Every finding on record at South Dade Nursing and Rehabilitation Center

Based on observations, interviews and record reviews, the facility failed to provide an environment free of accident hazards for one (Resident#156) out of one sampled resident as evidenced by an observation of Resident #156 in bed unattended while the bed was in a high position. There were 166 residents residing in the facility at the time of survey. The findings included:On 12/09/25 at 10:20 AM, the surveyor observed Resident #156 lying in bed with legs extended over the edge of the bed. The bed was in a high position. (photo evidence) A call light was in reach; however, Resident#156's arms appeared to be contracted. No staff were present. The surveyor immediately notified Staff E, Certified Nursing Assistant (CNA), about the identified concern. Staff E, CNA, immediately lowered the bed. The surveyor interviewed Staff E, CNA, about the facility's protocol for supervising residents to prevent falls. Staff E stated, If no staff is present, the bed should be low and the head of bed up so the resident doesn't fall. This resident cannot walk but can move the legs. I left it up because I was getting another staff member to help me take the resident out of the bed. Staff C, Registered Nurse (RN), was present for the interview.Record review of a demographic sheet revealed Resident#156 was admitted on [DATE] with diagnosis that included: Intracranial injury with loss of Consciousness.Record review of a Quarterly Minimum Data Set reference dated 9/30/25 revealed Resident#156 had a Brief Interview of Mental Status score of 11 indicating moderate cognitive impairment, required substantial/maximal assistance for transfers, and no falls since admission/entry or reentry or the prior assessment.Record review of a care plan initiated on 12/29/22 and revised on 9/23/25 revealed Resident #156 was at risk for falls related to impaired mobility, Hemiplegia-Muscle weakness, Anxiety and Reduced mobility with interventions that included: Keep bed in lowest position.On 12/09/25 at 11:11 AM The Director of Nursing and Assistant Director of Nursing were made aware of the identified concerns and stated, Staff are responsible for monitoring residents to ensure safety. Record review of Facility's policy titled Falling Star issued on 10/1/2021, 8/2023 revealed Policy: The residents will receive adequate supervision, assistance and assistive devices to aid in the prevention of falls. Each resident will be evaluated for safety risks including falls and accidents. Care plans will be created and implemented based on the individual's risk factors to aid in the prevention of falls.

Based on observations, interviews, and record reviews, the facility had failed to obtain admission orders for a medicated patch for one (Resident #175) out of three sampled newly admitted residents. Resident #175 had an undated medicated patch that the resident reported was for hypertension on the left shoulder but there was no corresponding physician's order in the resident's clinical records, which noted orders for oral hypertensive medications that the resident had been receiving since admission. This deficient practice could have caused severe hypotensive reactions for Resident #175, who had been admitted from the hospital to the facility six days earlier. At the time of the survey, 166 residents resided in the facility.Observation on 12/09/25 at 11:20 AM revealed an undated patch on Resident # 175's left shoulder. (photo evidence) Upon interview, Resident#175 stated: This patch is for hypertension and is to be changed monthly. I received it from the hospital, and I told staff, but no one has done anything. The surveyor notified Staff C, Registered Nurse (RN) who stated, I don't know about a patch and I will check.Observation and interview on 12/09/25 at 11:20 AM revealed an undated patch on Resident #175's left shoulder. (photo evidence) Resident #175 revealed: This patch is for hypertension and is to be changed monthly. I received it from the hospital, and I told staff, but no one has done anything. The surveyor then notified Staff C, a Registered Nurse (RN), who replied, I don't know about a patch and I will check. On 12/9/25 at 12:07 PM, the 3rd floor RN Supervisor approached the surveyor and stated, No one knows what type of patch it is. [Resident#175] came from the hospital and does not want to remove it. I spoke to the doctor today and the doctor will come to see the resident and possibly gives new orders. Surveyor asked, Are skin checks done upon admission? The RN, Supervisor replied: Yes but that was missed.On 12/9/25 at 2:56 PM, the Director of Nursing approached the surveyor and revealed they had received new orders for a medicated patch for hypertension for Resident#175.The demographic sheet review revealed that Resident#175 was admitted on [DATE] with diagnoses including Essential (PRIMARY) Hypertension (HTN). Record review revealed all Minimum Data Sets were in progress.Record review of a December 2025 physician's order sheet revealed an order dated 12/3/25 for Metoprolol Succinate Oral Capsule Extended Release 24 Hour Sprinkle 50 Milligrams (MG) by mouth one time a day for HTN.Record review of a care plan initiated on 12/04/25 and Revision on 12/05/25 revealed Resident #175 was at risk for cardiac/circulatory complications related to: Hyperlipidemia, HTN, Coronary Artery Disease and Congestive Heart Failure with interventions that included: Give medications as ordered, monitor for adverse signs, and symptoms.Record review of the facility's policy titled Physician Services dated 3/1/21 revealed Intent: It is the policy of the facility to ensure Physician Services are in accordance to State and Federal regulations.

Based on record reviews observations and interviews, the facility stored drugs and biologicals contrary to professional standards. Specifically, one out of three medication rooms had expired medical supplies; two out of six medication carts had loose pills, and medications were found at the bedsides of two out of 166 residents who resided in the facility during the survey. The findings included: Record review of facility policy titled Labeling of Medications Storage of Drugs and Biologicals implemented on 11/28/2019, reviewed and revised on 8/2023 revealed Policy: It is the policy of this facility to ensure that all medications and biologicals used in the facility will be labeled and stored in accordance with current state, federal regulations. Resident #45 On 12/08/25 at 10:57 AM Resident #45 was observed in bed with eyes closed in no apparent distress. A bottle of medicated shampoo was observed at bedside. (photo evidence) On 12/08/25 at 11:07 AM Staff C, Registered Nurse (RN) was notified about the identified concern and removed the bottle. Staff C, RN was interviewed about the facility's protocol for medication storage and stated, There should be no medications at the bedside. This shampoo is kept in the wound cart. I do frequent rounds to make sure no medications are in the room. During a follow up observation on 12/09/25 at 10:31 AM Resident #45 was observed lying in bed with eyes closed, no apparent distress and two packets of Vitamin C were observed on Resident's nightstand. (photo evidence) On 12/09/25 at 10:51 AM Staff C, RN, was notified about the identified concern and removed the packets. On 12/09/25 at 10:54 AM Staff D, Certified Nursing Assistant (assigned CNA) stated, I check residents throughout the shift. I did not see any medications at the bedside. I know no medications should be at the bedside. On 12/09/25 at 11:09 AM, the Director of Nursing approached surveyor in the dining room and stated, In reference to the Vitamin C packets, they were brought in and left in the room by a visitor. The visitor was educated. Staff are expected to do rounds and remove any medications from bedside. 2nd Floor East Medication Cart. On 12/09/2025 at 11:26 AM, during inspection of the 2nd Floor East Medication Cart alongside Staff B, Licensed Practical Nurse (LPN), a loose pill was found in the cart; Staff B, LPN revealed loose pills are not supposed to be inside the cart. Resident # 94 On 12/08/2025 at 12:09 PM, an over-the-counter cough medication was observed on Resident # 94's bed. The resident stated, That's mine, don't touch. (Photographic evidence) Observation on 12/09/2025 at 09:45 AM in Resident # 94's room, an aerosol treatment was in use, medication was observed on the table tray beside the bed. The resident asked surveyor what was being looked at stating the items belonged to her and that she had brought them in previously. (Photographic evidence) On 12/10/2025 at 12:51 PM, Resident # 94 was observed lying in bed in an upright/sitting position with the television on. Cough medicine was observed on the resident's bedside table tray. On 12/11/2025 at 7:48 AM, Resident # 94 was watching television; cough medication was observed on the resident's bed along with other personal items within her reach. (Photographic evidence) Interview on 12/11/2025 at 08:37 AM, the Director of Social Services revealed all medications must be stored and managed by nursing staff. An interview conducted on 12/11/2025 at 08:50 am revealed Staff F, Registered Nurse (RN), had not seen the cough medication in Resident # 94's room that day. She reported observing the resident with medications and other personal items in her room in the past. Staff attempted to educate the resident, explaining that facility policy prohibited keeping medications in her room. 4th Floor Medication Room On 12/09/2025 at 10:04 AM, during an inspection of the 4th Floor Medication Room alongside Staff A, License Practical Nurse (LPN), expired medical supplies were found that included: Ten (10) Eternal Distal End Transition Connector with cap (expired 11-28-2025), one (1) Intravenous (IV) start kit (expired 04-30-2025) and two (2) Suction Yankers (expired 03-28-2025). 4th Floor East Medication Cart On12/09/2025 at 10:31 AM inspection of the 4th Floor East Medication Cart alongside Staff A, LPN, a loose pill was found in the cart. Interview on 12/11/2025 at 01:06 PM, the Director of Nursing (DON) stated: There should never be any expired medications or supplies in the medication rooms. Central Supply is responsible for stocking the rooms and checking for expired items to replace them. Nurses are expected to check expiration dates before each med pass and properly dispose of anything expired or call the pharmacy as needed. Expired medications are placed in the drug buster. Nurses are expected to check expiration dates before each med pass and properly dispose of anything expired or call the pharmacy as needed. Expired medications are placed in the drug buster, and the same applies to any loose pills; there should be no loose pills in the carts, and nurses are required to check for them daily and dispose of them appropriately. The 11:00 PM to 7:00 AM shift nurses are responsible for checking the carts each night, including insulin and any other items that may be expired. Class III

Based on observations, interview and record review, the facility's quality assurance and assessment committee failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem areas related to repeated deficient practice for F755 Pharmacy Services and Procedures and F867 QAPI-QAA Improvement Activities .These repeated deficient practices has the potential to affect any of the 179 residents residing in the facility at the time of the survey. The findings included: Review of the facility's survey history revealed, during a Recertification survey with exit dated 03/09/2023 the facility was cited F755 Pharmacy Services and Procedures and F867 QAPI-QAA Improvement Activities. Record review of the facility policy and procedure title Quality Assurance Performance Improvement (QAPI), implemented June 2021states- It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Policy Explanation and Compliance Guidelines: 11. Governance and Leadership a) The governing body and/or executive leadership is responsible and accountable for the QAPI program. b) Governing oversight responsibilities include, but are not limited to the following: I. Approving the QAPI plan annually, and as needed. II. Ensuring the program is ongoing, defined, implemented, maintained and addresses identified concerns. III. Ensuring the program is sustained during transitions in leadership and staffing. IV. Ensuring the program is adequately resourced, including ensuring staff time, equipment, and technical training as needed. V. Ensuring the program identifies and prioritizes problems and opportunities that reflect organizational processes, functions, and services provided to residents based on performance indicator data and resident and staff input, and other information. VI. Ensuring that corrective actions address gaps in systems and are evaluated for effectiveness. VII. Setting clear expectations around safety, quality, rights, choice and respect. c) The QAA Committee shall communicate its activities and the progress of its subcommittee PIPs to the governing body (if leadership role is greater than the administrator) at least quarterly, with a formal meeting no less than annually. d) The QAA Committee shall submit supporting documentation of ongoing QAPI activities to the governing body upon request. e) QAPI training that outlines and informs staff of the elements of QAPI, and goals of the facility will be mandatory for all staff. Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated 04/25/24, 05/30/24, and 06/27/24 documented the facility had a QAA Committee meeting monthly. Attendees included: Administrator, Medical Director, Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Control Preventionist/Risk Manager, Dietary Manager, Clinical Dietician, Director of Housekeeping, Director of Maintenance, Director of therapy, Director of Human resources, Director of admissions, Director of Business office, Director of Social Services, Director of Activities, MDS (Minimum Data Set) Coordinator, and Consultant Pharmacist. Quality Assurance and Performance Improvement (QAPI) overview and interview was conducted on 7/26/2024 at 9:34 AM with the Director of Nursing/Quality Assurance (QA), Administrator/QA, Assistant Director of Nursing/QA. They reported, the QAA Committee meets every month on the last Thursday of the month; the last meeting was held on 06/27/2024. The committee consists of the Medical Director, Administrator, DON, Assistant Director of Nursing (ADON), corporate staff, pharmacy representative and all interdisciplinary team members. The focus of QA committee is to go over every department's reportable incident, benchmarks, and projects issues. If we are noticing trends in any area we investigate the root cause analysis of the trend, we then come up with interventions, collect the data, work on fixing the issues and follow up with the department heads in the concerned areas. The findings are reported at the following month's QA meeting, we then decide if to continue the interventions or resolve.

Based on observations, record review and interview the facility failed to ensure accuracy in providing medications to meet needs for three residents (Resident #121, Resident #95 and Resident #163) out of 17 sampled residents as evidenced by three medication omissions noted during medication administration observation. There were 179 residents residing in the facility at the time of survey. The findings Included: On 07/24/2024 at 08:31 AM a medication administration observation was made on the second floor, [NAME] medication cart with Staff H, Licensed Practical Nurse (LPN) for Resident #121. During medication administration Staff H, LPN dispensed one (1) Calcium 500 plus vitamin D chewable tablet into the medication cup. Review of the Electronic Medication Administration Record (EMAR) revealed Resident #121 physician order dated 5/29/2023 for Oyster Shell Calcium/Vitamin D Tablet 500-200 Milligram (mg) per Unit directions- give 1 tablet by mouth two times a day for SUPPLEMENT. Staff H, LPN approached the room and was stopped by surveyor and asked to return to medication cart. The surveyor asked if this was the correct form of medication and Staff H, LPN replied: No the order is for the regular tablet, but I don't have it in my cart right now I will notify my supervisor. On 07/24/2024 at 08:52 AM a medication administration observation was made on the third floor, east medication cart with Staff N, Registered Nurse (RN) for Resident #95. During medication administration Staff N, RN dispensed one Aspirin 81 mg chewable tablet into the medication cup. Record review of electronic medication administration record revealed physician order dated 10/20/2023 for Aspirin Tablet 81 mg, directions- give 1 tablet by mouth one time a day for Deep Vein Thrombosis Prophylaxis. Staff N, RN approached the room and was stopped by surveyor and asked to return to medication cart. The surveyor asked Staff N, RN if that was the correct form of medication. Staff N, RN replied: No this is not the correct form of Aspirin according to the physician's order, I will dispose of this pill and give the Enteric coated form. On 07/24/2024 at 09:52 AM a medication administration observation was made on the third floor, east medication cart with Staff I, RN for Resident #163. During medication administration Staff I, RN dispensed one Diphenhydramine Hydrochloride (HCL) 25 mg tablet into the medication cup. Record review of electronic medication administration record revealed physician order dated 7/20/2024 for Diphenhydramine HCl Capsule 25 MG directions- give one capsule by mouth one time a day for Skin erythema for 5 Days. Staff I, RN approached the room and was stopped by surveyor and asked to return to the medication cart. The surveyor asked if that was the correct form of medication. Staff I, RN replied: No this is not the correct form and I do not have the capsules in my cart and will notify the physician. Record review of Policy entitled Medication Preparation for Dispensing no date revealed Policy: all medications will be prepared (blister card, vials, Atromick box) and administered in a manner consistent with the general requirements outlined in this policy. Procedure: D. Medication inspection. 1. Conform that the medication name and dose are correct.

Based on observations, record reviews, and interviews, the facility failed ensure two residents (Resident #142, Resident #117) out of two residents observed during dining were treated with respect and dignity, as evidenced by staff member observed standing while feeding the residents. This facility's deficient practice has the potential to affect any of the 114 residents residing in the facility that required assistance from staff with eating. The finding included: Observation of Resident #117 on 07/21/2024 at 12:30 PM revealed the resident sitting up in bed, Staff A set up the tray and opened containers. The staff was then observed feeding the resident while standing by the resident's bed. Interview with Staff A, Certified Nursing Assistant (CNA) on 07/21/2024 at 12:30 PM. Staff A explained she did not get the chair because the chair was behind the wheelchair, and she will grab the chair now. Review of clinical records for Resident #117 revealed an initial admitted [DATE] and readmitted [DATE]. Clinical diagnosis includes but not limited to Degenerative Disease of Nervous System, Unspecified Psychotic Disturbance, Mood Disturbance, and Anxiety. Observation of Resident #142 on 07/21/2024 at 12:42 PM revealed the resident sitting up in bed, staff set up the tray and opened containers. Staff B, a Registered Nurse (RN) was observed feeding the resident while standing at the resident's bedside. Interview on 07/21/2024 at 12:42 PM; Staff B, RN revealed he is comfortable feeding the resident like that. He asked, Do I need to grab a chair? Review of clinical records for Resident #142 revealed an initial admitted [DATE] and readmitted on [DATE]. Clinical diagnosis includes but not limited to Dysphagia Following Other Cerebrovascular Disease and Muscle Weakness (Generalized). Interview with Director of Nursing on 07/25/2024 at 11:01AM. She reported the Certified Nursing Assistants (CNAs) and nurses received orientation training when they were hired. In the training the CNAs were trained with the protocol for feeding the residents, to grab a chair and be seated to be at the same level as the resident in a dignified manner. The CNAs and nurses when they were hired, they were following the prior hired CNAs and nurses to see the process with care. After those days of training, if the staff required more training, then they would be given by the facility. Record review of Policy and Procedures on Residents Rights implemented on 11/27/2019 revised by Corporate team revealed Policy: The facility will inform the resident both orally and in writing in a language that the resident understands his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility will also provide the resident with prompt notice (if any) of changes in any State or Federal laws relating to resident rights or facility rules during the resident's stay in the facility. Receipt of any such information must be acknowledged in writing. Resident Rights 1-Residents rights. The resident has the right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility.

Based on record review and interview the facility failed to ensure a level 1 Preadmission Screening and Resident Review (PASRR) was completed accurately prior to admission and failed to revise the screening following admission for one resident (Resident #63) out of 17 sampled residents. There were 179 residents residing in the facility at the time of the survey. The findings Included: Record Review of Resident #63's Level I PASRR (Preadmission Screening and Resident Review) documented Section I: PASRR Screen Decision Making: A: MI (Mental Illness) or suspected MI (check all that apply) - Anxiety and Major Depressive disorder checked off. Findings based on documented history were-Section II Other indicators for PASRR screening Decision-Making: All checked no. Does individual have validating documentation to support dementia or related neurocognitive disorder - no. Section III Not a provisional admission. Section IV No diagnosis or suspicion of SMI or ID indicated. Level II PASRR evaluation not required. PASRR Level I dated 1/5/2024. Record Review of Resident #63's Psychological Intake Note dated 6/24/2022 revealed the presenting problem was Schizophrenia and Depression. Patient had a long history of Schizophrenia and depression well controlled on medications. Diagnosis listed: Schizophrenia, Major Depressive Disorder, Recurrent episode, Moderate and Unspecified Anxiety Disorder Record Review of Resident #63's Psychological Consultation dated 7/2/2024 revealed diagnosis include: Schizophrenia and Major depressive disorder, Anxiety. Review of the medical records for Resident #63 revealed resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Paranoid Schizophrenia, Major Depressive Disorder and Anxiety Disorder. Review of the Physician's Orders Sheet for Resident #63 revealed orders that included but not limited to: Trazodone Hydrochloride 100 milligram(MG) Tablet- Give 1 tablet by mouth at bedtime for Depression dated 1/5/2024, Escitalopram Oxalate Tablet 10 MG -Give 1 tablet by mouth one time a day for Depression dated 3/18/2024, Risperidone 3 MG Tablet- Give 1 tablet by mouth every 12 hours for Paranoid Schizophrenia dated 6/14/2024, and Mirtazapine Tablet 7.5 MG- Give 1 tablet by mouth at bedtime for Depression dated 7/2/2024. Record review of Resident # 63's Admission Minimum Data Set (MDS) dated [DATE] revealed: Section A 1500 resident is not currently considered by the state level II PASRR process to have a SMI (Serious Mental Illness) or ID (Intellectual Disability) or a related condition. Section I for Active diagnosis documented Anxiety disorder, Depression, Schizophrenia. Section N for Medications documented resident is taking antipsychotic, antidepressant on a daily basis in the last 7 days. Section O for Special Treatments documented the resident received no psychological therapy. Record review of Resident #63 's Care Plan Reference Date 11/7/2022 and start date 7/19/2025 revealed: Resident is at risk for drug related side effects due to use of psychotropic meds for the diagnosis of: Anxiety, Major Depressive Disorder and Schizophrenia. The interventions included: Encourage activities as tolerated and monitor for behavior/mood changes. On 07/26/2024 at 9:34 AM The Director of Nurses (DON) stated: I oversee completing The PASRRs for residents. My process is to base the PASRR on the information that the hospital gives us before admission. After a psychiatric evaluation that indicates a new mental disorder diagnosis, I am not required to complete a new PASRR. Review of the facility's Policy and Procedure titled PASRR (Pre-Admission Screening and Resident Review) issue 3/2021 Policy: It is the policy of the facility to assure that all residents admitted to the facility receive a Pre-Admission Screening and Resident Review, in accordance with State and Federal Regulations. Procedure: 5. A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has a mental illness or intellectual disability for resident review.

Based on observations, record review and interview the facility failed to follow the care plan for two residents (Resident #102 and Resident #72) as evidenced by observations of Resident #102 in bed with full length siderails and observation of Resident # 72 in bed with one full length of two full length padded siderails in the down position while in bed. There were 179 residents residing in the facility at the time of the survey. The findings included: On 07/22/2024 at 9:19 AM Resident #102 was observed in bed with full length bilateral side rails in the up position. On 07/24/2024 at 12:22 PM Resident #102 was observed in bed with full length bilateral side rails in the up position. Resident #102 stated she is comfortable and feels safe with the siderails and staff move the siderails upon request because she cannot move them herself. Review of the medical records for Resident #102 revealed the resident was admitted to the facility on [DATE] with diagnosis that included but not limited to Parkinsonism. Review of the Physician's Orders Sheet for Resident #102 revealed order dated 1/24/2024 for 1/2 side rails while in bed every shift for bed mobility/enabler. Monitor for placement/safety. Record review of Resident #102 's Care Plan with reference date 04/19/2024 revealed the resident uses 1/2 side rail as an enabler. Interventions included: Put one half side rail up as enabler. Check and release every 2 hours for ADLs (Activities of Daily Living). Ensure that there is no gap between the mattress and the rails. Evaluate the need for continued use on a quarterly basis or as needed. Place call bell and frequently used items within reach and answer calls promptly. Review of Resident #102's Quarterly Minimum Data Set (MDS) dated [DATE] documented in Section C for Cognitive Pattern Brief Interview of Mental Status (BIMS) score of 14 out of 15 to indicate the resident is cognitively intact. On 07/24/2024 at 12:58 PM Staff J, Registered Nurse (RN) stated: This resident currently has full bilateral side rails in place and the physician's order states half (1/2) bilateral side rails. I will inform restorative nursing to change the side rails to 1/2 length as per physician order. Resident #72 On 07/22/24 at 10:18 AM Resident #72 was observed in bed. The right full length padded side rail was in the down position and the left side full length padded side rail in the up position. No staff present. (photo evidence) On 07/24/24 at 11:20 AM Resident #72 was observed in bed eating lunch independently; the right full length padded side rail noted in the down position and left in the up position. No staff was present. (photo evidence) Record review of Resident #72's demographic sheet revealed an admitted [DATE] with diagnosis that included but not limited to Epilepsy. Record review of Resident #72's physician orders revealed orders dated /13/2023 for Seizures precaution every shift for Preventative measures; order dated 5/6/2024 for B/L (Bilateral) full padded side rails for seizures precautions. Record review revealed a Care Plan initiated on 08/08/2023 and revised on 05/06/2024 for Resident #72's usage of Bilateral full padded side rails while in bed due to seizure. The interventions included: Check and release every 2 hours for ADLs. Ensure that there is no gap between the mattress and the rails. Reviewed the Modification of Quarterly MDS with reference date 5/4/2024 Section C revealed a BIMS score of 3 out of 15 indicating severe cognitive impairment. On 07/24/2024 at 11:23 AM Restorative Registered Nurse (RN) and Staff M, Certified Nursing Assistant (CNA), and restorative CNA approached surveyor. Staff M, CNA stated: I placed the right-side rail in the down position to fit the side table for [Resident # 72] to eat lunch. I left [Resident #72] in the room with one side rail in the down position during lunch because [Resident #72] eats lunch independently. Restorative CNA stated: I do rounds throughout the day to ensure the ordered restorative interventions are in place for the residents. The Restorative RN stated: The bilateral full length padded side rails should be in the up position while the resident is in bed unless staff is present. Review of the facility's Policy and Procedure titled Care Plan date: 3/1/2021. Policy: It is the policy of the facility to create Care Plans in accordance to State and Federal regulations. 10. All staff who personnel who provide care, and at resident's option, private duty nurses or personnel who are not employees of the facility, will be knowledgeable of, and have access to, the resident's plan of care.

Based on observations, record review and interviews the facility failed to provide a safe environment for two residents (Resident #43 and Resident #72) out of 17 sampled residents as evidenced by an observation of Resident #43 with smoking materials while not in the designated smoking area. There were 26 residents that smoked residing in the facility that smoked. Observation of one resident (Resident #72) out of two residents reviewed for side rails was noted with one of two full lengths bilateral padded siderails in the down position while in bed and unattended by staff. There were 179 residents residing in the facility at the time of this survey. The findings included: On 07/21/2024 at 12:24 PM Resident #43 was approached while entering the elevator for an interview. Resident #43 stated: I am going downstairs to smoke. I keep my cigarettes and a lighter on me. Resident #43 showed a lighter and box of cigarettes to surveyor. (photo evidence) On 07/21/2024 at 12:26 PM Resident #43 was accompanied by surveyor to the designated smoking area. Resident #43 was observed smoking in the designated area, two staff members were present. On 07/21/2024 at 12:28 PM Staff E and Staff F stated: We are the staff stationed in the smoking area. We keep all the smoking materials including lighters and cigarettes in a locked caddy next to us. (Showed surveyor the cabinet). We light cigarettes for the residents and keep the aprons as well and give them to residents as per their care plan. No residents are allowed to keep cigarettes or lighters on their person. On 07/21/2024 at 12:43 PM Resident #43 approached the surveyor during the interview with Staff E and Staff F and stated he had finished smoking and will return to room. Resident returned to floor with lighter. On 07/21/2024 at 12:58 PM. The Director of Nursing (DON) reported residents are not able to keep lighters on their person; all residents have been educated on the protocol, but a lot have access to outside sources that bring in smoking paraphernalia. On 07/21/2024 at 01:02 PM Resident #43 stated he was allowed to keep his lighter on him. Resident #43 and surveyor returned to smoking area and spoke with the Staff E and Staff F. Resident #43 showed his lighter and a Staff E and Staff F told Resident #43 that he needs to relinquish the lighter and Resident #43 refused. Record review of demographic sheet for Resident #43 revealed an admitted [DATE] with diagnosis that included: Nicotine dependence. Record review of Medicare - 5 Day Minimum Data Set (MDS) with reference date 7/8/2024, Section C revealed Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicated no cognitive impairment. Section E revealed no potential indicators of Psychosis. Section GG revealed Resident #43 required set up/ clean up assistance for eating and oral hygiene. Section H revealed Resident #43 was always continent of bowel/bladder. Section J revealed Received scheduled pain medication regimen in last 5 days. Section N revealed the resident was taking antidepressant medications. Record review of a Care Plan initiated on 06/10/2024 and revised on 6/25/2024 for Resident #43 revealed Resident chooses to smoke. Interventions included: Educate resident on facility smoking policy, keep resident's smoking materials stored at nurses' station, monitor for unsafe actions while smoking and intervene promptly, and provide smoking materials to resident in smoking area(s) only. Record review of Policy titled Smoking Policy, not dated, Policy: This facility shall establish and maintain safe resident smoking practices. Procedure: Prior to and upon admission, residents shall be informed of the facility smoking policy, including designated smoking area and the extent to which the facility can accommodate their smoking or nonsmoking preferences. 13. Residents are not permitted to give smoking articles to other residents. 15. This facility maintains the right to confiscate smoking articles found in violation of our smoking policies. 16. Confiscated items will be itemized and ultimately returned to the resident or his/her legal representative. Resident #72 On 07/22/24 at 10:18 AM Resident #72 was observed in bed. Right side full length padded side rail in the down position and the left side full length padded side rail in the up position. No staff present. (photo evidence) On 07/24/24 at 11:20 AM Resident #72 was observed in bed eating lunch independently. Right side full length padded side rail in the down position and left in the up position. No staff was present. (photo evidence) Record review of Resident #72's demographic sheet revealed an admitted [DATE] with diagnosis that included Epilepsy. Record review of Modification of Quarterly MDS with reference date 5/4/2024 Section C revealed a BIMS score 3 out of 15 indicated severe cognitive impairment. Section E revealed no Potential Indicators of Psychosis, no Rejection of Care, and no wandering. Section GG revealed supervision or touching assistance was required for eating and partial/moderate assistance for transfer. Section H revealed Resident #72 was always incontinent of bowel and bladder. Section P revealed Bed rail not used. Record review of Resident #72's physician orders revealed orders dated 5/13/2023 for Seizures precaution every shift for Preventative measures order dated 5/6/2024 for B/L (Bilateral) full padded side rails for seizures precautions, 7/5/2024 for Valproic Acid Oral Solution 250 Milligrams(mg) per 5 milliliters (ml) directions Give 5 ml by mouth three times a day related to EPILEPSY, and 7/28/2021 for Levetiracetam Tablet 500 MG directions Give 1 tablet by mouth two times a day for Seizures. Record review revealed a Care Plan initiated on 08/08/2023 and revised on 05/06/2024 for Resident #72's usage of Bilateral full padded side rails while in bed due to seizure. The interventions included: Check and release every 2 hours for ADLs (Activities of Daily Living). Ensure that there is no gap between the mattress and the rails. On 07/24/2024 at 11:23 AM the Restorative Registered Nurse (RN) and Staff M, Certified Nursing Assistant (CNA), and restorative CNA approached surveyor. Staff M, CNA stated: I placed the right-side rail in the down position to fit the side table for [Resident # 72] to eat lunch. I left [Resident #72] in the room with one side rail in the down position during lunch because [Resident #72] eats lunch independently. Restorative CNA stated: I do rounds throughout the day to ensure the ordered restorative interventions are in place for the residents. Restorative RN stated, the bilateral full length padded side rails should be in the up position while the resident is in bed unless staff is present. Record review of policy entitled Accidents and Incidents dated 3/1/2021 revealed Policy: It is the policy of the facility to report Accidents and Incidents in accordance to State and Federal regulations. Procedure: 1. The facility will ensure that: a. The resident environment remains as free from accidents hazards as is possible, and b. Each resident receives adequate supervision and assistance devices to prevent accidents.

Based on observations, record review and interviews the facility failed to administer oxygen therapy at the prescribed rate for one resident (Resident # 26) out of two residents reviewed. As evidenced by observations of Resident # 26 receiving oxygen via nasal cannula at 3 Liters Per Minute (LPM). There were 14 residents residing in the facilty that are require oxygen therapy. The finding included: During observation on 07/22/2024 at 9:15 AM Resident # 26 was noted in bed sleeping with nasal cannula in her nose. The oxygen concentrator's flow meter was set at 3 LPM. Record review of the physician orders dated 06/13/2024 documented orders for Oxygen at 2 LPM via nasal cannula as needed. During observation on 07/23/2024 at 11:30 AM The resident was in bed, awake with the head of the bed elevated with nasal cannula in her nose and the oxygen concentrator's flow meter was set at 3 LPM. Observation of Resident # 26 on 07/24/24 at 02:37 PM Resident was in bed sleeping; the nasal cannula was in place and the oxygen flow meter was set up at 2 LPM. Review of clinical records for Resident # 26 revealed an initial admitted [DATE]. Clinical diagnosis includes but not limited to, Chronic Obstructive Pulmonary Disease, Unspecified; Respiratory Failure, Unspecified, Whether Hypoxia or Hypercapnia; Respiratory Disorders in Disease Classified Elsewhere; Dependence on Supplemental Oxygen. Review of the Admission Minimum Data Set (MDS) Section O Special Treatments, Procedures and Programs dated 05/08/2024 revealed the resident was receiving oxygen therapy. Review of the Care Plan initiated on 05/01/2024 with next review date 08/08/2024 the resident is at risk for ineffective breathing pattern related to COPD. Patient has Shortness of Breath or trouble breathing when lying flat. Goal: the resident will demonstrate an effective respiratory rate, depth and pattern, increase activity tolerance discomfort through next review date for 90 days. Interventions: Adjust head of bed and body positioning to assist ease of breathing. Administer medication and oxygen as ordered. Arrange activities to allow adequate rest and increase activities as tolerated. Instruct resident in relaxation techniques. Keep Head of Bed elevated to facilitate easy respirations. Monitor laboratories reports and refer to doctor. Monitor lungs sounds, pallor, cough and character of sputum. Monitor resident's anxiety and give support/assistance as needed. Monitor respiratory rate, depth and effort. Interview with Staff C Registered Nurse on 07/23/2024 at 11:35 AM. She stated the protocol that she follows every day at start of the shift is to make rounds and check the residents and the orders for oxygen; She explained did not realized the order for Resident #26 was 2 LPM and the concentrator flow meter was set at 3 LPM. Interview with Director of Nursing (DON)on 07/26/2024 at 8:31 AM. The DON was informed of the concerns regarding the oxygen setting for Resident #26. She reported the protocol was for the nurses to make rounds at starting of the shift and ensure the oxygen concentrator was set following doctor's orders. Record review of Policy and Procedures: Oxygen Concentrator issued 03/2020 revealed Policy: To administer oxygen for the treatment of certain diseases or conditions. Policy Explanation and Compliance Guidelines: The maintenance department, or oxygen concentrator supplier, assists with the maintenance of oxygen concentrators according to manufacturer's recommendations and as needed. Oxygen should be administered only under orders of the attending physician, except in the case of an emergency, in an emergency, oxygen may be administered without physician's order, however, the order should be obtained immediately after the crisis is under control. 1- Care of the Resident- a-Obtain physician's orders for the rate of flow and route of administration of oxygen (mask, nasal cannula, etc.).

Based on observations, record review and interview the facility failed to have a medication error rate below 5% as evidenced by three medication omissions out of 25 medications administration opportunities. There were 179 residents residing in the facility at the time of survey. On 07/24/2024 at 08:31 AM a medication administration observation was made on the second floor, [NAME] medication cart with Staff H, Licensed Practical Nurse (LPN) for Resident #121. During medication administration Staff H, LPN dispensed one (1) Calcium 500 plus vitamin D chewable tablet into the medication cup. Record review of Electronic Medication Administration Record (EMAR) revealed Resident #121 physician order dated 5/29/2023 for Oyster Shell Calcium/Vitamin D Tablet 500-200 Milligram (mg) per Unit directions- give 1 tablet by mouth two times a day for SUPPLEMENT. Staff H, LPN approached the room and was stopped by surveyor and asked to return to medication cart. Staff H was asked if this was the correct form of medication and Staff H, LPN replied: No the order is for the regular tablet, but I don't have it in my cart right now I will notify my supervisor. On 07/24/2024 at 08:52 AM a medication administration observation was made on the third floor, east medication cart with Staff N, Registered Nurse (RN) for Resident #95. During medication administration Staff N, RN dispensed one Aspirin 81 mg chewable tablet into the medication cup. Review of the electronic medication administration record revealed physician order dated 10/20/2023 for Aspirin Tablet 81 mg, directions- give 1 tablet by mouth one time a day. Staff N, RN approached the room and was stopped by surveyor and asked to return to medication cart. Staff N, RN was asked if that was the correct form of medication. Staff N, RN replied: No this is not the correct form of Aspirin according to the physician's order, I will dispose of this pill and give the Enteric coated form. On 07/24/2024 at 09:52 AM a medication administration observation was made on the third floor, east medication cart with Staff I, RN for Resident #163. During medication administration Staff I, RN dispensed one Diphenhydramine Hydrochloride (HCL) 25 mg tablet into the medication cup. Review of the electronic medication administration record revealed physician order dated 7/20/2024 for Diphenhydramine HCl Capsule 25 MG directions- give one capsule by mouth one time a day for 5 Days. Staff I, RN approached the room and was stopped by surveyor and asked to return to the medication cart and was asked if that was the correct form of medication. Staff I, RN replied: No this is not the correct form and I do not have the capsules in my cart and will notify the physician. Record review of Policy entitled Medication Preparation for Dispensing no date revealed Policy: all medications will be prepared (blister card, vials, Atromick box) and administered in a manner consistent with the general requirements outlined in this policy. Procedure: D. Medication inspection. 1. Conform that the medication name and dose are correct.

Based on observations, record review and interview the facility failed to properly store medications and biologics for two residents out of 17 sampled residents as evidenced by observations of medication at the bedside of Resident #62 and Resident #373 and unattended pills in a medication cup on top of second floor's East Medication cart. There were 179 residents residing in the facility at the time of survey. The findings Included: On 07/21/2024 at 10:38 AM a tube labeled Hydrocortisone 1/2 % cream observed on side table and a bottle of normal saline solution on Resident#62's nightstand (photo evidence) The surveyor notified the 7:00 AM-3 :00 PM supervisor, Registered Nurse (RN) and Staff D, Licensed Practical Nurse (LPN). All entered room together. The 7:00 AM-3 :00 PM RN, supervisor removed a bottle of normal saline and a tube of hydrocortisone cream and stated that over the counter medications are not allowed to be kept in resident's rooms for safety purposes. Staff D, LPN stated I do rounds shift with the previous nurse when I come on my shift. I visualize each resident and check their rooms to ensure no potentially hazardous materials are present. I did not visualize these items in resident's room during rounds. On 07/21/2024 at 11:52 AM a metered dose inhaler and a tube of pain relief cream was observed on side table next to Resident#373's bed. (photo evidence) Staff D, LPN was made aware and entered room with surveyor and removed medications. On 07/23/2024 at 8:20 AM an observation was made on the second floor; there were three pills inside a medication cup unattended on top of the East Medication cart. (photo evidence) On 07/23/24 at 08:21 AM Staff D, LPN returned to the East medication cart. (translated by Staff J, RN) Staff D, LPN stated I left the medication to get a book I needed; this is not proper protocol, and medications should not be left unattended. On 07/26/24 at 10:02 AM, the Director of Nursing stated, all department heads do sweeps of residents' rooms daily to remove any unauthorized medications or materials that can harm the residents; we educate the residents at that time if something is found. No medications should be left on top of the medication cart unattended. Record review of Policy entitled Labeling of Medications Storage of Drugs and Biologicals date implemented 11/28/2017 date reviewed/revised: 1/16/2019 Policy: It is the policy of this facility to ensure that all medications and biologicals used in the facility will be labeled and stored in accordance with current state, federal regulations. Policy explanation and Compliance Guidelines: 1. All medications and biologicals will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices.

Based on observations, record review and interview the facility failed to meet infection control standards for one resident (Resident #30) out of 17 sampled residents as evidenced by an observation of an unchanged Intravenous dressing. There were 179 residents residing in the facility at the time of the survey. The findings included: On 07/21/2024 at 10:11 AM Resident #30 was observed in bed. An Intravenous (IV) site dressing dated 7/17 was observed on the resident's left upper extremity. An empty bag labeled Ceftriaxone 1 Gram/Normal saline 100 ML IV medication hanging on pole next to resident, dated 7/21. (photo evidence) On 07/25/2024 at 03:50 PM Resident #30 was observed in bed. An Intravenous (IV) site dressing dated 7/17 was observed on left upper extremity. Review of the medical records for Resident #30 revealed resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included: Endocarditis. Review of the Physician's Orders Sheet for Resident #30 revealed orders that included: Transparent dressing change every 72 hours every night for seven days dated 7/16/2024, Ceftriaxone Sodium Reconstituted 1 GM IV every 24 hours for Respiratory Infection for seven days dated 7/16/2024, Check IV site every shift for signs and symptoms of infection infiltration or pain document dated 7/16/2024. Review of Resident # 30's Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE] revealed Section C- a Brief Interview for Mental Status score was undetermined. Section GG- partial/moderate assistance for personal hygiene and dependent for transfer. Section I- No Urinary tract infection (UTI) (LAST 30 DAYS). Record review of Resident #30 's Care Plan revealed Resident had renal insufficiency related to chronic kidney disease with a goal to be free from infection through the review date. Interventions included: Monitor for signs or symptoms of hypovolemia or hypervolemia. On 07/25/2024 at 04:15 PM, The evening shift supervisor was notified by surveyor that Resident #30's IV dressing was dated 7/17. The evening shift supervisor revealed IV dressings should be changed every 72 hours and Resident #30's IV should have been changed and will be changed now. On 07/26/2024 at 09:02 AM. The facility's Infection Preventionist reported the facility protocol for midline or central IV lines dressings changes is weekly; the physician's order supersedes the protocol. Record review of facility's Policy entitled, PICC/Midline/CVAD Dressing change date implemented 3/2020 Policy: It is the policy of this facility to change peripherally inserted central catheter (PICC), midline or central venous access device (CVAD) dressing weekly or if soiled, in a manner to decrease potential for infection and or cross contamination. Physician's orders will specify type of dressing and frequency of changes.

Based on observation, record review, and interview, the facility failed to protect the residents' right to be free from neglect by arranging for seven residents to sleep restrained in recliners and for one resident in a wheelchair and failed to ensure incontinent care and or assistance was being provided to meet their needs. On 3/6/2023, seven residents were observed at 4:00 AM sleeping in recliners in the third floor dining room. The seven residents in recliners had the footrest of the recliners wedged with a chair underneath the footrests of the recliners so they could not lower the recliner and one resident was sitting up in a wheelchair in the dining room. This affected 8 out of 41 sampled residents (Resident # 428, Resident #63,Resident # 81,Resident # 112, Resident #127, Resident #172, Resident # 9 and Resident # 52). On 03/07/2023, it was determined the findings posed Immediate Jeopardy (IJ) to the health and safety of the residents admitted to the facility existed based on the facility's failure to provide care and services to meet the residents' needs by leaving seven residents restrained in recliners and one resident in a wheelchair to sleep in a commingled environment. 42532 The findings included: Resident # 428 On 03/06/2023 at 4:00 AM, upon entering the third-floor darkened dining area seven residents were observed sleeping in recliners with the footrests being held up with chairs (including Resident #428). There was one resident (Resident #52) seated in a wheelchair asking for assistance to go the bathroom. One (Resident #9) out of the seven residents recliner was wedged between a wall and column with a chair under the footrest. (Photographic evidence). There was one Certified Nursing Assistant (CNA) Staff K, in the dining room who was observed sitting in a chair with his feet up in another chair, covered and appeared to be sleeping; Staff K woke up when the surveyors entered the dining room, his eyes appeared to be red, and his hair was disheveled. Review of the facility's policy titled Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin dated implemented 10/20/2019, date reviewed/Revised 10/15/2022 revealed Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The Definitions section included: Neglect means failure of the facility, its employee's, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. On 03/06/2023 at 04:11 AM, Staff E, a Registered Nurse (RN) stated he was the night supervisor. Staff E reported that the residents were in the dining room because when they were alone in their rooms, they tried to get out of bed, so the nurses brought them to the third-floor dining room to guarantee that they would not fall. Staff E further stated; Residents that were like this, we brought them all in one area. It was not the normal routine, only if I did not have enough CNAs. These residents were getting out of bed and at risk of falling. We have tried non-pharmacological interventions. On 03/06/2023 at 05:18 AM, an interview was conducted with Staff K, CNA. Staff K stated he was a Patient Care Assistant (AKA Patient Care Attendant) and six months ago he did the test to become a CNA and when he started as CNA, he had orientation on abuse/neglect in-services education. Staff K was asked about the residents observed in the dining area. Staff K reported that the residents were in the dining area because the residents had a history of falls, and it was a preventative measure and he put the chair under the footrest of the recliners to keep the residents' legs from falling off and his intention was to keep the residents safe and comfortable. Staff K added that the resident that was asking to go to the bathroom, started to ask when the surveyors entered the dining room. Staff K reported the nurse was in charge of taking the residents to their rooms. The Nurses for the third usually call the nurses for the other floors to get the residents. Observation of Resident # 428 on 03/06/2023 at 06:55 AM revealed the resident in bed awake the resident reported he was hungry. There was a recliner and an oxygen concentrator at bedside. Review of the clinical records for Resident # 428 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include, but not limited to, Other Seizures; Type 2 Diabetes Mellitus without Complications; Unspecified Atrial Fibrillation; Dysphagia Following Cerebral Infarction; Other abnormalities of Gait and Mobility; Major Depressive Disorder, Recurrent, Unspecified. Review of Physician's orders dated 03/03/2023 documented orders to turn and reposition every 2 to 3 hours every shift for prevention. Orders dated 03/03/2023 revealed Fall precautions every shift for preventive measures for skin breakdown. Review of the Admission Minimum Data Set (MDS) dated [DATE] (In progress) documentation in Section C for Cognitive Pattern revealed the Resident's Brief Interview for Mental Status (BIMS) summary score was 11 out of 15 indicating the residents cognition is moderately impaired. Section H for Bowel and Bladder revealed the resident was always incontinent. Review of the Baseline Care Plan-initiated on 03/03/2023 with next review date 06/01/2023 documented: Psychosocial Goal: Maintain resident's dignity, safety to self and others and adjustment to facility during stay. Interventions: Administer and monitor the effectiveness and side effects of medications as ordered. Approach in a calm manner. Offer alternative location and activity as needed. Intervene as needed to protect the rights and safety of the residents and others. The resident has self-care deficit and need staff assistance to perform and complete ADLs (Activities of Daily Living) secondary to: Impaired mobility. Goal: Resident's ADL needs will be met through the next review date. Interventions: Allow the resident to perform tasks at own pace. Break tasks into subtasks to make them easier to follow/complete. Provide verbal cues as needed. Observe for decline from current function and report if identified. Review of Skin/Wound Note dated 03/06/2023 revealed the resident was seen today at bedside by wound care team, skin assessment performed, and no new skin impairment noted, continue with same plan of care, will continue to monitor. Review of an initial psychiatric consultation dated 03/07/2023 revealed the resident's main complaint: I was so sad; my anxiety is worse because I cannot sleep. The documented notes indicated: Current home medication and vital signs were carefully reviewed. Treatments: Continue with home medication, refill provided. Follow up after one month, for medication management. 45019 Resident # 63 During an observation on 03/06/2023 at 5:10 AM Resident # 63 was observed in the third-floor dining room in a recliner chair facing the wall asleep, the foot of the reclining chair was propped up by a dining room chair. During an interview on 03/06/2023 at 05:20 AM, Certified Nursing assistant, Staff K was asked how long the residents were in the dining room, Staff K reported the residents that were in the dining room in the recliners started coming to the dining room around 1:00 AM. On 03/06/2023 at 05:42 AM, Staff D, a Certified Nursing Assistant (CNA) who works the 11:00 PM to 7:00 AM shift, assisted the surveyor with Resident # 63's, skin assessment in the resident's room. Both legs and thighs were clean and intact, healed skin on sacrum, upper extremities were clean and intact. The disposable brief was noted with urine. The resident's bed had bilateral quarter side rails position in middle of bed and bilateral floor mats. On 03/07/2023 at 07:41 AM Resident # 63 was observed in bed asleep. The bed was in lowest position and bilateral floor mats present. Review of the medical records for Resident # 63 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Unspecified Dementia, Unspecified severity, without behavioral disturbance, Psychotic disturbance, Mood disturbance, Anxiety, Insomnia, Other Schizophrenia, and Major Depressive Disorder. Review of the Physician's Orders Sheet (POS) for March 2023 revealed Resident # 63 had orders that included but not limited to: Falling Star Program every shift. Medications included: Temazepam capsule 30 Milligram (MG) give one (1) capsule by mouth at bedtime related to insomnia unspecified. Lorazepam tablet 0.5 MG give one tablet by mouth one time a day related to anxiety disorder, unspecified. Trazodone tablet 100 mg give one tablet by mouth at bedtime related to major depressive disorder. Citalopram hydrobromide tablet 20 MG give one tablet by mouth one time a day for depression related to major depressive disorder, recurrent, unspecified and Divalproex sodium tablet delayed release 250 MG give 1 tablet by mouth three times a day for mood stabilization. Review of Resident # 63 's Annual Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns- Brief Interview for Mental status score was unable to be determined, indicating the resident is severely cognitively impaired. Section E for behaviors documented Behaviors not exhibited, No Potential Indicators of Psychosis. Section G for Functional Status documented the resident requires limited assistance for bed mobility, extensive assistance for transfer, dressing and toilet use with one person assistance and supervision for eating. Section H for bladder and bowel documented the resident is always incontinent of bowel and bladder. Section J for Health Conditions documented the resident had no falls. Section M for Skin Conditions documented-no pressure ulcers, and no skin issues. Section N for Medications documented the resident received antianxiety, antidepressants and hypnotics in the last 7 days. Section O for Special Treatments and Procedures documented the resident received no Special Treatments, Procedures, and Programs. Section P for Restraints documented No restraints used in bed or chair, and no alarms used. Review of Resident # 63's Bowel and Bladder Elimination Task List documented on 3/5/2023 at 12:16 AM, 2:26 PM and 10:25 PM Resident # 63 was not available for care. On 3/6/2023 at 12:38 AM resident not available for care, at 2:53 PM incontinent care provided, at 6:29 PM not applicable (NA) and at 11:50 PM incontinent care provided. Record review of Resident # 63's psychiatry progress dated 03/07/2023 documented: Symptom Description and Subjective Report-Resident was seen for follow up and medication management. Patient continues to have great difficulty initiating and maintaining sleep. Staff reports that without constant observation, patient attempts to get out of her bed as she does, during the day out of her wheelchair without assistance, increasing her risk of falls. Nursing staff gives medication around 9:00 PM and patient falls asleep within an hour. About 3 to 4 hours later patient is up with disinhibited behaviors. She was found today in the common area, screaming, and cursing at staff. Due to her insomnia at night, patient is somnolent in the morning and then begins with agitation and aggression towards the afternoon and evening . Plan: 1. Discontinue Lunesta at night. 2. Restart Temazepam 30 MG at night as patient has taken in the past and tolerated well. 3. Decrease Lorazepam to 0.5 mg BID to limit daytime sedation. 4. Continue remainder of psychotropic medications. 5. Monitor closely for psychotropic medication adverse effects. Record review of Resident # 63 's Care Plans Reference Date 03/03/2023 revealed: Resident has insomnia. Interventions included but not limited to: Avoid providing caffeine containing beverages. Discourage resident from taking late afternoon naps. Engage resident in more activities during the day. Give medications as ordered and monitor effectiveness. Monitor resident's sleeping pattern. Provide a quiet, restful environment during hour of sleep. Provide nonpharmacological interventions such as: massage, distractions, music therapy, encourage relaxation, etc. Provide warm beverages at bedtime as desired. Resident is at risk for drug related side effects due to use of psychotropic medications for the diagnosis of: Anxiety, Depression, Major Depressive Disorder, Bipolar Disorder, Schizophrenia, Schizoaffective, Psychosis, Tourette's, and Huntington's disease. Interventions included but not limited to: Assess for fall risk and precautions needed. Change position to promote comfort. Check and change brief as needed. Encourage activities such as TV (television) and music. Monitor behavior and mood every shift and document . Monitor for adverse side effects of drugs (lethargy, dizziness, increase in confusion, gait disturbance). Resident is at risk for falls related to Impaired mobility, Unsteady gait, Use of psychoactive meds, and Dementia. Interventions Included but not limited to: Bilateral floor mats while in bed to minimize risk of fall injuries .Check at frequent intervals of one hour to monitor for unsafe actions and intervene promptly while in room. Falling Star program. Instruct/ remind to call for assistance with all transfers. Keep bed in lowest position. Observe for safety. Resident is at risk for alteration in skin integrity related to bowel and bladder incontinence, Diabetes Mellitus, Impaired bed mobility. Interventions Included but not limited to: Incontinence care - manage moisture. Inspect skin daily. Turning and repositioning. Resident is incontinent of bowel and or bladder as evidence by: Always incontinent. Interventions Included but not limited to: Allow resident enough time for Bowel and Bladder needs . Check every 2 to 3 hours for wetness/soiling and change promptly. Provide prompt response to incontinence care needs. Side rail up as an enabler in bed and prompt to assist with positioning/repositioning. Review of the skin/wound care progress notes for Resident #63 dated 3/6/2023 timestamped 9:17 AM late entry documented: Resident seen today at bedside by wound care team, no complaint of pain or discomfort at this time, skin assessment done, no new skin impairment noted, old scar observed in the sacrum, no treatment needed. will continue to monitor. Review of the nursing progress notes for Resident # 63 dated 3/6/2023 time stamped 5:11 PM late entry documented: Resident received in stable condition . Resident # 81 During observation on 03/06/2023 at 05:10 AM Resident #81 was observed in the 3rd floor dining room in a recliner chair facing the wall asleep, the foot of the reclining chair was propped up by a dining room chair. On 03/06/2023 at 6:08 AM the 11:00 PM to 7:00 AM CNA, Staff R assisted surveyor with Resident #81's skin assessment in the resident's room. The resident's upper and lower extremities were noted clean and intact, dialysis port on right upper chest, sacral and perineal area clean and intact, no redness, dry adult disposable brief in place no odor, bilateral floor mats and full side rails present. On 03/07/2023 at 07:36 AM Registered Nurse Supervisor, (Staff B) reported that Resident # 81 went to the hospital related to respiratory distress. Review of the medical records for Resident #81 revealed resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Muscle weakness (generalized), Unspecified Dementia, unspecified severity without behavioral disturbance, Psychotic disturbance, Mood disturbance, Anxiety, Insomnia unspecified, Unspecified Psychosis not due to a substance or known physiological condition and Major Depressive Disorder recurrent unspecified. Resident # 81 was discharged to the hospital on 03/06/2023 and anticipated to return to the facility. Review of the Physician's Orders Sheet for March 2023 revealed Resident # 81 had orders that included but not limited to: Falling Star Program, and on 3/6/23- transfer resident to Hospital via 911 Diagnosis: Respiratory Distress. Medications included: Temazepam capsule 15 MG- give 1 capsule by mouth at bedtime related to insomnia, Mirtazapine tablet 7.5 MG give 1 tablet by mouth at bedtime related to major depressive disorder, recurrent, unspecified, Quetiapine Fumarate tablet 100 MG -give 1 tablet by mouth three times a day for psychosis related to unspecified psychosis not due to a substance or known physiological condition, and Divalproex Sodium tablet delayed release 250 MG-give 1 tablet by mouth three times a day for mood stabilization. Review of Resident # 81's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns- Brief Interview for Mental status score was unable to be determined, indicating the resident is severely cognitively impaired. Section E for Behaviors documented behaviors not exhibited, No Potential Indicators of Psychosis. Section G for Functional Status documented the resident requires extensive assistance for Activities of Daily Living (ADLs) with one person assistance. Section H for bladder and Bowel documented the resident is always incontinent of bowel and bladder. Section J for Health Conditions documented the resident had two or more falls since admission, no shortness of breath (SOB), and no scheduled or as needed (PRN) pain medications were received in the last 5 days. Section M for Skin Conditions documented-No pressure ulcers, and no skin issues. Section N for Medications documented the resident received insulin, antipsychotic, antidepressants, and hypnotics in the last 7 days. Section O for Special Treatments and Procedures documented the resident received dialysis in the last 14 days. Section P for Restraints documented No restraints used in bed or chair, and no alarms used. Resident # 81's Bowel and Bladder Elimination Task List documented on 3/5/2023 at 2:46 AM and 2:40 PM resident received incontinent care. At 11:59 PM the resident was not available for care. On 3/6/2023 at 12:32 AM resident received incontinent care, 2:41 PM and 10:48 PM resident not available for care. Review of Resident # 81's psychiatry progress note on 03/03/2023 documented: Symptom Description and Subjective Report-Patient has Major Neurocognitive disorder, Insomnia, and Unspecified anxiety disorder on renal dialysis who was seen today for follow up and medication management. Patient has had an overall improvement in mood and sleep since last evaluation. Staff are no longer reporting that patient is up all night and were able to engage today and evaluation. He is more alert and less somnolent during the day. Patient has not been attempting to pull out his lines during dialysis. There have been no reports of difficulty initiating or maintaining sleep. Record review of Resident # 81's Care Plans revealed: Resident is at risk for drug related side effects due to use of psychotropic medications. Interventions included but not limited to: Assess for fall risk and precautions needed. Encourage activities as tolerated. Monitor behavior and mood every shift and document . Resident is at risk for falls related to history of falls, unsteady gait, Dementia, use of psychoactive meds, and new environment. Interventions included but not limited to: Anticipate and meet needs. Assist resident with transfers and mobility. Bilateral floor mats when in bed to minimize risk of injuries . Check at frequent intervals of one hour to monitor for unsafe actions and intervene promptly. Encourage to attend activities. Falling Star Program. Monitor medication regimen. Observe for safety .Resident is incontinent of bowel and/or bladder as evidence by: Always incontinent, Interventions included but not limited to: Resident will be kept clean and dry as possible. Apply skin moisture barrier post incontinence care. Check every 2 to 3 hours for wetness/soiling and change promptly. Cue/check and assist bathroom/bedpan/urinal upon waking, before and after each meal, at bedtime and as needed. Provide prompt response to incontinence care needs. Resident #112 During observation on 03/06/2023 at 5:10 AM Resident # 112 was observed in the third-floor dining room in a recliner chair facing the wall asleep, the foot of the reclining chair was propped up by a dining room chair. On 03/06/2023 at 06:03 AM, Staff D, a CNA for the 11:00 PM to 7:00 AM shift, assisted nurse surveyor with Resident # 112's, skin assessment in the resident's room. The residents lower extremities were noted clean and intact, small dark spots to anterior bilateral legs, upper extremities clean and intact, hands and fingers no bruises, no redness noted, sacrum and perineal area-clean and intact, no redness noted. The disposable adult brief was noted with urine. Review of the medical records for Resident #112 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Alzheimer's disease unspecified, Insomnia unspecified, Unspecified psychosis not due to a substance or known physiological condition, Anxiety disorder unspecified, Unspecified mood [affective] disorder, Major depressive disorder recurrent, unspecified, and Muscle weakness (generalized). Review of the Physician's Orders Sheet for March 2023 revealed Resident #112 had orders that included but not limited to: Falling Star Program. Medications included: Temazepam capsule 30 MG- give one capsule by mouth at bedtime for insomnia. Lorazepam tablet 0.5 MG give one tablet by mouth two times a day related to anxiety disorder unspecified. Quetiapine Fumarate tablet 100 MG give- 1 tablet by mouth three times a day related to unspecified psychosis not due to a substance or known physiological condition. Trazodone HCL tablet 100 MG -give one tablet by mouth at bedtime related to major depressive disorder, recurrent, unspecified. Record review of Resident #112 's Medicare 5 Day Minimum Data Set (MDS) dated -1/30/2023 revealed: Section C for Cognitive Patterns- Brief Interview for Mental status score was unable to be determined, indicating the resident is cognitively impaired. Section E for behaviors documented Behaviors not exhibited, No Potential Indicators of Psychosis. Section G for Functional Status documented the resident requires Extensive assistance for transfer, bed mobility and toilet use with one person assistance and Supervision for eating. Section H for bladder and Bowel documented the resident is always incontinent of bowel and bladder. Section J for Health Conditions documented the resident had no falls, no shortness of breath (SOB), and no scheduled or as needed (PRN) pain medications were received in the last 5 days. Section M for Skin Conditions documented-No pressure ulcers, and no skin issues. Section N for Medications documented the resident received antipsychotics, insulin, antidepressants, hypnotics, antianxiety, antibiotic and anticoagulants in the last 7 days. Section O for Special Treatments and Procedures documented resident received no Special Treatments, Procedures, and Programs. Section P for Restraints documented No restraints used in bed or chair, and no alarms used. Record Review of Resident #112's Bowel and Bladder Elimination Task List documented on 3/5/2023 at 12:17 AM and 2:30 PM resident was not available for care, at 10:59 PM resident received incontinent care. On 3/6/2023 at 12:39 AM and 10:46 PM resident was not available for care, at 2:49 PM resident is continent and at 11:43 PM resident received incontinent care. Record review of Resident #112's Psychiatry progress Note dated 03/07/2023 documented: Symptom Description and Subjective Report-Resident has a psychiatric history of, Unspecified anxiety disorder, and Major Neurocognitive disorder, who was seen today for reevaluation and medication management . When evaluating today in the dining room, patient attempted to get up out of his chair twice throughout the evaluation. Performed in-depth psychopharmacological medication management and monitoring. Assessment: Moderately worse than previous visit. Plan: one. Discontinue Lunesta 2 MG By mouth (PO) at night (HS) as patient continues with insomnia. 2. Restart Temazepam 30 milligrams at bedtime. 3. Continue remainder psychotropic medications. 4. Monitor closely for psychotropic medication adverse effects . Record review of Resident #112's care plans with reference dated 01/20/2023 revealed: Resident has insomnia. Interventions included but not limited to: Avoid providing caffeine containing beverages. Discourage resident from taking late afternoon naps. Engage resident in more activities during the day. Give medications as ordered and monitor effectiveness. Monitor resident's sleeping pattern. Provide a quiet, restful environment during hour of sleep. Provide warm beverages at bedtime as desired. History of falls. Interventions included but not limited to. Assist resident with transfers and mobility .Check at frequent intervals to monitor for unsafe actions and intervene promptly. Falling Star program. Instruct/ remind to call for assistance with all transfers. Keep bed in lowest position. Resident is at risk for alteration in skin integrity related to Diabetes Mellitus and impaired mobility. Interventions included but not limited to: Resident will maintain skin integrity with daily skin prevention through the next review date. Apply skin moisturizer/barrier creams after incontinence care. Bilateral heel protectors while in bed. Carefully turn and reposition every 2 hours and as needed. Change promptly when wet or soiled. Float/offload heels. Incontinence care - manage moisture. Inspect skin daily for any changes and notify nurse as needed. Turning and repositioning (specify). Use moisturizers and barrier creams. Review of the skin/wound care progress notes for Resident #112 dated 3/6/2023 timestamped 1:24 PM late entry documented: Resident seen today at bedside by wound care team, skin assessment performed, and no new skin impairment noted, continue with same plan of care, will continue to monitor. Review of the nursing progress notes for Resident #112 dated 03/06/2023 timestamped 09:48 AM late entry documented: Resident received in stable condition .Nursing staff will continue to assist and support patient with ADLs. Safety and comfort measures in place. Resident #127 During observation on 03/06/2023 at 4:10 AM Resident #127 was observed in the third-floor dining room in a recliner chair facing the wall asleep, the foot of the reclining chair was propped up by a dining room chair. On 03/06/2023 at 06:27 AM, the CNA for the 11:00 PM to 7:00 AM shift, Staff D assisted surveyor with Resident #127's, skin assessment in the resident's room- perineal, sacrum-clean, and intact, no redness noted, upper and lower extremities clean and intact, dry adult brief. Bilateral quarter side rails on upper bed. Review of the medical records for Resident #127 revealed resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Major depressive disorder recurrent unspecified, Unspecified psychosis not due to a substance or known physiological condition, Vascular Dementia unspecified severity without behavioral disturbance, Psychotic disturbance mood disturbance, and Anxiety, Primary Insomnia, Anxiety disorder unspecified, Mood disorder due to known physiological condition unspecified, altered mental status unspecified, Muscle weakness (generalized) and other abnormalities of gait and mobility. Review of the Physician's Orders Sheet for March 2023 revealed Resident #127 had orders that included but not limited to: Lorazepam tablet 0.5 MG- give one tablet by mouth two times a day related to anxiety disorder, unspecified. Quetiapine Fumarate tablet 200 MG- give one tablet by mouth at bedtime related to unspecified psychosis not due to a substance or known physiological condition. Temazepam capsule 30 MG- give one capsule by mouth at bedtime for insomnia. Record review of Resident # 127's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns- Brief Interview for Mental status score was unable to be determined, indicating the resident is severely cognitively impaired. Section E for behaviors documented Behaviors not exhibited, No Potential Indicators of Psychosis. Section G for Functional Status documented the resident requires extensive assistance for ADLs with one person assistance. Section H for bladder and Bowel documented the resident is always incontinent of bowel and bladder. Section J for Health Conditions documented the resident had no falls, no shortness of breath (SOB), Section M for Skin Conditions documented-No pressure ulcers, and no skin issues. Section N for Medications documented the resident received antipsychotics, antidepressants, hypnotics, and antianxiety in the last 7 days. Section O for Special Treatments and Procedures documented resident no Special Treatments, Procedures, and Programs. Section P for Restraints documented No restraints used in bed or chair, and no alarms used. Record Review of Resident #127's Bowel and Bladder Elimination Task List documented on 3/5/2023 at 12:14 AM, resident was not available for care. On 3/6/2023 at 12:40 AM, 2:52 PM and 11:48 PM resident was not available for care. Record review of Resident #112's Psychiatry progress note dated 03/07/2023 documented: Symptom Description and Subjective Report-Resident has a Neurocognitive disorder due to Alzheimer's disease, and dementia related psychosis and a history of Seizure Disorder, Hypertension, and Diabetes Mellitus, seen for follow up and medication management. Patient has not been doing well. She was found today somnolent during the day due to great difficulty initiating and maintaining sleep for the past several nights. Patient continues with episodes of irritability and agitation during the day as well as disinhibited behaviors. Patient attempts to get out of her chair constantly throughout the day as well as at night from her bed. When .Assessment: Moderately worse than previous visit. Plan: one. Increase Temazepam to 30 MG at night (HS) 2. Decrease Clonazepam to 0.5 MG twice a day (BID) to limit daytime sedation despite ongoing behaviors three. Continue remainder psychotropic medications. 4. Monitor closely for psychotropic medication adverse effects . Record review of Resident #127 's Care Plans Reference Date 01/17/2023 revealed: Resident is on sedative/hypnotic therapy related to Insomnia. Interventions included but not limited to: Resident will be free of any discomfort or adverse side effects of hypnotic use through the review date. Administer sedative/hypnotic medications as ordered by physician. Monitor/document side effects and effectiveness. Evaluate other factors potentially causing insomnia, for example: environment (excessive heat, cold, or noise), lighting, physical activity, facility routines, caffeine/medications. Attempt to modify and control these external factors before initiating hypnotic therapy. Monitor/Document/Report PRN for following adverse effects of sedative/hypnotic therapy: daytime drowsiness, confusion, loss of appetite in the morning, increased risk of falls and fractures, dizziness. Provide nonpharmacological interventions such as: massage, distractions, music therapy, encourage relaxation .Change position to promote comfort. Check and change brief as needed. Encourage activities such as TV and music. and intervene promptly. Keep bed in lowest position. Resident is at risk for alteration in skin integrity related to impaired mobility and diabetes mellitus. Interventions included but not limited to: Resident is incontinent of bowel and bladder as evidence by: Always incontinent. Interventions included but not limited to: Resident will be kept clean and dry as possible by next review date. Apply skin moisture barrier post incontinence care. Check every two to three hours for wetness/soiling and change promptly . Review of the nursin [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure residents are free from the use of physical restraints as evidenced by the facility's staff inhibit seven (7) residents the freedom of movement by placing one resident in a recliner wedged between a wall and a column and placing a chair at the foot of the recliner to restrict the lowering of the foot of the recliners for all seven residents observed in recliners asleep in the common 3rd floor dining room. This affected 7 out 8 sampled residents (Resident #9, #63, #81, #112, #127, #172, #428) observed in the facility's 3rd floor dining room. On 03/07/2023, it was determined the findings posed Immediate Jeopardy (IJ) to the health and safety of the residents admitted to the facility existed based on the facility's failure to provide care and services to meet the residents' needs by leaving seven residents restrained in recliners and one resident in a wheelchair to sleep in a commingled environment. On 3/9/2023, after receiving an acceptable IJ Removal Plan, it was verified the IJ was removed on 3/8/2023, but deficient practice still existed at a lower scope and severity of (E). The findings included: 42532 On 03/06/2023 at 4:00 AM, upon entering the third-floor darkened dining area seven residents were observed sleeping in recliners with the footrests being held up with chairs (including Resident #428). There was one resident (Resident #52) seated in a wheelchair asking for assistance to go the bathroom. One (Resident #9) out of the seven residents recliner was wedged between a wall and column with a chair under the footrest. (Photographic evidence). There was one Certified Nursing assistant (CNA) Staff K, in the dining room who was observed to be sitting in a chair with his feet up in another chair, covered and appeared to be sleeping; Staff K woke up when the surveyors entered the darkened dining room, his eyes appeared to be red, and his hair was disheveled. Review of the facility's policy titled Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin dated implemented 10/20/2019, date reviewed/Revised 10/15/2022 revealed Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The Definitions section included: Neglect means failure of the facility, its employee's, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. On 03/06/2023 at 04:11 AM, Staff E, a Registered Nurse (RN) stated he was the night supervisor. Staff E reported that the residents were in the dining room because when they were alone in their rooms, they tried to get out of bed, so the nurse brought them to the third-floor dining room to guarantee that they would not fall. Staff E further stated; Residents that were like this, we brought them all in one area. It was not the normal routine, only if I did not have enough CNAs. These residents were getting out of bed and at risk of falling. We have tried non-pharmacological interventions. Staff E reported he only had had 4 CNAs working. On 03/06/2023 at 05:18 AM, an interview was conducted with Staff K, CNA. Staff K stated he was a Patient Care Assistant (PCA) and six months ago he did the test to become a CNA and when he started as CNA, he had orientation on abuse/neglect in-services education. Staff K was asked about the residents observed in the dining area. Staff K reported that the residents were in the dining area because the residents had a history of falls, and it was a prevention measure and he put the chair under the footrest of the recliners to keep the residents' legs from falling off and his intention was to keep the residents safe and comfortable. Staff K added that the resident that was asking to go to the bathroom, started to ask when the surveyors entered the dining room. Staff K reported the nurse was in charge of taking the residents to their room. The Nurses for the third usually call the nurses for the other floors to get the residents. Observation of Resident # 428 on 03/06/2023 at 06:55 AM revealed the resident in bed awake. Record review of the clinical records for Resident # 428 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include, but not limited to, Other Seizures; Type 2 Diabetes Mellitus without Complications; Unspecified Atrial Fibrillation; Dysphagia Following Cerebral Infarction; Other abnormalities of Gait and Mobility; Major Depressive Disorder, Recurrent, Unspecified. Review of Physician's orders dated 03/03/2023 documented orders to turn and reposition every 2 to 3 hours every shift for prevention. Orders dated 03/03/2023 revealed Fall precautions every shift for preventive measures. Review of the Admission Minimum Data Set (MDS) dated [DATE] (In progress) documentation in Section C for Cognitive Pattern revealed the Resident's Brief Interview for Mental Status (BIMS) summary score was 11 out of 15 indicating the residents cognition is moderately impaired. Section H for Bowel and Bladder revealed the resident was always incontinent. Review of the Baseline Care Plan-initiated on 03/03/2023 with next review date 06/01/2023-Psychosocial. Goal: Maintain resident's dignity, safety to self and others and adjustment to facility during stay. Interventions: Administer and monitor the effectiveness and side effects of medications as ordered. Approach in a calm manner. Offer alternative location and activity as needed. Intervene as needed to protect the rights and safety of the residents and others. The resident had a self-care deficit and needed staff assistance to perform and complete ADLs (Activities of Daily Living) secondary to: Impaired mobility. Goal: Resident's ADL needs will be met through the next review date. Interventions: Allow the resident to perform tasks at own pace. Break tasks into subtasks to make them easier to follow/complete. Provide verbal cues as needed. Observe for decline form current function and report if identified. Review of Skin/Wound Note dated 03/06/2023 revealed the resident was seen today at bedside by wound care team, skin assessment performed, and no new skin impairment noted, continue with same plan of care, will continue to monitor. Review of an initial psychiatric consultation dated 03/07/2023 revealed the resident's main complaint: I was so sad; my anxiety is worse because I cannot sleep. The documented notes indicated: Current home medication and vital signs were carefully reviewed. Treatments: Continue with home medication, refill provided. Follow up after one month, for medication management. 45019 Resident # 63 During an observation on 03/06/2023 at 5:10 AM Resident # 63 was observed in the third-floor dining room in a recliner chair facing the wall asleep, the foot of the reclining chair was propped up by a dining room chair. During an interview on 03/06/2023 at 05:20 AM, Certified Nursing assistant, Staff K was asked how long the residents were in the dining room, Staff K reported the residents that were in the dining room in the recliners started coming to the dining room around 1:00 AM. On 03/06/2023 at 05:42 AM, Staff D, a Certified Nursing Assistant (CNA) who works the 11:00 PM to 7:00 AM shift, assisted the surveyor with Resident # 63's, skin assessment in the resident's room. Both legs and thighs were clean and intact, healed skin on sacrum, upper extremities were clean and intact. The disposable brief was noted with urine. The resident's bed had bilateral quarter side rails position in middle of bed and bilateral floor mats. On 03/07/2023 at 07:41 AM Resident # 63 was observed in bed asleep. The bed was in lowest position and bilateral floor mats present. Review of the medical records for Resident # 63 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Unspecified Dementia, Unspecified severity, without behavioral disturbance, Psychotic disturbance, Mood disturbance, Anxiety, Insomnia, Other Schizophrenia, and Major Depressive Disorder. Review of the Physician's Orders Sheet (POS) for March 2023 revealed Resident # 63 had orders that included but not limited to: Falling Star Program every shift. Medications included: Temazepam capsule 30 Milligram (MG) give one (1) capsule by mouth at bedtime related to insomnia unspecified. Lorazepam tablet 0.5 MG give one tablet by mouth one time a day related to anxiety disorder, unspecified. Trazodone tablet 100 mg give one tablet by mouth at bedtime related to major depressive disorder. Citalopram hydrobromide tablet 20 MG give one tablet by mouth one time a day for depression related to major depressive disorder, recurrent, unspecified and Divalproex sodium tablet delayed release 250 MG give 1 tablet by mouth three times a day for mood stabilization. Review of Resident # 63 's Annual Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns- Brief Interview for Mental status score was unable to be determined, indicating the resident is severely cognitively impaired. Section E for behaviors documented Behaviors not exhibited, No Potential Indicators of Psychosis. Section N for Medications documented the resident received antianxiety, antidepressants and hypnotics in the last 7 days. Section O for Special Treatments and Procedures documented the resident received no Special Treatments, Procedures, and Programs. Section P for Restraints documented No restraints used in bed or chair, and no alarms used. Record review of Resident # 63's psychiatry progress dated 03/07/2023 documented: Symptom Description and Subjective Report-Resident was seen for follow up and medication management. Patient continues to have great difficulty initiating and maintaining sleep. Staff reports that without constant observation, patient attempts to get out of her bed as she does, during the day out of her wheelchair without assistance, increasing her risk of falls. Nursing staff gives medication around 9:00 PM and patient falls asleep within an hour. About 3 to 4 hours later patient is up with disinhibited behaviors. She was found today in the common area, screaming, and cursing at staff. Due to her insomnia at night, patient is somnolent in the morning and then begins with agitation and aggression towards the afternoon and evening . Plan: 1. Discontinue Lunesta at night. 2. Restart Temazepam 30 MG at night as patient has taken in the past and tolerated well. 3. Decrease Lorazepam to 0.5 mg BID to limit daytime sedation. 4. Continue remainder of psychotropic medications. 5. Monitor closely for psychotropic medication adverse effects. Record review of Resident # 63 's Care Plans Reference Date 03/03/2023 revealed: Resident has insomnia. Interventions included but not limited to: Avoid providing caffeine containing beverages. Discourage resident from taking late afternoon naps. Engage resident in more activities during the day. Give medications as ordered and monitor effectiveness. Monitor resident's sleeping pattern. Provide a quiet, restful environment during hour of sleep. Provide nonpharmacological interventions such as: massage, distractions, music therapy, encourage relaxation, etc. Provide warm beverages at bedtime as desired. Resident is at risk for drug related side effects due to use of psychotropic medications for the diagnosis of: Anxiety, Depression, Major Depressive Disorder, Bipolar Disorder, Schizophrenia, Schizoaffective, Psychosis, Tourette's, and Huntington's disease. Interventions included but not limited to: Assess for fall risk and precautions needed. Change position to promote comfort. Check and change brief as needed. Encourage activities such as TV (television) and music. Monitor behavior and mood every shift and document. Resident is at risk for falls related to Impaired mobility, Unsteady gait, Use of psychoactive meds, and Dementia. Interventions included but not limited to: Bilateral floor mats while in bed to minimize risk of fall injuries .Check at frequent intervals of one hour to monitor for unsafe actions and intervene promptly while in room. Falling Star program. Instruct/ remind to call for assistance with all transfers. Keep bed in lowest position. Observe for safety. Side rail up as an enabler in bed and prompt to assist with positioning/repositioning. Resident # 81 During observation on 03/06/2023 at 05:10 AM Resident #81 was observed in the 3rd floor dining room in a recliner chair facing the wall asleep, the foot of the reclining chair was propped up by a dining room chair. Review of the medical records for Resident #81 revealed resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Muscle weakness (generalized), Unspecified Dementia, unspecified severity without behavioral disturbance, Psychotic disturbance, Mood disturbance, Anxiety, Insomnia unspecified, Unspecified Psychosis not due to a substance or known physiological condition and Major Depressive Disorder recurrent unspecified. Resident # 81 was discharged on [DATE]. Review of the Physician's Orders Sheet for March 2023 revealed Resident # 81 had orders that included but not limited to: Falling Star Program, and on 3/6/23- transfer resident to Hospital via 911 Diagnosis: Respiratory Distress. Medications included: Temazepam capsule 15 MG- give 1 capsule by mouth at bedtime related to insomnia, Mirtazapine tablet 7.5 MG give 1 tablet by mouth at bedtime related to major depressive disorder, recurrent, unspecified, Quetiapine Fumarate tablet 100 MG -give 1 tablet by mouth three times a day for psychosis related to unspecified psychosis not due to a substance or known physiological condition, and Divalproex Sodium tablet delayed release 250 MG-give 1 tablet by mouth three times a day for mood stabilization. Review of Resident # 81's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns- Brief Interview for Mental status score was unable to be determined, indicating the resident is severely cognitively impaired. Section E for Behaviors documented behaviors not exhibited, No Potential Indicators of Psychosis. Section G for Functional Status documented the resident requires extensive assistance for Activities of Daily Living (ADLs) with one person assistance. Section J for Health Conditions documented the resident had two or more falls since admission, no shortness of breath (SOB), and no scheduled or as needed (PRN) pain medications were received in the last 5 days. Section N for Medications documented the resident received insulin, antipsychotic, antidepressants, and hypnotics in the last 7 days. Section O for Special Treatments and Procedures documented the resident received dialysis in the last 14 days. Section P for Restraints documented No restraints used in bed or chair, and no alarms used. Review of Resident # 81's psychiatry progress note on 03/03/2023 documented: Symptom Description and Subjective Report-Patient has Major Neurocognitive disorder, Insomnia, and Unspecified anxiety disorder on renal dialysis who was seen today for follow up and medication management. Patient has had an overall improvement in mood and sleep since last evaluation. Staff are no longer reporting that patient is up all night and were able to engage today and evaluation. He is more alert and less somnolent during the day. Patient has not been attempting to pull out his lines during dialysis. There have been no reports of difficulty initiating or maintaining sleep. Record review of Resident # 81's Care Plans revealed: Resident is at risk for drug related side effects due to use of psychotropic medications. Interventions included but not limited to: Assess for fall risk and precautions needed. Encourage activities as tolerated. Monitor behavior and mood every shift and document . Resident is at risk for falls related to history of falls, unsteady gait, Dementia, use of psychoactive meds, and new environment. Interventions included but not limited to: Anticipate and meet needs. Assist resident with transfers and mobility. Bilateral floor mats when in bed to minimize risk of injuries . Check at frequent intervals of one hour to monitor for unsafe actions and intervene promptly. Encourage to attend activities. Falling Star Program. Review of the nursing progress notes for Resident # 81 dated 3/6/2023 timestamped 6:39 AM documented: Resident observed in recliner awake, stable condition. Respiration even and unlabored. No signs/symptoms of pain or discomfort noted at this time. Resident ate breakfast 100% and ready to undergo dialysis treatment at this time in house. Review of the nursing discharge summary progress notes for Resident # 81 dated 3/6/2023 timestamped 1:15 PM late entry documented: Transportation arrived at unit to transfer patient .Report given to receiving emergency staff, and patient was transferred safely onto stretcher. MD and family members were notified at time of transfer. On 03/07/2023 at 07:36 AM Registered Nurse Supervisor, (Staff B) reported that Resident # 81 went to the hospital related to respiratory distress. Resident #112 During observation on 03/06/2023 at 5:10 AM Resident # 112 was observed asleep in the third-floor dining room in a recliner chair facing the wall, the foot of the reclining chair was propped up by a dining room chair. On 03/06/2023 at 06:03 AM, Staff D, a CNA for the 11:00 PM to 7:00 AM shift, assisted nurse surveyor with Resident # 112's, skin assessment in the resident's room. The disposable adult brief was noted with urine. Bilateral quarter side rails on upper bed. Review of the medical records for Resident #112 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Alzheimer's disease unspecified, Insomnia unspecified, Unspecified psychosis not due to a substance or known physiological condition, Anxiety disorder unspecified, Unspecified mood [affective] disorder, Major depressive disorder recurrent, unspecified, and Muscle weakness (generalized). Review of the Physician's Orders Sheet for March 2023 revealed Resident #112 had orders that included but not limited to: Falling Star Program. Medications included: Temazepam capsule 30 MG- give one capsule by mouth at bedtime for insomnia. Lorazepam tablet 0.5 MG give one tablet by mouth two times a day related to anxiety disorder unspecified. Quetiapine Fumarate tablet 100 MG give- 1 tablet by mouth three times a day related to unspecified psychosis not due to a substance or known physiological condition. Trazodone HCL tablet 100 MG -give one tablet by mouth at bedtime related to major depressive disorder, recurrent, unspecified. Record review of Resident #112 's Medicare 5 Day Minimum Data Set (MDS) dated -1/30/2023 revealed: Section C for Cognitive Patterns- Brief Interview for Mental status score was unable to be determined, indicating the resident is severely cognitively impaired. Section E for behaviors documented Behaviors not exhibited, No Potential Indicators of Psychosis. Section G for Functional Status documented the resident requires extensive assistance for transfer, bed mobility and toilet use with one person assistance and supervision for eating. Section H for bladder and Bowel documented the resident is always incontinent of bowel and bladder. Section J for Health Conditions documented the resident had no falls, no shortness of breath (SOB), and no scheduled or as needed (PRN) pain medications were received in the last 5 days. Section N for Medications documented the resident received antipsychotics, insulin, antidepressants, hypnotics, antianxiety, antibiotic and anticoagulants in the last 7 days. Section O for Special Treatments and Procedures documented resident received no Special Treatments, Procedures, and Programs. Section P for Restraints documented No restraints used in bed or chair, and no alarms used. Record review of Resident #112's Psychiatry progress Note dated 03/07/2023 documented: Symptom Description and Subjective Report-Resident has a psychiatric history of, Unspecified anxiety disorder, and Major Neurocognitive disorder, who was seen today for reevaluation and medication management . When evaluating today in the dining room, patient attempted to get up out of his chair twice throughout the evaluation. Performed in-depth psychopharmacological medication management and monitoring. Assessment: Moderately worse than previous visit. Plan: one. Discontinue Lunesta 2 MG By mouth (PO) at night (HS) as patient continues with insomnia. 2. Restart Temazepam 30 milligrams at bedtime. 3. Continue remainder psychotropic medications. 4. Monitor closely for psychotropic medication adverse effects . Record review of Resident #112's care plans with reference dated 01/20/2023 revealed: Resident has insomnia. Interventions included but not limited to: Avoid providing caffeine containing beverages. Discourage resident from taking late afternoon naps. Engage resident in more activities during the day. Give medications as ordered and monitor effectiveness. Monitor resident's sleeping pattern. Provide a quiet, restful environment during hour of sleep. Provide warm beverages at bedtime as desired. History of falls. Interventions included but not limited to. Assist resident with transfers and mobility .Check at frequent intervals to monitor for unsafe actions and intervene promptly. Falling Star program. Instruct/ remind to call for assistance with all transfers. Keep bed in lowest position. Carefully turn and reposition every 2 hours and as needed. Review of the nursing progress notes for Resident #112 dated 03/06/2023 timestamped 09:48 AM late entry documented: Resident received in stable condition .Nursing staff will continue to assist and support patient with ADLs. Safety and comfort measures in place. Resident #127 During observation on 03/06/2023 at 4:10 AM Resident #127 was observed asleep in the third-floor dining room in a recliner chair facing the wall, the foot of the reclining chair was propped up by a dining room chair. Review of the medical records for Resident #127 revealed resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Major depressive disorder recurrent unspecified, Unspecified psychosis not due to a substance or known physiological condition, Vascular Dementia unspecified severity without behavioral disturbance, Psychotic disturbance mood disturbance, and Anxiety, Primary Insomnia, Anxiety disorder unspecified, Mood disorder due to known physiological condition unspecified, altered mental status unspecified, Muscle weakness (generalized) and other abnormalities of gait and mobility. Review of the Physician's Orders Sheet for March 2023 revealed Resident #127 had orders that included but not limited to: Lorazepam tablet 0.5 MG- give one tablet by mouth two times a day related to anxiety disorder, unspecified. Quetiapine Fumarate tablet 200 MG- give one tablet by mouth at bedtime related to unspecified psychosis not due to a substance or known physiological condition. Temazepam capsule 30 MG- give one capsule by mouth at bedtime for insomnia. Record review of Resident # 127's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns- Brief Interview for Mental status score was unable to be determined, indicating the resident is severely cognitively impaired. Section E for behaviors documented Behaviors not exhibited, No Potential Indicators of Psychosis. Section G for Functional Status documented the resident requires extensive assistance for ADLs with one person assistance. Section J for Health Conditions documented the resident had no falls, no shortness of breath (SOB), Section M for Skin Conditions documented-No pressure ulcers, and no skin issues. Section N for Medications documented the resident received antipsychotics, antidepressants, hypnotics, and antianxiety in the last 7 days. Section O for Special Treatments and Procedures documented resident no Special Treatments, Procedures, and Programs. Section P for Restraints documented No restraints used in bed or chair, and no alarms used. Record Review of Resident #127's Bowel and Bladder Elimination Task List documented on 3/5/2023 at 12:14 AM, resident was not available for care. On 3/6/2023 at 12:40 AM, 2:52 PM and 11:48 PM resident was not available for care. Record review of Resident #112's Psychiatry progress Note dated 03/07/2023 documented: Symptom Description and Subjective Report-Resident has a Neurocognitive disorder due to Alzheimer's disease, and dementia related psychosis and a history of Seizure Disorder, Hypertension, and Diabetes Mellitus, seen for follow up and medication management. Patient has not been doing well. She was found today somnolent during the day due to great difficulty initiating and maintaining sleep for the past several nights. Patient continues with episodes of irritability and agitation during the day as well as disinhibited behaviors. Patient attempts to get out of her chair constantly throughout the day as well as at night from her bed. When .Assessment: Moderately worse than previous visit. Plan: one. Increase Temazepam to 30 MG at night (HS) 2. Decrease Clonazepam to 0.5 MG twice a day (BID) to limit daytime sedation despite ongoing behaviors three. Continue remainder psychotropic medications. 4. Monitor closely for psychotropic medication adverse effects . Record review of Resident #127 's Care Plans Reference Date 01/17/2023 revealed: Resident is on sedative/hypnotic therapy related to Insomnia. Interventions included but not limited to: Resident will be free of any discomfort or adverse side effects of hypnotic use through the review date. Administer sedative/hypnotic medications as ordered by physician. Monitor/document side effects and effectiveness. Evaluate other factors potentially causing insomnia, for example: environment (excessive heat, cold, or noise), lighting, physical activity, facility routines, caffeine/medications. Attempt to modify and control these external factors before initiating hypnotic therapy. Monitor/Document/Report PRN for following adverse effects of sedative/hypnotic therapy: daytime drowsiness, confusion, loss of appetite in the morning, increased risk of falls and fractures, dizziness. Provide nonpharmacological interventions such as: massage, distractions, music therapy, encourage relaxation .Change position to promote comfort. Check and change brief as needed. Encourage activities such as TV and music. Keep bed in lowest position. Resident #172: During observation on 03/06/2023 at 04:10 AM Resident #172 was observed in the third-floor dining room asleep in a recliner chair facing the wall, the foot of the reclining chair was propped up by a dining room chair. On 03/06/2023 at 05:45 AM, Resident #172 was observed to be taken out of 3rd floor dining room, the resident was observed to be awake, the resident had a small cut to the right eyebrow, and a bruise under the left eye. On 03/06/2023 at 05:49 AM Resident #172 was observed in her room, Staff G, CNA prepared to take her out of the recliner and put her in her bed. Staff B, Registered Nurse Supervisor came to assist the Staff G. A strong odor of urine was smelled after the resident was moved from the recliner to the bed. The blanket that was underneath Resident #172 felt wet when touched with a gloved hand and a urine stain observed on the blanket. Resident #172's incontinent brief was removed for incontinence care, and the entire front and back of brief was soaked. Slight redness was observed on the resident's buttocks. The resident was given incontinence care, ointment applied to buttocks, and a new incontinence pad was applied. (Photos obtained). Review of the medical records for Resident #172 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Muscle weakness (generalized) other abnormalities of gait and mobility, Dementia in other diseases classified elsewhere unspecified, severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Unspecified Psychosis not due to a substance or known physiological condition, altered mental status, unspecified and anxiety disorder. Review of the Physician's Orders Sheet for March 2023 revealed Resident #172 had orders that included but not limited to: Inspect skin every shift, fall precautions bilateral one-half siderails while in bed and turn and reposition every 2-3 hours. Medications included: Mirtazapine oral tablet 7.5 MG (Mirtazapine)- give 7.5 MG by mouth at bedtime for insomnia. Quetiapine Fumarate oral tablet 25 MG (Quetiapine Fumarate) -give 25 MG by mouth two times a day for psychosis. Clonazepam oral tablet 0.5 MG (Clonazepam)- give one tablet by mouth in the evening for anxiety and Melatonin oral capsule 5 MG (Melatonin)-give 5 mg by mouth at bedtime for insomnia. Record review of Resident #172's Admission Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns- Brief Interview for Mental status score (BIMS) is three on a 1-15 scale, indicating the resident is severely cognitively impaired. Section E for behaviors documented Behaviors not exhibited, No Potential Indicators of Psychosis. Section G for Functional Status documented the resident requires Limited assistance for eating, extensive assistance for transfer, bed mobility and toilet use with one-person assistance. Section J for Health Conditions documented the resident had no falls, no shortness of breath (SOB), and no scheduled or as needed (PRN) pain medications were received in the last 5 days. Section N for Medications documented the resident received antipsychotics in the last 7 days. Section O for Special Treatments and Procedures documented resident received no Special Treatments, Procedures, and Programs. Section P for Restraints documented No restraints used in bed or chair, and no alarms used. Record review of Resident #172's Care Plans Reference Date 02/07/2023 revealed: The resident is on sedative/hypnotic therapy related to Insomnia. Interventions included but not limited to: Administer sedative/hypnotic medications as ordered by physician. Monitor/document side effects and effectiveness every shift. Evaluate other factors potentially causing insomnia, for example: environment- (Excessive heat, cold, or noise), lighting, inadequate physical activity, facility routines, caffeine/medications. Attempt to modify and control these external factors before initiating hypnotic therapy. Provide nonpharmacological interventions such as: massage, distractions, music therapy, encourage relaxation. Resident is at risk for drug related side effects due to use of psychotropic medications: Interventions included but not limited to: Assess for fall risk and precautions needed. Change position to promote comfort. Check and Change brief as needed. Encourage activities such as television and music. Monitor behavior and mood every shift and document. Monitor for behavior/mood changes. Resident is at risk for alteration in skin integrity. Interventions included but not limited to: Float/offload heels. Incontinence care - manage moisture. Turning and repositioning (specify). Use moisturizers and barrier creams. Weekly skin audit. Resident is incontinent of bowel and/or bladder as evidence by: Always incontinent. Interventions included but not limited to: Apply skin moisture barrier post incontinence care. Check every 2 to 3 hours for wetness/soiling and change promptly. Provide prompt response to incontinence care needs. 47124 Resident #9 In an observation conducted on 3/06/23 at 4:00 AM, upon entering 3rd floor dining room. Resident # 9 was observed asleep in a recliner with the footrest propped up by a dining room chair. Resident 9 was noted to be wedged betwee [TRUNCATED]

Based on observation, interview, the facility's administration failed to implement and provide services effectively and efficiently related to ensuring safety measures were in place to prevent negligence and ensure residents are free from restraints and receive the highest practicable quality of care. The facility ' s administration failed to ensure adequate interventions for supervision was assigned to ensure the safety of residents. The facility's administration failed to ensure incontinence care, positioning and implement appropriate and dignified levels care to meet residents identified needs. This affected 8 out 8 sampled residents (Resident #9, #52, #63, #81, #112, #127, #172, #428) observed in the 3rd dining room at 4:00AM on 3/6/2023. On 03/07/2023, it was determined the findings posed Immediate Jeopardy (IJ) to the health and safety of the residents admitted to the facility existed based on the facility's failure to provide care and services to meet the residents' needs by leaving seven residents restrained in recliners and one resident in a wheelchair to sleep in a commingled environment. On 03/9/2023, after receiving an acceptable IJ Removal Plan, it was verified the IJ was removed on 03/8/2023, but deficient practice still existed at a lower scope and severity of (E). (Refer to F600 and F604). The findings included: On 03/06/2023 at 4:00 AM, upon entering the third-floor darkened dining room area seven residents were observed sleeping in recliners with the footrests being held up with chairs (including Residents #9, #63, #81, #112, #127, #172, #428). There was one resident (Resident #52) seated in a wheelchair asking for assistance to go the bathroom. One (Resident #9) out of the seven residents recliner was wedged between a wall and column with a chair under the food rest. (Photographic evidence). There was one Certified Nursing Assistant (CNA) Staff K, in the dining room who was observed to be sitting in a chair with his feet up in another chair under cover and appeared to be sleeping; Staff K woke up when the surveyors entered the darkened dining room, his eyes appeared to be red, and his hair was disheveled. On 03/06/23 at 04:11 AM, Staff E, a Registered Nurse (RN) stated he was the night supervisor. Staff E reported that the residents were in the dining room because when they were alone in their rooms, they tried to get out of bed, so the nurse brought them to the third-floor dining room to guarantee that they would not fall. Staff E further stated; Residents that were like this, we brought them all in one area. It was not the normal routine, only if I did not have enough CNAs. These residents were getting out of bed and at risk of falling. We have tried non-pharmacological interventions. Staff E reported, he only had had 4 CNAs working. On 03/06/23 at 05:18 AM, an interview was conducted with Staff K, CNA. Staff K stated he was a Patient Care Assistant (PCA) and six months ago he did the test to become a CNA and when he started as a CNA, he had orientation on abuse/neglect in-services education. Staff K was asked about the residents observed in the dining area. Staff K reported, that the residents were in the dining area because the residents had a history of falls, and it was a prevention measure and he put the chair under the footrest of the recliners to keep the residents' legs from falling off and his intention was to keep the residents safe and comfortable. Staff K added that the resident that was asking to go to the bathroom, started to ask when the surveyors entered the dining room. Staff K reported, the nurse was in charge of taking the residents to their room. The Nurses for the third floor usually called the nurses for the other floors to get the residents. On 03/06/23 at 05:40 AM, met with NHA and DON next to 3rd floor elevator, they were informed about the residents were found in the dining room in recliners facing the wall. The television (TV) off. Seven residents are in the dining room at this time. The DON reported the residents are placed in the dining room to decrease the pharmacological interventions for the residents and to have an activity. The DON and the Nursing Home Administrator (NHA) were shown the residents in the dining room. They were shown how the chairs were placed underneath the foot of the recliners that prevented the residents from lowering their recliners. They were told this is considered to be a restraint to have a chair wedged under the recliners footrest. During the review of the facility's policies and procedures, it was determined the facility staff failed to follow policies and procedures for: Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin dated implemented 10/20/2019, date reviewed/Revised 10/15/2022 revealed Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The Definitions section included: Neglect means failure of the facility, its employee's, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress and The facility's policy and procedures for Side Rails and Restraint Reduction dated 6/4/2020 included in part, Policy: It is the intention of this facility for each resident to attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Restraints will not be used for staff convenience. The facility's policy and procedure for Administration dated 3/1/2021 includes in part: It is the policy of the facility to provide appropriate Administration in accordance to State and Federal Regulation. Procedure: Item #1 - The facility shall comply with all applicable standards and rules of the agency and shall be under the administrative direction and charge of a licensed administrator. Item #4 - Facility Management is responsible to assist the administrator in overseeing the day to day operations of all department in the facility. Item #6 - Responsible to monitor each department's activities and communications to elevate performance per facility policies and legal requirements. Item #13 - Address and promptly resolve any identified resident care issues. Item #14 - Ensure resident care is provided in accordance with facility policies and meets professional standards of care. Review of the job description for the Administrator included, but was not limited to, the primary purpose of this position is to direct the day to day functions of the facility in accordance with current federal, state and local standards, guidelines and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to residents at all times. The Duties and Responsibilities included in part: Plan, develop, organize, implement, evaluate and direct the facility's programs and activities in accordance with guidelines issued by the governing body. Assume the administrative authority, responsibility and accountability for all programs in the facility. Ensure each resident receives necessary care and services to attain and maintain the highest practical, mental and psychosocial well-being consistent with the resident's comprehensive assessment and plan of care. Ensure that all employee's, residents, visitors and the general public follow the facility's established policies and procedures. Develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property as well as established facility policies and procedures to investigate such allegations and oversee training as required. Review of the job description for the Director of Nurses included, but was not limited to, the primary purpose of this position is to plan, organize, develop and direct the overall operation of the nursing services department in accordance with current federal, state and local standards, guidelines and regulations that govern the facility and as directed by the Administrator and the Medical Director to ensure that the highest degree of quality care is maintained at all times. The Duties and Responsibilities included in part: Develop and maintain nursing policies and procedures that conform to current standards of nursing practice, facility mission and state and federal regulations. Oversee the staff development program to ensure nursing team members have the tools, training and resources to properly care for residents in accordance with facility policies and the resident assessment. Plan, develop, organize, implement, evaluate and direct the nursing services department as well as its programs and activities in accordance with current rules, regulations and guidelines that govern the nursing care facilities. Assign a sufficient number of Certified Nursing Assistants for each shift to ensure that routine nursing care is provided to meet the daily nursing care needs of each resident. The facility's IJ Removal Plan was accepted on 3/9/2023 and was verified as completed on 3/9/2023. The effective date of the IJ removal was on 3/8/23: The IJ Removal Plan indicated: 1. On 3/7/2023-Reviewed in-service documentation for supervisors completed by the Nursing Home Administrator (NHA) and Director of Nurses (DON) Only Registered Nurses and Licensed Practical Nurses attended this in-service. Topic-Providing adequate supervision to residents-Goal-To ensure CNA are supervised. As of 03/08/2023: 29 Registered Nurses out of 32 Registered Nurses and 10 Licensed Practical Nurses out of 12 Licensed Practical Nurses had received in-services. 2. Performance Improvement Plan - Reviewed for residents sleeping in the recliner during the 11:00 PM to 7:00 AM shift; staff placed chair under the recliner which is a restraint; Staff member assigned to supervise the resident was noted to be sleeping, staff failed to check and change to residents who were in the recliner. Documents information on the IJ Removal Plan. 3. Quality Assurance Performance Improvement (QAPI) AD HOC Meeting on 03/7/2023 with the NHA, DON, ADON, Department Heads and Medical Director to review and approve the performance improvement plan. 4. Performance Improvement Project Worksheet Root Cause Analysis dated 03/6/2023. 5. Evaluation of the 8 residents for Pressure Ulcer Prevention - completed by the wound care team on 3/6/23, no new open areas noted. 6. Teachable Moment for supervisor, Staff E on 03/06/2023. 7. Staff K, CNA for the 11:00 PM to 7:00 AM shift was contacted about investigation on 03/06/2023. 8. Inservice on 03/06/2023 - Topic Administrator, Director of Nursing, Assistant Director of Nursing Job Duties and Responsibilities, Resident Rights, Abuse Prevention, Restraints, ADLs, and Toileting. Present by Regional Director of Clinical Services. 9. Inservice 03/06/2023 Resident Rights, Abuse Prevention, Restraints, Activities of Daily Living (ADLs) and Toileting by NHA and DON, attended by all Department Heads, Director of Social Services, Director Activities, Human Resources Director, Infection Preventionist, Nursing Supervisor 3:00 PM to 11:00 PM shift , Business Office Manager, Wound Care Nurse, Charge Nurse 3rd Floor, Maintenance Director, Nursing Supervisor 7:00 AM to 3:00 PM, Nursing Supervisor 11:00 PM to 7:00 AM, Restorative Nurse, Charge Nurse 2nd Floor, Charge Nurse 4th Floor. 10. Inservice Topic - Providing Adequate Supervision to residents by NHA and DON for Nurse supervisors that were on 03/06/2023. Inservice on 03/07/2023, 03/08/2023. 11. Inservice Education - 03/06/2023 to 03/07/2023 Covered Policy & Procedures for Resident Rights, Abuse Prevention, Restraints, ADLS, Toileting Presented by Social Worker, NHA and DON. 12. Facility Administrations - Interview with supervisor Staff E, on 03/06/2023 about the incident. 13. Facility Administration - Interview on 03/06/2023 with Staff H, 11:00 PM to 7:00 AM Registered Nurse about the incident 14. Facility Administration - Interview on 03/06/2023 with Staff C, 11:00 PM to 7:00 AM Registered Nurse about the incident. 15. Facility Administration - Interview on 03/06/2023 with Staff K, C N A, about the incident. 16. Psychiatric Evaluation on 03/07/2023 for Residents #9. #52, #63, #112, #127, #172, #428. 17. Care Plans for 8 residents (Residents #9, #52, #63, #81, #112, #127, #172, #428) updated to at risk for drug related side effect due to use of psychotropic meds. 18. Federal Immediate reports to Department of Children and Family (DCF) on 03/07/2023 at 1:30PM, reported by the Social Services Director (cases #178496, #178503, 178497, 178509, 178490, 178508, 178499 and178507) 19. On 3/09/2023, the surveyors reviewed the case numbers for Resident # 428, Resident #63, Resident # 81, Resident # 112, Resident #127, Resident #172, Resident # 9, and Resident # 52. 19. On 03/09/2023, the surveyors Interviewed 36 staff members from shifts 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM. All confirmed receiving the education and explained what they learned. 20. Every 2-hour rounds were completed, and documentation was started on 03/06/2023 at 3:00 pm and is ongoing. 21. As of 03/08/2023 a total of 180 out of 202 staff members had been educated.

Based on observation, interview, and record review, the facility failed to implement their policy and procedures on abuse by not filing the immediate report within the required time of two hours related to allegations of abuse and neglect. As evidenced by at 4:00 AM during initial tour the survey team observed seven residents (Resident # 9, Resident #63, Resident # 127, Resident # 112, Resident #172, Resident #428 and Resident #81) sleeping in recliners and one resident (Resident # 52) seated in a wheelchair in the 3rd floor dining room out of eight residents who were reviewed for abuse. This facility practice had the potential to have a negative impact on the health and safety of all 176 residents residing in the facility at the time of the survey. The findings included Observation on 03/06/2023 at 4:00 AM. Upon entering third floor-dining area, seven residents were observed sleeping in recliners with the footrest of the recliners propped up on dining room chair. Furthermore one resident (Resident # 9) recliner was wedged between a column and the wall.(Photographic evidence. There was one resident (Resident # 52) seated in wheelchair asking for assistance to go the bathroom. The Certified Nursing Assistant (CNA) Staff K was observed seated in a chair with his feet up on another chair and appeared to be sleeping. Interview with Staff E, RN on 03/06/23 at 04:11 AM. He stated he is the night supervisor. He stated the residents were alone in their room, they tried to get out of bed. The nurse brought them here to guarantee that they were not falling. Residents that were like this, we brought them all in one area. It was not the normal routine, only if I don't have enough of CNAs. He stated he had 4 CNAs on the floor. These residents were getting out of bed and at risk for falling. We have tried non-pharmacological interventions. Interview with Staff K CNA on 03/06/23 05:18 AM. He stated he was a Patient Care Assistant (PCA) and six month ago he did the test to became CNA. He stated when he started as CNA, he had orientation on abuse/neglect in-services. He stated that what they do it here, these residents had history of falls and it is a prevention. He stated the resident asking to go to the bathroom, she started to ask when the surveyors entered to the dining room. He stated the nurse is the one in charge to take the residents to their room. He stated the nurses for the third floor call the nurse for another floor. He stated he put the chair under the recliner's foot to keep the resident legs from falling off. He stated was his intention to keep the residents safe and comfortable. On 03/06/2023 at 05:40 AM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were met with next to 3rd floor elevator, they were informed about the seven residents found in the dining room in recliners facing the wall. The television (TV) off, and that the seven residents are in the dining room at this time. The DON reported the residents are placed in the dining room to decrease the pharmacological interventions for the residents and to have an activity. The DON and the Nursing Home Administrator (NHA) were shown the residents in the dining room. They were shown how the chairs were placed underneath the foot of the recliners that prevented the residents from lowering their recliners. They were told this is considered to be a restraint to have a chair wedged under the recliners footrest. Record review of Immediate Federal Report revealed the Immediate Report was completed and filed on 03/07/2023 (# 178490) for Resident # 9, Immediate Report filed on 03/07/2023 (178507) for Resident # 428, Immediate Report filed on 03/07/2023 (178509) for Resident # 52, Immediate Report filed on 03/07/2023 (178496) for Resident # 172, Immediate Report filed on 03/07/2023 (178499) for Resident #112, Immediate Report filed on 03/07/2023 ( 178503) for Resident # 127, Immediate Report filed on 03/07/2023 (178508) for Resident # 81, Immediate Report filed on 03/07/2023 for Resident # 63. All reports were filed at 1:30 PM. Interview with the Administrator on 03/09/2023 at 7:25 PM. She stated that when she was informed about the allegations of abuse incident in the third floor dining room, and later about the Immediate Jeopardy (IJ) for the same deficiency she was focus in training education for staff and focus on immediate responses to remove the IJ. She stated she forgot that it had to be reported and filed an Immediate Report within 24 hours. Record review of Abuse, Neglect, Exploitation, Misappropriation, Mistreatment and Injury of Unknown Origin dated implemented 10/20/2019, date reviewed 10/15/2022 revealed Policy: it is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. VII. Reporting/Response of Abuse, Neglect and Exploitation. When abuse, neglect or exploitation is suspected: Immediately report all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes

Based on observations, interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F609 Reporting of Alleged Violations related to the facility failed to implement their policy and procedures on abuse by not filing the immediate report within two hours for allegations of abuse observed by survey team of seven residents (Resident # 9, Resident #63, Resident # 127, Resident # 112, Resident #172, Resident #478, Resident #81) sleeping in recliners and one resident (Resident # 52) seated in a wheelchair in the third floor dining room, out of eight residents whose abuse report were reviewed. This facility practice had the potential to have a negative impact on the health and safety of all 176 residents residing in the facility at the time of the survey. The finding included: Record review of the facility's survey history revealed, during a recertification survey with exit date November 19, 2021, F609 Reporting of Alleged Violations, Implementation of facility policy and procedures for reporting allegations of abuse/neglect by not filling an immediate report related to abuse/neglect/exploitation allegation. The facility was cited as evidenced for not filling an immediate report of abuse allegations voiced by two residents. During this survey with exit date March 9, 2023 the facilty was cited F609 again for failing to file an immediate reprort for allegation of abuse/neglect/exploitation related to observation by the survey team at 4:00 AM in the darkened dining room on the facility' third floor where seven residents (Resident # 9, Resident #63, Resident # 127, Resident # 112, Resident #172, Resident #428, Resident #81) were observed sleeping in recliners that were restraine with the footrest being wedged with dining chirs limiting the residents from lowering the footrest. One resident out of the seven (Resident #9) ws placed between a wall and a colum with the foot rest of the recliner restricted with a chair. There was one resident (Resident # 52) was seated in a wheelchair also in the third floor dining room complaining of being wet and needed to use the restroom. During this observation the Certified Nursing Assistant was notedsleeping while seated covered in a chair with his feet up on another chair. During an interview with the Administrator on 03/09/2023 at 7:25 PM. She stated they have Quality Assurance and Performance Improvement (QAPI) meetings were held on the third week of the month. She stated the members of the QAPI are Administrator, director of Nursing, Assistant Director of Nursing, Medical Director, Infection Preventionist, Wound Care Nurse, Restorative Nurse, Rehabilitation Director, Dietitian, Psychiatrist, Pharmacy Consultant, Human Resources Director, Medical Records Director, Admission Director, Social Services Director, Maintenance Director, Housekeeping Director and Department Heads. She stated that when she was informed about the allegations of abuse incident in the third-floor dining room, and later about the Immediate Jeopardy (IJ) for the same deficiency she was focus in training education for staff and focus on immediate responses to remove the IJ. She stated she forgot that it had to be reported and filed an Immediate Report within 24 hours. Record review of Abuse, Neglect, Exploitation, Misappropriation, Mistreatment and Injury of Unknown Origin dated implemented 10/20/2019, date reviewed 10/15/2022 revealed Policy: it is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. VII. Reporting/Response of Abuse, Neglect and Exploitation. When abuse, neglect or exploitation is suspected: Immediately report all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes

Based on observations, interviews, and record review the facility failed to ensure the dishwashing machine was operating properly. This has the potential to affect 160 out of 176 residents who reside in the facility at the time of survey. The findings included: Record review of the facility's policies and procedures revealed: The temperature for the dish machine will be recorded three times a day. Temperatures found not to be at the designated level will be reported to the Director of Nutritional Service or supervisor immediately. Temperatures will be recorder on a Log. 1. While the dishwasher is running, with a rag going through it, the temperature of the wash tank and rinse tank will be recorder. Temperatures will be recorded for each meal. 2. The wash tank should be 140 - 160 degrees Fahrenheit, or as specified by the manufacturer. 3. the rinse tank should be above 180 degrees Fahrenheit, unless a low temperature machine is used, then the temperature should be greater than 140 Fahrenheit. 4. Any temperatures recorded outside the acceptable level shall be reported to the supervisor immediately. Maintenance will be notified. In the event that the mechanical dishwashing machine malfunctions, the disposable temperature sensor test strips will be used to determine dishwasher temperature. If adequate temperature is not reached maintenance will be notified, and disposable single service articles will be used. Any non-disposable articles that are used will be hand washed using the manual washing and sanitizing method. According to Hazard Analysis and Critical Control Points (HACCP) standards, which are widely adopted to ensure food safety, temperature test should be carried out regularly, both during the washing and the rinsing phases of the cleaning cycle. This will help to ensure maximum dishwasher efficiency, and ascertain that the temperature is high enough to destroy bacteria that are lingering on cutlery and dishes. On 03/07/23 at 09:33 AM during the first observation of the dishwashing in progress revealed the dishwashing machine was a [ brand] multi tank machine high temperature sanitization. The three temperature gauges was noted with the following temperature readings - Wash was noted three temperature gauges; Wash was noted at 130 degrees Fahrenheit (F) (the required temperature should be 150 degrees F), Rinse was noted at 165 degrees F and final rinse was noted at 191 degrees F (the required temperature should be 180 degrees F). On 03/07/23 at 1:33 PM during the second observation of the dishwashing in progress revealed the dishwashing machine was a [ brand] multi tank machine high temperature sanitization. Three temperature gauges; Wash was noted at 180 degrees F (supposed to be required temperature of 150 degrees F), Rinse was noted at 170 F (required temperature should be 165 degrees F) and the Final Rinse was noted at 191 degrees F (the required temperature should be 180 degrees F). During the observation on 03/07/23 at 01:33 PM the Food service director stated, that is very strange because we always made sure that the temperature is right before we start washing the dishes. The Dietary Supervisor stated, I took the temperature before in the morning and it was correct. On 03/08/23 at 09:59 AM Dietary Supervisor reported; the control gauge was bad, and they changed it. There is a log that they check every day. I have been the one in charge of checking it and it has been fine, yesterday the gauge was bad, and they fixed it.

Based on observation, interview, and record review the facility failed implement its facility grievance protocol to address and resolve a concern voiced by one resident (Resident #125) out of three residents reviewed. As evidenced by the facility's failure to assist Resident #125 who requested assistance to communicate with her son. The findings included the following. On 03/06/2023 at 09:46 AM, during an interview Resident #125 stated her son lives in Colombia and the facility is not assisting her with communicating with him. Resident #125 stated she has no phone but would like to have communication via [ Free messaging and video calling app] or another way for free. During a follow up interview on 03/08/2023 at 12:05 PM, Resident #125 revealed Staff M, Social Services Assistant came to her room today and stated she will apply for a cell phone for her under a government plan where elderly people received cell phones. Resident #125 reported she did not tell Staff M that she wanted a cell phone to communicate directly with her son; but had told the guy who is the Administrator. When asked who the staff was that she spoke to because the Administrator is a female. Resident #125 stated; I said it to the one that is here at nights and always has a sweater on around his neck. Resident #125 revealed that she could not remember the name of the staff. During the interview Staff L, a Registered Nurse (RN) entered the resident's room and was able to identify the staff based on the description provided by Resident #125 to be the night shift supervisor (Staff E). On 03/08/2023 Staff E, RN was not in the facility and unable to be reached for an interview. On 03/08/2023 at 12:25 PM, Staff L revealed she learned today that Staff M, Social Service Assistant was getting a cell phone for Resident #125. Staff L reported that Resident #125 never told her that she wanted a cell phone and Resident #125 communicated with her son through the phone at the nursing station. Staff L stated it seems like Resident #125 wants to be able to call her son directly because he has been the one calling her. Staff L explained that Resident #125 had a personal cell phone, and had lost it. Staff L was asked if there was any communication from Staff E, the night shift's supervisor about Resident #125's request for assistance to communicate with her son and to have a phone, Staff L stated she did not know anything. Staff L was asked about the facility's procedure when staff received any concerns, requests, complaints, or grievances. Staff L stated they did not complete any paperwork for grievances, when a resident voices a concern or problem the staff would go and verbally inform the Social Services Assistant (Staff M) or anyone working in Social Services, and Social services will follow up. During an interview with Staff M, Social Services Assistant on 03/09/2023 at 10:30 AM related to Resident #125's concern and requested assistance to communication with her son. Staff M revealed she did not know Resident #125 wanted a phone and was requesting communication with her son by phone. Staff M explained that yesterday was the first time she was made aware, and she had already enrolled Resident #125 in the government program for a phone, it was successful, and the resident should be receiving a phone in the next 3 to 4 weeks. Staff M stated that in the meantime she will get information on Resident #125's son contact information to assist Resident #125 with communication. Staff M stated Staff E, the night shift's nurse supervisor described by Resident #125 as the person whom she asked for assistance with communication through a phone, never told her about it. Staff M called the Director of Social Services on the phone to check if the night shift's nurse supervisor reported that the resident requested communication with her son to her. The Director of Social Services revealed she had not received any report. Staff M, Social Services Assistant stated if the night supervisor (Staff E) had told her about Resident #125's request they would have addressed it as a grievance and follow up because the specific department who should have resolved the issue in this case would be Social Services. Interview with the Director of Social Services on 03/09/2023 at 10:41 AM revealed she never received information about Resident #125 requesting to be provided with a phone. The Director of Social Services stated Resident #125 never reported she has a son in Colombia and that she wanted to be assisted with communicating with her son. Resident #125 mentioned she has a son and gave his name, but no further information was provided, and Resident #125's son information was not in the chart. Resident #125's siblings and a friend are the only contact information in Resident #125's chart (face sheet). The Director of Social Services reported that the night shift's nurse supervisor (Staff E) never told her about Resident #125's request to be assisted with a phone. If Staff E had reported it to Social Services, they would have taken care of the situation as a grievance and applied for a phone call from the government program for Resident #125, which was done after they found out yesterday. The Director of Social Services was asked about the facility's grievance procedure, the Director of Social Services reported; the procedure is anyone can report a grievance, as long as a resident reports any concerns, the staff receiving the concern should fill out the grievance form and give it to Social Services for an investigation and follow up. The facility's Social Services Department has the grievance policy and procedures together with the blank grievance forms at every nursing station inside a bin attached to the wall. The official grievance information is posted all around the building with the Director of Social Services name and where she can be reached. At times if the staff brings the concern verbally, Social Services will fill out the form and proceed with the grievance. During an interview with Staff Q, RN on 03/09/23 at 01:30 PM, Staff Q revealed she is not aware of the grievance procedure because had recently started working in the facility, and she was not so familiar with long term care. Staff Q was asked how she would proceed if a resident voiced a request or complaint, Staff Q stated, I will resolve it. When Staff Q was asked how she would resolve it, she reported it would depend on the situation. When she was given specific situations like resident complaining about the food she stated she would call the kitchen to bring other choice of food that resident would like to eat, asked how she would do it of the concern is about missing personal property she stated she would tell the CNA (Certified Nursing Assistant) so she can search and if needed contact the laundry. When asked how she would proceed if the clothes were not found, Staff Q stated, I will tell the supervisor. When asked if she was familiar with the grievance procedure, Staff Q stated she did not know anything about grievances, and she did not know about the grievance forms placed in the bin in the nurses' station. During an interview on 03/09/2023 at 1:35 PM, Staff L, RN revealed she did not know until today about the grievance forms, and today she learned the forms were in the bin at the nursing station. Record review of Resident #125's Face sheet revealed the resident was admitted to the facility on [DATE]. There was no information about her son in the chart. Diagnoses included but not limited to Acute kidney failure, unspecified, Essential (primary) hypertension, Muscle weakness (generalized), Difficulty in walking, not elsewhere classified, anxiety disorder, unspecified, and psychotic disorder with delusions due to known physiological condition. Review of Resident #125's Minimum Date Set (Quarterly) dated 01/28/2023 revealed Brief Interview for Mental Status (BIMS) score 15 out of 15 indicating the resident is cognitively intact. Review of Resident #125's progress notes revealed on 11/2/2022 at 1:00 PM documented: Resident came back from an appointment . Resident in stable condition .Patient noted that she missed her phone. She said that she left her phone .inside a napkins box that she left there too. Will continue to monitor. Review of Social Services Noted dated 1/19/2023 at 11:29 revealed Care plan meeting was held by the interdisciplinary team in room to discuss her plan of care. She remains long term with the same level of cognition since last review date. No issues or concerns were voiced at this time. Advance directives and care plans are active and on file. Note dated 03/08/2023 at 12:15 PM [Resident #125] asked social worker to try to find a way for her to communicate with her son in Colombia. Social worker advised her it will be worked on. She verbalized satisfaction. Note dated 03/08/2023 at 1:42 PM documented: Social Worker ordered [Resident #125] a free government phone . Enrollment successful. Review of a printed verification of the application made by Staff M, Social Services Assistant to the government program to obtain a mobile phone revealed Resident #125's account was approved for benefits and will be received within 7 to 10 days from the qualification date. Review of Grievance Log dated from 10/2023 to 03/2023 revealed no grievance filed on behalf of Resident #125 related request to be assisted with a phone or communication with her family. Review of the facility's Policy and Procedure on Grievance dated 03/01/2021 revealed: INTENT: It is the policy of the facility to have a Grievance Process in accordance with State and Federal regulations. PROCEDURE: 1. The facility will have a grievance procedure available to its residents and their families. The grievance procedure must include: a. An explanation of how to pursue redress of a grievance . d. A procedure for providing assistance to residents who cannot prepare a written grievance without help.