Based on record review and interview the facility failed to ensure a prophylactic antibiotic was monitored for effectiveness and not prescribed in excessive duration for one of five residents (R8) reviewed for unnecessary medications in the sample of 18. Findings include: A Health Status Note dated 03/4/22 documents R8 received a new order for Cephalexin 250 milligrams for frequent UTIs (urinary tract infection). This order has no end date. A Consultant Pharmacist Communication to Physician signed by V8, Consultant Pharmacist, on 03/10/23 documents, Antibiotic use without symptoms - Cephalexin. Under the drug usage guidelines use antibiotics routinely or indefinitely without symptoms is discouraged due to increased risk for potential side effects and the development of antibiotic resistance. V5, R8's physician, responded, Prophylaxis, UTI recurrent. An identical Communication was written by V8 on 01/10/24 regarding R8's Cephalexin. V5 responded, Recurrent UTI/need for PPX (prophylaxis). R8's medical record documents as of 05/08/24 she is still receiving Cephalexin 250 milligrams daily as a prophylactic medication to prevent UTIs. R8 was diagnosed and treated for UTIs on 08/30/23, 11/25/23, 01/26/24, 04/30/24 and 05/06/24. On 05/08/24 at 12:35 PM V2, Director of Nursing, confirmed R8 has been diagnosed and treated for five UTIs since 08/30/23. V2 stated there is no system in place to monitor the effectiveness of the antibiotic prescribed to R8. V2 confirmed R8 has been on a daily dose of Cephalexin since 03/04/22. On 05/08/24 at 2:34 PM, V5, R8's physician confirmed R8 has received a prophylactic dose of antibiotic for over two years. Policy dated 01/18/23 titled Suspected Urinary Tract Infection Policy and Procedure documents, Residents of long-term care facilities (LTCF) tend to have risk factors for the development of urinary tract infections (UTI), making UTIs one of the most common infections presenting in nursing facility residents. However, overuse and/or unnecessary treatment with antibiotics can lead to bacterial resistance and unwanted side effects.

2) On 5/8/2024, at 10:05 a.m., V6/Certified Nursing Assistant, during indwelling catheter care donned gloves. V6 then without changing gloves, proceeded to transfer R40, using a sit to stand lift, to R40's bed. V6 pulled down R40's pants and incontinence brief. V6 then adjusted the empty trash bag on R40's bed; grabbed a clean, wet, soapy, wash rag and wiped R40's catheter tubing. V6 placed the dirty rag in a plastic trash bag on R40's bed; grabbed a clean, wet, soapy, wash rag and wiped R40's genital area. V6 placed the dirty rag in the plastic trash bag on R40's bed. V6 grabbed the clean wet rag and rinsed R40's catheter tubing and R40's genital. V6 placed rag in the trash bag; grabbed a dry towel and dried R40's genital and catheter tubing. V6 placed the towel in the trash bag; adjusted R40's catheter tubing; pulled up R40's incontinence brief and pants. On 5/8/24, at 10:10 am., V6 confirmed V6 should have, but did not, change gloves during catheter care when going from dirty to clean. On 5/8/24, V2/Director of Nursing confirmed the expectation that V6 should have changed gloves, during catheter care when going from dirty to clean. Based on observation, interview, and record review the facility failed to perform hand hygiene during resident cares for two of 12 residents (R36 and R40) reviewed for infection control in a sample of 18. Findings include: 1) R36's current Care Plan, documents that R36 has an indwelling urinary catheter and that R36 requires staff assistance with all cares. On 05/08/24 at 8:30 am, R36 was sitting on the commode in R36's bathroom and V4 (Certified Nursing Assistant/CNA) was performing indwelling urinary catheter care. While wearing the same soiled gloves V4 (CNA) then completed the following tasks: set up two wash basins to cleanse R36 of stool; emptied R36's indwelling urinary catheter drainage bag (leg bag) of urine into the commode; washed and wiped bowel/stool off R36's buttocks; pulled up R36's pants; and assisted R36 to the wheelchair. V4 then removed V4's soiled gloves. V4 did not perform hand hygiene or change gloves during R36's cares. On 05/08/24 08:35 am, V4 (Certified Nursing Assistant/CNA) stated, I should have changed gloves after I did catheter care and before cleaning bowel from (R36's) rectum. On 5/8/24 at, V2 (Director of Nursing) stated, The Nurses and CNA's (Certified Nursing Assistant's) should be performing hand hygiene during all cares, especially when they go from a contaminated area to clean. Facility Catheter Care, Urinary Policy, undated, documents: the purpose of this procedure is to prevent catheter-associated urinary tract infections; place equipment on the bedside stand; wash and dry hands thoroughly or use antimicrobial hand gel; put on gloves, thoroughly rinse perineal area including the penis/scrotum; thoroughly rinse perineal area in same order, using fresh and clean washcloth; gently dry perineum; rinse washcloth or use a clean one and apply soap or skin cleansing agent; wash and rinse the rectal area thoroughly, including under the scrotum, anus and buttocks and dry; discard any disposable items into the designated containers; remove gloves and discard into designated container; wash and dry hands thoroughly or use antimicrobial hand gel; reposition and make resident comfortable; clean the bedside stand if used; and wash and dry your hands thoroughly.

Based on record review and interview the facility failed to follow an Antibiotic Stewardship program. This failure has the potential to affect all 41 residents who currently reside in the facility. Findings Include: CMS form 671 signed by V1, Administrator, on 05/08/24 documents there are 41 residents living in the facility. On 5/8/24 at 10:30 AM V3 (Licensed Practical Nurse/Infection Preventionist) stated that the facility utilizes the McGreer Criteria which are written definitions of what constitutes an infection. The Facility's Infection Control Monitoring Logs for January, February, March, and April 2024 listed all of the residents who had been on antibiotics for infections, there was no documentation of monitoring of signs and symptoms of infections prior to antibiotic use, or any documentation of any evidence-based criteria used to define any of the infections prior to antibiotic use. On 5/8/24 at 10:40 AM V6 (Registered Nurse/ Assisted Director of Nursing) stated We need to train our nurses on McGreer Criteria for identifying what is an infection and what does not meet the criteria. The Facility's Antibiotic Stewardship policy dated 4/7/2020 documents The facility will develop an Antibiotic Stewardship Program that promotes appropriate use of antibiotics for quality of care, successful resident outcomes and reduction of potential adverse consequences related to antibiotic use. A collaborative effort between the resident/resident representative, interdisciplinary team, practitioners, Medical Director, pharmacist and leadership team is essential for success of the Antibiotic Stewardship Program. The Facility's Antibiotic Stewardship policy also documents when the nurse suspects that the resident has an infection, the nurse will perform an evaluation of the resident that includes Resident signs and symptoms, assessment/vital signs, interview the resident for symptoms. The Nurse will document all assessment findings in the electronic medical record. The Facility's Antibiotic Stewardship policy also documents The Infection Preventionist will track antibiotic use and monitor adherence to evidence-based criteria, including documentation related to antibiotic selection and use.

Based on observation, interview and record review, the facility failed to change oxygen tubing and humidification bottle as ordered for one resident (R4) out of one resident reviewed for oxygen administration in a sample of 15. Findings include: The facilities Oxygen Administration policy undated, documents 1. Verify there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Equipment and Supplies: 2. Nasal cannula, nasal catheter, or mask (as ordered) 3. Humidifier bottle. On 05/02/23 at 10:10 AM, R4's oxygen tubing was dated 10/29 and the humidification bottle was dated 10/22. R4's medical record documents R4 received oxygen via nasal cannula on 1/6/23 and 2/6/23. R4's physician orders dated 11/26/22 documents Change oxygen/nebulizer tubing weekly while in use. On 5/2/23 at 11:10 AM, V4, Infection Preventionist, verified she documented R4 as being on oxygen on 1/6/23 and 2/6/23 and stated I would have documented that she was on oxygen because that's what she was on at the time. (R4) does wear her oxygen from time to time because she believes it makes her feel better. On 5/2/23 at 11:15 AM, V2, Director of Nursing (DON), verified oxygen tubing and humidifier bottle date and stated It's supposed to be changed weekly. I'm not sure why it hasn't been changed since October.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide informed consent for an antipsychotic medication, failed to identify target behaviors and failed to identify an appropriate supporting diagnosis for one resident (R22) with a diagnosis of Dementia of five residents reviewed for unnecessary medications in the sample of 15. Findings include: Facility Policy/Psychotropic Medication Policy dated 1/16/19 documents: Prior to the administration of a psychotropic medication, the following includes a process for the IDT (Interdisciplinary Team) and resident/resident representative to participate in the care process: The indication for any psychotropic medication will be thoroughly documented in the clinical record to include an appropriate supporting diagnosis and identification of behavioral symptom(s) being treated. Antipsychotic Medication: Diagnoses alone do not necessarily warrant the use of an antipsychotic medication. Antipsychotic medications may be indicated if: Behavioral symptoms present a danger to the resident or others; Expressions or indications of distress that are significant distress to the resident; If not clinically contraindicated, multiple non-pharmacological approaches have been attempted, but did not relieve the symptoms which present a danger or significant distress to the resident. If antipsychotic medications are prescribed, documentation must clearly show indication for the medication, multiple attempts to implement care-planned, non-pharmacological approaches and ongoing evaluation of the effectiveness of these interventions. A Psychotropic Drug Assessment will be completed on admission, quarterly, an irregularity identified in the pharmacist's medication regimen review and with significant changes of condition. Consent: Provide the resident/resident representative with information on the medication, indication, dose, side effects, adverse consequences and goal of treatment. The goals of psychotropic medication and non-pharmacologic approaches will be addressed in the resident's care plan. The care plan will also include the classification of psychotropic drug(s) to be monitored for side effects daily. On 5/2/23 and 5/3/23 R22 was observed sitting in his room and also sleeping/napping in bed after lunch. On 5/2/23 R22 was sitting in his room in a wheelchair. After being greeted, R22 began talking about people and events in a rambling but calm manner. R22 was able to answer simple questions, however, could not stay focused on topic and would continue to ramble. Psychotropic Medication Consent indicates Abilify 2mg daily was signed by R22's representative on 2/9/23 and consent signed on 3/13/23 indicates Abilify was increased to 3mg on that date. Neither consent indicates a diagnosis, indication for use, specific side effects or target behaviors. Current POS (Physician's Order Summary) indicates R22 has orders for Abilify (antipsychotic) 3mg (milligrams) daily related to Severe Unspecified Dementia with Mood Disturbance, Severe Recurrent Major Depressive Disorder with Psychotic Symptoms. CNA (Certified Nurse Assistant) Behavior Monitoring indicates: February 2023 Rejection of care/twice; yelling/9 times; abusive language 6 times, March 2023 Rejection of care/once; yelling/10 times; abusive language twice; wandering/once, April 2023 Yelling/twice; abusive language/once and May 2023 No behaviors. R22's Current Care Plan indicates R22 has a behavior problem related to Dementia. R22 is alert with confusion; known to yell out at staff during cares and has been known to refuse care and medications. R22 can become verbally aggressive with staff during cares. R22 will often watch television and yell out at the television; will have conversations with himself at times. [NAME] has been known to have hallucinations/delusions with paranoid behaviors. R22's Care Plan also indicates (R22) uses psychotropic medications related to Major Depressive Disorder with psychotic features. R22's Care Plan does not identify what type/category of psychotropic (antipsychotic) R22 receives or target behaviors. Progress Note dated 4/5/23 at 4:47am indicates R22 usually sleeps well and engages in confused conversation at times. Progress Note dated 4/13/23 at 11:41am indicates R22 was alone in his room after breakfast, staff overheard R22 talking and swearing at (someone) however no one else was in the room. Note indicates behavior was discussed with spouse who stated, I just don't think that medicine is doing him a bit of good anymore. Physician Note dated 3/13/23 indicates R22 has diagnosis of Dementia without behavioral disturbance and behavior is cooperative. Note indicates to Avoid medications on Beer's List. (The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, commonly called the Beer's List, are guidelines published by the American Geriatrics Society (AGS) for healthcare professionals to help improve the safety of prescribing medications for adults 65 years and older. The Beer's List includes the antipsychotic Abilify). Psychotropic Medication Consent indicates Abilify 2mg daily was signed by R22's representative on 2/9/23. Consent does not indicate an indication for use, diagnosis, side effects or target behaviors. On 5/3/23 at 3:10pm V2, DON (Director of Nursing) stated prior to starting the Abilify, R22 was having multiple episodes per day of yelling at the TV, yelling at self and seemed distressed. V2 stated that R22 was referred to Behavioral Health Services and they recommended to start R22 on Abilify. V2 stated the Behavioral Health practitioner told her There was all this evidence that Abilify is not even an antipsychotic until it reaches a certain dosage. V2 stated we did increase the dosage once and (R22's) wife wanted us to increase it more because she believed it was helping although his behaviors did return.