**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, policy review, and the Resident Assessment Instrument (RAI) Manual, the facility failed to compete a Minimum Data Set (MDS) significant change assessment for a resident starting on hospice services for 1 of 2 residents reviewed (Resident #16). The facility reported a census of 38 residents. Findings include: The MDS dated [DATE] for Resident #16 documented a Brief Interview for Metal Status (BIMS) score of 9 indicating moderate cognitive impairment. Review of the Clinical Census revealed Resident #16 started on hospice care 11/15/23. Record review of Resident #16 Progress Notes dated 11/15/23 at 12:01 PM documented the resident was admitted to hospice services. An interview on 1/08/24 at 1:40 PM Staff A, Registered Nurse (RN) reported the facility should complete a new MDS when there is a significant change in the resident since last MDS completed and update the Care Plan. On 1/08/23 at 2:05 PM, the Director of Nursing (DON) reported an MDS is completed when there is a significant change, quarterly, annually, admission, death, or discharge. She expects staff to update the Care Plans daily. Review of the facility policy titled MDS 3.0 documents to see the RAI Manual on how to identify a significant change and the timeline for completing it. Review of the Long-Term Care Facility RAI 3.0 User's Manual dated 10/01/23 stated in Chapter 2, page 23, directed the following: A Significant Change in Status Assessment (SCSA) is required to be performed when a resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14 days from the effective date of the hospice election. A SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving his/her highest practicable well-being at whatever stage of the disease process the resident is experiencing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and policy review the facility failed to update the Care Plan to address risk factors and interventions related to high risk medication for 1 out of 12 residents reviewed for comprehensive Care Plans (Resident #16). The facility reported a census of 38 residents. Findings include: Resident #16's MDS assessment dated [DATE] documented a Brief Interview for Metal Status (BIMS) score of 9 indicating moderate cognitive impairment. Review of the December 2023 Medication Administration Record revealed the following orders: a. Lorazepam 0.5 mg PO (by mouth) every 2 hours as needed for anxiety/restlessness with a start date of 12/04/23 b. Morphine Sulfate 20 mg/ml give 0.25 ml PO every 2 hours as needed for pain/shortness of breath with a start date of 11/16/23. Review of the Care Plan lacked directions regarding the high risk medication to monitor for potential adverse consequences/complications. On 1/08/23 at 2:05 PM, the Director of Nursing (DON) reported she expects staff to update the Care Plans daily. Review of the facility policy titled Care Plan documented the plan of care should be modified to reflect the care currently required/provided for the resident. It lacked direction for timeline in which the care plan should be updated.

Based on record review, staff interviews, and policy review the facility failed to provide quality and preventative care for 1 of 1 residents (Resident #30) when three (3) falls occurred after self transfers and/or ambulation in attempts to get to/from the bathroom and root cause analysis was not implemented into the residents plan of care. The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) Assessment for Resident #30 dated 2/26/23 revealed a Brief Interview of Mental Status (BIMS) of 15 indicating no cognitive impairment. It informed he needed extensive assist of one (1) person with bed mobility, transfers, walking in room, and toilet use. It also revealed he had a catheter in place and had a fall in the past month prior to his admission to the facility. Record review of an Incident Report dated 3/21/2023 for Resident #30 revealed he was found in his room on the floor when coming back from the bathroom and obtained an abrasion and a skin tear to his right elbow. Record review of an Incident Report dated 7/26/23 for Resident #30 revealed he was found in his room on the floor when attempting to go the the bathroom no injuries were obtained. Record review of an Incident Report dated 10/12/23 for Resident #30 revealed he was found in his room on the floor when coming back from the bathroom and obtained a skin tear to his right arm. The MDS Assessment for Resident #30 dated 10/30/23 documented a BIMS of 15. It informed he was dependent on staff for toilet use and needs substantial/maximal assistance (staff do more than half the effort) for chair to bed transfers, toilet transfers, and siting to standing. Record review of Resident #30's Care Plan on 1/8/2024 lacked revision to his plan of care and interventions implemented from falls while at the facility since his admission Care Plan on 2/22/2023. Record review of and e-mail correspondence on 1/9/24 at 2:13 PM with the Administrator revealed fall interventions are now put in place for Resident #30 Care Plan for falls that occurred on 3/21/2023, 7/26/2023, and 10/12/2023. She also informed two (2) interventions were resolved and have been unresolved now. She informed the facility is unsure why they were resolved. During an interview with the Director of Nursing (DON) on 1/10/2024 at 11:20 AM revealed she would expect all fall interventions to be implemented into the residents plan of care. Record review of the facilities policy Fall Prevention and Management dated 3/29/2023 instructed the facility to perform root cause analysis which is a method for identifying the cause of a problem so that the best solutions can be identified and put into place.

Based on record review, staff interviews, and policy review the facility failed to have the physician give rationale for continuation of antibiotic therapy for 1 of 1 residents (Resident #32) who entered the facility on a daily antibiotic. The facility reported a census of 38 residents. Findings include: Review of Resident #32's orders instructed for her to take an antibiotic (Minocycline 50 milligrams (mg)) everyday for prevention of Urinary Tract Infection (UTI) due to a personal history of UTI's. Review of Resident #32's Progress Notes revealed she had not been diagnosed for a UTI since admission to the facility. Review of a Progress Note dated 10/30/2023 at 11:36 AM by the facilities Consultant Pharmacist revealed a request was made to Resident #32's provider to review antibiotic (Minocycline) use. Review of a document titled, Note to Attending Physician/Prescriber dated 10/31/23 documented a note to Resident #32's provider informing him she is taking antibiotics (Minocycline 50 mg) everyday for prevention of UTI and extended use of antibiotics may increase the risk for bacterial resistance and to review continued need for use of the antibiotic to ensure the benefits exceed the risk. The physician signed and dated the document, however did not give supporting rationale to why she should continue to take the antibiotic. Review of Resident #32's current Care Plan on 1/10/2024 lacked documentation for when a review would be completed for extended use of her antibiotic treatment (Minocycline) everyday and side effects to look for. During an interview with the Director of Nursing on 1/10/24 at 11:08 AM revealed she would expect a rationale for continued antibiotic use. Review of the facilities policy titled, Medication: Drug Regimen Review dated 2/10/2023 revealed the following: Medication reconciliation is a comparison of admitting medication orders to medication taken at home and/or at the hospital to ensure order accuracy and resident safety. Medication reconciliation is an important process that must be completed for every resident upon admission.