**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that residents were free from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, there were no interventions developed to prevent sexual abuse when 2 residents were in a relationship and one was cognitively impaired. This deficiency was found to have occurred at a past non-compliance. Resident Identifiers: 174 and 175. Findings included: 1. Resident 174 was admitted to the facility on [DATE] and discharged on 5/8/24 with diagnoses which included hemiplegia and hemiparesis, abnormalities of gait and mobility, essential hypertension, migraine, epilepsy, and gastro-esophageal reflux disease. Resident 174's medical record was reviewed on 12/2/24 through 12/5/24. An admission Minimum Data Set (MDS) assessment revealed resident 174 had a Brief Interview for Mental Status (BIMS) score of 15, indicating this resident's cognitive status was mildly impaired. Progress notes for resident 174 revealed the following: a. On 5/2/24 at 1:25 PM, This nurse and a CNA [Certified Nursing Assistant] witnessed this resident asking another resident to help cut up her food, and to bring her items saying that she needs extra help. This was witnessed in the dining room on more than one occasion and also in her bedroom. b. On 5/2/24 at 8:20 PM, . A CNA reported to this nurse that the same male resident was found in this resident's bed of a different night. This resident has been told by staff, administration and social services that this behavior is inappropriate. c. On 5/7/24 at 7:57 PM, This nurse was notified by another resident that I should check on resident in her room. Upon entering the room resident was in her bed and another resident appeared to be 'tucking' her into bed. This nurse informed both residents that this is not acceptable behavior and that they are not allowed to enter each other's rooms. Resident was disgruntled and asked the other resident to 'give her a kiss before leaving'. This nurse reiterated that this was inappropriate behavior and that he needed to come with me. Residents' roommate was also upset that a male had entered the room. Resident was left safely in her bed with call light and hydration within reach. It was documented that both resident's rooms were down the same hallway in the facility. There was no documentation found or provided that either resident was relocated during the allegation period. The care plan for resident 174 was not updated during the allegation period. No capacity to consent for a relationship was located in the medical record. 2. Resident 175 was admitted to the facility on [DATE] and discharged on 6/1/24 with diagnoses which included athrosclerotic heart disease of native coronary artery without angina pectoris, anemia, unspecified dementia, cognitive communication deficit, reduced mobility, need for assistance with personal care, muscle weakness, and abnormalities of gait and mobility. On 12/18/23, a Montreal Cognitive Assessment (MOCA) was completed for resident 175. The resident was assessed as having a score of 10/30 indicating moderate cognitive impairment. On 4/25/24, a MOCA was completed for resident 175. The resident was assessed as having a score of 11/30 indicating moderate cognitive impairment. On 3/20/24, a BIMS score was completed for resident 175. The resident was assessed as having a score of 9 indicating moderate cognitive impairment. Progress notes for resident 175 revealed the following: a. On 3/22/24, a social service summary note revealed, . [Resident 175] has a diagnoses of dementia and needs staff to help anticipate needs. Resident can communicate with others but does have confusion. b. On 4/10/24, a provider note revealed, .Given his underlying dementia and need for assistance with ADLs [Activities of Daily Living] and ADLs [sic] I certify he is appropriate for skilled nursing facility level of care. c. On 5/2/24 at 9:54 AM, . This resident was seen in another resident's room early in the morning. This other resident is a female and she was asking this resident to do things for her and fetch things for her, like her remote or move her water closer to her. The CNA put a stop to this again reminding the female resident that she needs to do as much for herself, but also told this resident that he needs to focus on himself and the female resident needs to focus on herself. d. On 5/2/24 at 8:19 PM, Resident was asked by another female resident to borrow his phone. When this resident's son came to visit, they were looking for the phone. The resident's phone was found in the female resident's bed. Administration and social services were notified and both residents were told that this is inappropriate behavior. This nurse was also told by a CNA that they found this resident in the bed of the female resident the other night. e. On 5/7/24, Nurse was notified by another resident that this resident was in a female resident's room. Upon entering the room this nurse witnessed resident attempting to 'tuck' female resident in bed. This nurse explained to resident that he cannot be in another resident's room. Resident appeared irritable and stated that he did not understand and that he was only trying to help her. Female resident asked this resident to give her a kiss before leaving. This nurse explained to both resident's that this is not appropriate behavior and that he needed to come with me. Resident did exit the room. This nurse educated resident on common areas, and that he is not allowed to enter anyone else's room. Resident expressed understanding. f. On 5/21/24 a provider note revealed, . Dementia with behavioral problem. It was documented that both resident's rooms were down the same hallway in the facility. There was no documentation found or provided that either resident was relocated during the allegation period. The care plan for resident 175 was not updated during the allegation period. No capacity to consent for a relationship was located in the medical record. On 12/4/24 at 1:17 PM, an interview was conducted with resident 37 who was resident 174's roommate at the time of the incident. Resident 37 stated she remembered resident 175 coming into their room, a lot. Resident 37 stated I guess he liked her. Resident 37 stated that resident 174 would ask him to do things for her and he would do them. Resident 37 stated she did not see anything because she stayed on her side of the room. On 12/5/24 at 9:43 AM, and interview was conducted with CNA 1. CNA 1 stated resident 174 had a tendency to be manipulative and would ask others to do things for her that she could do for herself. CNA 1 stated resident 174 had the poor me act going most of the time. CNA 1 stated resident 174 was a little alert and oriented but sometimes confused. CNA 1 stated that she was aware of resident 174 and resident 175 being together a lot, they would go into each other's rooms and hold hands. CNA 1 stated resident 175 was pleasantly confused, he needed to be directed and shown where his room was because he would get disoriented. CNA 1 stated they were supposed to report any signs that residents may have been in a relationship to administration. CNA 1 stated she did not report anything to administration. On 12/5/24 at 9:45 AM, an interview was conducted with Nursing Assistant (NA) 1. NA 1 stated she was working nights at the time resident 174 and 175 were residents. NA 1 stated resident 174 would ask resident 175 to do things for her most of the time and encourage him to go into her room with her. NA 1 stated resident 175 had sundowners really bad and when night time would come he would get really confused as to where he was or what you were talking about. NA 1 stated per policy we were supposed to see, stop, and report if we saw something. NA 1 stated administration was already aware of resident 174 and 175 being close so she did not bring it up again. On 12/5/24 at 10:04 AM, an interview was conducted with CNA 2. CNA 2 stated she did remember resident 174 and 175. CNA 2 stated that resident 174 would go into 175's room a lot. CNA 2 stated that she did see resident 174 and 175 being friendly with each other while they were in the facility. CNA 2 stated the staff were to see, stop, and report if they see something like that and CNA 2 stated that she told the administrator the resident 174 was seen going into resident 175's room. CNA 2 stated she did not remember any changes being made or any education being done when that happened. On 12/5/24 at 10:38 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she did remember resident 174 and 175. RN 1 stated that resident 174 was alert and oriented and liked to manipulate another resident into doing things for her. RN 1 stated that resident was resident 175. RN 1 stated resident 175 was cognitively impaired and would get disoriented and need redirecting at times. RN 1 stated resident 175 would not usually go into other resident's rooms but he did go into resident 174's room. RN 1 stated she found resident 175 in resident 174's room a couple of times and asked him to leave. On 12/5/24 at 10:45 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated resident 175 was alert and oriented but resident 174 would get confused and needed guidance to find his room. The ADON stated resident 175 did go into resident 174's room. The ADON stated there was one incident where resident 175 was tucking resident 174 into bed as you would a child. The ADON stated she asked resident 175 to leave, he became upset and resident 174 then asked him to give her a kiss before he left the room. The ADON stated she told them that was inappropriate and resident 175 left the room unhappy. The ADON stated if they saw any residents that appeared to be in a relationship they were to notify Social Services or the Administrator. The ADON stated she did not report the relationship to anyone. On 12/5/24 at 1:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated she did remember resident 174 and 175. The DON stated residents were assessed to determine consent for a consensual relationship by having a conversation with them. The DON stated resident 174 was alert and oriented and able to make decisions for herself and the DON stated she felt resident 175 was able to make the decision because his cognitive level improved while he was in the facility and after he left. The DON stated a specific conversation to determine whether the residents were in a relationship or if they were able to consent did not happen. On 12/5/24 at 1:00 PM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated there were no residents in relationships in the facility currently and there were no staff in relationships with residents. The CRN stated she was unsure if the facility had a consensual consent policy. On 12/5/24 at 1:05 PM, an interview was conducted with the Administrator (ADM). The ADM stated he was made aware of the alleged abuse allegation when another facility called and informed him. The ADM stated he was under the impression the residents were in a consensual relationship. The ADM stated while the residents were at the facility he was aware of the them being close but had no knowledge of any sexual abuse. The ADM stated he had a discussion with them about a relationship. The ADM stated the outcome from the discussion was that both of the residents were able to make the decision for themselves. The ADM stated to determine if a resident was able to consent to a consensual relationship a conversation was had with each resident to determine what a relationship means to them and determine what each resident wanted. The ADM stated if a resident was unable to make the decision due to cognitive ability the family was then involved. The ADM stated the family for either resident was not involved in this case because both residents seemed to be able to make the decision for themselves. The ADM stated after the allegation was brought to their attention a Quality Assurance and Performance Improvement (QAPI) plan was put into place and education with the staff was completed. Corrective action The exhibit 358 revealed that staff became aware of the incident on 10/18/24 at 11:00 AM. The exhibit revealed that resident 174 alleged, .[resident 174] was involved in an alleged incident that is sexual in nature during her stay . On 11/6/24, the DON and the ADM were unable to get in touch with resident 174 and 175 by telephone, so the DON and the ADM went to the residence of resident 174 and 175, two separate residences to interview the residents. Exhibit 359 revealed that the Administrator and Director of Nursing of the facility visited [resident 174] in her home with her family present. During interview DON asked [resident 174] about her relationship with [resident 175]. [Resident 174] relayed that she and [resident 175] were friends but at least on one other occasion they exchanged mutual affections including kissing. [Resident 174] stated that one night during bed time [resident 175] came to visit her in her room which he had done on other occasions that while she was in her bed he lifted her shirt up, touched her breast and put his hand down her pants. [Resident 174] said she yelled for him to stop and told him to leave her room which he did. Resident stated that this was an isolated incident. [Resident 174] states she did not report this to any staff. Further, [resident 174's] daughter said she was unaware of this alleged incident until the investigation. However, [resident 174] said that she told her friend [name omitted] and that her roommate [name omitted] was in the room at the time of the alleged incident and aware of the situation. [Resident 174] stated that she felt safe at the facility and would like to come back. A summary on interviews revealed, During our investigation, there were no known witnesses. [Resident 37] was [resident 174's] roommate at the time and [resident 174] stated that she was in the room during the time of alleged incident. Upon interview with [resident 37], she stated that she had no memory of [resident 174] yelling at or asking alleged perpetrator [resident 175] to leave their room. She just remembered both of them frequently enjoying the company of one another. A summary of the information from the investigation revealed, Inconclusive. After our investigation we were not able to verify or refute whether or not the allegation had occurred. After review of the charts of each resident, and also reviewing all interviews it was determined that former residents [175] and [174] did have some form of consensual relationship, where they spent time with each other and were affectionate. The two people that [resident 174] stated were aware of the alleged incident denied having knowledge of the incident. On 12/5/24, the facility provided the QAPI plan dated 11/8/24 which identified the issue as Resident and Relationships where All residents were identified as being at risk. The system correction that was put into place was, All staff to be educated on importance of identifying and reporting to Administrator relationships between residents. Social services educated on appropriate follow-up to determine appropriateness of relationship and updating care plan per IDT [Interdisciplinary Team] discussion. Monitoring was done by, Administrator to do a review of the 24 hour report in the morning before morning meeting or potential documentation of resident relationship. With a resolution date of 12/8/24. The QAPI plan was observed to be signed by the QAPI committee members. On 12/5/24, the facility provided the QAPI plan dated 11/8/24 which identified the issue as Recognizing Abuse where All Residents were identified as being at risk. The system correction that was put into place was, All staff to be educated on importance of identifying abuse and addressing it immediately and appropriately (stopping it, and notifying the administrator). In addition, staff will review specific abuse examples and go through the proper procedures when abuse is identified. Monitoring was done by, Administrator to do a review of the 24 hour report in the morning before morning meeting. LMS training assigned to all staff in the building on abuse. With a resolution date of 12/8/24. The QAPI plan was observed to be signed by the QAPI committee members. On 12/5/24, the education slide show was provided to and reviewed by this surveyor. The education topics reviewed were Residents, Intimacy, and Sexual Contact and abuse scenarios with educational slides provided for each topic. On 12/5/24 an Assessment of Resident Capacity to Consent to Intimacy was provided by the facility and was part of the education given to the facility staff on 11/8/24. Inservices on abuse and reporting were documented as being given to the staff on the following dates: a. 6/20/24 b. 7/25/24 c. 8/30/24 d. 9/20/24 e. 10/17/24 f. 11/8/24 g. 11/14/24 h. 11/22/24 On 11/11/24 the Residents, Intimacy, and Sexual Contact slide education and abuse scenarios was reviewed again with the staff. On 12/5/24, the 24 Hour Report audits on abuse and relationships were reviewed by the administration from 11/11/24 through 12/5/24 with no concerns being documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not implement their written policies and procedures for investigation of abuse allegations. Specifically, an incident of potential sexual abuse was not investigated timely. Resident identifiers: 174 and 175. Findings include: 1. Resident 174 was admitted to 4/28/24 with diagnoses which included hemiplegia and hemiparesis, abnormalities of gait and mobility, essential hypertension, migraine, epilepsy and gastro-esophageal reflux disease. 2. Resident 175 was admitted to the facility on [DATE] with diagnoses which included athrosclerotic heart disease of native coronary artery without angina pectoris, anemia, unspecified dementia, cognitive communication deficit, reduced mobility, need for assistance with personal care, muscle weakness and abnormalities of gait and mobility. The medical records for resident 174 and 175 were reviewed 12/2/24 through 12/5/24. The State Survey Agency (SSA) received a 358 report dated 11/6/24 indicating that another facility where resident 174 resided called on 10/18/24 and informed the previous facility that resident 174 had reported being in a sexual incident with resident 175 while a resident at the facility. On 12/4/24, an Incident Witness Interview Report dated 10/18/24 was conducted with four residents in the facility. No other investigation reports were located or provided. On 12/5/24, an interview was conducted with the Administrator (ADM) and the Director of Nursing (DON). The ADM and DON were asked about the 358 report. The ADM stated he was made aware of the situation after being called by the other facility but did not do a full investigation at that time. The DON stated she did ask a few resident the questions on the Incident Witness Interview Report when she found out about the call but a complete investigation was not done. When asked why the incident was not reported to the SSA until 11/6/24 the ADM and DON stated they were unsure if it needed to be reported since the residents were not longer residents at the facility. The ADM stated he had talked with the long term care manager and was told they should report it. The ADM stated that is when it was reported to the SSA. The facility policy titled Abuse: Prevention of and Prohibition Against under the section labeled Policy revealed, It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Facility staff are prohibited from taking, keeping, using or distributing photographs or video recordings of Facility residents in any manner that would demean or humiliate a resident, regardless of whether the resident provided consent and regardless of the resident's cognitive status. This includes using any type of equipment (e.g., cameras, smart phones, or other electronic devices) to take, keep, or distribute inappropriate photographs or recordings on social media. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation. Corrective action On 12/5/24 the facility provided the QAPI plan dated 11/8/24 which identified the issue as Recognizing Abuse where All Residents were identified as being at risk. The system correction that was put into place was, All staff to be educated on importance of identifying abuse and addressing it immediately and appropriately (stopping it , and notifying the administrator). In addition, staff will review specific abuse examples and go through the proper procedures when abuse is identified. Monitoring was done by, Administrator to do a review of the 24 hour report in the morning before morning meeting. LMS training assigned to all staff in the building on abuse. With a resolution date of 12/8/24. The QAPI plan was observed to be signed by the QAPI committee members. Inservices on abuse and reporting were documented as being given to the staff on the following dates: 1. 6/20/24 2. 7/25/24 3. 8/30/24 4. 9/20/24 5. 10/17/24 6. 11/8/24 7. 11/14/24 8. 11/22/24 On 12/5/24 the 24 Hour Report audits on abuse and relationships were reviewed by the administration from 11/11/24 through 12/5/24 with no concerns being documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 out of 26 sampled residents, that the facility did not ensure that allegations of abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than 2 hours after the allegation was made, if the allegation involved abuse or resulted in serious bodily injury, to the Administrator of the facility, the State Survey Agency (SSA), and adult protective services (APS), and the results of all investigations were reported to the Administrator and the SSA within 5 working days of the incident. Specifically, allegations of abuse were not reported at the time of the allegation to the SSA or APS. Resident identifiers: 174 and 175. Findings include: 1. Resident 174 was admitted to 4/28/24 with diagnoses which included hemiplegia and hemiparesis, abnormalities of gait and mobility, essential hypertension, migraine, epilepsy and gastro-esophageal reflux disease. 2. Resident 175 was admitted to the facility on [DATE] with diagnoses which included athrosclerotic heart disease of native coronary artery without angina pectoris, anemia, unspecified dementia, cognitive communication deficit, reduced mobility, need for assistance with personal care, muscle weakness and abnormalities of gait and mobility. The medical records for resident 174 and 175 were reviewed from 12/2/24 through 12/5/24. On 5/2/24 at 1:25 PM, a nurses note indicated that this nurse and a CNA (Certified Nursing Assistant) witnessed this resident [resident 174] asking another resident to help cut up her food, and to bring her items saying that she needs extra help. This was witnessed in the dining room on more than one occasion and also in her bedroom. This resident [resident 174] was already told that she needs to ask staff for help with these things. On 5/2/24 at 8:20 PM, a nurses note indicated that this resident [resident 174] asked a make (sic) resident [resident 175] to use his phone. When the other resident's son visited today, A search was conducted for his father's phone. It was found in this resident's bed. A CNA reported to this nurse that the same male resident [resident 175] was found in this resident's bed of a different night. This resident has been told by staff, administration and social services that this behavior is inappropriate. Review of the facility's form 358 for this incident indicated that although the facility was made aware of the incident on 10/18/24 at 11:00 AM, the facility did not report it to the SSA until 11/6/24 at 1:10 PM, approximately 19 days after the incident was reported to the facility. The facility policy titled Abuse: Prevention of and Prohibition Against under the section labeled Identification revealed, . Facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor or the Facility administrator immediately. The Facility will assist staff in identifying abuse, neglect, and exploitation of residents, and misappropriation of resident property. This includes identifying the different types of abuse-mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This also includes taking, keeping, using or distributing photographs or video recordings of Facility residents in any manner that would demean or humiliate a resident, regardless of whether the resident provided consent and regardless of the resident's cognitive status with any type of device. Corrective action On 12/5/24 the facility provided the QAPI plan dated 11/8/24 which identified the issue as Recognizing Abuse where All Residents were identified as being at risk. The system correction that was put into place was, All staff to be educated on importance of identifying abuse and addressing it immediately and appropriately (stopping it , and notifying the administrator). In addition, staff will review specific abuse examples and go through the proper procedures when abuse is identified. Monitoring was done by, Administrator to do a review of the 24 hour report in the morning before morning meeting. LMS training assigned to all staff in the building on abuse. With a resolution date of 12/8/24. The QAPI plan was observed to be signed by the QAPI committee members. Inservices on abuse and reporting were documented as being given to the staff on the following dates: 1. 6/20/24 2. 7/25/24 3. 8/30/24 4. 9/20/24 5. 10/17/24 6. 11/8/24 7. 11/14/24 8. 11/22/24 On 12/5/24 the 24 Hour Report audits on abuse and relationships were reviewed by the administration from 11/11/24 through 12/5/24 with no concerns being documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, for 2 of 26 sampled residents, that the facility, in response to allegations of abuse, neglect, exploitation, or mistreatment, failed to provide evidence that all alleged violations were thoroughly investigated. Specifically, an allegation of suspected sexual abuse was not thoroughly investigated. Resident identifier: 174 and 175. 1. Resident 174 was admitted to 4/28/24 with diagnoses which included hemiplegia and hemiparesis, abnormalities of gait and mobility, essential hypertension, migraine, epilepsy and gastro-esophageal reflux disease. 2. Resident 175 was admitted to the facility on [DATE] with diagnoses which included athrosclerotic heart disease of native coronary artery without angina pectoris, anemia, unspecified dementia, cognitive communication deficit, reduced mobility, need for assistance with personal care, muscle weakness and abnormalities of gait and mobility. The medical records for resident 174 and 175 were reviewed 12/2/24 through 12/5/24. The exhibit 358 revealed that staff became aware of the incident on 10/18/24 at 11:00 AM. The exhibit revealed that resident 174 alleged, .[resident 174] was involved in an alleged incident that is sexual in nature during her stay . Exhibit 359 revealed that the Administrator and Director of Nursing of the facility visited [resident 174] in her home with her family present. During interview DON asked [resident 174] about her relationship with [resident 175]. [Resident 174] relayed that she and [resident 175] were friends but at least on one other occasion they exchanged mutual affections including kissing. [Resident 174] stated that one night during bed time [resident 175] came to visit her in her room which he had done on other occasions that while she was in her bed he lifted her shirt up, touched her breast and put his hand down her pants. [Resident 174] said she yelled for him to stop and told him to leave her room which he did. Resident stated that this was an isolated incident. [Resident 174]states she did not report this to any staff. Further, [resident 174's] daughter said she was unaware of this alleged incident until the investigation. However, [resident 174] said that she told her friend [name omitted] and that her roommate [name omitted] was in the room at the time of the alleged incident and aware of the situation. [Resident 174] stated that she felt safe at the facility and would like to come back. A summary on interviews revealed, During our investigation, there were no known witnesses. [Resident 37] was [resident 174's]roommate at the time and [resident 174]stated that she was in the room during the time of alleged incident. Upon interview with [resident 37], she stated that she had no memory of [resident 174] yelling at or asking alleged perpetrator [resident 175] to leave their room. She just remembered both of them frequently enjoying the company of one another. A summary of the information from the investigation revealed, Inconclusive. After our investigation we were not able to verify or refute whether or not the allegation had occurred. After review of the charts of each resident, and also reviewing all interviews it was determined that former residents [175] and [174] did have some form of consensual relationship, where they spent time with each other and were affectionate. The two people that [resident 174] stated were aware of the alleged incident denied having knowledge of the incident. On 12/5/24 at 1:30 PM, an interview was conducted with the Administrator (ADM)and the Director of Nursing (DON). The DON stated when they were informed of the incident she interviewed 4 residents about feeling safe in the facility but a full investigation was not done until a couple weeks later. The ADM stated the investigation was not completed immediately when the incident was reported to the facility. The ADM stated they were unsure if one needed to be completed since the residents no longer resided at the facility but after a discussion with the long term care manager it was determined an investigation was needed. The ADM stated a QAPI plan was then put into place improving the understanding of the types of abuse, how to report abuse, the investigation process and staff education was completed. The facility policy titled Abuse: Prevention of and Prohibition Against under the section labeled Investigation revealed, . 1. All identified events are reported to the Administrator immediately. 2. After receiving the allegation, and during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm (See, Protection, below). 3. A licensed nurse will immediately examine the resident upon receiving reports of alleged physical or sexual abuse. The findings of the examination shall be recorded in the resident's medical record. 4. All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee. Upon receiving a report or allegation of a potential violation of this policy involving the taking, keeping, using, or distributing photos or video recordings, the Administrator or his or her designee will analyze the allegations and determine whether the conduct at issue implicates resident privacy or security as protected by the Health Insurance Portability and Accountability Act (HIPAA). Any such actual or potential violation will be managed as per the Facility's HIPAA policies and procedures. 5. The investigation will include the following: An interview with the person(s) reporting the incident; An interview with the resident(s); Interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate; A review of the resident's medical record; An interview with staff members (on all shifts) who may have information regarding the alleged incident; Interviews with other residents to whom the accused employee provides care or services or who may have information regarding the alleged incident; An interview with staff members (on all shifts) having contact with the accused employee; and A review of all circumstances surrounding the incident. 6. To the extent there is evidence that could be used in a criminal investigation, staff will immediately notify the Administrator or his/her designee. Staff are not to tamper with or destroy any such evidence at any time. 7. At the conclusion of the investigation, the Facility will attempt to determine if abuse, neglect, misappropriation of resident property, or exploitation has occurred. 8. The investigation, and the results of the investigation, will be documented. 9. All phases of the investigation will be kept confidential in accordance with the Facility's policies governing the confidentiality of medical records and privilege of quality assurance/ quality improvement programs. Corrective action On 12/5/24 the facility provided the QAPI plan dated 11/8/24 which identified the issue as Recognizing Abuse where All Residents were identified as being at risk. The system correction that was put into place was, All staff to be educated on importance of identifying abuse and addressing it immediately and appropriately (stopping it , and notifying the administrator). In addition, staff will review specific abuse examples and go through the proper procedures when abuse is identified. Monitoring was done by, Administrator to do a review of the 24 hour report in the morning before morning meeting. LMS training assigned to all staff in the building on abuse. With a resolution date of 12/8/24. The QAPI plan was observed to be signed by the QAPI committee members. Inservices on abuse and reporting were documented as being given to the staff on the following dates: 1. 6/20/24 2. 7/25/24 3. 8/30/24 4. 9/20/24 5. 10/17/24 6. 11/8/24 7. 11/14/24 8. 11/22/24 On 12/5/24 the 24 Hour Report audits on abuse and relationships were reviewed by the administration from 11/11/24 through 12/5/24 with no concerns being documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, one multi-dose vial was not labeled with an opened date, and a medication was taped back into the medication blister pack. Resident identifiers: 162. Findings included: Resident 162 was admitted to the facility on [DATE] with diagnoses which included fracture of lower end of left tibia, type 2 diabetes mellitus with diabetic neuropathy, Bell's palsy, muscle wasting and atrophy. On 12/4/24 at 8:16 AM, an observation was made of the 100-hall medication cart. An opened vial of Humulin 100 ml/units injection solution for resident 162 was located in the top right drawer of the medication cart and it did not have an opened date written on the vial. On 12/4/24, at 8:17 PM, an observation was made of a medication blister pack located in the locked drawer of the 100-hall medication cart. Resident 162's blister pack of Absenting 100 mg was observed to have a pill taped back into the 35 numbered space. On 12/04/24 at 8:17 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she did not see an opened date on the Humulin injection solution vial. LPN 1 stated there should be an open date on the vial. LPN stated that medications should not be taped back in blister packs, they should be disposed of properly. On 12/04/24 at 8:47 AM, an interview with the Director of Nursing (DON) was conducted. DON stated that when insulin vials were opened, they should be marked with an open date. DON stated that medication should not be taped back into the blister pill packs and that refused medications should be disposed of.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined, the facility did not provide the necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish unless circumstances of the individual's clinical condition demonstrated that such diminution was unavoidable. Specifically, for 1 out of 24 sampled residents, a resident was not provided assistance with eating. Resident identifier: 48. Findings included: Resident 48 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, essential hypertension, hyperlipidemia, reduced mobility, cognitive communication deficit, dysphagia and lack of coordination. On 4/30/23 at 11:48 AM, an observation was made of resident 48. Resident 48 was sitting in his wheelchair with his bedside table in front of him. Resident 48 was observed to be drooling from his mouth, unshaven, hair disheveled, and his shirt was saturated with liquid with bits of uneaten food resting on his chest. Resident 48 was observed to not be wearing a clothing protector. No staff were observed in the room with resident 48. Resident 48 had a built-up spoon in his right hand which held oatmeal. Resident 48's hands were observed to tremble. Resident 48 attempted to bring the oatmeal to his mouth, the food fell off the spoon onto his shirt. Resident 48 took another spoonful and was observed to use both hands to bring the spoon to his mouth, half of the contents of the spoonful made it into resident 48's mouth. Resident 48 stated he had been trying to eat his breakfast for the past two and a half hours and no one had come in to help him eat. Resident 48 stated, The dining room is no place for a resident like me and they don't want to help me. On 4/30/23 at 12:07 PM, an observation was conducted of a staff member in the 300 hallway passing out beverages for the lunch meal to the residents. The staff member was observed to enter resident 48's room and asked resident 48 if he needed any other drinks. The staff member exited resident 48's room and did not offer resident 48 assistance with the breakfast meal. Resident 48 was observed with the breakfast meal tray in front of him on the bedside table. On 4/30/23 at 12:08 PM, an observation was conducted of Licensed Practical Nurse (LPN) 1 administering resident 48's medications. LPN 1 did not offer resident 48 assistance with the breakfast meal. On 4/30/23 at 12:13 PM, an observation was conducted of a staff member delivering the lunch meal tray to resident 48. The staff member was observed to remove the breakfast meal tray and placed the lunch meal tray on the bedside table in front of resident 48. Resident 48 was observed to hold onto the breakfast meal tray when the staff member tried to remove the tray. LPN 1 was observed to ask the staff member to get resident 48 a fresh bowl of oatmeal from the kitchen. The staff member exited resident 48's room with the breakfast meal tray and did not offer resident 48 assistance with the lunch meal. On 4/30/23 at 1:22 PM, a follow up interview was conducted with resident 48. Resident 48 sat in his chair with his bedside table in front of him. No staff were observed in the room with resident 48. During the resident interview the Corporate Resource Nurse came into the room and offered resident 48 oatmeal and asked if he would like some assistance with eating his lunch. Resident 48 stated he would like his grilled cheese warmed up and would like assistance after he had finished talking with this surveyor. [Note: Lunch was served at 12:15 PM, and resident 48 had not received help with eating until this surveyor entered the room at 1:22 PM]. On 5/1/23, resident 48's medical record was reviewed. A quarterly Minimum Data Set assessment dated [DATE], revealed resident 48 required one person physical assistance with eating. A care plan dated 9/26/22, revealed that resident 48 was at risk for altered Activities of Daily Living (ADL) related to decline in functional ADL activity such as eating. Resident 48 required supervision to limited assistance with eating. The goal was resident 8 would be able to participate in part of ADL activity and have needs met. Some interventions included provide assistance or cueing with meals as needed. Built up silverware was added to the care plan after the survey had commenced. On 5/2/23 at 12:54 PM, an interview was conducted with LPN 1. LPN 1 stated the facility did assign people to feed the residents who needed assistance. The Certified Nursing Assistants (CNAs) were assigned to the residents and they had a binder where they kept track of that information. LPN 1 stated they did not always have enough staff to provide assistance with feeding the residents that needed help everyday. On 5/2/23 at 1:05 PM, an observation was made of the CNA binder. There was an untitled form in the binder which documented which CNA would pass trays and assist residents with feeding. Resident 48 was not noted as a resident who required feeding assistance on 4/26/23, 4/27/23, 4/28/23, 4/29/23, 4/30/23, and 5/1/23, for the day and evening meals. In the CNA binder resident 48 was noted as a resident who required feeding assistance on 5/2/23 and 5/3/23, for the day and evening meals. [Note: These dates occurred after the survey commenced.] A form titled Breakfast/Lunch/Dinner had a list of all residents in the facility who required feeding assistance provided by the facility. Resident 48 was written in on the last copy provided, previous copies of the form did not have resident 48 listed as requiring feeding assistance. On 5/2/23 at 1:06 PM, an interview was conducted with CNA 1. CNA 1 stated there were a few CNAs that go to the dining room to help the residents at meal time. CNA 1 stated they encouraged all of the residents to go down but most wanted to stay in their room. CNA 1 stated the CNAs made sure the residents meals were all set up. CNA 1 stated we communicate with each other on which residents needed to be assisted with feeding and then one of the CNAs on the floor would help feed. CNA 1 stated resident 48 needed help with dressing, brief changes, and that he needed help every day with eating. CNA 1 stated resident 48 was doing pretty good then this April he had not been doing very good so the staff were helping him more now. CNA 1 stated resident 48 needed help with each meal. On 5/2/23 at 1:13 PM, an interview was conducted with CNA 2. CNA 2 stated that she had been assigned the 100 hallway and room [ROOM NUMBER] and 401. CNA 2 stated that her daily assignments included checking resident briefs and before 10:00 AM, CNA 2 was to get all resident vital signs. CNA 2 stated she was to provide assistance for residents that needed help to dining. CNA 2 stated that resident 38 required assistance with eating because resident 38's hands did not work at all. CNA 2 stated that resident 48 required assistance with eating and resident 48 required a hour and a half to eat breakfast today. CNA 2 stated that resident 34 required assistance with eating, but resident 34 would go to the main dining room for meals. CNA 2 stated there was a CNA book that would show which CNA was assigned for showers and to feed residents. CNA 2 stated she was not assigned to resident 48 today, but she was asked to provide feeding assistance to resident 48. CNA 2 stated that she was unsure which CNA was assigned to provide feeding assistance to resident 38 today. CNA 2 stated there were enough CNAs to provide assistance to residents with eating because there were not that many residents that required assistance. CNA 2 stated that most residents that require assistance with eating went to the dining room. On 5/2/23 at 1:26 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the expectation of the facility was that the nurses and CNAs would provide the best possible care to each resident and treat them like they would their own family. The DON stated the staff would encourage the residents to go to the dining room for meals, if they were willing. The DON stated a quarterly nursing assessment was used to determine if a resident needed assistance with eating. The DON stated each nurse should also be able to determine if a resident had difficulty eating and required assistance. The DON stated if a resident required assistance the CNA should stay with the resident until they were done eating their meal. The DON stated resident 48 required assistance with eating and should have received it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility did not ensure residents who were unable to carry out activities of daily living (ADL), received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, for 1 out of 24 sampled residents, a resident did not receive timely feeding assistance that she needed at meal time. Resident identifier: 38. Findings included: Resident 38 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, wedge compression fracture, malignant neoplasm of colon, acute respiratory failure with hypoxia, secondary malignant neoplasm of liver and intrahepatic bile duct, major depressive disorder, generalized anxiety disorder, retention of urine, and history of falling. On 5/1/23 at 12:52 PM, resident 38 was observed to activate the call light system. The Health Information Management (HIM) staff member was observed to answer resident 38's call light. Resident 38 stated to the HIM that she needed help, she had been waiting over an hour, and she was not happy. Resident 38's lunch meal tray was observed on the bedside table against the wall and the bedside table was observed in the highest position. The lunch meal tray was observed to be out of reach from resident 38. The HIM was observed to provide feeding assistance to resident 38. [Note: The posted lunch meal time for the 100 and 400 hallways was 11:30 AM.] Resident 38's medical record was reviewed on 5/1/23. A quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 38 required extensive assistance of one person with eating. In addition, the MDS assessment documented that resident 38 had a Brief Interview for Mental Status (BIMS) score of 15. A BIMS score of 13 to 15 suggests the patient was cognitively intact. A care plan focus initiated on 2/2/23, documented [Resident 38] has ADL Self Care Performance Deficit r/t [related to] new admission, Urinary Retention, Dehydration, Metastatic colon cancer of liver, spinal compression fx [fracture], DVT [deep vein thrombosis], obesity, weakness, deconditioning, right hip, right knee, right ankle, right elbow, right wrist, right fingers, right shoulder, left hip, left knee, left elbow, left wrist, left fingers, left shoulder contractures present on admission. Care plan interventions included, but were not limited to, EATING: requires assistance to eat. The intervention was initiated on 5/1/23. On 5/2/23 at 11:54 AM, an observation was conducted of resident 38's lunch meal tray being delivered to resident 38's room. At 12:02 PM, resident 38 was observed to return from therapy. The therapist was observed to position resident 38 in the wheelchair near the bed and placed the bedside table with the lunch meal tray in front of resident 38. The food was observed to be covered with the warmer dome. At 12:18 PM, resident 38 was observed to activate the call light system. At 12:22 PM, a nurse was observed to enter resident 38's room and resident 38 told the nurse that she needed help eating. The nurse was observed to provide resident 38 with feeding assistance. On 5/2/23 at 1:13 PM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that she had been assigned the 100 hallway and room [ROOM NUMBER] and 401. CNA 2 stated that her daily assignments included checking resident briefs and before 10:00 AM, CNA 2 was to get all resident vital signs. CNA 2 stated she was to provide assistance for residents that needed help to dining. CNA 2 stated that resident 38 required assistance with eating because resident 38's hands did not work at all. CNA 2 stated that resident 48 required assistance with eating and resident 48 required a hour and a half to eat breakfast today. CNA 2 stated that resident 34 required assistance with eating, but resident 34 would go to the main dining room for meals. CNA 2 stated there was a CNA book that would show which CNA was assigned for showers and to feed residents. CNA 2 stated she was not assigned to resident 48 today, but she was asked to provide feeding assistance to resident 48. CNA 2 stated that she was unsure which CNA was assigned to provide feeding assistance to resident 38 today. CNA 2 stated there were enough CNAs to provide assistance to residents with eating because there were not that many residents that required assistance. CNA 2 stated that most residents that require assistance with eating went to the dining room. The CNA book was reviewed. CNA 2 was assigned to provide feeding assistance to resident 38 on 5/2/23. On 5/2/23 at 1:26 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the expectation of the facility was that the nurses and CNAs would provide the best possible care to each resident and treat them like they would their own family. The DON stated the staff would encourage the residents to go to the dining room for meals, if they were willing. The DON stated a quarterly nursing assessment was used to determine if a resident needed assistance with eating. The DON stated each nurse should also be able to determine if a resident had difficulty eating and required assistance. The DON stated if a resident required assistance the CNA should stay with the resident until they were done eating their meal. On 5/2/23 at 1:55 PM, an interview was conducted with the Physical Therapy Assistant (PTA). The PTA stated that she would do active assistive range of motion with resident 38's upper body. The PTA stated that resident 38 could not move her arms or her legs much. The PTA stated that she had gotten resident 38 strong enough that resident 38 could use her motorized wheelchair independently. The PTA stated that resident 38 was not able to eat without assistance from staff. The PTA stated that Occupational Therapy was also working with resident 38. On 5/2/23 at 2:00 PM, an interview was conducted with resident 38. Resident 38 stated that typically she would have to push her call light to get assistance with meals. Resident 38 stated that she would usually have to wait 30 minutes to a hour for assistance. Resident 38 stated that she was not sure if the delay was a staffing issue, but it seemed like there were not enough staff. Resident 38 stated that some days the staff assisted here within 15 minutes. Resident 38 stated that the staff had to pass out all the meal trays before the staff could provide her with assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that a feeding assistant had completed a state-approved training course before providing feeding assistance to residents. Specifically, for 1 out of 24 sampled residents, the Health Information Management (HIM) staff member was providing feeding assistance to a resident without having completed a state-approved training course. Resident identifier: 38. Findings included: Resident 38 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, wedge compression fracture, malignant neoplasm of colon, acute respiratory failure with hypoxia, secondary malignant neoplasm of liver and intrahepatic bile duct, major depressive disorder, generalized anxiety disorder, retention of urine, and history of falling. On 5/1/23 at 12:52 PM, resident 38 was observed to activate the call light system. The HIM staff member was observed to answer resident 38's call light. Resident 38 stated to the HIM that she needed help, she had been waiting over an hour, and she was not happy. Resident 38's lunch meal tray was observed on the bedside table against the wall and the bedside table was observed in the highest position. The lunch meal tray was observed to be out of reach from resident 38. The HIM was observed to provide feeding assistance to resident 38. [Note: The posted lunch meal time for the 100 and 400 hallways was 11:30 AM.] Resident 38's medical record was reviewed on 5/1/23. A quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 38 required extensive assistance of one person with eating. In addition, the MDS assessment documented that resident 38 had a Brief Interview for Mental Status (BIMS) score of 15. A BIMS score of 13 to 15 suggests the patient was cognitively intact. A care plan focus initiated on 2/2/23, documented [Resident 38] has ADL [activities of daily living] Self Care Performance Deficit r/t [related to] new admission, Urinary Retention, Dehydration, Metastatic colon cancer of liver, spinal compression fx [fracture], DVT [deep vein thrombosis], obesity, weakness, deconditioning, right hip, right knee, right ankle, right elbow, right wrist, right fingers, right shoulder, left hip, left knee, left elbow, left wrist, left fingers, left shoulder contractures present on admission. Care plan interventions included, but were not limited to, EATING: requires assistance to eat. The intervention was initiated on 5/1/23. On 5/2/23 at 2:06 PM, an interview was conducted with the HIM. The HIM stated that she was the medical records staff member. The HIM stated that she had not been trained to provide feeding assistance to residents, but she had worked with people that had disabilities. The HIM stated that she knew to be on the residents level when providing feeding assistance and that was why she had asked resident 38 if she could sit down next to her while she assisted resident 38 with eating. The HIM stated that she knew to make sure the food was in bite sized pieces. On 5/3/23 at 8:39 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the only staff in the facility allowed to provide feeding assistance to the residents would be the CNAs and nursing staff. The DON stated there were no paid feeding assistants in the facility.

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service. Specifically, food items in the walk-in refrigerator and walk-in freezer located in the kitchen were open to air, and the resident snack refrigerator was not clean. Findings included: 1. On 4/30/23 at 9:13 AM, an initial walk through of the kitchen was completed. In the walk-in freezer, a box of beef hamburger patties were found open to air. A box of mixed frozen vegetables was also found to be open to air. In the walk-in refrigerator, a box of uncooked bacon strips was observed to be open to air. On 5/3/23 at 10:09 AM, a second walk through of the kitchen was completed. In the walk-in freezer, a box with sausage patties was found to be open to air, a box of beef patties was open to air, a box with pre-made breakfast omelettes was open to air, and a box containing mixed frozen vegetables was open to air. On 5/3/23 at 10:30 AM, an interview was conducted with the Dietary Manager (DM). The DM stated staff had been educated about not only closing the boxes in the refrigerator and freezer, but securing the plastic the food items were being stored in within the boxes. The DM stated she would provide additional education to the kitchen staff about closing food items in the refrigerator and freezer. 2. On 4/30/23 at 9:40 AM, an interview was conducted with Dietary Aide (DA) 1, and DA 2 regarding the facility outside food policy. DA 1 stated if residents brought food into the facility from outside sources, the food was placed into the resident snack refrigerator that was located in the Certified Nursing Assistant (CNA) area in hallway 3. DA 1 stated that the facility required the food items to have a name, room number, and date on them. DA 2 stated the policy for keeping outside food was posted on the refrigerator. DA 1 stated the refrigerator was cleaned out every two weeks. DA 2 stated the refrigerator was cleaned out once each week. On 4/30/23 at 9:46 AM, an observation was made of the resident snack refrigerator. In the freezer section, a piece of popped popcorn was observed to be in the main area of the freezer. The refrigerator section was observed to be unclean with spilled orange juice on the bottom level and the middle glass shelf. Dried orange juice was also observed to be on the floor outside the refrigerator. Several small plates containing a small cup of covered cottage cheese and some with crackers were observed to be stacked on the bottom level of the refrigerator. On the outer part of the refrigerator door, the policy about outside food was taped to the door. The policy stated if food was placed in the refrigerator, it must be labeled with the resident's name, their room number, and the date it was placed into the refrigerator. The policy stated food would be discarded after three days in the refrigerator. Additionally, a flyer attached to the door contained information about safe food storage. A temperature log was also attached to the door and had been completed. On 5/1/23 at 2:50 PM, an observation was made of the resident snack refrigerator. Orange juice was observed to be on the bottom level of the refrigerator and on the shelf above it. Dried orange juice was also observed to be on the floor outside of the refrigerator. The plates containing the cottage cheese and crackers were no longer in the refrigerator. On 5/2/23 at 8:40 AM, an observation was made of the resident snack refrigerator. Orange juice was observed to be on the bottom level of the refrigerator and on the shelf above it. A piece of popped popcorn was observed to be in the freezer. On 5/2/23 at 11:26 AM, an interview was conducted with the DM. The DM stated the nursing staff were responsible to clean out the resident snack refrigerator of old food items and any messes that might have occurred. The DM stated the resident snacks were kept in the resident snack refrigerator for the evening snack offering. The DM stated residents did not keep food in the kitchen. The DM stated resident food brought from outside the building was kept in the resident snack refrigerator. The DM stated the policy for bringing in outside food was located on the outside portion of the refrigerator door. On 5/2/23 at 1:50 PM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated snack items were offered to every resident at night. The CNA Coordinator stated snacks were kept in the resident snack refrigerator. The CNA Coordinator stated the dietary staff were responsible for cleaning and cleaning out the resident snack refrigerator. On 5/3/23 at 8:10 AM, an observation was made of the resident snack refrigerator. Orange juice was observed to be on the bottom level and the shelf just above the bottom level. Dried orange juice was also observed to be on the floor outside of the refrigerator. A piece of popped popcorn was observed to be inside the freezer. On 5/3/23 at 8:30 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the Administrator (ADM) was responsible for emptying out the refrigerator. The DON stated the ADM had been doing this task since the previous DON had left. The DON stated the refrigerator should be cleaned out weekly. The DON stated the housekeeping staff should also be cleaning out the resident snack refrigerator. The DON stated she was not aware that the refrigerator was not being cleaned out. The DON stated she would provide more education to staff and be sure the task was put on the schedule to ensure the cleaning was completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility did not notify the physician for 1 of 26 sampled residents after the residents experienced a significant change in condition or a need to alter treatment. Specifically, a resident experienced low blood sugar levels that were outside of physician-set parameters, and the physician was not notified. Resident identifier: 28. Findings include: Resident 28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included diabetes, acute respiratory failure, cerebral infarction, hemiplegia, anemia, atrial fibrillation, and protein calorie malnutrition. Resident 28's medical record was reviewed on 8/17/21. Resident 28's physician's orders were reviewed and revealed the following: a. On 12/21/20, Insulin Lispro Inject as per sliding scale before meals and at bedtime: If 150- 200 = 2 units 201-250 = 4 units 251-300 = 6 units 301-350 = 8 units 351-400 = 10 units b. On 7/1/21, For blood sugar less than 65 or greater than 450 follow facility protocol. [Note: The physician's orders did not provide instructions for staff if resident 28 had a blood glucose (BG) level between 401 and 449.] On 8/17/21 at 11:09 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that for blood sugars less than 65 or greater than 450, the facility protocol was to notify the provider and get orders. Resident 28's July 2021 Medication Administration Record (MAR) and progress notes were reviewed and revealed the following: a. On 7/28/21 at 7:30 AM, resident 28's BG level was 56. There were no corresponding progress notes to indicate facility staff had contacted the physician. Resident 28's August 2021 MAR and progress notes were reviewed and revealed the following: a. On 8/1/21 at 7:30 AM, resident 28's BG level was 61. There were no corresponding progress notes to indicate facility staff had contacted the physician. b. On 8/8/21 at 7:30 AM, resident 28's BG level was 64. There were no corresponding progress notes to indicate facility staff had contacted the physician. c. On 8/13/21 at 7:30 AM, resident 28's BG level was 64. There were no corresponding progress notes to indicate facility staff had contacted the physician. d. On 8/16/21 at 7:30 AM, resident 28's BG level was 61. There were no corresponding progress notes to indicate facility staff had contacted the physician. e. On 8/17/21 at 7:30 AM, resident 28's BG level was 62. There were no corresponding progress notes to indicate facility staff had contacted the physician. On 8/18/21 at 1:10 PM, a follow up interview was conducted with the DON. The DON stated that when a resident's BG was outside of parameters, the protocol was to assess the resident, and then based on the nurses assessment, a determination could be made to notify the physician or not. The DON further stated that there was not a written facility protocol or policy regarding BG levels that were outside of parameters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility did not develop and implement a comprehensive person-centered care plan. The care plan needed to include measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, for 1 of 26 sampled residents, the care plan was not updated with suicidal ideation interventions after multiple expressions of suicidal ideations. In addition, a suicidal care plan was not initiated until approximately 4 months after the resident first expressed suicidal ideations and was readmitted from a Geropsych unit. Resident identifier: 45. Findings include: Resident 45 was admitted to the facility on [DATE] with a readmission on [DATE] and 5/27/21 with diagnoses which included but not limited to major depressive disorder, suicidal ideations, type 2 diabetes mellitus without complications, sequelae of cerebral infarction, demyelinating disease of central nervous system, disorders of brain, anxiety disorder, and reduced mobility. Resident 45's medical record was reviewed on 8/19/21. A Care Plan Focus initiated on 8/5/20, documented [Resident 45] has Potential for mood problem r/t (related to) Admission. A Goal initiated on 8/5/20 and revised on 8/16/21, documented Will have improved sleep pattern by reporting adequate rest or documented episodes of insomnia less than weekly through the review dat (sic). The Interventions initiated on 8/5/20, included the following: a. Educate family and caregivers regarding expectations of treatment, concerns with side effects and potential adverse effects, evaluation, maintenance. b. Encourage to express feelings. c. Monitor, record, and report to Medical Director (MD) mood patterns signs and symptoms of depression, anxiety or sad mood. d. Monitor, record, and report to MD as needed (prn) acute episode feelings or sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite or eating habits, change in sleep patterns, diminished ability to concentrate, and change in psychomotor skills. [Note: The care plan was not updated with suicidal ideation interventions after resident 45 had multiple expressions of suicidal ideations.] On 2/8/21 at 1:45 PM, a Nursing Progress Note documented Pt (patient) has been making statements of feeling like he has poor quality of life and that he is depressed and lonely. His roommate had been out of the room for a couple weeks but was moved back into the room today. Pt doesn't have a plan to hurt himself. He said he would be willing to talk with someone about this. Referral made to [name of mental health services]. On 3/26/21 at 3:36 AM, a Nursing Progress Note documented resident is very depressed and made suicidal statements. stated he would cut his wrists but he didn't have a knife. he talked about his previous roommate and how he missed him since his death. kept stating he has no reason to live and no one cares. cried a little. asked if he would like to talk to someone. notified nurse manager on call. spent a lot of one on one emotional support time with this resident. On 3/26/21 at 1:02 PM, a Nursing Progress Note documented Res (resident) seen by NP (Nurse Practitioner) related to c/o (complaints of) and observed depressive statements. Upon assessment and medication review received new orders for Cymbalta 60mg (milligrams) PO (by mouth) QAM (every morning) r/t depression r/t medical condition. On 4/6/21 at 10:50 AM, an Activities Progress Note documented . Resident is calling out less w/ (with) increased time out of bed w/ 1:1 (one-on-one) interventions. On 4/9/21 at 5:53 PM, a Nursing Progress Note documented Resident making statements about wanting to kill themselves. Asked resident if they had a plan and they stated they would not be able to carry out any plan. Increased checks performed on resident. Resident has had suicidal thoughts in the past. Currently on Cymbalta. Nurse managers notified. Social work notified. MD will see resident on Monday. [Note: Increased checks were unable to be located in the medical record. The one on one activity log was reviewed. A one on one activity was provided on 4/9/21 at 11:17 AM.] On 4/12/21 at 2:17 PM, a Nursing Progress Note documented Resident was seen today by NP d/t (due to) suicidal statements made without specific plan. Labs, meds (medications), vitals reviewed. Resident recently started on Cymbalta, increased dose during visit today. Social work working to arrange visit with psych (psychiatric) this week. [Note: There was no documentation located in the medical record indicating that a psych visit was arranged for resident 45. The last referral to a local mental health services was made on 2/28/21. The one on one activity log was reviewed. A one on one activity was provided on 4/12/21 at 11:48 AM.] On 4/16/21 at 5:56 PM, a Nursing Progress Note documented Resident made a comment earlier when going down to dining room for lunch. He stated: 'I just want to commit suicide.' Nurse asked resident if he had a plan. Resident stated he didn't have a plan. On 4/26/21 at 12:46 PM, a Nursing Progress Note documented Resident was seen today by NP for c/o anxiety, staff reports of yelling out and inability to redirect. Labs, meds, vitals reviewed. See order to obtain UA (urinalysis), titrate down Cymbalta, add Buspar. Resident OK with plan of care. On 5/5/21 at 4:15 PM, a Nursing Progress Note documented CNA (Certified Nursing Assistant) called nurse into residents room due to suicidal thoughts. Resident stated they wanted to kill themselves. Asked resident if they had a plan and they stated they would not be able to carry anything out physically. Stated they just feel sad all the time. Resident is on Buspirone 5 mg and Cymbalta 30 mg. MD notified. Will continue to monitor resident and adjust medications as needed. Social work notified. Nurse managers notified. Will continue to monitor resident. [Note: The one on one activity log was reviewed. A one on one activity was provided on 5/5/21 at 12:06 PM.] On 5/11/21 at 8:30 PM, a Nursing Progress Note documented This evening pt. stated three times that he wanted to die and tried to wrap the call light cord around his neck. Nurse went in and visited with pt. and asked him what was wrong and pt. stated that he was bored. Nurse parked her cart by pt.'s room and visited with him will she pulled pills. This seemed to lift his spirits and pt. stopped making remarks about wanting to dye (sic). Pt. is asleep in bed. [Note: The one on one activity log was reviewed. A one on one activity was provided on 5/11/21 at 12:51 PM.] On 5/20/21 at 3:01 PM, a Social Services Progress Note documented Went and talked to [resident 45] about how he was currently feeling and the statements he had made. He stated that if the cord was around his neck it was an accident but he did want to die. He said if he could kill himself he would. I asked him if we could get him some help for this and he said I doubt anyone can help. I let him know we wanted to help and could send him out to get help and he agreed to go. EMS (Emergency Medical Services) was called. A message was left with [name of mental health services] as well to see if they had been seeing him since the referral was resent on 5/6/21. Awaiting call back. On 5/20/21 at 5:10 PM, a Nursing Progress Note documented This nurse was witnessed to EMS and [name of mental health services] crisis workers speaking with resident in regards to negative statements made by resident. He continued with active suicide statements resident did volunteer to go to hospital for psych assessment. Resident left with out struggle from center. On 5/20/21 at 5:20 PM, a Nursing Progress Note documented Res, with noted suicidal statements to social worker this day. But statements conflicting, resident stated he didn't want to die but if he could kill himself he would. Call light cord removed immediately from room due to this being a potential concern, and resident given alternative device to call for assistance and educated on how to use this, resident placed on q (every) 15minute watch. [name of MD] notified of this and stated to send resident to ER (Emergency Room) for evaluation. EMS called, mobile crisis outreach team as well as EMTs (Emergency Medical Technicians) arrived and assessed resident. Resident left facility via EMS to [name of hospital] for evaluation at approx. (approximately) 1545. Resident emergency contact [name removed] called by floor nurse to notify of transfer and resident current situation. No answer, message left by floor nurse. On 5/21/21 at 10:53 AM, a Nursing Progress Note documented Clarification from previous note, resident taken to [name of local hospital] and admitted to their Geropsych unit. On 5/25/21 at 2:24 PM, a Social Services Progress Note documented [name of mental health services] called today in regards to psych eval referral. They are aware he is in a psych facility at this time. They will see him on 6/7/21 if he is back in the facility at that time. Resident 45 was a readmission from a Geropsych unit on 5/27/21. A Care Plan Focus initiated on 5/27/21 and revised on 6/3/21, documented Resident has a history of suicidal ideation. Resident returned from an inpatient psychiatric stay on 5/27/21. A Goal initiated on 5/27/21 and revised on 8/16/21, documented Resident will be free of any self injury and have a reduction of suicidal ideation by review date. The Interventions initiated on 6/3/21, included the following: a. If resident expresses suicidal ideation assess for suicide risk and plan. Provided Crisis number to call if resident was in crisis. Send for inpatient psych placement if resident was high risk. b. Monitor, record, and report to MD any risk for harming others: increased anger, labile [NAME] or agitation, feels threatened by others or thoughts of harming someone. c. Monitor, record, and report to MD prn risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing medications or therapies, sense of hopelessness or helplessness, and impaired judgement or safety awareness. d. Resident referred to [name of mental health services] for mental health follow up. [Note: A suicidal care plan was not initiated until approximately 4 months after resident 45's first expression of suicidal ideation and resident 45 was readmitted from a Geropsych unit.] On 5/28/21 at 11:02 AM, a Social Services Progress Note documented [Resident 45] came back from psych hospital yesterday. He stated that he doesn't know if he feels any better but that he doesn't have a plan to hurt himself. Offered pt a new room with a new roommate that might be more talkative and he accepted. The room is closet (sic) to the nurses station as well. Pt does not have a call light in his room but is using a tab alarm to make his needs known at this time. Staff will be purchasing a bell today to use. On 5/28/21 at 12:11 PM, a Nursing Progress Note documented Resident is re-admit on 5/27. Was hospitalized for suicidal thoughts. Today resident stated they wanted to be dead. Asked resident if they wanted to kill themselves. Resident stated, 'They had been thinking about it'. Asked resident if they had a plan. Resident stated no. Resident also stated, 'It was all talk' and he would never do it. Nursing managers aware. On call MD made aware. Resident is on Q15 minute checks. They also have an alarm instead of a call button cord for safety measures. Will continue to monitor. On 6/3/21 at 4:07 PM, a Social Services Progress Note documented Pt reported to PASRR (Preadmission Screening and Resident Review) evaluator that he is still depressed and wants to die and he has a plan to overdose. He also told her he didn't have the courage to do it. I went and talked to him and he said he would if he could get enough 'equipment' to do it. National Suicide Hotline called. I was placed on hold while they called him. Awaiting next step. On 6/3/21 at 5:06 PM, a Social Services Progress Note documented MCOT (Mobile Crisis Outreach Team) came to assess pt. They don't feel he needs to return to psych hospital. They do want 15 min (minute) checks continued. They discussed his appointment with [name of mental health services] counselor coming up on Monday and pt willing to talk to him in hopes of making him feel better. He did say he has no way of stepping in front of train and cant (sic) get enough meds to harm himself so although he wants to die he cant (sic) kill himself. On 6/5/21 at 5:25 PM, a Nursing Progress Note documented Aide (CNA) came to me and said that the pt made a comment to her that he no longer wants to live. I went and discussed the statement with the pt and he stated that he does not have a plan and that he is not suicidal. When asked if he wanted to go to the hospital, he stated that 'it depends on if they are just going to put me on the back burner'. I also asked him if he was feeling anxious which he said that he was not. Pt is currently on 15min checks, NP was notified at 1505 (3:05 PM), no new orders were given. A review of the forms that the staff documented 15 minute checks for resident 45 revealed that 15 minute checks were not provided on 6/5/21. The last 15 minute check form provided was dated 6/7/21. A PASRR Letter Of Determination dated 6/6/21, documented to continue 15 minute checks until resident 45 was free of suicidal thinking or until a qualified professional has determined he was at low risk of self-harming. [Note: The mental health services worker on 6/8/21, was unable to remove the 15 minute checks for resident 45. The next documented qualified professional visit was conducted on 7/23/21, by the consulting Licensed Clinical Social Worker (LCSW).] On 6/8/21 at 1:54 PM, a Nursing Progress Note documented Pt seen by [name of mental health services] today. He will start seeing him weekly. He was not able to remove the q 15min checks at this time. They will continue until at least his next visit Wed. (Wednesday). On 7/23/21 at 3:29 PM, a Social Services Progress Note documented by the consulting LCSW documented Met with resident to assess his mental status. Resident was hospitalized in May after suicidal ideation. Resident has been seen by [name of mental health services] for follow up. Resident described that at the time of his hospitalization he just wasn't happy with where he was at in life but that he does not have any thoughts of suicide currently. He has been using a bell instead of a call light; however, this does not appear to be necessary any longer. Recommend monitoring for suicidal statements, stockpiling pills, talking about death and/or giving away items. [Name of mental health services] to continue to follow up with counseling. On 8/19/21 at 12:32 PM, an interview was conducted with the Patient Care Coordinator (PCC). The PCC stated that resident 45 did not feel any different when he was readmitted after his stay at the psych hospital. The PCC stated she had called the crisis team after resident 45 was readmitted and the crisis team told her that resident 45 was in no immediate danger and to follow up with mental health services. The PCC stated the resource Social Worker met with resident 45. The PCC stated the resource Social Worker initiates care plans. The PCC stated she had made the referral to mental health services but mental health services did not think they were allowed in the facility. The PCC stated mental health services were essential and allowed in the facility. The PCC stated resident 45's statements were more anxious then suicidal. The PCC stated the NP made the medication change based on resident 45 being anxious and not suicidal. The PCC stated resident 45's call light was removed and resident 45 was provided with a bell. The PCC stated the resource LCSW decided that resident 45 could have the call light back. On 8/19/21 at 1:27 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if mental health services was unable to come to the facility she would arrange a telehealth visit. On 8/19/21 at 1:52 PM, an interview was conducted with the DON, the PCC, the Administrator, and the Corporate Resource Nurse (CRN). The DON stated mental health services would schedule with the provider when a referral was made. The DON stated she was not sure if follow up on the referral to mental health services for resident 45 was done. The CRN stated the PCC would followup with referrals to mental health services. The PCC stated she could not remember if she followed up with mental health services and she was trying to get better at that. The DON stated they were not excluding providers from the facility. The DON stated if mental health services did not respond to a referral an in house provider would see the resident. The DON stated an in house provider would include the MD, NP, or the Physician Assistant. The CRN stated they were told by mental health services they were back logged and the provider was out a lot this year. The DON stated the LCSW would provide consultation with the resident care plans. The DON stated it would depend on the care plan and who would update it. The DON stated if resident 45 needed assistance he was able to use the call light and staff would go in and talk with resident 45. The DON was asked about interventions to keep resident 45 safe during the time he was making suicidal statements. The DON stated they were looking for a room mate that resident 45 enjoyed speaking with and would talk with resident 45. The CRN stated the nurses would talk with resident 45 a lot and make him feel better. The DON stated the staff would spend time with resident 45. The Administrator stated resident 45 was encouraged to participate in activities and they were offered daily. The CRN stated activities was providing 1:1 activities to resident 45. The CRN stated that resident 45 made statements that suicide would not be intentional and it would be an accident. The CRN stated resident 45 had changed his behaviors to calling out instead of the suicidal statements. The DON stated resident 45 was having some anxiety and was not always redirectable. The DON stated when the NP spoke with resident 45 he stated the Cymbalta was making him to tired. The CRN stated other antidepressant medication had been tried. The DON stated the Cymbalta was tapered to start the Buspar because resident 45 told the NP that he was anxious. The DON stated when resident 45 was readmitted the call light was removed and 15 minute checks were initiated for a short time until resident 45 was safe. The DON stated the Crisis Team was called after resident 45 was readmitted and resident 45 had his room changed so he would be closer to the nurses station for visualization and interaction. The DON stated resident 45 had stopped the suicidal statements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility did not provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, for 1 of 26 sampled residents, a resident with suicidal ideations was not provided interventions. Resident identifier: 45. Findings include: Resident 45 was admitted to the facility on [DATE] with a readmission on [DATE] and 5/27/21 with diagnoses which included but not limited to major depressive disorder, suicidal ideations, type 2 diabetes mellitus without complications, sequelae of cerebral infarction, demyelinating disease of central nervous system, disorders of brain, anxiety disorder, and reduced mobility. Resident 45's medical record was reviewed on 8/19/21. A Care Plan Focus initiated on 8/5/20, documented [Resident 45] has Potential for mood problem r/t (related to) Admission. A Goal initiated on 8/5/20 and revised on 8/16/21, documented Will have improved sleep pattern by reporting adequate rest or documented episodes of insomnia less than weekly through the review dat (sic). The Interventions initiated on 8/5/20, included the following: a. Educate family and caregivers regarding expectations of treatment, concerns with side effects and potential adverse effects, evaluation, maintenance. b. Encourage to express feelings. c. Monitor, record, and report to Medical Director (MD) mood patterns signs and symptoms of depression, anxiety or sad mood. d. Monitor, record, and report to MD as needed (prn) acute episode feelings or sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite or eating habits, change in sleep patterns, diminished ability to concentrate, and change in psychomotor skills. [Note: The care plan was not updated with suicidal ideation interventions after resident 45 had multiple expressions of suicidal ideations.] The Order Summary was reviewed and the following medications were documented: a. On 7/24/20, Effexor extended release 75 mg (milligrams) in the morning (QAM) for depression r/t medical condition. Discontinued on 12/17/20. b. On 12/20/20, Effexor extended release 75 mg QAM for depression r/t medical condition. Discontinued on 1/5/21. [Note: No documentation was located within the medical record indicating why the antidepressant was discontinued.] c. On 1/5/21, Remeron 7.5 mg at bedtime (QHS) for appetite stimulant for 30 days. Discontinued on 2/4/21. [Note: Remeron was classified as an antidepressant medication.] d. On 3/24/21, Trazodone 50 mg QHS for sleep. [Note: Trazodone was classified as an antidepressant medication.] On 2/8/21 at 1:45 PM, a Nursing Progress Note documented Pt (patient) has been making statements of feeling like he has poor quality of life and that he is depressed and lonely. His roommate had been out of the room for a couple weeks but was moved back into the room today. Pt doesn't have a plan to hurt himself. He said he would be willing to talk with someone about this. Referral made to [name of mental health services]. On 3/26/21 at 3:36 AM, a Nursing Progress Note documented resident is very depressed and made suicidal statements. stated he would cut his wrists but he didn't have a knife. he talked about his previous roommate and how he missed him since his death. kept stating he has no reason to live and no one cares. cried a little. asked if he would like to talk to someone. notified nurse manager on call. spent a lot of one on one emotional support time with this resident. [Note: The one on one activity log was reviewed. No one on one activity was provided on 3/26/21.] On 3/26/21 at 1:02 PM, a Nursing Progress Note documented Res (resident) seen by NP (Nurse Practitioner) related to c/o (complaints of) and observed depressive statements. Upon assessment and medication review received new orders for Cymbalta 60mg PO (by mouth) QAM r/t depression r/t medical condition. On 3/26/21 at 4:12 PM, a Social Services Progress Note documented Pt had made depressive statements and was put in the book for provider for possible med (medication) intervention. New order for Cymbalta by NP. A Physician's order dated 3/26/21, documented Cymbalta 60 milligrams by mouth in the morning for depression r/t medical condition. On 4/6/21 at 10:50 AM, an Activities Progress Note documented . Resident is calling out less w/ (with) increased time out of bed w/ 1:1 (one-on-one) interventions. On 4/9/21 at 5:53 PM, a Nursing Progress Note documented Resident making statements about wanting to kill themselves. Asked resident if they had a plan and they stated they would not be able to carry out any plan. Increased checks performed on resident. Resident has had suicidal thoughts in the past. Currently on Cymbalta. Nurse managers notified. Social work notified. MD will see resident on Monday. [Note: Increased checks were unable to be located in the medical record. The one on one activity log was reviewed. A one on one activity was provided on 4/9/21 at 11:17 AM.] On 4/12/21 at 2:17 PM, a Nursing Progress Note documented Resident was seen today by NP d/t (due to) suicidal statements made without specific plan. Labs, meds (medications), vitals reviewed. Resident recently started on Cymbalta, increased dose during visit today. Social work working to arrange visit with psych (psychiatric) this week. [Note: There was no documentation located in the medical record indicating that a psych visit was arranged for resident 45. The last referral to a local mental health services was made on 2/28/21. The one on one activity log was reviewed. A one on one activity was provided on 4/12/21 at 11:48 AM.] A Physician's order dated 4/12/21, documented Cymbalta 90 mg by mouth in the morning for depression r/t medical condition. On 4/16/21 at 5:56 PM, a Nursing Progress Note documented Resident made a comment earlier when going down to dining room for lunch. He stated: 'I just want to commit suicide.' Nurse asked resident if he had a plan. Resident stated he didn't have a plan. [Note: The one on one activity log was reviewed. No one on one activity was provided on 4/16/21.] On 4/26/21 at 12:46 PM, a Nursing Progress Note documented Resident was seen today by NP for c/o anxiety, staff reports of yelling out and inability to redirect. Labs, meds, vitals reviewed. See order to obtain UA (urinalysis), titrate down Cymbalta, add Buspar. Resident OK with plan of care. A Physician's order dated 4/26/21, documented Cymbalta 60 mg by mouth in the morning for depression r/t medical condition for 7 days. Discontinue Cymbalta on 5/4/21. A Physician's order dated 4/26/21 and started on 5/4/21, documented Cymbalta 30 mg by mouth in the morning for depression r/t medical condition for 7 days. Discontinue Cymbalta on 5/11/21. A Physician's order dated 4/26/21, documented buspirone 5 mg by mouth two times a day (BID) for anxiety r/t medical condition for 7 days. Discontinue buspirone on 5/3/21. A Physician's order dated 5/3/21, documented buspirone 5 mg by mouth three times a day (TID) for anxiety r/t medical condition. A Psychotropic Monthly Review dated 4/27/21, documented Cymbalta 90 mg daily was reviewed. Resident 45's target behaviors for the Cymbalta were depressive statements. Resident 45 had 4 episodes and the recommended action was to discontinue. In addition, Buspar 5 mg BID times 1 week then increase to TID was reviewed. Resident 45's target behaviors for Buspar were anxious statements. Resident 45 had no episodes and the recommended action was to maintain. On 5/5/21 at 4:15 PM, a Nursing Progress Note documented CNA (Certified Nursing Assistant) called nurse into residents room due to suicidal thoughts. Resident stated they wanted to kill themselves. Asked resident if they had a plan and they stated they would not be able to carry anything out physically. Stated they just feel sad all the time. Resident is on Buspirone 5 mg and Cymbalta 30 mg. MD notified. Will continue to monitor resident and adjust medications as needed. Social work notified. Nurse managers notified. Will continue to monitor resident. [Note: The one on one activity log was reviewed. A one on one activity was provided on 5/5/21 at 12:06 PM.] On 5/5/21 at 4:55 PM, a Social Services Progress Note documented Sent an email to [name of mental health services] to find out if they had been seeing pt since referral in Feb (February). Awaiting reply. On 5/6/21 at 4:58 PM, a Social Services Progress Note documented Received email from [name of mental health services]. They stated they remember receiving the referral and thought they had given to a case worker but wanted me to resend it. I resent referral. On 5/11/21 at 8:30 PM, a Nursing Progress Note documented This evening pt. stated three times that he wanted to die and tried to wrap the call light cord around his neck. Nurse went in and visited with pt. and asked him what was wrong and pt. stated that he was bored. Nurse parked her cart by pt.'s room and visited with him will she pulled pills. This seemed to lift his spirits and pt. stopped making remarks about wanting to dye (sic). Pt. is asleep in bed. [Note: The one on one activity log was reviewed. A one on one activity was provided on 5/11/21 at 12:51 PM.] On 5/20/21 at 3:01 PM, a Social Services Progress Note documented Went and talked to [resident 45] about how he was currently feeling and the statements he had made. He stated that if the cord was around his neck it was an accident but he did want to die. He said if he could kill himself he would. I asked him if we could get him some help for this and he said I doubt anyone can help. I let him know we wanted to help and could send him out to get help and he agreed to go. EMS (Emergency Medical Services) was called. A message was left with [name of mental health services] as well to see if they had been seeing him since the referral was resent on 5/6/21. Awaiting call back. On 5/20/21 at 5:10 PM, a Nursing Progress Note documented This nurse was witnessed to EMS and [name of mental health services] crisis workers speaking with resident in regards to negative statements made by resident. He continued with active suicide statements resident did volunteer to go to hospital for psych assessment. Resident left with out struggle from center. On 5/20/21 at 5:18 PM, a Nursing Progress Note documented Resident was sent to [name of hospital] ER (Emergency Room) for suicidal statements via ambulance at approximately 1545 (3:45 PM). Message was left with contact [name removed]. On 5/20/21 at 5:20 PM, a Nursing Progress Note documented Res, with noted suicidal statements to social worker this day. But statements conflicting, resident stated he didn't want to die but if he could kill himself he would. Call light cord removed immediately from room due to this being a potential concern, and resident given alternative device to call for assistance and educated on how to use this, resident placed on q (every) 15minute watch. [name of MD] notified of this and stated to send resident to ER for evaluation. EMS called, mobile crisis outreach team as well as EMTs (Emergency Medical Technicians) arrived and assessed resident. Resident left facility via EMS to [name of hospital] for evaluation at approx. (approximately) 1545. Resident emergency contact [name removed] called by floor nurse to notify of transfer and resident current situation. No answer, message left by floor nurse. On 5/21/21 at 10:53 AM, a Nursing Progress Note documented Clarification from previous note, resident taken to [name of local hospital] and admitted to their Geropsych unit. On 5/25/21 at 2:24 PM, a Social Services Progress Note documented [name of mental health services] called today in regards to psych eval referral. They are aware he is in a psych facility at this time. They will see him on 6/7/21 if he is back in the facility at that time. Resident 45 was a readmission from a Geropsych unit on 5/27/21. A Care Plan Focus initiated on 5/27/21 and revised on 6/3/21, documented Resident has a history of suicidal ideation. Resident returned from an inpatient psychiatric stay on 5/27/21. A Goal initiated on 5/27/21 and revised on 8/16/21, documented Resident will be free of any self injury and have a reduction of suicidal ideation by review date. The Interventions initiated on 6/3/21, included the following: a. If resident expresses suicidal ideation assess for suicide risk and plan. Provided Crisis number to call if resident was in crisis. Send for inpatient psych placement if resident was high risk. b. Monitor, record, and report to MD any risk for harming others: increased anger, labile [NAME] or agitation, feels threatened by others or thoughts of harming someone. c. Monitor, record, and report to MD prn risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing medications or therapies, sense of hopelessness or helplessness, and impaired judgement or safety awareness. d. Resident referred to [name of mental health services] for mental health follow up. [Note: A suicidal care plan was not initiated until approximately 4 months after resident 45's first expression of suicidal ideation and resident 45 was readmitted from a Geropsych unit.] The Hospital History of Present Illness note dated 5/21/21, documented that during a crisis evaluation, resident 45 continued to endorse suicidal ideations and reported a plan to either use a knife to cut his wrists or overdose on his medications. The note further documented that since resident 45 arrived he has presented as anxious and dysphoric. Resident 45 has made several suicidal statements, and frequently repeats I want to die. Resident 45 had been prescribed Effexor in the past, but was no currently prescribed any psychotropic medications other than Buspar for anxiety. Resident 45 denies he has ever experienced an adverse reaction to any medications. Resident 45 agrees to begin treatment with sertraline to target his depressive symptoms. The Diagnosis, Assessment, and Plan documented resident 45 meets criteria for major depressive disorder. The Multi-Axial Assessment documented resident 45 with major depressive disorder, recurrent, severe without psychotic features with anxious distress. On 5/28/21 at 11:02 AM, a Social Services Progress Note documented [Resident 45] came back from psych hospital yesterday. He stated that he doesn't know if he feels any better but that he doesn't have a plan to hurt himself. Offered pt a new room with a new roommate that might be more talkative and he accepted. The room is closet (sic) to the nurses station as well. Pt does not have a call light in his room but is using a tab alarm to make his needs known at this time. Staff will be purchasing a bell today to use. On 5/28/21 at 12:11 PM, a Nursing Progress Note documented Resident is re-admit on 5/27. Was hospitalized for suicidal thoughts. Today resident stated they wanted to be dead. Asked resident if they wanted to kill themselves. Resident stated, 'They had been thinking about it'. Asked resident if they had a plan. Resident stated no. Resident also stated, 'It was all talk' and he would never do it. Nursing managers aware. On call MD made aware. Resident is on Q15 minute checks. They also have an alarm instead of a call button cord for safety measures. Will continue to monitor. A review of the forms that the staff documented 15 minute checks for resident 45 revealed that 15 minute checks were not provided on 5/28/21, 5/31/21, 6/1/21, 6/2/21, and 6/3/21. On 6/3/21 at 4:07 PM, a Social Services Progress Note documented Pt reported to PASRR (Preadmission Screening and Resident Review) evaluator that he is still depressed and wants to die and he has a plan to overdose. He also told her he didn't have the courage to do it. I went and talked to him and he said he would if he could get enough 'equipment' to do it. National Suicide Hotline called. I was placed on hold while they called him. Awaiting next step. On 6/3/21 at 5:06 PM, a Social Services Progress Note documented MCOT (Mobile Crisis Outreach Team) came to assess pt. They don't feel he needs to return to psych hospital. They do want 15 min (minute) checks continued. They discussed his appointment with [name of mental health services] counselor coming up on Monday and pt willing to talk to him in hopes of making him feel better. He did say he has no way of stepping in front of train and cant (sic) get enough meds to harm himself so although he wants to die he cant (sic) kill himself. On 6/5/21 at 5:25 PM, a Nursing Progress Note documented Aide (CNA) came to me and said that the pt made a comment to her that he no longer wants to live. I went and discussed the statement with the pt and he stated that he does not have a plan and that he is not suicidal. When asked if he wanted to go to the hospital, he stated that 'it depends on if they are just going to put me on the back burner'. I also asked him if he was feeling anxious which he said that he was not. Pt is currently on 15min checks, NP was notified at 1505 (3:05 PM), no new orders were given. A review of the forms that the staff documented 15 minute checks for resident 45 revealed that 15 minute checks were not provided on 6/5/21. The last 15 minute check form provided was dated 6/7/21. A PASRR Letter Of Determination dated 6/6/21, documented to continue 15 minute checks until resident 45 was free of suicidal thinking or until a qualified professional has determined he was at low risk of self-harming. [Note: The mental health services worker on 6/8/21, was unable to remove the 15 minute checks for resident 45. The next documented qualified professional visit was conducted on 7/23/21, by the consulting Licensed Clinical Social Worker (LCSW).] On 6/8/21 at 1:54 PM, a Nursing Progress Note documented Pt seen by [name of mental health services] today. He will start seeing him weekly. He was not able to remove the q 15min checks at this time. They will continue until at least his next visit Wed. (Wednesday). On 6/29/21 at 2:13 PM, a Social Services Progress Note documented Received email from [name of mental health services] that they have been backed up related to PASRRs and they will call to schedule an appointment to see [resident 45] again. On 7/9/21 at 12:00 PM, a Social Services Progress Note documented Email sent to [name of mental health services] to get update on when they will be in again to see patient as they have not been in since first assessment. On 7/23/21 at 3:29 PM, a Social Services Progress Note documented by the consulting LCSW documented Met with resident to assess his mental status. Resident was hospitalized in May after suicidal ideation. Resident has been seen by [name of mental health services] for follow up. Resident described that at the time of his hospitalization he just wasn't happy with where he was at in life but that he does not have any thoughts of suicide currently. He has been using a bell instead of a call light; however, this does not appear to be necessary any longer. Recommend monitoring for suicidal statements, stockpiling pills, talking about death and/or giving away items. [Name of mental health services] to continue to follow up with counseling. On 8/19/21 at 12:32 PM, an interview was conducted with the Patient Care Coordinator (PCC). The PCC stated that resident 45 did not feel any different when he was readmitted after his stay at the psych hospital. The PCC stated she had called the crisis team after resident 45 was readmitted and the crisis team told her that resident 45 was in no immediate danger and to follow up with mental health services. The PCC stated the resource Social Worker met with resident 45. The PCC stated the resource Social Worker initiates care plans. The PCC stated she had made the referral to mental health services but mental health services did not think they were allowed in the facility. The PCC stated mental health services were essential and allowed in the facility. The PCC stated resident 45's statements were more anxious then suicidal. The PCC stated the NP made the medication change based on resident 45 being anxious and not suicidal. The PCC stated resident 45's call light was removed and resident 45 was provided with a bell. The PCC stated the resource LCSW decided that resident 45 could have the call light back. On 8/19/21 at 1:27 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if mental health services was unable to come to the facility she would arrange a telehealth visit. On 8/19/21 at 1:52 PM, an interview was conducted with the DON, the PCC, the Administrator, and the Corporate Resource Nurse (CRN). The DON stated mental health services would schedule with the provider when a referral was made. The DON stated she was not sure if follow up on the referral to mental health services for resident 45 was done. The CRN stated the PCC would followup with referrals to mental health services. The PCC stated she could not remember if she followed up with mental health services and she was trying to get better at that. The DON stated they were not excluding providers from the facility. The DON stated if mental health services did not respond to a referral an in house provider would see the resident. The DON stated an in house provider would include the MD, NP, or the Physician Assistant. The CRN stated they were told by mental health services they were back logged and the provider was out a lot this year. The DON stated the LCSW would provide consultation with the resident care plans. The DON stated it would depend on the care plan and who would update it. The DON stated if resident 45 needed assistance he was able to use the call light and staff would go in and talk with resident 45. The DON was asked about interventions to keep resident 45 safe during the time he was making suicidal statements. The DON stated they were looking for a room mate that resident 45 enjoyed speaking with and would talk with resident 45. The CRN stated the nurses would talk with resident 45 a lot and make him feel better. The DON stated the staff would spend time with resident 45. The Administrator stated resident 45 was encouraged to participate in activities and they were offered daily. The CRN stated activities was providing 1:1 activities to resident 45. The CRN stated that resident 45 made statements that suicide would not be intentional and it would be an accident. The CRN stated resident 45 had changed his behaviors to calling out instead of the suicidal statements. The DON stated resident 45 was having some anxiety and was not always redirectable. The DON stated when the NP spoke with resident 45 he stated the Cymbalta was making him to tired. The CRN stated other antidepressant medication had been tried. The DON stated the Cymbalta was tapered to start the Buspar because resident 45 told the NP that he was anxious. The DON stated when resident 45 was readmitted the call light was removed and 15 minute checks were initiated for a short time until resident 45 was safe. The DON stated the Crisis Team was called after resident 45 was readmitted and resident 45 had his room changed so he would be closer to the nurses station for visualization and interaction. The DON stated resident 45 had stopped the suicidal statements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility did not ensure residents' drug regimens were free from unnecessary drugs- an unnecessary drug is any drug when used without adequate monitoring. Specifically, for 1 of the 26 sampled residents, the facility provided a resident with blood pressure medication outside of the prescribed parameters for use. Resident identifier: 27. Findings included: Resident 27 was admitted to the facility on [DATE] with medical diagnoses that included but not limited to pneumonitis due to inhalation of food and vomit, essential hypertension (HTN), acute respiratory failure with hypoxia, toxic encephalopathy, alcohol abuse with intoxication, severe protein-calorie malnutrition, reduced mobility with generalized muscle weakness, cognitive communication deficit, dysphagia following cerebral infarction, hyperlipidemia, chronic obstructive pulmonary disease, major depressive disorder, and personal history of transient ischemic attack. On 8/16/21 at 11:41 AM, resident 27 was interviewed. Resident 27 stated he had issues with dizziness when going from laying down to standing, and resident 27 stated because of this reason, the facility was watching his blood pressure readings and medication. On 8/18/21, resident 27's medical record was reviewed. A Nursing Note from 7/20/21 documented, Res (resident) seen by NP (Nurse Practitioner) today r/t (related to) ongoing dizziness when sitting or standing . New orders given for: .add to metoprolol to hold if SBP (Systolic Blood Pressure) < (less than) 110. A physician's order within resident 27's medical record documented, Metoprolol Succinate ER (extended release) Tablet Extended Release 24 Hour 25 MG (milligrams) Give 1 tablet by mouth in the morning for HTN hold for SBP <110- Start Date: 7/21/21. The July and August 2021 Medication Administration Record was reviewed and documented the following: a. On 7/23/21, resident 27 had a blood pressure reading of 108/78 mmHg (millimeters of mercury) prior to metoprolol administration. The metoprolol was coded as provided to resident 27. b. On 8/6/21, resident 27's had a blood pressure reading of 96/52 mmHg prior to metoprolol administration. The metoprolol was coded as provided to resident 27. On 8/18/21 at 12:57 PM, Registered Nurse (RN) 1 was interviewed. RN 1 stated resident 27 received a metoprolol medication for high blood pressure in the mornings. RN 1 stated there were parameters to keep in mind when administering the medication, and resident 27 should not receive metoprolol if the systolic blood pressure was below 110 because resident 27 had trouble with low blood pressures. RN 1 stated the nurse who administered the medication would be prompted to check and record resident 27's blood pressure prior to providing the metoprolol, and the nurse should know if the systolic blood pressure was too low and resident 27 should not be provided metoprolol. On 8/18/21 at 1:23 PM, the Director of Nursing (DON) was interviewed. The DON was asked about the administration of resident 27's metoprolol medication. The DON stated the medication was given to resident 27 outside of the prescribed parameters on 7/23/21 and 8/6/21, and the DON stated the facility would have to complete some re-education with staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, it was determined the facility did not maintain medical records on each resident that are complete and readily accessible. Specifically, for 2 of the 26 sampled residents, the facility did not have all recent physician or nurse practitioner visit notes within the residents' electronic medical record. Resident identifiers: 15 and 39. Findings included: 1. Resident 15 was most recently readmitted to the facility on [DATE] with medical diagnoses that included but not limited to chronic respiratory failure, repeated falls, type 2 diabetes mellitus, morbid obesity, unspecified protein-calorie malnutrition, muscle weakness, chronic kidney disease, bipolar disorder, right bundle-branch block, gastro-esophageal reflux disease, hyperlipidemia, obstructive sleep apnea, glaucoma and blindness of the right eye. On 8/16/21 at 12:25 PM, resident 15 was interviewed. Resident 15 stated he had experienced an issue with fluid accumulation in his ankles for the past couple months, and resident 15 stated nothing was being done at that time for the fluid accumulation in his lower extremities. Resident 15's medical record was reviewed on 8/19/21. An initial history and physical was available within resident 15's medical record dated 6/16/21. On 8/18/21 at 2:30 PM, the Director of Nursing (DON) was interviewed. The DON was asked about the location of other physician assessments of resident 15. The DON stated having to locate the assessments. An email received on 8/18/21 at 2:44 PM, from the DON included the following documents: a. A physician visit documented by a Nurse Practitioner (NP) dated 6/21/21. b. A physician visit documented by a NP dated 6/28/21. c. A physician visit documented by a NP dated 7/15/21. d. A physician visit by a Medical Doctor dated 7/15/21. [Note: The physician visit notes were unable to be located within resident 15's medical record for review.] The physician note completed by a NP dated 6/28/21 documented, Edema BLE (bilateral lower extremities) 2.6% weight gain and 1 week Tubigrips [compression stockings] on the morning off at bedtime. On 8/18/21 at 12:57 PM, Registered Nurse (RN) 1 was interviewed. RN 1 stated being unaware of any interventions resident 15 had in place for fluid accumulation. RN 1 stated if there was an intervention it would be located within resident 15's Order Summary. A review of the Order Summary did not include orders for, 1 week Tubigrips on the morning off at bedtime, as expressed in the 6/28/21, NP visit note. [Note: The 6/28/21, NP visit note was unable to be located within resident 15's medical record.] 2. Resident 39 was admitted to the facility on [DATE] with medical diagnoses that included, but not limited to sepsis, acidosis, urinary tract infection, acute and chronic respiratory failure, pneumonitis due to inhalation of food and vomit, muscle weakness with difficulty in walking, toxic encephalopathy, chronic obstructive pulmonary disease, asthma, generalized anxiety disorder, post-traumatic stress disorder, cirrhosis of the liver, diverticulitis, major depressive disorder, hypertension, cognitive communication deficit, and wedge compression fracture of the thoracic vertebra. Resident 39's medical record was reviewed on 8/19/21. The medical record was reviewed regarding medication adjustments to anti-anxiety medication and included the following documentation: a. A Nursing note dated 7/26/21, documented, Note text: Res (resident) seen by NP, new order given for xanax to be scheduled TID (three times a day), b. A Nursing note dated 7/29/21 documented, Note Text: Pt (patient) seen by NP today. Vitals, orders, labs assessed. See new orders. On 8/17/21 at 2:42 PM, the DON was interviewed. The DON was asked the location of NP visit notes and assessments from 7/26/21 and 7/29/21. The DON stated she would have to locate the documentation. On 8/17/21 at 2:51 PM, an email was received from the DON which contained documentation of NP visits dated 7/26/21 and 7/29/21. [Note: The NP visit notes were unable to be located within resident 39's medical record for review.] On 8/17/21 at 10:48 AM, the Medical Records manager was interviewed. The Medical Records manager stated there was a pile of documents to be filed. The Medical Records manager stated that she tried to sort the documents and upload the records by category. The Medical Records manager stated It can get behind. On 8/19/21 at 10:31 AM, the DON was interviewed. The DON stated the facility was aware of an issue with having all physician's visits timely placed into the residents' medical records. The DON stated the facility had thought to either have the physicians document directly within the residents' medical record or have documentation sent directly to the Medical Records manager through a secure e-mail. The DON stated, at this time, the physician would see residents, documentation of visits occurs off-site and the physician then sends the documentation to the facility or brings in a paper copy. The DON was unable to quantify the time between a physician visit, when the facility received documentation of the visit, and when the documentation was accessible within the residents' medical record. On 8/19/21 at 10:39 AM, RN 2 was interviewed. RN 2 stated it had been an issue being able to locate physician visit notes within residents' medical records. RN 2 stated if she had a physician note to go back to it would help her better understand the residents' care. RN 2 reported at this time once the NP came to the facility any orders would be provided to the Assistant Director of Nursing, and then the orders would be communicated to the nurses.