Every finding on record at Continuing Care at Highland Springs

Based on interview and record review the facility failed to ensure each resident received 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 for 1 of 6 residents (Resident #1) reviewed for behavioral services. The facility failed to provide behavioral health care and services to Resident #1 who continued to express suicidal ideations and display signs and symptoms of depression after inpatient treatment for suicidal ideations at a behavioral health hospital stay from [DATE]-[DATE], resulting in Resident #1 ingesting a lethal dose of diphenhydramine (Benadryl) and expiring on [DATE]. An IJ was identified on [DATE] at 5:07 PM. The IJ template was provided to the facility on [DATE] at 5:25 PM. While the IJ was removed on [DATE] at 4:45 PM, the facility remained out of compliance at a scope of a Isolated with a severity level potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not having their behavioral health service needs met, serious physical harm, injury, and/or death. Findings include: Record review of Resident #1's quarterly MDS dated [DATE] indicated the resident was a [AGE] year-old female who admitted to the facility on [DATE] and re-admitted to the facility on [DATE] from an inpatient psychiatric center with diagnoses of bipolar disorder (mental health condition that causes extreme mood swings that range from depressive lows to manic highs), major depressive disorder recurrent, severe with psychotic symptoms (mood disorder that causes a persistent feeling of sadness and loss of interest and may make a person feel like life isn't worth living as well as hallucinations and delusions), vascular dementia moderate, with psychotic disturbance (changes in thinking and memory that occur when there isn't enough blood flow to part of the brain), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and epilepsy (brain condition that causes reoccurring seizures. Record review reflected Resident #1 had a BIMS score of 14, which meant she had little to no cognitive impairment. The MDS also reflected Resident #1 experienced feeling down, depressed, or hopeless two to six days (several days) in the last two weeks. The MDS reflected the resident was independent with upper body dressing, oral hygiene, and personal hygiene. The MDS reflected the resident was partial/moderate assistance with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear Record review of Resident #1's care plan, dated [DATE], reflected Resident #1 was hospitalized at a behavioral health facility from [DATE]-[DATE] and [DATE]-[DATE]. Record Review of Resident #1's care plan, dated [DATE], reflected Resident #1 would exhibit or express depression because her [family member] died, she did not have closure and did not get to say goodbye, she says she has no money; and she feels family doesn't visit much and feels stuck in her little room. Record Review of Resident #1's care plan, dated [DATE], reflected signs/symptoms of depression which included a lack of appetite, trouble sleeping at night, and would sleep in. The care plan also reflected that Resident #1 would speak with the social worker if she needed counseling and that the social worker was her mental health professional. Record Review of Resident #1's care plan, dated [DATE], reflected Resident # 1 had suicidal ideations. Interventions included listening and providing comfort when Resident #1 was confused and agitated as well as communicating in a manner that promoted mental and psychological wellbeing Record review of Resident #1's Physician's Orders reflected resident had orders for:Sertraline 25 mg (3 tabs (75 mg)) Tablet oral with a start date of [DATE] to treat depressionMirtazapine 7.5 mg tablet (1) Tablet Oral with a start date of [DATE] to treat major depressive disorderRisperidone .5 mg tablet (3 tabs (1.5mg)) Tablet Oral with a start date of [DATE] to treat bipolar disorder Record review of Resident #1's Progress Notes by LVN L, dated [DATE] at 5:54 AM, reflected: The aid notified this nurse that the patient wrapped a draw sheet around the neck the nurse aide helped the patient to unwrapped [sic] the draw sheet, patient states the she wants to died [sic] and join her [family member] but death is not coming fast. Notified MD order to keep a close eye on the patient every 15 mins[sic] and wait for further instructions. Record review of Resident #1's Progress Notes, dated [DATE] at 2:21 PM by Social Worker N reflected: .Sw met with Resident and her mood had declined in the day. Resident reported she was a disappointment and did not want to do anything. She did not want to eat and just wanted to sleep .Sw walked into her room. She stated she wanted to die yet denied any plan and stated she would not do anything to harm herself. Physician notified. Resident has a .caregiver with her from 2-4pm daily. Sw to remain available as needed. Record Review of Resident #1's Progress Notes, dated [DATE] at 6:21 AM, by LVN L reflected: Patient approached this nurse and said that she was told to notify somebody if she is feeling suicidal, she states right now am feeling suicidal am looking for a bottle of pills to take I don't care anymore. Patient sited at the nursing station with this nurse, resident continue to express that since her [family member] died the feeling [sic] of suicide have been in her mind, notified NP order to send resident to .hospital.patient called 911 and after the police spoke with the patient they told this nurse that the patient states that she will use the light bulb in her room to cut herself. Patient was transported by the police car to .hospital. Record Review of Resident #1's Progress Notes, dated [DATE] at 4:15 PM, by LVN B reflected: Per administration, no special precautions necessary. Will continue to monitor frequently and provide active listening for patient to express feelings. Pt is at this time sitting in her room watching TV, no distress noted. Personal sitter here from 1400-1600(2:00 PM-4:00PM), pt went outside with sitter and ate a snack. Record Review of Resident #1's Progress Notes, dated [DATE] at 5:47 PM, LVN B reflected: .Pt reports to nurse that she has had in the past sudden, severe episodes of itching all over her body. When these happened, she would take 2 Benadryl and the itching would cease. She explained, I feel like its happening again. Pt brought an unopened bottled of Benadryl from her drawer. Explained that all medications should be kept in her locked cabinet for safety, and that no medication can be given without a medical provider's knowledge and providing the nurse with an order and directions. Pt verbalized understanding and handed bottle to this nurse. Medication locked in cabinet. Provider notified, new order received for diphenhydramine 25 mg-give 2 tabs (50 mg) PO now x1dose. May repeat 50mg x 1dose in 8 hours if itching persists. MAR updated. Benadryl given. Pt reports medication effective at this time. Teaching provided to pt about not having medication in her room, it must be locked in the cabinet. Pt verbalized understanding. Record Review of Resident #1's Medical Records from local hospital dated [DATE] reflected: Summary: [AGE] year-old female presents by EMS for acute unresponsiveness. Patient was found unresponsive in her place of living by staff. EMS reports that they found an empty Benadryl bottle and partially empty Benadryl bottle and will concern for an overdose. Patient had multiple seizures witnessed by EMS. Patient did not have a witnessed cardiac arrest. Her [family member] committed suicide by self-inflicted gunshot wound to the head 14 months ago according to family. Patient is DNR and this was confirmed by her [family member AA].He said that he is concerned she may intentionally overdosed because she has made threats of suicide recently and her [family member] committed suicide 14 months ago. The patient was pronounced at 10:51 AM. Record review of Resident #1's electronic health care record on [DATE] reflected no evidence that Resident #1 was receiving behavioral health services at the time of her suicide. Interview on [DATE] at 11:21 AM with CNA A revealed that she made rounds upon her initial arrival on [DATE] for her 6:00 AM-2:00 PM shift. CNA A stated she checked on Resident #1 at approximately 6:10 AM and saw Resident #1 resting peacefully. CNA A then revealed at 8:45 AM when she went to take Resident #1 her breakfast, she saw Resident #1 lying crooked on the bed with her feet hanging off of the bed and her head perpendicular on the bed. CNA A revealed that she asked Resident #1 if she needed help getting back into bed. CNA A stated that she saw Resident #1's eyes open, but Resident #1 would not answer. CNA A revealed she could feel the resident's pulse, but Resident #1 continued to not answer her. CNA A stated that she felt she needed to notify her nurse due to the resident's unresponsiveness. CNA A stated that she did not notice any pill bottles on her nightstand when she made her rounds when she made her earlier morning round. CNA A revealed that the resident looked normal, and she did not see anything unusual like a bottle of pills on the bedside table. CNA A revealed that when making rounds and when she put away laundry, she looked for anything out of the ordinary or out of place and would report it to the nurse. CNA A stated that Resident #1 often slept all day through her shift and did not eat breakfast or lunch. CNA A stated she did not hear Resident #1 make statements about suicidal ideations. CNA A revealed that Resident #1 had a sitter two hours per day from 2:00 PM to 4:00 PM. CNA A stated that on[DATE] Resident #1 did not eat breakfast or lunch and had no abnormal behaviors that day. Interview on [DATE] at 12:06 PM with LVN B revealed that CNA A came and requested her assistance and stated that Resident #1 was breathing differently on [DATE]. LVN B stated that Resident #1 was lying perpendicular on her bed and breathing differently with her eyes open. LVN B said that Resident #1's pupils were dilated, and she was pale in color. LVN B thought she could be hypoglycemic. However, she saw pink emesis on the sheets. LVN B stated she looked over and saw two bottles on her nightstand and realized Resident #1 must have taken something. LVN B stated she stepped out into the hallway and requested assistance from LVN C. LVN B stated she dialed 911 while LVN C assisted Resident #1. LVN B revealed that while they were waiting for emergency services, Resident #1 vomited pink emesis, which had two pills in it, and two seizures that lasted between 30 and 45 seconds. LVN B said that she was unaware how many pills the resident swallowed; LVN B stated that one bottle was fuller than the other bottle. LVN B stated that emergency services took the fuller bottle with them so that the doctors would know how many pills the resident had taken. LVN B stated that Resident #1 had continued to express suicidal ideations after her third return from a behavioral health facility in [DATE] for a few months. LVN B stated she reported the continued suicidal ideations to Medical Director D and management the DON. LVN B stated Resident #1 was not sent out to a behavioral health center for her continued suicidal ideations. LVN B stated for the last six months she believed Resident #1 was depressed as evidenced by Resident #1 sleeping all day. LVN said that Resident #1 would often tell her that she was sad. LVN stated that the facility increased Resident #1's activities to aide with her depression. LVN B said that at the time she believed the added activities were benefiting Resident #1 as well as counseling by the Social Worker. LVN B was unaware of how or when Resident # 1 obtained the Diphenhydramine. LVN B stated that Resident #1 went out with her personal sitters to stores for shopping because she did have a credit card and access to funds. Interview on [DATE] at 12:55 PM with the DON revealed he received a call from LVN B on [DATE]. The DON stated that LVN B revealed Resident #1 could have ingested pink pills that were diphenhydramine. The DON said that there was only one pill left in one bottle, but there were pills on the floor and bed (each pill bottle contained 100 pills). The DON stated that LVN B and LVN C placed a rebreather on the resident which raised her oxygen from the low 70's to the low 90's. LVN B called emergency services for Resident #1. The DON explained that LVN B found pink emesis on Resident #1's bed. While waiting for emergency services, Resident #1 also vomited again, and two pills were present in the emesis. The DON revealed Resident #1 had suicidal ideations previously and had been sent to an in-patient facility two times for expressing suicidal ideations in [DATE] and [DATE]. The DON also stated that Resident #1 previously had attempted suicide at the facility when she was found to have a bed sheet wrapped around her neck and was sent to an in-patient treatment facility for the suicide attempt in [DATE]. The DON said that the in-patient behavioral health facility changed the resident's medications while she was there to her current medications. The DON also revealed that he thought the resident's depression and anxiety had improved the last few months. The DON stated staff tried to encourage Resident #1 to go to activities, but she wanted to stay in her room. The DON stated he went to the building after speaking with LVN B. He stated that he in-serviced nurses on securing medications and had the nurses complete room searches to ensure that residents did not have medications in their room. The DON also revealed that he asked all the alert residents the PHQ9 questions to determine if there were any other residents with depression or suicidal ideations. The DON reported there were no current residents with suicidal ideations. In-Serviced staff that if a resident said they are having suicidal ideations, the staff is to stay with them and use their cell phone to call the nurse or administration until someone comes to assess and notify the provider. The DON stated he expected the personal sitters to inform their charge nurse if the resident purchased medications at any store while they were out. The DON stated that if medications were not given to the charge nurse and locked up, the resident could be at risk of side effects or death if taken. Telephone interview on [DATE] at 1:19 PM with Family Member AA revealed that Resident #1's [family member] shot and killed himself 18 months previously in the facility's independent living apartment while Resident #1 was in the hospital. Family Member AA also stated that approximately three months after her [family member] committed suicide, Resident #1 was found with bed sheets wrapped around her neck in an attempt to end her life in the facility. Family member AA stated that he was told by staff that any medication brought to the facility was to be given to the nurse so it could be locked up. Family member AA revealed Resident #1 expressed suicidal ideations two other times, and the facility sent the resident out to a behavioral health center for treatment. Family member AA stated that he visited Resident #1 five days previous to the resident's suicide. Family member AA was not able to continue the conversation because he was on his way to the funeral home. Interview on [DATE] at 2:12 PM with the Administrator revealed that it was reported to her that the CNA A made rounds at approximately 6:20 AM on [DATE] and Resident #1 was sleeping peacefully. The Administrator stated that about 7:15 AM the nurse and aide CNA A and LVN B went in together again to make rounds and again Resident #1 was sleeping peacefully. The Administrator said that it was again reported to her that CNA A went into Resident #1's room and found that something was wrong with Resident #1, and then went and got LVN B. The Administrator revealed that LVN B reported to her that LVN B checked Resident #1's vitals and found that Resident #1's oxygen was low. And during this process, LVN B noticed pink emesis on the resident's sheets. LVN B then reported to the Administrator that she saw two bottles of diphenhydramine sitting on Resident #1's nightstand. The Administrator stated that LVN B called emergency services. LVN B reported to the Administrator that Resident #1had two seizures while waiting for emergency services to arrive and transport her to the hospital. The Administrator stated that the resident was sent out and admitted to a behavioral health facility three times while she was a resident of their facility in [DATE], [DATE], and [DATE]. The Administrator stated Resident #1 had made a suicide pact with her husband. And when her husband committed suicide, she attempted suicide and was found by staff to have a bedsheet around her neck in her room [DATE]. The Administrator revealed that after the resident returned from her stay at the behavioral health facility and suicide attempt, the facility paid for a 24-hour sitter for a period of time (time unknown by Administrator). However, the Administrator stated that Resident #1 expressed to her that the sitter's presence made her feel like she was being punished and therefore made her feel more depressed. So, the Administrator and Resident #1 agreed the sitter would stay with the resident for two hours per day for the hours of 2:00 PM to 4:00 PM. The Administrator stated that the Medical Director made numerous psychological referrals, but the family and residents declined to pay out of pocket for the counseling appointments. The Administrator said that she thought that Resident #1 was doing better because she had attended outings recently. Administrator declined to answer when asked if LVN B notified her of Resident #1's continued depression and statements after her last in-patient mental health facility. The Administrator stated she expected the personal sitters to notify the resident's charge nurses and give the medication to the charge nurse if any medication was obtained while they were out shopping (because the resident could have bought the Benadryl when out with a personal sitter). The Administrator stated that risks to the residents if this was not done could be death or other medical repercussions due to a medication contradiction to the resident's daily medications. Interview on [DATE] at 2:47 PM with Medical Director E revealed that she is the medical director of the independent living portion of the continuum of care retirement community. Medical Director E stated she was Resident #1's physician in the community before she became a resident at the independent living portion of the facility. Medical Director E stated that Resident #1 had been depressed her whole life and had stayed at mental health facilities before she came to the facility and additional hospital stays for self-neglect. Medical Director E stated that Resident #1 had been unhappy her whole life, and she and the facility had put hours of time into trying to get help for Resident #'1 depression. Medical Director E stated Resident #1 denied help offered by the facility's Social Workers. Medical Director E stated that you can't make someone accept help. Telephone Interview on [DATE] at 10:34 AM with Social Worker M revealed that Resident #1 told her that she would not try to kill herself though she and her [family member] had a suicide pact. Social Worker M stated that Resident #1 revealed that she did not like behavioral hospitals, and she did not want to end up back in one. Social Worker M stated that staff did not report to her Resident #1 continued to express suicidal ideations and depressions. Social Worker M said that after each time the resident was admitted to a behavioral health facility, she would have approximately four counseling sessions. Social Worker M stated Resident #1 refused help from her or to speak with her at all for the last six months. Social Worker M also revealed that Resident #1 was not seeing another therapist, and she did not think Resident #1 desired help from outside source. Social Worker M said that if Resident #1 had expressed suicidal ideations to her, she would have informed her doctor and ensured that she was sent out to a mental health facility. Telephone interview on [DATE] at 11:03 AM with personal sitter F revealed that she sat two hours per day from 2:00 PM to 4:00 PM with Resident #1 on her assigned days. Sitter F stated that she worked on [DATE], the day before Resident #1's suicide. Sitter F revealed that some days Resident #1 would sleep all day and would not be awake when or dressed when she arrived for her 2:00 PM shift. Sitter F stated on some days the resident would agree to be dressed, and she would walk the resident to the on-site pond to feed the ducks. Sitter F revealed that Saturday was a day that Resident #1 stayed in bed. Sitter F revealed that when she left her shift at 4:00 PM, Resident #1 was still sleeping and had not been out of bed all day. Sitter F stated that Resident #1 did not eat breakfast or lunch because she had not been awake at all that day. Sitter F stated that Resident #1 did not express suicidal ideations when she sat with her on previous day. Sitter F also stated she did not see any medications accessible to Resident #1 in her room. Sitter F also revealed that she did not take Resident #1 to any stores during the times she sat with her. Personal Sitter F said that she would have taken any medications purchased by a resident to the charge nurse when she arrived back at the facility. Sitter F explained that Resident #1's care plan stated that she had depression and anxiety. Telephone Interview on [DATE] at 11:27 AM with personal sitter G revealed that she last sat with Resident #1 on [DATE]. Sitter G stated that Resident #1 was having a good day that day. Sitter G revealed that Resident #1 woke up at 3:00 PM and she assisted Resident #1 with dressing. Sitter G said she then escorted Resident #1 to a singing activity. Sitter G stated that Resident #1 never expressed suicidal ideation or acted depressed when she sat with her. Sitter G explained that Resident #1's care plan stated that she had depression and anxiety. Sitter G also stated she did not see any medications accessible to Resident #1 in her room. Personal Sitter G stated that she did not take Resident #1 to a local pharmacy, and she was unaware of how Resident #1 obtained the diphenhydramine. Personal Sitter G said that she would have taken any medications purchased by a resident to the charge nurse when she arrived back to the facility. Telephone interview on [DATE] at 11:34 AM with personal sitter H revealed that she had been Resident #1's sitter for about a year. Personal Sitter H stated that she sat with Resident #1 two hours per day from 2:00 PM to 4:00 PM. Personal Sitter H revealed that on the last day she sat with Resident #1, the resident was pleasant and happy. Personal Sitter H stated she did not know what Resident #1's care plan reflected about Resident #1's signs of depression and interventions. Personal Sitter H revealed that Resident #1 did not voice suicidal ideations. And Personal Sitter H stated if Resident #1 did voice suicidal ideations, she would have reported it to her supervisor. Sitter H also stated she did not see any medications accessible to Resident #1 in her room. Personal Sitter H stated that she did not take Resident #1 to a local pharmacy, and she was unaware of how Resident #1 obtained the diphenhydramine. Telephone interview on [DATE] at 11:45 AM with personal Sitter I revealed that she had been Resident #1's sitter for about a year. Personal Sitter I stated that she sat with Resident #1 two hours per day from 2:00 PM to 4:00 PM and Sitter I revealed that she took Resident #1 to a local pharmacy in [DATE]. Sitter I said she recalled Resident #1 purchased candy and acetaminophen. Sitter I stated that she reported to the nurse Resident #1's purchase of acetaminophen and took the medication to the nurse. Sitter I stated that Resident #1 slept a lot and spoke about missing her [family member]. However, Resident #1 did not express suicidal ideations. Sitter I said she would have reported suicidal ideations to her supervisor. Telephone interview on [DATE] at 1:07 PM with personal Sitter J revealed she had been Resident #1's sitter for about a year. Personal Sitter I stated that she sat with Resident #1 two hours per day from 2:00 PM to 4:00 PM. Personal Sitter J stated she accompanied Resident #1 to the store on [DATE]. Personal Sitter J stated that the resident bought a sweater and chocolate. Personal Sitter J revealed Resident #1 did not express suicidal ideations, but she would have reported it to her supervisor if she had. Personal Sitter J also stated Resident #1 did not purchase medications including Benadryl at the store. Interview on [DATE] at 1:14 PM revealed that Medical Director D saw Resident #1 on [DATE]. Medical Director D stated that she continued Resident #1's medications that were prescribed by the mental health facility that she was discharged from on [DATE]. Medical Director stated that when she saw Resident #1 on [DATE], her mood was better, and the resident denied suicidal ideations. Medical Director D revealed Resident #1 was supposed to be seeing a geriatric psychiatrist provider for mental health therapy, but Family Member AA and Resident #1 stated that they were not happy with him and canceled the appointments and declined his services. Medical Director D stated that after Resident #1 refused to continue seeing her psychiatrist, she made five more referrals. And Family Member AA and Resident #1 declined to see them because there would be out of pocket expenses, or the referred doctor did not take geriatric patients. Medical Director D said that on [DATE] Resident #1 agreed to a tele visit with the last referred geriatric psychologist. However, Family Member AA did not want to pay the out-of-pocket expense for the insurance. Medical Director D stated that Resident #1 would tell staff that she did not want to live. But then tell her when she made her rounds that she was doing good and did not want to see a psychologist. Medical Director D revealed she believed that she would not tell her that she needed help or choose to see a psychologist because she did not want to be admitted to a mental health facility. Resident #1 expressed to Medical Director D that she did not like her stays at her previous mental health facilities. Medical Director D stated that Resident #1 learned what statements needed to be said to get her sent out to a mental health facility. Medical Director D revealed that she thought the resident was mentally doing better because she saw her eating in the dining room. Medical Director D also stated that after the first two mental health facility stays, the resident had personal sitters 24 hours per day. Then the resident asked not to have a sitter after the third mental health facility admission. Medical Director revealed she was unaware of how and where Resident #1 obtained two bottles of diphenhydramine. Interview on [DATE] at 2:52 PM with CNA K revealed that she was Resident #1's CNA on the 2:00-10:00PM Monday through Friday. CNA K stated that Resident #1 slept in some days until after lunch. CNA K said that she did not hear Resident #1 express suicidal ideations. CNA K also stated that she knew Resident #1 went to the pharmacy on three separate occasions with her private sitters, but she could not recall which sitter took her or when. CNA K said that it never occurred to her or the other staff to look in her bags to see if there were any harmful items. CNA K said that she reviewed Resident #1's care plan and encouraged Resident #1 to attend activities to help with her depression. Record review of the facility policy Suicide Threats, dated 07/2025, reflected: Policy.1. If a resident is threatening to commit suicide to a staff member, that staff member must reported [sic] situation immediately. 2. The licensed nurse shall immediately notify CC Leadership On call and campus dispatch. 3. A staff member must remain with the resident until the licensed nurse / medical provider arrives to examine the resident. 4. Administration, Nursing Administration, in conjunction with the Medical Provider, determine the appropriate interventions including (1) the potential of providing 1:1 supervision to promote the safety of the resident and (2) the potential need for evaluation/treatment at the emergency or acute care facility. 5. An assessment of the resident's actions and expressions will be made by the interdisciplinary care plan team as soon as possible of such incident to determine interventions that may be necessary to prevent the recurrence of such threats. Revised care/service plans will be developed to reflect such interventions. 6. Documentation of the incident must be recorded in the resident's medical record and an Incident Report completed. This was determined to be an Immediate Jeopardy (IJ) situation on [DATE] at 5:00 PM. The Administrator was notified at 5:15 PM. The Administrator was provided with the IJ template on [DATE] at 5:24 PM and a Plan of Removal (POR) was requested. The Plan of Removal (POR) was accepted on [DATE] at 12:20 PM and indicated the following: Immediate action: 1. Staff immediately initiated emergency response procedures including (nurse assessed resident. Checked blood sugar, and administered oxygen) when resident #1 was found by the nurse vomiting and convulsing with an almost empty bottle of Benadryl at bedside. The facility was notified that the resident expired at the hospital following the event.2. The nursing staff completed a 100% room sweep of all skilled nursing residents' rooms to ensure no outside or unauthorized medications were present in residents' rooms. No additional unauthorized medication was found as of [DATE].3. A communication will be sent to all family members of skilled nursing regarding our medication policy for outside medications. This will be completed by 01.20.26. We will send monthly for the next three months. Communication on facility policy for outside medications will be added to the admission packet for all new residents.4. The Director of Nursing initiated interviews withal staff that have cared for resident #1 in the past week to confirm if any signs or changes in resident mood or suicidal ideations were observed. No manifestations of suicidal ideations or mood change were observed in past week.5. Suicide threats are to be taken seriously and immediately reported to the licensed nurse, clinical leaders, campus dispatch and/or administration. *If a resident threatening to commit suicide to a staff member, that staff member must report situation immediately to licensed nurse. *The licensed nurse shall immediately notify CC Leadership on Call and campus dispatch. *Administration, Nursing Administration, in conjunction with the Medical Provider, will determine the appropriate interventions including: The potential of providing 1:1 supervision to promote the safety of the resident and The potential need for evaluation/treatment at an emergency or acute care facility *An assessment of the resident's actions and expression (mood and behaviors) will be made by the interdisciplinary care plan team as soon as possible of such incident to determine interventions that may be necessary to prevent the recurrence of such threats. Revised care/service plans will be developed to reflect such interventions. *Documentation of the incident must be recorded in the resident's medical record and an Incident Report completed.6. The Director of Nursing or designees will conduct wellness interviews of all 38 interviewable residents utilizing PHQ9 questions #1,2, and 9 to assess for any immediate signs of depression, depression symptoms and/or thoughts of self-harm. Any resident identified with concerning responses will have appropriate interventions implemented immediately including provider notification, psychiatric refe

Based on interview and record review, the facility failed to develop and implement a comprehensive centered care plan for each resident that includes measurable objectives to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #1) of 6 residents reviewed for care plans. The facility failed to develop a care comprehensive care plan with interventions and actions the facility could take that were specific to Resident #1's suicidal ideations when she admitted to the facility from an in-patient behavioral health facility on [DATE]. On [DATE] Resident #1 ingested approximately a bottle and a half of Benadryl (Diphenhydramine) and expired at the local hospital. An IJ was identified on [DATE] at 5:07 PM. The IJ template was provided to the facility on [DATE] at 5:25 PM. While the IJ was removed on [DATE] at 4:45 PM, the facility remained out of compliance at a scope of Isolated with a severity level potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure place residents at risk of not having their needs met, serious physical harm, injury, and/or death. Findings include: Record review of Resident #1's quarterly MDS dated [DATE] indicated the resident was a [AGE] year-old female who admitted to the facility on [DATE] and re-admitted to the facility on [DATE] from an inpatient psychiatric center with diagnoses of bipolar disorder (mental health condition that causes extreme mood swings that range from depressive lows to manic highs), major depressive disorder recurrent, severe with psychotic symptoms (mood disorder that causes a persistent feeling of sadness and loss of interest and may make a person feel like life isn't worth living as well as hallucinations and delusions), vascular dementia moderate, with psychotic disturbance (changes in thinking and memory that occur when there isn't enough blood flow to part of the brain), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and epilepsy (brain condition that causes reoccurring seizures. Record review reflected Resident #1 had a BIMS score of 14, which meant she had little to no cognitive impairment. The MDS also reflected Resident #1 experienced feeling down, depressed, or hopeless two to six days (several days) in the last two weeks. Record review of Resident #1's care plan, dated [DATE], reflected Resident #1 was hospitalized at a behavioral health facility from [DATE]-[DATE] and [DATE]-[DATE]. Record Review of Resident #1's care plan, dated [DATE], reflected Resident #1 would exhibit or express depression because her [family member] died, she did not have closure and did not get to say goodbye, she says she has no money; and she feels family doesn't visit much and feels stuck in her little room. Record Review of Resident #1's care plan, dated [DATE], reflected signs/symptoms of depression which included a lack of appetite, trouble sleeping at night, and would sleep in. The care plan also reflected that Resident #1 would speak with the social worker if she needed counseling and that the social worker was her mental health professional. Record Review of Resident #1's care plan, dated [DATE], reflected Resident # 1 had suicidal ideations. Interventions included listening and providing comfort when Resident #1 was confused and agitated as well as communicating in a manner that promoted mental and psychological wellbeing Record review of Resident #1's Physician's Orders reflected resident had orders for:Sertraline 25 mg (3 tabs (75 mg)) Tablet oral with a start date of [DATE] to treat depressionMirtazapine 7.5 mg tablet (1) Tablet Oral with a start date of [DATE] to treat major depressive disorderRisperidone .5 mg tablet (3 tabs (1.5mg) Tablet Oral with a start date of [DATE] to treat bipolar disorder Record review of Resident #1's Progress Notes by LVN L, dated [DATE] at 5:54 AM, reflected: The aid notified this nurse that the patient wrapped a draw sheet around the neck the nurse aide helped the patient to unwrapped [sic] the draw sheet, patient states the she wants to died [sic] and join her husband but death is not coming fast. Notified MD order to keep a close eye on the patient every 15 mins[sic] and wait for further instructions. Record review of Resident #1's Progress Notes, dated [DATE] at 2:21 PM by Social Worker N reflected: .Sw met with Resident and her mood had declined in the day. Resident reported she was a disappointment and did not want to do anything. She did not want to eat and just wanted to sleep .Sw walked into her room. She stated she wanted to die yet denied any plan and stated she would not do anything to harm herself. Physician notified. Resident has a .caregiver with her from 2-4pm daily. Sw to remain available as needed. Record Review of Resident #1's Progress Notes, dated [DATE] at 6:21 AM, by LVN L reflected: Patient approached this nurse and said that she was told to notify somebody if she is feeling suicidal, she states right now am feeling suicidal am looking for a bottle of pills to take I don't care anymore. Patient sited at the nursing station with this nurse, resident continue to express that since her husband died the feeling [sic] of suicide have been in her mind, notified NP [NAME] order to send resident to .hospital.patient called 911 and after the police spoke with the patient they told this nurse that the patient states that she will use the light bulb in her room to cut herself. Patient was transported by the police car to .hospital. Record Review of Resident #1's Progress Notes, dated [DATE] at 4:15 PM, by LVN B reflected: Per administration, no special precautions necessary. Will continue to monitor frequently and provide active listening for patient to express feelings. Pt is at this time sitting in her room watching TV, no distress noted. Personal sitter here from 1400-1600 (2:00 PM - 4:00 PM), pt went outside with sitter and ate a snack. Record Review of Resident #1's Progress Notes, dated [DATE] at 5:47 PM, LVN B reflected: .Pt reports to nurse that she has had in the past sudden, severe episodes of itching all over her body. When these happened, she would take 2 Benadryl and the itching would cease. She explained, I feel like its happening again. Pt brought an unopened bottle of Benadryl from her drawer. Explained that all medications should be kept in her locked cabinet for safety, and that no medication can be given without a medical provider's knowledge and providing the nurse with an order and directions. Pt verbalized understanding and handed bottle to this nurse. Medication locked in cabinet. Provider notified, new order received for diphenhydramine 25 mg-give 2 tabs (50 mg) PO now x1dose. May repeat 50mg x 1dose in 8 hours if itching persists. MAR updated. Benadryl given. Pt reports medication effective at this time. Teaching provided to pt about not having medication in her room, it must be locked in the cabinet. Pt verbalized understanding.Record Review of Resident #1's Medical Records from local hospital dated [DATE] reflected: Summary: [AGE] year-old female presents by EMS for acute unresponsiveness. Patient was found unresponsive in her place of living by staff. EMS reports that they found an empty Benadryl bottle and partially empty Benadryl bottle and will concern for an overdose. Patient had multiple seizures witnessed by EMS. Patient did not have a witnessed cardiac arrest. Her husband committed suicide by self-inflicted gunshot wound to the head 14 months ago according to family. Patient is DNR and this was confirmed by her son.He said that he is concerned she may intentionally overdosed because she has made threats of suicide recently and her husband committed suicide 14 months ago. The patient was pronounced at 10:51 AM. Record Review of Social Worker M Progress Notes, dated [DATE], reflected: .Social worker made follow-up visit for ongoing counselling. Social work has attempted numerous visits, resident previously had either been asleep or out of her room. Today, she was available, her caregiver was with her. She has a caregiver 2 hours every day to assist with activities. She is doing well. They just got back from the pharmacy. She has not seen her son.It is better when she can get out of her room. Interview on [DATE] at 12:55 PM with the DON revealed that each department is responsible for their part of a resident's care plan. The DON stated that the MDS Coordinator has been employed at the facility for about a month, but she has been in-training. The DON also stated that the Clinical Manager was responsible for the nursing portion of care plans including interventions. The DON also revealed that there was currently no clinical manager employed at the facility, and there had not been for about two weeks. The DON stated that if there was no clinical manager, he would be responsible for care plans. The DON also stated that there were interventions for Resident #1's suicidal ideations. The DON stated that he thought Resident #1 was following the interventions on the care plan because she was attending activities and speaking with the facility Social Worker per the care plan. And the DON stated that he thought the interventions on the care plan were appropriate, so no more interventions had been added. After the interview, the DON updated Resident #'1's care plan for her suicidal ideations. Interview on [DATE] at 2:12 PM with the Administrator revealed that it was reported to her that the CNA A made rounds at approximately 6:20 AM on [DATE] and Resident #1 was sleeping peacefully. The Administrator stated that about 7:15 AM the nurse and aide CNA A and LVN B went in together again to make rounds and again Resident #1 was sleeping peacefully. The Administrator said that it was again reported to her that CNA A went into Resident #1's room and found that something was wrong with Resident #1, and then went and got LVN B. The Administrator revealed that LVN B reported to her that LVN B checked Resident #1's vitals and found that Resident #1's oxygen was low. And during this process, LVN B noticed pink emesis on the resident's sheets. LVN B then reported to the Administrator that she saw two bottles of diphenhydramine sitting on Resident #1's nightstand. The Administrator stated that LVN B called emergency services. LVN B reported to the Administrator that Resident #1had two seizures while waiting for emergency services to arrive and transport her to the hospital. The Administrator stated that the resident was sent out and admitted to a behavioral health facility three times while she was a resident of their facility in [DATE], [DATE], and [DATE]. The Administrator stated Resident #1 had made a suicide pact with her husband. And when her husband committed suicide, she attempted suicide and was found by staff to have a bedsheet around her neck in her room [DATE]. The Administrator revealed that after the resident returned from her stay at the behavioral health facility and suicide attempt, the facility paid for a 24-hour sitter for a period of time (time unknown by Administrator). However, the Administrator stated that Resident #1 expressed to her that the sitter's presence made her feel like she was being punished and therefore made her feel more depressed. So, the Administrator and Resident #1 agreed the sitter would stay with the resident for two hours per day for the hours of 2:00 PM to 4:00 PM. The Administrator stated that the Medical Director made numerous psychological referrals, but the family and residents declined to pay out of pocket for the counseling appointments. The Administrator said that she thought that Resident #1 was doing better because she had attended outings recently. Administrator declined to answer when asked if LVN B notified her of Resident #1's continued depression and statements after her last in-patient mental health facility. The Administrator stated she expected the personal sitters to notify the resident's charge nurses and give the medication to the charge nurse if any medication was obtained while they were out shopping (because the resident could have bought the Benadryl when out with a personal sitter). The Administrator stated that risks to the residents if this was not done could be death or other medical repercussions due to a medication contradiction to the resident's daily medications. The Administrator also revealed that she believed Resident #1's care plan had appropriate interventions because the Social Worker was available to Resident #1, and Resident #1 had attended activities recently. The Administrator stated that the MDS Coordinator was responsible overall for residents' care plans. Interview on [DATE] at 2:47 PM with Medical Director E revealed that she is the medical director of the independent living portion of the continuum of care retirement community. Medical Director E stated she was Resident #1's physician in the community before she became a resident at the independent living portion of the facility. Medical Director E stated that Resident #1 had been depressed her whole life and had stayed at mental health facilities before she came to the facility and additional hospital stays for self-neglect. Medical Director E stated that Resident #1 had been unhappy her whole life, and she and the facility had put hours of time into trying to get help for Resident #'1 depression. Medical Director E stated Resident #1 denied help offered by the facility's Social Workers. Medical Director E stated that you can't make someone accept help. Telephone Interview on [DATE] at 10:34 AM with Social Worker M revealed that Resident #1 told her that she would not try to kill herself though she and her husband had a suicide pact. Social Worker M stated that Resident #1 revealed that she did not like behavioral hospitals, and she did not want to end up back in one. Social Worker M stated that staff did not report to her Resident #1 continued to express suicidal ideations and depressions. Social Worker M said that after each time the resident was admitted to a behavioral health facility, she would have approximately four counseling sessions. Social Worker M stated Resident #1 refused help from her or to speak with her at all for the last six months. Social Worker M also revealed that Resident #1 was not seeing another therapist, and she did not think Resident #1 desired help from outside source. Social Worker M said that if Resident #1 had expressed suicidal ideations to her, she would have informed her doctor and ensured that she was sent out to a mental health facility. Review of the facility's Care/Service Plans, dated 05/2021, reflected: .8. Care Plans will be reviewed, revised, if applicable, on an ongoing basis by the interdisciplinary team with any change in condition and after each assessment, including both comprehensive and quarterly review assessments. In addition, Post-Acute residents will have their care plan reviewed weekly. and Long Term care residents will have their care plan reviewed at a minimum of quarterly. All interdisciplinary team members will document any updates/changes on care plan copy in the guest/resident suite/apartment/designated accessible location and review update with designated care associate.* This was determined to be an Immediate Jeopardy (IJ) situation on [DATE] at 5:00 PM. The Administrator was notified at 5:15 PM. The Administrator was provided with the IJ template on [DATE] at 5:24 PM and a Plan of Removal (POR) was requested. The Plan of Removal (POR) was accepted on [DATE] at 12:20 PM and indicated the following: Immediate Actions: 1. Staff immediately initiated emergency response procedures including (nurse assessed resident. Checked blood sugar, and administered oxygen) when resident #1 was found by the nurse vomiting and convulsing with an almost empty bottle of Benadryl at bedside. The facility was notified that the resident expired at the hospital following the event. 2. The Director of Nursing initiated interviews with all staff that have cared for resident #1 in the past week to confirm if any signs or changes in resident mood or suicidal ideations were observed. No manifestations of suicidal ideations or mood change were observed in past week. The Director of Nursing or designees will conduct wellness interviews of all 38 interviewable residents utilizing PHQ9 questions #1, #2, and #9 to assess for any immediate signs of depression, depression symptoms and/or thoughts of self-harm. Any resident identified with concerning responses will have appropriate interventions implemented immediately including provider notification, psychiatric referral, and appropriate updates to their plan of care. The social worker or designee will visit all residents with concerning responses weekly for one month and reassess the visits needed. The Social Worker Nursing will conduct wellness interviews of the five non interviewable residents utilizing PHQ9 questions #1 and #2. Any resident identified with concerning responses will have appropriate interventions implemented immediately including provider notification, psychiatric referral, and appropriate updates to their plan of care. The social worker or designee will visit all residents with concerning responses weekly for one month and reassess the visits needed. The Regional Director of Clinical Operations completed a 100% audit of MDS''s completed since [DATE], confirming that zero residents had answered yes to thoughts of better off dead on [DATE]. The regional director of clinical operations completed 100% of MDS completed since [DATE]-current with depressive symptoms. The Director of Nursing or designee will conduct an audit or all current resident care plans to validate that they have measurable objectives, timeframes, and interventions to address their mental health and psychosocial needs identified in the comprehensive assessment to prevent serious harm or death. Discrepancies will be corrected promptly. 3. Director of Health Services Education and Training for the facilitywill train the Staff Development Coordinator, and/or designee on the policy for comprehensive person center care plans that have measurable objectives, time frames, and interventions to address their mental health needs. The facility staff development coordinator and/or designee will provide education to all leadership and licensed nurses on the facility policy for comprehensive person centered care plan that has measurable objectives, time frames and interventions to address their mental health needs. *All the aforementioned training shall be documented on a facility Management Training Roster. The Nursing Home Administrator (NHA) and Human Resources (HR) shall maintain copies of these records. Re-training shall occur at least annually. *All employees who have not been trained due to absence, schedule rotation or other factors will be removed from the schedule until the required training is completed and documented. *Ongoing-standard operating procedures and process for handling of unauthorized outside medications and required actions if noted in resident rooms will be made part of ongoing new hire orientation for all licensed nurses and nurse managers. 4. Identified at risk residents will be reviewed daily during clinical meeting to assess for changes in depressive symptoms and/or suicidal ideations. 5. The Social Worker or designee will perform weekly wellness interviews using PHQ9 questions #1, #2, and #9 with a randomized sample of 10% of residents for four weeks then monthly for two months, any identified concern will have appropriate interventions implemented immediately including provider notification, psychiatric referral, care plan updates and safety measures. The social worker will conduct wellness interviews of the five non interviewable residents utilizing the staff observations PHQ9 questions #1 and #2. The DON or designee will conduct a weekly audit of all newly admitted residents for one month then monthly for two months to confirm PHQ 9 assessments were completed and appropriate care plan interventions were implemented. The Director of Nursing or designee will conduct an audit of all current resident care plans to validate that they have measurable objectives, time frames, an interventions to address their mental health and psychosocial needs identified in the comprehensive assessment to prevent their assessment to prevent serious harm or death weekly for one week, monthly for two months. Discrepancies will be corrected promptly. The Director or designee will conduct a weekly audit of all newly admitted residents for one month then monthly for two months to validate that they have measurable objectives, timeframes, and interventions to address their mental health and psychosocial needs identified in the comprehensive assessment to prevent serious harm or death. Audit findings will be reviewed during the Quality Assurance and Performance Improvement meetings monthly, additional audits and education will be determined based on findings. 6. Date of Completion [DATE]. Monitoring of facility's Plan of Removal included the following: Record review of the PHQ-9, dated [DATE], by the DON regarding depression and suicidal ideations with residents was reviewed and. There were 31 residents included. One resident was found to have depression (Resident #2) and one resident (Resident #3) was found to express he would be better off dead Resident. Resident #3 care plan, dated [DATE], reflected the following interventions: chaplain visits, counselor visits, programming activities in room, outside referral to appropriate resources including social worker and/or counselor. Social worker will assess Resident #3 weekly for 30 days and coordinate mental health follow up as needed. Wife denied mental health at this time on [DATE]. Resident #2 care plan, dated [DATE], reflected interventions the following interventions: encourage group programming and socialization outside, referrals to counselor as needed and as suicidal risks warranted, all staff will report any statements of self-harm or withdrawal to the nurse immediately. Nurse will notify provider immediately of any increase suicidal ideations, statements of self-harm, or .changes. Nursing/programming staff will encourage me to participate in daily routine activities and report any refusals or signs of isolating to charge nurse. Interview on [DATE] at 2:30 PM with CNA A revealed she was in-serviced to alert a nurse if medication is found in the resident's room. CNA A revealed she was in-serviced about Residents #2 and Resident #3's depression and care plans. CNA A also stated that if a resident has a suicidal ideation, she would report it to the charge nurse by calling the nurse and stay with the resident until the nurse came to assess the resident. CNA A also said that she was in-serviced to be familiar with each resident's care plan. Interview on [DATE] at 2:37 PM with CNA T revealed he was in-serviced to alert a nurse if medication is found in the resident's room. CNA T revealed he was in-serviced about Residents #2 and Resident #3's depression and care plans. CNA T also stated that if a resident has a suicidal ideation, he would report it to the charge nurse by calling the nurse and stay with the resident until the nurse came to assess the resident. CNA T also said that he was in-serviced to be familiar with each resident's care plan. Interview on [DATE] at 2:45 PM with CNA U revealed she was in-serviced to alert a nurse if medication is found in the resident's room. CNA U revealed she was in-serviced about Residents #2 and Resident #3's depression and care plans. CNA U also stated that if a resident has a suicidal ideation, she would report it to the charge nurse by calling the nurse and stay with the resident until the nurse came to assess the resident. CNA U also said that she was in-serviced to be familiar with each resident's care plan. Interview on [DATE] at 2:52 PM with CNA K revealed she was in-serviced to alert a nurse if medication is found in the resident's room. CNA K revealed she was in-serviced about Residents #2 and Resident #3's depression and care plans. CNA K also stated that if a resident has a suicidal ideation, she would report it to the charge nurse by calling the nurse and stay with the resident until the nurse came to assess the resident. CNA K also said that she was in-serviced to be familiar with each resident's care plan. Interview on [DATE] at 3:01 PM with CNA V revealed she was in-serviced to alert a nurse if medication is found in the resident's room. CNA V revealed she was in-serviced about Residents #2 and Resident #3's depression and care plans. CNA V also stated that if a resident has a suicidal ideation, she would report it to the charge nurse by calling the nurse and stay with the resident until the nurse came to assess the resident. CNA V also said that she was in-serviced to be familiar with each resident's care plan. Interview on [DATE] at 3:06 PM with Activity Director S revealed she was in-serviced to alert a nurse if medication is found in the resident's room. Activity Director S revealed she was in-serviced about Residents #2 and Resident #3's depression and care plans. Activity Director S also stated that if a resident has a suicidal ideation, she would report it to the charge nurse by calling the nurse and stay with the resident until the nurse came to assess the resident. Activity Director S also said that she was in-serviced to be familiar with each resident's care plan. Interview on [DATE] at 3:11 PM with CNA W revealed he was in-serviced to alert a nurse if medication is found in the resident's room. CNA W revealed he was in-serviced about Residents #2 and Resident #3's depression and care plans. CNA W also stated that if a resident has a suicidal ideation, he would report it to the charge nurse by calling the nurse and stay with the resident until the nurse came to assess the resident. CNA W also said that he was in-serviced to be familiar with each resident's care plan. Interview on [DATE] at 3:15 PM with CNA X revealed she was in-serviced to alert a nurse if medication is found in the resident's room. CNA X revealed she was in-serviced about Residents #2 and Resident #3's depression and care plans. CNA X also stated that if a resident has a suicidal ideation, she would report it to the charge nurse by calling the nurse and stay with the resident until the nurse came to assess the resident. CNA X also said that she was in-serviced to be familiar with each resident's care plan. Interview on [DATE] at 3:42 PM with CNA Y revealed she was in-serviced to alert a nurse if medication is found in the resident's room. CNA Y revealed she was in-serviced about Residents #2 and Resident #3's depression and care plans. CNA Y also stated that if a resident has a suicidal ideation, she would report it to the charge nurse by calling the nurse and stay with the resident until the nurse came to assess the resident. CNA Y also said that she was in-serviced to be familiar with each resident's care plan. Interview on [DATE] at 3:42 PM with CNA Z revealed she was in-serviced to alert a nurse if medication is found in the resident's room. CNA Z revealed she was in-serviced about Residents #2 and Resident #3's depression and care plans. CNA Z also stated that if a resident has a suicidal ideation, she would report it to the charge nurse by calling the nurse and stay with the resident until the nurse came to assess the resident. CNA Z also said that she was in-serviced to be familiar with each resident's care plan. Interview on [DATE] at 3:19 PM with LVN P revealed she was in-serviced about Residents #2 and Resident #3's depression and care plans. LVN P stated that Resident #2 had a private sitter with her twenty-four hours per day 7 days a week. LVN P stated that if she finds any medication out in a resident's room to the nurse or if the resident starts talking about suicidal ideations, she will notify the nurse immediately and stay with the resident until the nurse comes. Interview on [DATE] at 3:22 PM with LVN Q revealed she was in-serviced about Residents #2 and Resident #3's depression and care plans. LVN Q stated that Resident #2 had a private sitter with her twenty-four hours per day 7 days a week. LVN Q stated that if she finds any medication out in a resident's room to the nurse or if the resident starts talking about suicidal ideations, she will notify the nurse immediately and stay with the resident until the nurse comes. Interview on [DATE] at 3:29 PM with CNA R revealed she was in-serviced about Residents #2 and Resident #3's depression and care plans. CNA R stated that Resident #2 had a private sitter with her twenty-four hours per day 7 days a week. CNA R stated that if she finds any medication out in a resident's room to the nurse or if the resident starts talking about suicidal ideations, she will notify the nurse immediately and stay with the resident until the nurse comes. Record review of the Train the Trainer In-Service, dated [DATE], included the DON, MDS Coordinator, and Wellness Manager in-serviced by the Education Coordinator covered the topics: Resident Mental Health Deterioration-Staff Action and Reporting and Medications in Skilled Nursing. Record review of the communication, dated [DATE], sent to all family members of the skilled nursing regarding medication policy for outside medications reviewed and included. Record review of the Better off Dead in-Service, dated [DATE], included the DON in-servicing the nursing staff regarding resident thoughts and saying they are Better off Dead. Staff were in-serviced on procedures of assessing residents and notifying the resident's provider if they say they feel they are better off dead. Record review of the staff interviews dated [DATE], of the past week about suicidal ideations of Resident #1 completed. Record review of the PHQ-9 questions, dated [DATE], by the Social Worker regarding depression and suicidal ideations with residents who are not interviewable was reviewed and included. There were seven residents identified with no findings Record review of the PHQ-9, dated [DATE], by the DON regarding depression and suicidal ideations with residents was reviewed and included. There were seven 31 residents included. One resident was found to have depression (Resident #2) and one resident (Resident #3) was found to express he would be better off dead. Record review of the Train the Trainer In-Service-Care Plans Live-dated [DATE], included the Staff Development, MDS Coordinator, and Wellness Manager in-serviced by the Education Coordinator over the topics of Resident Mental Health Deterioration-Staff Action and Reporting and Medications in Skilled Nursing. Record review of the signature sheet for the Ad Hoc QAPI committee meeting, held on [DATE], reviewed and included the DON, Director of Continuing Care, DON, Medical Director D, Medical Director E, Social Worker, and MDS, AED, and ED. On [DATE] at 4:45 PM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a scope of isolated with a potential form more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for three (Residents #5, #7, and #33) of six residents reviewed for care plans. The facility failed to ensure Residents #5, #7, and #33's comprehensive care plans addressed their use of psychotropic medications (drugs that affect the mind, emotions, and behavior) and related behavioral concerns as identified in their comprehensive assessments. This failure could place residents at risk of receiving inadequate interventions not individualized to their mental health care needs. 1.Record review of Resident #5's annual MDS dated [DATE], reflected the [AGE] year-old female resident was admitted to the facility on [DATE] and had severely impaired cognitive function. Diagnoses included: Alzheimer's Disease (a brain disease that slowly destroys memory, thinking, and the ability to carry out daily tasks), and Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms (severe, persistent sadness and loss of interest that interferes with daily life accompanied by hallucinations or delusions), Dementia in other disease classified elsewhere, severe, with psych disturbances (a condition where dementia symptoms arise from a different underlying illness and are characterized by a severe decline in cognitive function along with psychotic disturbance). Staff assessment of Resident #5's mood reflected over the past 2 weeks showed she experienced poor appetite or overeating at a frequency of 2-6 days and self-isolating at a frequency of rarely. Record review of Resident #5's Active Physician's Orders for September 2025 reflected she was prescribed Sertraline (Zoloft, used to treat a variety of mental health conditions by increasing the level of the neurotransmitter serotonin in the brain) 100 mg tablet one time a day for depression with a start date of 06/30/2025. Record review of Resident #5's Comprehensive Care Plan dated 06/07/2025 revealed there were no goals or interventions related to her depression or Alzheimer's Disease diagnoses, behaviors associated with these diagnoses, or the use of the psychotropic medication (Zoloft) used to treat depression. 2. Review of Resident #7's admission MDS assessment dated [DATE] reflected the [AGE] year-old female resident was admitted to the facility on [DATE] and had intact cognitive function. Diagnoses included: Major Depressive Disorder, recurrent, severe with psych symptoms, (severe, persistent sadness and loss of interest that interferes with daily life accompanied by hallucinations or delusions) and anxiety disorder (ongoing uncontrollable, and excessive worry, fear, or dread that significantly interferes with daily life). Resident self-assessment of her mood reflected over the past 2 weeks showed she experienced feeling down, depressed, or hopeless at a frequency of 2-6 days. Record review of Resident #7's Active Physician's Orders for September 2025 reflected she was prescribed the following medications: Zoloft (used to treat a variety of mental health conditions by increasing the level of the neurotransmitter serotonin in the brain) 25 mg tablet one time a day for depression with a start date of 07/11/2024. Abilify (an atypical antipsychotic medication that treats certain mental and neurological conditions, it works by balancing levels of dopamine and serotonin in the brain to help regulate mood, thoughts, and behavior) 2 mg tablet one time a day to treat depressive psychosis with delusion with a start date of 05/29/2025. Record review of Resident #7's Comprehensive Care Plan dated 07/22/2025 did not reflect any goals or interventions related to her depression, anxiety or the use of psychotropic medications (Zoloft and Abilify). 3. Review of Resident #33's Quarterly MDS assessment dated [DATE] revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had mild cognitive impairment. Diagnoses included: Major Depressive Disorder, Single Episode, Unspecified (a single severe bout of depression where a person experiences prolonged low mood, loss of interest, and other symptoms for at least two weeks, but there is not enough information to specify the severity of the depression). Resident self-assessment of her mood reflected over the past 2 weeks showed she experienced feeling down, depressed, or hopeless at a frequency of 2-6 days and self-isolating at a frequency of rarely. Record review of Resident #33's Active Physician's Orders for September 2025 reflected she was prescribed Lexapro (antidepressant medication used to treat certain mental health conditions by balancing serotonin levels in the brain) 5 mg tablet one time a day with a start date of 02/19/2025. Review of Resident #33's Care Plan dated 05/22/2025 revealed the care plan did not reflect any goals or interventions related to her depression diagnosis or the use of the psychotropic medications, Lexapro. In an interview with the Clinical Manager on 09/10/2024 at 12:00 PM, she explained the difference between a Comprehensive Assessment and a Comprehensive Care Plan. When a patient is admitted , staff open a holistic admission assessment, which serves as the baseline care plan. Once all disciplines complete their sections, the holistic was closed and a Comprehensive Care Plan was opened, carrying over the information. However, she noted that at times the incorrect button was clicked, preventing old information from transferring into the new care plan. The Clinical Manager stated that everything included on the interim care plan should be reflected in the Comprehensive Care Plan, including medications such as antipsychotics, antidepressants, insulin, anticoagulants, and psychotropics. She emphasized the importance of including mental health medications, as this guides staff in understanding residents' conditions, how to approach them, and how to respond if issues arose. During an interview on 09/11/2025, at 12:45 p.m., ADON explained she was responsible overall for care plans for the facility. She stated medications such as antidepressants and antipsychotics must be reflected in residents' care plans, as that would allow the team to monitor effectiveness and determine whether adjustments in dosage may be needed. She stated that she, along with the clinical manager, ensured interventions related to psychotropic use were implemented and updated when changes occurred. The ADON emphasized that the interdisciplinary team (including the ADON, DON, social worker, therapy manager, dietician, clinical manager, and activities staff) reviewed care plans weekly to ensure accuracy, with audits also occurring once a week. While she was not aware of concerns regarding three specific residents care plans, she stated that updates are typically made as care progresses. She noted she had not spoken to the Clinical Manager directly but oversaw her work and was responsible for ensuring she understood and followed the care plan process. Record review of Care/Service Plans Policy dated 05/2021 reflected the following: Each guest/resident will have an individualized Care/Service plan developed. Care/Service Plans will include guest/resident preferences, strengths, routines, personal and cultural preferences and choices as well as clinical needs. A comprehensive person centered care plan will be developed by the Interdisciplinary Team and be completed within 72 hours of admission and will include measurable objectives, preferences, goals, any specialized services as a result of the PASARR evaluation, resident's discharge plan and will address the resident's medical, nursing, mental and psychosocial needs as identified from the resident's comprehensive assessment.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food was properly stored in the facility's freezer. These failures could place residents at risk for food-borne illnesses. Observation of the facility's freezer on 09/09/24 at 9:23 AM revealed: - 1 tub of ice cream with lid open and exposed to air; - 1 box of pie crust shells open and exposed to air; - 1 box of biscuits open and exposed to air; In an interview on 09/09/2025 at 9:45 AM, the Chef stated she had been unaware that some boxes were open and exposing food to air. She admitted she did not know how to address the issue and had not realized it was a problem. The Chef explained that she was new to the position, still in training, and unsure about the facility's procedures. She added that she reported directly to the Dietary Manager, who was responsible for training her in proper food safety practices. In an interview with the Dietary Manager on 9/10/2025, at 2:00 p.m., she explained she oversaw all kitchen operations. She stated that all frozen foods were expected to be wrapped, covered, or sealed once their original boxes were opened. She stated the managers closing each night were responsible for walking through the kitchen to check labels, cleanliness, and any opened items, though no record was kept of these checks. She stated that the freezers were reviewed nightly at closing. She identified the risks of leaving frozen foods unwrapped as foodborne illness, freezer burn, contamination from exposure to bacteria or cross-contamination between raw and ready-to-eat foods, and overall loss of product quality. She emphasized that uncovered foods were discarded to prevent these risks, as improper handling could affect both safety and resident satisfaction. Review of the facility policy titled Standard Operating Procedure for Food and non-food storage, dated 04/2024 reflected the policy did not have guidelines for opened foods stored in the freezer.

Based on interview and record review, the facility failed ensure residents were free of any significant medication errors for one (Residents #27) of two residents reviewed for medications.The facility failed to ensure LNV A administered a medication as ordered to Resident #27 by crushing Aspirin ER (used to prevent cardiovascular events like heart attack and stroke in high-risk patients) and Potassium ER Chloride (mineral supplement prescribed by a doctor to treat or prevent hypokalemia (low potassium levels); medications that should not be crushed. This deficient practice placed residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.Record review of Resident #27's admission record dated 09/10/25 revealed an admission date of 04/05/24 with diagnoses which included, hypertensive heart disease with heart failure, presence of cardiac pace maker, reduced mobility, peripheral vascular disease, and lymphedema (a condition characterized by swelling in the body's tissues due to a buildup of lymph fluid). Record review of Resident #27's quarterly assessment MDS dated [DATE] revealed she had a BIMS score of 15, indicating no cognitive impairment. Record review of Resident #27's care plan dated on 09/10/25 revealed, for the nurse/aide to administer medications per the orders and monitor for side effects from the medications, and the resident will not have any complications from the medications. Record review of Resident #27's physicians orders dated September 2025 revealed the physician prescribed for Resident #27 to receive the following medications:Carvedilol 25 mg 1 tabletPotassium Chloride 20 milliequivalent ER(Extended Release) , 1 tabletAspirin 81 mg ER 1 tabletChlortalidone 25 mg 1 tabletThera M-plus 9 mg, Iron 400 mcg 1 tabletSystane eye dropsAmlodipine 5 mg 1 tablet Observation on 09/10/25 at 09:42 AM, revealed LVN A crushed together and administered the following medications to Resident #52:Carvedilol 25 mg 1 tabletPotassium Chloride 20 milliequivalent ER (Extended Release) ,1 tablet - indicated not to crushAspirin 81 mg ER 1 tablet - indicated not to crushChlortalidone 25 mg 1 tabletThera M-plus 9 mg, Iron 400 mcg 1 tabletAmlodipine 5 mg 1 tablet In an interview with LVN A on 09/10/2025 at 3:08 PM revealed she worked in the morning shift and administered medications. LVN A stated she had been in-serviced and had medications audit administering medications per the physician orders and following the five rights of medication administration. LVN A stated she was not supposed to crush medication if it indicated not to crush or if it was an ER medication. She stated she did not realize the medications were extended release. LVN A stated she was not supposed to crush the medications because the medications were supposed to be released slowly and not at once with could lead to side effects like stomach irritation. In an interview on 09/11/2025 at 12:19 PM with the DON he stated LVN A had reported to the DON that she had crushed medications that were not supposed to be crushed because they were extended releasing medications. The DON stated the staff had been in-serviced on medication administration. The DON stated the staff was not supposed to crush the extended-release medications because they were supposed to dissolve in the stomach, and they could have side effectives like stomach irritation and the medications not being effective. Review of the facility policy dated 04/2005 and titled Medication Administration, Receipt, Storage & Disposal, reflected, . Medications are administered in accordance with Nursing Standards of practice and state law.4. Trained staff designated to administer medications will verify that he/she is administeringmedications using the 5 Rights of Medication Administration/Assistance and aredocumented immediately following completion of task for each resident.i) Right residentii) Right medicationiii) Right doseiv) Right timev) Right route .

Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 1 of 1 facility's reviewed for grievances. The facility failed to make information known to Resident's and their Representatives either individually or through postings in prominent locations throughout the facility on who the facility grievance official was, their contact information, how to file an anonymous grievance and their right to obtain a written decision related to their grievance. The facility failed to ensure Resident's #1,# 2, and# 3 had information known to them on how to file a grievance or concern, who the grievance official was, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. These failures could affect the Resident's and their representatives' abilities to file a grievance in a timely manner and inhibit their right to request a written decision regarding the resolution of their grievance. These failures could affect Resident's #1, #2, and #3 by not having the necessary information available to file a grievance or concern either orally or anonymously, in a timely manner. Findings Include: 1. Record Review of Resident #1's Quarterly MDS with an ARD (Assessment Reference Date) of 06/26/2024, revealed she was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's diagnoses included: Chronic Diastolic Heart Failure (Cardiac condition where the left ventricle of the heart is stiff and does not fill with blood properly), Scoliosis (Sideways curvature of the spine), Major Depressive Disorder (Clinical Depression), and Anxiety Disorder (group of mental disorders characterized by significant and uncontrolled feelings of anxiety and fear). Resident #1 had a BIMS (Brief Interview of Mental Status) score of 10, indicating a moderately impaired cognition. Record Review of Resident #1' physician progress note dated 07/08/2024 revealed that Resident #1 was seen by MD A on 07/08/2024 for a follow-up visit at the facility. The progress note revealed that Resident #1 was oriented to person, place and time and Resident #1's judgement and insight were fair. The progress note revealed that Resident #1 had capacity to make health care decisions. Interview with Resident #1 on 07/30/2024 at 10:30am revealed that she had been a resident at the facility for a few months at that time. Resident #1 revealed that she transferred to the healthcare center from the campuses Independent Living Community. Resident #1 revealed that she has had concerns in the past, but was unsure of who to report the concerns to. Resident #1 revealed that, in the past, she would go to her family member. Resident #1 revealed that she did not know who the facility grievance official is, how to file a grievance in an anonymous way or that she was entitled to a written decision regarding the resolution to her grievance or concern from the facility. Resident #1 revealed that she had not been educated on the facilities policies or procedures related to grievances. 2. Record Review of Resident #2's Quarterly MDS with an ARD (Assessment Reference Date) of 06/28/2024, revealed she was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #2's diagnoses included: Aphasia (Comprehension and Communication Disorder), Major Depressive Disorder (Clinical Depression) and Chronic Kidney Disease Stage 3 (Moderate Kidney Damage). Resident #2 had a BIMS score of 15 indicating no cognitive impairment. Record Review of Resident #2's physician progress note dated 07/05/2024 revealed that Resident #2 was seen by MD A on 07/05/2024 for a follow-up visit at the facility. The progress note revealed that Resident #2 was awake and alert in bed, but had some word finding difficulties while talking. The progress note revealed that Resident #2 had capacity to make health care decisions. Interview with Resident #2 on 07/31/2024 at 9:20AM revealed that she had been a resident at the facility for 8 or 9 months. Resident #2 revealed that she did not know who the facility grievance official was, how to file a grievance in an anonymous way, or that she was entitled to a written decision regarding the resolution to her grievance or concern from the facility. Resident #2 revealed she would go to the facility Operations Director or Social Worker if she had a grievance. Resident #2 revealed that she had not seen any postings on how to file a grievance or her rights as a resident related to grievances. Resident #2 revealed that nobody at the facility had educated her on the facility's policies or procedures related to grievances. 3. Record Review of Resident #3's Quarterly MDS with an ARD (Assessment Reference Date) 01/29/2024, revealed she was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #3's diagnoses included: Major Depressive Disorder (Clinical Depression), Aphasia following unspecified cerebrovascular disease (Comprehension and Communication Disorder following conditions like a stroke, brain bleed, brain aneurysm), and Personal History of Transient Ischemic Attack (Temporary period of symptoms similar to stroke). Resident #3 had a BIMS score of 15 indicating no cognitive impairment. Record Review of Resident #3's physician progress note dated 07/30/2024 revealed that Resident #3 was seen by MD A on 07/30/2024. The progress note revealed that Resident #3 got frustrated at times due to her expressive aphasia, but was redirectable by staff. The progress note revealed that Resident #3 was alert and oriented to person, place, and time. An observation and interview with Resident #3 on 07/31/24 at 9:05AM revealed Resident #3 was sitting in her lounge chair. Surveyor greeted resident, Resident #3 became frustrated when trying to answer surveyor questions, interview continued via written communication per Resident #3's request. Resident #3 revealed that she had been at the facility for a few months. Resident #3 revealed that she felt frustrated because staff was unable to recognize what she wanted Resident #3 revealed that she had not filed a concern or grievance because she was not sure who to go to. Resident #3 revealed that she does not know how to file a grievance or concern in an anonymous way or that she was entitled to a written decision regarding her grievance or concern from the facility. Resident #3 revealed that she had not seen any postings on how to file a grievance or concern or her rights related to grievances. Resident #3 revealed that nobody at the facility had educated her on the facility's policies or procedures related to grievances. Observation of the facility on 07/30/24 at 1:30PM revealed no postings related to the facilities policy on grievances, who the grievance official was, their contact information, how to file a grievance in an anonymous way, or their right to a written decision related to their grievance from the facility. Observation of the facility on 07/31/24 at 11:05AM revealed no postings related to the facilities policy on grievances, who the grievance official, their contact information, how to file a grievance in an anonymous way or their right to a written decision related to their grievance from the facility. Observation of the facility on 08/01/2024 at 10:00AM revealed no postings related to the facilities policy on grievances, who the grievance official was, their contact information, how to file a grievance in an anonymous way, or their right to a written decision related to their grievance from the facility. Interview with CNA B on 08/01/24 at 9:00AM revealed that she had been working at the facility for about three years. CNA B revealed the facility procedure on grievances was if a resident were to come to her or any staff member with a concern or grievance, she would tell the Unit Manager. CNA B stated that the facility grievance official was the Administrator. CNA B revealed that she was aware that residents had the right to file a grievance in an anonymous way, but could not state how the resident's in the facility could. CNA B could not reveal where the facility provided specific information related to grievances processes and procedures and information for the facility Grievance Official. Interview with LVN A on 08/01/24 at 9:30AM revealed that the facility policy on grievances was if a resident were to come to her or any staff member with a concern or grievance, she would tell the Unit Manager or the Administrator. LVN A revealed that the facility grievance official was the Administrator. LVN A revealed that she was aware that residents had the right to file a grievance in an anonymous manner, but could not state how the resident's in the facility could file a grievance anonymously. CNA B could not reveal where the facility provided specific information related to grievances processes, procedures and information for the facility Grievance Official. Interview with the Unit Manager for Post-Acute Care on 08/01/24 at 3:00PM revealed that the facility policy on grievances was that if a resident came to her or any staff member with a grievance, it should be filed immediately with the Social Worker. The Social Worker would then give the filed grievance to herself and Administrator for investigation and follow-up. The Unit Manager revealed that the Social Worker was the facility Grievance Official. The Unit Manager revealed that residents were informed of the facility's procedures related to grievances in their town hall meetings. The Unit Manager revealed that she was unsure who informed residents on the grievance procedures on admission. The Unit Manager could not reveal where the facility provided specific information related to grievances processes, procedures, and information for the facility grievance official. Interview with the DON on 08/01/2024 at 3:20PM revealed that the facility policy on grievances was that the facility Social Worker was tasked with filing and handling all facility grievances. The DON revealed that if a resident went to a staff member with a concern or grievance the staff member should tell the Social Worker immediately. The DON revealed that the Social Worker was the facility grievance official. The DON revealed that he was aware that residents had the right to file a grievance in an anonymous manner, but could not state how the resident's in the facility could file a grievance in an anonymous manner. The DON could not reveal where the facility provided specific information related to grievances processes, procedures, and information for the facility grievance official. Interview with the Social Worker on 08/01/24 at 3:45PM revealed that the facility's grievance policy and procedure was if a resident had a grievance or concern, they could reach out to the Ombudsman. The Social Worker revealed that if the grievance was facility related, then the resident could tell any staff member and that staff member would alert the social worker. The Social Worker revealed that she was the facility grievance official since she kept the grievance binder. The Social Worker revealed that once a grievance was then an investigation would occur and the assigned department head would follow-up for resolution. The Social Worker could not reveal where the facility provided specific information related to grievances processes, procedures and information for the facility grievance official. Interview with the Administrator on 08/01/24 at 4:26PM revealed that the facility grievance policy and procedure was if residents have a concern or grievance, that staff member would get the Social Worker. The Administrator revealed that the Social Worker would begin the grievance process and then it would be spoken about the following day in the stand-up morning meeting which included all the department heads. The Administrator revealed that residents were informed of the facility's grievance policies and procedures in the admission agreement. The Administrator did not reveal how residents could file an anonymous grievance. Review of the facility's admission agreement titled, Acknowledgement and Receipt of Admission Documents, dated 09/2021, revealed a section titled, Facility Practice Disclosures. Facility Practice Disclosures revealed a subsection titled, Concerns. The subsection revealed that it is the policy of the facility that all resident and family concerns will be addressed thoroughly, without fear of reprisal and followed to resolution in a timely fashion. Concerns may be presented to any staff member orally, in writing or in person and may be reported anonymously. Review of the facility's admission agreement did not reveal or identify the facility Grievance Official for whom is responsible for overseeing the grievance process, receiving, and tracking grievances to their conclusions or the residents right to obtain a written decision regarding his or her grievance. Review of the facility's admission agreement did not reveal how the residents, or their representatives could file a grievance in an anonymous manner if they chose to do so. Review of the facility's policy on grievances titled, Grievance/Concerns Investigations and Resolutions, dated 07/2023, revealed that grievances may be filed orally or in writing and can be filed anonymously . The Grievance Officer for Skilled Nursing [is the] Social Worker. Review of the facility's policy on grievances revealed that residents will be notified of their right to file a grievance via the Residents Rights document provided upon admission to the community. Review of the facility's admission agreement titled, Acknowledgement and Receipt of Admission Documents, dated 09/2021, revealed a section titled, Resident's [NAME] of Rights. This section revealed that that resident's had the right to complain about the resident's care or treatment. The complaint may be made anonymously or communicated by a person designated by the resident. Record Review of this document did not reveal any additional information regarding grievances or concerns.

Based on interview, and record review, the facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program for 4 (Resident #3, Resident #5, Resident #7, Resident #8) out of 4 residents reviewed for PASARR assessments. The facility failed to transcribe PL1s' (PASARR Level 1 Screenings) to the LTC Online Portal for 4 (Resident #3, Resident #5, Resident #7, Resident #8) out of 4 residents reviewed for PASARR assessments. This failure could place residents who are eligible for PASARR services at risk of not receiving needed services. Findings Include: Record Review of Resident #5's Admission MDS with an ARD (Assessment Reference Date) of 03/16/2024 revealed she was an [AGE] year-old-female who admitted to the facility on [DATE]. Resident #5's active diagnoses included: Major Depressive Disorder (Clinical Depression), Legal Blindness, Chronic Obstructive Pulmonary Disease (Progressive Lung Disease). Resident #5 had a BIMS score of 11 indicating a moderately impaired cognition. Record Review of document titled, PASRR Level 1 Screening dated 03/11/2024 revealed that Resident #5' PL1 screening indicated that Resident #5 did not have evidence or indicator of mental illness, intellectual disability, or developmental disability. Record Review of the document titled PASRR Level 1 Screening dated 03/11/2024 for Resident #5 revealed that the facility did not transcribe or submit the PL1 for Resident #5 to the LTC Online Portal. Record Review of Resident #3's Quarterly MDS with an ARD (Assessment Reference Date) 01/29/2024, revealed she was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #3's diagnosis included: Major Depressive Disorder (Clinical Depression), Aphasia following unspecified cerebrovascular disease (Comprehension and Communication Disorder following conditions like a stroke, brain bleed, brain aneurysm), and Personal History of Transient Ischemic Attack (Temporary period of symptoms similar to stroke). Resident #3 had a BIMS score of 15 indicating no cognitive impairment. Record Review of document titled, PASRR Level 1 Screening dated 10/23/23 revealed that Resident #3's PL1 screening indicated that Resident #3 did not have evidence or indicator of mental illness, intellectual disability, or developmental disability. Record Review of the document titled PASRR Level 1 Screening dated 10/23/23 for Resident #3, revealed that the facility did not transcribe or submit the PL1 for Resident #3 to the LTC Online Portal. Record Review of Resident #7's Admission MDS with an ARD (Assessment Reference Date) of 07/18/2024 revealed she was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #7's active diagnosis included: Major Depressive Disorder (Clinical Depression), Unspecified Dementia (Major Neurocognitive Disorder), and Spinal Stenosis (Narrowing of the Spine). Resident #7 had a BIMS score of 12 indicating moderately impaired cognition. Record Review of document titled, PASRR Level 1 Screening dated 07/12/2024 revealed that Resident #7's PL1 screening indicated Resident #7 did not have evidence or indicator of mental illness, intellectual disability, or developmental disability. Record Review of the document titled, PASRR Level 1 Screening dated 07/12/2024 for Resident #7 revealed that the facility did not transcribe or submit the PL1 for Resident #7 to the LTC Online Portal. Record Review of Resident #8's Admission MDS with an ARD (Assessment Reference Date) of 07/08/2024 revealed she was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #8's diagnosis included: Major Depressive Disorder (Clinical Depression), Alzheimer's Disease (Brain disorder that causes memory loss and behavior changes), and Delirium due to know physiological condition(Serious change in mental abilities due to a disorder or condition). Record Review of document titled, PASRR Level 1 Screening, dated for 07/03/2024 revealed that Resident #8's PL1 screening indicated Resident #8 did not have an evidence or indicator of mental illness, intellectual disability, or developmental disability. Record Review of the document titled PASRR Level 1 Screening dated 07/03/2024 for Resident #8 revealed that the facility did not transcribe or submit the PL1 for Resident #8 to the LTC Online Portal. Interview with the DON on 07/30/2024 at 2:55PM revealed the facility ensured every new admission entered the facility with a completed Level 1 screening. The Level 1 screenings were then placed in the resident's hard charts. The DON revealed that the MDS nurse should have been uploading the PL1's to the LTC Online Portal and ensuring they accurately reflected the resident's clinical condition or diagnoses. The DON revealed that when a resident admits to their facility with a positive PL1 this will trigger a Level II screening from the local mental health authority. The DON revealed that he was unsure how the local mental health authority was being notified of the positive PL1 admissions if none of the PL1's were being submitted to the LTC Online Portal. The DON revealed that if the PL1's were not being submitted to the LTC Online Portal, then this could have placed residents at risk of missed services. Interview with the MDS Nurse on 07/31/24 at 3:37PM revealed that the facility ensured that all new admissions admit to the facility with a completed PL1 screening. The Level 1 screenings were then placed in the resident's hard charts. The MDS nurse revealed that the facility was not uploading any PL1's to the LTC Online Portal as they were unaware, they had to . The MDS nurse revealed the facility did not have an identified person who was responsible for ensuring the PL1's were accurate on admission. The MDS nurse revealed that if the PL1's were not submitted to the LTC Online Portal then this could have placed residents at risk of missed services. Interview with the Administrator on 07/31/24 at 3:58PM revealed that she was unsure of the PASARR requirements or processes. The Administrator revealed that the current procedure was to ensure all new admissions had a PL1 screening then the PL1 would be placed into the resident's hard chart. The Administrator revealed that the facility was not transcribing or uploading any resident's PL1's to the LTC Online Portal . The Administrator revealed that the facility did not have a designated person at the facility to oversee PASARR procedures. Review of the facility's policy titled, Pre-Admission Screening and Resident Review (PASRR), dated 06/2021 revealed that if the Level 1 Screen is positive, the individual should be referred to the local mental health screening agency for a Level 2 evaluation prior to admission, unless they qualify for an exemption. Review of the document titled, Detailed Item by Item Guide for Local Authorities and Nursing Facilities to Complete the PASRR Level 1 Screening Form by Texas Health and Human Services dated for June 2023 revealed that example of MI diagnoses are . Mood Disorder (Bipolar Disorder, Major Depressive Disorder, or other Mood Disorder).

Based on observation, interview and record review, the facility failed to accurately submit a PL1 (PASARR Level 1 Screening) screening when residents admitted with a diagnosis of Mental Illness, Intellectual Disability or Developmental Disability for 3 (Resident #5, Resident #7, Resident #8) out of 4 residents reviewed for PASARR screenings. The facility failed to submit a new PL1 screening when residents were diagnosed with a new diagnosis of Mental Illness, Intellectual Disability or Developmental Disability during their stay for 1 (Resident #3) out of 4 residents reviewed for PASARR screenings. The facility failed to ensure that Resident #5, Resident #7, and Resident #8 had accurate PL1's on admission. 1. The facility failed to submit a correct PL1 screening for Resident #5 when she admitted to the facility on [DATE] with an active diagnosis of Major Depressive Disorder. 2. The facility failed to submit a new PL1 screening when Resident #3 was diagnosed on [DATE] with Major Depressive Disorder during her stay. 3. The facility failed to submit a correct PL1 screening for Resident #7 when she admitted to the facility on [DATE] with an active diagnosis of Major Depressive Disorder. 4. The facility failed to submit a correct PL1 screening for Resident #8 when he admitted to the facility on [DATE] with an active diagnosis of Major Depressive Disorder. These failures could affect residents by not receiving a Level II PASARR Evaluation to assess for needed services. Findings Include: 1. Record Review of Resident #5's Admission MDS with an ARD (Assessment Reference Date) of 03/16/2024 revealed she was an [AGE] year-old-female who admitted to the facility on [DATE]. Resident #5's active diagnosis included: Major Depressive Disorder (Clinical Depression). Resident #5 had a BIMS score of 11 indicating a moderately impaired cognition. Record Review of Resident #5's History of Present Illness (HPI) revealed a date of service of 03/11/2024 from MD A. The HPI revealed the resident had a history of MDD (Major Depressive Disorder) with chronic anxiety. Review of HPI document revealed that Resident #5 was being treated for MDD (Major Depressive Disorder). Record Review of document titled, PASRR Level 1 Screening dated 03/11/2024 revealed that Resident #5' PL1 screening indicated that Resident #5 did not have evidence or indicator of mental illness, intellectual disability, or developmental disability. Record Review of the document titled, PASRR Level 1 Screening dated 03/11/2024 for Resident #5 revealed that the Facility did not transcribe or submit Resident #5's PL1 to the LTC Online Portal. Record Review of the document titled, PASRR Level 1 Screening dated 03/11/2024 for Resident #5 revealed that the Facility did not correct the PL1 to indicate Resident #5 did in fact have a diagnosis of Mental Illness. The facility failed to submit a correct PL1 to the LTC Online Portal. 2. Record Review of Resident #3's HPI revealed a date of service of 10/25/24 from MD A. HPI revealed that Resident #3 was not currently being treated or had an active diagnosis of MDD (Major Depressive Disorder). Record Review of Resident #3's Quarterly MDS with an ARD of 01/29/2024, revealed she was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #3's diagnoses included: Major Depressive Disorder (Clinical Depression . Resident #3 had a BIMS score of 15 indicating no cognitive impairment. Record Review of Resident #3's Quarterly MDS revealed Resident #3 had a current diagnosis of MI (Mental Illness) of MDD (Major Depressive Disorder). Record Review of document titled, PASRR Level 1 Screening dated 10/23/23 revealed that Resident #3's PL1 screening indicated that Resident #3 did not have an evidence or indicator of mental illness, intellectual disability, or developmental disability. Record Review of the document titled, PASRR Level 1 Screening dated 10/23/23 for Resident #3, revealed that the Facility did not transcribe or submit Resident #3's PL1 to the LTC Online Portal. Record Review revealed that the Facility did not submit a new PL1 when Resident #3 was diagnosed with a MI (Mental Illness) during her stay at the facility. 3. Record Review of Resident #7's Admission MDS with an ARD of 07/18/2024 revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #7's active diagnosis included: Major Depressive Disorder (Clinical Depression), Unspecified Dementia (Major Neurocognitive Disorder), and Spinal Stenosis (Narrowing of the Spine). Resident #7 had a BIMS score of 12 indicating a moderately impaired cognition. Record Review of Resident #7's HPI revealed a date of service of 07/15/2024 from MD A. HPI revealed that resident had a history of MDD (Major Depressive Disorder) with psychosis. Review of HPI document revealed that Resident #5 was being treated for MDD (Major Depressive Disorder). Record Review of document titled, PASRR Level 1 Screening dated 07/12/2024 revealed that Resident #7's PL1 screening indicated Resident #7 did not have an evidence or indicator of mental illness, intellectual disability, or developmental disability. Record Review of the document titled PASRR Level 1 Screening dated 07/12/2024 for Resident #7 revealed that the Facility did not transcribe or submit Resident #7's PL1 to the LTC Online Portal. Record Review revealed that the Facility did not correct the PL1 to indicate Resident #7 did in fact have a diagnosis of Mental Illness. The facility failed to submit a correct PL1 to the LTC Online Portal. 4. Record Review of Resident #8's Admission MDS with an ARD (Assessment Reference Date) of 07/08/2024 revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #8's diagnosis included: Major Depressive Disorder (Clinical Depression), Alzheimer's Disease (Brain disorder that causes memory loss and behavior changes), and Delirium due to know physiological condition (Serious change in mental abilities due to a disorder or condition). Record Review of Resident #8's HPI (History of Present Illness) revealed a date of service of 07/05/2024 from MD A. HPI revealed that resident had a history of MDD (Major Depressive Disorder) with psychotic features. Review of HPI document revealed that Resident #8 was being treated for MDD (Major Depressive Disorder). Record Review of document titled, PASRR Level 1 Screening, dated for 07/03/2024 revealed that Resident #8's PL1 screening indicated Resident #8 did not have an evidence or indicator of mental illness, intellectual disability, or developmental disability. Record Review of the document titled, PASRR Level 1 Screening dated for 07/03/2024 for Resident #8 revealed that the Facility did not transcribe or submit Resident #8's PL1 to the LTC Online Portal. Record Review revealed that the Facility did not correct the PL1 to indicate Resident #8 did in fact have a diagnosis of Mental Illness. The facility failed to submit a correct PL1 to the LTC Online Portal. Interview with the DON on 07/30/2024 at 2:55PM revealed that the MDS nurse was responsible for ensuring that all residents PL1's were correct, reflect their current and active diagnoses and were submitted to the LTC Online Portal. The DON revealed that if a resident had a positive PL1 then the local mental health authority would come to the facility and complete the Level II screening. The DON revealed that if PL1's were incorrect and did not accurately reflect the resident's current diagnoses this could have placed the residents at risk for missed services. Interview with the MDS nurse on 07/31/24 at 3:37PM the facility was not uploading any PL1's to the LTC Online Portal as they were unaware they had to. The MDS nurse revealed that the facility was not auditing PL1's to ensure they accurately reflected the residents' diagnoses. The MDS nurse revealed she was not aware the facility had to submit a new PL1 if a resident is diagnosed with Mental Illness, Intellectual disability or Developmental Disability during their stay at the facility. The MDS nurse revealed that if the PL1's were not being submitted to the LTC Online Portal accurately this could place the residents at risk for missed services. Interview with the Administrator on 07/31/24 at 3:58PM revealed that she was unsure of the PASARR requirements or processes. The Administrator revealed that the current procedure was to ensure all new admissions had a PL1 screening then the PL1 would be placed into the resident's hard chart. The Administrator revealed that the facility was not transcribing or uploading any PL1's to the LTC Online Portal. The Administrator revealed that the facility did not have a designated person at the facility to oversee PASARR procedures or to ensure that the PL1's reflected the residents' current diagnoses. Review of the facility's policy titled, Pre-Admission Screening and Resident Review (PASRR), dated 06/2021 revealed that if the Level 1 Screen is positive, the individual should be referred to the local mental health screening agency for a Level 2 evaluation prior to admission, unless they qualify for an exemption.

Based on observation, interview and record review, the facility failed to provide food that was palatable for two (lunch meal 08/01/24) of four meals reviewed for palatability. [NAME] L added water to the puree recipe on 07/31/2024 . The facility failed to serve pureed mashed potatoes, root vegetable soup, purred roast beef that was palatable. The facility failed to serve mechanical chopped roast beef or root vegetable soup that was palatable. These failures could affect residents by placing them at risk of weight loss, altered nutritional status and a diminished quality of life. Findings Included: Observation on 08/01/24 at 1:05pm of lunch test tray revealed the pureed lunch was served on a tray with a cover. The purred lunch tray revealed a white ceramic container with pureed mashed potatoes, pureed roast beef, both items were in the same container in round formations. The pureed lunch was also served with a white ceramic bowl, covered by plastic which contained pureed root vegetable soup and a white ceramic bowl containing a brown sauce, which was meant for the pureed roast beef. Pureed lunch test tray revealed the mashed potatoes to be bland, texture was thick. The Pureed lunch tray revealed the root vegetable soup to be overly salty. The Pureed lunch tray revealed the pureed roast to be bland, textured was thick. Observation on 08/01/24 at 1:05pm of lunch test tray revealed the mechanical lunch was served on a tray with a cover. The mechanical lunch tray revealed mechanically chopped roast, served with a salad which contained: lettuce, tomatoes, and chopped carrots which was served with buttermilk ranch. The mechanical lunch tray was also served with carrots that were chopped into large pieces. The Mechanical lunch tray revealed the roast beef to be dry, thin consistency that resembled breadcrumbs and the flavor resembled ground beef. The Mechanical lunch tray revealed the mechanical chopped carrots to remain in whole form. In an Interview with [NAME] L on 08/01/2024 at 12:24 PM, she stated t she added water to the puree meal. She stated that she has added water to puree previously to add a softer texture to the food. She stated she was not trained or informed not to add water to the puree meals. She stated the risk/harm that could be caused in adding water to a resident's pureed meal was that it could change the taste of the meal. She stated that adding the water to a pureed recipe could also cause a resident to become ill or sick. In an Interview with the Dietary Manager on 08/01/2024 at 12:30 PM, she stated that staff have been trained and educated not to add water when preparing the puree meals. She stated that the harm that could be caused by adding water to a puree recipe could decrease the nutritional value for the meal. She stated that added water to the puree meal could also change the taste and flavor of the meal. She stated that she would speak with the Sous Chef, and they would reeducate and train the staff on how to properly prepare puree meals. Interview with the Dietician on 08/01/24 at 1:25pm revealed she expected all meals to be served warm and flavorful. The dietician tasted the pureed mashed potatoes and stated the mashed potatoes lacked flavor that was appetizing. The Dietician revealed it was the responsibility of the kitchen staff to taste the food for palatability and flavor before the food was served to the residents. The Dietician revealed they do not follow a recipe for puree diets. The Dietician reported that the facility did not have a puree recipe. Interview with Dietary Manager on 08/01/24 at 1:30pm revealed she expected all meals to be served warm and flavorful. The Dietary Manager tasted the pureed mashed potatoes and confirmed the mashed potatoes lacked flavor. The Dietary Manager tasted the pureed root vegetable soup and stated it was too thick and too salty. The Dietary Manager tasted the mechanical roast beef and stated it resembled ground beef and the flavor did not match roast beef. The Dietary Manager revealed it was the responsibility of the kitchen staff to taste the food for palatability and flavor before the food was served to the residents. Interview with Sous Chef on 08/01/24 at 1:43pm revealed that they are limited on the flavors they can use as the company does not allow sodium enhanced seasonings. Interview with the Administrator on 08/01/24 at 4:00pm revealed it was her expectation that the food was served to the residents warm and per the diet orders. The Administrator revealed she did not try the food served for lunch on 08/01/24. Record Review of the facility policy titled, SOP Texture Modified Diets dated 01/2024, revealed that the Mechanical Soft with Ground Meat diet should be fork tender or easily mashed tableside with fork into finely chopped pieces. Pureed Diet should be pureed to a smooth consistency thick enough to mound on the plate, and [NAME] or formed to give an attractive plate presentation. Record review of the job duties of the Sous Chef for Dining Services revealed, Responsible for ensuring the efficiency quality and production of all food items, to include receiving, storage and sanitation. 3. Directs the preparation and service accuracy for all forecasted menu items to include recipes, proper food handling, food safety, temperature control, taste, consistency, diet restrictions (therapeutic and consistency when applicable) and portion control, utilizing production forecast Record review of the facility's list of residents who receive Modified Diets/Liquids included 4 Residents.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: The facility fialed to ensure that food in the kitchen was labeled, dated and/or sealed. These deficient practices could affect 42 residents who received meals and/or snacks from the main kitchen and place them at risk for food borne illness. Findings Included: Observation of the kitchen on during the Initial Brief Tour on 07/30/2024 at 9:25 AM, revealed that inside the large freezer there was rack in the entry of the freezer that contained a silver pan of pink shrimp on a sheet pan. There was a piece of parchment paper covering the shrimp with a florescent green label dated 07/30. There was 1 open box of celery and green bell peppers that were on the bottom of the shelf. The refrigerator contained an open container of fruit cups that were unsealed. There were 3 large white containers on the floor underneath the counter that stored loose sugar, brown rice and flour. All 3 large white containers were ajar and were not sealed. The 3 large white containers were not labeled and there were white measuring scoops observed in all 3 large white containers. The ice machine had dust on the side vents. There was a white towel with red stain observed on top of the grate for the beverage dispenser for apple juice, orange juice and cranberry juices. The 4 slice Bread Toaster had crumbs on the top and bottom. The 16 ounce open containers of Seasonings of Black Pepper, Ground All Spice were not labeled and dated. On a rack in the kitchen there was 1 paper cup of coffee on a shelf in the kitchen that was unsealed. In an Interview with the Dietary Manager on 07/30/2024 at 2 PM, she stated herself and the Sous Chef are the Supervisors in the Kitchen. She stated any food that was not sealed, labeled and dated correctly can cause the potential for food-born illness to the residents and the kitchen staff. She stated her expectation was for the staff to be reeducated and trained so that the mistake was not made again. In an Interview with the Sous Chef on 07/30/2024 at 2:15 PM, he stated he was the Supervisor of the staff in the kitchen alongside the Dietician. He stated he was unaware that the vegetables, such as the green bell peppers and celery could not be stored in an open box and that was his first time hearing about that. He was directed to throw the shrimp away in the trashcan due to the Menu having seafood salad with shrimp on 08/01/2024 for the Lunch Meal. He stated that the harm to the residents ingesting freeze dried food due to incorrect food storage could be sickness and air-borne illnesses. Record review of the document, Record Learning Content for In-Service Training revealed, Infection Control: Basic Concepts, Infection Control: Enhanced Barrier Precautions, Infection Control and Food Safety Fundamentals. Record review of the facility's policy for Dining Services, SOP (Standard Operating Procedure) Food | Non-Food Storage revised 02/2024, revealed Purpose/Scope: To ensure that all food and merchandise received will be properly handled and stored to maintain food safety. SOP: Food is stored in compliance with applicable federal, state and local regulations regarding sanitary storage conditions. Perishable Storage: 6. In the refrigerator, covered cooked food is to be stored on shelves above raw food to prevent cross-contamination from dripping . 8. All produce is removed from original box and stored in plastic food storage containers. Non-Perishable Storage: 6. Dry bulk foods, such as flour, sugar, and rice will be labeled and stored in metal or plastic containers with tight fitting lids. Scoops for dispensing these items will be stored separately in a holder. 7. All foods are removed from boxes and stored in proper location in the storeroom according to the order sheets. Training / Education: Education regarding this policy and procedure will be completed with appropriate personnel as needed. Ongoing training and education will be provided on an as needed basis, as determined by the employee's direct supervisor / manager. Record review of the facility's policy for Dining Services, General Services and Housekeeping, Restaurant and Cafe Cleaning dated 06/17/2024, revealed Purpose/Scope: The purpose of this policy is to establish guidelines and procedures for the cleaning of the restaurants and cafes in both Independent Living and Continuing Care. This policy aims to provide a clean, safe and sanitary environment for residents, employees, and visitors by outlining the responsibilities, schedules, and standards for restaurant and cafe cleaning. This policy applies to [NAME] Senior Living, LLC, its managed communities, and its affiliates. Definitions: High-Touch Surfaces: those that people frequently touch with their hands, which could therefore become easily contaminated with microorganisms and picked up by others on their hands. For example, door handles, light switches, and shared equipment. Policy: It is the policy of the company that restaurants and cafes shall be cleaned and disinfected in a manner which promotes a clean, safe and sanitary environment. Housekeeping is responsible for regularly cleaning all restaurants and cafes according to the procedures and schedule outlined in this policy. These areas must be kept free of litter, dust, dirt, and any visible marks or stains using approved products and techniques and should only be cleaned by Housekeeping during non-operating hours. Record review of the job duties of the Clinical Dietitian for Dining Services revealed, The Dietitian plans, develops, implements and maintains programs and systems of nutritional care.Assists in the supervision of organization, sanitation and safety of dining rooms, kitchen, storage areas, and loading dock. Record review of the job duties of the Sous Chef for Dining Services revealed, Responsible for ensuring the efficiency quality and production of all food items, to include receiving, storage and sanitation. 2. Manages daily kitchen production and food Preparation for on-time service of resident meals . 4. Supervises proper presentation of all food items and to provide maximum appeal and freshness. 7. Supervises organization and sanitation of dining rooms, kitchen, storage areas and loading dock. Record review of the job duties of the General Manager for Dining Services revealed, Manages all aspects of mealtime preparation, service and the overall efficiency of the Kitchen, Dining Room, In-Room dining program and Resident meal service in Family dining areas. a. Directly manages the overall dining program including meal service/Front of House and culinary/Back of House program (menu development, preparation, service, delivery and financial) and supports the hospitality program. b. Responsible for the overall supervision and efficiency of culinary, utility staff and service associates (including training, evaluating and disciplining). Supports supervision, direction and efficiency of meal service and hospitality with all Continuing Care staff (Care Associates, Program staff, Nursing, CC managers, etc.) c. Assures the dining program (meal service and nutrition clinical care) is in compliance with all Federal, State and Local regulations and is provided with a hospitality focus. d. Provides dining service training for functions . Essential Duties and Responsibilities: include the following. 17. Ensures that food and supplies are inventoried, ordered, received and stored according to facility standards. 18. Monitors preparation and service accuracy for all menu items to include recipes, proper food handling, food safety, proper temperature, taste, consistency, diet restrictions (therapeutic and consistency when applicable) and portion control using the production sheets. 19. Ensures proper presentation of all food items and to provide maximum appeal and freshness . Maintains effective communication with all managers, fell ow supervisors, subordinates and all other coworkers. 22. Ensures that food service programs are in operated in compliance with federal, state and/or local laws and statutes. Supervisory Responsibilities: Supervises the Culinary staff, Utility staff and Service Associates. Works with Care Associates, Nurses, and Program Staff. Works closely with the Clinical Dietitian. 1. Record review of facility's policy for Infection Prevention: Infection Prevention and Control Safe & Sanitary Environment revised 07/2021, revealed .5. Dining Venues: All food contact surfaces will be cleaned and sanitized after each use, between tasks and the beginning of the shift. 2. All Food Service cooking and preparation equipment will be cleaned and sanitized after each use and maintained in a clean and sanitized condition. 3. Equipment that supports cooking equipment is also included in partnership with General Services, the cleaning of these items will be scheduled accordingly and cleaned in accordance with the SOP for each item. (I.e. Hood/Baffle cleaning). 4. All food service equipment will be cleaned and sanitized following scientific cleaning procedures for each specific piece of equipment. Follow the detailed cleaning instructions per equipment .Daily, weekly, and monthly cleaning schedules will be written and followed for all food service equipment. Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

Based on observation and interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 2 (Pod 1 and Pod 2) out of 2 units reviewed for environment. 1. The facility failed to ensure that the mechanical lift on Pod 1 was locked and secured when not in use. 2. The facility failed to ensure that the mechanical lift on Pod 2 was locked and secured when not in use. 3. The facility failed to ensure a parked wheelchair in the common area on Pod 1 was locked and secured when not in use. 4. The facility failed to ensure that razors intended for shaving use were locked and secured. These failures could place residents at risk for falls and/or injury. Findings Include: Observation of the facility's Pod 1 Unit on 07/30/24 at 9:45 am revealed an unlocked and unsecured mechanical lift parked in front of a resident's room. Observation of the facility's Pod 1 Unit on 07/30/24 at 9:50am revealed an unlocked and unsecured wheelchair in the unit's common area. Observation of the facility's Pod 2 Unit on 07/30/24 at 9:58am revealed an unlocked and unsecured mechanical lift parked in front of a resident's room. Observation of the facility's Pod 2 Unit on 07/30/24 at 10:10am revealed a wheeled supply cart, unlocked, which contained several blue razor blades. Interview with LVN B on 07/30/24 at 10:30am revealed that they had several resident's on the unit's on Pod 1 and Pod 2 that required mechanical lift assistance. LVN B revealed that once the staff was finished with the mechanical lift they should be stored in the facility's Spa Room and locked. LVN B revealed that wheelchairs, when not in use, were kept in the resident's bathrooms or at their bedside locked if the resident could independently transfer without assistance. LVN B revealed wheelchairs for public use were kept in a separate room and should not have been kept in the common area unlocked. LVN B revealed a risk for leaving facility equipment unlocked when not in use was injury to the resident or staff. Interview with LVN A on 08/01/24 at 9:30 AM revealed that wheelchairs, for common use, were kept in the facility's spa room. LVN A revealed that Hoyer lifts, when not in use, were supposed to be locked and kept at the end of the hallways. LVN A revealed that every staff member was responsible for ensuring equipment was locked and safely stored. LVN A revealed that used razors should be immediately placed in the sharps container, unused razors should be kept locked in the facility's storage room. LVN B revealed a risk to improperly storing equipment could be injury to the resident or staff. Interview with CNA C on 08/01/24 at 12:36PM revealed that mechanical lifts, when not in use, were kept in the hallways and they should be kept locked. CNA C revealed that unused wheelchairs should not be kept unlocked in common areas and should be stored in the bathrooms. CNA C revealed that razor blades were kept locked in the facility's supply room, but CNA C stated razor blades as well could be kept unlocked in resident's rooms. CNA C revealed risks of improperly storing equipment could be resident's injuring or cutting themselves. Interview with the Unit Manager for Post-Acute Care on 08/01/24 at 3:00PM revealed that mechanical lifts were to be kept off the hallway and away from exit doors. Unit Manager revealed that mechanical lifts and wheelchairs should be stored and locked when they were not in use. The Unit Manager revealed that razors were kept locked in the storage closet and should never be kept in an unlocked compartment. The Unit Manager revealed that risks of improperly storing equipment could be residents potentially cutting or injuring themselves. Interview with the DON on 08/01/24 at 3:20PM revealed that all equipment including mechanical lifts and wheelchairs were to be kept in the storage room. The DON revealed that everyone was responsible for ensuring safe storage and maintenance of all facility equipment. The DON revealed that razors were to be be kept in the facility's supply room, which was locked and never to be kept in an unlocked compartment. The DON revealed that risks of improperly storing equipment could be residents potentially cutting or injuring themselves. Interview with the Administrator on 08/01/24 at 4:26PM revealed that mechanical lifts were kept at the end of the hallways, not blocking the exits or in the facility spa room when not in use. The Administrator revealed that the mechanical lifts were to be locked when not in use. The Administrator revealed that it was the facility Unit Manager's responsibility for overseeing and rounding to ensure all equipment on the unit's was stored safely and properly. The Administrator revealed that razors were kept locked in the facility's supply room, if resident's were able to safely shave themselves independently, they could keep razors in their room. The Administrator revealed that risks of improperly storing equipment could be residents potentially cutting or injuring themselves. The facility did not provide a policy related to mechanical lifts , wheelchairs or razor blade storage.

Based on interview and record review, the facility failed to ensure that the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences of 1 (Resident #1) of 4 residents reviewed for activities of daily living. 1. The facility failed to ensure that Resident #1 had a mobility device that was accessible and comfortable to her that promoted independence, activity involvement and psychosocial need. This failure could place residents at risk of increased isolation and depression. Findings Include: Record Review of Resident #1's Quarterly MDS with an ARD (Assessment Reference Date) of 06/26/2024, revealed an [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's diagnoses included: Chronic Diastolic Heart Failure (Cardiac condition where the left ventricle of the heart is stiff and does not fill with blood properly), Scoliosis (Sideways curvature of the spine), Major Depressive Disorder (Clinical Depression), and Anxiety Disorder (group of mental disorders characterized by significant and uncontrolled feelings of anxiety and fear). Resident #1 had a BIMS score of 10, indicating a moderately impaired cognition. Record Review of Resident #1's comprehensive care plan titled, [Facility Name] Holistic Care Plan dated 06/26/2024 revealed that Resident #1's daily routine was to attend activities and events that involve socialization on campus. The care plan revealed that Resident #1's health decline upset her and she did not want to lose her independence. Care Plan revealed that Resident #1 required total (Hoyer) lift transfer. Care Plan revealed that Resident #1 enjoyed going outside to sit for a while, go outside and walk, and to be around animals. Care Plan revealed that the facility would provide Resident #1 with an environment that was conducive to mental and psychosocial wellbeing. Record Review of Resident #1' physician progress note dated 07/08/2024 revealed that Resident #1 was seen by MD A on 07/08/2024 for a follow-up visit at the facility. The progress note revealed that Resident #1 was oriented to person, place and time and Resident #1's judgement and insight were fair. The progress note revealed that Resident #1 had the capacity to make health care decisions. Record Review of document titled, Physical Therapy Evaluation and Plan of Care dated for 07/30/24 revealed that Resident #1 started physical therapy services on 03/21/24. Physical Therapy evaluation revealed that Resident #1 had a fall out of bed and sliding out of wheelchair. Physical Therapy evaluation revealed that Resident #1 would benefit from skilled physical therapy services to reduce noted functional deficits including w/c (wheelchair) mobility and safety. Physical Therapy Evaluation revealed that therapy interventions would include wheelchair skills transfer training. Physical Therapy Evaluation revealed that Resident #1's Long Term Goals would be to demonstrate improved wheelchair mobility to min A (Minimal Assistance) level to be able to propel WC (Wheelchair) > 100 feet and make turns without assist for increase function and mobility. Record Review of document titled, PT (Physical Therapy) Discharge Summary dated for 07/30/24 revealed that Resident #1 was discharged from physical therapy services on 04/12/2024. Review of the Physical Therapy Discharge Summary revealed that Resident #1 did not meet her long-term goals. Physical Therapy Discharge Summary revealed that Resident #1 required dependent assistance when sitting in [her] wheelchair, but was usually not in her wheelchair due to pain. Physical Therapy Discharge Summary revealed that resident #1 had a power wheelchair, but did not like to utilize it due to back pain. Review of document titled Occupational Therapy Evaluation and Plan of Care dated for 07/30/24 revealed that Resident #1 started occupational therapy services on 03/22/24. Occupational therapy evaluation revealed that Resident #1 stated to Occupational Therapist that she would like to get out of bed and she did not like being in bed for prolonged periods of time. Occupational Therapy Evaluation revealed that Resident #1's Short Term Goals was that Resident #1 will tolerate sitting in her wheelchair for >3 hours for increased access to community social activities. Review of document titled, OT (Occupational Therapy) Discharge Summary dated for 07/30/2024 revealed that Resident #1 was discharged from Occupational Therapy services on 04/20/2024. Occupational Therapy Discharge summary revealed that Resident #1's short term goal of tolerating sitting in a wheelchair for >3 hours for increased access to community social activities was not met. Resident #1 did not sit in w/c (wheelchair), Resident #1 tolerated sitting in recliner for about 3 hours. Record Review of document titled, Social Work/RSC Charting dated for 06/24/24 revealed that Resident #1 remained in her room; either in bed or her recliner. Resident #1 stated she felt down at times due to not getting out of her room. Staff had attempted to put Resident #1 in the WC (Wheelchair) and get her to activities, yet she asked to be transferred back to bed due to discomfort being in the WC (Wheelchair). Record Review of document titled, Nursing Charting dated for 07/29/24 revealed that Resident #1 was asked if she wanted to sit in her W/C (Wheelchair) and Resident #1 refused and stated not today. Interview with Resident #1 on 07/30/2024 at 10:30AM revealed that she had been a resident at the facility for a few months at that time. Resident #1 revealed that she transferred to the healthcare center from the campuses Independent Living Community. Resident #1 revealed that she had been unable to utilize her power wheelchair due to the size, as it was too narrow. Resident #1 stated it was uncomfortable for her for prolonged periods of time. Resident #1 revealed that the facility had brought her two manual wheelchairs, but they were too short and narrow. Resident #1 revealed that the facility had not attempted to provide another mobility device for her. Resident #1 revealed that she had felt confined and isolated to her room as she is unable to move in and out of her room without a mobility device. Resident #1 revealed that she had been unable to attend social activities or go outside, which were things that she enjoyed. Resident #1 revealed that at that time, she gave up on trying to get out of her room and asked the staff to just put her in her recliner. Resident #1 revealed that if she had a comfortable wheelchair, she would be able to get out of her room. Observation on 07/30/24 at 10:40am of Resident 1's room revealed three mobility devices in Resident #1's bathroom, which was located in Resident #1's room. Observation revealed a black power wheelchair located in the back with Resident #1's name. The power wheelchair appeared to be dusty with several incontinence supplies stacked on the power wheelchair seat itself. Observation revealed two other mobility devices in front of the power wheelchair which included two manual wheelchairs. Resident #1 revealed that the two manual wheelchairs are too short and two small in width to be able and sit for more than thirty minutes at a time. Resident #1 revealed the power wheelchair is too narrow to be able and sit for more than thirty minutes at a time. Interview with Therapy Manager on 07/30/24 at 11:55AM revealed that Resident #1 was assessed for power wheelchair usage on admission and approved, but due to resident's statements that it was too uncomfortable, staff had not been placing her in the power wheelchair. The Therapy Manager revealed that Resident #1's wheelchair tolerance was low, and her current power wheelchair was too narrow. Therapy Manager revealed that they attempted last week with two manual wheelchairs, but this was unsuccessful. Therapy Manager revealed that they had not attempted other alternatives for mobility devices or started the process to assess the resident for a new power wheelchair. The Therapy Manager did not reveal why the facility did not provide other mobility device alternatives or risks for not providing proper mobility equipment for residents. Interview with the Social Worker on 07/31/24 at 12:51PM revealed that Resident #1 expressed on admission her desire to use a power wheelchair. The Social Worker revealed that Resident #1 was assessed by therapy per Resident #1's request for power wheelchair usage. The Social Worker revealed that on 07/30/24, after the situation was [NAME] to her attention by the surveyors, the Social Worker met with Resident #1 and removed the manual wheelchairs from her room. The Social Worker confirmed that both the manual wheelchairs and power wheelchair were uncomfortable for Resident #1. The Social Worker was unsure of other mobility device alternatives that the facility provides. Interview with CNA D on 08/01/24 at 3:57PM revealed that she had been working at the facility for almost a year on the 2pm-10pm shift and she was typically assigned to Resident #1. CNA D revealed that Resident #1 could vocalize her needs and preferences. CNA D revealed that she was typically in the recliner when she got to her shifts and was unsure why Resident #1 did not utilize a wheelchair or other mobility device. CNA D revealed that Resident #1 had not expressed to her feelings of isolation or depression. CNA D revealed that if a resident needed a mobility device and does not have one that accommodates their needs, she would tell her charge nurse. Interview with the DON on 07/31/24 at 2:50PM revealed that residents needs and preferences are assessed on the baseline care plan. The DON stated the admitting nurse is the one who completed the baseline care plan. The DON revealed that Resident #1's power wheelchair was not fitting and the facility provided a manual wheelchair at that time. The DON revealed he was unaware the manual wheelchair did not fit as well. The DON revealed they had other mobility devices available if needed and that the facility can provide alternative devices, but the DON could not state what other mobility devices the facility had on hand to provide. The DON revealed that a risk for not providing proper mobility equipment for residents would be increased feelings of isolation. Record Review of the Facility's policy titled, Holistic Assessment Post- Acute and Long-Term Care revealed that, Guests/residents who will be residing in either Post Acute or Continuing Care neighborhood will be assessed by an interdisciplinary team at time of admission, re-admission, quarterly and/or significant change of condition per state and federal guidelines to establish preferences, routines, and care/clinical needs. The assessment will focus on the guests'/residents' preferences, daily routines and care/clinical needs.

Based on observation, interview, and record review, the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #12) of 8 residents reviewed for quality of life. The facility failed to ensure Resident #12 was taken to the bathroom when he requested and did not have to soil himself. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for falls, and a decreased quality of life. Findings include: 1. Record review of Resident #12's Admission MDS assessment dated [DATE], reflected Resident #12 was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included heart failure, fracture of the left, 4th finger, primary osteoarthritis, and chronic kidney disease. Resident #12 had a BIMS score of 12 which indicated Resident #12's cognition was moderately impaired. Resident #12 required maximum assistance with toileting. He was occasionally incontinent of urine and was never incontinent of bowel. He was not on a toileting a schedule. Review of Resident #12's Comprehensive Care Plan, dated 07/05/24, reflected the resident required the extensive assistance of one staff for toileting. An observation and interview on 07/30/24 at 10:51 AM with Resident #12 revealed the resident was seated in his wheelchair in his room. Both of his wrists were swollen and misshapen. He said he had arthritis and was not able to use them very well and required staff to cut his food for him. He said that the staff were too busy to take care of him and on 07/30/24 he had to wait over an hour to get help. He said that sometimes it would happen 3-4 times a day. He said on 07/30/24 in the morning before breakfast he soiled himself because no one came to help him to the bathroom. An interview on 07/30/24 at 1:29 PM with CNA A revealed she had worked at the facility for five years. She said the morning of 07/30/24 she arrived at the facility at 7:00 AM, but instead of going to Resident #12's room she gave 2 residents a shower first. She said she did not get to the resident until 7:45 AM. She said she did not know if he pressed the call light for help to the bathroom before she got to his room. She said someone else could have answered his call light and she did not know he had called for help. She said she would usually do check and change with him when he got up, after breakfast, and he would notify her after that. She said staff did not check residents at shift change when giving report. She said she did not know who covered the 6:00 AM - 7:00 AM part of her shift on 07/30/24. She said residents could get bedsores if they were not taken to the bathroom when they needed to go. An observation and interview on 08/01/24 at 10:15 AM with Resident #12 and his family member revealed when he had to soil himself, he felt like staff did not really care about him and just rushed in and rushed out of his room. An interview on 08/01/24 at 1:13 PM with RN B revealed she provided care to Resident #12 and had worked at the facility for 5 years. She said the resident was continent during the day and staff would take him to the bathroom when asked to go. She said she did not work on 07/30/24 and it was the responsibility of all staff to answer the call lights. An interview on 08/01/24 at 2:00 PM with the Clinical Manager for Post-Acute Care revealed she had worked at the facility for five and half months. She said she did not know if Resident #12 was incontinent during the day. She said he was not on a toileting schedule, and he was alert and oriented and could call for help. She said call lights were supposed to be answered in less than 5 minutes. She said she checked Resident #12's call light record for 07/29/24 - 07/30/24 for the hours between 10:00 PM - 8:00 AM and the resident pressed the call light 10 times. She said the longest wait time was 16 minutes. She said it was unusual for him to press his call light so many times and she did not know why he did. She said she wanted staff to do end of shift rounds for the residents, but she said it did not always happen. The Clinical Manager for Post-Acute Care said she did not know who or if a staff covered for CNA A the morning of 07/30/24 between the hours of 6:00 AM - 7:00 AM. She said a resident was at risk for falls and dignity issues if they had to soil themselves. She said the facility was well staffed. An interview on 08/01/24 at 3:10 PM with the DON revealed he had worked at the facility for 4 weeks. He said residents were supposed to be checked on every 2 hours. He said call lights were supposed to be answered as soon as possible. He said it was his expectation that staff check on residents at the start of their shift. He said Resident #12 was at risk for dignity issues if he was left to soil himself. Record Review of the facility policy titled Resident Rights - Continuing Care revised 06/06/23 reflected, The facility will promote and protect the rights of each resident and places a strong emphasis on individual dignity and self-determination .

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of three residents (Resident #1, #2, and #3) of 18 residents reviewed for medications and pharmacy services. The facility failed to ensure nurses were adequately counting narcotic cards and blister packs, narcotic count audits were conducted to prevent a drug diversion, and nurses were properly disposing of narcotics. Resident #1 and Resident #3 were missing narcotics. Resident #1, #2, and #3 had unexplained wasted (disposed) narcotics from May 2023 to December 2023. The noncompliance was identified as PNC. The noncompliance began on 05/16/23 and ended on 12/11/23. The facility had corrected the noncompliance before the survey began. This failure could affect residents by placing them at risk of not having their medications available as prescribed or possible drug diversions. Findings included: Review of Resident #1's quarterly MDS assessment, dated 11/29/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: cancer, hypertension, hyponatremia, hyperlipidemia , and depression. Her BIMS score was a 7 out of 15, which meant the resident was severely cognitively impaired. Her pain management section revealed she received a scheduled pain medication regimen. Review of the facilities Narcotic Notebooks, undated, revealed Resident #1's controlled drug receipt/record/disposition form dated 11/26/23 -12/06/23 for hydrocodone was missing. Review of Resident #1's November 2023 MAR, dated 11/01/23 -11/30/23, reflected she was administered Norco 10mg-325mg (one) tablet orally three times daily as ordered. Review of the facility's PIR dated 12/11/23 reflected Resident #1 was missing 12 tablets of hydrocodone from 11/26/23 - 12/06/23. Resident #1 had unexplained wasted (disposed) hydrocodone on 05/16/23, 10/08/23, and 10/10/23 . The PIR was completed by the Administrator. Resident #1's December 2023 MAR was requested on 02/07/24 and was not provided by the Administrator. Review of Resident #1's January 2024 MAR, dated 01/01/24 - 01/31/24, reflected she was administered Norco 10mg-325mg (one) tablet orally three times daily as ordered . Review of Resident #2's significant change in status MDS assessment, dated 01/19/24, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: hypertension, peripheral vascular disease, renal insufficiency, hyperlipidemia , Alzheimer's disease, non-Alzheimer's dementia, depression, and cataracts. Her BIMS score revealed she was rarely/never understood. Her pain management section revealed she received a scheduled pain medication regimen. Review of Resident #2's November 2023 MAR, dated 11/01/23 - 11/30/23, reflected she was administered Norco 5mg-325mg (one) tablet orally three times daily as ordered. Review of the facility's PIR dated 12/11/23 reflected Resident #2 had one unexplained wasted (disposed) hydrocodone pill on 11/08/23. Review of Resident #2's face sheet dated 02/07/24 reflected she passed away on 02/06/24 at 6:40 AM. Resident #2 was receiving hospice services and passed away at the facility. Review of Resident #3's admission MDS assessment, dated 08/18/23, revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: anemia, atrial fibrillation, hypertension, peripheral vascular disease, hyperlipidemia, arthritis, hip fracture, Alzheimer's disease, non-Alzheimer's dementia, anxiety disorder, and post-traumatic stress disorder. His BIMS score was a 3 out of 15, which meant the resident was severely cognitively impaired. His pain management section revealed she received a scheduled pain medication regimen. Resident #3's August 2023 & September 2023 MAR were requested on 02/07/24 and was not provided by the Administrator. Review of Resident #3's controlled drug receipt/record/disposition forms dated August 2023 and September 2023 for hydrocodone were missing. Review of Resident #3's physician order dated 08/25/23 reflected discontinue previous narcotic orders; Norco 10/325 mg tablet by mouth every six hours. Review of Resident #3's face sheet dated 02/07/24 reflected he discharged from the facility on 10/16/23 at 11:00 AM. Review of the facility's PIR dated 12/11/23 reflected Resident #3 had one unexplained wasted (disposed) hydrocodone pill on 08/15/23. Review of the in-service titled Narcotic Count Sheet Process and Narcotic/Controlled Substance Policy Review, dated 12/28/23, revealed the facility in-serviced all nurses. Record review of the facility's provider investigation report regarding Resident #1 revealed the facility identified the failure which caused Resident #1's, #2's, and #3's drug diversion and they reported the incident to HHSC on 12/11/23. The facility also identified measures to prevent a similar occurrence, including in-servicing nurses on the medication re-order process, narcotic reconciliation process, wasted medication policy, and reporting missing narcotics to the ADON or DON. The facility added a new reconciliation sheet to ensure accurate reconciliation of all narcotics. At the time of entry by the surveyor, the facility had not fully implemented these measures as evidenced by: - in-service nurses regarding adequate way to count narcotics. - in-service nurses regarding wasting (disposal) of narcotics. - Ensure nurses were not sharing keys to the narcotic lock boxes. Interview with LVN C on 02/05/24 at 1:39 pm revealed she wasted (disposed) of narcotics by discarding the pill in the sharps container or smashing the pill to rinse it down the drain. She stated during narcotic count she did not review the Disposition of Narcotic sheet/Med cards log. She stated the DON was responsible for reviewing that log. She stated she would not know if the narcotic count was inaccurate if the resident's narcotic sheet and card were missing. She was in-serviced on 12/29/23 regarding narcotic count sheet process and narcotic/controlled substance policy review. Interview with LVN D on 02/05/24 at 1:59 pm revealed during narcotic count she did not review the Disposition of Narcotic sheet/Med cards log. She stated the DON was responsible for reviewing that log. She stated she would not know if the narcotic count was inaccurate if the resident's narcotic sheet and card were missing. Interview with LVN E on 02/05/24 at 2:47 pm revealed during narcotic count she did not review the Disposition of Narcotic sheet/Med cards log. She stated the DON was responsible for reviewing that log. She stated she would not know if the narcotic count was inaccurate if the resident's narcotic sheet and card were missing. Interview with LVN B on 02/05/24 at 3:48 PM and 02/08/24 at 3:34 PM was attempted and voicemail was left. Interview with RN A on 02/05/24 at 4:09 PM revealed Resident #1 was missing one hydrocodone pill during a narcotic count on 12/01/23. RN A stated she and LVN B did not know the facility policy or procedure regarding missing narcotics. RN A stated she and LVN B falsely documented Resident #1's hydrocodone pill as wasted (disposed) on 12/01/23. RN A stated she did not report the missing narcotic pill to the DON because she was afraid. She stated she did not receive an in-service regarding reporting and documenting missing narcotics prior to the incident. She stated the incident was not reported to the DON until 12/10/23. RN A stated she received a disciplinary action for falsifying documentation and failure to report a missing narcotic. Interview with the DON on 02/05/24 at 5:00 pm revealed on 12/10/23 RN A reported that she and LVN B failed to report Resident #1's missing hydrocodone pill during narcotics count on 12/01/23. The DON stated on 12/10/23 Resident #1's narcotics count sheet dated 11/26/23 -12/06/23 could not be located. She stated from 12/10/23 to 12/11/23 an audit was conducted of all residents receiving narcotics. She stated she discovered Resident #1 was missing 12 hydrocodone pills. The DON stated she also discovered Resident #3 (discharged ) was missing 54 tablets of hydrocodone and the corresponding narcotics sheets for August 2023 and September 2023. She stated Resident #1, #2, and #3 had unexplained wasted (disposed) narcotics from May 2023 to December 2023 by the same nurse, LVN F. She stated LVN F was terminated on 12/20/23. The DON stated the previous drug regimen required nurses to count all resident narcotic cards cumulatively on one form and count the resident's pills individually on a different form. She stated the nurses were not responsible for reviewing the start/end date of the narcotics. She stated nurses were required to place the narcotic count sheets of the discontinued and/or completed medications in the residents' chart then dispose of the narcotic cards. She stated the ADON and Clinical Manager were responsible for auditing the narcotic count sheets weekly by utilizing a medication room check sheet. She stated the ADON and Clinical Manager were not utilizing the medication room check sheet to audit the narcotic count sheets. She stated the new narcotic count included a form requiring nurses to document discontinued, completed, and new narcotics. The DON stated the nurses were required to place the narcotic count sheet of the discontinued and/or completed medications in the front of the narcotics count book then keep the narcotics card in the locked cabinet. She stated since the facility did not have an ADON or Clinical Manager, she audited the narcotics count sheets weekly. The DON stated the nurses were still required to count all resident narcotic cards cumulatively on one form and count the resident's pills individually on a different form. She stated nurses were in-serviced on 12/29/23 regarding narcotic count sheet process and narcotic/controlled substance policy review. She stated the nurses were still not responsible for reviewing the start/end date of the narcotics. Observation of LVN D, LVN C, and LVN E completing the facility narcotic count on 02/06/24 from 10:19 am to 10:28 am revealed the nurses did not check the Disposition of Narcotic sheet/Med cards log or the dates on the residents' individual count sheets. The nurses were checking to see if the residents' name, prescription, and number of pills matched the individual narcotic sheet and narcotic card. Review of the Disposition of Narcotic sheet/Med cards log undated revealed the following information to be completed by the nurse and reviewed by the DON; date, resident name, medication/dosage, number of tablets, number of cards received/removed, new order or refilled/new admission, medication completed, resident deceased , and medication discontinued. Record review of the facility policy, Narcotics/Controlled Substances, dated 05/2021, revealed, All discrepancies in the narcotic count are reported to the Clinical Manager/Delegating Nurse/Nurse Supervisor immediately. Record review of the facility policy, Medication Administration, Receipt, Storage & Disposal, dated 10/2023, revealed, Discontinued or expired medications shall be destroyed within 30 days or sooner per state regulation, in the facility, or if unopened and properly labeled, returned to the pharmacy per state regulation. Destruction of narcotics will be completed per state regulations/state board of pharmacy.

Based on observation, interview, and record review the facility failed to provide or arrange services as outlined by the comprehensive care plan to meet professional standards for one (Residents #1) of 18 residents observed for medication administration. RN A and LVN B failed to report Resident #1 was missing one hydrocodone pill during narcotic count. RN A and LVN B failed to properly document Resident #1's missing hydrocodone pill during narcotic count. The noncompliance was identified as PNC. The noncompliance began on 12/01/23 and ended on 12/11/23. The facility had corrected the noncompliance before the survey began. These failures could affect residents by placing them at risk of not having their medications available as prescribed or possible drug diversions. Findings include: Review of Resident #1's quarterly MDS assessment, dated 11/29/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: cancer, hypertension, hyponatremia (the concentration of sodium in her blood was abnormally low), hyperlipidemia (an elevated level of lipids in her blood), and depression. Her BIMS score was a 7 out of 15, which meant the resident was severely cognitively impaired. Her pain management section revealed she received a scheduled pain medication regimen. Review of the facilities Narcotic Notebooks, undated, revealed Resident #1's controlled drug receipt/record/disposition form dated 11/26/23 -12/06/23 for hydrocodone was missing. Review of the facilities in-service Medication Administration Observation Checklist, dated 08/03/23, revealed nursing staff were not educated during the in-service regarding report of missing narcotics and documenting missing narcotics. RN A did not attend the in-service. LVN B attended the in-service. Review of the facility's employee roster revealed RN A was hired on 05/30/22. LVN B was hired on 07/15/19. Review of RN A's and LVN B's disciplinary actions, undated, revealed they were in violation of inappropriate storage of controlled medication, pre-pulling multiple residents' medication, discrepancies not immediately reported to the manager, and co-signed a wasted (disposed) pill that was not witnessed. RN A and LVN B were in-serviced regarding no pre-pulling multiple resident medications, immediately report any narcotic discrepancies immediately to the manager, and do not co-sign medication wasted (disposed) without witnessing the waste (disposal) of the medication. Observation of the facility narcotic count on 02/06/24 from 10:19 am to 10:28 am revealed there were no missing medications to report or document. Interview with LVN B on 02/05/24 at 3:48 PM and 02/08/24 at 3:34 PM was attempted and voicemails were left. Interview with RN A on 02/05/24 at 4:09 PM revealed Resident #1 was missing one hydrocodone pill during a narcotic count. RN A stated she and LVN B did not know the facility policy or procedure regarding missing narcotics. RN A stated she and LVN B falsely documented Resident #1's hydrocodone pill as wasted (disposed). New She stated she was in-serviced after receiving disciplinary action. Interview with the DON on 02/05/24 at 5:00 PM revealed she expected all nurses to report missing narcotics immediately. The DON stated RN A and LVN B should not have documented the missing hydrocodone pill as wasted. She stated she monitored nursing staff to ensure skills checks/competency by rounding and auditing narcotics. The DON stated Resident #1 might be at risk of a drug diversion. The DON stated nurses were previously in-serviced regarding reporting missing narcotics and documentation on 12/2022. Review of the facility's policy, Narcotics/Controlled Substances, dated May 2021, reflected, If the cause of the discrepancy cannot be determined and/or the count does not balance, report the matter to the nursing management on call/on duty.

Based on interview and record review, the facility failed to assess each resident quarterly (every 3 months) using the MDS (minimum data set) form specified by the state and approved by CMS for one (Resident #33) of five residents reviewed for quarterly assessments. The facility failed to ensure Resident #33 had a quarterly MDS assessment . This failure could place residents at risk of not receiving necessary care or receiving inappropriate care for their conditions. Findings: Record review of Resident #33's face sheet, dated 05/24/23, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included Parkinson's disease , failure to thrive, and dementia. Record review of Resident #33's electronic health chart revealed the last MDS Assessment was completed on 01/26/23 . There was no record of a more recent one completed. In an observation and attempted interview on 05/22/23 at 10:00 AM with Resident #33 revealed she was lying in bed in her room and was not responding to questions. In an interview on 05/23/23 at 2:15 PM with the MDS Coordinator revealed she was the one responsible for ensuring MDS Assessments were completed for each resident at least quarterly or every 92 days. The MDS Coordinator said the electronic health record system automatically created a schedule that tells the staff when a resident's MDS Assessment was due for the next quarter. The MDS Coordinator said she looked at the schedule and saw that Resident #33's was not due until June 2023 and had skipped her quarterly March 2023 MDS Assessment due to a glitch. The MDS Coordinator said that the last MDS assessment completed for Resident #33 was finalized in January 2022, so she was due for one in March 2023 for her next quarterly MDS Assessment. The MDS Coordinator said the purpose of the quarterly MDS Assessment was to catch up on any changes and because it was required by CMS. In an interview on 05/23/23 at 2:40 PM with the DON revealed the MDS Coordinator was responsible for ensuring MDS Assessments were completed quarterly. The DON said the purpose of the quarterly MDS Assessment was to capture information on the resident and that time and update the assessment when changes occurred based on the resident's abilities at that time. The DON said the electronic health record system created an automatic schedule and skipped Resident #33's March 2023 quarterly MDS Assessment after her last one was finalized in January 2023. Review of the facility's policy, revised 06/21, and titled MDS Completion and Management reflected: MDS Tracking .3. A Quarterly MDS is to be completed, per the MDS 3.0 RAI Manual, by the team on each resident who remains in skilled nursing. 4. The MDS Coordinator or designee maintains the electronic schedule for MDS completion with the EMR application. 5. The MDS Coordinator or designee schedules subsequent assessments.

Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 6 residents (Residents #25) for care plan revisions, in that: The facility failed to ensure Resident #25's care plan was revised to include not using the gait belt during transfers These failures could place residents at risk of receiving inappropriate care. The findings include: Record review of Resident #25's face sheet dated 05/23/23 revealed an initial admitted [DATE]. Admitting diagnoses included displaced fracture of base of neck of left femur, periprosthetic (broken) fracture around internal prosthetic left hip joint, adult failure to thrive, bipolar disorder, dyskinesia (uncontrolled involuntary movement), dementia and osteoporosis MDS assessment review for significant change (acute hospital) dated 04/06/23 reflected the Resident #25 had a BIMS score of 01 (indicating severe cognitive impairment). She needed extensive to total assistance with ADLs. Record review of Resident #25's care plan, last revised 05/19/23 reflected Resident #25 needed a gait belt Observation on 05/23/23 at 12:04 pm revealed RN A assisting Resident #25 from the floor to the wheelchair by lifting Resident #25 under the arms. In an interview on 05/23/23 at 02:38 PM with RN A, she stated the Resident #25 had behaviors. Nurse stated if staff used the gait belt on Resident #25, Resident #25 would think that they were restraining her down, and the resident would start fighting and she could harm herself. Asked why the care plan indicated to use the gait belt, nurse stated then the care plan needed to be updated to indicate the resident did not use the gait belt. Nurse stated Resident #25 was able to assist during transfers, so the staff only did support the resident, so she did not lose balance. RN A stated the care plan needed to be revised and updated so that the resident's care was provided without any adverse effects. In an interview on 05/23/23 at 02:42 PM with the DON, she stated the Resident #25 had behaviors for a few months and she will not allow the staff to apply the gait belt because she felt like she was being restrained. Asked why the care plan indicated to use the gait belt, she stated the care plan needed to be updated to indicate the resident could not use the gait belt or the Hoyer lift because she was not able to. DON stated the Clinical Manager was responsible for revising and updating the care plan. She further stated the technique the staff used could have been the best way to transfer Resident #25 because the resident was able to bear much weight. DON stated the care plan needed to be revised and updated so that the staff were able to provide appropriate care to the resident. In an interview on 05/23/23 at 03:16 PM with the Clinical Manager, he stated he completed and revised the care plan. He further stated the care plan needed to reflect the resident's needed care. Regarding Resident #25's care plan, he stated her care plan had been revised on 05/19/23. He further stated Resident #25 was not supposed to use the gait belt during transfers because the resident felt like she was restrained. The Clinical Manager stated he was supposed to update the resident's care plan to reflect the that she did not need the gait belt, but he didn't. He stated he will update the care plan. Clinical manager stated the care plan needed to be revised to indicate the resident's care needs and the staff to be aware on how to provide care to the resident. Review of the facility policy dated 05/23/23 and titled Care/Service Plans reflected, .Each guest/resident individualized care/service plan will be revised to reflect any changes in condition and will be reviewed at designated internals at a minimum based on service line (Skilled Nursing/Long Term Care/Assisted Living/Memory Care). 8. Care Plans will be reviewed, revised if applicable, on an ongoing basis by the interdisciplinary team with any change in condition and after each assessment, including both comprehensive and quarterly review assessments.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure the temperatures of food items were recorded. 2. The facility failed to ensure food items were properly labeled, dated, and stored in accordance with professional standards. These failures could place residents, who receive food from the kitchen, at risk for food contamination and food-borne illness. Findings included: An observation on 10/13/22 at 10:30 AM of the facility's food temperature log contained in the facility's Red Book revealed no recorded temperatures for breakfast, lunch, or dinner for the following dates: 10/08/22, 10/09/22, 10/10/22, 10/11/22, and 10/12/22. There were no recorded temperatures for the breakfast service on 10/13/22. An observation on 10/13/22 beginning at 10:35 AM revealed large white bins labeled sugar, flour, and rice under the food preparation area of the kitchen. The lids of all three bins were soiled with a yellow oily substance and food particles. There was a green substance, that appeared to be lettuce, in the sugar bin. Scoops were observed in the food items inside bins labeled sugar, flour, and rice. Three metal containers containing food were not covered, labeled, or dated. A bin labeled black beans was observed in the dry storage room with a scoop submerged in the black beans. An interview on 10/13/2022 at 10:40 AM with the Sous Chef revealed all meal service temperatures were taken and recorded in the Red Book before food was placed in the hot box for transport to the serving area. She said the Red Book contained the food temperature logs. She said there was no record of food temperatures in the Red Book for 10/08/22, 10/09/22, 10/10/22, 10/11/22, and 10/12/22, and breakfast on the 10/13/22. She said the cooks were responsible for recording the temperatures for each meal in the Red Book, and she was responsible for monitoring the task to ensure it was completed. She said she had not followed-up to ensure the temperatures were completed and recorded since 10/08/2022 when she started having a staff shortage. She stated the facility staff took the food temperatures and recorded temps for all food items prior to service to ensure the finished product was held at a temperature between 135 and 165 degrees. She said she would review the Red Book randomly to ensure this was being done. She said not taking food temperatures and recording them placed residents at risk of food borne illness. She stated scoops left in dry food items food items was an infection control concern and could contaminate food and lead to food borne illness. She said the bin covers should be clean and free of any substance that could get into the contained food item. She said she did not have a cleaning scheduled for every task in the kitchen, but the Cooks were responsible for the kitchen's general cleanliness. An interview on 10/13/22 at 10:50 AM with Cook A revealed she was responsible for taking and recording food temperatures for all food before placing it in the hot box for delivery to the food service areas of the facility. She said she was not sure why the temperatures were not recorded since 10/08/22. She said the cook was responsible for taking the food temperatures and recording the temperatures, but she was not the only cook. When asked if she cooked breakfast on 10/13/22, she responded, Yes. She stated she had taken the the breakfast food temperatures, but she had not recorded the temperaturs. She said she was trained to take the temperatures and recorded the temperatures for all food the left the kitchen. She said the Red Book was her guide. She said not doing so placed residents at risk of receiving food of unsafe temperatures and food borne illnesses. She stated the uncovered, undated, and unlabeled food in the three metal containers was left over puree she had prepared for lunch service. She said she prepared them earlier in the morning but could not say what time. She said one container contained ribs and the other two contained vegetables. She said they should be covered, labeled, and dated. An interview and observation on 10/13/2022 beginning at 11:00 AM with the Sous Chef revealed the uncovered, undated, and unlabeled food in the three metal inserts should be thrown out. The Sous Chef was observed telling Cook A to throw out the items, Cook A covered the items with plastic wrap and placed them in the walk-in refrigerator. The Sous Chef told Cook A to throw the items out a second time and Cook A did. The Sous Chef stated the food was not properly stored, dated, and labeled which placed residents at risk of food borne illness. An interview on 10/13/2022 at 11:23 AM with the Administrator revealed the kitchen staff did not report directly to her but rather to the Food Services Manager. She stated the Food Services Manager had been out on leave and the Director of Dining Services was now overseeing the kitchen. She stated the kitchen staff should check and log the temperatures for all food leaving the kitchen to ensure it was appropriate to serve residents. She said not doing so placed residents at risk of food [NAME] illness. An observation interview on 10/13/2022 at 12:30 PM revealed Cook A filling in temperatures in the Red Book for breakfast, lunch, and diner on October 8th, 2022. When asked what she was doing, she said she remembered the temperatures for that day and was adding them to the log. She said she also added the temperatures to the log for breakfast dated 10/13/2022. She said the temperatures should be added to the log at the time they were taken. An interview on 10/13/2022 at 12:40 PM with the Director of Dining Services revealed he was responsible to oversee all kitchen operations at the facility. He said the Kitchen Manager was on leave and he was filling in until their return. He stated the kitchen staff should have temped and recorded those temperatures for each meal services on October 8th, 9th, 10th, 11th, 12th, and breakfast on the 13th, 2022. He said the facility recorded the temperatures of food served to residents ensure it was an appropriate and safe temperature to limit food [NAME] illness. He said the cooks take and record the temperatures in the facility's Red Book and the Sous Chef was responsible to ensure the tasks was being completed. He said the Red Book was self explanatory and layed out step by step direction for food safety. He said food should always be dated, labeled, and stored properly minimize contamination and food [NAME] illness. An interview on 10/13/2022 at 12:47 PM with the DON revealed she was concerned if the kitchen staff were not taking and recording temperatures of food leaving the kitchen. She said it could place residents at risk of food [NAME] illness. She said although there had not been any current resident issues with GI, Diarrheas, or stomach issues not ensuring food was served at a safe temperature could place residents at risk. An interview on 10/13/2022 at 1:58 PM the Infection Preventionist revealed she did all the tracking of infections including GI. She said she did rounds in the kitchen to ensure proper hand hygiene, food handling, and food temperatures as part of her Infection Preventionist duties. She said she had not been in the kitchen recently but had not seen any issues during past visits. She said food temperatures are needed to ensure food was at the proper temperature to prevent infection or GI problems. Record review of the facility's policy titled Food Temperatures, dated May 2012 revealed Temperatures will be taken and recorded prior to loading food into the hot food transport carts, again in the servicing area at time of delivery by the continuing care staff person. Temperatures of all food are checked with a thermometer. All temperatures are recorded on a temperature log. Record review of the facility's policy titled Food Labeling and Dating, dated 04/2016 revealed All food and non-food supplies will be clearly labeled, and food items dated. All opened items or items not in original containers will be covered, clearly labeled, and dated. Leftover food will be stored in appropriate containers or wrapped and dated. Leftover foods and potentially hazardous foods will be chilled and held at 41 degrees or below. Monitoring of this policy will be done by the department head. Record review of the Food and Drug Administration Food Code dated 2017 reflected: Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils revealed (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 3-305.11 Food Storage. (A) Except as specified in (B) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) FOOD in packages and working containers may be stored less than 15 cm (6 inches) above the floor on case lot handling EQUIPMENT as specified under S 4-204.122. 3-305.14 Food Preparation. During preparation, UNPACKAGED FOOD shall be protected from environmental sources of contamination. 3-307.11 Miscellaneous Sources of Contamination. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food was properly stored in the facility's refrigerator, freezer, and dry storage. 2. The facility failed to ensure expired/spoiled foods were discarded. 3. The facility failed to ensure the floor in the freezer was free from spills and unpackaged food. These failures could place residents at risk for food-borne illness. Findings Included: Observation of the facility's refrigerator on [DATE] at 10:44 AM revealed: - 2 yellow bell peppers with fuzzy white spots; - 3 green bell peppers with fuzzy white spots; - 3 bags of diced celery dated use by [DATE]; - 1 open bag of diced celery dated use by [DATE]; - 1 ginger root with fuzzy white spots; and - 1 bag of raw chicken leaking pinkish colored fluid onto two boxes of chicken. Observation of the facility's freezer on [DATE] at 10:59 AM revealed: - 1 box of potato skins open and exposed to air; - 1 box of wavy pasta sheets open and exposed to air; - 2 boxes of beer battered cod open and exposed to air; - 1 box of southwestern chicken eggrolls open and exposed to air; - 1 package of strawberry cheese and lemon squares open and exposed to air; - 2 brown dried spills on the freezer floor; and - 3 white onion slices on the freezer floor. Observation of the facility's dry storage on [DATE] at 11:23 AM revealed: - 4 coffee packets open and exposed to air; and - 1 bag of yellow cornmeal open and exposed to air. Observation of the main area in the kitchen under a prep table on [DATE] at 11:30 AM revealed: - 3 red onions with fuzzy white spots. In an interview with the Dietary Manager on [DATE] at 11:48 AM revealed she completed walk throughs in the kitchen weekly and as needed. She stated everyone was responsible for food storage. She stated the freezer floor was swept weekly and deep cleaned every other week. She stated her expectation was for dietary staff to immediately clean any noticed spills. She stated residents could be at risk of food borne illnesses. Review of the facility policy titled Food / Non-Food Storage, dated [DATE], revealed, Food is stored in compliance with applicable federal, state and local regulations regarding sanitary storage conditions. Review of U.S Department of Health and Human Services Food Code, dated 2017, revealed, ,d+[DATE].15 Package Integrity reflected: Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants. Review of the Food and Drug Administration Food Code, dated 2017, reflected, .,d+[DATE].12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food ,d+[DATE].11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for four (Residents #1, #4, #22 and #26) of 12 residents reviewed for care plans. The facility failed to ensure Residents #1, #4, #22, and #26's comprehensive care plans addressed their use of [MEDICAL CONDITION] medications and related behavioral concerns as identified in their comprehensive assessments. This failure could place residents at risk of receiving inadequate interventions not individualized to their mental health care needs. Findings included: 1. Review of Resident #1's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was [AGE] year old female admitted to the facility on [DATE]. She had active [DIAGNOSES REDACTED]. She was severely cognitively impaired and had long and short-term memory/recall ability. She was unable to be interviewed for mood concerns, but staff assessment indicated she had no mood issues. She had no [MEDICAL CONDITIONS], verbal or physical behavioral issues, no wandering or rejection of care. She received antipsychotic, antianxiety and antidepressant medications. The CAA (Care Area Assessment) summary of the MDS indicated that her [MEDICAL CONDITION] medications were required to be care planned. Review of Resident #1's physician's orders [REDACTED].½ tablet daily at 10 AM and one 25mg tablet at 3 PM for major [MEDICAL CONDITION] (start date 7/23/19); [MEDICATION NAME] ([MEDICATION NAME]) 30 mg one by mouth every night at bedtime (start date 07/18/19); [MEDICATION NAME] ([MEDICATION NAME]) 0.5mg three times a day as needed, and [MEDICATION NAME] with calibrated dropper 0.25-1 ml orally by mouth as needed for anxiety (start date 07/25/19). According to U.S. National Library of Medicine Quetiapine ([MEDICATION NAME]) is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. (accessed on 10/25/19 from https://medlineplus.gov/druginfo/meds/a 9.html) According to U.S. National Library of Medicine [MEDICATION NAME] ([MEDICATION NAME]) is in a class of medications called antidepressants. It works by increasing certain types of activity in the brain to maintain mental balance. (accessed on 10/25/19 from https://medlineplus.gov/druginfo/meds/a 9.html) According to the U.S. Library of Medicine [MEDICATION NAME] ([MEDICATION NAME]) is used to treat anxiety disorders and panic disorder . [MEDICATION NAME] is in a class of medications called benzodiazepines. It works by decreasing abnormal excitement in the brain. (accessed on 10/28/19 from https://medlineplus.gov/druginfo/meds/a 1.html) According to the U.S. National Library of Medicine [MEDICATION NAME] is used to relieve anxiety. [MEDICATION NAME] is in a class of medications called benzodiazepines. It works by slowing activity in the brain to allow for relaxation. (accessed on 10/28/19 from https://medlineplus.gov/druginfo/meds/a 3.html) Review of Resident #1's Medication Administration Record [REDACTED]. She received [MEDICATION NAME] three times from 10/01/19-10/17/19. She did not receive any [MEDICATION NAME] during that time. Review of Resident #1's Comprehensive Care Plan dated 10/23/18 revealed there were no goals or interventions related to her anxiety or depression diagnoses, behaviors associated with these diagnoses, or the use of the [MEDICAL CONDITION] medications ([MEDICATION NAME], and [MEDICATION NAME]) used to treat these condition. The care plan reflected she took an antipsychotic medication ([MEDICATION NAME]) due to yelling, screaming, calling out names and taking clothes off in public areas. 2. Review of Resident #4's Admission MDS assessment dated [DATE] revealed she was [AGE] year old female admitted to the facility on [DATE]. She had active [DIAGNOSES REDACTED]. She had unclear speech and sometimes understood others. She had severe cognitive impairment. The assessment revealed there were no mood concerns, [MEDICAL CONDITIONS], verbal or physical behavioral issues, wandering or rejection of care. She received antipsychotic, antianxiety and antidepressant medications. The CAA (Care Area Assessment) summary of the MDS assessment indicated that her [MEDICAL CONDITION] medications were required to be care planned. Review of Resident #4's electronic clinical record and paper chart reflected no current physician orders [REDACTED]. Review of Resident #4's MAR for (MONTH) 2019 reflected she was currently ordered [MEDICATION NAME] 25 mg at noon and 50 mg at bedtime for depression (start date 6/24/19), [MEDICATION NAME] 0.25 mg at bedtime and as needed (start date 4/15/19), [MEDICATION NAME] 1 ml PRN (as needed)for restlessness and agitation (start date 6/06/19) and [MEDICATION NAME] 5 mg every day for depression (start date (6/24/19). According to the U.S. National Library of Medicine [MEDICATION NAME] ([MEDICATION NAME]) is used to treat depression and generalized anxiety disorder . [MEDICATION NAME] is in a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs). It works by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance. (accessed at https://medlineplus.gov/druginfo/meds/a 5.html on 10/28/19) Review of Resident #4's Comprehensive Care Plan dated 06/28/19 did not reflect any goals or interventions related to her depression or the use of [MEDICAL CONDITION] medications ([MEDICATION NAME] or [MEDICATION NAME]). The care plan only reflected she took an antipsychotic medication ([MEDICATION NAME]) due to becoming anxious and being physically abusive, with the intervention being a time out. 3. Review of Resident #22's Quarterly MDS assessment dated [DATE] revealed she was an [AGE] year-old female admitted to the facility on [DATE]. She had active [DIAGNOSES REDACTED]. She had mild cognitive impairment, and had noted mood issues related to feeling down, trouble sleeping, and feeling hopeless. She had no [MEDICAL CONDITIONS], verbal or physical behavioral issues, or wandering or rejection of care. She received antianxiety and antidepressant medications. Review of Resident #22's physician's orders [REDACTED]. According to the U.S. National Library of Medicine [MEDICATION NAME] (Duloxetine) is used to treat depression and generalized anxiety disorder Duloxetine is in a class of medications called selective serotonin and [MEDICATION NAME] reuptake inhibitors (SNRIs). It works by increasing the amounts of serotonin and [MEDICATION NAME], natural substances in the brain that help maintain mental balance and stop the movement of pain signals in the brain. (accessed at https://medlineplus.gov/druginfo/meds/a 0.html on 10/28/19) Review of Resident #22's MAR for (MONTH) 2019 reflected she was administered [MEDICATION NAME] and [MEDICATION NAME] daily. Review of Resident #22's Care Plan dated 05/17/18 revealed the care plan did not reflect any goals or interventions related to her depression [DIAGNOSES REDACTED]. 4. Review of Resident #26's annual MDS assessment dated [DATE] revealed he was an [AGE] year old male admitted to the facility on [DATE]. His active [DIAGNOSES REDACTED]. He had severe cognitive impairment and the only mood concern was related to trouble sleeping. He had no [MEDICAL CONDITIONS], verbal or physical behaviors, or wandering or rejection of care. He received antipsychotic, antidepressant, and antianxiety medications. The CAA (Care Area Assessment) summary of the MDS indicated that his [MEDICAL CONDITION] medications were required to be care planned. Review of Resident #26's physician's orders [REDACTED]. 08/15/18), and Trazadone HCL 100mg every night (start date 09/06/18 ). According to the U.S. National Library of Medicine [MEDICATION NAME] XR ([MEDICATION NAME]) is used to treat depression . generalized anxiety disorder . and panic disorder . [MEDICATION NAME] is in a class of medications called selective serotonin and [MEDICATION NAME] reuptake inhibitors (SNRIs). It works by increasing the amounts of serotonin and [MEDICATION NAME], natural substances in the brain that help maintain mental balance. (accessed from https://medlineplus.gov/druginfo/meds/a 0.html on 10/28/19) According to the U.S. National Library of Medicine [MEDICATION NAME] is used to treat depression. [MEDICATION NAME] is in a class of medications called serotonin modulators. It works by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance. (accessed from https://medlineplus.gov/druginfo/meds/a 8.html on 10/28/19) Review of Resident #26's MAR for (MONTH) 2019 reflected he was administered [MEDICATION NAME], and Trazadone daily, but did not receive PRN [MEDICATION NAME] during the time interval. Review of Resident #26's Care Plan dated 08/23 /18 did not reflect any goals or interventions related to his depression and use of [MEDICAL CONDITION] medications [MEDICATION NAME], and Trazadone. The care plan only reflected he took the antipsychotic medication [MEDICATION NAME] because he will wake up early AM and looking for wife. In an interview on 10/17/19 at 11:29 AM the DON stated she was the person who made sure the resident care plans were completed. She reviewed the care plans of Residents #1, #4, #22 and #26 and confirmed the care plans did not address the use of all prescribed [MEDICAL CONDITION] medications and their associated [DIAGNOSES REDACTED]. and the charge nurses documented in their specific areas, including medications and behaviors. Then, the DON merged their documentation into what would become the comprehensive care plan. She said going forward, they would work on care planning all [MEDICAL CONDITION] meds and related behavioral issues. Review of the facility's policy titled Psychoactive Medication Management, revised (MONTH) 2019, reflected, .Procedure 1. An interdisciplinary team will assess the guest/resident for the root cause of expressions/actions to determine the best approaches and/or interventions to assist with expression, outburst, difficult situations, etc.; .4. Care/individual service plan will reflect words/phrases and activities that cause distress and approaches/actions to help guest/resident avoid and/or work through difficult times; 5. Non-medicinal approaches are identified, attempted, modified and documented as needed in the electronic medical record and care/service plan.