**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record reviews, and review of the facility's policy titled Helping Avoid Nosocomial Developed Skin Breakdown, the facility failed to provide activities of daily living (ADL) care to one of 25 sampled residents (R) (R13). Specifically, the facility failed to ensure that thorough incontinence care was provided to R13. This deficient practice had the potential to place R13 at risk of developing infections, foul odor, and skin breakdown. Findings include: Review of the facility's policy titled Helping Avoid Nosocomial Developed Skin Breakdown, reviewed 4/2024, included Incontinence cleansing and skin barriers may be used for incontinence patients. Review of R13's electronic medical records (EMR) revealed diagnoses including, but not limited to, debility, cardiorespiratory condition, and fracture. Review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed Section GG (Functional Abilities and Goals) documented R13 was dependent on staff for toileting, bathing, upper and lower body dressing, personal hygiene, and mobility. Section H (Bowel and Bladder) documented the resident was always incontinent of bowel and bladder. Section M (Skin Conditions) documented that R13 had a risk of pressure ulcers and had one stage 4 pressure ulcer. Observation on 3/12/2025 at 4:50 pm revealed Certified Nursing Assistant (CNA) AA performed incontinence care on R13 but did not lift the scrotum to clean around it or clean the surrounding areas. In an interview on 3/12/2025 at 5:10 pm, CNA AA confirmed she did not lift R13's scrotum to clean around it or clean the surrounding areas during incontinent care. She stated she should have cleaned the scrotum, but she did not. She stated when she did not clean the scrotal area properly, it could cause moisture in the area. In an interview on 3/13/2025 at 10:27 am, Licensed Practical Nurse (LPN) DD stated during incontinence care of the male resident, the resident's scrotum was to be lifted and the surrounding surface cleaned properly. LPN DD stated there might be residual urine or moisture in the perineal area, and if it was not cleaned and dried properly, the resident's skin condition could be affected. In an interview on 3/13/2025 at 10:50 am, the Director of Nursing (DON) stated during incontinence care, the scrotum was to be lifted and cleaned around the area. She further stated that if this was not done, it could cause moisture buildup and skin breakdown in the residents.

Based on observations, record reviews, staff interviews, and a review of the facility's policies titled Hand Hygiene, and Standard Precaution/Use of PPE [Personal Protective Equipment], the facility failed to ensure infection control processes were followed during resident care for one of 25 sampled residents (R) (R13). The deficient practice had the potential to increase the potential for cross-contamination and spread of infection. Findings include: Review of the facility's policy titled Hand Hygiene, reviewed 12/27/2024, revealed the Purpose section stated, Hand Hygiene is the single most important means of preventing the spread of infection. The use of gloves does not replace hand washing. The Guidelines section included, .Glove use: Change gloves and perform hand hygiene during patient care, if: Moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs. Review of the facility's policy titled Standard Precautions/Use of PPE, reviewed 12/27/2024, revealed the Intent section stated, It is the policy of this facility that: 1) all patient blood and body fluids will be considered potentially infectious. 2) standard precautions are indicated for all patients. The Guidelines section included, . Change gloves during patient care if the hands will move from a contaminated body site (e.g.[such as] perineal area) to a clean body site (e.g., face). Observation on 3/12/2025 at 4:50 pm revealed Certified Nursing Assistant (CNA) AA did not change her gloves while providing incontinence and activities of daily living (ADL) care to R13. Observation revealed CNA AA used one pair of gloves while providing incontinence and ADL care to R13. Further observation revealed that CNA AA removed her gloves before removing the gown she wore during the incontinence and ADL care. Observations revealed that she removed the gloves, then removed the gown with her bare hands by grasping the front of the gown, pulling it forward to remove it, and gathering it with both bare hands before placing it in the garbage bin. In an interview on 3/12/2025 at 5:10 pm, CNA AA confirmed she did not change her gloves while providing incontinence and ADL care to R13. She stated she should have changed her gloves because the resident could get an infection when the same gloves were used from dirty areas to clean areas. She further stated she should not have used the same gloves to put on the resident's clothes and touch the bed remote that she wore during incontinence care. CNA AA further stated that bacteria could spread from the dirty gloves to the resident and surrounding areas. CNA AA confirmed she did not remove her gown per infection control protocol after completing incontinence care. She confirmed she removed the gloves first, used her bare hands to grasp the front of her gown, removed it with her bare hands, and placed it in the garbage bin. She stated she should not have touched the outside of the gown with her bare hands because the germs or bacteria on the dirty gown could cause the spread of infection. In an interview on 3/13/2025 at 10:27 am, Licensed Practical Nurse (LPN) DD stated when removing gowns, the gown should be pulled away from the body with the gloves on, from inwards to outwards from the neck downwards to ensure germs from the outside of the gown do not get transferred to others or the resident. LPN DD further stated gloves should be changed if soiled or when going from a clean surface to a dirty surface. He stated one pair of gloves should not be used to provide incontinence care and ADL care since this could cause cross-contamination, and the resident could get an infection and get sick. In an interview on 3/13/2025 at 10:50 am, the Director of Nursing (DON) stated that gloves should be changed between incontinence care and other ADL care. She stated that it was not appropriate for the same gloves to be used throughout the procedure and that glove change was necessary when moving from dirty to clean. The DON stated that not changing gloves could cause the spread of infection. She further stated that gowns were to be removed before removing gloves to prevent the spread of germs.

Based on observation, interview, and facility policy review, the facility failed to ensure all hot food items were held above 135 degrees on the steam table to prevent food borne illness. This deficient practice had the potential to effect 36 of 42 resident that receive regular or mechanical soft textured diet. Findings include: Observation on 10/8/22 at 12:45 p.m. revealed the Dietary Manager (DM) assisting with obtaining hot food temperatures on the steam table using the facility's calibrated thermometer. Steam table temperatures were obtained halfway through lunch meal service. Continued observation revealed a deep square steam table pan containing tater tots had a temperature of 130 degrees. During an interview on 10/8/22 at 12:45 p.m. the DM confirmed that the tater tots were 130 degrees. The DM stated that hot foods should be at least 135 degrees on the steam table. Review of facility policy titled Food Preparation and Distribution revealed that hot foods should be held at or above 135 degrees Fahrenheit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and facility policy review, the facility failed to allow two of 13 residents (Residents (R) 41 and R22) the right for self-determination by failing to honor their bathing preference. Findings include: Review of the facility's policy titled, Skilled Inpatient Services a Comprehensive Patients' Rights Program, was provided by the Administrator on 04/28/21 at 11:31 AM, and revealed, . We believe that all staff should understand the importance of treating patients with care and respect, and honoring patients' right to make personal choices. 1. Review of a Face Sheet, found in R41's electronic medical record (EMR) under the Resident file, indicated the resident was admitted on [DATE] with diagnoses that included spinal stenosis and difficulty walking. Review of R41's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/16/20, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. The assessment noted the resident indicated a bathing choice was important to him. Review of paper documents, untitled, for R41, were dated 01/25/21 through 04/14/21, indicated the resident had nail care performed, mouth care was performed, his hair was combed, and lotion was applied on his skin. The forms failed to identify if the resident was asked if he wanted a tub bath, bed bath, or a sponge bath. During an interview with R41 on 04/26/21 at 12:54 PM, the resident said that he has not been offered a shower since his admission and only received a bed bath. The resident stated staff told him he could not be given a shower since he was a large man. The resident said he would like to take a shower instead of getting a bed bath all the time. During an interview on 04/28/21 at 8:16 AM, Certified Nursing Assistant (CNA) 9 stated she was aware the resident received bed bathes only. During an interview on 04/28/21 at 9:54 AM, the Director of Nursing (DON) stated the staff address preferences and R41 did not like to get up due to his weight. The DON said the shower bed was bariatric and all that the resident needs to do was to ask staff if he could be showered. During an interview on 04/28/21 at 10:10 AM, CNA10 said R41 only received bed baths. During an interview on 04/29/21 at 11:56 AM, the DON stated when a resident was admitted preferences were identified in the MDS assessment. The DON confirmed that the records that identified if nail care was provided, if oral care was provided, if R41's hair was combed was an activities of daily living record and not bathing records that would indicate if the resident was offered a preference in bathing. 2. Review of R22's undated Face Sheet, located in the resident's EMR, revealed R22 was admitted to the facility on [DATE] with diagnoses which included but were not limited to, congestive heart failure (CHF), difficulty in walking, and chronic obstructive pulmonary disease (COPD). Review of R22's most current annual MDS with an ARD of 05/03/20, which was provided by the facility's Regional Nurse, on 04/29/21 at 9:00 AM, in the Activities Room, revealed the resident had a BIMS of 15, which indicated the resident was cognitively intact. R22 had no behaviors, was totally dependent on staff for bathing, and was always incontinent of bowel and bladder. The resident's Preferences for Customary Routine and Activities, indicated that it was Somewhat important, to choose between a tub bath, shower, bed bath, or sponge bath. Review of R22's Care Plan, located in the resident's EMR under the care plan tab, revealed a care plan titled, Self-care deficit, which was initiated 10/22/18, and reviewed 02/15/2021. The self-care deficit care plan indicated, Bed bath daily, encourage patient to assist with care. Observation and interview on 04/26/21 at 9:49 a.m., R22 was noted to have facial hair on her chin. R22 stated she would like to have a shower but only gets bed baths. The resident revealed she had not been showered since she was admitted to the facility. Observation and interview on 04/27/21 at 9:10 AM with R22, revealed she had a bed bath earlier in the morning, and the CNA cleaned off the resident's facial hair. The resident indicated she would like to have the facial hair removed more often, and still would like to shower. Interview on 04/28/21 at 9:55 AM with the DON revealed R22's MDS from 05/13/20 recorded the resident felt it was somewhat important to choose between bath, shower, bed bath, and sponge bath, which means the Certified Nursing Assistants should ask what R22's preference is each time the resident is bathed. Interview on 04/28/21 at 10:37 a.m. with the Activities Specialist, revealed she assesses all newly admitted residents upon admission regarding bathing preferences and R22 felt it was somewhat important to choose between bath, shower, bed bath, and sponge bath, and CNAs should ask the resident her preference each time the resident is bathed. The Activities Specialist indicated resident's bathing preferences should be in the resident's EMR under the Data Collection tab, but there were no bathing preferences listed for R22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure that one (Resident (R) 41), out of a survey sample of three reviewed for accident hazards, received adequate supervision and assistance devices to prevent two separate falls from bed during the provision of care, thus placing the resident at potential harm. Findings include: Review of a facility document titled, Fall Management, dated 03/16, revealed . Each patient is assisted in attaining/maintaining his or her highest practicable level of function by providing the patient adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls. Each patient's risk for falls is evaluated by the interdisciplinary team (IDT). If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. The Director of Nursing/Designee is responsible for coordination of an interdisciplinary approach to managing the processes for prediction, risk assessment, treatment, evaluation, monitoring, and calculation of resident falls Review of a Face Sheet, found in R41's electronic medical record (EMR) under the Resident file, indicated the resident was admitted on [DATE] with diagnoses that included spinal stenosis and cervical radiculopathy (when a nerve has been damaged and may cause weakness in upper extremities). Per review a Care Plan, found in R41's EMR under Care Plan, tab indicated R41 had a history of falls. Review of R41's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/11/20, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. The assessment noted the resident was extensive assistance in bed and required the assistance of two staff members. Review of an Event Initial Note, found in R41's EMR under Nurses Notes, dated 08/14/20 indicated R41 rolled out of bed. The Certified Nursing Assistant (CNA) 7 alerted the clinical staff immediately after the incident and the resident was assessed and had no injuries. The resident representative and the medical provider were both notified. Review of a document titled, Event QAPI (Quality Assurance Performance Improvement) Tool, dated 08/14/20, reported R41 rolled out of bed and the resident landed on a floor mat next to his bed. There was no evidence identified the resident required the assistance of two staff members during bed mobility during the provision of care. Review of R41's MDS with an ARD of 11/16/20 still indicated R41 required the assistance of two staff members with bed mobility. Review of an Event Initial Note, found in R41's EMR under Nurses Notes, dated 01/23/21 indicated R41 rolled out of bed during the provision of care. CNA8 alerted the clinical staff immediately after the incident and the resident was assessed and had no injuries. The resident representative and the medical provider were both notified. Review of a document titled Event QAPI Tool, dated 01/23/21, revealed R41 rolled out of bed when CNA8 changed his adult brief. During an interview on 04/27/21 at 10:29 AM, R41 stated he fell from his bed twice. The resident explained that one staff member pulled a sheet up from underneath him. The resident stated he was unable to grip his grab bar and rolled over and landed on his hands and his knees. The resident went onto state the second fall happened by another staff member. The second fall occurred when the staff member provided care to the resident and per the resident, his feet slipped off the bed. This time, according to the resident he was able to grab onto his grab bars and guide himself to the ground. The resident confirmed he was not injured after these two falls. The resident confirmed each staff member provided him assistance, while he was in bed, without a second staff member present. During an interview on 04/28/21 at 8:30 AM, CNA7 confirmed she was the staff member who provided care to R41 while he was in bed. CNA7 said she was the only one who provided him care at this time. CNA7 said she receives information on how to provide care to a resident from a handheld device called a Point of Care (POC). CNA7 stated the resident asked to be changed. CNA7 said the resident can assist in changing his position while in bed. CNA7 said the resident just rolled out of bed. She went onto state currently there are two staff members assigned to the resident during the provision of care. During an interview on 04/28/21 at 3:54 PM, the MDS Coordinator stated it was her understanding the handheld POC devices had information on the resident's activities of daily living (ADL) so the CNAs could see what they needed to do for each resident. A request was made to see this device and it was not provided. During an interview on 04/28/21 at 6:39 PM, CNA8 confirmed he was the only staff member present when he was fixing the sheet under the resident. CNA8 stated he asked R41 to roll over and then the resident landed on the floor. CNA8 said he typically receives direction on how to provide care to the residents with a POC device. CNA8 said there was no information identified on the POC device that would inform him the resident required the assistance of two staff members while he was in bed. CNA8 stated there was new guidance to have two staff members present during the provision of care for the resident. During an interview on 04/29/21 at 8:48 AM, the MDS Coordinator and the Regional Nurse were present. The Regional Nurse stated the POC device would have given CNAs direction on what care was needed for a resident. The Regional Nurse stated they cannot print up this section on the POC device. During an interview on 04/29/21 at 11:35 AM, the Director of Nursing (DON) confirmed she was the staff member who investigated the falls. The DON said every fall was discussed in the morning meeting to identify how each fall could be prevented. The DON was asked about the 08/14/20 and what preventative measures were implemented after this fall since R41 sustained a second fall on 01/23/21. The DON stated the resident more than likely did not want to wait for a second staff member to assist in the provision of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, Pharmacy document review, review of the Seroquel package insert review, and facility policy review, the facility failed to ensure adequate indications, specifically proper diagnoses, for the use of antipsychotic medications for three of five sampled residents reviewed for unnecessary medications (Resident (R) 15, R16, and R29). Finding include: Review of the facility's policy titled, Pharmacy Services Monitoring Psychotropic Medication, dated 2019, revealed it did not address the use of psychotropic medications on residents who did not have diagnoses of psychosis. Review of a document titled Pharmacy Services, dated 2019 as copyrighted, revealed . The pharmacist, in conjunction with the nurse, physician, and other disciplines involved in the patient's care, closely monitors psychotropic medication prescribed for the patient. failed to address indications for use of an antipsychotic medication. Review of the medication insert for Seroquel revealed, .Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. SEROQUEL is not approved for elderly patients with dementia-related psychosis. Retrieved on 04/29/21. file:///C:/Users/tgriffith/Desktop/Sparta%20Health/020639s064lbl.pdf 1. Review of R15's undated Face Sheet, located in the resident's electronic medical record (EMR), under the face sheet icon, revealed the resident was admitted to the facility on [DATE], with diagnoses that included but were not limited to, personal history of traumatic brain injury, calcified tendinitis, and age-related osteoporosis. R15's most recent Minimum Data Set (MDS), with and assessment reference date (ARD) of 02/13/21, was provided by the Regional Nurse on 04/29/21 at 9:00 AM and reviewed at that time. The MDS revealed R15 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS also revealed the resident had verbal behavioral symptoms directed toward others for 1 to 3 days in the 7 days prior to the assessment. The MDS revealed R15 had received antipsychotic medication 7 of 7 days prior to the assessment. Review of R15's Physician's Order, dated 11/17/2020, located under the orders tab in the resident's EMR, revealed the resident was ordered Lamotrigine (an anticonvulsant medication, sometime used in the treatment of bipolar disorder) 100 mg tablet by mouth one time per day for Psychosis. Review of R15's Medication Administration Record (MAR), dated 04/01/2021 to 04/30/2021, located under the Med & Treat tab, revealed the resident received the physician ordered Lamotrigine 100 mg tablet by mouth at every morning from 04/01/21 to 04/29/21. Review of R15's Care Plan for psychotropic drug use, dated 12/15/20 and reviewed 02/23/21, indicated the resident was to be monitored for behaviors and side effects for psychotropic drug use. Observation on 04/26/21 at 9:08 a.m., in hall in wheelchair returning to room per self. Resident was pleasant, no behaviors noted. Observation on 04/26/21 at 2:13 p.m., R15 was in the Dining Room playing Family Feud with other residents during Activities. Resident was joining in the game with appropriate behaviors. Observation on 4/27/21 at R15 up to bathroom, getting dressed for the day per self. Pleasant and talkative. No behaviors observed. 2. Review of R16's undated Face Sheet, located in the resident's EMR, under the face sheet icon, revealed the resident was admitted to the facility on [DATE], with diagnoses that included but were not limited to, Alzheimer's disease, major depressive disorder, restlessness, and agitation. R16's most recent MDS, with and ARD of 02/07/21, was provided by the Regional Nurse on 04/29/21 at 9:00 AM and reviewed at that time. The MDS revealed R16 had a Brief Interview for Mental Status (BIMS) score which had not been assessed because the resident was rarely or never understood. The MDS also revealed the resident had no behaviors for potential indicators of psychosis. The MDS indicated R16 had received antipsychotic medication seven of seven days prior to the assessment. Review of R16's Physician's Order, dated 11/01/2019, located under the orders tab in the resident's EMR, revealed the resident was ordered quetiapine (an antipsychotic medication) 25 mg tablet by mouth at bedtime, to treat bpsd (behavioral and psychological symptoms of dementia). Review of R16's Medication Administration Record (MAR), dated 04/01/21 to 04/30/21, located under the Med & Treat tab, revealed the resident received the physician ordered quetiapine every night at bedtime from 04/01/21 to 04/29/21. Review of R15's Care Plans indicated a plane for anti-psychotic drug use, dated 02/20/19 and reviewed 02/15/21. Observation on 04/26/21 at 8:52 a.m., in room sitting in chair by with breakfast on over-the-bed table before her. Resident was not actively eating, eyes closed, did not respond when spoken to. No behaviors observed. Observation on 04/26/21 at 11:51 a.m., R16 was sitting up in chair in room in front of television, dressed, well kempt. No behaviors observed. Observation on 4/28/21 at 4:35 p.m., resident sitting in the facility entry area. Alert and responded to greeting but did not reply. No behaviors observed. Interview on 04/29/21 at 12:37 p.m., the facility's Medical Director revealed that the use of antipsychotics for Alzheimer's disease and dementia was an issue he and the facility needed to talk about as antipsychotics continued to be used. The Medical Director indicated residents who take antipsychotic medications should have a diagnosis of some type of psychosis. The medical director indicated bpsd was not an appropriate diagnosis for the use of antipsychotics, and a diagnosis of psychosis should have been added when R16 was admitted . 3. Review of a Face Sheet, found in R29's EMR under the Resident file, indicated the resident was admitted on [DATE] with diagnosis of altered mental status and Alzheimer's disease. Review of a Physician's Telephone .Order, found in R29's EMR under the Orders tab, dated 02/27/20, revealed the physician prescribed Seroquel 25 mg one tablet to be administered to the resident for alcohol abuse. Review of a Care Plan, found in R29's EMR under the Care Plan tab, dated 03/04/20 as initiated, indicated the resident was on a psychotropic medication and was easily agitated and the goal was to reduce the number of episodes of striking out at others. Interventions included to not argue with the resident when he had fearful delusions, to document the episodes of refusing care, and to monitor behavior as indicated. There was no indication(s) for use noted in the care plan to address the use of the Seroquel. Review of a paper document titled, Psychoactive Medication Consent Form, signed as dated 06/15/20, indicated, Seroquel 25 mg was to be administered one time a day for bipolar disorder. Review of Behavior Monitoring, found in R29's EMR under the Other tab, dated 09/01/20 through 04/29/21, revealed for the months of 09/2020 and 10/2020 the behavior monitored was for depressed mood and the diagnosis to support the use of Seroquel was psychosis. There was no evidence the resident experienced psychotic behavior for the months of 09/2020 and 10/2020. For the months of 11/2020, 12/2020, 01/2021, 02/2021, 03/2021, and 04/2021 the behavior monitored was for depressed mood and the diagnosis to support the use of Seroquel was Alzheimer's disease. There was no evidence the resident experienced psychotic behavior for the months 11/2020 through 04/29/21. Review of Nurses Note, found in R29's EMR under Nurses Note tab from 01/29/21 through 04/28/21 revealed the resident would refuse medications that were offered to him. There was no evidence the resident had psychotic behaviors. Review of eMAR (electronic medication administration record) found under R29's EMR (Med (Medication) & Treat (Treatment), tab for the months of 02/01/21 through 03/21/21, revealed the resident received 25 mg of Seroquel each night at bedtime for a diagnosis of psychosis. From 03/21/21 through 03/24/21 the resident was in the hospital being treated for pneumonia. Beginning 03/24/21 through 04/28/21, the eMAR indicated the resident received 25 mg of Seroquel each night at bedtime for a diagnosis of Alzheimer's disease. Review of R29's MDS with an ARD of 03/28/21, revealed the resident had a BIMS which could not be determined, and the facility indicated the resident had poor short- and long-term memory problems. The assessment noted the resident had no mood problems. The assessment noted the resident had behavioral symptoms such as hitting, kicking, or grabbing others within the past one to three days. The assessment also noted the resident had verbal behavioral symptoms such as yelling or threatening others within the past one to three days. During an interview on 04/28/21 at 8:16 AM, Certified Nursing Assistant (CNA) 9 stated R29 stated it takes two staff members to provide the resident with personal care and if there was just one person present, the resident will refuse care. CNA9 stated the resident was easy to work with and if the resident had behaviors, she would alert nursing about it and then reapproach the resident again to see if he would allow her to provide him care. An attempt was made to interview R29 on 04/28/21 at 8:22 AM and the resident did not respond to questions. During an interview on 04/8/21 at 9:00 AM, Licensed Practical Nurse (LPN) 13 stated R29 had no behavioral issues such as verbal or physical aggression. LPN13 then demonstrated on the EMR how behavior monitoring happens and stated the behaviors were associated with the medications the resident was prescribed and he was monitoring for depression. During an interview on 04/28/21 at 10:06 AM, CNA10 stated she was not afraid of R29 and he has never tried to hit her. CNA10 said there were times the resident wants to be left alone. During an interview on 04/28/21 at 6:39 PM, CNA8 stated R29 could get riled up a bit. CNA8 said when the resident gets riled up he would just walk away from him and then reapproach the resident later. CNA8 said the resident will scream and yell when he does not want a staff member to touch him and when this happens, he reports it to nursing. During an interview on 04/29/21 at 12:00 PM, the Regional Nurse stated the Seroquel was used for R29's behaviors toward others such as acting out towards staff and when he does not want assistance from the staff. The Director of Nursing (DON) was also present during this interview. The DON stated the resident could be very aggressive with staff and would not speak with staff. During an interview on 04/29/21 at 12:35 PM, the Medical Director stated the resident had a gradual dose reduction on other psychotropic medication late last year and did not like to decrease two psychotropic medications at the same time. The Medical Director stated Seroquel was a fantastic medication for dementia with behaviors and given the resident's history of encephalopathy the use of Seroquel has helped the resident. The Medical Director stated we were learning from the survey process and we need to discuss the use of psychotropic medications more often. The Medical Director stated there needs to be an appropriate diagnosis when an antipsychotic medication was used and to further evaluate the reasons why a person was on a medication. The Medical Director stated if a resident does not need a medication the goal was to get rid of the medication. During an interview on 04/29/21 at 1:41 PM, the Consultant Pharmacist stated he has been coming out to the facility to do monthly medication reviews for the past five years. The Consultant Pharmacist stated the goal was to have a resident on the lowest possible dose of an antipsychotic medication. The Consultant Pharmacist stated R29 had two gradual dose reductions in 2020 and used to be prescribed Seroquel 100 mg twice a day. He went onto state the resident was currently on 25 mg of Seroquel one time a day. The Consultant Pharmacist stated the diagnosis of Alzheimer's disease and the use of Seroquel was considered off label use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, patient rights documents and facility policy review, the facility failed to implement care plan interventions to prevent falls for one (Resident (R) 41). Staff failed to provide care as required per R41's care plan, including the number of staff necessary to prevent accidents during the provision of care. As a result, the resident fell from his bed to the floor on two occasions. The facility failed to ensure R41 and R22's preferences for bathing were integrated into the care plan. The facility failed to develop a comprehensive care plan for R9 regarding nutritional risk, out of a survey sample of 13 reviewed for care plans. Findings include: Review of the facility's policy titled, Skilled Inpatient Services Patient's Plan of Care, dated 2020, was provided by the Administrator on 04/28/2021 at 11:31 AM, and revealed, .Each patient will have a person-centered comprehensive care plan developed and implemented to meet his other preferences.The patient's care plan should be reviewed after each MDS assessment and revised based on changing goal, preferences and needs. Review of a document titled, Patients Plan of Care, dated 2020 as copyrighted, revealed . Each patient will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the patient's medical, physical, mental and psychosocial needs. A comprehensive care plan should be developed within 7 days after completion of the comprehensive MDS assessment. When developing the comprehensive care plan, facility staff should use the MDS to assess the patient's clinical condition, cognitive and functional status, and use of services.The patient's care plan should be reviewed after each MDS assessment and revised based on changing goals, preferences and needs of the patient and in response to current interventions. The comprehensive care plan should also be updated as ongoing clinical assessments identify changes. 1.Review of a Face Sheet, found in R41's electronic medical record (EMR) under the Resident file, indicated the resident was admitted on [DATE]. Review of a Care Plan, found in R41's EMR under the Care Plan tab, dated 03/12/20, indicated the resident required assistance with hygiene. The care plan specifically informed staff the resident was non-weight baring, had a history of falls, and required extensive assistance with bed mobility. An intervention initiated on 08/14/20 noted the resident required two staff members during the provision of care for support. Review of the Event Initial Note, found in R41's EMR under Nurses Notes, dated 08/14/20 and 01/23/21, revealed the resident fell out of bed on each date, while only one staff member provided personal care to the resident when he was in bed. During an interview on 04/27/21 at 10:29 AM, R41 stated he fell from his bed twice, and both incidents involved one staff member providing him care while he was in bed instead of two staff members. 2. Review of a Care Plan, found in R41's EMR under the Care Plan, tab dated as initiated 10/12/20, indicted the resident was to be provided bed baths per schedule. There was no evidence, in the resident's care plan, which showed the resident's preference in making the decision to take a shower or a bed bath. During an interview with R41 on 04/26/21 at 12:54 PM, the resident said he would prefer to take a shower instead of a bed bath. 3. Review of a Face Sheet, found in R9's electronic medical record (EMR) under the Resident file, indicated the resident was admitted on [DATE], with a diagnosis of cerebral infarction (stroke). Review of R9s Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/08/20, revealed the resident had a Brief Interview for Mental Status (BIMS) which could not be determined. Under the Care Area Assessment (CAA), the resident triggered under nutritional status and directed staff to develop a care plan. Review of a Care Plan, found in R9's EMR under the Care Plan tab, failed to identify nutrition under a care area. During an interview on 04/28/21 at 3:54 p.m., the MDS Coordinator stated she was hired recently and was in the process of reviewing care plans for each resident and individualizing them. The MDS Coordinator stated the comprehensive assessment guides the development of the care plan and if an area triggered under the CAA this would be carried through to the care plan. A subsequent interview was conducted on 04/29/21 at 9:31 AM, the MDS Coordinator confirmed R9 triggered under nutrition and it was not carried through to the care plan. During an interview on 04/29/21 at 11:33 AM, the Director of Nursing (DON) stated it was her understanding that an issue that was triggered under the CAA staff were required to proceed to the development of the care plan with the associated triggered area. 4. Review of R22's undated Face Sheet, located in the resident's EMR, revealed R22 was admitted to the facility on [DATE] with diagnoses which included but were not limited to, congestive heart failure (CHF), difficulty in walking, and chronic obstructive pulmonary disease (COPD). Review of R22's most current annual MDS, with an ARD of 05/03/20, revealed the resident had a BIMS of 15, which indicated the resident was cognitively intact. R22 had no behaviors, was totally dependent on staff for bathing, and was always incontinent of bowel and bladder. The resident's Preferences for Customary Routine and Activities, indicated that it was Somewhat important, to choose between a tub bath, shower, bed bath, or sponge bath. Review of R22's Care Plan, located in the resident's EMR under the care plan tab, revealed a care plan titled, Self care deficit, which was initiated 10/22/18, and reviewed 02/15/21. The self-care deficit care plan indicated, Bed bath daily, encourage patient to assist with care. Observation and interview on 04/26/21 at 9:49 a.m., R22 was noted to have facial hair on her chin. R22 indicated she would like to have a shower but only gets bed baths. The resident revealed she had not been showered since she was admitted to the facility. The resident revealed she was told she could not have showers because she was not able to stand. Observation and interview on 04/27/21 at 9:10 a.m. with R22, revealed she had a bed bath earlier in the morning, and the CNA cleaned off the resident's facial hair. The resident indicated she would like to have the facial hair removed more often, and still would like to shower. Interview on 04/28/21 at 9:55 a.m. with the DON revealed R22's MDS from 05/13/20 recorded the resident felt it was somewhat important to choose between bath, shower, bed bath, and sponge bath, which means the Certified Nursing Assistants should ask what R22's preference is each time the resident is bathed. Interview on 04/28/21 at 10:37 a.m. with the Activities Specialist, revealed she assesses all newly admitted residents upon admission regarding bathing preferences and R22 felt it was somewhat important to choose between bath, shower, bed bath, and sponge bath, and CNAs should ask the resident her preference each time the resident is bathed. The Activities Specialist indicated resident's bathing preferences should be in the resident's EMR under the Data Collection tab, but there were no bathing preferences listed for R22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer one of five residents (Resident (R) 29), and/or their representative, reviewed for pneumonia vaccinations, the opportunity for the resident to be vaccinated in accordance with CDC guidelines. The resident and/or their representatives were unable to share in clinical decision making with the medical provider as they were not given information or offered PCV13. The failed practice had the potential to increase the risk for pneumonia. Findings include: Review of the Centers for Disease Control and Prevention (CDC) website titled, Pneumococcal Vaccine Recommendations revealed, For adults 65 years or older who do not have an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant and want to receive PCV13(Prevnar 13), AND PVC13ND PPSV23 (Pneumovax23).Administer 1 dose of PCV13 first then give 1 dose of PPSV23 at least 1 year later. If the patient already received PPSV23, give the doe of PCV13 at least one year after they received the most recent dose of PPSV23. Anyone who received any doses of PPSV23 before age [AGE] should receive 1 final does of the vaccine at age [AGE] or older. Retrieved online 04/29/21 at http://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html. Review of the facility policy titled, Skilled Inpatient Services Immunization of Patients, dated 2020, was provided by the Administrator on 04/28/21 at 11:00 AM. The policy revealed, .The patient/family representative will receive education and be informed about the benefits and risks of immunizations before being offered the vaccine.The facility will assure documentation in the patient's medical record of the information/education provided regarding the benefits and risks of immunization and the administration or refusal of or medical contraindications to the vaccine.Assess patients on admission for the need of vaccination against Streptococcus pneumoniae infection according to the following criteria:.65 years or older, History of Prior Vaccination.None or unknown.Administer PCV13 followed in 1 year by PPSV23. Review of the Electronic Medical Record (EMR) of the undated Face Sheet, under the face sheet icon, revealed R29 was admitted to the facility on [DATE] with diagnoses that included but were not limited to chronic obstructive pulmonary disease (COPD). The resident was 65 years or older upon admission. Review of the EMR Immunization record under the Immunization tab, indicated R29 was administered .unknown PPV. on 03/01/01. Review of the EMR immunization record failed to reveal the resident was offered the PCV13. During an interview on 04/28/21 at 3:21 p.m., the Director of Nursing confirmed R29 was not offered or administered the PCV13. The DON indicated the vaccine should have been offered to the resident upon admission per CDC guidelines and facility policy.