**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview the facility failed to revise and update care plans to include and address high risk medications and side effects to watch for in 3 out of 12 sampled residents reviewed for comprehensive care plans (Resident #20, #21 and #22). The facility reported a census of 27 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #20 documented diagnoses of cancer, hypertension and diabetes mellitus. The MDS showed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderately cognitive impairment. The MDS revealed the resident was taking diuretic medication in the review period. Review of the Order Summary Report signed by the physician dated 10/21/24 revealed an order for spironolactone tablet (diuretic medication) daily with a start date of 11/29/22 and furosemide tablet (diuretic medication) daily with a start date of 11/4/22. Review of the current Care Plan undated lacked information regarding the side effects of diuretic medication. 2. The MDS assessment dated [DATE] for Resident #21 documented hypertension, depression and low back pain. The MDS showed a BIMS score of 03 indicating severe cognitive impairment. The MDS lacked information of the resident taking opioid medication. Review of the Order Summary Report signed by the physician dated 9/12/24 revealed an order for morphine sulfate (opioid pain medication) with a start date of 7/12/24. Review of the current Care Plan undated lacked information regarding the usage and side effects of opioid pain medication. 3. The MDS assessment dated [DATE] for Resident #22 documented hypertension, orthostatic hypotension and edema. The MDS showed a BIMS score of 15 indicating no cognitive impairment. The MDS revealed the resident was taking anticoagulant medication in the review period. Review of the Order Summary Report signed by the physician dated 9/12/24 revealed an order for Eliquis daily (anticoagulant medication) with a start date of 2/25/24. Review of the current Care Plan undated lacked information regarding the side effects of anticoagulant medication usage. Interview on 11/14/24 at 8:58 a.m., with Staff A, Co-Director of Nursing revealed the facility only has a baseline care plan policy and after that the facility follows the RAI manual. Interview on 11/13/24 at 2:36 p.m., with Staff A, Co-Director of Nursing revealed the side effects to watch for should have been listed on the care plan for the staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS assessment dated [DATE] for Resident # 7 identified a BIMS score of 0, indicating severe cognitive impairment. The MDS included diagnoses of anxiety disorder and depression. Resident #7 received an antidepressant for seven out of seven days in the lookback period. The Notice of Negative Level I Screen Outcome dated 6/2/22 revealed the PASRR level I screen remains valid for your stay at the nursing facility and should be transferred with you if you relocate. No further level I screening is required unless you are known to have or are suspected of having a major mental illness or an intellectual or developmental disability and exhibit a significant change in treatment needs. Further review revealed the following questions indicated the answer to be no: a. Does the individual have any of the following Major Mental Illnesses, which included major depression? b. Does the individual have any of the following mental disorders, which include anxiety disorder? c. Currently or in the past, has the individual received any of the following mental health services? d. Does the individual have a diagnosis of dementia or Alzheimer's disease? The undated Care Plan Focus reflected that Resident #7 used an antidepressant medication related to depression. The Physician's Order Summary dated 4/13/23 signed by the provider listed diagnoses of generalized anxiety disorder and major depressive disorder, recurrent. The Telehealth Progress Notes dated 2/6/23 described that Resident #7 reported having some hallucinations (hearing or seeing things not there) of seeing farm animals at times but stated it did not disturb him. He had a couple incidents of agitation and aggression since his last appointment. The note listed the following medications: a. 7/2/21: Lexapro (escitalopram) take 10 MG by mouth every day due to major depressive disorder. b. 8/25/22: Seroquel (quetiapine) take 50 MG by mouth daily due to behavioral disorders associated with dementia. c. Desyrel (trazodone) take 75 MG by mouth at night due to anxiety disorder and trouble sleeping. The Pharmacy Review - GDR Request Psychotropic Medications signed by the provider on 1/10/23 directed to please continue medications as ordered. Resident #7 continued to sundown (increased confusion that starts in the late afternoon into the night), paranoia (irrational suspicion or mistrust of others) and hallucinations at bedtime. Review of Resident #7's chart lacked a follow-up and resubmission of his PASRR due to his diagnosis of anxiety disorder, information regarding mental health services, or the increase in mental health symptoms. The facility reported that they did not have a policy for PASRRs, as they follow the PASRR recommendations. On 8/23/23 at 11:06 AM the Social Services explained that she expected the PASRR to have been resubmitted with the updated diagnosis and mental health symptoms. Based on clinical record review and staff interview, the facility failed to refer two residents with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 2 out of 3 residents (Residents #6 and #7) reviewed for PASRR requirements. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 documented diagnosis of dementia, depression, and anxiety disorder. The MDS included diagnoses of anxiety disorder and depression. Resident #7 used an antidepressant for seven out of seven days in the lookback period. Resident #6's Notice of Negative Level I Screen Outcome dated 11/2/16 revealed the PASRR level 1 screen remains valid for your stay at the nursing facility and should be transferred with you if you relocate. No further level I screening is required unless you are known to have or are suspected of having a major mental illness or an intellectual or developmental disability and exhibit a significant change in treatment needs. Further review revealed the following questions indicated the answer to be no: a. Does the individual have any of the following Major Mental Illnesses, which included major depression? b. Does the individual have any of the following mental disorders, which include anxiety disorder? c. Currently or in the past, has the individual received any of the following mental health services? d. Does the individual have a diagnosis of dementia or Alzheimer's disease? The Care Plan Focus revised 6/5/23 reflected that Resident #6 used antidepressant medication related to depression, agitation, and anxiety. The Intervention indicated that Resident #6 saw a psychiatric advanced registered nurse practitioner (PARNP) for symptoms and behaviors related to anxiety and depression. The Psychiatrist/Mental Health Provider Notes dated 8/25/22 at 12:55 PM listed that Resident #6 had significant agitation during his telehealth visit. The PARNP planned to increase his Zoloft to 50 milligrams (mg). The Progress notes listed that Resident #6 continued to see the PARNP on the following days 9/29/22, 11/9/22, 12/21/22, 1/6/23, 2/6/23, 4/6/23, and 6/8/23. The Telehealth Progress Notes dated 6/8/23 at 12:30 PM indicated that Resident #6 had a significant history of anxiety and dementia. Other diagnoses listed in the notes included major neurocognitive disorder and generalized anxiety disorder. The Medication list included the following orders: a. 12/9/22: Zoloft (sertraline) 50 milligrams (MG), take 75 MG by mouth for generalized anxiety disorder. b. 12/21/22: Trazodone 50 MG tablet, take 25 MG by mouth at night for major depressive disorder and trouble sleeping. The Order Summary Report dated 7/13/23 signed by the physician listed diagnoses of generalized anxiety disorder, depression, and dementia in other diseases classified elsewhere with behavioral disturbances. Review of Resident #6's chart on 8/23/23 showed the facility lacked a follow-up and resubmission of a PASRR with the additional diagnosis of major depressive disorder, major neurocognitive disorder, dementia, anxiety disorder and lacked information of the initiation of mental health services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, and staff interviews, the facility failed to follow a comprehensive care plan for one (Resident #15) of sixteen residents reviewed. The facility reported a census of 32 residents. Findings include: Resident #15's Minimum Data Set (MDS) assessment dated [DATE] included diagnoses of Alzheimer's dementia and osteoporosis. The MDS identified Resident #15 as totally dependent on two persons for bed mobility and transfers. Resident #15 required total assistance of one person with dressing, toilet use, personal hygiene, and eating. A Brief Interview for Mental Status (BIMS) not completed, as resident rarely/never understood. The staff assessment for Resident #15's mental status indicated she had a short-term memory problem, a long-term memory problem, and had severely impaired daily decision making skills. The MDS identified Resident #15 had an impairment on both sides to her upper and lower extremities. On 6/6/22 at 1:52 PM, observed Resident #15 resting in bed and positioned on her left side, with a blue hand roll (splint device) in her left hand, and noted contractures to her right hand's fingers with no device in that hand. On 6/7/22 at 9:59 AM, witnessed Resident #15 resting in bed, positioned on her back, with both hands resting on her upper abdomen with no splint devices in either hands. Noted a sign on the wall with the following documentation: carrot (splint device) in right hand and blue roll to left hand during the day and remove at meals. Observed the blue roll on Resident #15's nightstand. On 6/8/22 at 8:47 AM, saw Resident #15 sitting in her wheelchair in her room, with a washcloth in each hand. Resident #15's Care Plan problem initiated 5/31/19 indicated to help her acheive and maintain physical, mental, and psychosocial functioning. The included goal initiated on 5/31/19 indicated to decrease further progression of hand contractures as evidenced by her ability to wear a hand splint. The included interventions directed the following a. (2/24/21) Staff to apply a therapy carrot in her right hand with her small finger placed at three centimeters (cm) marking. Perform gentle passive range of motion (PROM) to carefully open digits before application. Place from palm into her hand to avoid shearing. Ensure the tip of her small finger was fully over the top of the carrot. Resident #15 should wear daily and nightly. Remove during meals for skin checks. b. (3/3/22) Place left c-grip splint every night and remove each morning daily. c. (5/31/19) Left hand: Blue hand roll in place during the day and remove at meals. On 6/8/22 at 12:00 PM, Staff A, Occupational Therapist (OT), stated that each resident's restorative program got added to the Care Plan by OT. Staff A said that she expected the staff to follow the restorative programs as recommended. The OT Discharge summary dated [DATE] the following comments: a. Resident #15 would tolerate appropriate splinting for one to two hours without any signs of skin irritation or skin breakdown. b. Staff would be consistent with OT recommendations related to Resident #15's range of motion (ROM), proper skin hygiene, wearing schedule, splint application, and splint removal. c. Resident #15 would tolerate ROM Functional Maintenance Program (FMP) and appropriate splinting to maintain ROM, prevent further contracture, decrease pain, and decrease skin breakdown. The Discharge Recommendations directed the staff on education in ROM, stretching, and splinting to maintain gains made during therapy. The Splint and Brace Program Established?Trained: indicated a therapy carrot on her right hand and a roll splint in her left hand. The prognosis to maintain current level of function documented as excellent with consistent staff support, excellent with participation in restorative nursing program, and excellent with participation in FMP. On 6/8/22 at 4:11 PM, the Nurse Consultant reported that she expected the staff to follow the resident's Care Plan.

Based on observation and staff interview, the facility staff failed to perform hand hygiene before and after using gloves for 1 out of 3 residents observed. The staff also failed to prevent cross contamination of a medication cup for 1 out of 3 residents observed. The facility reported a census of 32. Findings: On 6/9/22 at 7:46 AM observed Staff B, Registered Nurse (RN), fail to perform hand hygiene before she applied gloves for the administration of Systane Balance Solution 0.6% eye drops to Resident #21. After the administration Staff B exited the room and discarded the gloves. Staff B failed to perform hand hygiene before she touched the medication box, medication cart, and goggles. The Medication Administration Record (MAR) documentation for 6/9/22 indicated that Staff B administered the Systane Balance Solution 0.6% eye drops to Resident #21. On 6/9/22 at 9:10 AM watched Staff B, RN, place Resident #24's calcium pills into a medication cup, then placed the mediation cup between her bicep and torso while she completed hand hygiene. After the nurse exposed the medication cup to her scrub top she gave Resident #24 the medication cup. Resident #24 placed her lips on the cup to take her medication. The MAR documentation for 6/9/22 indicated Staff B administered Calcium-D 600-400 Milligram-Unit (mg/U) tablets to Resident #24. The policy titled Handwashing revised 5/20 instructed staff to wash their hands with either soap and water or with an alcohol-based handrub before and after providing direct resident care, before and after using disposable gloves, and following contact with blood or any other infectious materials. Hands will also be washed after completion of a dirty task, prior to beginning a clean task. On 6/9/22 at 9:55 AM, the Director of Nursing, (DON), acknowledged that she witnessed Staff B fail to complete hand hygiene before and after using gloves for eye drop administration. The DON also acknowledged Staff B failed to prevent possible cross contamination when she placed the medication cup against her scrubs. The DON stated, absolutely the nurse should sanitize her hands before putting on gloves and afterwards. There was no denying that. On 6/9/22 at 2:55 PM, the Administrator stated, they absolutely expected the staff to perform hand hygiene before and after using gloves that is a standard. The Administrator acknowledged a risk of cross contamination occurred when Staff B placed the medication cup against her scrub top.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #28's MDS assessment dated [DATE] documented a BIMS score of 13, indicating intact cognition. On 6/7/22 at 9:39 AM, Resident #28 reported that Care Conferences did not occur. The review of Resident #28's EHR progress notes dated 11/8/21 - 6/8/22 lacked documentation of Care Conference meetings or a review of the Care Plan with her and each required member of the IDT. On 6/8/22 at 10:00 AM, the DON said that they used to do care conferences before COVID. The DON explained that she in progress to get them going again. Each department head reviewed the Care Plan with the residents. The DON listed the departments to be: dietary, social services, activities and MDS nurses. When asked if she expected Care Conference progress notes to be completed by each department the DON commented that they should be doing them. On 6/8/22 at 12:10 PM, the Nurse Consultant reported that she had already identified the Care Conference documentation issue. The Nurse Consultant reported they were currently working on a plan of correction. The Nurse Consultant reported the facility lacked a policy for Care Conferences. Based on resident interviews, clnical record reviews, and staff interviews, the facility failed to provide Care Conferences or have each member of the Interdisciplinary Team (IDT) review the Care Plan with the resident for five (Residents #4, #12, #14, #19, and #28) of sixteen residents reviewed. The facility reported a census of 32 residents. Findings include: 1. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. On 6/6/22 at 2:11 PM, Resident #4 stated she didn't know of any care conferences. She reported that she didn't attend a Care Conference or get invited to one. The review of Resident #4's Electronic Health Record (EHR) progress notes dated 11/2/21 - 6/9/22 lacked documentation of Care Conference meetings or a review of the care plan with her and each required member of the IDT. 2. Resident #12's MDS assessment dated [DATE], documented a BIMS score of 14, indicating intact cognition. On 6/6/22 at 1:10 PM, Resident #12 stated he didn't know what a Care Plan meetings was. Resident #12 denied being invited or attending a Care Plan meeting. The review of Resident #12's EHR progress notes dated 3/31/22 - 6/9/22 lacked documentation of a Care Conference meeting or a review of his Care Plan with him and each required member of the IDT. 3. Resident #14's MDS assessment dated [DATE] documented a BIMS score of 15, indicating no cognitive impairment for decision-making. On 6/7/22 at 10:05 AM, Resident #14 reported that she didn't get invited to Care Plan Conferences. The review of Resident #14's EHR progress notes dated 12/19/21 - 6/9/22 lacked documentation of care conference meetings or review of care plan with resident and each required member of the IDT. 4. Resident #19's MDS assessment dated [DATE] documented a BIMS score of 15, indicating no cognitive impairment for decision-making. On 6/6/22 at 1:24 PM, Resident #19 stated he didn't know of Care Plan meetings. Resident #19 explained that her did not attend or get invited to one. The review of Resident #19's EHR progress notes dated 11/2/21 - 6/9/22 lacked documentation of Care Conference meetings or a review of his Care Plan with him and each required member of the IDT. During an interview on 6/7/22 at 3:00 PM, the Director of Nursing (DON) explained that they were currently not holding care conferences due to novel Coronavirus 2019 (COVID), or group meetings. The DON added that each quarter each discipline meets with the residents individually and reviews their Care Plan with them.