.Based on record review, observations, and interviews, the facility failed to implement fall prevention interventions for 1 resident (#49), out of 16 sampled residents. Specifically, a staff failed to ensure the resident correctly applied non-skid socks as outlined in the care plan. This failed practice placed the resident at risk for a fall and/or injuries.Findings:Resident #49 Record review on 6/29/25-7/3/25 revealed, Resident #49 was admitted to the facility with diagnoses that included traumatic ischemia of muscle related to a fall (decrease in the blood supply to a muscle due to a traumatic injury), Parkinson's disease without dyskinesia (degenerative brain condition that affects muscle control and movement), and lumbosacral radiculopathy (pain in the lower back and hip that radiates down the back of the thigh into a leg caused by compressed nerve roots). Review of Resident #49's, Care Plan Report, initiated on 2/11/25, revealed: . [Resident #49] has an ADL [activities of daily living] self-care performance deficit. Interventions. DRESSING: The resident requires limited assistance by (1) staff to dress.Position.CNA [Certified Nursing Assistant].Review of Resident #49's Care Plan Report, initiated 2/11/25, revealed: . [Resident #49] is High risk for falls r/t [related to] previous fall.Ensure that [Resident #49] is wearing appropriate footwear non-skid socks when ambulating or mobilizing in w/c [wheelchair]. CNA. LPN [Licensed Practical Nurse]. RN [Registered Nurse]. Review of Resident #49's, Minimum Data Set (MDS- a federally required nursing assessment), OBRA Quarterly Assessment, dated 5/20/25, revealed: .Mobility. Walk 10 feet.Independent. Walk 50 feet with two turns. Independent.An observation on 6/29/25 at 9:10 AM, revealed Resident #49 was noted to be wearing his/her yellow non-skid socks inside out. During this observation, the resident stated, the yellow socks were a little loose. He/she then got up from his/her bed, walked to the shelves and then proceeded to show the grey unopened non-skid socks on his/her shelf. He/she stated, that one fits a little better.An observation on 6/30/25 at 10:36 AM, revealed Resident #49 was noted to be wearing his/her yellow non-skid socks inside out. During this observation, CNA #1 knocked on the door, walked into the room, and asked the resident if he/she needed anything. The resident declined, and CNA #1 stated, Oh, your socks are inside out, and proceeded to leave the room without fixing Resident #49's socks. During an interview on 6/30/25 at 10:50 AM, when asked if he/she knew the purpose of the bottom white markings (tread grips) of the non-skid socks, and Resident #49 stated, no.An observation on 7/1/25 at 9:36 AM, Resident #49 was noted to be wearing his/her yellow non-skid socks inside out. During this observation, the resident got up from his/her chair and walked to his/her bed area to grab a personal item.During an interview on 7/2/25 at 9:51 AM, CNA #2 stated if a resident was found to not be utilizing the fall prevention measures such as using the call-light, using non-skid socks, or wearing proper footwear, he/she would attempt education and/or assist to help correct. When asked what he/she would do if he/she had found a resident with non-skid socks that are worn inside-out, CNA #2 stated that he/she would attempt to correct them so that the grippers are on the bottom of the feet, if the resident allowed, and notify the floor nurse if the resident declined.During an interview on 7/3/25 at 9:39 AM, CNA #3 stated he/she was trained to utilize the care plan when getting to know the residents and how to care for them. He/she further stated, the care plan contained resident-centered interventions, and staff were trained to follow these interventions that were planned to help mitigate the risk for falls.During an interview on 7/3/25 at 12:20 PM, Nursing Supervisor (NS) #2 stated CNA staff were expected to follow the resident's care plan, and if there were interventions that were not working for the resident, they were to notify the nurses on the floor and/or the NS on duty, which could lead to a revision of the care plan, if necessary.Review of the facility's policy Assessing Falls and Their Causes, revised on 7/2024, revealed: .Falls are a leading cause of morbidity and mortality among the elderly in nursing homes. Residents must be assessed. for potential risk of falls. Relevant risk factors must be addressed properly.Review of the facility's policy Fall Risk Assessment, revised on 3/2024, revealed: .The nursing staff. will seek to identify and document resident risk factors for falls and establish a resident-centered fall prevention plan based on relevant assessment information. The staff will seek to identify environmental factors that may contribute to falling. The staff and attending physician will collaborate and identify and address modifiable risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable.Review of the facility's policy Care Plans, Comprehensive Person-Centered, last revised on 1/2025, revealed: . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to:. receive the services and/or items included in the plan of care. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.

.Based on record review, observation, and interview, the facility failed to administer a medication through the route ordered for 1 resident (#34), out of 16 sampled residents. This failed practice created a medication error and placed the resident at risk of adverse reactions.Findings:Resident #34Record review on 6/29/25-7/3/25 revealed Resident #34 was admitted to the facility with diagnoses that included intracranial (brain) injury, gastrostomy (a surgical procedure where a feeding tube called a percutaneous endoscopic gastrostomy, or PEG tube, is inserted through the abdominal wall to provide direct access into the stomach), and post-traumatic seizures.Review of Resident #34's eMAR (electronic medication administration record) revealed: .levETIRAcetam [an anti-seizure medication] Oral Solution 100 MG [milligram]/ML [milliliter] . Give 10 ml via PEG-Tube two times a day for seizure .-Start Date- .05/19/2025 0900 [9:00 AM] .An observation on 6/30/25 at 2:37 PM, revealed Licensed Nurse (LN) #1 prepared Levetiracetam oral solution in a medication cup. LN #1 asked the resident if he/she was ready for medications to which the resident nodded his/her head. LN #1 raised Resident #34's head of bed and then gave the resident the medication cup. The resident took the medication by mouth and requested water after.During an interview on 6/30/25 at 2:38 PM, LN #1 explained that although the order specified administration of the medication via PEG tube, the resident had been taking all intake, including medications, by mouth. LN #1 further stated that the resident had undergone a swallow study, which supported Resident #34's transition from PEG-tube feedings to oral intake. However, the PEG-tube remained in place pending a reassessment for removal. During an interview on 7/1/25 at 11:25 AM, LN #2 stated the Charge Nurse (CN) would notify the floor nurses if there were changes to the physician's order for a resident and it would be recorded in electronic health record system. He/she further added, orders could be placed or changed by the floor nurse, if necessary, after communicating with the provider.During an interview on 7/2/25 at 10:55 AM, the Director of Nursing (DON) stated Resident #34's orders to change the route for the PO [by mouth] trial (monitored attempt to give a patient food, fluids, or medication by mouth to evaluate their ability to safely swallow and tolerate oral intake) should have been completed when the resident came back from his/her appointment and after the recommendations were received and noted by the Charge Nurse. Review of the facility's policy Administering Medications, last revised 1/2025, revealed: .Policy Statement .Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders .10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medications, right dosage, right time and right method (route) of administration before giving the medication .Review of Lippincott Nursing Procedures, Safe Medication Practices, published in 2023, revealed: .To promote a culture of safety and to prevent medication errors, nurses must . adhere to the five rights of medication administration: .administer the medication by the right route .

.Based on record review, observation, and interview, the facility failed to ensure infection control procedures were properly implemented in the facility for 3 residents (#s 4, 54, and 58) out of 16 sampled residents. Specifically, the facility failed to: 1) ensure Certified Nurse Assistants (CNAs) used required personal protective equipment (PPE) while caring for residents (#'s 4 and 54) who were on enhanced barrier precautions (EBP-the use of gown and gloves during high-contact resident care activities); and 2) ensure a clean environment during Resident #58's wound care. These failed practices placed the residents at risk of infection which could have affected their overall health and wellbeing.Findings:Use of PPEResident #4Record review on 6/29/25-7/3/25 revealed Resident #4 was placed on EBP due to the presence of an indwelling catheter (a medical device that drains urine from the bladder leading to a drainage bag).An observation on 6/30/25 at 3:42 PM, revealed a sign posted on the door outside of Resident #4's room. The sign read: STOP Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and leaving the room. Providers And Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities . Device care or use .urinary catheter .An observation on 6/30/25 at 3:45 PM, LN #1 administered medications to Resident #4. Further observation revealed Certified Nursing Assistant (CNA) #1 knocked on the door, walked into the room, completed hand hygiene with the alcohol-based sanitizer, then put on a pair of gloves. Next, he/she walked over to the right side of the resident's bed and drained urine from the catheter bag. The CNA stated, there was 300 mL [milliliter] output, to LN #1. It was noted CNA #1 was not wearing a gown during the observation.During an interview on 6/30/25 at 3:50 PM, CNA #1 stated there were signs posted on the resident's door to help indicate to staff whether they need to follow precautions. He/she stated hand hygiene, wearing a gown and gloves were required when a catheter bag was being emptied due to them being on EBP. Resident #54Record review on 6/29/25-7/3/25 revealed Resident #54 was on EBP due to the use of an indwelling catheter.An observation on 7/2/25 at 11:17 AM, revealed a sign posted on the door outside of Resident #54's room. The sign read: STOP Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and leaving the room. Providers And Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities . Changing Linens . Providing Hygiene. Further observation revealed CNA #4 and Student #1 entered the resident's room. Both CNA #4 and Student #1 sanitized their hands with alcohol-based hand sanitizer, put on gloves, then gathered supplies for resident care. CNA #4 and Student #1 stood on each side of the bed. Both proceeded to remove Resident #54's blanket, pillows, soiled chucks (an absorbent pad used to protect the bedding). Next, they placed a clean fitted sheet onto the bed and inserted clean chucks under Resident #54's buttocks. Then, CNA #4 repositioned Resident #54 onto his/her left side after which Student #1 cleaned the resident's back using wet wipes. Afterwards, Student #1 placed a wedge pillow under Resident #54's legs. CNA #4 changed his/her gloves without performing hand hygiene. CNA #4 and Student #1 assisted Resident #54 with repositioning in bed and placed a clean blanket over the resident's legs. CNA #4 gathered all soiled sheets and chucks and placed them under the bathroom sink. Afterwards, CNA #4 and Student #1 removed their gloves and performed hand hygiene. It was noted both CNA #4 and Student #1 were not wearing gowns for the duration of the task.During an interview on 7/2/25 at 2:13 AM, the Infection Preventionist (IP) stated staff were expected to follow the EBP recommendations posted on the residents' door during resident cares.During an interview on 7/3/25 at 10:10 AM, the Director of Nursing (DON) was asked if all staff were trained on EBP, the DON stated: Yes. Review of the facility's policy, Enhanced Barrier Precautions, adopted 3/27/24, revealed: .[EBP] .Purpose: To reduce transmission of multidrug resistant organisms (MDROs) .Policy: Care staff will wear gowns and gloves during high contact activities.when caring for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.Clean wound care environmentAn observation on 7/2/25 at 10:41 AM, revealed LN #3 performed hand hygiene, and put on a gown and gloves. Afterwards, without cleaning the surface, and without putting down a clean surface barrier, LN #3 placed wound dressing supply packages, an opened syringe with saline, and gloves on the windowsill. Then, LN #3 continued wound care for Resident #58.During an interview on 7/3/25 at 10:02 AM, when asked what the standard practice should be when preparing supplies for wound care, the DON stated the LNs could use a bedside table or use a part of the bed. She further stated if the LN preferred to use a bedside table, the LN should clean the bedside table before placing the wound care supplies on it. The DON added that if the LN preferred to use the bed, the wound dressing package, once opened, could serve as a surface barrier for placing supplies. Review of the facility's policy Wound Care, 2001 MED-PASS (unknown acronym), revised on 3/2024, revealed: .use disposable cloth (paper towel is adequate) to establish a clean field on resident's overbed table. Place all items to be used during procedure on the clean field.

. Based on record review and interview the facility failed to complete a comprehensive admission assessment using the Resident Assessment Instrument 3.0 Minimum Data Set (MDS, a federally required nursing assessment for long term care residents) for one resident (#204), out of 14 sampled residents. This failed practice had the potential to cause inaccurate health and functional status for the resident, of which placed the resident at risk for inconsistent care. Findings: Record review on 6/17-21/24, revealed Resident #204 was admitted to the facility with diagnoses that included Parkinsons disease (a progressive disorder that affects the nervous system and causes movement problems, such as shaking, stiffness, and difficulty with balance and coordination), and neurocognitive disorder with Lewy bodies (a form of dementia where abnormal amounts of protein deposits are located in the nerve cells of the brain affecting cognitive functioning). Review of Resident #204's MDS Summary, dated 6/11/24, revealed sections A (Identification), B (Hearing, Speech, and Vision), C (Cognitive Patterns), D (Mood), and V (Care Areas Assessment Summary) were all In Progress. Review of Resident #204's Care Plan, dated 6/6/24, revealed the following focus areas: . [Resident #204] has a hearing impairment. [Resident #204] uses anti-anxiety medications escitalopram r/t [related to] Anxiety disorder. [Resident #204] uses anti-depressant medication Escitalopram. [Resident #204] has impaired cognitive function/dementia or impaired thought processes r/t Dementia. During an interview on 6/21/24 at 11:11 AM, the MDS Nurse stated the facility had fourteen days after admission to complete a comprehensive admission assessment. After reviewing Resident #204's chart, she stated the admission assessment should have been completed by 6/19/24. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, dated 10/2023, revealed: admission (Comprehensive) . MDS Completion Date. 14th calendar day of the resident's admission. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and interview, the facility failed to complete a comprehensive reassessment within 14 days after the Resident was diagnosed with dementia for one resident (#28) out of 14 sampled residents. This failed practice had the potential to decrease the resident's quality of life and jeopardized potential for maintaining functional independence at the highest possible level. Findings: Resident #28 Record review from 6/17-21/24 revealed Resident #28 was admitted to the facility in April 2024 with diagnoses that included cardiac arrest, and hypertensive heart disease (prolonged unmanaged high blood pressure) with heart failure. Further review revealed on 5/13/24, an additional diagnosis was added by the facility's provider of severe vascular dementia with psychotic disturbance (a condition caused by restricted blood flow to parts of the brain characterized by impaired reasoning, planning, judgement, and memory). Behaviors: Record review of the MDS (Minimum Data Set, a federally required nursing assessment) OBRA (Omnibus Budget Reconciliation Act) admission assessment, dated 4/24/24 revealed: Section E - Behavior . Psychosis . None of the above [hallucinations or delusions] . Overall Presence of Behavioral Symptoms .No . Record review of the care plan focus dated 4/29/24 revealed, Resident #28 was: .independent for meeting emotional, intellectual, physical, and social needs . Record review of SNF [Skilled Nursing Facility] Visit Note dated 5/13/24, revealed: Nursing has noted some pretty intense agitation, anxiety, and hallucinations especially in the evenings this is pretty consistent .Examples of hallucinations include believing [he/she] had fish all over [him/her], also stating that someone in the therapy gym has been kidnapping [him/her] for days at a time and holds [him/her] hostage . Mood: Record review of the MDS OBRA admission assessment, dated 4/24/24 revealed: Section F - Mood . Feeling down, depressed, or hopeless . No . Record review of SNF [Skilled Nursing Facility] Visit Note dated 4/24/24, the provider stated: Mood and Affect: Pleasant and cooperative. Review of IDT [Interdisciplinary Team] Care Conference 1.0 dated 5/1/24 stated, [Resident #28] reports that [he/she] is very scared but is unsure why [he/she] is scared. Record review of the progress notes dated 5/14/24 at 11:08 AM revealed: .CNA [Certified Nursing Assistant] was outside of room and resident was heard stating I can't wait to kill myself. During an observation on 6/17/24 at 2:59 PM, revealed Resident #28 in bed yelling out Please God. repeatedly. Review of the facility's Resident Matrix printed on 6/17/24 revealed the column for Alzheimer's/Dementia was checked for Resident #28. Emergent Unstable Event: Record review of the nursing progress notes dated 5/20/24 at 6:27 AM revealed: Called to resident room at 0530. Resident calling out help me I can't breathe . Lungs diminished and wheezy throughout. O2 sat [oxygen blood saturation] = 88% Neb tx [nebulizer treatment] provided but resident not able to cooperate due to disorientation and anxiety. Resident removed neb [nebulizer] and continues to holler. Record review of the nursing progress notes dated 5/20/24 at 1:48 PM revealed: This nurse called [emergency room] to receive report on resident. Will be admitting resident of observation [due to] hypoxia [low levels of oxygen in body tissues] . Record review of the hospital Discharge summary dated [DATE] revealed: Hypoxemic respiratory failure .Plan transition to Lasix [medication used to reduce extra fluid in the body] .start Symbicort [inhaler medication for control and prevention of wheezing and shortness of breath] Review of the MDS on 6/20/24 for Resident #28 revealed a Significant Change in Status Assessment (SCSA) was not completed. During an interview on 6/21/24 at 10:36 AM, the MDS Nurse stated that a diagnosis of dementia might qualify as a significant change if there was a change in the resident's functional status. If it looked like the resident was not going to get better, the diagnosis would be confirmed in an IDT meeting where they would review and make changes to different aspects of care if needed. She confirmed the last IDT meeting was on 5/1/24, which was before the diagnosis of dementia was made. During an interview on 6/21/24 at 2:49 PM, the Director of Nursing (DON) reviewed Resident #28's chart and agreed that the diagnosis of dementia was a new diagnosis on 5/13/24 and that a SCSA should have been completed in addition to an IDT meeting. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 dated 10/2023, revealed A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. .

. Based on record review and interview, the facility failed to ensure range of motion (ROM) exercises were provided to 1 resident (#6), out of 14 sampled residents. This failed practice had the potential to place the resident at risk of not receiving the necessary care and therapy to maintain his/her level of mobility. Findings: Review on 6/17-21/24, revealed Resident #6 was admitted to the facility with diagnoses that included sepsis (an infection of the bloodstream) and quadriplegia (complete paralysis of the body from the neck down). During an interview on 6/17/24 at 2:19 PM, Resident #6 stated he/she had difficulty moving his/her arms. When asked if he/she had therapy, Resident #6 stated No. Review of Minimum Data Set (MDS- a federally required nursing assessment) admission Assessment, dated 4/22/24, revealed: Section GG. Functional Limitation in Range of Motion A. Upper extremity 2=impairment on both sides, B. Lower extremity 2=impairment on both sides. Review of Resident #6's Care Plan, dated 4/15/24, revealed: Focus: . [Resident #6] has limited physical mobility related to quadriplegia, Desired outcome: [Resident #6] will maintain current level of mobility, [Resident #6] will remain free of complications related to immobility . Intervention: . resident is totally dependent . PT/OT, referral as ordered, PRN [as needed] . During an interview on 6/19/24 at 9:13 AM, Restorative Nurse Aide (RNA) #1 stated he/she provided ROM exercises to Resident #6 three times a week. RNA #1 also stated that ROM exercises were coordinated with a physical therapist. When asked of the ROM goals for Resident #6, RNA #1 stated Resident #6 had very limited movement. Resident #6 could touch his/her phone, grab his/her wheelchair and wheel himself/herself around. The goal was to sustain the resident's ability. Review of the Maple Springs RNA Program, dated 4/23/24, revealed Resident #6 had 2-3 x/week ROM. Further review revealed: Goals: Maintain ROM in UB [upper body] and Avoid Contractures .ROM: UE [upper extremity] ROM at all joints of the upper body shoulders, elbow, wrist, digits. During an interview on 6/21/24 at 1:00 PM, Physical Therapist (PT) #1 stated Resident #6 had restorative care. Surveyor requested for a copy of the restorative plan and RNA documentation of the restorative care provided to Resident #6. During an interview on 6/21/24 at 3:46 PM, when asked of the status of RNA documentation, the Director of Nursing (DON) stated the RNA had a hard time accessing the point click care (PCC-the facility's electronic health record) and the PCC was not saving RNA notes. When asked if PCC was not saving notes since 4/23/24 as indicated date in the RNA Program, the DON stated it was not saving. The DON further stated she did not know that RNA notes were not saved and there was no other place the documentation could be saved. The DON stated the RNA started charting on 6/20/24 because the DON asked for it. Review of the facility's policy Restorative Nursing Services, dated 12/2023, revealed: . Restorative goals may include, but not limited to supporting and assisting the resident in: a. adjusting or adapting to changing abilities; b. developing, maintaining or strengthening his/her physiological and psychological resources. .

. Based on record review and interview, the facility failed to review the drug regimen for 1 resident (#18), out of 14 sampled residents, for adequate parameters of a medication dose range order (orders in which there are dosing amount options over a prescribed range). This failed practice had the potential to expose the resident to unnecessary medications. Findings: Review on 6/17-21/24 revealed Resident #18 was admitted to the facility under hospice care for diagnoses that included dementia, unspecified severity, with agitation. Resident #18 had a history of stroke which had contributed to the decline of his/her dementia. Review of Resident #18's electronic medication administration record (eMAR), dated 6/2024, revealed the following pain medication: Morphine Sulfate (Concentrate) Solution [liquid form of morphine, a narcotic used to treat moderate to severe pain] 20 milligrams [mg] / [per] milliliter [ml] - Give 0.25ml [or 5mg] by mouth every 2 hours as needed for moderate to severe pain/shortness of breath. Further review of this order revealed the following instructions that included a range order: May have 0.25mL to 1.0mL by mouth or under tongue. Further review of these instructions revealed no parameters for the dosage ranges provided to determine which dose should be administered when. The start date for this medication order was on 10/4/23 for 14 days, ending on 10/17/23. This medication was then renewed on 10/18/23 and ordered to continue until 6/18/24. Review of Resident #18's Morphine administration history, from 10/2023 to 6/2024, revealed that Resident #18 mostly received the maximum dose of 1.0ml (or 20mg) of Morphine when given: 10/7/23 - 1ml 10/8/23 - 1ml 10/16/23 - 1ml 11/5/23 - 1ml 11/6/23 - 1ml 11/13/23 - 1ml 11/19/23 - 1ml 2/3/24 - 0.25ml 3/15/24 - 0.25ml 6/16/24 - 1ml 6/17/24 - 1ml 6/18/24 - 0.5ml During an interview on 6/20/24 at 12:02 PM, when asked about Resident #18's Morphine PRN medication and the associated range order without parameters, Pharmacist #20 (who oversaw the facility resident's medication management) stated range orders usually come from hospitals and the facility usually discontinued those for more accurate dosage orders. Pharmacist #20 further stated that range orders also came from hospice agencies and can be difficult to consistently administer at the minimum therapeutic dose, as residents tend to ask for the maximum dose. During an interview on 6/20/24 at 3:01 PM, when asked about Resident #18's Morphine PRN medication and the associated range order without parameters, Physician #5 (who managed residents in the facility) stated he/she hadn't overseen Resident #18's medication management as the resident was on hospice status. Physician #5 further stated that hospice residents were seen by hospice agencies who had full control of the resident's care, to include medication management. During an interview on 6/20/24 at 4:03 PM, when asked about Resident #18's Morphine PRN medication and the associated range order without parameters, the Ancora Hospice Medical Director (who oversaw Resident #18's care) stated he was aware of hospital guidelines to give parameters of a range of pain levels and associated doses of medication per level of pain, however hospice agencies didn't provide parameters with range orders. The Ancora Hospice Medical Director stated the idea behind range orders in hospice was to give the lowest dose first and move up in dose if needed. When informed of the maximum dose administration history with Resident #18's Morphine PRN order, the Ancora Hospice Medical Director stated the maximum dose was not intended to be administered first, but an option if needed when smaller doses were ineffective. Review of the facility's policy Medication Orders, dated 12/2023, revealed: . The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. Recording Orders. Medication Orders - When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered . PRN Medication Orders - When recording PRN medication orders, specify the type, route, dosage, frequency, strength and the reason for administration . Review of the facility's policy Administering Medications, dated 12/2022, revealed: . If a dosage is believed to be inappropriate or excessive for a resident . the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns . When asked for a policy regarding the policy and procedures for hospice resident care at the facility, the Director of Nursing stated there was no policy regarding hospice resident care in the facility. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and interview, the facility failed to ensure three residents' (#6; and #28) transfer notices were sent to the Alaska Office of the State Long Term Care Ombudsman (LTCO). This failed practice had the potential to affect all residents, based on a census of 53, by: 1) denying residents the added protection from being inappropriately discharged ; 2) providing the residents with access to an advocate who can inform them of their options and rights; and 3) ensuring the Office of the State (LTCO) was aware of facility practices and activities related to transfers and discharges. Findings: Record review from 6/17-21/24 revealed Resident #6 was admitted to the facility with diagnoses that included sepsis (an infection of the bloodstream), and quadriplegia (complete paralysis of the body from the neck down). Further review revealed the resident suffered from uncontrolled pain in the right hip. The staff observed Resident #6's right leg was abnormally shorter than the left leg. The provider ordered the resident to the emergency department for evaluation and the resident was hospitalized on [DATE]. No LTCO notification of the facility-initiated transfer was found on the record. Further record review revealed Resident #28 was admitted to the facility with diagnoses that included cardiac arrest, and hypertensive heart disease (prolonged unmanaged high blood pressure) with heart failure. Further review revealed the resident was hospitalized on [DATE] for pulmonary edema (a buildup of fluid in the air spaces or tissues of the lungs). No LTCO notification of the facility-initiated transfer was found on the record. During an interview on 6/21/24 at 2:54 PM, the Director of Nursing (DON) stated that the staff who sent facility-initiated transfers/discharge notifications to the LTCO had resigned in May 2024. She did not know if the Ombudsman was notified for Residents #6 and #28. During an interview on 6/21/24 at 5:29 PM, the Administrator stated that facility-initiated transfers/discharge notification was sent once a month via email to the Ombudsman's office. Unfortunately, the staff that handled the monthly notifications resigned in May 2024 and he was unable to access the staff's email account. He had called the Ombudsman's office earlier that day and confirmed they had received notifications for January, March, and April 2024. No notification for the month of May 2024 was sent. During an email correspondence with the office of the LTCO, on 6/21/24 at 1:35 PM, the LTCO wrote the facility had been inconsistent with sending the monthly facility-initiated discharges, and confirmed that only January, March, and April 2024 were received from the facility. Review of the facility's policy Transfer or Discharge, Facility-Initiated, dated 10/22, revealed: When residents who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers, NOT discharges, because the resident's return is generally expected . A copy of the [transfer or discharge] notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. .

. Based on record review, observation, and interview, the facility failed to ensure comprehensive care plans were developed and implemented with smoking care needs for two residents (#'s 11, and 33), out of 14 sampled residents. Specifically, the facility failed to address risk factors and include specific information concerning the residents' smoking in their care plans. This failed practice had the potential to place the residents at risk for harm. Findings: Resident #11 Record review on 6/17-21/24, revealed Resident #11 was admitted with diagnoses that included a right ankle fracture which was surgically fused making the joint immobile, diabetes, high blood pressure, and acute respiratory failure with hypoxia (below normal oxygen levels in the blood). An observation on 6/19/24 at 4:28 PM, revealed Resident #11 was outside by the dumpster listening to music and smoking. Review of the handwritten facility provided list of smokers, revealed Resident #11 was included on this list. Review of Resident #11's MDS (Minimum Data Set - A Federally required nursing assessment) admission assessment, dated 4/5/24, revealed: Section J1300. Current Tobacco Use . No . Yes did not contain an answer. Review of the facility's electronic health record Assessment tab on 6/19/24 at 2:16 PM, revealed no smoking assessment was conducted for Resident #11. Review of Resident #11's Care Plan, dated 4/5/24, revealed no focused care planning for Resident #11's smoking. During an interview on 6/19/24 at 2:20 PM, the Director of Nursing (DON) confirmed Resident #11 was a smoker but was not able to provide a smoking assessment for Resident #11. Resident #33 Record review on 6/17-21/24, revealed Resident #33 was admitted with diagnoses that included a left below the knee amputation, peripheral vascular disease (where the blood vessels located anywhere outside the heart have narrowing, blockage, or spasms), and nicotine dependence. During an interview on 6/17/24 at 11:33 AM, Resident #33 stated that he/she rolled his/her own cigarettes and kept the cigarette rolling supplies (loose tobacco and papers) and lighter in his/her room. When he/she smoked, he/she did not wear a protective apron and did not feel that it was necessary because he/she had been smoking for a very long time and could control where the ashes fell. Review of Resident #33's most recent MDS quarterly review assessment, dated 3/13/24, revealed: Section J1300. Current Tobacco Use . No . Yes . had a check mark beside Yes, indicating Resident #33 smoked. Review of Resident #33's Care Plan, dated 4/8/24, revealed no care planning for Resident #33's smoking. Review of the facility's electronic health record Assessment tab on 6/19/24 at 2:10 PM, revealed no smoking assessment was conducted for Resident #33. During an interview on 6/19/24 at 2:20 PM, the Director of Nursing (DON) confirmed Resident #33 was a smoker but was not able to provide a smoking assessment for Resident #33. During an additional interview on 6/21/24 at 4:00 PM, the DON confirmed that smoking should be included in the care plans for all residents who smoke. She further stated that somethings (such as smoking) were not coming over from the admission assessment. Review of the facility's policy Care Plans, Comprehensive Person-Centered, dated 12/2019, revealed: . The comprehensive, person-centered care plan will: . Incorporate identified problem areas . Incorporate risk factors associated with identified problems . Reflect the resident's expressed wishes regarding care and treatment goals . .

. Based on record review and interview, the facility failed to ensure comprehensive care plans were revised to meet the changing needs of 2 residents (#'s 10 and 18), out of 14 sampled residents. Specifically, the facility failed to revise care plans to reflect: 1) the level of support needed during appointments for 1 resident (#10); 2) the interventions added for fall prevention for 1 resident (#18); and 3) the interventions trained to address behavioral/emotional needs for 1 resident (#18). These failed practices placed the residents at risk for less than the highest practicable mental, physical, and psychosocial well-being. Findings: Resident #10 - Level of Support Needed Record review on 6/17-21/24 revealed Resident #10 was admitted to the facility with diagnoses that included locked-in state (virtual total paralysis with retained consciousness), and dysphagia (difficulty swallowing). Resident #10 was also not able to communicate verbally. Further review revealed Resident #10 was totally dependent on staff for all Activities of Daily Living (ADLs) to include bed mobility, transfers, wheelchair placement and positioning, bathing, toileting, dressing, eating, and oral hygiene. Nutrition for Resident #10 was through tube feeding (a tube inserted directly into a person's stomach through the abdominal wall) but was able to enjoy pleasure feeding by mouth of soft pureed foods and pudding-like thickened liquids. Further review revealed Resident #10's parents have been his/her legal guardians and conservators since 2017 and have been given the court authority to meet the essential requirements for physical health or safety, to protect [Resident #10's] rights . to provide for [Resident #10's] medical care. During an interview on 6/17/24 at 3:09 PM, Resident #10's mother stated that Resident #10 communicated by using a letter board and eye movements, or with an iPad communication program that spoke as he/she typed. Resident #10's mother stated that some staff were familiar with these methods of communication with Resident #10, however it required training to learn. When asked if Resident #10 had received regular dental care while in the facility, Resident #10's mother stated he/she had, however the last dental appointment did not go well. Resident #10's mother stated that it was arranged that she would attend the last dental appointment with Resident #10, to be a support person and to verbalize Resident #10's needs to the dentist due to Resident #10's locked in state and difficulty swallowing. Resident #10's mother stated that the original dental appointment had been changed without her being informed and Resident #10 was driven to the appointment by the facility, however ended up attending the appointment alone. Resident #10's mother stated Resident #10 had no one to communicate for him/her and Resident #10 relayed to his/her mother afterwards that the experience was awful and he/she experienced choking from water used during the dental treatment and was distressed throughout the appointment. During an interview on 6/21/24 at 3:27 PM, when asked about the situation with Resident #10's last dental appointment, the Director of Nursing (DON) stated Resident #10 had attended a dental appointment on 12/8/23, and for reasons she could not explain, ended up attending the appointment alone. The DON stated usually, Resident #10 always attended appointments with family or a Certified Nursing Assistant (CNA) that knew him/her very well and was able to help communicate for him/her. When asked if it was written in Resident #10's care plan that Resident #10 needed to be accompanied on appointments, the DON stated there was nothing written to say that Resident #10 cannot go to appointments alone, but that it was a well-known fact that everyone knew. Review of Resident #10's Nurse's Note, dated 12/8/23 at 12:28 PM, revealed: Resident up in [wheelchair], alert. Resident leaving with driver for [appointment] . Review of Resident #10's Nurse's Note, dated 12/8/23 at 4:55 PM, revealed: Resident returned to facility from [appointment] . with driver at [3:15 PM] this afternoon. Review of Resident #10's care plan, first initiated 1/14/20, revealed the following identified focus concerns: - Focus: [Resident #10] has oral/dental health problems. (Date initiated: 1/14/20. Revision on: 2/4/20) . Interventions: Coordinate arrangements for dental care, transportation as needed/as ordered. (Date initiated on 2/4/20). Further review revealed no intervention to ensure Resident #10 was accompanied by a guardian or staff member to these dental appointments. Resident #18 - Fall Prevention Review on 6/17-21/24 revealed Resident #18 was admitted to the facility under hospice care for diagnoses that included dementia, unspecified severity, with agitation. Resident #18 had a history of stroke which had contributed to the decline of his/her dementia. Further review revealed Resident #18 has had 28 falls since his/her admission 8 months ago. A review of Resident #18's Initial Post Fall Clinical Review documentation, dated 10/4/23 through 6/17/24 which was completed after each fall, revealed how the fall occurred and any additional interventions that were added to Resident #18's care to prevent further falls: 1) 10/4/23: unwitnessed, found on floor on left side in front of his/her wheelchair (wc). - Review of documentation revealed: . Interventions added for safety . an alarm for chair would be good . 2) 10/7/23: unwitnessed, found on floor, wc in front of him/her. - Review of documentation revealed: . Intervention added for safety . Mats on Floor . 3) 10/12/23: unwitnessed, found on floor in doorway of room, wc behind him/her. - Review of documentation revealed: . Intervention added for safety . Education on safety . 4) 10/26/23: unwitnessed, found on floor in front of wc. - Review of documentation revealed: . Intervention added for safety . Resident transferred to bed and mat lay next to bed . 5) 10/29/23: unwitnessed, heard resident yell out, found on floor by wc. - Review of documentation revealed: . Intervention added for safety . education on safety . 6) 11/21/23 at 2:08 AM: unwitnessed, found on floor by bed. - Review of documentation revealed: . Intervention added for safety . Mats on floor . Resident bed set to lowest setting and lamp is on in [his/her] room. Staff will increase rounding on resident . 7) 11/21/23 at 5:25 PM: resident found on [his/her] knees on floor by [his/her] bed. - Review of documentation revealed: . Intervention added for safety . Not sure what else we can do. CNA [certified nursing assistant] had just been in [his/her] room. Bed is low. Mat on floor . 8) 11/25/23: unwitnessed, found lying on floor in dining room. - Review of documentation revealed: . Intervention added for safety . Q [every] 30 minute rounding . 9) 12/2/23: unwitnessed, found on floor between bed and window. - Review of documentation revealed: . Intervention added for safety . Mats on floor . moved the bed against wall as per resident request . 10) 12/3/23: unwitnessed, found on floor legs on floor mat, body and arms off floor mat. - Review of documentation revealed: . Intervention added for safety . floor alarm requested . 11) 12/5/23: unwitnessed, fell from wc and found on floor. - Review of documentation revealed: . Intervention added for safety . Low bed . 12) 12/8/23: witnessed, stood in dining room to transfer from wc to chair. Fell back and landed on buttocks; - Review of documentation revealed: . Intervention added for safety . Education on safety . 13) 12/13/23: witnessed, stood by bed grabbed onto bedside table and seen slide to floor onto buttocks; - Review of documentation revealed: . Intervention added for safety . [resident] has fall alarm, bed in lowest and mattress on floor . 14) 12/24/23: unwitnessed, fell from bed. - No Initial Post Fall Clinical Review was provided for this fall. 15) 1/21/24: witnessed, fell when he/she stood from wc and fell back. Did not hit head. - Review of documentation revealed: . Intervention added for safety . Mats on floor . 16) 1/24/24: unwitnessed, found on floor between bed and window. - Review of documentation revealed: . Intervention added for safety . due to confusion I am unaware of any others not implemented that would help . 17) 2/1/24: unwitnessed found on floor by bed, blood on head and hands. - Review of documentation revealed: . Intervention added for safety . Resident is confused often and forgets that [he/she] is unable to walk . 18) 2/3/24: unwitnessed; - Review of documentation revealed: . Intervention added for safety . already has alarm and mattress on floor . 19) 2/5/24: unwitnessed, found on the floor in another resident's room. - Review of documentation revealed: . Intervention added for safety . residents room was moved yesterday so that [he/she] could be on a busier hall with more people walking by . 20) 2/12/24: unwitnessed, found on floor outside of room in front of wc. - Review of documentation revealed: . Intervention added for safety . resident was a 1:1 [one staff to one resident] until [he/she] slept . 21) 2/18/24: unwitnessed, found on floor next to wc. - Review of documentation revealed: . Intervention added for safety . [patient] placed in low bed, alarm on, mats on floor, monitoring . 22) 2/29/24: unwitnessed, found on floor in front of wc. - Review of documentation revealed: . Intervention added for safety . Mats on floor . 23) 3/9/24: unwitnessed, found on floor in hall outside of room. Fell from wc. - Review of documentation revealed: . Intervention added for safety . all interventions resumed . 24) 3/24/24: witnessed fall, resident slid out of wc onto floor. - No Initial Post Fall Clinical Review was provided for this fall. 25) 4/2/24: unwitnessed, found on floor in bathroom. - Review of documentation revealed: . Intervention added for safety . Call light adjusted . 26) 4/26/24: witnessed, resident slid out of wc onto floor. - Review of documentation revealed: . Intervention added for safety . clothing/shoe adjustment . [wc] alarm in place and alerted CNA of incident . 27) 4/27/24: witnessed, resident slid out of wc onto floor. - Review of documentation revealed: . Intervention added for safety . clothing/shoe adjustment . [wc] alarm in place and alerted CNA of incident . 28) 6/17/24: witnessed, resident slid out of wc onto floor. - Review of documentation revealed: . Intervention added for safety . current orders for bed and [wc] alarm, low bed, mats on floor. Frequent monitoring while up in [wc] . During an interview on 6/20/24 at 3:04 PM, when asked how the facility monitors resident falls and ways to minimize the risks of falls, Physician #5 stated there was a fall huddle, or meeting for falls, that occurred every Monday. During the meeting each resident fall would be discussed, and interventions would be discussed to add to the resident's care to help prevent further falls. During an interview on 6/21/24 at 9:14 AM, when asked about Resident #18's plan of care and any interventions added to help prevent falls, Physician #11, who was Resident #18's primary provider, stated when staff reported Resident #18's fall there was always discussion about interventions that could be added. Increased toileting, fall mat, bed in lowest position at all times, and increased rounding were all added. During an interview on 6/21/24 at 2:57 PM, when asked what interventions had been placed during Resident #18's stay at the facility for fall prevention, the Director of Nursing (DON) stated interventions for a fall mat by the bed, increased monitoring was moved to every two hours, increased toileting, and increased 1:1 activity, as well as having Resident #18 attend activities in the activity room, was all initiated. The DON further stated that the chair and bed alarm were also initiated. Fall Huddle Review Review of the facility provided Weekly Fall Meeting minutes revealed Resident #18 was first documented at the 12/11/23 meeting, which documented his/her 11th fall on 12/5/23. No interventions were added at this time. Further review revealed: - 12/18/23 meeting: Documented Resident #18's 12/13/23 fall, which was his/her 13th fall. The intervention documented was all staff to get resident more activities throughout day. - 12/26/23 meeting: Documented Resident #18's 12/24/23 fall, which was his/her 14th fall. No new interventions were documented at this time. - 2/5/24 meeting: Documented Resident #18's 2/3/24 fall, which was his/her 18th fall. The intervention that was documented was Room change - 109. - 2/19/24 meeting: Documented Resident #18's 2/18/24 fall, which was his/her 21st fall. No new interventions were documented at this time. - 3/4/24 meeting: Documented Resident #18's 2/29/24 fall, which was his/her 22nd fall. No new interventions were documented at this time. - 3/25/24 meeting: Documented Resident #18's 3/24/24 fall, which was his/her 24th fall. The intervention that was documented was PT to [evaluate] [wc]. - 4/8/24 meeting: Documented Resident #18's 4/2/24 fall, which was his/her 25th fall. No new interventions were documented at this time. - 4/29/24 meeting: Documented Resident's 4/26/24 fall, which was his/her 26th fall. The intervention that was documented was [rehabilitation] adjust chair. Further review of the fall huddles meeting minutes provided by the facility revealed no other falls or interventions were documented for Resident #18. Fall Mats Review of Resident #18's record revealed it could not be determined when exactly the fall mats were initiated. Where the use of fall mats was first documented on 10/7/23 Initial Post Fall Clinical Review form, there was no order for fall mats in Resident #18's medical record. The risk and benefits form for a fall mat was not completed until 12/1/23, which was after the eighth fall. Chair and Bed Alarm Review of Resident #18's record revealed an order for a motion detector and chair alarm, dated 4/3/24, on the day of the 25th fall. The risk and benefits forms for the chair and bed alarms were not completed until 4/23/24. Care Plan Review Review of Resident #18's care plan revealed the following identified focus problem: [Resident #18] is at risk for falls [related to] weakness and decreased safety awareness. Date initiated: 10/3/2023, Revision on: 10/17/2023. Further review of the care plan revealed: 1) the fall mat was not added to the care plan until 1/15/24, which was more than three months after its first documented use; 2) increased toileting was not on the care plan; 3) the chair alarm and the bed alarm were not on the care plan; 4) Increasing 1:1 activity was not added to the care plan until 1/30/24, after the 16th fall; 5) Encouraging Resident #18 to attend activities was added to the care plan on 3/26/24, after the 24th fall. Resident #18 - Behavior Interventions Review on 6/17-21/24 revealed Resident #18 had documented history of multiple times of striking out, hitting, grabbing onto staff, and injuring staff during day-to-day cares. This was attributed to Resident #18's dementia. Further review revealed Resident #18 was also on the antipsychotic medication Seroquel and the antianxiety medication Lorazepam (Ativan). Review of Resident #18's care plan revealed the identified focus problems: 1) [Resident is at risk for anxiety, loneliness, grief, coping with death/dying. Date initiated: 1/22/2024. Revision on: 1/30/2024. The only intervention added to this focus problem was provide empathic listening. Date initiated: 1/22/2024. 2) [Resident #18] is experiencing delirium and agitation. Date initiated: 1/22/2024. Revision on: 1/30/2024. Interventions for this focus problem were: 1) Encourage patient and/or caregiver(s) to express needs, fears, concerns, and frustrations. Date initiated: 1/22/2024; and 2) Hospice to assess coping mechanisms of family. Provide support, as needed. Date initiated: 1/22/2024. 3) [Resident #18] has a risk for behavior problems [related to] Dementia. Date initiated: 10/16/2023. Revision on: 10/17/2023. Interventions for this focus problem were: 1) Administer medications as ordered. Monitor/document for side effects and effectiveness. Date initiated: 10/16/2023; 2) Anticipate and meet the resident's needs. Date initiated: 10/16/2023; and 3) Explain all procedures to the resident before starting and allow the resident to adjust to changes. Date initiated: 10/16/2023. Revision on: 10/17/23. Further review of the care plan revealed no interventions on how best to interact or work with the resident to minimize agitation and risk of aggressive behavior. During an interview on 6/21/24 at 9:14 AM, when asked if there were interventions that could be used for working with Resident #18 that would minimize agitation or aggression, Physician #11 stated the key to working with Resident #18 was that staff needed to approach him/her in a friendly manner and he/she had to be able to see you approaching. Physician #11 stated he/she had never had any aggression from him/her when working with Resident #18. If spoken to loudly or if staff approached him/her from behind, this could trigger aggression. Physician #11 further stated that there were concerns that night shift staff had not been as patient with Resident #18, which caused aggression. Physician #11 stated he/she approached the DON and requested staff be educated on how best to work with Resident #18, to be more patient, friendly, and speak and move calmly around him/her. During an interview on 6/21/24 at 2:55 PM, when asked about the request for staff training from Physician #11 concerning how to work best with Resident #18, the DON stated she remembered this request and stated she tailored some training with CNAs who worked with Resident #18, such as not getting in his/her face, getting on his/her level, speak in a normal tone, and identifying Resident #18's tell-alls or cues he/she had, like a special look, that told staff they needed to disengage and try later. When asked if these techniques were added to Resident #18's care plan for all staff to use, the DON stated they were not added to the care plan. Review of the facility's policy Care Plans, Comprehensive Person-Centered, dated 2001, revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical psychosocial and functional needs is developed and implemented for each resident . The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and interview, the facility failed to ensure two nursing staff (Certified Nursing Assistant [CNA] #3 and Licensed Nurse [LN] #7), out of 15 personnel records reviewed, had valid Cardiopulmonary Resuscitation (CPR) certificates. This failed practice placed all residents at risk for not receiving timely CPR or emergency care when needed. Findings: CNA#3 Review of the personnel records on [DATE] at 3:16 PM, revealed CNA #3 was hired on [DATE] with an expired CPR certificate, dated 10/2023. Review of CNA #3's work schedule, revealed the CNA worked on the following dates: 5/15-16/24, [DATE], 5/21-24/24, [DATE], [DATE], [DATE], [DATE], 6/4-6/24, and 6/10-12/24, with a total of 17 days worked without a valid CPR certificate. During an interview with the Human Resources Director (HRD) on [DATE] at 9:53 AM, the HRD stated CNA #3 was a new employee, but the HRD was not aware that CNA #3's CPR certificate was expired. The HRD stated she received CNA #3's CPR card that morning with a valid date of 6/2026. LN#7 Review of the personnel records on [DATE] at 3:16 PM, revealed LN #7's CPR certificate expired on [DATE] and had a new CPR certificate dated [DATE]. Review of LN #7's work schedule revealed LN worked on the following dates: [DATE], 6/11-13/24, [DATE], 6/18-19/24, with a total of 7 days worked without a valid CPR certificate. During an interview with the HRD [DATE] at 9:58 AM, the HRD stated LN #7 thought his/her CPR was good for the month of June and did not realize it was expired. HRD stated the LN was working on the floor for two weeks without valid CPR. During an interview with the HRD [DATE] at 9:58 AM, the HRD stated the facility had CPR training every month. She further explained for those CNAs who were previously certified, they would take it on the next training date. The HRD further stated CNAs were hired and allowed to work without active CPR certificates but not allowed to provide CPR to residents during an emergency. Other staff on duty with active CPR would intervene in case of emergency. During an interview and document review on [DATE] at 2:21 PM, the HRD stated the facility had no CPR policy. She provided a page of the Employee Handbook, dated 12/2023, which revealed: . CPR All employees that provide care for residents are required to provide evidence of passing a First Aid/CPR class within the first 30 days of hire. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and interview, the facility failed to ensure residents were free from accident hazards and/or received adequate supervision. Specifically, the facility failed to: 1) Ensure the care plan was followed regarding the total number of staff needed for safe bed mobility for 1 Resident (#6), out of 14 sampled residents; 2) Ensure neurological assessments, after unwitnessed falls, were conducted accurately for 1 Resident (#18), out of 14 sampled residents; and 3) Ensure 3 residents (#'s 11; 16; and 33), out of 3 residents reviewed for smoking, were assessed for safe storage of smoking paraphernalia (cigarettes and lighter or matches). These failed practices created a potential for accidents and injury to the residents. Findings: 1) Care Plan - Bed Mobility Resident #6 Record review on 6/17-21/24 revealed Resident #6 was admitted to the facility with diagnoses that included Type 2 Diabetes (chronic condition involving insulin resistance), osteomyelitis (bone infection), stage 4 pressure ulcer (deep skin sore), quadriplegia (complete paralysis of the body from the neck down), neuromuscular dysfunction of the bladder (impaired bladder control), chronic obstructive pulmonary disease (lung disease), anemia (low red blood cell count), and anxiety (mental health condition). Review of the physician's orders for Resident #6 revealed a plan of care (POC) ordered on 4/15/24, approving the plan of care for this resident to continue current physicians orders as written including medications and treatments, and appropriate activities, unless otherwise specified. Review of Resident #6's care plan, dated 5/6/24 with a target completion date on 7/14/24, revealed: Bed mobility: the resident is totally dependent on (2) staff for repositioning and turning in bed; Toilet use: the resident is totally dependent on (2) staff for toilet use; and Transfer: the resident is totally dependent on (2) staff for transferring. An observation on 6/19/24 at 12:00 PM, made after the wound care team changed a pressure sore dressing and while staff prepared to transfer Resident #6 to the shower, revealed CNA #1 repositioned Resident #6 in bed, placing a Hoyer sling under both sides of Resident #6 with a 1-person assist, rotating him/her from side to side. Resident #6 was observed to grimace and become tearful during this repositioning. At the time of this observation, a second CNA (CNA #2) was out of the room retrieving extra clean supplies. CNA #2 later returned and together with CNA #1 performed the transfer of Resident #6 with the Hoyer lift (Hoyer lift - mechanical device designed to lift and transfer patients) to the bathroom in preparation for hygiene care. Review of a document regarding Resident #6's bed mobility POC Response History indicated that on 6/19/24 Resident #6 was total dependence - full staff performance. Review of the facility's policy Activities of Daily Living (ADL's) Supporting, revised March 2018, revealed: . Total dependence - full staff performance of an activity with no participation by resident for any aspect of the ADL activity. Resident was unwilling or unable to perform any part of the activity over entire 7-day look back period . During an interview on 6/19/24 at 1:00 PM, CNA #1 stated: to know what type of transfer is required, we have multiple ways: the report sheets which are 'print outs' we receive at the beginning of the shift, there we can see their level of care, but we can also look inside their Armoire closets [Armoire - large freestanding wardrobe] and our tablets and then we do what we need to do. An observation on 6/21/24 at 1:19 PM, of the Armoire sheet posted on the inside of Resident #6 Armoire revealed: . transfer: Hoyer . Fall risk: No . Further review revealed no documentation of the number of staff required for bed mobility or transfers. A review of the unit's report sheet, dated 6/21/24 and used for Resident #6 at the time of this interview, revealed: . Transfers: Hoyer . Notes: 1/1 assist with meals, encourage to turn position, educate about wound, Quadriplegic. Further review revealed no documentation of the number of staff required for bed mobility or transfers. During an interview on 6/19/24 at 1:15 PM, Licensed Nurse (LN) #6 confirmed what CNA #1 had said regarding the process of discerning what type of assist to perform and while reviewing the current Report Sheet described above. After consulting the online care plan, LN #6 then manually altered the Report Sheet mentioned above, and added the following: Notes: Requires 2 person assist in bed mobility and repositioning. When asked if the CNA's had access to the plan of care, LN #6 stated: they don't have access to it online, they can only see their interventions on the tablet and what is written in the report sheet, which is updated by the nurses on every shift. During an interview on 6/19/24 at 1:00 PM, CNA #1 stated: regarding morning care of Resident #6, I was putting the sling first since Resident #6 helps in bed and by grabbing the sheet and keeping it close to my body, in case he/she rolls then he/she still has room to roll and not fall off the bed. CNA #1 also stated he/she was under the impression Resident #6 was a 1 Person assist while in bed. During an interview on 6/20/23 at 11:00 AM, the CNA coordinator stated: regarding the typical workflow of a CNA first thing CNA's do is a shift meeting with charge nurse of their hallways, then they walk around and check AM vitals, AM cares, showers, help with breakfast, get people ready in their rooms; they are given 1 report sheet for each hallway and the dietary outline; also, there are 2 CNA's and 1 nurse per hallway, except for the hospice hall .regarding the process of discerning what type of assist to perform, they can consult the report sheet and inside the wardrobe - Armoire there is a fillable form that PT [Physical Therapy] updates . they can also access the [NAME] online, which has a simplified version of the Care Plan for bed mobility and transfers. When the bed mobility observation earlier with Resident #6 and the 1 Person Assist was discussed, the CNA coordinator stated that the CNAs should always follow the order for transfer in the plan of care. Review of the facility Policy on Activities of Daily Living (ADL's) Supporting, revised March 2018, revealed: . Policy interpretation and Implementation . Appropriate care and services will be provided for residents who are unable to carry out ADL's independently . in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care) . Mobility (transfer and ambulation, including walking) . Elimination (toileting). 2) Neurological Checks - Unwitnessed Falls Resident #18 Review on 6/17-21/24 revealed Resident #18 was admitted to the facility under hospice care for diagnoses that included dementia, unspecified severity, with agitation. Resident #18 had a history of stroke which had contributed to the decline of his/her dementia. Further review revealed Resident #18 has had 28 falls since his/her admission 8 months ago. Review of the facility's protocol Falls - Definition [and] Protocol, undated, revealed: . If the resident has [h]it their head or if the fall was unwitnessed, neuro checks should be started. Review of Resident #18's unwitnessed falls revealed the following Neurological Assessment Flow Sheets with discrepancies: 1) 10/4/23 - unwitnessed fall, resident was found on floor on left side in front of his/her wheelchair (wc). Review of Resident #18's Neurological Assessment Flow Sheet, dated 10/4/23, revealed the assessment were to be completed 10/4-8/23. Further review revealed: - The assessments for Level of Consciousness, Pupil Response, Motor Functions, and Pain Response were not completed on 10/4/24 at 5:20 PM (the first set to be completed); - The second and third sets had no dates or times and was not completed at all, documented In dining room for dinner; - The assessment Motor Functions was not completed on 10/4/23 at 6:30 PM (the fourth set to be completed), documented unable; - The fifth set assessment included a time of 7:30 PM and only included the blood pressure, pulse, respirations, and oxygen saturation level. No other assessment was completed; and - The rest of the neurological assessment flow sheet was left blank. 2) 10/7/23 - unwitnessed fall, resident was found on floor, wc in front of him/her. Review of Resident #18's Neurological Assessment Flow Sheet, dated 10/7/23, revealed the assessment were to be completed 10/7-11/23. Further review revealed the assessments were not completed on 10/8/23 at 4:00 AM and 10/8/23 at 8:00 AM, and documented the resident was sleeping. 3) 10/12/23 - unwitnessed fall, resident was found on floor in doorway of room, wc behind him/her. Review of Resident #18's Neurological Assessment Flow Sheet, dated 10/12/23, revealed the assessments were to be completed 10/12-15/23. Further review revealed the assessments were not completed on 10/12/23 at 6:30 PM; 10/12/23 at 7:30 PM; 10/12/23 at 8:30 PM; 10/13/24 at 12:20 AM; 10/13/23 at 4:30 AM, and documented the resident was sleeping. Vital signs were not completed for night shift 10/13/23 and night shift 10/14/23. 4) 10/26/23 - unwitnessed fall, resident was found on floor in front of wc. Review of Resident #18's Neurological Assessment Flow Sheet, dated 10/26/23, revealed the assessments were to be completed 10/26-29/23. Further review revealed the assessments were not completed on 10/26/23 at 3:00 PM; 10/26/23 at 3:30 PM; 10/26/24 at 4:30 PM; 10/26/24 at 5:30 PM; and 10/27/23 at 1:30 AM, and documented the resident was sleeping. 5) 11/21/23 at 5:25 PM - resident was found on [his/her] knees on floor by [his/her] bed. Review of Resident #18's Neurological Assessment Flow Sheet, dated 11/21/23 at 5:25 PM, revealed the assessments were to be completed 11/21-24/23. Further review revealed vital signs were not obtained for the night shift 11/24/24 assessment. 6) 1/24/24 - unwitnessed fall, resident was found on floor between bed and window. Review of Resident #18's Neurological Assessment Flow Sheet, dated 1/24/24, revealed the assessments were to be completed 1/24-28/24. Further review revealed: - The Level of Consciousness; Pupil Response; Motor Functions; and Pain Response assessments were not completed for 1/24/24 at 11:20 PM; 1/24/24 at 11:50 PM; 11/25/24 at 12:50 AM; and 11/25/24 at 1:50 AM; - The assessment was not completed at all on 1/25/24 at 5:50 AM; and - Vital signs were not completed on day shift of 1/27/24 or night shift on 1/27/24. 7) 2/1/24 - unwitnessed fall, resident was found on floor by bed, blood on head and hands. Review of Resident #18's Neurological Assessment Flow Sheet, dated 2/1/24, revealed the assessments were to be completed 2/1-5/24. Further review revealed the assessments were not completed on 2/1/24 at 11:40 PM and 2/2/24 at 4:40 AM and documented the resident was sleeping. 8) 3/9/24 - unwitnessed fall, resident was found on floor in hall outside of room. Fell from wc. Review of Resident #18's Neurological Assessment Flow Sheet, dated 3/9/24, revealed the assessments were to be completed 3/9-13/24. Further review revealed the Pupil Response assessment was not completed on 3/9/24 at 10:55 PM and documented sleeping - unable to determine. 9) 4/2/24 - unwitnessed fall, resident was found on floor in bathroom. Review of Resident #18's Neurological Assessment Flow Sheet, dated 4/2/24, revealed the assessments were to be completed 4/1-5/24, however ended on dayshift 4/4/24. A second flow sheet was created on 4/4/24 at 9:45 PM, and the assessments were continued on this sheet. Further review revealed the assessments were not completed on dayshift on 4/6/24. During an interview on 6/21/24 at 4:14 PM, the Director of Nursing (DON) stated it was the expectation of the facility when a neurological assessment was initiated, it was to be completely and accurately filled out. The DON further stated the neurological assessments should not be skipped if a resident was sleeping because sleeping is not necessarily a good thing. The DON stated the facility had recognized this type of deficiency before and educated staff on the importance of completing neurological assessments, even if the resident was sleeping. Review of the facility's policy Neurological Assessment (Routine), dated 12/2023, revealed: The following information should be recorded in the resident's medical record. The date and time the procedure was performed. The name and title of the individual(s) who performed the procedure. All assessment data obtained during the procedure. How the resident tolerated the procedure. If the resident refused the procedure, the reason(s) why and the intervention taken. The signature and title of the person recording the data. Reporting . Notify the supervisor if the resident refuses the procedure . 3) Safe Smoking Assessments Resident #11 Record review on 6/17-21/24, revealed Resident #11 was admitted with diagnoses that included a right ankle fracture which was surgically fused making the joint immobile, diabetes, high blood pressure, and acute respiratory failure with hypoxia (below normal oxygen levels in the blood). An observation on 6/19/24 at 4:28 PM, revealed Resident #11 was outside by the dumpsters listening to music and smoking. Review of the handwritten facility provided list of smokers revealed Resident #11 was included on this list. Review of the facility's electronic health record Assessment tab on 6/19/24 at 2:16 PM, revealed no smoking assessment was conducted for Resident #11. Review of Resident #11's Care Plan, dated 4/5/24, revealed no care planning for Resident #11. During an interview on 6/19/24 at 2:20 PM, the Director of Nursing (DON) confirmed Resident #11 was a smoker but was not able to provide a smoking assessment for Resident #11. Resident #16 Record review on 6/17-21/24, revealed Resident #16 was admitted to the facility with diagnoses that included hemiplegia (weakness or paralysis of one side of the body), hemiparesis (partial paralysis of one side of the body), epilepsy (a neurological disorder that causes seizures, or unusual sensations or behavior) and major depressive disorder (mood disorder). Review of Resident #16's Care Plan, dated 2/8/23, revealed: Focus . [Resident #16] is a smoker. desired outcome . [Resident #16] will not suffer injury from unsafe smoking practices. intervention .notify charge nurse immediately if it is suspected resident violated facility's smoking policy, observe clothing and skin for signs of cigarette burns . During an interview and concurrent observation on 6/17/24 at 2:36 PM, Resident #16 stated he/she smoked cigarettes. The Resident showed his/her opened pack of Marlboro. When asked where he/she kept his/her cigarettes and lighter or match, Resident #16 stated in his/her room. When asked if the facility knew that he/she was smoking, Resident #16 stated, yes. When asked if the facility conducted a smoking assessment, he/she stated, no. Review of the facility's electronic health record Assessment tab on 6/19/24 at 10:56 AM, revealed no smoking assessment was conducted for Resident #16. Resident #33 Record review on 6/17-21/24, revealed Resident #33 was admitted with diagnoses that included a left below the knee amputation, peripheral vascular disease (where the blood vessels located anywhere outside the heart have narrowing, blockage, or spasms), and nicotine dependence. During an interview on 6/17/24 at 11:33 AM, Resident #33 stated that he/she rolled his own cigarettes and kept the cigarette rolling supplies (loose tobacco and papers) and lighter in his/her room. When he/she smoked, he/she did not wear a protective apron and did not feel that it was necessary because he/she had been smoking for a very long time and could control where the ashes fell. Review of the facility's electronic health record Assessment tab on 6/19/24 at 2:10PM, revealed no smoking assessment was conducted for Resident #33. During an interview on 6/19/24 at 2:20 PM, the Director of Nursing (DON) confirmed Resident #33 was a smoker but was not able to provide a smoking assessment for Resident #33. During a joint interview on 6/19/24 at 2:43 PM, with the DON and Assistant Director of Nursing (ADON), the DON stated there were no smoking assessments in the electronic health record (EHR). The DON stated smoking assessment should have been done. The ADON stated upon admission, residents who smoked would sign the smoking policy stating the facility was a non-smoking campus. The DON stated after admission, the resident would not smoke for a while but when the resident would see other residents smoking, then the resident would start smoking. The DON explained Resident #16 quit smoking for a while and recently started again, she found out the other day [6/18/24] that Resident #16 was smoking again. During the same interview, the DON stated the residents who smoke kept their matches or lighters in their rooms. When asked how the facility managed residents' matches or lighters and cigarettes, the DON stated, we have not had anyone (residents) unsafe. The DON stated the facility would not necessarily know when the resident would bring in cigarettes and matches or lighters. When asked, how the facility ensured there were no risk of fire, the DON stated, that's a hard one. She stated the residents who smoked were cognitive. The residents had the right to say no. The DON further stated the facility had not tried the process of keeping cigarettes and lighters. During a follow-up interview on 6/19/24 at 3:19 PM, the DON stated a smoking assessment was not done for Resident #16 because the resident signed the no smoking policy upon admission. Review of the facility's Smoking/Vaping Policy, signed on 1/20/23, by Resident #16, revealed: . Maple Springs is a smoke -free . campus. Smoking . not permitted on Maple Springs property. residents who wish to smoke . must do so off the property. there are no designated smoking times or locations. Review of the facility's Smoking Policy - Residents, dated 12/2023, revealed: . Policy Statement[:] this facility shall establish and maintain safe resident smoking practices. Maple springs is a smoke free campus. Policy interpretation and implementation 1. Prior to and upon admission, resident shall be informed of the facility no smoking or vaping policy. 2. The resident will be evaluated prior to admission to determine if he or she is a smoker or non-smoker. If smoking, the evaluation will include a. current level of tobacco consumption; method of tobacco consumption; desire to quit smoking, if a current smoker; facility provider will offer to order smoking cessation medication upon admission as needed. 3. The facility has the right to confiscate smoking articles found in violation of our smoking policies. 4. Confiscated property will be itemized and ultimately returned to the resident . .

. Based on record review and interview, the facility failed to ensure the residents right to be informed, in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care and treatment recommendations were upheld. Specifically, the facility failed to ensure the Psychotropic Medication Informed Consent [and] Risk/Benefit Statement forms, used for education and consent for psychotropic medications (any drug that affects brain activities associated with mental processes and behavior), were completed accurately, timely, and by health care providers with an original signature for 9 sampled residents (#'s 6; 8; 15; 16; 18; 28; 33; 35; and 204) and 8 unsampled residents (#'s 2; 7; 19; 25; 31; 37; 41; and 105), out of 25 residents on psychotropic medications. This failed practice violated the resident's right to be informed and afforded the opportunity to ask questions of their health care provider and placed them at risk for unnecessary medication and/or adverse reactions. Findings: Record review on 6/16-21/24 revealed the facility used a Psychotropic Medication Informed Consent [and] Risk/Benefit Statement form (identified as consent form moving forward), dated 3/2023, to educate and obtain consent from residents and/or their representatives on any psychotropic medication recommended for use. This form would be used upon resident admissions if the resident was currently taking a psychotropic medication, or would be used if a psychotropic medication was initiated during their stay. Further review revealed the form documented the following information: - I [resident or representative name] have received information regarding the risks and benefits associated with using the psychotropic drugs that have been ordered for [resident's name] for the specific diagnosis listed below, manifesting target symptoms/behaviors . A list of diagnoses was available to check the appropriate diagnosis for individual residents. - Name and Dosage of psychotropic medication(s) A space to write the medication and dose was provided. - . The benefits expected from this medication . A list of benefits was on the form. - The risks or side effects associated with this medication include, but are not limited to . A list of risks or side effects for different classes of medications: hypnotics/sedatives; antidepressants; anxiolytics (antianxiety medications); and antipsychotics were listed on the form. A review of the consent section of the form revealed the following places to check if agreed: - The risks and benefits of the use of psychotropic medication(s) have been explained to me; - I have asked, and had answered, all of the questions, which pertain to the use of psychotropic medication(s); - I understand and consent to the use of the medication described above; and - I do not consent to the use of the above mentioned medication. The consent form had a place for In person consent to indicate the individuals signing were present at the time of the form's completion: Physician Signature; Resident Name (print); and Resident Signature or Resident's Representative Signature. This was the only signature line for health care providers to sign on. There was also a place for Telephone Consent/Refusal: (2 staff witnesses) and had places for name of person giving consent/refusal; and two spaces for nurse signature. An observation on 6/20/24 at 10:38 AM, during an explanation of all the admission paperwork documents in an admission packet by Licensed Nurse (LN) #33, revealed a blank consent form with the Medical Director's signature photocopied on it. When asked about the photocopied signature on the blank consent form, LN #33 confirmed this form was used during admissions of new residents. During an interview on 6/21/24 at 4:23 PM, the Medical Director stated she approved her signature to be photocopied on a blank consent form for repeated use. The Medical Director further stated the nurses completed the consent forms with residents. When asked if there was anywhere in the chart that reflected the health care providers reviewed the admission paperwork to include the consent forms for psychotropic medications, the Medical Director stated there wasn't anywhere in the chart that she signed to say she reviewed these forms. Review on 6/17-21/24 of all 25 resident records, who were currently on psychotropic medications, revealed the following residents had consent forms that contained health care provider's photocopied signatures. Further review revealed some of the following residents also either had missing consent forms for psychotropic medications doses being administered, consents were not obtained prior to psychotropic medication administration, and/or consents were not accurately obtained with appropriate consent, for the following residents: Resident #2 Escitalopram (Lexapro - an antidepressant) Resident #2's consent form was for the use of escitalopram 20 milligrams (mg). This form was signed by the resident on 5/2/24. The Medical Director's photocopied signature was on this form with the handwritten date of 5/2/24. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent. Resident #6 Resident #6 had multiple consent forms for multiple psychotropic medications: Buspirone (an anxiolytic) The first consent form was for the use of buspirone 20 mg. This form was dated 4/15/24 and two nurses signed on the Resident's Representative Signature line under the In Person Consent section. Further review revealed no resident representative listed on the consent form. The Medical Director's photocopied signature was on this form with a computer-generated date of 4/15/24. Duloxetine (an antidepressant) The second consent form was for the use of duloxetine 60mg. This form was dated 4/15/24 and two nurses signed on the Resident's Representative Signature line under the In Person Consent section. Further review revealed no resident representative listed on the consent form. The Medical Director's photocopied signature was on this form with a computer-generated date of 4/15/24. Trazadone (an antidepressant) The third consent form was for the use of Trazadone 100mg. This form was dated 4/20/24 and two nurses signed on the Resident's Signature line and documented 2 nurse signature [with] resident. The Medical Director's photocopied signature was on this form with a handwritten date of 4/20/24. Further record review revealed Resident #6 started Trazadone on 4/15/24, five days prior to the date of the consent form. Hydroxyzine (an antihistamine, but can be used to treat anxiety) 1. The fourth consent form was for the use of Hydroxyzine with no dose indicated. There was no class of medication marked to review risks or potential side effects for this medication. The resident's daughter signed this form on 4/24/24. Further review revealed the daughter put her name on the Resident's Name (print) line and signed her name on the Resident Signature line. The Medical Director's photocopied signature was on this form with a handwritten date of 4/24/24. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent. 2. The fifth consent form was for the use of Hydroxyzine 50mg every 6 hours PRN (as needed) and used for anxiety. The class of medication marked was anxiolytics. This form was dated 5/23/24 and two unrecognizable signatures were on the Resident's Signature line and documented verbally acknowledged. The Medical Director's photocopied signature was on this form with a handwritten date of 5/23/24. Lorazepam (an anxiolytic) The sixth consent form was for the use of Lorazepam 0.5mg. This form was dated 5/23/24 and two unrecognizable signatures were on the Resident's Signature line and documented verbally acknowledged. The Medical Director's photocopied signature was on this form with a handwritten date of 5/23/24. Resident #7 Resident #7 had two psychotropic medication consent forms: Fluoxetine (an antidepressant) The first consent form was for the use of Fluoxetine 20mg. This form was signed by the resident on 4/18/24. Further review the resident did not mark the section I have asked, and had answered, all of the questions, which pertain to the use of psychotropic medication(s) of the form. The Medical Director's photocopied signature was on this form with a handwritten date of 4/18/24. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent. Mirtazapine (an antidepressant) The second consent form was for the use of Mirtazapine 7.5mg. This form was signed by the resident on 4/18/24. Further review the resident did not mark the section I have asked, and had answered, all of the questions, which pertain to the use of psychotropic medication(s) of the form. The Medical Director's photocopied signature was on this form, however, was not dated. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent. Resident #8 Resident #8 had two psychotropic medication consent forms: Seroquel (an antipsychotic) The first consent form was for the use of Seroquel 25mg twice a day and 50mg at bedtime (HS). This form had an illegible marking on the Resident Signature line, dated 4/17/24. The Medical Director's photocopied signature was on this form with a handwritten date of 4/17/24. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent. Citalopram (Celexa - an antidepressant) The second consent form was for the use of citalopram 20mg. This form was dated 4/20/24 and it was documented in the telephone consent/refusal section that a resident representative was called for consent. It was documented left a VM [voicemail] under the representative's name and two nurses signed the form. No documentation was added later to prove education was provided, or verbal consent was ever obtained. The Medical Director's photocopied signature was on this form with a handwritten date of 4/20/24. Further record review revealed Resident #8 started Citalopram on 4/18/24, two days prior to the facility's attempt to obtain consent. Resident #15 Risperdal (an antipsychotic) Review of Resident #15's medication administration record revealed an order for Risperidone Oral Tablet (Risperdal) Give 0.5mg by mouth every morning and at bedtime for mood disorder. The start date for this order was 12/21/23. Review of Resident #15's consent forms for Risperdal revealed: - The first consent form was for the use of Risperdal with no specified dose. This form was signed by the resident representative on 3/18/20. Further review revealed the resident representative did not mark the consent sections of The risks and benefits of the use of psychotropic medication(s) have been explained to me and I have asked, and had answered, all of the questions, which pertain to the use of psychotropic medication(s). Physician #22's original signature was on this consent form and dated 4/4/20. - The second consent form was for the use of Risperdal 0.25mg. This form was dated 4/6/23 and two nurse signatures were on the Resident Signature line with 2 nurse signature documented. Further review revealed no information that the resident representative was contacted for consent. Physician #22's original signature was on this consent form and dated 4/6/23. Further review of Resident #15's medical record revealed no consent for the current dose of Risperdal 0.5mg currently being administered. Resident #16 Lexapro Resident #16's consent form was for the use of Lexapro 15mg. This form was dated 5/11/24 and it was documented in the telephone consent/refusal section that the resident gave consent and was signed by two nurses. Physician #22's original signature was on this form and dated 5/11/24. Further record review revealed Resident #16 started Lexapro 10mg on 1/18/23, 479 days prior to the date of the consent form, and the dose changed to 15mg on 2/28/23, 438 days prior to the date of the consent form. No other consent forms for Lexapro were found in the resident's medical record. Resident #18 Resident #18 had multiple consent forms for multiple medications: Lorazepam 1. The first consent form was for the use of liquid Lorazepam 2 milligram (mg)/(per) milliliter (ml). This form was signed by the resident representative on 10/4/23. Physician #5's photocopied signature was on this form with a handwritten date of 10/4/23. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent. 2. The second consent form was for the use of Lorazepam 1mg. This form was signed on 11/14/23 and consent was obtained by telephone consent with the resident representative and two nurse signatures. Physician #22's photocopied signature was on this form with a handwritten date of 11/14/23. Further record review revealed Resident #18 started this Lorazepam medication as an every hour PRN (as needed) dose on 10/3/23, 42 days prior to this consent being obtained. 3. The third consent form was for the use of Lorazepam 0.5mg three times a day and every hour PRN dose. This form was signed on 3/4/24 and consent was obtained by telephone consent with the resident representative and two nurse signatures. The Medical Director's photocopied signature was on this form with a handwritten date of 3/4/24. Further record review revealed Resident #18's Lorazepam order that was started on 3/4/24 was for 1mg three times a day and every hour PRN Lorazepam dose was 1mg, not 0.5mg as the consent indicated. 4. The fourth consent form was for the use of Lorazepam 1mg three times a day. This form was signed on 3/6/24 and consent was obtained by telephone consent with the resident representative and two nurse signatures. The Medical Director's photocopied signature was on this form with a handwritten date of 3/6/24. Further record review revealed Resident #18's Lorazepam order that was started on 3/6/24 was for 0.5mg three times a day, not 1mg as the consent indicated. No new consent form for this dosage change was in Resident #18's medical record. Resident #18's every hour PRN Lorazepam order stopped on 3/6/24. 5. The fifth consent form was for the use of Lorazepam 0.5mg twice a day. This form was signed on 3/13/24 and consent was obtained by telephone consent with the resident representative and two nurse signatures. The Medical Director's photocopied signature was on this form with a handwritten date of 3/13/24. Further record review revealed this scheduled dose of Lorazepam started on 3/13/24. Resident #18's every hour PRN Lorazepam order was restarted on 3/16/24, three days after the 3/13/24 consent was obtained. No new consent form for this dosage change was in Resident #18's medical record. Seroquel (an antipsychotic) 1. The first consent form was for the use of Seroquel 50mg. This form was signed by the resident representative on 10/4/23. Physician #5's photocopied signature was on this form with a handwritten date of 10/4/23. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent. Further record review revealed Resident #18 started Seroquel on 10/2/23, two days prior to this consent being documented. Further review revealed the dose of Seroquel changed on 10/17/23 to Seroquel 50mg twice a day, for a total of 100mg daily. No new consent for this dosage change was in Resident #18's medical record. 2. The second consent form was for the use of Seroquel 75mg at bedtime and 50mg PRN. This form was signed on 11/14/23 and consent was obtained by telephone consent with the resident representative and two nurse signatures. Physician #22's photocopied signature was on this form with a handwritten date of 11/14/23. Further record review revealed Resident #18 started Seroquel 75mg at bedtime on 11/1/23, 13 days prior to this consent being obtained. On 11/2/23, Resident #18 was started on Seroquel 50mg daily at 9:00 AM, not PRN like the consent form indicated. No new consent form for this dosage change was in Resident #18's medical record. 3. The third consent form was for the use of Seroquel 75mg twice a day. This form was signed on 3/4/24 and consent was obtained by telephone consent with the resident representative and two nurse signatures. The Medical Director's photocopied signature was on this form with a handwritten date of 3/4/24. Trazadone Resident #18's consent form was for the use of Trazadone 25mg. This form was signed on 11/14/23 and consent was obtained by telephone consent with the resident representative and two nurse signatures. Physician #22's photocopied signature was on this form. Further record review revealed Resident #18 started Trazadone on 10/5/23, 40 days prior to the consent being obtained. No other consent forms for Trazadone were found in the resident's medical record. Resident #19 Resident #19 had two psychotropic medications on one consent form: Paroxetine (an antidepressant) and Xanax (a sedative) Resident #19's consent form was for the use of paroxetine 40mg and Xanax 0.5mg. This form was dated 5/15/24 and consent was obtained by telephone consent with the resident representative and two nurse signatures. Physician #22's original signature was on this form and dated 5/29/24, 14 days after the resident signed the consent form. Further record review revealed Resident #19 started paroxetine 20mg on 2/4/22, 831 days prior to the consent being obtained. Resident #19's paroxetine dose was changed to 40mg on 12/21/23. No other consent forms for paroxetine were in the resident's record. Further record review revealed Resident #19 started Xanax 0.5mg on 9/30/22, 593 days prior to the consent being obtained. No other consent forms for Xanax were in the resident's record. Resident #25 Resident #25 had two psychotropic medication consent forms: Duloxetine 1. The first consent form was for the use of Duloxetine 60mg. This form was signed by the resident on 4/12/24. The Medical Director's photocopied signature was on this form with a handwritten date of 4/12/24. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent from the resident. Hydroxyzine 2. The second consent form was for the use of hydroxyzine 25mg. This form was signed by the resident on 4/16/24. The Medical Director's photocopied signature was on this form with a handwritten date of 4/16/24. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent from the resident. Further review revealed a nurse's initials were on bottom left second page of the form which indicated Document in Point Click Care that a telephone consent/refusal was obtained and scan this document under the Misc [Miscellaneous] tab, with heading of Consent: Medications. This consent was not obtained through telephone consent. Resident #28 Resident #28 had multiple consent forms for multiple medications: Clonazepam (a sedative) 1. The first consent form was for the use of clonazepam with no specified dose. This form was signed on 5/19/24 and consent was obtained by telephone consent with the resident representative and two nurse signatures. The Medical Director's photocopied signature was on this form. This signature was not dated. Further record review revealed Resident #28 started Clonazepam on 5/18/24, 1 day prior to the consent being obtained. 2. The second consent form was a photocopy of the original with the words updated with dose on the upper right corner of the consent form's first page. The dose 0.5mg Q AM [every morning] was added after the word Clonazepam. This form had no indication the resident representative authorized the addition of a dose to the consent form, or that the resident representative was called to be informed it was added. The Medical Director's photocopied signature was on this form. This signature was not dated. Further record review revealed Resident #18 started an additional order of Clonazepam 0.5mg every 24 hours PRN agitation on 5/24/24, which changed to 0.5mg every 12 hours PRN agitation on 6/17/24. No new consent for this dosage change was in Resident #28's medical record. Hydroxyzine 1. The third consent form was for the use of hydroxyzine 25mg. The indication for use was for generalized itching. The class of medication was marked as anxiolytics. This form was signed on 4/29/24 and consent was obtained by telephone consent with the resident representative and two nurse signatures. The Medical Director's photocopied signature was on this form with a handwritten date of 4/29/24. 2. The fourth consent form was for the use of hydroxyzine 25mg. The class of medication was marked as Other and documented at antianxiety. No risks or side effects associated with this medication was not documented on the consent form. This form was dated 6/4/24 and consent was obtained by telephone consent with the resident representative and two nurse signatures. The Medical Director's photocopied signature was on this form. This signature was not dated. Seroquel 1. The fifth consent form was for the use of Seroquel 25mg. This form was signed on 5/13/24 and had an illegible marking on the Resident Signature line. Physician #5's original signature was on this form dated 5/13/24. 2. The sixth consent form was for the use of Seroquel 25mg at HS. This form was half filled out by a nurse in blue ink, the other half was filled out by the resident in black. This form was dated 5/13/24 and consent was obtained by telephone consent with the resident representative and two nurse signatures. None of the sections for consent were marked: The risks and benefits of the use of psychotropic medication(s) have been explained to me; I have asked, and had answered, all of the questions, which pertain to the use of psychotropic medication(s); I understand and consent to the use of the medication described above; or I do not consent to the use of the above mentioned medication. The Medical Director's photocopied signature was on this form. This signature was not dated. 3. The seventh consent form was for the use of Seroquel 50mg. This form was dated 5/24/24 and consent was obtained by telephone consent with the resident representative and two nurse signatures. The Medical Director's photocopied signature was on this form with a handwritten date of 5/24/24. 4. The eighth consent form was for the use of Seroquel 100mg at HS and continue 50mg in AM. This form was dated 6/10/24 and consent was obtained by telephone consent with the resident representative and two nurse signatures. The Medical Director's photocopied signature was on this form with a handwritten date of 6/10/24. Resident #31 Resident #31 had two psychotropic medication consent forms: Seroquel 1. The first consent form was for the use of Seroquel 50mg. This form was signed on 11/14/23 and the resident signed this form with an illegible marking to the left of the resident's printed name added by staff. Physician #22's photocopied signature was on this form with a handwritten date of 11/14/23. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent from the resident. Further record review revealed Resident #31 started Seroquel on 10/13/23, 32 days prior to the 11/14/23 consent form. No other consent forms for Seroquel were in the resident's medical record. Lorazepam 2. The second consent form was for the use of Lorazepam 1mg. This form was signed on 11/14/23 as well and had another illegible marking but this time was over Physician #22's photocopied signature that had a handwritten date of 11/14/23. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent from the resident. Resident #33 Resident #33 had two psychotropic medication consent forms: Wellbutrin (an antidepressant) 1. The first consent form was for the use of Wellbutrin 150mg. This form was signed by the resident on 5/10/24. The Medical Director's photocopied signature was on this form and had a handwritten date of 3/13/24, 58 days prior to the resident's consent was obtained. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent from the resident. Further record review revealed Resident #33 started Wellbutrin on 3/13/24, the day the Medical Director's photocopied signature was dated. No other consent forms for Wellbutrin were in the resident's medical record. Duloxetine 2. The second consent form was for the use of duloxetine 30mg. This form was signed by the resident on 5/10/24. The Medical Director's photocopied signature was on this form and had a handwritten date of 3/16/24, 55 days prior to the resident signing. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent from the resident. Further record review revealed Resident #33 started Duloxetine on 3/16/24, the day the Medical Director's photocopied signature was dated. No other consent forms for Duloxetine were in the resident's medical record. Resident #35 Resident #35 had two psychotropic medications with multiple consent forms: Sertraline The first consent form was for the use of Sertraline 50mg. This form was signed by the resident on 2/28/24. The Medical Director's photocopied signature was on this form had a handwritten date of 2/28/24. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent from the resident. Trazadone 1. The second consent form was for the use of Trazadone 150mg. This form was signed by the resident on 3/4/24. The Medical Director's photocopied signature was on this form with a handwritten date of 2/28/24, which was the date of admission for Resident #35 and 6 days prior to the resident signing. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent from the resident. Further record review revealed Resident #35 started Trazadone 150mg at bedtime on 2/28/24, the day of admission. No new consent form for this dosage change was in Resident #35's medical record. 2. The third consent form was for the use of Trazadone 50mg. This form was signed by the resident on 3/13/24. The Medical Director's photocopied signature was on this form with a handwritten date of 3/13/24. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent from the resident. Resident #37 Duloxetine Resident #37's consent form was for the use of duloxetine 30mg. This form was dated 2/29/24 and was obtained through telephone consent with a resident representative and two nurse signatures. The Medical Director's photocopied signature was on this form with a handwritten date of 2/29/24. Further record review revealed a second consent form for the same medication and same dose was completed and dated 4/27/24. This form was completely filled out and signed by the resident. Further review revealed this consent form was initialed by the resident on the sections of The risks and benefits of the use of psychotropic medication(s) have been explained to me and I have asked, and had answered, all of the questions, which pertain to the use of psychotropic medication(s), however there was a computer-generated pre-typed X on the line to indicate I understand and consent to the use of the medication described above. The Medical Director's photocopied signature was on this form and Resident #37 wrote the date 4/27/24 for this signature. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent from the resident. Resident #41 Resident #41 has two psychotropic medications and multiple consent forms: Venlafaxine (an antidepressant) The first consent form was for the use of Venlafaxine 150mg. This form was signed by the resident on 5/10/24. The Medical Director's photocopied signature was on this form and had a handwritten date of 5/5/24, five days prior to the resident signing. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent from the resident. Further record review revealed Resident #41 started Venlafaxine 150mg on 5/5/24, the day the Medical Director's photocopied signature was dated. No other consent forms for Venlafaxine were in the resident's medical record. Hydroxyzine 1. The second consent form was for the use of hydroxyzine 25mg. This form was dated 4/10/24 and consent was documented in the telephone consent/refusal section. The word telephone was lined out and the words In Person were added. The form indicated the resident was on the name of person giving consent/refusal line and signed by two nurses. Medical Director's photocopied signature was on this form with a handwritten date of 4/10/24. 2. The third consent form was for the use of hydroxyzine 25mg as well. This form was signed by the resident on 5/29/24. The Medical Director's photocopied signature was on this form with a handwritten date of 5/29/24. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent from the resident. Resident #105 Resident #105 had three psychotropic medication consent forms: Amitriptyline (an antidepressant) The first consent form was for the use of amitriptyline 100mg. This form was signed by the resident representative on 6/5/24. The Medical Director's photocopied signature was on this form with a handwritten date of 6/5/24. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent. Fluoxetine The second consent form was for the use of fluoxetine 20mg. This form was signed by the resident representative on 6/5/24. Further review revealed the resident's printed name was not on the In person consent line and the resident's representative signed on the Resident's Signature line. The Medical Director's photocopied signature was on this form with a handwritten date of 6/5/24. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent. Memantine (cognitive enhancing medication to treat dementia associated with Alzheimer's) The third consent form was for the use of Memantine 10mg. This form was signed by the resident representative on 6/5/24. The Medical Director's photocopied signature was on this form with a handwritten date of 6/5/24. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent. Further review of this consent form revealed the class of this medication was marked as other. No risks or side effects were documented on the co[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, interview and observation, the facility failed to ensure: 1) physicians completed the Physician Orders for Life-Sustaining Treatment (POLST - Physician orders that clarify life sustaining measures if needed, to include cardiopulmonary resuscitation [CPR], initial treatment orders, and medically assisted nutrition) physician order forms with residents; and 2) were signed and dated with an original signature for 9 sampled residents (#'s 3; 6; 8; 17; 28; 33; 35; 38; and 204), out of 14 sampled residents reviewed; and 35 unsampled residents (#'s 2; 4; 5; 7; 11; 14; 21; 22; 24; 25; 26; 30; 31; 32; 34; 36; 37; 39; 40; 41; 42; 45; 46; 48; 49; 103; 104; 105; 203; 205; 206; 253; 254; 303; and 304), out of 39 unsampled residents reviewed. This failed practice had the potential to deny these residents to be offered life sustaining options by an authorized health care provider, placing them at risk for not understanding the risk and benefits of those options which could affect their overall well-being and end of life choices. Findings: Record review on 6/17-21/24 revealed all resident charts contained a completed POLST order form. During an interview on [DATE] at 2:05 PM, Licensed Nurse (LN) #1 stated POLST forms were completed by nurses on every admission. During an interview on [DATE] at 9:42 AM, LN #24 stated POLST forms were completed by charge nurses. An observation on [DATE] at 10:38 AM, during an explanation of all the admission paperwork documents in an admission packet by LN #33, revealed a blank POLST form with a photocopy of the Medical Director's signature on it. When asked about the photocopied signature on the blank POLST form, LN #33 confirmed these forms were used during admissions of new residents. Review of all 53 resident records revealed the following POLST physician order forms were used with provider signatures photocopied onto a blank form and later filled out during the resident's admission: 1) The Medical Director's photocopied signature was on 40 resident's POLST forms, Resident #'s 2; 3; 4; 5; 6; 7; 8; 11; 17; 21; 22; 24; 25; 26; 28; 32; 34; 35; 36; 37; 38; 39; 40; 41; 42; 45; 46; 48; 49; 103 104; 105; 203; 204; 205; 206; 253; 254; 303; and 304. 2) Physician #22's photocopied signature was on four resident POLST forms, Resident #'s 14; 30; 31; and 33. During an interview on [DATE] at 4:23 PM, the Medical Director stated she approved her signature to be photocopied on a blank POLST for repeated use. The Medical Director further stated it was the nurses who completed the POLST forms upon admission and confirm the resident's wishes. When asked if there was anywhere in the chart that reflected the health care providers reviewed the admission paperwork to include the POLST form, the Medical Director stated there wasn't anywhere in the chart that she signed to say she reviewed these forms. Review of the facility's blank POLST form, dated [DATE], revealed: Health care providers should complete this form only after a conversation with their patient or the patient's representative . This is a medical order . Further review revealed a section on the POLST form for the health care provider to sign: . Signature: Health Care Provider (required, eSigned [electronically signed] documents are valid) Verbal orders are acceptable with follow up signature: I have confirmed that this order was discussed with the patient or his/her representative. The orders reflect the patient's known wishes, to the best of my knowledge. (Note: Only licensed health care providers authorized by law to sign POLST form in Alaska may sign this order.) . .

. Based on record review and interview, the facility failed to ensure medical records were accurately completed in accordance with accepted professional standards of practice. Specifically, the facility failed to ensure: 1) The Psychotropic Medication Informed Consent [and] Risk/Benefit Statement forms, used for education and consent for psychotropic medications (any drug that affects brain activities associated with mental processes and behavior), were completed accurately, timely, and by authorized health care providers with an original signature for 9 sampled residents (#'s 6; 8; 15; 16; 18; 28; 33; 35; and 204) and 8 unsampled residents (#'s 2; 7; 19; 25; 31; 37; 41; and 105), out of 25 residents on psychotropic medications in the facility. 2) The nursing staff accurately documented the removal of a medication patch for one resident (#41) out of 25 medication administrations reviewed. These failed practices created incomplete medical records and/or inaccurate documentation, which placed these residents at risk for inconsistencies in care and treatment provided. Findings: 1) Psychotropic Medication Informed Consent Record review on 7/16-21/24 revealed the facility used a Psychotropic Medication Informed Consent [and] Risk/Benefit Statement form (identified as consent form moving forward), dated 3/2023, to educate and obtain consent from residents and/or their representatives on any psychotropic medication recommended for use. This form would be used upon resident admissions, if the resident was currently taking a psychotropic medication, or would be used if a psychotropic medication was initiated during their stay. Further review revealed the form documented the following information: - I [resident or representative name] have received information regarding the risks and benefits associated with using the psychotropic drugs that have been ordered for [resident's name] for the specific diagnosis listed below, manifesting target symptoms/behaviors . A list of diagnoses was available to check the appropriate diagnosis for individual residents. - Name and Dosage of psychotropic medication(s) A space to write the medication and dose was provided. - . The benefits expected from this medication . A list of benefits was on the form. - The risks or side effects associated with this medication include, but are not limited to . A list of risks or side effects for different classes of medications: hypnotics/sedatives; antidepressants; anxiolytics (antianxiety medications); and antipsychotics were listed on the form. A review of the consent section of the form revealed the following places to check if agreed: - The risks and benefits of the use of psychotropic medication(s) have been explained to me; - I have asked, and had answered, all of the questions, which pertain to the use of psychotropic medication(s); - I understand and consent to the use of the medication described above; and - I do not consent to the use of the above mentioned medication. The consent form had a place for In person consent to indicate the individuals signing were present at the time of the form's completion: Physician Signature; Resident Name (print); and Resident Signature or Resident's Representative Signature. This was the only signature line for health care providers to sign on. There was also a place for Telephone Consent/Refusal: (2 staff witnesses) and had places for name of person giving consent/refusal; and two spaces for nurse signature. An observation on 6/20/24 at 10:38 AM, during an explanation of all the admission paperwork documents in an admission packet by Licensed Nurse (LN) #33, revealed a blank consent form with the Medical Director's signature photocopied on it. When asked about the photocopied signature on the blank consent form, LN #33 confirmed this form was used during admissions of new residents. During an interview on 6/21/24 at 4:23 PM, the Medical Director stated she approved her signature to be photocopied on a blank consent form for repeated use. The Medical Director further stated the nurses completed the consent forms with residents. When asked if there was anywhere in the chart that reflected the health care providers reviewed the admission paperwork to include the consent forms for psychotropic medications, the Medical Director stated there wasn't anywhere in the chart that she signed to say she reviewed these forms. Review on 6/17-21/24 of all 25 resident records, who were currently on psychotropic medications, revealed the following residents had consent forms that contained health care provider's photocopied signatures. Further review revealed some of the following residents also either had missing consent forms for psychotropic medications doses being administered, consents were not obtained prior to psychotropic medication administration, and/or consents were not accurately obtained with appropriate consent, for the following residents: Resident #2 Escitalopram (Lexapro - an antidepressant) Resident #2's consent form was for the use of escitalopram 20 milligrams (mg). This form was signed by the resident on 5/2/24. The Medical Director's photocopied signature was on this form with the handwritten date of 5/2/24. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent. Resident #6 Resident #6 had multiple consent forms for multiple psychotropic medications: Buspirone (an anxiolytic) The first consent form was for the use of buspirone 20 mg. This form was dated 4/15/24 and two nurses signed on the Resident's Representative Signature line under the In Person Consent section. Further review revealed no resident representative listed on the consent form. The Medical Director's photocopied signature was on this form with a computer-generated date of 4/15/24. Duloxetine (an antidepressant) The second consent form was for the use of duloxetine 60mg. This form was dated 4/15/24 and two nurses signed on the Resident's Representative Signature line under the In Person Consent section. Further review revealed no resident representative was listed on the consent form. The Medical Director's photocopied signature was on this form with a computer-generated date of 4/15/24. Trazadone (an antidepressant) The third consent form was for the use of Trazadone 100mg. This form was dated 4/20/24 and two nurses signed on the Resident's Signature line and documented 2 nurse signature [with] resident. The Medical Director's photocopied signature was on this form with a handwritten date of 4/20/24. Further record review revealed Resident #6 started Trazadone on 4/15/24, five days prior to the date of the consent form. Hydroxyzine (an antihistamine, but can be used to treat anxiety) 1. The fourth consent form was for the use of Hydroxyzine with no dose indicated. There was no class of medication marked to review risks or potential side effects for this medication. The resident's daughter signed this form on 4/24/24. Further review revealed the daughter put her name on the Resident's Name (print) line and signed her name on the Resident Signature line. The Medical Director's photocopied signature was on this form with a handwritten date of 4/24/24. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent. 2. The fifth consent form was for the use of Hydroxyzine 50mg every 6 hours PRN (as needed) and used for anxiety. The class of medication marked was anxiolytics. This form was dated 5/23/24 and two unrecognizable signatures were on the Resident's Signature line and documented verbally acknowledged. The Medical Director's photocopied signature was on this form with a handwritten date of 5/23/24. Lorazepam (an anxiolytic) The sixth consent form was for the use of Lorazepam 0.5mg. This form was dated 5/23/24 and two unrecognizable signatures were on the Resident's Signature line and documented verbally acknowledged. The Medical Director's photocopied signature was on this form with a handwritten date of 5/23/24. Resident #7 Resident #7 had two psychotropic medication consent forms: Fluoxetine (an antidepressant) The first consent form was for the use of Fluoxetine 20mg. This form was signed by the resident on 4/18/24. Further review revealed the resident did not mark the section I have asked, and had answered, all of the questions, which pertain to the use of psychotropic medication(s) of the form. The Medical Director's photocopied signature was on this form with a handwritten date of 4/18/24. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent. Mirtazapine (an antidepressant) The second consent form was for the use of Mirtazapine 7.5mg. This form was signed by the resident on 4/18/24. Further review revealed the resident did not mark the section I have asked, and had answered, all of the questions, which pertain to the use of psychotropic medication(s) of the form. The Medical Director's photocopied signature was on this form, however, was not dated. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent. Resident #8 Resident #8 had two psychotropic medication consent forms: Seroquel (an antipsychotic) The first consent form was for the use of Seroquel 25mg twice a day and 50mg at bedtime (HS). This form had an illegible marking on the Resident Signature line, dated 4/17/24. The Medical Director's photocopied signature was on this form with a handwritten date of 4/17/24. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent. Citalopram (Celexa - an antidepressant) The second consent form was for the use of citalopram 20mg. This form was dated 4/20/24 and it was documented in the telephone consent/refusal section that a resident representative was called for a consent. It was documented left a VM [voicemail] under the representative's name and two nurses signed the form. No documentation was added later to prove education was provided, or verbal consent was ever obtained. The Medical Director's photocopied signature was on this form with a handwritten date of 4/20/24. Further record review revealed Resident #8 started Citalopram on 4/18/24, two days prior to the facility's attempt to obtain consent. Resident #15 Risperdal (an antipsychotic) Review of Resident #15's medication administration record revealed an order for Risperidone Oral Tablet (Risperdal) Give 0.5mg by mouth every morning and at bedtime for mood disorder. The start date for this order was 12/21/23. Review of Resident #15's consent forms for Risperdal revealed: - The first consent form was for the use of Risperdal with no specified dose. This form was signed by the resident representative on 3/18/20. Further review revealed the resident representative did not mark the consent sections of The risks and benefits of the use of psychotropic medication(s) have been explained to me and I have asked, and had answered, all of the questions, which pertain to the use of psychotropic medication(s). Physician #22's original signature was on this consent form and dated 4/4/20. - The second consent form was for the use of Risperdal 0.25mg. This form was dated 4/6/23 and two nurse signatures were on the Resident Signature line with 2 nurse signature documented. Further review revealed no information that the resident representative was contacted for consent. Physician #22's original signature was on this consent form and dated 4/6/23. Further review of Resident #15's medical record revealed no consent for the current dose of Risperdal 0.5mg currently being administered. Resident #16 Lexapro Resident #16's consent form was for the use of Lexapro 15mg. This form was dated 5/11/24 and it was documented in the telephone consent/refusal section that the resident gave consent and was signed by two nurses. Physician #22's original signature was on this form and dated 5/11/24. Further record review revealed Resident #16 started Lexapro 10mg on 1/18/23, 479 days prior to the date of the consent form, and the dose changed to 15mg on 2/28/23, 438 days prior to the date of the consent form. No other consent forms for Lexapro were found in the resident's medical record. Resident #18 Resident #18 had multiple consent forms for multiple medications: Lorazepam 1. The first consent form was for the use of liquid Lorazepam 2 milligram (mg)/(per) milliliter (ml). This form was signed by the resident representative on 10/4/23. Physician #5's photocopied signature was on this form with a handwritten date of 10/4/23. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent. 2. The second consent form was for the use of Lorazepam 1mg. This form was signed on 11/14/23 and consent was obtained by telephone consent with the resident representative and two nurse signatures. Physician #22's photocopied signature was on this form with a handwritten date of 11/14/23. Further record review revealed Resident #18 started this Lorazepam medication as an every hour PRN (as needed) dose on 10/3/23, 42 days prior to this consent being obtained. 3. The third consent form was for the use of Lorazepam 0.5mg three times a day and every hour PRN dose. This form was signed on 3/4/24 and consent was obtained by telephone consent with the resident representative and two nurse signatures. The Medical Director's photocopied signature was on this form with a handwritten date of 3/4/24. Further record review revealed Resident #18's Lorazepam order that was started on 3/4/24 was for 1mg, three times a day, and every hour PRN. Lorazepam dose was 1mg, not 0.5mg as the consent indicated. 4. The fourth consent form was for the use of Lorazepam 1mg three times a day. This form was signed on 3/6/24 and consent was obtained by telephone consent with the resident representative and two nurse signatures. The Medical Director's photocopied signature was on this form with a handwritten date of 3/6/24. Further record review revealed Resident #18's Lorazepam order that was started on 3/6/24 was for 0.5mg three times a day, not 1mg as the consent indicated. No new consent form for this dosage change was in Resident #18's medical record. Resident #18's every hour PRN Lorazepam order stopped on 3/6/24. 5. The fifth consent form was for the use of Lorazepam 0.5mg twice a day. This form was signed on 3/13/24 and consent was obtained by telephone consent with the resident representative and two nurse signatures. The Medical Director's photocopied signature was on this form with a handwritten date of 3/13/24. Further record review revealed this scheduled dose of Lorazepam started on 3/13/24. Resident #18's every hour PRN Lorazepam order was restarted on 3/16/24, three days after the 3/13/24 consent was obtained. No new consent form for this dosage change was in Resident #18's medical record. Seroquel (an antipsychotic) 1. The first consent form was for the use of Seroquel 50mg. This form was signed by the resident representative on 10/4/23. Physician #5's photocopied signature was on this form with a handwritten date of 10/4/23. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent. Further record review revealed Resident #18 started Seroquel on 10/2/23, two days prior to this consent being documented. Further review revealed the dose of Seroquel changed on 10/17/23 to Seroquel 50mg twice a day, for a total of 100mg daily. No new consent for this dosage change was in Resident #18's medical record. 2. The second consent form was for the use of Seroquel 75mg at bedtime and 50mg PRN. This form was signed on 11/14/23 and consent was obtained by telephone consent with the resident representative and two nurse signatures. Physician #22's photocopied signature was on this form with a handwritten date of 11/14/23. Further record review revealed Resident #18 started Seroquel 75mg at bedtime on 11/1/23, 13 days prior to this consent being obtained. On 11/2/23, Resident #18 was started on Seroquel 50mg daily at 9:00 AM, not PRN like the consent form indicated. No new consent form for this dosage change was in Resident #18's medical record. 3. The third consent form was for the use of Seroquel 75mg twice a day. This form was signed on 3/4/24 and consent was obtained by telephone consent with the resident representative and two nurse signatures. The Medical Director's photocopied signature was on this form with a handwritten date of 3/4/24. Trazadone Resident #18's consent form was for the use of Trazadone 25mg. This form was signed on 11/14/23 and consent was obtained by telephone consent with the resident representative and two nurse signatures. Physician #22's photocopied signature was on this form. Further record review revealed Resident #18 started Trazadone on 10/5/23, 40 days prior to the consent being obtained. No other consent forms for Trazadone were found in the resident's medical record. Resident #19 Resident #19 had two psychotropic medications on one consent form: Paroxetine (an antidepressant) and Xanax (a sedative) Resident #19's consent form was for the use of paroxetine 40mg and Xanax 0.5mg. This form was dated 5/15/24 and consent was obtained by telephone consent with the resident representative and two nurse signatures. Physician #22's original signature was on this form and dated 5/29/24, 14 days after the resident signed the consent form. Further record review revealed Resident #19 started paroxetine 20mg on 2/4/22, 831 days prior to the consent being obtained. Resident #19's paroxetine dose was changed to 40mg on 12/21/23. No other consent forms for paroxetine were in the resident's record. Further record review revealed Resident #19 started Xanax 0.5mg on 9/30/22, 593 days prior to the consent being obtained. No other consent forms for Xanax were in the resident's record. Resident #25 Resident #25 had two psychotropic medication consent forms: Duloxetine 1. The first consent form was for the use of Duloxetine 60mg. This form was signed by the resident on 4/12/24. The Medical Director's photocopied signature was on this form with a handwritten date of 4/12/24. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent from the resident. Hydroxyzine 2. The second consent form was for the use of hydroxyzine 25mg. This form was signed by the resident on 4/16/24. The Medical Director's photocopied signature was on this form with a handwritten date of 4/16/24. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent from the resident. Further record review revealed a nurse's initials were on bottom left second page of the form which indicated Document in Point Click Care that a telephone consent/refusal was obtained and scan this document under the Misc [Miscellaneous] tab, with heading of Consent: Medications. This consent was not obtained through telephone consent. Resident #28 Resident #28 had multiple consent forms for multiple medications: Clonazepam (a sedative) 1. The first consent form was for the use of clonazepam with no specified dose. This form was signed on 5/19/24 and consent was obtained by telephone consent with the resident representative and two nurse signatures. The Medical Director's photocopied signature was on this form. This signature was not dated. Further record review revealed Resident #28 started Clonazepam on 5/18/24, 1 day prior to the consent being obtained. 2. The second consent form was a photocopy of the original with the words updated with dose on the upper right corner of the consent form's first page. The dose 0.5mg Q AM [every morning] was added after the word Clonazepam. This form had no indication the resident representative authorized the addition of a dose to the consent form, or that the resident representative was called to be informed it was added. The Medical Director's photocopied signature was on this form. This signature was not dated. Further record review revealed Resident #28 started an additional order of Clonazepam 0.5mg every 24 hours PRN agitation on 5/24/24, which changed to 0.5mg every 12 hours PRN agitation on 6/17/24. No new consent for this dosage change was in Resident #28's medical record. Hydroxyzine 1. The third consent form was for the use of hydroxyzine 25mg. The indication for use was for generalized itching. The class of medication was marked as anxiolytics. This form was signed on 4/29/24 and consent was obtained by telephone consent with the resident representative and two nurse signatures. The Medical Director's photocopied signature was on this form with a handwritten date of 4/29/24. 2. The fourth consent form was for the use of hydroxyzine 25mg. The class of medication was marked as Other and documented as antianxiety. No risks or side effects associated with this medication was not documented on the consent form. This form was dated 6/4/24 and consent was obtained by telephone consent with the resident representative and two nurse signatures. The Medical Director's photocopied signature was on this form. This signature was not dated. Seroquel 1. The fifth consent form was for the use of Seroquel 25mg. This form was signed on 5/13/24 and had an illegible marking on the Resident Signature line. Physician #5's original signature was on this form dated 5/13/24. 2. The sixth consent form was for the use of Seroquel 25mg at HS [bedtime]. This form was half filled out by a nurse in blue ink, the other half was filled out by the resident in black. This form was dated 5/13/24 and consent was obtained by telephone consent with the resident representative and two nurse signatures. None of the following sections for consent were marked: The risks and benefits of the use of psychotropic medication(s) have been explained to me; I have asked, and had answered, all of the questions, which pertain to the use of psychotropic medication(s); I understand and consent to the use of the medication described above; or I do not consent to the use of the above mentioned medication. The Medical Director's photocopied signature was on this form. This signature was not dated. 3. The seventh consent form was for the use of Seroquel 50mg. This form was dated 5/24/24 and consent was obtained by telephone consent with the resident representative and two nurse signatures. The Medical Director's photocopied signature was on this form with a handwritten date of 5/24/24. 4. The eighth consent form was for the use of Seroquel 100mg at HS and continue 50mg in the AM. This form was dated 6/10/24 and consent was obtained by telephone consent with the resident representative and two nurse signatures. The Medical Director's photocopied signature was on this form with a handwritten date of 6/10/24. Resident #31 Resident #31 had two psychotropic medication consent forms: Seroquel 1. The first consent form was for the use of Seroquel 50mg. This form was signed on 11/14/23 and the resident signed this form with an illegible marking to the left of the resident's printed name added by staff. Physician #22's photocopied signature was on this form with a handwritten date of 11/14/23. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent from the resident. Further record review revealed Resident #31 started Seroquel on 10/13/23, 32 days prior to the 11/14/23 consent form. No other consent forms for Seroquel were in the resident's medical record. Lorazepam 2. The second consent form was for the use of Lorazepam 1mg. This form was signed on 11/14/23 as well and had another illegible marking but this time was over Physician #2's photocopied signature that had a handwritten date of 11/14/23. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent from the resident. Resident #33 Resident #33 had two psychotropic medication consent forms: Wellbutrin (an antidepressant) 1. The first consent form was for the use of Wellbutrin 150mg. This form was signed by the resident on 5/10/24. The Medical Director's photocopied signature was on this form and had a handwritten date of 3/13/24, 58 days prior to the resident's consent was obtained. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent from the resident. Further record review revealed Resident #33 started Wellbutrin on 3/13/24, the day the Medical Director's photocopied signature was dated. No other consent forms for Wellbutrin were in the resident's medical record. Duloxetine 2. The second consent form was for the use of duloxetine 30mg. This form was signed by the resident on 5/10/24. The Medical Director's photocopied signature was on this form and had a handwritten date of 3/16/24, 55 days prior to the resident signing. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent from the resident. Further record review revealed Resident #33 started Duloxetine on 3/16/24, the day the Medical Director's photocopied signature was dated. No other consent forms for Duloxetine were in the resident's medical record. Resident #35 Resident #35 had two psychotropic medications with multiple consent forms: Sertraline The first consent form was for the use of Sertraline 50mg. This form was signed by the resident on 2/28/24. The Medical Director's photocopied signature was on this form had a handwritten date of 2/28/24. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent from the resident. Trazadone 1. The second consent form was for the use of Trazadone 150mg. This form was signed by the resident on 3/4/24. The Medical Director's photocopied signature was on this form with a handwritten date of 2/28/24, which was the date of admission for Resident #35 and 6 days prior to the resident signing. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent from the resident. Further record review revealed Resident #35 started Trazadone 150mg at bedtime on 2/28/24, the day of admission. No new consent form for this dosage change was in Resident #35's medical record. 2. The third consent form was for the use of Trazadone 50mg. This form was signed by the resident on 3/13/24. The Medical Director's photocopied signature was on this form with a handwritten date of 3/13/24. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent from the resident. Resident #37 Duloxetine Resident #37's consent form was for the use of duloxetine 30mg. This form was dated 2/29/24 and was obtained through telephone consent with a resident representative and two nurse signatures. The Medical Director's photocopied signature was on this form with a handwritten date of 2/29/24. Further record review revealed a second consent form for the same medication and same dose was completed and dated 4/27/24. This form was completely filled out and signed by the resident. Further review revealed this consent form was initialed by the resident on the sections of The risks and benefits of the use of psychotropic medication(s) have been explained to me and I have asked, and had answered, all of the questions, which pertain to the use of psychotropic medication(s), however there was a computer-generated pre-typed X on the line to indicate I understand and consent to the use of the medication described above. The Medical Director's photocopied signature was on this form and Resident #37 wrote the date 4/27/24 for this signature. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent from the resident. Resident #41 Resident #41 has two psychotropic medications and multiple consent forms: Venlafaxine (an antidepressant) The first consent form was for the use of Venlafaxine 150mg. This form was signed by the resident on 5/10/24. The Medical Director's photocopied signature was on this form and had a handwritten date of 5/5/24, five days prior to the resident signing. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent from the resident. Further record review revealed Resident #41 started Venlafaxine 150mg on 5/5/24, the day the Medical Director's photocopied signature was dated. No other consent forms for Venlafaxine were in the resident's medical record. Hydroxyzine 1. The second consent form was for the use of hydroxyzine 25mg. This form was dated 4/10/24 and consent was documented in the telephone consent/refusal section. The word telephone was lined out and the words In Person were added. The form indicated the resident was on the name of person giving consent/refusal line and signed by two nurses. Medical Director's photocopied signature was on this form with a handwritten date of 4/10/24. 2. The third consent form was for the use of hydroxyzine 25mg as well. This form was signed by the resident on 5/29/24. The Medical Director's photocopied signature was on this form with a handwritten date of 5/29/24. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent from the resident. Resident #105 Resident #105 had three psychotropic medication consent forms: Amitriptyline (an antidepressant) The first consent form was for the use of amitriptyline 100mg. This form was signed by the resident representative on 6/5/24. The Medical Director's photocopied signature was on this form with a handwritten date of 6/5/24. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent. Fluoxetine The second consent form was for the use of fluoxetine 20mg. This form was signed by the resident representative on 6/5/24. Further review revealed the resident's printed name was not on the In person consent line and the resident's representative signed on the Resident's Signature line. The Medical Director's photocopied signature was on this form with a handwritten date of 6/5/24. No other staff's signatures or initials were on the form to indicate who provided education or obtained consent. Memantine (cognitive enhancing medication to treat dementia associated with Alzheimer's) The third consent form was for the use of Memantine 10mg. This form was signed by the resident representative on 6/5/24. The Medical Director's photocopied signature was on this form with a handwritten date of 6/5/24. No other staff's signatures or initials were on the form to indicate who provided education or obtained

Based on record review and interview the facility failed to ensure the resident representative consented the psychotropic medication dosage changes before medication administration. This failed practice placed the 1 resident (#4), out 4 residents reviewed for psychotropic medications, at risks of unnecessary medication and adverse effects. Findings: Record review on 7/6/23 revealed Resident #4 was admitted to the facility with diagnoses that included Alzheimer's disease, dementia with other behavioral disturbance and anxiety disorder. Physician Orders Review of the physician's orders revealed the following medication dosage changes for Risperidone (Risperdal: an antipsychotic drug used to help regulate mood, behaviors, and thoughts): Order Date: 9/28/22 and end Date: 5/18/23: risperiDONE Tablet 2 MG Give 2 mg by mouth at bedtime for aggression; Order Date: 10/24/22 and end Date: 2/28/23: risperiDONE Tablet 1 MG Give 1.5 mg by mouth one time a day for aggression related to DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE WITH BEHAVIORAL DISTURBANCE (F02.81); Order Date: 3/1/23 and end Date: 3/22/23: risperiDONE Tablet 1 MG Give 1 mg by mouth one time a day for aggression related to DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE WITH BEHAVIORAL DISTURBANCE (F02.81); Order Date: 3/23/23 and end Date: 4/27/23: risperiDONE Tablet 1 MG Give 0.5 mg by mouth one time a day for aggression related to DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE WITH BEHAVIORAL DISTURBANCE (F02.81); Order Date: 5/18/23 and end Date: 5/31/23: risperiDONE Oral Tablet 1 MG (Risperidone) Give 1.5 mg by mouth at bedtime for aggression; Order Date: 5/31/23 and end Date: 6/1/23: risperiDONE Oral Tablet 1 MG (Risperidone) Give 1 mg by mouth at bedtime for aggression; Order Date: 6/2/23 and end Date: 6/14/23: risperiDONE Oral Tablet 1 MG (Risperidone) Give 1 mg by mouth at bedtime for aggression related to DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE (F02.818) Observe for delusions, hallucinations, harm to self or others; Order Date: 6/14/23 and end Date: 6/27/23: risperiDONE Oral Tablet 1 MG (Risperidone) Give 1.5 mg by mouth at bedtime for aggression related to DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE (F02.818) Observe for delusions, hallucinations, harm to self or others; Order Date: 6/27/23 and end Date: 7/2/23: risperiDONE Oral Tablet 1 MG (Risperidone) Give 2 mg by mouth at bedtime for aggression related to DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE (F02.818) Observe for delusions, hallucinations, harm to self or others. Medication Administration Record Review of the Medication Administration Record revealed Risperidone was given daily as ordered. Behavioral Note Review of Resident #4's Behavioral Note, dated 2/7/23, revealed: If there is an increase of agitation/aggression the Risperidone HS dose will be increased . [Resident representative] agreed to allow Lorazepam/Ativan for an acute exacerbation of behaviors .Plan .continue with .Risperidone/Risperdal 1.5 mg daily and 2 mg HS . Further review of the note revealed no documentation that the RR was consulted about or approved the increase in Risperidone HS dose. During an interview on 7/8/23 at 12:30 PM, the Administrator stated the facility had no Psychotropic Medication Consent policy. He stated the facility provided the resident with the Psychotropic Medication informed consent and risks and benefits statement. During an interview on 7/8/23 at 1:26 PM, the Director of Nursing stated there should have been a Psychotropic Medication consent every time there was a change in the medication dosage. She stated the Psychiatric Advanced Nurse Practitioner (PANP) was instructed on 7/6/23 to complete the consent form every time there was a change in the medication dosage. Psychotropic Medication Consent Review of the Psychotropic Medication Consent revealed consent forms were signed on: 4/6/23 for Risperidone 0.5 mg; 5/13/23 for .Risperidone 2 mg; 5/18/23 for Risperdal 1.5 mg; 5/31/23 for Risperidone/ Risperdal 1mg; 6/21/23 for Risperidone 1.5 mg until 6/27/23, 2 mg 6/27/23-7/4/23, 2.5 mg 7/4/23-7/11/23, [and] 3 mg 7/11/23 Further review of the consent forms revealed the following dosage changes were not covered with a signed consent: 1/1-31/23: 1.5 mg one time a day and 2 mg by mouth at bedtime for aggression 2/1-28/23: 1.5mg one time a day and 2 mg by mouth at bedtime for aggression 3/1-31/23: 1mg one time a day and 2 mg by mouth at bedtime for aggression 3/23-31/23: 0.5 mg one time a day for aggression 4/1-5/23: 1mg one time a day and 2 mg by mouth at bedtime for aggression 5/1-12/23: 2 mg by mouth at bedtime for aggression 6/14-20/23: 1.5 mg by mouth at bedtime for aggression During an interview on 7/8/23 at 2:38 PM, the PANP stated whenever there was a medication dosage change, Resident #4 had honeymoon phase meaning the Resident did not exhibit aggression. The PANP stated both her and the Resident Representative (RR) agreed to a plan that when the aggressive behaviors returned, they would increase the dosage of Risperidone. When the PANP actually increased the dosage, the RR was upset. The PANP stated it happened 2-3 month ago. She further stated last week [she could not provide the exact date], the RR agreed to increase the dosage to 2 mg. The resident was discharged on Risperidone 2 mg. When asked if there was a consent signed for each Risperidone dosage change, the PANP only stated the DON had given her the responsibility starting 7/6/23 to complete a Psychotropic Medication Risk and Benefits and Consent form whenever there would be a change of the medication dosage. During an interview on 7/6/23 at 4:01 PM, the RR stated he/she agreed to the plan of weaning Resident #4 from psychotropic medication. He/she stated on that 6/19/23 the PANP increased the Risperidone from 1 mg to 1.5mg and then kept increasing it by 0.5 mg. He/she did not agree to that plan. The RR stated the plan 3-4 months ago was to keep decreasing the dosage until the resident was totally off the medication. When asked if there was a plan to increase the medication dosage if the Resident manifested aggressive behavior, the RR stated we were supposed to re-evaluate the plan at those times. The RR further stated the PANP could not increase the dosage without contacting the RR.

. Based on record review and interview, the facility failed to obtain informed consent for psychotropic medications (medications in the class of either antipsychotics, antianxiety, or antidepressants that would have affected behavior, mood, thoughts, or perception) prior to use for 1 resident (#1), out of 5 sampled residents for unnecessary medications. This failed practice denied the resident the right to consent to medications and be informed of the risk and benefits for medication use. Findings: Record review from 3/20-24/23 revealed Resident #1 was admitted to the facility with diagnoses that included major depressive disorder, recurrent moderate and schizoaffective disorder (a combination of schizophrenia and mood disorder symptoms), depressive type. Review of Resident #1's current Physician Orders revealed an order for Duloxetine HCI Capsule [antidepressant] Delayed Release Particles 60 MG [;] Give 60 mg by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE . with a start date of 10/22/22. Further review revealed no psychotropic medication informed consent for the duloxetine. During an interview on 3/23/23 at 11:34 AM, the Director of Nursing (DON) stated psychotropic medication consents should have been reviewed quarterly for risks and benefits and continued monitoring. During a follow-up interview on 3/24/23 at 2:11 PM, the DON confirmed Resident #1 had not signed a consent for the antidepressant medication duloxetine. Review of facility policy Psychoactive Medications, undated, revealed Maple Springs will ensure that residents who have not used a psychoactive medication, are not given psychoactive drug therapy unless it is necessary to treat a specific condition as diagnosed and documented in the medical record . .

. Based on record review and interview, the facility failed to ensure resident rights to self-determination were honored. Specifically, the facility failed to provide a method for storing perishable food brought in by family or visitors. This failed practice denied the residents the right to store perishable food brought into the facility. Findings: During a collaborative group meeting on 3/22/23 at 1:30 PM, residents of the facility voiced their concern that there was no way to store perishable food brought into the facility by family or visitors. The residents stated there was no refrigerator to store their food. During an interview on 3/23/23 at 2:06 PM, the Kitchen Manager stated that when residents asked for food to be stored/refrigerated it was a hard no and that no resident-owned food was kept in the kitchen. During an interview on 3/23/23 at 3:41 PM, the Director of Nursing (DON) stated there was not a specific resident refrigerator maintained for resident food, as this would have required recording of temperatures and everyone having access. Review of the facility's policy Foods Brought by Family/Visitors, revised 10/2017, revealed: Food brought to the facility by visitors and family is permitted . Food brought by family/visitor that is left with the resident to consume later will [be] labeled and stored in a manner that it is distinguishable from facility-prepared food. Non-perishable foods will be stored in re-sealable containers with tight-fitting lids. Intact fresh fruit may be stored without a lid. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date . .

Based on record review and interview, the facility failed to resolve a grievance for 1 resident (#24) out of 16 sampled residents. Specifically, the resident's complaint was not fully resolved, and the resident did not receive a written grievance decision which included the steps taken to investigate the grievance and a summary of pertinent finding or conclusions regarding the resident's concerns. This failed practice denied the resident information regarding a resolution of the grievance. Findings: Record review from 3/20-24/23 revealed Resident #24 was admitted to the facility with diagnoses that included hemiplegia (weakness on one side of the body) and seizure disorder. Further review revealed the Resident had a BIMS (brief interview for mental status) score of 15, indicating the Resident was cognitively intact. During an interview on 3/21/23 at 8:40 AM, Resident #24 stated he/she had $800.00 (eight hundred dollars) go missing out of his/her wallet last month. When asked who he/she reported the missing money to, the Resident stated he/she reported this to the front desk and the social worker. When asked what the facility did after the report, the Resident stated nothing was done and he/she felt like the facility swept it under the rug. The Resident further stated he/she found his/her wallet in his/her pants pocket, but the money was missing. During the interview the Resident named staff members who saw the money laying out on the bed prior to it going missing. When asked how the facility investigated the missing money, Resident #24 stated no one asked him/her anything, but he/she had reported it. The Resident further stated his/her [family member] knew how much money he/she had because the family member took care of his/her bank account and knew how much money the Resident was given. Review of the facility's Grievance Log revealed no grievances or investigation into the Resident's lost money. During an interview on 3/22/23 at 12:56 PM, Certified Nursing Assistant (CNA) #2 stated if a resident reported missing money, he/she would have let the Director of Nursing (DON) know. When asked if he/she received reports of missing money, CNA #2 stated he/she could not remember who, but had received a couple complaints of missing money that he/she reported to the DON. When asked if he/she was aware of Resident #24's complaint of missing money, CNA #2 stated he/she was aware, and Resident #24 was pretty with it [had intact cognition]. During an interview on 3/23/23 at 2:00 PM, the DON stated she was aware of the Resident's complaint of missing money, and she informed the Resident Advocate (RA). When asked about the grievance process for Resident #24's complaint, the DON stated to ask the RA because she was not sure if the Resident's complaint was in the grievance log. During an interview on 3/23/23 at 3:00 PM, when asked what types of complaints rise to the formal grievance level, the RA stated a report of neglect, harm or theft of property would go to formal grievance process depending on the Resident. The RA stated if a resident had $40 go missing, the facility would have asked if that resident wanted the money replaced or would have given that resident a locked box. The RA stated the Administrator had a locked box in his office for the resident's use. When asked about Resident #24's complaint rising to the grievance level, the RA stated normally it would have, however, she called the Resident's family member who said the Resident's story was inconsistent, so that's why the complaint did not rise to the formal grievance process. The RA further stated she thought the Resident was involved in a scam where you give $500 to get $50,000 and thought maybe the money could have been scammed from the Resident. Review of a Communication Note, dated 1/16/23 at 2:52 PM revealed [The Resident] reported [his/her] wallet missing with $800 cash. When I first spoke to the resident about the money, [he/she] could not tell me where or when [he/she] had last seen [his/her] wallet. [He/She] said that [he/she] never takes it out of [his/her] jacket pocket and that [he/she] had not left [his/her] room that whole day. However, resident did go outside to smoke and rehab that day. [The resident] then reports finding [his/her] wallet in a clean pair of pants. [He/She] said [his/her] ID was still in there, but the cash was gone. CNA on shift reported that [the resident] told her that [he/she] had dropped [his/her] wallet and cash outside. Tried calling resident's POA [power of attorney-family member] multiple times and [he/she] has not returned our calls. Will follow up with resident's POA to see if [he/she] has resident's cash or if [he/she] knows if resident ever had cash. Currently, resident does not know when, where, or how [he/she] lost [his/her] cash. Review of a Communication Note, dated 1/18/23 at 3:42 PM revealed Resident's [family member] returned our calls regarding the missing wallet and cash. According to [the family member], about 3 weeks ago [the Resident] asked [the family member] for money because [he/she] was involved in some type of scam where you give $500 and they will give you $50,000 in return. After a heated argument with [the Resident, the family member] admitted against my better judgement, I gave [him/her] a large amount of cash. [The family member] is not sure whether or not [the Resident] gave into the scam, or if the money was really stolen. [The family member] does state that [the Resident's] stories are different every time and out of character for [him/her]. Another note, when [the family member] took [the Resident] out shopping today, [he/she] noticed [the Resident] had a $50 bill in [his/her] wallet. When [the family member] asked where that came from [the Resident] said the thief left the $50 but took everything else. [His/Her] original story was that all the money was stolen with nothing left. [The family member] does not want to file a formal complaint. [The family member] believes in the near future it will make itself clear. Review of the facility's policy, Grievance Policy and Procedure, not dated, revealed Purpose- To outline a consistent approach to handle complaints by residents .or their representatives .All residents have the right to prompt efforts by Maple Springs to resolve grievances the resident may have .Grievances/complaints may be presented .Verbally and documented by the person accepting the complaint using a grievance form .Maple Springs will appoint a Grievance Officer whose duties include .Receiving and tracking grievance through to their conclusion .Leading any necessary investigations by the facility .Issuing written grievance decisions to the resident .Within 10 working days, the grievance official shall provide the person who initiated the grievance a written report detailing the findings of the investigation about the complaint. Review of the facility's policy, ABUSE POLICIES, dated 10/2020, revealed Investigating Misappropriation of Resident Property .An investigation will be triggered upon report of an incident of misappropriation of a resident's property .Interviews will be conducted with the following individuals .The individual who initially reported the incident .When the incident is regarding a lost item .The interviewer will ask the resident, their family, and/or legal representative for permission to look for the missing item in the resident's bedroom .Other possible locations will be searched as needed . .

. Based on record review, interview, observation and document review, the facility failed to ensure safety equipment was checked per manufacturer's instructions for 1 resident (#36) out of 1 resident sampled for wandering. Specifically, the wanderguard tag device (worn by the resident to alert the facility if the resident eloped) was checked monthly instead of weekly. This failed practice had the potential to cause harm if the resident wandered outside during a time the equipment was not functioning. Record review from 3/20-24/23 revealed Resident #36 was admitted to the facility with diagnoses that included dementia, depression, and diabetes. During an interview on 3/20/23 at 2:47 PM, Resident #36's POA (power of attorney) stated he/she was called by the facility in the past because the Resident had wandered outside. The POA stated the Resident now has a wanderguard device in place. An observation on 3/22/23 at 9:30 AM revealed Resident #36 seated at the dining room table upstairs, wearing a wanderguard tag device on his/her ankle. During an interview on 3/23/23 at 11:43 AM, Licensed Nurse (LN) #1 stated Resident #36 wandered occasionally. When asked the process for checking the Resident's wanderguard tag device, LN #1 stated he/she checked to make sure the Resident was wearing the device daily. When asked about ensuring the tag device remained functional, LN #1 stated he/she did not check the device, but maintenance checked the device and they had a checklist. During an interview on 3/23/23 at 2:00 PM, when asked about checking the tag device worn by the Residents, the Director of Nursing (DON) stated if the Resident went to the emergency room and the alarm did not go off, that would be a way to check the system. The DON further stated the device was checked prior to placing it on the Residents and he/she did not know about the testing. During an interview on 3/24/23 at 11:00 AM, the DON stated the facility did not have a policy regarding the wanderguard system, but the facility followed the manufacturer's instructions for the device. During an interview on 3/24/23 at 3:36 PM, the Assistant Director of Nursing (ADON) stated the Licensed Nurses checked the placement of the wanderguard tag device to ensure the Resident was wearing it, and those checks were documented in the electronic health record. The ADON further stated the Administrator did the monthly checks and provided the manufacturer's instructions and monthly logs to review. Review of the facility provided document WANDERGUARD BLUE WANDER MANAGEMENT SOLUTION USER AND DEPLOYMENT GUIDE, not dated, revealed Communication- The Detector communicates only with the Tag [the device the resident wears on the wrist or ankle] .Best Practice: It is recommended to have the Tag battery checked at least once a week. Review of the facility provided document, Maple Springs Wasilla Monthly Test Wanderguard, dated 2/10/23, revealed the battery check was completed for Resident #'s 34 and 36 once during the month of February, rather than weekly. Further review of the logs revealed the batteries were checked on a monthly basis. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and interview, the facility failed to ensure 1 resident (#8) out of 2 residents sampled with a foley catheter (a hollow tube inserted into the bladder to drain urine) was assessed timely for discontinuation of the catheter. This failed practice had the potential to keep the device in place for longer than clinically necessary and increased the potential for the resident to develop a urinary tract infection. Findings: Record review from 3/20-24/23 revealed Resident #8 was admitted to the facility on [DATE] with diagnoses that included unspecified fracture of the lower end of the right tibia (shinbone), diabetes, and chronic kidney disease. Further review revealed the resident admitted to the facility with a foley catheter in place. During an observation on 3/20/23 at 3:14 PM, Resident #8 was observed lying in bed with a foley catheter hanging from the lower frame of his/her bed. During an interview on 3/20/23 at 3:17 PM, Resident #8 stated he/she was admitted to the long term care facility with a foley catheter that he/she received during his/her hospital stay. Further review of the Resident's diagnoses revealed no documented diagnoses suggesting the need for long term foley catheter placement. During an interview on 3/22/23 at 12:56 PM, Certified Nursing Assistant (CNA) #2 explained the process for cleaning the catheter and stated Resident #8 may have had urine leakage because the powder on the Resident got junky, so he/she would have cleaned that. During an interview on 3/22/23 at 1:59 PM, Licensed Nurse (LN) #1 stated when a Resident admitted to the facility with a catheter, the nurses just kept the catheter in place unless the physician gave orders for removal. When asked if Resident #8 was able to use the bedpan for his/her bowels, LN #1 stated Resident #8 was able to use the bedpan. During an interview on 3/22/23 at 4:24 PM, when asked the process for assessing catheter removal, the Assistant Director of Nursing (ADON) stated the facility would have assessed why the Resident required a catheter, a wound for example, and then would have let the physician know that the wound was resolved, and if the physician chose to remove the catheter, the facility had standing orders for bladder retraining. When asked why Resident #8 still had a catheter in place, the Director of Nursing (DON) stated the Resident was on bedrest for a time. The ADON stated bedrest would not be a reason to keep a catheter in. The ADON further stated Resident #8 was on a Lasix (a diuretic medication), but that medication was not a reason to keep the catheter in place. When asked how she ensured a Resident did not keep a catheter too long, the DON stated she spoke to the nurse about Resident #8 the morning of 3/22/23 and there was not a good reason why the catheter was still in place. During an interview on 3/24/23 at 2:27 PM, when asked if Resident #8 was a candidate for foley catheter removal, the Medical Director (MD) stated the Resident could have been a candidate and the foley catheter was never addressed when the Resident was being discharged from the hospital. The MD, after reviewing Resident #8 electronic medical record, stated the Resident was examined yesterday (3/23/23) and the plan was to remove his/her foley catheter in three days. Review of the facility's document Resident Standing Orders, dated 3/2022, revealed Foley Catheter- If there are orders to remove a foley catheter, use the following protocol after removing the catheter . Further review revealed no orders to assess the Resident for timely removal of the foley catheter. .

. Based on record review, observation, and interview, the facility failed to ensure administration of enteral nutrition (a liquid diet delivered by way of tube feeding) was free of possible complications for 1 resident (#29), out of 2 residents observed for enteral nutrition. Specifically, the facility failed to ensure the resident's head of the bed was positioned no lower than 30 degrees in elevation during enteral feedings. This failed practice had the potential to cause aspiration (liquid entering the lungs). Findings: Record review from 3/20-24/23 revealed Resident #29 was admitted to the facility with diagnoses that included hemiplegia and hemiparesis (paralysis or weakness of one side of the body) following cerebral infarction (lack of blood flow to the brain) affecting right dominant side and severe protein-calorie malnutrition (lack of proper nutrition). An observation on 3/20/23 at 10:02 AM, revealed Resident #29 lying in bed with an enteral feeding being administered at 80 milliliters per hour. Further observation revealed the head of the bed to be almost flat in orientation. During an interview on 3/20/23 at 10:13 AM, Licensed Nurse (LN) #3 stated Resident #29 did not have to be elevated in bed to 30 degrees as the enteral nutrition amount being administered was so minimal. Review of Resident #29's Care Plan, revised 4/20/21, revealed: .Ensure [Resident's] HOB [head of bed] elevated 40 degrees during and thirty minutes after tube feed [enteral feed] . During an interview on 3/22/23 at 4:48 PM, the Director of Nursing stated that the head of the bed needed to be elevated to 30 degrees while enteral nutrition/flushes were administered. Review of facility policy Enteral Nutrition, revised 11/2018, revealed: .Risk of aspiration is assessed by the nurse and provider and addressed in the individual care plan. Risk of aspiration may be affected by . Improper positioning of the resident during feeding . .

. Based on interview and observation, the facility failed to ensure reconciliation of a controlled drug (narcotic medication for pain) was accurate. Specifically, the facility failed to ensure liquid narcotic medication volume was accurately reconciled for 1 resident out of 8 residents sampled during medication cart review. This failed practice had the potential for inaccurate narcotic reconciliation. Findings: Narcotic Medication Reconciliation During an interview on 3/22/23 at 11:02 AM, the Director of Nursing (DON) stated the narcotics (controlled drugs) were kept in the medication cart on each unit. The DON further stated the nurses would have reconciled the controlled drugs at shift change. The DON stated the oncoming nurse and the outgoing nurse would have reconciled (counted) the amount of medication in the blister pack (a type of packaging in which a product is sealed in plastic, often with a cardboard backing) and the data was entered into the narcotic log book. During an interview on 3/22/23 at 1:30 PM, Licensed Nurse (LN) # 1 stated the controlled drugs were kept in a secured drawer in the medication cart. LN #1 further stated the narcotic medications were reconciled by checking the medication on hand within the blister pack and the amount of medication documented in the narcotic log. Medication Reconciliation for Liquid Narcotic During an observation with concurrent interview on 3/22/23 at 12:15 PM, during the medication cart observation, LN #2 showed this surveyor the contents of the medication cart on his/her unit. Further observation revealed there was a HYDROC-ACET 7.5/325/15 ML bottle (pain medication) for Resident #25. When asked how he/she would have reconciled the amount left in the bottle, LN #2 stated he/she would not have measured the contents left in the bottle, because there would have been residual loss of the medication left in the measuring cup. When asked if the medication bottle was calibrated, LN #2 stated there was no way to see the level of the medication in the bottle, because the bottle was dark brown and non-transparent. During an interview on 3/24/23 at 9:20 AM, when asked how he/she would have completed the narcotic log for Resident #25's HYDROC-ACET 7.5/325/15 ML, LN #2 stated he/she would have written the amount given to the resident and would have deducted it from the stock amount. LN #2 further stated the pharmacy sent a new bottle (by showing the new bottle) but was still the same dark bottle. Further observation of the medication label revealed: Hydrocodone bitartrate and acetaminophen oral solution . [Resident #25's name] Give 5-10 ml via Peg-tube [percutaneous tube in the stomach] every 4 hours as needed for pain. During an interview on 3/24/23 at 10:50 AM, the DON stated the LNs would not have been able to know the amount of liquid medication left in the dark bottle after administration. The nurses would only know of a discrepancy based on calculated doses at the completion of the medication. When asked the normal process of liquid medication reconciliation, the DON stated the liquid medication would have been measured in a measuring cup to determine the exact amount. The DON further stated she was going to bring this concern to the attention of the pharmacist. During an interview on 3/24/23 at 11:37 AM, when asked how the nurse would have determined the amount of liquid medication left in the bottle, the Pharmacist stated there was a calibration on the side of the bottle to measure the medication. The medication was in a dark bottle to prevent sunlight exposure and maintain medication stability. An observation of the liquid narcotic bottle on 3/24/23 at 12:18 PM, revealed no calibration. LN #2 confirmed there was no calibration measurements on the bottle. .

Based on record review and interview, the facility failed to ensure duplicative medications ordered for constipation, were written with adequate indications for use for 1 resident (#37), out of 16 sampled residents. Specifically, the facility failed to ensure: 1) clear guidance on when to use Senna (medication used for constipation) in the bowel protocol; and 2) the as needed bowel medication orders included sequence for use. These failed practices had the potential to inadequately medicate the resident. Findings: Record review on 3/20-24/23 revealed Resident #37 was admitted to the facility with diagnoses that included chronic kidney disease and diabetes. During an interview on 3/20/23 at 2:56 PM, Resident #37 stated he/she received a stool softener every day, however he/she still struggled with constipation. Resident #37 described his/her bowel movements as hard stool and difficult to pass. Review of the facility's Bowel Protocol, undated, revealed the purpose of the protocol was To provide timely interventions to assist with prevention of constipation and other complications. The Bowel Protocol procedure included: - Upon admission, Miralax and Bisacodyl suppositories will be added as PRN [as needed] medication and will be available to all residents; - All residents on narcotics will have Senna tablets added to their orders. Obtain specific order from MD [medical doctor]; - If no bowel movement reported follow the following protocol: If no bowel movement for 3 days, the nurse will administer Miralax and prune juice in the morning; If no BM [bowel movement] by night shift, administer another dose of Miralax; On Day 4 of no bowel movement, nurse will give suppository. If no results, nurse will contact MD for further instructions. Further review of the Bowel Protocol revealed no protocol for the timing of when to administer the Senna oral tablets. Review of Resident #37's Medication Administration Record (MAR), dated March 2023, revealed the following medications for constipation: Scheduled medication: 1) Docusate Sodium Tablet 100 MG give 100 mg by mouth every morning and at bedtime for constipation. As needed medication: 1) Bisacodyl Suppository insert 1 suppository rectally every 24 hours as needed for constipation, dated 2/28/23. 2) Miralax Powder (Polyethylene Glycol 3350) give 17 gram by mouth every 12 hours as needed [PRN] for constipation, dated 2/28/23. 3) Senna Oral Tablet 8.6MG (Sennosides) give 8.6mg by mouth every 12 hours as needed for constipation, dated 2/28/23. During an interview on 3/23/23 at 10:23 AM, the Pharmacist stated ordered sequence of use for as needed constipation medications were not necessary because the nurses followed a Bowel Protocol which instructed them on which medication to use and when to use it. During an interview on 3/23/23 at 3:36 PM, the Director of Nursing (DON) stated the as needed medication orders for constipation should have defined a sequence of use to indicate when the medications should have been used. The DON further stated the Bowel Protocol should have been updated to include pill form medications (like Senna) for constipation. .

. Based on observation and interview, the facility failed to ensure drugs used in the facility were labeled in accordance with accepted professional practices. Specifically, the facility failed to ensure the label on the Melatonin (a supplement used for insomnia) blister pack for 1 discharged resident was not re-labeled as stock medication and put into use within 1 medication cart out of 3 medication carts observed. This failed practice placed all residents that received this medication from this cart at risk of misuse of prescribed medication. Findings: During an observation and concurrent interview on 3/22/23 at 12:15 PM, Licensed Nurse (LN #2) showed the contents of the medication cart on his/her unit. Further observation revealed a bubble pack for Melatonin 1 MG tabs had a resident's name crossed out. Further observation revealed a handwritten note on the pack which read stock. When asked about the melatonin bubble pack label, LN #2 stated that resident was discharged , and the left-over medication was used as floor stock for other residents. During an interview on 3/24/23 at 11:37 AM, when asked if a medication that belonged to a resident who had been discharged was approved to be used as stock supply for other residents, the Pharmacist stated no, the medication should have been sent home with the resident or returned to the pharmacy so the resident could have been reimbursed. According to Food and Drug Administration (FDA), Drug safety, dated 5/2022, accessed at https://www.fda.gov/media/158522/download, revealed: .Blister packs may improve patient adherence and minimize the risk of accidental exposure to the drug. Additionally, blister packs can be designed so that critical information stays with the medication throughout the intended use of the product by the end user . .

. Based on record review and interview, the facility failed to ensure menus were accurate for 2 residents (#s 37 and 304), out of 16 sampled residents. This failed practice caused the residents to receive an incorrect diet which could have affected their overall health and wellbeing. Findings: Resident #37 Record review on 3/20-24/23 revealed Resident #37 was admitted to the facility with diagnoses that included pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and heart), saddle embolus of pulmonary artery (a large blood clot), and diabetes. Review of Resident #37's dietary card, dated 3/22/23, revealed: Diet: 2 Gm Na (low sodium). Review of Resident #37's electronic diet order, dated 3/16/23, revealed: NAS (No Added Salt) diet. Review of Resident #37's Order and Communication forms, dated 2/28/23, 3/4/23, and 3/7/23, all revealed a No Added Salt diet was checked as the diet order. Resident #304 Record review on 3/20 -24/23 revealed Resident #304 was admitted to the facility with diagnoses that included hypertensive heart (heart conditions caused by high blood pressure) and chronic kidney disease (gradual loss of kidney function) with heart failure, biventricular heart failure (a condition where both sides of the heart can't pump enough blood to the body and lungs), atherosclerotic (hardening and narrowing of arteries) heart disease, and hyperlipidemia (an excess of fatty substances called lipids, largely cholesterol and triglycerides, in the blood). During an interview on 3/20/23 at 2:53 PM, Resident #304 stated he/she was not on a special diet but was diabetic. Review of Resident #304's dietary card, dated 3/22/23, revealed: Diet: 2 Gm NA (low sodium). Review of Resident #304's electronic diet order, dated 3/17/23, revealed: NAS (No Added Salt) diet. Review of the Order and Communication form, dated 3/13/23, revealed a No Added Salt diet was checked as the diet order. During an interview on 3/23/23 at 9:01 AM, the Dietician stated that a 2-gram sodium diet was not the same as a no salt added diet. Residents #37 and #304 should have been receiving a no salt added diet after reviewing the resident's charts. During an interview on 3/23/23 at 9:54 AM, the Kitchen Manager stated that foods for a 2-gram sodium diet were prepared differently than foods for no added salt diet. After reviewing the resident's charts, the kitchen manager stated that the dietary cards were documented incorrectly and the dietary cards should have reflected a NAS diet. Review of the facility's policy Policy & Procedure Manual Transmission of Diet Orders, dated 2019, revealed: .Nursing staff will send the diet order to the food and nutrition services department as soon as possible after admission or diet change . Meal identification cards/tickets will be adjusted to reflect changes in diet and food preferences as needed . Review of the facility's policy Policy & Procedure Manual Therapeutic Diets, dated 2019, revealed: .Diets will be offered as ordered by the physician or designee . The individual's medical record and diet on file in the food and nutrition service office's system must be reviewed on a regular basis to assure that they are in agreement . .

. Based on record review, observation, and interview, the facility failed to ensure 5 residents (#'s 1; 24; 50; 155; and 305), out of 16 sampled residents, were assessed to determine safety prior to self-administration of medications. This failed practice placed the residents at risk of medication errors, and potential drug interactions. Findings: Review on 3/24/23 of the facility's policy Self-Administration of Medications, dated 12/2022, revealed: As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medication is clinically appropriate for the resident .In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment including (but not limited to) the resident's: a. Ability to read and understand medication labels; b. Comprehension for the purpose and proper dosage and administration time for his or her medications; c. Ability to remove medication from a container and to ingest and swallow (or otherwise administer) the medication; and d. Ability to recognize risks and major adverse consequences of his or her medications. Resident #1 Record review from 3/20-24/23 revealed Resident #1 was admitted to the facility with diagnoses that included osteoarthritis, essential hypertension, and type 2 diabetes mellitus with diabetic polyneuropathy (damage or disease affecting nerves throughout the body). An observation on 3/20/23 at 3:27 PM, revealed a tube of Diclofenac (Voltaren) gel (a topical analgesic for pain relief) on the bedside table. Record review of Resident #1's Physician Orders, active orders as of 3/22/23, revealed no current order for Voltaren gel. During an interview on 3/22/23 at 1:03 PM, Licensed Nurse (LN) #3 stated he/she did not know Resident #1 had a tube of Voltaren gel at the bedside and stated this medication had been discontinued. During an interview on 3/23/23 at 10:21 AM, LN #4 stated Resident #1 had visitors that brought items in for the Resident. During an interview on 3/23/23 at 1:03 PM, the Director of Nursing (DON) stated an assessment for self-administration of medications was required before residents were allowed medications at their bedside and Resident #1 did not have a completed self-administration assessment. Resident #24 Record review from 3/20-24/23 revealed Resident #24 was admitted to the facility with diagnoses that included hemiplegia (paralysis or weakness on one side of the body), seizure disorder, and hypertension (high blood pressure). During an observation and interview on 3/21/23 at 8:51 AM, Resident #24 stated he/she was not smoking now and presented a bottle of nicotine replacement lozenges from his/her bedside table that he/she received at his/her appointment on 3/20/23. The bottle contained 24 lozenges. Further observation of the Resident's room revealed: - 1 unopened box of nicotine gum, 2mg pieces, 110 pieces total; - 1 unopened box of nicotine lozenges, 2mg pieces, 72 pieces total; - 1 opened box of nicotine gum- contents not examined; - 1 opened box of nicotine lozenges- contents not examined. When asked how many lozenges he/she consumed today, the Resident stated he/she ate 2 lozenges this morning. The Resident further stated he/she was wearing a nicotine patch that the staff placed on him/her every morning. Review of Resident #24's electronic medication administration record (eMAR), dated 3/21/23, revealed no documented doses of nicotine lozenges consumed. Review of Resident #24's current Physician's orders revealed orders for: - Nicotine Mini Mouth/Throat Lozenge .Give 2 mg by mouth every 1 hours as needed for smoking cessation. Nicotine gum 2mg chew 1 piece up to [every] 1 [hour as needed]- may alternate lozenges and gum up to 12 pieces per day. May keep 6 [pieces] at bedside at a time, start date was 2/1/23; - Nicotine Transdermal Patch .Apply 7 mg transdermally [to skin] in the morning for smoking cessation. Apply topically to skin daily, remove old patch in AM, start date was 2/1/23; and - Stop Nicotine replacement therapy if [Resident] smokes or uses nicotine patches two times a day, with a start date of 1/25/23. During a follow up interview on 3/23/23 at 11:22 AM, when asked how much nicotine replacement he/she took yesterday (3/22/23), Resident #24 shook his/her bottle of lozenges and stated he/she took those. When asked how many, the Resident stated he/she did not know. Review of Resident #24's eMAR, dated 3/22/23, revealed no documented doses of nicotine lozenges consumed. During an interview on 3/23/23 at 11:43 AM, LN #1 stated Resident #24 used the nicotine patches daily, and the Resident also consumed the nicotine replacement lozenges and gum. When asked how he/she kept track of the amount of nicotine replacement the Resident consumed, the LN stated the gum and lozenges were kept in the resident's room, and he/she would have offered the resident a piece and then would have charted it. The LN further stated there was no documented doses of lozenges on the Resident's eMAR dated 3/22/23. During an interview on 3/23/23 at 2:00 PM, when asked to review Resident #24's assessment for self administration of medications, the DON stated the Resident was not assessed. The DON further stated the facility should have had an assessment to know how often the Resident was consuming the nicotine replacements. During an interview on 3/24/23 at 11:12 AM, when asked if a Resident could have overdosed on nicotine gum or lozenges if the patch was being worn, the Pharmacist stated he was not happy with what was going on and followed up with the provider. The Pharmacist further stated he recommended the patch or the gum/lozenges. The Pharmacist stated he had reviewed the PRN (as needed) dosages and the Resident had not been consuming too much, and he recommended going down on the dosage. Review of the facility's policy Self-Administration of Medications, dated 12/2022, revealed If the resident is able and willing to take responsibility for documenting their self-administration of medications, the resident will be instructed on how to complete a record indicating the administration of the medication. Resident #50 Record review on 3/20-24/23 revealed Resident #50 was admitted to the facility with diagnoses that included morbid obesity with alveolar hypoventilation (one cannot move enough air in and out of the lungs, due to obesity, this leads to low oxygen levels and too much carbon dioxide levels) and sepsis (life-threatening infection). An observation on 3/20/23 at 3:47 PM, revealed Resident #50 had an albuterol inhaler and a tube of Voltaren Gel in his/her room. During an interview on 3/20/23 at 3:47 PM, Resident #50 stated he/she used the albuterol inhaler and Voltaren gel independently, whenever he/she needed them. Albuterol Inhaler Record review of Resident #50's Medication Administration Record (MAR), dated February 2023 and March 2023, revealed no order for an albuterol inhaler. Record review of Resident #50's medical record revealed no Self-Administration Assessment within the record. During an interview on 3/23/23 at 10:12 AM, Resident #50 stated the inhaler was albuterol. He/she further stated he/she brought the inhaler into the facility when he/she was admitted . Resident #50 stated he/she got the inhaler from a personal physician prior to being admitted to the facility. Record review of Resident #50's Personal Effects Inventory, dated 2/23/23, revealed 1 inhaler was documented as being part of the resident's belongings upon admission. Review of Resident #50's Care Plan, initiated 3/2/23, revealed no identification of problems with breathing or a need for an albuterol inhaler. Review of Resident #50's admission MDS (Minimum Data Set - a federally mandated nursing assessment), dated 2/27/23, revealed Extreme obesity with alveolar hypoventilation was identified under section I of the Active Diagnoses list. During an interview on 3/23/23 at 3:30 PM, LN #7 stated he/she was only made aware today that Resident #50 had an inhaler. He/she stated an order for the albuterol inhaler would need to be obtained. Voltaren Gel Record review of Resident #50's MAR, dated March 2023, revealed an order for Voltaren Gel dated 3/16/23: Voltaren External Gel 1% (Diclofenac Sodium (Topical)) Apply to left knee topically every 6 hours as needed for pain unsupervised self-administration apply 4g [grams] topically to left knee as needed. May keep at bedside and self administer. Record review of Resident #50's medical record revealed no Self-Administration Assessment within the record. During an interview on 3/20/23 at 3:47 PM, Resident #50 stated he/she usually used the Voltaren Gel at night. When asked how he/she measured out 4 grams of medication, Resident #50 stated he/she guesses and measured out about half an inch on his/her finger. When asked if the nurses had provided a measuring card for accurate dispensing of the Voltaren Gel, the Resident replied no. During an interview on 3/23/23 at 12:22 PM, the DON stated leadership had recently found out that providers were writing orders for self-administration of medication without getting approval or having self-administration assessments completed prior to initiating the orders. Resident #155 Record review from 3/20-24/23 revealed Resident #155 was admitted to the facility with diagnoses of functional quadriplegia, severe protein-calorie malnutrition, and a pressure ulcer of the sacral region. An observation with concurrent interview on 3/20/23 at 3:40 PM, revealed a bottle of Pepto Bismol liquid on the bedside table. Resident #155 stated my [spouse] brought the Pepto Bismol in and that it worked for me. Further observation revealed an undetermined amount emptied from the bottle. Record review of Resident #155's Physician Orders, active orders as of 3/22/23, revealed no order for the Pepto Bismol medication. During an interview on 3/23/23 at 1:03 PM, the DON stated an assessment for self-administration was required before the residents were allowed to keep medications at the bedside and Resident #155 did not have a completed self-administration assessment. Resident #305 Record review on 3/20-24/23 revealed Resident #305 was admitted to the facility with diagnoses that included hemiplegia and hemiparesis (weakness and/or paralysis of one side of the body) following a stroke affecting right dominant side, stable fracture of T11 - T12 vertebrae (lower thoracic spine fractures), and diabetes. An observation on 3/20/23 at 3:19 PM, revealed multiple bottles of vitamins and supplements sitting on a shelf in Resident #305's room. The bottles included: - Zinc 50 milligrams (mg); - Garlic 1,000mg; - Vitamin D3 extra strength 50 micrograms (mcg); - Quercetin 1,000mg; - Turmeric Curcumin 2,600mg; - Vitamin E 180mg; - B-1 100mg; - Graviola 5,000mg; - Ceylon Cinnamon Apple Cider Vinegar Turmeric Bioperine Ginseng Root 3,255mg; - Salonpas pain patches (contains Camphor 3.1%, Menthol 6.0%, and Methyl Salicylate 10.0% topical analgesics for pain relief); - Colloidal Silver for the eyes, the bottle reads 1-2 sprays, safe for kids with pink eye, During an interview on 3/20/23 at 3:19 PM, Resident #305 stated the nurse had told him/her that he/she could take these on his/her own. Resident #305 further stated he/she did not take these vitamins and/or supplements every day, just sometimes. Record review of Resident #305's Medication Administration Record (MAR), dated March 2023, revealed an order dated 3/16/23: Self administration assessment for having medications at bed side (in the assessment tab) one time only for assessment for 1 day. Further review revealed this order was never initiated by an LN as completed. Record review of a Self-Administration Assessment in Resident #305's medical record revealed this assessment was dated 3/6/23 and was completed blank. Nothing was documented on the form. During an interview on 3/23/23 at 12:22 PM, the DON stated a self-administration assessment would be needed for medications a resident would have taken independently, this included vitamins and supplements. The DON further stated a self-administration assessment must be completed before self-administration of any medication could have occurred. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and interview, the facility failed to ensure the MDS (Minimum Data Set- A federally required nursing assessment) accurately reflected the resident's status at the time of assessment. Specifically, the facility failed to: 1) complete a discharge assessment for 1 unsampled resident (#3), out of 1 reviewed for resident assessment; 2) assess for hearing aids for 2 residents (#'s 2 and 37), out of 16 sampled residents; 3) ensure oxygen therapy and/or CPAP (continuous positive airway pressure) use were identified for 2 residents (#'s 37 and 50), out of 16 sampled residents; and 4) ensure a broken denture was identified for 1 resident (#304), out of 16 sampled residents. These failed practices placed the residents at risk for receiving an inaccurate care plan, interventions, and recieving less than optimal care. Findings: Resident #3 Record review on 3/20-24/23 revealed Resident #3 was admitted to the facility with diagnosis that included heart failure. Review of the Interdisciplinary Discharge summary, dated [DATE], revealed Resident #3 was .transferring to [another Long-term Care facility]. During an interview on 3/24/23 at 9:35 AM, when asked about the MDS for Resident #3 being triggered for resident assessment over 120 days old, the MDS Coordinator (MDSC) stated the discharge assessment was not completed when the Resident transferred to another long-term care facility on 1/16/23. The MDSC explained that she would normally get an alert in Point Click Care (PCC- an online electronic health record) but she did not get an alert to conduct discharge assessment at that time. The MDSC admitted she had no answer for the missed assessment. Resident #2 During an interview on 3/21/23 at 1:11 PM, Resident #2 stated he/she had hearing aids, but they needed to be cleaned (of ear wax). Review on 3/23/23 at 9:56 AM of Resident #2's MDS admission Assessment, dated 1/23/23, revealed under Hearing aid or other hearing appliance used the column was marked as No. Review of Admission/readmission Evaluation-V 5, dated 1/18/23 at 3:27 PM, revealed Resident #2 was admitted to the facility with hearing aids for both ears. During an interview on 3/24/23 at 2:14 PM, the MDSC stated there was no formal assessment for hearing, so she would have reviewed the Resident's admission assessment. When asked if Resident #2 hearing aids were coded on the MDS, the MDSC stated the hearing aids were listed on the admission assessment, but they were not coded to the MDS assessment. When asked why it was important to have the hearing aids coded to the MDS, the MDSC stated so staff were aware of the devices, aware of batteries, and because it could have affected the Resident's care. The MDSC further stated the MDS information was then generated to the Resident's care plan. Resident #37 Record review on 3/20-24/23 revealed Resident #37 was admitted to the facility with diagnoses that included pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and heart), saddle embolus of pulmonary artery with acute cor pulmonale (a large blood clot gets stuck where the main pulmonary artery branches off into a Y-shape to go into each lung causing the right side of the heart to fail), and diabetes. Hearing Aids During an interview on 3/20/23 at 2:47 PM, Resident #37 stated he/she had hearing aids, but they were not working. Resident #37 stated he/she came to the facility with broken hearing aids and hasn't used them since being admitted . During this interview, Resident's hearing was very poor making it necessary for the surveyor to shout out the interview questions. Resident #37 would cup his/her ears and shout What! You need to speak up I can't hear you! Review of Resident #37's Admission/readmission Evaluation - V5, dated 2/28/23, revealed: Impairments and Devices . Impairments: Hearing . Ability to hear: Highly impaired . Devices: Hearing Aid Left and Right . Hearing/Vision/Communication care plan: Desired outcome: The resident will be able to make basic needs known on a daily bases through the review date . Intervention: Ensure hearing aids (both ears) are in place . Review of Resident #37's MDS admission Assessment, dated 3/6/23, revealed under Hearing aid or other hearing appliance used the column was marked as No. During an interview on 3/23/23 at 5:06 PM, the MDSC stated Resident #37's hearing aids should have been identified on the admission MDS. Oxygen Therapy An observation on 3/20/23 at 2:54 PM, revealed a CPAP machine (a machine to help with obstructive sleep apnea, to ensure a person continues breathing while asleep) placed on Resident #37's bedside cabinet. The CPAP's mask was connected to an oxygen tube and 2 liters of oxygen was still flowing into the CPAP mask from an oxygen apparatus on the wall. Further observation revealed an alert sign on the resident's door frame which read, No Smoking, Oxygen In Use. Review of Resident #37's medical record revealed no order for the use of oxygen. Review of Resident #37's MDS (Minimum Data Set - A Federally mandated assessment) admission assessment, dated 3/6/23, revealed oxygen therapy was not identified under Section O: Special Treatment and Programs. Further review revealed BiPAP [bilevel positive airway pressure]/CPAP was identified under both columns of While NOT a Resident and While a Resident. During an interview on 2/23/23 at 5:06 PM, the MDS Coordinator stated Resident #37's MDS should have identified oxygen use as a treatment. Resident #50 Record review on 3/20-24/23 revealed Resident #50 was admitted to the facility with diagnoses that included morbid obesity with alveolar hypoventilation (one cannot move enough air in and out of the lungs, due to obesity, this leads to low oxygen levels and too much carbon dioxide levels) and sepsis (life-threatening infection). An observation on 3/20/23 at 3:47 PM, revealed a CPAP machine placed on Resident #50's bedside cabinet. The CPAP's mask was connected to an oxygen tube and 6 liters of oxygen was flowing into the CPAP mask from an oxygen apparatus on the wall. Further observation revealed an alert sign on the resident's door frame which read, No Smoking, Oxygen In Use. Review of Resident #50's medical record revealed no order for the use of oxygen. Review of Resident #50's MDS admission assessment, dated 2/27/23, revealed neither oxygen therapy or the resident's CPAP were identified under Section O: Special Treatment and Programs. During an interview on 2/23/23 at 5:06 PM, the MDSC stated Resident #50's MDS should have identified oxygen use and the CPAP as treatments. Resident #304 During an interview on 3/20/23 at 2:49 PM, Resident #304 stated his/her upper dentures broke during a fall prior to admission. During a subsequent interview on 3/22/23 at 2:43 PM, Resident #304 stated, no one ever asked me about my dentures and would like help getting them fixed so it would be easier to eat. During an interview on 3/22/23 at 1:41 PM, the admission Nurse stated he/she confirmed the Resident's dentures were broken and charted this on Resident #304's admission Assessment form. When asked what happened when there's a need identified during the admission assessment, he/she stated that it should have showed up on the MDS for further care planning. Record review of Resident #304's Admission/readmission Evaluation - V 5, dated 3/13/23, revealed Section F. Impairments and Devices of the assessment: 6. Devices (care profile) . J Dental Appliance . Upper Full . 6. Comments: Denture broke during fall . and Section G of the assessment: (2a) Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose) was checked. Record review of Resident #304's MDS, dated [DATE], revealed: Section L (a) A. Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose), was documented as No. During an interview on 3/24/23 at 11:23 AM, the MDSC stated Resident #304's broken dentures were noted in the initial admission assessment. When asked if it was noted in the MDS system that Resident #304 had broken dentures or indicated that he/she used dentures to eat, the MDS Coordinator stated that it was not, but it should have been. .

. Based on record review, interview, and observation, the facility failed to ensure care plans were individualized to meet the medical and psychosocial needs for 6 residents (#'s 2; 13; 34; 37; 50; and 304) out of 16 sampled residents. This failed practice placed the residents at risk for not receiving necessary services to address their individual needs. Findings: Resident #2 Record review on 3/20-24/23 revealed Resident #2 was admitted to the facility with diagnoses that included cerebral palsy and seizure disorder. During an interview on 3/21/23 at 1:11 PM, Resident #2 stated he/she had hearing aids, but they needed to be cleaned (of ear wax). Review of Admission/readmission Evaluation-V 5, dated 1/18/23 at 3:27 PM, revealed Resident #2 was admitted to the facility with hearing aids for both ears. Review of Resident #2's current care plan revealed no documentation of hearing deficit or hearing aids. During an interview on 3/23/23 at 2:14 PM, the Minimum Data Set (MDS) Coordinator stated the Resident's care plan should have included hearing and tasks with hearing aids so that staff were aware. The MDS Coordinator further stated it was important for staff to be aware of hearing aid batteries so the Resident's care would not be affected. Review of the facility's policy, Care Plans, Comprehensive Person-Centered, dated 12/2019, revealed The comprehensive, person-centered care plan will .Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Resident #13 During an interview with concurrent observation on 3/20/23 at 3:02 PM, Resident #13 stated he/she had left sided peripheral vision loss. Observation revealed the bedside table was on the left side of the bed. Further observation revealed a water cup, the TV remote control, and other personal items were set on top of the table. Review on 3/22/23 at 9:35 AM of Resident #13 Minimum Data Set (MDS-a federally required nursing assessment) admission Assessment, dated 2/6/23, revealed Section B. B1000. Vision 1. impaired-sees large print, but not regular print in newspapers/books was marked. The MDS also revealed V0200. CAA (Care Area Assessment) and Care Planning, A. CAA Results, 03. Visual function A. Care Area Triggered and B. Addressed in Care Plan were marked. Review of the Care Plan on 3/22/23 at 9:35 AM, revealed there was no documentation regarding Resident #13's visual function. During an interview on 3/23/23 at 10:47 AM, MDS Coordinator stated she would have made the admission assessment within five days. When asked about CAA visual function triggered and addressed in the care plan, the MDS Coordinator confirmed visual function was triggered and it was not documented in the care plan. The MDS Coordinator explained the Resident was wearing glasses at time of the assessment. The MDS Coordinator added the visual function should have been documented in the care plan. When asked if she knew the Resident had left peripheral vision loss, the MDS Coordinator stated she did not know that the Resident had left peripheral vision loss. Resident #34 Record review on 3/20-24/23 revealed Resident #34 was admitted to the facility with diagnoses that included dementia and Alzheimer's Disease. During an interview on 3/21/23 at 9:28 AM, Resident #34's power of attorney (POA) stated the facility would have liked to discharge the Resident, but the Resident had no place else to go. The POA stated he/she had consulted assistive living homes, but Resident #34's needs were too intensive and the Resident had been declined. The POA further stated the Resident had made progress and he/she wished for the Resident to remain at the facility. Review of Resident #34's current care plan, revised on 7/21/22, revealed [Resident] wishes to stay here at Maple Springs until other placement is found. Further review revealed Desired Outcome .[Resident's] discharge goals are: (SPECIFY abilities, dates, milestones) .[Resident] will demonstrate correct administration of medications/treatments (SPECIFY). During an interview on 3/23/23 at 9:41 AM, when asked about Resident #34's care plan outcomes for discharge goals, Licensed Nurse (LN) # 8 stated the outcomes documented were generic, and the facility should have changed the care plan to specify the individual outcomes for the Resident. Review of the facility's policy, Care Plans, Comprehensive Person-Centered, dated 12/2019, revealed .Include the resident's stated goals upon admission and desired outcomes .Reflect the resident' expressed wishes regarding care and treatment goals . Resident #37 Record review on 3/20-24/23 revealed Resident #37 was admitted to the facility with diagnoses that included pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and heart), saddle embolus of pulmonary artery with acute cor pulmonale (a large blood clot gets stuck where the main pulmonary artery branches off into a Y-shape to go into each lung causing the right side of the heart to fail), and diabetes. An observation on 3/20/23 at 2:54 PM, revealed a CPAP (continuous positive airway pressure) machine (a machine to help with obstructive sleep apnea, to ensure a person continues breathing while asleep) placed on Resident #37's bedside cabinet. The CPAP's mask was connected to an oxygen tube and 2 liters of oxygen was flowing into the CPAP mask from an oxygen apparatus on the wall. Further observation revealed an alert sign on the resident's door frame which read, No Smoking, Oxygen In Use. Review of Resident #37's Care Plan revealed an identified focus problem, dated 2/28/23, [Resident #37] has altered respiratory status/difficulty breathing and interventions, dated 2/28/23, BIPAP/CPAP/VPAP [variable positive airway pressure] Settings: Titrated pressure: (Specify) cmH2O [centimeter of water] via (Specify: nasal pillow, nose mask or full-face mask) (Specify [Frequency]). Further review revealed no specifications were documented into the Care Plan to meet Resident #37's CPAP pressure, mask type, or frequency needs. Further review revealed no documentation regarding oxygen therapy. During an interview on 2/23/23 at 5:06 PM, the MDS Coordinator stated Resident #37's Care Plan should have been specific to the Resident's individual CPAP needs and to include oxygen therapy. Resident #50 Record review on 3/20-24/23 revealed Resident #50 was admitted to the facility with diagnoses that included morbid obesity with alveolar hypoventilation (one cannot move enough air in and out of the lungs, due to obesity, this leads to low oxygen levels and too much carbon dioxide levels) and sepsis (life-threatening infection). An observation on 3/20/23 at 3:47 PM, revealed a CPAP machine placed on Resident #50's bedside cabinet. The CPAP's mask was connected to an oxygen tube and 6 liters of oxygen was flowing into the CPAP mask from an oxygen apparatus on the wall. Further observation revealed an alert sign on the resident's door frame which read, No Smoking, Oxygen In Use. Review of Resident #50's Care Plan revealed no focus problem for the resident's CPAP use or oxygen therapy. During an interview on 2/23/23 at 5:06 PM, the MDS Coordinator stated Resident #50's Care Plan should have included the oxygen therapy and CPAP use. Resident #304 Record review from 3/20-24/23 revealed Resident #304 was admitted to the facility with diagnoses that included obstructive sleep apnea (complete or partial obstruction of the upper airway leading to reduced or absent breathing during sleep), acute respiratory failure with hypoxia (oxygen deficiency in the body's tissues), acute respiratory failure with hypercapnia (a high concentration of carbon dioxide in the blood). An observation on 3/20/23 at 2:49 PM, revealed Resident #304 sitting in his/her room wearing a nasal cannula (a device that delivers oxygen directly through a tube into the nose). Two liters of oxygen was being delivered through the nasal cannula. An observation on 3/23/23 at 5:22 PM, revealed a No Smoking, Oxygen in Use sign was posted on Resident #304's room door frame. Further review revealed no specifications were documented in the Care Plan to meet Resident #304's oxygen therapy such as frequency needs, interventions, or goals. During an interview on 3/23/23 at 4:54 PM, the MDS Coordinator stated he/she reviewed Resident #304's medical record and stated the oxygen orders should have been on the medical record but the orders were not documented, so the oxygen was not reflected on the care plan as it should have been. Review of facility policy titled, Oxygen Administration, dated 10/2022, under the section titled Preparation read: Review the resident's care plan to assess for any special needs of the resident. .

. Based on record review, observation, and interview, the facility failed ensure respiratory care was consistent with professional standards of practice for 3 residents (#'s 37; 50; and 304), out of 16 sampled residents. This failure had the potential to place the residents at risk for inconsistent care, and potential respiratory complications. Findings: Resident #37 Record review on 3/20-24/23 revealed Resident #37 was admitted to the facility with diagnoses that included pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and heart), saddle embolus of pulmonary artery with acute cor pulmonale (a large blood clot gets stuck where the main pulmonary artery branches off into a Y-shape to go into each lung causing the right side of the heart to fail), and diabetes. An observation on 3/20/23 at 2:54 PM, revealed a CPAP (continuous positive airway pressure) machine (a machine to help with obstructive sleep apnea, to ensure a person continues breathing while asleep) placed on Resident #37's bedside cabinet. The CPAP's mask was connected to an oxygen tube and 2 liters of oxygen was flowing into the CPAP mask from an oxygen apparatus on the wall. Further observation revealed an alert sign on the resident's door frame which read, No Smoking, Oxygen In Use. Review of Resident #37's medical record revealed no order for the use of oxygen. Further review revealed no orders or instructions for the cleaning of the CPAP. Review of Resident #37's MDS (Minimum Data Set - A Federally mandated assessment) admission assessment, dated 3/6/23, revealed oxygen therapy was not documented under Section O: Special Treatment and Programs. Further review revealed BiPAP [bilevel positive airway pressure]/CPAP was documented under both columns of While NOT a Resident and While a Resident. Review of Resident #37's Care Plan revealed an identified focus problem, dated 2/28/23, [Resident #37] has altered respiratory status/difficulty breathing and interventions, dated 2/28/23, BIPAP/CPAP/VPAP [variable positive airway pressure] Settings: Titrated pressure: (Specify) cmH2O [centimeter of water] via (Specify: nasal pillow, nose mask or full-face mask) (Specify [Frequency]). Further review revealed no specifications were documented in the Care Plan to address Resident #37's CPAP pressure, mask type, or frequency needs. Further review revealed no documented oxygen therapy interventions. During an interview on 2/23/23 at 5:06 PM, the MDS Coordinator stated Resident #37's MDS should have identified oxygen use as a treatment. The MDS Coordinator further stated Resident #37's Care Plan should have been specific to the resident's individual CPAP needs. The MDS Coordinator stated an order for the oxygen and CPAP cleaning should have been in the resident's chart but was not. Resident #50 Record review on 3/20-24/23 revealed Resident #50 was admitted to the facility with diagnoses that included morbid obesity with alveolar hypoventilation (one cannot move enough air in and out of the lungs, due to obesity, this leads to low oxygen levels and too much carbon dioxide levels) and sepsis (life-threatening infection). An observation on 3/20/23 at 3:47 PM, revealed a CPAP machine placed on Resident #50's bedside cabinet. The CPAP's mask was connected to an oxygen tube with 6 liters of oxygen flowing into the CPAP mask from an oxygen apparatus on the wall. Further observation revealed an alert sign on the resident's door frame which read, No Smoking, Oxygen In Use. Review of Resident #50's medical record revealed no order for the use of oxygen. Review of Resident #50's MDS admission assessment, dated 2/27/23, revealed neither oxygen therapy or the resident's CPAP were identified under Section O: Special Treatment and Programs. Review of Resident #50's Care Plan revealed no documentation for the resident's CPAP use or oxygen therapy. During an interview on 2/23/23 at 5:06 PM, the MDS Coordinator stated Resident #50's MDS should have identified oxygen use and the CPAP as treatments. The MDS Coordinator further stated Resident #50's Care Plan should have included the oxygen therapy and CPAP use. The MDS Coordinator stated an order for the oxygen should have been in the resident's chart but was not. Resident #304 Record review from 3/20-24/23 revealed Resident #304 was admitted to the facility with diagnoses that included obstructive sleep apnea, acute respiratory failure with hypoxia (oxygen deficiency in the body's tissues), and acute respiratory failure with hypercapnia (a high concentration of carbon dioxide in the blood). An observation on 3/20/23 at 2:49 PM, revealed Resident #304 sitting in his/her room wearing a nasal cannula (a device that delivers oxygen directly through a tube into the nose). Two liters of oxygen was flowing into the nasal cannula from the oxygen apparatus on the wall. Further observation revealed an alert sign on the resident's door frame which read, No Smoking, Oxygen In Use. Review of Resident #304's medical record revealed no order for the use of oxygen. Review of Resident #304's MDS admission assessment, dated 3/20/2023, revealed: .Section O - Special Treatments and Programs .Oxygen therapy [columns While Not a Resident and While a Resident were both checked]. Record review of the Care Plan, revised on 3/20/23, revealed no specifications were documented to address Resident #304's oxygen therapy such as frequency needs, interventions, or goals. During an interview on 3/23/23 at 4:54 PM, the MDS coordinator stated that she was responsible for updating the care plan once she received orders after the initial admission assessment. When asked about Resident #304's oxygen use, the MDS Coordinator stated an order for the oxygen should have been in the resident's chart but was not. During a subsequent interview on 3/23/23 at 4:59 PM, the Assistant Director of Nursing stated that oxygen use required a physician's order. Review of Oxygen Therapy: Nasal Cannula Or Oxygen Mask (Ambulatory) - CE, dated 12/20/22, accessed at: https://elsevier.health/en-US/preview/oxygen-therapy-nasal-cannula-or-oxygen-mask-ambulatory-ce, revealed, Alert: Oxygen is considered a medication and requires a practitioner's order; administer it cautiously and observe the patient closely for adverse reactions. Review of Ventilation: Noninvasive CPAP And BIPAP - CE, dated 09/30/21, accessed at: https://elsevier.health/en-US/preview/ventilation-noninvasive-cpap-and-bipap, revealed, Preparation: Review the practitioner's order for NPPV (noninvasive positive pressure ventilation, CPAP) with the respiratory therapist, including the device, settings and the use of humidification and oxygen. Review of the facility policy, Oxygen Administration, revised 10/2020, revealed: .Verify that there is a physician's order for this procedure .

. Based on observation, interview, and record review, the facility failed to ensure patient care equipment was monitored to ensure it was in a safe operating condition. Specifically, the facility failed to: 1) complete daily maintenance checks on 2 emergency code carts (emergency cart/equipment used for resuscitation); and 2) maintain and monitor a unit freezer. This failed practice: 1) placed residents residing in the facility, that were a full code, at risk for adverse outcomes in the event of malfunctioning emergency equipment, and 2) placed residents at risk for receiving food not stored at appropriate temperatures which increased the chance of food borne illnesses. Findings: Emergency Code Cart: Observations conducted 3/20-24/23 revealed incomplete daily code cart maintenance logs on 2 code carts (Hatchers code cart and Main code cart). - Hatchers code cart log for the month of March revealed it was checked 14 out of 23 days total. - Main code cart log for the month of March revealed it was checked 9 out of 23 days total. During an interview on 3/23/23 at 5:18 PM, the MDS Coordinator stated she oversaw the maintenance of the code carts and that she had not been keeping them up. She stated they should have been checked every day. Unit Freezer: An observation of the second-floor unit freezer on 3/22/23 at 3:16 PM, revealed: - No temperature gauge in or around freezer; - No temperature log present During an interview on 3/23/23 at 3:42 PM, the DON stated that he/she forgot the second-floor unit freezer was up there. It was used to store ice cream for long term care residents who wanted a snack at night. The DON stated that kitchen stocks it now, and there has never been a thermometer or a temperature log for the freezer. During an interview on 3/23/23 at 9:54 AM, the Dietary Manager stated the kitchen did not maintain the second-floor freezer and that it belonged to nursing to store nighttime snacks for the residents because the kitchen was locked up at night. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to store food under proper sanitation and food handling practices in the central kitchen. This failed practice placed all residents (based on a census of 55) at risk for foodborne illnesses and communicable disease. Findings: An observation of the central kitchen on 3/20/23 at 9:26 AM, revealed: 1) Walk in refrigerator: - Soiled whipped cream can 13 oz.; - Opened sour cream container, unlabeled with no used by date; - Opened 10-pound box of breakfast sausage with inner bag opened. The sausages were exposed to air; - Dried brown substance dripping down outer container of 1 gallon Lea and [NAME] Worcestershire sauce; - Dried brown substance dripping down outer container of 1 gallon Kikkoman soy container; - Dried brown substance dripping down outer container of 169 oz [NAME] balsamic vinegar; - Carton of Dr Pepper labeled Em taped to the carton. - Plastic container labeled Em taped to the container, contained two Fast Twitch energy drink cans and one [NAME] energy drink can; 2) Walk in freezer: - Brussels sprouts in zip-lock not dated; - Dole frozen pineapple cubes 5 lb bag; opened, not dated. 3) Dry storage bins in main kitchen: - Open panko and sugar bags being stored in original manufacturer bags, in the same bin; - Open cake flour and broad flour bags, stored in original manufacturer bags, in the same bin; - Open all-purpose flour and ionized granulated salt bags, stored in original manufacturer bags, in the same bin; 4) Main Kitchen: - Breads, buns, muffins, and tortilla packages were stored on a shelf with clean dishes, cups, and plates above and surrounding the food items. Clean serving trays were stacked on the shelves below the food. During an interview on 3/20/23 at 9:58 AM, the Kitchen Manager stated the carton of Dr. Pepper and a container of energy drinks that were labeled Em belonged to [NAME] #1. The Kitchen Manager further stated staff should not store their personal drinks in the walk-in refrigerator. An observation of the central kitchen on 3/22/23 at 11:49 AM, revealed: 1) Bananas were being stored on the bottom shelf underneath the serving line. The bananas were surrounded by containers holding clean silverware and clean dishes; 2) A green onion container, that was observed previously to have had a use by date of 3/21/23, was relabeled with a new use by date of 3/22/23, with the previous label visible; 3) Dishwasher #1 found a plastic utensil that was coated in debris while sorting clean silverware that had just come out of the dishwasher. He/She showed it to the Kitchen Manager who directed him/her to throw it away and continue sorting. The sorted silverware was not rewashed. An observation of the second-floor unit freezer on 3/22/23 at 3:16 PM, revealed: - Freezer bag containing two pints of sorbet labeled with Certified Nursing Assistant (CNA) #1's name; - No temperature gauge in or around freezer; - No temperature log present; During an interview on 3/22/23 at 3:27 PM, CNA #1 stated the sorbet in the second-floor unit freezer belonged to him/her. During an interview on 3/23/23 at 9:54 AM, the Dietary Manager stated staff were not to store personal food items in the main walk-in refrigerator or in the second-floor unit freezer. He/she further stated the kitchen did not maintain the second-floor freezer and that it belonged to nursing to store nighttime snacks for the residents because the kitchen was locked up at night. When asked if the kitchen should have utilized a previously used container to store green onions with a new use by date, the Dietary Manager stated that a completely new container should have been utilized. He/she also stated that if a batch of cleaned silverware was found to have utensils that were still soiled that all the silverware needed to be re-washed. Review of the facility's policy Policy & Procedure Manual Food Safety and Sanitation, dated 2019, revealed: Food is protected from contamination (dust, flies, rodents, and other vermin) . When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food . .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and interview, the facility failed to ensure State Laws were followed. Specifically, the facility failed to ensure individuals employed by the facility had a valid criminal history background check for 4 employees: 1) Certified Nursing Assistant (CNA) #4; 2) Neighborhood Helper (NH) #1; 3) [NAME] #2; and 4) Housekeeper #1. This failed practice violated State background check Alaska Administrative Code (AAC) and placed all residents (based on a census of 55) at risk for receiving care and services from individuals with barrier crimes and no valid variance. Findings: Review of the facility's State of Alaska license revealed an effective date of 7/1/22 through 6/30/24. Review of the Alaska Department of Health Division of Health Care Services website, accessed at https://dhss.alaska.gov/health/dhcs/Pages/hflc/Background-Check.aspx, revealed: Background checks are required for all individuals associated with the facilities overseen by the Health Facilities Licensing & Certification Program as defined in the Criminal Background Check Regulations . The current regulation which provides a common, consistent definition of barrier conditions for all programs 7 AAC 10.900 - 7 AAC 10.990 . In the event you receive notification from the background check unit stating you have been issued a Not Eligible determination a variance request may be submitted . Review of the State of Alaska 7 AAC 10.900(b), dated 1/12/12, revealed: . Each individual who is to be associated with the entity or provider in a manner described in this subsection must have a valid criminal history check conducted under 7 AAC 10.900 - 7 AAC 10.990 if that individual is [AGE] years of age or older and will be associated with the entity or provider as . an employee . if that employee has regular contact with recipients of services . Review of the State of Alaska 7 AAC 10.910, dated 1/12/12, revealed: . A provider must request a background check under this section, or provide proof of a valid fingerprint-based background check, for each individual to be associated with the provider in any manner described in 7 AAC 10.900(b). A provider must request a background check . to hire or retain an employee . the background check must be completed before appointment or hiring . Review of the State of Alaska 7 AAC 10.905(g) and 7 AAC 10.905(h), dated 6/29/17, revealed: (g) If an applicant does not pass a background check . the applicant is prohibited from associating with a provider in any manner described in 7 AAC 10.900(b) . (h) If an individual is charged with a barrier crime, that individual is barred from any contact with recipients of care during the pendency of the charge, unless the department grants a variance . Review of the State of Alaska 7 AAC 10.915(f), dated 7/2017, revealed: Except as provided otherwise in this subsection, a provider shall, within 24 hours after receiving notification under (d) or (e) of this section, terminate association with the applicant in accordance with 7 AAC 10.960. If the provider or the applicant requests a variance . the applicant may remain associated with the provider, pending a decision on the request if (1) the applicant is removed from direct contact with recipients of services; and (2) the provider ensures that the applicant is provided with direct supervision if that applicant is present in any area where services are provided, during hours of operation . During an interview on 3/23/23 at 10:33 AM, the Human Resources (HR) Director stated during the hiring process, a background check to include fingerprinting was conducted prior to starting employment. This is completed for employees who will have direct contact with residents in the facility. The HR Director further stated that if a background check became ineligible, the staff would have been removed from working until a variance was completed. When asked if there were any employees currently waiting for a variance approval, the HR Director stated there were four: 1) CNA #4; 2) NH #1; 3) [NAME] #2; and 4) Housekeeper #1. The HR Director further stated that the facility received notice on 1/27/23 that these four employee's background checks were received with a conclusion they were not eligible to work. When asked if these four employees were still working despite not having valid background checks, the HR Director stated each employee had initiated a variance application and they were still working as the variance applications were being processed. CNA #4 Review of CNA #4's timesheet, dated 1/27/23 to 3/26/23, revealed CNA #4 had worked 21 days, a total of 241 hours and 45 minutes, after the facility was notified of CNA #4's background check ineligibility. NH #1 Review of NH #1's timesheet, dated 1/27/23 to 3/26/23, revealed NH #1 had worked 24 days, a total of 193 hours and 45 minutes, after the facility was notified of NH #1's background check ineligibility. Cook #2 Review of [NAME] #2's timesheet, dated 1/27/23 to 3/26/23, revealed [NAME] #2 had worked 40 days, a total of 305 hours and 15 minutes, after the facility was notified of [NAME] #2's background check ineligibility. Housekeeper #1 Review of Housekeeper #1's timesheet, dated 1/27/23 to 3/26/23, revealed Housekeeper #1 worked 36 days, a total of 229 hours and 9 minutes, after the facility was notified of Housekeeper #1's background check ineligibility. Review of the facility's Background Checks protocol, undated, revealed: All offers of employment at Maple Springs are contingent upon clear results of a thorough background check . Background checks will include . Criminal History: includes review of criminal convictions and probation. The state Background Check Unit will perform the Criminal History check as they do with all healthcare employees in the state, and will advise Maple Springs whether an individual is eligible or ineligible for work . .

Based on observation and record review, the facility failed to ensure 1 resident (#4), out of 1 resident observed, was treated in a dignified manner that respected individuality and his/her care needs. Specifically, staff assisting the resident with dining walked away from the resident, performed other tasks, and stood over the resident while assisting him/her with the meal. This failed practice placed the resident at risk for psychosocial harm from feelings of poor self-esteem and/or self-worth and a potential for a poor quality of life. Findings: An observation on 12/21/22 at 10:08 AM, revealed Resident #4 was seated in a Geri-chair (large, padded chair that is designed to help seniors with limited mobility) in the hall outside his/her room. Certified Nursing Assistant (CNA) #1 was standing next to the Resident and feeding him/her eggs from a breakfast tray located on the top if a cart nearby. While feeding the Resident, CNA #1 was looking at a green I-Pad, and periodically gave the Resident two bites of eggs. At 10:15 AM, the CNA walked to the other side of the hallway and placed the I-Pad on the hall table, took a drink from a cup and walked back over to the Resident. The CNA then gave the Resident another bite of his/her eggs. At 10:13 AM, a call light went off in a room down the hall, the CNA #1 left the Resident #4 and responded to the call light. After emptying that resident's urinal, CNA #1 returned to feeding Resident #4 his/her eggs. At 10:15 AM the CNA left the unit and did not return. Observation of the breakfast tray revealed Resident #4 had consumed half of his/her eggs. On 12/21/22 at 10:16 AM, Resident #4 commented I need some water. There were no staff in the area to assist the Resident with the remainder of his/her meal or get them water that was requested. On 12/21/22 at 10:27 AM, Neighborhood Helper #5 picked up Resident #4's tray and, without asking the Resident if he/she needed anything else and returned the tray to the kitchen. Review of Resident #4's medical record on 12/21/22 revealed the Resident had diagnoses that included dysphagia (difficulty swallowing) following cerebral infarction (stroke) and dementia. Review of Resident #4's care plan revealed, [Resident #4] has an ADL [activities of living self-care performance deficit [related to] stroke. Interventions included Eating: The resident requires extensive assistance by staff to eat. Review of the facility's policy Resident Rights, dated February 2020, revealed: Each resident has the right to be treated with dignity and respect, and to have access to services inside and outside the facility.

Based on observation, interview, and record review, the facility failed to provide assistance with dining for 2 residents (#2 and #5), of 3 residents observed dining. Specifically, the facility failed to ensure residents that required support and/or assistance with eating were provided needed assistance. This failed practice placed the residents at risk for potential harm from weight loss, hunger, dehydration, and decreased quality of life. Findings: Resident #5 An observation on 12/21/22 at 11:03 AM, revealed Resident #5 was brought back to his/her room by the hairdresser. The Resident was seated in a reclining Geri-chair (a large padded wheeled chair designed to help residents with limited mobility), a bedside table was located to the left of the Resident. Three large plastic drinking cups and a breakfast tray were located on the bedside table. The flatware on the tray was wrapped in a clean, cloth napkin. The lid of a yogurt container had been removed, and the yogurt was untouched. The remainder of the breakfast meal was untouched and was still covered with a lid. During an interview on 12/21/22 from 11:03-11:35 AM, Resident #5 stated he/she had not been assisted with breakfast prior to his/her hairdressing appointment. The Resident stated because of his/her limited mobility, he/she struggled to unwrap the flatware and cut up any food. The Resident further stated the water, crystal light, and soda in the cups were from last night and he/she prefers ice in his/her water and drinks. The Resident added if he/she wanted fresh water it would have to be requested. Record review on 12/20-21/22 revealed Resident #5 had diagnoses that included kyphosis (curvature of the spine) and weight loss. The Resident had been receiving Hospice services. Review of a MDS (Minimum Data Set) Quarterly Assessment, dated 10/08/22, revealed Resident #5's Functional Status: . G0100. Activities of Daily Living (ADL) Assistance . H. Eating-how resident eats and drinks, regardless of skill. Do not include eating/ drinking during medication pass. Includes intake nourishment by other means . Resident #5 was coded as 1. Supervision-oversight, encouragement, or cueing and 1. Set-Up help only. Review on 12/21/22 of Resident #5's comprehensive care plan, revealed: [Resident #5] has a self-care performance deficit [related to] mobility problems & kyphosis [curvature of the spine] .interventions .Eating: [Resident #5] needs supervision of 1 to eat, cut food in bite sized pieces. Date Initiated: 7/02/2019 Revision on: 11/20/2022. Review of the Tasks, completed on 12/21/21, revealed: ADL-Eating for 0900 was initialed as completed on 11:41 [AM] and 1300 [1:00 PM] was initialed at 13:41 [1:41 PM]. Resident #2 An observation on 12/21/22 at 12:21 PM, revealed Resident #2's breakfast tray was on a bedside table in his/her room. The breakfast on the plate was untouched and there was a fork lying next to the plate. During an interview on 12/21/22 at 1:00 PM, Resident #2's representative stated the Resident had not been assisted with breakfast that morning. The Representative stated the tray had been sitting there since he/she got here this morning and Resident #2 needed assistance with dining. The Resident's representative stated he/she brings in snacks for the Resident as he/she was not always assisted with meals by staff. Record review on 12/20-21/22 revealed Resident #2 had diagnoses that included Non-Alzheimer's dementia and anxiety. Review of a MDS Quarterly Assessment, dated 10/05/22, revealed Resident #2's Functional Status: . G0100. Activities of Daily Living (ADL) Assistance . H. Eating-how resident eats and drinks, regardless of skill. Do not include eating/ drinking during medication pass. Includes intake nourishment by other means . Resident #2 was coded as 3. Extensive assistance-resident involved in activity; staff provide weight-bearing support. 2. One-person physical assist. Review of Resident #2's comprehensive care plan, undated, revealed: Resident #2 has an ADL self-care performance deficit. Interventions included EATING: [Resident #2] requires 1 staff to assist [him/her] in eating. [Resident #2] needs to be up out of bed for all meals. During an interview on 12/21/22 at 4:45 PM, Certified Nursing Assistant (CNA) #1 stated he/she was responsible for 15 residents. The CNA stated there was a neighborhood helper on the unit, but they could not assist with feeding the residents. The CNA stated a float CNA was supposed to come every 2 hours to assist with repositioning and turning residents. CNA #1 stated Resident #5 needed set up assistance. .