:48 PM, during an interview, the Human Resource Manager confirmed that CNA #26 did not have the minimum of 12 in-service hours a year.

Based on an interviews the facility failed to employ a Certified Dietary Manager (CDM) that met the requirements as follows: (A) A certified dietary manager; or (B) A certified food service manager; or (C) Had similar national certification for food service management and safety from a national certifying body; or (D) Had an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or (E) Had two or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that included topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving. This failure could potentially affect all 29 residents in the facility who eat food prepared in the kitchen (residents were identified by the Resident Matrix provided by the Administrator on 05/12/25). If the facility fails to employ qualified dietary staff, residents nutritional needs may not be met and they could likely suffer adverse outcomes. The findings are: A. On 05/12/25 at 1:36 PM, during an interview, Dietary Staff #16 revealed that the facility did not have a dietary manager (DM). B. On 05/12/25 at 1:38 PM, during an interview, [NAME] #16 revealed the following: 1. The facility did not have a DM. 2. They had not had a DM for approximately a month. 3. He was not sure if the facility had a dietitian. C. On 05/15/25 at 12:17 PM, during an interview, the Administrator confirmed the following: 1. The dietitian works at the facility one day a week. 2. The facility had not had a DM since 04/18/25. 3. The facility hired a DM that was expected to start on 05/23/25.

Recite from 05/22/24 Based on observation and interview, the facility failed to store and serve food under sanitary conditions in accordance with professional standards of food service safety for all 29 residents in the facility (residents were identified by resident matrix provided by the Administrator on 05/12/25) who eat food or drinks stored in the nutrition refrigerator or freezer when staff failed to: 1. Maintain refrigerator temperatures in the nutrition refrigerators (refrigerator near the nursing station that contains drinks and snacks for residents). 2. Food stored in the nutrition refrigerator was not expired. 3. Food stored in the nutrition refrigerator or freezer had an expiration date. 4. Food that was supposed to be frozen was not thawed in the refrigerator. If the facility fails to adhere to safe food storage, residents could likely be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are: A. On 05/15/25 at 11:53 AM, during an observation of the nourishment room refrigerator revealed there was no temperature log for the refrigerator or freezer. B. On 05/15/25 at 11:54 AM, during an interview, RN #16 stated that the kitchen staff take the temperatures in the nourishment room refrigerator. C. On 05/15/25 at 12:05 PM, during an interview, Dietary Aide (DA) #16 stated she was unsure where the nourishment room temperature log was. D. On 05/15/25 at 12:21 PM, during an observation of the nutrition refrigerator and freezer revealed the following: 1. A sandwich was in the refrigerator with a date written on it of 03/04/25. 2. A bag of shredded cheese in the refrigerator with an expiration date of 05/03/25. 3. Several individually packaged peanut butter and jelly sandwiches in the refrigerator with no date and no expiration date. The wrappers stated thaw and serve (should be stored in the freezer until ready to serve). E. On 05/15/25 at 12:24 PM, during an interview, the DON confirmed the following: 1. The sandwich in the nutrition room refrigerator was expired. 2. The cheese in the nutrition room refrigerator was expired. 3. The individually packaged peanut butter and jelly sandwiches did not have a date that they would expire. 4. The individually packaged peanut butter and jelly sandwiches should have had a date that they expired written on them and should have been stored in the freezer and not the refrigerator. 5. There was no refrigerator or freezer temperature log in the nutrition room. 6. She was unsure if anyone had been checking the temperature of the nutrition room refrigerator or freezer. 7. Kitchen staff were responsible for the following in the nourishment room: a. Taking temperatures of the refrigerator and freezer. b. Stocking refrigerator and freezer and other snacks in the room. c. Removing expired items. F. On 05/15/25 at 12:38 PM, during an interview, DA #16 confirmed the kitchen staff had not been checking temperatures for the nutrition room refrigerator and freezer. She was unable to determine the last time the nutrition room refrigerator and freezer temperatures had been checked.

Past Noncompliance Based on interview and record review, the facility failed to promote resident self-determination (the ability to make your own choices and decisions without being controlled by others) for 3 (R #1, R #2, and R #3) of 4 (R #1, R #2, R #3 and R #4) residents reviewed for choices when staff did not accommodate the residents wishes to go out into the community. If the facility does not honor residents' choices, then residents are likely to feel a loss of independence and self-worth leading to feelings of frustration and depression. The findings are: A. Record review of an anonymous complaint dated 11/13/24 revealed residents haven't left the facility for anything other than medical appointments for over a year and residents would like to go shopping. B. On 02/27/25 at 10:45 AM during an interview, the Activities Director stated the following: 1. She used to take residents out into the community to go shopping and to the casino. 2. The facility has not been taking residents out into the community for several years. 3. The facility did not return to their regular activities after the coronavirus (COVID-19 disease; acute disease in humans which is characterized mainly by fever and cough and can progress to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) pandemic (outbreak of infectious disease that occurs over a wide geographical area, pandemic dates per the World Health Organization were 03/11/20 through 05/05/23). 4. The facility added a shopping trip to the monthly activities calendar. 5. The facility took residents shopping on December 17, 2024, January 28, 2025, and February 18, 2025. 6. The resident council agenda includes discussing and approving each month's activities calendar to include the monthly shopping trip. C. On 02/27/25 at 9:24 AM, during an interview with R #1, she stated the facility had stopped taking residents shopping but restarted the shopping trips in the last two months. D. On 02/27/25 at 10:01 AM, during an interview with R #2, she stated that the facility had stopped taking residents shopping a few years ago but she has been shopping this year (2025). E. On 02/27/2025 at 11:40 AM, during an interview with R #3, he stated he did not remember shopping in 2024 but he has been shopping this year (2025) but does not remember the exact dates. This deficient practice was cited as past noncompliance: -Based on the facility's investigation of the ombudsman's concern to the facility administrator on 11/08/24 regarding residents wanting to go shopping, the following interventions were implemented prior to the survey investigation which included: -The administrator implemented an audit to determine which residents would like to go shopping. -Activities staff planned the first shopping trip to be held on 12/17/24 and the calendar was discussed at the resident council meeting in November 2024. -The following month's activities calendar including the shopping trip are discussed and approved at monthly resident council meetings. -R #1, R #2, and R #3 were interviewed and confirmed that they have been out shopping this year (2025). -R #4 was interviewed and confirmed that she has been offered to go shopping but has not felt up to going but she may participate in the future.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a comprehensive Minimum Data Set Assessment was completed within 14 calendar days after admission for 2 (R #151 and R #156) of 3 (R #151, R #155, and R #156) residents reviewed. This deficient practice could likely result in residents' preferences and care needs not being met. The findings are: R #151 A. Record review of R #151's admission record revealed an admission date of 04/26/24. B. Record review of R #151's medical record revealed an admission MDS assessment was in progress (assessment has been started but all sections have not been completed) on 05/22/24. C. On 05/22/24 at 10:00 AM, during an interview with the Infection Control Nurse (RN who signs off on completed MDS assessments), he confirmed the following: 1. R #151 was admitted to the facility on [DATE]. 2. R #151's admission MDS assessment was still in progress and was not completed within 14 days of admission. R #156 D. Record review of R #156's admission record revealed an admission date of 05/06/24. E. Record review of R #156's medical record revealed an admission MDS assessment was in progress on 05/22/24. F. On 05/22/24 at 10:00 AM, during an interview with the Infection Control Nurse, he confirmed the following: 1. R #156 was admitted to the facility on [DATE]. 2. R #156's admission MDS assessment was still in progress and was not completed within 14 days of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive care plan for 1 (R #54) of 4 (R #51, R #52, R #53, and R #54) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the needs of the residents. The findings are: A. Record review of R #54's medical record revealed R #54 was admitted on [DATE]. On 05/19/24 at 3:07 PM, during an interview, R #54 stated that she has swelling to her legs and wears stockings every day to help decrease the swelling. B. Record review of R #54's physician's orders revealed: 1. Order date 07/14/21, apply TED hose (compression stockings that help prevent or decrease the occurrence of blood clots and swelling in the legs) to bilateral lower extremities (both legs) in the morning for edema (swelling caused due to excess fluid accumulation in the body tissues). 2. Order date 07/14/21, remove TED hose every day at bedtime for edema. 3. Order date 04/16/24, monitor for edema every shift for edema in bilateral lower extremities. 4. Furosemide (diuretic medication that helps the body get rid of extra water by increasing the amount of urine made) 20 MG (strength of medication) give 3 tablets by mouth in the morning for edema. C. Record review of R #54's care plan initiated (started) 06/29/21 revealed that edema and the interventions to treat and monitor were not included in her care plan. D. On 05/22/24 at 2:44 PM, during an interview, the DON confirmed that R #54's comprehensive care plan did not include the treatment and monitoring for edema as ordered.

Based on record review and interview, the facility failed to ensure physician's orders were entered for 1 (R #155) of 1 (R #155) residents reviewed for behavioral health. This deficient practice could likely result in resident's not receiving the appropriate medications or treatment and lead to worsening of the resident's condition. The findings are: A. On 05/20/24 at 9:34 AM, during an interview with R #155's Power of Attorney (POA, the authority to act for another person in specified or all legal or financial matters), she stated the following: 1. R #155 had been depressed (a common mental disorder that involves depressed mood or loss of pleasure or interest in activities for long periods of time). 2. R #155 had not been eating or drinking very well. 3. She spoke with the facility doctor on 05/19/24 and was told that a medication would be ordered to help R #155 with depression and to increase her appetite. B. Record review of R #155's entire medical record revealed the record did not contain any orders or progress notes from the provider's visit on 05/19/24. C. On 05/20/24 at 2:15 PM, during an interview with LPN #21, he revealed the following: 1. There were no progress notes or physician's orders in R #155's electronic medical record or in the binder at the nurses station that contained documents from the provider for the provider visit on 05/19/24. 2. The provider usually gives a verbal order to the nurse so an order can be entered into the electronic medical record. 3. Sometimes the nurses are given a provider progress note to review and contact the provider for any questions. 4. He recommended talking to the Medical Records Clerk about any progress notes from 05/19/24. D. On 05/20/24 at 2:52 PM, an interview with the Medical Records Clerk revealed she did not have any provider progress notes for R #155 on 05/19/24. E. Record review of R #155's physician's progress note, dated 05/19/24 revealed the provider was going to order R #155 Mirtazapine (an atypical antidepressant used in the treatment of major depressive disorder) 7.5 mg for one week then increase to 15 mg for depression. F. Record review of physician's orders revealed R #155 did not have an order for Mirtazapine. G. On 05/21/24 at 11:18 AM, during an interview with LPN #21, he confirmed the following: 1. R #155's provider progress note, dated 05/19/24, said the provider was going to start R #155 on Mirtazapine 7.5 mg for one week then increase to 15 mg for depression. 2. R #155 did not have a physician order for Mirtazapine. H. On 05/22/24 at 9:31 AM, during an interview with the Administrator, she confirmed the following: 1. The provider is expected to deliver or fax progress notes to medical records after each visit. 2. The medical records clerk is expected to give the nurses the progress notes to review and enter any orders. 3. The facility is working on developing a better way of communicating with the provider.

Based on observation and interview, the facility failed to ensure call lights worked and that the pull cords for the call lights in the resident's bedrooms were in reach to allow residents to call for help using the call light system, for 1 (R #207) of 3 (R #202, R #204, and R #207) residents randomly sampled for call light function. If the facility does not have a functioning call light system, then residents are unlikely to get their immediate needs met by facility staff. The findings are: A. On 05/19/24 at 3:00 PM, during an observation of R #207 bedroom, revealed the call light cord was missing. B. On 05/19/24 at 3:08 PM, during an interview with R #207, she stated, I don't have a call light (the call light cord was missing), no wonder the aides do not come. R #207 stated that she knows to press the call light cord to call for assistance. C. On 05/19/24 at 3:28 PM, during an interview with LPN #31, she confirmed R #207 did not have call light cord and stated [Name of R #207] does not use her call light.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure care plan revision and care plan meeting requirements occurred for 6 (R #51, R #54, R #102, R #103, R #154, and R #202) of 9 (R #51, R #54, R #102, R #103, R #151, R #154, R #155, R #156, and R #202) residents reviewed for care plans when they failed to: 1. Revise the care plan with the most current resident information for R #51, R #54, R #102, R #103, and R #202. 2. Have the required Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities, and includes other appropriate staff or professionals in disciplines as determined by the resident's needs) members participate in the care plan meeting for R #154. 3. Have the care plan meeting within seven days after the completion of the MDS assessment for R #154. These deficient practices could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: R #51 A. On 05/19/24 at 2:32 PM, during an interview, R #51 stated she has a wound on her left heel. B. Record review of R #51's physician's orders revealed: 1. Order date 04/19/24, diabetic ulcer (a slow-healing wound that commonly appears on the ball of the foot due to complications of diabetes) on left heel, cleanse and apply skin prep until resolved every night shift every other day for wound care. 2. Order date 05/13/24, refer to [name of agency] wound care for in-house visits and treatment of any wounds. 3. Order date 05/14/24, skin graft (healthy skin placed over damaged or missing skin to promote new skin growth) in place, monitor it's still in place, and in good contact. Do not remove graft. Cover to not get wet. Wound care being done by outside wound care nurse/agency. C. Record review of R #51's care plan dated 04/19/24, revealed the following: 1) Avoid exposure to temperature extremes: Heating pads, Hot water bottles, Heat lamps, Hot/cold solutions and soaks, Sunburn, Ice packs. 2) Avoid mechanical trauma (SPECIFY): Constrictive shoes, Cutting and trimming corns and calluses, Adhesive tapes, Improper shaving, Vigorous massage. 3) Determine and treat cause: poor fitting shoes, poor blood sugar control, pressure area, infection. 4) Monitor Blood Sugar Levels. 5) Monitor/document wound: Size, Depth, Margins: periwound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene, 6) Document progress in wound healing on an ongoing basis. Notify MD as indicated. 7) Monitor/document/report PRN any s/sx of infection: [NAME] drainage, Foul odor, Redness and swelling, Red lines coming from the wound, Excessive pain, Fever. 8) Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. 9) No documentation of R #51's wound care orders in place 10) No documentation that R #51 was seen by an outside wound care provider. 11) NO documentation that R #51 had a skin graft in place. D. On 05/22/24 at 2:30 PM, during an interview, the DON confirmed that R #51's care plan had not been updated to reflect the current treatment for R #51's wound. R #54 E. Record review of R #54's Quarterly MDS assessment, dated 03/27/24, Section GG: Functional Abilities and Goals revealed: 1. Question GG0130.A - Eating; The resident is independent. The resident completed the activity by themselves with no staff assistance. 2. Question GG0130.C - Toileting hygiene; The resident required supervision or touching assistance. Staff provide verbal cues and/or touching/steadying as resident completes the activity. 3. Question GG0130.F - Upper body dressing; The resident is independent. The resident completed the activity by themselves with no staff assistance. 4. Question GG0130.G - Lower body dressing; The resident required supervision or touching assistance. Staff provide verbal cues and/or touching/steadying as resident completes the activity. 5. Question GG0130.I - Personal hygiene; The resident is independent. The resident completed the activity by themselves with no staff assistance. 6. Question GG0170.E - bed to chair transfer; The resident required partial/moderate assistance. One staff helps and provides less than half the effort. F. Record review of R #54's care plan, revision date 04/08/24, revealed: 1. EATING: R #54 requires supervision. 2. TOILETING: R #54 requires limited assistance (highly involved in performing a given activity, and yet still receives physical help in performing the activity). 3. DRESSING: R #54 requires limited assistance. 4. PERSONAL HYGIENE: R #54 requires supervision. 5. TRANSFERS: R #54 requires extensive assistance. G. On 05/22/24 at 2:44 PM, during an interview, the DON confirmed that R #54's care plan was not updated to reflect R #54's ADL abilities. R #102 H. On 05/19/24 at 2:40 PM, during an interview and observation, R #102's dentures were floating in his mouth. When R #12 would talk, his dentures would move and not stay in place. I. On 05/20/24 at 11:47 AM, during an interview, CNA #11 said that he helps R #102 with his dentures every day, putting them in, taking them out. CNA #11 said that R #102's dentures don't fit well. CNA #11 said that he has told the nurse several times that R #102's dentures don't fit well for a long time now. J. On 05/20/24 at 11:44 AM, during an interview, the DON said that she confirmed that R #102's dentures are moving in his mouth (the DON did not specify when she became aware of R #102's loose dentures). K. Record review of R #102's care plan dated 04/02/24 revealed the care plan did not have any documentation of dentures. L. On 05/22/24 at 10:17 AM, during an interview, the DON said that R #102's care plan should document that his dentures are not fitting well and what they are doing about it. R #103 M. On 05/19/24 at 2:23 PM, during an interview and observation, R #103 said that she didn't know when the last time she had been to the dentist was. It was observed that R #103 had missing front top teeth. R #103 said that she would like to have some dentures so that she could eat better. N. record review of R #103's medical record revealed the diagnosis complete loss of teeth, unspecified cause. O. Record review of R #103's MDS assessment dated [DATE] revealed Section L oral/dental status Check all that apply . Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose) was not selected. P. Record review of R #103's dental record dated March 2019, revealed that it is documented that R #103 has dentures. Q. Record review of R #103's care plan dated 03/23/24 revealed the care plan did not have any documentation of dentures, missing teeth, or oral care. R. On 05/22/24 at 10:45 AM, during an interview, the DON said R #103 did have dentures and said they were in her drawer. R #103 told the DON that she did not wear them because they did not fit well. The DON confirmed that R #103's dentures were not documented on R #103's care plan. The DON confirmed that R #103's dental care and dentures should be documented. R #202 S. Record review of a document (unnamed) for pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) revealed the following: a. R #202 acquired pressure injury in the facility on the coccyx . treatment: barrier cream for 02/19/24. b. 02/26/24 size 3.5x3, depth: 0.01, intervention code 9 (dressing), treatment: nothing checked. c. 03/12/24-no size or depth documented. 03/18/24-no size documented, depth: 0.01, treatment: barrier cream. d. 04/01/24-no size or depth documented, treatment: barrier cream. e. healed 04/03/24. T. Record review of R #202 care plan 04/23/24 revealed the care plan did not include R #202's the pressure ulcer wound (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time). U. Record review of R #202 Quarterly MDS dated [DATE] revealed the following: a. R #202 is at risk of pressure ulcers b. Section M Skin Conditions has no check marks for the pressure wound for R #202 V. On 05/22/24 at 10:04 AM, during an interview with the DON, she stated her expectation is for R #202's wound care or change of care be added on the care plan. The DON confirmed R #202 had a pressure ulcer and it was not added to the care plan. R #154 Timing of Care Plan Meetings W. Record review of R #154's face sheet revealed an admission date of 04/13/24. X. Record review of R #154's Quarterly Minimum Data Set assessment revealed it was in progress (not completed). Y. Record Review of R #154's Social Services Note, dated 05/20/24, revealed R #154 had a care plan meeting on 05/20/24 (not within 7 days after the completion of the quarterly MDS assessment). Z. On 05/21/24 at 11:57 AM, during an interview with the Social Services Worker (SSW), she confirmed the following: 1. R #154 had a care plan meeting on 05/20/24. 2. The MDS coordinator gives her a monthly calendar with the dates that the resident's MDS assessments are due to be completed so that she can schedule the care plan meetings accordingly. 3. She tries to schedule the care plan meeting about a week before the MDS assessment is scheduled to be completed (not within 7 days after the completion of the MDS assessment). Interdisciplinary Team Participation AA. Record Review of R #154's Social Services Note, dated 05/20/24, revealed the following: 1. R #154's representative attended the meeting. 2. The SSW, DON, and therapy worker attended the care plan meeting on 05/20/24. BB. On 05/21/24 at 11:57 AM, during an interview with the SSW, she confirmed the following: 1. She sets up the care plan meeting with the resident or their representative. 2. She invites the DON, activities director, dietary manager, SSW, director of therapy, the resident, and their representative. 3. She does not invite the provider or the CNA's. 4. She does not ask the provider or CNA's for their input prior to the care plan meeting. 5. She does invite the nurses, but they don't usually attend. 6. She does ask the nurses for concerns prior to the care plan meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure residents received appropriate treatment and services to maintain or prevent a decrease in range of motion for some of the 25 residents in the facility that could benefit from therapy services or a restorative nursing program (RNP; nursing service that often follows skilled rehabilitation services provided by physical or occupational therapists with the goal to maximize function and prevent functional decline in residents dependent on staff for certain actions) (resident were identified by the resident Census list provided by the Administrator on 05/19/24), when they failed to have a process to: 1) Evaluate residents for range of motion (ROM, the angular distance and direction a joint can move between the flexed and extended position) needs, and 2) Provide services to residents who could benefit from a RNP. These deficient practices could likely result in decreased mobility or a decrease in residents' abilities to participate or perform their own activities of daily living (ADLs). The finding are: A. On 05/22/24 at 10:42 AM, during an interview with the DOR, he revealed the following: a. Rehabilitative services staff do not evaluate every resident for ROM needs. b. Therapy evaluations are only completed for residents that have an order. c. Therapy does not recommend RNP for residents who do not qualify for therapy services or when they discharge from therapy because the facility does not have a RNP. d. There are several residents in the facility that would benefit from a RNP (did not specify which residents would benefit). B. Record review of R #156's face sheet revealed resident was admitted to the facility on [DATE]. C. On 05/19/24 at 2:15 PM, during an observation of R #156, revealed the following: 1. He laid in bed with the head of the bed flat. 2. The fingers on R #156's left hand were bent. D. On 05/19/24 at 2:15 PM, during an interview with R #156, he stated the following: 1. He had been unable to sit up for nine years. 2. He had arthritis in his hands, wrists, elbows, and fingers. 3. He wanted to be able to bend his hips to be able to sit in a chair. 4. He had not had a physical therapy or occupational therapy evaluation since he arrived. E. Record review of R #156's physician's orders revealed there were no orders for occupational therapy, physical therapy, or restorative nursing services. F. Record review of R #156's care plan, dated 05/08/24, revealed there were no interventions for increasing R #156's mobility or prevent a decrease in his range of motion (ROM). G. On 05/21/24 at 9:49 AM, during an interview with the Director of Rehabilitative Services (DOR), he confirmed the following: 1. R #156 did not have an order for therapy services or to be evaluated by therapy. 2. R #156 would be a good candidate for RNP. H. On 05/22/24, during an interview with CNA #21, she revealed the following: 1. She had not done any ROM exercises with R #156 or any other residents. 2. She had not been trained to provide ROM exercises with residents. I. On 05/21/24 at 9:50 AM, during an interview with the DON, she confirmed the following: 1. R #156 has pain when he moves. 2. R #156 lays in bed all the time. 3. R #156 has not had an evaluation for therapy. 4. CNA's are not trained or expected to complete ROM exercises with residents. 5. The facility does not have a RNP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that residents had a physician visit at least every 60 days for 3 (R #52, R #53, R #54, and R #202) of 5 (R #51, R #52, R #53, R #54, and R #202) residents reviewed for physician's visits. This deficient practice could likely result in residents not receiving the required medical assessment which could cause a delay in care and treatment of medical conditions. The findings are: R #52: A. Record review of R #52's Electronic Medical Record (EMR) revealed: 1. R #52 was admitted to the facility on [DATE]. 2. Last physician visit was on 12/17/23. R #53: B. Record review of R #53's EMR revealed: 1. R #53 was admitted to the facility on [DATE]. 2. Last physician visit was on 11/11/23. R #54: C. Record review of R #54's EMR revealed: 1. R #57 was admitted to the facility on [DATE]. 2. Last physician visit was on 12/17/23. D. On 05/22/24 at 2:20 PM, during an interview with the medical records clerks, she confirmed R #52 and R #54's last physician visit was on 12/17/23. She confirmed that the last visit for R #53 was on 11/11/23. E. On 05/22/24 at 2:44 PM, during an interview the DON confirmed that the information provided by the medical records clerk was correct and R #52, R #53, and R #54 did not have any additional physician's visits. R #202 F. Record review of R #202's admission record not dated, revealed R #202 admission date was 11/13/18. G. Record review of the physicians note dated 01/13/24, revealed R #202 was last seen by local doctor. H. Record review of R #202's entire medical record revealed no other physician notes were provided to confirm R #202 was seen again. I. On 05/22/24 at 10:04 AM, during an interview with the DON, she confirmed R #202 was last seen by local physician on 01/13/24, but there were no other follow-up progress notes. The DON stated all physician progress notes were requested but have not been obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents obtained dental services for 2 (R #102 and R #202) of 3 (R #102, R #103 and R #202) residents sampled for dental services, when they failed to ensure residents receive routine dental care to include an annual inspection of the mouth for signs of disease, dental cleaning, fillings, or minor partial or full denture adjustments. This deficient practice is likely to cause the resident unnecessary pain, embarrassment over the condition/appearance of teeth, and potential dental or oral complications. The findings are: A. Record review of R #102's medical record revealed an admission date of 03/08/23. B. On 05/19/24 at 2:40 PM, during an observation of R #102, R #102's dentures were floating in his mouth. When R #102 would talk, his dentures would move and not stay in place. C. On 05/20/24 at 11:47 AM, during an interview, CNA #11 said that he helps R #102 with his dentures every day, putting them in, taking them out, etc. CNA #11 said that R #102's dentures do not fit well. CNA #11 said that he has told the nurse several times that R #102's dentures do not fit well for a long time now. D. On 05/20/24 at 11:44 AM, during an interview, the DON said that she confirmed that R #102's dentures were moving in his mouth (the DON did not specify when she became aware of R #102's loose dentures). E. On 05/22/24 at 10:17 AM, during an interview, the DON said that R #102 has not been to a dentist. The DON confirmed that R #102 should see a dentist because R #102's dentures should not be moving as much as they are, and they should not be so loose. R #202 F. Record review of R #202's admission record no date revealed R #202 was admitted to the facility on [DATE]. G. On 05/20/24 at 9:30 AM, during an interview with R #202 Family Member, she stated that R #202 has not been taken to the dentist in a while (unknown date). H. Record review of R #202's entire medical record revealed the following: a. R #202 has not seen a dentist b. No dental appointments scheduled. I. On 05/20/24 at 3:09 PM, during an interview with LPN #32 he confirmed there were no dental appointments for R #202 and she had not seen by dentist since before she was admitted .

Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #51) of 4 (R #51, R #53, R #54 and R #202) residents reviewed for documentation accuracy. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information. The findings are: R #51 A. Record review of R #51's Skin only evaluation completed by LPN #3 on 04/19/24 revealed diabetic foot ulcer (a slow-healing wound that commonly appears on the ball of the foot due to complications of diabetes) of the left outer heel. B. Record review of R #51's physician's orders revealed, an order date 05/13/24, refer R #51 to [name of agency] wound care for in-house visits and treatment of any wounds. C. Record review of R #51's wound care consultation note dated 05/13/24 revealed, wound #1 is located to the left heel, wound #1 was at stage 2 pressure ulcer (open wound to the skin caused by pressure, that has progressed to affect both the top and bottom layers of the skin but has not yet affected the fatty tissue beneath). D. On 05/22/24 at 2:30 PM, during an interview the DON confirmed that the LPN #3 had documented the wound incorrectly as a diabetic foot ulcer and confirmed that R #51's wound was a pressure ulcer as documented by the wound care practitioner on 05/13/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide behavioral health training (training that helps staff recognize and respond to various behavioral and mental health issues that residents may present with) for 3 staff (RN #1, LPN #1, and CNA #1) of 4 (RN #1, LPN #1, CNA #1, and CNA #2) staff sampled for training. This deficient practice could likely result in residents not receiving the services necessary to attain or maintain their physical, mental, and psychosocial (involving both psychological and social aspects) well-being. The findings are: A. Record review of R #51's admission record (no date), revealed that she was admitted to the facility on [DATE] with the diagnosis of Unspecified mood (affective) disorder (condition that severely impacts mood). B. Record review of R #53's admission record (no date), revealed that she was admitted to the facility on [DATE] with the diagnosis of Schizoaffective disorder, bipolar type (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). C. Record review of R #54's admission record (no date), revealed that she was admitted to the facility on [DATE] with the diagnosis of Anxiety disorder, unspecified (condition where individuals experience anxiety-like symptoms that cause severe distress or impairment). D. Record review of staff training records revealed RN #1, LPN #1, and CNA #1 did not complete training for behavioral health needs. E. On 05/22/24 at 3:25 pm, during an interview the Administrator confirmed that RN #1, LPN #1, and CNA #1 did not have any additional trainings. F. On 06/10/24 at 2:53 PM, during an interview the DON confirmed the following: 1) RN #1's hire date was 07/12/21. 2) LPN #1's hire date was 09/14/23. 3) CNA #1's hire date 06/27/06. 4) RN #1, LPN #1, and CNA #1 do work with all residents in the facility. 5) The facility does admit residents mental health diagnosis (i.e. depression, anxiety, etc.).

Based on record review and interview, the facility failed to provide services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This deficient practice could affect all 25 residents, as identified on the facility census list provided by the Director of Nursing on 05/19/24. This deficient practice could likely result in residents not receiving the services they need for optimal quality of care. The findings are: A. Record review of the staff timesheets from 04/22/24 through 05/21/24 revealed that the facility did not have an RN present for 8 consecutive hours on the following dates: 1. 04/26/24 RN hours worked were 5 hours and 45 minutes. 2. 05/04/24 RN did not work any hours. 3. 05/10/24 RN hours worked were 7 hours and 36 minutes. 4. 05/13/24 RN hours worked were 7 hours and 18 minutes. B. On 05/22/24 at 3:18 PM, during an interview the administrator confirmed that a RN did not work on 05/04/24. The Administrator also confirmed that the facility did not have an RN for 8 hours on 04/26/24, 05/10/24, and 05/13/24.

Based on record review and interview, the facility failed to document the temperature of the walk-in refrigerator and walk-in freezer. This failure could potentially affect all 25 residents in the facility who eat food prepared in the kitchen (residents were identified by the Resident Matrix provided by the Administrator on 05/19/24). If the facility fails to adhere to safe food storage, residents could likely be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are: A. Record review of the walk-in refrigerator temperature log revealed temperatures were not documented at all for the following dates: 1. 05/11/24 2. 05/12/24. 3. 05/17/24 4. 05/18/24 5. 05/19/24 B. Record review of the freezer temperature log revealed temperatures were not documented at all for the following dates: 1. 05/11/24 2. 05/12/24 3. 05/17/24 4. 05/18/24 5. 05/19/24 C. On 05/21/24 at 12:39 PM, during an interview the DM reviewed the temperature logs and confirmed that they did have missing dates indicating that the temperatures were not checked and documented. The DM confirmed that the temperatures for the walk-in refrigerator and walk in freezer should be documented three times a day on the temperature logs. The DM said they are supposed to be checked every day and that kitchen staff is trained on how to check the temperatures and how and where to document the temperatures. The DM said that her expectation is that they actually look at the temperatures and document what the temperature is registering at the time.

Based on record review and interview the facility's Quality Assurance Performance Improvement (QAPI) Committee failed to establish and implement policies and procedures for feedback, data collections system, monitoring, and adverse event monitoring. This deficient practice could likely result in the facility not having opportunities for improvement, obtaining feedback from staff, the residents and the resident's representative to identify problems or concerns. The findings are: A. Record review of the Quality Assurance Performance Improvement (QAPI) Committee binder revealed, the facility do not have any policies and procedures in place. B. On 05/22/24 at 2:43 PM during an interview the Administrator confirmed did not have policy and procedures for QAPI. The Administrator stated that the facility was in the process of updating the policies and procedures for QAPI since previous policy and procedures were not working for the facility. The Administrator stated they also had new staff that needs to be retrained on the new QAPI policies and procedures.

Based on record review and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections when they failed to have a water management program to minimize the risk of Legionella [a bacteria that can grow in parts of building water systems that are continually wet (e.g., pipes, faucets, water storage tanks, decorative fountains) and cause a serious type of pneumonia], and other opportunistic pathogens (bacteria that do not usually cause diseases in healthy people but may become extremely injurious to unhealthy individuals) in the building's water system. This failure could potentially affect all 25 residents who live in the facility (residents were identified by the Resident Matrix provided by the Administrator on 05/19/24). If the facility fails to maintain an effective infection control program, then infections could spread to residents throughout the facility, resulting in illness. The findings are: A. Record review of the facility's infection control program revealed the facility did not have a water management program to minimize the risk of Legionella and other opportunistic pathogens from spreading through the facility's water system. B. On 05/21/24 at 12:46 PM, during an interview with the Maintenance Director, he confirmed the following: 1. He was unaware of any water management program the facility had to minimize the risk of Legionella and other opportunistic waterborne pathogens from growing. 2. He did not have a map of the water system and potential sources for the growth of waterborne pathogens. 3. He was unaware of where Legionella or other waterborne pathogens can grow. C. On 05/21/24 at 12:51 PM, during an interview with the Administrator, she confirmed the facility did not have a water management program in place to minimize the risk of Legionella or other opportunistic waterborne pathogens. D. On 05/22/24 at 9:46 AM, during an interview with the Infection Control Nurse, he confirmed that he had not been doing anything to minimize the risk of Legionella or other opportunistic waterborne pathogens.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to create a Baseline Care Plan (a plan that includes the instructions needed to provide effective and person-centered care upon admission) within 48 hours of admission for 1 (R #126) of 1 (R #126) resident sampled for Baseline Care Plans. This deficient practice could likely result in the resident not receiving the appropriate care and services and may place the resident at risk of harm. The findings are: A. Record review of R #126's admission Record revealed that R #126 was admitted on [DATE] and had the following principal diagnosis: Displaced fracture (bone broken into two or more parts) of fifth metatarsal (bone on the base of the small toe). R #126's admission record also included diagnosis of Major Depressive Disorder, Recurrent (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities). B. Record review of R #126's Physician's orders revealed: Order date 06/08/23 Citalopram (medication to treat depression) 10 MG Give 1 tablet by mouth in the morning . C. Review of R #126's Baseline Care Plan created 06/08/23 did not reveal care planning for the fracture or for antidepressant medication. D. On 06/15/23 at 2:42 PM, during an interview, the ADON confirmed that R #126's Baseline Care Plan did not include a plan for the principal diagnosis (foot fracture) or the antidepressant medication.

Based on record review and interview, the facility failed to ensure documents in resident records were complete for 1 (R #77) of 2 (R #77 and R #126) residents reviewed for advanced directives (legal document in which a person specifies what actions should be taken for their health when they are no longer able to make decisions for themselves, due to illness or incapacity). This deficient practice could likely result in staff not knowing a resident's medical intervention wishes and could result in delay of care, or going against a resident's wishes. The findings are: A. Record review of R #77's Medical Records revealed: 1. admission date of 05/31/23 2. Advance Directive form dated 05/31/23 revealed the Signature of Authorized Health Provider was blank. B. On 06/15/23 at 2:33 PM, during an interview, the Administrator confirmed that a physician still needs to sign R #77's Advance Directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that a comprehensive assessment was completed within 14 days of admission for 2 (R #9 and R #23) of 9 (R #3, R #5, R #7, R #9, R #15, R #17, R #18, R #19 and R #23) residents sampled for MDS (Minimum Data Set/comprehensive health) assessment. This deficient practice could likely lead to residents' needs and preferences not being met. The findings are: R #9 A. Record review of R #9's admission Record revealed she was admitted to the facility on [DATE]. B. Record review of R #9's MDS assessment revealed Signature of RN Assessment Coordinator verifying assessment completion signed on 02/13/23. R #23 C. Record review of R #23's admission Record revealed she was admitted to the facility on [DATE]. D. Record review of R #23's MDS assessment revealed Signature of RN Assessment Coordinator verifying assessment completion signed on 02/22/23. E. On 06/15/23 at 2:32 PM, during an interview, the ADON stated that the facility was aware of the situation and confirmed that the MDS assessments had not been completed within 14-days of admission for R #9 and R #23.

Based on record review and interview, the facility failed to ensure that 4 (R #3, R #5, R #7, and R #9) of 9 (R #3, R #5, R #7, R #9, R #15, R #17, R #18, R #19 and R #23) residents reviewed for Resident Assessments had MDS (Minimum Data Set; Comprehensive Assessment) transmitted (sent electronically and accepted into the CMS [Centers for Medicare and Medicaid services] system) within 14 days of completion. This deficient practice could likely lead to residents receiving less than optimal care. The findings are: R #3 A. Record review of R #3's Quarterly MDS revealed the assessment was completed on 04/24/23. B. On 06/15/23 during a record review of R #3's MDS assessments, it revealed the Quarterly MDS assessment had not been transmitted. R #5 C. Record review of R #5's Quarterly MDS revealed the assessment was completed on 05/02/23. D. On 06/15/23 during a record review of R #5's MDS assessments, it revealed the Quarterly MDS assessment had not been transmitted. R #7 E. Record review of R #7's Quarterly MDS revealed the assessment was completed on 05/09/23. F. On 06/13/23 during a record review of R #7's MDS assessments, it revealed the Quarterly MDS assessment had not been transmitted. R #9 G. Record review of R #9's Quarterly MDS revealed the assessment was completed on 04/25/23. H. On 06/13/23 during a record review of R #9's MDS assessments, it revealed the Quarterly MDS assessment had not been transmitted. I. On 06/15/23 at 2:32 PM, during an interview, the ADON stated that the facility was aware of the situation and confirmed that the MDS assessments had not been transmitted within 14-days of completion for R #3, R #5, R #7, and R #9.

Based on observation, interview, and record review, the facility failed to provide respiratory care (health care discipline specializing in the promotion of optimum cardiopulmonary function, health and wellness) that was consistent with professional standards of practice for 1 (R #6) of 1 (R #6) resident sampled for respiratory care when they failed to change R #6's nasal cannula (medical device to provide supplemental oxygen therapy to through the nose) within 7 days of the previous change. This deficient practice could likely cause the nasal cannula to become obstructed, non-functional, and unsanitary and not provide the resident with the oxygen needed. The findings are: A. Record review of R #6's Physicians Orders dated 04/19/23 revealed Oxygen gas; 4 Liters. Amount to administer 4 Liters/minute (L/m)via nasal cannula continuous for COPD (Chronic Obstructive Pulmonary Disease: airflow blockage and breathing-related problems) . B. Record review of R #6's Care Plan dated 04/15/23 revealed Impaired Gas Exchange Chronic Obstructive Pulmonary Disease (COPD) . Administer oxygen as prescribed or per standing order set concentrator to 4L nasal cannula and monitor for desaturation (a decrease in the oxygen of 3% or 4% or more from baseline (a minimum or starting point used for comparisons). C. On 06/11/23 at 2:34 PM, during an observation of R #6 in the dining area, it was observed that R #6's nasal cannula had a piece of tape indicating the date of last change was 06/04/23. D. On 06/11/23 at 2:34 PM, during an interview with R #6, she stated that staff usually change her nasal cannula every Sunday evening. E. On 06/13/23 at 12:00 PM, during an observation of the dining area, it was observed that R #6's nasal cannula had a piece of tape indicating that the date of last change was 06/04/23. F. On 06/13/23 at 12:00 PM, during an interview with CNA #11, she confirmed that R #6's cannula had not been changed since 06/04/23 (more than 7 days). G. On 06/15/23 at 12:09 PM, during an interview with the Administrator, she stated that resident nasal cannulas are supposed to be changed once a week.

Based on interview and record review, the facility failed to ensure that medically-related social services were provided for 1 (R #3) of 3 (R #3, R #5 and R #127) residents reviewed for behavioral/emotional health. This deficient practice could likely lead to residents not attaining, or maintaining, their highest practicable mental and psychosocial well-being. The findings are: A. On 06/12/23 at 12:50 pm, during an interview, R #3 stated that she gets sad because no one visits with her and even other residents just walk by my room .it hurts to be here and not have anyone. B. Record review of R #3's admission Record (no date) revealed the diagnosis of Schizoaffective disorder, bipolar type (mental health disorder that can include hallucinations or delusions with periods of heightened emotion, ranging from joy to rage) and Depression (mood disorder that causes a persistent feeling of sadness and loss of interest). C. Record review of R #3's Electronic Medical Record (EMR) revealed that she receives behavioral health services for medication management from the local health services center. D. Record review of R #3's EMR and Progress Notes from 12/01/2022 through 06/15/2023 revealed no documentation of social service visits. E. On 06/15/23 at 2:38 pm, during an interview, the ADON stated that the facilities new social services staff member just started the week of 06/05/23 and confirmed that there were no progress notes or records showing that the previous social services staff member worked with R #3. The ADON stated she is currently working on getting contracted mental health personnel to come to the facility to complete counseling visits with residents.

Based on record review and interview, the facility failed to ensure that psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) were prescribed for specific diagnoses for 1 (R #7) of 1 (R #7) resident sampled for unnecessary medications, when they failed to use an approved diagnosis for use of psychotropic medication. This deficient practice could likely result in residents receiving improper medications. The findings are: A. Record review of physician orders for R #7 dated 05/03/23 revealed: 1. RisperDAL Tablet 0.5 MG (risperiDONE) [used to treat schizophrenia, bipolar disorder, or irritability associated with autistic disorder] Give 1 tablet by mouth in the evening for Behavior Management related to Unspecified Mood [Affective] Disorder. 2. Black box warning (required by the FDA for certain medications that carry serious safety risks) states, Increased mortality (the state of being subject to death) in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Risperidone is not approved for the treatment of patients with dementia-related psychosis. B. On 06/14/23 at 1:44 PM, during an interview with the ADON, she confirmed that the R #7 did not have a proper diagnosis for Risperdal and said that is why they have scheduled a senior psychiatric evaluation for R #7. ADON further stated she is working on getting Senior Psychcare (elderly mental health services) referrals for every resident on psychotropic medications. C. On 06/15/23 at 12:02 pm, during an interview with the Administrator, she stated that proper evaluations have not been getting done for residents on psychotropic medications and she is in the process of getting them done. The Administrator further stated that R #7 did not have an acceptable diagnosis for Risperdal.

Based on observation and interview, the facility failed to properly store medication in the medication cart for 1 (R #13) of 8 (R #4, R #8, R #9, R #11, R #12, R#13, R #17 and R #126) residents reviewed during medication pass when the facility failed to ensure R #13's medication was not expired. This deficient practice could result in residents receiving medication that is ineffective. The findings are: A. On 06/14/23 at 2:35 pm, during an observation of the medication cart, R #13's Polymyxin B (antibiotic used to treat infection) drops were opened on 03/01/23 and expired on 05/01/23. B. On 06/14/23 at 2:36 pm, during an interview, RN #1 confirmed that R #13's Polymixin B drops were expired but, were still being used because it is only being used for R #13's feet. C. On 06/15/23 at 2:42 PM, during an interview, the ADON confirmed that expired medications should be removed from the medication carts upon expiration.

Based on observation and interview, the facility failed to store and serve food under sanitary conditions in accordance with professional standards of food service safety. This could affect all 25 residents in the facility who eat food prepared in the kitchen (residents were identified Resident Matrix provided by the Administrator on 06/11/23), when they failed to: 1. Ensure food items in the dry pantry were labeled and dated, 2. Perform hand hygiene, 3. Handle resident's plates in a sanitary manner, 4. Ensure boxes were off the floor. If the facility fails to adhere to safe food handling practices, hygiene practices, and safe food storage, residents are likely to be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are: A. On 06/11/23 at 10:29 am, during an observation of the kitchen's dry pantry revealed the following: 1. 2 packs of crackers with no open date or expiration dates 2. 1 pack of goldfish crackers with no open date or expiration date 3. Salad dressing with no open date or expiration date 4. 6 stacks of boxes sitting directly on the floor B. On 06/11/23 at 10:31 am, during an observation of the kitchen's freezer and refrigerator revealed 1 box sitting directly on the floor in the freezer and 1 box on the floor in the refrigerator. C. On 06/11/23 at 12:09 pm, during dining observation revealed that Dietary Aid (DA) #21 was wearing 1 pair of gloves throughout meal time and serving residents drinks and passing out food trays, with no hand hygiene done between tasks. D. On 06/12/23 at 12:11 pm, during an interview, the Dietary Manager confirmed that DA #21 should be performing hand hygiene between tasks, and should not be wearing the same pair of gloves throughout meal time. E. On 06/12/23 at 12:20 pm, during dining observation, LPN #21 was observed passing out food in the dining room and had her thumb on the plate, and no hand hygiene was done between tasks. F. On 06/13/23 at 1:13 pm, during and interview, the Infection Control nurse confirmed that the staff should not be handling the food plates with their thumb in the plate, and he is was working on an in-service for all staff. G. On 06/13/23 at 1:20 pm, during and interview, the Dietary Manager confirmed that the items in the dry pantry should have a date when its opened, and an expiration date. She also confirmed that the staff should be performing hand hygiene between tasks, and no boxes should be left on the floor.

Based on interview and record review, the facility failed to ensure that licensed nurses (RN's and LPN's) and CNA's are able to demonstrate competency in skills and techniques necessary to care for residents' needs. This could affect all 25 residents in the facility (residents were identified by Resident Matrix provided by the Administrator on 06/11/23). This deficient practice could likely result in Nurses and CNA's working with residents without adequate competencies to do; so resulting in injury or inappropriate care being provided to the residents. The findings are: A. Record review of the personnel files revealed no competencies for the following staff: LPN #2, RN #22, RN #23, CNA #21, CNA #22, and CNA #23. B. On 06/15/23 at 2:33 pm, during an interview, the Infection Preventionist revealed that there were no competencies on file for any of the nurses or CNA's. During an interview at that time, the Administrator confirmed that no competencies had been completed for any of the nursing staff.

Based on record review and interview, the facility failed to have full-time Director of Nursing (DON). This has the potential to affect all 25 residents in the facility, (residents were identified by the Resident Matrix provided by the Administrator on 06/11/23). This deficient practice could likely result in residents not receiving the services that they need for optimal quality of care. The findings are: A. Record review of the facility's staff list revealed the facility did not have a DON (or acting DON). B. On 06/11/23 at 2:33 pm, during an interview, the Administrator confirmed that the facility did not have a DON employed at that time.

Based on record review and interview, the facility failed to provide performance reviews and specific in-service education, based on the outcome of those reviews for 3 (CNA #21, CNA #22, and CNA #23) of 3 (CNA #21, CNA #22, and CNA #23) CNA's reviewed for education. This deficient practice could likely result in CNA's not getting the training competencies needed to care for their residents, resulting injury or insufficient care to residents. The findings are: A. Record review of CNA's #21, #22, and #23 personnel files revealed no performance reviews. B. On 06/15/23 at 2:33 pm, a joint interview with the Infection Preventionist and Administrator revealed that there were no performance reviews on file for CNA #21, CNA #22, and CNA #23.

Based on record review and interview, the facility failed to submit direct care staffing information to the federal agency overseeing certification for long term care facilities for January 2023-March 2023. This has the potential to affect all 25 residents in the facility, (residents were identified by the Resident Matrix provided by the Administrator on 06/11/23). This deficient practice could likely result in inaccurate direct care staffing information for residents/facility. The findings are: A. Record review of Payroll Base Journal (PBJ) Staffing Data Report (report from the data base of the federal agency overseeing certification for long term care facilities) dated, Quarter #2 2023 (January 1 - March 31) revealed: 1. Failed to Submit Data for the Quarter. B. On 06/15/23 at 2:33 PM, during an interview, the Administrator revealed that she started her employment at the facility at the end of March 2023 and could not answer as to why the PBJ was not submitted for Quarter #2.

Based on record review and interview, the facility failed to ensure that 3 (CNA #21, CNA #22, and CNA #23) of 3 CNA's (CNA #21, CNA #22, and CNA #23) received their required annual training of no less than 12 hours per year. This deficient practice could likely result in CNA's not receiving the necessary training to meet the care needs of the residents. The findings are: CNA #21: A. Record review CNA #21's online training revealed: 1. No 12 hours of in-services per year, 2. No Abuse/Neglect training, and 3. No training on identifying resident needs (behavioral health, communication) CNA #22: B. Record review of CNA #22's online training revealed: 1. No 12 hours of in-services per year, and 2. No training on identifying resident needs (behavioral health, communication) CNA #23: C. Record review of CNA #23's online training revealed: 1. No 12 hours of in-services per year, 2. No Abuse/Neglect training, 3. No Dementia training, and 4. No training on identifying resident needs (behavioral health, communication) D. On 06/15/23 at 2:33 PM, during a joint interview with the Infection Preventionist and Administrator revealed that the 12 hours of annual training for CNA #21, CNA #22, and CNA #23 were not completed. The Administrator also confirmed CNA #21, CNA #22 and CNA #23 were missing the above trainings.