**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 33 residents. The sample included 12 residents with two reviewed for bed rail use. Based on observation, interview, and record review the facility failed to provide bed rails with gaps less than four and three-quarters inches per Food and Drug Administration (FDA) guidelines for safety. This deficient practice placed Resident (R) 2 and R13 at risk for injury. Findings included: - R2's Electronic Medical Record documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), delusional disorders (untrue persistent beliefs held by a person although evidence shows it was untrue), anxiety disorder (a mental or emotional disorder characterized by apprehension, uncertainty, and irrational fear), and insomnia (inability to sleep). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS documented R2 required moderate staff assistance for upper body dressing, transfers, maximum assistance for lying to sitting, and toileting, and was dependent on staff for lower body dressing. The MDS documented R2 had no falls since the prior assessment of 09/24/24. The Fall Care Area Assessment (CAA), dated 12/10/24, documented R2 received several medications that could cause dizziness, utilized a walker to ambulate, performed transfers with assistance, had urgency incontinence (involuntary passage of urine occurring soon after a strong sense of urgency to void), unsteady balance, and a history of falls. R2's Fall Care Plan, dated 12/10/24, documented the resident was at high risk for falls. The car plan directed staff to ensure the resident was wearing appropriate footwear when ambulating and educated R2 to use the call light when needing to get out of bed. The care plan lacked direction for the use of bed rails. The Fall Note dated 07/15/24 at 10:20 AM, documented R2 attempted to self-transfer into bed and her legs gave out. She stated she did not hit her head and had no noted injury. On 02/05/25 at 08:00 AM, R2 laid in bed with half rails up. The bed rails had long wide gaps. She was dressed, wore a left cam boot (orthopedic device used to immobilize and support the ankle joint after injuries), and right foot gripper sock. On 02/06/25 at 10:45 AM, Administrative Staff E verified the bed rail gaps measured four and three-eighths inches by twenty-one inches in the top rail and the bottom rail had a long wide gap of four and three-eighths inches by forty-two inches. Administrative Staff E stated when she did the bed rail assessments, she only measured the height of the gaps. The facility's Long Term Care Unit Resident Safety policy, dated 06/20/2018, stated all side rails must be assessed upon admission and recommendations would be made for transfer bar or use of a rail. The facility failed to provide bed rails with gaps less than four and three-quarters inches wide, placing R2 at risk for injury. - The Electronic Medical Record (EMR) for R13's diagnoses included 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 and chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R13's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. The MDS documented R13 required substantial to maximum assistance with mobility-rolling left to right. The MDS lacked documentation the resident had side rails. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/30/24, recorded R13 was able to verbalize needs and is very boisterous with requests frequently, can make daily decisions, is oriented to self, surroundings, questioning situations, has impaired safety awareness and a fear of falling. R13's medical record recorded a Side Rail Assessment completed on 11/19/24 documented the resident was not able to get out of bed and could not get out safely. The side rail safety documented the half rails the resident had requested while in bed. The side rail assessment documented the side rails are used on the left side of the bed and the resident verbalized understanding of the risk. On 02/05/25 at 01:50 PM, a one-half side rail was on the left side of R13's bed. The side rail gaps measured 4 and 3/8 inches by 21 and 1/2 inches between rails. On 02/06/25 at 10:45 AM, Administrative Nurse E verified the gaps measured greater than 4 ¾ inches between the bars and stated when she did the assessments, she only measured the width one way. The Long Term Unit Resident Safety, policy, dated 06/20/18, documented safety and handling of residents are the nursing staff's highest priority. The policy documented bed rails shall be elevated to the proper level when transferring the resident to/from the bed to the chair. The policy documented the bed rails may be up on those residents under the influence of sedation, immediate postoperative residents, and those who in the judgment of the charge nurse or supervisor feel that rails must be up for safety measures. All side rails would be assessed upon admission. Recommendations would be made for a transfer bar or the use of rails. The facility failed to adequately assess R13's actual rail in use to ensure safe openings and failed to assess for safe use a side rail prior to placing on R13's bed. This deficient practice placed R13 at risk for preventable entrapment, accident, or injury.

The facility had a census of 33 residents. Based on record review and interview, the facility failed to ensure the staff person designated as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training in infection prevention and control. This placed the residents at risk for lack of identification and treatment of infections. Findings included: - On 02/07 /25 at 01:30 PM, Administrative Nurse F stated she was responsible for the Infection Prevention and Control Program and lacked certification as an Infection Preventionist. Administrative Nurse E stated she had enrolled in the program, and completed the training modules, but had not received the certification. The Infection Prevention Plan policy dated 09/24/24, documented the infection prevention committee including the Infection Preventionist would implement, develop, and update the infection prevention policies and procedures, and educate and train faculty and staff. The Infection Preventionist would also assess competency of tasks, compliance with hand hygiene, and personal protective equipment. The policy documented the Infection Prevention Committee would ensure proper EVS cleaning and disinfection policies and procedures were in place to determine when to implement respiratory hygiene measures and implement and update employee health policies. The Infection Preventionist would handle collection management and analysis of quality measures including Antibiotic Stewardship, central lines, catheters, and surveillance. The Infection Preventionist would provide notification to State and local health departments of reportable diseases and conditions. The Infection Preventionist would prepare, collect, manage, and distribute reports; as well as assess patients with symptoms and active infection to determine placement of transmission-based precautions. The Infection Preventionist would handle the determination of appropriate cleaning and disinfectant supplies, for healthcare workers exposed to contagious pathogens, and preperation for re-emerging diseases or future pandemics. The Infection Preventionist policy, dated 09/24/24, documented the Strategies of the Infection Preventionist would include the following: -Employment of an individual with appropriate infection control and prevention knowledge to manage the program. -Incorporate appropriate regulatory and accreditation requirements into the organizational processes. -Referencing and resourcing guidelines from relevant organizations regarding current inpatient, outpatient, long-term care infection control practices, -Participate in effective risk management and performance improvement activities designed to improve patient care, education, and research, encouraging adherence to sound principles and organizational polices. -Provide Infection Prevention and Control education regarding regulation, guidelines, risk management concerns, and performance improvement initiatives. -Conduct surveillance, monitoring, and reporting of infection control practices in clinical areas. -Annual TB surveillance and report to the Employee Health Nurse. -Annual Review of the Infection Control Plan to assess risk and establish program priorities. -Provide written assessment annually to the Patient safety committee. -Quarterly data analysis including tracking and trending of infection diseases and potential for acquisition and transmission within the organization and committee through the Infection Control Committee. -Periodic notifiable reporting audits -Surveillance rounds through all clinic sites at least every six months and as needed The facility failed to ensure the person designated as the Infection Preventionist completed the required certification. This deficient practice placed the residents at risk for lack of identification and treatment of infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to thoroughly investigate two separate incidents of resident-to-resident incident between three sampled residents, Resident (R)26 and R8; R26 and R22 in another incident. This placed the residents at risk for further injury and unidentified abuse or mistreatment. Findings included: - The Electronic Medical Record (EMR) for R26 documented diagnoses of dementia without behavioral disturbance, and delusional disorder (untrue persistent belief or perception healed by a person although evidence shows it was untrue). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R26 had severely impaired cognition and required limited assistance of one staff for bed mobility, transfers, toileting, and supervision and one staff assistance for ambulation. The MDS further documented R26 had verbal behaviors, other behaviors, and rejection of care one to three days, and wandered four to six days, and received antipsychotic (medication used to treat psychosis and other mental emotional conditions), antianxiety (medication that calm and relax people with excessive anxiety) medication seven days of the look-back period. The Nurse's Note, dated 12/02/22 at 09:50 PM, documented R26 wandered into another resident's room and proceeded to touch her feet and move her blanket. The note further documented staff redirected R26 out of the room as R26 stated she wanted me to do things for her. Staff assessed both residents, and no injury was found. The Nurse's Note, dated 01/14/23 at 04:24 PM, documented R26 was in R8's room, kneeling at her bedside. The note further documented R8 was lying in bed, with her top partially up. The staff went to take R26 out of the room, R8 stated, Don't take him away, I haven't seen him in a long time. The note documented R8 stated, nothing physically happened. On 05/30/23 at 04:35 PM, Administrative Nurse D stated she did remember both incidents. She stated she had a few notes from the risk management meetings but stated she did not have an incident or investigation report for either incident. The facility Resident to Resident Altercations policy, dated 10/20/22, documented each resident residing in the facility had the right to be free from mental, physical, sexual, and verbal abuse, mistreatment and exploitation of personal property. It is the policy of the facility to ensure there are effective systems in place to prevent resident to resident altercations from occurring while the resident is in the facility. If the resident to resident altercation has occurred, the facility would protect all residents involved in the incident and all other residents at risk immediately, the administrator/ or director of nursing would immediately begin the investigation of the incident and report the incident to the state reporting agency as required within two hours if significant injury occurred or within 24 hours if no injury found. The investigation would be conducted per the abuse, neglect, and exploitation policy to determine triggers to behaviors, root cause analysis of incident, an immediate and follow up intervention to protect all residents of the facility. The facility failed to investigate two separate resident to resident incidents for R26, this placed the residents at risk for injury and unidentified abuse or mistreatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan that included Resident (R)17's history of bowel obstruction (a gastrointestinal condition in which digested material is prevented from passing normally through the bowel) and interventions to prevent constipation (difficulty passing stool). This placed the resident at risk for impaction (the condition of being or process of becoming impacted, especially of feces in the intestine) and bowel obstruction. Findings included: -- The Electronic Medical Record (EMR) for R17 documented diagnoses of Alzheimer's disease (progressive mental deterioration due to generalized deterioration of the brain), anxiety (feeling of worry, nervousness, or unease), depression (persistent sadness and lack of interest or pleasure in previously rewarding or enjoyable activities), hypertension (high blood pressure) dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), and constipation. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, ambulation, toileting and personal hygiene. The MDS further documented R17 was frequently incontinent of bowel. R17's EMR lacked evidence a bowel monitoring care plan with interventions to prevent constipation was developed. The Physician's Order, dated 12/04/20, directed staff to administer Dulcolax (medication used for constipation) suppository, 10 milligrams (mg), rectally, as needed, for constipation. The Physician's Order, dated 03/01/21, directed staff to administer polyethylene glycol (medication used for constipation), 17 grams (gr), by mouth, daily, for constipation. The Physician's Order, dated 03/10/22, directed staff to administer Milk of Magnesia (medication used for constipation), 30 milliliters, by mouth, as needed for constipation. The Physician's Order, dated 04/05/23, directed staff to administer MiraLax (medication used for constipation), 17 grams (gr), by mouth, daily, for constipation. The medication was discontinued on 05/10/23 The Physician's Order, dated 05/11/23, directed staff to administer MiraLax, 17 gr, by mouth, every other day, for constipation. The Physician's Order, dated 04/23/23, directed staff to administer Dulcolax delayed release, 2 tablets, by mouth, as needed, for constipation. The Nurse's Note, dated 04/03/23 at 04:34 PM, documented R17 complained of stomach pain and sat on the commode with no results. The note further documented R17 hollered out in pain; her abdomen was softly distended, and she had good bowel sounds in all four quadrants but was tender to the touch. The note documented R17 vomited brown emesis but had prune juice earlier in the day and continued to complain of abdominal discomfort; the physician was notified. The Nurse's Note, dated 04/03/23 at 05:46 PM, R17 was taken to the emergency room and admitted for acute bowel obstruction. The Surgical Consultation Report, dated 04/04/23, documented R17 had a partial small bowel obstruction with no signs of ishemia (a restriction in blood supply to the tissue), is distal, and bowel shows signs of chronic partial small bowel obstruction and adhesions (an abnormal union of membranous surfaces due to inflammation or injury) that appears clinically resolved. The report further documented R17 was a poor candidate for surgery due to her dementia and could go back to the facility on a regular diet. The Nurse's Note, dated 04/04/23 at 04:00 PM, documented R17 would return and directed staff to keep R17's bowels loose and call the emergency room if she had any pain or bloating. The note further documented R17's MiraLax was changed to daily and as needed, and had a bowel movement. The Final Computerized Tomography (a test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue and blood vessels) Report, dated 04/06/23, documented the final diagnoses for R17 was sigmoid diverticulitis (a condition that occurs when small pouches, or sacs, form and push outward through weak spots in the wall of your colon), and a small bowel obstruction. On 05/30/23 at 09:20 AM, observation revealed Certified Nurse Aide (CNA) O placed a gait belt around R17's waist. CNA O and CNA P stood R17 up from her wheelchair chair and transferred her onto the commode. On 05/30/23 at 09:29 AM, Licensed Nurse (LN) G stated R17 had bowel movements up to the time she went to the hospital. LN G stated staff were advised to not let R17 have any foods with seeds, and staff were watching R17's bowels closely. On 05/30/23 at 01:45 PM. Administrative Nurse E stated she should have developed a care plan for R17 to direct staff on what to monitor for with constipation and bowel obstruction. On 05/31/23 at 08:00 AM, Administrative Nurse D stated a care plan for R17 should have been developed to monitor for constipation. The facility's Comprehensive Care Plans policy, dated 05/31/23, documented the interdisciplinary team should develop a care plan after the comprehensive assessment and reviewed quarterly to consist of problems including those triggered with the care area assessments. The facility failed to develop a comprehensive care plan that included R17's history of bowel obstruction and interventions to prevent constipation. This placed the resident at risk for impaction and bowel obstruction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to revise, with person centered interventions for falls, the care plan for two sampled residents, Resident (R) 17 and R26, and lacked direction in the plan of care to staff for anticoagulant (blood thinner) medication for R8. This placed the residents at risk for uncommunicated and unmet care needs. Findings included: - The Electronic Medical Record (EMR) for R17 documented diagnoses of Alzheimer's disease (progressive mental deterioration due to generalized deterioration of the brain), anxiety (feeling of worry, nervousness, or unease), depression (persistent sadness and lack of interest or pleasure in previously rewarding or enjoyable activities), hypertension (high blood pressure) and dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, ambulation, toileting and personal hygiene. The MDS further documented R17 had unsteady balance, and lower impairment on one side. R17 wandered, had two or more non- injury falls, and did not use any alarms. R17's Quarterly MDS, dated 05/09/23, documented R17 had severely impaired cognition, and required extensive assistance of two staff for bed mobility, transfers, dressing, personal hygiene, and toileting. The assessment further documented R17 had unsteady balance, wandered, and had no functional impairment. R17 had two or more non-injury falls and used a wander alarm. The Fall Risk Assessment, dated 03/01/22, 05/31/22, 08/16/22, 11/16/22, 02/07/23, and 05/08/23, documented R17 was at risk for falls. The Fall Care Plan, dated 05/18/23, initiated on 05/28/20, directed staff to continue interventions on the at-risk plan. The update, dated 06/02/20, directed staff to open the door partially to observe R17 and watch for escalating behaviors. The update, dated 08/13/20, directed staff to determine and address causative factors of the fall. The update, dated 10/31/20, directed staff to do 30-minute visual checks. The update, dated 02/23/21, directed staff to place a baby monitor in her room to help if resident got restless while in bed. The update, dated 04/21/21, directed staff to place a mattress in the floor by the bed. The update, dated 07/23/21, directed staff to offer to assist her to bed if tired. The update dated, 09/02/21, directed staff to close the door to her room during the day, it may detour her from wanting to go in the room by herself. The update dated 09/20/21 directed staff to assist R17 to the bathroom after every meal. The update, dated 10/03/21, directed staff to do 30-minute visual checks. The update, dated 11/07/21, directed staff to anticipate her needs and watch for signs that R17 would stand up. The care plan lacked further person-centered interventions to prevent further falls. The EMR documented falls on these dates: 05/29/22, 08/31/22, 01/24/23, 02/19/23, 02/24/23, 04/13/23, 04/19/23, 04/20/23, 05/03/23, 05/07/23, 05/12/23, 05/23/23, and 05/27/23. R17's clinical record lacked evidence of causative factors for the falls and any resident centered interventions put into place after the falls to prevent further falls. On 05/30/23 at 09:20 AM, observation revealed Certified Nurse Aide (CNA) O placed a gait belt around R17's waist. CNA O and CNA P stood R17 up from her wheelchair chair and transferred her onto the commode (a portable toilet). On 05/30/23 at 10:30 AM, observation revealed R17 propelled herself in her wheelchair throughout the facility hallways. On 05/30/23 at 09:30 AM, CNA O stated R17 had a few falls as she would often stand up by herself and fall or lean too far over in her wheelchair and fall out. On 05/30/23 at 10:00 AM, Licensed Nurse (LN) G stated R17 was impulsive, at risk for falls and staff try to intervene so she does not fall. LN G further stated, there was a monitor in R17's room so staff can try to get to R17 before she would fall. On 05/31/23 at 07:55 AM, Administrative Nurse E stated she should put new interventions on the care plan On 05/31/23 at 08:00 AM, Administrative Nurse D stated all falls were reviewed at the weekly at-risk meetings to discuss interventions to prevent falls and should be documented on the care plan. The facility's Fall Prevention in Resident Care Center policy, dated 11/06/22, documented, falls are the most common accident in nursing facilities and the residents care plan would be written to include interventions for each resident, specific to their needs and abilities. The policy further documented the care plans may include patient teaching, follow-up, documentation and after the fall. The resident may be considered a high fall risk and more care plan interventions may be needed. The staff were trained regarding all appropriate interventions and the information after a fall would be trended by risk management. The facility's Care Plans policy, dated 09/09/16, documented the facility provides individualized, interdisciplinary plan of care for all residents that are appropriate to the resident's needs, strengths, limitations, and goals based on initial recurrent and continual needs of the resident. The team will evaluate the progress toward meeting the goals of the care, treatment and services, revises the plan of care, treatment and services, collaborates with the resident and/or surrogate decision maker and family in reviewing and revision of the plan for care. The facility failed to revise, with person centered interventions for falls, the care plan for R17. This placed the resident at risk for uncommunicated and unmet care needs. - The Electronic Medical Record (EMR) for R26 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), delusional disorder (untrue persistent belief or perception healed by a person although evidence shows it was untrue), and chronic kidney disease stage 4 (the kidneys are moderately or severely damaged and are not working as well to filter waste from the blood). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R26 had severely impaired cognition and required extensive assistance of one staff for transfers, toileting, personal hygiene, limited assistance of one staff for bed mobility, and supervision and one staff assistance for ambulation. The assessment further documented R26 had unsteady balance, wandered, and had no functional impairment. R26 had no falls and used a motion sensor and elopement alarm daily. The Quarterly MDS, dated 05/16/23, documented R26 had severely impaired cognition and required limited assistance of one staff for bed mobility, transfers, toileting, and supervision and one staff assistance for ambulation. The MDS further documented R26 had unsteady balance, and no functional impairment. R26 had one non-injury fall, and used a motion sensor and elopement alarm daily. The Fall Risk Assessment, dated 02/14/23 documented R26 at risk for falls. The Fall Care Plan, dated 05/15/23 initiated on 08/31/22, documented R26 was a moderate risk for falls and directed staff to anticipate and meet the resident's needs. The update, dated 05/20/23, directed staff to ensure R26's call light was within reach and encourage him to use it for assistance as needed as R26 needs prompt response for all requests for assistance. The Nurse's Note, dated 03/12/23 at 03:20 PM, documented staff witnessed R26 stand in front of the recliner he had been sitting in and walk toward the door in front of him. R26 got tripped up on the television stand and slowly went down to the ground and landed on his right side. The note further documented R26 did not hit his head and moved all extremities without difficulty. The Nurse's Note, dated 05/18/23 at 10:15 AM, documented R26 stood up from a straight back chair to walk and was stand-by assist from staff. The note further documented R26 walked by a resident who was in a wheelchair, tried to grab the wheelchair, tripped over his own feet, fell and landed on his left hip. The note documented, R26 hit his left shoulder on the side of a recliner and hit his head on the back of the recliner, staff applied a gait belt to the resident and assisted him to stand. R26 reported discomfort to his left hip but no bruising or redness was noted, and he was taken to the couch to lay down. The note documented R26 was taken to the emergency room for evaluation and no fractures were found. The Nurse's Note, dated 05/19/23 at 03:50 PM, documented R26 was lying on the couch in the living room area as staff walked into the medication room and when they came out, R26 was on his hands and knees and stated he hit his head hard. The noted documented a small area of blood on the left side of his forehead. R26 was assisted by staff to the couch, and he complained of low back and left leg pain. The Nurse's Note, dated 05/20/23 at 05:20 AM, documented the motion sensor in R26's room activated and as staff went into the room, R26 fell out of bed. The note documented staff assessed R26 for injuries and R26 was reminded to not transfer himself. The Nurse's Note, dated 05/30/23 at 07:58 PM, documented R26 transferred himself into a recliner and staff tried to help him slide back, he slid forward onto the floor. On 05/30/23 at 08:10 AM, observation revealed Certified Nurse Aide (CNA) M and CNA N placed a gait belt around R26's waist, stood on either side of him and walked with him to his room. Further observation revealed R26 was unsteady, and the CNAs sat him down in his recliner. On 05/30/23 at 12:30 PM, observation revealed R26 tried to get up out of his wheelchair and staff were able to reach him before he started to walk. On 05/30/21 at 1:45 PM, observation revealed R26 laid on the couch in the living room area. Further observation revealed he stood up and started to ambulate, was very unsteady, and staff were able to reach him to assist him. On 05/30/23 at 08:15 AM, CNA M stated R26 used to walk alone but since his falls, he needs two staff to ambulate him. CNA M further stated R26 has a motion sensor and a camera for staff to see him when staff are at the nurse's station. On 05/30/23 at 01:00 PM, Licensed Nurse (LN) G stated R26 often tried to get up on his own and wandered in the facility but since he has had falls, he does not ambulate as well and needs staff assistance. LN G stated R26 had been at the emergency room and there were no fractures found. On 05/31/23 at 07:55 AM, Administrative Nurse E stated she should update the care plans with interventions to prevent falls. On 05/31/23 at 08:00 AM, Administrative Nurse D stated all falls were reviewed at the weekly at-risk meetings to discuss interventions to prevent falls and should be documented on the care plan. The facility's Fall Prevention in Resident Car Center policy, dated 11/06/22, documented, falls are the most common accident in nursing facilities and the residents care plan would be written to include interventions for each resident, specific to their needs and abilities. The policy further documented the care plans may include patient teaching, follow-up, documentation and after the fall. The resident may be considered a high fall risk and more care plan interventions may be needed. The staff were trained regarding all appropriate interventions and the information after a fall would be trended by risk management. The facility's Care Plans policy, dated 09/09/16, documented the facility provides individualized, interdisciplinary plan of care for all residents that are appropriate to the resident's needs, strengths, limitations, and goals based on initial recurrent and continual needs of the resident. The team will evaluate the progress toward meeting the goals of the care, treatment and services, revises the plan of care, treatment and services, collaborates with the resident and/or surrogate decision maker and family in reviewing and revision of the plan for care. The facility failed to revise, with person centered interventions for falls, the care plan for R26. This placed the resident at risk for uncommunicated and unmet care needs. - R8's Electronic Medical Record documented diagnoses of osteoporosis (bone disease that develops when bone mineral density and bone mass decreases), cervicalgia (neck pain), hypertension (high blood pressure), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), gastro-esophageal reflux disease (occurs when stomach acid or bile flows into the food pipe and irritates the lining), atrial fibrillation (an irregular and often very rapid heart rhythm) and a history of Covid-19 (respiratory infection). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of six, indicating severely impaired cognition. The MDS documented R8 required supervision for eating and extensive assistance of two staff for all other activities of daily living (ADL). The MDS documented R8 had range of motion (ROM) impairment in both legs, unsteady balance requiring assistance, used a wheelchair and had no falls in the lookback period. The MDS documented R8 received scheduled anticoagulant (blood thinning) medications. The Care Plan, dated 04/18/23, lacked staff direction to monitor for abnormal bleeding or bruising related to the use of anticoagulant medication. The Physician Order, dated 10/16/20, directed staff to administer Eliquis (blood thinning medication) 5 mg, twice per day, for the diagnosis of atrial fibrillation. On 05/25/23 at 02:10 PM, observation revealed R8 in bed, with the room door open, and her call light in reach. On 05/30/23 at 03:38 PM, Administrative Nurse D verified the care plan should include to observe for abnormal bleeding or bruising related to the use of Eliquis. The facility's Care Plan policy, dated 09/09/16, stated the facility would provide a plan of care appropriate to the resident's needs, limitation and goal based on continued needs of the resident. The services furnished would attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility failed to care plan for staff to monitor for adverse effects such as abnormal bleeding or bruising related to the use of the anticoagulant medication, placing R8 at risk for uncommunicated care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 31 residents. The sample included 12 residents, with seven reviewed for accidents. Based on observation, record review, and interview, the facility failed to implement person-centered interventions for two sampled residents, Resident (R)17 and R26, and failed to follow the resident's care plan for R8 regarding gait belt use during transfers. This placed the residents at risk for further falls and injury. Findings included: - The Electronic Medical Record (EMR) for R17 documented diagnoses of Alzheimer's disease (progressive mental deterioration due to generalized deterioration of the brain), anxiety (feeling of worry, nervousness, or unease), depression (persistent sadness and lack of interest or pleasure in previously rewarding or enjoyable activities), hypertension (high blood pressure) and dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, ambulation, toileting and personal hygiene. The MDS further documented R17 had unsteady balance, and lower impairment on one side. R17 wandered, had two or more non- injury falls, and did not use any alarms. R17's Quarterly MDS, dated 05/09/23, documented R17 had severely impaired cognition, and required extensive assistance of two staff for bed mobility, transfers, dressing, personal hygiene, and toileting. The assessment further documented R17 had unsteady balance, wandered, and had no functional impairment. R17 had two or more non-injury falls and used a wander alarm. The Fall Risk Assessment, dated 03/01/22, 05/31/22, 08/16/22, 11/16/22, 02/07/23, and 05/08/23, documented R17 was at risk for falls. The Fall Care Plan, dated 05/18/23, initiated on 05/28/20, directed staff to continue interventions on the at-risk plan. The update, dated 06/02/20, directed staff to open the door partially to observe R17 and watch for escalating behaviors. The update, dated 08/13/20, directed staff to determine and address causative factors of the fall. The update, dated 10/31/20, directed staff to do 30-minute visual checks. The update, dated 02/23/21, directed staff to place a baby monitor in her room to help if resident got restless while in bed. The update, dated 04/21/21, directed staff to place a mattress in the floor by the bed. The update, dated 07/23/21, directed staff to offer to assist her to bed if tired. The update dated, 09/02/21, directed staff to close the door to her room during the day, it may detour her from wanting to go in the room by herself. The update dated 09/20/21 directed staff to assist R17 to the bathroom after every meal. The update, dated 10/03/21, directed staff to do 30-minute visual checks. The update, dated 11/07/21, directed staff to anticipate her needs and watch for signs that R17 would stand up. The care plan lacked further person-centered interventions to prevent further falls. The EMR documented falls on these dates: 05/29/22, 08/31/22, 01/24/23, 02/19/23, 02/24/23, 04/13/23, 04/19/23, 04/20/23, 05/03/23, 05/07/23, 05/12/23, 05/23/23, and 05/27/23. R17's clinical record lacked evidence of causative factors for the falls and any resident centered interventions put into place after the falls to prevent further falls. On 05/30/23 at 09:20 AM, observation revealed Certified Nurse Aide (CNA) O placed a gait belt around R17's waist. CNA O and CNA P stood R17 up from her wheelchair chair and transferred her onto the commode (a portable toilet). On 05/30/23 at 10:30 AM, observation revealed R17 propelled herself in her wheelchair throughout the facility hallways. On 05/30/23 at 09:30 AM, CNA O stated R17 had a few falls as she would often stand up by herself and fall or lean too far over in her wheelchair and fall out. On 05/30/23 at 10:00 AM, Licensed Nurse (LN) G stated R17 was impulsive, at risk for falls and staff try to intervene so she does not fall. LN G further stated, there was a monitor in R17's room so staff can try to get to R17 before she would fall. On 05/31/23 at 08:00 AM, Administrative Nurse D stated all falls were reviewed at the weekly at-risk meetings to discuss interventions to prevent falls and should be documented on the care plan. The facility's Fall Prevention in Resident Car Center policy, dated 11/06/22, documented, falls are the most common accident in nursing facilities and the residents care plan would be written to include interventions for each resident, specific to their needs and abilities. The policy further documented the care plans may include patient teaching, follow-up, documentation and after the fall. The resident may be considered a high fall risk and more care plan interventions may be needed. The staff were trained regarding all appropriate interventions and the information after a fall would be trended by risk management. All falls would have follow-up documentation for every shift for 48 hours, which would include vital signs, signs and symptoms of pain, behavior problems, subsequent falls or anything out of the ordinary, including admission to the hospital. The facility failed to implement preventative interventions after all falls for cognitively impaired R17, placing her at risk for further falls and injury. - The Electronic Medical Record (EMR) for R26 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), delusional disorder (untrue persistent belief or perception healed by a person although evidence shows it was untrue), and chronic kidney disease stage 4 (the kidneys are moderately or severely damaged and are not working as well to filter waste from the blood). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R26 had severely impaired cognition and required extensive assistance of one staff for transfers, toileting, personal hygiene, limited assistance of one staff for bed mobility, and supervision and one staff assistance for ambulation. The assessment further documented R26 had unsteady balance, wandered, and had no functional impairment. R26 had no falls and used a motion sensor and elopement alarm daily. The Quarterly MDS, dated 05/16/23, documented R26 had severely impaired cognition and required limited assistance of one staff for bed mobility, transfers, toileting, and supervision and one staff assistance for ambulation. The MDS further documented R26 had unsteady balance, and no functional impairment. R26 had one non-injury fall, and used a motion sensor and elopement alarm daily. The Fall Risk Assessment, dated 02/14/23 documented R26 at risk for falls. The Fall Care Plan, dated 05/15/23 initiated on 08/31/22, documented R26 was a moderate risk for falls and directed staff to anticipate and meet the resident's needs. The update, dated 05/20/23, directed staff to ensure R26's call light was within reach and encourage him to use it for assistance as needed as R26 needs prompt response for all requests for assistance. The Nurse's Note, dated 03/12/23 at 03:20 PM, documented staff witnessed R26 stand in front of the recliner he had been sitting in and walk toward the door in front of him. R26 got tripped up on the television stand and slowly went down to the ground and landed on his right side. The note further documented R26 did not hit his head and moved all extremities without difficulty. The Nurse's Note, dated 05/18/23 at 10:15 AM, documented R26 stood up from a straight back chair to walk and was stand-by assist from staff. The note further documented R26 walked by a resident who was in a wheelchair, tried to grab the wheelchair, tripped over his own feet, fell and landed on his left hip. The note documented, R26 hit his left shoulder on the side of a recliner and hit his head on the back of the recliner, staff applied a gait belt to the resident and assisted him to stand. R26 reported discomfort to his left hip but no bruising or redness was noted, and he was taken to the couch to lay down. The note documented R26 was taken to the emergency room for evaluation and no fractures were found. The Nurse's Note, dated 05/19/23 at 03:50 PM, documented R26 was lying on the couch in the living room area as staff walked into the medication room and when they came out, R26 was on his hands and knees and stated he hit his head hard. The noted documented a small area of blood on the left side of his forehead. R26 was assisted by staff to the couch, and he complained of low back and left leg pain. The Nurse's Note, dated 05/20/23 at 05:20 AM, documented the motion sensor in R26's room activated and as staff went into the room, R26 fell out of bed. The note documented staff assessed R26 for injuries and R26 was reminded to not transfer himself. The Nurse's Note, dated 05/30/23 at 07:58 PM, documented R26 transferred himself into a recliner and staff tried to help him slide back, he slid forward onto the floor. On 05/30/23 at 08:10 AM, observation revealed Certified Nurse Aide (CNA) M and CNA N placed a gait belt around R26's waist, stood on either side of him and walked with him to his room. Further observation revealed R26 was unsteady, and the CNAs sat him down in his recliner. On 05/30/23 at 12:30 PM, observation revealed R26 tried to get up out of his wheelchair and staff were able to reach him before he started to walk. On 05/30/21 at 1:45 PM, observation revealed R26 laid on the couch in the living room area. Further observation revealed he stood up and started to ambulate, was very unsteady, and staff were able to reach him to assist him. On 05/30/23 at 08:15 AM, CNA M stated R26 used to walk alone but since his falls, he needs two staff to ambulate him. CNA M further stated R26 has a motion sensor and a camera for staff to see him when staff are at the nurse's station. On 05/30/23 at 01:00 PM, Licensed Nurse (LN) G stated R26 often tried to get up on his own and wandered in the facility but since he has had falls, he does not ambulate as well and needs staff assistance. LN G stated R26 had been at the emergency room and there were no fractures found. On 05/31/23 at 08:00 AM, Administrative Nurse D stated all falls were reviewed at the weekly at-risk meetings to discuss interventions to prevent falls and should be documented on the care plan. The facility's Fall Prevention in Resident Car Center policy, dated 11/06/22, documented, falls are the most common accident in nursing facilities and the residents care plan would be written to include interventions for each resident, specific to their needs and abilities. The policy further documented the care plans may include patient teaching, follow-up, documentation and after the fall. The resident may be considered a high fall risk and more care plan interventions may be needed. The staff were trained regarding all appropriate interventions and the information after a fall would be trended by risk management. All falls would have follow-up documentation for every shift for 48 hours, which would include vital signs, signs and symptoms of pain, behavior problems, subsequent falls or anything out of the ordinary, including admission to the hospital. The facility failed to implement interventions for cognitively impaired R26, placing him at risk for further falls and injury. - R8's Electronic Medical Record documented diagnoses of osteoporosis (bone disease that develops when bone mineral density and bone mass decreases), cervicalgia (neck pain), hypertension (high blood pressure), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and atrial fibrillation (an irregular and often very rapid heart rhythm). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of six, indicating severely impaired cognition. The MDS documented R8 required supervision for eating and extensive assistance of two staff for all other activities of daily living (ADL). The MDS documented R8 had range of motion (ROM) impairment in both legs, unsteady balance requiring assistance, used a wheelchair and had no falls in the lookback period. The MDS documented R8 had frequent severe pain, received scheduled pain medication, anticoagulant (blood thinning) and opioid (narcotic) medications. The Fall Care Area Assessment (CAA), dated 04/11/23, documented R8 had a history of chronic pain in her joints, was on a medication which may cause urgency for toileting, had anxiety issues, and was on other medications that may alter thought processes. The assessment stated the care plan would be continued and updated as needed to keep the resident free of injury from falls. The Fall Risk Assessment, dated 04/11/23, documented a score of six, indicating R8 at risk for falls. The Activities of Daily Living (ADL) Care Plan, dated 04/18/23, directed staff to provide staff assistance of two with a gait belt for transfers. The care plan stated R8 may attempt to help if her joints were not hurting too much; she had a lot of pain that hindered her movements so staff were directed to be gentle and move slowly. The Fall Care Plan, dated 04/18/23, stated R8 was at low risk for falls related to increased anxiety when she feels her needs are not met. The care plan noted on 05/21/23 the resident fell, and no new intervention were documented. The Progress Note, dated 05/21/23 at 04:35 PM, documented R8 hollered out that she fell, and staff found her on the floor lying on her right side with her blankets wrapped around her feet. The note stated staff assisted R8 to bed with assist of two staff via arm-leg transfer and no injury was noted. On 05/30/23 at 12:34 PM, observation revealed Certified Nurse Aide (CNA) M and CNA N transferred R8 from her wheelchair to a commode (bedside toilet) by holding her under her bent and raised arms. Staff did not use a gait belt for security. After performing incontinence cares, the staff transferred R8 from the commode to her bed with the same bent-arm technique and no gait belt. On 05/30/23 at 12:34 PM, CNA M stated R8 refused to let staff use a gait belt because it hurt too much. On 05/30/23 at 03:28 PM, Administrative Nurse D verified the care plan directed staff to use a gait belt when transferring R8. She stated the resident was afraid of falling. The facility's Fall Prevention policy, dated 11/06/22, stated basic preventive measures to be used for fall prevention included staff to use a gait belt for transfers. The care plan would be written to include interventions for each resident, specific to their needs and abilities. After a fall the resident may be considered a high risk for falls and more care plan interventions may be needed. Train the staff carefully regarding all appropriate interventions. The facility failed to use a gait belt, as directed by the plan of care, for R8 during transfers. This placed the residnet at risk for falls and injuries related to improper transfer technique.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 31 residents. The sample included 12 residents with one reviewed for weight loss. Based on observation, interview, and record review the facility failed to implement interventions to prevent further weight loss after Resident (R)8 had a weight loss in February 2023 and continued to lose weight. This deficient practice placed R8 at risk for continued weight loss and malnutrition. Findings included: - R8's Electronic Medical Record documented diagnoses of osteoporosis (bone disease that develops when bone mineral density and bone mass decreases), cervicalgia (neck pain), hypertension (high blood pressure), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), gastro-esophageal reflux disease (occurs when stomach acid or bile flows into the food pipe and irritates the lining), atrial fibrillation (an irregular and often very rapid heart rhythm) and a history of Covid-19 (respiratory infection). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of six, indicating severely impaired cognition. The MDS documented R8 required supervision for eating and extensive assistance of two staff for all other activities of daily living (ADL). The MDS documented R8 had range of motion (ROM) impairment in both legs, unsteady balance requiring assistance, used a wheelchair and had no falls in the lookback period. The MDS documented R8 had frequent severe pain, received scheduled pain medication, anticoagulant (blood thinning) and opioid (narcotic) medications. The MDS documented R8 weighed 107 pounds (lbs.) and had no swallowing or dental problems. The Nutrition Care Area Assessment (CAA), dated 04/11/23, documented R8 had minimal nutritional intake, frequent pain, anxiety issues, and medications that may decrease appetite. The Nutrition Care Plan, dated 04/18/23, stated R8 preferred softer food items, at times she may request something different. R8 liked hot cocoa with some of her meals, and needed cottage cheese with every meal. The care plan directed staff to provide and serve diet as ordered, supplements as ordered every meal; the Registered Dietician (RD) would evaluate and make diet change recommendations as needed. Staff were to weigh R8 at the same time of day and record every Monday morning before breakfast. The care plan directed staff to monitor for pocketing food, coughing, choking, refusing to eat, and appearance of concern during meals. Staff were to monitor, record, and report to the physician signs or symptoms of malnutrition, including significant weight loss defined as three lbs in one week, greater than (>) five% in one month, >7.5% in three months, or >10% in six months. The Physician Order, dated 09/28/21, directed staff to provide a regular texture and consistency diet. Review of R8's weights revealed the following: 01/30/23 - 112.6 lbs. 02/27/23 - 106.1 lbs. 03/27/23 - 109.4 lbs. 04/24/23 - 102.6 lbs. 05/29/23 - 102.0 lbs. The Annual Nutrition Assessment, dated 04/11/23, documented R8 weighed 107.9 lbs., and her goal weight was 120 lbs The rate of unplanned weight loss was <5% in one month, <7.5% in three months, <10% in six months. R8 had poor appetite, weight had been stable over last month, but R8 lost 9.9 lbs. in the last 6 months (8%). R8 received a regular diet, generally ate independently with setup help, sometimes required assistance, and received an Ensure (liquid nutrition drink) supplement. The RD to the facility Dietary Manager e-mail, dated 04/11/2023, stated she saw a note that the resident was getting Ensure daily. The RD wrote her previous assessment stated R8 received Thrive (ice cream supplement), but the medical record lacked documentation she received any supplement. The dietary manager replied R8 just received hot chocolate. Review of the facility's current dietary orders for R8 did not include any supplement or instruction other than regular diet. Review of the medical record, January 2023 to May 30,2023, revealed no documentation of R8 receiving a supplement or other nutritional intervention other than a regular diet. On 05/30/23 at 08:10 AM, observation revealed R8 in her wheelchair at a dining table with crisp rice cereal, hot chocolate, cottage cheese, juice, and water. R8 was tearful and stated she wanted her real mamma. She did not attempt to eat at first; after a while she ate a bite or two of cereal, then sat with her eyes closed. At 840 AM, Licensed Nurse (LN) G asked her if she would like to eat some more. Later, another staff encouraged her to eat. On 05/30/23 at 12:08 AM, R8 independently ate chicken noodle soup. She also had cottage cheese, hot chocolate, and tea. On 05/30/23 at 08:55 AM, LN H stated R8 requested the same food every day. LN H said R8 usually feeds herself, and staff stop by and encourage her to eat. On 05/30/23 at 03:28 PM, Administrative Nurse D stated the scale had been moved during construction, so she thought the weights were inaccurate. Staff were to monitor R8's eating and her weight was reviewed in risk management meetings. Administrative Nurse D stated R8 received Prosource supplement in hot chocolate with meals which the kitchen sent to the dining room. Administrative Nurse D stated R8 had some issues of nausea, vomiting and loose stools late January or early February. On 05/30/23 at 04:45 PM, Dietary Staff (DS) BB stated on 02/14/23 she noted R8 had a 6.9 lbs. weight loss and discussed pain management related to increasing her appetite during the risk management meeting. On 2/20/23 she noted another weight change and questioned nursing if something else was going on regarding the weight loss and questioned if R8 needed supplements. Nursing reported staff had moved the scale and it needed re-calibrated. They would check to see if weights returned to normal. On 03/28/23 R8 lost weight again and a supplement was discussed. DS BB stated R8 drank well but did not eat food well. DS BB stated the 04/10/23 care plan directed staff to ensure supplement but DS Bb was unsure if that meant R8 received an Ensure drink. DS BB stated if a weight was three or more lbs. different from the last one she discounted it as incorrect if nursing had a reasonable explanation of why it might be wrong. DS BB stated she had not notified the RD in late February, early March of the significant weight loss. On 05/31/23 at 10:55 AM, Administrative Nurse E reported the scales had been re-calibrated. On 05/31/23 at 10:55 AM, LN I stated R8 liked ice cream and staff give her Thrive ice cream (nine grams protein, 270 calories). LN I said staff started serving R8 hot chocolate with every meal, but may have to change to Carnation Instant Breakfast (CIB). On 05/31/23 at 11:10 AM, Administrative Nurse D verified staff had not immediately involved the dietician regarding R8's weight loss and had not provided interventions to prevent further weight loss after the weight loss and discussion in risk management meetings. The facility's Weight Monitoring Gain/Loss policy, dated 11/06/21, stated residents would be evaluated for weight stabilization and identification of weight loss and would be provided treatment to prevent weight loss unless their physician indicated a planned weight loss program. Resident would be weighed weekly, weights would be reviewed weekly by the risk management team, including the dietician, and recommendations would be reviewed with action plan. The facility failed to implement interventions to prevent further weight loss after R8 had a weight loss in February 2023 and continued to lose weight. This deficient practice placed R8 at risk for continued weight loss and malnutrition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 31 residents. The sample included 12 residents, with two reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care. Based on observation, record review, and interview, the facility failed to provide the necessary dementia care and services for one sampled resident, Resident (R) 26, who had dementia related behaviors which significantly impacted R26 and other resident's quality of life. This placed the resident at risk for injury and unmet needs. Findings included: - The Electronic Medical Record (EMR) for R26 documented diagnoses of dementia without behavioral disturbance, and delusional disorder (untrue persistent belief or perception healed by a person although evidence shows it was untrue). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R26 had severely impaired cognition and required limited assistance of one staff for bed mobility, transfers, toileting, and supervision and one staff assistance for ambulation. The MDS further documented R26 had verbal behaviors, other behaviors, and rejection of care one to three days, and wandered four to six days, and received antipsychotic (medication used to treat psychosis and other mental emotional conditions), antianxiety (medication that calm and relax people with excessive anxiety) medication seven days of the look-back period. The Cognition Care Plan, dated 05/15/23, initiated on 08/31/22, directed staff to cue, reorient, and supervise as needed. The update, dated 12/12/22, directed staff to offer R26 nuts and bolts to separate, to help distract him and keep him busy. The update, dated 02/20/23, directed staff to redirect him and ask him to take a walk with staff and talk about farming. The Elopement Care Plan, dated 05/15/23, initiated on 09/16/22, documented R26 was an elopement risk, significantly intrudes on the privacy of others, wore an elopement bracelet. The plan directed staff to distract him by offering pleasant diversions, structured activities, food, conversation, television, and books the resident preferred. The care plan documented a motion alert was placed in his room so that staff was alerted to his exiting his room and they could direct him where to go and would prevent him from entering other resident rooms. The Physician's Order, dated 11/03/22, directed staff to administer buspiridone HCI (an antianxiety medication), 5 milligrams (mg), by mouth, twice a day, for dementia. The medication was discontinued on 03/30/23. The Physician's Order, dated 01/21/23, directed staff to administer Seroquel (an antipsychotic medication), 25 mg, by mouth, at bedtime, for delusions. The Physician's Order, dated 01/23/23, directed staff to administer lorazapam (an antianxiety medication), 0.5 mg, by mouth, every four hours, as needed, for agitation. The medication was discontinued on 02/02/23. The Physician's Order, dated 03/27/23, directed staff to administer Ativan (an antianxiety medication), 0.5 mg, by mouth, every 4 hours, as needed for agitation. This medication was discontinued 04/04/23. The Physician's Order, dated 03/30/23, directed staff to administer Paxil (an antidepressant medication), 20 mg, by mouth, daily, for inappropriate sexual behavior. The Nurse's Note, dated 11/21/22 at 01:22 AM, documented R26 walked across the hall from his room, ripped down the stop sign to another resident's room and opened the door. Staff then redirected the resident. The Nurse's Note, dated 11/22/22 at 02:30 AM, documented R26 went into another resident's room and sat in their chair, Staff tried to get him out of the chair, and he got agitated. Staff were able to direct him back to his room. The Nurse's Note, dated 12/02/22 at 09:50 PM, documented R26 wandered into another resident's room and proceeded to touch her feet and move her blanket. The note further documented staff redirected R26 out of the room as R26 stated she wanted me to do things for her. Staff assessed both residents, and no injury were found. The Nurse's Note, dated 12/15/22 at 05:45 AM, documented R26 squatted down in front of the medication room and had a large bowel movement, grabbed a cotton ball off the medication cart and wiped his buttocks with it and then tossed it on to the floor. The note documented staff asked the resident why he had done that instead of using his bathroom; he stated there was a fire in his room. The Nurse's Note, dated 12/24/22 at 06:40 PM, documented staff received a call from another resident's family member telling staff R26 was in their family member's room. The note documented staff went to the room, the door was closed, and light were off. R26 was asleep on the other resident's bed. The female resident stated she was unable to get to her call light to inform the staff he was in her room so her family (who she was on the phone talking with) offered to call the facility. The note documented staff were able to wake R26 and take him out of the room. The Nurse's Note, dated 01/02/23 at 05:56 PM, documented R26 went behind another resident's wheelchair, and touched the wheelchair. The other resident told R26 not to touch her wheelchair. The note further documented R26 stated he could touch it if he wanted to. R26 was redirected. The Nurse's Note, dated 01/13/23 at 12:50 PM, documented staff found R26 in another resident's bathroom; staff directed R26 to his room. The Nurse's Note, dated 01/14/23 at 04:24 PM, documented R26 was in R8's room, kneeling at her bedside. The note further documented R8 was lying in bed, with her top partially up. The staff went to take R26 out of the room, R8 stated, Don't take him away, I haven't seen him in a long time. The note documented R8 stated, nothing physically happened. The Nurse's Note, dated 01/24/23 at 05:53 AM, documented R26 woke up , thought his house was on fire, went into other resident rooms, tried to wake the residents, because he thought there was a fire. The note further documented R26 continued to wander in the lobby stating there was a fire as staff told him they put out the fire. The Nurse's Note, dated 02/01/23 at 08:16 PM, documented R26 went into another resident's room and tried to use the bathroom and tried to hit staff as they redirected him out of the room. The Nurse's Note, dated 02/07/23 at 05:25 PM, documented R26 tried to reach inside of the medication cart. R26 balled up his fist and cursed as staff tried to stop him. The Nurse's Note, dated 02/08/23 at 02:08 PM, documented staff redirected R26 four times from other resident rooms, continued to pace up and down hallways approaching doors to get out. The Nurse's Note, dated 03/31/23 at 01:16 PM, documented staff were called to another resident's room by a family member and reported R26 was in their family members room and would not leave. Staff attempted to remove R26 from the room and he sat on the other resident's bed, trying to lay down. Staff were able to get R26 to leave the room and took him back to his room. The Nurse's Note, dated 04/21/23 at 09:20 PM, documented staff saw, in the camera, R26 had his window open, his pants pulled down, and he tried to urinate out the window. The Nurse's Note, dated 04/24/23 at 05:28 AM, documented R26 went into another resident's room, wandered around the room, woke the resident up, and called the resident a derogatory name as he was leaving their room. The Nurse's Note, dated 05/05/23 at 01:18 AM, documented R26 pulled the fire alarm. The Nurse's Note, dated 05/10/23 at 07:10 PM, documented R26 climbed under a stop sign that covered another resident's room, twice, and left when asked. The Nurse's Note, dated 05/17/23 at 07:39 PM, documented R26 tried to grab medications from the medication cart, staff put her hands over the medications, and told him he could not mess with the medications. On 05/30/21 at 1:45 PM, observation revealed R26 laid on the couch in the living room area. Further observation revealed he stood up and started to ambulate, was very unsteady, and staff were able to reach him to assist him. On 05/30/21 at 08:10 AM, Certified Nurse Aide (CNA) M stated, before R26 had his falls, R26 wandered around the facility, in and out of residents, which upset the other residents. CNA M further stated staff redirected him and placed a camera in his room so staff could monitor R26 when he would get up and wander. On 05/30/23 at 01:00 PM, Licensed Nurse (LN) G stated R26 was supposed to go to a behavioral health unit to be evaluated but then he had a fall, which caused him to be unable to wander around because his leg hurt. LN G stated the facility wanted to wait until R26 was better, and then he will be reassessed to see if he still needs to go. LN G stated R26 has had different tests to see if there is something wrong with hR26's leg but thus far nothing had been discovered. LN G stated R26 was easy to redirect if he was approached right, and stated R26's family told her that when he was at home, he would wander around at night from room to room. On 05/30/23 at 04:35 PM, Administrative Nurse D stated, R26 had been on the waiting list at the behavioral health unit for three months but since he has had the fall, he has not wandered, the behavioral health unit want to wait until he is medically stable before they would take him. The facility Dementia Care-Behavior Management policy, dated 11/06/21, documented the facility was committed to serving the needs of all elders with dementia. The facility promoted person centered care by truly putting the needs of elders first, not just medical or physical needs, and all the staff would be educated on appropriate dementia care and dealing with difficult behaviors prior to working with elders with dementia. The policy documented all behaviors related to dementia would be monitored and documented for the purpose of tracking and trending those behaviors to develop person centered behaviors and identifying unmet needs. A evaluation of current behavior management programming interventions by staff on a continuous basis and documented in the clinical record of interventions attempted and success of those interventions. The facility failed to provide the necessary dementia health care and services and supervision for R26 who had dementia related behaviors that significantly impacted his quality and life and that of other residents. This placed the resident at risk for injury and unmet needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 31 residents. The sample included 12 residents with five residents reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to ensure the consultant pharmacist identified and reported Resident (R) 16's as needed (prn) lorazepam (an antianxiety medication) lacked a stop date as required by Center for Medicare and Medicaid Services (CMS). This deficient practice placed R16 at risk for unnecessary medications. Findings included: - R16's Electronic Medical Record documented diagnoses including cervicalgia (neck pain), hypertension (high blood pressure), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and atrial fibrillation (an irregular and often very rapid heart rhythm). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented R16 limited assistance for dressing, toileting, and supervision for all other activities of daily living (ADL). The MDS documented R16 received antianxiety drugs seven days of the lookback period. The Medication Care Plan, dated 04/25/23, directed staff to follow her preferences and routine as closely as possible to help decrease anxiety issues. The Physician Order, dated 06/30/2020, directed staff to administer lorazepam 0.5 milligrams (mg), PRN, once per day. The order lacked a stop date. The Consultant Pharmacist Reviews, dated 07/26/22, through 04/30/23, lacked notation of the PRN lorazepam without a stop date. On 05/30/23 at 08:50 AM, Licensed Nurse (LN) H administered medications to R16 at the dining table. R16 took the medications whole with water, a few at a time. On 05/30/23 at 03:28 PM, Administrative Nurse D verified the PRN lorazepam order lacked a stop date and stated the pharmacist consultant had not noted the lack of a stop date. The facility's Psychotropic Medication Monitoring policy, dated 11/26/21, stated orders for PRN psychotropic medications would be time limited to 14 days or less and only for specific clearly documented circumstances. The pharmacist would monitor psychotropic drug use in the facility to ensure medications were not used for excessive dosage or duration. The facility failed to ensure the consultant pharmacist identified and reported R16's PRN psychotropic medications lacked a stop date as required by CMS. This deficient practice placed R16 at risk for unnecessary medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 31 residents. The sample included 12 residents with five residents reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to ensure Resident (R) 16's as needed (prn) lorazepam (an antianxiety medication) had a stop date as required by Center for Medicare and Medicaid Services (CMS). This deficient practice placed R16 at risk for adverse side effects related to psychotropic (altering mood or mind) medication use. Findings included: - R16's Electronic Medical Record documented diagnoses including cervicalgia (neck pain), hypertension (high blood pressure), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and atrial fibrillation (an irregular and often very rapid heart rhythm). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented R16 limited assistance for dressing, toileting, and supervision for all other activities of daily living (ADL). The MDS documented R16 received antianxiety drugs seven days of the lookback period. The Medication Care Plan, dated 04/25/23, directed staff to follow her preferences and routine as closely as possible to help decrease anxiety issues. The Physician Order, dated 06/30/2020, directed staff to administer lorazepam 0.5 milligrams (mg),PRN, once per day. The order lacked a stop date. The Consultant Pharmacist Reviews, dated 07/26/22, through 04/30/23, lacked notation of the PRN lorazepam without a stop date. On 05/30/23 at 08:50 AM, Licensed Nurse(LN) H administered medicationss to R16 at the dining table. R16 took the medications whole with water, a few at a time. On 05/30/23 at 03:28 PM, Administrative Nurse D verified the PRN lorazepam order lacked a stop date and stated the pharmacist consultant had not noted the lack of a stop date. The facility's Psychotropic Medication Monitoring policy, dated 11/26/21, stated the facility would make every effort to comply with state and federal regulations related to the use of psychopharmacological medications. The policy stated orders for PRN psychotropic medications would be time limited to 14 days or less and only for specific clearly documented circumstances. The pharmacist would monitor psychotropic drug use in the facility to ensure medications were not used for excessive dosage or duration. The facility failed to ensure R16's PRN lorazepam had a stop date as required by CMS. This deficient practice placed R16 at risk for adverse side effects related to psychotropic medication use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 27 residents. The sample included 12 residents of which one was reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to provide a copy of the facility bed hold policy to Resident (R) 10 or her representative for her facility-initiated hospitalization. Findings included: - The Quarterly Minimum Data Assessment (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) of eight, which indicated moderate cognitive impairment. The MDS documented the resident required extensive staff assistance with activities of daily living (ADLs) except supervision with eating. The ADL Care Plan, revised on 10/08/21, documented the resident required staff assistance with ADLs except set up assistance with eating. The Nurse's Note, dated 09/14/21 at 12:55 PM, documented the facility received a call from the physician and the resident was admitted to the hospital. The note documented the resident's family member was notified of the resident's admittance to the hospital but lacked documentation the family member was provided the facility's bed hold policy. On 11/17/21 at 02:39 PM, observation revealed the resident sat in a recliner with her eyes open, television on and remote control in her hand. On 11/22/21 at 10:57 AM, Administrative Nurse D verified the facility had not provided the resident or her representative a copy of the facility bed hold policy when the resident was admitted to the hospital on [DATE]. Administrative Staff D stated the facility provided the resident or her representative a copy of the bed hold policy on admittance to the facility and was unaware it was to be provided when the resident went to the hospital. On 11/22/21 at 10:59 AM, Administrative Nurse E verified the facility did not provide the resident or representative with a copy of the bed hold policy when the resident went to the hospital on [DATE]. Administrative Nurse E stated the facility provided the resident or representative with a copy of the bed hold policy on admission and was unaware they were to provide one when the resident went to the hospital. The facility's Bed Hold Policy, revised on 01/10/02, documented the purpose of the policy was to assure our residents can return to their own room and personal belongings after they are out of the facility for any reason. This policy will be explained to each new private pay resident with the admission financial agreement by the nurse, Social Service Designee (SSD) before the responsible party signs the agreement. Then, when the resident is out of the facility for any reason, including hospitalization, the responsible party will be asked to sign the bed hold agreement until the resident returns. The facility failed to provide a copy of the bed hold policy for R10 or her representative for her 09/14/21 hospitalization.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 27 residents. The sample included 12 residents. Based on observation, interview and record review, the facility failed to assess one sampled Resident (R) 23, for bowel problems when the resident had no bowel movement (BM) for more than three days. Findings included: - R23's Physician's Orders, dated 09/29/21, included diagnoses of hypertension (high blood pressure), Parkinson's Disease (progressive nervous system disorder that affects movement), and Alzheimer's Disease (progressive disease that destroys memory and other important mental functions). The Quarterly Minimum Data Set (MDS), dated [DATE], documented Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The MDS documented the resident required extensive staff assistance with all activities of daily living (ADLs) including toileting. The MDS documented the resident did not walk and was always incontinent of bowel. The ADL Care Plan, dated 09/28/21, directed staff to provide assistance of two staff for toileting with the sit to stand mechanical lift (device used for transfers) and a bedside commode (portable toilet). The Physician's Orders, dated 09/18/20, directed staff to administer the following medications as needed (PRN): Miralax (bowel laxative), 17 grams every 24 hours. Milk of Magnesia (MOM) (laxative), 30 milliliters (ml), limited to three doses in one month. Bisacodyl (laxative), delayed release 5 milligrams (mg), 2 tablets, no other direction. Bisacodyl suppository (a dosage form used to deliver medications by insertion into the rectum where feces is stored before its release), no dosage or time frame listed. Review of R23's BM documentation revealed staff documented no BM during the following time periods: 10/06 - 10/09 = 4 days, no assessment documented. 10/24 - 10/27 = 4 days, no assessment documented. 11/03- 11/09 = 7 days, no assessment documented. The Progress Note, dated 11/10/21 at 12:40 PM, documented nursing administered a bisacodyl suppository for continued constipation and the rectum was full of formed BM and no abdominal assessment was documented. The Progress Note, dated 11/17/21 at 04:35 PM, documented MOM PRN was administered one time and no assessment was documented. The Progress Note, dated 11/18/21 at 01:45 PM, documented two tablets of bisacodyl was administered and no assessment was documented. The Progress Note, dated 11/19/21 at 10:54 AM, documented a bisacodyl suppository was administered and no assessment was documented. Review of the BM record revealed on 11/19/21 (day five without a BM) the resident had a large BM. Review of the progress notes and medical record revealed no assessment for pain, symptoms, date of last BM, recent food/fluid intake, vital signs, auscultation of bowel sounds, and palpation of the abdomen on 11/10, 11/17, 11/18, or 11/19/21. On 11/18/21 at 07:25 am, observation revealed R23 at a table in the small activity area with a 200 ml glass of water in front of her. Staff served her meal and assisted her. R23 drank 200 ml cranberry juice, 120 ml ice water, and ate at least 50% of her meal. On 11/18/21 at 08:10 AM, Certified Nurse Aide (CNA) M stated the resident would take a drink as long as you offer her one. CNA M stated R23 does not drink on her own, and when staff are providing cares, we offer drinks. CNA M stated the resident did not used to have constipation but had started to and was currently on the BM laxative list. On 11/18/21 at 12:55 PM, CNA N stated the resident had not had a BM this morning and she verified that with the other morning aides. On 11/18/21 at 01:15 PM, Licensed Nurse (LN) H stated staff do not document intake of fluids unless ordered and offer fluids whenever they are in her room. LN H stated R23's last BM documented on 11/13/21 and the nurse gave her MOM yesterday. LN H contacted the morning nurse to ask if she had anything for bowels this morning and the nurse verified she had provided no bowel interventions today and requested the afternoon nurse to administer bowel intervention. LN H stated on 09/29/21, the physician discontinued the scheduled Miralax. On 11/18/21 at 02:40 PM, Administrative Nurse D stated bowel protocol starts on the fourth day without a BM. She verified staff had not documented a BM for the resident for the past four days and this was day five without a BM. Administrative Nurse D verified staff should have documented assessment for bowel sounds, pain, or tenderness. On 11/22/21 at 01:20 PM, LN G verified staff had not documented/performed an assessment of the resident's bowel sounds or abdomen, per policy, prior to administering bowel laxatives. The facility's Bowel Protocol for Constipation, dated 04/20/09, documented all residents are assessed by shift for bowel patterns per CNA reporting. The licensed nurse on each shift will generate a Bowel Report at the beginning of the shift and initiate the Bowel Protocol as appropriate. If the resident had no BM in the previous nine 8 hour shifts or only small documented BM during the same period: the licensed nurse will assess for pain, symptoms, date of last BM, recent food/fluid intake, vital signs, auscultation of bowel sounds, and palpation of the abdomen. Following the assessment: Day one- provide warm prune juice or wet fruit at breakfast and if no BM by 8 AM, give MOM 30 ml. Day two- give 1 or 2 Dulcolax tabs. If no BM by 2 PM, give Dulcolax suppository. Day three of no BM- call physician by 9 AM. The facility failed to provide abdominal assessment or auscultation of bowel sounds for R23's constipation, placing the resident at risk for complications related to constipation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 27 residents. The sample included 12 residents with six reviewed for unnecessary medications. Based on observation, interview, and record review, the consultant pharmacist failed to notify the Director of Nursing, physician, and medical director of the requirement for a stop date for psychotropic medication (drug that affects behavior, mood, thoughts, or perception) ordered for Resident (R) 9. Findings included: - R9's Physician Orders documented a diagnosis of recurrent depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and did not include a diagnosis of anxiety (feeling of worry, nervousness, or unease). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS documented the resident was independent with most activities of daily living (ADLs) and required supervision for eating and walking. The MDS further documented the resident received antidepressant (drug used to treat depression) and diuretic (any substance that promotes diuresis, the increased production of urine) medications. The Medication Care Plan, dated 06/16/21, directed staff to monitor/document/report any adverse reactions to antianxiety therapy treatment of anxiety (fear), such as drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision and safety. The Physician Order, dated 06/04/20, directed staff to administer lorazepam (drug used to treat anxiety) 0.5 milligrams (mg) as needed (PRN), three times daily for anxiety, indefinitely. Review of the consultant pharmacist monthly Medication Regimen Reviews, dated 07/27/21, 08/24/21, 09/28/21, and 10/19/21, all revealed no notation of the lack of a stop date for R9s lorazepam PRN. On 11/22/21 at 09:55 AM, observation revealed R9 and his spouse sat at a dining table eating breakfast with no abnormal mood or behavior noted. On 11/22/21 at 10:33 AM, Administrative Nurse E verified the PRN lorazepam lacked a stop date. On 11/22/21 at 10:40 AM, Administrative Nurse D verified the consultant pharmacist had not notified her of the lack of a stop date for the PRN Ativan. The facility's Psychotropic Medication Monitoring policy, dated 07/20/17, documented the facility would make every effort to comply with state and federal regulations related to the use of psychopharmacological medications to include regular review for continued need, appropriate dosage, side effects, risks, or benefits. Psychotropic medications include anti-anxiety/hypnotic, antipsychotic and antidepressant classes of drugs. Orders for PRN psychotropic medications will be time limited to 14 days or less and only for specific clearly documented circumstances. The policy documented the consulting pharmacist monitored psychotropic drug use to ensure medications are not used in excessive doses or for excessive duration. The consultant pharmacist would notify the physician and the director of nursing whenever a psychotropic medication is past due for review. The facility's consultant pharmacist failed to notify the Director of Nursing, physician, and medical director of the requirement for a stop date for the PRN lorazepam for R9, placing the resident at risk for receiving unnecessary psychotropic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 27 residents. The sample included 12 residents with six reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure one sampled Resident (R) 9 did not receive psychotropic medication (drug that affects behavior, mood, thoughts, or perception) without a stop date. Findings included: - R9's Physician Orders, documented a diagnosis of recurrent depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and did not include a diagnosis of anxiety (feeling of worry, nervousness, or unease). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS documented the resident was independent with most activities of daily living (ADLs) and required supervision for eating and walking. The MDS further documented the resident received antidepressant (drug used to treat depression) and diuretic (any substance that promotes diuresis, the increased production of urine) medications. The Medication Care Plan, dated 06/16/21, directed staff to monitor/document/report any adverse reactions to antianxiety therapy (treatment of anxiety (fear), such as drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision and safety. The Physician Order, dated 06/04/20, directed staff to administer lorazepam (drug used to treat anxiety) 0.5 milligrams (mg) as needed (PRN), three times daily for anxiety, indefinitely. The Physician Order, dated 10/28/21, directed staff to obtain a psychiatric (mental health) consult. The Psychiatric Consultant Note, date 11/15/21, recommended the primary physician discontinue PRN lorazepam. Review of September, October, and November 2021 Medication Administration Record (MAR) revealed PRN lorazepam was still available and documented no administration of the PRN lorazepam. On 11/22/21 at 09:55 AM, observation revealed R9 and his spouse sat at a dining table eating breakfast with no abnormal mood or behavior noted. On 11/22/21 at 10:33 AM, Administrative Nurse E verified the PRN lorazepam lacked a stop date. She stated the risk management team discussed the psychiatric consultant's order, including discontinuation of lorazepam, and did not process the order until the primary physician agreed. On 11/22/21 at 10:40 AM, Administrative Nurse D verified the resident had not been using the lorazepam, and the facility was waiting for the physician to review and discontinue the lorazepam. Administrative Nurse D verified the consultant pharmacist had not noted the lack of a stop date for the PRN Ativan. The facility's Psychotropic Medication Monitoring policy, dated 07/20/17, documented the facility would make every effort to comply with state and federal regulations related to the use of psychopharmacological medications to include regular review for continued need, appropriate dosage, side effects, risks, or benefits. Psychotropic medications include: anti-anxiety/hypnotic, antipsychotic and antidepressant classes of drugs. Orders for PRN psychotropic medications will be time limited to 14 days or less and only for specific clearly documented circumstances. The policy documented the consulting pharmacist monitored psychotropic drug use to ensure medications are not used in excessive doses or for excessive duration. The consultant pharmacist would notify the physician and the director of nursing whenever a psychotropic medication is past due for review. The facility failed to obtain a stop date for the physician ordered PRN lorazepam for R9, placing the resident at risk for receiving unnecessary psychotropic medications.