**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a policy for use of, sensor alarm pads (a device that alerts staff when a resident moves or leaves their bed or chair) and to ensure consistent monitoring of the use of the sensor alarm pads for the bed and chair, for one of three sampled residents (Resident 26) while the sensor alarm pads were utilized. This deficient practice had the potential to place Resident 26 at risk for decline in physical functioning, reduced mobility, and loss of dignity due to the unmonitored use of sensor alarm pads. Findings: During a review of Resident 26's admission Record, the admission Record indicated Resident 26 was originally admitted on [DATE] with a re-admission date on 3/22/2025 with diagnoses of chronic obstructive pulmonary disease ([COPD], a chronic lung disease causing difficulty in breathing), hypertension ([HTN], high blood pressure), dementia (a progressive state of decline in mental abilities), and atrial fibrillation ([A-Fib], (a condition that causes irregular and fast heartbeat in the heart). During a review of Resident 26's History and Physical (H/P) dated 3/25/2025, the H/P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 26's Minimum Data Set ([MDS], a resident assessment tool) dated 3/26/2025, the MDS indicated Resident 26 was severely cognitively (ability to make decisions of daily living) impaired and required moderate assistance (helper does less than half the effort) on self-care abilities such as eating, required maximal assistance (helper does more than half the effort to complete the task) with oral hygiene, toileting hygiene, shower/bathe, upper and lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 26 required maximal assistance with mobility such as rolling left and right, sitting to lying position, lying to sitting on side of bed, bed to chair transfers, and toilet transfers. During a review of Resident 26's Order Summary Report, the Order Summary Report indicated, sensor pad alarm while in bed to alert staff when Resident 26 is trying to get out of bed unassisted, informed consent obtained by medical doctor from responsible party, ordered on 3/22/2025. The Order Summary Report indicated sensor pad alarm in wheelchair to alert staff when Resident 26 is trying to get out of wheelchair unassisted informed consent obtained by medical doctor from responsible party ordered on 3/22/2025. During a review of Resident 26's Medication Administration Record ([MAR], used to document medications taken by the resident) for April 2025, there was missing documentation for April 5th during the nocturnal shift, April 14th during night shift, April 21st during night and nocturnal shift to monitor the resident when the sensor alarm pads were in use. During an observation on 4/21/2025 at 10:47 a.m., in Resident 26's room, Resident 26 was resting in bed with eyes closed. There was a box attached to the bed with a wire attached to the box connect to the alarm pad underneath Resident 26 who as resting in bed. During a concurrent interview and record review on 4/23/2025 at 2:59 p.m., with the MDS Coordinator (MDSC), Resident 26's MAR for April 2025 was reviewed. The MDSC stated staff should be monitoring the residents and the sensor alarm pads every shift to make sure the sensor alarms pads were still there and if the sensor alarm pads were working properly. The MDSC stated if the monitoring was not done every shift or as needed, the residents could be at risk for falls. The MDSC stated monitoring should be done every shift to make sure residents are safe and it should have been documented in the MAR. The MDSC stated if it was not documented, the monitoring was not done. The MDSC stated not aware if there was a policy for sensor alarm pads being utilized. During an interview on 4/24/2025 at 3:20 p.m. with the Director of Nursing (DON), the DON stated sensor alarm pads should be monitored every shift. The DON stated the importance of monitoring the residents and the sensor alarm pads was to make sure the sensor alarm pads were functioning and in place. The DON stated monitoring of the sensor alarm pads should be done every shift and documented to make sure the sensor alarm pads were serving their purpose of alerting staff [NAME] Resident 26 tried to get up unassisted. The DON stated high fall risk residents will fall if monitoring was not done every shift or as needed. The DON stated there was no policy and/or procedure for the bed and chair sensor alarm pads being utilized for residents and that there should be a policy for bed and chair sensor alarm pads since it was an intervention being used for fall risk residents. The DON stated a policy, and procedure was how the facility would monitor and document interventions being done with residents and if the interventions are effective. The facility did not have a policy regarding use of bed and chair alarms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 12) who was incontinent (unable to voluntarily control retention of urine or feces in the body) of bowel and bladder, was provided a retraining and/or toileting program (a structured approach to help individuals regain or improve control over their bowel and bladder functions), to regain the resident's normal bowel and bladder function as much as possible. This failure had a potential to result in Resident 12's inability to regain control of bowel and bladder function and can lead to a loss of dignity. Findings: During a review of Resident 12's admission Record, the admission Record indicated, Resident 12 was initially admitted to the facility on [DATE] and last re-admission was on 9/24/2024 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), overactive bladder (a bladder has a strong urge to pass urine even when your bladder isn't really full), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 12's History and Physical (H&P), dated 9/27/2024, the H&P indicated, Resident 12 was alert and oriented. During a review of Resident 12's Minimum Data Set (MDS - a resident assessment tool), dated 3/31/2025, the MDS indicated Resident 12 required moderate assistance (Helper does less than half the effort) from one staff for transfer, toileting hygiene, shower/bathe self, supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and /or contact guard assistance as resident completes activity) from one staff for bed mobility, dressing, personal hygiene, and independent for eating. The MDS indicated, Resident 12's cognition (The mental process of thinking, learning, remembering, being aware of surroundings, and using judgment) was intact. During an interview on 4/21/2025, at 10:46 a.m., with Resident 12, in Resident 12's room, Resident 12 stated, she did not want to talk about her incontinence issue because it made her feel embarrassed. During a concurrent interview and record review on 4/23/2025, at 3:48 p.m., with the Minimum Data Set Coordinator (MDSC), Resident 12's MDS, dated [DATE] and 3/31/2025 were reviewed. The MDS, dated on 9/30/2024, indicated, Resident 12 was frequently incontinent for urine, occasionally incontinent for bowel, and was not on a bowel and bladder toileting program. The MDS, dated on 3/31/2024, indicated, Resident 12 was frequently incontinent for urine, occasionally incontinent for bowel, and was not on bowel and bladder toileting program. MDSC stated, Resident 12 was a candidate for bowel and bladder retraining program, but the facility did not have the program currently. MDSC stated, she believed that Resident 12 would benefit from bowel and bladder retraining program to promote highest functional ability. During an interview on 4/23/2025, at 4:11 p.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated, Resident 12 had few episodes of incontinence, but she was continent most of the time. CNA 1 stated, Resident 12 was not in the bladder and bowel retraining program and there was no set schedule for toileting for Resident 12. During an interview on 4/23/2025, at 4:18 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, Resident 12 was a candidate for the retraining program and would benefit from the retraining program. LVN 2 stated, she was not sure of a bowel and bladder retraining program at the facility. During an interview on 4/24/2025, at 3:21 p.m., with the Director of Nursing (DON), the DON stated, Resident 12 was a candidate for the retraining program and should be in the program. The DON stated, the facility's policy and procedure for the retraining program was outdated and should be revised. The DON stated, she should have provided an in-service (staff training and education) to staff regarding the facility's bowel and bladder retraining program. The DON stated, the staff should screen the resident for bowel and bladder function and place the resident in a retraining program if the resident (general) is screened as a possible candidate. The DON stated, the bowel and bladder retraining program was important to preserve current level of function and promote achieving highest functional level for Residenrt 12. During a review of Resident 12's Bowel and Bladder Evaluation, dated 9/26/2024, the Bowel and Bladder Evaluation indicated, Resident 12 was a possible candidate and scored 12 (score 0-4 good candidate, 5-8 likely candidate, 9-12 possible candidate, 13-16 unlikely candidate, 17-20 not a candidate). During a review of Resident 12's Bowel and Bladder Evaluation, dated 3/31/2025, the Bowel and Bladder Evaluation indicated, Resident 12 was a possible candidate and scored 12. During a review of Resident 12's Care Plan (CP), dated from 9/2024 to 4/2025, the CP indicated, there was no care plan regarding bowel and bladder retraining program. During a review of Resident 12's Order Summary Report (OSR), dated 4/24/2025, the OSR indicated, there was no order to place Resident 12 in the retraining program. During a review of the facility's Policy and Procedure (P&P) titled, Bowel and Bladder Retraining, revised 5/2007, the P&P indicated, POLICY: It is the policy of this facility that bowel and bladder retraining will be provided for residents with the potential to benefit from such a program. When medically appropriate. bowel and bladder retraining is the preferred treatment option for incontinence. PURPOSE: Achieve as nearly normal filling and emptying of bladder as possible. To re-train incontinence residents in bladder and bowel control when medically feasible. Advantages for resident: I. Regain confidence and self-esteem. 2. Less skin breakdown and odor. 3. Cooperation with activities and ambulation. Assessment Process: 1. Complete assessment form. 2. Record database for three (3) days by stating: INC. - CONT. - DRY every two (2) hours around the clock on Elimination Diary Form. 3. On the fourth (4) day, determine if bowel and bladder retraining is appropriate. 4. If not appropriate. document on original Bowel and Bladder Retraining Assessment Form; or if appropriate, initiate formal program by placing forms in B&B notebook. 5. Document decision on original Bowel and Bladder Retraining Assessment Form. 6. Notify licensed nurse through Nursing Communication 24-hour Report Book. 7. Place copy of original assessment in B&B notebook. 8. Address bowel and bladder retraining on resident's care plan . 10. Each incontinent resident must be assessed for potential successful bowel and bladder retraining. Before a formalized bowel and bladder retraining program is initiated, a physician's order must be obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 17) received multivitamins with minerals in accordance with physician orders during medication administration. This deficient practice had the potential to result in weakness and fatigue due to low levels of vitamins and minerals for Resident 17. Findings: During a review of Resident 17's admission Record (a document containing demographic and diagnostic information), dated 4/22/2025, the admission record indicated Resident 17 was originally admitted to the facility on [DATE] and readmitted on [DATE]. During a review of Resident 17's History and Physical, dated 2/2/205, the document indicated Resident 17 had the capacity to understand and make decisions. During a review of Resident 17's Minimum Data Set MDS (MDS - a federally mandated resident assessment tool), dated 1/28/2025, the MDS indicated Resident 17's cognition was moderately impaired. The MDS indicated that Resident 17 needed maximal assistance from facility staff for Activities of Daily Living (ADLs) such as eating, oral hygiene, toileting hygiene, showering, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During an observation on 4/22/2025 between 10:11 a.m. and 10:36 a.m., Licensed Vocational Nurse (LVN) 2 prepared and administered nine medications as listed below to be administered for Resident 17 but did not include multivitamins with minerals. 1. One tablet of amlodipine (a medication used to treat high blood pressure) 5 milligrams ([mg] a unit of measurement for mass) 2. One tablet of chlorthalidone (a medication used to reduce the amount of water in the body and to treat high blood pressure) 25 mg 3. One tablet of methimazole (a medication used to treat high thyroid) 5 mg 4. One tablet of propranolol (a medication used to treat high blood pressure) 10 mg 5. One tablet of bupropion (a medication used to treat depression) extended release (XL) 150 mg 6. One tablet of thiamin (vitamin B1) (a vitamin used to treat low level of vitamin B1) 100 mg 7. One tablet of vitamin C (a vitamin used to treat low level of vitamin C) 500 mg 8. One tablet of hydrocodone-acetaminophen (a combination medication used to treat pain) 5-325 mg During a review of medication reconciliation and review of Resident 17's Order Summary Report (a document containing a summary of all active physician orders), dated 4/22/2025, the document indicated, but not limited to, the following medications: Multiple Vitamins-Minerals Tablet, give 1 tablet by mouth one time a day for supplement, order date 4/22/2025, start date 4/23/2025 Multivitamin-Minerals Oral Tablet, give 2 tablets by mouth one time a day for supplement, order date 1/24/2025, start date 1/25/2025 During a review of Resident 17's Medication Administration Record ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 4/1/2025 to 4/30/2025, the multivitamin with minerals was not documented as administered. During a review of Resident 17's care plan report, creation date of 1/24/2025, the note indicated, has nutritional problem or potential nutritional problem related to diagnosis of status post fall, leukocytosis (a medical condition with high number of white blood cells in the blood), altered level of consciousness and mild anterior wedge compression fracture with history of chronic back pain .hypertension (HTN - high blood pressure), arthritis (inflammation of the joints), atrial fibrillation (irregular heart beat and rhythm). During an interview on 4/22/2025 at 2:14 p.m. with LVN 2, LVN 2 stated she forgot to administer multivitamins with minerals to Resident 17 on 4/22/2025. LVN 2 stated Resident 17 could feel lethargic or weak due to possible low levels of vitamins and minerals. During an interview on 4/23/2025 at 4:53 p.m. with the Director of Nursing (DON), DON stated facility nurse should have given multivitamins with minerals to Resident 17 per physician order for it to be effective for the resident's health. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 2012, the P&P indicated, Medications are administered as prescribed in accordance with written orders of the attending physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Seroquel (generic name - quetiapine, a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought]) for one of four sampled residents (Resident 12) was indicated for a specific, diagnosed condition as documented in the medical evaluation and record. This deficient practice had the potential to place Resident 12 at risk for significant adverse events (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of an unnecessary psychotropic drug (a medication that affects brain activities associated with mental processes and behavior), which could result in impairment or decline in the resident's mental, physical condition, functional, and psychosocial status. Findings: During a review of Resident 12's admission Record (a document containing demographic and diagnostic information), dated 4/22/2025, the admission record indicated Resident 12 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to, schizophrenia (a mental illness that is characterized by disturbances in thought) and depression (a mood disorder characterized by persistent sadness and loss of interest in activities). During a review of Resident 12's Minimum Data Set MDS (MDS - a federally mandated resident assessment tool), dated 3/31/2025, the MDS indicated Resident 12's cognition was intact. The MDS indicated Resident 12 was independent for Activities of Daily Living (ADLs) such as eating, needed supervision level assistance from the facility staff for oral hygiene, upper body dressing, lower body dressing and personal hygiene, moderate assistance for toileting, showering and putting on/taking off footwear. The MDS indicated diagnoses of schizophrenia, but did not indicate bipolar disorder. During a review of Resident 12's Order Summary Report (a list of all currently active medical orders), dated 4/22/2025, the order summary report indicated the following physician order: Quetiapine Fumarate Oral Tablet 50 mg, give 1 tablet by mouth at bedtime for schizoaffective (a mental illness that combines symptoms of schizophrenia and symptoms of a mood disorder, such as mania or depression) disorder manifested by (m/b) disorganized thought processes and paranoia, order date 9/24/2024, start date 9/24/2024. Aripiprazole (a medication used to treat mental conditions such as depression and bipolar disorder) Oral Tablet 15 milligrams ([mg] a unit of measurement for mass), give 1 tablet by mouth one time a day for bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) manifested by (m/b) sudden mood change, order date 9/24/2024, start date 9/25/2024. During a review of Resident 12's psychiatry initial evaluation and consultation notes, dated 1/10/2025, 3/3/2025 and 2/5/2025, the documents respectively indicated, The patient, with a documented history of major depressive disorder and bipolar disorder, underwent an initial 45-minute, and 16-minute psychiatry evaluations. The documents indicated diagnoses of Major Depressive Disorder (MDD) and bipolar disorder, and no diagnosis of schizophrenia was documented. During a review of Resident 12's MAR, dated 4/1/2025 to 4/22/2025, 3/1/2025 to 3/31/2025 and 2/1/2025 to 2/28/2025, the MAR indicated quetiapine fumarate 50 mg was documented as administered every day at bedtime for schizoaffective disorder. During a review of Resident 12's Medication Administration Record ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 4/1/2025 to 4/22/2025, 3/1/2025 to 3/31/2025 and 2/1/2025 to 2/28/2025, the MAR indicated aripiprazole 15 mg was documented as administered every day for bipolar disorder. During a review of Resident 12's MAR, dated 4/1/2025 to 4/22/2025 and 3/15/2025 to 3/31/2025, the MAR indicated zero episodes documented or left blank (-) for anti-psychotic target behavior: disorganized thought process and paranoia, monitor episodes of targeted behavior every shift. During a review of Resident 12's MAR, dated 2/1/2025 to 2/28/2025, the MAR did not indicate any documentation of monitoring for anti-psychotic target behavior: disorganized thought process and paranoia, monitor episodes of targeted behavior every shift. During a review of Resident 12's MAR, dated 4/1/2025 to 4/22/2025, 3/1/2025 to 3/31/2025 and 2/1/2025 to 2/28/2025, the MAR indicated zero episodes documented or left blank (-) for monitor episodes of psychotic behavior (bipolar disorder) m/b sudden mood change (aripiprazole) every shift. During a concurrent interview and record review on 4/23/2025 at 3:50 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 12's MAR with documentation for antipsychotic target behaviors, bipolar episodes and side effects dated until 4/9/2025 were reviewed. The document indicated zero episodes. LVN 2 stated she had been working at the facility only for one and half month and she had only seen Resident 12 with good behavior and straightforward answers. LVN 2 stated Resident 12 had been taking quetiapine and aripiprazole daily but since no behavior episodes were reported, reevaluation won't hurt her. During a phone interview on 4/24/2025 at 10:40 a.m. with the psychiatry Nurse Practitioner (NP) 1, NP 1 stated Resident 12 had medical diagnoses of bipolar disorder and depression based on her evaluation of the resident. NP 1 stated Resident 12 did not have a diagnosis of schizophrenia. NP 1 stated, I do not believe that the MDS stating schizophrenia is accurate. NP 1 stated she needed to reassess Resident 12 before she could comment on current instructions for quetiapine for schizoaffective disorder. NP 1 stated aripiprazole and quetiapine could be given together for bipolar disorder. During an interview on 4/24/2025 at 12:20 p.m. with the Director of Nursing (DON), DON stated DON stated there should have been a diagnosis for psychotropic medications because medication should not be given without a diagnosis. DON stated if an antipsychotic (a category of psychotropic medications) was given to resident without diagnoses, it would be considered as an unnecessary medication and could give side effects such as sleepiness and inability to function. DON stated when she checked Skilled Nursing Facility (SNF) 1's records, Resident 12's admitting diagnoses were bipolar disorder, depression and anxiety. DON stated the hospital's admission records, dated 09/2024 and 03/2024, did not have any diagnoses. DON stated there was an inaccuracy in diagnoses in Resident 12's MDS because MDS indicated diagnoses of schizophrenia and no bipolar disorder, whereas psychiatry evaluation indicated bipolar disorder and no schizophrenia. DON stated the inaccurate record of medical diagnoses would affect resident's treatment plan. DON stated the resident might not be getting treatment with the right medications causing negative impact on resident's cognition and behaviors. After survey exit on 4/24/2024, DON submitted a document titled, Skilled Nursing Facility (SNF) 1 Progress Notes, dated 9/12/2024, which indicated a documented plan to discontinue Seroquel, but the surveyed facility did not discontinue Seroquel. The document indicated, psychiatry consult due for gradual dose reduction (GDR) schizoaffective disorder .plan discontinue Seroquel, continue Abilify (generic name - aripiprazole) 15 mg daily. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medications, reviewed date 12/2023, the P&P indicated, It is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinic record. Psychotropic medications shall not be administered for the purpose of discipline or convenience.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident 11's multivitamin liquid bottle indicated a manufacturer expiration date in accordance with manufacturer's specifications and facility's policy and procedures (P&P) titled, Medication Storage dated 2012 and Medication Ordering and Receiving from Pharmacy Provider, Medications Brought to Care Center by Resident or Family Member, dated 2012 in one of one inspected medication room (Station 1 Medication Room). This deficient practice had the potential to result in Resident 11 receiving multivitamin liquid that had become expired, ineffective, or toxic due to improper labeling and/or storage possibly leading to adverse effects from the multivitamin. Findings: During a review of Resident 11's admission Record (a document containing demographic and diagnostic information), dated [DATE], the admission record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses including but not limited to, tinea unguium (fungal infection of the nails), alcohol abuse and cognitive communication deficit. During a review of Resident 11's History and Physical, dated [DATE], the document indicated Resident 11 did not have the capacity to understand and make decisions. During a review of Resident 11's Minimum Data Set MDS (MDS - a federally mandated resident assessment tool), dated [DATE], the MDS indicated Resident 11's cognition was severely impaired. The MDS indicated the Resident 11 needed supervision level assistance from the facility staff for Activities of Daily Living (ADLs) such as eating, moderate assistance for oral hygiene, upper body dressing and personal hygiene, and maximal assistance for toileting hygiene, showering, lower body dressing and putting on/taking off footwear. During a concurrent observation and interview on [DATE] at 11:32 a.m. with Licensed Vocational Nurse (LVN) 3 in Station 1 Medication Room, there was a dark-brown colored bottle with a manufacturer label that indicated, Marry Ruth's Liquid Morning Multivitamin Hair Growth stored in the medication refrigerator. The liquid multivitamin bottle did not indicate a manufacturer expiration date. LVN 3 stated she could not find the expiration date on the bottle that had facility's handwritten label indicating Resident 11's first name, room number and an open date of [DATE]. During a concurrent observation and interview on [DATE] at 12:11 p.m. with the Director of Nursing (DON), DON tried to remove the facility's handwritten labels from the liquid multivitamin bottle to find the manufacturer expiration date. DON stated she was not able to find the expiration date for Resident 11's liquid multivitamin bottle. DON stated it was important to have an expiration date to determine if the multivitamin was still safe and effective to be administered to Resident 11. DON stated liquid multivitamin was Resident 11's home medication that she brought to the facility to be taken for hair growth. DON was not able to indicate where Resident 11's liquid multivitamin was sourced from. During an interview on [DATE] at 12:37 p.m. with LVN 4, LVN 4 stated Resident 11 brought the sealed bottle of liquid multivitamin. LVN 4 stated Resident 11's liquid multivitamin did not have an expiration date and without an expiration date, it would be difficult to know how long Resident 11 had the product. LVN 4 stated it would not be safe or effective to administer liquid multivitamin intended for hair growth to Resident 11. During a review of Resident 11's Order Summary Report (a document containing a summary of all active physician orders), dated [DATE], the document indicated, but not limited to, the following medication: Multivitamin Oral Liquid (Multiple Vitamins with Minerals), give 30 milliliters ([mL] a unit of measurement for volume) by mouth one time a day for multivitamin and hair growth, order date [DATE], start date [DATE] During a review of Resident 11's nursing progress notes, dated [DATE], the document indicated a note, MD was made aware of new order for [NAME] Ruth's multivitamin plus hair growth oral liquid (30 mL). Discontinue order for multivitamin/minerals tablets. During a review of Resident 11's Medication Administration Record ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated [DATE] to [DATE], the multivitamin oral liquid was documented as administered 15 times from [DATE] to [DATE]. During a review of the facility's P&P titled, Medication Ordering and Receiving from Pharmacy Provider, Medications Brought to Care Center by Resident or Family Member, dated 2012, the P&P indicated, Medications brought into the care center by a resident or family member are used only upon written order by the resident's attending physician, after the contents are verified, and if the packaging meets the state, federal, and pharmacy's guidelines. Other unauthorized medications are not accepted by the care center. During a review of the facility's P&P titled, Medication Storage, dated 2012, the P&P indicated, Medications and biologicals are stored properly, following manufacturer's recommendations or those of the supplier to maintain their integrity and to support safe administration. The provider pharmacy dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices established by the United States Pharmacopeia (USP).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an accurate medical diagnosis was documented for one of three sampled residents (Resident 21), by failing to ensure Resident 21's diagnoses of adjustment disorder with depressed mood a specific type of adjustment disorder where the dominant symptoms are those associated with depression, such as low mood, tearfulness, and feelings of hopelessness, in response to a stressful event or life change was reflected. This deficient practice had the potential to negatively impact the provision of necessary care and services and portray an inaccurate reflection of resident receiving care in the facility. Findings: During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertension ([HTN], high blood pressure), hyperlipidemia (too much fat particles in the blood), diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), and glaucoma (a group of eye diseases that damage the optic nerve, which connects the eye to the brain, leading to vision loss). During a review of Resident 21's history and physical (H/P) dated 2/27/2025, the H/P indicated Resident 21 has the capacity to understand and make decisions. During a review of Resident 21's Minimum Data Set ([MDS], a resident assessment tool) dated 3/25/2025, the MDS indicated Resident 21 had moderate cognitive (thinking process) impairment and required set up or clean up assistance (helper sets up or cleans up while resident completes the activity) with self-care abilities such as eating, required moderate assistance (helper does less than half the effort while resident completes the task) with oral hygiene, and personal hygiene, required maximal assistance (helper does more than half the effort completing task) with upper body dressing and was dependent (helper does all of the effort while resident does none of the effort to complete the task) with toileting hygiene, shower/bathe, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 21 was taking an antidepressant medication. The MDS did not have the mood disorder diagnosis listed in the active diagnoses section of the MDS. During a review of Resident 21's psychiatric (relating to mental illness or it's treatment) consult note dated 3/3/2025, the psychiatric (medical doctor who specializes in mental health, including substance use disorders and prescribed a medication and administer medical treatments for mental health disorders) consultation note indicated Resident 21 had a documented history of major depressive disorder (mood disorder characterized by persistent sadness, loss of interest or pleasure, and other symptoms that interfere with daily life), continued to exhibit symptoms of major depressive disorder. The psychiatric consultation notes also indicated diagnosis of adjustment disorder. During a review of Resident 21's psychologist (a professional who practices psychology and studies mental states, perceptual, cognitive, emotional, and social processes and behavior) consultation note dated 3/6/2025, the psychologist consultation note indicated that Resident 21 was diagnosed with adjustment disorder with depressed mood as evidenced by reported emotional and behavioral response to medical conditions, functional limitations, increased need for assistance and rehab placement. During a concurrent interview and record review on 4/23/2025 at 3:18 p.m., with the MDS Coordinator (MDSC), Resident 21's admission record, MDS assessment dated [DATE], and the psychologist consultation note dated 3/6/2025 were reviewed. The MDSC stated there should have been a diagnosis of mood disorder in Resident 21's admission records medical diagnosis information. The MDSC stated the importance of maintaining accurate diagnoses information for Resident 21 was to make sure Resident 21 was receiving care based on care plan, to monitor resident safety, and to monitor episode of depression. MDSC stated there should be communication with the psychologist and/or psychiatrist doctor and that if there are any changes in the resident diagnosis and treatment, the facility can make sure diagnosis are accurate and any irregularities can be corrected. MDSC stated there should be a medical diagnosis of a mood disorder before any medication was ordered. During a concurrent interview and record review on 4/24/2025 at 4:15 p.m., with the Director of Nursing (DON), Resident 21's admission record, MDS assessment dated [DATE], psychologist consultation note dated 3/6/2025 was reviewed. The DON stated Resident 21 had adjustment disorder with depressed mood and the admission record medical diagnosis information should have indicated that resident has some type of depressed mood disorder. The DON stated the importance of having accurate medical diagnosis information was that it is a reflection of the resident, to make sure it reflects the resident in the clinical chart to meet their needs and to prevent confusion. The DON stated the admission record medical diagnosis information needed to be accurate to reflect the resident so facility can refer to psychology and/or psychiatry consult as needed if the resident has a mental illness/disorder so the plan of care can be effective in treating the resident. During a review of the facility's policy and procedure (P/P) titled Resident Assessment and Associated Processes, dated 12/2023, the P/P indicated it was the policy of this facility that resident's will be assessed, and the findings documented in their clinical health record. These will be comprehensive, accurate, standardized reproducible assessment of each resident an accurate comprehensive assessment will be made of the resident's needs, strengths, goals, life history and preferences each individual who completes a portion of the assessment will electronically sign and certify the accuracy of that portion of the assessment, as well as the date the data was obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation. interview and record review, the facility failed to implement infection control measures by failing to ensure: A. Resident 148's visitor was wearing Personal Protective Equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) while the visitor (Vistor 1) was assisting the resident. B. To place Resident 148 in Contact Isolation (a preauction that is used for patients with diseases caused by bacteria and viruses that are spread through direct and indirect contact) due to possible clostridium difficile (C. diff- a highly contagious bacteria that causes severe diarrhea) infection while waiting for lab result. This failure had the potential to result in compromised infection control measures to prevent the potential spread of infection among residents, staff, and visitors. Findings: During a review of Resident 148's admission Record, the admission Record indicated, Resident 148 was admitted to the facility on [DATE] with diagnoses including pneumonia (an infection/inflammation in the lungs), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 148's History and Physical (H&P), dated 4/21/2025, the H&P indicated, Resident 148 had fluctuating ability to make medical decisions. During a review of Resident 148's Minimum Data Set (MDS - a resident assessment tool), dated 4/25/2025, the MDS indicated Resident 148 required moderate assistance (Helper does less than half the effort) from one staff for oral hygiene, toileting hygiene, shower/bathe self, dressing, personal hygiene, bed mobility, transfer, and supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and /or contact guard assistance as resident completes activity) from one staff for eating. A. During a concurrent observation and interview on 4/21/2025, at 11:35 a.m., with Resident 148's Visitor 1 in Resident 148's room, Visitor 1 was sitting next to Resident 148's bed without wearing PPE such as a mask, gown, and gloves. Visitor 1 placed her handbag on Resident 148's bed and assisted Resident 148 to reposition by pulling her shoulder towards the left side and placing a pillow behind her. There was an Enhanced Barrier Precaution (EBP- an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities) signage placed on the foot of Resident 148's bed board. The visitor stated, she did not see the EBP signage because it was not placed in a visible place and the staff did not explain anything about wearing PPE. During an interview on 4//21/2025, at 11:30 a.m., with Certified Nurse Assistant (CNA) 2 in Resident 148's room, CNA 2 stated, she did not see the EBP signage because it was placed on the foot of the bed board. CNA 2 stated, it was not placed in a visible place such as outside of the entrance near the isolation cart and the color of the signage blended to color of the foot board. CNA 2 stated, the staff and visitors should wear PPE when providing care or touching Resident 148 who was placed on EBP isolation to prevent spreading of infection and cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another). CNA 2 stated, she should have educated and offered the visitor PPE. During an interview on 4/24/2025, at 9:10 a.m., with the Infection Preventionist Nurse (IPN), the IPN stated, anyone who had high contact (touching) such as bathing, touching, changing, hygiene care, and repositioning a resident who was on EBP isolation should wear PPE to prevent cross contamination and spreading infection. The IPN stated, this would apply to the visitors as well. The IPN stated, Resident 148 was diagnosed with pneumonia and staff should have ensured Visitor 1 was wearing a mask. The IPN stated, EBP signage should be placed in a visible place. During a review of Resident 148's Care Plan (CP), initiated and revised on 4/21/2025, the CP Focus indicated, Resident 148 had community acquired pneumonia. The CP Interventions indicated to Place enhanced barrier precautions and monitor for signs and symptoms of pneumonia. During a review of the facility's Policy and Procedure (P&P) titled, IPCP Standard and Transmission-Based Precautions, revised 3/2024, the P&P indicated, Procedure: Enhanced Barrier Protection {EBP}: used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. a. PPE: The use of gown and gloves for high-contact resident care activities is indicated . c. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: i. Dressing, ii. Bathing/showering, iii. Transferring, iv. Providing hygiene, v. Changing linens, vi. Changing briefs or assisting with toileting, vii. Device care or use . 6. Implementation: a. The facility will implement a system to alert staff, residents and visitors that a resident is on TBP: i. Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves). ii. For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves .e. Provide education to residents and visitors as needed. B. During an observation and interview on 4/24/2025, 9:16 a.m., with Resident 148 in her room, there was no isolation signage placed. There was no isolation cart near the entrance. Resident 148 stated, she had diarrhea more than five times yesterday and the nurse collected the stool sample. During a concurrent observation and interview on 4/24/2025, at 9:28a.m., with Licensed Vocational Nurse (LVN) 5 in a hallway near Resident 148's room, LVN 5 was passing medications and came out of the resident 148's room. LVN 5 performed hand hygiene by using sanitizer and did not clean hands with soap and water. LVN 5 stated, Resident 148 was not on any isolation because EBP was discontinued. LVN 5 stated, she got the report from night shift regarding Resident 148 had diarrhea, but she did not know that she had more than five times. LVN 5 stated, if the resident had multiple diarrheas, the resident should be placed on contact isolation that required wearing PPE upon entering the room and washing hands with soap and water while waiting for the lab result to protect the resident and staff themselves from C-diff. During an interview on 4/24/2025, at 9:36 a.m., with IPN, IPN stated, if the resident had diarrheas more than three times a day, the nursing staff should have placed the resident in contact isolation and wearing PPE before entering the room. IPN stated, the nursing staff should have washed hands with soap and water when finishing providing care per the policy. IPN stated, the nursing staff might jeopardize safety of other residents by not placing Resident 148 on contact isolation and not perform hand hygiene with soap and water. During an interview on 4/24/2025, at 3:21 p.m., with Director of Nursing (DON), DON stated, all staff and visitors needed to follow isolation precaution, and staff should educate the visitors regarding precaution and PPE. DON stated, the staff should place contact isolation for Resident 148 while waiting for lab result to prevent further spreading infection. During a review of Resident 148's Care Plan (CP), initiated and revised on 4/23/2025, the CP Focus indicated, Resident 148 had diarrhea. The CP Interventions indicated, give anti-diarrheal medication and encourage fluid intake, but there was no intervention for contact isolation precaution. During a review of the facility's Policy and Procedure (P&P) titled, IPCP Standard and Transmission-Based Precautions, revised 3/2024, the P&P indicated, Policy: Transmission-Based Precautions are the second tier of basic infection control and used in addition to Standard Precautions for patients who are or may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. Procedure: 2. Contact Precautions are used with a known infection that is spread by direct or indirect contact with the resident or the resident's environment. (e.g. MDROs). Note: Contact precautions/isolation are required for patients with MDROs with: o Draining wounds or secretions/excretions that cannot be covered and contained, o Acute diarrhea . b. Personal protective equipment {PPE): i. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. ii. [NAME] PPE upon room entry, then doff and properly discard PPE and perform hand hygiene before exiting the patient room to contain pathogens.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure four out of five sampled residents' (Resident 14 and Resident 21, Resdent 28 amd 12)'s Minimum Data Set ([MDS], a resident assessment tool) was coded appropriately when: a.Resident 14's MDS was not coded correctly in the bladder and bowel portion. b.Resident 21's MDS was not coded correctly in the active diagnosis portion. c. Resident 28's MDS was not coded correctly to reflect Resident 28 had Bed sensor alarm (a safety device a pressure sensitive pad use to detect when a resident leaves their bed) and chair sensor alarm( a safety device a pressure sensitive pad use to detect when a resident leaves their bed). d.Resident 12's MDS was not coded correctly to reflect a diagnosis of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) The deficient practice resulted in an inaccurate depiction of Resident 14, Resident 21, Resident 28, and Resident 12's current health status. Findings: a.During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including asthma (a chronic respiratory disease characterized by inflammation and narrowing of the airways, making breathing difficult), hypertension ([HTN], high blood pressure), atrial fibrillation ([A-Fib], (a condition that causes irregular and fast heartbeat in the heart), and hyperlipidemia (too much fat particles in the blood). During a review of Resident 14's history and physical (H/P) dated 4/6/2025, the H/P indicated Resident 14 had the capacity to understand and make decisions. During a review of Resident 14's MDS dated [DATE], the MDS indicated Resident 14 had intact cognitive (thinking process) skills and was independent (resident completes the activity by themselves with no assistance from a helper) with self-care abilities such as eating, required supervision (helper provides verbal cues as resident completes the task) with oral hygiene, personal hygiene, and upper body dressing, required moderate assistance (helper does less than half the effort completing task) with toileting hygiene, lower body dressing, and putting on/taking off footwear and maximal assistance (helper does more than half the effort) with shower/bathe. The MDS indicated Resident 14 required supervision during mobility such as rolling left and right, sit to lying position, and lying to sitting on side of bed, required moderate assistance with sit to stand position, bed to chair transfer, toilet transfers, shower transfers, and walking 10 to 50 feet. The MDS indicated Resident 14 was always incontinent with urinary continence (loss of voluntary control of urination) and occasionally incontinent with bowel continence (loss of voluntary control of bowl movements). During a review of Resident 14's Bowel and Bladder Evaluation dated 2/15/2025, the Bowel and Bladder evaluation indicated Resident 14 as incontinent. During a concurrent observation and interview on 2/4/2025 at 10:23 a.m., with Resident 14 in her room, Resident 14 was resting in bed watching television. Resident 14 stated she was not incontinent. Resident 14 stated she could not ambulate to the bathroom without assistance because she just had surgery on her right hip. During a concurrent interview and record review on 4/23/2025 at 4:03 p.m., with the MDS Coordinator (MDSC), the MDS dated [DATE] and the Bowel and Bladder Evaluation dated 2/15/2025 was reviewed. The MDSC nurse stated the resident was alert and oriented and could tell staff if she needed to go to the restroom, so she was not incontinent. The MDSC nurse stated the MDS should have been coded as always continent because the resident was alert and oriented and knows when she needed to go to the restroom. The MDSC nurse stated the MDS assessment was coded incorrectly. The MDSC nurse stated if the MDS was not coded correctly, the plan of care for the resident would not be appropriate for the resident. b.During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including HTN, high blood pressure), hyperlipidemia (too much fat particles in the blood), diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), and glaucoma (a group of eye diseases that damage the optic nerve, which connects the eye to the brain, leading to vision loss). During a review of Resident 21's H/P dated 2/27/2025, the H/P indicated Resident 21 had the capacity to understand and make decisions. During a review of Resident 21's MDS dated [DATE], the MDS indicated Resident 21 had moderate cognitive impairment and required assistance with set up or clean up (helper sets up or cleans up while resident completes the activity), required moderate assistance (helper does less than half the effort while resident completes the task) with self-care abilities such as eating and required maximal assistance (helper does more than half the effort completing task) with oral hygiene, and personal hygiene, as dependent (helper does all of the effort while resident does none of the effort to complete the task) with upper body dressing, with toileting hygiene, shower/bathe, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 21 required maximal assistance with mobility such as rolling left and right, sit to lying position, lying to sitting on side of bed, and bed to chair transfers, was dependent on sit to stand position, toilet transfers, and shower transfers. The MDS indicated Resident 21 was taking an antidepressant medication (medications used to treat depression [a persistent mood disorder characterized by feelings of sadness, loss of interest, and a range of physical and cognitive symptoms that significantly interfere with daily life]). Resident 21 did not have a mood disorder diagnosis in the active diagnoses portion of the MDS. During a review of Resident 21's psychiatric (relating to mental illness or its treatment) consult note dated 3/3/2025, the psychiatric consultation note indicated Resident 21 had a documented history of major depressive disorder, and continued to exhibit symptoms of major depressive disorder. The psychiatric consultation notes also indicated diagnoses of adjustment disorder (a mental health condition characterized by an excessive emotional or behavioral reaction to a specific stressful event or life change). During a review of Resident 21's psychologist consultation note dated 3/6/2025, the psychologist consultation note indicated that Resident 21 was diagnosis with adjustment disorder with depressed mood as evidence by reported emotional and behavioral response to medical conditions, functional limitations, increased need for assistance and rehab placement. During a review of Resident 21's Order Summary Report, the Order Summary Report indicated sertraline (medication used to treat depression) oral tablet (pill) 100 milligram ([mg], unit of measurement) give one tablet by mouth one time a day for depression manifested by verbalization of feeling depressed, informed consent obtained by medical doctor from Resident 21 ordered on 2/26/2025. During a concurrent interview and record review on 4/23/2025 at 3:18 p.m. with MDS Coordinator (MDSC), the MDS dated [DATE] and psychologist consultation note dated 3/6/2025 was reviewed. The MDSC nurse stated MDS assessment should have been coded to indicate that Resident 21 had a depressed mood disorder because she was seen by psychology and psychiatry consult that stated resident was diagnose with adjustment disorder with depressed mood and was taking an antidepressant medication. The MDSC stated the importance of ensuring the MDS assessment was accurate was to make sure Resident 21's care plans were based on an accurate MDS that reflected the diagnoses of the resident. During a concurrent interview and record review on 4/24/2025 at 4:15 p.m., with the Director of Nursing (DON), the MDS assessment dated [DATE] for Resident 14, Bowel and Bladder evaluation dated 2/15/2025, the MDS assessment dated [DATE] for Resident 21, the psychologist consultation note dated 3/6/2025 for Resident 21 were reviewed. The DON stated the MDS assessment for Resident 14 was inaccurate because Resident 14 was continent and stated the MDS assessment was coded that Resident 14 was incontinent. The DON stated the importance of accurate assessment of the MDS was to meet the needs of the residents, to provide the proper care needed for the residents, and to maintain their functioning status. The DON stated the MDS assessment for Resident 21 was also not accurate as the MDS assessment for active diagnosis section, there should have been a diagnosis of mood disorder because Resident 21 was taking an antidepressant medication for depress mood. The DON stated the psychologist consultation note indicated that the resident had a diagnosis of adjustment disorder with depressed mood and the MDS assessment should have indicated that Resident 21 had some type of depressed mood disorder. The DON stated the MDS assessment needed to be accurate to reflect Resident 14's and Resident 21's diagnoses and health status so the facility can give person centered care. c.Based on observation, interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- an assessment and care screening tool) related to Bed sensor alarm ( a safety device a pressure sensitive pad use to detect when a resident leaves their bed) and chair sensor alarm( a safety device a pressure sensitive pad use to detect when a resident leaves their bed ) was accurately documented for one of three randomly selected residents (Resident 28) This deficient practice had the potential to negatively affect Resident 28's plan of care and delivery of necessary care and services. Findings: During a review of Resident 28's admission Record, the admission Record indicated, Resident 28 was initially admitted to the facility on 8/6/ 2021 and last admission was on 3/27/2025 with diagnoses including hemiplegia and hemiparesis (muscle weakness or partial paralysis not being able to move a body part) following cerebral infarction (brain tissue dies due to lack of blood flow) affecting the right dominant side. HTN and abnormalities in gait (walking) and mobility ( (moving). During a review of Resident 28's MDS dated [DATE], the MDS indicated Resident 28 had significant cognitive impairment. The MDS indicated Resident 28 required partial moderate assistance (helper lifts or holds trunk or supports trunk or limbs but provides less than half the effort) with eating, oral hygiene, upper body dressing, personal hygiene and needs help on indoor mobility. During a record review of Resident 28's Order Summary Report (OSR), as of 3/27/2025 the OSR indicated an order for sensor pad alarm on bed to alert staff when trying to get out of bed unassisted and on 3/27/2025 an order for sensor alarm pad in wheelchair to alert staff when trying to get out of wheelchair unassisted. During a concurrent interview and record review on 4/23/2025 at 3:31 p.m., with the MDSC nurse, the MDSC nurse stated Resident 28 had a sensor bed pad alarm and a sensor bed alarm. The MDSC nurse stated she did not document the sensor pad alarm and the sensor bed alarm in Resident 28's MDS. The MDSC nurse stated the sensor bed alarm and sensor chair alarm was a form of restraint (when a patient avoids moving or repositioning themselves in a chair of bed due to fear of triggering the alarm). The MDSC nurse stated documenting sensor pad alarms helps in making sure it is used appropriately. During an interview on 4/24/2025 at 3:00 p.m., with the DON, the DON stated bed sensor alarms and chair sensor alarms should be documented in section P of the MDS. The DON stated if the assessment is not correct it does not reflect what the resident is getting, and the facility was not keeping Resident 28 safe. The DON stated if the chair and bed alarm is not documented or monitored it may not serve its purpose and the resident may still fall. d.During a review of Resident 12's admission Record (a document containing demographic and diagnostic information), dated 4/22/2025, the admission record indicated Resident 12 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to, schizophrenia (a mental illness that is characterized by disturbances in thought) and depression (a mood disorder characterized by persistent sadness and loss of interest in activities). During a review of Resident 12's Minimum Data Set MDS (MDS - a federally mandated resident assessment tool), dated 3/31/2025, the MDS indicated Resident 12's cognition was intact. The MDS indicated Resident 12 was independent for Activities of Daily Living (ADLs) such as eating, needed supervision level assistance from the facility staff for oral hygiene, upper body dressing, lower body dressing and personal hygiene, moderate assistance for toileting, showering and putting on/taking off footwear. The MDS did not indicate a medical diagnosis for bipolar disorder. During a review of Resident 12's Order Summary Report (a list of all currently active medical orders), dated 4/22/2025, the order summary report indicated the following physician order: Aripiprazole (a medication used to treat mental conditions such as depression and bipolar disorder) Oral Tablet 15 milligrams ([mg] a unit of measurement for mass), give 1 tablet by mouth one time a day for bipolar disorder manifested by (m/b) sudden mood change, order date 9/24/2024, start date 9/25/2024. During a review of Resident 12's psychiatry initial evaluation and consultation notes, dated 1/10/2025, 3/3/2025 and 2/5/2025, the documents respectively indicated, The patient, with a documented history of major depressive disorder and bipolar disorder, underwent an initial 45-minute, and 16-minute psychiatry evaluations. The documents indicated diagnoses of Major Depressive Disorder (MDD) and bipolar disorder, and no diagnosis of schizophrenia was documented. During a review of Resident 12's Medication Administration Record ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 4/1/2025 to 4/22/2025, 3/1/2025 to 3/31/2025 and 2/1/2025 to 2/28/2025, the MAR indicated aripiprazole 15 mg was documented as administered every day for bipolar disorder. During an interview on 4/23/2025 at 3:30 p.m. with the Minimum Data Set Coordinator (MDSC), the MDSC stated Resident 12's MDS indicated diagnoses of schizophrenia and depression. MDSC stated facility staff would look at the psychiatry evaluation to verify the accuracy of the diagnoses in MDS, but she was not sure how the diagnoses were entered for Resident 12 because MDSC was not at the facility when they were entered. MDSC stated there was an inaccuracy of assessments and there was a possibility that the care plans would not be according to what was necessary for the resident's care. MDSC stated there could be side effects from unnecessary use of psychotropic medications for elderly residents which could cause unwanted side effects, such as cognitive impairment and increased risk for falls. MDSC stated the medications should have been prescribed only if there was a valid diagnosis. During a phone interview on 4/24/2025 at 10:40 a.m. with the psychiatry nurse practitioner (NP) 1, NP 1 stated Resident 12 had medical diagnoses of bipolar disorder and depression based on her evaluation of the resident. NP 1 stated Resident 12 did not have a diagnosis of schizophrenia. NP 1 stated, I do not believe that the MDS stating schizophrenia is accurate. During an interview on 4/24/2025 at 12:20 p.m. with the Director of Nursing (DON), DON stated when she checked Skilled Nursing Facility (SNF) 1's records, Resident 12's admitting diagnoses were bipolar disorder, depression and anxiety. DON stated the hospital's admission records, dated 09/2024 and 03/2024, did not have any diagnoses. DON stated there was an inaccuracy in diagnoses in Resident 12's MDS because MDS indicated diagnoses of schizophrenia and no bipolar disorder, whereas psychiatry evaluation indicated bipolar disorder and no schizophrenia. DON stated the inaccurate record of medical diagnoses would affect resident's treatment plan. DON stated the resident might not be getting treatment with the right medications causing negative impact on resident's cognition and behaviors. During a review of the facility's policy and procedure (P/P) titled Resident Assessment and Associated Processes, dated 12/2023, indicated it is the policy of this facility that resident's will be assessed and the findings documented in their clinical health record. These will be comprehensive, accurate, standardized reproducible assessment of each resident and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified comprehensive assessment includes the completion of the MDS MDS data is signed/stored electronically in the clinical health record and is readily and easily accessible to all professionals who need to review the information in order to provide care to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop a care plan for two of three sampled residents (Resident 28 and Resident 29) when : a. Resident 28 had an order for a bed sensor alarm (a safety device a pressure sensitive pad use to detect when a resident leaves their bed) and a chair sensor alarm (a safety device a pressure sensitive pad used to detect when a resident tries to get up from the chair) b. Resident 29 refusing to get out of bed and attend activities for three days . Findings: During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was originally admitted on [DATE] with a re-admission date on 3/22/2025 with diagnoses including chronic obstructive pulmonary disease ([COPD], a chronic lung disease causing difficulty in breathing), hypertension ([HTN], high blood pressure), dementia (a progressive state of decline in mental abilities), and atrial fibrillation ([A-Fib], (a condition that causes irregular and fast heartbeat in the heart). During a review of Resident 28's History and Physical (H/P) dated 3/25/2025, the H/P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 28's Minimum Data Set ([MDS], a resident assessment tool) dated 3/26/2025, the MDS indicated Resident 28 was severely cognitivly (ability to make decisions of daily living) impaired, and required moderate assistance (helper does less than half the effort) on self-care abilities such as eating, required maximal assistance (helper does more than half the effort to complete the task) with oral hygiene, toileting hygiene, shower/bathe, upper and lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 28 required maximal assistance with mobility such as rolling left and right, sitting to lying position, lying to sitting on side of bed, bed to chair transfers, and toilet transfers. During a review of Resident 28's Order Summary Report, the Order Summary Report indicated; sensor pad alarm (a device, typically a pressure-sensitive pad, used to alert facility staff when a resident moves or leaves their bed or chair unassisted) in bed to alert staff when Resident 28 was trying to get out of bed unassisted, informed consent obtained by medical doctor from responsible party ordered on 3/22/2025. The Order Summary Report indicated sensor pad alarm in wheelchair to alert staff when trying to get out of wheelchair unassisted informed consent obtained by medical doctor from responsible party ordered on 3/22/2025. During a review of Resident 28's comprehensive care plan dated 3/13/2025, the comprehensive care plan did not indicate a care plan addressing Resident 26's use of bed and chair sensor alarm pads in place. During an observation on 4/21/2025 at 10:47 a.m., in Resident 28's room, Resident 28 was resting in bed with eyes closed. There was a box attached to the bed with a wire attached to the box underneath Resident 28. During a concurrent interview and record review on 4/23/2025 at 2:59 p.m. with the MDS Coordinator (MDSC), Resident 28's the Order Summary Report and comprehensive care plan dated 3/13/2025 were reviewed. The MDSC stated sensor alarm pads should have been care planned, to monitor the effectiveness of the sensor alarm pads. The MDSC stated there should have been interventions in place to make sure the sensor alarm pads were effective in alerting staff and keeping Resident 28 safe from falling. The MDSC stated if the interventions in the care plan were not effective, the interventions could be reassessed, and new interventions would be added. The MDSC stated a comprehensive care plan should be a focused individualized care plan, and how staff should be caring for the residents based on the interventions being done on the floor. The MDSC stated the comprehensive care plan did not have a focus for the sensor alarm pads and to guide staff on how to care for Resident 28's pad alarms. During a concurrent interview and record review on 4/24/2025 at 3:20 p.m. with the Director of Nursing (DON), Resident 28's comprehensive care plan dated 3/13/2025 was reviewed. The DON stated sensor alarm pads should have been care planned. The DON stated the importance of having a comprehensive care plan was that it was a plan of care on how facility staff will be providing care to the residents. The DON stated there should have been a separate care plan for sensor alarm pads to monitor the effectiveness of the sensor alarm pads and its functioning purpose. DON stated the comprehensive care plan should make sure the residents still have a need for the sensor alarm pads. b.During a review of Resident 29's admission Record, the admission Record indicated, Resident 29 was initially admitted to the facility on [DATE] and last admission was on 1/29/2025 with diagnoses including cerebral infarction (brain tissue dies due to lack of blood flow) due to blockage of a blood vessel in the brain, essential (primary) Hypertension ( high blood pressure) and muscle weakness ( generalized). During a record review of Resident 29's H&P, the H&P indicated Resident 29 did not have the capacity to understand and make decisions. During a review of Resident 29's MDS dated [DATE] , the MDS indicated, Resident 29 was dependent (resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity) with shower/ bath, toilet hygiene, eating , lower body dressing, putting on and taking off footwear and substantial/ maximum assistance ( helper lifts or holds trunk or limbs and provides more than half the effort) with chair/ bed -to chair transfer. During a record review of Resident 29's Order Summary Report (OSR), as of 3/27/2025 the OSR indicated an order dated 3/26/2025 for skilled physical therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) every day, 5 times per week for 4 weeks. PT may include therapeutic exercises, therapeutic activities, neuromuscular (relating to nerves and muscles) re-education ,wheelchair management, gait training , manual therapy and patient caregiver education and training. During a review of resident 29's care plan dated 1/30/2025 the care plan indicated Resident 29 had a pressure ulcer (injury to skin and underlying tissue due to unrelieved pressure) or potential for pressure ulcer development, theinterventions were for Resident 29 to get out of bed unless contraindicated. During an interview on 4/23/2025 at 10:30 a.m., with Certified Nurse Assistant 2 (CNA 2), CNA 2 stated Resident 29 had refused to get up for the past three days , CNA 2 stated resident 29 never get out of bed. CNA 2 stated when a resident refuses to get out of bed she reports the refusal to her charge nurse. CNA 2 stated it is important to get the resident out of bed to prevent beds sores. During an interview on 4/23/2025 at 10:36 a.m., with Licensed Vocational Nurse (LVN 1) , LVN 1 stated he was aware Resident 29 did not want to get out of bed and when a resident refuses multiple times a plan of correction is done, and the doctor is called. LVN 1 stated there must be a care plan so the nurses can focus on the resident's problem. During an interview on 4/ 24/2025 at 3:00 p.m., with the Director of nursing (DON), the DON stated the bed sensor alarm and wheelchair sensor alarm for Resident 28 should have a separate sectionin the care plan so staff can focus where nurses can monitor the placement of the sensor alarm and if it is functioning. The DON stated CNA's notify the LVN when Resident 29 refuses to get out of bed and the LVN charts it and notifies the doctor and family, and then care plan it. The DON stated it was important to do a care plan for Resident 29 refusing to get out of bed and must be reflective to meet the residents needs so that we can refer them to the right DON stated it is important the resident gets out of bed to improve their sensory stimulation. During a review of the facility's policy and procedure (P/P) titled, Comprehensive Person-Centered Care Plan, dated 12/2023, indicated the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person- centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment the facility IDT will develop and implement a comprehensive person-centered, culturally-competent, and trauma-informed care plan for each resident within seven (7) days of completion of the Resident Minimum Data Set (MDS) and will include resident's needs identified in the comprehensive assessment, any specialized services as a result of PASARR recommendation, and resident's goals and desired outcomes, preferences for future discharge and discharge plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement the antibiotic stewardship program (the effort to ensure that [antibiotics - medicines that fight bacterial infections in people and animals] are used only when necessary and appropriate) for two of four sampled residents (Resident 148 and Resident 14) as evidenced by: A. Failing to identify the indication of use and assess Infection Surveillance (an active reassessment of an antimicrobial prescription 48-72 hours after first administration) of Zosyn (a prescription drug that's used to treat or prevent certain infections intravenously) for Resident 148. B. Failing to implement Infection Surviellance of daptomycin (medication used to treat infection) for Resident 14. This deficient practice had the potential for resident to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: A. During a review of Resident 148's admission Record, the admission Record indicated, Resident 148 was admitted to the facility on [DATE] with diagnoses including pneumonia (an infection/inflammation in the lungs), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 148's History and Physical (H&P), dated 4/21/2025, the H&P indicated, Resident 148 had fluctuating ability to make medical decisions. During a review of Resident 148's Minimum Data Set (MDS - a resident assessment tool), dated 4/25/2025, the MDS indicated Resident 148 required moderate assistance (Helper does less than half the effort) from one staff for oral hygiene, toileting hygiene, shower/bathe self, dressing, personal hygiene, bed mobility, transfer, and supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and /or contact guard assistance as resident completes activity) from one staff for eating. During a review of Resident 148's Order Summary Report (OSR), dated 4/24/2025, the OSR indicated, give Zosyn intravenous solution 4-0.5 milligram (mg)/100 milliliter (ml) every eight hours for pneumonia for two days was ordered on 4/21/2025 and completed on 4/23/2025. During a review of Resident148's Care Plan (CP), initiated and revised on 4/21/2025, the CP Focus indicated, Resident 148 had community acquired pneumonia. The CP Interventions indicated, give medications as ordered and monitor/document for side effects and effectiveness. During a concurrent interview and record review on 4/24/2025, at 9:36 a.m., with the IPN, Resident 148's Infection Surveillance, dated 4/21/2025 was reviewed. The Infection Surveillance indicated, there was no documentation and was left blank. The IPN stated, Resident 148 received Zosyn (mediction used to treat infection) through Intravenous (IV) therapy from the General Acute Care Hospital (GACH) prior to admission to the facility and Resident 148 continued to receive the Zosyn at the facility.The IPN stated, she did not do Infection Surveillance (equivalent to Antibiotic Time Out) assessment. The IPN stated, she was not sure if Zosyn antibiotic administration for Resident 148 met McGeer's Criteria (criteria used to determine appropriate use of antibiotics). The IPN stated, Zosyn administration for Resident 148 was completed yesterday, and she (IPN) should have done Infection Surveillance assessment to see if Zosyn was indicated because unnecessary use of antibiotics could lead to develop antibiotic resistance. During a concurrent interview and record review on 4/24/2025, at 4:21 p.m., with the Director of Nursing (DON), Resident 148's Infection surveillance, dated 4/24/2025 was reviewed. The Infection Surveillance indicated, McGeer's Criteria was not met for Zosyn. The DON stated, she completed the Infection Surveillance assessment and realized Resident 148's condition did not meet McGeer's criteria for recieving Zosyn, but the Zosyn was given already. The DON stated, all antibiotics should be assessed, monitored, and evaluated for the indication and duration of the therapy to prevent unnecessary use of antibiotics that could develop resistance, and unnecessarily suffer from adverse reaction and side effects. B. During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including asthma (a chronic respiratory disease characterized by inflammation and narrowing of the airways, making breathing difficult), hypertension ([HTN], high blood pressure), atrial fibrillation ([A-Fib], (a condition that causes irregular and fast heartbeat in the heart), and hyperlipidemia (too much fat particles in the blood). During a review of Resident 14's H&P dated 4/6/2025, the H&P indicated has the capacity to understand and make decisions. During a review of Resident 14's MDS dated [DATE], the MDS indicated Resident 14 had intact cognitive skills and was independent (resident completes the activity by themselves with no assistance from a helper) with self-care abilities such as eating, required supervision (helper provides verbal cues as resident completes the task) with oral hygiene, personal hygiene, and upper body dressing, required moderate assistance (helper does less than half the effort completing task) with toileting hygiene, lower body dressing, and putting on/taking off footwear and maximal assistance (helper does more than half the effort) with shower/bathe. The MDS indicated Resident 14 required supervision mobility such as rolling left and right, sitting to lying position, and lying to sitting on side of bed, required moderate assistance with sit to stand position, bed to chair transfer, toilet transfers, shower transfers, and walking 10 to 50 feet. During a review of Resident 14's Order Summary Report, the Order Summary Report indicated daptomycin intravenous ([IV], existing or taking place within, or administered into, a vein or veins) solution reconstitute 850 milligram ([mg], unit of measurement) intravenously one time a day for right hip wound MRSA ([Methicillin-resistant Staphylococcus aureus], infection caused by a type of bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections) infection for 35 days ordered on 4/4/2025. During a review of Resident 14's Infection Surveillance dated 4/4/2025, the Infection Surveillance indicated the surveillance by body system indicated other infections such as right hip surgical wound infection with antibiotic treatment daptomycin 850 mg IV one time a day started on 4/5/2025 and that infection preventionist note meets criteria for infection. The Infection Surveillance also indicated infection preventionist note that Resident 14 was currently on daptomycin 850 mg IV one time a day. During a review of the Antibiotics Stewardship binder, the Antibiotic Stewardship binder indicated a list of all the residents in the facility that were receiving antibiotics with the reason for antibiotic use, the start date, the end date and the signs and symptoms or testing residents had done. Resident 14 was not on the list of residents who were receiving antibiotics in the facility. During a review of Resident 14's care plan dated 4/6/2025, the care plan indicated interventions such as monitor/document/report to medical doctor as needed for signs and symptoms of infection at the site such as drainage, inflammation, swelling, redness and warmth. The care plan also indicated to give medication as ordered and monitor/document for effectiveness, side effects, monitor/document/report to medical doctor as needed for signs and symptoms of MRSA infection such as inflammation around the wound sites, drainage, lethargy, headache, increased heart rate, urinary tract infections, and toxic shock syndrome. During an observation on 2/4/25 at 10:23 a.m., of Resident 14 in her room, Resident 14 was resting in bed watching television. Resident 14 stated she had revision surgery on her right hip replacement on 3/25/2025. Resident 14 stated she was getting antibiotics through her PICC (peripherally inserted central catheter, a long, thin tube inserted into a vein in the arm and threaded up to a larger vein near the heart) line on right upper arm. During a concurrent interview and record review on 4/24/2025 at 11:33 a.m., with the IPN, the Order Summary Report, antibiotics stewardship binder, and Infection Surveillance dated 4/4/2025 were reviewed. The IPN stated Resident 14 was started on daptomycin 850 mg intravenously one time a day for right hip wound MRSA infection for 35 days. The IPN stated she was aware that Resident 14 was on IV antibiotics, but that Resident 14 was not monitored in the antibiotics stewardship binder for residents who are on antibiotics. The IPN stated residents that are not being monitored while receiving antibiotics may experience adverse effects, the medication might not be affective anymore and residents might get another infection.The IPN stated the Infection Surveillance was done when Resident 14 was started on the antibiotic, but another assessment was not done after to see if the medication was effective, if it needed to be continued and no monitoring was done. During a concurrent interview and record review on 4/24/2025 at 4:50 p.m. with the DON, the Infection Surveillance dated 4/4/2025 was reviewed. The DON stated there was no monitoring done for Resident 14 while the on antibiotic. The DON stated Resident 14 was first assessed on 4/4/2025 when the antibiotic was ordered but there have been no other assessments done after to see if the antibiotic was still required. The DON stated there was no monitoring in place to see if there was still a need for the antibiotic. The DON stated the importance of monitoring residents on antibiotics was to see if the antibiotics were working, and to monitor any signs or symptoms if the antibiotics was still needed. The DON stated the IPN should have followed up with the doctor for prolonged use of the antibiotic because the resident can develop resistance to the antibiotic. During a review of the facility's policy and procedure (P/P) titled, Antibiotic Stewardship, dated 12/2023, indicated is the policy of this facility to implement an Antibiotic Stewardship Program (ASP) that is incorporated in the overall Infection Prevention and Control Program which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use . review data, monitor and summarize antibiotic use from pharmacy data, such as the rate of new starts, types of antibiotics prescribed summarize antibiotic resistance patterns based on laboratory data incorporate monitoring of antibiotic use, including the frequency of monitoring/review, report on number of antibiotics prescribed and the number of residents treated each month, assess residents for any infection using McGeer's criteria, require antibiotic orders to include the indication, dose, and duration . facility may consider antibiotic time-out (TO) practices. A time-out can be considered a stop order of an antibiotic when a diagnostic test or symptoms of resident do not support the diagnosis of infection. These practices include improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and implementing an antibiotic review process, also known as an antibiotic time-out, for all antibiotics prescribed in the facility . IP or designee will be responsible for infection surveillance and [NAME] tracking. IP or designee will collect and review data. During a review of the facility's Policy and Procedure (P&P) titled, Antibiotic Stewardship, revised 12/2023, the P&P indicated, Policy :It is the policy of this facility to implement an Antibiotic Stewardship Program (ASP) that is incorporated in the overall Infection Prevention and Control Program which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. This policy has the potential to limit antibiotic resistance in the post-acute care setting, while improving treatment efficacy and resident safety, and reducing treatment-related costs. This policy will include basic elements about antibiotic resistance and opportunities for improvement. Procedure: 1. Leadership: a. The team may consist of the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Pharmacy Consultant and Laboratory Representative. b. The team will: o Review data, monitor and summarize antibiotic use from pharmacy data, such as the rate of new starts, types of antibiotics prescribed, or days of antibiotic treatment per 1,000 resident days o Summarize antibiotic resistance patterns based on laboratory data, for example, the last 18 months; and/or o Track measures of outcome surveillance related to antibiotic use (e.g. C. difficile, MRSA, and/or CRE) o Incorporate monitoring of antibiotic use, including the frequency of monitoring/review o Report on number of antibiotics prescribed and the number of residents treated each month o Assess residents for any infection using McGeer's criteria. o Require antibiotic orders to include the indication, dose, and duration . 4. Action: a. Facility may consider antibiotic time-out (TO) practices. o A time-out can be considered a stop order of an antibiotic when a diagnostic test or symptoms of resident do not support the diagnosis of infection. oThese practices include improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and implementing an antibiotic review process, also known as an antibiotic time-out, for all antibiotics prescribed in the facility. Antibiotic reviews provide clinicians with an opportunity to reassess the ongoing need for and choice of an antibiotic when the clinical picture is clearer and more information available. 5. Tracking: a. IP or designee will be responsible for infection surveillance and [NAME] tracking. b. IP or designee will collect and review data. B. [NAME] Resident 14

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the call lights for two out of four residents sampled (Residents 8 and 155) were within reach. The deficient practice had the potential to result in delayed care and services that promote the residents' well-being. Findings: During a review of Resident 8's admission record, dated 4/6/2024, the admission record indicated Resident 8 was initially admitted to the facility on [DATE] and recently readmitted to the facility on [DATE] with diagnoses including muscle weakness, schizophrenia (mental illness that affects how a person thinks, feels and behaves), diabetes mellitus (disorder where the body cannot regulate glucose or sugar like it should), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 8's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/7/2024, the MDS indicated Resident 8 had severe impairment in cognitive (thinking reasoning, remembering) skills for daily decision making. The MDS indicated Resident 8 needed set up assistance with eating, supervision with personal hygiene, and substantial assistance from staff, where staff does more than half the effort, with oral hygiene. During a review of Resident 155's admission record, dated 4/6/2024, the admission record indicated Resident 155 was admitted to the facility on [DATE] with diagnoses including aftercare following joint (the part of the body where two or more bones meet to allow movement) replacement surgery, presence of right artificial hip joint, cognitive communication deficit, dementia, and history of falling. During a review of Resident 155's MDS, dated [DATE], the MDS indicated Resident 8 had moderate cognitive impairment. The MDS indicated Resident 155 needed set up or clean up assistance with eating, oral hygiene, and personal hygiene, and Resident 155 needed substantial assistance where helper does more than half the effort with toilet hygiene and upper body dressing. The MDS indicated Resident 155 was dependent on staff where helper does all the effort with showering, lower body dressing and putting on or taking off footwear. During a concurrent observation and interview on 4/06/2024 at 8:17 a.m., with Licensed Vocational Nurse 4 (LVN 4), at Resident 8 and 155's room, Resident 8's call light was noted hanging on Resident 8's headboard and Resident 155's call light was hanging on the wall away from Resident 155's reach. LVN 4 stated Resident 8 and 155's call lights were out of their reach and needed to be closer and accessible to the residents so they could call if they needed help. LVN 4 proceeded to place the call lights within Resident 8 and 155's reach. During an interview with the Director of Nursing (DON) on 4/7/2024 at 5:40 p.m., the DON stated the residents' call lights need to be within reach to ensure their needs were met. During a review of the facility's policy and procedure titled Call light/Bell, revised 5/2007, the policy indicated it was the facility policy to provide the residents a means of communication with nursing staff. The policy indicated the call device need to be within the residents' reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of one sampled residents (Resident 37's) 7-day-bed-hold (a guaranteed reservation for residents that are transferred out emergently) was honored, by admitting a new resident to Resident 37's bed. This deficient practice violates Resident 37's right to come back to his guaranteed bed and is against the facility's policy and procedure for bed hold. Findings: During a record review of Resident 37's admission Record, the admission Record indicated the resident was admitted on [DATE] then re-admitted on [DATE] to the facility with diagnoses that included acute respiratory failure with hypoxia (often caused by a disease or injury that affects your breathing, such as pneumonia, opioid overdose, stroke, or a lung or spinal cord injury), essential primary hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition). During a record review of Resident 37's Minimum Data Set ([MDS] standardized screening and care planning tool) dated 3/6/2024, the MDS indicated the resident had the capacity to understand others and was able to be understood by staff. The MDS indicated Resident 37 required maximal assistance (helper does more than half the effort) from one staff for toileting hygiene, dressing, transfer, bed mobility, and supervision or touching assistance (helper provides verbal cues and /or touching/contact guard assistance) from one staff for eating. During a record review of the census (a complete count of residents admitted to the facility) dated 4/4/2024, the census indicated the facility had 4 beds that were on bed hold. During an interview on 4/6/2024 at 3:45 p.m., and record review of the census dated 4/4/2024 with the receptionist, the receptionist stated she is responsible for updating the census daily. The receptionist stated that she updates the census if there is a new admission or a discharge to reflect the accurate number of residents in the facility and the residents on bed-hold. The receptionist added that she also counts the days of the bed-hold, so she knows when to make the beds available for new admissions. The receptionist stated she makes beds that should be on-hold available to new admissions by asking the Director of Nursing for permission so they can continue to admit new residents. The receptionist stated she is not aware if that is okay, but she follows what the DON or Administrator tell her to do. During a review of Resident 37's medical record, the medical record indicated a physician's order dated 3/30/2024 at 3:25 p.m., to transfer Resident 37 to the General Acute Care Hospital (GACH) emergency room due to a critical laboratory result (a medical test result that requires transfer to the GACH). During a record review of Resident 37's medical record, the medical record indicated a physician's order dated 4/4/2024 at 12:07 a.m., for a bed-hold for 7 days. During a concurrent interview on 4/6/2024 at 2:35 p.m., and record review of the census dated 4/4/2024 with the Director of Nursing (DON), the DON stated every time the facility sends a resident to the hospital there is a 7-day-bed-hold which means that the bed will be on-hold for the resident in case they come back within the 7-days they can have their own bed back. The DON stated that the medical insurance pays to reserve that bed for the resident. The DON stated that Resident 37's bed that is on bed hold is room [ROOM NUMBER]A, which is now occupied by another newly admitted male resident. The DON stated if the hospital were to transfer Resident 37 back to the facility there would be no available bed for him because his bed was occupied by another resident while Resident 37 was on bed hold. During a record review of the facility census dated 4/3/2024 Resident 37 was in bed 10 A on Day 4 of bed-hold, on 4/4/2024 day 5 of the bed-hold, a new resident was admitted to bed 10A. During a continued interview and record review of the facility's census dated 4/1/2024 through 4/6/2024, on 4/6/2024 at 2:55 p.m., with the DON, the DON stated the facility accommodates newly admitted residents by giving away beds that are on bed-hold. The DON stated that the Centers for Medicare and Medical Services (a federal health insurance agency) pays the facility to reserve the residents' bed for 7 days. The DON further added that it is residents' rights to hold the bed while they are in the GACH and the facility should not give it to a new resident while the bed is still on hold. During a review of the facility's policy and procedure (P&P) titled Bed hold dated 12/2023, the P&P indicated the resident or resident's representative will be notified in writing of the right to exercise the bed hold provision of 7 days upon admission and provide a second notice before transfer to a general acute care hospital or before the resident goes on therapeutic leave. In the event of an emergency transfer, the second notice will be provided within 24 hours. A copy of this notification shall become a part of the resident's health record at the time of transfer. Each notice shall include the duration of the state bed- hold policy that the resident's bed will be held for the duration of 7 days, during which time the resident is permitted to return and resume residence in the facility, it also includes the amount require to be paid by the resident to hold the bed for the duration of the bed-hold period.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, Licensed Vocational Nurse (LVN) 3 failed to check for gastrostomy tube ([G-tube] a surgical opening made into the stomach to provide nutritional support) placement (the correct positioning or location of something) and patency (being open) per the physician's orders, prior to administering medications for one of one sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for peritonitis (inflammation, swelling of the lining of the belly or abdomen), pain, and unnecessary hospitalization from administering medications into a G-tube which may have been dislodged. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral palsy (a group of permanent movement and posture disorders which limit activity), abnormalities of gait and mobility, abnormal posture, and seizures (sudden, uncontrolled body movements and changes in behavior which occur because of abnormal electrical activity of the brain). During a review of Resident 1's History and Physical (H&P) dated 10/18/2023, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated 1/18/2024, the MDS indicated Resident 1's cognitive (ability to make decisions of daily living) skills for daily decision making were severely impaired and Resident 1 was never understood and was never able to understand others. During a review of Resident 1's Order Summary Report (Physician's Orders, the Physician's Orders indicated an order was placed on 10/16/2023 for the licensed nurses to check Resident 1's feeding tube placement and patency before and after giving medications, before starting feedings, and every shift. During an observation on 4/7/2024 at 9:13 a.m., in Resident 1's room, with LVN 3, LVN 3 was observed preparing to administer the following medications: 1. Lactulose Oral Solution 10 grams (a metric unit of mass equal to one thousandth of a kilogram)/15 milliliter ([mL] a unit of measure of volume), 30 mL every four hours for high ammonia (a waste product that bacteria in the intestines make when digesting protein [a nutrient that the body needs to grow and maintain itself]) level. 2. Cholecalciferol Tablet 1000 units (a measurement), give one tablet one time a day for supplement. 3. Folic Acid 1 milligrams ([mg] - a unit of measure of weight) tablet, give one tablet one time a day for supplement. 4. Keppra Oral Solution 100 mg /mL, give 15 mL every 12 hours for seizure disorder. 5. Senna Oral Tablet, give 2 tablets twice a day for bowel management. 6. Lamotrigine Oral Tablet 25 mg, give 1 tablet every 12 hours for seizure disorder. 7. Multiple Vitamin and Mineral, give 5 mL daily for supplement. 8. Lacosamide 10mg/mL, give 20 mL every 12 hours for seizure disorder. During a continued observation on 4/7/2024 at 9:18 a.m., in Resident 1's room, with LVN 3, LVN 3 was observed administering medications to Resident 1. LVN 3 did not check for G-tube patency or placement prior to administering Resident 1's medications. During an interview on 4/7/2024 at 9:28 a.m., with LVN 3, LVN 3 stated, she forgot to check Resident 2's G-tube for placement and patency prior to administering Resident 1's medications. LVN 3 stated the process of checking the G-tube for patency and placement includes injecting 10mL of air into the G-tube, auscultating (listening to) the abdomen (stomach area) with a stethoscope (medical device used to listen to internal body sounds) and withdrawing gastric residual (stomach contents) from the G-tube. LVN 3 stated that if you hear a whooshing sound while injecting the air into the G-tube site, then the placement is correct. By withdrawing gastric residual from the G-tube you are also able to check for correct placement and patency. During an interview on 4/7/2024 at 5:39 p.m. with the Director of Nursing (DON), the DON stated, that licensed nurses must check for G-tube placement and patency prior to administering medications to a resident. The DON state that the purpose of checking the G-tube is to ensure the G-tube is in the correct place and it is patent. If the licensed nurses don't check for correct placement or patency, and the G-tube is dislodged (displacement of a device), there is a potential for the medications being administered directly into the peritoneum (the tissue which lines the abdominal wall and cavity) which could lead to infection and unnecessary hospitalization. During a review of the LVN Job Description, dated 12/17/2021, the Job Description indicated the LVN's essential duties and responsibilities included the following: 1. Implementing and maintaining established policies, procedures, objectives .and infection control. 2. Administering services within the applicable scope of nursing practice, which may include catheterization, tube feedings, suctions .etc., as appropriate and in accordance with applicable standards. During a review of the facility's policy and procedure (P&P), titled Medication Administration, Enteral Tubes, dated 2012, the P&P indicated to verify tube placement by inserting a small amount of air into the tube with the syringe and listen to the stomach with a stethoscope for gurgling sounds and to aspirate stomach contents with a syringe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide quality of care and services in accordance with professional standards of practice for one of three residents (Resident 8) when: 1. The facility failed to ensure the physician and the Registered Dietician ([RD] a health professional who has special training in diet and nutrition) were notified immediately, as indicated in the nutrition care plan, after Resident 8 was identified with severe weight loss on 2/5/2024 and 4/5/2024. a. On 2/5/2024, Resident 8 was identified to have a 9.73 % weight loss and the physician and RD were notified of the weight loss on 2/8/2024, three days later. b. On 4/5/2024, Resident 8 was identified to have 7.7 % weight loss and the physician and RD were notified of the weight loss on 4/6/2024, a day after the weight loss was identified. 2. The facility failed to ensure the Interdisciplinary team's ([IDT] resident's health care team consisting of various specialties) recommendations made on 2/8/2024 were implemented in a timely manner. The IDT recommendations were made on 2/8/2024, three days after the weight loss was identified on 2/5/2024 and the recommendations were ordered twelve days after the weight loss was identified on 2/17/2024. a. Resident 8's order for Boost Glucose Control (nutritional supplement) was not ordered and Resident 8 did not receive the supplement until 2/17/2024, twelve days after weight loss was identified. The resident was not provided a total of 380 kilocalories (kcal, a unit of measure) and 32 grams of protein per day for approximately twelve days. b. Resident 8's order for Megestrol Acetate Suspension (appetite stimulant) was placed and carried out on 2/17/2024 and Resident 8 did not receive the appetite stimulant until twelve days after weight loss was identified. c. The No Added Salt (NAS) portion of the diet for Resident 8 was removed from the diet order on 2/17/2024, twelve days after the weight loss was identified. 3. The facility failed to ensure Resident 8's amount eaten for every meal was recorded as indicated in the care plan intervention, initiated on 9/10/2023, and IDT recommendation to monitor resident intake on 2/8/2024. From 2/7/2024 to 3/7/2024 and 3/9/2024 to 4/6/2024, out of 177 meals 50 meals were not monitored and the amount eaten by Resident 8 was not recorded. 4. The facility failed to ensure Resident 8 received the ordered Consistent Carbohydrate Diet (CCHO, diet with the same amount of carbohydrates [sugars], main nutrients in our diet, every day), regular texture, thin liquids consistency, fortified, with chopped meat. On 4/7/2024, Resident 8 was served CCHO diet, regular texture, thin liquids consistency, fortified (extra nutrients added), with chopped meat and with no added salt (NAS). 5. The facility failed to ensure the Nutrition care plan was updated in a timely manner after the severe weight loss was identified on 2/5/2024 and the IDT made recommendations on 2/8/2024; The Nutrition care plan was updated on 3/5/2024, a month after the severe weight loss was identified. These deficient practices resulted in Resident 8 having insidious (gradual unintended weight loss over time) severe weight loss of 7.7 % in one month (March to April) and 15% weight loss in three months (January to April) due to lack of monitoring and delayed interventions and placed Resident 8 at higher risk for malnutrition (body does not get enough nutrients), poor wound healing and feelings of depression (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily life). On 1/5/2024, Resident 8 weighed 113 lbs. and on 4/5/2024, Resident 8 weighed 96 lbs. The resident lost a total of 37 lbs. from 1/5/2024 to 4/5/2024. Findings: During a review of Resident 8's admission record, dated 4/6/2024, the admission record indicated Resident 8 was initially admitted to the facility on [DATE] and recently readmitted to the facility on [DATE] with a diagnoses including sepsis (infection of the blood), muscle weakness, dysphagia (difficulty swallowing), mild calorie protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and functions), schizophrenia (mental illness that affects how a person thinks, feels and behaves), diabetes mellitus (disorder where the body cannot regulate glucose or sugar like it should), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 8's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/7/2024, the MDS indicated Resident 8 had severe impairment in cognitive (thinking reasoning, remembering) skills for daily decision making. The MDS indicated Resident 8 needed set up assistance with eating, supervision with personal hygiene, and substantial assistance from staff, where staff does more than half the effort, with oral hygiene. The MDS indicated Resident 8 was 64 inches in height and last weighed 104 pounds (lbs.) and the resident had a weight loss of 5 percent or more in the last month. During a review of an untitled care plan, initiated on 12/18/2023, the care plan indicated Resident 8 had a nutritional problem or potential nutritional problem. The care plan indicated the resident will maintain adequate nutritional status as evidenced by maintaining weight greater than 104 lbs. with no signs and symptoms of malnutrition. The care plan interventions indicated the following: a. Initiated on 9/10/2023 and target date 6/14/2024, administer medications as ordered and monitor and report to the physician as needed for any signs and symptoms of decreased appetite. b. Initiated on 9/21/2023 and target date 6/14/2024, if weight decline persists, contact physician and dietician immediately and to monitor and report to the physician as needed any signs and symptoms of decreased appetite. c. Initiated on 3/5/2024 and target date 6/14/2024, provide supplements as ordered Boost Glucose control, twice a day, and diet as ordered by physician. During a review of Resident 8's Weight Summary, the summary indicated the following weights for Resident 8: 1. On 1/5/2024, 113 lbs. 2. On 2/5/2024, 102 lbs. (9.7% weight loss in one month) 3. On 3/5/2024, 104 lbs. 4. On 4/5/2024, 96 lbs. (7.7% weight loss in one month and 15% weight loss in three months) During a review of Resident 8's medical record titled Nutrition Interdisciplinary Team Update, dated 2/8/2024 at 5:12 p.m., the Nutrition Interdisciplinary Team Update, indicated Resident 8's most recent weight was 102 lbs. on 2/5/2024 which indicated an 11 lb. weight loss or 9.7%. weight loss in one month. The document indicated Resident 8 was underweight. The IDT recommendations included an appetite stimulant for weight stabilization, continue to monitor weight response, discontinue the No Added Salt (NAS) part of the diet, and continue the rest of the diet as ordered, add Boost Glucose Control (a nutrient rich drink with minimal impact on blood sugar), 237 milliliters (ml- unit of measure of volume) twice a day with med pass (scheduled medication administration) and weekly weights for four weeks. During a review of Resident 8's Order Summary report, as of 4/7/2024, the report indicated on 2/17/2024, for Resident 8 to receive: a. CCHO diet regular texture, thin liquids (no restriction) consistency, fortified (increased nutrients). Chopped meat, b. Boost Glucose Control two times per day for supplement 237 ml with med pass, c. Megestrol Acetate Suspension 400 milligrams/ 10 ml, give 10 ml by mouth, one time a day, for appetite stimulant. During a review of Resident 8's medical record titled, Dietary - Amount Eaten from 2/7/2024 to 3/7/2024, the record indicated 31 meals out of 90 meals were left blank, with no amount eaten documented, indicating meal intake was not monitored. During a review of Resident 8's medical record titled Response History, Amount Eaten from 3/9/2024 to 4/6/2024, the record indicated 19 out of 87 meals were left blank, with no amount eaten documented, indicating meal intake was not monitored. During a review of Resident 8's Medication Administration Record (MAR) for 3/2024, the MAR indicated Resident 8 had the following ordered: a. On 2/17/2024, Megestrol Acetate Suspension 400 mg/10 ml, Give 10 ml by mouth one time a day for appetite stimulant. Resident 8 did not receive the medication from 2/9/2024 to 2/16/2024; there were 8 missed doses. (R8 gained weight during this time (On 2/5/2024, 102 lbs. On 2/16/2024, 105 lbs.) b. On 2/17/2024, Boost Glucose Control, two times per day for supplement, 237 ml with med pass. Resident 8 did not receive the supplement from 2/9/2024 to 2/17/2024 in the morning; there were 17 missed opportunities. During a review of Resident 8's Nutrition Interdisciplinary Team Update, dated 4/6/2024 at 5:31 p.m., the update indicated Resident 8 lost 8 lbs. and had a 7.7% weight loss in one month. The update indicated Resident 8 was underweight, and goal was for Resident 8 to weigh over 104 lbs. The update indicated Resident 8 needed 1590 to 1908 kilocalories (Kcal- unit of energy produced from nutrients). The document indicated Boost Glucose control would provide 190 kcal and 16 grams of protein (nutrient for muscle function), twice a day with med pass. During a concurrent interview with the MDS Registered Nurse (MDS RN) and record review of Resident 8's medical records on 4/6/2024 at 1:01 p.m., the MDS RN stated Resident 8 had had a severe weight loss of 7.7 % when Resident 8 weighed 104 lbs. on 3/5/2024 to 96 lbs. on 4/5/2024. The MDS RN stated the physician, and the RD should have immediately been notified after the weight loss was identified because Resident 8 was high risk for dehydration and malnutrition. During a concurrent observation and interview on 4/7/2024, at 8:33 a.m., with Registered Dietician 1(RD 1), in Resident 8's room, Resident 8 was eating breakfast without a salt packet on her breakfast tray and the diet profile card indicated Resident 8's diet was CCHO NAS Regular, chopped meat, fortified. The RD stated the diet profile card, food tray, and the order did not match and Resident 8 should have had a salt packet with the resident's breakfast tray. During a concurrent interview and record review on 4/7/2024, at 8:35 a.m., with the RD, Resident 8's Nutrition Interdisciplinary Team Update, dated 2/8/2024 at 5:12 p.m., was reviewed. The RD confirmed Resident 8 had a severe weight loss of 9.7 % on 2/5/2024 when Resident 8 weighed 113 lbs. on 1/5/2024 to 102 lbs. on 2/5/2024. The RD stated the physician and dietician was not aware of the weight loss until 2/8/2024, three days after the weight loss was identified. The RD stated the IDT did not address the severe weight loss immediately and the RD stated the IDT usually addresses severe weight loss within three days. The RD stated the IDT team made recommendations on 2/8/2024 for Boost Glucose Control twice a day with med pass, an appetite stimulant, to remove the NAS portion of the diet for Resident 8, and to continue to monitor the Resident 8's meal intake and weights. During a continued interview and record review on 4/7/2024, at 8:45 a.m., with the RD, Resident 8's MAR for 2/2024 and Resident 8's Order Summary report as of 4/7/2024 were reviewed. The RD confirmed the IDT recommendations were all carried out and ordered on 2/17/2024, twelve days after the weight loss was identified. The RD could not provide an explanation as to why the interventions were all delayed just that it was unacceptable. (The resident gained weight during that time 2. On 2/5/2024, 102 lbs. On 2/16/2024, 105 lbs.). During a continued interview and record review on 4/7/2024, at 8:50 a.m., with the RD, Resident 8's records titled Dietary - Amount Eaten from 2/7/2024 to 3/7/2024 and Response History, Amount Eaten from 3/9/2024 to 4/6/2024 were reviewed. The RD confirmed not all Resident 8's meals were monitored and documented, and we do not know if Resident 8 ate or not on those days. During a continued interview and record review on 4/7/2024, at 8:55 a.m., with the RD, Resident 8's Nutrition Interdisciplinary Team Update, dated 4/6/2024 at 5:31 p.m., was reviewed. The RD confirmed Resident 8 had a severe weight loss of 7.7 % when Resident 8 weighed 104 lbs. on 3/5/2024 to 96 lbs. on 4/5/2024. The RD stated the physician and RD was not notified immediately of the weight loss and was notified the next day on 4/6/2024. During an interview and record review with the Infection Preventionist (IP) on 4/7/2024 at 8:35 a.m. Resident 8's Response History, Amount Eaten from 3/9/2024 to 4/6/2024, was reviewed. The IP confirmed 19 out of 87 meals were left blank, with no amount eaten documented, indicating meal intake was not monitored. During a continued interview and record review with the IP on 4/7/2024 at 8:45 a.m., Resident 8's care plans were reviewed. The IP confirmed Resident 8's Nutrition care plan, initiated on 12/18/2023, was updated on 3/5/2024, 30 days after the severe weight loss was identified on 12/5/2024, indicating the recommendations made by the IDT team. The IP did not provide an explanation for the month delay of updating the care plan just that it should have been updated when the weight loss was identified on 2/5/2024. During a follow up interview and record review with the IP on 4/7/2024 at 11:57 a.m., Resident 8's Dietary - Amount Eaten from 2/7/2024 to 3/7/2024, was reviewed. The IP confirmed 31 meals out of 90 meals were left blank, with no amount eaten documented, indicating meal intake was not monitored. The IP stated with no documentation to confirm we do not know if Resident 8 ate or not. The meal intake percentage should have been documented to ensure a clear picture of Resident 8's status. During a follow up interview with the RD on 4/7/2024 at 1:19 p.m., the RD stated Boost Glucose Control 237 ml twice a day equates to 380 kcal and 32 grams of protein per day. From 2/5/2024 to 2/17/2024, Resident 8 did not receive the nutritional supplement that provided the added caloric and protein intake recommended by the IDT team. During an interview with the Dietary Supervisor (DS) on 4/07/2024 at 7:57 p.m., the DS stated she did not do the tray audit for 3/2024 so Resident 8 was served the incorrect order. The DS stated the correct diet should be served to the residents to prevent malnutrition and dehydration. During an interview with the Director of Nursing (DON) on 4/7/2024 at 8:00 p.m., the DON stated Resident 8 had severe weight loss identified on 2/5/2024 and on 4/5/2024 and the physician and dietician should have been notified immediately so the severe weight loss can be addressed sooner. The DON confirmed Resident 8's weight loss was identified on 2/5/2024, the IDT made recommendations on 2/8/2024, and the orders were entered on 2/17/2024, twelve days after the weight loss was first identified. The DON stated the IDT recommendations should have been implemented sooner so Resident 8 can start gaining weight and not lose more weight. The DON confirmed Resident 8's meal intake was not monitored and documented for every meal and the DON stated it should have been documented because if it was not documented it was not done. The DON confirmed the wrong diet was served to Resident 8 on 4/7/2024 and the DON stated the correct therapeutic diet should be served to the residents to prevent malnutrition. The DON stated the severe weight loss of 7.7 % in one month (March to April) and 15% weight loss in three months (January to April) was avoidable and it happened due to lack of monitoring and delayed interventions. During a review of the facility's policy and procedure titled Nutrition Status Management, revised/reviewed on 12/2023, the policy indicated the facility will assess each resident's nutritional status and needs, including medications and medical conditions to ensure that all residents maintain acceptable parameters of nutritional status, such as body weight and other available data, unless the resident's clinical condition demonstrates that it was not possible. The policy indicated: a. Nutritional assessment included weighing and weight changes, oral intake of foods and fluids and nutrition prescriptions. b. The IDT will monitor and reevaluate the resident's response or lack of response of the interventions and revise or discontinue the approaches or justifying the continuation of current approaches. c. Any resident weighed that varies from the previous reporting period by 5% or 5 lbs. in 30 days, 7.5% in 90 days and 10% in 180 days will be evaluated by the interdisciplinary team to determine the cause of weight loss and gain and intervention required. d. The IDT will update and revise the care plan as appropriate. During a review of the facility's policy and procedure titled Diet Orders, 2023, the policy indicated diet orders prescribed by the physician will be provided by the Food and Nutrition Services Department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the enteral (method of supplying nutrients directly into the gastrointestinal tract) feeding administration set, and piston syringe were signed and dated per facility's policy and procedure, to prevent complications of gastrostomy tube ([G-tube] an artificial opening into the stomach to deliver medication, nutrition, and hydration) for one of one sampled residents (Resident 1). This failure had the potential for Resident 1 getting infections due to the enteral feeding set being used beyond it's use-by date. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the resident was admitted on [DATE] then re-admitted on [DATE] to the facility with diagnoses that included acute respiratory failure with hypoxia (often caused by a disease or injury that affects your breathing), pneumonia (an infection of the air sacs in one or both the lungs), hypotension (low blood pressure). During a record review of Resident 1's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 1/18/2024, the MDS indicated Resident 1 was rarely or never understood by others and was rarely or never understood. The MDS indicated Resident 1 was dependent (Helper does all the effort) for toileting hygiene, oral hygiene, dressing upper and lower, putting on and off footwear and personal hygiene. During a record review of the physician's order dated 10/16/2023, the physician's order indicated change enteral administration set with every formula (enteral feeding solution) bottle change. During an observation on 4/6/2024 at 7:46 a.m., at Resident's 1 room the enteral administration set and the piston syringe was undated and unsigned. During a concurrent observation and interview on 4/6/2024 at 8:12 a.m. with Licensed Vocational Nurse 1 (LVN) 1, LVN 1 stated that every time a nurse changes the formula they should also change the administration set and piston syringe, LVN 1 stated that since the enteral feeding administration set was not dated and signed it was not safe to say when it was changed. During an interview on 4/7/2024 at 6:10 p.m., with the Director of Nursing (DON), the DON stated LVN charge nurses are responsible to make sure on a daily basis the administration set and the piston syringe is changed to prevent any contamination or possible cause of infection. The DON stated that it should have a date and signature daily to be able to identify if it was done or not. During a record review of the facility's policy and procedure (P&P) titled Gastrostomy tube Care and management revised 12/2023, the P& P indicated clean all accessories, including syringes, after each use, the syringe will be discarded and replaced on a daily basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure: 1. The primary care physician visited Resident 37 to assess and continue admission orders from the hospital and complete a history and physical (H&P) making sure the facility provided the care needed during the stay in the facility for one of one sampled resident (Resident 37). 2. Ensure Resident 29's physician conducted a monthly visit for the month of 3/2024. This deficient practice has the potential to not provide Resident's 37 and 29 the appropriate medical interventions during their facility stay and had the potential to have issues or concerns missed which they may have wanted to discuss with their physician. Findings: 1. During a record review of Resident 37's admission Record, the admission Record indicated the resident was admitted on [DATE] then re-admitted on [DATE] to the facility with diagnoses that included acute respiratory failure with hypoxia (often caused by a disease or injury that affects breathing) essential primary hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), benign prostatic hyperplasia (harmless prostate enlargement) . During a record review of Resident 37's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 3/6/2024, the MDS indicated the resident had the capacity to understand others and was able to be understood by staff. The MDS indicated Resident 37 required maximal assistance (helper does more than half the effort) from one staff for toileting hygiene, dressing, transfer, bed mobility, and supervision or touching assistance (helper provides verbal cues and /or touching/contact guard assistance) from one staff for eating. During a record review of a physician admission progress notes dated late entry 3/18/2024, physician admission progress notes indicated Resident 37 was admitted to the hospital with anemia (deficiency of healthy red blood cells in blood), pneumonia (an infection of the air sacs in one or both the lungs), and sepsis (a life-threatening complication that occurs due to an infection) and was treated with intravenous (IV- intravenous usually refers to a way of giving a drug or other substance through a needle or tube inserted into a vein) medication. During a concurrent interview and record review on 4/7/2024 at 2:30 p.m., with the Corporate Medical Records (MR) staff of Resident 37's unsigned and not done H &P, the MR stated that the H&P should be done within 72 hours of admission unless the Medical Doctor(MD) in the facility is the same one as the one from the hospital. The MR stated it is the responsibility of the medical records department to audit and make sure the physician comes and visits within the allowable timeframe. The MR stated if physician doesn't come in timely, she would inform the Director of Nursing (DON) and the DON would coordinate with the MD. During a concurrent interview and record review on 4/7/2024 at 5:15 p.m., with the DON, the DON stated the MD needs to come to the facility within 72 hours of admission to evaluate the residents' condition, do H & P and sign Physician's orders (PO). The DON stated it was important to make sure the MD saw the resident in a timely manner to ensure appropriate care and services were provided to the Resident. The DON stated it was the DON's responsibility to make sure this regulation was being followed. The DON stated the H&P was missed and the Physicians orders were not signed. 2. During a review of Resident 29's admission Record (Face Sheet), the Face Sheet indicated Resident 29 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including fracture (broken bone) of the left femur (thigh bone), osteoarthritis (the tissues in the joint [a part of the body where two or more bones meet to allow movement] break down over time), and abnormalities of gait and mobility. During a review of Resident 29's History and Physical (H&P) dated 1/30/2024, the H&P indicated Resident 29 had the capacity to understand and make decisions. During a review of Resident 29's MDS, dated [DATE], the MDS indicated Resident 29's cognition (ability to make decisions of daily living) was intact and had the ability to understand and be understood by others. The MDS indicated Resident 29 required substantial/maximum assistance from staff for shower/bathe self, and for lower body dressing. The MDS indicated Resident 29 required partial/moderate assistance from staff for toilet transfer, sit to stand, toilet hygiene and rolling left to right in bed. During an interview on 4/6/2024 at 8:41 a.m., with Resident 29, Resident 29 stated, she had not seen her doctor since I haven't seen her physician since November of last year. Resident 29 stated she had some questions about her care that she would like to discuss with him, but had not seen him. During a review of Resident 29's Physician Progress Notes, dated 2/2024, the Physician Progress notes indicated Resident 29 was seen by her physician on 2/14/2024. There was no documentation indicating Resident 29 was seen by her physician after 2/14/2024. During a review of Resident 29's Nursing Progress Notes, dated 3/2024, there was no documentation by the licensed nurses or facility staff indicating Resident 29's physician was notified of the missed monthly visit for the month of 3/2024. During an interview on 4/7/2024 at 5:39 p.m., with the DON, the DON stated all residents are required to be seen by their physician monthly, at least every 30 days. During a review of the facility's policy and procedure (P&P) titled, Documentation and Charting dated 5/2012, the P&P indicated each resident must be under the care of a licensed physician authorized to practice medicine in this state and must be seen by the physician at least every thirty (30) days. The P&P indicated physician's orders must be signed by the physician and dated when such order was signed. During a record review of the facility's policy and procedure(P&P) titled Physician Visits revised 06/2015, the P & P indicated residents must be seen by a physician at least once every thirty (30) days for the first ninety days after admission, and at least every sixty thereafter. The initial comprehensive shall be made no later than 30 days after a resident's admission into the Skilled Nursing Facility (SNF).

Basedoninterviewandrecordreviewthefacilityfailedtoensurethecomputedtomographyscan([CT]imagingteststodetectinternalinjuriesanddisease withintravenouscontrast(toadministermaterialsdirectlytothepersonsveintoenhancetheimagesofthetest, orderedon3/14/2024, toruleoutClostridioidesdifficile(germthatcausesinfectionofthecolon / Colitisrelapsediagnosiswithdiarrhea(loosewaterystools foroneofoneresident(Resident48) wascompleted ThedeficientpracticehadthepotentialtoresultinanundiagnosedproblemwhichcouldhaveplacedResident48 athigherriskforphysicaldecline Findings DuringareviewofResident48'sAdmissionRecord dated4/6/2024, theadmissionrecordindicatedResident48 wasadmitted tothefacilityon3/1/2024 withdiagnosesincludinginfectiousgastroenteritis(aninflammation[responsetoinjurycausingredness swelling pain lossoffunctionandheat]oftheliningofthestomachandintestines andcolitis(diseasecharacterizedbyinflammationoftheinnerliningofthecolon andcystitis(infectionofthebladder[organthatholdstheurine] withouthematuria(bloodintheurine. DuringareviewofResident48'sMinimumDataSet(MDS, astandardizedassessmentandcarescreeningtool dated3/7/2024, theMDSindicatedResident48 hadmoderateimpairmentincognitive(thinkingreasoning remembering skillsfordailydecisionmaking TheMDSindicatedResident48 neededsetuporcleanupassistancewitheatingandoralhygiene supervisionwithtoiletingandupperbodydressing andpartialassistwhenhelperdoeslessthanhalfthetaskwithshowering lowerbodydressing andpersonalhygiene DuringareviewofResident48'sOrderSummaryreport asof4/6/2024, thereportindicatedaphysiciansorderdated3/14/2024, foraCTwithintravenouscontrasttoruleoutClostridioidesdifficile/ Colitisrelapsediagnosiswithdiarrhea Duringaninterviewandrecordreviewon4/7/2024 at3:26 pm, withLicensedVocationalNurse1 (LVN1), Resident48'sorderforCTscanwasreviewed LVN1 statedroutineordersshouldbecompletedintwentyfourhoursorassoonasreasonablypossible Duringaninterviewandrecordreviewon4/7/2024 at3:30 pm, withLVN1, Resident48'smedicalrecordswerereviewedandtherewasnodocumentedevidencetheCTscanwithIVcontrastwascompleted LVN1 statedtheCTscanshouldhavebeencompletedtoseeifResident48 hadcolitisoranyacute(severeandsuddenonset problems Duringaninterviewandrecordreviewon4/7/2024 at5:39 pm, withtheDirectorofNursing(DON, theDONstatedifaCTscanwasorderedthenitshouldhavebeendonetoruleoutanyacuteinjuriesordiseases DuringareviewofthefacilityspolicyandproceduretitledXRay EKGUS ECHO, undated thepolicyindicateduponreceivinganorderforXRay UltrasoundorEchocardiogram eitherfromthefacilityortheattendingphysician amobileunitwillbedispatchedtothefacility DuringareviewofthefacilitysFacilityAssessmentTool, Updated8/10/2023, thetoolindicatediftheresidentcarewouldbeprovidedusingclinicalresourcesavailable Thetoolindicatedradiologyserviceswereprovidedthroughcontractualagreementsforbothroutineandstatradiologyneeds

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure Resident 8 received the ordered Consistent Carbohydrate Diet (CCHO, diet with the same amount of carbohydrates [sugars], main nutrients in our diet, every day), regular texture, thin liquids consistency, fortified (extra nutrients added), with chopped meat, on 4/7/2024. This deficient practice placed Resident 8 at higher risk for continued severe weight loss (weight loss greater than 5 percent in one month and greater than 7.5 percent in three months) and at higher risk for malnutrition (body does not get enough nutrients). Findings: During a review of Resident 8's admission record, dated 4/6/2024, the admission record indicated Resident 8 was initially admitted to the facility on [DATE] and recently readmitted to the facility on [DATE] with a diagnoses including sepsis (infection of the blood), muscle weakness, dysphagia (difficulty swallowing), mild calorie protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and functions), schizophrenia (mental illness that affects how a person thinks, feels and behaves), diabetes mellitus (disorder where the body cannot regulate glucose or sugar like it should), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 8's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/7/2024, the MDS indicated Resident 8 had severe impairment in cognitive (thinking reasoning, remembering) skills for daily decision making. The MDS indicated Resident 8 needed set up assistance with eating, supervision with personal hygiene, and substantial assistance from staff, where staff does more than half the effort, with oral hygiene. The MDS indicated Resident 8 was 64 inches in height and last weighed 104 pounds (lbs.) and the resident had a weight loss of 5 percent or more in the last month. During a review of Resident 8's Order Summary report, as of 4/7/2024, the Order Summary report indicated an order dated 2/17/2024, for CCHO diet regular texture, thin liquids consistency, fortified, with chopped meat. During a review of an untitled care plan, initiated on 12/18/2023, the care plan indicated Resident 8 had a nutritional problem or potential nutritional problem. The care plan indicated the resident would maintain adequate nutritional status as evidenced by maintaining weight greater than 104 lbs. with no signs and symptoms of malnutrition. The care plan interventions, initiated on 3/5/2024, indicated to provide diet as ordered by the physician. During a concurrent observation and interview on 4/7/2024, at 8:33 a.m., with Registered Dietician 1(RD) 1, in Resident 8's room, Resident 8 was observed eating breakfast without a salt packet on her breakfast tray and the diet profile card indicated Resident 8's diet was CCHO no added salt (NAS) Regular, chopped meat, fortified. RD 1 stated Resident 8's diet profile card, food tray, and the order did not match and Resident 8 should have had a salt packet with the her breakfast tray. During an interview with the Dietary Supervisor (DS) on 4/07/2024 at 7:57 p.m., the DS stated Resident 8 was served the incorrect order. The DS stated the correct diet should be served to residents to prevent malnutrition. During an interview with the Director of Nursing (DON) on 4/7/2024 at 8:00 p.m., the DON confirmed the wrong diet was served to Resident 8 on 4/7/2024 and the DON stated the correct therapeutic diet should be served to residents to prevent malnutrition. During a review of the facility's policy and procedure titled Diet Orders, 2023, the policy indicated diet orders prescribed by the physician will be provided by the Food and Nutrition Services Department.

Based on interview and record review, the facility's Quality Assessment and Assurance ([QAA] to develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] designated to bring about constant and measurable improvement in the services provided at the facility for continual improvement of quality care) committee failed to ensure the facility's administrator attended the monthly meetings. This deficient practice has a potential for the QAA committee not to identify and not to respond to systemic problems to improve services for the residents. Findings: During the entrance conference on 4/6/2024 at 10:46 a.m. with the Director of Nursing (DON), the DON stated that they do the monthly QAPI meeting to identify the concerns of residents', to improve the services and care of the residents in the facility. During a concurrent interview and record review of the QAA meeting minutes for the month 3/2024 on 4/7/2024 at 6:00p.m., with the Director of Nursing (DON), the DON stated that the admin is present during the meeting, but the administrator did not sign the attendance sheet. The DON stated that anybody that is present during the meeting should sign in to indicate they are physically present in the meeting. Neither the Infection Preventionist (IP), nor the DON signed the attendance sheet. During a record review of the facility's 2024 Quality Assurance and Performance Improvement (QAPI) Plan, it indicated the Administrator, and the QA Committee of the governing body have the responsibility for integrating the QAPI plan. The Administrator is responsible for direct oversight for all functions of the QAPI committee and reports directly to the governing body. The Administrator has received training on QAPI and used the Centers for Medicare and Medicaid Services (CMS), American Health Care Association (AHCA), Health Services Advisory Group(HSAG) websites for research. The Facility Administrator has the ultimate responsibility for the QAPI plan. The Administrator must make sure there is a plan in place and that all department heads are aware of their individual responsibilities according to the plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to offer the influenza (Flu-an infection of the nose, throat and lungs, which are part of the respiratory system) vaccine and pneumococcal vaccine (vaccine that helps prevent pneumonia, an infection that inflames the air sacs in one or both lungs) to two of six sampled residents (Resident 1 and Resident 104). This failure had the potential to result in Residents 1 and 104 acquiring and transmitting the flu and pneumonia to other residents, staff, and visitors. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the resident was admitted on [DATE] then re-admitted on [DATE] to the facility with diagnoses that included acute respiratory failure with hypoxia (often caused by a disease or injury that affects breathing) pneumonia (an infection of the air sacs in one or both the lungs), hypotension (low blood pressure). During a record review of Resident 1's Minimum Data Set ([MDS] standardized screening tool) dated 1/18/2024, the MDS indicated Resident 1 was rarely or never understood by others and was rarely or never been understood. The MDS indicated Resident 1 was dependent (Helper does all the effort) for toileting hygiene, oral hygiene, dressing upper and lower, putting on and off footwear and personal hygiene. During a record review of the immunization (fortifying the body against infections) tab record for Resident 1, the immunization record did not indicate that Resident 1 received the flu and pneumococcal vaccinations. During a review of Resident 104's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses that included hypertension (high blood pressure), falls and spinal stenosis (when the space inside the backbone is too small). During a record review of the History and Physical (H&P) dated 4/2/2024, the H&P did not indicate whether resident has the capacity to make decisions. During a record review of the resident consent for influenza, pneumococcal and covid-19 (a severe infection that is easily transmittable) vaccination dated 4/1/2024, the consent indicated that that Resident 104 agreed to receive the influenza, pneumococcal and covid-19 vaccines. During a concurrent interview and record review of the immunization records of Resident 104 and Resident 1 with the Infection Preventionist Nurse (IPN) on 4/6/2024 at 4:35 p.m., the IPN stated Resident 104 signed the consent on 4/1/2024 for all three vaccines (Influenza, Pneumonia and Covid vaccine) but it was never administered. The IPN stated she did not think she was allowed to administer the flu vaccine during the non- flu season. The IPN further added for Resident 1 she did not know who would give the consent since Resident 1 did not have a responsible party, so she never offered any the vaccinations to her. During a record review of Resident 1's Initial Interdisciplinary Team (IDT- resident's health care team consisting of various specialties) conference dated 10/17/2023 under immunizations and consents, the record indicated reviewed with case worker and obtained verbal consent. During a continued interview and record review of the immunization records for Resident 1 and Resident 104 with the IPN on 4/7/2024 at 4:58 p.m., the IPN stated she should have administered both the flu and pneumonia vaccines since Resident 1 and Resident 104 were at risk for getting the flu and pneumonia and they are both elderly and had multiple medical condition that make them vulnerable to infections. The IPN stated that the flu vaccine and pneumonia vaccine is a good protection against the flu and pneumonia. During an interview with the Director of Nursing (DON) on 4/7/2024 at 6:01 p.m., the DON stated that it was the responsibility of the IPN to make sure all the vaccines was offered to all eligible staff and residents in the facility. The DON stated that if the consent is signed, the IPN has 72 hours to administer the vaccines. The DON stated if it is not documented it is not done. During a record review of the facility's policy and procedure (P&P) revised 7/2023, titled Immunizations-Resident, the P&P indicated the facility will offer and administer flu and pneumococcal immunization to eligible residents after providing education on the risks and potential side effects of the vaccine and obtaining consent, eligibility to receive may include, but it is not to current vaccine status, season/time of the year, medical contra indications or resident preference/choice. If the resident was admitted outside the influenza season, the facility is not expected to offer the vaccine to the resident and will be handled on a case-by-case basis depending on individual needs and preferences along with the physician recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that Resident 104 received the covid-19 (an disease caused by a virus, which is characterized mainly by fever and cough and can progress to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) vaccination. This deficient practice placed Resident 104 at risk of acquiring serious infections such as pneumonia and covid-19 that could result in serious symptoms. Findings: During a record review of Resident 104's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses that included hypertension (high blood pressure), falls and spinal stenosis (happens when the space inside the backbone is too small). During a review of the History and Physical (H&P) dated 4/2/2024, the H&P did not indicate if Resident 104 had the capacity to make decisions. During a concurrent interview and record review of the immunization (administered resistance to an infection) record of Resident 104 with the Infection Preventionist Nurse (IPN), the IPN stated Resident 104 signed the consent on 4/1/2024 for the Covid vaccine, but it was never administered. The IPN stated that she has not had a chance to administer the vaccination yet, but she was aware that the consent was signed on 4/1/2024. The IPN stated that vaccines are protection against infectious disease, and Resident 104 is vulnerable and elderly so she is at risk for getting the virus if not vaccinated. During a record review of the resident consent for covid-19 vaccination dated 4/1/2024, the consent indicated that that Resident 104 agreed to receive the covid-19 vaccine. During an interview with the Director of Nursing( DON) on 4/7/2024 at 6:01 p.m., the DON stated that it is the responsibility of the IPN to make sure all the vaccines were offered to all eligible staff and residents in the facility. The DON stated that from the day the consent is signed, the IPN has 72 hours to administer the vaccine. The DON stated if it is not documented it is not done. During a record review of the facility's policy and procedure (P&P) revised 7/2023, titled Immunizations-Resident, the P&P indicated the facility will offer and administer flu, pneumococcal and Covid-19 immunization to eligible residents after providing education on the risks and potential side effects of the vaccine and obtaining consent, eligibility to receive may include, but it is not to current vaccine status, season/time of the year, medical contra indications or resident preference/choice. The P&P indicated each resident is offered a covid-19 immunization unless the immunization is contraindicated or the resident has already been immunized, document administration details in the residents medical record if administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide treatment and services to maintain or prevent further decrease in joint range of motion (ROM, full movement potential of a joint) and/or mobility for four of 12 sampled residents (Resident's 11, 20, 30, and Resident 43). The facility failed to ensure that Resident's 11, 20, 30 and Resident 43 received Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) treatment five times a week as indicated in the residents' care plans. This deficient practice had the potential for Resident's 11, 20, 30 and Resident 43 to have an avoidable decline in range of motion and mobility. a. During a review of Resident 11's admission Record (Face Sheet), the Face Sheet indicated the resident was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including major depressive disorder (a mood disorder which causes a persistent feeling of sadness and loss of interest), dementia (the loss of thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life activities), osteoarthritis (tissues in the joint [part of the body where two or more bones meet to allow movements] break down over time), and muscle wasting (a weakening, shrinking, and loss of muscle caused by disease or lack of use). During a review of Resident 11's Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated 2/7/2024, the MDS indicated Resident 11's cognition (ability to make decisions of daily living) was moderately impaired and was always able to understand and be understood by others. The MDS indicated Resident 11 required substantial/maximum assistance (helper lifts or holds trunk or limbs and provides more than half the effort) from staff for toileting hygiene, showering/bathing, upper body dressing, and lower body dressing. The MDS indicated Resident 11 was totally dependent (resident does none of the effort to complete the activity) for rolling left to right in bed, sitting to lying in bed, lying to sitting on the side of the bed, toilet transfer, and for tub/shower transfer. The MDS indicated Resident 11 did not walk during the assessment period. During a review of Resident 11's untitled Care Plan, initiated on 9/22/2018, the Care Plan indicated Resident 11 was identified to have an activity of daily living (ADL) self-care performance deficit related to confusion, poor communication, gait/balance (manner of walking) problems dementia, and depression. The Care Plan goal indicated Resident 11 will maintain current level of function through the review date of 5/18/2024. The Care Plan interventions for Resident 11 included for RNA to assist with bilateral (both) upper (UE) and lower extremity (LE) exercises in all planes (moving side-to-side, front, and back, or rotationally) as tolerated five times a week. During a review of Resident 11's Order Summary Report (Physician's Orders), the Physician's orders indicated an order was placed on 4/1/2024, for RNA to assist with bilateral upper and lower extremity exercises in all planes as tolerated every day shift, five times a week. During a review of Resident 11's RNA Treatment Flow Sheet dated April 2024, the RNA Treatment Flowsheet indicated there was no documentation on 4/1/2024, and from 4/5/2024 to 4/7/2024 that Resident 11 had received RNA therapy. The Treatment Flow Sheet Indicated RNA treatment was not completed as five times a week as ordered. b. During a review of Resident 12's Face Sheet, the Face Sheet indicated Resident 12 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including difficulty in walking, muscle weakness, major depressive disorder, and Alzheimer's disease (a brain disorder which slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). During a review of Resident 12's History and Physical (H&P) dated 2/3/2023, the H&P indicated Resident 12 did not have the capacity to understand and make decisions. During a review of Resident 12's MDS dated [DATE], the MDS indicated Resident 12's cognition was moderately impaired and was usually understood and was usually able to understand others. The MDS indicated Resident 12 required substantial/maximum assistance from staff for toilet transfer, tub/shower transfer, toileting hygiene, and shower/bathing. The MDS indicated Resident 12 did not walk during the assessment period. During a review of Resident 12's untitled Care Plan, initiated on 2/8/2022, the Care Plan indicated Resident 12 was identified to have an ADL self-care performance deficit related to depression and Alzheimer's dementia. The Care Plan goal indicated Resident 12 will maintain current level of function through the review date of 4/14/2024. The Care Plan interventions for Resident 12 included for RNA to assist with range of motion ([ROM] activity aimed at improving movement of a specific joint) and ambulation as ordered. During a review of Resident 12's Physician's Orders, the Physicans Orders indicated an order dated 4/1/2024, for RNA to assist with bilateral upper and lower extremity exercises in all planes as tolerated every day shift, five times a week. During a review of Resident 12's RNA Treatment Flow Sheet dated April 2024, the RNA Treatment Flowsheet indicated there was no documentation on 4/1/2024, and from 4/5/2024 to 4/7/2024. The RNA Treatment Flow Sheet Indicated RNA treatment was not completed five times a week as ordered. c. During a review of Resident 30's admission Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including rheumatoid arthritis (the body attacks itself and damages the joints), polyneuropathies (the simultaneous malfunction of many peripheral [away from the center of the body] nerves [carry messages to and from the brain and spinal cord] throughout the body), muscle weakness, abnormalities of gait and mobility, and abnormal posture. During a review of Resident 30's H&P dated 2/10/2024, the H&P indicated Resident 30 had the capacity to understand and make decisions. During a review of Resident 30's MDS dated [DATE], the MDS indicated Resident 30's cognition was intact and was always able to understand and be understood by others. The MDS indicated Resident 30 required substantial/maximum assistance from staff for rolling left to right in bed, sitting to lying in bed, and lying to sitting on the side of the bed. The MDS indicated Resident 30 was totally dependent on staff for eating, oral hygiene, toileting hygiene, shower/bath, upper body dressing, and lower body dressing. The MDS indicated Resident 30 did not walk during the assessment period. The MDS further indicated Resident 30 had functional limitations in ROM on both upper extremities (shoulder, elbow, wrist, hand). During a review of Resident 30's untitled Care Plan, initiated on 2/4/2024, the Care Plan indicated Resident 30 was identified to have an ADL self-care performance deficit related to acute (sudden onset) weakness. The Care Plan goal indicated Resident 30 will maintain current level of function through the review date of 5/4/2024. The Care Plan interventions for Resident 30 included for bilateral upper extremity (BUE) resting hand splints (supports the wrist and joints of the fingers and thumb to make sure they are positioned correctly) for up to two to six hours or as tolerated, with skin checks, before and after splint application five times a week. The Care Plan interventions included BUE and bilateral lower extremities (BLE) exercises in all planes as tolerated five times a week. During a review of Resident 30's Physician's Orders dated 3/7/2024, the Physician's Orders indicated an order was placed for Resident 30 to have BUE and BLE active range of motion ([AAROM] movement at a given joint with a person's own effort and assistance from an external force or another person) exercises in all planes as tolerated every day shift, five times a week, Monday through Friday. During a review of Resident 30's Physician's Orders dated 3/8/2024, the Physician's Orders indicated an order was placed for Resident 30 to have bilateral upper extremity resting hand splints for up to two hours or as tolerated, with skin checks, before and after splint application, every day, five times a week Monday through Friday. During a review of Resident 30's RNA Treatment Flow Sheet dated March 2024, for the RNA order for resident hand splints, there was no documentation on the RNA Treatment Flow Sheet indicating Resident 30 received RNA hand splint application from 3/25/2024 to 3/29/2024. The RNA Treatment Flow Sheet indicated RNA treatments were not completed five times a week as ordered. During a review of Resident 30's RNA Treatment Flow Sheet dated March 2024, the RNA Treatment Flow sheet indicated no documentation for the RNA order for BUE and BLE AAROM exercises, that Resident 30 received BUE and BLE AAROM exercises on 3/28/2024. The RNA Treatment Flow Sheet indicated RNA treatments were not completed five days a week as ordered. During a review of Resident 30's Physician's Orders dated 4/1/2024, the Physician's Orders indicated an order was placed for Resident 30 to have BUE and BLE AAROM exercises in all planes as tolerated every day shift, five times a week. During a review of Resident 30's Physician's Orders dated 4/1/2024, the Physician's Orders indicated an order was placed for Resident 30 to have bilateral upper extremity resting hand splints for up to two to six hours or as tolerated, with skin checks, before and after splint application, every day, five times a week. During an interview on 4/6/2024 with Resident 30, Resident 30 stated, I know my order is to have my hands splinted every day, but I have only had my hands splinted once this week and my bilateral arm and leg exercises have been done only once this week as well. I know both of my orders are for five times a week, but I don't know why I'm not getting my therapy. I am already having problems with my hands, I can't feed myself, and I'm afraid I'm going to get worse if I don't get my therapy, that is what I'm here for, right? During a follow-up interview on 4/7/2024 at 4:25 p.m. with Resident 30, Resident 30 stated, I didn't receive my therapy yesterday or today. I thought maybe I would get my therapy later in the day yesterday, but it never happened. Today I didn't get my therapy either. I don't know why it wasn't done. d. During a review of Resident 43's Face Sheet, the Face Sheet indicated Resident 43 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including left femur (thigh bone) fracture (broken bone), abnormalities of gait and mobility, and dementia. During a review of Resident 43's History and Physical (H&P) dated 2/22/2024, the H&P indicated Resident 43 did not have the capacity to understand and make decisions. During a review of Resident 43's MDS dated [DATE], the MDS indicated Resident 43's cognition was intact and was usually understood and was usually able to understand others. The MDS indicated Resident 43 required substantial/maximum assistance from staff for sitting to standing, chair to bed/bed to chair transfer, toilet transfer, toileting hygiene, tub/shower transfer, and shower/bathing. The MDS indicated Resident 43 could only walk 10 feet (once standing, the ability to walk 10 feet in a room, corridor, or similar space) with substantial/maximum assistance from staff during the assessment period. The MDS further indicated Resident 43 had lower extremity impairment on one side. During a review of Resident 43's untitled Care Plan, initiated on 3/20/2024, the Care Plan indicated Resident 43 was identified to have an ADL self-care performance deficit related to dementia and history of depression. The Care Plan goal indicated Resident 43 will maintai functional abilities through the review date of 6/18/2024. The Care Plan interventions for Resident 43 included for BUE and BLE ROM exercises in all planes as tolerated five times per week. During a review of Resident 43's Order Summary Report (Physician's Orders), an order was placed on 4/1/2024, for RNA to assist with BUE and BLE exercises in all planes as tolerated every day shift, five times a week. During a review of Resident 43's RNA Treatment Flow Sheet dated April 2024, the RNA Treatment Flowsheet indicated the documentation section was blank on 4/1/2024, 4/5/2024, and 4/7/2024. The RNA Treatment Flow Sheet Indicated RNA treatment was not completed five times a week as ordered. During an interview on 4/6/2024 at 3:50 p.m., with the Director of Rehab (DOR) the DOR stated, residents receive RNA services to maintain their ROM, and to prevent further decline. If residents are not getting RNA therapy as ordered by the physician that places the residents at risk for further decline, and contractures (a permanent tightening of the muscles, tendons [a tough band of dense fibrous connective tissue which connects muscle to bone], skin, and nearby tissues which cause the joints to shorten and become very stiff). During an interview with the Director of Nursing (DON) on 4/7/2024 at 5:39 p.m., the DON stated, The purpose of implementing the resident's care plan interventions is to help prevent resident's further health decline. It is the responsibility of the nursing staff to implement the resident's care plan interventions as indicated. By not following the RNA interventions, it puts the residents at risk for further decline in mobility. The RNA was not available for interview during the period the recertification survey was conducted. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, revised 12/2023, the P&P indicated a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The P&P indicated the interventions are actions, treatments, procedures, or activities which are designed to meet an objective. CROSS REFERENCE TO F688

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and services to maintain or prevent further decrease in joint range of motion (ROM, full movement potential of a joint) and/or mobility for four of 12 sampled residents (Resident's 11, 12, 30, and Resident 43). The facility failed to ensure that Residents 11, 12, 30 and Resident 43 received Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) treatment five times a week as ordered. This deficient practice had the potential for Resident's 11, 12, 30 and Resident 43 to have an avoidable decline in range of motion and mobility. Findings: A. During a review of Resident 11's admission Record (Face Sheet), the Face Sheet indicated the resident was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including major depressive disorder (a mood disorder which causes a persistent feeling of sadness and loss of interest), dementia (the loss of thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life activities), osteoarthritis (tissues in the joint [part of the body where two or more bones meet to allow movements] break down over time), and muscle wasting (a weakening, shrinking, and loss of muscle caused by disease or lack of use). During a review of Resident 11's Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated 2/7/2024, the MDS indicated Resident 11's cognition (ability to make decisions of daily living) was moderately impaired and was always able to understand and be understood by others. The MDS indicated Resident 11 required substantial/maximum assistance (helper lifts or holds trunk or limbs and provides more than half the effort) from staff for toileting hygiene, showering/bathing, upper body dressing, and lower body dressing. The MDS indicated Resident 11 was totally dependent (resident does none of the effort to complete the activity) for rolling left to right in bed, sitting to lying in bed, lying to sitting on the side of the bed, toilet transfer, and for tub/shower transfer. The MDS indicated Resident 11 did not walk during the assessment period. During a review of Resident 11's untitled Care Plan, initiated on 9/22/2018, the Care Plan indicated Resident 11 was identified to have an activity of daily living (ADL) self-care performance deficit related to confusion, poor communication, gait/balance (manner of walking) problems dementia, and depression. The Care Plan goal indicated Resident 11 will maintain current level of function through the review date of 5/18/2024. The Care Plan interventions for Resident 11 included for RNA to assist with bilateral (both) upper (UE) and lower extremity (LE) exercises in all planes (moving side-to-side, front, and back, or rotationally) as tolerated five times a week. During a review of Resident 11's Order Summary Report (Physician's Orders), the Order Summary Report indicated an order was placed on 4/1/2024, for RNA to assist with bilateral upper and lower extremity exercises in all planes as tolerated every day shift, five times a week. During a review of Resident 11's RNA Treatment Flow Sheet dated April 2024, the RNA Treatment Flowsheet indicated the documentation section was blank on 4/1/2024, and from 4/5/2024 to 4/7/2024. The Treatment Flow Sheet Indicated RNA treatment was not completed five days a week, as ordered. B. During a review of Resident 12's Face Sheet, the Face Sheet indicated Resident 12 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including difficulty in walking, muscle weakness, major depressive disorder, and Alzheimer's disease (a brain disorder which slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). During a review of Resident 12's History and Physical (H&P) dated 2/3/2023, the H&P indicated Resident 12 did not have the capacity to understand and make decisions. During a review of Resident 12's MDS dated [DATE], the MDS indicated Resident 12's cognition was moderately impaired, was usually understood and was usually able to understand others. The MDS indicated Resident 12 required substantial/maximum assistance from staff for toilet transfer, tub/shower transfer, toileting hygiene, and shower/bathing. The MDS indicated Resident 12 did not walk during the assessment period. During a review of Resident 12's untitled Care Plan, initiated on 2/8/2022, the Care Plan indicated Resident 12 was identified to have an ADL self-care performance deficit related to depression and Alzheimer's dementia. The Care Plan goal indicated Resident 12 will maintain current level of function through the review date of 4/14/2024. The Care Plan interventions for Resident 12 included for RNA to assist with range of motion ([ROM] activity aimed at improving movement of a specific joint) and ambulation as ordered. During a review of Resident 12's Physician's Orders, the Physician's Orders indicated an order was placed on 4/1/2024, for RNA to assist with bilateral upper and lower extremity exercises in all planes as tolerated every day shift, five times a week. During a review of Resident 12's RNA Treatment Flow Sheet dated April 2024, the RNA Treatment Flowsheet indicated the documentation section was blank on 4/1/2024, and from 4/5/2024 to 4/7/2024. The RNA Treatment Flow Sheet Indicated RNA treatment was not completed as five days a week as ordered. C. During a review of Resident 30's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including rheumatoid arthritis (the body attacks itself and damages the joints), polyneuropathies (the simultaneous malfunction of many peripheral [away from the center of the body] nerves [carry messages to and from the brain and spinal cord] throughout the body), muscle weakness, abnormalities of gait and mobility, and abnormal posture. During a review of Resident 30's H&P dated 2/10/2024, the H&P indicated Resident 30 had the capacity to understand and make decisions. During a review of Resident 30's MDS dated [DATE], the MDS indicated Resident 30's cognition was intact and was always able to understand and be understood by others. The MDS indicated Resident 30 required substantial/maximum assistance from staff for rolling left to right in bed, sitting to lying in bed, and lying to sitting on the side of the bed. The MDS indicated Resident 30 was totally dependent from staff eating, oral hygiene, toileting hygiene, shower/bath, upper body dressing, and lower body dressing. The MDS indicated Resident 30 did not walk during the assessment period. The MDS further indicated Resident 30 had functional limitations in ROM on both upper extremities (shoulder, elbow, wrist, hand). During a review of Resident 30's untitled Care Plan, initiated on 2/4/2024, the Care Plan indicated Resident 30 was identified to have an ADL self-care performance deficit related to acute (sudden onset) weakness. The Care Plan goal indicated Resident 30 will maintain current level of function through the review date of 5/4/2024. The Care Plan interventions for Resident 30 included for bilateral upper extremity resting hand splints (supports the wrist and joints of the fingers and thumb to make sure they are positioned correctly) for up to two to six hours or as tolerated, with skin checks, before and after splint application five times a week. The Care Plan interventions included bilateral upper extremities (BUE) and bilateral lower extremities (BLE) exercises in all planes as tolerated five times a week. During a review of Resident 30's Physician's Orders dated 3/7/2024, the Physician's Orders indicated an order was placed for Resident 30 to have BUE and BLE active range of motion ([AAROM] movement at a given joint with a person's own effort and assistance from an external force or another person) exercises in all planes as tolerated every day shift, five times a week, Monday through Friday. During a review of Resident 30's Physician's Orders dated 3/8/2024, the Physician's Orders indicated an order was placed for Resident 30 to have bilateral upper extremity resting hand splints for up to two hours or as tolerated, with skin checks, before and after splint application, every day, five times a week Monday through Friday. During a review of Resident 30's RNA Treatment Flow Sheet dated March 2024, the RNA Treatment Flow Sheet indicated there was no documentation indicating Resident 30's hand splints, had been applied as ordered from 3/25/2024 to 3/29/2024. The RNA Treatment Flow Sheet indicated RNA treatments were not completed for five of the five days ordered. During a review of Resident 30's RNA Treatment Flow Sheet dated March 2024, the RNA Treatment Flow sheet indicated there was no documentation on that Resident 30 received BUE and BLE AAROM exercises on 3/28/2024. The RNA Treatment Flow Sheet indicated RNA treatments were not completed for one of the five days ordered. During a review of Resident 30's Physician's Orders dated 4/1/2024, the Physician's Orders indicated an order was placed for Resident 30 to have BUE and BLE AAROM exercises in all planes as tolerated every day shift, five times a week. During a review of Resident 30's Physician's Orders dated 4/1/2024, the Physician's Orders indicated an order was placed for Resident 30 to have bilateral upper extremity resting hand splints for up to two to six hours or as tolerated, with skin checks, before and after splint application, every day, five times a week. During an interview on 4/6/2024 with Resident 30, Resident 30 stated, I know my order is to have my hands splinted every day, but I have only had my hands splinted once this week and my arm and leg exercises have been done only once this week as well. I know both of my orders are for five times a week, but I don't know why I'm not getting my therapy. I am already having problems with my hands, I can't feed myself, and I'm afraid I'm going to get worse if I don't get my therapy, that is what I'm here for, right? During a follow-up interview on 4/7/2024 at 4:25 p.m. with Resident 30, Resident 30 stated, I didn't receive my therapy yesterday or today. I thought maybe I would get my therapy later in the day yesterday, but it never happened. Today I didn't get my therapy either. I don't know why it wasn't done. D. During a review of Resident 43's Face Sheet, the Face Sheet indicated Resident 43 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including left femur (thigh bone) fracture (broken bone), abnormalities of gait and mobility, and dementia. During a review of Resident 43's History and Physical (H&P) dated 2/22/2024, the H&P indicated Resident 43 did not have the capacity to understand and make decisions. During a review of Resident 43's MDS dated [DATE], the MDS indicated Resident 43's cognition was intact and was usually understood and was usually able to understand others. The MDS indicated Resident 43 required substantial/maximum assistance from staff for sitting to standing, chair to bed/bed to chair transfer, toilet transfer, toileting hygiene, tub/shower transfer, and shower/bathing. The MDS indicated Resident 43 could only walk 10 feet (once standing, the ability to walk 10 feet in a room, corridor, or similar space) with substantial/maximum assistance from staff during the assessment period. The MDS further indicated Resident 43 had lower extremity impairment on one side. During a review of Resident 43's untitled Care Plan, initiated on 3/20/2024, the Care Plan indicated Resident 43 was identified to have an ADL self-care performance deficit related to dementia and history of depression. The Care Plan goal indicated Resident 43 will maintain functional abilities through the review date of 6/18/2024. The Care Plan interventions for Resident 43 included for BUE and BLE ROM exercises in all planes as tolerated five times per week. During a review of Resident 43's Order Summary Report (Physician's Orders), an order was placed on 4/1/2024, for RNA to assist with BUE and BLE exercises in all planes as tolerated every day shift, five times a week. During a review of Resident 43's RNA Treatment Flow Sheet dated April 2024, the RNA Treatment Flowsheet indicated the documentation section was blank on 4/1/2024, 4/5/2024, and 4/7/2024. The RNA Treatment Flow Sheet Indicated RNA treatment was not completed for one out of the five days ordered. During an interview on 4/6/2024 at 3:50 p.m., with the Director of Rehab (DOR) the DOR stated, residents receive RNA services to maintain their ROM, and to prevent further decline. If residents are not getting RNA therapy as ordered by the physician that places the residents at risk for further decline, and contractures (a permanent tightening of the muscles, tendons [a tough band of dense fibrous connective tissue which connects muscle to bone], skin, and nearby tissues which cause the joints to shorten and become very stiff). During an interview with the Director of Nursing (DON) on 4/7/2024 at 5:39 p.m., the DON stated if a resident doesn't receive the RNA services as ordered, the resident is at risk for further decline in mobility. The RNA was not available for interview during the period the recertification survey was conducted. During a review of the facility's RNA Job Description Dated 12/17/2021, the RNA Job Description indicated the essential duties and responsibilities include to perform RNA and rehabilitative procedures as instructed. During a review of the facility's policy and procedure, Physician's Orders, Telephone Orders and Recapitulation Process, undated indicated all physician's orders are in effect for 45 days from the date of the physician's signature unless otherwise specified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to communicate the following consultant pharmacist's recommendations in the Medication Regimen Review ([MRR] a thorough evaluation of the medication list of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) to the physician for two of twelve residents (Resident 20 and 13). The facility failed to: a. Attempt the gradual dose reduction (GDR), of Resident 20's Escitalopram (medication for depression), and b. Gradually discontinue Resident 13's Pantoprazole (medication that reduces acid in the stomach. These deficient practices had the potential to result in Resident 20 and 13's continued use of unnecessary medications which leads to adverse drug reactions and negative health outcomes for the residents. Findings: a. During a review of Resident 20's admission Record (Face Sheet), the Face Sheet indicated Resident 20 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including diabetes mellitus (DM) a chronic disease characterized by elevated levels of blood glucose [or blood sugar] in a bloodstream), end stage renal disease (a condition in which the kidneys [one of a pair of organs in the abdomen which remove waste and extra water from the blood (as urine) and help keep chemicals balanced in the body] lose the ability to remove waste and balance fluids), and depression (a constant feeling of sadness and loss of interest, which stops a person from doing normal activities). During a review of Resident 20's Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated 1/29/2024, the MDS indicated Resident 20's cognition (ability to make decisions of daily living) was intact and had the ability to understand and be understood by others. The MDS indicated Resident 20 received antianxiety (medication used to treat symptoms of anxiety, such as feelings of fear, dread, uneasiness, and muscle tightness, which may occur as a reaction to stress) and antidepressant medication (medication used to treat depression) during the assessment period. During a review of Resident 20's Order Summary Report (Physician's Orders), the Order Summary Report indicated a physician's order dated 8/21/2023 for Escitalopram Oxalate 5 milligrams ([mg] a unit of measure of weight) give one tablet by mouth (PO) one time a day for depression manifested by verbalization of feeling depressed. During a concurrent interview and record review on 4/7/2024 at 5:39 p.m., with the Director of Nursing (DON), Resident 20's MRR dated 2/5/2024 was reviewed. The MRR indicated, Please evaluate the continuous use of Escitalopram 5 mg PO daily for depression since 8/2023. Facility must attempt a gradual dose reduction (GDR) in two separate quarters (with at least one month in between attempts), unless clinically contraindicated. Please check one of the following below to keep the facility in compliance. Upon further review, there were no checks marked to indicate whether the physician agreed or disagreed with the pharmacists' recommendation. The DON stated, she could not find any documentation that the physician was notified of, or responded to the pharmacist's recommendation for Resident 20's GDR attempt on 2/5/2024 for Escitalopram 5 mg for MRR therefore no GDR was performed for Resident 20. b. During a review of Resident 13's admission Record, dated 4/6/2024, the admission record indicated Resident 13 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including gastroesophageal reflux disease ([GERD] occurs when stomach acid repeatedly flows back into the esophagus [tube connecting your mouth and stomach]).without esophagitis (inflammation [response to injury causing redness, swelling, pain , loss of function and heat]of esophagus), muscle weakness, abnormalities of gait and mobility, and sepsis (infection in the blood). During a review of Resident 13's MDS, dated [DATE], the MDS indicated Resident 13 had severe impairment in cognitive skills for daily decision making. The MDS indicated Resident 13 needed substantial assistance from staff, where staff does more than half the effort, with personal hygiene and eating; and Resident 13 was dependent on staff, where helper does all the effort, with oral hygiene, toilet hygiene, showering, and dressing. During a review of Resident 13's Order Summary report, as of 4/7/2024, the report indicated a physician's order dated 12/15/2023, for Pantoprazole Sodium Oral tablet delayed release 40 mg, Give one tablet by mouth (PO) in the morning for GERD. During a review of Resident 13's Note to Attending Physician/ Prescriber, printed on 2/9/2024, the note indicated the MRR for the resident was conducted on 2/5/2024. The note indicated the pharmacist left the following recommendations for Resident 13: 1. Resident 13 has been on Pantoprazole 40 mg PO every morning for GERD prophylaxis since 12/15/2023. 2. Long term proton pump inhibitor ([PPI] medicines that work by reducing the amount of stomach acid made in the lining of the stomach) was associated with many side effects such as osteoporosis/ weakening of bones (increased fall risk), increased infections such as Clostridioides difficile (germ that causes infection of the colon) and pneumonia and rebound gastric acid hypersecretion (recurrence of symptoms due to an increase in gastric acid secretion above pre-treatment levels after stopping PPI therapy). 3.Resident 13 was not on any direct acting oral anticoagulant (blood thinner) to warrant indefinite PPI gastroprotection (serving to protect the stomach from damage). 4. For the physician to evaluate if Pantoprazole can be tapered to Pantoprazole 40 mg PO once every other day for two weeks then discontinued. 5. If prophylaxis (action taken to prevent disease) was necessary, for the physician to consider a different type of medication like Famotidine (medication to treat GERD) 20 mg daily for one month. The note indicated the section, Physician/ Prescriber Response was left blank. The section indicating if the physician agreed, disagreed with the pharmacist's recommendation was left blank. The section for the physician's signature and date was left blank. During a telephone interview on 4/07/2024 at 9:35 a.m. with the pharmacist, the pharmacist stated prolonged Protonix use was not recommended because of all the side effects and especially bad for the bones so Pharm D usually made recommendations to gradually discontinue the medication and recommended alternatives. During an interview and record review on 4/7/2024 at 5:39 p.m., with the DON, Resident 13's Note to Attending Physician/ Prescriber, printed 2/9/2024, was reviewed and the note indicated the MRR for the resident was conducted on 2/5/2024. The note indicated the physician portion of the note was blank. The DON stated the MRR was conducted by the pharmacist on 2/5/2024 and the note was blank because it was not given to the physician for review. The DON stated the charge nurses were responsible for relaying the pharmacists' recommendations to the physician. The DON stated if the recommendations were not relayed to the physicians, residents were at risk for consuming unnecessary medications that can be harmful for the residents. During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Review and Reporting, and dated 2012, the P&P indicated the consultant pharmacist and the care center follow up on the recommendations to verify that appropriate action has been taken. The P&P indicated the recommendation shall be acted upon within a reasonable timeframe. The P&P indicated the physician may accept or act on recommendation or reject recommendation and provide an explanation for disagreement. During a review of the facility P&P, titled Consultant Pharmacist Reports, dated 11/2017, indicated the MRR was conducted to evaluate a resident's response to medication therapy to prevent or minimize adverse consequences related to medication therapy. The P&P indicated that the consultant pharmacist's recommendations are acted upon and documented by the facility staff and/or the prescriber.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the licensed nurses acted upon the Pharmacists' Consultation Report by notifying Resident 20's physician about the pharmacist recommendation to attempt a gradual dose reduction of Escitalopram Oxalate (medication used to treat depression [a constant feeling of sadness and loss of interest, which stops a person from doing normal activities]) 5 milligrams ([mg] a unit of measure of weight) give one tablet by mouth (PO) one time a day for depression manifested by verbalization of feeling depressed. This deficient practice resulted in a recommended gradual dose reduction not performed for Resident 20 and had the potential to place other residents who were receiving antidepressant (medication used to treat depression) medications at risk for use of unnecessary medication. Findings: During a review of Resident 20's admission Record (Face Sheet), the Face Sheet indicated Resident 20 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including diabetes mellitus (DM) a chronic disease characterized by elevated levels of blood glucose [or blood sugar] in a bloodstream), end stage renal disease (a condition in which the kidneys [one of a pair of organs in the abdomen which remove waste and extra water from the blood (as urine) and help keep chemicals balanced in the body] lose the ability to remove waste and balance fluids), and depression. During a review of Resident 20's Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated 1/29/2024 indicated Resident 20 cognition was intact and had the ability to understand and be understood by others. The MDS indicated Resident 20 received antianxiety (medication used to treat symptoms of anxiety, such as feelings of fear, dread, uneasiness, and muscle tightness, which may occur as a reaction to stress) and antidepressant medication during the assessment period. During a review of Resident 20's Order Summary Report (Physician's Orders), the Order Summary Report indicated an order dated 8/21/2023 for Resident 20 to receive Escitalopram Oxalate 5 mg one tablet PO one time a day for depression. During a concurrent interview and record review on 4/7/2024 at 5:39 p.m., with the Director of Nursing (DON), Resident 20's medication regimen review ([MRR] a review of all medications the patient is currently using to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy), dated 2/5/2024 was reviewed. The MRR indicated, Please evaluate the continuous use of Escitalopram 5 mg PO daily for depression since 8/2023. Facility must attempt a gradual dose reduction (GDR) in two separate quarters (with at least one month in between attempts), unless clinically contraindicated. Please check one of the following below to keep the facility in compliance. Upon further review, no checks were marked on indication of disagree or agreeance of the GDR. The DON stated, I can't find the doctor's response to the pharmacist's recommendation for Resident 20's GDR attempt on 2/5/2024 for Escitalopram 5 mg for MRR. No GDR was performed for Resident 20. During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Review and Reporting, and dated 2012, the P&P indicated the consultant pharmacist and the care center follow up on the recommendations to verify that appropriate action has been taken. The P&P indicated the recommendation shall be acted upon within a reasonable timeframe. The P&P indicated the physician may accept or act on recommendation or reject recommendation and provide an explanation for disagreement. During a review of the facility P&P, titled Consultant Pharmacist Reports, dated 11/2017, indicated the MRR was conducted to evaluate a resident's response to medication therapy to prevent or minimize adverse consequences related to medication therapy. The P&P indicated that the consultant pharmacist's recommendations are acted upon and documented by the facility staff and/or the prescriber.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Obtain informed consent (process by which a healthcare provider educates a resident about the risks and benefits, and alternatives of a given procedure or intervention) prior to the administration of psychotropic drugs (medication that affects brain activities associated with mental process and behavior) for one out of four sampled residents (Resident 35) as indicated in the facility's policy and procedure (P&P). 2. Do a Gradual Dose Reduction ([GDR] an attempt to decrease or discontinue psychotropic) medication after three months of starting on the psychotropic medication, unless clinically contraindicated) for two of twelve sampled residents (Resident 5 and Resident 20). These deficient practices resulted in Resident 5 receiving Lorazepam (brand name Ativan, a medication used to treat anxiety [feeling of fear, dread, and uneasiness], and Resident 20 receiving Escitalopram (brand name Lexapro, a medication used to treat depression [a constant feeling of sadness and loss of interest, which stops a person from doing normal activities]) without clinical justification for use, and Resident 35 receiving unnecessary psychotropic medication. Findings: 1. During a record review of Resident 35's admission Record, the admission Record indicated the resident was admitted on [DATE] then re-admitted on [DATE] to the facility with diagnoses that included hyperlipidemia (an unhealthy level of fats in the blood), type 2 diabetes mellitus (a common condition that causes the level of sugar (glucose) in the blood to become too high), fracture (break) of unspecified part of neck of right femur (thigh bone), subsequent encounter for closed fracture with routine healing (occur almost exclusively as a result of a traumatic hip dislocation). During a record review of Resident 35's Minimum Data Set ([MDS] standardized assessment and care planning tool) dated 1/9/2024, the MDS indicated Resident 35 was able to be understood by others and was able to understand. The MDS indicated Resident 35 was dependent (helper does all the effort) for shower/bathe self, lower body dressing, put on and take off footwear, toileting hygiene, substantial/ maximal assistance (helper does more than half the effort) for personal hygiene and upper body dressing. The MDS also indicated no behavior symptom were present. During an observation on 4/6/2024 at 8:46 a.m., with Resident 35 in his bedroom, Resident 35 was observed calm and cooperative. No behaviors were noted. During a concurrent observation and interview on 4/7/2024 at 9:24 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated she was already familiar with Resident 35. CNA 2 further added that sometimes Resident 35 gets agitated when you don't explain to him what you are about to do. But Resident 35 most of the time was cooperative to familiar nurses and staff that already know how to handle Resident 35. During a concurrent interview and record review of the medication administration record (MAR) on 4/7/2024 at 10:36 a.m., with the Infection Preventionist Nurse (IPN), the IPN stated that Resident 35's physician's order specified to call the daughter before administering lorazepam 0.5 milligram ([mg] unit of measure of weight). During a record review of the medication administration record (MAR) for the month of 4/2024, the MAR indicated a physician's order for Lorazepam 0.5 mg by mouth every eight (8) hours as needed for agitation/ restlessness/ anxiety/combative call daughter prior to giving. During a record review of the controlled drug record for Resident 35, the record indicated Resident 35 received Lorazepam 0.5 mg on 3/27/2024 at 9:15 p.m., 3/28/24 at 4:30 p.m., 4/2/2024 at 4:43 p.m., 4/4/2024 at 3:35 p.m. and 4/6/2024 at 8:18 p.m. During a continued interview and record review on 4/7/2024 at 10:48 a.m. with the IPN, the IPN stated that she could not locate in the MAR or in the progress notes that the daughter was informed prior to administering the medication to Resident 35. The IPN stated that the informed consent was not signed and not completed for Resident 35's 0.5 mg Lorazepam, as well. The IPN stated it is the responsibility of charge nurse who got the order from the prescribing Doctor to make sure the consent was completed and signed by the Resident or responsible party (RP) prior to administering the psychotropic medication. During a record review of the informed consent, it was not signed nor dated. The informed consent form was not completed with the medication name and justification of why it is necessary for Resident 35's care and treatment. 2. During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including fibromyalgia (a chronic [long-lasting] disorder which causes pain and tenderness throughout the body, as well as fatigue [low or lack of energy] and trouble sleeping), diabetes mellitus (DM) a chronic disease characterized by elevated levels of blood glucose [or blood sugar] in a bloodstream) type 2, and anxiety disorder. During a review of Resident 5's History and Physical (H&P) dated 7/2/2021, the H&P indicated Resident 5 has the capacity to understand and make decisions. During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5's cognition (ability to make decisions of daily living) was intact and had the ability to understand and be understood by others. The MDS indicated Resident 5 received antianxiety (medication used to treat symptoms of anxiety, such as feelings of fear, dread, uneasiness, and muscle tightness, which may occur as a reaction to stress), opioids (powerful pain-reducing medications), and hypoglycemic medication (used to lower the level of glucose [blood sugar in the blood]) during the assessment period). During a review of Resident 5's Order Summary Report (Physician's Orders), the Order Summary Report indicated an order dated 6/30/2021 for Ativan 0.5 mg one tablet by mouth every 12 hours for anxiety as manifested by overly concern of health affecting day to day activities. 2a. During a review of Resident 20's admission Record (Face Sheet), the Face Sheet indicated Resident 20 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including diabetes mellitus, end stage renal disease (a condition in which the kidneys [one of a pair of organs in the abdomen which remove waste and extra water from the blood (as urine) and help keep chemicals balanced in the body] lose the ability to remove waste and balance fluids), and depression (a constant feeling of sadness and loss of interest, which stops a person from doing normal activities). During a review of Resident 20's MDS dated [DATE], the MDS indicated Resident 20's cognition was intact and had the ability to understand and be understood by others. The MDS indicated Resident 20 received antianxiety (medication used to treat symptoms of anxiety, such as feelings of fear, dread, uneasiness, and muscle tightness, which may occur as a reaction to stress) and antidepressant medication (medication used to treat depression) during the assessment period. During a review of Resident 20's Order Summary Report, the Order Summary Report indicated an order dated 8/21/2023 for Escitalopram Oxalate 5 mg one tablet by mouth (PO) one time a day for depression manifested by verbalization of feeling depressed. During a concurrent interview and record review on 4/7/2024 at 5:39 p.m., with the Director of Nursing (DON), the facility's Psychotropic and Sedative (a medication taken for its calming or sleep-inducing effect)/Hypnotic (medications used which are intended to promote or improve sleep) Utilization by Resident dated 2/1/2024 to 2/9/2024 was reviewed. The Psychotropic and Sedative/Hypnotic Utilization indicated, The following is a comprehensive list of all psychotropic and hypnotic orders for each resident. The next evaluation field is the pharmacist's recommendation for the next formal assessment of the particular order. Upon further review, The Psychotropic and Sedative/Hypnotic Utilization indicated, there was no documentation when the last GDR was done for Resident 5. The DON stated, she did not know when Resident 5 had her last GDR and based on the documentation, Resident 5 never had a GDR since it was ordered on 6/30/3021. During a continued interview and record review on 4/7/2024 at 5:50 p.m., with the DON, Resident 20's Medication Regimen Review ([MRR] a review of all medications the patient is currently using to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy), dated 2/5/2024 was reviewed. The MRR indicated, Please evaluate the continuous use of Escitalopram 5 mg PO daily for depression since 8/2023. Facility must attempt a gradual dose reduction (GDR) in two separate quarters (with at least one month in between attempts), unless clinically contraindicated. Please check one of the following below to keep the facility in compliance. Upon further review, no checks were marked on indication of disagree or agreeance of the GDR. The DON stated she could not find the doctor's response to the pharmacist's recommendation for Resident 20's GDR attempt on 2/5/2024 for Escitalopram 5 mg for MRR. The DON stated that no GDR was performed for Resident 20 During an interview and record review of Resident's 35 medical record for the psychotropic medication with the DON on 4/7/2024 at 6:00 p.m., the DON stated she could not believe that the nurses are administering medication without the consent and not calling the daughter since it specifically indicated on the physician's order. DON stated that consent needs to be completed prior to administering medication since the family might not agree to any psychotropic medications, it is the responsibility of the charge nurse to inform the daughter prior to administering the medication. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medications, revised 12/2023 the P&P indicated, It is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Based on a comprehensive assessment, the facility will ensure that residents who use psychotropic drugs receive GDRs, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. The facility's Interdisciplinary Team (IDT) will review to ensure informed consent was obtained prior to medication use, and attempt/consider a GDR, if appropriate. During a record review of the facility's P&P titled use of chemical restraints revised 05/2014, the P& P indicated no chemical restraint will be utilized without specific physician's order or without a specific consent or without a diagnosed specific condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Ensure monitoring of the medication refrigerator temperature on 4/5/2024 was done per the facility's policy and procedure (P&P) titled, Storage of Medication. This deficient practice had the potential for exposure of the medication to extreme temperatures potentially leading to loss of strength of the medications, causing residents to receive ineffective medication dosages. 2. Ensure Resident 52's one opened Insulin Glargine -Yfgn (brand name Semglee Pen, a medication used to control the level of sugar [glucose] in the blood) and one opened Insulin Lispro Kwikpen (brand name Humalog Kwikpen, a medication used to control the level of sugar in the blood) stored in the medication refrigerator was labeled with an open date per the facility's policy and procedure (P&P) titled, Medications with Special Expiration Date Requirements. This deficient practice of failing to label medications per the manufacturers' requirements and the facility's P&P increased the risk of Resident 52 to have received medication that had become ineffective or toxic due to improper labeling possibly leading to health complications resulting in hospitalization or death. 3. Properly label a multi-dose vial of Tuberculin (brand name Aplisol, a medication used in a skin test (injecting medication into the surface layer of the skin which is measured after 48 to 72 hours) to help diagnose tuberculosis [TB, a potentially serious infectious bacterial disease which mainly affects the lungs]) with an open date per the facility's P&P titled, Medications with Special Expiration Date Requirements. These deficient practices of failing to label medications per the manufacturers' requirements and the facility's P&P increased the risk of all residents receiving medication that had become ineffective or toxic due to improper labeling possibly leading to health complications resulting in hospitalization. 1. During a concurrent interview and record review on 4/6/2024, at 11:19 a.m., with the Licensed Vocational Nurse (LVN) 2, the medication refrigerator Temperature Monitoring Record dated 2/2024 was reviewed. The Temperature Monitoring Record indicated there was no documentation indicating the refrigerator temperature was checked on 4/5/2024. LVN 2 stated that the licensed nurses are responsible for monitoring the refrigerator temperature every day. LVN 2 stated that if the licensed nurses don't check the refrigerator temperature every day, they might not know if the temperature was out of range for the medications which are required to be stored in the refrigerator. During a review of the facility's P&P titled, Storage of Medication, dated 2012, the P&P indicated, medications requiring refrigeration or temperatures between 2°Centigrade ( [C]a unit of measure of temperature) (36 °Fahrenheit [F] a unit of measure of temperature) and 8 °C (46 °F) are kept in a refrigerator with a thermometer to allow temperature monitoring. 2. During a review of Resident 52's admission Record (Face Sheet), the Face Sheet indicated Resident 52 was originally admitted to the facility on [DATE] with metabolic encephalopathy (disturbance of brain function), diabetes mellitus ([DM] a chronic disease characterized by elevated levels of blood glucose [or blood sugar] in a bloodstream) type 2, and seizures (sudden, uncontrolled body movements and changes in behavior which occur because of abnormal electrical activity in the brain). During a review of Resident 52's History and Physical (H&P) dated 4/2/2024, the H&P indicated Resident 52 had the capacity to understand and make decisions. During a review of Resident 52's Minimum Data Set ([MDS] standardized assessment and care-screening tool) dated 4/1/2024 , the MDS indicated Resident 52's cognition (ability to make decisions of daily living) was intact and had the ability to be understood and understand others. The MDS indicated Resident 52 received hypoglycemic (medications used to lower blood sugar) medication during the assessment period. During a concurrent observation and interview on 4/6/2024 at 11:24 a.m., of Station 1's medication refrigerator, with LVN 2, the following medications were found not labeled with an opened date: 1. One Insulin Glargine -Yfgn for Resident 52 was found open but not labeled with an open date. 2. One Insulin Lispro Kwikpen for Resident 52 was found open but not labeled with an open date. According to the manufacturer's product labeling, once opened, Insulin Glargine - Yfgn and Insulin Lispro Kwikpen may be stored in a refrigerator up to 28 days. LVN 2 stated the Insulin Glargine - Yfgn and Insulin Lispro Kwikpen for Resident 52 are opened and not labeled with an open date. LVN 2 stated that Glargine - Yfgn and Insulin Lispro Kwikpen need to be labeled with an open date once opened so the licensed nurses know when they'll expire. LVN 2 stated administering expired medications to residents could cause clinical complications which could possibly result in hospitalization. During a review of the facility's P&P titled, Medications with Special Expiration Date Requirements, dated 2012, the P&P indicated medications should include the date of opening on the container/vial. 3. During a concurrent observation and interview on 4/6/2024 at 11:36 a.m., with the Licensed Vocational Nurse (LVN 2), one multi-dose vial of Tuberculin was found open but not labeled with an expiration date. According to the manufacturer's product labeling, once opened, Tuberculin must be stored in the refrigerator for up to 30 days. LVN 2 stated, Tuberculin needs to be labeled with an open date once the vial is opened so the licensed nurses know when it expires. Administering expired medications to residents could cause clinical complications which could potentially result in hospitalization. During an interview on 4/7/2024 at 5:39 p.m., with the Director of Nursing (DON), the DON stated, that when the licensed nurses open a new multi-dose medication, they must document the open date and an expiration date on the medication. If there is no opened date on the medication, there is no way for the licensed nurses to know when the open or expiration date is and potentially administer expired medication to the residents which could result in a change in condition and unnecessary hospitalization. During a review of the facility's P&P titled, Medications with Special Expiration Date Requirements, dated 2012, the P&P indicated medications should include the date of opening on the container/vial.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility failed to ensure a baseline care plan for one of three sampled residents (Resident 1). Resident 1 did not have a baseline care plan that identified that Resident 1 refused and Resident 1 ' s family member (FM) refused to attend the Integrated Discharge Disciplinary Team (IDT the Residents health care team made up of various specialties). This deficient practice had the potential for Resident 1 to not receive appropriate care and treatment specific to her needs. Findings: During a review of Resident 1 ' s admission Record the admission Record indicated the facility admitted Resident 1 o the facility on 12/31/2022 and readmitted her on 1/25/2024 with diagnoses of essential (primary) hypertension (high blood pressure, pulmonary fibrosis, unspecified (a disease where there is scarring of the lungs making it hard to breath) and rheumatoid arthritis , unspecified (a chronic progressive disease-causing inflammation in the joints). During a review of Resident 1 ' s history and physical (H&P) report dated 12/30/2022, the H&P indicated resident 1 had the ability to understand and make decisions. During a review of the Resident 1 ' s Minimum Data Set (MDS- a comprehensive assessment and care planning tool) dated 1/30/2024, the MDS indicated Resident 1 is dependent (helper does all of the effort. Resident puts forth none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity) with showering, upper and lower body dressing. During a record review of Resident 1 ' s progress notes a late entry entered and dated 1/30/2024 indicated Resident 1 and Resident 1 ' s daughter had declined to attend IDT meetings. During a review of Residents 1 ' s medical record, the medical record indicated the last IDT meeting was on 10/11/2023. During an interview on 3/5/2024 at 1:16 p.m., with the Social Worker (SW), the SW stated facility staff had an ITD meeting with Resident 1 and Resident 1 ' s daughter on 10/11/ 2023. The SW stated this is when Resident 1 and her daughter stated they did not want to attend future IDT meetings. The SW also stated that she I did not explain the risks and benefits of IDT meetings to the Resident 1 or her daughter. The SW stated when the resident and/or the resident ' s representative do not attend IDT meetings, the Residents needs and concerns may not be met. The SW stated there was not a care plan initiated for Resident 1 and her daughter ' s refusal to attending IDT meetings. The SW stated importance of initiating a care plan is to address all resident needs. During an interview on 3/5/2024 at 2:52 p.m., with the Director of Nursing (DON), the DON stated IDT meetings are held upon admission and quarterly (every three months). The DON stated Resident 1 was readmitted on [DATE] and staff had 14 days to complete an IDT meeting with the Resident. The DON also verified the last IDT meeting was on 10/11/2024. The DON stated the Resident and the daughter refused to have any further IDT meetings. The [NAME] stated when the Resident and family refuses to attend IDT meetings the staff is responsible for having an IDT meeting and the family ' s refusal should be care planned. The DON stated it is important to have IDT meetings and to care plan residents ' refusal to attend. She stated we need to address all concerns of the residents and meet their needs. During a review of the facility ' s policy and procedure (P/P) titled Policy/Procedure-Nursing Administration Care Planning Revised 5/2019, the P/P indicated it is the policy of this facility and the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident. Scheduling and preparation of the care plan meeting calendar is completed by the MDS Coordinator and / or Social Services Designee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to readmit one out of two sampled residents (Resident 1) from the General Acute Care Hospital 1 (GACH1) after the resident was cleared by GACH 1 to return to the facility on 9/14/2022. This deficient practice resulted in denial of Resident 1 ' s right to return to the facility where she lived. Findings: During a review of the facility census (daily official count and list of residents admitted to the facility) dated 10/13/2023, the census indicated 40 in house residents and 3 bed holds (if a resident is transferred out, the facility reserves the resident ' s bed for seven days) for residents not in the facility. During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses including cerebral palsy (a condition that affects muscle tone, movement, and coordination that limit activity), dysphagia (difficulty swallowing), muscle weakness, diabetes mellitus (high blood sugar) and urinary tract infection. During a review of Resident 1's History and Physical (H&P), dated 7/29/2023, the H&P indicated Resident 1 does not have capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated 7/13/2023, the MDS indicated Resident 1's cognition (the ability to think, reason, and understand) was severely impaired. The MDS indicated Resident 1 was totaly dependant on two-person assistance for bed mobility, toileting, eating, dressing, and personal hygiene. During a review of Resident 1 ' s order summary dated 9/8/2023, the order summary note indicated Resident 1 had a seven-day bed hold, in place if Resident 1 were to be temporarily transferred out, and readmitted . During a review of Resident 1 ' s Physician ' s orders dated 9/30/2023, the order indicated to transfer Resident 1 to a GACH due to desaturation (abnormally low blood oxygen concentration). During a review of Resident 1 ' s general acute care hospital (GACH) ombudsman (public advocate) notification, dated 10/10/2023, the ombudsman notitification indicated the facility declined to take the resident back on 10/3/2023 because Resident 1 had Candida auris (C- auris: a type of yeast that can cause severe illness and spreads easily) and the facility stated they did not have an isolation room, and could not accomodate Resident 1. During an interview on 10/13/2023, at 12:35 pm, with the Director of Nursing (DON), the DON stated the facility could not readmit Resident 1 due to a C-auris diagnosis. The DON stated Resident 1's C-auris diagnosis required a dedicated room and staff to care for Resident 1 and the facility staff were not trained for this type of isolation. During an interview on 10/13/2023, at 12:45 p.m. with social worker (SW) of the GACH, the SW stated the skilled nursing facility informed her that they don ' t have an isolation bed, so they would not be taking the resident back. During an interview on 10/13/2023, at 1:35 pm, with the admission Coordinator (AC), the AC stated the facility cannot take residents on isolation for Candida auris , because the facility is not equipped for that. A resident with C-auris infection requires a lifetime isolation, and more attention than regular residents, if the residents are sharing rooms or bathrooms, we are exposing our other residents. According the Centers for disease control (CDC: Federal agency that supports the nation's health promotions, prevention and preparedness) if a skilled nursing facility has a resident positive for C-auris, the facility should place the resident on transmission based precautions (measures and tools used to prevent the spread of infections), ensure the appropriate use of gowns and gloves, performe hand hygiene, and the use of appropriate disinfectants. (https://www.cdc.gov/fungal/candida-auris/fact-sheets/cdc-message-infection-experts.html). During a review of the facility ' s policy and procedure (P/P) titled Bed Hold & Readmission revised on 1/2022, the P/P indicated If the resident's hospitalization or therapeutic leave exceeds the bed-hold period of 7 days, the resident may return to the facility to their previous room, if available, or immediately upon the first availability of a bed in a semi-private room, if the resident requires the services provided by the facility; and Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services.

Based on observation, interview, and record review, the facility failed to ensure one of 40 sampled residents (Resident 12) was not provided grooming of fingernails. This deficient practice had the potential to result in Resident 12 being predisposes to microorganisms that can cause infection and a decrease self-esteem. Findings: On 4/7/2022 at 11:00 a.m., a review of the electronic medical record indicated that Resident 12 was admitted at the facility on 7/28/2012 with the diagnosis of Osteomyelitis (inflammation of the bone or bone marrow due to infection) of the Lumbar (lower part of the back) region of the Vertebra (series of small bones forming the backbone); Malignant Neoplasm (a disease in which abnormal cells divide uncontrollably and destroy body tissue) of the Prostate; Unspecified Anemia ( a condition in which the blood does not have enough healthy red blood cells); Chronic Obstructive Pulmonary Disease ( a group of diseases that cause airflow blockage and breathing related problems) with Acute Lower Respiratory Infection; Hypertension (blood pressure higher than normal); Atrial Fibrillation (irregular and very rapid heart rhythm); Localized Edema (swelling caused by excess fluid trapped in body tissues); Asthma (a respiratory condition marked by spasms in the bronchi {any major passages of the lungs}of the lungs, causing difficulty breathing); Congestive Heart Failure (a serious condition in which the heart does not pump blood as efficiently as it should); Recurrent Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities); Dysphagia (difficulty in swallowing); Cognitive Communication Deficit; Hyperlipidemia (abnormally high concentration of fats in the blood); Idiopathic neuropathy (damage of the peripheral nerves where cause is undetermined); Gastroesophageal Reflux (a condition in which the gastric fluid flows backward into the esophagus {a canal that connects the throat to the stomach}); Generalized Muscle Weakness and Lack of Coordination. A concurrent review of the Minimum Data Set (MDS) a standardized assessment and care screening tool, dated 1/10/2022, indicated Resident 12's cognition is mildly impaired and need cuing on recall of date and time orientation, however, the resident was able to make his needs and preferences known. On 4/7/2022 at 10:38 a.m., during a concurrent observation and interview, Resident 12's fingernails on both hands were observed appropriately ¼ inch long and with brown substance underneath. Resident 12 stated he had a shower last week and the activity personnel who trim his fingernails had not been in lately. When asked when was the last time his nails were trimmed, Resident 12 stated he had nail care about 2 to 3 weeks ago. On 4/7/2022 at 10:42 a.m., during an interview with CNA 1, CNA 1 stated grooming of the residents include bed bath, showers, shaving for males, tooth brushing and care/ trimming of fingernails. On 4/8/2022 at 9:49 a.m., during an interview with LVN 1, LVN stated grooming and hygiene is part of the daily activities of living provided by the nursing assistants to the residents. LVN 1 further stated that if residents are not assisted with the activities of daily living, the residents will get sick due to possibility of infection and can have skin concerns such as skin tears/ abrasions due to scratching. On 4/8/2022 at 10:08 a.m., during a concurrent observation and interview, observed Resident 12 awake in bed and watching TV. While Resident 12 was holding the TV's remote control, observed fingernails to both hands still dirty (brown substance under the nails) and untrimmed. Resident 12 verbalized, while looking at his fingernails, They look dirty and it is concerning. On 4/8/2022 at 11:11 a.m., during a record review of the facility's document log titled CNA Skin Observation Binder confirmed with LVN 1 that Resident 12's last documented shower and nail care was 12/6/2021. A concurrent review of the facility's policy titled, Quality of Care- ADL Care dated and revised 11/2007, indicated residents are given treatment and services to maintain or improve his/ her abilities. This policy also indicated under procedures: (2) residents who are unable to carry out activities of daily living (ADL) will receive assistance as needed.

Based on observation, interview, and record review, the facility failed to develop a care plan for activities for one of 40 sampled residents (Resident 12). This deficient practice had the potential to negatively impact the resident's physical, cognitive and emotional health. Findings: On 4/5/2022 at 1:00 p.m., a review of the electronic medical record indicated that Resident 12 was admitted at the facility on 7/28/12 with the diagnosis of Osteomyelitis (inflammation of the bone or bone marrow due to infection) of the Lumbar (lower part of the back) region of the Vertebra (series of small bones forming the backbone); Malignant Neoplasm (a disease in which abnormal cells divide uncontrollably and destroy body tissue) of the Prostate; Unspecified Anemia ( a condition in which the blood does not have enough healthy red blood cells); Chronic Obstructive Pulmonary Disease ( a group of diseases that cause airflow blockage and breathing related problems) with Acute Lower Respiratory Infection; Hypertension (blood pressure higher than normal); Atrial Fibrillation (irregular and very rapid heart rhythm); Localized Edema (swelling caused by excess fluid trapped in body tissues); Asthma (a respiratory condition marked by spasms in the bronchi {any major passages of the lungs}of the lungs, causing difficulty breathing); Congestive Heart Failure (a serious condition in which the heart does not pump blood as efficiently as it should); Recurrent Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities); Dysphagia (difficulty in swallowing); Cognitive Communication Deficit; Hyperlipidemia (abnormally high concentration of fats in the blood); Idiopathic neuropathy (damage of the peripheral nerves where cause is undetermined); Gastroesophageal Reflux (a condition in which the gastric fluid flows backward into the esophagus {a canal that connects the throat to the stomach}); Generalized Muscle Weakness and Lack of Coordination. A concurrent review of the Minimum Data Set (MDS) a standardized assessment and care screening tool, dated 1/10/2022, indicated Resident 12's cognition is moderately impaired and need cuing on recall of date and time orientation, however, the resident is able to make his needs and preferences known. The Minimum Data Set indicated the resident loves to be around animals and pets. It is important to the resident to do his favorite activities and do things with groups of people. During an observation and concurrent interview on 4/5/2022 at 10:12 a.m., Resident 12 was observed in bed with eyes closed. Resident 12 opened his eyes when greeted. The resident stated, I have been in this facility for 3 years and I have not been out of bed for a while. Resident 12 stated, with a sad facial expression, he only watch movies in his room and verbalized That is all I have for now. Resident 12 concluded the interview and stated he would like to get out of bed and join Bingo in the dining room. During an observation on 4/6/2022 at 8:00 a.m., and 1:00 p.m., Resident 12 observed in bed asleep and no activity staff at the bedside. During an observation on 4/7/2022 at 8:00 a.m., and 2:46 p.m., Resident 12 observed in bed asleep and no activity staff in the room. On 4/7/2022 at 10:26 a.m., during an interview with CNA 1, CNA 1 stated Resident 12 only watches TV and the Activities personnel sometimes come and play cards with the resident 12. On 4/7/2022 at 2:57 p.m., during an interview with the Activity Director (AD), the AD stated the Activity Assistant (AA) perform activity rounds in the morning between 9:00 a.m. to 10:30 a.m. with the residents confined in bed and residents in the yellow zone. AD further stated the activities offered for these residents are nail care, reading materials, radio/TV, sensory stimulation but she does not know how long the Activity Assistant spend time with each resident. On 4/7/2022 at 3:14 p.m., during an interview with the AA, the AA stated she provides radio listening, reading materials, coloring and crosswords to residents confined in bed and residents in the yellow zone. AA further stated there are 18 residents in this group and she spends 10 minutes with each resident from 9:00 a.m. to 10:00 a.m., which is the daily activity routine. AA concluded the interview and stated activity log is not updated in the electronic medical record and she is unable to provide a log for the residents' activities. On 4/8/2022 at 9:16 a.m., during an interview with the Director of Nurses (DON), the DON stated there is no excuse that residents are not offered activities. The DON further stated all residents must be provided activities consistently while acknowledging their choice of activity. The DON concluded the interview by stating if residents are not provided activities, they can decline in general and will feel left out. On 4/8/2022 at 11:51 a.m., during an interview and concurrent record review with the AD, she stated that she has records of all the residents activities. The AD showed the Task Section, through the electronic medical record, and it indicated an Independent and a one on one activity for Resident 12. Resident 12 response and tolerance to the activity was not documented. On 4/8/2022 at 12:30 p.m., a review of the facility's electronic medical record was conducted and a specific and individualized care plan of activities for Resident 12 was not documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and services to maintain or prevent further decrease in joint range of motion (ROM, full movement potential of a joint) and/or mobility for one of 12 sampled residents (Resident 6). The facility failed to ensure that Resident 6 received Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) treatment five times a week as ordered. This deficient practice had the potential for Resident 6 to have an avoidable decline in range of motion and mobility. Findings: A review of Resident 6's admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including chronic pain syndrome (persistent pain that lasts over three months), hypertensive heart disease without heart failure (heart disease that occurs due to long periods of high blood pressure), and morbid obesity (health condition involving excessive body mass). A review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 01/05/2022 indicated the resident had intact cognitive skills for daily decision making and required extensive assistance (resident involved in activity with staff assistance for weight bearing support) from staff for bed mobility (moving in bed to and from different positions such as side to side), transfers (moving from one surface to another such as bed to chair), dressing, toileting, and personal hygiene. MDS indicated Resident 6 was totally dependent (full staff performance) on staff for bathing and did not walk during the assessment period. The MDS further indicated that Resident 6 had functional limitations in ROM on one upper extremity (shoulder, elbow, wrist, hand) and one lower extremity (hip, knee, ankle, foot). A review of Resident 6's undated care plan titled ADL Self Care Performance Deficit indicated the resident was at high risk for further decline in ROM. The care plan indicated for RNA to assist wit active range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) for bilateral (both) lower extremity (LE) as tolerated once a day, five times a week. A review of the Resident 6's physician's order dated 5/12/2021, the order indicated for RNA for perform AAROM exercises for bilateral lower extremities as tolerated once a day, five times a week. On 04/06/2022 at 03:27 p.m., a review of the RNA treatment Flow Sheets for December 2021, January 2022, February 2022, March 2022, and April 2022, treatment notes indicated the following: 1. December 2021: X noted on 12/4, 12/5, 12/6, 12/7, 12/11, 12/12, 12/13, 12/14, 12/18, 12/19, 12/20, 12/21, 12/25, 12/26, 12/27, 12/28. Blank boxes noted on 12/3, 12/17, and 12/29. RNA treatment not completed for 11 days. 2. January 2022: X noted on 1/1, 1/2, 1/3, 1/4, 1/8, 1/9, 1/10, 1/11, 1/15, 1/16, 1/17, 1/18, 1/22, 1/23, 1/24, 1/25, 1/29, 1/30, and 1/31. RNA treatment not completed for 9 days. 3. February 2022: X's noted on 2/1, 2/5, 2/6, 2/7, 2/8, 2/12, 2/13, 2/14, 2/15, 2/17, 2/19, 2/20, 2/21, 2/22, 2/26, 2/27, and 2/28. RNA treatment not completed for 9 days. 4. March 2022: X's on 3/1, 3/5, 3/6, 3/7, 3/8, 3/12, 3/13, 3/14, 3/15, 3/19, 3/20, 3/21, 3/22, 3/26, 3/27, 3/28, and 3/29. RNA treatment not completed for 9 days. During an interview and record review on 04/07/2022 at 01:52 p.m., Restorative Nursing Aide 1 (RNA 1) reviewed Resident 6's physician's orders and confirmed an order for RNA to conduct BLE AAROM as tolerated once a day five days a week. RNA 1 reviewed Resident 6's RNA treatment flow sheets for December 2021, January 2022, February 2022, March 2022, and April 2022 and stated an X in the box or a blank box meant that the RNA treatment was not completed that day. RNA 1 stated that staff initials in a box indicated that RNA treatment was completed that day. RNA 1 stated that the X in all the Monday and Tuesday boxes were incorrect and should instead be on Saturday and Sunday because RNA treatments were not provided on Saturday or Sunday. RNA 1 confirmed that Resident 6 did not receive RNA treatment five days a week as ordered. RNA 1 stated that if a resident did not receive RNA treatments ordered by the physician, the resident was at risk for pressure sores (Injury to skin and underlying tissue resulting from prolonged pressure on the skin) and contractures (loss of motion of a joint). During an interview with the Director of Rehab (DOR) on 04/07/2022 03:15 p.m., the DOR stated that potential outcomes of a resident not receiving RNA services as ordered would put the resident at risk for a change in a resident's condition and a decline in function. During an interview with the Director of Nursing (DON) on 04/08/2022 at 1:39 p.m., the DON stated that the facility did not have a policy regarding following physician's orders as prescribed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to clarify physician orders for an accurate dose of MiraLAX AX (medication used to treat occasional constipation) for one of three residents (Resident 38). This deficient practice had the potential to result in Resident 38 having unintended complications related to bowel patterns that can lead to constipation. Findings: During an observation on 4/7/2022 at 8:46 a.m., in front of resident 38's room, Licensed Vocational Nurse (LVN) 5 was observed preparing MiraLAX for administration to Resident 38. LVN 5 poured 1 cap full in a cup of 6 ounces of water. During a review of Resident 38's Order Summary Report (OSR), dated 6/30/2021, the OS indicated, MiraLAX Powder (Polyethylene Glycol 3350) Give 25 gram (gm) by mouth two times a day for bowel management dissolve with 6-8 ounces of water or juice. During a concurrent observation and interview on 4/7/2022, at 11:27 a.m., with LVN 5 in front of medication cart, MiraLAX bottle directions printed as, 1 cap full equal to 17 mg. LVN 5 stated order for MiraLAX is 25 mg, only gave one cap full which equaled to 17 mg, if given two cap fulls then it would equal to 34 mg. LVN 5 stated, When the dose is different than what is on the bottle the doctor or pharmacist need to be called to verify the dosage. During a review of Resident 38's admission Record AR, AR indicated Resident 38 was admitted to the facility on [DATE] with diagnosis including hypothyroidism (condition in which your thyroid gland doesn't produce enough of certain crucial hormones), type 2 diabetes mellitus (disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), major depressive disorder (mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts), bilateral primary osteoarthritis (degeneration of joint cartilage and the underlying bone) of knee. During a review of the Minimum Data Set Assessment (MDS), a standardized assessment and care screening tool, dated 2/17/2022, indicated Resident 38 was cognitively intact. During an interview on 4/7/2022, at 12:07 p.m., with LVN 5, LVN 5 stated, Staff should have caught the discrepancy since 6/21/2022. Pharmacy said MiraLAX is not available in 25 gm. During a review of Resident 38's Medication Administration Record (MAR), dated March 2022, the MAR indicated, Resident 38 was administered 25 gm of MiraLAX. During an interview on 4/8/2022, at 6:14 p.m., with the Director if Nursing (DON), the DON stated, MiraLAX is not effective if the dosage is not given per physician order. During a review of the facility's policy and procedure (P&P) titled Medication Administration revised 5/2007, the P&P indicated prior to administering the resident's medication, the nurse should compare the drug and dosage schedule on the resident's MAR with the drug label. NOTE: If there is any reason to question the dosage or the schedule, the nurse should check the physician's orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Administer two medications necessary to treat Resident 12's anemia. The deficient practice had the potential to result in a delay of alleviating of or worsening of Resident 12's anemia. 2. Replace inhalation (INH) solution medication in the Emergency Kit ([E-kit] medications needed immediately) in a timely manner, taken for Resident 202 for Nurses Station (Station 1). The deficient practice had the potential to result in a delay in administration of necessary emergency medication for the residents. 3. Properly document resident names on E-kit slips at one of two Nurses Stations (Station 1). The deficient practice had the potential to result in unclear communication which could have led to issues with follow-up evaluations and treatment. Findings: 1. During a concurrent observation and interview on 4/6/2022, at 1:46 p.m., at Station 1, with Director of Nursing (DON), there was a full dose syringe of Epogen (medication used to treat low red blood cell levels) and a full dose of Procrit (medication used to treat low red blood cell levels) for Resident 12 was found. One bottle had a dispensed date of 3/15/2022, and the other of 3/28/2022. DON stated she was not sure if medications were given and will check 3/2022 Medication Administration Record (MAR). During a review of Resident 12's admission Record (AR), the AR indicated, Resident 12 was admitted to the facility on [DATE], with diagnoses not limited to anemia (condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should), and osteomyelitis (inflammation or swelling that occurs in the bone). During a review of Resident 12's Minimum Data Set ([MDS] a standardized comprehensive assessment and care screening tool), dated on 1/10/2022, the MDS indicated Resident 12 was cognitively(ability to make decisions of daily living) moderately impaired. During a review of Resident 12's Order Summary (OS), OS indicated, Resident 12 had an order for Procrit Solution 40000 Unit (U)/Milliliter (ML) (Epoetin Alfa) Inject 40000 unit subcutaneously ([SQ]beneath, or under, all the layers of the skin) one time a day every Monday for ANEMIA. During a concurrent interview and record review, on 4/07/2022, at 10:55 a.m., with DON, DON presented copies of pharmacy delivery receipts for Resident 12's Procrit (Epogen) since order date 3/15/2022. The order indicated Procrit 40,000 U every Monday. DON stated the pharmacy delivered a total of 3 doses of Procrit (dates: 3/16/22 x 1 dose, 3/21/22 x 1 dose, and 3/28/22 x 1 dose). DON acknowledged that there were 2 doses of Procrit in the medication room refrigerator during observation of 4/6/2022. During a concurrent interview and record review, on 4/7/2022, at 10:55 a.m., with DON, DON presented a copy of Resident 12's Medication Administration Record (MAR), DON stated the nurses documented that Resident 12 received one dose each on 3/21/2022, 3/28/2022, & on 4/4/2022. DON stated there should not have been two doses remaining when the facility received three doses total and MAR indicated three doses had been given. DON stated Procrit was not in the E-kit medications and the facility had no other resident on the same medication during the same period. During a review of Resident 12's Lab Results Report (LRR), LRR for hemoglobin ([HGB]a protein in the red blood cells) and hematocrit, (reflects the percentage of blood volume that is composed of red blood cells) related to total blood cell count. Resident 12's levels were all below the normal reference range. LRR indicated reference range indicated hemoglobin 13.5- 17.5 gram (gm) per deciliter (dl), and hematocrit 40.0- 51.0 percent (%). Resident 12's LRR indicated the following: 3/1/2022: Hemoglobin: 11.0 gm/dl Hematocrit: 33.8 % 3/21/2022: Hemoglobin: 9.2 gm/dl Hematocrit: 28.3 % 3/28/2022: Hemoglobin: 9.2 gm/dl Hematocrit: 28.3 % 4/6/2022: Hemoglobin: 9.2 gm/dl Hematocrit: 28.9 % 4/7/2022: Hemoglobin: 9.2 gm/dl Hematocrit: 28.6 % During a review of Resident 12's Care Plan (CP), no date, the CP indicated, Resident 12's goals, will maintain lab values within acceptable parameters per MD (medical doctor) through review date, will remain free if signs and symptoms or complications related to anemia through review date. The CP interventions indicated, give medications as ordered. Procrit Solution 40000 u/ml (Epoetin Alfa) inject 40000 U SQ one time a day every Monday for anemia, hold of HGB level more than 10. During a review of the facility's policy and procedure (P&P) titled Medication Administration revised 5/07, the P&P indicated, Medications must be administered in accordance with the written orders of the attending physician. Unless otherwise specified by the residents attending physician, routine medications should be administered as scheduled. Should a drug be withheld, refused, or given other than at the scheduled time, the nurse must initial and circle the MAR space provided for that particular drug. The nurse must enter an explanatory note on the reverse side of the MAR when drugs are withheld, refused, or given other than at scheduled times. 2. During a concurrent observation and interview on 4/6/2022, at 1:46 p.m., with DON, in the nurse's station one medication room, there was a cabinet under the sink labeled E-kit. From inside the cabinet, DON pulled out a stack of E- kits. One of them labeled as sub- acute E-kit, had a green zip tie as all the other ones had red zip tie. DON stated green zip tie indicated it was opened prior. DON opened the E-kit with green zip tie and there was an E-kit Usage Kit Slip dated 3/23/2022 for Resident 202, Ipratropium 0.5/2.5 ml x 1 and abutter x 1. DON confirmed it had been nine days, since the medication was used from the E-Kit. DON confirmed the mediations should have been replaced in the E-Kit but was not. DON stated there was a potential for a delay in resident's care when E- kits are not replenished as soon as possible. During a review of Resident 202's admission record, the record indicated, Resident 202 was admitted to the facility on [DATE], with diagnoses not limited to pulmonary hypertension (a type of high blood pressure that affects the arteries in the lungs and the right side of the heart), sepsis (body's extreme response to an infection), kidney failure (condition in which the kidneys stop working and are not able to remove waste and extra water from the blood or keep body chemicals in balance), and heart failure (condition in which the heart can't pump enough blood to meet the body's needs). During a review of the facility's P&P titled Medication Ordering and Receiving From Pharmacy Provider dated 9/10, the P&P indicated, Inform the pharmacy of items used from the emergency kit. This can be done immediately by fax or telephone during normal pharmacy hours. This will signal the pharmacy to replace the E-kit or item, within 72 hours as applicable per state law. 3. During a concurrent interview and record review, on 4/6/2022, at 1:46 p.m., with DON, in nurse's station one medication room, there was an E-kit Usage folder. DON confirmed that four out of 84 E-kit Usage slips were incomplete such as missing resident names. During a review of the facility's P&P titled Medication Ordering and Receiving from Pharmacy Provider dated 9/10, the P&P indicated, Upon removal of any medication or supply item from the emergency kit, the nurse documents the medication or item used on an emergency kit log. Items to be documented include: Resident's name.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to communicate the consultant pharmacist's recommendation in the Medication Regime Review (MRR), (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 the physician for one of five residents (Resident 16) for unnecessary medications. This deficient practice resulted in a recommended gradual dose reduction not performed for Resident 16, with a potential for adverse drug reaction for the resident. Findings: a. During a review of the admission face sheet, the face sheet indicated Resident 16 was admitted to the facility on [DATE], with diagnoses not limited to diverticulitis (infection or inflammation of pouches that can form in your intestines), depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (feeling of fear, dread, and uneasiness). During a review of Resident 16's Minimum Data Set ([MDS] a comprehensive assessment and care screening tool), dated 2/11/2022, MDS indicated Resident 16 was moderately cognitively (ability to make decisions of daily living) impaired. During a review of Resident 16's physicians' orders, dated 2/6/2019, the order indicated, Lexapro Tablet 10 milligrams (gm) (Escitalopram Oxalate) Give one tablet (tb) by mouth (PO) one time a day for depression manifested by verbalization of sadness. During a concurrent interview and record review on 4/8/2021, at 12:41 p.m., with Director of Nursing (DON), Resident 16's MRR, a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy), dated 2/2/2022 was reviewed. The MRR indicated, Please evaluate the continuous use of Lexapro 10 milligrams PO daily for depression since 7/2021. Facility must attempt a gradual dose reduction (GDR) in two separate quarters (with at least one month in between attempts), unless clinically contraindicated. Please check one of the following below to keep the facility in compliance. Upon further review, no checks were marked to indicate disagree or agreeance of GDR. DON stated, Couldn't find doctor's response to pharmacist recommendation for resident's GDR attempt 2/2/2022 for Lexapro 10 mg for MRR. DON stated that no GDR performed. During a review of the facility policy and procedure (P&P), titled Consultant Pharmacist Reports, dated 11/2017, indicated the MRR was conducted to evaluate a resident's response to medication therapy in order to prevent or minimize adverse consequences related to medication therapy. The policy and procedure indicated that the consultant pharmacist's recommendations are acted upon and documented by the facility staff and/or the prescriber. During a review of the facility's P&P titled, Medication Regimen Review and Reporting, dated 9/10, the P&P indicated The consultant pharmacist and the care center follow up on the recommendations to verify that appropriate action has been taken. Recommendation shall be acted upon within a reasonable timeframe. Physician may accept or act on recommendation or reject recommendation and provide an explanation for disagreement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of seven residents (Resident 16), who had a physicans order for insulin (used to control the level of the sugar-glucose in the blood) according to a sliding scale (a dosing regimen that prescribes how much insulin to give for different levels of blood sugar) was free from significant medication error when insulin was potentially omitted. This deficient practice placed the resident at risk of inadequate blood sugar management, which can cause hyperglycemia (high blood sugar), or hypoglycemia (abnormal low blood sugar) which untreated can lead to complications, such as eye, kidney, or heart disease, nerve damage, loss of consciousness and even death. Findings: During a review of the admission face sheet, the face sheet indicated Resident 16 was admitted to the facility on [DATE], with diagnoses of type 2 diabetes mellitus ([DM] impairment in the way the body regulates and uses sugar [glucose] as a fuel), chronic kidney disease (kidneys are damaged and cannot filter blood the way they should), and hyperlipidemia (blood has too many lipids [ fats], such as cholesterol and triglycerides). During a review of Resident 16's Minimum Data Set ([MDS] a comprehensive assessment and care screening tool), dated 2/11/2022, MDS indicated Resident 16 was moderately cognitively (ability to make decisions of daily living) impaired. During a review of Resident 16's order, dated 2/23/2021, the order indicated as follows: Humulin R Solution 100 Unit/ml (Insulin Regular Human) Inject as per sliding scale: If 70 milligram (mg)/deciliter (dl)- 150 mg/dl= 0 units, Blood Sugar (BS) less than 70 mg/dl notify MD; 151 mg/dl -200 mg/dl= 2 unit 201 mg/dl-250 mg/dl= 4 units 251 mg/dl -300 mg/dl=6 units 301 mg/dl- 350 mg/dl=8 units 351 mg/dl-400 mg/dl=10 units BS more than 400 mg/dl= 12 units then notify the physician, subcutaneous (beneath, or under, all the layers of the skin) two times a day for DM. During a concurrent interview and record review, on 4/8/2022, at 9:15 a.m., with Minimum Data Set Nurse and Director of Nursing (DON), Resident 16's Medication Administration Record (MAR), dated 3/2022 was reviewed. The MAR indicated, Resident 16 had an omitted BS check on 3/27/2022 for 0630. MDS stated, There are no notes on missing blood glucose for 3/27/2022. DON stated, There shouldn't be any blanks and should be documented somewhere regarding resident blood glucose results. If missing nurse probably checked it but didn't document it or didn't do it. During a review of Resident 16's Plan of Care developed on 11/7/2020, the care plan interventions indicated, Fasting Serum Blood Sugar as ordered by doctor. During a review of the facility's policy and procedure (P&P) titled Medication Administration revised 5/07, the P&P indicated, Medications must be administered in accordance with the written orders of the attending physician. Should a drug be withheld, refused, or given other than at the scheduled time, the nurse must initial and circle the MAR [Medication Administration Record] space provided for that particular drug. The nurse must enter an explanatory note on the reverse side of the MAR when drugs are withheld, refused, or given other than at scheduled times.

Based on observation, interview and record review, the facility failed to maintain proper temperature controls for medications requiring storage in the medication room. This deficient practice had the potential of medication exposure to extreme temperatures in the medication storage room in station 1, potentially leading to loss of strength of the medications, causing residents to receive ineffective medication dosages. Findings: During a concurrent observation and interview on 4/6/2022, at 1:46 p.m., with Director of Nursing (DON), in station 1 medication room, the medication room did not have a room thermometer. DON stated, she did not know the temperature in the medication room because there was no thermometer as they do not monitor the inside of the medication room. During a review of the facility's policy and procedure (P&P) titled, Medication Storage dated 9/10, the P&P indicated, Medications requiring storage at 'room storage' are kept at temperatures ranging from 15°C (59°F) to 30°C (86°F).

Based on observation, interview and record review, the facility failed to ensure expired food was not stored in the kitchen and accessible to be used in preparing foods in accordance with professional standards for food service safety. This practice had the potential to result in the residents ingesting expired food and can result in foodborne illnesses and can lead to symptoms such as nausea, vomiting, stomach cramps, and diarrhea including decrease in food flavoring and taste. Findings: a). During an observation on 4/5/2022 at 8:26 a.m. of the spice shelf, there was an egg shade pure food color bottle with an open date of 2/10/2021, with no expiration date. The egg shade pure food color, was missing on the Dry food storage guidelines. There was a rum flavor liquid with an open date of 2/10/2021, with no expiration date. The rum flavor liquid was missing on the Dry food storage guidelines. There was poultry seasoning with an open date of 5/10/2021, with a best by date of 10/6/2021. During an interview on 4/6/2022 at 2:22 p.m. with DS, DS stated, for all the products we check the best by date and expiration date. We also, check the expiration sheet for manufacture recommendations and we check the expiration date four times a week. We use the FEFO system (First Expired First Out). If we use the product beyond the best by date the product is decreased in quality and the taste will not be the same. We will not serve that to the residents because it will not have a good flavor. Every time, we use a new box we label it with the date we received it and the date the bottle was open. We also check the expiration date on the bottles, but we do not make any notes for the best by date. DS stated, if we serve a resident expired food or products the resident can get sick, not only one resident but all the residents in the facility. If we do not see the expiration date on the bottle, we check the manufacturer paper and if there is no expiration date showing, we discard the product because we would not know when it was expired. DS stated, I will call the manufactures for information about the products and the expiration date. a. During an observation on 4/6/2022 at 11:51 p.m. in the dry food storage room, the surveyor observed the following: 1. Pistachio flavor pudding was opened on 7/8/2021 with a best by date of 3/10/2022. 2. Gelatin orange was opened on 12/8/2021, with no expiration date. 3. During a record review of Dry food storage guidelines dated 2017, indicated opened gelatin orange can only be kept on the shelf for three months. 4. Lemon pudding was opened on 4/24/21 with a best by date of 2/17/2022. During an interview on 4/7/2022 at 2:04 p.m. with DS, DS stated, we do not have a log system to monitor products that are ready to be expired or products past the best by date. DS stated, The only thing, I do is to rotate the products. The boxes that were found with pistachio and lemon pudding with the best by date past due I would eventually find it. I think it was a mistake not checking the best by date. If the best by date was past, I will not serve those products to resident because the quality is lower, and the flavor will decrease. I do not have a proof when the last time lemon or pistachio pudding, was served but I think it was in January. DS further stated we receive new products twice a week. If I am not here the head cook receives those. DS stated, I oversee the expiration date and best by date on products. During a review of the facility's policy and procedure titled General Receiving of Delivery of Food and Supplies dated 2018, the P&P indicated food deliveries will be inspected to assure high quality food and supplies. They are to be received in proper conditions. Carefully inspect deliveries for proper labeling, temperature, and appearance. Label all items with the delivery date or a use-by date. During a review of the facility's policy and procedure titled Storage of Food and Supplies dated 2017, the P&P indicated, food and supplies will be stored properly and in a safe manner. Labels should be visible, and the arrangement should permit rotation of supplies so the oldest items will be used first. All food will be dated-month, day, year. All food products will be used per the times specified in the Dry Food Storage Guidelines No food will be kept longer than the expiration date on the product.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide physical therapy (PT) and occupational therapy (OT) evaluations as ordered for one of 12 sampled residents (Resident 6). This deficient practice had the potential to prevent Resident 6 from maximizing her functional mobility (the way in which one moves in the environment to complete everyday tasks), joint range of motion (ROM, full movement potential of a joint), and activities of daily living (ADL, basic activities such as eating, dressing, toileting) while residing in the facility. Findings: A review of Resident 6's admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including chronic pain syndrome (persistent pain that lasts over three months), hypertensive heart disease without heart failure (heart disease that occurs due to long periods of high blood pressure), and morbid obesity (health condition involving excessive body mass). A review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 01/05/2022 indicated that the resident was cognitively intact. MDS indicated that Resident 6 required extensive assistance (resident involved in activity with staff assistance for weight bearing support) for bed mobility (moving in bed to and from different positions such as side to side), transfers (moving from one surface to another such as bed to chair), dressing, toileting, and personal hygiene. Resident 6 required total dependence (full staff performance) for bathing and did not walk during the assessment period. The MDS further indicated that the resident had functional limitations in range of motion on one upper extremity (shoulder, elbow, wrist, hand) and one lower extremity (hip, knee, ankle, foot). A review of Resident 6's undated care plan titled Activities of Daily Living (ADL) Self Care Performance Deficit indicated that the resident was at high risk for further decline in range of motion. The care plan indicated for PT and OT evaluation and treatment per physician's order under interventions/tasks. A review of Resident 6's physician's orders indicated an order dated 01/26/2022 for PT and OT evaluation and treatment. During an interview and record review on 04/06/2022 at 4:00 p.m., the Director of Rehabilitation Services (DOR) reviewed Resident 6's clinical record and confirmed physician's orders for PT and OT evaluations on 01/26/2022. The DOR stated she was not aware of PT and OT evaluation and treatment orders dated 01/26/2022. The DOR reviewed Resident 6's rehabilitation therapy records and confirmed Resident 6 was last evaluated by PT on 04/13/2021 and by OT on 04/15/2021. The DOR stated that PT and OT evaluations were not done as ordered. During an interview on 04/07/2022 at 10:54 a.m., the DOR stated if a resident did not receive PT and OT as ordered by the physician, then it put the resident at risk for a change in a resident's condition and a decline in function. During an interview with the Director of Nursing (DON) on 04/08/2022 at 1:39 p.m., the DON stated that the facility did not have a policy regarding following physician's orders as prescribed.

Based on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship by failing to: 1). Ensure Resident 46 was prescribed an antibiotic drug without meeting the criteria, after being screened for a urinary tract infection UTI (common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract), and failing to provide a McGeer's criteria surveillance list. 2). Provide a McGeer's criteria surveillance documentation for (Resident 198). Resident 198 was prescribed antibiotic drug without following McGeer's surveillance. These deficient practices had the potential to result in antibiotic resistance (not effective to treat infection) due to unnecessary or inappropriate antibiotic use. Findings: a). During a review of the admission record for Resident 46 dated 3/21/2022, the record indicated Resident 46 had diagnosis that included traumatic subdural hemorrhage without loss of consciousness subsequent encounter (It is caused by a traumatic head injury, such as a blow to the head or a fall. This indicates that there is significant bleeding inside the skull, and pressure against the brain), radiculopathy, lumbar region (disease involving the lumbar spinal nerve root. This can manifest as pain, numbness, or weakness of the buttock and leg), other cervical disc degeneration, unspecified cervical region (It develops when one or more of the cushioning discs in the cervical spine starts to break down due to wear and tear). During a review of Residents 46's Minimum Data Set (MDS -a resident assessment tool) dated 3/25/2022, the MDS indicated Resident 46 has the capacity to understand and to make decisions and was always continent of bladder and bowel. During a review of the Interact Change in Condition Evaluation for Resident 46 dated 4/2/2022, the evaluation indicated the resident had symptoms of a burning sensation when urinating. During a review of Resident 46's physician's order dated 4/2/2022, the order indicated to administer Macrobid (antibiotics) capsule 100 milligrams (mg) give one capsule by mouth two times a day for UTI. The physicians order further indicated Macrobid was started on 4/2/2022 and discontinued on 4/7/2022. During a review of the Infection Report Surveillance form, the Surveillance form indicated that both criteria 1 and 2 must be present for antibiotics use. 1. Acute dysuria or acute pain, swelling, or tenderness of the testes, epididymis, or prostate 2. One of the following microbiologic sub criteria a. At least 100,000 cfu/ml of no more than 2 species of microorganism in a voided urine sample b. At least 100 cfu/ml of any number of organisms in a specimen collected by in and out catheter. Resident 46 only had a new onset of acute dysuria, which was one sub criteria sign and symptom of a urinary tract infection. The urine culture results received on 4/4/2022 indicated No growth after 48 hours and did not meet criteria. During an interview on 4/8/2022 at 2:14 p.m. with IP/DSD, IP/DSD stated, we use McGeer's criteria whether the resident meets criteria or not. We will notify the MD. Fill out the McGeer's Criteria form for Infection Surveillance Checklist before the antibiotic start. IP stated the medications for resident 46 were stopped as of today. The start date was 4/3/2022. The resident received six doses. Before an antibiotic is initiated, staff need to make sure the resident meets the criteria. I don't have a checklist. The DSD ensures this is checked, and the backup is the DON. There is no McGeer's surveillance list for Resident 46. During an interview on 4/8/2022 at 2:29 p.m. with DON, DON stated, it is important, to have the McGeer's checklist to make sure the resident is not getting an antibiotic without an actual infection to treat, because it creates resistance and possible other infections. b). During a review of the admission record for Resident 198 dated 4/1/2022, the admission record indicated Resident 198 had diagnoses that included sepsis, unspecified organism (classified as a condition due to bacteria when it can also be due to viruses, fungi, or protozoa). Methicillin resistant staphylococcus aureus infection (MRSA) (a bacterium that causes infections in different parts of the body), cellulitis of left lower limb (a common, potentially serious bacterial skin infection). During a review of Resident 198's initial admission record dated 4/1/2022 indicated Resident 198 does not have the capacity to understand and make decisions. During a review of the physician's orders for Resident 198 dated 4/1/2022, the orders indicated to administer vancomycin HCL solution (antibiotics) 1250 milligrams (mg) intravenously one time a day for MRSA for two weeks. Vancomycin was discontinued. The orders further indicated physician's order dated 4/6/22 to administer Zyvox (antibiotic) 600 mg tablet by mouth every 12 hours for MRSA of the wound for 14 days. During an interview on 4/8/2022 at 2:29 p.m. with the DON, it was asked how many doses of vancomycin did resident 198 receive? The DON stated the antibiotic was supposed to be administered for 14 days, Resident 198 come with a midline, but it was pulled out; DON placed a peripheral line, but it was pulled out the next day. The DON stated, she notified the doctor, and was told to change to oral antibiotic. The resident was on an antibiotic from the hospital. DON stated will find the hospital record. DON further stated, If the resident is on an antibiotic usually the doctor will order to continue the medications to prevent unnecessary drugs, the McGeer's list will be checked. During a record review of a random McGeer's surveillance list for Cellulitis, Soft Tissue or Wound Infection, based on checklist, the criteria for antibiotic use is met, for resident 198, however there is no McGeer's surveillance list with Resident 198's name. During a review of the facility's policy and procedure titled, Infection Prevention and Control Program. Antibiotic Stewardship dated 9/2017, indicated that it is the policy of this facility to implement an Antibiotic Stewardship Program (ASP) that is incorporated in the overall Infection Prevention and Control Program which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotics use. The Procedure indicates the following: 1). The facility may consider antibiotic time out (TO) practice. A time-out can be considered a stop order of antibiotic when a diagnosis test or symptoms of resident do not support the diagnosis of infection. 2). Assess residents for any infection using standardized tools and criteria. A separate report will be maintained for the number of residents on antibiotics that did not meet McGeer's criteria for active infection. 3). Incorporate monitoring of antibiotic use, including the frequency of monitoring/review.

Based on observation, interview, and record review the facility failed to ensure the pneumonia (PNA) (an infection of the lungs) vaccinations (medication to prevent a particular disease) was administered timely (within admission)) to one of one resident (Resident 36). This deficient practice placed Resident 36 at a higher risk of acquiring and transmitting pneumonia to other residents in the facility. During a review of the admission record for resident 36 dated 2/23/2022, the admission record indicated diagnosis that included end stage renal disease (ESRD) (kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), muscle weakness (generalized) (lack of strength in the muscles.) anemia, unspecified (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues.) During a review of Resident 36 History and Physical (H&P), dated 2/23/2022, the H&P indicated Resident 36 has the ability to understand and make medical decisions. During a record review of California Immunization Registry (CIR) for Resident 36, the CIR indicated Pneumo Poly 23 vaccine (PV 23) (protect against many, but not all types of pneumococcal bacteria) was received on 12/27/2015. During a record review of the Pneumonia Vaccine Consent form for resident 36 dated 2/15/2022 , the consent form indicated Resident 36 refused the vaccine because Resident 36 stated she had gotten the vaccine in 8/2021. The IP/DSD stated, No I have not offered her. The charge nurses, DON can offer. During an interview on 4/8/2022 at 1:54 p.m. with IP/DSD, IP/DSD stated on 6/16/2021, Resident 36 stated she had already gotten the vaccine but did not know the date. IP stated We just go to the CIR'S, which gives us the public record on when the last vaccine was given. The resident has ESRD. It was determined her last PV 23 was given on 12/27/2015 and was uploaded in Point Click Care system (PCC) on 3/29/2022 by DON. During an interview on 4/08/2022 at 2:38 p.m. with the DON, DON stated, not sure about the criteria for PNA vaccine for those 60 and above but can find out. If there is no immunization record, we must interview the resident or family. We also need to contact the primary physician if they have the immunization. The immunization needs to be administered every five years. Resident 36 has not received the vaccine in seven years. When CIR'S does not match, we need to call the primary MD to ask if they have a record, if none we need to let the resident know she has not gotten her PNA vaccine more than five years ago. DON stated, No I haven't called the primary doctor office. [NAME] stated, Yes we will contact the MD and notify the resident and offer to her. If she refuses we will explain the risks and benefits. During a review of facility's policy and procedure title, Care and Treatment, Immunization, Influenza and Pneumococcal dated 9/2017, the P&P indicated, to minimize the risk of resident acquiring, transmitting, or experiencing complications from pneumonia by assuring that each resident, is informed about the benefits and risk of immunization. Each resident is offered a pneumococcal immunization unless the immunization is medically contradicted, and the resident has already been immunized. If declined, document the reason why resident did not receive the pneumococcal immunization. (Electronic Immunization Record). Administration of the Pneumococcal vaccination will be made in accordance with current Centers for Disease Control and Prevention recommendations at time of vaccination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Do a Gradual Dose Reduction ([GDR] an attempt to decrease or discontinue psychotropic [medications that act on the mind] medication after three months of starting on the psychotropic medication, unless clinically contraindicated) for two of three residents (Resident 16 and Resident 36). This deficient practice resulted in Resident 16 receiving Escitalopram (brand name Lexapro, a medication to treat depression), and Resident 36 receiving Aripiprazole (brand name Abilify, a medication to treat depression) and Fluoxetine (brand name Prozac, an antidepressant medication that works in the brain) without clinical justification for use. 2. Ensure a proper physician consultation evaluation for Aripiprazole for one of three residents (Resident 36). This deficient practice had the potential for Resident 36 to take medications and experience side effects and adverse effects without being evaluated by a mental health proffesional for appropriateness, before administering psychotropic medications. 3. Ensure a physician order for an, 'as needed' anti-psychotic drug was not renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication for one of three residents (Resident 37). This deficient practice had the potential to result in the use of unnecessary psychotropic drugs, Lorazepam (brand name Ativan, a medication to treat anxiety) for Resident 37 and could lead to side effect and adverse consequence such as a decline in quality of life and functional capacity. Findings: 1. During a review of the admission face sheet, the face sheet indicated Resident 16 was admitted to the facility on [DATE], with diagnoses not limited to diverticulitis (infection or inflammation of pouches that can form in your intestines), depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (feeling of fear, dread, and uneasiness). During a review of Resident 16's Minimum Data Set ([MDS] a comprehensive assessment and care screening tool), dated 2/11/2022, MDS indicated Resident 16 was moderately cognitively (ability to make decisions of daily living) impaired. During a review of Resident 16's physicans order, dated 2/6/2019, the order indicated, Lexapro Tablet 5 milligrams (gm) (Escitalopram Oxalate) Give one tablet (tb) by mouth (PO) one time a day for depression manifested by irritable mood. During a review of Resident 16's Medication Regimen Review ([MRR] a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy), dated 2/2/2022, the MAR indicated, Please evaluate the continuous use of Lexapro 10 milligrams PO daily for depression since 7/2021. Facility must attempt a gradual dose reduction in two separate quarters (with at least one month in between attempts), unless clinically contraindicated. Please check one of the following below; Agree or Disagree : Upon further review, no checks were marked to indicate the ordering physician agreed or disagreed trying a GDR. During an interview with Director of Nursing (DON), on 4/8/2022, at 12:41 9 a.m., DON acknowledged the doctor did not respond to the pharmacist recommendation dated 2/2/2022 for resident 36's GDR attempt for Lexapro 10 mg for MRR. DON stated that no GDR was performed. 1 a. During a review of the admission face sheet, the face sheet indicated Resident 36 was readmitted on [DATE], with diagnoses not limited to Postprocedural Status (the condition of a patient in the period following a surgical operation), psychosis (condition that affects the way your brain processes information), depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (feeling of fear, dread, and uneasiness). During a review of Resident 36's Minimum Data Set MDS, dated [DATE], the MDS indicated Resident 36 was moderately cognitively impaired. During a review of Resident 36's physician's orders, dated 9/9/2021, the orders indicated, Aripiprazole tablet 20 MG give one tablet by mouth one time a day for psychosis manifested by striking out. Fluoxetine HCL (hydrochloric acid) capsule 20 milligrams give one capsule by mouth two times a day for depression manifested by verbalization of sadness. During an interview with Director of Nursing (DON), on 4/8/2022, at 8:48 a.m., DON stated, there was no record of a GDR trial for Abilify and Prozac for Resident 36. During a review of the facility's policies and procedures (P&P) titled, Psychotropic Drug Use, revised 8/17, the P&P indicated Based on a comprehensive assessment of a resident, the facility will ensure that: Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Upon initial comprehensive assessment, the Social Services designee shall review new admissions for any psychiatric, mood or behavior disorders, mental and psychosocial difficulties, and/or physicians orders for psychotropic medications. These residents will be referred to the facility's Psychotropic Drug Review Committee and/or the Psychiatrist to ensure: Attempt/consider a GDR, if appropriate. 2. During a review of Resident 36's Order Summary (OS), dated 5/31/2021, the OS indicated, Aripiprazole tablet 20 MG give one tablet by mouth one time a day for schizophrenia manifested by striking out. On 9/9/2021 the diagnosis was changed, Aripiprazole tablet 20 MG give one tablet by mouth one time a day for psychosis manifested by striking out. During an interview with Director of Nursing (DON), on 4/8/2022, at 8:48 a.m., DON confirmed there was no psychiatric evaluation performed for Resident 36 since 5/2021 even though the diagnose that was originally schizophrenia, was later changed to psychosis without a psychiatric evaluation. During a review of the facility's policies and procedures (P&P) titled, Psychotropic Drug Use, revised 8/17, the P&P indicated It is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. 3. During a review of Resident 37's Psychotherapy Note, dated 3/2022, the Psychotherapy Note indicated, Resident 37's Psychiatric Diagnose was: Acute Psychiatric Disorder. Lorazepam (brand name Ativan 1 milligram every eight hours as needed. During a review of the admission face sheet indicated Resident 37 was admitted to the facility on [DATE] and 6/4/2021, with diagnoses not limited to sepsis (body's extreme response to an infection), depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (feeling of fear, dread, and uneasiness). During a review of Resident 37's Minimum Data Set ([MDS] a comprehensive assessment and care screening tool), dated 3/6/2022, indicated Resident 36 was moderately cognitively impaired. During a review of Resident 37's Order Summary Report (OSR), dated 4/8/2022, the OSR indicated, Resident 37 had an order for Ativan tablet 1 milligram give one tablet via G- Tube every eight hours as needed for anxiety manifested by restlessness. Ativan had an order date of 3/22/2022. During a concurrent interview and record review on 4/8/2022 at 9:00 a.m., with Director of Staff Development (DSD), of Resident 37's Medication Administration Record (MAR), dated 4/2022, the MAR indicated Ativan was administered on 4/6/2022 at 1:57 p.m. DSD stated Resident 37 has an order for Ativan as needed ordered 3/22/2022. DSD confirmed last time Resident 37 received Ativan was on 4/6/2022 at 1:57 p.m., it had been 17 days, past the revaluate and reorder date. DSD stated the process for antipsychotic 'as needed' prescriptions needed to be reevaluated and renewed every 14 days. DSD acknowledged there was no noted doctor note for Ativan continuation past 14 days as needed. During an interview with Director of Nursing (DON), on 4/8/2022, at 8:48 a.m., DON stated, Psychotropic, 'as needed' medication orders are only good for 14 days so the doctor can evaluate if there was still a need to continue the medication. During a review of the facility's policies and procedures (P&P) titled, Psychotropic Drug Use, revised 8/17, the P&P indicated As needed orders for psychotropic drugs are limited to 14 days . if the attending physician or prescribing practitioner believes that it is appropriate for the as needed psychotropic medication order to be extended beyond 14 days, he or she should document their rationale in the residence medical record and indicate the duration for the as needed order. As needed orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Based on observation, interview, and record review, the facility failed to provide adequate space for therapy in the rehabilitation gym as evidenced by multiple binders, cardboard boxes, plastic containers, a laptop, bags, a water bottle, and office supplies were placed on the therapy mat (an adjustable padded surface used for therapy treatment) that is used for residents during therapy. This deficient practice had the potential to minimize equipment use and usable treatment space for residents during therapy. Findings: During an observation of the rehabilitation gym on 04/06/2022 at 3:47 p.m., six binders, two clipboards, two cardboard boxes, three plastic containers, a laptop, two bags, one water bottle, and office supplies were observed on top of therapy mat. During an observation and interview with the Director of Rehabilitation Services (DOR) on 04/06/2022 at 4:00 p.m., DOR stated that the therapy mat was used for residents who had trouble standing, sitting, and/or demonstrated decreased endurance. The DOR stated that there were multiple binders, cardboard boxes, plastic containers, a laptop, bags, and office supplies on the therapy mat. The DOR stated that there should not be any items on the therapy mat because the mat was used for therapy treatment with residents. The DOR stated that there was a storage area outside where staff should place items. During an interview with the Director of Nursing (DON) on 04/08/2022 at 1:39 p.m., the DON stated that the facility did not have a policy for maintaining rehabilitation space.

Based on observation, interview, and record review, the facility failed to routinely clean and remove lint from the dryer. This deficient practice had the potential to cause a fire and/or injury to all residents and staff in the facility. Findings: During an observation, interview, and record review, with the Director of Maintenance (DM) and housekeeper/laundry aide (HKLA) on 04/07/2022 at 8:57 a.m., the dryer filter was observed to be dirty and entirely covered in lint and debris. The DM stated that the lint trap was dirty and that it needed to be cleaned. The DM proceeded to clean the dryer filter and stated that it was supposed to be cleaned after every two loads. The DM and HKLA stated that it was important to clean the filters regularly due to fire risk. The DM stated staff needed to document and initial on the dryer filter cleaning log. Upon review of the dryer filter cleaning log, the DM and HKLA stated the log was blank for today, 04/7/2022 for 6:00 a.m. and 8:00 a.m. The DM and HKLA stated if the log was not initialed and was blank, then it indicated that the task was not completed. A review of the facility's policy and procedure revised 2007 titled, Laundry, Dryer, indicated laundry employee will record the cleaning and lint removal at least every two hours while the dryer is in use.