**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 147 residents with four residents in the sample for indwelling catheter care. Based on observation, interviews, and record review the facility failed to ensure Resident (R) 1 received appropriate catheter care when staff inserted the wrong-sized suprapubic catheter (a tube inserted through the abdomen into the bladder to drain urine into a collection bag). This deficient practice placed the resident at risk for pain and catheter-related complications. Findings included: - R1's Physicians Orders dated 10/24/24 documented a diagnosis of neuromuscular dysfunction of the bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system). R1's admission Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS noted R1 was independent with activities of daily living (ADL). The MDS did not indicate R1 had an indwelling catheter. R1's Quarterly MDS dated 05/28/25 recorded a BIMS score of 15. The MDS noted R1 had an indwelling catheter. R1's Care Plan dated 05/07/25 documented he had a suprapubic catheter, 20 French (external diameter of the catheter) with 10 cubic centimeters (cc) [NAME] and directed staff to change the catheter monthly on the fifth and as needed (PRN) for neurogenic bladder. On 05/07/25 at 02:04 PM, R1's Progress Notes documented the facility nurse attempted to replace R1's suprapubic catheter because staff had placed the wrong size catheter (12 French). The note documented the nurse attempted to place a 20 French catheter but was unable to place it after several attempts using descending diameter sizes. The note recorded the nurse was finally able to place the 12 French. On 05/09/25 at 03:46 PM, R1's Progress Notes documented R1 returned from a urology (specializing in the urinary system) appointment with a 16 French suprapubic catheter; R1's next scheduled appointment was 06/13/25. R1's Physician's Order dated 05/09/25 indicated R1 had a suprapubic catheter due to obstructive uropathy (urine flow is restricted due to an obstruction) and required a 16 French catheter. Observation on 06/16/25 at 12:35 PM revealed Licensed Nurse (LN) G provided suprapubic catheter care for R1. Observation further revealed no concerns with the catheter. R1 denied complaints of pain or discomfort during the procedure. On 06/16/25 at 03:45 PM, Administrative Nurse E said a facility nurse tried to replace the 12 French catheter that was placed in error with the 20 French catheter as ordered. Administrative Nurse E said that as soon as the 12 French catheter was removed, the site started closing quickly and the staff nurse was barely able to get the 12 French back in place. Administrative Nurse E said staff called the physician and the physician was stretching R1's catheter opening out again slowly. On 06/16/25 at 04:30 PM, Administrative Nurse D stated she expected staff to use the proper indwelling catheter size as ordered. The facility policy Catheter Care dated 2022 directed staff to report any complications the resident may have with burning, tenderness, or pain; and report other information in accordance with facility policy and professional standard of practice.

The facility reported a census of 147 residents; four residents were sampled. Based on observation, interviews, and record review the facility failed to maintain an effective infection control program related to Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing indwelling suprapubic catheter care (a tube inserted through the abdomen into the bladder to drain urine into a collection bag). Additionally, staff failed to disinfect the Hoyer lift (full-body mechanical lift) after use. This placed the residents at risk for infections. Findings included: - Observation on 06/16/25 12:35 PM Licensed Nurse (LN) G providing suprapubic catheter care for Resident (R)1. LN G donned gloves but no gown and proceeded with the catheter care. Observation on 06/16/25 at 11:20 AM revealed LN H assisted Certified Nurse Aide (CNA) M with transferring R2 from her bed to the shower chair using the Hoyer lift. Upon leaving R2's room LN H took the Hoyer lift and placed it in the hallway cubby without wiping down the lift. On 06/16/25 at 03:40 PM, Administrative Nurse E stated the staff were supposed to follow the instructions on EBP. Administrative Nurse E further stated staff should clean the lifts after use and in between residents. On 06/16/25 at 4:30 PM, Administrative Nurse D stated she expected the staff to verify the EBP correctly and she expected the staff to wipe down the lifts between each resident. The facility's policy Enhanced Barrier Precautions dated 10/07/24 recorded EBP precautions in addition to standard and contact precautions will be implemented during high-contact care activities when caring for residents that have an increase to acquiring a multidrug-resident organism (MDRO) such as a resident with wounds, indwelling medical devices or residents with infection or colonized with MDRO. The facility's policy Cleaning and Disinfection of Resident-Care Items and Equipment dated 2018 directed that resident care equipment, including reusable items and durable medical equipment, will be cleaned and disinfected according to CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. Reuseable resident care equipment will be decontaminated and /or sterilized between residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The Diagnoses tab of R13's Electronic Medical Record (EMR) documented diagnoses of schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), epilepsy (brain disorder characterized by repeated seizures), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (HTN-elevated blood pressure), intellectual disabilities, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), sleep apnea (a disorder of sleep characterized by periods without respirations), adult failure to thrive (includes not doing well, feeling poorly, weight loss, and poor self-care that could be seen in elderly individuals), and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). The Modification of Significant Change Minimum Data Set (MDS) dated 11/15/24, documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R13 had an impairment on both sides of his body. The MDS documented R13 was dependent on staff for activities of daily living (ADLs). R13's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 11/15/24 documented that R13 had impaired cognitive function or impaired thought processes related to developmental delays. R13's Communication CAA dated 11/15/24 documented R13 had a diagnosis of cerebral palsy and had impairment with communication. R13's Care Plan dated 12/02/24 documented R13 suffered from a self-care deficit related to a decline in his prior level of independence resulting in the need for continued medical care related to cerebral palsy, intellectual disabilities, low vision, schizoaffective disorder, epilepsy, and adult failure to thrive. R13's plan of care documented R13 was dependent on staff for oral hygiene, personal hygiene, and eating. On 12/01/24 at 08:32 AM R13 sat in the dining area in his wheelchair, awaiting his breakfast, Certified Nurse's Aide (CNA) M walked by R13, grabbed his juice glass, and gave him a drink while standing over R13, and then walked away. CNA M did not speak to R13 during the observation. On 12/04/24 at 12:33 PM, Licensed Nurse (LN) G stated if a staff member was helping a resident eat or drink, the staff member should be at eye level with the resident and engaging with the resident. On 12/04/24 at 12:48 PM, Certified Nurse's Aide (CNA) M stated staff should sit next to the resident, and never just walk by the resident to give them a drink or a bite to eat. On 12/04/24 at 02:21 PM Administrative Nurse D stated staff should be engaging with residents when helping a resident eat or drink. She stated staff members should never stand over a resident while they assist the resident with eating. The facility's Quality of Life-Dignity policy revised on 02/2020 documented that each resident should be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth, and self-esteem. Residents would be always treated with dignity and respect. The facility's culture was one that supports and encourages humanization and individuation for residents and honors resident choices, preferences, values, and beliefs. The facility failed to ensure R13's dignity when staff stood over R13 to give him a drink of his juice and did not interact. This deficient practice placed R13 at risk for impaired dignity and decreased psychosocial well-being. The facility identified a census of 147 residents. The sample included 29 residents with two residents reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 75's right to be treated with respect, and dignity when her clothing protector was not removed after the meal was finished. The facility also failed to ensure a dignified dining experience for R13 when staff stood over him instead of sitting beside him. This deficient practice placed these residents at risk for negative psychosocial outcomes and decreased dignity. Findings included: - R75's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational ion (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a progressive mental disorder characterized by failing memory and confusion). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. R75's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 09/26/24 documented she was cognitively impaired. R75's Care Plan dated 09/12/24 documented she required substantial to maximum assistance with meals. The plan of care documented she was dependent on staff assistance with all other activities of daily living. The plan of care dated 09/24/24 documented it was very important to R75 to receive snacks between meals. On 12/02/24 at 10:32 AM R75 sat in her high-back wheelchair in the dining room asleep. R75 had a clothing protector attached around her neck that had fallen off her left shoulder and arm. R75 was not positioned at a dining room table and there were no drinks or food on any dining room tables. On 12/04/24 at 12: 25 PM, Certified Nurse Aide (CNA) N stated no resident should have a clothing protector on if they are not eating or drinking. CNA N stated having a clothing protector left on would be a dignity concern. On 12/04/24 at 12:35 PM, Licensed Nurse (LN) H stated R75 should not have a clothing protector left on after the meal had ended. On 12/04/24 at 02: 21 PM, Administrative Nurse D stated she expected all the clothing protectors removed after each meal. The facility's Quality of Life-Dignity policy last revised on 02/20 documented each resident would be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth, and self-esteem. Residents would be always treated with dignity and respect. The facility's culture was one that supports and encourages humanization and individuation for residents and honors resident choices, preferences, values, and beliefs. The facility failed to ensure R75's right to be treated with respect, and dignity when her clothing protector was not removed after the meal was finished. This deficient practice placed R75 at risk for negative psychosocial outcomes and decreased dignity.

The facility identified a census of 147 residents. The sample included 29 residents with one reviewed for notification of changes. Based on observation, record review, and interviews, the facility failed to notify Resident (R)13's guardian of changes related to the addition of psychotropic (alters mood or thoughts) medications. This deficient practice placed R13 at risk for uninformed care choices or inability to consent or decline treatment. Findings included: - The Diagnoses tab of R13's Electronic Medical Record (EMR) documented diagnoses of schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), epilepsy (brain disorder characterized by repeated seizures), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (HTN-elevated blood pressure), intellectual disabilities, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), sleep apnea (a disorder of sleep characterized by periods without respirations), adult failure to thrive (includes not doing well, feeling poorly, weight loss, and poor self-care that could be seen in elderly individuals), and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). The Modification of Significant Change Minimum Data Set (MDS) dated 11/15/24, documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R13 had an impairment on both sides of his body. The MDS documented R13 was dependent on staff for activities of daily living (ADLs). R13's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 11/15/24 documented R13 had impaired cognitive function or impaired thought processes related to developmental delays. R13's Psychotropic Drug Use Care Area Assessment (CAA) dated 11/15/24 documented R13 had a diagnosis of cerebral palsy and antisocial personality, and R13 had been prescribed antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medications. R13's CAA documented he would be monitored for behaviors and treated to help decrease his anxiety and depression. R13's CAA documented he received psychotropic medication and was at risk for adverse side effects. R13's Care Plan dated 12/02/24 documented R13 used Ativan (antianxiety medication) and nursing was to monitor and administer R13's antianxiety medication as ordered by the physician. The plan directed nurses to monitor for side effects and effectiveness of the medication every shift. R13's plan of care documented nursing was to monitor the resident for safety and monitor for increased risk of confusion, loss of balance, and cognitive impairment. R13's EMR under Orders documented the following physician's order: Lorazepam gel (Ativan) one milligram (mg) per one milliliter(ml) every eight hours as needed for agitation or anxiety apply 0.5mg topically every eight hours as needed (PRN) agitation dated 11/24/24. The order lacked a stop date. R13's clinical record lacked evidence of guardian notification for the new Ativan gel order. On 12/01/24 at 08:32 AM R13 sat in the dining area in his wheelchair, awaiting his breakfast. On 12/04/24 at 09:24 AM R13's guardian stated the nursing staff had called her about care plans and falls. R13's guardian stated she had never been called or informed about adding any medication, or medication changes. On 12/04/24 at 12:33 PM Licensed Nurse (LN) G stated it was the nurses' duty to call guardians and resident representatives and inform them of any medication changes. LN G stated when the guardian or representative was called, staff documented the communication in the progress nursing note section of the EMR. On 12/04/24 at 03:21 PM Administrative Nurse D stated it the charge nurse should call the resident's guardian with any changes. Administrative Nurse D stated the unit nurse managers run a report of all new orders daily, and unit managers could also follow up with a guardian or representative on any medication change or change of condition. The facility did provide a policy for notification of changes. The facility failed to notify R13's guardian of changes related to the addition of psychotropic medications. This deficient practice placed R13 at risk for uninformed care choices or inability to consent or decline treatment.

The facility identified a census of 147 residents. The sample included 29 residents reviewed for comprehensive assessments and timing. Based on observation, record review, and interviews, the facility failed to ensure the significant change Minimum Data Set (MDS) for Resident (R) 16 was accurately coded as required by the Resident Assessment Instrument (RAI) Manual. This placed R16 at risk for an inaccurate care plan and unmet care needs. Findings included: - R16 ' s Electronic Medical Record (EMR) recorded diagnoses of end-stage renal disease (ESRD-a terminal disease of the kidneys), and gastrostomy (the introduction of a nutrient solution through a surgically inserted tube into the stomach through the abdominal wall). R16 ' s Significant Change MDS dated 09/24/24 documented a Brief Interview for Mental Status (BIMS) score of eight which indicated a moderately impaired cognition. R16 was on a physician-prescribed weight gain regimen. R16 ' s MDS section K0520 Nutritional Approaches lacked documentation of a feeding tube (administration of nutritionally balanced liquefied foods or nutrients through a tube) and the percent of calories and amount of fluids provided per the feeding tube. R16 ' s Nutritional Care Area Assessment (CAA) dated 10/01/24 documented R16 was currently on enteral feedings and water flushes. R16 was at risk for dehydration. The registered dietician would monitor her intake and nursing staff would provide feeding. R16 ' s Tube Feeding CAA was not triggered. R16 ' s Care Plan last revised on 09/18/24 directed staff that R16 was dependent on staff for tube feeding and water flushes. The staff was directed to see physician orders for current feeding orders. R16 ' s Order Summary Report in the EMR documented a physician ' s order dated 07/18/24 for Nepro (therapeutic nutrition designed to help meet the specific nutrition needs of people on dialysis) nutritional supplement oral liquid 237 milliliters (ml) via feeding tube twice daily. On 12/03/24 at 11:45 AM R16 wheeled herself out to the dining room for lunch. R16 stated she was able to eat regular meals but did have the enteral feeding to supplement her meals due to a recent weight loss and her being on dialysis (a procedure where impurities or wastes are removed from the blood) therapy. On 12/04/24 at 02:04 PM Administrative Nurse F stated it appeared the dietician did not mark R16 ' s MDS for the enteral feeding when they completed the nutritional and tube feeding parts of the MDS. Administrative Nurse F stated that R16 was on enteral feeding and that she would do a modification to the MDS to ensure it was marked correctly. On 12/04/24 at 02:21 PM Administrative Nurse D stated she did not complete any part of the MDS but would expect the MDS staff that completed them to make sure they would be coded correctly. The facility did not provide a policy regarding the MDS as requested. The facility failed to ensure R16 ' s significant change MDS section K050 Nutritional Approaches was accurately coded as required by the RAI Manual. This placed R16 at risk for an inaccurate care plan and unmet care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 147 residents. The sample included 29 residents with Resident (R) 93 reviewed for abuse. Based on observation, record review, and interview, the facility failed to ensure staff provided appropriate and safe assistance with activities of daily living (ADL) to R93 during a transfer which resulted in bruises to both R93's arms. This deficient practice placed R93 at risk of decreased ADL ability, pain, and psychosocial distress. Findings included: - R93's Electronic Medical Record (EMR) documented diagnoses of repeated falls, hypertension (HTN-elevated blood pressure), blindness in one eye, and dementia (a progressive mental disorder characterized by failing memory and confusion). R93's Significant Change Minimum Data Set (MDS) dated 06/28/24 documented she had a Brief Interview for Mental Status (BIMS) score of 10 which indicated a moderately impaired cognition. R93 required substantial to maximal assistance of staff for bed-to-chair (or wheelchair) transfers. R93 had a history of one fall without injury and one fall with injury since her prior assessment. R93 was on hospice services. R93's Quarterly MDS dated 06/28/24 documented she had a BIMS score of 13 which indicated intact cognition. R93 was dependent on staff for bed-to-chair transfers. R93 had not had any falls since the prior assessment. R93 was on hospice services. R93's Functional Abilities Care Area Assessment (CAA) dated 07/01/24 documented she suffered from a self-care deficit related to a decline in her prior level of independence resulting in the need for continued medical care. She was on hospice services, and further decline was anticipated due to a cognitive communication deficit. R93's Care Plan initiated on 03/28/24 and last revised on 11/20/24 directed staff that R93 was dependent on two staff, using a Hoyer lift (full body mechanical lift) for chair-to-bed or bed-to-chair transfers. Prior to the 11/20/24 revision, the care plan directed R93 required substantial to maximal assistance but did not indicate the use of a [NAME] belt or how many staff were required. A Progress Note in R93 ' s EMR dated 11/19/24 at 03:40 PM documented that on 11/19/24 the hospice nurse contacted Administrative Nurse D to report that a hospice aide reported that Certified Nurse Aide (CNA) P transferred R93 in a rough manner. The hospice nurse stated that R93 had a purple mark in the shape of a thumb on each arm. Administrative Nurse D and the nurse manager went to talk to R93 and assess her. R93 reported that CNA P transferred her on 11/17/24 to her chair. R93 wanted the pads in the chair smoothed out but CNA P did not smooth them out and CNA P used R93 ' s upper arms to transfer her to the chair. R93 had a bruise in the shape of a thumb on each of her upper arms which was purple in color. R93 ' s provider was notified and stated she would assess the resident the following day. A Progress Note dated 11/21/24 at 11:58 AM from R93 ' s provider documented the resident was seen that day per request of Administrative Nurse D. R93 was seen in her room and said a staff member was trying to get her to transfer to her wheelchair but the resident was concerned because the wheelchair was full of bed pads. The resident said she told the aide she did not want to move with all the pads in the wheelchair. R93 thought the staff looked frustrated and mashed her arms. R93 said she and the aide had not had any prior animosity and she was not sure why the CNA did that. R93 said the aide just seemed determined to make her do what CNA P wanted. R93 denied pain. Assessment of R93 revealed her bilateral upper extremity bicep areas (upper arm area) had nearly symmetric single ecchymotic (bruising) lesions in the shape of a thumbprint present, without edema. The nurse manager and Administrative Nurse D were notified and were reviewing the episode with plans to make changes for a safe transfer for R93. The facility report documented an incident with R93 and CNA P that occurred on 11/17/24. Administrative Nurse D was notified by the hospice nurse, that the hospice aide had reported that facility CNA P had transferred R93 in a rough manner. CNA P used R93 ' s upper arms to transfer her to the chair. R93 had a bruise in the shape of a thumb on each of her upper arms which was purple in color. CNA P reported that R93 refused to be transferred with the gait belt. CNA P attempted to transfer R93 with the help of another CNA and R93 became stiff, arched her back, and was unwilling to grab the wheelchair per direction from the aides to assist with the transfer. CNA P held R93 ' s arms to keep her from falling as she transferred R93 to her wheelchair. Licensed Nurse (LN) J was asked how the resident transferred and said she had not transferred R93 recently. LN J went to try to transfer R93 and she again arched her back and would not cooperate with the transfer. R93 was downgraded to a Hoyer lift for transfer and a referral was sent for therapy. CNA P was counseled on always using a gait belt and if the resident refused to use the gait belt the transfer was to be stopped and notify the charge nurse. CNA P grabbed R93 by the arm to prevent her from falling. R93 was care planned to be a partial moderate assist with transfers, revealing she needed assistance from staff during the transfer. CNA P attempted to use the gait belt and R93 refused to allow the aide to place the belt around her. R93 insisted on transferring without the gait belt. CNA P did get another staff to help to ensure R93 was safe. CNA P was unaware that if a resident refused to use the gait belt to transfer, the transfer should be downgraded to a Hoyer lift to ensure the resident's safety. CNA P was educated regarding the proper use of the gait belt during transfers and demonstrated competency with partial moderate assist transfers. On 12/02/24 at 01:08 PM, R93 sat in her wheelchair in her room and said that CNA P was trying to transfer her on 11/17/24 and would not straighten the pads in her wheelchair. R93 said that CNA P grabbed her upper arms to transfer her to her wheelchair from her bed and left bruises on her arms. On 12/04/24 at 12:58 PM, CNA P stated R93 was upset that the pads in her wheelchair were not flat, so she transferred R93 from her wheelchair back to her bed but R93 did not want to sit back in the wheelchair, so she went to get another aide to help her. CNA P stated R93 did not want the gait belt on her to transfer so CNA P grabbed R93 by her upper arms to prevent her from falling while transferred to her wheelchair. On 12/04/24 at 01:00 PM LN I stated she could not say, without looking at the care plan, how R93 transferred but thought R93 was a Hoyer transfer. On 12/04/24 at 02:21 PM Administrative Nurse D stated she had thought R93 had been a one-person assist using a gait belt prior to the incident on 11/17/24 but would have to look at the care plan to verify that information. Administrative Nurse D stated that R93 was a two-person Hoyer lift for transfers now. Administrative Nurse D stated an investigation was done regarding the incident with R93 and CNA P, which resulted in a suspension until the investigation was completed. Administrative Nurse D stated CNA P was reeducated regarding proper transfer technique. The Activities of Daily Living (ADLs), Supporting policy documented that residents would be provided with the care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who were unable to carry out ADLs independently would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Interventions to improve or minimize a resident's functional abilities would be in accordance with the resident's assessed needs, preferences, stated goals, and recognized standards of practice. The facility failed to ensure staff provided appropriate and safe ADL assistance to R93 during a transfer which resulted in bruises to both R93's arms. This deficient practice placed R93 at risk of decreased ADL ability, pain, and psychosocial distress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 147 residents. The sample included 29 residents with seven residents reviewed for treatment and services to prevent and/or heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 22's heels were offloaded either by boots or a pillow and further failed to ensure R13 was provided a pressure-reducing cushion for his wheelchair. This placed R22 and R13 at increased risk for pressure ulcer development and delayed healing. Findings Included: - R22's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body), Methicillin-resistant Staphylococcus aureus (MRSA-a type of bacteria resistant to many antibiotics), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting the right dominant side, cognitive communication deficit, muscle weakness, congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), and dysphagia (swallowing difficulty). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented that R22 had an impairment on one side of his lower body. The MDS documented R22 was dependent on staff for lower body dressing and putting on and taking off footwear, oral hygiene, and toileting. The MDS documented R22 was at risk for pressure ulcers and had a Stage 1 (pressure wound which appears reddened, does not blanche, and may be painful but is not open) over a bony prominence, and had an unhealed pressure ulcer on admission. R22's Pressure Ulcer/ Injury Care Area Assessment dated 11/05/24 documented R22 was admitted with a right lateral foot deep tissue injury (DTI- purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) and a surgical wound on 10/25/24. R22 required assistance with bed mobility. R22's Care Plan revised 11/12/24 documented R22 was admitted with a right lateral foot DTI and surgical wound. Staff were to ensure adequate and proper repositioning every two hours, and as needed (PRN). Staff were to monitor skin condition with care, for color or texture changes, redness, edema, and incontinence-associated skin damage and report findings to the charge nurse. R22 was to use a pressure-reducing device in his chair and wheelchair. R22's EMR under Orders documented the following physicians' orders: Reposition the resident every two hours. Always keep heels offloaded every shift dated 10/31/24. R22's medical record lacked documentation R22 refused offloading. On 12/03/24 at 12:10 PM, R22 lay on his bed. R22's heel rested directly on the mattress. R22's heels were not offloaded. On 12/03/24 at 12:30 PM R22 laid on his bed visiting with his family. R22's heels were directly on the mattress. R22's heels were not offloaded. On 12/04/24 at 12:31 PM, R22 stated he was unaware his heels were supposed to be off the mattress. He stated he had boots, and sometimes the staff put the boots on him. R22 stated staff would put a pillow under his legs, which was usually at night. R22 stated he was not able to take his boots off or remove the pillow from under his legs. On 12/04/24 at 12:48 PM, CNA M stated he did have access to the [NAME] (a nursing tool that gives a brief overview of the care needs of each resident), but he usually referred to the daily report sheet. CNA M stated he carried the daily report sheet and could refer to the sheet if he was unsure what each resident needed for care. CNA M stated it was not on the daily report to float R22's heels. On 12/04/24 at 12:33 PM, Licensed Nurse (LN) G said ensuring boots are on the resident or offloading their heels would be the charge nurses' responsibility. LN G stated she did not think R22 could take his boots off on his own or remove a pillow if his heels were offloaded. On 12/04/24 at 02:21 PM Administrative Nurse D stated applying boots to a resident or ensuring heels were offloaded would be on the nurse's task, but the charge nurse could delegate that duty to the CNA if the nurse was busy. Administrative Nurse D stated the staff all work together to ensure all tasks are completed. The facility's Pressure Ulcers/Skin Breakdown policy revised on 04/18 documented that the nursing staff and practitioner would access and document an individual significant risk factors for developing pressure ulcers. The medical provider will help identify medical interventions related to wound management. A medical provider will order pertinent treatments, including pressure reduction surfaces, wound cleansing, and or dressings. The facility failed to ensure R22's heels were offloaded either by boots or a pillow. This placed R22 at increased risk for pressure ulcer development and delayed healing. - The Diagnoses tab of R13's Electronic Medical Record (EMR) documented diagnoses of schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), epilepsy (brain disorder characterized by repeated seizures), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (HTN-elevated blood pressure), intellectual disabilities, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), sleep apnea (a disorder of sleep characterized by periods without respirations), adult failure to thrive (includes not doing well, feeling poorly, weight loss, and poor self-care that could be seen in elderly individuals), and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). The Modification of Significant Change Minimum Data Set (MDS) dated 11/15/24, documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R13 had an impairment on both sides of his body. The MDS documented R13 was dependent on staff for activities of daily living (ADLs). The MDS documented R13 was at risk for pressure ulcers and had one or more Stage 1 (pressure wound which appears reddened, does not blanche, and may be painful but is not open) or higher. R13's Pressure Ulcer/ Injury Care Area Assessment dated 11/15/24 documented R13 was incontinent of bowel and bladder and required assistance with toileting and toileting hygiene. R13 would be assisted every two hours and as needed (PRN). R13's Care Plan dated 08/27/24 documented that staff were to ensure adequate and proper repositioning every two hours and PRN. Staff were to avoid massaging over bony prominences and may use lotions and moisturizers to prevent skin from drying out. Staff were to monitor skin condition with care, for color or texture changes, redness, edema, and incontinence-associated skin damage and report findings to the charge nurse Staff were to provide supplements as ordered for wound healing. R13 was to have a pressure-reducing device in his chair and or wheelchair and a pressure-reducing mattress. On 12/01/24 at 08:32 AM R13 sat in the dining area in his wheelchair. R13 had a blue and white blanket in his chair. R13 did not have a cushion in place. On 12/02/24 at 08:21 AM, R13 sat in the dining area in his wheelchair, R13 had a blue and white blanket in his chair. R13 did not have a cushion in place. On 12/03/24 at 08:17 AM, R13 sat in the dining area in his wheelchair. R13 did not have a cushion in place. On 12/04/24 at 11:43 AM Therapy Director GG stated therapy staff worked with R13 on positioning. She stated the therapy staff should have noticed that R13 did not have a cushion in his wheelchair. She stated nursing and therapy were responsible for ensuring the resident's care plan was followed. On 12/04/24 at 12:23 PM, Licensed Nurse (LN) G stated all staff have access to each resident's care plans. LN G stated she was unaware that R13 did not have a cushion in his wheelchair. She stated that it was the Certified Nurse Aide's (CNA) responsibility to help the resident into their wheelchair, but ultimately the nurse in charge was responsible for ensuring each resident had what they needed to stay safe. On 12/04/24 at 12:48 PM, CNA M stated he did have access to the [NAME] (a nursing tool that gives a brief overview of the care needs of each resident), but he usually referred to the daily report sheet. CNA M stated he carried the daily report sheet and could refer to the sheet if he was unsure what each resident needed for care. CNA M stated he could not remember the last time there was a cushion in R13's wheelchair. On 12/04/24 at 02:21 PM, Administrative Nurse D stated the CNAs would be the first check to ensure the cushion was in place; the charge nurse would be the second check, and the unit manager should have been notified the resident's cushion was not in place. The facility's Pressure Ulcers/Skin Breakdown policy revised on 04/18 documented that the nursing staff and practitioner would access and document an individual significant risk factors for developing pressure ulcers. The medical provider will help identify medical interventions related to wound management. A medical provider will order pertinent treatments, including pressure reduction surfaces, wound cleansing, and or dressings. The facility failed to ensure R13 had a cushion in his wheelchair. This placed R13 at increased risk for pressure ulcer development.

The facility identified a census of 147 residents. The sample included 29 residents with two residents reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 52's physician-ordered supplemental oxygen supply was turned on. The facility failed to ensure R109's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) was stored appropriately when not in use. This placed R52 and R109 at risk of respiratory complications and possible infection. Findings included: - R52's Electronic Medical Record (EMR) documented diagnoses of respiratory failure (a condition where your blood does not have enough oxygen), dysphagia (swallowing difficulty), aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit), dementia (a progressive mental disorder characterized by failing memory and confusion), and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) with hypoxia (inadequate supply of oxygen). R52's Significant Change Minimum Data Set (MDS) dated 09/14/24 documented a Brief Interview for Mental Status (BIMS) score of six which indicated severely impaired cognition. R52 had impairment on both sides of his lower extremity and used a wheelchair for mobility. R52 required substantial assistance with bathing, lower body dressing, and transfers. R52 required oxygen therapy. R52 was on hospice services. R52's Functional Abilities Care Area Assessment (CAA) dated 09/23/24 documented R52 suffered from self-care deficit secondary to assistance required in activities of daily living (ADLs), impaired balance and transition during transfers, and functional impairment in activity related to COPD and dementia. R52's Care Plan last revised on 06/26/24 directed staff of R52's supplemental oxygen as needed. The plan directed staff may titrate to keep oxygen saturation (percentage of oxygen in the blood) level above 90 percent (%). R52's Order Summary under the Orders tab of the EMR documented a physician's order dated 09/11/24 for continuous oxygen at one liter (L) per nasal cannula (NC). May titrate to keep oxygen saturation above 91%. A nurse Progress Note dated 11/20/24 at 08:51 AM for R52 documented an order was received from the provider for a chest X-ray. A nurse Progress Note: dated 11/21/24 at 08:07 AM for R52 documented the chest x-ray results were received and noted right basilar airspace opacities (findings that indicate something is in the space where air should be in the lungs) that was concerning for developing pneumonia. R52's provider had reviewed the results and ordered Amoxicillin (a medication used to treat bacterial infections) twice daily for seven days for pneumonia (an infection of the lungs). R52's Orders Summary under the Orders tab of the EMR documented a physician's order dated 11/21/24 for Amoxicillin to be given two times daily by mouth for pneumonia. On 12/02/24 at 07:47 AM, R52 sat in his wheelchair in his room, his NC was on and connected to his oxygen concentrator (a machine that provides supplemental oxygen) but the concentrator was not turned on. R52 was having some slight trouble getting his breath. Staff were notified that R52's concentrator was not on. On 12/04/24 at 12:55 PM, Certified Nurse Aide (CNA) O stated R52 was on continuous oxygen and should either have a portable oxygen tank with him or his NC should be connected to his concentrator in his room and be on at all times. On 12/04/24 at 01:00 PM Licensed Nurse (LN) I stated a resident who was on continuous oxygen should have the concentrator with them or always have a portable oxygen tank with them. LN I stated the aides should be making sure the concentrator was on when they did rounds. On 12/04/24 at 02:21 PM Administrative Nurse D stated she would expect nursing staff to check residents when getting them up or during rounds to ensure that their oxygen was on. Administrative Nurse D stated that R52 had gone to the hospital back in September and had been treated for pneumonia last month, so he was more vulnerable to respiratory issues. The Oxygen Administration policy was revised in October 2010 and documented to verify that there was a physician's order for the procedure. Review the physician's order or facility protocol for oxygen administration. Review the resident's care plan to assess for any special needs of the resident. Oxygen therapy was administered by way of an oxygen mask or an NC. The facility failed to ensure R52's physician-ordered supplemental oxygen supply was turned on. This placed R52 at risk of respiratory complications and possible infection. - R109's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of the need for assistance with personal care, cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and sleep apnea (a disorder of sleep characterized by periods without respirations). The Quarterly MDS dated 11/07/24 documented R109 had moderately impaired cognition. The MDS documented that R109 used a CPAP during the observation period. R109's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 01/22/24 documented she required staff assistance related to her CVA. R109's Care Plan dated 03/24/24 documented staff would clean her CPAP mask cushion and nose with soap and water and then hang it to dry. R109's EMR under the Orders tab revealed the following physician orders: Clean CPAP mask and tubing daily with soap and water and hang to air dry dated 05/09/24. On 12/03/24 at 04:14 PM, R109 sat out at the dining room table. In her room, R109's CPAP mask and tubing laid directly on her CPAP machine on the bedside table next to the bed. On 12/04/24 at 12:25 PM, Certified Nurse Aide (CNA) N stated she would clean R109's CPAP in the morning after she assisted R109 out of bed. CNA N stated she would clean the CPAP mask with a disinfectant wipe and then store the mask in a plastic bag. On 12/04/24 at 12:35 PM, Licensed Nurse (LN) H stated she would clean R80's CPAP mask every morning with soap and water and then hang it to dry. LN H stated the CPAP mask should never be placed directly on the bedside table or the CPAP machine. On 12/04/24 at 02:21 PM, Administrative Nurse D stated she expected the nurse on the unit to clean the CPAP mask with soap and water. Administrative Nurse D stated that the mask was to hung to air dry. Administrative Nurse D stated the CPAP mask should never be stored directly on the bedside table or top of the CPAP machine. The facility was unable to provide a policy related to the storage of respiratory equipment. The facility failed to ensure R109's CPAP mask was stored in a sanitary manner. This placed R109 at increased risk for respiratory infection and complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 147 residents. The sample included 29 residents with three residents reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to monitor Resident (R) 80's access site for complications at least daily and document the arteriovenous (AV-a surgically created connection between an artery and a vein used for hemodialysis) fistula for the thrill (palpable vibration) and bruit (an audible vascular sound associated with turbulent blood flow usually heard with a stethoscope that may occasionally also be palpated as a thrill) every day. This deficient practice placed R80 at risk of adverse outcomes and physical complications related to dialysis. Findings included: - R80's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of end-stage renal disease (ESRD-a terminal disease of the kidneys), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), a need for assistance with personal care, and cognitive communication deficit. The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R80 received dialysis during the observation period. The Quarterly MDS dated 05/13/24 documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R80 received dialysis during the observation period. R80's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 05/13/24 documented he required staff assistance with toileting and personal hygiene. R80's Care Plan dated 09/24/24 documented that staff would monitor, document, and notify the physician of any signs or symptoms of infection of his access site. The plan of care documented nursing staff would check and change his dressing daily at the access site. R80's EMR under the Orders tab revealed the following physician orders: Dialysis on Monday, Wednesday, and Friday for end-stage renal disease. Arteriovenous fistula (AVF- is an abnormal connection between an artery and a vein) located on the left upper extremity dated 09/22/24. A review of R80's EMR under the Assessment tab revealed Pre/Post Dialysis Evaluation reviewed from 09/11/24 through 11/29/24. The assessments documented assessment for signs of infection of his AVF and bruit and thrill on the days he received dialysis (three days weekly). R80's clinical record lacked evidence of daily assessment of R80's AVF and monitoring of thrill and bruit. On 12/03/24 at 03:15 PM, R80 sat in a recliner in his room with his lower extremities elevated as he watched the news on the TV. On 12/04/24 at 12:25 PM, Certified Nurse Aide (CNA) N stated she would help R80 get dressed and ready for dialysis. On 12/04/24 at 12:35 PM, Licensed Nurse (LN) H stated she would assess his access site every Monday, Wednesday, and Friday when received dialysis. LN H stated his AVF should be assessed at least daily and that would usually be documented on the Treatment Administration Record (TAR). On 12/04/24 at 02:21 PM, Administrative Nurse D stated she expected the nursing staff to assess R80's bruit and thrill every shift. Administrative Nurse D stated the nursing staff did not change the resident's dialysis access site dressing. Administrative Nurse D stated the nursing staff should monitor for any bleeding or any signs of infection. Administrative Nurse D stated the assessment of the access site would be documented on the resident's TAR. The facility's Dialysis policy last revised 09/2010 documented the staff would check thrills/bruit of grafts and fistulas, documented in EMR. When to remove the dressing from the access site placed on from the dialysis center. Monitor for signs and symptoms of infection including, but not limited to, fever, redness, tenderness, and bleeding at the fistula site. The facility failed to monitor R80's dialysis access site for the thrill, bruit, and signs of infection, bleeding, and the status of the dressing in place. This deficient practice placed R80 at risk of potential adverse outcomes and physical complications related to dialysis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 147 residents. The sample included 29 residents with two residents reviewed for trauma-informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Resident (R) 75's and R107 posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) and failed to implement individualized interventions to prevent re-traumatization. These deficient practices placed R75 and R107 at risk for decreased psychosocial well-being and ineffective treatment. Findings included: - R75's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational ion (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a progressive mental disorder characterized by failing memory and confusion). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. R75's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 09/26/24 documented she was cognitively impaired. R75's EMR under the Assessments tab revealed Activities/Social history and Initial Assessment dated 09/16/24 under the Trauma Informed Care section documented she had a history of trauma, and the intervention would be the staff would recognize her specific triggers and avoid re-traumatization. R75's Care Plan dated 09/27/24 documented staff would recognize her specific triggers to avoid re-traumatization. The plan of care lacked individualized interventions that identified ways to decrease exposure to triggers that could re-traumatize her. On 12/02/24 at 10:32 AM R75 sat in her high-back wheelchair in the dining room asleep. R75 had a clothing protector attached around her neck that had fallen off her left shoulder and arm. R75 was not positioned at a dining room table and there were no drinks or food on any dining room tables. On 12/04/24 at 12: 25 PM, Certified Nurse Aide (CNA) N stated she was not aware R75 had experienced trauma in her past. CNA N stated she was not aware of what triggers might retraumatize R75. On 12/04/24 at 12:35 PM, Licensed Nurse (LN) H stated she was not aware R75 had experienced trauma in her past. LN H stated she did not know what triggers could retraumatize R75. On 12/04/24 at 02:21 PM, Administrative Nurse D stated each resident was assessed for trauma-informed care at the time of admission to the facility, after changes in the psychosocial well-being of the resident and with every MDS. Administrative Nurse D stated if a resident had a history of past trauma personalized interventions should be listed on the resident plan of care to prevent the resident from being re-traumatized. The facility's Trauma Informed Care policy last revised 03/2019 documented the facility would guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. The facility supported a culture of emotional well-being and physical safety for staff, residents, and visitors. Trauma-informed care was culturally sensitive and person-centered. Caregivers are taught strategies to help eliminate, mitigate, or sensitively address a resident's triggers. As part of the comprehensive assessment, identify the history of trauma or interpersonal violence when possible. Identifying past trauma or adverse experiences may involve record review or the use of screening tools. Utilize trained and qualified staff members who have established a rapport with the resident to assess him or her for previous trauma. Interact with all residents and visitors in a manner that is welcoming and kind, without being intrusive. Reduce or eliminate unnecessary stimuli (noise, lighting, unwanted or sudden physical contact, etc.). The facility failed to identify trauma-based triggers related to R75's history of trauma and implement individualized interventions to prevent re-traumatization. These deficient practices placed R75 at risk for decreased psychosocial well-being and ineffective treatment. - R107's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of cognitive communication deficit, need for assistance with personal care, intellectual disability, PTSD, and schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. The MDS documented R107 had a diagnosis of PTSD. The Quarterly MDS dated 11/06/24 documented a BIMS score of 11 which indicated moderately impaired cognition. The MDS documented that R107 had a diagnosis of PTSD. R107's Psychosocial Well-Being Care Area Assessment (CAA) dated 08/20/24 documented she was having adjustment issues to admission affecting her desire to do things. R107's Care Plan dated 08/12/24 documented staff would engage her in simple, structured activities that avoided overly demanding tasks. The plan of care lacked individualized triggered -specific interventions that identified ways to decrease exposure to triggers that could re-traumatize her. R107's EMR lacked evidence of a Trauma Informed Care Assessment. The facility was unable to provide evidence a trauma-based care assessment was completed for R107 who had a diagnosis of PTSD. On 12/03/24 at 01:47 PM R107 sat in her wheelchair as she rolled herself up the hallway from her room to the dining room area. On 12/04/24 at 12:50 PM, Certified Nurse Aide (CNA) O stated she was not aware of any resident who had a diagnosis of PTSD. On 12/04/24 at 12:57 PM, agency Licensed Nurse (LN) I said she was not aware of any resident that had a diagnosis of PTSD. On 12/04/24 at 02:21 PM, Administrative Nurse D stated each resident was assessed for trauma-informed care at the time of admission to the facility, after changes in the psychosocial well-being of the resident and with every MDS. Administrative Nurse D stated if a resident had a history of past trauma personalized interventions should be listed on the resident plan of care to prevent the resident from being re-traumatized. Administrative Nurse D stated she was not sure why R107 was not assessed for trauma-based care at the time of her admission or at the time of her quarterly MDS. The facility's Trauma Informed Care policy last revised 03/2019 documented the facility would guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. The facility supported a culture of emotional well-being and physical safety for staff, residents, and visitors. Trauma-informed care was culturally sensitive and person-centered. Caregivers are taught strategies to help eliminate, mitigate, or sensitively address a resident's triggers. As part of the comprehensive assessment, identify the history of trauma or interpersonal violence when possible. Identifying past trauma or adverse experiences may involve record review or the use of screening tools. Utilize trained and qualified staff members who have established a rapport with the resident to assess him or her for previous trauma. Interact with all residents and visitors in a manner that is welcoming and kind, without being intrusive. Reduce or eliminate unnecessary stimuli (noise, lighting, unwanted or sudden physical contact, etc.). The facility failed to identify trauma-based triggers related to R107's diagnosis of PTSD and implement individualized interventions to prevent re-traumatization. These deficient practices placed R107 at risk for decreased psychosocial well-being and ineffective treatment.

The facility identified a census of 147 residents. The sample included 29 residents with two reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care. Based on interviews, record review, and observations, the facility failed to provide dementia-related behavioral services for Resident (R)30 to promote her highest practicable level of well-being. This deficient practice placed R30 at risk for decreased quality of life, isolation, and impaired dignity. Findings Included: - The Medical Diagnosis section within R30's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), history of seizures (violent involuntary series of contractions of a group of muscles), epilepsy (brain disorder characterized by repeated seizures), and insomnia (difficulty sleeping). R30's Significant Change Minimum Data Set (MDS) completed 10/30/24 noted a Brief Interview for Mental Status (BIMS) score of five indicating severe cognitive impairment. The MDS noted that verbal and physical behaviors were observed for one to three days during the assessment. The MDS noted her behaviors interfered with her care and put her at risk for injuries. The MDS noted her behaviors put others at risk for physical injury and intruded on the privacy of others. The MDS noted she rejected care one to three days during the assessment. The MDS indicated she had no upper or lower extremity impairments. The MDS noted she required substantial to maximal assistance with bed mobility, toileting, dressing, personal hygiene, and transfers. The MDS noted she required supervision or touch assistance while ambulating. R30's Cognitive Loss Care Area Assessment (CAA) completed 10/29/24 indicated she had impaired cognitive function and thought processes related to her medical diagnoses. The CAA instructed staff to identify themselves during each interaction, reduce distractions, and use consistent simple sentences. The CAA instructed staff to provide cues and report changes in cognitive function. R30's Functional Abilities CAA completed 10/29/24 indicated she required assistance with her activities of daily living (ADLs), transfers, and ambulation. R30's Behavioral CAA completed on 10/29/24 indicated she received herbal supplementation for her continued behaviors. The CAA noted she would be assisted and monitored during her behaviors. The CAA noted she had verbal and physical behaviors that were disruptive to her and other resident's treatment and care environment. R30's Care Plan 07/01/24 indicated she had a self-care deficit related to her decline of independence and medical diagnoses. The plan noted the level of ADL assistance needed was determined by her cognitive functioning from day to day. The plan noted most days she required set-up to partial assistance with personal hygiene, dressing, toileting, transfers, bed mobility, and personal hygiene. The plan noted her level of needed assistance would increase with confusion or behavioral episodes. The plan noted she had a communication deficit related to her cognitive decline and impaired thought processes. The plan instructed staff to keep her routine consistent and provide cues to reorient her. The plan instructed staff to supervise her as needed for confusion. R30's Care Plan indicated she had aggressive behaviors towards others and would refuse care at times. The plan noted she would scream out if staff did not provide one-to-one care for her. The plan instructed staff to anticipate her needs and administer her medications as ordered (07/01/24). The plan instructed staff to intervene during behaviors to protect the rights and safety of others (07/01/24). The plan noted to remove R30 from situations if she became combative or agitated (08/09/24). The plan instructed staff to monitor her behavior episodes and attempt to determine the underlying causes 08/09/24). The plan instructed staff to explain treatment and procedures prior to completing them on her (08/09/24). The plan indicated staff will assist her with developing coping methods to prevent behaviors (08/09/24). The plan instructed staff to provide one-to-one care during behaviors until she calmed down (08/12/24). The plan indicated she started cannabidiol (CBD - herbal supplementation used for anxiety and agitation) during behavioral episodes (09/20/24). The plan instructed staff to provide one-to-one walk and pray with her to help diffuse behaviors (09/20/24). The plan instructed staff to allow her time to process requests and speak in short sentences (11/20/24). The plan instructed staff to be at eye level when talking with R30 (11/20/24). The plan lacked potential triggers or causes for her behaviors toward others and individualized non-pharmacological interventions to prevent repeated behaviors around meal services. The plan lacked techniques related to redirecting R30 during confusion and agitation. R30's EMR under Progress Notes on 08/06/24 indicated she had an altercation with another resident in the dining room. The note indicated R30 became verbally aggressive towards other residents resulting in her arm being grabbed by the resident. The note indicated staff separated the residents and R30 was able to calm down. The note indicated she was given her CBD gummy and provided one-to-one supervision for the evening. R30's EMR under Progress Notes on 08/13/24 indicated she attempted to enter another resident's room and became aggressive with both staff and the resident in the room. The note indicated that R30 was started on her CBD gummy supplement and provided one-to-one supervision. R30's EMR under Progress Notes on 10/06/24 indicated she had become verbally aggressive during dinner and began yelling at other residents. The note indicated she struck another resident at the dinner table. R30's EMR under Progress Notes on 10/29/24 indicated she had an altercation with a resident upon being touched by the other resident. The note indicated no injuries were found. The note identified impulsive behaviors as the root cause. On 12/04/24 at 10:20 AM R30 walked around the circular hallway within the memory care unit. R30's representative assisted her around the circular hallway. R30 reported she enjoyed her walks around the unit with staff. She stated it kept her moving and happy. On 12/04/24 at 11:01 AM Certified Medication Aide (CMA) RR stated R30's behaviors have improved within the last two months. She stated that R30 would have good and bad days depending on her cognition. She stated that R30 could become physically aggressive with staff and other residents around mealtime or when she sat close to them. She stated the facility put her on CBD gummies recently for anxiety and her behaviors. She stated staff would have to provide one-on-one time with her at times to calm her down and prevent outbursts. She stated that R30's behaviors would be unpredictable and often no real triggers would be known. She stated that R30 liked to take walks and listen to music. On 12/04/24 at 11:25 AM Administrative Nurse E stated that R30 liked to take walks and have one-to-one time with staff. She stated that R30 liked to recite the Lord's Prayer and Hail Mary prayers. She stated staff were expected to take their time explaining things to her and be patient. She stated that R30's behaviors would come and go. She stated that R30's representative visits her frequently to help keep her routine consistent. She stated medication changes were made to improve R30's behaviors and she's taking the CBD supplements. On 12/05/24 at 02:20 PM Administrative Nurse D stated staff were expected to monitor R30 during activities and mealtimes. She stated staff should remain close and intervene if she became confused or agitated. She stated staff were to offer her walks and talk with her if she became upset or agitated. She was not sure if the care plan identified potential triggers or causative factors for R30's behaviors. The facility's Behavioral Health Services policy revised 02/2019 indicated all residents will be provided behavioral health services as needed to attain or maintain the highest practicable level of psychical, mental, and psychosocial well-being. The policy noted the facility will provide service and treatment to include individualized interventions and supervision. The facility was unable to provide a policy related to dementia care as requested on 11/04/24. The facility failed to provide dementia-related behavioral services for R30 to promote her highest practicable level of well-being. This deficient practice placed R30 at risk for decreased quality of life, isolation, and impaired dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 147 residents. The sample included 29 residents with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) recommendations were acknowledged and/or acted upon for Resident (R) 75. This deficient practice placed R75 at risk for unnecessary medication use and possible adverse side effects. Findings included: - R75's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational ion (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a progressive mental disorder characterized by failing memory and confusion). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R75 received antianxiety (a class of medications that calm and relax people) and antidepressant (a class of medications used to treat mood disorders) medication during the observation period. R75's Psychotropic Drug Use Care Area Assessment (CAA) dated 09/26/24 documented she was ordered an antianxiety medication for anxiety. R75's Care Plan dated 09/20/24 documented that nursing staff would assess R75's functional status prior to the initiation of drug use to serve as a baseline. R75's EMR under the Orders tab revealed the following physician orders: Ativan (antianxiety mediation) oral tablet 0.5 milligrams (mg) give one tablet by mouth as needed for anxiety or restlessness dated 10/10/24. The order lacked a stop date. On 11/27/24 call durable power of attorney (DPOA) prior to administration of the as-needed Ativan medication. R75's Monthly Medication Review (MMR) reviewed for September 2024 addressed the requirement for a rationale for continued availability and a specific future stop date for the antianxiety medication Ativan. The facility was unable to provide documentation the physician reviewed and addressed the CP's recommendations. On 12/02/24 at 10:32 AM R75 sat in her high-back wheelchair in the dining room asleep. R75 had a clothing protector attached around her neck that had fallen off her left shoulder and arm. R75 was not positioned at a dining room table and there were no drinks or food on any dining room tables. On 12/04/24 at 09:30 AM, Administrative Nurse D stated she was unable to find a physician response to the CP's September 2024 MRR. Administrative Nurse D stated the CP would print the MRRs and hand-deliver them to her. Administrative Nurse D stated would divide the nursing portion of the MRRs out to each unit manager. Administrative Nurse D stated she expected the unit managers to address the nursing portion of the MRRs. Administrative Nurse D stated she would hand deliver the MRRs to each of the physicians. Administrative Nurse D stated once the physician had reviewed the MRRs, she would give them to the unit managers to make the changes if any new orders, and then they are given to medical records to be scanned into the resident's EMR. The facility's Medication Regimen Review policy last revised 05/2019 documented the consultant pharmacist reviewed the medication regimen of each resident at least monthly. The consultant pharmacist provided the director of nursing services and the medical director with a written, signed, and dated copy of all medication regimen reports. Copies of medication regimen review reports, including physician responses, are maintained as part of the permanent medical record. The facility failed to ensure CP recommendations had been addressed for R75's as-needed antianxiety medication Ativan which lacked a stop date. This deficit practice placed her at risk of adverse side effects of psychotropic medication and unnecessary medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 147 residents. The sample included 29 residents with six reviewed for unnecessary medications. Based on record review, observations, and interviews, the facility failed to follow instructions related to medication monitoring when staff administered Resident (R)303's anti-hypertensive (class of medication used to treat high blood pressure) medications outside the physician-ordered parameters. This deficient practice placed R303 at increased risk for unnecessary medication and side effects. Findings included: - The Medical Diagnosis section within R303's Electronic Medical Records (EMR) included diagnoses of acute respiratory failure, atherosclerotic heart disease (reduced blood flow due to blockages in the arteries within the heart), atrial fibrillation (rapid, irregular heartbeat), hypertension (high blood pressure), and chronic kidney disease. R303's EMR revealed he was admitted on [DATE] and discharged on 11/15/24 to an acute care facility for emergency treatment. R303 did not have a Minimum Data Set (MDS) or Care Area Assessment (CAA) completed. R303's Care Plan initiated 11/07/24 indicated he required supervision or touch assistance with dressing, meal set-up, personal hygiene, dressing, transfers, toileting, and bathing. The plan indicated he took medications with Black Box Warning (BBW- the highest safety-related warning that medications can be assigned by the Food and Drug Administration) and he was at risk for adverse interactions. The plan instructed staff to monitor and report changes related to his anti-hypertensive medications to his medical provider. R303's EMR under Physician Orders revealed an order dated 11/08/24 for staff to administer 10 milligrams (mg) of amlodipine besylate (antihypertensive medication) by mouth once daily for hypertension. The order instructed staff to hold the medication if R303's systolic blood pressure (SBP-relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) was less than (<) 110 millimeters of mercury (mmHg). R303's EMR under Physician Orders revealed an order dated 11/08/24 for staff to administer 20 mg of lisinopril (antihypertensive medication) by mouth once daily for hypertension. The order instructed staff to hold the medication if R303's SBP was less than 110 mmHg. R303's EMR under Physician Orders revealed an order dated 11/08/24 for staff to administer five milligrams of terazosin (antihypertensive medication) by mouth once daily for hypertension. The order instructed staff to hold the medication if R303's SBP was less than 110 mmHg. R303's EMR revealed he was admitted to an acute care facility on 11/15/24 related to low blood pressure. A review of R303's November 2024 Medication Administration Report (MAR) revealed his morning blood pressure was taken before his medications were administered on 11/09/24. The MAR revealed his SBP was 99 mmHg. The MAR revealed his lisinopril, terazosin, and amlodipine were administered. The EMR revealed his antihypertensive medications were held on 11/10/24, 11/12/24, and 11/14/24 due to low blood pressure. An inspection of R303's medication punch cards revealed all three medications were punched out on 11/09/24. On 12/04/24 at 11:01 AM Certified Medication Aide (CMA) R stated the MAR should flag documented blood pressures outside the parameters to prevent the medications from being given to residents with chronically low blood pressure. She stated that licensed staff were required to review the medication orders before administering all medications. She stated staff should check each resident's vital signs before administering antihypertensive medications. On 12/04/24 at 11:30 AM Administrative Nurse E stated the MAR would require a resident's blood pressure to be entered before medication administration. She stated staff were required to check the medication orders and parameters before giving the medications. On 12/04/24 at 12:20 PM Administrative Nurse D stated R303's antihypertensive medications should not have been given if his systolic pressure was 99 mmHg. She verified the medication had been administered. The facility's Administering Medications policy (undated) indicates the medication is to be administered in a safe and timely manner. The policy indicated staff were to administer medications in accordance with the prescriber's orders. The policy indicated that licensed staff will check to verify the correct residents, dosage amount, time, date, and route of the administration. The policy indicated staff would hold and notify the medical provider if the medications were outside the provided order parameters or not given. The facility administered R303's anti-hypertensive medication outside the physician-ordered parameters. This deficient practice placed R303 at increased risk for unnecessary medication and side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The Diagnoses tab of R13's Electronic Medical Record (EMR) documented diagnoses of schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), epilepsy (brain disorder characterized by repeated seizures), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (HTN-elevated blood pressure), intellectual disabilities, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), sleep apnea (a disorder of sleep characterized by periods without respirations), adult failure to thrive (includes not doing well, feeling poorly, weight loss, and poor self-care that could be seen in elderly individuals), and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). The Modification of Significant Change Minimum Data Set (MDS) dated 11/15/24, documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R13 had an impairment on both sides of his body. The MDS documented R13 was dependent on staff for activities of daily living (ADLs). The MDS documented R13 was taking anti-anxiety medication during the observation period. R13's Psychotropic Drug Use Care Area Assessment (CAA) dated 11/15/24 documented R13 had a diagnosis of cerebral palsy and antisocial personality, and R13 had been prescribed antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medications. R13's CAA documented R13 would be monitored for behaviors and treated to help decrease his anxiety and depression. R13's CAA documented R13 received psychotropic medication and was at risk for adverse side effects. R13's Care Plan dated 12/02/24 documented R13 used Ativan (antianxiety medication) and nursing was to monitor and administer R13's antianxiety medication as ordered by the physician. The plan directed nursing to monitor for side effects and the effectiveness of the medication every shift. R13's plan of care documented nursing was to monitor the resident for safety and monitor for increased risk of confusion, loss of balance, and cognitive impairment. R13's EMR under Orders documented the following physician's order: Lorazepam gel (Ativan) one milligram (mg) per one milliliter(ml) every eight hours as needed for agitation or anxiety apply 0.5mg topically every eight hours as needed (PRN) agitation dated 11/24/24. The order lacked a stop date. On 12/01/24 at 08:32 AM R13 sat in the dining area in his wheelchair, awaiting his breakfast. On 12/04/24 at 12:33 PM, Licensed Nurse (LN) G stated she was unsure how long a PRN antianxiety medication order could be active. LN G stated the physician puts all narcotic orders in electronically, and the order goes directly to the pharmacy. LN G stated the unit manager was responsible for reviewing all new orders and responsible to ensure all PRN psychotropic medication had a duration for use. On 12/04/24 at 02:21 AM Administrative Nurse D stated the pharmacist reviews all orders entered electronically, and the unit nurse managers monitor every new order and was to ensure there was a duration. Administrative D stated the facility would have to review its process. She stated every psychotropic medication should have a 14-day stop date. The facility's Psychotropic Medication Use policy, revised in 2016, documented antipsychotic medications would be prescribed at the lowest possible dosage for the shortest period and were subject to gradual dose reduction and re-review. Each resident's drug regimen must be free from unnecessary drugs. The facility failed to ensure R13 had a stop date for his PRN antianxiety medication. This deficient practice placed R13 at risk for unnecessary psychotropic medication administration. The facility identified a census of 147 residents. The sample included 29 residents with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the as-needed (PRN) psychotropic (alters mood or thought) medication had a 14-day stop date or a specified duration with supporting physician documentation for Resident (R) 75's and R13's PRN psychotropic medications. This placed these residents at risk for unnecessary medication administration and possible adverse side effects. Findings included: - R75's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational ion (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a progressive mental disorder characterized by failing memory and confusion). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R75 had received antianxiety (a class of medications that calm and relax people) and antidepressant (a class of medications used to treat mood disorders) medication during the observation period. R75's Psychotropic Drug Use Care Area Assessment (CAA) dated 09/26/24 documented she was ordered an antianxiety medication for anxiety. R75's Care Plan dated 09/20/24 documented that nursing staff would assess R75's functional status prior to the initiation of drug use to serve as a baseline. R75's EMR under the Orders tab revealed the following physician orders: Ativan (antianxiety mediation) oral tablet 0.5 milligrams (mg) give one tablet by mouth as needed for anxiety or restlessness dated 10/10/24. The order lacked a stop date. On 11/27/24 call durable power of attorney (DPOA) prior to administration of the as-needed Ativan medication. R75's EMR lacked evidence of a physician documented rationale for the extended PRN Ativan which included a specified duration. On 12/02/24 at 10:32 AM R75 sat in her high-back wheelchair in the dining room asleep. R75 had a clothing protector attached around her neck that had fallen off her left shoulder and arm. R75 was not positioned at a dining room table and there were no drinks or food on any dining room tables. On 12/04/24 at 12:33 PM, Licensed Nurse (LN) G stated she was unsure how long a PRN antianxiety medication order could be active. LN G stated the physician puts all narcotic orders in electronically, and the order goes directly to the pharmacy. LN G stated the unit manager was responsible for reviewing all new orders and responsible to ensure all PRN psychotropic medication had a duration for use. On 12/04/24 at 02:21 AM Administrative Nurse D stated the pharmacist reviews all orders entered electronically, and the unit nurse managers monitor every new order and was to ensure there was a duration. Administrative D stated the facility would have to review its process. She stated every psychotropic medication should have a 14-day stop date. The facility's Psychotropic Medication Use policy, revised in 2016, documented antipsychotic medications would be prescribed at the lowest possible dosage for the shortest t period and were subject to gradual dose reduction and re-review. Each resident's drug regimen must be free from unnecessary drugs. The facility failed to ensure R75's PRN Ativan had a stop date, or a physician ordered specified duration for administration. This placed R75 at risk for unnecessary medication administration and possible adverse side effects.

The facility identified a census of 147 residents. The sample included 29 residents with Resident (R) 93 reviewed for hospice services. Based on observation, record review, and interview, the facility failed to ensure collaboration of care between R93's hospice provider and the facility. This placed R93 at risk of inadequate end-of-life care. Findings included: - R93's Electronic Medical Record (EMR) documented diagnoses of repeated falls, hypertension (HTN-elevated blood pressure), blindness in one eye, and dementia (a progressive mental disorder characterized by failing memory and confusion). R93's Significant Change Minimum Data Set (MDS) dated 06/28/24 documented she had a Brief Interview for Mental Status (BIMS) score of 10 which indicated a moderately impaired cognition. R93 required substantial to maximal assistance of staff for bed-to-chair (or wheelchair) transfers. R93 had a history of one fall without injury and one fall with injury since her prior assessment. R93 was on hospice services. R93's Quarterly MDS dated 06/28/24 documented she had a BIMS score of 13 which indicated intact cognition. R93 was dependent on staff for bed-to-chair transfers. R93 had not had any falls since the prior assessment. R93 was on hospice services. R93's Functional Abilities Care Area Assessment (CAA) dated 07/01/24 documented she suffered from a self-care deficit related to a decline in her prior level of independence resulting in the need for continued medical care. She was on hospice services, and further decline was anticipated due to a cognitive communication deficit. R93's Hospice Care Plan initiated on 06/24/24 and revised on 09/30/24 directed staff to adjust the provisions of activities of daily living (ADLs) to compensate for the resident's changing abilities. The staff was directed to assess the resident's coping strategies and respect the resident's wishes. Staff was to encourage a support system of family and friends. Staff was to observe the resident closely for signs of pain, administer pain medication as ordered, and notify the physician immediately if there was breakthrough pain. The care plan lacked staff direction regarding how to collaborate with hospice, what supplies the hospice service provided, or when hospice staff would make visits. On 12/03/24 at 07:47 AM R93 sat in her wheelchair, at the dining room table, visiting with another resident while she waited for breakfast to be served. On 12/03/24 at 12:55 PM Certified Nurse Aide (CNA) O stated a resident's care plan would let them know if a resident was on hospice. CNA O stated most of the supplies that the hospice provided were kept in the resident's room but as far as the care plan listing those items, she did not believe the care plan had that information on it. CNA O stated each resident was provided a binder by their hospice provider that listed when the hospice staff would visit each week. On 12/03/24 at 01:00 PM Licensed Nurse (LN) I stated the hospice book for R93 should list what supplies were provided by hospice as well as when the hospice staff would make visits weekly. LN I stated she would expect R93's facility plan of care to reflect what hospice provided and how to contact them but could not verify for certain whether R93's Care Plan listed that or not. On 12/04/24 at 02:21 PM Administrative Nurse D stated each resident that received hospice care had a hospice book provided by hospice that listed all the items, medications, and how often hospice staff would visit in it. Administrative Nurse D stated nursing staff knew to look in the hospice book if they had any questions about hospice. Administrative Nurse D stated that R93's Care Plan did not contain that hospice information as far as she was aware. The Hospice Program policy revised in July 2017 documented: in general, it was the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided was appropriately based on the individual resident's needs. Communicating with the hospice provider to ensure the needs of the resident were addressed and met 24 hours per day. Collaborating with the hospice representatives and coordinating facility staff participation in the hospice care planning process for residents receiving these services. Coordinated care plans for residents receiving hospice service would include the most recent hospice plan of care as well as the care and service provided by the facility to maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility failed to ensure collaboration of care between R93's hospice provider and the facility. This placed R93 at risk of inadequate end-of-life care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The Diagnoses tab of R13's Electronic Medical Record (EMR) documented diagnoses of schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), epilepsy (brain disorder characterized by repeated seizures), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (HTN-elevated blood pressure), intellectual disabilities, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), sleep apnea (a disorder of sleep characterized by periods without respirations), adult failure to thrive (includes not doing well, feeling poorly, weight loss, and poor self-care that could be seen in elderly individuals), and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). The Modification of Significant Change Minimum Data Set (MDS) dated 11/15/24, documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R13 had an impairment on both sides of his body. The MDS documented R13 was dependent on staff for activities of daily living (ADLs). The MDS documented R13 had no falls since admission. The Falls Care Area Assessment dated 11/15/24 documented R13 was at risk for falls due to cerebral palsy, an antisocial personality, immobility, epilepsy, and the need for assistance. R13's Care Plan revised 08/24/24 documented R13 was at risk for falls related to poor vision, epilepsy, and the need for assistance with ambulation and transfers. R13's plan of care documented that staff should encourage the use of non-skid footwear during ambulation and transfers. R13's plan of care dated 09/18/24 documented that staff were to ensure R13 had adequate lighting during waking hours, and they could leave the bathroom light or night light on during hours of sleep. Staff were also to ensure R13's call light was within his reach while he was in his room unsupervised, and staff should promptly respond to his call light. R13's plan of care dated 11/18/24 documented that a Dycem (non-slip mat used for stabilization and grip to prevent slipping) was added to his wheelchair; R13 continued occupational therapy (OT) services for seating and positioning. The plan documented a hospice medication review for scheduled pain medication, and a perimeter mattress was to be applied to R13's bed. R13's EMR under Event Note dated 08/16/24 documented R13 was found on his side, on the floor mat in the fetal position by physical therapy (PT). R13 was unable to verbalize how he fell. The possible root cause was that R13 was impulsive, and had a mental diagnosis. R13 appeared combative, was in a new environment, or could be hungry or thirsty. Staff notified the physician of the fall and placed a scoop mattress. Staff checked and changed R13 due to incontinence. The lighting was appropriate, and R13 was offered fluids and snacks. R13's EMR under Interdisciplinary Team Note dated 09/19/24 documented a fall on 09/18/24. The root cause was R13 slid out of his wheelchair and the immediate intervention was a Dycem was added to his wheelchair. OT was to evaluate the cushion for his wheelchair. R13's EMR under Interdisciplinary Team Note dated 11/18/24 documented a fall on 11/18/24. The root cause of the fall was R13 was having behaviors; he was spitting out his medication and hitting his head on the table. The nurse aide was in the room when R13 put himself on the floor. The immediate intervention was a request for a medication review from R13's provider. On 12/01/24 at 08:32 AM R13 sat in the dining area in his wheelchair, R13 had a blue and white blanket in his chair. R13 did not have a cushion or a Dycem in place. On 12/02/24 at 08:21 AM, R13 sat in the dining area in his wheelchair, R13 had a blue and white blanket in his chair. R13 did not have a cushion or a Dycem in place. On 12/03/24 at 08:17 AM, R13 sat in the dining area in his wheelchair. R13 did not have a cushion or a Dycem in place. On 12/04/24 at 11:43 AM Therapy Director GG stated therapy staff worked with R13 on positioning. She stated the therapy staff should have noticed R13 did not have a Dycem in his wheelchair. She stated nursing and therapy were responsible for ensuring the resident's care plan was followed. On 12/04/24 at 12:23 PM, Licensed Nurse (LN) G stated all staff have access to each resident's care plans. She that it was the Certified Nurse Aide's (CNA) responsibility to help the resident into their wheelchair, but ultimately the nurse in charge was responsible for ensuring each resident had what they needed to stay safe. On 12/04/24 at 12:48 PM, CNA M stated he did have access to the [NAME] (a nursing tool that gives a brief overview of the care needs of each resident), but he usually referred to the daily report sheet. CNA M stated he carried the daily report sheet and could refer to the sheet if he was unsure what each resident needed for care. On 12/04/24 at 02:21 PM, Administrative Nurse D stated the CNAs would be the first check to ensure the resident Dycem was in place; the charge nurse would be the second check, and the unit manager should have been notified the resident's Dycem was not in place. The facility's Falls policy revised on 05/22 documented that on admission the nurse would complete the fall risk assessment. The nurse would identify individuals with a history of falls and risk factors for falling. Nurses would chart high-risk status and interventions on the care plan and ensure that they have therapy on admission as appropriate. The facility failed to ensure R13's Dycem was placed in his wheelchair to prevent falls. This deficient practice placed R13 at risk for continued falls and related injuries. - R27's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of obesity (excessive body fat), acute respiratory failure ( a serious condition that occurs when the lungs are unable to provide the body with enough oxygen or remove enough carbon dioxide), Down's syndrome (chromosomal abnormality characterized by varying degrees of mental retardation and multiple defects), sleep apnea (a disorder of sleep characterized by periods without respirations), hypotension (low blood pressure), dysphagia (swallowing difficulty), aphasia (condition with disordered or absent language function), asthma (a disorder of narrowed airways that causes wheezing and shortness of breath), and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The admission Minimum Data Set (MDS) for R27 dated 09/24/24 recorded a Brief Interview for Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R27 needed substantial to maximum assistance from staff for eating and was dependent on staff for dressing her upper and lower body and for all hygiene. The MDS documented R27 was dependent on staff for chair-to-bed transfers. The MDS documented R27 had not had a fall since admission. R27's Cognitive Loss/ Dementia Care Area Assessment dated 09/24/24 documented R27 would maintain the current level of cognitive function through the review date. Staff were to engage in simple, structured activities that avoid overly demanding tasks. The CAA documented R27 had impaired cognitive function or impaired thought processes related to developmental delays. R27's Communication Care Area Assessment dated 09/24/24 documented R27 was primarily nonverbal. At times, R27 would make verbal noises but nothing discernible. R27 did maintain eye contact when being spoken to, and staff were to meet R27's needs. R27's Care Plan revised 09/27/24 documented R27 was at risk for falls. R27's plan of care documented that staff were to ensure R27's call light was within her reach, and staff could leave the bathroom light on or night light on during hours of sleep. Staff should respond promptly to R27's call light. R27's plan of care dated 09/29/24 documented that R27 would have a fall mat on the floor next to her bed. R27's plan of care documented she would have a defined perimeter mattress and would be the first one up for dinner. R27's EMR under Progress Note dated 11/18/24 documented that R27's roommate informed staff that R27 was sitting on the side of her bed. When the Certified Nursing Aide (CNA) entered R27's room, the CNA observed R27 sitting upright on the floor next to her bed. Staff assisted R27 to the laying position and placed her sling under her. Staff transferred R27 to her bed with a Hoyer (total body mechanical lift) and noted an abrasion down the left side of R27's back. The nursing staff notified the unit manager and physician. R27's EMR under Interdisciplinary Team Note dated 11/22/24 documented the root cause of the fall from 11/18/24 was R27 was sitting on the side of her bed, and the immediate intervention was to place a defined perimeter mattress on R27's bed and a fall mat. On 12/02/24 at 01:14 PM R27 laid on her bed awake, with a stuffed animal beside her. R27 did not have a fall mat in place beside her bed. On 12/03/24 at 01:17 PM, R27 lay on her bed with her eyes shut. R27 did not have a floor mat in place beside her bed. On 12/04/24 at 12:23 PM, Licensed Nurse (LN) G stated all staff had access to each resident's care plan. She said that it was the CNA's responsibility to help the resident into their wheelchair or bed, but ultimately the nurse in charge was responsible for ensuring each resident had what they needed to stay safe. On 12/04/24 at 02:21 PM, Administrative Nurse D stated the CNAs would be the first check to ensure the resident's fall mat was in place; the charge nurse should also be following up to ensure what was in the care plan was being followed through. The facility's Falls policy revised on 05/22 documented that on admission the nurse would complete the fall risk assessment. The nurse would identify individuals with a history of falls and risk factors for falling. Nurses would chart high-risk status and interventions on the care plan and ensure that they have therapy on admission as appropriate. The facility failed to ensure that R27's fall mat was placed beside her bed per her plan of care. This deficient practice placed R27 at risk for fall-related injuries. The facility reported a census of 147 residents. The sample included 29 with 11 residents reviewed for accidents. Based on record review, interviews, and observations, the facility failed to ensure a safe environment free from accident hazards for Residents (R)5 and R32. The facility additionally failed to implement care-planned fall interventions for R13 and R27. This deficient practice placed the residents at risk for preventable falls and injuries. Findings Included: - The Medical Diagnosis section within R5's Electronic Medical Records (EMR) included diagnoses of cognitive communication deficit, transient ischemic cerebral attack (TIA- temporary episode of inadequate blood supply to the brain), weakness, history of falls, chronic kidney disease, and abnormalities with mobility. R5's Quarterly Minimum Data Set (MDS) completed 09/24/24 noted a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. The MDS noted she required partial to moderate assistance with transfers, bed mobility, toileting, bathing, personal hygiene, and oral hygiene. The MDS noted she required substantial to maximal assistance with lower body dressing and putting on her footwear. The MDS noted she had no falls since her admission. R5's Fall Care Area Assessment (CAA) completed 07/08/24 indicated she had a history of falls before her admission and was at risk related to her medical diagnoses. The CAA noted she could make her needs known to staff. R5's Functional Abilities CAA completed 07/08/24 indicated she required assistance with her activities of daily living (ADLs) and transfers. The plan instructed staff to anticipate her needs when indicated. The CAA noted she could make her needs known to staff. R5's Care Plan initiated 07/01/24 indicated she was at risk for falls related to her history of falls and medication side effects. The plan indicated she required partial to moderate assistance with transfers, dressing, bed mobility, personal hygiene, toileting, and bathing. The plan noted she had one fall since her admission to the facility on [DATE] related to her self-ambulating in her room without calling for staff assistance. The plan indicated she was placed on occupational therapy to improve mobility functions and continued her physical therapy program. The plan indicated she was on a functional maintenance program related to ambulation and ADLs. The plan did not include documentation related to moving her bed to a high position when not in use. On 12/02/24 at 11:30 AM staff propelled R5 to the dining room area in the Memory Care Unit. Upon moving R5 out of her room, the staff stated Let's put her bed in the high position so she can't get back in it. Staff then placed R5's bed in the highest position. On 12/03/24 at 08:23 AM R5's bed was in the highest position. R5 sat at the dining room table. On 12/04/24 at 07:11 AM R5 slept in her bed. Her bed was in the medium to low position. On 12/04/24 at 10:00 AM R5's empty bed was placed in the high position. On 12/04/24 at 10:20 AM Certified Nurses Aide (CNA) LL stated R5 was impulsive and often attempted to stand or transfer herself without staff assistance. She stated staff had to closely watch R5 while she was in her room and provided frequent checks for ADLs. On 12/04/24 at 11:01 AM Certified Medication Aide (CMA) RR stated staff had to closely watch R5 due to her impulsive behavior to self-transfer and attempt to ambulate without staff assistance. She stated staff should ensure her room was free of clutter and provide frequent toileting. She stated that R5 has had only one fall attempting to ambulate in her room. On 12/04/24 at 02:22 PM Administrative Nurse D stated R5's bed should not be left in the high position due to her risk of falling and cognitive impairment. She stated staff were to leave it in the low position and assist her into and out of bed. The facility's Falls-Clinical Protocol revised 05/2022 indicated the facility will assess each resident's functional abilities and identify pertinent interventions to prevent subsequent falls. The policy noted the facility will provide ongoing monitoring and assessment of individuals at risk for falls. The facility failed to ensure R5's care environment was free from accident hazards when staff intentionally placed the bed in a high position to try to prevent R5 from getting in bed herself. This placed R5 at risk for preventable accidents and injuries. - R32's Electronic Medical Record (EMR) recorded diagnoses of hypertension (HTN- an elevated blood pressure), and absence of the left and right leg above the knee. R32's Significant Change Minimum Data Set (MDS) dated 09/14/24 documented R32 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated a moderately impaired cognition. R32 required partial assistance for rolling left and right, substantial to maximal assistance for sitting to lying, and was dependent on staff for transfers. R32 had not had any falls since the prior assessment. R32's Cognition Care Area Assessment (CAA) dated 09/19/24 documented he had a BIMS score of 11 and had mild cognitive impairment. Staff would assist and anticipate the resident's needs. R32 needed assistance with activities of daily living (ADLs), transfers, hygiene, dressing, and bathing. Staff would provide assistance every two hours and as needed. R32's Care Plan last revised on 11/05/24, directed staff that R32 was at risk for falls secondary to being dependent with transfers. Staff were directed that R32 had a visual reminder in his room to use the call light for assistance prior to getting up and to re-educate staff to keep his bedside table close for him to reach things. Staff were to ensure the call light was within reach while in his room unsupervised. Staff were to encourage R32 to use his call light to alert staff for assistance. Staff were directed to respond promptly. Staff were directed to ensure a safe environment with an even floor, free from spills and or clutter, and have personal items within reach. The care plan lacked staff guidance for bed height placement. R32's Fall Risk Evaluation dated 12/02/24 documented a fall risk score of seven. If the total score was 10 or greater, the resident should be considered at high risk for potential falls. On 12/02/24 at 08:00 AM R32 was lying in bed. The bed height was noted to be in a high position. On 12/02/24 at 12:15 PM, R32 was noted in his bed. The bed height was noted to be in a high position. On 12/04/24 at 12:55 PM Certified Nurse Aide (CNA) O stated no resident's bed should ever be in a high position unless care was being provided or that was the resident's personal preference. CNA O stated a resident's care plan should document a high bed level preference but would not expect a resident who was a fall risk to have their bed in a high level. On 12/04/24 at 01:00 PM Licensed Nurse (LN) I stated a resident's bed should not ever be in a high position unless a care was being provided. LN I stated R32 was at risk for falls so his bed should not be left in a high position by staff. On 12/04/24 at 02:21 PM Administrative Nurse D stated she expected her staff to ensure R32's bed was never left at high height due to the risk of falls. Administrative Nurse D stated that R32 was dependent on staff for transfers and the only time his bed would need to be in a high position was when staff were providing care to him. The Falls - Clinical Protocol policy revised in May 2022 documented that on admission the nurse would complete a Fall Risk Assessment. The nurse would identify individuals with a history of falls and risk factors for falling. The staff would document in the medical record a history of one or more recent falls. Chart high-risk status and interventions on the care plan. Ensure that the resident has therapy on admission as appropriate. The facility failed to ensure R32's bed was maintained at a safe height for fall prevention. This placed R32 at risk for fall-related injuries.

The facility identified a census of 147 residents. The facility identified 41 residents on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) and four residents on contact precautions (safeguards designed to reduce the risk of transmission of microorganisms by direct or indirect contact). Based on record review, observations, and interviews, the facility failed to ensure Resident (R)109's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask and the nasal cannulas for R45, R27, and R57 were stored in a sanitary manner when not in use and further failed to implement adequate hand hygiene and ensure the shared blood pressure cuff was sanitized after resident use. These deficient practices placed the residents at risk for infectious diseases. Findings included: - On 12/03/24 at 07:47 AM Certified Medication Aide (CMA) S obtained R93's blood pressure using a small blood pressure cuff. CMA S removed the small blood pressure cuff from the portable blood pressure machine and placed the cuff into the basket without sanitizing it. CMA S then removed the larger-sized blood pressure cuff from the basket, attached it to the blood pressure machine, and used it on R113 without performing hand hygiene first. CMA S did not sanitize the larger blood pressure cuff after use. On 12/03/24 at 08:19 AM R45's nasal cannula laid over the back of R45's wheelchair while he was eating breakfast in the dining room. On 12/03/24 at 11:57 AM R27's nasal cannula laid on the floor in the dining room, and a kitchen staff member passing trays to the resident's room stepped on the nasal cannula. R27's nasal cannula was then picked up and laid on the back of R27's wheelchair. On 12/03/24 at 12:01 PM, R57's nasal cannula hung over the bed rail in her room, R57 did not have any type of container to place the nasal cannula in. On 12/03/24 at 04:14 PM, R109 sat out at the dining room table. R109's CPAP mask and tubing were laid directly on her CPAP machine on the bedside table next to the bed. On 12/04/24 at 11:10 R27's nasal cannula was hanging over the back of R27's wheelchair. On 12/04/24 at 12:25 PM, Certified Nurse Aide (CNA) N stated she would clean R109's CPAP in the morning after she assisted R109 out of bed. CNA N stated she would clean the CPAP mask with a disinfectant wipe and then store the mask in a plastic bag. On 12/04/24 at 12:33 PM, Licensed Nurse (LN) G stated all staff were educated to place nasal cannulas not in use in a pull string bag. LN G stated ensuring the nasal cannula were stored appropriately was all nursing staff's responsibility. On 12/04/24 at 12:35 PM, Licensed Nurse (LN) H stated she would clean the residents' CPAP masks every morning with soap and water and then hang them to dry. LN H stated the CPAP mask should never be placed on the bedside table or the CPAP machine. On 12/04/24 at 02:21 PM, Administrative Nurse D stated she expected the nurse on the unit to clean the CPAP mask with soap and water. Administrative Nurse D stated that the mask was to hung to air dry. Administrative Nurse D stated the CPAP mask should never be stored directly on the bedside table or top of the CPAP machine. Administrative Nurse D stated nasal cannulas not in use are to be stored in a plastic bag, she stated that was everyone's responsibility. Administrative Nurse D stated she expected her staff to clean or sanitize the blood pressure cuffs, between residents. The Infection Prevention and Control policy dated 2019 documented that the primary mission was to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure R109's CPAP mask was stored in a sanitary manner, and nasal cannulas for R45, R27, and R 57 were stored in a sanitary manner and further failed to implement adequate hand hygiene ensuring shared blood pressure cuffs were sanitized after resident use. These deficient practices placed the residents at risk for infectious diseases.

The facility identified a census of 147 residents. Based on record review and interviews, the facility failed to ensure direct care staff had received the required resident rights. This placed the residents at risk for impaired care and decreased quality of life. Finding included: - On 12/04/24 a review of the provided training for agency Certified Nurses Aid (CNA) MM, CNA NN, and CNA OO revealed the following: CNA MM's facility-provided credentialling file lacked evidence training was completed for resident rights training. CNA NN's facility-provided credentialling file lacked evidence training was completed for resident rights training. CNA OO's facility-provided credentialling file lacked evidence training was completed for resident rights training. On 12/04/24 at 02:21 PM Administrative Nurse D stated she reviewed all the nursing staff information sent by the agency staffing company before a staff member worked. Administrative Nurse D stated upon the nursing staff reporting for the first shift she would go over dementia training, infection control, abuse, falls, and change in condition. Administrative Nurse D stated she assumed that the agency group made sure the nurse aides had the required training and education needed to work. The facility did not provide a policy regarding nurse aide required training as requested. The facility failed to ensure direct care staff had received resident rights training. This placed the residents at risk for impaired care and decreased quality of life.

The facility had a census of 89 residents. The sample included 18 residents. Based on record review and interview, the facility failed to provide three sampled residents, Resident (R)13, R38 and R189 (or their representative) the completed Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055, (CMS) Centers for Medicare and Medicare Services which placed them at risk to make uninformed decisions about their skilled care Findings included: - The Medicare ABN form 10055 informed the beneficiary that Medicare may not pay for future skilled therapy services. The form included an option for the beneficiary to receive specific services listed, and bill Medicare for an official decision on payment. The form stated 1) I understand if Medicare does not pay, I will be responsible for payment, but can make an appeal to Medicare, (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services, (3) I do not want the listed services. The facility failed to provide R13 the completed form 10055, which estimated the cost for the services to be able to make an informed choice whether the resident wanted to receive the items or services, knowing he/she may have to pay out of pocket. The resident's skilled services ended on 12/01/22. The facility failed to provide R38 the completed form 10055, which estimated cost for the services to be able to make an informed choice whether the resident wanted to receive the items or services, knowing he/she may have to pay out of pocket. The resident's skilled nursing services ended on 02/01/23. The facility failed to provide R189 the completed form 10055, which the estimated cost for the services to be able to make an informed choice whether the resident wanted to receive the items or services, knowing he/she may have to pay out of pocket. The resident's skilled nursing services ended on 11/28/22. On 02/22/23 at 11:00 AM, Social Services X verified the facility staff had not provided the resident and/or their representative the CMS form 10055. On 02/22/23 at 04:00 PM, Administrative Staff A verified the facility had not provided the resident and/or their representative the CMS 10055 form. Upon request the facility did not provide an Advance Beneficiary Notice of Non-Coverage policy. The facility failed to provide R13, R38, and R189, or their representatives, the completed ABN 10055 form when discharged from skilled care, which placed them at risk to make uninformed decisions about their skilled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 89 residents. The sample included 18 residents with seven reviewed for accidents. Based on observation, interview, and record review the facility failed to review or revise the care plan to prevent further falls for Resident (R) 19 after three of her falls. This deficient practice placed R19 at risk for further falls and injury. Findings included: - R19's Electronic Medical Record (EMR) documented diagnoses of severe dementia (group of thinking and social symptoms that interferes with daily functioning), unsteadiness on feet, muscle weakness, and chronic pain. The Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of zero, and short- and long-term memory problems with severely impaired decision making. The MDS documented R19 required extensive assistance of one staff for eating, hygiene, extensive assistance of two staff for bed mobility, transfers, walking, locomotion, toileting, dressing and total assistance with bathing. The MDS documented R19 had impaired balance and unable to stabilized without help, no range of motion impairment, and used a wheelchair. The Fall Care Area Assessment (CAA), dated 01/20/23, documented R19 was at risk for falls secondary to balance and gait issues with transitions and ambulation. The Fall Care Plan, dated 01/17/23, documented R19 was at risk for falls secondary to balance, gait issues, ambulation, frequent falls, severe dementia, poor safety awareness, communication deficit, and potential medication side effects. The care plan directed staff to ensure R19 wore proper footwear prior to assisting her with transfers. The 03/20/2022 care plan update stated R19 was sent to the emergency room and received one staple to the back of her head. No further direction for staff for prevention of falls. The 06/19/2022 care plan update stated R19 was transported to the emergency room and returned with a new order for pain medication. No further direction for staff for prevention of falls. The 09/25/22 care plan update directed staff to perform frequent checks when R19 was in bed. The Progress Note, dated 03/20/22 at 0751 AM, documented staff found R19 on the floor in her bathroom, seated upright with her feet and legs positioned in front of her, wearing tennis shoes. There was a splatter of blood on the bathroom floor behind her and a scant amount of blood was visible on the back of the resident's head. The physician order staff to send to R19 to the hospital. The Progress Note, dated 06/19/22 at 07:40 PM, documented R19 fell and hit her head, but did not lose consciousness per staff report. The note stated R19 had a medium sized hematoma (bruise with swelling) on the back of her head with a 3-centimeter (cm) purple/black line imprinted in it. Swelling and redness was also noted to outer area of purple line from hitting the door frame. R19 sent to the hospital via emergency services. The Progress Note, dated 06/20/2022 07:40 PM, stated the root cause of R19's fall was severe dementia; R19 walked around the neighborhood constantly, and lost her balance. The intervention would be a therapy screen. The Progress Note, dated 09/02/22 at 03:02 PM, R19 was found by staff in her own room but on the other side where she has a roommate, lying on her back. The fall was unwitnessed, neurological checks were started and were at baseline for the resident. The note directed staff would assist the resident in taking a rest break after breakfast and lunch. This was not noted on R19's plan of care. The Progress Note, dated 09/25/22 at 03:35 PM, staff found R19 on the floor in her room, on her back right next to her bed and a pile of covers. Upon assessment resident did not appear to be in any pain; her pupils were equal round reactive to light, hand grasps equal and strong. She had no bruising to her back or buttocks, and did not appear to have hit her head. Since the fall was not witnessed, proceeded with neurological checks as a precaution and they were at baseline. The note stated the nurse encouraged staff to perform frequent visual checks when the resident was resting in bed since she was prone to getting up and out of bed on her own. The note recorded the root cause was R19 was tangled in blankets and directed frequent checks when R19 was in bed, but did not specififcy frequency. The Progress Note, dated 12/26/22 at 05:58 AM, documented staff found R19 on the floor in her room with her head resting on her bed rail with no visible injuries noted. The note documented staff notified her physician via fax and requested an order for non-skid socks while in bed due to the resident ambulated at will and had poor safety awareness due to dementia. On 02/22/23 at 07:45 AM, observation revealed Certified Nurse Aide (CNA) O and Certified Medication Aide (CMA) S used the total lift to transfer R19 from her bed to her wheelchair. R19 spoke unintelligible words, but when asked if she had pain, R19 replied No. Further observation revealed deep purple bruising to the upper back of R19's right arm, with yellowing bruising to the distal upper arm. When staff dressed R19, staff was gentle with R19's right arm, but she still clenched her teeth. When staff brought R19 out to the dining room, she had a sling on her right arm. On 02/27/23 at 08:50 AM, Administrative Nurse D verified the care plan had not been updated after each fall and verified the lack of pertinent, effective and measurable fall prevention interventions. The facility's Managing Falls and Fall Risk policy, dated 2022, stated based on previous evaluations and current data staff would identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling or try to minimize complications from falling. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remained relevant. The facility failed to review or revise R19's care plan to prevent further falls, placing R19 at risk for further falls or injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 89 residents. The sample included 18 residents with six residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide necessary services to maintain good personal hygiene, including bathing for one of the six reviewed for ADLs, Resident (R)33. This placed the resident at risk for poor personal hygiene and infection. Findings included: - R33's Electronic Medical Record (EMR) recorded diagnoses of congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), diabetes mellites (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and muscle weakness. R33's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R33 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognition impairment. The MDS recorded R33 required extensive assistance of one staff for most activities of daily living and bathing. The Activities of Daily Living Care Plan, dated 01/09/23 indicated the R33 required assistance with ADL care. The care plan recorded the resident required extensive assistance of one staff with bathing and personal hygiene. The care plan lacked frequency or days of bathing. R33's Skin Integrity; Shower/Bathing Review documented the resident received a bath twice a week. The December Bathing Report documented the resident received a bath on the following days: 12/03/22 12/07/22 12/10/22 12/14/22 12/17/22 The resident refused the following dates: 12/21/22 12/24/22 12/28/22 12/31/22 01/04/23 01/07/23 The January Bathing Report documented the resident received a bath/shower on the following days: 01/11/23 (25 days no bath/shower) 01/14/23 01/17/23 01/18/23 01/21/23 01/25/23 01/28/23 On 02/21/22 at 03:55 PM, observation revealed R33 sat in a wheelchair in her room with the bedside tablet in front of her. Continued observation revealed the resident's hair appeared uncombed and greasy. On 02/27/22 at 10:00 AM, Administrative Nurse D verified the residents have scheduled bath/shower days and the aides document on shower sheets; if the resident refused, the aides would inform the charge nurse who would talk to the resident and document in the electronic health record the resident reason for refusal. The facility's Activities of Daily Living (ADLs) policy, dated 2022 (no month documented), recorded the residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out ADLs independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services would be provided for residents who are unable to carry out ADLs independently, with the onset of the resident who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care , including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care); mobility (transfer and ambulation, including walking); elimination (toileting); dining (meals and snacks); and communication (speech, language, and any functional communication systems). The facility failed to provide the necessary care and bathing services for R33, placing the resident at risk for poor hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 89 residents. The sample included 18 residents with seven reviewed for accidents. Based on observation, interview, and record review the facility failed to identify and implement meaningful, resident-centered interventions to prevent falls for Resident (R) 19 and failed to complete ongoing monitoring for fall related injuries after falls. This deficient practice placed R19 at risk for further falls or injury. Findings included: - R19's Electronic Medical Record (EMR) documented diagnoses of severe dementia (group of thinking and social symptoms that interferes with daily functioning), unsteadiness on feet, muscle weakness, and chronic pain. The Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of zero, and short- and long-term memory problems with severely impaired decision making. The MDS documented R19 required extensive assistance of one staff for eating, hygiene, extensive assistance of two staff for bed mobility, transfers, walking, locomotion, toileting, dressing and total assistance with bathing. The MDS documented R19 had impaired balance and unable to stabilized without help, no range of motion impairment, and used a wheelchair. The Fall Care Area Assessment (CAA), dated 01/20/23, documented R19 was at risk for falls secondary to balance and gait issues with transitions and ambulation. The Fall Care Plan, dated 01/17/23, documented R19 was at risk for falls secondary to balance, gait issues, ambulation, frequent falls, severe dementia, poor safety awareness, communication deficit, and potential medication side effects. The care plan directed staff to ensure R19 wore proper footwear prior to assisting her with transfers. The 03/20/2022 care plan update stated R19 was sent to the emergency room and received one staple to the back of her head. No further direction for staff for prevention of falls. The 06/19/2022 care plan update stated R19 was transported to the emergency room and returned with a new order for pain medication. No further direction for staff for prevention of falls. The 09/25/22 care plan update directed staff to perform frequent checks when R19 was in bed. The 01/02/23 care plan update directed staff to place of fall mat and Physical Therapy (PT) to evaluate R19 for a wheelchair positioning cushion. The 01/06/23 care plan update directed staff to assist R19 with ambulating before dinner using gait belt and wheelchair to follow as she attempts to ambulate without assistance before dinner. The 01/22/23 care plan update stated medication review. The 01/30/23 care plan update stated R19 was downgraded to a total lift with assistance of two staff for transfers when she was stiff or rigid. The Fall Risk Assessments for the past year, dated 09/02/22 (16), 09/25/22 (15), and 01/6/23 (20) all indicated R19 was at high risk for falls (10 or higher indicated high fall risk). The Progress Note, dated 03/20/22 at 0751 AM, documented staff found R19 on the floor in her bathroom, seated upright with her feet and legs positioned in front of her, wearing tennis shoes. There was a splatter of blood on the bathroom floor behind her and a scant amount of blood was visible on the back of the resident's head. The physician order staff to send to R19 to the hospital. The Progress Note, dated 06/19/22 at 07:40 PM, documented R19 fell and hit her head, but did not lose consciousness per staff report. The note stated R19 had a medium sized hematoma (bruise with swelling) on the back of her head with a 3-centimeter (cm) purple/black line imprinted in it. Swelling and redness was also noted to outer area of purple line from hitting the door frame. R19 sent to the hospital via emergency services. The Progress Note, dated 06/20/2022 07:40 PM, stated the root cause of R19's fall was severe dementia; R19 walked around the neighborhood constantly, and lost her balance. The intervention would be a therapy screen. The Progress Note, dated 07/19/22 at 01:18 AM, documented staff found the resident lying down on the floor in the hallway, lying on her right side and asking for help. Later the resident complained of hip pain, and the nurse noted her right hip was swollen. X-rays revealed no acute injury. The root cause was dementia and R19 had difficulty making her needs known. The intervention was pain medication and staff obtained an order for X-ray of R19's right hip due to complaint of pain. The note stated the practitioner would review R19's medications. The Progress Note, dated 09/02/22 at 03:02 PM, R19 was found by staff in her own room but on the other side where she has a roommate, lying on her back. The fall was unwitnessed, neurological checks were started and were at baseline for the resident. The note recorded the immediate intervention was to assist the resident in taking a rest break after breakfast and lunch but this was not added to the care plan. The Progress Note, dated 09/25/22 at 03:35 PM, staff found R19 on the floor in her room, on her back right next to her bed and a pile of covers. Upon assessment the resident did not appear to be in any pain; her pupils were equal round reactive to light, hand grasps equal and strong She had no bruising to back or buttocks, and did not appear to have hit her head. Since the fall was not witnessed, staff proceeded with neurological checks as a precaution and they were at baseline. The note stated the nurse encouraged staff to perform frequent visual checks when R19 was resting in bed since she was prone to getting up an out of bed on her own. The note indicated the root cause was R19 was tangled in blankets and directed an immediate intervention to provide frequent checks when in bed though no time or frequency was specified. The Progress Note, dated 12/26/22 at 05:58 AM, documented staff found R19 on the floor in her room with her head resting on her bed rail with no visible injuries noted. The note documented staff notified her physician via fax and requested an order for non-skid socks while in bed due to the resident ambulated at will and had poor safety awareness due to dementia (after six falls). The note stated neurological assessments were initiated. The Progress Note, dated 1/2/23 at 05:30 PM, staff found R19 face down with arms and legs extended straight out. R19 wore shoes, call light was within reach, and her bed was in lowest position. No apparent injuries were noted, and neurological assessments were started. The note listed an immediate intervention for a fall mat, PT to evaluate R19 for a wheelchair positioning cushion. The Progress Note, dated 02/19/23 at 05:49 PM, documented R19 had a large bruise, approximately 14cm x 11.5cm to her right upper arm and a smaller bruise, approximately 9cm x 4cm, to the left of the larger bruise. The note stated both bruises were dark purple with light yellow at edges and had no swelling. R19 was guarding her right arm with tenderness. Her family was in house and notified of bruising. Per R19's representative's request, staff notified hospice and asked for an x-ray. R19's medical record lacked neurological assessments after R19's 03/20/22 fall with head injury. The 06/19/22 fall with head injury neurological flowsheet was missing two scheduled neurological checks. The 09/25/22 unwitnessed fall neurological flowsheet had seven missing checks. On 02/22/23 at 07:45 AM, observation revealed Certified Nurse Aide (CNA) O and Certified Medication Aide (CMA) S used the total lift to transfer R19 from her bed to her wheelchair. R19 spoke unintelligible words, but when asked if she had pain, R19 replied No. Further observation revealed deep purple bruising to the upper back of R19's right arm, with yellowing bruising to the distal upper arm. When staff dressed R19, staff was gentle with R19's right arm, but she still clenched her teeth. When staff brought R19 out to the dining room, she had a sling on her right arm. On 02/27/23 at 08:50 AM, Administrative Nurse D verified staff had not completed neurological assessments after R19's unwitnessed fall and falls with head injury on 03/20/22, 06/19/22, and 09/25/22. She verified the care plan had not been updated after each fall with pertinent, effective and measurable fall prevention interventions. The facility's Managing Falls and Fall Risk policy, dated 2022, stated based on previous evaluations and current data staff would identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling or try to minimize complications from falling. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remained relevant. The facility failed to provide care and services to prevent further falls for R19, placing R19 at risk for further falls or injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 89 residents. The sample included 18 residents with one reviewed for pain. Based on observation, interview, and record review the facility failed to prevent a medication error when pain medications were not administered as ordered by the physician for Resident (R) 19. This deficient practice place R19 at risk to potentially receive harmful amounts of her pain medication. Findings included: - R19's Electronic Medical Record (EMR) documented diagnoses of severe dementia (group of thinking and social symptoms that interferes with daily functioning) and chronic pain. The Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of zero, and short- and long-term memory problems with severely impaired decision making. The MDS documented R19 required extensive assistance of one staff for eating, hygiene, extensive assistance of two staff for bed mobility, transfers, walking, locomotion, toileting, dressing and total assistance with bathing. The MDS documented R19 had impaired balance and unable to stabilized without help, no range of motion impairment, and used a wheelchair. R19's Pain Care Plan, dated 01/17/23, directed staff to administer pain medication as ordered and staff to monitor pain as she was unable to voice the extent of her pain. The Progress Note, dated 01/03/23 at 05:49 PM, documented R19 was admitted to hospice with the diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). New orders included oxycodone (narcotic pain medication used to treat severe pain), 5 milligrams (mg), take one tablet every four hours as needed for pain, resulting in six possible administrations. The Physician Order, dated 01/04/23, directed staff to administer oxycodone 5 mg four times per day at 08:00 AM, 12:00PM, 04:00PM and 08:00PM, for pain. R19's Medication Administration Record (MAR), dated January 2023, documented staff administered oxycodone 5 mg every four hours from 01/04/23 to 01/09/23 unless the resident was sleeping or refused. R19 received oxycodone the following times: 01/04/23 at 08:00PM 01/05/23 at 12:00AM, 04:00AM, 08:00AM,12:00PM, 04:00 PM, and 08:00 PM. 01/06/23 at 12:00PM, 04:00PM and 08:00PM 01/07/23 at 08:00AM and 08:00PM. 01/08/23 at 04:00 AM, 08:00AM and 12:00PM 01/09/23 at 12:00AM, 04;00AM and 08:00AM The Progress Note, dated 01/05/23 at 03:36 PM, documented R19 continued taking scheduled oxycodone every four hours for pain, and upon assessment R19 was observed holding her head but she was sleeping. She has been resting in bed most of the shift. The Progress Note, dated 01/09/23 at 12:05 PM, documented staff spoke with R19's hospice nurse stating that family felt that R19 was being overmedicated. The note documented the facility reviewed the oxycodone prescription in the EMR and the medication frequency was put in incorrectly to be given every four hours instead of four times per day. The order was updated to match the original physician's order of oxycodone 5 milligrams (mg), four times per day. On 02/22/23 at 07:45 AM, observation revealed Certified Nurse Aide (CNA) O and Certified Medication Aide (CMA) S used the total lift to transfer R19 from her bed to her wheelchair. R19 spoke unintelligible words, but when asked if she had pain, R19 replied No. Further observation revealed deep purple bruising to the upper back of R19's right arm, with yellowing bruising to the distal upper arm. When staff dressed R19, staff was gentle with R19's right arm, but she still clenched her teeth. When staff brought R19 out to the dining room, she had a sling on her right arm. On 02/27/23 at 08:50 AM, Administrative Nurse D stated providers entered their own medication orders in the facility's computer system which flagged a nurse to review. She said the facility did get some written or verbal orders. She verified staff had not correctly transcribed the physician orders for the pain medications and R19 had received more oxycodone than was prescribed. The facility's Administering Medications policy, dated 2022, stated medications were administered in accordance with prescriber orders, including any required time frame. The facility failed to ensure R19 was free from significant medication errors when staff administered an incorrect dose of pain medication placing R19 at risk to potentially receive harmful amounts of her pain medication.

The facility had a census of 89 residents. The sample included 18 residents. Based on observation, interview, and record review the facility failed to ensure the medication for Resident (R) 5 was labeled in accordance with currently accepted professional standards. This deficient practice placed R5 at risk for medication errors. Findings included: - On 02/22/23 at 08:51 AM, observation revealed Certified Medication Aide (CMA) S applied a Salon Pas (pain medication) patch, 3.1/6%, to each of R5's knees. The Physician Order, dated 04/02/21, directed staff to apply the Salon Pas patch to R5's mid and lower back for pain daily. On 02/22/23 at 01:06 PM, Licensed Nurse (LN) G verified the physician's order directed staff to administer R5's Salon Pas patches to his mid and lower back. On 02/22/23 at 01:14 PM, CMA S showed R5's Salon Pas medication box had a handwritten message to apply to both legs. The pharmacy label was still on the box with the instruction to apply to mid and lower back. On 02/22/23 at 01:15 PM, Administrative Nurse E verified the physician order directed staff to apply to mid and lower back and if the physician changed the order, staff were to have pharmacy change the label. The facility's Administering Medications policy, dated 2022, stated medications were administered in accordance with prescriber orders. The policy stated the individual administering the medication checked the label to verify the right resident, right dosage, right time, and right method of administration. The facility failed to ensure the medication for R5 was labeled in accordance with currently accepted professional standards, placing R5 at risk to not receive his medication appropriately.

The facility had a census of 89 residents. The sample included 18 residents with one reviewed for urinary catheter (tube inserted into the bladder to drain urine) or urinary tract infection (UTI). Based on observation, record review and interview the facility staff failed to change gloves when providing Resident (R) 18 incontinent cares and continued to provide care with the same soiled gloves. This placed the resident at risk for infection. Findings included: - R18's Electronic Medical Record documented R18 had diagnoses of Parkinson's disease (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), dementia (progressive mental disorder characterized by failing memory, confusion), and muscle weakness. R18's Quarterly Minimum Data Set, dated 01/20/23, documented R18 had a Brief Interview of Mental Status (BIMS) score of 13, which indicated intact cognition. The MDS documented R18 required extensive staff assistance with transfers, locomotion off unit, bed mobility, toiler use and personal hygiene, limited staff assistance with locomotion on unit, and supervision with eating. The MDS documented R18 was frequently incontinent of bowel and urine. R18's Bowel and Bladder Care Plan, revised 01/24/23, documented R18 was frequently incontinent of bladder and bowel, wore incontinent products for skin protection and dignity. The care plan instructed staff to assess/record/report to the physician any signs or symptoms of UTI. The care plan documented R18 required extensive staff assistance by one staff member for her toileting needs, staff were to assist her upon rising for the day, before and after each meal/activity and approximately every two hours and as needed (PRN). On 02/22/23 at 12:29 PM, observation revealed Certified Nurse Aide (CNA) Q propelled R18 in a wheelchair to her bathroom in her room, and applied a gait belt to R18. CNA Q then applied gloves, and placed 18's left hand on the grab bar on the wall while assisting R18 to stand and pivot back towards the toilet. CNA Q pulled down R18's pants and incontinent brief and assisted R18 in sitting on the toilet. R18 urinated, stated she was done, and CNA Q assisted R18 in standing, then provided perineal (genital area) care. Further observation revealed CNA Q, with the same soiled gloves, pulled up the resident's incontinent brief and pants, then touched R18's gait belt when assisting her in transferring to her wheelchair. With the same soiled gloves, CNA Q touched the handles of the wheelchair to propel R18 to the bathroom sink, then removed and discarded her gloves. CNA Q verified she had not changed her gloves and stated she had worked for the facility for five years and no one had shown her how to change gloves after providing perineal care, due to R18 was not stable when standing. CNA Q stated she would change gloves between dirty and clean when providing perineal care if R18 was in bed. On 02/27/23 at 09:02 AM, Licensed Nurse (LN) H stated when she provided perineal care for R18, she would change gloves between dirty and clean. The facility's Perineal Care Policy, revised February 2018, instructed staff to place the equipment on the bedside stand, arrange the supplies so they could be easily reached, wash and dry hands or use hand sanitizer, put on gloves, wipe the resident's perineal area, from front to back, wipe the resident's rectal area thoroughly, then remove and discard gloves. The facility staff failed to change gloves when providing R18 incontinent cares and continued to provide care with the same soiled gloves. This placed the resident at risk for infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - On 02/21/23 at 11:54 AM, during the noon meal, observation revealed Certified Medication Aide (CMA) M administered R50's eye drops at the dining room table, with several residents in the dining room, eating their noon meal and able to view the procedure. On 02/21/23 12:19 PM, observation during the noon meal revealed CMA M administered R15's nasal spray at the dining room table with two other residents at her table and several other residents eating their meals in the dining room able to view the procedure. On 02/22/23 at 08:18 AM, observation during the breakfast meal service revealed CMA M administered R50's nasal spray, at the dining room table, with six residents present and able to view the procedure. On 02/22/23 at 08:21 AM, observation during the breakfast meal service revealed CMA M administered R50's eye drops at the dining room table with six residents present and able to view the procedure. Review of R15 and R50's care plans lacked documentation which indicated staff could administer the eye drops and nasal spray at the dining room table. On 02/22/23 08:23 AM, CMA M stated it was care planned that staff could administer R15's nasal spray and R50's eye drops at the dining room table. On 02/27/23 at 10:15 AM, Administrative Nurse D stated if staff needed to administer R15's nasal spray or R50's eye drops while they were seated at the dining room table, staff should remove them to their rooms and administer the medications there. The facility's Resident Rights Policy, revised 2022, documented all residents had the right to a dignified existence and should be treated with respect, kindness, and dignity. The facility failed to treat R15 and R50 with dignity when staff administered R15's nasal spray and R50's eye drops at the dining room table with several other residents present. This placed them at risk for an undignified experience. - R21's Electronic Medical Record (EMR) recorded diagnoses of neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R21's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of two (severely cognitively impaired), and an indwelling urinary catheter (a tube in the bladder to drain urine). R21's Care Plan, dated 12/23/22, recorded the resident had a suprapubic catheter (urinary catheter inserted into the bladder through the abdomen) for neurogenic bladder post back surgery. The care plan recorded staff were to flush the catheter per physician order and assist with drainage bag throughout the day. The care plan lacked any guidance for staff to cover the urinary catheter bag. On 02/21/23 at 04:10 PM, observation revealed R21 rested in bed, with the uncovered urinary catheter bag hanging on the right side of the bed frame, visible from the hall. On 02/22/23 at 08:00 AM, observation revealed R21 sitting up in bed, with the uncovered urinary catheter bag hanging on the right side of the bed frame, visible from the hall. On 02/27/23 at 08:50 AM, Administrative Nurse F stated the resident's urinary catheter bag should be covered at all times. The facility's Resident Right policy, 2022 (no month documented), documented the staff shall treat all residents with kindness respect and dignity. The policy documented Federal and State laws guarantee certain basic rights to all residents of this facility and theses rights include the resident's right to: a dignified existence, be treated with respect, kindness, and dignity. The facility failed to cover R21's urinary catheter bag, placing the resident at risk for embarrassment and an undignified living environment. The facility had a census of 89 residents. The sample included 18 residents. Based on observation, interview, and record review the facility failed to promote dignity during the dining experience for residents in two of three dining rooms when staff scraped off soiled plates next to residents who were still eating and nursing staff administered eye drops and nasal spray medications in the dining room in front of other residents. The facility further failed to ensure a dignity cover for R21's urinary drainage bag. This deficient practice placed residents at risk for impaired dignity and embarrassment. Findings included: - On 02/22/23 at 09:02 AM, while several residents were still eating, observation revealed Certified Medication Aide (CMA) R wheeled the garbage cart between dining tables, scraping off soiled plates within one foot of seated residents still dining. On 02/22/23 at 12:40 PM, observation revealed Dietary Staff (DS) CC cleaned off tables with residents still sitting there. Continued observation revealed DS CC wheeled the garbage cart around the room, behind and beside residents, when he scraped off soiled plates. The facility's Resident Rights policy, dated 2022, stated residents had the right to be treated with respect, kindness, and dignity. The facility failed to promote dignity during the dining experience for residents in two of three dining rooms when staff scraped off soiled plates next to residents who were still eating, placing the residents at risk for a less than dignified dining experience.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 135 residents with 27 residents included in the sample and two residents reviewed for hospitalizations. Based on interview and record review the facility failed to provide Resident (R) 274 and his representative written notice of the reason for the transfer/discharge to the hospital. Findings included: - Review of the Physician's Orders in the Electronic Medical Record (EMR) dated 06/11/21 revealed R274 had diagnoses of: cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area, also known as a stroke) and epilepsy (brain disorder characterized by repeated seizures). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition with seizures noted. Review of the Quarterly MDS dated 04/07/21 revealed a BIMS of 11, indicating moderately impaired cognition with seizures noted. Review of the ADL Care Area Assessment (CAA) dated 01/22/21 revealed R 274 was at another community for short term rehabilitation after his stroke and transferred to the facility for long-term Care. The Discharge return anticipated MDS dated 05/27/21 revealed R 274 transferred to an acute care hospital. The Care Plan dated 06/14/21 revealed R 274 transferred a local hospital on [DATE] and returned on 06/12/21. A Nurse Progress Note dated 05/27/21 at 04:57 PM revealed R 274 transported via gurney to a local emergency room at approximately 04:40 PM. During an interview on 06/24/21 at 02:19 PM, Social Service Designee (SSD) D revealed he did not send out a written notice of transfer to the resident or resident representative. SSD D stated she thought the nurse completed this. During an interview on 06/24/21 at 02:06 PM, Business Office Manager E revealed she called the resident representative to let them know about the transfer. The facility's 12/2016 Transfer or Discharge Notice policy stated the resident and/or representative would be notified in writing of . the reason for transfer or discharge, the effective date of the transfer or discharge, and the location to which the resident transferred or discharged . A copy of the notice would be sent to the Office of the State Long-Term Care Ombudsman and the reasons for the transfer or discharge would be documented in the resident's medical record. The facility failed to provide written notice of the reason for a transfer as soon as practicable to R274 or their representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 135 residents with 27 residents included in the sample and two residents reviewed for hospitalizations. Based on interview and record review the facility failed to provide Resident (R) 274 and his representative with a bed-hold policy upon transfer to the hospital. Findings included: - Review of the Physician's Orders in the Electronic Medical Record (EMR) dated 06/11/21 revealed R 274 had diagnoses of: cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area, also known as a stroke) and epilepsy (brain disorder characterized by repeated seizures). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition with seizures noted. Review of the Quarterly MDS dated 04/07/21 revealed a BIMS of 11, indicating moderately impaired cognition with seizures noted. Review of the ADL Care Area Assessment (CAA) dated 01/22/21 revealed R 274 was at another community for short term rehabilitation after his stroke and transferred to the facility for long-term care. The Discharge return anticipated MDS dated 05/27/21 revealed R 274 transferred to an acute care hospital. The Care Plan dated 06/14/21 revealed R 274 transferred to a local hospital on [DATE] and returned on 06/12/21. A Nurse Progress Note dated 05/27/21 at 04:57 PM revealed R 274 transported via gurney to a local emergency room at approximately 04:40 PM. Review of R 274's EMR for bed hold/written notification revealed no notifications were found. During an interview on 06/23/21 at 04:12 PM, Licensed Nurse (LN) F revealed bed holds should be completed and included in the scanned documents section of the resident's EMR. During an interview on 06/24/21 at 02:06 PM, Business Office Manager E revealed she completed the written bed holds when a resident transferred to the hospital. Business Office Manager E stated on admission the resident received the agreement that has information dealing with a bed hold and she did not send a bed hold policy again when the resident transferred to the hospital. Interview with Administrative Nurse B on 06/28/21 at 08:00 AM revealed the bed hold should be placed in the medical record and go out with them to the hospital. Review of the Bed-Holds and Returns policy revised March 2017 revealed, Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. The facility failed to ensure R 274 and/or his representative received written notice of the facility's bed hold policy for his hospitalization between 05/27/21 to 06/12/21.

The facility census totaled 135 residents with 27 residents in the sample. Based on observation, interview, and record review the facility failed to update Resident (R)98's care plan with care and maintenance of the Bilevel Positive Airway Pressure (BIPAP- machine that uses pressure to push air into the lungs, opening the lungs and improving the level of oxygen in the blood and decreasing the carbon dioxide) equipment and supplies. Findings included: - R98's pertinent diagnoses from the Physician's Orders Diagnosis in the Electronic Medical Record (EMR) dated 05/05/21 revealed chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 01/28/21 Significant Change Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition and use of a BIPAP. Review of the 01/28/21 Activities of Daily Living [ADLs] Care Area Assessment (CAA) revealed R98 was recently hospitalized for acute (quick onset) chronic (long-term) hypercapnia (excessive carbon dioxide in the bloodstream) respiratory failure with hypoxia (inadequate supply of oxygen) and pneumonia (an inflammation of the lungs). She had a history of sleep apnea (disorder of sleep characterized by periods without respirations) with BIPAP required when sleeping. The 09/26/20 Respiratory System Care Plan revealed staff encouraged the use of BIPAP daily. The BIPAP orders included the settings, but lacked information about cleaning the equipment after use or storage. Observation of R98 on 06/23/21 at 04:29 PM revealed the resident in bed with her BIPAP noted on the shelf by her bed on a grocery sack instead of in a storage bag. The mask of the BIPAP had bits of food/saliva/debris. Observation of R98 on 06/24/21 at 08:37 AM revealed the BIPAP on the shelf again, not in a storage bag, with the same unclean appearance. Interview with Administrative Nurse B on 06/28/21 at 10:23 AM revealed the care plan should include the BIPAP and the expectations for the BIPAP, but she would not expect to see how often the BIPAP should be cleaned or stored. Review of 12/2016 Care Plans, Comprehensive Person-Centered policy revealed the comprehensive, person-centered care plan will describe the services provided to attain or maintain the resident's highest practicable physical well-being, identify the professional services that are responsible for each element of care, and reflect currently recognized standards of practice for problem areas and conditions. Assessments of residents are ongoing and care plans are revised as information about the residents and conditions change. The facility failed to update R98's care plan with the care and maintenance of the BIPAP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 135 residents with 27 included in the sample. Based on observation, interview, and record review the facility failed to ensure one of two residents reviewed for ADLs (Activities for Daily Living) received assistance from staff for grooming as evidenced by Resident (R) 103 was unshaven and had fingernails that needed to be trimmed. Findings included: - Review of the Physician Progress Note dated 06/02/21 for R103 revealed the following diagnosis: Dementia without behaviors (progressive mental disorder characterized by failing memory, confusion). Review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score three which indicated severely impaired cognition. R103 required limited assistance with personal hygiene and dressing, and activity did not occur for bathing. Review of the Quarterly MDS dated 05/26/21 revealed a BIMS of three which indicated severely impaired cognition. R103 required extensive assistance with personal hygiene and dressing, and physical assistance for part of the bathing experience. Review of the Cognitive Loss/Dementia Care Area Assessment (CAA) dated 12/03/21 revealed R103 scored three on the BIMS indicating severe cognitive impairment. Review of the ADL Functional /Rehabilitation Potential Care Plan reviewed/revised on 05/27/21 revealed R103 needed extensive assistance with daily ADL care. Review of the Point of Care History for bathing report for April 2021 documented that R103 received a shower on 04/16/21 and 04/27/21. Bathing activity did not occur for all other dates. Review of the Point of Care History for bathing report for May 2021 documented that R103 received a shower on 05/04/21, 05/20/21, 05/25/21 and 05/28/21 and refused on 05/11/21 and 05/18/21. Review of the Point of Care History for bathing report for June 2021 documented R103 received a shower on 06/08/21, 06/11/21, 06/15/21, and 06/18/21. An observation on 06/23/21 at 08:56 AM revealed R103 sat in his chair in his room watching television. R103 looked unshaven with heavy stubble, and some of his nails needed to be trimmed and cleaned. An observation on 06/24/21 at 12:01 PM revealed R103 sat in the dining room independently eating his lunch. R103 wore clean clothes. His face had heavy stubble and his nails needed to be trimmed. During an observation on 06/28/21 at 08:38 AM revealed R103 needed to be shaved and his fingernails needed to be trimmed. During an interview on 06/24/21 at 09:59 AM, Certified Nurse Aide (CNA) S stated R103 required extensive assistance with ADLs. CNA S stated R103 was not resistive to cares. CNA S stated she did not know the bathing schedule, but thought R103 received a shower at least twice weekly. CNA S stated R103 should be shaved with his bath, and the nurses completed his nail care. During an interview on 06/28/21 at 08:33 AM, CNA T stated staff bathed R103 twice a week on second shift and he should be shaved and have his nails trimmed at that time or as needed. CNA T stated R103 was usually not resistive to cares. During an interview on 06/28/21 at 10:51 AM, CNA U stated R103 was supposed to receive a bath or shower twice a week. CNA U stated second shift took care of his bathing and this would be the time R103 should be shaved and have his fingernails trimmed. CNA U stated R103 usually did not refuse cares. CNA U stated if R103 needed to be shaved or have his fingernails trimmed staff could do this at any time. During an interview on 06/24/21 at 12:56 PM, Licensed Nurse (LN) V stated R103 required extensive assist with dressing, bathing and personal hygiene. LN V stated staff shaved R103 during shower days which were twice a week. LN V stated the CNAs would normally care for his nails during shower days and did not know if R103 refused to have his nails cut. During an interview on 06/28/21 at 3:12 PM, Administrative Nurse B stated she expected staff to adhere to R103's bathing schedule and chart that it was either given or the resident refused. Administrative Nurse B stated staff should trim resident nails and shave the resident each time they were bathed at minimum or according to what the resident requested. Review of the Fingernails/Toenail, Care of policy, revised February 2018, revealed, Nail care includes daily cleaning and regular trimming. The facility failed to ensure staff shaved R103 and trimmed his fingernails.

The facility census totaled 135 residents with 27 residents in the sample with one resident reviewed for respiratory care. Based on observation, interview, and record review the facility failed to ensure that Resident (R)98's Bilevel Positive Airway Pressure (BIPAP- machine that uses pressure to push air into the lungs, opening the lungs and improving the level of oxygen in the blood and decreasing the carbon dioxide) was maintained and stored in a sanitary manner. Findings included: - R98's pertinent diagnoses from the Physician's Orders Diagnosis in the Electronic Medical Record (EMR) dated 05/05/21 revealed chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 01/28/21 Significant Change Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition and use of a BIPAP. Review of the 01/28/21 Activities of Daily Living [ADLs] Care Area Assessment (CAA) revealed R98 was recently hospitalized for acute (quick onset) chronic (long-term) hypercapnia (excessive carbon dioxide in the bloodstream) respiratory failure with hypoxia (inadequate supply of oxygen) and pneumonia (an inflammation of the lungs). She had a history of sleep apnea (disorder of sleep characterized by periods without respirations) with BIPAP required when sleeping. The 09/26/20 Respiratory System Care Plan revealed staff encouraged the use of BIPAP daily. The BIPAP orders included the settings, but lacked information about cleaning the equipment after use or storage. The 02/01/20 Physician Orders revealed the staff encouraged use of BIPAP every shift daily. A Progress Note dated 04/05/21 at 03:41 AM revealed R98 continued on Rocephin (antibiotic) for pleural effusion (abnormal accumulation of fluid in the lungs) and leukocytosis (an increase in the number of white cells in the blood due to infection). Her lung sounds were diminished in bilateral (both) bases [of her lungs]. The resident wore her BIPAP throughout the shift aside from when eating, drinking, and taking medications. Review of a Progress Note dated 05/26/21 at 09:44 AM revealed R98 wore her BIPAP while sleeping. Observation of R98 on 06/23/21 at 04:29 PM revealed the resident in bed with her BIPAP noted on the shelf by her bed on a grocery sack instead of in a storage bag. The mask of the BIPAP had bits of food/saliva/debris. Observation of R98 on 06/24/21 at 08:37 AM revealed BIPAP noted to be set on the shelf again, not in a storage bag, with the same appearance as noted yesterday. Interview with R98 on 06/24/21 at 08:54 AM revealed, no staff ever cleaned her BIPAP, and they put it on her shelf by her bed, there was never a storage bag used. Interview with CNA I on 06/24/21 at 08:22 AM revealed the resident already had her BIPAP off this morning when she came in, but her BIPAP should have been in a clean bag for storage. She stated, she did not know why it was not in a clean bag. Interview with CNA H on 06/24/21 at 11:11 AM revealed she did not know who cleaned the BIPAP, but she thought the nurses did that. She had never seen staff clean the BIPAP, but it should be in a clean bag on the oxygen concentrator, or on the resident's shelf. Interview with LN F on 06/24/21 at 10:47 AM revealed the third shift nurses completed the BIPAP cleaning before the shift ended at 06:00 AM. She was unsure if the staff documented it, but figured it should be documented in the treatments on the Treatment Administration Record (TAR) by the nurses. If the nurses cleaned the BIPAP, it would be with warm water, soap, and let the BIPAP dry. She then stated, third shift nurses completed the cleaning of the BIPAP and should document on the daily duty sheets. She continued that the BIPAP should be stored in a clean bag when not in use and the bag should be changed weekly. Interview with Administrative Nurse B on 06/28/21 at 10:23 AM revealed the BIPAP should be cleaned weekly with soap and water, and should be stored in a clean bag once completely dry. Interview with Provider C on 06/24/21 at 09:35 AM revealed the best way to clean a BIPAP mask and tubing would be with soap and water. For a resident with COPD/lung issues that coughs a lot and has phlegm (mucus), cleaning the BIPAP tubing would be more important than cleaning the mask, because of the potential for infection. Normal food particles would probably not be an issue. The BIPAP should be stored in a sanitary manner to lessen the event of infection. Review of the 2004-2021 Keeping it Clean: Continuous Positive Airway Pressure (CPAP- machine to help a person breathe more easily during sleep [similar to a BIPAP]) Hygiene education revealed it was vitally important to keep everything as clean as possible, as hoses/tubing and masks can be a prime breeding ground for bacteria and mold. If sick, it is smart to wash the mask, tubing, humidifier and filter daily until the sickness symptoms are gone. The mask and tubing need a full bath once a week to keep it free of dust, bacteria and germs. Review of revised 03/2015 CPAP/BIPAP Support policy revealed the masks and tubing [must be] cleaned daily by placing in warm, soapy water and soaking/agitating for five minutes. Mild dish detergent is recommended. Rinse with warm water and allow it to air dry between uses. The facility failed to ensure that R98's BIPAP was maintained and stored in a sanitary manner.

The facility census totaled 135 residents, with five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to complete physician orders in response to the monthly Medication Regimen Reviews (MRR) from the consultant pharmacist for Resident (R) 60 for the addition of an end date for the resident's PRN psychotropic medication and correction to the antipsychotic medication diagnosis. Findings included: - Review of R60's pertinent diagnoses from the Physician's Orders in the Electronic Health Record (EHR) dated 05/03/21 documented Major Depressive Disorder (MDD) major mood disorder), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and muscle spasms. Review of the 05/08/21 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of seven, indicating moderately impaired cognition with no behaviors. R60 received antipsychotic medications on a routine bases only with no as needed (PRN) doses received. R60's Psychotropic Drug Use Care Area Assessment (CAA) dated 05/08/21 documented R60 had the diagnosis of depression for which she received aripiprazole (antipsychotic medication). She had the diagnosis of anxiety for which she received alprazolam (anti-anxiety medication). According to the CAA, R60's current dosages appeared to be therapeutic for her conditions. The 06/04/21 Care Plan documented that for R60's mood, she used medications to assist with managing signs and symptoms of depression and that they were to consult the Medication Administration Record (MAR). For anxiety staff were to monitor effectiveness of medications. Physician Orders documented that on 05/17/21 R60 had an order for alprazolam tablet 0.5 milligram (mg) by mouth for anxiety three times a day PRN with no end date noted. The resident also had an order for aripiprazole 5 mg tablet by mouth daily for MDD dated 05/03/21. Review of the Medication Regimen Review (MRR) dated 05/26/2021 recommended that staff check diagnoses for medications, with a note to pay close attention to the diagnosis on the antipsychotic medication aripiprazole. Facility staff noted the recommendation on 05/24/21. Also, a recommendation that there was no stop date noted for PRN alprazolam to which the physician responded with six months and a diagnosis of chronic anxiety on 05/26/21. Observation of R60 on 06/22/21 at 10:50 AM revealed R60 in bed watching TV with no signs or symptoms of distress and no involuntary movements. An interview with Licensed Nurse (LN) P on 06/24/21 at 09:50 AM confirmed R60's alprazolam was PRN and had no stop date. She revealed the provider did not specify an end date. The nurse managers completed the MRRs and the physician responses to them, but if they were not available the nurses completed them. The diagnosis for the aripiprazole was MDD per the providers order, normally the pharmacist would note if the diagnosis was incorrect. She stated that the MDD looked correct to her. On 06/28/21 at 10:32 AM Administrative Nurse B confirmed the MRR was sent and noted, the PRN psychotropic medication had no end date, and the diagnosis was not correct for the antipsychotic medication. Her expectation was that when the nurse received the recommendation, that the nurse would clarify the antipsychotic diagnosis, and the end date of the PRN psychotropic medications with the physician and correct it on the MAR. On 06/29/21 at 02:15 PM Pharmacy Consultant W revealed in general, the facility had a policy on the follow through for recommendations. The diagnoses almost always appeared in the history and physical reports that come with each resident, and it is more housekeeping to ensure they are attached to the medications. They would need to go in and update those things. If the same issues reoccurred the next month, she would say something again. But with residents in PACU, they are usually short-term stay. Review of the facility's Medication Regimen Review policy revised May 2019 documented that the attending physician would document in the medical record that the irregularity had been reviewed and the (if any) action taken to address it. The facility failed to complete physician orders in response to the monthly MRR from the consultant pharmacist for R60 for the addition of an end date for the resident's PRN psychotropic medication and correction to the antipsychotic medication diagnosis.

The facility census totaled 135 residents, with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to monitor Resident (R)60's effectiveness of Lasix (diuretic, medication used to promote the excretion of fluids) as ordered by the physician. Findings included: - Review of R60's pertinent diagnoses from the Physician's Orders in the Electronic Health Record (EHR) dated 05/03/21 documented hypertension (elevated blood pressure) and chronic obstructive pulmonary disease (COPD, progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). Review of the 05/08/21 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of seven, indicating moderately impaired cognition. R60 weighed 193 pounds and received diuretics three of the seven day look back period. R60's Cognitive Loss/ Dementia Care Area Assessment (CAA) dated 05/08/21 documented R60 scored seven on the BIMS, indicating severely impaired cognition. The 05/03/21 Care Plan documented that staff were to assess and monitor for medication effectiveness and signs and symptoms of side effects of medication administration. Physician Orders documented on 05/21/21 R60 had an order to have a daily weight obtained and that staff were to notify the provider if R60 gained three pounds (lbs.) or more in one day or gained five lbs. or more in one week. The resident also had an order for Lasix 40 milligrams (mg) tablet by mouth daily for hypertension. Review of 05/21/21 to 06/23/21 Medication Administration Record (MAR) and Treatment Administration Records (TAR) documented the following missing weights: 06/04/21, 06/07/21, 06/08/21, 06/09/21, 06/10/21, 06/11/21, 06/13/21, and 06/17/21, for a total of eight missing daily weights. On 06/22/21 at 10:50 AM resident observed in her room in bed watching TV, with no signs or symptoms of distress, and minimal edema noted. On 06/24/21 at 03:09 PM Certified Nurse Aide (CNA) O revealed staff weighed R60 maybe daily, that every resident was weighed weekly in post-anesthesia care unit, rehabilitation unit (PACU) unless the nurse informed them otherwise, and they would report the weights to the nurses. On 06/24/21 at 09:50 AM Licensed Nurse (LN) P revealed R60 received Lasix for heart failure and that she was a daily weight. If she gained three pounds in a day, or five pounds in a week the provider was to be notified. On 06/28/21 at 10:32 AM Administrative Nurse B revealed her expectation for weights, they should be weighed per order, and the physician should be notified as per the order. The facility's Administering Medications policy revised April 2019 documented medications are administered in accordance with prescriber orders and that staff were to check/ verify vital signs as necessary. The facility failed to obtain weights daily for R60 per the physician's order to ensure her medications were accurately monitored.

The facility census totaled 135 residents, with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to initiate doctor's orders to limit the time frame of an as needed (PRN) psychotropic medication and obtain an appropriate indication for use of an antipsychotic medication for Resident (R) 60. Findings included: - Review of R60's pertinent diagnoses from the Physician's Orders in the Electronic Health Record (EHR) dated 05/03/21 documented Major Depressive Disorder (MDD major mood disorder), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and muscle spasms. Review of the 05/08/21 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of seven, indicating moderately impaired cognition with no behaviors. R60 received antipsychotic medications on a routine bases only with no PRN doses received. R60's Psychotropic Drug Use Care Area Assessment (CAA) dated 05/08/21 documented R60 had the diagnosis of depression for which she received aripiprazole (antipsychotic medication). She had the diagnosis of anxiety for which she received alprazolam (anti-anxiety medication). According to the CAA, R60's current dosages appeared to be therapeutic for her conditions. The 06/04/21 Care Plan documented that for R60's mood, she used medications to assist with managing signs and symptoms of depression and that they were to consult the Medication Administration Record (MAR). For anxiety staff were to monitor effectiveness of medications. Physician Orders documented that on 05/17/21 R60 had an order for alprazolam tablet 0.5 milligrams (mg) by mouth for anxiety three times a day PRN with no end date noted. The resident also had a 05/03/21 order for aripiprazole 5 mg tablet by mouth daily for MDD. Review of the Medication Regimen Review (MRR) dated 05/26/2021 recommended that staff check diagnoses for medications, with a note to pay close attention to the diagnosis on the antipsychotic medication aripiprazole. Facility staff noted the recommendation on 05/24/21. Also, a recommendation that there was no stop date noted for PRN alprazolam to which the physician responded with six months and a diagnosis of chronic anxiety on 05/26/21. Observation of R60 on 06/22/21 at 10:50 AM revealed R60 in bed watching TV with no signs or symptoms of distress and no involuntary movements. An interview with Licensed Nurse (LN) P on 06/24/21 at 09:50 AM confirmed R60's alprazolam was PRN and had no stop date. She revealed the provider did not specify an end date. She stated that the MDD diagnosis for aripiprazole looked correct to her. On 06/28/21 at 10:32 AM Administrative Nurse B confirmed the PRN psychotropic medication had no end date, and the diagnosis was not correct for the antipsychotic medication. The facility's Antipsychotic Medication Use policy, revised December 2016, documented that antipsychotic medications will be prescribed at the lowest possible dose and for the shortest period possible. Antipsychotic medications shall use a diagnosis consistent with the definition Diagnostic and Statistical Manual of Mental Disorders. The facility failed to implement physician orders to limit the time frame of use for a psychotropic medication and to obtain an appropriate diagnosis for use of an antipsychotic medication.

The facility census totaled 135 residents. The facility had one main kitchen with five satellite kitchens. Based on observation, interview, and record review the facility failed to ensure sanitary use of gloves while preparing and serving food to residents in one of five satellite kitchens on the 200 Hall. Twenty-six residents resided on 200 Hall. Findings included: - Observation on 06/22/21 at 11:27 AM revealed Dietary Aide Q in the 200 Hall satellite kitchen served lunch, wore gloves, and used utensils to serve except when he unwrapped the baked potatoes and touched the potatoes with the same gloves he used to open cabinets, touch utensils, retrieve plates, papers, touch plates, and push up his glasses. Interview with Dietary Aide Q on 06/22/21 at 11:47 AM revealed he used utensils for handling food and indicated he wore gloves, so it was ok. Interview with Dietary Manager R on 06/22/21 at 02:42 PM verified Dietary Aide Q only worked on the 200 Hall and if staff used gloves, they should remove them if they have touched something other than the food, because we use utensils for everything. He should have removed the gloves, washed his hands with soap and water, then apply new gloves before touching the food. Review of the facility's 2013 Service of Food policy directed staff to distribute and serve food in a safe, accurate, timely and acceptable manner. Food service employees will minimize bare-hand and arm contact with exposed food that is not in a ready-to-eat form. Gloves will be used for one task only and discarded when soiled, damaged, or interruptions occur in the operation that could soil the gloves. Hands should be washed before putting gloves on, when changing, or after removing gloves. The facility failed to ensure sanitary use of gloves while preparing and serving food to residents on the 200 Hall.