MORNINGSTAR OF BOULDER

A licensure complaint, prompted by complaint investigation #CO42069, was completed on 5/13/26. No deficiencies were cited.

A revisit survey was completed on 4/7/25 for all previous deficiencies cited on 10/08/24. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 4/7/25 for all previous deficiencies cited on 8/13/24. The facility is in compliance with all deficiencies that were cited.

A complaint revisit was completed on 10/8/24 for all previous deficiencies cited on 5/3/23. A deficiency was cited. The regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24.

Based on interview and record review, the residence failed to update a comprehensive assessment whenever the resident's condition changed from baseline status, affecting one sample resident (#32). This deficiency was cited previously during a state licensure survey on 5/3/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings Include:1. Residence PolicyThe residence's Assessment policy, dated July 2021, read in part that the frequency of assessments included change in condition, not limited to a significant change in health requiring additional tasks added to the care plan. The residence's Change of Condition and Short-Term Observation policy, dated July 2021, read in part: examples of changes in condition included wounds/skin tears. 2. Record reviewResident #32 was admitted to the residence on 3/6/24 with diagnosis including dementia. An incident report, dated 8/20/24, read Resident #32 had a small skin tear on his left knee. Progress notes read in part:On 9/30/29 while assisting Resident #32 to bed, a skin tear was discovered on his right shin, and it was actively bleeding. Resident #32 reported hitting his leg on his wheelchair. On 10/5/24 a skin tear was noted on the back of the residents right arm. The comprehensive assessment, dated 9/4/24, read in part that the resident had no skin concerns. The residence did not update the comprehensive assessment following any of the above changes in Resident #32's condition. 3. InterviewsOn 10/8/24 at approximately 4:00 p.m., the resident care coordinator said the skin tears for Resident #32 were addressed in the care plan. On 10/8/24 at approximately 4:30 p.m., the wellness director said the assessment should have been updated after the discovery of the Resident #32's skin tears.

A relicensure survey was completed on 10/8/24. No deficiencies were cited. A change of ownership survey was completed on 9/5/23.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.12.9 The comprehensive assessment shall be updated for each resident at least annually and whenever the resident's condition changes from baseline status.

A complaint revisit was completed on 10/8/24 for all previous deficiencies cited on 5/3/23. The residence is in compliance with all regulations surveyed. The regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24.

A complaint revisit was completed on 10/8/24 for all previous deficiencies cited on 5/3/23. The residence is in compliance with all regulations surveyed. The regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24.

An appeal of an involuntary discharge survey prompted by #CO36166 was completed on 8/13/24. A deficiency was cited.

Based on interviews and record review, the residence failed to include in the initial 30-day involuntary discharge a detailed explanation of the reasons for the discharge, including facts and evidence supporting each reason given by the residence and a recounting of events leading to the involuntary discharge, including interactions with the resident prior to the notice and actions that were taken to avoid discharge and failed to contain a practitioner assessment of the resident's current needs in relation to the resident's medical condition when an involuntary discharge was initiated due to a medical condition that cannot be treated with services routinely provided by the residence's staff or an external service provider, affecting one resident (#1). Findings include:The January 2024 Grievance Policy read in part that the residence administrator was in charge of the grievance process related to discharges and that the residence had no more than five business days after the submission of a grievance to respond to the grievance. The involuntary discharge notice, dated 5/1/24, revealed that the residence did not include in the 30-day involuntary discharge a detailed explanation of the reasons for the discharge, including facts and evidence supporting each reason given by the residence and a recounting of events leading to the involuntary discharge, including interactions with the resident prior to the notice and actions that were taken to avoid discharge, and failed to include a practitioner assessment of the resident's current needs in relation to the resident's medical condition when an involuntary discharge was initiated due to a medical condition that cannot be treated with services routinely provided by the residence's staff or an external service provider a practitioner's assessment of the resident's current needs in relation to the resident's medical condition that prompted the discharge. On 8/12/24 at 11:07 a.m., a representative of Resident #1 stated the residence did not include evidence that the resident's health status had changed from the time the resident's admission to the residence, evidence of actions taken by the residence to avoid discharge or a practitioner's assessment in the 30-day involuntary discharge the residence issued to him as the resident's representative. He added the residence did not provide the 30-day discharge directly to Resident #1. On 8/12/24 at 3:17 p.m., the administrator stated the residence provided a 30-day involuntary discharge dated 5/1/24 to the representative of Resident #1. He stated that Resident #1 was discharged due to the inability to meet the resident's needs. The administrator stated that the resident moved in with both a catheter and required transfer assistance. He affirmed the residence did not include in the initial discharge a detailed explanation of the reasons for the discharge, including facts and evidence supporting the changed health status of the resident, evidence supporting the residence's actions to avoid discharge, or a practitioner's assessment of the resident's current needs in relation to the resident's medical condition when an involuntary discharge was initiated due to a medical condition that cannot be treated with services routinely provided by the residence's staff or an external service provider.

A licensure complaint prompted by #CO30367, #CO30371, #CO31760, #CO31792 and #CO31979 was completed on 5/3/23. Deficiencies were cited.

Based on observation, record review and interview, the residence failed to comply with applicable state regulations pertaining to life safety code, affecting 77 current residents. Specifically, on 5/2/23 at 7:00 a.m., the residence's final panel read "Missing." At approximately 1:00 p.m., the fire panel was reporting as normal. At 6:09 p.m., the fire panel read "Network FLT." On 5/3/23, at 6:56 a.m., the fire panel read "Network FLT" and additionally read "network link lost." A representative from the monitoring company stated the fire suppression system was currently not working appropriately. This included all of zone one in the residence and needed service. The representative stated that monitoring company was being alerted of the trouble code hourly. The representative stated the panel alerted twice hourly that there was trouble and that the most recent hour had alerted four times that the residence was having a disconnect. The representative stated it was concerning that the panel was being manually reset and not fully repaired. The representative further stated the monitoring company had been alerted of trouble since 4/26/23 after a fire alarm signal was reported. The representative stated network failure was a concern because that meant the network may not alert the monitoring company properly and added restoring the panel did not fix the problem and could actually cause the panel to completely stop alerting the monitoring company. The representative stated in the current state the fire panel was not operating in some capacity the way that it should have and it was best to fix the panel before an emergency occurred and the panel failed to alert properly. This failure created an immediate jeopardy risk of burn injury to 77 current residents residing in the residence. On 5/3/23, the department directed the residence to provide written evidence that the risk had been removed. Findings include: 1. References and Residence Agreementa. According to the 2021 Code of Colorado Regulations (CCR) 8 CCR 1507-31 Building, Fire, and Life Safety Code Enforcement and Certification of Inspectors for Health Facilities Licensed by the State of Colorado, Part 9.2.1, The Business Entity shall ensure that building systems are inspected, tested, and maintained as required by the adopted codes and referenced standards.b. According to the 2021 Code of Colorado Regulations (CCR) 8 CCR 1507-31 Building, Fire, and Life Safety Code Enforcement and Certification of Inspectors for Health Facilities Licensed by the State of Colorado, Part 3.1, The technical requirements of these rules are supported primarily by codes developed by the International Code Council (IEBC) and the National Fire Protection Association (NFPA). These two organizations were membership associations dedicated to building safety and fire prevention. These rules establish minimum requirements where the Division is the Authority Having Jurisdiction for building systems using prescriptive and performance related provisions, which are widely used to construct residential and commercial buildings. The appropriate portions of the adopted codes will be applied as prescribed by the adopted codes themselves. Where there are differing provisions for new and existing construction, all work taking place after April 1, 2019 must meet the requirements for new construction and as amended per provisions of IEBC and NFPA 101.c. The residence's Resident Agreement, dated January 2020, read in part: The residence provided an automatic fire suppression system that complied with applicable life safety code requirements. 2. Information provided by the administrator of record regarding a series of events prior to the onsite investigation revealed the followinga. A handwritten list of attempted calls to the fire panel monitoring company provided by the administrator of record on 5/3/23 at approximately 1:20 p.m., read:The interim administrator had attempted to contact the fire panel monitoring company by telephone on 3/20/23, 3/26/23 and 4/19/23. However, no documentation was provided regarding the calls. The maintenance director had attempted to contact the fire panel monitoring company by telephone on 4/22/23, 4/24/23 and 5/2/23 at 8:00 p.m. Additionally, the maintenance director had left a voicemail or text message to the monitoring company on 4/19/23, 4/21/23, 4/22/23 and 4/24/23. However, no documentation was provided regarding the calls, text messages or voicemail's that were left. b. Email communication between the regional maintenance technician, the monitoring company and the repair company was provided on 5/2/23 at 9:36 a.m., and read;On 3/28/23 at 10:51 a.m., email communication from a representative of the monitoring company read; "Just an update. I have been resourcing the FCI (fire control instrument) parts that you need for your fire alarm repair. Once I have this information, I will get back with you regarding supply and scheduling." On 4/26/23 at 10:25 a.m., email communication from the regional maintenance technician read "I just left a message for (a representative) regarding the fire panel issues we are having here at (the residence). Can you do me a huge a favor (sic) and follow up with him regarding the urgency of getting this repaired and resolved." On 4/26/23 at 5:10 p.m., email communication from the regional maintenance technician read "(the representative) just called me to let me know he has a technician available Monday 5/1/23 from (a repair company) to trouble shoot the multiple issues we are having with our fire panel here at (the residence). (The representative) said he will get the quote over to you to get to (the vice president facilities management) for approval. I will loop in the team here at the community regarding Monday 4/26/23 appointment (sic) provided approval of your quote."On 5/1/23 at 5:10 p.m., email communication from a representative of the repair company read in part; "... was the issue resolved today 5/1?" No additional communication was documented from the residence to the fire panel repair company after 4/26/23 until 5/2/23.3. On 5/2/23 (the first date of the onsite investigation) the following was revealed: On 5/2/23 at approximately 7:00 a.m., the fire panel in the front entrance of the residence presented a trouble code that read "missing". On 5/2/23 at approximately 7:52 a.m., the fire panel in the back hall of the residence's secure environment presented a trouble code that read "missing."On 5/2/23 at approximately 1:04 p.m., the fire panel in the residence's front entrance read "system normal."On 5/2/23 at 6:09 p.m., the fire panel in the front entrance presented a trouble code that read " Netwk FLT" and "Network Link Lost. Net Port 2"On 5/2/23 at 9:41 a.m., email communication from the interim administrator to the fire repair company read in part; "(the department) is here and they want answers on the fire panel and who to contact at (the repair company)"On 5/2/23 at approximately 7:00 a.m., Staff #26 stated she was unsure why the fire panel was alarming. She acknowledged the fire panel had been alarming since she arrived onsite to work her shift on 5/2/23. On 5/2/23 at 7:14 a.m., the interim administrator stated the fire panel had presented a trouble code for approximately two weeks prior to the onsite visit. She stated the repair company should have been to the residence the day prior to the onsite investigation to work on the panel. However, she stated the repair company had not shown up to the residence. The interim administrator stated the repair company was unsure what was wrong with the fire panel and could not provide a clear answer on what the trouble code was. On 5/2/23 at 8:02 a.m., the memory care coordinator stated she was unsure what was wrong with the fire panel or why the fire panel had been alarming. 4. On 5/3/23 the following was revealed:On 5/3/23 at 6:56 a.m., the fire panel in the front entrance presented a trouble code that read " Netwk FLT" and "Network Link Lost. Net Port 1"On 5/3/23 at 9:57 a.m., the fire panel in the back hall of the residence's secure environment presented a trouble code that read " Netwk FLT" and "Network Link Lost. Net Port 1"On 5/3/23 at approximately 7:08 a.m., a representative from the fire panel repair company stated her understanding was the repair company did not complete the actual monitoring of the fire panel, only completed repairs and inspections. The representative stated the repair company was aware there was an issue with the fire panel that had to do with programming. The representative stated a repair person from a third party company had been at the residence on 5/2/23 and started to reprogram the entire system. The representative stated the prior programming codes were missing and that the repair person was working on getting the system back to operating per code requirements. The representative stated the repairs had been completed; however, she could not answer if the system was working properly. On 5/3/23 at approximately 7:15 a.m., a second representative from the repair company stated he believed the fire panel was alerting the monitoring company; however, there was no record that the monitoring company was being alerted. The representative stated the residence had received a deficiency form during the panel inspection because of the panel failures. The representative from the repair company stated the third party repair technician reported the system was able to send signals but the repair technician was unsure what was actually being reported. On 5/3/23 at 7:37 a.m., a representative from the fire panel monitoring company stated the system was currently reporting a trouble code in zone zero and it appeared the panel was resetting itself. She stated the panel was alerting that the residence was having a disconnect from the panel. The representative stated she was unaware the residence had been manually resetting the panel. She stated it was a concern that the panel was not resetting itself. The representative stated the fire panel had alerted the monitoring company of trouble every hour twice starting at approximately 3:00 a.m. on 5/3/23. She stated the panel had alerted trouble four times in the one hour prior to the telephone call. The representative stated the monitoring company had been alerted of trouble codes routinely since 4/26/23 after the system was put in test mode for a fire alarm. The representative stated a network failure code was a concern because that meant the network may not have alerted the monitoring company properly. She stated manually restoring the panel did not fix the problem and could cause the panel to completely stop alerting the monitoring company altogether. The representative stated there was no documentation in the system that the residence had reached out to the monitoring company for repair of the system after 4/26/23. The representative from the monitoring company stated "(in the) current state, the fire panel is not operating in some capacity the way that it should and it would be best to resolve before an emergency and the panel fails to alert appropriately." On 5/3/23 at 9:15 a.m., the maintenance director stated he had begun employment at the residence approximately three weeks prior to the onsite visit. He stated the fire panel had been alarming at the residence since he began employment. The maintenance director stated the repair company had informed him that the network failure issue was a firmware problem. He stated his understanding was the fire panel had a communication issue. The maintenance director confirmed the residence had done no testing to determine if the panel was properly alerting the monitoring company. On 5/3/23 at 9:29 a.m., the administrator of record stated the fire panel had been alarming for approximately five to six weeks. He stated he was unsure what the issue was exactly, but believed it had been related to a programming issue. He stated the monitoring company had not been super helpful with the issues so the residence utilized a different repair company. 5. Immediate Jeopardy Risk - Written Evidence, Immediate Correction The investigation established that the findings above placed the 77 current residents at immediate jeopardy risk for burn injury. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.16 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 5/3/23 at 10:21 a.m., the administrator of record submitted written evidence that read in pertinent part; "Plan to address immediate concern: Front Desk Concierge to monitor 11 hours the fire panel and call 911 (emergency medical services) immediately if alarm sounds (qualified medication administration person [QMAP]) on (evening and overnight) shift to monitor 13 hours the fire panel and call 911 immediately if alarm triggers. This provides 24 hours coverage and observation to ensure immediate monitoring. Plan to address concern of communication between system and monitoring company: Work with local fire department, pull alarm, see if they call (monitoring company). Coordinate with county dispatch to ensure monitoring company is alerted and no delays in response are occurring. Plan to address concern in the on term solution: Working with (two repair companies) to determine what needs to be reprogrammed on the panel."However, the plan did not address fire watch and what would be monitored during fire watch. Additionally, there was no element of how to document fire watch and monitor that fire watch was occurring. The plan did not include an immediate resolution. The plan did not include ongoing monitoring and documentation of monitoring. The administrator of record was directed to submit additional written evidence. On 5/3/23 at 11:07 a.m., the administrator of record submitted written evidence that read in pertinent part; "Plan to address immediate concern: Dedicated Fire Watch individual or designee will be responsible for 24 hours of monitoring. In addition, Front Desk Concierge to be on alert 11 hours the fire panel and call 911 immediately if alarm triggers (observing for visual strobe lights and audio siren) (QMAP)on (evening and overnight) shift to be on alert 13 hours and call 911 immediately if alarm triggers. This provides 24 hours Fire Watch and observation to ensure immediate monitoring. This will be documented via signature sheet of Fire Watch individual and designees. This sheet to be reviewed by ED (administrator of record) or designee to ensure fire watch is occurring. Plan to address concern of communication between system and monitoring company: Immediate testing on 5/3/23 will be conducted. Community will work with local fire department, pull alarm, see if they call (monitoring company). Coordinate with county dispatch to ensure monitoring company is alerted and no delays in response are occurring. Plan to address concern in the on term solution: Working with (monitoring and repair companies) as the monitoring and inspection companies to determine what needs to be reprogrammed on the panel. We will seek to have (sic). We will obtain daily updates from (the monitoring and repair companies) and reach out if no response."However, the plan did not contain an immediate resolution to ensure the panel was operating correctly. Additionally, the plan did not contain an ongoing monitoring element or a documentation element of monitoring. The administrator of record was directed to submit additional written evidence. On 5/3/23 at 12:06 p.m., the administrator of record submitted additional written evidence that read in pertinent part; "Plan to address immediate concern: Dedicated Fire Watch individual or designee will be responsible for 24 hours of monitoring. Fire Watch will include monitoring for signs of fire, strobe lights and smell of smoke, listening for alarms. This will occur in rooms, common areas, hallways every 30 (minutes). In addition, Front Desk Concierge to be on alert 11 hours the fire panel and call 911 immediately if alarm triggers (observing for visual strobe lights and audio siren) (QMAP) on (evening and overnight) shift to be on alert 13 hours and call 911 immediately if alarm triggers. This provides 24 hours Fire Watch and observation to ensure immediate monitoring. This will be documented via signature sheet of Fire Watch individual and designees. This sheet to be reviewed by ED or designee to ensure fire watch is occurring. Staff will be trained on Fire Watch. Training will come from ED and MD (maintenance director) or designee. Fire Watch will occur in common areas, hallways every 30 (minutes). Plan to address concern of communication between system and monitoring company: Immediate testing on 5/3/23 will be conducted. Community will work with local fire department, pull alarm, see if they call (monitoring company). Coordinate with county dispatch to ensure monitoring company is alerted and no delays in response are occurring. Plan to address concern in the on term solution: Working with (monitoring and repair companies) as the monitoring and inspection companies to determine what needs to be reprogrammed on the panel. We will seek to have (sic). We will obtain daily updates from (monitoring and repair companies) and reach out if no response. Documented via written communication in email format. A final report will be obtained at close."On 5/3/23 at 3:41 p.m., the administrator of record sent email communication that read in part; "As part of our response to the Immediate Jeopardy citation, we performed a test of our fire system and found that the initial concern that the fire panel issue that the fire suppression system would not properly alert the monitoring company not to be true. When tested, we found an immediate response from the monitoring company that shows the system has been, currently is, and will continue to be operational. We are confident that with this being established, there is no immediate threat to resident safety, no delay in notification, and no risk of putting our residents at burn injury risk. We believe that this does not pose an immediate risk of serious injury, harm, impairment or death to the resident. While we followed all requests in order to put fire watch in place to mitigate the possibility of harm while the fire system was in question, we feel that this is no longer necessary as we have proven the system works ... We do acknowledge in full that the issues with system does need to be fixed, we are being notified by the monitoring company for each of these coding/notification issues. The main panel is functioning as it should however, it is the remote enunciators in the lobby that are having faults that are causing the false codes. We have as described in the initial (immediate jeopardy) response plans in place to repair this." Additionally, the email included forwarded email communication from the fire panel repair company, dated 5/3/23 at 3:30 p.m., that read in part; "I am writing to update you on the status of the fire alarm system at (the residence). After conducting a thorough review, we have determined that the fire alarm monitoring is functioning correctly. However, we found issues with the fire alarm networked system which is causing the notification to not work as intended. The issue appears to be related to network problems, which might be caused by the amplifier card that is going in and out of trouble."

Based on observation, record review and interview, the residence failed to notify the department of a change in administrator, at least 30 days calendar days in advance, affecting 77 current residents. (Cross reference Q540)Findings include: 1. Record review On 5/2/23, review of the department's database revealed the administrator of record was list as the residence's administrator as of 3/1/23. The department's database revealed the interim administrator had not been listed as the residence's administrator of record from 3/1/23 until 4/30/23. On 5/3/23 at 1:34 p.m., email communication from a representative of the department read in part: The department was notified the residence administrator was changed to the administrator of record on 3/2/23. The email read prior to that notification the last notification to the department was made on 6/3/22 to notify the department the former administrator had been the residence's administrator since 1/30/22. The email confirmed the department had not been notified that the interim administrator had been the residence's administrator between 3/1/23 and 4/30/23. 2. ObservationsOn 5/2/23 at approximately 7:00 a.m., upon entrance to the residence Staff #26 was asked to notify the administrator the surveyors entered the residence. Staff #26 notified the interim administratorOn 5/2/23 at approximately 7:00 a.m., the administrator of record was identified in the visitor sign in kiosk as the business office manager (BOM). On 5/2/23 at 7:06 a.m., a posting on the wall read the on duty director was the interim administrator. 3. InterviewsOn 5/2/23 at approximately 7:00 a.m., Staff #26 stated the interim administrator was living at the residence and that she would alert her that the surveyors arrived. Staff #26 stated the interim administrator was a traveling administrator and was at the residence because the residence currently did not have an administrator. On 5/2/23 at 7:14 a.m., the interim administrator stated she had been the residence's administrator since 2/28/23 when the former administrator resigned. She stated the administrator of record had been promoted to administrator one day prior to the onsite visit. The interim administrator stated prior to the administrator of record's promotion she had been the responsible for the oversight of the building. On 5/2/23 at 7:23 a.m., Staff #22 stated the interim administrator was the residence's current administrator and that the administrator of record was the current BOM. She stated the administrator of record would assume the role of administrator after a new BOM was hired and trained. On 5/2/23 at 8:02 a.m., the memory care director stated the interim administrator was the residence's current administrator. She stated the administrator of record was the BOM and was in training to become the administrator. On 5/2/23 at 10:09 a.m., the administrator of record stated in early March 2023 the residence had changed the administrator of record to his name with the department since the former administrator had resigned. He stated the interim administrator had been responsible for oversight and had been training him to be the administrator. On 5/2/23 at 1:56 p.m., Staff #27 stated the interim administrator was the residence's current administrator. She stated she believed the administrator of record had recently been promoted and was currently the BOM. On 5/2/23 at 2:11 p.m., the family member of Resident #24 stated the interim administrator was the current administrator until the residence was able to hire a permanent administrator. On 5/2/23 at 2:36 p.m., the family member for Resident #16 stated he believed the residence administrator was the interim administrator. He stated the administrator of record was the BOM and responsible for finances. On 5/2/23 at 4:33 p.m., the administrator of record stated that the residence staff had been notified of his promotion to administrator on 5/1/23, once his promotion was official. On 5/3/23 at 9:04 a.m., the family member for Resident #9 stated the interim administrator was the residence's administrator. On 5/3/23 at 12:32 p.m., the family member for Former Resident #28 stated the interim administrator was the residence administrator after the former administrator left the residence. She stated the administrator of record had been promoted from BOM to the assistance executive director. On 5/3/23 at 2:08 p.m., the administrator of record stated the interim administrator had been the residence administrator until he was able to take over as the administrator. He stated he did not believe the department had been notified of the interim administrator. The administrator of record stated in March 2023 it had been discussed the possibility that he would become the residence's administrator; however, he was unsure if he wanted to be the administrator long term.

Based on observation, record review and interview, the residence failed to ensure the administrator complied with all applicable state laws to help prevent the possible development and transmission of coronavirus (COVID-19), additionally, the residence failed to ensure the administrator managed the day to day operations, affecting 77 current residents. Findings include: 1. ReferenceThe Residential Care Facility (RCF) Comprehensive Mitigation Guidance, updated 2/22/23, required residences to:- Each facility must establish and maintain a COVID-19 mitigation, vaccine, and treatment plan that promotes vaccine confidence and acceptance.- At a minimum, this plan must include: The name and location of the COVID-19 vaccine and treatment provider(s) that will be used by the residence to get vaccines and treatments. - Ensure information in EMResource was updated during the bi-monthly reporting period following the assignment of duties. 2. Record review On 5/2/23 at 9:36 a.m., the interim administrator provided the residence's ongoing vaccination plan, updated on 4/15/23. The vaccination plan did not include the location of the COVID-19 vaccine and treatment providers the residence used. On 5/2/23 at 10:25 a.m., a representative of the department provided the residence's most recent EMResource. The following sections had not been updated since 2/22/23: Current Staff Current Residents Review of the residence's current staff list read the residence had 78 current staff compared to the 74 reported on EMResource. Review of the residence's current resident roster had 77 current residents compared to the 74 reported on EMResource. 3. InterviewOn 5/3/23 at the administrator of record stated he had worked with the interim administrator and the vice president of wellness to on the ongoing vaccination plan and to ensure EMResource was updated. The administrator of record stated the vaccination plan should have included the location information for the vaccination provider. He stated EMResource was being updated. However, he had not taken point or been involved with updating EMResource. The administrator of record acknowledged both the ongoing vaccination plan and EMResource needed to be updated. 4. Day to Day Operations (Cross reference B 260)During the onsite investigation on 5/2-5/3/23, it was established the administrator of record did not manage the day to day operations of the residence. During the onsite investigation the interim administrator provided documents requested by the surveyors and acknowledged she had been responsible for the day to day operations. Review of resident assessments revealed the following: On 4/21/23 the interim administrator signed the most recent assessment for Resident #25, dated 4/17/23, as the administrator (executive director). On 5/1/23 the interim administrator signed the most recent assessment for Resident #22, dated 3/30/23, as the administrator (executive director). Additionally, EMResource listed the interim administrator as the residence's contact person. On 5/2/23 at approximately 7:00 a.m., Staff #26 stated the interim administrator was the residence's current administrator. On 5/2/23 at 7:14 a.m., the interim administrator stated the administrator of record had been promoted one day prior to the onsite visit. She stated she had been the administrator from 2/28/23 until 5/1/23 and had currently been managing the day to day operations of the residence. On 5/2/23 at 7:23 a.m., Staff #22 stated the interim administrator was the residence's current administrator. She stated the interim administrator was responsible for the day to day operations of the residence. On 5/2/23 at 8:02 a.m., the memory care coordinator stated the interim administrator was the residence's current administrator. She stated the administrator of record was the residence's business office manager (BOM) and was training to be the next administrator. She stated the interim administrator was responsible for managing everything with theresidence, including oversight of resident care and services. On 5/2/23 at 10:09 a.m., the administrator of record stated that he had been changed to the administrator of record in March 2023. He added the change was to only put a name for the administrator. The administrator of record stated the interim administrator oversaw the day to day operations of the residence and had been training him to be the administrator. The administrator of record stated "I have not be doing the day to day." On 5/2/23 at 1:56 p.m., Staff #27 stated the interim administrator was the residence's current administrator. She stated she believed the administrator of record had recently been promoted and was currently the BOM. On 5/2/23 at 2:11 p.m., the family member of Resident #24 stated the interim administrator was the current administrator until the residence was able to hire a permanent administrator. On 5/2/23 at 2:36 p.m., the family member for Resident #16 stated he believed the residence administrator was the interim administrator. He stated the administrator of record was the BOM and responsible for finances. He confirmed he contacted the interim administrator with concerns. On 5/2/23 at approximately 4:33 p.m., the administrator of record stated, contrary to his previous statement, that he had been responsible for managing the day to day operations of the residence. He stated the staff had been notified of his promotion one day prior to the onsite visit. However, the official handoff between the administrator of record and the interim administrator had not occurred. The administrator of record confirmed the interim administrator had signed off on the resident care plans. On 5/3/23 at 9:04 a.m., the family member for Resident #9 stated the interim administrator was the residence's administrator. On 5/3/23 at 12:32 p.m., the family member for Former Resident #28 stated the interim administrator was the residence administrator after the former administrator left the residence. She stated the administrator of record had been promoted from BOM to the assistance executive director. On 5/3/23 at 2:08 p.m., the administrator of record stated the interim administrator had been the residence administrator until he was able to take over as the administrator. The administrator of record stated, contrary to his previous statements, that the responsibility of managing the day to day operations was shared between himself and the interim administrator.

Based on record review and interview the residence failed to ensure staff was sufficient in number to assist residents affecting 77 current residents. Findings include:The residence's resident agreement, dated 1/2020, read in part: In addition to management and non-care staff members the residence utilized a computer software program to determine resident acuity which allowed the residence to determine appropriate staffing levels necessary to meet the needs of the resident population. The residence's undated staffing policy read in part: Staffing levels shall be determined according to the census at the residence and the range of acuity levels of the residents. The residence realizes that the acuity levels of the resident population may change and agreed that the staffing levels would change to meet the needs as required. "Sufficient staff will be employed on all shifts to ensure the provision of services necessary to meet the needs of all residents, including all services to be provided as listed on all Resident (care plans) and all services to be provided as detailed in each Resident Agreement." On 5/2/23 at 1:56 p.m., Staff #27 stated the residence was not sufficiently staffed. She stated staff felt rushed to complete tasks and not be able to complete all of resident care. She stated staffing in the secure environment was better then the staffing ratio in the assisted living portion of the residence. She stated showers did get missed as a result of insufficient staffing. Staff #27 stated if day shift did not get around to the resident task during the day, then it would get pushed off onto the night shift to complete. Staff #27 stated that when there is a build up of showers as a result of not having enough staff to complete resident care tasks then staff were unable to catch up on the lack of resident care. She stated in the evening staff were to empty trash and make beds; however, when there was a build up of tasks from the previous shift resident tasks such as trash and bedding did not always get completed. On 5/2/23 at 3:20 p.m., Residents #26 and #27 stated there were not enough staff at the residence. They stated that due to insufficient staffing, activities for the residents suffered. Both residents stated that other residents do not seem to be affected because they had family that visited often. Both residents expressed desire for more staff and resident involvement. On 5/2/23 at 3:30 p.m., the family member for Resident #22 stated that the residence did experience a shortage in staffing. He stated that there was not enough caregivers at the residence and that recently Resident #24 soiled himself and the family needs assistance to change him. He stated that they had pushed the button on the wall; however, no one came to assist the resident. The family member further stated that after some time had passed they pushed the resident's call pendent and staff showed up five minutes later. On 5/2/23 at 3:33 p.m., Resident #14 stated she required assistance with eating and was for the most part, independent with activities of daily living. Resident #14 further stated the residence did not have enough staff to meet residents' needs. She stated areas of the residence that suffered as a result of insufficient staffing were housekeeping and activities. Resident #14 further stated since she required assistance with eating she would have to wait for staff to assist her in the dining room. The resident further stated that dining room staff were not allowed to assist her with eating and she would have to wait for a caregiver to assist her. Resident #14 stated sometimes she had to wait a long time to get assistance with eating. The resident stated there were times that she had to go to the front desk and have staff paged in order to get help. Resident #14 further stated that she would intentionally go down to meal service half way through, when staff were not as busy in hopes of getting assistance with eating. Resident #14 added "itis the worst, waiting for someone to come feed me. I am paying for that service and I just need fed." On 5/3/23 at 12:32 p.m., the power of attorney (POA) for Former Resident #28, stated the residence did not have enough staff to meet residents' needs. She stated that the secure environment at times lacked enough caregivers to meet the needs of the residents. She stated when Former Resident #28 had increased behavioral expressions staff were not sufficient in number to assist the former resident when she was experiencing aggression and meet the needs of the other residents. The POA stated when Former Resident #28 would have aggression, the residence would telephone her to come to the residence and calm down the former resident. She stated that as a family member who paid for the residence to provide services, she should have not been asked to calm down Former Resident #28 and there should have been enough staff to assist. On 5/3/23 at 2:08 p.m., the administrator of record (AOR) stated that the residence had experienced instances of insufficient staffing. However, he stated that he would not see the staffing problem at the residence different from any other building. The AOR further stated that hiring and retention was difficult. He confirmed that he had been made aware that Resident #28 had experienced times that staff were not able to always assist her with eating timely.

Based on record review and interview the residence failed to have a readily available roster that included emergency contact information and a residence diagram that showed room location, affecting 77 current residents. Findings include: On 5/2/23 at 8:45 a.m., the interim administrator provided two different copies of the residence's resident roster. Review of the resident rosters revealed: The first copy of the resident roster was a single page that contained resident names and room numbers. The first copy of the resident roster did not include emergency contact information or a residence diagram that showed room location. The second copy of the resident roster was 12 pages and contained resident names, room numbers, date of birth, resident status, product type (secure environment or nonsecure environment), advance directive information and compliance percentage. The second copy of the residence roster did not include emergency contact information or a residence diagram that showed room location. On 5/3/23 at approximately 2:08 p.m., the administrator of record stated the resident roster should have included resident room number, resident emergency contact information, and the residence's floor plans. He stated the provided rosters should have included the correct information. The administrator of record stated the two provided rosters were not what the residence used as a roster typically. On 5/3/23 at 3:56 p.m., the administrator of record provided a third copy of the resident roster. The third copy of the resident roster was 39 pages and contained resident names, contact information along with contact type, phone numbers, addresses, email addresses and preferred contact preference. Additionally, a seven page floor plan of the residence was provided. The third copy of the resident roster did not contain resident room numbers. The contact information provided was practitioner contact information for some residents and emergency contact information for other residents. On 5/3/23 at 3:57 p.m., the surveyor asked if the residence had condensed roster that was a list that included resident names, room numbers and emergency contact information. On 5/3/23 at 5:29 p.m., after the completion of the survey, the vice president of wellness submitted an fourth copy of the resident roster via email. the fourth copy of the resident roster was 20 pages long and contained resident photographs, resident names, room numbers, emergency contact information, physician contact information, resident status, pharmacy information and a notes section. The fourth copy of the resident roster was 20 pages and was not readily available.

Based on observation, interview and record review the residence failed to either directly or indirectly through a resident agreement provide protective oversight, personal services and a safe and sanitary environment affecting one sample resident (#24). Specifically, Resident #24 was admitted to the residence on 5/2/22 with diagnoses that consisted of osteoporosis without current pathological fracture, Alzheimer's disease and anxiety disorder unspecified. An assessment for Resident #24, dated 2/21/23, read the resident required a sit-to-stand lift for all transfers and required two staff to operate the lift. However, on 4/16/23 Staff #28 attempted to transfer Resident #24, by herself and used the sit-to-stand lift. Resident #24 subsequently slipped out of the sling and according to the incident report it took four staff to lift the resident off the floor. On 5/2/23 at approximately 7:30 a.m., Staff #24 transferred the resident by herself and used the mechanical lift. A second observation at approximately 4:12 p.m., Staff #18 attempted to transfer her from her recliner to a standing position. The staff member did not use the mechanical lift and attempted to transfer Resident #24 independently. The staff member was unsuccessful and left the resident in her recliner to get a second staff member to assist. The two staff members came back into the room and transferred Resident #24 from the recliner to a standing position to get her to walk to her wheelchair. The resident was not in a standing position and continued to try to sit as the two staff members guided her to the wheelchair approximately 10 steps away. The external service provider stated that Resident #24 was not able to participate in transfers in any capacity. She stated that the mechanical lift that Resident #24 required for transfers required two staff at all times to ensure the safety of the resident. The external service provider added that the resident was not able to safely be transferred without the use of the lift. She stated that one staff person using the two person mechanical lift put Resident #24 at risk for serious injury and or harm. This failure created an immediate jeopardy risk of protective oversight to Resident #24. On 5/2/23, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. Residence Policy and References:a. The residence's resident agreement, dated 1/2020, read in part: The resident would receive supervision and assistance as defined in the care plan for the resident. The residence provided assistance with activities of daily living (ADLs) on a 24 hour basis, which included assistance with mobility, toileting, bladder management and personal hygiene. b. The residence's pet agreement, dated 1/2020, read in part: The resident would diligently maintain cleanliness of litter boxes as well as pet sleeping and feeding areas. c. Chapter VII regulations governing assisted living residences, defines protective oversight as guidance of a resident as required by the needs of the resident or as reasonably requested by the resident, including the following (B) Monitoring the activities of the resident while on the premises to ensure the resident's health, safety and well-being, including monitoring the resident's needs and ensuring that the resident receives the services and care necessary to protect the resident's health, safety, and well-being.d. Chapter VII regulations governing assisted living residences, defines personal services as those services that an assisted living residence and its staff provide for each resident including, but not limited to: A) An environment that is sanitary and safe from physical harm, (D) Assistance with activities of daily living. 2. Protective Oversight/Safe EnvironmentResident #24 was admitted to the residence on 5/2/22 with diagnoses that consisted of osteoporosis without current pathological fracture, Alzheimer's disease and anxiety disorder unspecified.a. On 5/2/23 during morning medication pass the following was revealed:At approximately 7:30 a.m., Staff #25 went to administer medications to Resident #24. Staff #25 knocked on the resident's door and attempted to gain entry. However, she could not enter Resident #24's room due to something that blocked entry to the room. Staff #25 subsequently stated that Resident #24 did not like to get out of bed. She stated Resident #24 required one staff member to complete ADLs and two staff members to transfer the resident out of bed. At approximately 7:25 a.m., Resident #24 could be heard through the closed door in a loud voice stating "ow (explicative) oh my god" and repeatedly in a loud voice saying ow. Staff #25 waited in the hallway until the door could be opened. At approximately 7:50 a.m., upon entry to the room, Resident #24 was seated in her wheelchair, Staff #24 was assisting the resident with ADLs. At approximately 7:50 a.m., Staff #24 stated she was transferring Resident #24 and stated the resident's lift was blocking the door which prevented entry into the room. At approximately 1:30 p.m., Staff #24 stated Resident #24 required the sit-to-stand for transfers. She stated earlier in the morning Resident #24 was too weak and could not assist with the transfer in the mechanical lift. Staff #24 added that the mechanical lift was not always used as sometimes staff could transfer without the assistance of the lift. The staff stated that normally she could use the mechanical lift on her own. However, she stated if Resident #24 was not following directions or having a bad day; it required two staff to operate the mechanical lift. She stated since being employed at the residence she had not received any transfer training and specifically had not received any training regarding the sit-to-stand lift utilized with Resident #24. Staff #24 further stated she had not been made aware of any falls that the resident sustained and none that involved the mechanical lift. At 2:08 p.m., Staff #28 stated on 4/16/23 she attempted to transfer Resident #24 with her mechanical lift, when the resident slipped off the lift. She stated that she was not aware prior to working with Resident #24 that the lift required two staff members to operate it safely. At 2:11 p.m., the power of attorney (POA) for Resident #24 stated that staff was having a difficult time managing Resident #24's transfer needs. She stated once external hospice was brought in a few months prior to the onsite investigation, the residence was able to manage the resident with transfer needs. The POA further stated that there was not always enough staff able to assist with Resident #24's transfer needs. She stated Resident #24 did not respond to caregiver commands and did not understand what staff wanted her to do when transferring. The POA stated that after the fall on 4/16/23, she was told staff were retrained that the lift required two staff at all times. At 3:17 p.m., the external hospice (EHRN) nurse for Resident #24 stated that the resident required the sit-to-stand mechanical lift for all transfers. She stated Resident #24 was unable to assist with transfers in any way due to her inability to follow instructions. The EHRN stated she was made aware Resident #24 slid out of the mechanical lift; however, she was not made aware by the residence that the reason the fall occurred was because one staff was operating the lift. She stated the mechanical lift required two staff at all times to use. She stated by staff not using two staff for the lift the resident was at risk for potential serious injury or harm, and reaffirmed two staff were required for safety reasons. b. The record for Resident #24 revealed the following:An assessment for Resident #24 dated, 2/21/23, read in part: Resident #24 required extensive grooming assistance, dressing with two caregivers, toileting with two caregivers, was on external hospice twice weekly. Resident #24 was at high risk for falls and used a sit-to-stand mechanical lift with two caregivers at all times. The care plan for Resident #24, dated 3/10/23, read the resident required sit-to-stand for transfers which required two staff to operate. An incident report for Resident #24, dated 4/16/23, read in part: A caregiver was using the sit to stand lift to transfer Resident #24 from her wheelchair to a couch when the resident slipped under the sling; it took four caregivers to pick her up off the floor. An external hospice order, dated 4/19/23, read in part: Resident #24 required a sit-to-stand lift which required two staff members to operate. The order further read the resident had a fall on 4/16/23 with no injuries noted and the resident required total care for ADL completion. Additionally, the order read that the sit to stand lift was required for all transfers due to the inability to transfer and bear weight, as the resident was unable to sit up without assistance, had poor truncal support and was not oriented to self or situation. c. On 5/2/23 at during afternoon care the following was revealed:At approximately 4:12 p.m., Staff #18 attempted to transfer Resident #24 from her recliner to a standing position. The staff member did not use the mechanical lift and attempted to transfer Resident #24 independently. The staff member was unsuccessful and left the resident in her recliner to get a second staff member to assist. The two staff members (#18, #19) came back into the room and transferred Resident #24 from the recliner to a standing position to get her to walk to her wheelchair. The resident was not in a standing position and continued to try to sit as the two staff members guided her to the wheelchair approximately 10 steps away. At 4:33 p.m., the administrator of record (AOR) stated Resident #24 was "a little bit higher of care that we provide on the terms of transfers and ADLs." He stated Resident #24 required a mechanical total body lift for transfers (not the sit-to-stand lift) and stated the residence had completed staff training on how to use the mechanical lift with external hospice. The AOR further stated the residence promoted for staff to transfer residents without the use of the lift, when they were able to safely transfer the resident. d. Immediate Jeopardy Risk- Written Evidence, Immediate Correction The investigation established that the findings above placed Resident #24 at immediate jeopardy risk for protective oversight. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.16 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 5/2/23 at 5:05 p.m., the AOR submitted written evidence that read in pertinent part: "1. All staff will be re-trained on the use of the (total body lift) with (two) people specifically for the resident in question. 2. All staff currently on shift will be trained 5/2/2023 by the director of rehab(ilitation). 3. All staff will sign off training immediately. 4. (Residence) staff will train shift to shift to ensure everyone on memory care staff are trained. With respect to how the facility will prevent this problem in the future: 1. All staff will have training upon hire and before working with the resident. 2. (AOR/BOM) or designee will track training weekly for new hires and monthly at QAPI (quality assurance program improvement) meetings. 3. Daily transfer audits by supervisors will be done weekly for 12 weeks and then monthly thereafter as deemed necessary by the QAPI committee."However, the written evidence did not indicate the risk had been removed because the written evidence needed to address the proper equipment, as Resident #24's lift was not a total body lift. Additionally, the written evidence needed to include training globally to prevent this from occurring with any other resident in the future, it needed to include how training would be documented and maintained along with how the audits would be documented and maintained. Further the written evidence needed to address staff that were not using the equipment at all and what oversight the AOR/BOM would have of the written evidence and immediate correction. On 5/2/23 at 5:36 p.m., the AOR/BOM submitted written evidence that read in pertinent part: "1. All staff will be retrained on the use of the Sit-to-Stand lift, ensuring that two staff member are present at all times. This training will also include the mandatory use of a mechanical device in the instances where the device has been care planned ... 3. (Residence) staff will be educated shift to shift to ensure everyone working in resident care receives training before providing care. 4. Training will be tracked with a signature page. (AOR) or designee will audit five days per week until all care team members have received education to ensure all staff working received proper training prior to their shift. Signed in-service sheets will be kept in the (AOR) office ... 1. All care staff will have training upon hire and before working with residents. An in-depth mechanical device training will take place at the community's next All Hands meeting. 2. (AOR) or designee will audit training weekly for new hires and review the audits monthly at QAPI meetings ... These audits will be completed weekly for 12 weeks, and then monthly thereafter as deemed necessary by QAPI committee."However, the written evidence did not indicate the risk had been removed because the written evidence needed to identify who would conduct the shift to shift training, the written evidence failed to address the failure of staff transferring the resident without using the required equipment and the failure of staff to follow the care plan for Resident #24. On 5/2/23 at 5:56 p.m., the AOR/BOM submitted written evidence that read in pertinent part:"1. All staff will be re-trained on the use of the Sit-To-Stand lift, ensuring that two staff members are present at all times. This training will also include the mandatory use of a mechanical device in instances where the device has been care planned ... With respect to staff transferring without lift: 1. Staff will be reeducated and progressive discipline will be implemented. 2. All staff will additionally be retrained on following care plans in (software system). We will conduct a comprehensive in-service to be conducted by (Regional Vice President of Wellness) or designee and documented by sign in sheet. No later than 5/25/2023."e. Personal Services/Sanitary EnvironmentOn 5/2/23 at approximately 7:30 a.m., the hallway outside of the room for Resident #24 had a strong odor of urine. On 5/2/23 at approximately 7:50 a.m., upon entry to the room for Resident #24 there was a bed adjacent to the door. The bed was unmade with a protective pad which was saturated in urine. The room had a strong odor of urine. On 5/2/23 at 1130 a.m., the hallway outside of Resident #24's room smelled of urine. On 5/2/23 at approximately 7:50 a.m., Staff #24 stated sometimes Resident #24's cat urinated outside of the litter box and onto the carpet. On 5/2/23 at 2:11 p.m., the POA for Resident #24 stated that staff had a difficult time managing Resident #24's incontinence. She stated once external hospice was brought in a few months prior to the onsite investigation the residence was able to manage the resident's incontinence better. However, she stated it was an ongoing concern and stated a few months prior to the on-site investigation she would find Resident #24's sheets soiled and feces on the floor. The POA further stated she noticed an odor of urine when she had visited the resident a few days prior to the onsite investigation. She stated that sometimes the odor would come from the resident's soiled sheets that the residence failed to launder. The POA stated that earlier in the day she had received a telephone call from a staff member at the residence who stated that Resident #24's cat was the cause of the urine smell in the room. However, the POA stated the resident had a private caregiver that came to the residence a couple times a week and cleaned the litter box. On 5/2/23 at 4:30 p.m., the vice president of wellness stated that the urine odor was from Resident #24's cat and the residence was working with the POA for solutions. An assessment for Resident #24 dated, 2/21/23, read in part: Resident #24 required extensive grooming assistance, toileting with two caregivers and was incontinent of bowel and bladder. The care plan for Resident #24, dated 3/10/23, read the resident required extensive toileting assistance with two caregivers to assist with the resident daily. The care plan did not address any level of assistance regarding Resident #24's cat. A progress note, dated 2/26/23, read staff spoke with POA to strategize on methods to address cat urine odor. POA stated the cat has been to the veterinarian within the past few months. The residence would discuss the urine odor with the veterinarian.

Based on observation, interview and record review the residence failed to complete a comprehensive assessment whenever the resident had a change of condition from baseline status affecting four of seven sample residents (#9, #17, #22, #25) and two former residents (#28, #31). (Cross-reference Q1150, Q1180)Findings include:1. Reference and Residence PolicyThe residence's resident agreement, dated 1/2020, read in part: Upon admission the residence performed a comprehensive preadmission assessment of the resident's individual needs. The needs identified through the assessment were included in the individual care plan for the resident. Chapter VII regulations governing assisted living residences, requires in part 12.9 that the comprehensive assessment shall include all the following items: (A) Information from the comprehensive pre-admission assessment described in Part 11.1; (B) Information regarding the resident's overall health and physical functioning ability; (D) Communication ability and any specific needs to facilitate effective communication; (E) Current diagnoses and any known or anticipated need or impact related to the diagnoses; (F) Food and dining preferences, unique needs and restrictions; (G) Individual bathroom routines, sleep and awake patterns; (H) Reactions to the environment and others, including changes that may occur at certain times or in certain circumstances; (I) Routines and interests; (J) History and circumstances of recent falls and any known approaches to prevent future falls; (K) Safety awareness; (L) Types of physical, mental, and social support required; and (M) Personal background, including information regarding any other individuals who are supportive of the resident, cultural preferences, and spiritual needs. 2. Resident #9 was admitted to the residence on 7/8/19 with a diagnosis including dementia. An assessment for Resident #9 dated 2/26/23 read in part: Community team members administer medications to the resident. The resident required moderate bathing assistance, check three times throughout the night, wellness checks each shift throughout the day, assistance with grooming, assistance with hearing aids, moderate assistance with toileting, urinary incontinence, bowel incontinence, unable to use call pendent, no external service providers needed. The assessment further read Resident #9 was diagnosed with anxiety, dementia, was restive to care, hallucinated, did not wander or exit seek, behavior expressions needing occasional intervention. An incident report, dated 4/17/23, read Resident #9 was observed to have been acting differently in the living room. The resident reported pain in her right arm, all over her body and was lethargic. Resident had low oxygen saturation and was subsequently sent to the emergency department (ED) for evaluation. An ED discharge summary, dated 4/17/23, read in part: Resident #9 was seen in the ED for altered mental status and diagnosed with a urinary tract infection (UTI). On 5/3/23 at 9:04 a.m., the responsible party for Resident #9 stated the resident went to the ED on 4/16/23 and was diagnosed with a UTI. He stated that this was the second time Resident #9 had a UTI in the last four months and further stated she had not had a history of UTIs. On 5/3/23 at 11:17 a.m. Wellness Nurse #1 (WN #1) stated that she was responsible for overseeing comprehensive assessments for all residents. She stated that UTIs were often caused by dehydration and poor hygiene. The WN #1 stated that Resident #9 needed reminders to drink, was resistant to care, was on a toileting schedule but was not sure how well the resident was with peri care. The WN#1 stated on 4/17/23, Resident #9 was in the common areas and collapsed. She said the resident did not have a fever, was already confused, her hands were cold and her oxygen was low. The WN #1 stated she had seen the symptoms before and was pretty sure Resident #9 had a UTI. She stated that anytime a resident was sent to the ED it would be considered a change of condition from baseline and Resident #9 should have had a comprehensive assessment completed to prevent further UTIs from reoccurring. On 5/3/23 at 1:46 p.m. the memory care coordinator (MCC) stated that comprehensive assessments were completed by the wellness nurses. She stated she was not present for the incident on 4/17/23; however, she stated she was aware of the incident. The MCC confirmed the UTI for Resident #9 was a change of condition and a comprehensive assessment should have been completed. On 5/3/23 at 2:08 p.m., the administrator of record (AOR) stated that assessments were completed by the wellness nurses and clinical support staff and confirmed Resident #9 should have had an assessment completed after her diagnosis of a UTI. 3. Former Resident #28 was admitted to the residence on 2/25/22, with a diagnosis including Alzheimer's disease. Progress notes for Former Resident #28, dated 3/1-3/31/23, read the following; On 3/1/23, Former Resident #28 was involved in a resident to resident altercation. She became frustrated with Former Resident #29 who had tried to help her with a cup of coffee but was too slow. Former Resident #28 threw her cup of coffee on the resident and then scratched the resident on the hand. Former Resident #29 responded by striking out at Former Resident #28 and which caused a scratch on her face. Both residents were immediately separated. Former Resident #28's daughter came immediately to help supervise her while she was agitated. On 3/14/23, Staff were taking vitals outside of Former Resident #28's room. As the staff members were doing so, the former resident came out of her room and was verbally aggressive against the staff members. Former Resident #28 then proceeded to grab onto a caregiver and pinched another caregiver. On 3/16/23, Former Resident #28 had become very angry with a staff member pointing her finger at her and screaming that she would telephone law enforcement. The former resident was accusing the staff of stealing from her. Staff stated they could see the former resident's face get very angry; however, nothing happened to trigger the anger. On 3/18/23, Former Resident #28 had another angry episode this afternoon, screaming and holding her fist up saying she was going to telephone law enforcement on staff. On 3/20/23, Former Resident #28 was really upset and aggressive when staff came back from a work break. The former resident was waiting at the door to the secure environment, grabbed the staff's arm, squeezed it and yelled really loudly. On 3/21/23, last night on 3/20/23, caregivers left the the secure environment because they were so afraid of Former Resident #28. The former resident pushed the sofa against the door to the secure environment to block staff and was yelling. On 3/22/23, Staff was in tears, crying inconsolably because the staff went into the former resident's room and the resident barricaded her in the room grabbing her arms and threatened the resident. The staff member yelled for help and was scared because Former Resident #28 would not let go of her arm. The former resident's private caregiver who was on duty, was not in the area. On 3/23/23, Former Resident #28 was aggressive towards staff, was in their face and threw water at them. A care conference was held, alternative placement was discussed, the former resident would have testing completed to decide the best course of action for effective medication management and Former Resident #28 would have a private caregiver in place to keep others safe. On 3/29/23, Former Resident #28 was aggressive with another resident. She was very agitated and exhibited verbal aggression with staff and residents. On 3/31/23, Former Resident #28 was aggressive today, she took away all the residents plates, when staff asked her give them back and to not take away plates, she became more upset and took the plates away again. An assessment, dated 12/19/22, read in part: Former Resident #28 required three nighttime wellness checks and if awake provide emotional support, reorient the former resident to time, place and situation as appropriate, staff to reassure Former Resident #28 she was safe, remove her from the situation, give her space to calm down safely and if interventions did not work contact a nurse or supervisor. The assessment further read the resident had difficulty with communication, staff to allow time for the former to think and express thoughts. However, the assessment was not updated when the former resident experienced a change in condition and required more physical, mental, and social support. On 5/2/23 at 12:45 p.m., the WN #1 stated she had heard Former Resident #28 was aggressive; however, she had never witnessed any aggression with the resident. She stated the former resident's aggression escalated quickly and the residence issued a 30 day discharge notice. On 5/3/23 at 1:46 p.m. the MCC stated Former Resident #28's increased behavioral expressions were a change in condition and a comprehensive assessment update should have been completed. 4. Resident #25 was admitted to the residence on 12/23/21 with a diagnosis that included unspecified dementia. A local law enforcement report, dated 4/24/23, read Resident #25 had been found in a male resident's room and was touching his genitals. The local law enforcement report identified the incident as an allegation of sexual abuse. An investigation of abuse, dated 4/24/23, read the residence had conducted an investigation of allegations of sexual abuse after a staff member walked into a male resident's room and found Resident #25 touching a male resident in a sexual manner. Progress notes for Resident #25, dated 1/30-4/29/23, read the following;On 1/30, 2/19, 2/20, 2/24 and 4/4/23, Resident #25 expressed suicidal ideations. The assessment for Resident #25, dated 4/17/23, read in part; Resident #25 had behavioral expression needing occasional intervention. The tasks read; "Intervention: Behavior Expression Triggers: Offer drinks or snack. take her for a walk or talk to her about her dogs or animal that she loves that conversations. If interventions are not working, contact nurse/supervisor." However, Resident #25 had not been reassessed after the allegation of sexual abuse on 4/24/23. Additionally, the assessment for Resident #25 did not include an assessment of Resident #25's suicidal ideations. On 5/3/23 at approximately 11:41 a.m., WN #1 stated Resident #25 should have been assessed after she had a change in condition. On 5/3/23 at 2:08 p.m., the AOR stated he was unsure if Resident #25 should have been assessed after the change of condition and exhibiting new behavioral expressions. 5. Resident #22 was admitted to the residence on 3/9/23 with no listed diagnoses. Progress notes for Resident #22, dated 3/9-5/2/23, read the following: On 3/13/23, staff documented Resident #22 had tested positive for coronavirus on 3/12/23. On 3/14/23, Resident #22 was confused and was found looking for his room in another resident's room. On 3/15/23, a change in level of care was noted to include assistance with toileting, dressing and night time checks. It was noted Resident #22 would state that he did not need assistance and that he was not incontinent while in fact he needed more assistance in general. On 3/24/23, it was noted Resident #22 had increased confusion. Staff noted the resident seemed unable to comprehend what was happening, unable to follow cuing and unable to eat his meals without assistance. On 4/1/23, Resident #22 wandered downstairs to the front desk and didn't know where he was or what he was doing. Staff assisted him get back to his room and into bed. On 4/3/23, staff noted Resident #22 had been wondering into other rooms and did not know how to get back to his room. Staff noted Resident #22 had gotten undressed in another resident's room. On 4/5/23, Resident #22 was noted to have been confused. On 4/8/23, the family member of Resident #22 expressed concern about the resident's increased delusions. On 4/27/23, Resident #22 wandered out of the dining room and was found by the physical therapist in the fitness center. He was escorted back to dining room but said he was unaware of where he was going. The assessment for Resident #22, dated 3/30/23, read in part; Resident #22 required minimal dining assistance and could eat independently. Resident #22 did not wander. However, Resident #22 was not assessed after a change in condition which included wandering behaviors and the inability to eat independently. On 5/2/23 at 3:30 p.m., the family member for Resident #22 stated Resident #22 had declined from his baseline after he had coronavirus. He stated the residence had discussed completion of an assessment for Resident #22 after he had moved from the nonsecure area to the secure environment. The family member for Resident #22 confirmed that Resident #22 required more care assistance since admission. On 5/3/23 at 11:41 a.m., WN #1 confirmed Resident #22 should have been reassessed after he started to wander. On 5/3/23 at approximately 2:08 p.m., the AOR stated Resident #22 had a cognitive decline after moving into the residence. He stated Resident #22 had increased confusion and had began to wander. The AOR stated Resident #22 required an updated assessment and added the residence had planned on reassessing the resident after he moved to the secure environment. 6. Resident #17 was admitted to the residence on 5/18/18 with diagnosis that included dementia without behavioral disturbance, psychotic disturbance and Alzheimer's disease with late onset. Progress notes for Resident #17, dated 3/4-5/2/23, read the following; On 3/4/23, Resident #17 sustained a skin tear to her right forearm. External hospice services were notified. On 3/13/23, Resident #17 sustained a skin tear to her left shin. An external hospice nurse assessed the resident. On 3/18/23, staff noted the dressing on Resident #17's left lower shin wound was off. The wellness nurse replaced the bandage and an external hospice nurse was notified. On 3/20/23, an external hospice nurse assessed Resident #17 after an unwitnessed fall. On 3/30/23, Resident #17 removed her dressing on her wound and the external hospice agency was notified. On 4/1/23, Resident #17 removed the bandage from her wound, the external hospice nurse was notified. On 4/4/23, Resident #17 removed the bandage from her wound, the external hospice nurse was notified. On 4/5/23, Resident #17 refused to allow the external hospice nurse to change the dressing on her wound. On 4/6/23, the external hospice nurse assesses Resident #17's wound and confirmed the wound was infected. New wound care orders were implemented and both the external hospice nurse and residence nurses needed to provided wound care services for Resident #17. On 4/8/23, Resident #17 was agitated during staff care. Resident #17 became physically aggressive with staff during incontinence care. On 4/10/23, the external hospice nurse identified a new skin tear on Resident #17's right elbow. The external hospice nurse provided wound care. On 4/21/23, the interim administrator met with the external hospice nurse to discuss Resident #17's increased difficulties with care. It was noted the resident had been increasingly combative with staff and resistant to care. The external hospice nurse increased Resident #17's Seroquel to manage behaviors. On 4/26/23, the external hospice nurse was notified that Resident #17 was not eating or leaving her room. Incident reports for Resident #17 read she had sustained falls without injury on 3/3/23 and 3/20/23. Additionally, Resident #17 sustained a fall with injury on 4/29/23. The assessment for Resident #17, dated 3/10/23, read in part; Residents #17 had a history of falls, a weak gait and overestimated or forgot limits. Resident #17 was noted as being at a high risk for falls. Resident #17 had no wounds. However, Resident #17 was not reassessed after documented changes in condition to include additional falls related to medication effects and development of wounds being treated by external hospice nurses. On 5/3/23 at 1:46 p.m., the MCC stated assessments were completed by the residence nurses. On 5/3/23 at approximately 2:08 p.m., the AOR acknowledged Resident #17 should have been assessed after she had a change in condition. 7. Former Resident #31 was admitted to the residence 5/10/22 with diagnosis including dementia without behavioral disturbance. Progress notes for Former Resident #31, dated 11/4/22-1/12/23, read the following; On 11/4/22, Former Resident #31 was sexually inappropriate with a staff member. On 12/10/22, Former Resident #31 was found in another resident's apartment without pants on. Former Resident #31 became verbally aggressive with staff when they attempted to intervene and threaten to become physically aggressive. Former Resident #31 left the resident's apartment and went to the dining room. Former Resident #31 refused staff attempts to redirect him to his room to put his pants on. Staff had to dress the resident in the dining room as other residents were uncomfortable. On 12/13/22, Former Resident #31 was found in a female resident's room and had to be escorted out of the room. On 12/15/22, Former Resident #31 was aggressive with staff when wanting to enter another resident's room and staff had to contact local law enforcement. On 12/16/22, staff noted speaking with a female resident to discuss the incident that had occurred one day prior. The female resident reported feeling better and not having been fearful or concerned at that time. On 12/17/22, Former Resident #31 was found wandering in the kitchen area looking for another female resident. The family member of Former Resident #31 requested staff sit with the former resident due to the wandering behavior and irritability with staff. On 12/17/22, Former Resident #31 attempted to enter another female resident's room. A female resident in the hallway reported being fearful due to a previous altercation that had occurred with Former Resident #31. On 12/19/22, the former administrator contacted the family member of Former Resident #31 regarding an incident that had occurred resulting local law enforcement to have been involved. It was requested that the family member provided a private caregiver during waking hours due to increased behaviors. On 12/31/22, the former administrator left a message for the family member of Former Resident #31 requiring that the family member either hire a private caregiver or the family member sit with the former resident due to wandering and behavioral concerns. The former administrator notified the family member another female resident's family reported concerns of safety regarding Former Resident #31 due to the former resident seeking out the female resident. On 1/12/23, Former Resident #31 was found kicking another resident's door and was aggressive with staff when they attempted to redirect him. The assessment for Former Resident #31, dated 12/26/22, read in part; Former Resident #31 was combative and severely agitated. However, Former Resident #31 had not been assessed after a change in condition in regards to wandering and sexual behavioral expressions with female residents. On 5/3/23 at approximately 11:41 a.m., WN #1 stated Former Resident #31 had been sexually inappropriate with female residents. She stated Former Resident #31 had began attempting to force himself into other resident's rooms. WN #1 stated Former Resident #31 should have been assessed after he had a change of condition. On 5/3/23 at approximately 2:08 p.m., the AOR stated he was unsure if Former Resident #31 should have been assessed. The AOR stated he had been less involved with resident care and was unaware if Former Resident #31 had a change of condition from his baseline.

Based on observation, interview and record review the residence failed to ensure each resident care plan detailed specific personal service needs and preferences along with the staff tasks necessary to meet those needs affecting five of seven sample residents (#9, #16, #17, #22, #25) and two former residents (#28, #31). (Cross-reference Q1146)Findings include:1. Residence Agreement The residence's resident agreement, dated 1/2020, read in part: Upon admission the residence performed a comprehensive preadmission assessment of the resident's individual needs. The needs identified through the assessment were included in the individual care plan for the resident. The care plan was updated according to state regulations and as necessary according to the resident's capabilities and changing needs. Additionally, the care plan updates would occur in light of any changing needs and as soon as reasonably necessary after a significant change in physical, cognitive or fundamental condition. 2. Resident #9 was admitted to the residence on 7/8/19 with a diagnosis including dementia. An incident report, dated 4/17/23, read Resident #9 was observed to have been acting differently in the living room. The resident reported pain in her right arm, all over her body and was lethargic. Resident had low oxygen saturation and was subsequently sent to the emergency department (ED) for evaluation. A ED discharge summary, dated 4/17/23, read in part Resident #9 was seen in the ED for altered mental status and diagnosed with a urinary tract infection (UTI). An assessment for Resident #9 dated 2/26/23 read in part: Community team members administer medications to the resident. The resident required moderate bathing assistance, check three times throughout the night, wellness checks each shift throughout the day, assistance with grooming, assistance with hearing aids, moderate assistance with toileting, urinary incontinence, bowel incontinence, unable to use call pendent, no external service providers, has anxiety, dementia, was restive to care, hallucinations, does not wander or exit seek, behavior expressions needing occasional intervention. A care plan for Resident #9, dated 2/23/23, read in part: The resident was resistant to care, required frequent Intervention, had behavioral expressions with noise, required assistance with dressing hearing aids, and mobility and was at risk for falls. However, the care plan failed to include staff tasks necessary to meet the needs when the resident was resistant to care, had behavioral expressions to noise and failed to list any fall interventions. Additionally, the care plan was not updated after the resident experienced a change in condition. On 5/3/23 at 9:04 a.m., the responsible party for Resident #9 stated the resident went to the emergency department on 4/16/23 and was diagnosed with a UTI. He stated that this was the second time Resident #9 had a UTI in the last four months and further stated she had not had a history of UTIs. On 5/3/23 at 11:17 a.m. Wellness Nurse #1 (WN #1) stated that she was responsible for overseeing care plans for all residents. She stated that UTIs were often caused by dehydration and poor hygiene. The WN #1 stated that Resident #9 needed reminders to drink, was resistant to care, was on a toileting schedule but was not sure how well the resident how well she was with peri care. The WN #1 stated on 4/17/23, Resident #9 was in the common areas and collapsed. She said the resident did not have a fever, was already confused, her hands were cold and her oxygen was low. The WN #1 stated she had seen the symptoms before and was pretty sure Resident #9 had a UTI. She stated that anytime a resident was sent to the ED it would be considered a change of condition from baseline and Resident #9 should have had a care plan update completed to prevent further UTIs from reoccurring. On 5/3/23 at 1:46 p.m. the memory care coordinator (MCC) stated that care plans were done by her and the wellness nurses. She stated she completed portions of the care plan such as bathing, dressing etc and the wellness nurses completed the portion for behaviors. The MCC stated Resident #9 required minimal assistance with toileting and dressing. She stated Resident #9 refused care, medications and wearing her hearing aids. The MCC stated Resident #9 often would lose her teeth, her hearing aids and sometimes would throw them away. The MCC stated she was not present for the incident on 4/17/23; however, she stated she was aware of the incident. She confirmed that the UTI for Resident #9 was a change of condition and a care plan update should have been completed. On 5/3/23 at 2:08 p.m., the administrator of record (AOR/BOM) stated that assessments were completed by the wellness nurses and clinical support staff and confirmed Resident #9 should have had the care plan update completed after her diagnosis of a UTI. 3. Former Resident #28 was admitted to the residence on 2/25/22, with a diagnosis including Alzheimer's disease. Progress notes for Former Resident #28, dated 3/1-3/21/23, read the following; On 3/1/23, Former Resident #28 was involved in a resident to resident altercation. She became frustrated with Former Resident #29 who had tried to help her with a cup of coffee but was too slow. Former Resident #28 threw her cup of coffee on the resident and then scratched the resident on the hand. Former Resident #29 responded by striking out at Former Resident #28 and which caused a scratch on her face. Both residents were immediately separated. Former Resident #28's daughter came immediately to help supervise her while she was agitated. On 3/14/23, staff were taking vitals outside of Former Resident #28's room. As the staff members were doing so,the former resident came out of her room and was verbally aggressive against the staff members. Former Resident #28 then proceeded to grab onto a caregiver and pinched another caregiver. On 3/16/23, Former Resident #28 had become very angry with a staff member pointing her finger at her and screaming that she would telephone law enforcement. The former resident was accusing the staff of stealing from her. Staff stated they could see the former resident's face get very angry; however, nothing happened to trigger the anger. On 3/18/23, Former Resident #28 had another angry episode this afternoon, screaming and holding her fist up saying she was going to telephone law enforcement on staff. On 3/20/23, Former Resident #28 was really upset and aggressive when she came back from a work break. The former resident was waiting at the door to the secure environment, grabbed the staff's arm, squeezed it and yelled really loudly. On 3/21/23, last night on 3/20/23, caregivers left the the secure environment because they were so afraid of Former Resident #28. The former resident pushed the sofa against the door to the secure environment to block staff and was yelling. On 3/22/23, staff was in tears, crying inconsolably because the staff went into the former resident's room and the resident barricaded her in the room grabbing her arms and threatened the staff. The staff member yelled for help and was scared because Former Resident #28 would not let go of her arm. The former resident's private caregiver who was on duty, was not in the area. On 3/23/23, Former Resident #28 was aggressive towards staff was in their face and threw water at them. A care conference was held, alternative placement was discussed, the former resident would have testing completed to decide the best course of action for effective medication management and Former Resident #28 would have a private caregiver in place to keep others safe. On 3/29/23, Former Resident #28 was aggressive with another resident. She was very agitated and exhibited verbal aggression at times with staff and residents. On 3/31/23, Former Resident #28 was aggressive today, she took away all the residents plates when we would give them back and ask her not to take away plates, she became more upset and took the plates away again. An assessment, dated 12/19/22, read in part: Former Resident #28 required three nighttime wellness checks and if awake provide emotional support, reorient the former resident to time, place and situation as appropriate, staff to reassure Former Resident #28 that she was safe, remove her from the situation, give her space to calm down safely and if interventions did not work contact a nurse or supervisor. The assessment further read the resident had difficulty with communication, staff to allow time for the former to think and express thoughts. A care plan, dated 3/10/23, read in part: Former Resident #28 had a mild communication impairment, staff to allow extra time for the resident to think and express thoughts, the resident's husband was a trigger, interventions were to give the resident space, reorient resident to time place and situation as appropriate, reassure her she is safe, remove her from the situation, give her space to calm down safely and if interventions were not working for staff to contact the nurse or supervisor when interventions fail to work. However, the care plan was not updated when the former resident experienced an increase in behavioral expressions along with staff tasks necessary to meet the resident's changing needs. On 5/2/23 at 12:45 p.m., the WN #1 stated she had heard Former Resident #28 was aggressive; however, she had never witnessed any aggression with the resident. She stated the former resident's aggression escalated quickly and the residence issued a 30 day discharge notice. The WN #1 further stated that the former resident had a private caregiver for an unknown amount of time. She stated the former resident did not like the private caregivers around her and they had to keep a safe distance. On 5/2/23 at approximately 1:30 p.m., Staff #24 stated Former Resident #28 was aggressive. She stated witnessed the aggression and did not work in the secure environment all of the time. Staff #24 stated if she was not sure of interventions required for the resident she would refer to the resident's care plan for direction. On 5/2/23 at 1:56 p.m., Staff #27 stated Former Resident #28 was aggressive towards staff and residents. Staff #27 stated that she had witnessed aggression towards others. She stated the intervention that she had been aware of was to offer the former resident flowers. She stated at times she was able to redirect the former resident; however, not all occasions was she successful with redirection. She confirmed care plans should always be updated as staff providing the direct care used them to assist the resident's. On 5/3/23 at 12:32 p.m., the power of attorney (POA) for Former Resident #28 stated the resident had an increase in behavioral expressions. She stated the residence required the family to obtain private care givers daily from 12:30 p.m. to 4:00 p.m. The POA stated on 2/16/23 the residence held a care conference for the former resident. At the care conference it was discussed that the residence was going to adjust some medications to see if it helped with Former Resident #28's aggression. The POA added that care conference was the first time she had ever seen the care plan for the former resident. The POA further stated when new staff worked in the secure environment; although she believed they were trained they would trigger Former Resident #28 and the former resident would pull the staff member's hair. The POA further confirmed that the private caregivers that were put in place to help manage the former resident's behavioral expressions and stated they had to keep distance from Former Resident #28 as she did not like them around. On 5/3/23 at 1:46 p.m. the MCC stated Former Resident #28's increased behavioral expressions were a change in condition and a care plan update should have been completed. 4. Resident #25 was admitted to the residence on 12/23/21 with a diagnosis that included unspecified dementia. A local law enforcement report, dated 4/24/23, read Resident #25 had been found in a male resident's room and was touching his genitals. The local law enforcement report identified the incident as an allegation of sexual abuse. An investigation of abuse, dated 4/24/23, read the residence had conducted an investigation of allegations of sexual abuse after a staff member walked into a male resident's room and found Resident #25 touching a male resident in a sexual manner. Progress notes for Resident #25, dated 1/30-4/29/23, read the following;On 1/30/23, 2/19/23, 2/20/23, 2/24/23 and 4/4/23, Resident #25 expressed suicidal ideations. The care plan for Resident #25, dated 4/17/23, read in part; Resident #25 had behavioral expression needing occasional intervention. The tasks read; "Intervention: Behavior Expression Triggers: Offer drinks or snack. take her for a walk or talk to her about her dogs or animal that she loves that conversations. If interventions are not working, contact nurse/supervisor." However, the care plan for Resident #25 did not identify the specific behavioral expressions Resident #25 had. The care plan for Resident #25 did not include Resident #25 had behavioral expressions that included suicidal ideations and inappropriate sexual behaviors. Additionally, four sections of the care plan for Resident #25 included interventions specific to another named resident that did not apply to Resident #25. On 5/3/23 at approximately 11:41 a.m., WN #1 stated the care plan for Resident #25 should have been updated to include the resident's behavioral expressions and should have included staff specific inventions for the behavioral expressions. On 5/3/23 at 1:24 p.m., the MCC stated the care plan for Resident #25 should have been updated to include her specific behaviors. She stated she was unaware that the care plan had not been updated. On 5/3/23 at 2:08 p.m., the AOR stated the care plan for Resident #25 should have been updated to included her specific behavioral expressions. He stated he was unaware that the care plan did not include her behavioral expressions. The AOR confirmed the care plan for Resident #25 should not have named another resident or included another resident's interventions. 5. Resident #22 was admitted to the residence on 3/9/23 with no listed diagnoses. Progress notes for Resident #22, dated 3/9-5/2/23, read the following: On 3/14/23, Resident #22 was confused and was found looking for his room in another resident's room. On 3/15/23, a change in level of care was noted to include assistance with toileting, dressing and night time checks. It was noted Resident #22 would state that he did not need assistance and that he was not incontinent while in fact he needed more assistance in general. On 3/24/23, it was noted Resident #22 had increased confusion. Staff noted the resident seemed unable to comprehend what was happening, unable to follow cuing and unable to eat his meals without assistance. On 4/1/23, Resident #22 wandered downstairs to the front desk and didn't know where he was or what he was doing. Staff assisted him get back to his room and into bed. On 4/3/23, staff noted Resident #22 had been wondering into other rooms and did not know how to get back to his room. Staff noted Resident #22 had gotten undressed in another resident's room. On 4/5/23, Resident #22 was noted to have been confused. On 4/8/23, the family member of Resident #22 expressed concern about the resident's increased delusions. On 4/27/23, Resident #22 wandered out of the dining room and was found by the physical therapist in the fitness center. He was escorted back to dining room but said he was unaware of where he was going. The Care plan for Resident #22, dated 3/27/23, read in part; Resident #22 required wellness checks twice per shift for safety and to address any needs. However, the care plan for Resident #22 did not address Resident #22's increased confusion and wandering or staff tasks necessary to ensure his safety with wandering. Additionally, the care plan for Resident #22 did not include Resident #22's need for assistance with eating and how staff were to have met the need. On 5/2/23 at 3:30 p.m., the family member for Resident #22 stated Resident #22 had declined from his baseline after he had coronavirus. He stated the residence had discussed updating the care plan for Resident #22 after he had moved from the nonsecure area to the secure environment. The family member for Resident #22 confirmed that Resident #22 required more care assistance since admission. On 5/3/23 at 11:41 a.m., WN #1 confirmed Resident #22's wandering behaviors should have been included in his care plan. On 5/3/23 at approximately 2:08 p.m., the AOR stated the care plan for Resident #22 should have been updated after he had a decline and required more assistance. He stated he believed the plan was to update the care plan once he moved into the secure environment. 6. Resident #17 was admitted to the residence on 5/18/18 with diagnosis that included dementia without behavioral disturbance, psychotic disturbance and Alzheimer's disease with late onset. Progress notes for Resident #17, dated 3/4-5/2/23, read the following; On 3/4/23, Resident #17 sustained a skin tear to her right forearm. External hospice services were notified. On 3/13/23, Resident #17 sustained a skin tear to her left shin. An external hospice nurse assessed the resident. On 3/18/23, staff noted the dressing on Resident #17's left lower shin wound was off. The wellness nurse replaced the bandage and an external hospice nurse was notified. On 3/20/23, an external hospice nurse assessed Resident #17 after an unwitnessed fall. On 3/30/23, Resident #17 removed her dressing on her wound and the external hospice agency was notified. On 4/1/23, Resident #17 removed the bandage from her wound, the external hospice nurse was notified. On 4/4/23, Resident #17 removed the bandage from her wound, the external hospice nurse was notified. On 4/5/23, Resident #17 refused to allow the external hospice nurse to change the dressing on her wound. On 4/6/23, the external hospice nurse assesses Resident #17's wound and confirmed the wound was infected. New wound care orders were implemented and both the external hospice nurse and residence nurses needed to provided wound care services for Resident #17. On 4/8/23, Resident #17 was agitated during staff care. Resident #17 became physically aggressive with staff during incontinence care. On 4/10/23, the external hospice nurse identified a new skin tear on Resident #17's right elbow. The external hospice nurse provided wound care. On 4/21/23, the interim administrator met with the external hospice nurse to discuss Resident #17's increased difficulties with care. It was noted the resident had been increasingly combative with staff and resistant to care. The external hospice nurse increased Resident #17's Seroquel to manage behaviors. On 4/26/23, the external hospice nurse was notified Resident #17 was not eating or leaving her room. The care plan for Resident #17, dated 3/10/23, read in part; Resident #17 wandered within the residence. Resident #17 received external hospice services. Resident #17 was resistant to care and required occasional intervention. The interventions read; "If interventions are not working, contact nurse/supervisor." Resident #17 required extensive incontinence assistance. However, the care plan did not address the staff tasks necessary to address Resident #17's resistance to care. The care plan did not address the specific external hospice agency information. Additionally, the care plan did not address Resident #17's wound care or the wellness nurse tasks necessary to support additional wound care needs. On 5/3/23 at 11:41 a.m., WN #1 stated the MCC was responsible for updating the care plans for residents residing in the secure environment. She stated the MCC was responsible for updating Resident #17's care plan. On 5/3/23 at 1:46 p.m., the MCC stated the care plan for Resident #17 should have included her wound care services, the external hospice agencies information and her behavioral expressions related to resistance to care. She stated she was not aware the care plan did not include the information. On 5/3/23 at approximately 2:08 p.m., the administrator of record stated that the care plan for Resident #17 should have included the behavioral expressions and staff tasks necessary to meet her needs regarding care. The administrator of record stated the wellness director would have been responsible for updating the care plan; however, the residence currently did not have a wellness director employed. 7. Resident #16 was admitted to the residence on 6/27/17 with diagnosis that included unspecified dementia and muscle weakness. The care plan for Resident #16, dated 12/19/22, read in part; staff were required to assist Resident #16 throughout meals and snacks by attempting to get her to eat independently with the hand-over-hand method, by cutting up her food and by helping her taste the food. Additionally, the care plan read if she did not start eating independently, staff would sit with her and assist throughout the meal. However, staff failed to follow Resident #16's care plan tasks to promote independence during meals. On 5/2/23 between 7:54 a.m. and 8:28 a.m., Staff #23 did not encourage Resident #16 to eat her meal independently. Staff #23 fed Resident #16 herself. Resident #16, at times, used her hand to cover her mouth and Staff #23 removed her hand and continued to feed Resident #16. Resident #16 refused to continue eating and Staff #23 continued to feed her. On 5/2/23 at 8:00 a.m., Staff #23 was unable to answer questions related to Resident #16's care plan. On 5/3/23 at 1:46 p.m., the MCC stated if the plan for Resident #16 read to encourage independence with eating the staff should have followed the care plan and encouraged her to independently eat. 8. Former Resident #31 was admitted to the residence 5/10/22 with diagnosis including dementia without behavioral disturbance. Progress notes for Former Resident #31, dated 11/4/22-1/12/23, read the following; On 11/4/22, Former Resident #31 was sexually inappropriate with a staff member. On 12/10/22, Former Resident #31 was found in another resident's apartment without pants on. Former Resident #31 became verbally aggressive with staff when they attempted to intervene and threaten to become physically aggressive. Former Resident #31 left the resident's apartment and went to the dining room. Former Resident #31 refused staff attempts to redirect him to his room to put his pants on. Staff had to dress the resident in the dining room as other residents were uncomfortable. On 12/13/22, Former Resident #31 was found in a female resident's room and had to be escorted out of the room. On 12/15/22, Former Resident #31 was aggressive with staff when wanting to enter another resident's room and staff had to contact local law enforcement. On 12/16/22, staff noted speaking with a female resident to discuss the incident that had occurred one day prior. The female resident reported feeling better and not having been fearful or concerned at that time. On 12/17/22, Former Resident #31 was found wandering in the kitchen area looking for another female resident. The family member of Former Resident #31 requested staff sit with the former resident due to the wandering behavior and irritability with staff. On 12/17/22, Former Resident #31 attempted to enter another female resident's room. A female resident in the hallway reported being fearful due to a previous altercation that had occurred with Former Resident #31. On 12/19/22, the former administrator contacted the family member of Former Resident #31 regarding an incident that had occurred resulting local law enforcement to have been involved. It was requested that the family member provided a private caregiver during waking hours due to increased behaviors. On 12/31/22, the former administrator left a message for the family member of Former Resident #31 requiring that the family member either hire a private caregiver or the family member sit with the former resident due to wandering and behavioral concerns. The former administrator notified the family member another female resident's family reported concerns of safety regarding Former Resident #31 due to the former resident seeking out the female resident. On 1/12/23, Former Resident #31 was found kicking another resident's door and was aggressive with staff when they attempted to redirect him. The care plan for Former Resident #31, dated 12/6/22, read in part; Former Resident #31 required daytime and night wellness checks. Former Resident #31 had no challenging situations identified, did not require special monitoring and made appropriate decisions. Additionally, the care plan for Former Resident #31 read he did not wander and staff were to assist and follow interventions to reduce behavioral expressions. However, the care plan for Former Resident #31 did not address the former resident's inappropriate sexual behaviors, physically aggressive behaviors or increased wandering. The care plan did not include the requirement for Former Resident #31 to have a private caregiver or family member during waking hours. Additionally, the care plan for Former Resident #31 did not address the staff tasks necessary to meet the former resident's needs to address the documented behavioral expressions and wandering. On 5/3/23 at approximately 11:41 a.m., WN #1 stated Former Resident #31 had been sexually inappropriate with female residents. She stated Former Resident #31 had began attempting to force himself into other resident's rooms. WN #1 stated the care plan for Former Resident #31 should have been updated to include his behavioral expressions. On 5/3/23 at approximately 2:08 p.m., the AOR stated the care plan for Former Resident #31 should have included more frequent checks. He added that he believed staff tasks necessary to meet the former resident's needs had been added to the care plan.

Based on record review and interview, the residence failed to implement a fall management program that included detailing in each resident's care plan the individualized approach necessary to address fall risk related to deficits in strength and balance, affecting two of four sample residents (#17, #22). Specifically, Resident #17 was admitted to the residence on 5/18/18. Resident #17 had documented falls on 3/3/23 and 3/20/23 resulting in no injury. The residence failed to update Resident #17's care plan to include individual approaches necessary to address the resident's fall risk. Subsequently, Resident #17 sustained a fall on 4/29/23 that resulted in a superficial abrasion approximately 11 centimeters (cm) in length down the posterior right ribcage believed to be from the wheelchair pedal. The resident complained of pain all over and was lethargic with her head down and eyes closed. Additionally, Resident #22 was admitted to the residence on 3/9/23, three days later on 3/12/23 the resident sustained a witnessed fall resulting in no injury. The residence failed to update Resident #22's care plan to include individual approaches necessary to address the resident's fall risk. Subsequently, Resident #22 sustained an unwitnessed fall on 3/19/23 that resulted in Resident #22 complaining of generalized pain in an unidentified area. Findings include: 1. Residence PolicyThe residence's Fall Management policy, dated March 2023, read in part; "... All new residents will be referred to the (residence's) (third) party provider for an initial fall evaluation to determine potential risk for falling. a. Appropriate interventions (if warranted) will be incorporated into the resident's care plan. The following protocol will be implemented followings falls: ... (two) or more falls. I. Refer to (third) party provider for evaluation and incorporate interventions (if warranted) into the resident's care plan. II. Refer to physician for physical exam. III. Update care plan as necessary. IV. Check for recent medication changes. V. Review and/or remove contributing factors. VI. Implement universal precautions ..."2. Resident #17 was admitted to the residence on 5/18/18 with diagnoses including dementia and Alzheimer's disease with late onset. a. Incident reports for Resident #17, dated March and April 2023, were reviewed and read the following: On 3/3/23, Resident #17 sustained an unwitnessed fall resulting in no injury. On 3/20/23, Resident #17 sustained an unwitnessed fall resulting in no injury. On 4/29/23, Resident #17 sustained a witnessed fall out of her wheelchair in the common area. Resident #17 had documented injuries that included a superficial abrasion approximately 11 centimeters (cm) in length down the posterior right ribcage. Resident #17 complained of pain all over and was lethargic and unable to open her eyes.b. Progress notes for Resident #17, dated 3/4-5/2/23, were reviewed and read the following: On 3/20/23, Resident #17 had an incident report was recorded for an unwitnessed fall in her apartment. The external hospice nurse for Resident #17 came to the residence and assessed the resident. A purple skin discoloration six cm by seven cm was noted to the resident's left forearm. Monitoring Resident #17 for three days was documented. On 4/30/23, staff documented day two of post witnessed fall observation. Resident #17 was noted as having an 11 cm scratch-like redness of superficial abrasion on her right lateral back. "Will continue to monitor her."c. The assessment for Resident #17, dated 2/15/23, read that Residents #17 had a history of falls, a weak gait and overestimated or forgot limits. Resident #17 was noted as being at a high risk for falls. d. The service plan for Resident #17, updated on 2/15/23, read Resident #17 was at high risk for falls. The service plan noted the goal was "Resident will remain safe and have a reduced likelihood of falls."The service plan listed interventions as "All staff are to report to the nurse any observed or reported falls, change in gait/balance, change in toileting ability, changes in cognition, and any observer (sic) safety hazards in the apartment (cluttered walkways, poor lighting, adaptive equipment in poor repair)." e. The care plan for Resident #17, updated on 3/10/23, was reviewed and did not include any information related to Resident #17 having been at risk for falls. The care plan read the following: Resident #17 required extensive assistance three times daily with bathroom assistance. Eight daily wellness checks for staff to check and if awake, provide emotional support and address any needs. Minimal assistance with escorts and extensive assistance with bathing and dressing. The care plan for Resident #17 had not been updated after she sustained falls on 3/3/23, 3/20/23 and 4/29/23 to include the individualized approach necessary to address her fall risk related to deficits in strength and balance or effects of medication to prevent additional falls. 3. Resident #22 was admitted to the residence on 3/9/23, with no listed diagnosis. a. Incidents reports for Resident #22, dated March 2023, were reviewed and read the following: On 3/12/23, Resident #22 had a witnessed fall in the dining room. Staff documented the resident was walking around a chair while holding onto it and the chair slid, causing Resident #22 to lose his balance and fall onto his buttocks. No injuries were noted. On 3/19/23, Resident #22 had an unwitnessed fall. Staff documented Resident #22 was found on the floor in between his bed and couch. No visible injuries were noted; however, Resident #22 complained of pain and was unable to identify where because he was confused. b. Progress notes for Resident #22, dated 3/11-5/1/23, were reviewed and read the following: On 3/14/23, staff document a day two post fall follow up. Resident #22 was noted to have no injuries and no complaints of pain. On 3/18/23, Resident #22 was noted as being weak and unsteady on his feet. Staff noted he may have required a wheelchair and physical therapy was pending. On 3/19/23, Resident #22 was found on the floor between his bed and his couch. Resident #22 complained of pain in an unidentified area. c. The assessment for Resident #22, dated 3/30/23, read Resident #22 had a history of falls and was at high risk for falls. d. The service plan for Resident #22, dated 3/30/23, read Resident #22 required fall interventions. The service plan goal read; "Resident will remain safe and have a reduced likelihood of falls"The service plan interventions read; "Mobility: Evaluate Assistive Device Use." e. The care plan for Resident #22, dated 3/27/23, was reviewed and did not include any information related to Resident #22 having been at risk for falls. The care plan read the following: Resident #22 required moderate assistance three times daily with bathroom assistance. Two daily wellness checks for staff to check and if awake, provide emotional support and address any needs. Minimal assistance with escorts and moderate assistance with bathing and dressing. The care plan for Resident #22 had not been updated after he sustained falls on 3/12/23 and 3/19/23 to include the individualized approach necessary to address her fall risk related to deficits in strength and balance to prevent additional falls. 4. InterviewsOn 5/2/23 at 7:23 a.m., Staff #22 stated if a resident fell the nurse on duty would evaluate the resident. She stated staff completed incident reports and notified the required parties that the resident fell. She stated the nurses were required to update the care plans after residents fell. Staff #22 stated that care plans had only been updated some of the time after falls, but not after all residents fell. On 5/2/23 at 9:36 a.m., the interim administrator stated the resident service plans were used for resident charges and the resident care plans were used for staff tasks necessary for resident care. On 5/2/23 at 3:30 p.m., the family member for Resident #22 stated he had been aware Resident #22 had fallen twice. He stated he was unsure if the residence had implemented any interventions to prevent Resident #22 from any additional falls. The family member of Resident #22 stated the resident had seen physical therapy a couple of times and that the understanding was Resident #22 should walk as much as he was able to. He added that was they only thing he had been aware that had been done after the falls. On 5/3/23 at 11:17 a.m., Wellness Nurse (WN) #1 stated the memory care coordinator was responsible for updating the care plan for Resident #17. She stated she believed staff should have been frequently monitoring Resident #17 to prevent falls. WN #1 stated that the care plan for Resident #17 should have been updated after she had fallen to include interventions to prevent additional falls. WN #1 confirmed Resident #22 had fallen twice and stated no interventions had been implemented to prevent additional falls from occurring. She stated she was aware the residence was required to update the care plans with interventions after residents had fallen. WN #1 confirmed the care plans had not been updated. On 5/3/23 at 1:46 p.m., the memory care coordinator stated she was responsible for updating resident care plans regarding grooming, showers, bathroom assistance and activities of daily living. The memory care coordinator stated the wellness nurses were responsible for updating the care plans to add fall interventions. The memory care coordinator added she participated in creating the interventions with the wellness nurses. On 5/3/23 at 2:08 p.m., the administrator of record stated if a resident sustained a fall the expectation was that the fall was documented in an incident report and a new intervention to prevent falls should have been added. The administrator of record stated the residence focused on including interventions in the care plans because they had been previously cited a deficiency for not updating care plans after residents had fallen. He stated the residence had worked hard to ensure the interventions were added to the care plans after residents had fallen. The administrator of record stated the care plan for Resident #17 should have been updated to include that she was at risk for falls and included interventions for staff to be able to read. The administrator of record stated the care plan for Resident #22 should have also been updated to include the interventions after he had fallen.

Based on interview and record review the residence failed to ensure residents had the right to be free from abuse affecting one current resident (#9) and two former residents (#28, #29). Specifically, on 1/3, 2/9 and 3/1/23 Former Resident #28 had three separate altercations that involved Resident #9 and Former Resident #29. On 1/3/23 Former Resident #28 and #29 had an incident of physical abuse which resulted in both residents slapping each other. On 2/9/23 Former Resident #28 had an incident of abuse which resulted in Resident #9 being found on the floor with pain in her left arm and a skin tear. A third incident of abuse with Former Resident #28 and Former Resident #29 resulted in coffee being poured on Former Resident #29, both residents with scratches and Former Resident #29 remaining fearful of Former Resident #28. Findings include:1. Reference and Residence Policy The residence's resident rights policy, dated 1/2020, read in part: The resident had the right to be free from physical abuse. Chapter II regulations governing assisted living residences, defines abuse as the willful infliction of injury, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. According to the department's occurrence reporting manual, dated May 2018, "Pain is considered injury. Even if a (resident) with dementia cannot express pain, any action that would normally be considered painful by a reasonable person should be considered an injury. For example, a slap that leaves no mark would normally be painful and should be considered reportable as an injury even if the (resident) cannot express the pain."2. Former Resident #28 was admitted to the residence on 2/25/22, with a diagnosis including Alzheimer's disease.a. Former Resident #28 and Resident #9Resident #9 was admitted to the residence on 7/8/19 with a diagnosis including dementia. An investigation, dated 2/9/23, read in part: Former Resident #28 was standing next to Resident #9 who she had an altercation with and complained that Resident #9 grabbed her and pushed her when they were walking across from each other. Former Resident #28 complained of shoulder and wrist pain. A progress note for Resident #9, dated 2/9/23, read in part: Resident #9 may have been pushed on the floor by another resident, she was crying when the wellness nurse arrived, she did not let staff help her off the floor or touch her left arm. Resident #9 had a skin tear above the left elbow and a small amount of blood was observed. Emergency medication services were notified and Resident #9 was taken to the emergency department (ED). A second progress note, dated 2/9/23, read Resident #9 returned to the residence around 4:30 p.m. The resident appeared sleepy and somewhat confused. The left elbow skin tear had steri-strips applied and was covered in a dressing; however, no wound care was ordered. Additionally, the progress note further read the x-ray revealed no evidence of a fracture. A practitioner's summary, dated 2/10/23, read in part: Resident #9 was seen for a post fall exam. Resident was pushed to the ground by another resident. Upon exam Resident a skin tear on the left elbow was president with steri-strips in place, Resident #9 was anxious and appeared tearful. A progress note, dated 2/11/23, read in part: Staff reported Resident #9 still experienced pain in her left arm as noted by facial grimacing and leaned on this area. A progress note dated, 2/15/23, read in part: Skin tear was now scabbed and steri-strips were off. Resident #9 complained of pain in left arm and mobility of the arm was restricted. On 5/2/23 at 12:45 p.m., the wellness nurse #1 (WN #1) stated on 2/9/23 she had been working when the incident of abuse occurred with Former Resident #28 and Resident #9. She stated that she did not witness the altercation but heard Resident #9 screaming. WN #1 stated Resident #9 was seated on the floor by the wall close to the former resident. WN #1 stated Resident #9 was in pain and did have a skin tear on her elbow. She stated after the incident Resident #9 kept a watch on Former Resident #28 as she seem concerned for her safety. On 5/2/23 at 1:56 p.m., Staff #27 stated stated she was working the day Resident #9 and Former Resident #28 had an incident of physical abuse. She stated although she did not directly witness the incident between the two residents, she did hear that Former Resident #28 stated Resident #9 was the aggressor and she was just defending herself. Staff #27 stated that after the incident between Former Resident #28 and Resident #9, Resident #9 stated she was going to find whoever pushed her and would kill them. On 5/3/23 at 9:04 a.m., a family member for Resident #9 confirmed that the resident had been in an altercation with another resident and was pushed to the ground. He stated after the incident Resident #9 was transported to the emergency department to evaluate her injuries. b. Former Resident #28 and Former Resident #29Former Resident #29 was admitted to the residence on 8/9/22 with a diagnosis including dementia with behavioral disturbance. An investigation, dated 1/3/23, read in part: Staff heard an argument between Former Residents #28 and #29. As staff approached the former residents, she saw Former Resident #28 slapping Former Resident #29. Staff attempted to separate the two former residents, when Former Resident #28 grabbed a hold of of Resident #29's sweater. The activity person took Former Resident #29 to her room "as I pulled (Former Resident #28 to the memory care coordinator's) office because she wanted to go get back at (Former Resident #29)." An investigation, dated 3/1/23, read in part: Former Resident #29 said she was pouring coffee for another resident when Former Resident #28 became agitated and threw coffee on Former Resident #29's shoulder. Former Resident #29 reported that the resident then came at her and "she threatened she would kill me" and "attacked her." At time of assessment Former Resident #29 had a small scratch on her left hand. The investigation further read that Former Resident #29 was fearful of Former Resident #28. Former Resident #28 had a scrape to the face and Former Resident #28 had a scrape on the hand. On 5/2/23 at 12:45 p.m. the WN #1 stated that Former Resident #28 had two incidents of abuse towards Former Resident #29 in a short amount of time and stated that was why Former Resident #28 was issued a discharge notice. On 3/3/23 at 2:08 p.m., the administrator of record (AOR) stated that the residence's care team completed abuse training and kept a watchful eye anytime they noticed that abuse occurred. He stated the residence did put steps in place to ensure abuse did not happen again. The AOR stated when abuse occurred the management team stepped up their observations and became vigilant. He confirmed that injuries did occur and confirmed the above incidents were abuse. He stated that ultimately resident abuse was why Former Resident #28 was issued a discharge notice

Based on record review and interview the residence failed to ensure that only medication that has been ordered by a practitioner was administered to residents affecting one of eight sample residents (#9). Findings include:The residence's Medication Administration Routine Policy and Procedure, dated July 2021, read in part: Medications may only be administered within the parameters of the practitioner's orders. Resident #9 was admitted to the residence on 7/8/19, with a diagnosis of unspecified dementia. The April 2023 MAR for Resident #9 read Keflex 500 mg was administered three times daily in which there was no evidence of a written practitioner's order from 4/18-4/20/23. On 5/2/23 at 12:42 p.m., the Wellness Nurse #1 stated Resident #9 went to the emergency department on 4/17/23 and was diagnosed with a urinary tract infection. She stated at the emergency department Resident #9 was prescribed antibiotics and the prescription was sent directly to the pharmacy and not the residence. She stated that she had just received the prescription from the pharmacy (the day of the onsite investigation) and acknowledged the residence should not administer medications unless there was a practitioner's order for administration.

Based on observation, interview and record review the residence failed to comply with authorized practitioner's orders associated with medication administration affecting three of six sample residents (#17,#22, #25) and two former residents (#28, #30). Specifically, Former Resident #30 was admitted to the residence with a diagnosis that included frontotemporal dementia. Former Resident #30 had a practitioner's order, dated 8/19/22, directing the residence to administer levetiracetam 100 mg/ml 10 ml every 12 hours. The residence failed to administer the medication as ordered on 10/29/22 evening dose and the 10/30/22 morning dose. Subsequently, Former Resident #30 sustained a seizure and was transported to the hospital by emergency medical services. The family member of Former Resident #30 stated the hospital identified the seizure was a direct result of the missed medication doses. Former Resident #30 sustained a decline in cognition and was unable to return to the residence. Specifically, Resident #17 was admitted to the residence with a diagnosis that include psychotic disturbance. On 4/21/23 a written practitioner's order directed the residence to administer Seroquel 50 mg twice daily to Resident #17. Staff reported to the external hospice nurse that Resident #17 appeared lethargic and sedated. On 4/27/23 a written practitioner's order directed the residence to discontinue Seroquel 50 mg twice daily and start Seroquel 25 mg daily in the morning and 50 mg daily at bedtime. However, the residence continued to administer 50 mg twice daily. Subsequently, Resident #17 sustained a fall that resulted in injury. Staff Documented after the fall that Resident #17 had been lethargic and unable to keep her head in an upright position. The external hospice nurse stated the continued dose of Seroquel and increased lethargy was a contributing factor to the resident's fall. Findings include:1. References and Residence Policy:The residence's Medication Errors Policy and Procedure, dated July 2021, read in part: The residence strives to eliminate medication errors/events. The purpose was to protect immediate and ongoing safety of residents and to provide standardized mechanisms for identifying, reporting and analyzing medication events in order to improve the quality of medication administration. Examples of medications errors include wrong dose administered, extra dose given, wrong time for administration. According to the Mayo Clinic, "Levetiracetam is used alone or together with other medicines to help control certain types of seizures (eg, partial seizures, myoclonic seizures, or tonic-clonic seizures) in the treatment of epilepsy. This medicine cannot cure epilepsy and will only work to control seizures for as long as you continue to use it ... Do not stop using levetiracetam without first checking with your doctor. Stopping the medicine suddenly may cause your seizures to return or to occur more often. Your doctor may want you to gradually reduce the amount you are taking before stopping it completely ..." MayoClinic.gov (2023) Levetiracetam, Retrieved from: https://www.mayoclinic.org/drugs-supplements/levetiracetam-oral-route/side-effects/drg-20068010?p=1According to the Mayo Clinic, "Quetiapine (Seroquel) is used alone or together with other medicines to treat bipolar disorder (depressive and manic episodes) and schizophrenia. Quetiapine extended-release tablet is also used together with other antidepressants to treat major depressive disorder ... Quetiapine is an antipsychotic medicine that works in the brain ... Quetiapine may cause drowsiness, trouble with thinking, trouble with controlling body movements, or trouble with your vision (especially during the first week of use), which may lead to falls, fractures, or other injuries ..." MayoClinic.gov (2023) Quetiapine, Retrieved from: https://www.mayoclinic.org/drugs-supplements/quetiapine-oral-route/side-effects/drg-20066912?p=12. Former Resident #30 was admitted to the residence on 2/25/22 with a diagnosis that included Frontotemporal dementia. A written practitioner's, dated 8/19/22, directed the residence to administer levetiracetam 100 mg/ml 10 ml every 12 hours. However, the October 2022 medication administration record (MAR) read the residence failed to administer the medication as ordered on the 10/29/22 evening dose and the 10/30/22 morning dose, for a total of two missed doses. Progress notes for Former Resident #30, dated 10/30/22, read the following: At 8:08 a.m., "Resident woke up with dried pink bloody saliva from right corner of his mouth down to his right ear. No injuries found in hislip (sic) and mouth at this time. His gait is unsteady when walking from his room to the dinning room. This nurse instructed staff monitorand (sic) assist ambulation to prevent fall." At 9:00 a.m., "Called and spoke to (external pharmacy), request STAT refill of Levetiracetam 100mg/mL ... This medications was notin (sic) with the cycle meds."At 10:20 a.m., the former resident was found siting with tilted head with no verbal response in the sofa in secure environment living room; bloody saliva ran down from bilateral corners of his mouth to his neck. When the nurse arrived she instructed the qualified medication administration person to call emergency medical services (EMS). Former Resident #30 did not have a medical orders for scope of treatment (MOST) form but face sheet read do not resuscitate. At 10:35 a.m., the former resident was transported to the emergency department by ambulance. An EMS report, dated 11/4/22, read Former Resident #30 was being transported from the hospital to another residence. The report read the former resident had been admitted to the hospital by EMS after sustaining a seizure. The hospital nurse reported the former resident was found unresponsive at place of residence, was rapidly declining and was admitted to external hospice services. The hospital nurse reported that the residence had not administered the former resident's daily dose of levetiracetam. On 5/2/23 at 8:02 a.m., the memory care coordinator (MCC) stated she was unsure of everything that had occurred with Former Resident #30. She stated she was aware he had a seizure but did not believe he had missed any medications. The MCC stated she was on vacation when the former resident was sent out and added she did not have all of the details of what happened. On 5/3/23 at 11:41 a.m., Wellness Nurse (WN) #1 stated she had been informed that Former Resident #30 had run out of his levetiracetam and had not been administered the medication. She stated he was found bleeding from his mouth by the weekend nurse. She stated a second incident occurred of Former Resident #30 bleeding from his mouth and he had been transported to the hospital. WN #1 stated the former resident did not come back to the residence and added she did not recall what the hospital had said occurred. WN #1 stated the medication for Former Resident #30 should have been available to have been administered and staff should have re-ordered the medication prior to the medication being unavailable. On 5/3/23 at 12:22 p.m., the family member for Former Resident #30 stated the residence staff did not administer two doses of his levetiracetam because the liquid medication was unavailable. She stated the residence had the pill form available but did not administer the pill form of the medication. The family member of Former Resident #30 stated the staff member that worked was new and was unaware of the medication. She stated after the former resident missed the medication doses he had sustained a seizure and was hospitalized. The family member of Former Resident #30 stated the former resident did not return to baseline and was discharged from the hospital on external hospice services because of the decline. She stated the practitioner at the hospital informed her if the former resident had not missed the doses of his medication he would not have hadthe seizure. The family member of Former Resident #30 stated the residence had reimbursed the entire months rent payment and paid for the cost associated with the ambulance ride after the incident occurred. On 5/3/23 at 1:46 p.m., the MCC stated she was unsure why Former Resident #30 did not come back to the residence. On 5/3/23 at 2:08 p.m., the administrator of record (AOR) stated Former Resident #30 did not receive his levetiracetam which had resulted in a seizure and the former resident being transported to the hospital. The AOR stated the residence had utilized a contracted staff at the time the event occurred. He stated the former resident had a negative health impact due to the contracted staff member failing to administer the medications. 3. Resident #17 was admitted to the residence on 5/18/18 with diagnosis that included dementia without behavioral disturbance, psychotic disturbance and Alzheimer's disease with late onset. A written practitioner's order, dated 4/21/23, directed the residence to administer Seroquel 50 mg twice daily to Resident #17. A progress note for Resident #17, dated 4/26/23, read WN #1 requested the external hospice nurse to adjust Resident #17's Seroquel due to decreased appetite, not coming out of her room and increased difficulty providing care. A second written practitioner's order, dated 4/27/23, directed the residence to discontinue Seroquel 50 mg twice daily and start Seroquel 25 mg daily in the morning and 50 mg daily at bedtime. However, the April 2023 MAR read the residence continued to administer Seroquel 50 mg twice daily on through 4/28/23, for a total of one wrong dose. An incident report for Resident #17, dated 4/29/23, read in part; Resident #17 sustained a witnessed fall out of her wheelchair in the common area. Resident #17 had documented injuries that included a superficial abrasion approximately 11 centimeters (cm) in length down the posterior right ribcage. Resident #17 complained of pain all over and was lethargic and unable to open her eyes. On 5/2/23 at 8:02 a.m., the MCC stated the qualified medication administration persons (QMAPs) and nurses ordered medication. She stated she was unaware of the changes to Resident #17's medication. On 5/3/23 at 1:32 p.m., the external hospice nurse for Resident #17 stated Resident #17 had started sequel due to increased behaviors related to resistance to care. The external hospice nurse stated Resident #17 had began to sleep throughout the day so the medication had been decreased to reduce sedation. She stated residence staff had reported to her Resident #17 was sedated after the medication was started. The external hospice nurse stated she was unaware that the residence had continued to administer the previous dose for an additional day. She stated that the delay in decreasing the medication would have contributed to Resident #17's fall due to the increased sedation. On 5/3/23 at 2:08 p.m., the AOR acknowledged the expectation was the medication be administered as ordered for Resident #17. 4. Resident #25 was admitted to the residence on 12/23/21 with a diagnosis that included unspecified dementia and major depression disorder. A written practitioner's order, dated 3/20/23, directed the residence to administer escitalopram 10 mg once daily. However, the April 2023 MAR read the medication had not been administered as ordered on 4/1/23 due to the medication being unavailable, for a total of one missed dose. On 5/2/23 at 8:02 a.m., the MCC stated at times medications had run out of stock, she stated if a medication was unavailable staff should have ordered the medication right away as they should not miss additional doses. On 5/2/23 at 12:34 p.m., the family member for Resident #25 stated he was not aware the resident had missed any medication doses. On 5/3/23 at 11:41 a.m., WN #1 stated the medication for Resident #25 should have been available to administer. She stated the medication circled on the MAR meant the medication was not administered as ordered. 5. Resident #22 was admitted to the residence on 3/9/23 with no listed diagnoses. A written practitioner's order, dated 3/13/23, directed the residence to administer brimonidine tartrate 0.2% solution 1 drop into each eye daily at 8:00 a.m. and 6:30 p.m. However, the April 2023 MAR read the medication was not administered as ordered on 4/15/23 due to the medication being unavailable, for a total of one missed dose. On 5/2/23 at 3:30 p.m., the family member for Resident #22 stated they were not aware Resident #22 had missed any doses of his eye drops. 6. Former Resident #28 was admitted to the residence on 2/25/22, with a diagnosis of Alzheimer's disease.a. SeroquelA written practitioner's order, dated 2/21/23, directed the residence to administer Seroquel 25 mg at 8:00 a.m. and 1:00 p.m. However, the March 2023 MAR read Seroquel 12.5 mg was administered at 8:00 a.m. and 1:00 p.m. on 3/1/23. A written practitioner's order, dated 2/21/23, directed the residence to administer Seroquel 50 mg once daily at bedtime. However, the March 2023 MAR read the medication was not administered on 3/1/23. A written practitioner's order dated 3/2/23, directed the residence to discontinue Seroquel 50 mg once daily at bedtime, However, the March 2023 MAR read the medication was not discontinued until 3/4/23. b. DepakoteA written practitioner's order, dated 3/8/23, directed the residence to administer Depakote DR Sprinkles 125 mg once daily at 1:00 p.m. However, the March 2023 MAR read the medication was not administered until 3/11/23. A written practitioner's order, dated 3/21/23, directed the residence to administer Depakote DR Sprinkles 250 mg at 1:00 p.m. However, the March 2023 MAR read the medication was not started until 3/24/23.c. OlanzapineA written practitioner's order dated 3/23/23, directed the residence to administer olanzapine 2.5 mg at 2:00 p.m. However, the March 2023 MAR read olanzapine 2.5 mg was administered with the noon meal on 3/26, 3/27, 3/29-4/4/23. On 3/3/23 at 11:17 a.m., the WN #1 stated that she worked hard and diligently not have medication exceptions that are not unavailable. She stated The residence's process for ordering and administering medications was as follows: The practitioner's office would fax medication orders to the pharmacy, the WN #1 would also send a copy of the medication order to the pharmacy, then the pharmacy would enter the order, approve the medication and have it sent to the residence. She stated once the medication was on the MAR then a residence nurse also has to approve the order on the MAR prior to staff having the ability to administer the medication. She stated ideally a medication would be ordered and the residence would have the medication by 7:00 p.m. that same day. The WN #1 further stated the process could take a long time, she stated that the residence was not staffed with a nurse to approve the MARs 24 hours a day seven days a week. She stated the residence's wellness director had the ability to approve medications from home; however, the WN #1 stated the residence was currently without a wellness director. The WN #1 further stated that the residence had switched electronic MAR programs on 3/1/23 which was why there may have been some errors on the first day during the change. She stated that the error with Depakote Sprinkles was due to the delay in the process. She stated that she had faxed the order on 3/9/23 to the pharmacy; it was just waiting on the approval until 3/11/23. The WN #1 stated regarding the olanzapine, was an error with the pharmacy transcribing the order. She stated that since it was time specific it should have reflected it on the MAR. The WN #1 further stated since the residence had it on the MAR as administered with the noon meal they had approximately four hours to administer the medication and not the time specified. On 3/3/23 at 12:32 p.m., the power of attorney for Former Resident #28 stated the former resident had been experiencing an increase in aggression. She stated that the residence had been working with the former resident's psychiatrist to determine the best medication to assist with managing the residents behavioral expressions. On 5/3/23 the administrator of record (AOR) stated the residence partnered with the former resident's psychiatrist and were very involved with making the changes to the medications. He stated more than once a week the residence was reviewing the medications and discussing the medications. The AOR further stated he relied on the nursing team at the residence to ensure medication changes were accurate. The AOR confirmed there was room for improvement regarding the residence medication administration systems. He stated time sensitive medications should have been reviewed on the MAR prior to administration and not sure why it had not been caught by the nursing department at the residence.

Based on interview and record review the residence failed to ensure each resident had an accurate medication administration record (MAR) affecting one of eight sample residents (#9) and one former resident (#28). Findings include:The residence's Medication Administration Routine Policy and Procedure, dated July 2021, read in part: Staff were required to sign the electronic medication administration record to correspond with medications given. 1. Resident #9 was admitted to the residence on 7/9/19, with diagnoses including unspecified dementia, postpartum mood disturbance, anxiety, major depressive disorder and paranoid personality disorder. A written practitioner's order, dated 3/14/23 and 4/25/23, directed the residence to administer fluoxetine HCI 10 mg once daily at night and to administer fluoxetine HCI 40 mg for a total of 50 mg once daily at night. However, the May 2023 MAR read to administer fluoxetine HCI 10 mg once daily at night in addition to fluoxetine HCI 10 mg for a total of 50 mg once daily at night and was documented as administered on from 4/1 through 5/2/23. On 3/3/23 at 11:16 a.m., the Wellness Nurse #1 (WN #1) stated the order had been entered incorrectly on the MAR by the pharmacy and not caught by the residence. 2. Former Resident #28 was admitted to the residence on 2/25/22 with a diagnosis that included Alzheimer's disease. A written practitioner's order, dated 3/21/23, directed the residence to administer Depakote 250 mg at 1:00 p.m. However, the March 2023 MAR read a dash mark on 3/28/23. On 3/3/23 at 11:16 a.m., the WN #1 stated that she did not know what a dash on the MAR meant. She confirmed that staff should have accurately documented the medication on the MAR.

Based on interview and record review the residence failed to on a quarterly basis audit the accuracy and completeness of the medication administration records. (Cross-reference Q1430, Q1468, Q1510)The findings include: The residence's Medication Care and Medication Administration Record (MAR) Audit Policy and Procedure, dated July 2021, read in part: Medications carts and MARs would be audited at least monthly by community team members. The purpose of audits was to help protect the safety of the residents, to discourage mishandling or misuse of medications to promote adherence to regulations and policies. The procedure further read regular audits would be conducted to ensure the overall safety of the medication storage system as well as accuracy and completeness of documentation. Each medication cart and medication administration record would be audited by the wellness director or designee at least once each month. The medication audit form for use in quality improvement to identify trends and implement changes to community processes as necessary. Medication Cart/Medication Administration Record Audits completed from 2/3/23 to present revealed the form focused on three areas of the medication program- MARs, controlled substances and cart audits. Specifically, the section of the audit related to MARs read the following areas were audited to ensure the accurateness and completeness of the MARs:MAR screen locked/blanked when unsupervised;MAR free from "misses" documentation;MAR free from "no inventory" documentation andCentrally stored med record used. However, the audit tool provided revealed no evidence of an audit completed to ensure the accuracy of the MARs in regards to the written practitioner's orders in relation to what was transcribed on the MARs and when the medications were administered. On 5/2/23 at 12:42 p.m., the vice president of wellness stated that the last quarterly audit the administrator had participated in was provided and completed in February 2023. On 5/3/23 at 11:17 a.m., the Wellness Nurse #1 stated that she and the other nurses at the residence split up completing the medication audits and did them with a qualified medication administration person. She stated that medication audits did not always include a review of the MARs. On 5/3/23 at 2:08 p.m., the administrator of record stated that the form for medication audits provided during the on-site investigation was more geared towards auditing medication carts and that particular audit did not address the accuracy of the MARs. He stated he was not sure if there were any other types of audits that the residence completed regarding the accuracy of the MARs.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.7.5 The assisted living residence shall select direct care staff based on such factors as the ability to read, write, carry out directions, communicate, and demonstrate competency to safely and effectively provide care and services. 17.14 Staff who assist feeding a resident shall be trained in the proper techniques for supporting nutrition and hydration by a licensed or registered professional qualified by education and training to assess choking risks, such as a registered nurse, speech language pathologist, or registered dietitian.

A licensure revisit was completed on 5/3/23 for the previous deficiency cited on 11/22/22. A deficiency was cited.

Based on observation, interview and record review the residence failed to comply with authorized practitioner's orders associated with medication administration affecting three of six sample residents (#17,#22, #25) and two former residents (#28, #30). Specifically, Former Resident #30 was admitted to the residence with a diagnosis that included frontotemporal dementia. Former Resident #30 had a practitioner's order, dated 8/19/22, directing the residence to administer levetiracetam 100 mg/ml 10 ml every 12 hours. The residence failed to administer the medication as ordered on 10/29/22 evening dose and the 10/30/22 morning dose. Subsequently, Former Resident #30 sustained a seizure and was transported to the hospital by emergency medical services. The family member of Former Resident #30 stated the hospital identified the seizure was a direct result of the missed medication doses. Former Resident #30 sustained a decline in cognition and was unable to return to the residence. Specifically, Resident #17 was admitted to the residence with a diagnosis that include psychotic disturbance. On 4/21/23 a written practitioner's order directed the residence to administer Seroquel 50 mg twice daily to Resident #17. Staff reported to the external hospice nurse that Resident #17 appeared lethargic and sedated. On 4/27/23 a written practitioner's order directed the residence to discontinue Seroquel 50 mg twice daily and start Seroquel 25 mg daily in the morning and 50 mg daily at bedtime. However, the residence continued to administer 50 mg twice daily. Subsequently, Resident #17 sustained a fall that resulted in injury. Staff Documented after the fall that Resident #17 had been lethargic and unable to keep her head in an upright position. The external hospice nurse stated the continued dose of Seroquel and increased lethargy was a contributing factor to the resident's fall. Findings include:1. References and Residence Policy:The residence's Medication Errors Policy and Procedure, dated July 2021, read in part: The residence strives to eliminate medication errors/events. The purpose was to protect immediate and ongoing safety of residents and to provide standardized mechanisms for identifying, reporting and analyzing medication events in order to improve the quality of medication administration. Examples of medications errors include wrong dose administered, extra dose given, wrong time for administration. According to the Mayo Clinic, "Levetiracetam is used alone or together with other medicines to help control certain types of seizures (eg, partial seizures, myoclonic seizures, or tonic-clonic seizures) in the treatment of epilepsy. This medicine cannot cure epilepsy and will only work to control seizures for as long as you continue to use it ... Do not stop using levetiracetam without first checking with your doctor. Stopping the medicine suddenly may cause your seizures to return or to occur more often. Your doctor may want you to gradually reduce the amount you are taking before stopping it completely ..." MayoClinic.gov (2023) Levetiracetam, Retrieved from: https://www.mayoclinic.org/drugs-supplements/levetiracetam-oral-route/side-effects/drg-20068010?p=1According to the Mayo Clinic, "Quetiapine (Seroquel) is used alone or together with other medicines to treat bipolar disorder (depressive and manic episodes) and schizophrenia. Quetiapine extended-release tablet is also used together with other antidepressants to treat major depressive disorder ... Quetiapine is an antipsychotic medicine that works in the brain ... Quetiapine may cause drowsiness, trouble with thinking, trouble with controlling body movements, or trouble with your vision (especially during the first week of use), which may lead to falls, fractures, or other injuries ..." MayoClinic.gov (2023) Quetiapine, Retrieved from: https://www.mayoclinic.org/drugs-supplements/quetiapine-oral-route/side-effects/drg-20066912?p=12. Former Resident #30 was admitted to the residence on 2/25/22 with a diagnosis that included Frontotemporal dementia. A written practitioner's, dated 8/19/22, directed the residence to administer levetiracetam 100 mg/ml 10 ml every 12 hours. However, the October 2022 medication administration record (MAR) read the residence failed to administer the medication as ordered on the 10/29/22 evening dose and the 10/30/22 morning dose, for a total of two missed doses. Progress notes for Former Resident #30, dated 10/30/22, read the following: At 8:08 a.m., "Resident woke up with dried pink bloody saliva from right corner of his mouth down to his right ear. No injuries found in hislip (sic) and mouth at this time. His gait is unsteady when walking from his room to the dinning room. This nurse instructed staff monitorand (sic) assist ambulation to prevent fall." At 9:00 a.m., "Called and spoke to (external pharmacy), request STAT refill of Levetiracetam 100mg/mL ... This medications was notin (sic) with the cycle meds."At 10:20 a.m., the former resident was found siting with tilted head with no verbal response in the sofa in secure environment living room; bloody saliva ran down from bilateral corners of his mouth to his neck. When the nurse arrived she instructed the qualified medication administration person to call emergency medical services (EMS). Former Resident #30 did not have a medical orders for scope of treatment (MOST) form but face sheet read do not resuscitate. At 10:35 a.m., the former resident was transported to the emergency department by ambulance. An EMS report, dated 11/4/22, read Former Resident #30 was being transported from the hospital to another residence. The report read the former resident had been admitted to the hospital by EMS after sustaining a seizure. The hospital nurse reported the former resident was found unresponsive at place of residence, was rapidly declining and was admitted to external hospice services. The hospital nurse reported that the residence had not administered the former resident's daily dose of levetiracetam. On 5/2/23 at 8:02 a.m., the memory care coordinator (MCC) stated she was unsure of everything that had occurred with Former Resident #30. She stated she was aware he had a seizure but did not believe he had missed any medications. The MCC stated she was on vacation when the former resident was sent out and added she did not have all of the details of what happened. On 5/3/23 at 11:41 a.m., Wellness Nurse (WN) #1 stated she had been informed that Former Resident #30 had run out of his levetiracetam and had not been administered the medication. She stated he was found bleeding from his mouth by the weekend nurse. She stated a second incident occurred of Former Resident #30 bleeding from his mouth and he had been transported to the hospital. WN #1 stated the former resident did not come back to the residence and added she did not recall what the hospital had said occurred. WN #1 stated the medication for Former Resident #30 should have been available to have been administered and staff should have re-ordered the medication prior to the medication being unavailable. On 5/3/23 at 12:22 p.m., the family member for Former Resident #30 stated the residence staff did not administer two doses of his levetiracetam because the liquid medication was unavailable. She stated the residence had the pill form available but did not administer the pill form of the medication. The family member of Former Resident #30 stated the staff member that worked was new and was unaware of the medication. She stated after the former resident missed the medication doses he had sustained a seizure and was hospitalized. The family member of Former Resident #30 stated the former resident did not return to baseline and was discharged from the hospital on external hospice services because of the decline. She stated the practitioner at the hospital informed her if the former resident had not missed the doses of his medication he would not have hadthe seizure. The family member of Former Resident #30 stated the residence had reimbursed the entire months rent payment and paid for the cost associated with the ambulance ride after the incident occurred. On 5/3/23 at 1:46 p.m., the MCC stated she was unsure why Former Resident #30 did not come back to the residence. On 5/3/23 at 2:08 p.m., the administrator of record (AOR) stated Former Resident #30 did not receive his levetiracetam which had resulted in a seizure and the former resident being transported to the hospital. The AOR stated the residence had utilized a contracted staff at the time the event occurred. He stated the former resident had a negative health impact due to the contracted staff member failing to administer the medications. 3. Resident #17 was admitted to the residence on 5/18/18 with diagnosis that included dementia without behavioral disturbance, psychotic disturbance and Alzheimer's disease with late onset. A written practitioner's order, dated 4/21/23, directed the residence to administer Seroquel 50 mg twice daily to Resident #17. A progress note for Resident #17, dated 4/26/23, read WN #1 requested the external hospice nurse to adjust Resident #17's Seroquel due to decreased appetite, not coming out of her room and increased difficulty providing care. A second written practitioner's order, dated 4/27/23, directed the residence to discontinue Seroquel 50 mg twice daily and start Seroquel 25 mg daily in the morning and 50 mg daily at bedtime. However, the April 2023 MAR read the residence continued to administer Seroquel 50 mg twice daily on through 4/28/23, for a total of one wrong dose. An incident report for Resident #17, dated 4/29/23, read in part; Resident #17 sustained a witnessed fall out of her wheelchair in the common area. Resident #17 had documented injuries that included a superficial abrasion approximately 11 centimeters (cm) in length down the posterior right ribcage. Resident #17 complained of pain all over and was lethargic and unable to open her eyes. On 5/2/23 at 8:02 a.m., the MCC stated the qualified medication administration persons (QMAPs) and nurses ordered medication. She stated she was unaware of the changes to Resident #17's medication. On 5/3/23 at 1:32 p.m., the external hospice nurse for Resident #17 stated Resident #17 had started sequel due to increased behaviors related to resistance to care. The external hospice nurse stated Resident #17 had began to sleep throughout the day so the medication had been decreased to reduce sedation. She stated residence staff had reported to her Resident #17 was sedated after the medication was started. The external hospice nurse stated she was unaware that the residence had continued to administer the previous dose for an additional day. She stated that the delay in decreasing the medication would have contributed to Resident #17's fall due to the increased sedation. On 5/3/23 at 2:08 p.m., the AOR acknowledged the expectation was the medication be administered as ordered for Resident #17. 4. Resident #25 was admitted to the residence on 12/23/21 with a diagnosis that included unspecified dementia and major depression disorder. A written practitioner's order, dated 3/20/23, directed the residence to administer escitalopram 10 mg once daily. However, the April 2023 MAR read the medication had not been administered as ordered on 4/1/23 due to the medication being unavailable, for a total of one missed dose. On 5/2/23 at 8:02 a.m., the MCC stated at times medications had run out of stock, she stated if a medication was unavailable staff should have ordered the medication right away as they should not miss additional doses. On 5/2/23 at 12:34 p.m., the family member for Resident #25 stated he was not aware the resident had missed any medication doses. On 5/3/23 at 11:41 a.m., WN #1 stated the medication for Resident #25 should have been available to administer. She stated the medication circled on the MAR meant the medication was not administered as ordered. 5. Resident #22 was admitted to the residence on 3/9/23 with no listed diagnoses. A written practitioner's order, dated 3/13/23, directed the residence to administer brimonidine tartrate 0.2% solution 1 drop into each eye daily at 8:00 a.m. and 6:30 p.m. However, the April 2023 MAR read the medication was not administered as ordered on 4/15/23 due to the medication being unavailable, for a total of one missed dose. On 5/2/23 at 3:30 p.m., the family member for Resident #22 stated they were not aware Resident #22 had missed any doses of his eye drops. 6. Former Resident #28 was admitted to the residence on 2/25/22, with a diagnosis of Alzheimer's disease.a. SeroquelA written practitioner's order, dated 2/21/23, directed the residence to administer Seroquel 25 mg at 8:00 a.m. and 1:00 p.m. However, the March 2023 MAR read Seroquel 12.5 mg was administered at 8:00 a.m. and 1:00 p.m. on 3/1/23. A written practitioner's order, dated 2/21/23, directed the residence to administer Seroquel 50 mg once daily at bedtime. However, the March 2023 MAR read the medication was not administered on 3/1/23. A written practitioner's order dated 3/2/23, directed the residence to discontinue Seroquel 50 mg once daily at bedtime, However, the March 2023 MAR read the medication was not discontinued until 3/4/23. b. DepakoteA written practitioner's order, dated 3/8/23, directed the residence to administer Depakote DR Sprinkles 125 mg once daily at 1:00 p.m. However, the March 2023 MAR read the medication was not administered until 3/11/23. A written practitioner's order, dated 3/21/23, directed the residence to administer Depakote DR Sprinkles 250 mg at 1:00 p.m. However, the March 2023 MAR read the medication was not started until 3/24/23.c. OlanzapineA written practitioner's order dated 3/23/23, directed the residence to administer olanzapine 2.5 mg at 2:00 p.m. However, the March 2023 MAR read olanzapine 2.5 mg was administered with the noon meal on 3/26, 3/27, 3/29-4/4/23. On 3/3/23 at 11:17 a.m., the WN #1 stated that she worked hard and diligently not have medication exceptions that are not unavailable. She stated The residence's process for ordering and administering medications was as follows: The practitioner's office would fax medication orders to the pharmacy, the WN #1 would also send a copy of the medication order to the pharmacy, then the pharmacy would enter the order, approve the medication and have it sent to the residence. She stated once the medication was on the MAR then a residence nurse also has to approve the order on the MAR prior to staff having the ability to administer the medication. She stated ideally a medication would be ordered and the residence would have the medication by 7:00 p.m. that same day. The WN #1 further stated the process could take a long time, she stated that the residence was not staffed with a nurse to approve the MARs 24 hours a day seven days a week. She stated the residence's wellness director had the ability to approve medications from home; however, the WN #1 stated the residence was currently without a wellness director. The WN #1 further stated that the residence had switched electronic MAR programs on 3/1/23 which was why there may have been some errors on the first day during the change. She stated that the error with Depakote Sprinkles was due to the delay in the process. She stated that she had faxed the order on 3/9/23 to the pharmacy; it was just waiting on the approval until 3/11/23. The WN #1 stated regarding the olanzapine, was an error with the pharmacy transcribing the order. She stated that since it was time specific it should have reflected it on the MAR. The WN #1 further stated since the residence had it on the MAR as administered with the noon meal they had approximately four hours to administer the medication and not the time specified. On 3/3/23 at 12:32 p.m., the power of attorney for Former Resident #28 stated the former resident had been experiencing an increase in aggression. She stated that the residence had been working with the former resident's psychiatrist to determine the best medication to assist with managing the residents behavioral expressions. On 5/3/23 the administrator of record (AOR) stated the residence partnered with the former resident's psychiatrist and were very involved with making the changes to the medications. He stated more than once a week the residence was reviewing the medications and discussing the medications. The AOR further stated he relied on the nursing team at the residence to ensure medication changes were accurate. The AOR confirmed there was room for improvement regarding the residence medication administration systems. He stated time sensitive medications should have been reviewed on the MAR prior to administration and not sure why it had not been caught by the nursing department at the residence.