**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 29 residents with 15 residents included in the sample. Based on observation, record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for one Resident (R)20, regarding the use of an electric recliner. Findings included: - Review of Resident (R)20's electronic medical record (EMR) revealed a diagnosis of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. She was dependent on staff for chair-to-bed-to-chair transfers. The inaccurate MDS documented the resident had one injury (except major) fall since the prior assessment. The Functional Abilities Care Area Assessment (CAA), dated 12/19/24, did not trigger. The Fall CAA, dated 12/19/24, documented the resident required staff assistance with cares. The Annual MDS, dated 12/05/24, documented the resident had a BIMS score of four, indicating severe cognitive impairment. She was dependent on staff for chair-to-bed-to-chair transfers. She had one injury (except major) fall since the prior assessment. The comprehensive care plan, revised 11/29/24, lacked staff instruction regarding the resident's use of an electric recliner in her room. Review of the resident's EMR revealed fall assessments, dated 10/28/24 and 12/17/24, which placed the resident at a moderate risk for falls. Fall assessments, dated 04/21/24 and 11/30/24, placed the resident at a high risk for falls. Review of the resident's EMR, revealed the resident had an injury (except major) fall in her room from her recliner on 10/28/24. Staff informed the nurse the resident's electric lift chair with the lift chair in the upper most position and the resident on the floor in front of the electric chair. Upon assessment, the resident had a reddened area to her spine. The resident had no further injuries, was able to move all of her extremities per her normal and her vital signs (VS) were within normal range (WNR). Staff initiated neurology checks (a medical assessment that evaluates the function of a patient's nervous system by testing their mental status, muscle strength, coordination, sensation, reflexes, and other neurological functions), which were all WNR. The interdisciplinary team (IDT) initiated a new intervention to keep the resident's lift chair unplugged when the resident was in the chair to prevent her from raising the chair on her own. Review of the resident's EMR revealed an Electric Recliner Assessment, dated 11/05/24, which documented the resident did not have the physical or cognitive ability to safely operate the electric recliner. No other Electric Recliner Assessments were available in the resident's EMR. Review of the resident's EMR, from 01/12/25 through 02/09/25, revealed the resident required substantial/maximal to dependent staff assistance with chair to bed to chair transfers. Review of the resident's EMR, from 01/12/25 through 02/09/25, revealed the resident required substantial/maximal to dependent staff assistance with going from sitting to standing. On 02/06/25 at 09:35 AM, Certified Medication Aide (CMA) S transferred the resident from her wheelchair to her electric recliner with extensive assistance and the use of the gait belt. The resident was unable to bear weight during the transfer. The electric recliner remained plugged in when the CMA left the room following cares. The controller to the electric recliner rested on the arm of the chair. On 02/06/25 at 10:47 AM, the resident sat in her electric recliner in her room. The electric recliner remained plugged in and the controller to the recliner rested on the arm of the chair. On 02/06/25 at 01:18 PM, Certified Nurse Aide (CNA) N and Licensed Nurse (LN) G transferred the resident from her wheelchair to her bed with extensive assistance and the use of a gait belt. The resident was unable to bear her full weight during the transfer. On 02/06/25 at 09:39 AM, CMA S stated staff were not to unplug the resident's electric recliner. Staff were to use the chair plugged in at all times. CNA S stated the resident was able to bear some weight during transfers but was unable to bear her full weight. On 02/06/25 at 01:18 PM, CNA N stated the resident could only bear minimal weight during transfers. Staff left the resident's electric recliner plugged in all of the time. On 02/06/25 at 01:18 PM, LN G stated the resident was not able to fully bear weight during transfers. LN G was unsure if the resident's electric recliner was to be plugged in or not. On 02/10/25 at 09:03 AM, Administrative Nurse D stated the facility did not complete an Electric Recliner Assessment for this dependent resident upon her admission to the facility. The only Electric Recliner Assessment the facility had was the one completed on 11/05/24. Administrative Nurse D stated the Electric Recliner Assessment should have been completed upon the resident's admission and then quarterly and with significant changes, thereafter. The facility policy for Assessments, revised 11/2024, included: The Electric Recliner Assessment shall be completed with use of the electric recliner initiation then quarterly, and as needed. The facility policy for Electronic Care Plan, revised 12/2020, included: The resident's care plan shall promote quality care and quality of life to attain the highest practical level of independence and dignity to each resident by facilitating communication about the resident's barriers, strengths, voice, choice and needs. The facility failed to develop and implement a comprehensive person-centered care plan for this dependent resident who utilized an electric recliner in her room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 29 residents with 15 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately revise Resident (R) 15's care plan after falls and failed to revise R 11's care plan for pressure ulcer care. This placed the residents at risk for uncommunicated care needs. Findings included: - The Electronic Health Records (EHR) documented R15 had the following diagnoses cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), muscle weakness, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), coronary artery disease (CAD- abnormal condition that may affect the flow of oxygen to the heart), hypertension (HTN-elevated blood pressure), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The 11/04/24 admission Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of 13, which indicated intact cognition and one non-injury fall from 10/30/24 thru 11/04/24. The 11/04/24 Falls Care Area Assessment (CAA) documented R15 was at risk for falls and received antidepressants for diagnosis of major depressive disorder. He has had one non injury fall since admission. He has not had a fall within the last year before admission. He is working with therapy to improve his strength and balance. The 1/19/25 Quarterly MDS documented a BIMS of 12, which indicated moderate cognitive impairment and two or more noninjury falls. The 02/05/25Care Plan documented the following fall interventions: 11/2/24 ensure R15 had his call light within reach and encourage him to use it to ask for assistance. 11/2/24 move R15's room closer to the nurse's station. 11/10/24 transfer pole to be placed near R15's bed on his left side. 11/24/24 transfer bar and grab bars in resident's bathroom. 12/07/24 fall lacked an intervention on the care plan. 12/13/24 a handlebar next to resident's closet. 12/15/24 bed in the lowest position. 12/20/24 nonskid strips on the floor. 01/25/25 computed tomography scan (CT- a noninvasive medical imaging procedure that uses X-rays to create detailed pictures of the inside of the body) of his head in order received to check for suspected neuro deficit to determine if neuro consultation is needed. Record review revealed this had not been completed. They Fall Risk Assessment documented R15 fluctuated between moderate to high risk for falls. The Progress Note on 11/02/24 at 01:13 AM documented a non-injury fall. The Fall Report documented a root cause analysis that he lost his balance and an intervention of a call light within reach. The Progress Note on 11/02/24 at 11:10 AM documented a non-injury fall. The Fall Report documented a root cause analysis confusion, post hospitalization and staff moved his room closer to the nurse's station. The Progress Note on 11/10/24 at 06:32 AM documented a non-injury fall. The Fall Report documented a root cause analysis that he lost his balance with an intervention of a transfer pole. The Progress Note on 11/24/24 at 03:43 AM documented a non-injury fall. The Fall Report documented a root cause analysis that he went to the bathroom unattended. with an intervention of a transfer pole and bar in the bathroom. The Progress Note on 12/07/24 at 01:05 AM documented a non-injury fall. There was no Fall Report that documented a root cause analysis, and it lacked an intervention. The Progress Note on 12/13/24 at 05:30 PM documented a fall that sent him to the ER. The Fall Report documented a root cause analysis that he lost his balance with an intervention of nonskid strips and a fall mat. The fall on 12/15/24 lacked a Progress Note. The Fall Report documented no root cause analysis, but an intervention of bed in lowest position. The Progress Note on 1/20/25 09:35 PM documented a non-injury fall. He was wearing slippery socks and got up to go to the bathroom. The Fall Report documented a root cause analysis that he lost his balance ant they put strips on the floor. The Progress Note on 1/25/25 at 10:46 PM documented a non-injury fall. The Fall Report documented a root cause analysis of suspected [NAME] deficit (an impairment or loss of function in the nervous system, affecting the brain, spinal cord, nerves, or muscles). During an observation on 02/05/25 at 09:26 AM, R15 was lying in bed the call light was on his over bed table that was several feet out of reach. He was asked where it was, he stated the call light was down there somewhere and pointed toward the head of the bed. There was no transfer bar beside his bed. During an observation on 02/05/25 at 01:58 PM, R15 sat in his recliner with no call light within reach. During an interview on 02/10/25 at 10:19 AM, Certified Nurse Aide (CNA) M reported that she looked at the care plan to know how to care for a resident. She reported that R15 had a fall mat and they do frequent checks. During an interview on 02/10/25 at 12:49 PM, Licensed Nurse (LN) G reported that interventions for falls was group effort. Confirmed there was not a transfer pole beside his bed in his room. During an interview on 02/10/25 at 11:20 AM, Administrative Nurse D was notified that R15 did not have his call light, she reported he should have his call light. She would fix that. She confirmed that the transfer pole was not in his room, it is on back order, also confirmed that R15 did not have the CT scan yet. Administrative D confirmed that there must be an appropriate intervention for each fall to keep the resident safe. The facility's Falls Management policy dated 12/2018, revised 12/2020 documented the plan of care was to address individualized resident focus, goals, and interventions directed towards reducing the resident's risk if injury and potential recurrence of falls. The resident's plan of care was to be reviewed and revised with each fall occurrence and a new intervention or interventions implemented. The facility failed to revise R15's care plan after falls. This placed the resident at risk for uncommunicated care needs. This deficient practice had the potential to have a negative effect on the overall physical and psychosocial well-being of the resident in the facility. - Resident (R)11's Electronic Health Record (EHR) revealed diagnoses included diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), morbid obesity (serious condition of excessive body weight that seriously impacts the health and well-being), and chronic kidney disease (CKD- a long-term condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood). The 04/25/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. R11's total severity score of zero, indicating no depression. R11 had a Foley catheter (tube inserted into the bladder to drain urine into a collection bag) in place and was always incontinent of bowel. R11 required set up assistance for oral care and eating. R11 was dependent on staff assistance with toileting hygiene, dressing, transfers, and extensive staff assistance with bed mobility. R11 had a chair cushion and a pressure reducing mattress. No pressure areas at that time. The 04/25/24 Pressure Ulcer/Injury Care Area Assessment (CAA) documented R11 had a Foley catheter (tube inserted into the bladder to drain urine into a collection bag) in place and was always incontinent of bowel. He had a mild risk of developing a pressure wound. He had a low air loss mattress. The 02/05/25 Care Plan documented. R11 had a stage two pressure ulcer to his buttock and directed the following interventions: Pressure reducing mattress. Wheelchair cushion when in wheelchair. Given multivitamin. Follow treatment orders. Registered dietician to consult. The 01/25/25 Physician Orders included an order for wound care to evaluate and treat for a Keloid (an overgrown scar) to R11's buttocks. The wound care provider note with a date of service 01/16/25, identified the wound a stage two pressure ulcer. The 01/30/25 Skin Condition Note noted shearing to an area of scar tissue that had reoccured along with shearing to the inner right buttock.The assessment documented R11 had a low air loss mattress and a cushion in his recliner. During an observation on 02/06/25 at 08:02 AM, R11 sat in his motorized scooter next to his room and waited to be assisted to bed. His motorized scooter, his recliner, and his manual high back wheelchair did not have a seat cushion. During an interview on 02/10/25 11:08 AM, R11 reported he did not have a cushion for his recliner, wheelchair, or motorized scooter. He reported he tried a cushion a couple months ago for about an hour or an hour and a half and it did not work. During an interview on 02/10/25 at 10:32 AM, Certified Medication Aide (CMA) U reported that R11 did not have a cushion and did not want a cushion. During an interview on 02/10/25 at 12:49 PM, Licensed Nurse (LN) G reported that R11 did not have a cushion in his recliner. During an interview on 02/11/24 at 8:31AM, Administrative Nurse D confirmed the care plan for R11 was incorrect, he did not have a cushion in his recliner, his high back wheelchair, or either of his motorized scooters, The facility's Wound Prevention and Management policy last updated 12/2018, documented the purpose of the policy was to develop interventions to decrease the incidence of residents who develop pressure ulcers. The policy documented residents that utilize a wheelchair will have a pressure reducing cushion. The facility's Electronic Care Plans policy revised 12/2020, documented that the facility was to develop a plan of care to attain and maintain the highest practical level of physical, psychological, emotional, and social wellbeing for each resident in the facility. The resident's person-centered plan of care was an active working document that reflects the care needs and resident's voice. The facility failed to revise R11's care plan to reflect the care need for the pressure area. This placed the resident at risk for uncommunicated care needs. This deficient practice had the potential to have a negative effect on the overall physical and psychosocial well-being of the resident in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 29 residents with 15 residents sampled, including two residents reviewed for skin issues. Based on observation, interview and record review, the facility failed to leave the shoes off one Resident (R)13, regarding the resident having abrasions (process of scraping or wearing something away) on the second toe of the right foot and the second and third toe of the left foot. Findings included: - Review of Resident (R)13's electronic medical record (EMR) revealed the following diagnoses: Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impairment. He required substantial to maximal staff assistance with putting on and taking off his footwear. The Functional Abilities Care Area Assessment (CAA), dated 09/19/24, documented the resident worked with restorative and required staff assistance with Activities of Daily Living (ADL) cares, at times. The Pressure Ulcer CAA, dated 09/19/24, documented staff would perform skin assessments per facility protocol. The Medicare Five-Day MDS, dated 01/05/25, documented the resident had a BIMS score of 12, indicating moderately impaired cognition. He required supervision to touching assistance of staff with lying to sitting to standing and walking 150 feet. The care plan for skin, revised 01/05/25, instructed staff the resident had skin abrasions (process of scraping or wearing something away) to his second and third toe of his left foot and the second toe of his right foot. Staff were to leave the resident's shoes off and only have him wear non-skid socks until the abrasions were healed. Review of the resident's EMR revealed the following physician's orders: Apply skin preparation (a skin disinfectant) to the resident's bilateral (both sides) toes, twice daily (BID), until healed, ordered 01/05/25. Resident to only wear non-skid socks until bilateral toe abrasions are healed, ordered 01/05/25. Review of the resident's EMR revealed a nursing note which documented: red abrasions to bilateral toes with a new order in place. Intervention for resident to only wear non-skid socks until healed. Staff are aware of the new intervention. On 02/05/25 at 09:03 AM, the resident sat in his wheelchair in the commons area. The resident wore white Velcro tennis shoes. On 02/05/25 at 02:31 PM, the resident sat in the recliner in his room. The resident wore white Velcro tennis shoes. On 02/06/25 at 08:05 AM, the resident sat at the dining room table and wore his white Velcro tennis shoes. On 02/10/25 at 10:07 AM, the resident sat in the recliner in his room and wore his white Velcro tennis shoes. On 02/10/25 at 11:19 AM, Licensed Nurse (LN) H entered the resident's room to administer the ordered treatment to the resident bilateral toes. LN H removed the resident's Velcro tennis shoes and socks to reveal his right foot, second toe wound measured 0.5 by 0.4 centimeters (cm), and had a tannish scab (a dry, rough protective crust that forms over a cut or wound during healing) covering the entire wound bed. The left foot second toe wound measured 1.0 by 0.5 cm and had a dark red scab covering the entire wound bed. The left foot third toe wound measured 0.3 by 0.2 cm and had a reddish colored scab covering the entire wound bed. The resident tolerated the treatment without signs or symptoms of pain or discomfort. On 02/06/25 at 03:37 PM, Certified Medication Aide (CMA) T stated the resident wore his shoes every day. On 02/06/25 at 03:39 PM, Certified Nurse Aide (CNA) S stated the resident currently had abrasions on some of his toes, but he was able to wear shoes. On 02/10/25 at 10:09 AM, CNA M stated the resident was not to wear tennis shoes due to abrasions on his toes. Staff were to only put non-skid socks on him. On 02/10/25 at 10:17 AM, Licensed Nurse (LN) H stated the resident was not to wear shoes due to the abrasions on his toes. On 02/10/25 at 10:40 AM, Administrative Nurse D stated the abrasions on the resident's toes were caused by ill-fitting shoes which have been removed from the facility by family. It was the expectation for staff to not put shoes on him until the areas to his toes were healed. The facility policy for wound Prevention and Management, revised 12/2018, included: If identified at risk or with actual alterations in skin integrity of feet, footwear will be addressed for appropriateness. The facility failed to leave the shoes off Resident (R)13 as ordered due to the abrasions on the second toe of the right foot and the second and third toe of the left foot.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 29 residents with 15 residents sampled, including four residents reviewed for pressure ulcers (PU). Based on interview, record review and observation, the facility failed to care and services to promote the healing of an existing PU for one Resident (R)13, regarding a stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed) PU behind the left ear and R 11, for failure of ensuring the resident had a pressure reducing cushion to his wheelchair. Findings included: - Review of Resident (R)13's electronic medical record (EMR) revealed a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. He used a walker and a wheelchair for locomotion. He was at risk for the development of pressure ulcers (PU) with no unhealed PUs at the time of the assessment. The Pressure Ulcer Care Area Assessment (CAA), dated 09/19/24, documented the resident had a mild risk for the development of PUs. The Medicare Five-Day MDS, dated 01/05/25, documented the resident had da BIMS score of 12, indicating moderately impaired cognition. He required supervision to touching assistance of staff to ambulate 150 feet. He was at risk for the development of PUs with no unhealed PUs at the time of the assessment. The skin care plan, revised 12/13/24, instructed staff the resident was at risk for skin breakdown and had a stage II ((partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed) PU to his left ear. Review of the resident's EMR revealed BRADEN assessments (a tool used to assess a patient's risk of developing pressure ulcers), which placed the resident at a moderate risk for the development of PUs completed on, 12/15/24 and 12/30/24. Review of the resident's EMR revealed the following physician's orders: Cleanse the PU behind the left ear with hypochlorous acid (a disinfective and sanitizer), apply Triple Antibiotic Ointment (TAO-a medicated ointment), and cover the wound with a gauze pad (a thin, loosely woven fabric pad), every day (QD), until healed, ordered 01/22/25. Pad the earpiece of resident's glasses and oxygen tubing, every day, related to PU behind left ear, ordered 01/22/25. On 02/06/25 at 08:05 AM, the resident sat in his wheelchair at the dining room table. The resident wore his glasses, but lacked padding behind his left ear, as ordered. On 02/06/25 at 10:09 AM, Licensed Nurse (LN) G entered the resident's room to do the PU treatment to the resident's left ear. The resident wore his glasses, but lacked padding behind his left ear, as ordered. On 02/10/25 at 10:07 AM, the resident sat in the recliner in his room. The resident wore his glasses, but lacked padding behind his left ear, as ordered. On 02/06/25 at 03:37 PM, Certified Medication Aide (CMA) T the resident was to have padding behind his left ear due to a PU. CMA T stated she was unsure why the padding was not in place. On 02/06/25 at 03:39 PM, CMA S stated the resident was to have padding behind his left year, but the padding was in place at that time. On 02/10/25 at 10:09 AM, Certified Nurse Aide (CNA) M confirmed the padding to the resident's glasses was not in place. On 02/06/25 at 10:09 AM, Licensed Nurse (LN) G stated the PU to the back of the resident's left ear was caused by oxygen tubing and his glasses. The resident no longer used the oxygen but continued to wear his glasses. The resident was to have padding behind his left ear while wearing his glasses but confirmed the padding was not always in place. On 02/10/25 at 10:40 AM, Administrative Nurse D stated it was the expectation for the staff to have the padding in place to the resident's left ear until the wound healed. The facility policy for wound Prevention and Management, revised 12/2018, included: The facility shall develop interventions to decrease the incidence of residents who develop pressure ulcers. The plan of care will address problems, goals, and interventions directed towards prevention of pressure ulcers and/or skin integrity concerns identified. The facility failed to provide care and services to promote the healing of an existing PU, regarding padding to the back of this resident's left ear. - Resident (R)11's Electronic Health Record (EHR) revealed diagnoses included diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), morbid obesity (serious condition of excessive body weight that seriously impacts the health and well-being), and chronic kidney disease (CKD- a long-term condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood). The 04/25/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. R11's total severity score of zero, indicating no depression. R11 had a Foley catheter (tube inserted into the bladder to drain urine into a collection bag) in place and was always incontinent of bowel. R11 required set up assistance for oral care and eating. R11 was dependent on staff assistance with toileting hygiene, dressing, transfers, and extensive staff assistance with bed mobility. R11 had chair cushion and a pressure reducing mattress. No pressure areas at that time. The 04/25/24 Pressure Ulcer/Injury Care Area Assessment (CAA) documented R11 had a Foley catheter (tube inserted into the bladder to drain urine into a collection bag) in place and was always incontinent of bowel. He had a mild risk of developing a pressure wound. He had a low air loss mattress. The 02/05/25 Care Plan documented. R11 had a stage two pressure ulcer to his buttock and directed the following interventions: Pressure reducing mattress. Wheelchair cushion when in wheelchair. Give multivitamin. Follow treatment orders. Registered dietician to consult. The 01/15/25 Physician Orders included an order for wound care to evaluate and treat for a Keloid to R11's buttocks. The 01/16/25, wound care provider note identified the wound on his buttock as a stage two pressure ulcer. The Wellness Meeting Note dated 1/16/2025 at 02:25 PM, documented R11 was working with Wound Care Plus to assess his skin flap area on buttock that he has had for years to see if there was anything else to relieve pressure/pain to that area. The 01/30/25 Skin Condition Note an area of scar tissue to the right buttock that had shearing was reoccurring. Also had shearing to inner buttock. Assessment documented a low air loss mattress and a cushion in his recliner. During an observation on 02/06/25 at 08:02 AM, R11 sat in his motorized scooter next to his room and waited to be assisted to bed. His motorized scooter, his recliner, and his manual high back wheelchair did not have a seat cushion. During an interview on 02/10/25 11:08 AM, R11 reported he did not have a cushion for his recliner, wheelchair, or motorized scooter. He reported he tried a cushion a couple months ago for about an hour or an hour and a half and it did not work. During an interview on 02/10/25 at 10:32 AM, Certified Medication Aide (CMA) U reported that R11 did not have a cushion and did not want a cushion. During an interview on 02/10/25 at 11:20 AM, Administrative Nurse D acknowledged that wound measurements had not been done and wound tracking and measuring was not up to standards, she was taking over wounds and was working on getting it in order. During an interview on 02/10/25 at 12:49 PM, Licensed Nurse (LN) G reported that R11 does not have a cushion in his recliner. During an interview on 02/11/24 at 8:31AM, Administrative Nurse D confirmed the care plan for R11 was incorrect, he did not have a cushion in his recliner, his high back wheelchair, or either of his motorized scooters. The facility's Wound Prevention and Management policy last updated 12/2018, documented the purpose of the policy was to develop interventions to decrease the incidence of residents who develop pressure ulcers. The policy documented residents that utilize a wheelchair will have a pressure reducing cushion. The facility's Electronic Care Plans policy revised 12/2020, documented that the facility was to develop a plan of care to attain and maintain the highest practical level of physical, psychological, emotional, and social wellbeing for each resident in the facility. The resident's person-centered plan of care was an active working document that reflects the care needs and resident's voice. The facility failed to properly assess the pressure ulcer and revise R11's care plan to reflect the care need for the pressure area. This placed the resident at risk for uncommunicated care needs.

The facility reported a census of 29 residents with 15 residents selected for review. Based on observation, interview, and record review, the facility failed to keep the residents free from unnecessary drugs when they gave an excessive dose of a medication without provider notification that medications were held, this caused adverse complications for resident (R) 17 and R134. This placed the residents at risk for future adverse complications. - Resident (R) 17's Electronic Health Record (EHR) revealed diagnoses, which included hypertension (HTN-elevated blood pressure) and dementia (progressive mental disorder characterized by failing memory, confusion). The 01/16/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. R17 required set up assistance for eating and required supervision or touching assistance with activities of daily living (ADLs) to include dressing, toileting hygiene, footwear, personal hygiene and standing. R17 had one injury fall. Review of the 02/06/24 Care Plan documented antihypertensive (class of medication used to treat high blood pressure) medications had a BBW. Review of the Physician Orders on 02/06/25 documented the following medications: Metoprolol Succinate (medication that treats high blood pressure) extended release 100 mg one tablet by mouth one time a day for hypertension. Start date 05/03/23. Clonidine HCl (medication that treats high blood pressure) Oral Tablet 0.1 MG one tablet by mouth three times a day hypertension. Start date 05/05/23. End date 01/21/25. Instructions to hold for systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) < (less than)130. Diltiazem HCl (medication that treats high blood pressure) extended-release tablet 120 mg. Give 1 tablet by mouth one time a day for hypertension. Start date 01/18/24. Instructions to hold for pulse < 60. Lisinopril (medication that treats high blood pressure) 20 mg one tablet by mouth one time a day for hypertension. Start date 05/21/24. Instructions to hold for SBP < 130. Clonidine HCl oral tablet 0.1 mg one tablet by mouth two times a day for hypertension. Start date 01/21/25. Review of the EMAR revealed: Diltiazem was held two times in August without provider notification. Diltiazem was held four times in October 2024 without provider notification. Diltiazem was held four times in November 2024 without provider notification. Diltiazem was held three times in December 2024 without provider notification. Diltiazem was held three times in January 2025 without provider notification. Lisinopril was held one time in October 2024 without provider notification. Lisinopril was held four times in November 2024 without provider notification. Metoprolol was held two times in August 2024 without provider notification. Metoprolol was held three times in October 2024 without provider notification. Metoprolol was held four times in November 2024 without provider notification. Metoprolol was held three times in December 2024 without provider notification. Metoprolol was held three times in January 2025 without provider notification. Clonidine HCl 0.1 mg three times a day was held 54 times in August without provider notification. Clonidine HCl 0.1 mg three times a day was held 37 times in September without provider notification. Clonidine HCl 0.1 mg three times a day was held 53 times in October 2024 without provider notification. Clonidine HCl 0.1 mg three times a day was held 56 times in November 2024 without provider notification. Clonidine HCl 0.1 mg three times a day was held 56 times in December 2024 without provider notification. Clonidine HCl 0.1 mg three times a day was held 30 times in January 2025. It was decreased to Clonidine HCl 0.1 mg two times a day on 01/21/25 and was held five more times in January without provider notification. The September EMAR had B/P documented from 94/67 to 187/103 without a documented assessment or provider notification. The October EMAR had B/P documented from 91/47 to 172/83. The November EMAR had B/P documented from 101/54 to 173/99. The December EMAR had B/P documented from 90/42 to 176/84. The January EMAR had B/P documented as low as 99/49 to 180/81. Review of Progress note from 08/01/24 to 02/06/25 revealed documentation of the following B/P with no documentation of assessment or physician notification. On 08/05/24 at 04:29 PM a Progress Note documented a B/P of 93/48. On 08/06/24 at 02:27 PM a Progress Note documented a B/P of 92/57. On 08/11/24 at 01:19 PM a Progress Note documented a B/P of 87/41. On 09/03/24 at 01:34 PM a Progress Note documented a B/P of 90/57. On 10/07/24 at 02:06 PM a Progress Note documented a B/P of 93/46. On 10/20/24 at 02:32 PM a Progress Note documented a B/P of 93/49. On 11/07/24 at 01:28 PM a Progress Note documented a B/P of 97/45. On 11/14/24 at 01:39 PM a Progress Note documented a B/P of 94/81. On 11/15/24 at 01:17 PM a Progress Note documented a B/P of 98/79. On 11/17/24 at 07:58 AM a Progress Note documented a B/P of 91/54. On 11/17/24 at 11:20 AM a Progress Note documented a B/P of 97/47. On 11/20/24 at 01:16 PM a Progress Note documented a B/P of 94/56 On 11/26/24 at 07:16 PM a Progress Note documented a B/P of 91/50. On 11/27/24 at 07:08 Pm a Progress Note documented a B/P of 93/76. On 11/29/24 at 02:02 PM a Progress Note documented a B/P of 95/54. On 11/30/24 at 07:23 PM a Progress Note documented a B/P of 96/53. On 12/06/24 at 07:09 PM a Progress Note documented a B/P of 92/44. On 12/10/24 at 02:02 PM a Progress Note documented a B/P of 91/63. On 12/19/24 at 01:05 PM a Progress Note documented a B/P of 90/56. On 12/23/24 at 01:09 PM a Progress Note documented a B/P of 79/51. On 01/07/25 at 01:32 PM a Progress Note documented a B/P of 93/52. On 01/12/25 at 03:17 PM a Progress Note documented a B/P of 90/54. On 01/20/25 at 11:58 AM a Progress Note documented a B/P of 98/57. On 01/21/25 at 01:02 PM a Progress Note documented a new order from the provider to decrease Clonidine to BID (with same parameters) due to med being held so often. During an interview on 02/10/25 at 12:39 PM, Administrative Nurse D revealed it was her expectation that staff would notify the provider if a medication was held or not given for any reason and that staff would document provider notification in the EHR. During an interview on 02/10/25 at 12:49 PM, Licensed Nurse (LN) G stated she notified the provider every time she held a medication and documented it in the EHR. When a medication is held, the provider should always be notified, During an interview on 02/10/25 at 03:58 PM, LN H stated he would notify the physician every time he held a medication and document it in the EHR. The facility lacked a policy on physician notification. The failed to keep the residents free from unnecessary drugs when they gave an excessive dose of an antihypertensive medication without notifying the provider of holding medications, this caused adverse complications for resident (R) 17. This placed the resident at risk for future adverse complications. - Resident (R) 134's Electronic Health Record (EHR) revealed diagnoses, which included diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) The admission Minimum Data Set (MDS) was not completed. Review of the 02/06/24 Care Plan documented R134 had a risk for hypoglycemia and hyperglycemia. Review of the Physician Orders on 02/06/25 documented the following medications: Lantus Subcutaneous Solution 100 units/ml (Insulin Glargine) (medication to lower blood sugar levels) 40 units subcutaneously two times a day related to diabetes. Started on 02/04/25. Novolog Flex Pen Subcutaneous Solution Pen-injector 100 units/ml (Insulin Aspart) (medication to lower blood sugar levels) 10 units subcutaneously before meals related to diabetes type two. Start date 02/04/25. Instructions to hold if R134 did not eat or if blood sugar was less than 110. Review of the EMAR revealed Novolog was held on the days and time following times: On 02/04/25 the morning dose was held for a blood sugar level of 90. On 02/05/25 the morning dose was held for a blood sugar level of 63. On 02/05/25 the supper dose was held for a blood sugar level of 88. On 02/06/25 the morning dose was held for a blood sugar level of 87. On 02/07/25 the supper dose was held for a blood sugar level of 99. On 02/08/25 the morning dose was held for a blood sugar level of 86. On 02/09/25 the morning dose was held for a blood sugar level of 68. On 02/09/25 the supper dose was held for a blood sugar level of 94. On 02/10/25 the morning dose was held for a blood sugar level of 72. Review of Progress note from 02/03/25 to 02/06/25 revealed the provider was notified only on the 02/05/25 that the insulin dose was held. During an interview on 02/10/25 at 12:39 PM, Administrative Nurse D revealed it was her expectation that staff would notify the provider if a medication was held or not given for any reason and that staff would document provider notification in the EHR. During an interview on 02/10/25 at 12:49 PM, Licensed Nurse (LN) G stated she notified the provider every time she held a medication and documented it in the EHR. When a medication is held, the provider should always be notified. During an interview on 02/10/25 at 03:58 PM, LN H stated he would notify the physician every time he held a medication and document it in the EHR. The facility lacked a policy on physician notification. The failed to keep the residents free from unnecessary drugs when they failed to notify the provider that insulin required to be held nine times in ten days, this had the risk for adverse complications for resident (R) 17. This placed the resident at risk for future adverse complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Review of Resident (R)18's electronic medical record (EMR) revealed a diagnosis of major depressive disorder (major mood disorder which causes persistent feelings pf sadness). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. He received antipsychotic ((medications used to treat psychosis (any major mental disorder characterized by a gross impairment perception)), an antibiotic (medication used to treat infections) and an antiplatelet (medication used to prevent platelets from sticking together and decrease your body ' s ability to form blood clots) during the assessment period. The Psychotropic Drug Use Care Area Assessment (CAA), documented the resident's physician would review and make adjustments to the resident's psychoactive medications, as needed. The Quarterly MDS, dated 01/02/25, documented the staff assessment for cognition revealed modified independence with daily decision making. He received antipsychotic, antidepressant, antiplatelet and anticonvulsant (medications used to treat seizures) medications during the assessment period. The care plan, revised 09/27/24, instructed staff the resident took antidepressant medication due to being tearful at times. Staff were to allow the resident to express his feelings without judgement or criticism. Review of the resident's EMR revealed the following physician's order: Venlafaxine (an antidepressant medication), 75 milligrams (mg), by mouth (po), every day (QD), for MDD, ordered, 07/03/24. On 02/10/25 at 12:30 PM, Administrative Nurse D stated the 07/09/24 MDS, which lacked documentation of an antidepressant medication being given during the assessment period, was inaccurate. The facility utilized the Resident Assessment Instrument (RAI) for the completion of MDSs. The facility failed to complete an accurate MDS for this dependent resident who received antidepressant medication. - Review of Resident (R)20's electronic medical record (EMR) revealed a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. She used a wheelchair for locomotion and was dependent on staff for chair to bed to chair transfers. She had one injury fall (except major) since the prior assessment. The Functional Abilities Care Area Assessment (CAA), dated 12/19/24, did not trigger. The Fall CAA, dated 12/19/24, documented the resident required staff assistance with all cares. The Annual MDS, dated 12/05/24, documented the resident had a BIMS score of one, indicating severe cognitive impairment. She used a wheelchair for locomotion and was dependent on staff for chair to bed to chair transfers. She had one injury fall (except major) since the prior assessment. The care plan, revised 11/29/24, instructed staff to use two staff and a gait belt while transferring the resident. Review of the resident's EMR, revealed the following Fall Assessments which placed the resident at a moderate risk for falls: 12/17/24 and 10/28/24. Review of the resident's EMR, revealed the following Fall Assessments which placed the resident at a high risk or falls: 11/30/24 and 04/21/24. Review of the resident's EMR, revealed the resident had an injury fall (except major) on 10/28/24, when she raised her electric recliner up and fell forward out of the chair. She received a reddened area to her mid, upper back. The resident's EMR lacked documentation of a fall for this resident between the dates of 12/05/24 and 12/19/24. On 02/10/25 at 09:03 AM, Administrative Nurse D stated the 12/19/24 MDS was inaccurate as the resident did not have a fall after 10/28/24. The facility utilized the Resident Assessment Instrument (RAI) for the completion of MDSs. The facility failed to complete an accurate MDS for this dependent resident with falls. The facility reported a census of 29 residents with 15 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the [NAME] Data Set for three residents: Resident (R) 15 and R20 related to falls; R18 related to antidepressant medication. This placed the residents at risk for uncommunicated care needs. Findings included: - The Electronic Health Records (EHR) documented R15 had the following diagnoses that included cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), coronary artery disease (CAD- abnormal condition that may affect the flow of oxygen to the heart), hypertension (HTN-elevated blood pressure), muscle weakness, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The 11/04/24 admission Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of 13, which indicated intact cognition and one non-injury fall from 10/30/24 thru 11/04/24. The 11/04/24 Falls Care Area Assessment (CAA) documented R15 was at risk for falls and received antidepressants for diagnosis of major depressive disorder. He has had one non injury fall since admission. He has not had a fall within the last year before admission. He is working with therapy to improve his strength and balance. The 11/2/24 at 01:13 AM Progress Note revealed staff found R15 on the floor in his room leaning back against his closet. R15 stated he was looking for his pants. The 11/2/24 at 11:10AM Progress Note revealed the nurse saw R15 in his room on the floor inside his door facing the door. He was unable to explain what happened. During an observation on 02/05/25 at 01:58 PM, R15 sat in his recliner with no call light within reach, The nurse was not outside the room at the nurses' station. During an interview on 02/10/25 at 11:20 AM, Administrative Nurse D confirmed that the MDS was incorrect. The facility utilized the Resident Assessment Instrument (RAI) for the completion of MDSs. The facility failed to accurately complete the MDS for (R)15 related to falls. This placed the resident at risk for uncommunicated care needs. - The Electronic Health Records (EHR) documented Resident (R) 1 had the following diagnoses that included spastic hemiplegia affecting left side (that causes muscle tightness and involuntary contractions in the limbs and extremities on one side of the body), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), seizure (violent involuntary series of contractions of a group of muscles), The 11/21/24 Annual Minimum Data Set (MDS) documented R1 had a brief interview for mental status (BIMS) of 12, which indicated intact cognition and was always incontinent of bowel and bladder also documented that he had a restorative program for amputation/prosthesis care and splint care six days out of the seven days in the look back period of 11/16/24 to 11/21/24. The 11/21/24 Incontinence Care Area Assessment (CAA) documented R1 was always incontinent of bowel and bladder. The 02/06/25 Care Plan documented a restorative program for an ankle-foot orthotic (AFO- a custom-made brace that supports the foot, ankle, and lower leg) to the left leg while awake and a left hand splint at night. Also, a passive range of motion program before staff put on the splint and after staff removed the splint. Staff documented R1 wore the leg brace every day in the last 30 days except 1/10/25, 1/11/24, 1/12/25, 1/13/25, and 1/24/25. The 02/06/25 Care Plan documented R1 was incontinent at times, he used a urinal and a bed pan. The bowel and bladder task record for the time prior to the MDS documented R1 was continent of bladder six times and incontinence nine times from 11/15/24 to 11/21/24. It also documented that R1 was continent of bowel on 11/16/24 and 11/18/24, The Progress Notes on 8/14/2024 at 11:30 AM documented that R1 needed a referral for an appointment at Progressive Prosthetics and Orthotics in [NAME], Mo for a new AFO brace and shoes as his brace did not fit him properly anymore. The Progress Notes on 8/20/2024 at 01:34 PM documented Dr. [NAME] saw R1 and was to send the referral to Progressive Prosthetics and Orthotics for R1 to see about a new AFO brace and shoes. No new orders received at this time. The Progress Notes from 11/15/14 to 11/21/24 revealed R1 was sometimes continent of bowel and bladder during this time. The 1/31/25 at 2:28 PM Restorative Aide Note documented a program of a left hand splint to be put on at night and off in the morning and left leg AFO to be worn daily- put on in morning and off at night. Restorative Aide documented that R1 was doing well with program, he was able to complete all task, and was wearing the splints as ordered. Also documented he participated actively, did not refuse. During an observation on 02/05/25 at 02:08 PM, R1 sat in the dining area in his wheelchair and watched television, His legs were wrapped, and he had no brace or AFO on his left leg. During an interview on 2/06/25 at 02:41 PM, Certified Medication Aide (CMA) S verified that R1 can be continent of bowel and bladder, but that he has urgency. She also stated that he had not worn his brace in a while because it was too small and he needed a new one. Unable to remember how long. During an interview on 02/10/25 10:32 AM, CMA U confirmed that R1 did not have an amputation or prosthetic, and R1's AFO was too small for him and that they were to get a new one for him. Also confirmed that R1 could let you know that he has to toilet when he wanted to go. During an interview on 02/10/25 at 11:20 AM, Administrative Nurse D confirmed that R1 was sometimes continent of bowel and bladder, and he did notify staff that he needed to go but had urgency so sometimes they didn't make it in time. Administrative Nurse D confirmed that R1 did not have an amputation or prosthetic, and R1's AFO was too small for him. They were working with insurance to get a new one. Confirmed that it should not have been documented that the program was done, because it couldn't be done. She took over as the MDS Coordinator and has been working on fixing thing. The facility utilized the Resident Assessment Instrument (RAI) for the completion of MDSs. The facility failed to accurately complete the MDS for (R)1 related to continence status and restorative care. This placed the resident at risk for uncommunicated care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 29 residents with 15 residents selected for review. Based on observation, interview, and record review, the facility failed to identify, implement, and reevaluate fall prevention interventions to prevent falls including failing to provide a call light within reach for Resident (R) 15, when staff preformed unsafe transfers and failed to follow the care plan for R20, and failed to follow the care plan by failing to provide the call light within reach R17 and R18. This placed the residents at risk for falls with injury. Findings included: - The Electronic Health Records (EHR) documented R15 had the following diagnoses that included cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), muscle weakness, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), coronary artery disease (CAD- abnormal condition that may affect the flow of oxygen to the heart), hypertension (HTN-elevated blood pressure), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The 11/04/24 admission Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of 13, which indicated intact cognition and one non-injury fall from 10/30/24 thru 11/04/24. The 11/04/24 Falls Care Area Assessment (CAA) documented R15 was at risk for falls and received antidepressants for diagnosis of major depressive disorder. He has had one non injury fall since admission. He has not had a fall within the last year before admission. He is working with therapy to improve his strength and balance. The 1/19/25 Quarterly MDS documented a BIMS of 12, which indicated moderate cognitive impairment and two or more noninjury falls. The 02/05/25 Care Plan documented the following interventions: 11/2/24 ensure R15 had his call light within reach and encourage him to use it to ask for assistance. 11/2/24 move R15's room closer to the nurse's station. 11/10/24 transfer pole to be placed near R15's bed on his left side. 11/24/24 transfer bar and grab bars in resident's bathroom. 12/07/24 fall lacked an intervention on the care plan. 12/13/24 handlebar next to resident's closet. 12/15/24 his bed in the lowest position. 12/20/24 nonskid strips on the floor. 01/25/25 computed tomography scan (CT- a noninvasive medical imaging procedure that uses X-rays to create detailed pictures of the inside of the body) of his head in order received to check for suspected neuro deficit to determine if neuro consultation is needed. The Fall Risk Assessment for R15 documented between 11/02/24 and 02/08/25 documented scores between 9 and 22. Which indicated R15 was moderate to high risk for falls. The Progress Note on 11/02/24 at 01:13 AM documented a non-injury fall. The Fall Report documented a root cause analysis that he lost his balance and an intervention of a call light within reach. The Progress Note on 11/02/24 at 11:10 AM documented a non-injury fall. The Fall Report documented a root cause analysis confusion, post hospitalization and staff moved his room closer to the nurse's station. The Progress Note on 11/10/24 at 06:32 AM documented a non-injury fall. The Fall Report documented a root cause analysis that he lost his balance with an intervention of a transfer pole. The Progress Note on 11/24/24 at 03:43 AM documented a non-injury fall. The Fall Report documented a root cause analysis that he went to the bathroom unattended. with an intervention of a transfer pole and bar in the bathroom. The Progress Note on 12/07/24 at 01:05 AM documented a non-injury fall. There was no Fall Report that documented a root cause analysis, and it lacked an intervention. The Progress Note on 12/13/24 at 05:30 PM documented a fall that sent him to the ER. The Fall Report documented a root cause analysis that he lost his balance with an intervention of nonskid strips and a fall mat. The fall on 12/15/24 lacked a Progress Note. The Fall Report documented no root cause analysis, but an intervention of bed in lowest position. The Progress Note on 1/20/25 09:35 PM documented a non-injury fall. He was wearing slippery socks and got up to go to the bathroom. The Fall Report documented a root cause analysis that he lost his balance ant they put strips on the floor. The Progress Note on 1/25/25 at 10:46 PM documented a non-injury fall. The Fall Report documented a root cause analysis of suspected [NAME] deficit (an impairment or loss of function in the nervous system, affecting the brain, spinal cord, nerves, or muscles). During an observation on 02/05/25 at 09:26 AM, R15 was lying bed, the call light was on his over bed table that was several feet out of reach. He was asked where it was, he stated the call light was down there somewhere and pointed toward the head of the bed. There was no transfer bar beside his bed. During an observation on 02/05/25 at 01:58 PM, R15 sat in his recliner with no call light within reach. During an interview on 02/10/25 at 10:19 AM, Certified Nurse Aide (CNA) M reported that she looked at the care plan to know how to care for a resident. She reported that R15 had a fall mat, and they do frequent checks. During an interview on 02/10/25 at 12:49 PM, Licensed Nurse (LN) G reported that interventions for falls was group effort. Confirmed there was not a transfer pole beside his bed in his room. During an interview on 02/10/25 at 11:20 AM, Administrative Nurse D was notified that R15 did not have his call light, she reported he should have his call light and she would fix that. She confirmed that the transfer pole was not in his room, it is on back order, also confirmed that R15 did not have the head CT yet even though it was the intervention for the fall on 01/25/25. Administrative D confirmed that there must be an appropriate intervention for each fall to keep the resident safe. The facility's Falls Management policy dated 12/2018, revised 12/2020 documented the plan of care was to address individualized resident focus, goals, and interventions directed towards reducing the resident's risk if injury and potential recurrence of falls. The resident's plan of care was to be reviewed and revised with each fall occurrence and a new intervention or interventions implemented. The facility failed to implement new interventions to prevent falls after several falls. This deficient practice placing her at risk for further falls. - Resident (R) 17's Electronic Health Record (EHR) revealed diagnoses, which included: dementia (progressive mental disorder characterized by failing memory, confusion), muscle weakness, reduced mobility, abnormal gait (manner or style of walking), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The 01/16/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. R17 required supervision or touch assistance with activities of daily living (ADL) to include dressing, toileting hygiene, footwear, personal hygiene and standing. The MDS documented R17 had one injury fall since the prior assessment. The 01/16/25 Falls Care Area Assessment (CAA) documented R17 had a fall with a head laceration that required staples. The CAA revealed therapy worked with R17 to improve her strength and balance. The CAA noted the resident was a fall risk and staff were to assist her as needed. The 01/16/25 Cognitive Loss/Dementia CAA documented R17 had a BIMS score of five. The CAA noted R17 usually understood others, others usually understood her, and staff were to assist with her cares as needed. The 02/06/25 Care Plan documented the following fall prevention interventions including to keep the call light with the resident's reach and educate the resident to use the call light. The Fall Risk Evaluation for R17, documented the resident was at moderate to high risk for falls. The Progress Note on 06/18/24 at 11:21 PM revealed R17 experienced a non-injury fall, where R17 said she sat down on the arm of her chair and slid off. The Progress Note on 09/19/24 at 06:03 AM revealed R17 experienced a non-injury fall, where R17 said she raised her electric chair too high and slid out. The Progress Note on 11/05/24 at 04:04 PM revealed R17 lost her balance, fell, hit her head, and was taken to the hospital by EMS, where she required staples to close the laceration. During an observation on 02/06/25 at 09:07 AM Maintenance Supervisor V checked the call lights in R17's room, with the surveyor. The call light in R17's room was activated by Maintenance Supervisor V but did not display on the computer monitor or alert to the staffs pager. The call light for R17's bathroom did not activate either. During an interview on 02/06/25 at 02:41 PM, CMA S stated the call lights and pagers worked most of the time. CMA S stated the CNAs in the past did not carry the pagers and the residents got used to nobody answering them. CMA S said the facility implemented a pager sign out book to get staff to grab a pager, a couple of months ago, and wrote staff up if they did not have a pager. CMA S said as far as she was aware, this fixed the problem. During an interview on 02/06/25 at 11:30 AM, Administrative Staff A was notified of the call lights that were not working. Administrative Staff A said Administrative Nurse D and Maintenance Staff V looked at the call lights about a week prior and they were working. Administrative Staff A stated that R17 preferred the hand bell. The surveyor informed her the handbell was not within R17's reach During an interview on 02/06/25 at 12:00 PM, Administrative Nurse D said she was aware some of the call lights got stuck on and would not reset. Administrative Nurse D stated Maintenance Saff V checked all of the call lights within the last month, and they were all working. Administrative Nurse D said some of the call lights needed batteries at that time. During an observation and interview on 02/06/25 at 02:26 PM, R17 sat in her recliner with her call light and hand bell out of her reach. The call light cord was loosely wound on the floor under the call light box. The surveyor handed the resident the call light, and R17 pushed the call light button. When asked, R17 reported she used the call light and she had used the hand bell a couple of times. R17 continued to push the call light button and said, It doesn't work right. You have to keep pushing the button and she continued to push it. At 02:58 PM on 02/06/25, no staff had responded to answer R17's call light. R17 kept pushing the call light button and said the staff will come eventually. The staff did stop by R17's room but not in response to the light. R17 stated, See. I told you. The call light display monitor did not show the call light was activated for R17. The facility policy Electronic Care Plan dated 12/2020, documented the resident's person-centered plan of care is an active working document that reflects the care needs and the resident's voice. The facility failed to follow the fall prevention interventions to prevent falls for cognitively impaired R17, who had a history of falls at facility, when the facility staff did not ensure R17's call light was within reach and functioning. This deficient practice placed R17 at risk for further falls with injury. - Review of Resident (R)20's electronic medical record (EMR) revealed a diagnosis of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. She was dependent on staff for chair-to-bed-to-chair transfers. The inaccurate MDS documented the resident had one injury (except major) fall since the prior assessment. The Functional Abilities Care Area Assessment (CAA), dated 12/19/24, did not trigger. The Fall CAA, dated 12/19/24, documented the resident required staff assistance with cares. The Annual MDS, dated 12/05/24, documented the resident had a BIMS score of four, indicating severe cognitive impairment. She was dependent on staff for chair-to-bed-to-chair transfers. She had one injury (except major) fall since the prior assessment. The fall care plan, revised 11/29/24, instructed staff the resident required one to two staff assistance with transfers and the use of a gait belt. The staff were to ensure the resident's call light was within reach at all times while she was in her room. Review of the resident's EMR revealed fall assessments, dated 10/28/24 and 12/17/24, which placed the resident at a moderate risk for falls. Fall assessments, dated 04/21/24 and 11/30/24, placed the resident at a high risk for falls. Review of the resident's EMR, revealed the resident had an injury (except major) fall in her room from her recliner on 10/28/24. Staff informed the nurse the resident's electric lift chair with the lift chair in the upper most position and the resident on the floor in front of the electric chair. Upon assessment, the resident had a reddened area to her spine. The resident had no further injuries, was able to move all of her extremities per her normal and her vital signs (VS) were within normal range (WNR). Staff initiated neurology checks (a medical assessment that evaluates the function of a patient's nervous system by testing their mental status, muscle strength, coordination, sensation, reflexes, and other neurological functions), which were all WNR. The interdisciplinary team (IDT) initiated a new intervention to keep the resident's lift chair unplugged when the resident was in the chair to prevent her from raising the chair on her own. Review of the resident's EMR revealed an Electric Recliner Assessment, dated 11/05/24, which documented the resident did not have the physical or cognitive ability to safely operate the electric recliner. No other Electric Recliner Assessments were available in the resident's EMR. Review of the resident's EMR, from 01/12/25 through 02/09/25, revealed the resident required substantial/maximal to dependent staff assistance with chair to bed to chair transfers. Review of the resident's EMR, from 01/12/25 through 02/09/25, revealed the resident required substantial/maximal to dependent staff assistance with going from sitting to standing. On 02/06/25 at 09:35 AM, Certified Medication Aide (CMA) S transferred the resident from her wheelchair to her electric recliner with extensive assistance and the use of the gait belt. The resident was unable to bear weight during the transfer. The electric recliner remained plugged in when the CMA left the room following cares. The controller to the electric recliner rested on the arm of the chair. On 02/06/25 at 10:47 AM, the resident sat in her electric recliner in her room. The electric recliner remained plugged in and the controller to the recliner rested on the arm of the chair. On 02/06/25 at 01:18 PM, Certified Nurse Aide (CNA) N and Licensed Nurse (LN) G transferred the resident from her wheelchair to her bed with extensive assistance and the use of a gait belt. The resident was unable to bear her full weight during the transfer. On 02/06/25 at 09:39 AM, CMA S stated staff were not to unplug the resident's electric recliner. Staff were to use the chair plugged in at all times. CNA S stated the resident was able to bear some weight during transfers but was unable to bear her full weight. On 02/06/25 at 01:18 PM, CNA N stated the resident could only bear minimal weight during transfers. Staff left the resident's electric recliner plugged in all of the time. On 02/06/25 at 01:18 PM, LN G stated the resident was not able to fully bear weight during transfers. LN G was unsure if the resident's electric recliner was to be plugged in or not. On 02/10/25 at 09:03 AM, Administrative Nurse D stated the intervention for the fall on 10/28/24 was to keep the lift chair unplugged when the resident sat in the chair. Administrative Nurse D stated a resident should be able to bear weight during a transfer for the transfer to be considered safe. The facility would possibly need to utilize the full body lift with the resident. Administrative Nurse D stated the 11/05/24 Electric Recliner Assessment, was the only assessment available. The facility policy for Falls Management, revised 12/2022, included: The plan of care shall address individualized resident focus, goals, and interventions directed towards reducing the resident's risk of injury and potential reoccurrence of falls. The facility policy for Assessments, revised 11/2024, included: The Electric Recliner Assessment shall be completed with use of the electric recliner initiation then quarterly, and as needed. The facility failed to practice safe transfers for this dependent resident who was unable to bear weight during transfers. Furthermore, the facility failed to complete an Electric Recliner Assessment for this confused resident who was found to be physically and cognitively unable to safely operate the electric lift chair. - Review of Resident (R)18's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. The resident had no limitation in range of motion (ROM). He used a walker for mobility. He required substantial/maximal assistance of staff for lying to sitting to the side of the bed, sit to stand and chair/bed-to-chair transfers. The resident had no falls since the prior assessment. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/09/24, documented the resident had a diagnosis of dementia and had the potential for falls. The Quarterly MDS, dated 01/02/25, documented the staff assessment for cognition revealed modified independence with daily decision making. He had limited ROM on one side of his lower extremity (LE) and used a walker and a wheelchair. He required substantial/maximal assistance of staff for lying to sitting to the side of the bed, sit to stand and chair/bed-to-chair transfers. The resident had two or more non-injury falls since the prior assessment. The fall care plan, revised 12/24/24, instructed staff to ensure the call light was within reach of the resident and to encourage him to use it for assistance. Staff were to keep a non-skid substance in the resident's recliner to prevent him from sliding and to install a transfer pole between his bed and recliner. Review of the resident's EMR revealed Fall Assessments dated 07/03/24, 12/15/24 and 12/24/24, which placed the resident at a high risk for falls. Review of the resident's EMR revealed a Fall Assessment dated 09/28/24, which placed the resident at a moderate risk for falls. Review of the resident's EMR revealed the resident had a non-injury fall in his room on 12/15/24 when he slid off his recliner seat and landed on the floor on his buttocks in front of his recliner. Review of the resident's EMR revealed the resident had a non-injury fall in his room on 12/25/24 when he fell to the floor while attempting to get out of bed unassisted. On 02/06/25 at 07:31 AM, the resident rested in bed. His call light was not within the resident's reach. On 02/06/25 at 01:29 PM, the resident rested in bed. His call light was not within the resident's reach. On 02/06/25 at 12:00 PM, Administrative Nurse D stated she knew some of the call lights would not turn off but was unaware there were so many call lights that did not work. The facility lacked a policy for call lights. The facility failed to ensure this dependent resident had a call light within reach for him to utilize to call for staff assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 29 residents with 15 residents sampled including five residents reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to monitor four Residents (R)12, R 17, R 18, and R 30, for use of antipsychotic medications (drugs used to treat psychosis-related conditions and symptoms), regarding the facility's failure to complete informed consents for the use of psychotropic (medications used to treat mental illnesses by affecting the chemical makeup of the brain and nervous system) and antipsychotic medications. Furthermore, the facility failed to monitor the use of an antianxiety (a class of medications used to treat anxiety disorders and related symptoms like excessive worry, fear, and tension) medication. Findings included: - Review of Resident (R)12's electronic medical record (EMR) revealed diagnoses which included: depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety (an emotion characterized by feelings of worry, unease, or fear, often in anticipation of a future threat or event). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. She received antianxiety medication (a class of medications used to treat anxiety disorders and related symptoms like excessive worry, fear, and tension) and antidepressant medication (medications used to treat mental illnesses by affecting the chemical makeup of the brain and nervous system) during the assessment period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 10/10/24, documented the resident received antidepressant and antianxiety medications. The Quarterly MDS, dated 01/09/25, documented the resident had a BIMS score of two, indicating severe cognitive impairment. She received antianxiety and antidepressant medications during the assessment period. The psychotropic medications care plan, revised 01/03/25, instructed staff to monitor and document any side effects of the resident's antianxiety and antidepressant medications and to notify the physician of any adverse reactions. Review of the resident's EMR revealed the following physician's orders: Prozac (an antidepressant medication), 10 milligrams (mg), by mouth (po), every day (QD), for a diagnosis of depression, ordered 11/02/20. Xanax (an antianxiety medication), 0.25 mg, po, at bedtime (HS), for a diagnosis of anxiety, ordered 03/13/24. Review of the resident's Medication Administration Record (MAR) from 01/01/25 through 02/06/25, revealed the resident received the medications, as ordered. Review of the resident's EMR revealed the facility lacked a signed and dated Informed Consent for the use of psychotropic medications. On 02/05/25 at 12:12 PM, the resident sat at the dining table in her wheelchair. No indication of tearfulness or anxiety. On 02/06/25 at 07:39 AM, Certified Medication Aide (CMA) U combed and styled the resident's hair before breakfast. The resident chatted and interacted with the CMA during her cares. No obvious outward evidence of depression or anxiety displayed at that time. On 02/11/25 at 11:05 AM, Administrative Nurse D stated the Informed Consent forms were not completed and signed for the residents who received psychotropic medications. The facility policy for Behavior Management and Psychotropic Medications, revised 11/2024, included: An informed consent will be completed for the use of psychotropic medications that affect brain activity for the residents prior to initial administration of the medication. The facility failed to complete an Informed Consent for this dependent resident who received psychotropic medications. - Review of Resident (R)18's electronic medical record (EMR) revealed the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The admission Minimum Data Set (MDS, dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. She received antipsychotic medication during the assessment period. (This inaccurate) MDS failed to document the resident received antidepressant medications throughout the assessment period.) The Psychotropic Drug Use Care Area Assessment (CAA), dated 07/09/24, documented the resident's medications would be reviewed by the pharmacy consultant and adjustments completed, as needed (PRN). The Quarterly MDS, dated 01/02/25, documented the staff assessment for cognition revealed modified independence for daily decision making. She received antipsychotic and antidepressant medications during the assessment period. The care plan for psychotropic medications, revised 09/27/24, instructed staff the resident took antidepressant medications for tearfulness and an antipsychotic medication for agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition). Review of the resident's EMR revealed the following physician's orders: Venlafaxine (an antidepressant medication), 75 milligrams (mg), by mouth (po), every day (QD), for a diagnosis of depression, ordered 07/03/24. Seroquel (an antipsychotic medication) 25 mg, po, twice daily (BID), for a diagnosis of depression, ordered 07/03/24. Review of the residents Medication Administration Record (MAR) from 01/01/25 through 02/06/25, revealed the resident received the medications, as ordered. Review of the resident's EMR revealed the facility lacked a signed and dated Informed Consent for the use of psychotropic medications. On 02/05/25 at 11:57 AM, Certified Medication Aide (CMA) U propelled the resident in his wheelchair to the dining room for lunch. The resident had no obvious outward indications of tearfulness or agitation. On 02/11/25 at 11:05 AM, Administrative Nurse D stated the Informed Consent forms were not completed and signed for the residents who received psychotropic medications. The facility policy for Behavior Management and Psychotropic Medications, revised 11/2024, included: An informed consent will be completed for the use of psychotropic medications that affect brain activity for the residents prior to initial administration of the medication. The facility failed to complete an Informed Consent for this dependent resident who received psychotropic medications. - Review of Resident (R)17's electronic medical record (EMR) revealed the following diagnoses: major depressive disorder (MDD-major mood disorder which causes persistent feelings pf sadness) and anxiety (emotion characterized by feelings of worry, unease, or fear, often in anticipation of a future threat or event). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. She received antidepressant medication (medications used to treat mental illnesses by affecting the chemical makeup of the brain and nervous system) during the assessment period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 01/16/25, documented the resident received antidepressant medication for a diagnosis of MDD. The Quarterly MDS, dated 10/24/24, documented the resident had a BIMS score of five, indicating severe cognitive impairment. She received an antidepressant medication during the assessment period. Review of the resident's EMR revealed the following physician's order: Fluoxetine (an antidepressant medication), 60 milligrams (mg) one-half tablet, by mouth (po), every day (QD), for a diagnosis of MDD, ordered 1/14/23. Review of the resident's Medication Administration Record (MAR) from 01/01/25 through 02/06/25, revealed the resident received the medications, as ordered. Review of the resident's EMR revealed the facility lacked a signed and dated Informed Consent for the use of psychotropic medications. On 02/11/25 at 11:05 AM, Administrative Nurse D stated the Informed Consent forms were not completed and signed for the residents who received psychotropic medications. The facility policy for Behavior Management and Psychotropic Medications, revised 11/2024, included: An informed consent will be completed for the use of psychotropic medications that affect brain activity for the residents prior to initial administration of the medication. The facility failed to complete an Informed Consent for this dependent resident who received psychotropic medications. - Review of Resident (R)30's electronic medical record (EMR) revealed the following diagnoses: anxiety (emotion characterized by feelings of worry, unease, or fear, often in anticipation of a future threat or event) and major depressive disorder (MDD-major mood disorder which causes persistent feelings of sadness) and insomnia (the inability to sleep). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. He received antidepressant (a class of medications used to treat mood disorders) and antianxiety medications (a class of medications that calm and relax people) during the assessment period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 12/16/24, documented the resident received antidepressant and antianxiety medications. The care plan for psychotropic medications instructed staff the resident took an antidepressant for insomnia and an antianxiety medication for agitation. Review of the resident's EMR revealed the following physician's order: Lorazepam (a class of medications that calm and relax people), 05 milligrams (mg), by mouth (po), every six hours, as needed (PRN), for a diagnosis of anxiety, ordered 12/09/24. Mirtazapine (class of medications used to treat mood disorders), 15 mg, po, at bedtime (HS), for a diagnosis of insomnia, ordered 12/10/24. Review of the resident's Medication Administration Record (MAR) from 12/09/24 through 02/06/25, revealed the resident's Mirtazapine medication was given as ordered. Review of the resident's Medication Administration Record (MAR) from 12/09/24 through 02/06/25, revealed the resident's Lorazepam was given 14 times with effective results. However, documentation failed to document any behaviors at the time of the antianxiety medication administration. Review of the resident's EMR revealed the facility lacked a signed and dated Informed Consent for the use of psychotropic medications. On 02/11/25 at 11:05 AM, Administrative Nurse D stated the Informed Consent forms were not completed and signed for the residents who received psychotropic medications. The facility policy for Behavior Management and Psychotropic Medications, revised 11/2024, included: An informed consent will be completed for the use of psychotropic medications that affect brain activity for the residents prior to initial administration of the medication. The facility failed to complete an Informed Consent for this dependent resident who received psychotropic medications.

The facility reported a census of 29 residents. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for two of the five Certified Nurse Aides (CNA) reviewed, CNA M and O, to ensure adequate appropriate cares and services provided to the residents of the facility. Findings included: - Review of five employee personnel files, employed by the facility for greater than one year, revealed the following concerns: 1. Certified Nurse Aide (CNA) M, hired 11/04/22, lacked an annual performance review in her personnel file. 2. CNA O, hired 11/27/23, lacked an annual performance review in her personnel file. On 02/10/25 at 10:03 AM, Administrative Nurse D confirmed the facility lacked annual evaluations for the two CNAs. The facility Employee Handbook included: Supervisors are to conduct performance evaluations of all full-time and part-time employees on an annual basis. The facility failed to complete an annual performance review at least every 12 months for these two CNAs, employed great than one year, to ensure appropriate cares and services were provided to the residents of the facility.

The facility reported a census of 29 residents. The sample included 15 residents. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program related to the staff improper hand hygiene with wound dressing changes and catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care. The facility failed to follow enhanced barrier precautions (a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDROs) in nursing homes) (EBP). This deficient practice had the potential to spread possible infections to the residents in the facility. Findings included: On 02/06/25 at 08:12 AM, Certified Medication Aide (CMA) U, Certified Nurse Aide (CNA) N, and Licensed Nurse (LN) G entered R11's room to transfer him and change the leg bag on the foley catheter to a full-sized bedside bag. The staff undressed him and changed out his catheter bag. They removed their gloves, but failed to preform proper hand hygiene before the put on new gloves and continued to dress R11 and got him ready to rest in bed. During an interview on 02/06/25 at 08:22 AM (CMA) U and (CNA) N revealed they forgot to put on the gown for EBP. Also discussed that they failed to preform hand hygiene after removing their gloves. CMA U stated they used to have hand sanitizer in the room on the shelf, but it was no longer there. On 02/06/25 at 10:09 AM, Licensed Nurse (LN) G performed a treatment and dressing change on R13. LN G washed hands with soap and water and dried with clean paper towels. Cleansed area with a gauze pad. LN G failed to peroform hand hygiene and change gloves prior to placing the clean dressing. On 02/10/25 at 12:46 PM, CNA P, was observed removing dirty sheets off R11's bed. CNA P confirmed she had just given R11 a bed bath and transferred him to his recliner, she did not wear the proper PPE. During an interview on 2/06/25 at 02:41 PM, CMA S stated that staff was required to use PPE when they cared for R11, and anyone that had a catheter or a wound and required EBP. CMA S stated that hand hygiene should always be done after gloves were removed. During an interview on 02/10/25 at 10:19 AM, CNA M reported that staff gown up and glove up every time they provided care for a resident with wounds or a catheter. CNA M reported that they were to always preform hand hygiene every time before they put on cloves and when they removed their gloves. During an interview on 02/10/25 at 11:20 AM, Administrative Nurse D confirmed that it was her expectation that all staff follow EBP and gown up when they completed care for a person with a catheter or an open wound. It was her expectation that all staff preform hand hygiene prior to putting on gloves and when they took them off and other times according to the policy, The facility failed to maintain an effective infection control program related to improper hand hygiene after removal of soiled gloves and failed to wear the proper PPE when staff cared for residents on EBP to prevent cross contamination in the facility.

The facility reported a census of 29 residents. The sample included 15 residents. Based on observation, interview, and record review the facility failed to maintain a functional emergency call system, which allowed residents to call for staff assistance from each resident's room, bedside, bathroom area, and/or bathing facilities and alarmed at a centralized staff work area. Findings included: - On 02/05/25 at 09:02 AM, Resident (R) 11 sat in his recliner with his emergency call light laying on the floor behind the table beside him. The emergency call light sat out of his reach. The resident reported he used his phone to call for assistance when his emergency call light did not work. On 02/05/25 at 09:26 AM, R15's emergency call light sat on the over-bed table and out of the resident's reach. On 02/05/25 at 10:16 AM, R16 stated the facility emergency call system did not always work and the resident reported using the phone to call for staff assistance at times. On 02/06/25 at 07:52 AM Licensed Nurse (LN) G and Certified Medication Aide (CMA) U reported they did not have pagers on them, which indicated a resident activated their emergency call light. CMA U stated there was a computer monitor, concealed by a curtain, which alerted staff a resident's emergency call light was activated and noted it could be seen in the commons area. On 02/06/25 at 07:57 AM CMA R stated she forgot to grab a pager to monitor resident emergency call lights. On 02/06/25 at 08:53 AM, during a call light observation with Maintenance Staff V to check the functionality of resident emergency lights revealed one resident room had a call light that only activated after three attempts and the shower room had two call lights, which did not work. Observation of call lights on 02/06/25 from 08:56 AM through 10:04 AM revealed 16 resident emergency call lights that malfunctioned by continuing to sound once deactivated, never activated on staff pagers, never activated on the facility computer, and/or did not activate at all. The observations included both resident rooms and bathrooms. During an interview on 02/06/25 at 10:06 AM, Maintenance Staff V stated he checked all of the staff pagers and call lights monthly. Maintenance Staff V completed a random weekly audit in addition to his monthly call light review. He reported in November or December he was notified of the resident emergency call lights not working and stated the facility immediately fixed the problem. Maintenance Staff V reported staff were taking the batteries out of the pagers and did not use them because they did not want to carry them. During an interview on 02/06/25 at approximately 11:30 AM, Administrative Staff A stated she was not aware of any current issues with the resident emergency call light system Administrative Staff A stated Administrative Nurse D and Maintenance Staff V checked all of the call lights about a week prior and everything was working properly. Administrative Staff A further stated she did not hear anything about staff choosing not to use their pagers. During an interview on 02/06/25 at 02:41 PM, CMA S stated the call lights and pagers worked most of the time. She stated the CNAs in the past did not carry the pagers and the residents got used to nobody answering them. The facility failed to provide a policy for the use of emergency call lights. The facility failed to maintain an emergency call system, which allowed residents to call for staff assistance from each resident's room, bedside, bathroom area, and/or bathing facilities and alarmed at a centralized staff work area.

The facility reported a census of 32 with 14 residents selected for review which included two residents reviewed for dressing changes. Based on observation, interview and record review, the facility failed to ensure timely dressing changes for one, resident (R)4, of the two residents reviewed. Findings included: - Review of Resident (R)4's medical record revealed diagnosis included osteomyelitis (bone infection) of a bone in the spine. The admission Minimum Data Set, was in progress for completion. The Admitting Care Plan, dated 05/04/23, instructed staff to administer ceftriaxone (an antibiotic) intravenously (directly into the blood stream) through the PICC (peripherally inserted central venous catheter) line every 24 hours, flush the PICC line, and change the dressing per the physician's orders. The Physician Orders, dated 05/04/23, instructed staff to administer ceftriaxone (an antibiotic), two grams, intravenously, through the PICC line every 24 hours, flush the line with 10 milliliters of normal saline before and after the antibiotic and change the PICC line dressing using sterile (a technique to eliminate contact with microorganisms that may contaminate the site) technique, every seven days. Observation, on 05/23/23 at 08:30 AM, revealed Licensed Nurse (LN)G administered the ceftriaxone to R4 through her PICC line. The dressing on the PICC line site documented a date of 05/03/23, and the edges of the dressing contained gray discolorations and evidence of areas of nonadherence. Interview, on 05/24/23 at 11:24 AM, with LN revealed, revealed staff typically should change the PICC line dressings every seven days. Interview, on 05/24/23 at 11:30 AM, with Administrative Nurse D, confirmed lack of dressing change for this resident every seven days as ordered by the physician and per facility policy. Administrative Nurse stated she added the dressing change to the resident's Treatment Administration Record (TAR) on 05/23/23. The facility policy Dressing Change for Vascular Access Devices, dated August 2021, instructed staff to change central venous access devices at established intervals and immediately if the integrity of the dressing was compromised. The facility failed to ensure staff provided this resident's PICC line dressing change every seven days, as ordered by the physician, to ensure the resident did not experience adverse effects or infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 32 residents with 14 residents sampled. Based on observation, interview and record review, the facility failed to serve one Resident (R)26 the physician ordered diet. Findings included: - Review of Resident (R)26's electronic medical record (EMR), revealed a diagnosis of dysphagia (swallowing difficulty). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. She required supervision with setup help for eating. The resident had swallowing issues which included coughing or choking and pain when swallowing. She had a mechanically altered diet which required a change in her food texture. She had no natural teeth or tooth fragments. The Nutritional Status Care Area Assessment (CAA), dated 12/25/22, documented the resident had a regular, mechanical soft diet with ground meats with gravy due to a diagnosis of dysphagia. The quarterly MDS, dated 03/23/23, documented the resident had a BIMs score of 12, indicating moderately impaired cognition. She required setup help only with eating and had no swallowing disorder. She had a mechanically altered diet which required a change in her food texture. She had no natural teeth or tooth fragments. The care plan for nutrition, revised 03/17/23, instructed staff the resident had a regular diet with mechanical soft foods with ground meats. Staff were to ensure the resident had plenty of gravy on her ground meat. Review of the resident's EMR, revealed a physician's order, which included: Regular mechanical soft diet with ground meat texture, add gravy to ground meat, for diagnosis of dysphagia, ordered 12/21/22. Review of the speech therapy (ST) report, dated 02/15/23, documented the resident preferred a mechanical soft diet with ground meat. On 05/23/23 at 12:31 PM, Certified Nurse Aide (CNA) N served the resident lunch, which consisted of a chicken strip cut into bite size pieces with gravy, cottage cheese and spanish rice with a cinnamon roll on the side. The resident fed herself a few bites of the spanish rice and cottage cheese without difficulty. On 05/23/23 at 12:40 PM, the resident stated she was unable to eat the chicken strip as she would not be able to chew and swallow the large pieces. She would have eaten the chicken strip if it had been ground. On 05/23/23 at 01:07 PM, Dietary staff BB stated the chicken strip had not been ground, as was the resident's order. Dietary staff BB stated the chicken strip should not have been served to the resident. On 05/23/23 at 01:09 PM, Dietary staff CC stated she had not ground the chicken strip because the machine she used for ground meat was dirty at the time she served the resident her lunch. On 05/23/23 at 01:21 PM, CNA N stated she noticed the meat was not ground but thought it was alright for the resident to have since the kitchen served it for the resident. On 05/24/23 at 03:36 PM, Licensed Nurse (LN) stated the resident was to have ground meat due to issues with swallowing. On 05/24/23 at 07:50 AM, Administrative Nurse D stated it was the expectation that residents be served the diet ordered by their physician. The facility policy for Diet Orders, undated, included: Each resident shall have a diet order prescribed by the physician and documented in the health record. The facility failed to serve this dependent resident the diet ordered by her physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 30 residents with 15 residents sampled, including one resident reviewed for dignity. Based on observation, interview, and record review, the facility failed to provide dignity for one Resident (R)8, by failure to cover his indwelling urinary catheter bag (tube placed in the bladder to drain urine into a collection bag), leaving it exposed for others to see. Findings included: - The Physician Order Sheet (POS), dated 08/03/21, documented Resident (R)8 had a diagnosis of neuromuscular dysfunction of the bladder (bladder problems due to disease or injury of the central nervous system). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. He required extensive assistance of two staff for toileting and had an indwelling urinary catheter. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 01/07/21, documented the resident had a suprapubic catheter (catheter inserted directly into the bladder through the abdomen) for a diagnosis of neurogenic bladder. The quarterly MDS, dated 07/02/21, documented the resident had a BIMS score of 3, indicating severe cognitive impairment. He required extensive assistance of two staff for toileting and had an indwelling urinary catheter. The Activities of Daily Living (ADL) care plan, dated 07/02/21, instructed staff to perform catheter care every shift. On 09/20/21 at 03:14 PM, the resident sat in his wheelchair in his room. His catheter collection bag hung underneath his wheelchair and lacked coverage with a dignity bag. The urine in the catheter collection bag was visible to anyone who walked past his room in the hallway. On 09/21/21 at 08:30 AM, the resident sat in his wheelchair in the dining room eating breakfast. His catheter collection bag hung underneath his wheelchair and lacked coverage with a dignity bag. The urine in the catheter collection bag was visible to anyone in the dining room or in the hallway. On 09/21/21 at 04:47 PM, the resident sat in his wheelchair in his room. His catheter collection bag hung underneath his wheelchair and lacked coverage with a dignity bag. The urine in the catheter collection bag was visible to anyone in the dining room or in the hallway. On 09/21/21 at 04:47 PM, Certified Nurse Aide (CNA) O stated, staff would put the resident's catheter collection bag in the dignity bag when the resident was in bed. When the resident was up in his wheelchair, staff would hang the bag underneath his wheelchair without coverage of a dignity bag. On 09/22/21 at 01:57 PM, Licensed Nurse (LN) G stated, the resident's catheter collection bag should be kept in a dignity bag at all times. On 09/23/21 at 08:44 AM, Administrative Nurse D stated, it was the expectation for staff to put the catheter collection bag in a dignity bag at all times to protect the dignity of the resident. The facility lacked a policy regarding the use of dignity bags for indwelling catheter collection bags. The facility failed to provide dignity with coverage, for this dependent resident's urine in the indwelling urinary catheter collection bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 30 residents with 15 selected for review. Based on observation, interview and record review, the facility failed to ensure the development of an individualized comprehensive care plan for activities for three sampled residents (R)79, R 23 and R15. Findings included: - Review of R 79's Physician Order Sheet, dated 09/08/21 revealed the resident admitted to the facility on [DATE], with diagnoses that included senile degeneration (progressive mental disorder characterized by failing memory, confusion), diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), and hypothyroidism (condition characterized by hyperactivity of the thyroid gland). The admission Minimum Data Set (MDS,) dated 09/06/21, assessed the resident with severe cognitive impairment, and verbal behavior directed toward others, on one to three days, of the seven day look back period. The resident required extensive assistance for mobility with impairment in functional range of motion in both sides of the lower extremities. The resident received five days of antipsychotic, and antianxiety medications during the seven day look back period. The Activity Care Area Assessment (CAA), dated 09/06/21, assessed the resident with severe impaired cognitive function and a diagnosis of unspecified dementia the resident had a diagnosis of unspecified dementia (progressive mental disorder characterized by failing memory, confusion), with behaviors. The resident had clear speech and usually understood staff. The resident had agitation and anxiety and yelled at staff. One-on-one activities will be offered to the resident. The Care Plan, reviewed 09/16/21, instructed staff to encourage the resident to attend activities and become integrated and involved with life in the facility. Staff instructed to encourage the resident to visit with other residents and attend activities to keep busy. The care plan lacked individualized interventions for activities of interest for this resident. Observation, on 09/20/21 at 08:00 AM, revealed the resident positioned in his wheelchair in the common tv area, with his eye closed. The resident responded to his name by opening his eyes slowly. Observation, on 09/20/21 at 10:00 AM, revealed the resident continued seated in his wheelchair in the common tv area with his eyes closed. The tv was playing a country western music advertising commercial. Observation, on 09/21/21 at 12:10 PM, revealed the resident opened his eyes during the noon meal, but remained somnolent while CNA M fed the resident. Interview, on 09/21/21 at 12:52 PM, with CNA N revealed she did not know what activity staff should provide to the resident. Interview, on 09/21/21 at 04:00 PM with CNA P, revealed the resident had yelling behaviors when first admitted , but now was cooperative and sleepy most of the time. CNA P did not know what activities staff provided to the resident. Interview on 09/23/21 at 09:15 AM, with Licensed Nurse (LN) G, revealed the resident had yelling behaviors when first admitted , but now was somnolent through the day. LN G did not know what activities staff provided to the resident as he did sit in his wheelchair in the common tv area but did not know if he listened to the tv. Interview, on 09/23/21 at 10:45 AM, with Administrative Nurse D, revealed she would expect staff to provide activities to the resident. Interview, on 09/23/21 at 9:00 AM with Administrative Nurse F, revealed staff should provide one on one activities for the resident, and the resident did not attend bingo or group activities. Administrative Nurse F stated staff developed the Care Plan for activities based on the MDS, CAA and family interview. The facility used the RAI (resident assessment instrument) manual for the care plan development. The facility failed to provide this dependent confused resident with a comprehensive individualized care plan for activities to enhance the quality of his life. - Review of resident (R)23's Physician Order Sheet, dated 09/10/21, revealed diagnoses included history of COVID-19, bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods) and dementia (a progressive mental disorder characterized by failing memory, confusion.) The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with severe impairment of cognitive function. The resident's preferences per staff interview revealed the resident liked animals, music, groups, outdoor and religious activities. The resident required extensive assistance of two staff for transfer and bed mobility and was dependent of staff for locomotion. The Activities Care Area Assessment (CAA), dated 08/19/21, assessed the resident with severe impaired cognitive function with clear speech, usually understands and was usually understood. The resident required total assistance with activities of daily living and was on hospice services. Staff to offer one on one activities. The Care Plan, reviewed 09/13/21, instructed staff to remind the resident of activities and allow the resident to attend activities/participate at her choice. The resident likes to join the bingo and move and stretch activity. The care plan lacked activities for the significant change in the resident's status. Observation, on 09/20/21 at 8:30 AM, revealed the resident seated in her wheelchair in the assistive feeding room. The resident attempted to hold her cup and drink out of it. The resident responded to Certified Nurse Aide (CNA) MM who assisted the resident to drink from her cup. Observation, on 09/20/21, at 10:00 AM, revealed the resident seated in her wheelchair, in the common tv area. The resident's eyes were closed, and she dropped a stuffed puppy onto the floor. The activity bingo was taking place in the dining area. Interview, on 09/21/21 at 03:00 PM, with CNA M revealed the resident does not attend activities and did not watch/listen to tv. Interview, on 09/21/21 at 4:20 PM with CNA P, revealed staff got the resident out of bed for supper last, and returned her to bed first after the evening meal due to fall risk. CNA P did not know what activities the staff should provide to the resident. Interview, on 09/22/21 at 12:18 PM, with Activity Staff Z, revealed the resident did not talk much, and did hold onto a stuffed dog. The resident liked to look out a window and used to like looking at the birds in the cage in the dining room when she used to wait for bingo to start. Activity Staff Z revealed she did not provide an activity of watching the birds. Interview, on 09/23/21 at 08:46 AM with Administrative Nurse D, revealed she would expect some activity for the resident and provide an appropriate care plan Interview, on 09/23/21 at 9:00 AM with Administrative Nurse F, revealed staff should provide one on one activities for the resident, and the resident did not attend bingo or group activities since her significant change in status after COVID-19 illness. Administrative Nurse D confirmed the care plan for the significant change in status did not update to reflect the resident's current status. The facility used the RAI (resident assessment instrument) manual for the care plan development. The facility failed to provide this dependent confused resident with a comprehensive individualized activity care plan to enhance the quality of her life. - Review of resident (R) 15's Physician Order Sheet, dated 09/22/21, revealed diagnoses included Alzheimer's dementia (progressive mental deterioration characterized by confusion and memory failure) traumatic brain injury and depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness.) The admission Minimum Data Set (MDS), dated [DATE], assessed the resident had severe cognitive impairment. Staff assessed the resident's activity preferences as listening to music and going outside, being around animals and groups of people and religious services. The Psychosocial Care Area Assessment (CAA), dated 07/02/21, assessed the resident had clear speech at times and understood verbal communications. The Care Plan, reviewed 08/13/21, instructed staff the resident had cognitive loss that affected her memory and the resident needed to develop a trusting therapeutic relationship with others. Staff need to establish a regular daily schedule. The care plan lacked individualized activities for the resident. Observation, on 09/20/21 at 10:00 AM, revealed the resident in her wheelchair in the common tv area. The resident made repetitive monotonal noises and did not focus on the television. Staff provided residents with bingo in the dining room at that time. Observation, on 09/21/21 at 08:30 AM, revealed the resident seated in her wheelchair in the assisted dining room. The resident had word salad and had repetition of noises. The resident propelled herself around the table and touched objects on the table. Interview, on 09/22/21 at 12:15 PM with Activity Staff Z, revealed the resident was unable to verbalize activity preferences and could not complete an activity assessment as family did not come in to interview. Activity Staff Z stated the resident liked to hold a baby doll at times and thought staff provided laundry for the resident to fold, but she dropped the items on the floor. Activity Staff Z stated she thought about a keyboard for the resident. Interview on 09/23/21 at 08:46 AM, with Administrative Nurse D, revealed she would expect staff to provide activities to the resident. Interview, with Administrative Nursing staff E, revealed the care plan was developed after the MDS assessment completed and should include activities of interest for the resident. The facility used the RAI (resident assessment instrument) manual for the care plan development. The facility failed to provide a comprehensive care plan for individualized activities for this confused resident activities to enhance the quality of her life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 30 residents with 15 residents sampled, including two residents sampled for bowel and bladder incontinence. Based on observation, interview, and record review, the facility failed to provide appropriate peri-care (cleansing of genitals and anal area) to prevent urinary tract infections for one of the two sampled residents, Resident (R)5. Findings included: - The Physician Order Sheet (POS), dated 08/03/21, documented Resident (R)5 had a diagnosis of muscle weakness. The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. The resident required extensive assistance of two staff for toilet use and she was always incontinent of bowel. The Activities of Daily Living Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 03/28/21, documented the resident required staff assistance of two for toilet use. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 03/28/21, documented the resident was incontinent of bowel and wore briefs for protection. The care plan for incontinence, dated 06/18/21, instructed staff to provide peri-care as needed (PRN). Review of the resident's electronic medical record (EMR), under the Tasks tab, included the resident had several incontinent bowel movements (BM) from 08/25/21 through 09/22/21 which required 1-2 staff for assistance with peri-care. On 09/20/21 at 01:37 PM, Certified Nurse Aides (CNA) Q and MM, entered the resident's room to perform peri-care following a bowel incontinence episode. The staff removed the resident's brief, dirty with a large amount of loose BM, and began to clean the resident. Both staff used one wipe for multiple swipes of the BM while cleaning the resident. Staff would wipe the resident from back to front during the hygiene cares. On 09/20/21 at 01:37 PM, CNA MM stated, he would use one wipe for multiple swipes when performing peri-care at times, depending on how much of a hurry he was in and also to conserve the wipes. CNA confirmed he had wiped the resident with a motion from the back through to the front a few times due to being in a hurry. On 09/20/21 at 01:37 PM, CNA O stated, she would swipe more than once with a wipe, but would fold the wipe in between swipes. On 09/22/21 at 01:57 PM, Licensed Nurse (LN) G stated, when doing peri-care staff should only use one wipe per one swipe. The facility does not have a shortage of supplies. There are plenty of wipes. On 09/23/21 at 08:44 AM, Administrative Nurse D stated, when doing peri-care staff are expected to wipe front to back and use one wipe for one swipe. Wipes should not be folded and reused. The facility does not have a shortage of supplies. The facility lacked a policy for peri-care. The facility failed to provide appropriate peri-care hygiene to prevent urinary tract infections, for this dependent resident with bowel incontinence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The reported a census of 30 resident with 15 selected for review, which included five residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure monitoring and diagnoses for resident (R)79's antipsychotic and anxiolytic (medication used for anxiety) medication and failed to ensure one resident R80 received reevaluation for as needed doses of Ambien and Valium, which continued past the 14-day limitation as required, to ensure the residents did not received medications with adverse side effects. Findings included: - Review of R 79's Physician Order Sheet, dated 09/08/21 revealed the resident admitted to the facility on [DATE], with diagnoses that included senile degeneration (progressive mental disorder characterized by failing memory, confusion), diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), and hypothyroidism (condition characterized by hyperactivity of the thyroid gland). The admission Minimum Data Set (MDS,) dated 09/06/21, assessed the resident with severe cognitive impairment, and verbal behavior directed toward others on one to three days of the seven day look back period. The resident required extensive assistance for mobility with impairment in functional range of motion in both sides of the lower extremities. The resident received five days of antipsychotic, and antianxiety medications during the seven day look back period. The Cognitive Loss Care Area Assessment (CAA), dated 09/06/21, assessed the resident with a diagnosis of unspecified dementia with behaviors. The resident had agitation and anxiety and yells at staff. The Psychotropic Drug Use CAA, dated 09/06/21, assessed the resident had Haloperidol (an antipsychotic medication used to treat schizophrenia [psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought] and when used with other medications may cause increased sedation), 2 milligrams (mg), three times a day, for agitation and also Lorazepam (a medication to decrease anxiety), 0.5 mg, every four hours, for agitation and anxiety. The Care Plan, revised 09/16/21, instructed staff the resident took multiple medications with a Black Box Warning (a warning by the Food and Drug Administration for certain medications that carry serious safety risks. Often these warnings communicate potential rare but dangerous side effects, or they may be used to communicate important instructions for safe use of the drug.) which placed him at potentially higher risk for adverse reactions. Staff instructed to observe/report any changes in mental status/mood/behavior caused by situational stressor. Staff instructed to provide a calm and safe environment to allow the resident to express feelings as needed, provide reassurance and monitor for psychosocial changes. Staff instructed to ask the resident why he wandered as he may want something that staff can help him with or reassure him and redirect him from exit seeking behavior. The resident may have pain, hunger or need to toilet. The Physician's Orders revealed the following: On 08/31/21, Haldol 1 milligram (mg) every (Q )8 hours (hr.) as needed (PRN) for delirium (sudden severe confusion, disorientation and restlessness) agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition) and hallucination (sensing things while awake that appear to be real, but the mind created). The resident received a total of four doses from 08/31/21 through 09/04/21. On 08/31/21, Lorazepam (an antianxiety medication) 0.5 mg, every four hours for agitation. The resident received 10 doses from 08/31/21 through 09/08/21 and this order was discontinued on 09/08/21. On 09/04/21, Haldol 2 mg, TID (three times a day) for agitation. On, 09/09/21, Lorazepam 1 mg, every four hours, then discontinued one day later, on 09/10/21. On 09/10/21, Lorazepam 0.5 mg every four hours, then discontinued 13 days later, on 09/23/21. On 09/23/21, Lorazepam 0.5 mg every six hours. Review of the medical record revealed a lack of monitoring for extrapyramidal ( (physical symptoms, including tremor, slurred speech, akathisia (inability to sit still constant movement), dystonia ( involuntary muscle contractions that cause slow repetitive movements , anxiety, distress, paranoia (feeling persecuted), and bradyphrenia (slowed thinking and processing of information, that are primarily associated with improper dosing of or unusual reactions to neuroleptic (antipsychotic) medications) side effects of Haldol. Review of the Behavior Monitoring in Point of Care electronic medical record, from 08/31/21 through 09/22/21, revealed one episode of yelling on 09/03/21 with no other behaviors documented. Review of the Progress Notes from 08/31/21 through 09/21/21, in the electronic medical record, revealed a lack of notation of the resident's behaviors. Observation, on 09/20/21 at 08:00 AM, revealed the resident positioned in his wheelchair in the common tv area, with his eye closed. The resident responded to his name by opening his eyes slowly. Observation, on 09/21/21 at 7:56 AM, revealed the resident seated in his wheelchair in the common tv area with his eye closed, moaning at times and sliding forward in his wheelchair. Certified Nurse Aide (CNA) O and Certified Medication Aide (CMA) R repositioned the resident in his wheelchair with the use of the lift sling. The resident minimally responded. CMA R stated the resident has had behaviors of yelling at the staff, but today the resident had no behaviors. The resident continued to remain seated in his wheelchair with his eyes closed. CMA R stated the medications made the resident sleepy. Observation, on 09/21/21 at 09:00 AM, revealed CMA R propelled the resident to the dining room for breakfast. CNA M fed the resident his breakfast. CNA M stated at that time that the resident had aggressive behavior when he first admitted to the facility, but now was cooperative. Observation, on 09/21/21 at 12:10 PM, revealed the resident opened his eyes during the noon meal, but remained somnolent while CNA M fed the resident. Observation, on 09/21/21 at 12:52 PM, revealed CNA O and CNA N transferred the resident to bed with the mechanical lift. The resident remained somnolent. CMA R and CNA N provided incontinence care for urine and stool. The resident required assistance to turn and reposition. Interview, on 09/21/21 at 12:52 PM, with CNA O, revealed when the resident first admitted he was very confused and wanted to go home and yelled at the staff. Interview, on 09/21/21 at 04:00 PM with CNA P, revealed the resident had yelling behaviors when first admitted , but now was cooperative and sleepy most of the time. Interview on 09/23/21 at 09:15 AM, with Licensed Nurse (LN) G, revealed the resident had yelling behaviors when first admitted , but now was somnolent through the day. Interview, on 09/23/21 at 10:45 AM, with Administrative Nurse D, revealed the resident should have the monitoring tool for extrapyramidal side effects upon admission to the facility and every quarter. Administrative Nurse E stated the resident's behaviors should be monitored and documented in the electronic record. Interview, on 09/23/21 at 11:30 AM, with consulting pharmacy staff GG, revealed the resident should have monitoring for extrapyramidal side effects upon admission and quarterly. Consulting staff GG stated diagnoses for Haldol should include what type of agitation/behaviors the resident exhibited to justify the use of Haldol and Lorazepam. The facility policy Behavior Management and Psychotropic Medications revised 12-2017, instructed staff to enhance the quality of life through behavioral interventions to minimize psychotropic medication use and monitor for adverse effects. AIMS (abnormal involuntary movement scale) or DISCUS (dyskinesia [inability to execute voluntary movements] identification system condensed user scale) are to be completed upon admission with initiation of antipsychotic medication. Staff were to monitor and document target behaviors every shift. The facility failed to monitor for adverse extrapyramidal side effects of the antipsychotic Haldol and failed to document the behaviors the resident exhibited to justify the benefit verses the risk of continued use of Haldol and Lorazepam to prevent adverse side effects. - Review of resident (R) 80's Physician Order Sheet, dated 09/03/21, revealed the resident admitted to the facility on [DATE], with diagnoses that included anxiety disorder, major depressive disorder (major mood disorder) and insomnia (inability to sleep.) The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive function, and received three days of antianxiety medications, six days of antidepressant and anticoagulant medications and 1 day of hypnotic medications during the seven day look back period. The Psychosocial Well-[NAME] Care Area Assessment (CAA), dated 09/09/21, assessed the resident with normal cognitive status and had little pleasure in doing things. The resident had diagnosis of anxiety and major depressive disorder and received therapy with the goal to return home. The resident received venlafaxine (an antidepressant 100 mg (milligrams) 0.5 tablet twice a day, diazepam (an antianxiety medication) 5 mg 0.5 tablet every eight hours as needed and zolpidem 10 mg, 0.5 tablet at night for insomnia. The Care Plan, dated 09/03/21, instructed staff the resident took medications with Black Box Warnings (a warning by the Food and Drug Administration for certain medications that carry serious safety risks. Often these warnings communicate potential rare but dangerous side effects, or they may be used to communicate important instructions for safe use of the drug.) Staff instructed to provide a calm, consistent, and matter of fact approach, encourage and praise the resident to participate in daily living activities. Staff instructed to encourage the resident to verbalize her feelings and thoughts. The Physician's Orders, dated 09/03/21, revealed the following medications of concern: On 09/03/21, Diazepam 5 milligram (mg), give 0.5 tablet every eight hours as needed for anxiety. On 09/03/21, Zolpidem 10 mg, give 0.5 tablet as needed for insomnia. Review of the Medication Administration Record from 09/03/21 through 09/22/21, revealed the resident received 11 doses of Diazepam and eight doses of Zolpidem. Observation, on 09/21/21 at 08:30 AM, revealed the resident sitting upright in her bed, asleep, with her breakfast on her over the bed table, uneaten. Interview, on 09/21/21 at 03:30 PM, with the resident, revealed she received therapy to build up strength to return home. Interview on 09/23/21 at 09:15 AM, with Licensed Nurse (LN) G, revealed the family members informed her that the resident routinely took the Zolpidem and Diazepam at home at night. Interview, on 09/23/21 at 10:45 AM, with Administrative Nurse D, confirmed the resident's family did inform the facility that the resident routinely took Zolpidem and Diazepam at home. Administrative Nurse D confirmed both medications continued past the 14-day limit for need for reevaluation for the continuation of the medications. Interview, on 09/23/21 at 11:30 AM, with Consulting Pharmacist GG, revealed he would expect the physician to reevaluate the Zolpidem and Diazepam after 14 days to reevaluate the medications for continued use. The facility policy Behavior Management and Psychotropic Medications, revised 12-2017, lacked a policy for the 14-day reassessment of as needed psychotropic medications. The facility failed to reevaluate the continued, as needed, use of Zolpidem and Diazepam past the 14-day use limitation, as required, to prevent adverse side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 30 residents with 15 residents sampled, including six residents reviewed for activities. Based on observation, interview, and record review, the facility failed to provide an ongoing program of individualized activities for five Residents (R)5, R 8, R 15, R 23, R 79, of the six sampled residents. Findings included: - The Physician Order Sheet (POS), dated 08/03/21, for Resident (R)5, documented diagnoses which included: anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome) and muscle weakness. The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 7, indicating impaired cognition. It was somewhat important to do her favorite activities, go outside to get fresh air and participate in religious services. She required extensive assistance of one staff for locomotion on and off of the unit. The Activities Care Area Assessment (CAA), dated 03/28/21, documented the resident had a diagnosis of a cerebral infarct (stroke-damage to tissues in the brain due to a loss of oxygen to the area) and for staff to offer activities to the resident. The quarterly MDS, dated 06/24/21, documented the resident had a BIMS score of 7, indicating impaired cognition. She required total assistance of one staff on and off of the unit. She was always incontinent of bowel and bladder. The care plan for activities, dated 06/18/21, instructed staff that the resident enjoyed talking with her family and 1:1 visits. Review of the resident's electronic medical record (EMR), under the Tasks tab, revealed one time of a staff member having a conversation with the resident. No other activities were documented as provided for the resident from 08/23/21 through 09/29/21. Review of the resident's Activity Assessment, dated 09/15/21, located under the Assessment tab of the resident's EMR, included the resident enjoyed reading her bible, visiting, learning classes and entertainment. She enjoyed watching TV and listing to the radio. On 09/21/21 at 10:51 AM, the resident sat in her wheelchair in her room. The TV was on, however, the resident was not watching it. On 09/20/21 at 01:00 PM, an activity of Book Reading took place in the facility. Staff did not invite the resident to attend. On 09/22/21 at 10:00 AM, an activity of Bingo took place in the facility. Staff did not invite the resident to attend. On 09/20/21 at 01:37 PM, Certified Nurse Aide (CNA) MM stated, the resident did not participate in activities. On 09/20/21 at 01:37 PM, CNA Q stated, the resident did not participate in activities because she was not able to do much on her own. On 09/21/21 at 04:20 PM, CNA O stated, the resident did not go to any activities in the facility. On 09/22/21 at 12:07 PM, CNA NN stated, activities are all documented in the resident's EMR. She does as much 1:1 with the residents as she can. At this time, there are not many activities for residents who require assistance. On 09/22/21 at 01:57 PM, Licensed Nurse (LN) G stated, the facility did not offer many activities for resident's who were unable to do things on their own. On 09/23/21 at 08:44 AM, Administrative Nurse D stated, it was the expectation for dependent residents to have some type of stimulation. The facility lacked an activities policy. The facility failed to provide an ongoing program of individualized activities for this dependent resident. - The Physician Order Sheet (POS), dated 08/03/21, documented Resident (R)8 had diagnoses which included: Parkinson's disease (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) and schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. It was somewhat important for him to listen to music he liked, be around animals such as pets, to keep up with the news, and to go outside when the weather was good. He required total assistance of one staff for locomotion on and off of the unit. The Activities Care Area Assessment, dated 01/07/21, did not trigger. The quarterly MDS, dated 07/02/21, documented the resident had a BIMS score of 3, indicating severely impaired cognition. He required extensive assistance of one staff for locomotion on and off of the unit. The activities care plan, dated 07/02/21, instructed staff to remind and encourage the resident to attend activities. Staff were to ensure the resident had an activity calendar in his room. Staff were to offer to visit with him 1:1 each day to encourage him to join in a group activity. Review of the resident's electronic medical record (EMR), under the Tasks tab, revealed the resident participated in conversation with staff twice from 08/24/21 thorough 09/21/21. No other activities were documented as provided for the resident. Review of the Activity Assessment, located in the resident's electronic medical record (EMR), dated 07/06/21, included that the resident enjoyed church services, visiting with others, entertainment, country music and pet visits. On 09/21/21, 09/22/21, and 09/23/20 at 10:00 AM, an activity of Bingo took place in the facility. Staff did not invite the resident to attend. On 09/20/21 at 03:14 PM, the resident sat in his darkened room with his eyes open. The TV was turned off, no music was playing, no activity calendar was in his room. On 09/21/21 at 04:47 PM, Certified Nurse Aide (CNA) O stated, the resident did not participate in activities. On 09/22/21 at 12:07 PM, CNA NN stated, activities are all documented in the resident's EMR. Shee does as much 1:1 with the residents as she can. At this time, there are not many activities for residents who require assistance. On 09/22/21 at 01:57 PM, Licensed Nurse (LN) G stated, in the past, the resident participated in activities all of the time, especially Bingo. Currently, there are not many activities available for resident's who aren't able to do things on their own. On 09/23/21 at 08:44 AM, Administrative Nurse D stated, it was the expectation for dependent residents to have some type of stimulation. The facility lacked an activities policy. The facility failed to provide an ongoing program of individualized activities for this dependent resident. - Review of R 79's Physician Order Sheet, dated 09/08/21 revealed the resident admitted to the facility on [DATE], with diagnoses that included senile degeneration (progressive mental disorder characterized by failing memory, confusion), diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), and hypothyroidism (condition characterized by hyperactivity of the thyroid gland). The admission Minimum Data Set (MDS,) dated 09/06/21, assessed the resident with severe cognitive impairment, and verbal behavior directed toward others, on one to three days, of the seven day look back period. The resident required extensive assistance for mobility with impairment in functional range of motion in both sides of the lower extremities. The resident received five days of antipsychotic, and antianxiety medications during the seven day look back period. The Activity Care Area Assessment (CAA), dated 09/06/21, assessed the resident with severe impaired cognitive function and a diagnosis of unspecified dementia the resident had a diagnosis of unspecified dementia (progressive mental disorder characterized by failing memory, confusion), with behaviors. The resident had clear speech and usually understood staff. The resident had agitation and anxiety and yelled at staff. One-on-one activities will be offered to the resident. The Care Plan, reviewed 09/16/21, instructed staff to encourage the resident to attend activities and become integrated and involved with life in the facility. Staff instructed to encourage the resident to visit with other residents and attend activities to keep busy. Observation, on 09/20/21 at 08:00 AM, revealed the resident positioned in his wheelchair in the common tv area, with his eye closed. The resident responded to his name by opening his eyes slowly. Observation, on 09/20/21 at 10:00 AM, revealed the resident continued seated in his wheelchair in the common tv area with his eyes closed. The tv was playing a country western music advertising commercial. Observation, on 09/21/21 at 12:10 PM, revealed the resident opened his eyes during the noon meal, but remained somnolent while CNA M fed the resident. Observation, on 09/21/21 at 12:52 PM, revealed CNA O and CNA N transferred the resident to bed with the mechanical lift. The resident remained somnolent. Interview with CNA N revealed she did not know what activity staff should provide to the resident. Interview, on 09/21/21 at 04:00 PM with CNA P, revealed the resident had yelling behaviors when first admitted , but now was cooperative and sleepy most of the time. Interview on 09/23/21 at 09:15 AM, with Licensed Nurse (LN) G, revealed the resident had yelling behaviors when first admitted , but now was somnolent through the day. LN G did not know what activities staff provided to the resident as he did sit in his wheelchair in the common tv area but did not know if he listened to the tv. Interview, on 09/23/21 at 10:45 AM, with Administrative Nurse D, revealed she would expect staff to provide activities to the resident. Interview, on 09/23/21 at 9:00 AM with Administrative Nurse F, revealed staff should provide one on one activities for the resident, and the resident did not attend bingo or group activities. The facility did not provide a policy for activities. The facility failed to provide this dependent resident with activity to enhance the quality of her life. - Review of resident (R)23's Physician Order Sheet, dated 09/10/21, revealed diagnoses included history of COVID-19, bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods) and dementia (a progressive mental disorder characterized by failing memory, confusion.) The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with severe impairment of cognitive function. The resident's preferences per staff interview revealed the resident liked animals, music, groups, outdoor and religious activities. The resident required extensive assistance of two staff for transfer and bed mobility and was dependent of staff for locomotion. The Activities Care Area Assessment (CAA), dated 08/19/21, assessed the resident with severe impaired cognitive function with clear speech, usually understands and was usually understood. The resident required total assistance with activities of daily living and was on hospice services. Staff to offer one on one activities. The Care Plan, reviewed 09/13/21, instructed staff to remind the resident of activities and allow the resident to attend activities/participate at her choice. The resident likes to join the bingo and move and stretch activity. Observation, on 09/20/21 at 8:30 AM, revealed the resident seated in her wheelchair in the assistive feeding room. The resident attempted to hold her cup and drink out of it. The resident responded to Certified Nurse Aide (CNA) MM who assisted the resident to drink from her cup. Observation, on 09/20/21, at 10:00 AM, revealed the resident seated in her wheelchair, in the common tv area. The resident's eyes were closed, and she dropped a stuffed puppy onto the floor. The activity bingo was taking place in the dining area. Interview, on 09/21/21 at 03:00 PM, with CNA M revealed the resident does not attend activities and did not watch/listen to tv. Interview, on 09/21/21 at 4:20 PM with CNA P, revealed staff got the resident out of bed for supper last, and returned her to bed first after the evening meal due to fall risk. Interview, on 09/22/21 at 12:18 PM, with Activity Staff Z, revealed the resident did not talk much, and did hold onto a stuffed dog. The resident liked to look out a window and used to like looking at the birds in the cage in the dining room when she used to wait for bingo to start. Activity Staff Z revealed she did not provide an activity of watching the birds. Interview, on 09/23/21 at 08:46 AM with Administrative Nurse D, revealed she would expect some activity for the resident. Interview, on 09/23/21 at 9:00 AM with Administrative Nurse F, revealed staff should provide one on one activities for the resident, and the resident did not attend bingo or group activities since her significant change in status after COVID-19 illness. The facility did not provide a policy for activities. The facility failed to provide this dependent resident with activity to enhance the quality of her life. - Review of resident (R) 15's Physician Order Sheet, dated 09/22/21, revealed diagnoses included Alzheimer's dementia (progressive mental deterioration characterized by confusion and memory failure) traumatic brain injury and depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness.) The admission Minimum Data Set (MDS), dated [DATE], assessed the resident had severe cognitive impairment. Staff assessed the resident's activity preferences as listening to music and going outside, being around animals and groups of people and religious services. The Psychosocial Care Area Assessment (CAA), dated 07/02/21, assessed the resident had clear speech at times and understood verbal communications. The Care Plan, reviewed 08/13/21, instructed staff the resident had cognitive loss that affected her memory and the resident needed to develop a trusting therapeutic relationship with others. Staff need to establish a regular daily schedule. The care plan lacked specific activities for the resident. Observation, on 09/20/21 at 10:00 AM, revealed the resident in her wheelchair in the common tv area. The resident made repetitive monotonal noises and did not focus on the television. Staff provided residents with bingo in the dining room at that time. Observation, on 09/21/21 at 08:30 AM, revealed the resident seated in her wheelchair in the assisted dining room. The resident had word salad and had repetition of noises. The resident propelled herself around the table and touched objects on the table. Interview, on 09/22/21 at 12:15 PM with Activity Staff Z, revealed the resident was unable to verbalize activity preferences and could not complete an activity assessment as family did not come in to interview. Activity Staff Z stated the resident liked to hold a baby doll at times and thought staff provided laundry for the resident to fold, but she dropped the items on the floor. Activity Staff Z stated she thought about a keyboard for the resident. Interview on 09/23/21 at 08:46 AM, with Administrative Nurse D, revealed she would expect staff to provide activities to the resident. The facility did not provide a policy for activities. The facility failed to provide this confused resident with activity to enhance the quality of her life.

The facility reported a census of 30 residents. Based on observation and interview, the facility failed to ensure sanitary food preparation and storage for the residents of the facility. Findings included: - Observation of the initial kitchen tour, on 09/20/21 at 09:47 AM, revealed the following items of concern in the refrigerator: Nine single serving containers of salsa dated 08/31/21 (20 days old). Tomato soup in a quart container, half full, labeled 08/30/21 (21 days old). Potato salad in a quart container, half full, labeled 08/30/21 (21 days old). The walk-in refrigerator contained an opened box of individually packaged butter positioned directly on the floor of the refrigerator. Three packages of white bread, with best by dates of 09/16/21 and two with the date of 09/19/21. One partial loaf of bread with best by date of 09/16/21. Three packages of hot dog buns with best by dates of 08/26/21 and two with best by dates of 09/12/21. Interview, on 09/20/21 at 09:57 AM, with dietary staff CC, confirmed the above refrigerated items should be stored three to five days after opening and confirmed the baked good items were past the best by date. Environmental tour of the kitchen on 09/22/21 at 02:26 PM, with Dietary Staff BB, revealed the following areas of concern: The deep fat fryer with dirt and grime on the fryer. Interview, at that time with Dietary Staff BB revealed it had not been used for approximately one month due to lack of cleaning/lack of staff. The four shelved cart holding spices contained debris and dust on all four shelves and the wheels contained an accumulation of grime. Three food service carts with beverages, tableware, and cooking implements contained shelves with dust/grime and wheels with accumulation of grime. The stove contained seven control knobs with grime and dust accumulation and six burners with an accumulation of grime and grease. Nine dish racks contained discolorations and scratches making sanitation difficult. Interview, on 09/22/21 at 03:00 PM, with Dietary Staff BB, confirmed the above areas in need of cleaning for sanitation and reveled staff follow the cleaning schedule for the above areas of concern, but due to lack of dietary staff, some issues were missed. Dietary Staff BB confirmed the baked goods were past their best by date and the above noted refrigerated items were beyond their storage time for safe consumption. The facility did not provide a policy for food storage. The facility policy Sanitation of Dining and Food Service Areas, dated 2016, instructed staff to uphold the sanitation in the dining areas according to a thorough,written schedule. The Cleaning Rotation, dated 2016, indicated stove top and food carts cleaned daily and shelves cleaned weekly. The facility failed to store and prepare food in a sanitary manner to prevent food borne illness for the residents of the facility.