Based on record review and interview, the facility failed to notify the physician of blood glucose levels per the physician's order for 1 of 14 residents reviewed for notification of change. (Resident 8) Findings include: The clinical record for Resident 8 was reviewed on 08/28/24 at 2:25 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 08/21/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, heart failure, hypertension, diabetes, anxiety, and depression. A current physician's order, with a start date of 03/20/24, indicated the resident was to be administered insulin lispro per a sliding scale. The physician was to be notified if the resident's blood glucose level was greater than 350. The June, July, and August 2024, EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the resident's blood glucose levels were greater than 350 on the following dates and times: - On 06/10/24 at 11:00 A.M., the resident's blood glucose level was 368, - On 06/20/24 at 11:00 A.M., the resident's blood glucose level was 355, - On 06/25/24 at 11:00 A.M., the resident's blood glucose level was 367, - On 07/08/24 at 11:00 A.M., the resident's blood glucose level was 399, - On 07/21/24 at 11:00 A.M., the resident's blood glucose level was 389, - On 08/19/24 at 7:00 A.M., the resident's blood glucose level was 358, and - On 08/19/24 at 11:00 A.M., the resident's blood glucose level was 394. The resident's clinical record lacked any documentation the physician was notified of the blood glucose levels. During an interview on 08/29/24 at 2:09 P.M., LPN (Licensed Practical Nurse) 2 indicated the resident's blood glucose levels were documented on the EMAR/ETAR. If the blood glucose was out of the parameter and if the nurse was required to call the physician it would be documented on the EMAR/ETAR and in a progress note. They would document if there were any new orders in a progress note. During an interview on 08/29/24 at 2:55 P.M., the DON (Director of Nursing) indicated the resident did not suffer any ill effects related to the physician not being notified of the blood glucose levels. The current facility policy titled, Blood Glucose Monitoring, with a revision date of 2/2015, was provided by the DON on 08/29/24 at 2:45 P.M. The policy indicated, .The physician will be notified when the resident's blood glucose is outside the physician stated parameters . 3.1-5(a)(2)

Based on record review and interview, the facility failed to monitor a resident's blood pressure as ordered by the physician's for 1 of 14 residents reviewed for quality of care. (Resident 7) Findings include: The clinical record for Resident 7 was reviewed on 08/27/24. A Quarterly MDS (Minimum Data Set) assessment, dated 08/05/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, diabetes, depression, and insomnia. A current physician's order, with a start date of 06/13/24, indicated the staff were to obtain the resident's blood pressure daily and to notify the physician's office if the systolic (top number) was less than 100. The blood pressure record was to be taken to the next appointment on 12/13/24. The June, July, and August 2024, EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) lacked any documented blood pressures. The Vitals Report for June, July, and August 2024, lacked documented blood pressures for Resident 7 on the following dates: 06/15/24, 06/16/24, 06/18/24, 06/20/24, 06/21/24, 06/24/24, 06/25/24, 06/29/24, 06/30/24, 07/27/24, 07/28/24, 07/31/24, 08/01/24, 08/02/24, 08/05/24, 08/06/24, 08/10/24, 08/11/24, 08/15/24, 08/16/24, 08/19/24, 08/20/24, and 08/22/24. During an interview on 08/29/24 at 11:05 A.M., LPN (Licensed Practical Nurse) 2 indicated when a resident had an order to monitor their blood pressure it would be documented on the EMAR/ETAR. During an interview on 08/29/24 at 11:08 A.M., the DON (Director of Nursing) indicated the resident's blood pressure should have been monitored daily per the physician's order. The current facility policy titled, Documenting Guidelines for Nursing with a revision date of 7/24, was provided by the DON on 08/29/24 at 2:45 P.M. The policy indicated, .To accurately document in an organized manner all information related to the resident in the medical record . 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident's record accurately reflected the administration of a narcotic medication for 1 of 3 residents reviewed for resident records. (Resident B) Findings include: The clinical record for Resident B was reviewed on 01/12/24 at 2:17 p.m. An admission MDS (Minimum Data Set) assessment, dated 12/02/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, prostate cancer and Chronic Obstructive Pulmonary Disease. The November 2023 EMAR (electronic medication administration record) indicated the resident could receive oxycodone/acetaminophen (a narcotic pain medication) 5 mg (milligrams), 325 mg every four hours PRN (as needed) for pain. During an interview on 01/12/23 at 2:13 P.M., Resident B indicated on Sunday 11/26/23 RN 2 asked him after lunch to take his PRN pain medication. He told her he was not having any pain and didn't need the medication. She told him if he didn't take it she would have to throw it away. The Controlled Substance Record indicated the resident received oxycodone/acetaminophen 5 mg, 325 mg on 11/26/23 at 7:15 A.M. and 1:00 P.M. Review of the November 2023 EMAR lacked documentation of the administration of the oxycodone/acetaminophen 5 mg, 325 mg on 11/26/23 at 7:15 A.M. and 1:00 P.M. During an interview on 01/16/24 at 2:01 P.M., RN 3 indicated a PRN medication should not be removed from the medication cart until the resident makes the request for the medication. Blanks in the EMAR indicated the medication was not given. When a controlled substance needed to be destroyed, there should be two nurses, the medication was placed in the drug buster container and both nurses sign the controlled substance record sheet. The current facility pharmacy policy with a revision dated of 01/10/22, was provided by the Director of nursing on 01/16/24 at 3:00 P.M. The policy indicated, .Document the administration of controlled substances in accordance with Applicable Law .Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application sight) on appropriate forms .Medication administration will be recorded on the MAR (Medication Administration Record)/EMAR or TAR (Treatment Administration Record) after given . This citation relates to Complaint IN00422886. 3.1-50(a)(1) 3.1-50(a)(2)

Based on interview and record review, the facility failed to identify pressure ulcers in a timely manner and document treatment administrations for 1 of 2 residents reviewed for pressure ulcers. (Resident 1) Findings include: During an interview on 06/07/23 at 9:31 A.M., Resident 1 indicated she had pressure wounds on her bottom that had recently healed. The resident's record was reviewed on 06/11/23 at 4:51 P.M. A Significant Change MDS (Minimum Data Set) assessment, dated 05/19/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, diabetes, heart failure, renal disease, and hypertension. The resident required extensive staff assistance with transferring, toileting, and personal hygiene. The resident was at risk for pressure ulcers, and currently had one Unstageable pressure ulcer (obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough [moist, non-viable tissue] or eschar [dead tissue]). A Wound Management Detail Report, dated 05/10/23, indicated a pressure ulcer was identified on the resident's left buttock that measured 1.3 cm (centimeters) x (by) 0.6 cm. The wound was unstageable, as it was 100% (percent) covered by slough. A Progress Note, dated 05/10/23 at 3:02 P.M., indicated a new, unstageable pressure ulcer was identified on the resident's left buttock. A new physician's order was obtained for treatment. The treatment was the daily application of Santyl (a medication that removed dead tissue from wounds) and an Optifoam dressing (a waterproof foam dressing with a high fluid-handling capacity). A Wound Management Detail Report, dated 05/26/23, indicated the pressure ulcer on the resident's left buttock measured 1 cm x 1 cm. The wound was still unstageable, as it was 100% covered by slough. A Wound Management Detail Report, dated 05/26/23, indicated a new pressure ulcer was identified on the resident's right buttock that measured 1.6 cm x 2 cm. This wound was unstageable, as it was 100% covered by slough. A Progress Note, dated 05/26/23, indicated a new, unstageable pressure ulcer was identified on the resident's right buttock. New interventions included a new wound treatment order, a low air loss mattress, and new physician's orders for a multivitamin and zinc supplements. The progress note indicated the current treatment order for the right buttock wound was Medihoney (a honey wound gel) and an Optifoam dressing. The May 2023 ETAR (Electronic Treatment Administration Record) was provided by the DON (Director of Nursing) on 06/12/23 at 1:03 P.M. The record indicated the following physician ordered treatments were administered: - The Santyl and Optifoam dressing treatment was administered daily to the left buttock from 05/10/23 until it was discontinued on 05/26.23, and - The Medihoney and Optifoam dressing treatment was administered daily to the left buttock from 05/26/23 until it was discontinued on 05/30/23. - A treatment listed on the May 2023 ETAR indicated nursing staff were to apply Skin Prep (a liquid, film forming dressing) to the dry area on the right buttock every shift from 05/10/23 until the treatment was discontinued on 05/30/23. The record lacked documentation of any other treatment to the wound on the resident's right buttock. Both wounds were documented as resolved on 05/30/23 in the Wound Management Detail Report. During an interview on 06/12/23 at 11:25 A.M., the DON indicated the wounds on the resident's buttocks should have been identified before they were unstageable wounds. The wound on the resident's right buttock was identified one day and gone a few days later. During an interview on 06/12/23 at 2:35 P.M., CNA (Certified Nurse Aide) 3 indicated staff were to look out for skin impairments. They would observe the residents' skin while assisting a resident with toileting, bathing, dressing, and undressing. If they found a wound, they would notify the nurse. They also filled out shower sheets on shower days and would note any skin impairments there. Resident 1 required enough assistance with ADLs (Activities of Daily Living) that her skin would be observed at least daily. The current facility policy, titled Skin Management Program, with a most recent revision date of 05/22, was provided by the DON on 06/12/23 at 1:03 P.M. The policy indicated, .It is the policy .to ensure that each resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable .a resident with pressure ulcers receives necessary care and treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing .Interventions to prevent wounds from developing and/or promote healing will be initiated . 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to store medications appropriately related to insulin pens for 1 of 2 medication carts reviewed. (Back Hall medication cart) Findings include: On 06/12/23 at 10:55 A.M., the Back Hall medication cart was observed with RN 2, and contained the following: - A Lispro insulin pen for Resident 5, with an open date of 05/14/23. The nurse verified the open date. The pen was 1/4 full. The resident had received the insulin that morning. - A Lispro insulin pen for Resident 7, with an open date of 05/14/23. The nurse verified the open date. The pen was 1/4 full. The resident had received the insulin that morning. During an interview on 5/14/23 at 10:58 A.M., RN 2 indicated the Lispro insulin pens were good for 30 days after the open date. During an interview on 06/12/23 at 2:00 P.M., the Administrator indicated the facility did not have a specific medication storage policy, they followed the pharmacy recommendations. The current facility pharmacy manual, with a revised date of 01/01/22, was provided by the DON on 06/12/23 at 11:45 A.M. The manual indicated, .Insulin Lispro pen once opened is good for 28 days . The pens should have been taken out of use after 06/10/23. 3.1-25(j) 3.1-25(o)

Based on observation, interview, and record review, the facility failed to provide fingernail care for 1 of 15 residents reviewed for Activities of Daily Living. (Resident 13) Findings include: During an observation and interview on 06/15/22 at 10:51 A.M., Resident 13 had long fingernails on both hands. He indicated his fingernails were long and he wished someone would cut them for him. During an observation and interview on 06/16/22 at 2:18 P.M., the resident was sitting in the hallway on the couch. The resident indicated his fingernails had not been trimmed. The fingernails on the residents left hand were long with some dark debris built up underneath a few of the nails. During an observation on 06/17/22 at 12:43 P.M., the resident was sitting in the dining room, eating lunch. The resident's fingernails were long with a dark buildup of debris underneath several of the nails. During an observation on 06/20/22 at 10:56 A.M., the resident was sitting in the dining room. The resident's fingernails were long and jagged with dark debris underneath several of the nails. The clinical record for Resident 13 was reviewed on 06/17/22 at 9:42 A.M. A Significant Change MDS (Minimum Data Set) assessment, dated 05/03/22, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, diabetes, anemia, heart failure, hypertension, depression, bipolar disorder, and schizophrenia. The resident required extensive assistance of two or more staff members with personal hygiene and total staff assistance with bathing. During an interview on 06/20/22 at 1:20 P.M., QMA (Qualified Medication Aide) 2 indicated resident showers were to be completed twice a week. During the shower she would check, cut, and clean the residents' fingernails. The Complete Care Plan was provided by the Corporate Clinical Nurse on 06/20/22 at 2:47 P.M. A Care Plan, with a start date of 05/19/22, indicated the resident required assistance and/or monitoring with AM/PM (morning and evening) care. The June 2022 Shower Day Skin Audit record was provided by the Corporate Clinical Nurse on 06/20/22 at 3:09 P.M. The record indicated the resident had received showers on the following dates: - 06/01/22, - 06/13/22, - 06/16/22, and - 06/19/22. During an interview on 06/21/22 at 2:43 P.M., the DON (Director of Nursing) indicated the facility did not have a policy related to ADL (Activities of Daily Living) care related to fingernails. The resident's fingernails should have been cleaned and trimmed on shower days and as needed. If the resident was a diabetic the nurse would trim the nails on shower days and as needed. 3.1-38(a)(2)(A)

Based on observation, interview, and record review, the facility failed to apply treatments to a resident's wound (Resident 12) for 1 of 15 residents reviewed for quality of care. Findings include: During an interview on 06/20/22 at 2:17 P.M., Resident 12 indicated he had open heart surgery well over a year ago. There had been problems with the wound healing in the past that required the use of a wound vac. The resident lifted his shirt, and his chest was observed. An approximately 12 cm (centimeter) long pink scar was observed in the center of the resident's chest. The resident's chest sloped inward on both sides along the length of the incision site. The resident indicated the surgical wound had been healed for quite some time, but the treatment that was in place a few months ago was to apply a cream to the area twice a day. Nursing staff didn't always apply the cream when it was supposed to be done. The resident's clinical record was reviewed on 06/21/22 at 2:14 P.M. A Significant Change MDS assessment, dated 01/13/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, heart failure, coronary artery disease, and hypertension. A progress note, dated 01/18/22 at 7:49 P.M., indicated the Nurse Practitioner was in to see the resident. A new physician's order was received to apply a protectant cream twice a day to the resident's old incision site on his chest. The facility Resident Council Minutes for the February 25, 2022 meeting were reviewed on 06/20/22 at 1:18 P.M. In the New Business section of the minutes, Resident 12 indicated the treatment to his chest was not getting done. The resident's January, February, and March 2022 TARs (Treatment Administration Record) indicated the resident had a physician's order with a start date of 01/18/22 that was discontinued on 03/30/22 to apply a protectant cream topically to the resident's chest incision twice daily for erythema (redness). The TAR lacked documentation the cream was applied at any time during the month of February. A progress note, dated 03/30/22 at 5:44 P.M., indicated a new physician's order was received to change the order for the protectant cream to the resident's chest from twice a day to once a day as needed. During an interview on 06/21/22 at 2:05 P.M., the Director of Nursing indicated the facility did not have a policy related to following MD orders. It was just standard nursing practice to follow MD orders. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to prevent an unstageable (full thickness tissue loss) pressure ulcer for 1 of 2 residents reviewed for pressure ulcers. (Resident 13) Findings include: During an observation on 06/21/22 at 10:02 A.M., Resident 13 was assisted back to his room from the hallway. RN 3 explained to the resident she was going to change the dressing to his buttocks. She washed her hands and donned gloves. She removed the old dressing that had a small amount of blood on the dressing. The wound was approximately the size of a nickel with a red/pink wound bed. The skin surrounding the wound was pink and healing. There was no odor. RN 3 cleansed the wound, doffed her gloves, washed her hands, and donned new gloves. She retrieved a tube of ointment from a plastic bag using both gloved hands. She removed the cap, applied a small amount directly to the wound bed, and spread the ointment with her left gloved finger. She covered the wound with a foam dressing. The clinical record for Resident 13 was reviewed on 06/17/22 at 9:42 A.M. A Significant Change MDS (Minimum Data Set) assessment, dated 05/03/22, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, diabetes, anemia, heart failure, hypertension, depression, bipolar disorder, and schizophrenia. The resident required extensive assistance of two or more staff members with personal hygiene and total staff assistance with bathing. The resident had an unhealed unstageable pressure ulcer. The March and April 2022 Progress Notes were provided by the Corporate Clinical Nurse on 06/20/22 at 2:47 P.M. The Progress Notes included the following: - 03/12/22 at 12:29 A.M., the resident had redness to the coccyx and needed assistance with all care, - 04/06/22 at 5:48 P.M., the resident required assistance of one to two staff with ADL's (Activities of Daily Living). The erythema continued on the bilateral buttocks, - 04/20/22 at 12:57 P.M., the resident reported pain with sitting on bottom. A treatment was being completed by the nurse. There was redness noted and no open areas. The April 2022 Shower Day Skin Audit records were provided by the Corporate Clinical Nurse on 06/20/22 at 3:09 P.M. The shower audits indicated the following: - 04/06/22, the resident had no new areas, continued with redness to the coccyx/sacrum and hips/buttocks, and ointment was initiated, - 04/20/22, the resident had redness to the coccyx/sacrum and hips/buttocks, there was unusual redness to the resident's body. - 04/25/22, the resident had no new areas, continued with redness to the coccyx/sacrum. The form indicated the areas were old areas. A Progress Note, dated 04/25/22 at 11:52 A.M., indicated a wound was found on the upper left buttock that measured 3 cm (centimeters) X (by) 3 cm. The wound was reported to the Nurse Practitioner and a new order was obtained to clean the wound with normal saline, cover with a thin layer of Santyl (an ointment that removes dead tissue) and cover with gauze dressing, daily. A Wound Management Detail Report, dated 05/01/22, indicated the resident had an unstageable-slough (yellow/white material in the wound bed), and/or eschar (dry black tissue) to the left buttocks that measured 3 cm X 3 cm. The wound had necrotic (dead) tissue and was 15% covered in eschar. A Wound Management Detail Report, dated 05/31/22, indicated the resident had an unstageable- slough and/or eschar to the left buttocks that measured 2.8 cm X 1.2 cm. The wound had a light amount of serosanguineous (pale red to pink, thin and watery) exudate with 85% of the wound covered in eschar. The resident was started on an antibiotic that day to aide in wound healing. A Wound Management Detail Report, dated 06/14/22, indicated the resident had a Stage 2 (loss of dermis presenting as a shallow open ulcer with a red-pink wound bed) to the left buttocks that measured 2.4 cm X 0.2 cm. The wound had a light amount of serous (clear, amber, thin, and watery) exudate. The Complete Care Plan was provided by the Corporate Clinical Nurse on 06/20/22 at 2:47 P.M. The Care Plan included the following: A Care Plan, with a start date of 02/23/22, indicated the resident was at risk for skin breakdown due to incontinence and impaired mobility. The resident removed the pressure reducing cushion from the chair. The interventions included to assist the resident with peri- care; keep clean and dry, encourage resident to turn and reposition at least every two hours; provide assistance as needed, house barrier cream at bedside; use as needed, incontinence care as needed using peri wash and moisture barrier, pressure reducing/redistribution mattress on the bed and pressure reducing cushion in the wheelchair. During an interview on 06/20/22 at 1:13 P.M., QMA (Qualified Medication Aide 2) indicated the resident would let staff know when he needed something. The resident had a urinary catheter and needed frequent help and queuing. The resident was incontinent of his bowels. The resident had a sore on his bottom, so the staff had to make sure the dressing was intact, and the resident would get cleaned up in the bathroom. The resident showers were completed twice a week. The staff would observe his skin and alert the nurse of any changes. During an interview on 06/20/22 at 2:14 P.M., LPN (Licensed Practical Nurse) 4 indicated when a resident had a new wound the wound would be assessed, the MD, DON (Director of Nursing), and family would be notified. Treatments would be started if ordered and a wound skin assessment event would be completed on the computer. During an interview on 06/20/22 at 2:07 P.M., the DON indicated the resident had been sitting in a chair in the dining room when his shirt had rolled up and it was noted the resident had a wound on his upper buttocks. The first time it was observed the wound already had necrotic tissue covering it. The nursing staff should monitor the resident's skin when taking them to the bathroom and when assisting them with changing their clothes. The resident would refuse showers at times. Any new redness or wounds should be communicated to the charger nurse and an assessment event completed on the computer. She would follow-up on any new wounds. If a resident had redness to the bottom that was blanchable the staff would apply cream. If a resident was started on a cream as a pressure prevention it would be documented in the progress notes. The current undated facility policy titled, Wound Care Prevention and Intervention was provided by the Corporate Clinical Nurse on 06/21/22 at 2:07 P.M. The policy indicated, The foundation of pressure injury management is prevention. The purpose of the recognition and assessment phases for residents who have not developed a pressure injury is to provide the framework for implementation of a prevention strategy that reduces the risk of pressure injury occurrence . The current facility policy titled, Dressing Change Clean Technique, dated 01/2010 was provided by the DON on 06/21/22 at 2:46 P.M. The policy indicated, .If using an ointment, or gel you may use a cotton-tip applicator or clean gloved finger. (If using clean gloved finger, remove gloves after application, perform hand hygiene, and put on new gloves prior to application of secondary dressing) . 3.1-40(a)(1) 3.1-40(a)(2)

2. Resident 19 was observed in her room in bed on 06/17/22 at 9:45 A.M. The resident's bed was in a low position, and a low air loss mattress was in place. The resident was laying on her right side leaning towards the wall. The resident was yelling out and indicated she would like some help to sit up. Staff were alerted and repositioned the resident in bed. The resident's clinical record was reviewed on 06/17/22 at 11:44 A.M. A Quarterly MDS assessment, dated 05/05/22, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, senile degeneration of the brain, hypertension, neurogenic bladder, malnutrition, and dysphagia. The resident received hospice services. The resident required extensive assistance from two staff members for bed mobility. The resident experienced one fall with a minor injury since the last assessment. A progress note, dated 05/01/22 at 08:57 P.M., indicated the resident was yelling help me help me get me off the floor. Staff entered the room, and the resident was sitting on her buttocks on the floor with her back resting on the frame of her bed. The resident was assessed, and her vital signs were normal. There was no apparent injury, but the resident's entire back was reddened. The resident was incontinent of stool at time of fall. The bed was in a high position, and the bed linens were scattered on the floor adjacent to the bed. The resident was assisted back into bed and pillows were placed on the side of the bed not resting against the wall to define bed parameters. The DON, Nurse Practitioner, Hospice Services, and the resident's family were notified of the fall. An IDT fall review note, dated 05/02/22 at 10:03 A.M., indicated the resident experienced a fall on 05/01/22 at 9:00 P.M. The resident rolled out of bed, was assessed by the nurse, and assisted back to bed with proper positioning. There were no injuries, and the resident was not in pain. The determined root cause of the fall was that positioning was difficult due to the resident leaning. The intervention put into place was to address the root cause of the fall. The facility was to ask the hospice nurse for a scoop mattress to help with positioning. During an interview on 06/21/22 at 1:20 P.M., the Hospice RN indicated facility nursing staff could contact hospice anytime. They could call the office or speak to the hospice nurse directly. A scoop mattress was something hospice could provide the resident. The facility never talked to hospice about a scoop mattress for the resident. The resident's fall risk care plan, with a start date of 10/31/20, was reviewed. The interventions included, but were not limited to, an intervention with a start date of 05/02/22 to have hospice assess the resident for a bolster mattress (a mattress with soft foam bolsters in place to define the edges of the bed and prevent falling). During an interview on 06/21/22 at 2:05 P.M., the DON indicated the resident did not currently have a scoop mattress. The current facility policy, titled Fall Management Program, dated 04/22/21, was provided by the DON on 06/21/22 at 2:50 P.M. The policy indicated, .ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls .all falls will be discussed .to determine root cause and other possible interventions to prevent future falls .the care plan will be reviewed and updated, as necessary . 3.1-45(a)(2) Based on interview, record review, and observations, the facility failed to implement interventions following falls for 2 of 4 residents reviewed for accident hazards. (Residents 15 and 19) Findings include: 1. During an interview on 06/20/22 at 3:13 P.M., LPN (Licensed Practical Nurse) 4 indicated Resident 15 had fallen several times recently. A recent fall had resulted in a fracture to her pelvis bone. She had poor safety awareness and still thought she could get up and ambulate on her own. She was very unsteady. The clinical record was reviewed on 06/21/22 at 11:12 A.M. A Significant Change MDS (Minimum Data Set) assessment, dated 05/05/22, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, fracture of her pubis, dementia, and diabetes. The resident required extensive assistance of two staff members for bed mobility, transfers, and toilet use. The progress notes were provided by the DON (Director of Nursing) on 06/21/22 at 11:05 A.M. A note, dated 04/20/22 at 1:26 P.M., indicated a CNA (Certified Nurse Aide) had found the resident sitting on the floor in the dining room. The resident indicated she was trying to pick a piece of paper up off of the floor and lost her balance. The NP (Nurse Practitioner) had been notified of the resident's blood pressure being 70/40. The NP gave a new order to obtain orthostatic blood pressures lying, sitting, and standing, every shift for three days and to document the blood pressure values. No orthostatic blood pressures were documented in the progress notes. The EMAR/ETAR (Electronic Medication Administration Record/Treatment Administration Record) for April 2022 was provided by the DON on 06/20/22 at 2:00 P.M. The record indicated the resident had an order, with a start date of 04/20/22 and an end date of 04/22/22, to obtain orthostatic blood pressure lying, sitting, and standing daily for three days. The record lacked documentation that the blood pressures had been obtained and no values were documented. The Vitals Report was provided by the DON on 06/20/22 at 2:00 P.M. The report indicated one set of orthostatic blood pressures had been obtained on 04/20/22 at 5:08 P.M. No other orthostatic blood pressure values were documented in the record. A care plan indicating the resident was at risk for falls was provided by the DON on 06/20/22 at 1:05 P.M. An intervention, with a start date of 04/21/22, indicated to obtain orthostatic blood pressures (lying, sitting, and standing) every shift for three days. The current IDT (Interdisciplinary Team) Comprehensive Care Plan Policy, with a revised date of 10/2019, was provided by the DON on 06/21/22 at 2:51 P.M. The policy indicated, .The care plan will include measurable goals and resident specific interventions based on resident needs .to promote the resident's highest level of functioning .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The clinical record for Resident 2 was reviewed on 06/16/22 at 2:26 P.M. A Quarterly MDS assessment, dated 05/26/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, stroke, cancer, anemia, hypertension, diabetes, anxiety, and depression. A Pharmacy Consultation report, issued on 05/18/22 indicated the resident received Simvastatin and had not had a blood test for a fasting lipid panel documented in the medical record in the previous 12 months. The recommendation was to monitor a fasting lipid panel and LFTs on the next convenient lab day and every 12 months thereafter. The clinical record lacked documentation to indicated the MD had been notified of the pharmacy recommendation. 4. The clinical record for Resident 13 was reviewed on 06/17/22 at 9:42 A.M. A Significant Change MDS assessment, dated 05/03/22, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, diabetes, anemia, heart failure, hypertension, depression, bipolar disorder, and schizophrenia. A Pharmacy Consultation report, issued on 04/15/22 indicated the resident received Pravastatin Sodium and had not had a blood test for a fasting lipid panel documented in the medical record in the previous 12 months. The recommendation was to monitor a fasting lipid panel and LFTs on the next convenient lab day and every 12 months thereafter. The clinical record lacked documentation to indicated the MD had been notified of the pharmacy recommendation. During an interview on 06/21/22 at 2:25 P.M., the DON indicated the labs were not completed and the resident's pharmacy recommendations should have been sent to the MD and addressed. The current facility policy titled, Medication Regimen Review, with a revision date of 03/03/20, was provided by the DON on 06/21/22 at 3:13 P.M. The policy indicated, .Facility should independently review each resident's medication regimen directly from the resident's medical chart and with Interdisplinary Care Team members, resident or Responsible Party, as needed .The pharmacist will address copies of resident's MRR's [Medication Regimen Review] to the Director of Nursing and/or physician and to the Medical Director. Facility staff should ensure the attending physician, Medical Director, and Director of Nursing are provided with copies of the MRR's. For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected . 3.1-48(a)(3) Based on record review and interview, the facility failed to implement pharmacy recommendations in a timely manner for 4 of 5 residents reviewed for unnecessary medications. (Residents 6, 18, 2, and 13) Findings include: 1. The clinical record for Resident 6 was reviewed on 06/17/22 at 1:20 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 03/24/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, stroke, diabetes, and hyperlipidemia. The resident's current physician's orders included an open ended order, with a start date of 07/29/21, indicated the resident was prescribed to have atorvastatin (a medication to treat high cholesterol and triglyceride levels), 80 mg (milligrams) at bedtime for hypercholesterolemia. A Pharmacy Consultation report, issued on 04/15/22, indicated the resident received Atorvastatin and had not had a blood test for a fasting lipid panel documented in the medical record in the previous 12 months. The recommendation was to monitor a fasting lipid panel and LFTs (Liver Function Tests) on the next convenient lab day and every 12 months thereafter. During an interview on 06/21/22 at 3:37 P.M., the DON (Director of Nursing) indicated the pharmacy recommendation had not been addressed and the recommended blood tests had not been obtained. 2. Theclinicalrecordfor Resident 18 wasreviewedon06/20/22 at 2:52 P.M. AQuarterlyMDSassessment dated [DATE], indicated the resident was severely cognitively impaired. The diagnoses included, butwerenotlimitedto stroke neurogenicbladder aphasia hypertension, seizuredisorder anxiety anddepression APharmacyConsultationreport dated01/12/22, indicated the resident received Atorvastatin 40 mg daily and had not had a blood test for a fasting lipid panel documented in the medical record in the previous 12 months. The recommendation was to monitor a fasting lipid panel and LFTs on the next convenient lab day and every 12 months thereafter. The Physician's Order record for January2022, was providedbytheDONon06/21/22 at 3:36 P.M. The record lacked documentation that the blood tests had been ordered. The DONindicatedthelabshadnotbeenordered