**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident's right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 6 residents (Resident #26), reviewed for resident rights. Resident #26's call light was on the floor and not within reach of the resident. This failure could place residents at risk of not receiving needed care and services in a timely manner. The findings were: Record review of Resident #26's face sheet dated 3/31/25 revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease (general term for memory loss and other cognitive abilities serious enough to interfere with daily life), dementia, unspecified (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and muscular Atrophy not otherwise specified (weakening, shrinking, and decreasing of muscle mass). Record review of Resident #26's quarterly MDS assessment dated [DATE] indicated the resident was unable complete the BIMS, and staff assessment of the resident's cognitive daily decision making indicated the resident was severely impaired cognitively. The resident required partial-moderate assistance for rolling left and right. The resident used a manual wheelchair, was impaired on one side of her upper body and both of her lower extremities, and the resident was always incontinent of bowel and bladder. Record review of Resident #26's undated care plan revealed a problem for urinary incontinence and interventions included to keep the call light within the resident's reach and to remind the resident to call for assistance. In an observation on 4/8/25 at 10:55 a.m. a facility maintenance staff member was in the hallway working on the call light for Resident #26's room. An unknown staff member had entered Resident #26's room at this time and exited within 30 seconds. In an observation and interview on 4/8/25 at 11:00 a.m., the maintenance staff member was no longer present. Resident #26 was in bed making a moaning noise when breathing but the resident appeared unaware of the moaning. The resident was able to answer a few questions appropriately but her speech was garbled and then the resident stated, I'm Good, thank you. The call light was plugged in to the wall and the cord was caught in the nightstand drawer and the end for the resident to press was on the floor next to the nightstand. The resident was able to lift her left arm and grab my hand with hers when I extended it in greeting . I was unable to understand the resident's answer when asked if she could use her call light as her speech remained garbled. In an observation and interview on 4/08/25 at 11:23 a.m., the call light remained on the floor in Resident #26's room. The DON stated the call light should not be on the floor. The DON stated the resident was able to talk and let the staff know if she needed assistance. The DON stated the consequences of the resident not having her call light in reach could be the resident would not receive the assistance she needed. In an interview on 4/11/25 at 4:35 p.m., the ADON stated Resident #30 could use the call light if given verbal reminders. The ADON stated the possible consequences of the resident not having her call light within reach could be the resident could fall trying to reach it. In an interview on 4/11/25 at 5:00 p.m., the DON stated maintenance had been working on Resident #26's call light and she was unsure what the issue had been but it had been fixed that same day. Review of the facility policy for ADL undated indicated Certified Nurse Aides (CNAs) must attend to the needs of all residents and provide the care that residents need at all times.

. Based on observations and interviews the facility failed to ensure each resident has a right to personal privacy and confidentiality of their personal and medical records. The facility failed to ensure the MAR binder (a binder with a list of residents' prescribed medications and when the medications were administered) on the west wing medication cart was kept confidential when it was left open and facing the hallway unattended while visitors and staff walked by. This could place residents at risk for private health information being viewed by unauthorized individuals. The findings were: In an observation on 4/8/25 at 9:25 a.m. in the hallway on the west wing slightly to the left of the entrance to the west wing hall there was a medication cart against the wall with the MAR binder open and facing the hallway, unattended. The MAR binder contained information on residents' medications. Multiple staff and visitors passed by the open binder on their way down the hallway. In an observation and interview on 4/8/25 at 9:26 a.m. revealed LVN D returned to the medication cart and stated she had just stepped away to put some laundry away. LVN D stated the MAR binder should not have been left open or unattended because unauthorized people could have access but she had stepped away briefly. In an interview on 4/8/25 at 4:45 p.m. the DON stated the MAR binder should not be left open and unattended to keep the resident information private. Medical records policy was requested and not received by time of exit. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain safe environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 7 Residents (Resident #17) who were observed for wheelchair use. The facility failed to ensure Resident #17's wheelchair armrest were in good repair. Both armrests were cracked and torn. This deficient practice could affect residents who used a wheelchair and could contribute to injuries; skin tears. The findings were: Review of Resident #17's annual MDS assessment, dated 3/6/25, revealed she was admitted to the facility on [DATE] with diagnosis of Cerebral Palsy. Her BIMS score was 9, reflective of moderate cognitive impairment, she had impaired range of motion on both lower extremities and she used a wheelchair for mobility. Review of Resident #17's Care Plan, revised 3/6/25, revealed Resident #17 had self-care deficit r/t cognitive deficit. Observation on 04/09/25 at 12:06 PM revealed Resident #17 sitting in a wheelchair. Both armrests were cracked and torn. Observation on 04/10/25 at 04:00 PM revealed Resident #17 sitting in a wheelchair in the dining room. Further observation revealed both armrests were cracked and torn exposing the padding. Interview on 04/10/25 at 05:00 PM with the Maintenance worker revealed he was in charge of replacing the armrests on the Resident's wheelchairs when torn. He stated he had not checked them in some time and staff had not reported there was a problem with Resident #17's wheelchair. Observation and interview on 04/10/25 05:05 PM revealed both armrests on Resident #17's wheelchair were cracked and torn. Interview with the Maintenance worker revealed Resident #17's wheelchair armrests were torn. He stated it was important to replace the torn armrests to ensure Resident #17 did not scratch her arms. Interview on 04/11/25 at 3:00 PM with the DON revealed the Maintenance worker would periodically check the Resident's wheelchairs to make sure they were functional and the armrests were not torn. The DON stated the Maintenance worker should replace any torn armrests because the Resident's could get skin tears. Requested a policy for maintaining resident equipment in good working order multiple times on 04/11/2025. A policy was not provided before exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident was free from physical restraints imposed for purposes of convenience that are not required to treat the resident's medical symptoms for the least amount of time and document ongoing re-evaluation of the need for restraints for 4 of 4 days during the survey period (4/8/25, 4/9/25, 4/10/25, and 4/11/25) reviewed for freedom from abuse. Resident #30 was seated in a Geri-chair with a tray table on 4/8/25, 4/9/25, 4/10/25, and 4/11/25 . The tray table was always present when the resident was out of bed and not removed for meals, or activities. And there was no documentation of ongoing re-evaluation of the need for restraints. This failure could place residents at risk for feelings of frustration, anger, humiliation, and could result in the residents being unnecessarily restrained in violation of their rights. The findings were: Record review of Resident #30's face sheet dated 3/31/25 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), hypertension (elevated blood pressure), and diabetes (chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces). Record review of Resident #30's quarterly MDS assessment dated [DATE] indicated the resident's BIMS was 99 indicating she was unable to complete the assessment. Staff assessment of the resident's cognitive daily decision making indicated the resident was severely impaired cognitively. The resident did not use any mobility devices including a wheelchair and no physical restraints or alarms were used and chair prevents rising was not used. Record review of Resident #30's undated care plan revealed a problem dated 9/15/23 for Geri-chair with or without tabletop and under this problem in the same column was Resident #30's name cannot walk and will try to get out of the Geri-chair. Tabletop is used to prevent a fall and to serve as a table for activities with a goal of resident safety will be maintained. Interventions included to check with the resident frequently to ascertain needs, toilet the resident per schedule and request, provide verbal reminder to the resident to call when needing assistance. (There were no interventions for removing the tabletop or assessing the continued need for the restraint.) Record review of Resident #30's physician orders dated 3/31/25 revealed an order for a Geri-chair with or without tabletop PRN (as needed) safety device to decrease falls with a date next to it for 9/1/23. Record review of Resident #30's informed consent for restraint use signed on 8/30/23 revealed Geri-chair was checked and under other was handwritten with or without tabletop. Under benefits of using this type of restraint was handwritten preventing potential life-threatening fall and initialed by the DON. Under the DON's initials were handwritten dates 2/5/24, and 4/9/25. Under less restrictive alternatives that had been used was handwritten wheelchair without tabletop. Record review of Resident #30's Treatment Administration Record for March 2025 revealed up in Geri-chair with or without tabletop for positioning comfort PRN with a start date of 9/1/23 and documented by unknown staff the resident only used this on 3/1/25, 3/4/25, 3/9/25, 3/13/25, 3/15/25, and 3/18/25. Record review of Resident #30's Treatment Administration Record for April 2025 revealed up in Geri-chair with or without tabletop for positioning comfort PRN with a start date of 9/1/23 and documented by unknown staff the resident only used this on 4/9/25, and 4/10/25. Record review of Resident #30's physical restraint elimination assessment form were the dates 1/5/24, 2/5/24, and 4/9/25 with no date for the 3rd column. All four columns were completed and were the exact same and had the score of 23 (21-35 indicating the resident was a good candidate for restraint elimination). On the 2nd page of the assessment for the dates 1/5/24, 2/5/24, and 4/9/25. Under item 1. there was a check mark for the resident being a good candidate. 2. Was the resident a candidate for restraint reduction or elimination was checked no. Under action plan was handwritten no restraint elimination at this time. Under additional comments was handwritten and signed by the DON the resident was unable to walk and tries to stand and walk if the tabletop is not on the Geri-chair. Under less restrictive measures to be used for 1/5/24 was handwritten fall risk, for 2/5/24 and 4/9/25 was left blank. For specific reason, medical symptom, or targeted behavior was blank for 1/5/24, and on 2/5/24, and 4/9/25 was handwritten fall risk. Record review of Resident #30's hospice addendum plan of care review/recert note dated 4/9/25 under interactivity was handwritten Tries to engage, in Geri-chair all day. On the 2nd page under Musculoskeletal was handwritten In Geri-chair all day, no falls reported. Record review of Resident #30's hospice plan of care review dated 3/26/25 under musculoskeletal was handwritten sits in Geri chair, does not ambulate. In an observation and interview on 4/8/25 at 1:30 p.m., Resident #30 was in the lobby-common area among other residents sitting on couches or in wheelchairs watching television. Resident #30 was seated upright in a Geri-chair with a tray table attached to the chair. Resident #30 was at the edge of the seat and had both her hands on the sides of the tray table and was periodically, vigorously shaking the tray table back and forth and looking around. The ADON was sitting at the nursing station facing the residents and stated the resident was always up in the Geri-chair with the tabletop when out of bed. The ADON stated the resident was not trying to remove the tray table but was restless. The ADON stated the resident would try to get up if the tray table was not attached and the resident was unable to walk. In an observation and interview on 4/9/25 at 2:00 p.m. Resident #30 was in the lobby-common area among other residents sitting on couches or in wheelchairs. Resident #30 was seated upright in a Geri-chair with a tray table attached to the chair. Resident #30 was in the middle of the seat and would periodically grab the tray table sides with both her hands and shake it side to side and would look around. The resident was able to move her upper body and trunk without difficulty and was seated upright without leaning to the side. The resident smiled when greeted but was unable to answer my questions. Resident #30 would attempt to speak but only unintelligible sounds would come out. In an observation on 4/10/25 at 2:30 p.m. Resident #30 was in the lobby-common area alone without any other residents or staff present. Resident #30 was seated in an upright Geri-chair with a tray table attached to it. The resident was seated in the middle of the seat with her upper back leaned back against the chair and had her hands on top of the tray table and would occasionally push against the tray table side closet to her. In an observation on 4/11/25 at 12:30 p.m. Resident #30 was in the dining room sitting upright in an upright Geri-chair with the tray table attached and the tray table was pushed under the half-moon feeding assistance table. In an observation on 4/11/25 at 2:00 p.m. Resident #30 was in the lobby-common area among other residents. Resident #30 was seated upright in a Geri-chair with a tray table attached and was moving around large adult Lego like blocks with her right hand. The resident was not pushing or shaking the tray table. In an observation on 4/11/25 at 4:00 p.m. Resident #30 was seated in a wheelchair at a table in the dining room without any physical restraint and was lifting items from the table during an activity and staff were supervising. Resident #30 was not attempting to get up out of the wheelchair. In an interview on 4/8/25 at 2:30 p.m. the DON stated the tray table attached to the Geri-chair was not a restraint and she had to mark it on the MDS. but the DON stated it was not a restraint due to the resident being unable to walk, and it was for her safety because the resident would get up and fall if the tray table was not attached. The DON stated it was also used for activities. In an interview on 4/11/25 at 4:35 p.m., the ADON stated she was unaware of any other interventions that were attempted for Resident #30 prior to or after Geri-chair with tray table use. In an interview on 4/11/25 at 5:30 p.m., the DON stated the RP for Resident #30 had come in and seen that the resident was not in a Geri-chair with the tray table for safety, and the RP was not pleased and was afraid Resident #30 would fall and get hurt. The DON stated the RP stated she would write a letter. The DON stated previous interventions attempted prior to the tray table were wheelchair alarms but the resident fell. The DON stated the resident's family suggested the tray table and it was used for activities, eating, and fall prevention. Review of the facility restraint policy undated indicated It is the practice of our facility to comply with federal and state laws governing the emergency use of restraints. In the absence of the law, our facility shall employ the following policy: Physical restraints may be used based on professional judgement to prevent harm to a resident or others, or to provide medical treatment to proceed unless the facility has notice that the resident has previously made a valid refusal of the treatment in question.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program for residents with newly evident or possible serious mental disorder for 1 of 4 Residents (Resident #4) whose records were reviewed. The facility failed to refer Resident #4 for Level I screening after being diagnosed with a mental disorder. This deficient practice could affect residents with a mental diagnosis and can result in residents not receiving services as identified by PASARR. The findings were: Review of Resident #4's annual MDS assessment, dated 2/6/25, revealed he was admitted to the facility on [DATE]. His BIMS score was 2 of 15 reflective of severe cognitive impairment. His diagnoses included Hypertension (high blood pressure), Dementia, Depression and Psychotic Disorder. Review of Resident #4's Psychiatric Subsequent Assessment, dated 2/14/25, revealed diagnoses included Persistent mood (affective disorder) unspecified and Major Depressive Disorder, recurrent, moderate. Further review revealed Assessment/Plan: Generalized anxiety was being treated with Effexor XR 1 tablet, 150 mg, daily. Persistent mood (affective disorder) unspecified was being treated with Depakote PR 1 tablet 500 mg BID, Trileptal 1 tablet 300 mg BID, Depakote 1 tablet 1000 mg QHS and Haldol 1 tablet 2 mg BID, Major Depressive Disorder recurrent, moderate is being treated with Effexor XR 1 tablet, 150 mg, daily. Interview on 04/11/25 at 01:54 PM with the DON revealed she was responsible for referring all Resident's for level I PASARR screening if they had a mental illness. She stated she did not believe Resident #4 had a psychiatric condition to request for a level I PASARR screening. She stated she had not talked with the Psychiatric NP about his condition. The DON reviewed Resident #4's Psychiatric Subsequent Assessment, dated 2/14/25. The DON stated she would refer Resident #4 for an evaluation because he could qualify for resources. She further stated not referring residents with a mental illness for a Level 1 evaluation could result in not benefiting from resources. Review of facility policy, Policy for PASSR, undated, read: This facility follows the PASSR guidelines to ensure that people with a Mental Illness, Intellectual disability Disorder or Development Disorder who are admitted to a Nursing Facility are getting the specialized services that are available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal and oral hygiene for 1 of 7 Residents (Resident #35) for Quality of Life. The facility failed to assist Resident #35 with washing her face and brushing her teeth. This deficient practice could affect residents who were unable to carry out activities of daily living and result in resident's being dissatisfied and having poor self-esteem. The findings were: Review of Resident #35's face sheet, dated 3/31/25, revealed she was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease and Dementia. Review of Resident #35's quarterly MDS assessment, dated 1/20/25, revealed her BIMS score was 10 of 15 reflective of moderate cognitive impairment. She had functional limitations in range of motion in both upper and lower extremities and she was dependent on staff for all ADL's including hygiene. Observation and interview on 04/09/25 11:00 AM revealed Resident #35 was lying in bed. Her face had a shine to it. Resident #35 presented as primarily Spanish speaking. She stated she was not able to get out of bed and needed assistance with all ADL's. She stated sometimes the CNA's would get upset when she asked for help and at times it would take an hour or two before they answered the call light. She stated she knew how long it took them because she had a clock on the wall and would look at the clock. Noted a clock mounted on wall by Resident #35's bed. Resident #35 stated the aides would usually wipe her face with a wash cloth and help brush her teeth. She stated they did not wipe her face down or wash her teeth today (04/08/25). She stated she felt dirty and was used to brushing her teeth daily. She stated she felt mal (English translation: bad). Interview on 04/09/25 at 11:15 AM with CNA F revealed they assisted residents with wiping their face down, swabbing their mouth, pericare and repositioning first thing in the morning. She stated she reported to work late and her partner assisted Resident #35 this morning (04/09/25). Interview on 04/09/25 at 11:46 AM with CNA G revealed she had worked at the facility for about 1 month. She stated some of her duties in the morning included wiping down the resident's face, cleaning their mouth and hands, changing them and repositioning them in bed. She stated she did not wipe down Resident #35's face or clean her mouth because she had to get another resident up from bed so she would not fall. CNA G stated she imagined Resident #35 felt bad and commented, I would feel bad. CNA G further stated not brushing a resident's teeth regularly could cause an infection. CNA G further stated she should complete these tasks daily. Interview on 04/09/25 at 1:00 PM with the DON revealed Resident #35 was bed bound and required total care. She stated she required assistance with all ADL's and stated CNA's should assist Resident #35 with personal hygiene; washing her face and brushing her teeth in the morning, after meals or as needed. The DON commented not providing care I'm sure would make (Resident #35) feel bad because it was important to help the Resident's maintain good hygiene. Review of facility policy, Policy for Activity of Daily Living, undated, read: Certified Nurse Aides (CNAs) must attend to the needs of all resident and provide the care that residents need at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 residents (Resident #26), reviewed for quality of care. Resident #26's nebulizer mask was uncovered and the elastic that holds it on to the resident's face was stretched around the uncovered nebulizer machine. The nebulizer mask had an unknown white substance on it. This failure could place residents at risk of cross contamination and respiratory illness. The findings were: Record review of Resident #26's face sheet dated 3/31/25 revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease (general term for memory loss and other cognitive abilities serious enough to interfere with daily life), dementia, unspecified (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and muscular Atrophy not otherwise specified (weakening, shrinking, and decreasing of muscle mass). Record review of Resident #26's quarterly MDS assessment dated [DATE] indicated the resident was unable complete the BIMS and staff assessment of the resident's cognitive daily decision making indicated the resident was severely impaired cognitively. The resident required partial-moderate assistance for rolling left and right. The resident used a manual wheelchair, was impaired on one side of her upper body and both of her lower extremities, and the resident was always incontinent of bowel and bladder. The resident had not received respiratory therapy for at least 15 minutes a day for the 7 previous days prior to this assessment. Record review of Resident #26's undated care plan revealed no problems or interventions for nebulizer treatments. Record review of Resident #26's physician orders dated 3/31/25 revealed an order for DuoNeb (a combination of two medicines called bronchodilators. It contains albuterol sulfate, and ipratropium bromide. These two medicines work together to help open the airways in your lungs.) 1 unit dose per nebulizer every 6 hours PRN for wheezing or shortness of breath with a date next to it of 11/29/22. Record review of Resident #26's physician orders revealed physician telephone orders dated 4/2/25 to continue DuoNeb every 6 hours PRN and schedule DuoNeb 1 unit dose every 6 hours for 5 days. Record review of Resident #26's MAR for April 2025 revealed the resident received DuoNeb every 6 hours for 5 days from 4/2/25 at 12pm and last dose on 4/7/25 at 6am. No PRN DuoNeb treatments were given. In an observation and interview on 4/8/25 at 11:00 a.m. ,Resident #26 was in bed making a moaning noise when breathing but the resident seemed unaware of the noise she was making. The resident was able to answer some questions but most of her speech was garbled. The resident was able to state clearly I'm Good, thank you. The resident stopped making the moaning noise when paying attention to me and attempting to answer questions. The resident's respirations were even and unlabored. There was a colorful fish shaped nebulizer machine sitting on the resident's nightstand. The nebulizer mask and tubing was attached to the machine and excess tubing caught in nightstand drawer. The nebulizer face mask side that goes over the nose and mouth was against the side of the fish shaped nebulizer machine and the elastic band on the mask that holds it on the resident's face was stretched around the fish shaped nebulizer machine holding it against the side of the machine. There was no cover on the nebulizer machine or the nebulizer mask. The nebulizer mask had a dried white colored substance on the mask where the resident's nose would be if she were wearing it. I was unable to determine if the substance was on the outside or inside of the mask. There was no date on the nebulizer mask or tubing. In an observation and interview on 4/8/25 at 11:23 a.m., the nebulizer mask and tubing remained uncovered with the white substance still present and stretched around the nebulizer machine. The DON stated she did not believe the resident was still on nebulizer treatments when asked if the mask should be covered or in a bag. The DON stated, again, she did not think the resident was still receiving nebulizer treatments. When asked what the consequences of the mask not being covered, the DON stated she was no longer receiving treatments. In an interview on 4/11/25 at 11:15 a.m., LVN E stated oxygen and nebulizer masks and tubing were changed once weekly on Sundays or sooner if needed. LVN E stated there was no specific place to document the changing of the masks and tubing, but they were all done weekly on Sundays regardless and the tubing and or masks would be dated and covered in a bag. In an interview on 4/11/25 at 11:18 a.m., LVN B stated the oxygen tubing and nebulizer masks were changed once weekly, but there was no place to specifically document it. LVN B stated the tubing should be dated and covered. LVN B stated if she found tubing not dated or soiled, she would replace it with a new one so not to introduce bacteria to the resident. A facility policy for Respiratory care was requested from the DON on 4/11/25 at 5:30 p.m. and was not received before exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete, accurately documented, and failed to safeguard medical record information against loss, destruction, or unauthorized use for 1 of 6 residents (Resident #19) reviewed for administration. Resident #19's nutrition assessment form had the correct resident name but the wrong admission date, wrong date of birth , the wrong height and ideal body weight range. This could place residents at risk for inaccurate health records and incorrect plans of action. The findings were: Record review of Resident #19's face sheet dated 3/31/25 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included dementia with behavioral disturbances (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life with behavior changes), diabetes (chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces), and vitamin D deficiency (the level of vitamin D in the blood is insufficient to maintain proper health). Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated the resident had a BIMS of 99 indicating the resident was unable to complete the assessment and staff assessment of the resident's cognitive daily decision making indicated the resident was severely impaired cognitively. The resident had a poor appetite or overeating 7 - 11 days (more than half of the days), and the resident had weight loss of 5% or more in the past month or 10% in the last 6 months. Record review of Resident #19's care plan revised on 4/3/25 revealed a problem for dehydration and handwritten next to it was weight loss, last date on the problem was handwritten 10/3/23. On the problem column included the resident did not like nectar or honey thick liquids. Interventions included mechanical soft diet handwritten with no date, other interventions included to assist the resident to drink 8 ounces of honey or nectar thick liquids with each medication pass. A dietary care plan date initialed 6/20/19 with a problem of mechanically altered diet with interventions for diet as ordered and to monitor intake. Record review of Resident #19's nutrition assessment form reflected assessments dated 10/2/24, and 1/23/25 and signed by the Dietician. The top of the form had Resident #19's name, an admission date of 2/19/18 was incorrect and the date of birth was 8/17/54, which was also incorrect he height of 65 inches had been lined through and 58 inches was written in, and the ideal body weight range of 112-138 was lined through and 85-105 was written in the same blue marker pen as the assessment information below it. In an interview on 4/11/25 at 10:10 a.m. the Dietician stated the nutritional assessments for Resident #19 were completed by her and she crossed out the ideal body weight range and wrote in the correct height and IBWR . The Dietician stated she was not aware the admission date and DOB were wrong. The Dietician stated those were the correct nutritional assessments for Resident #19. The Dietician stated she had been having computer issues. In an interview on 4/11/25 at 5:30 p.m. the DON stated the possible consequences of the nutritional assessments not having the correct resident information could be they would not have a true weight and dietary assessment of the resident. Medical records policy was requested and not received by time of exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services and failed to have a communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day for 1 of 3 residents (Resident #88), reviewed for hospice services. Resident #88's hospice binder and medical record had no hospice visit nursing notes and the facility staff nurses were not aware the hospice documentation was needed as part of the medical record. This failure could place residents at risk of decreased continuity of care, not receiving necessary care and services in a timely manner. The findings were: Record review of Resident #88's face sheet dated 4/1/25 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with hospice services already in place. The resident's diagnoses included anxiety state not otherwise specified (ongoing anxiety and worry that does not meet the specific diagnostic criteria), chronic pain (wide range of persistent discomfort lasting beyond 3 months and originates from various sources, including injury, disease, or unknown causes), insomnia (trouble falling asleep, staying asleep, or getting good quality sleep), and depression (a common mental disorder that involves a depressed mood or loss of pleasure or interest in activities for long periods of time). Record review of Resident #88's Medical Record revealed no MDS information due to the resident being a new admission. Record review of Resident #88's Interdisciplinary Care Plan dated 3/31/25 revealed it was a one-page form with general areas with boxes to check under the specific areas. The resident being on hospice care was not on the resident's care plan. Record review of Resident #88's consolidated physician's orders dated 3/31/25 revealed an order to contact the specific hospice with phone number for change of condition, transfer, and death. Record review of Resident #88's hospice binder revealed information on contacting the hospice, CNA sign in sheets for care and showers. There were no licensed nurse visit notes in the hospice binder. Record review of Resident #88's Medical Record revealed no hospice licensed nursing visit notes. In an interview on 4/11/25 at 9:09 a.m. LVN B stated they did not have any notes from hospice nurses. LVN B stated the resident's hospice start date was 9/26/24 per the resident's medical records. LVN B stated the hospice nurses gave the facility nurses a verbal report. In an interview on 4/11/25 at 10:16 a.m. LVN B stated she had contacted Resident #88's hospice provider to send the hospice nursing notes and she was waiting for them to fax them. In an observation on 4/11/25 at 2:35 p.m. revealed the hospice nursing visit notes from her admission date to 4/9/25 for Resident #88 were in the resident's hospice binder. In an interview on 4/11/25 at 5:30 p.m. the DON stated the consequences of not having the hospice notes on the Resident #88's medical record was there would be better communication .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise residents comprehensive care plan for 4 of 12 Residents (Resident #4, Resident #19, Resident #27 and Resident #30) reviewed for Comprehensive Resident Centered Care Plan. 1. The facility failed to revise Resident #4's Care Plan for the use of 1/2 SR and to provide timeframe's for the review period. 2. The facility failed to revise Resident #19's care plan for diet and care plan interventions after weight loss. 3. The facility failed to revise Resident #27's Care Plan for the use of 1/2 SR. 4. The facility failed to revise Resident #30's care plan interventions for physical restraint. These deficient practices could affect any resident and could contribute to resident's not receiving needed care and services as identified in the residents medical record and or MDS. The findings were: 1. Review of Resident #4's annual MDS assessment, dated 2/6/25, revealed he was admitted to the facility on [DATE]. His BIMS score was 2 of 15 reflective of severe cognitive impairment. His diagnoses included Hypertension (high blood pressure), Dementia, Depression and Psychotic Disorder. He had functional limitation in range of motion on one side on upper extremity and on both sides on lower extremities and he required partial to moderate assistance from staff for bed mobility; rolling left and right. Review of Resident #4's Care Plan revised on 3/28/25 revealed problem: 1/2 SideRail to bed; Goal: Resident will be able to assist with transfers, repositioning and bed mobility; Interventions: Instruct resident on techniques on how to use 1/2 SideRail to change position while in bed and Show resident how to use 1/2 SideRail to assist with transferring. Further review revealed the Care Plan did not reflect Resident #4's medical condition for the use of the Side Rail, it did not include measurable timeframe's and interventions and it did not reflect Resident #4 should be reassessed for the use of the 1/2 Side Rail to ensure he used it safely. Interview on 04/11/25 at 01:54 PM with the DON revealed she and staff had worked with Resident #4 for years and knew him well. She stated Resident #4's condition had not changed and although she understood the requirement for the Care Plan to reflect the Resident's current condition, care and services needed. The DON stated she did not believe not updating the Care Plan would negatively impact Resident #4 in any way. 2. Record review of Resident #19's face sheet dated 3/31/25 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included dementia with behavioral disturbances (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life with behavior changes), diabetes (chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces), and vitamin D deficiency (the level of vitamin D in the blood is insufficient to maintain proper health). Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated the resident had a BIMS score of 99 indicating the resident was unable to complete the assessment and staff assessment of the resident's cognitive daily decision making indicated the resident was severely impaired cognitively. The resident had a poor appetite or overeating 7 - 11 days (more than half of the days), and the resident had weight loss of 5% or more in the past month or 10% in the last 6 months. Record review of Resident #19's care plan revised on 4/3/25 revealed a problem for dehydration and handwritten next to it was weight loss, last date on this problem was handwritten 10/3/23. On the problem column included the resident did not like nectar or honey thick liquids. Interventions included mechanical soft diet handwritten with no date, other interventions included to assist the resident to drink 8 ounces of honey or nectar thick liquids with each medication pass. A dietary care plan date initialed 6/20/19 with a problem of mechanically altered diet with interventions for diet as ordered and to monitor intake. There were no measurable timeframe's for any goals on the care plan. Record review of Resident #19's consolidated physician orders dated 4/1/25 revealed a diet order of Pureed no concentrated sweets with thin liquids and diabetic shakes dated 7/30/24. Record review of Resident #19's nutritional assessment dated [DATE] indicated the resident was on a pureed diet and may have mechanical soft snacks. 3. Review of Resident #27's face sheet, dated 3/31/25, revealed he was admitted to the facility on [DATE] with diagnoses including Vascular Dementia and Depressive Disorder. Review of Resident #27's quarterly MDS assessment, dated 2/27/25, revealed his BIMS score was 15 of 15 reflective of no cognitive impairment. He had functional limitation of range of motion on both lower extremities and he required set up assistance from staff for bed mobility; rolling left and right. Review of Resident #27's Care Plan revised on 3/28/25 revealed problem: 1/2 SideRail to bed; Goal: Resident will be able to assist with transfers, repositioning and bed mobility; Interventions: Instruct resident on techniques on how to use 1/2 SideRail to change position while in bed and Show resident how to use 1/2 SideRail to assist with transferring. Further review revealed the Care Plan did not reflect Resident #27's medical condition for the use of the Side Rail and it did not include measurable timeframe's and interventions did not reflect Resident #27 should be reassessed for the use of the 1/2 Side Rail to ensure he used it safely. Interview on 04/11/25 at 03:32 PM with the ADON revealed Resident #27 started using a 1/2 SR since his left leg was amputated over 1 year ago. She stated Resident #27's Care Plan did not include the Resident's medical condition to reflect why he was using a SR and timeframe's for using the SR. She stated there was no indication Resident #27 should be reassessed for the use of a SR. The ADON stated the Care Plan should be an accurate representation of Resident #27's medical condition and necessary care and services needed. She stated nursing staff should use the Care Plan as a guide when providing care and if not current, then staff may not provide Resident #27 with the care and services identified. 4. Record review of Resident #30's face sheet dated 3/31/25 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), hypertension (elevated blood pressure), and diabetes (chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces). Record review of Resident #30's quarterly MDS assessment dated [DATE] indicated the resident's BIMS was 99 indicating she was unable to complete the assessment. Staff assessment of the resident's cognitive daily decision making indicated the resident was severely impaired cognitively. The resident did not use any mobility devices including a wheelchair and no physical restraints or alarms were used and chair prevents rising was not used. Record review of Resident #30's undated care plan revealed a problem dated 9/15/23 for Geri-chair with or without tabletop and under this problem in the same column was Resident #30's name cannot walk and will try to get out of the Geri-chair. Tabletop is used to prevent a fall and to serve as a table for activities with a goal of resident safety will be maintained. Interventions included to check with the resident frequently to ascertain needs, toilet the resident per schedule and request, provide verbal reminder to the resident to call when needing assistance. (There were no interventions for removing the tabletop or assessing the continued need for the restraint.). There were no measurable time frames for care plan goals. Record review of Resident #30's physician orders dated 3/31/25 revealed an order for a Geri-chair with or without tabletop PRN (as needed) safety device to decrease falls with a date next to it for 9/1/23. In an observation and interview on 4/8/25 at 1:30 p.m., Resident #30 was in the lobby-common area among other residents sitting on couches or in wheelchairs watching television. Resident #30 was seated upright in a Geri-chair with a tray table attached to the chair. Resident #30 was at the edge of the seat and had both her hands on the sides of the tray table and was periodically, vigorously shaking the tray table back and forth and looking around. The ADON was sitting at the nursing station facing the residents and stated the resident was always up in the Geri-chair with the tabletop when out of bed. The ADON stated the resident was not trying to remove the tray table but was restless. The ADON stated the resident would try to get up if the tray table was not attached and the resident was unable to walk. In an observation and interview on 4/9/25 at 2:00 p.m. Resident #30 was in the lobby-common area among other residents sitting on couches or in wheelchairs. Resident #30 was seated upright in a Geri-chair with a tray table attached to the chair. Resident #30 was in the middle of the seat and would periodically grab the tray table sides with both her hands and shake it side to side and would look around. The resident was able to move her upper body and trunk without difficulty and was seated upright without leaning to the side. The resident smiled when greeted but was unable to answer my questions. Resident #30 would attempt to speak but only unintelligible sounds would come out. In an observation on 4/10/25 at 2:30 p.m. Resident #30 was in the lobby-common area alone without any other residents or staff present. Resident #30 was seated in an upright Geri-chair with a tray table attached to it. The resident was seated in the middle of the seat with her upper back leaned back against the chair and had her hands on top of the tray table and would occasionally push against the tray table side closet to her. In an observation on 4/11/25 at 12:30 p.m. Resident #30 was in the dining room sitting upright in an upright Geri-chair with the tray table attached and the tray table was pushed under the half-moon feeding assistance table. In an observation on 4/11/25 at 2:00 p.m. Resident #30 was in the lobby-common area among other residents. Resident #30 was seated upright in a Geri-chair with a tray table attached and was moving around large adult Lego like blocks with her right hand. The resident was not pushing or shaking the tray table. In an observation on 4/11/25 at 4:00 p.m. Resident #30 was seated in a wheelchair at a table in the dining room without any physical restraint and was lifting items from the table during an activity and staff were supervising. Resident #30 was not attempting to get up out of the wheelchair. In an interview on 4/11/25 at 4:35 p.m., the ADON stated the DON was responsible for revising all the resident care plans and the ADON did not participate in care planning. In an interview on 4/11/25 at 5:30 p.m., the DON stated she was responsible for care plan interventions and the care plans were updated and new interventions might be handwritten. A request was made for a Care Plan policy multiple times on 4/11/25 and it was not provided before exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail and review the risks and benefits of bed rails with the resident or resident representative for 4 of 7 Residents (Resident #4, Resident #14, Resident #17 and Resident #27) whose records were reviewed. 1. Nursing staff failed to attempt to use the least restrictive alternatives before using a 1/2 SR for Resident #4. They also failed to indicate the benefits and risks for using a 1/2 SR or to assess Resident #4 for its use. 2. Nursing staff failed to obtain a consent for the use of 1/2 SR for Resident #14 and failed to assess her once a 1/2 SR was implemented. 3. Nursing staff failed to obtain a consent or to assess Resident #17 for the use of 1/2 SR. 4. Nursing staff failed to attempt to use least restrictive alternatives before using 1/2 SR for Resident #27, to indicate the benefits and risks for using 1/2 SR and failed to assess him for use. These deficient practices could affect residents who used side rails and could result in avoidable accidents and or injuries. The findings were: 1. Review of Resident #4's annual MDS assessment, dated [DATE], revealed he was admitted to the facility on [DATE]. He had a BIMS score of 2 out of 15 reflective of severe cognitive impairment. He had impaired vision and he required partial to moderate assistance for bed mobility (rolling left and right). Review of Resident #4's Care Plan, dated [DATE], revealed problem: 1/2 SR to bed., Goal Resident will be able to assist with transfers, repositioning and bed mobility. Interventions: Instruct resident on techniques of how to use 1/2 side rails to change position while in bed. Show resident how to use 1/2 side rails to assist with transferring. Review of Resident #4's, Informed Consent for Restraint Use, dated [DATE], revealed The facility, with a physician order may need to use a restraining device after a trial of less restrictive measures have failed, at it has been determined through consultation with appropriate health team professional that it may be used for specific time periods to enable and promote great functional independence. (The definition of a restraint is any device from which the resident is able to free self). Further review revealed there was no indication of the risks and benefits or the less restrictive alternatives that had been used. Further review revealed the physician did not sign the consent. Observation and interview on [DATE] at 10:15 AM revealed Resident #4 lying in bed with one 1/2 SR up on right side of the bed by the wall. Attempted interview with Resident #4 revealed he was alert to self. Resident #4 was asked if was able to lower the SR. He was not able to answer the question. Resident #4 had a blank stare. Interview on [DATE] at 01:54 PM with the DON revealed she reviewed Resident #4's side rail consent, dated [DATE]. The DON stated nursing staff should reassess Resident #4 periodically to determine if he could still use the SR safely, to ensure he would not get stuck or have other accidents. The DON stated the consent did not reflect the benefits, risks or devices used prior to using the SR. The DON stated not following procedure could result in resident's getting injured or worse. 2. Review of Resident #14's face sheet, dated [DATE], revealed she was admitted to the facility on [DATE] with diagnoses including Senile Dementia with cognitive impairment, Mood Disorder unspecified, Psychosis/Confusion NOS and Anxiety State NOS. Review of Resident #14's MDS assessment revealed her BIMS was 9 of 15 reflective of moderate cognitive impairment. Review of Resident #14's Care Plan, dated [DATE], revealed problem: 1/2 SR to bed., Goal Resident will be able to assist with transfers, repositioning and bed mobility, Interventions Instruct resident on techniques of how to use 1/2 side rails to change position while in bed. Show resident how to use 1/2 side rails to assist with transferring. Review of Resident #14's consolidated physician's orders, dated [DATE], revealed an order 1/2 side rails to bed to assist with repositioning and mobility when in bed Q shift, dated [DATE]. Review of Resident #14's consents revealed there was not a consent for SR use. Review of Resident #14's assessments revealed a Side Rail Assessment, last reviewed on [DATE] read no SR in use. Interview on [DATE] at 01:54 PM with the DON revealed the use of SR's required nursing staff to obtain physician's order, consent which included risks and benefits and other interventions used prior to using SR's, complete an assessment, re-assessment periodically and to include in the care plan. The DON reviewed Resident #14's medical chart related to SR use and stated a physician's order and care plan were the only documents in place for Resident #14. She stated a SR should not be used until at a minimum a consent was obtained and the resident was assessed for safety to avoid accidents and the resident getting injured. 3. Review of Resident #17's quarterly MDS, dated [DATE], revealed she was admitted to the facility on [DATE]. Her BIMS score was 9 of 15 reflective of moderate cognitive impairment. Her diagnoses included Cerebral Palsy and Seizure Disorder or Epilepsy. She had functional limited range of motion on one side on her upper extremity and on both sides on her lower extremities, she was dependent on staff for bed mobility; rolling left to right. Review of Resident #17's Care Plan, revived [DATE], revealed she used SR as an enabler and safety device r/t confusion, weakness, forgetful, s/p CVA, hemiplegia, paraplegia and seizure d/o. Interventions: Assess for use of SR, notify family, get consent, apply 1/2 SR as indicated, make sure mattress fits snuggly against SR to avoid gap. for entrapment. Maintenance and nursing staff to monitor daily. SR to help avoid injury when necessary. Reassess SR use every 90 days. Reduce/remove SR only if indicated no longer needed. Review of Resident #17's consolidated physician's orders for [DATE] revealed an order 1/2 side rails to bed to assist with repositioning and mobility when in bed Q shift. Review of Resident #17's medical chart revealed there was not a consent for the use of 1/2 SR. Review of Resident #17's assessments revealed she was not assessed for the use of 1/2 SR. Interview on [DATE] at 01:54 PM with the DON revealed the use of SR's required nursing staff to obtain a physician's order, consent which included risks and benefits and other interventions used prior to using SR's, to complete an assessment, re-assessment periodically and to include in the care plan. The DON reviewed Resident #17's medical chart related to SR use. She stated nursing staff obtained a physician's order and included the use of SR's in Resident #17's Care Plan. She stated a SR should not be used until at a minimum a consent was obtained and the resident was assessed for safety to avoid accidents and injuries. 4. Review of Resident #27's face sheet, dated [DATE], revealed he was admitted to the facility on [DATE] with diagnoses including Vascular Dementia and Depressive Disorder. Review of Resident #27's quarterly MDS assessment, dated [DATE], revealed his BIMS score was 15 of 15 reflective of no cognitive impairment. He had functional limitation of range of motion on both lower extremities and he required set up assistance from staff for bed mobility; rolling left and right. Review of Resident #27's Care Plan, dated [DATE], revealed Problem: 1/2 SR to bed. Goal revealed Resident will be able to assist with transfers, repositioning and bed mobility. Interventions: Instruct resident on techniques of how to use 1/2 side rails to change position while in bed. Show resident how to use 1/2 side rails to assist with transferring. Review of Resident 27's consolidated physician's orders for [DATE] revealed an order May have 1/2 side rails on bed for mobility and repositioning Q shift. Review of Resident #27's informed consent for restraint use, dated [DATE], revealed it did not reflect the benefits and risks for using 1/2 side rail and there was no indication a least restrictive alternative was used. Review of Resident #27's Side Rail Assessment, dated [DATE], revealed he was not using a SR at the time. Further review revealed there was not a current reassessment for Resident #27. Observation and interview on [DATE] at 03:06 PM revealed Resident #27 sitting in a wheelchair. He stated he used the side rail while in bed. He would use it to turn during care or to sit up in bed. He stated he was not able to release the side rail, but was not able to get out of bed on his own related to both his legs being amputated. Interview on [DATE] at 03:32 PM with the ADON revealed Resident #27 started using a SR when his left leg was amputated over 1 year ago. She stated in reviewing Resident #27's consent in his chart, dated [DATE], it did not reflect the benefits and risks involved. She stated the assessment completed on [DATE], reflected he was not using SR's at the time. The ADON stated the use of SR's required a physician's order, a consent, an assessment and it should be included in the care plan. She stated residents who used SR's should also be reassessed periodically to determine if the SR's were benefiting the resident and to ensure the resident was using safely otherwise the resident could sustain injuries. Review of facility policy, SideRails Policy, undated, revealed Residents using siderails for bed mobility or transfer. will get an order from their Physician so they can use the siderails. Staff will instruct the resident on how to use them as indicated in the residents' care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility based on a comprehensive assessment of a resident failed to ensure residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 2 of 7 Residents (Resident #4 and Resident #35) whose records were reviewed for psychotropic medications. 1. Nursing staff failed to ensure Resident #4's informed consent for Haldol (anti-psychotic medication) included the psychiatric condition, assessment for the use of the medication, the risks and benefits and the need for the use of the medication. 2. Nursing staff failed to ensure Resident #35's informed consent for Seroquel (antipsychotic medication), failed to identify the condition being treated and the potential beneficial side effects of the use of the medication. These deficient practices could affect residents who were receiving psychoactive medications and contribute to the administration of unnecessary antipsychotic medications. The findings were: 1. Review of Resident #4's annual MDS assessment, dated 2/6/25, revealed he was admitted to the facility on [DATE]. His BIMS score was 2 of 15 reflective of severe cognitive impairment; diagnoses included Dementia, Depression and Psychotic Disorder and it reflected he was receiving antipsychotic medication on a routine basis. Review of Resident #4's Care Plan, revised 4/9/25, revealed he was receiving psychotropic medication and one of the interventions included to administer medication as ordered. Review of Resident #4's consolidated physician's orders, dated April 2025, revealed an order for Haldol 1 mg. 1.5 tablets equals 1.5 mg, PO 2 x daily, DX: Mood Disorder unspecified. Review of Resident #4's consent for antipsychotic medication treatment, signed by Resident #4's representative on 2/23/23, revealed an order for Haldol one 5 mg tablet tablet by mouth BID for agitation. Further review revealed the physician did not sign the consent. There was no indication of the psychiatric condition, assessment for the use of the medication, the risks and benefits and the need for the use of the medication. Review of Resident #4's MAR for April 2025 revealed he was receiving Haldol per physician's orders. Interview on 04/11/25 at 01:54 PM with the DON revealed she did not believe Resident #4 had a psychiatric condition. She reviewed the diagnosis from a psychiatric provider which revealed a diagnosis of persistent mood disorder unspecified and MDD recurrent and moderate. She also reviewed Resident #4's physician's orders for April 2025 and the consent for Haldol. She stated the consent should be completely filled out to reflect why the resident was receiving the medication. Nursing staff who completed the consent should explain to the resident why the medication was prescribed and the benefits versus the risks. The DON stated not following procedures could result in residents taking medications that were not needed and adverse side effects. 2. Review of Resident #35's face sheet, dated 3/31/25, revealed she was admitted to the facility on [DATE], with diagnoses including Dementia and agitation. Review of Resident #35's quarterly MDS assessment, dated 1/20/25, revealed her BIMS score was 10 of 15 reflective of moderate cognitive impairment. Her diagnosis included Depression and she received antipsychotic medication on a routine basis. Review of Resident #35's Care Plan, dated 10/8/24, revealed she was receiving psychotropic medication and one of the interventions included to administer medication as ordered. Review of Resident #35's consolidated physician's orders for April 2025 revealed an order for Seroquel 25 mg, 1 tablet PO 8 PM. used for agitation. Review of Resident #35's MAR for April 2025 revealed Resident #35 was receiving Seroquel per physician orders. Review of Resident #35's informed consent for Seroquel (antipsychotic medication) signed by Resident's Guardian revealed it did not identify the condition being treated and the potential beneficial side effects of the use of the medication. Interview on 04/11/25 at 06:51 PM with the DON revealed Resident #35's consent should have been completely filled out to reflect why the Resident was receiving the medication. She stated it was important to be in compliance with the regulation. The DON stated not following procedures could result in residents taking medications that were not needed and adverse side affects. Review of a facility policy tilted, USE OF PSYCHOTROPIC MEDICATIONS, undated, revealed: Psychotropic medications must be ordered by a Physician and must have a Diagnosis for the use of the medication. A consent form explaining the use, benefits and adverse reaction of the medication, must be signed by the Responsible person or Guardian of the resident, if resident cannot fully comprehend what he is signing. Nurses must inform resident's Physician if there is a problem associated with the use of the medication.

Based on observation, interview and record review the menus were not followed, were not updated periodically and were not reviewed by the facility's dietician in 1 of 1 kitchen. 1. Dietary Staff failed to follow the menu on 04/08/25 for 1 of 1 meal; lunch meal. 2. The facility failed to ensure the Dietician reviewed the updated facility menus at the time the menus were made available. for about 5 months These deficient practices could affect all residents and could contribute to residents not being satisfied with their meal options. The findings were: 1. Observation on 04/08/25 at 09:15 AM revealed the monthly menu at a glance for April 2025 was not posted outside the kitchen or around the dining room. Observation on 04/08/25 at 12:18 PM revealed Dietary Staff serving baked ham, pinto beans, mixed vegetables, canned fruit and tea/water. Review of the menu (followed for 04/08/25 included baked ham, pirogues, mixed vegetables, canned fruit and tea/water. Interview on 04/08/25 at 2:45 PM with the FSS revealed she did not post the monthly menu at a glance for April 2025. She stated she did not know if they had one and stated she followed the extended menu dated June 2024. The FSS stated this was the only monthly menu she had available. She stated the lunch menu on, 04/08/25, called for baked ham, mixed vegetables and pirogues (filled dumpling) She stated she served pinto beans instead of pirogues because she did not believe the residents would like them. She stated she did not know what it was and did not try to find out what they were. She stated the Dietician told her it was ok to make changes as long as she added it to the substitution log. The FSS stated she had not kept a substitution log in months. Interview on 04/10/25 at 03:21 PM with the DON and FSS revealed they used a company that provided the facility with menus. The DON stated they should provide updated menus but the Assistant ADM was the FSS's direct supervisor and would have more information. Interview on 04/10/25 at 03:30 PM with the Assistant ADM and the FSS revealed the facility received updated menus from a food company including monthly meals at a glance and extended menus. She stated the menu at a glance was usually posted by the kitchen window. The FSS stated she did not know what happened to them and it had been some time since she had seen one posted She stated she had been using the extended menu's dated June 2024. The Assistant ADM stated the food company provided new menus every 6 months. The FSS again stated she would change the menu if she did not believe the residents liked specific food items. She stated, at times, she would let the Assistant ADM know about the changes. The Assistant ADM stated she would remind the FSS to add the changes to the substitution log. The FSS stated she had not been keeping a substitution log. She further stated she did not discuss changes with the Dietician prior to changing the menu. The Assistant ADM stated administrative staff would meet weekly and she would remind the FSS to follow the menu. She stated she did not have a copy of the most recent menus and had not looked to see if the menu at a glance was posted 2. Review of the current menus were presented for the months of February 2025 through September 2025. Interview on 04/10/25 at 4:00 PM with the ADM revealed the updated menus were sent to their sister facility instead of to them. He stated he knew they would send updated menus every 6 months or so but had not looked or called to find out about the most recent menus. Interview on 04/11/25 at 10:12 AM with the Dietician Consultant revealed she had been asking the ADM for about 5 months if he had printed the menus sent by the food company. She stated she told the ADM she had not reviewed or signed them. The Dietician stated the menus at a glance were not posted so the residents had no idea what they would be served. They only had the menu the dietary staff posted the day of. The Dietician stated dietary staff had been serving meals based on last years menu's; using the extension menu. She stated they did not have menu recipes, substitution options and the purchase guide used to help dietary staff plan their meals. The Dietician stated she believed the new menus came out during August 2024. She stated she understood the FSS was out intermittently last year due to illness and she learned most recently she was exchanging out food items. The Dietician stated she had told the FSS to change out meat for meat, starch for starch etc if she was going to make changes. Review of facility policy, PURPOSE OF DIETARY DEPARTMENT, undated, revealed; The purpose of the Food service Department is to prepare and serve meals in a safe, effective and pleasingly manner and under the standards of sanitation. The meals ·are prepared in accordance with physician's orders and to meet as far as possible the recommended dietary allowances of the Food and Nutrition. I. The Food Service Supervisor will be responsible for the total operation of the Department. The duties are: A. The supervision of all food service personnel. B. Participation in meeting of heads of department. C. Planning of general diets (Dietitian will approve menus),, and preparation and serving of all diets. II. A qualified dietary consultation will serve as consultation to the Administrator and Food Service Supervisor. 3. To provide guidance to the Food Service Supervisor and staff regarding all procedures and problems in the department. 4. To approve all menus. 11. MENUS AND NUTRITIONAL ADEQUACY. a. Menus shall be planned and followed to meet nutritional needs in accordance with the attending physician's orders and the National Research Council recommended dietary allowances.

. 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 for 1 of 1 kitchen. The facility failed to serve the cold chicken penne pasta salad and the mechanical vegetable mixture at 41 F or below for the evening meal service. This failure could place residents at risk for food borne illness. The findings were: In an interview on 04/11/2025 at 5:00 PM, [NAME] A reported the evening meal consisted of a cold plate of a chicken penne pasta salad and soup. [NAME] A stated she had cooked the chicken and pasta earlier in the afternoon for the evening meal and placed them in the refrigerator to cool down, then placed the chicken penne pasta salad on ice on the steamtable. Observation on 04/11/2025 at 5:01 PM reveaked [NAME] A took the temperatures of the food on the steamtable with a thermometer. The temperature of the chicken penne pasta salad was 62 degrees F and the mechanical vegetable mixture of cooked broccoli, cauliflower, and carrots was 70 degrees F. The chicken penne pasta salad and the mechanical vegetable mixture were in steamtable pans with ice under the pans. In an interview on 04/11/2025 at 5:02 PM, [NAME] A stated the vegetable mixture of cooked broccoli, cauliflower, and carrots were for residents who received a mechanical soft diet, and was to be served as a cold dish. In a further interview on 04/11/2025 at 5:08 PM, [NAME] A stated the temperature of the cold food (chicken penne pasta salad and the cooked mechanical vegetable mixture) should be 40 degrees F or below when served. In an interview on 04/11/2025 from 5:11 PM to 5:13 PM, the FSS stated the temperature of the chicken penne pasta salad should be 40 degrees F to 45 degrees F when served, and the harm of not serving it below 41 degrees F was the food product could go bad and the residents could get sick. The FSS stated the chicken penne pasta salad was prepared the afternoon of 04/11/2025. Observation on 04/11/2025 at 5:15 PM of the menu board on the wall across from the kitchen revealed the evening menu was soup, crackers, chicken penne pasta salad, tomato/cucumber salad and spice cake. Observation on 04/11/2025 from 5:17 PM to 5:36 PM revealed [NAME] A served the chicken penne pasta salad, that was above 41 degrees F, to residents who received a regular diet and mechanical soft diet; and served the mechanical vegetable mixture, that was above 41 degrees F, to residents who received a mechanical soft diet. In an interview on 04/11/2025 at 5:38 PM, the FSS stated she had assisted [NAME] A prepare the chicken penne pasta salad earlier around 3 PM when the pasta was cooked and the FSS had grilled chicken thighs for the salad which was why the FSS thought the salad was still warm by the evening meal service time despite being placed in the refrigerator prior to the meal service. In a joint interview on 04/11/2025 at 6:55 PM with the Administrator and Assistant Administrator, the Administrator stated the cold food served at the evening meal (the chicken penne pasta salad and the mechanical vegetable mixture) should have been served at a temperature of 41 degrees or below. The Assistant Administrator stated previously when a pasta meat salad was on the menu, the salad would be made the day before so the salad would be cold enough to serve the next day. Record review of the FDA Food Code 2022, Chapter 3-501.16(A)(2), pages 75-76, revealed Except during preparation, cooking or cooling, time/temperature control for safety food [sic] shall be maintained: (2) at 5 degrees Celsius (41 degrees F) or less. Record review of the facility's undated Dietary Policy on Preparation and Service of Food revealed Food shall be prepared by methods which insure (sic) retention of flavor, appearance, quality and nutrients. The food service supervisor and cooks will be responsible for quality of food .7. Hot foods will be served at a minimum temperature of 140 degrees F. and cold foods will be served as a maximum of 45 degrees F. .

Based on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 of 5 staff (NA A and NA B) whose records were reviewed. The facility failed to ensure NA A and NA B were screened through the EMR and NAR registry to ensure they were employable. These deficient practices could affect any resident and contribute to resident abuse, neglect, exploitation and misappropriation of resident property. The findings were: This deficient practice could affect all residents and result in staff not being eligible to provide direct care to residents. The findings were: 1. Review of pre-employment search revealed NA A had not been screened through the EMR and NAR registries during 2023 through 2024. Review of employee/staffing schedule from 1/29/25 to 1/31/25 revealed NA A worked from 10:00 PM to 6:00 AM on 1/29/25. A VM on 1/30/25 at 5:32 PM was left for NA A requesting she return the call. NA did not return the call by the end of the investigation period. 2. Review of pre-employment search revealed NA A and NA B had not been screened through the EMR and NAR registries during 2023 through 2024. Review of employee/staffing schedule from from 1/29/25 to 1/31/25 revealed NA B was scheduled to work on 2:00 PM to 10:00 PM shift on 1/30/25. Interview on 1/29/25 at 3:33 PM with the ADM revealed he provided original background checks at the time of hire for employees NA A and NA B . The ADM stated EMR and NAR checks had not been conducted from 2023 to 2024. He stated NA A and NA B had worked for in the capacity as CNA's for years and were supervised by nursing staff. He stated he had known the employees a long time and knew they are hirable. However, stated he understood they had to run EMR/NAR background checks every year to check their certifications and for any acts of misconduct as part of the abuse/neglect policy to ensure the safety of residents He stated he understood both NA A and NA B had received extensions to secure their certification but had not been certified. A VM on 1/30/25 at 5:49 PM was left for NA B requesting she return the call. She did not return the call by the end of the investigation period. Review of a facility policy, dated 10/2024, read in relevant part The facility has developed and implemented policies and procedures that include the following components R/T Abuse/neglect/ misappropriation of resident property. 1. Screening 2. Training 3. Prevention 4. Identification 5. Investigation 6. Protection 7. Reporting Procedure 1. All staff hired at {Facility}will have two reference checks documented at the time of hiring. Each employee will have a criminal history check done, and be checked through the misconduct registry/nurse aide registry. All licensed staff will be checked through their prospective boards. Review of a facility policy, [Facility}, undated, read In accordance to Chapter 253 of the Health and Safety Code the purpose of the Employee Misconduct Registry is to ensure that unlicensed personnel who commits acts of abuse, neglect, exploitation and misappropriation or misconduct against residents and customers are denied employment in HHSC- regulated facilities and agencies. HHSC-regulated facilities and agencies are required to check the Employee Misconduct Registry and the Nurse Aide Registry before hiring an individual and on an annual basis to determine if the individual is listed on either registry as having committed an act of abuse, neglect, exploitation, misappropriation or misconduct against a resident or consumer and is, therefore, unemployable.

Based on interview and record review the facility failed to ensure before allowing an individual to serve as a nurse aide, a facility must receive registry verification that the individual has met competency evaluation requirements for 2 of 3 Staff (NA A and NA B) whose records were reviewed. The facility failed to ensure NA A and NA B completed a nurse aide program and received their certification. This deficient practice could affect all residents and result in staff not being eligible to provide direct care to residents. The findings were: 1. Review of NA A's personnel file revealed there was no documentation NA A completed a nurse aide course and received a certification. Review of employee/staffing schedule from 1/29/25 to 1/31/25 revealed NA A worked from 10:00 PM to 6:00 AM on 1/29/25. A VM on 1/30/25 at 5:32 PM was left for NA A requesting she return the call. NA A did not return the call by the end of the investigation period. 2. Review of NA B's personnel file revealed there was no documentation NA B completed a nurse aide course and received a certification. Review of employee/staffing schedule from 1/29/25 to 1/31/25 revealed NA B was scheduled to work on the 2:00 PM to 10:00 PM shift on 1/30/25. Interview on 1/29/25 at 3:33 PM with the ADM revealed NA A and NA B had worked for the facility in the capacity as CNA's for years and were supervised by nursing staff. He stated he understood both NA A and NA B had received extensions to secure their certification , but had not been certified. The ADM further stated NA B had actually completed the course and failed the test. He stated she told him, she was not going to test again. The ADM stated he understood it was required by State that an NA complete a course and become certified to work in the capacity of a CNA to ensure they had the skills necessary to provide residents with direct care. A VM on 1/30/25 at 5:49 PM was left for NA B requesting she return the call. She did not return the call by the end of the investigation period.

Based on interview and record review the facility failed to provide training to their staff that at a minimum educated these staff on procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property for 2 of 5 staff (NA A and NA B) whose records were reviewed for abuse training. Staff NA A and NA B did not have their training for abuse or neglect for the year 2024. This deficient practice could affect any resident and contribute to resident abuse and or neglect. The findings were: 1. Review of employee personnel file revealed NA A had not completed training for resident abuse or resident neglect for the year 2024. Review of in-service dated 10/4/24 for ANE, Resident Rights, Restraints, and Fall prevention revealed NA A did not attend the in-service. A VM on 1/30/25 at 5:32 PM was left for NA A requesting she return the call. NA did not return the call by the end of the investigation period. 2. Review of pre-employment search revealed NA B had not completed training for resident abuse or resident neglect for the year 2024. Review of in-service dated 10/4/24 for ANE, Resident Rights, Restraints, and Fall prevention revealed NA B did not attend the in-service. Interview on 1/30/25 at 5:00 PM with the DON and Administrator revealed NA A and NA B had not completed abuse training during 2024. The DON stated she conducted the in-services and was responsible for ensuring all staff was trained on abuse and neglect upon hire and annually to ensure the resident's safety. A VM on 1/30/25 at 5:49 PM was left for NA B requesting she return the call. She did not return the call by the end of the investigation period. Review of a facility policy, dated 10/2024, read in relevant part The facility has developed and implemented policies and procedures that include the following components R/T Abuse/neglect/ misappropriation of resident property. 1. Screening 2. Training 3. Prevention 4. Identification 5. Investigation 6. Protection 7. Reporting Procedure 1. All staff hired at {Facility}will have two reference checks documented at the time of hiring. Each employee will have a criminal history check done, and be checked through the misconduct registry/nurse aide registry. All licensed staff will be checked through their prospective boards. 2. All staff will be trained on hire and at least twice yearly on issues such as: Abuse prohibition practices. Intervention with aggression/catastrophic reactions Reporting allegations Recognizing burnout/stress Definitions of abuse, neglect, and misappropriation Page 2 3. Reporting concerns/incidents/grievances by residents providing residents/families/staff with information on reporting and resolving concerns/grievances. Identifying those residents at risk, correcting situations in which abuse/neglect. Misappropriation may occur.

Based on interviews and record review, the facility failed to ensure that the assessments accurately reflected the resident's status for 1 of 3 residents (Resident #35) reviewed for assessments: The facility reported diagnoses included depression, psychotic disorder( serious illness that affects the mind and make it hard for someone to think clearly make good judgements), schizophrenia (mental disorder characterized by reoccurring episodes of psychosis that are corrected with a general misperception of reality), and post-traumatic stress disorder( a mental health condition that is triggered by a traumatic event) on Resident #35's most recent MDS assessment, (dated 01/04/2024). No medical record available in the resident's chart or that the DON/Owner could provide supported the resident having been given those diagnoses at that time or historically. This failure could affect residents who had been at the facility more than 14 days by contributing to inadequate care based on inaccurate assessments. The findings were: Record review of Resident #35's face sheet, (with at report date of 09/01/2023), revealed an admission date of 08/30/2023 and included the following diagnoses: Dementia with behavioral disturbance, hypertension, diabetes with chronic kidney disease, and hyperlipidemia (high cholesterol). Record review of Resident #35's most recent Quarterly MDS assessment, (01/04/2024), indicated the resident had the following diagnoses under Section I, (Psychiatric/Mood Disorder): Depression (other than Bipolar), Psychotic Disorder (other than Schizophrenia), Schizophrenia, and Post Traumatic Stress Disorder, PTSD. Interview with the DON/Owner on 03/06/2024 at 2:38 p.m., she stated she checked the box indicating Resident #35 had depression, psychotic disorder, schizophrenia, and post-traumatic stress disorder in error and should not have because the resident did not have any of those diagnoses. She further explained she had been completing a lot of MDS's at the time and must have made a mistake and that mistake did not have any effect on the resident or the resident's care. Stated she is responsible for completing all MDS assessments at the facility and did not believe the residents' MDS not being accurately completed effected resident care or the resident in any way. A facility policy related to completion of MDS in facility, was requested prior to exit, however no policy was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #4 and resident # 141) of 8 residents reviewed for care plans. Resident #4 had no care plan in his chart. Resident #141's care plan was incomplete and only had two pages in the care plan. The findings included: Record review of Resident #4's electronic face sheet dated 05/10/2018 reflected he was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: nontraumatic intracerebral hemorrhage (bleeding in the brain), vitamin D deficiency, hyperlipidemia (too much fat in the blood), and age-related nuclear cataract (clouding and thickening of the eye lens). Record review of Resident #4's MDS assessment dated [DATE] reflected he scored a 2/15 on his BIMS which signified he was severely cognitively impaired. Record review of Resident #4's medical chart showed there was no care plan filed in his chart. Record review of Resident #141's electronic face sheet dated 02/29/2024 reflected he was admitted on [DATE]. His diagnoses included: epilepsy (disorder of the brain characterized by repeated seizures), muscle weakness, anxiety, and age-related physical debility. Record review of Resident #141's medical chart showed an incomplete care plan. In an interview on 3/8/2024 at 10:30 am with the DON, she stated there have been situations which have led to documents missing in the chart. She stated the facility had hired someone to thin the charts. She stated the OIG , had also requested documents out of the chart which caused the chart to be missing documents. She stated that the facility does not have a Care Plan policy, but that the facility follows federal and state regulations.

Based on interviews and record review the facility failed to ensure all resident assessments completed within the previous 15 months in the resident's active record were maintained in the resident's active medical records for 6 of 6 residents reviewed for MDS assessments. (Resident #1, Resident #10, Resident #13, Resident #18, Resident # 21, and Resident #35) in that -MDS assessments for Resident #1, Resident #10, Resident #13, Resident #18, Resident # 21, and Resident #35 were not accessible to staff and ready to review, when the DON/Owner was not on site and able to unlock the cabinet in which all resident MDS assessments were stored. These failures affected 6 residents and placed them at risk of not having their assessments available for review. Findings included: Record review of Resident #1's face sheet revealed an admission date of 02/09/2016 and included the following diagnoses: Schizophrenia (mental disorder characterized by reoccurring episodes of psychosis that are corrected with a general misperception of reality) , paranoid state (thought process that is believed to possibly lead to delusion and irrationality), depressive disorder, anemia(deficiency of healthy red blood cells may cause fatigue and unexplained weakness) and in situ of the breast (breast cancer). Record review of Resident #10's face sheet revealed an admission date of 06/19/2023 and included the following diagnoses: cerebral infarction , hypertension, anxiety, seizure disorder/convulsions, depressive disorder, and dysphagia. Record review of Resident #13's face sheet revealed an admission date of 07/27/2021 and included the following diagnoses: hypertension, acute renal failure, and dementia. Record review of Resident #18's face sheet revealed an admission date of 01/04/2018 and included the following diagnoses: Schizophrenia, Parkinson's disease, anemia, chronic pain syndrome, dementia, seizure disorder/convulsions, hallucinations, and delusional disorder. Record review of Resident #21's face sheet revealed an admission date of 12/05/2023 and included the following diagnoses: cerebral infarction (stroke)., diabetes mellitus (high blood sugar), CKF(chronic kidney failure), dementia (cognitive decline in thoughts and abilities), and dysphagia (difficulty in swallowing). Record review of Resident #35's face sheet revealed an admission date of 08/30/2023 and included the following diagnoses: Dementia, with behavioral disturbance, hypertension, diabetes with chronic kidney disease, and hyperlipidemia (high cholesterol) In an interview with the DON/ Owner on 03/05/2024 at approximately 4:00 p.m. requested medical records for Resident #1 and Resident #35. The DON/Owner said they were behind the nurses' station. On 03/06/2024 at approximately 10:00 am this state surveyor went to the nurses' station to get the medical records for Resident #1 and Resident #35, began reviewing them and noticed there were no MDS assessments in either chart. On 03/06/2024 at approximately 10:45 am this state surveyor asked the DON/Owner where the MDS information was for Resident #1 and Resident #35. The DON/Owner explained all MDS assessments were kept on paper in her office in a locked filing cabinet. If staff want to view them, they have to ask her to get them out of the locked filing cabinet in her office. She said she did not see that as a problem and said, all they have to do is ask to see them. The DON/Owner stated she usually gets to the facility around 9:00 a.m. and leaves a little after 6:00 p.m. On 03/07/2024 at approximately 3:25 p.m. this state surveyor went to the nurses' station to get charts for Resident #10, Resident #13, Resident #18, and Resident #21. After reviewing each of the Resident's charts, there were not MDS assessments in any of those 4 charts either, making the total charts initially reviewed which contained no MDS Assessment for 6 of 6 residents. On 03/07/2024 at 5:45 p.m. with the DON/Owner and the Administrator/Owner, they said they were aware there were no MDS assessments in the resident's medical records and directed the state surveyor to let the DON/Owner know which MDS assessments need to be viewed and she would provide them. The Administrator/Owner explained they recently hired a nurse, but no longer worked for the company and was only employed by the facility for a short time. Then he said they think the medical records staff person, (that no longer works for the company), took a lot of records out of the resident charts which should not have been removed. The Administrator then explained the facility did not keep the MDS assessments in the charts and did not know that information should be maintained as a part of the master record. During the same interview, the DON/Owner stated she was responsible for completing all MDS Assessments and ensuring they are maintained as required for all residents in the facility.

Based on observations and interviews the facility failed to provide a safe functional, sanitary, and comfortable environment for residents, staff, and the public. The facility failed to ensure good general safety precautions were in place in one outside building, 39.11 feet away from the nursing facility; where food was stored, staff complete laundry services for residents, and facility maintenance items were stored. Findings Included: During an observation on 03/06/2024 at approximately 5:45 p.m., the following observations were made: A building adjacent to the main nursing facility building was used to house the laundry room, food pantry, and the maintenance room. The maintenance room and laundry room were separated by a cinder brick wall, the pantry and the maintenance room were separated by a gypsum wall. The building measured at approximately 39.11 feet away from the main building. The following discrepancies were noted: 1. Dryer electrical cord was wrapped around the flexible gas connection. 2. Flexible gas tubing connected to the dryer was being held in place by a wire tie around a galvanized pipe. 3. Maintenance room had flammable liquids and gasses stored inside to include two e-size, gas powered lawn equipment, 1 can (110 fluid ounces) of engineered premixed fuel, and 1-quart container of paint thinner, along with various flammable aerosol spray cans. 4. The Maintenance room had numerous electrical wires hanging down from the ceiling, exposed. The electrical wires were live/energized, and covered with black tape, some had wired connection. Further observation revealed where the sheath around the wired had fallen apart exposing the electrical wire. During an interview with the Administrator, after the observation on 03/06/2024 at approximately 6:15 p.m., the Administrator said, We use that building for storage and laundry, it has a completely different address than the building we are in now, (referring to the building the residents live in). We get a different water and electric bill for that building as well. The Administrator then said, We will correct the identified concerns brought to our attention immediately, we want everything to be the way it is supposed to be.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility for 1 of 2 (Resident #1) residents reviewed for transfer and discharged rights. The facility failed to readmit Resident #1 after an acute care hospital stay resulting in Resident #1 not being permitted to stay in the facility pending placement or appeal. This deficient practice could place residents residing in the facility at risk of not being able to remain at the facility, resulting in violation of their rights. Findings: Record review of Resident #1's admission record, dated 07/18/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Parkinson's disease, COPD, high blood pressure, dementia, repeated falls, and weakness. The face sheet indicated a family member was designated as his responsible party. Record review of Resident #1's progress notes, dated 11/24/23, revealed the following: Received AM call from case manager .ready for discharge on [DATE] the administrator will not allow resident because of his behavior attack on LVN and CNA, hospital informed called resident representative but unable to leave a message. Record review of admission MDS, dated [DATE] revealed a BIMS of 7 which indicated severe cognitive impairment. Further review of section E: behaviors revealed the resident had no behaviors. During an interview on 12/14/23 at 2:45 p.m. the Administrator stated Resident #1 was still at the hospital. The Administrator stated the hospital tried to send him back but they would not accept him back because he needed psych services and he was still in a psych unit at the hospital. The Administrator stated the resident never paid for services at the nursing home and they never received any compensation from Resident #1. During an interview on 12/15/23 at 2:16 p.m. the hospital Case worker stated Resident #1 was admitted to the hospital on [DATE]. The Case Worker stated the facility did not apply for insurance for the resident in a timely manner and he was not insured, and the facility would not accept him back because he was not paying. The Case Worker stated the assistant Administrator told her good luck finding another facility who would accept Resident #1 because he did not have insurance and had behavior issues. The Case Worker stated they were trying to find a place to accept the resident and she was unable to discharge him because the facility refused to accept him back, his family would not take him, and he could not care for himself. During an interview on 12/18/23 at 10:14 a.m. the Resident Representative stated Resident #1 was at the hospital and was diagnoses with a brain tumor. The RP stated the facility is waiting for a response from Medicaid before they know if they will accept him back or not because his family can not pay the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure before transferring or discharging a resident, the notice of transfer or discharge was made by the facility at least 30 days before the resident was transferred or discharged for 1 of 2 residents (Resident #1) reviewed for discharge requirement. The facility refused to accept Resident #1 back on 11/25/2023 after emergently discharging Resident #1 to acute care (on 11/23/2023) for attacking an LVN and CNA. Resident #1's Responsible Party was not given a 30-day discharge notice when the facility refused to readmit Resident #1 from the acute care hospital on [DATE]. These failures could place residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options and appeal process. Findings Include: Record review of Resident #1's admission record, dated 07/18/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Parkinson's disease, COPD, high blood pressure, dementia, repeated falls, and weakness. The face sheet indicated a family member was designated as his responsible party. Record review of Resident #1's progress notes, dated 11/24/23, revealed the following: Received AM call from case manager .ready for discharge on [DATE] the administrator will not allow resident because of his behavior attack on LVN and CNA, hospital informed called resident representative but unable to leave a message. Record review of admission MDS, dated [DATE] revealed a BIMS of 7 which indicated severe cognitive impairment. Further review of section E: behaviors revealed the resident had no behaviors. During an interview on 12/14/23 at 2:07 p.m., LVN C stated Resident #1 had only been here a few months. He would get out of control for no reason and he would talk about [NAME]. The day of the incident he was hitting people and the pole while seated in a Geri chair with a tray connected. The CNA calmed him down. He grabbed her hand and LVN C went to help the CNA. He then grabbed LVN C by the neck and threw her to the ground. LVN C stated he had never been that aggressive before. LVN C stated staff called the police due to Resident #1's behaviors. LVN C stated the police and firefighters came and told staff they could not do anything, and a nurse supervisor said they could not have him there because of the behavior. LVN C stated the police said because Resident #1 had dementia and they had nothing to give him and even if they had something to give him, they could not get close to him to give it to him. LVN C stated the Fire and EMS stated the resident was quiet at that time and LVN C said that was because he had 6 big men around him. LVN C stated all the staff were women and the EMS took him to the hospital for further evaluation. During an interview on 12/14/23 at 2:45 p.m. the Administrator stated Resident #1 was still at the hospital. The Administrator stated the hospital tried to send him back but they would not accept him back because he needed psych services and he was still in a psych unit at the hospital. The Administrator stated the resident never paid for services at the nursing home and they never received any compensation from Resident #1. During an interview on 12/15/23 at 10:00 a.m. the DON stated Resident #1 started going crazy in October of 2023. The DON stated Resident #1 became a danger to other residents and staff due to his aggressive behaviors. The DON stated they did notify the Resident Representative that he was sent to the hospital. The DON stated he was never formally discharged because it was an emergency situation. The DON stated they would accept the resident back after he was established with psychiatric services. The DON stated she was not aware of a nursing note from 11/24/23 that stated the facility was contacted by the hospital on that date and the Administrator refused to accept the resident back. During an interview on 12/15/23 at 2:16 p.m. the hospital Case worker stated Resident #1 was admitted to the hospital on [DATE]. The Case Worker stated the facility did not apply for insurance for the resident in a timely manner and he was not insured, and the facility would not accept him back because he was not paying. The Case Worker stated the assistant Administrator told her good luck finding another facility who would accept Resident #1 because he did not have insurance and had behavior issues. The Case Worker stated they were trying to find a place to accept the resident and she was unable to discharge him because the facility refused to accept him back, his family would not take him, and he could not care for himself. During an interview on 12/18/23 at 10:14 a.m. the Resident Representative stated Resident #1 was at the hospital and was diagnoses with a brain tumor. The RP stated the facility is waiting for a response from Medicaid before they know if they will accept him back or not because his family can not pay the facility. During an interview on 12/18/23 at 2:11 p.m. CNA A stated Resident #1 was hitting the side of the chair and was loud. They bought him food and water and then he started throwing the food. He was yelling and broke the table off his chair and threw it across the room. CNA stated Resident #1 grabbed her by the arm, then grabbed LVN C and took her to the floor. Record review of facility's, undated, policy titled Nursing Facility admission and Financial Agreement reflected .16. Transfer and discharge: if a resident is transferred from the facility, or is on a therapeutic home leave (in excess of three days from Medicaid residents), without arranging for a bed hold, facility shall process the discharge of the resident. If the resident desires to be readmitted after discharge, resident shall be treated as a new applicant for the purpose of admission. Medicaid residents who are medically eligible shall be readmitted to the first available bed. Except in an emergency, resident shall not be transferred or discharged without prior consultation with the resident, residents attending physician and responsible party and written notification describing the reasons for the transfer or discharge and resident right to appeal the transfer or discharge. Residents may be transferred or discharged if: a. necessary for residents welfare and residents needs cannot be met in facility; b. resident no longer needs services provided by the facility; c. resident is endangering the safety of other persons in the facility; d. resident is endangering the health of other individuals in the facility; e. resident fails, after reasonable and appropriate notice, to pay, or have paid under Medicaid or Medicare for goods and services provided by facility; f. facility ceases to participate in the program that pays for residence care; or g. resident has not resided in the facility for 30 days. Written notice will be given to the resident/responsible party for all planned discharges and transfers. 30 days written notice will be given for discharges and transfers planned pursuant to subsections (e) and (f) above. All discharges will be made as soon as practicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave for 1 of 2 residents (Resident #1) reviewed for discharge requirement, in that: 1. The facility failed and refused to readmit Resident #1 from the hospital where he was transferred for evaluation and treatment. 2. The facility failed to give Resident #1 or his RP a 30 day discharge notice. These deficient practices could affect residents discharged from the facility and their ability to return to the facility. Findings Include: Record review of Resident #1's admission record, dated 07/18/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Parkinson's disease, COPD, high blood pressure, dementia, repeated falls, and weakness. The face sheet indicated a family member was designated as his responsible party. Record review of Resident #1's progress notes, dated 11/24/23, revealed the following: Received AM call from case manager .ready for discharge on [DATE] the administrator will not allow resident because of his behavior attack on LVN and CNA, hospital informed called resident representative but unable to leave a message. Record review of admission MDS, dated [DATE] revealed a BIMS of 7 which indicated severe cognitive impairment. Further review of section E: behaviors revealed the resident had no behaviors. During an interview on 12/14/23 at 2:45 p.m. the Administrator stated Resident #1 was still at the hospital. The Administrator stated the hospital tried to send him back but they would not accept him back because he needed psych services and he was still in a psych unit at the hospital. The Administrator stated the resident never paid for services at the nursing home and they never received any compensation from Resident #1. During an interview on 12/15/23 at 10:00 a.m. the DON stated Resident #1 started going crazy in October of 2023. The DON stated Resident #1 became a danger to other residents and staff due to his aggressive behaviors. The DON stated they did notify the Resident Representative that he was sent to the hospital. The DON stated he was never formally discharged because it was an emergency situation. The DON stated they would accept the resident back after he was established with psychiatric services. The DON stated she was not aware of a nursing note from 11/24/23 that stated the facility was contacted by the hospital on that date and the Administrator refused to accept the resident back. The DON stated she did not have the following: 1) Resident/Representative verbal or written notice of intent to leave the facility. 2) Comprehensive care plan that includes the resident's goals for admission and discharge 3) Discharge planning process 4) Discharge summary 5) Signed physician order of discharge 6) Notice to Adult Protective Service (APS) 7) Meeting with Interdisciplinary Team (IDT) about discharge 8) Required 30-day notice to Resident #1 9) No communication with receiving facility During an interview on 12/15/23 at 2:16 p.m. the hospital Case worker stated Resident #1 was admitted to the hospital on [DATE]. The Case Worker stated the facility did not apply for insurance for the resident in a timely manner and he was not insured, and the facility would not accept him back because he was not paying. The Case Worker stated the assistant Administrator told her good luck finding another facility who would accept Resident #1 because he did not have insurance and had behavior issues. The Case Worker stated they were trying to find a place to accept the resident and she was unable to discharge him because the facility refused to accept him back, his family would not take him, and he could not care for himself. During an interview on 12/18/23 at 10:14 a.m. the Resident Representative stated Resident #1 was at the hospital and was diagnoses with a brain tumor. The RP stated the facility is waiting for a response from Medicaid before they know if they will accept him back or not because his family can not pay the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure it received registry verification for 1 (CNA A) of 4 employees reviewed for registry verification prior to allowing an applicant to serve as a nurse aide in that: The facility failed to ensure CNA A had a current nurse aide certification while employed at the facility, while actively providing care for residents. This failure could result in residents being provided care by staff who have not provided documentation of training and competency in providing care. The findings included: Review of CNA A's personnel file reflected a date of hire of [DATE]. The last Employability Status Check Search that was completed on [DATE] reflected CNA A's NAR status expired on [DATE]. Review of the daily nursing staff schedule , for [DATE] reflected CNA A worked on [DATE] on shift 10-6 (10:00 PM - 6:00 AM) under the Aides section. During an interview on [DATE] at 2:00 p.m. CNA A stated she worked at the facility as a CNA and had been working as a CNA since may of 2023. Interview on [DATE] at 3:18 PM, the DON stated there was an ADON who would help with CNAs becoming certified and license verification. The DON stated the ADON was not currently working. The DON stated CNA A had previously worked for the facility in the past and came back in May of 2023 and was working as a CNA. The DON stated they thought CNA A was able to work as a CNA with an expired certification because of a waiver . The DON stated they did not have a policy for CNA requirements and they followed state regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess each resident quarterly (every 3 months) using the Minimum Data Set form specified by the state and approved by CMS for 1 of 6 residents (Resident #25) whose MDS assessments were reviewed, in that: Resident #25's Quarterly MDS Assessment was not completed or submitted. This deficient practice could place residents at-risk of not having their assessments completed timely. The findings were: Record review of Resident #25's face sheet, with a report date of 06/01/2022, revealed the resident was admitted on [DATE] with diagnoses that included: HTN NOS (hypertension or high blood pressure), Senile Dementia uncomp (mental deterioration or loss of intellectual ability, that is associated with or the characteristics of old age), Diabetes Mellitus (refers to a group of diseases that affect how the body uses blood sugar (glucose), and Vitamin D Deficiency ( low level of the Vitamin D). Record review of Resident #25's information provided by the facility MDS Coordinator, revealed the resident's last completed MDS provided by the facility was dated 10/17/2022. During an interview with the MDS Coordinator on 02/02/2023 at 2:08 p.m., the MDS Coordinator confirmed Resident #25's MDS, dated [DATE], was the last MDS completed for Resident #25. The MDS Coordinator stated Resident #25 should have had another assessment on approximately January 1, 2023. She stated she never saw any information indicating the nursing assessment portion of the MDS assessment had been completed, therefore she did not complete the remaining portion of the MDS assessment or submit the MDS to CMS and further stated she overlooked the need for MDS submission for Resident #25. Record review of the RAI (Resident Assessment Instrument) Manual OBRA Assessment Summary, dated 10/2018, revealed, The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to transmit a resident assessment within the required time frame for 2 of 5 residents (Residents #4 and #32) reviewed for data encoding and transmission in that: 1. Resident # 4's last MDS assessment submitted was on 10/04/2022 and no other MDS was transmitted prior to the survey. 2. Resident #32's last MDS assessment submitted was on 10/06/2022 and no other MDS was transmitted prior to the survey. This failure could affect residents who resided in the facility and put them at risk of not having their assessments transmitted timely. The findings were: 1. Record review of Resident #32's face sheet, dated 1/10/23 revealed an [AGE] year old female admitted on [DATE] with diagnoses that included senile dementia (mental deterioration in old age, characterized by loss of memory and control of bodily functions), anxiety and chronic pain syndrome. Record review of Resident #32's medical record revealed the resident's last MDS assessment was completed on 1/05/2023 by the DON but was not transmitted as of 01/31/2023. 2. Record review of Resident #4's face sheet, dated 9/24/18 revealed a [AGE] year old female admitted on [DATE] and re-admitted on [DATE] with diagnoses that included hypertension (high blood pressure), anxiety, depressive disorder, chronic pain syndrome and osteoarthritis (degeneration of joint cartilage and the underlying bone). Record Review of Resident #4's medical record revealed the resident's last MDS assessment was completed on 01/11/2023 by the DON but was not transmitted as of 01/31/2023. During an interview on 02/02/2023 at 2:15 p.m. the MDS Coordinator stated the MDS assessment for Resident #4 and Resident # 32 should have been transmitted within 14 days of their completion but were not, she said she is the responsible party for submitting all MDS assessments completed within the facility. Review of the MDS 3.0 RAI Manual v1.17.1_October 2019, Section 5.2 Timeliness Criteria revealed: Encoding Data: Within 7 days after completing a resident's MDS assessment or tracking record, the provider must encode the MDS data (i.e., enter the information into the facility MDS software). The encoding requirements are as follows: - For a comprehensive assessment (Admission, Annual, Significant Change in Status, and Significant Correction to Prior Comprehensive), encoding must occur within 7 days after the Care Plan Completion Date (V0200C2 + 7 days). - For a Quarterly, Significant Correction to Prior Quarterly, Discharge, or PPS assessment, encoding must occur within 7 days after the MDS Completion Date (Z0500B + 7 days). - For a tracking record, encoding should occur within 7.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services to include procedures that assured the accurate dispensing and administering of all drugs to meet the needs of 1 of 6 residents (Resident #4) reviewed for medication administration in that: LVN D left Resident #4's medication at the bedside. This deficient practice could affect residents and place them at risk of not receiving the therapeutic dosage and drug diversion. The findings were: Record review of Resident #4's face sheet, dated 9/24/18, revealed a [AGE] year old female admitted on [DATE] and re-admitted on [DATE] with diagnoses that included hypertension (high blood pressure), anxiety, depressive disorder, chronic pain syndrome and osteoarthritis (degeneration of joint cartilage and the underlying bone). Further review of the face sheet, under Allergies, revealed Resident #4 was identified as having seasonal allergies. Record review of Resident #4's most recent quarterly MDS, dated [DATE] revealed the resident was moderately impaired for daily decision-making skills. Record review of Resident #4's Physician Orders for February 2023 revealed an order for Flonase 50 micrograms, 1 puff inhalation, PRN (as needed) every day for seasonal allergies, with order date 3/23/21 and no end date. During an observation and interview on 2/3/23 at 9:26 a.m., Resident #4, sitting up in bed, was observed with Flonase nasal spray on the bedside table at the foot of the bed. Resident #4 stated her nose was sprayed that morning because of allergies. Resident #4 further stated, I spray myself in the nose sometimes, but the nurse brings it to me. I guess she forgot to take it with her. During an interview on 2/3/23 at 9:39 a.m., Medication Aide C stated, residents in the facility, including Resident #4 could not have medications left at the bedside. Medication Aide C stated medications left at the bedside could be used by other residents and could overdose. Medication Aide C stated, the medication aides did not administer nasal sprays, only the nurse. During an interview on 2/3/23 at 9:42 a.m., LVN D stated she had administered the Flonase nasal spray to Resident #4 and was called away to another room and forgot she had left it at the resident's bedside table. LVN D stated, Resident #4 was able to self-administer the nasal spray but had to instruct and watch the resident as she applied the nasal spray. LVN D stated she was not supposed to leave medications at the bedside for any residents, including Resident #4 because other residents could get hold of the nasal spray, break the bottle or use it incorrectly such as spraying it in the mouth instead of the nose. During an interview on 2/3/23 at 12:44 p.m., the DON stated the facility did not identify any residents who could self-medicate. The DON stated medications could not be left at the bedside because the resident could overuse the medication and there were residents in the facility who wandered and could use the medication not intended for them and cause a reaction. The DON stated it was the expectation of the nursing staff and medication aides to ensure the resident took their medication before leaving the bedside. During an interview on 2/3/23 at 1:15 p.m., RN Consultant A stated, medications were not supposed to be left at the bedside and only the medication aide and the nurse were to administer medications and secondly, the resident may not know what to do with it. The facility did not provide a policy and procedure on Pharmaceutical Services at the time of the exit.

**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 timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 7 of 7 residents (Resident #11, #30, #32, #4, #22, #18 and #1) reviewed for care plans in that: Residents #11, #30, #32, #4, #22, #18 and #1 were not assessed for pain per the physician's orders and as per the measurable objectives and timeframes addressed on the comprehensive person-centered care plan. This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs. The findings were: a. Record review of Resident #11's face sheet, dated 3/3/22 revealed a [AGE] year old female admitted on [DATE] with diagnoses that included chronic renal failure (longstanding disease of the kidneys leading to kidney failure), hypothyroidism (abnormally low activity of the thyroid gland resulting in slowing of metabolic changes in adults) and diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy). Record review of Resident #11's most recent Annual MDS assessment, dated 11/28/22 revealed the resident was severely cognitively impaired for daily decision-making skills and was triggered for pain. Record review of Resident #11's Physician Orders for February 2023 revealed the following order: Charge nurse to assess for pain every shift with order date 11/19/21 and no end date. Further review of the physician's orders revealed Resident #11 was treated with Lidocaine 5% patch to back, on in the morning and off in the evening, every other day for generalized pain, with order date 11/21/21 and no end date. Record review of Resident #11's comprehensive person-centered care plan, revision date 11/22/22 revealed Resident #11 had pain with interventions that included, Assess characteristics of pain: location, severity on a scale of 1-10, type, frequency. Further review of the comprehensive person-centered care plan revealed, Monitor for potential side effects of pain medication: Altered mental status, Anxiety, Constipation, Depression, Dizziness, Lack of appetite, Nausea, Pruritis, Respiratory depression, Sedation, Urinary retention, Vomiting. Record review of Resident #11's TAR (Treatment Administration Record) for January 2023 and February 2023 revealed no documentation for the location, severity or frequency of pain and no monitoring for potential side effects of pain medication per the comprehensive person-centered care plan. Further review of the TAR revealed facility staff had initialed under the charge nurse to assess for pain every shift section of the TAR but there was no documentation provided on what type of an assessment was made or if the resident had experienced any pain. During an interview on 2/3/23 at 8:39 a.m., Resident #11 stated her whole body hurt because she had fibromyalgia (a chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness and insomnia). Resident #11 further stated she was not aware if she had received medication, could not remember receiving any medication at all, or if she had been asked by the nurse if she had experienced any pain. Resident #11 stated, I don't remember. b. Record review of Resident #30's face sheet, dated 5/31/22 revealed an [AGE] year old male admitted on [DATE] with diagnoses that included congestive heart failure (chronic condition in which the heart doesn't pump blood as well as it should), chronic kidney disease stage III (kidneys are damaged and can't filter blood the way they should) and osteoarthritis. Record review of Resident #30's most recent Annual MDS assessment, dated 10/29/22 revealed the resident was severely cognitively impaired for daily decision-making skills and was triggered for pain. Record review of Resident #30's Physician Orders for February 2023 revealed the following order: Charge nurse to assess for pain every shift, with order date 10/15/21 and no end date. Further review of the physician's orders revealed Resident #30 was treated with Tramadol 50 mg (milligram) twice daily for pain, with order date 5/5/22 and no end date. Record review of Resident #30's comprehensive person-centered care plan, revision date 10/25/22 revealed the resident had pain with interventions that included, Assess characteristics of pain: location, severity, or pain scale. Further review of the comprehensive person-centered care plan revealed, Monitor for potential side effects of pain medication: Altered mental status, Anxiety, Constipation, Depression, Dizziness, Lack of appetite, Nausea, Pruritis, Respiratory depression, Sedation, Urinary retention, Vomiting. Record review of Resident #30's TAR for January 2023 and February 2023 revealed no documentation for the location, severity or frequency of pain and no monitoring for potential side effects of pain medication per the comprehensive person-centered care plan. Further review of the TAR revealed facility staff had initialed under the charge nurse to assess for pain every shift section of the TAR but there was no documentation provided on what type of an assessment was made or if the resident had experienced any pain. During an interview on 2/3/23 at 8:40 a.m., Resident #30 stated he did not usually have pain, had been given pain medications but it was a long time ago. Resident #30 further stated he was not certain what type of pain medication he received and had not been asked by a nurse if he was in pain. c. Record review of Resident #32's face sheet, dated 1/10/23 revealed an [AGE] year old female admitted on [DATE] with diagnoses that included senile dementia (mental deterioration in old age, characterized by loss of memory and control of bodily functions), anxiety and chronic pain syndrome. Record review of Resident #32's most recent admission MDS Assessment, dated 10/6/22 revealed the resident was severely cognitively impaired for daily decision-making skills and was triggered for pain. Record review of Resident #32's Physicians Orders for February 2023 revealed the following order: Charge nurse to assess for pain every shift, with order date 9/29/22 and no end date. Further review of the physician's orders revealed Resident #32 was treated with Celebrex 100 mg two times daily for chronic pain syndrome with order date 9/23/22 and no end date. Record review of Resident #32's comprehensive person-centered care plan, revision date 1/4/23 revealed the resident had pain with interventions that included to assess characteristics of pain: location, severity on a scale of 1 to 10 and frequency. Further review of the comprehensive person-centered care plan revealed, monitor for potential side effects of pain medication: Altered mental status, Anxiety, Constipation, Depression, Dizziness, Lack of appetite, Nausea, Pruritis, Respiratory depression, Sedation, Urinary retention, Vomiting. Record review of Resident #32's TAR for January 2023 and February 2023 revealed no documentation for the location, severity or frequency of pain and no monitoring for potential side effects of pain medication per the comprehensive person-centered care plan. Further review of the TAR revealed facility staff had initialed under the charge nurse to assess for pain every shift section of the TAR but there was no documentation provided on what type of an assessment was made or if the resident had experienced any pain. During an interview on 2/3/23 at 9:17 a.m., Resident #32 stated she received medication for pain and further stated, the nurse did not come back to ask if I was still in pain, they never do. I have never been asked by the nurse if I'm in pain. d. Record review of Resident #4's face sheet, dated 9/24/18 revealed a [AGE] year old female admitted on [DATE] and re-admitted on [DATE] with diagnoses that included hypertension (high blood pressure), anxiety, depressive disorder, chronic pain syndrome and osteoarthritis (degeneration of joint cartilage and the underlying bone). Record review of Resident #4's most recent quarterly MDS, dated [DATE] revealed the resident was moderately impaired for daily decision-making skills and was triggered for pain. Record review of Resident #4's Physician Orders for February 2023 revealed the following order: Charge nurse to assess for pain every shift, with order date 3/8/18 and no end date. Further review of the physician's orders revealed Resident #32 was treated with acetaminophen 650 mg twice daily for pain, with order date 1/3/21 and no end date. Record review of Resident #4's comprehensive person-centered care plan, revision date 1/4/23 revealed the resident had pain with interventions that included to assess characteristics of pain: location, severity on a scale of 1-10, type, frequency. Further review of the comprehensive person-centered care plan revealed, Monitor for potential side effects of pain medication: Altered mental status, Anxiety, Constipation, Depression, Dizziness, Lack of appetite, Nausea, Pruritis, Respiratory depression, Sedation, Urinary retention, Vomiting. Record review of Resident #4's TAR for January 2023 and February 2023 revealed no documentation for the location, severity or frequency of pain and no monitoring for potential side effects of pain medication per the comprehensive person-centered care plan. Further review of the TAR revealed facility staff had initialed under the charge nurse to assess for pain every shift section of the TAR but there was no documentation provided on what type of an assessment was made or if the resident had experienced any pain. During an interview on 2/3/23 at 9:26 a.m., Resident #4 stated she was given medication for pain sometimes twice a day. Resident #4 further stated, the nurse does not ask me if I am in pain, hardly ever comes back after I ask for pain medication and doesn't come back after the pain medication is given. e. Record review of Resident #22's face sheet, dated 5/31/22 revealed a [AGE] year old female admitted on [DATE] with diagnoses that included senile dementia with cognitive impairment (severe mental deterioration in old age, characterized by loss of memory and control of bodily function), osteoarthritis and generalized pain. Record review of Resident #22's most recent Annual MDS assessment, dated 11/18/22 revealed the resident was moderately impaired for daily decision-making skills and was triggered for pain. Record review of Resident #22's Physician Orders for February 2023 revealed the following order: Charge nurse to assess for pain every shift, with order date 9/12/19 and no end date. Further review of the physician's orders revealed Resident #22 was treated with acetaminophen 1000 mg twice daily for generalized pain, with order date 7/27/22 and no end date. Record review of Resident #22's comprehensive person-centered care plan, revision date 11/18/22 revealed the resident had pain with interventions that included, pain scale and Monitor for potential side effects of pain medication: Altered mental status, Anxiety, Constipation, Depression, Dizziness, Lack of appetite, Nausea, Pruritis, Respiratory depression, Sedation, Urinary retention, Vomiting. Record review of Resident #22's TAR for January 2023 and February 2023 revealed no documentation for the location, severity or frequency of pain and no monitoring for potential side effects of pain medication per the comprehensive person-centered care plan. Further review of the TAR revealed facility staff had initialed under the charge nurse to assess for pain every shift section of the TAR but there was no documentation provided on what type of an assessment was made or if the resident had experienced any pain. During an interview on 2/3/23 at 9:33 a.m., Resident #22 stated she was not sure if she received medication for pain, had asked the nurse for pain medication two days ago and was given the medication but was not sure what it was. Resident #22 further stated, the nurse never asks about pain and I don't recall them coming back asking me about pain. f. Record review of Resident #18's face sheet, dated 4/13/21 revealed a [AGE] year old male admitted on [DATE] and re-admitted on [DATE] with diagnoses that included hypertension (high blood pressure), osteoarthritis (degeneration of joint cartilage and the underlying bone causing pain and stiffness) and hyperlipidemia (high cholesterol). Record review of Resident #18's most recent Quarterly MDS assessment, dated 10/30/22 revealed the resident was moderately cognitively impaired for daily decision-making skills and was triggered for pain. Record review of Resident #18's Physician Orders for February 2023 revealed the following order: Charge nurse to assess for pain every shift, with order date 3/8/18 and no end date. Further review of the physician's orders revealed Resident #18 was treated with Gabapentin 100 mg twice daily for pain, with order date 1/11/19 and no end date. Record review of Resident #18's comprehensive person-centered care plan, revision date 10/25/22 revealed the resident had pain with interventions that included, Assess characteristics of pain: location, severity on a scale of 1 to 10, frequency. Further review of the comprehensive person-centered care plan revealed, , Monitor for potential side effects of pain medication: Altered mental status, Anxiety, Constipation, Depression, Dizziness, Lack of appetite, Nausea, Pruritis, Respiratory depression, Sedation, Urinary retention, Vomiting. Record review of Resident #18's TAR for January 2023 and February 2023 revealed no documentation for the location, severity or frequency of pain and no monitoring for potential side effects of pain medication per the comprehensive person-centered care plan. Further review of the TAR revealed facility staff had initialed under the charge nurse to assess for pain every shift section of the TAR but there was no documentation provided on what type of an assessment was made or if the resident had experienced any pain. During an interview on 2/3/23 at 9:48 a.m., Resident #18 stated he did not receive medication for pain, was not in pain and was never in any pain. Resident #18 stated he was asked about pain at least three times a day. g. Record review of Resident #1's face sheet, dated 10/1/21 revealed an [AGE] year old female admitted on [DATE] with diagnoses that included type 2 diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), subdural hemorrhage (pool of blood between the brain and its outermost covering, usually caused by a head injury), anxiety and congestive heart failure. Record review of Resident #1's most recent Significant Change MDS, dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills, received hospice services and was triggered for pain. Record review of Resident #1's Physician Orders for February 2023 revealed the following order: Charge nurse to assess for pain every shift, with order date 3/8/18 and no end date. Further review of the physician's orders revealed Resident #1 was treated with Tylenol #3 (Tylenol with codeine), two tablets twice daily for bilateral osteoarthritis of knees, with order date 3/23/22 and no end date. Record review of Resident #1's comprehensive person-centered care plan, revision date 12/14/22 revealed the resident had pain with interventions that included Assess characteristics of pain: location, severity on a scale, frequency. Discuss with resident factors that precipitate pain and what may reduce it. Further review of the comprehensive person-centered care plan revealed, Monitor for potential side effects of pain medication: Altered mental status, Anxiety, Constipation, Depression, Dizziness, Lack of appetite, Nausea, Pruritis, Respiratory depression, Sedation, Urinary retention, Vomiting and Reassess interventions with any changed in response to pain or pain medications and with every assessment. Record review of Resident #1's TAR for January 2023 and February 2023 revealed no documentation for the location, severity or frequency of pain and no monitoring for potential side effects of pain medication per the comprehensive person-centered care plan. Further review of the TAR revealed facility staff had initialed under the charge nurse to assess for pain every shift section of the TAR but there was no documentation provided on what type of an assessment was made or if the resident had experienced any pain. An attempt at an interview on 2/2/23 at 2:24 p.m., with Resident #1 was unsuccessful. The resident was not interviewable. During an interview on 2/2/23 at 2:25 p.m., LVN E stated, the physician order for the charge nurse to assess for pain every shift was kind of a standing order. LVN E stated it could not be determined if the initials marked on the TAR indicated the resident did not have pain and there would have to be additional documentation if the resident experienced pain but looking at the TAR you can't tell that. During an interview on 2/2/23 at 2:47 p.m., LVN F stated the physician order for the charge nurse to assess for pain every shift was standard for all residents. LVN F stated she had worked for the facility since 2013 and this has always been in place since I started working here. I did question that. LVN F stated, the TAR only indicates that the nurse looked at the resident, but the initials don't indicate an assessment really was done because it just looks like the TAR is just being checked off. During an interview on 2/2/23 at 3:05 p.m., LVN G stated, the charge nurse was tasked with assessing for pain which was standard for most residents. LVN G stated, I can't really say that whoever initialed the TAR actually went in the room and did an assessment on the resident. During an interview on 2/2/23 at 4:06 p.m., LVN ADON B stated, the order for the charge nurse to assess for pain every shift was a standing order applied to every resident. LVN ADON B stated, the initials on the TAR for the section charge nurse to assess for pain merely showed the nurse's initial but did not truly indicate what type of assessment was done or whether the resident was or was not in pain. LVN ADON B stated, the TAR doesn't really indicate if a true assessment for pain was done. During an interview on 2/2/23 at 5:00 p.m., the DON stated, the order for the charge nurse to assess for pain every shift was a standing order applied to all residents. The DON stated, initials on the TAR indicated the resident did not experience any pain but if they did have pain then the nurse would refer to the medication aide to give pain medication. This is the system they had when I started. The initials on the TAR are too vague because it's not giving you a true picture of the patient and whether or not they have pain. We should be documenting the type of pain, where the pain is, if medication was effective if given and if not we need to call the doctor and let him know. The DON stated, the comprehensive person-centered care plan gives a true picture of how the resident is being taken care of. During an interview on 2/3/23 at 1:15 p.m., RN Consultant A stated, most of the time we document by exception. RN Consultant A further stated, we are not documenting for what you come to see what we did, we are more concerned with the family. If the MDS triggers a care area, that drives the care plan and the care plan was not really used as a tool for the nurses and sometimes they look at the care plan and sometimes they don't. RN Consultant A stated the DON was responsible for developing and revising the care plan as needed. RN Consultant A stated, the purpose of the care plan is to have some information available to the staff on how to take care of the resident. The care plan should be a true picture of what the resident is like. Record review of the facility policy and procedure for Care Plans, undated revealed in part, .Facility follows the CMS Long-Term Care Resident Assessment Instrument, User's Manual, Version 3.0, published by the American Health Care Association .