**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 3 residents (Resident #5 and 36) reviewed for accidents, for Resident #5 the facility failed to implement the comprehensive care plan for a resident with a history of repeated falls and for Resident #36 the facility failed to develop a comprehensive care plan related to the resident's behavior of flailing arms. The findings include: 1. Resident #5 had diagnoses that included schizophrenia and bipolar disorder. The quarterly MDS dated [DATE] identified Resident #5 had moderate cognitive impairment and required one person assist with ambulation and toileting. The care plan dated 3/12/25 identified Resident #5 was at risk for falls related to a history of unsteady gait and noncompliance with asking for assistance. Interventions included ambulation with assist of one with a walker and do not leave the resident unattended when out of bed during the day. Physician's order dated 3/25/25 directed assist of one with two wheeled rolling walker for transfers and ambulation. A facility reported event dated 4/7/25 identified at 11:15 AM Resident #5 was observed lying on the floor in his/her room on the left side. Resident #5 reported he/she was walking to use the bathroom, lost balance and fell. Resident #5 denied hitting his/her head and there were no injuries noted on assessment. The physician and resident representative were notified. An accident follow up statement dated 4/7/25 identified NA #1 was assigned to Resident #5, who was last seen at 10:00 AM when the resident was provided toileting assistance. NA #1 was later notified by a co-worker Resident #5 was observed on the floor in h/her room. An interview with the DNS on 5/22/25 at 7:59 AM identified the root cause of the fall resulting from NA #1 leaving Resident #5 in h/her room unattended according to the care plan. An interview with NA #1 on 5/22/25 at 12:26 PM identified he was the assigned nurse aide during the 7:00 AM to 3:00 PM shift on 4/7/25. Resident #5 had eaten in the dining room earlier in the day and could not recall if he or another aide had brought the resident back to his/her room. NA #1 later observed Resident #5 sitting alone in his/her room and provided toileting assistance. Afterward, NA #1 left Resident #5 sitting on his/her bed and was informed a short time later the resident was observed on the floor. NA #1 indicated he was unaware Resident #5 was not to be left unattended in his/her room during the day and routinely left Resident #5 unattended in his/her room during the day. NA #1 further identified following the incident, he was instructed by the DNS to keep a close eye on Resident #5. A review of the facility policy for fall prevention directed the facility to identify residents at risk for falling, evaluate the factors that places the resident at risk and implement measures to prevent falls. 2. Review of the hospital discharge documentation dated 4/21/23 through 4/29/23 identified Resident #36 was brought into the hospital by the resident representative for multiple falls. The resident representative indicated Resident #36 had 1 unwitnessed fall on 4/20/23 and another unwitnessed fall on 4/21/23 at the assisted living facility. Resident #36 was diagnosed with several fractures including a left wrist carpal bone fracture, left distal radial fracture, left ulnar fracture, left wrist/hand fractures. Resident #36 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, fracture of left wrist carpal bone, fracture of left pubis, and repeated falls. The care plan dated 10/13/24 identified Resident #36 had an activity of daily living (ADL) self-care performance deficit related to dementia and was totally dependent on caregiver. Interventions included to transfer with a mechanical lift to a customized wheelchair with assist of two. The quarterly MDS dated [DATE] identified Resident #36 had severely impaired cognition and was dependent on staff for transfers with two persons physical assist. A physician's order dated 1/1/25 directed to transfer out of bed via mechanical lift to customized wheelchair with pelvic positioning belt, head rest and leg rests with assist of two. The nurse's note dated 1/14/25 at 11:03 AM identified Resident #36 was noted to have a pink rash area on left forearm and was scratching the area. House lotion applied with good effect. The nurse's note failed to reflect documentation of a thorough assessment to the left forearm. The reportable event form dated 1/15/25 identified at approximately 9:45 AM Resident #36 was noted to have a slightly red left wrist area (injury of unknown origin). An x-ray of the left arm was ordered which identified a distal ulna fracture with mild displacement, and mild soft tissue swelling. The APRN was notified of the x-ray results with order for an orthopedic consultation. Investigation initiated. Resident #36 was unable to verbalize what happened, had no falls or unusual incidents in the last week. The care plan dated 1/15/25 identified Resident #36 presents with swollen, red left forearm, and a left ulna fracture. Intervention included orthopedic consultation, medication for pain as needed, and padding applied to side rails on bed. Review of a statement written by NA #6 dated 1/15/25 identified she was assigned to Resident #36 on 1/13/25 on the 3:00 PM - 11:00 PM shift and 1/14/25 on the 3:00 PM - 11:00 PM shift. NA #6 indicated on 1/14/25 on the 3:00 PM - 11:00 PM shift she reported to RN #2 that Resident #36 was scratching his/her arm, and when clothing was being removed, he/she yelled. NA #6 indicated RN #2 indicated she had taken care of it this morning and someone had already reported it. NA #6 indicated she and NA #9 continued to provide care. The APRN progress note dated 1/16/25 at 7:49 AM identified Resident #36 was found to have a swollen area on the left forearm distally. Resident #36 has a history of a left wrist fracture that was radial in nature. X-ray was done and a distal left ulnar fracture was found. Recommendations included orthopedic consultation, non-weight bearing to left arm, therapy as needed, and Tylenol for pain as needed. Review of the orthopedic consultation form dated 1/17/25 identified Resident #36 has a diagnoses of left ulna shaft fracture. Recommendations include short arm EXO brace on at all times, follow up in 4 weeks, repeat x-ray, and non-weight bearing to left upper extremity. The nurse's note dated 1/17/25 at 1:40 PM identified Resident #36 had an orthopedic appointment this morning and returned with an EXO brace on left wrist. The resident has a follow-up appointment on 2/3/25. Review of a statement written by NA #1 dated 1/17/25 identified he worked on 1/13/25 on the 7:00 AM - 3:00 PM shift and 1/15/25 on the 7:00 AM - 3:00 PM shift. NA #1 indicated Resident #36 had no behavioral issues, and no pain during his shift on 1/13/25. NA #1 indicated on 1/15/25 he was informed by a co-worker that Resident #36 wrist was discolored and slightly swollen. Review of a statement written by RN #2 dated 1/17/25 identified she worked on 1/13/25 on the 7:00 AM - 3:00 PM shift and 1/14/25 on the 7:00 AM - 3:00 PM shift, and the 3:00 PM - 11:00 PM shift. RN #2 indicated she was not aware of anything that occurred with Resident #36 that may have led to this injury. RN #2 indicated there was some small pink area on the left wrist which appeared to look like irritation. RN #2 indicated lotion was applied to the area, no swelling was noted. The summary report dated 1/17/25 at 3:04 PM identified Resident #36 is confused, non-ambulatory, transfers with a mechanical lift and assist of 2 persons. All staff were questioned. No unusual events occurred. The resident is fidgety when in bed. The resident had a medication change on 1/10/25 when the Escitalopram (used to treat depression and anxiety disorder) was decreased from 15mg to 10mg daily. Side rail pads were added to the side rails, a body pillow was added to the left side of the bed to prevent the resident from rolling out of bed. As a result of this investigation, there was no clear understanding of how this injury occurred. Interview with Person #1 on 5/21/25 at 9:47 AM identified Resident #36's left arm/wrist was slightly swollen on 1/14/25. Person #1 indicated he/she did not tell the staff of the swelling. Interview with NA #1 on 5/21/25 at 10:13 AM identified he was assigned to Resident #36 on 1/15/25 on the 7:00 AM - 3:00 PM shift. NA #1 indicated after morning care he was dressing Resident #36 and when he guided his/her left hand to put it through the shirt Resident #36 was saying ouch, ouch. NA #1 indicated the left arm was not swollen at that time. NA #1 indicated he told the nurse that Resident #36 had pain in the left arm. NA #1 indicated he does not remember who the nurse was. NA #1 indicated Resident #36 has a habit of grabbing your hands during care or anything near and swinging (flailing) his/her arms. NA #1 indicated now the side rails are padded and a pillow is placed by the side rails. Interview with RN #4 on 5/21/25 at 10:45 AM identified she does not remember the incident because it was so long ago and indicated to read her statement. RN #4 indicated Resident #36 used to be fidgety and would flail his/her arms. Interview with LPN #1 on 5/21/25 at 11:06 AM identified she worked on 1/13/25, 1/14/25, and 1/15/25 from 8:00 AM - 5:30 PM. LPN #1 indicated she remembered NA #1 brought Resident #36 to the dining room for breakfast. LPN #1 indicated Resident #36's left forearm looked swollen and she immediately notified RN #1 who assessed the resident. LPN #1 indicated she did not get report from the 11:00 - 7:00 AM nurse that Resident #36's left arm was swollen. LPN #1 indicated Resident #36 used to flail his/her arms constantly but not anymore. LPN #1 indicated she did not document in the resident record when Resident #36 flailed his/her arms. Interview with the DNS on 5/21/25 at 12:38 PM identified she was not aware of Resident #36 flailing his/her arms. The DNS indicated if she was aware of the behavior she would have initiated a care plan and put interventions in place. The DNS indicated the nursing staff had not informed her of the behavior of flailing. Interview with MD #1 on 5/22/25 at 9:16 AM identified he was aware of the incident on 1/15/25 with Resident #36's left distal ulna fracture. MD #1 indicated the ulna bone is located on the pinkie side of the forearm. MD #1 indicated a distal ulna fracture comes from a direct blow or from a fall landing on the forearm or landing on an outstretched arm. MD #1 indicated the resident had to hit the forearm somewhere to obtain the fracture. MD #1 indicated he was not aware of Resident #36 flailing his/her arms. MD #1 indicated there is a possibility flailing of the arms can indeed cause a fracture of the forearm. MD #1 indicated there are risk factors with distal ulna fracture such as osteoporosis, post-menopausal women, and history of falls. Interview with RN #1 on 5/22/25 at 8:20 AM identified the DNS is responsible for initiating care plans and updating care plans. RN #1 indicated the licensed nurses do not initiate or update care plans. RN #1 indicated there will be new processes put into place. Review of the care plan dated 10/13/24, which was in effect on 1/15/25 when the resident began exhibiting pain in the left wrist, failed to reflect documentation or interventions to address the resident's behavior of flailing his/her arms. Review of the nurse's notes dated 1/1/25 - 1/31/25 failed to reflect documentation of Resident #36's behavior of flailing of arms. Although attempted, an interview with RN #2, APRN #2, NA #8 was not obtained. Although requested, a facility care plan policy was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #5) reviewed for accidents, the facility failed to revise the care plan following a fall for a resident with a history of repeated falls. The findings include: Resident #5 had diagnoses that included schizophrenia, bipolar disorder and overactive bladder. The quarterly MDS dated [DATE] identified Resident #5 had moderate cognitive impairment and required one person assist with ambulation and toileting. The care plan dated 3/12/25 identified Resident #5 was at risk for falls related to a history of unsteady gait and noncompliance with asking for assistance. Interventions included ambulation with assist of one with a walker and do not leave the resident unattended when out of bed during the day. Physician's order dated 3/25/25 directed assist of one with two wheeled rolling walker for transfers and ambulation. A facility reported event dated 4/7/25 identified at 11:15 AM Resident #5 was observed lying on the floor in his/her room on the left side. Resident #5 reported he/she was walking to use the bathroom, lost balance and fell. Resident #5 denied hitting his/her head and there were no injuries noted on assessment. The physician and resident representative were notified. An accident follow up statement dated 4/7/25 identified NA #1 was assigned to Resident #5, who was last seen at 10:00 AM when the resident was provided toileting assistance. NA #1 was later notified by a co-worker Resident #5 was observed on the floor in h/her room. A review of the post-accident report and care plan failed to identify the care plan had been revised after the 4/7/25 fall to prevent future falls. An interview with the DNS on 5/22/25 at 7:59 AM identified the root cause of the fall was identified as NA #1 leaving Resident #5 in his/her room unattended. The DNS further identified the care plan had not been updated as the interdisciplinary team ran out of interventions to put in place to prevent future falls. A review of the facility policy for fall prevention directed the facility to identify residents at risk for falling, evaluate the factors that places the resident at risk and implement measures to prevent falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #41) reviewed for quality of care, the facility failed to ensure staff maintained current CPR (cardiopulmonary resuscitation) certification. The findings include: Resident #41 had diagnoses that included Parkinson's disease, and hypertension. The quarterly MDS dated [DATE] identified Resident #41 had moderate cognitive impairment required two person assist with bed mobility, transfers and toileting. The care plan dated [DATE] identified Resident #41 had advance directives specifying full code status meaning all life saving measures were to be implemented in the event of a medical emergency. Physician's order dated [DATE] directed full code status. A late entry nurse's note dated [DATE] at 9:00 PM identified between 8:00 PM and 8:30 PM, Resident #41 vomited a large amount twice and had a large bowel movement. A nurse's note dated [DATE] at 9:53 PM identified RN #4 was notified by the medication nurse, that Resident #41 was not breathing and the pulse was not palpable on assessment. Resident #41's status was verified full code and CPR was initiated. EMS was called at approximately 8:50 PM. Resident #41 was pronounced at 9:21 PM by the ED Physician. An interview with RN #4 on [DATE] at 9:12 AM identified Resident #41 had a vomiting episode and loose bowel movement earlier in the evening and later the resident had an explosive bowel movement. RN #4 went to assess the resident who was somewhat responsive but did not look well. RN #4 went to get the emergency cart. Upon return, Resident #41 was unresponsive with no pulse. RN #4 indicated she began chest compressions until the emergency medical response team arrived and took over. RN #4 identified she was unable to provide documentation of current CPR certification. An interview with the DNS on [DATE] at 12:45 PM identified she was responsible for maintaining CPR certifications for staff but had not maintained one for RN #4 as an oversight. Subsequent to surveyor inquiry, RN #4 obtained an updated CPR certificate. A review of the facility policy for CPR directs that CPR will be performed by a CPR certified licensed nurse. Although requested, a copy of RN #4's previous CPR certification was not provided. Attempts to interview NA #7 were unsuccessful.

Based on review of facility documentation, the facility assessment, and interview, the facility failed to ensure intravenous (IV) therapy certifications and competencies were completed for 6 of 11 licensed nursing staff. The findings include: Review of the IV Therapy Certifications and Infusion Medications Administration Competencies binder failed to identify the following: RN #7 (hired on 5/2/15) was certified in IV therapy or had completed an Infusion Medications Administration Competency. RN #4 (hired on 4/24/18) was certified in IV therapy or had completed an Infusion Medications Administration Competency. RN #5 (hired on 11/29/21) was certified in IV therapy or had completed an Infusion Medications Administration Competency. RN #2 (hired on 5/27/22) was certified in IV therapy or had completed a 2024 annual Infusion Medications Administration Competency; competency was last completed on 8/8/23. RN #6 (hired on 7/6/22) was certified in IV therapy or had completed a 2024 annual Infusion Medications Administration Competency; competency was last completed on 8/12/23. LPN #4 (hired on 2/21/25) was certified in IV therapy or had completed an Infusion Medications Administration Competency. Interview and review of facility documentation with the DNS on 5/21/25 at 9:42 AM identified that she was responsible for overseeing the IV therapy program, as well as the nursing staff's education and competencies for IV therapy, and that there were 6 licensed nurses with no IV therapy certification or annual competency on file. The DNS indicated that their IV therapy certifications were old and therefore the facility did not have a copy on file. The DNS identified that IV therapy was not part of the nursing orientation, and while there was no documentation of a competency and/or annual competency being completed, she observed and validated each of the nurses administering IV medication or fluids. The DNS further indicated that it was not often that the facility had residents requiring IV therapy, but the 6 nurses had administered IV medications or fluids, on residents. The DNS identified that currently there were no residents in the facility receiving IV therapy, and she planned to have IV competencies completed for all licensed and unlicensed nursing staff, in June. The DNS further identified that while she did not have a policy that speaks to IV therapy certifications and competencies, the facility's practice was to have nursing staff complete an annual IV therapy competency. The Facility Assessment 2025 Synopsis directs all staff to receive the following education and testing of competency: specialized care-catheterization, colostomy care, diabetic blood glucose testing, oxygen administration, suctioning, pre-op and post-op care, IV-line care, tube feedings, wound care/dressings, and dialysis care. The Facility Assessment further directs the following will be conducted on licensed nursing staff annually: medication administration-injectable, oral, subcutaneous, topical, and intravenous. Although requested, a facility education for IV therapy policy was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to discard Insulin 28 days after it was opened according to professional standards. The findings include: Observation on [DATE] at 10:43 AM of a medication cart with LPN #1 identified the following. A vial of Novolog Insulin 100 units/ml 10 ml approximately ¾ full with an open date of [DATE], and a sticker that the Insulin was good for 28 days once opened. A vial of Lantus Insulin approximately ¼ full with an open date of [DATE], and a sticker indicating to discard 28 days after opening. Two vials of Aspart Insulin 100 units/ml 10 ml approximately 1/3 full with an open date of [DATE], and a sticker that indicated discard 28 days after opening. A vial of Lantus Insulin 100 units/per ml approximately ¼ full with an open date of [DATE] and a sticker that indicated discard 28 days after opening. Interview with LPN #1 on [DATE] at 10:48 AM indicated that she was the full-time charge nurse and administered medications, including Insulin to residents on both units. LPN #1 indicated that she administered the Insulin with a [DATE] and [DATE] open date yesterday and today. LPN #1 indicated that the Insulin once opened was only good for 28 days and then discarded. LPN #1 indicated that she did not check the dates on the Insulin vials prior to using them. LPN #1 indicated that she would discard the 4 vials and replace them. Interview with RN #2 on [DATE] at 10:52 AM indicated the charge nurse was responsible to date the Insulin vials when opened and discard them after 28 days. RN #2 indicated that there was new Insulin available. Interview with the DNS on [DATE] at 8:51 AM indicated that when the charge nurse opens a new vial of Insulin she is responsible to date it. The DNS indicated the nurses should be looking at the expiration date prior to each use and discard expired Insulin. Review of the vials and ampules of injectable medication policy identified expiration dates for unopened vials expire based on manufacturers expiration date. Opening a vial triggers a shortened expiration date. Although requested, the facility failed to provide a policy on the length of time Insulin can be used after being opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident #15 and 78) reviewed for unnecessary medications, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. The findings include: 1. Resident #15 was admitted to the facility in December 2024 with diagnoses that included dementia with mood disturbances, hyperlipidemia, and spiral fracture of arm. The care plan dated 12/17/24 identified Resident #15 had impaired cognition due to dementia. Interventions included cues, supervise, and reorient resident as needed. The admission MDS dated [DATE] identified Resident #15 had moderately impaired cognition and exhibited no hallucinations or delusions. Resident #15 did not show any physical or verbal behaviors directed towards others and had not rejected care. Resident #15 was receiving antipsychotic, antidepressant, and diuretic medications. A physician's order dated 1/31/25 directed to administer Seroquel (antipsychotic medication) 25 mg in the morning and 50 mg at bedtime for vascular dementia with moderate mood disturbances. Review of the progress notes dated 1/1/25 to 2/28/25 failed to reflect Resident #15 was seen by the pharmacist for a monthly medication review. A physician's order dated 3/20/25 directed to administer Seroquel 25 mg once in the afternoon for vascular dementia with moderate mood disturbances. The Pharmacracy Monthly Medication Review dated 3/24/25 identified Resident #15 had a recent fall. A review of medications indicates Resident #15 is receiving the following which may be causative or contributing to the falls. If no change is indicated, please note that the medication is necessary and potential risk versus therapeutic benefit of current Seroquel therapy in the next progress note. Additionally, consider monitoring orthostatic blood pressures each shift for 3 days and report systolic changes greater than 20 mm/Hg or diastolic changes greater than 10 mm/Hg to the provider. The Pharmacy Monthly Medication Review dated 5/8/25 (46 days later) identified the psychiatric APRN indicated she would reevaluate the Seroquel for a possible gradual dose reeducation. Resident #15 has poor safety awareness, does not ask for assistance and there are no reports that Resident #15 was drowsy or sedated. Interview with the DNS on 5/21/25 at 10:58 AM indicated pharmacy recommendations should be responded to by the physician or APRN within 2 weeks of receiving the recommendation. Further, after clinical record review, the DNS indicated there was no documentation that Resident #15 was seen by the pharmacy for a medication regimen review in February 2025. The DNS indicated she was responsible for implementing the physician's order for orthostatic blood pressures as per the pharmacy recommendation dated 3/24/25, however, it was not done. The DNS indicated that the psychiatric APRN did not receive the 3/24/25 pharmacy recommendation until 5/8/25, 6 weeks later, because she did not put the pharmacy recommendation in APRN communication book. Interview with the psychiatric APRN (APRN #1) on 5/21/25 at 11:15 AM identified she was responsible to respond to the pharmacy recommendations when she receives them in her communication book from the DNS. APRN #1 indicated that she did not receive the pharmacy recommendation from 3/24/25 until 5/8/25. APRN #1 indicated that when the pharmacist comes into the facility and makes recommendations she will reply to the recommendation on her next visit, and she is in the facility once every other week. APRN #1 indicated that her expectation was that the pharmacy recommendations would be completed within 2 weeks of the pharmacist visit. The interview MD #1 on 5/21/25 at 11:30 AM indicated that the pharmacy recommendations are addressed by the facility APRN for all medical concerns and by the psychiatric APRN for psychiatric medications. MD #1 indicated the DNS was responsible for getting the pharmacy reports and placing them into the white book for medical APRN who comes into the facility once a week. MD #1 indicated that his expectation was they would get done right away but he thinks they have a month to get them completed. MD #1 indicated that his expectation is it would be done in the week but no later than a month. Interview with Pharmacist #1 on 5/21/25 at 11:35 AM indicated that the providers have to complete the recommendations within a month. Although requested, a facility policy for pharmacy recommendations and pharmacy month reviews were not provided. 2. Resident #78 had diagnoses that included anxiety disorder and dementia. The quarterly MDS dated [DATE] identified Resident #78 was severely cognitively impaired and required two person assist with bed mobility and transfers. The care plan dated 11/3/24 identified Resident #78 required psychotropic medications related to depression and anxiety. Interventions included administering medications as ordered and arrange for psychiatric consultation as indicated. Physician's order dated 11/23/24 directed to administer Ativan 0.5mg every six hours as needed for anxiety with no stop date. Pharmacy recommendations dated 3/24/25 identified Resident #78 was receiving as needed psychotropic medication which was required to be re-evaluated after 14 days. Recommendations included noting the medical justification of the continued use of as needed Ativan and specifying the number of days the as needed order was to continue. An interview with the DNS on 5/20/25 at 8:37 AM and 5/21/25 at 10:27 AM identified she was responsible for addressing all pharmacy recommendations. All recommendations were to be provided to medical or psychiatry with the expectation of a documented response. The DNS indicated that while hospice had been involved with Resident #78's care on a routine basis, she had not discussed the recommendations with them as an oversight. The DNS further indicated she did not maintain any record keeping of pharmacy recommendations after the pharmacy mailed them to the facility. The interview with MD #1 on 5/21/25 at 11:30 AM indicated that the pharmacy recommendations are to be addressed by the facility APRN's (medical or psychiatry). MD #1 indicated the DNS was responsible to place the pharmacy reports into the white book for the medical APRN who comes into the facility once a week. MD #1 indicated that his expectation is it would be done in the week but no later than a month. An interview with APRN #1 on 5/22/25 at 10:54 AM identified she had previously provided psychiatric services to Resident #78 prior to receiving hospice care and that no requests had been made to re-evaluate the use of as needed Ativan until surveyor inquiry. APRN #1 indicated she would normally prescribe an initial as needed dose of Ativan for 14 days followed by a re-evaluation, but that hospice would need to review the recommendations before its initiation. A review of the facility policy for psychotropic medication directed that the facility will administer medications, including PRN psychotropic medications according to state and federal guidelines and according to pharmacy policies.

Based on review of facility documentation, facility policy and interviews, the facility failed to complete annual nurse aide performance evaluations. The findings include: Interview and review of facility documentation identified the facility employs a total of 25 nurse aides for all three shifts (7:00 AM - 3:00 PM shift, 3:00 PM - 11:00 PM shift, and 11:00 PM - 7:00 AM shift). Review of the personnel files of NA #1, NA #7, and NA #8 failed to reflect that annual performance evaluations had been completed. Interview with the DNS on 5/21/25 at 12:12 PM identified she has been employed by the facility for 7 years. The DNS indicated she has not completed nurse aide performance evaluations since she has been in the position. The DNS indicated annual nurse aide performance evaluations had not been completed in 2021, 2022, 2023, 2024, and 1/1/25 - 5/21/25. Interview with the Administrator on 5/21/25 at 12:20 PM identified he was not aware that the DNS had not completed nurse aide performance evaluations in 7 years. Review of the facility employee handbook identified performance improvement the facility will make efforts to periodically review the employee work performance. The performance improvement process will take place on an annual basis, or as needs dictate. The performance improvement process is a means for increasing the quality and value of the employee work performance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of two (2) residents (Resident #1) who were reviewed for pressure ulcers, the facility failed to ensure complete and accurate documentation for a resident with a scheduled skin inspection who subsequently developed a pressure ulcer. The findings include: Resident #1's diagnoses included multiple sclerosis, neuromuscular dysfunction of the bladder and dementia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was moderately cognitively impaired, required extensive two person assist with bed mobility, transfers, total care with bathing, was at risk for the development of pressure ulcers and did not have any unhealed pressure ulcers. The Resident Care Plan dated 10/9/23 identified Resident #1 had a potential for impairment to skin integrity related to decreased mobility, incontinence (bowel) and muscle spasms of the lower extremities with interventions that directed to apply an alternating pressure mattress and return to bed after lunch daily to limit time seated in wheelchair and off load pressure to buttocks. A physician's order dated 11/1/23 directed a weekly skin assessment on Friday's during the 3:00 PM - 11:00 PM shift. Review of skin assessments from 10/4/ through 10/27/23 the clinical record failed to include a documented weekly skin assessment for 10/27/23. A nurse's note dated 11/1/23 at 11:37 PM identified Resident #1 had developed an open area to the coccyx (tail bone), which appeared necrotic, measuring 3 cm x 5 cm. A second macerated (breakdown in skin tissue) was also noted that measured 3 cm x 3 cm. The dressing was clean, dry, and intact. The Advance Practice Registered Nurse (APRN) and wound team to follow up for further evaluation. A subsequent Skin Only Evaluation dated 11/2/23 identified Resident #1 had developed an unstageable pressure ulcer at the coccygeal region that measured 2 cm x 3 cm with an unknown depth. A second moisture associated skin damage was also identified on the left buttock. A Wound Consultation dated 11/2/243 identified unstageable necrosis to the sacrum measuring 2.3 cm x 3 cm x 0.2 cm depth. A plan was in place for debridement. Orders were placed for calcium alginate, Santyl and a dry protective dressing every other day, An interview with Registered Nurse, RN #1 on 2/2/24 at 1:41 PM identified she was the assigned nurse on 10/27/23 during the 3:00 PM to 11:00 PM shift and would have been responsible for the Weekly skin inspection for Resident #1 during that time. RN #1 stated she did complete the weekly skin assessment on 10/27/23 and identified no skin integrity issues. RN #1 indicated she may not have completed the documented assessment. An interview with the Director of Nursing (DNS) on 2/2/24 at 2:44 PM identified she would expect -nursing staff to complete skin assessments on a weekly basis. Although requested, a policy complete and accurate documentation was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, observations, facility documentation, facility policy and interviews for one (1) of two (2) residents,(Resident #1), who were reviewed for pressure ulcers, the facility failed to ensure appropriate infection control practices were followed for a resident receiving a wound treatment. The findings include: Resident #1's diagnoses included multiple sclerosis, neuromuscular dysfunction of the bladder and dementia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was moderately cognitively impaired, required extensive two person assist with bed mobility, transfers, total care with bathing, was at risk for the development of pressure ulcers and did not have any unhealed pressure ulcers. The Resident Care Plan dated 11/5/23 identified Resident #1 had an unstageable pressure ulcer related to decreased mobility. Interventions directed to assess, record, monitor wound status and stage of healing weekly and provide treatment(s) as ordered. A physician's order dated 1/31/24 directed to irrigate the wound of the coccyx with normal saline. Moisten 4x4 gauze with normal saline, loosely pack wound and cover with a dressing twice daily and as needed. An observation during Resident #1's wound treatment on 2/2/24 at 10:10 AM identified Registered Nurse #2 cleansed the wound with a saturated piece of gauze and then begin to pack the wound with a second piece of gauze moistened with saline without the benefit of doffing her gloves, performing hand hygiene, and donning a clean pair of gloves. The task was interrupted and subsequently performed observing appropriate infection control practices. An interview with RN #2 on 2/2/24 at 10:10 AM identified that she would normally change gloves and perform hand hygiene between tasks but was nervous and therefore did not perform the task. An interview with the Director of Nursing, DNS on 2/2/24 at 2:44 PM identified she would expect nursing staff to change gloves and perform had hygiene between dirty and clean tasks. Although requested, a policy for hand hygiene during wound care was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility policy, review of facility documentation and interviews for one of three sampled residents (Resident #16) who experienced severe pain and inability to bear weight (change in condition) and required hospitalization, the facility failed to ensure that the APRN/physician was consistently updated when the resident's symptoms of pain persisted, inability to bear weight and the ordered ultrasound was not administered. The findings include: Resident #16's diagnoses included dementia, anxiety, hypertension, benign prostatic hyperplasia, and abnormalities with gait. The resident care plan dated 3/12/23 identified Resident #16 had an ADL (activities of daily living) self-care performance deficit related to dementia with interventions that included: assistance of one person with dressing and personal hygiene/showering. A fall risk assessment dated [DATE] identified Resident #16 was at high risk for falls. The quarterly MDS assessment dated [DATE] identified Resident #16 had moderately impaired cognition, no behavioral symptoms, required supervision with bed mobility, transfers, ambulation, and eating, required limited assistance with dressing, toilet use and personal hygiene. The assessment further noted that Resident #16's balance when moving from a seated position to a standing position and when moving on and off the toilet was unsteady but he/she was able to stabilize with assistance, no identified functional range of motion deficits, utilized a can or crutch for mobility, and experienced one fall without injury in the past three months. Monthly physician's orders for the month of May/2023 directed Resident #16 was to ambulate independently with a cane. The nurse's note dated 6/11/23 at 7:50 AM identified Resident #16 reported severe pain to right leg/upper thigh and would not let this writer touch his/her leg. Tylenol was given with good effect. The right lower extremity was noted to be swollen and appeared larger than the left lower extremity and no bruises were observed. The note further identified that the on-call APRN (#2) was notified and gave an order for Tylenol 975 mg (milligrams) every eight hours and obtain right lower extremity ultrasound to rule out deep vein thrombosis. The nurse's note dated 6/11/23 at 1:51 PM identified Resident #16 continued to have right lower extremity pain with a pain score of ten out of ten (10/10 representing the highest level of pain/ severe pain). The further identified that the ultrasound had not been completed, and Resident #16 was up in the wheelchair in the afternoon and was unable to bear weight on the right lower extremity and required the assistance of two staff to transfer the resident into the wheelchair. It further noted that Resident #16 had non pitting edema and the resident noted that his/her right heel and knee were the most painful. The nurse's note dated 6/11/23 at 9:16 PM identified Resident #16 continued to complain of right lower extremity pain with no warmth or redness noted on assessment. The note identified that a call was placed to the company responsible for administering the ultrasound to ascertain the time they would be arriving to perform the ultrasound. According to the nurse's note the company identified that they would be in that night. The nurse's note dated 6/12/23 at 2:54 PM identified Resident #16 was noted to have right leg shortening and external rotation in the morning. The APRN was notified at 9:00 AM and ordered the resident be sent to the hospital emergency department for further evaluation. In addition, the note identified that in the afternoon they were notified that Resident #16 was admitted to the hospital for a right intertrochanteric femur fracture. The hospital Discharge summary dated [DATE] identified that facility provided history that Resident #16 was well until 6/10/23 at 11:00 PM. In the early morning of 6/11/23 Resident #16 complained of hip pain and stayed in bed because of inability to ambulate independently as before. The note further identified that Resident #16 presented to the emergency department with right hip pain and externally rotated right leg. X-ray imaging of the right hip identified a displaced intertrochanteric femur fracture with fracture extending through the greater and lesser trochanter. Interview with RN #2 on 6/21/23 at 1:09 PM identified that at approximately 1:30 AM on 6/11/23 a NA notified her that Resident #16 was complaining of pain. She noted that she went and assessed the resident and identified that Resident #16 was in pain, guarding the area and did not want her to touch him/her. She noted that she administered Tylenol to the resident and afterward the resident fell asleep. RN #2 further noted that she continued to check on Resident #16 throughout the shift and noted that he/she appeared to be asleep. She identified that she called the APRN around 7:00 AM to provide an update that Resident #16 had pain to the right leg, was guarding the upper thigh towards the groin and there was swelling. Additionally, she noted that Resident #16 stayed in bed all night, and the APRN ordered Tylenol 975 MG and an ultrasound. Interview on 6/21/23 at 1:29 PM with APRN #2 identified that on 6/11/23 RN #2 called her to provide an update on Resident #16 and she inquired if there were any other injuries or bruising and RN #2 identified that there were none. APRN #2 identified that since there was no suspicion that the resident had fallen, she ordered an ultrasound. APRN #2 further identified that she was on call for Saturday (6/10/23) and Sunday (6/11/23). She conveyed that she did not receive any follow up phone calls from the facility regarding Resident #16. She also noted that if she had been notified that the ultrasound was not administered and that Resident #16 had experienced a change in condition (as identified by nursing, where Resident #16 was reporting increased pain/discomfort, unable to bear weight to affected limb and required an assistance of at least two persons to move from one surface to the other), she would have changed Resident #16's pain medication, ordered an immediate X-ray of the affected area and directed that the resident be sent out to hospital for further evaluation. Interview on 6/22/23 at 8:45 AM with RN #3 identified Resident #16 had a history of arthritis so she assumed that might have been the problem and noted Resident #16 usually got out of bed and walked to the dining room daily for lunch. RN #3 identified that when Resident #16 was unable to get out of bed on 6/11/23 the nursing staff including herself had to help him/her. RN #3 further identified that Resident #16 was assisted by three persons (on 6/11/23) using the stand pivot technique to assist Resident #16 get out of bed to the wheelchair because he/she could not bear weight on the right lower limb and was in pain. In addition, RN #3 identified that two staff helped him/her to stand and pivot while the third person placed the wheelchair behind the resident. RN #3 further noted that she expected the ultrasound company to show up within 24 hours. She also identified that based on her judgement there was nothing else that could have been done because Resident #16 received assistance to complete activities as needed and the Tylenol was being administered as ordered. RN #3 identified that she left work at 3:00 PM. Interview on 6/22/23 at 11:45 AM with the DNS identified that the clinical record failed to reflect documentation that APRN #2 was updated regarding Resident #16's persistent pain and inability to bear weight and the ultrasound company not completing the ultrasound. She identified that it was expected that nursing staff would call the APRN/ physician and provide update regarding the status of Resident #16. She further identified that the staff moved Resident #16 because they assumed that the resident's arthritis was causing his/her pain and discomfort. A review of the facility's Resident Change of Condition (COC) policy identified that a resident change of condition is defined as any clinically significant deviation from a resident's baseline (normal self) status. The change may be physical, behavioral, functional, or cognitive. The purpose of identifying a COC is to appropriately treat and if necessary, notify the physician or designee, responsible party and transfer the resident to the hospital in a timely manner. The policy further identified that when a COC is noted, the RN will complete an assessment and notify physician or designee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, review of facility policy, and interviews for three of four sampled residents (Residents #2, #13, and #35) with bathrooms in their rooms, the facility failed to ensure that the water temperatures in the resident bathrooms were maintained within the required range of 105.0 to 120.0 degrees Fahrenheit. The findings include: 1. Resident #2's diagnoses included schizoaffective disorder, bipolar disorder, dementia, adjustment disorder, and hypertension. The quarterly MDS assessment dated [DATE] identified Resident #2 was cognitively intact and required limited assistance for bed mobility, dressing, transfers, ambulation, toilet use and personal hygiene. The resident care plan (RCP) dated 6/5/23 identified a self-care deficit due to psychiatric symptoms with interventions that included: set up assistance for bathing and showering, remind and encourage resident to take showers at times and provide frequent checks for incontinence. Observation on 6/20/23 at 12:30 PM of water temperatures in Resident #2's bathroom registered a temperature of 128.6 F (Fahrenheit). Interview on 6/20/23 at 12:40 PM with the Director of Maintenance identified that he randomly checks the water temperatures in resident rooms every day and logs the temperatures in a water temperature logbook. Review of the logbook for the period of January/2023 through June/2023 identified documented room temperatures that were all within acceptable parameters. Observation on 6/20/23 at 12:50 PM with the Director of Maintenance of Resident #2's bathroom water temperature identified a temperature of 131.1 F. Interview on 6/20/23 at 1:30 PM with the Administrator identified that all faucets would be checked for temperatures and signs placed on all faucets with instructions for safety. The Administrator further identified that all staff would be in-serviced on the safety plan and maintenance would adjust the water temperatures and continue to check the water temperatures throughout the day and night until the temperatures register within the correct range. The facility Water Temperature Policy states that the facility water temperatures shall be maintained between 105.0 to 120.0 degrees Fahrenheit. 2. Resident #13's diagnoses include gait abnormalities, Parkinson's disease, normal pressure hydrocephalus and dementia. The quarterly MDS assessment dated [DATE] identified Resident #13 had severe cognitive impairments, required extensive assistance for bed mobility, dressing, toileting and hygiene, was totally dependent for transfers and required supervision with eating. The RCP dated 5/27/23 identified a self-care deficit with interventions that included assistance with bathing, bed mobility, dressing, eating, personal hygiene, and transfers. Observation on 6/20/23 at 12:30 PM of water temperatures in Resident #13's bathroom registered a temperature of 128.6 F (Fahrenheit). Interview on 6/20/23 at 12:40 PM with the Director of Maintenance identified that he randomly checks the water temperatures in resident rooms every day and logs the temperatures in a water temperature logbook. Review of the logbook for the period of January/2023 through June/2023 identified documented room temperatures that were all within acceptable parameters. Observation on 6/20/23 at 12:50 PM with the Director of Maintenance of Resident #13's bathroom water temperature identified a temperature of 131.1 F. Interview on 6/20/23 at 1:30 PM with the Administrator identified that all faucets would be checked for temperatures and signs placed on all faucets with instructions for safety. The Administrator further identified that all staff would be in-serviced on the safety plan and maintenance would adjust the water temperatures and continue to check the water temperatures throughout the day and night until the temperatures register within the correct range. The facility Water Temperature Policy states that the facility water temperatures shall be maintained between 105.0 to 120.0 degrees Fahrenheit. 3. Resident #35's diagnoses included heart failure, type 2 diabetes, osteoarthritis, and history of falls. The quarterly MDS assessment dated [DATE] identified Resident #35 had moderately impaired cognition, required limited assistance for bed mobility, transfers, and ambulation, required extensive assistance for hygiene, toileting, and dressing. The RCP dated 5/18/23 identified a self-care deficit with interventions that included: assist with bathing, showers, bed mobility, dressing, eating set up, hygiene, and toileting. Observation of water temperatures in Resident #35's bathroom on 6/20/23 at 12:30 PM registered a temperature of 128.6 F. Observation on 6/20/23 at 12:30 PM of water temperatures in Resident #35's bathroom registered a temperature of 128.6 F (Fahrenheit). Interview on 6/20/23 at 12:40 PM with the Director of Maintenance identified that he randomly checks the water temperatures in resident rooms every day and logs the temperatures in a water temperature logbook. Review of the logbook for the period of January/2023 through June/2023 identified documented room temperatures that were all within acceptable parameters. Observation on 6/20/23 at 12:50 PM with the Director of Maintenance of Resident #35's bathroom water temperature identified a temperature of 131.1 F. Interview on 6/20/23 at 1:30 PM with the Administrator identified that all faucets would be checked for temperatures and signs placed on all faucets with instructions for safety. The Administrator further identified that all staff would be in-serviced on the safety plan and maintenance would adjust the water temperatures and continue to check the water temperatures throughout the day and night until the temperatures register within the correct range. The facility Water Temperature Policy states that the facility water temperatures shall be maintained between 105.0 to 120.0 degrees Fahrenheit.

Based on review of the facility assessment and interview for the intravenous therapy program, the facility failed to identify that licensed and nurse aide staff had demonstrated competency or were educated related to intravenous therapy use. The findings include: Review of the Facility Assessment document dated 9/1/22 identified that the facility would provide intravenous medications and that education and testing of competency for intravenous line care would be provided. Interview with the DNS on 6/22/23 at 1:21 PM failed to identify documentation that licensed nursing or nursing assist facility staff had received education or competencies for intravenous line managment as indicated on the facility assessment and per the facility policy. Review of the Qualifications for Nurse Providing Infusion Therapy policy dated 8/2018 directed documented successful completion of infusion therapy education, documented completion of clinical competencies, and documented annual infusion education which could consist of in-servicing, formal infution therapy educationn programs and or clinical competencies. Additional education and competency in central line care must be demonstrated.

Based on interview, review of facility narcotic records, clinical record review, and facility policy for 3 of 11 sampled residents (Resident #1, #6 and #16) who were reviewed for controlled substance records (narcotics), the facility failed to accurately reconcile controlled medication or identify the potential for diversion for controlled medications. The findings include: 1. Resident #1's diagnoses included cervical disc disorder, type 1 diabetes, and morbid obesity. 2. Resident #6's diagnoses included bipolar disorder and schizophrenia. 3. Resident #16's diagnoses included anxiety disorder, and unspecified dementia mild with anxiety. During a review of the controlled substance disposition records (narcotic sign out forms), irregularities for the correct number of medications administered to Resident #6 failed to match the physician's order at the top of the form. Further, for Resident #1 and Resident #16 the controlled substance disposition records identified that the medication had been distributed twice at the same time to Resident #1 and Resident #16, double the amount of medication prescribed. Interview and review of the Controlled Drug Disposition records with the Director of Nursing Services (DNS) for Resident #1, #6, and #16 indicated that the irregularities were not picked up during the reconciliation process. The DNS identified that the process of reviewing for drug irregularities, that medications were not given correctly or not investigated for possible diversion, was her responsibility, and that moving forward she would be paying closer attention. Review of the Medication Storage in the Facility/Controlled Substance Storage policy dated February 2019, identified that the Consultant Pharmacist or designee routinely monitors controlled substance storage, and records such as individual controlled substance accountability sheets during routine medication storage inspections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, and interviews for one of three residents (Resident #18) reviewed for unnecessary medication, the pharmacist failed to report a medication irregularity regarding a Gradual Dose Reduction (GDR) for Risperidone (anti-psychotic medication). The findings include: Resident #18's diagnoses included Wernicke's encephalopathy, asthma, depression, malignant left breast cancer. The resident 's physician's orders for the month of June/2023 directed to administer Risperidone tablet (antipsychotic medication) 0.25 milligrams (mg) by mouth twice a day. The origination date of the order was identified as 6/14/22. The psychiatric progress note dated 1/31/23 at 1:13 PM identified Resident #18 had good compliance with medication, no evidence of agitation or compulsive behaviors, and no sign of anxiety, hyperactive or attention difficulties. The note further identified Resident #18's behavior in session was cooperative and attentive with no gross behavioral abnormalities. The quarterly MDS assessment dated [DATE] identified Resident #18 was cognitively intact, did not exhibit any behaviors, required limited assistance with bed mobility, transfers, toileting, ambulation, and hygiene, utilized a rolling walker for mobility. The Resident Care Plan (RCP) dated 3/30/23 identified Resident #18 used anti-psychotic medication with interventions that included: administer psychotropic medication as order by physician, monitor and document for any adverse reaction of psychotropic medication, monitor and record occurrence of targeted behavior symptoms and document per facility protocol, Abnormal Involuntary Movement Scale (AIMS) testing every 6 months and monthly orthostatic blood pressure. Review of the monthly behavior/intervention flow record from January/2023 through May/2023 identified Resident #18 was monitored for the targeted behavior of aggression toward staff and others. The documentation identified that the resident did not display the targeted behaviors for the time period reviewed. Review of the monthly pharmacist medication regimen review record from January/2023 through June/2023 for Resident #18 did not identify any irregularities with his/her current medication at the time of the review. Review of psychiatric progress note dated 6/6/23 at 8:28 PM identified Resident #18 had no evidence of agitation or impulsive behavior, was calm, attentive, pleasant, communicative and had a relaxed demeanor. The note further identified that there were no signs of anxiety or attention difficulties. Review of the psychiatric progress notes for the period of June/2022 to June/2023 failed to identify that a GDR of the Risperidone had been attempted in the past year and review of the monthly medication regimen reviews for the same time period failed to identify that the pharmacist made a recommendation for a GDR of the Risperidone Interview with the Physician Assistant (PA #1) on 6/21/23 at 11:30 AM identified that she was responsible for assessing Resident #18 for a GDR. She also identified that the Risperidone 0.25 mg was prescribed for Resident #18's delusional disorder and aggressive behaviors toward staff and others. PA #1 further noted Resident #18 been on Risperidone 0.25 mg twice a day since April 20, 2020. She could not offer a reason why a GDR had not been attempted in the past and noted that she had been treating the resident since April of 2022 and noted that she had not attempted a GDR of the Risperidone because Resident #18 had a recent diagnosis of breast cancer. Interview with Pharmacist #1 on 6/22/23 at 12:20 PM identified that he was responsible for reviewing Resident #18's monthly medication regimen for medication irregularities. He also identified that when a resident is taking an anti-psychotic medication without a corresponding medical diagnosis, he would review the resident's behavior log, medication dosage and physician notes and would request a recommendation for GDR for any resident taking an anti-psychotic medication. He further noted that he would recommend a GDR for anti-psychotic medication when the resident's behavior was stable in the past quarter and identified that no irregularity on his monthly medication regimen meant there was no recommendation at the time of his review. Pharmacist #1 did not offer a reason as to why a recommendation for a GDR of the Risperidone had not been attempted over the past year (June/2022 to June/2023) Review of the facility's Medication Regime Review policy identified that the consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. In performing medication regimen reviews, the consultant pharmacist incorporates federal mandated standards of care and other applicable professional standards. The consultant pharmacist also identifies irregularities through a variety of sources including the resident's clinical record, pharmacy record and other applicable documents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, and interviews for one of three residents (Resident #18) reviewed for unnecessary medication, the facility failed to ensure gradual dose reduction was attempted when a resident was receiving Risperdal (anti-psychotics medication). The findings include: Resident #18's diagnoses included Wernicke's encephalopathy, asthma, depression, malignant left breast cancer. The resident 's physician's orders for the month of June/2023 directed to administer Risperidone tablet (antipsychotic medication) 0.25 milligrams (mg) by mouth twice a day. The origination date of the order was identified as 6/14/22. The psychiatric progress note dated 1/31/23 at 1:13 PM identified Resident #18 had good compliance with medication, no evidence of agitation or compulsive behaviors, and no sign of anxiety, hyperactive or attention difficulties. The note further identified Resident #18's behavior in session was cooperative and attentive with no gross behavioral abnormalities. The quarterly MDS assessment dated [DATE] identified Resident #18 was cognitively intact, did not exhibit any behaviors, required limited assistance with bed mobility, transfers, toileting, ambulation, and hygiene, utilized a rolling walker for mobility. The Resident Care Plan (RCP) dated 3/30/23 identified Resident #18 used anti-psychotic medication with interventions that included: administer psychotropic medication as order by physician, monitor and document for any adverse reaction of psychotropic medication, monitor and record occurrence of targeted behavior symptoms and document per facility protocol, Abnormal Involuntary Movement Scale (AIMS) testing every 6 months and monthly orthostatic blood pressure. Review of the monthly behavior/intervention flow record from January/2023 through May/2023 identified Resident #18 was monitored for the targeted behavior of aggression toward staff and others. The documentation identified that the resident did not display the targeted behaviors for the time period reviewed. Review of the monthly pharmacist medication regimen review record from January/2023 through June/2023 for Resident #18 did not identify any irregularities with his/her current medication at the time of the review. Review of psychiatric progress note dated 6/6/23 at 8:28 PM identified Resident #18 had no evidence of agitation or impulsive behavior, was calm, attentive, pleasant, communicative and had a relaxed demeanor. The note further identified that there were no signs of anxiety or attention difficulties. Review of the psychiatric progress notes for the period of June/2022 to June/2023 failed to identify that a GDR of the Risperidone had been attempted in the past year and review of the monthly medication regimen reviews for the same time period failed to identify that the pharmacist made a recommendation for a GDR of the Risperidone Interview with the Physician Assistant (PA #1) on 6/21/23 at 11:30 AM identified that she was responsible for assessing Resident #18 for a GDR. She also identified that the Risperidone 0.25 mg was prescribed for Resident #18's delusional disorder and aggressive behaviors toward staff and others. PA #1 further noted Resident #18 been on Risperidone 0.25 mg twice a day since April 20, 2020. She could not offer a reason why a GDR had not been attempted in the past and noted that she had been treating the resident since April of 2022 and noted that she had not attempted a GDR of the Risperidone because Resident #18 had a recent diagnosis of breast cancer. Interview with DNS on 6/21/23 at 12:30 PM identified that the psychiatrist group would be responsible in assessing resident's anti-psychotic for a GDR. She also identified that she would expect the psychiatrist group to evaluate resident's anti-psychotic medication for a GDR when appropriate in compliance with federal regulation. She further identified that Resident #18 behavior had been stable. The facility was not able to provide documentation that Resident #18 risperidone GDR was attempted when requested during the survey. Review of facility policy title Medication Monitoring and Management identified that residents who were admitted on an anti-psychotic medication or facility initiated anti-psychotic medication therapy, the facility must attempt a GDR in two separate quarters within the first year unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated. A GDR would be considered clinically contraindicated if the targeted behavior returned or worsened after the most recent attempt and physician would document the clinical rationale for why any attempted dose reduction would likely impair the resident's function, increased distressed behavior and cause psychiatry instability.

Based on observation, interviews, and facility policy during an inspection of medication storage for the only medication cart in the facility, the facility failed to store ophthalmic medications appropriately to prevent cross contamination. The findings include: Observation with RN #1 on 6/21/23 at 11:10 AM of the medication cart identified that Resident #4's, Resident #10's, and Resident #20's Artificial Tears eye drops were stored together in one compartment without the use of dividers, plastic bags, or use of the individual boxes in which the medications were originally contained to prevent cross contamination. Interview with RN #1 on 6/21/23 at 11:10 AM identified the eye drops should have been kept in a plastic bag to separate for each resident. RN #1 further indicated that it was the responsibility of every nurse who used the medication cart to ensure eye drop containers were stored individually and separately. Subsequently to surveyor inquiry, RN #1 removed eye drops from the medication cart. Interview with the Pharmacy Consultant on 6/21/23 at 3:10 PM identified that over-the-counter eye drops, and eye drops for each resident should be stored separately in a plastic bag, in the original box, or in compartments for infection control (to prevent cross contamination). Review of the facility Medication Storage in the Facility/Storage of Medications policy dated February 2019 identified ophthalmic solutions should be stored separately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, and interviews for one sampled resident (Resident #20) reviewed for dental services, the facility failed to provide routine dental services to meet the resident's needs. The findings include: Resident #20's diagnoses included obstructive and reflux uropathy, macular degeneration, and chronic atrial fibrillation. A dental consult dated 3/28/23 identified Resident #20 needed hygiene visits and x-rays. The quarterly MDS assessment dated [DATE] identified Resident #20 had intact cognition, required supervision with transfers and eating, and limited assistance with dressing and personal hygiene. The Resident Care Plan dated 4/13/23 identified the resident was at risk for oral/dental health problems and had his/her own teeth. Interventions identified to coordinate arrangements for dental care, transportation as needed and as ordered. Interview with the DNS on 6/21/23 at 10:16 AM identified that the dental consult dated 3/28/23 identified that the resident was seen by the dental provider and identified that Resident #20 needed a hygiene visit and x-rays; however, there was no dental follow up to the recommendations from the dental provider. The DNS further identified that the dental provider makes the hygiene schedule, and the DNS was not aware the resident was due to be seen as she had no tracking system in place to follow up with dental recommendations. Interview with Dental Provider Staff #1 on 6/21/23 at 10:44 AM identified that the notes from each visit with recommendations are emailed to the facility the day the provider sees the residents, and the facility receives a copy of the consult. Dental Provider Staff #1 further identified that the hygienist was back at the facility on 6/12/23, however Resident #20 was not seen. Dental Provider staff #1 was not sure why Resident #20 was not on the schedule and questioned if there was a billing issue as they did not have Medicaid insurance for Resident #20 but would check and get back in touch. Interview on 6/21/23 at 11:08 AM with Dental Provider Staff #2 identified the resident had Medicare listed and no Medicaid therefore would have had to pay out of pocket and noted that this information had been relayed to the DNS via telephone and could provide documentation that the information had been conveyed to the DNS. A note dated 6/1/23 at 11:12 AM provided by the Dental Provider identified that the resident did not have dental coverage and further treatment would require a payor source and this was the information that they noted was provided to the DNS. Interview with the DNS on 6/21/23 at 11:52 AM and 2:41 PM identified Resident #20's payor source was Medicaid and therefore there would have not been a billing issue. She identified that she would send the Medicaid information to the dental provider. The DNS further identified that she had not received the communication regarding no dental coverage and that further treatment would require a payor source because she would have contacted the resident's Power of Attorney to discuss. Although a policy for dental was requested one was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, and interviews for one of thirty residents, (Resident #4), observed during the lunch meal, the facility failed to provide adaptive equipment according to the dietary slip and physician order. The findings include: Resident #4's diagnoses included cerebral vascular accident (stroke), arthritis, and heart failure. The change in condition Minimum Data Set assessment dated [DATE] identified, Resident #4 was without cognitive impairment, she/he required assist of 2 staff for bed mobility, dressing, and transfers. Additionally, she/he required the extensive assistance of 1 staff for meals. The care plan dated 5/25/23 identified that Resident #4 had an activities of daily living deficit, related to a cerebral vascular accident (stroke), and left arm contracture. Observation and review of the dietary slip, during the lunch meal, on 6/20/23 at 12:06 PM directed the use of cups with handles. Observation of Resident #4 identified that she/he had received his/her lunch meal as well as beverages, but the facility had failed to provide the cups with handles as directed by the dietary slip. Interview and review of the dietary slip with Dietary Aide (DA) #2 on 6/20/23 at 12:31 PM, identified Resident #4's dietary slip required the use of cups and mugs with handles for drinks. DA #2 identified that she failed to check the dietary slip prior to providing Resident #4 with beverages. Further DA #2 identified that information directing adaptive equipment was posted in the kitchen, but that she had failed to review that information prior to lunch service. The DA #2 indicated that she should have provided Resident #4 with cups with handles for his/her beverages as directed. Review of the physician's order dated 6/19/23 directed facility staff to place drinks in cups with handles. Although DA #2 indicated that it could have been a new order, the original physician order for cups with handles was dated 2/28/23. A second observation during the lunch meal on 6/21/23 at 12:00 PM identified Resident #4 had regular cups, without the benefit of handles. Interview with the Director of Nursing Service (DNS) on 6/22/23 at 12:12 PM, identified that although she had requested the occupational therapist write an adaptive equipment policy, the written policy had not been completed and that adaptive equipment should be provided as indicated on the dietary slip.

Based on observations during the kitchen tour, review of facility policy and interviews, the facility failed to ensure items were appropriately labeled and dated when opened and failed to discard expired foods prior to the expiration date. The findings include: Observations during a tour of the kitchen on 06/20/23 at 9:55 AM identified the following: Refrigerator #1 (white) A. Use by date of sour cream was 6/15/23. B. Feta shredded cheese lacked both an opened and expiration date. C. American shredded cheese lacking an opened date. D. Mozzarella shredded cheese lacking both an opened and expiration date. E. Parmesan cheese that expired on 5/11/23. Refrigerator #2 (double door stainless steel) Barbeque sauce that was transferred from the original container to a plastic container on 6/8/23 but lacked an expiration date. Interview with the Food Service Supervisor (FSS) on 6/20/23 at 10:14 AM, identified all food should have a date when opened and an expiration date. The FSS indicated that foods are generally good for 7 days once opened. Additionally, the FSS identified all cooks were responsible for ensuring opened dates were written on containers, he was responsible to check the refrigerators to ensure food items were not expired and were dated when opened, and that he must have missed the undated and expired items. Subsequent to surveyor inquiry, the undated and expired food items were discarded. Review of the undated Food Safety Requirements policy directed, in part, to follow the national standards of food storage in a safe manner in long term care facilities. By doing so, critical control points are identified during the food preparation process, to prevent, reduce or eliminate foodborne hazards in the nursing facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 residents (Resident #5 and 24) reviewed for positioning, the facility failed to ensure physician orders were obtained for the use of a custom wheelchair with lap tray. The findings include: 1. Resident #5's diagnoses included Parkinson's disease and Lewy Body dementia. An Occupational Therapy note dated 11/6/20 identified Resident #5 utilized a custom wheelchair with a lap tray for optimal positioning. A physician's order dated 3/10/21 directed to transfer Resident #5 with the assistance of 2 staff to the custom wheelchair. The quarterly MDS dated [DATE] identified Resident #5 had severely impaired cognition, required extensive assistance of 2 staff for transfers, and used a wheelchair. The care plan dated 7/8/21 identified Resident #5 was at risk to fall related to confusion. Interventions included to transfer the resident out of bed to a custom wheelchair with a lap tray for pelvic positioning. Multiple random observations on 7/8/21 identified Resident #5 was seated in a wheelchair with a full lap tray. Review of the clinical record failed to reflect a physician's order for the use of a full lap tray. Interview, review of the clinical record, and facility documentation with LPN #1 on 7/12/21 at 5:15 PM identified residents using a custom wheelchair and a lap tray should have a physician's order, and it should be on the TAR for signature. Observation, review of the clinical record and interview with the DNS on 7/12/21 at 5:27 PM identified that Resident #5 was seated in a custom wheelchair with a full lap tray, and although residents should have a physician's order directing use of a custom wheelchair, she was unable to locate a current physician's order that directed use of the full lap tray. 2. Resident #24's diagnoses included Multiple Sclerosis and dementia. An Occupational Therapy note dated 1/21/21 identified Resident #24 utilized a custom wheelchair with a lap tray to achieve support for self-feeding to reduce the risk of aspiration. The quarterly MDS dated [DATE] identified Resident #24 had moderately impaired cognition, required total assist amcefor transfers, was non-ambulatory, used a wheelchair, and was dependent for locomotion on/off the unit. The care plan dated 6/3/21 identified Resident #24 had a custom wheelchair due to a decline in functional seating related to Multiple Sclerosis. Interventions included to use a lap tray on the custom wheelchair for positioning, and to monitor for side effects. Observations on 7/8/21 at 10:00 AM, and additional intermittent observations on 7/12/21 and 7/13/21 identified Resident #24 was seated in a wheelchair with a full lap tray. Review of the clinical record failed to reflect a physician's order that directed use of a full lap tray. Interview, review of the clinical record and facility documentation with LPN #1 on 7/12/21 at 5:15 PM identified residents using a custom wheelchair with lap tray should have a physician's order. LPN #1 identified she was unable to locate a physician's order that directed use of the custom wheelchair and lap tray for Resident #24 and was unable to locate any record on the TAR that the custom wheelchair and lap tray were being used. Observation, review of the clinical record and interview with the DNS on 7/12/21 at 5:27 PM identified that Resident #24 was in a custom wheelchair with a full lap tray, and although residents should have a physician's order directing the use of a custom wheelchair with lap tray, she was unable to locate a current physician's order. The DNS further identified that Resident #24 last had a physician's order for the use of the custom wheelchair dated 1/6/21 but was discharged to the hospital on 1/7/21. The DNS indicated that when Resident #24 was readmitted to the facility on [DATE] the custom wheelchair with lap tray order was not included in the readmission orders; the order should have been included upon Resident #24's readmission. Interview with the DNS on 7/14/21 at 11:55 AM identified subsequent to surveyor inquiry, Resident #5 and Resident #24 were being evaluated by therapy and new orders would be obtained as recommended by therapy. Review of the Custom Wheel Chair Policy directed a Custom Wheel Chair will require a physician's order, the order will reflect specifics; chair type or style. Example: custom wheelchair, tilt in space per 24-hour positioning plan with tray for upper extremities, pelvic belt, head rest, pelvic stabilizer, foot rest, etc.