Every finding on record at Windsor the Ridge Rehabilitation Center

Based on interview and record review, the facility failed to explain the risks and benefits of psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) during the consent process to the responsible party for one of 5 sampled residents (Resident 108).This failure resulted in Resident 108's responsible party not fully informed about the psychotropic medications, including their nature, degree, duration, probability of side effects, significant risks, and potential interactions with other drugs the resident is receiving.Cross reference to F0757.Findings:Review of Resident 108's admission record indicated, was admitted to the facility on [DATE] with diagnoses including cervical spinal stenosis (a condition where the spinal canal in the neck becomes narrowed, putting pressure on the spinal cord and nerves), bacteremia (the presence of bacteria in the bloodstream), depression (a serious mood disorder characterized by persistent sadness, loss of interest, and other symptoms that interfere with daily life), and post-traumatic stress disorder (PTSD - a mental health condition that can develop after a person experiences or witnesses a traumatic event).During a concurrent interview and record review on 9/24/25 at 11:12 AM with Licensed Vocational Nurse (LVN) 3, Resident 108's order summary for 9/2025 was reviewed. The order summary indicated the following medications: 9/17/25: Quetiapine fumarate (also known as Seroquel - a drug used to treat schizophrenia, a serious mental health condition) oral tablet 25 milligrams (mg). Give 0.5 tablet by mouth at bedtime related to PTSD manifested by (m/b) delirium (a sudden, temporary state of confusion that can cause a person to have trouble paying attention, thinking clearly, and being aware of their surroundings).9/15/25: Ramelteon (a drug used to treat insomnia) oral tablet 8 mg. Give 1 tablet by mouth at bedtime related to depression m/b inability to sleep.9/15/25: Sertraline hydrochloride (HCl) (a drug used to treat depression) oral tablet 100 mg. Give 1 tablet by mouth one time a day related to depression m/b verbalization of feeling sad.LVN 3 stated that the Assistant Director of Nursing (ADON) obtained verbal consent from Resident 108's responsible party, resident's healthcare decision maker, on 9/15/25 for the use of Ramelteon, Sertraline, and Quetiapine.A review of Resident 108's Psychotropic Medication Administration Disclosure and Informed Consent for the use of Ramelteon, Sertraline, and Quetiapine indicated that verbal consent was obtained from the Resident 108's responsible party on 9/15/25. However, the Informed Consent document did not specify the name of the physician who obtained the verbal consent and explained the risks and benefits of Ramelteon, Sertraline, and Quetiapine.During an interview on 9/24/25 at 12:02 PM, the ADON stated, she obtained verbal consent via telephone from Resident 108's responsible party to start the Ramelteon, Sertraline, and Quetiapine. The ADON also stated that the risk and benefits were not explained to the responsible party during the consent process. The ADON stated, If it's an order from the hospital, we don't do the risk and benefits unless it is a new order in the facility.During an interview on 9/26/25 at 9:55 AM, the Director of Nursing (DON) stated that the physician should explain the risks and benefits when obtaining consent for use of any psychotropic medications.During a telephone interview on 9/26/25 at 1:08 PM, Resident 108's responsible party stated that she did not receive a call from the facility to obtain her consent for the use of Ramelteon, Sertraline, and Quetiapine. Furthermore, she stated that the risks and benefits associated with these medications were not explained during the consent process. Resident 108's responsible party also mentioned that despite visiting daily, she did not receive any written information nor was she asked to sign an informed consent for the use of Ramelteon, Sertraline, and Quetiapine.According to the facility's Psychotropic Administration Informed Consent form, the Practitioner Attestation section indicated, Following the facility's procedures for obtaining Informed Consent to Psychotropic medication Use, I have reviewed the following with the Resident/Resident Representative the following material information: .The Informed Consent was received by the Resident/Resident Representative in the language, or in any form of material information they understand. The possible non-pharmacologic approaches that could address the resident's needs. The nature of the treatment and the nature and seriousness the resident's illness . The nature, degree, duration, and probability of the side effects, significant risks, and possible interactions with other drugs the resident is receiving . The Informed Consent section also indicated, The information above regarding the risks and benefits of psychotropic medication has been verbally explained to me and/or provided in writing.Review of facility's undated policy and procedure titled, Antipsychotic/Psychotropic Medication Use, indicated, .8. Before administering antipsychotic/psychotropic medication, the prescribing practitioner shall obtain Informed Consent, which will be verified by a Licensed Nurse.

Based on observation, interviews and record review, the facility did not ensure one of 5 residents ( Resident 8) receiving medication to treat a specific diagnosed condition, when Resident 8 has an order for Depakote ER oral tab 250 mg one tab by mouth at bedtime for Dementia in other Diseases Classified Elsewhere, moderate, with other Behavioral Disturbance manifested by verbal sexual disinhibition.This failure has potential for residents receiving unnecessary medication.Review of admission Record of Resident 8, admitted on [DATE] and readmitted [DATE] with diagnoses including: Dementia (a brain disorder that causes decline in memory and thinking) in other disease classified elsewhere, moderate with other behavioral disturbances, Anxiety Disorder ( a mental condition like persistent worry, fear and nervousness), Depression( condition with persistent sadness, hopelessness and loss of interest, Urinary Tract Infection ( infection of the urinary tract caused by bacteria). During an observation on 9/22/25 at 11 AM, there is Enhanced Barrier Precaution (EBP) on the door. Resident 8 is sitting on the bed, alert and smiling when introduced myself. Has a foley catheter, with bag cover and a basin on the floor. Did not give any answer to other question if he is getting care he needs. He touched his stomach and stated, I'm hungry.During a review of Resident 8's Minimum Date Set (MDS), dated [DATE], the Brief Interview for Mental Status (BIMS - brief screening for mental status) score is 3, indicating cognitive impairment. During an interview on 9/25/25 at 11 AM, with Social Services Director (SSD), SSD stated , resident 8 is receiving Depakote for mood stabilizer, he yells out to staff during care.Review of Order Summary Report, dated September 25.2025, the Order Summary Report indicated, Depakote ER Oral Tablet Extended Release 24 Hour 250 mg (Divalproex Sodium) Give 1 tablet by mouth at bedtime related to Dementia in Other Diseases Classified Elsewhere, Moderate, with other Behavioral Disturbances m/b verbal sexual disinhibition.Review of Medication Administration Record (MAR) dated 9/1/-9/30/25, the MAR indicated,: Anti-Convulsant : Monitor episodes of manifested by (m/b) verbal sexual disinhibition every shift. Review of facility document Psychoactive medications documentation of maintenance as determined by the Primary Physician, dated 9/17/25, the Psychoactive medication documentation indicated, Depakote ER 250 mg once a day (QD), diagnosis: dementia with behavioral disturbance.Review of facility document Psychotropic Medication Administration Disclosure, the Drug Information indicated, Anti-manic Drug: Depakote Extended Release (ER) 250 mg at bedtime r/t Dementia with behavioral disturbance m/b verbal sexual disinhibition.During an interview on 9/25/25 at 11:30 AM, with facility Pharmacist, pharmacist stated, is aware that Depakote ER is ordered for Dementia. The Pharmacist Medication Regimen Review (MRR) on 4/18/2025, indicated recommendation for Depakote's Food and Drug Administration (FDA) approved diagnoses for use.During an interview on 9/25/25 at 12:10PM, with Director of Nursing (DON), DON stated, is aware of the issue. Has notified the Physician of the recommendation from pharmacist. No changes made till now.During an interview on 9/25/25 at 3PM, with Licensed Vocational Nurse (LVN) 1, LVN1 stated, she knows the resident well, he is fine but can be verbally and physically aggressive, can hit and grab, staff needs to be careful. But we found out that we can leave him in the room with tv on, he is quiet. He does not like the noise out here by the nursing station. He is bilingual. He takes Namenda in AM and Depakote at night.During an interview on 9/26/25 at 11:15 AM, with Certified Nursing Assistant (CNA1), CNA1 stated, resident is combative, grabbing staff, he is verbally and physically touching. Needs 2 people as buddy system during care to this resident.Review of facility Policy and Procedure, Antipsychotic/Psychotropic Medication Use, dated 6/21, Policy indicated, Policy Statement: Antipsychotic medications may be considered for residents with dementia, but only after medical, physical, functional, psychological, emotional, psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Policy Interpretation: 6. Diagnosis of a specific condition, an indication of use, and targeted behavior for which antipsychotic/psychotropic mediations are necessary to treat will be based on a comprehensive assessment of the resident.

Based on observation, interview, and record review, the facility failed to ensure that restorative care services were provided to one resident (Resident 11) by not applying the resident's Ankle Foot Orthosis (AFO-a brace that you wear on your lower leg and foot to help you walk better and more safely) as ordered by the physician.This failure to implement restorative interventions as ordered had the potential to contribute to functional decline, increased risk of falls, and reduced quality of life for Resident 11. Findings:A review of Resident 11 admission record dated 9/25/2025, the admission record indicated, Resident 11 had contracture (muscle or joint gets stuck in one position and can't move properly anymore) left foot, muscle weakness and Alzheimer's (brain condition that slowly affects a person's memory, thinking, and ability to do everyday tasks) Disease .During observation on 9/24/2025 at 10:22AM, resident was lying in bed watching television without AFO on Resident 11 left foot.During an interview 11 on 9/24/2025 at 10:23AM with Resident 11, Resident 11 stated, I want it that's fine if they put it on. But it has been weeks that they didn't put it on.During an interview on 9/24/2025 at 10:43AM with Restorative Nursing Assistant (RNA), RNA confirmed the AFO was not applied and stated, The splint is not on, I did not put it on this morning, I only work as RNA during Friday, Saturday, Sunday. I don't know who will do it if I'm not here.Interview on 09/24/2025 at 1:38 PM with Assistant Director of Nursing (ADON), The ADON stated, There is no monitoring in the system to confirm whether the splint was applied. The last documented application was on 06/27/2025.A review of Rehabilitation screen document dated 4/11/2025, the rehabilitation screen document indicated, current program.current therapy orders or restorative programs.Patient is having history of severe bilateral ankle plantar flexion contracture. Therapist did give AFO splints for both ankles. Caregiver education done with CNA and Nursing also, initiated on and off schedule for splints.A review of Physician Order dated 5/14/2025, the physician order indicated, RNA to apply BAFO (Bilateral AFO) to bilateral (both side) ankle, 6/week, for 8 hours as tolerated with skin check.A review of Care Plan dated 3/21/2025, the care plan indicated, Resident 11 has impaired mobility with left foot contracture.monitor for pain and reposition for comfort, order for patient will wear left resting splint QD (everyday).A review of Functional Impairment - Clinical Protocol dated 3/2018, the Functional Impairment - Clinical Protocol indicated, Assessment and recognition .3. The staff and physician will identify individuals with potential for significant improvement in function or significant decline in function, including the ability to perform activities of daily living. Monitoring and follow-up, 1. The staff will monitor and document the resident/patient's function (for example, evidence of reduced ADL dependency, improved ambulation, improved balance and gait, etc) and will discuss this with the physician periodically in conjunction with a discussion of medical interventions and plans of care.

Based on interview and record review, the facility failed to adequately monitor and supervise one of three sampled residents, Resident 23, who repeatedly left the premises without the facility's knowledge.This failure posed risks to Resident 23's health and safety, including heat or cold exposure, being struck by a vehicle, dehydration, and other medical complications, potentially affecting their overall well-being.Findings:Review of Resident 23's admission record indicated, was readmitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (high blood sugar) with other skin complications, hypertension (high blood pressure), alcohol dependence, depression, muscle weakness, and other abnormalities of gait and mobility.Review of Resident 23's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 7/13/25 indicated a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 4, which means severe cognitive (thought process) impairment. The MDS indicated Resident 23's functional abilities and mobility required set-up help.Review of Resident 23's care plan dated 7/8/25 indicated, [Resident 23] has impaired/decline in cognitive function or impaired thought processes related to: -Illiterate, unable to read or write -Impaired decision making AEB: BIMS of 4-indicates severe cognitive impairment.During a concurrent interview and record review on 9/25/25 at 4:12 PM with the Assistant Director of Nursing (ADON), Resident 23's elopement assessment dated [DATE] was reviewed. The elopement assessment indicated a score of 3 which means at risk for elopement. The ADON also reviewed Resident 23's elopement care plan indicating at risk for elopement as evidenced by (AEB) exit seeking behavior and history of elopement and was initiated on 7/11/25. The ADON stated a wander guard was put in place on 7/11/25 as intervention for resident's exit seeking behavior.During an interview on 9/25/25 at 4:32 PM, the Director of Nursing (DON) stated that Resident 23 exited the facility through the sliding door in his room without staff knowledge on 7/19/25. The DON stated Resident 23 was then found walking closed to his ex-wife's apartment. Per DON, interventions implemented after this incident included increased supervision and 1:1 supervision on certain days. The DON was asked what increased supervision and 1:1 supervision on certain days means. The DON was not able to explain and provide documentation that these interventions were implemented. The DON stated, just increased supervision of the resident.Review of Resident 23's elopement care plan initiated on 7/19/25 and revised on 8/28/25 indicated, [Resident 23] has increase supervision-initiated r/t leaving the facility without staff knowledge. The care plan indicated interventions including, Ensure bedroom screen door is locked at all times. Initiated increased supervision and monitoring . Monitor and document behaviors and triggers that may lead to elopement. Monitor wander guard #36 placement and functioning.Review of Resident 23's Activities Progress Note dated 9/5/25 indicated, At 1545, resident attempted to leave the facility but was redirtected and convinced to return inside. Wanderguard was removed and not on LW when sighted leaving. Wanderguard was found (#36) and was placed back onto LW. RP was connected and agreed to pick up resident to run errands in order to decrease exit-seeking behaviors. Resident is on Q 1 hour monitoring location until further notice.Review of Resident 23's Interdisciplinary Care Conference dated 9/5/25 indicated, Resident 23 was observed with exit-seeking behavior during the morning shift, verbalizing wanting to leave the facility to visit his daughter and grandchildren.Recommendations: Increased supervision by staff. Wanderguard, intact, functioning, and location in place.Review of Resident 23's eINTERACT Change in Condition Evaluation - V 5.1 dated 9/13/25 indicated, At approximately 18:30 PM, the resident exited the facility without staff knowledge. Elopement (A situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision) protocol was immediately initiated, staff conducted thorough search in each resident room. outside the facility surrounding and resident was not located, 911 was called and report the elopement incident, all documents and description of resident were provided, MD and RP aware. Admin and DON notified.During an interview on 9/25/25 at 3:26 PM, Registered Nurse (RN) 1 stated that on 9/13/25 at 6:30 PM, he noticed Resident 23 was not in his bed nor inside the facility. RN 1 stated they were not able to find Resident 23 so he called 911 (emergency services) and notified the responsible party and the Administrator. During further interview, RN 1 stated that Resident 23 had his wander guard (a technology system used in facilities like hospitals and senior living homes to prevent residents at risk of wandering from leaving a secure area) on his left wrist but nobody heard the alarm when resident left. RN 1 also stated that they did not find Resident 23's wander guard in the facility. RN 1 further stated that Resident 23 was high risk for elopement thus, he was placed on one-on-one (1:1) supervision in July 2025 but was discontinued in mid-August 2025. RN 1 also stated that Resident 23 had episodes of leaving the facility prior to this incident.During an interview on 9/25/25 at 3:58 PM, Certified Nursing Assistant (CNA) 2 stated that Resident 23 had left the facility more than once and placed a designated CNA to provide 1:1 supervision. CNA 2 also stated that an order and intervention to check resident every 15-20 minutes was in place.Review of Resident 23's active orders for September 2025 indicated, Monitor episode of exit seeking the facility every shift for episode of elopement. Monitor wander guard placement #36 to left wrist for function and location every shift. Monitor wander guard for placement and functioning hourly.Review of Resident 23's elopement care plan revised on 9/11/25 indicated, [Resident 23] has increase supervision-initiated r/t leaving the facility without staff knowledge . [Resident 23] noted removing wander guard using metal utensils. The care plan indicated interventions including, Ensure bedroom screen door is locked at all times. Initiated increased supervision and monitoring . Monitor and document behaviors and triggers that may lead to elopement. Monitor wander guard #36 placement and functioning. Provide plastic utensils in all meals.During a concurrent interview and record review on 9/25/25 at 4:53 PM with the DON Resident 23's care plan was reviewed. The DON stated that the new intervention they added on 9/11/25 was to provide plastic utensils in all meals to resident. The DON also stated that increased supervision and monitoring was continued.Review of the facility's policy and procedure titled, Elopement, revised 2/21/25, indicated, .The facility shall establish and utilize

Based on interview and record review, the facility failed to ensure that a prescribed psychotropic (a medicine that affects your brain and changes how you think, feel, or behave) medication was ordered and available for one of one sampled residents (Resident 34), resulting in a delay in administration.This failure had the potential to compromise Resident 34 mental health stability, disruption of therapeutic treatment, and adverse effects on the resident's psychosocial well-being. During a medication pass observation conducted on 9/24/2025 at 10:20 AM, front of room [ROOM NUMBER], a psychotropic medication Seroquel 25mg was not available for Resident 34.Interview on 9/24/2025 at 10:21AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Seroquel ( a medicine that helps balance chemicals in the brain to improve mood, thinking, and behavior) is not available, I don't know what happened, I think I ordered it last Saturday (9/20/2025), I faxed the refill order to the pharmacy. I need to call pharmacy. When asked to show the documentation the LVN faxed it, LVN stated, I don't where it is.Concurrent Interview and record review on 9/24/2025 at 10:50AM with Assistant Director of Nursing (ADON), ADON stated, If the medication is running low, staff are expected to request a refill. There is a sticker in the bubble pack that serves as a reminder to reorder. In the system, the Seroquel 25 mg was ordered on Monday, 9/22/2025. If the medication is not received, staff should follow up with the pharmacy to ensure timely delivery. I will find out what happened regarding the lack of delivery.Review of Resident 34's Medication Administration Record (MAR) dated 9/24/2025, the MAR indicated the following order, Quetiapine Fumerate Oral tablet 25mg , Give 1 tablet by mouth one time only for physical and verbal aggression towards others related to unspecified psychosis not to substance or known physiological condition. The MAR also noted that the medication was placed on hold (HD).During a review of Resident 34's titled admission Record (AR), the AR indicated, Diagnosis information, Alzheimer's Disease, Unspecified Psychosis not due to a substance or known Physiological condition.During a review of the facility's policy and procedure (P&P) titled, Medication Ordering and Receiving from Pharmacy dated April 2008, the P&P indicated, Medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt.If not automatically refilled by the pharmacy, repeat medications (refills) are written on a medication order form/ordered by peeling the bottom part of the pharmacy label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose and ordered as follows: a. Reorder medication 5 days in advance of need to assure an adequate supply is on hand.c. the refill order is called in faxed, or otherwise transmitted to the pharmacy.

Based on observation, interview and record review, the facility did not ensure that the medication for 1 resident (Resident 8), was changed in response to identified irregularities, when during a Medication Regimen Review (MRR) by pharmacist, gave recommendation for approved diagnoses for use of Depakote Extended Release (ER).This failure has potential for residents receiving unnecessary medications.Review of admission Record, admitted on [DATE] and readmitted [DATE] with diagnoses including: Dementia (a brain disorder that causes decline in memory and thinking) in other disease classified elsewhere, moderate with other behavioral disturbances, Anxiety Disorder ( a mental condition like persistent worry, fear and nervousness), Depression( condition with persistent sadness, hopelessness and loss of interest, Urinary Tract Infection ( infection of the urinary tract caused by bacteria). During a record review, Order Summary Report, dated September 25.2025, the Order Summary Report indicated, Depakote ER Oral Tablet Extended Release 24 Hour 250 mg (Divalproex Sodium) Give 1 tablet by mouth at bedtime related to Dementia in Other Diseases Classified Elsewhere, Moderate, with other Behavioral Disturbances m/b verbal sexual disinhibition.Review of Medication Administration Record dated 9/1/-9/30/25, the Medication Administration Record indicated, Anti-Convulsant : Monitor episodes of m/b verbal sexual disinhibition Q shift. Review of facility document Psychoactive medications documentation of maintenance as determined by the Primary Physician dated 9/17/25, the Psychoactive medication documentation indicated, Depakote ER 250 mg QD, diagnosis: dementia with behavioral disturbance.Review of facility document Psychotropic Medication Administration Disclosure Drug Information, the drug information indicated, Anti-manic Drug: Depakote ER 250 mg Q HS r/t Dementia with behavioral disturbance m/b verbal sexual disinhibition.During an interview on 9/25/25 at 11:30 Am, with facility Pharmacist, pharmacist atated, is aware that Depakote ER is ordered for Dementia. the pharmacist Medication Regimen Review (MRR) dated 4/18/2025, gave recommendation for Depakote's FDA approved diagnoses for use.Review of MRR note to attending Physician by PharmD, dated 4/18/25, the note indicated, This resident is receiving Depakote for dementia .please note that the following are the only FDA approved diagnoses for use of Depakote: Absence Seizures, Migraine prophylaxis, myoclonic seizures, partial seizures, Bipolar disorder, Mania. Please do either of the following: clarify the diagnosis or document risk vs benefits for using Depakote for any off-label diagnosis.During an interview on 9/25/25 at 12:10PM, with Director of Nursing (DON), DON stated , she is aware of the issue. Has notified MD of the recommendation from pharmacist. No changes till now.Review of Nurses progress notes, dated 4/28/25, entered by DON, the nurses progress notes indicated, MRR review related to Depakote to use off label. Notify MD to document risk and benefits. RP aware. No further notes were found. Notes did not indicate risks and benefits documentation by a physician.Review of facility Policy and Procedure (P&P) titled Consultant Pharmacy Reports, Medication Regimen Review (Monthly Report), dated 6/2021, the P&P indicated: Policy: The consultant pharmacist performs a comprehensive medication regimen(*MRR) at least monthly. Procedure: . D. Resident-specific irregularities and /or clinically significant risks resulting from or associated with medications are documented and reported to the Director of Nursing, and/or prescriber as appropriate. E. Recommendations are acted upon and documented by the facility staff and the prescriber. 1. Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing by the next physician visit.

Based on observation, interview, and record review, the facility failed to ensure one of 5 sampled residents (Resident 108) was free from unnecessary drugs when Quetiapine (also known as Seroquel - a drug used to treat schizophrenia, a serious mental health condition) was administered to treat Resident 108's post-traumatic stress disorder (PTSD - a mental health condition that can develop after a person experiences or witnesses a traumatic event) related delirium (a sudden, temporary state of confusion that can cause a person to have trouble paying attention, thinking clearly, and being aware of their surroundings). Additionally, Quetiapine was not indicated in Resident 108's discharge medication list and physician's assessment and plan.This failure resulted in Resident 108 receiving unnecessary drugs and place residents on psychotropic medications at risk for adverse health consequences which could negatively impact the residents' mental, physical, and psychosocial well-being.Findings:Review of Resident 108's admission record indicated, was admitted to the facility on [DATE] with diagnoses including cervical spinal stenosis (a condition where the spinal canal in the neck becomes narrowed, putting pressure on the spinal cord and nerves), bacteremia (the presence of bacteria in the bloodstream), depression (a serious mood disorder characterized by persistent sadness, loss of interest, and other symptoms that interfere with daily life), and post-traumatic stress disorder (PTSD - a mental health condition that can develop after a person experiences or witnesses a traumatic event).During an observation on 9/22/25 at 11:58 AM, in resident's room, Resident 108 was sleeping in bed with the television on.During a concurrent interview and record review on 9/24/25 at 11:12 AM with Licensed Vocational Nurse (LVN) 3, Resident 108's order summary for 9/2025 was reviewed. The order summary indicated, on 9/17/25, Resident 108 was ordered with Quetiapine fumarate oral tablet 25 milligrams (mg). Give 0.5 tablet by mouth at bedtime related to PTSD manifested by (m/b) delirium. LVN 3 stated she did not observe Resident 108 manifesting any behavioral symptoms since admission.During an interview on 9/24/25 at 12:02 PM, the ADON stated that it was an order from the hospital to continue Resident 108 on Quetiapine for delirium.Review of Resident 108's discharge summary from the acute hospital dated 9/15/25, under Brief Summary of Hospital Course indicated, .Delirium developed during this period (hospital course), but neurological exam remained non-focal (full neurological examination did not find a problem in a specific, localized area of the nervous system). The discharge summary also indicated Resident 108 received seroquel 12.5 (milligrams) qhs (every hour of sleep) PRN (as needed) for agitation and insomnia. Additionally, the Seroquel (quetiapine) was not included in the discharge medication list for Resident 108.Resident 108's History and Physical (H&P) dated 9/16/25 was reviewed. Under the section of diagnosis, assessment, and plan of the H&P indicated #depression and #insomnia were under the diagnosis of PTSD. Additionally, the section also indicated to continue Ramelteon, Sertraline, and trazodone as needed (prn). There was no mention of Quetiapine to be continued.During a concurrent interview and record review on 9/26/25 at 9:55 AM with the Director of Nursing (DON), Resident 108's order summary for 9/2025 was reviewed. The order summary indicated: QUEtiapine Fumarate Oral Tablet 25 MG (Quetiapine Fumarate) Give 0.5 tablet by mouth at bedtime related to POST-TRAUMATIC STRESS DISORDER, UNSPECIFIED (F43.10) m/b (manifested by) [blank]. - Order Status: Discontinued - Start Date: 09/15/2025 QUEtiapine Fumarate Oral Tablet 25 MG (Quetiapine Fumarate) Give 0.5 tablet by mouth at bedtime related to POST-TRAUMATIC STRESS DISORDER, UNSPECIFIED (F43.10) m/b delirium. - Order Status: Active - Start Date: 09/17/2025During a concurrent interview, the DON stated that the Quetiapine was originally ordered on 9/15/25 but was placed on hold to clarify the manifestations. Quetiapine was started on 9/17/25 for PTSD m/b delirium.Further interview and record review indicated, the DON verified that the physician's progress notes including the H&P indicated Resident 108's PTSD diagnosis but did not mention to continue the Quetiapine. The DON also reviewed the discharge summary from the acute hospital but was unable to find an order for Quetiapine in the discharge medication list.During further interview and record review on 9/26/25 at 10:04 AM, the DON stated that Resident 108's behavior monitoring in the Medication Administration Record (MAR) dated 9/15/25 through 9/26/25 indicated no behaviors manifested. The DON stated that a resident exhibiting behaviors for 72 hours should be evaluated for a true behavior prior to ordering and starting a psychotropic medication.Review of the facility's undated policy and procedure titled, Antipsychotic/Psychotropic Medication Use, indicated: .1. Residents will only receive antipsychotic/psychotropic medications when necessary to treat specific conditions for which they are indicated and effective. 2. The Attending Physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others . 5. Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for appropriateness and indications for use. The interdisciplinary team will: .b. Re-evaluate the use of antipsychotic medication at the time of admission and/or within two weeks to consider whether the medication can be reduced, tapered, or discontinued. c. Based on assessing the resident's symptoms and overall situation, the Physician will determine whether to continue, adjust, or stop existing antipsychotic medication. 6. Diagnosis of a specific condition, an indication of use, and targeted behavior for which antipsychotic/psychotropic medications are necessary to treat will be based on a comprehensive assessment of the resident. 7. Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders. 9. Diagnoses alone do not warrant the use of antipsychotic/psychotropic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: The behavioral symptoms present a danger to the resident or others; AND: (1) The symptoms are identified as being due to mania or psychosis.or (2) Behavioral interventions have been attempted and included in the plan of care.

Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of three residents (Resident 1) when the facility did not administer medication as ordered by a physician for Resident 1. Finding: Review of Resident 1's medical record indicated Resident 1 was admitted on [DATE] and had diagnoses including essential hypertension (HTN-high blood pressure). Review of Resident 1's physician's order, dated 7/31/24, indicated Norvasc (a hypertension medication) oral tablet 10 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount), give 1 tablet by mouth one time a day related to essential hypertension, hold for SBP (systolic blood pressure) <110 and HR (heart rate) <60. Review of Resident 1's November 2024 Medication Administration Record (MAR) indicated Norvasc oral tablet was administered from 11/1/24 to 11/11/24, except on 11/3/24, which documented sleeping. There was no documented BP or HR to administer Norvasc to Resident 1 on the MAR from 11/1/24 to 11/11/24. During an interview and record review on 11/15/24 at 1:30 p.m. with the director of nursing (DON), she confirmed the above record review and acknowledged that Resident 1's BP and HR should have been checked prior to administering Norvasc. Review of Resident 1's care plans indicated there was no care plan to address hypertension. During a telephone interview and record review on 11/25/24 at 10:05 a.m. with the DON, she confirmed there was no care plan to address Resident 1's hypertension and acknowledged a care plan should have been developed to address the resident's hypertension. During a review of the facility's undated policy and procedure titled Administering Medications, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. The following information is checked/verified for each resident prior to administering medications: b. Vital signs, if necessary. During a review of the facility's policy and procedure titled Physician Orders, effective date 3/22/2022, the P&P indicated, Documentation pertaining to physician orders will be maintained in the resident's medical record. Current month's administration records will be maintained in the MAR/TAR binders. During a review of the facility's policy and procedure titled Care Plan Comprehensive, effective date 8/25/2021, the P&P indicated, The facility's Interdisciplinary Team, in coordination with the resident and/or his/her family or representative, must develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, physical, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of two residents when the facility did not follow the physician's order to monitor Resident 1's inappropriate behavior. This failure had the potential to compromise residents' safety and health in the facility. Findings: Review of Resident 1's clinical record indicated Resident 1 was admitted on [DATE] and had diagnoses of parkinsonism (a disorder of the central nervous system that affects movement), mood disorder (a mental health condition that affects emotional state), and mild cognitive impairment (decline in memory and thinking). Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 2/20/24, indicated he had a brief interview for mental status (BIMS, a structured cognitive [relating to the mental process involved in knowing, learning, and understanding things] test) score of 14 (cognitively intact). Review of Resident 1's care plan for episodes of inappropriate touching towards staff initiated on 2/22/24 included an intervention of monitor for episodes of inappropriate touching. Review of Resident 1's interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) progress notes: Behavior management dated 2/29/24 at 3:40 p.m. indicated Activities director reported to SSD (social service director) that resident continues to be inappropriate with activities staff. SSD reminded resident that he has already been spoken to previously regarding inappropriate behaviors. Resident to continue to be monitored for behaviors. Review of Resident 1's physician's order, dated 2/19/24, indicated Behavioral charting: Monitor for inappropriate behaviors such as touching staff inappropriately every shift. Review of Resident 1's Behaviors-Interventions-Side Effects ([NAME]), dated 2/2024 to 5/2024, indicated Resident 1 had physician's orders to monitor his inappropriate behaviors every shift from 2/19/24 to 5/15/24. There was no documentation in the medical record indicating staff monitored Resident 1's inappropriate behavior every shift from 2/19/24 to 5/6/24. During an interview and record review on 5/17/24 at 12:15 p.m. with the director of nursing (DON), she reviewed the above medical record and confirmed that there was no documentation in the medical record that staff monitored Resident 1's inappropriate behavior every shift as ordered from 2/19/24 to 5/6/24. During a review of the facility's policy and procedure (P&P) titled Physician Orders, Accepting, Transcribing and Implementing (Noting), revised 11/2012, the P&P indicated, Licensed nursing personnel will ensure that telephone and verbal orders will be recorded and implemented. During a review of the facility's policy and procedure (P&P) titled Documentation, revised 11/2012, the P&P indicated, All documentation will be completed as required for each resident.

Based on observation, interview, and record review, the facility failed to attempt, offer, and document the use of bed rail (adjustable metal or rigid plastic bars that attach to the bed) alternatives for 17 of 67 residents (Resident 6, 10, 15, 19, 24, 29, 31, 40, 43, 54, 61, 62, 66, 80, 81, 84, and 94) , and obtain informed consent for one of 67 residents (Resident 199) prior to installation of the bed rails. These failures had the potential to put the residents at risk for entrapment and serious injury. Findings: During the initial tour observation on 3/24/24 at 2:25 p.m., Resident 6, 10, 15, 19, 24, 29, 31, 40, 43, 54, 61, 62, 66, 80, 81, 84, 94, and 199 had upper bed rails elevated and in use. During a concurrent observation and interview on 3/27/24 at 3:02 p.m. with the Director of Staff Develement (DSD), the DSD confirmed above residents had bed rails elevated and in use. She stated the bed rails were for turning and repositioning. During a concurrent interview and record review on 3/28/24 at 9:08 a.m. with the Medical Record Director (MRD), Resident 199's bed rail consent was reviewed. The consent indicated it was signed on 3/25/24, and the MRD confirmed that there was no other bed rail consent. During a concurrent interview and record review on 3/29/24 at 8:44 a.m. with the administrator (ADM), Resident 6, 10, 15, 19, 24, 29, 31, 40, 43, 54, 61, 62, 66, 80, 81, 84, and 94's Bed Rail Evaluations and Resident 199's Bed Rail Consent were reviewed. The ADM stated bed rail evaluation and consent should be done and obtained before using the bed rails. She confirmed there were no documentation evidences indicated the use of alternatives for Resident 6, 10, 15, 19, 24, 29, 31, 40, 43, 54, 61, 62, 66, 80, 81, 84, and 94. She also confirmed Resident 199's bed rail consent was obtained after the bed rails were already installed and in use. During a review of the facility's policy and procedure (P&P) titled SIDE-RAIL SAFETY revised 11/2012, the P&P indicated, Bed rails should only be used to enable the resident to facilitate mobility. Bed rails will be used in a safe manner, which prevents injury, when any type of Rails is required to assist with bed mobility or used per resident's request for an increased sense of security; by the interdisciplinary team IDT as a physical restrict per restraint policy and procedure. Another alternative should be attempted prior to use of side rails as a restraint, such as low beds, mats, alarms, toileting schedules, or other less restrictive devices. 1. Side-rail safety assessment will be done by a licensed nurse and/or the IDT on admission (if rails are used); when side0rails are implemented; and no less often than quarterly as long as any type of side-rail is being used by a resident. [ .] 5. If side-rails meet the definition of a physical restraint per facility policy, the Physical Restraint Policy and Procedure will be followed, including the requirements regarding assessment, consent and physician orders. 44583 46553 46939

Based on observation, interview and record review, the facility failed to ensure: 1. The recipe for Spinach was followed according to ingredient list for approximately 15 of 96 sampled residents 2. Accurate diets were not served according to resident preferences for two of 96 sampled residents (Resident 36 & Resident 51) These failures had the potential for adverse reactions to foods added to recipes without residents being aware, and for residents to not eat foods according to personal preferences. Findings: 1. During a concurrent observation and interview on 3/26/24 at 11:59 a.m. with Cook A, Cook A added cooked red bell peppers to the cooked spinach. Cook A stated, I am adding them for some more color. During a review of Club Spinach recipe (undated), recipe indicated, Ingredient spinach, chopped, granul [sic] garlic, black pepper, margarine. During an interview, on 3/28/24 at 10:04 a.m. with the Dietary Manager (DM), the DM stated, there are no red bell peppers in the spinach recipe. I told the cook to add them in for extra color. We should follow the ingredient lists. 2. During an observation on 3/26/24 at 12:15 p.m., Cook A plated spinach with red bell peppers added to them onto Resident 36's lunch plate. Dietary aide B read the meal ticket tray and placed Resident 36's lunch plate onto the meal cart, then moved onto the next plate. During a review of Resident 36's Noon Meal Ticket dated 3/26/24, the ticket indicated, Dislikes: BELL PEPPER. During an observation on 3/26/24 at 12:22 p.m., Cook A plated Resident 51's lunch tray with gravy poured over the turkey. Dietary Aid B plated the tray in the meal cart and moved onto the next resident. During a review of Resident 51's Noon Meal Ticket, dated 3/26/24, the ticket indicated, Dislikes: GRAVY. During an interview on 3/36/24 at 12:25 p.m. with the DM, the DM stated, Residents food preferences should always be followed, including their dislikes. During a review of the facility's Policy & Procedure (P&P) titled, Standardized Recipes dated 2020, the P&P indicated, 1. Each recipe shall include the following: a. All ingredients in order of introduction to the recipe. 6. Each resident has specific food and beverage preferences detailed on a tray card or in a tray identification system, so accurate diets are served.

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices in the kitchen when: 1. Dietary Aide (DA) C did not perform hand hygiene after cleaning the floor and touching dirty surfaces; 2. Multiple food items were kept in the freezer after the use by date; and 3. Canned food with major dents were not identified and removed from dry storage shelf These failures had the potential to spread food-borne illness to residents in the facility. Findings: 1. During an observation on 3/26/24, at 11:28 a.m., in the kitchen, DA C cleaned the floors with a broom, then threw trash into the trash can touching the surface of the trash can with his bare hands. DA C then went to the sink and washed his hands with only water for approximately 15 seconds, then dried his hands. DA C then walked over to the dishwasher and began unloading clean utensils with his bare hands. During an interview on 3/26/24, at 11:30 a.m., with DA C, DA C stated, I did not wash my hands with soap after cleaning, I should have used soap before unloading the clean dishes. 2. During a observation on 3/24/24 at 2:20 p.m., in the kitchen, Freezer #3 contained frozen hot dog and hamburger buns. One package of approximately 6 hot dog buns was labeled with an open date of 3/9/24, and a use by date of 3/16/24. One package of approximately 7 hamburger buns was labeled with an open date of 3/18/24, and no use by date. One package of approximately 6 hamburger buns was labeled with an open date of 3/7/24 with a use by date of 3/16/24. During an interview on 3/24/24, at 2:22 p.m., with Cook A, Cook A stated, those hot dog and hamburger buns should be thrown away if they were past the use by date. Cook A stated they were all past the use by dates. 3. During an observation on 3/24/24, at 2:30 p.m., in the kitchen, a dented can of black beans was on the shelf in dry storage area, with other canned foods for use. A cardboard box labeled dented cans for send back, was observed in the corner of the dry storage, the black bean can was not placed in this box, located on the shelf for use by staff. During a concurrent observation and interview on 3/26/24 at 10:35, with Dietary Manager (DM), the dented can of black beans was noted to be on the shelf in the same location. DM stated, we have a box for the dented cans, and that can should not be used because it has a major dent in it. During a review of the facility's policy and procedure (P&P) titled, Hand Hygiene, dated 2019, the P&P indicated, Employees are required to wash their hands thoroughly: .after touching objects that may be soiled.Handwashing: . wet hands.apply soap.

Based on observation, interview, and record review, the facility failed to ensure respect and dignity was maintained for five of 24 sampled residents (Residents 94, 199, 91, 3, and 44) when staff failed to provide privacy sleeves for above residents' indwelling catheter (a catheter placed in the bladder to drain urine) urinary bags. This failure had the potential to affect the emotional and psychosocial well-being of the residents. Findings: 1. During an observation on 3/24/24 at 2:40 p.m. at the entrance of Resident 94's room, Certified Nursing Assistant (CNA) N was preparing to empty Resident 94's urinary bag inside his room, the resident's urinary bag was visible from outside of the room. During a follow up observation on 3/24/24 at 3:30 p.m. in Resident 94's room, the resident's urinary bag was not covered with a privacy sleeve. 2. During an observation on 3/25/24 at 9:18 a.m. at the entrance of Resident 199's room, the resident's urinary bag was not covered with a privacy sleeve, and the bag was visible from outside of the room. During an interview on 3/29/24 at 9:30 a.m. with the Administrator (ADM), the ADM stated any resident with an urinary bag should have their bag covered with a privacy sleeve. 44583 3. Review of Resident 91's Admission Record indicated, Resident 91 was admitted to the facility with diagnoses including aphasia (a language disorder wherein the person is unable to communicate effectively to others) following cerebral infarction (also called stroke), hemiplegia (paralysis of one side of the body/a severe or complete loss of strength in the arm, leg, and sometimes face on one side of the body) and hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body) following unspecified cerebrovascular disease (CVA - also referred to as stroke) affecting right dominant side (more skillful side), and benign prostatic hyperplasia (an enlarged prostate [a gland just below the bladder]) with lower urinary tract symptoms (examples include leaking urine, having sudden and frequent urges to pee, having a weak stream or feeling like unable to empty the bladder). Review of Resident 91's minimum data set (MDS - an assessment tool) Admission/5-day assessment, dated 3/2/2024, indicated, Resident 91's brief interview for mental status (BIMS - an assessment to test a person's cognition level) was 7 [a BIMS score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact] which meant Resident 91 had severe cognitive impairment. During an observation on 3/24/2024 at 3:43 p.m., inside Resident 91's room, Resident 91 was sitting up on wheelchair with urine bag hanging under the wheelchair without a cover. It was observed, Resident 91's roommate had two visitors inside the room. During another observation on 3/25/2024 at 10:25 a.m., inside Resident 91's room, Resident 91 was observed sitting on his wheelchair with urine bag hanging under the wheelchair without a cover. It was observed, Resident 91's roommate had one visitor inside the room. 4. Review of Resident 3's Admission Record indicated, Resident 3 was admitted to the facility with diagnoses including pneumonia (infection of one or both lungs), dysphagia (difficulty in swallowing), neuromuscular dysfunction of bladder (the nerves and muscles don't work together very well resulting to bladder may not fill or empty correctly), and retention of urine (a condition in which the resident is unable to empty all urine from the bladder). Review of Resident 3's MDS Admission/5-day scheduled assessment, dated 2/28/2024, indicated, Resident 3's BIMS score was 15, which meant Resident 3 had an intact cognition. During an observation on 3/24/2024 at 4:00 p.m., at the hallway in front of Resident 3's room, Resident 3's bed was positioned near the door and the urine bag was placed at the right lower side of Resident 3's bed. Resident 3's urine bag was not covered, had urine, and could easily be seen by passersby at the hallway. During a concurrent observation and interview with certified nurse assistant F (CNA F) on 3/25/2024 at 9:37 a.m., inside Resident 3's room, CNA F confirmed Resident 3's urine bag was not covered. CNA F could not confirm the importance of covering the urine bag. During a concurrent observation and interview with licensed vocational nurse G (LVN G) on 3/25/2024 at 9:48 a.m., inside Resident 3's room, LVN G confirmed the urine bag was not covered. LVN G stated the urine bag should be covered for others not to see Resident 3's urine. During an interview with minimum data set coordinator (MDSC - a nurse who does residents' assessment) on 3/27/2024 at 2:19 p.m., MDSC stated residents' urine bag should be covered for resident's dignity. During a review of the facility's policy and procedure titled, Privacy/Dignity, date revised 10/24/17, indicated, Always ensure privacy and/or dignity of resident is respected . 46553 5. During an observation on 3/25/24 at 9:18 a.m., Resident 44 was lying in bed. His urinary bag for his indwelling catheter was hanging on the portable commode next to his bed. The urinary bag was not covered, and the contents were visible. During a concurrent observation and interview on 3/25/24 at 9:26 a.m. in Resident 44's room with Licensed Vocational Nurse (LVN) M, verified Resident 44's urine bag was not covered. LVN M stated the urinary bag should be covered even though when it was hanging on the commode. During a review of the facility's policy and procedure (P&P) titled, Dignity , revised 10/24/17, the P&P indicated, All employees shall treat residents' families and visitors, and fell ow workers with kindness, respect, and dignity. [ .] Always ensure privacy and /or dignity of resident is respected during care [ .]. A nursing home resident has the right to personal prIvacy of not only his/her own physical body, but also his/her person space, including accommodations and personal care.

Based on observation, interview, and record review, the facility failed to implement their policies on self-administration of medication (resident takes medication without staff assistance) when there were no assessments performed for self-administration of medications, and medications were left at the bedside for 2 of 24 sampled residents (Residents 84 and 3). These failures had the potential for unsafe and improper administration of medications. Findings: 1. Review of Resident 84's Admission Record indicated, Resident 84 was admitted to the facility with diagnoses including displaced intertrochanteric fracture of right femur (broken thigh bone), Alzheimer's disease (a progressive disease that destroys memory and mental functions), fall on same level from slipping, tripping, and stumbling, and cognitive communication deficit (problems with a person's ability to think, learn, remember, use judgement, and make decisions). Review of Resident 84's Minimum Data Set (MDS - an assessment tool) Significant change in status and 5-day scheduled assessment, dated 2/10/2024, indicated Resident 84's brief interview for mental status (BIMS - an assessment to test a person's cognition level) was 9, (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact] which meant Resident 84 had moderately impaired cognition. During a concurrent observation and interview with Resident 84 on 3/24/2024 at 3:21 p.m., inside Resident 84's room, Resident 84 was lying in bed. A bottle of medication for upset stomach/antidiarrheal was observed on top of Resident 84's bedside drawer. Resident 84 stated, I brought that medicine from home. During a concurrent interview and record review on 3/24/2024 at 3:35 p.m., Registered Nurse (RN) H reviewed Resident's physician orders. RN H confirmed Resident 84 had no order for the medication for upset stomach/antidiarrheal. RN H further confirmed Resident 84 had no order to leave the medication at bedside. During a follow up observation and interview with RN H and Resident 84 on 3/24/2024 at 3:45 p.m., inside Resident 84's room, RN H confirmed Resident 84 had the medication for upset stomach/antidiarrheal on top of the bedside drawer. RN H stated Resident 84 should not have medication at bedside. Resident 84 stated, I need it and I will take it if needed. 2. Review of Resident 3's Admission Record indicated, Resident 3 was admitted to the facility with diagnoses including pneumonia (infection of one or both lungs), dysphagia (difficulty in swallowing), neuromuscular dysfunction of bladder (the nerves and muscles don't work together very well resulting to bladder may not fill or empty correctly), and retention of urine (a condition in which the resident is unable to empty all urine from the bladder). Review of Resident 3's MDS Admission/5-day scheduled assessment, dated 2/28/2024, indicated, Resident 3's BIMS score was 15, which meant Resident 3 had an intact cognition. During a concurrent observation and interview with Resident 3 on 3/24/2024 at 4:00 p.m., inside Resident 3's room, Resident 3 was lying in bed and a bottle of eye drop medication was observed on top of Resident 3's overbed table. Resident 3 stated she used the eye drop medication for her dry eyes. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) G on 3/25/2024 9:48 a.m., inside Resident 3's room, LVN G confirmed Resident 3's eye drop medication was placed on top of her overbed table. LVN G stated Resident 3 should not have the eye drop medication at bedside. During a follow up interview and record review on 3/25/2024 at 9:50 a.m., LVN G reviewed Resident 3's physician orders. LVN G confirmed Resident 3 did not have orders of eye drops for dry eyes and order for Resident 3 to have medication at bedside. During an interview on 3/29/2024 at 9:33 a.m. with the MDS Coordinator (MDSC), the MDSC stated they have a policy that residents should not have medications stored at bedside unless it was ordered by the physician and the assessment indicated resident was safe to self-administer the medication. During a review of the facility's policy and procedure (P&P) titled, Self-Administration of Medication, date revised 11/2012, the P&P indicated, If the resident expresses a desire to self-administer their medications, or a physician orders self-administration, the facility will not allow the resident to self-administer meds (medications) until the following procedure are one: Licensed Nurse will complete the Self-Administration Assessment which includes the resident's physical and cognitive ability to safely administer and store their medication(s) .

Based on interview and record review, the facility failed to provide two of three sampled residents (Resident 13 and 83) with the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN, a financial liability notice). This failure could lead to resident unknowingly assume financial liability for receiving services that were not covered by Medicare. Findings: During a review of Resident 13's face sheet (a document that contains a summary of a resident's personal and demographic information) and Notice of Medicare Non-Coverage ((NOMNC, a notice that indicates when a resident's stay at a SNF is no longer paid by Medicare), it indicated Resident 13 was admitted to the facility on [DATE] and his stay was paid by Medicare (federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities) until 12/19/23 and currently resided at the facility. During a review of Resident 83's face sheet and NOMNC, it indicated Resident 83 was admitted to the facility on [DATE] and her Medicare benefits was from 12/2/23 until 1/12/24 and currently resided at the facility. During an interview on 3/27/24 at 10:31 a.m. with the Business Office Manager (BOM), the BOM confirmed Resident 13 and 83's stay were partially covered by Medicare, after their Medicare benefits ended, they stayed at the facility. She stated she never issued a SNFABN before and was not aware of anything about SNFABN until 3/11/24 when she was provided a training webinar regarding SNFABN. She further stated she would start to issue SNFABN based on the regulation moving forward. During an interview on 3/29/24 at 9:30 a.m. with the Administrator (ADM), the ADM stated the two residents were supposed to receive SNFABN when their Medicare benefits ended. During a review of the facility's policy and procedure (P&P) titled SNF Expedited Review NOMNC, SNFABN, Denial Letters, & ABN R-131, revised August 2021. The P&P indicated, 6. Part A covered stay: SNF determines Part A stay ending due to skilled services ending. Medicare days remain and Beneficiary stays in the center (even if for just 1 day). Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage Form CMS-10055 (SNFABN) deliver with the NOMNC to ensure timely delivery. - YES

Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, a clinical assessment tool) for one of 24 sampled residents (Resident 63). Failure to accurately assess the resident had the potential to compromise the facility's ability to provide resident-centered care plan interventions. Findings: During a review of Resident 63's face sheet (a document that contains a summary of a resident's personal and demographic information), it indicated Resident 63 was admitted to the facility on [DATE] with diagnosis of bipolar disorder (a serious mental illness that causes unusual shifts in mood). During a review of Resident 63's level I Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure individuals with mental disorders and intellectual disabilities are not inappropriately placed in nursing homes for long-term care) dated 6/1/22, the PASRR indicated Yes for Section III - Serious Mental Illness Screen: 10. Does the individual have a diagnosed mental disorder such as Depression, Anxiety, Panic, Schizophrenia/Schizoaffective Disorder, Psychotic, Delusional, and/or Mood Disorder? During a concurrent interview and record review on 3/27/24 at 3:33 p.m. with the MDS Coordinator (MDSC), Resident 63's MDS dated [DATE] was reviewed. MDS section A1500 PASRR indicated No for question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? The MDSC confirmed that section A1500 on the MDS dated [DATE] should have been coded Yes for that question. During a review of the facility's policy and procedure (P&P) titled Resident Assessment Instrument (RAI/MDS) revised 11/2012. The P&P indicated, The Resident Assessment Instrument will be completed timely and accurately, per Federal Guidelines, and will serve as a foundation for the comprehensive care planning process.

Based on interview and record review, the facility failed to ensure a Level II PASRR (Pre-Admission Screening and Resident Review, a federal requirement to help ensure individuals with mental disorders and intellectual disabilities are not inappropriately placed in nursing homes for long-term care) was completed for two of 24 residents (Residents 41 and 61). This failure had the potential to put the residents at risk for not receiving appropriate care and services for their mental health conditions. Findings: Review of Resident 41's clinical record indicated they had diagnoses including paraplegia (the inability to move the lower part of the body, schizophrenia (a mental condition) and morbid obesity (too much body weight). Review of Resident 41's record, indicated Resident 41 had a positive Level I PASRR screen, completed on 9/28/21. Review of Resident 41's record also indicated the Level II PASRR was not completed due to the reason The Individual was isolated as a health and safety precaution, in a letter dated 2/18/22. During an interview on 3/27/24 at 1:52 p.m. with the Minimum Data Set Coordinator (MDSC), the MDSC stated the Level I PASRR was done either on admission or prior to admission, and that all PASRR letters were uploaded into the electronic health record (EHR). The MDSC also stated It's a team effort as to who is responsible for making sure the PASRR is done. During a follow up interview on 3/28/24 at 9:43 a.m. with the MDSC, the MDSC stated the state portal website for PASRR does not trigger if a Level II was not done. 46939 During a review of Resident 61's PASRR dated 9/28/21, the PASRR indicated, the level I PASRR was positive, and Resident 61 would need a level II PASRR completed. During an interview on 3/28/24, at 10:13 a.m. with the MDSC, MDSC stated, Resident 61 was in isolation due to an infectious disease when he was scheduled for the level II PASRR, so it was closed. They never followed through to complete a new level II PASRR. Resident 61 did not get the required level II PASRR Screen. Review of the facility's policy Preadmission Screening and Resident Review (PASRR), dated July 2016, indicated A PASRR will be completed and submitted online for new admission within 24 hours, and Recommendations from the Determination Letter will be included in the individuals Plan of Care.

Based on observation, interview, and record review, the facility failed to develop and implement individualized, resident-centered care plans for 3 of 24 sampled residents (Residents 74, 3 and 18) when care plans for: 1. Resident 74's feeling of sadness was not developed and implemented; 2. Oxygen (a colorless, odorless gas) and anticoagulant (sometimes called blood thinning medications) used for Resident 3 was not developed; and 3. Oxygen used for Resident 18 was not developed. These failures had the potential to result in the residents not receiving the care and services necessary to maintain their health, safety and well-being. Findings: 1. Review of Resident 74's Admission Record indicated, Resident 74 was admitted to the facility on [DATE] with diagnoses including hypo-osmolality (a condition where the levels of electrolytes, proteins, and nutrients in the blood are lower than normal) and hyponatremia (low sodium [can be found in table salt or in processed foods] level in blood), adult failure to thrive (when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), alcohol use, and weakness. Review of Resident 74's clinical records titled, Social Services Assessment & Documentation, dated 2/29/2024, indicated, .Wife dies 3 weeks ago .b. Typical mood throughout life: sad. Further review indicated, resident verbalized feeling sad and depressed since the passing of his wife 3 weeks ago . Review of Resident 74's Minimum Data Set (MDS, an assessment tool) Admission/5-day assessment dated [DATE], indicated, Resident 74's Brief Interview for Mental Status (BIMS, an assessment to test a person's cognition level) was 15 [a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact], which indicated Resident 74 had an intact cognition. Further review of the MDS indicated, Resident 74 had a total severity score of 07 in the mood interview which indicated, Resident 74 had mild depression. During a concurrent observation and interview on 3/24/2024 at 3:00 p.m. inside Resident 74's room, Resident 74 was sitting up on wheelchair. Resident 74 stated he lost his wife in February. During an interview with Social Service Director (SSD) on 3/27/2024 at 1:13 p.m., SSD stated Resident 74 did not get up upon admission, had lack of motivation, and preferred to stay in his room. SSD further stated Resident 74 refused to participate therapy. SSD confirmed she offered a psychiatry or psychology consult but Resident 74 declined. During a follow up interview and record review on 3/27/2024 on 3:25 p.m., SSD reviewed Resident 74's MDS, list of care plans and social services (SS) documentations. SSD confirmed Resident 74 had mild depression, and no other mood interventions were implemented after the 2/29/2024 assessment. SSD further confirmed there was no care plan to address Resident 74's mild depression. SSD stated a care plan regarding Resident 74's mild depression should have been developed. SSD further stated care plan is important for staff to determine the psychosocial needs of residents and to get the whole picture of how to take care of the resident. 2a. Review of Resident 3's Admission Record indicated, Resident 3 was admitted to the facility with diagnoses including pneumonia (infection of one or both lungs), dysphagia (difficulty in swallowing), heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), unspecified asthma (inflammatory disease of the airway that often causes wheezing, coughing, and shortness of breath), acute embolism (a sudden block in an artery [blood vessel] caused by blood clots or other substances) and thrombosis (a blood clot within blood vessels that limits the flow of blood) of unspecified deep veins of unspecified lower extremity (lower leg), other pulmonary embolism (a sudden blockage of an artery in the lung), and dependence on supplemental oxygen. Review of Resident 3's MDS Admission/5-day scheduled assessment, dated 2/28/2024, indicated, Resident 3's BIMS score was 15, which indicated Resident 3 had an intact cognition. Review of Resident 3's Order Summary Report dated 3/27/2024, indicated, Oxygen - Oxygen at 2L/min [liters - a metric unit of capacity, per minute] Via [thru] NC [nasal cannula - a device that consists of plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostrils for oxygen administration] as needed for SOB [shortness of breath] as needed related to DEPENDENCE ON SUPPLEMENTAL OXYGEN . Further review indicated, the use of oxygen was ordered on 2/24/2024. During an observation on 3/24/2024 at 4:00 p.m., inside Resident 3's room, Resident 3 was lying in bed and had oxygen at 2 L/min via NC in placed. During another observation on 3/25/2024 at 9:18 a.m., inside Resident 3's room, Resident 3 was lying in bed, overbed table was placed in front of her and had oxygen at 2 L/min via NC in placed. During a concurrent interview and record review on 3/27/2024 at 2:07 p.m., MDS Coordinator (MDSC) reviewed Resident 3's order summary report and list of care plans. MDSC confirmed Resident 3 had an order for oxygen use as needed and a care plan for oxygen used was not developed. MDSC stated there should have been a care plan developed for oxygen used to guide staff on how to care of resident with oxygen. 2b. Review of Resident 3's Order Summary Report dated 3/27/2024, indicated, Eliquis [a brand name of Apixaban - anticoagulant/blood thinner medication] Oral Tablet 2.5 MG [milligrams, unit of measurement] Give 1 tablet by mouth two times a day for DVT [deep vein thrombosis, a medical condition that occurs when a blood clot forms in a deep vein] prophylaxis [protective or preventive treatment] related to ACUTE EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VEINS OF UNSPECIFIED LOWER EXTREMITY. During a concurrent interview and record review on 3/28/2024 at 10:27 a.m., the Director of Staff Development (DSD) reviewed Resident 3's order summary report and list of care plans. The DSD confirmed Resident 3 was taking Eliquis as ordered and a care plan for used of Eliquis was not developed. The DSD stated used of Eliquis should have been care planned for staff to know how to managed Resident 3's used of anticoagulant. 46939 3. During an observation on 3/27/24, at 1:02 p.m., in Resident 18's room, Resident 18 was noted to have oxygen on at his bedside, delivered via a NC. During a review of Resident 18's Order Summary Report dated 1/13/24, an order for On continuous O2 [oxygen] per NC @ 2Lmin. During a review of Resident 18's Care Plan dated, 3/28/24, indicated no care plan for the use of oxygen. During an interview on 3/29/24, at 9:28 a.m., with Interim Director of Nursing (IDON), IDON stated, if a resident was receiving oxygen, they should have a care plan for it. IDON stated, Resident 18 did not have a care plan for oxygen use. During a review of the facility's policy and procedure (P&P) titled, Care Plan, Baseline and Comprehensive, revised 2017, the P&P indicated, 4. A comprehensive person-centered care plan consistent with resident rights will include measurable objectives and time frames to meet resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being.

Based on interview, and record review, the facility failed to update the fall care plan for one of 8 residents (Resident 84) when interdisciplinary team (IDT, team composed of members from different departments involved in resident's care) did not review and revised Resident 84's fall risk care plan with subsequent falls. This failure resulted in Resident 84's two more subsequent falls. Findings: Review of Resident 84's Admission Record indicated, Resident 84 was admitted to the facility with diagnoses including displaced intertrochanteric fracture of right femur (broken thigh bone), Alzheimer's disease (a progressive disease that destroys memory and mental functions), fall on same level from slipping, tripping, and stumbling, and cognitive communication deficit (problems with a person's ability to think, learn, remember, use judgement, and make decisions). Review of Resident 84's Minimum Data Set (MDS, an assessment tool) Significant change in status and 5-day scheduled assessment, dated 2/10/2024, indicated Resident 84's Brief Interview for Mental Status (BIMS, an assessment to test a person's cognition level) was 9, [a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact] which indicated Resident 84 had moderately impaired cognition. Further review of Resident 84' MDS indicated, Resident 84 had fallen in the past month and had a fracture related to the fall. Review of Resident 84's Change in Condition Evaluation dated 2/3/2024, indicated, Resident 84 had an unwitnessed fall and was sent out to the hospital for possible injury evaluation. There was no documentation the IDT reviewed and revised Resident 84's fall risk care plan when Resident 84 returned from hospitalization . Review of Resident 84's Interdisciplinary Fall dated 2/13/2024, indicated, Resident 84 had another unwitnessed fall on this date, inside the restroom. Further review indicated, Care plan updated to prevent recurrence. There were no new fall risk interventions tried since 2/13/2024 to prevent further falls. Review of Resident 84's Interdisciplinary Fall dated 3/19/2024, indicated, Resident 84 had a witnessed fall on this date, inside her room. Further review indicated, Resident 84 was walking into her room with the used of the four wheeled walker (4WW, an assistive device that gives support to maintain balance or stability while walking), attempted to turn but lost her balance. The record indicated, Care plan updated to prevent recurrence. There were no new fall risk interventions dated 3/19/2024. During a concurrent interview and record review on 3/28/2024 at 10:33 a.m. with the Director of Staff Development (DSD), Resident 84's fall risk care plan was reviewed. The DSD confirmed Resident 84 was a fall risk and had fallen in the facility. The DSD further confirmed the fall risk care plan was not updated when Resident 84 fell on [DATE] and 3/19/2024. During a review of the facility's policy and procedure (P&P) titled, FALLS MANAGEMENT, revised 11/2012, the P&P indicated, Recent falls will be reviewed daily by a designated facility fall team, to evaluate cause, determine additional strategies as needed to prevent recurrence for each resident and further revise the care plan .

Based on observation, interview, and record review, the facility failed to ensure the residents received the necessary care and services for two of six residents (Residents 148 and 15) when licensed nurses did not follow the physician's order for oxygen supplement (a therapy that provides extra air to breathe in) for Residents 148 and 15. These failures had the potential to affect the residents' care and could jeopardize their health and well-being. Findings: 1. Review of Resident 148's Admission Record indicated, Resident 148 was admitted to the facility with diagnoses including chronic respiratory failure (a condition when lungs cannot release oxygen to blood causing shortness of breath) with hypoxia (occurs when oxygen level in the body organs are low), and chronic obstructive pulmonary disease (COPD - a long lasting lung disease). Review of Resident 148's Order Summary Report, indicated Resident 148 had an order for continuous oxygen administration at 2 liters (L, metric unit of volume) per minute (min) via (thru) nasal cannula (NC, a device that consists of plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostrils for oxygen administration). During observations on 3/24/2024 at 3:43 p.m. and 3/25/2024 at 10:25 a.m., in Resident 148's room, Resident 148 was lying in bed and was on oxygen at 2.5 L/min via NC. During a concurrent observation and interview on 3/26/2024 at 11:17 a.m. in Resident 148's room with Licensed Vocational Nurse (LVN) L, Resident 148 was on oxygen at 2.5 L/min via NC. LVN L confirmed the observation. During a follow up interview and record review on 3/26/2024 at 11:22 a.m. with LVN L, LVN L reviewed Resident 148's order summary report. LVN L confirmed Resident 148's oxygen administration order was supposed to be at 2 L/ min. LVN L stated, we should follow whatever the order is. 2. Review of Resident 15's Admission Record indicated, Resident 15 was admitted to the facility with diagnoses including respiratory failure with hypoxia, chronic diastolic heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), and unspecified asthma (inflammatory disease of the airway that often causes wheezing, coughing, and shortness of breath). Review of Resident 15's Order Summary Report, indicated Resident 15 had an order for continuous oxygen administration at 3 L/min via NC. Further review indicated, Resident 15 had the oxygen order since 1/29/2024. During an observation on 3/25/2024 at 10:28 a.m., in Resident 15's room, Resident 15 was seated on a wheelchair, using oxygen at 2 L/min via NC. During a concurrent observation and interview on 3/26/2024 at 11:19 a.m. in Resident 15's room with LVN L, Resident 15 was seated on a wheelchair and was using oxygen at 2 L/min via NC. LVN L confirmed the observation. LVN L stated the order for the oxygen was decreased from 3 L to 2 L per minute. During a follow up concurrent interview and record review on 3/26/2024 at 11:25 a.m. with LVN L, LVN L reviewed Resident 15's order summary report. LVN L confirmed Resident 15's oxygen administration order was supposed to be at 3 L per minute. LVN L stated he was not sure why the oxygen administration to Resident 15 was dropped to 2 L per minute. LVN L further stated Resident 15's oxygen administration level should be at 3 L per minute as ordered by the physician. During an interview on 3/29/2024 at 9:23 a.m. with the Minimum Data Set Coordinator (MDSC), the MDSC stated if it was non urgent, nurses should refer to the physician's order prior to administration of oxygen. During a review of the facility's policy and procedure titled, OXYGEN (Emergency/Documentation/Humidifier/Precautions/Mode of Delivery/Storage/Use/Transporting), date revised 11/2012, indicated, .verify physician's order. Written orders for oxygen therapy are to include: a. Mode of delivery; b. Liter flow rate; c. Duration of therapy. Oxygen is a drug, and excessive levels may be harmful.