**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, review of facility documentation and interviews for four sampled residents (Residents #22, #26, #30 and #49) who received psychiatric medications and received psychiatric services, the facility failed to ensure psychiatric visits were documented in a timely manner. The findings include: 1. Resident #22's diagnoses included dementia, anxiety disorder, and delusional disorder. The annual MDS assessment dated [DATE] identified Resident #22 had severely impaired cognition, required maximal assistance with dressing, personal hygiene, moderate assistance with bed mobility and transfers and ambulated using a walker with moderate assistance. The care plan dated 1/20/25 identified Resident #22 was receiving psychotropic medication related to vascular dementia with behavioral disturbances and major depressive disorder with interventions that included resident sees the psychiatric team routinely for care. The physician's order dated 3/19/25 directed for evaluation and ongoing treatment by psychiatry. Review of the psychiatry progress note dated 11/21/24 at 12:13 PM by APRN #1 identified she added a new medication Memantine (used to treat memory loss) 5mg for one week then to increase to 10 mg daily and she would reassess for further increase at next visit. Review of the clinical record failed to identify any further documentation from APRN #1 in Resident #22's medical record. Interview with APRN #1 on 3/25/25 at 3:10 PM identified her schedule varies as it relates to seeing patients: as stable patients are seen within 2 to 3 months and less stable patients are seen frequently within 2 to 4 weeks. APRN #1 identified she saw Resident #22 as recent as last month. When asked where she had documented her notes after her visits, she indicated that she was behind in her documentation, but the resident had been seen. In addition, APRN #1 identified that the expectation is that she enters her notes into the EMR after her visit. When asked if she had let the DNS/Administrator know how far behind she was, she indicated that she had not. She stated that she would get documentation entered in by the end of the day. In an interview with the DNS on 3/26/25 at 9:35 AM she identified that she was unaware that APRN #1 was behind in her documentation. The DNS added that her expectation is that all documentation is entered after each encounter is completed. The DNS identified that APRN #1's EMR does not interface with the facility's EMR, therefore she cuts and pastes her notes into the facility's EMR. Interview with the Medical Director of the Mental Health Specialist (MD #2) on 3/28/25 at 9:19 AM identified he expects that when a resident is seen by the provider the notes are put in the resident chart for continuity of care. Interview with APRN #2 on 3/28/25 at 10:41 AM identifies that she could communicate via texting system with the psychiatry APRN. She further identified she could only review the notes that were available, and it was expectation was that documentation to be completed timely. Subsequent to surveyor's inquiry APRN #1 entered notes in the EMR on 3/25/25 for visits with Resident #22 which had occurred on 12/3/24, 12/10/24, 12/31/24, and 1/21/25. Although requested, a facility policy for documentation was not provided. In an interview with the DNS on 3/28/25 at 10:30 AM identified the facility does not have a policy for documentation but it is the facility's practice to enter documentation into the EMR after each resident encounter. 2. Resident #26's diagnoses included Alzheimer's disease, adult failure to thrive, and pain. The quarterly MDS assessment dated [DATE], identified Resident #26 had severe cognitive impairment and was dependent for all personal hygiene and activities of daily living. The physician's order dated 3/19/25 directed to obtain a psychiatry evaluation and treatment as needed. The Resident Care Plan dated 3/21/25 identified Resident #26 received psychotropic medications. Interventions included psychiatric services as needed. Review of the 5/15/24 Behavioral Health note written by APRN#1 indicated that a follow-up re-assessment visit would be scheduled in 3 months. Review of the clinical record did not contain any further documentation from APRN #1. In an interview with APRN #1 on 3/25/25 at 3:10 PM she confirmed that she had seen Resident #26 in August and was behind in her documentation. She identified that the expectation is that she enters her documentation into the EMR after her visit. When asked if she let the DNS/Administrator know how far behind she was, she indicated that she had not. She noted that she would enter the documentation of the visit by the end of the day. In an interview with the DNS on 3/26/25 at 9:35 AM she identified that she was unaware that APRN #1 was behind in her documentation. Further she stated that her expectation is that all documentation is entered after each encounter is completed. The DNS identified that APRN #1's EMR does not interface with the facility's EMR, therefore she cuts and pastes her notes into the facility's EMR. In an interview with MD#2 on 3/28/25 at 9:19 AM identified that the expectation is when the resident is seen by the provider, the notes are put in the resident's chart for continuity of care. Subsequent to surveyor inquiry all notes were entered into the EMR on 3/26/25 for the following visits: 8/14/24, 8/28/24, 1/9/25, and 2/20/25. A documentation policy was requested; however, one was not provided as the facility does not have a policy for documentation. The facility practice is to enter documentation into the EMR after each resident encounter. 3. Resident #30's diagnoses included dementia with behavioral disturbances, nutritional deficiency, and chronic pain. The quarterly MDS assessment dated [DATE] identified Resident #30 had severely impaired cognition, was short tempered or easily annoyed, had disorganized thinking, exhibited verbal behavioral symptoms directed toward others, and was dependent on staff for all mobility and transfers. The care plan dated 2/11/25 identified Resident #30 was being monitored for psychotropic medications and behaviors with interventions that included: offer food or emotional support, seen by the psychiatric team as needed for care, attempt gradual dose reduction (GDR) as ordered by provider, monitor behaviors and response to medications, AIMS (Abnormal Involuntary Movement Scale) per facility policy and as needed, monitor medication for therapeutic effects and document target symptoms. The physician's orders dated 3/4/25 directed to administer the following medications: Quetiapine (antipsychotic medication) 25 mg give twice per day with 50 mg dose at 5pm and 9 pm Sertraline (antidepressant) 25 mg by mouth with food as part of a 37.5 mg dose once a day Nursing progress notes dated 11/19/24 at 6:59 PM identified the resident was seen by the psychiatric APRN with no new orders. Nursing progress notes dated 1/9/25 at 5:16 PM identified Resident #30 was seen that afternoon by the psychiatric APRN and indicated there were no new orders. Review of Resident #30's clinical record on 3/25/25 at 1:00 PM identified that the last noted documentation from the psychiatric APRN (APRN #1) was dated 11/20/24 and identified the resident was seen to assess mood/behavior and to review psychiatric medications. Review of the Psychiatric Referral Log identified Resident #30 was seen by the psychiatric APRN on 3/26/25. Review of the clinical record failed to identify documentation of the visit. Interview on 3/25/25 at 3:10 PM with APRN#1 identified that she documents her notes in a different computer system and is responsible for transferring the notes to the resident's clinical record. Further, she did not provide an explanation as to why the notes were not up to date in Resident #30's clinical record. She also noted that she had not communicated to anyone that she was behind with her documentation. Interview on 3/26/25 at 9:35 AM with the DNS identified that she was not aware that APRN#1's documentation was not completed. The DNS indicated that her expectation is that all documentation be entered into the computer when the resident is seen. The DNS further identified that APRN#1 used a different computer system to write her notes and that she was required to cut and paste the notes into the facility's EMR (electronic medical record). Interview on 3/28/25 at 9:19 AM with the Medical Director of the mental health specialists (MD #2) identified that the expectation for documentation is that when the resident is seen by the provider, the notes should be put in the resident's chart immediately to ensure continuity of care. Interview on 3/28/25 at 10:41 AM with APRN #2 identified that she is able to text with APRN#1 should she have questions. APRN#2 indicated that she can only read what is available and that communication with APRN#1 was minimal and that she usually received verbal report from nursing staff. Interview on 3/27/25 at 2:09 PM with APRN #1 identified her notes for Resident #30 had not been entered since 11/20/24 and was unable to identify why. APRN#1 indicated she had seen the resident, made some medication changes and that the resident had a gradual dose reduction and would upload the notes that night. APRN#1 indicated that she communicates with nursing staff regarding changes. Review of the medical record on 3/28/25 identified that APRN #1 entered notes into Resident #30's medical record at 11:41 PM on 3/27/25 for visits dated 1/9/25 and 2/20/25. 4. Resident #49's diagnoses included cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, The quarterly MDS assessment dated [DATE] identified Resident #49 had intact cognition, did not exhibit behavioral symptoms, and received antianxiety and antidepressant medication. The care plan dated 1/14/25 identified Resident #49 was taking psychotropic drugs and interventions included: attempt a gradual dose reduction (GDR) per regulations and as recommended by MD/APRN to see the psychiatric team as needed for care, monitor behavior and response to medication, monitor for side effects and therapeutic effects, provide coaching on appropriate behaviors. Physician's orders dated 3/19/25 directed evaluation and on-going treatment by psychiatry, note the presence of target behaviors of yelling, inappropriate sexual comments, and paranoia, at the end of each shift. Physician's orders included Duloxetine capsule delayed release (antidepressant) 60 mg once a day, Lorazepam (antianxiety) 0.5 mg tablet (give ½ tablet twice a day), Trazodone (antidepressant) 50 mg tablet ½ tablet once daily in addition to ½ tablet by mouth every 4 hours as needed for anxiety or agitation. Interview on 3/25/25 at 3:10 PM with APRN#1 identified that she documents her notes in a different computer system and is responsible for transferring the notes to the resident's clinical record. Further, she did not provide an explanation as to why the notes were not up to date in Resident #49's clinical record. She also noted that she had not communicated to anyone that she was behind with her documentation. Interview on 3/26/25 at 9:35 AM with the DNS identified that she was not aware that APRN#1's documentation was not completed. The DNS indicated that her expectation is that all documentation be entered into the computer when the resident is seen. The DNS further identified that APRN#1 used a different computer system to write her notes and that she was required to cut and paste the notes into the facility's EMR (electronic medical record). Interview on 3/27/25 at 11:40 AM with the Administrator and DNS identified the expectation for documentation is that it is to be completed in real time, or when the resident is seen the documentation should be completed. Additionally, the Administrator indicated that the facility did not have a policy that outlined expectations for documentation. Interview on 3/27/25 at 2:05 PM with APRN#1 identified she saw the resident frequently and indicated she did not have a reason for not having any documentation in the computer. Interview on 3/28/25 at 9:19 AM with MD#2 identified the expectation for documentation is that when the resident is seen by the provider, the notes should be put in the resident's chart to ensure continuity of care. Subsequent to surveyor's inquiry APRN#1 entered notes into the facility EMR on 3/27/25 for visits that occurred with Resident #32 on 12/10/24, 12/17/24, 12/31/24, 1/16/25, 1/21/25, 1/30/25, 2/4/25, 2/11/25, 2/18/25, 2/25/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, review of facility documentation, review of facility policy/procedure and interviews for three of five sampled residents (Resident #46, Resident #47, and Resident #50), reviewed for immunizations, the facility failed to ensure that the pneumococcal vaccine was offered and administered as required. The findings include: Resident #46 was admitted to the facility in November/2024 with diagnoses that included mild neurocognitive disorder, bipolar disorder, and Vitamin D deficiency. The quarterly MDS assessment dated [DATE] identified Resident #46 had intact cognition. According to the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults dated 3/15/23 for adults 65years or older complete pneumococcal vaccine schedules identified adults >65 years who had received the PPSV23 only (pneumococcal vaccine) at any age have an option to receive after one year the pneumococcal vaccine (PCV20 or PCV15). Review of Resident #46's Pneumococcal Vaccination history under the Preventative Health Care tab identified the resident had received the PPSV 23 (pneumococcal vaccine) on 2/13/2023 prior to his/her admission to the facility and no records of the Prevnar 13 vaccine (PCV 13) being administered previously. Review of the Authorization for Examinations, Laboratory Studies and test consent form which includes immunizations identified Resident #46's representative had given consent and received education regarding the pneumococcal vaccine on 10/16/24. Review of Resident #46 clinical records failed to identify that he/she had received the vaccination at the facility or had change his/her decision. Interview with the Infection Preventionist (IP) (RN #3) on 3/27/25 at 9:45 AM identified the IP was responsible for reviewing medical records to obtain vaccination history, obtained consents and ensuring the appropriate vaccine was offered and administered to the resident. IP identified she had sent a consent to the resident's representative on 2/6/25 with no response but did not realize that on admission residents are provided with a consent form that includes vaccines consent along with education on admission. RN #3 was asked if she had any prior documentation since the resident admission in November that would indicate that she had made efforts to obtain vaccination history or consent from the resident representative which she responded that she only had the email sent on 2/6/25. RN #3 identified that the Resident #46 was eligible to receive PCV 20 after one year based on CDC pneumococcal vaccine schedule. Review of the Pneumococcal Vaccination for Residents policy identified that each resident or their responsible party will be asked on admission if they have previously had the pneumococcal vaccination and at what age (i.e. [AGE] years of age, 65 at the time of vaccination). The records that accompany the resident will also be used to determine immunization status. The policy further identified if there is no prior evidence of vaccination, the vaccine will be offered to the resident at that time, based on the CDC recommended schedule. Resident #47 was admitted to the facility in July/2024 with diagnoses that included dementia, mood disturbance, and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #47 had severely impaired cognition. The assessment further identified that the resident did not receive the pneumococcal vaccine with no reason as to why the vaccine was not offered. According to the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults dated 3/15/23 for adults 65years or older complete pneumococcal vaccine schedules identified adults >65 years and had no prior vaccination of the pneumococcal vaccine are eligible for receiving the PCV20 vaccine or the PCV15 vaccine (pneumococcal vaccine) then after one year the PPSV23 vaccine. Review of Resident #47's Pneumococcal Vaccination history under the Preventative Health Care tab failed to identify any previous history/record of pneumococcal vaccination. Review of the Authorization for Examinations, Laboratory Studies and test consent form which includes immunizations identified Resident #47's representative had given consent and received education regarding the pneumococcal vaccine on 7/11/24 and had indicated that the last dose of pneumococcal was in 12/22. Interview with the Infection Preventionist (IP) (RN #3) on 3/27/25 at 9:45 AM identified the IP was responsible for reviewing medical records to obtain vaccination history, obtained consents and ensuring the appropriate vaccine was offered and administered to the resident. The IP identified she had no records of past vaccination for the resident and had sent a pneumococcal vaccination consent to the resident's representative on 2/6/25 but did not realize that on admission residents are provided with a consent form that includes vaccines consent along with education on admission. RN #3 was asked if she had any prior documentation since the resident admission in July that would indicate that she had made efforts to obtain vaccination history or consent from the resident representative which she responded that she only had the email sent on 2/6/25. RN #3 identified Resident #47 was eligible to receive PCV 20 based on CDC pneumococcal vaccine schedule. Interview with the DNS and the Administrator on 3/27/25 at 10:30 AM identified that the facility did not have a set timeframe to obtain vaccination history. The DNS identified that a nurses note would not be required to document that the facility was obtaining the vaccination history, but an internal tracking system should be utilized. Review of the Pneumococcal Vaccination for Residents policy identified that each resident or their responsible party will be asked on admission if they have previously had the pneumococcal vaccination and at what age (i.e. [AGE] years of age, 65 at the time of vaccination). The records that accompany the resident will also be used to determine immunization status. The policy further identified if there is no prior evidence of vaccination, the vaccine will be offered to the resident at that time, based on the CDC recommended schedule. Resident #50 was admitted to the facility in August/2024 with diagnoses that included Alzheimer's disease, chronic pain syndrome, and hypertension. The quarterly MDS assessment dated [DATE] identified Resident #50 had moderately impaired cognition. According to the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults dated 3/15/23 for adults 65years or older complete pneumococcal vaccine schedules identified adults >65 years have an option to receive the pneumococcal vaccine 20 (PVC 20) if they had already received both Prevnar 13 (PCV 13) at any age and/ pneumococcal vaccine (PPSV23) at or after age [AGE] years old and are eligible to receive after 5 years the PCV20 or another dose of the PPSV23 after shared decision with the provider and the patient. Review of Resident #50's Pneumococcal Vaccination history under the Preventative Health Care tab in the pneumococcal vaccine with a created date of 8/15/24 identified the resident had received the PPSV 23 (pneumococcal vaccine) on 11/12/2007 and Prevnar 13 vaccine (PCV 13) on 8/19/2015 which was prior to his/her admission to the facility. Review of the Authorization for Examinations, Laboratory Studies and test form which includes immunizations identified the Resident #50's representative had given consent and received education regarding the pneumococcal vaccine on 8/14/24. Review of Resident #46 clinical records failed to identify that he/she had received the vaccination at the facility or had change his/her decision. Interview with the Infection Preventionist (IP) (RN #3) on 3/27/25 at 9:45 AM identified the IP was responsible for reviewing medical records to obtain vaccination history, obtained consents and ensuring the appropriate vaccine was offered and administered to the resident. The IP identified she had not offered any pneumococcal vaccine to Resident #50 because she was utilizing the CDC vaccine schedule that was dated 4/1/22, which based on the resident's vaccination history he/she was updated. However, based on the updated pneumococcal vaccine schedule, which she has been utilizing, the resident should have been offered the PCV 20 or another dose of PPSV 23. Review of the Pneumococcal Vaccination for Residents policy identified that each resident or their responsible party will be asked on admission if they have previously had the pneumococcal vaccination and at what age (i.e. [AGE] years of age, 65 at the time of vaccination). The records that accompany the resident will also be used to determine immunization status. The policy further identified if there is no prior evidence of vaccination, the vaccine will be offered to the resident at that time, based on the CDC recommended schedule.

Based on review of facility documentation, review of facility policy, and interviews, the facility failed to provide documentation that their flushing program logs were maintained according to the facility's water management plan. The findings include: Review of the Facility Water Management Plan with the Director of Maintenance for the years 2023 through March 2025 on 3/26/25 at 11:45 AM identified the facility water management plan included flushing monthly, annual testing and that the facility also had a contract with a vendor for their water management program. The Director of Maintenance provided a log titled Domestic Hot Water Heaters Monthly Draining for 2024 in which only the months of January, February, March and April were checked off as completed. The Director of Maintenance identified that whenever the flush was completed it should have been signed off by the maintenance staff. In a notarized Affidavit statement dated 3/27/24 by the Maintenance staff (Maintenance #1) who was responsible for documenting and flushing the hot water domestic heater in 2024) identified he had completed the flushes as required and did not document the flushes at the time he completed them for the months of May 2024 through December 2024. Although a request was made on 3/27/25 and 3/28/25 for the flushing program logs from April 2023 through March 2025, the facility failed to provide such documentation and had only provided the monthly draining log of the hot water domestic heater. Review of the Annual Water Management Plan Revision and Updates dated 8/31/21 in which the Director of Maintenance identified that was current and in effect along with the Facility's Environmental Assessment and Procedure and water management binder with the Director of Maintenance on 3/27/25 at 12:58 PM identified the Water Management Plan in fact included a flushing program using the mitigations steps identified in facility's Environmental Assessment and Procedures which were hot water storage tank; facility ice machine; showers/tubs/faucets that are uncommonly used to be flushed for 3-5 minutes monthly, which should be documented and kept in the service section of their plan; and eyewash station to be flushed monthly for 3 minutes which should be documented and kept in the service section of their plan as well as to utilized the flushing program log provided. The Director of Maintenance identified that the boiler was drained monthly, ice machines were serviced semi-annually by an outside vender, eye washes were flushed and will provide paperwork, tubs were flushed when not in use and unused sink and shower heads are being flushed by housekeeping but would not be able provide a log for such flushing. A review of the service section of the plan failed to identify any servicing of the ice machine, flushes of the eyewash station or any flushing of uncommonly used areas such as showers, tubs, or faucets. He further identified the facility did not utilize the logs provided by the water management vendor as they had their own. Interview with Maintenance #1 on 3/27/25 at 12:58 PM identified he only flushes the boiler. In an interview with Housekeeping (Housekeeper #1) on 3/28/25 at 8:85 AM it was identified that bathrooms including showers are cleaned daily. Housekeeper #1 identified faucets in the showers are turned on for approximately 30 seconds when cleaning showers in bathroom that are not being used to rinse the showers and are turned on for a longer time to rinse showers that have being just used when cleaning. The housekeeper further identified they were not aware of flushing any unused faucet in the resident's bathroom. Interview with the Director of Maintenance on 3/28/25 at 9:15 AM identified that Maintenance #1 was trained to document in the logs whenever the boiler was flushed. He further identified that he was unable to provide documentation of the flushes for the tub and the eyewash stations as those tags were taken when they were removed during the construction. He did identify that he should document when flushes were completed but did not have the paperwork that he flushed any uncommonly used faucets, tubs, or showers. He also identified that not all the showers were being used even though each resident had their own showers in their room. Interview with the Administrator on 3/28/25 at 10:30 AM identified she was aware of the water management plan as she is a part of the committee and that it involves annual testing, quarterly meetings, boiler flushing, hot water faucet flushes in all areas, flushing of eyewash station and servicing of the ice machine. She identified that when areas are flushed it should be documented at the time of the flush. She identified that the facility was granted a waiver for no tubs on 8/30/23 and prior to the waiver flushes were done and documented on the tag on the tub which was removed when the tub was taken during construction. The Administrator also identified that the eyewash stations were flushed, and the tags were also removed with construction. She further indicated that if there were any unused faucets the Director of Maintenance was responsible for identifying those areas for flushing and documentation not the housekeepers. Review of the facility resident areas identified an eyewash station at the sink in both cleaning utility rooms were without tag to indicate flushes and/inspections. In a tour with the Administrator on 3/28/25 at 10:45 AM identified eyewash station in the cleaning utility room that was without tags which would indicate the flushes. She was asked when the eyewash stations were installed, and she responded that she would find out and get back to the surveyor. In an interview with the Administrator on 3/28/25 at 11:00 AM it was identified that the eyewash stations were installed in August of 2024 and according to the Director of Maintenance they were flushed but he was unable to provide documentation of the flushing. Interview with Person #1 (an expert of water management planning) on 3/28/24 at 12:57 PM identified it is best practice to document flushes as it shows the facility is meeting their control measures, water is moving, and it is important to maintain such documents as it shows mitigations. Review of the Water Management Policy identified facility should maintain the environmental assessment, sampling, and management plan and any associated sampling results on the facility premises for at least three years, such records should be made available to the local and the state department upon request. The facility Water Management plan Revision and Updates identified areas noted to be included in the flushing program are low flow areas (areas with minimum to no usage), purging of storage tanks and other desired location. Also, to document areas of compliance such as water flushing program eye wash station protocol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy, and interview for 1 sampled resident (Resident #40) with an indwelling catheter, the facility failed to ensure a privacy cover was utilized to conceal a urinary containment bag. The findings include: Resident # 40's diagnoses included benign prostatic hyperplasia, unspecified dementia, and urinary retention. The quarterly MDS assessment dated [DATE] identified Resident #40 had severe cognitive impairment and required total assistance with toileting, personal hygiene, and dressing. A physician's order dated 3/17/23 directed catheter care and to maintain foley catheter to gravity drainage. The Resident Care Plan dated 3/23/23 identified Resident #40 utilized a urinary containment device with interventions that included to provide Resident #40 with privacy to maintain dignity with any personal care. Observation on 3/27/23 at 9:37 AM identified Resident #40 was in the unit television room seated in a wheelchair with an uncovered urinary containment bag that was hooked to the side of the wheelchair. The urinary containment bag contained amber colored urine, that was potentially visible to staff, residents, and visitors. Interview with RN #13 on 3/27/23 at 9:37AM identified Resident #40 had an uncovered containment bag filled with urine that was visible. RN# 13 indicated that he was unaware if the facility had a policy to keep Resident #40's urinary bag covered to ensure dignity and privacy. A review of the facility's Foley Catheter policy identified that privacy covers for drainage bags are recommended for the resident's privacy and dignity.

**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 1 of 2 sampled residents, (Resident #35) reviewed for positioning, the facility failed to ensure a resident was repositioned in a timely fashion. The findings include: Resident #35's diagnoses included unspecified dementia with behavioral and mood disorders, non-traumatic brain dysfunction, depression, and bipolar disorder. The annual MDS assessment dated [DATE] identified Resident #35 had severe cognitive impairment, required extensive assistance with bed mobility, transfers, and toilet use. The assessment further noted that Resident #35 was totally dependent on staff for locomotion and was always incontinent of bowel and bladder. The Resident Care Plan dated 2/15/2023 identified Resident #35 had memory and speech impairments, required assistance with personal care, and was at risk for pressure ulcer development. Care plan interventions included: check the resident for turning and positioning at least three times per shift. Intermittent observations on 3/23/23 from 11:23 AM through 1:15 PM identified Resident #35 seated in his/her wheelchair in a reclined position with eyes closed. Constant observations from 9:10 AM through 12:42 PM on 3/28/23 identified Resident #35 seated in his/her wheelchair in a reclined position in the day room. During the observation period, Resident #35 not repositioned. At 12:43 PM, RN #5 administered medications to Resident #35 but failed to provide further care. At 1:05 PM NA #6 moved Resident #35 to the dining table. At 1:10 PM NA #6 moved Resident #35 from a reclined to an upright position. Constant observations on 3/28/23 from 9:10 AM through 1:10 PM failed to indicate that Resident #35 was repositioned, checked for incontinence, or provided with incontinent care for approximately 4 hours. Following the observation period RN #8 was made aware at 1:17 PM of the failure of staff to provide Resident #35 with incontinent care and/or repositioning. Observation on 3/28/23 at 1:40 PM identified Resident #35 appeared lethargic. NA#3 and NA#6 determined Resident #35 was unable to utilize his/her usual method of transfers (a mechanical sit to stand lift) to be placed on the toilet, instead NA #3 and NA #6 assisted Resident #35 to bed with the use of a mechanical lift (total lift) to provide care. Although Resident #35's incontinent brief was dry, Resident #35's buttocks and upper legs were noted to be reddened with notable indentations patterned after the waffle cushion that she/he was seated upon. In addition, the skin along the resident's upper back and spine was reddened and blanchable. NA#6 indicated that Resident #35 might answer when asked about incontinence but was unable to initiate asking for assistance. NA #6 further identified that repositioning was considered complete when the wheelchair was reclined or there was a change in position, and that all staff were responsible to ensure repositioning. NA#6 stated she did not know how many times Resident #35 had been repositioned since she/he was placed in the dayroom around 7:00 AM through the time NA #6 placed Resident #35 at the dining table at 1:10 PM. NA #6 indicated that she did not know why the resident was not repositioned or provided incontinent care but conveyed that it was the responsibility of the nurses' aides. Interview with RN #8 on 3/28/23 at 9:50 AM identified incontinent care is provided to residents 3 to 4 times per shift and as needed and Nurse Aides provide incontinent care first thing in the morning, on arrival at or around 7:00 AM. Further, RN #8 identified that some residents prefer to sleep later, but that would be reflected in the resident's care plan. Review of the facility's Bowel and Bladder Assessment policy identified that residents will be toileted and/or checked 3-4 times each shift. Review of the facility's policy for Prevention of Pressure identified that for prevention of pressure ulcers, a minimum of incontinence care, and turning and repositioning is provided at least every 2 hours and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, interviews, and review of facility policy, for one of three residents reviewed for pressure ulcers, (Resident #28), the facility failed to ensure offloading of heels as per physician's orders for a resident at risk of developing a pressure ulcer. The findings include: Resident #28's diagnoses included dementia and difficulty walking. Resident #28's admission Minimum Data Set (MDS) dated [DATE] identified Resident #28 had severe cognitive impairment, was totally dependent on one staff for bed mobility, was at risk for developing pressure ulcers, and had no pressure ulcers. A Braden skin assessment dated [DATE] identified a score of 18 indicating Resident #28 was at risk for pressure sore development. The care plan dated 2/27/20 identified Resident #28's right toe was reddened and the left toe was noted with a suspected deep tissue injury (DTI). Interventions included heel float boots while in bed. Wound assessment dated [DATE] identified Resident #28 with a DTI to the left great toe measuring 3 cm x 0.2 cm. The physician's orders dated 2/27/29 directed that Resident #28 have heel float boots while in bed. A nurse's note dated 2/27/20 identified the Advanced Practice Registered Nurse (APRN) was updated regarding Resident #28's red, blanchable right great toe and suspected DTI to left great toe. The note further identified to see new orders for skin prep, non-skid socks, heel float boots, and bed cradle. Observation and interview with Nurse Aide (NA) #4 on 3/4/20 at 6:29 AM identified that Resident #28's heels were not elevated. Resident #28 was wearing gripper sock and his/her heels were directly on the bed surface, were not offloaded with heel float boots, and no heel float boots were found in the room. Observation and interview on with Licensed Practical Nurse (LPN) #3 on 3/4/20 at 6:32 AM identified Resident #28 was without the benefit of heel float boots or offloading of heels and no heel float boots in the room. LPN #3 identified Resident #28 had orders for heel float boots and further identified that she/he would expect offloading of heels. Interview with LPN #3 on 3/4/20 at 6:33 AM identified that Resident # 28 had current orders for heel float boots while in bed, identified that Resident # 28 should have been wearing them, and LPN #3 was calling therapy at the time to obtain boots. Resident care card copies for NA use were provided to the surveyor by the Assistant Director of Nurses (ADNS) and LPN #3 on 3/4/20 at 6:38 AM. The care card did not reflect the need for heel float boots. Interview with NA #6 on 3/4/20 at 6:44 AM identified NA #6 did not know Resident # 28 was to have boots or elevated heels. NA #6 further identified the care card packet, taken from his/her pocket and dated 2/27/20 (same date as provided to surveyor), did not identify to use heel float boots for Resident #28. Interview with NA #4 on 3/4/20 at 6:50 AM identified that the care card packet he/she used dated 2/27/20, did not direct the use of heel boots for Resident #28. Interview and record review with the ADNS, with LPN #3 present, on 3/4/20 at 6:52 AM identified that the care cards get updated weekly on Thursdays by the unit secretary. LPN #3 identified that the master copy of care cards was updated, but the copies for staff were not updated. The ADNS identified that until the care cards have the weekly update, the information is given in report and staff can write in this information. The ADNS identified that this was missed for Resident #28, and identified that nursing staff are responsible for this. The facility policy for Pressure Ulcer/Non-Pressure Ulcer Risk Management identified: Determine the cause of the pressure ulcer and remove the causative agent if possible. Interventions may include: Maintain activity and mobility as follows for immobile residents: Heels are extremely vulnerable and must be elevated completely off the bed or chair surface. Use pillows, positioning devices and/or suspension boot devices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, review of facility documentation, review of facility policy, and interviews for two of five sampled residents (Residents #54 and #60) reviewed for unnecessary medications, the facility failed to monitor for target behaviors or assess the potential side effects related to the use of antipsychotics. The findings include: a. Resident #54's diagnoses included Parkinson's disease, Dementia, Spondylolisthesis, lack of coordination, generalized weakness, and cognitive communication deficit. A physician's order dated 12/23/2019 directed to provide quetiapine 50mg (antipsychotic) three times a day. The admission Minimum Data Set, dated [DATE] identified that Resident #54 was cognitively intact. Physician's orders dated 12/31/2019 directed the activity level for Resident #54 as an assist of 1 staff member for transfer. The Resident Care Plan (RCP) dated 12/24/2019 identified that Resident #54 utilized psychotropic medications due to dementia. Interventions included to monitor medications for serious side effects as well as therapeutic effects, documenting target symptoms on the nurse's psychoactive flow sheet. The RCP further identified that Resident #54 was at risk for falls due to the diagnosis of Parkinson's disease, with interventions of transfer and ambulate with rolling walker with assist of 1 staff. Review of Resident #54's medical record failed to reflect documentation of target behavior monitoring from 12/24/2019 to 1/16/2019. A physician's order dated 1/13/2019 directed to provide quetiapine 50mg (antipsychotic) three times a day. Target Behavior monitoring sheets dated 1/16/19 to 1/31/19 identified Resident #54's target symptoms as night terror and identified no demonstration of this behavior for day and evening shifts. The Target Behavior monitoring sheets dated 1/16/19 to 1/31/19 lack documentation for the night shift. A psychiatric Advanced Practice Registered Nurse (APRN) note dated 1/29/2020 identified that Resident #54 had Dementia with depression and behavioral disturbances currently presenting with symptoms of increased depression. Target Behavior monitoring sheets dated 2/1/2020 to 3/3/2020 identified Resident #54's target symptoms as night terror and identify no demonstration of this behavior for day and evening shifts. The Target Behavior monitoring sheets dated 2/1/2020 to 3/3/2020 failed to reflect documentation for the night shift. Review of Resident #54's medication administration records for December, 2019, January, February, and March, 2020 identified Resident #54 received all scheduled doses of medication. Facility policy for Psychoactive Medication Use identified that facility staff should monitor the resident's behavior as per facility policy using a behavioral chart or behavioral assessment record for resident's receiving psychotropic medication. b. Resident #60 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with behavioral disturbance, major depressive disorder, apraxia, anxiety, and Alzheimer's disease. A physician's order dated 6/19/19 directed to administer Seroquel 12.5 milligrams (mg) by mouth once per day at 11:00 AM, Seroquel 25 mg by mouth once per day at 4:00 PM, and Trazodone 50 mg by mouth three times per day. A physician's order dated 6/19/19 directed to obtain orthostatic blood pressures once per month before the 11th of the month. A physician's order dated 6/21/19 directed to administer Lexapro 10mg once per day. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #60 was severely cognitively impaired and required extensive assistance with personal hygiene and dressing. In addition Resident #60 received antipsychotic and antidepressants daily over the last 7 days. The Resident Care Plan (RCP) dated 6/20/19 identified Resident #60 received psychotropic medication. Interventions directed to monitor medication for therapeutic effects and document how Resident #60's target symptoms were doing, on the nurse's psychoactive flow sheet. A review of Resident #60's blood pressure log from 7/1/2019 through 2/29/2020 identified orthostatic blood pressures were not obtained per physician's order for the months of July 2019, November 2019, and February 2020. A pharmacy consultation report dated 7/2/19 identified Resident #60 received an antipsychotic, Seroquel with a recommendation to please update the medical record to include a list of symptoms or target behaviors (e.g., hallucinations, scratching) including their impact on the resident with desired outcomes. The psychiatry progress note dated 7/10/19 identified Resident #60 was seen to assess medications with recommendations to continue all medications to allow for longer period of adjustment before attempting gradual dose reduction (GDR). A pharmacy consultation report dated 8/5/19 identified REPEATED RECOMMENDATION from 7/2/19 for Resident #60 who received an antipsychotic, Seroquel recommendation please update the medical record to include a list of symptoms or target behaviors (e.g., hallucinations, scratching) including their impact on the resident with desired outcomes. The psychiatry progress note dated 8/14/19 identified Resident #60 could be irritable and anxious at times. In addition, Resident #60 was easily distracted, easily over stimulated, he/she was alert with poor judgement, and had impaired memory. Assessment and plan medications well tolerated, would not consider GDR at this time, continue all medications, and reassess in 2 months. The psychiatry progress note dated 10/23/19 identified Resident #60 had a general decline with increased sleepiness at times. Assessment and plan, no recent behavior symptoms, overall decline may tolerate GDR. Plan to discontinue Seroquel 12.5 mg daily morning dose, continue other medications, and reassess in 2-3 weeks. A physician's order dated 10/23/19 directed to discontinue Seroquel 12.5mg by mouth at 11:00 AM once per day. The psychiatry progress note dated 11/13/19 identified since discontinuing Seroquel 12.5mg daily morning dose, Resident #60 has had increased irritability and frustration, was more resistive to care, and was occasionally combative. Assessment and plan due to increased symptoms since morning dose of Seroquel discontinued, restart Seroquel 12.5mg daily morning dose, continue all other medications, and reassess in 2-4 weeks. A physician's order dated 11/13/19 directed to administer Seroquel 12.5mg by mouth once per day every morning. The psychiatry progress note dated 12/4/19 identified Resident #60 was combative at times toward staff, with an improvement in mood. Assessment and plan, mood improved, would not consider any changes at this time, continue medications, and reassess in 1 month. The significant change MDS assessment dated [DATE] identified Resident #60 was severely cognitively impaired and required extensive assistance with personal hygiene, dressing, transfers, and locomotion. In addition Resident #60 received antipsychotic and antidepressants daily over the last 7 days. The psychiatry progress note dated 1/8/2020 identified Resident #60 was having difficulty with ambulation and feeding self with increased confusion. Assessment and plan, did not tolerate prior attempt to discontinue Seroquel 12.5mg morning dose decline is anticipated with advancing dementia current medications well tolerated. Continue all medications as ordered for now, reassess in 6-8 weeks, and at that time will consider decreasing Trazodone. The Resident Care Plan dated 1/9/2020 identified Resident #60 received psychotropic medication. Interventions directed to monitor medication for therapeutic effects and staff to document how Resident #60's target symptoms were doing on the nurse's psychoactive flow sheet. The psychiatry progress note dated 2/19/2020 identified Resident #60 had occasional periods of increased anxiety. Assessment and plan, given occasional symptoms would not consider GDR of medications as they continue to be of benefit continue all medications. Interview and clinical record review with Licensed Practical Nurse (LPN) #1 on 3/3/2020 at 1:51 PM identified any resident prescribed psychotropic medications has target behaviors monitored every shift. LPN #1 would expect Resident #60 to have a behaviors monitored every shift, however he/she was unable to provide documentation to reflect that Resident #60 had a current behavior monitoring flowsheet nor any prior month flow sheets to reflect behavior monitoring since Resident #60's admission on [DATE]. In addition LPN #1 indicated during the working shift all nurses including herself/himself are responsible for documenting behaviors on the flowsheet. LPN #1 could not explain why Resident #60 has not had any target behaviors monitored. Interview with the Director of Nurses (DNS) on 3/3/2020 at 2:17 PM indicated any resident on psychotropic medications has target behaviors monitored every shift by the nurse working that shift. The DNS would expect a specific target behavior or behaviors to be monitored and documented on the flowsheet kept in the white binder at the nurses stations. In addition the DNS was unable to provide documentation to reflect orthostatic blood pressures were obtained in July 2019, November 2019, or February 2020 for Resident #60. Subsequent to surveyor inquiry LPN #1 started a Psychoactive Medication Flowsheet for Resident #60 dated 3/3/2020 with a target behavior of hallucinations. Review of facility orthostatic blood pressure policy identified orthostatic blood pressures are obtained monthly on elders who are on psychoactive medication to monitor for possible adverse effects. Review of the facility's psychotropic medication use policy identified staff should be monitoring the resident's behavior using the psychoactive medication flowsheet every shift with the identified target behaviors.