**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident representative and staff interview, and policy and procedure review, the facility failed to notify family of changes for 1 of 3 sample residents (#1). The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #1 had a BIMS score of 12 out of 15, which indicated s/he had moderate cognitive impairment, and diagnoses which included cerebral infarction due to occlusion. Review of the facility incident review showed the resident had a fall during a transfer on 2/16/25. The following concerns were identified: a. Review of a progress note dated 2/18/25 and timed 3:30 AM showed the resident's representative called the facility on 2/17/25 at 7:40 PM to express a concern that the resident had a fall on 2/16/25 that was not reported to her, and the resident may have hurt [his/her] wrist. Further review showed that following the call the resident was assessed by the nurse and had no obvious open areas, no deformities or swelling, no apparent guarding or motor deficits in any limb; close inspection of left wrist shows no grimace or overt signs of pain elicited upon passive manipulation and observed active motion of the wrist: there is a slight bluish-colored bruising with indistince margins at lateral aspect of the wrist and a small, dry scab approx 1cm [centimeter] long x 2mm [millimeter] wide on the dorsal aspect of the wrist and this does not appear to need a bandage. b. Review of a progress note dated 2/18/25 and timed 3:24 PM showed an x-ray of the resident's left wrist showed no fracture. c. Interview with CNA #1 on 4/2/25 at 10:31 AM revealed the resident pulled his/her right foot up during the transfer, and when s/he started to slide out of the sling, the CNA called for assistance and lowered the resident to the floor. Further interview revealed the resident had not lifted his/her foot before during a transfer. The CNA revealed she reported the incident to the nurse on duty at that time. d. Interview with the DON on 4/2/25 at 11:04 AM confirmed the resident's representative was not called after the fall, and the facility policy was to notify the resident's family after a fall. Further interview revealed the nurse on duty was a traveler and was not aware of the policy to notify family after an assisted fall. Further interview revealed immediate education was given to the nurse on the policy. e. Interview with the resident representative for resident #1 on 4/2/25 at 12:25 PM revealed that during a visit with the resident on 2/17/25 the resident had told her s/he had a fall during a transfer on 2/16/25. Further interview revealed the resident had a bruise on his/her wrist, and the representative was upset she had not been notified about the fall. 2. Review of the policy titled Resident Falls last reviewed on 5/1/23 showed .In the event of a fall, family members of residents will be notified as well as the provider if the resident sustains an injury or possible injury .**A fall is anytime a patient falls, or a patient would have fallen if staff would not have been there to assist the patient to the floor.

Based on medical record review, staff interview, and facility policy and procedure review, the facility failed to ensure residents right to request/refuse/discontinue treatment for 1 of 1 sample residents (#45) with a do not resuscitate (DNR) status. The findings were: 1. Review of the electronic medical record on 1/7/25 at 2:26 PM showed resident #45 had a DNR code status, however there was no evidence the resident elected the DNR code status. 2. Interview with the DON on 1/9/25 at 10 AM revealed the electronic medical record showed no sign of a declaration of code status. Further interview revealed the provider should have filled out the code status; however, it was not in the electronic medical record. 3. Review of the facility's policy DNR Policy updated 3/15/18 showed .1. At the time of admission the Social Services person or Charge Nurse shall determine if the resident has executed a Living Will or has a signed statement for DNR.5. The physician shall assume the responsibility for writing the DNR order by: a. Writing and dating the order on the Physician's order sheet b. The order will be updated every 30 days and signed by the Physician. 6. If the resident is mentally incompetent (determined by a Physician), the resident's guardian and/or the Durable POA for health care decisions (designated by the Living Will or by written statement from the resident prior to the mental incompetency) may make the DNR designation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, medical record review, and policy and procedure review, the facility failed to ensure residents received services to maintain good personal hygiene for 2 of 3 sample residents (#7, #33) reviewed for activities of daily living. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #7 had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included cerebrovascular accident, transient ischemic attack, or stroke and Parkinson's disease. Further review showed the resident required partial/moderate assistance with bathing and upper and lower body dressing. The following concerns were identified: a. Interview with the resident on 1/7/25 at 9:21 AM revealed s/he did not feel there was enough staff because s/he did not get showers regularly. b. Review of the bathing records for October, November, and December of 2024 and January of 2025 showed the resident went 6 days without a shower from 10/18/24 to 10/25/24, 11/22/24 to 11/29/24, 12/6/24 to 12/13/24, and 12/13/24 to 12/20/24. Further review showed the resident went 10 days without a shower from 12/27/24 to 1/7/25. There were no documented refusals for the resident. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #33 had a BIMS score of 15 out 15, which indicated the resident was cognitively intact, and had diagnoses which included Parkinson's disease. Further review showed the resident required partial/moderate assistance with bathing and lower body dressing. The following concerns were identified: a. Interview with the resident on 1/7/25 at 11:03 AM revealed the facility only offered showers 2 days per week and at times s/he did not receive a shower because there was not enough staff. b. Review of the bathing records for October, November, and December of 2024 and January of 2025 showed the resident went 6 days without a shower from 10/1/24 to 10/9/24, for 9 days from 10/15/24 to 10/25/24, for 10 days from 10/25/24 to 11/5/24, for 6 days from 11/8/24 to 11/15/24, for 9 days from 11/19/24 to 11/29/24, for 6 days from 12/6/24 to 12/13/24 and 12/13/24 to 12/20/24, and for 10 days from 12/27/24 to 1/7/25. Further review showed the resident refused bathing on 10/4/24, 10/18/24, 10/29/24, 11/12/24, and 11/22/24 and there was no evidence the resident was offered bathing on another day. 3. Interview with the DON on 1/8/25 at 4:24 PM revealed residents should get at least 1 shower per week and ideally would have 2 showers per week. She confirmed showers were only provided on scheduled days and the facility did not have a plan to ensure bathing when the staff member who provided bathing was not available. 4. Review of the facility policy titled Resident Baths last revised on 6/15/18 showed .All residents will receive a full-body bath at least once a week. An exception to this may be made if the resident is so ill that it would not be in their best interest to insist. For residents who are ill or unable to tolerate the tub or shower bath, a bed bath is an acceptable substitute .3. All residents will be bathed more frequently as the desire, or if soiling has occurred that requires a tub bath or shower .10. We recognize that all residents have the right to refuse baths, clothing changes, and other measures of good hygiene. If any resident chooses not to accept these services, the CNA will inform the nurse in charge of that resident's care, of the refusal. The nurse will then have the responsibility of persuading the resident to accept care. If the resident still adamantly refuses the bath, the nurse will document in the resident's chart. Offers for the bath will be continued until the resident will accept .12. Residents will be scheduled for baths on two days per week, as has been the practice. If residents refuse a bath on one day, or if the care center staffing does not allow for baths on one of those days, it may be postponed until the next shift, the next day, or the next scheduled bath day. All schedules and cares give must always be in the best interest of care and comfort for the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy and procedure review, the facility failed to ensure an appropriate diagnoses and attempt removal of an indwelling urinary catheter for 1of 1 sample resident (#7). The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #7 had a BIMS score of 14 out 15, which indicated the resident was cognitively intact, and no genitourinary diagnoses except renal insufficiency, renal failure, or end-stage renal disease. Further review showed the resident was independent with toileting hygiene, personal hygiene, and toilet transfer, was always continent of bowel, was not on a toileting program, and had an indwelling catheter placed. The following concerns were identified: a. Observation on 1/7/25 at 9:21 AM showed the resident was in his/her room and a catheter drainage bag was hanging on the side of the resident's trash can. b. Review of a hospital discharge note dated 6/13/24 showed the resident was discharged from the hospital to the facility following antibiotic therapy for 21 days. Further review showed .[S/he] will continue with Foley catheter secondary to urine incontinence and recurrent infection . c. Review of the physician orders showed no evidence of an appropriate diagnosis for the placement of a foley catheter. d. Interview with the DON on 1/8/25 at 4:16 PM revealed the resident previously had wounds on his/her legs and the catheter was placed to prevent infections in the legs. She revealed the facility had not attempted an external catheter or bladder retraining and she was aware the resident did not have an appropriate diagnosis for catheter placement. 2. Review of a facility policy titled Bowel & Bladder Training last revised on 8/15/18 showed .All residents who are admitted to [the facility] will be evaluated for Bowel and Bladder training The functions of the bowel and bladder conditions of each resident will be reassessed on a quarterly basis in conjunction with the care plan and MDS conferences, to assure the monitoring of these conditions and to enable prompt treatment if a problem should occur in bowel and bladder function .Residents will not qualify for Bowel or Bladder retraining if they have the following conditions: Multiple Sclerosis, Quadriplegia, neurogenic bladder, severe benign prostatic hypertrophy, comatose, Alzheimer's disease, combative and uncooperative to retraining, and if the resident is unable to cooperate due to being cognitively impaired .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Review of the admission MDS assessment dated [DATE] showed resident #2 resident had short-term memory loss and diagnoses which included Alzheimer's dementia, anxiety disorder, and depression. Further review showed the resident didn't exhibit any behaviors during the look-back period. Review of the medication administration record showed the resident received fluoxetine (antidepressant) 20 mg daily, buspirone (antianxiety) 10 mg daily, lorazepam (antianxiety) 0.5 mg twice daily, and olanzapine (antipsychotic) 10 mg daily. The following concerns were identified: a. Review of the medical record showed no evidence the facility had identified or was monitoring medication specific target symptoms related to the psychotropic medications. 7. Interview with the DON on 1/8/25 at 4:31 PM confirmed the facility had not identified and did not monitor medication specific target symptoms for the psychotropic medications. 8. Review of the policy titled Antipsychotic medication use/PRN psychotropic/ antipsychotic order procedure last reviewed 5/1/23 showed 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 2. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. 3. The attending physician will identify, evaluate, and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of psychotropic medications .PRN orders for psychotropic drugs are limited to 14 days initially. PRN orders for anxiolytics and antipsychotics must be reviewed for appropriateness 14 days after initiation. Providers must document the rational [sic]/benefit for continuing this prn order in the clinical record and must also indicate when this order will be re-evaluated. 1. Stop dates will be put in when ordering PRN psychotropic. They will not exceed 14 days for initial order. If provider documents the continue [sic] need and extends the timeframe, order can be adjusted to fit the timeframe. Timeframe cannot be indefinite or lifetime, 2-12 months max. This can be repeated as deemed necessary . Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure target symptoms were identified and monitored for 6 of 6 sample residents (#2, #9, #36, #44, #45, #47) and failed to ensure PRN orders for psychotropic medications were limited to 14 days for 1 of 6 sample residents (#44) reviewed for unnecessary psychotropic medications. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #44 had a BIMS score of 5 out of 15, which indicated severe cognitive impairment and diagnoses which included Alzheimers/dementia with agitation and depression. The MDS showed the resident had a mood score of 0, which indicated no signs or symptoms of depression, and the resident exhibited behaviors such as verbal behavior directed at others and wandering. Further review showed the resident received antipsychotic medication and antidepressent medication during the look-back period. Review of the physician orders showed the resident received olanzapine (antipsychotic) 7.5 milligrams (mg) by mouth twice a day, sertraline (antidepressant) 50 mg by mouth every day, and lorazepam (antipsychotic) 0.5 mg by mouth every day, PRN. The following concerns were identified: a. Review of the medical record showed no evidence the facility had identified or was monitoring medication specific target symptoms related to the psychotropic medications. b. Review of the physician's progress notes dated 10/23/24 showed the physician re-ordered the use of lorazepam 0.5 mg by mouth daily as needed, however there was no indication of a stop date. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #36 had a BIMS score of 0 out of 15, which indicated severe cognitive impairment, and diagnoses which included Alzheimers/dementia, anxiety and depression. The MDS showed the resident had a mood score of 0, which indicated no signs or symptoms of depression, and exhibited behaviors of inattention, disorganized thinking, physical behavior directed toward others, rejection of care, and wandering. Further review showed the resident received antipsychotic medication and antidepressent medication during the look-back period. Review of the physician orders showed the resident received lorazepam (antidepressant) 0.5 mg by mouth three times a day, quetiapine (antipsychotic) 150mg by mouth twice a day, and quetiapine (antipsychotic) 75mg by mouth at every lunch. The following concerns were identified: a. Review of the medical record showed no evidence the facility had identified or was monitoring medication specific target symptoms related to the psychotropic medications. 3. Review of the quarterly MDS assessment dated [DATE] showed resident #45 had a BIMS score of 2 out of 15, which indicated severe cognitive impairment, and diagnoses which included Alzheimer's dementia, anxiety, and agitation due to dementia. The MDS showed the resident had a mood score of 0, which indicated no signs or symptoms of depression, and the resident exhibited behaviors such as verbal behavior directed at others and wandering. Further review showed the resident received antipsychotic medication and antidepressant medication during the look-back period. Review of the physician orders showed the resident received sertraline (antidepressant) 50 mg by mouth daily and lorazepam (antianxiety) .5mg by mouth every day as needed (PRN) for agitation-sedation. The following concerns were identified: a. Review of the medical record showed no evidence the facility had identified or was monitoring medication specific target symptoms related to the psychotropic medications. 4. Review of the quarterly MDS assessment dated [DATE] showed resident #47 had a BIMS score of 7 out of 15, which indicated severe cognitive impairment, and diagnoses which included Alzheimers/dementia, anxiety and depression. The MDS showed the resident had a mood score of 1, which indicated minimal signs or symptoms of depression, and exhibited behaviors of inattention, delusions, verbal behavior symptoms directed toward others, rejection of care, and wandering. Further review showed the resident received antipsychotic medication and antidepressant medication during the look-back period. Review of the physician orders showed the resident received quetiapine (antipsychotic) 100 mg by mouth twice a day, lorazepam (antianxiety) 1 mg by mouth at noon and 1 mg by mouth at night. The following concerns were identified: a. Review of the medical record showed no evidence the facility had identified or was monitoring medication specific target symptoms related to the psychotropic medications. 5. Review of the quarterly MDS assessment dated [DATE] showed resident #9 had a BIMS score of 14 out of 15, which indicated intact cognition, and diagnoses which included anxiety disorder, depression and insomnia. Review of the physician orders for the resident showed an order for venlafaxine (antidepressant) 150 mg daily and trazodone (antidepressant) 50 mg daily. The following concerns were identified: a. Review of the medical record showed no evidence the facility had identified or was monitoring medication specific target symptoms related to the psychotropic medications.

Based on resident representative and staff interview, grievance review, state survey agency incident database review, and policy and procedure review, the facility failed to ensure allegations of abuse were reported for 1 of 4 sample residents (#3) reviewed for allegations for abuse. The findings were: 1. Interview with the resident representative for resident #3 on 8/27/24 at 6:02 PM revealed the resident's spouse reported a CNA had pushed the resident down onto a chair on 8/25/24; however, she did not think the facility believed the spouse. 2. Review of a Complaint/Grievance form dated 8/25/24 showed [Spouse of resident #3] said CNA pushed [resident] down to sit in chair. 2. Review of the state survey agency incident database showed no evidence an allegation of abuse was reported for resident #3 on or after 8/25/24. 3. Interview with CNA #4 on 8/27/24 at 6:21 PM revealed she was providing 1 to 1 care for resident #3 on 8/25/24. Further interview revealed the DON arrived at the facility and sent the CNA home due to an allegation of abuse; however, after the DON watched the camera footage, she was told there was no evidence she abused the resident. 4. Interview with the DON on 8/28/24 at 11:22 AM confirmed the spouse of resident #3 reported a staff member had pushed the resident down into a chair roughly; however, the spouse was unable to see if the CNA did anything. The DON revealed the CNA was sent home and an investigation was initiated. Further interview confirmed the allegation was not reported to the state survey agency. 5. Review of the policy titled Abuse Prevention Program last revised on 5/1/23 showed .7. Investigate and report any allegations of abuse within timeframes as required by federal requirements .

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure care plans were developed and implemented for 2 of 4 sample residents (#1, #2) following resident to resident altercations. The findings were: 1. Review of an incident dated 8/4/24 showed resident #2 punched resident #1 in the mouth with his/her fist. Further review showed resident #1 had a small cut and mild swelling. Review of an incident dated 7/21/24 showed resident #3 walked up to resident #1, grabbed resident #1's face, and resident #1 slapped resident #3 in the face. The following concerns were identified: a. Review of the care plan for resident #1 last updated 7/1/24 showed no resident specific interventions related to altercations on 7/21/24 or 8/4/24. b. Review of the care plan for resident #2 last updated 7/20/24 showed no resident specific interventions related to aggression toward other residents or staff and no updated interventions related to the altercation on 8/4/24. 2. Interview with CNA #1 on 8/28/24 at 10:58 PM revealed resident #2 was kind of dangerous, attacked staff, was aggressive without provocation, and usually goes after resident #1. Further interview revealed staff implemented things they knew about residents because resident specific interventions were not on the care plans. 3. Interview with the MDS assessment coordinator on 8/28/24 at 11:22 PM revealed care plans should communicate interventions to staff and care plans have been a struggle. Further interview revealed the facility did not complete any type of analysis following incidents and confirmed care plans were not updated with all identified interventions. 4. Review of the policy titled Resident to Resident Altercations last revised on 6/2/20 showed .If two residents are involved in an altercation, staff will .e. Review the events with Nursing Supervisor and Director of Nursing, and possible measures to try to prevent additional incidents .g. Make any necessary changes in the care plan approaches to any or all of the involved individuals .

Based on medical record review and staff interview, the facility failed to complete a discharge summary which included a recapitulation of the resident's stay for 1 of 1 resident (#58) reviewed for discharge to another nursing home or swing bed. The findings were: 1. Review of the 9/13/23 discharge MDS assessment for resident #58 showed s/he had been discharged to Another nursing home or swing bed and a return to the facility was not anticipated. The following concerns were identified: a. Review of the resident's medical record showed a 9/13/23 Facility Transfer form had been completed which indicated the resident had been transferred to a swing bed. Further review of the medical record showed no evidence a discharge summary had been completed. Interview with the DON on 10/17/23 at 5:19 PM confirmed the discharge summary had not been completed.

Based on observation, medical record review, staff interview, and review of policy and procedures the facility failed to develop and implement a comprehensive person-centered care plan or 1 of 6 residents (# 18) reviewed for behavior indicators. The findings were: 1. Review of the care plan for resident #18, dated 6/10/22, showed diagnoses of Alzheimer's dementia, history of cerebral vascular accident, and chronic left hip pain. Review of the progress note dated 7/9/22 at 11:44 PM showed [Res #18] and another resident wanting to go out outside after supper. Review of the progress note dated 7/12/22 at 6:24 PM showed Resident has attempted at least 5 times during 3p-7p shift to go out the patio doors. Resident has attempted to get on the elevator twice, stating [s/he] needed to go downstairs and outside to look for [her/his] phone. Review of the progress note dated 7/13/22 at 9:11 PM showed Resident wanting to go out on the patio or downstairs this evening; no extra staff to go with [her/him]. Complains to other residents which makes them angry also. Trying to get on elevator to get downstairs. Intervention by this RN. Resident did go over to [special care unit] and then could not get back out the doors. Heard banging on the doors by this RN. Review of the progress note dated 7/16/22 at 8:28 PM showed Resident consistently trying to get out patio doors. Wants to be outside. The following concerns were identified: a. Observations performed on 8/15/22 through 8/17/22 showed resident #18 frequently tried to get on the elevator with staff and visitors. b. Review of the care plan for resident #18 last dated 6/10/22 showed the only behavior indicator to be [S/he] tends to take things that don't belong to [her/him]. c. Interview with the DON on 8/17/22 at 4:47 PM revealed the resident attempted to elope frequently. It was further revealed this behavior should have been addressed in the care plan, along with interventions. d. Review of Policy and Procedure CCN-100-46 last reviewed on 12 /28/21, showed It will be the policy of the New Horizons Care Center to have a care plan on each resident admitted to the Care Center. These will be reviewed and revised quarterly and more often if the resident's condition warrants it.

Based on observation, resident interview, staff interview, and policy review the facility failed to ensure food temperatures were maintained at an acceptable temperature for 1 of 3 units (Pod 2). The findings were: Observation on 8/17/22 at 11 AM showed covered food was in the steamer table ready for staff to plate. Further observation showed plated food was delivered to Pod 2 at 12 PM. At 12:15 PM one of the last trays was served to the residents. The last tray of food was checked by the dietary manager. The meat temperature was measured at 102 Fahrenheit (F) and the vegetables at 120 degrees F. Interview at that time with the dietary manager confirmed the temperatures were lower than they should be. Further, she stated the cook takes the temperature of the food prior to serving the plates. The food temperature is not checked again after that initial check. Once the trays are loaded in the carts they go directly to the different pods. Once delivered to the pod, it is the nursing staff that serves the trays to the residents. Interview with resident #31 on 8/16/22 at 1:19 PM revealed the food was cold, and did not taste good. Interview with dietitian on 8/17/22 at 3:41 PM revealed the facility needed to recheck the food temperature once it gets out to the residents. It is something we need to improve on. Review of the policy Food Temperatures last reviewed 12/29/21, showed Food temperatures will be within state guidelines . 4. The Dietary Supervisor will monitor and take appropriate steps if temperatures are not in acceptable ranges.