**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled residents (6) had a Level II Preadmission Screening and Resident Review (PASRR) screening (a federally mandated program that requires all individuals applying for admission to or currently residing in a Medicaid-certified nursing facility to be screened to determine if they have a serious mental illness, intellectual disability, or developmental disability. Level I screening is conducted to identify if individual has a PASRR condition; if positive, a comprehensive Level II evaluation is performed to determine individual needs, appropriate placement, and services.) completed. Findings include:1. Record review of resident 6's PASRR dated 12/20/23 revealed:*She did not have an intellectual or developmental disability (IDD).*She did not have a serious mental illness.*She was not required to have a Level II PASRR unless she had a serious mental illness, IDD, or a significant change in her treatment needs. *She was admitted to the facility on [DATE]. *During her stay at the facility, she was diagnosed with anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) on 8/15/24.*During her stay at the facility, she was diagnosed with major depressive disorder (a mental health condition with persistent feelings of sadness, hopelessness, and loss of interest in activities) on 4/21/25.-A physician order was received on 8/29/24, and she was started on buspirone (an antianxiety medication used to treat anxiety) 7.5 milligram (mg) tablets three times daily to treat her anxiety.-A physician order was received on 11/21/24, and she was started on quetiapine (an antipsychotic medication used to treat a variety of mental health conditions) 25 mg tablet twice daily to treat her anxiety.-A physician order was received on 2/16/25, and she was started on bupropion (an antidepressant medication used to treat depression) 300 mg tablet daily to treat her anxiety.-A physician order was received on 4/21/25, and she was started on mirtazapine (an antidepressant medication) 15 mg tablet by mouth at bedtime.*She was discharged to a hospital on 7/16/25 and readmitted on [DATE].*She was diagnosed with dementia (a group of symptoms affecting memory, thinking, and social abilities) with behavioral disturbances (consistent, unhealthy pattern of behaviors that significantly interfere with daily functions) on 8/19/25.-A physician order was received on 8/26/25, and she was started on an additional dose of quetiapine 12.5 mg twice daily to treat her anxiety.*Her 8/13/25 Brief Interview for Mental Status (BIMS) assessment score was 0, which indicated she had severe cognitive impairment. She did not complete the assessment.-She had severely impaired daily decision-making skills, and she rarely/never understood others, so a staff assessment of her mental status was completed.-She had short-term and long-term memory problems, inattention (being easily distracted), and disorganized thinking (unclear flow of ideas).*During her stay at the facility, she was prescribed and taking an antipsychotic (a drug used to treat conditions like schizophrenia and bipolar disorder) medication and other psychotropic (drugs that affect a person's mental processes and behavior) medications to manage her diagnoses of anxiety, depression, and behaviors. *No documentation in her EMR indicated that a Level II PASRR had been completed with her significant change in treatment needs. 2. Interview on 8/21/25 at 10:05 a.m. with director of nursing (DON) B revealed:*She does not complete PASRR screenings.*She stated that PASRR screenings should be in the resident's EMRs.*She stated that social services designee (SSD) F was responsible for completing the residents' PASRR screenings. 3. Interview on 8/25/25 at 4:33 p.m. with social services director (SSD) F revealed: *She confirmed that she was responsible for completing the residents' PASRR screenings.*She stated that she was unaware that she should have completed PASRR Level II screenings if a resident experienced a significant change in their mental or physical condition.*She agreed residents should be referred to the local contact agency for a resident review upon a significant change in their mental or physical condition.*She confirmed that she had not completed a level II PASRR for resident 6.*She confirmed that resident 6 should have had a level II PASRR completed when she started on an antipsychotic medication. 4. Administrator A was out of the facility and not available for an interview throughout the survey. 5. Review of the facility's December 2023 PASRR policy revealed: *Purpose:*To ensure that Nursing Facility (NF) applicants and residents with Serious Mental Illness (SMI) or Mental Retardation (MR) are:- Placed appropriately (least restrictively).- Evaluated and admitted or allowed to remain in a NF only if they can be appropriately served in a NF.- Provided with the MI/MR services they need, including Specialized Services (SS).*Procedure:*PASRR evaluation and determination documents should be on the chart (current chart, not archived). In SD the following documents need to be available in the active chart:- Screening for Admissions to the Nursing Facility for Mental Illness, Mental Retardation, Developmental Disabilities.- PASRR Level I screening determination.- PASRR Level II screening determination.*PASRR findings and recommendations should be reflected in plan of care.*PASRR Resident Review requirement:- NF must refer a resident to the state mental health or mental retardation authority for RR [resident review] upon significant change in mental or physical condition.*MDS Significant Change in Status Assessment (SCSA):- Evaluation process required upon significant change in physical or mental conditions.- NF will need to have well developed protocol and definition of significance.- Establish NF standard operating procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure that a comprehensive care plan was developed within 14 days of their admission for four of four sampled residents (1, 7, 21, and 26) reviewed. Findings include:1. Review of resident 1's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. The first care plan was documented 19 days later on 9/10/24. 2. Review of resident 21's EMR revealed: She was admitted to the facility on [DATE]. *A baseline care plan dated 8/5/25 had areas that were partially filled out. *The areas that were filled out on the form included: -Initial goals, dietary orders, social services, activities of daily living (ADLs), special treatments, bowel and bladder, skin concerns, and physician orders. *The areas that were not filled out on the form included: -Therapy services, alarms and restraints, medications, discharge plans, and resident or caregiver education needs. *There was no documentation of the development of a comprehensive care plan after that baseline care plan. 3. Review of resident 12's EMR revealed the resident was admitted to the facility on [DATE]. The resident's comprehensive care plan was created 93 days later on 7/17/25. There have been no documented revisions to the comprehensive care plan since it was created on 7/17/25. 4. Review of resident 3's EMR revealed: *Her admission date was 6/12/25. *Her baseline care plan was completed on 6/13/25. *Her comprehensive care plan was developed on 7/18/25, 36 days from the date of her admission. 5. Interview on 8/21/25 at 2:55 p.m. with Minimum Data Set (MDS) nurse/assistant director of nursing (ADON) E revealed: *She was responsible for completing the resident's comprehensive care plans. -She stated, “I take responsibility,” and agreed that the above residents' comprehensive care plans were not created within 14 days of their admission. -She had purchased additional resources to support her learning process, including a care plan manual. 6. Interview on 8/25/25 at 12:42 p.m. with director of nursing (DON) B regarding the development of resident 3's comprehensive care plan revealed: *She confirmed resident 3's comprehensive care plan had not been completed within 14 days of her admission to the facility. *She would have expected all residents' comprehensive care plans to be completed within 14 days of their admission. 7. Review of the provider's 12/2023 Care Plan Policy and Procedure revealed: *”Basic Responsibility: MDS Coordinator or designee” *”Care plan will be developed by an interdisciplinary team with participation of the resident, family, and/or representative (when available). Care plans include active and historical diagnoses, goals and/or expected outcomes, specific nursing interventions so that any nursing staff member is able to quickly identify a resident's individual needs and to decrease the risk of incomplete, incorrect, or inaccurate care, and to enhance continuity of nursing care.” *”MDS Coordinator or designee will be in charge of notifying the following departments for completion of the care plan by day 14 of admission. Each discipline will update the care plan as changes occur between assessments and scheduled care conferences. -Social Services -Dietary -MDS Coordinator -Activities” *”Each discipline will update the care plan as changes occur between assessments and scheduled care conferences.” *”Care Plans will be reviewed quarterly, annually, and with any significant change in resident condition.” *”Care plans are written by exception from Resident Centered Care Plan Facility Standards and Short Term Care Plans. They include measurable outcomes and identify interventions that are specific to the individual resident with defined time frames and parameters. Target dates are through next review period unless otherwise specified.”

Based on observation, interview, record review, and policy review, the provider failed to ensure that three of three sampled residents (3, 5, and 8) who used bed rails/bars attached to the bed had other attempted interventions documented. Findings include: 1. Observation and interview on 8/20/25 at 2:48 p.m. with resident 5 revealed:*Her bed had quarter bed rails attached to the sides of her bed, and they were in the up position.*She stated she had asked for bed rails to be installed on her bed so she could use them to get in and out of bed.*She did not remember signing a consent form, or having other alternatives attempted before the bed rails were installed on her bed. Review of the resident 5's signed 7/1/25 Bed Rails Informed Consent for Use revealed the area to document Alternatives considered but not attempted because they were considered inappropriate included a handwritten note of Resident Requested. 2. Observation and interview on 8/21/25 at 10:45 a.m. with resident 8 revealed:*Her bed had a bed rail on the right side of her bed, in the up position.*She stated she had asked for the bed rail to help her get in and out of bed.*She thought she had signed a consent form but was not certain. Review of resident 8's electronic medical record (EMR) revealed:*Her 8/21/25 care plan included that she used a transfer loop [bed] to maximize her independence with turning and repositioning in bed.*Her 4/25/25 Bed Rail Assessment included: she was non-ambulatory, she had a history of falling, she displayed poor bed mobility or difficulty moving to a sitting position on the side of the bed, she had difficulty with balance or poor trunk control, she had expressed a desire to have Side Rails/Assist Bar (bed rail) for safety and comfort.-The area that documented Side Rail Placement included bilateral (both sides) bed rails to serve as an enabler to promote independence, and she expressed a desire to have Side Rails/Assist Bar.*Her 7/25/25 Bed Rail Assessment had been started but was not completed. Resident 8's 7/8/25 Bed Rails Informed Consent for Use, signed by her representative, revealed:*She used an upper, left side, one-quarter bed rail.*The area to document Alternatives considered but not attempted because they were considered inappropriate included a handwritten note of N/A [not applicable] This is per resident request. 3. Observation on 8/25/25 at 10:20 a.m. with resident 3 revealed:*The right side of her bed had a bed rail attached to it, and it was in the up position.*She stated she used the bed rail to help her to sit up when she was in her bed. Review of resident 3's EMR revealed:*Her admission date was 6/12/25.*Her 6/12/25 baseline care plan indicated she used a one-quarter right bed rail on her bed.*Her 6/12/25 Bed Rail Assessment included: she had a history of falling, she displayed poor bed mobility or difficulty moving to a sitting position on the side of the bed, she had postural hypertension, she had not expressed a desire to have Side Rails/Assist Bar for safety and/or comfort, and she was visually challenged.-The area that documented Side Rail Placement included a side rail on the right side and that she expressed a desire to have Side Rails/Assist Bar.-There were no documented attempts for alternatives to bed rails. *Her EMR did not include any documented attempts at alternatives to bed rails. Resident 3's signed 7/21/25 Bed Rails Informed Consent for Use revealed:*She used an upper, left-sided, one-quarter bed rail.*The area to document Alternatives considered but not attempted because they were considered inappropriate included a handwritten note of N/A - Resident Requested. 4. Interview on 8/21/25 at 2:55 p.m. with Minimum Data Set nurse (MDS)/assistant director of nursing (ADON) E regarding resident use of side rails on their beds revealed:*Every three months, a side/bed rail assessment was to be completed for each resident.*Side/bed rails are used for mobility and positioning and are coded as a restraint on those residents' MDS assessments. Interview on 8/25/25 at 12:40 p.m. with director of nursing (DON) B regarding residents' use of side/bed rails revealed:*When a resident was admitted , and they requested a side rail, one was attached to their bed.-There were no alternatives to the side rails attempted before they were provided to the resident.*She was not aware that alternatives needed to be attempted before providing the resident with a side rail. 5. Review of the provider's 12/2023 Proper Use of Bed Rails policy revealed:*Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails.*The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs.*The facility will attempt to use appropriate alternatives prior to installing or using bed rails. Alternatives include, but are not limited to:-a. Roll guards-b. Foam bumpers-c. Lowering the bed-d. Concave mattresses*If no appropriate alternatives are identified, the medical record should include evidence of the following:-a. Purpose for which the bed rail was intended and evidence that alternatives were tried and were not successful.

Based on observation, interview, and record review, the provider failed to ensure the required daily nurse staffing information, including the total number and actual hours worked by licensed and unlicensed nursing staff, and the resident census was current and posted daily. Findings include: 1. Observation on 8/25/25 at 3:15 p.m. of the posted nurse staffing information revealed:*The form was posted on a board outside the activities room.*Staff scheduled to work that day were listed by shift: AM [day] SHIFT (6A-6P) and NOC [night] SHIFT (6P-6A).*Below each shift, a list of pod one, pod two, and pod three, with the name of a staff member next to it, was on that form.-There were three hallways in the facility with resident rooms, which the staff called pods.*No categories to indicate whether each nursing staff member listed was a registered nurse (RN), licensed practical nurse (LPN), or certified nursing assistant (CNA) were included on that form.*The total number of RN, LPN, and CNA staff members who were scheduled to work was not listed on that form.*The staff members' hours worked were combined and listed for each shift in the Total Hours area on that form.*A separate piece of paper was posted above the nurse staffing information form that listed room numbers and the names of the residents who resided in those rooms. It did not specify the total number of residents in the facility (resident census).-The date on that resident listing indicated it had last been updated on 8/12/25. 2. Interview on 8/26/25 at 10:01 a.m. with director of nursing (DON) B revealed:*Business office manager (BOM) H was responsible for posting the daily nurse staffing information form.*She thought that BOM H had been updating that form if there was a staffing change.*DON B was unaware that the total number and actual hours worked by each nursing staff's discipline, and the current resident census, should have been listed on the posted staffing information form. 3. Interview on 8/26/25 at 10:47 a.m. with BOM H revealed:*She was not aware that the total number and actual hours worked by each nursing staff's discipline, and the current resident census, should have been listed on the posted staffing information form. *She updated the staffing information form when there was a staffing change, but those updates usually happened a week later and were used for their internal record-keeping.*She was not aware that the posted staffing information needed to be updated daily to reflect the current staffing of the facility for the residents and visitors to review. 4. A policy regarding posting nursing staffing information was requested for review on 8/26/25. DON B stated the provider did not have a specific policy related to posting nursing staffing information.

Based on observation and interview, the provider failed to ensure the bed/side rails for three of three sampled residents (3, 5, and 8) who had side rails on their beds were inspected for safety, including entrapment (being caught between bed system parts) risk, before being placed on the residents' beds and were monitored after installation to ensure they were maintained in safe conditions for use and free of entrapment risks.Findings include: 1. Observation on 8/20/25 at 2:48 p.m. with resident 5 revealed her bed had one-fourth-size side rails attached to the sides of her bed, and they were in the up position. 2. Observation and interview on 8/21/25 at 10:45 a.m. with resident 8 revealed her bed had a side rail on the right side of her bed, in the up position. 3. Observation on 8/25/25 at 10:20 a.m. with resident 3 revealed the right side of her bed had a side rail attached to it, and it was in the up position. 4. Interview on 8/25/25 at 12:35 p.m. with maintenance manager G revealed:*When the nursing department notified him that a resident wanted side rails attached to their bed, he would install side rails to that resident's bed.*He had not performed routine maintenance or checked to ensure the safety of the side rails on resident beds, including entrapment. Administrator A was not in the facility and not available for an interview throughout the survey. 5. Review of the provider's 12/2023 Proper Use of Bed Rails policy revealed:*If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails. - Assessment of the resident, the bed, the mattress, and rail for entrapment risk (which would include ensuring bed dimensions are appropriate for resident size/weight.*The facility will assure the correct installation and maintenance of bed rails, prior to use. This includes:-a. Checking with the manufacturer(s) to make sure the bed rails, mattress, and bed frames are compatible.-b. Ensuring that the bed's dimensions are appropriate for the resident by:- Inspecting and regularly checking the mattress and bed rails for areas of possible entrapment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure that two of two sampled residents (6 and 7), who experienced two or more areas of decline from their baseline conditions, had a significant change in status assessments completed related to fractures that resulted from their falls. Findings include:1. Review of resident 6's electronic medical record (EMR) revealed: *She was admitted to the facility on [DATE] and readmitted on [DATE]. *Her diagnoses included dementia (a group of symptoms affecting memory, thinking, and social abilities) with behavioral disturbances (consistent, unhealthy pattern of behaviors that significantly interfere with daily functions), major depressive disorder (a mental health condition with persistent feelings of sadness, hopelessness, and loss of interest in activities), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). *Her 8/13/25 Brief Interview for Mental Status (BIMS) assessment score was 0, which indicated she had severe cognitive impairment. She did not complete the assessment. -She had severely impaired daily decision-making skills, and she rarely/never understood others, so a staff assessment of her mental status was completed. -She had short-term and long-term memory problems, inattention (being easily distracted), and disorganized thinking (unclear flow of ideas). *She fell in her room on 7/16/25 and was taken to the emergency room by ambulance. *She was hospitalized on [DATE] with a diagnosed fracture of her left hip and returned to the facility on 8/6/25. *Her Minimum Data Set (MDS) assessments (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) had been completed quarterly. *Her MDS dated [DATE] was not coded for dementia. *A significant change MDS assessment was not completed to reflect her significant status changes related to: -A left hip fracture that required surgical repair. -An increase in mental status changes. -An impairment to her lower extremity (leg). -An increase in pain. --She was started on an opioid (medication to treat moderate to severe pain) medication for additional pain control. -A decline in her activities of daily living (ADLs). --Her oral hygiene assistance changed from having needed setup help to needing partial/moderate staff assistance. --Her toileting hygiene changed from having been independent to requiring substantial or maximum staff assistance. --Her shower/bath assistance needs increased from partial/moderate help to being dependent on staff for bathing. --Her walking with a walker, covering all distances, changed from having been independent to needing partial or moderate staff assistance to walk ten feet. --Her positioning in bed and sitting up changed from having been independent to partial/moderate staff assistance. --Her chair, bed, and toilet transfers changed from having been independent to partial/moderate staff assistance. --Her ability to move around in her wheelchair changed from having been independent to dependence on staff. 2. Interview on 8/21/25 at 2:55 p.m. with Minimum Data Set (MDS) nurse/assistant director of nursing (ADON) E revealed: *She was hired on 12/2/24 as a full time employee. -Her roles and responsibilities included ADON and MDS nurse. *She confirmed that she was responsible for completing the residents' MDS assessments. *She stated she was still learning the process on her own, following the MDS manual instructions, and had a lot to learn. -She stated, “I take responsibility,” and she had purchased additional resources to support her learning process. -She needed a minimum of six months of experience with the MDS process before testing. *She stated that she had not completed the course training to become MDS certified, but had recently signed up to get the class completed. *She confirmed that she had not completed significant change assessments with residents who experienced a change in condition. 3. Review of resident 7's EMR revealed: *Her admission date was 5/16/24. *Her diagnoses included: dementia with behaviors, a history of falling, pain in her right hip, anxiety, and diabetes (a condition involving disruptions in how the body regulates blood sugar). *Her 3/2/25 BIMS assessment score was a 1, which indicated she had severe cognitive impairment. *On 5/31/25, she had transferred herself out of her bed, into her wheelchair, and then she fell out of the wheelchair and onto the floor. -She had an “open gash” to her left eyebrow, a skin tear (torn skin) to her left knee, and her left forearm, and she complained of pain in her “left leg”. -She was transferred to the emergency department and then admitted to the hospital with a diagnosis of a non-operative “Greater Trochanter” (bony prominence located at the upper end of the thigh bone) fracture. *She was readmitted to the facility on [DATE], with a nurse progress note that indicated “Resident readmits with a scab to her left eyebrow. She has bruising on various locations at various healing stages to her left side. She has a large, swollen, deep bruise [bruised] area the side [size] of a tennis ball to her left hip. Resident bruising r/t [related to] fall.” *A significant change MDS assessment was not completed after her return from the hospital, to reflect her significant status changes related to: -Prior to falling, she “frequently attempts to ambulate to look for her husband and often forgets to use her walker”. She was able to walk with the assistance of a staff member and the use of a walker. Staff provided her with mobility throughout the facility with a wheelchair. -After she fell, and her thigh bone was fractured, she was unable to walk and needed staff assistance to transfer and reposition in and out of her bed. -Her cognition had declined. 4. Interview on 8/25/25 at 12:32 p.m. with MDS nurse/ADON E revealed: *Resident 7 was hospitalized on [DATE] with a fractured thigh bone, after she had fallen. She returned to the facility on 6/17/25. *MDS nurse/ADON E confirmed a significant change MDS should have been completed when resident 7 returned from the hospital. -She stated resident 7's ADL needs had changed after her 5/31/25 fall, primarily in the areas of bed mobility and ambulation. She used a walker before the fall, and after she fell, she used a wheelchair. -She indicated she had no training on the completion of a resident's MDS. 5. Review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1 October 2024 revealed: *A “significant change” is a major decline or improvement in a resident's status that: -“1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered “self-limiting”;” -2. Impacts more than one area of the resident's health status; and -3. Requires interdisciplinary review and/or revision of the care plan.” *Decline in two or more of the following: Resident's decision-making ability has changed; -Presence of a resident mood item not previously reported by the resident or staff and/or an increase in the symptom frequency (PHQ-2 to 9©), e.g., increase in the number of areas where behavioral symptoms are coded as being present and/or the frequency of a symptom increases for items in Section E (Behavior); -Changes in frequency or severity of behavioral symptoms of dementia that indicate progression of the disease process since the last assessment; -Any decline in an ADL physical functioning area (e.g., self-care or mobility) (at least 1) where a resident is newly coded as partial/moderate assistance, substantial/maximal assistance, dependent, resident refused, or the activity was not attempted since last assessment and does not reflect normal fluctuations in that individual's functioning; -Resident's incontinence pattern changes or there was placement of an indwelling catheter; -Emergence of unplanned weight loss problem (5% change in 30 days or 10% change in 180 days); -Emergence of a new pressure ulcer at Stage 2 or higher, a new unstageable pressure ulcer/injury, a new deep tissue injury or worsening in pressure ulcer status; -Resident begins to use a restraint of any type when it was not used before; and/or -Emergence of a condition/disease in which a resident is judged to be unstable”.

Based on observation, interview, record review, Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.19.1 October 2024 review, the provider failed to ensure two of two sampled residents' (3 and 4) Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessments were accurately coded for the area of restraints. Findings include: 1. Observation on 8/19/25 at 11:10 a.m. of resident 4's room revealed her bed had a side rail attached to it, on the left side of the bed, and it was the up position. 2. Observation on 8/25/25 at 12:20 p.m. of resident 4 in her bed, revealed the left side rail was in the up position. 3. Review of resident 4's medical record revealed:*Her admission date was 10/10/24.*Her 7/14/25 Brief Interview of Mental Status assessment (BIMS) score was an 8, which indicated she had moderate cognitive impairment.*Her diagnoses included: adjustment disorder (mental health condition characterized by emotional or behavioral symptoms that develop in response to a stressful life event), anxiety (the apprehensive anticipation of future danger or misfortune, accompanied by feelings of distress, sadness, or symptoms such as restlessness or irritability), depression (depressed mood or loss of interest and pleasure), intellectual disability, hearing loss, insomnia (sleep disorder), osteoarthritis (a common joint disease that causes pain, stiffness, and swelling), and heart failure (condition in which the heart cannot fill with enough blood or pump blood with enough force to meet the body's needs).*Her 7/10/25 Bed Rail Assessment indicated she used the left side rail on her bed to serve as an enabler to promote her independence while in bed. *Her 8/20/25 care plan indicated:-She needed partial assistance of one staff member for transferring from one surface to another.-There was a transfer loop (side rail) on her bed to maximize her independence with turning and repositioning when in her bed.*Her 8/16/25 MDS was coded that she used a side rail as a restraint.-There was no other indication in her EMR of a restraint being used. 4. Review of resident 3's medical record revealed:*Her admission date was 6/12/25.*Her 6/12/25 BIMS assessment score was a 15, which indicated her cognition was intact.*Her diagnoses included: depression, pain in her left shoulder and arm, weakness, abnormal gait (walk) and mobility, chronic pain, amnesia, heart failure, and incontinence (involuntary urine or bowel leakage).*Her 6/25/25 Bed Rail Assessment indicated she had requested and used a side rail on the right side of her bed.*Her 8/25/25 care plan did not include that she used a restraint or a side rail.*Her 6/25/25 MDS was coded that she used a side rail as a restraint.-There was no other indication in her EMR of a restraint being used. 5. Interview on 8/21/25 at 2:55 p.m. with MDS Nurse/ADON E regarding coding side rails as restraints on a resident's MDS assessment revealed:*She was responsible for ensuring MDS assessments were completed.*She completed a residents' side rail assessment every quarter, and used that information to complete the resident's MDS assessment.-The side rails were used for the residents' mobility and positioning when in bed.*She confirmed the bed/side rails were not restraints.-She had coded the side rails as restraints on the residents' MDS, as that is how she understood the instructions in the RAI manual.-She confirmed she had not reviewed the entire section of the RAI manual related to restraints and how to code a side rail if it was not a restraint.*She had been the MDS nurse for about six months and was just learning the process.-She had not had any formal training in how to complete an MDS. 6. Review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1 October 2024 revealed: SECTION P: RESTRAINTS AND ALARMSIntent: The intent of this section is to record the frequency that the resident was restrained by any of the listed devices or an alarm was used, at any time during the day or night, during the 7-day look-back period. Assessors will evaluate whether or not a device meets the definition of a physical restraint or an alarm and code only the devices that meet the definitions in the appropriate categories.*Coding Instructions*Identify all physical restraints that were used at any time (day or night) during the 7-day look-back period. After determining whether or not an item listed in (P0100) is a physical restraint and was used during the 7-day look-back period, code the frequency of use:-Code 0, not used: if the item was not used during the 7-day look-back period or it was used but did not meet the definition.*Bed rails include any combination of partial or full rails (e.g., one-side half-rail, one-side full rail, two-sided half-rails or quarter-rails, rails along the side of the bed that block three-quarters to the whole length of the mattress from top to bottom, etc.). Include in this category enclosed bed systems. Bed rails used as positioning devices. If the use of bed rails (quarter-, half- or three-quarter, one or both, etc.) meet the definition of a physical restraint even though they may improve the resident's mobility in bed, the nursing home must code their use as a restraint at P0100A.*Bed rails used with residents who are immobile. If the resident is immobile and cannot voluntarily get out of bed because of a physical limitation or because proper assistive devices were not present, the bed rails do not meet the definition of a physical restraint. For residents who have no voluntary movement, the staff need to determine if there is an appropriate use of bed rails. Bed rails may create a visual barrier and deter physical contact from others. Some residents have no ability to carry out voluntary movements, yet they exhibit involuntary movements. Involuntary movements, resident weight, and gravity's effects may lead to the resident's body shifting toward the edge of the bed. When bed rails are used in these cases, the resident could be at risk for entrapment. For this type of resident, clinical evaluation of alternatives (e.g., a concave mattress to keep the resident from going over the edge of the bed), coupled with frequent monitoring of the resident's position, should be considered. While the bed rails may not constitute a physical restraint, they may affect the resident's quality of life and create an accident hazard. *In classifying any manual method or physical or mechanical device, material or equipment as a physical restraint, the assessor must consider the effect it has on the resident, not the purpose or intent of its use. It is possible that a manual method or physical or mechanical device, material or equipment may improve a resident's mobility but also have the effect of physically restraining them.*Definition Physical Restraints-Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body (State Operations Manual, Appendix PP).- Remove easily means that the manual method or physical or mechanical device, material, or equipment can be removed intentionally by the resident in the same manner as it was applied by the staff (e.g., side rails are put down or not climbed over, buckles are intentionally unbuckled, ties or knots are intentionally untied), considering the resident's physical condition and ability to accomplish their objective (e.g., transfer to a chair, get to the bathroom in time).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure the resident or the resident's representative was involved in the development of a baseline care plan and given a copy of that care plan within 48 hours of admission for four of four sampled residents (1, 7, 21, and 26) reviewed. Findings include: 1.Review of resident 7's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *The resident had a resident representative who acted on her behalf. *There was no documentation to support her (date) baseline care plan was reviewed and acknowledged [ML1] [DW2] by resident 7 or her representative. *There was no documentation that resident 7 or her representative was involved with the development of the baseline care plan or given a copy of it. 2. Review of resident 21's EMR revealed: *A baseline care plan dated 8/5/25 had areas that were partially filled out. *The areas that were filled out on the form included: -Initial goals, dietary orders, social services, activities of daily living (ADLs), special treatments, bowel and bladder, skin concerns, and physician orders. *The areas that were not filled out on the form included: -Therapy services, alarms and restraints, medications, discharge plans, and resident or caregiver education needs. *The form was signed by director of nursing (DON) B, social services director (SSD) F, and Minimum Data Set (MDS) nurse/assistant director or nursing (ADON) E. *There was a section at the end of the form that indicated “Written Summary of Baseline Care Plan (To be delivered to resident/responsible party no later than [the] completion of [the] comprehensive care plan).” *There was no documentation that the resident or resident representative was involved with the development of the baseline care plan or given a copy of it. 3. Review of resident 1's EMR revealed: *She was admitted to the facility on [DATE]. *The baseline care plan was completed on 8/27/24 by previous DON R. *There was no documentation that the resident was involved with the development of the baseline care plan or given a copy of it. 4. Review of resident 26's EMR revealed: *She was admitted to the facility on [DATE]. *The first baseline care plan was developed on 11/18/24. That care plan did not include any documentation of the resident involvement. *There was no documentation that the resident was involved with her care plan until 12/6/24. 5. Interview on 8/21/25 at 2:46 p.m. with certified nurse aide (CNA) M revealed: *She was a contracted CNA and had started at the facility three days ago. *She was given pocket care plans (a document that identifies residents' care needs and interventions) along with task lists to be completed at the beginning of her shifts. *She had not been there long enough to see the process for developing a care plan for a newly admitted resident. 6. Interview on 8/21/25 at 2:51 p.m. with unlicensed medication aide (UMA) K revealed she thought that when a resident weas admitted to the facility, SSD F would complete the resident assessment and provided the CNAs with a paper outlining how to care for the basic needs of the new resident. 7. Interview on 8/21/25 at 2:55 p.m. with MDS nurse/ADON E revealed: *DON B completes the resident baseline care plan upon admission. *She confirmed that care plans are not being updated from the baseline care plan as the residents' care needs change. 8. Review of the provider's 12/2023 Care Plan Policy and Procedure revealed: *”Basic Responsibility: MDS Coordinator or designee” *”Care plan will be developed by an interdisciplinary team with participation of the resident, family, and/or representative (when available). Care plans include active and historical diagnoses, goals and/or expected outcomes, specific nursing interventions so that any nursing staff member is able to quickly identify a resident's individual needs and to decrease the risk of incomplete, incorrect, or inaccurate care, and to enhance continuity of nursing care.” *”Upon admission, resident will be assessed by the Charge Nurse and a baseline care plan will be developed with information gathered from the resident and resident's family within 48 hours of their admission.”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure the resident's care plan was reviewed and revised to reflect the current necessary care needs for six of six sampled residents (5, 6, 12, 21, and 26). Findings include: 1. Review of resident 6's electronic medical record (EMR)revealed: *She was admitted to the facility on [DATE] and readmitted on [DATE]. *Her diagnoses included dementia (a group of symptoms affecting memory, thinking, and social abilities) with behavioral disturbances (consistent, unhealthy pattern of behaviors that significantly interfere with daily functions), major depressive disorder (a mental health condition with persistent feelings of sadness, hopelessness, and loss of interest in activities), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). *Her 8/13/25 Brief Interview for Mental Status (BIMS) assessment score was 0, which indicated she had severe cognitive impairment. She did not complete the assessment. -She had severely impaired daily decision-making skills, and she rarely/never understood others, so a staff assessment of her mental status was completed. -She had short-term and long-term memory problems, inattention (being easily distracted), and disorganized thinking (unclear flow of ideas). *She fell in her room on 7/16/25 and was hospitalized for a left hip fracture. *She returned to the facility on 8/6/25. *Her 2/7/24 care plan was not revised to reflect her changed condition upon her re-admission on [DATE] after she fell and sustained a left hip fracture regarding: -Her left hip fracture, sustained from falling that was surgically repaired. -Her impairment of her left lower extremity (leg). -Her weight-bearing status. -Her need for physical therapy services. -Her increased pain and the start of the opioid pain medication, tramadol, on 7/25/25. -Her change in mental status. --Disorganized thinking and altered level of consciousness. -Her dementia with behaviors. -Her decline in her ADLs. --Her oral hygiene assistance changed from setup help to partial/moderate staff assistance. --Her toileting hygiene changed from independence to requiring substantial or maximum staff assistance. --Her shower/bath assistance decreased from partial/moderate help to staff-dependent. --Her walking with a walker, covering all distances, changed from independent to needing partial or moderate staff assistance to walk ten feet. --Her positioning in bed and sitting up changed from independent to partial/moderate staff assistance. --Her chair, bed, and toilet transfers changed from independent to partial/moderate staff assistance. --Her ability to move around in her wheelchair changed from independent to staff dependence. -Her use of an anticoagulant (a medication that helps prevent blood clots from forming by slowing down the body's clotting mechanisms). --She had an order for one Eliquis 2.5 mg tablet two times daily. *Her psychotropic medications, monitoring for their side effects, gradual dose reductions, and monthly pharmacy and physician reviews were not included in the care plan. 2. Interview on 8/21/25 at 2:55 p.m. with MDS nurse/ADON E revealed: *She was hired on 12/2/24 as a full-time employee. -Her roles and responsibilities included ADON and MDS nurse. *She confirmed that she was responsible for completing and revising the residents' comprehensive care plans. *She confirmed that the revisions had not been completed with new orders or as areas were resolved or changed. *She stated that DON B completed the baseline care plans. *She stated she was still learning the process on her own, following the MDS manual instructions, and had a lot to learn. -She stated, “I take responsibility,” and she had purchased additional resources to support her learning process, including a care plan manual. -She needed a minimum of six months of experience with the MDS process before testing. *She stated that she had not completed the course training to become MDS certified, but had recently signed up to get the class completed. 3. Interview on 8/25/25 at 12:05 p.m. with DON B revealed: *Care plans were located at the nurses' station for staff to utilize. *Nursing staff also used walking care plans (a personalized document that assesses the residents' specific actions and treatments that need to be implemented during their daily care) when working on the floor. *She stated that baseline and comprehensive care plans were available in the residents' EMRs. 4. Review of resident 1's EMR revealed: *She was admitted to the facility on [DATE]. The first care plan was documented 19 days later on 9/10/24. *Her care plan included 25 areas of focus with listed interventions. -21 of the 25 areas in her care plan had no documented updates to the interventions since 9/12/24. 5. Review of resident 21's EMR revealed: *She was admitted to the facility on [DATE]. *There was no documentation of the development of a comprehensive care plan after the baseline care plan was completed with missing interventions. 6. Review of resident 26's EMR revealed: *She was admitted to the facility on [DATE]. The first care plan was created on 11/11/24. *Her care plan included ten areas of focus with listed interventions. -Six of the ten areas had no documented revision after 11/18/24. 7. Review of resident 12's EMR revealed: *The resident was admitted to the facility on [DATE]. The comprehensive care plan was created 93 days later on 7/17/25. There have been no documented revisions to the comprehensive care plan since it was created on 7/17/25. 8. Interview on 8/20/25 at 2:48 p.m. with resident 5 revealed: *She was aware the facility was a non-smoking facility, as there were “signs everywhere”. *She had smoked a couple of times outside, was “caught”, and told she could not smoke there. Because of this, she gave the cigarette and lighter to staff “sometimes” when she went outside. Review of resident 5's medical record revealed: *She was admitted on [DATE]. *Her diagnoses included: nicotine dependence with cigarettes. *She had a 7/25/25 physician's order for nicotine gum once every one to two hours as needed. *Her 8/25/25 care plan included: -An 8/8/25 focus area that indicated she had a diagnosis of osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue) related to inadequate calcium intake, and the interventions included “Do not smoke”. -There were no other interventions, including that she was non-compliant with the rules of a non-smoking facility or that she used nicotine gum. Observation and interview on 8/20/25 at 2:48 p.m. with resident 5 revealed: *Her bed had one-quarter side rails attached to the sides of her bed, and they were in the up position. *She stated she had asked for side rails to be installed on her bed so she could use them to get in and out of bed. Her care plan did not include that she used a side rail on her bed. Review of the provider's 2023 Smoke Free Facility policy revealed: *”Residents with a history of smoking will be further assessed to determine whether or not interventions are needed to help them cope with the “Smoke Free” policy. Examples include pharmacological and/or behavioral interventions to curb urges to smoke.” *”If a resident does not abide by the smoking policy, care plan revisions shall be documented and implemented to promote safety.” Review of the provider's 12/2023 Proper Use of Bed Rails policy revealed: *”The facility will continue to provide necessary treatment and care to the resident who has bed rails in accordance with professional standards of practice and the resident's choices. This should be evidenced in the resident's records, including their care plan, including, but not limited to, the following information:” -a. The type of specific direct monitoring and supervision provided during the use of the bed rails, including documentation of the monitoring; -b. The identification of how needs will be met during use of the bed rails, such as for re-positioning, hydration, meals, use of the bathroom and hygiene”. -“e. The identification of who may determine when the bed rail will be discontinued; and -f. The identification and interventions to address any residual effects of the bed rail (e.g., generalized weakness, skin breakdown)”. *”The interdisciplinary team will make decisions regarding when the bed rail will be used or discontinued, or when to revise the care plan to address any residual effects of the bed rail.” Interview on 8/21/25 at 2:55 p.m. with MDS nurse/ADON E regarding care plans revealed: *She was responsible for revising the residents' care plans when there were changes in their care needs or condition, to keep the care plans updated to reflect their current needs. -She stated she had not been updating the residents' care plans. Review of the provider's 12/2023 Care Plan Policy and Procedure revealed: *”Each discipline will update the care plan as changes occur between assessments and scheduled care conferences.” *”Care Plans will be reviewed quarterly, annually, and with any significant change in resident condition.” *”Care plans are written by exception from Resident Centered Care Plan Facility Standards and Short Term Care Plans. They include measurable outcomes and identify interventions that are specific to the individual resident with defined time frames and parameters. Target dates are through next review period unless otherwise specified.”

Based on record review, interview, and policy review, the provider failed to ensure:*Psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) ordered to be given as needed were not discontinued after 14 days, and did not have a rationale documented for continued use for four of nine sampled residents (7, 13, 21, and 30) reviewed with physician's orders for psychotropic medications.*Abnormal Involuntary Movement Scale (AIMS) (an assessment to identify the severity of involuntary movements in residents taking neuroleptic medications) assessments were routinely completed to evaluate for signs of adverse effects for eight of nine sampled residents (1, 6, 7, 13, 18, 21, 23, and 30) reviewed with physician's orders for psychotropic medications.*Consent forms for the use of psychotropic medications were obtained for nine of nine sampled residents (1, 6, 7, 13, 18, 21, 23, 26, and 30) reviewed with physician's orders for psychotropic medications. Findings included:1. Review of resident 21's electronic medical record (EMR) revealed: *Four orders for Lorazepam (a psychotropic antianxiety medication) for the diagnosis of “unspecified dementia, unspecified severity, with anxiety.” *An 8/5/25 physician's order for “Lorazepam [a psychotropic antianxiety medication] 0.5 milligrams (mg). Give 0.5 tablet orally [by mouth] every two hours as needed.” *An 8/5/25 physician's order for “Lorazepam [a psychotropic antianxiety medication] 1 mg. Give 0.5 tablet orally every two hours as needed.” *An 8/5/25 physician's order for “Lorazepam [a psychotropic antianxiety medication] 1.5 mg. Give 0.5 tablet orally every two hours as needed.” *An 8/5/25 physician's order for “Lorazepam [a psychotropic antianxiety medication] 2 mg. Give 0.5 tablet orally every two hours as needed.” -There was no stop date for the medication or a rationale to continue the as needed doses beyond 14 days documented in the above Lorazepam orders. *She was prescribed Seroquel (an antipsychotic medication) on 8/5/25 for the diagnosis of “unspecified dementia, unspecified severity, with anxiety.” -There was no documented psychotropic consent for the resident's use of Lorazepam or Seroquel. -The resident was not assessed for tardive dyskinesia (TD) using an Abnormal Involuntary Movement Scale (AIMS). TD was a possible side effect of Seroquel. 2. Review of resident 26's EMR revealed: *She was prescribed Memantine (a psychotropic medication used to treat moderate to severe Alzheimer's disease) with the directions to “give one cap [capsule] by mouth every morning” on 11/1/24 for her diagnosis of dementia. -There was no documented consent for the resident's use of the Memantine medication in the resident's EMR. 3. Review of resident 1's EMR revealed: *The resident had a 8/19/25 prescription for Citalopram (a psychotropic antidepressant medication) with the instructions to “give 1 tab [tablet] by mouth once daily” for her diagnosis of anxiety. *The resident had a 3/20/25 prescription for Buspar (a psychotropic antianxiety medication) with the instructions to “give 1 tab by mouth three times daily” for her diagnosis of anxiety. -There was a psychotropic medication consent signed for Buspar. There was no consent signed for Citalopram. -Both Citalopram and Buspar can cause TD. There were no AIMS performed to assess the resident for potential side effects of the medications, including TD. 4. Review of resident 6's EMR revealed: *An 8/29/24 physician's order for buspirone (a psychotropic antianxiety medication) 7.5 mg to be given three times daily for her diagnosis of anxiety disorder. *An 11/21/24 physician's order for quetiapine (an antipsychotic medication) 25 mg to be given twice daily, with the indication for use being her anxiety. *An 8/26/25 physician's order for quetiapine 12.5 mg to be given twice daily was not documented with a diagnosis or an indication for its use. *A 2/16/25 physician's order for bupropion (a psychotropic antidepressant medication) 300 mg to be given daily for her diagnosis of anxiety disorder. *A 4/21/25 physician's order for mirtazapine (a psychotropic antidepressant medication) 15 mg to be given at bedtime, with the indication for use being her depression. -A signed psychotropic consent form dated 4/21/25 for her use of mirtazapine was retained in her EMR. *No documentation in her EMR indicated that psychotropic medication consent forms had been completed and signed for the resident's use of buspirone, quetiapine, and bupropion. *No documentation in her EMR indicated that an AIMS assessment had been completed to assess for potential side effects of the medications. 5. Review of resident 7's EMR revealed: *A 1/17/25 physician's order for lorazepam 1 mg to be given once daily as needed for panic attacks. *No 14-day discontinuation date or reassessment with rationale for continued use of the 'as needed' lorazepam by the physician had been documented in her EMR. *No documentation in her EMR indicated that a psychotropic medication consent form had been completed and signed for the resident's use of the lorazepam. *No documentation in her EMR indicated that an AIMS assessment had been completed to assess for potential side effects of the medication. 6. Review of resident 13's EMR revealed: *A 10/21/24 physician's order for sertraline (a psychotropic antidepressant medication) 50 mg to be given at bedtime, with the indication for use being behaviors. *A 7/10/25 physician's order for lorazepam 0.5 mg to 2 mg (one to four tablets) to be given every two hours as needed, with the indications for use being anxiety, pain, restlessness, or dyspnea (shortness of breath). *A 7/11/25 physician's order for morphine sulfate (a medication with risk for abuse and addiction used to treat moderate to severe pain) solution 100 mg per 5 milliliters (mL) to be given 0.25 mg to 0.75 mg (5 mL to 15 mL) every three hours as needed, with indications for use being pain or air hunger (a severe sensation of not being able to get enough air). *No 14-day discontinuation dates or reassessment for the rationale for continued use of the 'as needed' medications by the physician had been documented in his EMR. *No documentation in his EMR indicated that a psychotropic medication consent form had been completed or signed for the resident's use of the above medications. *No documentation in his EMR indicated that an AIMS assessment had been completed to assess for potential side effects of the medications. 7. Record review of resident 18's EMR revealed: *A 10/21/24 physician's order for sertraline 100 mg to be given every morning, with the indication for use being behaviors. *A 11/27/24 physician's order for quetiapine 50 mg to be given three times daily, with the indication for use being behaviors. *A 6/2/25 physician's order for buspirone 10 mg to be given twice daily, with the indication for use being behaviors. *No documentation in her EMR indicated that a psychotropic medication consent form had been completed or signed for the resident's use of the above medications. *No documentation in her EMR indicated that an AIMS assessment had been completed to assess for potential side effects of the medications. 8. Review of resident 23's EMR revealed: *A 9/22/24 physician's order for escitalopram (a psychotropic antidepressant medication) 20 mg to be given at bedtime, with the indications for use being depression and anxiety breakthrough. *An 8/23/25 physician's order for lorazepam 0.5 mg to 1 mg (1 to 2 tablets) every two hours as needed, with the indication for use being anxiety. *An 8/23/25 physician's order for morphine sulfate solution 100 mg per 5 mL to be given 0.25 mg to 0.75 mg (5 mL to 15 mL) every three hours as needed, with the indication for use being pain or air hunger. *A physician assessed and renewed her lorazepam and morphine use orders on 8/23/25. *No documentation in her EMR indicated that a psychotropic medication consent form had been completed or signed for the resident's use of the above medications. *No documentation in her EMR indicated that an AIMS assessment had been completed to assess for potential side effects of the medications. 9. Review of resident 30's EMR revealed: *A 10/14/24 physician's order for fluoxetine (a selective serotonin reuptake inhibitor (SSRI) medication, a drug used to treat various mental health conditions) 40 mg to be given daily, with the indication for use being depression. *A 10/14/24 physician's order for trazodone (a psychotropic antidepressant medication)100 mg to be given at bedtime, with the indication for use being sleep. *A 3/25/24 physician's order for one bupropion 150 mg and one 10 mg tablet to be given twice daily, for her diagnoses of anxiety and depression. *A 3/25/24 physician's order for lamotrigine (a medication for bipolar disorder)100 mg to be given at bedtime, for her diagnosis of bipolar disorder. *A 3/25/24 physician's order for risperidone (an antipsychotic medication used to treat several mental health conditions) 1 mg to be given twice daily, for her diagnosis of bipolar disorder. *An 8/8/25 physician's order for oxycodone (a potent opioid analgesic used to treat moderate to severe pain) 5 mg to be given every twelve hours, with the indication for use being pain management. She could also take one 5 mg tablet once daily as needed. *No 14-day discontinuation date or reassessment with rationale for continued use of the 'as needed' medications by the physician had been documented in her EMR. *No documentation in her EMR indicated that a psychotropic medication consent form had been completed or signed for the resident's use of the above medications. *Her last AIMS assessment was completed on 6/26/24. 10. Interview on 8/21/2025 at 9:58 a.m. with registered nurse (RN) N revealed: *She stated that as needed controlled medications (medications classified at risk for abuse and addiction) that require a maintained count can only be administered by nurses. -There were as-needed controlled medications that required 14-day renewals or were discontinued and were locked in the medication cart. *The pharmacist reviewed the resident's charts every month. *She stated that the as needed medications should be reviewed every 14 days and would either be discontinued or have their orders renewed. 11. Interview on 8/21/25 at 10:05 a.m. and again on 8/25/25 at 2:44 p.m. with director of nursing (DON) B revealed: *She stated that residents receiving as-needed psychotropic medications ordered by physicians must have a visit by the physician and be reassessed for the as needed medication order renewals every 14 days. *The pharmacy would send a message to the physician on HUCU (a confidential communication platform) regarding new prescription orders, including any as needed psychotropic medications that may be required. *She stated that no progress note would be completed at that time for the resident. *The physician's office staff would add the resident to the next scheduled rounds for the physician to assess the resident and complete the progress note. *She stated that the best process would be for them to wait until the visit occurred, but some medications would be ordered and filled before the physician's visit. *DON B would receive an email report from consultant pharmacist D with nursing and physician recommendations. *DON B would place a copy in the “physician folder” at the nurse's station for the physician to review during rounds with residents. *MD C was scheduled twice weekly for resident visits at the facility and would address the recommendations then. *She stated that after she completed August's pharmacy recommendation review, she noted that July's physician recommendations were still in the provider folder at the nurses' station, unaddressed. -She was unable to recall the date. *She stated that consultant pharmacist D should have been monitoring resident medications due for renewal every 14 days during her monthly visit. *She stated the “pharmacy was not tracking the 14-day renewals consistently.” *She stated, “consultant pharmacist D was only reviewing them when in the facility to complete resident chart reviews.” *DON B stated that the 14-day stop dates for as-needed psychotropic medications had been identified by her as a problem over the past few months. *DON B had no process in place before July 2025 to monitor medications that required 14-day renewals. *She stated she was now using a desk calendar to track the medications, but “the process was not the best.” -She expected herself to audit the medications that required 14-day renewals every two weeks. *She confirmed that some psychotropic as needed medication stop dates were entered as “indefinite and that no 14-day stop dates were entered when the orders were entered into the EMR system. *She confirmed that some residents' medications with a 14-day stop date requirement had continued to be given beyond 14 days. *A psychotropic risk assessment tool was not utilized routinely for residents on psychotropic medications to monitor for adverse side effects. *She stated, the order to monitor for side effects in place on the resident's treatment administration record (TAR) was not an assessment.” *DON B stated she would only complete an AIMS assessment when recommended by consultant pharmacist D. *DON B confirmed that the AIMS assessments were not performed routinely, such as upon admission, quarterly, or after significant changes in the resident's condition. *DON B confirmed that psychotropic medication consent forms were not completed or updated as they should be for residents (1, 6, 7, 13, 18, 21, 23, 26, and 30) on psychotropic medications. *She stated that the facility currently had no psychotropic medication policy and was unable to provide a related policy for review. *DON B provided a toolkit packet from the American Health Care Association (AHCA) and the National Center for Assisted Living (NCAL) titled “Clinical Considerations of Antipsychotic Medication Management”. -She used the toolkit as a guide. *She stated that the process for psychotropic medications needed improvement. *She confirmed that the 14-day stop dates for as-needed psychotropic medications and the process for monitoring adverse effects using an AIMS assessment were neither reported nor tracked in the facility's QAA/QAPI program. 12. Interview on 8/21/25 at 11:00 a.m. with Minimum Data Set (MDS) nurse/assistant director of nursing (ADON) E revealed: *She did not complete an AIMS assessment for residents during their MDS assessment time frames. *She agreed and confirmed that AIMS assessments should be completed with residents on psychotropic medications to monitor for adverse side effects. 13. Telephone interview on 8/26/2025 at 11:06 a.m. with consultant pharmacist D revealed: *She completed monthly resident chart reviews. *She made nursing and physician recommendations for dose reductions, discontinuations, renewals, labs, and reviewed departmental progress notes. *She stated, “I take responsibility for monitoring the 14-day renewals and stop dates for the as-needed psychotropic medications when I am at the facility.” *Her process was to email DON B her recommendation report monthly with her findings, which would have included medications that needed to be addressed. -The report could include psychotropic medications that would need a 14-day renewal or discontinuation. *She stated that it would take 30 days or longer for MD C to respond to her recommendations. 14. Telephone interview on 8/26/25 at 11:34 a.m. with medical director C revealed: *Monthly medication reviews were conducted each month. *He was unable to provide any guidance regarding the 14-day stop dates for as-needed psychotropic medications. *He stated that he would like “the rules sent to him that showed an assessment was needed to be re-done with renewing medications.” *He stated, “I think nursing will put in their own reasons or diagnosis,” they do whatever is easiest for them.” *He confirmed that he does not assign a diagnosis to his medication orders. *He stated, “It should be inferred from my progress notes. 15. Administrator A was out of the facility and not available for an interview throughout the survey. 16. Review of the provider's 2023 Director of Nursing job description revealed: *”Planning, organizing, developing and directing the overall operations of the Nursing Service Department in accordance with local, state and federal standards and regulations, established facility policies and procedures and as may be directed by the Administrator and the Medical Director, to provide appropriate care and services to the residents.” 17. Review of the provider's December 2023 Medical Director Physician Agreement revealed: *”EXIBIT A,” *”DUTIES AND RESPONSIBILITIES,” *“A. …Physician's duties and responsibilities shall include, but are not limited to:” -“1. Monitoring medical care in the Facility to assist Facility in providing adequate and appropriate medical services to the patients in the Facility…” --“(c) evaluating reports of inadequate medical care, including drug irregularities, and advising on appropriate corrective steps to correct any identified concerns;” -“5. Consulting with the Administrator and the director of nursing services in monitoring the adequacy of both the nursing staff and the Facility to meet the psychosocial as well as the medical and physical needs of patients.” *”B. Physician agrees to abide by all Facility policies and procedures in performing Physician's duties hereunder…” 18. Review of the provider's December 2023 Medication Monitoring policy revealed: *”Policy: *This facility takes a collaborative, systematic approach to medication management, including the monitoring of medications for efficacy and adverse consequences.” *”Definitions: *Adverse consequences is a broad term referring to unwanted, uncomfortable, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status.” *”Indications for use: *Refers to the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals and is consistent with manufacturer's recommendations and/or clinical practice guidelines.” *”Policy Explanation and Compliance Guidelines: *5. Licensed nurses, with periodic oversight by nurse managers, shall: -b. Adhere to facility policies and current standards of practice for administration and monitoring of medications. *“6. Interventions shall be identified on the resident's comprehensive plan of care for the systematic monitoring of high-risk medications to facilitate early identification of adverse consequences. *7. Target symptoms and goals for use of medications shall be indicated on the resident's plan of care. The interdisciplinary team shall evaluate progress toward meeting the goals in accordance with timeframes indicated on the plan of care, but no less than quarterly or when significant changes in status occur. *8. Each resident's medication regimen is reviewed by a licensed pharmacist at designated intervals, and whenever changes in condition that could be related to medications are noted. Irregularities are reported and addressed in accordance with facility policy for medication regimen reviews and addressing irregularities.”

Based on observation, interview, record review, and policy review, the provider failed to ensure:*MD C fulfilled his role and responsibilities to assist according to the provider's medical director physician agreement to provide guidance in developing and implementing patient care policies and the duties as a member of the QAA/AQPI committee, including evaluating and guiding other committee members on corrective plans for high-risk or problem-prone areas identified. Findings include:1. Interview on 8/21/25 at 10:05 a.m. and again on 8/25/25 at 2:44 p.m. with director of nursing (DON) B revealed:*She stated that residents receiving as-needed psychotropic medications ordered by physicians must have a visit by the physician and be reassessed for the as needed medication order renewals every 14 days. *The pharmacy would send a message to the physician on HUCU (a confidential communication platform) regarding new prescription orders, including any as needed psychotropic medications that may be required.*She stated that no progress note would be completed at that time for the resident. *The physician's office staff would add the resident to the next scheduled rounds for the physician to assess the resident and complete the progress note. *She stated that the best process would be for them to wait until the visit occurred, but some medications would be ordered and filled before the physician's visit.*DON B would receive an email report from consultant pharmacist D with nursing and physician recommendations. *DON B would place a copy in the physician folder at the nurse's station for the physician to review during rounds with residents.*MD C was scheduled twice weekly for resident visits at the facility and would address the recommendations then. *She stated that after she completed August's pharmacy recommendation review, she noted that July's physician recommendations were still in the provider folder at the nurses' station, unaddressed.-She was unable to recall the date.*She confirmed that some residents' medications with a 14-day stop date requirement had continued to be given beyond 14 days.*She stated that the facility currently had no psychotropic medication policy and was unable to provide a related policy for review. *DON B provided a toolkit packet from the American Health Care Association (AHCA) and the National Center for Assisted Living (NCAL) titled Clinical Considerations of Antipsychotic Medication Management.-She used the toolkit as a guide.*She stated that the process for psychotropic medications needed improvement.*She confirmed that the 14-day stop dates for as-needed psychotropic medications and the process for monitoring adverse effects using an AIMS assessment were neither reported nor tracked in the facility's QAA/QAPI program. 2. Interview on 8/21/25 at 4:31 p.m. with DON B revealed: *The facility's policies and procedures were reviewed annually or whenever a policy was revised. *She stated that she and Administrator A reviewed the policies and procedures in January 2025.*She stated that MD C had not reviewed the policy and procedures to date.*She stated that there was currently no designated board member reviewing the facility policies and procedures. 3. Observation and interview on 8/25/25 at 12:05 p.m. with DON B regarding the facility's policy and procedure binder and current process revealed: *The policy and procedure binder contained a tracking form that tracked the following:- Policy name, date implemented, implemented by, date reviewed, and reviewed by.*The most recent policy and procedure review was documented 1/2025 and initialed by Administrator A and DON B.*No documentation had been identified or documented that MD C had acknowledged that he had reviewed the facility's policies and procedures.*No documentation had been identified or documented that a board member had acknowledged that they had reviewed the facility's policies and procedures.*Don B confirmed that neither MD C nor a board member discussed, reviewed, or signed to acknowledge the facility's policies and procedures during the 2025 scheduled board or QAA/QAPI meetings. 4. Telephone interview on 8/26/2025 at 11:06 a.m. with consultant pharmacist D revealed:*She completed monthly resident chart reviews.*She made nursing and physician recommendations for dose reductions, discontinuations, renewals, labs, and reviewed departmental progress notes.*Her process was to email DON B her recommendation report monthly with her findings, which would have included medications that needed to be addressed.*She stated that it would take 30 days or longer for MD C to respond to her recommendations. 5. Telephone interview on 8/26/25 at 11:34 a.m. with MD C revealed: *Monthly medication reviews were conducted each month.*He was unable to provide any guidance regarding the 14-day stop dates for as-needed psychotropic medications. *He stated that he would like the rules sent to him that showed an assessment was needed to be re-done with renewing medications.*He did not know if he had attended the last six months of the QAA/QAPI meetings, and stated, he would have to check his calendar.*MD C provided no other information regarding his active involvement in the facility's QAA/QAPI process.*He stated, I think nursing will put in their own reasons or diagnosis, they do whatever is easiest for them. *He confirmed that he does not assign a diagnosis to his medication orders.-The diagnoses are recorded in his progress notes. *He stated, It should be inferred from my progress note.*He thought he had reviewed the policies with DON B, and stated, he would have to check his calendar.*MD C provided no other information regarding his active involvement in the facility's policy and procedure process. 6. Administrator A was out of the facility and not available for an interview throughout the survey. 7. Review of the provider's December 2023 Medical Director Physician Agreement revealed:*AGREEMENT,*EXIBIT A,*DUTIES AND RESPONSIBILITIES,* A.Physician's duties and responsibilities shall include, but are not limited to:- 1. Monitoring medical care in the Facility to assist Facility in providing adequate and appropriate medical services to the patients in the Facility.- 2. Assisting in the development of and ensuring the implementation of patient care policies, which policies shall include, without limitations:-- (a) admission, transfer and discharge policies,-- (b) infection control policies;-- (c) policies on use of restraints;-- (d) policies on physician privilege and practices;-- (e) policies on responsibilities of non-physician healthcare workers.-- (f) policies related to accidents and incidents;-- (g) policies regarding ancillary services, such as laboratory, radiology, and pharmacy:-- (h) policies regarding use of medications:-- (i) policies regarding use and release of clinical information; and-- (j) policies regarding overall quality of care.- 5. Consulting with the Administrator and the director of nursing services in monitoring the adequacy of both the nursing staff and the Facility to meet the psychosocial as well as the medical and physical needs of patients.- 7. Consulting with the Administrator on matters of employee health policies.- 10. Providing advice regarding policies and programs of public health agencies.*B. Physician agrees to abide by all Facility policies and procedures in performing Physician's duties hereunder.

Based on observation, interview, record review, and policy review, the provider failed to maintain an effective quality assessment and assurance (QAA) committee that ensured:*Medical director (MD) C, regional director (RD) T, business office manager (BOM) H, consultant pharmacist D, dietary manager (DM) U, and maintenance manager (MM) G attended the QAA/QAPI meetings at least quarterly as members of the QAA committee. *There was evidence that MD C had assisted with the development, coordination, review, and acknowledgement of the facility's QAA/QAPI policies and procedures and program overview. Findings include:1. Interview and observation on 8/25/25 at 12:05 p.m. with DON B regarding the QAPI binders and process revealed:*The facility conducted monthly QAA/QAPI meetings with committee members.*Each department member on the committee was expected to attend the monthly meetings.-Committee member attendance was tracked for each meeting.*Each committee member was expected to bring a report of the information they monitored.*She stated that attendance by committee members needed improvement.*She stated that MD C had not attended the meetings regularly and was not highly involved in the process. *She stated that an acting board oversaw the facility, but no board member was assigned to review and acknowledge the facility policies and procedures or oversee the QAA/QAPI program.*It was verified that no reports by MD C were maintained in Administrator A's binder.*It was verified that committee members' reports were missing from Administrator A's binder in various months. 2. Review of the provider's QAA/QAPI meetings attendance records from February 2025 through July 2025 revealed:*Attendance was marked with a check next to each committee member's name if they attended the meeting.*There was no documentation on the attendance record that indicated MD C attended any meetings during the six-month period reviewed. *There was no documentation on the attendance record that indicated dietary manager (DM) U attended any meetings during the six-month period reviewed.*It was documented that RD T attended one meeting in March 2025 during the six-month period reviewed. *It was documented that MM G attended one meeting in March 2025 during the six-month period reviewed.*It was documented that BOM H attended one meeting in July 2025 during the six-month period reviewed. *It was documented that consultant pharmacist D attended one meeting in July 2025 during the six-month period reviewed.* The other committee members regularly attended meetings. *DON B confirmed that neither MD C nor a board member discussed, reviewed, or signed the facility's policies and procedures to acknowledge approval during scheduled board or QAA/QAPI meetings. 3. Telephone interview on 8/26/25 at 11:34 a.m. with MD C revealed:*He did not know if he had attended the last six months of the QAA/QAPI meetings, and stated, he would have to check his calendar.*MD C provided no other information regarding his active involvement in the facility's QAA/QAPI process. 4. Administrator A was out of the facility and not available for an interview throughout the survey. 5. Review of the provider's 2023 Director of Nursing job description revealed:*Planning, organizing, developing and directing the overall operations of the Nursing Service Department in accordance with local, state and federal standards and regulations, established facility policies and procedures and as may be directed by the Administrator and the Medical Director, to provide appropriate care and services to the residents.*Plans, develops, organizes, implements, evaluates and directs the overall operations of the Nursing Services department, as well as its programs and activities, in accordance with current state and federal laws and regulations. 6. Review of the provider's 2023 Administrator job description revealed:*Leads, guides and directs the operations of the healthcare facility in accordance with local, state and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents.*Plans, develops, organizes, implements, evaluates, and directs the overall operation of the facility as well as its programs and activities, in accordance with current state and federal laws and regulations. 7. Review of the provider's 2023 Business Office Manager job description revealed:*Participates in QAPI or facility assessment activities as needed, such as carrying out duties assigned as part of the performance improvement committee. 8. Review of the provider's December 2023 Medical Director Physician Agreement revealed:*AGREEMENT,*1.1 Services. - .Physician agrees to perform the duties and responsibilities set forth in Exhibit A.- Physician agrees to serve on the QA [Quality Assurance] Committee of the Facility.- Physician shall participate in QA Committee services and functions in accordance with all applicable requirements of federal, state, local and/or Facility laws.*1.3 Records and Reports.- (a) Physician acknowledges and agrees.Physician participating in any QA Committee scheduled. - .Record of participation in QA Committee meetings shall be kept as required.- (b) Physician shall prepare reports and other records related to Physician's activities.*DUTIES AND RESPONSIBILITIES,* A.Physician's duties and responsibilities shall include, but are not limited to:-- (a) providing consultation to the QA Committee in matters relating to patient care services;-- (c) evaluating reports of inadequate medical care, including drug irregularities, and advising on appropriate corrective steps to correct any identified concerns;- 2. Assisting in the development of and ensuring the implementation of patient care policies, which policies shall include .- .9. Consulting with the Administrator as to recommendations, proposed plans for implementation, and continuing assessments of, the clinical care of patients, through the QA Committee process. 9. Review of the provider's December 2023 Quality Assessment and Assurance (QAA) Committee policy revealed:*Policy:*[The facility] will employ a Quality Assessment and Assurance (QAA) Committee that will act as the responsible Interdisciplinary Team for all facility practice, function, and review.*Policy Explanation and Compliance Guidelines:- 1. Quality Assessment and Assurance committee members will meet monthly to review all aspects of business within each department.- 2. Quality Assessment and Assurance Chair will review old business and any other outstanding projects or QAPI plans.- 3. Committee members will provide written review of each item of business and provide minutes/reports to Committee chair.- 4. Committee members will participate in Quarterly QA meetings which will include all ancillary staff, RD, and Medical Director.*Committee Members (Interdisciplinary Team is subject to change with notification to Committee Chair).- Committee Chair/President-Administrator A.- Committee Vice-DON B.- Business Office-BOM H.- Social Services/Activities-SSD F.- Maintenance/Environmental Services-MM G.*Ancillary Staff:- Medical Director C.- Caring Professionals Regional Director T.- Pharmacy consultant H.- Registered Dietician V. - Dietary Manager U.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the provider failed to ensure:*The resident or the resident's representative was given a bed hold notice for five of five sampled residents (6, 7, 8, 26, and 30) who transferred to the hospital. *The ombudsman was notified of resident transfers to the hospital for three of five sampled residents (6, 26, and 30) who transferred to the hospital. Findings include:1. Review of resident 6's electronic medical record (EMR) revealed: *The resident had a resident representative who acted on her behalf. *She was hospitalized on [DATE], and her EMR did not contain any documentation that indicated her resident representative had received a bed hold notification. *No documentation in her EMR indicated that the ombudsman had been notified of her transfer to the hospital. 2. Review of resident 30's EMR revealed: *She was hospitalized on [DATE] and 3/22/25, and her EMR did not contain any documentation that indicated she or her resident representative had received a bed hold notification. *No documentation in her EMR indicated that the ombudsman had been notified of her transfer to the hospital. 3. Record review of resident 26's EMR revealed she was hospitalized on [DATE]. There was no documentation in her EMR that her resident representative had received a bed hold notification or that the ombudsman had received notification of her transfer to the hospital. 4. Review of resident 8's EMR revealed: *She was hospitalized on [DATE] and on 5/19/25. *The resident had a resident representative who acted on her behalf. *There was no documentation in her EMR that her representative had received a bed hold notification for those transfers to the hospital. 5. Review of resident 7's EMR revealed she was hospitalized on [DATE] and on 7/5/25. *The resident had a resident representative who acted on her behalf. *There was no documentation in her EMR that indicated her representative had received a bed hold notification for those transfers to the hospital. 6. Interview on 8/21/25 at 3:47 p.m. with director of nursing (DON) B, regarding bed hold notices revealed: *The admission agreement included a bed hold notification notice. *Bed hold policies were signed on the resident's initial admission day. -The resident or the representative was not provided a bed hold notice each time the resident was hospitalized . *The resident's bed was always held, unless the resident or the representative said they did not want to hold the bed. *She was not aware that a bed hold notice was required with each transfer to the hospital. 7. Interview on 8/25/25 at 2:12 p.m. with business office manager (BOM) H revealed she was not responsible for reporting the resident transfers or discharges to the Ombudsman, and she was not sure who was. 8. Interview on 8/25/25 at 2:19 p.m. with social service director F revealed she was not responsible for reporting resident transfers or discharges to the Ombudsman, and she was not sure who was. 9. Contact on 8/25/25 at 3:55 p.m. with Ombudsman S revealed she had not received notifications from the provider regarding residents who had transferred or discharged to the hospital. 10. Administrator A was out of the facility and not available for an interview throughout the survey. 11. Review of the 12/7/23 provider's admission agreement revealed: *”The Notice of a Bed-Hold Policy is provided to the Resident/financially responsible party upon admission and at the time of transfer.” *”For Medicaid (Title XIX) residents, government regulations specify that Medicaid will pay for a maximum of fifteen (15) bed hold days per therapeutic leave and five (5) hospitalization days. For extended hospitalization, a Resident may be charged at a rate of the lowest Medicaid daily RUG rate to maintain their bed at Facility. *”If the source of payment for the residents [resident's] stay is Medicare Part A or Private Pay and the resident/financially responsible party requests to have the bed/room held, the resident is responsible for private payment based on semi or private room rate to maintain their bed/room at [the] facility.” 12. Review of the provider's 12/7/23 Bed-Hold Policy revealed: *”It is the policy of [providers' name] to inform you of our bed-hold procedure upon admission to the facility and in the event of a hospitalization or therapeutic home visit.” *”If you choose not to sign the bed-hold policy, it may result in discharge.” *”In the event of an unplanned leave, the facility may obtain verbal agreement or denial of the bed-hold and the written notice will be faxed to the facility where hospitalized or mailed designated responsible party or POA [power of attorney]. Once notified of the bed-hold policy, the designated responsible party or POA has until [the] end of business hours the day of notice to agree or deny.”

Based on Payroll Based Journal (PBJ) CASPER (Certification and Survey Provider Enhanced Reporting) reports, interview, and record review, the provider failed to ensure the PBJ data was submitted accurately to the Centers for Medicaid and Medicare Services (CMS) for Federal Fiscal Quarter 2 (Q2) (January, February, and March 2025). Findings include: 1.Review of the provider's Q2 2025 PBJ submission report to CMS revealed there was no registered nurse (RN) coverage (worked for eight consecutive hours each day) on 1/26/25, 2/2/25, 3/1/25, 3/8/25, 3/15/25, and 3/22/25. Interview with 08/21/2025 at 12:30 p.m. with director of nursing (DON B) revealed:*She confirmed there was not always a registered nurse for eight consecutive hours each day at the facility.*She confirmed there was no registered nurse (RN) coverage on the days indicated for Q2 2025. *She was not aware that RN coverage was needed seven days per week.*She confirmed the provider had no nurse waiver. Interview on 8/21/25 at 12:45 p.m. with business office manager (BOM) H regarding PBJ submission and RN coverage revealed:*She started her employment as the BOM at the facility in January of 2025.*Administrator A had assisted her in the submission of the Q2 2025 PBJ data to CMS.*She completed the nurse scheduling and was aware that a skilled nursing facility needed RN coverage seven days a week, but was not aware that this was required for a nursing facility that was not skilled. Interview and review of the provider's licensed nurse schedule from 8/1/25 through 8/24/25 8/26/25 at 3:05 p.m. with BOM H revealed there was no RN coverage, 8/9/25, 8/17/25, and 8/24/25. Interview and review of the provider's licensed nurse schedule from 8/1/25 through 8/24/25 on 8/26/25 at 3:15 p.m. with DON B confirmed there were three days with no RN coverage, which included 8/9/25, 8/17/25, and 8/24/25. Review of the provider's 6/2025 Facility Assessment revealed there was no indication that an RN was required to work for eight consecutive hours a day, seven days a week. The provider had no staffing policy.

Based on Payroll Based Journal (PBJ) CASPER (Certification and Survey Provider Enhanced Reporting) reports, interview, and record review, the provider failed to ensure the PBJ data was submitted accurately to the Centers for Medicaid and Medicare Services (CMS) for Federal Fiscal Quarter 2 (Q2) (January, February, and March 2025). Findings include: 1. Review of the provider's Q2 2025 PBJ submission report to CMS revealed:*There was no recorded 24-hour licensed nurse coverage on 1/2/25, 2/19/25, 3/15/25, and 3/22/25.*There was no registered nurse (RN) coverage for consecutive eight hours daily on 1/26/25, 2/2/25, 3/1/25, 3/8/25, 3/15/25, and 3/22/25. Interview with 08/21/2025 at 12:30 p.m. with director of nursing (DON B) regarding submission of PBJ data revealed:*She confirmed there was no registered nurse (RN) coverage on the days indicated for Q2 2025. *She was not aware that RN coverage was needed seven days per week.*She was able to provide documentation that there was 24-hour licensed nurse coverage for the days indicated for Q2 2025, but not for the consecutive eight hours of RN coverage. Interview on 8/21/25 at 12:45 p.m. with business office manager (BOM) H regarding PBJ submission and RN coverage.*She started in January.*Administrator A had assisted her in the submission of the Q2 2025 PBJ data to CMS.*She does the scheduling and was aware that a skilled nursing facility needed RN coverage 7 days a week, but was not aware that a nursing facility that was not skilled did also. Review of licensed nurse schedule from 8/1/25 through 8/24/25 and interview on 8/26/25 at 3:05 p.m. with BOM H revealed there were three days with no RN coverage, 8/9/25, 8/17/25, and 8/24/25. Review of licensed nurse schedule from 8/1/25 through 8/24/25 and interview on 8/26/25 at 3:15 p.m. with DON B confirmed there were three days with no RN coverage, 8/9/25, 8/17/25, and 8/24/25.

Based on observation, interview, record review, and policy review, the provider failed to maintain an effective, ongoing quality assurance and performance improvement (QAPI) program regarding quality of care and outcomes to ensure:*A performance improvement plan (PIP) was implemented, actions were taken, and improvements were evaluated for the high-risk and problem-prone areas identified. This included the 14-day as needed psychotropic medication stop dates, missing consent forms, and the assessment tools used to monitor adverse side effects in residents taking psychotropic medications.*Governing board member oversight of the facility's QAPI program. Findings include:1. Interview on 8/21/25 at 10:05 a.m. and again on 8/25/25 at 2:44 p.m. with director of nursing (DON) B revealed:*She stated that residents receiving as needed psychotropic medications ordered by physicians must have a visit by the physician and be reassessed for the as needed medication order renewals every 14 days. *The pharmacy would send a message to the physician on HUCU (a confidential communication platform) regarding new prescription orders, including any as needed psychotropic medications that may be required.*She stated that no progress note would be completed at that time for the resident. *The physician's office staff would add the resident to the next scheduled rounds for the physician to assess the resident and complete the progress note. *She stated the pharmacy was not tracking the 14-day renewals consistently.*She stated, consultant pharmacist D was only reviewing them when in the facility to complete resident chart reviews.*DON B stated that the 14-day stop dates for as needed psychotropic medications had been identified by her as a problem over the past few months.*DON B had no process in place before July 2025 to monitor medications that required 14-day renewals.*She stated she was now using a desk calendar to track the medications, but the process was not the best. -She expected herself to audit the medications that required 14-day renewals every two weeks.*She confirmed that some psychotropic as needed medication stop dates were entered as indefinite and that no 14-day stop dates were entered when the orders were entered into the EMR system. *She confirmed that some residents' medications with a 14-day stop date requirement had continued to be given beyond 14 days.*A psychotropic risk assessment tool was not utilized routinely for residents on psychotropic medications to monitor for adverse side effects. *She stated, the order to monitor for side effects in place on the resident's treatment administration record (TAR) was not an assessment.*DON B stated she would only complete an AIMS assessment when recommended by consultant pharmacist D.*DON B confirmed that psychotropic medication consent forms were not completed or updated as they should be for residents (1, 6, 7, 13, 18, 21, 23, 26, and 30) on psychotropic medications.*She stated that the facility currently had no psychotropic medication policy and was unable to provide a related policy for review. *DON B provided a toolkit packet from the American Health Care Association (AHCA) and the National Center for Assisted Living (NCAL) titled Clinical Considerations of Antipsychotic Medication Management.-She used the toolkit as a guide.*She stated that the process for psychotropic medications needed improvement.*She confirmed that the 14-day stop dates for as needed psychotropic medications and the process for monitoring adverse effects using an AIMS assessment were neither reported nor tracked in the facility's QAPI program. 2. Interview and observation on 8/25/25 at 12:05 p.m. with DON B regarding the provider's QAPI binders and process revealed:*The facility conducted monthly QAPI meetings with committee members.*Each department member on the committee was expected to attend the monthly meetings.*Each committee member was expected to bring a report of the information they monitored.*She stated that an acting board oversaw the facility, but no board member was assigned to review and acknowledge the facility policies and procedures or to oversee the QAPI program.*She stated that the QAPI committee had not yet implemented a PIP into the QAPI process that had been identified.*Review of Administrator A's QAPI binder confirmed that there was no clear PIP plan, including the process, procedure, and expected improvement outcomes, recorded or maintained for the high-risk and problem-prone areas that were identified with the 14-day as needed psychotropic medication stop dates, consents, and the assessment tools. -It was verified that no reports by MD C were maintained in Administrator A's binder.-It was verified that committee members' reports were missing from Administrator A's binder in various months. *She stated she was auditing nurse documentation as part of a PIP, but she did not record the necessary information to identify the results.*She did not report her information at the scheduled QAPI monthly meetings.*Review of DON B's PIP binder confirmed there was no clear process to measure improvement outcomes.-Clear and consistent data was not recorded or maintained in DON B's QAPI binder 3. Interview on 8/21/25 at 11:00 a.m. with Minimum Data Set (MDS) nurse/assistant director of nursing (ADON) E revealed:*She did not complete an AIMS assessment for residents during their MDS assessment time frames.*She agreed and confirmed that AIMS assessments should be completed with residents on psychotropic medications to monitor for adverse side effects. 4. Telephone interview on 8/26/2025 at 11:06 a.m. with consultant pharmacist D revealed:*She completed monthly resident chart reviews.*She made nursing and physician recommendations for dose reductions, discontinuations, renewals, labs, and reviewed departmental progress notes.*She stated, I take responsibility for monitoring the 14-day renewals and stop dates for the as-needed psychotropic medications when I am at the facility.*Her process was to email DON B her recommendation report monthly with her findings, which would have included medications that needed to be addressed.-The report could include psychotropic medications that would need a 14-day renewal or discontinuation.*She stated that it would take 30 days or longer for MD C to respond to her recommendations. 5. Telephone interview on 8/26/25 at 11:34 a.m. with MD C revealed:*Monthly medication reviews were conducted each month.*He was unable to provide any guidance regarding the 14-day stop dates for as needed psychotropic medications. *He stated that he would like the rules sent to him that showed an assessment was needed to be re-done with renewing medications.*MD C provided no other information regarding his active involvement in the facility's QAPI process. 6. Administrator A was out of the facility and not available for an interview throughout the survey. 7. Review of the provider's 2023 Director of Nursing job description revealed:*Planning, organizing, developing and directing the overall operations of the Nursing Service Department in accordance with local, state and federal standards and regulations, established facility policies and procedures and as may be directed by the Administrator and the Medical Director, to provide appropriate care and services to the residents.*Plans, develops, organizes, implements, evaluates and directs the overall operations of the Nursing Services department, as well as its programs and activities, in accordance with current state and federal laws and regulations.*Acts in an administrative capacity in the absence of the Administrator. 8. Review of the provider's 2023 Administrator job description revealed:*Leads, guides and directs the operations of the healthcare facility in accordance with local, state and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents.*Plans, develops, organizes, implements, evaluates and directs the overall operation of the facility as well as its programs and activities, in accordance with current state and federal laws and regulations. 9. Review of the provider's 2023 Business Office Manager job description revealed:*Participates in QAPI or facility assessment activities as needed, such as carrying out duties assigned as part of the performance improvement committee. 10. Review of the provider's December 2023 Medical Director Physician Agreement revealed:*AGREEMENT,*1. Obligations of Physician.*1.1 Services. - .Physician agrees to perform the duties and responsibilities set forth in Exhibit A.- Physician agrees to serve on the QA [Quality Assurance] Committee of the Facility.- Physician shall participate in QA Committee services and functions in accordance with all applicable requirements of federal, state, local and/or Facility laws.- .Physician shall report to the administrator of the Facility.*1.3 Records and Reports.- (a) Physician acknowledges and agrees.Physician participating in any QA Committee scheduled. - .Record of participation in QA Committee meetings shall be kept as required.- (b) Physician shall prepare reports and other records related to Physician's activities.*EXIBIT A,*DUTIES AND RESPONSIBILITIES,* A.Physician's duties and responsibilities shall include, but are not limited to:- 1. Monitoring medical care in the Facility to assist Facility in providing adequate and appropriate medical services to the patients in the Facility.-- (a) providing consultation to the QA Committee in matters relating to patient care services;-- (c) evaluating reports of inadequate medical care, including drug irregularities, and advising on appropriate corrective steps to correct any identified concerns;- 2. Assisting in the development of and ensuring the implementation of patient care policies, which policies shall include, without limitations:-- (c) policies on use of restraints;-- (g) policies regarding ancillary services, such as laboratory, radiology, and pharmacy:-- (h) policies regarding use of medications:-- (j) policies regarding overall quality of care.- 3. Participating in Facility's development of a system to assure that a medical care plan is prepared for each patient which covers medications, nursing care, restorative services, client and other services, and, if appropriate, a plan for discharge.- 4. Assisting Facility in the development and implementation of effective patient care utilization review.- 5. Consulting with the Administrator and the director of nursing services in monitoring the adequacy of both the nursing staff and the Facility to meet the psychosocial as well as the medical and physical needs of patients.- .9. Consulting with the Administrator as to recommendations, proposed plans for implementation, and continuing assessments of, the clinical care of patients, through the QA Committee process.*B. Physician agrees to abide by all Facility policies and procedures in performing Physician's duties hereunder. 11. Review of the provider's December 2023 Quality Assessment and Assurance (QAA) Committee policy revealed:*Policy:*[The facility] will employ a Quality Assessment and Assurance (QAA) Committee that will act as the responsible Interdisciplinary Team for all facility practice, function, and review.*Policy Explanation and Compliance Guidelines:- 1. Quality Assessment and Assurance committee members will meet monthly to review all aspects of business within each department.- 2. Quality Assessment and Assurance Chair will review old business and any other outstanding projects or QAPI plans.- 3. Committee members will provide written review of each item of business and provide minutes/reports to Committee chair.

Based on interview, record review, and policy review, the provider failed to ensure infection control practices and facility policies were followed regarding the assessment for the risk of Legionella (bacteria that can grow in water and cause serious illness), the implementation of measures to prevent the growth of Legionella, and the establishment of testing protocols for Legionella.Findings include:1. Interview on 8/26/25 at 10:01 a.m. with director of nursing (DON) B revealed:*There was a hallway in the facility that was not currently occupied by residents.*That hallway had eight rooms in it.*Two of those rooms were currently being used by contracted travel staff, and the remaining rooms were vacant.*She did not know if the water in the vacant rooms was being flushed to avoid stagnant water in the pipes.*She did not know if there was a water flow map for the facility to identify areas where Legionella could grow and spread.*Maintenance manager (MM) G would be responsible for the provider's water management program.*There had been no cases of Legionella infections identified at the facility. 2. Interview on 8/26/25 at 10:38 a.m. with MM G about the provider's water management program to prevent waterborne pathogens revealed:*The water systems had not been assessed to determine where Legionella or other opportunistic pathogens could grow.*No measures had been implemented to prevent the growth of Legionella in the facility.*Testing protocols to monitor for the presence of Legionella in the facility's water system had not been followed as indicated in their policy.*He was not aware of the need to routinely flush water in vacant rooms to avoid stagnant water and potential growth of waterborne pathogens such as Legionella in the pipes. 3. Review of the facility's 2023 Legionella Surveillance policy revealed:* Policy-It is the policy of this facility to establish primary and secondary strategies for the prevention and control of Legionella infections.* Definitions:-Primary prevention strategy refers to the approaches to prevention and control of Legionella infections in health care facilities with no identified cases.* Policy Explanation and Compliance Guidelines-Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems.-In the absence of Legionella infections for a period of at least one year, the facility shall implement primary prevention strategies.* Principles of Legionella transmission:- Legionella grows best in water temperatures of 77 degrees Fahrenheit to 108 degrees Fahrenheit, particularly in water that is not moving or that does not have enough disinfectant (i.e. pH 6.5-8.5) to kill germs.* Primary prevention strategies:-Diagnostic testing:--The facility will test the water supply inside the facility annually.- Temperature controls:--Cold water shall be stored and distributed below 68 degrees Fahrenheit.--Hot water shall be stored above 140 degrees Fahrenheit and circulated at a minimum return temperature of 124 degrees Fahrenheit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure one of one cognitively impaired sampled resident's (1) unwitnessed fall had been thoroughly investigated to rule out potential abuse or neglect. Findings include: 1. Review of resident 1's electronic medical record (EMR) revealed: *She was admitted to the facility on [DATE]. Her diagnoses had included chronic obstructive pulmonary disease, diabetes, depression, anxiety, and chronic kidney disease. -The resident used supplemental oxygen at night. *A 2/10/25 nurse progress note indicated the resident was found sitting on her floor next to her recliner at 2:30 a.m. that morning. The resident had an unwitnessed fall. -She had a skin tear to her right upper arm related to the fall. She had not verbalized having any pain. *A 3/24/25 care conference note indicated the resident was alert and oriented to person and place. She was able to make her needs known. She was able to propel herself in a wheelchair throughout the facility. She had required the assistance of one staff for her activities of daily living and toileting needs. *Her 4/2/25 Brief Interview for Mental Status (BIMS) assessment score was 8. That indicated she was moderately cognitively impaired. Interview on 4/23/25 at 12:20 p.m. with licensed practical nurse (LPN) C regarding resident 1's above fall revealed: *Resident 1 was able to use the bathroom on her own. She had worn a pull-up briefs. *She was occasionally incontinent of bowel and bladder. That usually had occurred during the night because the resident was a hard sleeper. *Resident 1 was modest and had not always used her call light when she knew she should have. *LPN C had worked the day shift on 2/10/25. The overnight nurse had reported the resident's fall to her during the change of shift report. *Resident 1 was still in bed when LPN C checked on her at about 7:30 a.m. on 2/10/25. She was complaining of left hip pain. -The resident was evaluated at the local emergency department (ED). Head and thoracic spine CTs (computed tomography scans), and a hip X-ray were negative for concerns. Review of the 2/10/25 Unwitnessed Fall report and interview on 4/23/25 at 12:00 p.m. with administrator A revealed: *Staff had found resident 1 sitting on the floor next to her recliner at 2:30 a.m. on 2/10/25. -I wet my bed and was trying to get my puppies out of bed so I could strip it and I lost my balance and landed on my bottom. *Under the Predisposing Physiological Factors section of the fall report Incontinent was not checked, even though the resident was incontinent at the time of her fall. *There was no indication in the report: -If staff had assisted the resident to change her bedding or her clothing, or if the resident was assisted back to bed for the night after the fall. -What time the resident was last seen in her bed before she had fallen. -If the resident's call light was within her reach before she had fallen. -If the resident was wearing her oxygen at the time of her fall or if her oxygen tubing had contributed to the fall. -What the suspected cause of the resident's right upper arm skin tear found after the fall was from. -What, if any treatment, was provided to the above skin tear. -If the resident would have been a candidate for a night time toileting schedule. *Administrator A stated the 2/10/25 fall report was reviewed by director of nursing (DON) B for quality assurance (QA). -It was expected DON B had identified the fall report was not fully completed and the fall was not thoroughly investigated. -DON B was not available to interview on this date. *Administrator A was responsible for the supervision of DON B. -She agreed the above fall report lacked the necessary details to have analyzed what changes could have been made to mitigate the likelihood of resident 1 falling again and prevent possible abuse and neglect from occurring. Review of the provider's 10/12/24 Compliance with Reporting Allegations of Abuse/Neglect/Exploitation policy revealed: *6. Investigation: The facility will investigate all allegations and types of incidents as listed above (including injuries of unknown source) in accordance to facility procedure for reporting/response as described below. *8. Reporting/Response: The facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation. The facility will analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure residents were accurately assessed to determine their safety risks and potential interventions for: *One of one sampled resident (1) with a history of falls. *One of one sampled resident 2 with a history of elopement. Findings include: 1. Review of resident 1's electronic medical record (EMR) revealed: *She was admitted to the facility on [DATE]. *She had fallen on 2/10/25 and required medical care outside of the facility related to that fall. *Her 9/19/24 quarterly Fall Risk Evaluation score was 8. -A score of 10 or greater indicated the resident was at high risk for potentially falling. -The Medication Use section of that evaluation was scored 0 based on the resident not having been administered medications that may increase the risk of falling such as: diuretics, hypoglycemics, and psychotropics. *Review of resident 1's April 2025 medication administration record revealed she had been administered hypoglycemic, diuretic, and psychotropic medications daily since her admission. *The Medication Use section of the 9/19/24 Fall Risk Evaluation should have been scored 4 for a total evaluation score of 12. 2. Continued review of resident 1's EMR revealed she: *Had no quarterly Fall Risk Evaluation completed after 9/19/24. *Had no Fall Risk Evaluation completed after her 2/10/25 fall. Interview on 4/23/25 at 11:30 a.m. with administrator A regarding resident 1 revealed: *The purpose of the Fall Risk Evaluation was to determine a resident's fall risk and implement interventions to prevent falls. -It was important those evaluations were accurately completed in a timely manner to enhance a resident's safety. *She agreed the resident's 9/19/24 Fall Risk Evaluation was incorrectly scored by the previous director of nursing (DON) who had completed it. *She stated residents' Fall Risk Evaluations were expected to have been completed at admission, quarterly, and after a resident had fallen. -Resident 1 had no quarterly Fall Risk Evaluations completed after 9/19/24. -No Fall Risk Evaluation was completed after the resident's 2/10/25 fall. *It was DON B's responsibility to have completed those evaluations at the expected times of admission, quarterly, and after each resident fall. -DON B was not available on 4/23/25 to interview. On 4/23/25 at 10:45 a.m. a Fall Risk Assessment policy was requested from administrator A. She stated they did not have a policy for that. 3. Review of resident 2's EMR revealed: *His admission date was 3/24/25. *His 3/24/25 Elopement Risk Evaluation score was 0 indicating he was not at risk for elopement. *A yes response on that evaluation to any of the following questions would have indicated he was at risk for elopement: -A history of elopement. -A history of attempting to leave the facility without informing staff. -Verbally expressing a desire to go home, packing belongings to go home or staying near an exit door. -Wandering behavior a pattern or goal-directed. *On 4/13/25 resident 2 had eloped from the facility. *His 4/13/25 post-Elopement Risk Evaluation score was 0 indicating he was not at risk for elopement. *The question of the resident having an elopement history was marked no. -It should have been marked yes to have accurately identified resident 2 as having an elopement history and being at risk for elopement. Interview on 4/23/25 at 3:15 p.m. with administrator A regarding resident 2's 4/13/25 post-Elopement Risk Evaluation revealed: *The purpose of the Elopement Risk Evaluation was to determine a resident's elopement risk and implement interventions to prevent elopement. -It was important those evaluations were accurately completed in a timely manner to enhance a resident's safety. *She agreed the resident's 4/13/25 Elopement Risk Evaluation was incorrectly scored by DON B. -It should have reflected the resident's 4/13/25 elopement history to have identified resident 2 was at risk for future elopements. *DON B was not available during the survey to interview. Review of the provider's December 2023 Elopements and Wandering Residents policy revealed 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, interview, and policy review, the provider failed to assess one of one sampled resident (2) for potential psychosocial harm after he had eloped (left without staff knowledge) from the facility. Findings include: 1. Observation on 4/23/25 at 11:00 a.m. of resident 2 revealed: *He had independently walked to the nurses' station and was speaking to administrator A in a frustrated tone. -Administrator A had reminded the resident he was not able to smoke inside the facility. -Resident 2 accepted that response and walked back to his room. Review of resident 2's electronic medical record (EMR) revealed: *He was admitted to the facility on [DATE]. *His diagnoses included a bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), a history of prostate cancer, alcohol abuse, unspecified intracranial (head) injury with traumatic brain injury, and nicotine dependence. *His 3/24/25 Brief Interview for Mental Status (BIMS) assessment score was 5. That indicated the resident had severe cognitive impairment. *Resident 2's 3/24/25 Elopement Risk Evaluation score was 0. That indicated he was not at risk for elopement. *On 4/13/25, resident 2 eloped from the facility. -There was no documentation to support social services designee (SSD) D had assessed the resident for any negative psychosocial outcome he may have had as a result of that elopement. Review of the provider's 4/14/25 SD DOH FRI revealed: *On 4/13/25 resident 2 had walked out of the facility with volunteers from a church group who had not known he was a resident. -The resident had attended the church group's church service that day. *After exiting the facility, the resident had walked to an ambulance service located a short distance from the facility. -The ambulance service had thought the resident was homeless and intoxicated, and they notified local law enforcement. *A background check completed by local law enforcement revealed the resident had an outstanding warrant in a nearby community. He was transported to that community by the local law enforcement. *After administrator A communicated with local law enforcement regarding resident 2's circumstances, arrangements were made for the resident to return to the facility. -A breathalyzer test was completed by local law enforcement upon resident 2's return to the facility. It was negative for alcohol ingestion. *Local law enforcement disclosed to administrator A, that while resident 2 was in the other county's custody, [resident 2] was handcuffed and [resident 2] had mentioned that his wrists were sore from that. -Director of nursing (DON) B's post-elopement skin assessment of resident 2 revealed redness to [resident 2's] wrists. *When DON B had spoken privately with the resident after the elopement, he was concerned [about] what he had done wrong, not understanding why they tried to arrest him, and that he had just wanted to go for a walk. Interview on 4/23/25 at 1:30 p.m. with resident 2 revealed: *He was awake and lying on top of his bed. His speech was unclear and difficult to understand. He answered basic questions without providing details or an explanation of his thoughts. *Regarding the 4/13/25 elopement, resident 2 had remembered walking outside of the facility with a group of people. He had not told the facility staff he was leaving. -He was taken away after he had left the facility, but he was unable to state by whom. They (presumably law enforcement) thought he had escaped. He was scared. *Resident 2 stated he was comfortable at the facility and he had no complaints. Interview on 4/23/25 at 1:45 p.m. with SSD D regarding resident 2's elopement revealed she: *Had spoken with resident 2 since the elopement, but she had not discussed the elopement with him even though she had known the event was traumatic for him. -Had no documentation to support she had assessed the resident for potential psychosocial harm related to that event. *Agreed it was her responsibility to have supported resident 2's psychosocial well-being following the event. That could have included interventions such as: -Providing him opportunities to express his feelings about that event to her. -Arranging for the resident to have been evaluated by a mental health provider if that was indicated. -Observing the resident for changes in his mood and behavior since the event (activity participation, appetite, sleeping pattern, irritability, etc.). -Interviewing staff regarding any changes in the resident's mood and behavior since the event. -Reviewing the resident's mood and behavior documentation and then analyzing it to support or refute changes that may have been related to the event. -Documenting in resident 2's EMR her interventions in response to the resident's 4/13/25 elopement. Interview on 4/23/25 at 2:05 p.m. with licensed practical nurse (LPN) C regarding resident 2's elopement revealed: *She worked the day resident 2 had eloped. *He was terrified after he was returned to the facility following the elopement. -He had stayed in his room after he was returned, and anytime he had stepped outside of his room he was insistent that a staff member knew he had left his room. Interview on 4/23/25 at 3:15 p.m. with the administrator A regarding resident 2 revealed: *The events surrounding his elopement had been traumatic for the resident. *She confirmed there was no documentation to support SSD D had assessed resident 2 for potential psychosocial harm post-elopement based on his known trauma related to that event, but she should have. *SSD D had not followed the provider's policy (below) related to her post-elopement responsibilities for resident 2. Review of the provider's December 2023 Elopements and Wandering Residents policy revealed: *6. Procedure Post-Elopement: -c. A social service designee will re-assess the resident and make any referrals for counseling or psychological/psychiatric consults. -g. Documentation in the medical record will include: findings from nursing and social service assessments, physician/family notification, care plan discussions, and consultant notes as applicable.