**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual review, medical record review, and interviews the facility failed to ensure MDS assessments were accurately coded for 1 resident (Resident #37) of 16 residents reviewed for MDS assessments. The findings include: Review of the MDS 3.0 RAI Manual, revised 3/18/2025, revealed .SECTION I .The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status .This section identifies active diseases and infections that drive the current plan of care .ACTIVE DIAGNOSES .Physician-documented diagnoses in the last 60 days that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring .Nursing Monitoring includes clinical monitoring by a licensed nurse . Review of the medical record revealed Resident #37 was admitted to the facility on [DATE], with diagnoses including Type 2 Diabetes, Anxiety, Major Depressive Disorder, and Post-Traumatic Stress Disorder (PTSD). Review of a Pre-admission Screening and Resident Review (PASRR) dated 12/14/2022, revealed Resident #37 had a Level 2 outcome related to a serious mental illness with diagnoses which included Post Traumatic Stress Disorder (PTSD), Anxiety, and Major Depressive Disorder. Further review of the PASRR Level 2 outcome revealed .The following specialized services should be provided to you .Someone with expertise in prescribing and monitoring psychiatric medications should continue to follow up with you to ensure your current medication regimen continues to be helpful .The following supports should be provided to you .You should be encouraged to engage .in various activities with others to improve social skills .You should be provided person-centered care to improve or maintain your functional ability so you can achieve your highest level of well-being possible .Staff should monitor your moods and behaviors closely and immediately report any changes to your care provider . Review of a physician's order dated 8/16/2024, revealed Resident #37 was being monitored by nurses for crying and social isolation. Review of a physician's order dated 8/16/2024, revealed Resident #37 was being monitored by nurses for making false accusations. Review of a physician's order dated 8/16/2024, revealed Resident #37 was being monitored by nurses for obsessive thoughts. Review of a Physician's order dated 9/12/2024, revealed .diazepam .5mg .given for anxiety .1 tablet .[twice a day] .[as needed] . Continued review revealed the medication continued to be active for the diagnoses of Anxiety. Review of Psychiatric Nurse Practitioner note dated 1/8/2025, revealed Resident #37 refused medications for depression and had a past medical history of PTSD. Further review of the Nurse Practitioner note dated 1/8/2025, revealed the resident had an active diagnosis of Anxiety and Depression. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the Resident #37 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review of the quarterly MDS assessment revealed the resident did not have an active diagnoses of PTSD, Anxiety, or Depression documented. Review of the comprehensive care plan for Resident #37 revised 2/11/2025, revealed the residents' plan of care included goals and interventions for PTSD, Anxiety, and Depression. Further review of the comprehensive care plan revealed Resident #37 would give false information and tell stories that would later be deemed false with appropriate goals and interventions implemented. During an interview on 4/9/2025 at 2:44 PM, MDS Licensed Practical Nurse (LPN) E stated the diagnoses of Anxiety, and Depression would only be considered active if the resident received medications for the diagnoses. When asked if PTSD, Anxiety, and Depression would be considered an active diagnosis if the resident had a Level 2 PASRR and the facility was providing nonpharmacological interventions recommended in the PASRR for the treatment of those diagnoses, the MDS LPN stated No. During further interview the MDS LPN stated the diagnoses of PTSD, Anxiety, and Depression were in the residents medical record but were not active diagnoses. When asked if a significant change MDS or Significant Change PASRR should have been submitted related to multiple previous psychiatric diagnoses that were determined to be inactive by the facility, MDS LPN E stated No. MDS LPN E stated she did not not submit PASRRs to the state designated authority. During an interview on 4/9/2025 at 3:00 PM, the Clinical Reimbursement Specialist (CRS) stated the resident's diagnoses of PTSD, Anxiety, and Depression were not active diagnoses. The CRS further stated the nurses monitoring Resident #37 for behaviors (crying, social isolation, and making false stories) would not be considered monitoring for PTSD, Anxiety, or Depression.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to resubmit a Pre-admission Screening and Resident Review (PASSR) timely after a new mental health diagnosis was added for 1 resident (Resident #5) of 7 residents reviewed for PASSR. The findings include: Review of the facility's policy titled, Pre-admission Screening and Resident Review (PASSR), revised 9/15/2023, revealed .PASSR is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASSR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental illness (SMI) and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings); and 3) receive the services they need in those settings .3. An individual is considered to have a serious mental illness if the individual meets the following requirements on diagnosis, level of impairment and duration of illness: Diagnosis. The individual has a major mental disorder diagnosable under the Diagnostic and Statistical Manual of Mental Disorders .A schizophrenic, mood, paranoid, panic or other severe anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability .Guidelines for Determining When A Significant Change Should Result in Referral for a PASSR Level II Evaluation: If a significant change in status assessment (SCSA) occurs for an individual known or suspected to have a mental illness, intellectual disability, or related condition .a referral to the State Mental Health or Intellectual Disability/Developmental Disabilities Administration authority for possible Level II PASSR evaluation must promptly occur as required .Referral should be made as soon as the criteria indicating such are evident-the facility should not wait until the SCSA is complete . Review of a PASARR Level 1 screen for Resident #5 dated 8/14/2023, revealed the resident had 2 mental health diagnoses which included Dementia and Depressive Disorder. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with a mental health diagnosis of Depression. Continued review revealed Resident #5 had been diagnosed with Generalized Anxiety Disorder on 7/28/2023 and with Bipolar Disorder, current episode manic without psychotic features, on 9/14/2023. Review of a quarterly Minimum Data Set (MDS) assessment for Resident #5 dated 1/9/2025, revealed Resident #5 had active diagnoses which included Depression and Bipolar Disorder. Continued review revealed Resident #5 had received Antipsychotic and Antidepressant medications. Review of the Comprehensive Care Plan revised on 1/22/2025 revealed Resident #5 had been care planned for Depression, Bipolar Disorder, and Anxiety. Review of a Psychiatry Progress Note, dated 3/19/2025, revealed Resident #5 had been referred to psychiatric services due to diagnoses which included Bipolar Disorder with Depression. Review of the medical record revealed a new PASARR for Resident #5 was not submitted after the new mental health diagnosis of Bipolar Disorder was added on 9/14/2023. During a record review and interview on 4/9/2025 at 2:48 PM, the Administrator stated it was his expectation that a new PASARR was to be completed after a new mental health diagnoses was added. The Administrator confirmed the facility failed to resubmit a new PASSR for Resident #5 to the state designated authority a new mental health diagnoses was added and identified by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observations, and interviews the facility failed to label and store 1 prefilled insulin syringe on 1 medication cart of 2 medication carts observed for medication storage. The findings include: Review of the facility's policy titled, Medication Storage Storage of Medication, dated 1/2025, revealed .Insulin products should be stored in the refrigerator until opened .Note the date on the label for insulin vials and pens when first used .opened insulin pens should be stored at room temperature .Refer to specific product labeling for additional detail . Review of the medical record revealed Resident #37 was admitted to the facility on [DATE], with diagnoses including Type 2 Diabetes, Anxiety, Major Depressive Disorder, and Post-Traumatic Stress Disorder (PTSD). Review of a Physician's order dated 11/1/2024, revealed Resident #37 had a physician's order for a prefilled Semaglutide insulin pen to be administered once a week on Thursdays. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the Resident #37 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. During an observation on 4/8/2025 at 8:10 AM, revealed a prefilled 3 milliliter (mL) Semaglutide insulin pen for Resident #37 stored on the Hope medication cart. Observation of the insulin pen revealed the packaging was opened, and the insulin pen was full indicating the pen had not been used. Further observation of the insulin pen packaging revealed .Boxed Warning .Refrigerate until opened .then store at room temperature .Date Opened . The insulin pen was not labeled with a date it was opened, indicating the pen should be stored in refrigeration. During an observation and interview on 4/8/2025 at 8:15 AM, Registered Nurse (RN) D observed the Semaglutide insulin pen and stated the insulin pen was full, unopened, and was not labeled with an open date or date the pen was removed from refrigeration. During further interview the RN stated she accepted the cart that morning and was unsure how long the insulin pen was on the cart and had been left out of refrigeration. The RN also stated the medication was available for resident use and confirmed the medication was not stored or labeled correctly. During an interview on 4/9/2025 at 2:07 PM, the Director of Nursing (DON) stated the Semaglutide insulin pen was stored on the medication cart and was available for resident use. During further interview the DON confirmed the Semaglutide pen was not labeled or stored correctly.

Based on facility policy review, observation, and interview, the facility failed to ensure garbage and refuse were properly contained in 1 of 2 dumpsters. The findings include: Review of the facility's undated policy titled, Dispose of Garbage and Refuse, revealed, .All garbage and refuse will be collected and disposed of in a safe and efficient manner .The Dining Services Director coordinates with the Director of Maintenance to ensure .the exterior dumpster area is maintained . During an observation of the outside dumpster area on 4/7/2025 at 11:20 AM, revealed the facility had 2 dumpsters. Continued observation revealed dumpster #2 did not have a dumpster plug in place and secured. During an interview on 4/7/2025 at 11:25 AM, the Dietary Manager (DM) confirmed the dumpster plug for dumpster #2 was missing, and a plug should be in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based medical record review, facility assessment review, and interview the facility failed to ensure the facility assessment was accurate to include residents with a diagnosis of PTSD. The findings include: Review of the medical record revealed Resident #37 was admitted to the facility on [DATE], with diagnoses including Type 2 Diabetes, Anxiety, Major Depressive Disorder, and Post-Traumatic Stress Disorder (PTSD). Review of the Facility assessment dated 2025, revealed .Assessment Period January 1 through December 31, 2024 .determine what resources are necessary to care for the facility's residents competently during both day-to-day operations and emergencies .discuss and document any diagnoses or special condition likely to be cared for in the coming year, care and services provided to meet the identified needs of the residents .Resident Population .Category .Psychiatric/Mood Disorders .Common diagnoses .Impaired Cognition . Further review of the 2025 facility assessment revealed residents with PTSD was not included in the resident population. During an interview on 4/9/2025 at 2:53 PM, the Administrator stated at the time of the facility assessment period, the facility had a resident with PTSD who received facility services for PTSD. The Administrator confirmed the facility provided service to residents with the diagnosis of PTSD and confirmed the facility assessment did not include the resident population with diagnoses of PTSD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record reviews, observations, and interviews, the facility failed to wear appropriate Personal Protective Equipment (PPE) when in the room for 3 residents (Resident #9, #2, and #57) of 16 residents reviewed for Infection Control. The findings include: Review of the facility's policy titled, Viral Respiratory Pathogens, dated 2/22/2025, revealed .guidelines are intended to ensure a comprehensive and effective response to respiratory illness outbreaks .PPE includes but is not limited to masks, gowns, gloves and eye protection .used as source control during outbreak situations .infection control policies and guidelines will be followed . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Cognitive Impairment, Cough, Need for Assistance with Personal Care, and Muscle Weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of a Physician's order dated 4/2/2025, revealed Resident #9 was on isolation droplet precautions with a stop date of 4/12/2025. Review of a comprehensive care plan dated 4/3/2025, revealed Resident #9 had an active Coronavirus Disease 2019 (COVID-19) infection and the resident was on droplet isolation precautions with staff to wear PPE as indicated. During an observation and interview on 4/7/2025 at 1:00 PM, Certified Nursing Assistant (CNA) B was observed entering Resident #9's room wearing a gown, a mask, and gloves. Further observation revealed the CNA entered the room without eye protection. CNA B confirmed Resident #9 was on isolation for COVID-19 and did not wear eye protection. During an observation on 4/7/2025 at 3:00 PM, Resident #9 had a sign on the door which read .STOP .DROPLET PRECAUTIONS .EVERYONE MUST .Make sure their eyes, nose and mouth are fully covered before room entry . Further observation of the signage revealed people entering the room were to wear a face shield or safety glasses. During an observation and interview on 4/8/2025, CNA C was observed entering Resident #9's room wearing a gown, a mask, and gloves. Further observation revealed the CNA entered the room without eye protection. CNA C confirmed Resident #9 was on isolation for COVID-19 and did not wear eye protection. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses including Rheumatoid Arthritis, Diabetes Mellitus, Alzheimer's Disease, Anxiety, and Dementia. Review of a quarterly MDS assessment dated [DATE], revealed Resident #2 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Review of the Comprehensive Care Plan dated 3/31/2025, revealed Resident #2 had been care planned for .Infection Control .Resident has an active infection: positive COVID-19 . Review of the Physician Order Report for Resident #2 dated 4/1/2025-4/30/2025, revealed orders .COVID-19 (+) Positive diagnosis monitoring symptom(s) .Isolation Droplet Precautions (COVID-19) . with a start date of 3/31/2025 and end date of 4/10/2025. Review of a Nurse Practitioner Progress note dated 4/2/2025, revealed Resident #2 was .seen today after testing positive for COVID-19 .She was started on [anti-viral medication] and placed in isolation . Review of a nursing progress note dated 4/7/2025 at 11:59 AM, revealed Resident #2 .Continues to be on isolation precaution's for Covid positive . Continued review of a nursing progress note dated 4/8/2025 at 10:21 AM, revealed Resident #2 .Continues to be on isolation precaution's for positive COVID . Review of the medical record revealed Resident #51 was admitted to the facility on [DATE], with diagnoses including Metabolic Encephalopathy, Diabetes Mellitus, Dementia, and Generalized Anxiety Disorder. Review of a quarterly MDS assessment dated [DATE], revealed Resident #51 scored a 4 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of the Comprehensive Care Plan dated 3/30/2025, revealed Resident #51 had been care planned for .Infection Control .Resident has an active infection: positive COVID-19 . Review of the Physician Order Report for Resident #51 dated 4/1/2025-4/30/2025, revealed orders .COVID-19 (+) Positive diagnosis monitoring symptom(s) .Isolation Droplet Precautions (COVID-19) . with a start date of 3/30/2025 and end date of 4/9/2025. Review of a nursing progress note dated 4/7/2025 at 7:30 AM, revealed Resident #51 .continues to be on contact/droplet precautions . Continued review of a nursing progress note dated 4/8/2025 at 10:22 AM, revealed Resident #51 .Continues to be on isolation precaution's from positive COVID . During an observation on 4/7/2025 at 12:42 PM, revealed isolation signage posted outside of Resident #2 and Resident #51's door which stated that a gown, gloves, mask, and eye protection must be worn by everyone when entering room. Continued observation revealed CNA A entered the room wearing only a gown, gloves, and mask. No eye protection was utilized. During an interview on 4/8/2025 at 3:30 PM, the Infection Preventionist stated if a resident was on droplet precautions or had COVID-19, the staff were expected to wear face shields or eye goggles with other PPE every time they entered the room. During further interview the Infection Preventionist confirmed the facility failed to follow infection control guidelines for Residents #9, #2, and #57.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to provide timely notification to the Power of Attorney and/or resident representative for 1 Resident (Resident #2) of a significant change in condition of 3 residents reviewed for notification, when Resident #2 had a significant mental status change which required a onetime injection of an antipsychotic medication. The findings include: Review of a facility policy titled, Notification of Change of Condition, revised 9/15/2023, revealed .to ensure appropriate individuals are notified of changes in condition .the facility must inform the resident, consult with the resident's physician; and notify consistent with his or her authority, the resident representative(s) when there is significant change in the resident's physical, mental, or psychosocial status .A need to alter treatment significantly . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy, Idiopathic Gout, Diabetes Mellitus, Protein-Calorie Malnutrition, Dementia without Behavioral Disturbance, Anxiety Disorder, Urinary Tract Infection, Dysphagia, and Depressive Episodes. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. No behaviors were noted during the assessment period. Review of the Nurse's Note for Resident #2 dated 10/25/2024 at 8:00 PM, revealed .Elder is up in hallway trying to enter other resident rooms stating, 'This is my room and I'm going in it.' Redirection from CNA [Certified Nursing Assistant] [CNA F] (1 on 1 with another elder) unsuccessful. Elder kicking and hitting at CNA [F] and trying to run her over with walker. CNA [G] then tries to deescalate situation and calm elder, elder also attempting to hit, kick and run over [CNA G] at this time. LPN [Licensed Practical Nurse] [LPN H] stated to this nurse when I entered into the nurses' station '[Medical Director] ordered a verbal one-time injection of Haldol r/t [related to] elders' behaviors.' This nurse and all staff fearful of elders' behavior towards staff and other elders. [LPN E] pulled Haldol injection to administer to elder. Elder being monitored by CNA [F] from 1 on 1 in elder's room . Review of the Nurse's Note for Resident #2 dated 10/26/2024 at 7:41 AM, revealed .Elder's son notified of last night's events. Son verbalized understanding with no questions at this time . During an interview on 2/10/2025 at 1:15 PM, the Director of Nursing (DON) stated .[Resident #2] did have an episode on 10/25/2024, with increased agitation, unable to be redirected, going into other resident rooms and attempting to remove the cover off one resident and attempting to remove other resident belongs .[the Medical Director] was in the facility and gave a onetime order for Haldol [antipsychotic medication] 5 mg [milligram] IM [intramuscular]. However, the family was not notified until the follow morning. With any significant change my [DON] expectation is that the family is notified as soon as the resident is safe. In this circumstance, if at all possible, I would have expected the family to be notified prior to the Haldol injection or as soon as possible after the injection which was not done .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, facility investigation review, medical record review, and interview, the facility failed to prevent misappropriation of property for 1 resident (Resident #9) of 6 residents reviewed for misappropriation of resident property. The facility was cited at F-602 at a Scope and Severity of D and was cited as past non-compliance. Noncompliance began on 4/10/2024, was corrected and ended on 4/12/2024. The facility is not required to submit a Plan of Correction for F-602. The findings include: Review of a facility policy titled, Abuse, Neglect and Misappropriation of Property, revised 9/15/2023, revealed .it is the organization's intention to prevent the occurrence of abuse . misappropriation of resident property .Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] and discharged on 6/28/2024 with diagnoses including Acute Kidney Failure, Nondisplaced Articular Fracture of Right Femur Methicillin Resistant Staphylococcus Aureus Infection, Osteopetrosis, Extended Spectrum Beta Lactamase (ESBL), Depressive Disorder, Anxiety Disorder, Chronic Obstructive Pulmonary Disease, and Acute Respiratory Disease. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 scored 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the Medication Administration Record (MAR) for Resident #9 dated 4/1/2024-4/30/2024, revealed Lasix 80 mg twice daily for edema, the medication was documented as administered as ordered. Review of the Physician's Note for Resident #9 dated 4/10/2024, revealed .asked to see and evaluate patient after a member of the nursing staff had taken some of the patient's Lasix out of her medication drawer. As far as the patient is aware however, she has not missed any medication doses. She takes this for peripheral edema. She denies any increased edema, dyspnea, or other complaints related to this. Upon chart review there is no history of CHF [congestive heart failure] but she does have a h/o [history of] neurogenic bladder and this intermittent edema may be nephrogenic in etiology .Peripheral edema appears euvolemic [having a normal amount of fluid in the body] at this time without any obvious adverse effects from the medication incident described . Review of a facility investigation dated 4/10/2024, revealed Resident #9 stated that as far as she knew she had never missed any doses of medication. Licensed Practical Nurse (LPN) C was suspended pending the investigation of alleged misappropriation of medication (Lasix). Resident #9 experienced no adverse effects per assessments. The facility substantiated the incident. The staff member was terminated During an interview on 2/5/2025 at 8:33 PM, LPN C stated .I was working several 12 hour and 16 shifts, there was a card of Lasix on in the bottom drawer [of the medication cart] the name had been torn off. I knew with no name we could not return it to the pharmacy without a name. My judgement was clouded, my father had been sick and lost his insurance he had suffered from CHF [congestive heart failure], he was getting blisters from all the fluid retention. I took two of the Lasix pills out of the card and put them in my pocket I put the card in my purse to dispose of later take it up front to the box that goes back to pharmacy .some pills were already missing from the card and there were some left on the card but I couldn't go through with it my conscience was eating at me .the nurse on the other hall was a newer nurse and she asked me to help her with a fall while I was helping her she asked me If I had anything for cramps or tampons, I told her yes in my purse. She went to look and that is when she saw the card [medication card containing the Lasix] that was somewhere around 1:00 or 2:00 AM [on 4/10/2024], That is when I guess she called whoever I didn't know she had seen it until the investigation. I did not leave the building with the card I put it in the shred box after I realized we couldn't get reimbursed because the name was torn off .I put the 2 pills in the sharp's container. I never left with any of the medication I just couldn't do it . During an interview on 2/5/2025 at 9:15 AM, the DON stated .[LPN D] called me around 5:00 AM [on 4/10/2024], and reported that she saw a pill card .in LPN C's bag [DON] notified the Administrator, and we came to the facility unannounced around 6:00 AM and spoke with LPN D. Requested her to do a witness statement as to what she saw then we approached [LPN C] and asked her. She [LPN C] originally denied the allegation .we [the Administrator and the DON] checked the shred it box. We found the pill card and the name label detached from the pill card in the shred box .we again ask [asked] LPN C about the medication, at that time she did state she had taken the card from the medication cart removed two of the pills for her dad she put the card in her purse .We checked the nurse's station where she was working including the shred it box and found the pill card minus the top part containing resident and medication information. We went through the shred it box to see if I could find the label and did not find it there. We then checked a different nurse's station she had worked on previously a couple of nights before and found the top of the medication card containing medication and resident information in that shred box. We then asked her about it that is when she said she had taken it and was going to use it for her dad. We suspended her during the investigation notified the pharmacy requested the medication replacement notified the Elder and her Spouse, and the MD [Medical Doctor] from what I gathered from what she [LPN C] told us is that she had removed the medication card containing the 80 mg Lasix removed 2 pills and then returned the card to the facility for disposal .I did count from the delivery date of 3/24/2024 to 4/10/2024 to see if it matched and the card was 2 pills off .we did substantiate misappropriation of resident property .she was terminated on 4/12/2024 . During an interview on 2/5/2025 at 10:08 AM, LPN D stated .I was working 3:00 AM to 7:00 AM. I went over to speak with [LPN C], she had gotten some tarot cards and told me they were cute to go look at them they are in my purse. I opened her purse, and I saw the pill card [medication card containing the Lasix]. I called the [Administrator] around 5:00 AM, my call did not go through the Administrator called me back at 5:12 AM. I Had another call from the Administrator at 5:40 AM, he was in route I think he got to the facility about 6:00 AM . During an interview on 2/6/2025 at 1:00 PM, the Medical Director stated .I saw [Resident #9] and assessed her, there was no physical evidence of any harm or any kind of distress. She reported not being aware of missing any of her medications. There was no evidence of any psychosocial changes in her behavior or any harm . The surveyor validated on site facility interventions and plan of correction as follows: Review of a facility investigation dated 4/10/2024, revealed the allegation was reported to the Nurse Licensure Board. Resident #9 stated that as far as she knew she had never missed mediation when needed. No staff or residents reported any concerns of misappropriation. Licensed Practical Nurse (LPN) C, Alleged Perpetrator (AP) was suspended following the allegation of the misappropriation of medication. Residents with a BIMS score of 8 or above were interviewed with no concerns. Residents with a BIMS score of 7 or below had complete head to toe physical assessments completed with no concerns. Staff working with the alleged perpetrator LPN C for the previous 30 days were interviewed with no concerns. Resident #9 was care planned previously for non-compliance with physician's orders. Resident #9 experienced no adverse effects per assessments. MD assessed and interviewed Resident #9. The facility substantiated the incident. The staff member was terminated. Staff educated and tested on misappropriation. Nursing staff and Medication Technician educated on medication disposal and drug diversion. Ongoing audits were initiated to mitigate misappropriation. On 2/12/2025 the surveyor reviewed the signed verification audits for each medication cart, 1 Registered Nurse interview and 1 Licensed Practical Nurse interview confirming completion of audit on 4/10/2025. On 2/12/2025 the surveyor reviewed the signed verification audit Medication Administration Record Card Audit , 1 Registered Nurse interview and 1 Licensed Practical Nurse interview confirming completion of audit on 4/10/2025. Reviewed signed verification audits for 4/10/2024-6/7/2024. On 2/12/2025 reviewed Pharmacy Delivery Manifests for affected resident validating delivery of resident's Lasix 80 mg on 3/1/2024, 3/24/2024, and 4/10/2024 60 count delivery manifests were signed by the nurse receiving the medications. On 2/12/2025 the surveyor reviewed the facility pharmacy statement validating the facility was billed for 18 80 mg Lasix for the affected resident. Interview with the DON confirmed 1 Lasix had been identified as unaccountable but to keep the medication card as evidence the facility had replace all 18 80 mg Lasix. On 2/12/2025 the surveyor reviewed the medical record confirming documentation of Resident notification. Reviewed the Physician's progress note dated 4/11/2024. On 2/12/2025 the surveyor reviewed the facility's submission form to the Tennessee Board of Nursing dated 4/10/2024. Interview with the Administrator validated communication with the Board or receipt and of completion of investigation. On 2/12/2024 the surveyor reviewed the facility self-report validating notification to the law enforcement, APS and the Ombudsman. On 2/12/2025 the surveyor reviewed the signed MAR card audit for all residents. , 1 Registered Nurse interview and 1 Licensed Practical Nurse interview confirming completion of audit on 4/10/2025. On 2/12/2025 the surveyor Reviewed skin assessments and resident interview compared to resident roster. On 2/12/2025 the surveyor reviewed education for the abuse policy with emphasis on misappropriation of property completed on 4/11/2024. Staff signatures were compared to staff roster. Interviews conducted with 2 Registered Nurses, 2 Licensed Practical Nurses, 5 Certified Nursing Assistances 2 Activity Personnel, 2 Dietary Personnel, 2 Housekeeping Personnel, and 1 Therapy Personnel. All interviewed staff were knowledgeable of the abuse policy and misappropriation of property 100% of staff educated. On 2/12/2025 the surveyor reviewed education provided to all nursing staff and Qualified Medication Aide (QMA) validated with attendance signatures, staff roster and interview with 1 QMA, 2 RN, and 2 LPNs. Interviewed staff knowledgeable of disposal of medications when and where. On 2/12/2025 the surveyor reviewed the pharmacy refill audits conducted Monday-Friday dated 4/12/2024-2/10/2025. Validated with interview with the DON. On 2/12/2025 the surveyor reviewed the signed MAR Card Audits for 4/10/2024-6/7/2024. On 2/12/2025 the surveyor reviewed Ad Hoc minutes for 4/11/2024 for content and attendance. On 2/12/2025 the surveyor reviewed Ad Hoc minutes for 4/18/2024, 4/26/2024, 5/3/2024, 5/3/2024, 5/10/2024, 5/17/2024, 5/24/2024, 5/31/2024, and 6/7/2024 for content and attendance. On 2/12/2025 the surveyor interviewed 2 family representatives with attention to concerns for abuse or neglect, resident rights, resident protection, notification of changes in condition, administration, staffing, nursing services, medication administration, access to clinical services, or unresolved grievances with no concerns identified. During an interview on 2/12/2025 AT 11:55 the DON stated .education is provided to new hires during orientation, I call if an employee is on leave, vacation, or leave, otherwise the education is provided prior to their next shift. The facility was cited F-602 as past non-compliance and surveyor verified and validated the corrective actions on site on 2/12/2025. The facility is not required to submit a Plan of Correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility improperly placed 1 of 2 (Resident #9) sampled residents on droplet transmission based precautions. The findings include: Review of the facility policy titled, Resident Rights revised 8/16/2018, revealed .Refuse transfer from a distinct part within institution . Review of the guidance titled, Centers for Disease Control and Prevention: Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, Nursing Homes & Long-Term Care Facilities dated 9/6/2021, revealed .In most circumstances, quarantine is not recommended for unvaccinated residents who leave the facility for less than 24 hours (e.g., for medical appointments, community outings with family or friends) and do not have close contact with someone with SARS-CoV-2 infection. Quarantining residents who regularly leave the facility for medical appointments (e.g., dialysis, chemotherapy) would result in indefinite isolation of the resident that likely outweighs any potential benefits of quarantine . Review of the facility policy titled, Novel Coronavirus (COVID-19) revised 10/28/2021, revealed .Unless otherwise defined by local, state or federal guidelines, qurantine is not recommened for unvaccinated residents who leave the facility for less than 24 hours (medical appoinments, community outings with family, etc.) and do not have close contact with someone with COVID-19 . Review of the facility policy titled, Novel Coronavirus (COVID-19) revised 11/15/2021, revealed .Unless otherwise defined by local, state or federal guidelines, qurantine is not recommened for unvaccinated residents who leave the facility for less than 24 hours (medical appoinments, community outings with family, etc.) and do not have close contact with someone with COVID-19 . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses which included Lewy Body Dementia, Fracture of Unspecified Part of Neck of Left Femur, and Chronic Kidney Disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated no cognitive impairment. Review of the physician orders dated 11/03/2021 to 11/17/2021, revealed .isolation r/t [related to] non vaccination . Observation of the door on 11/15/2021 to 11/17/2021, revealed signage for droplet precautions and PPE (personal protective equipment) outside of Resident #9's door. During an interview on 11/16/2021 at 10:07 AM, Resident #9 stated she was unvaccinated for COVID-19 and had gone out to eat with family. When Resident #9 returned to the facility she was placed on qurantine for 14 days. Further interview revealed Resident #9 had not been in contact with anyone with COVID-19 and had adhered to wearing a mask in public. During an interview on 11/17/2021 at 1:45 PM, Licensed Practical Nurse (LPN) #2 also known as the Unit Manager stated she confirmed the facility was following its policy at the time when Resident #9 was placed on droplet transmission based precautions. During an interview on 11/17/2021 at 4:00 PM, the Infection Preventionist confirmed Resident #9 did not stay overnight during the family outing and did not show signs and symptoms of COVID-19. Continued interview revealed the positivity rate was high and the facility felt they had to perform all the precautions for a resident upon return to the facility. During an interview on 11/17/2021 at 7:14 PM, the Interim Director of Nursing (IDON) confirmed the facility was following their policies provided by the corporate administration. During an interview on 11/17/2021 at 7:24 PM, the Administrator confirmed if the facility had the policy updates Resident #9 would not have gone into qurantine after coming from a family outing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility failed to revise 1 of 31 (Resident #62) sampled residents for comprehensive care plans. The findings include: Review of the facility policy titled, Comprehensive Care Plans revised [DATE], revealed .Care plans are ongoing and revised as information about the resident and the residents's condition change . Review of the medical record revealed Resident #62 was readmitted to the facility on [DATE] with diagnoses which included Pneumonitis, Paraplegia, and Chronic Pain Syndrome. Review of the Discharge Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #62 died in the facility on [DATE]. Review of the Discharge orders dated [DATE], revealed comfort measures for Resident #62. Review of the Care Plan revised [DATE], revealed no problems or interventions for comfort measure related to Resident #62. During an interview on [DATE] at 4:18 PM, Licensed Practical Nurse (LPN) #2 also known as the Unit Manager confirmed she did not see comfort measures on the comprehensive care plan for Resident #62. Further interview confirmed the nurses were responsible for reviewing and updating the care plans. During an interview on [DATE] at 7:14 PM, the Interim Director of Nursing (IDON) confirmed if there were any changes to the resident's care, the resident's care plan needed to be updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation and interview, the facility failed to label and date nebulizer tubing and store a nebulizer mask in a safe and sanitary manner for 1 of 12 (Resident #50) sampled residents reviewed receiving respiratory treatments. The findings include: Review of the facility policy titled Oxygen Administration using Simple Mask OR Venturi-Mask Clinical Practice Guidelines dated 10/23/2020, revealed .The purpose of this procedure is to provide guideline for safe oxygen administration .Follow relevant infection control procedures as appropriate . Review of the medical record revealed Resident #50 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease, Pneumonia, and Bronchitis. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #50 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Review of the current physician orders dated 11/11/2021, revealed .change oxygen tubing every week Once a day on Tue (Tuesday); Night 1900-0700 [7 PM-7 AM] Check humidification bottle every shift, change when empty. Twice A Day; 0700-11:00 [7 AM-11:00 AM]; 19:00-23:00 [7 PM -11 PM] .Albuterol Sulfate [a medication to treat wheezing and shortness of breath] Solution (2.5 MG/3ML [milligram/milliliter]) (0.083%) 1 inhalation [DX (Diagnosis) Chronic Obstructive Pulmonary Disease, Unspecified] Four Times A Day; 8:00, 12:00, 16:00 [4 PM] Nebulization , 20:00 [8 PM] . Observation in the resident's room on 11/15/2021 at 10:40 AM, revealed Resident #50's nebulizer oxygen tubing was not dated and the nebulizer mask was not in a bag. Observation and interview in Resident #50's room with Licensed Practical Nurse #3 on 11/15/2021 at 3:15 PM, confirmed the resident's nebulizer oxygen tubing and nebulizer mask was not dated or stored in a bag. During an interview on 11/16/2021 at 9:30 AM, the Interim Director of Nursing (IDON) confirmed the nebulizer tubing and mask needed to be dated and stored in a bag when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to have an order for a Do Not Attempt Resuscitation POST (Physician Orders for Scope of Treatment) form for 1 of 31 (Resident #9) sampled residents reviewed. The findings include: Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses which included Lewy Body Dementia, Fracture of Unspecified Part of Neck of Left Femur, and Chronic Kidney Disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated no cognitive impairment. Review of the care plan revised 9/20/2021, revealed .Resident has the following Advanced Directives: DO NOT Resuscitate (DNR) Category Advanced Directives . Review of the POST form dated 8/3/2021, revealed a DNR with limited additional interventions and no artifical nutrition by tube (feeding tube) was selected. Review of the current physician orders dated 10/16/2021-11/16/2021 revealed no orders for DNR. During an interview on 11/16/2021 at 4:18 PM, Licensed Practical Nurse (LPN #2) also known as the Unit Manager confirmed she did not see any orders for a DNR. Continued interview confirmed the nurses were to go over the residents choices and once decided update the orders and face sheet. During an interview on 11/17/2021 at 7:16 PM, the Interim Director of Nursing (IDON) confirmed an order was to be placed into the electronic record for a DNR.

Based on facility policy review, observation and interview, the facility failed to dispose of expired medications and biological's in the medication room and on 1 of 3 medication carts observed. The findings include: Review of the undated facility policy Medication Administration General Guidelines revealed .Manufacturer recommendations for beyond use dating should take precedence, taking into consideration 'not to exceed' limitations .The beyond date use dating, which only lists month/year, falls to the last day of that month . Observation and interview in the medication room with Licensed Practical Nurse (LPN) #5 on 11/16/2021 at 3:18 PM, revealed five unopened bottles of vitamin supplement tablets, expired on 8/21/2021. One container of disinfectant wipes expired on 10/2021. During an interview LPN #5 confirmed the five unopened bottles of vitamin supplements and one container of disinfectant wipes were expired. Observation and interview of the medication cart on Hope Hallway with Registered Nurse (RN) #1 on 11/16/2021 at 3:56 PM, revealed one bottle of iron tablets expired on 10/2021. During an interview RN #1 confirmed the iron tablets were expired. During an interview on 11/17/21 at 8:19 AM, with the Administrator and Interim Director of Nursing confirmed expired medications are not to be found on the medication carts or in the medication room. The Administrator confirmed the proper procedure would be to check all medications and dispose of expired medications in both the medication room and the medication carts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation and interview, the facility failed to provide a sanitary environment to help prevent transmission of infection for 14 of 15 residents meal trays observed during the noon meal on 11/15/2021. The findings include: Review of the undated facility policy Policies and Practices-Infection Control revealed .This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections . Observation of Haven Hall on 11/15/2021 at 12:11 PM, revealed Certified Nurse Assistant (CNA) #1 removed a meal tray from the meal cart, took it into room [ROOM NUMBER] B and sat it on the over bed table. Continued observation revealed CNA #1 removed the lid from the tray and resident stated I do not want this can you get me something else. Further observation revealed CNA #1 brought the meal tray out of the room and placed it back on the meal cart. Observation of Haven Hall on 11/15/2021 at 12:16 PM, revealed CNA #1 and CNA #2 continued to deliver the other 14 meal trays. During an interview on 11/15/2021 at 12:21 PM, CNA #2 confirmed trays are not supposed to leave the room until after the meal and would be picked up when all trays are picked up. During an interview on 11/15/2021 at 12:22 PM, CNA #1 confirmed she took the refused meal tray from 124 B's room and placed it back on the remaining undelivered meal cart. During continued interview CNA #1 stated I am new and I am not sure of the rules. During an interview on 11/16/2021 at 9:52 AM, the Interim Director Of Nurse (IDON) confirmed when a tray is refused, it is not going to be put on the cart with the clean trays it stays in room until trays are removed from the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation and interview, the facility failed to provide a sanitary and comfortable environment 1 of 60 (Resident #49) sampled residents reviewed. The findings include: Review of the undated facility policy titled, Resident Rights revealed .All residents will be treated in a manner and in an environment that promotes maintenance or enhancement of quality of life . Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Gastrostomy Status, Protein-Calorie Malnutrition, and Type 2 Diabetes Mellitus with Hyperglycemia. Review of the 5-day admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated severe cognitive impairment. Observation and interview in Resident #49's room on 11/15/2021 at 11:10 AM, revealed heavily soiled washcloth with brown debris was lying on his bed. When asked if he had requested to keep a washcloth with him in the bed he stated no. Observation in Resident #49's room on 11/15/2021 at 11:23 AM, revealed Certified Nurse Assistant (CNA) #2 was in the room assisting Resident #49 and did not remove the dirty washcloth from the bed. During an observation and interview in Resident #49's room with Licensed Practical Nurse (LPN) #3 on 11/15/2021 at 11:23 AM confirmed the CNA#2 was assisting Resident #49 and did not remove the soiled washcloth. During an interview on 11/17/2021 at 7:15 PM, the Interim Director Of Nursing confirmed we put the soiled linens in a bag and they go to the soiled utility room, it (soiled washcloth) should not have been left in the bed.