**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's Brief Interview for Mental Status (BIMS) for one of 24 sampled residents (Resident (R) 51). The failure placed the resident at possible unmet needs. Findings include: Review of R51's undated admission Record, located in the resident electronic medical record (EMR) under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] with a diagnosis that included, chronic obstructive pulmonary disease with (acute) exacerbation, major depressive disorder, single episode, moderate and anxiety disorder, unspecified. Review of R51's quarterly MDS with an Assessment Reference Date (ARD) of 05/12/24 located in the resident's EMR under the MDS tab, revealed the BIMS score of 13 out of 15, indicating cognitively intact. An annual MDS with an ARD of 07/29/24 revealed a BIMS score of 00 out of 15, which indicated severely impaired cognition A quarterly MDS with an ARD of 10/23/24 revealed a BIMS score of 15 out of 15, which indicated intact cognition. A quarterly MDS with an ARD of 01/17/25 revealed a BIMS score of 00 out of 15, which indicated severely impaired cognition. A quarterly MDS with an ARD of 04/14/25 revealed a BIMS score of 15 out of 15, which indicated R51 was cognitively intact. During an interview on 04/28/25 at 6:09 PM with the Minimum Data Set Coordinator (MDSC), about the accuracy of R51's BIMS, the MDSC was unable to give any rationale for why the scores were so different. During an interview on 04/28/25 at 6:28 PM at the Administrator, verified that the BIMS scores of R51 were incorrect. The Administrator stated that the Social Service Director (SSD), who completes the BIMS score, was not coding 1x, which would capture the refusal to answer instead of unable to answer. During an interview on 04/29/25 at 3:39 PM, the SSD stated I was doing the score incorrectly when the resident refused to respond. I have been in-service on the appropriate way to document the refusal. R51 at times would refuse to answer questions for the assessment, and I would make a 0 instead of a 1x that would capture refusal instead of being unable to answer.

Based upon observations and interviews, the facility failed to post the daily staffing report in a prominent place accessible to all residents and visitors. This failure had the potential for residents, family, friends, or other visitors to not know the ratio of nursing staff to residents, causing uncertainty of the ability and availability of the staff for residents' needs. Findings include: Observations on 04/28/25 at 9:56 AM and at 12:46 PM of the facility revealed no staffing report posted in the facility. Interview on 04/28/25 at 4:18 PM with the Administrator regarding the staffing posting, the Administrator took this surveyor to an area that was the employee entrance only. At the entrance, there was a bulletin board with announcements for staff. On that board was the staffing posting. The Administrator acknowledged that the staffing posting was not visible to the resident's family, friends, or other visitors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure one of four residents reviewed for behaviors (Resident (R)32) received appropriate treatment and services for his diagnosis of serious mental illnesses and for his behaviors out of a total sample of 27 residents. This failure increased the risk of psychosocial harm and/or physical harm from other residents to R32 and increased the risk of psychosocial harm to the residents coping with R32's behaviors. Findings include: Review of the electronic medical records (EMR), Face Sheet tab, indicated R32 was admitted to the facility on [DATE] with diagnosis including but not limited to unspecified intellectual disabilities, Schizophrenia with behavioral disturbances and hallucinations, and psychotic and combative behaviors. Review of the EMR, Documents tab revealed hospital referral documents, dated 09/26/23, that indicated R32 had a history of seizure disorder and intellectual disability and presented to the hospital emergency room with altered mental status, intellectual delay, and confusion. Review of R32's EMR, admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/29/23, revealed a zero of 15 score on his Brief Interview for Mental Status (BIMS) assessment that indicated severe cognitive impairment. Further review of the MDS revealed R32 was at risk for decline of psychosocial well-being. The care plan Care Area Assessment (CAA) document located in the EMR, MDS tab, dated 09/29/23, stated consideration was made for R32's psychosocial well-being but a care plan for psychosocial well-being was declined with the rationale that R32 was always up and out of his room. The MDS documented the seriousness of his behavioral symptoms and that R32 is an immediate threat to self-due to his long-standing mental health problem associated with the behavioral disturbances of schizophrenia, bipolar disorder, depression, and anxiety disorder. Factors identified in the MDS to exacerbate his behaviors included alarm use. The MDS identified R32 was at risk for elopement and behaviors. R32 had a wander guard device on his right wrist that activated an alarm each time he approached an exit door of the facility. The MDS CAA analysis of findings documented for activities indicated R32 had been involved in several group activities and was ambulatory throughout the facility but did not identify his specific activity interest or structured activities specific to his needs, as required. Review of R32's EMR, Documents tab, revealed a Pre-admission Screening and Resident Review (PASARR) Level II South Carolina Intellectual Disability Authority Determination, dated 01/19/24, that R32 did not have an Intellectual Disability (ID) as defined under the current Pre-admission Screening and Resident Review (PASARR) regulation. The document indicated, based on R32's psychiatric diagnosis, that the nursing facility was required to contact the South Carolina Mental Health Authority to conduct a review of R32's Level II PASARR. Review of R32's EMR, Documents tab, revealed a document titled Level II State Mental Health Authority Determination, dated 09/11/24, that determined R32's needs could be met in a nursing facility with specific psychiatric/mental services required for structured socialization activities, psychotherapy, crisis intervention services, development and training of necessary daily living skills and development of personal support networks. The document also stated that the nursing facility rehabilitation services were less intensive than specialized services that must be provided or arranged for by the nursing facility through a Mental Health Facility/Center named Coastal Empire. The facility could not provide documentation that specialized services were provided to R32. During an interview with the facility Administrator on 04/29/25 at 1:00 PM, he indicated he was not aware of the mental health services required for R32 as stipulated in the South Carolina Mental Health Authority review. Review of R32's EMR, MDS tab, quarterly MDS with an ARD of 02/27/25 revealed R32 required a wander/elopement alarm that monitors resident movement and alerts the staff when movement to elope is detected. R32 takes antipsychotics on a routine basis and that a GDR (Gradual Dose Reduction) had not been attempted. Documentation indicated R32's diagnoses included seizure disorder, psychotic disorder (other than schizophrenia), Schizophrenia, metabolic encephalopathy, parkinsonism, and unspecified intellectual disabilities. Documented behavioral symptoms not directed at others included pacing, rummaging, public disrobing, smearing bodily wastes, and verbal/vocal symptoms like screaming, and disruptive sounds occurred daily. Documented was no evidence of an acute change in mental status from R32's baseline and that his inattention, disorganized thinking, and altered level of consciousness was present and fluctuated in severity. A BIMS was conducted and concluded with a summary score of 00 out of 15 indicating severe cognitive impairment. Review of the EMR, MDS tab revealed a Care Plan, dated 03/09/25, for behavioral symptoms of hallucinations related to psychosis, the care plan goal stated R32: will not harm self or others secondary to hallucinations with interventions to include administering medications as ordered, and to evaluate/record/report effectiveness and any adverse side effects. Also documented intervention was to communicate with R32's provider to determine the need for hospitalization and to determine if hallucinations pose danger to R32 or others. Also documented as an approach/intervention stated do not confront, argue against, or deny R32's hallucination, and to keep distance between R32 and others during hallucinations, and to encourage resident to discuss feelings, impulses, and hallucinations to validate reality. The Care Plan also documented R32 has a risk for impaired verbal communication related to disordered thinking secondary to schizophrenic disorder as evidenced by inappropriate speech. The care plan for R32's behavioral symptoms problem documented the following: presents with behavioral symptoms, wanders unsafely, refuses medication at times, shows aggression in attempts to knock medication from nurse hand, refuses ADL care at times, consistently ask and look for cigarettes and snacks, spits/urinates/defecates on floor, pushes/hits staff, attempts to bite staff, wanders in other resident rooms and takes their food/turns the lights on in other resident rooms and shakes them, sleeps in empty beds other than his own, he is difficult to redirect and is at risk for behaviors towards others. Interventions documented in his care plan included educate R32 on appropriate behavior and importance of keeping hands to self and to intervene/redirect as needed to protect the rights and safety of others, approach in a calm manner, divert attention, remove from situation, and take to another location as needed. Review of the EMR, Orders tab, revealed physician orders for R32 included a monthly injection of 2.5 mg Haldol decanoate, and 7.5 mg injection of Risperdal every two weeks. Review of the Medication Administration Report (MAR) for the month of March and April 2025, revealed the following refusals by R32: R32's order for Valproic acid solution for Schizophrenia 10 ml oral three times each day was refused 63 times of 90 scheduled to be administered. R32 also refused valproic acid solution 10 mg three times each day 82 times of 90 scheduled doses for April 2025. R32 refused all benztropine (used to treat abnormal body movements caused by antipsychotic medications) tabs 2 mg for the entire month of March 2025 and April 2025. R32's lactulose 30 mg one time each day for metabolic encephalopathy was refused for the entire month of March and April 2025. R32 refused all levetiracetam (to treat seizures)10 mg every 12 hours for epilepsy for the month of March and April 2025. Review of R32's EMR, Progress Notes tab, nursing progress notes documented R32 was discharged to the hospital five times in the previous 120 days related to his mental health diagnoses. Progress notes indicated hospital discharges related to R32's mental health occurred on 01/01/25, 02/08/25, 02/20/25, 04/21/25, and 04/26/25. R32 returned to the facility less than 24 hours after each discharge. The progress notes also documented two room changes related to his mental health behaviors that occurred on 03/31/25 and 04/18/25. During an interview with Licensed Practical Nurse (LPN)2 on 04/28/25 at 11:38 AM, she stated R32 consistently wandered in and out of other resident rooms where he urinates and defecates on the floor multiple times each day. She also stated R32 also urinates and defecates on the floor in many other areas of the nursing facility including the hallways and the dining room. LPN2 said R32 was not easily redirected and displayed combative behaviors when an attempt was made to redirect him from unsafe wandering and wandering into other resident rooms. LPN2 stated R32 constantly removed food from other residents' rooms, from staff lunch bags, and from resident food trays during meal service. She stated that R32 wandered independently without one-to-one supervision. Review of R32's EMR, Progress Notes tab, nursing progress notes, revealed R32 wandered around disrobing inappropriately, urinating and defecating on the floor throughout the facility and in other resident rooms, taking other residents' belongings, removing food from resident rooms and from meal trays during meal service, and attempting to bite staff upon redirection, on 04/12/25, 03/17/25, 03/13/25, 01/30/25, 01/25/25 , 01/07/25, 12/31/24, 12/24/24, 12/18/24, 12/17/24, 12/16/24, 12/13/24, 12/11/24, 12/10/24, 12/02/24, 11/30/24, 11/27/24, 11/16/24, and 11/01/24. Observation of R32 on 04/27/25 at 7:30 AM identified R32 was sleeping in his bed and appeared clean and dry with no evidence of discomfort. Observation of R32 on 04/28/25 at 11:00 AM identified R32 sitting in the activity room with a staff member with his head lying on the table with staff member stroking his back. R32 did not respond to verbal interaction. Observation of R32 on 04/28/25 at 4:00 PM identified R32 sitting in the activity room with a staff member with his head lying on the table with a staff member stroking his back. R32 did not respond to verbal interaction. R32 was discharged to the hospital on [DATE] at 9:00 PM and was not present in the facility for additional observations during the survey. During a resident council meeting conducted by a surveyor on 04/28/25 at 2:30 PM, R69 reported that R32 came into her room a few weeks ago during the night and turned the light on and asked her for a cookie. R3 stated R32 has come into his room, put his hand on his face, and woke him up during the night. R27 stated the facility usually has two certified nurse aides at night and they just can't keep up with him, and that [R32] urinates and defecates anywhere he wants and has gotten outside a couple of time by pushing his way through the door.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain a comprehensive Facility Assessment that adequately addressed the care needs of residents with serious mental illness. Per the 2025 Facility Assessment review, the facility did not properly evaluate or establish the necessary care protocols, services, and staff competency requirements essential for managing residents with serious mental health conditions. This failure to assess and provide the resources needed for resident care, including mental health services, based on their acuity levels and diagnoses, had the potential to impact all 79 current residents. Findings include: Review of the electronic medical record (EMR) Face Sheet tab revealed R32 was admitted to the facility on [DATE] with a diagnosis, which included unspecified intellectual disabilities, Schizophrenia with behavioral disturbances and hallucinations, and psychotic and combative behavior. Review of R32's referral documents dated 09/26/23, in the resident's EMR from the hospital discharge summary to the facility, indicated R32 had a history for seizure disorder and intellectual disability who presented to the hospital emergency room with altered mental status, intellectual delay, and confusion. A review of R32's EMR Minimum Data Set (MDS) with an Assessment Reference Date of 09/06/24 assessment revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment. During an interview on 04/29/25 at 10:27 AM with the Administrator and Senior Nurse Consultant (SNC), it was indicated that the Facility Assessment captured the facility for the periods of 08/01/23 through 07/31/24. R32 was admitted to the facility on [DATE]. The SNC confirmed that the FA would have captured 11 months of the resident in the facility. While the report stated that the facility can accommodate patients with psychiatric conditions and mood disorders, it failed to address their ability to manage residents with more severe mental illnesses and behaviors, such as those exhibited by R32. Cross Reference: F742 Treatment and Services for Mental and Psychosocial Concerns.

Based on record review and interviews, the facility failed to ensure Resident (R)54 with decisional capacity to make his own health care decisions was afforded the right to formulate an advance directive for 1 of 1 residents reviewed for Advance Directives. Findings include: The facility did not provide the policy for Advance Directives. The facility admitted R54 with diagnoses including, but not limited to, end stage renal disease, falls, hypertension and glaucoma. Review of the Minimum Data Set (MDS) assessment dated at the time of admission revealed a Brief Interview for Mental Status (BIMS) is score of 15 out of 15, indicating R54 was cognitively intact. Record review on 09/19/23 at 11:42 AM revealed a form titled, Decisional Capacity, dated 04/05/2023. The physician checked the box which states, This resident DOES have the capacity to make healthcare decisions for self. Further review of the medical record on 09/19/23 at 11:42 AM revealed a form titled, Intro to Admission. The form identified an admission to another facility, in another town, and was signed by the family member for R54. The form did not mention the current facility that R54 is a resident of and the representative's relation to R54 is unknown. The section titled, Patient/Resident Signature (to be signed by Patient/Resident only), was not signed by R54. During an interview on 09/19/23 at 11:55 AM with Social Services, she provided the document of Intro to Admission, and stated that the consent for the family member to sign was verbal. During an interview on 09/19/23 at 1:42 PM, the Director of Nursing stated the consent was verbal and went on to say that the resident may have been too sick to sign the form at the time of admission.

Based on review of facility policy, record review, and interviews, the facility failed to ensure Resident (R)54 and her representative received notice of transfer or discharge in writing and in a language they could understand, and the reason for transfer, for 1 of 5 residents reviewed for hospitalization. Findings include: Review of the facility policy titled, Involuntary Transfers and Discharges, revealed under section III, Required Notice Before Involuntary Transfer or Discharge, Number 1 states, The healthcare center must provide notice to the patient, guardian, or representative, and the patient's physician in writing and language that they understand. The facility must keep a copy of the notice in the medical record. The facility admitted R54 with diagnoses including, but not limited to, endstage renal disease, congestive heart failure, atrial fibrillation, acute myocardial infarction, depression and anxiety. Review of R54's medical record on 09/18/23 at 11:42 AM, revealed a form titled, SNF/NF to Hospital Transfer Form filled out, but no documentation to ensure R54 or R54's representative received a copy of the form. Further review of the form revealed, no signatures or indication that the reason for transfer was explained to the resident or the representative. There is no signature as to who filled out the form, or who received a copy of the form. Further review of the medical record for R54 revealed an additional hospital transfer on 05/29/23, with no signature as to who filled out the form, or who received a copy of the form. During an interview on 09/18/23 at 12:20 PM with the Director of Nursing (DON) stated that he would have to check for additional information. The DON provided no further information concerning the hospitalization for R54.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure a quarterly, Minimum Data Set (MDS) assessment for Resident (R)54 was coded correctly for dialysis for 1 of 1 residents reviewed for Dialysis. Findings include: The facility admitted R54 with diagnoses including, but not limited to, diabetes mellitus type 2, gastroparesis and end stage renal disease. R54 is dependent on hemodialysis and is scheduled for it on Mondays, Wednesdays, and Fridays. Review on 09/18/2023 at 11:30 AM of the quarterly MDS dated [DATE] revealed section O for special treatments, procedures and programs was not coded for dialysis for R54. During an interview on 09/18/2023 at 11:45 AM with Licensed Practical Nurse (LPN)6 reviewed and confirmed that dialysis was not coded on the quarterly MDS.

Based on interviews and record reviews, the facility failed to ensure that Resident (R)41 had an accurate level-1 Preadmission Screening and Resident Review (PASARR) assessment for 1 of 3 residents reviewed for PASARR. Findings include: In an interview on 09/20/23 at 10:00 AM, the Director of Health Services (DHS) stated that the facility did not have a policy for assuring PASSARs are completed accurately. The DHS stated that they follow state regulations and he expects PASSARs to be completed correctly and accurately. The DHS further stated that the documents should be done prior to the resident coming into the facility and that Social Services is responsible for the accuracy of the PASSARs and making sure that all diagnosis and major mental illnesses are listed on the PASSAR once the resident is in the facility. A review of R41s Face sheet indicated the facility admitted R41 with a diagnosis that included schizoaffective disorder, bipolar type upon admission. A Review of R41's admission Minimum Data Set (MDS), with an Assessment Reference Date of 07/09/21, revealed R41 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R 41 had moderate cognitive impairment. Further review of the MDS revealed R41 had an active diagnosis of Schizophrenia. A review of R41's Medical Record indicated a diagnosis of schizoaffective disorder, dated 07/03/21. A review of R41's Level-1 PASARR dated 07/02/21, indicated R41 did not have a mental illness. Psychotropic Drugs Prescribed to the resident, listed on the Level-1 PASSAR included Restoril 30 milligrams (mg) by mouth (PO) at bedtime and Xanax .5mg every (Q) 8 hours. During an interview on 09/20/23 at 10:08 AM, Social Services stated that the admissions director should make sure that the PASSAR are completed and accurate. She stated that she is not trained to do PASSARs yet, therefore she is unable to touch PASSARs. She stated that she was unaware of R41's PASSAR not being updated with a mental illness of Schizophrenia upon admission. She stated that a possible outcome if the PASSAR is not completed correctly is that the resident will not receive the correct care. She stated that she expects the PASSARs to be completed correctly and the resident to be treated correctly. During an interview on 09/20/23 at 11:07 AM, the MDS Coordinator stated that she does not update the PASSAR. She stated that she looks to see if they have one. She stated that she does reports in the morning meetings if one is missing. She stated that she was not aware of R41's mental illness upon admission. During an interview on 09/20/23 at 12:04 PM, the Administrator stated that he expected PASSARs to be completed and accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, interviews and review of the medical literature in Facts and Comparisons, Epocrates and Drugs.com, the facility failed to ensure Resident (R)67 did not have multiple drug therapies that could cause central nervous system depression for 1 of 6 residents reviewed for unnecessary medications. Findings include: Review of R67's Face Sheet revealed R67 was admitted to the facility on [DATE] with diagnoses including but not limited to schizophrenia and dementia. A review of R67's physician orders by the Medical Director (MD) revealed the following orders: Trazodone (an antidepressant) 50 mg (milligram) at bedtime prescribed 01/19/23 open ended (no end date) for insomnia. Melatonin 3 mg x2 at bedtime prescribed 01/24/23 open ended for insomnia. Hydrocodone - acetaminophen 5-325 mg twice daily PRN (as needed) prescribed 02/10/23 open ended for pain, do not exceed 2 per day. Memantine 10 mg twice daily prescribed 04/04/23 open ended for dementia. Seroquel (quetiapine 400 mg) twice daily prescribed 08/03/23 open ended for vascular dementia with behavioral disturbance/Schizophrenia. Rexulti (brexpiprazole) 1 mg once daily prescribed 08/11/23, open ended for Schizophrenia. Depakote (divalproex) Sprinkles 250 mg once daily and 125 mg at bedtime both prescribed 08/14/23 open ended for Mood. Further review of the physician orders failed to find an order for monitoring of vital signs. A review of R67's progress notes dated 03/21/23 at 7:50 PM revealed, resident was in an altercation resident found aggressive toward her roommate. resident did not sustained any injury. A review of R67's progress notes revealed Psychiatry/LifeSource notes were being entered into the medical record progress notes 2-15 days after the date of the visit as follows: -Psychotherapy Comprehensive Clinical Assessment performed on 04/07/23 and R67 found not to be appropriate for CBT (cognitive behavioral therapy) due to her cognitive decline and inability to hold a conversation and entered into the medical record (EITMR) on 04/13/23. -04/20/23 LifeSource Service(s): Discharge Summary which stated A comprehensive psychological assessment of the resident took place on April 7, 2023. The final treatment plan was dated and patient was last seen on April 7, 2023. Discontinue psychotherapy services only . EITMR 04/25/23 -04/24/23 Psychiatry Initial Visit with recommendations/plan to Start Depakote 20 mg po QHS (at bedtime), EITMR 04/26/23 -06/19/23 with recommendation/plan, Patient continues to exhibit behaviors as documented in HPI (history of present illness) section; recommend increasing Depakote to 250 mg po BID x 3 days, then Dose should be Depakote 250mg po qd and Depakote 500 mg po QHS. Increase seroquel to 400 mg po BID (twice daily) (max dose is 800 mg a day), EITMR 07/05/23 -07/31/23 with recommendations/Plan Start rexulti 0.5 mg po x 7 days then increase to 1 mg po daily., EITMT 08/14/23 and -08/31/23 with no recommended changes to current dose of medication. EITMR 9/7/23 During an observation on 09/17/23 at approximately 11:18 PM and 12:15 PM, R67 was in room with door open laying on the bed, bed in a low position. R67 was wrapped in sheet/blanket, laying in the fetal position near foot of bed. R67 had no response to questions and only made an occasional sound. There were no staff members noted on that hall. During an observation on 09/18/23 at approximately 9:26 AM, 10:35 AM, 1:32 PM and 3:44 PM, R67 was in room with door open, laying at foot of the low bed next to door. R67 was wrapped in a sheet, laying in the fetal position, making no sound. During an interview on 09/18/23 at approximately 1:41 PM, Certified Nursing Assistant (CNA)6 stated R67 seems to lie in that position most of the time. During an observation on 09/19/23 at approximately 10:35 AM, 11:26 AM and 1:27 PM, R67 was in with door partially closed, laying on foot of low bed next to door. R67 was wrapped in a sheet, laying in the fetal position, making an occasional sound. During an interview on 09/19/23 at approximately 2:06 PM, CNA 5 stated R67 had been in bed all day, but had eaten a hearty lunch. On 09/18/23 at approximately 3:10 PM a review of the Facts and Comparisons, Epocrates and Drug.com medical literature revealed potential moderate drug interactions between trazodone, divalproex, melatonin, quetiapine, brexpiprazole due to central nervous system depressant effects which may be additively or synergistically be increased in patients taking multiple drug that cause these effect, especially in elderly or debilitated patients. Sedation and impairment of attention, judgement, thinking, and psychomotor skills may increase. Vital signs (blood pressure, orthostatics, temperature and pulse) for brexpiprazole should be monitored during first 3-4 weeks of treatmenrt and every 4 weeks after dose change. Monitor blood pressure due to combination which may increase risk of CNS depression, psychomotor impairment, hyperthermia, hypotension, including orthostasis, syncope. During observations on 09/17/23 - 09/19/23, R67 was in bed and not involved in activities. Review of R67's progress notes dated May 2023 - September 2023 revealed R67 frequently charted as sleeping in bed and failed to show R67 being involved in any activities. A review of R67's January 2023 - September 2023 progress notes revealed the Consultant Pharmacist had stated Medication regimen reviewed for problems an/or irregularities, Recommendation made. on 01/30/23, 02/20/23, 03/29/23, 04/16/23, 05/16/23, 06/21/23, 07/22/23, 08/6/23 and 09/15/23. Further review of the progress notes revealed an entry dated 08/16/23 related to CMS-F757: Duplicate Antipsychotic Drugs which stated This patient is currently receiving duplicate antipsychotic drugs Quetiapine 400mg (milligram) BID (twice daily) and Brexpiprazole 1mg QD (daily). The typical treatment pathway is to maximize the dose of a single agent prior to adding a second drug. Consider tapering to D/C (discontinue) Brexpiprazole and may increase the Quetiapine if needed. The recommendation further included specific recommendations for action. During an interview on 09/19/23 at approximately 2:22 PM, the Medical Director (MD) called and stated that the resident is being seen by a psychiatric service and the facility places the orders for psychotherapeutic agents made by the psychiatric service under his name. The MD did not recall seeing pharmacist recommendations made on 08/16/23 related to duplicate antipsychotic drugs Seroquel and Rexulti for R67 and was unaware of a need for blood pressure monitoring. During an interview on 09/19/23 at approximately 3:40 PM, the DON stated that pharmacist recommendations come to him and the nursing staff sends them to the prescribing physician if he hasn't picked them up, but was otherwise unclear as to the process as it related to Licensure orders for medications. The DON was unaware of a pharmacist recommendation made on 08/16/23 related to duplication of therapy related to two antipsychotic drugs (Seroquel and Rexulti) for R67 and was unaware that LifeSource orders for Seroquel and Rexulti had been faxed to the pharmacy with the MD as the prescriber, not LifeSource. The DON stated that the MD defers to LifeSource when it comes to prescribing psychiatric medications. The DON further stated he would provide a copy of policy and procedures related to, 1) LifeSource and its recommendations/orders and 2) handling of pharmacist recommendations and would provide copies of all other pharmacist recommendations. On 09/20/23 at approximately 9:30 AM, the DON had been unable to provide copies of other recommendations made by the Consultant Pharmacist or a copy of the requested policy and procedure related to LifeSource, but did provide a copy of the 08/16/23 Consultant Pharmacist Communication to Physician (Medical Director) which had been checked Duplicate agents are being used due to differing mechanisms of action that result in augmention in managing behavior symptoms. Usage is based on clinical experience or medical literature and the risk vs benefit has been considered. and Duplicate agents with differing degrees of D (dopamine receptor) 2 binding are being used in an attempt to use lower dosages of each individual agent. Usage is based on clinical experience or medical literature and the risk vs benefit has been considered. and Duplicate agents are being used for different indications/symptoms (please specify below) and the risk vs benefit has been considered. The OTHER below had been checked and signed by the Medical Director on 09/20/23 stating Rexulti is approved (FDA) (Food and Drug Administration) for agitation dementia to target . (unable to decipher) . in notes sent . (unable to decipher) .

Based on record reviews and interviews, the facility failed to ensure Resident (R)44 was afforded the opportunity to participate in activities of choice and further failed to ensure R44 was invited to out of room activities related to his preferences and interest for 1 of 4 reviewed for activities. Findings include: Review of R44's Face Sheet revealed, the facility admitted R44 with diagnoses including, but not limited to, cognitive deficits, difficulty walking, anemia, bradycardia and psychosis. Review of R44's activity attendance sheets for 06/20/23 through 09/19/23, revealed R44 was included in choir practice on 08/09/23 and on 08/22/23 R44 had his hair cut and shampooed, and was shaven and received a massage. No other activities were documented on the attendance sheets for the 3 month period. Review on 09/19/23 at 4:00 PM of the Comprehensive Plan of Care for R44 included independent activities and watching TV, music, singing, football and outside activities. No documentation was found in the medical record to ensure R44 was invited to any activities that he may have enjoyed. During an interview on 09/20/23 at 10:42 AM, the Activity Director stated that she had not invited R44 to any activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, interviews and medical literature in Facts and Comparisons, Epocrates and Drugs.com, the facility failed to coordinate psychiatric care for Resident (R)67 with LifeSource, Inc. for 1 of 6 residents reviewed for unnecessary medications. Findings include: Review of R67's Face Sheet revealed R67 was admitted to the facility on [DATE] with diagnoses including but not limited to schizophrenia and dementia. A review of January - September, 2023 progress notes for R67 revealed the Consultant Pharmacist stated Medication regimen reviewed for problems an/or irregularities, Recommendation made. on 01/30/23, 02/20/23, 03/29/23, 04/16/23, 05/16/23, 06/21/23, 07/22/23, 08/6/23 and 09/15/23. Further review of the progress notes revealed an entry dated 08/16/23 related to CMS-F757: Duplicate Antipsychotic Drugs which stated This patient is currently receiving duplicate antipsychotic drugs Quetiapine 400mg (milligram) BID (twice daily) and Brexpiprazole 1mg QD (daily). The typical treatment pathway is to maximize the dose of a single agent prior to adding a second drug. Consider tapering to D/C (discontinue) Brexpiprazole and may increase the Quetiapine if needed. The recommendation further included specific recommendations for action. During an interview on 09/19/23 at 2:22 PM the Medical Director (MD) stated that the resident is being seen by a psychiatric service and the facility places the orders for psychotherapeutic agents made by the psychiatric service under his name. He did not recall seeing pharmacist recommendations made on 08/16/23 related to duplicate antipsychotic drugs Seroquel and Rexulti for R67 and was unaware of a potential need for blood pressure monitoring. During an interview on 09/19/23 at 2:32 PM, the Administrator stated that psychiatric services are provided by LifeSource and that the Social Services Director enters their orders into the computer system under the Medical Director's name. When asked to whom at the facility pharmacist recommendations are given to, he stated to the Director of Nursing (DON) and that he would have the DON come see me. During an interview on 09/19/23 at approximately 3:40 PM, the DON stated he was unaware of a pharmacist recommendation made on 08/16/23 related to duplication of therapy related to two antipsychotic drugs (Seroquel and Rexulti) for R67 and was unaware that LifeSource orders for Seroquel and Rexulti had been faxed to the pharmacy with the Medical Director as the prescriber, not LifeSource. The DON stated that the Medical Director defers to LifeSource when it comes to prescribing psychiatric medications. Stated he would provide a copy of policy and procedures related to LifeSource and its recommendations/orders and handling of pharmacist recommendations and would provide copies of all other pharmacist recommendations. During an interview on 09/20/23 at approximately 9:30 AM, the DON was unable to provide copies of other recommendations made by the Consultant Pharmacist or a copy of the requested policy and procedure related to LifeSource.

Based on review of the facility policy, observations and interviews, the facility failed to follow a procedure during wound care for Resident (R)21 to prevent infection and to promote wound healing for 1 of 4 residents reviewed with pressure ulcers. Findings include: Review of the undated facility policy titled, Procedure: Guidelines for Cleansing and observing a Wound, states, in the procedure, 7. Gently clean the wound with the ordered cleanser or normal saline. 8. Work from clean areas to less clean areas. 9. To cleanse an injury or pressure ulcer, work in half circles or full circles, beginning in the center of the wound and working outward. Cleanse the skin at least one inch beyond the edge of the dressing. Use a new sponge for each circle. 10. Avoid rubbing back and forth. Rinse using the same technique. 11. Use each gauze sponge once, then discard it. Review of R21's Face Sheet revealed the facility admitted R21 with diagnosis including, but not limited to pressure ulcers. Review of R21's physician's order stated, Cleanse wound with wound cleanser, pat dry, apply medihoney and then calcium alginate 3 times weekly and cover and secure. During an observation of wound care on 09/19/23 at 10:40 AM, for R21 by Licensed Practical Nurse (LPN)1 revealed the following: LPN1 knocked on the door and R21 invited us in. LPN1 explained the procedure to R21. Neither LPN1 or the Certified Nursing Assistant (CNA) washed their hands. The CNA applied gloves, and LPN1 cleansed her hands with hand sanitizer from a dispenser inside the resident's room. LPN1 applied a pair of gloves. The CNA raised the bed, and LPN1 removed the tape from the resident's brief, opened the brief and the CNA and LPN1 positioned R21 onto his right side facing the wall ensuring that R21 was over far enough using the draw sheet to assist him over. LPN1 removed the soiled dressing which was observed with a moderate amount of drainage. LPN1 then removed her gloves and cleaned her hands with hand sanitizer and then applied gloves. LPN1 then opened a drape over the over bed table and proceeded to open the gauze and then sprayed them with wound cleanser and took several in hand and rubbed across the wound going back and forth across both wounds several times using the same wound cleanser soaked gauze. LPN1 then removed her gloves and cleansed her hands with sanitizer, applied gloves, she then opened the medihoney and squeezed a large amount onto a 2x2 gauze and rubbed the 2x2 of medihoney onto one wound and then the other wound using the same 2x2 gauze of medihoney. LPN1 then opened a 4x4 square of Maxorb II, Alginate and placed the entire sheet over the 2 wounds and then covered the wounds with a foam dressing. LPN1 then took a marker and wrote the date, time and her initials on the outer dressing. LPN1 then aided the CNA in ensuring the resident was comfortable and then she removed her gloves and cleansed her hands before leaving R21's room. During an interview on 09/19/23 at 11:00 AM, LPN1 confirmed that she had used the same 2x2 soaked gauze with wound cleanser and cleaned back and forth across both wounds.

Based on review of facility policy, observations, interviews and record review, the facility failed to ensure Resident (R)26 was free from potential entrapment of bedrails for 1 of 1 residents reviewed for bedrails. Findings include: Review of a facility policy titled, Bed Rails with a revised date of 02/01/18, documented, Policy Statement: As further described in this policy, prior to using bed rails, the risk of doing so for a particular patient should be evaluated by appropriate staff of the healthcare center (as described herein) and discussed with the patient and/or the patient's representative. Scope: This policy applies to the healthcare center nursing staff. Definition: Bed rails (also referred to as side rails) are adjustable metal or rigid plastic bars that attach along the side of a patient's bed for the purpose of preventing a patient from falling out of the bed or for assisting a patient independently to turn or maneuver themselves in the bed. Bed rails are available in a variety of types, shapes, and sizes, ranging from full, to one-half, one-quarter, or one-eighth lengths of a bed. While some bed rails are designed by a manufacturer as a component part of a patient bed, others are not, and may be installed along the side of a bed. Entrapment is an event in which a patient is caught, trapped, or entangled in the space in or about a bed rail. Procedure: 3. Prior to installing or using bed rails on a patient's bed, the patient should be assessed by the admitting nursing and/or the inter-disciplinary team (IDT) to determine whether the use of bed rails would constitute an enabler or a restraint for the patient. All factors of a patient's functional ability should be taken into consideration when making this determination. When it has been determined by the admitting nurse and/or IDT that bed rails are medically necessary for a patient's care the following procedures should be followed prior to their use: 1. The patient and/or the patient's representative should be educated on the proper use of bed rails as well as the risks of using bed rails, which should include, but not be limited to, the risk of entrapment. 2. The nurse should complete the initial/annual observation for physical device form in determining whether the bed rails should be considered an enabler or a restraint for the patient. 3. A partner from the Maintenance Department should examine the bed and determine that the dimensions of the bed are appropriate for the patient and confirm that the bed rails to be installed or used, by raising the bed rails if the bed rails are a component part of the bed), are appropriate for the size and weight of the patient using the bed. In addition, this partner will confirm that the manufacturer's instructions have been followed to ensure a proper fit and that the bed rails are in proper working order. 4. The nursing and maintenance staff should regularly inspect the mattress and bed rails for areas of possible entrapment. A review of R26's Face Sheet indicated the facility admitted R26 with diagnoses including but not limited to: Alzheimer's disease, syncope and collapse, muscle weakness, unsteadiness on feet, repeated falls, contracture, left hand-post left wrist fracture, abnormalities of gait and mobility, and anorexia. Review of R26's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/11/23, revealed R26 had a Staff Assessment for Mental Status (SAMS) score of 3, indicating that R26 is severely impaired for cognitive skills for daily decision making. R26 required limited assistance with bed mobility, extensive assistance with transfer, eating, and toileting and totally dependent on staff for bathing. Review of R26's Care Plan, initiated 07/30/19, revealed R26 is total care and requires assistance with Activities of Daily Living (ADL) functions per staff with interventions that included 1/4 side rails for turning and repositioning to assist with bed mobility. Review of R26's Physician Orders, for the month 08/2023, revealed an order, dated 05/05/22 for 1/4 side rails for turning and repositioning. Review of Joerns Bed Frames UltraCare XT, the manufacture's guidelines for the bedrails/bedframe revealed Warning: Possible Injury. Improper installation could result in the pendent holder producing a hazard by protruding from the bed. Carefully follow all installation and user instructions. Failure to do so could result in injury or death. Head End Mattress Side Stop 1. Mattress Side Stop is designated to help keep mattress from sliding laterally on the mattress support platform. Please read important warnings related to Mattress Side Stop and follow all instructions below, prior to use. 3. Replace mattress, making sure mattress fills width between stops. Review of consent for the use of bed rails, signed by R26's Representative (RP), dated 04/06/22, revealed R26's RP's signature of consent for the use of bed rails. During an observation on 09/17/23 at 12:25 PM, R26 was observed in bed lying on their right side in a fetal position, R26 was sucking their thumb and mumbling to self. R26's bed rails were observed with approximately 6 gap between the mattress and bedrail. R26's head was leaning against the bed rail with the corner of a white pillow tucked partially between the mattress and bed rails. During an interview on 09/19/23 at 2:23 PM, the Director of Health Services (DHS) stated that they did not have a bed evaluation for R26. During an interview on 09/19/23 at 1:22 PM, Registered Nurse (RN)6 (the resident's hospice nurse) stated that the resident is unable to move themselves. RN6 stated that the resident is seen by hospice two times weekly. During an interview on 09/17/23 at approximately 12:30 PM, the DHS stated that there was a gap between the mattress and the bed rails. He stated that it was unsafe for the resident. The DHS also stated that it could potentially become an entrapment hazard for the resident. During an interview on 09/20/23 at 12:04 PM, the Administrator stated that he expected a bed assessment to be completed on all residents for the safety use of bedrails before the resident was placed in the bed. The Administrator further stated that he also expected a consent to use the bedrails be signed by the resident or the residents RP before use. The Administrator stated that he expects the bedrails to be properly fitted and placed on the bed and for all residents to be free from entrapment with the use of bedrails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record reviews, observations, and interviews, facility failed to ensure that the enteral feeds for Resident (R)6 were running at the correct rate, was properly labeled, and properly connected for 1 of 1 resident reviewed for tube feeding. Findings Include: Review of the facility procedure guide titled Enteral tube feeding, duodenal and jejunal dated 11/18/20 in the Preparation of Equipment section states, Make sure the enteral formula is labeled clearly with patient identification information, the type of formula, the method of administration, the date and time of preparation, and the name of the person preparing the formula (If appropriate). Verify the enteral formula label with the practitioner's order. Furthermore, the implementation Section states, Trace the tube from the patient to its point of origin to make sure it's connected to the proper port before beginning the tube feeding. Review of R6's Face Sheet revealed R6 was admitted to the facility on [DATE] with diagnoses including: Parkinson's disease, dysphagia, dementia, moderate protein calorie malnutrition and type 2 diabetes. Review of R6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/07/23 revealed a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicating R6 was severely cognitively impaired. Review of R6's Physicians Orders dated 03/14/23 states Jevity 1.2 @ 75 ml/hr. x 22 hours per day off at 4 am and back on at 6 am. During an observation on 09/17/23 at 11:55 AM, revealed R6's tube feed was observed without a date, time or initials. During an observation on 09/18/23 at 9:41 AM, revealed R6's tube feed was observed without a date, time or initials During an interview on 09/19/23 at 3:58 PM, the Director of Health Services (DHS) stated that it is his expectations that his staff verify tube feed rates when beginning their shift with the previous nurse and that nurses are responsible for managing and maintaining residents tube feeds. During an observation on 09/19/23 at 10:37 AM, revealed R6 lying in bed, with Jevity tube feed running at 80 milliliters (mls)/hour(hr.), furthermore R6's tube feed was not properly connected and was leaking out onto his bed and shirt, and was not properly labeled. During an observation on 09/20/23 at 7:54 AM, revealed R6 lying in bed, with Jevity tube feed running at 80mls/hr. During an interview on 09/20/23 at 7:57 AM, Registered Nurse (RN) 3 stated that typical tube feed rates are verified with the previous shift nurse and that she had not verified the rate or had she been in the resident room to check his tube feed rate. During an interview on 09/20/23 at 8:54 AM Licensed Practical Nurse (LPN)2 stated that she was responsible for ensuring R6's tube feed was started at 6 am. LPN 2 states that R6's tube feed should be turned off at 4:00 AM for 2 hours and restarted at 6 AM at 75mls/hr. LPN 2 was unable to provide a reason as to why R6's feed was running at an incorrect rate at 80 mls/hr.

Based on review of facility policy, observations, interviews and record review, the facility failed to ensure Resident (R)26 had proper evaluations for the use of bedrails for 1 of 1 residents reviewed for bedrails. Findings include: Review of a facility policy titled, Bed Rails with a revised date of 02/01/18, documented, Policy Statement: As further described in this policy, prior to using bed rails, the risk of doing so for a particular patient should be evaluated by appropriate staff of the healthcare center (as described herein) and discussed with the patient and/or the patient's representative. Scope: This policy applies to the healthcare center nursing staff. Definition: Bed rails (also referred to as side rails) are adjustable metal or rigid plastic bars that attach along the side of a patient's bed for the purpose of preventing a patient from falling out of the bed or for assisting a patient independently to turn or maneuver themselves in the bed. Bed rails are available in a variety of types, shapes, and sizes, ranging from full, to one-half, one-quarter, or one-eighth lengths of a bed. While some bed rails are designed by a manufacturer as a component part of a patient bed, others are not, and may be installed along the side of a bed. Entrapment is an event in which a patient is caught, trapped, or entangled in the space in or about a bed rail. Procedure: 3. Prior to installing or using bed rails on a patient's bed, the patient should be assessed by the admitting nursing and/or the inter-disciplinary team (IDT) to determine whether the use of bed rails would constitute an enabler or a restraint for the patient. All factors of a patient's functional ability should be taken into consideration when making this determination. When it has been determined by the admitting nurse and/or IDT that bed rails are medically necessary for a patient's care the following procedures should be followed prior to their use: 1. The patient and/or the patient's representative should be educated on the proper use of bed rails as well as the risks of using bed rails, which should include, but not be limited to, the risk of entrapment. 2. The nurse should complete the initial/annual observation for physical device form in determining whether the bed rails should be considered an enabler or a restraint for the patient. 3. A partner from the Maintenance Department should examine the bed and determine that the dimensions of the bed are appropriate for the patient and confirm that the bed rails to be installed or used, by raising the bed rails if the bed rails are a component part of the bed), are appropriate for the size and weight of the patient using the bed. In addition, this partner will confirm that the manufacturer's instructions have been followed to ensure a proper fit and that the bed rails are in proper working order. 4. The nursing and maintenance staff should regularly inspect the mattress and bed rails for areas of possible entrapment. A review of R26's Face Sheet indicated the facility admitted R26 with diagnoses including but not limited to: Alzheimer's disease, syncope and collapse, muscle weakness, unsteadiness on feet, repeated falls, contracture, left hand-post left wrist fracture, abnormalities of gait and mobility, and anorexia. Review of R26's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/11/23, revealed R26 had a Staff Assessment for Mental Status (SAMS) score of 3, indicating that R26 is severely impaired for cognitive skills for daily decision making. R26 required limited assistance with bed mobility, extensive assistance with transfer, eating, and toileting and totally dependent on staff for bathing. Review of R26's Care Plan, initiated 07/30/19, revealed R26 is total care and requires assistance with Activities of Daily Living (ADL) functions per staff with interventions that included 1/4 side rails for turning and repositioning to assist with bed mobility. Review of R26's Physician Orders, for the month 08/2023, revealed an order, dated 05/05/22 for 1/4 side rails for turning and repositioning. Review of Joerns Bed Frames UltraCare XT, the manufacture's guidelines for the bedrails/bedframe revealed Warning: Possible Injury. Improper installation could result in the pendent holder producing a hazard by protruding from the bed. Carefully follow all installation and user instructions. Failure to do so could result in injury or death. Head End Mattress Side Stop 1. Mattress Side Stop is designated to help keep mattress from sliding laterally on the mattress support platform. Please read important warnings related to Mattress Side Stop and follow all instructions below, prior to use. 3. Replace mattress, making sure mattress fills width between stops. During an observation on 09/17/23 at 12:25 PM, R26 was observed in bed lying on their right side in a fetal position, R26 was sucking their thumb and mumbling to self. R26's bed rails were observed with approximately 6 gap between the mattress and bedrail. R26's head was leaning against the bed rail with the corner of a white pillow tucked partially between the mattress and bed rails. During an interview on 09/19/23 at 2:23 PM, the Director of Health Services (DHS) stated that they did not have a bed evaluation for R26. During an interview on 09/17/23 at approximately 12:30 PM, the DHS stated that there was a gap between the mattress and the bed rails. He stated that it was unsafe for the resident. The DHS also stated that it could potentially become an entrapment hazard for the resident. During an interview on 09/20/23 at 12:04 PM, the Administrator stated that he expected a bed assessment to be completed on all residents for the safety use of bedrails before the resident was placed in the bed. The Administrator further stated that he also expected a consent to use the bedrails be signed by the resident or the residents RP before use. The Administrator stated that he expects the bedrails to be properly fitted and placed on the bed and for all residents to be free from entrapment with the use of bedrails.

Based on review of facility policy, observations and interviews, the facility failed to ensure sufficient nursing staff to meet the residents needs for multiple days. Findings include: A review of a facility policy titled State Minimum Staffing for Healthcare Centers, with a reviewed date of 12/05/22, specified, Policy Statement: The facility will maintain the minimum staffing hour in accordance with federal law and the respective state's rules and regulations. Staffing shall be sufficient to meet the healthcare needs of each patient/resident as identified in the patient/resident's plan of care. Daily nursing hours will be posted at each facility in accordance with federal regulations. 1.) Each facility will complete the Daily Nursing Hours for Healthcare Centers Form. Information on the form will include c.) Resident census d.) The total number of each category directly responsible for resident care per shift. (Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants) e.) The actual working hours for each partner in each category per shift. f.) The total number of hours worked for each category per shift. During an observation on 09/17/23 at 11:55 AM, Resident (R)6 was observed laying in a urine-soaked bed without an absorbent pad underneath the resident. During an observation and interview on 09/17/23 at 12:00 PM, R41 stated care is ok but that the staff gets busy, and they need more staff. R41 stated they she has been waiting to get up in her chair. There were 4 dirty cups observed on the resident's bedside table to her left. R41 stated she is soiled and hasn't been changed this morning yet. R41 was still wearing her night gown. During an observation on 09/17/23 at 2:54 PM, R41 was sitting in wheelchair located in the doorway of their room. R41 had a nasal canula placed in her nose, the nasal canula oxygen tubing was observed stretched as far as it could go. R41 was verbalizing that she needed help getting cleaned up. R41 stated to surveyors that she wanted to get to the dining room but she was soiled and was looking for help to get cleaned up before going down to the dining room. During an observation on 09/17/23 at 12:02 PM, R62 was observed sitting on the side of the bed. R62's bed sheets were observed soiled and with what appeared to be dried feces. R62's brief appeared to be leaking feces. During an observation on 09/18/23 at 9:41 AM, R62 was observed lying in bed soaked with urine. Urine was also noted to be in a puddle under the resident's bed and on the sides of the resident's bed. There was a foul odor of urine, emanating from the resident's room. During an interview on 09/17/23 at 10:07 AM, Licensed Practical Nurse (LPN)5 stated that Certified Nursing Assistants (CNAs) are to round on residents soon after getting report from previous shift staff and then every two hours thereafter during their shift. During an interview on 09/17/23 at 12:05 PM, R62 stated that someone had been in their room that morning and that the staff member stated that they would return to get them cleaned up, but they never came back. During an interview on 09/17/23 at 12:25 PM, CNA4 stated that this was her first-time rounding and that she was unsure when the night shift had last rounded on the residents. CNA4 further stated that she had begun her shift at 7:00 AM but that there were only three staff members to care for all the residents on the hall. During an interview on 09/19/23 at 2:10 PM, multiple residents during the resident council meeting voiced their concerns regarding staffing. Residents stated that the facility is short staffed during all shifts. The residents also stated that the staff that they do have is overworked. The residents went on to say that they are not getting the care that they need because there isn't anyone to call. During an interview on 9/19/23 at 2:51 PM, unit manager LPN7 stated that she does not do the staffing and the Director of Health Services (DHS) is responsible for staffing. LPN7 stated that she does try and help to call in staff when they are short staffed. During an interview on 09/19/23 at 3:28 PM, the DHS stated that he was unaware that residents located on the Palmetto wing had not received proper Activities of Daily Living (ADL) and Incontinence care on 09/17/23. During an interview on 09/19/23 at 3:33 PM, the DHS stated that he was not aware that 22 days of the Daily Nursing Hours for Healthcare forms were not completed with actual staffing hours worked or resident census out of the month. The DHS stated that the facility is short-staffed and that he is unsure how many days out of the month they have been short-staffed. During an interview on 09/19/23 at 3:50 PM, Registered Nurse (RN)5 stated that they do not have enough staff to run 3 RNs, so they have been running off 2 RNs. During an interview on 09/20/23 at 9:08 AM, LPN7 stated that they are regularly short staffed and that she expects all residents to receive the care they need in a timely manner. LPN7 stated that she would be upset and mad if she was in the residents' shoes and not receiving the care needed and depending on staff for their care. During an interview on 09/20/23 at 12:04 PM, the Administrator stated that a shortage of staffing is a big deal everywhere and that he knows that they are short staffed. The Administrator stated that he expects the unit managers to make sure that the residents are getting the care that they need and to ensure that the staff are doing their job. The Administrator stated that he expects to have adequate staffing to ensure that they can meet the needs of the residents in a timely manner.

Based on record review and interviews, the facility failed to ensure that pharmacist drug regimen review recommendations for Resident (R)67 were acted on in a timely manner for 1 of 6 residents reviewed for unnecessary medications. Findings included: A review of January - September, 2023 progress notes for R67 revealed the Consultant Pharmacist had stated Medication regimen reviewed for problems an/or irregularities, Recommendation made. on 1/30/23, 2/20/23, 3/29/23, 4/16/23, 5/16/23, 6/21/23, 7/22/23, 8/6/23 and 9/15/23. Further review of the progress notes revealed an entry dated 8/16/23 related to CMS-F757: Duplicate Antipsychotic Drugs which stated This patient is currently receiving duplicate antipsychotic drugs Quetiapine 400mg (milligram) BID (twice daily) and Brexpiprazole 1mg QD (daily). The typical treatment pathway is to maximize the dose of a single agent prior to adding a second drug. Consider tapering to D/C (discontinue) Brexpiprazole and may increase the Quetiapine if needed. The recommendation further included specific recommendations for action. During an interview on 09/19/23 at 2:22 PM, the Medical Director (MD) stated that R67 is being seen by a psychiatric service and the facility places the orders for psychotherapeutic agents made by the psychiatric service under his name. The MD did not recall seeing pharmacist recommendations made on 08/16/23 related to duplicate antipsychotic drugs Seroquel and Rexulti for R67 and was unaware of a potential need for blood pressure monitoring. During an interview on 09/19/23 at 2:32 PM, the Administrator stated that psychiatric services are provided by LifeSource and that the Social Services Director enters their orders into the computer system under the MD's name. The Administrator stated pharmacist recommendations are given to the Director of Nursing (DON). During an interview on 09/19/23 at approximately 3:40 PM, the DON stated that pharmacist recommendations come to him and the nursing staff sends them to the prescribing physician if he hasn't picked them up, but was otherwise unclear as to the process as it related to Licensure orders for medications. The DON was unaware of a pharmacist recommendation made on 08/16/23 related to duplication of therapy related to two antipsychotic drugs (Seroquel and Rexulti) for R67 and was unaware that LifeSource orders for Seroquel and Rexulti had been faxed to pharmacy with the MD as the prescriber, not LifeSource. The DON stated that the MD defers to LifeSource when it comes to prescribing psychiatric medications and would provide a copy of policy and procedures related to LifeSource and its recommendations/orders and handling of pharmacist recommendations and would provide copies of all other pharmacist recommendations. During an interview on 09/20/23 at approximately 9:30 AM, the DON was unable to provide copies of other recommendations made by the Consultant Pharmacist or a copy of the requested policy and procedure related to LifeSource, but did provide a copy of the 8/16/23 Consultant Pharmacist Communication to Physician (Medical Director) which had been checked Duplicate agents are being used due to differing mechanisms of action that result in augmention in managing behavior symptoms. Usage is based on clinical experience or medical literature and the risk vs benefit has been considered. and Duplicate agents with differing degrees of D (dopamine receptor) 2 binding are being used in an attempt to use lower dosages of each individual agent. Usage is based on clinical experience or medical literature and thee risk vs benefit has been considered. and Duplicate agents are being used for different indications/symptoms (please specify below) and the risk vs benefit has been considered. The OTHER below had been checked and signed by the Medical Director on 9/20/23 stating Rexulti is approved (FDA) (Food and Drug Administration) for agitation dementia to target (unable to decipher) in notes sent (unable to decipher) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, interviews and medical literature in Facts and Comparisons, Epocrates and Drugs.com the facility failed to ensure that Resident (R)67 was free of unnecessary medications for 1 of 6 residents reviewed for unnecessary medications. Findings include: Review of R67's Face Sheet revealed R67 was admitted to the facility on [DATE] with diagnoses including but not limited to schizophrenia and dementia. A review of R67's physician orders by the Medical Director (MD) revealed the following orders: Trazodone (an antidepressant) 50 mg (milligram) at bedtime prescribed 01/19/23 open ended (no end date) for insomnia. Melatonin 3 mg x2 at bedtime prescribed 01/24/23 open ended for insomnia. Hydrocodone - acetaminophen 5-325 mg twice daily PRN (as needed) prescribed 02/10/23 open ended for pain, do not exceed 2 per day. Memantine 10 mg twice daily prescribed 04/04/23 open ended for dementia. Seroquel (quetiapine 400 mg) twice daily prescribed 08/03/23 open ended for vascular dementia with behavioral disturbance/Schizophrenia. Rexulti (brexpiprazole) 1 mg once daily prescribed 08/11/23, open ended for Schizophrenia. Depakote (divalproex) Sprinkles 250 mg once daily and 125 mg at bedtime both prescribed 08/14/23 open ended for Mood. Further review of the physician orders failed to find an order for monitoring of vital signs. A review of R67's progress notes dated 03/21/23 at 7:50 PM revealed, resident was in an altercation resident found aggressive toward her roommate. resident did not sustained any injury. A review of R67's progress notes revealed Psychiatry/LifeSource notes were being entered into the medical record progress notes 2-15 days after the date of the visit as follows: -Psychotherapy Comprehensive Clinical Assessment performed on 04/07/23 and R67 found not to be appropriate for CBT (cognitive behavioral therapy) due to her cognitive decline and inability to hold a conversation and entered into the medical record (EITMR) on 04/13/23. -04/20/23 LifeSource Service(s): Discharge Summary which stated A comprehensive psychological assessment of the resident took place on April 7, 2023. The final treatment plan was dated and patient was last seen on April 7, 2023. Discontinue psychotherapy services only . EITMR 04/25/23 -04/24/23 Psychiatry Initial Visit with recommendations/plan to Start Depakote 20 mg po QHS (at bedtime), EITMR 04/26/23 -06/19/23 with recommendation/plan, Patient continues to exhibit behaviors as documented in HPI (history of present illness) section; recommend increasing Depakote to 250 mg po BID x 3 days, then Dose should be Depakote 250mg po qd and Depakote 500 mg po QHS. Increase seroquel to 400 mg po BID (twice daily) (max dose is 800 mg a day), EITMR 07/05/23 -07/31/23 with recommendations/Plan Start rexulti 0.5 mg po x 7 days then increase to 1 mg po daily., EITMT 08/14/23 and -08/31/23 with no recommended changes to current dose of medication. EITMR 9/7/23 During an observation on 09/17/23 at approximately 11:18 PM and 12:15 PM, R67 was in room with door open laying on the bed, bed in a low position. R67 was wrapped in sheet/blanket, laying in the fetal position near foot of bed. R67 had no response to questions and only made an occasional sound. There were no staff members noted on that hall. During an observation on 09/18/23 at approximately 9:26 AM, 10:35 AM, 1:32 PM and 3:44 PM, R67 was in room with door open, laying at foot of the low bed next to door. R67 was wrapped in a sheet, laying in the fetal position, making no sound. During an interview on 09/18/23 at approximately 1:41 PM, Certified Nursing Assistant (CNA)6 stated R67 seems to lie in that position most of the time. During an observation on 09/19/23 at approximately 10:35 AM, 11:26 AM and 1:27 PM, R67 was in with door partially closed, laying on foot of low bed next to door. R67 was wrapped in a sheet, laying in the fetal position, making an occasional sound. During an interview on 09/19/23 at approximately 2:06 PM, CNA 5 stated R67 had been in bed all day, but had eaten a hearty lunch. On 09/18/23 at approximately 3:10 PM a review of the Facts and Comparisons, Epocrates and Drug.com medical literature revealed potential moderate drug interactions between trazodone, divalproex, melatonin, quetiapine, brexpiprazole due to central nervous system depressant effects which may be additively or synergistically be increased in patients taking multiple drug that cause these effect, especially in elderly or debilitated patients. Sedation and impairment of attention, judgement, thinking, and psychomotor skills may increase. Vital signs (blood pressure, orthostatics, temperature and pulse) for brexpiprazole should be monitored during first 3-4 weeks of treatmenrt and every 4 weeks after dose change. Monitor blood pressure due to combination which may increase risk of CNS depression, psychomotor impairment, hyperthermia, hypotension, including orthostasis, syncope. During observations on 09/17/23 - 09/19/23, R67 was in bed and not involved in activities. Review of R67's progress notes dated May 2023 - September 2023 revealed R67 frequently charted as sleeping in bed and failed to show R67 being involved in any activities. A review of R67's January 2023 - September 2023 progress notes revealed the Consultant Pharmacist had stated Medication regimen reviewed for problems an/or irregularities, Recommendation made. on 01/30/23, 02/20/23, 03/29/23, 04/16/23, 05/16/23, 06/21/23, 07/22/23, 08/6/23 and 09/15/23. Further review of the progress notes revealed an entry dated 08/16/23 related to CMS-F757: Duplicate Antipsychotic Drugs which stated This patient is currently receiving duplicate antipsychotic drugs Quetiapine 400mg (milligram) BID (twice daily) and Brexpiprazole 1mg QD (daily). The typical treatment pathway is to maximize the dose of a single agent prior to adding a second drug. Consider tapering to D/C (discontinue) Brexpiprazole and may increase the Quetiapine if needed. The recommendation further included specific recommendations for action. During an interview on 09/19/23 at approximately 2:22 PM, the Medical Director (MD) called and stated that the resident is being seen by a psychiatric service and the facility places the orders for psychotherapeutic agents made by the psychiatric service under his name. The MD did not recall seeing pharmacist recommendations made on 08/16/23 related to duplicate antipsychotic drugs Seroquel and Rexulti for R67 and was unaware of a need for blood pressure monitoring. During an interview on 09/19/23 at approximately 3:40 PM, the DON stated that pharmacist recommendations come to him and the nursing staff sends them to the prescribing physician if he hasn't picked them up, but was otherwise unclear as to the process as it related to Licensure orders for medications. The DON was unaware of a pharmacist recommendation made on 08/16/23 related to duplication of therapy related to two antipsychotic drugs (Seroquel and Rexulti) for R67 and was unaware that LifeSource orders for Seroquel and Rexulti had been faxed to the pharmacy with the MD as the prescriber, not LifeSource. The DON stated that the MD defers to LifeSource when it comes to prescribing psychiatric medications. The DON further stated he would provide a copy of policy and procedures related to, 1) LifeSource and its recommendations/orders and 2) handling of pharmacist recommendations and would provide copies of all other pharmacist recommendations. On 09/20/23 at approximately 9:30 AM, the DON had been unable to provide copies of other recommendations made by the Consultant Pharmacist or a copy of the requested policy and procedure related to LifeSource, but did provide a copy of the 08/16/23 Consultant Pharmacist Communication to Physician (Medical Director) which had been checked Duplicate agents are being used due to differing mechanisms of action that result in augmention in managing behavior symptoms. Usage is based on clinical experience or medical literature and the risk vs benefit has been considered. and Duplicate agents with differing degrees of D (dopamine receptor) 2 binding are being used in an attempt to use lower dosages of each individual agent. Usage is based on clinical experience or medical literature and the risk vs benefit has been considered. and Duplicate agents are being used for different indications/symptoms (please specify below) and the risk vs benefit has been considered. The OTHER below had been checked and signed by the Medical Director on 09/20/23 stating Rexulti is approved (FDA) (Food and Drug Administration) for agitation dementia to target . (unable to decipher) . in notes sent . (unable to decipher) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, interviews and medical literature in Facts and Comparisons, Epocrates and Drugs.com the facility failed to ensure that Resident (R)67 was free of unnecessary psychotherapeutic medications for 1 of 6 residents reviewed for unnecessary medications. Findings include: Review of R67's Face Sheet revealed R67 was admitted to the facility on [DATE] with diagnoses including but not limited to schizophrenia and dementia. A review of R67's physician orders by the Medical Director (MD) revealed the following orders: Trazodone (an antidepressant) 50 mg (milligram) at bedtime prescribed 01/19/23 open ended (no end date) for insomnia. Melatonin 3 mg x2 at bedtime prescribed 01/24/23 open ended for insomnia. Hydrocodone - acetaminophen 5-325 mg twice daily PRN (as needed) prescribed 02/10/23 open ended for pain, do not exceed 2 per day. Memantine 10 mg twice daily prescribed 04/04/23 open ended for dementia. Seroquel (quetiapine 400 mg) twice daily prescribed 08/03/23 open ended for vascular dementia with behavioral disturbance/Schizophrenia. Rexulti (brexpiprazole) 1 mg once daily prescribed 08/11/23, open ended for Schizophrenia. Depakote (divalproex) Sprinkles 250 mg once daily and 125 mg at bedtime both prescribed 08/14/23 open ended for Mood. Further review of the physician orders failed to find an order for monitoring of vital signs. A review of R67's progress notes revealed Psychiatry/LifeSource notes were being entered into the medical record progress notes 2-15 days after the date of the visit as follows: -Psychotherapy Comprehensive Clinical Assessment performed on 04/07/23 and R67 found not to be appropriate for CBT (cognitive behavioral therapy) due to her cognitive decline and inability to hold a conversation and entered into the medical record (EITMR) on 04/13/23. -04/20/23 LifeSource Service(s): Discharge Summary which stated A comprehensive psychological assessment of the resident took place on April 7, 2023. The final treatment plan was dated and patient was last seen on April 7, 2023. Discontinue psychotherapy services only . EITMR 04/25/23 -04/24/23 Psychiatry Initial Visit with recommendations/plan to Start Depakote 20 mg po QHS (at bedtime), EITMR 04/26/23 -06/19/23 with recommendation/plan, Patient continues to exhibit behaviors as documented in HPI (history of present illness) section; recommend increasing Depakote to 250 mg po BID x 3 days, then Dose should be Depakote 250mg po qd and Depakote 500 mg po QHS. Increase seroquel to 400 mg po BID (twice daily) (max dose is 800 mg a day), EITMR 07/05/23 -07/31/23 with recommendations/Plan Start rexulti 0.5 mg po x 7 days then increase to 1 mg po daily., EITMT 08/14/23 and -08/31/23 with no recommended changes to current dose of medication. EITMR 9/7/23 During an observation on 09/17/23 at approximately 11:18 PM and 12:15 PM, R67 was in room with door open laying on the bed, bed in a low position. R67 was wrapped in sheet/blanket, laying in the fetal position near foot of bed. R67 had no response to questions and only made an occasional sound. There were no staff members noted on that hall. During an observation on 09/18/23 at approximately 9:26 AM, 10:35 AM, 1:32 PM and 3:44 PM, R67 was in room with door open, laying at foot of the low bed next to door. R67 was wrapped in a sheet, laying in the fetal position, making no sound. During an interview on 09/18/23 at approximately 1:41 PM, Certified Nursing Assistant (CNA)6 stated R67 seems to lie in that position most of the time. During an observation on 09/19/23 at approximately 10:35 AM, 11:26 AM and 1:27 PM, R67 was in with door partially closed, laying on foot of low bed next to door. R67 was wrapped in a sheet, laying in the fetal position, making an occasional sound. During an interview on 09/19/23 at approximately 2:06 PM, CNA 5 stated R67 had been in bed all day, but had eaten a hearty lunch. On 09/18/23 at approximately 3:10 PM a review of the Facts and Comparisons, Epocrates and Drug.com medical literature revealed potential moderate drug interactions between trazodone, divalproex, melatonin, quetiapine, brexpiprazole due to central nervous system depressant effects which may be additively or synergistically be increased in patients taking multiple drug that cause these effect, especially in elderly or debilitated patients. Sedation and impairment of attention, judgement, thinking, and psychomotor skills may increase. Vital signs (blood pressure, orthostatics, temperature and pulse) for brexpiprazole should be monitored during first 3-4 weeks of treatmenrt and every 4 weeks after dose change. Monitor blood pressure due to combination which may increase risk of CNS depression, psychomotor impairment, hyperthermia, hypotension, including orthostasis, syncope. During observations on 09/17/23 - 09/19/23, R67 was in bed and not involved in activities. Review of R67's progress notes dated May 2023 - September 2023 revealed R67 frequently charted as sleeping in bed and failed to show R67 being involved in any activities. A review of R67's January 2023 - September 2023 progress notes revealed the Consultant Pharmacist had stated Medication regimen reviewed for problems an/or irregularities, Recommendation made. on 01/30/23, 02/20/23, 03/29/23, 04/16/23, 05/16/23, 06/21/23, 07/22/23, 08/6/23 and 09/15/23. Further review of the progress notes revealed an entry dated 08/16/23 related to CMS-F757: Duplicate Antipsychotic Drugs which stated This patient is currently receiving duplicate antipsychotic drugs Quetiapine 400mg (milligram) BID (twice daily) and Brexpiprazole 1mg QD (daily). The typical treatment pathway is to maximize the dose of a single agent prior to adding a second drug. Consider tapering to D/C (discontinue) Brexpiprazole and may increase the Quetiapine if needed. The recommendation further included specific recommendations for action. During an interview on 09/19/23 at approximately 2:22 PM, the Medical Director (MD) called and stated that the resident is being seen by a psychiatric service and the facility places the orders for psychotherapeutic agents made by the psychiatric service under his name. The MD did not recall seeing pharmacist recommendations made on 08/16/23 related to duplicate antipsychotic drugs Seroquel and Rexulti for R67 and was unaware of a need for blood pressure monitoring. During an interview on 09/19/23 at approximately 3:40 PM, the DON stated that pharmacist recommendations come to him and the nursing staff sends them to the prescribing physician if he hasn't picked them up, but was otherwise unclear as to the process as it related to Licensure orders for medications. The DON was unaware of a pharmacist recommendation made on 08/16/23 related to duplication of therapy related to two antipsychotic drugs (Seroquel and Rexulti) for R67 and was unaware that LifeSource orders for Seroquel and Rexulti had been faxed to the pharmacy with the MD as the prescriber, not LifeSource. The DON stated that the MD defers to LifeSource when it comes to prescribing psychiatric medications. The DON further stated he would provide a copy of policy and procedures related to, 1) LifeSource and its recommendations/orders and 2) handling of pharmacist recommendations and would provide copies of all other pharmacist recommendations. On 09/20/23 at approximately 9:30 AM, the DON had been unable to provide copies of other recommendations made by the Consultant Pharmacist or a copy of the requested policy and procedure related to LifeSource, but did provide a copy of the 08/16/23 Consultant Pharmacist Communication to Physician (Medical Director) which had been checked Duplicate agents are being used due to differing mechanisms of action that result in augmention in managing behavior symptoms. Usage is based on clinical experience or medical literature and the risk vs benefit has been considered. and Duplicate agents with differing degrees of D (dopamine receptor) 2 binding are being used in an attempt to use lower dosages of each individual agent. Usage is based on clinical experience or medical literature and the risk vs benefit has been considered. and Duplicate agents are being used for different indications/symptoms (please specify below) and the risk vs benefit has been considered. The OTHER below had been checked and signed by the Medical Director on 09/20/23 stating Rexulti is approved (FDA) (Food and Drug Administration) for agitation dementia to target . (unable to decipher) . in notes sent . (unable to decipher) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of facility policy, the facility failed to properly store medications and biologicals in 1 of 2 treatment carts. Findings Include: Review of facility policy titled Medication Storage in the Healthcare Centers last reviewed on [DATE] states, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. Procedures 12. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and recorded from the pharmacy, if a current order exists. Observation on [DATE] at 8:44 AM, of a treatment cart on the 200-hall revealed one expired IV start kit with an expiration date of [DATE] and two expired 3M Tegaderm dressings with an expiration date of [DATE]. During an interview on [DATE] at 9:15 AM, Licensed Practical Nurse (LPN)1 stated that she checks the treatments carts daily, however she did not check the IV start kits as they don't frequently use them, furthermore LPN1 did not have an explanation as for why the expired 3M tegaderm dressings were in the treatment cart and not discarded. During an interview on [DATE] at 9:27 AM, the Director of Health Services (DHS) stated that LPN1 is responsible for maintaining the treatment carts, furthermore the DHS stated that his expectations were that the treatment carts are to be checked, cleaned, organized and fully stocked Monday- Friday, the days during which LPN 1 works.

Based on review of facility policy, observation, and interview the facility failed to ensure Personal Protective Equipment (PPE) was used during the sorting of soiled linen into the washers. Findings include: Review of the undated facility policy titled, Infection Control - Linen and Laundry, states, It is the policy of this facility to implement and adhere to this policy to mitigate or decrease infections caused by sources of microbial contamination through collection, handling, sorting, transportation, processing, and storage of laundry. According to facility policy, PPE are barriers, (e.g., gloves, gowns and masks) designed to protect mucous membranes, skin and clothing from coming in contact with potentially infectious microorganisms. The procedure states, 2. Soiled laundry will be handled as contaminated and all partners will practice standard precautions when handling or exposed to to soiled laundry. Standard precautions involve wearing the appropriate PPE when handling or exposed to soiled laundry. Number 3 states, Personal protective equipment (e.g., gown, gloves, and mask will be readily available for use and must be worn, as indicated, to protect employees from exposures. Section C, Handling of Soiled Laundry, number 1. Soiled laundry will be handled as little as possible and with the minimum of agitation to prevent contamination of the air, surfaces and persons handling the laundry. During an observation on 09/19/23 at 3:30 PM, revealed Laundry Worker (LW)2 sorting soiled linen and placing it in the washers. LW2 was wearing a gown to protect her clothes, and gloves, but she was not wearing a mask or a face shield. LW2 was additionally observed, holding the soiled linen in front of her face and shaking it before placing it into the washers. During an interview on 09/19/23 at 3:40 PM, LW2 stated sometimes they do and sometimes they don't, when asked if they should be wearing a mask or face shield.

Based on review of the facility policy, record reviews and interview, the facility failed to ensure Resident (R)41 received education for the Pneumococcal Vaccination prior to receiving it and giving consent prior to receiving the Influenza Vaccination. The facility further failed to ensure R23 received education for the Influenza Vaccination prior to receiving it. The facility additionally failed to offer R67 the Pneumococcal Vaccine and failed to ensure R55 received education prior to receiving the Pneumococcal Vaccine for 3 of 5 residents reviewed for the Influenza and Pneumococcal Vaccinations. The findings include: Review of the undated facility policy titled, Influenza (FLU) Vaccinations for Health Care Center Residents, states, All residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with the vaccinations against influenza. The Health Care Center shall provide pertinent information about the significant risks and benefits of vaccines to residents and/or family members: for example, risk factors have been identified for specific age groups or individuals with risk factors such as allergies. If the resident is cognitively impaired as evidenced by scoring on the resident's MDS, the authorized responsible party will be contacted, and his/her wishes will be followed in this matter. Review of the undated facility policy titled, Pneumococcal Vaccinations, states, All patients/residents who reside in this healthcare center are to receive the pneumococcal vaccine(s) within the current CDC guidelines unless contraindicated by their physician or refused by the patient/resident or the patient/resident's family. If the patient/resident is cognitively impaired as evidenced by scoring on the MDS, the responsible party will be contacted and their wishes will be followed in this matter. The procedure, number 2. states, A Vaccination Information Statement (VIS) will be provided to inform the patient/resident/family member of the side effects, benefits, and the risks of the vaccine. This education will be documented on the Interdisciplinary Teaching Record. Review on 09/19/23 at 03:15 PM of the medical record for R23 revealed, no education was provided prior to receiving the Influenza Vaccine. Review on 09/19/23 at 03:15 PM of the medical record for R55 revealed no education was provided prior to receiving the Pneumococcal Vaccine. Review on 09/19/23 at 03:15 PM of the medical record for R41 revealed, no consent for the Flu Vaccine and no education for the Pneumococcal Vaccine prior to receiving them. Review on 09/19/23 at 03:15 PM of the medical record for R67 revealed that she was not offered the Pneumococcal Vaccine prior 09/19/23. During an interview on 09/19/23 at 3:20 PM these findings were confirmed by Registered Nurse (RN)5, the Infection Preventionist.

Review of R41's Face sheet indicated the facility admitted R41 with diagnoses including but not limited to, schizoaffective disorder and bipolar type. Review of R 41's medical record indicated a diagnosis of schizoaffective disorder, dated 07/03/21. Review of R41's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/09/21, revealed R41 had a Brief Interview for Mental Status (BIMS) score of 9 our of 15, which indicated R41 had moderate cognitive impairment. R41 required extensive assistance with bed mobility and toileting. R41 required limited assistance with transfers and required supervision with meal setup. Review of 41's comprehensive care plan, revealed no Care Plan to address R41's diagnosis of Schizophrenia. During an interview on 09/20/23 at 11:07 AM, the MDS Coordinator stated that she was not aware of R41's mental illness and she was not aware of R41 not being care planed for the mental illness. The MDS Coordinator stated that the resident's mental illness could go untreated if the resident is not care planned for the mental illness. During an interview on 09/20/23 at 12:04 PM, the Administrator stated that he expected all major mental illness to be care planned so that the resident can be treated correctly with medications or referrals to psychiatry. Based on record reviews and interviews the facility failed to implement and/or develop a comprehensive plan of care for Resident (R)33, R44 and R41 for 3 of 6 residents reviewed for care plans. Findings include: The facility admitted R33 with diagnoses including, but not limited to anoxic brain damage, cognitive communication deficit, and pseudobulbar affect. Review of R33's comprehensive plan of care dated 07/21/22 revealed a problem that states, Resident is limited in ability to take showers due to past history of abuse. Resident should only take bed baths. The long term goal is, Resident will be bathed only by bed baths. The approach dated 07/21/22 states, Monitor for presence of pain/intolerance during grooming/personal hygiene and signs of discomfort. Review of a form titled Point of Care ADL Report for the months June, July, August and September revealed R33 did not receive a bath daily, however R33 did receive a shower for 18 days. On 09/19/23 at 3:15 PM when brought to the attention of staff no additional information was provided as to why R33 was receiving showers. The facility admitted R44 with diagnoses including, but not limited to, malignant neoplasm of the prostate, major depressive disorder, dementia with behavior disturbance and chronic pain. Review of R44's activity attendance from 06/19/23 through 09/19/23 revealed R44 attended choir practice on 08/09/23 and on 08/21/23 R44 received a hair cut, shave and shampoo. No other activities were documented for June, July, August or September. Review of R44's comprehensive plan of care dated 11/07/19 under the category of activities states, He needs to be invited and assisted to activities of interest. He enjoys TV, music, singing, football and outside activities. The goals stated, Allow his preference of independent activities of choice through next review. Resident will attend group activities twice, weekly through next review. The interventions state, Staff will discuss with resident the monthly calendar to see which planned activities interest him and then remind him when scheduled. Resident has declined all group invitations. Will continue to invite and encourage participation. Invite and assist to activities of interest. During an interview on 09/20/23 at 11:40 AM the Activity Director stated that she is only one person and she has not invited him to activities as much as she should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and reviews of facility policy and procedure the facility failed to ensure prompt and thorough incontinent care was provided for two Residents (R)6 and R62. Furthermore, the facility failed to ensure R33 received baths for 3 of 5 residents reviewed for Activities of Daily Living (ADLs). Findings Include: Review of facility procedure guide titled Elimination and Toileting: Incontinence Prevention revealed, manage incontinence according to the client's care plan not for staff convenience. Furthermore Providing Peri-Care states urine and feces are very irritating to the skin and mucous membrane and will cause irritation and breakdown if not thoroughly and promptly removed. Review of the undated facility policy titled, Documentation: Charting Activities of Daily Living (ADLs) states, It is required for Activities of Daily Living (ADL) care given by a Certified Nursing Assistants and Nurses to be documented under Care Assist in patient's/resident's Electronic Health Record (EHR). For all healthcare centers not utilizing EHR, all documentation will be completed using the CNA ADL Flow Sheet Form. Review of R6's Face Sheet revealed R6 was admitted to the facility on [DATE] with diagnoses including but not limited to: Parkinson's disease, dysphagia, dementia, moderate protein calorie malnutrition and type 2 diabetes. Review of R6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/07/23 revealed a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicating R6 was severely cognitively impaired. During an observation on 09/17/23 at 11:55 AM revealed, R6 was laying in a urine-soaked bed without an absorbent pad underneath. R6 appeared to be wearing a visibly soaked tee shirt. During an observation on 09/18/23 at 9:41 AM revealed, R6 again lying in urine-soaked linens and clothes. Review of R62's Face Sheet revealed R62 was admitted to the facility on [DATE] with diagnoses including but not limited to: dementia, vascular dementia with behavioral disturbances, type 2 diabetes, acute cerebrovascular insufficiency, weakness and difficulty walking. Review of R62's annual MDS with an ARD of 06/28/23 revealed a BIMS score of 10 out of 15 indicating R62 was moderately cognitively impaired. During an observation on 09/17/23 at 11:55 AM revealed, R62 was sitting in bed and the sheets appeared to be covered in dried feces. A strong unpleasant odor was emanating from the room. During an interview on 09/17/23 at 12:05 PM, R62 stated that someone had been in his room that morning and stated that they would return to get him cleaned up but they never came back. During an observation on 09/18/23 at 9:41 AM revealed, R62 lying in a urine-soaked bed with a puddle of urine under his bed and on both sides of the bed, with a foul odor coming from the room. During an interview with on 09/17/23 at 12:25 PM, Certified Nursing Assistant (CNA)4 stated that this was her first time rounding and that she was unsure when the night shift had last rounded on the residents. CNA4 further stated that she had begun her shift at 7:00 AM but that there were only three staff members to care for the residents on this hall. During an interview on 09/18/23 at 10:07 AM, Licensed Practical Nurse (LPN)5 stated that she makes the CNAs schedule and normally has it posted by 6:30 AM, if there are no changes to be made. Furthermore, LPN5 states that CNAs are to make rounds on residents soon after getting a report from previous staff and then every two hours. During an interview on 09/19/23 at 3:28 PM, the Director of Health Services (DHS) states that he was unaware that residents did not receive proper ADL and incontinence care on 09/17/23. The DHS also states that it is his expectation that residents are cleaned in a timely manner and rounded on appropriately. Review of R33's Face Sheet revealed, the facility admitted R33 with diagnoses including, but not limited to: anoxic brain damage, hallucinations, repeated falls, muscle weakness, lack of coordination ad communication deficit. During an observation on 09/17/23 at 11:20 AM, revealed R33 laying in bed. R33's hair was not clean and the resident was wearing a hospital gown. The hospital gown had dried food on the chest area of the gown and R33 had food around her mouth. Review on 09/19/23 at 2:11 PM of the documentation for R33's bathing revealed in June 2023, R33 did not receive a bath on 06/01/2023, 06/02/2023, 06/03/2023, 06/05/2023, 06/06/2023, 06/07/2023, 06/09/2023. Also R33 did not receive any type of bath on 06/10/2023, 06/11/2023, 06/14/2023, 06/18/2023, 06/19/2023, 06/20/2023, 06/25/2023 or 06/28/2023. In July 2023, R33 had no documentation to ensure she received a bath on 07/02/2023, 07/03/2023, 07/04/2023, 07/09/2023, 07/10/2023, 07/12/2023, 07/17/2023, 07/21/2023, 07/23/2023, 07/25/2023, 07/26/2023 and on 07/31/2023. Furthermore, for the month of August 2023 R33 did not receive a bath of any type on 08/02/2023, 08/04/2023, 08/05/2023, 08/06/2023, 08/07/2023, 08/08/2023, 08/09/2023, 08/10/2023, 08/15/2023, 08/16/2023, 08/18/2023, 08/20/2023, 08/22/2023, 08/23/2023, and 08/24/2023. Further review of the documentation for baths revealed in September 2023, R33 was not documented as receiving a bath on 09/02/2023, 09/07/2023, 09/08/2023, 09/14/2023, 09/16/2023 and 09/17/2023. During an interview on 09/19/23 at 3:04 PM, the Director of Nursing (DON) offered no reasoning for the missed baths and stated it just may be the documentation was not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, observations and interviews, the facility failed to ensure that food was properly stored and labeled in 2 of 2 unit nourishment rooms. Findings include: Review of the facility policy titled Labeling, Dating, and Storage revised 11/11/22 revealed, It is the policy of PruittHealth for all partners who assist in handling, preparing, serving, and storing food and beverage items follow the proper procedures for labeling, dating and storage to ensure proper food safety. During an observation and interview on 09/18/23 at approximately 9:35 AM, the [NAME] Wing nourishment room refrigerator revealed that it was empty and unplugged from electrical outlet with an unopened 8 ounce container of whole milk sitting on counter which was warm to touch and labeled by manufacturer Keep refrigerated 33 degrees F (Fahrenheit) - 48 degrees F. These findings were confirmed on Certified Nursing Assistant (CNA)6 who stated she did not know why the refrigerator was unplugged. Further observation of the [NAME] Wing nourishment room on 09/18/23 at approximately 9:48 AM revealed the following: two clear, hand knotted, approximately 4 x 4 inch plastic bags containing an unidentified light brown colored chips, not properly labeled. A snack box located beside the refrigerator and one large opened bag of Blue Ribbon brown rice, inside a zip lock bag, not properly labeled. These findings were confirmed by Licensed Practical Nurse (LPN)6. During an observation on 09/18/23 at approximately 9:55 AM, the Palmetto Wing nourishment room was unlocked with wandering residents nearby and the refrigerator door identified as NOURISHMENT REFRIGERATOR'S with a statement which read: .Resident's personal foods may be stored (space permitted) if 1. The item is labeled with resident's name and the item is dated. Labels are available with the temperature log. NO STAFF PERSONAL ITEMS ARE ALLOWED IN THESE REFRIGERATOR'S: PLEASE USE THE REFRIGERATOR IN THE BREAK ROOM . and included a handwritten noted which stated please put 3 day date if you have anything in here. There was a Food Refrigerator Freezer Temperature Log labeled Palmetto Nourishment Refrig which showed that it was not being consistently checked each AM (morning) and PM (evening) temperatures as specified on the log. The refrigerator contained one container of a thick orange liquid in clear plastic cup which was not properly labeled, one plastic bag containing a Styrofoam clam shell container which was not properly labeled. Observation of the refrigerator freezer compartment revealed one large unidentified Styrofoam cup with a straw, which contained a frozen brown liquid not properly labeled, one unopened container of TGI (thank goodness it's) Friday Loaded Potato Skins not properly labeled, one opened container of [NAME] Strawberry Cheesecake ice cream not properly labeled, one unopened frozen cone of Blue Bunny Vanilla ice cream not properly labeled, one plastic bag containing a frozen bread-like material which was not properly labeled, and one opened and eight ounce container of Diet Shasta Ginger Ale not properly labeled. Further observation of the Palmetto Wing cabinets and counter top revealed one green plastic container with lid containing a multi-colored fruit loop like substance which was not properly labeled. During an interview on 09/18/23 at approximately 10:11 AM, these findings were confirmed by CNA5 who proceeded to discard the unidentified thick orange liquid in the sink.

Based on manufacturer's recommendations, observations and interviews, the facility failed to ensure an excessive amount of lint was removed from 2 of 2 clothes dryers, which has the potential to cause a fire. Findings include: Review of the manufacturer's recommendations for the clothes dryers, titled, Important Safety Instructions, states under number 12. Always clean the lint filter daily. Number 13, states, Keep area around the exhaust opening and adjacent surrounding area free from the accumulation of lint, dust, and dirt. During an observation on 09/19/23 at 3:10 PM, of the laundry room revealed 2 of 2 clothes dryers with an excessive amount of lint in the lint basket, on all 3 upper sides of the clothes dryer, and on the wiring. During an interview on 09/19/23 at 3:10 PM, Laundry Worker (LW)1 stated, when brought to her attention, we only keep the floor of the dryer clean, maintenance cleans around the wiring and the upper insides of the dryers. During an interview on 09/19/23 at 3:30 PM, the Housekeeping Supervisor stated that Maintenance cleans the wiring over the lint basket and upper insides of the dryers, and the backs of the dryers. During an interview on 09/19/23 at 3:45 PM, the Maintenance Director, provided a check off sheet where occasionally he cleans the inside of the dryers from lint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to complete Comprehensive Assessments within 14 calendar days after admission and not less than once every 12 months for nine (9) out of 24 residents reviewed for Minimum Data Set (MDS) completion. (Residents #3, #11, #37, #38, #47, #149, #154, #248, #249) Findings include: Review of the facility policy titled MDS (Minimum Data Set) Assessment Accuracy dated 10/24/18 revealed, admission Assessment (Comprehensive) must be completed no later than the 14th calendar day following the resident's admission. The Assessment Reference Date (ARD) must be no later than the 14th calendar date of the resident's admission. Annual admission Assessment (Comprehensive) ARD must be no later than 366 days from the ARD of the previous Omnibus Budget Reconciliation Act (OBRA) Comprehensive Assessment. Review of Resident #3's clinical record revealed s/he was admitted into the facility on 1/25/18. Review of the Annual MDS 3.0 dated 6/28/21 revealed no Registered Nurse (RN) Assessment Coordinator Signature verifying Assessment Completion as of 8/13/21. Review of Resident #11's clinical record revealed s/he was admitted to the facility on [DATE]. Review of the admission MDS Assessment revealed an ARD of 5/1/21 and a completion date of 5/22/21 more than 14 days after Resident #11 was admitted to the facility. Review of Resident #37 clinical record revealed s/he was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a completion date of 7/13/21. Review of Resident #38's clinical record revealed s/he was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a completion date of 7/24/21. Review of Resident #47's clinical record revealed s/he was admitted to the facility on [DATE]. Review of the Care Area Assessments (CAAs), on 8/12/21 for the MDS Assessment completed on 7/30/21 were not signed as completed by the Registered Nurse. Therefore the MDS Assessment was not completed within the 14 days of admission to the facility. Review of Resident #149's clinical record revealed s/he was admitted to the facility on [DATE]. Review of the admission MDS Assessment revealed an ARD of 7/29/21. Further review of the MDS revealed it was not completed as of 8/12/21. Review of Resident #154's clinical record revealed s/he was admitted to the facility on [DATE]. Review of the admission MDS revealed an ARD of 7/20/21. Further review of the MDS revealed it was not completed as of 8/12/21. Review of Resident #248's clinical record revealed s/he was admitted to the facility on [DATE]. Review of the facility admission Minimum Data Set (MDS) dated [DATE] revealed Resident #248 had an admission MDS Assessment completed and signed on 8/4/21 by a Registered Nurse (RN), more than 14 days after the ARD of 6/3/2021. Review of Resident #249's clinical record revealed s/he was admitted to the facility on [DATE]. Review of the facility admission Minimum Data Set (MDS) dated [DATE] revealed Resident #249 had an admission MDS Assessment not completed, dated or signed by a Registered Nurse (RN). The admission MDS remains more than 14 days after the ARD of 6/29/2021. Interview with the Administrator on 8/13/21 at 12:28 p.m. revealed the facility had two (2) Nurses that completed the MDS assessments. Those two (2) Nurses resigned when COVID started, and a Regional Nurse took over completing them. In February, the facility hired a Nurse to complete the MDS assessments and s/he resigned in May. At the present time, the facility had staff from outside this facility completing the MDS assessments. Interview with the Director of Health Services (DHS) on 8/13/21 at 1:47 p.m. revealed the MDS Assessments have been late for a while, since I got here in February at least. The DHS stated, Corporate has been handling the MDS assessments and are still behind.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to complete Quarterly Minimum Data Set (MDS) Assessments at least every 92 days for eight (8) of 24 residents reviewed for MDS completion. (Residents #1, #2, #8, #10, #30, #41, #42, #44) Findings include: Review of the facility policy titled MDS (Minimum Data Set) Assessment Accuracy dated 10/24/18 revealed, Quarterly Assessment (Non-Comprehensive) Assessment Reference Date (ARD) must be no later than 92 calendar days from the previous Omnibus Budget Reconciliation Act (OBRA) Assessment of any type. Review of Resident #'s1 clinical record revealed s/he was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed no Registered Nurse (RN) signature by 8/13/21. Resident of Resident #8's clinical record revealed s/he was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] and the next Quarterly MDS Assessment completed on 8/8/21. Review of Resident #10's clinical record revealed s/he was admitted into the facility on 4/1/15. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed no signature by an RN on 8/13/21. Review of Resident #30's clinical record revealed s/he was admitted into the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the RN signature on 7/2/21, more than 14 days after the ARD of 5/6/21. Review of Resident #41's clinical record revealed s/he was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a completion date of 8/1/21. Review of Resident #42's clinical record revealed s/he was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #42 had a Quarterly Assessment completed and signed on 8/1/21 by a RN, more than 14 days after the ARD of 6/23/2021. Review of Resident #44's clinical record revealed s/he was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a completion date of 8/1/21. Interview with the Administrator on 8/13/21 at 12:28 p.m. revealed the facility had two (2) Nurses that completed the MDS assessments. Those two (2) Nurses resigned at the start of COVID, and a Regional Nurse took over completing them. In February the facility hired a Nurse to complete the MDS assessments and he/she resigned in May. At the present time the facility had staff from outside this facility completing the MDS assessments. Interview with the Director of Health Services (DHS) on 8/13/21 at 1:47 p.m. revealed the MDS Assessments have been late for a while, since I got here in February at least. The DHS stated, Corporate has been handling the MDS assessments and are still behind.