**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure timely services were provided for a head injury as ordered by the physician, notification to the family of the incident, and ensure fall interventions in place. This affected one (Resident #22) of three residents reviewed for falls. The facility census was 44. Findings include:Record review revealed Resident #22 admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, and fatigue. Review of a care plan dated 11/18/24 revealed Resident #22 was at risk for falls related to deconditioning. The goal was to have less incidents of falls with injuries through the review date. Interventions included but were not limited to anticipate and meet resident's needs, call light in reach, dycem to wheelchair seat, non-skid strips to the floor on the left side of bed, visual cues to remind resident to use call lights, and a safe environment. Review of a physician order from Physician #101 dated 04/10/25 revealed staff should verify fall precautions are in place every day and night shift for Resident #22. Review of a Fall Risk Evaluation dated 07/15/25 revealed Resident #22 had no falls in the past three months, had intermittent confusion, had a balance problem while standing and walking, and required the use of assistive devices. Review of a minimum data set (MDS) dated [DATE] revealed Resident #22 had mildly impaired cognition, no behaviors, and had no falls since admission. Review of a nursing note dated 08/10/25 at 10:15 A.M. by Licensed Practical Nurse (LPN) #107 revealed Resident #22 was found on the floor in her room next to her bed and stated she was reaching for a remote and rolled off the bed onto the floor. During assessment of Resident #22, a laceration to the left side of her head was identified and Resident #22 stated she hit it on the bedside table. No other injuries were noted and all extremities were moving as usual for resident. Resident #22 was assisted off the floor by two staff members into her wheelchair, the wound on her head was cleansed and bacitracin was applied to the injury. LPN #107 documented Resident #22's daughter was made aware of the fall, and the on-call physician was made aware. Neurochecks were initiated and within normal limits and resident was educated to use her call light to ask for help reaching items she had dropped. Review of a nursing note dated 08/10/25 at 4:07 P.M. by LPN #107 revealed at around 3:15 P.M., a scheduled neurocheck was completed and Resident #22 was noted to have a fixed left eye and all previous neurochecks had been within normal limits. Resident #22 was noted to have confusion, and her words were jumbled and did not make sense. The physician was made aware the family requested Resident #22 go to the emergency department and 911 was called at 3:26 P.M. Resident #22 left the facility in the ambulance at 4 P.M. Report was called to the emergency department. Review of a nursing note dated 08/10/25 at 8:35 P.M. by LPN #102 revealed Resident #22 returned to the facility with four staples to her head and no new orders. Review of a triage note dated 08/10/25 at 11:59 P.M. by Nurse Practitioner (NP) #105 an electronic communication between NP #105 and LPN #107 which revealed the following:- LPN #107: Resident #22, vital signs were 97.2 degrees Fahrenheit temperature, 55 beats per minute, 21 breaths per minute, blood pressure of 144/62 and oxygen of 95% on room air. Resident #22 was found on the floor next to the bed, stated she was reaching for the remote, did hit head when fell on bedside table handle causing a 4 (four) centimeter (cm) laceration to the left side of her head, cleansed and applied bacitracin, no other injuries noted, resident is not on blood thinners and neurochecks are within normal limits.- NP #105 responded with: any change in mental status? Is patient able to recall the event? Any complaints of pain anywhere? Any cuts, abrasions, bruising, or open areas due to fall or any bleeding? How is range of motion (ROM)? Is patient able to flex and bend extremity? Any swelling to extremity or joint? Is patient on a blood thinner? How is pupil reactivity to light? Any difficulty breathing or shortness of breath? Any sweats, nausea, headache or chest pain?- LPN #107: No changes in mental status, able to recall event, ROM is per resident's normal, extremities move well, pupil reactions is good, no other symptoms and not on a blood thinner.- NP #105: New order for laceration, cleanse site with warm water and soap daily, pat dry, apply steri-strips to area, monitor vital signs every 4 hours for 24 hours, neurochecks per facility protocol, notify of any increase in lethargy, change in mental status or difficulty with following commands, continue to monitor patient and vital signs, continue to follow facility protocol and follow up with primary care provider. Interview on 09/19/25 at 12:51 P.M. with Certified Nursing Assistant (CNA) #113 revealed Resident #22 had an incident where she was not sent out to the hospital until after six hours after her head was injured and still bleeding. CNA #113 stated she had been assigned to the memory care unit but she was taking her residents out to church then helped the aides on the long term unit when she heard screaming. CNA #113 stated there were only two nurses in the building and they had four halls to cover and the nurse for Resident #22's hall was on the memory care unit. CNA #113 stated another aide stayed with Resident #22 while she went to memory care to send the nurse (LPN #107) to help the resident and due to only CNA #113 and LPN #107 being assigned to memory care, CNA #113 had to stay on the unit to supervise the residents while LPN #107 assisted Resident #22. CNA #113 stated the fall happened at about 10:15 A.M. and LPN #107 returned to the memory care unit at about 11 A.M. because lunch was coming out to be served. CNA #113 stated neither she nor LPN #107 left the memory care unit until approximately 2 P.M. CNA #113 stated she checked on Resident #22 at 2 P.M. and her head was still bleeding and she could no longer remember where she was anymore. CNA #113 stated she notified LPN #107 and thought she had gone to help, but CNA #113 was then contacted by Registered Nurse (RN) #100 who stated if she need anything while LPN #107 was gone to let him know. CNA #113 stated she asked RN #100 about Resident #22 and he did not know what she was talking about. CNA #113 stated Resident #22 did not have a bandage or anything on her head, just a salve and Resident #22 had received 4 staples when she went out to the hospital. Observation on 09/19/25 at 1:13 P.M. revealed Resident #22 was sleeping in her bed. She had non-skid strips on the floor underneath her bed on the right side instead of on the left side of the bed per care plan and there was no dycem underneath the cushion of her wheelchair. Interview on 09/19/25 at 1:16 P.M. with RN #100 revealed he was called to Resident #22's room to help because she had fallen. Resident #22 had hit her head and it was bleeding, Resident #22 was assessed for severe injury and then the doctor was contacted. RN #100 stated the instructions were to keep Resident #22 onsite and watch her per the fall protocol and neurochecks. RN #100 stated later in the day, LPN #107 was on break and Resident #22's family was visiting and requested he evaluate her. RN #100 stated Resident #22's left eye was pin-point and fixed so he let the on-call doctor know and sent Resident #22 to the emergency room. Observation and interview on 09/19/25 at 1:40 P.M. with Hospitality Aide (HA) #115 confirmed Resident #22's non-skid strips were not in place to the left of her bed and there was no dycem in her wheelchair seat per the plan of care. Interview on 09/19/25 at 1:45 P.M. with Resident #22's responsible party (RP) revealed after noon, she came to the facility to see Resident #22 and was immediately approached in the hallway by a nervous-looking LPN #107 who informed her Resident #22 had fallen earlier in the shift and hit her head but was doing well. RP stated Resident #22 was in her wheelchair in the dining room when she arrived, so she went to sit with her. A glob of salve was on the wound, but it appeared the wound was bleeding through the salve. RP stated Resident #22 was initially okay with recalling the event, then an aide approached after a while and Resident #22 could not long recognize RP. RP stated Resident #22 told her she was confused, and because she figured Resident #22 would need to go to the hospital soon, RP ran home to take care of something and before she came back, CNA #113 had called and stated Resident #22's memory was getting worse. When RP returned approximately twenty minutes later, Resident #22 had been put in her recliner in her room, and her head appeared to be seeping blood and the recliner was soaked. RP stated no one had done neurochecks during her initial visit and when she had returned to the facility, LPN #107 wasn't there so RN #100 checked on Resident #22 and sent her to the emergency room. Interview on 09/19/25 at 2:26 P.M. with LPN #107 revealed Resident #22 rolled out of bed reaching for something that had fallen on the floor so she and RN #100 assessed her immediately because they heard her fall. LPN #107 stated Resident #22's neurochecks were good, vitals were good, and they cleaned the blood the best they could and assessed for other injuries. LPN #107 stated the gash to Resident #22's head was hidden in her hair but she didn't think it looked deep. LPN #107 stated they helped Resident #22 off the floor and got her back into bed, she notified the physician and family and continued neurochecks throughout the day. LPN #107 admitted despite charting she contacted the family at the time of the incident, she did not contact them right away and it may have been a couple hours later because the fall happened in the middle of medication pass. LPN #107 stated she tries to contact family members as soon as she gets the time to do it. LPN #107 stated she had left the building later in the day to get a catheter for another resident and she thought she might have missed a neurocheck for Resident #22 during the time and probably should have asked RN #100 to cover it for her. LPN #107 stated she came back to the facility and RN #100 had examined Resident #22 at her family's request and noticed her left eye was fixed and he was sending her to the hospital. LPN #107 stated Resident #22's eye did look a little different. LPN #107 stated Resident #22 came back to the facility the same day with 4 staples in her head. Interview on 09/19/25 at 3:02 P.M. with Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed family should be contacted as soon as the resident is stable and the physician has been notified because they need to be aware of new orders and participate in care decisions. DON stated it does not matter if medication pass is interrupted, the urgent incident takes precedence and needs to be addressed completely prior to returning to routine tasks. DON and ADON confirmed NP #105 entered a progress note with an order for Resident #22 to have steri-strips in place to her head injury. Interview on 09/19/25 at 3:02 P.M. with Resident #22 revealed she could recall she had a fall because she went to pick something up and rolled out of bed. Resident #22 said her head hurt because she hit it during the fall and ended up with these in her head (while indicating to the wound). Resident #22 stated she could not recall if she was confused after the fall or not but she recalled getting staples and thought she still had them. During the interview, an observation was made of Resident #22's recliner and there was a fist-sized stain on the chair where her head would have been laying after being placed in the recliner. Interview on 09/19/25 at 3:10 P.M. with LPN #111 revealed she was the manager on call at the time of the incident. LPN #111 stated RN #100 notified her of the incident while LPN #107 cared for Resident #22. LPN #111 stated she was made aware neurochecks were good, her head was initially bleeding but was stopped quickly, the wound was cleaned, and they placed bacitracin on the wound because they couldn't place a dressing on her head due to her hair. LPN #111 stated later in the day she was called by RN #100 again because Resident #22's left eye was fixed and he wanted to send her to the emergency room. Resident #22 returned the same day. Review of an undated policy titled Notification of Physician and Family revealed the physician and family will be notified of change in condition after any incident/accident involving the resident which results in an injury or any fall; a significant change in mental or psychosocial status in a life-threatening condition or clinical complication; a need to alter treatment; a decision to transfer or discharge; a change in room or roommate; any change or medical condition which in the professional judgment of the staff requires notification; and any bruise or injury of unknown origin. This deficiency represents non-compliance investigated under Complaint Number 2611114.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement pressure ulcer prevention precautions for Resident #206 identified as having a facility acquired deep tissue injury (DTI) (Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue). This affected one ( Resident #206) of three residents reviewed for skin impairment. The facility census was 43.Findings include: Review of the closed medical record for Resident #206 revealed an admission date of 02/27/25 and was discharge to the hospital on [DATE]. Resident #206 diagnoses included aftercare following joint replacement surgery, dysphagia, non-rheumatic aortic valve stenosis, left bundle branch block, hypertension, urinary retention and recent gastrointestinal hemorrhage.Review of the Braden scale assessment dated [DATE] revealed Resident #206 was at a high risk for pressure ulcers with a score of 17. Review of the nursing admission assessment dated [DATE] revealed Resident #206 had bruising noted to right and left inner forearm and top of left hand related to intravenous sites during hospital stay. Resident #206 left medial midfoot had a small scab and left hip had surgical incision measuring 13 centimeters (cm) in length, zero cm in width and depth. Review of the admission five day Medicare Minimum Data Set (MDS) dated [DATE] revealed Resident #206 was cognitively intact with feelings of depression noted and no behaviors. Resident #206 had impaired range of motion to one side of lower extremities and used a wheelchair for mobility. Resident #206 required a set up for meals and substantial to maximum assistance from staff with toileting hygiene, bathing, bed mobility, sit to stand and transfers. The resident had an indwelling foley catheter and was occasionally incontinent of bowels. Resident #206 received scheduled and as needed pain medications along with non-pharmacological interventions. She had frequent pain that interfered with therapy and day to day activities at a moderate level. The only fall noted on assessment happened prior to admission resulting in recent hip replacement surgery. Resident #206 had no skin impairments noted except for surgical incision to left hip and had a pressure reducing device to bed. Review of the plan of care dated 03/03/25 revealed Resident #206 had the potential for impairment to skin integrity related to decreased mobility. The interventions included to encourage good nutrition and hydration to promote healthier skin, follow facility protocols for treatment of injury, identify and document any potential causative factors and eliminate or resolve when possible, resident required pressure relieving/reducing mattress, use caution during transfers and bed mobility to prevent striking arms, legs and hands against any hard surfaces, and weekly treatment documentation.Review of the initial pressure ulcer assessment by the wound nurse dated 04/03/25 revealed Resident #206 had a deep tissue injury to left heel that measured three centimeters (cm) by three cm by 0.1cm in depth. The deep tissue injury was intact with calloused skin noted on surrounding area/tissue. There was no odor or drainage noted. The left heel was cleansed with wound cleanser, skin prep applied, covered with non-adherent pad and wrapped in kerlix. The nurse noted the son stated he noticed Resident #206 rubbing her foot on the back nylon strap of her wheelchair pedal when sitting up in the wheelchair. Resident #206 was educated on the importance of reducing friction and placing feet further forward when feet were resting on the pedals. The nurse offered to pad the straps on the pedals and the resident and son declined. Resident #206 was educated to elevate bilateral lower extremities on pillows with heels floating off the bed while in bed and when resting in recliner. Resident #206 was encouraged to have good food and fluid intake to aid in healing the skin.Review of the physician orders and Treatment Administration Record (TAR) for Resident #206 revealed no orders to float heels or wear heal protectors while in bed. A new order on 03/29/25 to cleanse area to left heel with wound cleanser, pat dry, cover with calcium alginate, non-adherent gauze, pad with ABD pad, wrap with kerlix and ace wrap. Dressing changed every day and as needed. Staff to offload Resident #206 bilateral heels when in bed every shift. On 04/02/25 the order was changed to cleanse the left heel with wound cleanser, apply skin prep, non-adherent pad and wrap with kerlix. Dressing changed daily until healed.Review of the plan of care dated 04/04/25 revealed Resident #206 had a pressure ulcer to left heel related to decreased mobility. The interventions included to educate resident and family as to cause of skin breakdown including transfers and positioning requirement, importance of taking care during ambulation/mobility, good nutrition, frequent repositioning, follow facility policies for prevention and treatment of skin breakdown, monitor/document/report any changes in skin status and educate resident and family of the importance of changing positions for prevention of pressure ulcers.Review of the Certified Nursing Assistant (CNA) history of documentation for Resident #206 revealed turning and repositioning every two hours as tolerated however, no documentation of floating heels while in bed.An interview on 08/06/25 at 10:30 A.M. with the Assistant Director of Nursing (ADON) confirmed Resident #206 did not have a deep tissue injury (pressure ulcer) to left heel upon admission. ADON also confirmed Resident #206 Braden scale (assessment to determine risk of developing a pressure ulcer) dated 02/27/25 on admission with a score of 17, put Resident #206 at high risk for development of a pressure ulcer. Resident #206 did not have a physician order to float heels or wear heel protectors when in bed. This deficiency represents non-compliance investigated under Complaint Number OH1319993.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain a complete and accurate medical record affecting Resident #206. This affected one (Resident #206) of nine resident medical record reviews. The facility census was 43.Findings include:Review of the closed medical record for Resident #206 revealed an admission date of 02/27/25 and was discharged to the hospital on [DATE]. Resident #206 diagnoses included aftercare following joint replacement surgery, dysphagia, non-rheumatic aortic valve stenosis, left bundle branch block, hypertension, urinary retention and recent gastrointestinal hemorrhage. Review of the admission five day Medicare Minimum Data Set (MDS) dated [DATE] revealed Resident #206 was cognitively intact with feelings of depression noted and no behaviors. Resident #206 had impaired range of motion to one side of lower extremities and used a wheelchair for mobility. Resident #206 required a set up for meals and substantial to maximum assistance from staff with toileting hygiene, bathing, bed mobility, sit to stand and transfers. The resident had an indwelling foley catheter and was occasionally incontinent of bowels. Resident #206 received scheduled and as needed pain medications along with non-pharmacological interventions. She had frequent pain that interfered with therapy and day to day activities at a moderate level. The only fall noted on assessment happened prior to admission resulting in recent hip replacement surgery. Resident #206 was assessed to hold food in her mouth, have coughing/choking during meals and complained of difficulty or pain when swallowing. The resident received a mechanically altered diet with no weight loss. Current weight was 124 pounds. Resident #206 had no skin impairments noted except for surgical incision to left hip and had a pressure reducing device to bed.Review of the progress notes revealed on 04/06/25 Resident #206 was not acting herself. The Nurse Practitioner ordered chest X-ray, breathing treatments, oxygen and laboratory testing. Resident #206 was later sent to the emergency room for evaluation and treatment. However, the nursing progress notes were silent related to resident condition, date and time resident was sent to the emergency room, report called to emergency room, any follow up with the hospital and no order to send resident to the emergency room for evaluation and treatment. An interview 08/06/25 at 8:30 A.M. with the Assistant Director of Nursing (ADON) confirmed the medical record for Resident #206 was incomplete. The record did not include an order to send resident to emergency room, documentation of signs and symptoms of illness, report called to emergency room, time and date of the squad pick up or any follow up related to emergency room visit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review and interviews, the facility failed to provide an appropriate transfer notice with Ombudsman notifications to either the resident or designated representative. This affected one resident (Resident #5) out of three residents reviewed for facility discharge. The facility census was 40. Findings include: Closed Record Review of Resident #5 on 02/04/25 at 11:21 A.M. revealed this resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE] with the following medical diagnoses: chronic kidney disease, GERD, chronic pain, altered mental status, osteoarthritis, fatigue, irritable bowel syndrome, neuralgia and neuritis, gout, hyperglycemia, depression, anxiety, arthritis, shortness of breath, difficult ambulation, and aspirin use. Review of the Minimum Data Set (MDS) assessment completed on 11/26/24 revealed Resident #5 was alert and oriented to name only and had severe cognitive impairment. Review of facility transfer and discharge information revealed no ombudsman notifications were completed. Review of facility notifications for this resident revealed the State Ombudsman was not notified of the transfer. Interview with the Administrator on 02/04/25 at 10:37 A.M. verified that one of the Ombudsman had informed the facility in the past that a notification was not necessary, and they did not need to be notified of each transfer. The Administrator verified the facility has not been submitting this information to the Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a significant change Pre admission Screening and Resident Review (PASARR) for Resident #7 and failed to ensure the admission PASARR was completed accurately for Resident #31. This affected two (Resident #7 and Resident #31) of four residents reviewed for PASARR. The facility census was 40. Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of 11/20/23 with diagnoses including unspecified dementia with psychotic disturbance, diabetes mellitus type two, peripheral vascular disease, visual hallucinations, auditory hallucinations, depressive disorder and bipolar disorder. Review of the physician order dated 11/20/23 revealed Resident #31 was ordered Celexa (antidepressant/antianxiety medication) 20 milligrams (mg) by mouth one time daily for anxiety. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #31 had intact cognition with no mood or behaviors. Resident #31 had diagnosis of dementia, depression and bipolar disorder. Resident #31 received antidepressant medication. Review of the plan of care for Resident #31 revealed Resident #31 had a behavioral problem exhibited being rude, demanding and verbally abusive to staff, and had a history of visual and auditory hallucinations. The goal was to have no increase in behavior problems through review date. the interventions included to administer medications as ordered, monitor for side effects/effectiveness of medications, attempt gradual dose reductions as ordered by physician, attempt to anticipate and meet the residents needs in timely manner, encourage and allow time to voice needs and concerns, attempt to use alternative interventions to medications to manage behaviors and attempt to determine/eliminate the underlying cause, intervene as necessary to protect the rights and safety of others, and consult behavioral health as needed. Review of the admission PASARR dated 11/15/23 revealed Resident #31 had indications of serious illness such as mood disorder and had dementia. Resident #31 had not been prescribed any psychotropic medications such as anti-psychotics, anti-depressants, anti-anxiety or mood stabilizers. Interview on 02/05/25 at 1:43 P.M. with Social Services Director #106 confirmed the admission PASARR dated 11/15/23 did not include the anti-depressant medication Celexa. 2. Record review for Resident #7 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Parkinsonism, Post Traumatic Stress Disorder (PTSD), and anxiety disorder. Review of the physicians order, dated 03/15/24, revealed the resident was admitted to hospice services. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 03/20/24, revealed the resident was receiving hospice services. Further record review for Resident #7 revealed a significant change PASARR assessment was not completed following the resident being newly admitted to hospice services or the completion of the Significant Change MDS assessment. Interview with Social Services Director #106 on 02/05/25 at 1:43 P.M. confirmed a significant change PASARR assessment had not been completed following Resident #7 beginning hospice services on 03/15/24 or after the Significant Change MDS assessment was completed on 03/20/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to invite Resident #31 to attend quarterly care conferences. This affected one resident of 12 reviewed for care planning and care conference. The facility census was 40. Findings include: Review of the medical record for Resident #31 revealed an admission date of 11/20/23 with diagnoses including unspecified dementia with psychotic disturbance, diabetes mellitus type two, peripheral vascular disease, visual hallucinations, auditory hallucinations, depressive disorder and bipolar disorder. Review of the physician orders dated 02/25 revealed several changes in medication since Resident #31 was admitted . Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #31 had intact cognition with no mood or behaviors. Resident #31 required partial to moderate assistance from staff to complete activities of daily living. Resident #31 had diagnosis of dementia, depression and bipolar disorder. Resident #31 received antidepressant medication. Review of the progress notes from 11/20/23 through 02/04/25 revealed no documentation that Resident #31 was invited or attended his quarterly care conferences. Review of the plan of care note dated 11/06/24 at 5:02 P.M. revealed the plan of care meeting was held with the plan of care team and Resident #31 sister via phone. The current plan of care, medications, code status and other orders were reviewed. All questions and concerns were addressed during the meeting. There was no indication Resident #31 was invited or attended. Review of the plan of care note dated 08/08/24 at 11:56 A.M. revealed the plan of care meeting was held with the plan of care team and Resident #31 daughter via phone on 08/07/24. The current plan of care, medications, code status, and other orders were reviewed. All questions and concerns were addressed during the meeting. There was no indication Resident #31 was invited or attended. Review of the plan of care for Resident #31 revealed no concerns. An interview on 02/04/25 at 8:11 A.M. revealed Resident #31 was not sure if he had went to any kind of meetings to talk about his care. An additional interview on 02/05/25 at 8:35 A.M. revealed Resident #31 stated he was sure he had not attended any meetings with the nurse or social worker about his care. Resident #31 also stated he did not recall anyone inviting him to attend such meetings. Resident #31 stated he would like to be involved in his care and make decisions about what he would like. An interview on 02/05/25 at 1:55 P.M. with Social Services #105 and MDS nurse #157 stated any resident below the intact cognition line per the Resident Assessment Instrument (RAI) were not invited to care conferences due to not being able to make decisions about their care. Resident #31 last Brief Interview of Mental Status (BIMS) score was 12, and prior to that it was three. Resident #31 fluctuates with his cognition. Social Services #105 confirmed Resident #31 was not invited to attend any of his care conferences. Social Services #105 also stated Resident #31 sister or daughter attended. Social Services #105 confirmed Resident #31 had the right to attend and that Resident #31 did not have a Power of Attorney or Guardian appointed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide an ordered psychiatric consult following a gradual dose reduction (GDR) recommendation. This affected one (Resident #35) out of five residents reviewed for unnecessary medications. The facility census was 40. Findings include: Record review of Resident #35 on 02/04/25 at 2:06 P.M. revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: Parkinson's disease, altered mental status, physical debility, hallucinations, osteoporosis, anxiety, depression, hyperlipidemia, GERD, constipation, dysphagia, edema, depression, and glossodynia. Review of the Minimum Data Set (MDS) assessment completed on 01/22/25 revealed resident was alert and oriented to name only and had minimal cognitive impairment Review of physician orders revealed this resident is receiving the following medications: Venlafaxine 150 milligrams (mg) 1 tablet by mouth twice daily for anxiety; Clozapine 100 mg 1 tablet by mouth daily at bedtime for hallucinations; Clozapine 25 mg 1/2 tablet by mouth daily at bedtime for hallucinations; and Pimavanserin 34 mg 1 tablet by mouth daily for depression. Review of the medication regimen review dated 12/01/24 revealed a recommendation was made for Clozapine, Pimavanserin, and Venlafaxine to use per current standards of practice for GDR consideration. Review of physician response dated 12/03/24 was to follow up with Ohio State University ([NAME]) psychiatric services for management of psychiatric medications. Review of physician orders and consult results revealed Resident #35 was not seen by the ordered psychiatric service which was written as the GDR response. No evidence of the ordering physician being notified was provided for the deviation of the order. Facility provided a new order for the resident to follow up with [NAME] psych was obtained on 02/04/25, which was not carried out previously. Interview with the Director of Nursing on 02/04/25 at 4:10 P.M. verified the facility had a breakdown in communication in regards to the consultation for psychiatric services for this resident. She verified instead of making an appointment with the written provider, the resident was seen in-house by the facility service, and the physician was not notified of this change to the order. She verified an appointment with the ordered provider was obtained on 02/04/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure interventions to prevent the worsening of contracture's were implemented. This affected one resident (#7) out of the two residents reviewed for limited range of motion during the annual survey. The facility census was 40. Findings include: Record review for Resident #7 revealed the resident was admitted to the facility on [DATE] and had diagnoses including Parkinsonism, Post Traumatic Stress Disorder (PTSD), and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/21/24, revealed the resident was assessed to have mildly impaired cognition and limited range of motion to bilateral upper extremities. Review of the Occupational Therapy Discharge Progress Note, signed 08/13/24, revealed recommendations skilled Occupational Therapy (OT) services indicated to promote skin integrity and Passive Range of Motion to left hand for application of therapy carrot daily for left hand stiffness. Review of the care plan, revised 08/15/24, revealed Resident #7 had potential for skin breakdown due to hand contracture's. Interventions included palm protector to right hand as ordered and staff to apply therapy carrot to left hand daily for four to six hours as indicated. Review of the active and discontinued physicians orders for Resident #7 revealed no orders for a palm protector or therapy carrot had been implemented. Review of the progress notes, dated 08/15/24 through 02/06/25, revealed no documentation related to the placement or refusal of therapy carrots or palm protectors. Observation on 02/03/25 at 1:35 P.M. revealed Resident #7 was lying in bed with no devices in place to the left or right hand. Both hands were observed to be contracted. A therapy carrot was lying on the bedside table next to the residents bed and a palm guard was lying on the nightstand in the corner of the room. Interview with Resident #7 at the time of the observation confirmed staff were supposed to place a therapy carrot and palm guard in her hands but frequently did not. Observation on 02/04/25 at 9:25 A.M. revealed Resident #7 was sitting up in a geri-chair in the dining area. The resident did not have any devices in place to the left or right hand. Observation on 02/05/25 at 2:55 P.M. revealed Resident #7 was lying in bed. The resident did not have any devices in place to the left or right hand. Interview with Occupational Therapist (OT) #222 on 02/06/25 at 10:20 A.M. confirmed Resident #7 had received Occupational Therapy services due to contracture's of the left hand. OT #222 confirmed a therapy carrot had been recommended upon discharge from therapy services to prevent worsening of contracture's. OT #222 confirmed nursing staff were to provide the specific details and orders for the application of devices after discharge from therapy services. Observation with OT #222 on 02/06/25 at 10:26 A.M. confirmed there was not a therapy carrot or palm guard in place to Resident #7's left or right hand. OT #222 pulled open the fingers of Resident #7 and the residents skin was intact with no visible alterations. Interview with Certified Nursing Assistant (CNA) #158 on 02/06/25 at 10:32 A.M. confirmed there were no orders or tasks in place for a therapy carrot, palm guard, or other device for Resident #7. CNA #158 confirmed she was not aware of Resident #7 requiring a palm guard or therapy carrot to be placed in her hands and was unsure if any other staff placed any devices in her hands. Interview with Licensed Practical Nurse (LPN) #125 on 02/06/25 at 10:38 A.M. confirmed there were no orders in place for a therapy carrot, palm guard, or other device to be placed in the hands of Resident #7. Interview with the Director of Nursing (DON) on 02/06/25 at 1:10 P.M. confirmed orders for the placement of a therapy carrot and a palm guard had not been put into place for Resident #7 following the residents discharge from OT services. The DON confirmed there was no evidence the resident had a therapy carrot or palm guard placed her in hands per the plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify causes and triggers for trauma. This affected one resident (#7) reviewed for PTSD during the annual survey. The facility identified one resident having a diagnosis of PTSD. The facility census was 40. Findings include: Record review for Resident #7 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Parkinsonism, PTSD, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/21/24, revealed the resident was assessed to have mildly impaired cognition. Review of the care plans for Resident #7 revealed there was not a plan of care in place addressing the residents PTSD or trauma. Further record review for Resident #7 revealed there was not an assessment of the cause of the residents PTSD or potential triggers for PTSD. Interview with Social Services employee #105 on 02/05/25 at 3:20 P.M. confirmed an assessment of the cause and triggers for Resident #7's PTSD had not been conducted and there was no plan of care in place to address the PTSD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure parameters for the monitoring and reporting of hypoglycemia (low blood sugar) were in place. This affected one resident (#31) out of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 40. Findings include: Review of the medical record for Resident #31 revealed an admission date of 11/20/23 with diagnoses including unspecified dementia with psychotic disturbance, diabetes mellitus type two, peripheral vascular disease, visual hallucinations, auditory hallucinations, depressive disorder and bipolar disorder. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #31 had intact cognition with no mood or behaviors. Resident #31 required partial to moderate assistance from staff to complete activities of daily living. Resident #31 had diagnosis of dementia, depression and bipolar disorder. Resident #31 received antidepressant medication and insulin. Review of the physician orders dated 02/25 revealed Resident #31 received the following medications for treatment of diabetes mellitus type two. Metformin 500 milligrams (mg) by mouth two times daily, Basaglar Kwik-pen 100 units (u) per milliliter (ml) subcutaneously two times daily and Novolog Flex-pen injector 100u/ml subcutaneously before meals per sliding scale of blood sugar 151-200 give two units, 201-250 give four units, 251-300 give six units, 301-350 give eight units, 351-400 give 10 units, 401-450 give 12 units and 451-500 give 15 units and notify provider. The physician orders did not include orders for low blood sugars or parameter of what constitutes a low blood sugar. Review of the nursing progress notes dated 11/20/23 through 02/05/25 revealed no concerns related to low blood sugars. Review of the plan of care revealed Resident #31 had diabetes mellitus with hyperglycemia (high blood sugar) with a goal to free from signs and symptoms of hyperglycemia through the next review date. The interventions included to administer diabetes medication as ordered, monitor for side effects and effectiveness of medications, dietary consult as needed, educate resident regarding medications and importance of compliance, fasting serum blood sugar/fingersticks as ordered, insulin per sliding scale orders, monitor/document and report as needed any signs and symptoms of hyperglycemia including increased thirst and appetite, frequent urination, weight loss fatigue, dry skin, poor wound healing, muscle cramps, Kussamaul breathing, acetone breath, stupor or coma, monitor and report any signs and symptoms of infection to open areas, offer substitute for foods not eaten, refer to podiatry as needed and nurse to wash feet daily with mild soap and water and dry thoroughly. There was no plan of care addressing hypoglycemia or low blood sugar. Interview on 02/05/25 at 8:41 A.M. with Registered Nurse (RN) #165 revealed if a resident had a low blood sugar,(unable to identify exact number for a low blood sugar) the nurse would follow the standing orders in the book located at the nursing station. The standing order stated if a resident had a low blood sugar (no parameter or number) and the resident was able to swallow, administer six ounces of orange juice and recheck the blood sugar in 15 minutes. If the blood sugar remained low, repeat and notify the physician. RN #165 confirmed the order did not have a parameter or number of what was a low blood sugar. Interview on 02/05/25 at 3:28 P.M. with the Director of Nursing (DON) #128 confirmed Resident #31 did not have parameters for a low blood sugar or orders to treat hypoglycemia (low blood sugar) including glucagon.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Resident #25 had the appropriate diagnosis for an antipsychotic medication. This affected one (Resident #25) of five residents reviewed for unnecessary medications. The facility census was 40. Findings include: Review of the medical record for Resident #25 revealed an admission date of 12/12/24 with diagnoses including metabolic encephalopathy, unspecified dementia with behavioral disturbance, insomnia, chronic pain, and diabetes mellitus with hyperglycemia. Review of the physician orders dated 02/25 revealed Resident #25 was ordered and received Risperdal 0.5 milligrams (mg) by mouth at bedtime for unspecified dementia with other behavioral disturbance. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #25 had moderate cognitive impairment with disorganized thinking. Resident #25 had physical behavioral symptoms, verbal behavioral symptoms, rejection of care and wandering. Resident #25 required partial to moderate assistance of one staff for activities of daily living. Resident #25 had diagnoses including dementia with behavioral disturbance, insomnia, metabolic encephalopathy, chronic pain and diabetes mellitus. Resident #25 received an antipsychotic medication. Review of the nursing progress notes from 12/12/24 through 02/05/25 revealed several notes related to Resident #25 behaviors. Review of the Certified Nursing Assistants (CNA) documentation revealed Resident #25 had episodes of behaviors daily. Review of the plan of care revealed Resident #25 had a behavior problem related to dementia and impaired cognition with a goal to exhibit less behaviors through the review date. The interventions included to administer medications as ordered, monitor for side effects and effectiveness, attempt a gradual dose reduction as ordered by physician, attempt to anticipate and meet resident needs, attempt to use alternative interventions to mediations to manage behavior episodes, intervene as necessary to protect the rights and safety of others, refer to psych services as needed. Review of the plan of care revealed Resident #25 used a psychotropic medication related to behavior management with a goal to remain free of psychotropic drug related complications including movement disorders, discomfort, hypotension, gait disturbance or constipation through review date. The interventions. included to administer psychotropic medications as ordered, monitor for side effects and effectiveness, consult with pharmacy and physician to consider dosage reduction when clinically appropriate at least quarterly, discuss with physician and family ongoing need for use of medication, review behaviors/interventions for effectiveness per facility policy, education resident/family about risks, benefits and side effects, and monitor/document and report any adverse reactions of psychotropic medications. Interview on 02/05/25 at 3:28 P.M. with the Director of Nursing (DON) #128 confirmed Resident #25 received Risperdal, an antipsychotic medication, for treatment of dementia with behavioral disturbance. DON #128 confirmed this was not an appropriate diagnosis for use of antipsychotic medication. The facility did not have a policy related to unnecessary medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, review of the facility Self-Reported Incident (SRI), and policy review, the facility failed to prevent physical abuse for one resident (#10) of three residents reviewed. The facility census was 48. Findings include: Review of the medical record for Resident #10, revealed an admission date of 04/08/22. Diagnoses included but were not limited to unspecified dementia, anxiety disorder, major depressive disorder, muscle weakness, and mood disorder due to known physiological condition. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 07 out of 15 indicating severe cognitive impairment. The resident was assessed to require substantial/maximal assistance with shower/bathe self, bed mobility, transfers and total dependence with toilet hygiene. This resident was also assessed to have skin tears under skin conditions. Review of the SRI dated 11/12/24 revealed an allegation of neglect that occurred on 11/11/24. A Certified Nurse Assistant (CNA) reported to the Assistant Director of Nursing (ADON) that the alleged perpetrator (CNA #100) had a conflict with Resident #10. Resident #10 became combative during care on the night shift. Resident #10 was noted to have a skin tear and bruising to both her hands. CNA #100 was removed from the schedule and an investigation occurred. Based on the investigation, CNA #100 was terminated. The facility substantiated the allegation of neglect. Review of a witness statement from CNA #343 dated 11/11/24 revealed she was getting report from CNA #100 when she reported her, and Resident #10 got in a fight. CNA #11 had stated that Resident #10 has had behaviors and was combative with her. When she was showering Resident #10 that day, she noticed the skin tear and bruising to both of her hands. Review of witness statement from CNA #344 dated 11/11/24 revealed during morning report, CNA #100 told her that Resident #10 and her had a fight, and she won. During morning rounds she observed bruises and a skin tear to Resident #10's hands. Review of witness statement from CNA #345 dated 11/13/23 revealed on 11/11/24 during report CNA #100 told her she and Resident #10 got in a fight, and she had won. Later in the morning, she noticed bruising to her hands. Review of witness statement from the Assistant Director of Nursing (ADON) dated 11/12/24 that on 11/11/24 CNA #100 had in report said that her and Resident #10 got into a fight, and she had won. She was also informed the resident had bruising and a skin tear noted to her hands. She then went check on Resident #10 and observed bilateral hand bruising and a skin tear to the left top hand. When interviewing Resident #10 she stated you know one of your girls did it and it's that girl that changes my diapers and gets me up early in the mornings. I didn't want to get up and she started pulling on my arms and scratched my hand. Investigation then was started. Review of the skin check dated 11/11/24 at 1:03 P.M. for Resident #10 revealed the following: a left dorsum hand ulnar location skin tear that measured 1.8 centimeters (CM) by 0.3 CM, a right dorsum right hand bruising and left dorsum left hand bruising. Interview on 12/26/24 at 12:01 P.M. with the Administrator confirmed the physical abuse occurred to Resident #10 per investigation from the ADON. Interview on 12/26/24 at 12:28 P.M. with CNA#343 revealed her statement was accurate and when she came on shift that morning CNA #100 was saying she won the fight with Resident #10. She told the nurse in charge and the ADON was notified. The ADON was unavailable for an interview. Review of the facility policy titled Abuse dated 04/25/18 revealed abuse is defined as the willful infliction of injury which results in physical harm. All residents have the right to be free from abuse, and to feel safe, cared for, and respected at all times. All allegations of abuse will be investigated and reported per policy This deficiency represents non-compliance investigated under Complaint Number OH00160291.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #197's medical record revealed an admission date of 11/01/19 with diagnoses of dementia without behavioral disturbance, hypertension and anxiety. Review of Resident #197's plan of care, dated 11/04/19 revealed many care areas including activities of daily living, and care provided for current diagnoses being provided by Hospice. Review of the physician's orders for Resident #197 revealed no current order or Hospice or palliative care. Review of Resident #197's admission MDS 3.0 assessment, dated 11/12/19 revealed the resident had minimal difficulty in hear and required the use of glasses. Resident #197 required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and transfers per two staff members. Resident #197 also required the use of pressure reducing devices to her bed and chair and sensor alert to her bed and chair for safety. Interview on 11/13/19 at 4:10 P.M. with Assistant Director of Nursing (ADON) #154 revealed the resident was removed from Hospice on 11/05/19 per resident and family request and confirmed Resident #197's plan of care had not been revised to reflect the discontinuation of Hospice services. 2. Review of Resident #20's medical record revealed an original admission date of 01/30/18 with the latest readmission of 10/11/19 with re-admitting diagnoses of acute impacted left femoral intertrochanteric fracture, unspecified fracture of the lower end of the right femur, dementia, diabetes mellitus and anxiety. Review of the resident's plan of care, dated 01/31/18 revealed the resident had a self-care performance deficit related to dementia with progressive decline expected. An intervention, initiated on 04/17/18 was for the resident to be seated in a high back wheelchair with anti-thrust cushion, bilateral footrests and foot and leg supports with lift blocks when up. Review of resident's five day MDS 3.0 assessment dated [DATE] revealed the resident had unclear speech, rarely/never understands others, rarely/never makes herself understood and had a severe cognitive deficit. Review of the mood and behavior section revealed she displayed indicators of depression and had both verbal and physical behaviors directed towards others. The resident required extensive assistance of two staff for bed mobility, personal hygiene and was dependent on two staff for transfers. Review of the resident's monthly physician's orders for November 2019 revealed no orders for positioning devices. On 11/13/19 at 10:37 A.M. observation of Resident #20 revealed she was sitting in a geriatric chair (a large, padded, comfortable reclining chair with casters designed to allow patients recovering from illness and surgery, or the elderly and infirm to get out of a bed and sit comfortably while being fully supported and transported to adjoining areas within a facility) with her feet elevated. On 11/15/19 at 8:19 A.M. observation of Resident #20 revealed she was sitting up in a geriatric chair in the dining room. On 11/15/19 at 1:30 P.M. interview with the Director of Nursing (DON) verified the resident no longer utilized the high back wheelchair and the resident's plan of care had not been revised to reflect the geriatric chair currently being used. Based on observation, record review and interview the facility failed to ensure care plans were revised for Resident #31 related to pain management, Resident #20 related to mobility devices and for Resident #197 related to Hospice services. This affected three residents (#31, #20 and #197) of 21 sampled residents whose care plans were reviewed. Findings Include: 1. Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, anorexia, mood disorder, hyperlipidemia, bradycardia, heart failure, osteoarthritis, essential hypertension, hypocalcemia, anemia and falls. Review of Resident #31's admission Minimum Data Set (MDS) 3.0 assessment, dated 02/14/19 revealed the resident's speech was clear, he usually understands, usually understood others, and his cognition was severely impaired. Per the assessment, Resident #31 was on scheduled pain medication and he was not in pain. Resident #31 did not reject care. Resident #31 required extensive assistance of one staff for personal hygiene. Resident #31 did not use oxygen. Review of Resident #31's plan of care, dated 02/08/19 revealed it did not address non-verbal expressions of pain. Interview with Resident #31's daughter on 11/12/19 at 2:18 P.M. revealed since the weekend she felt the resident was in pain. She stated she had reported this to the nurse but was not sure the nurses addressed this. Observation of Resident #31 during the interview revealed he was moaning. The resident's fists were observed to be clenched and he was observed groaning. Observation of Resident #31 on 11/13/19 at 1:43 P.M. revealed he was laying in bed on his back. The resident's fists were clinched and his arms were shaking. On 11/14/19 at 11:00 P.M. Resident #31 was observed in bed laying on his back with his fists clinched and his arms were shaking. Interview with the Director of Nursing (DON) on 11/15/19 at 9:06 A.M. confirmed Resident #31's care plan was not revised to include non-verbal expressions of pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #21 and Resident #22 were provided the necessary care and services to maintain the resident's dining ability, ability to eat independently. This affected two residents (#21 and #22) of four residents reviewed for activities of daily living (ADL) care. Finds Include: 1. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included pneumonia, delusional disorder, glaucoma, essential hypertension, abnormal weight loss, dementia with behavioral disturbance, major depressive disorder, hypothyroidism,and malignant neoplasm of female breast. Review of Resident #21's plan of care, dated 02/20/19 revealed to assist her as needed with her activities of daily living. Review of Resident #21's Minimum Data Set (MDS) 3.0 assessment, dated 02/26/19 and 09/21/19 revealed her speech was clear, she was understood, she understands, and her cognition was severely impaired. Resident #21 had no behaviors, did not reject care and wandered one to three days. Resident #21 required supervision with set up help to eat. Resident #21 had no swallowing problems and no significant weight changes. Review of Resident #21's November 2019 physician's orders revealed a regular diet and two nutritional supplement three times a day. Observation of Resident #21 on 11/12/19 from 11:34 A.M. to 12:12 P.M. revealed she was served a hamburger, mixed vegetables, potatoes, and diced peaches. Resident #21 did not eat, and she was not encouraged to eat. Resident #21 was again observed during the evening meal on 11/12/19 from 5:24 P.M. to 5:46 P.M. The resident was served broccoli, rice, chicken, and sherbet. The resident did not eat and was not encouraged to eat. Interview with State Tested Nursing Assistant (STNA) #185 on 11/13/19 at 2:56 P.M. revealed Resident #21 fed herself and if she did not eat then staff would give her a shake or something. STNA #185 stated sometimes Resident #21 was combative with care but she would eat if she was encouraged. Interview with the Director of Nursing (DON) on 11/13/19 at 3:22 P.M. revealed staff should have encouraged Resident #21 to eat during the meal observations noted above. 2. Review of Resident #22's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, anxiety disorder, insomnia, constipation, wandering, major depression, irritability, type two diabetes, essential hypertension, anemia and hypothyroidism. Review of Resident #22's annual MDS 3.0 assessment, dated 03/21/19 revealed the resident's speech was clear, she sometimes understands, sometimes understood and her cognition was severely impaired. Resident #22 had physical and verbal behaviors one to three days and did not reject care. Resident #22 required supervision with set up help to eat, had no swallowing problems, and no significant weight changes. Review of Resident #22's quarterly MDS dated [DATE] revealed the resident had physical and verbal behaviors daily, rejected care one to three days, and wandered one to three days. Review of Resident #22's November 2019 physician's orders revealed a regular diet and a nutritional supplement twice daily. Observation of Resident #22 on 11/12/19 from 11:34 A.M. to 12:12 P.M. revealed she was served a hamburger, mixed vegetables, potatoes, and diced peaches. Resident #22 did not eat and she was not encouraged to eat. Resident #22 was again observed during he evening meal on 11/12/19 from 5:24 P.M. to 5:46 P.M. The resident was served broccoli, rice, chicken, and sherbet. The resident did not eat and was not encouraged to eat. Interview with STNA #126 on 11/15/19 at 7:47 A.M. revealed sometimes Resident #22 needed to be cued. She stated sometimes Resident #22 would eat and sometimes she would not. Interview with the Director of Nursing (DON) on 11/13/19 at 3:22 P.M. revealed staff should have encouraged Resident #22 to eat during meal observations noted above.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure Resident #15 and Resident #31, who were dependent on staff for activities of daily living received timely and adequate assistance with dressing and personal hygiene. This affected two residents (#15 and #31) of four reviewed for activities of daily living. Findings Include: 1. Review of Resident #15's medical record revealed an admission date of 08/20/19 with the admitting diagnoses of anxiety, dementia and depression. Review of the resident's plan of care, dated 08/21/19 revealed the resident had a self-care performance deficit related to Alzheimer's disease progression. Interventions included to set-up supplies for care and assist with activities of daily living. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 08/28/19 revealed the resident had clear speech, usually understands others, makes himself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of one. Review of the mood and behavior section revealed he displayed indictors of depression and wandered on a daily basis. The resident required limited assistance of one for dressing. Review of the resident's progress notes from 08/20/19 through 11/14/19 revealed no documentation the resident refused to change his clothing. Review of the resident's dressing documentation for the past 30 days revealed no episodes of the resident refusing to dress. On 11/13/19 at 10:34 A.M. observation of Resident #15 revealed the resident was sitting in a chair holding a cup of coffee. The resident was dressed in a gray long sleeved shirt, navy blue sweat pants, white socks and sandals. The resident was not interviewable. On 11/14/19 at 3:40 P.M. the resident remained dressed in the same gray long sleeved shirt, navy blue sweat pants, white socks and saddles. On 11/15/19 at 8:17 A.M. observation of the resident revealed he was sitting at the dining room table singing to himself. The remained dressed in the same gray long sleeved shirt, navy blue sweat pants, white socks and saddles. On 11/15/19 at 8:29 A.M. interview with State Tested Nursing Assistant (STNA) #104 revealed the resident required staff to assist him to dress and change his clothes. The STNA indicated the resident did not have pajamas and he slept in his clothing. The STNA verified she had not changed he resident's clothing on 11/13/19, 11/14/19 or 11/15/19 as of this time. 2. Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, anorexia, mood disorder, hyperlipidemia, bradycardia, heart failure, osteoarthritis, essential hypertension, hypocalcemia, anemia and falls. Review of Resident #31's activity of daily living care plan, dated 02/08/19 revealed it did not address how often he wanted shaved. Review of Resident #31's admission MDS 3.0 assessment, dated 02/14/19 revealed the resident's speech was clear, he usually understands, usually understood others, and his cognition was severely impaired. Resident #31 did not reject care. Resident #31 required extensive assistance of one staff for personal hygiene. Review of Resident #31's quarterly MDS 3.0 assessment, dated 10/03/19 revealed the resident sometimes understands and he rejected care four to six days in a week. Observation of Resident #31 on 11/12/19 at 2:00 P.M. revealed he had facial hair that was long. Interview with Resident #31's daughter on 11/12/19 at 2:09 P.M. revealed her father did not like facial hair, and she had to complain to staff in order to get his face shaved. Observation of Resident #31 on 11/13/19 at 10:30 A.M. revealed he was not shaved. Observation of Resident #31 on 11/14/19 at 7:50 A.M. revealed he was not shaved. Observation of Resident #31 at 10:38 A.M revealed his face was shaven at this time. Interview with STNA #159 on 11/14/19 at 10:41 A.M. revealed she had shaved Resident #31 that morning. She confirmed he had several days growth of facial hair at that time. She stated she knows he was shaved on Saturday because she had shaved him then. STNA #159 stated Resident #31 used to reject care but in the last several weeks he did not reject care. STNA #159 stated she shaved men daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #31's oxygen tubing and humidification/water bottle were dated. This affected one resident (#31) of one resident reviewed for oxygen therapy. The facility identified seven residents received respiratory care. Findings Include: Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, anorexia, mood disorder, hyperlipidemia, bradycardia, heart failure, osteoarthritis, essential hypertension, hypocalcemia, anemia and falls. Review of Resident #31's admission Minimum Data Set (MDS) 3.0 assessment, dated 02/14/19 revealed the resident's speech was clear, he usually understands, usually understood others, and his cognition was severely impaired. Resident #31 did not reject care. Resident #31 required extensive assistance of one staff for personal hygiene. The assessment revealed Resident #31 did not use oxygen. Review of Resident #31's physician's orders revealed on 10/09/19 an order for oxygen at two liters per minute as needed when his oxygen saturations levels were less than 92 percent. Observation of Resident #31 on 11/13/19 at 10:30 A.M. revealed his oxygen tubing and water bottle were not dated. The oxygen concentrator was on but the resident's nasal cannula was on the floor. At 11:28 A.M. the resident was observed wearing the nasal cannula. There was no date on the tubing at that time. Interview with Registered Nurse (RN) #150 on 11/13/19 at 2:23 P.M. confirmed Resident #31's oxygen with humidification was not dated. RN #150 was unaware the tubing needed to be dated. Additional interview with RN #150 at 3:02 P.M. revealed the tubing and water bottle were supposed to be dated when they were changed weekly on Sunday.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to implement a comprehensive and individualized pain management program for Resident #31. This affected one resident (#31) of one resident reviewed for pain. Findings Include: Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, anorexia, mood disorder, hyperlipidemia, bradycardia, heart failure, osteoarthritis, essential hypertension, hypocalcemia, anemia and falls. Review of Resident #31's plan of care, dated 02/08/19 revealed it did not address non-verbal expressions of pain. Review of Resident #31's admission Minimum Data Set (MDS) 3.0 assessment, dated 02/14/19 revealed the resident's speech was clear, he usually understands, usually understood others, and his cognition was severely impaired. The assessment revealed Resident #31 was on scheduled pain medication and he did not have any pain. Resident #31 did not reject care. Resident #31 required extensive assistance of one staff for personal hygiene. Review of Resident #31's quarterly MDS 3.0 assessment, dated 10/03/19 revealed the resident was was unable to report if he was in pain. Review of Resident #31's November 2019 physician's orders revealed an order to monitor the resident for pain every shift. Document pain scale rating or faces scales every shift. Resident #31 received a pain medication (Meloxicam) 7.5 milligrams daily for pain. Review of Resident #31's medication administration record (MAR) for September, October, and November 2019 revealed Resident #31's pain was documentated to be 0. Interview with Resident #31's daughter on 11/12/19 at 2:18 P.M. revealed since the weekend she felt the resident had been in pain. She stated she reported this to the nurse but was not sure the nurses addressed it. Observation of Resident #31 during the interview revealed he was moaning, clenching his fists and groaning. Observation of Resident #31 on 11/13/19 at 1:43 P.M. revealed he was laying in bed on his back. The resident's fists were clenched and his arms were shaking. On 11/14/19 at 11:00 P.M. Resident #31 was observed laying in bed on his back with his fists clenched and his arms shaking. Interview with State Tested Nursing (STNA) #159 on 11/14/19 at 10:41 A.M. revealed in the past several weeks Resident #31's condition had declined. She stated he was no longer safe in a wheelchair because he was drawing up his arms and legs and his hands were in fists and were shaking. STNA #159 stated she did not know why this was happening. Interview with Registered Nurse (RN) #150 on 11/14/19 at 11:27 A.M. revealed Resident #31 had been clenching his fists since she started two weeks ago. RN #150 stated the resident was not able to state whether or not he was in pain at this time. Interview with the Director of Nursing (DON) on 11/15/19 at 9:06 A.M. revealed she did not think about Resident #31's clenching and shaking as pain. The DON stated the nurses needed to be educated related to non-verbal expressions of pain. The DON confirmed Resident #31 was not able to verbally express pain at this point.

Based on record review and interview the facility failed to ensure Resident #197's medical record was accurate to reflect the discontinuation of Hospice services. This affected one resident (#197) of 24 residents whose medical records were reviewed. Findings Include: Review of the medical record for Resident #197 revealed an admission date of 11/01/19 with diagnoses of dementia without behavioral disturbances, hypertension and anxiety. Review of the progress notes for Resident #197 revealed multiple notes including notes on 11/12/19, and 11/13/19 revealing the resident was receiving Hospice services. Interview on 11/13/19 at 4:10 P.M. with Assistant Director of Nursing (ADON) #154 revealed Resident #197 was discharged from Hospice on 11/05/19. However, nursing staff continued to document the resident was receiving Hospice services after this date.

Based on observation and staff interview the facility failed ensure residents who resided on the secured dementia unit were provided the necessary utensils to assist with independent meal consumption resulting in a potential undignified dining experience for the residents on the unit. This affected 13 residents (#20, #39, #22, #7, #17, #31, #15, #44, #13, #29, #2, #38 and #21) 13 residents who resided on the secured dementia unit. The facility census was 57. Findings Include: On 11/12/19 at 11:34 A.M. observation of the lunch meal revealed Resident #20, #39, #22, #7, #17, #31, #15, #44, #13, #29, #2, #38 and #21 were served only a spoon and a fork with their meal. The residents were not provided with a knife. At 12:00 P.M. State Tested Nursing Assistant (STNA) #189 was observed to cut Resident #39's hamburger in half using a fork and a spoon. STNA #189 had to remove the tomato from the hamburger in order to cut it, cut the hamburger and then returned the tomato to it. On 11/12/19 at 5:24 P.M. observation of the evening meal revealed Resident #20, #39, #22, #7, #17, #31, #15, #44, #13, #29, #2, #38 and #21 were served only a spoon and a fork with their meal. The residents again were not provided a knife. Interview with Licensed Practical Nurse (LPN) #130 on 11/15/19 at 7:30 A.M. revealed she did not know why the residents on the unit did not get a knife with their meal tray. She stated the residents on the unit had Alzheimer's dementia diagnosis and that may be why. However, she stated no resident had threatened or hurt anyone with a knife. Interview with the Director of Nursing on 11/15/19 at 3:35 P.M. confirmed there was no reason why residents on the unit could not have a knife with their meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the medical record for Resident #11 revealed an admission date of 12/14/18 with diagnoses of pain in her left shoulder, dementia with behavioral disturbances, anxiety and osteoarthritis. Review of Resident #11's activity assessment, dated 12/15/18 revealed the resident had interest in books, newspapers, magazines, music and fresh air when the weather was good. Review of Resident #11's quarterly MDS 3.0 assessment, dated for 08/08/19 revealed resident with minimal difficulty in hearing, and impaired vision with the use of glasses. Resident #11 was impendent with bed mobility, walking, locomotion on and off the facility unit and eating. Review of Resident #11's care plan, dated 10/16/19 revealed no activity plan of care had been developed for the resident. Review of Resident #11's activity log for the month of 10/2019 and 11/2019 revealed the resident participated mostly in independent activities in her room. Resident #11 would occasionally attend group activities and would go outside for fresh air a few times a day. Interview on 11/14/19 at 2:30 P.M. with Activity Director #200 revealed she does not make a care plan care dedicated to activities if the resident was participating in activities. Activity Director #200 thought an activity care plan was only needed if the resident was not participating in activities. Based on record review and interview the facility failed to ensure comprehensive care plans related to activities were developed for Resident #11, #15, #17, #20 and #21. This affected five residents (#11, #21, #17, #15 and #20) of 21 sampled residents whose care plans were reviewed. Findings Include: 1. Review of Resident #20's medical record revealed an original admission date of 01/30/18 with the latest readmission of 10/11/19 with readmitting diagnoses of acute impacted left femoral intertrochanteric fracture, unspecified fracture of the lower end of the right femur, dementia, diabetes mellitus and anxiety. Review of the resident's admission activities assessment dated [DATE] revealed the resident enjoyed exercises, outdoors, music, religious, arts and crafts and cooking. The assessment indicated the facility was unsure if the resident was interested in activities. Further review of the resident's medical record revealed no additional assessment involving the resident's family. Review of the resident's plan of care revealed no plan of care addressing the resident's activity deficit was developed. Review of resident's five day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had unclear speech, rarely/never understands others, rarely/never makes herself understood and had a severe cognitive deficit. Review of the mood and behavior section revealed she displayed indicators of depression and had both verbal and physical behaviors directed towards others. The resident required extensive assistance of two staff for bed mobility, personal hygiene and was dependent on two staff for transfers. On 11/15/19 01:30 P.M. interview with the Director of Nursing (DON) verified no activity plan of care had been developed for Resident #20. 2. Review of Resident #15's medical record revealed an admission date of 08/20/19 with the admitting diagnoses of anxiety, dementia and depression. Review of the resident's comprehensive MDS 3.0 assessment dated [DATE] revealed the resident had clear speech, usually understands others, makes himself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of one. Review of the mood and behavior section revealed the resident displayed indictors of depression and wandered on a daily basis. Review of the daily preferences revealed it was somewhat important to do his favorite activities. Review of the resident's plan of care revealed the resident had no plan of care addressing his activity deficit or preferences. On 11/14/19 at 1:57 P.M. with Activity Director #200 verified the resident did not have an activity plan of care. 3. Review of Resident # 17's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbance, senile dementia, major depression recurrent, anxiety disorder, macular degenerations, type two diabetes, femur fracture and peripheral vascular disease. Resident #17 resided on the secure care unit (SCU). Review of Resident #17's activity assessment, dated 07/07/15 revealed her past and present interests were card games, bingo, outdoors, television, music, religious, van outings, arts and crafts, reading, and discussion. Resident #17 wanted to walk and stay busy during the day. Record review revealed Resident #17 did not have a plan of care for activities. Review of Resident #17's annual MDS 3.0 assessment, dated 03/13/19 revealed her speech was clear she understands others, was understood and her cognition was severely impaired. Resident #17 had no behaviors, did not reject care, and wandered daily. Review of Resident # 17's activity interest revealed it was very important for her to have books/magazines, to listen to music, somewhat important for her to be around animals, not very important to keep up with the news, very important to do things with groups of people, to do favorite activities, to go outside, and somewhat important to participate in religious services. Resident # 17 was independent with no set up for bed mobility and to transfer. Review of Resident # 17's quarterly MDS 3.0 assessment, dated 09/02/19 revealed the resident no longer wandered. Interview with Activity Director (AD) #200 on 11/15/19 at 9:58 A.M. confirmed Resident #17 did not have an activity plan of care in place. 4. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included pneumonia, delusional disorder, glaucoma, essential hypertension, abnormal weight loss, dementia with behavioral disturbance, major depressive disorder, hypothyroidism and malignant neoplasm of female breast. Resident #21 resided on the SCU. Review of Resident #21's activity assessment dated [DATE] revealed her past and present interests were card games, bingo, sports, outdoors, music, religion, arts and crafts, gardening, parties, cooking, discussion and dancing. Resident #21 wanted to spend her day doing whatever she wanted. Record review revealed Resident #21 did not have an activity care plan. Review of Resident #21's admission MDS 3.0 assessment, dated 02/26/19 revealed her speech was clear, she understood, understands, and her cognition was severely impaired. Resident #21 had no behaviors, did not reject care and wandered one to three days. Review of Resident #21's activities interests revealed it was somewhat important for her to have books/magazine to read, to listen to music, be around pets, not very important to keep up on the news, somewhat important to do things in groups very important to do favorite activities, and to participate in religious services. Resident #21 required extensive assistance of two staff for bed mobility and to transfer. Review of Resident #21's quarterly MDS 3.0 assessment, dated 09/21/19 revealed the resident usually understands, was usually understood, she had verbal behaviors one to three days a week and was independent in bed mobility and to transfer. Interview with Activity Director (AD) #200 on 11/15/19 at 9:58 A.M. confirmed Resident #21 did not have an activity plan of care in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #15's medical record revealed an admission date of 08/20/19 with the admitting diagnoses of anxiety, dementia and depression. Review of the resident's admission activity assessment, dated 08/20/19 revealed the resident had clear speech, with his past a and present interests of television and reading noted. The resident was unable to complete the remainder of the form. The medical record did not contain an interview with the family to establish the resident's activity preferences. Review of the resident's comprehensive MDS 3.0 assessment dated [DATE] revealed the resident had clear speech, usually understands others, makes himself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of one. Review of the mood and behavior section revealed the resident displayed indictors of depression and wandered on a daily basis. Review of the daily preferences revealed it was somewhat important to do his favorite activities. Review of the resident's plan of care revealed the resident had no plan of care addressing his activity deficit or preferences. Review of the resident's activity log revealed of the 12 days in August 2019 he participated six days. In September 2019 of the 30 days he participated 12 days. In October 2019 of the 31 days he participated 20 days. In November 2019 of the 14 days he participated five days. On 11/13/19 at 10:34 A.M. observation of Resident #15 revealed the resident was sitting in a chair holding a cup of coffee, the resident finished the coffee and told the surveyor he was ready to go. He was not engaged in any type of activity. The unit had no active activities going on at that time. One staff member was sitting in a chair working on an electronic tablet. The television was on with a movie playing, but no residents were watching it. On 11/13/19 at 2:18 P.M. observation of Resident #15 revealed the resident was sitting in a chair in the dining room/activity room eating a cookie and drinking a cup of coffee. There were no staff present and no activities occurring. On 11/14/19 at 1:50 P.M. the resident was sitting in a recliner in the dining room with his eyes closed. On 11/14/19 at 3:00 P.M., observation revealed Activity Director (AD) #200 woke the resident who was sleeping in the recliner and gave him a newspaper to read. The resident accepted the paper and read it for approximately two minutes and then got up and began walking about the secure unit. On 11/15/19 at 8:17 A.M. observation of the resident revealed he was sitting at the dining room table with his eyes closed singing to himself. A State Tested Nursing Assistant (STNA) retrieved a bucket of plastic clips to make chains from the activity storage closet and approached Resident #39 and asked if she wanted to play with them. No attempts were made to include the other residents, including Resident #15 sitting in the dining room in the activity. On 11/15/19 at 1:30 P.M. interview with the Director of Nursing (DON) verified the secure care unit had little to no activities that met the resident's interests. 5. Review of Resident #20's medical record revealed an original admission date of 01/30/18 with the latest readmission of 10/11/19 with the re-admitting diagnoses of acute impacted left femoral intertrochanteric fracture, unspecified fracture of the lower end of the right femur, dementia, diabetes mellitus and anxiety. Review of the resident's admission activities assessment, dated 01/30/18 revealed the resident enjoyed exercises, outdoors, music, religious, arts & crafts and cooking. The assessment indicated the facility was unsure if the resident was interested in activities. Further review of the resident's medical record revealed no additional assessment involving the resident's family. Review of the resident's plan of care revealed no plan of care addressing the resident's activity deficit was in place. Review of resident's five day MDS 3.0 assessment, dated 10/18/19 revealed the resident had unclear speech, rarely/never understands others, rarely/never makes herself understood and had a severe cognitive deficit. Review of the mood and behavior section revealed she displayed indicators of depression and had both verbal and physical behaviors directed towards others. The resident required extensive assistance of two staff for bed mobility, personal hygiene and was dependent on two staff for transfers. Review of the resident's activity log revealed of the 27 days in August 2019 she participated in activities on seven days. In September 2019 of the 30 days she participated 19 days. In October 2019 of the 28 days she participated 16 days. In November 2019 of the 14 days he participated nine days. On 11/13/19 at 10:37 A.M. observation of Resident #20 revealed she was sitting in a geriatric chair with her feet elevated. The resident's eyes were closed but she was moaning periodically. There were no attempts made by staff to engage the resident in any type of activities. On 11/14/19 at 1:10 P.M. observation of the resident revealed she was sitting up in her geriatric chair with no staff interaction or activities observed. On 11/15/19 at 8:19 A.M. observation of Resident #20 revealed she was sitting up in her geriatric chair in the dining room. The activity person retrieved a bucket of plastic clips to make chains. She sat down at a table with three residents and began an activity. No attempt was made to involve the other residents, including Resident #20 in the dining area. On 11/15/19 at 1:30 P.M. interview with the Director of Nursing (DON) verified the secure care unit had little to no activities that met the resident's interests. Based on observation, record review and interview the facility failed to develop and implement a comprehensive activities program designed to meet the total care needs of all residents. This affected five residents (#15, #17, #20, #21 and #22) of nine sampled residents reviewed for activities. Findings Include: 1. Review of Resident # 17's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbance, senile dementia, major depression recurrent, anxiety disorder, macular degenerations, type two diabetes, and femur fracture, and peripheral vascular disease. Resident #17 resided on the secure care unit (SCU). Review of Resident #17's activities assessment, dated 07/07/15 revealed her past and present interests were card games, bingo, outdoors, television, music, religious, van outings, arts and crafts, reading, and discussion. Resident #17 wanted to walk and stay busy during the day. Record review revealed Resident #17 did not have a plan of care for activities. Review of Resident # 17's annual Minimum Data Set (MDS) 3.0 assessment, dated 03/13/19 revealed the resident's speech was clear, she understands, was understood and her cognition was severely impaired. Resident #17 had no behaviors, did not reject care, and wandered daily. Review of Resident #17's activity interest revealed it was very important for her to have books/magazines, to listen to music, somewhat important for her to be around animals, not very important to keep up with the news, very important to do things with groups of people, to do favorite activities, to go outside, and somewhat important to participate in religious services. Resident # 17 was independent with no set up for bed mobility and to transfer. Review of the Activity calendar revealed activities were provided on the SCU at 9:00 A.M., 11:00 A.M. and 3:00 P.M. The activities listed included balloon valley ball, bingo, corn hole, sing along, and manicures. Review of Resident #17's activity participation log for August 2019 revealed of the 31 days she participated in activities on 17 days. In September 2019 of the 30 days she participated in activities on 11 days. In October 2019 of the 31 days Resident #17 participated in activities 18 days. In November 2019 of the 14 days she participated in activities on four days. Observation of Resident #17 on 11/13/19 between 10:14 A.M. to 11:28 A.M. revealed until 11:00 A.M. she was in her room laying on her bed with no stimulation. No book/magazines were observed in Resident #17's room. Her television was not on and there was no music in her room. At 11:00 A.M. Resident #17 walked to the dining room and Activity Aide (AA) #142 asked Resident #17 if she wanted to play bingo. Resident #17 played bingo. AA#142 was not observed on the unit until 11:00 A.M. No books, magazines, or other types of activities were available. The activity closet was locked and not available to residents. Observation on 11/13/19 from 1:50 PM until 3:00 P.M. revealed the television was on but Resident #17 was not watching it, she was sitting in a chair in the dining room. At 2:40 P.M. Resident #17 went back to her room. At 2:54 P.M. AA #142 arrived on the unit and turned the radio on while the television was still on. AA #142 left both devices on. No books, magazines, or other types of activities were available. The activity closet was locked and not available to residents. Observation on 11/14/19 from 9:11 A.M. to 10:03 A.M. revealed Resident #17 was in her room with no activities and staff did not offer or encourage the resident to participate in any activities. No book/magazines were observed in Resident #17's room. Her television was not on and there was no music in her room. AA #142 was not observed on the unit. No books, magazines, or other types of activities were available. The activity closet was locked and not available to residents. Interview with AA #142 on 11/15/19 at 9:55 A.M. revealed Resident #17 was more with it than the other residents. AA #142 stated Resident #17 loved bingo otherwise she stayed her room. AA #142 stated she spends about four hours on the SCU as she had three activities daily and helped serve lunch. AA #142 stated she provided activities for the other two units in the facility as well. AA #142 stated residents on the SCU did not attend activities off the unit because there was too much stimulation for them. Interview with Activity Director (AD) #200 on 11/15/19 at 9:58 A.M. revealed SCU had their own activity calendar. The activities provided were more individualized addressing the things those residents liked. AD #200 stated the groups were smaller. AD #200 stated Resident #17 does not come out of her room much. On 11/15/19 at 1:30 P.M. interview with the Director of Nursing (DON) verified the secure care unit had little to no activities that met the resident's interests. 2. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included pneumonia, delusional disorder, glaucoma, essential hypertension, abnormal weight loss, dementia with behavioral disturbance, major depressive disorder, hypothyroidism and malignant neoplasm of female breast. Resident #21 resided on the SCU. Review of Resident #21's activity assessment, dated 02/19/19 revealed her past and present interests were card games, bingo, sports, outdoors, music, religion, arts and crafts, gardening, parties, cooking, discussion, and dancing. Resident #21 wanted to send her day doing whatever she wanted. Record review revealed Resident #21 did not have an activity care plan. Review of Resident #21's admission MDS 3.0 assessment, dated 02/26/19 revealed the resident's speech was clear, she understood, understands and her cognition was severely impaired, Resident #21 had no behaviors, did not reject care and wandered one to three days. Review of Resident #21's activities interests revealed it was somewhat important for her to have books/magazine to read, to listen to music, be around pets, not very important to keep up on the news, somewhat important to do things in groups very important to do favorite activities, and to participate in religious services. Resident #21 required extensive assistance of two staff for bed mobility and to transfer. Review of Resident #21's quarterly MDS 3.0 assessment, dated 09/21/19 revealed the resident usually understands, was usually understood, she had verbal behaviors one to three days a week and she was independent in bed mobility and to transfer. Review of the Activity calendar revealed activities were provided on the SCU at 9:00 A.M., 11:00 A.M. and 3:00 P.M. The activities listed included balloon valley ball, bingo, corn hole, sing along, and manicures. Review of Resident #21's activity participation log for August 2019 revealed of the 31 days she participated in activities on nine days. In September 2019 of the 30 days she participated 10 days. In October 2019 of the 31 days, Resident #21 participated in activities 10 days. In November 2019 of the 13 days she actively participated in activities on nine days. Observation of Resident #21 on 11/13/19 between 10:14 A.M. to 11:28 A.M. revealed until 11:00 A.M. she was sitting in a chair holding a baby doll asleep. At 11:00 A.M. AA #142 asked Resident #21 if she wanted to play bingo. Resident #21 sat at the bingo table and State Test Nursing Assistant (STNA) #128 placed chips on the bingo card as the resident just sat there. AA#142 was not observed on the unit until 11:00 A.M. No books, magazines, or other types of activities were available. The activity closet was locked and not available to residents. Observation on 11/13/19 from 1:50 PM until 3:00 P.M. revealed the television was on but Resident #21 was not watching it, she was sitting in a chair. At 2:54 P.M. AA #142 arrived on the unit and turned the radio on while the television was still on. AA #142 left both devices on and did not engage Resident #21. No books, magazines, or other types of activities were available. The activity closet was locked and not available to residents. Observation on 11/14/19 from 9:11 A.M. to 10:03 A.M. revealed Resident #21 was sleeping in a chair in the nurse's station, staff did not offer or encourage the resident to participate in any activities. No books, magazines, or other types of activities were available. The activity closet was locked and not available to residents. Interview with AA #142 on 11/15/19 at 9:55 A.M. revealed Resident #21 like her baby doll and she liked music and to dance. AA #126 stated Resident #21 would play bingo, but she could be very combative, so she had to be careful how she approached the resident. AA #126 stated Resident #21 could really beat on staff. AA #142 stated she spends about four hours on the SCU as she had three activities daily and helped serve lunch. AA #142 stated she provided activities for the other two units in the facility as well. AA #142 stated residents on the SCU did not attend activities off the unit because there was too much stimulation for them. Interview with AD #200 on 11/15/19 at 9:58 A.M. revealed SCU had their own activity calendar. The activities provided were more individualized addressing the things those residents liked. AD #200 stated the groups were smaller. AD #200 stated Resident #21 likes her baby dolls and to dance. On 11/15/19 at 1:30 P.M. interview with the Director of Nursing (DON) verified the secure care unit had little to no activities that met the resident's interests. 3. Review of Resident #22's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, anxiety disorder, insomnia, constipation, wandering, major depression, irritability, type two diabetes, essential hypertension, anemia and hypothyroidism. Review of Resident #22's activities assessment, dated 03/20/18 revealed the resident liked exercises, the outdoors, television, music, gardening, reading, and cooking. Resident #22 liked to spend her days outdoors. Review of Resident #22's annual MDS 3.0 assessment, dated 03/21/19 revealed the resident's speech was clear, she sometimes understands, sometimes understood, and her cognition was impaired. Resident #22 had physical behaviors, verbal behaviors, and rejected care one to three days. Resident #22's assessment for activities was conducted by interviewing staff. This assessment revealed Resident #22 liked reading books/magazines, listening to music, being around pets, doing things with groups of people, participating in favorite activities, and spending time outdoors. Resident #22 required limited assistance of two staff for bed mobility and was independent to transfer. Review of Resident #22's quarterly MDS 3.0 assessment, dated 09/21/19 revealed the resident had physical and verbal behaviors daily, and required supervision of one staff for bed mobility. Review of Resident #22's activities plan of care, dated 11/14/19 revealed she did not participate in structured activities and she would have meaningful visits or show interest in activities two times a week. Review of the Activity calendar revealed activities were provided on the SCU at 9:00 A.M., 11:00 A.M. and 3:00 P.M. The activities listed included balloon valley ball, bingo, corn hole, sing along, and manicures. Review of Resident #22's activity participation log for August 2019 revealed of the 31 days she participated in activities on 19 days. In September 2019 of the 30 days she participated 12 days. In October 2019 of the 31 days Resident #21 participated in activities 19 days. In November 2019 of the 14 days she actively participated four days. Observation of Resident #22 on 11/13/19 between 10:14 A.M. to 11:28 A.M. revealed she was wandering without purpose on the SCU. At 11:00 A.M. AA #142 was observed playing bingo with three residents. AA#142 was not observed on the unit until 11:00 A.M. No books, magazines, or other types of activities were available. The activity closet was locked and not available to residents. Observation on 11/13/19 from 1:50 PM until 3:00 P.M. revealed the television was on but Resident #22 was not engaged in activities and she was wandering without purpose on and off. At 2:54 P.M. AA #142 arrived on the unit and turned the radio on while the television was still on. AA #142 left both devices on and did not engage Resident #22. No books, magazines, or other types of activities were available. The activity closet was locked and not available to residents. Observation on 11/14/19 from 9:11 A.M. to 10:03 A.M. revealed Resident #22 was not engaged in activities and she was wandering without purpose on and off. No books, magazines, or other types of activities were available. The activity closet was locked and not available to residents. Interview with AA #142 on 11/15/19 at 9:55 A.M. revealed Resident #22 mostly wandered and she was difficult to get involved in activities. AA #142 stated Resident #22 could be very combative, so she had to be careful how she approached the resident. AA #142 stated Resident #22 could really beat on staff. AA #142 stated she spends about four hours on the SCU as she had three activities daily and helped serve lunch. AA #142 stated she provided activities for the other two units in the facility as well. AA #142 stated residents on the SCU did not attend activities off the unit because there was too much stimulation for them. Interview with AD #200 on 11/15/19 at 9:58 A.M. revealed SCU had their own calendar. The activities provided were more individualized addressing the things those residents liked. AD #200 stated the groups were smaller. AD #200 stated Resident #22 liked to garden. She confirmed there was no gardening activities for Resident #22. On 11/15/19 at 1:30 P.M. interview with the Director of Nursing (DON) verified the secure care unit had little to no activities that met the resident's interests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #197's medical record revealed an admission date of 11/01/19 with diagnoses of dementia without behavioral disturbances, muscle weakness and anxiety. Review of Resident #197's physician's orders revealed an order, dated 11/02/19 for the antipsychotic medication, Haloperidol 0.5 milligrams (mg) 1 tablet by mouth every two hours as needed for anxiety with no stop dated noted. Review of Resident #197's plan of care, dated 11/04/19 revealed impaired cognitive function/dementia or impaired thought process related to dementia. Review of Resident #197's admission MDS 3.0 assessment, dated 11/12/19 revealed the resident required extensive assistance for bed mobility, dressing, toilet use, and transfers with two staff member assistance. Review of Resident #197's Medication Administration Record (MAR) for 11/2019 revealed resident received Haloperidol 0.5 mg on 11/12/19 at 8:19 P.M., on 11/10/19 at 8:43 P.M. and again on 11/08/19 at 8:20 P.M. for anxiety. Review of the behavior log for Resident #197 revealed a documented behavior of yelling and screaming on 11/09/19 only. Review of the behavior log for 11/12/19, 11/10/19, and 11/08/19 revealed no evidence of any behaviors which would indicate the use of the as needed Haloperidol. Observation on 11/12/19, 11/13/19, 11/14/19, and 11/15/19 between 9:00 A.M. and 5:00 P.M. of Resident #197 revealed the resident was not exhibiting any type of behaviors. Interview on 11/13/19 at 4:10 P.M. with Assistant Director of Nursing (ADON) #154 revealed the resident was prescribed Haloperidol for an inappropriate diagnoses, was prescribed the medication for longer than 14 days and was administered the medication without proper indication or documentation of behaviors. Based on observation, record review and interview the facility failed to ensure residents had adequate indication for the use of psychotropic medications and/or failed to ensure the justified use of an as needed (PRN) antipsychotic medication for greater than 14 days. This affected four residents (#21, #22, #31 and #197) of five residents reviewed for unnecessary medication use. Findings Include: 1. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included pneumonia, delusional disorder, glaucoma, essential hypertension, abnormal weight loss, dementia with behavioral disturbance, major depressive disorder, hypothyroidism and malignant neoplasm of female breast. Review of Resident #21's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident's speech was clear, she understood, understands, and her cognition was severely impaired. Resident #21 had minimal depression, no indicators of psychosis, no behaviors, did not reject care and wandered one to three days. Resident #21 received an antipsychotic medication and antidepressant medications daily. Review of Resident #21's plan of care, dated 04/15/19 revealed she had behavior problems of resistance to care and combativeness related to dementia. The care plan revealed Resident #21's daughter would confer with Resident #21's neurologist regarding behavior medications for suggestions. Resident #21 received Seroquel for behaviors. Review of Resident #21's quarterly MDS 3.0 assessment, dated 09/21/19 revealed the resident usually understands, usually understood, she had verbal behaviors one to three days a week and was independent in bed mobility and to transfer. Review of Resident #21's November 2019 physician's orders revealed an order for the antipsychotic medication, Seroquel 25 milligrams (mg) twice daily for dementia with behaviors. Resident #21 had target behaviors of hitting/kicking, spitting, and refusal of care. There was no evidence Resident #21 displayed symptoms to justify the use of the Seroquel. Interview with State Tested Nursing Assistant (STNA) #185 on 11/13/19 at 2:56 P.M. revealed Resident #21 would bite, spit, holler and was combative with care. STNA #185 stated Resident #21 did not hallucinate or have delusions. Interview with the Director of Nursing (DON) on 11/13/19 at 3:22 P.M. revealed the facility did not obtain documentation from Resident #21's neurologist, they just sent them changes in the medications. The DON confirmed there was no evidence to support the use of the Seroquel. 2. Review of Resident #22's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, anxiety disorder, insomnia, constipation, wandering, major depression, irritability, type two diabetes, essential hypertension, anemia and hypothyroidism. Review of Resident #22's plan of care, dated 03/19/19 revealed the resident had behavior problems of hitting self, striking out at others, exit seeking, throwing objects and placing herself on the floor. The care plan revealed the resident received Seroquel, Ativan and Zoloft for these behaviors. Review of Resident #22's annual MDS 3.0 assessment, dated 03/21/19 revealed the resident's speech was clear, she sometimes understands, sometimes understood, and her cognition was severely impaired. Resident #22 had minimal depression, no indicators of psychosis, had physical behaviors, and verbal one to three days, that did not significantly impact the resident or others, rejected care one to three days and did not wander. Resident #22 received an antipsychotic medication, an antianxiety medication, and an antidepressant medication daily. Review of Resident #22's quarterly MDS 3.0 assessment, dated 09/21/19 revealed the resident had physical and verbal behaviors daily, rejected care one to three days and wandered one to three days. Review of Resident #22's November 2019 physician's orders revealed she had an order for Seroquel 50 mg twice daily related to irritability and anger, an order for the antianxiety medication, Ativan 0.5 mg for anxiety and an order for the antidepressant medication, Zoloft 50 mg daily for major depression. Resident #22's target behaviors were urinating on the floor and bowel movements in the sink, hitting, throwing objects, yelling, placing self on floor, beating doors, and exit seeking and attempting to or causing harm to herself or others. Review of Resident #22's behavior tracking revealed she had no targeted behaviors in October 2019. From 11/01/19 to 11/14/19 the resident displayed two episodes of attempting to cause harm to herself or others and three episodes of anxiety. There was no evidence Resident #22 expressed symptoms to justify the use of the Seroquel. Interview with STNA #185 on 11/13/19 at 10:52 A.M. revealed Resident #22's behaviors included fiddling with things. The STNA stated she takes the stop sign off other resident's doors and could be combative with care. Interview with the DON on 11/14/19 at 3:29 P.M. confirmed there was no evidence to support the use of Seroquel for Resident #22. 3. Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, anorexia, mood disorder, hyperlipidemia, bradycardia, heart failure, osteoarthritis, essential hypertension, hypocalcemia, anemia and falls. Review of Resident #31's admission MDS 3.0 assessment, dated 02/14/19 revealed the resident's speech was clear, he usually understands, usually understood, his cognition was severely impaired, and he had minimal depression. Resident #31 had no indicators of psychosis, no behaviors, did not reject care and wandered daily. Resident #31 received a daily antipsychotic medication and one day of an antidepressant. Review of Resident #31's quarterly MDS 3.0 assessment, dated 10/03/19 revealed the resident sometimes understands others, had physical behaviors one to three days and rejected care four to six days. The assessment revealed Resident #31 received an antidepressant medication daily. Review of Resident #31's physician's orders for November 2019 revealed the resident had an order for the antipsychotic medication, Seroquel 25 mg twice daily and Seroquel 12.5 mg daily for mood disorder, and an order for the antidepressant medication, Trazadone 50 mg daily for anxiety. Resident #31 had target behaviors of elopement, threats or attempts of hitting staff during care, yelling out, and cursing. Review of Resident #31's current plan of care revealed Resident #31 received Seroquel for behaviors. Review of Resident #31's behavior grids revealed in October 2019 revealed the resident had one episode of attempted elopement and one episode of putting himself on the floor. From 11/01/19 to 11/13/19 the resident had no documented behaviors. Interview with STNA #159 on 11/14/19 at 10:41 A.M. revealed Resident #31 had behaviors in the past but no longer exhibited any behaviors. She stated Resident #31 had no delusions or hallucinations. Interview with Registered Nurse (RN) #150 on 11/14/19 at 11:27 A.M. revealed Resident #31 had no behaviors and no delusions or hallucinations. Interview with the DON on 11/15/19 at 9:06 A.M. revealed Resident #31 did not express behaviors that justified the use of Seroquel.