**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 35 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of a 14-day stop date or the required physician documentation and specified duration, for Resident (R)10's ongoing as-needed (PRN) antianxiety (class of medications that calm and relax people) medication. This placed R10 at risk for unintended effects related to psychotropic drug medications. Findings include: - R10's Electronic Health Record (EHR) revealed diagnosis of Alzheimer's (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), and 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). R10's Significant Change Minimum Data Set (MDS), dated [DATE], recorded R10 had severely impaired cognition. The MDS recorded she required extensive assistance from two staff with bed mobility and transfers. The MDS lacked documentation R10 received an antianxiety medication during the observation period. R10's Care Plan, dated 06/10/24, recorded R10 required extensive assistance with most activities of daily living (ADL) care. R10's Care Plan lacked documentation for the resident's antianxiety medication and the indication for the use of the medication. The Physician's Order, dated 05/31/24, directed the staff to administer lorazepam (antianxiety) 0.5 milligram (mg). Give 0.5 mg every six hours as needed for anxiety. The order lacked a stop date. R10's EHR lacked evidence of a specified duration which included a physician's rationale for the extended use. R10's consultant pharmacist monthly reviews, completed on 06/30/24, lacked evidence that the CP had identified the PRN lorazepam with no stop date. On 07/23/24 at 07:45 AM, R10 sat in a Broda chair (special chair with tilt and recline capability) at the dining room table. Certified Medication Aide (CMA) MM administered the resident's morning medications. On 07/22/24 at 03:00 PM, Administrative Nurse D verified the resident received lorazepam PRN that lacked a stop date. Administrative Nurse D verified the pharmacist had sent monthly reviews to the facility for concerns that lacked a recommendation for a stop date for the lorazepam. The facility's Consult Pharmacist Services Provider Requirements dated 06/01/2023, documented that regular and reliable consult pharmacist services are provided to elders. The pharmacist would review the medication regimen (drug regimen review) of each elder in the health center at least monthly incorporating federally mandated standards of care in addition to other applicable professional standards, and documentation of the reviews and findings in the elders' clinical record. The facility failed to ensure the CP identified and reported the lack of a 14-day stop date for the use of PRN lorazepam for R10. This placed the resident at risk for unnecessary antipsychotic medication with side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 35 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure a 14-day stop date or a specified duration with rationale for R10's ongoing as-needed (PRN) antianxiety (class of medications that calm and relax people) medication. This placed R10 at risk for unintended effects related to psychotropic (alters mood or thought) drug medications. Findings include: - R10's Electronic Health Record (EHR) revealed diagnosis of Alzheimer's (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), and 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). R10's Significant Change Minimum Data Set (MDS), dated [DATE], recorded R10 had severely impaired cognition. The MDS recorded she required extensive assistance from two staff with bed mobility and transfers. The MDS lacked documentation R10 received an antianxiety medication during the observation period. R10's Care Plan, dated 06/10/24, recorded R10 required extensive assistance with most activities of daily living (ADL) care. R10's Care Plan lacked documentation for the resident's antianxiety medication and the indication for the use of the medication. The Physician's Order, dated 05/31/24, directed the staff to administer lorazepam (antianxiety) 0.5 milligram (mg). Give 0.5 mg every six hours as needed for anxiety. The order lacked a stop date. R10's EHR lacked evidence of a specified duration which included a physician's rationale for the extended use. R10's consultant pharmacist monthly reviews, completed on 06/30/24, lacked evidence that the CP had identified the PRN lorazepam with no stop date. On 07/23/24 at 07:45 AM, R10 sat in a Broda chair (special chair with tilt and recline capability) at the dining room table. Certified Medication Aide (CMA) MM administered the resident's morning medications. On 07/22/24 at 03:00 PM, Administrative Nurse D verified the resident received lorazepam PRN that lacked a stop date. The facility's Unnecessary Drugs and Psychotropic Drug Use policy, dated 10/12/2-022, documented the resident would be administered psychotropic medication only when necessary to treat specific diagnoses and document conditions. The facility would limit the timeframe for PRN psychotropic medications, to 14 days, unless a longer timeframe is deemed appropriate by the attending physician or the prescribing Practitioner. Limiting PRN psychotropic medications, which are antipsychotic medications, to 14 days and not entering a new order without first evaluating the resident. The interdisciplinary team would identify and document the resident's indication for use. Orders for PRN psychotropic and or antipsychotic medications that are not prescribed to treat a diagnosis-specific condition or do not meet the PRN requirements for psychotropic and antipsychotic medications. The facility failed to ensure R10's PRN lorazepam had a 14-day stop date or specified duration placing R10 at risk for adverse side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 35 residents. The sample included 12 residents with one reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R)10. This placed R10 at risk for inappropriate end-of-life care. Findings included: - R10's Electronic Health Record (EHR) revealed diagnosis of Alzheimer's (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), and 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). R10's Significant Change Minimum Data Set (MDS), dated [DATE], recorded R10 had severely impaired cognition. The MDS recorded she required extensive assistance from two staff with bed mobility and transfers. The MDS documented the resident received hospice services. R10's Care Plan, dated 06/10/24, recorded R10 required extensive assistance with most activities of daily living (ADL) care. R10's Care Plan documented the resident received hospice services due to a terminal prognosis and directed staff to adjust the provision of ADLs to compensate for R10's change in needs and consult a physician and social services to have hospice care for the resident. The care plan directed the staff to observe the resident closely for signs of pain, administer pain medications ordered, and notify the physician if there is breakthrough pain. The care plan lacked instruction on the services provided by hospice including hospice staff visits, supplies and medical equipment provided by hospice, and medications covered by hospice. R10's medical records revealed the resident was admitted to hospice care on 05/31/24 but lacked evidence of coordination of care between the hospice and the facility. The facility had received a hospice plan of care dated 06/03/24. The review revealed there was no communication book or external document. On 07/23/24 at 07:45 AM, R10 sat in a Broda chair (special chair with tilt and recline capability) at the dining room table. Certified Medication Aide (CMA) MM administered the resident's morning medications. On 07/24/24 at 12:00 PM, Administrative Nurse E verified the facility lacked specific information on the facility care plan that coordinated with the hospice care plan. The Hospice Policy and Procedure policy, dated 06/01/23, documented the facility's goal of palliative and end-of-life care is to prevent and relieve suffering and to support the best possible quality of life for residents and the resident's family members regardless of the stage of the disease or the need for other therapies. End-of-life care would be provided based on a comprehensive and systematic delivery of care and services. Quality end-of-life care would include medical treatment that is appropriate and evidenced-based, continuity of comprehensive care, care customized to the resident's and family member's preference, care adapted to serve the residents and families, and assisting the resident to live as fully as possible. The care plan is based on the ongoing assessment and reflects goals set by the resident's family or surrogate in collaboration with the interdisciplinary team (IDT) including the resident's physician. In collaboration with the resident, family, and other involved health care professionals, the IDT develops the care plan with additional input, when indicated, from other community providers such as community services, and spiritual leaders. Changes in the care plan are based on the evolving needs and preferences of the resident and family, with recognition of the complex, competing, and shifting priorities in the goals of care. The IDT provides services to the resident and family consistent with the care plan to include chaplains, nurses, physicians, social workers, and other therapeutic disciplines who provide palliative care services to residents and family members. The IDT communicates regularly -at least weekly or more often as required by the clinical situation to plan, review, evaluate, and update the care plan, with input from both the resident and the family. The facility failed to coordinate care between the facility and the hospice provider for R10, who received hospice services. This deficient practice placed her at risk for inappropriate end-of-life care.

The facility identified a census of 35 residents. The sample included 12 residents with five residents reviewed for immunizations, Resident (R)10, R2, R1, R3, and R18, to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to evaluate for eligibility and offer or obtain an informed declination or a physician-documented contraindication for the pneumococcal PCV20 vaccination per the latest guidance from the Centers for Disease Control and Prevention (CDC). This placed the residents at risk for pneumococcal infection and related complications. Findings included: - Review of R10, R2, R1, R3, and R18's clinical medical records lacked evidence the facility or the resident representative received or signed a consent or informed declination for the pneumococcal vaccine PCV20. On 07/23/24 at 03:00 PM, Administrative Nurse F stated residents were offered the pneumonia vaccines on admission, and as indicated; the facility sent out the Centers for Disease Control and Prevention (CDC) vaccination sheets and a sheet the facility had formatted that included multiple vaccinations at the top of the form and the resident or the residents representative were to circle the one they authorize the resident to receive. The form had the choice of a pneumonia vaccine but did not specify if the resident should receive the PVC13, PVC20, or PVC23. On 07/23/24 at 03:00 PM, when asked for a list of residents who were eligible for the Prevnar 20 (PCV20) vaccination, Administrative Staff A verified they would have the consultant pharmacist provide them with the residents who would be eligible for the PVC20, which was all but two residents in the facility who already received the PVC20. The facility's Immunization Policy, undated, documented all residents would be offered the pneumococcal vaccination on admission and as approved by the primary care physician after investigating/inquiry related to current immunization status, The policy documented the CDC recommends two vaccines for all adults over 65 years or older. The policy documented the resident received the PVC 13 and the PVC 23 but lacked guidance on when to administer the PVC20. The facility failed to offer the PCV20 pneumococcal vaccination. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from pneumonia.

The facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 35 residents who resided in the facility and received meals from the facility kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 07/23/24, a review of the noon meal consisted of barbeque meatballs, red potato salad, creamy sweet corn, dinner roll, and chocolate pudding. On 07/23/24 at 11:30 AM, observation revealed Dietary Staff BB in the kitchen overseeing the preparation of the noon meal. On 07/22/24 at 12:30 PM, Dietary Staff BB verified he was not a certified dietary manager. Dietary Staff BB stated he had not started the certified dietary manager classes. On 07/24/24 at 10:58 AM, Administrative Staff A verified Dietary Staff BB had no dietary manager certification. The facility's undated Dietary Supervisor Certified Dietary Manager (CDM) Policy, documented the CDM qualifications and position requirements were the following: Successful completion of the state's CDM certification course. Ability to read and write English but not necessary for English primary language Ability to do simple math Ability to learn special diets Good personal hygiene ServSafe Certification required Membership in the state association of nutritional and food service professionals 2 years experience in food service in a healthcare setting preferred Exceptional interpersonal skills. Exceptional organizational skills. Ability to meet the dietary needs of the facility's diverse census. The facility failed to employ a full-time certified dietary manager for 35 residents who resided in the facility and received meals from the kitchen. This placed the residents at risk of not receiving adequate nutrition.

The facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, in one of one kitchen. This placed the residents who received their meals from the facility's kitchen at risk for foodborne illness. Findings included: - On 07/22/24 at 07:50 AM, observation in the kitchen revealed the following: The refrigerator had an unlabeled, undated half-full plastic bag of chicken strips, an unlabeled and undated plastic bag with five hamburger patties, an uncovered metal pan of blueberry crisp, and an unsealed plastic bag of yellow cheese slices. The dry storage area had an unlabeled, undated five-pound plastic bag of white cake mix, half full, and an unlabeled, undated five-pound plastic bag of Devil's Food cake mix, half full. The chest-style deep freezer located in the dry storage area had approximately one-quarter to one-half inch (in) of ice buildup all around the inside of it. On 07/22/23 at 7:55 AM, Dietary Staff (DS) CC verified the issues in the kitchen. On 07/23/24 at 10:30 AM, observation in the kitchen revealed one-floor tile located in the dry storage room, in front of the white chest deep freezer, had a missing piece in the lower corner approximately one-quarter to one-half inch wide and five inches long; a piece was also missing in the upper right corner of the same tile approximately one-half inch wide by four inches long. On 07/23/24 at 01:15 PM, Dietary Manager (DM) BB verified the issue with the ice in the white chest deep freezer and the tile in the dry storage room and stated the deep freeze needed to be defrosted. DM BB stated staff should make sure food items are in a sealed container, labeled and dated before they place them in the refrigerator and dry storage area. The facility's Dietary Purchases, Receipt, and Storage Policy, revised 10/24/22, documented all products would be labeled with the date received in the facility. The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the 35 residents who received their meals from the facility's kitchen. This placed the 35 residents at risk for foodborne illness.

The facility identified a census of 27 residents with three reviewed for privacy and confidentiality in regard to their care at the facility. Based on record review, observation, and interview, the facility failed to protect the privacy of Resident (R) 1 when in February of 2023 Certified Nurses Aide (CNA) M took a video which included Resident (R) 1's lower legs and feet, and posted it to a social media site. R1's representative saw the video on the social media site and recognized R1's pants and shoes. R1's representative notified the facility on 05/05/23 of the video posted by CNA M. CNA M's job had previously been terminated on 04/09/23 for other infractions. The video of R1 was taken off of the social media site. This deficient practice placed R1 at risk for impaired psycho-social wellbeing and impaired privacy. Findings included: - The Electronic Medical Record (EMR) documented R1 had diagnoses of senile degeneration of the brain, hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following a cerebral infarct (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) effecting the left, non-dominant side, and major depressive disorder (major mood disorder). The Quarterly Minimum Data Set (MDS), dated 04/14/23, documented R1 had a Brief Interview for Mental Status (BIMS) score of twelve which indicated R1 was moderately cognitively impaired. The MDS further documented required extensive assistance of one to two staff for bed mobility, transfer, locomotion on and off the unit, dressing, toileting, personal hygiene, and bathing. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 10/21/22, documented R1 needed focuses to help her maintain as much cognition as possible as her cognitive decline was permanent and progressive, R1 was documented as being easily distractible. The Activities of Daily Living/Rehabilitation Potential CAA, dated 10/21/22, documented R1 needed extensive assistance with her activities of daily living. R1 had a history of a cerebral infarct affecting her left side and has a contracture (shortening of the muscle) of her left forearm. The Impaired Cognitive Function Care Plan, dated 04/20/23, directed staff to reduce any distractions, turn off television, radio, and close door the door, provide R1 with necessary cues. Staff were directed to communicate with R1 in a consistent, clear directive conversation. Staff were directed to cue, reorient, and supervise R1 as needed. The Facility Report of Concern, dated 05/05/23, documented R1's representative went to the facility and spoke with the charge nurse on duty and voiced a complaint that former employee, CNA M, posted a video on a social media site with R1's feet in it. The charge nurse on duty reported the complaint to Administrative Nurse D. The video was taken off the social media site. CNA M had been terminated previously on 04/09/23. The facility Cell Phone Policy was updated, audits of employee's cell phones being on their person were completed, and an in-service training was completed with all staff. The facility did not report the incident to the State Agency (SA). On 05/31/23 at 09:30 AM, observation revealed R1 sat in her recliner watching TV. On 05/31/23 at 09:30 AM, R1 stated that she liked living in the facility and received good care at the facility. On 05/31/23 at 10:00 AM, Administrative Nurse D stated that at the time of the incident in February of 2023, no one at the facility had any idea that a video had been taken. Administrative Nurse D stated she was unaware of the incident until R1's representative had made the facility aware of the incident. Administrative Nurse D stated the facility did not have a cell phone policy but a policy was put into place after this incident. Administrative Nurse D stated it was against the facility's policy to post any pictures or videos to social media sites. Administrative Nurse D stated that R1's representative told the facility that she was going to report the incident to the state so she and Administrative Staff A did not think they were required to report the incident. On 05/31/23 at 10:30 AM, Administrative Staff A stated that he was the interim administrator and he was not at the facility at the time of the incident. Administrative Staff A stated that he was the acting administrator of the facility on 05/05/23 when the incident was reported the facility. Administrative Staff A stated that posting pictures or videos of residents of the facility was against the social media policy. Administrative Staff A stated the facility did not report the incident to the state agency because R1's representative said she was going to report the incident. The facility's Personal Cell Phone Policy, dated 05/08/23, documented all personal cell phones are prohibited from resident rooms, bath houses, commons area, and facility halls. In an effort to provide for the privacy of the residents personal cell phones are not to be on staff's person in the facility. Personal cell phones are to be left in the car, in the break room, or left with the charge nurse on duty. The facility's Social Networking and Other Web-Based Communications Policy, dated 02/06/20, documented unless specifically instructed, employees are not authorized and therefore restricted to speak on the behalf of the facility. Employees may not publicly discuss residents, elders, family members, employees, vendors, volunteers or any work related matters, whether confidential or not, outside the facility authorized communications. Employees are expected to respect the privacy of the facility and its employees and elders and are prohibited from disclosing personal employee or non-employee information and any other proprietary and non-public information that employees have access to. Per the facility's social media policy, if a shared photograph or recording of an elder or the manner that the photo is used, demeans or humiliates an elder, regardless of whether the elder provided consent and regardless of elder's cognitive status, abuse includes and will be reported, investigated and resolved but not limited to: photographs, recordings containing nudity, sexual and intimate relations, bathing, showering, dressing, toileting, providing perineal care, agitating an elder to elicit a response, derogatory statements directed at an elder, showing a body part without the resident's face whether it is chest, limbs or back, or showing an elder in a compromising situation. The facility failed to protect R1's privacy which placed R1 at risk for R1's psycho-social well-being and privacy infringed.

The facility identified a census of 27 residents with three reviewed for privacy and confidentiality in regard to their care at the facility. Based on record review, observation, and interview, the facility failed to report an incident to the State Agency as required when in February of 2023, the facility received an allegation of abuse concerning Certified Nurse's Aide (CNA) M and Resident (R)1. This deficient practice placed R1 at risk for ongoing and/or unidentified abuse or mistreatment. Findings included: - The Electronic Medical Record (EMR) documented R1 had diagnoses of senile degeneration of the brain, hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following a cerebral infarct (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) effecting the left, non-dominant side, and major depressive disorder (major mood disorder). The Quarterly Minimum Data Set (MDS), dated 04/14/23, documented R1 had a Brief Interview for Mental Status (BIMS) score of twelve which indicated R1 was moderately cognitively impaired. The MDS further documented required extensive assistance of one to two staff for bed mobility, transfer, locomotion on and off the unit, dressing, toileting, personal hygiene, and bathing. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 10/21/22, documented R1 needed focuses to help her maintain as much cognition as possible as her cognitive decline was permanent and progressive, R1 was documented as being easily distractible. The Activities of Daily Living/Rehabilitation Potential CAA, dated 10/21/22, documented R1 needed extensive assistance with her activities of daily living. R1 had a history of a cerebral infarct affecting her left side and has a contracture (shortening of the muscle) of her left forearm. The Impaired Cognitive Function Care Plan, dated 04/20/23, directed staff to reduce any distractions, turn off television, radio, and close door the door. Provide R1 with necessary cues. Staff directed to communicate with R1 in a consistent, clear directive conversation. Staff were directed to cue, reorient, and supervise R1 as needed. The Facility Report of Concern, dated 05/05/23, documented R1's representative went to the facility and spoke with the charge nurse on duty and voiced a complaint that a former employee, CNA M, posted a video on a social media site with R1's feet visible in it. The charge nurse on duty reported the complaint to Administrative Nurse D. The video was taken off of the social media site. CNA M had been terminated previously on 04/09/23. The facility Cell Phone Policy was updated, audits of employees' cell phones being on their person were completed, and an in-service training was completed with all staff. The facility did not report the incident to the SA. On 05/31/23 at 09:30 AM, observation revealed R1 sat in her recliner watching TV. On 05/31/23 at 09:30 AM, R1 stated that she liked living in the facility and received good care at the facility. On 05/31/23 at 10:00 AM, Administrative Nurse D stated that at the time of the incident in February of 2023 no one at the facility had any idea that a video had been taken. Administrative Nurse D stated she was unaware of the incident until R1's representative had made the facility aware of the incident. Administrative Nurse D stated the facility did not have a cell phone policy but a policy was put into place after this incident. Administrative Nurse D stated it was against the facility's policy to post any pictures or videos to social media sites. Administrative Nurse D stated that R1's representative had told the facility that she was going to report the incident to the state so she and Administrative Staff A did not think they were required to report the incident. On 05/31/23 at 10:30 AM, Administrative Staff A stated that he was the interim administrator and he was not at the facility at the time of the incident. Administrative Staff A stated that he was the acting administrator of the facility on 05/05/23 when the incident was reported the facility. Administrative Staff A stated that posting pictures or videos of residents of the facility was against the social media policy. Administrative Staff A stated the facility did not report the incident to the state agency because R1's representative said she was going to report the incident. The facility's undated Reporting Abuse, Neglect or Misappropriation of a Resident, documented that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported per Federal and State law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than two hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the administrator of the facility and to other officials including the State Survey Agency and adult protective services in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility per agreement with th3e local law enforcement agency. The facility's Personal Cell Phone Policy, dated 05/08/23, documented all personal cell phones are prohibited from resident rooms, bath houses, commons area, and facility halls. In an effort to provide for the privacy of the residents personal cell phones are not to be on staff's person in the facility. Personal cell phones are to be left in the car, in the break room, or left with the charge nurse on duty. The facility's Social Networking and Other Web-Based Communications Policy, dated 02/06/20, documented unless specifically instructed, employees are not authorized and therefore restricted to speak on the behalf of the facility. Employees may not publicly discuss residents, elders, family members, employees, vendors, volunteers or any work-related matters, whether confidential or not, outside the facility authorized communications. Employees are expected to respect the privacy of the facility and its employees and elders and are prohibited from disclosing personal employee or non-employee information and any other proprietary and non-public information that employees have access to. Per the facility's social media policy, if a shared photograph or recording of an elder or the manner that the photo is used, demeans or humiliates an elder, regardless of whether the elder provided consent and regardless of elder's cognitive status, abuse includes and will be reported, investigated and resolved but not limited to: photographs, recordings containing nudity, sexual and intimate relations, bathing, showering, dressing, toileting, providing perineal care, agitating an elder to elicit a response, derogatory statements directed at an elder, showing a body part without the resident's face whether it is chest, limbs or back, or showing an elder in a compromising situation. The facility failed to report an incident where R1's privacy was infringed upon which placed R1 at risk for ongoing abuse and/or mistreatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 26 residents. The sample included 13 residents, with eight reviewed for accidents. Based on observation, record review, and interview, the facility failed to revise the care plan with the use of the power lift recliner for Resident (R)25, placing the resident at risk for accidents and injury related to the power lift chair. Findings included: - R25's diagnosis included dementia (progressive mental disorder characterized by failing memory and confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R25 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, and toileting. The MDS further documented R25 had unsteady balance, functional impairment on both upper extremities, and had no falls during the look-back period. Review of the Electronic Medical Record lacked documentation an Electric Recliner Assessment was completed for the resident. The Fall Risk Assessments, dated 03/11/22, 06/03/22, 06/11/22, and 06/28/22, documented the resident a high fall risk. The Fall Care Plan, dated 06/13/22, directed staff to ensure R25's had a safe environment with the floors free from spills or clutter, a reachable call light, bed in the lowest position, and personal items withing reach. The fall care plan documented the resident did not have any safety awareness and to continue with interventions already in place, ensure the resident used the electronic personal safety alarm and keep the resident in line of sight. The Fall Investigation, dated 06/11/22, documented at 03:20 PM, staff heard R25's personal alarm sounding, and the resident was observed on the floor in front of a recliner in the living room. Staff assisted the resident to her wheelchair and obtained vital signs. R25 was noted to have skin tears to her right eyebrow 0.6 centimeters (cm) and right pinky finger 0.6 cm. The areas were cleaned, band aides applied, and ice packs to the areas. The fall investigation further documented the resident had been in the power lift recliner in the living room. The Fall Investigation, dated 06/28/22, documented at 09:45AM, R25 was seated in a power lift chair in the living room, the control to her recliner was in the chair. Staff observed R25 moving and pushing the electric control which caused her to fall forward on the floor. R25 was noted to have two small lacerations to the bridge of her nose, a bloody nose and bleeding from her mouth on top of the gum line. Staff assisted the resident back into the recliner, then to the wheelchair and transported her to bed and noted she was incontinent of bowel. Staff assessed the resident, provide cares, and started neurological checks. The investigation further documented staff would not place R25 in a power lift chair and keep the resident in line of sight. On 06/30/22 at 01:00 PM, observation revealed R25 sat in a regular (no power lift chair) recliner in the living room. Further observation revealed the resident the resident had her eyes closed and the footrest was elevated. On 07/05/22 at 09:00 AM, Administrative Nurse E verified the resident had two falls from a power lift chair with injury and the facility had not completed a power lift chair assessment for the resident. Administrative Nurse E verified the resident could not use the power lift chair controls safely and verified the care plan was not updated with the falls. The facility's Plan of Care Conference policy, dated November 2003, documented to provide optimal, holistic care to each resident on an individual basis, an interdisciplinary care plan would be established on admission and reviewed and revised on a regular schedule. The care plan is initiated on the date of admission by the assessment process by all disciplines and is completed in 21 days. All care plans will be reviewed and update by the team every 90 days and will revise regularly as changes occur. The facility's Goals and Objectives, Care Plan policy, dated 2001, documented care plans would incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Care plan and objectives are defined as the desired outcome for a specific resident's problem and are derived from information contained in the resident's comprehensive assessment and are resident oriented, are behaviorally stated, are measurable, and contain timetables to meet the resident's needs in accordance with the comprehensive assessment. The policy documented the goals and objectives are reviewed and/or revised; when there has been a significant change in the resident's condition, when the desired outcome has not been achieved, when the resident has been readmitted to the facility from a hospital/rehabilitation stay; and at least quarterly. The facility failed to revise R25's care plan with interventions for safe use of the power lift recliner or the regular recliner. This placed the resident at risk for complications and future injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 26 residents. The sample included 13 residents, with eight reviewed for accidents. Based on observation, record review, and interview, the facility failed to identify and implement interventions to prevent accidents for Resident (R) 25 who had two falls from a recliner and sustained a laceration and injury on her nose and face. This placed the resident at risk for further injury. Findings included: - R25's diagnosis included dementia (progressive mental disorder characterized by failing memory and confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R25 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, and toileting. The MDS further documented R25 had unsteady balance, functional impairment on both upper extremities, and had no falls during the look-back period. Review of the Electronic Medical Record lacked documentation an Electric Recliner Assessment was completed for the resident. The Fall Risk Assessments, dated 03/11/22, 06/03/22, 06/11/22, and 06/28/22, documented the resident a high fall risk. The Fall Care Plan, dated 06/13/22, directed staff to ensure R25's had a safe environment with the floors free from spills or clutter, a reachable call light, bed in the lowest position, and personal items withing reach. The fall care plan documented the resident did not have any safety awareness and to continue with interventions already in place, ensure the resident used the electronic personal safety alarm and keep the resident in line of sight. The Fall Investigation, dated 06/11/22, documented at 03:20 PM, staff heard R25's personal alarm sounding, and the resident was observed on the floor in front of a recliner in the living room. Staff assisted the resident to her wheelchair and obtained vital signs. R25 was noted to have skin tears to her right eyebrow 0.6 centimeters (cm) and right pinky finger 0.6 cm. The areas were cleaned, band aides applied, and ice packs to the areas. The fall investigation further documented the resident had been in the power lift recliner in the living room. The Fall Investigation, dated 06/28/22, documented at 09:45AM, R25 was seated in a power lift chair in the living room, the control to her recliner was in the chair. Staff observed R25 moving and pushing the electric control which caused her to fall forward on the floor. R25 was noted to have two small lacerations to the bridge of her nose, a bloody nose and bleeding from her mouth on top of the gum line. Staff assisted the resident back into the recliner, then to the wheelchair and transported her to bed and noted she was incontinent of bowel. Staff assessed the resident, provide cares, and started neurological checks. The investigation further documented staff would not place R25 in a power lift chair and keep the resident in line of sight. On 06/30/22 at 01:00 PM, observation revealed R25 sat in a regular (non powered) recliner in the living room. Further observation revealed the resident had her eyes closed and the footrest was elevated. On 07/05/22 at 09:00 AM, Administrative Nurse E verified the resident had two falls from a power lift chair with injury and the facility had not completed a power lift chair assessment for the resident. Administrative Nurse E verified the resident could not use the power lift chair controls safely. The facility's Fall Management policy, dated July 2022, documented staff would assure the facility provided the highest possible level of care for the resident safety and comfort with minimal fall occurrence. With every fall, a fall management assessment and fall care plan will be completed by the charge nurse, and the primary care physician and responsible party would be notified. The fall management assessment would be routed to the director of nursing for review, and the DON or the charge nurse will contact physical therapy or occupational therapy for evaluation. A fall follow up form would be initiated along with the Fall Management Assessment and completed by the charge nurse for each shift for 72 hours after the fall. The facility failed to prevent falls for R25, who had two falls with minor injury from a power lift recliner. This placed the resident at risk for further falls and injury

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 26 residents. The sample included 13 residents, with one reviewed for side rails. Based on observation, record review, and interview, the facility failed to assess Resident (R)11's side rails for safe use. This placed the resident at risk for injury. Findings included: - R11's diagnosis included systemic inflammatory response syndrome (serious condition in which there is inflammation throughout the body,) diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin,) bilateral hip fractures, fracture thoracic (middle section of the spine) levels 11 and 12, and weakness. R11's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R11 required extensive assistance of one staff with bed mobility and transfers. The MDS lacked documentation the resident had bed side rails. The Activities of Daily Living (ADLs) Care Plan, dated 11/08/21, indicated R11 required extensive staff assistance with most ADLs due to muscle weakness and impaired balance. The Care Plan lacked indication of the use of a side rail to assist with repositioning in bed. R11's electronic medical record lacked a side rail assessment. On 06/30/22 at 08:30 AM, observation revealed R11 seated in a recliner in room with his feet elevated and eyes closed. On 7/05/22 at 08:35 AM, observation revealed an upper one-third side rail on the outer right side of the bed. The upper opening measured 15.5inches long by 14.5 inches wide on the bottom of the rail to the top of the mattress. The side rail was attached to the bed with wire ties and was able to move back and forth out of the bed frame. On 07/05/22 at 0:45 AM, Administrative Staff A verified the bed rails should not be on R11's bed and verified the rails had too large of openings. On 07/05/22 at 09:00AM, Administrative Nurse Staff E verified the residents medical record lacked a side rail assessment for safety of the rails. The facility's Restraint Use Policy and Procedures policy, undated, recorded the facility creates and maintains an environment that fosters minimal use of restraints. The purpose of selective restraints use is to enhance resident quality of life by assuring safety while promote an optimal level of function. The facility failed to adequately assess R11 for the appropriate side rail, placing him at risk for accident or injury.

The facility had a census of 26 residents. The sample included 13 residents. Based on observation, record review and interview the facility failed to provide comfortable sound levels promoting a homelike dining environment. This placed the residents at risk for an unpleasant dining experience. Findings included: - On 06/29/22 at 11:33AM, observation in the dining room revealed Resident (R) 1 sat in a wheelchair at the dining table. Further observation revealed R1 hollered loudly, made hooting noises, growled and was disruptive. On 06/29/22 at 12:10PM, observation revealed R16 sat on a dining chair across the table from R1. Further observation revealed R1 continued to holler loudly. R16 stood up and moved to a different dining table. R1 became louder, and made hooting type noises. R16 then stood up again and stated, I am going back to my room to eat, I just can't stand this anymore. On 06/30/22 at 11:50AM, observation revealed R1 sat in a wheelchair at the dining table. Further observation revealed R1 hollered loudly and made growling and hooting noises while other residents were being served and ate the noon meal. On 07/05/22 at 12:05PM, observation revealed R1 sat in a wheelchair at the dining table. Further observation revealed R1 hollered loudly while other residents seated at dining table ate the noon meal. On 06/30/22 at 01:30PM, Certified Nurse Aide (CNA) M verified R1 was disruptive during dining, and other residents complained about the noise when they were eating meals. On 07/05/22 at 10:10AM, Administrative Staff A verified R1 was disruptive and hollered during meals and stated it had been going on for several months. On 07/06/22 at 9:50AM, Social Service/Activity Staff verified R1 was disruptive and loud during meals. Social Service/Activity Staff stated residents had complained for several months about it being too loud when they were eating. The facility's undated, Dining Room Standards policy, stated the community will ensure and maintain a cheerful dining experience with comfortable sound levels. The facility failed to provide a homelike dining environment for the residents who ate meals in the dining room, placing them at risk for an unpleasant dining experience.

The facility had a census of 26 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to follow-up or resolve resident grievances, placing the residents at risk for unresolved concerns. Findings included: - On 06/30/22 at 01:30PM, during private discussion with the residents of the resident council, residents verbalized an ongoing unpleasant dining experience due to a resident who hollered and was disruptive during meals. Council members verbalized no resolution from the facility regarding the council's grievance. Review of the resident council meeting minutes for March, April, May and June 2022, revealed grievances by council members regarding a resident who hollered loudly during meals. The council minutes lacked documentation of the facility's action to resolve the grievance. Review of the facility's grievance log lacked documentation of any grievances in the facility. On 07/05/22 at 12:05PM, observation revealed R1 sat in a wheelchair at the dining table. Further observation revealed R1 hollered loudly while other residents seated at dining table ate the noon meal. On 06/30/22 at 01:30PM, Certified Nurse Aide (CNA) M verified R1 was disruptive during dining, and other residents complained about the noise when they were eating meals. On 07/05/22 at 10:10AM, Administrative Staff A verified R1 was disruptive and hollered during meals and stated it had been going on for several months. On 07/06/22 at 9:50AM, Social Service/Activity Staff verified R1 was disruptive and loud during meals. Social Service/Activity Staff stated residents had complained for several months about it being too loud when they were eating. The facility's Grievance Policy, dated 03/2022, stated Residents may present any concerns they have through a grievance resolution procedure. This facility attempts to resolve promptly all concerns. Residents have the right to receive prompt efforts by management. Grievances are to be followed up on and response provided to the individual or group with the resolution of the concern. The facility's Resident Council, policy dated 10/2003, stated the residents shall meet once a month to discuss any problems they may had and the facility will work towards alleviating these grievances. The facility failed to respond to resident council grievances, placing the residents in the facility at risk for unresolved issues.

The facility had a census of 26 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to monitor and adhere to cleaning and disinfecting shared equipment which consisted of a digital thermometer and oxygen saturation clip, (a device used to monitor oxygen in the blood) placing the residents at risk for infection. Findings included: - On 06/29/22 at 08:00AM, upon entrance into the facility observation revealed a sign in sheet to document entrance into the facility, a small brown wooden box which contained a digital thermometer and a oxygen saturation clip. Further observation revealed no supplies for disinfecting or cleaning the thermometer or oxygen clip after use. On 07/05/22 at 7:30AM, observation continued to reveal no supplies were available to clean the digital thermometer or oxygen clip used by all who entered the facility. On 07/05/22 at 08:10AM, Administrative Staff A verified no supplies were available at the sign in area of the facility to clean the digital thermometer or oxygen clip. Administrative Staff A stated she did not realize there were no supplies available at the sign in station. The facility's Infection Control policy, dated 03/16/2022, stated equipment is to be cleaned and disinfected after each use. The facility failed to ensure shared equipment was cleaned and disnfected between uses, placing the residents at risk for infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 29 residents. Based on observation, interview, and record review, the facility failed to ensure hazardous chemicals were inaccessible to the two independently mobile, cognitively impaired residents of the facility. Findings included: - On 01/07/21 at 12:55 PM, observation revealed the doors of the activity room open with no staff in the room. Further observation revealed the cabinet under the sink was unlocked and held the following: one 16-ounce bottle of [NAME] whirlpool disinfectant cleaner with the label stating causes severe eye and skin damage. one quart spray bottle of peroxide multi surface cleaner and disinfectant, half full, with the label stating hazardous to human and animals, causes moderate eye irritation. On 01/07/21 at 12:55 PM, Activity Staff Z verified the hazardous chemicals should be locked up. On 01/13/21 at 03:30 PM, Administrative Nurse E reported two independently mobile, cognitively impaired residents. The facility's Control of Hazardous Chemicals policy, dated June 2020, documented all containers of hazardous chemicals with warning labels are to be locked and inaccessible at all times to avoid accessibility to elders in the facility. The facility failed to ensure hazardous chemicals were inaccessible to residents, placing the independently mobile, cognitively impaired residents at risk for chemical accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R16's Quarterly MDS, dated 11/27/20, documented the resident had severe cognitive impairment, required extensive assistance with mobility, toileting, personal hygiene, on a current toilet program, frequently incontinent of urine and bowel, and received antibiotics. The Urinary Incontinence CAA, dated 06/11/20, documented the resident had a UTI in past month, required extensive assistance with mobility, toileting, personal hygiene, and incontinent once during the look back period. The Urinary Incontinence Care Plan, dated 11/27/20, documents the resident had functional mixed bladder incontinence related to dementia, history of UTI, impaired mobility and loss of peritoneal tone. The care plan directed staff to use large sized disposable incontinent briefs, change as needed, and clean peri-area with each incontinence episode. On 01/12/21 at 09:09 AM, observation revealed CNA N and CNA S assisted the resident to a shower room for toileting. Both CNAs transferred the resident with a sit to stand lift (mechanical lift to aid in going from sitting to standing or visa versa) to the toilet, removed her incontinent pull up soiled with urine and bowel. Resident allowed to sit on the toilet and encouraged to finish emptying her bladder and bowels. When the resident finished, staff preformed hygiene care to the resident cleansing the rectal area several times with wet disposable wipes, and the vaginal area once. Staff applied a clean incontinent brief by dragging the brief on the under side of the resident's shoes. On 01/13/21 at 10:50 AM, Administrative Nurse E stated if staff saw an issue with incontinence, training was provided. Administrative Nurse E stated an incontinence care checklist was completed upon hire and there were increased UTIs this month. The facility Perineal Care policy, dated February 2018, documented staff were to provide cleanliness and comfort to the resident to prevent infections and skin irritation. Steps in the procedure directed staff to wash the perineal area by wiping front to back, separating the labia (externally visible portion of the female genitalia), wash the peri area moving from inside outward toward the thighs, and wash the rectal area thoroughly wiping from the base of the labia towards, and extending over, the buttocks. The facility failed to provide thorough and proper incontinence care during toileting for R16, who had a history of UTIs, placing the resident at risk for further UTIs. - R25'sadmission MDS, dated 12/22/20, documented the resident had moderately impaired cognition, required extensive assistance of two staff for toileting, personal hygiene, and mobility, frequently incontinent of urine and bowel, and had a UTI in the past 30 days. The Urinary Incontinence CAA, dated 12/28/20, documented the resident required extensive assistance with toileting, wanted to self-direct her toileting schedule, and the focus was to provide prompt assistance. The Urinary Care Plan, dated 12/29/20, documented the resident had bladder incontinence related to history of UTIs, impaired mobility and loss of peritoneal tone, and used large disposable incontinent briefs. The care plan directed staff to clean peri-area with each incontinence episode and assist to the toilet on rising, before and after meals, at bedtime, and as needed. On 01/12/21 at 08:45 AM observation revealed CNA N and CNA S assisted the resident to sit on a commode, incontinent brief lowered and revealed urine and bowel movement in the brief. After the resident finished voiding, both CNAs cleaned her rectal area several times with disposable wipes, and only once to the vaginal area, then applied a clean incontinent brief by dragging it over the bottom of the resident's shoes. On 01/13/21 at 10:50 AM, Administrative Nurse E stated if staff saw an issue with incontinence, training was provided. Administrative Nurse E stated an incontinence care checklist was completed upon hire and there were increased UTIs this month. The facility Perineal Care policy, dated February 2018, documented staff were to provide cleanliness and comfort to the resident to prevent infections and skin irritation. Steps in the procedure directed staff to wash the perineal area by wiping front to back, separating the labia (externally visible portion of the female genitalia), wash the peri area moving from inside outward toward the thighs, and wash the rectal area thoroughly wiping from the base of the labia towards, and extending over, the buttocks. The facility failed to provide thorough and proper incontinence care during toileting for R25, who had a history of UTIs , placing the resident at risk for further UTIs. The facility had a census of 29 residents. The sample included 12 residents with five reviewed for urinary tract infections (UTI). Based on observation, interview, and record review, the facility failed to provide proper peri care to four of five sampled residents, Resident (R) 2, R7, R16, and R25. Findings included: - R2's Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS documented R2 required assistance of two staff with toilet use, on a toileting program, frequently incontinent of bladder and bowel, and received antibiotics three days of the look back period. The Urinary Incontinence Care Area Assessment (CAA), dated 10/02/20, documented R2 remained frequently incontinent of urine and continued to require extensive assistance with toileting. The Urinary Care Plan, dated 01/08/21, documented the resident required extensive to total assistance of one to two staff for toileting upon arising, before and after meals, and at bedtime (approximately every two hours) while awake. The resident used disposable incontinent briefs and staff were to change the brief with peri care as needed. The Physician Order, dated 07/03/20, directed staff to administer Bactrim DS (double strength-antibiotic), twice daily for five days for a diagnosis of UTI. The Hospital Progress Note, dated 09/20/20, documented the hospital admitted R2 for sepsis syndrome (potentially life-threatening condition caused by the body's response to an infection) due to UTI. The Physician Order, dated 12/03/20 directed staff to administer Macrobid (antibiotic),100 milligrams (mg) twice daily for seven days for UTI. The Physician Order, dated 01/04/21, directed staff to administer Bactrim DS, twice daily for five days for UTI. On 01/11/21 at 11:20 AM, observation revealed Certified Nurse Aide (CNA) M and CNA N assisted the resident to the toilet, resident incontinent of a small amount of urine a small bowel movement. CNA M provided bowel incontinence care but did not wipe the frontal peri area which had been in contact with urine. The CNA removed soiled gloves before pulling up the brief and clothing. On 01/12/21 at 04:36 PM, CNA Q and CNA P assisted the resident to her bathroom, brief had a small amount of bowel movement, but no urine. CNA Q used moist wipes and reached under and forward toward the frontal peri area to wipe front to back. CNA Q removed her soiled gloves, pulled up the resident's brief and clothing, then washed her hands. On 01/11/21 at 11:23 AM, CNA N stated R2 dribbled urine when she stood up and then urinated in the toilet. On 01/13/21 at 10:50 AM, Administrative Nurse E stated if staff saw an issue with incontinence, training was provided. Administrative Nurse E stated an incontinence care checklist was completed upon hire and there were increased UTIs this month. The facility's Perineal Care policy, dated February 2018, documented staff were to provide cleanliness and comfort to the resident to prevent infections and skin irritation. Steps in the procedure directed staff to wash the perineal area by wiping front to back, separating the labia (externally visible portion of the female genitalia), wash the peri area moving from inside outward toward the thighs, and wash the rectal area thoroughly wiping from the base of the labia towards, and extending over the buttocks. The facility failed to provide thorough and proper incontinence care after toileting for R2, who had been diagnosed with UTIs four times in the past six months, placing the resident at risk for further UTIs. - R7's Annual MDS, dated 01/01/21, documented the resident had severe cognitive impairment, required assistance of two staff for toileting, on a toileting program, always incontinent of urine, and frequently incontinent of bowel. The Urinary Incontinence CAA, dated 01/01/21, documented the resident frequently incontinent, assisted to toilet regularly, and required extensive assistance with toileting. The CAA directed staff to encourage fluids and monitor the resident for UTI's. The Urinary Care Plan, dated 01/08/21, directed staff to assist the resident to use the restroom regularly, on arising, before and after meals, at bedtime, and as needed. The care plan further directed staff to use disposable incontinent briefs, change as needed, and clean peri-area with each incontinent episode. The care plan further directed staff to encourage fluids during the day to promote prompted voiding responses and monitor for signs or symptoms of UTIs. The Urinary Analysis, dated 12/22/20, documented 4+ bacteria (normal 0) in the urine and the culture grew Escherichia coli (E. coli-type of bacteria commonly found in the gastrointestinal (GI) tract). The Hospital Discharge Summary, dated 12/25/20, documented the resident had UTI with sepsis (the body's often deadly response to infection or injury) and intermittent fevers. The Nurse's Note, dated 01/11/21 at 08:37 AM, documented staff received the resident's urinalysis results that showed Enterococcus faecalis (GI bacteria), and faxed it to the physician. The physician ordered Macrobid (antibiotic),100 mg daily for seven days, and cefdinir (antibiotic), 300 mg for five days for a UTI. On 01/11/21 at 10:20 AM, observation revealed CNA O woke the resident, placed a gait belt on her, assisted her to stand, and ambulated to the bathroom, resident incontinent of a large amount of urine. CNA O removed the soiled brief and her soiled gloves and placed a new brief and slacks on the resident. CNA O told the resident her nightgown was wet with urine and needed changed. After toileting, CNA O provided bowel incontinence care, removed gloves, and pulled up resident's clothing without providing peri care to the resident's frontal peri area. On 01/13/21 at 09:55 AM, CNA R stated staff removed the resident's incontinent brief and cleansed her inner thighs if urine touched there. CNA R stated staff were to use periwash, clean the crevices and frontal peri area, front to back. On 01/13/21 at 10:50 AM, Administrative Nurse E stated if staff saw an issue with incontinence, training was provided. Administrative Nurse E stated an incontinence care checklist was completed upon hire and there were increased UTIs this month. The facility Perineal Care policy, dated February 2018, documented staff were to provide cleanliness and comfort to the resident to prevent infections and skin irritation. Steps in the procedure directed staff to wash the perineal area by wiping front to back, separating the labia (externally visible portion of the female genitalia), wash the peri area moving from inside outward toward the thighs, and wash the rectal area thoroughly wiping from the base of the labia towards, and extending over, the buttocks. The facility failed to provide thorough and proper incontinence care during toileting for R7, who had been diagnosed with UTIs twice in the past month, placing the resident at risk for further UTIs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 29 residents. The sample included 12 residents with five reviewed for unnecessary medication. Based on observation, interview, and record review, the facility's pharmacist consultant failed to notify the physician or director of nursing that staff failed to notify the physician for out of parameter blood sugars for one of three sampled diabetic residents, Resident (R) 10. Findings included: - R10's Physician Order Sheet (POS), dated 10/28/20, documented a diagnosis of diabetes mellitus (when the body cannot use glucose (sugar), not enough insulin (hormone that allows cells throughout the body to uptake glucose) made or the body cannot respond to the insulin). The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented the resident required supervision with eating, extensive assistance of two staff for all other activities of daily living, and received insulin seven days of the lookback period. The Medication Care Plan, dated 10/30/20, directed staff to provide diabetes medication as physician ordered, monitor and document for side effects and effectiveness, and obtain fasting blood sugar and glucometer (instrument used to calculate blood sugar) checks as physician ordered. The Physician Order, dated 10/23/20, directed staff to obtain blood sugar checks before meals and at bedtime, and notify the physician if the blood sugar was less than 60 milligrams/deciliter (mg/dl) or greater than 350 mg/dl. R10's October and December 2020 Medical Administration Record (MAR) documented the following out of parameter blood sugars: 10/24/20 at 05:00 PM- 57 mg/dl 12/16/20 at 07:00 AM- 54 mg/dl 12/17/20 at 08:00 PM- 437 mg/dl 12/24/20 at 08:00 AM- 55 mg/dl R10's medical record lacked documentation staff notified the physician of the out of parameter blood sugars. On 01/12/21 at 04:50 PM, observation revealed Licensed Nurse (LN) G administered medication to the resident. On 01/12/21 at 09:27 AM, LN G stated nurses obtained the resident's blood sugar and notified the physician by fax if it was out of the parameters. LN G verified the facility lacked documentation staff notified the physician of the four out of parameter blood sugars. On 01/12/21 at 10:01 AM, Administrative Nurse D verified the pharmacist consultant failed to bring to her, or the physician's, attention that staff failed to notify the physician of out of parameter blood sugars and document interventions taken for the four out of parameter blood sugars. The facility Consultant Pharmacist Services Provider Requirements policy, dated April 2019, documented the pharmacist provides pharmaceutical care services including reviewing the medication regimen of each resident at least monthly and documenting the review and findings in the resident's clinical record, communicating potential or actual problems detected related to medication therapy orders to the physician and the director of nursing. The facility's pharmacist consultant failed to notify the director of nursing or the physician of the lack of reporting R10's out of parameter blood sugars, placing the resident at risk to not have physician direction for his diabetic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 29 residents. The sample included 12 residents with five reviewed for unnecessary medication. Based on observation, interview, and record review, the facility failed to notify the physician as ordered for out of parameter blood sugars for one of three sampled diabetic residents, Resident (R) 10. Findings included: - R10's Physician Order Sheet (POS), dated 10/28/20, documented a diagnosis of diabetes mellitus (when the body cannot use glucose (sugar), not enough insulin (hormone that allows cells throughout the body to uptake glucose) made or the body cannot respond to the insulin). The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented the resident required supervision with eating, extensive assistance of two staff for all other activities of daily living, and received insulin seven days of the lookback period. The Medication Care Plan, dated 10/30/20, directed staff to provide diabetes medication as physician ordered, monitor and document for side effects and effectiveness, and obtain fasting blood sugar and glucometer (instrument used to calculate blood sugar) checks as physician ordered. The Physician Order, dated 10/23/20, directed staff to obtain blood sugar checks before meals and at bedtime, and notify the physician if the blood sugar was less than 60 milligrams/deciliter (mg/dl) or greater than 350 mg/dl. R10's October and December 2020 Medical Administration Record (MAR) documented the following out of parameter blood sugars: 10/24/20 at 05:00 PM- 57 mg/dl 12/16/20 at 07:00 AM- 54 mg/dl 12/17/20 at 08:00 PM- 437 mg/dl 12/24/20 at 08:00 AM- 55 mg/dl R10's medical record lacked documentation staff notified the physician of the out of parameter blood sugars. On 01/12/21 at 04:50 PM, observation revealed Licensed Nurse (LN) G administered medication to the resident. On 01/12/21 at 09:27 AM, LN G stated nurses obtained the resident's blood sugar and notified the physician by fax if it was out of the parameters. LN G verified the facility lacked documentation staff notified the physician of the four out of parameter blood sugars. On 01/12/21 at 10:01 AM, Administrative Nurse D verified staff were to notify the physician of out of parameter blood sugars and document interventions taken. The facility's Diabetes- Clinical Protocol policy, dated September 2017, documented the risk of hypoglycemia (low blood sugar) should be considered in any treatment plan as it is a significant and high risk complication of treatment. The physician will order desired parameters for monitoring and reporting information related to blood sugar management. The staff will incorporate such parameters in the Medication Administration Record and care plan. The facility failed to notify R10's physician of out of parameter blood sugars, placing the resident at risk to not have physician direction for his diabetic medications.

The facility had a census of 29 residents. The sample included 12 residents with five reviewed for immunizations. Based on record review and interview, the facility failed to provide current Centers for Disease Control and Prevention (CDC) pneumococcal and influenza vaccine information to make an informed decision for five of five sampled residents, or their representatives, Resident (R)14, R23, R2, R9, R18. Findings included: - On 01/12/21 at 10:00 AM, review of R14, R23, R2, R9, and R18's immunization records documented the use of the CDC's Inactive Influenza Vaccine, What You Need to Know Vaccine Information Statement, dated 08/07/15, but lacked the current fact sheet dated 08/15/19, and the Pneumococcal Polysaccharide Vaccine (PPSV): What you need to Know Vaccine Statement, dated 11/05/15, but lacked the current fact sheet dated 10/30/19. On 01/13/21 at 02:41 PM, Administrative Nursing Staff E verified the facility had not provided the residents, or their representatives, the current information for the administration of influenza and pneumococcal immunizations. The facility's Influenza and Pneumococcal Immunization policy, dated August 2016, documented prior to the vaccination, the resident or their representative, will be provided information and education regarding the benefits and potential side effects of the vaccine, and current information from the CDC will be provided. The facility failed to provide R14, R23, R2, R9, and R18, or their representatives, with the current CDC influenza and pneumococcal immunization information, placing the residents at risk for making uniformed decisions.

The facility had a census of 29 residents. Based on observation, interview, and record review, the facility failed to ensure proper cleaning of one of two upright freezers in the facility kitchen. Findings include: - On 01/07/21 at 12:40 PM, observation in the facility kitchen revealed an upright freezer with one and a half inches of thick frost on each of the three shelves. On 01/12/21 at 02:30 PM, (five days later) observation in the facility kitchen revealed the same upright freezer continued with one and a half inches of thick frost on each of the three shelves. On 01/12/21 at 02:30 PM, Dietary Staff BB verified the freezer needed to be defrosted. On 01/13/21 at 10:31 AM, Administrative Staff A verified dietary staff were to defrost freezers when needed. The facility's Cleaning Instructions for Reach In Refrigerator and Freezer policy, dated 2011, instructed staff to defrost freezer as needed to help maintain airflow throughout the freezer. The facility failed to ensure proper cleaning of one freezer in the facility kitchen, placing the 29 residents in the facility at risk for unhealthy food.