Based on medical record review, staff interviews, and observation, the facility failed to ensure development and implementation of comprehensive resident care plans. This affected three (Residents #3, #12, #129) of 15 residents reviewed for care plans. The facility census was 29. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 09/06/05 with diagnoses including heart failure, dementia, and presence of cardiac pacemaker. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #3 dated 01/10/24 revealed this resident was moderately cognitively impaired. Review for the care plan for Resident #3 initiated 09/06/05 revealed it did not include care and monitoring of the resident's pacemaker. Interview on 03/06/24 at 2:45 P.M. with the Director of Nursing (DON) confirmed Resident #3 had a pacemaker in place but was unsure how often pacemaker checks were to be conducted. The DON further confirmed Resident #3's care plan did not outline the care and services the facility was to provide for the resident's pacemaker. 2. Review of the medical record for Resident #12 revealed an admission date of 06/06/19 with diagnoses including bipolar disorder, paranoid schizophrenia, schizoaffective disorder, and psychotic disorder with delusions. Review of the quarterly MDS assessment for Resident #12 dated 12/28/23 revealed the resident was mildly cognitively impaired. Review of the physicians' orders for Resident #12 revealed an order dated 03/06/24 for Tagamet 400 milligrams (mg) to be administered daily for sexual behaviors. Review for the care plan for Resident #12 initiated 06/06/19 revealed it did not include the resident's sexual behaviors and/or use of Tagamet for sexual behaviors. Interview on 03/06/24 at 2:45 P.M. with the DON confirmed Resident #12 exhibited negative sexual behaviors which were being managed with the medication, Tagamet. The DON further confirmed Resident #12's care plan did not include the resident's sexual behaviors and the care and services the facility was to provide regarding management of the negative sexual behaviors. 3. Review of the medical record for Resident #129 revealed an admission date of 02/22/24 with diagnoses including diabetes mellitus type two, hypertension, non-Hodgkin's lymphoma with metastasis to the bones and fracture of the shaft of the right humerus. Review of the plan of care for Resident #129 initiated 02/22/24 revealed it did not include care and treatment regarding the cast to the resident's right arm. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for Resident #129 dated February 2024 and March 2024 revealed they did not include care related to the resident's cast to the right arm, circulation checks or skin checks. Review of the MDS for Resident #129 dated 02/25/24 revealed the resident was cognitively impaired and required assistance from staff for activities of daily living (ADLs.) Review of the nurse progress note for Resident #19 dated 02/29/24 timed at 11:50 A.M. revealed the resident returned from the orthopedic physician appointment with no new orders. The note did not include monitoring of Resident #129 skin, circulation or edema to right hand. Observations on 03/04/24 at 9:16 A.M. and on 03/06/24 at 11:33 A.M. of Resident #129 revealed the resident's lower right arm was in a cast with edema noted to the resident's fingers on the right hand. Interview on 03/06/24 at 3:12 A.M. with Licensed Practical Nurse (LPN) #140 confirmed Resident #129 was admitted with a cast to lower right arm and the resident's fingers were swollen. LPN #140 confirmed there were no orders to monitor the circulation, skin or edema to the resident's right hand. Interview on 03/06/24 at 3:25 P.M. with the DON confirmed Resident #129's care plan did not include interventions related to the resident's cast care or circulation and skin check for the right hand.

Based on medical record review, observation, and staff interview the facility failed to ensure care and services were provided to residents with casts to the extremities. This affected one (Resident #129) of one residents with a cast and 13 sampled residents. The facility census was 28. Findings include: Review of the medical record for Resident #129 revealed an admission date of 02/22/24 with diagnoses including diabetes mellitus type two, hypertension, non-Hodgkin's lymphoma with metastasis to the bones and fracture of the shaft of the right humerus. Review of the plan of care for Resident #129 initiated 02/22/24 revealed it did not include care and treatment regarding the cast to the resident's right arm. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for Resident #129 dated February 2024 and March 2024 revealed they did not include care related to the resident's cast to the right arm, circulation checks or skin checks. Review of the MDS for Resident #129 dated 02/25/24 revealed the resident was cognitively impaired and required assistance from staff for activities of daily living (ADLs.) Review of the nurse progress note for Resident #19 dated 02/29/24 timed at 11:50 A.M. revealed the resident returned from the orthopedic physician appointment with no new orders. The note did not include monitoring of Resident #129 skin, circulation or edema to right hand. Observations on 03/04/24 at 9:16 A.M. and on 03/06/24 at 11:33 A.M. of Resident #129 revealed the resident's lower right arm was in a cast with edema noted to the resident's fingers on the right hand. Interview on 03/06/24 at 3:12 A.M. with Licensed Practical Nurse (LPN) #140 confirmed Resident #129 was admitted with a cast to lower right arm and the resident's fingers were swollen. LPN #140 confirmed there were no orders to monitor the circulation, skin or edema to the resident's right hand. Interview on 03/06/24 at 3:25 P.M. with the DON confirmed Resident #129's care plan did include interventions related to the resident's cast care or circulation and skin check for the right hand.

Based on record review, staff interview, and review of the facility policy the facility failed to ensure the physician provided a response to consultant pharmacist recommendations. This affected one (Resident #4) of five residents reviewed for unnecessary medications. The facility census was 28. Findings include: Review of the medical record for Resident #4 revealed an admission date of 09/02/23 with diagnoses including dementia, anxiety, depression and unspecified psychosis. Review of the physician orders for Resident #4 dated March 2024 revealed the resident was ordered Seroquel (antipsychotic) 50 milligrams (mg) by mouth for agitation. Review of the Minimum Data Set (MDS) assessment for Resident #4 dated 12/14/23 revealed resident had moderate cognitive impairment. Review of the consultant pharmacist's recommendation for Resident #4 dated 01/30/24 revealed the resident was receiving Seroquel for a diagnosis of agitation and it was recommended to consider changing to an appropriate diagnosis or titration off the medication. The physician signed the recommendation on 02/17/24 but did not document acceptance or denial of the pharmacy recommendation. Interview on 03/05/24 at 12:42 P.M. with the Director of Nursing (DON) confirmed the physician did not document a response to the pharmacy recommendation for Resident #4 dated 01/30/24. Review of the facility policy titled Pharmacy Recommendations revised January 202 revealed the consultant pharmacist performed a comprehensive review of each resident's medication regiment routinely as required by regulations. The DON or the Assistant Director of Nursing (ADON) would review the recommendations with the physician and Medical Director as soon as practical but no later than 30 days. Any urgent recommendations must be addressed immediately. The DON would track the recommendations and ensure any changes were implemented into the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy, the facility failed to ensure physician's orders were in place for wound care treatment for residents. This affected one ( Resident #18) of one residents reviewed for wound care. The facility census was 23. Findings Include: Review of the medical record for Resident #18 revealed an admission date of 06/06/19 with diagnoses including malignant neoplasm of the brain with surgery, open wound to scalp and frontal lobe function deficit following cerebrovascular disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #18 had moderate cognitive impairment. Resident #18 required limited assistance of one staff person for activities of daily living. Resident #18 did not have any pressure areas but did require a non surgical dressing with or without topical medication other than to his feet. Review of the physician orders for 04/22 revealed there was not an order for treatment to the open area to Resident #18's scalp. Review of the Treatment Administration Record (TAR) for 04/22 revealed no documentation of treatment. However, the weekly skin assessment last completed on 04/23/22 by the Director of Nursing indicated the resident had a wound to his scalp measuring two centimeters (cm) by three cm from a surgical incision. The area had a treatment of honey gel and cover with a Band-Aid. Review of the nursing progress notes from 01/22 through 04/22 was silent on wound care and treatment. Review of the plan of care for at risk for impaired skin integrity/an open skin cancer lesion to head dated 05/21/20, revealed treatments per order and skin assessment as ordered. An observation of Resident #18 on 04/19/22 at 10:57 A.M., 04/20/22 at 9:19 A.M. and 1:40 P.M. revealed a Band-Aid in place to the top of his head. An interview on 04/20/22 at 11:10 A.M. with Registered Nurse (RN) #211 revealed the resident had a treatment to the top of his head. It was completed daily. An observation on 04/20/22 at 11:48 A.M. of wound care for Resident #18 revealed RN #211 washed hands, put on her gloves and removed the old Band-Aid from residents scalp. The wound was not bleeding. She placed the Band-Aid in her gloves, removed and washed her hands. RN #211 then put on her gloves, had the honey gel in a medicine cup and a large Band-Aid on the over the bed table on a paper towel. RN #211 cleansed the area with wound cleanser, patted dry. The area had no drainage, redness or odor noted. RN#211 removed gloves, washed hands, put on new gloves and used a sterile swab to apply the honey gel to the wound. She then covered the wound with the large Band-Aid that was dated and initialed. RN #211 placed the trash in the can, removed gloves and washed hands. An interview on 04/20/22 at 2:55 P.M. with the Director of Nursing (DON) revealed the DON completed the weekly skin/wound assessment which included the measurements and treatment. The DON confirmed there was not an order for the current treatment in the physicians orders or on the TAR. The DON said the wound was treated, but did not have documentation. Review of the facility policy titled Wound Care, dated 12/20 revealed wounds would be evaluated when observed and weekly until resolved. Wounds will be monitored for location, size (measure width, length, and depth), undermining, tunneling, exudates, necrotic tissue and presence or absence of granulation tissue and epitheliazation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to ensure residents pain medications were available for administration and failed to ensure ordered pain medication was administered as ordered. This affected one resident (#21) out of the two residents reviewed for pain management. The facility census was 23. Findings include: Record review for Resident #21 revealed the resident was admitted to the facility on [DATE] and had diagnoses including osteoarthritis, nondisplaced fracture of the scapula and left shoulder, anxiety, obesity, and acquired absence of limb. Review of the admission Minimum Data Set (MDS) assessment, dated 03/06/22, revealed this resident had mildly impaired cognition. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting. This resident was assessed to have occasional pain and to have received scheduled pain medication. Review of the care plan, dated 03/14/22, revealed this resident was at risk for pain. Interventions included to administer medication as ordered. Review of the physicians order, dated 02/24/22, revealed an order to administer one Percocet 10-325 milligram (mg) tablet every four hours for pain. Review of the Controlled Drug Use Record for Resident #21's Percocet 10-325 mg tablets revealed the last tablet was removed from a card for administration on 04/09/22 at 8:00 P.M. There was no documentation of the medication being available for administration from any other sources until 04/12/22 at 7:00 A.M. Review of the Controlled Drug Use Record for Percocet 5-325 mg tablets revealed the record contained a label containing Resident #21's name with a filled date of 04/11/22. The directions indicated to administer one tablet of Percocet 5-325 mg tablet every four hours for pain. The record contained hand written writing at the top of the sheet which read 2 tabs. Documentation on the record revealed two tablets had been pulled from the card every four hours from 04/12/22 at 7:00 A.M. through 04/14/22 at 8:00 P.M. to be administered to the resident. Review of the Medication Administration Record (MAR) for 04/2022 revealed on 04/11/22 at 4:00 P.M. and on 04/12/22 at 4:00 A.M. the residents Percocet 10-325 mg dose was documented as not being administered. All other scheduled doses of Percocet 10/325 mg were documented as being administered as ordered every four hours from 12:00 A.M. on 04/10/22 through 04/14/22 at 8:00 P.M. Interview with Resident #21 on 04/18/22 at 8:26 P.M. revealed the facility had run out of the residents ordered Percocet 10-325 mg tablets and the resident had not received the medication for approximately two days. Interview with Licensed Practical Nurse (LPN) #217 on 04/20/22 at 10:57 A.M. verified there was no record of the Percocet 10-325 mg tablets being available for administration to Resident #21 from 04/09/22 at 8:00 P.M. through 04/12/22 at 7:00 A.M. Interview with the Regional Director of Clinical Services (RCDS) #300 on 04/20/22 at 1:12 P.M. verified the order for Resident #21 was for the resident to receive one tablet of Percocet 10-325 mg every four hours and the resident had received two tablets of Percocet 5-325 mg instead from 7:00 A.M. on 04/12/22 through 8:00 P.M. on 04/14/22. Interview with Registered Nurse (RN) #211 on 04/21/22 at 8:30 A.M. verified Resident #21 had not been administered scheduled Percocet 10-325 mg tablets for two days as the medication was unavailable. RN #211 verified the MAR contained inaccurate documentation of the administration of the Percocet 10-325 mg tablets on 04/10/22 and 04/11/22 as RN #211 had documented them as being administered in error. RN #211 verified RN #211 had hand-written 2 tabs on the top of the Controlled Drug Use Record for the residents Percocet 5-325 mg tablets which resulted in the resident receiving double the amount of ordered acetaminophen every four hours from 04/12/22 at 7:00 A.M. through 04/14/22 at 8:00 P.M. RN #211 verified the label on the Controlled Drug Use Record for the residents Percocet 5-325 mg tablet read to administer one every four hours. Review of the facility policy titled Medication Administration-General Guidelines, revised 11/2018, revealed medications were to be administered in accordance with the written orders of the prescribed. If a dose of regularly scheduled medication was not available, it was to be documented on the MAR along with an explanatory note.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to provide an appropriate diagnosis for the use of an antipsychotic. This affected one resident (Resident #17) out of five residents reviewed for unnecessary medications. The facility census was 33. Findings include: Record Review of Resident #17 revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: osteoarthritis, atherosclerotic heart disease, dementia, nicotine dependence, coronary angioplasty, COVID-19, mood disorder, benign prostatic hyperplagia, pain, diabetes mellitis, anxiety, depression, hypertension, gastro-esophageal reflux disease, urine retention, hyperlipidemia, and nutritional deficiencies. Review of the Minimum Data Set (MDS) assessment completed on 02/09/22 revealed this resident had moderate to severe cognitive impairments. Review of Physician Orders revealed this resident is receiving the following medications: Seroquel 25 milligrams (mg) 1 tablet by mouth daily for unspecified dementia with behavioral disturbances and Seroquel 25 mg 1 tablet by mouth daily at bedtime for unspecified dementia with behavioral disturbances. Interview with Regional Clinician #300 on 04/20/22 at 02:35 P.M. verified Unspecified Dementia with Behavioral Disturbance is not an acceptable diagnosis for the use of Seroquel. Also verified the resident takes this medication on a daily basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to timely complete a significant change Minimum Data Set (MDS) 3.0 assessment for Resident #3 following the initiation of Hospice services. This affected one resident (#3) reviewed for hospice services. Findings include: Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbances, hypertension, atherosclerotic heart disease, Alzheimer's disease, type two diabetes mellitus and malignant neoplasm of the prostate. Review of the Hospice level of care, dated 07/06/21 revealed Resident #3 elected to receive Hospice services effective 07/16/21. Review of the significant change MDS 3.0 assessment, dated 08/11/21 revealed this assessment was completed 26 days after Resident #3 was admitted to Hospice services. Interview with MDS Coordinator #905 on 11/16/21 at 1:25 PM verified the significant change MDS assessment for Resident #3 had been completed on 08/11/21. Interview with Regional Director of Clinical Services (RDCS) #845 on 11/16/21 at 1:50 P.M. verified the significant change assessment for Resident #3 should have been completed within 14 days of the time the resident began Hospice services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Minimum Data Set (MDS) assessments for Resident #3 were accurately completed. This affected one resident (#3) of three residents reviewed for hospice services and/or pressure ulcers. Findings include: Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbances, hypertension, atherosclerotic heart disease, Alzheimer's disease, type two diabetes mellitus and malignant neoplasm of the prostate. a. Review of the Hospice level of care, dated 07/06/21 revealed Resident #3 elected to receive Hospice services effective 07/16/21. Review of Section O of the significant change MDS 3.0 assessment, dated 08/11/21 revealed Resident #3 was not identified to have received Hospice services. Review of Section O of the quarterly MDS 3.0 assessment, dated 11/11/21 revealed Resident #3 was not identified to have received hospice services. b. Review of the weekly skin assessments, physician's orders, and progress notes, dated 06/01/21 through 11/11/21 revealed no evidence Resident #3 had any type of pressure ulcer during this time. Review of Section M of the significant change MDS 3.0 assessment, dated 08/11/21 revealed Resident #3 was assessed to have an unhealed Stage II pressure ulcer. Interview with MDS Coordinator #905 on 11/16/21 at 1:25 P.M. verified the MDS 3.0 assessments for Resident #3, dated 08/11/21 and 11/11/21, had not been completed accurately as the resident had been receiving Hospice services at the time of the assessments. MDS Coordinator #905 revealed she would immediately complete a modification for both assessments to correct the errors. Interview with Licensed Practical Nurse (LPN) #311 on 11/16/21 at 1:40 P.M. revealed Resident #3 had treatment orders in place for self inflicted scratches to his buttocks but had never had any areas of pressure. Interview with Chief Clinical Officer (CCO) #921 on 11/16/21 at 2:55 P.M. verified Section M of the significant change MDS 3.0 assessment, dated 08/11/21, contained inaccurate documentation of an unhealed Stage II pressure ulcer for Resident #3.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure fall safety interventions were in place as care planned for Resident #14, who was at risk for falls and had a history of falls. This affected one resident (#14) of nine residents reviewed for falls. Findings include: Record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including bipolar disease, paranoid schizophrenia, hearing loss, malignant neoplasm of brain, history of cerebrovascular accident (CVA), muscle weakness and need for assistance with personal care. Review of the plan of care, initiated 03/02/20 revealed Resident #14 was at risk for falls and potential injury due to impaired balance, unsteady gait and history of falls. Interventions included ensure resident wearing footwear properly, or non-skid socks, non-skid strips to floor at bedside, encourage to stand from seated position using arms of the chair, apply shoes before ambulating and therapy ordered as needed. Record review revealed Resident #14 sustained a fall of 08/08/21 in his room at the bedside resulting in a right knee abrasion. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/01/21 revealed Resident #14 had moderately impaired cognition and required limited assistance from staff for bed mobility, transfers, walking, toileting, eating and hygiene. Review of the fall risk assessment, dated 11/06/21 revealed Resident #14 was at moderate risk for falls and had multiple falls in the past six months. Symptoms included jerking when turning and noted the resident was unbalanced when standing. Review of a physician's order, dated 11/15/21 revealed to ensure proper footwear when ambulating, ensure resident wore threaded footwear when up , must sit in chair when smoking not at picnic table, non-skid socks, occupational therapy to evaluate and treat three to five times weekly for neuro- muscular reeducation and the anti-psychotic medication, Haldol 0.5 milligrams one time a day and 5 milligrams at bedtime for behaviors. On 11/15/21 at 3:43 P.M. Resident #14 was observed ambulating and was noted to be unsteady on his feet when exiting from his room. On 11/15/21 at 3:45 P.M. observation of Resident #14's room revealed no non-skid floor strips near the resident's bed. On 11/16/21 at 3:30 P.M. interview with Regional Operations Nurse (RN) #845 verified Resident #14 did not have non-skid floor strips in place. RN #845 revealed the non-skid floor strip intervention, initiated on 03/02/20, was discontinued on 11/16/21 because the resident didn't need it any longer. During the interview, RN #845 revealed new flooring had been installed last week in Resident #14's room and the non-skid floor strips were not replaced on the floor at that time. On 11/17/21 at 9:03 A.M. interview with Maintenance Director #156 revealed the non-skid floor strips in Resident #14's room had not been replaced since the new flooring had been installed. Review of the facility policy titled Fall Policy, dated 10/01/18 revealed the facility was to complete a review of resident falls and implement interventions to attempt to prevent or reduce falls and injuries related to falls.