**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #216) of 8 residents reviewed for baseline care plans. The facility failed to include Resident #216's use of insulin and anticoagulant medications in her baseline care plan. This failure could result in residents not receiving needed care and treatment. Findings Included: Record review of Resident #216's admission Record dated 05/20/2025 revealed she was a [AGE] year-old female admitted [DATE] with diagnoses which included Type 2 Diabetes Mellitus, Heart Failure, Peripheral Arterial Disease (an accumulation of plaque (fats and cholesterol) in the arteries in your legs or arms), Hyperlipidemia (high cholesterol), Muscle Wasting and Atrophy (decrease in muscle size and wasting of muscle tissue), and Dysphagia (difficulty swallowing). Record review of Resident #216's 5-day MDS assessment dated [DATE] revealed a BIMS score of 15, indicating intact cognition. Record review of Resident #216's Baseline Care Plan initiated 05/11/2025 revealed medications insulin and anticoagulant were not included. Record review of Resident #216 ' s Physician Orders dated 5/11/2025 revealed, Tresiba Flex Touch Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Degludec) inject 32 units subcutaneously in the morning for DM #2 hold if BS less than 100 and Eliquis Oral Tablet 2.5mg (Apixaban) Give 1 tablet by mouth two times a day for PAD. Record review of Resident #216's electronic Medication Administration Record for May 2025 revealed Eliquis oral tablet 2.5mg 1 tablet by mouth was administered twice a day, started 05/12/2025 and Tresiba Flex Touch Subcutaneous solution Pen injector 100 unit/ml (Insulin Degludec) 32 units injected subcutaneously in the morning, started 05/12/2025. During an interview with MDS nurse on 05/19/25 at 3:05 p.m., stated that the baseline care plan was to be completed within 48 hours. She stated that the admitting floor nurses were responsible for completing the baseline care plan upon admission and the registered nurses sign it off. The MDS nurse stated the essential information that should be included in the baseline care plan should be the resident ' s cognition status, ADLs, respiratory, and medications. The MDS stated that it was important to have that information in the baseline care plan because the resident could fall, elope or have a reaction to a medication. During an interview with LVN A on 05/19/25 3:15 p.m., she stated the baseline care plan was completed between 24-48 hours. He stated the baseline care plan should include information such as medications like insulin, anticoagulants, antidepressants, and code status. LVN A stated insulin should be in baseline care plan to manage the resident ' s diabetes, so they won ' t go into hypoglycemia or hyperglycemia. To make sure we were not giving too much insulin. He stated that the anticoagulants were important to be on the baseline care plan, so they won ' t bleed out. This information was important for better patient care. The admitting nurse was responsible for completing the baseline care plan. During an interview with the DON on 05/19/25 at 3:18 p.m., the DON stated that the nurses were responsible for completing the baseline care plan. She stated that she overlooks the baseline care plans and signs them off. The DON stated the baseline care plans were to be completed within 72hours, but she signs them off before 24hours. She stated that by signing them she acknowledges that it was complete. She stated that the baseline care plan should include the advance directive, allergies, and medications. The DON looked at Residents #216 baseline care plan and under medications, she confirmed that the insulin and anticoagulants were not checked off. She stated that if the resident was currently taking them then the medications needed to be on the baseline care plan. The DON stated the negative outcome was that it would not be care planned and the resident would not have a proper plan of care. Record review of the facility policy titled Baseline Care Plan reviewed 10/05/2023 revealed, Policy: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Policy Explanation and Compliance Guidelines: The baseline care plan will: Be developed within 48 hours of a resident's admission. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders. ii. Physician Orders .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one resident (Resident #10) of five residents reviewed for supervision. The facility failed to ensure Resident #10, who required assistance of 2 staff for bed baths, was not given a bed bath by 1 staff. These failures could place residents at risk of being in an unsafe environment and at risk for accidents and injury. Findings included: Record review of Resident #10's face sheet dated 05/20/25 revealed a [AGE] year-old female with an original admission date of 07/27/12. Diagnoses included paraplegia (a condition characterized by the partial or complete loss of movement and sensation in the lower half of the body, specifically both legs), mood disorder (a serious mental illness that causes persistent and intense changes in a person ' s mood, energy, and behavior), and schizoaffective disorder (diagnosed when a person experiences symptoms of both schizophrenia and a mood disorder [like depression or mania] concurrently). Record Review of Resident #10's Quarterly MDS Assessment, dated 02/14/25, reflected, - BIMS score was blank which indicated the resident had severe cognitive impairment. - Always incontinent of bladder and bowel. - She took antipsychotic and antidepressant medications. - Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Record review of Resident #10's quarterly care plan dated 02/17/25 reflected: FOCUS: · I require assistance with all my ADLS due to impaired mobility and cognitive impairment. Date Initiated: 02/25/2024 Revision on: 02/25/2024 GOALS: · I will have self-care needs met and have few, if any, complications through the review date. Date Initiated: 02/25/2024 Revision on: 05/18/2025 Target Date: 05/28/2025 INTERVENTIONS/TASKS: · FUNCTIONAL PERFORMANCE: BATHING: Shower/ bathe self: Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Tub/ shower transfer: Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Date Initiated: 02/25/2024 Revision on: 02/25/2024 LN CNA. Observation on 05/20/25 at 09:15 AM, revealed Resident #10 was getting a bed bath with CNA B in attendance. Resident #10 was uncovered, brief tabs detached and pulled down. The bath water was murky with soap bubbles. In an interview on 05/20/25 at 09:45 AM, CNA B stated Resident #10 was a 2-person assist for bed bath. CNA B stated she was the only one in Resident #10's room giving a bed bath when the surveyor came in to the room. CNA B stated CNA C went in to help her with Resident #10 's bed bath a few seconds after the surveyor left the room. CNA B stated she already knew if a resident was a 1- or 2-person assist, but if a resident was new, she would ask the nurse if the new resident was a 1- or 2- person assist. CNA B stated if 1 person went in to assist Resident #10, if you closed the curtain and Resident #10 could not see her tv, she would hit the CNA. CNA B stated she did not know if they had any in-servicing on 1- or 2- person assists. In an interview on 05/20/25 at 09:45 AM, CNA D stated if a resident required a mechanical lift, they were a 2-person assist. She said with Resident #10, it depended on how she was behaving whether she was a 1- or 2-person assist. CNA D stated therapy was asked if a new resident were a 1- or 2- person assist. She said sometimes the nurse would tell them if a resident were a 1- or 2-person assist. CNA D stated sometimes she would check the POC when a resident was new. She said if a resident who required a 2-person assist was helped by only 1 person, the resident could fall. In an interview on 05/20/25 at 09:50 AM, RN E stated Resident #10 was a 2-person assist. RN E stated the resident's Care Plan tells whether a resident was a 1- or 2-person assist. RN E stated the charge nurse was responsible for monitoring the CNA for 1- or 2-person assist. RN E stated, I have seen a couple of in-services going around for 1- or 2-person assist, but I do not know when. When RN E was asked what could happen if a resident was a 2-person assist and only one person was assisting, RN stated, That sounds like hypothetical, and I do not want to answer. RN E then stated, 1- or 2-person assists are geared to safety reasons. In an interview on 05/20/25 at 01:27 PM, CNA C stated she assisted CNA B with bed bath for Resident #10 that morning (05/20/25). CNA C stated she was outside the door when the surveyor was in asking questions. CNA C stated Resident #10 was a 2-person assist because she kicked and hit. CNA C stated they had an in-service on 1- or 2-person assist about a month ago. CNA C stated she would check the [NAME] (a concise, quick -reference system for resident information) when she had questions about a patient and when there was a new patient. In an interview on 05/20/25 at 02:55 PM, LVN A stated the nurses or CNAs can check the care plan or [NAME] to see if a resident is a 1- or 2-person assist. He said the 24-hour report can also be checked for changes in assist. LVN A stated it was the nurse ' s responsibility to notify the CNAs of any changes. He said it was the nurse ' s responsibility to monitor the CNAs to make sure they were following the care plan. LVN A stated injury to either the resident or CNA can occur if a 2-person assist is only done by one CNA. In an interview on 05/20/25 at 03:05 PM, the DON stated the charge nurse, and all licensed nurses are responsible to supervise CNAs. She said the CNAs are in-serviced at least monthly on 1- or 2-person assists. The DON stated the [NAME] should be checked when providing care. She stated that the nurses are notified of changes in resident's condition and the nurses notify the CNAs. She said if a resident who was a 2-person assist had only a 1-person assist, the resident could fall or get injured. In an interview on 05/20/25 at 03:35 PM, the Administrator and ADON F stated they had a policy on ADLs, but not on supervision, [NAME] or CNAs responsibility on whether a resident was a 1- or 2-person assist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 1 ([DATE]) of 90 days reviewed for RN hours, for the months [DATE], through [DATE] The facility failed to have RN coverage for 1 day on Saturday, [DATE]. This failure could place residents at risk of harm by denying residents the advanced critical thinking skills a registered nurse could provide. The findings were: Record review of the facility's RN timesheets, no date, reflected the on Saturday [DATE]; the facility only had RN coverage for 3.91 hours. During an interview on [DATE] at 1:39 p.m., the DON said it was her responsibility to ensure the facility had RN coverage for 8 consecutive hours every day. She said if the scheduled RN were to call in then it would be her and the ADONs responsibility to look for another RN or one of them would have to cover the shift. The DON said she could not remember what happened on [DATE] that the scheduled RN only worked 3.91 hours. The DON said either she or the ADON might have covered the remainder of the shift on [DATE] but since they were salary, they were not required to clock in to document that day. The DON said the negative outcome of not having an RN in the facility for 8 consecutive hours could be that the certain tasks only an RN could do,(i.e., signing off on baseline care plans, removing midline/picc catheters, and/or pronouncing a resident deceased ) could not be performed. In an interview on [DATE] at 1:46 p.m., the Administrator said it was the DON's responsibility to ensure she scheduled an RN for 8 consecutive hours every day but ultimately it was her responsibility the Administrator. The Administrator said the negative outcome of not having an RN work 8 consecutive hours every day could be that the tasks that only an RN could perform like administering certain medications and treatments would not be done. The Administrator said the facility had sufficient RNs to cover their 8 consecutive hours shift every day. Record review of the facility's Nursing Services-Registered Nurse (RN) policy dated [DATE] reflected: Policy: It is the intent of the facility to comply with Registered Nurse requirements as per Social Security Act 1919 and 1819. Policy Explanation and Compliance Guidelines: 1.the facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days a week. (The requirement for 8 consecutive hours of RN services can be met by any RN or multiple RNs.) The hours worked by the DON would be considered applicable towards the requirement. Record review of the facility's policy Nursing Services and Sufficient Staff dated [DATE] reflected: Policy: It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and obtain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The Facility's census, acuity, and diagnoses of the resident population will be considered based on the facility assessment. Policy Explanation and Compliance Guidelines: 8. Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident's drug regimen was free of unnecessary drugs for one (Resident #10) of five resident reviewed for medications. The facility failed to have an adequate indication for the use of the medication risperdal (Risperdone - an antipsychotic) for Resident #10. This failure could put residents at risk of harm from adverse reactions or harmful side effects. Findings included: Record review of Resident #10's face sheet dated 05/20/25 revealed an [AGE] year-old female with an original admission date of 07/27/12. Diagnoses included paraplegia (a condition characterized by the partial or complete loss of movement and sensation in the lower half of the body, specifically both legs), mood disorder (a serious mental illness that causes persistent and intense changes in a person ' s mood, energy, and behavior), and schizoaffective disorder (diagnosed when a person experiences symptoms of both schizophrenia and a mood disorder [like depression or mania] concurrently). Record Review of Resident #10's Quarterly MDS Assessment, dated 02/14/25, reflected her BIMS score was blank, which indicated the resident had severe cognitive impairment. She was always incontinent of bladder and bowel. Section I reflected Resident #10 had an active diagnosis of schizophrenia (e.g., schizoaffective disorder and schizophreniform disorders). She took antipsychotic and antidepressant medications. Record review of Resident #10's quarterly care plan dated 02/17/25 reflected: FOCUS: · I have schizophrenia, I receive Risperdal to help control my symptoms (mood changes, yelling) Date Initiated: 02/25/2024 Revision on: 02/25/2024 GOALS: · I will receive my ordered medications and be free of psychotropic drug related complications through review date. Date Initiated: 02/25/2024 Revision on: 05/18/2025 Target Date: 05/28/2025 INTERVENTIONS/TASKS: · Black Box Warning: Risperdal Warning: Increased mortality in elderly patients with dementia-related psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Risperidone is not approved for the treatment of patients with dementia-related psychosis. Date Initiated: 02/25/2024 LN · Monitor behaviors. Notify MD of new or worsening behaviors Date Initiated: 02/25/2024 LN SS · Monitor/document/report PRN any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Date Initiated: 02/25/2024 LN · Pharmacy consultant to review medications per facility policy Date Initiated: 02/25/2024 Revision on: 02/25/2024 LN. FOCUS: · I have a mood problem r/t Disease Process (SCHIZOPHRENIA) Date Initiated: 01/25/2025 Revision on: 01/25/2025 GOALS: · I will have improved mood state happier, calmer appearance, no s/sx of depression, anxiety or sadness through the review date. Date Initiated: 01/25/2025 Revision on: 05/18/2025 Target Date: 05/28/2025 INTERVENTIONS/TASKS: · Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 01/25/2025 LN RN · Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.) Date Initiated: 01/25/2025 LN RN · Monitor/record/report to MD prn acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/ eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills Date Initiated: 01/25/2025 LN RN · Monitor/record/report to MD prn mood patterns s/sx of depression, anxiety, sad mood. Date Initiated: 01/25/2025 LN RN · Monitor/record/report to MD prn risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons Date Initiated: 01/25/2025 CNA LN RN. Record review of physician ' s diagnosis on 08/22/24 reflected, Schizoaffective Disorder. Record review of Nursing - Psychoactive Medication Quarterly Evaluation dated 08/23/24, reflected Medical Diagnosis warranting use F25.1 Schizoaffective Disorder, Depressive Type. Record review of physician ' s order dated 08/23/24 reflected, risperDAL Oral Tablet 1 MG (Risperidone) Give 1 tablet by mouth at bedtime for schizophrenia. Attempted interview on 05/20/25 at 01:40 PM, with PCP for Resident #10 who diagnosed Resident #10 with schizoaffective disorder on 08/22/24. Answering service to pass on message to doctor to call surveyor. Attempted interview on 05/20/25 at 02:00 PM, with NP who signed consent for Risperdal 1 mg at bedtime for Resident #10 on 08/23/24. Receptionist will pass a message along for NP to call surveyor. Attempted interview on 05/20/25 at 02:28 PM, with Medical Director of the facility whose name was on the order for Resident #10's Risperdal 1 mg at bedtime. No answer. Voicemail left. In an interview on 05/20/25 at 02:55 PM, LVN A stated that the nurse who took the physician ' s order was the one who put it in PCC (residents' charts system). LVN A stated the orders are double checked by two nurses and the ADONs and DON. In an interview on 05/20/25 at 03:05 PM, the DON stated the nurse who gets the order was the one who put it in PCC. The DON stated all orders were double checked. She said if the wrong diagnosis was put on the order, it would be an inappropriate regimen. She said if the wrong diagnosis was care planned, the interventions may be inappropriate. In an interview on 05/20/25 at 03:53 PM, the DON notified surveyor that schizophrenia was in the medical diagnosis. Surveyor checked and schizophrenia was added on 05/20/25 under medical diagnosis. DON stated the NP's notes on 10/05/24, 01/27/25, and 05/01/25 had schizophrenia in the note for a diagnosis. In an interview on 05/20/25 at 04:07 PM, NP stated she signed the Antipsychotic Consent for Risperdal for Resident #10 for schizoaffective disorder. NP stated Resident's PCP diagnosed Resident with schizoaffective disorder on 08/22/24. NP stated three of her notes on 10/05/24, 01/27/25, and 05/01/25 had the diagnosis of schizophrenia. The original diagnosis of schizoaffective disorder was given by PCP and not NP. NP stated schizophrenia was not on the medical diagnosis on any other paperwork except hers and the order the nurse put in PCC. NP stated the diagnosis should be schizoaffective.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 resident (Resident #10) of 5 residents whose care plans were reviewed for accurate records. Resident #10 was diagnosed with schizoaffective disorder but parts of her medical record inaccurately indicated she had schizophrenia. This failure could place residents at risk of not receiving appropriate care to meet their current needs. Findings included: Record review of Resident #10's face sheet dated 05/20/25 revealed a [AGE] year-old female with an original admission date of 07/27/12. Diagnoses included paraplegia (a condition characterized by the partial or complete loss of movement and sensation in the lower half of the body, specifically both legs), mood disorder (a serious mental illness that causes persistent and intense changes in a person ' s mood, energy, and behavior), and schizoaffective disorder (diagnosed when a person experiences symptoms of both schizophrenia and a mood disorder [like depression or mania] concurrently). Record Review of Resident #10's Quarterly MDS Assessment, dated 02/14/25, reflected her BIMS score was blank, which indicated the resident had severe cognitive impairment. She was always incontinent of bladder and bowel. Record Review of Resident #10's quarterly care plan dated 02/17/25 reflected: FOCUS: · I have schizophrenia, I receive Risperdal to help control my symptoms (mood changes, yelling) Date Initiated: 02/25/2024 Revision on: 02/25/2024 GOALS: · I will receive my ordered medications and be free of psychotropic drug related complications through review date. Date Initiated: 02/25/2024 Revision on: 05/18/2025 Target Date: 05/28/2025 INTERVENTIONS/TASKS: · Black Box Warning: Risperdal Warning: Increased mortality in elderly patients with dementia-related psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Risperidone is not approved for the treatment of patients with dementia-related psychosis. Date Initiated: 02/25/2024 LN · Monitor behaviors. Notify MD of new or worsening behaviors Date Initiated: 02/25/2024 LN SS · Monitor/document/report PRN any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Date Initiated: 02/25/2024 LN · Pharmacy consultant to review medications per facility policy Date Initiated: 02/25/2024 Revision on: 02/25/2024 LN. FOCUS: I has a mood problem r/t Disease Process (SCHIZOPHRENIA) Date Initiated: 01/25/2025 Revision on: 01/25/2025 GOALS: ·I will have improved mood state happier, calmer appearance, no s/sx of depression, anxiety or sadness through the review date. Date Initiated: 01/25/2025 Revision on: 05/18/2025 Target Date: 05/28/2025 INTERVENTIONS/TASKS: ·Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 01/25/2025 LN RN · Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.) Date Initiated: 01/25/2025 LN RN · Monitor/record/report to MD prn acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/ eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills Date Initiated: 01/25/2025 LN RN ·Monitor/record/report to MD prn mood patterns s/sx of depression, anxiety, sad mood. Date Initiated: 01/25/2025 LN RN ·Monitor/record/report to MD prn risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons Date Initiated: 01/25/2025 CNA LN RN. Record review of PCP 's diagnosis on 08/22/24 reflected, Schizoaffective Disorder. Record review of Nursing - Psychoactive Medication Quarterly Evaluation dated 08/23/24, reflected Medical Diagnosis warranting use F25.1 Schizoaffective Disorder, Depressive Type. Record review of physician ' s orders dated 08/23/24 reflected, risperDAL Oral Tablet 1 MG (Risperidone) Give 1 tablet by mouth at bedtime for schizophrenia. In an interview on 05/20/25 at 03:53 PM, the DON notified surveyor that schizophrenia was in the medical diagnosis. Surveyor checked and schizophrenia was added on 05/20/25 under medical diagnosis. DON stated the NP's notes on 10/05/24, 01/27/25, and 05/01/25 have schizophrenia in the note for a diagnosis. In an interview on 05/20/25 at 04:07 PM, NP stated she signed the Antipsychotic Consent for Risperdal for Resident #10 for schizoaffective disorder. NP stated Resident's PCP diagnosed Resident with schizoaffective disorder on 08/22/24. NP stated three of her notes on 10/05/24, 01/27/25, and 05/01/25 had the diagnosis of schizophrenia. The original diagnosis of schizoaffective disorder was given by PCP and not NP. NP was notified schizophrenia was not on the medical diagnosis on any other paperwork except hers and the order the nurse put in PCC. NP stated the diagnosis should be schizoaffective.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activity professional for 61 of 61 residents. The facility did not have a qualified Activities Professional to direct their activities program. This deficient practice could affect any resident and could result in residents not receiving activities that were individualized to match the skills, abilities, and interests/preferences of each resident. The findings were: Record review on 05/20/25 at 10:30 a.m. of the facility's Administrative and other licensed professional staff Licensure audit revealed the current Activity Director was not certified. In an interview on 05/20/25 at 12:00 p.m., the HR Coordinator said the facility's Activity Director was not certified. In An interview on 05/20/25 at 12:38 p.m., the AD, said she had been hired as the Activity Director on 01/15/25. She said when she was hired, she was advised by the facility's Administrator she needed to enroll in an AD program within 6 months of being hired. She said she had no previous experience in being an AD. She said she had recently (not sure of date) submitted the required paperwork and fee to enroll in an online AD program. She said as of 05/20/25, she had not been officially enrolled. She said the program consisted of 180 hours to be completed at her own pace. In an interview on 05/20/25 at 1:30 a.m., the Administrator said the qualifications to be an Activity Director were to have their AD certificate or be an occupational therapist. She said the current AD started working at the facility on 01/15/25 and did not have the required qualifications. She said she, the current AD, had signed an agreement that stated she would enroll in and begin an AD program within 6 months of her hire date. She said it was her responsibility to ensure the AD had enrolled in an AD program within 6 months. The Administrator said during the morning meeting she had made it a point to ask the current AD on the status of her enrollment in an AD program. The Administrator said the facility did not have a policy on the requirements for an AD, only a job description. The Administrator said the current AD did not have any of the following state requirements: licensed or registered, eligible for certification as a therapeutic recreation specialist, or an activities professional by a recognized accrediting body on or after October 1, 1990, had 2 years of experience in a social or recreational program with the last 5 years, one of which was full-time in a therapeutic activities program; or was a qualified occupational therapist or occupational therapy assistant; or Had completed a training course approved by the state Record review of the written agreement signed on 01/20/25 by the Administrator and the current AD reflected: This agreement is made on [DATE]th, 2025, between facility and AD. AD is required to enroll in and begin an AD program within 6 months of this agreement. The deadline for enrollment is June 20th, 2025. Record review of the facility's job description for the job title of AD reflected: Education/Training Requirements: Bachelor's Degree in therapeutic recreation or equivalent training experience if preferred. Licensing Requirements: Certified Therapeutic Recreation Specialist (CTRS). Experience Requirements: Two years of experience in a social or recreational program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for medications. The facility failed to ensure nursing staff filled Resident #1's prescribed Acetaminophen-Codeine Tablet 300-30 MG. This failure could place residents at risk of not being adequately treated for pain and for receiving less than therapeutic benefits of their medication. Findings include: Record review of Resident #1's face sheet, dated 4/24/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included acquired absence of left leg below knee (a condition where an individual has had a surgical or traumatic removal, amputation, of part of the left leg below the knee joint), peripheral vascular disease (a condition that affects the blood vessels outside the heart and brain, primarily the arteries and veins, causing reduced blood flow to the limbs), type 2 diabetes mellitus with hyperglycemia (a chronic condition where the body either doesn't produce enough insulin or can't effectively use the insulin it does produce, leading to high blood sugar levels) and cellulitis of right lower limb (a bacterial skin infection that can cause redness, swelling, pain, and tenderness in the affected area.) Record review of Resident #1 care plan, dated 1/16/2025, revealed Resident #1 had risk for pain related to left below Knee Amputation. Resident #1 BIMS was 14. Record review of Resident #1's Medication Administration Record for February 2025, revealed Acetaminophen-Codeine Tablet 300-30 Milligrams, give 1 tablet by mouth every 6 hours for pain, and Resident #1 missed 3 doses (1 dose on 2/8/25 at 6:00 p.m. and 2 doses 2/9/25 at 12: a.m. and 6:00 a.m. During an interview on 4/23/2025 at 9:40 a.m., Resident #1 said he had in pain to his right lower extremity, he said he asked for his pain pill and LVN A went to give him a pill that did not looked like his pain medication.Resident #1 said that he got an oval shape pill and said his Tylenol #3 was a round shape pill. Resident #1 said he took the medication because he was in pain. Resident #1 said he asked LVN A three times if that pill was the Tylenol #3 he usually took, the resident said LVN A said yes the three times he asked her. Resident #1 said on 2/10/25 he filed a grievance and spoke the administrator. During a phone interview on 4/24/2025 at 2:54 p.m., LVN A revealed Resident #1 did not have a filled prescription for Acetaminophen-Codeine Tablet 300-30 MG. She also stated the resident had an active order for this medication as of 1/18/2025 and she was unsure why it had not been filled. LVN A said that the morning nurse had called the physician assistant asking for a refill. LVN A said she got a Tylenol 500mg and gave it to Resident #1. LVN said she went back to reassess Resident #1 and he was sleeping. LVN A said she signed off on the medication record the Acetaminophen-Codeine Tablet 300-30 MG by mistake. LVN A said she forgot to add the order for Tylenol 500mg to Resident #1's electronic medical record. LVN A explained she was very familiar with the resident. LVN A said she had a standing order from the physician for Tylenol 500mg but forgot to add it and signed off on the electronic medication administration chart of Resident #1. LVN A said she did not had access to the cubex (emergency medication supply system) and she did not inform anyone that Resident #1 was out of the Acetaminophen-Codeine Tablet 300-30 MG. LVN A said that she was supposed to call the DON or ADON. During an interview on 4/24/25 at 3:40 p.m., the physician assistant said he was familiar with Resident #1's chronic pain. The Physician assistant first stated Resident #1's pain was 9 out of 10 on the scale of 1 to 10, would not have subsided with one acetaminophen 500 milligram tablet, after further discussion he said he was not sure if it would have been enough because Resident #1 regularly complained of pain without signs of distress. During a phone interview on 4/24/25 at 4:00 p.m., the pharmacist stated the facility received a new Tylenol #3 blister pack for Resident #1 on 2/9/25 at 12:00 p.m. The Pharmacist said he received a call from the Physician Assistant for a refill on Acetaminophen-Codeine Tablet 300-30 MG. The Pharmacist said the blister pack was delivered on 2/9/25. During an interview on 4/28/25 at 9:50 a.m., RN B said he worked on 2/8/25 in the morning shift. RN B said the resident was not in pain and he gave the last pill of the Acetaminophen-Codeine Tablet 300-30 MG at 12:00 p.m. RN C said he contacted the Physician Assistant to ask him for a refill. RN B said on 2/5/25 he called the physician assistant and told him Resident #1 was running low on the Acetaminophen-Codeine Tablet 300-30 MG. RN B said all nurses knew there was medication available on the cubex for an emergency. RN B said the blister packs had a blue line and when the medication was low to that blue line, that meant it was time to reorder the medication from the pharmacy. During an interview on 4/28/2025 at 11:30 a.m., the DON said she was not aware about this incident with Resident #1 until 2/10/25 when Resident #1 filed a grievance. The DON said an investigation was initiated. The DON said nurses were trained on how to access the medications from the cubex and nurses knew to contact her or the ADON if the medication was not available on the cubex. The DON said the Physician assistant or the doctor had to call the pharmacy for the refill because this medication was a controlled medication, and the pharmacy needed a prescription for it. The DON said nurses did not know when the doctor was going to call the pharmacy, but she knew RN B called the physician assistant to informed him the resident was running low on the medication. The DON said the Acetaminophen-Codeine Tablet 300-30 MG was received at the facility on 2/9/25. The DON stated it was the facility's responsibility to ensure the resident had all of her ordered medications at the facility once the resident was transferred to long term care. The DON said when she spoke to the resident he was very upset because he felt LVN A lied about the medication he received. During an interview on 4/28/2025 at 12:00 p.m., the Administrator said Resident #1 spoke to her to file a grievance on 2/10/25. The Administrator said she started an investigation and spoke to LVN A and asked her what had happened, the Administrator said LVN A said to her she gave Resident #1 a Tylenol 500mg instead of Acetaminophen-Codeine Tablet 300-30 MG, because LVN A did not want for Resident #1 to get upset because it was not available. The Administrator said LVN A got a write up and was trained on how to access the cubex, medication administration and call supervisors when any medication was not available. Record review on 4/24/25 of Employee counseling report, dated 2/14/25, revealed LVN A statement documented I did tell patient it was a pain pill because i did not want to trigger an episode of patient getting upset and making a big issue of not having the narcotic available. I did not specify Tylenol just said pain pill. Record review of the facility's policy titled Controlled Substances Prescriptions, stated under section, Policy - before a controlled drug can be dispensed, the pharmacy must be in a receipt of a clear, complete, and signed written prescription from a person lawfully authorized to prescribed. A char order is not equivalent to a prescription for controlled drugs. Therefore the prescriber issuing the chart order must also provide the pharmacist with a valid prescription. The written prescription may be faxed to the pharmacy for long-term care facility residents. Record review of the facility's policy titled Pain Management stated under section, Policy: The facility must ensure that pain management is provided to residents who require such services,, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained for each resident that was complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for medication administration. The facility failed to ensure Resident #1's Medication Administration Record (MAR) reflected the administration of Tylenol (medication to treat pain) was accurately documented. This deficient practice could place residents at risk for less than therapeutic benefits and/or not receiving ordered medications. Findings include: Record review of Resident #1's face sheet, dated 4/24/25, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #1 had diagnoses which included acquired absence of left leg below knee (a condition where an individual has had a surgical or traumatic removal, amputation, of part of the left leg below the knee joint), peripheral vascular disease (a condition that affects the blood vessels outside the heart and brain, primarily the arteries and veins, causing reduced blood flow to the limbs), type 2 diabetes mellitus with hyperglycemia (a chronic condition where the body either doesn't produce enough insulin or can't effectively use the insulin it does produce, leading to high blood sugar levels), cellulitis of right lower limb (a bacterial skin infection that can cause redness, swelling, pain, and tenderness in the affected area.) Record review of Resident #1's Physician Orders, dated 4/24/25, revealed an order for Acetaminophen-Codeine Tablet 300-30 Milligrams, give 1 tablet by mouth every 6 hours as needed for pain. Record review of Resident #1's Medication Administration Record for February 2025, revealed Acetaminophen-Codeine Tablet 300-30 Milligrams, give 1 tablet by mouth every 6 hours for pain. Resident #1 missed 3 doses (1 dose on 2/8/25 at 6:00 p.m. and 2 doses 2/9/25 at 12: a.m. and 6:00 a.m. Record review of Resident #1 care plan, dated 1/16/2025, revealed Resident #1 had risk for pain related to left Below Knee Amputation. During an interview on 4/23/2025 at 9:40 a.m., Resident #1 said he had pain to his right lower extremity, he said he asked for his pain pill, and LVN A went to give him a pill that did not looked like his pain medication. Resident #1 said he took the medication because he was in pain. Resident #1 said he asked LVN A three times if that pill was the Tylenol #3 he usually took. The resident said LVN A said yes the three times he asked her. Resident #1 said on 2/10/25 he filed a grievance and spoke the administrator. Resident #1 said that the Tylenol 500 milligram that he took helped from a 9 on a scale from 1 to 10 to a 8. During a phone interview on 4/24/2025 at 2:54 p.m., LVN A revealed Resident #1 did not have a filled prescription for Acetaminophen-Codeine Tablet 300-30 MG. She also stated the resident had an active order for this medication as of 1/18/2025 and said she was unsure why it had not been filled. LVN A said that she got a Tylenol 500mg and gave it to Resident #1 LVN said that she went back to reassess Resident #1 and he was sleeping. LVN A said that she signed off on the medication record the Acetaminophen-Codeine Tablet 300-30 MG by mistake. LVN A said she forgot to add the order for Tylenol 500mg to Resident #1's electronic medical record. LVN A explained she was very familiar with the resident. LVN A said that she had a standing order from the physician for Tylenol 500mg but forgot to add it and signed off on the electronic medication administration chart of Resident #1. LVN A said that she did not had access to the cubex (emergency medication supply system) and that she did not inform anyone that Resident #1 was out of the Acetaminophen-Codeine Tablet 300-30 MG. During an interview on 4/24/25 at 3:40 pm, the physician assistant said that he was familiar with Resident #1 chronic pain. Physician assistant first stated Resident #1's pain 9 out of 10 on the scale 1 to 10 would not have subsided with one acetaminophen 500 milligram tablet, after further discussion he said that he was not sure if would have been enough because Resident #1 regularly complain of pain without signs of distress. During a phone interview on 4/24/25 at 4:00 pm the pharmacist verified that the facility received a new Tylenol #3 blister pack for Resident #1 on 2/9/25 at 12:00 pm. Pharmacist said that he received a call from Physician Assistant for a refill on Acetaminophen-Codeine Tablet 300-30 MG. pharmacist said the blister pack was delivered on 2/9/25. During an interview on 4/28/2025 at 11:30 a.m., the DON said she was not aware about this incident with Resident #1 until 2/10/25 when Resident #1 filed a grievance. DON said that an investigation was initiated. DON said that nurses were trained on how to access the medications from the cubex and nurses knew to contact her or the ADON if the medication was not available on the cubex. DON said that the Physician assistant or the doctor had to call the pharmacy for the refill because this medication was a controlled medication, and the pharmacy needed a prescription for it. DON said that nurses did not know when the doctor was going to call the pharmacy, but she knew RN B called the physician assistant to informed him resident was running low on the medication. DON said that the Acetaminophen-Codeine Tablet 300-30 MG was received at the facility on 2/9/25. The DON agreed that it was the facility's responsibility to ensure the resident had all of her ordered medications at the facility once the resident was transferred to long term care. DON said that when she spoke to resident he was very upset because he felt LVN A lied about the medication he got. The DON said LVN A should have documented giving the Tylenol 500mg on the electronic medication record. LVN A said that she forgot to input the order on Resident#1's medical administration record. During an interview on 4/28/2025 at 12:00 p.m. with the Administrator said that Resident #1 spoke to her to file a grievance on 2/10/25. The administrator said that she started an investigation and spoke to LVN A and asked her what had happened, the administrator said that LVN A said to her that she gave Resident #1 a Tylenol 500mg instead of Acetaminophen-Codeine Tablet 300-30 MG because LVN A did not wanted for Resident #1 to get upset because was not available. The administrator said that LVN A got a write up and was trained on how to access the cubex, medication administration and call supervisors when any medication was not available. Record review on 4/24/25 of Employee counseling report dated 2/14/25 revealed LVN A statement I did tell patient it was a pain pill because i did not want to trigger an episode of patient getting upset and making a big issue of not having the narcotic available. I did not specify Tylenol just said pain pill. Record review of the facility's policy titled Medication Administration, revealed: Medications are administered by a licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination of infection. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR.

**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 was provided with professional standards of practice for 1 of 3 residents (Resident #1) reviewed for oxygen in that: Resident #7's oxygen was administered at 4.0 Lpm instead of 2 Lpm via nasal cannula as ordered by physician. This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased qualify of care. The findings included: Record review of Resident #7's admission Record dated 03/26/24, revealed a [AGE] year old female, admitted to facility on 12/22/22. Her diagnosis included: Chronic obstructive pulmonary disease (COPD - a group of lung diseases that cause breathing difficulties and airflow blockage. COPD is a progressive disease that damages the lungs or airways, making it hard to breathe), and respiratory failure (a condition in which your blood does not have enough oxygen or has too much carbon dioxide). Record review of Resident #7's quarterly MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition. MDS Section O Special Treatments, Procedures, and Programs Respiratory Treatments was blank. Record review of Resident #7's Care Plan dated 03/22/24, revealed, FOCUS: I am at risk for respiratory distress due to sleep apnea, COPD, history of hypoxia/SOB. Date initiated: 01/10/23. INTERVENTIONS/TASKS: Black box warning (morphine). -Give medications as ordered by physician. Monitor/document side effects and effectiveness. Atropine sulfate (for excessive secretions), albuterol, Formoterol, Budesonide, ipratropium-albuterol, morphine (see pain care plan for black box warning) Date initiated: 09/28/23. -May suction secretions pre use of Yanker PRN Date initiated: 09/28/23. -Monitor for s/sx of respiratory distress and report to MD PRN: respirations, pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis (sweating), headaches, lethargy, confusion, atelectasis (partial or complete collapse of lung or section of a lung), hemoptysis (coughing up of blood or blood-tinged sputum from the lungs or tracheobronchial tree), cough, pleuritic (chest) pain, accessory muscle usage, skin color. -Oxygen/CPAP use as ordered. -Promote lung expansion and improve air exchange by positioning with proper body alignment. Date initiated: 09/28/23 . Record review of Resident #7's Order Summary dated 03/26/24 revealed: -Start date: 03/25/24 Oxygen at 2 LPM via NC (nasal cannula) continuously while in bed r/t hypoxia. Observation on 03/26/24 at 10:49 a.m., the signage on Resident #7's door read Oxygen In Use and the resident's O2 concentrator was set at 4 Lpm. In an interview on 03/26/24 at 11:19 a.m., LVN G, the day nurse for Resident #7, went into Resident #7's room and reset Resident #7's oxygen machine to 2 Lpm. LVN G stated when she checked the O2 setting earlier that morning (03/26/24), it was set on 2 Lpm. LVN G stated Resident #7 sometimes resets the O2 so they (the nurses) were continually monitoring it. LVN G stated it was not good for Resident #7 to be on 4 Lpm when the order was for 2 Lpm. She said the resident would be receiving too much oxygen if she were getting 4 Lpm and would become more short of breath. In an interview on 03/29/24 at 02:05 p.m., LVN B, 2-10 shift nurse for Resident #7, went into Resident #7's room and checked the O2 setting. LVN B stated she had caught Resident #7 moving the O2 level yesterday (03/28/24), setting it on 4 Lpm. LVN B stated she informed hospice and hospice stated it was ok for her to have it at 4 Lpm and they gave an order for 4 Lpm. LVN B stated the nurses check O2 setting against the doctor's order at the beginning of shift and she checks the O2 settings 2-3 times during her shift. She said yesterday (03/28/24) when she was checking O2 settings on her shift, is when she saw Resident #7 moving her O2 setting and she notified hospice. In an interview on 03/29/24 at 02:15 p.m., the DON stated O2 settings are checked by nurses every shift at least once a shift against the physician's order. The DON stated too little oxygen could cause hypoxia or the resident could become short of breath. The DON stated too much oxygen can over inflate the lungs. The facility did not provide a policy on Oxygen Administration.

Resident #38 FTag Initiation 03/29/24 09:42 AM Care Plan: • I receive antidepressant medication (Zoloft) r/t s/s of major depressive disorder- anxietyH •I will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. •Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. •Black Box Warning Zoloft Warning: Suicidality and antidepressant drugs Antidepressants increased the risk of suicidal thoughts and behavior in pediatric and young adult patients in short-term studies. Closely monitor all antidepressant-treated patients for clinical worsening, and for emergence of suicidal thoughts and behaviors. •Black Box Warning: Zoloft Warning: Suicidality and antidepressant drugs Antidepressants increased the risk of suicidal thoughts and behavior in pediatric and young adult patients in short-term studies. Closely monitor all antidepressant-treated patients for clinical worsening, and for emergence of suicidal thoughts and behaviors. •Monitor/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt loss, n/v, dry mouth, dry eyes • I receive antipsychotic medications (olanzapine) r/t history of bipolar disorder. •I will zero to minimal side effects of medication usage •Black Box Warning: olanzapine Warning: Increased mortality in elderly patients with dementia-related psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of 17 placebo-controlled trials (modal duration, 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients between 1.6 and 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was approximately 4.5%, compared with a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (eg, heart failure, sudden death) or infectious (eg, pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patient is not clear. Olanzapine is not approved for treatment of patients with dementia-related psychosis. •Monitor behaviors. Notify MD of new or worsening behaviors •Monitor/document/report PRN any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. •Obtain lab work as ordered and notify MD of results •Pharmacy consultant to review medications per policy

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 Resident (Resident #36) of 6 residents reviewed for medications in that: Resident #36 was administered Risperdal (antipsychotic medication) twice daily for vascular dementia. This failure could place residents on psychoactive medications at risk for adverse consequences such as impairment or decline of an individual's mental or physical condition. The findings were: Record review of Resident #36's admission Record dated 03/27/24, revealed a [AGE] year old male, admitted to facility on 01/15/24. His diagnosis included: Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), and dementia (a general term for a group of diseases that cause a loss of cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life). Record review of Resident #36's quarterly MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition. Record review of Resident #36's Care Plan dated 01/22/24, revealed, FOCUS: I received antipsychotic medications (Risperdal) r/t vascular dementia. Date initiated: 01/27/24. INTERVENTIONS/TASKS: - Monitor behaviors. Notify MD of new or worsening behaviors. Date initiated: 01/27/24 - Monitor/document/report PRN any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24 - Pharmacy consultant to monitor medications at least monthly. Date initiated: 01/27/24. Record review of Resident #36's Order Summary dated 03/29/24 revealed, Resident #36 had the following orders: Start date: 03/14/24 Risperdal Oral Tablet 0.5mg (Risperidone) Give 1 tablet by mouth two times a day for vascular dementia. (Risperidone is an antipsychotic used to treat schizophrenia, bipolar disorder, and irritability caused by autism) Record review of Resident #36's February 2024 and March 2024 MAR (Medication Administration Record) revealed, Risperdal 0.5mg tablet was administered twice a day from 02/01/24 through the morning dose on 03/29/24. In an interview on 03/29/24 at 02:05 p.m., LVN B stated there was not supposed to be an indication of Alzheimer's or Dementia for antipsychotics orders. She said there was usually a black box warning on the antipsychotic for Alzheimer's or Dementia residents receiving it. LVN B stated if she saw that (Alzheimer's or Dementia indication) on an order, she would call the physician or NP to clarify and notify of the order. In an interview on 03/29/24 at 02:15 p.m., the DON stated antipsychotics with a diagnosis of Alzheimer's or dementia was an improper diagnosis to put on an order with an antipsychotic. Attempted telephone interview on 03/29/24 at 04:07 p.m., with NP D, who prescribed Risperdal for Resident #36, related to dementia. Message stated office was closed for the holiday (Good Friday). No voicemail left. Attempted telephone interview on 03/29/24 at 04:08 p.m., with MD E concerning Risperdal 0.5mg tab twice daily prescribed to Resident #36 with an indication of vascular dementia. No answer. Voicemail left. No return call received. Record review of facility's policy Psychotropic Medication, date implemented 08/15/22, revealed, Policy Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s).

Observation and interview revealed the facility failed to provide a safe and functional environment for residents, staff, and the public in 1 of 4 resident rooms, and in 1 of 1 patio smoking area, observed for environmental conditions. 1. Cold water in Resident #38's bathroom was not functioning. 2. The facility failed to ensure the designated smoking area was free from cigarette butt trash. These failures could affect residents by placing them at risk for diminished quality of life due to no running cold water, the lack of a well-kept environment that could place residents at risk, resulting in an environment that is not safe, sanitary, or comfortable for residents, staff, and visitors. Findings included: 1.During an observation on 03/26/24 at 03:25 PM Resident # 38 had no running cold water in his bathroom. In an interview on 03/28/24 at 01:42 PM the Maintenance Director stated the water in Resident #38's bathroom was shut off for trouble shooting approximately for a few days due to the sink being clogged. The Maintenance Director stated he removed one of the hoses in Resident #38's bathroom to unclog the drain and forgot to turn the valve on when he was done with the repairs. The Maintenance Director stated every morning an Ambassador (an administrator assigned to a hall) does a hall walk through and check for functionality of water, call lights, etc. The Maintenance Director stated Resident's cold water in the bathroom was fixed on Tuesday, 3/26/24 and the ADON was the Ambassador to check for functionality of water on Resident #38's hall. In an interview on 03/28/24 at 01:50 PM the ADON stated she was the Ambassador assigned to Resident #38's hall to make sure equipment and water were functioning. The ADON stated she informed the Maintenance Director on Tuesday 3/26/24, that the cold water in Resident #38's bathroom was not running but only told the Maintenance Director verbally and did not input the work order into the facility's work order system. The ADON stated on Wednesday 3/27/24 when she checked the water in Resident #38's bathroom, it was working but could not remember if she turned on the hot or cold water at that time. The ADON stated she did not check the water in Resident # 38's room on 3/28/24 but knows she was supposed to as part of making sure the water was functioning properly as it was part of the Ambassadors duties. In an interview on 03/28/24 at 01:55 PM Resident # 38 stated he does not use the restroom and did not notice there was no running cold water in his bathroom. Resident #38 stated it did not affect him in any way. Resident #38 noted with a Foley catheter and above knee left leg amputation. On 03/29/24 at 12:47 PM the Administrator stated there was no policy on environment. 2.Observation on 03/29/24 at 1:42 p.m. revealed cigarette butts were found inside a trash can designated for trash only in the patio designated for smokers. The trash can did not have a functioning lid and was rusted on the inside as well as the outside. Several cigarette butts were also found in a planter pot. In an interview on 03/29/24 at 1:43 p.m. the Maintenance Director said the cigarette butts were not supposed to be thrown in either that trash can or the planter pot. He pointed towards the ashtray and trashcan that were designated for disposal of cigarette butts. The Maintenance Manager said that housekeeping was in charge of cleaning the patio. In an interview on 03/29/24 at 3:08 p.m. the Housekeeping Manager said her staff was responsible for cleaning the patio designated for resident who like to smoke. She said they clean the area every other day. She does not have a tracking log documented when it was cleaned or who cleaned the area, she said she designates a person to do the task. The Housekeeping Manager said the area should have been cleaned and does not know what happened, why it was not cleaned. She also said she would have it cleaned immediately and would have staff clean the area daily. In an interview on 03/29/24 at 4:19 p.m. the Administrator said cigarette butts should be thrown in the trashcans that are designated for cigarette butts. She said housekeeping staff is in charge of cleaning the designated smoking patio at least twice a week. She also said there is no check off list to document when it was done. The Administrator said t this issue was brought to her attention and that she is having the rusted trash can as well as the planter pot removed immediately. On 03/29/24 at 12:47 PM the Administrator stated there was no policy policy on environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 3 of 4 residents (Resident #36, Resident #7, and Resident #38) reviewed for resident rights, in that: 1.Resident #36 did not have a signed (by RP), dated consent for psychotropic medications (Risperdal, clonazepam, buspirone, fluvoxamine, or Wellbutrin XL ER) he received. 2.Resident #7 did not have signed (by RP), dated consents for psychotropic medications (clonazepam, buspirone, Seroquel, Paxil, and Trazadone) she received. 3.) The facility failed to ensure consent forms were properly completed or signed by a responsible party prior to administration of antipsychotic and anti-depressant medication for Resident #38. This failure could place residents who received psychoactive medications without informed consents and placed 33 additional residents who received psychoactive medications at risk of receiving treatments without informed consent. Findings include: 1.Record review of Resident #36's admission Record dated 03/27/24, revealed a [AGE] year old male, admitted to facility on 01/15/24. His diagnosis included: Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Dementia (a general term for a group of diseases that cause a loss of cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life), cerebral infarction (stroke), hypertension (high blood pressure), anxiety disorder, heart disease, and obsessive-compulsive disorder (a personality disorder characterized by excessive orderliness, perfectionism, attention to details, and a need for control in relating to others). Record review of Resident #36's quarterly MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition. Record review of Resident #36's Care Plan dated 01/22/24, revealed FOCUS: I receive antidepressant medication (fluvoxamine) r/t OCD. Date initiated: 01/27/2024 INTERVENTIONS/TASKS: - administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness q shift. Date initiated: 01/27/24 - Monitor/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, , withdrawal, decline in ADL ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, n/v (nausea/vomiting), dry mouth, dry eyes. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24 FOCUS: I received antipsychotic medications (Risperdal) r/t vascular dementia. Date initiated: 01/27/24 INTERVENTIONS/TASKS: - Monitor behaviors. Notify MD of new or worsening behaviors. Date initiated: 01/27/24 - Monitor/document/report PRN any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24 - Pharmacy consultant to monitor medications at least monthly. Date initiated: 01/27/24. FOCUS: I receive anti-anxiety medications (clonazepam, buspirone) r/t anxiety. Date initiated: 01/27/24 INTERVENTIONS/TASKS: Black box warning for clonazepam. -Monitor the resident for safety. The resident is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance and cognitive impairment that looks like dementia and increases risk of falls, broken hips, and legs. Date initiated: 01/27/24 - Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24. Record review of Resident #36's Order Summary dated 03/29/24 revealed, Resident #36 had the following orders: -Start date: 01/16/24 Fluvoxamine Maleate Oral Tablet 100mg (Fluvoxamine Maleate) Give 1 tablet by mouth one time a day for OCD (Fluvoxamine Maleate is a Selective Serotonin Uptake Inhibitor [SSRI] antidepressant). -Start date: 02/06/24 Buspirone HCl oral tablet 5mg (Buspirone HCl) Give 1 tablet by mouth two times a day for anxiety obsessive compulsive disorder (Buspirone is an anxiolytic for treatment of anxiety). Start date: 03/14/24 Clonazepam Oral tablet 0.5mg (Clonazepam) Give 1 tablet by mouth two times a day for anxiety/restlessness (Clonazepam is a benzodiazepine - sedative - that can treat seizures, panic disorder, and anxiety). Start date: 03/14/24 Risperdal Oral Tablet 0.5mg (Risperidone) Give 1 tablet by mouth two times a day for vascular dementia. (Risperidone is an antipsychotic used to treat schizophrenia, bipolar disorder, and irritability caused by autism). Start date: 03/14/24 Wellbutrin XL Oral Tablet Extended Release 24 Hour 150mg (Buproprion HCl) Give 1 tablet by mouth two times a day for smoking cessation aid. (Wellbutrin is an antidepressant and smoking cessation aid). Start date: 03/14/24 Memantine HCl Oral Tablet 10mg (Memantine HCl) Give 1 tablet two times a day for dementia. (Memantine HCl is used to treat moderate to severe confusion [dementia] related to Alzheimer's Disease). Record review of 02/01/2024 to 02/29/2024 Pharmacy Recommendations revealed, on 02/29/24 Pharmacist wrote under Resident #36, Please ensure the state required standardized informed consent for antipsychotics is placed on residents chart for risperidone. No consents for Fluvoxamine, Bupropion HCl, Clonazepam or Wellbutrin. Consent for Risperdal was signed by resident and not RP. Consent was not dated. Record review of Resident #36's February 2024 MAR and March 2024 MAR revealed: Fluvoxamine 100mg tablet was administered one time a day from 02/01/24 - 02/29/24, and 03/01/24 - 03/29/24. Buspirone HCl 5mg tablet was administered twice a day from 02/01/24 - 02/29/24, and 03/01/24 - 03/29/24. MAR was printed the morning of 03/29/24 so only the morning dose shows as given on 03/29/24. Clonazepam 0.5mg tablet was administered twice a day 02/01/24 - 02/16/24. Morning dose on 02/17/24 was administered. The evening dose on 02/17/24 was not checked off. Clonazepam 0.5mg tablet was administered 03/18/24 - morning dose on 03/29/24. Risperdal 0.5mg tablet was administered twice a day from 02/01/24 through the morning dose on 03/29/24. Wellbutrin XL Extended Release 24 Hour 150mg tablet was administered twice a day from 02/01/24 through the morning dose on 03/29/24. 2.Record review of Resident #7's admission Record dated 03/26/24, revealed a [AGE] year old female, admitted to facility on 12/22/22. Her diagnosis included: Chronic obstructive pulmonary disease (COPD - a group of lung diseases that cause breathing difficulties and airflow blockage. COPD is a progressive disease that damages the lungs or airways, making it hard to breathe), respiratory failure (a condition in which your blood does not have enough oxygen or has too much carbon dioxide), hypertension (high blood pressure), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings,, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and epilepsy (a chronic brain disease that causes recurrent seizures, which are brief episodes of involuntary movement. Seizures are caused by excessive electrical activity in the brain which can affect how it works temporarily). Record review of Resident #7's quarterly MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition. Record review of Resident #7's Care Plan dated 03/22/24, revealed, FOCUS: I am receiving anti-anxiety medication (clonazepam, buspirone) r/t anxiety disorder. INTERVENTIONS/TASKS: Black box warning for clonazepam. -Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness q shift. Date initiated: 01/10/23. -Monitor the resident for safety. The resident is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance and cognitive impairment that looks like dementia and increases risk of falls, broken hips, and legs. Date initiated: 01/10/23 - Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Date initiated: 01/10/23 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/10/23. FOCUS: I am receiving antidepression medication (trazadone) r/t insomnia. Date initiated: 01/10/23. INTERVENTIONS/TASKS: Black box warning trazadone. -Administer medications as ordered by physician. Monitor for side effects and effectiveness q shift. Date initiated: 01/10/23. -Evaluate other factors potentially causing insomnia, for example, environment (excessive heat, cold or noise), lighting, inadequate physical activity, facility routines, caffeine/medications. Attempt to modify and control these external factors before initiating hypnotic therapy. Date initiated: 01/10/23. -Monitor/document/report PRN for following adverse effects of sedative/hypnotic therapy: daytime drowsiness, confusion, loss of appetite in the morning, increased risk for falls and fractures, dizziness. Date initiated: 01/10/23. -Precede or accompany hypnotic use by other interventions to try to improve sleep. Date initiated: 01/10/23. FOCUS: I have major depression and I am receiving antidepression medication (Paxil). Date initiated: 11/29/23. INTERVENTIONS/TASKS: - administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness q shift. Date initiated: 11/29/23 -educate resident/family/caregivers about risks, benefits and side effects and/or toxic symptoms as needed. Date initiated: 11/29/23 - Monitor/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, , withdrawal, decline in ADL ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, n/v (nausea/vomiting), dry mouth, dry eyes. Date initiated: 11/29/23. FOCUS: I am receiving antipsychotic medication (Seroquel) r/t schizophrenia. Date initiated: 01/10/23. INTERVENTIONS/TASKS: Black box warning. -Discuss side effects of medications with resident/RP as needed. Date initiated: 01/10/23. -Monitor behaviors. Notify MD of new or worsening behaviors. Date initiated: 01/10/23. -Monitor vital signs as ordered by MD and PRN. Date initiated: 01/10/23. FOCUS: I am at risk for respiratory distress due to sleep apnea, COPD, history of hypoxia/SOB. Date initiated: 01/10/23. INTERVENTIONS/TASKS: Black box warning (morphine). -Give medications as ordered by physician. Monitor/document side effects and effectiveness. Atropine sulfate (for excessive secretions), albuterol, Formoterol, Budesonide, ipratropium-albuterol, morphine (see pain care plan for black box warning) Date initiated: 09/28/23. -May suction secretions pre use of Yanker PRN Date initiated: 09/28/23. -Monitor for s/sx of respiratory distress and report to MD PRN: respirations, pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis (sweating), headaches, lethargy, confusion, atelectasis (partial or complete collapse of lung or section of a lung), hemoptysis (coughing up of blood or blood-tinged sputum from the lungs or tracheobronchial tree), cough, pleuritic (chest) pain, accessory muscle usage, skin color. -Oxygen/CPAP use as ordered. - Promote lung expansion and improve air exchange by positioning with proper body alignment. Date initiated: 09/28/23 Record review of Resident #7's Order Summary dated 03/26/24 revealed, Resident #7 had the following orders: -Start date: 03/26/23 Buspirone HCl oral tablet 10mg (Buspirone HCl) Give 1 tablet by mouth three times a day related to anxiety disorder (Buspirone is an anxiolytic for treatment of anxiety). -Start date: 09/26/23 Clonazepam Oral tablet 0.5mg (Clonazepam) Give 1 tablet by mouth every 8 hours related to anxiety disorder (Clonazepam is a benzodiazepine - sedative - that can treat seizures, panic disorder, and anxiety). -Start date: 10/06/23 Seroquel Oral Tablet 100mg (Quetiapine Fumarate) Give 1 tablet three times a day related to anxiety disorder (Seroquel is an antipsychotic medication) -Start date: 11/28/23 Paxil Oral Tablet 20mg (Paroxetine HCl) Give 1 tablet by mouth one time a day related to major depressive disorder, single episode, anxiety disorder. (Paxil is used to treat depression and anxiety. It is a SSRI.) -Start date: 12/14/23 Trazadone HCl Oral Tablet 100mg (Trazadone HCl) Give 1 tablet by mouth three times a day related to anxiety disorder (Trazadone is an antidepressant and sedative) -Start date: 03/25/24 Oxygen at 2 LPM via NC (nasal cannula) continuously while in bed r/t hypoxia. Record review of Resident #7's February 2024 MAR and March 2024 MAR revealed: -Buspirone HCl 10mg tablet was administered three times a day from 02/01/24 - 03/29/24. MAR was printed the morning of 03/29/24 so only the morning dose shows as given on 03/29/24. -Clonazepam 0.5mg tablet was administered every 8 hours 02/01/24 - 03/28/24 at midnight, 08:00 a.m., and 04:00 p.m. Clonazepam 0.5mg tablet was administered at midnight and 08:00 a.m. on 03/29/24. - Seroquel 100mg tablet was administered three times a day from 02/01/24 - 02/28/24. On 03/29/24, Resident #7 received the first two administrations of Seroquel 100mg tablet. - Paxil 20mg tablet was administered one time a day from 02/01/24 - 03/29/24. -Trazadone HCl 100mg tablet was administered three times a day from 02/01/24 - 03/28/24. Trazadone HCl 100mg was administered at midnight and 08:00 a.m. on 03/29/24, pending the 05:00 p.m. dose. Record review of psychotropic consent forms for Buspirone HCL 10mg tablet, Clonazepam 0.5mg tablet, Seroquel 100mg tablet, Paxil 20mg tablet, and Trazadone HCl 100mg tablet were signed by Resident #7 and not by Resident #7's RP and consents were undated. There was no consent form for clonazepam 0.5mg tablet. 3.) Record review of Resident #38's face sheet dated 3/28/2024 reflected a [AGE] year-old male with an admission date of 10/16/2023. Diagnoses included bi-polar disorder (mental illness characterized by extreme mood swings), and major depressive disorder (mental disorder characterized by pervasive low mood, low self-esteem, and loss of interest in normal enjoyable activities). Record Review of Resident #38's physician orders indicated: 1.) Olanzapine Oral Tablet 2.5 MG Give 1 tablet by mouth two times a day for bipolar disorder. Dated:1/26/2024 2.) Zoloft Oral Tablet 50 MG (Sertraline HCl) Give 1 tablet by mouth at bedtime for depression. Dated: 1/26/2024 21:00 Record review of Resident #38's care plan dated 11/04/2023 reflected Resident #38 may be physically and verbally aggressive at times due to multiple problems including dementia, bipolar disorder, and major depression. Resident #38 was to be administered medications Olanzapine as ordered. Monitor/document for side effects and effectiveness. Resident #38 did receive antidepressant medication Zoloft r/t s/s of major depressive disorder anxiety. Record review of Resident #38's MDS dated [DATE] indicated a BIM score of 00 (severe cognitive impairment) and the use of antipsychotic and antidepressant medications. No behaviors were indicated. Record review of Resident #38's clinical record revealed there was no consent form for the medication Zoloft and the consent form for Olanzapine did not have the medication name on the form, was not dated, and was signed by the resident who had a responsible party and was cognitively unable to sign the consent form. In an interview on 03/28/24 at 12:00 p.m., the DON stated there was a binder at the nurse's station with the consents. The DON stated they were not on PCC (electronic charting system) under miscellaneous. Observation on 03/28/24 at 01:30 p.m., revealed 35 residents consents undated and some were not signed by the RP. Resident #36 and Resident #7 signed their consent even though they had an RP and were not their own RP. Resident #7 did not have a consent for Clonazepam. Resident #36 did not have a consent for Fluvoxamine, Bupropion HCl, Clonazepam or Wellbutrin. Resident #38 did not have a consent form for the medication Zoloft and the consent form for Olanzapine did not have the medication name on the form, was not dated, and was signed by the resident who had a responsible party and was cognitively unable to sign the consent form. In a phone interview on 03/28/24 at 02:35 p.m., Resident #38's RP stated she could not remember if she signed a consent form for Resident #38's antipsychotic or anti-depressant but does not believe she signed anything for medications. The RP stated she knew Resident #38 did display mood swings and figured he would be taking some kind of medication for the mood swings but could not remember if she signed anything giving consent. In an interview on 03/29/24 at 02:05 p.m., LVN B stated the nurse who gets the order for psychotropics or antipsychotics, was the person who would get the consent (signed and dated), notified the RP and would get their approval (consent) for the medication. LVN B stated RPs gave consent or they do not. LVN B stated the consent form was always dated. LVN B stated she made a progress note concerning getting approval for the medication and then she would put the consent in the tray at the nurse's station for MDS to scan into PCC under miscellaneous. In an interview on 03/29/24 at 02:14 PM the DON stated, yes there is supposed to be a consent form for appropriate usage for the medication. The DON stated the consent form could have been overlooked or misplaced for the medication Zoloft for Resident #38, but could not confirm. The DON stated consent form audits were conducted monthly by herself and the ADON but was now going to be started weekly. The DON stated if a resident was cognitively aware, that resident was able to sign his or her consent form. The DON stated that if a resident does have a responsible party, then the responsible party should have been the one to sign the consent form. The DON stated that possible negative outcomes could be the resident could have symptoms from the medication and the family or RP being unaware of what medications that resident was being administered. The DON stated there was no policy for consent forms. Resident #47 FTag Initiation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 of 10 residents (Resident #38, Resident #36, and Resident #7) reviewed for pharmacy services. 1.) The facility failed to ensure consent forms were properly completed or signed by a responsible party prior to administration of antipsychotic and anti-depressant medication. This failure could affect all residents who require a consent form for medications at risk for lack of proper assessment when their medications are administered. Findings included: 1.Record review of Resident #38's face sheet dated 3/28/2024 reflected a [AGE] year-old male with an admission date of 10/16/2023. Diagnoses included bi-polar disorder (mental illness characterized by extreme mood swings), ) and major depressive disorder (mental disorder characterized by pervasive low mood, low self-esteem, and loss of interest in normal enjoyable activities), transient ischemic attack (mini stroke caused by a brief blockage of blood flow to the brain), and cerebral infarction (stroke caused by blood supply to the brain is blocked or reduced causing death to the brain tissue.). Record review of Resident #38's MDS dated [DATE] reflected a BIM score of 00 (severe cognitive impairment). Record Review of Resident #38's physician orders indicated: 1.) Olanzapine Oral Tablet 2.5 MG Give 1 tablet by mouth two times a day for bipolar disorder. Dated:1/26/2024 2.) Zoloft Oral Tablet 50 MG (Sertraline HCl) Give 1 tablet by mouth at bedtime for depression. Dated: 1/26/2024 21:00 Record review of Resident #38's care plan dated 11/04/2023 reflected Resident #38 may be physically and verbally aggressive at times due to multiple problems including dementia, bipolar disorder, and major depression. Resident #38 was to be administered medications Olanzapine as ordered. Monitor/document for side effects and effectiveness. Resident #38 did receive antidepressant medication Zoloft r/t s/s of major depressive disorder anxiety. Record review of Resident #38's MDS dated [DATE] reflected a BIM score of 00 (severe cognitive impairment). Record review on 3/28/24 at 1:15pmof Resident #38's clinical record revealed there was no consent form for the medication Zoloft. The and the consent form for Olanzapine did not have the medication name on the form, was not dated, and was signed by the resident who has had a responsible party and was cognitively unable to sign the consent form. 2.Record review of Resident #36's admission Record dated 03/27/24, revealed a [AGE] year old male, admitted to facility on 01/15/24. His diagnosis included: Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Dementia (a general term for a group of diseases that cause a loss of cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life), cerebral infarction (stroke), hypertension (high blood pressure), anxiety disorder, heart disease, and obsessive-compulsive disorder (a personality disorder characterized by excessive orderliness, perfectionism, attention to details, and a need for control in relating to others). Record review of Resident #36's quarterly MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition. Record review of Resident #36's Care Plan dated 01/22/24, revealed FOCUS: I receive antidepressant medication (fluvoxamine) r/t OCD. Date initiated: 01/27/2024 INTERVENTIONS/TASKS: - administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness q shift. Date initiated: 01/27/24 - Monitor/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, , withdrawal, decline in ADL ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, n/v (nausea/vomiting), dry mouth, dry eyes. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24 FOCUS: I received antipsychotic medications (Risperdal) r/t vascular dementia. Date initiated: 01/27/24 INTERVENTIONS/TASKS: - Monitor behaviors. Notify MD of new or worsening behaviors. Date initiated: 01/27/24 - Monitor/document/report PRN any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24 - Pharmacy consultant to monitor medications at least monthly. Date initiated: 01/27/24. FOCUS: I receive anti-anxiety medications (clonazepam, buspirone) r/t anxiety. Date initiated: 01/27/24 INTERVENTIONS/TASKS: Black box warning for clonazepam. -Monitor the resident for safety. The resident is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance and cognitive impairment that looks like dementia and increases risk of falls, broken hips, and legs. Date initiated: 01/27/24 - Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24. Record review of Resident #36's Order Summary dated 03/29/24 revealed, Resident #36 had the following orders: -Start date: 01/16/24 Fluvoxamine Maleate Oral Tablet 100mg (Fluvoxamine Maleate) Give 1 tablet by mouth one time a day for OCD (Fluvoxamine Maleate is a Selective Serotonin Uptake Inhibitor [SSRI] antidepressant). -Start date: 02/06/24 Buspirone HCl oral tablet 5mg (Buspirone HCl) Give 1 tablet by mouth two times a day for anxiety obsessive compulsive disorder (Buspirone is an anxiolytic for treatment of anxiety). Start date: 03/14/24 Clonazepam Oral tablet 0.5mg (Clonazepam) Give 1 tablet by mouth two times a day for anxiety/restlessness (Clonazepam is a benzodiazepine - sedative - that can treat seizures, panic disorder, and anxiety). Start date: 03/14/24 Risperdal Oral Tablet 0.5mg (Risperidone) Give 1 tablet by mouth two times a day for vascular dementia. (Risperidone is an antipsychotic used to treat schizophrenia, bipolar disorder, and irritability caused by autism). Start date: 03/14/24 Wellbutrin XL Oral Tablet Extended Release 24 Hour 150mg (Buproprion HCl) Give 1 tablet by mouth two times a day for smoking cessation aid. (Wellbutrin is an antidepressant and smoking cessation aid). Start date: 03/14/24 Memantine HCl Oral Tablet 10mg (Memantine HCl) Give 1 tablet two times a day for dementia. (Memantine HCl is used to treat moderate to severe confusion [dementia] related to Alzheimer's Disease). Record review of 02/01/2024 to 02/29/2024 Pharmacy Recommendations revealed, on 02/29/24 Pharmacist wrote under Resident #36, Please ensure the state required standardized informed consent for antipsychotics is placed on residents chart for risperidone. No consents for Fluvoxamine, Bupropion HCl, Clonazepam or Wellbutrin. Consent for Risperdal was signed by resident and not RP. Consent was not dated. Record review of Resident #36's February 2024 MAR and March 2024 MAR revealed: Fluvoxamine 100mg tablet was administered one time a day from 02/01/24 - 02/29/24, and 03/01/24 - 03/29/24. Buspirone HCl 5mg tablet was administered twice a day from 02/01/24 - 02/29/24, and 03/01/24 - 03/29/24. MAR was printed the morning of 03/29/24 so only the morning dose shows as given on 03/29/24. Clonazepam 0.5mg tablet was administered twice a day 02/01/24 - 02/16/24. Morning dose on 02/17/24 was administered. The evening dose on 02/17/24 was not checked off. Clonazepam 0.5mg tablet was administered 03/18/24 - morning dose on 03/29/24. Risperdal 0.5mg tablet was administered twice a day from 02/01/24 through the morning dose on 03/29/24. Wellbutrin XL Extended Release 24 Hour 150mg tablet was administered twice a day from 02/01/24 through the morning dose on 03/29/24. 3.Record review of Resident #7's admission Record dated 03/26/24, revealed a [AGE] year old female, admitted to facility on 12/22/22. Her diagnosis included: Chronic obstructive pulmonary disease (COPD - a group of lung diseases that cause breathing difficulties and airflow blockage. COPD is a progressive disease that damages the lungs or airways, making it hard to breathe), respiratory failure (a condition in which your blood does not have enough oxygen or has too much carbon dioxide), hypertension (high blood pressure), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings,, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and epilepsy (a chronic brain disease that causes recurrent seizures, which are brief episodes of involuntary movement. Seizures are caused by excessive electrical activity in the brain which can affect how it works temporarily). Record review of Resident #7's quarterly MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition. Record review of Resident #7's Care Plan dated 03/22/24, revealed, FOCUS: I am receiving anti-anxiety medication (clonazepam, buspirone) r/t anxiety disorder. INTERVENTIONS/TASKS: Black box warning for clonazepam. -Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness q shift. Date initiated: 01/10/23. -Monitor the resident for safety. The resident is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance and cognitive impairment that looks like dementia and increases risk of falls, broken hips, and legs. Date initiated: 01/10/23 - Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Date initiated: 01/10/23 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/10/23. FOCUS: I am receiving antidepression medication (trazadone) r/t insomnia. Date initiated: 01/10/23. INTERVENTIONS/TASKS: Black box warning trazadone. -Administer medications as ordered by physician. Monitor for side effects and effectiveness q shift. Date initiated: 01/10/23. -Evaluate other factors potentially causing insomnia, for example, environment (excessive heat, cold or noise), lighting, inadequate physical activity, facility routines, caffeine/medications. Attempt to modify and control these external factors before initiating hypnotic therapy. Date initiated: 01/10/23. -Monitor/document/report PRN for following adverse effects of sedative/hypnotic therapy: daytime drowsiness, confusion, loss of appetite in the morning, increased risk for falls and fractures, dizziness. Date initiated: 01/10/23. -Precede or accompany hypnotic use by other interventions to try to improve sleep. Date initiated: 01/10/23. FOCUS: I have major depression and I am receiving antidepression medication (Paxil). Date initiated: 11/29/23. INTERVENTIONS/TASKS: - administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness q shift. Date initiated: 11/29/23 -educate resident/family/caregivers about risks, benefits and side effects and/or toxic symptoms as needed. Date initiated: 11/29/23 - Monitor/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, , withdrawal, decline in ADL ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, n/v (nausea/vomiting), dry mouth, dry eyes. Date initiated: 11/29/23. FOCUS: I am receiving antipsychotic medication (Seroquel) r/t schizophrenia. Date initiated: 01/10/23. INTERVENTIONS/TASKS: Black box warning. -Discuss side effects of medications with resident/RP as needed. Date initiated: 01/10/23. -Monitor behaviors. Notify MD of new or worsening behaviors. Date initiated: 01/10/23. -Monitor vital signs as ordered by MD and PRN. Date initiated: 01/10/23. FOCUS: I am at risk for respiratory distress due to sleep apnea, COPD, history of hypoxia/SOB. Date initiated: 01/10/23. INTERVENTIONS/TASKS: Black box warning (morphine). -Give medications as ordered by physician. Monitor/document side effects and effectiveness. Atropine sulfate (for excessive secretions), albuterol, Formoterol, Budesonide, ipratropium-albuterol, morphine (see pain care plan for black box warning) Date initiated: 09/28/23. -May suction secretions pre use of Yanker PRN Date initiated: 09/28/23. -Monitor for s/sx of respiratory distress and report to MD PRN: respirations, pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis (sweating), headaches, lethargy, confusion, atelectasis (partial or complete collapse of lung or section of a lung), hemoptysis (coughing up of blood or blood-tinged sputum from the lungs or tracheobronchial tree), cough, pleuritic (chest) pain, accessory muscle usage, skin color. -Oxygen/CPAP use as ordered. - Promote lung expansion and improve air exchange by positioning with proper body alignment. Date initiated: 09/28/23 Record review of Resident #7's Order Summary dated 03/26/24 revealed, Resident #7 had the following orders: -Start date: 03/26/23 Buspirone HCl oral tablet 10mg (Buspirone HCl) Give 1 tablet by mouth three times a day related to anxiety disorder (Buspirone is an anxiolytic for treatment of anxiety). -Start date: 09/26/23 Clonazepam Oral tablet 0.5mg (Clonazepam) Give 1 tablet by mouth every 8 hours related to anxiety disorder (Clonazepam is a benzodiazepine - sedative - that can treat seizures, panic disorder, and anxiety). -Start date: 10/06/23 Seroquel Oral Tablet 100mg (Quetiapine Fumarate) Give 1 tablet three times a day related to anxiety disorder (Seroquel is an antipsychotic medication) -Start date: 11/28/23 Paxil Oral Tablet 20mg (Paroxetine HCl) Give 1 tablet by mouth one time a day related to major depressive disorder, single episode, anxiety disorder. (Paxil is used to treat depression and anxiety. It is a SSRI.) -Start date: 12/14/23 Trazadone HCl Oral Tablet 100mg (Trazadone HCl) Give 1 tablet by mouth three times a day related to anxiety disorder (Trazadone is an antidepressant and sedative) -Start date: 03/25/24 Oxygen at 2 LPM via NC (nasal cannula) continuously while in bed r/t hypoxia. Record review of Resident #7's February 2024 MAR and March 2024 MAR revealed: -Buspirone HCl 10mg tablet was administered three times a day from 02/01/24 - 03/29/24. MAR was printed the morning of 03/29/24 so only the morning dose shows as given on 03/29/24. -Clonazepam 0.5mg tablet was administered every 8 hours 02/01/24 - 03/28/24 at midnight, 08:00 a.m., and 04:00 p.m. Clonazepam 0.5mg tablet was administered at midnight and 08:00 a.m. on 03/29/24. - Seroquel 100mg tablet was administered three times a day from 02/01/24 - 02/28/24. On 03/29/24, Resident #7 received the first two administrations of Seroquel 100mg tablet. - Paxil 20mg tablet was administered one time a day from 02/01/24 - 03/29/24. -Trazadone HCl 100mg tablet was administered three times a day from 02/01/24 - 03/28/24. Trazadone HCl 100mg was administered at midnight and 08:00 a.m. on 03/29/24, pending the 05:00 p.m. dose. Record review of psychotropic consent forms for Buspirone HCL 10mg tablet, Clonazepam 0.5mg tablet, Seroquel 100mg tablet, Paxil 20mg tablet, and Trazadone HCl 100mg tablet were signed by Resident #7 and not by Resident #7's RP and consents were undated. There was no consent form for clonazepam 0.5mg tablet. In a phone interview on 03/28/24 at 02:35 PM Resident #38s RP stated she could not remember if she signed a consent form for Resident #38's antipsychotic or anti-depressant but does not believe she signed anything for medications. The RP stated she knew Resident #38 did display mood swings and figured he would be taking some kind of medication for the mood swings but could not remember if she signed anything giving consent. In an interview on 03/29/24 at 02:14 PM the DON stated, yes there is supposed to be a consent form for appropriate usage for the medication. The DON stated the consent form could have been overlooked or misplaced for the medication Zoloft but could not confirm. The DON stated consent form audits were conducted monthly by herself and the ADON but was now going to be started weekly. The DON stated if a resident was cognitively aware, that resident was able to sign his or her consent form. The DON stated that if a resident does have a responsible party, then the responsible party should have been the one to sign the consent form. The DON stated that the RP for Resident #38 was made aware of the medications Resident #38 was taking but was only told verbally. The DON stated that possible negative outcomes could be the resident could have symptoms from the medication and the family or RP being unaware of what medications that resident was being administered. The DON stated there was no policy for consent forms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for two of 10 Residents (Resident #219 and Resident #15) that were reviewed for infection control and transmission-based precautions policies and practices, in that: 1. LVN A did not change gloves after cross-contamination by touching Resident #219's remote prior to glucose check and did not change gloves and perform hand prior to insulin administration. 2. The facility did not place contact precautions signage outside Resident #15's when there was an order for Resident #15 to be in isolation due to an infection. 3. Housekeeping C failed to don PPE (Personal Protection Equipment) before he entered Resident #15's room. 4. The facility failed to have biohazard bin or soiled laundry bin in Resident #15's room to dispose of PPE and soiled linen before leaving room. These failures could place residents at risk for infection through cross-contamination of pathogens and infectious diseases. The findings include: 1.Record review of Resident #219's face sheet date 03/2/24 reflected a [AGE] year-old-woman with an admission date of 03/22/24. Diagnosis included type two diabetes (insufficient insulin production of the body). Record review of Resident #219's MDS dated [DATE] reflected a BIM score of 4 (severe cognitive impairment. Record review of Resident #219's physician orders dated 03/26/24 indicated the resident received Novolog Injection Solution per Sliding scale. During a medication administration observation on 03/28/24 at 11:41 AM LVN A performed hand hygiene, put on gloves, grabbed Resident #219's remote with gloved hands, and proceeded to check Resident #219's blood sugar with the glucose monitor without removing contaminated gloves. LVN A then grabbed Resident #219's insulin and administered the medication with the same gloves used to touch Resident #219's remote and blood glucose check. In an interview on 03/28/24 at 11:41 AM LVNA stated after touching Resident #219's remote, she should have removed her gloves, performed hand hygiene, and put on new gloves prior to checking Resident #219's blood glucose. LVN A stated she was nervous and should have removed gloves, preformed hand hygiene, and put on new gloves prior to giving Resident #219's insulin injection. LVN A stated in-service on infection control was about two weeks ago. LVN A stated if the object touched by a gloved hand had bodily fluids or bacteria, it could lead to an infection by cross contamination. In an interview on 03/29/24 at 10:10 AM the DON stated changing gloves after glove contamination was done to prevent the spread of infection which could potentially cause cross harm to the resident. The DON stated LVN A should have changed gloves after touching Resident #219's remote and after checking Resident 219's blood glucose. The DON stated last in-service on infection control and hand hygiene was about two weeks ago but is ongoing as staff are reminded daily about hand hygiene. 2. Record review of Resident #15's admission Record dated 03/28/24, revealed a [AGE] year old male, admitted to facility on 07/03/23. His diagnoses included, urinary tract infection, brain cancer, dementia (general term for a group of diseases that cause a loss of cognitive functioning, such as thinking, remembering, and reasoning), hypertension (high blood pressure), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), Parkinsonism (a disorder of the central nervous system that affects movement, often including tremors), heart failure, paraplegia (a chronic condition that causes partial or complete paralysis of the lower half of the body). Record review of Resident #15's 02/21/24 Significant Change of status MDS revealed BIMS 09 (moderate cognitive impairment). Record review of Resident #15's 02/27/24 Care Plan revealed: FOCUS: Resident has infection of the (specify). Date initiated: 03/21/24. INTERVENTIONS/TASKS: -Administer antibiotic as per MD orders. Date initiated: 03/21/24 -Administer antipyretic as per MD orders. Date initiated: 03/21/24 -Follow facility policy and procedures for line listing, summarizing, and reporting of infections. Date initiated: 03/21/24. -Maintain universal precautions when providing resident care. Date initiated: 03/21/24. -Provide independent or 1:1 activities as tolerated by the resident. Reduce exposure to other residents while infection is active. Date initiated: 03/21/24. Record review of Resident #15's Order Summary dated 03/28/24 revealed: Orders dated 03/21/24, Contact isolation due to ESBL urinary tract infection. Merrem Intravenous Solution Reconstituted 1 GM (Meropenem) Use 1 gram intravenously every 8 hours for ESBL of the urine for 14 days. Record review of Resident #15's March 2024 MAR revealed, Resident #15 received antibiotic every 8 hours starting 03/21/24 at 04:00 p.m. through 08:00 a.m. 03/29/24. Observation on 03/26/24 at 02:48 p.m., Housekeeping C went into Resident #15's room that had PPE hanging on the door. Housekeeping C entered room without donning PPE. There was not a Contact Precaution signage on the door. In an interview on 03/26/24 at 02:57 p.m., LVN F stated the Resident #15 had ESBL to the urine and was on precautions. LVN F stated he was not sure whether Resident #15 was on droplet or contact precautions. LVN F stated everyone entering the room should be wearing mask, gloves, and gown. LVN F stated if someone did not wear the correct PPE, the infection could be spread to other residents. In an interview on 03/26/24 at 03:01 p.m., Housekeeping C stated he should have worn PPE going into Resident #15's room, but he forgot. Housekeeping C stated he had been working at the facility for about a month and did not know what could happen if he did not wear PPE in a room that was on precautions. Housekeeping C stated he would ask the floor nurse, LVN F, who was the nurse for that hall and that resident. Observation on 03/27/24 at 09:10 a.m., Resident #15 had no bins for soiled laundry or biohazards to discard used PPE in his room. In an interview on 03/29/24 at 11:23 a.m., the Housekeeping Manager stated environmental was responsible for putting biohazard, linen, and trash cans in isolation rooms. She stated they had put one in Resident #15's room as soon as he was put on isolation. The Housekeeping Manager stated when surveyor went into room and there was no laundry bin or biohazards bin in Resident #15's room, someone must have taken it out to disinfect it. In an interview on 03/29/24 at 02:05 p.m., LVN B stated nurses put the Transmission Based Precaution (TBP) sign on the residents' doors if they have a contact precaution infection. LVN B stated ADONs would put the signage up on weekends. LVN B stated nurses, maintenance or housekeeping put the trash bins or soiled laundry bins in the resident's room, who is on TBP, to dispose of PPE or soiled linens or clothes. LVN B stated the nurses are the ones who notify maintenance or housekeeping of the TBP. In an interview on 03/29/24 at 02:15 p.m., the DON stated the ICP (Infection Control Preventionist) was responsible for putting TBP signage on the doors of residents with a transmission based precaution. The DON stated she is the ICP. The DON stated people entering a room on TBP without putting on PPE can become infected. The DON said housekeeping could either get or spread infection from entering the TBP room without PPE. The DON said specific bins in a TBP room for trash and linens are there to prevent cross-contamination or infection spread. The DON stated housekeeping was responsible for putting special bins in the TBP room. Review of facility's Infection Prevention and Control Program dated 5/13/23 stated: This facility has established and maintains an infection prevention and control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease. 4. Standard Precautions: c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. d. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies. 5. Isolation protocol (Transmission-Based Precautions): a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines. b. Residents will be placed on the least restrictive transmission-based precaution for the shortest duration possible under the circumstances. 16. Staff Education a. All staff shall receive training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention and control program, including policies and procedures related to their job function. b. All staff shall demonstrate competence in relevant infection control practices. c. Direct care staff shall demonstrate competence in resident care procedures established by our facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 3 of 3 residents (R #1, R #2, and R #3) reviewed for accuracy of records. 1. The facility did not document R #1's nursing progress note on 12/09/23 reflecting LVN A's communication with NP regarding a follow up after R #1 had a fall on 12/05/23. 2. The facility did not completely document R #2 and R #3's neurological checks started on 11/18/23 and 12/05/23 for R #2 and on 10/26/23, 12/04/23, and 12/13/23 for R #3 for falls. This failure could place residents with falls at risk of not receiving adequate care and services. The findings included: Record review of R #1's face sheet reflected an [AGE] year-old male with original admission date of 06/12/23. His diagnosis included: unspecified dementia, muscle wasting and atrophy, vertigo, epilepsy, insomnia, depression, cognitive communication deficit, dysphagia, Alzheimer's disease, disease of stomach and duodenum, and history of malignant neoplasm of prostate. Record review of R #1's MDS assessment dated [DATE] reflected a BIMS score of 7 (cognitively severely impaired). Record review of R #1's care plan dated 12/13/23 reflected R #1 was at risk for falls related to impaired mobility, vertigo, and poor safety awareness. R #1's gait was unsteady and often forgot to ask for assistance. Date initiated: 06/12/23. Interventions: offer assistance to the bathroom upon rising, before meals, and at bedtime. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Ensure the resident is wearing appropriate footwear. Medications as ordered. Provide a safe environment with even floors, free from spills/clutter, and adequate light. Therapy to evaluate and treat. Record review of R #1's progress notes dated 12/09/23 reflected there was no progress note documented for LVN A's communication with the NP regarding a follow up for the fall R #1 had on 12/05/23 and old bruising. Record review of R #1's progress notes dated 12/09/23-12/18/23 reflected no adverse or negative outcomes related to the lack of documentation. Record review of R #2's face sheet reflected a [AGE] year-old female with original admission date of 12/22/22. Her diagnosis included: chronic obstructive pulmonary disease, hypertension, muscle wasting and atrophy, chronic kidney disease, major depressive disorder, insomnia, anxiety disorder, schizophrenia, and type 2 diabetes. Record review of R #2's MDS assessment dated [DATE] reflected a BIMS score of 11 (cognitively moderately impaired). Record review of R #2's care plan dated 12/13/23 reflected R #2 was at risk for falls related to weakness and poor safety awareness. Date initiated: 09/28/23. Interventions: staff to ensure that resident is wearing appropriate footwear. Call light is within reach and encourage resident to use it for assistance as needed. Encourage the resident to participate in activities that promote exercise and physical activity for strengthening and improved mobility. Provide a safe environment with even floors, free from spills/clutter, and adequate light. Record review of R #2's neurological checks started on 11/18/23 reflected check Q8H#6 (check every 8 hours #6) was not documented as completed. Checks started on 12/05/23 reflected check Q8H#4, Q8H#5, and Q8H#6 (checks every 8 hours #4, #5, and #6) were not documented as completed. Record review of R #2's progress notes dated 11/18/23-12/18/23 reflected no adverse or negative outcomes related to the lack of documentation. Record review of R #3's face sheet reflected a [AGE] year-old male with original admission date of 06/26/23. His diagnosis included: muscle wasting and atrophy, dementia, cognitive communication deficit, dysphagia, hypertension, repeated falls, mood disorder, insomnia, anemia, and cirrhosis of liver. Record review of R #3's MDS assessment dated [DATE] reflected a BIMS score of 2 (cognitively severely impaired). Record review of R #3's care plan dated 12/13/23 reflected R #3 was at risk for falls related to weakness and poor safety awareness. R #3 had a history of falls prior to admission and had a history of frequent falls. Date initiated: 06/26/23. Interventions: ensure call light is within reach and encourage the resident to use it for assistance as needed. Encourage the resident to participate in activities that promote exercise and physical activity for strengthening and improved mobility. Ensure resident is wearing appropriate footwear. Fall mat. Offer assistance to the toilet every 2-3 hours while awake. Provide a safe environment with even floors, free from spills/clutter, and adequate light. Therapy to evaluate and treat. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/team as to causes. Record review of R #3's neurological checks started on 10/26/23 reflected check Q8H#2 (check every 8 hours #2) was not documented as completed. Checks started on 12/04/23 reflected check Q8H#1 (check every 8 hours #1) was not documented as completed. Checks started on 12/13/23 reflected check Q8H#6 (checks every 8 hours #6) was not documented as completed. Record review of R #3's progress notes dated 10/26/23-12/18/23 reflected no adverse or negative outcomes related to the lack of documentation. Interviews with R #2 and R #3 on 12/13/23, and with R #1 on 12/18/23 indicated they were not good historians and/or could not provide relevant information. Interview with LVN A on 12/13/23 at 4:45 PM. LVN A said she worked on 12/05/23 with R #1 and found R #1 on the bathroom floor at around 9 AM. LVN A said she assessed R #1 and followed the fall protocol including initiating the neurological checks. LVN A said neurological checks were started on 12/05/23, checks were normal, and there were no concerns that R #1 had hit his head. LVN A said neurological checks would be able to indicate if R #1 hit R #1's head or if R #1 had anything else going on internally. LVN A said the neurological checks were completed 4 times every 15 minutes, 2 times every 30 minutes, 2 times every 1 hour, 4 times every 4 hours, and then 6 times every 8 hours, until 72 hours were completed. LVN A said the neurological checks were initiated after the fall and then the next nurses took over to complete the neurological checks until the 72 hours were completed. LVN A said the neurological checks were done by several nurses. LVN A said she worked on 12/09/23 with R #1 and communicated a follow up with the NP regarding R #1 having bruising to the right side of R #1's back/hip area and to the back of R #1's right ear. LVN A said the NP indicated the bruising looked old and was related to the fall on 12/05/23. LVN A said she documented all progress notes in R #1's EMR. Interview with NP on 12/18/23 at 4:40 PM. NP said LVN A had reported the bruising to the on-call service on 12/09/23. NP said the on-call NP did not give any new orders as the bruising was noted to be old as it was related to the fall on 12/05/23. Interview with DON on 12/18/23 at 5:00 PM. DON said on 12/09/23, LVN A had informed DON that LVN A followed up with the on-call NP regarding R #1 having some bruising from the fall on 12/05/23. DON said the NP did not give any new orders as the bruising was old. DON said perhaps LVN A did not document in R #1's EMR regarding the communication with the on-call NP but DON knew LVN A did speak to the on-call NP. DON said neurological checks were initiated for head concerns or falls, especially if the fall was unwitnessed and the facility did not know if the resident hit their head. DON said the neurological checks are completed for 72 hours. DON said there would be no reason for the neurological checks to be discontinued unless the resident was sent to the hospital or was no longer at the facility for another reason. DON said the nurses need to ensure to document the neurological checks. DON said there have been no indications or concerns that neurological checks are not being completed appropriately. DON said the neurological checks started on 11/18/23 and 12/05/23 for R #2 and on 10/26/23, 12/04/23, and 12/13/23 for R #3 were for falls. DON said the neurological checks should have been complete as R #2 and R #3 were not sent to the hospital on those days and were available in the building. DON said perhaps the nurses just forgot to document in R #2 and R #3's EMR. DON said although there was no negative outcome to the residents, the neurological checks need to be documented completely. DON said if there was a thorough assessment done, then DON does not believe there would be a negative outcome for the resident due to the lack of documentation. Interview with ADM on 12/18/23 at 5:35 PM. ADM said was made aware of the concern regarding the incomplete documentation for R #1, R #2, and R #3. ADM said there were no concerns or indications reported that the neurological checks were not completed or that staff did not follow protocols, but documentation was important. Documentation in Medical Record Policy date implemented 10/24/22 reflected Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in th3e resident's medical record in accordance with state law and facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision for 1 resident (Resident #1) of 5 residents reviewed for supervision, in that The facility failed to ensure Resident #1 received supervision to prevent Resident #1 from ingesting chemicals he found in another resident's room at the facility. The facility failed to ensure Resident #2 did not bring chemicals into the facility he kept hidden in a Pringles can in his room while at the facility. These failures could place residents at risk of being in an unsafe environment and at risk for accidents and injury. Findings included: Record review of Resident #1's admission Record dated 10/20/23 revealed a [AGE] year old male with an admission date of 10/10/16 and diagnoses which included: Stroke, Transient cerebral ischemic attack (a brief stroke-like attack that, despite resolving within minutes to hours, still requires immediate medical attention to distinguish from an actual stroke), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), systemic lupus erythematosus (an inflammatory disease caused when the immune system attacks its own tissues that can affect the joints, skin, kidneys, blood cells, brain, heart, and lungs), hypertension (high blood pressure), acquired absence of left leg above the knee, dysphagia (difficulty or discomfort in swallowing, as a symptom of disease), and . Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed he required extensive assistance with 2+ person physical assistance for bed mobility, dressing, toilet use, required extensive assistance with 1-person physical assistance for personal hygiene, and was totally dependent on 2+ person assist for transfers. Resident #1 had a feeding tube requiring 1-person physical assistance for eating. Resident #1 was always incontinent of bowel and bladder. Resident #1 had a BIMS of 99 (severe cognitive impairment). Record review of Resident #1's Care Plan dated 10/18/23 revealed he would sometimes go outside without letting staff know. An intervention listed was Staff will remind [Resident #1] to notify staff when going outside and Staff will monitor [Resident #1's] location at 'regular and frequent intervals'. Date initiated 12/18/2019 with revision on 12/15/2022. [Resident #1] liked to hoard items under his blanket while in his wheelchair, such as snacks and items he possibly tried to eat the food by mouth even though he had a risk of aspiration (a condition in which food, liquids, saliva, or vomit is breathed into the airways). An intervention was for Staff to observe if [Resident #1] was taking items under his blanket while utilizing his wheelchair as a safety precaution. Date initiated was 12/18/2019 with a revision on 12/15/2022. Record review of Resident #1's Progress Note dated 10/18/23 at 01:22 p.m., written by ADON C, revealed she was notified by CNA E, Resident #1's lips and mouth were blue tinged along with his left hand also being blue. Record review of Resident #1's Progress Note dated 10/18/23 at 02:30 p.m. Nurse Note written by DON revealed a call was placed to the poison control center with recommendations to monitor resident for drooling and excessive vomiting, and to wipe his mouth. Record review of Resident #1's Progress Note dated 10/18/23 at 08:33 p.m. Nurse Note written by LVN A revealed the chest x-ray results from 10/18/23 was reported to doctor/NP D who gave a new order for nebulizer treatments every 6 hours for 5 days and to repeat the chest x-ray on Friday, 10/20/23. Record review of Physician's Note written by NP D on 10/18/23 at 02:10 p.m., revealed HPI (History of Present Illness): [AGE] year old male is seen today due to reported ingestion of bathroom cleaner' on examination patient sounds congested. Assessment & Plan: Accidental ingestion of bathroom cleaner (resolved) Plan: asymptomatic (no symptoms) monitor symptoms obtain CXR (chest x-ray) for congestion. Physical Assessment: Respiratory: Auscultation: rhonchi (course, loud sounds caused by constricted larger airways, including the tracheobronchial passages). Assessment and Plan: Abnormal cxr (chest x-ray) likely bacterial pneumonia (new). Plan: start with Doxy x (times) 7 days monitor symptoms. Record review of Resident #1's Progress Note dated 10/18/23 at 02:30 p.m. Nurse Note written by DON revealed a call was placed to the poison control center with recommendations to monitor resident for drooling and excessive vomiting and to wipe his mouth. Record review of Resident #1's x-ray results dated 10/18/23 at 04:43 p.m., revealed Findings: There is no abnormal radiopaque foreign body. Record review of Resident #1's Progress Note dated 10/19/23 at 08:36 a.m. Nurse Note written by LVN B, revealed Resident #1 was in bed with the head of bed slightly elevated. Resident #1 had no signs or symptoms of distress noted. LVN B documented Resident #1 denied any discomfort. Record review of Resident #1's Progress Note dated 10/19/23 at 09:46 a.m. Nurse Note written by LVN B revealed results for the chest x-ray were received and she reported the findings to NP D/doctor. LVN B wrote new orders were received to start doxycycline (antibiotic) 100mg via PEG (feeding tube) twice a day for 7 days for pneumonia. Record review of NP D's Physician's Note dated 10/24/23 at 02:50 p.m. for Resident #1 revealed Abnormal cxr (chest x-ray) bacterial pneumonia. In an interview on 10/20/23 at 11:35 a.m., the DON stated Resident #1 goes all over in his electric wheelchair and he had a feeding tube so he had nothing by mouth. She said she believed what happened was, Resident #1 had gone into Resident #2's room and saw a can of Pringles on the nightstand and was going to help himself to some chips. The DON stated Resident #2 told her that his family had brought him in a couple toilet bowl cleaners, and he had put them in an empty Pringles can because he did not think he was allowed to have them. The DON stated the doctor had been notified, Poison Control had been called, NP D had come to assess Resident #1 soon after the incident occurred. The DON stated Resident #1 had a chest x-ray done, and Resident #1 was being monitored. DON stated they did a sweep of the facility on Wednesday (10/18/23), checking for chemicals in residents' rooms. She stated they would be doing another sweep again today (10/20/23). DON stated staff had been in-serviced on chemicals in residents' rooms and what to look for when they went into residents' rooms. In an interview on 10/20/23 at 02:14 p.m., The Administrator stated they (he and the DON) had removed the toilet bowl cleaner tabs from Resident #2's room, and the Administrator had them in his office. The Administrator stated he had also spoken to Resident #2's family to let them know about the toilet bowl cleaner and to let them know he had it in his office where they could pick it up. In an observation on 10/20/23 at 02:48 p.m., revealed Resident #1 was lying in bed with the head of bed inclined. Resident #1 was well-groomed. The call light within Resident #1's reach. Resident #1 closed his eyes and would not speak to the surveyor when she asked if he had an incident the other day. In an observation on 10/20/23 at 02:55 p.m., revealed Resident #2 was not in his room. There were two Pringles cans sitting on top his small refrigerator. In an observation and interview on 10/20/23 at 02:59 p.m., revealed Resident #2 was sitting in the dining room drinking coffee and listening to music. Resident #2 stated he used to keep blue toilet tabs in a Pringles can, but someone went in and took one, so the Administrator took the toilet bowl cleaner tabs and put them in his office. Resident #2 stated he liked having the toilet tabs in his room because they made his room smell good. He said he was a little sad that he could not have them anymore, but he understood that if someone came and took the tabs and tried to eat them, they could get very sick. Resident #2 stated from now on, he would only have Pringles in the Pringles can and nothing else. He said if anyone would come in his room and get anything out of the Pringles can, it would only be chips. In an interview on 10/20/23 at 03:16 p.m., LVN B stated she received the order from NP D to get an x-ray of Resident #1's chest. LVN B stated the x-ray results did not show anything and the NP gave the order to repeat the chest x-ray on 10/20/23. The chest x-ray was returned with the finding of pneumonia and the resident was started on an antibiotic. LVN B stated Resident #1 had no problems after he was found with blue on his lips and hand. He had not had emesis (vomiting), drooling or anything. LVN B stated Resident #1 had remained the same as he always had. In an interview on 10/20/23 at 03:25 p.m., ADON C stated that day (10/18/23), one of the CNAs called her and told her Resident #1's hand, lips, and mouth were blue. ADON C stated she saw the blue tablet on his bedside when she walked into Resident #1's room. ADON C stated she assessed Resident #1, took his vitals which were within normal limits, and cleaned him up. ADON C stated she checked his mouth really well and there was no blue or any particles in his mouth just outside his mouth. ADON C stated she notified NP D and NP D went in to assess Resident #1. ADON C stated NP D ordered x-rays to check his throat for particles or anything that may show up. ADON C stated Resident #1 showed no distress at any time. ADON C stated he acted the way he always did. ADON C stated the x-ray results were negative for anything in his throat. ADON C stated monitoring had been started for vomiting and drooling which he did not exhibit. ADON C stated they (nursing and administration) checked all the residents' rooms for any chemicals or anything that was not supposed to be in their rooms, in-services concerning chemicals took place with all the staff, and they were to keep their eyes open for any chemicals the residents may have from family bringing items in. In an interview on 10/20/23 at 04:10 p.m., the DON stated she was notified the day of the incident with Resident #1. The DON stated she notified the Administrator, and they went into Resident #1's room to interview him. She stated Resident #1 was in no distress. The DON stated Resident #1 did not say anything. The DON stated she and the Administrator went to Resident #2's room to interview him. She said the bathroom was checked and the water in the toilet was blue. The DON stated Resident #2 had told her he liked the blue water and the clean smell. The DON stated Resident #2 told them his family brought in the toilet bowl cleaners and he put them in an empty Pringles can because he did not think he was allowed to have them. The DON stated Resident #2 said he did not think anyone would get in the Pringles can. The DON stated Resident #2 gave the toilet bowl cleaner tabs, still in the Pringles can, to the Administrator who put them in his office. In an interview on 10/20/23 at 06:00 p.m., the DON stated the Care Plan was incorrect. The DON stated Resident #1 did not have a pattern of behavior taking items and hiding them in his wheelchair. The DON stated Resident did not have a pattern of wandering into other residents' rooms. The DON stated Resident #1 was kept within eyesight of the staff. The DON stated he wandered to look out the doors. Review of facility's Elopements and Wandering Residents policy dated 11/21/22 revealed: Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing wandering or elopement risk. Policy Explanation and Compliance Guidelines: 3. The facility shall establish and utilize a systemic approach to monitoring and managing resident at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risk, and monitoring for effectiveness and modifying interventions when necessary. 4. Monitoring and Managing Residents at Risk for Elopement and Unsafe Wandering d. Adequate supervision will be provided to help prevent accidents or elopement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #5) reviewed for implementation of care plan. Resident # 5's care plan did not list the physician's recommendation that the resident's feet, not be elevated and compression socks placed on the resident as a nursing response to edema. The failure could lead to staffing receiving nursing care which are contradicted by a physician's recommendation and could lead to residents experiencing medical complications or harm. Findings were: Record review of Resident #5's face sheet dated 01/26/23 revealed, Resident #5 was a male age [AGE] re-admitted on [DATE] with diagnoses that included: Parkinson (neurological disease), generalized edema, and peripheral vascular disease (poor blood flow). RP (responsible party) was listed as: a family member. Record review of Resident #5's MDS dated [DATE] , revealed: o BIMS was 11 (0-5=severe impairment 6-12 (moderate impairment) 13-15 (cognitively intact) o ADLs: B/B (bowel and bladder) frequently incontinent of both. Transfer was extensive two staff and Bed Mobility was extensive one staff. Record review of Resident #5's Care Plan, revised 01/25/23 , revealed, the goals and interventions included: I (Resident #5) have an abnormal heart rhythm, high blood pressure, coronary heart disease, congestive heart failure and high cholesterol that put me at risk for complications. Interventions included: medications, monitoring for edema, and taking vital signs. [The care plan did not have information about Resident #5's legs not being elevated as an intervention for edema; or not using compression socks] Record review of Resident #5's MAR dated January 2023 revealed Lasix 20 mgs daily was given for CHF; changed to 40 mgs on 01/25/23. Record review of Resident #5's Change of Condition dated 1/24/23 written by LVN A read: resident with edema to left lower extremity. New NP orders raised the dosage of Lasix to 40 mgs to once per day. Record review of Resident #5's Physician' Orders, dated 01/24/23 , revealed an order for Lasix 40 mgs one tab daily.[Response to the swelling on 01/24/23] Previous dosage was 20 mgs per day. During an observation on 01/24/23 at 02:13 PM, Resident #5 revealed: a swollen leg on his left leg; the left leg was not elevated and no compression socks were present; the resident had skid socks. During an interview on 01/24/23 at 2:15 PM, Resident #5 stated, the left leg hurt and it was swollen. [Resident # 6 did not state how long the leg had been swollen or when the pain started.] During an observation and interview on 01/24/23 at 2:20 PM , LVN A revealed: the resident (#5) had edema on the left leg; and it was swollen. LVN A stated , the skin on the left leg that was swollen was not hot . but was not elevated and no support socks present .and (LVNA ) will call the MD. Observation revealed that LVN A lifted Resident #5's legs and rested them on a pillow on the bed the resident was lying on. LVN A stated that she was aware that it was contraindicated that compression socks were not to be placed on Resident #5 because the resident did not want the socks; and the socks would increase the swelling. She/he added that there were no physician or NP orders not to place compression socks on the resident; and she/he was not aware of any orders not to elevate the resident's feet when edema was present; or that the care plan had been updated. During an interview on 01/24/23 at 2:54 PM, the DON revealed: Resident #5' had co-morbidities, CHF and vascular disease which were contraindicated for compression socks and the NP did not recommend compression socks . The DON stated, the swelling could have developed acutely .resident was seen between noon and 1 PM and did not complain about swelling. The DON did not want to answer the question about elevating a resident's feet who had a history of edema; or whether the care plan had been updated. The DON stated there were no written orders contraindicating placing compression socks on Resident #5 or elevating the resident's feet as a response to edema. During an interview on 01/26/23 at 1:56 PM, LVN B revealed: the care plan indicated the facility was monitoring for edema on Resident #5. LVN B stated that nursing practice for edema was to raise the legs and place compression socks if ordered or the resident wanted the compression socks. Per LVN B , the standard course of treatment was to raise the resident's legs to avoid swelling for a resident with a diagnosis of edema. LVN B stated that the care plan was not updated to reflect the physician's recommendation that Resident #5's legs not be elevated or compression socks placed on the resident's feet. During an observation and interview on 01/26/23 at 2:41 PM, Resident #5 was sitting in a wheel chair in his room. LVN C removed the resident's regular sock and revealed that swelling was still present to the left leg below the knee. Resident #5 revealed he still had generalized pain. During an interview on 01/26/23 at 2:44 PM, LVN D revealed: interventions to deal with edema included: off-loading (raising the leg to minimize swelling). LVN D stated the swelling Resident #5 was recent (1/24/23) and he had a history of swelling due to DVT (deep vein thrombosis, CHF and vascular disease. LVN D stated that anytime the resident was in bed it is recommended to off-load. LVN D was not aware of any orders dealing with the elevation of the resident's feet or the use of compression socks or any changes to the care plan. During a telephone interview on 01/26/23 at 3:11 PM, the NP revealed: Resident #5 had co-morbidities to include edema and back pain; and swelling of the leg could develop within 3-4 hours. The NP did not recommend compression socks given the resident's CHF and vascular disease. The NP stated that the elevation of the resident's feet might not be the best cause of treatment given the resident's history of back pain and CHF. The NP stated they did not want a back flow of blood which could be created by the elevation of the resident's feet.[The NP made no comments about revising the care plan to reflect her latter recommendations] During an interview on 01/26/23 at 6 PM, the DON revealed: putting a pillow beneath Resident #5's left leg was contraindicated because of the resident's comorbidities that included CHF and vascular disease. However, The DON stated, there was no doctor's orders for Resident #5's feet not to elevated as an intervention for edema. [The DON was made aware by the surveyor that observation revealed that a nurse had elevated the resident's legs on a pillow once the edema was discovered.] The DON added that the timeline for the edema development was between 1 PM to 2:14 PM when the edema was observed by the surveyor. The DON added that the resident had expressed no pain or showed no signs of edema while being transported from the dining hall on 01/24/23 at 1 PM and laid to rest in his bed; the resident was transported in his wheel chair. [The DON made no comments about revising the care plan to address nursing practice for edema for Resident #5]. During an interview on 01/27/23 at 8:37 AM, the DON stated, the NP did not write orders for Resident #5's feet not be elevated and not to place compression socks on the resident because it was contraindicated. The DON added he did not follow-up on the NP writing orders because it was outside his realm to question an NP. [The DON made no comments about revising the care plan to address nursing practice for edema for Resident #5]. During a telephone interview on 01/27/23 at 9:25 AM, the NP revealed that elevating Resident #5's feet was contraindicated because the resident had chronic back problems and CHF. Also, compression socks were contraindicated because the resident could not tolerate the socks. The NP stated, I did not write orders involving not to elevate Resident #5's feet and not to place compression socks. [On 1/27/23 at 8:44 AM, the surveyor requested a policy on edema treatment and Nursing Staff following MD orders from the Administrator] During an interview on 01/27/23 at 11:00 AM, the DON stated that the facility did not have a policy on nursing staff following MD orders. His expectation was that nursing staff follow physician orders or recommendations. Record review of existing facility 's computerized policies dated 2015 did not reveal the existence of a policy on nursing staff following MD orders. During an interview on 01/27/2023 at 8:45 am, LVN A stated, I elevated as a nursing intervention Resident #5's feet on 01/24/23. LVN A, added , she/he elevated Resident #5 legs with a pillow. She/he also stated, there were no orders for compression socks and no orders to not elevate the feet. LVN A revealed if nursing interventions were contraindicated then orders should have been present. LNV A called NP on 01-24-2023 and the only order given was to increase Lasix to 40 mg.

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for food service safety: 1. There was flaking of ceiling paint in 5 locations in the kitchen 2. A ceiling vent in the kitchen was loose and secured on one side with painter's tape 3. There was a hole in the main dining hall measuring 1 inch by 5 inches [measured by surveyor] This deficient practice could place residents who eat meals from the kitchen at risk for spread of infections, food contamination, and food borne illness. Findings were: Observation on 01/24/23 at 10:10 AM of kitchen revealed: flaking ceiling paint at 5 locations in the ceiling. Some of the flaking paint was above the washing sink and above a corner of the coffee maker. Other flaking paint was near the ceiling at the entrance to the kitchen. During a joint interview on 01/24/23 at 11:36 AM, the Maintenance Director revealed: the flaking paint in the ceiling should not be that way because the paint could fall on items in the kitchen. The Maintenance Director added that he had no work orders for repairing the ceiling in the kitchen The Administrator revealed that the flaking paint could pose an infection control issue to the residents if the paint chips/flakes fell in the coffee or on food tray. The Administrator added that he was not aware of the flaking paint in the kitchen. During an interview on 01/25/23 at 8:30 AM, the FSS revealed that the flaking paint on the ceiling was reported to the Maintenance Director about one week ago; and a work order might have been submitted. The FSS stated that the flaking paint could pose a hazard to residents if the paint chips or flakes fell in the food or liquids. During an observation on 01/25/23 at 10:00 AM, one ceiling kitchen vent above the stove was not properly secured. A blue piece of tape was holding a side of the vent. Also, there was a hole on the plaster board in the main dining hall measuring 2 by 6 inches.[measured by the surveyor with a 12 inch ruler] During an interview on 01/25/223 at 10:05 AM, the FSS revealed no work order was made for the unsecured vent above the stove and no work order existed for the hole in the wall in the main dining hall. The FSS stated the unsecured vent was a fall hazard; and the hole in the dining hall wall could create an opening for pests. During an interview on 01//25/23 at 10:30 AM, the Dietician revealed that the unsecured vent needed to be repaired because it was a potential fall hazard. Also, the hole in the dining room wall presented an opening for pests. The Dietician was not aware of any work orders for the unsecured vent and the hole in the dining room. During an interview on 01/25/23 at 10:35 AM, the Maintenance Director who has been managing the facility for three years was not aware of the unsecured vent and the hole in the dining room. The Maintenance Director denied any work orders had been written by kitchen staff about the unsecured vent and the hole in the wall in the dining room. He added that taping the vent with painter's tape was not the correct way to secure a vent. Record review of facility's work order #22 dated 01/25/23 authored by the FSS revealed the work order only addressed ceiling lights and not the repair of the peeling paint in the kitchen. Work order log did not document a work order for fixing the hole in the dining room and securing the ceiling vent in the kitchen. Record review of facility's TELS computer program dated 01/25/23 revealed: maintenance areas that need to be checked were: painting, covers/vents, and wall maintenance. The TELS program did not document that the flaking paint in the kitchen ceiling, the unsecured vent in the ceiling, and the hole in the dining room were observed or fixed.