Based on interview and record review, the facility failed to provide a copy of the bed hold policy for a resident who transferred to the hospital for one of three residents (R4) reviewed for bed holds in the sample of 31. Findings include: The Facility Transfer Procedures Policy dated (revised) 10/25/2024, documents The charge nurse will notify the appropriate persons of pending transfer to the hospital, reason for transfer, hospital being transferred to, and obtain consent for transfer from the resident's legal representative. Copies of the following will be sent to the resident: Notice of Transfer and Bed Hold Policy form for Resident; Resident Representative; or Healthcare POA (Power of Attorney). R4's Time of Transfer, dated 8/30/24 at 5:03 PM, documents R4 was transferred to the local hospital with paramedics for evaluation, decline in condition, and medical necessity. R4's medical record does not document a bed hold policy was provided to R4 upon being transferred to the hospital on 8/30/24. On 11/27/24 at 2:00 PM, V9 (Nurse Consultant) confirmed R4 was sent to the hospital on 8/30/24. V9 stated I searched for proof of my nurse that day giving Notice of Transfer and Bed Hold policy, but she did not do it. The nurse working that day should have done it, it is something we missed and will be working on.

Based on observation, interview, and record review the facility failed to document and care plan targeted behaviors to warrant the use of an anti-psychotic medication, monitor for underlying conditions prior to increasing an anti-psychotic medication dose, and perform a comprehensive evaluation for the use of an anti-psychotic for one of one resident (R66) reviewed for anti-psychotic medication use with the diagnosis of Dementia in the sample of 31. Findings include: The facility's Psychotropic Medication Use and Behavior Monitoring policy dated 10/2021 documents, Psychotropic medication refers to drugs which are used for anti-psychotic, anti-depressant, anti-anxiety, and/or hypnotic purposes. It is the policy of the facility to keep each resident's medication regimen free from unnecessary drugs. Psychotropic medications will not be administered for the purpose of discipline or staff convenience and when not required to treat the resident's symptoms. Psychotropic drug therapy will be instituted at the lowest dose for the shortest duration of time to control the specific and documented behavioral problems as prescribed the physician. The resident's need for psychotropic medication will be monitored, as well as when the resident has received optimal benefits from the medication and when the medication dose can be lowered or discontinued. This monitoring shall include identification of the resident's behaviors that the psychotropic drug could conceivable address (target behaviors). Assessment of potential cause of the behaviors that, if addressed, could eliminate the behaviors without the use of psychotropic drugs (medical, environmental, family stresses, adjustment reactions, etc.) Discussion of non-medical behavior management strategies that have been implemented in an attempt to reduce/eliminate the behaviors prior to initiation of drug treatment and the resident's response to these interventions. Behaviors for which psychotropic medications should not be used include crying out, yelling, screaming, fidgeting, insomnia, nervousness, not-cooperative, poor self-care, restlessness, simple pacing, unsociability, and wandering. R66's Physician's Orders dated 2-15-23 document R66's Risperidone (anti-psychotic medication) was increased from 0.25 mg (milligrams) daily at bedtime to 0.5 mg daily at bedtime for the diagnosis of Behavioral Disorders associated with Dementia. R66's Physician's Orders dated 2-15-23 through 9-19-23 document R66 has received Risperidone 0.5 mg one tablet at bedtime for the diagnosis of Behavioral Disorders associated with Dementia since 2-15-23. R66's Electronic Health Record does not include documentation of the facility assessing or monitoring R66 for underlying conditions prior to increasing R66's Risperidone on 2-15-23. R66's MDS (Minimum Data Set) Assessments dated 4-14-23 and 7-7-23 document R66 is severely cognitively impaired and has no behavioral symptoms that impact the resident or others, cause significant risk of injury to himself or others, or interfered with R66's cares. R66's Care Plan (Resident Care Guide) dated 7-13-23 does not include the targeted behaviors or non-pharmacological interventions to address targeted behaviors for the use of R66's Risperidone. On 09/19/23 from 9:35 AM to 10:15 AM R66 was sitting in the recliner eating breakfast. R66 had no behaviors during this time. On 09/20/23 at 10:45 AM, R66 was sitting in the recliner watching television in the dining area. R66 had no behaviors during this time. On 09/20/23 at 10:46 AM, V9 (CNA/Certified Nursing Assistant) stated, I have worked here three years and have always taken care of (R66). (R66) does not have any behaviors or aggressiveness. (R66) does not have behaviors with cares. (R66) just gets fidgety. On 09/20/23 at 10:50 AM, V10 (CNA) stated, I take care of (R66) regularly. (R66) just fidgets with cares. (R66) does not have any behaviors and does not refuse cares. 09/20/23 09:55 AM, V2 (Director of Nursing) stated, (R66) does not have an anti-psychotic medication evaluation in his medical record. (R66's) Risperidone was increased from 0.25 mg (milligrams) daily at bedtime to 0.5 mg daily at bedtime on 2-15-23 due to (R66) resisting cares with staff. We (the facility) did not evaluate (R66) for underlying conditions prior to increasing the Risperidone. (R66) is using Risperidone for the diagnoses of Dementia with behaviors. (R66's) care plan does not include the target behaviors that Risperidone is being used for.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident call lights were responded to in a timely manner for 2 of 18 residents (R1 and R39) reviewed for call lights in a sample of 34. Findings include: The facility's Job Description for Certified Nursing Assistant (CNA), revised 10-1-07, documents Scope of Position: The purpose of the Certified Nursing Assistant (CNA) position is to provide each of the assigned residents with routine daily nursing care and services in accordance with the resident's care plan and with the policies and procedures of this facility under the direction of the (a.)Lead CNA (b.)Unit Coordinator (c.)Charge Nurse (R.N./L.P.N.) (d.)Assistant Director of Nursing (e.)Director of Nursing or (f.)Administrator, to assure that the highest degree of quality of resident care is provided at all times .Job Responsibilities: 1. Provide personal care to residents in a manner conducive to their safety and comfort consistent with the facility clinical policies and procedures as well as state/federal guidelines and regulations. Including a minimum of the following: .i. Promptly respond to resident's call lights. 1. On 10-11-22 at 10:11 am, R39 stated that R39 has to wait a long time for staff to come when R39 puts the call light on. R39 stated I have waited an hour before. R39 stated R39 has had urinary accidents while waiting and I go through a lot of diapers. I'm getting used to it. It's been this way since I've been here. R39's current Care Plan documents R39 admitted to the facility on [DATE]. R39's admission Minimum Data Set/MDS assessment, dated 8-8-22, documents R39 is cognitively intact, requires extensive assistance with transfers and toileting, is frequently incontinent of bladder, and consistently continent of bowel. On 10-12-22 at 12:34 pm, V9 (R39's family member) sat in R39's room and stated the following: Yesterday V9 was with (R39) when (R39) put the call light on to use the bathroom (for a bowel movement) at 25 minutes past the hour. V9 could not recall what time of day it was, but it was 10 minutes past the next hour (total of 45 minutes) before someone came. (R39) held it for that long but was passing gas. (R39) grumbled about it. 2. The Quarterly MDS (Minimum Data Set) assessment for R1, dated 9/23/22, documents R1 is cognitively intact and requires extensive assistance with transfers, toileting, and is occasionally incontinent of bladder and frequently incontinent of bowel. The Current Care Plan for R1 documents Provide prompt assistance to the toilet upon request to promote my continence. On 10/11/22 at 10:29 AM, R1 stated It takes them way too long to answer the call lights. I wait at least 20 minutes on a consistent basis. On 10/12/22 at 12:44 PM, upon entering hallway, noted R1's call light sounding and lit up over R1's door. On 10/12/22 at 12:54 PM, R1 propelled his wheel chair out into the hallway and waited for a staff member to come by. At this same time R1 alerted a staff member that was walking past him that he needed assist to the bathroom. Unable to determine when the call light was initiated however, total observed wait time was ten minutes. R1 stated he had been waiting for over 30 minutes for someone to come and no one came until he went and sat in the hallway. On 10/14/22 at 9:34 AM, V2 DON (Director of Nursing) stated the facility does not have a specific policy and procedure for resident call lights. On 10/14/22 at 1:50 PM, V2 stated, Obviously we want them (the staff) to answer call lights immediately if they can, if possible; but realistically, goals would be five to ten minutes.

Based on observation, interview, and record review, the facility failed to change gloves during toileting for two of three residents (R39 and R60) reviewed for incontinence care in a sample of 34. Findings include: The facility's policy Toileting Assistance, dated 5-2010, documents Procedure: TOILETING: Wash your hands and gather equipment .Put on disposable gloves if needed and additional PPE if indicated .Assist resident onto toilet or with appropriate receptacle .Once elimination has been completed, perform peri care .Remove your soiled gloves and wash your hands. Apply new clean gloves .Position resident comfortable with call light within reach .Throw gloves in soiled/urinated attends in the garbage bag provided in each resident's bathroom and dispose of immediately in the dirty utility room. Perform hand hygiene. The Facility's policy Infection Control Handwashing, undated, documents PURPOSE: To provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs and infections .NOTES: Always follow Standard Precautions. Gloves are to be worn when contact with blood, bodily fluids, mucous membranes, dressings, non-intact skin, etc., is anticipated. Change gloves and discard after each resident contact. One (1) pair of gloves - one (1) resident. Change gloves when moving from a contaminated body site to a clean body site on the same resident. 1. On 10-11-22 at 9:52 am, V8 Certified Nursing Assistant/CNA assisted R39 with toileting. After R39 voided V8 wiped R39's front and back areas. With the same soiled gloves V8 pulled up a clean incontinence brief, R39's pants up and adjusted R39's shirt. V8 removed V8's gloves then without hand sanitizing V8 assisted R39 to a recliner then left the room for a straw. V8 retrieved a straw just down the hall, brought it back to the room opened it and placed it in R39's drink. V8 tied up the bathroom garbage and then hand sanitized and left the room. On 10-13-22 at 1:30 pm, V8 CNA stated that V8 should have changed V8's soiled gloves after cleaning R39 up. 2. On 10-12-22 at 9:25 am, V8 Certified Nursing Assistant/CNA and V4 Infection Control Preventionist/ICP assisted R60 to stand with the lift and transported R60 to the bathroom. With gloved hands V8 CNA removed R60's soiled brief then lowered R60 to the toilet. After R60 voided and with the same soiled gloves V8 CNA wiped R60's perineal area front to back. With the same soiled gloves V8 CNA put a clean incontinence brief on and handled the lift to transfer R60 back to bed. As V8 CNA assisted R60 into the bed, V8 touched R60's clothing and skin, pulled the linens up and adjusted the head of the bed with the bed control. V8 then used hand sanitizer on V8's gloves and assisted R60 to eat/drink a little. On 10-12-22 at 9:45 am, V8 CNA stated I should have changed my gloves after removing her brief and again after wiping her. There weren't any in the bathroom. Then I used hand sanitizer on my gloves thinking that may help.