**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident received reasonable accommodation of needs for one of 22 sampled residents (Resident 9) by failing to ensure resident was in a comfortable position during meals. This deficient practice resulted in Resident 9 in feeling exhausted and uncomfortable while eating. Findings: During a record review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of spinal stenosis (a tightening of the spinal canal that causes nerve pain), osteoporosis (weakening of bones, leading to a decrease in bone density and an increased risk for fractures), and reduced mobility. During a record review of Resident 9's Minimum Data Set (MDS, a federally mandated resident assessment and tool), dated 10/29/2024, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was moderately impaired. The MDS indicated Resident 9 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) for eating. During a record review of Resident 9's care plan, dated 8/26/2024, the care plan indicated Resident 9 had a potential for alteration in nutrition related to lack of coordination, spinal stenosis (narrowing of the spine which puts pressure on the spinal cord and nerves), and decline in activities of daily living. The care plan interventions were to assess likes and dislikes, provide needed assistance during meals, and monitor through nutrition alert meeting as needed. During an observation on 11/4/2024 at 12:10 PM in the dining room, Resident 9 was sitting on the dining chair and the dining table was at Resident 9's eye level. Resident 9 held the lunch plate on her lap with her left hand while she used her right hand to feed herself. During a concurrent observation in the dining room and interview on 11/4/2024 at 12:17 PM with Restorative Nursing Aide (RNA 1), RNA 1 stated Resident 9 was hunched and sitting in the chair. RNA 1 stated every time Resident 9 was straightened up she would go back to the hunched position. RNA 1 stated they had tried to add cushion to her chair to make her higher so she could eat on the table, but Resident 9's feet would hang on the chair and Resident 9 did not like her feet to hang. RNA 1 stated the table was high for Resident 9. RNA 1 stated Resident 1 was eating with her plate on her lap. RNA 1 stated Resident 9 ate with her plate on her lap all the time. During an observation on 11/4/2024 at 12:24 PM of Resident 9 in the dining room, Resident 9 finished eating lunch and placed her plate and cup on the table, she sighed and stated, I'm exhausted. During an interview on 11/7/2024 at 8:53 AM with Resident 9, Resident 9 stated when she ate in the dining room, she could not reach her food on the dining table. Resident 9 stated staff put her plate on the table, and she tried to eat on the table. Resident 9 stated she got tired, and it was not comfortable eating on the table since the table was so high for her. Resident 9 stated it was hard to eat with the plate on the table since she had to tilt her head back each time she ate. Resident 9 stated it was horrible since the table was too high. Resident 9 stated, It's like feeding a midget. Resident 9 stated it was ideal for her to eat at the table instead of holding her plate on her lap while eating but felt that holding her plate was better than reaching up to the table while eating. Resident 9 stated when she reached up to the table to eat, it hurt all over her bones and was not comfortable. Resident 9 stated she was always placed at the regular table where it was too high for her. Resident 9 stated, I don't think people realize it, it's hard for me to eat like that. During an interview on 11/7/2024 at 9:35 PM with the Director of Nursing (DON), the DON stated residents should eat at their comfortable level. The DON stated the table should be above the waist and the residents' hands should be resting comfortably on the table. The DON stated the table should not be positioned at the residents' face while eating since this was not the proper way for a resident to be positioned while eating. The DON stated this could result in a bad posture while eating, cause discomfort and place the residents at risk for aspiration (inhaling small particles of food or drops of liquid into the lungs). During a record review of the facility's Policy and Procedure titled, Quality of Life - Accommodation of Needs, revised 11/2010, the policy indicated the resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its Change in a Resident's Condition or Status policy by failing to notify the physician regarding a significant weight loss for one of three sampled residents (Resident 31) as indicated on the care plan. This deficient practice had the potential to result in delayed provision of necessary care and services. Findings: During a record review of Resident 31's admission Record indicated Resident 31 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of hyperlipidemia (a condition in which there are high levels of fat particles in the blood), dementia (progressive brain disorder that slowly destroys memory and thinking skills) and left artificial hip joint. During a record review of Resident 31's Weight Tracking System Report, the record was as follows: - 5/29/2024 184 lbs - 6/3/2024 184 lbs - 6/6/2024 161 lbs (-23 lbs in three days, 12.5% weight loss) - 6/10/2024 160 lbs (-24 lbs, 13.0% weight loss) During a record review of Resident 31's Nutrition Risk Assessment, dated 6/3/2024, the record indicated care planned weight goal was to maintain weight 184 lbs plus or minus six (6) lbs by the next review. During a record review of Resident 31's Interdisciplinary Notes, dated 6/10/2024, the record indicated a weekly weight loss of 23 lbs and the physician was notified of the weight loss (4 days after). During a record review of Resident 31's Registered Dietician Notes, dated 6/11/2024, the record indicated Resident 31 was referred to nutrition alert due to 24 pounds, 13.0% weight loss in the past week. During a record review of Resident 31's Minimum Data Set (MDS, a federally mandated resident assessment and tool), dated 8/26/2024, the record indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was intact. The MDS indicated Resident 31 required substantial/ maximal assistance (helper does more than half the effort) for shower/bathe self, upper and lower body dressing, and chair/bed-to-chair transfer. During a record review of Resident 31's nutrition care plan, dated 9/25/2024, the care plan indicated monitor weekly weights per facility protocol, report significant changes in weight to physician and registered dietician. During an interview on 11/6/2024 at 3:28 PM with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident was 184 lbs upon admission on [DATE]. LVN 2 stated on 6/3/2024 Resident 31 was still 184 lbs, then three days later Resident 31 weighed 161 lbs (-23 lbs). LVN 2 stated five (5) lbs weight loss in one week or one month needed to be reported to the physician. LVN 2 stated the physician needed to assess Resident 31 for her weight loss. LVN 2 stated the physician and registered dietician needed to be contacted as soon as the weight loss was noted. During a concurrent record review of Resident 31's electronic medical records with LVN 2, LVN 2 stated there was no physician notification on 6/6/2024 for Resident 31's weight loss. LVN 2 stated the physician should have been contacted as soon as they were contacted by the Restorative Nursing Aide of Resident 31's weight. LVN 2 stated the licensed nurses still needed to notify the physician since Resident 31's weight loss was more than 5 lbs. LVN 2 stated the physician should have been informed since Resident 31 might not be eating, have a poor appetite, require laboratory work, and require physician intervention to determine the reason why Resident 31 lost weight. During an interview on 11/7/2024 at 9:41 PM with the Director of Nursing (DON), the DON stated weight loss was a change of condition. The DON stated significant weight loss was 5% weight loss or weight gain in one month or 10% weight loss or weight gain in 6 months. The DON stated the physician should have been informed of planned and unplanned weight loss. The DON stated the standard of practice was for the licensed nurses to notify the physician of the weight loss within the shift or endorsed to the next shift to notify the physician. The DON stated there was going to be a delay in treatment for weight loss when the physician was not notified. During a record review of the facility's P&P titled, Change in a Resident's Condition or Status, revised 2/2021, the policy indicated the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition. Notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain confidentiality of the resident's electronic health record (EHR) for one (1) of 22 sampled residents (Resident 45) by failing to turn off the computer screen and leaving it unattended, exposing the resident's EHR which included the resident's medical condition, list of medications, and other information regarding resident care to others not authorized to view. This deficient practice had the potential to result in the violation of Resident 45's privacy and confidentiality. Findings: During a review of Resident 45's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses which included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), benign prostatic hyperplasia (BPH, also known as an enlarged prostate, is a noncancerous condition in which the prostate gland becomes larger than normal), and insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep) During a review of Resident 45's Minimum Data Set (MDS, a federally mandated assessment tool), dated 8/27/2024, the MDS indicated Resident 45 was assessed to have moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 45 was assessed to be needing substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, roll left and right, toilet transfer, tub/shower transfer, and walk 10-150 feet. During observation in front of Resident 45's room on 11/6/2024 at 11:02 AM, Licensed Vocational Nurse 1 (LVN 1) went inside Resident 45's room. LVN 1 did not turn off the computer monitor on top of the medication cart which was parked along the hallway where other residents and/ or facility staff were passing by. During a concurrent observation and interview with LVN 1 on 11/6/2024 at 11:08 AM, LVN 1 was observed leaving Resident 45's room and proceeded to use the computer on top of the medication cart after administering medication to Resident 45. LVN 1 stated, I should have closed the chart monitor (computer monitor) for Residents 45's privacy. It is important to turn off computer because of Health Insurance Portability and Accountability Act (HIPAA- a federal law that protects sensitive health information from disclosure without the patient's consent) and to protect the privacy of Resident 45's medical record. During an interview with LVN 2 on 11/6/2024 at 11:25 AM, LVN 2 stated, the licensed nurses must ensure that the staff close the EHR/ computer monitor on the top of the medication cart to prevent exposure of residents' information. LVN 2 stated it is the residents' rights not to have the resident's health information exposed to others. During a review of the facility's policy and procedure titled, Confidentiality of Information and Personal Privacy, revised on 10/2017, the P&P indicated the facility will protect and safeguard resident confidentiality and personal privacy. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. Access to resident personal and medical records will be limited to authorized staff and business associates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide Restorative Nursing Services (a program available in nursing homes to help residents maintain any progress made during therapy treatments, enabling them to achieve their highest practicable level of functioning) as ordered by the physician to increase, prevent, or maintain range of motion (ROM, full movement potential of a joint) for one of three sampled residents (Resident 2). This deficient practice placed Resident 2 at risk for decline in physical functions and developing contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in the extremities (a limb of the body, such as the arm or leg) for not receiving the ordered exercises. Findings: During a review of Resident 2's admission Record, the record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of chronic obstructive pulmonary disease (COPD, disease that causes obstructed airflow from the lungs), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and heart failure (a lifelong condition in which the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen). During a review of Resident 2's Physician's Order, dated 11/16/2023, the record indicated RNA for bilateral upper extremities (BUE, both arms from shoulder to hands) / bilateral lower extremities (BLE, both legs from hip to foot) active range of motion (AROM, the ROM that can be achieved when opposing muscles contract and relax, resulting in joint movement) five (5) times a week as tolerated. During a review of Resident 2's Restorative Nursing Assistant (RNA) Daily Charting, the record indicated Resident 2 received RNA services for BUE and BLE AROM as tolerated as follows for the month of September 2024. - Week 1: 11/3/2024, 11/5/2024, and 11/6/2024 - Week 2: 11/10/2024, 11/12/2024, and 11/13/2024 - Week 3: 11/17/2024, 11/19/2024, and 11/20/2024 - Week 4: 11/24/2024, 11/26/2024, and 11/27/2024. During a review of Resident 2's RNA Daily Charting, the record indicated Resident 2 received RNA services for BUE and BLE AROM as tolerated as follows for the month of October: - Week 1: 10/1/2024, 10/3/2024, 10/4/2024 - Week 2: 10/8/2024, 10/10/2024, 10/11/2024 - Week 3: 10/15/2024, 10/17/2024, 10/18/2024 - Week 4: 10/22/2024, 10/24/2024, 10/25/2024 - Week 5: 10/29/2024, 10/31/2024. During a review of Resident 2's RNA Daily Charting, the record indicated Resident 2 received RNA services for BUE and BLE AROM as tolerated as follows for the month of November: - Week 1: 11/1/2024 - Week 2: 11/3/2024, 11/5/2024, 11/7/2024. During a review of Resident 2's Minimum Data Set (MDS, a federally mandated resident assessment and tool), dated 9/13/2024, the record indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was intact. The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort) for upper and lower body dressing, personal hygiene, roll left and right, sit to lying, and lying to sitting on side of bed. The MDS also indicated Resident 2 had three days of active range of motion for the restorative program performed. During a review of Resident 2's activity of daily living (ADL) function rehabilitation care plan, dated 9/25/2024, the care plan indicated staff interventions were to encourage independence in ADLs by providing cues and monitor for continued independence, allow to participate with ADLs to tolerance, and RNA for AROM to BUE/BLE five times a week as tolerated. During a concurrent review of Resident 2's care plan, physician order, RNA Daily Charting, and Resident 2's electronic medical record and interview on 11/7/2024 at 8:34 AM with the Care Plan Coordinator (CPC), CPC stated Resident 2's care plan indicated Resident 2 had RNA services five times a week for upper and lower extremities as tolerated. CPC also stated the physician had ordered RNA services to be done five times per week. CPC stated RNA services were only being done three (3) times a week and not 5 times a week per physician order. CPC stated there were no notes indicating Resident 2's refusal of RNA services for the missing two times per week for RNA services. During a concurrent review of Resident 2's RNA Daily Charting interview on 11/7/2024 at 9:12 AM with Restorative Nursing Aide 1 (RNA 1), RNA 1 stated Resident 2 received RNA services 5 times a week. RNA 1 stated Resident 2 would refuse to complete RNA services once a month. RNA 1 stated Resident 2's refusals for RNA services should be documented on the chart. RNA 1 stated she did not see any notes for Resident 2 refusing RNA services. RNA 1 stated it was important for Resident 2 to receive her RNA services to prevent her from becoming contracted since Resident 2 spent most of her time in bed and refused to get out of bed. During a concurrent review of Resident 2's Physician's Order Summary on 11/7/2024 at 9:52 AM with Director of Occupational Therapy (DOT), DOT stated the physician had ordered RNA services for upper and lower extremity exercises and range of motion. DOT stated the physician ordered RNA services 5 times throughout the week to maintain functional status throughout. DOT stated 5 times per week RNA services was recommended for maintenance of general functional status, range of motion, and activity tolerance since Resident 2 generally choose to stay in bed. DOT stated based on the physician's order, the RNA should have followed the physician's order unless the resident refused services which should be documented in the Refused section. During a review of the facility's Policy and Procedure (P&P) titled, Resident Mobility and Range of Motion, revised 7/2017, the policy indicated residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in range of motion. During a record review of the facility's P&P titled, Restorative Nursing Services, revised 7/2017, the policy indicated restorative goals may include, but are not limited to supporting and assisting the resident in participating in the development and implementation of his/her plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the physician addressed the medication regimen review (MRR/Drug Regimen Review - a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) to indicate a reason for disagreeing with the pharmacist recommendation for gradual dose reduction (GDR- the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of Ativan (lorazepam- a medication used for anxiety [feeling of fear, dread, or uneasiness that can be mild or severe]) for one of 22 sampled residents (Resident 17) on 10/25/2024. This deficient practice had the potential to result in adverse medication outcome for potential unnecessary medications to Resident 17. Findings: During a review of Resident 17's admission Record, the admission Record indicated Resident 17 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included major depressive disorder (MDD- a mood disorder that causes a persistent feeling of sadness and loss of interest), unspecified pain, and anxiety disorder (fear characterized by behavioral disturbances). During a review of Resident 17's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 9/6/2024, the MDS indicated Resident 17 was assessed having severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 17 required setup or clean-up assistance with eating. Resident 17 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self, lower body dressing, and toilet transfer. Resident 17 did not have any mood or behavioral symptoms. During a review of Resident 17's Physician's Orders form, dated 11/7/2024, the Physician's Orders form indicated an order, with a start date of 10/23/2024, for Ativan 0.5 milligrams (mg- unit of measurement) tablet (tab)- ½ tab=0.25 mg by mouth (po) every (q) evening at 1 PM for anxiety manifested by (m/b) restlessness. The Physician's Orders also indicated an order, with a start date of 10/25/2024, for Ativan 1 mg tab- 1.5 mg by mouth every evening for anxiety disorder unspecified m/b restlessness. During a review of Resident 17's Care Plan titled, Psychotropic Drugs (medications that impact the brain and nervous system's chemical makeup to treat mental illnesses), dated 9/30/2024, the care plan indicated Resident 17 had the potential for drug related complications associated with the use of psychotropic medication to manage mood/behavior related to depression, psychosis (a mental state where a person has difficulty distinguishing reality from what is real), anxiety, and impulse disorder (a condition that makes it difficult to control actions or reactions). The care plan indicated an intervention to attempt/initiate gradual dose reduction as recommended by pharmacy consultant and as ordered by MD. During a review of Resident 17's Interdisciplinary (IDT- a coordinated group of experts from different fields) Note, dated 10/25/2024, the IDT Note indicated, Informed Physician Assistant 1 (PA 1) regarding pharmacy recommendation, he made new orders to change current dosage of Ativan 1.5 mg q 7PM to Ativan 1.5 mg q 6PM and change mirtazapine (a drug used to treat depression) 45 mg to mirtazapine 30mg q hour of sleep (hs). Informed Medical Doctor 1 (MD 1) with the orders and agreed to continue with it. Daughter 1 (DTR 1) is aware and agreed. Noted new orders and carried out. Endorsed to oncoming shift. During a concurrent interview and record review with the Director of Nursing (DON), on 11/7/2024, at 11:17 AM, Resident 17's Note to Attending Physician/Prescriber form, printed on 10/18/2024, was reviewed. The DON stated PC 1's drug recommendation on the Note to Attending Physician/Prescriber form indicated Resident 17 takes lorazepam 0.25 mg PM (4:00 PM) and 1.5 mg q PM (7:00 PM). Please consider a dose reduction, perhaps decreasing the 7PM dose to 1mg. If a gradual dose reduction is contraindicated, please specify why. During the same interview with the DON on 11/7/2024, at 11:17 AM, facility's policy and procedure (P&P), titled, Consultant Pharmacist Reports, dated 12/2016, was reviewed. The DON stated the P&P indicated, Recommendations are acted upon and documented by the facility staff and or the prescriber. Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing by the next physician date. The DON stated PA 1 and MD were notified of PC 1's drug recommendation report as soon as it was received. The DON stated Resident 17's family was also informed regarding PC 1's recommendation and requested for only the mirtazapine dose to be decreased. The DON stated PA 1 decreased Resident 17's mirtazapine from 45 mg to 30 mg and changed the Ativan administration time from 7PM to 6PM but did not decrease the Ativan dose as recommended by PC 1. The DON stated the MD sees residents in the facility every Wednesday but does not know why the MD did not indicate the reason why the drug recommendation was not accepted. The DON stated there was no documented explanation from the MD for not decreasing Resident 17's Ativan dose from 1.5 mg to 1mg.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the drug regimen for one (1) of five sampled residents (Resident 17) was free from unnecessary drugs by failing to assess the continued need for Tylenol (acetaminophen- used relieve mild to moderate pain from headaches, muscle aches, and to reduce fever) after it was not administered as needed for pain for more than ninety (90) days. This deficient practice had the potential for Resident 17 to suffer adverse reactions from unnecessary drug including bleeding easily and bruising. Findings: During a review of Resident 17's admission Record, the admission record indicated Resident 17 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included major depressive disorder (MDD- a mood disorder that causes a persistent feeling of sadness and loss of interest), unspecified pain, and anxiety disorder (fear characterized by behavioral disturbances). During a review of Resident 17's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 9/6/2024, the MDS indicated Resident 17 was assessed having severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 17 required setup or clean-up assistance with eating. Resident 17 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self, lower body dressing, and toilet transfer. Resident 17 did not receive as needed pain medications as needed and did not have the presence of pain. During a review of Resident 17's Physician's Orders, dated 11/7/2024, the Physician's Orders indicated an order, with a start date of 4/10/2024, for Tylenol Extra Strength 500 milligram (mg- unit of measurement) 1 tablet (tab) by mouth twice daily for pain management. Resident 17 also had an order, with a start date of 10/27/2020, for Tylenol Extra Strength 500 mg 1 tab by mouth every four hours for pain as needed, last dose 4/16/2024. During a review of Resident 17's care plan During a review of Resident 17's Physician's Orders, dated 11/7/2024, the Physician's Orders indicated an order, with a start date of 6/18/2019, to assess pain level every shift: Pain scale: 0=no pain 1-3= mild pain 4-7= moderate pain 8-10= severe pain During a concurrent interview and record review with the Director of Nursing (DON), on 11/7/2024, at 3:56 PM, Resident 17's Medication Record from 8/2024, 9/2024, 10/2024, and 11/2024, was reviewed. The DON stated Resident 17 was assessed for pain every four (4) hours. The DON stated Resident 17 was assessed to have a pain level of 0 from 8/2024, 9/2024, 10/2024, and 11/2024. During the same concurrent interview and record review with DON, on 11/7/2024, at 3:56 PM, the DON stated Resident 17's Medication Record indicated Resident 17 did not receive any Tylenol Extra Strength 500 mg 1 tab by mouth every four hours as needed for pain from 8/2024, 9/2024, 10/2024, and 11/2024. The DON stated Resident 17's pain was managed by the Tylenol dose she received twice daily. The DON stated Resident 17's order for Tylenol Extra Strength 500 mg 1 tab by mouth every four hours as needed for pain medication was considered unnecessary if it has not been administered to Resident 17 for more than 90 days. During a review of the facility's policy and procedure (P&P), titled, Medication Utilization and Prescribing-Clinical Protocol, revised on 7/2016, the P&P indicated the following: The physician and staff will review the rationale for existing medications that lack a clear indication or are being used intermittently on a PRN (as needed) basis. The physician and staff will adjust existing medications based on their efficacy and the continued presence of relevant conditions and risks. The staff and physician will periodically re-evaluate the conditions and symptoms for which each resident is receiving medications to ensure that the medication and dosage are still relevant and are not causing undesired complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services by failing to properly label the medications with the date opened of one (1) of 8 sampled residents as indicated on the facility policy. This deficient practice had the potential for adverse reaction if these improperly labeled medications were administered to Resident 45. Findings: During a review of Resident 45's admission Record indicated the resident was admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses which included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), benign prostatic hyperplasia (BPH, also known as an enlarged prostate, is a noncancerous condition in which the prostate gland becomes larger than normal), and insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep) During a review of Resident 45's Minimum Data Set (MDS, a federally mandated assessment tool), dated 8/27/2024, the MDS indicated Resident 45 was assessed to have moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 45 was assessed to be needing substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, roll left and right, toilet transfer, tub/shower transfer, and walk 10-150 feet. During a review of Resident 45's Physician's Order dated 6/30/2024 indicated carbidopa 25 milligrams (mg, unit of measure) - levodopa 100mg (is commonly used to treat Parkinson's disease). Take 1 tab by mouth 3 times a day for Parkinson's disease. During an observation of Resident 45's medication administration with Licensed Vocational Nurse 1 (LVN 1) on 11/6/2024 at 11 AM, there was no label of date opened on the medication bottle of carbidopa- levodopa was observed. During a concurrent observation and interview with LVN 1 on, 11/6/2024 at 11:05 AM, LVN 1 observed Resident 45's medication bottle carbidopa- levodopa has no date open written on the medication container. LVN 1 stated, the facility should have labeled the medicine bottle with date the bottle was opened/ firs used. LVN 1 stated If we are the one who opened the medicine bottle, we should have written down the date open on the container. During an interview with LVN 1 on 11/12/2024 at 11:06 AM, LVN 1 stated, it is important to write or label the medicine container with the date it was opened, and the reason is for the staff to find out the date that the medication was received and to account the number/ amount of medications inside the container. During an interview with LVN 2 on 11/6/2024 at 11:21 AM, LVN 2 stated, licensed nurse counts the pills inside the medicine bottle and document in a log if the medication is from an outside pharmacy including all over- the - counter (OTC) provided by family. LVN 2 stated, We do not count the medications if the medicine container came in sealed from the facility's pharmacy. We log it on the logbook. The staff who started to administer the medication to the resident and opened the medicine bottle should write the date opened on the medication container. During an interview with LVN 2 on 11/6/2024 at 11:22 AM, LVN 2 stated, It is important to label the medication container to make sure that medications were given as directed, to prevent missing medications, and account every pill inside the medication bottle. During a review of the facility's policy and procedure titled, Administering Medications revised 4/2019, indicated the expiration /beyond use date on the medication label is checked prior to administering. The policy also indicated when opening a multi-dose container, the date opened is recorded on the container.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide food that accommodated food preferences for one (1) of two sampled residents (Resident 40). This deficient practice had the potential to result in decreased meal intake and can lead to weight loss and malnutrition. Findings: During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses that included unspecified atrial fibrillation (afib- irregular and often very fast heartbeat that can lead to blood clots in the heart), heart failure (a serious condition in which the heart does not pump blood as efficiently as it should), and essential hypertension (high blood pressure). During a review of Resident 40's History and Physical examination (H&P), dated 5/16/2024, the H&P indicated Resident 40 did not have the capacity to understand and make decisions. During a review of Resident 40's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 8/16/2024, the MDS indicated Resident 40 was assessed having intact memory and cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 40 required setup or clean-up assistance with eating and oral hygiene. Resident 40 was independent (completes the activity by themself with no assistance from a helper) with sit to stand and toilet transfer. During a review of Resident 40's Physician's Orders, dated 11/6/2024, the Physician's Orders indicated an order, with a start date of 7/1/2021 for regular diet; okay to substitute to mechanical soft () three times a day. During a review of Resident 40's care plan titled, Nutrition. dated 8/28/2024, the care plan indicated Resident 40 had the potential for alteration in nutrition and the intervention indicated to offer alternative meal when available if Resident 40 does not like what is being served and order food, but cannot decide that to eat. The care plan also indicated Resident 40 had the potential for weight loss due to (d/t) poor appetite and the intervention indicated to provide diet as ordered. During an observation of Resident 40, in the dining room, on 11/4/2024, at 12:04 PM, Resident 40 was sitting on the dining table with green tea, water and apple juice in front of her. Certified Nursing Assistant 3 (CNA 3) placed Resident 40's food tray in front of Resident 40. Resident 40's food tray included a dinner roll, sweet potatoes, green beans, ground chicken arrabiata, and chopped lemon dill tilapia. CNA 3 walked back to the serving table and returned to Resident 40 with a bowl of chicken congee and chicken noodle soup. During a review of Resident 40's tray card (a card that contains information about a resident's meal service, including allergy, dislikes, preferences, standing orders (written instructions that specifies dietary guidelines for residents who meet certain criteria), special utensil requirements), dated 11/4/2024 lunch, the tray card indicated a standing order for Jello, 4 fluid ounce (fl oz- unit of measurement) apple juice, congee (rice porridge), 4 fl oz hot tea (green tea), 4 ounce (oz- unit of measurement) soy milk, and ¼ cup white rice. During a concurrent interview and review with the Director of Staff Development (DSD), on 11/4/2024, at 12:40 PM, Resident 40's tray card for lunch was reviewed. The DSD stated Resident 40 was not served white rice, soy milk, and Jello with the rest of her meal. During an interview with CNA 3, on 11/9/2024, at 10:33 AM, CNA 3 stated Resident 40 wrote down her food preference in the morning of 11/4/2024. CNA 3 stated she did not read Resident 40's lunch tray card on 11/4/2024. CNA 3 stated she did not check if there were missing food items on Resident 40's food tray before giving it to Resident 40. CNA 3 stated it was important that Resident 40 is provided with the food requested to eat because of her history of weight loss. During an interview with the Director of Nursing (DON), on 11/7/2024, at 10:41 AM, the DON stated the food preferences of the residents should always be followed for the residents' dignity. Furthermore, the DON stated residents with a history of weight loss should be provided with food that they prefer to encourage them to eat. During a review of the facility's policy and procedure (P&P), titled, Resident Dining Profile and Food Preferences, revised on 1/2024, the P&P indicated Residents on a modified/therapeutic diet are offered similar choices as the main meal in compliance with their diet restrictions. The P&P indicated food substitutions are provided when the Resident chooses not to consume meal items served and should be of equal nutritional value to the planned menu item. The P&P further indicated individual Resident choice at or between meals takes precedence over recorded preferences unless the requested item contains a recorded food allergen or is not consistent with the diet order. Reasonable accommodations regarding meal planning and need for recipes and purchased items outside the scope of the planned menu will be made for those residents with extensive dislikes, food allergies and/or special dietary needs. During a review of the facility's P&P, titled, Quality of Life-Accommodation of Needs, revised on 11/2010, the P&P indicated the facility's environment and staff behaviors are directed toward assisting the Resident in maintaining and/or achieving independent functioning, dignity and well-being. The P&P also indicated, The residents individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. During a review of the facility's P&P, titled, Resident Rights, revised on 2/2021, the P&P indicated Employees shall treat all residents with kindness, respect, and dignity. The P&P indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence and to be treated with respect, kindness, and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included muscle weakness, difficulty in walking, benign paroxysmal vertigo unspecified ear (a common inner ear disorder that can cause vertigo or a false sense of spinning or movement), and history of falling. During a review of Resident 24's MDS, dated [DATE], the MDS indicated Resident 24 was assessed having moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 24 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, shower/bathe self, upper/lower body dressing, and putting on/taking of footwear. Resident 24 also required partial moderate assistance with sit to stand, chair/bed-to-chair transfer (ability to transfer to and from a bed to a chair), toilet transfer, and walking 10 feet (ft- unit of measurement). The MDS indicated Resident 24 had a one (1) fall with no injury since the last prior assessment on 6/6/2024. During a review of Resident 24's Morse Fall Scale Assessment form, dated 9/27/2024, the form indicated a total fall risk score of 65 (a score of 51 or above indicated high risk for falls). During a review of Resident 24's Interdisciplinary (IDT- a group of healthcare professionals who work together to help people receive the care they need) Note, dated 5/25/2024, the IDT Note indicated, At 6:15 AM, heard sensor pad. Entered into resident's room and found resident on the floor on his left side in front of his recliner. Certified Nursing Assistant (CNA) put resident in his recliner .color pale with abrasion (when the surface layer of the skin has been broken) to right cheek measuring 0.3 centimeter (cm-unit of measurement) x 0.3 cm color red and skin tear to right eyebrow area measuring 0.2 cm x 0.2 cm with blood drainage. During a review of Resident 24's IDT Note, dated 7/13/2024, the IDT Note indicated, At 12:10 PM, heard sensor pad alarm in room [ROOM NUMBER], 2 staff check and found Resident on the floor in side lying position in front of bathroom .Resident was noted with laceration (a deep cut or tear in the skin) in back of head size 4 cm x 1 cm, with small amount of bleeding .complain of (c/o) pain 5/10 .asked Resident what happened Resident, Resident stated 'I fell, I don't know how. Called Medical Doctor 1 (MD 1) and reported the incident with new order to transfer to General Acute Care Hospital (GACH) via regular ambulance. During a review of Resident 24's IDT Note, dated 8/30/2024, the IDT Note indicated, At 9:15 AM, summoned to room [ROOM NUMBER] by CNA, observed resident on the floor, sitting position, in front of the bed with wheelchair (w/c) behind him, alert, and verbally responsive .Upon investigation, resident stated he slid from his w/c resulting for him to sit on the floor .CNA reported that heard an alarm and when went to the resident's room, observed resident on the floor. Per CNA, he saw resident sitting in a w/c wheeling himself on the station. Sensor pad was on and functioning well. During a review of Resident 24's IDT Note, dated 9/24/2024, the IDT Note indicated, At 11:33 AM, I heard sensor pad alarm going off. When I enter Res. room notice res. sitting on the floor at the end of the footrest of the recliner chair, notice call light on his lap. Sensor pad alarm turn off alarm and working properly. When I asked Res. what happen, Res. stated I slide from the recliner chair when I was trying to stand up to reach for my W/C he stated this recliner is very tricky. During an interview with Resident 24, on 11/4/2024, at 3:48 PM, Resident 24 stated he was admitted to the facility after sustaining a fall. Resident 24 stated he had fallen four times in the facility. Resident 24 stated he fell by the bathroom but could not remember why he fell. During an interview with Licensed Vocational Nurse 1 (LVN 1), on 11/6/2024, at 11:40 AM, LVN 1 stated Resident 24 had a history of falls prior to admission. LVN 1 stated Resident 24 has fallen four (4) times in the facility since admission. LVN 1 stated Resident 24 fell in front of his recliner the first time he fell on 5/25/2024. LVN 1 stated Resident 24 was found on the floor in a side lying position in front of the bathroom the second time he fell on 7/13/2024. LVN 1 stated Resident 24 slid off his wheelchair and was found sitting on the floor in front of his bed the third time he fell on 8/30/2024. LVN 1 stated Resident 24 was found sitting on the floor after he slid from his recliner when he tried to reach for his wheelchair the fourth time he fell on 9/27/2024. LVN 1 stated the sensor pad alarm alerted staff each time Resident 24's fell. LVN 1 stated the interventions in the care plan should be resident-centered. LVN 1 stated it was the responsibility of the licensed nurses and the Care Plan Coordinator (CPC) to revise the care plan. LVN 1 stated the care plan should be reviewed by the CPC to assess if the interventions were effective or if it needed to be updated. During a concurrent review of Resident 24's care plan, dated 5/25/2024, and interview with the CPC on 11/6/2024, at 12 PM, CPC stated the care plan indicated Resident 24 was found on the floor on his left side on 5/25/2024. CPC stated Resident 24's care plan intervention did not and should have indicated interventions such as specific safety measures related to the risk and cause of the fall to prevent fall reoccurrence. During a concurrent review of Resident 24's care plan, dated 8/30/2024, and interview with the CPC on 11/6/2024, at 12:02 PM, CPC stated the care plan indicated Resident 24 slid from the wheelchair during self-propel on 8/30/2024. CPC stated Resident 24's care plan intervention did not and should have indicated interventions to include wheelchair safety during self-propel and transfer to prevent fall reoccurrence. During a concurrent review of Resident 24's care plan, dated 9/27/2024, and interview with the CPC on 11/6/2024, at 12:04 PM, CPC stated the care plan indicated Resident 24 was noted sitting on the floor in his own room on 9/27/2024. CPC stated the care plan problem did not indicate Resident 24 was found at the footrest of the recliner chair. CPC stated the care plan interventions did not and should have indicated safety measures when Resident 24 tries to stand up from recliner to transfer to the wheelchair and when sitting on the recliner to prevent fall reoccurrence. During a concurrent interview with the CPC and record review, on 11/6/2024, at 12:06 PM, Resident 24's care plan titled, Falls, was reviewed. The CPC stated Resident 24's care plan did not include interventions on wheelchair safety or how to prevent Resident 24 from sliding off the recliner. The CPC stated the facility staff should be proactive in preventing falls for Resident 24. The CPC stated Resident 24's care plan for falls should be specific to Resident 24's fall risk because he tends to slip and fall in his room. The CPC stated the care plan interventions should be reassessed if not effective to meet the goal. During an interview with the Director of Nursing (DON), on 11/7/2024, at 10:44 AM, the DON stated Resident 24's had a history of falls and hi specific needs to prevent falls should be included in the care plan for prevent falls from recurring. 3. During a review of Resident 29's admission Record, the admission Record indicated Resident 29 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia (a brain disorder that results in memory loss, poor judgment, and confusion), history of falling, and unsteadiness on feet. During a review of Resident 29's Care Plan titled, Falls, dated 7/26/2024, the care plan indicated Resident 29 needed supervision to substantial assistance with activities of daily living (ADLs). It indicated Resident 29 ambulates using a walker with staff, has impaired cognition, and has poor safety awareness. It indicated Resident 29 needs cueing and reminder for safe functioning related to dementia, hypertension (HTN- high blood pressure), PAD, CKD, hyperlipidemia, osteoporosis, macular degeneration, edema, osteoarthritis (OA- a progressive disorder of the joints, caused by a gradual loss of cartilage), Vitamin B deficiency, and CAD. The care plan indicated the following interventions to minimize risk of fall or injury daily: Sensor pad alert as ordered. Explain risks and benefits to resident and representative. Bed and chair sensor pad alarm at all times. Monitor proper placement and function of sensor pad every (q) shift. During a review of Resident 29's MDS, dated [DATE], the MDS indicated Resident 29 was assessed having severely impaired cognitive skills for daily decision making. Resident 29 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shoer/bathe self, and lower body dressing. Resident 29 required partial/moderate assistance with sit to stand, chair/bed-to-chair transfer, and toilet transfer. Resident 29 required supervision or touching assistance with walking 10 feet and walking 50 feet with two turns. The MDS indicated Resident 29 had a one (1) fall with injury (except major) since the last prior assessment on 7/8/2024. During a review of Resident 29's Physician's Orders form, dated 11/6/2024, the Physician's Orders form indicated an order, with a start date of 6/5/2024, for bed and chair sensor pad alarm at all times- every shift for unsafe behavior manifested by (m/b) getting up unassisted and record number of episodes. During a review of Resident 29's Morse Fall Scale Assessment form, dated 10/21/2024, the form indicated a total fall risk score of 70 (a score of 51 or above indicated high risk for falls). During a concurrent observation of Resident 29 and interview with an unidentified staff member, on 11/4/2024, at 10:55 AM, Resident 29 was observed sitting on a chair outside her room. Resident 29 had a white cord hanging from her chair. The unidentified staff member walked by and stated the white cord was the sensor pad alarm. Resident 29 attempted to stand up and the sensor pad alarm did not go off. The unidentified staff member checked the white box that was connected to the sensor pad alarm and stated the sensor pad was not turned on. During a concurrent observation of Resident 29 and interview LVN 1 on 11/6/2024, at 3:41 PM, Resident 29 was observed sitting on a chair outside her room. Resident 29 was observed shifting and attempting to stand up from her chair. LVN 1 stated Resident 29 always sits on the chair outside her room. LVN 1 stated the chair had a sensor pad alarm because Resident 29 had a history of falls and tends to stand up without assistance from staff. LVN 1 observed Resident 29 attempt to stand up from the chair. The sensor pad alarm did not go off. LVN 1 checked the white box connected to the sensor pad alarm and stated the sensor pad alarm was off. LVN 1 stated the sensor pad alarm should always be on when Resident 29 is sitting on her chair. LVN 1 observed Resident 29 attempt to stand up from the chair again. The sensor pad alarm did not go off. LVN 1 checked the white box and stated the sensor pad alarm was on but did not know why the alarm did not go off. LVN 1 asked Resident 29 to stand up and repositioned the sensor pad alarm. LVN 1 asked Resident 29 to stand up again and the sensor alarm pad went off. LVN 1 stated the sensor pad needs to be completely underneath Resident 29 for the alarm to go off when Resident 29 stands. LVN 1 stated the sensor pad alarm was important because it notifies the staff when Resident 29 moves and tries to get up from her seat without assistance. LVN 1 stated it was important for Resident 29's sensor pad alarm for the safety of the Resident and to prevent falls. LVN 1 stated it was the responsibility of the CNAs and the Charge Nurses (CN) to make sure the sensor pad alarm was on and in the right position. During an interview with the DON, on 11/7/2024, at 11:01 AM, the DON stated the sensor alarm pad needs to always be on to know when the residents need assistance. The DON stated it was important to provide the residents assistance in a timely manner to prevent falls in the facility. The DON stated it was the responsibility of the CNAs and the CNs to make sure the sensor pad alarms are turned on. During a review of the facility's policy and procedure (P&P), titled, Falls and Fall Risk, Managing, revised on 3/2018, the P&P indicated the following: Based on previous evaluation and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the attending physician, will implement a Resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each Resident at risk or with a history of falls. Examples of initial approaches might include exercise and balance training, rearrangement of room furniture, improving footwear, changing the lighting, etc. If falling recurs despite initial interventions, stall will implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, cased on assessment of the nature of category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g. hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the Resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. If the Resident continues to fall, stall will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. Based on observation, interview and record review, the facility failed to provide interventions to prevent accidents (any unexpected or unintentional incident, which results or may result in injury or illness ) for three (3) of 3 sampled residents (Resident 61, 29, and 24) by failing to: 1. Ensure a functional bed sensor pad (alerting device intended to monitor a resident's movement) for Resident 61's use, as indicated on the physician's order and failed to ensure resident's call light was within reach, as indicated on the fall care plan. 2. Identify and eliminate all foreseeable accident hazards and include care plan interventions to address underlying cause of fall for Resident 24 who had a history of falls on 5/25/2024, 7/13/2024, 8/30/2024, and 9/27/2024. 3. Ensure Resident 29's sensor pad alarm was properly positioned and turned on and worked at all times. These deficient practices placed Residents 61, 24, and 29 at risk for falls and injury which had the potential to result in serious consequences like fractures (break in the bone), hospitalization, and death. Findings: 1. During a review of Resident 61's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses which included heart failure (a lifelong condition in which the heart muscle cannot pump enough blood to meet the body needs for blood and oxygen), paroxysmal atrial fibrillation (PAF, is a type of irregular heartbeat, or arrhythmia [an irregular heartbeat, or a problem with the rate or rhythm of your heart], that occurs in brief episodes that last less than seven days), muscle weakness, and unsteadiness on feet. During a review of Resident 61's Minimum Data Set (MDS, a federally mandated assessment tool), dated 11/4/2024, the MDS indicated Resident 61 had severe cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 61 needed partial/ moderate assistance (helper does less than half the effort, helper lifts, hold, or supports trunk or limbs but provides less than half the effort) with toileting hygiene, sit to stand, chair/bed -to chair transfer, toilet transfer. Resident 61 also needed supervision or touching assistance (helper provides verbal cues and/or touching/ steadying and/or contact guard assistance as resident completes activity) with oral hygiene, roll left and right, sit to lying, lying to sitting on side of the bed, and walk 10-150 feet. During a review of Resident 61's Physician's Orders, dated 10/8/2024, the Physician's Order indicated bed sensor pad at all times every shift for unsafe behavior manifested by getting up unassisted and record number of episodes. During a review of Resident 61's Fall Care Plan (CP), dated 8/13/2024, the CP indicated Resident 61 was at risk for self-injury from fall related to medical conditions, sensory alterations, balance, gait, assistive devices, cognition, mood/behavior, safety awareness, compliance, and medications. Goal indicated will follow safety suggestions and limitation with supervision and verbal reminders for better control of risk factors. Interventions included: Ensure that adaptive devices: walker are within reach. Encourage and assist placement of proper non-skid footwear. Observe for non-verbal signs of restlessness that may precipitate movement and attempts to stand/walk unattended. Observe for unsteady /unsafe transfer or ambulation and provide stand by or balance support as needed. Keep call light within reach at all times. Answer promptly and notify Resident 61 that help is coming. During an observation in Resident 61's Room on 11/7/2024 at 11:28 AM, Resident 61's call light was not within her reach. The call light was observed on the top drawer of the bedside table which was on the opposite side of the bed. The pad alarm machine box was hanging on the right side of the bed. The pad alarm did not make a sound/alarm when Resident 61 was trying to get out of her bed multiple times. During a concurrent observation in Resident 61's room and interview with Certified Nurse Assistant 1 (CNA 1) on 11/7/2024 at 11:29 AM, CNA 1 observed and stated the pad alarm did not make a sound /alarm when Resident 61 was observed trying to get out of her bed. CNA 1 stated Resident 61's call light was not within her reach and was placed on the top drawer of the bedside table which was on the opposite side of the bed. During a concurrent observation and interview with CNA 1 on 11/7/2024 at 11:32 AM, CNA 1 stated the pad alarm was placed on the left side of the bed and should have been placed in the middle of the bed where Resident 61was laying down for it to work. During an interview with CNA 1 on 11/7/2024 at 11:34 AM, CNA 1 stated, it was important for the pad alarm to make a sound/alarm to alert the staff , prevent Resident 61 might end up from falling. During a review of facility's policy and procedure (P&P) titled, Safety and Supervision of Residents revised on 7/2017, the P&P indicated the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. It also indicated to reduce accidents risks and hazards shall include the following: ensuring that interventions are implemented. During a review of facility's P&P titled, Falls and Managing Fall Risk, revised on 3/2018, the P&P indicated position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner.

Based on observation, interview, and record review, the facility failed to label food items in the kitchen with item name, opened and expiration date as indicated in the facility's policy and procedure. This deficient practice had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness such as food poisoning with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: During a concurrent observation and interview on 11/7/2024 at 7:49 AM with dietary supervisor (DS) in the walk-in refrigerator of the main kitchen, the following were observed: a. Four trays of marinated fish fillet have no labels for the name of the food item, date, and time it was prepared and no label of use-by date. b. Three trays of prepared Jello have no lids to cover the trays of the Jello, there were no labels for the name of the food item, date, and time it was prepared and no label of use-by date. c. One loaf of banana bread in the metal container has no wrapping, no lid, and there was no label for the name of the food item, date, and time of prepare and the use by date. DS stated all the food trays should always be labeled with the food item name, preparation date and time, and the use by date for each food item. DS stated all the ready to eat food items are supposed to be covered with lids or shrink wrap (transparent plastic film used to cover/ enclose food items) to prevent food contaminations. During a concurrent observation and interview on 11/7/2024 at 8:09 AM with dietary service director (DD) and DS in the walk-in freezer, the following were found: a. Three (3) bags of frozen meat were randomly sitting on top of two paper boxes, the 3 bags of frozen meat were not labeled with food item name, there were no purchase date, no expiration date and no best use by date. b. Two (2) packages of snap pea not labeled with expiration date. c. Two packages of breakfast waffles not labeled with food item name, and no use by date. d. One bag of cream puffs with no food item name and no expiration date. DD and DS stated all food items were supposed to be labeled with food item name and labeled with the used by date. During a concurrent observation and interview on 11/7/2024 at 8:23 AM with DD and DS in the dry food storage area next to the main freezer observed one bag of buttermilk biscuit mix and was not labeled with used by date. During a review of the facility's policy and procedure (P&P) titled, Food and Supply Storage, revised on 1/2024, the P&P indicated all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. The policy and procedure also indicated cover, label and date unused portions and open packages.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a resident centered care plan to address functional assistance needed with Activities of Daily Living (ADL) for one of two sampled residents (Resident 1) in accordance with the facility policy. This failure had the potential for Resident 1 not to receive interventions specific to the residents needs, which could result in injury and fall. Findings: A review of Resident 1's admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included dementia (the impaired ability to remember, think or make decisions that interferes with doing everyday activities), difficulty in walking and fracture (break in the bone) of the right femur (thigh bone). A review of Resident 1's History and Physical Examination, dated 3/15/23, indicated Resident 1 does not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment care screening tool), dated 12/13/23, indicated the resident was severely impaired with cognitive (difficulty with or unable to make decisions, learn, remember things) skills for daily decision making. Resident 1 needed substantial/maximal assistance (helper does more than half the effort; helper lifts or holds trunk or limbs and provides more than half the effort) with walking, transfers (how resident moves to and from bed, chair, wheelchair, standing position), dressing and personal hygiene & required setup or clean-up assistance with eating. During an interview on 1/17/24 at 2:13 PM with Restorative Nursing Assistant (RNA), RNA stated that Resident 1 needed two-person assistance with walking. During a concurrent record review of Resident 1's ADL Function Care Rehab Care Plan and interview on 1/17/24 at 3:46 PM with Physical Therapist (PT), Resident 1's care plan indicated Resident 1 needed Substantial assist with walking. PT stated, I understand substantial assist as the resident only needing one person assist with ambulation (walking). PT also stated care plan should have indicated that the resident was max assist to totally dependent with two people for ambulation. PT stated, It is not safe for the resident to ambulate with only one person since she might fall and sustain further injury. During an interview on 1/17/24 at 4:04 PM with Care Plan Coordinator (CPC), CPC stated, I inputted substantial assist with ambulation in Resident 1's care plan since that is what is reflected on the resident's MDS. CPC stated, I should have made the care plan entry more specific, clear, and easy to understand by facility staff especially since I believe that the resident should ambulate with two-person assistance for her safety and to prevent her from falling. During a record review of Resident 1's Interdisciplinary Team (IDT) Conference Record, dated 1/12/24, IDT Conference Record indicated that the resident required up to extensive to total assistance with ADLs. A review of Resident 1's Falls Care Plan, dated 1/8/24, indicated, Consult with therapy regarding current functional status and follow all recommendations and the restorative programs. A review of the facility's policy and procedure titled, Care Area Assessments, revised November 2019 indicated to Include specific interventions, including those that address common causes of multiple issues. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised March 2022, indicated, The care plan interventions are derived from a thorough analysis of information gathered as part of the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure that the call light (device used by residents to call staff) was within reach for one of 19 sampled residents (Resident 75). The call light was observed on the floor, out of reach (more than the arm's length) of Resident 75. This failure had the potential to put Resident 75 at risk for fall that could lead to a serious injury and/ or death. Findings: A record review of Resident 75's face sheet (admission records) indicated Resident 75 was admitted in the facility on 3/11/2023 with admitting diagnoses of generalized muscle weakness (weakness of the muscle that affects the entire body), unsteadiness of the feet, and history of falls. A review of Resident 75's Minimum Data Set (MDS - a standardized assessment tool that measures the health status in nursing home residents), dated 9/1/2023, indicated, Resident 75 requires assistance with activities of daily living, including bed mobility (how resident moves while in bed such as turning from side to side), transferring, walking, dressing (how resident puts on clothing, including footwear), eating, toileting, and personal hygiene. A review of Resident 75's care plan (document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) titled, Falls, dated 9/26/2023, indicated Resident 75 is at risk for falls. The care plan also indicated the resident's call light should be kept within reach. During a concurrent observation and interview on 11/13/2023 at 8:56 AM inside Resident 75's room, Resident 75 was sitting on the right side of the bed, and near the foot of the bed. Resident 75 stated she needed assistance from the facility staff but cannot find her call light to alert the staff. The resident's call light was observed on the floor, on the left side of the bed, and near the head of the bed. During an interview on 11/13/2023 at 9:00 AM inside Resident 75's room with Certified Nursing Assistant (CNA) 4, CNA 4 was called to the room by the surveyor to assist Resident 75. CNA 4 stated the call light is on the floor and is not accessible and within the reach of Resident 75. CNA 4 stated the call light should be close and within the resident's reach. During an interview on 11/13/2023 at 9:52 AM with Licensed Vocational Nurse (LVN) 5, LVN 5 stated Resident 75 needs to have their call light within reach to call for assistance. LVN 5 stated Resident 75 is a fall risk and can suffer an accident if staff fail to assist the resident when resident needed assistance and was unable to call the facility staff. A review of the facility's policy titled, Answering the Call Light, revised 9/2022, indicated the facility is to ensure that the call light is accessible to the resident when in bed to ensure timely responses to the resident's needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were provided a homelike environment for three of 19 sampled residents (Resident 53, Resident 76, and Resident 57) by failing to provide a working wall clock with the correct time. This deficient practice had the potential to negatively impact the resident's quality of life and further confuse the residents. Findings: A review of Resident 53's admission record indicated Resident 53 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm (another term for a cancerous tumor) of unspecified site of right female breast, muscle weakness and difficulty in walking. A review of Resident 53's History and Physical dated 12/14/2022 indicated Resident 53 does not have the capacity to understand and make decisions. A review of Resident 53's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 8/23/2023, indicated Resident 53 needs extensive assistance with a one-person assistance for bed mobility (ability to move around in bed), transfers, dressing, toilet use and personal hygiene. During an observation on 11/13/2023, at 9:52 AM, the wall clock in Resident 53's room indicated the time of 2:43 and the seconds hand was stuck on the 44 second indicator. During an interview on 11/13/2023 11:35 AM, Licensed Vocational Nurse (LVN) 5 stated, the wall clock in Resident 53's room was 2:43 and was not the correct time. A review of Resident 76's admission record indicated Resident 76 was admitted to the facility on [DATE] with diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), muscle weakness and generalized weakness. A review of Resident 76's History and Physical, dated 8/15/2023, indicated Resident 76 does not have the capacity to understand and make decisions. A review of Resident 76's MDS dated [DATE], indicated Resident 76 needs extensive assistance with a one-person assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. A review of Resident 57's admission record indicated Resident 57 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder (persistent and excessive worry that interferes with daily activities), age related physical debility, muscle weakness, difficulty in walking. A review of Resident 57's History and Physical, dated 5/24/2023, indicated Resident 57 can make needs known but can not make medical decisions. A review of Resident 57's MDS, dated [DATE], indicated Resident 57 needs extensive assistance with a one-person assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. During an observation on 11/13/2023 at 9:55 AM the wall clock in Resident 76 and 57's room indicated the time of 9:43 and the seconds hand was stuck on the 25 second indicator. During a concurrent observation in Resident 53's room and interview on 11/13/2023 at 11:27 AM, Resident 53's wall clock still read 2:43 and the seconds hand was stopped at the 44-second mark. LVN 5 stated, the wall clock had low battery that is why it was not giving the correct time. LVN 5 also stated, all wall clocks should be in good working order for residents to tell the time correctly. LVN 5 stated, the facility is the resident's home, and the residents needed the correct time in their clock because the wrong time could further confuse the residents. During a concurrent interview with LVN 5 on 11/14/2023 9:52 AM, LVN 5 stated most of the residents in the facility need frequent reorientation and that LVN 5 uses wall clocks to re-orient residents to time. LVN 5 stated, reorienting residents is important to do for the residents' well-being. During an interview with Certified Nurse Assistant (CNA) 3 on 11/15/2023 3:07 PM, CNA 3 stated a resident can get confused, especially at night. CNA 3 stated Resident 53 is forgetful at times. CNA 3 also stated the wall clock is an equipment used to show the residents the current time. CNA 3 stated, it is important to have the correct time in the clock because residents use it to know the time. Having the wrong time can add to the confusion of the residents. Can 3 further stated, Residents 76 and 57 are alert and uses the wall clock to know the time of the day. A review of the facility Policy & Procedure titled, Homelike Environment, revised 2/2021 indicated, Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a resident-specific care plan addressing the Preadmission Screening and Resident Review II (PASRR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are appropriately placed in nursing homes for long term care) recommendations for one of 19 sampled residents (Resident 27). This deficient practice had the potential for Resident 27 to not get the appropriate care and interventions for her mental needs. Findings: A review of Resident 27's Profile Face Sheet (admission record) indicated Resident 27 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included dementia (a brain disorder that results in memory loss, poor judgment and confusion), psychosis (mental disorder characterized by a disconnection from reality), and anemia (condition where the blood does not carry enough oxygen to the rest of the body). A record review of Resident 27's Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) Level 1 Screening result dated 5/12/2023 indicated Resident 27 was positive for suspected MI (mental illness) and required a Level II Mental Health Evaluation Referral. A record review of Resident 27's PASRR Individualized Determination Report, dated 5/17/2023, indicated Resident 27 had a significant medical condition with mental stressors and required nursing care. The recommendation for mental health rehabilitation activity included therapeutic community, dance, music, art, exercise, leisure, recreation, orientation, education, and/or skill building activities. The report also indicated the recommendation for supportive services included interactions with facility staff that encourage problem solving, socialization, reality orientation or focus on therapeutic goals. A review of Resident 27's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 9/15/2023, indicated Resident 27 had severely impaired cognition (thought process and ability to reason or make decisions) for daily decision making. The MDS indicated Resident 27 needed extensive assistance (resident involved in activity, staff provides weight bearing support) with one-person physical assist for bed mobility, transfer, locomotion (movement or the ability to move from one place to another) off unit, dressing, eating, toilet use, and personal hygiene and needed limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with one-person assist physical assist for locomotion on unit. Resident 27 needed supervision with one-person assist with walk in room and corridor. During an interview with the Director of Nursing (DON), on 11/16/2023, at 8:53 AM, the DON stated PASSR II recommendations are given to the Care Plan Coordinator (CPC) once it is received so CPC can add in the resident's care plan. During a concurrent interview and record review on 11/16/2023, at 9:01 AM, with the CPC, Resident 27's care plan dated 10/3/2023 under the category Activities was reviewed. CPC stated Resident 27 did not have a specific care plan for PASRR II recommendations. CPC stated Resident 27's Activities care plan intervention were generic and not specific to the resident's condition/ wants and like and the interventions were generic. CPC stated every resident has different wants and likes which should be reflected in the care plan interventions. During an interview with the DON on 11/16/2023, at 2:29 PM, the DON stated, all PASSR II recommendations need to be incorporated in the resident's care plan. The DON stated it is important for Resident 27 to have an individualized care plan because of her medical history. The DON stated it is important to have care plan with PASSR II recommendations because this would provide the staff with information on how to address the individual needs of Resident 27. A review of the facility's policy and procedure (P&P) titled, Goals and Objectives, Care Plans, revised on 4/2009, the P&P indicated, Care Plans shall incorporate goals and objectives that lead to the Resident's highest obtainable level of independence. The P&P also indicated, Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment and are resident oriented; are behaviorally stated; are measurable; and contain timetables to meet the resident's needs in accordance with the comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Cross Reference with F692 and F726 Based on interview and record review, the facility failed to review and revise a care plan to address a significant weight loss (weight loss of five percent in one month) for one of 19 sampled residents (Resident 35). This deficient practice placed Resident 35 at risk for further decline in nutritional status and continued weight loss, which could result in serious harm. Findings: A review of Resident 35's admission Record indicated Resident 35 was admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease (COPD- disease that causes obstructed airflow from the lungs), thyrotoxicosis (an abnormal high blood levels of triiodothyronine (T3) and thyroxine (T4) which are your body's thyroid hormones), and hypertension (high blood pressure). A review of the Resident 35's History and Physical (H&P, the initial clinical evaluation and examination of the patient), dated 7/20/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 35's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 10/9/2023, indicated Resident 35 was not cognitively (mental action or process of acquiring knowledge and understanding) intact for daily decision making. The MDS indicated Resident 35 required supervision or touching assistance for eating and oral hygiene. The MDS also indicated Resident 35 required partial/moderate assistance (helper does less than half the effort) for toilet hygiene, shower/bathe, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness). The MDS also indicated Resident 35 required set up or clean-up assistance for toilet transfer and shower transfer. A review of Resident 35's Weight Tracking System indicated as follows: - On 10/12/2023, the resident's weight was 127 pounds (lbs., unit of measurement). - On 11/03/2023, the resident's weight was 123 lbs. - On 11/11/2023, the resident's weight was 120 lbs., (5.51% weight loss in 30 days). A review of Resident 35's Care Plan titled, Nutrition, dated 10/23/2023, indicated Resident 35 had a potential for alteration in nutrition. The care plan did not reflect Resident 35's actual weight loss of 5.5% on 11/11/2023. During a record review of Resident 35's weight, Care Plan, Nurses and Dietary notes and concurrent interview and on 11/15/2023 at 11:30 AM with LVN 2, LVN 2 stated Resident 35 had a weight loss of 5.51 %. LVN 2 stated nurses needed to notify the doctor right away for a weight loss of more than 5 lbs. in one month. LVN 2 stated there were no documentation indicating the resident's doctor was notified from 11/11/2023 to 11/15/2023 regarding Resident 35's weight loss of 5.5 %. LVN 2 stated Resident 35 experienced a change in condition when he lost 7 lbs. LVN 2 stated when Resident 35 lost 7 lbs. in one month, the doctor was not and should have been notified. LVN 2 stated Resident 35's care plan was not and should have been updated due to weight loss. During an interview on 11/15/2023 at 2:45 PM with the Director of Nursing (DON), the DON stated a weight loss of 5% is considered a change of condition. The DON stated the licensed nurses or the dietician needed to notify the doctor right away and find out the underlying cause for the weight loss. The DON stated the resident's weight loss may be due to a mental issue, poor appetite, and may require medication, dietary, and nursing interventions. The DON stated the Care Plan Coordinator (CPC) and Registered Dietician (RD) were in charge of updating the nutrition care plan. The DON stated Resident 35's care plan for nutrition needed to be updated with the addition of new interventions due to the weight loss. A review of the facility's policy and procedure titled, Goals and Objectives, Care Plans, revised 4/2009, indicated goals and objectives are reviewed and/or revised when there has been a significant change in the resident's condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Cross Reference with F657 and F726 Based on interview and record review, the facility failed to maintain acceptable parameters of nutritional status for one of one sampled resident (Resident 35) in accordance with the facility policy by failing to: a. Notify the resident's physician of Resident 35's significant weight loss (weight loss of five percent in one month) of 5.5 percent (%) in a month . b. Conduct an Interdisciplinary Team Nutrition Alert meeting (a systematic and interdisciplinary approach to identify, track, intervene, monitor, and follow-up with residents at high risk for significant weight changes, dehydration (harmful reduction in the amount of water in the body), and any other nutrition-related concerns) to address Resident 35's significant weight loss. c. Obtain and implement interventions to prevent further weight loss. This deficient practice placed Resident 35 at risk for further decline in nutritional status, which could result in harm. Findings: A review of Resident 35's admission Record indicated Resident 35 was admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease (COPD- disease that causes obstructed airflow from the lungs), thyrotoxicosis (an abnormal high blood levels of triiodothyronine (T3) and thyroxine(T4) which are your body's thyroid hormones), and hypertension (high blood pressure). A review of the Resident 35's History and Physical (H&P, the initial clinical evaluation and examination of the patient), dated 7/20/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 35's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 10/9/2023, indicated Resident 35 was not cognitively (mental action or process of acquiring knowledge and understanding) intact for daily decision making. The MDS indicated Resident 35 required supervision or touching assistance for eating and oral hygiene. The MDS also indicated Resident 35 required partial/moderate assistance (helper does less than half the effort) for toilet hygiene, shower/bathe, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness). The MDS also indicated Resident 35 required set up or clean-up assistance for toilet transfer and shower transfer. A review of Resident 35's Weight Tracking System indicated as follows: - On 10/12/2023, the resident's weight was 127 pounds (lbs., unit of measurement). - On 11/03/2023, the resident's weight was 123 lbs. - On 11/11/2023, the resident's weight was 120 lbs., (-5.51% weight loss in 30 days). A review of Resident 35's Care Plan titled, Nutrition, dated 10/23/2023, indicated to monitor weight and notify the doctor of significant weight changes. The care plan also indicated to notify the doctor of significant loss of appetite or meal refusals. A review of Resident 35's Daily Charting for Eating Total % of Intake indicated as follows: - On 11/1/2023, the resident consumed 26-50% for dinner. - On 11/7/2023, the resident consumed 0% for lunch. - On 11/8/2023, the resident consumed 25% or less for lunch and 0% for dinner. - On 11/9/2023, the resident consumed 25% or less for lunch and 25% or less for dinner. - On 11/11/2023, the resident consumed 26-50% for dinner. - On 11/12/2023, the resident consumed 26-50% for lunch and 26-50% for dinner. - On 11/14/2023, the resident consumed 25% or less for lunch. - On 11/15/2023, the resident consumed 25% or less for lunch and 26-50% for dinner. A review of the Interdisciplinary Notes (nursing notes) for the month of November 2023, did not indicate the doctor was notified of Resident 35'weight loss of 5.5%. A review of the Dietary Notes for the month of November 2023, did not indicate the doctor was notified of Resident 35's 5.5% weight loss. During a concurrent record review of Resident 35's Weight Tracking System and Nursing Notes and an interview on 11/15/2023 at 11:22 AM with the Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 35 had experienced a loss of appetite since he recently lost his wife last month who was also his roommate. LVN 1 stated Resident 35 was not eating enough and needed encouraging during mealtimes. LVN 1 stated Resident 35 lost seven (7) lbs. from 10/12/2023 to 11/11/2023. LVN 1 stated a 7 lb. weight loss was significant. LVN 1 stated when residents have a weight loss of three (3) to five (5) lbs., the licensed nurses needed to contact the doctor right away. LVN 1 stated there was no documented evidence the doctor was contacted to obtain interventions to address and prevent Resident 35 from further weight loss. During an interview on 11/15/2023 at 12:27 PM with the Assistant Director of Dining Services (ADDS), the ADDS stated a 5% weight loss within 30 days is considered a significant weight loss. The ADDS stated when residents have a 5% weight loss, a nutrition alert would be done, and a meeting would be conducted to address the weight loss by providing nutritional interventions. The ADDS stated a nutrition alert meeting was not done this week since the Registered Dietician (RD) was on vacation. The ADDS stated nutrition alerts were done weekly. The ADDS stated the last Nutrition Alert Meeting Minutes was done on 11/7/2023. During an interview on 11/15/2023 at 2:45 PM with the Director of Nursing (DON), the DON stated a weight loss of 5% is considered a change of condition. The DON stated the licensed nurses or the dietician needed to notify the doctor right away and find out the underlying cause for the weight loss. The DON stated the resident's weight loss may be due to a mental issue, poor appetite, and may require medication, dietary, and nursing interventions. The DON stated the Care Plan Coordinator (CPC) and Registered Dietician (RD) were in charge of updating the nutrition care plan. The DON stated Resident 35's care plan for nutrition needed to be updated with the addition of new interventions due to the weight loss. During an interview on 11/16/2023 at 8:15 AM with the Director of Staff Development (DSD), the DSD stated when the Certified Nursing Assistant (CNA - general) or Restorative Nursing Aide (RNA - general) was made aware of a resident weight loss of more than 5 lbs. in one month, the CNA or RNA need to notify the charge nurse and dietician. The DSD stated the licensed nurses would need to document the weight loss and notify the doctor right away. The DSD also stated the CNA/RNA would need to notify the charge nurse so the charge nurse could contact the doctor to try to prevent continued weight loss, find other factors contributing to the weight loss, and order any necessary laboratory work. During an interview on 11/16/2023 at 9:21 AM with the CPC, the CPC stated meetings for significant weight loss were done weekly on Tuesdays. The CPC stated, We did not have the weekly weight loss meeting last Tuesday (11/14/2023) since the RD was on vacation. The CPC stated Resident 35's care plan titled, Nutrition, indicated to monitor weight and notify MD of significant changes. A review of the facility's policy and procedure titled, Nutrition Alert/High Risk, revised 1/2023, indicated unplanned significant weight loss of 5% in one month qualifies a resident for Nutrition Alert/High Risk. Regularly scheduled Nutrition Alert/High Risk meetings are held on a weekly schedule to review all identified residents on the Nutrition Alert/High Risk. A review of the facility's policy and procedure titled, Nutrition (Impaired)/Unplanned Weight Loss, revised 9/2017, indicated the staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, revised 2/2021, indicated the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical condition. The nurse will also notify the resident's attending physician when there has been a specific instruction to notify the physician of changes in the resident's condition. Notifications to the physician will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.

Cross Reference with F657 and F726 Based on interview and record review, the facility failed to ensure Restorative Nursing Aide 1 (RNA 1) had the appropriate skill sets and proficiencies to provide nursing services for resident in response to a change in condition of significant weight loss (five percent weight loss in one month) for one of 19 sampled residents (Resident 35). This deficient practice had the potential to place Resident 35 and other residents who may be at risk for decline in nutritional status, suffer from unplanned weight loss. Findings: A review of Resident 35's Weight Tracking System indicated as follows: - On 10/12/2023, the resident's weight was 127 pounds (lbs., unit of measurement). - On 11/03/2023, the resident's weight was 123 lbs. - On 11/11/2023, the resident's weight was 120 lbs., (-5.51% weight loss in 30 days). During a concurrent record review of Resident 35's Nursing Notes and interview with Licensed Vocational Nurse 1 (LVN 1) on 11/15/2023 at 11:22 AM, LVN 1 stated Resident 35 lost seven (7) lbs. from 10/12/2023 to 11/11/2023. LVN 1 stated a 7 lb. weight loss was significant. LVN 1 stated when residents have a weight loss of three (3) to five (5) lbs. they needed to contact the doctor right away. LVN 1 stated there was no documented evidence that the doctor was contacted for Resident 35's weight loss to obtain orders for further interventions to prevent weight loss. During a concurrent record review of Resident 35's weight and interview on 11/15/2023 at 11:30 AM with LVN 2, LVN 2 stated RNA 1 was responsible for taking Resident 35's weight and informing the Registered Dietician (RD) and licensed nurse of weight loss. During a concurrent interview and record review of Resident 35's Weight Record with RNA 1, RNA 1 stated Resident 35 was placed on weekly weights on 11/11/2023. RNA 1 stated Resident 35's weight was 120 lbs. on 11/11/2023. RNA 1 stated Resident 35's weight would be taken weekly after 11/11/2023 and his weight would be compared to the weights taken the following weeks. RNA 1 stated she disregarded all previous weights prior to the weekly weight started on 11/11/2023. RNA 1 stated she needed to report to the licensed nurses when residents have a weight loss of 5 lbs or more. RNA 1 stated she did not report Resident 35's weight loss of 7 lbs. from 10/12/2023 to 11/11/2023. A review of the facility's policy and procedure titled, Restorative CNA Position Description, dated 3/2011, indicated the RNA was to complete weekly and monthly weights for residents and report unusual weight changes to the Charge Nurse. A review of the facility's policy and procedure titled, Nutrition (Impaired)/Unplanned Weight Loss, revised 9/2017, indicated the staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor the effectiveness of psychotropic medications (a type of medication that affects brain activities associated with mental processes and behavior) for one of five sampled residents (Resident 76). This failure had the potential to put the resident at risk for not receiving the appropriate treatment. Findings: A review of Resident 76's face sheet (admission record) indicated the resident was admitted on [DATE] with admitting diagnoses of dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), psychosis (mental disorder that affects how a person thinks, feels, and behaves), and cognitive communication deficit (loss of ability to communicate). A review of Resident 76's Minimum Data Set (MDS - a standardized assessment tool that measures health status in nursing home residents), dated 9/1/2023, indicated the resident has impaired cognition (an individual's ability to process thoughts and the ability to perform the various mental activities most closely associated with learning and problem solving) and requires extensive assistance with bed mobility and activities of daily living. A review of Resident 76's physician's orders, dated 7/17/2023, indicated the resident is to be given 50 milligrams (mg) of Seroquel (a medication that treats several kinds of mental health conditions), at bedtime, for psychosis manifested by voicing of being afraid causing the resident to constantly get up unassisted or unsafely to go somewhere. A review of Resident 76's physician's orders, dated 7/18/2023, indicated the resident is to be given 25 mg of Seroquel, once daily, for psychosis manifested by voicing of being afraid causing the resident to constantly get up unassisted or unsafely to go somewhere. A review of Resident 76's titled medication administration record (MAR), did not indicate documentation from 7/18/2023 to 11/14/2023 that staff have been monitoring Resident 76's behavior of voicing of being afraid. During a concurrent interview and record review of Resident 76's MAR for 7/2023 to 11/2023, on 11/15/2023 at 8:44 AM, Licensed Vocational Nurse (LVN) 2 stated, there was no documented evidence in the resident's MAR that the resident's behavior of voicing of being afraid was monitored and documented. LVN 2 stated, staff have not been monitoring Resident 76's behavior of voicing of being afraid and that monitoring should have been done to ensure the effectiveness of Seroquel and that residents receive the correct treatment for their medical condition. During an interview on 11/15/2023 at 10:40 AM with Certified Nursing Assistant (CNA) 4, CNA 4 stated that Resident 76 did not verbalize to the staff before attempting to get up. CNA 4 stated that she has never recalled the resident ever voicing out ever being afraid. During an interview on 11/15/2023 at 3:07 PM with CNA 3, CNA 3 stated that Resident 76 has not voiced out ever being afraid. During an interview on 11/15/2023 at 3:14 PM with LVN 5, LVN 5 stated, she has never heard Resident 76 voicing that the resident is afraid since the medication was ordered on 7/18/2023. LVN 5 stated, if licensed nurses were able to monitor and document Resident 76's behavior of voicing of being afraid, then the licensed nurses could have known that there was no behavior noted by licensed nurses and other CNAs and that they would have been able to notify the physician to check if the medication can be reduced or is still necessary. During an interview on 11/15/2023 at 10:45 AM with the Care Plan Coordinator (CPC), CPC stated, residents receiving psychotropic medications have care plans (document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) that address the plan to monitor each behavior associated with each psychotropic medication. CPC stated that behavior monitoring every shift is done to assess if psychotropic medications are still necessary and for the gradual dose reduction (the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of medications. During an interview on 11/15/2023 at 2:26 PM with the Director of Nursing (DON), the DON stated, monitoring of Resident 76's behavior is necessary to ensure the effectiveness of Resident 76's Seroquel and to assess if the medication is still needed or if the dose can be reduced according to the resident's needs. A review of the facility's policy titled, Psychotropic Medication Use, dated 7/2022, indicated that psychotropic medication management includes adequate monitoring for the effectiveness of the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for one of one sampled resident (Resident 2) when the oxygen tubing observed touching the floor. This deficient practice had the potential to spread respiratory infection to Resident 2. Findings: A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE]. Resident 2's diagnoses included chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease that causes obstructed airflow from the lungs, acute respiratory failure (occurs when you do not have enough oxygen in your blood) with hypercapnic (happens when you have too much carbon dioxide in your blood) and chronic bronchitis (is inflammation and irritation of the bronchial tubes[these tubes are the airways that carry air to and from the air sacs in your lungs]). A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 10/26/2023, indicated Resident 2 has intact cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. Resident 2 total dependent (helper does all the effort. Resident does none of the effort to complete the activity) in toileting hygiene, shower/bathe self, upper/lower body dressing, and putting on/taking off footwear. During an observation inside Resident 2's room on 11/13/2023 at 10:16 AM, Resident 2 was receiving oxygen at two (2) liters per minute (lpm) via nasal cannula with humidifier. The oxygen tubing was observed touching the floor. During a concurrent observation in Resident 2's room and interview with Licensed Vocational Nurse (LVN) 1 on 11/13/2023 at 10:17 AM, LVN 1 stated, Oxygen tubing should not be touching the floor. We stick it inside the bag located at the back of the oxygen machine because of infection control. Bacteria or germs will go into Resident's nose, eyes, mouth and spread the infection. If the oxygen was touching the floor, we have to replace it right away. During a concurrent observation in Resident 2's room and interview with LVN 1 on 11/13/23 at 10:23 AM, LVN 1 stated, The oxygen tubing was touching the floor. It was contaminated, so to be safe, we have to change it immediately. A review of facility's policy and procedure (P&P) titled, Departmental (Respiratory Therapy)- Prevention of Infection, dated 11/2011, P&P indicated to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff.

Based on observation, interview, and record review, the facility failed to: 1. Label food in the kitchen with item name, opened and expiration date, and discard expired food as indicated on the facility's policy and procedure. a. Two opened packages of bread (English muffin and white loaf bread) in the working station were not labeled to indicate date food items were opened. b. Three trays of blueberry dessert, cornbread, and chocolate cake placed on a rack in the dry storage room were not labeled with item name and date when they were made. c. An opened box of cinnamon streusel coffee mix and corn flakes crumbs were not labeled to indicate date when it was opened. d. A container with brown grains in the dry storage did not have a label to indicate the food item. e. Four packages of mandarin orange sauce were not labeled to indicate expiration date. f. A package of chocolate chip cookies was not labeled to indicate expiration date. g. A tray of expired left over Boston cream pie dated 6/23/2023 was not discarded. 2. Ice cream freezer log did not have a documentation for temperatures taken from 11/1/2023 to 11/13/2023 and Freezer 1 has no temperature documented for 11/13/2023. 3. The facility failed to follow infection control measures in the kitchen when: a. A personal tumbler with tea was in Freezer 1. b. An open box of gloves was placed on top of food container and tray of disposable utensils. c. A book and opened package of table napkins were in the main freezer storage. These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness ([food poisoning] with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization. Findings: 1. During a concurrent observation in the kitchen and interview with the Dining Services Director (DND) and Kitchen Staff 2 (KS 2) on 11/13/2023 at 8:45 AM, there was no label on the two opened packages of bread (English muffin and white loaf bread) in the working station. DND stated, We label the bread after opening the bag and before putting it back in the refrigerator. KS 2 stated, No, I do not have label on the breads. Are we supposed to label them? During a concurrent observation in the kitchen and interview with the DND on 11/13/2023 at 8:53 AM, there were no labels to include the date and name of the item of the three trays of blueberry dessert, cornbread, and chocolate cake placed on a rack in the dry storage room were made. DND stated, The food trays needed to be labeled with the food item and date it was prepared every time. During a concurrent observation in the dry storage room and interview with the DND on 11/13/2023 at 8:59 AM, in the dry storage were the following: a. An opened box of cinnamon streusel coffee mix and corn flakes crumbs without a label to indicate when it was opened. b. A container with brown grains did not have a label to indicate the food item. DND stated, he could not verify what was inside the container because it did not have a label to identify the food item. The DND stated the container should have been labeled with the food item. DND stated the opened box of cinnamon streusel coffee mix and corn flakes crumbs was not and should have an open date label. During a concurrent observation in the kitchen and interview with the DND on 11/15/2023 at 11:30 AM, there was no label to indicate the date when the milk container inside the refrigerator was opened. DND stated, the kitchen staff should label the milk container with the date it was opened. During a concurrent observation in the main freezer storage and interview with the DND on 11/15/2023 at 11:38 AM, in the main freezer storage were the following: a. There were four packages of mandarin orange sauce with no expiration date. b. A package of chocolate chip cookies with no expiration date. c. A tray of expired left over Boston cream pie dated 6/23/2023. DND stated all food items stated the food items were supposed to be labeled with item name and dated with the open and used by date. A review of the facility's policy and procedure titled, Food and Supply Storage, dated 1/2023, indicated all food, non- food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Cover, label and date unused portions and open packages. Discard food past the use - by or expiration date. Dry storage store foods in their original packages. Foods that must be opened must be stored in NSF approved containers that have tight - fitting lids. Label both the bin and the lid. Hang scoop. Scoops may be stored in bins on a scoop holder. The food level must be no closer than one inch below the handle of the scoop. 2. During a concurrent observation in the kitchen and interview with the Kitchen Staff 1(KS 1) on 11/13/2023 at 8:39 AM, Freezer 1 had no temperature recorded on the freezer log on 11/13/2023. KS 1 stated, There was no thermometer inside the freezer that is why there is no temperature recorded for Freezer 1 this morning. During a concurrent observation in the kitchen and interview with the DND on 11/13/2023 at 8:49 AM, the ice cream freezer log did not have a documentation for temperatures taken from 11/1/2023 to 11/13/2023. DND stated, The staff should be checking the freezer temperature and log it in every shift, in the morning and in the afternoon. A review of the facility's policy and procedure titled, Cold Storage Temperatures, dated 1/2023, indicated temperatures of food storage areas and cold food vendors are monitored and action is taken to maintain temperatures within ranges recommended by licensing and surveying agencies. Each refrigerated storage unit shall have an independent thermometer in addition to the built in thermometer. The thermometer shall be placed in the warmest part of the unit, typically near the door, readily accessible and placed so that it is not in the direct line of the air stream from the unit's fan. Supervisor each morning at opening and evening at closing, record temperatures of each storage unit, initial each entry. 3. During a concurrent observation and interview with the DND on 11/15/2023 at 11:27 AM, There was a personal tumbler with tea in Freezer 1. DND stated, Personal item should not be in the freezer. During a concurrent observation and interview with the DND on 11/15/2023 at 11:32 AM, there was a set of keys left in the small delivery cart containing clean plates. DND stated the keys were for the doors in the kitchen and it should not have been left in the delivery cart. DND stated, The person in charge in the morning should have it on them all the time. During a concurrent observation and interview with the DND on 11/15/2023 at 11:35 AM, an opened box of gloves was placed on top of the tray of the disposable utensils. DND stated, It should not be there. During a concurrent observation in the freezer storage and interview with the DND on 11/15/23 11:48 AM, there was a book and opened package of table napkins in the main freezer storage. DND stated, the items should not have been stored there. A review of the facility's policy and procedure titled, Associate Security Policies for Department, revised 1/2023, indicated jackets, sweaters, handbags, cell phones and other personal items are to be stored in appropriate locations as defined by management. These items must not be stored in food production or service areas. Department keys are never loaned or borrowed. All keys should remain on the person to which they are assigned. Any extra keys should be secured in the unit safe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to reasonably accommodate the needs of two of 20 sampled Residents (Resident 13 and 15) in accordance with the facility policy by failing to ensure: a. Resident 13's call light (device used by a resident to signal his or her need for assistance from professional staff) was within the resident's reach b. Resident 15's electronic (digital) clock on his bedside table personal equipment was set with the current time. as indicated in the facility's policy. This deficient practice had the potential to result in delay of care or services necessary for the Resident 13's wellbeing and had the potential for Resident 15 to get disoriented with time, which could affect Resident's participation with daily activities and over all wellbeing. Findings: a. A review of Resident 13's admission Record indicated resident was originally admitted to the facility on [DATE] and then readmitted on [DATE] with a diagnoses of hypertension (abnormally high blood pressure), hyperlipidemia (abnormally high concentration of fats or lipids in the blood), and Type 2 diabetes mellitus (a disease in which your blood glucose, or blood sugar, levels are too high). A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/31/22, indicated Resident 13 was severely impaired with cognitive skills for daily decision making (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 13 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer, dressing, personal hygiene and totally dependent with locomotion on and off unit and toilet use. The MDS indicated Resident 13 uses corrective lenses and was able to see large print, but not regular print in newspapers/books. A review of Resident 13's Visual Functions care plan, dated 7/06/22, indicated staff interventions included were to place call light within reach and to answer promptly. During an observation in Resident 13's room on 11/11/22 at 8:39 AM, Resident 13 was observed laying in bed calling out for water. Resident 13's call light was observed on the floor between Resident 13's bed and bedroom wall. During a concurrent observation in Resident 13's room and interview with Certified Nursing Assistant 4 (CNA 4) on 11/11/22 at 8:42 AM, CNA 4 verified Resident 13's call light was on the floor. CNA 4 stated the call light should always be within resident's reach so that Resident 13 may be able to call when she needs assistance. CNA 4 stated she did not know why the call light was on the floor. During observation in Resident 13's room on 11/12/22 at 7:28 AM, Resident 13 was observed calling out to Jesus. Resident 13's call light was observed hanging over the head of Resident 13's bed. During a concurrent observation in Resident 13's room and interview with Licensed Vocational Nurse 3 (LVN3) on 11/12/22 at 7:29 AM, Resident 13's call light was observed hanging over the head of Resident 13's bed. LVN 3 stated the call light should always be within resident's reach to prevent an accident or injury to a resident trying to call for assistance. During an interview with Director of Nursing (DON) on 11/13/22 at 4:38 PM, DON stated it is the facility's practice to always leave the call light within residents' reach. The DON stated it is important for all residents to have their call light within reach to get assistance from the staff when in distress to prevent accident. A review of the facility's policy and procedure titled, Answering the Call Light, revised in May 2021, indicated when the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. b. A review of Resident 13's admission Record indicated Resident 15 was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses that included cognitive communication deficit(an impairment in organization/ thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), primary hypertension(a type of high blood pressure that has no clearly identifiable cause) A review of Resident 15's History and Physical, dated 8/17/22, indicated the resident did not have capacity to understand or make decisions. On 11/11/22 at 8:35 AM, during initial tour of the facility, an observation of an electronic clock on the bedside table next to Resident 15's bed had the time of 9:35 AM. There was a wall clock observed in Resident 15's room with the time of 8:35 AM. Resident 15 stated he had notified the nurses that his bedside clock had the wrong time, but no one fixed it. Resident 15 stated he sometimes gets confused with having two clocks with two different times in his room. Resident 15 stated he did not like not knowing what the correct time was because he relies on the time of his bedside clock for his daily activities. On 11/12/22 at 7:20 AM, during a concurrent observation in Resident 15's room and interview with licensed vocational nurse 3 (LVN 3), LVN 3 stated Resident 15's electronic clock at bedside did not have the current time. LVN 3 stated it is everyone's (nurses, maintenance, housekeepers) responsibility to make sure everything in the resident's room is working properly. LVN 3 stated he was not aware the clock had the wrong time but would fix it. On 11/13/22 at 7:55 AM during interview, LVN 3 stated he forgot to fix the time on Resident 15's bedside clock. LVN 3 stated he would fix Resident 15's clock right away. On 11/13/22 at 4:30 P.M. during an interview, the Director of Nursing (DON) stated it is important for the facility to maintain the clocks in residents' room in working condition so the residents are aware of the current time and day, especially for the residents who has dementia(loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) . The DON stated ensuring that the clocks have the right time will help the residents with reality orientation. A review of the facility's policy and procedure titled, Homelike Environment, revised February 2021, indicated Resident are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure personal equipment were in good repair for one of three (3) sampled residents. Resident 15's electronic (digital) clock on his bedside table was not set with the current time. This deficient practice had the potential for Resident 15 to get disoriented with time, which could affect Resident's participation with daily activities and over all wellbeing. Findings: A review of Resident 13's admission Record indicated Resident 15 was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses that included cognitive communication deficit(an impairment in organization/ thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), primary hypertension(a type of high blood pressure that has no clearly identifiable cause) A review of Resident 15's History and Physical, dated 8/17/22, indicated the resident did not have capacity to understand or make decisions. On 11/11/22 at 8:35 AM, during initial tour of the facility, an observation of an electronic clock on the bedside table next to Resident 15's bed had the time of 9:35 AM. There was a wall clock observed in Resident 15's room with the time of 8:35 AM. Resident 15 stated he had notified the nurses that his bedside clock had the wrong time, but no one fixed it. Resident 15 stated he sometimes gets confused with having two clocks with two different times in his room. Resident 15 stated he did not like not knowing what the correct time was because he relies on the time of his bedside clock for his daily activities. On 11/12/22 at 7:20 AM, during a concurrent observation in Resident 15's room and interview with licensed vocational nurse 3 (LVN 3), LVN 3 stated Resident 15's electronic clock at bedside did not have the current time. LVN 3 stated it is everyone's (nurses, maintenance, housekeepers) responsibility to make sure everything in the resident's room is working properly. LVN 3 stated he was not aware the clock had the wrong time but would fix it. On 11/13/22 at 7:55 AM during interview, LVN 3 stated he forgot to fix the time on Resident 15's bedside clock. LVN 3 stated he would fix Resident 15's clock right away. On 11/13/22 at 4:30 P.M. during an interview, the Director of Nursing (DON) stated it is important for the facility to maintain the clocks in residents' room in working condition so the residents are aware of the current time and day, especially for the residents who has dementia(loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) . The DON stated ensuring that the clocks have the right time will help the residents with reality orientation. A review of the facility's policy and procedure titled, Homelike Environment, revised February 2021, indicated Resident are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise and update the plan of care for two (2) of 2 sampled residents (Resident 13 and 21) for the use of psychotropic drugs (medications used to treat certain mental/mood conditions). This deficient practice placed the resident at risk for not receiving the necessary services and treatment related to the use of Psychotropic drugs in the facility. Findings: 1. A review of Resident 13's admission Record indicated resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of depression (mood disorder that causes a persistent feeling of sadness and loss of interest), and Type 2 diabetes mellitus (a disease in which your blood glucose, or blood sugar, levels are too high). A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 10/31/2022 indicated Resident 13's has severely impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 13's indicators of psychosis (severe mental disorder that causes abnormal thinking and perception) included delusions (an unshakable belief in something untrue). A review of Residents 13's Medication Record Report, dated 11/01/2021 until 11/30/2021, indicated an order for the following: a. Trazadone ( medication used in the management and treatment of major depressive disorder ) 75 milligrams (mg, unit of measurement) take one (1) tablet by mouth at bedtime for depression manifested by (m/b) unable to sleep b. Seroquel(medication is used to treat certain mental/mood conditions such as schizophrenia [mental disorder characterized by abnormal social behavior and failure to understand what is real], bipolar disorder [extreme mood swings that include mania {emotional highs} and depression which may lead to impaired functioning), 25 mg tablet (Quetiapine) give ½ tablet = 12.5 mg by mouth every evening for psychosis m/b delusion calling mama and [NAME]. A review of Resident's 13's Care Plan, dated 07/06/2022, with a goal date of 10/04/2022 indicated Resident 13 has potential for drug related complications associated with the use of psychotropic medication to manage behavior related to depression and psychosis. 2. A review of Resident 21's admission Record indicated resident was a originally admitted on [DATE] and readmitted on [DATE] with a diagnoses of major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (involves persistent and excessive worry that interferes with daily activities), and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) A review of the MDS, dated [DATE], indicated Resident 21's has mildly impaired cognition. The MDS indicated Resident 21's indicators of Psychosis included delusions. A review of Residents 21's Medication Record Report, dated 11/01/2021 until 11/30/2021, indicated an order for the following: a. Remeron (Mirtazapine, drug used to treat depression ) 15 mg 1 tablet by mouth at bedtime for depression m/b self-reporting feelings of sadness. b. Seroquel 25 mg tablet give 1/2 tablet by mouth twice daily for psychosis m/b combativeness. c. Ativan (Lorazepam, medicine used to treat the symptoms of anxiety disorders 1 mg tablet by mouth once daily every morning routine for anxiety m/b restlessness. A review of Resident's 21's Care Plan, dated 07/06/2022, with a goal date of 10/04/2022, indicated Resident 21 has potential for drug related complications associated with the use of psychotropic medication to manage mood/behavior related to depression, anxiety, and impulse disorder. On 11/12/2022 at 10:27 A.M., during a concurrent record review of Resident's 13's and 21's care plan titled, Psychotropic Drugs, and interview with the Care Plan Coordinator (CPC), the CPC stated, the care plans were created 07/06/2022 and had an update date of 10/04/2022, but they had not been updated. The CPC stated, a care plan should be revised and updated quarterly, anytime there is a change of condition, and change in a physician's order. The CPC stated it is important to have an updated and current care plan for all residents because sometimes behaviors that are being monitored could change or the approach may not be working. The CPC stated sometimes she got busy and forgets to update the care plans by the required goal/update such as for Residents 13 and 21. On 11/13/2021 at 4: 30 P.M, during an interview with the Director of Nursing (DON), the DON stated care plans should be revised quarterly, annually, and when there is significant change. The DON stated having a current and updated care plan helps the staff to monitor Residents appropriately for adverse effects of the medication they are receiving. The DON stated it is the responsibility of the CPC or any of the licensed nurses to update the care plans. The DON stated the facility provided the care plan revision policy, however upon review of the facility policy titled, Care Plan, the policy did not include revision of care plans.

Based on interview and record review, the facility failed to ensure the initial and annual competency (applied skills and knowledge that enable people to successfully perform at their profession) evaluation requirements for two (2) of five (5) Certified Nurse Assistants (CNAs) were completed as indicated on the facility policy and procedure. 1. CNA 2 was newly hired at the facility on 5/10/2022 with no documented evidence of a completed initial competency. 2. CNA 3 with no documented evidence of a completed annual competency in 2021. This deficient practice had the potential for a knowledge and training deficit among the CNAs, which can lead to inadequate resident care. Findings: 1. During a concurrent record review of the employee file and interview with the Director of Staff Development (DSD) on 11/13/2022 timed at 10:30 AM, the DSD stated that CNA 2 was hired on 5/10/2022. The DSD stated CNA 2 did not have an initial competency training document on file because it was missing. The DSD further stated she could not find the document checklist in CNA 2's individual folder, which would have had CNA's 2 signature acknowledging the training was done. 2. During a concurrent record review of the employee file and interview with the DSD on 11/13/2022 timed at 10:35 AM, the DSD stated CNA 3 was hired on 6/11/2013. DSD stated CNA 3 did not have a documented evidence of an annual competency completed for 2021. During an interview with the DSD and Assistant Director of Nursing (ADON) on 11/13/2022 timed at 10:00 AM, the DSD stated a new or rehired CNA is required to go through orientation training which includes a review of the CNA's job description and work responsibilities. The DSD further stated after the CNA's orientation period, which is usually two weeks, she will assess the CNA's knowledge and skill level to determine if the CNA is ready to work on the nursing floor. The DSD stated the initial training and annual competencies are important to prevent any adverse outcome on the residents such as knowing how to prevent a a fall or develop a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin). The DSD further stated she is responsible for overseeing the CNA's initial and annual competency. The ADON stated the DSD position was vacant from 9/2021 to 5/2022. The ADON further stated during this time, she and the DON were responsible for the CNA's new hire and annual competencies but does not recall a new hire competency being done for CNA 2 and an annual competency for CNA 3 in 2021. A review of the facility's Policy and Procedure titled, Nurse Aid Qualifications and Training Requirements, dated 5/2019, indicated that a nursing aid must be competent to provide designated nursing care and nursing related services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. A review of Resident 13's admission Record indicated the resident was admitted initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis that included hypertension (abnormally high blood pressure), hyperlipidemia (abnormally high concentration of fats or lipids in the blood), type 2 diabetes mellitus (a disease in which your blood glucose, or blood sugar, levels are too high). A review of Resident 13's MDS, dated [DATE], indicated Resident 13's had severe impairment in cognitive skills. A review of Resident 13's Physician's Order for November 2022 indicated the following physician orders: a. Seroquel (Quetiapine, a drug treat schizophrenia, bipolar disorder, and depression) 25 mg tablet, give half tablet (12.5 mg) PO QPM for psychosis, manifested by delusion calling mama and [NAME], dated 11/02/22. b. Monitor side effects antipsychotic such as: sedation, drowsiness/dizziness, dry mouth, constipation, blurred vision, extrapyramidal reaction, weight, seizures, urinary retention, tardive dyskinesia, cognitive/behavior impairment, akathisia, pseudo-Parkinsonism, orthostatic hypotension, unsteady on feet, and/or high blood sugar. A review of Resident 13's Physician's Order: Seroquel Side Effects Summary, dated 11/1/22, indicated Resident 13 had 0 side effects from Seroquel for the month of October 2022. A review of Resident 13's MAR for the month of November 2022, indicated Resident 13 had 0 signs and symptoms of side effects from anti-psychotic, Seroquel from 1/1/22 to 11/12/22. A review of Resident 13's care plan for psychotropic drugs dated 7/6/22, indicated Resident 13 had the potential for drug related complications associated with the use of psychotropic medication to manage behavior related to depression and psychosis. The care plan indicated the interventions that included to observe for antidepressant side effects: such as orthostatic hypotension and tachycardia. A review of Resident 13's Vital Stats for period 11/1/22 to 11/13/22, indicated Resident 13's vital signs such as temperature, HR, respiratory rate and BP were only taken and recorded/documented on 11/2/22, 11/4/22, and 11/7/22. 9. A review of Resident 17's admission Record indicated the resident was admitted initially to the facility on 6/17/04 and readmitted on [DATE] with a diagnosis that included depression (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.) and anxiety disorder (disorder involves persistent and excessive worry that interferes with daily activities). A review of Resident 17's H&P, dated 9/7/22, indicated Resident 17 did not have the capacity to understand or make decisions. A review of Resident 17's Physician's Order for November 2022 indicated the following physician orders: a. Remeron tablet 15 mg, give half tablet (7.5 mg) PO QHS for depression, manifested by verbalization of sadness; depression manifested by poor appetite. Monitor side effects of anti-depressant every shift: fatigue, headache, tremor, somnolence, dizziness, insomnia, agitation, palpitations/tachycardia, gastrointestinal, nausea and vomiting, diarrhea/constipation, anorexia, dry mouth/thirst, increased appetite, confusion/delirium-sodium level, pain, and skin rash. A review of Resident 17's MAR for the month of November 2022, indicated Resident 17 had 0 signs and symptoms of side effects from anti-depressant, Remeron from 1/1/22 to 11/13/22. A review of Resident 17's care plan for psychotropic drugs dated 9/12/22, indicated Resident 17 had the potential for drug related complications associated with the use of psychotropic medication to manage mood/behavior related to anxiety and insomnia. The care plan indicated interventions that included to observe for antidepressant side effects: such as orthostatic hypotension and tachycardia. During an interview on 11/12/22 at 3:15 PM, LVN 3 stated licensed nurses would monitor residents who were taking psychotropic medications for any signs and symptoms of side effects. LVN 3 stated side effects monitoring would be reflected in the resident's eMAR as a number code. During an interview on 11/13/22 at 1:32 PM, LVN 5 stated when residents admit to the facility, nurses would check and monitor resident's vital signs every shift for 72 hours, then weekly and would document in weekly summary and would log the vital signs on the resident's eMAR. LVN stated licensed nurses would monitor residents for psychotropic medications' side effects and would document 0 in eMAR if no side effects were observed. LVN 5 stated licensed nurses assessed residents for orthostatic hypotension by checking residents if they were not feeling good. LVN 5 stated if residents passed out, licensed nurses would check residents' BP. LVN 5vstated licensed nurse would monitor residents for tachycardia by monitoring residents for any signs of shortness of breath or palpitations. LVN 5 stated by not monitoring residents orthostatic BP or heart rate, licensed nurses were not accurately monitoring residents' psychotropic medications side effects as ordered. During an interview on 11/13/22 at 4:32 PM, the Director of Nursing (DON) stated residents on psychotropic medications should be monitored every shift. The DON stated residents on psychotropic medications could experience side effects like dizziness, difficulty of walking, tachycardia, etcetera. The DON stated residents taking psychotropic medications could also experience orthostatic hypotension, thus checking BP while sitting, standing, and lying were important. The DON stated if licensed nurses were not checking residents heart rate or BP then the assessment for signs of psychotropic side effects were not accurate. A review of facility's policy and procedure (P&P) titled, Antipsychotic Medication Use, revised in 12/2016, indicated nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician such as orthostatic hypotension or arrhythmias (irregular heartbeat). 3. A review of Resident 21's admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses that included anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and major depressive disorder (a mood disorder that interferes with daily life). A review of Resident 21's History and Physical (H&P), dated 10/1/21, indicated Resident 21 could make needs known but could not make medical decisions. A review of Resident 21's Minimum Data Set (MDS, a standardized resident assessment and care-screening tool), MDS, dated [DATE], indicated the resident required extensive assistance from staff for transferring, dressing, toileting, and personal hygiene. A review of Resident 21's Physician's Order for November 2022 indicated the following physician orders: a. Remeron [Mirtazapine, antidepressant/drug that treats depression (mental disorder characterized by persistently depressed mood or loss of interest in activities)] tablet 15 mg, to give 1 tablet by mouth (PO) at bedtime (QHS) for depression, manifested by self-reporting feeling of sadness, dated 5/12/22. b. Monitor side effects of anti-depressant every shift: fatigue, headache, tremor, somnolence (drowsiness), dizziness, insomnia (inability to sleep), agitation (anxiety), palpitations/tachycardia (fast heart rate), gastrointestinal (GI, relating to the stomach and the intestines), nausea and vomiting, diarrhea/constipation, anorexia (lack or loss of appetite for food), dry mouth/thirst, increased appetite, confusion/delirium-sodium (nutrient) level, pain, and skin rash. A review of Resident 21's Medication Administration Record (MAR) for the month of November 2022, indicated Resident 1 had 0 signs and symptoms of side effects from anti-depressant, Remeron from 11/1/22 to 11/12/22. A review of Resident 21's care plan for psychotropic drugs dated 7/6/22, indicated Resident 21 had the potential for drug related complications associated with the use of psychotropic medication to manage mood/behavior related to depression, anxiety, and impulse disorder (condition in which a person has trouble controlling emotions or behavior). The care plan indicated the interventions that included to observe for antidepressant side effects: such as orthostatic hypotension and tachycardia. A review of Resident 21's Vital Stats from 11/1/22 to 11/13/22, indicated Resident 21's vital signs (group of medical signs that indicate the status of the body's vital functions) such as temperature, PR, respiratory (breathing) rate and BP were taken and recorded/ documented on 11/1/22 and 11/8/22. 4. A review of Resident 25's admission Record indicated the resident initially admitted to the facility on [DATE] with diagnoses that included major depressive disorder, mild cognitive (thinking and reasoning) impairment, and essential hypertension. A review of Resident 25's MDS, dated [DATE], indicated the resident required extensive assistance from staff for transferring, dressing, toileting use, and personal hygiene. A review of Resident 25's Physician's Order for November 2022 indicated the following physician orders: a. Remeron 15 mg, to give 1 tablet PO QHS for depression, manifested by poor appetite eating less than 50% of meals, dated 3/17/22. b. Monitor side effects of anti-depressant every shift for palpitations/tachycardia. A review of Resident 25's MAR for the month of November 2022 indicated, Resident 25 had 0 signs and symptoms of side effects from anti-depressant, Remeron from 1/1/22 to 11/12/22. A review of Resident 25's care plan for psychotropic drugs dated 11/9/22, indicated Resident 25 had the potential for drug related complications associated with the use of psychotropic medication to manage mood/behavior related to depression, anxiety, and impulse disorder. The care plan indicated interventions that included to observe for antidepressant side effects: such as orthostatic hypotension and tachycardia. A review of Resident 25s Vital Stats for period 11/1/22 to 11/13/22 indicated Resident 25's vital signs such as temperature, PR, respiratory (breathing) rate and BP were only taken and recorded/documented on 11/6/2022 and 11/12/2022, and 11/13/2022 (total of 3 days for the month of November). 5. A review of Resident 26's admission Record indicated the resident initially admitted to the facility on [DATE] with diagnoses that included major depressive disorder, dementia and chronic obstructive pulmonary disease (COPD, group of lung diseases that block airflow and make it difficult to breathe). A review of Resident 26's H&P, dated 5/6/2022, indicated Resident 26 has altered mental status (mental capacity) with significant cognitive dysfunction (impairment). A review of Resident 26's MDS, dated [DATE], indicated the resident required extensive assistance from staff for dressing, personal hygiene. A review of Resident 26's Physician's Order for November 2022 indicated the following physician orders: a. Mirtazapine tablet 15 mg, to give 1 tablet PO QHS for depression manifested by poor appetite eating less than 50% meals, dated 5/6/22. b. Monitor side effects of anti-depressant every shift for palpitations/tachycardia. A review of Resident 26's MAR for the month of November 2022 indicated, Resident 26 had 0 signs and symptoms of side effects from anti-depressant, Remeron from 1/1/22 to 11/12/22. A review of Resident 26's care plan for psychotropic drugs dated 9/22/22, indicated Resident 26 had the potential for drug related complications associated with the use of psychotropic medication to manage mood/behavior related to depression, anxiety, and impulse disorder. The care plan indicated interventions that included to observe for antidepressant side effects: such as orthostatic hypotension and tachycardia. A review of Resident 26's Vital Stats for period 11/1/22 to 11/13/22, indicated Resident 26's vital signs were only taken and recorded/documented on 11/2/22 and 11/9/22. 6. A review of Resident 30's admission Record indicated the resident was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included muscle weakness, spinal stenosis (occurs when one or more bony openings within the spine begin to narrow and reduce space for the nerves) and osteoarthritis (occurs when flexible tissue at the ends of bones wears down). A review of Resident 30's H&P, dated 6/18/22, indicated Resident 30 did not have the capacity to understand or make decisions. A review of Resident 30's MDS, dated [DATE], indicated Resident 30 required extensive assistance with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 30's Physician's Order for November 2022 indicated the following physician orders: a. Zyprexa (Olanzapine-antipsychotic/used to treat psychotic conditions) tablet 2.5 mg, to give 1 tablet PO QHS for psychosis manifested by striking out during nursing care dated 9/12/22. b. Monitor side effects of anti-psychotic every shift for orthostatic hypotension. A review of Resident 30's MAR for the month of November 2022 indicated, Resident 30 had 0 signs and symptoms of side effects from anti-psychotic, Zyprexa from 11/1/22 to 11/12/22. A review of Resident 30's care plan for psychotropic drugs dated 10/3/22, indicated Resident 30 had the potential for drug related complications associated with the use of psychotropic medication to manage mood/behavior related to psychosis. The care plan indicated interventions that included to observe for antidepressant side effects: such as orthostatic hypotension and tachycardia. A review of Resident 30's Vital Stats for period 11/1/22 to 11/13/22 indicated Resident 30's vital signs were only taken and recorded/documented on 11/6/22 and 11/13/22. On 11/12/22 at 4:21 PM, during an interview with a Licensed Vocational Nurse 6 (LVN 6) and review of Resident 30's electronic MAR (eMAR), LVN stated licensed nurses were monitoring Resident 30 and other residents who are taking psychotropic medications for side effects every shift. LVN 6 stated licensed nurses would document the corresponding number/code for whatever side effects the residents were experiencing. LVN stated Resident 30, licensed nurses were monitoring Resident 30 for anti-psychotic side effects every shift and would document 0 if no side effects identified/observed and/or would document number 1 for sedation, 2 for drowsiness, etcetera. 7. A review of Resident 62's admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses that included dementia, muscle weakness, syncope (fainting) and collapse. A review of Resident 62's H&P, dated 10/19/2022, indicated Resident 62 did not have the capacity to understand and make decisions. A review of Resident 62's MDS, dated [DATE], indicated Resident 62 required limited assistance from staff for bed mobility, transferring, dressing, eating, toileting, and personal hygiene. A review of Resident 62's Physician's Order for November 2022 indicated the following physician orders: a. Mirtazapine tablet 7.5 mg, to give 1 tablet PO QPM for depression manifested by poor appetite eating less than 50% meals, dated 1/6/22. b. Monitor side effects of anti-depressant every shift for palpitations/tachycardia. A review of Resident 62's MAR for the month of November 2022 indicated, Resident 62 had 0 signs and symptoms of side effects from anti-depressant, Remeron from 11/1/22 to 11/12/22. A review of Resident 62's care plan for psychotropic drugs dated 11/11/22, indicated Resident 62 had the potential for drug related complications associated with the use of psychotropic medication to manage mood/behavior related to depression, anxiety, and impulse disorder. The care plan indicated interventions that included to observe for antidepressant side effects: such as orthostatic hypotension and tachycardia. A review of Resident 62's Vital Stats for period 11/1/22 to 11/13/22 indicated Resident 62's vital signs were only taken and recorded/documented on 11/4/22, 11/9/22, and 11/11/22. Based on interview, and record review, the facility failed to provide adequate pharmacy services for nine (9) of 9 sampled Residents. 1. Resident 78's medication was not accounted for when the medication was brought into the facility. 2. Resident 3's anticoagulant (medication used to prevent blood clots) medication was not monitored for side effects 3. Residents 21, 25, 26, 30, 62, 13, and 17, heart rate (HR, the number of times each minute that the heart beats) and blood pressure (BP, pressure inside the blood vessels) were not being checked and documented every shift (7 AM to 3 PM, 3 PM to 11 PM, 11 PM to 7 AM) to identify signs of psychotropic side effects such as tachycardia (rapid heartbeat, HR over 100 beats a minute) and orthostatic hypotension (form of low blood pressure that happens when standing up from sitting or lying down). These deficient practices had the potential for the residents to experience unidentified side effects which could lead to serious health complications requiring hospitalization or death. Findings: 1. A review of Resident 78's admission Record indicated the resident admitted to the facility on [DATE] with diagnoses of hypertension (HTN, high blood pressure), gout (a type of arthritis [inflammation or swelling of one or more joints] that occurs when extra uric acid in the body forms crystals in the joints), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 78's History and Physical, dated 6/9/22, indicated the resident did not have capacity to understand or make decisions. A review of Resident 78's Minimum Data Set (MDS, standardized assessment and care-screening tool), dated 9/14/22, indicated the resident required extensive assistance (staff provide weight bearing support) from staff for transferring, dressing, eating, toileting, and personal hygiene. A review of Resident 78's Physician's Orders, dated 6/10/22, indicated an order for Losartan Potassium (a medication used to treat high blood pressure) 100 milligram (mg, a unit of measurement) take 1 tab by mouth (PO) once daily (QDay) for HTN. A review of Resident 78's Physician's Orders, dated 6/10/22, indicated an order for Allopurinol (a medication used to treat gout) 100 mg tablet, take 1 tab PO QDay for gout. A review of Resident 78's monthly Medication Administration Record (MAR) for June, August, September, and October 2022, indicated the licensed nurses documented that Losartan and Allopurinol were administered as ordered at 9 am. A review of Resident 78's monthly MAR for July 2022, indicated Allopurinol and Losartan were not administered because the resident refused on 7/9/22. The July 2022 MAR indicated the licensed nurses documented that Losartan and Allopurinol were administered all the other days as ordered at 9 am. A review of Resident 78's monthly MAR for November 2022, indicated dated 11/1/22 to 11/12/22 indicated the licensed nurses documented that Losartan and Allopurinol were administered as ordered at 9 am from 11/1/22 to 11/12/22. During an observation and interview with a Licensed Vocational Nurse 1 (LVN 1) of Medication Cart 1 in [NAME] Station II on 11/12/22 at 7:40 AM, the following medications were observed in a clear orange medication bottle for Resident 78: a. Allopurinol (used to treat gout and certain types of kidney stones) 100 milligrams (mg, a unit of measurement) tablet, take 1 tablet every day as directed. 22 tablets left in the bottle. b. Losartan (used to treat high blood pressure hypertension and to help protect the kidneys from damage due to diabetes) 100 mg tablet, take 1 tablet every day as directed. 23 tablets left in the bottle. Allopurinol indicated a fill date on 5/28/22 with a quantity of 90 tablets. Losartan indicated a fill date of 5/28/22 with a quantity of 90 tablets. Both medications were observed with black writing on the bottle indicating date opened (D.O.) on 6/10/22. LVN 1 stated if both medications (Allopurinol and Losartan) were filled on 5/28/22 and dated opened on 6/10/22, the medications should all be completed (none left in the bottle). LVN 1 stated she did not know why there were tablets (Losartan and Allopurinol) remaining. LVN 1 stated the Resident 78's Responsible Party (RP) might have brought the extra medications to the facility. LVN 1 stated she would not count the contents of the medications if it was not from the facility's pharmacy if the medication bottle was opened. LVN 1 stated the date opened indicated the first dose given from that medication bottle. During an observation and interview, on 11/12/22 at 4:39 PM, Resident 78's RP was pushing the resident in a wheelchair in the facility. RP stated she brought in Resident 78's medications for the licensed nurses to administer to Resident 78. RP stated she did not know if Resident 78 was refusing medications and/or if medications were not administered. RP stated the facility staff did not notify her if doses were missed. During an interview, on 11/13/22 at 7:50 AM, LVN 5 stated medication reconciliation was performed by the night (11 pm to 7 am) shift and was important to perform as to reflect each resident's current and most updated order from the physician. LVN 5 stated all licensed nurses were responsible to check all medications the resident and/or family brought into the facility. LVN 5 stated licensed nurses were responsible for ensuring that the resident had a physician's order. LVN 5 stated it was typical for residents or resident's family to bring in outside medication, but the facility was responsible for checking all medications and the contents of the medication and ensuring the resident had a physician's order for outside medications to be administered. LVN 5 stated licensed nurses must count the quantity of all resident's medications when receiving outside, sealed/unsealed medications, and must verify the medications with another licensed nurse. LVN 5 stated the medication was then logged into a binder titled, Outside Pharmacy and Family Log, to account for the resident's medication. LVN 5 stated each nurse's station had their own specific binder. LVN 5 stated if it was not logged on the binder, licensed nurses would be unable to track and account for resident's medications that the family brought into the facility. During an interview, on 11/13/22 at 10:05 AM, the Director of Nursing (DON) stated when family brings medications into the facility for residents, licensed nurses were expected to check the prescription and compare it to the physician's order. Once confirmed appropriate order, the medication was then logged into the binder titled, Outside Pharmacy and Family Log, for the nurse's station the resident resided in. The DON stated whoever received the medication was responsible to log the medication in the binder. The DON stated when medication bottles were unsealed, the licensed nurse must count the contents of the medication in the bottle with another licensed nurse for verification. The DON could not provide documentation Resident 78's Allopurinol and Losartan were counted initially and/or explain why there were remaining medications (if it was opened on 6/10/22). A review of [NAME] I Station's Outside Pharmacy and Family Log, on 11/12/22 at 8:12 AM, LVN 5 stated the log did not indicate Resident 78 received any medications. A review of [NAME] II Station's Outside Pharmacy and Family Log,on 11/13/22 at 9:22 AM, LVN 4 stated the log did not indicate Resident 78 received any medications. A review of [NAME] Station's Outside Pharmacy and Family Log, on 11/13/22 at 2:15 PM, LVN 3 stated the log did not indicate Resident 78 received any medications. A review of the facility's policy and procedure (P&P) titled, Administering Medications, revised 4/19, indicated medications were administered in a safe and timely manner, and as prescribed. A review of the facility P&P titled, Medication Storage in the Facility, dated 4/08, indicated medications and biologicals were stored safely, securely, and properly following manufacturer's recommendations of those of the supplies. The P&P indicated the transfer of medications from one container to another was done only by pharmacy. A review of the facility's P&P titled, Reconciliation of Medications on Admission, revised 7/17, indicated to ensure medication safety by accurately accounting residents' medications, routes, and dosages upon admission or readmission to the facility. The P&P indicated medication reconciliation reduced medication errors and enhanced resident safety by ensuring that the medications the resident needed and had been taking continued to be administered without interruption. A review of the facility's P&P titled, Medications Brought to the Facility by a Resident or Family Member, dated 9/14, indicated medication brought into the facility by a resident or family member was used only upon written order by the resident's attending physician, after the contents were verified, and if the packaging met the facility's guidelines. The P&P indicated licensed nurses received medications delivered to the facility and documented delivery of the medication on the appropriate form. 2. A review of Resident 3's Face Sheet (a record of admission) indicated the resident admitted to the facility on [DATE] with diagnoses that included atrial fibrillation [A Fib, an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart], presence of a cardiac pacemaker [a small device that's placed (implanted) in the chest to help control the heartbeat], and heart failure (heart's inability to pump an adequate supply of blood to the body). A review of Resident 3's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 9/30/22, indicated the resident no impairment in cognitive skills (ability to make daily decisions). A review of Resident 3's monthly Physician Orders for November 2022, indicated the following orders for the resident: a. Eliquis (Apixaban, a medication used to prevent serious blood clots from forming due to a certain irregular heartbeat) 2.5 mg tablet by mouth (PO) two times a day (BID) for A Fib. b. Monitor for any signs and symptoms of bleeding related to Xarelto (Rivaroxaban, a medication used to prevent blood clots from forming due to a certain irregular heartbeat every shift for A Fib). The Physician orders did not indicate an order to monitor for any signs and symptoms of bleeding for Eliquis, nor did the Physician orders indicate an order for Xarelto. A review of Resident 3's care plan titled, Risk for complications from use of blood thinning medication related to A-Fib, dated 7/20/22, indicated the resident was receiving Eliquis 2.5 mg one (1) tablet PO BID for A-Fib and did not have Xarelto. During an observation in Resident 3'sroom and interview on 11/11/22 at 10 AM, Resident 3 had discoloration to her hands and face. Resident 3 stated she always had some discoloration to her hands and face due to a history of skin cancer. Resident 3 stated she had a stroke and was on medications to prevent blood clots. During an interview and record review of Resident 3's Physician Orders on 11/13/22 at 7:50 AM, Licensed Vocational Nurse 5 (LVN 5) stated medication reconciliation was performed by the night shift (11 PM to 7 AM) licensed nurses, in which the resident's medications were reviewed according to the physician's orders and updated to ensure accuracy. LVN 5 stated that Resident 3's anticoagulant medication, Eliquis, did not match the physician's order for monitoring bleeding related to the medication Xarelto. LVN 5 stated that Eliquis and Xarelto were different anticoagulant medications. LVN 5 stated she could not recall if Resident 3 was ever on Xarelto. During an interview on 11/13/22 at 9:58 AM, the Director of Nursing (DON) stated it was important to monitor for bleeding because there was a risk for bleeding while the resident was on Eliquis. The DON stated Resident 3's physician order and Medication Administration Record (MAR) indicated Resident 3 was on Eliquis, but licensed nurses were monitoring for bleeding for the use of Xarelto. The DON stated accuracy of resident's records was important to ensure safety and to avoid confusion. A review of the facility's policy and procedure titled, Anticoagulant- Clinical Protocol, revised 11/18, indicated nurses shall assess and document current anticoagulation therapy, including drug and current dosage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure PRN (given as needed and not on a regular schedule) order for Ativan (psychotropic medication [medication which affects brain activities associated with mental processes and behaviors] used to treat anxiety [fear characterized by behavioral disturbances]) was not extended beyond 14 days without a documented rationale for extended use for one out of five residents (Resident 21) in accordance with the facility policy and procedure. This deficient practice increased the risk for Resident 21 to experience adverse effects of psychotropic medication therapy including, but not limited to, dizziness, drowsiness, leading to an overall negative impact on her physical, mental, and psychosocial well-being. Findings: A review of Resident 21's admission record indicated the resident was initially admitted to the facility on [DATE] with diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning), anxiety disorder and major depressive disorder (a mood disorder that interferes with daily life). A review of Resident 21's History and Physical (H&P), dated 10/1/2021, indicated Resident 21 can make needs known but cannot make medical decisions. A review of Resident 21's Minimum Data Set (MDS, a standardized resident assessment and care-screening tool), dated 9/19/2022, indicated Resident 21 required extensive assistance (resident involved in activity; staff provide weight-bearing support) with bed mobility, transfer, dressing, toilet use, personal hygiene and required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) with eating. A review of Resident 21's Physician's Order for November 2022 indicated the physician order of Ativan (Lorazepam) tablet 0.5 milligrams (mg- a unit of measurement), to give 1 tablet by mouth every 24 hours as needed for anxiety manifested by hitting staff dated 7/2/2022 and with end date of 7/26/2022. A review of Resident 21's Physician's Progress Notes dated 7/17/2022, indicated, Resident 21's attending physician (AP) 1 documented to keep the Ativan 0.5 mg every 24 hours as needed due to Resident 21's severe aggression for 30 days. A review of Resident 21's Medication Administration Record (MAR) for the month of November 2022, indicated to give Ativan 0.5 mg tablet every 24 hours as needed for anxiety with a start date of 7/26/2022 and end date of N/A (not applicable). On 11/12/22 at 3:15 PM, during interview, Licensed Vocational Nurse 3 (LVN 3) stated he was not sure why the AP 1 ordered Ativan PRN for 30 days instead of 14 days. On 11/12/22 at 3:34 PM, during a concurrent interview with LVN 5 and review of Resident 21's Physician's order for the month of November 2022, LVN 5 stated Ativan 0.5 mg PRN was initially ordered on 7/2/22 and was re-ordered on 7/26/22. LVN 5 stated there were no documented rationale for Ativan 0.5 mg PRN when it was reordered on 7/26/22. LVN 5 stated she reminded the AP 1 that the facility's protocol for PRN psychotropic medication was limited to only 14 days due to risk of adverse effects, but the AP 1 likes to order PRN Ativan psychotropic medication for 30 days. LVN 5 stated AP 1 must renew the Ativan 0.5 mg PRN with documented rationale every 30 days. During an interview on 11/13/22 at 10:19 AM, the Director of Nursing (DON) stated PRN psychotropic medication can be extended beyond 14 days if residents were using it very often. The DON stated the doctor does not want to be bothered in renewing the medication very often. The DON stated the doctors were aware that PRN psychotropic should be limited to 14 days, but some doctors do not listen and wanted it for 30 days. The DON stated PRN psychotropic medication can be ordered for more than 14 days if there were proper rationale and/or indication form the doctor. A review of facility's policy and procedure titled Antipsychotic Medication Use revised in December 2016, indicated the following: 1. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. 2. The need to continue PRN orders for psychotropic medications beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication/

Based on observation, interview, and record review, the facility failed ensure the safe storage of medications by labeling when medications were opened. During an inspection of one of three medication carts (Medication Cart 2), two opened bottles of vitamins were not labeled when it was opened. This deficient practice had the potential for the residents to take medications past recommended use after opening. Findings: During an inspection of Medication Cart 2 and interview with a Licensed Vocational Nurse 1 (LVN 1), on 11/12/22 at 8:03 AM, the following medications were opened and not labeled with an open date: 1. One bottle of Vitamin D (nutritional supplement) 25 microgram (mcg, unit of measurement) 100 tablets. 2. One bottle of Rosuvastatin Calcium (Crestor, used to treat high blood cholesterol). LVN 1 stated the medications should be labeled when it was opened. LVN 1 stated the licensed nurses were responsible for checking all medications were properly labeled and stored to ensure residents did not receive expired medications. LVN 1 stated if used after expiration or the use by date, there was a chance it (the medications) might not work as intended and could cause harm to the resident. A review of facility's policy and procedures (P&P) titled, Administering Medications, revised in April 2019, indicated the expiration/beyond use date on the medication label was checked prior to administering. When opening a multi-dose container, the date opened was recorded on the container.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to address food preferences and/or provide an alternative food menu for one of three sampled residents (Resident 187). This deficient practice had the potential for the resident to not meet their nutritional needs. Findings: A review of Resident 187's admission Record indicated the resident admitted to the facility on [DATE] with diagnoses including essential hypertension (high blood pressure that does not have a known secondary cause), history of fall, and convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement). A review of Resident 187's Physician Orders for the month of November 2022, indicated a physician order for the resident to have a regular, consistent carbohydrate (eating the same amount of carbohydrates every day to help keep blood sugar levels stable) diet, three times a day. A review of Resident 187's care plan for nutrition dated 11/4/22, indicated Resident 187 had nutritional concerns related to his condition such as HTN, diabetes mellitus (a condition that affects the way the body processes blood sugar), and chronic kidney disease (gradual loss of kidney function affecting the body's ability to filter waste and excess fluid from the blood) with interventions that included to assess likes and dislikes, honor dietary preferences. and offer alternative meals when available if the resident did not like what was served. A review of Resident 187's Food Preference Record dated 11/4/22, indicated the resident's breakfast preference were to have oatmeal, toast, scrambled eggs, bacon, coffee, and water. It also indicated the resident normally only ate oatmeal at home. During an interview on 11/11/22 at 8:42 AM, Resident 187 stated he was admitted to the facility a week ago (11/4/22) and had concerns about his food. Resident 187 stated he never got breakfast he wanted. Resident 187 stated one day (on 11/11/22) the facility served him scrambled egg, bacon, one sausage, and a toast. Resident 187 stated he preferred one egg over easy and a toast. Resident 187 stated when he first came in the facility, no one asked him what he liked, disliked, or if he had any breakfast preferences. Resident 187 stated there was another incident the facility served breakfast he did not like and because he waited for almost an hour he did not want to ask any more for an alternative. During the same interview on 11/11/22 at 8:42 AM, inside Resident 187's room, Certified Nurse Assistant 1 (CNA 1) gave Resident 187 lunch menu for that day (11/11/22). Resident 187 informed CNA 1 about his problem with breakfast. CNA 1 told Resident 187 that the facility did not provide a breakfast menu since they served almost the same breakfast all the time. Resident 187 stated he did not want the same food for breakfast every day. CNA 1 informed Resident 187 to let the kitchen staff or the nurses know about his request. Resident 187 told CNA 1 that he went one time to the kitchen and was informed by the kitchen staff that he cannot request when the food was not there yet. Resident 187 stated he does not know what the best time is to tell the kitchen staff about his food request. CNA 1 told Resident 187 that she will ask someone from the kitchen to talk to him that day to ask for his food preference, especially food menu. Resident 187 stated he does not have a problem with the facility's food quality but more on miscommunication. On 11/12/22 at 9:07 AM, during a concurrent interview with Resident 187 and review of Resident 187's meal ticket dated 12/12/22, indicated Resident 187's breakfast preferences to have two strips of bacon, black coffee, scrambled egg, oatmeal, toast, and water, no ice. Resident 187 stated he already told them that he wanted/liked coffee, milk, tomato juice, eggs over easy, cornflakes or cheerios, and toast. Resident 187 stated the kitchen staff indicated foods he did not want or liked. Resident 187 also stated no one came to talk to him or explained why the kitchen was not able to provide the food he requested. During an interview on 11/12/22 at 9:12 AM, Licensed Vocational Nurse 1 (LVN 1) stated if residents wanted something else from the menu, residents could request for an alternative by letting the staff in the dining room know or let the nurse know. During an interview on 11/12/22 at 10:23 AM, the Registered Dietitian (RD) stated upon admission RD would speak with newly admitted residents and ask for their allergies, likes, dislikes and food preferences. RD stated the facility had an alternative menu and residents could request for food not on the regular menu. RD stated if for any reason the facility was not able to accommodate resident's request, they would explain it to the resident or would call the resident's family if they could set something up. RD stated menu were posted in each station and residents would be given a check off menu before lunch and dinner. RD stated, unfortunately they did not have a menu for breakfast, but most breakfast items were available. RD stated residents could go to the kitchen as well and let the kitchen staff know if residents preferred something else. RD stated she spoke with Resident 187 during admission but Resident 187's breakfast preferences changed on a daily basis. RD stated she could update resident's preference in the system daily. During an interview on 11/13/22 at 3:41 PM, the Director of Nursing (DON) stated the dietitian would talk to the residents about food preferences upon admission. The DON stated the facility could accommodate residents' food preferences and the facility provided alternative menus. If the residents' preferences changed, the resident could tell the nurses then they would notify the kitchen staff. The DON stated RD would update resident's preferences if it changed. A review of facility's policy and procedure (P&P) titled, Resident Food Preferences, revised in 7/2017, indicated individual food preferences would be assessed and communicated to the interdisciplinary team (IDT, team of healthcare professionals from different professional disciplines). The P&P indicated the food services department would offer a variety of foods at each scheduled meal, as well as access nourishing snacks throughout the day and night.

Based on observation, interview, and record review, the facility failed to store food properly to prevent growth of microorganisms that could cause food borne illness. This deficient practice had the potential to result in foodborne illness. Findings: During initial kitchen tour with the Director of Dining Services (DDS), on 11/11/22 timed at 8:45AM an oatmeal container was left opened in the dry food storage area. The DDS stated the oatmeal container should have been closed because leaving it open exposed the oatmeal to bacteria and the residents could get food poisoning. A review of the facility's policy and procedure (P&P) titled, Food and Supply Storage, revised 1/2022, indicated all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility failed to ensure personal food items and other food were properly stored and labeled. The following items were observed inside Medication room [ROOM NUMBER]: 1. Dry food inside one clear Ziploc bag labeled with Resident 61's name but not labeled with date inside the medication room refrigerator. 2. One opened bottle, 48 ounce (oz-unit of measurement) of apple sauce, not labeled with open date, inside the medication room refrigerator. 3. One box of green tea and one packet of crackers were found inside the medication room drawer. This deficient practice had the potential for the cross contamination of medications and spread of infection to other residents. Findings: During a medication storage observation with a Licensed Vocational Nurse 2 (LVN 2), on 11/12/22 at 2:31 PM, two refrigerators were found inside Medication room [ROOM NUMBER] (one small refrigerator for refrigerated medications and one tall white refrigerator for facility house supply items that needed to be refrigerated): 1. Inside the white tall refrigerator, one clear Ziploc bag with dry snacks, labeled with a resident's name (Resident 61), 2. Inside the white tall refrigerator, one opened bottle, 48 ounces (oz, a unit of measurement) of apple sauce not labeled with date opened. 3. One box of green tea and one packet of crackers, unlabeled with name and date also found inside the Medication room [ROOM NUMBER] drawer mixed with facility's urine specimen collection containers (sample taken for medical testing). During the same observation and interview, on 11/12/22 at 2:32 PM, LVN 2 stated that the opened apple sauce should be labeled with date when it was first opened. LVN 2 stated personal foods like the box of green tea and crackers should not be stored inside the medication room for infection control issues. LVN 2 stated resident's snacks or food should not be inside the medication room and should be labeled with name and date when it was received. During an interview on 11/12/22 at 2:53 PM, the Director of Nursing (DON) stated personal food could not be stored in the medication room refrigerator. The DON stated if family wanted to bring food, families could give it to the staff and store it in the refrigerator in the lunchroom designated for residents and families. A review of facility's policy and procedure (P&P) titled, Resident Food Services, Use and Storage of Food Brought to residents from Outside, revised in 1/2021, indicated the following if the prepared food was not served immediately to the resident, the food must be stored in a container with a tight-fitting lid, clearly labeled with the resident's name and room number, the date the food was brought to the resident, and also the use-by-date. Food should be consumed or used within 72 hours or per storage policy. The P&P also indicated if the food was potentially hazardous, it must be stored either under refrigeration in the unit's pantry refrigerator or the resident's personal refrigerator (if available).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 10. A review of Resident 13's admission Record indicated the resident was admitted initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis that included hypertension (abnormally high blood pressure), hyperlipidemia (abnormally high concentration of fats or lipids in the blood), type 2 diabetes mellitus (a disease in which your blood glucose, or blood sugar, levels are too high). A review of Resident 13's MDS, dated [DATE], indicated Resident 13's had severe impairment in cognitive skills. A review of Resident 13's Physician's Order for November 2022 indicated the following physician orders: a. Seroquel (Quetiapine, a drug treat schizophrenia, bipolar disorder, and depression) 25 milligram (mg, a unit of measurement) tablet, give half tablet (12.5 mg) PO every evening (QPM) for psychosis (mental disorder characterized by a disconnection from reality) manifested by delusions of calling mama and [NAME]. b. Monitor side effects antipsychotic such as: sedation, drowsiness/dizziness, dry mouth, constipation, blurred vision, extrapyramidal reaction, weight, seizures, urinary retention, tardive dyskinesia, cognitive/behavior impairment, akathisia, pseudo-Parkinsonism, orthostatic hypotension, unsteady on feet, and/or high blood sugar. A review of Resident 13's care plan for psychotropic drugs dated 7/6/22, indicated Resident 13 had the potential for drug related complications associated with the use of psychotropic medication to manage behavior related to depression and psychosis. The care plan indicated the interventions that included to observe for antidepressant side effects: such as orthostatic hypotension and tachycardia. 11. A review of Resident 17's admission Record indicated the resident was admitted initially to the facility on 6/17/04 and readmitted on [DATE] with a diagnosis that included insomnia (a sleep disorder in which you have trouble falling and/or staying asleep) and anxiety disorder (disorder involves persistent and excessive worry that interferes with daily activities). A review of Resident 17's H&P, dated 9/7/22, indicated Resident 17 did not have the capacity to understand or make decisions. A review of Resident 17's Physician's Order for November 2022 indicated the following physician orders: a. Remeron tablet 15 mg, give half tablet (7.5 mg) PO QHS for depression, manifested by verbalization of sadness; depression manifested by poor appetite. Monitor side effects of anti-depressant every shift: fatigue, headache, tremor, somnolence, dizziness, insomnia, agitation, palpitations/tachycardia, gastrointestinal, nausea and vomiting, diarrhea/constipation, anorexia, dry mouth/thirst, increased appetite, confusion/delirium-sodium level, pain, and skin rash. A review of Resident 17's care plan for psychotropic drugs dated 9/12/22, indicated Resident 17 had the potential for drug related complications associated with the use of psychotropic medication to manage mood/behavior related to anxiety and insomnia. The care plan indicated interventions that included to observe for antidepressant side effects: such as orthostatic hypotension and tachycardia. During an interview on 11/13/22 at 1:13 PM, the Care Plan Coordinator (CPC) stated care plans were an indicator of a resident's overall status and wellbeing. The CPC stated care plans were used to make a resident's life better and ensure the quality of care for the resident. The CPC stated care plans were resident specific in which residents' concerns were identified and incorporated. The CPC stated that the care plans was generalized and not specific to each residents and did not have a specific deadline and was on going. During an interview on 11/13/22 at 1:32 PM, LVN 5 stated when residents come in the facility for admission, nurses would check and monitor resident's vital signs every shift for 72 hours, then weekly and would document in the weekly summary and would log in vital sign documentation in the eMAR. LVN 5 stated licensed nurses would monitor residents for psychotropic medications' side effects and would document 0 in eMAR if no side effects were observed. LVN 5 stated licensed nurses assess residents for orthostatic hypotension side effects by checking residents if they were not feeling good and if the residents passed out, licensed nurses would check residents' BP. LVN 5 stated licensed nurse would monitor residents for tachycardia side effects by monitoring residents for any signs of shortness of breath and palpitations. LVN 5 stated by not monitoring residents orthostatic BP and pulse rate, licensed nurses were not accurately monitoring residents' psychotropic medications side effects as ordered. During an interview on 11/13/22 at 4:30 PM, the Director of Nurses (DON) stated the care plan was utilized daily and was the plan of care for a resident in every aspect. The DON stated care plans must be resident-centered and resident specific indicated by a resident's specific medical condition. The DON stated the residents care plan must have a goal that was measurable and must be indicated by a specific time frame and objective. The DON stated that a resident's care plan must address the resident's specific problem, and that when care plans were not resident specific and indicated with a measurable goal the efficacy of the plan of care could not be determined or appropriately assessed. The DON stated care plan should not be generalized and should be specific to each resident. A review of the facility policy and procedure titled, Care Plans, Comprehensive Person- Centered, revised 3/22, indicated a comprehensive person-centered care plan included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was developed and implemented for each resident. The policy indicated the comprehensive person- centered care plan included measurable objectives and timeframes. 3. A review of Resident 8's admission Record indicated the resident initially admitted to the facility on [DATE] with diagnoses including essential hypertension (HTN, high blood pressure that does not have a known secondary cause), dementia (a group of thinking and social symptoms that interferes with daily functioning), and urine retention (difficulty urinating and completely emptying the bladder). A review of Resident 8's MDS, dated [DATE], indicated the resident had no impairment in cognitive skills (ability to make daily decisions) and required extensive assistance (resident involved in activity, staff provide weight-bearing support) from staff for bed mobility, transferring, dressing, toileting, and personal hygiene. A review of Resident 8's Physician's Order for the month of November 2022 indicated the following physician orders: a. Amlodipine Besylate [used treat high blood pressure (BP)] tablet, 5 milligrams (mg, a unit of measurement), to give 1 tablet by mouth (PO) every day (QDay). b. Diltiazem CD (used treat high blood pressure) capsule, extended release 24 hour (slowly released into the body over a period of time, usually 24 hours), 360 mg, to give 1 capsule PO QDay. c. Losartan 100 mg - hydrochlorothiazide [(HCTZ, medication used to treat water retention) a combination medication used to treat high blood pressure], 12.5 mg PO every evening (QPM). A review of Resident 8's Medication Administration Record (MAR) for the month of November 2022, indicated Resident 8's blood pressure medications (Amlodipine, Diltiazem CD, and Losartan-HCTZ) were given every day as ordered without parameters when to not give the medications. The MAR indicated a BP check every week on Tuesday at nighttime. The MAR indicated the last BP check was done on 11/8/22. A review of Resident 8's care plan for medical conditions dated 7/21/22, indicated Resident 8 had an alteration in cardiac (relating to the heart) status related to HTN with the following interventions: a. Check and record heart rate, BP, and respirations (breathing). Inform the physician of readings outside of normal range. b. Assess for cardiac distress, change in vital signs (group of medical signs that indicate the status of the body's vital functions, such as heart rate, BP, respiratory rate, and temperature), chest pain, dizziness, pallor (unhealthy pale appearance), apprehension (anxiety), and diaphoresis (excessive sweating). c. Check BP every week on Tuesday. During a medication administration observation and interview, on 11/12/22 at 8:42 AM, LVN 1 attempted to administer BP medications (Amlodipine, Diltiazem CD, and Losartan-HCTZ) and did not check the resident's BP because the resident did not have BP parameters (guideline/restriction) or an order to check BP prior to administration. On 11/12/22 at 8:45 AM, during an interview and record review of Resident 8's eMAR, LVN 1 stated licensed nurse checked BP of residents who were taking BP medications once a week and would check vital signs once a week also for weekly summary. LVN 1 stated licensed nurses did not check residents BP unless there was a change in condition like unresponsiveness, dizziness or lightheadedness, or if ordered by the resident's physician. LVN 1 stated Resident 8 did not have any order for parameters any of the BP meds. 4. A review of Resident 187's admission Record indicated the resident admitted to the facility on [DATE] with diagnoses including essential HTN, history of fall, and convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement). A review of Resident 187's Physician's Order for the month of November 2022, indicated a physician order for Lisinopril (used to treat high blood pressure) tablet, 5 mg, to give 1 tablet PO QDay. A review of Resident 187's MAR for the month of November 2022, indicated Resident 187's BP medication (Lisinopril) was given daily on 11/5/22 to 11/11/22 as ordered without BP parameters. There was no documentation on the MAR that BP was taken from 11/5/22 to 11/11/22. A review of Resident 187's care plan for medical conditions dated 11/7/22, indicated Resident 187 had an alteration in cardiac status related to HTN with the following interventions: a. Check and record heart rate, BP, and respirations. Inform the resident's physician for readings outside of normal range. b. Assess for cardiac distress, change in vital signs, chest pain, dizziness, pallor, apprehension, and diaphoresis. During a medication administration observation and interview with LVN 1 on 11/12/22 at 9:02 AM, LVN 1 observed attempted to administer Resident 187's BP medication (Lisinopril) and stated she did not check the resident's BP because the resident did not have BP parameters or an order to check BP prior to administration. 5. A review of Resident 21's admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses that included anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and major depressive disorder (a mood disorder that interferes with daily life). A review of Resident 21's History and Physical (H&P), dated 10/1/21, indicated Resident 21 could make needs known but could not make medical decisions. A review of Resident 21's MDS, dated [DATE], indicated the resident required extensive assistance from staff for transferring, dressing, toileting, and personal hygiene. A review of Resident 21's Physician's Order for November 2022 indicated the following physician orders: a. Remeron [Mirtazapine, antidepressant/drug that treats depression (mental disorder characterized by persistently depressed mood or loss of interest in activities)] tablet 15 mg, to give 1 tablet PO at bedtime (QHS) for depression, manifested by self-reporting feeling of sadness, dated 5/12/22. b. Monitor side effects of anti-depressant every shift for palpitations/tachycardia. A review of Resident 21's care plan for psychotropic drugs dated 7/6/22, indicated the resident had the potential for drug related complications associated with the use of psychotropic medication to manage mood/behavior related to depression, anxiety, and impulse disorder (condition in which a person has trouble controlling emotions or behavior). The care plan indicated the following interventions: a. Observe for antidepressant side effects: orthostatic hypotension (measuring BP while sitting and standing; BP and pulse are taken in two positions: supine and standing) and tachycardia. Notify the physician of noted side effects to determine if benefits of therapy outweigh side effects. b. Observe for antipsychotic (medications used to treat psychotic disorders [severe mental disorders that cause abnormal thinking and perceptions]) side effects: orthostatic hypotension and tachycardia. Notify the physician of noted side effects to determine if benefits of therapy outweigh side effects. 6. A review of Resident 25's admission Record indicated the resident initially admitted to the facility on [DATE] with diagnoses that included major depressive disorder, mild cognitive (thinking and reasoning) impairment, and essential hypertension. A review of Resident 25's MDS, dated [DATE], indicated the resident required extensive assistance from staff for transferring, dressing, toileting use, and personal hygiene. A review of Resident 25's Physician's Order for November 2022 indicated the following physician orders: a. Remeron 15 mg, to give 1 tablet PO QHS for depression, manifested by poor appetite eating less than 50% of meals, dated 3/17/22. b. Monitor side effects of anti-depressant every shift for palpitations/tachycardia. A review of Resident 25's care plan for psychotropic drugs dated 11/9/20/22, indicated the resident had the potential for drug related complications associated with the use of psychotropic medication to manage mood/behavior related to depression, anxiety, and impulse disorder. The care plan indicated the following interventions: a. Observe for antidepressant side effects: orthostatic hypotension and tachycardia. Notify the physician of noted side effects to determine if benefits of therapy outweigh side effects A review of Resident 25's Vital Stats for period 11/1/22 to 11/13/22 indicated Resident 21's vital signs BP was taken on 11/1/22 and 11/8/22 and vital signs were only taken and recorded/documented on 11/6/22 and 11/12/22, and 11/13/22. No documented evidence orthostatic BP were taken for the month of November 2022. 7. A review of Resident 26's admission Record indicated the resident initially admitted to the facility on [DATE] with diagnoses that included major depressive disorder, dementia and chronic obstructive pulmonary disease (COPD, group of lung diseases that block airflow and make it difficult to breathe). A review of Resident 26's H&P, dated 5/6/2022, indicated Resident 26 has altered mental status (mental capacity) with significant cognitive dysfunction (impairment). A review of Resident 26's MDS, dated [DATE], indicated the resident required extensive assistance from staff for dressing, personal hygiene. A review of Resident 26's Physician's Order for November 2022 indicated the following physician orders: a. Mirtazapine tablet 15 mg, to give 1 tablet PO QHS for depression manifested by poor appetite eating less than 50% meals, dated 5/6/22. b. Monitor side effects of anti-depressant every shift for palpitations/tachycardia. A review of Resident 26's care plan for psychotropic drugs dated 9/22/22, indicated the resident had the potential for drug related complications associated with the use of psychotropic medication to manage mood/behavior related to Depression, anxiety, and impulse disorder. The care plan indicated the following interventions: a. Observe for antidepressant side effects: orthostatic hypotension and tachycardia. Notify the physician of noted side effects to determine if benefits of therapy outweigh side effects. b. Observe for antipsychotic side effects: orthostatic hypotension and tachycardia. Notify the physician of noted side effects to determine if benefits of therapy outweigh side effects. A review of Resident 26's Vital Stats for period 11/1/22 to 11/13/22, indicated Resident 26's vital signs were only taken and recorded/documented on 11/2/22 and 11/9/22. No documented evidence orthostatic BP were taken for the month of November 2022. 8. A review of Resident 30's admission Record indicated the resident was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included muscle weakness, spinal stenosis (occurs when one or more bony openings within the spine begin to narrow and reduce space for the nerves) and osteoarthritis (occurs when flexible tissue at the ends of bones wears down). A review of Resident 30's H&P, dated 6/18/22, indicated Resident 30 did not have the capacity to understand or make decisions. A review of Resident 30's MDS, dated [DATE], indicated Resident 30 required extensive assistance with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 30's Physician's Order for November 2022 indicated the following physician orders: a. Zyprexa (Olanzapine-antipsychotic/used to treat psychotic conditions) tablet 2.5 mg, to give 1 tablet PO QHS for psychosis manifested by striking out during nursing care dated 9/12/22. b. Monitor side effects of anti-psychotic every shift for orthostatic hypotension. A review of Resident 30's care plan for psychotropic drugs dated 10/3/22, indicated Resident 30 had the potential for drug related complications associated with the use of psychotropic medication to manage mood/behavior related to psychosis. The care plan indicated the following interventions: a. Observe for antipsychotic side effects: orthostatic hypotension and tachycardia. Notify the physician of noted side effects to determine if benefits of therapy outweigh side effects. A review of Resident 30's Vital Stats for period 11/1/22 to 11/13/22 indicated Resident 30's vital signs were only taken and recorded/documented on 11/6/22 and 11/13/22. No documented evidence orthostatic BP were taken for the month of November 2022. 9. A review of Resident 62's admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses that included dementia, muscle weakness, syncope (fainting) and collapse. A review of Resident 62's H&P, dated 10/19/2022, indicated Resident 62 did not have the capacity to understand and make decisions. A review of Resident 62's MDS, dated [DATE], indicated Resident 62 required limited assistance from staff for bed mobility, transferring, dressing, eating, toileting, and personal hygiene. A review of Resident 62's Physician's Order for November 2022 indicated the following physician orders: a. Mirtazapine tablet 7.5 mg, to give 1 tablet PO QPM for depression manifested by poor appetite eating less than 50% meals, dated 1/6/22. b. Monitor side effects of anti-depressant every shift for palpitations/tachycardia. A review of Resident 62's MAR for the month of November 2022 indicated, Resident 62 had 0 signs and symptoms of side effects from anti-depressant, Remeron from 1/1/22 to 11/12/22. A review of Resident 62's care plan for psychotropic drugs, dated 11/11/22, indicated Resident 62 had the potential for drug related complications associated with the use of psychotropic medication to manage mood/behavior related to depression, anxiety, and impulse disorder. The care plan indicated the following interventions: a. Observe for antidepressant side effects orthostatic hypotension and tachycardia. Notify the physician of noted side effects to determine if benefits of therapy outweigh side effects. A review of Resident 62's Vital Stats for period 11/1/22 to 11/13/22 indicated Resident 62's vital signs were only taken and recorded/documented on 11/4/22, 11/9/22, and 11/11/22. No documented evidence orthostatic BP were taken for the month of November 2022. Based on interview and record review, the facility failed to implement resident-centered care plans with measurable outcomes for 11 of 11 sampled residents (Residents 14, 46, 8, 187, 21, 25, 26, 30, 62, 13, and 17). This deficient practice generalized residents care with the inability to assess improvements and or declines in a resident health status. Findings: 1. A review of Resident 14's admission Record indicated the resident admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure), urinary tract infection (UTI, infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract), and osteoporosis (a bone disease that occurs when the body loses too much bone, makes too little bone, or both). A review of Resident 14's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 11/2/22, indicated the resident did not have any impairment in cognitive skills (ability to make daily decisions) and required extensive assistance (staff provide weight bearing support) from staff for transferred, dressing, toilet use, and personal hygiene. A review of Resident 14's care plan for Falls, initiated on 10/23/22, indicated the resident was found lying down next to her bed with head resting on a fabric. The care plan goal indicated will minimize risk of fall or injury A review of Resident 14's care plan for cardiac, initiated 10/26/22, indicated Resident 14 had a diagnosis of hypertension and hyperlipidemia [high levels of fat particles (lipids) in the blood]. The care plan indicated the goal of, will minimize risk for cardiac distress. 2. A review of Resident 46's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses of hypertension, depression, and hypothyroidism (thyroid gland doesn't produce enough thyroid hormone). A review of Resident 46's MDS, dated [DATE], indicated the resident had moderate impairment in cognitive skills and required limited assistance from staff for bed mobility, transferring, dressing, toileting, and personal hygiene. A review of Resident 46's Care Plan for Hypothyroidism, dated 7/26/22, indicated the goal, will minimize complications of hypothyroidism of hyperthyroidism symptoms. A review of Resident 46's Care Plan Osteoporosis, dated 7/26/22, indicated the goal, will minimize risk for spontaneous fracture and other complications from osteoporosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a medication pass administration observation and interview, on 11/12/22 at 8:42 AM, LVN 1 attempted to administer BP medications (Amlodipine, Diltiazem CD, and Losartan-HCTZ) to Resident 8 and did not check the resident's BP. LVN 1 stated she did not check the resident's BP because the resident did not have an order for BP parameters (guideline/restriction) prior to administration. On 11/12/22 at 8:45 AM, during an interview and record review of Resident 8's eMAR, LVN 1 stated licensed nurses checked BP of residents who were taking BP medications once a week and would check vital signs once a week also for weekly summary. LVN 1 stated licensed nurses did not check residents BP unless there was a change in condition like unresponsiveness, dizziness or lightheadedness, or if ordered by the resident's physician. LVN 1 stated Resident 8 did not have any order for parameters for any of the BP meds. A review of Resident 8's admission Record indicated the resident initially admitted to the facility on [DATE] with diagnoses including essential HTN, dementia, and urine retention (difficulty urinating and completely emptying the bladder). A review of Resident 8's MDS, dated [DATE], indicated the resident had no impairment in cognitive skills and required extensive assistance from staff for bed mobility, transferring, dressing, toileting, and personal hygiene. A review of Resident 8's Physician's Order for the month of November 2022 indicated the following physician orders: a. Amlodipine Besylate (used treat high BP) tablet, 5 mg to give 1 tablet PO every day (QD). b. Diltiazem CD (used treat high blood pressure) capsule, extended release 24 hour (slowly released into the body over a period of time, usually 24 hours), 360 mg, to give 1 capsule PO QDay. c. Losartan 100 mg - hydrochlorothiazide [(HCTZ, medication used to treat water retention) a combination medication used to treat high blood pressure], 12.5 mg PO every evening (QPM). A review of Resident 8's MAR for the month of November 2022, indicated Resident 8's BP medications (Amlodipine, Diltiazem CD, and Losartan-HCTZ) were given everyday as ordered without BP parameters. The MAR indicated a BP check every week on Tuesday at nighttime. The MAR indicated a BP measurement taken on 11/8/2022. A review of Resident 8's care plan for medical conditions dated 7/21/22, indicated Resident 8 had an alteration in cardiac (relating to the heart) status related to HTN with the following interventions: a. Check and record heart rate, BP, and respirations (breathing). Inform the physician of readings outside of normal range. b. Assess for cardiac distress, change in vital signs (group of medical signs that indicate the status of the body's vital functions, such as heart rate, BP, respiratory rate, and temperature), chest pain, dizziness, pallor (unhealthy pale appearance), apprehension (anxiety), and diaphoresis (excessive sweating). c. Check BP every week on Tuesday. A review of Resident 8's Vital Stats from 11/1/22 to 11/13/22, indicated a BP measurement and documentation done on 11/8/22 and 11/12/22. 4. During a medication pass administration observation and interview with LVN 1 on 11/12/22 at 9:02 AM, LVN 1 observed attempted to administer Resident 187's BP medication (Lisinopril) and stated she did not check the resident's BP because the resident did not have BP parameters or an order to check BP prior to administration. A review of Resident 187's admission Record indicated the resident admitted to the facility on [DATE] with diagnoses including essential HTN, history of fall, and convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement). A review of Resident 187's Physician's Order for the month of November 2022, indicated a physician order for Lisinopril (used to treat high blood pressure) tablet, 5 mg to give 1 tablet PO QDay. A review of Resident 187's MAR for the month of November 2022, indicated Resident 187's BP medication (Lisinopril) was given daily on 11/5/22 to 11/11/22 as ordered without BP parameters. There was no documentation on the MAR that BP was taken from 11/5/22 to 11/11/22. A review of Resident 187's care plan for medical conditions dated 11/7/22, indicated Resident 187 had an alteration in cardiac status related to HTN with the following interventions: a. Check and record heart rate, BP, and respirations. Inform the resident's physician for readings outside of normal range. b. Assess for cardiac distress, change in vital signs, chest pain, dizziness, pallor, apprehension, and diaphoresis. During an interview on 11/13/22 at 9:56 AM, the Director of Nursing (DON) stated not all residents who were on BP medications had BP parameters to monitor, and the parameters were dependent on certain physicians. The DON stated vital signs, including BPs were not checked daily. The DON stated BP measuring was only conducted with a change in condition or with signs and symptoms of hypertension/hypotension. The DON stated even if a resident was on BP medications, some residents did not have parameters, therefore BP measuring did not need to be performed. The DON stated BP measuring for some residents were done weekly. The DON stated BP monitoring should be done for any resident who was taking BP medications. The DON stated it had been an issue that she had brought up to the facility previously. The DON stated BP monitoring for any resident who was on BP medication was a basic nursing practice and that BP should be obtained daily and prior to administration of all BP medications. A review of the facility policy and procedure titled, Administering Medications, revised 4/2019, indicated prior to administering medication the following information was checked/verified for each resident for vital signs, if necessary. A review of the facility's policy and procedure titled, Blood Pressure, Measuring, revised 9/2010, indicated Hypertension was defined as blood pressure over 140/90 millimeters of mercury (mm/Hg) and should be reported to the physician. The policy indicated hypotension was defined as blood pressure less than 100/60 mm/Hg and should be reported to the physician. The policy indicated staff should record several readings throughout the day, including before and after meals. Based on observation, interview, and record review the facility failed to ensure five of five sampled residents (Residents 49, 46, 14, 8, and 187) received appropriate care and services, according to current standards of practice. The facility did not check Residents 49, 46, 14, 8, and 187 blood pressures (BPs) prior to administration of BP medications. This deficient practice had the potential for residents not to be monitored adequately for exacerbation in side effects of administered medications. Findings: 1. During a medication pass observation and interview, on 11/12/22 at 8:21 AM, a Licensed Vocational Nurse 2 (LVN 2) prepared blood pressure (BP) medications to administer to Resident 49 and did not check the resident's BP. LVN 2 stated she did not check the resident's BP because the resident did not have an order for specific parameters for blood pressure medications. A review of Resident 49's admission Record indicated the resident admitted to the facility on [DATE] with diagnoses of hypertension (HTN, high blood pressure), arthritis (inflammation or swelling of one or more joints), and dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). A review of Resident 49's Minimum Data Set (MDS, standardized assessment and care planning tool), dated 10/13/22, indicated the resident had severe impairment in cognitive skills (ability to make daily decisions) required extensive assistance (resident involved with activity, staff provided weight-bearing support) from staff for dressing, toileting, and personal hygiene. A review of Resident 49's Physician Orders, dated 4/2/21, indicated an order for lisinopril (treat high blood pressure and heart failure) 30 milligrams (mg, a unit of measurement) one (1) tablet (tab) by mouth (PO) daily (QD) for HTN. A review of Resident 49's Physician Orders, dated 4/2/21, indicated an order for Isosorbide Mononitrate (effective in the short-term for decreasing systolic blood pressure, pulse pressure, and pulse wave reflection in patients with systolic hypertension) extended release (ER) 24 hour, 1 tab PO twice daily (BID) for HTN. A review of Resident 49's Care Plan for Hypertension, dated 10/27/22, indicated an intervention to check and record heart rate, blood pressure and respirations and to inform the physician of readings outside of normal range. The Care Plan indicated to administer medications as ordered and to monitor for side effects. The care plan indicated to assess for cardiac distress such as change in vitals signs. The care plan indicated to check blood pressure every week on Sunday. 2. During a medication pass observation and interview on 11/12/22 at 8:32 AM, LVN 2 observed preparing Resident 46's BP medication and did not check the resident's BP prior to administration. LVN 2 stated she did not check the resident's BP because the resident did not have an order for BP parameters. A review of Resident 46's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses of HTN, depression, and hypothyroidism (thyroid gland doesn't produce enough thyroid hormone). A review of Resident 46's MDS, dated [DATE], indicated Resident 46 had moderate impairment in cognitive skills and required limited assistance from staff for transferring, dressing, toileting, and personal hygiene. A review of Resident 46's Physician Orders, dated 12/3/21, indicated an order for Diltiazem (a medication used to treat high BP and chest pain) extended release (ER) 120 mg capsule, take 1 capsule PO QD for HTN. A review of Resident 46's Care Plan for hypertension, dated 7/26/22, indicated the approach to check and record heart rate, blood pressure and respirations and to inform the physician of readings outside of normal range. The Care Plan indicated to administer medications as ordered and to monitor for side effects. The care plan indicated to check and log blood pressure every week on Sunday. During a medication pass observation and interview on 11/12/22 at 8:44 AM, LVN 2 prepared to administer Resident 14's BP medication and did not check the resident's BP before administration. LVN 2 stated Resident 14 did not have an order for BP parameters so she did not have check it before administrating. LVN 2 stated residents BP were obtained weekly. A review of Resident 14's admission Record indicated the resident admitted to the facility on [DATE] with diagnoses of hypertension, urinary tract infection (UTI, infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract), and osteoporosis (a bone disease that occurs when the body loses too much bone, makes too little bone, or both). A review of Resident 14's MDS, dated [DATE], indicated the resident did not have any impairment in cognitive skills and required extensive assistance from staff for transferred, dressing, toilet use, and personal hygiene. A review of Resident 14's Physician Orders, dated 10/27/22, indicated an order for Amlodipine (medication used to high blood pressure) 5 mg, take 1 tablet PO QD for HTN. A review of Resident 14's Care Plan for hypertension, dated 10/26/22, indicated the approach to check and record heart rate, blood pressure and respirations and to inform the physician of readings outside of normal range. The Care Plan indicated to administer medications as ordered and to monitor for side effects. The care plan indicated to check blood pressure every week on Monday. During an interview on 11/13/22 at 7:50 AM, LVN 5 stated residents who were on BP medication were initially monitored daily for BP prior to medication administration. LVN 5 stated once the BP was considered stabilized within the next three months, BP was then conducted once a week. LVN 5 stated if a residents BP was abnormal (not within range) then the resident's physician was notified. LVN 5 stated some residents' BP monitoring was ordered weekly and some were ordered monthly, depending on the residents' physicians. LVN 5 stated to counteract episodes of HTN or hypotension, BP monitoring should be conducted and measuring of the resident's BP was necessary to ensure appropriate range.