**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide nursing services according to accepted professional standards of clinical practice for two (#17 and #18) out of 18 residents reviewed out of 18 sample residents. Specifically, the facility: -Failed to transcribe physician's orders into the electronic medical record (EMR) correctly for Resident #17 and Resident #18; and,-Failed to notify a provider when Resident #17 had a change in condition and obtain a physician's order to hold a routinely scheduled medication Findings include: I. Failure to transcribe physician's orders into the EMR correctly A. Professional reference According to the National Institutes of Health (NIH), National Library of Medicine, Hypoglycemia (Nursing) (12/26/22), retrieved on 9/16/25 from https://www.ncbi.nlm.nih.gov/books/NBK568695/#:~:text=It%20is%20the%20nurse's%20responsibility,possible%20side%20effects%20of%20hypoglycemia, Hypoglycemia is often defined by a plasma glucose concentration below 70 milligram (mg)/ deciliter (dl); however, signs and symptoms may not occur until plasma glucose concentrations drop below 55 mg/dl. It is the nurse's responsibility to assess for signs and symptoms of hypoglycemia and to report any abnormal findings. It is also the nurse's responsibility to assess that medications are taken as prescribed and report any possible side effects of hypoglycemia.B. Resident #171. Resident status Resident #17, age less than 65, was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included multiple sclerosis (autoimmune disease that affects the central nervous systems), type 1 diabetes and neuromuscular dysfunction of the bladder. The 6/30/25 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) score of three out of 15. 2. Observations and interviews On 9/8/25 at 11:40 a.m. licensed practical nurse (LPN) #1 was preparing Resident #17's medications for administration. LPN #1 checked Resident #17's blood sugar while he was in the dining room eating lunch. LPN #1 said the resident's blood sugar was 316 milligrams per deciliter (mg/dl).LPN #1 checked the physician's orders for sliding scale insulin and realized the physician's order did not reflect a blood sugar of 316 mg/dl. LPN #1 said Resident #17 came back from the hospital yesterday (9/7/25) with a new physician's order for Humalog and she had not transcribed it into the EMR correctly. She notified the director of nursing (DON) of the error and called the provider on call to clarify the order. 3. Record review A review of Resident #17's September 2025 CPO revealed the following physician's order: Humalog Kwikpen Solution pen-injector 100 units/milliliter (ml), inject as per sliding scale: if 136-180 mg/dl = 2 units, 181-225 mg/dl = 4 units, 226-270 mg/dl = 6 units, 271-315 mg/dl = 8 units, 321-360 mg/dl = 10 units. Blood sugar 50-70 mg/dl: give four ounces of juice or one cup of milk. Notify the on-call physician if the blood sugar is above 400 mg/dl, subcutaneously with meals for type 1 diabetes mellitus with other diabetic neurological complications, ordered 9/7/25 and discontinued 9/8/25.-The physician's order failed to include a blood sugar ranging from 316-320 mg/dl. C. Resident 18A. Resident status Resident #18, age less than 65, was admitted on [DATE] and discharged on 6/7/25. According to the June 2025 CPO, diagnoses included malignant neoplasm of the uterus (uterine cancer), acute kidney failure and hypertension (high blood pressure).The 5/27/25 MDS assessment documented the resident had moderate cognitive impairment with a BIMS score of 10 out of 15. B. Record review A review of Resident #18's September 2025 CPO revealed the following physician's orders: Morphine sulfate oral solution 100 mg/5 milliliters (ml), give 0.25 ml by mouth every four hours as needed for pain/restlessness, ordered 6/4/25 and discontinued 6/6/25. Morphine sulfate oral solution 100mg/5ml, give 2.5 ml by mouth every two hours as needed for pain/restlessness, ordered 6/6/25 and discontinued 6/9/25. -LPN #1 entered the order for Morphine as 2.5 ml instead of 0.25 ml (see interviews below).C. Staff interviews The DON and the chief executive officer (CEO) were interviewed together on 9/10/25 at 10:30 a.m. The DON said LPN #1 came to her when entering the morphine order into the computer. The DON said that LPN #1 did not check off the final check mark to complete an order to be able to push it through and make it an active order. The DON said she checked off the final checkmark in the order to make it an active order without double checking the order. She said the order should have been morphine sulfate, 0.25 ml every two hours, but instead was transcribed to 2.5 ml every two hours. The DON said every nurse checking off a physician's order should double check that the order matched exactly what was prescribed. The DON said there was an automated note that came after she signed off on the incorrect order that she did not see saying that the order was outside the recommended dose. The DON said that the next nurse on night shift brought it to the DON's attention, saying the order was incorrect. The DON said that the nurse confirmed she was going to correct the order. The DON said the order never was corrected and she did not know where the breakdown came from. The DON said she reviewed the controlled substance count sheet and confirmed that the dose of 0.25 ml was given each time. The DON said she confirmed the final count of the medication left was the correct amount. III. Failure to notify a physician when Resident #17 had a change in condition and obtain a physician's order to hold a routinely scheduled medicationA. Resident #171. Record review The 6/21/25 nursing progress note documented Resident #17's fasting blood sugar was low today. It was 53 mg/dl at breakfast and the nurse did not give Lantus. The blood sugar was within normal limits at lunch of 91mg/dl. This was on the provider note (see interview below). A review of Resident #17's September 2025 CPO revealed the following physician's order: Lantus subcutaneous solution, 100 units/ml (long acting insulin), inject 18 units subcutaneously in the morning related to type one diabetes mellitus with other neurological complications, ordered 1/24/25 and discontinued 6/24/25. 2. Staff interviews The DON and the CEO were interviewed together on 9/10/25 at 10:30 a.m. The DON said if a resident's blood sugar was outside of the normal limits, she would expect the provider on call to be notified right away. She said the provider note that the nurse was referring to in the progress note was a once daily note that was sent to the provider from the DON. The DON said this was a list of non-urgent items such as needing a stool softener. The DON said blood sugars outside of the normal limits should not be put on this list and should instead be called into the provider right away. LPN #2 was interviewed on 9/10/25 at 3:00 p.m. She said she would always notify the provider, the DON and the medical power of attorney (POA) right away if a resident experienced a change in condition. She said if she had a scheduled medication due and was unable to administer it to the resident, she would notify the DON and the provider.

Based on observations and interviews, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the possible development and transmission of Coronavirus (COVID-19) on one of one unit. Specifically, the facility failed to: -Ensure staff wore and removed personal protective equipment (PPE) correctly; and, -Ensure infection control practices were followed during medication pass. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC), revised 5/8/23, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During Coronavirus Disease 2019, retrieved 12/18/23 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html Source control options for HCP (healthcare personnel) include a NIOSH (National Institute for Occupational Safety and Health) approved particulate respirator with N95 filter or higher. Source control is recommended for individuals in healthcare settings who: Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection, for 10 days after their exposure. Source control is recommended more broadly as described in CDC's Core IPC Practices in the following circumstances: By those residing or working on a unit or area of the facility experiencing a SARS-CoV-2 or other outbreak of respiratory infection; universal use of source control could be discontinued as a mitigation measure once the outbreak is over ( no new cases of SARS-CoV-2 infection have been identified for 14 days); Eye protection (goggles or a face shield that covers the front and sides of the face) worn during all patient care encounters. I. Facility policy The Infection Control policy, issued 5/1/21, was received from the director of nursing (DON) on 12/13/23 at 12:18 p.m. The policy documented in pertinent part, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies. II. Failure to ensure staff doffed (removed) and donned (put on) PPE properly for COVID-19 isolation rooms A. Observations The two Covid-19 isolation rooms were observed on 12/11/23 at 9:56 a.m. Two isolation carts were noted in front of resident rooms and both of the rooms had clear plastic zippered material covering the doorways. At 9:57 a.m. certified nurse aide (CNA) #1 and CNA #2 prepared to enter the room. CNA #1 put on a yellow cloth gown and gloves and entered the room. She was wearing the same surgical mask she had been wearing previously. CNA #2 removed her surgical mask and set it on the table outside of the room. She put on a yellow cloth gown, gloves and a new surgical mask and entered the room with CNA #1. Both CNA #1 and CNA #2 assisted the isolated resident with toileting. At 10:08 a.m., CNA #1 and CNA #2 exited the room. They both had removed their yellow cloth gowns in the room. Upon exiting the room, the CNAs rolled up the gowns and put them back in the storage bin outside of the room. They removed and disposed of their gloves in the room. CNA #1 asked CNA #2 if they were reusing the yellow gowns and CNA #2 responded that they were and that is why they put them back in the storage bin. CNA #1 left the area. CNA #2 disposed of the surgical mask that she was wearing inside the room and put on the original surgical mask that she had left on the table outside of the room. On 12/12/23 at 2:39 p.m., licensed practical nurse (LPN) #1 was observed sitting at the nursing station. She had a surgical mask under her chin. It was not covering her nose or mouth. On 12/12/23 at 2:41 p.m., LPN #1 was observed sitting at the nursing station. She had a surgical mask under her chin. It was not covering her nose or mouth. On 12/13/23 at 9:37 a.m., LPN #1 was observed sitting at the nursing station. She had a surgical mask under her chin. It was not covering her nose or mouth. B. Interviews CNA #2 was interviewed on 12/11/23 at 10:10 a.m. She said there were two rooms on isolation precautions for positive Covid-19 tests. She said the room she just exited would be coming off of isolation in the next couple of days. She said all staff should be wearing N95 masks but since the isolation was almost over she did not think it was important. She said the CNA's had to reuse the isolation gowns and that was why she put her gown back in the container after she exited the room. The DON was interviewed on 12/11/23 at 10:50 a.m. She said Covid-19 positive residents were placed on a ten day isolation. She said the correct process for entering an isolation room was to perform hand hygiene, don a gown, gloves and N95 mask. Upon exiting the room, she said all of the PPE should be removed in the room and put into a red biohazard bag before exiting. Once staff was outside of the room the red bag should be placed in a specific trash can and the staff should perform hand hygiene again. She said it was not appropriate to wear a surgical mask when providing care inside an isolation room or to reuse the gowns. She said she would re-educate staff on the proper technique for PPE. The DON was interviewed again on 12/13/23 at 9:56 a.m. She said all of the staff had been told they were required to wear a surgical mask covering their nose and mouth unless they were in the break room to eat. She said it was important for staff to follow proper mask procedures to avoid contamination and spread of the Covid-19 virus. Licensed practical nurse LPN #1 was interviewed on 12/13/23 at 10:04 a.m. She said she was aware of the mask mandate for the facility that was currently being required due to the Covid-19 outbreak. She said all staff and visitors were to wear masks covering their nose and mouths at all times. She said masks should be worn properly even if the nurse was sitting at the nurses station. III. Failure to follow infection control practices during medication pass A. Observations Licensed practical nurse (LPN) #1 was observed on 12/12/23 at 11:54 a.m. during medication administration. She had just returned from a meeting with the DON when she approached the cart and began preparing medications for a resident. -She did not sanitize her hands prior to getting a medication cup and dropping the medications in it. LPN #1 carried the medication cup to the resident in the dining room and the resident put the cup to her lips to take the medications. LPN #1 took the medication cup back from the resident and threw it away in the trash can. She returned to the medication cart and got another medication cup to begin preparing the medication for the next resident. -She did not sanitize her hands prior to preparing the next resident's medications She carried the medication cup to the resident in the dining room and the resident put the medication cup to her lips to take the medication. LPN #1 took the medication cup back from the resident and threw it in the trash. At 11:58 a.m., LPN #1 took the medication cup back from a resident in the dining room and threw it in the trash. She proceeded to touch a handheld radio, scratch her head, use the computer mouse and unlock the medicine cart with her keys. She then got a medication cup and began putting the medications in the cup for the next resident. -She did not sanitize her hands prior to preparing the next resident' s medications At 12:00 p.m., LPN #1 administered medications mixed with applesauce to a resident in the dining room. She used a spoon to administer the medications to the resident After the resident ingested the medications she threw the medication cup and spoon into the trash can. She returned to the medication cart and unlocked the cart using her keys. She got a medication cup and began dropping the medications into the medication cup for the next resident. -She did not sanitize her hands prior to preparing medications for the next resident. She took the medication cup to the resident who put the medication cup to their lips to take the medications. LPN #1 took the cup back from the resident and threw it in the trash. -Without sanitizing her hands, LPN #1 then got another resident a cup of coffee from the kitchen and gave it to the resident. At 12:07 p.m., LPN #1 prepared and administered medications in a medication cup to another resident in the dining room. She threw the medication cup in the trash and returned to the medication cart. She got a new medication cup from the cart and began preparing medications for the next resident. She put the medications in the medication cup with some applesauce, took it to the resident and administered it. She then threw the medication cup and spoon in the trash and returned to the medication cart. -She did not sanitize her hands prior to preparing the medications for the next resident. At 12:16 p.m., LPN #1 began preparing medications for the next resident. An alarm began sounding at the nurses station so she walked to the nurses station and pushed a button to cancel the alarm. She returned to the medication cart and placed a medication cup on top. The alarm began sounding again so she returned to the nurses station and pushed the button again to cancel the alarm. She returned to the medication cart and continued to prepare the medications for the next resident in the dining room. -She did not sanitize her hands after touching the button on the alarm at the nurses station She carried the medication cup to the resident in the dining room and the resident placed the cup to their lips to take the medications. LPN #1 took the medication cup back and threw it in the trash. -She did not sanitize her hands prior to preparing the next resident's medications. At 12:20 p.m., LPN #1 delivered a medication cup to a resident in the dining room. The resident placed the medication cup to his lips to take the medication. LPN #1 took the medication cup back and threw it in the trash. She walked back to the medication cart, got a medication cup and placed it on top of the cart. She unlocked the medication cart with her keys and began preparing the medication for the next resident. -She did not sanitize her hands prior to preparing the next resident's medications She carried the medication cup to the resident and he refused to take the medication. LPN #1 returned to the medication cart and put the medication in the medication waste container and threw the medication cup away. B. Interviews The DON was interviewed on 12/13/23 at 9:56 a.m. She said all staff were expected to wash their hands or use hand sanitizer between each medication pass. She said staff should use hand sanitizer before getting the medications, after taking the medication to the resident and again before starting the next resident. She said it was important to perform hand hygiene to prevent the spread of pathogens from one resident to the next. LPN #1 was interviewed on 12/13/23 at 10:04 a.m. She said nursing staff should use hand sanitizer between each resident during medication administration. She said failure to perform hand hygiene between each resident could result in germs spreading from resident to resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain the emergency response cart and equipment in safe operating condition for one of one emergency response (crash) cart. Specifically, the facility failed to: -Ensure staff completed the daily equipment checks; -Ensure expired items were removed from the crash cart; and, -Ensure emergency oxygen canister on the emergency response cart was maintained and ready for use. Findings include: I. Professional references A. According to [NAME], [NAME], (2022). Crash cart preparedness and failure to rescue a case study review. Retrieved on 12/18/23, from https://www.researchgate.net/publication/360555126_Crash_cart_preparedness_and_Failure_to_rescue_A_case_study_review and read in pertinent part, A crash cart is a mobile cabinet on wheels that contains equipment required for emergency cardio-pulmonary resuscitation. The carts are individualized and conveniently located throughout healthcare facilities for rapid access in the event of an emergency. A crash cart is typically located in the setting of an unexpected medical emergency. This could include severe allergic reaction, cardiac or respiratory arrest, and conditions with an unexpected sudden deterioration of vital signs. This would require equipment located on the card cart which would be used by a credentialed life support provider. While crash carts vary depending on location, the fundamentals for the crash cart will contain similar equipment. Although the organization of requirements for a crash cart is not generic, there is a fundamental standard which provides effortless access to emergency medical equipment. Note that all these organizational points are checked, dated, and signed by the staff member who performed the daily routine inventory and inspection. Top shelf/drawer -The top section typically has the most frequently used equipment employed in a resuscitation event such as power cords and personal protective equipment. Side or rear -The oxygen cylinder should be secure on the side of the cart, with a full oxygen pressure level; -A suction apparatus/charging battery for the portable use; -A sharps container should be secure on cart; and, -A rigid plastic/fiberglass backboard for chest compressions. Recommended equipment and medications -Organization and location specific. Recommended maintenance -Check expiration dates on equipment and medications per organization policy and replace as required. Schedule inventory check The purpose of a crash cart inventory is to organize a schedule of when to check for expiration dates of equipment and supplies. Check that equipment is operating as required in the event of an emergency. In addition to recording who performed the inventory checks, with dates, times, and signatures. An alarming situation for the healthcare personnel requiring a crash cart is to find unusable equipment or expired medications in an emergency. Ensuring that an up-to-date, accurate, and truthful inventory record can avoid potential patient safety situations such as absence of equipment, equipment failure, expired or missing medication, and empty oxygen cylinders. The patient safety risk incident failure to rescue is perpetrated by healthcare professionals when they do not check cart accurately. Failure to follow standard or policy for checking equipment compromises patient safety and creates potential to harm patients. II. Facility policy The Nursing Home Crash Cart policy, issued 12/23, was received from the director of nursing (DON) on 12/13/23 at 12:18 p.m. and read in pertinent part, The DON will ensure the equipment is stocked in the E-Cart (emergency cart). The DON contacts the materials management clerk for the equipment supplies. The E-Cart will be inventoried and restocked after each use and checked at least monthly and documented by nursing staff. All emergency equipment in the E-Cart will be checked monthly by the DON. Once a month the E-Cart should be opened and checked for outdated supplies. Internal and external equipment should be checked by ensuring proper function of equipment. E-Cart checks should be documented on the lists maintained on the E-Cart. E-Carts will be maintained and supplied in accordance with the crash cart minimum requirements list which include respiratory equipment. III. Observations Crash cart #1 was observed on 12/12/23 at 9:02 a.m. The following items were found: -There was not a daily checklist on the cart; -One 100 milliliter (ml) bottle of sterile water, expired on 12/21; -Ambu (manual self-inflating resuscitator) bag, expired in 2013; -Midline catheter, expired on 12/31/2020; -Catheterization tray, expired on 2/13/2020; -Suction tubing, expired on 3/1/21; -Yankauer device (oral suctioning tool), expired on 7/19/17; -Yankauer device, expired on 7/31/23; -Three sets of sterile gloves, all expired in April 2020; -Sterile gloves, expired in August 2020; -Basic oxygen mask, expired on 6/31/23; -Carbon dioxide detector, expired on 7/9/19; -Carbon dioxide detector, expired on 7/11/2020; -Two suction tray kits, both expired on 2/13/2020; -Two boxes of standard gloves, expired in June 2015 and May 2015; and, -The oxygen canister on the cart did not have any oxygen in it. IV. Interviews The DON was interviewed on 12/12/23 at 11:39 a.m. The DON said she was responsible for completing the daily checklists for the crash cart. She said she would contact the supply department and have them go over everything on the crash cart and order new supplies. She said she would make sure the oxygen canister was replaced with a full canister immediately. The DON said it was important for the crash cart to be stocked with current ready to use supplies and equipment to be able to effectively resuscitate someone in the event of an emergency. Licensed practical nurse (LPN) #1 was interviewed on 12/13/23 at 10:04 a.m. She said she did not know who was responsible for checking the crash cart or the items on it. She said she was not instructed to do so. She said the crash cart should have all of the supplies required to be able to use if someone had an emergency and needed to be revived.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents were as free from unnecessary psychotropic drugs as possible for three (#6, #8 and #14) of six residents out of 15 sample residents. Specifically, the facility failed to: -Provide documentation that a risk versus benefit statement to justify the resident's continual use of the medications was provided to the resident and/or the resident's representative for Resident #6, Resident #8, and Resident #14; -Attempt a gradual dose reduction (GDR) of an antipsychotic medication for a resident with dementia for Resident #6 and Resident #8; and, -Appropriately assess Resident #14's need for the use of an antipsychotic medication for a diagnosis of nausea. Findings include: I. Facility policy and procedure The Psychopharmacological Medication Use policy, revised June2022, was provided by the nursing home administrator (NHA) on 8/31/22 at 8:45 a.m. It read in pertinent part, Psychopharmacological (psych) medications are used to relieve symptoms of psychotic behaviors, depression, anxiety and agitation. It is the policy of this facility to use screening and assessment to determine the proper use of psychopharmacological medications in accordance with state and federal regulations. The facility supports the appropriate use of psych medications that are therapeutic and enabling for residents suffering from mental conditions. A consent form will be discussed with the resident and family at admission or upon initiation of psychotropic medication stating the risks versus the benefits and the non-pharmacological interventions that will be in place and attempted. The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental and/or behavioral management as well as psych medications, can be utilized to meet the needs of the individual resident. Psychotropic medication will be reviewed for the need to conduct a gradual dose reduction (GDR). State regulations require a GDR every six months for the first year and yearly thereafter. Appropriate monitoring and documentation will be maintained in residents' charts. II. Resident #6 A. Resident status Resident #6, age [AGE], was admitted on [DATE]. According to the August 2022 computerized physician orders (CPO), diagnoses included unspecified dementia with behavioral disturbance, restlessness and agitation, and major depressive disorder, recurrent with severe psychotic symptoms. The 6/20/22 minimum data set (MDS) assessment revealed that the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) of eight out of 15. He required one-person limited assistance with bed mobility, transfers, dressing, and toilet use. He required supervision for personal hygiene. The 6/20/22 MDS assessment further revealed the resident did not exhibit any potential indicators of psychosis such as delusions or hallucinations. He did not exhibit any physical or verbal behaviors, rejection of cares, or wandering behaviors during the seven day MDS assessment look-back period. He received an antipsychotic medication daily. B. Observations On 8/28/22 at 5:10 p.m., Resident #6 was seated in his recliner in his room watching television. He was pleasant, and smiling. He said his wife had gone shopping and had not yet returned. He said he was concerned about how much money she might have spent. On 8/29/22 at 9:37 a.m., Resident #6 was seated in his recliner with the footrest up. He was asleep. On 8/29/22 at 4:25 p.m., Resident #6 was wheeling his wheelchair in the hallway. He was smiling and greeting people as he passed by them in the hallway. On 8/30/22 at 8:27 a.m., Resident #6 was wheeling his wheelchair in the hallway. He is smiling and pleasant. As a staff member walked past him, the resident smiled and said good morning. C. Record review Review of Resident #6's August 2022 CPO revealed the following physician's orders: Ziprasidone HCl (Geodon) capsule 20 milligrams (mg) by mouth two times a day related to dementia with behavioral disturbance. The order had a start date 2/28/22. Monitor behaviors related to antipsychotic medication: increased agitation, calling out for family, physical aggression, or verbal aggression. The order had a start date of 3/1/22. Non-pharmacological interventions to be used for agitation: reassurance, reposition, redirection, encourage to attend nursing home activities, television, visit one on one with staff, and ask resident if having pain. The order had a start date of 12/30/21. Review of Resident #6's psychotropic medication care plan, initiated 3/1/22 and revised on 6/22/22, revealed the resident used Geodon (an antipsychotic medication) related to dementia with behaviors. Pertinent interventions included discussion with the physician/family regarding ongoing need for use of the medication, educating the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of psychotropic medication drugs being given, and monitoring/recording occurrence for target behavior symptoms and non-pharmacological interventions attempted and their effectiveness - see treatment administration record (TAR). -The care plan did not list the specific target behaviors or non-pharmacological interventions for the resident. -Review of Resident #6's electronic medical record (EMR) failed to show documentation that a risk versus benefit statement to justify the resident's use of the medications was provided to the resident and/or the resident's representative. Review of Resident #6's behavior tracking sheets (monitoring of physical/verbal behaviors, wandering, and frequent crying), which were documented by the certified nurse aides (CNA), were reviewed for 2/1/22 through 8/29/22. The behavior tracking sheets revealed the following: -February 2022 (prior to starting the antipsychotic medication): the resident exhibited behaviors on 19 days out of 28 days; -March 2022 (after starting the antipsychotic medication: the resident exhibited behaviors on six days out of 31 days; -April 2022: the resident exhibited behavior on six days out of 30 days; -May 2022: the resident exhibited behavior on four days out of 31 days; -June 2022: the resident exhibited behaviors on three days out of 30 days; -July 2022: the resident exhibited behaviors on 12 days out of 31 days; and, -August 2022: the resident exhibited behaviors on five days out of 29 days. Review of Resident #6's treatment administration record (TAR) from 2/122 through 8/29/22 revealed the following: -February 2022 (prior to starting the antipsychotic medication): the resident exhibited behaviors on 19 days out of 28 days; -March 2022 (after starting the antipsychotic medication: the resident exhibited behaviors on four days out of 31 days; -April 2022: the resident exhibited behavior on one day out of 30 days; -May 2022: the resident exhibited behavior on one day out of 31 days; -June 2022: the resident exhibited behaviors on zero days out of 30 days; -July 2022: the resident exhibited behaviors on three days out of 31 days; and, -August 2022: the resident exhibited behaviors on four days out of 29 days. -Despite the nurse and CNA documentation which indicated Resident #6's clinical condition had improved overall and/or stabilized, as evidenced by his decrease in behaviors, the facility failed to attempt a GDR of the antipsychotic medication, as is required two times within the first year of the medication being started unless clinically contraindicated. -There was no documentation from the physician in the resident's EMR which indicated a GDR of the medication was clinically contraindicated. Review of Resident #6's EMR revealed the following progress notes documented in pertinent part: 2/5/22 at 4:43 a.m: Resident continues with verbal and physical aggression, yelling out throughout the night, getting out of bed unassisted, noncompliant and uncooperative with care. 2/9/22 at 4:37 a.m: Resident with physical and verbal aggression during cares, continues to yell and call out throughout the night, noncompliant with cares, continues to get out of bed, one on one with staff, redirectirection, and re-approach without success, also refuses to take medication. 2/9/22 at 2:04 p.m: Resident has been very anxious since waking up this morning. Resident believes that this is a hotel and we are not allowing him to leave. He has threatened to 'call the cops' multiple times. When the resident's wife came to visit he was yelling at her and thinks she is seeing other men and that is why he can't go home. Wife crying with today's visit. Attempted to redirect, reposition, one on one with staff. 2/10/22 at 2:06 a.m: Resident has not been to sleep tonight. He has scooted around his room, self transferred to his wheelchair and propelled himself down the hallway. He has called out frequently looking for his wife. He yelled for anyone who walked down the hallway. He was also caught standing against the door jamb going to the hallway twice. He was looking for a way out. He also was asking for breakfast. He wanted oatmeal and coffee. When he was told that it would be at least 6 hours before breakfast was ready, he said he would die of hunger before breakfast time. We gave him some hot chocolate and instant oatmeal. 2/11/22 at 3:20 a.m: Resident has been very active after being assisted to bed. Climbing out of bed, removing all clothing on the lower half of his body. Redirection and one on one with staff helped. In his conversations with the CNAs he was sexually inappropriate. 2/13/22 at 9:33 p.m: Resident was exit seeking this evening. He was trying to go find his wife and his dog. We convinced him that his wife was at home getting some rest and he needed rest also. 1:1 was required to keep him semi-calm. 2/14/22 at 4:18 a.m: Resident has been calling out for his wife all night. He has slept for short periods of time, 15 - 20 minutes at a time. He is then climbing out of bed and crawling around on his mattresses and floor, pulling off his clothing, including the brief or pull-up. He has required lots of 1:1 attention to keep from waking/disturbing other residents. 2/15/22 at 6:12 a.m: Resident did not sleep all night, would not keep his clothes or briefs on. Would not stay on lowered bed or mattresses on the floor. Agitated when trying to get him on the mat or put on briefs. Urinated on floor and mats. Would get up on own and ambulated clear down the hall to the front lobby and got in the closet. One on one and reassurance not effective. Very difficult to redirect. 2/18/22 at 2:45 p.m: Resident was having increased agitation today and was looking everywhere for his wife. Resident was redirected several times by different staff members with little success. As needed medication given as ordered. The resident is currently visiting with his wife in his room and signs/symptoms of agitation have decreased. 2/21/22 at 5:45 a.m: Resident slept very little. Refused to stay in bed. Crawls onto the mat and into hallways. When assisted back to bed crawls right back in the hallway. Resident put in wheelchair and wheeled up and down halls most of the night yelling for wife. Resident was in the front lobby, got in the closet and tore out coats and when trying to get out of the closet swung at staff. Very difficult to redirect. One on one and reassurance. 2/24/22 at 5:38 a.m: Resident continued crawling out of bed throughout the night, does not use call light, yelling and calling out all night, verbally and physically aggressive towards staff, uncooperative with cares, one on one with staff, redirect, and re-approach all unsuccessful. 2/25/22 at 5:22 a.m: Resident continues with aggressive behavior with cares, both verbally and physically, hitting and kicking, continues crawling out of bed at night, yelling and calling out throughout the night, one on one with staff, redirect, and re-approach all without success. 2/28/22 at 5:35 a.m: Resident was very restless throughout the night. Unable to keep resident in bed. [NAME] wheelchair up and down halls, calling out for wife. Difficulty to keep out of other residents' rooms. Very difficult to redirect. One on one given, snacks given and non-effective. 2/28/22 at 11:00 a.m: Communication with physician and power of attorney (POA): Notified physician of escalation of resident's behaviors, staff is unable to calm him down or redirect. New orders received and noted. Notified residents POA of new orders. 3/28/22 at 8:24 p.m: Resident was out to supper meal. Took 100% of supper meal and was pleasant and cooperative with taking meds. After supper, was upset and wanted his car and wanted to talk to his wife and go home. Called wife and resident visited with wife and daughter and yelled at them on the phone. Very difficult to redirect. Staff one on one and reassurance with resident and he calmed down. Resting well at this time in bed. 3/31/22 at 1:19 p.m: Resident woke up from a nap and was crying insisting that he was dead and no one could see him. He stated that he died three years ago and woke up as a ghost on earth. One on one with staff provided with emotional support and reassurance provided. Then while walking to lunch he started yelling down the hall 'There is that (derogatory word). Get her the hell out of here' and was pointing at a staff member. Redirected resident to the dining room. In the dining room, resident continued to call that staff member a (derogatory word). Tried to redirect resident but resident insisted that he knew this staff member when he was younger and she betrayed him and would do it to everyone. After lunch, the resident rested in his chair with call light within reach. Wife here to visit. No other behaviors noted. 5/4/22 at 5:07 p.m: Resident became very emotional while wife was visiting. The resident stated that he hates his disease and wishes that the 'good lord would just take me'. One on one provided by staff with reassurance and emotional support. 6/30/22 at 8:33 p.m: Resident disruptive with another resident, entering other resident's room through shared bathroom, yelling and arguing with the other resident, refusing to leave room. One on one with staff and redirect with little success, increased resident's agitation. 8/6/22 at 4:17 p.m: Today resident showed several different instances of verbal aggression and agitation. During the parade he was cussing at staff members and calling CNAs 'bunch of dumb (derogatory word)'. He also continuously tried to roll down the sidewalk onto the street. Would not pick feet up for staff members to wheel his wheelchair back to a safe area. Once staff members were able to assist him inside he stood up from his wheelchair and walked aggressively toward a staff member, yelling that he wanted the police. He was also very upset due to not having his car and called all staff members liars when told that his wife has the car. Also stated 'well she's going to pay for that if that's the truth' referring to his wife. Also yelling at police officers in the parade for help. Interventions taken for behaviors today included one on one with different staff members throughout the day, reassurance that his wife has the car and is at home, and also this nurse showed the resident his chart to show him when he was admitted here. Interventions ineffective. Continues to be verbally aggressive towards staff members. Wife was here to visit with him this afternoon, after talking with his wife about the car, the resident shows no further aggression while she is visiting. 8/13/22 at 5:45 a.m: Resident noncompliant with cares in the morning, yelling and aggressive with staff. 8/15/22 at 4:12 p.m: Resident noted to have increase in agitation today. Agitation displayed verbally. Yelling at staff to 'shut up'. Also was calling wife names and made her cry. Wife did not tell staff what he said, but was visibly upset. Interventions used for agitation today included one on one with different staff members throughout the day, attempted to reassure, but was ineffective. All interventions ineffective, resident continued to be verbally aggressive to staff and wife. 8/26/22 at 3:38 p.m: Resident is noted to be verbally aggressive toward staff members when staff try to explain to him why his wife is not here to visit today. Interventions taken today to help with agitation included reassurance that his wife did not abandon him, but had personal circumstances today where she could not visit, snacks and beverages given for distraction, and also different staff members provided one on one with resident throughout the day. Interventions are effective for some staff members, but for others, the resident continues to be verbally angry and upset. Review of a Psychotropic Medication Review form dated 8/29/22 revealed the physician did not recommend any changes to Resident #6's antipsychotic medication. The form was signed by the facility's interdisciplinary team (IDT), the medical director, and the pharmacist. -The form did not document a clinical rationale for failing to decrease the resident's medication. -The form also documented that the date of the last risk versus benefit statement was not applicable. D. Interviews Dietary aide (DA) #2 was interviewed on 8/30/22 at 8:36 a.m. DA #2 said she had not seen Resident #6 exhibit any behaviors. She said he could be ornery, however, she said she had never seen him be aggressive or mean. CNA #2 was interviewed on 8/30/22 at 9:00 a.m. CNA #2 said Resident #6 would sometimes get confused. He said the resident could be verbally aggressive to his wife and to staff. He said he had never seen the resident be physically aggressive. CNA #2 said when the resident was agitated, staff usually tried to spend one on one time with him. He said that would sometimes work to calm the resident down. He said if one-on-one time did not decrease the behavior, staff would try to distract the resident by offering food or coffee. CNA #2 said if the resident could not be calmed, staff would keep him in their line of sight to make sure he was safe until he calmed down. CNA #3 was interviewed on 8/30/22 at 9:10 a.m. CNA #3 said Resident #6 exhibited behaviors at times. He said the resident would often try to leave and say he did not belong at the facility or look for his wife. He said staff would try to redirect him with snacks or sit in the front lobby with the resident. CNA #3 said if the resident could not be redirected, staff would make sure he was safe and the resident would usually calm down. He said he had only seen the resident be physically aggressive one or two times. He said the resident would swat at a staff member if he was upset, however, he said it was not very aggressive. CNA #3 said the resident would sometimes get upset and be verbally aggressive, but would usually calm down with redirection or leaving him alone for a while. Registered nurse (RN) #1 was interviewed on 8/30/22 at 10:45 a.m. RN #1 said Resident #6 was very verbally and physically aggressive when he was first admitted to the facility in December 2021. She said he had a very difficult time settling in. RN #1 said the resident did not exhibit any physical behaviors anymore. She said he could sometimes exhibit some verbal behaviors, however the behaviors were nothing like they were when he first admitted . She said the resident liked to talk and reminisce about the past. RN #1 said he was fairly redirectable now. She said his behaviors never interfered with other residents. She said his behaviors were all directed at staff or his wife. The NHA, the medical record coordinator (MRC), and the social services coordinator (SSC) were interviewed together on 8/30/22 at 2:50 p.m. The NHA said Resident #6 had multiple physical and verbal behaviors when he was admitted to the facility in December 2021. She said he was lashing out at staff, yelling, and exit seeking. She said he had been very difficult to redirect. She said since the antipsychotic medication was added to his medication regimen, the resident was able to hold conversations with staff members, and no longer exhibited many behaviors. She said when he did have behaviors, he was usually redirectable. The NHA said the IDT and the physician had not attempted to reduce the resident's medication because he was doing so much better on the medication. She said the physician had not documented a statement which indicated that reducing the dose of the resident's medication would be clinically contraindicated. The NHA said the risk versus benefit form for psychotropic medications was supposed to be filled out by the physician. She said once the form was completed, a facility staff member would have the risk versus benefit discussion with the POA. She said the discussion would be documented in the resident's progress notes. The NHA confirmed that there was no documentation in Resident #6's EMR that indicated the risk versus benefit discussion had taken place with the resident's POA. III. Resident #8 A. Resident status Resident #8, age greater than 90, was admitted on [DATE]. According to the August CPO, diagnoses included Alzheimer's disease, major depressive disorder, and other depressive episodes. The 6/26/22 MDS assessment revealed that the BIMS was not conducted. The staff assessment for mental status was also not conducted. According to the 4/3/22 MDS assessment, the resident's cognitive skills for daily decision making were severely impaired. The 6/26/22 MDS assessment revealed that the resident required one person extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. The 6/26/22 MDS assessment further revealed the resident exhibited potential indicators of psychosis such as delusions or hallucinations. She did not exhibit any physical or verbal behaviors, rejection of cares, or wandering behaviors during the seven day MDS assessment look-back period. She received an antipsychotic medication daily. B. Observations On 8/28/22 at 4:50 p.m., Resident #8 was lying in bed with her bed in a low position. The resident was sleeping. On 8/29/22 at 9:40 a.m., Resident #8 was seated in her recliner with the footrest up. She was awake. The resident was calm and was not exhibiting any behaviors. On 8/30/22 at 8:42 a.m., Resident #8 was again seated in her recliner calmly in her room. C. Record review Review of Resident #8's August 2022 CPO revealed the following physician's orders: Zyprexa tablet 2.5 mg by mouth in the evening for dementia with behaviors. The order had a start date of 10/24/19. Behavioral monitoring for antipsychotic use: Exit seeking, distressful yelling for family/need for transportation. The order had a start date of 2/26/21. Non-pharmacological interventions for antipsychotic medication use: provide distraction through preferred activity per list posted on closet door, enter her reality and engage her in reminiscing. The order had a start date of 2/26/21. Review of Resident #8's psychotropic medication care plan, initiated 8/28/28 and revised on 5/8/21, revealed the resident used antipsychotic medications related to Alzheimer's dementia with behaviors/agitation. Pertinent interventions included administering antipsychotic medications as ordered by physician, attempting and documenting non-pharmacological interventions and effectiveness every shift, discussing continued need for psychotropic medications in the Psychotropic Medication Review Meeting and approaching physician for a gradual dosage reduction when clinically appropriate, and monitoring/recording occurrence of target behavior symptoms (see TAR). -The care plan did not list the specific target behaviors or non-pharmacological interventions for the resident. -Review of Resident #8's electronic medical record EMR failed to show documentation that a risk versus benefit statement to justify the resident's use of the medications was provided to the resident and/or the resident's representative. Review of Resident #8's behavior tracking sheets (monitoring of physical/verbal behaviors, wandering, and frequent crying), which were documented by the certified nurse aides (CNA), were reviewed for 2/1/22 through 8/29/22. The behavior tracking sheets revealed the following: -February 2022: the resident exhibited behaviors on 11 days out of 28 days; -March 2022: the resident exhibited behaviors on seven days out of 31 days; -April 2022: the resident exhibited behavior on five days out of 30 days; -May 2022: the resident exhibited behavior on three days out of 31 days; -June 2022: the resident exhibited behaviors on five days out of 30 days; -July 2022: the resident exhibited behaviors on four days out of 31 days; and, -August 2022: the resident exhibited behaviors on three days out of 29 days. Review of Resident #8's TAR from 2/122 through 8/29/22 revealed the following: -February 2022: the resident exhibited behaviors on zero days out of 28 days; -March 2022: the resident exhibited behaviors on zero days out of 31 days; -April 2022: the resident exhibited behavior on zero days out of 30 days; -May 2022: the resident exhibited behavior on two days out of 31 days; -June 2022: the resident exhibited behaviors on zero days out of 30 days; -July 2022: the resident exhibited behaviors on three days out of 31 days; and, -August 2022: the resident exhibited behaviors on zero days out of 29 days. -Despite the nurse and CNA documentation which indicated Resident #8 was not exhibiting behaviors which warranted the use of an antipsychotic medication, the facility failed to attempt a GDR of the antipsychotic medication, as is required two times within the first year of the medication being started and annually thereafter unless clinically contraindicated. -There was no documentation from the physician in the resident's EMR which indicated a GDR of the medication was clinically contraindicated. Review of Resident #8's EMR revealed the following progress notes documented in pertinent part: 2/9/22 at 1:49 p.m: Resident was crying today. Was able to redirect resident and provide one on one with staff. 5/25/22 at 4:42 p.m: Resident crying. One on one with staff provided. 5/31/22 at 1:09 p.m: Resident has had poor appetite today with multiple episodes of crying. One on one with staff provided with reassurance. 7/7/22 at 9:52 a.m.: Resident was crying. Stated she didn't know what she was going to do. One on one with staff provided with emotional support and redirection was effective. 7/27/22 at 12:39 p.m: Resident tearful and crying in the dining room. One on one with staff provided with reassurance and distraction. The resident offered a nap as well. -There were no other behavior notes documented in the progress notes. Review of a Psychotropic Medication Review form dated 8/29/22 revealed the physician did not recommend any changes to Resident #8's antipsychotic medication. The form was signed by the facility's interdisciplinary team (IDT), the medical director, and the pharmacist. The form documented the resident had exhibited no behaviors. -The form did not document a clinical rationale for failing to decrease the resident's medication. -The form did not include a date of the last risk versus benefit statement. D. Interviews DA #2 was interviewed on 8/30/22 at 8:36 a.m. DA #2 said Resident #8 would sometimes tell staff to get out of her room. She said she had never seen the resident be physically or verbally aggressive with anyone. CNA #2 was interviewed on 8/30/22 at 9:00 a.m. CNA #2 said Resident #8 could be difficult at times, but for the most part she was pleasant. He said sometimes the resident could get upset when staff tried to change her brief. He said she would push staff away, but then she would allow them to complete care. CNA #2 said he had never seen the resident be really verbally or physically aggressive. CNA #3 was interviewed on 8/30/22 at 9:10 a.m. CNA #3 said he had never seen Resident #8 have any behaviors. He said sometimes the resident would yell out to get up, but he had never seen her with verbal or aggressive behaviors. RN #1 was interviewed on 8/30/22 at 10:45 a.m. RN #1 said Resident #8 would sometimes cry, however, she said that was the extent of her behaviors. She said the resident could occasionally get upset with staff during care, but she was not physically or verbally aggressive. RN #1 said staff would play music for her to calm her down. She said if the resident got agitated, it was usually because she wanted to lay down but had difficulty expressing her needs. RN #1 said if staff put the resident to bed and put her music on, the resident would calm down quickly. The NHA, the MRC, and the SSC were interviewed together on 8/30/22 at 2:50 p.m. The NHA said Resident #8 had been on the Zyprexa since 2019. She said the resident should have had several GDRs attempted since starting the medication. The NHA said the only behaviors the resident exhibited were crying episodes, asking where her family was, and other typical dementia questions. She said the resident did not have any verbal or physical aggression. She said there should be behaviors documented in the resident's EMR to justify keeping her on an antipsychotic medication. The NHA confirmed there were very few behaviors documented in the resident's EMR. The NHA confirmed that there was no documentation in Resident #8's EMR that indicated the risk versus benefit discussion had taken place with the resident's POA. IV. Resident #14 A. Professional reference According to [NAME] Nursing Drug Handbook, 2020, read in part: Olanzapine (Zyprexa), an antipsychotic. Black Box Alert: Elderly patients with dementia related psychosis are at increased risk for mortality due to cerebrovascular events. Uses: schizophrenia and acute mania in bipolar disorder. Off-label use: prevention of chemotherapy induced nausea/vomiting. B. Resident status Resident #14, age [AGE], was admitted on [DATE]. According to the August 2022 CPO, diagnoses included heart failure, pancreatic insufficiency and prostate cancer. The 7/12/22 MDS assessment revealed moderately impaired cognition with a brief interview for mental status (BIMS) score nine out of 15. He required limited assistance with bed mobility, transfers, dressing, toilet use and personal hygiene, and supervision with walking and eating. Medications included an antipsychotic administered daily. C. Resident observations and interview Resident #14 was interviewed on 8/28/22 at 5:00 p.m. He said he was independent in his room and throughout the facility using his walker. He said he was not aware of any psychotropic medications that he was taking. Resident #14 was observed in the dining room on two occasions, on 8/28/22 at 5:30 p.m., eating dinner, and on 8/30/22 at 12:15 p.m. during lunch meal. He ate most food for both meals, approximately 80% without any observed difficulties or signs of nausea. The resident was interviewed on 8/30/22 at 2:50 p.m. He said he did not have any issues with appetite or nausea. He said he was eating most of his meals 100% and did not experience any problems. D. Record review The comprehensive care plan revealed the following: -The resident uses antipsychotropic (an antipsychotic) medication r/t (related to) disease process, prostate CA (cancer)/ nausea. Dated 8/29/29. Interventions included: administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness q-shift (every shift). Consult with pharmacy, MD (physician) to co[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection, including COVID-19 for two of two rooms. Specifically, the facility failed to: -Ensure housekeeping staff followed proper hand hygiene protocols when cleaning resident rooms; -Ensure proper room cleaning procedures were followed; -Ensure spray bottles were properly labeled with the disinfectant they contained; and, -Ensure housekeeping staff adhered to the appropriate wet/contact/dwell time (the time a chemical must remain in contact on a surface in order to eradicate organisms) for disinfection. Findings include: I. Professional references A. The Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings (updated January 2020), retrieved on 9/1/22 from https://www.cdc.gov/handhygiene/providers/guideline.html, read in pertinent part, Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: after touching a patient or the patient's immediate environment and after contact with blood, body fluids, or contaminated surfaces. B. The CDC: Healthcare-Associated Infections (HAIs) 4.1 General Environmental Cleaning Techniques (updated on 4/21/2020), retrieved on 9/1/22 from https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html, read in pertinent part, Proceed from cleaner to dirty areas to avoid spreading dirt and microorganisms. Clean low touch surfaces before high touch areas surfaces. Some common high touch surfaces were sink handles, bedside tables, call bells, door knobs, light switches, bed rails, wheel chairs, and counters where medications or supplies were prepared. Proceed from high areas to lower areas (top to bottom) to prevent dirt and microorganisms from dripping/falling onto surfaces below thus contaminating already cleaned surfaces. Change cleaning cloths between each resident zone (use a new cleaning cloth for each resident area). Never shake mop heads and cleaning cloths-it disperses dust or droplets that could contain microorganisms. C. Dwell Times Explained (dated 4/7/21), retrieved on 9/1/22 from https://vitaloxide.com/blogs/blog/dwell-times-explained, read in pertinent part, Giving a surface a quick spray, followed immediately by a wipe or two, may not allow enough time for the product to work effectively. To make sure a disinfectant is doing its job, it's crucial to follow the recommended 'dwell time', also known as 'contact time' or 'kill time.' The Environmental Protection Agency (EPA) defined dwell time as the amount of time that a sanitizer or disinfectant must be in contact with a surface and remain wet to achieve the product's advertised elimination (kill) rate. Disinfectant solutions could target a wide range of pathogens, and the surfaces these pathogens inhabit could vary greatly. To ensure a surface has been thoroughly disinfected, it is essential to always pay attention to the dwell time recommendations on the product's label. II. Facility policy and procedures A. The Handwashing Policy, last revised 1/29/22, was provided by the nursing home administrator (NHA) on 8/31/22 at 8:45 a.m. It read, in pertinent part, The purpose of this policy is to state that handwashing is the single, most important way to prevent the spread of infection. Hands are exposed to pathogens in the work area continuously. Proper hand washing will help prevent spreading pathogens from one resident to the next and to staff. All personnel will wash their hands according to CDC guidelines to prevent the spread of infections. Using Alcohol-Based Hand Rubs (ABHR): Alcohol containing hand sanitizers may be used. Alcohol content must be 60% or greater. Apply enough product to thoroughly wet hands. Rub hands together until dry. Key opportunities to perform hand hygiene: When coming on duty prior to entering work area, after removing gloves, when the hands are obviously soiled, between handling of individual residents, on completion of duty. B. The Room Cleaning Policy, last revised 2/2020, was provided by the chief financial officer (CFO) on 8/29/22 at 3:00 p.m. It read, in pertinent part, To prevent the spread of infection within the facility by maintaining a thoroughly clean and safe environment. An approved disinfectant will be used. Cleaning should always progress from the least soiled areas, and from high to low areas so that the dirtiest areas and debris that falls on the floor will be cleaned last. -The policy had not been revised since before the COVID-19 pandemic. III. Room cleaning observations A. room [ROOM NUMBER] On 8/29/22 at 9:45 a.m. housekeeper (HSK) #1 was observed cleaning room [ROOM NUMBER]. The room was a double occupancy room, however, there was only one resident residing in the room. The room was not an isolation room. HSK #1 began by sanitizing her hands with alcohol based hand rub (ABHR) and putting on a pair of gloves. She proceeded to enter the room and dumped the trash cans in the room and the bathroom. She returned to her cart to dispose of the trash. She unlocked a compartment on her cart and removed a container which contained various cleaners and disinfectants. She relocked the compartment and returned to the room with the container. HSK #1 placed the container of chemicals on top of the trash can by the sink. HSK #1 proceeded to spray the sink area with a spray bottle containing a yellow colored disinfectant. The spray bottle was not labeled with the name of the chemical contained in the bottle. After spraying the sink area with the disinfectant, HSK #1 applied Creme Cleanser to the inside of the sink and faucet. She then wiped off the faucet and the inside of the sink with a rag and turned on the water to rinse the sink. She tossed the rag on the floor just inside the entrance to the room. HSK #1 then proceeded to wipe the disinfectant off the sink area with a clean dry rag. The disinfectant had been on the surface of the sink area for four minutes. She again tossed the rag on the floor, just inside the entrance of the room. Without changing her gloves or sanitizing her hands, HSK #1 then proceeded to spray the yellow colored disinfectant on the dresser and other flat surfaces on side B of the room. She immediately wiped off the disinfectant with a dry rag without allowing the disinfectant to sit on the surfaces for any amount of time. HSK #1 again tossed the rag on the floor, just inside the entrance of the room. Without changing her gloves or sanitizing her hands, HSK #1 proceeded to spray the yellow colored disinfectant on the dresser and other flat surfaces on the unoccupied side of the room, side A. She again immediately wiped the disinfectant off with a rag without allowing the disinfectant to sit on the surface for any amount of time. After wiping off the surfaces on side A, HSK #1 picked up all of the rags that had been thrown on the floor of the room. She returned to her cart and disposed of the rags in the dirty rag bin on her cart. Without changing her gloves or sanitizing her hands, HSK #1 returned to the room to clean the toilet area. She sprayed the toilet bowl with a spray bottle containing a purple colored disinfectant. The spray bottle containing the disinfectant was not labeled. She then proceeded to clean the toilet bowl with a scrub brush. After using the scrub brush on the toilet bowl, she rinsed the brush with a spray hose, which was attached to the bathroom wall. HSK #1 then proceeded to tap the toilet brush on the side of the toilet several times which caused liquid from the toilet brush to spray on multiple surfaces in the bathroom. Without changing her gloves or sanitizing her hands, HSK #1 sprayed the outside of the toilet with the purple colored disinfectant and then immediately wiped the disinfectant off all of the surfaces without allowing the disinfectant to sit on the surface for any amount of time. After cleaning the toilet, without changing her gloves or sanitizing her hands, HSK #1 grabbed the yellow colored disinfectant spray bottle and sprayed all of the door handles in the room. After spraying the door handles, HSK #1 returned to her cart carrying the container of cleaners and disinfectants. She was still wearing the same gloves she had been wearing the entire time she cleaned and disinfected the room. HSK #1 took a set of keys from her pocket, opened the locked compartment on her cart, and put the container of cleaners/disinfectants away. She did not change her gloves or sanitize her hands. HSK #1 proceeded to grab another rag from her cart, then went back to the room to wipe off the door handles still wearing the dirty gloves. As HSK #1 was returning to the room to wipe off the door handles, she used her dirty gloves to pull up her pants. After wiping off the door handles, she returned to her cart and put the rag in the dirty rag bin on her cart. HSK #1 was then observed touching her face mask with her dirty gloves. Without changing her gloves or sanitizing her hands, HSK #1 returned to the room to sweep the floor. After sweeping the floor, she mopped the room, starting on side B and then working her way to side A. She mopped the bathroom last. While she mopped the room, HSK #1 continued to pull up her pants with her dirty gloves. At 10:15 a.m., HSK #1 returned the mop to the mop bucket outside the room. She removed her gloves and sanitized her hands with ABHR. She said she was finished cleaning the room. At 10:25 a.m. HSK #1 opened the door to the housekeeping closet where the cleaning chemicals/disinfectants were stored. She said the spray bottles were filled from the bigger bottles of chemicals stored in the closet. HSK #1 said the yellow colored chemical was Pine Quat. The instructions on the bottle of Pine Quat said to let the chemical sit on surfaces for a full 10 minutes for effective disinfection. HSK #1 said the purple colored disinfectant was X-Effect. The instructions on the bottle of X-Effect said treated surfaces must remain wet for 10 minutes. B. room [ROOM NUMBER] On 8/29/22 at 11:30 a.m., HSK #1 was observed cleaning room [ROOM NUMBER]. The room was a double occupancy room with two residents residing in it. The room was not an isolation room. HSK #1 began by sanitizing her hands with ABHR and putting on a pair of gloves. She proceeded to enter the room and dumped the trash cans in the room and the bathroom. She sprayed both trash cans with Pine Quat disinfectant and then immediately wiped them down with a dry rag and replaced the bags in the cans. She did not allow the disinfectant to sit on the trash can surfaces for the required 10 minutes. HSK #1 took the dirty rag and trash to her cart. She removed her gloves, sanitized her hands with ABHR, and put on a new pair of gloves. HSK #1 returned to the room and sprayed the door handles and flat surfaces on both sides of the room with Pine Quat disinfectant. After spraying the sink area with the disinfectant, HSK #1 applied Creme Cleanser to the inside of the sink and faucet. She then wiped off the faucet and the inside of the sink with a rag and turned on the water to rinse the sink. She tossed the rag on the floor just inside the entrance to the room. HSK #1 then proceeded to wipe the disinfectant off the sink area with a clean dry rag. The disinfectant had been on the surface of the sink area for three minutes. She again tossed the rag on the floor, just inside the entrance of the room. HSK #1 then used the same gloves and rag that had been used on the sink area to wipe down the flat surfaces on side B of the room. The disinfectant had been on the flat surfaces for five minutes. HSK #1 picked up the dirty rags from the floor, returned to her cart, placed the rags in the dirty rag bin, removed her gloves and sanitized her hands with ABHR. She put on a new pair of gloves, grabbed a clean dry rag from her cart, returned to the room and proceeded to wipe down side A. HSK #1 then used the same rag to wipe the door handles. The disinfectant had been on the surface on side A for eight minutes. The surfaces were no longer wet when she wiped them down. HSK #1 returned to her cart and disposed of the dirty rag in the bin on her cart. Without changing her gloves or sanitizing her hands, she returned to the room and swept the floor. After sweeping the floor, HSK #1 proceeded to clean the toilet. She sprayed the toilet bowl with the X-Effect disinfectant. She then proceeded to clean the toilet bowl with a scrub brush. After using the scrub brush on the toilet bowl, she rinsed the brush with a spray hose, which was attached to the bathroom wall. HSK #1 proceeded to tap the toilet brush on the side of the toilet several times which caused liquid from the toilet brush to spray on multiple surfaces in the bathroom. She next sprayed the outside of the toilet with the X-Effect disinfectant. She allowed the X-Effect disinfectant to sit for one minute before wiping it off with a rag. After disinfecting the toilet, HSK #1 returned to her cart, disposed of the rag, changed her gloves and sanitized her hands. She put on a new pair of gloves and returned to the room to mop. At 11:52 a.m., HSK #1 returned the mop to the mop bucket, removed her gloves and sanitized her hands with ABHR. She said she was finished cleaning the room. IV. Staff interviews HSK #1 was interviewed on 8/29/22 at 10:15 a.m. HSK #1 said she sanitized her hands at the beginning of cleaning a room and then put on gloves. She said she would remove her gloves and sanitize her hands again when she was finished cleaning the room. She said she would put on a new pair of gloves prior to starting to clean a new room. She said hands should probably be sanitized after cleaning the toilet and new gloves put on. She said the toilet should be the last thing cleaned. She said she could not remember the names of the cleaners she was using. She thought they had to sit on the surface for a dwell time of five minutes. The chief financial officer (CFO), who oversaw the housekeeping staff, was interviewed on 8/29/22 at 12:06 p.m. The CFO said the housekeepers received annual training on infection control and how to properly clean a room. She said the training was a video on a website that they watched. She said the video included the types of chemicals the housekeepers should use, and the proper way to clean a room. She said the new housekeepers then spent about a week with an experienced housekeeper. She said the facility conducted random audits to make sure rooms were being cleaned properly, however, she said she did not have documentation of the audits. The CFO said the housekeepers should use one disinfectant for all surfaces. She said the facility had just switched to a different chemical, however she could not remember the name of the chemical. She said she thought the dwell time for the disinfectant was five minutes. She said she would find the information. She said the disinfectant should be left on surfaces, and remain wet, for the recommended amount of time to properly disinfect. She said spray bottles should be clearly labeled with the name of the chemical they contained. The CFO said toilet brushes should not be tapped on the edge of the toilet bowl because that had the potential to spread germs to other surfaces. She said HSK #1 should have changed her gloves and sanitized her hands any time she touched something dirty and after she cleaned the toilet. She said gloves should also be changed and hands sanitized between each side of a resident room. She said the toilet should always be the last item cleaned in the room. The NHA, who was an RN and the facility's certified infection preventionist, was interviewed on 8/30/22 at 1:00 p.m. The NHA said she was in the process of training a nurse to help with infection prevention. She said when cleaning a room, gloves should be changed and hands should be sanitized anytime they touch something dirty. She said the toilet should be the last thing cleaned in a room. The NHA said HSK #1 should have cleaned one side of the room and then the other. She said she should have changed gloves, sanitized hands, and used separate rags on each side of the room. The NHA said spray bottles should be properly labeled with the name of the chemical in the bottle. She said manufacturer's instructions should always be followed for chemical dwell times to ensure surfaces were thoroughly disinfected V. Facility followup On 8/29/22 at 3:00 p.m., the CFO provided information on the X-Effect disinfectant. She said the disinfectant was an Environmental Protection Agency (EPA) approved disinfectant. She said the chemical had a recommended dwell time of 10 minutes. The CFO also provided documentation infection control/room cleaning training for HSK #1. The training included how to set up the cleaning cart, hand hygiene, how to clean an occupied resident room, how to clean a discharged resident room, how to clean a resident isolation room, how to clean a resident bathroom, and how to clean and disinfect high touch surfaces. The training documentation provided indicated HSK #1 had received training on 8/5/2020, 6/11/21, and 5/10/22. VI. Facility COVID-19 status The NHA was interviewed on 8/30/22 at 1:00 p.m. The NHA said the resident census was 23. She said the facility had no current COVID-19 positive residents or staff members. She said there were no COVID-19 tests pending for residents or staff. The NHA said the facility was currently in an outbreak status. She said all staff and residents had been tested on [DATE] and all tests had come back negative. She said all staff and residents would be tested again on 9/1/22, per the guidance of the state health department. The NHA said if all tests from 9/1/22 came back negative, the facility would no longer be in the outbreak status.

Based on record review and interviews, the facility failed to ensure all staff had current abuse and dementia care training. Specifically, the facility failed to ensure five out of five licensed nurses and CNAs reviewed within the previous year received dementia management training and abuse prevention training. Findings include: I. Record review Staff competencies/annual training for the selected nursing staff (CNAs and licensed nurses) were requested from the NHA on 8/29/22 at 12:30 p.m. The NHA provided the staff new hire competency checklists the following day on 8/30/22 at 5:13 p.m. -However, there was no record of annual training to include abuse, neglect and exploitation training and dementia care training. II. Staff interview The NHA was interviewed on 8/29/22 at 12:30 p.m. She said she did not have the training records and competency checklists available to her and would need to contact her HR representative to send her the requested documentation. She said her director of nursing (DON) was no longer employed and she could not find the employee training logs and competency checklists. The NHA said she was not sure where those were kept and was concerned her DON did not keep record of the facility training. She said she did not believe the annual training had been completed for 2021 or 2022. She said she was not sure when the last all staff training was completed to include dementia care training and abuse training. She said she would work with her HR representative to schedule the required annual training. She said she would usually depend on the DON to assist her with the training, however she currently did not have a DON on staff.

Based on record review and interviews, the facility failed to designate a registered nurse (RN) to serve as the director of nursing (DON) on a full time basis. Specifically, the facility utilized the nursing home administrator (NHA) to also serve as the DON and she was unable to work full time hours as the DON. Cross-reference F686 for the facility's failure to monitor and prevent pressure ulcers. Findings include: I. Record review Review of the August 2022 nursing schedule revealed there was not a DON scheduled for the month of August 2022. The NHA was on the schedule as an RN and NHA for the month of August 2022. She was not assigned to work the floor as a nurse, however she was scheduled to provide the nursing oversight. II. Staff interviews The NHA was interviewed on 8/29/22 at 12:30 p.m. She said she did not have a registered nurse designated as the DON on a full time basis. She said her previous DON left and she did not have the position filled for a few months. She said she did have RNs she delegated tasks with the DON position not filled. She said she offered the DON position to RN #1, however she declined the position. She said she had two open management positions she was covering to include the DON position as well as the dietary manager (DM) position. She said it was difficult to fill her management positions because of their rural location. III. Additional information Review of the state facility licensing database showed the 3/3/22 facility license update documented the NHA has served as the DON since 12/8/21.

Based on record review and interviews, the facility failed to employ a director of food and nutrition services with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 23 census residents. Specifically, the facility utilized the nursing home administrator (NHA) to also serve as the dietary manager (DM) and she was unable to work full time hours as the DM. Cross-reference F692 for the facility's failure to monitor and prevent significant weight loss. Findings include: I. Record review Review of the August 2022 dietary department schedule revealed there was not a DM scheduled for the month of August 2022. The dietary department had a day and evening shift cook scheduled and one to two dietary aides scheduled for each shift, however there was not a designated full time qualified DM scheduled weekly as required. II. Staff interviews The NHA was interviewed on 8/29/22 at 12:30 p.m. She said she did not have a dedicated dietary manager for the department. She said she had a contracted certified dietary manager (CDM) that provided offsite support weekly as well as onsite visits two days a week. The NHA said she also had a registered dietitian (RD) that provided clinical oversight for diet changes one day every other week. The NHA said she had a dietary manager that did not complete her certification and had not worked there for over a year. She said the department had been without a dedicated DM for over a year and she had been filling in when needed as the DM. She said the dietary cook (DC) #2 and dietary aide (DA) #1 had been with the dietary department for over 14 years and they were able to run the kitchen well without a DM, however she understood she needed to fill the position. She said it was difficult to fill her management positions because of their rural location. The RD was interviewed on 8/29/22 at 1:30 p.m. She said she was new to the facility and recently started in July 2022. She said she came into the facility one day every two weeks and worked remotely the rest of the time. She said there was a contracted CDM that came in two days a week to provide oversight to the dietary department. The RD said she mainly focused on reviewing new admission diets, change of conditions in diets and weight loss. She said the dietary department currently did not have a full time DM, however DC #2 helped with the weekly ordering of the food and the organization of the kitchen. DC #2 was interviewed on 8/30/22 at 12:15 p.m. He said he had worked in the kitchen as a cook for 14 years. He said the kitchen has been without a DM for around one year. He said they had a contracted CDM that came in twice a week to help with the management of the dietary department. He said DA #1 had also been working in the kitchen for over 14 years and helped keep the kitchen clean and organized. He said he was the main cook for the daytime and there was an evening cook as well. He said he did not assist with any management of the dietary department, however he did take over the weekly ordering of the food and helped organize the kitchen and food storage areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure two (#8 and #19) out of three of 21 sample residents reviewed were free from abuse. Specifically, the facility failed to prevent incidents of physical abuse toward Resident #8 and #19 by Resident #16. I. Facility policy The Abuse Prevention policy, issued date of 5/2019, was provided by the director of nurses (DON) on 5/19/21 at 10:30 a.m. read in pertinent part; Purpose: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom form corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and phyican or chemical restraint not required to treat the residents symptoms. Policy: It is the policy of the facility to ensure that all of the residents are free from abuse, neglect, misappropriation of resident property and exploitation. II. Resident #16 A. Resident status Resident #16, age [AGE], was admitted on [DATE]. According to the May 2021 computerized physician orders (CPO), pertinent diagnoses included dementia without behavioral disturbances, depression and heart failure. The 4/18/21 minimum data set (MDS) assessment revealed the resident had a cognitive deficit with a brief interview for mental status (BIMS) of seven out of 15. She required extensive assistance with two people for bed mobility, transfers, toilet use, dressing and limited assistance for personal hygiene. She had delusions. III. Incidents of resident-to-resident abuse A. 4/5/21 with Resident #8 1. Resident status Resident #8, age [AGE], was admitted on [DATE]. According to the May 2021 computerized physician orders (CPO), pertinent diagnoses included heart failure and diabetes. The 3/15/21 minimum data set (MDS) assessment revealed the resident had a cognitive deficit with a brief interview for mental status (BIMS) of seven out of 15. She required extensive assistance with one person for dressing total care of two people for transfers and toileting. She had limited assistance with one for hygiene. She had physical and verbal behaviors directed toward staff and rejection of cares. 2. Facility investigative report The facility investigative report dated 4/5/21, was provided by the nursing home administrator (NHA) on 5/19/21 at 10:30 a.m., it read in pertinent part; Resident #8 passed by Resident #16, when Resident #16 reached out and grabbed her. Resident #8 yelled and the staff were there immediately. Both residents were assessed and no injuries were noted. Both residents were taken to their rooms. Resident #16 was assessed for pain as that increased her agitation at times. She did receive pain medication. Resident #8 was interviewed and assessed for pain. She said she was in pain but did not recall the incident. Staff was educated on close monitoring of Resident #16, and to give her alternative activities such as video call to her daughter and family, coloring, soft music, pain medication to her knees, interaction with staff with a calm voice. Resident monitoring by staff when she was in the hallway independently. All notifications to the police department, ombudsman and family were completed.`Behavior nurse note for Resident #16 dated 4/5/21 at 8:23 p.m. read in pertinent part; Resident #8 passed in front of Resident #16 and Resident #16 grabbed Resident #8 right arm in an aggressive manner. Resident #8 screamed and staff separated the residents. No significant injuries noted. Resident #16 was assisted to her room and assisted with night cares in bed and no further outburst occurred. NHA was notified. B. 4/6/21 with Resident #19 1. Resident status Resident #19, age [AGE], was admitted on [DATE]. According to the May 2021 computerized physician orders (CPO), pertinent diagnoses included traumatic brain injury, dementia and coronary artery disease. The 4/26/21 minimum data set (MDS) assessment revealed the resident had a cognitive deficit. She required extensive assistance with one person for dressing and limited assistance with one person for toileting, transfers and hygiene. She had delusions and rejection of cares. 2. Facility investigative report The facility investigative report dated 4/6/21, was provided by the nursing home administrator (NHA) on 5/19/21 at 10:30 a.m., it read in pertinent part; Resident #16 was being assisted with the sit to stand lift in the hallway when Resident #16 aggressively grabbed Resident #19 by the arm and attempted to hurt her. Licensed practical nurse (LPN) immediately intervened. Resident #16 was transferred to the bathroom as they were in the process of assisting with that during the incident. Once the task was completed, Resident #16 was assessed for pain, and medication was given. Resident was given the opportunity to call her daughter as that often relieved her agitation. She was placed away from other residents and monitored by staff. Resident #19 was assessed for injury and none were noted. Resident #19 was interviewed and said she did not recall the incident and she was not fearful of any resident in the building. The police, physician and family were called and the facility. Staff were educated to monitor the resident and to monitor the close proximity of Resident #16 to other residents when in the activity room and the hallway. All notifications to the police department, ombudsman and family were completed. Behavior nurse note for Resident #16 dated 4/6/21 at 5:34 p.m. read in pertinent part; Resident #16 grabbed another resident aggressively on the upper arm. Resident #16 was removed from the situation, placed in her room, given pain medication, massage and allowed to watch her daughter on video call. Director of nurses (DON) was notified. IV. Record review for Resident #16 There was a computerized physicians order dated 4/29/21 for Resident #16 that read in pertinent part ' Document non-medication interventions for anxiety manifested as verbal and physical aggressive behaviors: Encourage diversional activities, coloring, music, and televisio. Assess for pain and or toileting needs. Calm reassuring approach. Assist her in watching a video-taped bible study presentation or other video from her daughter. Document intervention attempted and chart effectiveness in progress note. -This order was put in 23 days after the abuse incidents occurred between residents. The activities of daily living (ADL) care plan for Resident #16 was revised 4/22/2021, it read in pertinent part; Resident #16 had a self care deficit related to dementia, impaired balance and limited mobility. The goal said the resident would maintain the current level of function. The anti-anxiety care plan for Resident #16 was revised on 4/21/21, it read in pertinent part; Resident #16 used anti-anxiety medication. The goal was Resident #16 would be free from discomfort or adverse reactions related to anti-anxiety therapy. The intervention was to administer anti-anxiety medication as ordered, monitor and document any signs and symptoms of adverse side effects of the medication daily. When anxious or agitated, offer and assist with thumb drive video to call family. Intervene before agitation escalates, engage away from source of agitation, engage calm in conversation. -This care plan was not updated after the incidents with both Resident #8 and #19 that occured on 4/5/21 and 4/6/21 to ensure additional steps were taken to keep other residents safe from Resident #16. -Record review of the care plan for Resident #16 revealed no care plan for delusions. V. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 5/19/21 at 9:30 a.m. She said when a resident had an altercation with another resident she made sure the residents were safe then she reported the incident to the nursing home administrator (NHA). She said a progress note was written and the family and physician were notified. Resident #16 had a lot of behaviors at times due to pain but since they increased her pain medication she had less agitation. The NHA was interviewed on 5/19/21 at 2:00 p.m. She said she had several incidents with Resident #16 lashing out at staff and other residents. She said there were multiple interventions used when Resident #16 became agitated. She said she did the investigation and substantiated for abuse because Resident #16 did grab Resident #8 and #19 arm. She said anytime an allegation of verbal, physical abuse, falls, neglect and injury of unknown origin it was reported to the State Agency. The nurses were responsible for completing a process note for any incident and the interdisciplinary team (NHA, DON, nurse, physician) updated the resident's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #18 A. Resident status Resident #18, age [AGE], was admitted on [DATE]. According to the May 2021 computerized physician orders (CPO), pertinent diagnoses included traumatic brain injury, dementia depression and seizure disorder. The 1/31/21 minimum data set (MDS) assessment revealed the resident had a cognitive deficit with a brief interview for mental status (BIMS) of 14 out of 15. She required extensive assistance with one person for dressing and limited assistance with one person for bed mobility, transfers, toilet use, and hygiene. She had no behaviors. B. Record review Record review on 5/18/21 at 9:30 a.m. revealed the following, in part, They concluded the resident had a possibility of hitting her head on the foot board during the night terror incident on 4/26/21 which the resident told the staff she was trying to get away. In conclusion of the investigation it was determined the resident may have sustained injury to her head on 4/26/21 during the night terror. Cross-reference F689 The nursing home administrator (NHA) provided no documentation to indicate staff members were questioned or other residents to complete a thorough investigation of an unwitnessed injury. C. Staff interviews Nursing home administrator (NHA) was interviewed on 5/19/21 at 2:00 p.m. She said the initial incident report for injuries of unknown origin or abuse allegations was completed by the nurse and she was notified to do the investigations. She said she did not put the information about Resident #18 head injury into the portal because there was no section to enter injuries of unknown origin in the portal. She said she knew injuries of unknown origin are reportable incidents so she investigated on her own with the paperwork she created. D. Follow up No further documentation was provided during or after the survey. Based on record review and interviews, the facility failed to ensure that all alleged violations were reported timely for two (#23 and #18) of four out of 21 sample residents. Specifically, the facility failed to report: -An allegation of physical abuse in a timely manner for Resident #23; and, -Resident #18's injury of unknown origin. I. Facility policies and procedures The Reporting and Abuse Investigations policy, last reviewed on May 2019, was provided by the director of nurses (DON) on 5/19/21 at 10:30 a.m. it read in pertinent part; All reports of abuse, neglect, exploitation, misappropriation of residents property, mistreatment and or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. An alleged violation of abuse, neglect, exploitation or mistreatment will be reported immediately, but not later than; -two hours if the alleged violation involves abuse or has resulted in serious bodily injury; or -24 hours if the alleged violation does not involve abuse. II. Resident #23 A. Representative allegation of abuse A Care Conference note dated 2/23/21 at 9:51 a.m., written by the DON, revealed during the care conference the POA had concerns regarding the resident's fall and how it happened. Cross-reference F610 failure to investigate allegations thoroughly. Investigation Report by the NHA dated 2/26/21 (not timed) regarding the resident's fall on 1/24/21 revealed during the care conference on 2/23/21 the family stated that the resident told them that she was pulled out of bed by a red haired nurse which caused her to trip and fall. This was new information for the facility. The Initial Report to the State Agency revealed the date of the allegation of physical abuse was reported to the facility by the family on 2/23/21 at 10:00 a.m. The initial report was submitted by the facility to the State Agency on 2/26/21 at 1:46 p.m. -This was three days after the facility was made aware by family in a care conference that the resident stated a red haired nurse pulled her/pushed her out of the bed causing her to trip and fall. B. Staff interview The nursing home administrator (NHA) was interviewed on 5/19/21 at 1:40 p.m. She said the first time she heard of this allegation was during a care conference on 2/23/21. She said she submitted the information to the State Agency system on 2/26/21 at 1:46 p.m. She said she should have reported it within two hours but was at a loss and researched what to do. She said the facility policy revealed to submit the report within two hours for physical abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to complete a through and timely abuse investigation for two(#18 and #23) out of four of 21 sample residents. Specifically, the facility failed to investigate thoroughly: -Resident #18's allegation of being grabbed by a male staff member; and, -Allegation of abuse reported by Resident #23's representative Findings include: I. Facility policy The Reporting and Abuse Investigations policy, last reviewed on May 2019, was provided by the director of nurses (DON) on 5/19/21 at 10:30 a.m. it read in pertinent part; All reports of abuse, neglect, exploitation, misappropriation of residents property, mistreatment and or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. An alleged violation of abuse, neglect, exploitation or mistreatment will be reported immediately, but not later than; - two hours if the alleged violation involves abuse or has resulted in serious bodily injury; or -24 hours if the alleged violation does not involve abuse. II. Resident #18 A. Resident status Resident #18, age [AGE], was admitted on [DATE]. According to the May 2021 computerized physician orders (CPO), pertinent diagnoses included traumatic brain injury, dementia depression and seizure disorder. The 1/31/21 minimum data set (MDS) assessment revealed the resident had a cognitive deficit with a brief interview for mental status (BIMS) of 14 out of 15. She required extensive assistance with one person for dressing and limited assistance with one person for bed mobility, transfers, toilet use, and hygiene. She had no behaviors. B. Record review Record review on 5/18/21 at 9:30 a.m. revealed the following, in part, They concluded the resident had a possibility of hitting her arm against the wall or foot board during the night terror incident on 4/26/21 which the resident told the staff she was trying to get away. During her night terror the resident said a male grabbed her arm, however there were no male staff working the night of 4/26/21. In conclusion of the investigation it was determined the resident may have sustained injury to her right arm on 4/26/21 during the night terror. Cross-reference F689 A schedule was provided by the NHA to indicate no male staff member was working, however, no documentation was provided to indicate staff members were questioned or other residents to complete a thorough investigation of an unwitnessed injury. The facility failed to thoroughly investigate the allegation made by Resident #18. C. Staff interviews Nursing home administrator (NHA) was interviewed on 5/19/21 at 2:00 p.m. She said the initial incident report for injuries of unknown origin or abuse allegations was completed by the nurse and she was notified to do the investigations. She said she put the information about Resident #18 head injury into the portal within a few hours and filled out the investigation form. She said injuries of unknown origin are reportable incidents. D. Follow up No further documentation was provided during or after the survey. II. Allegation of abuse reported by Resident #23's representative The Fall Scene Investigation Report dated 1/24/21 at 8:10 a.m., revealed the resident had an unwitnessed fall at this time. The resident was in her room alone and unattended. The resident was found seated on her buttocks with her legs straight out in front of her. She was located on the floor in the middle of the room facing the bathroom. Incident note dated 1/24/21 at 12:45 p.m., revealed a follow-up on the resident's fall by the nursing home administrator (NHA). The NHA called the hospital this morning and was told the resident would be admitted . The nurse told the NHA that the family had been to the hospital to see the resident. Communication with the family note dated 1/25/21 at 12:48 p.m., by the NHA revealed a return call to the resident's power of attorney (POA) to discuss the fall on 1/24/21. The POA asked questions regarding the staff rounding (visualization of the resident) that was completed on the resident. The NHA explained the last round on the resident was at approximately 6:45 a.m., and she refused care at this time. The NHA told the POA that the resident was independent in room, requiring cueing at times, but often refused any help from staff. The NHA explained that staff went into the resident's room to get her for breakfast and the resident was found on the floor. The POA was appreciative of the call and the provided information. The POA had no concerns at this time. Nursing admission Screening history dated 1/27/21 at 2:43 p.m., revealed the resident returned from the hospital. Care Conference note dated 2/23/21 at 9:51 a.m., by the DON revealed during the care conference the POA had concerns regarding the resident's fall and how it happened. Investigation Report by the NHA dated 2/26/21 (not timed) regarding the resident's fall on 1/24/21 revealed during the care conference on 2/23/21 the family stated that the resident told them that she was pulled out of bed by a red haired nurse which caused her to trip and fall. This was new information for the facility. The NHA wrote that according to the incident reports, a CNA went to get the resident for breakfast and found the resident seated on the floor with her legs out in front of her. The resident was sent to the hospital for further evaluation. During the initial investigation, because the resident was independent in her room, the conclusion was the resident slipped in her room related to wearing socks that were non-skid socks. This event did not meet the criteria of reporting through the State Agency. This incident was re-evaluated and did not agree with the family's statement of staff involvement with the fall On 2/26/21 staff attempted to interview the resident. She said that a red haired nurse (first name provided) pulled her out of bed and broke her leg. After this statement, the resident refused to talk further with staff. The facility had three to four CNAs that had red hair but no nurses with red hair. The resident named a CNA with red hair but her hair was actually black. Of the CNAs that were working on the day of the fall, one had red hair. -The CNA with red hair, however, was not interviewed during the investigation. It was determined that the resident was potentially walking in her room and fell as there was no other person in the room that we were unable to determine. At the time of the fall, staff were helping other residents with morning routines. The Initial Report to the State Agency revealed the date of the allegation of physical abuse was reported to the facility by the family on 2/23/21 at 10:00 a.m. The initial report was submitted by the facility to the State Agency on 2/26/21 at 1:46 p.m. This was three days after the facility was made aware by family in a care conference that the resident stated a red haired nurse pulled her/pushed her out of the bed causing her to trip and fall (cross-reference F609 for failure to report timely). C. Staff interviews The DON was interviewed on 5/19/21 at 12:28 p.m. She reviewed the nurse notes for the resident's fall on 1/24/21. She said the notes revealed the resident was alone in her room at the time of the fall. She said to her knowledge there were no staff in her room at the time of the fall. She was sent to the hospital almost immediately after the fall. The DON said the first she knew about the concern about the resident's fall being caused by a red haired nurse (named) at the care conference on 2/23/21. She said the facility did not have any staff member with the name provided by the resident. She said the facility did not have any red haired nurses. She said after the family's allegation, the NHA reported the allegation in the State Agency. She said did not interview any staff because the NHA was the abuse coordinator. The NHA was interviewed on 5/19/21 at 1:40 p.m. She said the first time she heard of this allegation was during a care conference on 2/23/21. She said she submitted it to the State Agency system on 2/26/21 at 1:46 p.m. She said she should have reported it within two hours but was at a loss and researched what to do. She said the facility policy revealed to submit the report within two hours for physical abuse. The NHA said the investigation was completed and the conclusion was unsubstantiated due to the fact the facility did not have a red haired nurse or a nurse with the name provided by the resident. She said there was staff in the room next to the resident's room and there were no staff in her room at the time of the fall. The NHA said she interviewed four staff members but did not have any documents from the staff or the staff names to collaborate the interviews. The NHA said she only interviewed the resident and did not interview any other residents. She said she did not feel the need to interview other residents because the resident was in the room by herself. She said none of the red haired staff members were working on the day of the fall. She said no staff were sent home during the investigation period which began 2/23/21 after notification during the care conference. The NHA said the facility had an Ambassador program with a staff member assigned to individual residents. She said they do weekly discussion with the residents and on the week of the fall 1/24/21, none of the residents in the facility at that time expressed that they were scared of any staff members or had concerns about any staff members. D. Conclusion The NHA reported the allegation of staff physical abuse to the State Agency three days after the allegation was made by the resident's family during a care conference (cross-reference F609). The NHA did not interview residents during the investigation period. The NHA interviewed two staff members; however, there was no specific statement documentation from the two staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure a comprehensive care plan was developed for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for two (#6 and #13) of four out of 21 sample residents. Specifically, the facility failed to ensure a comprehensive care plan was developed for: -Resident #6's use of oxygen and respiratory cares, and, -Resident #13's use of an antidepressant for insomnia related to lower extremity pain. I. Facility policies and procedures The Care Plan policy, revised November 1988, was provided by the director of nursing (DON) on 5/19/21 at 12:47 p.m. The policy revealed, the plan should be evaluated according to the goals set out in the plan, following each assessment and whenever the resident's condition changes. -A comprehensive cafe plan must be developed for each resident that included measurable objectives and timetables to meet a resident's needs. The plan must developed within seven days after the completion of the comprehensive resident assessment, prepared by an interdisciplinary team that included the attending physician, a registered nurse responsible for the resident, and other appropriate staff as determined by the resident's needs and with the participation of the resident, family/legal representative to the extent practicable. -The care plan should be periodically reviewed and revised at least quarterly and per significant change in the resident's physical/mental/psychosocial condition. -The care plan would be reviewed to ensure that the plan and updates were timely and that the plans contained identifiable integrated staff input, resident/legal representative and physician participation. II. Resident #6 A. Resident status Resident #6, age [AGE], was admitted on [DATE]. According to the May 2021 computerized physician orders (CPO), pertinent diagnoses included chronic pulmonary disease (COPD), respiratory failure and heart failure. The 3/9/21 minimum data set (MDS) assessment revealed the resident had a cognitive deficit. She required extensive assistance with two people for dressing, toileting, transfers and limited assistance with one person for hygiene. She had hallucinations and used oxygen. B. Observations Resident #6 was observed on 5/17/21 at 1:15 p.m. sitting in her reclining chair in her room. She wore oxygen, she had a nebulizer machine on her bedside table and she moaned because she was short of breath. -At 1:32 p.m. she pulled her call light bell out of the pocket of the recliner chair and an alarm went off, certified nurse aide (CNA) #1 went into the room to check on her, reassured her she was there to help and left to go get the nurse. -At 1:53 p.m. medical records (MR), who was a nurse, assisted Resident #6 to use a nebulizer medication treatment to help with her shortness of breath. Resident #6 was observed on 5/19/21 at 10:35 a.m. to sit in her recliner chair. She had her oxygen on via nasal cannula and she was calm. She said hi to people who walked by her. -At 12:15 p.m. she was observed in the dining room, she wore her oxygen via nasal cannula. C. Record review The May 2021 computerized physician orders (CPO) for Resident #6 read in pertinent part; -May apply oxygen at two liters (L) per nasal cannula every day and at night, order date was 5/4/21; -Ipratropium-Albuterol Solution medication, inhale orally every 12 hours for COPD, order start day 4/29/21 and discontinued on 5/4/21; -Ipratropium-Albuterol Solution medication, inhale orally every six hours as needed for shortness of breath or wheezing via nebulizer, start date was 5/13/21. -Combivent Respimat Aerosol Solution medication, one puff inhaled orally four times a day for COPD order start date was 5/4/21. -Fluticasone Propionate Suspension one puff in each nostril at bedtime for COPD start date was 4/29/21. -Record review of Resident #6 care plans on 5/18/21 at 9:30 a.m. revealed no care plan for oxygen and no care plan for respiratory medications. D. Interviews CNA #1 was interviewed on 5/18/21 at 12:30 p.m. She said Resident #6 did wear oxygen and she had shortness of breath at times. She said the resident had to use the inhaled medication a lot to help her with her anxiety. Registered nurse (RN) #1 was interviewed on 5/18/21 at 1:10 p.m. She said she was in charge of doing a minimal data set (MDS) monthly review and when there was a discrepancy she would fix it. The MDS guide assisted with care planning for each resident. She said the facility had a quarterly meeting with the interdisciplinary team to discuss any updates or changes needed to the care plan. The director of nurses (DON) was interviewed on 5/18/21 at 1:30 p.m. She said when a resident entered the facility to admit or readmit, a care plan was created to show the care needed for each resident. She said when a change of condition occurred the care plan was updated by the nurse or the interdisciplinary team. The staff then followed the care plan for each resident. The nursing home administrator (NHA) was interviewed on 5/19/21 at 2:00 p.m. She said the medical records (MR) nurse started the care plan with the director of nurses (DON). She said the care plans were updated when a change occurred to the resident. She said a progress note followed any changes. III. Resident #13 (cross-reference F758 for unnecessary medication) A. Resident status Resident #13, age [AGE], was admitted on [DATE]. According to the May 2021 computerized physician orders (CPO), diagnoses included dementia without behavioral disturbance, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side. The 4/5/21 minimum data set (MDS) assessment revealed the resident was moderately impaired in cognition with a brief interview for mental status (BIMS) score of nine out of 15. The resident was totally dependent on staff for bed mobility, transfers and dressing. B. Record review A nurse practitioner note dated 4/29/21 at 3:20 p.m., revealed the resident had pain in her lower extremity etiology uncertain insomnia. Will administer Amitriptyline (antidepressant medication) not for depression but rather for treating the insomnia and hopefully pain control also. The physician's order dated 4/29/21 at 4:41 p.m., revealed to administer Amitriptyline, 25 milligrams (mg) by mouth at bedtime related to lower extremity pain. This order was discontinued on 5/5/21 at 10:50 a.m. The physician's order dated 5/5/21 at 10:50 a.m., revealed to administer Amitriptyline, 25 mg by mouth at bedtime for insomnia related to lower extremity pain. -The resident's clinical record did not reveal a care plan for the use of an antidepressant medication with measurable goals and objectives. -The record also did not include non-pharmacological interventions to be attempted prior to the administration of the medication. The medication administration record (MAR) for May 2021 revealed the resident was administered the antidepressant medication 18 consecutive times. C. Staff interviews The DON was interviewed on 5/19/21 at 9:45 a.m. She said the resident did not have a care plan for the use of an antidepressant medication. A care plan should have been developed to include goals, interventions for the medication and non-pharmaceutical interventions to be implemented prior to the administration of the medication. She said the facility was not tracking the resident's behaviors for the use of this medication. -At 12:14 p.m., the DON said the antidepressant was ordered for insomnia related to lower extremity pain. She said the facility did not have a care plan for the resident's insomnia and one should have been developed. She said the facility was not tracking the resident's hours of sleep. The nursing home administrator (NHA) was interviewed on 5/19/21 at 1:51 p.m. She said a care plan for the use of an antidepressant should have been developed with measurable goals and interventions. She said the plan should have included non-pharmacological interventions to be implemented prior to the administration of the antidepressant. She said the facility should have been tracking the resident's behaviors for the use of this medication. The NHA said a care plan for insomnia should have been developed and the facility should have been tracking the resident's hours of sleep.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to keep the resident free from accident hazards as was possible for one (#18) of four out of 21 sample residents. Specifically the facility failed to: -Ensure thorough and complete neurological assessment for an unwitnessed head injury for Resident #18. I. Facility policy The Occurrence Reporting Policy, reviewed date on 10/2020, was provided by the nursing home administrator (NHA) on 5/1/21 at 1:20 p.m., it read in pertinent part; It was the facilities policy to provide a safe environment as free from hazards as possible and to report the occurances, that meet the elements to be reportable, to the Colorado Department of Public Health and Environment within two hours after the occurence or the facility become aware of the occurrence. Procedure: When an incident occurs an Incident Report and or occurrence report was completed by the charge nurse at the time of the incident. The report was given to the director of nurses (DON) and NHA for review. The report was reviewed within two hours to determine if the elements were met for a reportable.The DON or NHA will submit the occurrence through the health facilities portal and submit the final report within five days after the investigation was completed. The Accident Incident Care and Documentation Guideline, not dated, was provided by the director of nurses (DON) on 5/19/21 at 10:30 a.m., it read in pertinent part; Charge nurse to assess the resident with vital signs and range of motion. Notify the physician and family. Complete the incident report and fall screen investigation report. Update care plan with an intervention. Record on the 24 hour report sheet and document neurological assessments in the computer. Vital signs and neurological status were done every 15 minutes for four times then every 30 minutes for four times then every four hours daily for three days. All other injuries check vitals and neurological status every eight hour shift for 24 hours The Neurological Assessment Flow sheet, provided by the DON on 5/19/21 at 10:30 a.m., read in pertinent part; Instructions were to document the date and time of each assessment. Document the level of consciousness, pupil response time, motor functions with hand grasps and extremities. Pain response, vital signs and any observations such as seizures, headache, vomiting and paralysis. II. Resident #18 status Resident #18, age [AGE], was admitted on [DATE]. According to the May 2021 computerized physician orders (CPO), pertinent diagnoses included traumatic brain injury, dementia depression and seizure disorder. The 1/31/21 minimum data set (MDS) assessment revealed the resident had a cognitive deficit with a brief interview for mental status (BIMS) of 14 out of 15. She required extensive assistance with one person for dressing and limited assistance with one person for bed mobility, transfers, toilet use, and hygiene. She had no behaviors. III. Resident observations and interview Resident #18 was observed and interviewed on 5/17/21 at 1:15 p.m. She was seated in her recliner chair in her room and was asleep, but woke when spoken to. She said she had no pain and she did have night terrors and often moved around in the bed. She reclined in her chair and fell asleep often during the interview. -On 5/19/21 at 3:00 p.m. the resident was interviewed and she said she had a history of night terrors and she did not recall having a fall. Her bed was observed to have enabled bars (half rails) on her bed. She said she used those to help her get out of the bed. The enablers had pads attached to them. The bed measured one inch between the enable bars which were 20 inches long on both sides of the bed were padded. Resident #18 was observed on 5/18/21 at 8:55 a.m. in another residents room. She sat in her wheelchair and rummaged through the drawers of the room. She appeared calm and looked around when staff walked by the room. IV. Record review A. Incident investigation note The incident accident report for Resident #18 dated 4/26/21 at 5:50 a.m. read in pertinent part; A resident yelled down the hallway Resident #18 needed help. Staff entered the room and found Resident #18 to lay backwards on the bed with her head by the foot of the bed. There was a small amount of blood to the back of the head. The investigation typed note regarding the head injury for Resident #18 was provided by the nursing home administrator (NHA) on 5/18/21 at 10:45 a.m., it read in pertinent part: On 4/26/21 Resident #18 was found with her feet at the head of the bed and head at the foot of the bed. Her head was lying on the foot board and blood was there. Resident had been having a restless night and the resident stated she was having bad dreams. Staff were in her room with one on one monitoring most of the night, however at 5:50 a.m. 4/26/21 the resident was heard yelling for help. The staff immediately entered her room to find her in the above noted position. Resident had no complaints concerning her head and a small amount of blood was there with no bump on her head. Vital signs were normal. NHA and DON attempted to reenact the incident from the reports of the staff. They concluded the resident had a possibility of hitting her head on the foot board during the night terror incident on 4/26/21. Cross-reference F609 failure to report. B. Nurse notes The nurse note for Resident #18, dated 4/26/21 at 6:23 a.m. read in pertinent part; Resident #18 had been restless most of the night and the resident stated I am having bad dreams. At 5:50 a.m. resident was found to be crossways at the foot of bed with the back of her head at the foot board. Resident denied pain from the head area, and the nurse saw a small amount of blood on the back of the resident's head. No bump found. Vitals signs completed. Ice applied to the back of her head area. Oncoming nurse was going to inform the doctor, family and the DON. The nurse note for Resident #18, dated 4/26/2021 at 9:40 a.m. read in pertinent part; Notified medical director and residents power of attorney of resident hitting her head on the enabler rail. Resident does have a one centimeter raised, bruised area on the back left side of her head. Resident #18 denied headache, dizziness and nausea. Neurological checks were completed and within normal limits prior to residents going to the assisted living center to visit her husband. The nurse note for Resident #18, dated 4/26/2021 at 7:57 p.m. read in pertinent part; Neurological checks were within normal limits, resident denies any nausea, vomiting, headache or vertigo but does complain of left arm kinda sore. Nurse offered pain medication but the resident refused and stated no its (pain) not that bad ''. Denied any pain to the back of the head areas and the resident refused ice to her head that evening. Night time cares given and in bed at this time. Bed low position, mat by bed. Call light at bedside. Over head light left on per residents complaint of night [NAME] and door left wide open for her. One on one and reassurance given. C. Neurological checks Neurological assessment flow sheet for Resident #18, revealed two assessments were completed on 4/26/21 at 5:50 a.m. The rest of the flowsheet was blank. The neurological checklist note for Resident #18 dated 4/26/21 at 5:50 a.m. revealed the vitals were completed, orientated to person, place and situation. Her level of consciousness was alert and confused. Her pupils and responses were equal and appropriate. Resident denied headache, nausea, vomiting, or vertigo and she had an ice pack to the head area. The neurological checklist note for Resident #18 dated 4/26/21 at 9:43 a.m. revealed the vitals were completed, orientated to person, place and situation. The resident was in the assisted living center visiting her husband. Her level of consciousness was alert and confused with no new onset of confusion. Her pupils and responses were equal and appropriate. Comment note read the medical director and the power of attorney were notified of the resident hitting her head that am. The resident had a one centimeter raised bruised area on the back left side of her head. The resident denied pain, dizziness or nausea. D. Care plan The fall care plan for Resident #18 revised on 5/6/21 read in pertinent part; Resident #18 had a high risk for falls related to confusion, unsteady gait, weakness dizziness and recent (4/29/21) fracture to the right humerus. The goal was to be free from falls with injury and then interventions were to anticipate and meet the residents needs. Ensure the resident was wearing appropriate footwear, non skid shoes. Follow fall protocols and have a physical therapy occupational therapy consultation and treatment as ordered. The activities of daily living (ADL) care plan for Resident #18 revised on 4/28/21, read in pertinent part; The resident had an ADL self-care performance deficit related to impaired balance, limited mobility and range of motion. The goal was the resident will maintain the current level of function in ADL. The intervention was to emulate with one to two people assist, bathing required by one person assistance. Bed mobility required one to two person assistance to reposition and to use the enable rail to assist with repositioning. V. Interviews Licensed practical nurse (LPN) #1 was interviewed on 5/19/21 at 3:00 p.m. She said Resident #18 had a history of night terrors and took medication to help with those. She said the resident had an unknown head injury which she said the staff found the resident to lay backwards in her bed and some blood on her sheets was found. She was not there on that day but received information in daily report. She said the resident had an enabler bar on her bed to help her get up out of bed and the pads on there had been there since she was admitted . She said when a resident hit their head or a fall occurred the fall packet was filled out. She said neurological checks were every 15 minutes for the first four hours then every 30 minutes for four hours and the assessments were documented on the neurological form and also documented in the computer. She said neurological assessments were completed to assess for any changes from the fall or head injury. A potential brain bleed could occur so neurological checks had to happen. Director of nurses (DON) was interviewed on 5/18/21 at 1:00 p.m. She said she had no reports of a fall only that Resident #18 had an incident on 4/26/21 where the resident was found in her bed with blood on her head. She said Resident #18 had night terrors and thrashed around in her bed often. She said when a resident had an injury of unknown origin, a fall or head injury, a neurological assessment was completed every 15 minutes for the first hour then every 30 minutes and the nurse documented the results in a progress note. She said the neurological checks were important with a head injury because a brain bleed may have occurred and the assessments showed any changes. Facility failed to complete neurological assessments in a thorough, timely manner, and in its entirety after a head injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure a consent was obtained either by the resident or the resident's representative prior to the administration of an antidepressant medication for one (#13) of six out of 21 sample residents. Specifically, the facility failed to: -Attempt non-pharmacological interventions prior to administering an antidepressant being used for insomnia; -Tracking the resident's hours of sleep with an antidepressant being used for insomnia; and, -Obtain a consent for the use of an antidepressant medication prior to the medication being administered to the resident 18 times. I. Facility policies and procedures The Psychopharmacological Medication Use policy, revised in January 2020, was provided by the director of nursing (DON) on 5/19/21 at 12:47 p.m. The policy revealed the purpose of the policy was to assure all residents in the facility received psychopharmacological medication in accordance with the expectations set forth by the state and federal regulations and to provide guidelines for the implementation of these requirements. -(2) A consent form would be discussed with the resident and family at admission or upon initiation of psychotropic medication stating the risks versus the benefits and non-pharmacological interventions that would be in place and attempted. -(6) Education would be given and informed consent would be obtained from the resident or the resident's power of attorney (POA) prior to the use of psychoactive medications. II. Resident #13 A. Resident status Resident #13, age [AGE], was admitted on [DATE]. According to the May 2021 computerized physician orders (CPO), diagnoses included dementia without behavioral disturbance, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side. The 4/5/21 minimum data set (MDS) assessment revealed the resident was moderately impaired in cognition with a brief interview for mental status (BIMS) score of nine out of 15. The resident was totally dependent on staff for bed mobility, transfers and dressing. B. Record review A nurse practitioner note dated 4/29/21 at 3:20 p.m., revealed the resident had pain in her lower extremity. The etiology was uncertain; insomnia. Staff would administer Amitriptyline (antidepressant medication) not for depression but rather for treating the insomnia and hopefully pain control also. The physician's order dated 4/29/21 at 4:41 p.m., revealed to administer Amitriptyline 25 milligrams (mg) by mouth at bedtime related to lower extremity pain. This order was discontinued on 5/5/21 at 10:50 a.m. The physician's order dated 5/5/21 at 10:50 a.m., revealed to administer Amitriptyline, 25 mg by mouth at bedtime for insomnia related to lower extremity pain. The resident's clinical record did not reveal a care plan for the use of an antidepressant medication with measurable goals and objectives (cross-reference F656 develop a comprehensive care plan). -The record also did not include non-pharmacological interventions to be attempted prior to the administration of the medication. The medication administration record (MAR) for May 2021 revealed the resident was administered the antidepressant medication 18 consecutive times. -There was no record of the facility tracking the resident's hours of sleep for insomnia. III. Staff interviews The DON was interviewed on 5/19/21 at 9:45 a.m. She said a consent form was not obtained for the use of the antidepressant medication prior to its administration to the resident. She agreed the resident had received 18 doses of the medication without the consent of the resident or the resident's representative. She said a consent form should have been obtained prior to the administration of this antidepressant medication. The DON provided a copy of a consent form dated 5/19/21 (after the survey started) that was signed by the resident's legal representative for the use of the antidepressant medication. She said interventions for the medication and non-pharmaceutical interventions to be implemented prior to the administration of the medication. She said the facility was not tracking the resident's behaviors for the use of this medication. -At 12:14 p.m., the DON said the antidepressant was ordered for insomnia related to lower extremity pain. She said the facility was not tracking the resident's hours of sleep. The nursing home administrator (NHA) was interviewed on 5/19/21 at 1:51 p.m. She said the resident's care plan should have included non-pharmacological interventions to be implemented prior to the administration of the antidepressant. She said the facility should have been tracking the resident's behaviors for the use of this medication. She said the facility should have been tracking the resident's hours of sleep. She said the facility should obtain a consent for the use of a psychoactive medication prior to the administration of the medication.