**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, the facility failed to place a resident's (Resident #83) call light within reach to allow for the resident to request staff assistance this was for 1 of 7 residents reviewed for accommodation of needs. The findings included: Resident #83 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis of one side of the body) affecting left side, need for assistance with personal care, and type 2 diabetes mellitus. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #83 was cognitively intact. He was dependent on staff for toileting hygiene, transfers, and dressing. He required maximum assistance with shower/baths, bed mobility, and dressing and moderate assistance with personal hygiene. He was always incontinent of bowel and bladder. He had functional limitation with range of motion of one side of his upper extremities. Resident #83 ' s care plan, last reviewed on 07/18/24, indicated he had an activities of daily living (ADL) self-care performance deficit related to hemiplegia and stroke. The interventions included for staff to encourage the resident to use bell to call for assistance. Another focus read Resident #83 had an actual fall and was at risk for further falls related to poor trunk control. The interventions included for staff to ensure resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needs a prompt response to all requests for assistance. A continuous observation was conducted on 08/05/24 from 12:11 PM through 12:32 PM of Resident #83. Resident #83 was lying in bed watching television. His lunch tray was brought in by Nursing Assistant (NA) #1. NA #1 raised the head of the bed up and assisted Resident #83 with setting his meal tray up and then exited the room. Resident 83 ' s call bell was on the floor out of his reach. An interview was conducted on 08/05/24 at 12:45 AM with Resident #83. He stated his call bell falls to the floor a lot and staff often forget to give it to him. He explained that he would wait for the nurse to bring in his medications or he would yell when he saw someone in the hall if he needed assistance. He also stated the call bell doesn ' t do any good if it was on the floor and it made him uneasy when he couldn ' t reach it. An observation and interview were conducted with Nursing Assistant (NA) #1 on 08/05/24 at 2:41 PM. He verified he was the direct care NA for Resident #83. He also verified the call bell in Resident #83 ' s room was on the floor beside the bed and out of his reach. He explained that he was in his room to give him his lunch try earlier but forgot to check call bell placement at that time. NA #1 then stated he did not realize Resident #83 ' s call bell was on the floor. He indicated he usually checks the call bell before leaving the rooms. NA #1 could not recall when Resident #83 last had his call bell. An interview was conducted on 08/07/24 at 12:43 PM with the Administrator and the Director of Nursing. They both stated the call bell should always be within the residents ' reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, the facility failed to protect 1 of 4 residents (Resident #19), for his right to be free from physical abuse as evidence by another resident (Resident #9) slapping him with an open hand to the side of his head. The findings included: Resident #9 was admitted to the facility on [DATE] with diagnoses that included schizophrenia and hemiplegia and hemiparesis of the left non-dominant side. Resident #9 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated his cognition was intact. He exhibited no behavior during the look-back period. Resident #9 ' s care plan, last reviewed on 07/29/24 revealed a focus that read he was verbally aggressive related to poor impulse control. Resident was verbally aggressive and threatened bodily harm to staff and other residents. The interventions included when Resident #9 became agitated for staff to intervene before agitation escalated, guide him away from source of distress, and engage calmly in conversation. Resident #19 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy, depression, and manic depression (bipolar disease). Resident #19's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated his cognition was intact. He exhibited no behavior during the look-back period. Resident #19 ' s care plan, last reviewed on 07/19/24 revealed a focus for him having a behavior problem. Resident #19 was easily agitated, episodes of refusing care, and hitting self when agitated. The interventions included he had episodes noted where he would yell out, [NAME], [NAME], bang, bang at inappropriate times and for staff to monitor behavior episodes and attempt to determine underlying cause. Another focus read that he had a communication problem related to him usually understanding verbal content, he usually understood others, and he had unclear speech. The interventions included to ensure/provide a safe environment and avoid isolation. The Facility Reported Incident (FRI) dated 07/22/24, revealed Resident #19 was witnessed striking his roommate, Resident #9. The report indicated the residents were immediately separated and an investigation began. The report also indicated there was no physical or mental injury or harm. Law enforcement was notified on 07/22/24 at 10:50 AM. A Behavior note dated 07/21/24 revealed Nursing Assistant (NA) #3 was walking past Resident #19 & #9 ' s room and witness Resident #19 slap Resident #9 in the face. Resident #19 stated he slapped Resident #9 because he wanted him to shut up. Resident #19 was educated to keep his hands to himself and stay on his side of the room. Attempts to interview NA #3 were unsuccessful. A statement written by Nursing Assistant #3 dated 07/22/24 revealed on 07/21/24 as she was walking down the hall, she could hear Resident #9 talking to himself as he did every night. She stopped at the room door and witnessed Resident #19 at Resident #9 ' s bed and he yelled, shut the f**k up. She immediately went into the room to intervene but before she could get to the residents Resident #19 slapped Resident #9 with an open hand on his right hand/forearm. Resident #9 ' s right arm was up near his face and when his arm came down it hit his face. She yelled for the nurse to assist. A phone interview was conducted on 08/08/24 at 4:20 PM with Nurse #2. She verified she was the nurse for Resident #19 and #9 on 07/21/24. She stated the Nursing Assistant (NA) #3 informed her Resident #19 slapped Resident #9 and she immediately separated the two residents. Nurse #2 explained Resident #19 stated he slapped Resident #9 because he would not stop talking. She moved Resident #9 to a different room. She indicated prior to the incident Resident #9 was talking to himself while he was in bed. He was not yelling or cussing. An interview with Resident #19 was conducted on 08/06/24 at 11:40 AM. He explained that Resident #9 was cussing him on 07/21/24 so he got up from his bed and slapped him across the head. He further explained Resident #9 just kept repeating the same words over and over and would not shut up, he was tired of hearing him. He stated he was not trying to hurt Resident #9 he just wanted him to be quiet. An interview with Resident #9 was conducted on 08/06/24 at 11:55 AM. His speech was very hard to understand due to talking very low and he mumbled at times. He answered yes and no questions appropriately. He stated Resident #19 slapped him with an open hand but did not explain why or any other details. He denied being in pain or being fearful when Resident #19 slapped him or afterwards. Interview with the Administrator was conducted on 08/07/24 at 12:43 PM. She indicated the residents had been a good match for roommates up until that point and she never expected an altercation would occur. She stated Nurse #2 moved Resident #9 to a different room immediately and the nurse started the investigation, which was what she would expect the nurse to do. She further stated Resident #19 and Resident #9 have continued to reside at the facility on different halls. However, the nurse should have called her to notify her of the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, Nurse #2 failed to implement the reporting portion of the abuse policy after Nurse Aide #3 (NA #3) told her Resident #19 slapped Resident #9 on the right hand/forearm. The facility also failed to notify Adult Protective Services (APS) regarding an allegation of abuse. This was for 1 of 4 Residents (Resident #9) reviewed for abuse. The findings included: a. A review of the facility's Abuse policy, last revised 2023, revealed new employees will be educated on the reporting process for abuse during the initial orientation. The policy read in part: The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes. A phone interview was conducted on 08/08/24 at 4:20 PM with Nurse #2. She verified she was the nurse for Resident #19 and #9 on the night of 07/21/24. She stated at approximately 2:45 AM NA #3 informed her Resident #19 slapped Resident #9, and she immediately separated the two residents. She moved Resident #9 to a different room. She also stated Resident #9 stated Resident #19 hit him and denied pain after he was slapped. She indicated prior to the incident Resident #9 was talking to himself while he was in bed. He was not yelling or cussing. She further stated she did not call to report the incident to the Administrator because she was unaware of the facility policy. Her main concern was to keep Resident #9 safe. Review of the orientation training, dated 07/19/24 through 07/22/24, which included the abuse policy, fire safety and emergency preparedness, was signed by Nurse #2 on 07/21/24 (after the incident). An interview with the Director of Nursing was conducted on 08/06/24 at 1:15 PM. She stated Nurse #2, agency nurse, was the nurse on duty when Resident #19 slapped Resident #9. She explained Nurse #2 did not notify the administration after the incident because she did not feel it was abuse. The DON further explained that orientation training was given to Nurse #2 on 07/21/24 (after the incident). An interview with the Administrator was conducted on 08/06/24 at 1:39 PM. She explained that Nurse #2, an agency nurse, was the nurse on duty when Resident #19 slapped Resident #9. She stated she had Nurse #2 come to the facility on [DATE] to write a statement related to the incident. When she questioned her on why she did not notify administration after Resident #19 slapped Resident #9 Nurse #2 told her because she did not feel it was abuse. Nurse #2 was reeducated on the abuse policy at that time. The Administrator then stated she expected nursing staff to report any type of abuse to the Administrator and/or the Director of Nursing immediately. b. An interview with the Administrator was conducted on 08/06/24 at 1:39 PM. She stated she submitted an initial report of abuse to the state regulatory agency on 07/22/24 regarding Resident #19 slapping Resident #9. She explained that she did not notify APS until 07/29/24 because she was unaware that she needed to report to APS. She indicated that she recently moved to North Carolina and her former state did not have to report to APS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff, Medical Director (MD) interviews and record review, the facility failed to complete a significant change Minimum Data Set (MDS) after 2 areas of significant decline. This was for 1 of 19 residents reviewed for MDS accuracy (Resident #24). The findings included: Resident #24 was admitted on [DATE] with cumulative diagnoses congestive heart failure, chronic obstructive pulmonary disease, and dementia. Review of his quarterly MDS dated [DATE] indicated Resident #24 had severe cognitive impairment and required substantial staff assistance with Activities of Daily Living (ADLs). He was coded as frequently incontinent of bladder and always incontinent of bowel, weight of 111 pounds with no known weight loss, and no pressure ulcers. A review of Resident #24's medical record revealed he developed a stage 3 ulcer described as pressure to his sacrum on 6/7/24. A review of Resident #24's weights for the last 3 months from 5/2/24 (113.2 pounds) to 7/25/24 (102.6 pounds) was a loss of 10.6 pounds or 9.36% weight loss in 3 months. Review of Resident #24's comprehensive care plan revealed a care area revised on 6/10/24 regarding a pressure ulcer to his sacrum related to incontinence, cognitive decline. New interventions included to assess, record and monitor wound healing and report improvements or declines to the MD, and to educate family and caregivers on importance of positioning/repositioning, mobility, nutrition and incontinence care. Another care area which had been revised on 6/14/24 regarding his potential for nutritional problems related to his mechanically altered and therapeutic diet and include significant weight changes. There were new interventions in place including a protein supplement and zinc added to aid in his wound healing. An interview was completed on 8/6/24 at 12:20 PM with the MD. He stated Resident #24 has had an overall physical decline in the last 3 months or so and his family had decided to go with comfort care rather than hospice. He stated as his condition progressed, the facility would continue to treat his pressure ulcer and his weight loss, but his family stated they did not want Resident #24 sent out to the hospital. The MD stated his pressure ulcer and weight loss were unavoidable. An interview was completed on 8/7/24 at 11:45 AM with the MDS Nurse. She stated she revised Resident #24's care plan for his newly developed pressure ulcer and weight loss in June and then opened a quarterly MDS on 7/23/24 and should have realized that a significant change MDS was needed instead of the quarterly. She stated it was her oversight. An interview was completed on 8/7/24 at 12:24 PM with the Administrator and the Director of Nursing (DON). The DON stated Resident #24 has had a continuous decline in recent months and a significant change MDS would have been expected before now. The Administrator stated she expected the MDS Nurse to have caught the 2 area of decline since those areas had already been captured in his care plan in June.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to provide abuse training to Nurse #2 prior to her working at the facility. This was for 1 of 5 employees reviewed for abuse training. The findings included: An interview with the Director of Nursing (DON) was conducted on 08/06/24 at 1:15 PM. She stated there was an incident of resident to resident abuse on 07/21/24 at 2:45 AM. Nurse #2, agency nurse, was the nurse on duty when Resident #19 slapped Resident #9. The DON explained Nurse #2 did not notify the administration after the incident because she did not feel it was abuse. The DON further explained that orientation training, which included the abuse policy, was given to Nurse #2 on 07/21/24. Review of orientation training, dated 07/19/24 through 07/22/24, which included the abuse policy, was signed by Nurse #2 on 07/21/24 at 7:00 PM. A phone interview was conducted on 08/08/24 at 4:20 PM with Nurse #2. She verified 07/20/24 was the first time she worked at the facility and then returned on 07/21/24 from 7:00 PM until 7:00 AM. She also verified she was the nurse for Resident #19 and #9 on the night of 07/21/24. She stated at approximately 2:45 AM on 07/21/24 Nursing Assistant (NA) #3 informed her Resident #19 slapped Resident #9 and she immediately separated the two residents. She moved Resident #9 to a different room. Nurse #2 further stated she did not call to report the incident to the Administrator because she was unaware of the facility policy regarding abuse. Nurse #2 then stated she received orientation education from the Director of Nursing which included the abuse policy on 07/21/24 at 7:00 PM. An interview with the Administrator was conducted on 08/06/24 at 1:39 PM. She explained that Nurse #2, an agency nurse, was the nurse on duty when Resident #19 slapped Resident #9. She stated she had Nurse #2 come to the facility on [DATE] to write a statement related to the incident. When the Administrator questioned her on why she did not notify administration after Resident #19 slapped Resident #9, Nurse #2 told her because she did not feel it was abuse. Nurse #2 was reeducated on the abuse policy on 07/22/24 by Administrator. The Administrator indicated the goal was for agency staff to be provided orientation prior to working their first shift by the DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, resident, and staff interviews, the facility failed to protect a resident's right to be free from sexual abuse for 2 of 2 residents investigated for resident-to-resident sexual abuse (Resident #1, resident #2). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included cerebral infarct, traumatic brain injury, and dementia. The resident's quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was severely visually impaired and severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 3 out of 15. The resident required extensive assistance of one person to complete bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS reflected the resident did not have behavioral symptoms directed toward others, to include public sexual acts, during the assessment period. Resident #1's care plan last revised on 9/12/2023 contained a focus for impaired cognition related to history of cerebral vascular accident (stroke) and traumatic brain injury. Interventions included verbal cueing and reorientation as needed. The care plan also had a focus for inappropriate sexual behaviors as evidence by masturbating in public/common areas. Interventions included redirecting the resident and removing the resident from public areas to a more private area. Resident #1 was followed by the Psychiatric Mental Health Nurse Practitioner (PMHNP). An after-visit summary dated 9/28/2023 indicated the resident was seen for neurocognitive disorder due to dementia without behaviors. Staff reported no concerns or behaviors. No apparent changes in behavior were noted by the PMHNP. Resident #1 was receiving Aricept for cognitive support and Depakote for mood stabilization. He also received fluoxetine for mood and anxiety symptoms. Recommendations were to continue current medications and redirection as needed. Resident #2 was admitted to the facility on [DATE] with diagnoses that included dementia without behaviors, psychotic disturbance, mood disturbance, and anxiety. The resident's MDS dated [DATE] documented Resident #2 was cognitively intact with a BIMS of 14 out of 15. Resident #2 required minimum assistance with dressing, toileting, and personal hygiene during the assessment period. He required supervision only for ambulation. He received no medications and had no behaviors during the assessment period. Resident #2's care plan was last updated on 8/10/2023. The care plan contained a focus for risk of impaired thought process related to dementia. Interventions included administering medications as ordered and monitoring for changes in behaviors and side effects. On 10/5/2023 the care plan was revised to include a focus for inappropriate sexual behavior. The interventions included the use of redirection and monitoring for behaviors. Resident #2 was followed by the PMHNP. An after visit summary dated 10/2/2023 indicated the resident was seen for neurocognitive disorder related to Alzheimer's type dementia. He was receiving Namenda and Aricept for cognitive support and was tolerating medication. Staff reported no concerns or issues. The PMHNP recommended no medications changes at that time. Record review revealed Resident #1 and Resident #2 were roommates from 5/3/2023 until 10/5/2023. The resident's medical record included a nursing note dated 10/5/2023. A Nurse Assistant (NA) observed Resident #2 standing next to Resident #1's bed. Resident #1 was lying in his bed. Resident #2 has his penis in Resident #1's mouth. The Medical Director (MD) was notified of the incident. Both residents' Responsible Party (RP) were notified by the Social Worker (SW) and the residents were separated and placed on every 15-minute (Q15) safety checks. The medical record contained a nursing note by the Unit Manager dated 10/5/2023 noted Resident #1 made a statement about letting Resident #2 come back to finish. Resident #1 was assessed. There was no oral trauma or evidence of semen when oral care was completed. A nursing progress note by the Unit Manager dated 10/5/2023 revealed Resident #2 was assessed to have no injury. He was immediately relocated to another room. The resident was angry, agitated, and yelling out in response to being moved into another room. Resident #1 was assessed by PMHNP on 10/11/2023. Per the visit summary, when the PMHNP asked Resident #1 about the incident with his roommate, he indicated it was consensual but would not disclose any additional information or answer any other questions regarding the incident. Resident #2 was assessed by the PMHNP on 10/11/2023. Per the visit summary, the resident could not recall the incident when asked about staff reports of Resident #2 participating in oral sex with his roommate. An interview was conducted with Resident #2 on 10/11/2023 at 8:15AM. He was in a private room. There was no staff in the room or outside the door of Resident #2's room. Resident #2 stated he did not recall an incident on 10/5/2023. He stated he did have a roommate up until 10/5/2023. He did not know why the facility staff moved him to another room. An interview was conducted with Resident #1 on 10/11/2023 at 11:00AM. He stated he did not recall the incident between him and his roommate on 10/5/2023. He further stated he had not been asked to participate in sexual activities against his will. He felt he was in a safe place. A second interview with Resident #1 at 2:06PM. He stated he could not recall the incident that occurred on 10/5/2023. He denied being asked to participate in sexual activity against his will. He stated he felt he was in a safe place. Nurse Assistant (NA) #1 was interviewed on 10/11/2023 at 11:15AM. She stated she entered the room of Resident #1 and Resident #2 to obtain a weight on Resident #2. She stated when she entered the room, the curtain between the beds was pulled. As she looked around the curtain, she saw Resident #2 standing at the top of Resident #1's bed. Resident #2 had his penis in Resident #1's mouth. NA#1 stated she was startled, apologized, and backed out of the room. NA#1 stated as she exited the room she saw Nurse #1 was across the hall and she reported her observation to Nurse #1. While NA#1 was speaking with Nurse#1 in the hall, Resident #2 exited the room and walked down the hall to the nurse's station. She and Nurse #1 then walked down the hall and reported the incident to the Unit Manger. NA#1 stated she did not ask either resident about the incident. She stated Resident #1 kept the covers over his head or kept looking down while staff moved Resident #2 and his personal belongings into another room. Resident #2 became angry and agitated over being moved into another room. He was yelling and making derogatory statements about the facility and the staff to the point it was disrupting to other residents. NA#1 stated she had never observed any sexual behaviors between Resident #1 and Resident #2 in the past. An interview was conducted with Unit Manger #1 on 10/11/2023 at 11:30AM. She stated Nurse #1 informed her of the incident. She immediately went to the room and Resident #1 was alone. She made sure Resident #1 was safe. During her assessment, Resident #1 stated he was fine and asked if Resident #2 was going to come back so they could finish. Unit Manager #1 stated Resident #1 had previous behaviors that included masturbating in public areas. She had never observed any sexual behaviors between Resident #1 and Resident #2 in the past. A telephone interview was conducted with Nurse #1 on 10/11/2023 at 12:22PM. She stated she was across the hall from Resident #1 and Resident #2's room when NA#1 alerted her to the situation. By that time Resident #2 was in the hall making his way to the nurse station. She immediately notified the Unit Manger. The residents were separated and placed on Q15 minute safety checks. She further stated Resident #2 was immediately moved into a private room. He became very agitated over the move. Nurse #1 stated she was very familiar with both residents and had never observed any sexual behaviors between them in the past. The Director of Nursing was not available for interview. On 10/11/2023 at 12:31PM an interview was conducted with the Administrator. She stated when she was made aware of the incident, the residents were immediately separated and assessed for injury. When the residents were interviewed independently, neither would indicate who initiated the interaction but neither appeared to be in any distress. Resident #2 was placed in a private room. She stated the Medical Director (MD), each resident's Responsible Party (RP) were made aware of the incident. The police department was contacted and declined to complete a report on the incident and the staff were provided in-service education on prevention of abuse. The Administrator stated mandatory reports to Adult Protection Services (APS) and DHHS were completed on 10/5/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews and interview with Nurse Practitioner (NP), Medical Director (MD), and Dental Office Customer Service Representative, the facility failed to refer a medically complex resident with multiple caries and broken teeth to an oral surgical center for recommended extractions in 1 of 1 resident (Resident #2) reviewed for dental care. The findings included: Resident #2 as admitted to the facility on [DATE] for diagnoses that included cerebral vascular accidents (stroke). The residents quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was rarely or never understood and her cognitive skills for daily decision making were severely impaired. Resident #2 required extensive assistance with activities of daily living and personal hygiene during the assessment period. On 8/8/2023 at 10:30AM Resident #2 was observed sitting up in her bed with her smart phone in her hand. Resident #2 did not speak when spoken to but she did open her mouth when writer demonstrated mouth opening. The resident was observed to have several discolored teeth and a strong odor coming from her mouth. Resident #2 was observed 8/8/2023 at 8:45AM. She was sitting up in her bed asleep. Her breakfast tray was still in front of her. The resident had eaten scrambled eggs, grits, and bacon. She had consumed 75% of her meal. At 12:00PM on 8/8/2023 Resident #2 was observed eating her lunch tray which included wide flat buttered noodles, and meatballs with brown gravy. The resident did not express discomfort while eating her meal. The resident's active physician orders did not contain a referral for oral surgery consult. Review of the resident's medical record revealed no weight loss. On 1/10/2023 the NP noted Resident #2 had dental caries and untreated dental caries could lead to bacteremia and subsequent heart valve vegetation (bacteria that settle on and destroy the heart valve). The medical record contained a progress noted dated 1/24/2023 that indicated the resident was seen by the dentist on that date and new orders were received. The note also indicated a follow up appointment would be scheduled by the provider. The facility provided a paper copy of an after-visit summary from an offsite dental office dated 5/25/2023 indicated the resident was seen at an offsite dental office for sedation and extractions. The summary indicated the dentist reviewed the resident's medical record and discovered she was on an anticoagulant. The dentist requested medical clearance from the MD prior to sedation and extractions. The resident returned to the facility without receiving treatment. The facility also provided a paper copy of a note from the dental office dated 6/12/2023. The note indicated a phone conversation took place between the dentist and the MD regarding exactly what treatment the resident required. The note indicated the MD did not want the resident to undergo sedation and extractions at the dental office due to the resident's medically complex condition. The note further indicated the MD would send over her recommendation of a dental surgical center and the dentist would send the referral to the dental surgical center of her choice. The medical record contained a note by the NP dated 6/13/2023. The note read in part, patient with significant need for dental intervention. Local dentist requesting extraction of 20 teeth under conscious sedation. MD requested that patient receive services in the outpatient surgical center. Patient has been treated for multiple abscesses and underwent multiple antibiotic therapy due to oral infection. Awaiting referral from dental surgeon in outpatient surgery center. On 6/19/2023 the NP again noted in the medical record she was awaiting referral to local oral surgeon. The medical record indicated Resident #2 was seen by the MD on 7/10/2023. The MD noted, pending referral to oral surgeon. Resident #2 was evaluated by the NP on 7/12/2023 and indicated again, currently awaiting referral from an ambulatory surgical clinic for patient to receive extractions in a medical facility. An interview was conducted with the Social Worker on 8/8/2023 at 12:24PM. She stated she is responsible for making sure residents are scheduled to see the dentist. She further stated Resident #2 was scheduled to see an offsite dentist in May but due to a miscommunication, the resident's anticoagulant was not stopped, and she could not get treatment that day. She stated Resident #2 did not have an existing appointment to a dentist or referral to an oral surgeon to her knowledge. A phone interview was conducted with the scheduler and transporter on 8/8/2023 at 1:00PM. She stated Resident #2 did not have an existing appointment with a dentist or oral surgeon. She further stated she was told the facility was waiting on a referral from the dental office. On 8/8/2023 a phone interview was conducted with the NP at 4:45PM. She stated Resident #2 was medically complex, on anticoagulants and had a history of strokes. The dental office requested medical clearance from the facility back in May. She stated she spoke with the MD regarding medical clearance and the MD called the dental office. The MD was not comfortable with the resident undergoing sedation and extraction of over 20 broken or infected teeth in the dental office so she requested the resident have the procedure performed in a dental surgical center when the resident could be monitored closely. The NP stated she had tried multiple times to reach the resident's family to determine if the resident had required prophylactic antibiotics for dental care in the past. She further stated that was not holding up the resident's referral to an oral surgeon. The NP stated she was waiting for the dental office to make the referral to a dental surgical center. The NP acknowledged that she had not reached out to the dental office to follow up on the referral, but she would do so. A phone interview was conducted 8/9/2023 at 8:05AM with a Customer Service Representative from the dental offices. She stated the dentist was waiting for the facility to contact them regarding what oral surgical center the resident's referral and records needed to be forwarded to. On 8/9/2023 at 8:50AM an phone interview was conducted with the MD. She stated when the dental office requested medical clearance for Resident #2, she called and spoke with the dentist regarding what dental treatment the resident required. She was informed the resident needed over 20 broken or infected teeth extracted. The MD stated Resident #2 was on anticoagulant and has had multiple strokes in the past, she was not comfortable with the treatment being completed in a dental office. She felt the resident needed to be monitored more closely and a dental surgical center or outpatient surgical center would be more appropriate. The MD stated she sat down with the NP and the Unit Manager and discussed finding a dental surgical center or outpatient surgical center. She stated the NP and the Unit Manger were to follow up with the resident's dental care. She was not aware the referral had not been made. The Unit Manager was no longer employed with the facility and attempts to contact her were not successful.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews with resident and staff, the facility failed to maintain a clean and homelike environment for 1 of 3 residents (Resident #8) reviewed for clean, sanitary, and homelike environment. The findings included: Resident #8 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis. The resident's admission Minimum Data Set (MDS) dated [DATE] indicated the resident had mild cognitive impairment, required supervision for completion of activities of daily living, and received IV antibiotics during the assessment period. On 6/20/2023 at 9:15AM Resident #8 was observed in his room, in his bed. A bag of IV Daptomycin (antibiotic) was observed lying on the bedside dresser. The bedside table was on the resident's left and held paper trash, a spray bottle of wound cleaning solution, and the lid to his bedside commode. On the floor beneath the bedside table were grits. There were two black flies on the grits. On the floor at the foot of the bed and to the right of a negative pressure wound therapy machine (wound vac) were several dried brownish red spots. On the floor beneath the bed laid a piece of dark grey foam (like that used with the wound vac) and more paper trash. The trash can was empty and did not have a liner. An interview was conducted with Resident #8 at the time of the observation. He stated the paper trash, and the wound care spray were left after his wound care the day prior. He did not know how long the dried reddish-brown spots had been on the floor, but he thought the spots were dried blood from either his wound or the wound vac machine. Resident #8 stated he understood staff were busy, but he would like his room to be cleaner. Nurse #1, assigned to Resident #8, entered the room around 9:20AM and stated the condition of the room was bad and a mess. He further stated the room was in that condition when he began his shift at 7:00AM. He explained that he did not have time to provide care and clean rooms. He denied notifying housekeeping or the Nurse Assistant of the condition of the resident's room. On 6/20/2023 at 11:32AM an interview was conducted with Nurse #2. She stated she completed wound care on Resident #8 on 6/19/2023. She did not recall leaving trash or the spray bottle of wound cleaner in the room. She stated the grey foam observed on the floor was from the wound care and she just overlooked it. She stated she did not recall if there was a liner in the trash can when she conducted wound care the previous day. At 4:00PM on 6/20/2023 and interview was conducted with Unit Manager #2. She stated Nurse #1 could have reached out to her, housekeeping, or other staff members to address the condition of Resident #8's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews with staff, the facility failed to administer intravenous (IV) medication per physician order for 1 of 1 (Resident #8) resident reviewed for medication administration. The findings included: Resident #8 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis. The resident's admission Minimum Data Set (MDS) dated [DATE] indicated the resident had mild cognitive impairment, required supervision for completion of activities of daily living, and received IV antibiotics during the assessment period. On 6/20/2023 at 9:15AM Resident #8 was observed in his room, in his bed. A bag of IV Daptomycin (antibiotic) was observed lying on the bedside dresser. An interview was conducted with Resident #8 at the time of the observation. He stated his nurse had placed the bag of antibiotic there earlier that morning. An interview was conducted with Nurse #1, assigned to Resident #8, at the time of the observation. Nurse #1 entered the resident's room and stated he left the bag there when the lab technician came to draw blood. He got distracted and forgot to hang the IV antibiotic. Nurse #1 was observed spiking the bag of Daptomycin, priming the IV line (removing the air), and attaching the IV line to a peripherally inserted central catheter (PICC) located in the resident's right upper arm. The resident's June 2023 Medication Administration Record (MAR) was reviewed and revealed the following order; 700 milligram (mg) Daptomycin intravenous one time a day for osteomyelitis of the right foot. The administration time was 12:00PM. The start date was 6/10/2023 and the end date was 7/14/2023. A second interview was conducted with Nurse #1on 6/20/2023 at 10:00AM. He stated the administration time was 9:00AM. Nurse #1 reviewed the resident's active orders and stated the administration time for Daptomycin was 12:00PM and he administered the medication too soon. He further stated it was an error on his part, he thought the medication was ordered for 9:00AM. On 6/20/2023 at 4:00PM an interview was conducted with Unit Manager #2. She stated Resident #8 is on two IV antibiotics. The Ertapenum was to be administered IV at 9:00AM and the Daptomycin was ordered for 12:00PM. Nurse #1 administered the Daptomycin immediately after the Ertapenem. Unit Manager #2 stated the nurse should have administered the IV antibiotics per physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and record review, the facility failed to provide nail care for a resident dependent on staff assistance with his activities of daily living (ADLs). This was for 1 (Resident #79) of 3 residents reviewed for ADLs. The findings included: Resident #79 was admitted [DATE] with Sepsis, Peripheral Vascular Disease and Diabetes. His quarterly Minimum Data Set, dated [DATE] indicated moderate cognitive impairment, no behaviors and staff extensive assistance was required with his personal hygiene. Resident #79's ADL care plan last revised on 5/27/23 read he required extensive assistance with his ADLs due to weakness and decreased mobility. Interventions included staff assistance with his ADLs and to encourage him to participate in his ADLs as able. Review of an audit form titled Quality Improvement Data Collection dated and completed on 6/13/23 read Resident #79's was audited for clean and trimmed nails. There were no documented comments or actions taken. The form was signed Nurse #1. An observation was completed of Resident #79 on 6/20/23 at 10:45 AM. Observed to the top right side of his head was a patch of skin with recent scratch marks with evidence of his skin being opened. Resident #79 stated he had psoriasis and scratched his head. He stated his psoriasis itched and he was clawing himself. Observation of his nails revealed jagged edges with the length extending past his fingertips and underneath his nails were a dried dark brown substance. Resident #79 stated it was dried blood from his scratching. He stated nobody had trimmed his nail is a long time, but the staff were cleaning underneath his nails with a wooden toothpick looking thing. He stated he received his showers as desired and was last showered on Saturday (6/17/23) but nobody cut his nails then. Review of Resident #79's shower sheet dated 6/17/23 indicated there was no observed need to trim his fingernails. This form was signed by Nursing Assistant (NA) #1 and Nurse #1. An interview was completed on 6/20/23 at 12:40 PM with Nurse #1. He stated Resident #79 was not known to refuse any ADLs to include nail care. Nurse #1 stated it was the NA's responsibility to assess all resident nails to ensure they were clean and did not need to be trimmed. Nurse #1 stated he had observed the area of psoriasis on his head and that he had been scratching it because it itched due his steroids being held to aid with the healing of his wound. He stated he had a call out to the Medical Provider asking for something for Resident #79's itching. An interview was completed on 6/20/23 at 2:33 PM with NA #1. She stated she was assigned Resident #79 on 6/17/23 and today 6/20/23 and he was not known to refuse nail care. She stated when he was showered on 6/17/23, his nails did not appear to be long or jagged, but she did clean underneath his nails because of the dried blood from his scratching himself. NA #1 stated during Resident #79's ADL care earlier today, she cleaned the dried blood from underneath his nails, but she did not trim or file them. She stated she would do it before the end of her shift. An interview was completed on 6/20/23 at 4:20 PM with the Administrator. She was unable to offer any explanation as to why Resident #79's nails were in the condition they were in earlier today.

Based on observations, record review and staff interviews the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented effective procedures and monitor the interventions that the committee put into place following a recertification and complaint investigation dated 5/4/23 for 1 deficiency in the area of Quality of Life at Activities of Daily Living (ADLs). The continued failure of the facility during two surveys of record in the same area showed a pattern of the facility's inability to sustain an effective Quality Assurance program. Findings included. This tag is cross referenced to: 1. F677- Based on observations, resident and staff interviews, and record review, the facility failed to provide nail care for a resident dependent on staff assistance with his activities of daily living (ADLs). This was for 1 (Resident #79) of 3 residents reviewed for ADLs. F677-cited 5/4/23-Based on observations, record review and resident and staff interviews, the facility failed to provide nail care for 1 of 1 dependent resident reviewed for ADLs. An interview was completed on 6/20/23 at 4:20 PM with the Administrator. She stated she did not know how the complaint survey resulted in 1 repeat citation originally cited during the recertification and complaint surveys dated 5/4/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews with residents and staff, the facility failed to maintain an effective pest control program that was free of fly activity for 3 of 3 (Residents # 4, #8, and #11) residents reviewed for pest control. The findings included: A customer service report by the pest control complany dated 5/17/2023 indicated interior area floor drains in the kitchen were in need of cleaning. Recommended cleaning in and around drains frequently to prevent pest breeding sites. Spot applications of pest control were applied to interior dining, interior halls, interior kitchen, interior offices, and entry points. a. Resident #4 was admitted to the facility on [DATE]. Resident #4's annual Minimum Data Set (MDS) dated [DATE] indicated the resident was mildly cognitively impaired and required extensive assistance with activities of daily living. On 6/20/2023 at 9:00AM Resident #4 was observed in his room, in his bed with his breakfast tray in front of him. There was a large black fly observed on the resident's grits and another large black fly on the corner of his plate next to eggs. The resident had his fork in his hand and was actively eating his meal. Resident #4 was interviewed during the observations and stated flies had been a problem for a while and they were getting worse. He could not remember the exact day or week he noticed the flies in his room. On 6/21/2023 at 9:05AM Nurse Assistant (NA) #1 was observed on Resident #4's hall. She was observed using her hand to swat at a fly. NA#1 was interviewed at the time of the observation and stated the facility did have a fly problem. She worked in the facility two days prior and the flies were not as bad then. She did not know why the flies were getting worse or how they might be entering the facility. b.Resident #8 was admitted to the facility on [DATE]. Resident #8's entry Minimum Data Set (MDS) dated [DATE]indicated the resident was mildly cognitively impaired and required some assistance with activities of daily living. On 6/20/2023 at 9:15AM Resident #8 was observed in his room, in his bed. There were multiple flies in his room. Observed grits on the floor to the left of Resident #8's bed. There were two large black flies on the grits. The resident was observed to have a visibly large wound with wound vac on his right lower extremity. An interview was conducted with Resident #8 at the time of the observation. He stated the facility did have a problem with flies. The problem seemed to be getting worse. He could not recall when he first saw flies in his room. At 10:00AM on 6/20/2023 an interview was conducted with Nurse #1, who was assigned to Resident #8. The interview was conducted in Resident #8's room. Nurse #1 stated the facility did have a problem with flies. He further stated the problem seemed to get worse as the outside weather warmed. He did not know how the flies might be entering the facility. He stated he saw the pest control company in the facility recently. c.Resident #11 was admitted to the facility on [DATE] with diagnoses that included cerebral vascular accident (stroke). Resident #11's quarterly Minimum Data Set (MDS) dated [DATE] indicated she was cognitively intact and required extensive assistance with activities of daily living. On 6/21/2023 at 2:30PM Resident #11 was observed sitting in her room looking through a book of word find puzzles. She was observed picking up a yellow fly swatter and swinging at a black fly. An interview was conducted with Resident #11 at the time of the observation. Resident #11 stated the fly problem had been going on for several weeks and seemed to be getting worse. She further stated her room is next to a door that opens to the outside so that may have increased the number of flies in her room. An interview was conducted with Nurse #3, who was assigned to Resident #11's hall. She stated the facility did have a problem with flies. The problem was facility wide and not just one area. At 3:00PM an observation of the nurse station was conducted. Multiple flies were observed at the nurse station. At 4:00PM an interview was conducted with Unit Manager #2. She stated she was aware of the fly problem. She believed the flies could have entered the facility when residents enter and exit the facility to the smoking area. Some of the residents were in wheelchairs and the door was held open for an extended period of time. The flies could have entered the facility on the wheelchairs. She stated the facility had routine pest control services. At interview was conducted with the Administrator. She stated the facility conducted routine pest control and evidence of a pest control program was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and staff interviews, the facility failed to provide a dignified dining experience by referring to a resident who needed assistance with meals as a feeder (Resident #59) .This was for 1 of 2 residents reviewed for dignity. Based on the reasonable person concept residents would not expect to be identified as a feeder. The findings included: Resident #59 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, dated [DATE] indicated Resident #59's cognition was severely impaired. Resident #59 required total assistance with eating. During an observation on 05/01/23 at 11:57 AM, Nurse Aide #5 was observed in the dining room of the memory care unit assisting with meal pass. When asked by another staff member if Resident #59 needed assistance with eating, she stated she's a feeder. The statement could be heard throughout the entire dining room where other residents were present. During an interview on 05/01/23 at 11:59 AM Nurse Aide #5 stated she identified Resident #59 as a feeder because she did not know what else to call a resident who needed assistance with meals. She thought it was a dignified label and used that term to identify residents who needed assistance with meals. An interview with the Director of Nursing (DON) on 05/04/34 at 11:44 AM revealed it was her expectation that staff should not utilize labels such as feeder to describe a resident and staff had been educated about not using feeder to identify residents who need assistance with meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interviews, and staff interviews, the facility failed to place a resident's call light (Resident #15 and #79) within reach to allow for the residents to request staff assistance for 2 of 3 residents reviewed for accommodation of needs. The findings included: 1. Resident #15 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular accident (CVA) with left sided hemiplegia (paralysis on one side of the body). The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15's cognition was fully intact. He had no behaviors and no rejection of care. He required the extensive assistance of 1 for bed mobility and supervision with set up help for eating. He had no functional limitations with range of motion on one side of his upper and lower extremities. Resident #15's active care plan indicated he has had falls related to limitations that included, in part, left sided hemiplegia. The interventions included ensuring his call light was within reach and encouraging the resident to use it for assistance as needed. An observed was conducted on 05/01/23 at 01:28 of Resident #15. He was observed asleep lying on his bed. His call light was on the floor under the left side of his bed. An observed was conducted on 05/02/23 at 08:50 AM of Resident #15. He was observed asleep lying on his bed. His call light was on the floor under the left side of his bed. An observation and interview were conducted on 05/03/23 at 10:01 AM with Nurse #1. He verified Resident #15 ' s call light was on the floor under his bed. He stated the call light should be within the residents reach at all times. He was observed putting the call light within residents reach. An observation and interview were conducted on 05/03/23 at 11:48 AM with Resident #15. He was lying in bed watching television. He stated the call light was on the floor all the time. He also stated when he needs something and/or when he needs assistance, he stated he will get up and try to get the call light so he can ring it, yell out for someone, or get up by himself. Resident #15 observed pulling self-up to the side of the bed using his right arm and the grab bar. He was not able to use his left side. He further stated sometimes he did fall when he attempted to get up unassisted. An interview was conducted on 05/03/23 at 12:10 PM with the Nurse Assistant (NA) #1, who was assigned to Resident #15 for the 7:00 AM to 3:00 PM shift, she revealed she was unaware the call light cord was not within reach. She indicated the resident didn ' t use his call light to request assistance very much, but it should still be within his reach. NA #1 indicated she normally places the call light within Resident #15's reach before leaving his room. An observation and interview were conducted on 05/03/23 at 2:47 PM with Nurse #1. He stated Resident #15 will throw his call light onto the floor after staff put it in reach. He further stated staff are used to Resident #15 doing everything for himself, he doesn ' t normally use his call light for assistance, and they forget to put the call light within reach. He then stated his call light should be within reach at all times. Review of nursing notes from January to present revealed no documentation of Resident #15 not using his call light or throwing the call light on the floor. An interview was conducted on 05/04/23 at 11:00 AM the Director of Nursing (DON), she stated the call light device should always be in the residents reach. 2. Resident #79 was admitted to the facility on [DATE] with diagnosis that included diabetes, diabetic neuropathy, anxiety, and dysphagia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #79's cognition was fully intact. He had no behaviors and no rejection of care. He required the extensive assistance of 1 for bed mobility and supervision with oversight, encouragement and/or cueing and set up help for eating. He had no functional limitations with range of motion. Resident #79's active care plan indicated was at high risk for falls fall and had a history of falls related to antipsychotic medications, debility, poor balance and unsteady gait. Interventions included for staff to be sure resident's call light was within reach and encourage the resident to use it for assistance as needed, the resident needs prompt response to all requests for assistance. An observation was conducted with Resident #79 on 05/02/23 at 8:48 AM. He was observed in his room in bed with his bedside table pulled over the left side of the bed. His call light was observed clipped to the bedsheet on the right side of his bed with the push button hanging off bed out of Resident #79 ' s reach. An observation and interview were conducted on 05/03/23 at 10:01 AM with Nurse #1. He verified Resident #79 ' s call light was on the floor. He stated the call bell was attached to the bed but had fallen off the bed and the call bell should be within the residents reach at all times. He was observed putting the call light within residents reach. An observation and interview were conducted on 05/03/23 at 11:45 AM with Resident #79. He was lying in bed watching television. He stated his call light was on the floor a lot. Resident #79 stated, I like to have it pinned where I can reach it. He further stated if he needed anything and can't reach it, he would yell out for someone to come to the room. An interview was conducted on 05/03/23 at 12:10 PM with the Nurse Assistant (NA) #1, who was assigned to Resident #79 for the 7:00 AM to 3:00 PM shift, she revealed she was unaware the call light was not within reach. She indicated the resident utilized his call light to request assistance. She stated it was clipped onto the sheet but must have fallen off the bed. NA #1 indicated she normally places the call light within Resident #79's reach before leaving his room. An interview was conducted on 05/04/23 at 11:00 AM the Director of Nursing (DON), she stated the call light device should always be in the residents reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of behaviors for Resident #59 and continence for Resident #5. This was for 2 of 17 residents reviewed for MDS accuracy. The findings included: 1. Resident #59 was admitted to the facility on [DATE] with diagnoses which included early onset Alzheimer's disease and generalized anxiety disorder. Resident #59 medical record also had a progress note dated 01/11/23 by Nurse #5 which indicated she had episodes of rocking back and forth and yelling. The resident's significant change Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was severely cognitively impaired and no behavioral symptoms were exhibited. The Former Social Services Director was interviewed on 05/03/23 at 9:45 AM. She stated she completed the behavior assessment by sitting down with Resident #59 and watching her behavior. She stated on the day she sat down with Resident #59 she was not experiencing any behaviors. She stated she did not know she needed to look through a resident's medical chart to determine if a resident was experiencing behaviors during the assessment period. She further stated it was a mistake when she identified Resident #59's current behavior status, care rejection, or wandering as worse. The Director of Nursing was interviewed on 05/04/23 at 9:45 AM. She stated staff needed more education how to complete the behavior section of the MDS assessment. 2. Resident #5 was admitted to the facility on [DATE] with diagnosis that included cerebrovascular accident (CVA) with left sided hemiplegia (paralysis on one side of the body). She also had an indwelling urinary catheter in place for neurogenic bladder. A physician's order dated 01/18/23 indicated Resident #5 to have a urinary catheter for neurogenic bladder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5's cognition was severely impaired. Resident #5 was coded as having an indwelling urinary catheter and was also coded as always incontinent of bladder. Resident #5's active care plan, last reviewed on 03/22/23, included a focus area having an indwelling urinary catheter for neurogenic bladder. A phone interview was conducted on 05/04/23 at 9:36 AM with the Minimum Data Set (MDS) Nurse. She stated Resident #5 had an indwelling urinary catheter and it was an error to have coded her with bladder incontinence. This area should have been coded as Not Rated. An interview was conducted on 05/04/23 at 11:00 AM with the Director of Nursing (DON). She stated the Minimum Data Set (MDS) assessment should have been coded to reflect Resident #5 ' s urinary continence accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with staff, the facility failed to request residents with a newly diagnosed mental illness be reevaluated for a level II Preadmission Screening and Resident Review (PASRR) for 2 of 2 residents reviewed for PASRR (Resident #57 and #59). The findings included: 1. Resident #57 was admitted to the facility on [DATE] with diagnoses which included, in part, other frontotemporal neurocognitive disorder. Review of Resident #57's current PASRR determination letter dated 10/02/19 revealed the resident remained a level I and determined no further screening was required unless a significant changed occurred to suggest a diagnosis of mental illness. Resident #57's annual Minimum Data Set Assessment (MDS) dated [DATE] indicated he was not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. Review of Resident #57's medical record revealed a new diagnosis of schizoaffective disorder was documented on 01/24/22. The April and May 2023 Medication Administration Records were reviewed and included a physician order dated 03/23/23 for 0.5 milligrams of Haloperidol by mouth at bedtime related to schizoaffective disorder and was noted as administered daily. The Former Social Services Director was interviewed on 05/03/23 at 10:08 AM. She stated she thought Resident #57 was admitted into the facility with the diagnosis of schizoaffective disorder; therefore, did not contact the state for a PASRR reevaluation. She stated she was not notified Resident #57 had a new diagnosis of schizoaffective disorder. She would have requested a reevaluation for a level II PASRR. An interview was conducted on 05/03/23 at 9:19 AM with the Social Services Director. The Social Services Director stated she had only been in the role since February 2023 and was still learning. She stated if a resident was newly diagnosed with a mental disorder, she would notify the state for a reevaluation for a level II PASRR. She stated since Resident #57's schizoaffective disorder was diagnosed prior to her starting, she did not know why the PASRR II screening was not completed. During an interview on 05/04/23 at 11:40 AM, the Director of Nursing (DON) revealed the facility should have requested an evaluation for a new PASRR when Resident #57 was newly diagnosed with a mental disorder. During an interview on 05/04/23 at 11:41 AM, the Administrator stated she expected a request for a PASRR evaluation when a resident was newly diagnosed with a mental disorder. 2. Resident #59 was admitted to the facility on [DATE] with diagnoses which included, in part, early onset Alzheimer's disease and cognitive communication deficit. Review of Resident #59's current PASRR determination letter dated 11/12/19 revealed the resident remained a level I and determined no further screening was required unless a significant changed occurred to suggest a diagnosis of mental illness. Review of Resident #59's medical record revealed a new diagnosis of schizoaffective disorder was documented on 07/27/22. The April and May 2023 Medication Administration Records were reviewed and included a physician order dated 02/02/23 for 50 milligrams of Quetiapine tablet - give 1 tablet by mouth two times a day related to schizoaffective disorder and was noted as administered daily. Resident #59's significant change Minimum Date Set (MDS) assessment dated [DATE] indicated she was not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. The Former Social Services Director was interviewed on 05/03/23 at 10:08 AM. She stated she thought Resident #59 was admitted into the facility with the diagnoses of schizoaffective disorder; therefore, did not contact the state for a PASRR reevaluation. She stated she was not notified Resident #59 had a new diagnosis of schizoaffective disorder. She would have requested a reevaluation for a level II PASRR. An interview was conducted on 05/04/23 at 9:49 AM with the Social Services Director. The Social Services Director stated she had only been in the role since February 2023 and was still learning. She stated if a resident was newly diagnosed with a mental disorder, she would notify the state for a reevaluation for a level II PASRR. She stated since Resident #59's schizoaffective disorder was diagnosed prior to her starting, she did not know why the PASRR II screening was not completed. During an interview on 05/04/23 at 11:40 AM, the Director of Nursing (DON) revealed the facility should have requested an evaluation for a new PASRR when Resident #59 was newly diagnosed with a mental disorder. During an interview on 05/04/23 at 11:41 AM, the Administrator stated she expected a request for a PASRR evaluation when a resident was newly diagnosed with a mental disorder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident and staff interviews, the facility failed to provide nail care for 1 of 1 dependent resident (Resident #79) reviewed for activity of daily living (ADL). The findings included: Resident #79 was admitted to the facility on [DATE] with diagnosis that included diabetes, diabetic neuropathy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #79's cognition was fully intact. He had no behaviors and no rejection of care. He required the extensive assistance of 1 for personal hygiene. He had no functional limitations with range of motion. Resident #79's active care plan, last reviewed 02/23/23, revealed a focus that read Resident #79 had an ADL self-care performance deficit related to sepsis, diabetes, and pneumonia. The interventions indicated staff were to check nail length, trim, and clean on bath days and as necessary. A review of Resident #79's nursing progress notes from 01/01/23 to 05/02/23 revealed no refusals of nail care documented. An observation and interview were conducted with Resident #79 on 05/01/23 at 10:36 AM. Fingernails on left hand were long, extending out 1/8th to 1/4th of an inch past the tip of finger, with brown/black substance under all fingers. Fingernails on his right hand were long, extending out 1/8th of an inch past the tip of finger, with brown/black substance under all fingers except the middle finger. He stated that his fingernails needed to be cut and to be cleaned. He stated the staff have not cut them recently. An observation was conducted with Resident #79 on 05/02/23 at 8:48 AM. He was observed in his room in bed with his bedside table pulled over the left side of the bed. Fingernails were still long with black/brown substance under them. An interview was conducted on 05/03/23 at 10:20 AM with Unit Manager #2. She stated the Nursing Assistants (NAs) are responsible for cleaning and cutting residents nails during showers/baths and/or when they see that it needs to be done. She further stated the NAs fill out a shower sheet which includes hair care, mouth care, shaved, and nail care as tasks during the shower to be completed. An observation was conducted on 05/03/23 at 12:10 PM with Resident #79. He was lying in bed watching television and eating lunch. Fingernails were still long with black/brown substance under them. An observation and interview were conducted with Resident #79 on 05/03/23 at 2:54 PM. Resident #79 was observed in bed watching television and stated he had just returned from receiving a shower. He then stated the Nursing Assistant (NA) cleaned his fingernails but did not cut them. Fingernails on both hands clean with no substance under the nails. He further stated his nails need to be cut because he kept scratching himself, but that NA would be going home for the day. An interview was conducted on 05/03/23 at 2:21 PM with Nursing Assistant (NA #3). She stated she cleaned and cut residents fingernails during the resident ' s shower days. She further stated Resident #79 was not scheduled to get a shower when she worked with him, and she did not realize his fingernails needed to be cleaned and/or cut. An interview was conducted on 05/03/23 at 3:16 PM with Nursing Assistant (NA #1). She stated she did give Resident #79 his shower and cleaned his nails but did not have nail clippers with her and forgot to go back and cut them. She verified his fingernails needed to be cut. She then stated cleaning and cutting fingernails were on the shower sheets to be performed during showers. An interview was conducted on 05/04/23 at 11:00 AM the Director of Nursing (DON). She stated nail care was to be looked at daily and on shower days and that nails should be cleaned and cut as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews the failed to maintain air mattress at residents weight for 3 of 3 residents reviewed. (Resident #5, Resident #79 & Resident #26). The findings included: 1. Resident #5 was admitted to the facility on [DATE] with diagnosis that included cerebrovascular accident (CVA) with left sided hemiplegia (paralysis on one side of the body), furuncle on the back, diabetes, and Alzheimer ' s Disease. Resident #5 ' s active orders did not include an order for an air mattress. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5's cognition was severely impaired. She required extensive assist with bed mobility and was coded to be at risk for pressure ulcers. She had range of motion impairment to one side of her upper extremities and to both sides of her lower extremities. Resident #5's active care plan, last reviewed on 03/22/23, included a focus area for activity of daily living (ADL) self-care performance deficit related to left hemiparesis (weakness or the inability to move on one side of the body), epilepsy and Alzheimer ' s Disease. Interventions included pressure reduction mattress to bed. Review of Resident # 5 ' s weight under vital signs in her electronic record revealed a weight of 155.8 pounds (lbs) as of 05/01/23. An observation on 05/01/23 at 11:55 AM was made. Resident #5 had a low air loss mattress to her bed with the weight pressure dial set at 350 pounds (lbs). An observation on 05/02/23 at 8:22 AM was made. Resident #5 had a low air loss mattress to her bed with the weight pressure dial set at 350 pounds (lbs). Resident # 5 ' s weight as of 05/01/23 was 155.8lbs. An observation on 05/02/23 at 8:49 AM was made of the Wound Nurse adjusting Resident #5 ' s air loss mattress to the correct weight. An interview was conducted on 05/02/23 at 11:47 AM the Wound Nurse. She stated she did adjust the air mattress setting on Resident #5 ' s mattress because it was incorrect. She verified the air mattress setting was on 350 pounds (lbs) and that it should be set according to the resident ' s weight. She further stated the floor nurses and herself are responsible for checking air mattress pressure daily. She then stated the Nursing Assistants (NAs) adjust the weight and they should not be changing the weight dial. An interview was conducted on 05/04/23 at 11:00 AM the Director of Nursing (DON), she stated the air mattresses should be set according to the resident ' s weight and there should be an active order for low air loss mattresses. She then stated the nurses and wound nurse were to check the pressures daily on all air mattresses in the building. 2. Resident #79 was admitted to the facility on [DATE] with diagnosis that included diabetes, diabetic neuropathy, and stage 2 pressure ulcer to buttock. Resident #79 ' s active orders did not include an order for an air mattress. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #79's cognition was fully intact. He had no behaviors and no rejection of care. He required the extensive assistance of 1 for bed mobility. He had no functional limitations with range of motion. He had an indwelling catheter and was frequently incontinent of bowel. Resident #79's active care plan, last reviewed 02/23/23, revealed no documentation of an air loss mattress. Review of Resident #79 ' s weight under vital signs in her electronic record revealed a weight of 144.0 pounds (lbs) as of 05/01/23. An observation on 05/01/23 at 1:28 PM was made. Resident #79 had a low air loss mattress to his bed with the weight pressure dial set at 320 pounds (lbs). An observation on 05/02/23 at 8:39 AM was made. Resident #79 had a low air loss mattress to his bed with the weight pressure dial set at 320 pounds (lbs). Resident # 79 ' s weight as of 05/01/23 was 144.0 lbs. An interview was conducted on 05/02/23 at 11:47 AM the Wound Nurse. She stated she did adjust the air mattress setting on Resident #79 ' s mattress because it was incorrect. She verified the air mattress setting was on 320 pounds (lbs) and that it should be set according to the resident ' s weight. She then stated the Nursing Assistants (NAs) adjust the weight and they should not be changing the weight dial. An interview was conducted on 05/04/23 at 11:00 AM the Director of Nursing (DON), she stated the air mattresses should be set according to the resident ' s weight and there should be an active order for low air loss mattresses. She then stated the nurses and wound nurse were to check the pressures daily on all air mattresses in the building. 3. Resident #26 was admitted on [DATE] and readmitted on [DATE] with cumulative diagnoses of a Cerebral Vascular Accident (CVA), Aphasia (inability to speak) Peripheral Artery Disease (PAD), history of arterial wounds and history of pressure ulcers. Review of Resident #26's was skin integrity care plan last revised on 3/3/23 indicated he had the potential for skin issues related to fragile skin and a history of arterial wounds. Interventions did not include the use of a PRM. Resident #26's quarterly Minimum Data Set (MDS) dated [DATE] read he had severe cognitive impairment, required extensive staff assistance with all of his activities of daily living (ADLs). The MDS was not coded for any skin impairments and was coded for the PRM. Review of Resident #26's most recent weight in the electronic medical record was dated 4/4/23 and a weight of 223.5 pounds. Review of Resident #26's May 2023 Physician orders did not include an order for a pressure relieving mattress (PRM). Review of the PRM's operational manual read the pump setting were based on Resident #26's body weight. An observation was completed on 5/1/23 at 11:00 AM of Resident #26. He appeared clean and absent of any evidence of discomfort. The PRM pump was set for a weight of 140 pounds. An observation was completed on 5/1/23 at 3:40 PM. There was no change in the PRM's weight setting. An observation was completed on 5/2/23 at 8:20 AM. There was no change in the PRM weight settings. An observation was completed on 9:00 AM and the PRM was now set for a weight of 220 pounds. An interview was completed on 5/2/23 at 8:52 AM with the Treatment Nurse. She stated Resident #26 was prescribed a PRM due to fragile skin and his history of wounds. She stated she did not adjust the PRM but Unit Manager (UM) #1 adjusted it. The Treatment Nurse stated she was responsible for checking the PRM's daily to ensure the pump settings were accurate. She was unable to explain why the PRM was set incorrectly on 5/1/23 and earlier 5/2/23. She stated if a PRM was not set according to the resident's weight, the PRM would not be an effective intervention. An interview was completed on 5/2/23 at 9:15 AM with the Director of Nursing (DON). She stated it was the Treatment Nurse's responsibly to check the pump settings daily on all the residents on PRM's. She stated it was possible that an aide may how bumped the settings and if a resident was alert and oriented and voiced that the PRM was to firm, the resident could ask for the PRM weight settings to be adjusted. She continued that Resident #26 was not able to make such a request due his mental status and aphasia. An interview was completed on 5/2/23 at 9:20 AM with UM #1. She stated she adjusted Resident #26's PRM pump settings this morning at approximately 8:45 AM. UM #1 stated she adjusted the PRM weight settings because it was not set according to Resident #26's actual weight. She further stated it was her responsibility to check the PRM pump setting daily to ensure they were set accurately. An interview was completed on 5/3/23 at 8:30 AM with Nurse #3. She stated she was not aware that Resident #26's PRM weight setting were incorrect until UM #1 adjusted it yesterday. She stated it was the responsible of the Treatment Nurse to check the PRM's daily for function and accurate settings. An observation was completed on 5/3/23 at 9:00 AM of Resident #26's PRM weight setting. It was set correctly for 220 pounds. An interview was completed on 5/3/23 at 2:10 PM with Nursing Assistant (NA) #2 and NA #6. They stated the aides were not allowed to adjust the settings on the PRM's. An interview was completed on 5/4/23 at 11:10 AM with the DON and the Administrator. The DON stated Resident #26's PRM should be set according to his weight and monitored to ensure accuracy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #3 was admitted to the facility 7/13/2018 with diagnoses that included Alzheimer's' dementia and dysphagia. Resident #3's quarterly Minimum Data Set (MDS) 3/4/2023 indicated the resident was severely cognitively impaired and was dependent on staff for all activities of daily living, personal hygiene, and eating. Resident #3's comprehensive assessment contained a focus for altered respiratory related to respiratory failure with excess secretions initiated on 11/12/2021. Interventions included maintaining a clear airway by encouraging resident to clear own secretions with effective coughing. If secretions cannot be cleared, suction as ordered/required to clear secretions. Resident #3 had the following active physician orders: Maintain suction set up at bedside. The start date was 3/18/2023. Suction orally as needed every hour for increased secretions. The start date was 4/30/2023. Change small tube between canister and suction machine monthly. [NAME] with date changed. Change on night shift every 1 month(s) starting on the 26th. The start date was 3/26/2023. Dispose of suction catheter tubing after each use. The start date was 3/18/2023. Change suction cannister every 72 hours or when 3/4 full. The start date was 3/18/2023. On 5/1/2023 at 12:53PM Unit Manager #2 was observed assisting Resident #3 with her lunch meal. Suction equipment was observed sitting on a bedside dresser to the left of the bed. In the suction canister was approximately 100ml of grey fluid with a black film on top. The suction tubing had a black substance from the oral suction apparatus to the cannister. The oral suction apparatus (Yankauer) also contained a black substance. On 5/2/2023 at 8:42AM NA #2 was observed assisting Resident #3 with her breakfast. The suction equipment was observed sitting on the bedside dresser to the left of the bed. In the suction canister was approximately 100ml of grey fluid with a black film on top. The suction tubing had a black substance from the oral suction to the cannister. The oral suction apparatus (Yankauer) also contained a black substance. On 5/3/2023 at 1:15 PM NA#2 was observed in Resident #3's room. She could not recall the last time the suction equipment was used and it appeared no one cleaned the set up after using it. She further stated the nurses maintain the suction equipment. The nurse assigned to Resident #3 on 5/1/2023 and 5/2/2023 was on vacation and unavailable for interview on 5/3/2023. On 5/3/2023 at 1:25 PM an interview was conducted with Unit Manager #1. She stated the nurse who typically works with Resident #3 was on vacation. She further stated she assisted Resident #3 with her meal earlier in the week but did not notice the suction equipment. Unit Manager #1 stated she did not recall the last time the suction equipment was used. The nurses were responsible for maintaining the suction equipment. She stated she believed the oversight occurred because the orders to maintain the suction equipment did not generate on the Treatment Administration Record (TAR) to prompt nurses to complete the tasks. An interview was conducted on 5/4/2023 at 11:10 AM with the Director of Nursing (DON) and the Administrator. The DON stated Resident #3's bedside suction equipment should have been maintained in a sanitary condition per the physician's orders. Based on observations, resident, staff, Nurse Practitioner (NP) and Medical Director (MD) interviews and record review, the facility failed ensure continuous oxygen was in use and obtain oxygen saturation percentages as ordered (Resident #77). The facility also failed to maintain bedside suction equipment in a sanitary condition as ordered by the Physician (Resident #3) This was for 2 of 3 residents reviewed for respiratory care. The findings included: 1. Resident #77 was admitted on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Resident #77's quarterly Minimum Data Set, dated [DATE] indicated moderate cognitive impairment and coded for the use of oxygen. Review of Resident #77's respiratory care plan last revised on 2/23/23 read he had altered respiratory status related to his COPD. Interventions included to administer oxygen as ordered. Review of Resident #77's May 2023 Physician orders included an order dated 11/25/22 read oxygen at 2 liters per minute (L/M) via a nasal cannula. Titrate oxygen up if saturations drop to less than 90% every shift for oxygen monitoring. Review of Resident #77's electronic medical records revealed his oxygen saturation rates from 3/1/23 to present were not documented as having been obtained every shift as ordered. An observation was completed on 5/1/23 at 3:40 PM of Resident #77. He was sleeping in bed wearing his continuous oxygen as ordered. An observation was completed on 5/2/23 at 9:00 AM of Resident #77. There was no change in the observation completed on 5/1/23. An interview was completed on 5/3/23 at 8:30 AM with Nurse #3. She stated Resident #77 was ordered continuous oxygen at 2 L/M. She stated there were no Physician orders to obtain any oxygen saturation percentages on Resident #77. She said his oxygen saturation were only checked whenever his vital signs were obtained. An observation was completed on 5/3/23 at 11:05 AM of Resident #77 sitting alone in the resident lounge/activity room. He had his head lying on the table with an unopened tank of oxygen missing the gauge and nasal cannula on the back of his wheelchair. An interview was completed on 5/4/23 at 11:00 Am with Nursing Assistant (NA) #8 who was assigned Resident #77 on first shift on 5/3/23 when he was found in the lounge/activity room without his oxygen. She stated she got him up yesterday but was not aware that his oxygen was continuous. An interview was completed on 5/3/23 at 11:17 AM with the MD. She stated the orders to check Resident #77's oxygen saturation levels every shift were important and needed to be obtained as ordered. She also stated Resident #77 should be wearing his oxygen at all times. An interview was completed on 5/4/23 at 11:10 AM with the Director of Nursing (DON) and the Administrator. The DON stated Resident #77's oxygen should be administered continuously, and his oxygen saturation levels should be obtained as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff, Consultant Pharmacist, and Medical Director (MD) interviews and record review, the Consultant Pharmacist failed to identify the need for an annual MD or psychiatric Nurse Practitioner (NP) documented rationale for the continued use of a prescribed antipsychotic medication (Geodon) at the current prescribed dosage for 1 (Resident #10) of 5 residents reviewed for unnecessary medications. The findings included: Resident #10 was originally admitted on [DATE] who's cumulative diagnoses included Schizoaffective Disorder. Review of a nursing note dated 3/22/22 at 3:31 PM read there were new orders to increase Resident #10's Geodon to 60 mg twice a day. There was no documentation in the electronic medical record for the rationale for increasing his Geodon. A review of Resident #10's May 2023 Physician orders included an order for Geodon 60 mg by mouth twice a day for Schizoaffective Disorder. The order was dated 3/22/22. Resident #10's antipsychotic care plan last revised on 6/7/22 for the use of the antipsychotic read it was prescribed for attention seeking behaviors, auditory/visual hallucinations/delusions and manipulative behaviors. Resident #10's last quarterly Minimum Data Set, dated [DATE] indicated he was cognitively intact and exhibited no behaviors. He was also coded for the use of an antipsychotic medication. Review of Resident #10's Consultant Pharmacist progress notes dated 3/27/23 and 4/26/23 did not identify the need for MD or psychiatric NP documentation of the rationale for the continued dosage of Resident #10's Geodon. An interview was completed on 5/3/23 at 11:17 AM with the MD. She stated the lack of annual documentation regarding the continued use of Resident #10's current Geodon dose was likely due to the Consultant Pharmacist's lack of identifying the need to reassess Resident #10's Geodon. A telephone message was left on 5/3/23 at 3:25 PM and 5/4/23 at 9:14 am for the Psychiatric NP to call surveyor. There were no return calls. An interview was completed on 5/4/23 at 10:47 AM with the Director of Nursing (DON). She stated the Consultant Pharmacist had not identified the need for the MD or psychiatric NP to provide annual documented rationale for the continued dose of Resident #10's Geodon at the ordered dosage. A telephone interview was completed on 5/4/23 at 3:26 PM with the Consultant Pharmacist. He stated since the Resident was followed by psychiatry, he did not make any recommendations regarding the need for annual MD or psychiatric NP documentation of the rationale of Resident #10's current dose of Geodon.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and staff interviews the facility failed to reconstitute (the process of adding a diluent to a dry ingredient to make it a liquid) an intravenous (IV) antibiotic prior to administration for 1 of 1 resident (Resident #17) reviewed for IV antibiotic administration. The findings included: Resident #17 was admitted to the facility on [DATE]. The resident's quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #17 was cognitively intact, required extensive assistance for all activities of daily living, was always incontinent of urine, and received diuretics 7 out of 7 days during the assessment period. Resident #17's comprehensive care plan was last updated 4/27/2023 and included a focus for risk of complications related to urinary tract infection with positive cultures. Resident #17's medical record included a physician's order for Meropenem (antibiotic) intravenous solution to be reconstituted and 1 gram administered intravenously three times a day for extended spectrum beta-lactamase (ESBL) urinary tract infection. The start date was 4/27/2023 with an end date of 5/8/2023. On 5/2/2023 at 10:17 AM the resident was observed lying in her bed with an intravenous line running from an empty 50 milliliter (ml) bag of normal saline to a peripherally inserted central catheter (PICC). The glass vial of Meropenem was observed to have dry white powder still in the vial. Nurse #3 was interviewed. She stated she hung the antibiotic at 8:00AM and was coming in the room to discontinue the infusion and flush the PICC line. Nurse #3 observed the IV set up and was unable to identify the antibiotic had not been reconstituted. When the error was pointed out, Nurse #3 stated she must have forgotten to reconstitute the medication prior to hanging and administering the medication. She further stated she would have the unit manager to hang another bag. On 05/04/2023 at 9:08 AM an interview was conducted with Unit Manager #1. She stated Nurse #3 made her aware the Meropenem had not been reconstituted prior to administration. She further stated nurses had received education on how to reconstitute antibiotics in glass vials using an adaptor. She believed it was an oversight by the nurse and not a lack of education. On 5/03/2023 10:49 AM an interview was conducted with the Nurse Practitioner. She stated she was not made aware of the missed medication administration. On 5/03/2023 at 11:21 AM an interview was conducted with the Medical Director. She stated she was not made aware of missed medication administration on 5/2/2023. An interview was conducted on 05/04/2023 at 11:13 AM with the Director of Nursing (DON). She stated Resident #17 should have received her IV antibiotic per physician's order. She believed more education regarding administration should be provided to nursing staff.

Based on observations, record review and staff interviews, the facility failed to label medications with the date they were opened on 1 of 2 medication carts (the Greenbrier Hall Medication Cart). Findings included: A. An observation was conducted on 05/02/23 at 4:01 PM of the nurse ' s medication cart on the Greenbrier Hall in the presence of Nurse #2. The observation revealed one multi-dose Glargine Insulin pen with no opened date. Nurse #2 verified the multi-dose Glargine insulin pen did not have an opened date labeled and was removed from the medication cart. B. An observation was conducted on 05/02/23 at 4:01 PM of the nurse ' s medication cart on Greenbrier Hall in the presence of Nurse #2. The observation revealed 2 multi-dose bottles of Humulin R Insulin with no opened date. Nurse #2 verified 2 multi-dose vials of Humulin R Insulin did not have an opened date labeled and were removed from the medication cart. An interview was conducted on 05/02/23 at 4:11 PM with Nurse #2. She stated she hadn't noticed the insulins were not dated. She also stated that she opened the multi-dose Glargine insulin pen on a different day but must have forgotten to write the opened date on the pen. She stated insulin should be labeled and dated when opened. An interview was conducted on 05/04/23 at 11:00 AM with the Director of Nursing (DON). She stated nurses were to date all insulin vials and pens upon opening and they should be checking dates daily prior to administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #57 was admitted to the facility on [DATE] with diagnoses which included frontotemporal neurocognitive disorder. Review of Resident #57's current Preadmission Screening and Annual Resident Review (PASRR) determination letter dated 10/02/19 revealed the resident remained a level I and determined no further screening was required unless a significant changed occurred to suggest a diagnosis of mental illness. Resident #57's annual Minimum Data Set Assessment (MDS) dated [DATE] indicated he was not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. Resident #57's care plan dated 03/01/23 indicated he has a focus area of a Level II PASRR due to serious mental illness. The goal included for Resident #57 to maintain current level of function through next review date. Interventions included to adjust and meet Activities of Daily Living needs, psychotropic medication management, and he was to be seen by psychiatric services with psychotropic medication management. An interview with the MDS Nurse on 05/04/23 at 9:45 AM revealed she did not do the care planning for level II PASRR. The social worker was responsible for completing the care plan of level II PASRR. The Social Services Director was interviewed on 05/04/23 at 9:49 AM. She stated she was responsible for care planning PASRR levels. She stated she had only been in the position since February 2023 and was still learning the role. She stated she did not know why she had care planned Resident #57 for a level II PASRR and would have to revise the care plan. During an interview with the Director of Nursing (DON) on 05/04/23 at 11:42 AM, she stated care plans should be reviewed and revised for accuracy. Based on record review and staff interviews, the facility failed to review and revise the care plans in the areas of pneumonia (Resident #79), infection (Resident #45), ambulation (Resident #3) and level 2 Pre-admission Screening and Resident Review (PASRR) (Resident #57). This was for 4 of 17 residents reviewed for care plans. The findings included: 1. Resident #79 was admitted to the facility on [DATE] with diagnosis that included bacterial pneumonia. Resident #79's active care plan, last reviewed on 02/23/23, revealed a focus that read resident had Pneumonia. Date Initiated: 11/30/2022. A phone interview was conducted on 05/04/23 at 9:36 AM with the Minimum Data Set (MDS) Nurse. She stated it was an oversite that the focus for pneumonia on Resident #79 ' s care plan had not been updated and removed. 2. Resident #45 was admitted to the facility on [DATE] with diagnosis that included other specified disorders of bone density. He had a diagnosis of osteomyelitis on 05/05/22. Resident #45's active care plan, last reviewed on 02/13/23, revealed a focus that read resident had an infection (osteomyelitis). Date Initiated: 05/05/22. A phone interview was conducted on 05/04/23 at 9:36 AM with the Minimum Data Set (MDS) Nurse. She stated it was an oversite that the focus for infection (osteomyelitis) on Resident #45 ' s care plan had not been updated and removed. An interview was conducted on 05/04/23 at 11:00 AM with the Director of Nursing (DON). She stated the focus for pneumonia on Resident #79 ' s care plan and the focus for infection (osteomyelitis) on Resident #45 ' s care plan should have been updated and removed. 4. Resident #3 was admitted to the facility 7/13/2018 with diagnoses that included Alzheimer's' dementia. Resident #3's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was severely cognitively impaired and was dependent on staff for all activities of daily living, personal hygiene, and eating. Walking in room or corridor did not occur and she was coded with functional limitation in range of motion for both lower extremities. Resident #3's comprehensive care plan was last revised on 4/20/2023 and contained a focus for self-care deficits related to impaired mobility, impaired vision, and impaired cognition. Interventions indicated residents were dependent upon staff to turn and reposition in bed during care rounds. Resident #3's comprehensive care plan also included a focus for elopement risk and wandering related to impaired safety awareness. The focus was revised 4/20/2023. An interview was conducted with NA#2 who was assigned to Resident #3 on 5/3/2023 at 1:15PM. She stated Resident #3 was not ambulatory and did not have wandering behaviors. On 5/3/2023 at 1:25PM an interview was conducted with Unit Manager #2. She stated Resident #3 was not ambulatory and did not have wandering behaviors. On 5/4/2023 at 9:45AM a phone interview was conducted with the Minimum Data Set (MDS) nurse who stated she revised the resident's care plan. She further stated the resident was no longer a elopement risk and the care plan should have been updated to reflect this. An interview was conducted with the Director of Nursing (DON) on 5/4/2023 at 11:13 AM. She stated the care plan should have been updated to reflect the resident's current functional ability and needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with staff and Medical Director, the facility failed to provide physician ordered behavioral health services for 1 of 1 (Resident #18) reviewed for behaviors. The findings included: Resident #18 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder and anxiety disorder. The resident's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was moderately cognitively impaired and had no behaviors during the assessment period. The resident's comprehensive care plan was last revised on 4/3/2023 contained a focus for the use of psychotropic medications as well as a focus for level II PASSR related to serious mental illness. Resident #18's medical record contained physician orders for the following behavioral medications: Give seroquel 75 milligram (mg) by mouth at bedtime for dementia-related psychosis. The start date was 4/17/2023. Give namenda, 5mg, by mouth two times a day for dementia. The start date was 2/17/2023 Give clonazepam, 0.5mg, by mouth two times a day for anxiety. The start date was 2/17/2023. Give bupropion, 450mg, by mouth one time a day for depression. The start date was 2/17/2023. Give escitalopram oxalate, 20 mg, by mouth at bedtime for depression. The start date was 2/17/2023. Give Aricept, 10mg, by mouth one time a day for dementia. The start date was 2/17/2023. Resident #18's medical record also contained a physician's order dated 2/17/2023 to consult psychiatry and treat as needed. On 2/21/2023 a second physician order for behavior health was requested and read as follows; consult behavioral health for evaluation of depression, anxiety, and dementia with psychosis. Noted concerns for significant amounts of medications. A third request for psychiatric services was ordered by the physician on 3/23/2023. A fourth physician's order for psychiatric evaluation related to depression, anxiety, and dementia related psychosis was requested on 4/17/2023. Resident #18's medical record did not contain any indication the resident was ever evaluated by behavioral health professionals. On 5/3/2023 at 10:37AM an interview was conducted with the Director of Nursing (DON). She stated there were notes or evaluations by a behavioral health professional in Resident#18's medical record because she had not been evaluated by psychiatric services while a resident in the facility. The DON stated she was aware of the 4 referrals for psychiatric evaluation because she entered the order on 3/23/2023. She further stated the referrals were given to the Director of Social Services who faxed the referral to the behavioral health provider. On 5/3/2023 at 10:43 AM an interview was conducted with the Director of Social Services. She stated she was responsible for sending out referrals to the behavioral health providers via fax. The Director of Social Services stated she saved fax confirmations when she faxed a referral, but she was not able to locate any fax confirmations for Resident #18. She further stated there was not a process in place for confirming the referrals were completed. On 5/3/2023 at 11:18 AM an interview was conducted with the Medical Director. She stated she requested a psychiatry consult on all residents who were admitted on psychotropic or antipsychotic medications. That is why the 2/17/2023 order was requested. She stated she was not aware the facility had no process in place to ensure referrals were completed but she did try and follow up on referrals herself. The Medical Director stated the facility recently changed behavioral health providers and that may have contributed to the difficulty getting orders completed. An interview was conducted with the DON and the Administrator on 5/4/2023 at 11:19 AM. The DON stated she expected referrals to be completed. She further explained the facility was working on a performance improvement plan to ensure referrals were completed.

Based on record reviews, observations, resident, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification survey completed on 05/04/23. This was for 5 deficiencies that were cited in the areas of resident rights, notice requirements before transfer, accuracy of assessments, care plan timing and revision, and drug regimen review. The duplicate citations during two federal surveys of record show a pattern of the facility's inability to sustain an effective QAPI program. The findings included: This citation is cross referenced to: 1. 550-Based on observations, record reviews, and staff interviews, the facility failed to provide a dignified dining experience by referring to a resident who needed assistance with meals as a feeder (Resident #59) .This was for 1 of 2 residents reviewed for dignity. Based on the reasonable person concept residents would not expect to be identified as a feeder. During the facility's recertification survey of 09/30/21, the facility failed to promote dignity by not providing privacy during an insulin injection and by standing while assisting a dependent resident during a meal. This was for 2 of 2 residents reviewed for dignity. 2. 623- Based on record review, Responsible Party interview, and staff interviews, the facility failed to notify the resident and/or the responsible party (RP) in writing of the reason for the transfer/discharge to the hospital for 2 of 2 sampled residents reviewed for hospitalizations (Residents #14 and #10). During the facility's recertification survey of 09/30/21, the facility failed to provide the resident and/or responsible party (RP) written notification of the reason for a hospital transfer for 3 of 3 residents reviewed for hospitalization. 3. 641- Based on staff interviews and record review, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of behaviors for Resident #59 and continence for Resident #5. This was for 2 of 17 residents reviewed for MDS accuracy. During the facility's recertification survey of 09/30/21, the facility failed to code the Minimum Data Set (MDS) assessments accurately in the areas of falls, medications, nutrition, restraints, and demographics. This was for 7 of 17 residents reviewed. 4. 657- Based on record review and staff interviews, the facility failed to review and revise the care plans in the areas of pneumonia (Resident #79), infection (Resident #45), ambulation (Resident #3) and level 2 Pre-admission Screening and Resident Review (PASRR) (Resident #57). This was for 4 of 17 residents reviewed for care plans. During the facility's recertification survey of 09/30/21, the facility failed to review and revise care plans in the area of falls and in the area of isolation precautions. This was for 2 of 17 resident care plans reviewed. 5. 756-Based on staff, Consultant Pharmacist, and Medical Director (MD) interviews and record review, the Consultant Pharmacist failed to identify the need for an annual MD or psychiatric Nurse Practitioner (NP) documented rationale for the continued use of a prescribed antipsychotic medication (Geodon) at the current prescribed dosage for 1 (Resident #10) of 5 residents reviewed for unnecessary medications. During the facility's recertification survey of 09/30/21, the facility failed to identify the need for target behaviors for the use of psychotropic medications. This was for 4 of 5 residents reviewed for unnecessary medications. An interview was completed on 05/04/23 at 11:10 AM with the Administrator. She stated she felt the repeat citations were due to the facility's recent staff changes in nursing management and not having a full time Minimum Data Set (MDS) Nurse at the facility.

Based on observations and staff interviews the facility failed to ensure leftover food items were labeled and dated in 1 of 1 walk-in refrigerators and failed to ensure the low temperature dish machine a reached a minimum temperature of 120 degrees Fahrenheit during the wash cycle. This practice had the potential to affect food served to all residents. The findings included: 1. During the initial kitchen tour of the walk-in refrigerator on 05/01/23 at 10:00 AM the following concerns were observed: - a container of leftover spaghetti was sealed with plastic wrap, unlabeled, and undated - a container of chicken noodle soup was sealed with plastic wrap, unlabeled, and undated - a container of chili beans was sealed with plastic wrap, unlabeled, and undated - a container of cooked rice was sealed with plastic wrap, unlabeled, and undated - a large cooked ham was wrapped in aluminum foil, unlabeled, and undated - a package of turkey deli meat was opened and undated - a package of cheddar cheese was opened and undated During an interview with the Dietary Manager (DM) on 05/01/23 at 10:05 AM, he stated those items should have been labeled and dated. He stated he has told staff in the past to label and date items when they are opened but did not know why those items were not labeled or dated at the time of the observation. The Administrator was interviewed on 05/04/23 at 11:47 AM. She stated the refrigerator should be checked daily and all food items should be labeled and dated. 2. A continuous observation of the kitchen's low temperature dish machine with the Dietary Manager (DM) on 05/01/23 between 2:50 PM and 3:00 PM revealed a Dietary Aide was working at the dish machine, pre-rinsing and feeding dirty kitchenware, which included 6 plate covers and 3 clear plastic dishes into the dish machine. The machine's wash temperature gauge read a registered temperature of 115 degrees Fahrenheit. The DM then used a calibrated thermometer to check the dish machine's water temperature. The internal wash temperature reached 107 degrees Fahrenheit. During an interview with the DM on 05/01/23 at 3:00 PM, he stated the dish machine was supposed to read 120 degrees Fahrenheit according to the temperature log sheet the facility follows. He stated temperatures should be taken after breakfast, lunch, and dinner. He stated he could not locate the temperature log for 05/01/23 and did not know how long the temperature gauge had been reading 115 degrees Fahrenheit. The Dietary Aide was not available for interview. An interview was completed with the Administrator on 05/04/23 at 11:47 AM. The Administrator stated she expected the dish machine to be in working order and at the correct temperature for sanitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff, resident and responsible party (RP) interviews and record review, the facility failed to honor a resident request for showers. This was for 1 resident (Resident #4) reviewed for choices. The finding included: Resident #4 was admitted on [DATE] with a diagnosis of Congestive Heart Failure (CHF). The quarterly Minimum Data Set, dated [DATE] indicated Resident #4 was cognitively intact, exhibited no behaviors and was coded as independent with bathing. Review of Resident #4's comprehensive care plan included one care area for assistance with his activities of daily living (ADLs). The care plan did not include any bathing/showering assistance. He was not care planned for noncompliance, rejection or refusal of care or staff assistance. An interview and observation was completed with Resident #4 on 2/23/23 at 9:00 AM. He was in his room eating breakfast, clean, groomed and dressed for the day. He voiced no complaints with the facility except for not getting his showers as scheduled. Resident #4 stated at one time, he received his showers as scheduled but it stopped and now the staff did not even offer him a shower. He stated he mentioned it to his RP yesterday when he did not get his scheduled shower on Monday. Review of Resident #4's shower documentation from 1/24/23 to 2/23/23 did not include any documentation that he received a shower. A telephone interview was completed with Resident #4's RP on 2/22/23 at 11:30 AM. She stated Resident #4 reported to her on 2/18/23 that he was not getting his scheduled showers. She stated she discussed her concern with the Director of Nursing (DON) recently and arrangements were made to change his shower days from Wednesdays and Saturdays to Mondays and Thursdays. She did not expand on the reason for the change in his shower days. An interview was completed with Nursing Assistant (NA) #1 on 2/23/23 at 10:30 AM. She stated Resident #4 preferred female assistance with his showers and that was why his shower days were recently changed. She stated there was a male aide that worked on Saturdays and Resident #4 would not allow the male aide to assist him with his showers. An interview was completed with the Unit Manager (UM) on 2/23/23 at 10:40 AM. She stated Resident #4 did receive his showers, but the days had to be changed because he did not want the male aide who worked every Saturday to assist him. The UM stated the DON spoke with him and his RP about his shower days and they were changed to Mondays and Thursdays on first shift. An interview was completed with the DON on 2/23/23 at 3:15 PM. She stated she spoke to Resident #4's RP on Saturday, she completed a grievance at that time, and she was still working on a resolution. She stated Resident #4 recently stated he did not want a male aide to assist him with his ADLs, but he offered no explanation. The DON stated she recently identified a problem with staff providing showers as scheduled so she reintroduced the use of the written shower sheets that required review and oversight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to provide written notification to the resident regarding bed hold when the resident was sent to the hospital for an evaluation for 1 of 1 resident (Resident #6) reviewed for hospitalization. The findings included: Resident #6 was admitted to the facility on [DATE]. Resident #6's admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 as cognitively intact. Her most recent MDS assessment on 2/11/23 was coded as discharge return anticipated. Resident #6's medical record revealed on 2/11/23 she was transferred to the hospital for a change in condition and did not return. Review of nursing notes on 2/11/23 revealed documentation written by Staff Nurse #1 at the time of Resident #6's discharge provided no statements regarding a bed hold notice being provided to the resident. During an interview with Resident #6 on 3/6/23 at 4:04 PM, she revealed she did not receive a bed hold notice upon transfer to the hospital on 2/11/23. Staff Nurse #1 was interviewed on 2/22/23 at 3:15 PM, and she revealed she had sent Resident #6 to the hospital on 2/9/23, and she was not aware of a bed hold form included in the transfer folder. She stated the form had never been discussed with her before. On 2/11/23, when Resident #6 was sent to the hospital again, Staff Nurse #1 stated she was helping Staff Nurse #2 with documentation, who was assigned to Resident #6 on that date. Attempts were made to contact Staff Nurse #2. She did not return attempted telephone calls and no longer worked at the facility. During an interview with the Director of Nursing (DON) on 2/22/23 at 1:33 PM, she stated medical records made a folder for residents to take with them to the hospital upon discharge, known as the transfer folder. The Medical Records Director was also present during the interview. The DON stated nursing staff were supposed to document in Resident #6's medical record that the transfer folder, including bed hold, went with her to the hospital on 2/11/23. She indicated she did not have proof that the transfer folder and bed hold document went with Resident #6 when she was discharged on 2/11/23. An interview was conducted with the Administrator on 2/23/23 at 4:26 PM, she stated the issue of Resident #6's bed hold was lack of knowledge with documentation during transfers by nursing staff. The Administrator indicated that nurses were aware of the bed hold documentation, but she was not sure if Resident #6 knew of the bed hold policy. She revealed her expectation was for all bed holds to be documented upon transfer and for Social Services to send written bed hold to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility's Quality Assurance Committee (QA) failed to maintain procedures and monitor interventions that the committee put into to place following complaints dated 10/23/20, 12/2/20 and 1/3/23 and the recertification survey dated 9/30/21. This was for 2 recited deficiencies in the area of Quality of Care at F689 and Nursing Services at F732. The continued failure of the facility during four federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The findings included: This citation is cross referenced to: F689-Based on staff and Wound Doctor interviews, record review and observations, the facility failed to safely position a resident in bed without injury when Resident #7 fell from a resident bed raised to the waist high position resulting in a subarachnoid hemorrhage (bleeding in the space that surrounds the brain). This was for 1 (Resident #7) of 3 residents reviewed for accidents. F689-cited 9/31/21-Based on record review, observations and staff interview, the facility failed to provide a hazard free environment by utilizing a power strip for a window air conditioner unit for 1 of 14 rooms occupied by residents in the memory care unit (room [ROOM NUMBER]). F732-Based on observations, staff interviews and record review, the facility failed to post total number and actual hours worked per shift for nursing staff for 54 of 54 days reviewed for accuracy. F732-cited 12/2/20-Based on review of the facility ' s required posted daily Nurse Staffing forms and staff interview, the facility failed to complete the posting requirements on 22 of 22 days reviewed (11/01/20 through 11/22/20). In an interview on 2/23/23 at 4:40 PM, the Administrator stated she felt the repeat citations were due to the facility's recent staff changes in nursing management. She stated she started 2 weeks ago, and the DON started 3 months ago.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, Medical Director, and Hospital Discharge Planner interviews, the facility failed to accommodate a bariatric resident's needs (Resident #1) by not providing a bariatric bed and bariatric lift pad/sling prior to Resident #1's admission. This resulted in the resident having to be transferred back to the hospital as the facility could not met the resident's care needs including not being able to complete the admission skin assessment, wound care orders, and personal care. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection, heart failure, respiratory failure, Body Mass Index (BMI) 70 or greater, and morbid (severe) obesity due to excess calories. The hospital Discharge summary dated [DATE] indicated Resident #1 had a past medical history of chronic respiratory failure, hypertension, chronic heart failure, and morbid obesity with BMI of 79. She presented to the hospital with complaints of generalized weakness and was found to have a urinary tract infection as well as low sodium levels. The discharge summary indicated Resident #1's weight was 230 kilograms (507 pounds). She was treated for the urinary tract infection with intravenous (IV) antibiotics and was deemed stable for discharge for short term rehabilitation. Review of the hospital referral information provided by the hospital and printed off by the facility's Admission's Coordinator on 12/28/22 at 12:05 PM revealed Resident #1 had a diagnosis of morbid obesity with a BMI over 70 and weighed 228 kilograms (502 pounds). The North Carolina Medicaid FL2 Level of Care Screening Tool dated 12/21/22 indicated in bold red letters Resident #1's weight was 500 pounds and 14.2 ounces and diagnoses included morbid obesity BMI over 70. The baseline care plan dated 12/28/22 indicated Resident #1 could easily communicate with staff and was alert and cognitively intact. She was assessed as not at risk for falls, no pressure ulcers, and no surgical sites. Resident #1 required two or more persons physical assistance with personal hygiene and bed mobility. The baseline care plan indicated the resident had an indwelling catheter and she was incontinent with bowels. The admission skin assessment dated [DATE] revealed Resident #1 had multiple open areas on her face, body, and her perineum area was raw. The posterior side of Resident #1 was unable to be assessed due to the facility staff's inability to turn her on her side. The wound care order dated 12/28/22 indicated wound care should be completed to bilateral thighs and buttocks every shift. Resident #1's thighs, perineum, and buttocks needed to be cleaned with incontinence wipes; allowed to dry; an antifungal powder to be applied to skin folds; and the wounds along the buttocks were to be covered with a foam absorbent dressing. A review of the order receipt of the bariatric bed revealed the bed was ordered on 12/29/22 (time unspecified) and was delivered 12/29/22 at 6:55 PM. The bariatric lift sling was delivered on 12/30/22 at 1:33 PM. A nursing note dated 12/29/22 at 5:39 PM completed by the Director of Nursing (DON) indicated Resident #1 was sent to the emergency room due to the facility's inability to meet Resident #1's needs. Resident #1 was in agreement with the transfer. Resident #1 refused to allow staff to do incontinence care before she left with EMS. The facility's Medical Director was notified. A phone interview was conducted with the Admissions Coordinator on 01/02/23 at 10:43 AM. She stated she received the referral for Resident #1 from the hospital. She stated she printed the referral and gave it to the DON to review. She indicated the DON did approve Resident #1 for admission. She stated she had spoken with the hospital Discharge Planner regarding Resident #1's admission and the Discharge Planner was not forth coming with Resident #1's weight or care needs. She stated she should have confirmed with the Administrator and the DON if the facility had bariatric equipment and she did not know the bariatric equipment was not in place prior to accepting Resident #1 for admission. She indicated the bariatric equipment should have been ordered and put into place before Resident #1 arrived at the facility. During a phone interview with the hospital Discharge Planner on 01/03/23 at 11:21 AM, she stated all of Resident #1's information, including her weight, were in the referral information. She indicated the facility did not ask questions regarding Resident #1's weight or care needs. She stated she assumed the facility knew about Resident #1's weight since it was listed in the referral information as well as on the FL2. She indicated the resident required a bariatric bed during her stay in the hospital but was able to leave the hospital via a standard stretcher. An interview with Nurse Assistant #1 (NA) was conducted on 01/03/23 at 1:30 PM. She stated she had worked with Resident #1 all day on 12/29/22 up until she went to the hospital. She stated Resident #1 was able to independently feed herself with the head of the bed elevated. She indicated Resident #1 needed 3 staff members to assist with personal care and repositioning. She stated the resident did have a small bowel movement during the last time they repositioned the resident. In attempting to provide personal care, the resident told the staff to stop. NA #1 stated the resident refused care due Resident #1 expressing she felt tired. She indicated Resident #1 wounds on her legs were weeping, which caused frequent changes of disposable pads. She stated it was difficult to change the pads due to the resident's inability to move her due to her weight and the size of the bed. On 01/03/23 at 1:23 PM, Nurse #2 was interviewed. She stated she was assigned to work with Resident #1 on 12/29/22. She indicated the resident could feed herself independently with the head of the bed raised up comfortably. She stated the resident needed maximum assistance with 3 staff members for repositioning and personal care. She indicated the resident could hold onto the bed railing and attempted to assist with repositioning. She indicated Resident #1's wounds on her legs were weeping, which required frequent disposable pad changes. She stated wound care on Resident #1's posterior side could not be completed due to the facility's staff inability to roll the resident completely on her side. She stated prior to Resident #1 going to the hospital, the resident had a small bowel movement while staff were trying to reposition the resident. She stated the resident requested the staff to stop because she was getting tired. She indicated Resident #1 requested to go to the hospital shortly afterward. Nurse #1 was interviewed on 01/03/23 at 12:15 PM. He indicated he was not assigned to work with Resident #1 but was asked to assist with personal care and repositioning. He stated he felt like the resident needed a bigger bed for her comfort and rehab potential. He stated Resident #1 could not be turned completely and it was difficult to position the resident on her side. He stated her could not recall Resident #1 ever being in distress while he helped with repositioning. He indicated he did let the DON know his concerns regarding Resident #1 needing a larger bed. During an interview with the DON on 01/03/23 at 11:57 AM revealed when she reviewed referrals, she typically looked for the resident's weight. She indicated she did not see Resident #1's weight listed on the referral information, and stated it was an oversight to not review Resident #1's weight prior to admission. She stated Resident #1 arrived the evening of 12/28/22 and reviewed her chart the morning of 12/29/22. She stated the bariatric bed was ordered after she reviewed Resident #1's hospital documentation and after concerns were expressed by Nurse #1 regarding Resident #1's weight and bed size. She indicated Resident #1 left the facility by EMS stretcher at 3:00 PM on 12/29/22 due to the facility not being able to meet her needs. The facility's Medical Director was interviewed on 01/03/23 at 3:41 PM. She stated she saw Resident #1 on 12/29/22. She stated the resident was pleasant, alert, oriented, appeared clean and free of malodor. She indicated she was told by staff that it was difficult to turn Resident #1 and the staff did not have adequate room to roll the resident over in the bed she was in. She indicated while the resident was in the bed, she was sitting comfortably with the head of the bed raised. She stated the resident complained of abdominal pain, which was present prior to the resident arriving to the facility. She did not indicate if the resident complained of pain when staff attempted to reposition her. She stated she was notified Resident #1 was sent back to the hospital because facility staff were unable to meet her care needs. During an interview with the Administrator on 01/03/23 at 4:00 PM revealed the facility failed to have bariatric equipment in place prior to Resident #1's admission. He stated he would not have accepted the Resident #1 until the proper medical equipment was at the facility prior to her admission. He indicated the facility should have called him the moment they realized the resident required a bariatric bed and equipment. He stated he would have ordered the equipment and it would have arrived that evening. A review of the Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting correction agenda and summary on 12/30/22 revealed the facility admitted a resident into the facility without having a bariatric bed available for her use. The bariatric bed was ordered after admission, but the resident was sent back to the hospital prior to the bed coming. Education was provided to the NAs, DON, Nurse Managers, Nurses, and Admissions Coordinator on the protocol to follow regarding admissions and availability of equipment. All staff were in-serviced on 12/29/22 and 12/30/22 on Activities of Daily Living Care (ADL): providing care to obese residents which require extensive assistance with ADLs; must use extra staff to always assist with ADL care and with transfers. The Admissions Director was educated on 12/30/22 regarding inquiring about referred resident's weight prior to admission to ensure equipment will arrive timely.

Based on record review, staff, Medical Director, and Hospital Discharge Planner interviews, the facility failed to provide leadership and oversight to ensure the facility had bariatric equipment in place in order to meet the needs of a bariatric resident prior to the resident's admission to the facility (Resident #1). The facility was unable to provide wound care and effective personal care, which caused Resident #1 to be sent back to the hospital. The finding included: This citation is cross referenced to F585. Based on record review, staff, Medical Director, and Hospital Discharge Planner interviews, the facility failed to accommodate a bariatric resident's needs (Resident #1) by not providing a bariatric bed and bariatric lift pad/sling prior to Resident #1's admission. This resulted in the resident having to be transferred back to the hospital as the facility could not met the resident's care needs including not being able to complete the admission skin assessment and wound care orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, staff and resident interviews, the facility failed to promote dignity by not providing privacy during an insulin injection (Resident #215) and by standing while assisting a dependent resident during a meal (Resident #59). This was for 2 of 2 residents reviewed for dignity. The findings included: 1. Resident #215 was admitted to the facility 3/17/2020 with diagnoses that included type two diabetes. Resident #215's most recent Minimum Data Set (MDS) dated [DATE] indicated the resident was mildly cognitively impaired and had no moods or behaviors. The resident required extensive assistance with activities of daily living (ADL) and received insulin injections 7 out of 7 days during the assessment period. On 9/28/2021 at 8:08 AM Nurse #4 was observed asking Resident #215 to lift her gown so she could administer insulin in her abdomen. The resident was sitting on the side of her bed, visible from the door and visible to her roommate. Nurse #4 did not shut the door or pull the privacy curtain prior to administering insulin. The resident's lower abdomen and her incontinent brief were exposed during the insulin administration. An interview was conducted with Resident #215 on 9/28/2021 at 12:18 PM. She stated she did not want to advertise. She wanted the nurse to close the door and pull the privacy curtain prior to administering insulin in her abdomen. When asked if the nurses routinely provided privacy during insulin administration, she stated some nurses did and others did not. On 9/29/2021 at 11:21 AM an interview was conducted with Nurse #4. She stated she typically does close the door and pull the curtain for privacy, but on that occasion, she just forgot. An interview was conducted with the Director of Nursing (DON) and the Administrator on 9/30/2021 at 12:39 PM. Both stated they expect staff to provide privacy and promote dignity for all residents. 2. Resident #59 was admitted on [DATE] with cumulative diagnoses of Diabetes and Dementia. Review of Resident #59's revised care plan dated 4/29/21 indicated she was dependent on staff to eat her meals. Resident #59's annual Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment and coded for extensive physical assistance for eating. In an observation on 9/28/21 at 8:50 AM, Resident #59 was sitting up in bed with Nurse #3 standing at the bedside feeding the resident. Observed was a chair in the room. Nurse #3 stated she normally does not stand while assisting a resident with eating because it was important to be at eye level when feeding Resident #59. In an interview on 9/30/21 at 12:39 PM, the Administrator stated it was his expectation that staff sit to assist residents with meals for dignity reasons.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #60 was admitted to the facility on [DATE] with diagnoses that included intervertebral disc degeneration of the lumbar region. Resident #60's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was mildly cognitively impaired, understood others, and could be understood by others. He required extensive assistance with activities of daily living. The facility's grievance log revealed Resident #60 filed two grievances. On 3/15/2021 Resident #60 filed a grievance regarding the length of his quarantine being 14 days instead of 7 days. On 9/15/2021 Resident #60 filed a grievance regarding Nurse Aides (NAs) not getting him out of bed in the morning at his preferred time and his preference for his nurses to manage his colostomy and not the NAs. On 9/29/2021 at 4:38 PM an interview was conducted with Resident #60. He stated he did meet with the social worker and the Director of Nursing (DON) regarding his grievances but he was not given or offered a written copy of resolutions for his grievances. An interview was conducted with the facility's social worker on 09/28/2021 at 11:08 AM. She stated she addressed most of the grievances. She further stated the DON and the Administrator did handle some grievances as well. The social worker stated she and the department heads investigated the grievances and all grievances were discussed in the stand-up meeting held every morning. The social worker stated she followed up with the residents regarding resolutions. The follow up was verbal. The social worker stated she was not aware the regulation required a written response summary. An interview was conducted with the Director of Nursing (DON) and the Administrator on 9/30/2021 at 12:39 PM. Both stated they expect residents to be given a written resolution regarding their grievances. Based on staff and Responsible Party (RP) interviews and record review, the facility failed to provide a written notification with the grievance resolution to the resident, RP and/or family member. This was for 3 (Resident #41, Resident #24 and Resident #60) of 3 residents reviewed for grievances. The findings included: 1. Resident #41 was admitted on [DATE] with cumulative diagnoses of dysphagia, contractures and anxiety. Review of Resident #41's electronic medical record (EMR) indicated he had an RP listed as his first emergency contact. Review of a grievance dated 2/2/21 read Resident #41's RP had concerns regarding communication, customer service and Resident #41's care. The form read as the resolution, a follow up phone call was conducted with the RP informing her of the results/resolution of her grievance. The form did not indicate a verbal or written grievance resolution was provided. The grievance form was also not signed by any facility staff acknowledging the grievance had be resolved. In an interview on 9/29/21 at 4:32 PM, the Social Worker (SW) stated she was the facility grievance officer. She stated she and the department supervisor listed in the grievance completed the grievance investigations together to resolve any concerns. The SW stated she always communicated verbally with the individual who initiated the grievance and asked if they wanted a copy of the grievance. She stated she was not aware until 9/28/21 that a written grievance response was required. In a telephone interview on 9/30/21 at 11:41 AM, Resident #41's RP stated she did not recall ever receiving anything in writing regarding a grievance and did not recall being offered a written grievance resolution. In an interview on 9/30/21 at 1:47 PM, the Administrator and DON stated it was their expectation a written grievance resolution be provided to the party that initiated the grievance. 2. Resident #24 was admitted on [DATE] with a diagnosis of a Cerebral Vascular Accident. Review of a grievance dated 4/20/21 read Resident #24's family member was concerned about his rapid decline in function. A care plan meeting was completed with Resident #24's family to discuss his expected continued decline and prognosis. The form indicated the family member received verbal grievance resolution and was signed by the Administrator. The form did not include any documented evidence that the family member received a written grievance resolution. Review of a grievance dated 6/21/21 read Resident #24's family member went to the facility to cut Resident #24's hair and was unable to gain access by ringing the door bell or by phone. The form read the receptionist was in the bathroom at the time he attempted to gain access. The form read the family member received verbal grievance resolution and was signed by the Social Worker. The form did not include any documented evidence that the family member received a written grievance resolution. In an interview on 9/29/21 at 4:32 PM, the SW stated she was the facility grievance officer. She stated she and the department supervisor listed in the grievance completed the grievance investigations together to resolve any concerns. The SW stated she always communicated verbally with the individual who initiated the grievance and asked if they wanted a copy of the grievance. She stated she was not aware until 9/28/21 that a written grievance response was required. A telephone interview was attempted on 9/30/21 at 11:00 AM with Resident #24's family member. There was no answer and surveyor was unable to leave a message. In an interview on 9/30/21 at 1:47 PM, the Administrator and DON stated it was their expectation a written grievance resolution be provided to the party that initiated the grievance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to complete a significant change in status Minimum Data Set (MDS) assessment within 14 days after the resident enrolled in the hospice program for 1 of 1 residents reviewed for hospice (Resident #62). The findings included: Resident #62 was originally admitted to the facility on [DATE] with multiple diagnoses that included dementia with Lewy Bodies, Parkinson's disease, and diabetes. Resident #62 was transferred to the hospital on 8/19/21 and returned to the facility on 8/26/21. The medical record for Resident #62 was reviewed and revealed a physician's order dated 8/26/21 to admit to hospice services due to a diagnosis of Alzheimer's disease. A review of Resident #62's care plan revealed a problem area initiated on 8/30/21 for Hospice services. A quarterly MDS assessment dated [DATE] indicated Resident #62 had moderately impaired cognition. Hospice was not coded. On 9/30/21 at 10:03 AM, the MDS Nurse was interviewed and stated a significant change in status MDS assessment should have been completed 14 days after Resident #62 enrolled in hospice services and she felt it was an oversight. An interview was completed with the Administrator and Director of Nursing on 9/30/21 at 12:39 PM and both stated it was their expectation for significant change in status MDS assessments to be completed as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and record review, the facility failed to complete a comprehensive care plan in the areas of contractures and physical restraints. This was for 2 (Resident #24 and Resident #32) of 17 residents reviewed for comprehensive care plans. The findings included: 1. Resident #24 was admitted on [DATE] with a diagnosis of a Cerebral Vascular Accident. Resident #24's quarterly Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment and he exhibited no behaviors. He was coded for total assistance with his activities of daily living and coded for impairment to his bilateral upper extremities. Review of Resident #24's care plan last revised on 6/30/21 did not include a care plan for contractures. In an interview on 9/30/21 at 10:15 AM, the MDS nurse stated she completed record review, interviews staff and completed observations with completing a comprehensive care plan. She stated Resident #24's bilateral hand contractures should have been care planned. She stated it was an oversight. In an interview on 9/30/21 at 1:47 PM, the Administrator and Director of Nursing (DON) stated they expected Resident #24's hand contractures would have been care planned. 2. Resident #32 was admitted on [DATE] with a diagnosis of a Cerebral Vascular Accident. Review of Resident #32's quarterly Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment and he exhibited no behaviors. He was coded for total assistance with all his activities of daily living (ADLs) and coded as having no restraints. Review of Resident #32' September 2021 Physician orders included an order dated 1/6/20 for an abdominal binder (a wide compression belt that encircles the abdomen) related to major depression disorder, poor safety awareness and a history of pulling out his feeding tube. Release the binder for activities of daily living (ADL) care and every 2 hours as needed every shift. Review of Resident #32's care plan last revised 9/9/21 did not include a care plan for an abdominal binder as a physical restraint. In an observation on 9/30/21 at 9:30 AM, Nurse #1 asked Resident #32 to unfasten his abdominal binder. There was no response from the resident. Nurse #1 made multiple attempts to have Resident #32 unfastened his abdominal binder. Resident #32 never moved nor acknowledged understand of what Nurse #1 was asking of him. Nurse #1 stated he had not personally ever seen Resident #32 attempt to remove his abdominal binder but there had been instances where it would be loose. He stated he could not say that maybe a staff member did not adequately secure the binder. In an interview on 9/30/21 at 10:15 AM, the MDS nurse stated she completed record review, interviews staff and completed observations with completing a comprehensive care plan. She stated she did not consider Resident #32's abdominal binder as a restraint. In an interview on 9/30/21 at 1:47 PM, the Administrator and DON stated they expected the residents to have a complete and comprehensive care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to review and revise care plans in the area of falls (Residents #31 and #62) and in the area of isolation precautions (Resident #62). This was for 2 of 17 resident care plans reviewed. The findings included: 1) Resident #31 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE]. His diagnoses included dementia with Lewy Bodies, atrial fibrillation, history of falls and unsteadiness on feet. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #31 had severe cognitive impairment and a wheelchair was used for mobility. Resident #31's care plan revealed a focus area for falls with interventions that included a referral for a high back wheelchair for positioning. This intervention was initiated on 4/23/21 and the care plan was most recently reviewed on 8/5/21. Observations were made of Resident #31 on 9/27/21 at 11:45 AM and 9/29/21 at 11:38 AM and he was sitting up in a regular wheelchair. An interview occurred with Nurse #2 and Nurse Aide (NA) #1 on 9/29/21 at 11:38 AM. Both verified Resident #31 used a regular wheelchair for mobility and was unable to recall if he had ever used a high back wheelchair. On 9/29/21 at 1:00 PM an interview was held with the Rehab Director who was familiar with Resident #31. She confirmed he was not using a high back wheelchair and was unaware if this had ever been used as an intervention for falls. The MDS Nurse was interviewed on 9/30/21 at 10:03 AM. She reviewed Resident #31's medical record and stated the intervention for a high back wheelchair should have been resolved when the care plan was reviewed, by her, on 8/5/21 as Resident #31 did not use this for mobility. An interview occurred with the Administrator and Director of Nursing on 9/30/21 at 12:39 PM. Both indicated it was their expectation for the care plan to be an accurate representation of the resident, when updated by the MDS Nurse. 2 a) Resident #62 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE]. His diagnoses included Parkinson's disease, history of falling, dementia with Lewy Bodies and unsteadiness on feet. A review of Resident #62's September 2021 physician orders included the following: - An order dated 8/26/21 for Hospice services. - An order dated 9/2/21 for the bed to be in the lowest position possible when resident is in bed. - An order dated 9/13/21 for fall mats to both sides of the bed, winged mattress, and low bed in lowest position for safety promotion interventions. Hospice to provide durable medical equipment (DME). A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #62 had moderately impaired cognition, use of a wheelchair for mobility and 2 or more falls with minor injury. Resident #62's care plan, last reviewed on 9/20/21, revealed a focus area for falls with interventions that included: - New bed/crank bed in place. Remove electrical bed. This was initiated on 3/5/21. - Make a referral to therapy upon return from the hospital. This was initiated on 6/16/21 and revised on 9/28/21. - Remove fall mats due to resident ability to get up and stand without assistance. Ensure bed is low. This was initiated on 1/2/21 and revised on 9/16/21. - Floor mat to right side of bed with left side of bed to wall. Check placement of mat every shift. This was initiated on 9/17/21 and revised on 9/20/21. On 9/27/21 at 10:46 AM, an observation occurred of Resident #62 while he was in bed. The electric bed was in the lowest position possible, winged mattress was present, fall mats were present to either side of the bed and the bed was not positioned against the wall. An interview was held with Nurse #2 on 9/28/21 at 10:30 AM, who verified hospice had provided an electric low bed for Resident #62, fall mats were placed on either side of the bed and a winged mattress was present as part of falls interventions. On 9/29/21 at 1:00 PM, an interview was conducted with the Rehab Director who was familiar with Resident #62. She explained since Resident #62 was active with Hospice services since 8/26/21, he would no longer be evaluated or treated for therapy services, unless hospice ordered it. The MDS Nurse was interviewed on 9/30/21 at 10:03 AM. She reviewed Resident #62's medical record and stated the interventions for a crank bed, therapy referrals and left side of bed against the wall should have been resolved from the care plan. The use of the fall mats should have been revised and the winged mattress should have been added to the care plan. All of these changes should have occurred when she reviewed the care plan on 9/20/21. An interview occurred with the Administrator and Director of Nursing on 9/30/21 at 12:39 PM. They both indicated it was their expectation for the care plan to be an accurate representation of the resident when updated by the MDS Nurse. b) Resident #62 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE]. His diagnoses included Parkinson's disease, history of falling, dementia with Lewy Bodies and unsteadiness on feet. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #62 had moderately impaired cognition and isolation or quarantine for active infectious disease was not coded. Resident #62's care plan revealed a focus area for isolation precautions due to resident has not had COVID vaccinations. This focus area was initiated on 9/1/21 and the care plan was most recently reviewed on 9/20/21. On 9/27/21 at 10:46 AM, an observation occurred of Resident #62 while he was in bed. There was no indication Resident #62 was under isolation precautions and a roommate was present in the room. An interview was held with Nurse #2 on 9/28/21 at 10:30 AM, who verified Resident #62 was under quarantine precautions shortly after his return from the hospital on 8/26/21 but was no longer under these precautions. The MDS Nurse was interviewed on 9/30/21 at 10:03 AM. She reviewed Resident #62's medical record and stated the focus care plan for isolation precautions should have been resolved when she reviewed the care plan on 9/20/21. An interview occurred with the Administrator and Director of Nursing on 9/30/21 at 12:39 PM. They both indicated it was their expectation for the care plan to be an accurate representation of the resident when updated by the MDS Nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and Physician #1 interviews and record review, the facility failed to ensure an air mattress ordered to promote wound healing was accurately set based on the resident's body weight. This was for 1 (Resident #59) of 2 residents reviewed for pressure ulcers. The findings included: Resident #59 was admitted on [DATE] with cumulative diagnoses of Diabetes, Dementia, contractures and a pressure ulcer to her sacrum. Resident #59's revised care plan dated 8/18/21 read she had a pressure ulcer to her sacrum. Interventions included an air mattress on her bed for pressure relief. Review of Resident #59's September 2021 Physician orders included an order dated 2/16/21 for an air mattress to her bed to promote wound healing. There was no order regarding the assessment of the air mattress for proper function and/or settings. Resident #59's annual Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment and extensive assistance with all her activities of daily living. Her weight was documented at 124 pounds. She was coded for one pressure ulcer present on admission with a pressure relieving mattress to her bed. The pressure ulcer Care Area Assessment read as follows: Resident was admitted with stage 4 pressure wound to sacrum. Resident will receive proper treatment for pressure wound per MD orders with positive healing noted thru next review. In an observation completed on 9/27/21 at 10:12 AM, Resident #59 was lying on her left side on an air mattress with the mattress weight setting of 300 pounds. In an observation completed on 9/28/21 at 8:50 AM, Resident #59 was lying on her left side on an air mattress with the mattress weight setting of 300 pounds. A wound care observation was conducted on 9/28/21 at 10:10 AM with the Treatment Nurse. There were no observed concerns related to the wound care. The Treatment Nurse stated when using an air mattress on the bed of a resident with a pressure ulcer, the pressure setting were determined by the resident's weight. She stated the nurses set the air mattress pressure based on the residents weight or unless otherwise specified by the Physician. In an observation and interview on 9/28/21 at 3:15pm, the Treatment Nurse and Nurse # 1 confirmed the air mattress weight setting was set for 300 pounds. The Treatment Nurse stated the setting should have been set to less than (<) 250 pounds and not 300 pounds. Nurse #1 stated Resident #59 did not weight much over 100 pounds and he adjusted the air mattress pressure to <250 pounds at this time. The Treatment Nurse stated the air mattress weight setting should be assessed weekly during the skin assessments. She stated she did not check the air mattress settings on a daily basis while completed wound care. She stated it was an oversight. In an interview on 9/29/21 at 2:34 PM, Physician #1 stated it was the nurses responsibility to ensure Resident #59's air mattress was set accurately based on her most recent weight of 124 pounds. In an interview on 9/30/21 at 12:29 PM, the Administrator and Director of Nursing stated it was their expectation that Resident #59's air mattress pressure setting were based on her weight of 124 pounds unless otherwise specified by the Physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interview, the facility failed to provide a hazard free environment by utilizing a power strip for a window air conditioner unit for 1 of 14 rooms occupied by residents in the memory care unit (room [ROOM NUMBER]). The findings included: During an observation of room [ROOM NUMBER] on 9/27/21 at 10:46 AM and 9/28/21 at 11:00 AM, a window air conditioner (AC) unit was plugged into a 6-receptacle power strip, by a resident's bed, not in use and easily accessible to residents. A review of the facility's undated policy titled, Power Cords and Extension Cords revealed, the use of power strips for non-Patient Care Related Electrical Equipment (i.e., personal electronics) only in long term care resident rooms without Patient Care Related Electrical Equipment and Power strips in patient care room but outside Patient Care Vicinity for non-related items are permitted. In addition, the policy stated, the electrical and mechanical integrity of the assembly is regularly verified and documented. An interview occurred with the Administrator and Maintenance Director on 9/29/21 at 11:00 AM. The Administrator stated the central air conditioner for the memory care unit was not operating correctly at the end of 2019 and several window AC units were placed at that time. They both explained, they felt the power strip was used as the AC power cord was not long enough to reach the wall receptacle. The Maintenance Director stated he began employment at the facility January 2020 and was aware the window units were present as well at the power strip. He further stated the central air conditioner for the memory care unit was replaced June 2021 and the window AC units were no longer used. Both the Administrator and Maintenance Director stated they would not have expected the AC unit in the window to be plugged into a power strip, instead it should have been plugged directly into the wall receptacle or a receptacle should have been placed on the wall within the distance needed to plug the AC window unit in directly. On 9/29/21 at 11:10 AM an observation of room [ROOM NUMBER] was made with the Maintenance Director where the window AC unit was plugged into a power strip, which was then plugged into the wall receptacle. The Maintenance Director stated power strips were allowed for items such as personal electronics in resident rooms and should be inspected and approved regularly. The Maintenance Director was unable to provide evidence of the facility regularly inspecting and approving the power strip observed in room [ROOM NUMBER]. The Maintenance Director stated he would remove the window AC unit and power strip.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, staff, pharmacist, the facility failed to obtain medication prescribed for pain which resulted in 10 missed doses for 1 of 5 (Resident #53) reviewed for unnecessary medications. The findings included: Resident #53 was admitted to the facility on [DATE] with most recent readmission on [DATE]. Her admitting diagnoses included osteomyelitis (bone infection) of the vertebrae in the lower lumbar region. The resident's hospital Discharge summary dated [DATE] revealed Resident #53 was discharged with orders for oxycodone 10 milligrams (mg) orally every four hours as needed (prn) for pain, and pregabalin 75mg capsule three times daily for pain. Resident #53's admission Minimum Data Set (MDS) dated [DATE] indicated she was severely cognitively impaired with behaviors positive for disorganized thinking. Resident #53 required extensive assistance with activities of daily living (ADL) and received opioid 6 out of 7 days during the assessment period. The resident was on scheduled medication for pain and prn (as needed) medication for pain. She characterized her pain as frequent and rated her pain 7 out of 10 during the assessment period. The August 2021 Medication Administration Record (MAR) revealed Resident #53 had an order for pregabalin capsules, 75mg to be given orally three times daily for pain with a start date for this 8/27/2021. The medication was not administered from 8/27/2021 through 8/30/2021. There were 10 missed administrations during that time period. Each missed administration was documented as a 9, indicating the medication was not available for administration. Further review of the August 2021 MAR revealed Oxycodone 10mg was administered orally every four hours 8/28/2021 through 8/30/2021. The August 2021 MAR revealed Resident #53's pain level was documented every shift. On 8/28/2021 her pain level was documented as 4-5 on a scale of 10 (with 10 being the worst pain ever experienced). Her pain level on 8/29/2021 was documented as zero every shift, and on 8/302021 her pain level was documented as low as 2 and as high as 7. Attempts to interview the resident were not successful. When asked to rate her pain level, she did not reply. A phone interview was conducted with Nurse # 5 on 9/29/2021 at 2:56 PM. She stated she worked Resident #53 on Saturday 8/28/2021 and Sunday 8/29/2021 and both days she called the pharmacy regarding the pregabalin. The pharmacist told her they had not received a hard script for the medication and could not fill it until the physician signed a hard script. She stated she sent a text to the facility's physician on 8/28/2021 and made him aware but she did not recall him texting her back. She called the pharmacy again on 8/29/2021 and was told the same thing. She could not recall if she called the physician again on 8/29/2021 to make him aware the pregabalin was not available. Nurse #5 felt the resident's pain was well controlled during her shifts. On 9/29/2021 at 2:37 PM an interview was conducted with Nurse #1. He stated he provided care for Resident #53 on 8/30/2021 and the pregabalin was not on the medication cart. He stated he personally called the pharmacy about the pregabalin and the pharmacist stated the hard script was not sent to the pharmacy. The facility's physician would need to write a script and send it to them before the order could be filled by the pharmacy. He stated he called and left a message for the facility's physician. He did not recall hearing back from pharmacy or the physician and the resident did not get the three scheduled doses of pregabalin on 8/30/2021. He stated he felt the resident's pain was well controlled during his shifts. A phone interview was conducted with the pharmacist on 9/30/2021 at 3:15pm. She stated the hard script for Resident #53's pregabalin was received in the pharmacy on 8/30/221 at 8:30 PM. She did note the hard script was dated 8/27/2021 and faxed from the facility, but not faxed to the pharmacy until 8/30/2021. She further stated the script was filled and the medication was in the facility the morning of 8/31/2021. On 9/29/2021 at 3:26 PM an interview was conducted with the unit manager who entered the physician's orders when the resident was admitted on [DATE] around 3:30 PM. She stated she did order the medication from pharmacy on 8/27/2021. She did not receive a communication from pharmacy on 8/27/2021 regarding a hard script for the medication but she was aware some medications required a hard script signed by the physician and pregabalin was one of them. She stated if there was a hard script for pregabalin, she did not see it when she put the orders in on 8/27/2021. She stated she did not call the physician and request a hard script for the pregabalin on 8/27/2021. Attempts to contact the facility's physician were not successful. An interview was conducted with the Director of Nursing (DON) and the Administrator on 9/30/2021 at 12:39 PM. The DON stated she had only been employed with the facility for a month and the Administrator stated he was not certain what the current process was for ordering medications that required a hard script. Both stated they needed to look into the process to see how it could be prevented in the future. Both stated they expect medications to be available for administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff, Medical Director (MD), Physician #1 interviews and record review, the facility failed to recognize the use of an abdominal binder (a wide compression belt that encircles the abdomen) previously identified as physical restraint and complete quarterly restraint assessments. The facility also failed to identify the use of a resident bed pushed up against a wall as a physical restraint. This was for 2 (Resident #32 and Resident #59) 2 residents reviewed for physical restraints. The findings included: 1. Resident #32 was admitted on [DATE] with a diagnosis of a Cerebral Vascular Accident. Review of Resident #32's feeding tube care plan included the intervention of an abdominal binder around his feeding tube (a tube inserted directly into the stomach for nutrition) as tolerated by the resident. This intervention was last revised on 10/16/19. Review of Resident #32' September 2021 Physician orders included an order dated 1/6/20 for an abdominal binder related to major depression disorder, poor safety awareness and a history of pulling out his feeding tube. Release the binder for activities of daily living (ADL) care and every 2 hours as needed every shift. Review of Resident #32' electronic medical record (EMR) included a Physical Restraint Review for Reduction assessment dated [DATE] indicated an abdominal binder was in use. The determination section F of the assessment read as follows: Are the current or considered device(s) or bed placement for the resident considered a restraint? The form indicated the choice of yes was checked. The assessment indicated Resident #32 was not a candidate for a restraint reduction or elimination due to a history of removing his feeding tube. Review of Resident #32's quarterly Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment and he exhibited no behaviors. He was coded for total assistance with all his ADLs and coded as having no restraints. In a medication administration observation on 9/28/21 at 10:20 AM, Nurse #1 removed Resident #32's covers and lifted his gown. Observed around Resident #32's abdomen was an off- white stretchy abdominal binder that went completely around his torso and was secured with Velcro covering the feeding tube insertion site. Nurse #1 did not loosen the abdominal binder to access Resident #32's feeding tube but rather pulled the binder up to access his feeding tube. Nurse #1 stated Resident #32 had to wear the abdominal binder due to a history of pulling out his feeding tube. In an interview on 9/28/21 at 3:25 PM, Nursing Assistant (NA) #4 stated she did not recall Resident #32 making any effort to remove or unfastened his abdominal binder. She stated as far as she was aware, the only time the abdominal binder was released was during ADL care and maybe when the nurse performed his feeding tube care. In an interview on 9/29/21 at 10:07 AM, the Director of Nursing (DON) stated the abdominal binder was not considered a restraint but rather served as protection of Resident #32's surgical site. She clarified the surgical site was the insertion site of his feeding tube. The DON stated when a restraint was needed, the facility had to complete a restraint assessment, obtain consent from the resident or the responsible party and obtain Physician orders. She stated any restraint had to be reassessed at least quarterly to determine continued medical necessity or if a restraint reduction should be attempted. In an interview on 9/29/21 at 10:32 AM, the MD stated Resident #32' abdominal binder was not a restraint, medically necessary and was considered an article of clothing. In an observation on 9/30/21 at 9:30 AM, Nurse #1 asked Resident #32 to unfasten his abdominal binder. There was no response from the resident. Nurse #1 made multiple attempts to have Resident #32 unfasten his abdominal binder. Resident #32 never moved nor acknowledged understand of what Nurse #1 was asking of him. Nurse #1 stated he had not personally ever seen Resident #32 attempt to remove his abdominal binder but there had been instances where it would be loose. He stated he could not say that maybe a staff member did not adequately secure the binder. In an interview on 9/30/21 at 9:40 AM, NA #6 stated Resident #32 was unable to unfastened or remove his abdominal binder and she had never observed him making any attempt to do so. In an interview on 9/30/21 at 1:47 PM, the Administrator and DON stated Resident #32's abdominal binder was medically necessary and did not consider it as a restraint. 2. Resident #59 was admitted [DATE] with cumulative diagnoses of seizures, anxiety, insomnia, bilateral knee contractures and dementia with behavioral disturbance. Review of Resident #59's two fall incidents in June 2021 (6/10/21 and 6/21/21) indicated she was found on the floor on the left side of her bed. Review of Resident #59's annual Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment and she exhibited both verbal and physical behaviors. She was coded for extensive to total assistance with her activities of daily living (ADLs). Resident #59 was coded as having no restraint. Review of Resident #59's fall care plan last included an intervention dated 8/18/21 that read: Resident will have a fall mat to the right side of her bed with the left side of the bed to the wall per family request. In an observation on 9/27/21 at 9:55 AM, Resident #59 was observed lying in her bed that was pushed up against the wall on her left side. In an observation on 9/28/21 at 8:50 AM, Resident #59 was observed lying in her bed that was pushed up against the wall on her left side. In an interview on 9/28/21 at 3:20 AM, the Staff Development Coordinator (SDC) stated recently Resident #59's family requested that her bed be pushed up against the wall on her left side because that was the side she had fallen from the bed in the past. The SDC stated Resident #59 would not be able to get out of her bed from the left side because the wall would prevent it. In an interview on 9/28/21 at 3:25 PM, Nursing Assistant (NA) #4 stated she came in one day and the bed had been moved up against the wall. She stated she thought it was to prevent Resident #59's from falling out of the bed. In an interview on 9/29/21 at 10:07 AM, the Director of Nursing (DON) stated there had been no restraint assessment and no consent was obtained because it was the request of the family. The DON stated Resident #59's bed against a wall was a restraint. The DON stated when a restraint was needed, the facility had to complete a restraint assessment, obtain consent from the resident or the responsible party and obtain Physician orders. She stated any restraint had to be reassessed at least quarterly to determine medical necessity or an attempt in a reduction. In an interview on 9/29/21 at 2:34 PM, Physician #1 stated the staff moved her bed up against the wall on that side to keep her from falling out of the left side of her bed. He stated he did not think it was possible for Resident #59 to get out of the bed on the right side unless assisted by the staff. In an interview on 9/30/21 at 9:20 AM, NA #5 stated the Resident #59's bed was put against the wall on her left side because that was the side she had experienced previous falls. In an interview on 9/30/21 at 1:47 PM, the Administrator and DON stated unless Resident #59's bed was moved away from the wall, it would be considered a restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Resident #32 was admitted to the facility on [DATE] with diagnoses that included hypertension, cardiovascular accident (stroke) and diabetes. Resident #32's quarterly Minimum Data Set (MDS) dated [DATE] indicated she was cognitively intact, understood by others and able to make herself understood. She was coded as male during the assessment period. Review of Resident #32's previous quarterly MDS dated [DATE] revealed the resident was coded as female. An interview was conducted with Resident #32 on 09/28/21 at 12:25 PM. She stated she was female, her assigned gender at birth was female. On 9/29/2021 at 3:00pm an interview was conducted with Nurse # 3. She stated she frequently provided care for Resident #32 and the resident's gender was female, and she lived as female. 09/29/21 at 3:09 PM an interview was conducted with the MDS nurse. She stated the demographic was an error on her part. Resident #32 should have been coded as female. On 9/30/2021 at 12:39pm and interview was conducted with the Director of Nursing and the facility Administrator. Both stated they expected the MDS to be coded correctly. Based on record reviews, observations and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessments accurately in the areas of falls (Residents #31, #45, and #62), medications (Residents #63 and #59), nutrition (Resident #32), restraints (Resident #32), and demographics (Resident #58). This was for 7 of 17 residents reviewed. The findings included: 1) Resident #31 was originally admitted to the facility on [DATE] with diagnoses that included dementia with Lewy Bodies, Atrial Fibrillation, and seizure disorder. Resident #31 transferred to the hospital on 7/22/21 and was readmitted to the facility on [DATE]. A review of Resident #31's medical record revealed he had no falls since readmission to the facility on 7/28/21. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #31 had severe cognitive impairment and was coded with 2 or more falls with no injury. On 9/30/21 at 10:03 AM, an interview occurred with the MDS Nurse who reviewed the MDS assessment dated [DATE] as well as Resident #31's medical record. The MDS Nurse confirmed Resident #31 has had no falls since his readmission to the facility on 7/28/21 and falls should have been coded as no falls instead of 2 falls with no injury. An interview was conducted with the Administrator and Director of Nursing on 9/30/21 at 12:39 PM and both stated it was their expectation for the MDS assessment to be coded accurately. 2) Resident #45 was admitted to the facility on [DATE] with multiple diagnoses that included unsteadiness on feet, dementia, and Parkinson's disease. A review of Resident #45's medical record revealed she had 2 falls with no injury on 7/29/21 and 8/12/21 within the 8/27/21 MDS assessment look back period. The quarterly MDS assessment dated [DATE] indicated Resident #45 had moderately impaired cognition. She was coded with 2 or more falls with no injury and 2 or more falls with minor injury. On 9/30/21 at 10:03 AM, an interview occurred with the MDS Nurse who reviewed the MDS assessment dated [DATE] as well as Resident #45's medical record. The MDS Nurse stated it was an error that 2 falls with minor injury was coded. An interview was conducted with the Administrator and Director of Nursing on 9/30/21 at 12:39 PM and both stated it was their expectation for the MDS assessment to be coded accurately. 3) Resident #62 was originally admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, dementia with Lewy Bodies and seizure disorder. He was most recently transferred to the hospital on 8/19/21 and readmitted to the facility on [DATE]. A review of Resident #62's medical record revealed he had falls on 9/1/21 with no injury, 9/11/21 with minor injury and 9/16/21 with minor injury since his return to the facility on 8/26/21. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #62 had moderately impaired cognition and was coded with 2 or more falls with minor injury. On 9/30/21 at 10:03 AM, an interview occurred with the MDS Nurse who reviewed the MDS assessment dated [DATE] as well as Resident #62's medical record. The MDS Nurse stated it was an oversight not to code the fall with no injury. An interview was conducted with the Administrator and Director of Nursing on 9/30/21 at 12:39 PM and both stated it was their expectation for the MDS assessment to be coded accurately. 4) Resident #63 was admitted to the facility on [DATE] with diagnoses that included vascular dementia with behavioral disturbances, insomnia and depression. A review of Resident #63's September 2021 physician orders included Melatonin 10 milligrams (mg) 1 tab by mouth at bedtime for insomnia and Trazodone (an antidepressant medication that can used to aide in sleep) 25mg 1 tab by mouth at bedtime for sleep aid. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #63 was cognitively intact and received 7 days of a hypnotic medication. On 9/30/21 at 10:03 AM, an interview occurred with the MDS Nurse who reviewed the MDS assessment dated [DATE] as well as Resident #63's medical record. The MDS Nurse stated when she coded the MDS assessment she was looking at the use of Trazodone rather than classification of the drug. She stated Trazodone should not have been coded as a hypnotic. An interview was conducted with the Administrator and Director of Nursing on 9/30/21 at 12:39 PM and both stated it was their expectation for the MDS assessment to be coded accurately. 5. Resident #32 was admitted on [DATE] with a diagnosis of a Cerebral Vascular Accident and a feeding tube (a tube inserted directly into the stomach for nutrition). Review of Resident #32's September 2021 Physician orders included an order dated 8/11/21 for a mechanical soft texture diet with thin liquids and an order for a frozen nutritional cup three times daily dated 2/17/21. Resident #32's September 2021 Physician orders included an order dated 9/2/21 for tube feeding continuously for nutritional support. Resident #32's September 2021 Physician orders also included an order dated 1/6/20 for an abdominal binder related to a history of removing his feeding tube. Review of Resident #32's quarterly Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment and he exhibited no behaviors. He was coded for total assistance with all his activities of daily living. Review of section K (Swallowing/Nutritional Status) indicated he was not coded for the nutritional approach of his feeding tube and not coded for any nutrition taken by mouth. Review of section P (restraints) indicated he was not coded for the use of an abdominal binder as a restraint to prevent Resident #32 from removing his feeding tube. During an medication observation with Nurse #1 on 9/28/21 at 10:20 AM, he stated Resident #32 took all medications through his feeding tube but did get a frozen nutritional supplement by mouth three times a day while on continuous tube feedings. Observed around Resident #32's abdomen was an off- white stretchy abdominal binder that went completely around his torso and was secured with Velcro covering the feeding tube insertion site. In an interview on 9/30/21 at 10:15 AM, the MDS Nurse stated she did not code section K or section P accurately. She stated she should have coded Resident #32 for his tube feedings and oral intake but stated she did not think the abdominal binder was considered a restraint. In an interview on 9/30/21 at 1:47 PM, the Administrator and Director of Nursing stated it was their expectation that the MDS be coded accurately. 6. Resident #59 was admitted [DATE] with cumulative diagnoses of seizures, anxiety, insomnia, bilateral knee contractures and dementia with behavioral disturbance. Review of Resident #59's September 2021 Physician orders included an order for Trazadone (antidepressant) as bedtime for insomnia. Review of Resident #59's annual Minimum Data Set (MDS) dated [DATE] indicated she was not taking any antidepressants but was taking an hypnotic. In an interview on 9/30/21 at 10:15 AM, the MDS Nurse stated she coded the Trazadone for what it was prescribed for rather than the medication classification. She stated it was inaccurate and an oversight. In an interview on 9/30/21 at 1:47 PM, the Administrator and Director of Nursing stated it was their expectation that the MDS be coded accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #53 was admitted to the facility on [DATE] with most recent readmission on [DATE]. Her admitting diagnoses included osteomyelitis (bone infection) of the vertebrae in the lower lumbar region, and major depressive disorder. Resident #53's admission Minimum Data Set (MDS) dated [DATE] indicated she was severely cognitively impaired with behaviors positive for disorganized thinking. Resident #53 required extensive assistance with activities of daily living (ADL) and received antipsychotic medications 7 out of 7 days, antidepressants 7 out of 7 days, and hypnotics 7 out of 7 days during the assessment period. A review of Resident #53's care plan, last updated on 8/30/2021, revealed the following focus area: Resident uses psychotropic medications related to disease process, major depressive disorder and is on antipsychotic and antidepressant medications. Interventions included; administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift and consult with pharmacy, physician, to consider dosage reduction when clinically appropriate at least quarterly. Resident has a behavior of yelling out for attention related to care or sometimes noted to call and want nothing. Interventions included, monitor for side effects and effectiveness. Resident #53's August 2021 and September 2021 Medication Administration Record (MAR) revealed an order for Seroquel 150 milligrams (mg) at bedtime for major depressive disorder with a start date of 8/27/2021. The MARs did not list target behaviors or any area to document if the behaviors were present. On 9/29/21 at 4:31pm and interview was conducted with NA #7. She stated she did work with Resident #53 and was familiar with her. When asked about behaviors being monitored related to antipsychotic use, she stated she was not sure but she thought it might be that the resident crawled out of bed sometimes. She was not sure where to find Resident #53's targeted behaviors. On 9/29/2021 at 4:32pm an interview was conducted with NA #8. She stated she worked with an agency but she was assigned to Resident #53 on 9/29/2021 and somewhat familiar with her. She stated she did not know what the resident's target behaviors were and she did not know where to find a list of target behaviors for Resident #53. On 9/29/21 at 4:33pm an interview was conducted with Nurse #6. She stated she was assigned to Resident #53 on 9/29/2021. When asked about target behaviors being monitored related to the use of Seroquel, she stated she was new to the facility and she did not know Resident #53's target behaviors or where to find them. She further stated she has observed the resident talking to people who are not in the room. Progress notes from 8/27/2021 through 9/29/2021 we reviewed for behavioral symptoms and revealed; On 9/20/2021 Nurse #4 documented the resident was yelling out and when asked what she needed, resident stated nothing. Resident #53 was reviewed during an Interdisciplinary Team Meeting on 9/24/2021. The target behavior discussed was documented as yelling out. On 9/29/2021 at 4:43pm an interview occurred with the Consultant Pharmacist who started working with the facility September 2021. He completed Resident #53's most recent medication review on 9/22/2021. He explained he referred to the nursing progress notes, physician notes, and psychiatric progress notes to monitor for specific behaviors related to antipsychotic medications. He further stated monitoring was accomplished with staff documentation when behaviors were present, and he would not have recommended target behaviors be monitored on a daily basis. The director of nursing was interviewed on 9/30/2021 at 12:39pm and stated it was her expectation for staff to identify the targeted behavioral symptoms associated with the use of Seroquel. 2) Resident #31 was originally admitted to the facility on [DATE] with a recent readmission date of 7/28/21. His diagnoses included dementia with Lewy Bodies, seizure disorder, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #31 had severe cognitive impairment. He displayed wandering behavior 1 to 3 days and received 7 days of an antipsychotic medication, during the 7 day assessment look back period. Resident #31's September 2021 physician orders included an order for Seroquel (an antipsychotic) 25 milligrams (mg) by mouth twice a day for anxiety and aggression related to dementia with Lewy Bodies. The date of the original order was 7/28/21. Review of the Consultant Pharmacist medication review notes for Resident #31 from August 2021 and September 2021 did not reflect the need for monitoring targeted behaviors. A review of Resident #31's nursing progress notes from 7/28/21 to 9/29/21 was completed and did not include documentation of any behaviors. Resident #31's Medication Administration Records (MAR's) from 7/28/21 to 9/29/21 indicated he received Seroquel as ordered and exhibited no behaviors. The MAR did not list any targeted behaviors for staff to monitor. On 9/27/21 at 11:45 AM, Resident #31 was observed sitting up in his wheelchair in the common area watching TV. He smiled when spoken to and appeared to be in good spirits. Nurse #2 was interviewed on 9/29/21 at 11:42 AM and stated there was not a specific behavior monitored for Resident #31, however if he was observed with any behaviors they would be documented in the nursing progress notes. Did she say if the resident ever had behaviors? On 9/29/21 at 4:43 PM, an interview occurred with the Consultant Pharmacist, who started working with the facility September 2021 and had completed the most recent medication review for Resident #31 on 9/21/21. He explained he referred to the nursing progress notes, physician and psychiatric progress notes to monitor for specific behaviors related to antipsychotic medications. He added monitoring was accomplished with staff documentation when behaviors were present, and he would not have recommended target behaviors to be monitored on a daily basis. The Director of Nursing was interviewed on 9/30/21 at 12:39 PM and stated it was her expectation for the Pharmacy Consultant to identify any irregularities regarding Resident #31 to include the need for targeted behaviors for the use of Seroquel. 3) Resident #63 was admitted to the facility on [DATE] with diagnoses that included vascular dementia with behavioral disturbance, insomnia, seizure disorder and depressive disorder. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #63 was cognitively intact and had no behaviors. He received 7 days of an antipsychotic medication, during the 7 day look back period. Resident #63's September 2021 physician orders included an order for Seroquel (an antipsychotic) 75 milligrams (mg) by mouth at bedtime for agitation related to vascular dementia with behavioral disturbance. The date of the original order was 5/14/21. Review of the Consultant Pharmacist medication review notes for Resident #63 from June 2021 until September 2021, did not reflect the need for monitoring targeted behaviors. A review of Resident #63's nursing progress notes from 5/14/21 to 9/28/21 was completed and revealed behavioral symptoms during August 2021 and September 2021 of racial slurs towards staff members, calling out for assistance instead of using call light, making threatening statements towards staff and the facility, and repetitive requests for assistance. Resident #63's Medication Administration Records (MAR's) from 5/14/21 to 9/28/21 indicated he received Seroquel as ordered and exhibited no behaviors. The MAR did not list any targeted behaviors for staff to monitor. On 9/28/21 at 10:12 AM, an interview and observation of Resident #63 occurred. He was observed sitting up in bed watching TV. He was pleasant and stated he preferred to spend most of his time in bed watching TV and resting. Nurse #1 was interviewed on 9/29/21 at 11:45 AM and stated behaviors were monitored on the MAR with documentation in the nursing progress notes. When asked what behaviors were displayed by Resident #63, stated mostly agitation and was unable to provide specific behaviors. On 9/29/21 at 4:43 PM, an interview occurred with the Consultant Pharmacist, who started working with the facility September 2021 and had completed the most recent medication review for Resident #63 on 9/22/21. He explained he referred to the nursing, physician and psychiatric progress notes to monitor for specific behaviors related to antipsychotic medications. He added monitoring was accomplished with staff documentation when behaviors were present, and he would not have recommended target behaviors to be monitored on a daily basis. The Director of Nursing was interviewed on 9/30/21 at 12:39 PM and stated it was her expectation for the Pharmacy Consultant to identify any irregularities regarding Resident #63 to include the need for targeted behaviors for the use of Seroquel. Based on observations, staff, Physician #1 and consultant Pharmacist interviews and record review, the consultant Pharmacist failed to identify the need for target behaviors for the use of psychotropic medications. This was for 4 (Resident #59, Resident #31, Resident #63, Resident #58) of 5 residents reviewed for unnecessary medications. The findings included: 1.Resident #59 was admitted [DATE] with cumulative diagnoses of seizures, anxiety, insomnia, bilateral knee contractures and dementia with behavioral disturbance. Review of Resident #59's September 2021 Physician orders included an order dated 8/18/21 for Haldol (antipsychotic) 1 milligram twice daily for yelling and screaming. Review of Resident #59's annual Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment and she exhibited both verbal and physical behaviors. She was coded for an antipsychotic taken 7 of the 7 days during the MDS look back assessment. The psychotropic Care Area Assessment read as follows: Resident takes psychotropic medications daily per MD orders for improvement of health status and will receive medications as ordered with no complications thru next review. Resident #59's revised care plan dated 8/18/21 read she used an antipsychotic medication related to yelling and screaming. Interventions included monitoring and recording the occurrence of the target behaviors. Review of Resident #59's September 2021medication administration record (MAR) did not include any place for the nurses to document any behaviors nor did the MAR indicated any target behaviors. Review of a Consultant Pharmacist note dated 9/22/21 read as follows: Pharmacy Review Note: MRR completed. Medical record reviewed including orders, available lab and progress notes. No recommendations at this time. Review of Resident #59's nursing notes since 9/1/21 to 9/27/21 did not include any notes regarding the resident exhibiting any behaviors. An observation on 9/27/21 at 10:12 AM, Resident #59 was sleeping on her left side in her bed. In another observation and interview, on 9/28/21 at 8:50 AM, Resident #59 was sitting up in bed being assisted with her breakfast. She was calm and cooperative. Nurse #3 stated she normally worked third shift so was not as familiar with Resident #59's behaviors but she was aware that she often yelled. In a wound care observation on 9/28/21 at 10:10 AM, Resident #59 was cooperative but was observed saying unintelligible speech and holding her doll. The Treatment Nurse and Nursing Assistant (NA) #3 stated Resident #59 was known to yell out and bang her doll against the wall. In an interview on 9/30/21 at 9:00 AM, Nurse #1 stated Resident #59 could be combative but due to her small stature, she was unable to do any harm. He stated Resident #59 often yelled out, screamed and sang throughout the day. At that time, Resident #59 began yelling in her room. Nurse #1 stated it was time for her morning medications and he was going to administer her medications at this time. Nurse #1 stated there was a placed on the MAR to document yes or no for behaviors. When asked to check the MAR for a place to document behaviors related to Haldol, he confirmed there was no place to document any behaviors but assumed the behaviors were what was written on the Physician order. In an interview on 9/29/21 at 1:17 PM, the Director of Nursing (DON) stated the nurses documented behaviors in the nursing notes. She stated the target behaviors were yelling and screaming and she was unsure how the behaviors were dropped off her MAR. In an interview on 9/29/21 at 2:34 PM, Physician #1 stated target behaviors should have been identified during the monthly pharmacy medication review. In an interview on 9/29/21 at 4:43 PM, the consultant Pharmacist stated not all psychotropic medications require behavior monitoring. He stated during his monthly medication review, he reviewed Physician #1 and psychiatric notes for any behaviors. He stated if he saw monitoring by the Physician and psychiatric provider, they would have had to have obtained their information from the staff. In an interview on 9/30/21 at 1:47 PM, the Administrator and DON stated it was their expectation that the consultant Pharmacist identify the need for target behaviors monitoring when using an antipsychotic.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #53 was admitted to the facility on [DATE] with most recent readmission on [DATE]. Her admitting diagnoses included osteomyelitis (bone infection) of the vertebrae in the lower lumbar region, and major depressive disorder. Resident #53's admission Minimum Data Set (MDS) dated [DATE] indicated she was severely cognitively impaired with behaviors positive for disorganized thinking. Resident #53 required extensive assistance with activities of daily living (ADL) and received antipsychotic medications 7 out of 7 days, antidepressants 7 out of 7 days, and hypnotics 7 out of 7 days during the assessment period. A review of Resident #53's care plan, last updated on 8/30/2021, revealed the following focus area: Resident uses psychotropic medications related to disease process, major depressive disorder and is on antipsychotic and antidepressant medications. Interventions included; administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift and consult with pharmacy, physician, to consider dosage reduction when clinically appropriate at least quarterly. Resident has a behavior of yelling out for attention related to care or sometimes noted to call and want nothing. Interventions included, monitor for side effects and effectiveness. Resident #53's August 2021 and September 2021 Medication Administration Record (MAR) revealed an order for Seroquel 150 milligrams (mg) at bedtime for major depressive disorder with a start date of 8/27/2021. The MARs did not list target behaviors or any area to document if the behaviors were present. On 9/29/21 at 4:31pm and interview was conducted with NA #7. She stated she did work with Resident #53 and was familiar with her. When asked about behaviors being monitored related to antipsychotic use, she stated she was not sure but she thought it might be that the resident crawled out of bed sometimes. She was not sure where to find Resident #53's targeted behaviors. On 9/29/2021 at 4:32pm an interview was conducted with NA #8. She stated she worked with an agency but she was assigned to Resident #53 on 9/29/2021 and somewhat familiar with her. She stated she did not know what the resident's target behaviors were and she did not know where to find a list of target behaviors for Resident #53. On 9/29/21 at 4:33pm an interview was conducted with Nurse #6. She stated she was assigned to Resident #53 on 9/29/2021. When asked about target behaviors being monitored related to the use of Seroquel, she stated she was new to the facility and she did not know Resident #53's target behaviors or where to find them. She further stated she has observed the resident talking to people who are not in the room. On 9/29/2021 at 4:43pm an interview occurred with the Consultant Pharmacist who started working with the facility September 2021. He completed Resident #53's most recent medication review on 9/22/2021. He explained he referred to the nursing progress notes, physician notes, and psychiatric progress notes to monitor for specific behaviors related to antipsychotic medications. He further stated monitoring was accomplished with staff documentation when behaviors were present, and he would not have recommended target behaviors be monitored on a daily basis. The director of nursing was interviewed on 9/30/2021 at 12:39pm and stated it was her expectation for staff to identify the targeted behavioral symptoms associated with the use of Seroquel. 2) Resident #31 was originally admitted to the facility on [DATE] with a recent readmission date of 7/28/21. His diagnoses included dementia with Lewy Bodies, seizure disorder, and depression. A psychiatry progress note dated 7/29/21 indicated Resident #31 was assessed as calm and alert. Staff reported no concerns. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #31 had severe cognitive impairment. He displayed wandering behavior 1 to 3 days and received 7 days of an antipsychotic medication, during the 7 day look back period. A review of Resident #31's care plan, last reviewed on 8/5/21, revealed the following focus areas: - Resident uses psychotropic medications (Seroquel) related to dementia with Lewy Bodies. The interventions included to monitor/record occurrences of targeted behavior symptoms (pacing, wandering, disrobing inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) and document per facility protocol. - Resident is at risk for behaviors related to diagnosis of Lewy Body Dementia with behavioral disturbances. History of declining medications, ADL care and other aspects of care prior to admission. Also, history of ramming wheelchair into staff's legs and ankles during periods of agitation, comments regarding suicide and refuses to wear facemask. The interventions included to monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Resident #31's September 2021 physician orders included an order for Seroquel (an antipsychotic) 25 milligrams (mg) by mouth twice a day for anxiety and aggression related to dementia with Lewy Bodies. The date of the original order was 7/28/21. Review of the Consultant Pharmacist medication review notes for Resident #31 from August 2021 and September 2021 did not reflect the need for monitoring targeted behaviors. A review of Resident #31's nursing progress notes from 7/28/21 to 9/29/21 was completed and did not include documentation of any behaviors. Resident #31's Medication Administration Records (MAR's) from 7/28/21 to 9/29/21 indicated he received Seroquel as ordered and exhibited no behaviors. The MAR did not list any targeted behaviors for staff to monitor. On 9/27/21 at 11:45 AM, Resident #31 was observed sitting up in his wheelchair in the common area watching TV. He smiled when spoken to and appeared to be in good spirits. An interview was held with Nurse Aide (NA) #1 on 9/29/21 at 11:38 AM, who was familiar with Resident #31. She stated he currently was without behaviors other than confusion and was accepting of care assistance. Nurse #2 was interviewed on 9/29/21 at 11:42 AM and stated there was not a specific behavior monitored for Resident #31, however if he was observed with any behaviors they would be documented in the nursing progress notes. Nurse #2 stated in the past Resident #31 would become easily agitated and attempt to stand up on his own as well as being belligerent to staff, but he has not had any negative behaviors for a while. An interview was completed with Physician #1 on 9/29/21 at 2:33 PM, who stated nursing staff would report if Resident #31 was displaying behaviors or side effects to a medication. Physician #1 added Resident #31's mood and behavior was stable on the current dose of Seroquel. Physician #1 stated he would expect target behaviors to be monitored for Resident #31's antipsychotic medication use and was unaware this was not occurring. The Unit Manager (UM) was interviewed on 9/29/21 at 3:15 PM and confirmed target behaviors were not monitored on the MAR just whether or not behaviors were present at the time of medication administration by marking yes or no on the MAR. On 9/29/21 at 4:43 PM, an interview occurred with the Consultant Pharmacist, who started working with the facility September 2021 and had completed the most recent medication review for Resident #31 on 9/21/21. He explained he referred to the nursing progress notes, physician and psychiatric progress notes to monitor for specific behaviors related to antipsychotic medications. He added monitoring was accomplished with staff documentation when behaviors were present, and he would not have recommended target behaviors to be monitored on a daily basis. The Director of Nursing was interviewed on 9/30/21 at 12:39 PM and stated it was her expectation for the staff to identify Resident #31's monitoring need for targeted behavioral symptoms for the use of Seroquel. 3) Resident #63 was admitted to the facility on [DATE] with diagnoses that included vascular dementia with behavioral disturbance, insomnia, seizure disorder and depressive disorder. A psychiatric progress note dated 9/14/21 revealed Resident #63 was talkative and at his baseline. No changes were noted. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #63 was cognitively intact and had no behaviors. He received 7 days of an antipsychotic medication, during the 7 day look back period. A review of Resident #63's care plan, last reviewed on 9/20/21, revealed the following focus areas: - Resident uses an antipsychotic medication. The interventions included to administer antipsychotic medication as ordered by the physician. Monitor for side effects and effectiveness every shift. - Resident has a behavior problem of being verbally inappropriate to staff, will yell out randomly, and uses racial slurs towards staff during periods of agitation. The interventions included to monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved and situations. Document behavior and potential cause. Resident #63's September 2021 physician orders included an order for Seroquel (an antipsychotic) 75 milligrams (mg) by mouth at bedtime for agitation related to vascular dementia with behavioral disturbance. The date of the original order was 5/14/21. Review of the Consultant Pharmacist medication review notes for Resident #63 from June 2021 until September 2021, did not reflect the need for monitoring targeted behaviors. A review of Resident #63's nursing progress notes from 5/14/21 to 9/28/21 was completed and revealed behavioral symptoms during August 2021 and September 2021 of racial slurs towards staff members, calling out for assistance instead of using call light, making threatening statements towards staff members and facility, and repetitive requests for assistance. Resident #63's Medication Administration Records (MAR's) from 5/14/21 to 9/28/21 indicated he received Seroquel as ordered and exhibited no behaviors. The MAR did not list any targeted behaviors for staff to monitor. On 9/28/21 at 10:12 AM, an interview and observation of Resident #63 occurred. He was observed sitting up in bed watching TV. He was pleasant and stated he preferred to spend most of his time in bed watching TV and resting. Nurse #1 was interviewed on 9/29/21 at 11:45 AM and stated there was not a specific behavior monitored for Resident #63, however if he was observed with any behaviors they would be documented in the nursing progress notes. When asked what behaviors were displayed by Resident #63, Nurse #1 stated mostly agitation and was unable to provide specific behaviors. An interview was completed with Physician #1 on 9/29/21 at 2:33 PM, who stated nursing staff would report if Resident #63 was displaying behaviors or side effects to a medication. Physician #1 stated he would expect target behaviors to be monitored for Resident #63's antipsychotic medication use and was unaware this was not occurring. The Unit Manager (UM) was interviewed on 9/29/21 at 3:15 PM and confirmed target behaviors were not monitored on the MAR just whether or not behaviors were present at the time of medication administration by marking yes or no. On 9/29/21 at 4:43 PM, an interview occurred with the Consultant Pharmacist, who started working with the facility September 2021 and had completed the most recent medication review for Resident #63 on 9/22/21. He explained he referred to the nursing, physician, and psychiatric progress notes to monitor for specific behaviors related to antipsychotic medications. He added monitoring was accomplished with staff documentation when behaviors were present, and he would not have recommended target behaviors to be monitored on a daily basis. The Director of Nursing was interviewed on 9/30/21 at 12:39 PM and stated it was her expectation for the staff to identify Resident #63's monitoring for targeted behavioral symptoms for the use of Seroquel. Based on observations, staff and Physician #1 interviews and record review, the facility failed to identify the need for target behaviors and monitor those behaviors for the use of psychotropic medications. This was for 4 (Resident #59, Resident #31, Resident #63, and Resident #53) of 5 residents reviewed for unnecessary medications. The findings included: 1.Resident #59 was admitted [DATE] with cumulative diagnoses of seizures, anxiety, insomnia, bilateral knee contractures and dementia with behavioral disturbance. Review of Resident #59's September 2021 Physician orders included an order dated 8/18/21 for Haldol (antipsychotic) 1 milligram twice daily for yelling and screaming. Review of Resident #59's annual Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment and she exhibited both verbal and physical behaviors. She was coded for an antipsychotic taken 7 of the 7 days during the MDS look back period. The psychotropic Care Area Assessment read as follows: Resident takes psychotropic medications daily per MD orders for improvement of health status and will receive medications as ordered with no complications thru next review. Resident #59's revised care plan dated 8/18/21 read she used an antipsychotic medication related to yelling and screaming. Interventions included monitoring and recording the occurrence of the target behaviors. Review of Resident #59's September 2021 medication administration record (MAR) did not include any place for the nurses to document any behaviors nor did the MAR indicated any target behaviors. Review of Resident #59's nursing notes since 9/1/21 to 9/27/21 did not include any notes regarding the resident exhibiting any behaviors. An observation on 9/27/21 at 10:12 AM, Resident #59 was sleeping on her left side in her bed. In another observation and interview, on 9/28/21 at 8:50 AM, Resident #59 was sitting up in bed being assisted with her breakfast. She was calm and cooperative. Nurse #3 stated she normally worked third shift so was not as familiar with Resident #59's behaviors but she was aware that she often yelled. In a wound care observation on 9/28/21 at 10:10 AM, Resident #59 was cooperative but was observed saying unintelligible speech and holding her doll. The Treatment Nurse and Nursing Assistant (NA) #3 stated Resident #59 was known to yell out and bang her doll against the wall. In an interview on 9/30/21 at 9:00 AM, Nurse #1 stated Resident #59 could be combative but due to her small stature, she was unable to do any harm. He stated Resident #59 often yelled out, screamed and sang throughout the day. At that time, Resident #59 began yelling in her room. Nurse #1 stated it was time for her morning medications and he was going to administer her medications at this time. Nurse #1 stated there was a placed on the MAR to document yes or no for behaviors. When asked to check the MAR for a place to document behaviors related to Haldol, he confirmed there was no place to document any behaviors but assumed the behaviors were what was written on the Physician order. In an interview on 9/29/21 at 1:17 PM, the Director of Nursing (DON) stated the nurses documented behaviors in the nursing notes. She stated the target behaviors were yelling and screaming and she was unsure how the behaviors were dropped off her MAR. In an interview on 9/29/21 at 2:34 PM, Physician #1 stated target behaviors should have been identified during the facility's monthly medication recommendations review. In an interview on 9/30/21 at 1:47 PM, the Administrator and DON stated it was their expectation that the facility identify the need for target behavior monitoring when using an antipsychotic.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility staff, Speech Therapist (ST), Registered Dietitian (RD) and Medical Director (MD) interviews and record review, the facility failed to clarify oral dietary recommendations and obtain dietary Physician orders for a resident with a feeding tube. This was for 1 (Resident #32) of 1 residents reviewed for tube feeding. The findings included: Resident #32 was admitted on [DATE] with a diagnosis of a Cerebral Vascular Accident and a feeding tube. An ST Evaluation and Plan of Treatment dated 12/10/20 read Resident #32 was referred to ST services due to mild oral dysphagia as evidenced by prolonged mastication. His diet at the time of the evaluation was regular texture with thin liquids. Resident received additional nutritional support via his feeding tube. The ST Discharge summary dated [DATE] read his long-term goal was met and the recommendation was unchanged. Resident #32 was to receive a regular diet with thin liquids. An RD progress note dated 2/5/21 read Resident #32 had a significant weight change of 7.5% weight loss in 90 days. The note read there was an order for a mechanical soft diet and the ST clarified that Resident #32 was ordered a regular diet. The mechanical soft diet order was discontinued. An RD progress note dated 2/26/21 read Resident #32's food trays were discontinued and his tube feeding was increased to continuous with a frozen nutritional cup by mouth three times daily. This was due to 10% weight loss in 180 days. The RD recommended a pleasure tray if cleared by ST. An RD progress note dated 4/28/21 read Resident #32 had a significant weight gain of 7.5% in 90 days. The note read his continuous tube feedings were discontinued and now to be administered every 4 hours. He was still receiving the frozen nutritional cup. An RD progress note dated 5/17/21 read Resident #32 was again prescribed continuous tube feeding with a frozen nutritional cup three times daily. The note read to continue the plan of care and the RD would continue to monitor. RD notes dated 6/14/21 and 7/30/21 read there were no changes in Resident #32's dietary orders. He was to continue to receive a frozen nutritional cup three times daily along with his continuous tube feeding. Resident #32's quarterly Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment and he exhibited no behaviors. He was coded for total assistance with all his activities of daily living. Review of section K (Swallowing/Nutritional Status) indicated he was not coded for the nutritional approach of his feeding tube and not coded for any nutrition taken by mouth. An RD progress note dated 8/12/21 read there was no change in Resident #32's continuous tube feeding or his frozen nutritional cup, but the new recommendation was for Resident #32 to receive a pleasure tray. Resident #32's September 2021 Physician orders included an order dated 8/11/21 for a mechanical soft texture diet with thin liquids and an order for a frozen nutritional cup three times daily dated 2/17/21. Resident #32's September 2021 Physician orders also included an order dated 9/2/21 for tube feeding continuously for nutritional support. An RD progress note dated 9/3/21 read Resident #32 may receive a pleasure tray and a frozen nutritional cup by mouth. There were no new recommendations related to his tube feeding. Resident #32's tube feeding care plan last revised on 9/9/21 read he required a feeding tube related to dysphagia and was to receive pleasure feedings as tolerated. In an observation on 9/27/21 at 11:39 AM, Resident #32 was lying in bed with the head of his bed elevated to approximately 45 degrees. His tube feeding was running continuously as ordered. In an interview on 9/28/21 at 11:00 AM, the Director of Nursing (DON) stated Resident #32 only ate a nutritional supplement by mouth and that he was not NPO (nothing by mouth). The DON reviewed the September 2021 Physician orders and noted the order dated 8/11/21 for a mechanical soft diet with thin liquids. She stated Resident #32 was not receiving a mechanical soft diet. She was unable explain why Resident #32 was not getting his diet as ordered. In an interview on 9/29/21 at 9:00 AM, the Dietary Manager (DM) stated he received a dietary communication form yesterday (9/28/21) for Resident #32 to receive a mechanical soft diet and thin liquids. He stated he recalled at one point, Resident #32 was NPO and changed to a pleasure tray but up until 9/28/21, he was only given the frozen nutritional cups three times daily. He stated he had not received any additional dietary communication forms except one dated 2/17/21 for the frozen nutritional supplement. In an interview on 9/29/21 at 10:32 AM, the MD stated Resident #32 should be NPO due to his severe dysphagia. A copy of the dietary communication form dated 9/28/21 for mechanical soft diet with thin liquids was reviewed by the MD. He stated he had never saw that form and it was not signed by him. In an interview on 9/29/21 at 12:15 PM, the ST stated she stated she was not aware that Resident #32 was not getting his dietary trays. She stated she was asked to evaluate Resident #32 yesterday (9/28/21) and completed a bedside swallow study. Based on the swallow study, Resident #32 displayed no overt signs or symptoms of aspiration/penetration. (Aspiration is when food or liquid goes into the trachea and goes below the vocal cords while penetration is when food or liquid goes into the trachea but stays above the vocal cords). The ST stated she recommended a mechanical soft diet with thin liquids and tapering of his tube feedings. She stated the DON and RD were working together to develop a tube feeding tapering schedule. The ST stated she watched Resident #32 eat his breakfast this morning and he consumed 25% without any problems. In a telephone interview on 9/29/21 at 2:52 PM, the RD stated she received a call from the facility yesterday (9/28/21) for clarification about Resident #32 diet orders. She stated she thought Resident #32 was receiving only a pleasure tray and the frozen nutritional supplement by mouth. The RD stated she was unaware of the order dated 8/11/21 for a mechanical soft diet. The RD stated she visited the facility twice monthly and after each visit, she emailed her recommendations to the Unit Managers (UMs) and the DON to obtain any needed Physician orders. The RD stated she only learned yesterday that Resident #32 was only receiving a frozen supplement by mouth. In an interview on 9/29/21 at 4:11 PM, the Staff Development Coordinator (SDC) stated she and other UM who recently resigned discovered there was a problem with Resident #32's diet orders. She stated they received clarification orders on 8/11/21 that he should be receiving a mechanical soft diet with thin liquids. The SDC stated it was possible that she nor the resigned UM forgot to complete a dietary communication form to give to the dietary department. In an interview on 9/30/21 at 1:47 PM, the Administrator and DON stated it was their expectation that Resident #32's oral dietary orders were clarified and accurate and Resident #32 receive his diet as ordered.