**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to adequately monitor resident behaviors for one resident (#16) receiving antipsychotic medications from a total sample of 11 residents. The findings include: A review of Resident #16's medical record revealed an admission date of 6/22/19 with a readmission on [DATE]. Her diagnoses included Alzheimer's disease, drug-induced subacute dyskinesia; other muscle spasms; depressive disorder, non-Alzheimer's dementia, and anxiety disorder. A review of the May 2022 Physician's Order Sheets revealed an active order for Quetiapine (Seroquel - antipsychotic) 25 milligrams (mg) at hour of sleep and monitor for side effects. The medical record did not reveal any orders for behavior monitoring for the ordered medication. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 5/2/22, revealed that Resident #16 received antipsychotic medication on seven of seven days during the assessment lookback period. She also received antidepressant, hypnotic and opioid medications during that time. A review of the May 2022 Medication Administration Record (MAR) revealed no monitoring of behaviors for the administration of antipsychotic (Quetiapine/Seroquel) medication. A review of the active care plan revealed a focus area for: Intermittent confusion, delusions, behaviors, related to Alzheimer's dementia with interventions for medications as ordered; document for side effects and effectiveness; review medications and records for causes of cognitive deficit. Prescribed psychotropic medications, related to behavior management, dementia, neuropathic pain, and chronic pain, anxiety, history of delusional thinking; administer medications as ordered by physician, monitor for side effects and effectiveness every shift; monitor/record occurrence of target behavior symptoms, refer to the physician's order and MAR. On 5/31/22 at 10:48 a.m., an interview was conducted with Agency Licensed Practical Nurse (LPN) A. When asked if monitoring of behaviors was expected for residents receiving antipsychotic medications, LPN A stated, yes. She stated side effects and behaviors were two separate orders and they were to be documented on the MAR. On 6/2/22 at 10:50 a.m., an interview was conducted with the Director of Nursing (DON) regarding Resident #16. She stated there should be an order and documentation for side effects and behavior monitoring for antipsychotic medications. She stated she did not see current documentation for behavior monitoring but there had been an order for behaviors in the past. Sometimes the electronic medical record dropped orders. When asked if reviews of antipsychotic monitoring had occurred, she stated they had been in the past but not recently. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and a staff interview, the facility failed to implement the comprehensive, person-centered care plan in order to meet residents' needs for one (Resident #14) of one resident reviewed for use of supplemental oxygen, from a total of 17 residents in the sample. The findings include: 1. On 3/22/2021 at 11:25 am, Resident #14 was observed lying in bed in his room. An oxygen concentrator was present with a clear nasal cannula, which was inserted in the resident's nostrils. The concentrator was set to administer oxygen at 2 liters per minute. A second observation of Resident #14 on 3/22/2021 at 3:06 pm, revealed the resident sitting in a recliner in his room with the nasal cannula applied. The oxygen concentrator was actively running and set to administer oxygen at 2 liters per minute. During a third observation of Resident #14 on 3/23/2021 at 10:52 am, he was observed lying in bed with the nasal cannula applied. Again, the oxygen concentrator was actively running and remained set to administer oxygen at 2 liters per minute. During a fourth observation of Resident #14 on 3/23/2021 at 2:16 pm, he was observed sitting in his room watching television. The oxygen concentrator was actively running and remained set to administer oxygen at 2 liters per minute however, the nasal cannula was displaced and under the resident's right eye. A record review for Resident #14 revealed he was admitted on [DATE]. His last readmission was on 12/2/2020. His diagnoses included neoplasm of the trachea, bronchus and lung; encounter for palliative care; cystitis; obstructive and reflux uropathy; chronic obstructive pulmonary disease; major depressive disorder; pulmonary hypertension; benign prostatic hyperplasia with lower urinary tract; unspecified atrial fibrillation; essential hypertension and personal history of malignant neoplasm of the prostate. A review of the current physician's orders revealed an order for Isosorbide Mononitrate extended release tablet, 60 mg (milligrams) by mouth in the morning; Oxygen at 3 liters per minute via nasal cannula continuously for shortness of breath related to lung mass; change oxygen tubing and replace humidified water container and clean filter to oxygen concentrator with warm water and reapply weekly; behavior monitoring and side effects monitoring due to use of psychoactive medication; hospice care; obtain temperature and oxygen saturation every shift and per COVID-19 protocol. A review of the resident's care plan revealed the following: FOCUS ONSET: 2/2/2021 Resident uses oxygen continuously. Desats when O2 is off. At risk for respiratory distress. He has a history of shortness of breath and lung mass. GOALS: Resident will have comfort in breathing. Will not show any signs or symptoms of respiratory distress through the review period 6/11/2021. INTERVENTIONS: Oxygen saturation per medical doctor order. Apply oxygen per medical doctor order. See medication administration record for oxygen order 3L/min via nasal cannula; O2 at 3l/min via nasal cannula continuous; change oxygen tubing, replace humified water container and clean filter to O2 concentrator with warm water and reapply weekly; provide rest periods when performing activities of daily living as needed; date and label tubing bag weekly when changed Wed nights 11pm-7am. FOCUS ONSET: 9/24/2019 Resident is at risk for respiratory distress. He has a history of fatigue. He has diagnoses of heart and lung disease. He has pulmonary neoplasm. GOALS: Resident will have comfort in breathing, will not show any sign and symptom of respiratory distress through next review date 6/11/2021. INTERVENTIONS: administer prescribed medication, observe for effectiveness, possible adverse effects and notify medical doctor as needed; observe for shortness of breath; administer medications as ordered; apply oxygen per medical director order; see medication administration record for oxygen order; oxygen saturation per medical doctor order; change O2 tubing weekly and as needed per medical doctor order; collaborate care with hospice services as indicated. A review of the quarterly minimum data set (MDS) assessment, signed by a Registered Nurse (RN) on 3/5/2021, revealed: Resident #14 had minimal difficulty hearing with clear speech and adequate vision. He usually understood others and was understood. He scored 1 out of a possible 15 points on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. He was documented as totally dependent with transfers, locomotion on/off the unit and toilet use. He required extensive assistance with dressing, eating and bed mobility. He had shortness of breath, required oxygen and received hospice care while a resident in the facility. A review of the facility's Oxygen Administration policy (reviewed and revised in July 2020) revealed, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences. During an interview with RN A on 3/23/2021 at 3:07 pm, she stated she had worked in the facility for nearly six months and was familiar with Resident #14. He received hospice care and had an order for oxygen at 3 liters per minute. The nurses in the facility supervised the oxygen and checked it each shift. The facility nurses were responsible for making sure that the oxygen concentrator was operable and set at the appropriate setting. The facility certified nursing assistants (CNAs) were responsible for ensuring that the nasal cannula was properly inserted. She stated the physician's orders advised when the tubing was to be changed as well as how many liters per minute the oxygen concentrator should be set for. She stated this information was in the resident's hard chart as well as in the electronic record. On 3/23/2021 at 4:11 pm, another observation of Resident #14's oxygen concentrator was made in the presence of RN A. She confirmed that the concentrator was set for 2 liters per minute. She confirmed that the setting was incorrect and that it should have been set for 3 liters per minute as ordered. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to adequately manage pain for one (Resident # 17) of one resident reviewed for pain management, from a total of 17 residents in the sample. The findings include: A review of Resident #17's medical record revealed she was admitted on [DATE]. Her admitting diagnosis was encounter for palliative care. Secondary diagnoses included osteoarthritis and anemia. The most recent comprehensive Minimum Data Set (MDS) assessment, dated 3/9/21, indicated the resident's cognition was impaired and she required extensive to total assistance with activities of daily living. She also received hospice services. On 3/22/21 at 10:24 AM, Resident #17 was observed lying in bed. She could be heard from the hallway yelling out repeatedly. Her speech was incoherent. Upon entering the resident's room, she was observed lying in her bed and was restless. She was moving all of her extremities in repeated motions while yelling out. Her brow was furrowed. She was not able to answer any questions. A review of the resident's physician's orders revealed an order dated 12/14/20, which read, Under care of Vitas Hospice. A physician's order dated 12/10/20 read, Pain assessment monitoring every shift. A physician's order dated 12/10/20 read, Meloxicam 15 mg (milligram) tablet, give one tablet by mouth daily as needed for arthritic pain. The order was discontinued on 3/19/21. A physician's order dated 12/10/20 read, Tylenol arthritis ER (extended release) 650 mg, give one tablet by mouth three times daily as needed for pain. The order was discontinued on 3/19/21. Continued review of the physician's orders revealed no available pain medications at the time the record was reviewed. (Photographic evidence obtained) A review of the resident's comprehensive care plan revealed a focus area indicating the resident was at risk for pain and that she had an alteration in communication. She would need staff to observe for non-verbal signs of pain. Interventions included monitoring for effectiveness of pain medication, observing for pain when assisting with activities of daily living (ADLs), and that the resident may have pain medications as needed as prescribed by the physician. The care plan also indicated that collaboration with hospice services was required. (Photographic evidence obtained) A comprehensive MDS assessment, dated 3/9/21, indicated the resident did present with behavioral symptoms such as rejection of care. Continued review of the resident's care plans revealed a focus area for hospice. Interventions included collaboration with hospice services as needed, observe effectiveness of pain medication, report unrelieved pain to the physician, request further orders in an effort to attain a level of comfort for the resident, and coordinate communication with the hospice provider. (Photographic evidence obtained) On 3/23/21 at 3:25 PM an observation was made of Resident #17. Upon approaching her room, her door was closed. Upon entering the room, the resident was noted to be lying in bed. She was positioned on her back. Her bed linens were lying on the floor and she was repeatedly moving both legs in the bed while yelling incoherently. Her brow was furrowed and facial grimacing was noted. A second interview with the resident was attempted, however, she was unable to answer any questions. On 3/24/21 at 11:15 AM, an interview was conducted with Employee C, Registered Nurse (RN). She confirmed that she was assigned to Resident #17, but that she was not familiar with the resident. She had just begun working at the facility as an agency employee. When asked whether she had conducted any pain assessments for Resident #17, RN C explained that she didn't think the resident had complained of any pain. When asked whether the resident would be able to verbalize complaints of pain, the nurse stated, I'm not sure. A review of the facility's policy titled, Pain Management, directed the staff to evaluate the resident for pain when residents presented with changes in behavior or mental status. The policy indicated behavioral signs and symptoms that may suggest the presence of pain included but were not limited to: fidgeting, increased or recurring restlessness, facial expressions, changes in behavior or decreased participation in activities of daily living, sighing, groaning, crying, whimpering, breathing heavily or screaming. The policy further directed staff to reassess residents with pain regularly, and to revise the pain management regimen if assessment findings indicated pain was not adequately controlled. (Photographic evidence obtained) On 3/24/21 at 2:00 PM, an interview was conducted with the Director of Nursing (DON). She explained that she had recently started working at the facility and that she was continuing to learn each resident's behaviors and routines. The DON acknowledged that Resident #17 frequently presented with episodes of yelling and restlessness, and that despite several adjustments to her psychotropic medications, her behaviors continued. During the interview, the resident's medication regimen was reviewed. The DON explained that she had discontinued the resident's meloxicam and Tylenol as part of the facility's policy to discontinue as-needed medications if they hadn't been used in a thirty-day period. On 3/24/21 at 2:40 PM, the DON entered the conference room and explained that the resident had been reassessed and that a scheduled pain medication regimen had been ordered. She then provided a copy of a newly obtained physician's order which read, Tylenol Arthritis ER (extended release) 650 mg tablet, give one tablet by mouth twice a day for pain. (Photographic evidence obtained) .

Based on observations, interviews, and record reviews, the facility failed to maintain a medication error rate of 5 percent or less. There were 25 opportunities for error with four errors identified, resulting in a medication error rate of 16% and involving three (Residents #5, #20 and #11) of three residents observed during medication administration. The findings include: 1. On 3/23/21 at 9:48 AM, an observation of medication administration was conducted for Resident #5 with Employee C, Registered Nurse (RN). Resident #5 had a physician's order for metoprolol tartrate (used to treat high blood pressure, chest pain and heart failure), 25 mg (milligram) tablet, give one tablet by mouth twice a day in AM/PM block for hypertension. The medication was scheduled for 6:00 AM and 6:00 PM. The medication was administered at 9:48 AM. Resident #5 had an order for Eliquis (used to treat/prevent blood clots and stroke for individuals with atrial fibrillation), 2.5 mg tablet, give one tablet by mouth twice daily in AM/PM block for atrial fibrillation. The medication was scheduled for 6:01 AM and 6:01 PM. The medication was administered at 9:48 AM. 2. On 3/23/21 at 9:56 AM, an observation of medication administration was conducted for Resident #20 with RN C. Resident #20 had a physician's order for Vimpat (anti-seizure medication), 100 mg tablet, one tablet by mouth two times per day for seizures. The order was scheduled for 8:00 AM and 8:00 PM. The medication was administered at 9:56 AM. 3. On 3/23/21 at 10:05 AM, an observation of medication administration was conducted for Resident #11 with RN C. Resident #11 had a physician's order for Labetalol (used to treat high blood pressure), 100 mg tablet, give one tablet by mouth every 12 hours for hypertension. There were parameters to hold the medication for a systolic blood pressure of less than 100 or a heart rate of less than 60. The nurse prepared the medication and entered the room. She did not check the resident's blood pressure or pulse. She then stated, I have your pills for you and handed the medication cup to the resident. As the surveyor was preparing to interject, the resident exclaimed, No blood pressure medicine! My blood pressure was really low this morning! On 3/23/21 at 10:10 AM, an interview was conducted with RN C. The nurse reviewed the Labetalol order for Resident #11 and acknowledged that the order contained parameters. She further acknowledged that she had not checked the resident's blood pressure or pulse prior to attempting administration of the medication. She explained that this was her second shift at the facility, and she was an agency employee. The nurse explained that she had received some training on the facility's electronic medication administration system, but she was still learning it. On 3/24/21 at 10:43 AM, an interview was conducted with the Director of Nursing (DON) regarding the findings of the medication administration observations. She stated she would conduct further training with the nurse immediately. She explained that the nurse was employed by an agency, and that the facility relied upon the agency's training to the nurse. A review of the facility's policy titled, Medication Administration, directed staff to obtain and record vital signs when applicable or per physician's order. The policy also directed staff to hold medication for those vital signs that were outside of the physician's prescribed parameters. The policy further directed the staff to administer the medication within 60 minutes prior to or after scheduled times unless otherwise ordered by the physician. (Photographic evidence obtained) .