**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure two (#49 and #141) of fifty- four sampled residents were assessed for self-administration of medications and failed to ensure physician orders had been obtained for medications observed on over-bed table of one (#141) of two residents observed. Findings included: 1. On 2/17/25 at 12:12 p.m., Resident #49 was observed speaking with a visitor while holding onto a nebulizer device. The observation showed the visitor leave the resident's room on 2/17/25 at 12:14 p.m. Resident #49 leaned over, turned on the nebulizer machine located on the bedside dresser, and put the nebulizer device to her mouth. The observation showed an aerosol-like mist coming from the end of the device. Review of Resident #49's admission Record revealed the resident was admitted on [DATE] and re-admitted on [DATE]. The record included diagnoses not limited to unspecified dementia unspecified severity without behavioral disturbance and chronic obstructive pulmonary disease (COPD) with (acute) exacerbation. Review of Resident #49's Medication Review Report, dated 2/18/25 at 3:42 p.m., did not reveal the resident had a physician order allowing for the self-administration of any medications. The orders showed an order for Ipratropium-Albuterol Solution 0.5-2.5 milligram (mg)/3 milliliter (mL) - 3 mL inhale orally via nebulizer every 6 hours as needed for shortness of breath. Lung sounds (LS) = C-clear, W-wheezing, R-rhonchi, CR-crackles, (or) D-diminished. Review of Resident #49's care plan included the following focuses with interventions: - Has altered cardiovascular status related to (r/t) diagnoses (dx) of A-fib, hypertension (HTN), (and) heart failure. The associated interventions instructed staff to assess for shortness of breath and cyanosis, and to observe and report as needed any changes in lung sounds on auscultation, edema, and changes in weight. - Has diagnosis (dx) of COPD. The interventions included to elevate head of bed in or out of bed during episodes of difficulty breathing, observe for difficulty breathing on exertion, and observe for signs/symptoms of acute respiratory insufficiency. The care plan did not include a focus or intervention showing the resident had been assessed for the self-administration of any medication. The facility did not provide the requested Self-Administration assessment for Resident #49. 2. On 2/17/25 at 10:31 a.m., Resident #141 was observed lying in bed with an over-bed table within reach of the resident. A bottle of sore throat spray containing a green liquid was observed on the table. On 2/18/25 at 10:38 a.m., Resident #141 was observed lying in bed with the over-bed table within reach, the observation revealed a bottle of throat spray with the top off containing green liquid sitting on top of the table. On 2/18/25 at 10:40 a.m., the resident confirmed it was a bottle of [name brand] throat spray that was used when the resident feels something coming on. The observation showed a jar of mentholated topical ointment on the over-bed table next to the bottle of throat spray. During the interview Staff A, Licensed Practical Nurse (LPN)/Unit Manager (UM), entered the room and stated the resident's call light was on. The staff member shut the light off at the head of the resident's bed and informed the resident she would send staff in to assist the resident. On 2/18/25 at 10:44 a.m. an unknown Certified Nursing Assistant (CNA) was observed entering the resident's room with clean linens. On 2/20/25 at 8:57 a.m., Resident #141 was observed lying in bed. The observation revealed the bottle of throat spray and mentholated topical ointment continued to sit on top of the resident's over-bed table and within reach of the resident. The observation revealed another jar of what appeared to be mentholated topical ointment on the bedside dresser. The resident reported using the throat spray 1-2 times a month when feeling something coming on and puts the ointment up her nose. She said, There's a lot of sickness in here. On 2/20/25 at 9:06 a.m., Staff A observed the throat spray and mentholated topical ointment on top of Resident #141's over-bed table. Staff A reported not knowing about the throat spray or ointment at the resident's bedside. The staff member informed the resident the items would have to removed and a physician order would have to be obtained for their use. Review of Resident #141's Order Summary Report, active as of 2/20/25 at 4:44 p.m. did not reveal a physician order for the self-administration of any medication. The report did not reveal the resident had an order for any type of throat spray or mentholated topical ointment. The facility reported 0 residents self-administered (medications). During an interview on 2/20/25 at 3:09 p.m., the Director of Nursing reported the facility had started working on allowing certain residents to self-administer medication. Review of the policy - Self-Administration of Medications, revised 6/1/24, revealed the applicability, This policy 2.1 sets forth procedures relating to resident self-administration of medications. The procedure included: 1. The so they should comply with the facility policy, applicable law in the state operations manual with respect to resident self-administration of medications. 2. Facility, in conjunction with the interdisciplinary care team, should assess and determine, with respect to each resident, whether self-administration of medications is safe and clinically appropriate, based on the residence functionality and health condition. 5. Facility should ensure that orders for self-administration list the specific medication(s) the resident may self-administer. 6. Facility staff should order new and refill medications from pharmacy for residents who self-administer medications to provide access to inadequate supplies of medications. 9. Facility should document in the residence care plan whether the resident or facility staff is responsible for the storage of the resident's medications. If the resident is responsible for the storage of his/ her medications, for sale they should provide a secure compartment for storage of such medications in accordance with facility policy, applicable law, the state operations manual and as follows: - 9.1 The medication storage compartment should be located in the residence room so that another resident is not able to access the medications. - 9.2 The storage compartment should be locked when not in use. 10. Facility staff should document the self-administration of medications on the resident's medication administration record (MAR) according to the medication administration schedule. 11. Facility should document the self-administration and self-storage of medications in the residence care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to file a grievance related to missing clothes for one resident (#57) out of eight residents sampled. Findings include: During an observation on 2/17/2025 at 9:00 a.m., and 12:00 p.m., Resident #57 was observed sitting on the side of her bed, fully dressed. She stated she had complained to the facility about her missing clothes, and nothing had been done about it. Resident #57 stated no one at the facility told her about the grievance process. Review of an admission Record dated 2/20/2025 showed Resident #57 was admitted to the facility originally on 5/3/2024 and readmitted on [DATE] with diagnoses to include but not limited to other specified fractures of left pubis, subsequent encounter for fracture with routine healing, pain in left hip. Review of a Minimum Data Set, dated [DATE] showed Section C, Cognitive Patterns, Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. During an interview conducted on 2/20/2025 at 12:30 p.m. with Staff E, Director of Housekeeping, Staff E stated Resident #57 reported to her that she was missing clothes. Staff E stated she was not able to find the clothing items Resident #57 reported and she did not assist Resident # 57 with filing a grievance. During an interview conducted on 2/20/2025 at 1:00 pm. with the Nursing Home Administrator (NHA), the NHA stated as soon as a complaint was brought to the staff's attention, she expected a grievance should be filed. The NHA stated for example, if a resident came to her about missing pajamas, she would expect a grievance to be filed, she would look at the inventory sheets to see if the items were inventoried, and they would come up with a resolution. Review of the facility policy titled, Grievance Program (Concern and Comment) Revised date 1/7/2025 showed Policy: 1. Residents and their families have the right to file a complaint without fear of reprisal. Upon request, the facility must give a copy of the grievance policy to the residents. Procedure 1. The facility will post in a prominent location throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously. 8. Following up with the residents and family to communicate resolutions or explanations and ensure that the issue was handled to the resident and family's satisfaction.

Based on record review and interview the facility failed to provide written notification to the resident and resident representative prior to an emergency transfer for one (#49) of two residents sampled for transfer and discharge rights. Findings included: Review of Resident #49's admission record revealed an initial admission date of 1/24/24, a transfer to the hospital on 1/30/25 and a readmission to the facility on 2/5/25. The admission record showed the resident was his own responsible party, and a family member was listed as the first emergency contact. A change in condition evaluation, dated 2/18/25, showed the resident had a large abscess to the left neck area and was having a slight issue with swallowing. An electronic transfer form dated 2/18/25 at 2:19 p.m. showed the resident was transferred to an acute care facility/hospital. Review of Resident #49's electronic record on 2/19/25 revealed no evidence of a written notice of transfer/discharge to the hospital to the resident for the 2/18/25 emergency hospitalization. An interview on 2/19/25 at 12:40 p.m. with the Executive Director (ED) confirmed Resident #49 was discharged to the hospital on 2/18/25, and it was a facility-initiated discharge. An interview was conducted on 2/19/25 at approximately 1:00 p.m. with the Social Service Director (SSD). The SSD reviewed electronic records and a stack of paperwork on his desk before reporting the written notice for the 2/18/25 transfer could not be found. An interview was conducted with Staff A, Licensed Practical Nurse (LPN)/Unit Manager (UM) on 2/19/25 at 1:23 p.m. The staff member stated during a transfer, staff complete a change in condition evaluation, a transfer form, an infection control evaluation, obtain a physician order to send to the hospital, and normally take the resident off the facility census. Staff A, LPN/UM stated she was present for Resident #49's transfer on 2/18/25. Staff A, LPN UM confirmed she did not provide a written notice of transfer/discharge to the resident prior to the transfer. On 2/19/25 at 1:36 p.m., the Director of Nursing (DON) brought Resident #49's hard chart and stated the SSD was making a copy of the transfer form. The DON stated the facility had 24 hours to provide a written notice of transfer/discharge to the resident. On 2/19/25 at 1:45 p.m., the SSD provided a Nursing Home Transfer and Discharge Notice (AHCA Form 3120) dated 2/18/25 for Resident #49. The SSD reported it was from the DON today (2/19/25), and per policy they have 24 hours to complete the form to allow for flex time. Review of the nursing home transfer form revealed the notice was documented as given to the resident on 2/18/25 with an effective date of 3/21/25. The reason for discharge or transfer was Your needs cannot be met in this facility with a brief explanation of MD [Medical Doctor] order to send to hospital for evaluation. The section marked Notice presented by: was signed and dated 2/19/25 by the SSD (as designee for the Nursing Home Administrator). The section marked Notice received by was documented verbal verification provided. Review of the signature line for the resident or representative name revealed the signature of the DON and Staff A, LPN/UM with a date of 2/18/25. A follow-up interview was conducted with Staff A, LPN on 2/20/25 at 9:15 a.m. Staff A, LPN/UM reviewed the transfer notice signed and dated by her on 2/18/25 for Resident #49. Staff A, LPN/UM stated the reason the resident did not sign the form was because the resident had already left the facility, and it required the signature of two nurses after the resident left. Review of the facility policy titled Notice of Transfers and Discharges, revised on 10/29/24, revealed: Policy: The facility will provide notice to the resident and/or resident representative in situations where the facility initiates a transfer or discharge . Timing of the Notice: (ii). Notice must be made as soon as practicable before transfer or discharge when - An immediate transfer or discharge is required by the resident's urgent medical needs. Procedure: The facility ensures that systems are implemented to provide written notification to the resident and resident representative prior to transfer or discharge for facility-initiated transfers/discharges. This written notification is provided on the notice of resident discharge or transfer form. a. Florida facilities should utilize the Transfer Discharge Notice Form (AHCA Form 3120-0002). Emergency Transfers: -When a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon as practicable before the transfer. During the interview with the SSD on 2/19/25 at 1:45 p.m. he stated the facility has a Quality Assurance and Performance Improvement (QAPI) plan on this. The SSD was asked to provide a copy of the QAPI plan at the time of interview. No documentation was provided prior to exiting the facility on 2/20/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 10. Review of Resident #18's admission Record showed the resident was admitted on [DATE]. The record revealed the principal diagnosis was unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety with additional diagnoses of cognitive communication deficit, other Alzheimer's disease, unspecified mood [affective disorder], and moderate recurrent major depressive disorder. Review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #18 had active diagnoses of Alzheimer's disease, non-Alzheimer's dementia, depression other than bipolar, cognitive communication deficit, and unspecified mood [affective] disorder. Review of Resident #18's Pre-admission Screening and Resident Review (PASRR) completed by Staff Q, Master Social Worker (MSW) on 2/16/25, did not show the resident had a primary diagnosis of dementia or a related neurocognitive disorder (including Alzheimer's disease). The screening revealed the resident had no diagnosis or suspicion of Serious Mental Illness or Intellectual disability and a Level II PASRR evaluation was not required. 11. Review of Resident #49's admission Record showed the resident was admitted on [DATE] and readmitted on [DATE]. The record revealed diagnoses of unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified epilepsy not intractable without status epilepticus, unspecified altered mental status, unspecified recurrent major depressive disorder, adjustment disorder with anxiety, cognitive communication deficit, unspecified dementia unspecified severity with psychotic disturbance, unspecified insomnia, and unspecified convulsions. Review of Resident #49's Level 1 PASRR completed by Staff Q on 6/20/24, revealed the resident did not have either a depressive disorder or Epilepsy per documented history and medications. The screening completion showed the resident did not have a diagnosis or suspicion of serious mental illness or intellectual disability and a Level II PASRR was not required. Review of Resident #49's Minimum Data Set (MDS) dated [DATE] included active diagnoses of non-Alzheimer's disease, seizure disorder or epilepsy, and adjustment disorder with anxiety. The assessment did not include the resident's diagnosis of unspecified recurrent major depressive disorder. An interview on 2/19/25 at 10:46 a.m. was conducted with Staff Q and the Social Service Director (SSD). Staff Q acknowledged she did the PASSR assessments by looking at hospital records, diagnoses, and medications. Staff Q reported seeing the residents before the facility's attending physicians. Staff Q stated when the resident had a new diagnosis, the physician was spoken with, notes were reviewed, and a new document (PASRR) was generated, also the facility had a psych meeting every Tuesday and changes in diagnoses and medications were discussed during the meetings. Review of the policy - Pre-admission Screening and Resident Review, (PASARR) reviewed on 9/26/24 revealed the facility will ensure that potential admissions are to be screened for possible serious mental disorders or intellectual disabilities and related conditions. This initial pre screening is referred to as PASSAR level I, and is completed prior to admission to a nursing facility. A negative level I screen permits admission to proceed in ends the PASSAR process unless a possible serious mental disorder or intellectual disability arises later. A positive level I screen necessitates an in depth evaluation of the individual by the state designated authority, known as PASSAR level II, which must be conducted prior to admission to a nursing facility. 1. Ensure level 1 PASSAR screening has been completed on potential admissions prior to admission. 2. A negative level 1 screen permits admission to proceed and ends the PASSAR process unless a possible serious mental disorder or intellectual disability arises later. 3. A record of the prescreening should be retained in the residence medical record. 4. A positive level 1 screen necessitates an in-depth evaluation of the individual by the state designated authority, known as PASSAR level 2, which must be conducted prior to admission to a nursing facility. 5. When a level 2 PASSAR screening is warranted it must be obtained as well as determination letter prior to admission. The level II PASSAR cannot be conducted by the nursing facility. 6. With respect to the responsibilities under PASSAR program, the state is responsible for conducting the screens preparing the PASSAR report, in providing or arranging the specialized services that are needed as a result of conducting the screens. a. The state is required to provide a copy of the past our report to the facility. This report must list the specialized services that the individual requires and that are the responsibility of the state to provide. All other needed services are the responsibility of that facility to provide. 7. The level II PASSAR determination and evaluation report specifies services to be provided by the facility and/ or specialized services defined by the state. 8. Recommendations from PASSAR level II determination and PASSAR evaluation report are to be incorporated into the person-centered care plan as well as in transitions of care. 9. As part of the PASSAR process, the facility is required to notify the appropriate state mental health authority or state intellectual disability authority when a resident with a mental disorder (MD) or intellectual disability (ID) has a significant change in their physical or mental condition. This will ensure the residents with a mental disorder or intellectual disability continue to receive the care and services they need in the most appropriate setting. 11. Facilities should look to their state PASSAR program requirements for specific procedures. PASSAR contact information for the SMH/ ID authorities and the state Medicaid agency. 13. Any resident with newly evident or possible serious mental disorder, ID or a related condition must be referred by the facility to the appropriate state designated mental health or intellectual disability authority for review. 14. Referral for a level 2 resident's review evaluation is required for individuals previously identified by PASSAR to have a mental disorder, intellectual disability, or a related condition who experiences significant change. 4. Review of the admission record for Resident #12 showed she was admitted to the facility on [DATE] with diagnoses to include dementia - 5/13/24, major depressive disorder - 5/13/24, and anxiety disorder - 5/13/24. Review of the level I PASRR for Resident #12 dated 5/14/24, revealed a qualifying secondary diagnosis of dementia was not checked. The review showed the Level I PASRR was incomplete, and a level II was not submitted for consideration following the qualifying diagnoses. 5. Review of the admission record for Resident #126 showed she was admitted to the facility on [DATE] with diagnoses to include dementia - 7/9/24, Alzheimer's disease - 9/1/23, adjustment disorder - 11/29/23, and anxiety disorder - 9/13/23. Review of the level I PASRR for Resident #126 dated 3/22/24, revealed a qualifying diagnosis of Alzheimer's Disease was not checked. The review showed the Level I PASRR was incomplete, and a level II was not submitted for consideration following qualifying diagnoses. 6. Review of the admission record for Resident #140, showed she was admitted to the facility on [DATE] with diagnoses to include dementia - 9/4/24, Alzheimer's disease - 9/4/24, major depressive disorder - 9/4/24, and anxiety disorder - 9/4/24. Review of the level I PASRR for Resident #140 dated 6/12/24, showed qualifying diagnoses of Alzheimer's Disease and dementia were not checked. The review showed the Level I PASRR was incomplete, and a level II was not submitted for consideration following qualifying diagnoses. 7. Review of the admission record showed Resident #130 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include dementia - 8/16/23, Alzheimer's disease - 11/8/22, mood disorder - 1/10/23, adjustment disorder - 1/10/23 and anxiety disorder - 4/16/24. Review of the level I PASRR for Resident #130 dated 6/20/24, showed qualifying diagnoses of Alzheimer's Disease and dementia were not checked. The review showed the Level I PASRR was incomplete, and a level II was not submitted for consideration following qualifying diagnoses. 8. Review of the admission record for Resident #23 showed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include dementia - 9/25/23, Alzheimer's disease - 7/26/21, mood disorder -11/30/22, adjustment disorder - 4/16/24, major depressive disorder - 7/26/21 and anxiety disorder - 4/16/24. Review of the level I PASRR for Resident #23 dated 6/21/24, showed qualifying diagnoses of Alzheimer's Disease and dementia were not checked. The review showed the Level I PASRR was incomplete, and a level II was not submitted for consideration following qualifying diagnoses. 9. Review of the admission record for Resident #54 showed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include psychosis - 8/8/13, mood disorder -7/24/24, dementia - 9/20/23, adjustment disorder with anxiety - 9/20/23, major depressive disorder - 8/8/13, and anxiety disorder - 7/1/24. Review of the level II PASRR for Resident #54 dated 3/22/24, showed Resident #54 was not rescreened after a new qualifying diagnosis in July 2024 for mood and anxiety disorders. The review showed a follow up Level I PASRR was not completed, and a level II was not resubmitted for consideration following qualifying diagnoses. Based on interview and record review, the facility failed to ensure Preadmission Screening and Record Review (PASSR) was completed accurately for eleven residents (#112, #144, #21, #12, #126, #140, #130, #23, #54, #18, and #49) out of 33 residents sampled. Findings included: 1. Review of the admission Record for Resident #112 showed the resident was admitted to the facility on [DATE] with diagnoses including major depressive disorder, generalized anxiety disorder, altered mental status (unspecified), and cognitive communication deficit. Review of Resident #112's most current Level 1 PASRR was dated 02/14/2023 revealed the PASRR did not show a diagnosis of dementia. Review of a physician progress noted dated 08/11/2024 revealed Resident #112 had a diagnosis of dementia. Review of a physician progress noted dated 11/22/2024 revealed Resident #112 had a diagnosis of dementia. Review of a physician progress noted dated 02/10/2025 revealed Resident #112 had a diagnosis of dementia. Review of Resident #112's electronic medical record (EMR) and the resident's paper chart revealed no updated PASRR to reflect the dementia diagnosis. 2. Review of the admission Record showed Resident #144 was admitted to the facility on [DATE] with diagnoses including cognitive communication deficit, adjustment disorder with depressed mood, dementia and altered mental status. Review of Resident #144's most recent PASRR, dated 02/16/2025, revealed Section 1: PASRR Screen Decision-Making, Section A and Section B did not have the diagnosis of Cognitive Communication Deficit noted. Section II Other Indications for PASRR Screen Decision-Making questions #5, #6 and #7 related to dementia were all answered no. 3. Review of the admission Record showed Resident #21 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder bipolar type, depression, anxiety disorder and seizures. Review of Resident #21's most current Level 1 PASRR dated 10/30/2024, revealed the PASRR did not show the diagnoses of epilepsy and dementia. Review of Resident #21 Minimum Date Set (MDS) Quarterly Assessment, dated 02/16/2025, revealed Section I - Active Diagnoses under the Neurological section Seizure Disorder or Epilepsy was checked as an active diagnosis. Review of a physician progress noted dated 07/14/2024 revealed Resident #21 had a diagnosis of dementia. Review of a physician progress noted dated 10/14/2024 revealed Resident #21 had a diagnosis of dementia. Review of a physician progress noted dated 11/19/2024 revealed Resident #21 had a diagnosis of dementia. Review of a physician progress noted dated 02/10/2025 revealed Resident #21 had a diagnosis of dementia. Review of Resident #21's electronic medical record (EMR) and the resident's paper chart revealed no updated PASRR to reflect the dementia and epilepsy diagnoses. During an interview on 02/19/2025 at 10:54 a.m., Staff Q, Social Worker (SW) said she was not aware of the diagnoses not listed on Resident's #21, #144 and #112 PASRR's. She said she would have to review the records. Staff Q said the facility did not do any dementia testing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide wound care in accordance with professional standards of practice and as ordered by the physician for one resident (#54) of two residents reviewed. Findings included: On 2/17/25 at 2:15 p.m., Staff H, Registered Nurse (RN) removed Resident #54's left foot covering. There were no dressings covering the medial and lateral foot wounds. Staff H checked the resident's footwear for bandages, none were found and said the dressings would be replaced immediately. Review of the admission record showed Resident #54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include diabetes mellitus, and disorder of the skin and subcutaneous tissue. Review of care plan for Resident #54, initiated 12/18/18 showed: Focus-A diagnosis of Diabetes Mellitus; Goal- no complications related to diabetes; Interventions to include- check all of body for skin breaks and treat promptly as ordered by the doctor. Another care plan initiated 11/29/24: Focus-potential for impairment to skin integrity and discoloration related to age, thin fragile skin, impaired mobility, incontinence .; Goal-free of injury through review date; Interventions to include follow facility protocols for treatment of injury, weekly treatment documentation to include measurement of each area of skin breakdown . Review of Resident #54's Minimum Data Set (MDS) dated [DATE], Section GG, functional abilities showed for lower body dressing, substantial or maximal staff assistance was needed. Review of Resident #54's physician orders, titled active orders as of 2/19/25, showed orders dated 1/21/25 to include, 1. cleanse open wound on left lateral foot gently with normal saline and pat dry. Then apply Santyl ointment (nickel-thickness) over wound bed only. Then cover with calcium alginate wound dressing and secure with dry absorbent dressing as needed for wound healing. 2) cleanse open wound on left medial foot gently with normal saline and pat dry. Then apply Santyl ointment (nickel-thickness) over wound bed only. Then cover with calcium alginate wound dressing and secure with dry absorbent dressing as needed for wound healing. Order dated 2/18/25, verify placement of wound dressing on left lateral and medial foot on 7 a.m.- 3 p.m. and 3 p.m.-11 p.m. shifts. Dressing change performed by 11 p.m.- 7 a.m. nurse. If the dressing is absent, please redress these wounds. During an interview on 2/17/25 at 2:34 p.m., Staff I, Registered Nurse (RN), Unit Manager (UM) said Resident #54's wounds were expected to have dressings as ordered by the physician. During an interview on 2/19/25 at 3:28 p.m., Staff G, Licensed Practical Nurse (LPN), Wound Care nurse said Resident #54 had diabetic wounds on the medial and lateral left foot. Resident #54 often removed wound dressings. A rolled gauze was used to help with dressing securement. Review of facility policy titled, Treatment Orders, revised 7/9/24 showed the following: Policy-treatment orders are written per physician's orders. Procedure-1) after observation/ evaluation of the affected skin area the physician is notified. 2) The physician writes a treatment order 3) the physician order is followed, as are the manufacturer's instructions for use for each product ordered .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to obtain physician ordered laboratory testing for one (#141) of fifty-four sampled residents. Findings included: On 2/17/25 at 10:31 a.m. Resident #141 was observed lying in bed. The resident reported being woken up at 4 a.m. to give pills. Review of Resident #141's admission Record showed the resident was admitted on [DATE] with a diagnosis of unspecified hypothyroidism. Review of Resident #141's January and February Medication Administration Records (MAR) revealed the resident was receiving Levothyroxine sodium 100 microgram (mcg) daily for hypothyroidism. The medication was scheduled for 6:00 a.m. daily. Review of Resident #141's January Treatment Administration Record (TAR) revealed an order dated 1/6/25 for Thyroid-Stimulating Hormone (TSH), Free T4, and Parathyroid Hormone (PTH) to be drawn every night shift. This order was discontinued on 1/21/25. The TAR showed the laboratory testing had been administered (per chart code of checkmark) on 1/6 - 1/14, 1/18, and 1/19/25. Staff members documented 10 = Other/See progress note on 1/15-1/17/25. Review of laboratory requisitions for Resident #141's hallway showed the resident had an Albumin, Basic Metabolic Panel (BMP), Complete Blood Count (CBC) with differential, and Magnesium drawn on 1/6/25 and a Complete Blood Count (CBC) with differential on 1/15/25. Review of medline.gov revealed a CBC with differential measured the different sizes, numbers and types of cells including white blood cells, red blood cells, platelets, hemoglobin, hematocrit, and mean corpuscular volume (MCV). The website revealed a BMP measured glucose, calcium, sodium, potassium, carbon dioxide, chloride, blood urea nitrogen (BUN), and creatinine. The review showed neither CBC or BMP measured thyroid hormones. Review of Resident #141's provider's note dated 1/6/25 showed the plan was to check PTH (corresponding with the resident's January TAR). Review of Resident #141's progress notes related to the order for TSH, Free T4, (and) PTH showed the following: - 1/12/25 at 8:34 a.m. - Called Lab for a weekend STAT draw. I was told that order does not meet requirements. - 1/16/25 at 2:02 a.m. - order need clarification, it's has been on since 01/7. - 1/17/25 at 6:07 a.m. - order need clarification it's has been on since 01/7. - 1/18/25 at 12:07 a.m. - order need clarification it's has been on since 01/7. Review of Resident #141's available laboratory results from 1/20 to 2/19/25 revealed results had been obtained for a T3 uptake, T4 (thyroxine), and TSH on 2/19/25, approximately 30 days after the January order was discontinued. The facility was unable to provide any thyroid panel results from 1/6 to 1/19/25, the time in which staff had documented on January TAR the panel had been completed. During an interview on 2/20/25 at 3:21 p.m., the Director of Nursing stated the expectation was to get labs as soon as possible. She reported the process was to put the ordered tests into the lab portal. She said the laboratory vendor came to the facility every day except for Sunday.

Based on observation, and interview, the facility failed to ensure direct care equipment was cleaned in between two (#149 and #218) of eight residents observed during the administration of medications. Findings included: On 2/19/25 at 8:17 a.m., an observation was conducted with Staff N, Licensed Practical Nurse (LPN) of the medication administration for Resident #149. The staff member removed a blood pressure wrist cuff from the bottom drawer of the medication cart and dispensed one 81 milligram (mg) chewable tablet of Aspirin, a half tablet of 20 mg Furosemide, and one 5 mg tablet of Lisinopril. Staff N placed the Lisinopril tablet in a separate medication cup then entered the resident's room. Staff N placed the blood pressure cuff on the resident's left wrist and informed the resident to lay arm on stomach. The staff member reported the first attempt to obtain blood pressure the cuff had registered an error. A second attempt was made with results of 101/48 and the staff member held the resident's Lisinopril. After administering the Aspirin and Furosemide, Staff N left the resident room, replacing the blood pressure cuff into the bottom drawer of med cart. On 2/19/25 at 8:25 a.m., a continued observation was conducted with Staff N of medication administration with Resident #218. The staff member opened the bottom drawer of med cart and extracted the wrist blood pressure cuff. Staff N dispensed the resident's medications, placing a 25 mg tablet of Losartan in a separate medication cup. The staff member entered the resident room and placed the blood pressure cuff on the left wrist, obtaining a blood pressure of 120/57. The staff member administered medications, holding the resident's Losartan before returning to the medication cart. An interview was conducted with Staff N on 2/19/25 at 8:35 a.m. The staff member reported having two blood pressure cuffs in the bottom drawer and one was observed in a fitted container, while the one used was sitting on med cart. Staff N confirmed using the same blood pressure cuff for Resident #149 and #218 and had not cleaned the cuff in between the residents. The staff member reported the cuff should have been cleaned between residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure residents were provided dining services and resident care with dignity for four residents (#63, #2, #26, and #72 ) out of eight sampled residents. Findings Include: 1. During an observation made on 02/17/25 at 1:03 pm., Resident #63 was sitting up in bed with her lunch tray placed in front of her. She was observed having a hard time picking up her food using a specialized spoon. At 1:42 p.m., Staff D, Certified Nursing Assistance, CNA was observed standing over Resident #63 assisting her with her meal. During an observation made on 02/19/2025 at 1:29 pm, Resident #63 was observed sitting up in her bed with her lunch tray in front of her. Staff D, CNA was observed standing over her assisting Resident #63 with her meal. Review of an admission Record dated 02/20/2025 showed Resident #63 was admitted to the facility originally on 7/1/2024 and readmitted on [DATE] with diagnoses to include but not limited to hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, abnormal posture, other feeding difficulties. During an interview conducted on 2/17/2025 at 2:00 p.m. with Staff D, she stated she was trained to sit down whenever she was assisting residents with their meals. Staff D stated she stood whenever she was assisting Resident #63 because she had to assist both residents in the room at the same time with their meal. During an interview conducted on 2/17/2025 at 2:15 p.m. with Staff B, License Practical Nurse (LPN), she stated she was never informed of how staff were supposed to be positioned when assisting residents with their meals. Staff B stated she had to find out if staff should sit down or stand up. During an interview conducted on 2/17/2025 at 2:30 p.m. with Staff F, License Practical Nurse LPN/ Unit Manager, she stated whenever staff were assisting residents with their meals, they were supposed to sit down at eye level facing the residents while assisting them. During an interview conducted on 02/19/2025 at 4:00 p.m. with the Director of Nurses (DON), she stated residents who required assistance with their meals should have staff sitting down next to their bed, with the residents at eye level when they are assisting a resident with their meal. 2. On 2/17/25 at 12:08 p.m., an unknown staff member was observed in the Golden unit dayroom placing clothing protectors on unknown residents, including Resident #2, awaiting meal service. On 2/17/25 at 12:54 p.m., Staff A, Licensed Practical Nurse/Unit Manager (LPN/UM) was heard saying you took your bib off to an unknown female resident sitting in the day room. On 2/19/25 at 1:08 p.m., Resident #2 was observed sitting in the Golden unit dayroom awaiting meal service. The observation revealed Staff Q, Master Social Work (MSW) entered the day room and placed a meal tray in front of the resident. The staff member removed a white sheer napkin from the tray and tucked it into the neckline of the resident's shirt. The staff member continued to set up the resident by peeling a banana with bare hands and placed the unpeeled fruit in front of the resident's plate directly onto the meal tray. During an interview on 2/20/25 at 3:18 p.m., the DON stated residents had a choice for wearing clothing protectors, If oriented, the resident would be asked and for non-oriented residents, the family members would be asked for permission. She stated it would be a personal preference to use a napkin for a protector. The DON stated the resident would be asked prior to putting on the protector and if non-oriented, a staff member would still ask the resident and the clothing protector would be added to the care plan. Review of a quarterly Minimum Data Set (MDS) with a target date of 1/20/25 revealed Resident #2's was not interviewed for a Brief Interview of Mental Status (BIMS) as the resident was rarely/never understood. The staff assessment of the resident showed the resident had short and long-term memory problems, and the cognitive skills for daily decision making was severely impaired. Review of Resident #2's electronic bedside care record, active as of 2/20/25, instructed staff regarding the residents' Eating/Nutrition needs: - To eat in an upright position, to eat slowly, and to chew each bite thoroughly. - Provide Nutrition - Snacks. - Occupational Therapy (OT) and Speech Language Pathologist (SLP) to screen as needed. Provide adaptive equipment as recommended. - Provide extensive tray set up during meal times and assist as needed. The review did not include care instructions to place a clothing protector or tuck napkin into neckline during meals. Review of Resident #2's care plan included the following focuses and associated interventions: - Resident had a incapacity (statement) and a family member was healthcare surrogate (HCS) and durable power of attorney. (DPOA). - Resident had actual preferences related to hair styling and napping locations. The one intervention showed the resident wished hair to bed washed as tolerated and uncut or styled. - Resident had potential risk for Activities of Daily Living (ADL) self-care performance deficits related to (R/T) multiple listed diagnoses. The interventions included did not show the resident's or HCS's choice was for the resident to wear a clothing protector or a napkin to be placed in neckline during mealtime. Review of the care plan for Resident #2 did not include the resident or family member's choice for the resident to wear a clothing protector or for a napkin to be placed in the neckline of the resident's shirt during meals. Review of the facility policy titled, Feeding a Resident, Revised dated 8/24/2023 showed Policy: This facility will ensure that 1. Properly trained personnel supervised by nursing assist residents as needed with meals and snacks and feed residents who are unable to feed themselves. Procedure 3. Sit to assist resident with eating. 3. On 2/17/25 at 1:02 p.m., Resident #26 reported feeling abused by staff who spoke French during care and when realized the resident also spoke French the staff would switch to Creole. The resident stated she had not informed anyone about feeling staff were abusive by speaking another language during care. Review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #26 was readmitted on [DATE], with a preferred spoken language of English. The resident's Brief Interview for Mental Status (BIMS) score was 15 of 15, which indicated intact cognition. The functional assessment revealed the resident had range of motion impairment on one side of upper extremity and one side of lower extremity and required substantial/maximal assistance with toileting hygiene, bathing/showering and dressing. Review of the Resident Council minutes, dated 12/5/24, revealed Resident #26 had attended the meeting. The minutes discussed the council reported Residents feel Certified Nursing Assistants (CNAs) should not be talking to each other during care. The minutes revealed a staff education was attached which showed staff were to Focus on resident when providing care, engage resident in discussion if resident likes to talk. During an interview on 2/20/25 at 2:31 p.m. with the Executive Director (ED). The ED stated Resident #26's allegations were reported to state agencies and law enforcement. The ED stated the resident reported some aides (identified two) spoke in a language other than English while providing care and made the resident feel uncomfortable at times with the most recent episode this past weekend. The NHA reported she interviewed residents on Resident #26's hallway and no other resident reported having heard any staff speaking other languages during care. 4. On 2/17/25 at 11:07 a.m., Resident #72 reported staff would talk in a different language when inside the resident's room and spoke a different language while providing resident care for most of the weekend. On 2/17/25 at 11:47 a.m. Resident #72 reported the incident of staff speaking different languages was the same incident already mentioned in resident council (resident was not listed as an attendee on 12/5/24). The resident stated staff speak different languages to each other during resident care, mostly recently occurring this past weekend. Review of Resident #72's admission Record showed the resident was admitted on [DATE] and included diagnoses not limited to unspecified peripheral vascular disease and type 2 diabetes mellitus with diabetic polyneuropathy. Review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #72's preferred language was English. The resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. Review of Resident #72's electronic bedside care record showed staff were to honor resident wishes daily each shift. Review of the facility's corporate website, located at lcca.com/about/mission, revealed: - We believe our residents are our highest priority. - We believe in the preservation of dignity, self-respect and resident rights in a loving and caring environment. - We believe in the resident-centered approach to care in which the total needs of the residents are met. The resident's family is encouraged to become closely involved with the center in meeting the resident's needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide proper foot care and treatment to maintain good foot health according to professional standards of practice for three residents ( #134, #141, and #140) out of fifty-three residents sampled. Findings Include: 1. During an observation on 02/17/2025 at 9:20 a.m., Resident #134 was observed lying down in bed dressed in his night clothes. Resident #134's great toe was observed with the toe nail sticking out of a hole on his left sock. Resident #134 stated he really needed his toenails cut because they were causing his feet to hurt. He stated he had asked staff repeatedly to cut his toenails, but no one would listen to him. Resident # 134 gave consent to take a picture of his toenails. Photographic evidence obtained. During an observation on 02/18/2025 at 3:00 p.m., Resident #134 was observed lying down in bed dressed in his night gown. He stated he had requested to have his toenails and his fingernails cut but staff would not assist him. Review of an admission Record dated 2/20/2025 revealed Resident #134 was admitted to the facility originally on 12/2/2024 and readmitted on [DATE] with diagnoses to include but not limited to Type 2 Diabetes Mellitus without Complications, Difficulty in Walking, Not Elsewhere Classified. Review of an Active Order Summary Report dated 02/20/2025, showed an active prescriber written podiatry consult dated 1/29/2025. Further review of the same order summary report showed another Podiatry Consult was obtained on 2/19/2025. Review of a Minimum Data Set (MDS) dated [DATE], showed Section C- Cognitive Patterns, Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. Further review of the MDS Section GG- Functional Abilities showed Resident #134 had functional limitation in range of motion due to impairment on one side on his lower extremity. Review of Resident #134 Care Plan created and revised on 12/5/2024, showed a focus for Resident #134 diagnoses of Diabetes Mellitus. Review of the same care plan showed the goal for Resident #134 will have no complications related to diabetes through the review date- date initiated 12/03/2024, revision on 12/31/2024, target date 03/04/2025. Review of the same care plan showed an intervention to refer Resident #134 to podiatrist/foot care as needed - date initiated 12/12/2024. During an interview conducted on 02/18/2025 at 2:00 p.m with Staff D, Certified Nursing Assistant (CNA), Staff D stated she did everything for Resident #134 related to his care. Staff D stated Resident #134 refused to take a shower, so she gave him bed baths. Staff D stated Resident #134's fingernails were dirty because he played with his bottom. She stated Resident #134 accused her of hitting him whenever she tried to clean his fingernails. Staff D stated Resident #134 had asked her to cut his toenails, but she told him she was not allowed to cut his toenail because the facility had special people to cut his nails. Staff D stated she could not remember if she reported to the nurse that Resident #134 needed his toenails cut. During an interview conducted on 2/18/2025 at 2:30 p.m. with Staff C, Register Nurse (RN), Staff C stated he had worked at the facility for a year, and he was familiar with Resident #134. Staff C stated he checked the resident's skin every day and Resident #134's skin looked great. Staff C stated when he did skin checks he looked to see if there were changes in the resident's skin. Staff C stated during his skin check he looked at Resident #134's fingernails and toenails to see if there were any changes. Staff C stated Resident #134 had some dirt under his fingernails yesterday, but his toenails looked good when he did his skin check. Staff C stated nurses, and the podiatrist were responsible for making sure the residents' nails were kept cut and maintained. The unit managers and the wound care nurse were responsible for adding residents on the list to be seen by the podiatrist. Staff C later stated while looking at Resident #134's feet that he did not look at the resident's feet when he did his skin check yesterday. He stated he did not know that his toenails were in the condition they were, if he had seen Resident #134's toenails, he would have notified the unit manager so the resident could have been added to the list to be seen by the podiatrist. During an interview conducted on 02/18/2025 at 3:00 p.m. with Staff F, License Practical Nurse/ Unit Manager, Staff F stated the expectations were that resident's fingernails and toenails should be maintained. Staff F stated staff were not allowed to cut the resident's toenails at the facility. If a resident needed their toenails cut, and they were a diabetic, they would get a podiatry consult and refer them to the podiatrist. Staff F stated Resident #134's nurse should have reported to him the condition of the resident's toenail so he could have obtained a podiatry consult. During an interview conducted on 02/18/2025 at 4:00 p.m. with the Director of Nurses (DON), the DON stated all residents' skin should be assessed, once a week, and more often when staff were providing care. The DON stated not all residents were seen by podiatry, only the ones that had a problem with their toenails, for example, if a resident had long nails, pain or anything abnormal, then those were the ones that would get a podiatry consult. The DON stated Resident #134 should have been referred to be seen by the podiatrist. 2. On 2/20/25 at 8:57 a.m., Resident #141 was observed with an brown adhesive dressing on her thumb and ring finger of her left hand. The thumbnail extended approximately ½-3/4 inches past the fingertip and had a yellowish-orange substance built up underneath the nail. The fingernail of the ring finger appeared to be cut short and was covered by the adhesive dressing. The resident reported having a nail fungus and wished the facility would cut the nails but had not offered to do so. Resident #141 stated the toenails had not been cut since coming to the facility. On 2/20/25 at 9:06 a.m. Staff A, Licensed Practical Nurse/Unit Manager (LPN/UM) stated she was unaware of the thumbnail and fingernail and informed Resident #141 she would cut them. The resident moved the blankets off her bilateral feet and showed the toenails bilaterally extended approximately ¼ past the end of toes and were thickened. The staff member asked if the resident was diabetic when the resident affirmed. The staff member stated the resident had been referred to podiatry last night, 2/19/25, after the toenails were observed and Staff A was unable to clip the toenails. Review of Resident #141's admission Record showed the resident had been admitted on [DATE]. The record revealed diagnoses not limited to Type 2 Diabetes Mellitus without complications and unspecified heart failure. Review of Resident #141's February Treatment Administration Record (TAR) showed an order had been obtained at 11:09 a.m. and discontinued at 5:30 p.m. on 2/20/25 for staff to clean nail bed of the first and fourth finger of the left hand, cover with dry bandage until podiatry/derm(atology) gave different orders every evening shift every 3 day(s) for wound bed. An order had been obtained on 2/20/25 at 5:30 p.m. instructing staff to cleanse 4th finger on left hand with normal saline and cover with dry clean dressing every evening shift every 7 day(s) for cracked nail, to start on 2/21/25. The TAR did not show staff had obtained an order to place adhesive dressings on thumb or ring finger of left hand as observed on 2/20/25 at 8:57 a.m. Review of Resident #141's Weekly Skin Integrity Data collection dated 2/18/25 at 5:29 p.m., showed the resident had dry skin. The evaluation did not mention fingernails or toenails were to be assessed. Review of Resident #141's Nursing (NRSG) Monthly Summary dated 2/5/24 showed fingernails were cut as needed (PRN) by staff and toenails were cut by podiatrist. The summary did not have comments made regarding the condition of the residents fingernails or toenails. Review of Resident #141's Order Summary Report dated 2/20/25 at 4:44 p.m., revealed an order for a podiatry consultation was made on 2/19/25. 3. On 2/20/25 at 11:20 a.m., during an interview and observation assisted by Staff L, CNA, Resident #140's toenails were between 1/8 to 1/4 inch in length from the nailbed. The great toenails appeared thick and curving at the tip of the nail. All nails were pale yellow. On 2/20/25 at 11:20 a.m., during an interview Staff L said she did not cut Resident #140's toenails because the resident had diabetes. Review of admission record showed Resident #140 was admitted to the facility on [DATE] with diagnoses to include type 2 diabetes mellitus. Review of monthly nursing summary dated 2/3/25 showed Resident #140's toenails were cut as needed (PRN) by the nursing staff. Review of Resident #140's care plan showed the following: Focus: the resident has diabetes, initiated 9/9/24. The goal is the resident will have no complications related to diabetes. The interventions include refer to podiatrist for foot care as needed. Review of the policy - Nail Care, reviewed 9/10/24 revealed the resident will receive assistance as needed to complete activities of daily living (ADLs). Any concerns with skin or nails identified during completion of nail care should be reported to the nurse who will document and report to the practitioner as needed. The policy acknowledged foot care regulation to ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must: (i) provide foot care and treatment, in accordance with professional standards of practice, and including to prevent complications from the residents medical condition(s) and (ii) if necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments. For general fingernail care for most residents, the following procedure will be followed: 1. ensure your fingernails are clean and trimmed to avoid injury and infection. 2. Explain the importance of fingernail care to the resident. 3. Assemble all necessary equipment, which may include fingernail Clipper, nail file or [NAME] board, orange sticks, wash basin, towel, and any other necessary equipment. 4. Provide privacy and perform nail care. 5. Do not trim the nail below the skin line and not to cut the skin or cuticle. 6. Report any abnormalities to the nurse. Special care must be given to resident with certain underlying conditions such as Diabetes, Raynaud's Disease, and certain vascular disease. For this group of residents, the procedure for fingernail care will be modified as listed below: 1. ensure fingernails are clean and trimmed to avoid injury and infection. 2. Explain the importance of fingernail care to the resident. 3. Assemble all necessary equipment, which may include fingernail Clipper, nail file or [NAME] board, orange sticks, wash basin, towel, and any other necessary equipment. 4. Provide privacy and perform nail care - Only licensed nurses are allowed to trim nails of residents in this group. Certified nursing assistants (CNAs) should file the nails. 5. Do not trim the nail below the skin line and not to cut the skin or cuticle. 6. Report any abnormalities to the nurse or practitioner as needed. For general toenail care for most residents, the following procedure will be followed, if after evaluation by the licensed nurse no contradictions are identified. Special care must be given to the resident with certain underlying conditions such as diabetes, Raynaud's disease, peripheral vascular disease, and other vascular disease. For this group of residents, the procedure for two nil care will be modified as listed below: 1. in general, residents that fall into this category should only have their toenails filed and not trimmed by the staff at the facility. 2. The staff should arrange for the resident to be seen by a podiatrist that either visits the facility periodically to provide services or sent to an independent Podiatry office for the evaluation and treatment. If during assessment by a licensed nurse, it is determined the residents nails need trimming prior to being seen by intermediate risk, a physician or licensed independent practitioner should evaluate and oversee the nail trimming process by a registered nurse. The physician or licensed independent practitioner will need to attest that prior to nail trimming, they have evaluated and determined the need for the toenails to be trimmed in the facility outweighs the risk of performing the trimming by a registered nurse. The registered nurse will follow the procedure below: 1. ensure toenails are clean and trim to avoid injury and infection. 2. Explain the importance of toenail care to the resident. 3. Assemble all necessary equipment, which may include fingernail Clipper, nail file or [NAME] board, orange sticks, wash basin, towel, and any other necessary equipment. 4. Provide privacy and perform nail care. 5. Do not trim the nail below the skin line and not to cut the skin or cuticle. 6. Report any abnormalities to the practitioner and/ or podiatrist.

Based on observation, review, and interview, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-three medication administration opportunities were observed, and fourteen errors were identified for six (#143, #37, #218, #117, #120, and #106) of eight residents observed. These errors constituted a 42.42% medication error rate. Findings included: 1. On 2/18/25 at 9:54 a.m. Staff B, Licensed Practical Nurse (LPN) obtained a blood pressure of 115/49 from Resident #143 and informed the resident that the blood pressure medication Hydralazine was going to be held for a while. On 2/18/25 at 9:58 a.m., an observation was made of Staff B dispensing the following medications for Resident #143: - Aspirin Enteric coated 81 milligram (mg) over-the-counter (otc) tablet - Magnesium oxide 400 mg otc tablet - Ferrous Sulfate 325 mg otc tablet The staff member confirmed dispensing 3 tablets for Resident #143, placed the tablets into a plastic envelope and crushed the tablets before placing the remnants into chocolate pudding. Staff B entered the resident's room and placed two individual spoonfuls of the pudding into the resident's mouth, followed by a nutritional supplement drink. The resident complained of a headache, rating the pain 8 of 10, and was offered Tylenol. The staff member returned to the medication cart and dispensed 2 tablets of Acetaminophen 325 mg, confirming the two tablets prior to the administration of the requested medication. An interview was conducted with Staff B on 2/18/25 at 10:09 a.m. The staff member stated some enteric coated medications can be crushed. Review of Resident #143's February Medication Administration Record (MAR) revealed the following issues with the resident observed administration: - Aspirin Tablet Chewable 81 mg - Give 81 mg by mouth one time a day for coronary artery disease (CAD). The staff member crushed an enteric coated Aspirin instead of the physician ordered chewable tablet. - Docusate Sodium capsule 100 mg - Give 1 capsule by mouth two times a day for constipation. Continue until stools are soften. This medication was not observed, however Staff B documented it was given. - Hydralazine oral tablet 10 mg - Give 1 tablet by mouth three times a day for hypertension. The observation revealed Hydralazine was not administered and Staff B stated Hydralazine was to be held due to blood pressure. The MAR showed the medication was administered with a documented blood pressure of 115/49. The progress notes for the resident showed the staff member had documented on 2/18/25 at 9:57 a.m. Hydralazine 10 mg tablet was held due to low blood pressure (BP). The physician order did not include parameters in which staff were to hold for blood pressure readings. Review of #143's Medication Admin Audit Report for 2/18/25 showed Staff B had documented hydralazine was administered on 2/18/25 at 9:57 a.m. and on 2/18/25 at 10:03 a.m. docusate sodium and aspirin 81 mg chewable was administered. 2. On 2/18/25 at 10:13 a.m., an observation was made of Staff M, Registered Nurse (RN) dispensing the following medications for Resident #37, the medication profile was colored red showing the medications were late: - Ferosol Iron 325 mg otc tablet - Multivitamin with mineral otc tablet - Eliquis 2.5 mg tablet - Nitrofurantoin Mcr 50 mg capsule - Sertraline HCl 25 mg tablet The staff member poured approximately 90 milliliters (mL) of a nutritional supplement liquid into a blue plastic cup. The staff member confirmed dispensing of 5 oral tablets (Sertraline had broken in half during the dispensing) then a half tablet of Sertraline fell out of medication cup. Staff M removed the other half from the cup, threw both halves away, and dispensed another 25 mg tablet of Sertraline. Resident #37 refused the nutritional supplement stating makes me throw up. The staff member administered the oral medications and on 2/18/25 at 10:21 a.m. documented the medications were given. Review of Resident #37's February Medication Administration Record (MAR) showed the psychotropic medication Sertraline, the antibiotic Nitrofurantoin, the multivitamin, and iron tablets were scheduled to be administered at 9:00 a.m. and the anticoagulant medication Eliquis was scheduled to be administered twice daily at 9:00 a.m. and 5 p.m. Review of Resident #37's progress notes for 2/18/25 did not show the physician was notified of the resident's scheduled medications had been administered late. 3. On 2/18/25 at 8:25 a.m., Staff N, LPN removed a wrist blood pressure cuff from the bottom drawer of the cart. The staff member dispensed the following medications for Resident #218: - Ferrous sulfate 325 mg otc tablet - Baclofen 5 mg tablet - Losartan potassium 25 mg tablet (placed in separate medication cup) The staff member entered the resident room and placed the blood pressure cuff on the resident's left wrist. The blood pressure obtained was 120/57. Staff N informed the resident the blood pressure was a little low for the Losartan and recommended the resident not take it. Staff N left the room and placed the Losartan tablet in the sharps container attached to the medication cart. Review of Resident #218's February Medication Administration Record (MAR) included the following physician orders: - Ferrous Gluconate oral tablet 324 (38 Fe) mg (Ferrous Gluconate) - Give 1 tablet orally two times a day for prophylaxis with meals. Scheduled times 7:30 a.m. and 4:30 p.m. - Losartan Potassium oral tablet 25 mg (Losartan Potassium) - Give 1 tablet by mouth one time a day for hypertension (htn). The MAR did not include parameters for the blood pressure medication to be held and the showed Staff N had documented the medication had been given. 4. On 2/19/25 at 8:51 a.m., an observation was made of Staff O, Registered Nurse (RN) dispensing the following medications for Resident #117: - Famotidine 20 mg tablet - Isosorbide Dinitrate 30 mg tablet - Labetalol 200 mg tablet - Clopidogrel 75 mg tablet - Amlodipine 10 mg tablet - Potassium chloride extended release (ER) 10 milliequivalents (meq) tablet - Metformin 1000 mg tablet - Divalproex delayed release (DR) 125 mg capsule - Aspirin enteric coated (EC) 81 mg otc tablet - Simethicone 125 mg otc tablet - placed in separate medication cup - Fish Oil 1000 mg otc capsule The staff member reported the resident was to receive Clonidine but had to check blood pressure prior to the administration. Staff O confirmed dispensing 11 tablets prior to entering the resident's room. The staff member obtained a blood pressure of 131/80 and a pulse of 90 from the resident's right arm. Staff O placed the 10 medications in the residents mouth with encouragement then placed the Simethicone tablet in the resident's mouth informing them to chew it. The staff member left the room (after verification the resident had swallowed the tablet) and reported Clonidine would be held due to the resident's blood pressure. Review of Resident #117's February MAR revealed the following issues: - Antacid Oral tablet chewable 500 mg (Calcium carbonate (Antacid)) - Give 1 tablet by mouth three times a day for upset stomach and heartburns. The MAR showed Staff O had documented this medication had been administered. - Loratadine 10 mg - Give 1 tablet by mouth one time a day for allergy symptoms. This medication was scheduled for 9:00 a.m. and not observed as administered. The review showed the resident did not have a scheduled or as needed (prn) order for Simethicone 125 mg chewable tablet. The resident did have an order for Simethicone suspension 40 mg/0.6 milliliter (mL) - Give 40 milligrams by mouth every 4 hours as needed for gas prn every bedtime (qHS), put in 8 ounces (oz) water. 5. On 2/19/25 at 8:39 a.m., an observation was made of Staff O, RN dispensing the following medications for Resident #120: - Amlodipine 2.5 mg tablet - Magnesium oxide 400 mg otc tablet The staff member stated the resident was to receive potassium but had to remove it from the machine due to it was not being here yet. Staff O went to the electronic medication dispenser and reported having to call the pharmacy as the potassium was not available. Staff O returned to the medication cart parked outside Resident #120's room, the resident was not in the room, the staff member searched the therapy departments without locating the resident. Staff O stated the 11 p.m. - 7 a.m. nurse had reported calling pharmacy (regarding the potassium) and she (Staff O) had called pharmacy yesterday and was told the potassium would be sent on the second round. The staff member placed the medication cup containing Resident #120's Amlodipine and Magnesium oxide on top of medication cart next to the insulated cooler containing pitcher of water then began the process of dispensing and administering medications for another resident. On 2/19/25 at approximately 9:08 a.m. Resident #120 returned to the room and Staff O administered the previously dispensed medications. The staff member stated therapy had informed her earlier that the resident's blood pressure was okay, normally would have taken it. Review of Resident #120's February MAR revealed the following Potassium order: Potassium Chloride (cl) tablet Extended Release (ER) 20 milliequivalents (meq) - Give 2 tablets by mouth one time a day for hypokalemia for 14 days. The MAR revealed Staff O documented Potassium was hold/see progress notes (7). Review of the electronic Medication dispenser showed the facility had Potassium Cl ER 10 meq capsules available. 6. On 2/19/25 at 11:25 a.m., an observation was made of Staff P, Licensed Practical Nurse (LPN) obtaining a blood glucose level from Resident #106. The staff member cleaned the left pointer finger with alcohol pad, lanced it and obtained a sample from the first drop of blood. The glucometer measured a blood glucose level of 256. The staff member returned to the medication cart, removing the resident's insulin lispro 100 unit/milliliter pen. The staff member wiped the end of the pen with an alcohol pad before screwing on a needle. The staff member returned to the resident room, sanitized hands, placed the pen on a paper towel laid upon the over-bed table, and donned gloves. The staff member dialed the pen to 6 units and injected the insulin into the back of the resident's right arm, unscrewed the needle and placed it into the rooms sharp box. An interview was conducted with Staff P on 2/19/25 at 11:35 a.m. The staff member reported normally does prime the insulin pen with 2 units but today she had not. Staff P stated she knows she was supposed to. Review of Resident #106's MAR revealed the resident was to receive Insulin Lispro per sliding scale subcutaneously before meals and at bedtime for diabetes mellitus (DM). The sliding scale showed the resident was to be administered 6 units for a blood glucose level of 256. During an interview on 2/19/25 at 5:12 p.m. the Director of Nursing (DON) stated the record should reflect what we are doing, late medications are medication errors and the process was to notify the physician, pharmacist, and family member, and to monitor the resident. She stated the physician was to be notified prior to administering late medications. The DON stated nurses are able to make nursing judgements related to holding the blood pressure medications. The DON reported staff were to prime insulin pens, crushing enteric coated medications are contraindicated, holding blood pressure medication would be specific to the resident condition, physician's would order blood pressure to be taken and (staff obtain) at least weekly blood pressures for residents. Review of the policy - Administration of Medications, reviewed 9/16/2024 revealed The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnosis in signs and symptoms. The facility must ensure that its medication error rates are not 5% or greater; and the facility must ensure that its residents are free from any significant medication errors. The policy defined medication error as This means the observed or identified preparation or administration of medications or biologicals which is not in accordance with: 1. The prescriber's order; 2. Manufacturer's specifications (not recommendations) regarding the preparation in administration of medication or biological; or 3. Accepted professional standards and principles which apply to professionals providing services. Accepted professional standards and principles include the various practice regulations in each State, and current commonly accepted health standards established by national organizations, boards, and councils. The procedure revealed: 1. Medication administration is the responsibility of those individuals who through certification and licensure are authorized in their state to administer medications any skilled nursing facility. 2. Staff who are responsible for medication administration will adhere to the 10 rights of Medication Administration: a. Right drug. Every drug administered must have an order from the provider. Compare the order with the medication administration record (MAR) for accuracy. b. Right resident. c. Right dose. Check the MAR (medication administration record) and the doctor's order before medicating. Use standard measuring devices such as syringes, graduated cups, or scaled droppers. If there is any doubt about the dose on the MAR or if there is a question on the drug, stop and verify all information before administering. d. Right route. e. Right time and frequency Check the order for when it would be given and when the last time it was given. f. Right documentation. Make sure to write the time and any remarks on the chart correctly. Medication administrations should be documented timely following the administration to the resident. g. Right assessment. Note the resident's history in any parameters during Drug Administration. h. Right to refuse. i. Right evaluation/ response. j. Right education and information. 3. A physician order that includes dosage, route, frequency, duration, and other required considerations including the purpose, diagnosis or indication for use is required for administration of medication. 10. The facility should refer to their pharmacy manual for additional guidance and resources on medication administration common in conjunction with state-specific guidelines regarding the administration of medications. Review of the policy - Blood Glucose Monitoring, reviewed 9/23/24, revealed associate to obtain capillary blood glucose specimens will do so in accordance with their scope of practice and in accordance with all applicable local, state, and federal guidelines. Specimens will be collected in a manner that adheres to current standards of practice in infection control standards. Review of the pharmacy - Guidance for Using Insulin Products, copyrighted 2023, revealed: 7. Prime pen-like devices prior to each and every injection to minimize air bubbles. Dial units as per below guidance in push into a drop of insulin is seen at the top of the needle. If it does not appear after multiple attempts (i.e., 2-8 attempts - refer to prescribing an information for precise number), change the needle. The documentation revealed Insulin lispro pens should be primed with 2 units.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility did not ensure dignity was maintained for two (Residents # 103 and #133) of two residents related to catheter exposure to the public during 3 of 4 days of survey. Photographic evidence was obtained Findings included: 1. During facility tours on 01/23/23 at 10:16 a.m., 01/24/23 at 11:25 a.m., and on 01/25/23 at 08:45 a.m., an observation was made of Resident #103's catheter that was visible from the hallway. Resident # 103 was noted laying on his bed, unaware his catheter was visible to everyone walking down the hallway. The resident's door was wide open and the privacy curtain was pulled to the head of the bed. In an interview with Resident #103 on 01/25/23 at 08:45 a.m., the resident stated he did not know his catheter was visible to passersby in the hallway. The resident stated it was no one's business to see his catheter. Resident #103 said, I'd like it covered. A review of Resident #103's electronic medical record (MAR) showed the resident was admitted to the facility on [DATE] with diagnoses to include: neuromuscular dysfunction of the bladder, encounter of artificial openings of urinary tract and malignant neoplasm of bladder. A review of the physician orders for Resident #103 dated 01/25/23 showed an order dated 08/28/22 indicating urostomy device to straight drainage due to a diagnosis of bladder cancer. A review of a quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #103 had a brief interview for mental status (BIMS) score of 14, indicating intact cognition. Section G, functional status showed Resident #103 required extensive assistance for Activities of Daily Living (ADLs) including toilet use. Section H indicated the resident had an ostomy (including urostomy, ileostomy and colostomy). A care plan dated 01/06/23 showed a focus indicating the resident had impaired bladder function related to a history of prostate cancer and had a urostomy present. Interventions included catheter care every shift. On 01/25/23 at 08:46 a.m., an interview was conducted with Staff C, Licensed Practical Nurse (LPN) Unit Manager. Staff C made the observation of Resident #103 from the hallway outside the resident's door. Staff C stated, that is not good, we should ensure a more dignified living. Staff C stated the resident's catheter should not be exposed to the public. She stated they should probably move it to the other side of the bed for privacy. Staff C stated the privacy flap should be pulled over to cover the output. Staff C stated they would switch out the catheter to one that provided privacy. She stated she had spoken to the certified nurse's aide (CNAs) and nurses. She stated in-servicing staff was a never-ending job. Staff C said, we owe it our residents. Staff C confirmed resident's catheters should not be exposed to the public. On 01/25/23 at 12:40 p.m., an interview was conducted with the Director of Nursing (DON). She stated Staff C had notified her there was a catheter that was exposed. The DON stated it was their goal to ensure resident's privacy was respected. She stated catheters should not be within sight of anyone walking down the hall. The DON confirmed a privacy bag should be provided for all residents with catheters. 2. On 01/24/23 at 3:53 p.m., Resident #133 was observed sleeping in bed. A urine catheter drainage bag was observed hanging on right side of bed, without a privacy cover, and visible from the room door. On 01/25/23 at 09:20 a.m., Resident #133 was observed seated in his wheelchair at the side of the bed, dressed, groomed, and talking on his cell phone. The urine catheter drainage bag was observed hanging from the side of the wheelchair without a privacy cover and visible from the door. A review of the clinical record for Resident #133 revealed an admission to the facility on [DATE], with diagnoses that included, but not limited to neuromuscular dysfunction of bladder as per the Face Sheet. A review of the Physician's Orders revealed: -Indwelling cath [catheter] to straight drainage, 16 FR [french], bulb 30 cc [cubic centimeters], may change for leakage or obstruction, DX [diagnosis]: neurogenic bladder During an interview with Staff A, Certified Nursing Assistant (CNA) on 01/25/23 at 09:50 a.m., she confirmed Resident #133 did not have a privacy cover on his urine catheter drainage bag. The CNA also confirmed the drainage bag should be covered. On 01/25/23 10:59 a.m., an interview was conducted with Staff B, Licensed Practical Nurse (LPN). The LPN confirmed Resident #133 had a urinary catheter and stated the drainage bag should be covered to ensure the resident's dignity. Staff B, LPN said the resident went to see the Urologist on Monday and stated, they don't put on a privacy bag, so someone should have applied one when he came back. Review of a facility policy titled, Dignity, dated 09/30/22, showed each resident has the right to be treated with dignity and respect with a focus to maintain and enhance the resident's self-esteem, self-worth and incorporating the resident's goals, preferences, and choices. Procedure included (h.) Refraining from practices demeaning to residents such as leaving urinary catheter bags uncovered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility did not ensure assessments and treatments were provided for two (Residents #49 and #94) of three residents reviewed for skin conditions. Findings included: 1. On 01/23/23 at 1:30 p.m., Resident #49 was observed with an undated dressing on her upper right arm. The dressing was noted with two small blood spots on the lower end of the dressing. The resident was noted to have another undated dressing on the front of her elbow on the upper right arm. The resident was not able to stretch out her arm. Resident #49 stated she had an incident with staff during a therapy session where her arm was caught on the door. The resident could not verify the timing of the incident. The resident stated since that incident, the dressing on her arm had not been changed. Review of a facility document titled, incident by incident type, dated 07/23/22 to 01/23/23 revealed the incident related to Resident #49's arm injury was not documented. Resident #49 was re-admitted to the facility on [DATE]. A quarterly minimum data set (MDS) dated [DATE] showed under section C, the resident had a brief interview for mental status (BIMS) score of 15, indicating intact cognition. Section G, functional status showed the resident was dependent on Staff and required extensive assistance for all activities of daily living (ADLs). Review of weekly skin integrity data collections showed: 01/23/23: skin intact, no new findings. Bruising to upper and lower extremities. Skin tear to right arm and left arm. 01/16/23: skin is intact, no new findings. Bruising noted to upper and lower extremities. 01/09/23: skin intact, no new findings. Bruising to upper and lower extremities. Edema noted to lower extremities, skin tear to right arm dressing in place. 01/02/23: skin intact, no new findings. Bruising to upper and lower extremities. Patient on blood thinner, skin tear to right forearm treatment in place. The review of skin assessments showed on-going concerns with bruising and skin tears. On 01/24/23 at 11:17 a.m. an interview was conducted with Resident #49. The resident stated her arm was hurting and no one had looked at it. The resident re-stated she was hurt when she was being transported to therapy. Resident #49 stated a nurse had put a dressing on the arm and no one had looked at it since then. The dressings were noted on the resident's arm, undated and with blood spotting visible to the surface. Review of the Physician orders dated 01/25/23 showed the resident did not have any orders to treat the skin tears and bruising. The review showed orders were initiated on 01/25/23 after this surveyor notified the facility of concerns. The new orders showed to clean right arm with normal saline, pat dry, and apply clean border dressing, leave in place for two days then remove and leave open to air. Review of a Medication Administration Record (MAR) for Resident #49 showed the resident was not receiving any treatment for the skin tears and bruising. On 01/25/23 at 8:45 a.m., an interview was conducted with Staff C, Licensed Practical Nurse (LPN) Unit Manager and Resident #49. Staff C observed the resident and stated she did not know why the resident had the undated dressings on her right arm. Staff C stated she was not aware of any incidents that may have caused the resident's injuries. She stated either way the dressings should be dated. Whoever put them on should have said something. Resident #49 stated the dressings had been on her arm for 2 to 3 weeks from an incident that happened when she was being assisted to therapy. The resident stated her arm got caught on the door and was bleeding from the injury. Resident #49 stated a nurse cleaned her up and put the bandage on. On 01/25/23 at 9:58 a.m., an interview was conducted with Staff C. Staff C stated the resident did not have any orders to treat the bruising. Staff C stated the nurse who was notified of the injury should have reported and contacted the physician to obtain orders. Staff C stated if the resident had orders in place, the wound care nurse would have looked at her and treated the skin tears. Staff C removed the dressing on the lower right arm revealing a dry scabbed area with dried blood. Staff C attempted to pull the second dressing off the upper right arm. Staff C stated she would have wound care assess her. Staff C said, It looks like she is still bleeding. Staff C stated she would contact the physician to obtain orders to treat. On 01/25/23 at 10:08 a.m., an interview was conducted with Staff C who reviewed the resident's orders and confirmed the resident did not have any orders to treat the skin tears. She stated the nurses should always obtain physician orders prior to treating. She stated an incident report should have been completed detailing the incident. Staff C confirmed the resident was still bruised and bleeding. Staff stated she will conduct an evaluation and follow-up with orders to treat. On 01/25/23 at 11:30 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated she just became aware the resident had an incident during therapy a few weeks ago. She stated she just spoke to the Director of Rehabilitation (DOR) and notified her if there was ever an injury incident in her department, she needed to submit a report and notify administration. The DON stated the DOR notified a nurse who put a dressing on the resident. She did not remember who it was. The DON stated the expectation was to assess the resident, obtain orders to treat if needed, and to report an injury incident . She stated the incident should have been documented and wound care should have been looking at her. The DON stated they were initiating an investigation. The DON confirmed the dressings should be dated. The DON stated anyone, a nurse or a certified nurses' aide (CNA) should have noted the bleeding dressing and done something about it. She stated they had educated all nurses who were in house and would continue to in-service. 2. On 01/23/23 at 11:45 a.m., Resident #94 was observed in bed. An attempt to interview the resident was unsuccessful. Resident #94's right hand and arm were observed bruised. The right hand had an undated bandage partially covering the bruise (photographic evidence obtained). On 01/23/23 at 3:30 p.m., Resident #94 was observed in the dining area, outside of the nursing station, with three undated dressings, one to the right arm and two on the left arm. The resident's assigned nurse was interviewed and stated she did not know why the resident had the bandages but she would look. On 01/25/23 at 9:50 a.m., Resident #94 was observed in bed with no bandages on her hands or arms. The admission Record revealed Resident #94 was initially admitted into the facility on [DATE] with a primary diagnosis of Parkinson's Disease. Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] indicated the resident was not able to complete the Brief Interview for Mental Status. A review of the Order Summary Report with active orders as of 01/25/23 revealed the following orders related to skin: Adaptive Device: Resident will wear bilateral palm guard splints 6 hours during the day to reduce fisted hand position and to prevent skin breakdown and to prevent contractures. Apply house lotion to bilateral arms and legs daily. Skin check to be completed and documented in the weekly skin check assessment. Treatment: Cleanse left forearm with Normal Saline (NS), pat dry, apply xeroform, cover with kerlix roll and tape three times per week and PRN (as needed) until resolved. Resident #94 did not have a treatment order in place related to skin impairment for the right hand or right arm. The document provided by the facility Incident by Incident Type dated 07/23/22 to 01/23/23 did not reflect any incidents for Resident #94. A care plan related to skin impairment initiated on 11/04/20 included but was not limited to the following intervention: treatment as/if ordered. On 01/25/23 at 9:50 a.m., Staff C, Licensed Practical Nurse (LPN), Unit Manager (UM), reported Resident #94 had an order in place to keep her in long clothes because she bumps against things and she had very fragile skin. Staff C stated she would have to look up the orders because she was not the nurse on the floor. The resident had Geri sleeves. The nurse reported she only saw an order for treatment to the left forearm in the resident's medical record. On 01/25/23 at 10:03 a.m., Staff C, LPN, UM, stated she looked at the orders and only saw an order for the left arm. She stated the bandages should be dated and there should be an order for treatment. Review of a facility policy titled, Skin Integrity and Pressure Ulcer/injury prevention and Management, reviewed 04/19/22, showed the facility intends to provide associates and licensed nursed with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment / documentation and provide treatment and care of skin and wounds utilizing professional standards. Under procedure, Skin observations occur throughout points of care provided by CNAs during an Activities of Daily Living (ADL) care. Any changes or open areas reported to the nurse. CNAs will also report to nurse if topical dressing is identified as soiled, saturated, or dislodged. Nurse will complete further inspection/assessment and provide treatment if needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure behavioral and side effect monitoring related to the use of psychotropic medication was completed for one (Resident #32) of five residents sampled for unnecessary medication use. Findings included: A review of Resident #32's medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses of dementia, anxiety disorder, and mood disorder. A review of Resident #32's physician's orders revealed an order, dated 1/18/2023 for Lorazepam 0.5 milligrams (mg) by mouth twice a day for anxiety and every 24 hours as needed for anxiety. Resident #32's physician's orders did not reveal orders for monitoring of behaviors or side effects related to use of Lorazepam. An interview was conducted on 1/25/2023 at 12:10 p.m. with Staff E, Licensed Practical Nurse (LPN). Staff E, LPN stated Resident #32 was prescribed Lorazepam both as needed and routinely and residents receiving psychotropic medications were monitored for any behavioral changes and side effects of the medication being used. Staff E, LPN reviewed Resident #32's physician's orders and confirmed Resident #32 did not have orders for monitoring of behaviors or side effects related to use of Lorazepam. Staff E, LPN stated Resident #32 should have an order for behavioral and side effect monitoring related to use of Lorazepam and the nurse who put the medication order in the electronic medical record should also put the orders in for monitoring. An interview was conducted on 1/25/2023 at 1:20 p.m. with the facility's Director of Nursing (DON). The DON stated behavioral monitoring related to use of psychotropic medications should be conducted to observe for any type of behavioral symptoms the resident may have, which would be documented in the resident's medical record every shift. The residents using psychotropic medications should also have an order in place for monitoring of side effects related to the specific class of medication being used, which was recorded in the resident's medical record every shift. The DON stated the orders for behavioral monitoring and side effect monitoring should be in place at the same time the medication was ordered. A telephone interview was attempted on 1/26/2023 at 11:08 a.m. with the facility's Consultant Pharmacist. A voicemail message was left for a return call, but the call was not returned. A review of the facility policy titled Psychotropic Medication Use, last revised on 10/24/2022, revealed under the section titled Procedure psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms. The policy also revealed facility staff should monitor the resident's behavior using a behavioral monitoring chart or behavioral assessment record for residents receiving psychotropic medications. Facility staff should monitor behavioral triggers, episodes, and symptoms and should document the number and/or intensity of symptoms and the resident's response to staff interventions.

Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5%. Twenty nine medication opportunities were observed and two errors were identified for Resident #107 resulting in an error rate of 6.9% Findings included: On 01/24/23 at 9:04 a.m., Staff D Licensed Practical Nurse (LPN) was observed administering medication to Resident #107. Staff D administered the following medications. -Vitamin C D5200 (mg) -Loratadine 10 mg - MVI (reg) 1 tablet -Fluticasone-Salmeterol Aerosol 100-50 micrograms/activation (mcg/act) 2 inhalations -Ferrex 150 -Lisinipril 10 mg -Sildenafil 20 mg -Oxybutynin ER 5 mg Following the medication administration observation, a review of the physician's orders for Resident #107 revealed there was no order for Loratadine 10 mg. The resident had a physician's order dated 09/15/2022 for Cetirizine (Zyrtec) 10 mg by mouth one time a day for allergies. A review of physician's order dated 09/15/2022, revealed an order for Fluticasone-Salmeterol Aerosol Powder Breath Activated 100-50 mcg/act, 1 inhalation, inhale orally every 12 hours for COPD Rinse mouth after using inhaler. Staff D was interviewed on 01/24/23 at 2:26 p.m. and stated, resident prefers Claritin (Loratadine) and he will tell you what works for him. Staff D stated Zyrtec (Cetirizine) was not even stocked on the cart. She said, The order was wrong and I gave the medication the resident prefers. Staff D said she would call the doctor and have the medication changed. During the interview Staff D confirmed she did not instruct the resident on the use of the inhaled medication. Record review showed that on 1/24/23 at 1430 (2:30 p.m.) the order for Cetirizine was discontinued, and an order was written for Loratadine tablet 10 mg by mouth one time a day for allergy. On 01/24/23 at 2:43 p.m. the Director of Nursing (DON) stated the resident should get the medication per the order and would talk with staff. The DON was informed the nurse handed the resident the inhaler without providing instruction. The DON stated, Residents should always be instructed when administering meds. A follow up interview with the DON was conducted on 01/25/23 at 8:38 a.m. The DON said she spoke to [Staff D] who made the errors and [Staff D] confirmed she gave medication that was not ordered in favor of what the resident wanted. Staff D also confirmed to the DON she did not instruct the resident how to use the inhaled medication. A voicemail was left for the consultant pharmacist on 01/26/23 at 11:10 a.m. No return call was received by completion of the survey. Review of the Facility's Pharmacy Services and procedure manual section 3.3.7 states Facility staff should verify the medication name an dose are correct when compared to the medication order on the medication administration Record. Section 5.5.7 Provide the resident with any necessary instructions (e.g., using and inhaler).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility did not ensure respiratory equipment was stored in a sanitary manner for six (Resident #40, #118, #14, #51, #49 and #103) of eight residents reviewed for respiratory care. Findings included: 1. During facility tours on 01/23/23 at 9:35 a.m., 01/24/23 at 11:15 a.m. and 01/25/23 at 8:22 a.m., Resident #40 was observed in her room in bed. An oxygen concentrator was noted at the head of her bed. The tubing and cannula were tucked on the handle and hung down to the floor. The tubing and cannula were not bagged. Resident #40 did not respond to the interview. Resident # 40 was admitted to the facility on [DATE]. Review of current physician orders dated 01/25/23 showed the resident did not have orders to administer oxygen. 2. On 01/23/23 at 10:34 a.m., 01/24/23 at 9:15 a.m. and 01/25/23 8:33 a.m., an observation was made of Resident #118's CPAP (continuous positive airway pressure ) device stored on top of a bedside table with the mask and tubing lying on top of personal items. The mouthpiece and tubing were exposed to the elements. On 01/25/23 at 8:33 a.m., an interview was conducted with Resident #118. The resident said, They leave the mouthpiece open to the dust, it's kind of nasty. They don't change it most of the time. The resident stated the mask was normally dirty because they did not clean it. A review of active physician orders for Resident #118 dated 01/25/23, showed the resident had orders for CPAP on while sleeping/napping and off while awake every shift for respiratory. On 01/25/23 8:35 a.m., an interview was conducted with Staff C, Licensed practical nurse (LPN)/ unit manager. Staff C observed the CPAP on top of the nightstand and stated she told the nurses to make sure it was bagged all the time. She stated she expected the nurses to wash the mouthpiece and put it in a bag. Staff C stated the tubing and masks should be changed as ordered, it should be changed weekly. 3. On 01/23/23 at 9:30 a.m., Resident #49's oxygen tubing and cannula were observed hanging on top of the concentrator. A travel oxygen tank was observed on back of her wheelchair with the tubing dangling to the side. The nebulizer mask was observed on top of the resident's bedside table uncovered. This observation was also made on 01/24/23 at 11:20 a.m. and 01/25/23 8:45 a.m. Resident #49 was admitted to the facility on [DATE] with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Active physician orders for the resident showed Oxygen sat (saturation) rates every shift and Ipratropium - albuterol solution 0.5 - 2.5 (3) MG/ML 3 ml inhale orally via nebulizer every 6 hours for COPD. 4. On 01/23/23 at 11:02 a.m., an observation was made of an oxygen concentrator stored on the side of Resident #14's bed. The cannula and tubing were hanging on the concentrator tank, with cannula exposed to the elements. On at 01/24/23 9:29 a.m., an interview was conducted with Resident #14. She stated she used the oxygen as needed, but it had been a while. The resident stated she had forgotten it was there. She stated when she used the oxygen, staff assisted her with it. Resident #14 was admitted to the facility on [DATE]. A review of her current physician orders showed no orders to administer oxygen. On 01/25/23 at 9:50 a.m., an interview was conducted with Staff C. Staff C observed the resident's oxygen equipment at bedside. She stated she had been trying to educate the nurses. Staff C stated, Respiratory equipment should be stored in bags and dated because it is unsanitary. The equipment should not be left to the open like that. Staff C stated she would initiate another in-service. In an interview on 01/25/23 at 10:12 a.m., Staff C stated the residents should have current respiratory orders and if the order was discontinued, the equipment should be removed from the room. 5. On 01/23/23 at 10:16 a.m., an observation was made of Resident #103's of a nebulizer machine on the resident's window sill. The mask was resting on the blinds, uncovered, and exposed to the elements. Resident #103 was admitted to the facility on [DATE] with diagnoses to include COPD. A review of active physician orders for Resident #103 showed ipratropium albuterol inhale orally every 6 hours for COPD. 6. During a tour on 01/23/23 10:29 a.m. and on 1/24/23 at 9:23 a.m. An oxygen concentrator was observed on the side of the Resident #51's bed. The tubing and nasal cannula were observed tucked into the concentrator tank handle with the cannula exposed to the elements. A review of Resident #51's record showed he was admitted to the facility on [DATE] with diagnoses to include COPD. A review of the current physician orders dated 01/25/23 showed the resident did not have current oxygen orders. On 01/25/23 at 8:21 a.m., an interview was conducted with Resident #51. He stated he used the oxygen as needed. He confirmed he had used the oxygen within the previous week. A follow -up was conducted on 01/25/23 at 09:50 a.m. an interview was conducted with Staff C. She made the observation of the resident's equipment at bedside with tubing hanging over the tank and tubing exposed to the element. Staff C stated she has been trying to educate the nurses. She stated respiratory equipment should be stored in bags and dated because it is unsanitary. On 01/25/23 at 11:30 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated the facility had a Respiratory Therapist (RT) who should be reviewing all the residents who were on oxygen and confirm orders were in place, to include PRN (As needed) use. She stated the RT was supposed to go around weekly and confirm all equipment was working, properly set, and properly stored. The DON stated the Central Supply department was responsible for changing out all tubing and masks on Sundays. She stated the nurses should be cleaning the equipment after each use and ensure it was stored in a dated bag. She stated she would reiterate the process. Review of a facility policy titled, oxygen administration/safety/storage/maintenance, issued 12/03/22, showed oxygen will be administered in accordance with physician orders and current standards of practice. Under infection control: #3. Store oxygen and respiratory supplies in a bag labeled with resident's name when not in use. #5. If oxygen is discontinued, discard all disposable pieces including filters (replace with new ones). Training requirements: all staff shall be educated on oxygen administration safety and storage upon hire annually and as indicated thereafter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility's policy, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for six (Residents #40, #78, #95, #55, #63 and #94) of seven residents sampled for PASARR Level II. Findings included: 1. A review of the electronic medical record (EMR) revealed Resident #40 was admitted to the facility on [DATE]. A Minimum Data Set (MDS) dated [DATE], showed in section I, Resident #40 was admitted with diagnoses of Depression and Schizophrenia. A review of a quarterly MDS dated [DATE] Section I showed the resident had current diagnoses of Depression and Schizophrenia. Review of Resident #40's PASSAR Level I screen dated 11/24/20 revealed no qualifying mental health diagnosis was indicated and no PASARR Level II was required. A Care plan dated 12/29/22 showed a goal initiated on 06/28/21 indicating the resident had actual risk for behavioral deficits and was combative towards staff. A goal initiated 12/04/20 showed the resident had potential risk for ineffective coping related to schizophrenia and bipolar. A goal initiated on 9/822 showed the resident had a diagnosis of Dementia. The record review showed a level II PASARR evaluation was not completed for a resident with a history of dementia and suspicion of a serious mental illness. A pharmacy consultation report dated December 1, 2022 through December 19, 2022 showed Resident #40 had recommendations related to a newly added psychiatric diagnosis of bipolar on 11/30/22. The pharmacy note showed: there is a diagnosis on file of schizophrenia, but not clear documentation of disease history. The 2020 history and physical shows a history of dementia. Recommendations from the pharmacy report showed: Provide additional documentation in the medical record that clarifies the diagnosis and indication of use. 1. The specific s/s (signs/symptoms) being treated for this indication or that led to this diagnosis. 2. The impact of the resident (e.g., increased distress, hallucinations, dangerous behaviors) 3. Documentation that causes (e.g., environmental, other medical conditions) and meds have been ruled out and that individualized non-pharmacological interventions are in place. Physician response dated 12/21/22 showed: per family history she has had mood swings and a strong family history of mental illness. A review of a psychiatry progress note dated 12/21/22, revealed [the] resident has a history of aggression with significant history of Mental illness. On 01/25/23 at 12:28 p.m., an interview was conducted with the facility's Psychiatrist. The psychiatrist stated Resident #40 was being treated for mood disorder. She stated the resident came in with a Schizophrenia diagnosis. Resident #40 had paranoia and used to be aggressive towards staff and had Olanzapine reduced. She stated the resident's family member confirmed she was diagnosed with Schizophrenia. The Psychiatrist confirmed she diagnosed her [Resident #40] with Bipolar because of the mood swings. She stated on 06/21/22 she had discussed the resident's psych history with the family and learned the resident had a significant history of mental health and was [NAME] Acted from another facility due to Suicidal ideation. The psychiatrist confirmed if a resident's diagnosis changed, their PASSAR should be reviewed I suppose. She stated if a resident had a significant history of mental health, the PASSAR should reflect that. A review of the medical record for Resident #40 revealed the resident was not assessed for PASARR Level II. 2. A review of the electronic medical record (EMR) revealed Resident #78 was admitted to the facility on [DATE]. Review of an admission MDS dated [DATE] section I showed Resident #78 was admitted with a diagnosis of bipolar disorder. A review of the quarterly MDS dated [DATE] section I, showed Resident #78 had a new diagnosis of anxiety disorder. A review of Resident #78's PASARR Level I screen dated 11/08/19 revealed no qualifying mental health diagnosis was indicated, and no PASARR Level II was required. A review of the medical record revealed the resident was not assessed for PASARR Level II. 3. A review of the electronic medical record (EMR) revealed Resident #95 was admitted to the facility on [DATE]. A review of an MDS dated [DATE] section I showed Resident #95 had a diagnoses of anxiety disorder and depression. A review of Resident #95's PASARR Level I screen dated 09/15/17 revealed no qualifying mental health diagnosis was indicated, and no PASARR Level II was required. A review of a document for Resident #95 titled, Resident information, dated 1/25/23, showed the resident had new diagnoses to include: mood disorder due to unknown psychological condition, bipolar disorder, and major depressive disorder. A review of the medical record revealed the resident was not re assessed for PASARR Level I upon admission or PASARR Level II upon acquiring new diagnosis. 4. Review of the electronic medical record (EMR) revealed Resident #55 was admitted to the facility on [DATE]. A review of an admission MDS dated [DATE] section I showed Resident #55 was admitted with diagnoses of bipolar disorder and depression. A review of a quarterly MDS dated [DATE] section I showed Resident #55 had diagnoses of bipolar disorder and depression. A review of a document for Resident #55 titled, Resident information, dated 01/25/23, showed the resident had new diagnosis of schizoaffective disorder. A review of Active Physician Orders for Resident #55 dated 1/25/23, showed the resident was prescribed Ziprasidone HCI Oral capsule 80 mg (Ziprasidone HCI), give 1 capsule by mouth two times a day for schizoaffective, dated 01/18/23. A review of Resident #55's PASARR Level I screen dated 8/19/21 revealed a qualifying mental health diagnosis was not indicated, and no PASARR Level II was required. A review of the medical record revealed the resident was not assessed for PASARR Level II following the new diagnosis. On 01/25/23 at 12:32 p.m., an interview was conducted with the Social Services Director ( SSD). She stated she reviewed PASARRs to make sure they were current and looked for diagnoses to make sure all current diagnosis were checked. She said after reviewing she notified the physician of any discrepancies to make sure they collaborated with psychiatry. The SSD stated she confirmed the diagnoses were current to ensure we were meeting the needs of the patient. If there was a problem or if a diagnosis was missing, she would notify the Director of Nursing (DON). The SSD reviewed the PASARRs for the sampled residents and said, diagnosis should be checked. I probably missed them. If a resident obtained a new diagnosis, a new PASARR should be obtained. The SSD stated she would discuss the findings with the DON. On 01/25/23 at 1:09 p.m., an interview was conducted with the DON. She stated PASARRs were completed prior to admission. She stated in the morning meeting all the departments review the new admission file. The SSD reviewed the PASSAR to make sure it was good, meaning current diagnoses were checked, content was complete, and to ensure accuracy of the content. The DON stated the SSD was reviewing resident files on an-ongoing basis, for completeness and accuracy. She stated following survey findings, they discussed the PASARRs and noted some were missing documented diagnoses, or they were not checked. She stated they would be reviewing in the morning meeting going forward to make sure current PASARRs were accurate and to see if we need to adjust. The DON said, if a resident had a new diagnosis, it should be reflected. We should submit a new PASARR for each new diagnosis. The clinical team would be reviewing this on an-going basis. The DON confirmed if a resident had a new significant mental health change, a level II PASARR should be submitted for review. DON stated they will be resubmitting those today for review. 5. A review of Resident #63's medical record revealed Resident #63 was admitted to the facility on [DATE] with diagnoses of psychosis, diabetes mellitus, and major depressive disorder. Resident #53 had a diagnosis of unspecified dementia added to the medical record on 11/6/2019. A review of Resident #63's Preadmission Screening and Resident Review (PASARR) dated 8/6/2013 revealed no qualifying mental health diagnosis and no PASARR Level II was required. A review of Resident #63's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/27/2022 revealed, under Section I: Active Diagnoses, diagnoses of Non-Alzheimer's Dementia, anxiety disorder, depression, and psychotic disorder. Review of Resident #63's medical record revealed the resident was not assessed for PASARR Level II. 6. A review of the admission Record revealed Resident #94 was admitted on [DATE] with diagnoses of delusion disorders and psychotic disorder with delusions due to known physiological condition. A review of Resident #94's PASARR Level I assessment dated [DATE] revealed no qualifying mental health diagnosis and no PASARR Level II was required. A review of Resident #94's medical record revealed a new diagnosis of unspecified dementia, unspecified severity, with psychotic disturbance. A review of Resident #94's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a diagnosis of psychotic disorder and the resident was not assessed for PASARR Level II. Review of a facility policy titled, Preadmission Screening and Resident Review (PASARR), revised 10/06/22, showed the facility will ensure that potential admissions are screened for possible serious Mental Disorders (MD) or Intellectual Disabilities (ID) and related conditions. This initial prescreening is referred to as PASARR level I and is completed prior to admission to a nursing facility. A negative level I screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. A positive level I screen necessities an in-depth evaluation of the individual by the state's designated authority known as PASARR level II which must be conducted prior to admission to a nursing facility. Under procedure: (1.) Ensure level I PASARR screening has been completed on potential admissions prior to admission. (5.) When a level II PASARR screening is warranted, it must be obtained as well as determination letter prior to admission. The level II PASARR cannot be conducted by the nursing facility. (13.) Any resident with newly evident or possible serious mental disorder, intellectual disability or a related condition must be referred by the facility to the appropriate state designated mental health or intellectual disability authority for review. (14.) Referral for level II resident review evaluation is required for individuals previously identified by PASARR to have a mental disorder, intellectual disability, or a related condition who experiences significant change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, photographic evidence and staff interviews, the facility failed to implement a care planned intervention related to the use of heel protectors for one resident (#15) of 47 sampled residents. Findings included: A medical record review conducted for Resident #15 on 3/09/21 revealed that Resident #15 was re-admitted to the facility on [DATE]. The admission Record indicated Resident #15 had multiple diagnoses that included hemiplegia affecting left non-dominate side, and general muscle weakness. The medical record revealed that Resident #15 had a plan of care with a focus related to the resident being at risk for break in skin integrity. The interventions included, heel protectors to BLE (bilateral lower extremities) while in bed, initiated on 1/20/21. A review of the medical record revealed a physician order dated 1/20/21 at 13:59 (1:59 p.m.) for heel protectors to BLE while in bed every shift. On 3/09/21 at 10:36 a.m. during an attempted interview with Resident #15, as the resident was lying in bed, an observation was made of heel protectors placed on a box on top of a chair in the corner of Resident #15's room. (Photographic Evidence Obtained) The resident was asked if he ever wore the boots while in bed, he nodded his head to indicate, no. On 3/10/21 at 12:08 p.m. a second observation was made of the resident in bed with no heel protectors applied while in bed. He was asked if he knew where his boots were, and he pointed to the closet. With the resident's permission, the closet was opened and the heel protectors were observed tucked away in between his clothing. (Photographic Evidence Obtained) On 03/11/21 at 10:36 a.m. during a visit to Resident #15's room, Staff C, Licensed Practical Nurse (LPN) was in the room with the resident and was asked if Resident #15 had on his heel protectors. Staff C pulled the sheet to uncover his feet and demonstrated that he did. She was asked if this was part of his care plan and she confirmed it was, and that he should be wearing them while in bed. 03/11/21 11:08 a.m. during an interview with the Director of Nursing, she confirmed that the heel protectors should be placed on Resident #15 while in bed and according to his care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident #115's medical record revealed that Resident #115 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, altered mental status, and major depressive disorder. A review of Resident #115's care plan revealed a problem, revised on 03/11/2021, that Resident #115 used antidepressant medications related to depression. Interventions included to administer antidepressant medications as ordered, observe for side effects and effectiveness every shift, and observe/report as needed any adverse reactions to antidepressant therapy. Resident #115's care plan also revealed a problem, revised on 03/11/2021, that Resident #115 used psychotropic medications related to disease process. Interventions included to administer psychotropic medications as ordered, observe for side effects and effectiveness every shift, and observe/report as needed any adverse reactions to psychotropic medications. A review of Resident #115's Minimum Data Set (MDS) Assessment revealed, under Section C - Cognitive Patterns, a BIMS score of 01, which indicated severe cognitive impact. The MDS assessment also revealed, under Section N - Medications, that Resident #115 received antipsychotic medications and antidepressant medications 7 days out of the 7 day assessment period. A review of Resident #115's physician orders for March 2021 revealed the following orders: - Divalproex Sodium 250 milligrams (mg) by mouth two times daily for psychosis with behavior, dated 02/16/2021. - Risperidone 0.5 mg by mouth three times daily for Alzheimer's with behavioral disturbances, dated 03/03/2021. - Sertraline Hydrochloride 100 mg by mouth one time daily for depression, dated 03/03/2021. A review of Resident #115's physician orders did not reveal an order for side effect monitoring related to psychotropic medication use. An interview was conducted on 03/11/2021 at 4:28 p.m. with Staff A, Registered Nurse (RN). Staff A, RN stated that side effect monitoring for psychotropic medications were documented in the electronic charting system and all residents that take psychotropic medications should have side effect monitoring documented every shift. Staff A, RN was not able to locate side effect monitoring in the electronic charting system for Resident #115. Staff A, RN stated that behavioral monitoring for psychotropic medications was completed on a paper form, but addressed that the paper form did not include monitoring for side effects. An interview was conducted on 03/11/2021 at 4:37 p.m. with the facility's Assistant Director of Nursing (ADON). The ADON stated that side effect monitoring should be documented in the electronic charting system every shift for residents that were taking psychotropic medications. The ADON was not able to find any documentation of side effect monitoring for Resident #115. An interview was conducted on 03/12/2021 at 11:56 a.m. with the facility's Director of Nursing (DON). The DON stated that side effect monitoring for residents that used psychotropic medications was documented every shift in the electronic documentation system. The DON also stated that if a resident was receiving a psychotropic medication, an order for side effect monitoring should be in the electronic charting system. Based on observations, record reviews, and interviews, the facility did not monitor specific behaviors for one resident (#84) and did not monitor the side effects of psychotropic medications for one resident (#115) out of five residents sampled for unnecessary medications. Findings included: 1. The pharmacy policy titled, Psychotropic Medication Use, that the facility provided, revised 11/28/16, indicated the policy sets forth procedures relating to psychotropic medication use. The procedure portion of the policy indicated: 1. Facility should comply with the Psychopharmacological Dosage Guidelines created by the Centers for Medicare and Medicaid Services (CMS), the State Operations Manual, and all other Applicable Law relating to the use of psychopharmacological medications including gradual dose reductions. The procedure identified the following: - 4. Psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms.; - 7. All medications used to treat behaviors must have a clinical indication and be used in the lowest possible dose to achieve the desired therapeutic effect. All medications used to treat behaviors should be monitored for: efficacy, risks, benefits, and harm or adverse consequences. - 12. Facility staff should monitor the resident's behavior pursuant to Facility policy using a behavioral monitoring chart or a behavioral assessment record for residents receiving psychotropic medication for organic mental syndrome with agitated or psychotic behavior(s). Facility staff should monitor behavioral triggers, episodes, and symptoms. Facility staff should document the number and/or intensity of symptoms, and the resident's response to staff interventions. A review of the admission Record revealed that Resident #84 was admitted on [DATE]. The admission Record included diagnoses of unspecified anxiety disorder, unspecified dementia without behavioral disturbance, and unspecified single episode major depressive disorder. The resident's Minimum Data Set (MDS) identified that she scored a 7 out of 15 on a Brief Interview of Mental Status (BIMS) assessment indicative of severe cognitive impairment. A review of Resident #84's physician orders for March 2021 indicated that the resident was being administered the following psychotropic medications: - Cymbalta (Duloxetine HCl) Capsule Delayed Release Particles - Give 40 milligrams (mg) by mouth two times a day for depression. The order started on 9/29/20. - Seroquel (Quetiapine Fumarate) tablet - Give 12.5 mg by mouth one time a day for mood disorders. The order started on 9/29/20. The Order Summary Report for March 2021 instructed the staff to monitor the side effects of the anti-depressant medication, Duloxetine, and the anti-psychotic medication, Seroquel. The report indicated staff were to monitor every shift for depression and to document if side effects were present and write a progress note if side effects were not present, to start on 9/26/18. The report identified that staff were to monitor every shift, related to the administration of Seroquel for dementia with behaviors and to document if side effects were present and write a progress note if side effects were not present, to start on 12/18/20. A review of the electronic Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for March 2021 did not include monitoring of the number of behavioral episodes, effectiveness of the intervention, or whether non-pharmaceutical interventions were attempted. During an interview at 10:59 a.m. on 3/11/21 the Director of Nursing (DON) stated that staff do document episodes of behaviors and monitor behaviors, however the monitoring is not in the computer, like the side effects. Staff B, Licensed Practical Nurse (LPN) stated on 3/11/21 at 11:43 a.m., that behaviors are documented in the electronic record under a behavior note and the documentation was done by exception. She reported that staff do inform psychological providers of any behaviors or if new behaviors are exhibited. On 3/11/21 at 2:10 p.m., when asked about the paper Behavior Monitoring Forms (BMF), Staff B stated, Oh I didn't know. When asked where the February (2021) BMFs were, Staff B stated she thought the DON had them. Staff B reported that Resident #84 cries one minute and was happy the next. A review of the Behavior Monitoring Form for Resident #84 indicated that staff were to monitor every shift for the behavior code 12 for the anti-depressant medication, Cymbal. The included behavior code legend indicated code 12 was for depressed withdrawn. The BMF indicated staff were to monitor the behavior code 22 for the antipsychotic, Seroquel. The legend identified that the code 22 was for mood changes. The BMF indicated that staff were to document the number of episodes, interventions, and outcome. The legend included non-pharmacological interventions numbered 1-12 for specific interventions and 13-15 for other, which interventions could be personalized. The outcome codes indicated staff were to document: I=improved, S=same, and W=worse. The Psychological Medication Management Follow-up, dated 3/3/21, indicated the chief complaint was confusion and Resident #84 had diagnoses of moderate recurrent major depressive disorder, Alzheimer's disease with late onset, and mood disorder due to known physiological condition with mixed features. The history of present illness indicated the symptom was changes in mood and got upset when talking about family as she does not remember daughter visiting or bringing her things. The past medical/psychiatric detail indicated the resident had a history (hx) of aggressive behavior towards a peer and hx of delusions that no one likes her. The psychological assessment identified the resident doing well with current meds. No recent aggression reported. Staff report no overt hallucinations (used to talk to someone when alone in the room). The target symptoms for medication was noted as behavioral disturbances and changes in mood. The care plan for Resident #84 identified the following: - A focus initiated 9/30/20 indicated Resident #84 had the potential to be verbally aggressive(cursing, hitting) related to (r/t) poor impulse control. A goal of the focus, initiated on 9/30/20, was that the resident would verbalize understanding of need to control verbally abusive behavior through the review date. The interventions associated with the focus included staff were to assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, and pain etc. - A focus initiated 2/1/19 indicated the resident had a behavior problem (keeping abundant amount of personal belongings in her room and unbagged for easy access per resident wishes). The goal identified that the resident would not experience behaviors that are harmful to self and others through next review date. The goal was initiated on 2/1/19, revised on 3/5/21, with a target date of 5/4/21. The interventions initiated on 2/1/19, were to observe for behavior episodes and attempt to determine underlying cause. - A focus indicated the resident had an alteration in behavior/mood as evident by hoarding. - A focus indicated the resident had a potential to be verbally aggressive (cursing, hitting) r/t poor impulse control and instructed staff to document observed behavior and attempted interventions. On 3/12/21 at 9:56 a.m., Staff B, LPN stated, when asked if Resident #84 became physically aggressive, She has. The staff member stated the resident does hoard crackers in her room and has a drawer of little things that she puts in little cups, and when family brings in candy the resident separated the pieces into little cups. On 3/11/21 the DON was asked for the February 2021 BMF for Resident #84's psychotropic medications. When asked, on 3/12/21 at 11:16 a.m., for a copy of the resident's February BMF, the DON stated that on 2/25/21 she discovered that the BMFs were not in the computer so she printed them (BMF) out and gave them to staff to start documenting behaviors. A review of Resident #84's BMF did not include the resident's reported behaviors of aggression and/or hoarding. During an interview on 3/12/21 at 12:06 p.m., the DON stated the facility printed a paper (BMF) and staff documented behaviors on a flowsheet and side effects in the computer. She stated she would expect the BMF to have a little more specific behaviors and staff to monitor for aggression.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-eight medication administration opportunities were observed, and four errors were identified for three residents (#3, #44, and #37) of five residents observed. These errors constituted a 14.29% medication error rate. Findings included: 1. On 3/10/21 at 4:08 p.m., an observation of medication administration with Staff A, Registered Nurse (RN) was conducted with Resident #3. Staff A was observed administering the following medications: - Novolog 100 unit/milliliter (u/mL) Flex Pen - 8 units subcutaneously per a blood glucose level of 347. - Hydralazine 50 milligram (mg) orally - Fish Oil 500 mg - 2 capsules - Levemir Insulin pen - 28 units subcutaneously The observation revealed that Staff A, RN dialed the Novolog Flex Pen to 2 units and informed Staff E, Licensed Practical Nurse (LPN), who was orientating, that to prime the pen, dial it to 2 units and wait a minute then turn the dial to the number of units. As Staff A was instructing Staff E, she dialed the insulin to 2 units held in the pen parallel to the floor during her instruction, then dialed the pen to 8 units. When asked how she primed the pen, she stated she had been taught to turn the dial to 2, wait a minute then turn it to the amount to be given. The LPN entered Resident #3's room then injected 8 units of Novolog insulin via Flex Pen into the upper right arm of the resident. She returned to the medication cart and removed a Levemir insulin pen from the medication cart. She placed a needle on the Levemir insulin pen, then dialed the pen to 28 indicative of 28 units. Staff A re-entered the resident's room, observed the resident take the oral medications, and then she injected 28 units of Levemir in the upper posterior right arm. At 4:32 p.m., Staff A stated she had primed the Levemir pen, however the observation did not reveal her dialing to 2 units and waiting a minute per her description of priming the insulin pen. When asked how turning the knob of the pen to 2 units primed the pen, she stated by doing that it was supposed to expel the air from the pen. The manufacturer's Quick Guide for each of the NovoLog Flex Pen and the Levemir FlexTouch pen instructed users as follows: - Prime your pen - Turn the dose selector to select 2 units. Press and hold the dose button. Make sure a drop appears. - Select your dose - Turn the dose selector to select the number of units you need to inject. The pharmaceutical literature included instructions on how to prepare the Novolog Flex Pen: - Giving the air shot before each injection. Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: - E. Turn the dose selector to select 2 units. - F. Hold your NovoLog Flex Pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. - G. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. If you do not see a drop of insulin after 6 times, do not use the NovoLog Flex Pen and contact Novo Nordisk. This information was obtained at https://www.novomedlink.com/content/dam/novonordisk/novomedlink/resources/generaldocuments/NovoLog%20FlexPen%20IFU%20PDF_LOCKED.pdf. The pharmaceutical literature included the following instructions on how to prepare the Levemir FlexTouch insulin pen: - Priming your Levemir FlexTouch Pen: - Step 7: Turn the dose selector to select 2 units. - Step 8: Hold the Pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top. - Step 9: Hold the Pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin, repeat steps 7 to 9, no more than 6 times. If you still do not see a drop insulin, change the needle, and repeat steps 7 to 9. https://www.novomedlink.com/content/dam/novonordisk/novomedlink/resources/generaldocuments/LevemirIFU.pdf According to the American Diabetes Association, Trends in Insulin Pen Priming, 2018 July, indicated that Priming insulin pens is recommended to remove air from needles to ensure full dose administration. The information was accessed at https://diabetes.diabetesjournals.org/content/67/Supplement_1/83-LB. During an interview at 4:50 p.m. on 3/10/21, the Director of Nursing (DON) was asked how to prime an insulin pen. She described the procedure in priming an insulin pen as dialing it to 2 units, push the insulin out (using dose button) to see a drop (of insulin) and then users were to dial the dose selector to the number of units to be administered. When the observation of Staff A priming of the insulin pens was shared, the DON confirmed the insulin pen had not been primed correctly. The DON was asked for a policy and procedure for administering insulin via a pen. 2. On 3/10/21 at 4:38 p.m., an observation of medication administration with Staff F, Licensed Practical Nurse (LPN) was conducted with Resident #44. Staff F was observed administering the following medications: - Calcium Carbonate 500 mg chewable tablet - Ferrous Sulfate 325 mg tablet - Senna S 50-8.6 mg tablet - Vitamin D3 1000 international unit (iu) capsule A review of Resident #44's physician orders indicated the following medications and dosages were to be administered: - Senna 8.6 mg tablet - Give 1 tablet by mouth at bedtime for constipation. Hold for loose stools. - Vitamin D tablet - Give 2000 iu by mouth one time a day for Vitamin D deficiency. 3. On 3/11/21 at 9:00 a.m., an observation of medication administration was conducted with Staff C, LPN, with Resident #37. Staff C was observed administering the following medications: - 2 Divalproex Delayed Release (DR) 125 mg sprinkles - Nifedipine Extended Release (ER) 90 mg tablet - Furosemide 40 mg tablet - Sertraline HCl 100 mg tablet - Lovastatin 20 mg daily - Creon DR capsule 12000 units, take with food/snack. - Calcium + D 600/200 mg tablet - Simethicone tab 125 mg - Acidophilus 1 billion capsule A review of Resident #37's physician orders indicated the following medication was to be administered with the noted instructions: - Creon Capsule DR 12000 unit, one capsule by mouth three times a day for [NAME] Syndrome. Take with food or snacks. An observation of Resident #37 at 9:14 a.m. was completed after the staff member administered the medication. Resident #37 was observed lying in bed, the over-the-bed table in front of the resident did not hold a meal tray or any snacks. When asked how breakfast was, he stated Great. An observation of the hallway outside of the resident room did not indicate a meal cart. On 3/12/21 at 12:29 p.m., the DON stated she had started education on the priming on the insulin pens and she stated she would have to review the Vitamin orders. When asked how long before or after a meal should Creon be administered, she stated she would have to look it up. The physician order was read to her and she stated she wondered who put the order into the computer. The DON reported that Resident #37 snacked all day long and had a drawer of snacks. The Consultant Pharmacist stated, on 3/11/21 at 1:47 p.m., that Creon should be given as close to a meal as possible. On 3/12/21 at 11:55 a.m. the Certified Dietary Manager (CDM) reviewed the times of the kitchen tray line. He stated the listed times are the times that the meal cart leaves the kitchen and should only take five (5) minutes to get to the hall. The review of the 200-hall tray line times indicated both of the halls meal carts would have arrived to the hallway between 6:30 and 6:40 a.m., two (2) hours 20-30 minutes prior to the resident receiving the medication Creon. The policy titled, Administration of Medications, revised 5/6/20, indicated all medications are administered safely and appropriately per physician order to address residents; diagnoses and signs and symptoms. A physician order that includes dosage, route, frequency, duration, and other required considerations including the purpose, diagnosis, or indication of use is required for administration of medication. The policy indicated Insulin - all formulations and strengths as a high-alert medication. Per the policy the facility identified the definition of a medication error was the observed or identified preparation or administration of medications or biologicals which is not in accordance with: 1. The prescriber's order. 2. Manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or 3. Accepted professional standards and principles which apply to professionals providing services. Accepted professional standards and principles include the various practice regulations in each state, and current commonly accepted health standards established by national organizations, boards, and councils.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to maintain drugs and biologicals used in the facility in accordance with currently accepted professional principles by not ensuring: 1. one treatment cart (Oasis Suites) was locked while unattended, 2. one comfort kit was discarded timely for a deceased resident in one medication room (Oasis Suites), 3. eye drops with an expiration date was dated when opened on one medication cart (Golden Hall), 4. insulin pens were dated when opened and refrigerated when unopened, and ProSource Plus undated in two medication carts (Oasis Suites Hall and Cypress Hall), and a Victoza pen was stored in the original pharmacy packaging in one medication cart (Oasis Hall) of a total of five treatment carts, seven medication carts and five medication rooms. Findings included: 1. On [DATE] at 11:55 a.m., a treatment cart was observed unlocked and unattended next to the nursing station on the 400-hall, Oasis Suites. Staff B, Licensed Practical Nurse (LPN) was on the resident hallway and Staff E, LPN, was standing at the medication cart parked on the opposite side and across from the nursing station. The first and second drawer of the cart contained prescribed topically ointments, the third drawer contained multiple boxed tubes of Zinc Oxide, and other drawers contained wound care supplies. At 11:57 a.m. on [DATE], Staff B, LPN arrived at the treatment cart and confirmed that the treatment cart was unlocked, unattended, and that residents could access inside the cart. (Photographic Evidence Obtained) 2. On [DATE] at 12:03 p.m. a review of the Oasis Suites medication room was conducted with Staff B. In an unsealed cardboard box, on the bottom shelf of the refrigerator, the following medications were observed inside: - 15 milliliters (mL) of Morphine Sulfate Oral Solution 100 milligram/5 milliliter (mg/mL); - A bottle containing 10 tablets of 0.5 mg Lorazepam (Ativan); - 2 Biscolax suppositories; - 4 650 mg Acetaminophen suppositories. A sticker on the box indicated [DATE] checked [initials]. The Ativan bottle was prescribed to Resident #137. Staff B stated she did not know the box was in the refrigerator. This box was identified as a hospice comfort kit. The admission Record for Resident #137 indicated the resident was initially re-admitted to the facility on [DATE]. A progress note, dated [DATE], identified Resident #137 passed away at 7:00 p.m. on [DATE] and Hospice was notified at that time. 3. On [DATE] at 12:37 p.m., a review was conducted with Staff C, LPN of the Golden Hall medication cart. An opened bottle of Latanprost eye drops, prescribed to Resident #87, was discovered without an open date. The pharmacy sticker instructed staff to keep the bottle refrigerated until opened and discard 42 days after opening. The staff member confirmed the bottle of Latanprost was opened. 4. A review of the Cypress Hall medication cart, on [DATE] at 12:44 p.m., was conducted with Staff G, LPN. An opened 30 mL bottle of ProSource Plus, a collagen and whey protein formula, was observed without an open date. The label on the bottle instructed users to discard three months after opening. Also observed in the Cypress Hall cart was an opened Novolog FlexPen without a documented open date. The FlexPen was prescribed to Resident #93 and dispensed by the pharmacy on [DATE]. An observation was conducted with Staff D, LPN at 1:09 p.m. on [DATE], of the Oasis Key Medication Cart #2. The observation indicated four insulin pens and one non-insulin pen were opened and noted with an open date: - Resident #135's Levemir FlexTouch pen was undated, opened, and dispensed by the pharmacy on [DATE]; - Resident #135's Novolog FlexPen was opened, undated, and dispensed on [DATE]; - Resident #136's Novolog FlexPen was opened, undated, and dispensed by the pharmacy on [DATE]; - Resident #136's Lantus Solostar pen was opened, undated and dispensed on [DATE]. A sticker attached to the pen instructed the user to discard after 28 days; - Resident #1's Victoza non-insulin pen was observed opened and undated. The bag where the Victoza pen was stored was a pharmacy-labeled for the resident's Lantus Solostar pen. According to the website: https://www.novonordiskmedical.com/our-products/storage-and-stability.html, a Victoza pen should be discarded 30 days after its first use, a Novolog Flexpen was to be discarded 28 days after its first use or before its first use if left at room temperature, and a Levemir FlexTouch pen should be discarded 42 days after its first use. During an interview at 1:47 p.m. on [DATE], the Consultant Pharmacist stated the unopened an undated insulin should be handled as if they were opened and dated with the date the pharmacy dispensed it. She stated that she would not store the Victoza pen in a Novolog bag; that it should be stored in a bag by itself and the Victoza comes in a box. The Consultant Pharmacist stated she did not have anything to do with the Hospice Comfort kit, found in the Oasis Suites refrigerator. The Director of Nursing stated, on [DATE] at 12:47 p.m., the expectation for opening an insulin pen is that it should be left in the refrigerator until labeled. She stated the Hospice Comfort Kit should have been given to her to destroy. The policy titled, 5.3 Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles, last revised on [DATE], indicated that the facility should ensure that all medications and biological's, including treatment items, are securely stored in a locked cabinet/cart of locked medication room that is inaccessible by residents and visitors. The facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. The facility should ensure that the medications and biologicals for each resident are stored in the containers in which they were originally received. The policy identified that the facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with Pharmacy return/destruction guidelines and other applicable law.

Based on observation, interview and record review the facility failed to store food in accordance with professional standards for food service safety by not ensuring pre-prepped desserts, a peanut butter and jelly sandwich, and a fruit plate with cut melon and grapes were dated, and not ensuring two personal water bottles were not stored in a cooler in the prep area of the kitchen, and that two measuring scoops were not stored in dry good containers. Findings included: On 3/9/21 at 9:27 a.m., a tour of the cooking, cleaning, and storage areas of the kitchen was conducted with the Certified Dietary Manager (CDM). An observation of the reach-in refrigerator located across from the steamer table revealed two cups of an orange whipped dessert on a tray were uncovered and undated. The CDM confirmed the orange whipped desserts and tray were not dated and should be. On the top shelf of the reach-in refrigerator was a peanut butter and jelly sandwich and a fruit plate with cut melon and grapes that were undated. During the tour an observation of the juice/coffee area identified a measuring scoop stored in a container of sugar. The CDM removed it and placed it on top of the container. In an under counter cooler in the prep area of the kitchen, were two opened bottles of water. When asked if the bottles of water should be in the cooler, the CDM stated, Absolutely not. During the continued tour on 3/9/21 an observation of the dry storage area revealed a baking sheet with individual portioned cereals in disposable bowls. The CDM stated that every morning the facility puts out about eight portions. The tray contained 10-15 servings of cereal and was dated 3/2/21. On a shelf, next to the door, was a 22 quart plastic container of flour with a measuring scoop inside it. The CDM confirmed the scoop should not be in the container. The facility policy titled, Food Brought into the Facility from Outside Sources, effective 10/4/2019, which indicated that food is stored, prepared, and distributed in accordance with professional standards for food safety. The facility policy titled, Food Safety, revised 11/28/17, revealed: Food is stored and maintained in a clean safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth. The Dry Storage section indicated, Scoops will be stored in a manner that does not have the potential to contaminate the food ingredients. For example, scoops will be stored outside of bins or placed in a holder on the side of the bin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility's Quality Assurance Committee failed to implement an effective plan of action related to behavior monitoring associated with the use of psychotropic medications for three residents (#6, #5, and #4 ) of three residents sampled. Findings included: A review of the facility's plan of correction for the recertification survey ending on 3/12/21 revealed the following measures would be taken to correct the deficient practice which was identified at F758: the Director of Nursing (DON)/designee was to audit residents receiving psychotropic medications to ensure Behavior Monitoring Flowsheets (BMFs) were initiated, nursing staff were educated in the implementation of BMFs if necessary, and weekly audits by Unit Managers to ensure that BMFs were initiated for those residents receiving psychotropics. The policy titled, Quality Assessment and Assurance Committee Meetings, issued 12/20/19 and reviewed 12/28/20, indicated the purpose was to provide guidance for conducting the Quality Assessment and Assurance Committee (QAA) meetings and may include documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities. 1. The admission Record for Resident #6 revealed the resident was admitted on [DATE] and 10/6/18. The admission Record included diagnoses not limited to unspecified single episode major depressive disorder. On 5/11/21 at 11:33 a.m., Resident #6 was observed lying in bed while Staff D, Unit Manager (UM), obtained a blood glucose level and administered the resident's insulin. The May 2021 Order Summary Report for active physician orders as of 5/11/21 for Resident #6 indicated that the resident received the following medication: - Escitalopram Oxalate 10 mg - Give 1 tablet by mouth one time a day for depression. The report did not include a physician order to monitor for side effects or behaviors related to the resident's depression. The May 2021 MAR and Treatment Administration Record (TAR) indicated Resident #6 had received the antidepressant medication as ordered. The BMF for Resident #6 indicated that the behaviors and interventions were to be monitored for the antidepressant medication - Escitalopram. A review of Resident #6's BMF did not indicate a behavior that staff were to be monitoring for related to the administration of an antidepressant medication or that staff had documented any episodes of behaviors, interventions or outcomes for any shift. Resident #6's care plan included the following focuses and interventions: - At risk for alteration in mood due to (d/t) dx of depression as evident by mood changes. The interventions instructed staff to administer psychotropic med as ordered and monitor effectiveness of psychotropic med, initiated on 10/28/18 and revised on 3/4/20. 2. The admission Record for Resident #5 revealed the resident was admitted on [DATE]. The admission Record included diagnoses not limited to unspecified dementia with behavioral disturbance, unspecified schizophrenia, other specified depressive episodes, brief psychotic disorder, and unspecified anxiety disorder. On 5/11/21 at 10:58 a.m., an observation was conducted of Resident #5 during the administration of medication by Staff B, LPN. The resident was sitting in a wheelchair and asked the same passerby's how are you and stated to the nurse numerous times that she wanted water. A review of the May 2021 Order Summary Report for active physician orders as of 5/11/21 indicated that Resident #5 had orders for the following medications and side effect monitoring: - Seroquel tablet 25 mg - Give one (1) tablet by mouth two times a day for psychosis *Hold for Sedation,* order date 07/01/20. - Sertraline Hydrochloride (HCl) tablet 50 mg - Give one (1) tablet by mouth at bedtime for depression, ordered 1/23/20. - Xanax tablet 0.5 mg (Alprazolam) - Give one (1) tablet by mouth at bedtime for insomnia, ordered 10/17/19. - Antipsychotic Medication: Seroquel tablet 25 mg. Side Effects: Common - Sedation, drowsiness, dry mouth, constipation, blurred vision, Extrapyramidal reaction, weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention. Nursing Alert: Tardive dyskinesia, seizure disorder, chronic constipation, glaucoma, diabetes, skin pigmentation, and jaundice. Monitor every shift. Document: (+) if side effects present and write progress note (-) side effects not present. - Anti-Depressant Medication: Sertraline HCl 50 mg Side Effects: Common - Sedation, Drowsiness, Dry Mouth, Blurred Vision, Urinary Retention, Tachycardia, Muscle Tremor, Agitation, Headache, Skin Rash, Photosensitivity (skin), Excess Weight Gain. Special Attention for: Heart Disease, glaucoma, chronic constipation, seizure disorder, and edema. Monitor every shift. Document: (+) if side effects present and write progress note (-) side effects not present. - Anti-Anxiety Medication: Xanax side effects: Sedation, Drowsiness, Ataxia (drunk walk), Dizziness, Nausea, Vomiting, Confusion, Headache, Blurred Vision, and Skin Risk. Nursing Alert: If given with other sedatives or hypnotics and alcohol. Monitor every shift. Document: (+) if side effects present and write progress note (-) side effects not present. The May 2021 MAR identified that Resident #5 was administered the above medications as ordered and that the staff had monitored the side effects of the anti-anxiety, anti-depressant, and antipsychotic medications. The Behavior Monitoring Flowsheet, May 2021, identified that staff were to document if any behaviors had been exhibited for the anti-anxiety, anti-depressant, and antipsychotic medications. The BMF did not specify what behaviors were to be monitored nor did the flowsheet identify the diagnoses related to the administration of the psychotropic medications. The BMF did reveal that staff had not monitored for behaviors related to the antipsychotic medication during the night shift on 5/2 - 5/7 and 5/9-5/10/21, antidepressant medications on 5/2-5/7 and 5/9-5/10/21, and antianxiety on 5/10/21. The BMF identified that staff had not monitored for behaviors related to the antipsychotic and antidepressant medications during the day shift on 5/7 ad 5/8/21 or the evening shift on 5/8/21. Resident #5's care plan indicated the following focuses and interventions: - At risk for change in mood or behavior due to medication condition. The interventions indicated that psychiatric were to be consulted as indicated, - Uses antidepressant medication relate to (r/t) depression. The interventions indicated that staff were to observe for side effects and effectiveness q (every) shift and to observe for and report as needed (prn) adverse reactions to antidepressant therapy. - Uses anti-anxiety medications r/t diagnosis (dx) anxiety. The interventions instructed staff to administer anti-anxiety medications, observe for side effects and effectiveness q shift, and observe for and report prn any adverse reactions to anti-anxiety therapy. - Uses psychotropic medications r/t dx of dementia with behaviors and dx of psychotic disorder with delusions. The interventions instructed staff to administer psychotropic medications and to observe side effects and effectiveness q shift and to observe for and report prn any adverse reactions of psychotropic medications. The care plan did not instruct staff to monitor for Resident #5's behaviors related to the administration of medications. 3. The admission Record for Resident #4 revealed the resident was admitted on [DATE] and 9/29/20. The admission Record for the resident included diagnoses not limited to dementia in other diseases classified elsewhere with behavioral disturbance, unspecified schizoaffective disorder, unspecified psychosis not due to a substance or known physiological condition, unspecified recurrent major depressive disorder, unspecified anxiety disorder, and unspecified insomnia. On 5/11/21 at 10:00 a.m., an observation was conducted of Resident #4's medication administration with Staff C, Licensed Practical Nurse (LPN), while the resident was lying in the bed. A review of Resident #4's Order Summary Report for active physician orders as of 5/11/21 indicated the resident was ordered the following psychotropic medications and corresponding side effect monitoring: -- Clonazepam 0.5 milligram (mg) - Give one (1) tablet by mouth every eight (8) hours for anxiety, ordered 9/29/20. -- Anti-Anxiety Medication: Clonazepam tablet 0.5 mg Side Effects: Sedation, Drowsiness, Ataxia (drunk walk), Dizziness, Nausea, Vomiting, Confusion, Headache, Blurred Vision, and Skin Risk. Nursing Alert: If given with other sedatives or hypnotics and alcohol. Monitor every shift. Document: (+) if side effects present and write progress note (-) side effects not present, ordered 9/29/20. --Seroquel 50 mg - Give one (1) tablet by mouth three (3) times a day for schizoaffective disorder, ordered 9/29/20. -- Antipsychotic Medication: Seroquel tablet 50 mg. Side Effects: Common - Sedation, drowsiness, dry mouth, constipation, blurred vision, Extrapyramidal reaction, weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention. Nursing Alert: Tardive dyskinesia, seizure disorder, chronic constipation, glaucoma, diabetes, skin pigmentation, and jaundice. Monitor every shift. Document: (+) if side effects present and write progress note (-) side effects not present ordered 12/7/2020. The May 2021 Medication Administration Record (MAR) identified that Resident #4 had been administered the above medications as ordered and staff had documented the lack of side effects that the resident had exhibited. The May 2021 Behavior Monthly Flowsheet (BMF) and the behavior/intervention/outcome codes indicated the following: - Anti-psychotic (AP), Seroquel tablet 50 mg for schizoaffective disorder as exhibited by 9, which the behavior legend identified as continuous screaming/yelling. - Anti-anxiety (AA), Clonazepam tablet 0.5 mg for anxiety as exhibited by 4, which the behavior legend identified as anxiety. The BMF did not include documentation that staff had monitored behaviors or interventions related to Resident #4's use of antipsychotic or antianxiety medications. Resident #4's care plan indicated the following focuses and interventions: - At risk for adverse side effects of psychotropic medications, schizoaffective disorder, and requires antipsychotic meds, initiated on 9/3/19 and revised on 4/16/21. The interventions instructed staff to administer psychotropic medications as ordered by physician, observe for side effects and effectiveness every (q) shift, observed for and report as needed (prn) any adverse reactions of psychotropic medications, and observe for occurrence of target behavior symptoms and document per facility protocol. - Has anxiety disorder, initiated on 7/17/20 and revised on 7/29/20. The interventions included administer anti-anxiety medications as ordered by physician and to observe for side effects and effectiveness q shift. Review of the policy titled, 3.8 Psychotropic Medication Use, effective 12/01/07 and last revised on 11/28/16, identified the following procedures: - 7. All medications used to treat behaviors must have a clinical indication and be used in the lowest possible dose to achieve the desired therapeutic effect. All medications used to treat behaviors should be monitored for: -- 7.1 Efficacy, -- 7.2 Risks, -- 7.3 Benefits, and -- 7.4 Harm or adverse consequences. - 12. Facility staff should monitor the resident's behavior pursuant to Facility policy using a behavioral monitoring chart or behavioral assessment record for residents receiving psychotropic medication for organic mental syndrome with agitated or psychotic behavior(s). Facility staff should monitor behavioral triggers, episodes, and symptoms. Facility staff should document the number and/or intensity of symptoms and the resident's response to staff interventions. At approximately 3:30 p.m., Staff D, UM identified that the BMF did not include any documentation related to the use of Resident #6's antidepressant. During an interview with the Interim Director of Nursing (DON) , she reviewed Resident #4's BMF and confirmed that staff had not documented behaviors related to the resident's anti-anxiety and antipsychotic medications. The DON reviewed Resident #5's BMF and confirmed there were no behaviors listed on the BMF related to the resident's anti-anxiety, antipsychotic, and anti-depressant medications. The DON reviewed Resident #6's BMF and confirmed that staff had not completed the documentation. During an interview, on 5/11/21 at 2:00 p.m., the Consultant Pharmacist stated the facility should be monitoring behaviors. The Consultant stated that each condition should have a behavior, for example: if treating depression with an antidepressant they should have a behavior to monitor. During an interview with the NHA and Interim DON, at approximately 7:00 p.m., they acknowledged that the deficiency was uncorrected.