**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, review of the State Agency Database and interviews the facility failed to ensure one resident was treated with respect and dignity. The deficient practice could result in residents not feeling safe. Findings include: Resident #1 was admitted on [DATE] with diagnoses that include obesity, unspecified mood disorder, and acute cholecystitis. The quarterly Minimum Data Set (MDS) assessment was completed on May 1, 2024. During the MDS assessment a Brief Interview for Mental Status (BIMS) was conducted and revealed that resident #1 had a score of 15 which indicated the resident was cognitively intact. A report was received by the State Agency (SA) on April 15, 2024 that indicated a resident was being mistreated by a Certified Nursing Assistant (CNA). The facility conducted an initial investigation which included an interview with resident #1 on April 15, 2024. Resident #1 indicated that staff #12 had taken over an hour to assist her when the call light went on. The resident also continued to indicate that staff #12 was rude by stating there have been people sitting in their shit all day, when the staff returned to provide care. The facility report also indicates that staff #12 was suspended during the course of the investigation. At the completion of the facility's investigation, staff #12 was provided education on customer service and has been re-assigned to a different unit to mitigate the possible of encountering resident #1. An interview was conducted on May 22, 2024 at 10:06 AM with resident #1. Resident indicated that she felt safe in the facility but had an issue with staff #12. Resident #1 indicated when she needed help a few weeks ago, staff #12 made a comment that made her feel bad. Resident #1 indicated she felt she needed to report it because she didn't know if staff #12 was making similar comments to other residents who might not be able to speak up for themselves. A phone interview was conducted with staff #12 on May 23, 2024 at 11:29 AM. Staff #12 indicated that it was a busy day on April 14, 2024 as several residents were having issues with loose stool. Staff indicated that when they went into resident #1's room to answer the call light, the resident informed staff she had bowel movement and needed to be cleaned up. Staff stated she responded to resident #1 with there are other individuals sitting with shit, but staff stated she did not say that with malice. Staff continued to indicate she had a lot going on during the shift and she had left the resident's room to remove herself from an escalating situation. Staff stated she took full responsibility and regreted it. Staff continued to state that the floor nurse took over with providing cares to resident #1 and she no longer worked in that unit. An interview was conducted with the facility Administrator (staff #5) on May 23, 2024 at 2:51 PM. Staff #5 referenced the facility's dignity policy when asked about dignity. Staff #5 said the expectation is for the employees and residents to have positive interactions and employees provide good customer service to the residents being served. When reviewing the situation between resident #1 and staff #12, staff #5 indicated that staff #12 did not meet their expectation of how the staff should interact with residents. Staff #5 continued by indicating that staff #12 has been coached on how to better respond in that situation and that staff #12 agreed she could have responded in a different manner. A review of the facility's policy titled, Resident Dignity- Rehab/Skilled, last reviewed/revised on November 16, 2023 stated, Ideas for maintaining a resident's dignity may include, but not be limited to: . treating residents with respect .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review, facility documents and facility policy, the facility failed to ensure that a resident (#52) was free from abuse from another resident (#53). Failure to ensure the resident was free from abuse resulted in an trochantric hip fracture. Findings include: -Resident #53 was admitted on [DATE] with diagnoses of dementia, emotional lability, and post traumatic stress disorder. Review of this resident's care plan did not include interventions for aggressive behaviors towards other residents. A progress note dated 9/13/23 included, Resident has been restless throughout the shift, unable to get R to sit down for any length of time. Resident has been going in and out of other R rooms taking things and then giving them to other Rs. Resident becomes verbally aggressive with other R and staff when redirect is attempted . A self report filed on 10/15/23 included Residents (#53) and (9#) both reside in the special care unit. Resident (#9) pushed on the entry/exit door, causing an alarm. (Resident #53)'s room is next to this door, and she frequently rearranges her closet. In response to the alarm, (Resident #53) hit (Resident #9) with the plastic clothing hangers she was holding. Residents separated, PCP notified. A progress note dated 10/25/2023 which included that Resident #53 threw a blanket at another R when the other R attempted to give (resident #53) her personal items back. However, review of the care plan did not find care planning interventions added for the incidents on 10/15/23 or 10/25/23. -Resident #52 was admitted on [DATE] with diagnoses of unspecified dementia. A facility self report dated 10/26/2023 included that Nurse in Special Care Unit heard loud noise from resident (#53)'s room, which is in the special care unit. Saw resident (#52) on the floor and resident (#53) standing. When asked what happened, (resident #53) stated I pushed her. (resident #53) has been placed on 1:1 care. (resident #52) will be transported to the hospital for evaluation. Hospital records for 10/26/23 from Tucson Medical Center included that this resident was admitted for a left trochanteric fracture and was provided a nailing trochanteric fixation. A care plan dated 10/27/20 included that the resident has a behavior symptom related to dementia with intervention to intervene as necessary to protect the rights and safety of others and to redirect if wandering becomes a danger to her or other residents. A progress noted dated 10/27/2023 included that the writer and the Director of Nursing Services notified Resident #52's daughter via telephone that resident #52 had a fall yesterday as a result of a resident to resident altercation, and was sent to the hospital per doctor order. This note included that this resident was at Tucson Medical Center and has a left hip fracture. During an interview conducted on 3/8/2024 at 11:59 AM with a Registered Nurse Clinical Care Leader (RN/staff #61) who said that she recalled there were two incidents with resident #53 and that the staff would redirect. She reviewed resident #53's care plan and said that she did not see the care plan was updated after the incident on 10/15/2023 or on 10/25/2023. An interview was conducted on 3/8/2024 at 12:30 PM with the Director of Nursing (DON/staff# 57) who said that care plans need to be updated immediately when there is an incident. The DON stated that resident #53 said she had pushed resident #52 when she was in resident #53's room. The DON further added that the two resident had always intermingled well together in the past. She said that her expectations are that we do not have abuse and that we have interventions to keep the residents safe. A policy titled Abuse and Neglect - Rehab/Skilled, Therapy & Rehab reviewed 7/6/23 revealed that the purpose of this policy was to ensure that residents are not subject to abuse by anyone, including but not limited to other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records, staff interviews, and the facility policy and procedures, the facility failed to follow the catheter care in accordance with professional standards for one resident #18. The deficient practice could increase the risk for resident discomfort, injury and infection. Findings include: Resident #18 was admitted on [DATE] with diagnosis including muscle wasting and atrophy, nutritional deficiencies, anxiety disorder, adult failure to thrive, age-related physical debility, protein-calorie malnutrition and palliative care. A review of the quarterly MDS (minimum data set) dated September 06, 2023 revealed a BIMS (brief interview of mental status score of 08, suggesting moderate cognitive impairment. The MDS further revealed that resident #18, currently has an in-dwelling catheter in place. A review of the physician orders revealed an order dated May 17, 2022 for a suprapubic catheter size 16 French with a 10 ml balloon, contingent on drainage. A review of the care plan dated December 20, 2023 revealed that a suprapubic catheter was in place for an anatomical abnormality. The care plan further notes interventions of monitoring for pain or discomfort, monitoring for UTI's (urinary tract infections), catheter care per shift and reporting any unusual observations to the nurse. An observation was conducted on March 4, 2024 at 2:45 PM. Resident #18 was seated in his wheelchair, being pushed by a Licensed Practical Nurse (LPN/staff #23) and the catheter bag was observed to be dragging on the floor underneath the wheelchair. An observation was conducted on March 6, 2024 at 8:50 AM. Resident #18 was observed seated in his wheelchair outside of the room on hall 300. The catheter bag was observed to be touching the floor underneath the resident's wheelchair. An observation was conducted on March 6, 2024 at 10:20 AM. Resident #18 was still observed in his wheelchair with the catheter bag touching the floor. An interview was conducted on March 6, 2024 at 10:05 AM with a Certified Nursing Assistant (CNA/ staff #84). The CNA stated that that regarding catheter bags, she would check for color of the output, ensure that the bag is covered for dignity and that it is off the ground. An interview was conducted on March 6, 2024 at 10:11 AM with staff #77 an LPN. Staff #77 stated that she would always check for the amount and color of the output when a resident is on a urinary catheter. She stated that she would make sure that the bag is covered and that it is not directly on the floor. She further stated that if the catheter bag was on the floor, it could pull out and cause damage to the resident. When resident #18 was pointed out to staff #77, she stated that the bag should not be on the floor. Staff #77 applied gloves and looked underneath the wheelchair and stated that she would have to see about how the bag could be elevated off the floor as she was unable to adjust it higher. She further stated that the tubing was yucky and needed to be changed as well. An interview was conducted on March 6, 2024 at 10:29 AM with the Director of Nursing (DON/staff #9). She stated that her expectation is that catheter bags stay low enough for drainage but stated that they should never touch the ground. She further stated that the risk could be an infection control issue. A review of the facility policy entitled catheter care, revised February 10, 2023 revealed that catheter tubing should never be allowed to touch the floor. The policy further states that in order to prevent urethral injury, avoid pulling or placing tension on the catheter. However, on several occasions the catheter bag was observed directly on floor with the potential for causing tension as the bag fills.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, and policy review, the facility failed to ensure one resident #18 was assessed for the safe use of enabler bars prior to installation and informed of the risks and benefits of their use. The sample size was 16. The deficient practice could impact the residents knowledge of the risks and benefits of enabler bars and cause potential injury if the resident was not an appropriate candidate for enabler bars. Findings include: Resident #18 was admitted on [DATE] with diagnosis including muscle wasting and atrophy, anxiety disorder, adult failure to thrive, age-related physical disability, protein-calorie malnutrition, and palliative care. A review of the quarterly MDS (minimum data set) dated September 06, 2023 revealed that the resident has a BIMS (brief interview of mental status) score of 08, suggesting moderate cognitive impairment. Section G of the MDS revealed that resident #18 is an extensive 2-person assist with transfers, and bed-mobility. Section P of the MDS revealed that bed rails are not used; however, enabler bars were present on the resident's bed. A review of the physician orders revealed no evidence of an order for enabler bars. A review of the care plan revealed that resident #18 had an ADL (activities of daily living) performance deficit and that he required 1-2 staff assistance and weightbearing support as well as 1-2 staff assistance for bed mobility. Transfers were noted to require a total lift with a medium high back sling and 2 staff. A review of the electronic health record, under all sections for resident #18, revealed no evidence of an assessment for enabler bars. An observation on March 04, 2024 at 2:36 PM revealed the presence of enabler bars on the resident's bed. A subsequent observation on March 06, 2024 at 8:18 AM revealed an enabler bars on the resident's bed. The enabler bars were observed to have a little wiggle when touched. An interview was conducted on March 06, 2024 at 8:20 AM with staff #84 a CNA (Certified Nursing Assistant). Staff #84 stated she believes that residents are assessed for grab or enabler bars. She further stated that if staff observe any concerns after the bars are installed that they would immediately alert maintenance and submit a work order. She stated that the turn-around is generally the same day. An interview was conducted on March 06, 2024 at 8:23 AM with staff #75 LPN (Licensed Practical Nurse). Staff #75 stated that residents are assessed for suitability of grab or enabler bars. She stated that maintenance installs the bars and periodically reviews them. She stated that if staff observe any concerns, the issues is reported, a work order placed and generally resolved the same day. An interview was conducted on March 06, 2024 at 8:45 AM with staff #27, the Maintenance Director. Staff #27 stated that he had just reviewed the safety of the grab and enabler bars on hall 300 and had not observed any concerns. He stated that he was not familiar with the resident assessment portion but did reveal that the enabler bars were directly attached to the bed frame via a bolt and pin actions, which is designed to have a little give to facilitate the up and down movement of the bars. Staff #27 reviewed the installation, security and safety of the enabler bars for resident #18. No further concerns for the installation of the enabler bars. An interview was conducted on March 6, 2024 at 9:40 AM with staff #77 a LPN. Staff #77 stated that an evaluation and mobility assessment is conducted prior to the installation of grab bars. She stated that the grab or enabler bars should also be care planned. She stated that she was unsure if a consent was needed. She stated that the expectation is that these steps are completed prior to installation on the resident's bed. Staff #77 stated that the risk could include impact on the resident's ability to safely transfer. An interview was conducted on March 06, 2024 at 12:30 PM with staff #9 the DON (Director of Nursing). Staff #9 stated that the expectation is to follow procedures as set forth in the facility policy. She stated that this would entail an resident assessment, data collection and an informed consent. She stated that there was no evidence of the assessment and consent for resident #18 in the record. Staff #9 stated that the risk is that it could be construed as a type of restraint for the resident. A review of the facility policy entitled Bed Safety with a review date of September 28, 2023 revealed that placement of bed rails, side rails and assist bars are applied for a medical provider-identified medical necessity. The policy further stated that medical necessity is supported by a resident assessment and data collection documentation which denotes that the resident is able to assist or be independent with bed mobility. The polciy further revealed that an informed consent would be obtained from the resident and/ or family and then documented in the medical record; however, the record revealed no evidence of data collection for enabler bars, assessment or an informed consent for resident #18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident # 2 was admitted into the facility on January 10, 2024 with diagnoses of acute respiratory failure with hypoxia, anxiety disorder, heart failure, and depression. A review of the admission MDS dated [DATE], revealed the resident had a BIMS score of 15, indicating cognitively intact. Review of an order summary report dated February 26, 2024, revealed Home Health was ordered to evaluate and treat for skilled nursing to monitor for signs and symptoms of acute respiratory failure, complications with chronic obstructive pulmonary disease, coronary artery disease, congestive heart failure after stay at skilled nursing facility following hospitalization for acute respiratory failure. Will need occupational and physical therapy to consult for safety and possible treatment in home. Review of a Discharge Summary report revealed resident was discharged on February 29, 2024 at 10:30 AM. On March 07, 2024 at 10:12 AM a document request for Ombudsman notification of resident #2's discharge was made to the Social Service Director (staff #55) and he stated that he did not update ombudsman about any discharges. Staff #55 further stated that the administrator would likely be the one responsible for most of the communication with the ombudsman. An interview was conducted with the Administrator (Staff #12) on March 07, 2024 at 10:15 AM. The administrator stated that discharges are approached as an interdisciplinary team. Further, the administrator stated that facility policy was that ombudsman should be notified of discharges and was something they have to work on. He further stated that he realized that they needed improvement on the discharge process and that if it is in the facility policy that it should be done to meet the facility's expectations. Staff #12 stated per regulation the ombudsman should be notified of facility-initiated discharges because they are a spokesperson for the resident so they are not discharged against their will. Staff #12 reiterated ombudsman was the voice for the residents and that they needed to improve their process. Review of facility policy titled, Discharge and Transfer - Rehab/Skilled, Therapy & Rehab reviewed/revised on January 3, 2024, revealed that with a facility-initiated transfer or discharge, the location must send a copy of the GSS # 223A or other state-required form to a representative of the Office of the State Long-Term Care Ombudsman. Based on record review, staff interviews, and review of policy, the facility failed to notifiy the Ombudsman of transfer/discharge for two residents (#23, #2). Findings included: -Resident #23 was admitted to the facility on [DATE] with diagnoses of respiratory failure unspecified with hypoxia, heart failure, and transient cerebral ischemic attack. Review of the most recent MDS (Minimum Data Set) revealed a BIMS (brief interview of mental status) score of 15, indicating no cognitive impairment. Facility census list revealed resident #23 was on a hospital leave on August 8, 2023 until August 14, 2023 and again on September 2, 2023 until September 9, 2023. An interview was conducted on March 6, 2024 at 2:18 P.M. with the Administrator (staff #12) and Director of Nursing (DON\staff #57). Staff #12 stated that no notification of transfer to the hospital was given to the family of resident #23 because resident was her own representative. In addition, the administrator stated they do not notify the ombudsman of any transfers/discharges, so there was no notification of transfer for resident #23.

Based on review of clinical records and policy, observations, and staff interviews the facility failed to ensure the environment remained free of accident hazards existing from unattended medications. The deficient practice of unattended medications does not align with accepted professional standards of practice and may result in undesirable medication-induced harm. Findings included: On March 6, 2024 at 9:14 AM a medication blister pack was observed unattended at the nurse's station where it was accessible to residents. The medication was Metformin Hydrochloride 500 milligram, a medication for diabetes mellitus. This observation prompted an interview with a nearby Licensed Practical Nurse (LPN/Staff # 77) who stated overhearing that a nurse had removed it from the medication cart after learning it had been discontinued for a resident (# 28). Staff #77 stated it should not have been left where it was but instead be placed in the medication room and notify pharmacy to have the medication picked up. Staff # 77 counted how many tablets were left on the blister pack which were 55 total. Staff #77 stated the risk with leaving the medication unattended were it may cause residents to have an allergic reaction or have hypoglycemia if taken by a resident who does not have diabetes. Staff # 77 assured medications should be locked away and then proceeded to take the medication blister pack to the medication room after the interview. An interview was conducted on 06, 2024 at 12:00 PM with Director of Nursing (DON/Staff # 9) who stated that the risks of leaving the unattended medication, Metformin is upset stomach or allergy. If they take one, it would possibly not cause much, but who is to say they might not take many. Staff # 9 stated leaving medication unattended did not meet facility expectations. Review of the facility's Clinical Services Policy titled, Medication: Acquisition Receiving Dispensing and Storage (reviewed/revised 03/02/2023) revealed: -Medication will be stored in a locked medication cart, drawer or cupboard. Only the person passing medications and the director of nursing services and/or designee will be permitted to have access to the keys to the medication storage areas.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure that one resident (#45) received the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) prior to the service end date. The sample size was 3. The deficient practice could result in unforeseen charges to the resident. Findings include: Resident #45 was admitted to the facility on [DATE] with diagnoses that included primary hypertension, unspecified fracture of left pubis, sequela, and Alzheimer's disease. Review of the SNF Beneficiary Protection Notification Review form presented to the facility to complete, revealed the resident Medicare Part A Skilled Services Episode start date was 01/11/22. The form contained a handwritten note that from 01/11/22 to 03/25/22, the resident was discharged to the hospital. Next to the question how was the Medicare Part A Service Termination/Discharge determined, was written 04/03/22 - 04/28/22. The form also indicated a NOMNC and SNFABN was provided to the resident. A SNF ABN was provided. The form was signed by the resident's representative on 01/11/22. However, there was no additional documentation provided to illustrate the care, reason for Medicare non-coverage, or estimated costs the resident and/or the resident's representative might incur. The admission Minimum Data Set assessment dated [DATE] revealed the resident scored 00 on the brief interview for mental status, indicating severely impaired cognition. A NOMNC form was provided that stated the Effective Date Coverage of your current Skilled Nursing (Medicare A Therapy) services will end 02/25/22. The form was signed by the resident's representative dated 03/01/22. The form also contained written information to sign and return the form in the prepaid envelope provided. The form was not dated to indicate that it had been provided prior to the deadline for immediate appeal. Review of the Part A discharge Minimum Data Set assessment dated [DATE] revealed the resident's Medicare Part A end of stay was 04/28/22. The resident was admitted on [DATE], had an admission MDS assessment dated [DATE], a discharge MDS assessment to an acute hospital return anticipated dated 03/23/22, and an entry tracking record dated 04/01/22. On 10/27/22 at 11:04 a.m., an interview was conducted with the Social Services Director (staff #10). She stated that she was not the member of staff responsible for providing NOMNCs or SNF ABNs. She stated that the receptionist completes those forms. At 11:10 a.m. on 10/27/22, an interview was conducted with the Business Office Coordinator (staff #65). She stated that she did not know about it. An interview was conducted on 10/27/22 at 1:35 p.m. with the Director of Nursing (DON/staff #17). She stated that she knew that advanced beneficiary notices need to be given before discharge and should include any charges that may be incurred out of pocket. The DON stated that the conversation between the resident's representative and the facility was verbal, and not written down. She stated that the bills had been paid on time every month.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record and staff interviews, the facility failed to ensure that a Level 2 PASARR (pre-admission screening and resident review screening tool) was completed for one sampled resident (#15). The deficient practice could result in necessary specialized services not being provided for residents who need it. Findings include: Resident #15 was admitted on [DATE] with diagnoses that included morbid obesity, type 2 diabetes mellitus, and enterocolitis. Review of the care plan dated 3/19/21 revealed the resident was receiving an antidepressant medication due to depression, and psychopharmacological medication due to schizoaffective disorder. Review of a Level I PASARR dated 4/5/2021 included diagnoses of Schizoaffective Disorder, Major Depression, Paranoid Disorder, and Anxiety Disorder were marked. However, further record review revealed resident #15 did not have any other PASARRs or a Level II that was submitted for further recommendation in services. Review of the physician orders revealed and order for: Abilify tablet 2 milligrams (mg) by mouth one time a day related to Schizoaffective Disorder dated 5/19/22 Cymbalta capsule delayed release particles 30 mg by mouth two times a day for depression related to Major Depressive Disorder, recurrent, severe with psychotic symptoms dated 8/30/22 Trazodone 150 mg daily for Depression/insomnia dated 9/06/22 An interview was conducted with the Social Services Director (staff #56) on 10/27/22 at 9:35 AM. Staff #56 stated that normally the PASARR comes from the hospital upon the resident's admission to the facility, and if the resident is coming from home they have to complete the PASARR. Staff 56 stated there are 3 nurse managers in the facility and that a nurse case manager keeps up on level 2 PASARR. An interview was conducted on 10/27/22 at 1:23 PM with the Director of Nursing (DON/staff #17), who stated the PASARR should come from the hospital with the resident. The DON stated that it does not, the facility will need to complete the PASARR to ensure residents are appropriate for the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure a complete discharge summary was completed regarding one resident (#49). The sample size was 2. The deficient practice could result in an ineffective transition to post-discharge care and increases the risk factors leading to preventable readmission. Findings include: Resident #49 was admitted to the facility on [DATE] with diagnoses of atherosclerotic heart disease of native coronary artery without angina pectoris, chronic kidney disease, and hypertension. The resident was discharged [DATE]. Review of the discharge minimum data set assessment dated [DATE] included a BIMS score of 15, which indicated the resident had intact cognition. Review of physician orders revealed an order dated 8/11/2022 for home health to evaluate and treat for skilled nursing, safety evaluation, physical therapy (PT)/occupational therapy (OT) after hospital stay for subdural hematoma with subsequent craniotomy; and an order dated 8/12/2022 for home health to evaluate and treat for skilled nursing transition of care, safety evaluation, PT/OT after hospital stay/SNF stay for subdural hematoma with subsequent craniotomy. Continued review of physician orders did not reveal an order for resident #49 to discharge home. Further review of the clinical record revealed there was not a discharge summary completed regarding resident #49 discharge home, or a progress note related to resident #49 discharge home. A nursing note entered by a Registered Nurse on 8/16/2022 at 10:36 am stated the writer had called and spoke with resident #49's spouse regarding welfare after discharge. The spouse reported being excited about the home health nurse and physical therapy coming in to help, that resident #49 was doing alright but could use the help. The spouse also stated the spouse reported that so far everything was alright and expressed appreciation for resident #49's physician. During an interview conducted on 10/27/22 at 1:23 PM with the Director of Nursing (staff #17), she stated the process and expectation is that a resident is discharged to a safe environment. The DON reviewed resident #49 clinical record, there was no discharge summary, discharge progress note, or discharge order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #39 was admitted on [DATE] and readmitted on [DATE] with diagnoses of encounter for other orthopedic, hypertension, and dysphagia. Review of a physician's order dated 6/24/2022 included Metoprolol Tartrate 50 mg tablet, 50 mg by mouth every morning and at bedtime for hypertension. Hold for SBP less than 110, HR (heart rate) less than 60. Review of the care plan initiated on 6/28/2022 revealed that there was not a focus, goal, or intervention regarding resident #39 use of Metoprolol Tartrate for hypertension. Review of the resident #39 vitals for blood pressure revealed the resident #39 received Metoprolol Tartrate while the blood pressure was below 110 in August 2022, on 8/1/2022, 8/2/2022, and 8/3/2022. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 1, indicating the resident had severely impaired cognition. Review of the resident #39 vitals for blood pressure revealed the resident #39 received Metoprolol while blood pressure was below 110 in October 2022, on 10/2/2022, 10/16/2022, and 10/22/2022. In an interview conducted on 10/27/22 at 1:23 PM with the DON (staff #17), the DON stated that the process and expectation for following medication administration with parameters, is that the medications need to be given within the parameters. Based on clinical record review and staff interview, the facility failed to ensure two residents (#26 and #39) did not receive unnecessary medications. The sample size was 5. The deficient practice increases the risk for residents to receive medications unnecessarily. Findings include: -Resident #26 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to occlusion or stenosis of small artery, hemiplegia affecting the left non-dominant side, and vascular dementia. A potential for dehydration/fluid deficit care plan revised 01/09/20 related to diuretic use had a goal to be free from symptoms of dehydration and to maintain moist mucous membranes and skin turgor. Interventions included weighing the resident on Monday, Wednesday, and Friday. Review of the physician orders included: -Furosemide (diuretic) 20 milligrams (mg); give 20 mg in the morning every Monday, Wednesday, and Friday related to localized edema. Hold for systolic blood pressure (SBP) less than 110. Start date 05/11/22. -hydralazine HCl (vasodilator) 25 mg; give 25 mg three times a day related to essential hypertension. Hold for SBP less than 120. Start date 06/10/22. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 00 on the brief interview for mental status, indicating severe cognitive impairment, and required extensive one to two-person physical assistance for most activities of daily living. However, review of the August 2022 Medication Administration Record (MAR) revealed that hydralazine HCl was administered on 3 occasions when the resident's SBP was less than the ordered parameter: -08/10 for a BP of 112/64 -08/14 for a BP of 119/64 -08/15 for a BP of 113/93 The September 2022 MAR revealed that Furosemide was administered on 1 occasion when the resident's BP was less than the ordered parameter: -09/23 for a BP of 94/67 Review of the MAR for September 2022 revealed that hydralazine HCl was administered more than 5 times when the resident's BP was below the parameter, including: -09/02 for a BP of 114/62 -09/09 for a BP of 116/65 -09/10 for a BP of 119/69 -09/23 for a BP of 94/67 -09/30 for a BP of 102/57 The October 2022 MAR indicated that Furosemide HCl was administered on 2 occasions when the resident's BP was below parameters: -10/05 for a BP of 101/62 10/21 for a BP of 109/77 In addition, the October 2022 MAR revealed for 5 administrations of hydralazine HCl when the resident's BP was less than the ordered parameter: -10/19 for a BP of 119/70 -Twice on 10/21 for BPs of 109/77 and 109/77 -Twice on 10/23 for BPs of 115/66 and 115/66 An interview was conducted on 10/27/22 at 12:44 p.m. with a Licensed Practical Nurse (LPN/staff #46). She stated that her process for medication administration included obtaining the resident's blood pressure before she administers medications. She stated that if the resident's blood pressure is too low, she will hold the medication. She stated that if the resident's blood pressure was really low, she would notify the physician. The LPN stated that the risks of administering an antihypertensive medication when the resident's blood pressure is too low would include a lower blood pressure, dizziness, or falls. The LPN stated that if the medications were administered, they would be considered unnecessary, and would be medication errors. On 10/27/22 at 2:14 p.m., an interview was conducted with the Director of Nursing (DON/staff #17). She stated that nurses should not administer the medication if the blood pressure was lower than the parameter. The DON stated that the nursing process would include notification of the provider, resident, family/representative, and the DON. She stated that the resident should also be monitored more closely. She stated that nursing staff would be re-educated.

Based on review of the Facility Assessment, staff interview, and review of policy and procedure, the facility failed to ensure that the facility-wide assessment was thoroughly completed, by failing to ensure the Facility Assessment included an evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff were available to meet each resident's need. The deficient practice could result in inadequate staffing levels. Findings include: Per the facility assessment, the facility staffs based on census number and acuity of residents. Staffing assignments are adjusted based on resident acuity and needs. If it is determined that current staffing levels/assignments are no longer effective, the Quality Assurance and Performance Improvement (QAPI) principles and model for improvement will be used to reevaluate and redesign staffing practices in order to meet acuity and needs of residents. However, further review of the assessment did not reveal an evaluation of the overall number of facility staff needed to ensure a sufficient number of qualified staff members were available to meet each resident's needs. An interview was conducted on 10/27/22 at 1:35 p.m. with the Interim Executive Director (staff #1). She stated that the components of the facility assessment include a physical description of the facility, the resident census, and the services they provide. She stated that further, the demographics of the residents and their conditions, key personnel in the building, the approximate number of staff members that are needed to meet the needs of the residents, and their competencies should be identified. She stated that adequate needs must be described in the facility assessment and that the consequences of not adequately defining these elements might mean the standard of care might not be upheld. The facility's policy titled Facility Assessment - Rehab/Skilled, reviewed/revised 10/27/2020, stated the purpose is to evaluate the resident population and identify resources needed to provide the necessary care and services. The policy stated the facility conducts and documents a facility-wide assessment to determine what resources are needed to care for residents competently during both day-to-day operations and emergencies. The facility reviews the assessment as necessary, and at least annually. The policy stated the facility's resources included all personnel, including managers, staff (both employees and those who provide services under contract) and volunteers, as well as their education and/or training, and any competencies related to resident care. The policy did not include an evaluation of the overall number of facility staff needed to ensure a sufficient number of qualified staff members were available to meet each resident's need.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews, and policy review, the facility failed to ensure that one resident (#3) was treated with respect and dignity during dining. The census was 52. The deficient practice could negatively impact the psychosocial well-being of residents. Findings include: Resident #3 was admitted to the facility on [DATE] with diagnoses of anoxic brain damage and muscle weakness. Review of the nutritional care plan initiated on December 5, 2017 and last revised on March 30, 2021 included a goal that the resident would maintain adequate nutritional status. Interventions included to monitor/document/report to the physician as needed for signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, and appears concerned during meals, and for the staff to provide assistance/cueing/encouragement as tolerated and as needed. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 10 which indicated the resident had moderate impaired cognition. The assessment included the resident required extensive assistance of one person with eating. During a dining observation conducted on June 23, 2021 at 12:43 PM, resident #3 was observed being assisted in the dining room by a Certified Nursing Assistant (CNA/staff #62). Staff #62 was observed sitting with her back turned to the resident talking to staff. Staff #62 was observed to turn occasionally to give resident #3 a bite of food and turn away from the resident without observing how the resident was chewing. The CNA rarely spoke to the resident. The CNA was observed at one point resting her hand on her head for approximately 30 - 60 seconds looking away while giving the resident some bites of food. An interview was conducted on June 23, 2021 at 1:32 PM with this CNA (staff #62), who stated that today she had only one person to assist with dining. The CNA stated that she was assisting resident #3 and entertaining another resident. She stated the other resident did not need assistance with eating. This CNA stated that she should have been watching to make sure the resident was not choking, chewing properly, and not pocketing. Staff #62 stated resident #3 pockets food and that she tries to gives the resident a lot of liquids to try and get the food down. Staff #62 stated sometimes management will say something about facing the resident and talking to the resident when feeding the resident. An interview was conducted on June 23, 2021 at 2:12 PM with a Registered Nurse (RN/staff #67). The RN stated that she would expect CNAs assisting residents with eating, to sit near the residents so they could see the residents face to face, tell the residents what they are eating, encourage them to eat, and talk to the residents. The RN stated that it was not right to assist a resident with eating not facing the resident or talking to the resident. In an interview conducted with the Director of Nursing (DON/staff #8) on June 24, 2021 at 2:17 PM, the DON stated that her expectations for staff assisting residents with dining is that the staff need to focus on the resident. The DON stated staff not facing a resident and not talking to a resident while assisting the resident with dining did not meet her expectation. A facility's policy titled Dignity in Dining - Food and Nutrition Services reviewed/revised April 5, 2021 stated the purpose is to provide dining in a manner that enhances resident dignity. The policy included employees promote resident independence and dignity in dining by treating each resident like an individual and focusing on making the dining experience as individualized as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #39 was admitted on [DATE]. Diagnoses included heart failure, seizures, and encounter for palliative care. Review of physician's admission orders included a verbal order dated 6/2/2021 for oxygen via nasal cannula 1-4 liters per minute as needed for dyspnea, hypoxia or acute angina and to titrate to maintain saturations at 90% or greater. Review of the Weights and Vital Summary revealed the resident's oxygen saturation was 97% on oxygen via nasal cannula on 06/02/2021 at 6:25 PM, 96% on oxygen via nasal cannula on 06/03/2021 at 4:12 AM, 98% on oxygen via nasal cannula on 06/04/2021 at 8:20 AM, 90% on oxygen via nasal cannula on 06/05/2021 at 9:03 PM, 94% on oxygen via nasal cannula on 06/07/2021 at 12:38 AM, and 97% on oxygen via nasal cannula on 06/08/2021 at 9:40 AM. A review of the admission MDS assessment dated [DATE] revealed a BIMS score of 13, denoting no cognitive impairment. However, the MDS assessment did not include that the resident had been using oxygen since admission. At 10:06 AM on 06/24/2021, an interview was conducted with the MDS Coordinator (staff #58). She stated the information to be entered for the assessment would have come from the admission packet, and that she would review the clinical record for diagnoses, comorbidities, special services, wound care, and medications. Staff #58 stated oxygen therapy should have been entered into Section O of the MDS assessment. Staff #58 stated that she reviewed the Treatment Administration Record (TAR) and that the TAR did not include documentation for oxygen, and for that reason she did not include oxygen therapy in the MDS assessment. A review of the facility's policy and procedure for MDS assessment reviewed/revised 12/16/2020 stated that during the observation period each team member will review the electronic medical record (EHR) to determine if there is accurate documentation to support coding for the MDS. Review of the RAI manual stated to review the resident's clinical record to determine whether or not the resident received oxygen within the last 14 days. The manual also stated to code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to the resident to relieve hypoxia in this item. The RAI manual also included .the importance of accurately completing the MDS cannot be over emphasized. The MDS is the basis for the development of an individualized care plan . Further, Federal regulations require that the assessment accurately reflects the resident's status. Based on clinical record reviews, staff interviews, policy review, and the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the Minimum Data Set (MDS) assessments for two residents (#49 and #39) were accurate. The sample size was 15. The deficient practice could result in MDS assessments not being accurate, and data that is not accurate for quality monitoring. Findings include: -Resident #49 was admitted on [DATE], with diagnoses that included rheumatoid arthritis (RA), pain, weakness, reduced mobility, and muscle weakness. Review of the care plan initiated 3/12/2021 revealed the resident had chronic pain/discomfort related to RA. The goal was that the resident would verbalize adequate relief of pain or ability to cope with incompletely relieved pain. Review of the admission MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate impaired cognition. Review of the assessment also revealed the pain assessment interview should be conducted with the resident. However, further review of the assessment revealed the pain assessment interview was not conducted with the resident. An interview was conducted with the MDS Coordinator (staff #58) on 06/24/2021 at 08:58 AM. She stated that she completes most of the sections on the admission MDS assessment. The MDS Coordinator stated the Director of Nursing (DON/staff #8) completes the pain section of the MDS assessment. An interview was conducted with the DON (staff #8) on 06/24/2021 at 09:30 AM, who stated that the MDS Coordinator notifies her when the pain assessment is due and that she completes the pain assessment portion of the MDS assessment. The DON also stated that ideally, the pain portion of the MDS assessment should always be completed. She reviewed the MDS assessment section for pain and stated that it was not completed as required and could result in the resident's pain not being addressed. Review of the facility's MDS 3.0 (Minimum Data Set) RAI - Rehab/skilled policy reviewed/revised 12/16/2020 revealed the MDS interviews must be conducted during the designated observation period. The pain assessments are preferably completed the day before, or the day of the Assessment Reference Date (ARD). Complete means that the interview questions have been saved, signed and locked. The policy also revealed that if any discipline is unable to complete its section (due to vacation, illness, etc.), the RN coordinator will assign another person to complete this section within the time frame. The RAI Manual revealed that obtaining information about pain directly from the resident, sometimes called hearing the resident's voice, is more reliable and accurate than observation alone for identifying pain. Information about pain that comes directly from the resident provides symptom-specific information for individualized care planning. Attempt to conduct the interview with all residents. This interview is conducted during the look-back period of the ARD. Directly asking the resident about pain rather than relying on the resident to volunteer the information or relying on clinical observation significantly improves the detection of pain. Resident self-report is the most reliable means for assessing pain. The RAI manual also revealed pain assessment provides a basis for evaluation, treatment need, and response to treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident and staff interviews, and review of policy and procedure, the facility failed to ensure that one sampled resident (#41) received treatment and care in accordance with professional standards of practice relating to the presence of edema. The deficient practice could result in residents not receiving treatment and care for edema. Findings include: Resident #41 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, dementia, and type two diabetes mellitus. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 14, which indicated that the resident had intact cognition. Observation of the resident were conducted at the following times: -June 21, 2021 at 11:39 a.m. Both of the resident's legs and feet were observed to be edematous. The resident's legs were observed to be in a dependent position, bent at the knee, and resting on the wheel chair foot rests. The foot rest were not elevated and no use of compression stockings was observed. -June 23, 2021 at 2:17 p.m. The resident was observed in the beauty shop. Unable to visualize the resident's legs at this time. The resident's legs were observed to be in a dependent position, bent at the knee, and resting on the wheel chair foot rests. The foot rest were not elevated. -June 23, 2021 at 2:24 p.m. The lower portion of the resident's legs were observed to have bilateral lower leg edema. The resident stated that she did not realize that her legs had edema/were puffy. She stated that she did not do anything to decrease the puffiness including elevating her legs. The resident's legs were observed to be in a dependent position, bent at the knee, and resting on the wheel chair foot rests. The foot rests were not elevated and no use of compression stockings was observed. -June 24, 2021 at 9:08 a.m. The observation was conducted in the resident's room. The resident was in the wheelchair sitting at the bedside table. The observation revealed that the resident's bilateral lower legs/ankles continued to be edematous. The foot rest were not elevated and no use of compression stockings was observed. Continued review of the clinical record did not reveal documentation about the edema to the resident legs or any orders/intervention for the edema. An interview was conducted on June 24, 2021 at 10:55 a.m. with a Certified Nursing Assistant (CNA/ staff #43). Staff #43 stated that she would be able to see if a resident had swelling in their legs when she was giving care/dressing the resident. The CNA stated that if the swelling was new she would let the nurse know and that the nurse would usually tell her to put on [NAME] hose to keep the swelling down. She stated that resident #41 had swelling in the legs on and off and mostly in the right leg. The CNA stated that nothing was being done for the resident's swelling, but that the resident would lay down between meals which improved the swelling in the resident's legs. The CNA also stated that she had reported the swelling to the nurse. An interview was conducted on June 24, 2021 at 12:55 p.m. with a Registered Nurse (RN/staff #29). She stated that if she observed a resident with edema or it was reported to her, she would notify the physician. She stated that sometimes the physician would increase the Lasix (diuretic) dose or do compression therapy (contraindicated with arterial insufficiency). The RN stated that if there was no contraindication to compression therapy they would use [NAME] stockings, ace bandages, or [NAME] hose. She stated that she would also encourage elevation of the edematous part because it would help with dependent edema. She stated that a review of the resident's medical record should reveal documentation from nursing that identified the resident's edema, recorded communication with the physician, and that the edema should be on the resident's care plan with interventions. The RN stated resident #41 had edema bilaterally to the lower extremities and that the leg edema started earlier this year when the resident had a weight gain. Staff #29 stated that compression therapy had been tried with the resident but that the resident did not like it/refused it. Staff #29 stated that the intervention for this resident's edema was for the resident to lay down between meals. She stated that laying down decreased the resident's edema a little bit, for a little while. She stated that the resident was on a diuretic. However, after reviewing the resident's medications, the RN stated that there was no diuretic ordered. The nurse reviewed the care plan and stated that the resident's edema was not on the care plan. The nurse reviewed the clinical record and stated that the documentation did not include the resident's edema. The RN stated that she had not spoken to the physician about the resident's edema. The RN further stated that the facility expectations were not met related to documentation and care planning of a resident with edema. An interview was conducted on June 24, 2021 at 1:50 p.m. with the Director of Nursing (DON/staff #8). The DON stated that she would expect that the presence of edema would be identified by facility staff, and addressed with the physician. She stated that the communication with the physician should be documented. The DON stated that she would expect ongoing edema to be on the care plan with interventions. She stated that the risk of undocumented edema was that a resident's edema may not be relayed to the next nurse or the resident may not have labs obtained as needed. The DON stated the identification, assessment, and communication to the physician regarding the presence of edema was important to ensure needed new interventions/medications were implemented. Review of a facility policy for Edema checks reviewed/revised June 23, 2021 revealed: The purpose was to determine the level and monitor the status of edema present. Edema is an abnormal accumulation of fluid in the intercellular body spaces or tissue. To treat edema, you must treat the underlying cause of the edema. Baseline data for edema should be part of the resident's clinical record. The policy also revealed to document that the charge nurse/physician was notified and any treatment ordered on the Treatment Administration Record (TAR), eAdmin Record or PN-Health Status as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure one of two sampled residents (#49) at risk for the development of pressure ulcers, received care consistent with professional standards. The deficient practice could result in delayed identification of skin issues. Findings include: Resident #49 was admitted on [DATE], with diagnoses that included rheumatoid arthritis (RA), pain, weakness, reduced mobility, and muscle weakness. Review of the care plan initiated on 03/22/2021 revealed the resident had potential for pressure ulcer development related to immobility and incontinence. The goal was that the resident would have intact skin, and be free of redness, blisters or discoloration. Interventions included to notify the nurse immediately of any new areas of skin breakdown noted during bath or daily care. A physician's order dated 04/21/2021 included for weekly skin assessment, nurse to complete skin observation assessment every day shift every Saturday for skin check. Further review of the clinical record revealed that the skin observation assessments were not conducted weekly as ordered on 05/01/2021 and 05/22/2021. An interview was conducted with the Director of Nursing (DON/staff #8) on 06/24/2021 at 09:49 AM. The DON stated skin observations should be completed on the date they are scheduled. She reviewed the clinical record for this resident and stated that there was an order for weekly skin observations and that there were two skin observations in May that had not been completed as ordered. The DON stated that if skin assessments are not completed as ordered, there could be a risk of an ulcer not being detected earlier and prevent severity. During an interview conducted with a Registered Nurse (RN/staff #69) on 06/24/2021 at 12:43 PM, the RN stated that the nurse on the unit is responsible for completing the skin observation assessments as ordered. A policy was requested from the facility regarding the skin observation process. The Administrator (staff #54) stated that they do not have a formal policy regarding the skin assessment form, but stated the User-Defined Assessment (UDA) process is what the facility follows. A review of the UDA process for the Skin Observation revealed that the assessment should be completed by a licensed nurse, and is used to document weekly skin checks and skin conditions. A review of the facility policy titled, Physician/Practitioner Orders, revealed that a physician, physician's assistant, nurse practitioner or clinical nurse specialist must provide orders for the resident's immediate care. Physician/Practitioner orders are a critical component to providing quality care to residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, clinical record review, and review of policy and procedure, the facility failed to ensure one sampled resident (#21) received safe transfers in accordance with professional standards of practice. The deficient practice increases the risk for accidents and resident injury. Findings include: Resident #21 was readmitted to the facility on [DATE] with diagnoses that included multiple sclerosis, urinary tract infection, and diabetes mellitus type 2. Review of the care plan initiated on March 3, 2021 revealed the resident had an ADL (Activities of Daily Living) self-performance deficient related to muscular sclerosis as evidenced by weakness, paralysis, and immobility. The goal was that the resident would improve their current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene. Interventions included 2 staff assist for scooting up in bed and getting out of bed using a total lift and medium high back transfer sling. The quarterly Minimum Data Set assessment dated [DATE] revealed the resident required extensive assistance of 2+ person for bed mobility and was total dependent of 2+ person physical assistance for transfer. During an interview conducted with resident #21 on June 21, 2021 at 11:04 a.m., resident #21 stated that from what she understands only a couple of staff members know how to use the total lift. The resident stated that her Certified Nursing Assistant (CNA) knows how to use the lift by herself, and that the CNA transfers her by herself on a regular basis. On June 23, 2021 at 1:38 p.m., an interview was conducted with a Restorative Nurse (staff #16), who stated using a total lift for a resident requires 2 staff. Staff #16 stated all CNAs and nurses are trained to how to use lifts during orientation and that the CNAs work in pairs when using a total lift. An interview was conducted with a CNA (staff #62) on June 23, 2021 at 3:01 p.m., who stated that she has a lot of residents on her hall that require the use of lifts, including 4 total lifts and 6 sit-to-stands. The CNA stated that she has become comfortable using the total lift on her own. Staff #62 stated that she knows she is not supposed to use the total lift on her own, but when there are only 2 CNAs caring for 38 or 39 residents and no one else is around, she does not know what else to do. On June 24, 2021 at 9:03 a.m., an interview was conducted with the Director of Nursing (DON/staff #8). She stated that total lifts are supposed to be 2-person transfers. She stated she was sure that is their policy and that is what she teaches. The DON stated CNAs are encouraged to ask for help, and all nurses have been trained and are qualified to help. The DON stated that 2 people are needed for positioning, and it is best practice. Review of the facility's Safe Resident Handling Program (SRHP) Resource Packet policy reviewed/revised May 25, 2021 included each rehab/skilled location offering services that include moderate to total assistance with mobility/transfers will follow the SRHP practices when performing mobilization and other care tasks that require employee assistance. Every employee, including contingency and agency staffing, have a responsibility to the safety and well-being of the residents, as well as, ensuring the safety of the environment in which they work. Certified, non-certified nursing assistant, and universal workers (over [AGE] years of age) will follow the resident plan of care/service plan for mobility device, type and size of sling, and number of employees to safely transfer or position the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record, staff interviews, and policy review, the facility failed to ensure one sampled resident (#37) with suicidal ideation was provided with treatment and services to attain the highest practicable mental and psychosocial well-being. The deficient practice could result in self-harm. Findings include: Resident #37 was admitted to the facility on [DATE] with diagnoses of major depressive disorder, anxiety disorder, altered mental status, hallucinations, and dementia with Lewy bodies. A review of the care plan initiated on April 9, 2021 revealed the resident used antidepressant medication related to depression. The goal was that the resident would show decreased signs and symptoms of depression and would be free from discomfort or adverse reactions related to antidepressant therapy. Interventions included reporting to the nurse signs and symptoms that included mood change, change in normal behavior, hallucinations/delusions, social isolation, withdrawal, and suicidal ideations. The admission Minimum Data Set (MDS) assessment dated [DATE] included a score of 10 on the Brief Interview for Mental Status indicating the resident had moderate impaired cognition. The assessment included the resident answered yes to feeling down, depressed, or hopeless over the last 2 weeks for 12-14 days. The assessment also included the resident answered yes to feeling bad about self or being a failure or having let self or family down over the last 2 weeks for 12-14 days. The assessment revealed the resident had thoughts of being better off dead or hurting themselves in some way for 12-14 days of 14 days. The assessment also revealed the resident's total severity score for the resident's mood interview was 21 which indicated the resident had severe depression. The MDS Coordinator progress notes dated April 16, 2021 revealed that when the resident was interviewed on the mood indicators of the MDS assessment, the resident had stated that she was better off dead. The note included the resident did not have a plan at that time. Also included in the note was that the physician was notified of the mood indictor results. A nursing mood/behavior progress note dated April 27, 2021 at 2:17 PM included the resident was crying frequently today especially when any staff approached her. Leaning way over in geri chair and refused care of keeping her safe. Yelling leave me alone and don't touch me. also, witnessed her hitting herself and verbalizing she wanted to end her life while making movements w/ her hand as if she were cutting her wrist. social worker contacted and had a visit with patient to assess situation. At present in activity room with other residents watching a movie. Another nursing note dated April 27, 2021 at 6:13 PM stated the resident had to be brought out of the activity room due to being disruptive with crying and whimpering, and inconsolable. The note included a Certified Nursing Assistant (CNA) had reported the resident was not eating during meals related to behavior of crying. A Suicide Risk assessment dated [DATE] revealed the question Has the resident verbalized suicidal ideation or intent to do self-harm? was answered yes and that the resident stated I want to end my life. The assessment included the question: Have you identified signs in the resident's behavior that lead you to believe that there is an escalated risk of self-harm? This question was answered yes, that the staff identified that there was some concern with talking with a CNA, that this resident had not eaten in 4 days, does not want to be at the facility and the family was not able to care for the resident at home anymore. However, review of the progress notes revealed no documentation of the physician or the resident's family being informed or of any interventions that had been put in place. A nursing eAdmin Record note dated April 30, 2021 at 1:14 PM stated the resident had been yelling and crying while sitting in the activity room and by the nurses' station. When asked what was wrong, the resident would not say anything or was hard to understand. The note included the resident calmed down a little bit after watching animal videos on TV and after therapeutic communication. A nursing eAdmin Record note dated May 1, 2021 at 8:11 PM revealed the resident had been crying in the chair this HS (bedtime). Review of a nursing eAdmin Record note dated May 3, 2021 at 2:02 PM included the resident was crying and kept trying to get out of the wheelchair. The note also included the resident stated to the nurse I don't want to take that. I just want to die. Review of another nursing eAdmin Record note dated May 15, 2021 at 1:09 PM stated the resident had been crying off and on, and trying to get up without assistance. The note also stated that the resident stated nothing was wrong except that she wanted to get out of here. A nursing eAdmin Record note dated May 24, 2021 at 3:00 PM stated the resident was yelling out help and that the nurse went to check on the resident. The note also stated the resident stated there is something wrong with my head. I am going crazy. Review of a nursing eAdmin Record note dated June 9, 2021 at 8:14 PM revealed the resident had been crying and yelling out that HS. A review of a nursing eAdmin Record note dated June 14, 2021 at 1:37 AM included the resident had been emotional and crying out some that morning. A review of the nursing eAdmin Record note dated Jun 14, 2021 at 9:46 PM stated the resident had been crying that HS. A mood and behavior nursing progress note dated June 22, 2021 included the resident kept leaning forward in the chair. The staff member asked why the resident kept doing that and the resident stated I'm trying to fall and break my neck. However, additional review of the clinical record did not reveal that a Suicide Assessment had been performed, the physician had been informed or any interventions had been put in place. An interview was conducted on June 23, 2021 at 2:12 PM with resident #37's Registered Nurse (RN/staff #67), who stated that if she had a resident with suicidal ideation, she would have a conversation with them and what they mean about that, ask if they have a plan, try to evaluate why they are feeling that way, and then she would report it to the Director of Nursing (DON) immediately. The RN stated that she would not leave the resident alone and that she would notify social services and the resident's physician. She stated that she would stay and talk to the resident because sometimes the residents do not really mean it and they do not have a plan. The RN also stated that she cannot think of anyone she's caring for who has suicidal ideation. An interview was conducted with Social Services (staff #46) on June 23, 2021 at 2:35 PM, who stated she would interview residents with suicidal ideation to see if they have a plan, ask if they will sign a contract that they will not self-harm, perform a risk assessment, email the physician and the DON, then document a note about it in the Electronic Medical Health Record, and follow up with the resident and council with them. Staff #46 stated that resident #37 had a hard time adjusting to the facility, and that the resident was feeling abandoned because the resident's spouse could not care for the resident anymore. Staff #46 stated the resident had stated that she just wanted to die in April but she had not heard it since. She stated the resident did not have a plan that she remembered. The Social Service staff stated that it is hard to get the time to council the resident but that she does what she can. Staff #46 stated the nurses inform her if there is something concerning or alarming and that she follows up immediately and will do an assessment. She reviewed the resident's June progress notes and stated that she will be following up on that today. An interview was conducted with the Case Manager RN (staff #16) on June 23, 2021 at 3:29 PM, who stated that if she had heard a resident was having suicidal ideation, she would notify Social Services so that they could conduct an assessment. Staff #16 stated that if it was a resident that had a plan to commit suicide, then the resident would be put on a watch and checked every 10 minutes or 15 minutes or whatever the policy is. She reviewed the progress notes for this resident and stated that the progress note dated June 22, 2021 was a note that a staff had put in through the point of care. Staff #16 stated that she thought it was important and should be addressed, so she documented it in a mood and behavior note. She stated that she did not know who wrote the note, that there was not a way to tell who had wrote it, and that it showed up in the notes that the CNAs put in. The Case Manager RN stated that she would assume the CNA would have told the nurse and that the nurse had already performed a suicide assessment. Staff #16 stated that she did not feel the resident could commit suicide because the resident does not have enough mobility and is usually at the nurses' station so the staff can keep an eye on her. She stated that she assumed the note was after the fact and that it was her fault. Staff #16 stated that she should have tried to find out if the physician had been notified, or the threat had been assessed. During an interview conducted with the RN MDS Coordinator (staff #58) on June 24, 2021 at 11:54 AM, staff #58 reviewed the admission MDS assessment and the care plan and stated that she did not see suicidal ideation in the care plan and that it should have been. She said that Social Services stated that she was develop a care plan for suicidal ideation and that suicidal ideation should have been in addressed in the care plan. An interview was conducted on June 24, 2021 at 12:01 PM with the Social Services Director (staff #46), who stated that she believed suicidal ideation should be on the care plan because it happened more than once. She reviewed the resident care plan and stated there was nothing directly related to suicide. Staff #46 stated it was something that they need to be aware of and that it needed to be addressed in the care plan. On June 24, 2021 at 12:33 PM, an interview was conducted with the DON (staff #8). The DON stated that she heard the resident did say something about falling out of the wheelchair and that the resident was struggling with abandonment. The DON stated that she sometimes thinks the residents just say things because it is a huge adjustment for residents. The DON stated that she did not think the resident was suicidal until yesterday. The DON also stated that she had not observe the resident be suicidal in the past and that the resident does not have a plan. A follow up interview was conducted on June 24, 2021 at 02:17 PM with the DON (staff #8), who stated the self-harm on the MDS assessment should have been care planned. She stated the physician should be notified and the resident asked if they have a plan. She stated people with dementia can have lucid thoughts long enough to commit suicide even if they do not have a plan. A facility's policy titled Suicide Precautions - Rehab/Skilled revealed the purpose of the policy is to provide for the safety of residents at risk for suicide, to identify/recognize possible signs of intent to commit suicide, and to increase employee awareness regarding suicide. This policy included that when the resident has verbalized suicidal ideation or intent, the social worker or registered nurse must assess the resident to determine the risk for self-harm and the ability of the center to keep the resident safe. Complete the Suicide Risk Assessment UDA and document any interventions in the care plan. If the resident is determined to be at risk, the staff should initiate a monitoring system to watch the resident at intervals no greater than every 15 minutes, call the physician, attempt to contract with the resident not to harm self, help the resident to identify a person or a plan that will help them feel safe immediately (i.e., family member who can stay with them). To the extent possible, remove all items that could cause self-injury (for example, shoelaces, belts, knives, call light cords, plastic bags, nylon stockings, clothing draw strings and any other sharp objects.). Consider moving the resident to a safe area for further observation if necessary, such as a lounge/day room located within an unobstructed view of the nursing station. The policy also included to consider the necessity of a mental health referral to further assess and treat as needed underlying causes and issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy reviews, the facility failed to ensure that one of five sampled residents (#37) was free from unnecessary drugs, by failing to administer drugs according to the physician ordered parameters. The deficient practice could result in low blood pressures and residents receiving drugs that may not be necessary. Findings include: Resident #37 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, essential hypertension, and Major Depressive Disorder A physician's order dated April 9, 2021 included for Metoprolol Tartrate (antihypertensive) 25 milligram by mouth every morning and at bedtime for hypertension, hold for systolic blood pressure (SBP) less than 110 and heart rate (HR) less than 60. Review of the Medication Administration Records (MARs) for April 2021, May 2021, and June 2021 revealed Metoprolol Tartrate was administered to the resident outside of parameters on the following days: April 12, HR 58 May 1, HR 50 May 3, HR 59 May 4, HR 59 and SBP 108 May 9, HR 52 May 16, SBP 109 May 20, HR 58 May 29, SBP 107 May 31, HR 54 June 9, SBP 106 An interview was conducted with a Registered Nurse (RN/staff #26) on June 24, 2021 at 12:20 PM, who stated that when administering a medication that affects blood pressure, she would obtain the resident's blood pressure. The RN stated that if the resident's blood pressure was below the physician's parameters, she would not give the medication. Staff #26 stated that she would document that it was not given and why. After reviewing resident #37's clinical record, the RN stated staff should have followed the ordered parameters and not administered the blood pressure medication. An interview was conducted with the Director of Nursing (DON/staff #8) on June 24, 2021 at 2:17 PM. The DON stated her expectations were that medications be administered exactly as ordered. She stated she expected medications to be administered within the ordered parameters. The DON stated if the resident's vitals were not within parameters, then the staff should hold the medication and notify the physician. She reviewed this resident's MAR for Metoprolol and stated that this medication was not administered correctly. A facility's policy titled Medication: Unnecessary - Rehab/Skilled reviewed/revised January 18, 2021 revealed that the purpose of this policy is to eliminate unnecessary use of medications. It included that each resident's drug regimen must be free from unnecessary drugs and that an unnecessary drug is any drug when used: In excessive dose (including duplicate therapy), for excessive duration, without adequate monitoring, without adequate indications for its use, in the presence of adverse consequences which indicate the dose should be reduced or discontinued or any combination of the reasons above. A facility's policy titled Medication Documentation - Rehab/Skilled reviewed/revised October 15, 2020 stated to notify the physician of any readings outside the parameters established by the physician.

Based on review of the Facility Assessment, staff interview, and review of policy and procedure, the facility failed to ensure that the facility-wide assessment was thoroughly completed, by failing to ensure the Facility Assessment included an evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff were available to meet each resident's need. The census was 52. The deficient practice could result in inadequate staffing levels. Findings include: Per the facility assessment, the facility staffs based on census number and acuity of residents. Staffing assignments are adjusted based on resident acuity and needs. If it is determined that current staffing levels/assignments are no longer effective, the Quality Assurance and Performance Improvement (QAPI) principles and model for improvement will be used to reevaluate and redesign staffing practices in order to meet acuity and needs of residents. However, further review of the assessment did not reveal an evaluation of the overall number of facility staff needed to ensure a sufficient number of qualified staff were available to meet each resident's needs. An interview was conducted with the administrator (staff #54) on June 24, 2021 at 1:46 p.m. She stated she was responsible for updating the facility assessment and that she had last updated it in July of 2020. Staff #54 stated the purpose of the facility assessment was to evaluate the resident population and the necessary resources to provide care and services. The administrator reviewed the facility assessment and stated that the term resources included personnel (managers and staff), but that the assessment did specifically include a number, or a staff to resident ratio, that would meet that requirement. The administrator stated that if she had included numbers in the assessment she could be cited if her staffing levels were lower. She stated that the facility policy stated the facility assessment should include the resources needed to competently care for residents during day-to-day operations or emergencies, but did not state the number of staff necessary to provide care to the residents. The facility's policy titled Facility Assessment - Rehab/Skilled stated the purpose is to evaluate the resident population and identify resources needed to provide the necessary care and services. The policy stated the facility conducts and documents a facility-wide assessment to determine what resources are needed to care for residents competently during both day-to-day operations and emergencies. The facility reviews the assessment as necessary, and at least annually. The policy stated the facility's resources included all personnel, including managers, staff (both employees and those who provide services under contract) and volunteers, as well as their education and/or training, and any competencies related to resident care. The policy did not include an evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff were available to meet each resident's need.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, review of the clinical record, and policy and procedure, the facility failed to ensure one sampled resident (#14) with a diagnosis of a serious mental illness was referred to the appropriate state-designated mental health or intellectual disability authority for review. The deficient practice could result in necessary specialized services not being provided for residents who need it. Findings include: Resident #14 was admitted to the facility on [DATE] with diagnoses that included schizophrenia unspecified (primary), unspecified psychosis not due to a substance or known physiological condition, and unspecified dementia. Review of the Preadmission Screening and Resident Review (PASRR) Level I Screening Document dated August 28, 2014 revealed the resident had a primary diagnosis of dementia and further stated that the resident did not have a primary diagnosis of serious mental illness as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM) IV including major depression, psychotic/delusional disorder (i.e., paranoid), mood disorder, or schizophrenia. Despite documentation that the resident had a diagnosis of schizophrenia with behaviors and a psychotic disorder, no evidence was found that the facility referred the resident to the appropriate state-designated mental health or intellectual disability authority for review or why the resident was not referred. A physician's order dated December 6, 2019 revealed for quetiapine fumarate (antipsychotic) extended release; give 200 milligram in the evening related to schizophrenia, unspecified. Further instructions included to document behaviors related to schizophrenia, such as refusing care, yelling at staff, hitting, and delusional ideas. Monitor for adverse side-effects such as: dizziness, tardive dyskinesia, difficulty swallowing, and orthostatic hypotension. A nursing progress note dated January 7, 2020 at 10:13 a.m. stated the resident had been incontinent of bowel that morning and had a significant amount of bowel movement on her. Staff providing care suggested that she go to the shower in order to get properly clean. The resident refused and in an angry tone said she was not going to take a shower. A nursing progress note dated March 6, 2020 at 1:51 p.m. revealed the resident had refused her medications stating she did not want to take any more pills. On April 10, 2020 at 1:34 p.m., a nursing progress note included the resident had refused lunch and wanted to stay in bed. The resident's family member called at 1:30 p.m., but the resident did not want to talk to the family member. A Nutrition Status note dated April 28, 2020 at 11:03 a.m. included that the resident had an insidious weight loss of about 20 pounds within the past 6 months, and that the weight loss was likely beneficial due to the resident's high body mass index. Review of a nursing progress note dated May 5, 2020 at 6:57 p.m. included the resident had been in bed since breakfast and refused lunch and dinner. A nursing progress note dated May 21, 2020 at 1:05 p.m. stated the resident went to bed after breakfast and refused to get up for lunch and refused the noon medications. A depression care plan dated June 4, 2020 related to self-isolation, tearfulness, and antidepressant medication had a goal the resident would remain free of signs or symptoms of depression, anxiety, or sad mood. Interventions included to monitor/record/report to health care provider as needed risk for harm to self, suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions, writing a note, etc.), intentionally harmed or tried to harm self, refusing to eat or drink, refusing medication or therapies, sense of hopelessness or helplessness, impaired judgement or safety awareness. Review of a communication with resident/family nursing note dated June 15, 2020 at 12:26 p.m. stated that consent was needed to send the resident to the hospital for further evaluation, medical workup, possible aggressive rehabilitation and psychiatric evaluation to rule out underlying issues contributing to her health decline. The note stated that there was also the chance that further psychiatric evaluation and treatment may be necessary once other health conditions were ruled out. A transfer to hospital nursing note dated June 15, 2020 at 1:15 p.m. revealed the resident was transferred to the emergency room for altered mental status. A nursing progress note dated June 18, 2020 at 12:15 p.m. stated the nurse had called the hospital for an update on the resident. Per the report, results of the tests performed had not concluded that the issues the resident was experiencing were related to anything physiological. The note included the resident was scheduled for a geripsyche consult that day. The note also included the resident was receiving both occupational therapy and physical therapy and participating well. Review of a nursing progress note dated June 22, 2020 at 2:21 p.m. stated that the nurse called the medical center to request an update on the resident. The note stated that the resident had been transferred and admitted to a geropsychiatric facility until the resident's condition stabilized. Review of the clinical record revealed the resident was readmitted to the facility on [DATE]. A nursing progress note dated July 8, 2020 at 1:10 p.m. stated that per the report obtained from the geropsychiatric nurse, the resident had improved since being admitted to the facility. The resident had been getting out of bed every day, eating meals, ambulating with a front walker, and had been on a regular toileting schedule which had improved some of her skin conditions. In addition, the note stated that the resident had some medication adjustments while at the center. Review of physician's orders dated July 8, 2020 included for duloxetine HCl (antidepressant) capsule delayed release sprinkle 30 milligrams (mg) every evening related to other specified depressive episodes, and lorazepam (anxiolytic) 0.5 mg three times a day for anxiety related to anxiety disorder, unspecified. Additionally, an order revealed for twice daily documentation of signs and symptoms of schizophrenia including yelling at staff, hitting, refusing care, or delusional ideas; signs or symptoms of depression including self-isolation and tearful episodes; adverse reactions to antipsychotic, anxiolytic, and antidepressant medications including dizziness, weight, drowsiness, weakness, headache, unusual bleeding, or jaundice; and non-pharmacological approaches including therapeutic communication, music therapy, and going for a walk two times a day. A review of a care plan initiated on July 9, 2020 revealed the resident had a behavior symptom related to schizophrenia/schizoaffective disorder, depression as evidenced by delusional thoughts regarding how the resident receives no care and assistance and then becoming so depressed that the resident does not want to eat, drink, get out of bed, and experienced acute ADL (activities of daily living) functional decline. The goal was that the resident would have fewer episodes of behaviors. Interventions included providing reassurance and encouragement. Interventions included to discuss with health care provider and family regarding the on-going need for use of medication. A PASRR Level I Screening Document dated July 28, 2020 revealed the resident had serious mental illnesses that included schizophrenia, major depression, and psychotic/delusional disorder. The screening document additionally revealed the resident had an anxiety disorder and that the symptoms related to adapting to change included hallucinations, excessive irritability, and physical threats (with no potential for harm), and that within the past two years, the resident had an inpatient psychiatric hospitalization. The document indicated that the resident had a diagnosis of dementia, but it was not a primary diagnosis. The document stated that the resident did not meet the criteria for respite admission for up to 30 days, and that she did not meet the criteria for nursing facility approval as a result of terminal state or severe illness. However, the document concluded that no referral was necessary for any Level II. The document was signed by a Registered Nurse (RN/staff #29). Attempts were made to conduct an interview with staff #29 on June 24, 2021 but were unsuccessful because staff #29 was unavailable. An interview was conducted on June 24, 2021 at 2:20 p.m. with the Social Services Director (staff #46). She stated that it is her responsibility to obtain and/or complete the PASRR screenings. She stated that she asked the nurse case manager (staff #29) to sign off on it after completion, just to make sure she had filled it out correctly. She stated that was why the nurse had signed the document. She reviewed the resident's PASRR screening dated July 28, 2020 and stated that a PASRR Level II screening was definitely something that Social Services should have put into place, especially since the resident has a primary diagnosis of schizophrenia. She stated that to her knowledge, the resident has never been assessed by a psychiatrist. She stated that she would definitely say that PASRR Level II services, including counselling, should have been implemented into the resident's plan of care. On June 24, 2021 at 3:08 p.m., an interview was conducted with the Director of Nursing (DON/staff #8). She stated that a PASRR screening should be completed before the resident is admitted to the facility. She stated that Social Services is responsible to collect that information from the hospital prior to the resident's admission, or provide the evaluation upon admission. The DON stated that it was her expectation that the Director of Social Services complete the PASRR evaluation. She stated that having a nurse complete the PASRR did not meet her expectations. The DON stated that she really did not know too much about the PASRR process or to whom the screening documentation should be sent. The DON stated that as long as it was well-managed, the facility may safely care for individuals with SMI/level II designation. The DON stated that a counselor sees residents, such as resident #14, and those appointments do not require a referral. She stated that the counselor communicates with the provider. The DON stated that in 2017, she remembered she felt like the resident needed to be evaluated by specialists because she felt like the facility was failing the resident. She stated that the resident went to a geropsychiatric consultation for about a week sometime later. She stated that when the resident came back, she had been prescribed serious amounts of Seroquel (antipsychotic) and that she did not know whether that was such a good thing either. Review of the Facility Assessment revised July 2020 revealed that the facility does not accept referrals for residents who are screened as Level II PASRR from referral sources, and that if a resident begins to show signs that they need specialized care that would involve Level II PASRR-type services, the facility would arrange an outside consultation and initiate transfer planning per policy and procedure to ensure a resident's individual needs can be met if they cannot be met at the facility any longer. Together with consultation sources/outside organizations, the facility works to identify the best plan to ensure resident needs, quality of care, and quality of life can be met and sustained. The facility policy titled Pre-admission Screening and Resident Review (PASARR) reviewed/revised December 21, 2020 stated its purpose is to determine admission criteria for residents with mental illness and/or mental retardation and to ensure that individuals with retardation, serious mental disorder or intellectual disability receive the care and services they need in the most appropriate setting. The policy stated that an individual is considered to have a serious mental disorder if the individual meets the following requirements on diagnosis, level of impairment, and duration of illness: the individual has a major mental disorder diagnosable under the Diagnostic and Statistical Manual of Mental Disorders which included schizophrenic, mood, paranoid, panic, or other severe anxiety disorder, somatoform disorder, personality disorder, or other mental disorder that may lead to chronic disability but not a primary diagnosis of dementia, including Alzheimer's disease or related disorder or a non-primary diagnosis of dementia, unless the primary diagnosis is a major mental disorder. The procedure included that the social worker will ensure that the PASARR Level I screening has been completed before or at the time of admission. Level I screening will be reviewed to determine whether a Level II screening is required. The Level II screening is conducted by the agency designated by the State to determine whether the prospective resident requires the level of services provided by the location or whether the individual requires specialized services. If a Level II screening is required and was not completed before admission, the location may be denied payment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #10 was admitted on [DATE] with diagnoses that included peripheral vascular disease, vascular parkinsonism, and vascular dementia. Review of the clinical record revealed physician orders dated 05/05/2021 for Santyl ointment 250 unit/gram to be applied to the right first, second, and fifth toe topically every day shift every Wednesday and Saturday for trauma wounds. Cleanse with normal saline, apply Santyl ointment to wound beds, followed by hydrophobic microbe binding dressing with hydrogel cut to fit wound areas, pad toes with extra gauze then wrap with kerlix and secure with Coban. A quarterly MDS assessment dated [DATE] included a BIMS score of 10, indicating the resident had moderate cognitive impairment. The MDS assessment also included that there was an application of ointments and dressing to the feet. Review of the Treatment Administration Record (TAR) for 06/2021 revealed the application of ointment and wrappings were recorded as completed on Wednesdays and Saturdays. However, review of the care plan did not reveal a care plan had been developed for the resident's skin care and treatment to the feet. During observations conducted on 6/21/2021 at 09:15 AM and 12:19 AM, and on 6/22/2021 at 10:14 AM, the resident was observed with wraps on the legs and feet. On 6/24/2021 at 10:45 AM, an interview was conducted with the DON (staff #8). She stated that the care plan is a guidance for person centered care that is specific for each resident. The DON stated the MDS Coordinator (staff #58) is responsible for the MDS assessment and the care plan. She stated information is gathered by review of the clinical record and by talking to people. Staff #8 stated that if a care area is not in the care plan, there is a possibility the resident would not receive the correct care. The DON stated that the skin care for resident #10 should have been included in the care plan. The facility's policy regarding care plans reviewed/revised 10/16/202 stated that the comprehensive care plan includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Each resident will have an individualized, person-centered, comprehensive plan of care. The care plan will emphasize the care and development of the whole person ensuring that the resident will receive appropriate care and services. The policy also stated that the care plan will address the relationship of items or services required and facility responsibility for providing those services. Residents will receive and be provided the necessary care and services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment. Based on clinical record reviews, observations, resident and staff interviews, and review of policy and procedure, the facility failed to ensure a care plan was developed for one resident (#41) related to edema, for one resident (#47) related to anticoagulant use, and for one resident (#10) related to skin condition/treatment. The sample size was 15. The lack of care plan development has the potential for staff to be unaware of the residents identified problems, how care and services are to be delivered, and the staff who are responsible to provide the necessary care and services. Findings include: -Resident #41 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, dementia, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated that the resident had intact cognition. Observation of the resident were conducted at the following times: -June 21, 2021 at 11:39 a.m. Both of the resident's legs and feet were observed to be edematous. The resident's legs were observed to be in a dependent position, bent at the knee, and resting on the wheel chair foot rests. The foot rest were not elevated and no use of compression stockings was observed. -June 23, 2021 at 2:17 p.m. The resident was observed in the beauty shop. Unable to visualize the resident's legs at this time. The resident's legs were observed to be in a dependent position, bent at the knee, and resting on the wheel chair foot rests. The foot rest were not elevated. -June 23, 2021 at 2:24 p.m. The lower portion of the resident's legs were observed to have bilateral lower leg edema. The resident stated that she did not realize that her legs had edema/were puffy. She stated that she did not do anything to decrease the puffiness including elevating her legs. The resident's legs were observed to be in a dependent position, bent at the knee, and resting on the wheel chair foot rests. The foot rests were not elevated and no use of compression stockings was observed. -June 24, 2021 at 9:08 a.m. The observation was conducted in the resident's room. The resident was in the wheelchair sitting at the bedside table. The observation revealed that the resident's bilateral lower legs/ankles continued to be edematous. The foot rest were not elevated and no use of compression stockings was observed. Review of the current care plan did not reveal a care plan had been developed to address the resident's edema. An interview was conducted with a Registered Nurse (RN/staff #29) on June 24, 2021 at 12:55 p.m., who stated that resident #41 had edema bilaterally to the lower extremities that started after the beginning of this year when the resident had a weight gain. After reviewing the resident's care plan, the RN stated that there was no care plan related to the resident's edema. The RN also stated that the facility expectations were not met related to care planning of a resident with edema. An interview was conducted on June 24, 2021 at 1:50 p.m. with the Director of Nursing (DON/staff #8). The DON stated that she would expect ongoing edema to be on the care plan with interventions. -Resident #47 was admitted to the facility on [DATE] with diagnosis that included atrial fibrillation, presence of cardiac pacemaker, embolism and thrombosis of arteries of the lower extremities, and vascular dementia. Review of a physician's order dated December 11, 2020 revealed for Apixaban (anticoagulant) tablet 2.5 milligrams (mg) by mouth two times a day related to unspecified atrial fibrillation. Review of an annual MDS assessment dated [DATE] revealed the resident received 7 days of an anticoagulant medication. A quarterly MDS assessment dated [DATE] revealed the resident received 7 days of an anticoagulant medication. Review of the current care plan did not reveal a care plan for the anticoagulant medication use. An interview was conducted with a RN (staff #16) on June 24, 2021 at 11:44 a.m., who stated that high risk medications, including anticoagulants, should be on the care plan. The RN stated that it was important for an anticoagulant to be on the care plan so that staff could give better care, know the things to watch for and monitor for. She stated the goal would be for the resident to have a good outcome. The nurse reviewed the care plan for resident #47 and confirmed there was no care plan developed for the use of the anticoagulant medication. In an interview conducted with the DON (staff #8) on June 24, 2021 at 1:46 p.m., the DON stated that she expected high risk medications, including anticoagulants, to have a care plan. She stated that the care planning would be important so that staff would know what they needed to monitor for related to the use of an anticoagulation medication. The DON reviewed the clinical record for resident #47 and stated that there was no care plan for the anticoagulant use.

Based on observation, staff and resident interviews, facility documentation and policy and procedure, the facility failed to ensure sufficient staff were available on a 24-hour basis to provide nursing care to residents in a timely manner. The facility census was 52. The deficient practice resulted in residents needs not being met timely. Findings include: During the initial phase of the survey, 5 out of 15 sampled residents identified concerns of not having enough staff as they had to wait anywhere from 30 minutes to over 2 or more hours for call lights to be responded to, on no specific shifts, resulting in incontinence, undue pain, and residents becoming agitated due to the long call light response times. Another concern mentioned was that residents who required assistance with meals were not being fed in a timely manner. As a result, the facility's staffing documentation and a random selection of payroll records were reviewed and included the following: June 5, 2021: there were 3.5 Certified Nursing Assistants (CNAs) who worked the day shift and the resident census was 52. June 11, 2021: there was a cumulative total of 3 CNAs who worked partial hours on the evening shift and the resident census was 51. June 17, 2021: there were 2 CNAs who worked the night shift and the resident census was 52. On June 21, 2021 at 1:02 p.m., a dining observation was conducted on the secured dementia unit (SCU). 7 residents were seated in the assisted dining area. A Certified Nursing Assistant (CNA/staff #35) was observed as she assisted one of the residents with her meal. After providing multiple bites of food to the resident, staff #35 abruptly got up from the table and walked across the dining room to assist another resident. Within several minutes, staff #35 returned to the first resident and attempted to resume feeding her. The resident refused the next bite. After a great deal of encouragement, the resident resumed her meal. However, staff #35 got up a second time to assist a different resident. When she returned to the table to assist the first resident again, the resident refused to eat. The resident ate about 25-50% of her meal. An interview was conducted with the CNA (staff #35) on June 21, 2021 at 1:17 p.m. She stated that usually there are 2 staff assisting with meals, and that sometimes one of the activities staff comes to assist when she is there alone. The CNA stated that frequently there are not enough staff to assist the residents with their meals, but that they do their best. On June 23, 2021 at 8:07 a.m., an interview was conducted with a Registered Nurse (RN/staff #31). She stated that officially, the main dining room is available at 6:30 a.m. She stated that residents that need assistance usually eat at about 8:00 - 8:30 a.m. The RN stated that staffing has been worse since the pandemic and that there are no paid feeding assistants. She stated that the more independent residents are able to get up and walk down to breakfast and the residents that need assistance with eating must wait until all the residents are up and in the dining room before they will be assisted. She stated that on that date there was one CNA per main hall (100 hall and 300 hall) and one float. The RN stated that on the secured unit, there was one nurse and one CNA. She said that in addition, the staffing coordinator who was also a CNA, was assisting with breakfast. An interview was conducted on June 23, 2021 at 11:45 a.m. with the Director of Nursing (DON/staff #8). She stated that her goal will always be to staff at 3.91 hours Per Patient Day (PPD) (Hours divided by census = labor per diem). The DON reviewed the facility Nursing Department PPD for May 23, 2021 through June 19, 2021 and stated that all the last numbers in the PPD column reflected less than 3.91, indicated that there was less staff during that time period. On June 23, 2021 at 1:38 p.m., an interview was conducted with the Restorative Nurse (staff #16). She stated that there has been a shortage of staff, and that it was not because they were picky about who they hire, there was just no one to hire. She stated that the time she spends helping out on the floor is time she could be doing restorative care. Staff #16 stated that restorative care should be available to the residents on a full-time basis. She stated that on most days she conducts an exercise class in the day room and that she tries to invite as many residents as she can. Staff #16 stated that nurses help out when there is only one CNA on the floor. She stated direct resident care is what is most important. An interview was conducted on June 23, 2021 at 2:14 p.m. with the Staffing Coordinator (staff #22). She stated that the facility has had an exodus of staff over the past few months and that they have been struggling for about 3 months. She stated that ideally, at the current census, staffing for days and evenings would include 5 CNAs for each shift: 2 CNAs on the SCU (for 12 residents), and 3 CNAs on the other two main units - one on each hall and a floater. Staff #22 stated that each of the other two main units (100 hall and 300 hall) had an average of 19-20 residents on them. In addition, she stated there should be one nurse on each cart - 3 total. She said that the night shift should be staffed with at least 3 CNAs and 2 nurses. Staff #22 stated that the CNAs utilize teamwork to accomplish their tasks. She stated that when there are only 2 CNAs, they try to get the showers done before breakfast. Staff #22 stated they are all sort of rising to the occasion to do the best that they can do to make sure the residents' needs are met. On June 23, 2021 at 3:01 p.m., an interview was conducted with a CNA (staff #62). She stated that she was assigned 19 residents that day. She stated that sometimes there was a CNA that floated between the two main units to help care for residents. She stated that the other unit also had 19 residents assigned to 1 CNA. She stated that the administrative staff help out sometimes. The CNA stated that she had a lot of residents that require lifts on hall 100, including 4 total lifts and 6 sit - to-stands. She stated that there were a lot of lifts to do by herself and that she has become comfortable using the Hoyer lift alone. She stated that she knows she is not supposed to, but when there are only 2 CNAs caring for 38 or 39 residents and no one else is around, she does not know what else to do. The CNA stated that if there were 2 CNAs on the night shift, they would help get residents up in the morning. The CNA also stated there was only one CNA working the night shift for at least 2 out of every 3 days that she works. Regarding meals, she stated that every one of the residents must be at the table before anyone gets served. She stated that she assists 9 residents at her table and the residents are used to it. The CNA stated that the residents at her table do not receive drinks before they eat breakfast. She stated safety for everyone was her concern regarding lack of staffing. The CNA stated she can keep up with toileting, but not really with showers. She stated that they have been short-staffed for quite a while, including before the pandemic. An interview was conducted on June 24, 2021 at 1:46 p.m. with the facility administrator (staff #54). She stated that she was responsible to update the facility assessment and that she updated it July 29, 2020. She stated that the purpose of the facility assessment was to evaluate the resident population and the necessary resources to provide care and services. The administrator reviewed the facility assessment and stated that the term resources included personnel (managers and staff). She stated that the assessment did not specifically include a number, or staff to resident ratio. She stated that if she had included numbers in the assessment she could be cited if her staffing levels were lower. Staff #54 stated that her first line of defense in addressing the staffing issues in the facility was to utilize agency. Staff #54 stated she began using agency staff in January 2021, but that she had not reached out to the county or the state for assistance. Review of the Facility Assessment revealed: -34 residents required extensive assistance with bed mobility; 17 required 2+ person physical assistance; and 5 were totally dependent. -27 residents required extensive assistance with transfers; 14 required 2+ person physical assistance; and 7 were totally dependent. -7 residents required extensive assistance with eating; 24 required 1-person assistance; 35 required supervision; and 3 were totally dependent. -35 residents required extensive assistance with toileting; 10 required 2+ person physical assistance; and 5 were totally dependent. -34 residents required extensive assistance with personal hygiene; 2 required 2+ person physical assistance: and 5 were totally dependent. The facility's policy titled Nursing Services Staff - Rehab/Skilled revised/reviewed May 27, 2021 stated the purpose was to provide appropriate staff for resident care in the nursing services department. The policy stated the facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, observations, staff interviews, and review of policy and procedure, the facility failed to ensure two of five sampled residents (#40 and #47) receiving psychotropic medications had consistent evidence of behavioral interventions, monitoring for side effects/adverse effects, identification and monitoring of target mood/behaviors, and/or non-pharmacological approaches. The deficient practice could result in a lack of identifying if targeted symptoms were improving or declining and residents experiencing possible adverse consequences. Findings include: -Resident #40 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, depressive episodes, adult failure to thrive, and dementia. Review of an Abnormal Involuntary Movement Scale (AIMS) dated December 28, 2018 revealed that the resident had no abnormal movements. Additional review of the clinical record revealed no evidence of another AIMS test completed for the resident. Review of the physician's orders revealed an order dated September 25, 2020 for Escitalopram Oxalate (antidepressant) 5 milligrams (mg) 1 tablet by mouth in the morning for depression, apathy, and anorexia. Continued review of the physician orders did not reveal orders to monitor for adverse medication side effect, target mood/behaviors, or non-medication interventions related to the antidepressant use. Review of the care plan initiated on September 28, 2020 revealed the resident used antidepressant medication related to depression and anorexia. The goal was that the resident would show decreased episodes of signs/symptoms of depression and be free from discomfort or adverse reactions related to antidepressant therapy. Interventions included reporting to the nurse the following signs and symptoms: confusion, mood change, change in normal behavior, hallucinations/delusions, social isolation, suicidal ideations, withdrawal, decline in ability to help with/do ADLs (activities of daily living), continence, cognitive functions, constipation, fecal impaction, no voiding, shuffle gait, rigid muscles, difficulty ambulating, balance problems, accidents, dizziness/vertigo, falls, movement problems, tremors, diarrhea, fatigue, insomnia, appetite loss, weight loss, muscle [NAME], or nausea/vomiting and to monitor the resident's condition based on clinical practice guidelines or clinical standards of practice related to the use of Escitalopram. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of zero which indicated severely impaired cognition. The assessment also revealed the resident was moving or speaking so slowly that other people could have noticed, or the opposite, being so fidgety or restless that the resident was moving around a lot more than usual for 12-14 days over the two weeks look back period. The assessment included the resident received 7 days of an antidepressant medication. Review of the Medication Administration Records (MAR) for April 2021, May 2021, and June 2021 revealed the resident received Escitalopram daily as ordered. Further review of the clinical record including these MARs and the Treatment Administration Records (TAR) for April 2021, May 2021, and June 2021, did not reveal documentation of monitoring for adverse medication side effect, target mood/behaviors, or non-medication interventions related to the antidepressant use. Multiple random observations conducted on different dates and times of the resident sitting in the wheelchair revealed the following: -On June 21, 2021 at 2:51 p.m., the resident was observed with the right hand on the right thigh exhibiting a continuous rolling motion of the thumb and forefinger of the right hand; -On June 22, 2021 at 3:27 p.m., the resident was observed the left hand over the right with the left thumb consistently stroking the dorsal part of the right middle finger. The left arm was observed to have a tremor-like movement that occurred intermittently.; -On June 23, 2021 at 7:30 a.m., the resident was observed with a continuous subtle rolling motion of the thumb and forefinger of the right hand; and a continuous pinching movement on the right arm by the left hand.; and, -On June 23, 2021 at 9:40 a.m., the resident was observed exhibiting a continuous light pinching movement on the right arm using the left hand. An interview was conducted with a Registered Nurse (RN/staff #26) on June 24, 2021 at 10:40 a.m., who stated that when a resident is on a psychotropic medication, staff chart behaviors every day. She stated that before administering the drug, she would make sure the resident did not have any side effects from the medication. She stated that she would look for behaviors (i.e. crying, sleeping a lot, anger issues). Staff #26 stated that for some residents she would use music therapy or therapeutic education. The RN stated that the monitoring of behaviors, side effects, and interventions was done every shift and documented with initials on the MAR and a progress note. The RN stated that an antidepressant is a psychotropic medication and monitoring was required. The nurse reviewed the clinical record for resident #40 and stated there was no monitoring being done and that it would need to be added. The RN stated that if monitoring was not being done, the risk would be that staff could miss something, especially side effects. The RN stated that she had observed an occasional pill rolling movement for resident #40 but that she had not documented or notified the doctor of the potential abnormal movement. An interview was conducted on June 24, 2021 at 1:35 p.m. with the Director of Nursing (DON/staff #8). She stated that, for a resident receiving a psychotropic medication, there should be ongoing documentation in the electronic MAR each shift. She stated that a resident receiving a psychotropic medication should have an order for daily documentation including adverse side effects and behaviors. She stated she would also like the staff to include therapeutic interventions. On review of the clinical record for resident #40, she stated that the resident did not have monitoring for side effects/target behavior/intervention. She stated that the risk was that the facility could be giving an unnecessary medication, not enough medication to treat the resident, and/or the facility may not be managing the resident's signs and symptoms properly. -Resident #47 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, vascular dementia, depressive episodes, and bipolar disorder. A physician order dated February 28, 2020 included to document signs and symptoms of depression: somnolence, refusal of care, decreased appetite. Monitor for adverse reactions: Duloxetine (depression): dry mouth, loss of appetite. Mirtazapine (depression as evidenced by poor appetite) dizziness, drowsiness, headache, insomnia, nervousness, diarrhea. Depakote/Divalproex Sodium (bipolar disorder) nausea and vomiting, drowsiness, weight gain, weakness. Non-pharmaceutical approaches: Therapeutic communication, music therapy, watching old movies, two times a day for depression. This order was transcribed onto the MARs and TARs. Continued review of the physician's orders revealed the following: -An order dated December 21, 2020 for Divalproex Sodium (anticonvulsant) delayed release sprinkle 125 mg give 1 capsule by mouth two times a day for bi-polar disorder. -An order dated March 2, 2021 for Mirtazapine (antidepressant) 15 mg give 1 tablet by mouth at bedtime for depression as manifested by lack of appetite/weight loss. -An order dated March 3, 2021 for Duloxetine Hydrochloride (antidepressant) delayed release sprinkle 30 mg give 1 capsule by mouth in the morning for depression with pain. However, the order did not include a specific target behavior(s) for the Duloxetine or Depakote use. Review of an annual MDS assessment dated [DATE] revealed a BIMS score of 2 which indicated the resident's cognition was severely impaired. The assessment included that in the two weeks look back period, the resident exhibited feeling down, depressed, or hopeless 2-6 days; and moving or speaking so slowly that other people could have noticed, or the opposite, being so fidgety or restless that the resident had been moving around a lot more than usual for 12-14 days. The assessment included that the resident received daily antidepressant medication. Review of the MARs/TARs for March 2021, April 2021, May 2021, and June 2021 revealed the resident received Duloxetine, Mirtazapine, and Divalproex Sodium. The documentation on the MARs included responses of +, -, and N/A without the included information to define what the symbols indicate such as whether it was the target behavior or a side effect. The documentation also did not differentiate between side effects and behaviors; the number of episodes exhibited and, did not indicate whether non-pharmacological approaches were attempted or administered related to the psychotropic medication use. Review of a quarterly MDS assessment dated [DATE] revealed a BIMS score of 7 which indicated the resident's cognition was severely impaired. The assessment included that in the two weeks look back period, the resident exhibited little interest or pleasure in doing things 2-6 days; trouble concentrating on things and moving or speaking so slowly that other people could have noticed, or the opposite, being so fidgety or restless that the resident had been moving around a lot more than usual for 12-14 days. The assessment also included the resident received daily antidepressant medication. Review of the nursing progress notes from March 1, 2021 through June 24, 2021 included inconsistent documentation of behaviors such as wandering, exit seeking, hallucinations, anxiety, agitation, and restlessness, which were not indicated as the target behaviors for the prescribed medications. The target behavior of poor appetite was not consistently documented on. The notes describing behaviors did not consistently include non-pharmacological approaches. There was not a progress note for every day/every shift regarding the antidepressant use/monitoring; in some instances where a + sign was indicated in the MAR, the corresponding progress note for that day did not document any behaviors and/or side effect; and in some instances where a - or N/A was indicated the note contained behavior documentation. An interview was conducted with a RN (staff #16) on June 24, 2021 at 11:44 a.m. She stated that for a resident receiving psychotropic medication there would be documentation each shift on the MAR for mood/behavior, side effects, and therapeutic interventions based on the medication being administered. The RN stated that they conduct meetings once a month where they review psychotropic medication and discuss regular dose reductions and that sometimes the pharmacist is at the meeting and will discuss dose reduction with them. Staff #16 stated that if she thought the mood/behavior/side effect concern was significant, she would document a mood/behavior note in the progress notes. The RN stated that if the entry on the MAR included a + sign, the reader should be able to see what the plus sign meant, and what intervention was done by facility staff in response to the plus sign, by looking in the progress notes. An interview was conducted with the DON (staff #8) on June 24, 2021 at 1:35 p.m. She stated that staff would document on the MAR each shift for residents that were receiving psychotropic medications. She stated that the + sign meant to her that the medication(s) was effective. She stated that she would also write a progress note on how the resident was doing that day. She stated that she did not know why any staff would write N/A. She stated that if the nurse marked something on the MAR there should be a note explaining why they marked it and how they responded. She stated she expected that there would be a note relating to the psychotropic medication use every shift/every day in the progress notes, especially if the resident was on more than one medication. Review of the facility policy for psychotropic medications revealed: The purpose is to evaluate behavior interventions and alternatives before using psychotropic medications and to eliminate unnecessary psychotropic medications. The definition of behavioral interventions was: Individualized non-pharmacological approaches that are provided as part of a supportive physical and psychosocial environment and are directed toward understanding, preventing, relieving and/or accommodating a resident's distress or loss of abilities, as well as maintaining or improving a resident's mental, physical, or psychosocial well-being. The definition of psychotropic medication was: Any drug that affects brain activities associated with mental processes and behavior. There drugs include, but are not limited to, drugs in the following categories: anti-psychotic; anti-depressant; anti-anxiety; and hypnotic. Each resident's drug regime must be free from unnecessary drugs. An unnecessary drug is any drug when used: in excessive does including duplicate drug therapy; for excessive duration; without adequate monitoring; without adequate indications for its use; and in the presence of adverse consequences that indicate the dose should be reduced or discontinued. Throughout the administration of the psychotropic medications, the following must be completed: Mood and behavior documentation must continue in order to indicate the effect the medication has on the behavior; Monitor for side effects of the medication. If a side effect occurs or worsening of a known side effect is noted, the nurse will make a note in the progress notes-Psychopharmacological medication/physical restraint in the electronic medical record and notify the physician and family/legal representative of this change in condition; monitor for effectiveness and potential adverse side consequences; the reduction committee will review the need for psychotropic medications at least every three months and document the rationale for continuing the medication. The committee also will need to evaluate: The resident's target symptoms and the effect of the mediation on the severity, frequency, and other characteristics; whether the resident experienced any medication-related adverse consequences during the previous quarter. Non-pharmacological interventions are recommended before medication interventions, attempt should be documented in the resident care record.