**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure that Resident (R)66 was appropriately assessed and dosed for 1 of 5 residents reviewed for unnecessary medications. Findings included: The facility policy titled, Psychotropic Medication dated 1/18 stated: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Review of the electronic medical record (EMR) revealed R66 was admitted to the facility on [DATE] with diagnoses including but not limited to major depressive disorder, persistent mood [affective] disorder and dementia with behavioral disturbance. On 12/04/24 at approximately 11:30 AM, a review of the EMR for R66 revealed that all doses had been administered according to the following physician orders: 1. quetiapine (Seroquel) fumarate Tab (tablet) 25 mg (milligram)-Give 1 tablet orally at bedtime related to Major depressive disorder with Start Date 07/01/2024 2000 (8:00 PM) and D/C (discontinued) Date 11/11/24 1232 (12:32 PM). 2. quetiapine fumarate Tab 25 mg (milligram)-Give 2 tablet by mouth at bedtime related to INSOMNIA with Start Date 11/11/2024 2000 and D/C Date 11/20/24 1025 (10:25 AM). 3. quetiapine fumarate Tab 50 mg (milligram)-Give 1 tablet by mouth at bedtime related to INSOMNIA with Start Date 11/20/2024 2000 (8:00 PM). Further review of the EMR MAR (medication administration record) revealed the following physician order: Resident receives psychotropic medication. Monitor for the following behaviors: hitting, biting, yelling, kicking, resisting care, moaning, wringing hands, pacing, etc. every shift Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings. Active O7/1/2024 0700 (7:00 AM) . On 12/04/24 at approximately 11:42 AM, review of the EMR MAR/TARs (medication administration record/treatment administration record) revealed: -7/2024 behaviors charted Yes on 16th, 26nd, 29th day shift and 9th, 24th, 29th evening shift with no description of the behaviors -8/2024 behaviors charted Yes on 10th, 12th day shift with no description of the behavior -9/2024 behaviors charted Yes on 10th day shift and 12th evening shift with no description of the behaviors -10/2024 behaviors charted Yes on 5th, 8th and and 2nd evening shift with no description of the behaviors -11/2024 no behaviors charted -12/2024 through 12/4/2024 no behaviors charted On 12/04/24 at approximately 11:55 AM, review of the EMR revealed AIMS (Abnormal Voluntary Movement) scores on 11/11/2024 and 9/3/2024 = 0.0 (0-29), which indicate no behaviors. On 12/04/24 at approximately 12:10 PM, review of R66's hard paper chart located at the nursing station revealed the following notes by NP (Nurse Practitioner )1: -11/6/2024 CHIEF COMPLAINT: Requested to review his medications per his daughter who is on HIPPA list to evaluate for what she thinks are some symptoms that are worsening with paranoia. HISTORY OF PRESENT ILLNESS: The patient does have dementia and does not have any significant behavioral disturbances here. He had obstructive sleep apnea and BIPAP has been added at bedtime within the last year. He does fairly well with that bust does not wear it the entire night. He also denies any significant issues. Appetite is good. He reports his breathing has been fine. He denies any shortness of breath. No significant activities are reported per nursing staff. MEDICATIONS: Reviewed on MAR. For depression and rest he is on Seroquel 25 mg at bedtime and also as an adjunct for pain he is on duloxetine 20 mg daily. He has Gabapentin t.i.d. (three times daily) for chronic pain and uses some hydrocodone. We have not seen any oversedation. No significant falls have been reported. ASSESSMENT/PLAN: 1. Dementia with some concerns for paranoia. 2. Hypothyroidism. 3. Chronic obstructive pulmonary disease with obstructive sleep apnea. 4. Gastroesophageal reflux disease. 5. Depression. 6. Dementia. PLAN FOR THERAPY: We will request his recent labs to be reviewed. We will also try to discuss the concerns with his family members as well. Hate to adjust medications that would inhibit him more at night wearing his CPAP (continuous positive airway pressure). We will continue for chronic obstruction disease, his DuoNebs and budesonide b.i.d. (two times daily) Continue chronic pain medication. Certainly consider adjusting if paranoia is truly observed. We will also evaluate TSH (thyroid stimulating hormone). -11/11/2024 CHIEF COMPLAINT: Follow-up from last week's visit when I was requested to look at the medication list from the family. HISTORY OF PRESENT ILLNESS: The family called me back after a left a message on the 6th. They called me back today on the 11th to give me more clarity as to their concerns. The daughter reports that R66 heard his roommate talking loudly on the telephone to someone and it frightened him and made him feel that he was going hurt someone or hurt other ladies here although this is certainly what R66 is understanding. He does have difficulty hearing and is in room with a roommate and unsure if this certainly happened or not. The daughter is requesting that his medications be adjusted to see if he would be less worried and concerned about this. ASSESSMENT/PLAN: Dementia with some concerns for agitation. PLAN FOR THERAPY: We will increase his Seroquel to 50 mg at bedtime to try to improve the worries over the feeling that someone is going to hurt someone. We will follow up with this and continue to monitor very closely. Further review of the paper medical record revealed the following statement: 11/11/24; increase Serouquelto 50mgs po by (mouth) daily and HS (bedtime) signed by NP1. During an interview on 12/04/24 at 01:43 PM, NP1 stated that she had been working at this facility since 2023. When asked, she stated that she was unaware of the FDA Food and Drug Administration) and CMS (Centers for Medicare and Medicare Services) guidelines for prescribing Seroquel (quetiapine), but was aware of the black box warning. She stated that the daughter of R66 had expressed concern about R66 having been frightened by his roommate and had requested an increase in his Seroquel dose. NP1 stated that with some reluctance due to a recent room change and different roommate who talks loud, she had increased the dose from 25 mg to 50 mg. NP1 acknowledged that there had been no behaviors reported by staff or indication of behaviors on his AIMS assessments and proceeded to write an order decreasing the quetiapine dose for R66 back to 25 mg. During an interview on 12/04/24 at approximately 2:17 PM, Medical Director (MD)1 stated that he had been coming to this facility for quite a few years and also saw residents at another facility. When asked, he stated that in the case of R66 you have to look at his medical history and there may have been reason to increase the Seroquel dose, but he was unable to describe any specific behaviors beyond the one incident reported to the NP by the daughter, that could have warranted the Seroquel increase from 25 mg to 50 mg on 11/11/24. During an interview on 12/04/24 at approximately 3:42 PM, the Administrator and DON (Director of Nursing) stated that NP1 is employed by MD1, not the [NAME] Group, that issues related to psychotherapeutic medication are brought to QAPI (Quality Assurance and Performance Improvement) and when informed that no details related to the type of behavior could be found, stated that the American Health Tech (AHT, their previous EMR system) included those details. They were unsure if specifics related to observed behaviors was charted in Point Click Care which was implemented at the facility on 7/1/2024 and that they would further investigate and advise. During an interview on 12/05/24 at approximately 8:31 AM, the DON stated that behavior specifics were not presently included in PCC (Point Click Care) and that this issue was being worked on. The DON provided an attending MD note regarding R66 dated 11/15/24, stating it had been provided to her on the previous evening (12/4/24). The note stated: CHIEF COMPLAINT: Follow-up on chronic obstructive pulmonary disease and chronic pain. HISTORY OF PRESENT ILLNESS: Patient has had some worsening behavioral issues with worsening paranoia. Seroquel was increased. This seems to have improved. He is tolerating this without any other problems. Breathing seems to be stable. He starts with a CPAP at night but usually takes it off at some point. Chronic pain seems to be at baseline with what limited history we can get from him. ASSESSMENT/PLAN: 1. Severe obstructive sleep apnea. Continue BIPAP (bilevel positive airway pressure). 2. Chronic obstructive disease. Continue DuoNebs. 3. Chronic pain: Continue Lorcet 5/325 every 4 hours p.r.n. (as needed) as well as Gabapentin and duloxtine, 4. Dementia. Continue Aricept 10 mg daily. He does have some paranoia and psychosis involved. Increase Seroquel to 50 mg. 5. Depression. Again, continue Seroquel. On 12/05/24 at approximately 8:43 AM, review of November 2024 MAR paper copies provided by the DON revealed that Quetiapine 25 mg had been administered at bedtime from 7/1/24 through 11/10/14, was changed to 25 mg x 2 tablets (50 mg) at bedtime on 11/11/24, then changed to 50 mg (1 tablet) at bedtime on 11/20/24. On 12/05/24 09:04 AM during an interview, the Administrator and DON confirmed that the first Seroquel 50 mg bedtime dose was administered pursuant to physician orders on 11/11/24 and that the note from MD1 which had been received the previous evening (12/4/24) was dated 11/15/24.

Based on observations, facility policy review, record review, and interviews, the facility failed to anchor an indwelling urinary catheter for 1 of 1 Resident (R)19 reviewed for catheters. This failure had the potential to cause harm by failing to prevent tugging/pulling, dislodging of the catheter, infection or inflammation pain, as well as severe trauma to the urethra. Findings Include: Review of the policy titled, Catheter Care (Female), dated 04/2008 revealed, the facility staff will Anchor catheter tube, hold securely and cleanse down the center of catheter tube approximately 4 inches with wipe/washcloth. Review of the medical record revealed the facility admitted R19 on 09/22/22, with diagnoses including, but not limited to, Chron's inflammatory bowel disease, urinary tract infection, anxiety disorder, bipolar disorder, muscle weakness, cognitive communication deficit, and neuromuscular dysfunction of bladder. Review of R19's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 09/29/22 revealed R19 had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. The resident displayed no behaviors and required extensive assistance for self-performing dressing, eating, toilet use, and personal hygiene. The MDS revealed R19 was admitted with an indwelling catheter and coded as always incontinent of bladder and bowel function. Review of physician's orders dated 09/22/22 indicated, foley catheter care, once daily. Review of R19's care plan dated 10/12/22 indicates she requires extensive to total assistance with activities of daily living (ADLs) related to cognitive loss, impaired mobility, paraplegia, muscle weakness, abnormalities of gait, and need for assistance with personal care, potential for variation in level of assistance required to complete ADLs r/t [related to] above dx [diagnoses] problem statements. The approach for care suggests Check for incontinent episodes approx Q2 hrs and provide care as needed; resident has use of briefs for dignity; provide perineal care as needed; apply moisture barrier with care to promote skin integrity, wash and dry well after each incontinent episode; encourage good intake of fluids; observe for s/s of uti; obtain u/a nd c&s as ordered for s/s of uti; change foley cath 16 fr with 10ml bulb as ordered; foley cath care as ordered; change foley cath as ordered; document foley output as ordered; administer meds as ordered. Review of an interdisciplinary note dated 10/20/22 at 2:57 AM revealed, 1:45 AM res pulled out cath. Noted in bag urine reddish orange amount 450cc in bag. Attempting to replace foley, res being aggressive with staff and stating that she was going to pull out again because she didn't need it. Attempted to explain to res the reason for foley while res calling me all sorts of things. Res stated it hurts inside her. Explained to res she pulled out the foley bulb fully inflated. Replaced foley with 16fr foley with 10 cc bulb. Review of an interdisciplinary note dated 10/31/22 at 1:49 AM revealed, Res in bed with her eyes closed . Res states that foley feels uncomfortable and would like it out. Explained to res the need for the foley and the place on her butt. Res stated she understood and agreed. Incontinent of bowel and incontinent care given as needed on rounds. Observation of R19 on 12/01/22 at 9:50 AM revealed the surveyor was not able to visually verify an anchor on either of R19's legs. Observation of R19 on 12/01/22 at 10:52 AM revealed Licensed Practical Nurse (LPN)2 and Certified Nursing Assistant (CNA)4 moved R19 from her wheelchair to her bed to observe if an anchor was on her leg. R19 did not want her pants to be taken down, so LPN2 pulled her left pant leg up and was not able to feel or see an anchor for her foley catheter. During an interview on 12/01/22 at 10:30 AM, Registered Nurse (RN)2 revealed the reason R19 has a catheter was due to a sacral wound that she was admitted to the facility with. RN2 was unable to provide information related to R19 having an anchor for her catheter. When asked by the surveyor to provide an anchor that the facility would use for catheter residents, RN2 had to retrieve one from a mass supply closet, that was not on the unit. RN2 provided a cath-secure multipurpose tube holder plus. Concurrently, the Staff Development Coordinator was standing in proximity to the surveyor and RN2, as she listened to the conversation, she proceeded to offer to provide another form of catheter anchor that is available for use for residents as well. During an interview with the Director of Nursing (DON) on 12/01/22 at 11:59 AM, s/he revealed staff has been trained on catheter care and is aware of the facility's policy. The in-service provided to all staff is a hands-on return demonstration for each competency. The DON stated her expectations are for all nurses to go by the facility's policies and to establish proper care of no tears or draining and verifying nothing is coming out of the indwelling catheter and the resident is comfortable. All information for catheter care is documented in the MAR and in the nurse's notes. Additionally, the DON stated she is aware of the risks that could potentially happen if the anchor would have an adverse response due to it not being properly cleaned and anchored.

Based on review of the facility policy titled, Gastrostomy/PEG Tube Feeding, record review, observation, and interview, the facility failed to ensure Resident (R)47 received tube feeding timely as ordered by the Physician for 1 of 1 resident reviewed with tube feeding. Findings include: Review of the facility policy titled, Gastrostomy/PEG Tube Feeding, states under Policy, Feeding to be performed upon order of physician to provide hydration/tube patency. Number 12, states, Hang formula as ordered by the physician. The facility admitted R47 with diagnoses including, but not limited to, nutritional deficiency, cerebrovascular accident, aphasia, dysphasia, anemia and moderate protein calorie malnutrition. Review of the medical record for R47 revealed Physician's orders dated 11/2022. The orders revealed an order dated 11/18/22 for Jevity 1.5 to infuse at 55 milliliters per hour with a 30 milliliter flush per hour of water to infuse from 10:00 AM to 6:00 AM via a feeding pump and to take off at 6:00 AM. The Jevity 1.5 was to infuse for 20 hours. An observation on 11/30/22 at 11:52 AM revealed the tube feeding was not infusing as ordered. During an interview on 11/30/22 at 12:10 PM, Licensed Practical Nurse (LPN)1 confirmed that the tube feeding was not infusing as ordered at 10:00 AM and stated, I was making my way down the hall, and got tied up with other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of facility policy and procedure, the facility failed to ensure that 1 of 3 closed records for hospitalization received bed hold notice upon transfer. The findings include: On [DATE] at 09:56 am record review of R #97 revealed the resident was admitted with the following diagnoses including but not limited to Cerebral Infarction, unspecified, Nutritional Deficiency, unspecified, Essential hypertension, Hyperlipidemia, Anemia, Personal history of disease of the nervous system, Acute respiratory failure with hypoxia, Non-ST elevation myocardial infarction, COPD (chronic obstructive pulmonary disease), Cerebral cryptococcosis, Gastro-esophageal reflux disease without esophagitis, Constipation, Acute kidney failure, Gastrointestinal hemorrhage, Toxic encephalopathy, Sarcoidosis, Weakness, Acute posthemorrhagic anemia, Parkinson's disease, Abnormal levels of other serum enzymes, Dysphagia, Chronic kidney disease stage 3, Pressure ulcer, unstageable, Sepsis, Pneumonia, Cardiomegaly, diastolic CHF(congestive heart failure), Schizophrenia, Unspecified visual loss, Muscle wasting and atrophy, Muscle weakness, Cognitive communication and Pressure ulcer of sacral region, Stage 3. On [DATE] at 09:45 am record review revealed R #97 was transferred to the hospital on [DATE]. Further review of the chart revealed no signed bed hold notice provided to the resident's representative post the resident's transfer to the hospital on [DATE]. On [DATE] at 11:23 am interview with Social Worker (SW) #1 revealed that the bed hold information and transfer form are normally sent to the hospital with the resident but the forms were not sent to the representative because the patient expired the next morning. Review of the medical record revealed documentation of the the facility contacting the hospital on [DATE] at 10:16 AM, A review for notification of insurance benefits and bed hold document revealed no documentation of the resident expiring prior to this time. Facility policy, Bed Hold Policy/Reserve Payment Policy/ Notification of Bed Hold, revealed 2. Bed-Hold Notice upon Transfer: If a resident requires transfer to an acute hospital, the facility will offer the resident the opportunity of electing to have the bed held for 10 days. Upon admission, the facility will notify the resident or the resident's representative of the bed-hold option. The resident or the resident's representative is liable to pay reasonable charges, not to exceed thee resident's daily room rate, for the bed-hold period. Insurance may not cover such costs. Medicaid provides payment for a bed-hold up to 10 days .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure a Significant Change assessment was completed in a timely manner for Resident #79 for 1 of 5 residents reviewed for Nutrition. The findings included: The facility admitted R #79, on 3/16/2021, with diagnoses including but not limited to, Pneumonia, Decubitus Ulcers, Vascular Dementia, Acute Respiratory Failure, and Functional Quadriplegia. Review on 5/13/2021 at approximately 9:55 AM of the medical record for Resident #79 revealed an admission weight of 223.2 pounds. Further review of the medical record for R #79 revealed a weight on 3/31/2021 of 208.2 pounds. On 4/6/2021 R #79 weighed 197.5 pounds. R #79 continued to loose weight and by 4/29/2021 his/her weight was 184.2 lbs. A weight loss since admission of 39 pounds. Further review of the Minimum Data Set (MDS) revealed that a significant change assessment had not been completed for the weight loss. Additional review of the medical record for Resident #79 revealed that the Foley catheter had been removed and the decubitus ulcers were healed and a significant change had not been completed for R #79's MDS. An interview on 5/13/2021 at approximately 10:00 AM of the Nutrition Note by the Registered Dietician dated 5/3/2021 stated, Resident had an 11.5 percent significant weight loss x 30 days. The Registered Dietician recommended, Discontinue the Prostat AWC 2 times daily because the wounds have resolved. Add No Sugar Added Medpass 2 times daily related to weight loss. The Resident will benefit from additional kcal's to prevent additional weight loss. During an interview on 5/13/2021 at approximately 10:10 AM with the MDS/Care Plan Coordinator revealed that he/she was not agreeable that a Significant Change Assessment should have been completed for R #79. During an interview on 5/13/2021 at approximately 10:30 AM with the Registered Dietician, he/she stated that he/she likes to wait 2 weeks before reassessing the resident again even though R #79 had already lost 39 pounds since admission on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and review of the Hospice Services Agreement, the facility failed to ensure coordination of care for Resident #90 related to assessments by the Registered Nurse (RN), Certification, and visits by the Social Worker (SW) and the Chaplain for 1 of 1 residents reviewed for Hospice Care and Services. The findings included: The facility admitted R #90 with diagnoses including, but not limited to, Cancer, Pain, Repeated Falls, Oxygen Dependent and Pneumonia. admission to Hospice Care and Services was prior to admission. Review on [DATE] at approximately 1:55 PM of the Hospice notebook for coordination of care between the Hospice entity and the Nursing Home revealed an expired Recertification dated [DATE] as end of service. The last visit from the RN, which was ordered to visit one time weekly, had a full assessment dated [DATE]. No documentation could be found in the notebook, nor the facility to ensure that the Chaplain and the SW had visited but was ordered by the physician as monthly. An interview on [DATE] at approximately 2:15 PM with the Administrator and the DON confirmed that the Recertification, the full assessments by the RN and the visits from the Chaplain and the SW were not in the facility. The Administrator went on to say that he/she had to remind the Hospice entity to complete the visits assessments and to get them to the facility in a timely manner. The Certificate for continued Hospice Care and Services was faxed to the facility, dated [DATE] through [DATE], on [DATE] at 2:25 PM. Review on [DATE] at approximately 3:00 PM of the facility, Hospice Services Agreement, under, Responsibilities & Acknowledgements of Hospice: states, c. Hospice will coordinate care with the attending physician and the Hospital Medical Director. Hospice will give in writing, to the facility signed physician orders regarding care of the patients.d. Hospice will supplement Facility services by providing certain routine hospice Services in accordance with the Hospice Care Plan and will document its activities in Facility's Patient records as directed by the facility. Routine hospice care and services will include services required by the Hospice Care Plan will be accomplished through visits made by nurses, social workers, Chaplains and hospice health aides,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure interventions were put into place to ensure a decrease in weight loss and or no further weight loss for Resident #79 for 1 of 5 residents reviewed for Nutrition. The findings included: The facility admitted R #79, on 3/16/2021, with diagnoses including but not limited to, Pneumonia, Decubitus Ulcers, Vascular Dementia, Acute Respiratory Failure, and Functional Quadriplegia. Review on 5/13/2021 at approximately 9:55 AM of the medical record for R #79 revealed an admission weight of 223.2 pounds. Further review of the medical record for R #79 revealed a weight on 3/31/2021 of 208.2 pounds. On 4/6/2021 R #79 weighed 197.5 pounds. R #79 continued to loose weight and by 4/29/2021 his/her weight was 184.2 lbs. A weight loss since admission of 39 pounds. An interview on 5/13/2021 at approximately 10:00 AM of the Nutrition Note by the RD dated 5/3/2021 stated, Resident had an 11.5 percent significant weight loss x 30 days. The RD recommended, Discontinue the Prostat AWC 2 times daily because the wounds have resolved. Add No Sugar Added Medpass 2 times daily related to weight loss. The Resident will benefit from additional kcal's to prevent additional weight loss. R #79 was receiving fortified mashed potatoes for lunch and dinner. No other interventions or supplements were documented as attempted. During an interview on 5/13/2021 at approximately 10:30 AM with the RD, he/she stated that he/she likes to wait 2 weeks before reassessing the resident again even though R #79 had already lost 39 pounds since admission on [DATE].

Based on observation, interview, and review of manufacturer recommendations, the facility failed to ensure that blood glucose strips and blood glucose controls were properly labeled post opening and that a nutritional shake was used within the manufacturer's time frame for 2 of 4 medication carts. The findings are: On 05/12/2021 at 11:23 am observation of (2) Medication Carts revealed (2) Assure Platinum test strip bottles with no date when opened denoted on the bottles and (1) bottle of Assure Platinum controls with no date when opened for usage. On 05/12/2021 at 11:44 am interview with Licensed Practical Nurse (LPN) # 3 revealed I am unsure of how long the test strips and the glucose controls are good for once opened or how long they have been in use but I will look it up. Review of the manufacturer's guidelines for Assure Platinum Test Strips revealed, Storage and Handling: When you first open the vial, write the date on the vial label. Use the test strips within 3 months of first opening the vial . Review of the manufacturer's guidelines for Assure Dose Control Solution, revealed Storage and Handling: Use the control solution within 90 days (3 months) of first opening. It is recommended that you write the date of opening on the control solution bottle label (Date Opened) as a reminder to dispose of the opened solution after 90 days . On 05/12/2021 at 10:37 am observation of LPN #2 during medication administration revealed Med Pass 2.0 Nutritional Shake dated 05/11/2021 with no time when opened. On 05/12/2021 at 11:20 am interview with LPN #2 revealed Med Pass is pulled by the 3rd shift nurse and put on the medication cart. I use it until I leave at the end of my 8 (eight) hour shift. On 05/12/2021 at 1:43 pm observation of the medication cart for the 200 and 500 Halls revealed Med Pass Fortified Nutritional Shake noted opened at 8 am and dated as 05/12. On 05/12/2021 at 1:45 pm interview with LPN #1 revealed that I use it for 4 days until its completed. I get my own shake for my med cart and I opened it at 8 am this morning. Review of the manufacturer's guidelines revealed Storage and Handling, Store in a cool, dry area. Do not expose to moisture or heat. Do not freeze. After open, consume product within 4 days if properly refrigerated. After open, consume product within 4 hours if not refrigerated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility policy titled, Clinical Records the facility failed to update Immunizations and Medical Records for R #72 R #72 was admitted to the facility on [DATE] with the diagnosis including but not limited to Nutritional deficiency, Unspecified Abnormalities of Gait and Mobility, Pruritus', Nausea, Constipation, Pain, Adult Failure to Thrive, Restlessness and Agitation, Other Depressive episodes, Hypothyroidism, Nutritional Anemia, Hypoxemia, Shortness of Breath, Hyperkalemia, Hyper Osmolality and Hyponatremia, Fluid Overload, Diarrhea, Insomnia, Difficulty in walking, Allergic Rhinitis, Dyspnea, and, Chronic Congestive Heart Failure. R #72 has a BIMS (Brief Interview for Mental Status) of 13. An interview with R #72 on 5/12/2021 at 12:41 revealed that R #72 goes out to Dialysis on Tuesday ' s, Thursday ' s, and Saturday ' s and could not remember if they received the Second Dosage of the COVID-19 Vaccine (2/11/2021) but could recall going to Dialysis on that date. A record review of the progress notes on 5/12/2021 at approximately 1:30 PM revealed that R #72 on 2/11/2021 at 11:17 AM Resident out of the facility with Med-One transport for Dialysis appointment, no distress noted upon departure. A progress note on 2/12/2021 at 11:28 revealed that Late Entry: Resident returned to the facility via Med-One transport from Dialysis. Chest Catheter dressing dry and intact, resident denies pain/discomfort, call light within reach. A record review of R #72 Health Record revealed a COVID-19 Vaccination Card dated on 1/14/2021 (First Dosage) and 2/11/2021 (Second Dosage), and a COVID-19 Vaccination Intake Consent Form signed and dated on 1/8/2021 by R #72. An interview with the Administrator and DON (Director of Nursing) on 5/12/2021 at 2:20 PM revealed that C.V.S. Pharmacy made special accommodations and came earlier than scheduled on that date so that R #72 could receive the Second Dosage of the COVID-19 Vaccine and attend Dialysis. The Administrator stated that the facility used the COVID-19 Vaccination Card as their documentation and proof of Vaccine administration but did not update the R #72 Medical Record. Review on 5/13/2021 at approximately 12:00 PM policy tilted Clinical Record revealed that Nurse's notes containing observations made by the nursing personnel will document the resident's course of treatment.