Based on observations, interviews, facility record review, it was determined that the facility failed to provide privacy during care for 1 (Resident #62) of 1 resident reviewed for privacy. Findings include: A review of the facility admission packet including the Resident Handbook, which provided the Arkansas Patient Rights Section 9, signed by the Resident #62 and admission Director #5 on 07/20/2024, indicated, residents have the right to have privacy in treatment. A review of the admission Record, indicated the facility admitted Resident #62 with diagnoses that included bacteremia and sepsis. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/24/2024, revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. During an observation and interview on 08/20/2024 at 2:28 PM, the Assistant Director of Nursing (ADON) entered Resident #62's room to perform a peripherally inserted central catheter (PICC) line dressing change. Resident #62's roommate with two family members were also in the room, all had direct line of sight to Resident #62 and the ADON during the procedure. The ADON failed to pull the room's curtain or ask Resident #62 if the resident was comfortable with spectators during the procedure. During the sterile part of the dressing change the ADON looked at the curtain divider and stated they should have pulled the curtain before performing the procedure.

Based on observation, record review, and interview, it was determined the facility failed to ensure physician orders were followed for 1 (Resident #62) of 1 resident observed receiving medications from 1 (Licensed Practical Nurse (LPN) #9) of 3 nurses observed during medication pass. Findings include: A review of a facility in-service titled, 7 Rights of medication Administration, dated 08/15/2024, indicated, Must Check All Before Administering Any Medication: 1. Right Resident 2. Right Medication 3. Right Dose 4. Right Route 5. Right Time 6. Right Documentation 7. Right Reason. A review of the admission Record, indicated the facility admitted Resident #62 with diagnoses that included local infection of the skin and subcutaneous tissue of the right toe. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/24/2024, revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact and had an infection of the right toe and was receiving an antibiotic by intravenous (IV) route. A review of Resident #62's Care Plan, revised 07/24/2024, revealed the resident had IV (intravenous) medication (an antibiotic) related to an infection of the right great toe. Interventions included administering an antibiotic per MD (medical doctor) orders, an Inservice of nursing staff on 08/15/2924 due to resident receiving the wrong medication by IV. A review of the Order Summary, revealed Resident #62 had an antibiotic being administered through a peripherally inserted central catheter (PICC) line (an access used for different medical purposes such as delivering fluids containing medications into a person's vein), a saline flush intravenous solution, Flush PICC line with 10cc (cubic centimeters) normal saline (NS) before and after IV medication administration, and a standing order for the SASH (saline, antibiotic, saline, heparin) protocol was to be followed with IV administration of antibiotic, 10cc / administer medication/Saline 10cc/heparin 5cc. A review of the Standing Orders [Named Medical Doctor]as of 08/07/2024, indicated the SASH protocol was to be used for PICC lines with medication administration. SASH protocol included 10cc NS, medication administration, 10cc NS, and 5cc Heparin. During an observation on 08/21/2024 at 5:08 AM, LPN #9 entered Resident #62's room to administer an antibiotic. LPN #9 attached a 10cc syringe containing Normal Saline, to the PICC line, located in the resident's right arm, and administered a portion of the saline. LPN #9 attached the antibiotic to the PICC line and infused the antibiotic using a medication pump. LPN #9 stated 8 and a half milliliters (ml) of normal saline was placed in the IV line prior to starting the antibiotic. [Milliliters and cubic centimeters are the same measurement or volume of a substance and wording is interchangeable] During an observation on 08/21/2024 at 6:04 AM, LPN #9 returned to Resident #62's room, turned off the medication pump and removed IV medication line from PICC line, attached a 10cc syringe containing 10ml of NS flush to the PICC line and administered a portion of the fluid. LPN #9 removed the NS syringe and attached a syringe containing 5ml of Heparin lock to the PICC line and administered the heparin. LPN #9 was asked how much NS flush was used and stated 7ml and 5ml of Heparin. During an interview on 8/21/2024 at 7:54 AM, LPN #9 was asked how much NS is ordered to flush the PICC line prior to administering Resident #62's antibiotic. LPN #9 stated 10ml and only 8 and a half was used. LPN #9 was asked how much NS is ordered to flush the PICC line after administering the antibiotic. LPN #9 stated 10ml and 7ml was used. LPN #9 stated 10ml should have been used both times because that is what the doctor ordered, and physicians orders should be followed because the NS is used to flush all the medication from the line to ensure the resident receives all the medication. During an interview on 08/22/2024 at 12:46 PM, the Director of Nursing (DON) stated staff should follow physician orders for flushing a resident's PICC line because it is in the best interest of the patient. If it is not done it could cause a decline in the resident's health.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure staff performed hand hygiene during meal assistance; failed to utilize Enhanced Barrier Precautions (EBP), to maintain sterile and aseptic technique during a dressing removal and failed to maintain aseptic technique for IV tubing, specifically no cap was in place on the tubing to maintain a barrier from contamination for 1 (Resident #62) of 1 resident reviewed for dressing change. Findings include: 1. A review of a facility in-service titled, 400 Hall Certified Nursing Assistant (CNA) Meal Service, dated 08/16/2024, indicated, 1. Keep staff hands from crossing over cups/bowls (inf control). A review of Resident #26's Care Plan, revised on 05/28/2024, revealed the resident had an activity of daily living (ADL) related to muscle loss and had a potential for fluid deficit related to confusion. Interventions included providing care and assistance as needed and encouraging resident to drink fluids. During an observation on 08/19/2024 at 1:20 PM, CNA) #7 was sitting on a stool on the right side of Resident #26. CNA #7 grasped the rim of Resident #26's cup of water, by placing their index finger inside the cup and their thumb on the outside of the rim of the cup, pulled the cup toward the resident, then picked up the cup by placing their hand over the opening and their fingers around the top rim, and handed the cup to the resident, who drank from the cup. CNA #7 rested their hands on their lap, palms down. No hand hygiene was done during this observation. A review of Resident #68's Care Plan, revised on 05/07/2024, revealed the resident had an ADL self-care deficit related to generalized weakness and was dependent on staff to eat. Interventions included encouraging Resident #68 to participate to the extent possible. During an observation on 08/19/2024 at 1:26 PM, CNA #7 was sitting to left of Resident #68, lifted their hands above the table, from their lap and picked up a fork and placed chocolate pudding in Resident #68's mouth, returned the fork to the plate and picked up a biscuit and broke off piece with their hands and gave it to Resident #68 who took a bite. CNA #7 put their hands back in their lap, palms down. CNA #7 lifted hands from their lap, grasped the rim of a cup containing iced tea, by placing their hand over the opening of the cup with their fingers touching the rim, and assisted resident to drink from the cup. No hand hygiene was performed during this observation. A review of Resident #51's Care Plan, revised 03/13/2024, revealed the resident had a communication problem, had limited physical mobility, had the potential for a nutritional problem, had dehydration, had an ADL deficit and required assistance eating. Interventions included anticipating and meeting needs, encouraging resident to drink, setting up resident's meal, encouraging resident to eat, and encouraging resident to participate to the extent possible, On 08/19/2024 at 1:22 PM, CNA #8 was sitting to the right of Resident #51, grasped the resident's cup of water with the palm of their hand over the opening and their thumb, middle, ring and small finger grasping the rim of the cup and a straw was being held in place between their index finger the knuckle of their middle finger. Resident #51 drank from the straw. No hand sanitation was performed during this observation. During an interview on 08/19/2024 at 1:57 PM, CNA #7 stated they should not have grabbed the cup by the rim while assisting Resident #26 or Resident #68 and should not touch resident's food with their bare hands because it could cause germs to be passed to resident. CNA #7 stated they were used to doing that for their son and Just did not think about it and should have sanitized their hands between residents and did not do so because there was not enough sanitizer in the room. The sanitizing station was located on a wall in the assisted dining area. During an interview on 08/19/2024 at 2:18 PM, CNA #8 stated they should have sanitized hands prior to feeding Resident #51 after their hands were in their lap and should not have touched the rim of the cup and straw prior to providing a drink to the resident because something could have dropped into cup from their hands or germs on their hands could have gotten into resident's mouth and caused problems. During an interview on 08/22/2024 at 12:48 PM, the Director of Nursing (DON) stated some residents have compromised immune systems and staff should perform hand hygiene while assisting residents in the dining room, so they are not passing germs from one resident to another and making everyone sick. Staff should not be picking up cups by the rims or placing their fingers inside a resident's cup and giving it to the residents. They should be holding cup by the side (demonstrated on cup on their desk). The DON further stated contaminates on their hands could be transferred to the residents and you don't put your fingers where the resident places their lips. 2. A review of a facility policy titled, Enhanced Barrier Precautions, dated August 2022, indicated Enhanced Barrier Precautions (EBP) are used as an infection prevention and control intervention. Under EBP, gowns and gloves are used during high contact resident care like device care of a central line. A review of a facility policy titled, Center Venous Catheter Dressing Changes, revised April 2017, indicated central line dressings should be done every 5-7 days. Removal of the old dressing is an aseptic technique. A review of a facility policy titled. Guidelines for Preventing Intravenous Catheter-Related Infections, revised August 2014, indicated aseptic techniques should be observed at all times when working with intravenous (IV) equipment, IV administration set for IV medications should be discarded if found without a sterile cap at the end of the tubing. A review of the admission Record, indicated the facility admitted Resident #62 with diagnoses that included bacteremia and sepsis, and that Resident #62 was admitted with a peripherally inserted central catheter (PICC) line, a type of central venous catheter, for long term IV medication administration. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/24/2024, revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. A review of Resident #62's admission Care Plan, dated 08/08/2024, revealed the resident had an infection of the right great toe. Interventions included EBP and IV medication administration through the right upper arm peripherally inserted central catheter, (PICC) line. Care of the PICC line included weekly dressing changes. During an observation on 08/20/2024 at 1:06 PM, Resident #62's cefazolin IV tubing was seen hanging on the IV pole. The end of the tubing was left but open to air without a cap. Resident #62's right upper arm PICC line dressing was dated 08/06/2024. During an interview on 08/20/2024 at 1:08 PM Registered Nurse (RN) #1 did not know the date on Resident #62's PICC line dressing and didn't not know the policy for how often dressings were changed. After accessing the Medication Administration Record (MAR), RN #1 stated it was due on Tuesdays. RN #1 stated no knowledge of a policy for IV tubing care. During a concurrent observation and interview on 08/20/2024 at 2:28 PM, the Assistant Director of Nursing (ADON) prepared setup for Resident #62's PICC line dressing without putting on a gown as required when utilizing EBP. The ADON stated the date on the PICC line dressing was 08/06/2024 and should have been changed a week ago. The ADON used gloved hands and touched Resident #62's face when applying a mask but did not remove the dirty gloves or perform hand hygiene prior to removing the old PICC line dressing. The ADON's left dirty gloved hand touched the PICC line insertion site while the right dirty gloved hand pulled the old dressing off. The ADON stated the IV medication tubing should have a cap on it to reduce infection risk from exposure and it now needed to be thrown away.

Based on observations, interviews, facility document review, and facility policy review, the facility failed to write the open date on medications for 4 (Resident #5, #32, #33, and #35) and maintained pharmacy packaging of a medication card for 1(Resident #5) of 2 medication carts observed for medication labeling and storage standards. The facility also failed to maintain possession of medication cart/room keys with authorized personnel for all residents in the facility. Findings include: A review of a facility policy titled, Medication Labeling and Storage, revised in February of 2023, indicated medications should remain stored in the packaging it was received from the pharmacy, multi-dose medication should be dated with the date it was opened, and only authorized personnel should have access to keys. During an observation and interview on 08/21/2024 at 2:27 PM, Licensed Practical Nurse (LPN) #2 was asked to retrieve medication for labeling review from the 200-hall medication cart. On inspection of Resident #32's Anoro Ellipita 62.5-25mcg (microgram) inhaler, Resident #33's Symbicort inhaler, and Resident #35's bottle of liquid morphine there were no open dates written on those 3 items. LPN #2 stated all 3 medications had doses utilized from them and were currently in use. Resident #5's Citalopram 20mg (milligram) tab medication card was observed to no longer have intact pharmacy packaging for slots number 29 and 30 instead tape across the back of those slot was holding a pill in each slot. LPN #2 stated someone must have put them back in. During inspection of the medications a person in black scrubs told LPN #2 they needed in the medication room to check the refrigerator and LPN #2 gave the person the set of keys she had used to open the medication cart. The person in black scrubs was seen walking to the medication room, unlocking the door with the keys, and going in alone. The person returned in a couple of minutes and returned the keys to LPN #2. During an interview on 08/21/2024 at 2:55 PM, the Director of Nursing (DON) stated the facility utilized the 28-day rule with opened multi use medications and agreed without the open date written on the medication there would be no way to determine the proper time to throw the medication out. When asked about the pharmacy packaging of two slots on the citalopram medication card being opened and then the pill taped back in the Nurse Consultant #6 stated we have always done that. During a follow-up interview on 08/21/2024 at 3:49 PM, LPN #2 stated the person the key was given to was someone with lab. LPN #2 did not know the person's name, title, or who they worked for. When asked why the facility keys including the key for the medication carts and medication storeroom were handed over to the unidentified lab personnel, the response was it was the LPN #2's practice. During a follow-up interview on 08/21/2024 at 4:08 PM, the Director of Nursing (DON) stated the person in black scrubs was a phlebotomist from their contracted lab company. The DON stated they come in for lab draws and retrieve any specimens from the specimen refrigerator in the medication room, but should not be given the keys to let themselves in. The DON stated LPN #2 should have retrieved the specimens and brought them to the lab personnel and agreed giving the keys to unauthorized personnel was a security issue.

Deficiency Text Not Available

Based on observation, interview and record review, the facility failed to notify the Resident's representative of changes to medication for one (Resident #1) of three (Resident #1, #2, and #3) sampled residents. The findings are: Resident #1 with an admission date of 08/11/2024 had a diagnosis of Parkinson's disease. The admission Minimum Data Set [MDS] with an assessment reference date [ARD] of 8/18/23 documented a staff assessment of mental status [SAMS] of severely impaired. Physician Orders dated 08/11/2023 documented, Carbidopa Levodopa 25/250 mg [milligrams] take 3 tablets four times a day. A change made on 11/06/2023 showed, Carbidopa-Levodopa Oral Tablet 25-250 MG (Carbidopa-Levodopa) Give 2 tablet by mouth four times a day related to Parkinson's Disease . then on 12/08/2023 to, Carbidopa-Levodopa Oral Tablet 25-250 MG (Carbidopa-Levodopa) Give 1 tablet by mouth four times a day related to Parkinsonism for 7 Days, Decrease to 1 tablet four times a day [QID] x 7 days then discontinue .Amantadine HCl Oral Capsule 100 MGH. Give 1 capsule by mouth two times a day related to Parkinson's Disease give medication with breakfast and supper, which was changed to Amantadine HCl Oral Capsule 100 MG (Amantadine HCl) Give 1 capsule by mouth two times a day related to Parkinson's Disease . Interdisciplinary Team [IDT] progress note dated 12/07/2023 documented, .Current Care Plan [CP] Interventions and Effectiveness: Carbidopa-Levodopa decreased to one tablet QID (four times per day) x 7 days then dc (discontinue) . Physician Assistant-Certified [PA-C] #1 progress notes dated 09/05/23, documented, .Neurologic: Coordination and Cerebellum: Resting tremor . PA-C #2 progress notes dated 09/29/23 documented, .Neurologic: Coordination and Cerebellum: Resting tremor . PA-C #3 progress notes dated 10/23/2023 documented, .Neurologic: Coordination and Cerebellum: Resting tremor . PA-C #4 progress notes dated 11/08/2023, 11/17/2023 and 12/05/2023 documented, .Neurologic: Coordination and Cerebellum: Resting tremor . PA-C #4 progress notes dated 12/11/2023 documented.Assessment Plan; 1. Parkinsons disease- Per Behavioral Medicine rec: resume gradual dose reduction [GDR]: (carbidopa Levodopa) 25-200 mg 1 tablet QID x 1 week discontinue (carbidopa levodopa) in 7 days . Unable to locate documentation in Resident #1's medical chart of notification to representative or responsible party of dosage decrease of carbidopa levodopa with intent to discontinue. On 05/06/2024 at 3:30 PM Resident 1's relative was interviewed on the phone. Relative stated the family was never made aware of decreasing or stopping Parkinson's medications. Also, said when PA-C #4 was asked by another relative why the medications were being stopped they were told it was due to Resident #1 not having tremors. Relative stated they were concerned due to Resident #1 being on this medication for over 20 years and having a deep brain stimulator that helps control Resident #1's tremors. On 05/07/2024 at 11:20 AM, PA-C #4 was interviewed by phone, and confirmed being familiar with Resident #1 and thinks the carbidopa levodopa was being decreased due to resident having a neurostimulator, to reduce side effects and to prevent the use of unnecessary medications. On 05/07/2024 at 4:42 PM, surveyor spoke with the Primary Care Physician [PCP]/ Medical Director, who said Resident #1's record is being reviewed at that time and confirmed being familiar with Resident #1's tremors and shuffling gait walk which is indicative of Parkinson Disease. They were not aware of Resident #1 having a deep brain stimulator and did not have record of a medication decrease in carbidopa levodopa.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a complete surgical history was obtained and surgical diagnosis history forwarded from the pre-admission screen for one Resident #1 of three (Resident #1, #2 & #3) sampled resident. This failed practice had the potential to have an adverse effect on the resident due to medical staff not having all the information to make an informed decision concerning care. The findings are: The pre-admission screen completed on 08/10/2023 documented, .has deep brain stimulator . Review of the pre-admission screen document Resident #1 was admitted on [DATE] and had a diagnosis of Parkinson's disease. The admission Minimum Data Set [MDS] with an assessment reference date [ARD] of 8/18/23 documented a staff assessment of mental status [SAMS] of severely impaired. Under section J of the MDS (Health Conditions), under neurological surgery, Insertion or removal of spinal or brain neurostimulators, electrodes, catheters, or drainage devices question is marked no, indicating Resident does not have this device. Resident #1's Physician's orders date of 08/23/2023 showed, an order for Carbidopa- for Parkinson's disease with an order date of 08/23/2023. The medication order was changed on 11/06/2023 from 3 tablets four times a day to 2 tablets four times a day. The medication order was changed again on 12/07/2024 to give 1 tablet four times a day. Review of hospital discharge paperwork dated 11/31/2023 listed medication, .Carbadopa-Levodopa 25/250 MG 2 tabs QID (four times a day) . Review of the Provider Progress notes did not address the Carbidopa-Levodopa dosage decrease with the intent to discontinue nor was there any communication with resident's spouse. On 05/06/2024 at 3:30 PM, Resident #1's spouse was interviewed on the phone, and said the family was never made aware of decreasing or stopping Parkinson's medications, and were concerned about the medication adjustment, and that Resident #1 had a deep brain stimulator that was helping a lot with Parkinson's symptoms, but Resident #1 still needed the medication. The family member stated the fact that Resident #1 had a deep brain stimulator was in Resident #1's chart, that this helped control the tremors but that the medication was still needed. On 05/07/2024 at 11:20 AM, Certified Physician's Assistant (PA-C) #4 was interviewed by phone and confirmed being familiar with Resident #1 and thinks the carbidopa levodopa was being decreased due to resident having a neurostimulator, to reduce side effects and to prevent the use of unnecessary medications. On 05/07/2024 at 3:30 PM the surveyor interviewed Licensed Practical Nurse [LPN] #1, who worked the secure unit. The surveyor asked LPN #1 and she noticed Resident #1 having tremors. LPN #1 replied, Maybe a little. When asked if she was aware of Resident #1 having a deep brain stimulator to help control tremors, LPN #1 confirmed not being aware. The surveyor asked LPN #1 if Resident #1 was noted to have an increase in tremors with the decrease in carbidopa levodopa. LPN #1 said she did not notice an increase in tremors. During an interview on 05/07/2024 at 4:42 PM Primary Care Physician]/ Medical Director, confirmed Resident #1 had tremors and walked with a shuffling gait indicative of Parkinson Disease but was not aware of the Resident having a deep brain stimulator and did not have record of a medication decrease in Carbidopa levodopa.

Based on interview, and record review, the facility failed to ensure generally accepted accounting principles were followed to ensure insurance premiums were paid timely for 1 (Resident #42) of 3 (Residents #2, #22 and #42) sampled residents whose personal funds were reviewed. The failed practice had the potential to affect 32 residents with resident trusts managed by the facility per a list provided by the Business Office Manager (BOM) on 06/01/23 at 10:08 AM. The findings are: 1. Resident #42's Annual Transaction Report provided by the BOM on 06/01/23 at 10:17 AM documented Dental Insurance Premiums of $111 - paid 02/28/23, 03/10/23 and 04/14/23. The Facility Notification dated 12/14/22 revealed the amount owed to Resident #42's dental insurance was $222 per month for the months of November 2022, December 2022, and January 2023, and the Facility Notification dated 05/05/23 revealed the amount owed to Resident #42's dental insurance was $111 per month from November 2022 through June 2023. 2. On 06/01/23 at 12:01 PM, the Surveyor asked the BOM if Resident #42's premium had been paid for November 2022 through January 2023. The BOM stated, [Resident #42] cancelled her insurance premium in June 2022 and kept dental. We contacted DHS [Department of Human Services] and they finally changed her liability. I don't know if it goes back to November. After reviewing the DHS notice, the BOM stated, [Insurance Provider] ended in June 2022 and her [Dental Provider] started in November. The Surveyor asked if payment of those premiums had occurred or if DHS had been notified of the dental premium starting later. The BOM stated, No, because I had not realized that. Maybe it did and we need to go back and pay for those months. I don't know on that one. 3. On 06/01/23 at 1:58 PM, the Surveyor asked the BOM what possible outcomes could occur if a resident's insurance premium was not paid. The BOM stated, They would lose their insurance. 4. On 06/01/23 at 2:00 PM, the Surveyor asked the Administrator what possible outcomes could occur if a resident's insurance premium was not paid. The Administrator stated, They could lose their insurance. 5. On 06/01/23 at 2:48 PM, the Consultant stated, We did not get the adjusted insurance premium until this month. The Surveyor asked if the insurance premium amount on the DHS Facility Notification should have been billed for November forward until the correction was received. The Consultant stated, We knew it was wrong, so we did not bill it. 6. On 06/01/23 at 3:28 PM, the Consultant stated, It is a verbal agreement with [Dental Insurance]. Sorry, I wish I had something in writing, but I don't. 7. The facility policy titled, Patient Trust, provided by the Administrator on 06/01/23 at 3:38 PM documented, .1. Trust accounts are the facility responsibility to maintain .2. Accurate ledger balances and individual resident trust accounting must be maintained at all times . i. Trust Draft authorization . allows the facility to make recurring deductions from the patient's trust monies . 11. Each month, the Patient Trust checkbook and individual ledgers . are reconciled .

2. Resident #227 had diagnoses Acute Respiratory Failure with Hypoxia and Multiple Myeloma not having achieved Remission. a. The Physician Orders dated 05/18/23 documented Oxygen @ [at] 2L/Min [liters per minute] via nasal cannula as needed for Shortness of Breath 2 liters/min per Nasal Cannula PRN and every shift for Shortness of Breath . Clean CPAP machine and tubing ensure it has water in the morning . b. The Comprehensive Care Plan with an initiated date of 05/18/23 did not address oxygen therapy of CPAP care. c. On 06/02/23 at 7:50 AM, the Surveyor asked the MDS Coordinator to pull up the Care Plan for Resident #227 and explain the process for initiating the Baseline Care Plan and staff responsible for completing the Baseline Care Plan. The MDS Coordinator said, The nurses initially assess the resident and starts the Baseline Care Plan, and then I follow up on it. The nurses are initially responsible for the Baseline Care Plan, and we have 48 hours to get it done. The Surveyor asked if it was appropriate to not include respiratory therapy for oxygen and CPAP in the Baseline Care Plan for Resident #227. The MDS Coordinator said, It is not appropriate, and should be included in the Baseline Care Plan. The Surveyor asked what the possible outcomes were of leaving respiratory therapy, oxygen, and CPAP off the Baseline Care Plan. The MDS Coordinator said, It can cause a readmission, hypercapnia, hypoxia, lots of things. d. The facility policy titled, Care Plans - Baseline, provided by the DON on 06/01/23 at 1:33 PM documented, Policy Statement A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. Policy Interpretation and Implementation . 2. The Interdisciplinary Team will review the healthcare practitioner's orders . and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders; b. Physician Orders; c. Dietary Orders; e. Social Services; and f. PASARR recommendation, if applicable. 3. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan . 3. The facility policy titled, Care Plans, Comprehensive Person-Centered, provided by the Administrator on 06/01/23 at 8:58 AM documented, Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation . 8. The comprehensive, person-centered care plan will: .b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . m. Aide in preventing or reducing decline in the resident's functional status and/or functional levels; n. Enhance the optimal functioning of the resident . Based on observation, record review and interview, the facility failed to develop and implement the plan of care for oxygen use for 2 (Residents #11 and #227) of 7 (Residents #5, #8, #9, #11, #22, #29 and #227) sampled residents who had Physician Orders for oxygen therapy as documented on a list provided by the Administrator on 06/01/23 at 8:58 AM. The findings are: 1. Resident #11 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Malignant Neoplasm of Bronchus or Lung. The admission Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 04/14/23 documented the resident did not receive oxygen therapy. a. The Physician Orders dated 04/04/23 documented, Oxygen @ [at] 3 L [liters] as needed for shortness of breath 3 liters/min [minute] per nasal cannula PRN [as needed] . Oxygen @ 3 L every shift for shortness of breath . b. The Nsg (Nursing) Admit/Readmit Assessment and Care Plan dated 04/04/23 revealed oxygen at 3 liters via nasal cannula. c. The comprehensive Care Plan with an initiated date of 04/04/23 and a revision date of 05/11/23 did not address care areas and/or interventions for oxygen therapy. d. On 05/30/23 at 11:06 AM, Resident #11 was asleep in his wheelchair with oxygen (O2) via nasal cannula at 4 lpm [liters per minute]. e. On 05/30/23 at 12:17 PM, Resident #11 was sitting in his wheelchair in his room with O2 via nasal cannula at 4 lpm. f. On 05/31/23 at 2:34 PM, the Surveyor asked the MDS Coordinator if Resident #11's Baseline Care Plan had oxygen marked. The MDS Coordinator stated, Yes it does. The Surveyor asked if the admission MDS had oxygen marked. The MDS Coordinator stated, No ma'am it is not. The Surveyor asked if that coding would impact the development of Resident #11's individualized Comprehensive Care Plan. The MDS Coordinator stated, Yes, it can. It pulls off the MDS. It does not have anything about oxygen on the Closet Care Plan. It [Comprehensive Care Plan] was done on 5/30 [05/30/23]. I know I am reaching. It was missed on there until yesterday. g. On 06/02/23 at 7:58 AM, the Surveyor asked the Interim Director of Nursing (DON) if all services provided to residents are care planned. The DON stated, Yes. The Surveyor asked if Resident #11 had a Care Plan for oxygen prior to survey entry. The DON stated, No, it was not. The Surveyor asked what the potential outcomes of oxygen therapy not being on the Closet or Comprehensive Care Plans. The DON stated, The resident would not get accurate care or the care he needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded for oxygen therapy for 1 (Resident #11) of 7 (Residents #5, #8, #9, #11, #22, #29 and #227) sampled residents with Physician Orders for oxygen therapy per a list provided by the Administrator on 06/01/23 at 8:58 AM, and failed to ensure MDS assessments were accurately coded for Preadmission Screening and Resident Review (PASARR) II for 3 (Residents #1, #2 and #5) of 4 (Residents #1, #2, #5 and #24) sampled residents with serious mental health diagnoses per a list provided by the Administrator on 06/01/23 at 8:58 AM. The findings are: 1. Resident #1 had diagnoses of Paranoid Schizophrenia and Anxiety Disorder, Unspecified. The Annual MDS with Assessment Reference Date (ARD) of 04/03/23 documented the resident was not currently considered by the Level II PASARR process to have a serious mental illness. a. A State Designated Professional Associates Assessment/Letter dated 08/17/94 provided by the Administrator on 06/01/23 at 2:00 PM documented recommendations for placement and specialized services for Resident #1 serious mental illness. b. A Care Plan with a revision date of 04/24/13 documented, Resident has a current diagnosis of Anxiety, Paranoid Schizophrenia . Behavioral health consults as needed . 2. Resident #2 had a diagnosis of Bipolar Disorder, Unspecified. The Annual MDS with an ARD of 07/27/22 documented the resident was not currently considered by the Level II PASARR process to have serious mental illness. a. A State Designated Professional Associates Assessment/Letter dated 11/04/04, provided by the Administrator on 06/01/23 at 8:58 AM documented, .Section 3: Psychiatrist's Conclusions . 2. Has been identified as having the following serious mental illness . Bipolar Disorder . b. A Care Plan with a revision date of 08/14/20 documented, The resident uses psychotropic medications Abilify r/t [related to] Disease process - Bi-Polar . 3. Resident #5 had diagnoses of Bipolar Disorder, Anxiety Disorder, and Unspecified Dementia. The Annual MDS with an ARD of 7/12/22 documented the resident was not currently considered by the Level II PASARR process to have a serious mental illness. a. a State Designated Professional Associates Letter dated 01/26/17 provided by the Administrator on 05/31/23 at 11:43 AM documented, .You do not require specialized services for your mental illness (MI), intellectual disability, and/or developmental disability (ID/DD) beyond the capabilities of a nursing facility . Surveyor: [NAME], [NAME] L 4. Resident #11 had diagnoses of Chronic Obstructive Pulmonary Disease and Malignant Neoplasm of Bronchus or Lung. The admission MDS with an ARD of 04/14/23 documented the resident did not receive oxygen therapy. a. The (Nursing) Admit/Readmit Assessment and Care Plan dated 04/04/23 revealed the resident had oxygen at 3 liters via nasal cannula. b. On 05/31/23 at 02:34 PM, the Surveyor asked the MDS Coordinator if Resident #11's Baseline Care Plan had oxygen marked. The MDS Coordinator stated, Yes it does. The Surveyor asked if the admission MDS had oxygen marked. The MDS Coordinator stated, I hope it does. It is not marked. No ma'am it is not. I need to do a correction to correct the coding. The Surveyor asked if that coding would impact the development of Resident #11's individualized Comprehensive Care Plan. The MDS Coordinator stated, Yes, it can. It pulls off the MDS. 5. On 06/02/23 at 7:57 AM, the Surveyor asked the MDS Coordinator if [Residents #1, #2 and #5] had diagnoses to require a PASSRR II. The MDS Coordinator stated, Looks like it yes for Resident #1 and Resident #5. I'm not seeing that it's [PASSRR] scanned, so I would not know for Resident #2. The Surveyor asked if the Annual MDS dated [DATE] was marked in Section A1500 for Resident #5, if the Annual MDS dated [DATE] was marked in Section A1500 for Resident #2, and if the Annual MDS dated [DATE] was marked in Section A1500 for Resident #1. The MDS Coordinator stated, I know [Resident #1] should be. It is marked No. For [Resident #5] it says No. That was the person before me. It should be marked Yes. For [Resident #2] it is marked No. I guess it should be marked Yes, but that one [PASARR] is not scanned in. The Surveyor asked if Resident #2's diagnoses would trigger a PASARR II. The MDS Coordinator stated, Probably with the psychotic disorder with delusions and Bipolar as well. We should have marked it Yes. The Surveyor asked what the possible outcomes could be for a PASRR not being marked accurately on the MDS. The MDS Coordinator stated, Um, honestly I am not 100% sure. I know it throws off our records with Medicaid and Medicare and obviously we are missing things that impact their care. 6. On 06/02/23 at 7:56 AM, the Surveyor asked the Director of Nursing (DON) if it is important that the MDS be coded correctly and why. The DON stated, Yes. To provide accurate care. The Surveyor asked what the outcome could be of not coding the MDS correctly for PASSAR. The DON stated, The resident may not get the services they need, and to provide the correct care. 7. The facility policy titled, Certifying Accuracy of the Resident Assessment, provided by the Administrator on 06/01/23 at 8:58 AM documented, Policy Statement All personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment. Policy Interpretation and implementation . 2. All personnel who complete any portion of the MDS assessment .must sign assessment certifying the accuracy of that portion of the assessment .

Based on observation, record review, and interview, the facility failed to ensure oxygen was administered at the Physician Ordered rate for 2 (Residents #11 and #227) and oxygen tubing was changed weekly for 1 (Resident #29) of 7 (Residents #5, #8, #9, #11, #22, #29 and #227) sampled residents who received oxygen therapy and failed to ensure Continuous Positive Airway Pressure (CPAP) tubing was stored to prevent contamination for 1 (Resident #227) of 2 (Residents #8 and #227) sampled residents with Physician Orders for CPAP therapy as documented on lists provided by the Administrator on 06/01/23 at 8:58 AM. The findings are: 1. Resident #11 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Malignant Neoplasm of Bronchus or Lung. a. Physicians Orders dated 04/04/23 documented, Oxygen @ [at] 3 L [liters] as needed for shortness of breath 3 liters/min [minute] per nasal cannula PRN [as needed] . Oxygen @ 3 L every shift for shortness of breath . b. On 05/30/23 at 11:06 AM, Resident #11 was asleep in his wheelchair with oxygen (O2) via nasal cannula at 4 lpm [liters per minute]. c. On 05/30/23 at 12:17 PM, Resident #11 was sitting in his wheelchair in his room with O2 via nasal cannula at 4 lpm. d. On 05/30/23 at 12:19 PM, the Surveyor asked Licensed Practical Nurse (LPN) #2 what Resident #11's O2 flow rate was set at. She stated, It's at 4. The Surveyor asked what the Physician Orders were. LPN #2 stated, I am not sure I will have to look it up. I don't want to say the wrong thing. LPN #2 looked in the electronic records and stated, It should be at 3. The Surveyor asked what the outcome could be if it is at the wrong rate. LPN #2 stated, Well, he does have Neoplasm and shortness of breath. It's not at the right rate. It's one over. e. On 05/31/23 at 10:53 AM, the Surveyor asked the Interim Director of Nursing (DON) when the oxygen concentrator rates were checked. The DON stated, Every shift. The Surveyor asked what the possible outcomes were for the concentrator being at the wrong flow rate. The DON stated, I guess it depends. I don't really know. I guess if a diagnosis could cause COPD or if it's too low and they don't get enough oxygen. Lots of things I suppose. 2. Resident #29 had diagnoses of Acute Respiratory Failure with Hypercapnia, Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Emphysema and Shortness of Breath. a. A Physicians Order dated 12/25/22 documented, Change and date O2 tubing and water bottle q [every] week every night shift every Sun [Sunday] . b. On 05/30/23 at 11:34 AM, Resident #29 was lying in bed receiving oxygen via nasal cannula. The O2 tubing and clear plastic storage bag were dated 05/21/23 and the humidifier bottle was not dated. c. On 05/30/23 at 12:35 PM, Resident #29 was lying in bed receiving oxygen via nasal cannula. The O2 tubing and clear plastic storage bag were dated 05/21/23 and the humidifier bottle was not dated. d. On 05/30/23 at 12:36 PM, the Surveyor asked LPN #2 what the date was on the oxygen tubing Resident #29 was currently using and the date on the storage bag. LPN #2 stated, 5/21. The Surveyor asked when the tubing was changed. LPN #2 stated, Weekly on Sundays. The Surveyor asked what the outcome could be if the tubing was not changed. LPN #2 stated, It's just dirty. She needs a clean one. They shouldn't be using dirty ones. e. On 05/30/23 at 12:44 PM, LPN #2 stated, I don't have an explanation for that. f. On 05/31/23 at 10:53 AM, the Surveyor asked the Interim DON when the oxygen tubing was changed. The DON stated, Weekly. The Surveyor asked what the possible outcomes were for the tubing not being changed. The DON stated, I guess it's infection control. That's the only thing I can think of. 3. Resident #227 had a diagnosis of Acute Respiratory Failure with Hypoxia. a. The Physician Orders dated 05/18/23 documented, Oxygen @ 2L/ Min via nasal cannula as needed for Shortness of Breath 2 Liters/min per nasal cannula PRN and every shift for Shortness of Breath . CPAP Per home settings at bedtime . Clean CPAP machine and tubing ensure it has water. in the morning . b. On 05/30/23 at 10:59 AM, the Surveyor asked Resident #227 how much oxygen she wears. Resident #227 said, 2-3 liters. Resident #227 had 1.5 liters oxygen. A nasal canula was in a bag, the oxygen tubing and humidifier bottle were dated 05/29/23. A CPAP mask was in a bag with no date. The oxygen tubing connected to the CPAP was dated 05/29/23. The open end was lying in the floor, between the window and the bed. Resident #227 said, That is not supposed to be there. I distinctly remember telling the new aide early this morning that it had to go into the bag, not the floor. c. On 05/30/23 at 2:20 PM, Resident #227 was resting in bed. The open end of the oxygen tubing dated 5/29, connected to CPAP, was lying in the floor under the bedside table. Resident #227 said, Staff has been in to check on me, but they still have not picked up that oxygen tubing. d. On 05/31/23 at 8:20 AM, Resident #227's CPAP hose was lying on the bedside table, unattached to the face mask and not in a bag. e. On 05/31/23 at 11:35 AM, the Surveyor asked LPN #1 to verify how much oxygen Resident #227 was receiving and the process for storing oxygen and CPAP tubing and supplies. LPN #1 said, She is on 1 liter of oxygen. LPN #1 picked up the tubing and hoses, some bagged and some not and said, It should be in a bag and dated. This CPAP hose is usually connected and stays in a bag. The Surveyor asked if it is acceptable for oxygen tubing to lay in the floor. LPN #1 said, No, it is not, and it should be thrown away. LPN #1 opened the top drawer of the bedside table and pulled out new tubing that was not in the original packaging. The Surveyor asked what the possible outcome of tubing and CPAP supplies not being stored properly could be. LPN #1 said, Introducing bacteria. f. On 05/31/23 at 12:38 PM, the Surveyor asked the DON who was responsible for the ongoing monitoring and storage of oxygen and CPAP equipment. The DON said, Nurses on the floor, Certified Nursing Assistants [CNA], or anyone that rounds. The Surveyor asked if it is appropriate for tubing to be on the floor. The DON said, It depends on if the resident is messing with it. The Surveyor asked what possible outcomes could come from the inappropriate storage of Oxygen/CPAP equipment and tubing on the floor. The DON said, Infection control probably. 4. A facility policy titled, CPAP/BiPAP [Bilevel Positive Airway Pressure] Support, provided by the Administrator on 06/01/23 at 8:58 AM documented, .Preparation l. Only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP mask. 2. Review the resident's medical record to determine his/her baseline oxygen saturation or arterial blood gases (ABGs), respiratory, circulatory and gastrointestinal status. 3. Review the physician's order to determine the oxygen concentration and flow . 4. Review and follow manufacturer's instructions for CPAP machine setup and oxygen delivery . The policy does not address the storage of the mask, hose and tubing when not in use. 5. A facility policy titled, Oxygen Administration, provided by the Administrator on 06/01/23 at 8:58 AM documented, .Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . Steps in the Procedure . 8. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered .

Based on observation, record review, and interview, the facility failed to ensure food was served in a sanitary manner to prevent cross contamination for 2 (Residents #26 and #65) of 5 (Residents #22 #26, #52, #63 and #65) sampled residents who are served meals in the 400 Hall Dining Room. This failed practice had the potential to affect 19 residents (total census: 75) who are served meals in the 400 Hall Dining Room as documented on a list provided by the Administrator on 06/01/23 at 8:58 AM. The findings are: 1. On 05/30/23 at 12:35 PM, Certified Nursing Assistant (CNA) #1 removed plastic wrap from cups and served chocolate cake, water, and tea to Resident #26 with her fingers on the rim of the cups and bowl. 2. On 05/30/23 at 12:37 PM, CNA #2 removed plastic wrap from cups and served chocolate cake, water, and tea to Resident #65 with her fingers resting on the rim of the cups and bowl. 3. On 05/31/23 at 3:16 PM, the Surveyor asked CNA #1 to explain the purpose of plastic wrap covering glasses and food when serving residents, and the process for serving food to the residents. CNA #1 said, Well I guess contamination purposes. Nobody has really shown me a process or talked to me about it. CNA #1 held her hand up demonstrating setting a cup down and said, Oh, I touched the rim. The Surveyor asked what the possible outcome was from touching the rim. She said, Contamination, and we have COVID. 4. On 06/01/23 at 9:35 AM, the Surveyor asked CNA #2 why it is important to serve meals in a sanitary manner without touching the rims of cups and bowls. CNA #2 said, Residents drink from the cups and it would be cross contamination. The Surveyor asked what the possible outcome was from not serving meals in a sanitary manner. CNA #2 said, Residents are vulnerable and more prone to get sick. 5. On 06/01/23 at 10:20 AM, the Surveyor asked the DON who was responsible for serving meals and what type of training they received. The DON said, The CNAs serve meals, but anyone can assist. The CNAs are trained before they get here. The Surveyor asked why it would be important to serve meals using sanitary practices. The DON said, For infection control. The Surveyor asked what a possible outcome could be of serving meals not using sanitary practices. The DON said, Residents could get sick.

Based on record review and interview, the facility failed to ensure a discharge summary was developed to include a recapitulation of the resident's stay, a final summary of the resident's status, and reconciliation of all pre and post discharge medications to provide necessary medical information and instructions for 1 (Resident #43) of 1 sampled resident who was discharged from the facility. The findings are: Resident #43 had diagnoses of Primary Adrenocortical Insufficiency and Major Depressive Disorder. The admission Minimum Data Set with an Assessment Reference Date of 01/19/2022 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and required limited assistance with transfers, toileting, and personnel hygiene. a. On 03/16/2022 at 12:45 PM, the Director of Nursing (DON) was asked for the recapitulation of Resident #43's stay. b. The Discharge Summary received from the Director of Nursing (DON) on 03/16/22 at 1:23 PM was not completed. The Discharge Summary did not address the following areas: 1) Current Medical & (and) Mental Health Diagnosis. 2) Brief medical history, current treatments, and therapies. 3) Medications and amount of medication released to resident/family at time of discharge. 4) Resident or Family Education. Instructions on medication administration; Pharmacy Education Program; Medications given to resident or family; Educational Materials. 5) Dietary Information, food allergies, diet type, diet, or fluid education and who these instructions were given to. 6) No signature of resident/family or facility staff. c. On 03/16/2022 at 1:30 PM, the DON was asked, Is there any documentation of what medications were sent with the resident when she was discharged ? The Administrator stated, The nurse is here that discharged her. She printed off the Medication Assessment Record and educated her with that. She was asked, Is there any documentation in the resident's chart that states that? She stated, No. d. The facility policy titled, Discharge Summary Planning, provided by the DON on 03/17/22 at 1:45 PM documented, . When a resident's discharge is anticipated, a discharge summary and post-discharge plan/discharge instructions will be developed to assist the resident to adjust to his/her new living environment . The discharge summary or post discharge instructions will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident . A copy of the discharge instructions will be provided to the resident and/or family member/care giver/responsible party at the time of discharge. Resident and/or family member/care giver/responsible party will sign that they have received a copy of the discharge instruction, and this will be scanned into the electronic medical record.

Based on observation and record review, the facility failed to ensure a side rail removed from a bed was not left on the floor to prevent a potential accident/hazard for 1 (Resident #8) of 17 (Residents #53, #168, #22, #49, #9, #8, #52, #33, #7, #40, #60, #59, #169, #50, #28, #11 and #218) sampled residents who had side rails and failed to ensure a wheelchair was not tattered and in poor condition to prevent a potential accident/hazard for 1 (Resident #8) of 21 (Residents #53, #168, #22, #49, #9, #58, #8, #52, #24, #33, #7, #40, #60, #59, #27, #169, #50, #28, #11, #218, and #46) sampled residents who utilized a wheelchair for mobility. The findings are: Resident #8 had a diagnosis of Dementia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/28/21 documented the resident scored 12 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required supervision with set up only for ambulation and transfers; for balance during transitions and walking he was not steady but able to stabilize without staff assistance and when moving from seated to standing position, walking, turning around and facing the opposite direction while walking, surface-to-surface transfer (transfer between bed and chair or wheelchair) and utilized a wheelchair. a. On 03/14/22 at 11:44 AM, Resident #8 was sitting in his wheelchair in his room. The left vinyl arm pad of the wheelchair and the back pad were tattered with rough edges. A side rail was lying on the floor at the end of the resident's bed, extending out approximately 6 inches from the side of the bed. b. The Care Plan with a revision date of 02/16/22 documented, The resident has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] Dementia . Resident chooses to use a wheelchair at times for mobility. Resident ambulates independently usually with no assistive device. Wheelchair to be cleaned Q week. Side rail for transfers . The resident is (High) risk for falls r/t Dementia, and poor gait . c. On 03/15/22 at 1:35 PM, Licensed Practical Nurse (LPN) #1 accompanied the surveyor to Resident #8's room and was asked, What is happening to the left arm pad on his wheelchair and the top of the back cushion? She replied, It's torn. LPN #1 was asked, Where it is torn, are the edges rough? She replied, Yes. LPN #1 was asked, Is the wheelchair in good condition? She replied, No. It needs to be replaced or repaired; it could cause a skin tear. LPN #1 was asked, What is that lying on the floor at the end of the resident's bed? She replied, A side rail. She was asked, Approximately how many inches is the side rail extending from the side of the bed? LPN #1 replied, 6 inches. LPN #1 was asked, Is that the proper storage place for that side rail? She replied, No, it could be a fall hazard. d. On 03/17/22 at 2:56 PM, the Director of Nursing (DON) was asked, When wheelchairs are tattered with rough edges, what does the facility do? She replied, We replace the part, if possible or we will replace the wheelchair if needed. The DON was asked, What could happen from the tattered vinyl? The DON replied, The resident could get a skin tear. The DON was asked, If a side rail is removed, what is done with it? She replied, It is placed in the garage. She was asked, Is it safe to store it on the floor at the end of a resident's bed, with 6 inches of it extending from the side of the bed? The DON replied, No, it a fall hazard. e. The facility policy titled, Assistive Devices and Equipment, provided by the DON on 03/17/22 at 3:20 PM documented, Our facility provides, maintains, trains and supervises the use of assistive devices and equipment for residents . 5. The following factors will be addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment . c. Device condition - devices and equipment will be maintained on schedule and according to manufacturer's instructions. Defective or worn devices will be discarded or repaired .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #60 had diagnoses of Sepsis, Cognitive Communication Deficit and Chronic Kidney Disease Stage 3. The Significant Change MDS with an ARD of 02/10/22 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a BIMS and required supervision and setup with eating. a. On 03/14/22 at 12:35 PM, Housekeeper #1 was sweeping Resident #60's floor while her lunch tray was in front of her. b. On 03/14/22 at 12:35 PM, the DON was asked, Should housekeeping be sweeping a resident ' s room while her lunch tray is in front of her? She stated, No. 2. Resident #28 had a diagnosis of Dementia. The Annual MDS with an ARD of 12/22/21 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a BIMS and required extensive physical assistance of one person with eating. a. The Care Plan with a revision date of 01/06/22 documented, .The resident has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] Alzheimer's . EATING: The resident requires (EXTENSIVE assistance) by (X [times]1) staff to eat . b. On 03/15/22 at 8:44 AM, Licensed Practical Nurse (LPN) #1 served Resident #28 her breakfast tray in her room. LPN #1 was standing beside the bed bending over Resident #28 spoon feeding her. LPN #1 was asked, When feeding the resident should you stand over her? LPN #1 replied, No. LPN #1 was asked, Why? She replied, Its a dignity issue. c. On 03/16/22 at 12:40 PM, Certified Nursing Assistant (CNA) #1 served Resident #28 her lunch tray in her room. CNA #1 was standing beside the resident's bed bending over the resident spoon feeding her. CNA #1 was asked, When feeding the resident, should you stand over her? She replied, No, I would sit beside her, if I had a chair. d. The facility policy titled, Assistance with Meals, provided by the Nurse Consultant on 03/15/22 at 2:27 PM documented, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity . Not standing over residents while assisting them with meals . 3. Resident #169 was admitted to the facility on [DATE] and had diagnoses of Obstructive and Reflex Uropathy, Neuromuscular Dysfunction of Bladder and Chronic Kidney Disease Stage 3. The admission Minimum Data Set (MDS) was not available for review at the time of the survey. a. The March 2022 Physician Orders documented, .Supra pubic cath [catheter] french (20) and bulb (30) cc [cubic centimeter]: change foley cath Q [every] 30 days PRN [as needed] leakage obstruction or patient removal every night shift starting on the 1st and ending on the 1st every month . Order Date 03/17/22 . b. Care Plan with an initiated date of 03/10/22 documented, The resident has (SPECIFY: Indwelling Suprapubic) Catheter: . No interventions were addressed.The resident has (chronic) renal failure . Monitor for s/sx [signs/symptoms] of infection, UTI [Urinary Tract Infection]. c. On 03/14/22 at 12:30 PM, Certified Nursing Assistant (CNA) #4 and CNA #5 transferred Resident #169 with the lift from her high back wheelchair to her bed. CNA #5 removed the resident's catheter bag from under the wheelchair and hung the catheter bag on the lift pad above the resident's bladder. The resident was lowered onto the bed without incident. CNA #5 hung the catheter bag on the right side of the bed. The catheter was not in a privacy bag. d. On 03/15/22 at 9:03 AM, Resident #169 was resting in bed, the catheter bag was hanging from the right side of bed with no privacy bag and was visible from the door entrance. e. On 03/15/22 at 1:33 PM, Licensed Practical Nurse (LPN) #1 was asked, To promote dignity should a catheter bag be in a privacy bag? She replied, Yes. f. On 3/15/22 at 1:42 PM, LPN #1 accompanied the surveyor to Resident #169's room. The resident was resting in bed, her catheter bag was hanging on the right side of the bed, no privacy bag noted. LPN #1 was asked, Should the resident's foley catheter be in a privacy bag? She replied, Yes. g. On 3/15/22 at 1:52 PM, the Director of Nursing (Don) was asked, To promote dignity should a catheter bag be in a privacy bag? The DON replied, Yes. Based on observation, record review and interview, the facility failed to ensure a resident had on matching shoes to promote dignity for 1 (Resident #27) of 23 (Residents #22, #64, #49, #1, #57, #9, #50, #218, #52, #61, #33, #7, #121, #40, #60, #59, #27, #169, #28, #20, #11, #46 and #26) sampled residents who required assistance with dressing; failed to ensure staff sat at the resident's eye level and did not stand over them while assisting them with eating to promote dignity for 1 (Resident #28) of 3 (Resident #57, #169 and #28) sampled residents who required assistance with eating according to lists provided by the Director of Nursing (DON) on 3/17/22; failed to ensure housekeeping did not sweep the floor while the resident was eating to promote respect for 1 of 1 (Resident #60) who eating lunch in her room and failed to ensure an indwelling urinary catheter drainage bag was concealed in a privacy bag to promote dignity for 1 (Resident #169) of 1 sampled resident who had an indwelling catheter. The finds are: 1. Resident #27 had diagnoses of Abnormalities of Gait and Mobility, Legal Blindness and Cognitive Communication Deficit. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/25/21 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required supervision and setup with dressing. a. The Plan of Care with a revision date of 12/17/2021 documented, .Resident has an ADL [Activities of Daily Living] self-care deficit r/t [related to] acute fx [fracture] of lumbar spine . requires supervision by one staff to dress . b. On 03/14/22 at 1:20 PM, Resident #27 was ambulating up and down the Secured Unit hallway with a rolling walker wearing two different shoes. She had on a navy blue with a white sole shoe on the right foot and a black with black sole shoe on the left foot. c. On 03/16/22 at 9:00 AM, Certified Nursing Assistant (CNA) #3 was asked, Is [Resident #27] capable of choosing a matching pair of shoes to wear and putting them on herself? She stated, Sometimes. She was asked, Who is responsible for making sure she has on matching shoes while ambulating throughout the Secured Unit? She stated, We [CNA's] are?

Based on record review and interview, the facility failed to ensure residents who have authorized the facility to manage personal funds are given instructions on how to request their personal funds after hours and on weekends. This failed practice had the potential to affect 32 residents who have authorized the facility to manage their personal funds according to a list provided by the Business Office Manager on 03/17/22 at 8:20 AM. The findings are: 1. On 03/16/22 at 1:35 PM, during Resident Council Meeting, residents were asked, Do you have access to your personal funds? Two of the four residents said they can get their money Monday through Friday but not after hours or on weekends. 2. On 03/17/22 at 8:00 AM, the Administrator was asked, Who is responsible for the management of the Resident's Personal Funds? She stated, The Business Office Manager. 3. On 03/17/22 at 8:15 AM, the Business Office Manager (BOM) (with the Business Office Consultant present) was asked, Are you the one responsible for getting the residents their money when they ask for it? She said, Yes. She was asked, Do they have access to their money when you are not here? She said, Yes. She was told that during the Resident Council Meeting yesterday two of the four said they do not have access to their money after hours and on weekends. She said, After hours we put money in the Med [Medication] Carts, and they need to ask the LPNs [Licensed Practical Nurses] for their money when I'm not here. She was then asked, Who is responsible for making sure they know what the process is for requesting money after hours and on weekends? She stated, I think it is covered in their admission Packet. 4. On 03/17/22 at 8:25 AM, the admission Packet was reviewed and did not address how to access personal funds after hours or on weekends. 5. On 03/17/22 at 9:28 AM, the admission Coordinator was asked, Is it covered in their admission Packet how residents who have their funds managed by the facility can access their money after hours and on weekends? She stated, No. She was asked, Who is responsible for making sure residents who have their personal funds managed by the facility know how to access their money after hours and on weekends? She stated, I don't really know, maybe the Business Office. She was informed that the BOM told this Surveyor she thought it was covered in the admission Packet. She was then asked, To your knowledge, does anyone at the facility make sure residents know how to access their money after hours or on weekends? She said, I guess not. 6. The facility policy and procedure titled, Policy and Procedure Patient Trust, provided by the Business Office Consultant on 03/18/22 at 8:15 AM documented, Policy: This facility manages patient personal funds as requested and in accordance with any and all applicable law. Procedure: The facility will manage patient personal funds via an interest-bearing account in the name of the facility with Patient Trust in the title. The following procedures are followed in managing patient trust accounts. Patient Trust Accounting: 10. Trust Cash-On-Hand must be available for patient cash requests.

5. Resident #24 had a diagnosis of Cerebral Infarction. The Annual Minimum Data Set with an Assessment Reference Date of 12/19/21 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status and required supervision and setup with dressing and eating, limited physical assistance of one person with personal hygiene and totally dependent on one person's physical assistance with bathing. a. On 03/14/22 at 1:40 AM, Resident #24 was out of his room. There were four nickel size and five pea size blood stains on his sheet. b. On 03/15/22 at 10:10 AM, Resident #24 was resting in bed, he to have four nickel size and five pea size blood stains on sheet. c. On 03/15/22 at 1:28 PM, Certified Nursing Assistant (CNA) #1 was asked, When are the resident's beds changed? CNA #1 replied, On shower days and as needed if soiled. d. On 03/15/22 at 1:33 PM, Licensed Practical Nurse (LPN) #1 was asked, When are the resident's beds changed? She replied, On shower days and as needed if soiled. LPN #1 was asked, Who is responsible to ensure bed sheets are being changed as needed? She replied, The floor nurses. e. On 03/15/22 at 1:37 PM, LPN #1 accompanied the surveyor to Resident #24's room. Resident #24 was sitting on the side of his bed. LPN #1was asked, What is on his sheet? She replied, It looks like blood stains? LPN #1 was asked, Should his sheets be changed? She replied, Yes. f. On 03/15/22 at 1:52 PM, the Director of Nursing (DON) was asked, When are the resident's beds changed? She replied, Immediately, if soiled, and on shower days. She was asked, Who is responsible to ensure bed sheets are being changed as needed? The DON replied, The floor nurses, and me. Based on observation and interview, the facility failed to ensure the floors were clean, trash was emptied, the toilet was flushed and a leak was repaired for 1 (Resident #49) of 1 resident on the 400 Hall and soiled bed linens were changed promptly to maintain a clean and sanitary environment for 3 (Residents #24, #27 and #121) of 20 (Residents #53, #168, #22, #49, #9, #58, #8, #52, #24, #33, #7, #40, #60, #59, #27, #169, #50, #28, #11 and #218) sampled residents who were dependent on staff for linen changes. The findings are: 1. Resident #49 had diagnoses of Type 2 Diabetes and Dementia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/01/22 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of two plus persons with toilet use and was frequently incontinent of urine and bowel. a. On 03/14/22 at 12:45 PM, in Resident #49's bathroom the toilet was full of a dark amber, cloudy, foul smelling liquid with the same colored liquid oozing approximately 1/8 inch out around the base of the toilet. Trash was overflowing out of the trash receptacle and there was a sticky substance on the entire floor of the bathroom. b. On 03/16/22 at 1:15 PM, in Resident #49's bathroom the toilet was full of a dark, cloudy, foul smelling liquid with a dark brown, semi soft, BM approximately 6 inches long with smears of a dark brown substance on the inside of the toilet, all over the seat of toilet, the raised seat and the poles and both arm rest of raised toilet seat. A brown liquid substance was oozing out around the base of the toilet approximately 4 inches and there was a sticky substance on the entire floor of bathroom. c. On 03/16/22 at 1:22 PM, Certified Nursing Assistant (CNA) #3 was asked to look at Resident #49's bathroom and was asked, Were you aware of the condition of this bathroom? She said, No, not until now, except I have been aware of the problem with this toilet not working [flushing] and that oozing out around the base for the last two months. She was asked, Have you made anyone aware of this? She said, Yes, maintenance. d. On 3/16/22 at 1:40 PM, Maintenance was asked to look at (Resident #49's) bathroom and as we approached the bathroom he said, Let me guess, the toilet? He was asked, You are aware of the condition of this toilet? He said, Yes, these two guys are constantly messing with this toilet, and I have worked on it off and on for last couple of months. He was asked, Have you made anyone aware that you have been unable to fix this toilet? He said, They are aware that I've been having issues with this toilet. I've had a couple of work orders to fix it. e. On 03/16/22 at 1:50 PM, the Administrator was asked to look at (Resident #49's) bathroom. She was asked, Who is responsible for fixing toilets that are not in good working order? She said, Maintenance. She was asked if she was aware that this toilet hasn't been working properly for a couple of months? She said, No. She was asked, Who is responsible for making sure that toilets and bathroom floors are clean? She said, Housekeeping. 2. Resident #121 had a diagnosis of Dementia. The admission MDS with an ARD of 02/01/22 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a BIMS and required extensive physical assistance of two plus persons with transfers and extensive physical assistance of one person with toilet use and personal hygiene use and was frequently incontinent of urine and always incontinent of bowel. a. On 03/14/22 at 12:48 PM, Resident #121's fitted bed sheet had three brown smears approximately 2 to 3 inches long. Resident #121 was in the Dining Room on the Secured Unit waiting on lunch to be served. 3. Resident #27 had diagnoses of Abnormalities of Gait and Mobility, Legal Blindness and Cognitive Communication Deficit. The Quarterly MDS with an ARD of 12/25/21 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a BIMS. a. On 03/14/22 at 12:50 PM, Resident #27's bed spread had three dime sized areas of food particles and two blood drops bright red in color approximately 1 to 1½ inches was on the pillowcase. Resident #27 was asked where blood came from. She was unable to verbalize; but did reach and point to her nose. 4. On 03/17/22 at 1:36 PM, the Director of Nursing and the Nurse Consultant were asked, Who is responsible for making sure the residents on the Secured Unit bed linens are clean after being soiled with food, feces and blood? They both said, The aides are.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a person centered comprehensive care plan was developed and completed for 2 (Residents #49 and #53) of 18 (Residents #7, #8, #9, #20, #24, #27, #28, #33, #40, #43, #49, #50, #53, #58, #60, #168, #169 and #218) sampled residents whose care plans were reviewed. This failed practice had the potential to affect all 73 residents currently residing in the facility per the Residents Census and Condition of Residents dated 03/14/22, The findings are: 1. Resident #49 was admitted on [DATE] with diagnoses of Unspecified Dementia with behavioral disturbances and Cognitive Communication Deficit. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/1/22 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview of Mental Status (BIMS) and required extensive physical assistance of two plus persons with bed mobility, transfers and toilet use and extensive physical assistance of one person with dressing and personal hygiene. a. The Plan of Care with a revision date of 12/06/21 did not address activities of daily living (ADLs). b. The Plan of Care with a revision date of 03/10/22 was incomplete. The amount of assistance and the number of staff required for bathing/showering, bed mobility, dressing, personal hygiene, and toilet use was not addressed. 2. Resident #53 was admitted on [DATE] with diagnoses of Unspecified Dementia without Behavioral Disturbance, Unspecified Psychosis not due to a Substance or known Physiological Condition and Chronic Kidney Disease. The admission MDS with an ARD of 02/01/22 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a BIMS and received an antipsychotic medication 6 days of the 7 day look back period and requires extensive one physical assistance for dressing & personal hygiene and extensive two plus person physical assistance for toileting. a. The Plan of Care with a revision date of 02/28/22 did not address ADLs and was incomplete. Throughout the entire Plan of Care there were 25 areas that asked for: r/t (related to), SPECIFY, SPECIFY FREQ (Frequency) and FREQ that were not completed. 3. On 3/17/2022 at 2:06 PM, the DON was asked, Who is responsible for developing and updating the residents Plan of Care? She stated, The Minimum Data Set Coordinator (MDS) and she is off on Maternity Leave as she had her baby two days ago. The MDS Coordinator was unavailable for interview. 4. The facility policy titled, Care Plan, Comprehensive Person-Centered, provided by the Nurse Consultant on 03/17/22 at 2:18 PM documented, .8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; .k. Reflect treatment goals, timetables, and objectives in measurable outcomes; .11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. a. When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers . 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS) .

Based on observation, record review and interview, the facility failed to ensure baths and/or showers were regularly provided to promote good personal hygiene and grooming for 1 (Residents #53) of 29 (Residents #1, #2, #7, #8, #9, #11, #20, #22, #24, #26, #27, #28, #33, #40, #46, #49, #50, #52, #53, #57, #58, #59, #60, #61, #64, #121, #168 and #169, #218); sampled residents; failed to ensure facial hair was removed for 4 (Residents #8, #49, #50 and #53) of 9 (Residents #8, #20, #40, #49, #50, #52, #53 #59, and #64) sampled residents; and failed to ensure fingernails were regularly trimmed and cleaned for 3 (Residents #28, #40 and #49) of 20 (Residents #1, #7, #9, #11, #20, #24, #26, #28, #33, #40, #46, #49, #50, #52, #57, #59, #60, #61, #64 and #169) sampled residents who were dependent for nail care, required assistance with shaving and with bathing. The findings are: 1. Resident #40 had a diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/11/22 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on Brief Interview of Mental Status (BIMS) and required extensive physical assistance of two plus persons for personal hygiene and one person physical assistance in part of bathing and had functional limitation in range of motion one side of the upper extremities and both sides of the lower extremities. a. The Plan of Care with a revision date of 03/02/22 documented, .The resident has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] . Check nail length and trim and clean on bath day and as necessary, report any changes to the nurse . b. On 03/14/22 at 11:56 AM, Resident #40 was lying in bed. Her left hand had a contracture, the fingernails on that hand were approximately 1/8 inch out past the nail pad. d. On 03/16/22 at 1:17 PM, the Director of Nursing (DON) was asked, Who clips and cleans toenails and fingernails? She stated, The CNAs [Certified Nursing Assistants] when they give a bath, and our Treatment Nurse does a lot of the nail care. The DON accompanied the surveyor to Resident #40 was lying in bed. She was asked, Can you look at her left hand? Resident #40's left hand was contracted into a fist, her fingernails were approximately 1/8 inch past the nail pad. The DON stated, Oh those nails need to be cut. 5. Resident #8 had a diagnosis of Dementia. The Quarterly MDS with an ARD of 11/28/21 documented the resident scored 12 (8-12 indicates moderately cognitively impaired) on a BIMS and required extensive physical assistance of one person with bathing and limited assistance with set up for personal hygiene. a. The Care Plan with a revision date of 07/02/21 documented, The resident has an ADL self-care performance deficit r/t Dementia . BATHING/SHOWERING: The resident requires limited assistance) by (X [times]1) staff with (showering) (2X per week) and as necessary. PERSONAL HYGIENE/ORAL CARE: The resident is able to: Independently. Resident does like to grow a beard. He will let staff know when he wants to shave . b. On 03/14/22 at 11:44 AM, Resident #8 was sitting in his wheelchair, he had approximately ¼ inch facial stubble. He was asked if he liked having a beard. He stated, I wish they would shave me. I like to be clean shaven. He stated, I get shaved on shower day. c. On 03/15/22 at 8:36 AM, Resident #8 was sitting in his wheelchair at the entrance to his room. He had facial stubble approximately ¼ inch in length. d. On 03/15/22 at 1:28 PM, CNA #1 was asked, When are the residents shaved? She replied, On shower days. e. On 03/15/22 at 1:33 PM, LPN #1 was asked, When are the residents shaved? She replied, During their shower. LPN #1 was asked, Who is responsible to ensure the residents are shaved as scheduled and as needed? She replied, The floor nurses. f. On 03/15/22 at 1:35 PM, LPN #1 accompanied the surveyor to Resident #8's room and was asked, When was the last time the resident was shaved? She replied, On his shower day, and today is his shower day. Resident #8 stated, I got a shower yesterday and they didn't shave me. g. The ADL - Bathing Schedule provided by the Nurse Consultant on 03/15/22 at 2:12 PM documented Resident #8 received a shower on 3/14/22 at 10:38 AM. h. On 03/15/22 at 1:52 PM, the DON was asked, When are the residents shaved? She replied, On shower days and when requested. The DON was asked, Who is responsible to ensure the residents are shaved as scheduled and as needed and or requested? She replied, The floor nurses, and me. 6. Resident #28 had a diagnosis of Dementia. The Annual MDS with an ARD of 12/22/21 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a BIMS and required extensive physical assistance of two plus persons with personal hygiene and one person physical assistance in part of bathing. a. The Care Plan with a revision date of 01/06/22 documented, The resident has an ADL self-care performance deficit r/t [related to] Alzheimer's . BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . b. On 03/14/22 at 11:51 AM, Resident #28 was lying in bed, the fingernails on her right hand had a brown substance under nail tips. c. On 3/15/22 at 1:28 PM, CNA #1 was asked, How often are the residents showered? She replied, Twice a week. CNA #1 was asked, Who does the residents showers? She replied, One CNA on the hall is scheduled to do them. CNA #1 was asked, Who performs nail care on the residents? CNA #1 replied, The CNAs, the nurses if they are a diabetic. She was asked, When is nail care completed? She replied, On shower days and as needed. d. On 03/15/22 at 1:33 PM, LPN #1 was asked, How often are the residents showered? She replied, Twice a week. LPN #1 was asked, Who does the residents showers? She replied, The CNAs. LPN #1 was asked, Who performs nail care on the residents? She replied, The CNAs and the nurses if they're a diabetic. LPN #1 was asked, When is nail care completed? She replied, Shower days and as needed. She was asked, Who is responsible to ensure nail care is being completed as needed? LPN #1 replied, The floor nurses. e. On 03/15/22 at 1:38 PM, LPN #1 accompanied the surveyor to the resident's room. Resident #28 was lying in her bed, covered with a blanket. LPN #1 was asked to look at the resident's nails. All of Resident #28's fingernails had a brown substance under the nail tip. LPN #1 was asked, What is that brown substance under her nail tips? She stated, Dirt or feces, I'm not sure but they need to be cleaned. f. On 03/15/22 at 1:52 PM, the DON was asked, How often are the residents showered? She replied, Twice a week and as needed. The DON was asked, Who does the residents showers? She replied, The CNAs. The DON was asked, Who performs nail care on the residents? She replied, The CNAs, if diabetics, the nurses. She was asked, When is nail care completed? She replied, On shower days and when needed. The DON was asked, Who is responsible to ensure nail care is completed as needed? She replied, The floor nurses, and me. 7. The facility policy titled, Fingernail/Toenail, Care of, provided by the Nurse Consultant on 03/15/22 at 2:27 PM documented, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections.Nail care includes daily cleaning and regular trimming. Proper nail care can aid in the prevention of skin problems around the nail bed.Trimmed and smooth nails prevent the resident from accidently scratching and injuring his or her skin . 2. Resident #53 had diagnoses of Unspecified Dementia without Behavioral Disturbance, Unspecified Psychosis not due to a Substance or known Physiological Condition and Chronic Kidney Disease. The MDS with an ARD of 02/01/22 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a BIMS and required extensive physical assistance of one person with dressing and personal hygiene. Bathing activity itself did not occur or family and/or non-facility staff provided care 100% (percent) of the time during the 7 day look back look back period. a. The Plan of Care with a revision date of 02/07/22 did not address ADL's. b. On 03/15/22 at 9:12 AM, Resident #53's wife stated her husband is typically clean shaven and she has had to trim his mustache and beard that has grown here, as well as his roommates. The wife stated her husband was in a dirty shirt and she asked a CNA if he had been showered and was told he had but was unsure why he was then in a dirty shirt. The wife stated she had to bring cologne because her smells and does not ever smell fresh. The wife was asked when her husband typically showered. The wife stated he showered every morning at home first thing because they did not allow dirty in their home. The wife stated she was not sure when he gets his showers because she has not been here when he has ever received one. The wife was asked how often she visits, and she stated she thinks she should come every other day, but she has been coming almost daily because she does not know what to do with herself. c. The ADL-Bathing Schedule from 2/14/22 to 3/14/22 provided by the DON on 03/16/22 at 12:26 PM documented Resident #53's bathing schedule as .Tuesday, Friday EVE [evening] and PRN [as needed] . The schedule documented Resident #53 refused on 02/24/22 (Thursday) and on 03/14/22 (Monday). He received a shower on 02/17/22 (Thursday), 02/28/22 (Monday) at 20:29 (8:29 PM) and at 22:33 (10:33 PM), 03/9/22 (Wednesday), 03/10/22 (Thursday), Not applicable was documented on 02/14/22 (Monday), 02/21/22 (Monday), 03/3/22 (Thursday), 03/7/22 (Monday). Resident #53 received 5 showers in 29 days. 3. On 03/17/22 at 1:36 PM, the Administrator, the Nurse Consultant, and the DON were asked who was responsible for nailcare, beard trimming, shaving, and showers. The DON stated, The CNAs were responsible and should be included with showers. They were asked what not applicable meant on the bathing schedule and the Nurse Consultant stated, We hate that button. The DON stated, We do not know what that means. We have told the CNAs not to use it when the resident refuses or when the resident is unavailable because they are offsite . 4. Resident #49 had diagnoses of Unspecified Dementia with Behavioral Disturbances and Cognitive Communication Deficit. The Quarterly MDS with an ARD of 02/01/22 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a BIMS and required extensive physical assistance of one with personal hygiene and one person physical assistance with bathing. a. The Plan of Care with a revision date of 03/10/22 was incomplete regarding his Activities of Daily Living (ADL) self-care deficit and the Plan of Care dated 12/05/21 did not address ADL's. b. On 03/16/22 at 9:02 AM, Resident #49 was sitting in a wheelchair at a dining table in the Secure Unit Dining Room. His fingernails were approximately 1/4 inch past the pads of his fingers and thumbs, jagged and had a brownish black substance under his fingernails. He had facial hair about his face. He was unable to answer questions regarding his personal care. c. On 03/16/22 at 9:45 AM, Resident #49 was sitting in a wheelchair in the hallway on the Secure Unit. He was asked to see his nails in the presence of CNA #3. She was asked, What does it look like under and on the sides of his nails? She said, Dirt and feces. She was asked, Who is responsible for making sure his nails are trimmed and cleaned? She did not answer but said to the resident, [Resident #49] I need to do your nail care! and left and returned and started nail care in the hallway. 5. Resident #50 had diagnoses of Parkinson's Disease, Alzheimer's Disease with late onset, Unspecified Dementia with Behavioral Disturbances and Schizophrenia. The Quarterly MDS with an ARD of 02/02/22 documented the resident scored 5 (0-7 indicates severely cognitively impaired) on a BIMS and required limited physical assistance of one person with personal hygiene. Bathing activity itself did not occur or family and/or non-facility staff provided care 100% (percent) of the time during the 7 day look back look back period. a. The Plan of Care with a revision date of 02/09/22 documented, .The resident has an ADL self-care performance deficit r/t [related to] Alzheimer's Dementia . DRESSING: The resident requires extensive assist [assistance] by 1 staff to dress. PERSONAL HYGIENE: The resident prefers to have a beard and mustache . The resident requires assist by 1 staff with personal hygiene and oral care. b. On 03/14/22 at 12:09 PM, Resident #50 was sitting in his room. His hair was uncombed, he had facial hair on the sides of his face approximately 1/16 of an inch long with a beard and mustache and food particles in his beard and on his t-shirt. c. On 03/16/22 at 9:21 AM, Resident #50 was sitting in his room. His hair was uncombed, and he had facial hair on both sides of face approximately 1/16 of an inch long and food particles in his beard. d. On 03/16/22 at 9:30 AM, CNA #3 was asked, Who is responsible for making sure [Resident #50] receives personal care such as shaving, and removing food particles from his beard and changing his food stained shirt? She stated, The CNAs are, but we've been off for two days and every time when we get back from being off this place, the residents are a mess. She was asked, Why has it not been taken care of this morning? She said, We've been slammed here this morning! We've been off the last two days and every time when we come back to this place, the residents are a mess! She was asked, Have you told anyone about this issue? She stated, Yes, they all know! e. On 03/17/22 at 1:36 PM, the DON and the Nurse Consultant were asked, Who is responsible for making sure residents on the Secured Unit nails are trimmed and cleaned, grooming and/or shaving men's beard's and making sure their clothes are clean after being soiled with food? They both said, The aides are.

Based on observation, record review and interview, the facility failed to ensure foot care was regularly provided and toenails were clean, trimmed, and free of jagged edges to prevent potential complications for 2 (Residents #9 and #40) of 20 (Residents #1, #7, #9, #11, #20, #24, #26, #28, #33, #40, #46, #49, #50, #52, #57, #59, #60, #61, #64 and #169) sampled residents who were dependent on staff for nail care. The findings are: 1. Resident #9 had diagnoses of Cognitive Communication Deficit and Muscle Wasting and Atrophy. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/01/21 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required supervision and setup with personal hygiene, bathing activity itself did not occur or family and/or non-facility staff provided care 100% (percent) of the time during the 7 day look back look back period. a. The Physician's Order dated 05/27/20 documented, .May see podiatrist . b. The Plan of Care with revision date of 03/05/22 documented, .Bathing/Showering: Check nail length and trim on bath day and as necessary. Report any changes to the nurse . c. On 03/14/22 at 11:53 AM, Resident #9 stated she needs a bath, wants nails clipped. I haven't had a bath in a couple of weeks. d. On 03/14/22 at 11:56 AM, Licensed Practical Nurse (LPN) #3 pulled Resident #9's socks off after the resident complained of not having nails trimmed. Resident #9's toenails were long 1/4 of an inch past the toe pad. The second toenail on the right foot was wrapped over the toe pad. LPN #3 was asked when the residents were to receive nail care. She stated, On their baths days. e. On 03/16/2022 at 1:04 PM, the Director of Nursing (DON) was asked, Do you have a Podiatrist that comes to the building? She stated, No. I really don't know. f. On 03/16/2022 at 1:17 PM the DON was asked, Who clips and cleans toenails and fingernails? She stated, The CNAs [Certified Nursing Assistants] when they bathe, and our Treatment Nurse does a lot of the nail care. She was asked, Does it appear that the nails have been clipped? She stated, No. She was asked, Should the resident's toenails be curved around the resident's toe pad? She stated, No. Resident #9 stated, I want my nails cut. The DON asked Resident #9, Have you told anybody? Resident #9 stated, No. The DON was asked, Is nail care part of the resident's ADLs? The DON stated, Yes. She was asked, When should nail care be done? She stated, On bath day, and if the CNA can't do it then they can tell the nurse. g. On 03/16/2022 at 1:25 PM, Resident #9 was with the DON in her room. Resident #9's toenails were 1/4 of an inch past the toe pad. The second toe on the right foot was ½ inch long and was wrapped around the toe pad. The DON asked Resident #9 if her toes hurt. Resident #9 stated, No, I want my nails cut. Resident #9 stuck out her hands when she stated she wanted nails cut. The DON asked Resident #9, Did you tell someone that you wanted your nails cut? Resident #9 stated, No. The DON was asked, Should a resident have to ask for nails to be cut? The DON stated, It should be done on bath days. 2. Resident #40 had a diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side. The Quarterly MDS with an ARD of 01/11/22 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a BIMS and required extensive physical assistance of two plus persons for personal hygiene and one person physical assistance in part of bathing and had functional limitation in range of motion one side of the upper extremities and both sides of the lower extremities. a. The Physician's Order dated 06/10/19 documented, .May see podiatrist . b. The Plan of Care with a revision date of 03/02/22 documented, .The resident has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] . Check nail length and trim and clean on bath day and as necessary, report any changes to the nurse . c. On 03/14/22 at 11:56 AM, Resident #40 was lying in bed. Resident #40 stated, They give me baths, but they don't cut my toenails. Licensed Practical Nurse (LPN) #3 pulled the sheet back from Resident #40's feet, her toenails were approximately ¼ inch long, thick, and jagged. d. On 03/16/22 at 1:04 PM, the Director of Nursing (DON) was asked, Do you have a Podiatrist that comes to the building? She stated, No. I really don't know. e. On 03/16/22 at 1:17 PM, the DON was asked, Who clips and cleans toenails and fingernails? She stated, The CNAs when they give a bath, and our Treatment Nurse does a lot of the nail care. The DON accompanied the surveyor to Resident #40's room. The DON was asked, Does it appear that the nails have been clipped? She stated, No. The DON asked Resident #40 if her toenails on the left great toe hurt. Resident #40 stated, Yes, if they move the covers over it. Residents #40's left great toenail extended up approximately 1/4 inch above the toenail bed. The toenails on the other four toes extended past the toe pad approximately ¼ inch. The great toenail on the right foot was thick. The other four toenails extended approximately ¼ inch past the toe pads. The DON stated, Her nails are long and need to be cut. 3. The facility policy titled, Fingernail/Toenail, Care of, provided by the Nurse Consultant on 03/15/22 at 2:27 PM documented, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections.Nail care includes daily cleaning and regular trimming. Proper nail care can aid in the prevention of skin problems around the nail bed.Trimmed and smooth nails prevent the resident from accidently scratching and injuring his or her skin .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure the catheter bag remained below the bladder during a transfer to prevent potential infection for 1 (Resident #169) of 1 sampled resident who had an indwelling catheter. The findings are: Resident #169 was admitted to the facility on [DATE] and had diagnoses of Obstructive and Reflex Uropathy, Neuromuscular Dysfunction of Bladder and Chronic Kidney Disease Stage 3. The admission Minimum Data Set (MDS) was not available for review at the time of the survey. a. The March 2022 Physician Orders documented, .Supra pubic cath [catheter] french (20) and bulb (30) cc [cubic centimeter]: change foley cath Q [every] 30 days PRN [as needed] leakage obstruction or patient removal every night shift starting on the 1st and ending on the 1st every month . Order Date 03/17/22 . MONITOR - Supra Pubic Cath drsg [dressing] for placement/excessive drainage; change PRN - Phys [Physician] to be notified if s/sx [signs and symptoms] of infection noted every evening and night shift for monitoring drsg/site .Order date 03/08/22 . b. Care Plan with an initiated date of 03/10/22 documented, The resident has (SPECIFY: Indwelling Suprapubic) Catheter: . No interventions were addressed.The resident has (chronic) renal failure . Monitor for s/sx [signs/symptoms] of infection, UTI [Urinary Tract Infection]. c. On 03/14/22 at 12:30 PM, Certified Nursing Assistant (CNA) #4 and CNA #5 transferred Resident #169 with the lift from her high back wheelchair to her bed. CNA #5 removed the resident's catheter bag from under the wheelchair and hung the catheter bag on the lift pad above the resident's bladder. The resident was lowered onto the bed without incident. CNA #5 hung the catheter bag on the right side of the bed. The catheter was not in a privacy bag. d. On 03/15/22 at 1:33 PM, Licensed Practical Nurse (LPN) #1 was asked, When the CNAs transfer a resident with a lift, should they hang the catheter bag from the lift pad, above the bladder? She replied, No. e. On 3/15/22 at 1:52 PM, the Director of Nursing (Don) was asked, To promote dignity should a catheter bag be in a privacy bag? The DON replied, Yes. She was asked, When CNAs are performing a transfer with a lift, should the catheter bag be hung on the lift pad, above the bladder? She replied, No. f. The facility policy titled, Emptying a Urinary Drainage Bag, provided by the Nurse Consultant on 03/16/22 at 2:09 PM documented, . Keep the drainage bag below the level of the resident's bladder .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #7 had diagnoses of Acute Respiratory Failure, and Personal History of COVID-19. The Significant Change of Condition MDS with an ARD of 11/22/2021 documented the resident scored 10 (8-12 indicates moderately cognitively impaired) on a BIMS and received oxygen therapy. a. The Physician's Order dated 08/06/19 documented, .02 at 2 L via nc as needed . b. The Plan of Care with a revision date of 12/06/21 documented, .The resident uses oxygen therapy . Oxygen settings 02 via nasal cannula . c. On 03/14/22 at 12:24 PM, Resident #7 was lying in bed with 02 at 3 l/m (liters a minute) via nc. d. On 03/15/2022 at 9:23 AM, Resident #7 was lying in bed with 02 at 3 l/m via nc. e. On 03/16/2022 at 8:28 AM, Resident #7 was lying in bed with 02 at 3 l/m via nc. f. On 03/16/2022 at 1:00 PM, LPN #2 was asked, Can you tell me what the resident ' s oxygen concentrator is set on? She stated, It's on three. She was asked, Can you tell me if this is the correct setting? She stated, I will have to look it up. g. On 03/17/22 at 8:34 AM, Resident #7 was lying in bed with 02 at 3 l/m via nc. 6. Resident #218 had diagnoses of Obstructive Sleep Apnea and Chronic Obstructive Pulmonary Disorder. The admission MDS with an ARD of 02/8/22 documented resident scored 8 (8-12 indicates moderately cognitively impaired) on a BIMS and received oxygen therapy and did not use a CPAP. a. The Plan of Care with a revision date of 02/15/22 documented, .altered respiratory status C-pap titrated pressure via nasal pillow . b. The Physician's Order dated 02/21/22 documented, C-pap (continues positive airway pressure) use every night. c. On 03/14/22 at 11:41 AM, Resident #218 was lying in bed with 02 at 2 l/m via nc. A CPAP mask was sitting on bedside table open to air not covered. d. On 03/15/22 at 8:34 AM, Resident #218 was lying in bed A CPAP mask was sitting on bedside table open to air, not cleaned. e. On 03/16/22 at 7:52 AM, Resident #218 was lying in bed A CPAP mask was sitting on bedside table open to air. A plastic bag dated, was lying on bedside table. f. On 03/16/22 at 1:25 PM, the DON was asked, Should a resident's CPAP mask be lying on a bedside table open to air? She stated, No, it should be bagged. At this time the mask was in a clear plastic bag. 7. The facility policy titled, Departmental (Respiratory Therapy) - Prevention of Infection, provided by the Nurse Consultant on 03/15/22 at 2:27 PM documented, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks, and equipment . among residents and staff . Change the oxygen cannulae (sic) and tubing every seven (7) days, or as needed . Keep the oxygen cannulae (sic) and tubing used PRN in a plastic bag when not in use . 8. The facility policy titled, CPAP/BiPAP Support', provided by the DON on 03/17/22 did not address storage when not in use. Based on observation, record review and interview, the facility failed to ensure oxygen tubing was dated to facilitate timely change-out for 2 (Residents #168 and #169) residents; storage bags for oxygen tubing were changed out regularly to prevent potential infection for 4 (Residents #24, 33, 168 and #169) residents; oxygen was administered at the physician-ordered flow rate to prevent potential complications for 1 (Resident #7) resident; and updraft and CPAP (Continuous Positive Airway Pressure) masks were stored in a bag or other closed container when not in use to prevent potential contamination for 2 (Residents #24 and #218) of 11 (Residents #168, #33, #40, #60, #27, #218, #22, #9, #7, #24 and #169) sampled residents who had physician orders for oxygen therapy. The findings are: 1. Resident #24 had diagnoses of Shortness of Breath, Chronic Obstructive Pulmonary Disease (COPD) and Heart Failure. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/19/21 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and did not receive oxygen therapy. a. The Care Plan with a revision date of 01/04/22 documented, The resident has Emphysema/COPD . The resident will be free of s/sx [signs/symptoms] of respiratory infections through review date . b. The Physician's Order dated 02/24/22 documented, Albuterol Sulfate Nebulization Solution 1.25 MG/3ML [Milligram/Milliliter] 1 inhalation inhale orally every 4 hours as needed for SOB [Shortness of Breath]/Wheeze . c. On 03/14/22 at 11:40 AM, Resident #24 was out of his room, an updraft machine was on bed side table and the updraft mask was hanging from drawer, not in a storage bag. d. On 03/15/22 at 10:10 AM, Resident #24 was resting in bed; the updraft machine was on bed side table and the updraft mask was hanging from drawer, not in a storage bag. e. On 3/15/22 at 1:37 PM, Licensed Practical Nurse (LPN) #1 accompanied the surveyor to Resident #24's room. Resident #24 was sitting on the side of his bed, his updraft mask was hanging from the bed side dresser drawer, not in a bag. LPN #1 was asked, Is his updraft mask stored properly? She replied, No it should be in a storage bag. 2. Resident #33 had a diagnosis of Chronic Obstructive Pulmonary Disease. The Quarterly MDS with an ARD of 01/06/22 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a BIMS and required oxygen therapy. a. The Physician's Order dated 10/12/21 documented, Change and date O2 [oxygen] tubing and water bottle q [every] night shift every Sun [Sunday] . Oxygen 2L[Liters]/min [per minute] per nasal cannula prn [as needed] to keep sats [saturations] above 90% [percent] every shift . b. The Care Plan with a revision date of 01/03/22 documented, .The resident has Emphysema/COPD . The resident will be free of s/sx of respiratory infections through review date . OXYGEN SETTINGS: O2 via [by way of] (nasal prongs) @ [at] (2)L (Continuous) . c. On 03/14/22 at 11:35 AM, Resident #33 was reclined in her recliner with oxygen at 2 liters per nasal cannula. Her wheelchair was beside the bed with an oxygen tank, the oxygen tubing was laying in seat of the chair, no storage bag present. d. On 03/15/22 at 8:28 PM, Resident #33 was out of her room, her oxygen tubing from the concentrator was lying on top of her made bed, not in a storage bag. e. On 3/15/22 at 1:45 PM, LPN #1 accompanied the surveyor to Resident #33's room. Resident #33 was reclined in her recliner. She had on oxygen at 2 liters per nasal cannula via oxygen concentrator. Her wheelchair was beside the bed with an oxygen tank, the oxygen tubing was laying in seat of the chair, no storage bag present. LPN #1 was asked, Is the oxygen tubing laying in the resident's wheelchair properly stored? She replied, No. She was asked, Should there be a storage bag on the oxygen tank to store the oxygen tubing? LPN #1 replied, Yes. 3. Resident #168 had diagnoses of Bronchopneumonia, Shortness of Breath and Heart Disease. The admission MDS with an ARD of 02/20/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and did not receive oxygen therapy. a. The Physician's Orders dated 03/07/22 documented, .Oxygen at 2L via NC [Nasal Cannula] as needed for SpO2 [Oxygen Saturation] lower than 90%/SOB . change and date oxygen tubing and water; clean filter weekly every night shift every Sun . b. The Care Plan with an initiated date of 03/08/22 documented, .The resident has Pneumonia r/t [related to] . The resident's pneumonia will be resolved without complications . OXYGEN SETTINGS: O2 via nasal cannula @ 2L. Humidified . c. On 03/14/22 at 12:02 PM, Resident #168 was lying in bed with oxygen via NC, the flow meter on the concentrator was at zero. The oxygen tubing connected to the oxygen tank on her wheelchair was looped around her wheelchair. The oxygen tubing on the concentrator and oxygen tank were not dated and there were no storage bags. d. On 3/15/22 at 8:53 AM, Resident #168 was sitting on side of the bed with oxygen at 2 Liters via NC. The oxygen tubing on the concentrator and oxygen tank were not dated and no storage bags were present. The oxygen tubing on the oxygen tank was looped around back of the wheelchair. e. On 3/15/22 at 1:33 PM, LPN #1 was asked, How often is oxygen tubing changed? She replied, Every Sunday. LPN #1 was asked, What is your policy on changing oxygen supplies? She replied, Change and date the humidity bottle, oxygen tubing and storage bag once weekly. She was asked, What is the proper way to store oxygen tubing when not in use? LPN #1 replied, The oxygen tubing needs to be placed in a storage bag. She was asked, Who is responsible to ensure oxygen is stored and labeled properly? She replied, The floor nurses. f. On 3/15/22 at 1:39 PM, LPN #1 accompanied the surveyor to Resident #168's room. Resident #168 was lying in her bed, she had on oxygen at 2 Liters via NC, a storage bag was on the floor. LPN #1 was asked, Is the oxygen tubing's or storage bag dated? LPN #1 stated, No. LPN #1 was asked, Is the oxygen tubing on the back of the wheelchair, that is coiled up and hanging from the oxygen tank, the proper way to store the oxygen tubing? LPN #1 replied, No. She was asked, Should the storage bag be lying on the floor? She replied, No. g. On 03/15/22 at 1:52 PM, the Director of Nursing (DON) was asked, How often is oxygen tubing changed? She replied, Once a week, on Sunday. She was asked, What is your policy on changing oxygen supplies? The DON replied, To change the filter, storage bag and oxygen tubing, and date everything. The DON was asked, What is the proper way to store oxygen tubing when not in use? She replied, In the plastic bag. She was asked, Who is responsible to ensure oxygen tubing is labeled and stored properly? She replied, The floor nurses, and me. 4. Resident #169 was admitted [DATE] and had diagnoses of Altered Cardiovascular Status. admission MDS was not available for review at the time of the survey. a. The Physician's Order dated 03/05/22 documented, .O2 at 2 to 3 liters per nasal cannula every shift . b. The Care Plan with an initiated date of 03/07/22 documented, .The resident has altered cardiovascular status . OXYGEN SETTINGS: O2 via nasal prongs @ 2L. Humidified . c. On 03/14/22 at 12:06 PM, Resident #169 was sitting in her high back wheelchair with oxygen at 2 liters via NC from an oxygen tank. The tubing was not dated and a plastic storage bag hanging from the concentrator was not dated. d. On 03/14/22 at 12:30 PM, Certified Nursing Assistant (CNA) #4 and CNA #5 transferred Resident #169 with the lift from her high back wheelchair to her bed. CNA #5 removed the oxygen tubing from Resident #169 and draped the tubing over the handle of the resident's chair. e. On 03/15/22 at 9:03 AM, Resident #169 was resting in bed with oxygen at 2 Liters via NC from her concentrator. Her high back wheelchair was at the foot of her bed, with the oxygen tubing wrapped around the oxygen tank. f. On 03/15/22 at 1:42 PM, LPN #1 accompanied the surveyor to Resident #169's room. She was asked, Is the resident's oxygen tubing, or storage bag dated? She replied, No. She was asked, Is the resident's oxygen tubing that is coiled up and hanging from the oxygen tank, properly stored? She replied, No.

Based on record review and interview, the facility failed to ensure the Drug Regimen Review physician orders were acted upon in a timely manner to discontinue an unnecessary psychotropic medication for 1 (Resident #58) of 24 (Residents #53, #58, #168, #22, #64, #49, #1, #57, #8, #2, #52, #33, #7, #121, #40, #60, #59, #27, #169, #50, #28, #11, #218 and #26) sampled residents who had physician orders for psychoactive medications. This failed practice had the potential to affect 51 residents who were on psychoactive medications as documented on a list provided by the Director of Nursing (DON) on 03/17/22 at 2:04 PM. The findings are: 1. Resident #58 had diagnoses of Vascular Dementia, Encephalopathy and Psychotic Disorder with Delusions due to known Physiological Condition. The Quarterly Minimum Data Set with an Assessment Reference Date of 02/09/22 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status and received 7 days of Antipsychotic and 7 days of Antidepressant 7 days of the 7 day look back period. a. The Physician's Order dated 09/08/20 documented, . Risperdal Tablet 0.5 MG Give 1 tablet by mouth at bedtime related to Psychotic Disorder with delusions due to known Physiological Condition . b. The Medication Regimen Review (MRR) in the Electronic Medical Record documented, .Antipsychotic recommendation: a) Antipsychotic GDR [Gradual Dose Reduction] . B. Please consider a gradual dose reduction or tapering of this medication . esigned by [Pharmacist #1] on 10/05/21. The Attending Physician / Prescribing Practitioner Response documented, .Make the following changes to drug regimen: D/C [discontinue] AM dose Risperdal 0.25mg. Continue HS [hour of sleep] dose of 0.5mg. Singed by [Physician #1] on 11/08/21 . c. The November 2021 Medication Administration Record (MAR) documented the AM dose was discontinued on 11/23/21, 15 days after Physician #1 ordered the dose reduction. d. The Care Plan with a revision date of 12/06/21 documented, .The resident uses psychotropic medications (Risperidone) r/t [related to] Behavior management . Administer Psychotropic medications as ordered by physician . e. On 03/16/22 at 12:55 PM, the DON was asked what the procedure was for notifying the physician of the pharmacist's recommendation. The DON stated she, prints the pharmacist's recommendation and places it in the correct physician's box. The physician makes notations and returns it to DON. The DON then enters the change notes into the system. f. The facility policy titled, Medication Regimen Reviews, provided by the Administrator on 03/17/22 at 10:25 AM documented, .9. The Consultant Pharmacist will provide the Director of Nursing Services and Medical Director with a written, signed, and dated copy of the report, listing . recommendations for their solutions .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure medications were administered only in the presence of documented indications for use and specific targeted behaviors were monitored, documented, and evaluated for causative factors for 1 (Resident #53) of 24 (Residents #53, #58, #168, #22, #64, #49, #1, #57, #8, #2, #52, #33, #7, #121, #40, #60, #59, #27, #169, #50, #28, #11, #218 & #26) sampled residents who had physician orders for psychoactive medications. This failed practice had the potential to affect 51 residents who had physician orders for psychoactive medications as documented on a list provided by the Director of Nursing (DON) on 03/17/22 at 2:04 PM. The findings are: 1. Resident #53 was admitted on [DATE] with diagnoses of Unspecified Dementia without Behavioral Disturbance, Unspecified Psychosis not due to a Substance or known Physiological Condition and Chronic Kidney Disease. The admission Minimum Data Set with an Assessment Reference Date of 02/01/22 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status and received and antipsychotic medication 6 days of the 7 day look back period. a. The Care plan with a revision date of 02/28/22 did not address antipsychotic behaviors or medications. b. The March 2022 Physician Orders documented, . Risperidone Tablet 0.5 MG [milligrams] Give 1 tablet by mouth one time a day related to unspecified psychosis not due to a substance or known physiological condition . Order Date 01/27/22 . Trazodone HCl [Hydrochloride] Tablet 50 MG Give 50 mg by mouth at bedtime related to unspecified Dementia without behavioral disturbance . Order Date 03/02/22 . c. A Physician Progress Note with an effective date of 03/02/22 16:21 (4:21 PM) documented, . Date of service: 02/18/22 .Dementia is advanced. Staff reports frequent refusal of care, and at times kicking, hitting, and inappropriate behaviors. Staff is able to redirect usually. Continues on therapy. Will likely need long-term care . d. A Physician Communication Progress dated 03/03/22 08:45 (AM) documented, .Resident has been getting up at night and walks in and out of residents rooms all hours of the night and when staff tries to redirect came become aggressive. Can we please have a prn [as needed] to help with this aggressiveness . thanks . Physician/Family Response: Order received from phys [physician] . Author: Treatment Nurse #2 . e. As of 03/16/22 at 2:00 PM, The Progress Notes from 02/01/22 to 03/10/22 documented an Alert Note for inappropriate or aggressive behaviors on the following days: 1) 02/03/22 at 10:36 AM - Grabbing Monitored-Resident not easily re-directed; Kicking Hitting Monitored-Resident not easily re-directed; Pinching/Scratching/Spitting-Resident not easily re-directed. Author: Treatment Nurse #1. 2) 02/09/22 at 22:59 (10:59 PM) - Sexually Inappropriate Monitor; Threatening Behavior Monitored; Kicking Hitting Monitored. Author: Treatment Nurse #1. 3) 02/19/22 at 09:10 (AM) - Rejection of Care Monitored; Grabbing Monitored. Author: Treatment Nurse #1. 4) 02/25/22 at 22:51 (10:51 PM) - Threatening Behavior Monitored-Resident re-directed; Pushing Monitored. Author: Treatment Nurse #1. Resident #53 had 4 days documented in the progress notes with an Alert Note of inappropriate or aggressive behaviors. f. On 03/16/22 at 2:10 PM, the DON was asked to explain the need for Trazadone as the progress notes were unclear. The DON stated she needed to check. g. On 03/17/22 at 8:30 AM, the DON provided a copy of the above progress notes dated 03/02/22 and 03/03/22 as the reason for Trazadone.