**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure completion of a discharge summary including a recapitulation of the resident's stay, and final status at discharge for 2 of 5 (Resident #6 and Resident #29) residents reviewed for discharge summary. The facility failed to complete a discharge summary for Resident #6 and Resident #29. This failure could place residents at risk of not having complete records after permanent discharge from the facility and disruption in the continuity of care. Findings included:Resident #6Record review of Resident #6's face sheet dated 07/09/2025 revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on 03/20/2025 with the following diagnoses Pneumonia (infection that inflames the lungs), hypertension (high blood pressure), and Dementia (general term for loss of memory). Record review of Resident #6's admission MDS assessment dated [DATE] revealed Section C Cognitive Patterns revealed Resident #6 had a BIMS score of 13, meaning cognitively intact; Section Q Participation in Assessment and Goal Setting revealed Resident #6's overall goal was to be discharged to the community. Record review of Resident #6's progress notes revealed: Dated 03/20/2025 at 11:22 AM discharged back to assisted living with all belonging. Record review of Resident #6's EMR on 07/08/2025 revealed no evidence that Resident #6 had a completed discharge summary. Resident #29Record review of Resident #29's face sheet dated 07/09/2025 revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on 04/15/2025 with the following diagnoses cerebral infraction(stroke), hypertension (high blood pressure), and kidney disease. Record review of Resident #29's admission MDS assessment dated [DATE] revealed Section C Cognitive Patterns revealed Resident #29 had a BIMS score of 15, meaning cognitively intact; Section Q Participation in Assessment and Goal Setting revealed Resident #29's overall goal was to be discharged to the community. Record review of Resident #29's Discharge MDS assessment dated [DATE] revealed Section A Identification Information revealed that Resident #29 discharged to the community on 04/15/2025. Record review of Resident #29's progress notes revealed: Date 04/15/2025 at 5:35 PM Resident discharged at 5:35 pm to home. Resident accompanied by her [family member]. Record review of Resident #29's EMR on 07/09/2025 revealed no evidence that Resident #29 had a completed discharge summary.During an interview on 7/08/2025 at 2:30 PM the MDS coordinator stated the nurse who discharged the resident was responsible for completing a discharge summary. The MDS Coordinator stated the discharge summary should have been in the resident's EMR. During an interview on 7/09/25 at 9:48 AM The DON stated her expectation was that every resident who had been discharged should have had a discharge summary in their EMR. The DON stated the discharge summary should have been completed by the nurse that discharged the resident. The DON stated the discharge summary was supposed to be completed in the resident's progress notes. The DON stated she was not able to locate a discharge summary for Resident #6 and Resident #29. The DON stated she was responsible to monitor, and that discharges were discussed in morning meeting. The DON stated what led to failure was staff did not complete the discharge summary. Record review of facility policy titled, Discharge Summary and Plan dated 11/28/2017 revealed; When a resident's discharge is anticipated, a discharge summary. will be developed to assist the resident to adjust to his/her new living environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care for 1 of 16 (Resident #82) residents reviewed for care plan completion. The facility failed to include Resident #82's colostomy and diagnosis of Diabetes Meletus in the baseline care plan within the required 48-hour timeframe. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified.Findings included:Record review of Resident #82's electronic face sheet dated 07/08/2025 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #82's diagnosis included Type 2 Diabetes Mellitus with Hyperglycemia (metabolic disease characterized by elevated blood sugars) and Colostomy status (colon diverted to an artificial opening in the abdominal wall).Record review of Resident #82's admission MDS assessment dated [DATE] revealed Section C Cognitive patterns revealed Resident #82 had a BIMS score 14 meaning cognitively intact. Section H Bladder and Bowel-Ostomy. Bowel continence-Always incontinent. Active Diagnosis-Diabetes Mellitus. Section Q Participation in Assessment Goal Setting revealed Resident #82's overall goal was to be discharged to the community.Record review of Resident #82's Physician's Orders revealed a start date of 07/01/2025, Inspect ostomy site skin for breakdown, signs of infection or excoriation of skin. Change ostomy appliance every 3 days.Record review of Resident #82's baseline care plan dated 07/01/2025 revealed no evidence of colostomy care or diabetes mellitus. During an observation and interview on 07/07/2025 at 11:00 AM revealed Resident #82 was sitting up in wheelchair in her room. Resident #82 was observed to have a colostomy to lower abdomen. Resident #82 stated she was not sure how long she had the colostomy. Resident #82 stated the staff took care of her colostomy. During an interview on 07/09/2025 at 09:05 AM the DON stated she monitored care plans by having daily clinical meetings and weekly quality of care meetings with the IDT. The DON stated baseline care plans were initiated by the charge nurse that admitted the resident. The DON stated the baseline care plan should have addressed the resident's diagnoses and any special needs or support. The DON stated she did not know why a baseline care plan had not addressed the colostomy or diagnosis of Diabetes Mellitus. The DON stated the effect of not having items on care plan was that staff would not have needed information to provide care. During an interview on 07/09/2025 at 09:15 AM the MDS Coordinator stated the charge nurse that admitted the resident was responsible for completing the baseline care plan upon admission. The MDS Coordinator stated the effect on residents could have been the resident's skin or stoma would not be monitored, and that could have caused complications for the resident. The MDS Coordinator stated the baseline care plan should have included the diagnosis, skin assessment and any medical devices. The MDS Coordinator stated she did not know how this failure occurred. The MDS Coordinator stated the IDT met each morning for clinical meetings where care plans were reviewed. Record review of facility's policy titled Care Plans-Baseline dated March 2022 revealed: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. Policy Interpretation and Implementation1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality of care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following:a. Initial goals based on admission orders and discussion with the resident/representativeb. Physician orders.c. Dietary ordersd. Therapy orderse. Social services andf. PASARR recommendations if applicableThe baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan (no later than 21 days after admission) The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan in developed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 1 (Resident #12) of 14 residents reviewed for hospice services.The facility failed to maintain the required hospice forms and documentation, that included certificate of terminal illness and hospice election form, to ensure that the needs of the resident were addressed and met 24 hours per day to ensure Resident #12 received adequate end-of-life care.This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. The findings included: Review of Resident #12's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: dementia, kidney disease, and high blood pressure.Review of Resident #12's admission MDS assessment dated [DATE], revealed a BIMS score of 13 which indicated no cognitive impairment. Review of Section O: revealed Resident #12 was on hospice care.Review of Resident #12's Comprehensive Care Plan initiated 04/11/2025, revealed: Focus: Resident is at the end stage of life and is utilizing Hospice.Review of Resident #12's electronic Physician's Orders revealed: Admit to Skilled Nursing Facility Medicare stay under the services of hospice, dated 04/10/2025.Review of Resident #12's clinical records revealed no evidence of the required hospice forms and documentation, that included certificate of terminal illness and the hospice election form.During an interview on 07/08/25 at 03:14 PM, the DON stated the =resident's certification of terminal illness, and the hospice election form should be in the hospice binder, located at the nurses' station, and available in the facility at all times. She stated she was not sure why it was not in the hospice binder. She stated the social worker was usually the person who was responsible for communication with hospice and ensuring that the required documents were in the facility. The DON stated the facility just recently hired a new social worker which was probably why the failure occurred.Review of the facility's policy titled, Hospice Program, revised July 2017, revealed in part: Policy Statement: Hospice services are available to residents at the end of life. Policy Interpretation and Implementation . 12. Our facility is responsible for: .d. Obtaining the following information from the hospice . 2.) Hospice election form 3.) Physician certification of the terminal illness specific to each resident.

Based on observation, interview, and record review, the facility failed to ensure that each resident received food that is palatable, attractive, and at a safe and appetizing temperature for 1 of 1 lunch meal tested for nutritive value, flavor, and appearance:The facility failed to provide palatable food served at an appetizing temperature and appetizing texture to residents on 07/07/2025.This failure could affect the residents by placing them at risk of poor food intake and/or dissatisfaction of the meals served.The findings included: During an observation and interview on 07/07/2025 at 11:01 AM revealed Resident #18 was sitting up in her recliner in her room. Resident #18 stated she had one complaint about the facility, the food. Resident #18 stated the kitchen over cooked the meat. Resident #18 stated the food was dry and tough on numerous occasions. During an observation and interview on 07/07/25 at 12:45 PM the DM joined to taste the food and take the temperature of the food on the test tray. The chicken breast was thin and dry, the temperature was 111 degrees Fahrenheit. The pork loin was tough and had a temperature of 104. The DM stated the chicken was dry and the pork was tough. The DM stated that the meats were not hot and were not at an appetizing temperature. The DM stated his expectation was that food should have been served to residents at a warm and appealing temperature. The DM stated he was responsible to ensure food was cooked and served to residents that was not overcooked and at a palatable temperature. The DM stated what led to failure of food not being warm was the facility was currently using plastic plates due to a new dishwasher being installed. The DM did not have a reason for the meat being over cooked. During an interview on 07/09/25 at 9:59 AM the ADMN stated his expectation was that food be cooked correctly, not be overcooked and served at an appetizing temperature. The ADMN stated the DM was responsible to ensure food was cooked properly and served at an appetizing temperature to residents. The ADMN stated the DM and himself were responsible to monitor staff and food to make sure food was cooked properly and served at an appetizing temperature. The AMDN stated he had made rounds during meal service and ate test trays in the dining room. The ADMN stated residents could have been affected by not wanting to eat food which could have resulted in weight loss. The ADMN stated improper training of staff and lack of oversight by the DM led to failure of food being overcooked and not at appetizing temperature. Record review of the facility policy titled, Food and Nutrition Services, dated October 2017, revealed Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and its served at a safe and appetizing temperature.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed.The facility failed to ensure that staff utilized proper personal hygiene practices while handling food. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.Findings included: Observation in the dining room, on 07/07/2025 between 12:00 PM and 12:45 PM revealed: DA-A entered the dining room to assist with plating the food and donned gloves(put gloves on) without washing her hands. She assisted with placing food on plates and serving to the residents. She went down the hall to the main kitchen with her gloves on, then returned to the dining room with the same gloves still on, did not perform hand hygiene, and continued to serve plates to residents. DA-A went down the hall to the main kitchen a total of 3 times and never washed her hands or changed her gloves. The DM entered the dining room and began assisting with the meal service and did not wash his hands. The DM placed a plate in the microwave, went and spoke to residents, placing his hand on one's shoulder, then returned and removed the plate from the microwave without washing his hands. The DM continued to assist with plating and serving food and never washed his hand and failed to change gloves.During an interview on 07/07/25 at 12:45 PM, the DM stated his expectation was for the staff to wash their hands constantly. The staff should wash their hands before handling any food and after touching anything other than food. He stated not using proper hand hygiene could cause infections. He stated he did not realize he had not washed his hands because he was just trying to help ensure the meal service went successfully. He stated he and his staff had been trained regarding hand hygiene and infection control. During an interview on 07/07/25 at 12:50 PM, DA-A stated she had been trained on hand hygiene and that she should have changed gloves and washed hands in between going down the hall and back. She stated she just got in a rush and got nervous because she was being watched. During an interview on 07/07/2025 at 1:00 PM, the Administrator stated hands must be washed prior to handling food and anytime that the hands were contaminated. He stated that was the DM's responsibility to ensure that the procedures were being followed. He stated not using proper hand hygiene would lead to cross contamination and infection. The Administrator verified that all residents ate from the kitchen and could be affected. The Administrator stated that he conducted observations of the dietary staff periodically. Review of facility policy titled, Preventing Foodborne Illness, revised November 2022, revealed: Policy Statement: Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Policy Interpretation and Implementation: 1. All employees who handle, prepare, or serve food are trained in the practices of safe food handling and preventing foodborne illness.6. Employees must wash their hands:.d. Before coming in contact with any food surfaces.g. During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing task.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were addressed for 1 of 5 residents (Resident #28) reviewed for unnecessary medications, psychotropic medications, and medication regimen review. The facility failed to address the Pharmacist Consultant recommendations for April 2024 and May 2024 for Resident #28 regarding psychotropic medications. These failures could place residents on psychotropic medications at risk for possible adverse side effects, adverse consequences, and decreased quality of life. Findings included: Review of Resident #28's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: anxiety, prediabetes, and fracture of right lower leg. Review of Resident #28's admission MDS assessment dated [DATE] revealed: a BIMS score of 15 which indicated no cognitive impairment. Further review of the MDS Section N Medications revealed no antianxiety medications taken in the last 7 days during the look back period (assessment period). Further review of MDS revealed the use of antipsychotics in the last 7 days during the look back period (assessment period). Review of Resident #28's Care plan initiated 04/26/2024 revealed: Focus: Resident uses anti-anxiety medications (hydroxyzine) related to anxiety disorder. Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness EVERY-SHIFT. Monitor/document/report PRN any adverse reactions to ANTI-ANXIETY therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, or hallucinations. Further review of care plan revealed: Focus: Resident uses psychotropic medications (risperidone) related to patient reported Tourette syndrome. Goal: The resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment through review date. Interventions: Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side effects and effectiveness EVERY-SHIFT. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate at least quarterly. Monitor/document/report PRN any adverse reactions of PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Review of Resident #28's Medication Regimen Review, dated 04/30/2024, revealed: Please clarify how long to be on PRN hydroxyzine- PRN psych meds should only be used for 14 days unless specified by the physician. Please clarify if patient should stay on med for 14 days or needs to be extended. Review of Resident #28's Medication Regimen Review, dated 05/29/2024, revealed: Please clarify how long to be on PRN hydroxyzine- PRN psych meds should only be used for 14 days unless specified by the physician. Please clarify if patient should stay on med for 14 days or needs to be extended. Review of Resident #28's electronic Physicians Orders revealed: Hydroxyzine HCl Oral Tablet 25 MG give 1 tablet by mouth every 8 hours as needed for anxiety, dated 04/25/2024 with no stop date. Review of Resident #28's Medication Regimen Review, dated 04/30/2024, revealed: Please monitor for side effects of antipsychotics since patient is on Risperdal (Risperidone). Review of Resident #28's Medication Regimen Review, dated 05/29/2024, revealed: Please monitor for side effects of antipsychotics since patient is on Risperdal (Risperidone). Review of Resident #28's electronic Physicians Orders revealed no evidence of an order to monitor for side effects of antipsychotics prior to 06/03/2024. Review of Resident #28's Medication Regimen Review, dated 04/30/2024, revealed: Resident is receiving the antipsychotic agent Risperdal 4mg at bedtime but lacks an allowable diagnosis to support its use. Currently, the diagnosis reads for depression .If clinically indicated, please identify one of the above diagnoses for our records to appropriately identify the use of this antipsychotic in this patient. If not, then please consider discontinuing this medication. Review of Resident #28's Medication Regimen Review, dated 05/29/2024, revealed: Resident is receiving the antipsychotic agent Risperdal 4mg at bedtime but lacks an allowable diagnosis to support its use. Currently, the diagnosis reads for depression .If clinically indicated, please identify one of the above diagnoses for our records to appropriately identify the use of this antipsychotic in this patient. If not, then please consider discontinuing this medication. Review of Resident #28's electronic Physicians Orders revealed: Risperidone oral tablet 4 mg 1 tablet at bedtime related diagnosis depression, dated 04/25/2024 . During an interview on 06/05/2024 at 4:15 PM, the DON stated her and the ADON shared the responsibility of monitoring and addressing the pharmacy recommendations. She stated pharmacy recommendations should ideally be addressed within 72 hours of receiving them. The DON stated that the letters to the physicians were faxed to the physicians immediately and it was her and the ADONs responsibility too follow-up and monitor. The DON stated the same recommendations should never be repeated on the following month recommendations because they should have been addressed. The DON stated Resident #28's April recommendations should have been addressed before the May recommendations were sent out. The DON stated the delay could have been due to the Medical Director not addressing psychotropic medications and the letters having to be sent to the psych doctor who responds in a less timely manner. The DON then acknowledged that these specific recommendations could have been fixed without notification from the doctor and she did not know why it was missed or not addressed until 06/03/2024 after the state surveyors entered the facility. She stated the effect on the resident could be receiving unnecessary medications. Review of the facility policy titled, Psychotropic Medication Use dated July 2022, revealed: Policy Statement: Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation: 1. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. 2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: a. Anti-psychotics; b. Anti-depressants; c. Anti-anxiety medications; and d. Hypnotics . 12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. A. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are not antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include a duration for the PRN order. (2) For psychotropic medications that are antipsychotics; PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. Review of Drugs.com for Hydroxyzine accessed on 06/05/2024 at https://www.drugs.com/hydroxyzine.html revealed: hydroxyzine also reduces activity in the central nervous system, it can be used as a sedative to treat anxiety and tension. This medication may impair your thinking or reactions. Hydroxyzine is for short-term use only. You should not take this medicine for longer than 4 months. Review of Drugs.com for Risperidone accessed on 06/05/2024 at https://www.drugs.com/risperidone.html revealed: Risperidone is an antipsychotic medicine that works by changing the effects of chemicals in the brain. Risperidone is also used to treat symptoms of bipolar disorder (manic depression) in adults.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to ensure residents with PRN orders for psychotropic drugs were limited to 14 days for 1 (Resident #28) of 5 residents reviewed for pharmacy services. The facility failed to ensure Resident #28 had stop dates for PRN hydroxyzine (medicine used to treat the symptoms of anxiety). This failure could place residents at risk for psychotropic medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. Findings included: Review of Resident #28's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: anxiety, prediabetes, and fracture of right lower leg. Review of Resident #28's admission MDS assessment dated [DATE] revealed: a BIMS score of 15 which indicated no cognitive impairment. Further review of the MDS Section N Medications revealed no antianxiety medications taken in the last 7 days during the look back period (assessment period). Review of Resident #28's Care plan initiated 04/26/2024 revealed: Focus: Resident uses anti-anxiety medications (hydroxyzine) related to anxiety disorder. Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness EVERY-SHIFT. Monitor/document/report PRN any adverse reactions to ANTI-ANXIETY therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, or hallucinations. Review of Resident #28's electronic Physicians Orders revealed: Hydroxyzine HCl Oral Tablet 25 MG give 1 tablet by mouth every 8 hours as needed for anxiety, dated 04/25/2024 with no stop date. Review of Resident #28's MAR, dated June 2024, revealed Hydroxyzine being administered daily. Review of Resident #28's Medication Regimen Review, dated 04/30/2024, revealed: Please clarify how long to be on PRN hydroxyzine- PRN psych meds should only be used for 14 days unless specified by the physician. Please clarify if patient should stay on med for 14 days or needs to be extended. Review of Resident #28's Medication Regimen Review, dated 05/29/2024, revealed: Please clarify how long to be on PRN hydroxyzine- PRN psych meds should only be used for 14 days unless specified by the physician. Please clarify if patient should stay on med for 14 days or needs to be extended. Review of Resident #28's physician progress notes from March 2024- June 2024 revealed no documented rationale for the continued provision of hydroxyzine or reason not to make it a scheduled medication . During an interview on 06/05/2024 at 4:15 PM, the DON stated her and the ADON shared the responsibility of monitoring and addressing the pharmacy recommendations. She stated pharmacy recommendations should ideally be addressed within 72 hours of receiving them. The DON stated the letters to the physicians were faxed to the physicians immediately and it was her and the ADONs responsibility too follow-up and monitor. The DON stated the same recommendations should never be repeated on the following month recommendations because they should have been addressed. The DON stated Resident #28's April recommendations should have been addressed before the May recommendations were sent out. The DON stated the delay could have been due to the Medical Director not addressing psych medications and the letters having to be sent to the psych doctor who responds in a less timely manner. The DON then acknowledged that these specific recommendations could have been fixed without notification from the doctor and she did not know why it was missed. She stated the effect on the resident could be receiving unnecessary medications. Review of facility policy titled, Psychotropic Medication Use dated July 2022, revealed: Policy Statement: Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation: 1. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. 2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: a. Anti-psychotics; b. Anti-depressants; c. Anti-anxiety medications; and d. Hypnotics . 12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. A. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are not antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include a duration for the PRN order. (2) For psychotropic medications that are antipsychotics; PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. Review of Drugs.com for Hydroxyzine accessed on 06/05/2024 at https://www.drugs.com/hydroxyzine.html revealed: hydroxyzine also reduces activity in the central nervous system, it can be used as a sedative to treat anxiety and tension. This medication may impair your thinking or reactions. Hydroxyzine is for short-term use only. You should not take this medicine for longer than 4 months.

Based on interviews and record review, the facility failed to maintain an ongoing Quality Assurance & Performance Improvement (QAPI) committee that included at minimum, the director of nursing services, the Medical Director or his/her designee, and at least three other members of the facility's staff, at least one of who must be the Administrator, owner, a board member, or other individual in a leadership role; and meets at least quarterly for 2 of 4 quarterly meetings (July 2023 & January 2024). The facility failed to ensure they held QAA quarterly meetings and had documentation that the required members were present in the meetings between April 27, 2023, to October 5, 2023, and between October 5, 2023, to March 28, 2024. This failure could place residents in the facility at risk for a reduced quality of care and life due to lack of efficiently identifying and resolving resident and facility issues. Findings included: Record review of the facility's Quality Assurance Performance and Improvement (QAPI) meeting minutes sign in sheets from May 2023 to May 2024 revealed one meeting on 10/05/2023 with the following attending: the Administrator, the Medical Director, the Director of Nursing, the Pharmacy Consultant, the Business Office Manager, the Director of Rehabilitation, and the Executive Director. The facility was unable to provide a sign in sheet for the meeting in July 2023. Record review of the facility's Quality Assurance Performance and Improvement (QAPI) meeting minutes sign in sheets from May 2023 to May 2024 revealed one meeting on 02/29/2024 with the following attending: the Administrator, the Pharmacy Consultant, the Business Office Manager, the Clinical Liaison, the Director of Rehabilitation, the Director Plant Operations, and the Assistant Director of Nursing. No signature found that the DON and the Medical Director or his/her designee attended. The facility was unable to provide a sign in sheet for the meeting in January 2024. During an interview on 06/04/2024 at 1:42 p.m., the ED stated he had provided all the QAPI sign in sheets that he had found. He stated another ADMN worked at facility during that time that the sign in sheets were missing. He stated he took over after the previous ADMN left the company and she had been keeping track of meetings on paper. The meeting paperwork was being stored in a desk and then it was moved into a bankers' boxes for storage. He stated he could not locate the sign in sheets. The ED verified that he was the acting ADMN after the original ADMN left the company and he verbally verified the meetings had been performed but was unable to provide proof. He stated that no negative effects were had on the residents. During an interview on 06/04/2024 at 2:47 p.m., the DON stated she and ADMN were responsible to ensure the sign in sheets at the QAPI meetings were filled out and retained. She stated she had been working for the facility since November 2022 full time and could verbally verify that the QAPI meetings had been held monthly. She stated she was not able to provide the sign in sheets from the meetings because they were moved into file boxes, and she was unable to locate them. She stated the acting ADMN after the original ADMN left the facility was the ED but now they have hired a new ADMN. The DON stated she did not feel any negative effects occurred on the residents since the meetings were performed. She stated the facility had now changed the process for retaining the sign in sheets and the facility will be uploaded into computer to prevent future meeting sign in sheets from being lost. Record review of facility policy titled Quality Assurance & Performance Improvement (QAPI) Program Plan dated 08/31/2022 revealed: the facility will maintain documentation and demonstrate evidence of its ongoing QAPI efforts that serve to identify report, investigate, analyze, and prevent adverse events. Documentation will reflect the development, implementation, and evaluation of corrective actions or performance improvement initiatives. Upon request, and as required by state and federal regulations, our QAPI program plan will be made available to state and federal survey agencies .At a minimum, the QAPI committee and associated meetings will be conducted on a quarterly basis.

Based on interviews and record review, the facility failed to ensure 2 of 8 (CNA-B and CNA-C) employees whose in-service records were reviewed had not received the required minimum 1-hour annual in-service training for Dementia. The facility failed to provide the required annual Dementia training to CNA-B, and CNA-C. This failure placed residents at risk for unmet needs due to untrained staff. Findings included: Record review of Personnel Files revealed: - Employee record for CNA-B revealed a hire date of 04/09/2024 and had no evidence of the required minimum 1-hour annual in-service training for Dementia. - Employee record for CNA-C revealed a hire date of 03/27/2024 and had no evidence of the required minimum 1-hour annual in-service training for Dementia . During an interview on 06/4/2024 at 5:25 PM the ADMN stated that the HR and the DON monitored staff trainings. He stated the facility protocols for Dementia training was a yearly 1-hour course but stated he did not know what the policies were. The ADMN stated he did not feel there would have been a negative impact for residents. He stated he would have to look further into what the failure would have been and stated his expectations for staff Dementia trainings to have been that all staff complete their required training upon orientation. Record Review of the facility policy titled In-Service Training, All Staff, Revised October 2023, revealed the following: Policy statement: All staff must participate in orientation and annual in-service training. Policy interpretation and implementation: 1. All staff are required to participate in regular in-service education. In-service education participation is considered working time for which staff are paid their regular wages. 2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers. 3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training .6. Required training plan topics include the following: .c. (3) dementia management and resident abuse prevention 7. Training Plans are developed and implemented for onboarding, annual, and as necessary based on the facility assessment, team member specific competency per regulatory guidelines. Additional training may include: . g. person-centered care: . l. intellectual disability; and/or m. mental disorders. 8. Completed training is documented for staff with HRIS program to include: a. the date and time of the training; b. the topic of the training; c. a summary of the competency assessment as applicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care of 4 (Resident #85, Resident #87, Resident #137, and Resident #185) of 4 residents reviewed for baseline care plan completion. The facility failed to complete the social services section in the baseline care plan for Resident #85, Resident #87, Resident #137, and Resident #185 within the required 48-hour timeframe. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified. Findings included: 1. Resident #85 Record review of the resident #85's face sheet dated 06/03/2021 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: unspecified fracture of T11-T12 vertebra (spinal fracture), muscle weakness, cognitive communication deficit, protein-calorie malnutrition, anemia, legal blindness, hypertension (high blood pressure), chronic atrial fibrillation (chronic irregular heart rhythm), and heart failure (heart disease). Record review of Resident #85's admission MDS dated [DATE] revealed: a BIMS score of 12 which indicated moderate cognitive impairment. Further review of the MDS Section D - Mood revealed resident had no self-isolation, hallucinations, or delusions. He did have verbal behavioral symptoms directed toward others that occurred 1 to 3 days. Record review of Resident #85's baseline care plan dated 05/22/2024 revealed the Social Services section was not completed. Record review of Resident #85's electronic medical record accessed on 06/05/2024 revealed comprehensive care plan was completed on 05/31/2024. 2. Resident #87 Record review of Resident #87's face sheet dated 06/03/2024 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: injury of cauda equina (injury that damaged or compressed a bundle of nerve roots at the bottom of the spinal cord), hypothyroidism (low thyroid hormone), protein-calorie malnutrition, obesity, hypertension (high blood pressure), spinal stenosis (narrowing of spinal canal), and fall. Record review of Resident #87's entry MDS dated [DATE] revealed: The resident was admitted to facility on 05/29/2024 from short-term general hospital. Record review of Resident #87's baseline care plan dated 05/29/2024 revealed the Social Services section was not completed. Record review of Resident #87's electronic medical record accessed on 06/05/2024 revealed comprehensive care plan had not been completed. 3. Resident #137 Record review of Resident #137's face sheet dated 06/03/2024 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: fracture of lesser trochanter of right femur (right leg bone fracture), fear of injury, pain in right leg, cognitive communication deficit, need for assistance with personal care, chronic obstructive pulmonary disease (lung disease), hypertension (high blood pressure), atrial fibrillation (irregular heart rhythm), and muscle weakness. Record review of Resident #137's admission MDS dated [DATE] revealed: a BIMS score of 10 which indicated moderate cognitive impairment. Further review of the MDS Section D - Mood revealed resident had no self-isolation, hallucinations, or delusions. Record review of Resident #137's care plan dated 05/21/2024 revealed the Social Services section was not completed. Record review of Resident #137's electronic medical record accessed on 06/05/2024 revealed comprehensive care plan was completed on 05/31/2024. 4. Resident #185 Record review of the resident #185's face sheet dated 05/30/2024 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: atrial fibrillation (irregular heart rhythm), muscle weakness, cognitive communication deficit, need for assistance with personal care, acute respiratory failure with hypoxia (inability for lungs to function and low oxygen level), anxiety disorder, anemia, hypertension (high blood pressure), heart failure (heart disease), and gastro-esophageal reflux disease without esophagitis (stomach gasses move into the esophagus). Record review of Resident #185's entry MDS dated [DATE] revealed: The resident was admitted to facility on 05/30/2024 from skilled nursing facility. Record review of Resident #185's baseline care plan dated 05/30/2024 revealed the Social Services section was not completed. During a phone interview on 06/05/2024 at 10:36 a.m., LVN A stated she was responsible with the other nurses to perform baseline assessments on admission. She stated that the assessment will populate in the UDA for nurses to perform as soon as possible. The LVN stated she did not fill in the social service section. She stated at one time someone else would fill in that section. She stated that she would print out the baseline care plan when she was done filling in the areas that she could so the resident or the responsible party could sign. During an interview on 06/05/2024 at 11:25 a.m., the DON stated she and the MDS nurse were responsible for monitoring that baseline care plans were completed. She stated she would expect that the social services section be filled in by a social worker or designee of the social worker. She stated nurses are responsible for performing the baseline care plan and that was why the section was not filled in on the baseline care plan. She stated the Social Worker assists with comprehensive care plan. The DON stated not filling out social service section could lead to psychosocial needs not being assessed and not being med potentially. During an interview on 06/05/2024 at 1:50 p.m., the interim ADMN stated the DON monitored that the baseline care plans were completed. He stated his expectation would be for each section to be addressed. He stated that he did not know why the social services section had not been filled in on the baseline care plans but he felt it may have been because the facility did not have a Social Worker at the time. The interim ADMN stated no negative outcome occurred to the residents because the facility was providing services to meet the residents' needs. During an interview on 06/05/2024 at 3:13 p.m., the MDS coordinator stated she and the DON monitored that baseline care plans were completed. She stated her expectation would be that the baseline plans have a discharge plan. She stated if the resident had a social service needed, then the facility would need to put something in place. She stated the social services section may not have been filled out because the facility did not have a Social Worker at that time. The MDS coordinator stated that if the resident had a need of social services, then the resident possibly would not get social services timely. Record review of facility policy titled; Care Plans-Baseline dated March 2022 revealed; The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care, and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. Physician orders; c. Dietary orders; d. Therapy services; e. Social services; and f. PASARR recommendation, if applicable. The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure an acceptable parameter of nutritional status was maintained for 1 of 3 residents (Resident #16) who was reviewed for nutritional status, in that: Resident #16 had a significant weight loss of 22.5 pounds, (13% loss 30 days). The facility did not provide any nutritional interventions for two weeks even though Resident #16 had a known history of weight loss. This failure could place residents at risk for further weight loss and decline in health due to nutritional needs not being met. Finding included: Review of Resident #16's admission Record dated 5/3/23 revealed he was an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included encephalopathy, altered mental status, malnutrition, dehydration, and muscle weakness. Review of Resident #16's Five-Day MDS assessment, dated 3/29/23 revealed He scored an 11 of 15 on his mental status exam (indicating moderate cognitive impairment) but showed signs of delirium including inattention, and disorganized thinking. He needed limited assistance of one staff for bed mobility, supervision while eating and was totally dependent on one staff for toileting. He was always incontinent of bladder and occasionally incontinent of bowel. He weighed 171 pounds with weight loss or gain not indicated. There were no skin issues identified. Review of Resident #16's CAA revealed delirium, cognitive loss/dementia, ADL function, urinary incontinence, psychosocial well-being, mood state, activities, falls, nutritional status, dehydration, and pressure injury were indicated for consideration for care plans. Review of Resident #16's weights revealed: 3/28/23 171 pounds 4/2/23 165 pounds 4/9/23 151 pounds (1st hospitalization, 11.7% loss in 30 days) 4/23/23 (readmission weight) 156 pounds 5/1/23 148.5 pounds (an additional 4% loss in 1 week) Review of Resident #16's Care Plan dated 3/27/23 revealed Focus: The resident has nutritional problem Related to diagnosis of Malnutrition Diet restrictions., The original identified goal on 3/27/23 revealed Resident will follow therapeutic diet as ordered by____. Identified interventions included: Instruct family about dietary modifications and acceptable snacks for the resident; Provide and serve diet as ordered; monitor intake and record each meal; and Registered Dietician to evaluate and make diet change recommendations as needed. Review of Resident #16's Care Plan updated on 5/2/23 revealed Focus: Resident #16's had unplanned weight loss related to acute illness, poor food intake, and recent hospitalization. The identified goal was the resident will have little to no weight loss throughout the review date. Identified interventions included give the resident supplements as ordered. Alert nurse/ dietitian if not consuming on a routine basis; Serve fortified cereal with breakfast daily, house shakes between meals and at bedtime, and ice cream at lunch daily; and offer substitutes as requested or indicated. Review of Resident #16's Physician Order Report, dated 5/5/23, revealed: 5/1/23 Health Shake after meals and at bedtime (2 weeks after re-admission) 5/1/23 Fortified Cereal at breakfast daily and ice cream at lunch. (2 weeks after re-admission) 4/25/23 General diet, mechanical soft, thin liquids (8 days after re-admission. Review of Nurse's Notes revealed: 4/17/23 Regular diet now, only eating about 25% per hospital report 5/1/23 Note Text: Per Registered Dietician recommendation Doctor ordered fortified cereal with breakfast daily, house shakes between meals and at bedtime, and ice cream at lunch daily. Resident and Responsible Party aware. Interview on 05/03/23 at 6:07 PM the DON explained Resident #16 was originally admitted on [DATE] and had Registered Dietician interventions ordered on 4/9/23 at the 20-pound loss mark. She said Resident #16 had a hospitalization with that weight loss .The DON clarified interventions done prior to the hospitalization were separate from what was implemented on 5/1/23. Follow up interview on 5/03/23 at 6:23 PM, the DON said on 4/6/23 the Registered Dietician recommended house shakes twice a day and super cereal with breakfast (hot cereal with additional nutrients and calories added). She said then Resident #16 was sent to the hospital on 4/11/23. The DON stated when Resident #16 returned on 4/17/23, and the Registered Dietician re-instated the same recommendations on 5/1/23. Interview on 5/04/23 at 10:05 AM, the DON stated there was a two-week span of time prior to the facility putting weight loss interventions in place. She said the facility was aware Resident #16 had a history of significant weight loss. The DON stated when residents were readmitted to the facility, they got the medication reconciliation with the diet orders and there was no interventions from the hospital. The DON stated Resident #16 had a nine-pound weight gain from fluids from the hospital. Interview on 5/04/23 at 10:39 AM, the Administrator was informed of Resident #16's weight loss. She voiced understanding of not putting in interventions for Resident #16 for two-weeks. Review of the facility's policy and procedure on Weight Management, revised 8/31/20, revealed: Policy: Resident's weights will be taken and recorded as instructed to establish a baseline weight and monitor changes. New Residents: 1. Will be weighted by nursing personnel two consecutive days upon admission to establish a baseline weight. 2. If a weight inconstancy occurs with the two admission weights, a request will be mafde to nursing personnel for the resident to be weighed on the third day following admission. 3. Following admission, the resident will be weighed by nursing personnel for a duration of four weeks and monthly thereafter. Weight Management: Weights will be completed in accordance with the Physician Orders. Significant Weight Change: Upon determination of casual/ impact factors, an individualized plan for subsequent weights will be developed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that met professional standards of care within 48 hours of the resident's admission for 7 of 9 residents (Residents #16, #21, #186, #188, #189, #193, and #194) reviewed for baseline care plans. The facility failed to complete baseline care plans for Residents within 48 hours of admission that included the minimum required healthcare information including ADL needs, therapy, specialized medication monitoring, fall risk, and pain relief interventions for Residents #16, Resident #21, Resident #186, Resident #188, Resident #189, Resident #193, and Resident #194. This failure could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met. Findings included: Review of Resident #16's admission Record dated 5/3/23 revealed he was an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included encephalopathy (altered brain function), altered mental status, irregular heartbeat, Bullous Disorder (a skin disorder), malnutrition, dehydration, and muscle weakness. Review of Resident #16's Five-Day MDS assessment, dated 3/29/23 revealed: He scored an 11 of 15 on his mental status exam (indicating moderate cognitive impairment) but showed signs of delirium including inattention, and disorganized thinking. He needed limited assistance of one staff for bed mobility, supervision while eating and was totally dependent on one staff for toileting. He was always incontinent of bladder and occasionally incontinent of bowel. He weighed 171 pounds with weight loss or gain not indicated. Review of Resident #16's CAA revealed delirium, cognitive loss/dementia, ADL function, urinary incontinence, psychosocial well-being, mood state, activities, falls, nutritional status, dehydration, and pressure injury were indicated for consideration for care plans. Review of Resident #16's Order Summary Report, dated 5/3/23, revealed orders: Mechanical Soft Diet dated 4/25/23 (chopped to small pieces to reduce choking hazard) Physical Therapy, Occupational Therapy, and Speech Therapy to evaluate and treat as indicated dated 4/17/23. Aspirin 81 mg once a day for anticoagulation beginning 4/17/23 Attempted interview and observation with Resident #16 on 5/2/23 at 10/25/23 a.m. showed Resident #16 was unable to stay focused on questions that involved more than a yes/no answer and was unable to focus on general conversation. Review of Resident #16's undated care plan showed no care plan for ADL status, cognitive ability, specialized diet, urinary incontinence, pain management, or therapy needs. Review of Resident #21's admission Record, dated 5/3/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included muscle wasting and atrophy (multiple sites), unilateral primary osteoarthritis right knee, unilateral osteoarthritis left knee, Type 2 Diabetes Mellitus, vitamin D deficiency, hyperlipidemia (high cholesterol), atherosclerotic heart disease (heart disease caused by the buildup of plaque on the walls of the arteries), occlusion and stenosis (narrowing and blocking of blood flow)of bilateral carotid arteries, gastro esophageal reflux disease, and long term (current) use of insulin. Review of Resident #21's admission MDS assessment dated [DATE] revealed the following: She scored a 15 on her mental status exam, indicating she was cognitively intact. She required at least one person assistance with most ADLs except eating and personal hygiene for which she only require setup assistance. She used a wheelchair for locomotion in the facility. She was continent of bowel and bladder and denied constipation at the time of the comprehensive assessment. She had received insulin 5 of 7 days prior to the assessment. Review of Resident #21's electronic order summary dated 5/3/23 revealed the following orders: Januvia Oral Tablet 100mg (Sitagliptin Phosphate) Give 1 tablet by mouth in the morning for Antidiabetic (order date 3/25/23, start date 3/26/23) Lantus SoloStar Solution Pen-Injector 100 unit/ml (Insulin Glargine) Inject 40 units subcutaneously at bedtime for Diabetes ***please contact physician if BG >500 or <50*** (order date1/16/23, start date 1/16/23) Review of Resident #21's Care Plan , last revision date 3/7/23 revealed no care plan for ADLs, risk for falls, pain management, or specialized medications. Review of Resident #186's admission Record, dated 5/3/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included frontal lobe and executive function deficit (decline in the ability to focus on certain tasks) following nontraumatic intracerebral hemorrhage (brain bleed), hemiplegia (one sided paralysis) and hemiparesis (one sided weakness) following cerebrovascular disease (stroke) affecting left non-dominant side, dysphagia (difficulty swallowing), hypertensive urgency (extremely high blood pressure without organ damage), cerebral edema (swelling of the brain), acute respiratory failure with hypoxia (low blood oxygen), osteoarthritis, gastrostomy status (feeding tube surgical placed into the stomach), hyperlipidemia (high cholesterol), and hypertension (high blood pressure). Review of Resident #186's admission MDS assessment dated [DATE] revealed the following: She scored 13 on her mental status exam indicating she was cognitively intact. She required two plus physical assistance for all ADLs. She used a wheelchair for locomotion in the facility. She was always incontinent of bowel and bladder. She was at risk for developing a pressure ulcer but had no wounds at the time of the assessment. CAAs triggered were ADL Functional/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter, Falls, Nutritional Status, Feeding Tube, Dehydration/Fluid Maintenance, Pressure Ulcer, Return to Community Referral. Review of Resident #186's electronic Order Summary dated 5/3/23 revealed the following orders: Occupational Therapy order clarification, patient is for skilled occupational therapy services 5 times a week for 30 days to treat with therapeutic ex, therapeutic act, neuromuscular re-education, self-care skills retraining, wheelchair management, manual therapy (order date 4/13/23) Pain assessment every shift (utilize 1-10 scale if alert and oriented/PAINAD scale if resident has confusion/dementia) every shift (order date 4/12/23, start date 4/13/23) Pressure relief device on bed/chair as needed (order date 4/12/23) Physical therapy clarification: patient to receive skilled physical therapy 5 times a week for 4 weeks for therapeutic ex, therapeutic act, neuromuscular re-education, gait training (order date 4/13/23) PT/OT/ST eval and treat as indicated (order date 4/12/23) Speech Therapy clarification: physician's order received, chart reviewed, history noted, evaluation completed, and plan of treatment developed on this date. ST to treat 3 times a week for 4 weeks to address cognitive-communication deficits and dysphagia. Treatment to include exercises, development and training in compensations, spaced retrieval, orientation, and safety awareness (order date 4/14/23) Suspend/Offload heels when in bed (order date 4/12/23) Acetaminophen Tablet 325mg give 2 tablets orally every 6 hours as needed for pain 2-10 (order date 5/3/23, start date 5/3/23) Acetaminophen Tablet 325mg give 2 tablets via PEG every 6 hours as needed for pain 2-10 (order date 4/12/23, start date 4/12/23) Carvedilol Oral Tablet 6.25mg give 1 tablet orally two times a day for hypertension hold and notify MD of SBP <90, DBP <50, pulse <50 (order date 5/3/23, start date 5/3/23) Carvedilol Oral Tablet 6.25mg give 1 tablet via PEG two times a day for hypertension hold and notify MD of SBP <90, DBP <50, pulse <50 (order date 4/12/23, start date 4/12/23) Dulcolax Suppository 10mg insert 1 suppository rectally every 24 hours as needed for constipation (order date 4/12/23, start date 4/13/23) Methocarbamol Oral tablet 500mg give 1 tablet orally every 6 hours as needed for muscle spam/pain (order date 5/3/23, start date 5/3/23) Methocarbamol Oral tablet 500mg give 2 tablets orally every 6 hours as needed for muscle spam/pain (order date 5/3/23, start date 5/3/23) Methocarbamol Oral tablet 500mg give 1 tablet via PEG every 6 hours as needed for muscle spam/pain (order date 4/27/23, start date 4/27/23) Methocarbamol Oral tablet 500mg give 2 tablets via PEG every 6 hours as needed for muscle spam/pain (order date 4/27/23, start date 4/27/23) Rosuvastatin Calcium oral tablet 5mg give 1 tablet orally at bedtime for antihyperlipidemic (order date 5/3/23, start date 5/3/23) Rosuvastatin Calcium oral tablet 5mg give 1 tablet via PEG at bedtime for antihyperlipidemic (order date 4/12/23, start date 4/12/23) Review of Resident #186's undated Care Plan revealed no care plan in place for specialized medication, pain management, risk for falls, ADLs, risk for pressure ulcers, or therapy needs. Review of Resident #188's admission Record, dated 5/3/23, revealed he was a [AGE] year-old male admitted to the facility 4/24/23 with diagnoses that included encounter for surgical aftercare following surgery on the digestive system, incisional hernia, ventral hernia, and intestinal obstruction. Review of Resident #188's admission MDS assessment dated [DATE] revealed the following: He scored a 15 on his mental status exam, indicating he was cognitively intact. He required at least 2-person physical assistance for all ADLs except for eating which only require setup. He was continent of bladder and frequently incontinent of bowel. He reported frequent pain that made it hard to sleep and limited his activities and he rated as moderate. He was a risk for developing pressure ulcers. He had a surgical wound present on admission. CAAs triggered were ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status, dehydration/fluid maintenance, pressure ulcer, pain, and return to community referral. Review of Resident #188's electronic Order Summary dated 5/3/23 revealed the following orders: Pain assessment every shift (utilize 1-10 scale if alert and oriented/PAINAD scale if resident has confusion/dementia) every shift (order date 4/24/23, start date 4/25/23) Methocarbamol oral tablet 750mg give 1 tablet by mouth every 6 hours as needed for muscle spasms (order date 4/28/23, start date 4/28/23) Tramadol HCL oral tablet 50mg give 1 tablet by mouth every 4 hours as needed for pain (order date 4/27/23, start date 4/27/23) Tramadol HCL oral tablet 50mg give 1 tablet by mouth three times a day for pain (order date 4/27/23, start date 4/27/23) Tylenol Extra Strength oral tablet 500mg give 2 tablets by mouth every 6 hours as needed for pain (order date 4/25/23, start date 4/25/23) Review of Resident #188's Care Plan, l ast revised 5/3/23, revealed no care plan for pain, risk for pressure ulcers or risk for falls. Review of Resident #189's admission Record dated 5/3/23 revealed she was an [AGE] year-old female admitted to the facility 4/18/23 with diagnoses that included fracture of lower end of left femur, hyperlipidemia (high cholesterol), and hypertension (high blood pressure). Review of Resident #189's admission MDS assessment dated [DATE] revealed the following: She scored a 15 on her mental status exam, indicating she was cognitively intact. She required at 2-person physical assistance with all ADLs except eating, which only required setup. She used a wheelchair for locomotion in the facility. She was always incontinent of bowel and bladder. She reported frequent pain rated at a 4. She had a fall with a fracture in the 6 months prior to admission. She was at risk for developing a pressure ulcer. She had a surgical wound present on admission. Her medications included an anticoagulant, antidepressant, and an opioid. She was dependent on oxygen therapy. CAAs triggered were ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status, pressure ulcer, psychotropic drug use, pain and return to community referral. Review of Resident #189's Order Summary dated 5/3/23 revealed the following orders: General diet mechanical soft texture, thin liquids consistency, mechanical soft (order date 5/2/23, start date 5/2/23) Ensure pudding two times a day (order date 5/1/23, start date 5/2/23) Keep leg immobilizer in place to left leg until follow up with ortho, check every shift for signs/symptoms of skin breakdown and impaired circulation (order date 4/19/23) Leave aquacel dressing in place to left leg surgical incision until follow up with ortho (order date 4/19/23) May have alcoholic beverage if not contraindicated (order date 4/18/23) May have dietary liberties on special occasions (order date 4/18/232) Non weight bearing times 3 months (order date 4/19/23) Occupational Therapy order clarification: patient is for skilled OT services 5 times a week for 30 days to treat with therapeutic exercises, therapeutic activities, neuromuscular re-education, group therapy, self-care skills retraining, wheelchair management to return to prior level of functioning (order date 4/19/23) Pain assessment every shift (utilize 1-10 scale if alert and oriented/PAINAD scale if resident has confusion/dementia) every shift (order date 4/18/23, start date 4/18/23) Pressure relief device on bed/chair as needed (order date 4/18/23) Physical therapy clarification: PT 5 weeks 4 for therapeutic exercises, therapeutic activities, neuromuscular re-education, manual therapy, gait training, group exercises, patient/caregiver education (order date 4/19/23) PT/OT/ST to eval and treat as needed (4/18/23) Acetaminophen oral tablet 500mg give 2 tablets by mouth every 6 hours as needed for pain 2-10 (order date 4/18/23, start date 4/18/23) Ezetimibe oral tablet 10mg give 1 tablet by mouth at bedtime for hyperlipidemia (order date 4/18/23, start date 4/18/23) Mirapex tablet 0.5mg give 1 tablet by mouth at bedtime for restless leg syndrome (order date 4/18/23, start date 4/18/23) Pantoprazole Sodium oral tablet delayed release 40mg give 1 tablet by mouth in the morning for GERD (order date 4/18/23, start date 4/19/23) Potassium Chloride ER tablet Extended Release 20meq give 1 tablet by mouth and at bedtime for hypokalemia (order date 4/18/23, start date 4/18/23) Rosuvastatin Calcium oral tablet 20mg give 1 tablet by mouth at bedtime for hyperlipidemia (order date 4/18/23, start date 4/18/23) Tramadol HCL oral tablet 50mg give 1 tablet by mouth every 4 hours as needed for pain 2-10 (order date 4/18/23, start date 4/18/23) Vesicare oral tablet 5mg give 1 tablet by mouth one time a day for bladder spasms (order date 4/18/23, start date 4/19/23) Xarelto oral tablet 20mg give 1 tablet by mouth one time a day for anticoagulation (order date 4/18/23, start date 4/19/23) Review of Resident #189's undated Care Plan revealed no care plan for ADLs, fall risk, nutritional status, pressure ulcer risk, pain management, specialized medications, or discharge planning. Review of Resident #193's admission Record, dated 5/3/23, revealed Resident #193 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included sepsis (blood infection), chronic obstructive pulmonary disease, malnutrition, and female genital prolapse, unspecified (female vaginal organs fall out). Review of Resident #193's admission MDS assessment dated [DATE], revealed: She scored a 15 of 15 on her mental status exam (indicating she was cognitively intact) She needed supervision assistance of one staff for ADLs and used a walker. Her diagnoses included hypertension, sepsis, malnutrition, and chronic obstructive pulmonary disease. She weighed 89 pounds with not-prescribed weight loss identified. She was an antibiotic for 5 of 5 days. Triggering CAAs were ADLs, Falls, Nutritional Status, Dehydration, Skin/Pressure Ulcers, and Return to the community. Review of Resident #193's Physician Order Report, dated 5/3/23, revealed: Physical Therapy, Occupational Therapy, and Speech Therapy evaluate and treat as indicated, dated 4/21/23 Melatonin Tablet 5 mg at bedtime for insomnia dated 4/21/23 (supplement used to treat insomnia) Review of Resident #193's electronic Care Plan revealed no care plan for antibiotic use, use of the walker for mobility, ADLs status, falls and weight loss. Review of Resident #194's admission Record, dated 5/3/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included leukemia (cancer of blood cells), anemia, diabetes, chronic obstructive pulmonary disease, dementia, hypertension, heart disease, and osteomyelitis (bone infection). Review of Resident #194's MDS section showed her admission MDS was not completed yet. Review of Resident #194's Order Summary Report, dated 5/3/23, revealed orders: Occupational Therapy dated 5/2/23 Pain Assessment every shift dated 5/1/23 Acetaminophen 500mg 2 tablets every 6 hours as needed dated 5/1/23 Donepezil 10 mg daily for dementia dated 5/1/23 Heparin Lock Flush Solution 100 unit/ml use 5 cubic centimeter intravenously twice a day for PICC dated 5/2/23 Pregabalin 150mg twice a day for neuropathy (nerve pain) Memantine 10 mg once a day for dementia Interview and observation of Resident #194 on 5/2/23 at 10:03 a.m. showed Resident #194 in bed. She had oxygen on, she explained she had been in the facility for two days and she received ADL Care and medications, but no one had come to assess her for anything. Review of Resident #194 electronic record on the afternoon of 5/3/23 revealed no care plan of any kind for Resident #194 for pain, ADL care, oxygen, therapy, cognitive status, or the PICC line. Interview on 5/03/23 at 4:20 PM, the DON and MDS Coordinator stated the MDS Coordinator had only been working at the facility for a couple of weeks. The DON stated the facility just switched to a new [electronic documentation program] environment. The DON said the facility's assessment started the care plan process on 2/4/23. The DON stated that care plans were triggered depending on what the admitting nurse clicked during the assessment. The DON stated the facility used the comprehensive care plan as the Baseline Care plan and the facility staff would build the care plan up as it went. The DON stated she was unaware that the ADL status of the residents was not care planned initially and stated it was something we need to look at. The DON said they had to click a button to address the ADLs. The DON stated she expected falls, skin, pain, nutrition, ADL status, weights, psychotropic medications, specific diagnoses including fractures and specialized medications like insulin or anticoagulants to be care planned. The DON stated baseline care plans were not getting done. She said staff would know what care the residents needed from the verbal reports between aide to aide and nurse to nurse. The DON stated there was no care plan for Resident #16's ADL status. The DON said the facility had been working out the bugs in the documentation program, and there had been a lot of bugs. She said ok when she reviewed Resident #189's care plan for the missing pain, falls, therapy, positioning, and mobility. Review of the facility's policy and procedure on Base Line Care Plan, revised 9/19/22, revealed: Policy Statement: All residents have the right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care when admitted to a [corporation] community health center. [The corporation] values the input of these persons and strives to involve residents' other supportive individuals in the delivery of health care services. Residents admitted to any [corporation] community health center will have a Baseline Care Plan formulated and developed within 48 hours of admission. The Baseline Care Plan will consist of the residents' plan of care/ care plan within [documentation program]. The admitting nurse or designee will develop a Baseline Care Plan in [the documentation program] within 48 hours of the resident's admission for the provision of person-centered care. The Baseline Care Plan will be developed based upon the identified needs of the resident with input from the resident and/or the resident's representative, and after reconciliation of the physician orders with the physician. The Baseline Care Plan will address but will not be limited to the following: a. Initial goals based on admission orders; b. cultural preferences; c. Physician Orders. d. dietary orders, e. Therapy services. f. social services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 9 residents (Residents #6, #16, #21, #186, #188, #189) reviewed for care plans in that: Resident #6 did not have care plans in place for insulin use or hypertensive monitoring. Resident #16 did not have care plans in place for delirium, cognitive loss/dementia, ADL status (including urinary incontinence), psychosocial well-being, falls, dehydration status, weight loss, or pressure injury. Resident #21 did not have care plans in place for her insulin use or constipation. Resident #186 did not have care plans in place for hypertension, hyperlipidemia, pain management, fall risk, constipation, risk for pressure ulcers, or therapy needs. Resident #188 did not have a care plan in place for pain management. Resident #189 did not have care plans in place for ADLs, hyperlipidemia, hypertension, pain management, fall risk, risk for pressure ulcers, mobility status, therapy needs, nutritional status/diet, restless leg syndrome, or gastroesophageal reflux disease. These failures could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included: Review of Resident #6's admission Record, dated 5/3/23, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included back problems with fracture, irregular heart rhythm, heart disease, diabetes, dementia with agitation, hypertension, and arthritis. Review of Resident #6's Quarterly MDS assessment dated [DATE] revealed: He received insulin injections for 7 of 7 days., Review of Resident #6's Order Summary Report, dated 5/3/23, revealed orders: Carvedilol Tablet 3.125 mg for hypertension, Hold and notify MD for systolic blood pressure less than 90 or diastolic blood pressure less than 50 and pulse less than 50. Dated 10/8/22 Insulin Glargine (long-acting insulin) 26 units subcutaneously at bedtime dated 9/15/22 Sliding scale short term insulin 151 - 200mg = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units dated 10/15/23. Review of Resident #6's Care Plan, last updated on 3/7/23 revealed, no care plan for insulin use or hypertensive monitoring. Review of Resident #16's admission Record dated 5/3/23 revealed he was an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included encephalopathy (altered brain function), altered mental status, irregular heartbeat, malnutrition, dehydration, and muscle weakness. Review of Resident #16's Five-Day MDS assessment, dated 3/29/23 revealed He scored an 11 of 15 on his mental status exam (indicating moderate cognitive impairment) but showed signs of delirium including inattention, and disorganized thinking. He needed limited assistance of one staff for bed mobility, supervision while eating and was totally dependent on one staff for toileting. He was always incontinent of bladder and occasionally incontinent of bowel. He weighed 171 pounds with weight loss or gain not indicated. There were no skin issues identified. Review of Resident #16's CAA revealed delirium, cognitive loss/dementia, ADL function, urinary incontinence, psychosocial well-being, mood state, activities, falls, nutritional status, dehydration, and pressure injury were indicated for consideration for care plans. Review of Resident #16's Order Summary Report, dated 5/3/23, revealed orders: Mechanical Soft Diet dated 4/25/23 (chopped to small pieces to reduce choking hazard) Review of Resident #16's weights between 3/28/23 and 4/9/23 showed an 11.7% loss in less than 30 days, and an additional 4% loss after re-admission to the facility. Review of Resident #16's undated care plan revealed there was no comprehensive care plan including personalized objectives for: delirium, cognitive loss/ dementia, ADL status, including urinary incontinence, psychosocial wellbeing, falls, dehydration status, weight loss or pressure injury. Review of Resident #21's admission Record, dated 5/3/23, revealed she was a [AGE] year-old female admitted to the facility 12/02/23 with diagnoses that included muscle wasting and atrophy (multiple sites), unilateral primary osteoarthritis right knee, unilateral osteoarthritis left knee, Type 2 Diabetes Mellitus, vitamin D deficiency, hyperlipidemia (high cholesterol), atherosclerotic heart disease (heart disease caused by the buildup of plaque on the walls of the arteries), occlusion and stenosis (narrowing and blocking of blood flow)of bilateral carotid arteries, gastro esophageal reflux disease, and long term (current) use of insulin. Review of Resident #21's admission MDS assessment dated [DATE] revealed the following: She scored a 15 on her mental status exam, indicating she was cognitively intact. She required at least one person assistance with most ADLs except eating and personal hygiene for which she only require setup assistance. She used a wheelchair for locomotion in the facility. She was continent of bowel and bladder and denied constipation at the time of the comprehensive assessment. She had received insulin 5 of 7 days prior to the assessment. Review of Resident #21's electronic order summary dated 5/3/23 revealed the following orders: May check for and remove hard stool as needed (order date 12/2/22) Colace Oral Capsule 100mg (Docusate Sodium) give 1 capsule by mouth every 24 hours as needed for softener (order date 1/9/23, start date 1/9/23) Januvia Oral Tablet 100mg (Sitagliptin Phosphate) Give 1 tablet by mouth in the morning for Antidiabetic (order date 3/25/23, start date 3/26/23) Lantus SoloStar Solution Pen-Injector 100 unit/ml (Insulin Glargine) Inject 40 units subcutaneously at bedtime for Diabetes ***please contact physician if BG >500 or <50*** (order date1/16/23, start date 1/16/23) Milk of Magnesia Oral Suspension 400 mg/5 ml (Magnesium Hydroxide) Give 30 ml by mouth every 8 hours as needed for constipation (order date 1/9/23, start date 1/9/23) Senna-Plus Oral Tablet 8.6-50 mg (Sennosides-Docusate Sodium) Give 1 tablet by mouth every 12 hours as needed for constipation (order date 4/5/23, start date 4/5/23) Review of Resident #21's Care Plan, last revision date 3/7/23, revealed the following: Resident #21's Care Plan did not address her insulin use. Resident #21's Care Plan did not address constipation, or the medications prescribed to her for it. Review of Resident #186's admission Record revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included frontal lobe and executive function deficit (decline in the ability to focus on certain tasks) following nontraumatic intracerebral hemorrhage (brain bleed), hemiplegia (one sided paralysis) and hemiparesis (one sided weakness) following cerebrovascular disease (stroke) affecting left non-dominant side, dysphagia (difficulty swallowing), hypertensive urgency (extremely high blood pressure without organ damage), cerebral edema (swelling of the brain), acute respiratory failure with hypoxia (low blood oxygen), osteoarthritis, gastrostomy status (feeding tube surgical placed into the stomach), hyperlipidemia (high cholesterol), and hypertension (high blood pressure). Review of Resident #186's Fall Risk Evaluation dated 4/12/23 at 6:31 PM revealed the following: Her level of consciousness was alert (oriented x 3). She had 1-2 falls in the past 3 months. There was no answer for her ambulation/elimination status. Her vision status was adequate. The answer regarding her gait/balance was N/A - not able to perform function. There was no drop noted between lying and standing in her systolic blood pressure. There was no answer the questions regarding her medications. She had 1-2 predisposing diseases present. The Risk for Falls, Visual Impairment and Clinical Suggestions sections were all blank. Her total score was a 5, indicating a low risk for falls. Review of Resident #186's admission MDS assessment dated [DATE] revealed the following: She scored 13 on her mental status exam indicating she was cognitively intact. She required two plus physical assistance for all ADLs. She used a wheelchair for locomotion in the facility. She was always incontinent of bowel and bladder. She was at risk for developing a pressure ulcer but had no wounds at the time of the assessment. CAAs triggered were ADL Functional/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter, Falls, Nutritional Status, Feeding Tube, Dehydration/Fluid Maintenance, Pressure Ulcer, Return to Community Referral. Review of Resident #186's electronic Order Summary dated 5/3/23 revealed the following orders: Occupational Therapy order clarification, patient is for skilled occupational therapy services 5 times a week for 30 days to treat with therapeutic ex, therapeutic act, neuromuscular re-education, self-care skills retraining, wheelchair management, manual therapy (order date 4/13/23) Pain assessment every shift (utilize 1-10 scale if alert and oriented/PAINAD scale if resident has confusion/dementia) every shift (order date 4/12/23, start date 4/13/23) Pressure relief device on bed/chair as needed (order date 4/12/23) Physical therapy clarification: patient to receive skilled physical therapy 5 times a week for 4 weeks for therapeutic ex, therapeutic act, neuromuscular re-education, gait training (order date 4/13/23) PT/OT/ST eval and treat as indicated (order date 4/12/23) Speech Therapy clarification: physician's order received, chart reviewed, history noted, evaluation completed, and plan of treatment developed on this date. ST to treat 3 times a week for 4 weeks to address cognitive-communication deficits and dysphagia. Treatment to include exercises, development and training in compensations, spaced retrieval, orientation, and safety awareness (order date 4/14/23) Suspend/Offload heels when in bed (order date 4/12/23) Acetaminophen Tablet 325mg give 2 tablets orally every 6 hours as needed for pain 2-10 (order date 5/3/23, start date 5/3/23) Acetaminophen Tablet 325mg give 2 tablets via PEG every 6 hours as needed for pain 2-10 (order date 4/12/23, start date 4/12/23) Carvedilol Oral Tablet 6.25mg give 1 tablet orally two times a day for hypertension hold and notify MD of SBP <90, DBP <50, pulse <50 (order date 5/3/23, start date 5/3/23) Carvedilol Oral Tablet 6.25mg give 1 tablet via PEG two times a day for hypertension hold and notify MD of SBP <90, DBP <50, pulse <50 (order date 4/12/23, start date 4/12/23) Dulcolax Suppository 10mg insert 1 suppository rectally every 24 hours as needed for constipation (order date 4/12/23, start date 4/13/23) Methocarbamol Oral tablet 500mg give 1 tablet orally every 6 hours as needed for muscle spam/pain (order date 5/3/23, start date 5/3/23) Methocarbamol Oral tablet 500mg give 2 tablets orally every 6 hours as needed for muscle spam/pain (order date 5/3/23, start date 5/3/23) Methocarbamol Oral tablet 500mg give 1 tablet via PEG every 6 hours as needed for muscle spam/pain (order date 4/27/23, start date 4/27/23) Methocarbamol Oral tablet 500mg give 2 tablets via PEG every 6 hours as needed for muscle spam/pain (order date 4/27/23, start date 4/27/23) Rosuvastatin Calcium oral tablet 5mg give 1 tablet orally at bedtime for antihyperlipidemic (order date 5/3/23, start date 5/3/23) Rosuvastatin Calcium oral tablet 5mg give 1 tablet via PEG at bedtime for antihyperlipidemic (order date 4/12/23, start date 4/12/23) (Resident #186 had started a trial of switching back to taking medications by mouth and eating a mechanical soft diet beginning 5/3/23 and the physician had not discontinued orders for medications via PEG at the time of the record review.) Review of Resident #186's undated Care Plan revealed no care plan in place for hypertension, hyperlipidemia, pain management, risk for falls, constipation, risk for pressure ulcers, or PT/OT/ST. Review of Resident #188's admission Record, dated 5/3/23, revealed he was a [AGE] year-old male admitted to the facility 4/24/23 with diagnoses that included encounter for surgical aftercare following surgery on the digestive system, incisional hernia, ventral hernia, and intestinal obstruction. Review of Resident #188's admission MDS assessment dated [DATE] revealed the following: He scored a 15 on his mental status exam, indicating he was cognitively intact. He required at least 2-person physical assistance for all ADLs except for eating which only require setup. He was continent of bladder and frequently incontinent of bowel. He reported frequent pain that made it hard to sleep and limited his activities and he rated as moderate. He was a risk for developing pressure ulcers. He had a surgical wound present on admission. CAAs triggered were ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status, dehydration/fluid maintenance, pressure ulcer, pain, and return to community referral. Review of Resident #188's electronic Order Summary dated 5/3/23 revealed the following orders: Pain assessment every shift (utilize 1-10 scale if alert and oriented/PAINAD scale if resident has confusion/dementia) every shift (order date 4/24/23, start date 4/25/23) Methocarbamol oral tablet 750mg give 1 tablet by mouth every 6 hours as needed for muscle spasms (order date 4/28/23, start date 4/28/23) Tramadol HCL oral tablet 50mg give 1 tablet by mouth every 4 hours as needed for pain (order date 4/27/23, start date 4/27/23) Tramadol HCL oral tablet 50mg give 1 tablet by mouth three times a day for pain (order date 4/27/23, start date 4/27/23) Tylenol Extra Strength oral tablet 500mg give 2 tablets by mouth every 6 hours as needed for pain (order date 4/25/23, start date 4/25/23) Review of Resident #188's Care Plan, last revised 5/3/23, revealed no care plan addressing pain management. Review of Resident #189's admission Record dated 5/3/23 revealed she was an [AGE] year-old female admitted to the facility 4/18/23 with diagnoses that included fracture of lower end of left femur, hyperlipidemia (high cholesterol), and hypertension (high blood pressure). Review of Resident #189's admission MDS assessment dated [DATE] revealed the following: She scored a 15 on her mental status exam, indicating she was cognitively intact. She required at 2-person physical assistance with all ADLs except eating, which only required setup. She used a wheelchair for locomotion in the facility. She was always incontinent of bowel and bladder. She reported frequent pain rated at a 4. She had a fall with a fracture in the 6 months prior to admission. She was at risk for developing a pressure ulcer. She had a surgical wound present on admission. Her medications included an anticoagulant, antidepressant, and an opioid. She was dependent on oxygen therapy. CAAs triggered were ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status, pressure ulcer, psychotropic drug use, pain and return to community referral. Review of Resident #189's Order Summary dated 5/3/23 revealed the following orders: General diet mechanical soft texture, thin liquids consistency, mechanical soft (order date 5/2/23, start date 5/2/23) Ensure pudding two times a day (order date 5/1/23, start date 5/2/23) Keep leg immobilizer in place to left leg until follow up with ortho, check every shift for signs/symptoms of skin breakdown and impaired circulation (order date 4/19/23) Leave aquacel dressing in place to left leg surgical incision until follow up with ortho (order date 4/19/23) May have alcoholic beverage if not contraindicated (order date 4/18/23) May have dietary liberties on special occasions (order date 4/18/232) Non weight bearing times 3 months (order date 4/19/23) Occupational Therapy order clarification: patient is for skilled OT services 5 times a week/30 days to treat with therapeutic exercises, therapeutic activities, neuromuscular re-education, group therapy, self-care skills retraining, wheelchair management to return to prior level of functioning (order date 4/19/23) Pain assessment every shift (utilize 1-10 scale if alert and oriented/PAINAD scale if resident has confusion/dementia) every shift (order date 4/18/23, start date 4/18/23) Pressure relief device on bed/chair as needed (order date 4/18/23) Physical therapy clarification: PT 5 weeks 4 for therapeutic exercises, therapeutic activities, neuromuscular re-education, manual therapy, gait training, group exercises, patient/caregiver education (order date 4/19/23) PT/OT/ST to eval and treat as needed (4/18/23) Acetaminophen oral tablet 500mg give 2 tablets by mouth every 6 hours as needed for pain 2-10 (order date 4/18/23, start date 4/18/23) Ezetimibe oral tablet 10mg give 1 tablet by mouth at bedtime for hyperlipidemia (order date 4/18/23, start date 4/18/23) Mirapex tablet 0.5mg give 1 tablet by mouth at bedtime for restless leg syndrome (order date 4/18/23, start date 4/18/23) Pantoprazole Sodium oral tablet delayed release 40mg give 1 tablet by mouth in the morning for GERD (order date 4/18/23, start date 4/19/23) Potassium Chloride ER tablet Extended Release 20meq give 1 tablet by mouth and at bedtime for hypokalemia (order date 4/18/23, start date 4/18/23) Rosuvastatin Calcium oral tablet 20mg give 1 tablet by mouth at bedtime for hyperlipidemia (order date 4/18/23, start date 4/18/23) Tramadol HCL oral tablet 50mg give 1 tablet by mouth every 4 hours as needed for pain 2-10 (order date 4/18/23, start date 4/18/23) Vesicare oral tablet 5mg give 1 tablet by mouth one time a day for bladder spasms (order date 4/18/23, start date 4/19/23) Xarelto oral tablet 20mg give 1 tablet by mouth one time a day for anticoagulation (order date 4/18/23, start date 4/19/23) Review of Resident #189's undated Care Plan revealed no care plan in place to address ADLs (including bowel and bladder incontinence), hyperlipidemia, hypertension, pain management, risk for falls, risk for developing pressure ulcers/skin integrity, mobility status, therapy needs, anticoagulant use, nutritional status/diet orders, restless leg syndrome, or gastroesophageal reflux disease. In an interview on 5/03/23 at 4:20 PM with the DON and MDS Coordinator, the DON stated the MDS Coordinator had only been working at the facility for a couple of weeks. The DON stated the facility just switched to a new [electronic documentation program] environment. The DON stated that care plans were triggered depending on what the admitting nurse clicked during the assessment. The DON stated she expected falls, skin, pain, nutrition, ADL status, weights, psychotropic medications, specific diagnoses including fractures and specialized medications like insulin or anticoagulants to be care planned. The DON stated staff would know what care the residents needed from the verbal reports between aide to aide and nurse to nurse. The MDS Coordinator stated that aides also had access to a [NAME] on the computer that the nurses populated from the electronic charts with relevant care information for each resident. The MDS Coordinator acknowledged that there were blanks in some of the resident's care plans and stated that the blanks were pulling over from assessments in the program. She stated they had been working to find out why it was happening. The DON said the facility had been working out the bugs in the documentation program, and there had been a lot of bugs. The DON stated there was no care plan for Resident #16's ADL status. She said ok when she reviewed Resident #189's care plan for the missing pain, falls, therapy, positioning, and mobility. Record review of facility policy Comprehensive Care Plan revision date 9/6/22 revealed, in part: The resident care plan will include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs, and will be developed and implemented for each resident The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment The comprehensive, person-centered care plan will: describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; incorporate identified problem areas; incorporate risk factors associated with identified problems; identify the professional services that are responsible for each element of care; reflect currently recognized standards of practice for problem areas and conditions The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 1 of 3 residents (Resident #139) reviewed for infection control. 1.LVN A failed to perform hand hygiene appropriately prior to providing wound care for Resident #139. 2.LVN A used dirty scissors to cut Vaseline gauze that was applied to wound for Resident #139. These failures could place residents at risk for transmission of diseases and organisms. The findings included: Review of Resident #139's Resident Face Sheet dated 5/3/23 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including fracture of shaft left fibula (lower leg), fracture of left tibia (lower leg), hypertension (high blood pressure), hyperlipidemia (high cholesterol), osteoarthritis (type of arthritis that occurs at the ends of bones), chronic atrial fibrillation (irregular heart rate caused by poor blood flow). Review of Resident #139's admission MDS, dated [DATE], revealed: Resident had BIMS score of 13, which suggested resident was cognitively intact. He required extensive to total assistance of one or two staff for all ADLs. He was occasionally incontinent of bowel and bladder. He had a surgical wound. Review of Resident #139s Care Plan, dated 4/14/23, revealed: Problem: Wound Management Post-Surgical to left lower extremity with staples Goal: Wound Will Show Signs of Improvement Interventions: Encourage Resident to elevate legs; Monitor ulcer for signs of progression or declination; Notify provider if no signs of improvement on current wound regimen; Provide wound care per treatment order. Observation on 05/02/23 at 10:45 AM revealed Resident #139 sitting in a recliner with leg propped up on bed. LVN A entered the room and told Resident #139 she was going to perform wound care. LVN A was observed hand washing. LVN A turned on the faucet, washed hands for 10 seconds with soap and water, turned off the faucet with her clean bare hands, then dried her hands with paper towels. LVN A removed soiled, saturated gauze with scissors. LVN A removed all old dressing and ABD pad saturated in drainage. LVN doffed gloves and disposed of soiled dressing. LVN washed hands with soap and water for less than 10 seconds, turned off the faucet with her clean bare hands, then dried her hands with paper towels. LVN A donned clean gloves and cleansed the wound. LVN A used the same scissors she used to cut the soiled gauze, to cut the xeroform (vaseline gauze) and applied xeroform (vaseline gauze) to surgical wound. LVN A secured the dressing with ABD pad and wrapped residents' leg with rolled gauze and tape. Interview on 05/03/23 at 1:50 PM, the ADON/ Infection Preventionist stated her expectation of handwashing was to wash hands appropriately prior to all resident care. The ADON stated the steps of correct handwashing were to turn faucet on, lather hands with soap and water, wash thoroughly for 20 seconds (hum the birthday song), rinse hands thoroughly, dry hands and use paper towel to turn off faucet. The ADON was informed of the observation and stated the facility did proficiency checks on hire and annually. She stated that she was in the process of doing a handwashing in-service currently. Interview on 05/04/23 at 09:30 AM the Administrator stated her expectation was for all her staff to perform appropriate handwashing prior to resident care. Administrator stated that any staff member not doing so would be pulled immediately and re-educated by DON. Interview with DON, DON stated that she would ensure skills check offs were completed with all staff prior to resuming work. Review of the facility's staff skills competencies on handwashing, dated 04/28/23, revealed: 1.Wash hands with clean running water and apply soap. 2. Rub hands together to make leather and scrub them well, be sure to scrub the backs of your hands, between your fingers, and under your nails. 3. Continue rubbing your hands for 20 seconds. 4. Rinse your hands well under running water. 5. Dry your hands using clean paper towels. Review of the facility's policy titled; Hand Hygiene revised on 6/26/2015. Policy statement reads: Hand hygiene is the most effective measure for preventing infections. Hand hygiene includes several actions intended to decrease colonization with transient flora. This objective can be achieved through handwashing (20 seconds) or hand disinfection with alcohol-based hand rub. The following procedures are the recommendations from CDC's new hand hygiene guidelines. Indications for hand hygiene include: -Anytime you remove protective gloves or PPE. -Before or after treating a cut or a wound. -Between performing different procedures on the same resident. Note: wearing gloves does not replace the need for hand hygiene. Hand washing technique: Use sink with warm running water. Push wristwatch and long uniform sleeves above wrist. Stand in front of sink keeping hands and uniform away from sink surface. Angle your hands downward in the sink. Wet hands. Apply soap to hands lathering thoroughly. Wash hands using friction for at least 20 seconds. Interlace fingers and rub palms and back of hands with circular motion. Rinse hands and wrists thoroughly keeping hands downward. Dry hands thoroughly from fingers to wrist. Turn water faucet off with paper towel. Discard paper towel in proper receptacle. Review of facilities policy titled; Wound Care Policy revised on 4/1/22. Policy statement: It is the policy of this facility to utilize evidence based clinical practice to provide one treatment in our skilled nursing and rehabilitation health centers. Facility will comply with current nursing standards, as well as state and federal guidelines related to the identification, treatment, and documentation of alterations in the skin integrity of our residents. Procedures: The facility will follow best practices and current recommendations set forth by the national pressure ulcer advisory panel, these guidelines will be utilized by all team members working in facility skilled nursing and rehabilitation health centers when treating wounds. These guidelines will be reviewed and updated as additional advances in the prevention and treatment. Physician's orders will be obtained and followed for all skin care treatment

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods were properly labeled and dated. 2. The facility failed to ensure that equipment and utensils were stored in a manner to prevent contamination from dust and debris. These failures could affect residents who received meals prepared meals from the kitchen at risk for food borne illness and cross-contamination. The findings included: Observation on 5/2/23 at 8:50 AM during the initial walkthrough of the kitchen revealed: - Rack of serving scoops and long-handled, metal measuring cups hanging above prep table, not inverted, and uncovered with no protection from splash, dust, or other airborne contaminants. - Shelf in dishwashing area containing plates and bowls stored serving side up not inverted and with no cover for protection from splash, dust, or other airborne contaminants. Observation on 5/2/23 at 9:30 AM of the dry storage room revealed: - 4, 1-gallon containers of Worcestershire sauce with no expiration date - 1, 1-gallon container of natural smoke sauce with no expiration date - 4, 3.2-ounce packets of ranch salad dressing mix with no expiration date - 2, 1-gallon container of deluxe mayonnaise with no expiration date - 4, 1-gallon containers of premium salsa picante with no expiration date - 1, 1-gallon container of raspberry vinaigrette dressing with no expiration date - 2, 1-gallon containers of lite Italian dressing with no expiration date - 6, 24-ounce packets of pepper gravy mix with no expiration date - 5, 13-ounce packets of brown gravy mix with no expiration date - 1, 11.3-ounce packet of pork roast gravy mix with no expiration date - 13, 14-ounce bottles of tomato ketchup with no expiration date - 1, 16-ounce bag of fully cooked real bacon bits with no expiration date - 4, 32-ounce jars of [NAME] capers with no expiration date - 1, 36-ounce box of long grain and wild rice with no expiration date - 5, 5-pound bags complete cornbread mix with no expiration date - 12, 16-ounce bags of egg meringue powder with no expiration date - 1, 5-pound bag of whole pitted dates with no expiration date - 1, 5-pound bag (opened, approximately 3 pounds remaining) of pecans with no expiration date - 3, 56-ounce bags of classic cornbread stuffing mix with no expiration date - 2, 7-ouce bags of no-bake cheesecake mix with no expiration date - 3, 5-pound bags of yellow cake mix with no expiration date - 6, 5-pound bags of white cake mix with no expiration date - 12, 24-ounce bags of citrus gelatin mix with no expiration date - 4, 24-ounce bags of red gelatin mix with no expiration date - 2, 6-pound bags of vanilla non-dairy soft serve mix with no expiration date - 6, 6-pound bags of chocolate non-dairy soft serve mix with no expiration date - 11, 2.75-ounce packets of lemon gelatin mix with no expiration date - 9, 24-ounce bags of chocolate instant pudding and pie filling with no expiration date - 2, 24-ounce bags of vanilla instant pudding and pie filling with no expiration date - 3, 21.1-ounce packages of tropical punch drink mix with no expiration date - 10, 24-ounce packages lemonade drink mix with no expiration date In an interview on 5/2/23 at 10:45 AM, the Director of Dietary Services stated that he was aware that a good amount of the food items in the dry storage were missing expiration or best by dates. He stated he had questioned that in the past but had not been able to find an answer in the corporate policies or from the distributor. He stated that the facility was in the process of switching to a new distributor that was more geared toward the healthcare industry and he hoped that he would have better luck with the new company. He stated that he kept a close eye on all the food items and that due to the size of the facility and the fact that they serve not just the nursing facility resident but also the assisted living and independent living, the food they had on hand does not typically stay in the facility long enough to go bad. He stated he did not like having food with no dates from the manufacturers in the kitchen though because it seemed unsafe to serve without knowing for sure how old the food actually was. He stated he tried to be proactive about it, but he had been unable to find the expiration dates for most of the foods on his own. In an interview on 5/2/23 at 3:20 PM the Administrator stated that she had been made aware of the issue regarding the lack of expiration dates on food items in the kitchen. She stated that she agreed with the Director of Dietary Services that it was a concern to serve food without knowing the exact age of the food. She also stated that the facility was in the process of changing food distributors and the new company was better suited to the health care industry. She stated that because the facility was a CCRC and the kitchen served not only the nursing home residents, but the assisted living and independent living residents, the kitchen did not keep food on hand for long periods of time. She acknowledged the issue of not having proper dating on food items. She stated that she was hopeful that the new distributor would alleviate that problem. Observation on 5/4/23 at 9:15 AM during follow up walkthrough of kitchen revealed: - Rack of serving scoops and long-handled, metal measuring cups hanging above prep table, not inverted, and uncovered with no protection from splash, dust, or other airborne contaminants. - Shelf in dishwashing area containing plates and bowls stored serving side up not inverted and with no cover for protection from splash, dust, or other airborne contaminants. In an interview on 5/4/23 at 10:00 AM the Director of Dietary Services stated that he was unaware that utensils and plates/bowls/cups had to be stored inverted to prevent exposure from splash, dust, and other airborne contaminants. He stated he would start working to change the storage of the scoops and measuring cups immediately. He stated that the shelf of plates observed were not normally in use and that they were backup for catering for the independent living side of the facility, but he would make sure that moving forward they were stored properly. The Director of Dietary Services paused interview to ask dietary staff how items that were used to serve nursing facility residents were stored, and Dietary Aid B stated that all plates, bowls and cups were stored serving side down at all times. Review of facility policy Food Receiving and Storage dated October 2017, revealed, in part: When food is delivered to the facility it will be inspected for safe transport and quality before being accepted. The food and nutrition services manager shall verify that latest approved inspection and also monitor the food quality of the supplier. Dry foods that are stored n bins will be removed from original packaging, labeled and dated (use by date). All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Review of the FDA Food Code 2017, Chapter 4: Equipment, Utensils, and Linens: Section 4-9 Protection of Clean Items: Subpart 4-903 Storing, revealed: Storing 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice for 2 (Resident #1 and Resident #2) of 10 residents reviewed for resident rights in that: The facility failed to promote Resident #1 and Resident #2's self-determination by not allowing her to choose her pharmacy of choice when receiving skilled nursing services. This failure could place residents at risk for poor self-esteem and decreased self-worth due to their preferences not being met. Findings Included: Review of Resident #1's electronic facesheet revealed she was a [AGE] year-old female who was admitted to the facility 07/20/2022 with diagnosis of congestive heart failure (heart muscle does not pump blood well), history of heart attack, pacemaker, and atrial fibrillation (irregular and often rapid heart rhythm that can lead to blood clots in the heart). Further review of Resident #1's electronic facesheet revealed resident was discharged on 02/03/2023 and her preferred pharmacy was Pharmacy B. Further review of Resident #1's electronic facesheet revealed she received skilled nursing services 07/20/2022 to 08/07/2022, 08/10/2022 to 08/25/2022, and 01/03/2023 to 01/30/2023. Review of Resident #1's comprehensive assessment dated [DATE] revealed a BIMS Summary Score of 15 which indicated no cognitive impairment. Review of Resident #1's admission agreement dated and electronically signed by Resident #1's on 07/20/2022 revealed: Resident designates Pharmacy B as Resident's pharmacy provider of choice . In the absence of a designated pharmacy, HC is authorized to use a duly licensed pharmacy of its choice, including one operated by an affiliate of HC. Review of Resident #1's medication administration records from 07/20/2023 to 02/03/2023 revealed that resident's preferred pharmacy was Pharmacy B. Review of Resident #1's progress notes on 09/12/2022 at 2:40pm, 09/13/2022 at 3:22pm, 10/17/2022 at 7:54am revealed nursing staff contacted Pharmacy A for medication re-fills. Review of Resident #1's statement of account from Pharmacy B with invoice date of 09/11/2022 revealed Resident #1 was billed $977.80 for medications dispensed from Pharmacy B during time when Resident #1 was not receiving skilled nursing services (08/26/2022, 09/02/2022, 09/04/2022, 09/05/2022, 09/06/2022, 09/10/2022, and 09/11/2022). During an interview on 03/23/2023 at 9:30am, Resident #1 stated that her preferred pharmacy was Pharmacy A. She stated she received a pharmacy invoice from Pharmacy B for unknown reason for $2135.80. She stated she was very upset that the facility did not let her choose her preferred pharmacy when receiving skilled nursing services. Review of Resident #2's electronic facesheet revealed she was an [AGE] year-old female who was admitted to the facility 02/08/2023 with diagnosis of stroke, atrial fibrillation (irregular and often rapid heart rhythm that can lead to blood clots in the heart), difficulty speaking and swallowing, and memory deficits. Further review of Resident #2's facesheet revealed her preferred pharmacy was Pharmacy B. Review of Resident #2's admission agreement dated and electronically signed by Resident #2 on 02/09/2023 revealed: Resident designates Pharmacy C as Resident's pharmacy provider of choice . In the absence of a designated pharmacy, HC is authorized to use a duly licensed pharmacy of its choice, including one operated by an affiliate of HC. During an interview on 03/23/2023 at 11:27am, the administrator stated that if a resident received skilled nursing services, the resident would receive medications from Pharmacy B during time of receiving skilled nursing services. She stated that when a resident receives skills nursing services, the resident's medications are 100% covered with contracted Pharmacy B. She stated that Pharmacy B gets a daily census of residents receiving and not receiving skilled services. She also stated that Pharmacy B has electronic access to verify resident's services if needed. She stated that the facility did not have a contract with Pharmacy A or Pharmacy C for residents who receive skilled nursing services. She also stated that she was aware that Resident's preferred pharmacy was Pharmacy A but did not know reason that the resident's preferred pharmacy was not listed in the resident record to include the facesheet and medication administration records. She stated that resident's preferred pharmacies should have been also listed on resident's facesheet and medication administration records to ensure that the resident's preferred pharmacy were utilized when the resident was no longer receiving skilled nursing services. Review of facility's admission policy with last revision date 03/01/2015 revealed: 4. HC's Obligations. HC Agrees to provide the following services to the Resident: 24 hour machine, personal care and/ 4 custodial care services in accordance with the residents written plan of care; Medically related social services; Dietary services, including the dietary consultant and the provision of a regular, special in supplemental diets including two feedings, this order from the physician; Over the counter drugs; regular laundry services (except dry cleaning); Room and bed, including housekeeping maintenance services; Basic personal hygiene items and services linens and bedding; Management of resident funds and H- based personal account; Assistance in obtaining dental services; Activities programs. Review of facility's statement of resident rights with last revision date 03/01/2015 revealed: You, the resident, do not give up any rights when you enter a nursing facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 10 residents reviewed for pharmaceutical services in that: The facility administration failed to ensure Resident #1 was not billed for pharmaceutical services from Pharmacy B. This failure could affect the residents from maintaining their highest physical, mental, and psychosocial well-being. Findings included: Review of Resident #1's electronic facesheet revealed she was a [AGE] year-old female who was admitted to the facility 07/20/2022 with diagnosis of congestive heart failure (heart muscle does not pump blood well), history of heart attack, pacemaker, and atrial fibrillation (irregular and often rapid heart rhythm that can lead to blood clots in the heart). Further review of Resident #1's electronic facesheet revealed resident was discharged on 02/03/2023 and her preferred pharmacy was Pharmacy B. Further review of Resident #1's electronic facesheet revealed she received skilled nursing services 07/20/2022 to 08/07/2022, 08/10/2022 to 08/25/2022, and 01/03/2023 to 01/30/2023. Review of Resident #1's comprehensive assessment dated [DATE] revealed a BIMS Summary Score of 15 which indicated no cognitive impairment. Review of Resident #1's admission agreement dated and electronically signed by Resident #1's on 07/20/2022 revealed: Resident designates Pharmacy B as Resident's pharmacy provider of choice . In the absence of a designated pharmacy, HC is authorized to use a duly licensed pharmacy of its choice, including one operated by an affiliate of HC. Review of Resident #1's medication administration records from 07/20/2023 to 02/03/2023 revealed that resident's preferred pharmacy was Pharmacy B. Review of Resident #1's progress notes on 09/12/2022 at 2:40pm, 09/13/2022 at 3:22pm, 10/17/2022 at 7:54am revealed nursing staff contacted Pharmacy A for medication re-fills. During an interview on 03/23/2023 at 9:30am, Resident #1 stated that her preferred pharmacy was Pharmacy A. She stated she received a pharmacy invoice from Pharmacy B for unknown reason for $2135.80 and a bill in September 2022 for about $900. She stated she was very upset of receiving the bill for a pharmacy that she did not choose. Review of Resident #1's statement of account from Pharmacy B revealed Resident #1 received an invoice on 09/11/2022 in the amount of $977.80 for medications dispensed by Pharmacy B on 08/26/2022, 09/02/2022, 09/04/2022, 09/05/2022, 09/06/2022, 09/10/2022, and 09/11/2022. Review of Resident #1's statement of account from Pharmacy B revealed Resident #1 received an invoice on 02/11/2023 in the amount of $2135.80 for medications dispensed by Pharmacy B on 12/03/2022, 01/05/2023, and 01/12/2023. Review of monthly Pharmacy B invoices to the facility revealed facility paid for Resident #1's medications during the following months: 07/2022 in the amount of $53.31 08/2022 with credit of $53.31 09/2022 in the amount of $3.48. During an interview on 03/23/2023 at 11:27am, the administrator stated that if a resident received skilled nursing services, the resident would receive medications from Pharmacy B during time of receiving skilled nursing services. She stated that when a resident receives skills nursing services, the resident's medications are 100% covered with contracted Pharmacy B. She stated that Pharmacy B gets a daily census of residents receiving and not receiving skilled services. She also stated that Pharmacy B has electronic access to verify resident's services if needed. She stated that Pharmacy A should have been used for medications when Resident #1 did not require skilled nursing services. The administrator stated she did not know reason Resident #1 and her family received an invoice from Pharmacy B. She also stated it was her responsibility to ensure the invoices to the facility from Pharmacy B had the correct residents so that residents were not billed improperly. Review of pharmacy contract between Pharmacy B and facility not dated revealed: 3.2 [NAME] and Collection: (c) Pharmacy shall bill Facility for Facility-Pay Products and Services, House Stock (if any), and other fees for which Facility is responsible under this Agreement . 3.3 Payment Terms: (a) Pharmacy shall submit a monthly invoice to Facility for Facility-Pay Products and Services, House Stock (if any), and other fees for which Facility is responsible under this agreement, which were provide during, or relate to, the prior month 3.4 Payment Disputes: (a) Facility shall notify Pharmacy of any mounts in dispute within thirty (30) days of the date of an invoice (the Invoice Date). No charge on an invoice may be disputed more than thirty (30) days after the Invoice Date.