**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 38 residents. The sample included 12 residents. Based on observation, record review, and, interview, the facility failed to revise the care plan with effective intervention to prevent re-traumatization for Resident (R)2 related to a diagnosis of post-traumatic stress disorder (PTSD-mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). This placed the resident at risk for impaired care due to uncommunicated care needs. Findings included: - R2's Electronic Medical Record (EMR) documented diagnoses of PTSD, epilepsy (brain disorder characterized by repeated seizures), heart failure, weakness, morbid obesity (excessive body fat), and localized edema (swelling). R2's Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had intact cognition. R2 used a walker and required substantial/maximal assistance with toileting and upper and lower body dressing. R2 required partial/moderate assistance with personal hygiene. R2 was independent with bed mobility and transfers. The MDS further documented a PTSD diagnosis. R2 received scheduled pain medication, an antianxiety (class of medications that calm and relax people), an antidepressant (class of medications used to treat mood disorders), and a diuretic (medication to promote the formation and excretion of urine). The Psychosocial Well-Being Care Area Assessment (CAA), dated 08/01/23, documented R2 had lost a close family member and had feelings of sadness, tearfulness, and loss. R2 stated he had accepted the loss but still had times of sadness. R2's Care Plan, initiated 04/28/21, documented R2 used antianxiety medications related to adjustment issues, his mother's death, and PTSD. The care plan directed staff to monitor anxiety, document side effects and effectiveness of antianxiety, and discuss with R2's health care provider and family if there is an ongoing need for the use of medications. The care plan lacked information regarding triggers and interventions related to R2's PTSD to prevent re-traumatization. The Trauma Assessment, dated 04/30/24, documented the purpose of the assessment was to identify residents who were survivors of trauma, to understand how trauma currently affected functioning, and to determine what triggers may cause re-traumatization. The assessment inquired if the resident had experienced some form of trauma or a stressful event, and R2's assessment recorded an answer of no, despite the diagnosis of PTSD The assessment further inquired how trauma currently affected the person, the trauma symptoms and triggers, support and coping strategies, and care planning. The latter portion of the assessment lacked descriptions and was incomplete. The Progress Note, dated 08/17/23 at 10:07 AM, documented R2 was in attendance at the care conference. The note further documented the review of R2's diet, weight, and activity involvement; there were no medication changes. The note recorded that a talk therapy appointment was set up for each month and the facility would transport R2 to sessions. The Progress Note, dated 05/07/24 at 10:19 AM, documented R2 verbalized feelings related to his emotional state and shared his grief with his caregivers. R2 expressed satisfaction with friendships and an improved mood state. R2 reported fewer episodes of anxiety behavior but had a continued need for 24-hour care in a nursing facility. On 06/27/24 at 02:05 PM, observation revealed R2 in his room, listening to music. R2 reported music helped his mood. On 07/02/24 at 09:57 AM Certified Nurse Aide (CNA) N reported knowledge of R2's PTSD diagnosis but was not aware of the cause or what may trigger the resident. CNA N reported she could tell when something was not right with R2's mood and said she tried to have an upbeat attitude which seemed to be effective. On 07/02/24 at 10:13 AM, Licensed Nurse (LN) J reported R2 was not having behaviors and was generally happy. LN J was not sure what may trigger PTSD for the resident. On 07/02/24 at 11:26 AM CNA P reported she thought R2's PTSD might have come from something experienced in his childhood and said R2 had not exhibited behaviors. On 07/02/24 at 11:19 AM, Administrative Nurse E verified the care plan lacked triggers or coping strategies for staff. On 07/02/24 at 02:28 PM, Administrative Nurse D verified R2 had a PTSD diagnosis which stemmed from a history of COVID-19 and his family member's death. Administrative Nurse D verified the care plan lacked triggers and coping strategies that would benefit the resident. The facility did not provide a care plan policy. The facility failed to ensure the care plan to include triggers that may cause re-traumatization related to R2 's diagnosis of PTSD which placed the resident at risk for impaired care due to uncommunicated care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 38 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide nursing care that met the standards of practice for Resident (R) 25 when nursing staff failed to monitor the resident's intake and administer tube feedings per the physician's orders and failed to monitor urine output and report decreased output to the physician. This deficient practice placed the resident at risk for medical complications. Findings included: - R25's Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), dysphagia (swallowing difficulty), gastrostomy status (G-tube: tube surgically placed through an artificial opening into the stomach), unspecified protein-calorie malnutrition, encephalopathy (broad term for any brain disease that alters brain function or structure), urogenital candidiasis (yeast infection), obstructive and reflux uropathy (blocked or reduce urine flow), urinary tract infection (UTI), and weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R25 had severe cognitive impairment, disorganized thinking, and an altered level of consciousness present which fluctuated. R25 had not exhibited behaviors. R25 had no functional range of motion impairment and used a walker and wheelchair for mobility. R25 was dependent on staff for eating, oral care, toileting, bathing, upper and lower body dressing, and mobility. The MDS further documented R25 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag) and was always incontinent of bowel. He had no pain or pain treatments. R25 had a feeding tube (G-tube) and a mechanically altered diet; he received 51 percent (%) or more of his total calories through tube feeding with a fluid intake of 501 cubic centimeters (cc)/day or more. The resident received an antipsychotic (class of medications used to treat major mental conditions that cause a break from reality), antidepressant (class of medications used to treat mood disorders), antibiotic (medication to treat infections), and antiplatelet (medication to prevent blood from clotting). The antipsychotics were received on a routine basis only with no gradual dose reduction (GDR) attempted and no physician-documented GDR as clinically contraindicated. R25 also received speech and occupational therapy. The Nutritional Status Care Area Assessment (CAA), dated 02/21/24, documented R25 had scored a six on the nutritional assessment which indicated he was malnourished. R25 had not been eating while he was hospitalized , so a G-tube was placed; all nutrition and medications were given through the tube. The Feeding Tube Care Area Assessment (CAA), dated 02/21/24, documented that while hospitalized , R25 was not eating; a G-tube was placed, and all nutrition and medications were given via tube. The Dehydration/Fluid Maintenance Care Area Assessment (CAA), dated 02/21/24, documented R25 receives all fluids through G-tube. R25 received water before and after feedings and one other time during the day. Labs were monitored as ordered. R25's Care Plan, dated 05/20/24, documented R25 had an indwelling catheter related to neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system) and instructed staff to monitor and document for pain or discomfort due to catheter. The plan directed staff to document output and monitor, record, and report to the health care provider for signs and symptoms of urinary tract infections. R25's Care Plan, dated 05/20/24, documented R25 met the criteria for malnutrition related to weight loss. The plan directed staff to monitor R25's weight weekly. R25's Care Plan, dated 05/20/24, documented R25 had nutrition problems related to G-tube feedings and medication. The care plan documented R25 had an order for a puree (smooth creamy constancy) diet and extremely thick liquids. R25 required assistance with eating; staff were to monitor for choking. The plan documented R25 had an order for Two- cal HN 2.0 (liquid nutritional supplement), 237 milliliters (ml) five times a day with 120 ml of water before and after feedings. R25's EMR recorded the following weights: 06/13/24 150.0 pounds (lbs.) 06/20/24 149.0 lbs. 06/27/24 146.8 lbs. The Physician Order, dated 06/14/24, directed staff to administer Two-cal HN 2.0 oral liquid 237 ml via G-tube three times a day related to dysphagia; flush with 120 ml of water before and after feeding. Administer if the resident ate less than 50% of his meal. The Dietary Progress Note, dated 06/26/24 at 09:35 AM, documented R25 had a loss of two pounds (lbs.) since 05/30/24. He received a regular diet with a minced and moist texture and had an oral intake of 51 to 100% at most meals. The tube feeding was changed to Two-cal HN 237 ml three times a day as needed if R25's intake was less than 50% at meals. R25's diet was supplemented with Boost Breeze (nutrition drink) daily at noon and the note recommended to increase the Boost to twice a day. R25's EMR lacked documentation of oral meal intake for 15 of 45 meal opportunities from 06/14/24 through 06/30/24. R25's EMR, including the Medication Administration Record/Treatment Administration Record (MAR/TAR), lacked documentation that staff assessed R25 for the need to administer, or that staff administered R25's physician-ordered Two-cal HN via his G-tube for those 15 of 45 opportunities when meal intakes were not monitored and recorded. R25's EMR under the Tasks for June 2024 recorded a urinary output of less than 30 ml hourly (720 ml) in a 24-hour period indicating minimal kidney function for 15 days in June 2024. R25's EMR lacked evidence the nursing staff identified this irregularity and reported it to R25's physician. On 06/27/24 at 08:30 AM, observation revealed R25 sitting in the dining room with Certified Nurse Aide (CNA) M sitting next to him. CNA M fed the resident a ground and minced diet of eggs, ground sausage, and a thin liquid supplement. R25 ate without any signs of difficulty. CNA M reported that R25 was eating well, but the resident had been in a mood for several days and had not eaten well. On 07/02/24 at 08:02 AM, CNA O reported that R25 required assistance with eating. CNA O stated the dietary staff recorded the intake of the resident. On 07/02/24 at 08:03 AM, Dietary Staff (DS) BB stated the dietary department recorded R25's intake into the EMR and reported to the charge nurse what R25's intake was, especially if the resident did not eat well. On 07/02/24 at 08:30 AM, Licensed Nurse (LN) H reviewed the EMR and stated R25 should have received supplemental G-tube feeding if he ate less than 50%. LN H said R25 continued with physician-ordered flush twice a day. to get water flushes two times a day. On 07/02/24 at 12:20 PM Administrative Nurse D stated R25's meal intakes should have been monitored and recorded and supplemental tube feeding given if the resident ate less than 50%. Administrative Nurse D verified nursing staff had not recorded supplemental feeding and verified it was the nurse's responsibility to ensure the need for supplemental feeding if needed. Administrative Nurse D said R25's urine output should be recorded in the EMR and it was the nursing staff's responsibility to assess for adequate urine output to promote health maintenance. The facility's Intake and Output with Hydration Guidelines policy, dated 05/07/24, the purpose of the policy is to measure fluid intake and/or output when ordered by the medical provider, on residents who receive G-tube feedings or have urinary catheters, to ensure that residents receive sufficient fluid intake to maintain proper hydration and health and to provide staff with ideas for hydration implementation. The policy further documented the facility to maintain acceptable parameters of nutritional status, unless the resident's clinical condition demonstrates that this is not possible or resident preference indicates otherwise and is offered sufficient fluid intake to maintain proper hydration and health. The facility failed to provide nursing care that met the standards of practice for R25 when nursing staff failed to monitor the resident's intake and administer tube feedings per the physician's orders and failed to monitor urine output and report decreased output to the physician. This deficient practice placed the resident at risk for medical complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 38 residents. The sample included 12 residents with three residents reviewed for urinary catheter care. Based on observation, interview, and record review, the facility failed to provide urinary catheter (a tube inserted into the bladder to drain urine into a collection bag) care in a manner to prevent urinary tract infections (UTI-an infection in any part of the urinary system) for Resident (R) 22 and R91. This placed the two residents at risk for infections and catheter-related complications. Findings included: - R22's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke), acute and chronic kidney failure (a condition in which the kidneys lose the ability to remove waste and balance fluids), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), hyperlipidemia (condition of elevated blood lipid levels), hypercholesterolemia (greater than normal amounts of cholesterol in the blood), anxiety disorders (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and urinary tract infection. The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. The MDS documented R22 had no behaviors. R22 required maximal to total assistance for mobility, dressing, and toileting and had a urinary catheter. The MDS documented R22 received insulin (a hormone used to regulate blood glucose levels), antipsychotics (a class of medications used to treat major mental conditions that cause a break from reality), and antidepressant medications (a class of medications used to treat mood disorders). R22 received psychiatric therapy and a gradual dose reduction (GDR) of the antipsychotic drug had been attempted. The Care Area Assessment (CAA), dated 05/10/24, stated R22 had a Foley (brand name) catheter due to retention, was prone to UTIs, and received a prophylactic (preventative in nature) antibiotic (a medicine that inhibits the growth of or destroys microorganisms). Staff provide catheter care every shift and the catheter is changed as ordered and as needed. R22's Care Plan, dated 05/14/24, stated R22 had a Foley catheter related to urinary retention and surgery, initiated on 05/08/23 and revised on 02/21/24. The care plan directed staff to monitor, and document for pain or discomfort due to the catheter initiated 05/08/23. Use enhanced barrier precautions (EBP -infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact care) with care. The plan instructed staff to wear disposable gowns when performing high-contact resident care activities, doff gown and gloves inside the resident room, and complete hand hygiene before leaving the room, initiated 03/29/24, and revised on 06/05/24. R22 has a Foley Catheter 16 French (Fr-size), initiated 05/08/23. The plan directed staff to document output initiated on 02/08/24 and perform catheter care by CNA (Certified Nurse Aide) every shift, initiated on 02/16/24, and revised on 03/29/24. R22 has the potential for UTI related to catheter use and a history of UTIs, initiated on 02/21/24. The plan directed staff to collect specimens for culture and sensitivity as ordered, initiated 02/21/24. R22's EMR documented UTIs with antibiotic medication ordered on 08/31/23, 12/30/23, 01/12/24, 02/14/24, and 04/01/24. The 02/14/24 and 04/01/24 urine cultures documented Carbapenem-resistant Enterobacteriaceae (CRE-resistant bacterial infection), a multi-drug resistant organism (MDRO common bacteria that have developed resistance to multiple types of antibiotics). The Progress Note, dated 06/05/24 at 11:40 AM, documented R22 was readmitted to the facility after hospitalization for UTI and received intravenous (IV-administered directly into the bloodstream via a vein) antibiotics. On 06/26/24 at 02:50 PM, observation revealed R22 in his wheelchair in the hall. CNA N assisted R22 to the common resident bathroom where she performed catheter care by emptying the drainage bag. CNA N donned gloves but no gown set the measuring container on a barrier on the floor, emptied the catheter drainage bag, and used an alcohol wipe on the port. CNA N changed gloves without washing her hands, placed the drainage bag back into a privacy bag under the wheelchair, and took the resident back out to the commons area. On 06/27/24 at 01:02 PM, observation revealed R22 in his wheelchair in the hall with the catheter drainage bag in a privacy bag under the wheelchair. Approximately two inches of catheter tubing dragged on the floor when he self-propelled into the nurse's office. There was a wet area observed on the front of R22's slacks and Licensed Nurse (LN) I placed a towel over the wet spot and wheeled the resident to another area to weigh him, per his request, while four inches of catheter tubing dragged on the floor during the transport. On 06/27/24 at 01:27 PM, observation revealed CNA O took R22 in his wheelchair to his room with the catheter tubing dragging on the hallway floor. On 07/02/24 at 09:32 AM, LN H stated staff were to provide catheter care every shift and said staff should use gowns and gloves. LN H stated staff should not provide care in the common bathroom without EBP. On 07/02/24 at 09:42 AM, Administrative Nurse D verified the catheter tubing should not be allowed to drag on the floor and that staff should not use the common bathroom for catheter care. She stated staff should have used EBP every time they provided any catheter care. The facility's Enhance Barrier Precautions (EBP) Protocol, directed staff to determine if EBP was needed for residents with wounds or indwelling medical devices and all residents infected or colonized with select MDROs. Staff was to set up a personal protective equipment (PPE) station inside the resident's room, notify staff that EBP was needed during high contact care, post signs on resident doors, update the care plan, and educate staff, residents, and family. The facility's Catheter Care policy, dated 02/10/23, stated every effort would be made to keep a resident's catheter covered or out of sight, and catheter tubing should never be allowed to touch the floor. When emptying the catheter bag, place a moisture-resistant barrier beneath the measuring container and avoid placing the container on the floor. When finished draining, clean the drainage port with an alcohol wipe and replace it in the holder. Measure and record the volume, discard the urine in the toilet and wash and dry the container according to facility procedures. The facility failed to provide urinary catheter care in a manner to prevent urinary tract infections R22. This placed the resident at risk for further UTI and other catheter-related complications. - R91's Electronic Medical Record (EMR) documented diagnoses of cervical/neck spine fracture and urinary hesitancy (difficulty starting or maintaining a urine stream). R91 was admitted to the facility on [DATE] following hospitalization for a fall and treatment of a urinary tract infection. R91's Catheter Care Plan, dated 06/25/24, stated R91 had an indwelling urinary catheter related to a neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system) and directed staff to monitor for pain or discomfort due to the catheter, document intake, and output, and provide catheter care every shift. The care plan stated R91 required enhanced barrier precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) related to the indwelling catheter, initiated on 06/26/24. Staff was to don a gown and gloves when performing high-contact care activities including dressing, bathing, transferring, providing hygiene such as shaving or brushing teeth, changing linens, repositioning, checking and changing, device care or use, and wound care initiated on 06/26/24. The plan directed staff to doff gown and gloves inside the resident's room and perform hand hygiene, initiated on 06/26/24. On 06/27/24 at 11:57 AM, observation revealed R91 stood in his bathroom and stated he had emptied his urinary leg bag just now in the bathroom. Certified Nurse Aide (CNA) Q assisted R91 to his recliner with a walker, gait belt, and minimal assistance. CNA Q gloved but did not don an isolation gown. She performed peri-care, removed gloves, and assisted R91 to stand and transfer to his wheelchair. On 07/01/24 at 08:35 AM, observation revealed R91 sat in his wheelchair at a dining table independently eating. R91's urinary catheter bag hung under his wheelchair without a privacy bag or cover and yellow urine was visible to other residents in the dining room. On 07/01/24 at 01:50 PM, observation revealed R91 in his room in a wheelchair. CNA M donned gloves, but no isolation gown, set a measuring container directly on the floor with no barrier, removed the catheter drainage bag from under the wheelchair, and set it on the floor. CNA M used an alcohol wipe on the port before and after draining the bag, dropped the alcohol wipe on the floor then picked it up and wiped the inside of the port holder on the bag with the contaminated wipe. CNA N attempted to place the drainage bag back into the privacy bag under the wheelchair, and at one point placed the urine collection bag on the floor while trying to attach the privacy bag under the wheelchair. CNA M removed his gloves and attached the privacy bag, handled the Foley bag, and then emptied the urine container into the toilet. He used hand gel before leaving the room. On 06/27/24 at 03:40 PM, Administrative Nurse D stated EBP should have been initiated for R91's catheter care the day he was admitted (06/25/24) and verified it had not been. On 07/01/24 at 01:57 PM, CNA M verified staff should not set the drainage bag on the bare floor. He was not aware the resident was on EBP for the catheter. On 07/01/24 at 02:00 PM, Administrative Nurse D verified the resident was on EBP and showed the bookmark size EBP sign attached to the doorframe. The resident had a small plastic three-drawer cart in the room with EBP supplies, but no sign to indicate that was what was in it. On 07/02/24 at 09:42 AM, Administrative Nurse D verified catheter tubing should not be allowed to drag on the floor and staff should not use the common bathroom for catheter care. Staff should have used EBP every time they provided any catheter care. The facility's Enhance Barrier Precautions (EBP) Protocol, directed staff to determine if EBP was needed for residents with wounds or indwelling medical devices and all residents infected or colonized with select MDROs. Staff was to set up a PPE station inside the resident's room, notify staff that EBP was needed during high contact care, post signs on resident doors, update the care plan, and educate staff, resident, and family. The facility's Catheter Care policy, dated 02/10/23, stated every effort would be made to keep a resident's catheter covered or out of sight, and catheter tubing should never be allowed to touch the floor. When emptying the catheter bag, place a moisture-resistant barrier beneath the measuring container and avoid placing the container on the floor. When finished draining, clean the drainage port with an alcohol wipe and replace it in the holder. Measure and record the volume, discard the urine in the toilet and wash and dry the container according to facility procedures. The facility failed to provide urinary catheter care in a manner to prevent urinary tract infections and to maintain dignity for R91. This placed R91 at risk for further UTI and other catheter-related complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 38 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R)2 received trauma-informed care to eliminate or mitigate triggers that may cause re-traumatization related to a diagnosis of post-traumatic stress disorder (PTSD-mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). This placed the resident at risk for unmet behavioral health care needs. Findings included: - R2's Electronic Medical Record (EMR) documented diagnoses of PTSD, epilepsy (brain disorder characterized by repeated seizures), heart failure, weakness, morbid obesity (excessive body fat), and localized edema (swelling). R2's Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had intact cognition. R2 used a walker and required substantial/maximal assistance with toileting and upper and lower body dressing. R2 required partial/moderate assistance with personal hygiene. R2 was independent with bed mobility and transfers. The MDS further documented a PTSD diagnosis. R2 received scheduled pain medication, an antianxiety (class of medications that calm and relax people), an antidepressant (class of medications used to treat mood disorders), and a diuretic (medication to promote the formation and excretion of urine). The Psychosocial Well-Being Care Area Assessment (CAA), dated [DATE], documented R2 had lost a close family member and had feelings of sadness, tearfulness, and loss. R2 stated he had accepted the loss but still had times of sadness. R2's Care Plan, initiated [DATE], documented R2 used antianxiety medications related to adjustment issues, his mother's death, and PTSD. The care plan directed staff to monitor anxiety, document side effects and effectiveness of antianxiety, and discuss with R2's health care provider and family if there is an ongoing need for the use of medications. The Trauma Assessment, dated [DATE], documented the purpose of the assessment was to identify residents who were survivors of trauma, to understand how trauma currently affected functioning, and to determine what triggers may cause re-traumatization. The assessment inquired if the resident had experienced some form of trauma or a stressful event, and R2's assessment recorded an answer of no, despite the diagnosis of PTSD The assessment further inquired how trauma currently affected the person, the trauma symptoms and triggers, support and coping strategies, and care planning. The latter portion of the assessment lacked descriptions and was incomplete. The Progress Note, dated [DATE] at 10:07 AM, documented R2 was in attendance at the care conference. The note further documented the review of R2's diet, weight, and activity involvement; there were no medication changes. The note recorded that a talk therapy appointment was set up for each month and the facility would transport R2 to sessions. The Progress Note, dated [DATE] at 10:19 AM, documented R2 verbalized feelings related to his emotional state and shared his grief with his caregivers. R2 expressed satisfaction with friendships and an improved mood state. R2 reported fewer episodes of anxiety behavior but had a continued need for 24-hour care in a nursing facility. On [DATE] at 02:05 PM, observation revealed R2 in his room, listening to music. R2 reported music helped his mood. On [DATE] at 09:57 AM Certified Nurse Aide (CNA) N reported knowledge of R2's PTSD diagnosis but was not aware of the cause or what may trigger the resident. CNA N reported she could tell when something was not right with R2's mood and said she tried to have an upbeat attitude which seemed to be effective. On [DATE] at 10:13 AM, Licensed Nurse (LN) J reported R2 was not having behaviors and was generally happy. LN J was not sure what may trigger PTSD for the resident. On [DATE] at 11:26 AM CNA P reported she thought R2's PTSD might have come from something experienced in his childhood and said R2 had not exhibited behaviors. On [DATE] at 11:19 AM, Administrative Nurse E reported R2 had experienced a personal history of COVID-19 (highly contagious respiratory virus) and had to be hospitalized far from the facility, due to lack of hospital bed availability. When R2 returned to the facility, a close family member also contracted Covid-19 and died. Administrative Nurse E said R2 began having thoughts that bothered him and had been throwing things. She reported R2 started seeing a counselor which helped. Administrative Nurse E verified the care plan lacked triggers or coping strategies for staff. On [DATE] at 02:28 PM, Administrative Nurse D verified R2 had a PTSD diagnosis which stemmed from a history of COVID-19 and his family member's death. Administrative Nurse D verified the care plan lacked triggers and coping strategies that would benefit the resident. The facility's Trauma Informed Care policy, dated [DATE], documented the purpose of the policy was to provide trauma-informed care and avoid re-traumatization. Trauma-informed care means being intentional by anticipating and avoiding institutional processes and practices that are likely to re-traumatize a resident who has a history of trauma. Staff will ensure that residents who experience trauma receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization. The facility failed to ensure R2 received trauma-informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident which placed the resident at risk for unmet care, emotional, and psychosocial needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R25 ' s Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), dysphagia (swallowing difficulty), gastrostomy status (G-tube: tube surgically placed through an artificial opening into the stomach), unspecified protein-calorie malnutrition, encephalopathy (a broad term for any brain disease that alters brain function or structure), urogenital candidiasis (yeast infection), obstructive and reflux uropathy (blocked or reduce urine flow), urinary tract infection (UTI), and weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R25 had severe cognitive impairment, disorganized thinking, and an altered level of consciousness present which fluctuated. R25 had not exhibited behaviors. R25 had no functional range of motion impairment and used a walker and wheelchair for mobility. R25 was dependent on staff for eating, oral care, toileting, bathing, upper and lower body dressing, and mobility. The MDS further documented R25 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag) and was always incontinent of bowel. He had no pain or pain treatments. R25 had a feeding tube (G-tube) and a mechanically altered diet; he received 51 percent (%) or more of his total calories through tube feeding with a fluid intake of 501 cubic centimeters (cc)/day or more. The resident received an antipsychotic (class of medications used to treat major mental conditions that cause a break from reality), antidepressant (class of medications used to treat mood disorders), antibiotic (medication to treat infections), and antiplatelet (medication to prevent blood from clotting). The antipsychotics were received on a routine basis only with no gradual dose reduction (GDR) attempted and no physician-documented GDR as clinically contraindicated. R25 also received speech and occupational therapy. The Psychotropic Drug Use Care Area Assessment (CAA), dated 02/21/24, documented R25 received an antidepressant for depression. It was hard to determine if the resident was depressed. He was not happy with his situation and would hit out at staff when they were giving care. The CAA further documented the monitoring of medication side effects and depression. R25's Care Plan dated 05/20/24 documented R25 received medications with Black Boxed Warnings (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration)or warnings of adverse consequences. The care plan directed staff to consult with the pharmacy and healthcare provider to consider dosage reduction when clinically appropriate. R25's Care Plan dated 05/20/24 documented R25 used psychotropic medications related to anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and directed staff to consult with the pharmacy and health care provider to consider dosage reduction when clinically appropriate; monitor for signs and symptoms of anxiety. The Physician Order dated 05/11/24 directed staff to administer Zyprexa (antipsychotic) 2.5 milligrams (mg) by mouth two times a day for anxiety and every six hours as needed for anxiety. The order lacked a 14-day stop date for the PRN dose. R25's EMR recorded Zyprexa 2.5 mg PRN dose was administered on 06/15/24 at 06:45 PM. The Progress Note dated 02/22/24 documented a note to the physician from the facility that R25 had more frequent yelling throughout the day and night; Tylenol PRN seemed ineffective and R25 denied pain. R25's family felt the behaviors were anxiety related, and R25 currently took Zyprexa 2.5 mg daily and Celexa (antidepressant) 20 mg daily. The physician responded by increasing R25's Zyprexa to 2.5 mg twice a day. The Consultant Pharmacist [CP] Progress Notes dated 03/28/24, 04/24/24, 05/28/24, and 06/25/24, lacked evidence the CP identified and reported related to the use of Zyprexa without an approved indication, or a documented physician rationale which included the nonpharmacological interventions which were tried and failed as well as a risk versus benefit for the use of an antipsychotic. The notes also lacked evidence the CP identified and reported the lack of the required 14-day stop date for the PRN Zyprexa. On 06/27/24 at 08:30 AM, observation revealed R25 sitting in the dining room with Certified Nurse Aide (CNA) M sitting next to him. CNA M fed the resident a ground and minced diet of eggs, ground sausage, and a thin liquid supplement. R25 ate without any signs of difficulty. CNA M reported R25 was eating well, but the resident had been in a mood for several days and had not eaten well. On 07/02/24 at 11:07 AM, CNA P reported R25 was not capable of verbalization most of the time. CNA P stated that R25 occasionally punched out at the staff, but not hard, and this usually happened during bathing. CNA P reported giving R25 time and space for about 10 minutes and this helped with behaviors. On 07/02/24 at 12:20 PM Administrative Nurse D verified R25's Zyprexa had an unapproved indication of anxiety. Administrative Nurse D verified the CP had not reported that the needed Zyprexa did not have a stop date The facility's Drug Regimen Review policy, dated 02/10/23, stated a drug regimen review was performed for each resident at least once a month by a licensed pharmacist. The licensed pharmacist completes the drug regimen review by assessing the medication list and the resident's medical chart to identify potentially significant medication issues and notifies the physician if any discrepancies are found or additional information needed. The pharmacist would follow up until a response was received from the physician. The pharmacist would review to identify that medication doses and duration are appropriate, medication-related errors, and gradual dose reductions. The pharmacist would complete a Medication Regimen Review summary and ensure the director of nursing services and the physician receive a copy. These reports must be acted upon. The facility failed to ensure the CP identified and reported that R25 lacked a 14-day stop for the use of PRN psychotropic medication and lacked an appropriate indication for Zyprexa. This placed the resident at risk for inappropriate use of medications. The facility had a census of 38 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to follow up on the Consultant Pharmacist (CP) recommendations regarding antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and psychotropic (alters mood or thought) medication use for Resident (R)22, R32, and R25 and failed to ensure the CP identified and reported the lack of a stop date for R25's as needed psychotropic medication. This placed the three residents at risk to continue receiving unnecessary psychoactive medications without an explanation of why the benefits outweighed the risks. Findings included: - R22's Electronic Medical Record (EMR) documented diagnoses of anxiety disorders (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cerebral infarction (stroke), acute and chronic kidney failure (condition in which the kidneys lose the ability to remove waste and balance fluids), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. The MDS documented R22 had no behaviors. R22 required maximal to total assistance for mobility, dressing, and toileting. R22 received antipsychotic and antidepressant medications (a class of medications used to treat mood disorders). The Psychotropic Drug Use Care Area Assessment (CAA), dated 05/10/24, stated R22 received a small dose of Zyprexa (antipsychotic) for anxiety and Celexa (antidepressant). The CAA documented that R22's mood has been stable, and he was doing well. R22 was seen by the tele-psych nurse for medication changes and status. R22's Care Plan, dated 05/14/24, directed staff to allow the resident time to respond due to slower processing of cognition skills. In the presence of behaviors or anxiety, staff were to provide opportunities for positive interaction and attention. The plan directed staff to minimize the potential for the resident's disruptive behaviors by offering tasks that divert attention. The plan directed staff to consult with the pharmacy and healthcare provider to consider dosage reduction when clinically appropriate. The Physician Order, dated 05/06/24, directed staff to administer Zyprexa (olanzapine) 2.5 milligrams (mg), two times a day for anxiety. The Physician Order, dated 03/18/2024, directed staff to administer Celexa (citalopram- antidepressant drug) 40 mg, at bedtime, for depression. The Medication Administration Record (MAR)/ Treatment Administration Record (TAR) documented R22 had no behaviors related to depression which included crying, isolation, yelling, change in mood, sadness, suicidal thinking, increased sleeping, or other depressive behaviors. R22 had no signs of psychosis which included crying, hallucinations, delusions, isolation, change in mood, sadness, suicidal thinking, increased sleeping, or other depressive behaviors. The Psychiatric Practitioner Note, dated 05/06/24, stated after tapering Zyprexa on 04/04/24, staff reported increased anxiety, excessive sleeping, and agitation. The prescriber increased Celexa to 30 mg after which staff reported some decrease in anxiety. The note stated R22's agitation begins at approximately 03:00 PM, but if identified, staff can calm R22 down most of the time. The practitioner ordered staff to continue Zyprexa 2.5 mg twice daily for mood or anxiety and increase Celexa to 40 mg daily. The Psychiatric Practitioner Note, dated 06/21/24, stated that R22 had a significant past psychiatric history. Staff reported increased anxiety, some frustration, and anxiety with communication due to a stroke. Staff reported that R22's anxiety levels had improved since he became aware of his schedule in advance. R22 stated he was doing well and not really having too much anxiety. He reported sleeping well and denied nightmares. The practitioner documented diagnoses of mood disorder with depressive features, dementia (a progressive mental disorder characterized by failing memory, and confusion), and generalized anxiety disorder. The note documented to continue to taper Zyprexa during subsequent visits as Kansas only approved the use of antipsychotics for certain diagnoses. The practitioner ordered to continue Celexa 20 mg daily for anxiety or mood. The Consultant Pharmacist Review, dated 11/14/23, questioned the diagnosis of anxiety for the use of Zyprexa. The physician responded- yes and documented anxiety without documenting a rationale for the indication or continued use of the antipsychotic medication. The Consultant Pharmacist Review, dated 12/13/23, recommended a gradual dose reduction (GDR) for Zyprexa and Celexa. The physician responded that R22 was evaluated by the psychiatric practitioner and ordered no changes without psychiatric physician involvement. No risk versus benefit rationale was documented. The Consultant Pharmacist Review, dated 06/06/24, recommended a GDR of Celexa 40 mg. The physician responded this was a recent increase with the in-house psychiatric practitioner, a GDR would be contradictive at this time. No risk versus benefit rationale was documented. On 06/27/24 at 07:31 AM, Licensed Nurse (LN) I administered an injection to R22. R22 stated he ate a good breakfast but couldn't remember exactly what he ate. On 07/01/24 at 01:22 PM, Administrative Nurse D verified the facility failed to follow up on the pharmacist consultant's recommendations to obtain an appropriate indication for use or a written rationale for the continued use of the Zyprexa which included the required documentation. The facility's Drug Regimen Review policy, dated 02/10/23, stated a drug regimen review was performed for each resident at least once a month by a licensed pharmacist. The licensed pharmacist completes the drug regimen review by assessing the medication list and the resident's medical chart to identify potentially significant medication issues and notifies the physician if any discrepancies are found or additional information is needed. The pharmacist would follow up until a response was received from the physician. The pharmacist would review to identify that medication doses and duration are appropriate, medication-related errors, and gradual dose reductions. The pharmacist would complete a Medication Regimen Review summary and ensure the director of nursing services and the physician receive a copy. These reports must be acted upon. The facility failed to follow up on the Pharmacist Consultant's recommendations regarding antipsychotic medication use for R22, placing the resident at risk for unnecessary psychotropic medications. - R32's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory, and confusion). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition. The MDS documented R32 was independent for mobility, toileting, walking, and dressing. The MDS documented R32 received antianxiety (a class of medications that calm and relax people) and antidepressant (a class of medications used to treat mood disorders) medications. R32's Care Plan, dated 04/15/24, stated R32 used anti-anxiety medications related to dementia with anxiety disorder and directed staff to monitor and document side effects and effectiveness. Monitor R32 frequently for safety. Offer diversionary activities such as one one-on-one discussions. Offer the use of a rocking chair to ease anxiety. The plan directed staff to consult with the pharmacy and healthcare provider to consider dosage reductions when clinically appropriate. The Physician Order, dated 10/11/23, directed staff to administer paroxetine (a type of antidepressant medication), 20 milligrams (mg) daily for anxiety. The Physician Order, dated 10/20/23, directed staff to administer clonazepam (antianxiety medication that works by increasing the levels of a calming chemical in your brain) 0.5 mg daily for dementia. The Pharmacist Consultant Review, dated 03/28/24, recommended a gradual dose reduction (GDR) of paroxetine 15 mg daily and clonazepam 0.5 mg daily which the pharmacist wrote had been administered since 10/11/23. The physician declined the recommendation and wrote clinically contraindicated without writing a rationale or risk versus benefit statement. The Physician Visit Note, dated 05/24/24, documented R32 had severe dementia but had adjusted to living in the facility and seemed to be happier. The note recorded there were no changes to R32's medications. On 07/01/24 at 12:55 PM, observation revealed R32 independently ambulated from his room to the commons area and sat for a music activity. He was very polite and calm. On 07/02/24 at 10:15 AM, Administrative Nurse D verified the facility had not obtained a physician-written risk versus benefit statement or rationale for continuing paroxetine and clonazepam as recommended by the pharmacist consultant. The facility's Drug Regimen Review policy, dated 02/10/23, stated a drug regimen review was performed for each resident at least once a month by a licensed pharmacist. The licensed pharmacist completes the drug regimen review by assessing the medication list and the resident's medical chart to identify potentially significant medication issues and notifies the physician if any discrepancies are found or additional information needed. The pharmacist would follow up until a response was received from the physician. The pharmacist would review to identify that medication doses and duration are appropriate, medication-related errors, and gradual dose reductions. The pharmacist would complete a Medication Regimen Review summary and ensure the director of nursing services and the physician receive a copy. These reports must be acted upon. The facility failed to follow up on the Pharmacist Consultant's recommendations regarding psychotropic medication use for R32, placing the resident at risk for unnecessary psychotropic medications.

The facility had a census of 38 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to ensure enhanced barrier precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for infection control were used when staff provided care for Resident (R) 22 and R91's urinary catheters (tube inserted into the bladder to drain urine into a collection bag). This placed residents at risk for potential infections and cross contamination. Findings included: - On 06/26/24 at 02:50 PM, observation revealed R22 in his wheelchair in the hall. CNA N assisted R22 to the common resident bathroom where she performed catheter care by emptying the drainage bag. CNA N donned gloves but no gown set the measuring container on a barrier on the floor, emptied the catheter drainage bag, and used an alcohol wipe on the port. CNA N changed gloves without washing her hands, placed the drainage bag back into a privacy bag under the wheelchair, and took the resident back out to the commons area. On 07/01/24 at 01:50 PM, observation revealed R91 in his room in a wheelchair. CNA M donned gloves, but no isolation gown, set a measuring container directly on the floor with no barrier, removed the catheter drainage bag from under the wheelchair, and set it on the floor. CNA M used an alcohol wipe on the port before and after draining the bag, dropped the alcohol wipe on the floor then picked it up and wiped the inside of the port holder on the bag with the contaminated wipe. CNA N attempted to place the drainage bag back into the privacy bag under the wheelchair, and at one point placed the urine collection bag on the floor while trying to attach the privacy bag under the wheelchair. CNA M removed his gloves and attached the privacy bag, handled the Foley bag, and then emptied the urine container into the toilet. He used hand gel before leaving the room. On 06/27/24 at 03:40 PM, Administrative Nurse D stated EBP should have been initiated for R91's catheter care the day he was admitted (06/25/24) and verified it had not been. On 07/01/24 at 02:00 PM, Administrative Nurse D verified the resident was on EBP and showed the bookmark size EBP sign attached to the doorframe. The resident had a small plastic three-drawer cart in the room with EBP supplies, but no sign to indicate that was what was in it. On 07/02/24 at 09:32 AM, LN H stated staff were to provide catheter care every shift and said staff should use gowns and gloves. LN H stated staff should not provide care in the common bathroom without EBP. On 07/02/24 at 09:42 AM, Administrative Nurse D verified the staff should have used EBP every time they provided any catheter care. The facility's Enhance Barrier Precautions (EBP) Protocol, directed staff to determine if EBP was needed for residents with wounds or indwelling medical devices and all residents infected or colonized with select MDROs. Staff was to set up a PPE station inside the resident's room, notify staff that EBP was needed during high contact care, post signs on resident doors, update the care plan, and educate staff, resident, and family. The facility failed to ensure EBP for infection control was used when staff provided care for R22 and R91's urinary catheters. This placed residents at risk for potential infections and cross-contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 38 residents. The sample included 12 residents with five reviewed for medications. Based on observation, interview, and record review, the facility failed to implement antibiotic (medication used to treat infections) stewardship protocols to avoid unnecessary and/or inappropriate antibiotic use to reduce the risk of adverse events, including antibiotic resistance, when the facility failed to monitor the effectiveness of and identified inappropriate extended administration of an antibiotic for Resident (R) 25. This placed the resident at risk for complications related to antibiotic use. Findings included: - R25 ' s Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), dysphagia (swallowing difficulty), gastrostomy status (G-tube: tube surgically placed through an artificial opening into the stomach), unspecified protein-calorie malnutrition, encephalopathy (broad term for any brain disease that alters brain function or structure), urogenital candidiasis (yeast infection), obstructive and reflux uropathy (blocked or reduce urine flow), urinary tract infection (UTI), and weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R25 had severe cognitive impairment, disorganized thinking, and an altered level of consciousness present which fluctuated. R25 had not exhibited behaviors. R25 had no functional range of motion impairment and used a walker and wheelchair for mobility. R25 was dependent on staff for eating, oral care, toileting, bathing, upper and lower body dressing, and mobility. The MDS further documented R25 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag) and was always incontinent of bowel. He had no pain or pain treatments. R25 had a feeding tube (G-tube) and a mechanically altered diet; he received 51 percent (%) or more of his total calories through tube feeding with a fluid intake of 501 cubic centimeters (cc)/day or more. The resident received an antipsychotic (class of medications used to treat major mental conditions that cause a break from reality), antidepressant (class of medications used to treat mood disorders), antibiotic (medication to treat infections), and antiplatelet (medication to prevent blood from clotting). The antipsychotics were received on a routine basis only with no gradual dose reduction (GDR) attempted and no physician-documented GDR as clinically contraindicated. R25 also received speech and occupational therapy. The Dehydration/Fluid Maintenance Care Area Assessment (CAA), dated 02/21/24, documented R25 receives all fluids through G-tube, R25 received water before and after feedings, and one other time during the day. Labs monitored as ordered. R25's Care Plan, dated 05/20/24, documented R25 received antibiotic therapy related to prophylactic (preventative in nature) for urinary tract infection and sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body). The care plan directed staff to monitor the resident condition based on clinical practice guidelines or clinical standards of practice related to the use of Augmentin (an antibiotic). The Physician Order, dated 05/12/24, directed staff to administer amoxicillin-potassium clavulanate oral tablet 875-125 milligrams (mg) by mouth in the morning daily for prophylactically UTI. The order lacked a stop date. R25's clinical record lacked evidence of physician-documented rationale for the extended use of Augmentin and a benefit statement that the benefit outweighed the risk of increased antibiotic resistance. On 07/01/24 at 09:44 AM, observation revealed Certified Nurse Aide (CNA) Q took R25 to his room via wheelchair. CNA Q explained she was going to drain and measure the catheter leg bag. CAN Q donned appropriate PPE for EBP, then she proceeded to drain the leg bag into a measuring device and cleansed the drainage spout before adjusting the drainage bag under R25 ' s pant leg. The urine was straw in color and measured 100 milliliters (ml). CNA Q reported the catheter is drained every shift and staff are to put the drained amount in the EMR. CNA Q stated she would report to the charge nurse if there was no urine in the drainage bag if the urine had a bad odor, or if the resident seemed to have pain in the bladder area. On 07/02/24 at 12:20 PM, Administrative Nurse D stated R25 had been on Augmentin since admission. Administrative Nurse D reported she had provided antibiotic stewardship information and inquired to discontinue the use of the antibiotic, but the physician declined. The facility's Antibiotic Stewardship policy, dated 12/07/23, documented the purpose of the policy was to decrease the incidence of multi-drug resistance organisms (MDROs), to promote appropriate use while optimizing the treatment of infections and reducing the possible adverse events associated with antibiotic use. The facility failed to implement antibiotic use protocols to avoid unnecessary and/or inappropriate antibiotic use to reduce the risk for adverse events, including antibiotic resistance when the facility failed to monitor effectiveness and identify the extended use of Augmentin for R25, which placed the resident at risk for complications related to antibiotic use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 38 residents. The sample included 12 residents in which five residents were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R)25, R31, and R22 had an approved indication for the use of an antipsychotic-(class of medications used to treat major mental conditions that cause a break from reality), and failed to ensure R25's as needed (PRN) antipsychotic had a stop date. The facility further failed to ensure R32 had a risk versus benefit statement for the continued use of clonazepam (an antianxiety- class of medications that calm and relax people) and paroxetine (an antidepressant class of medications used to treat mood disorders) without a gradual dose reduction. This placed the residents at risk of receiving unnecessary psychotropic (alters mood or thought) medications. Findings included: - R25's Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), dysphagia (swallowing difficulty), gastrostomy status (G-tube: tube surgically placed through an artificial opening into the stomach), unspecified protein-calorie malnutrition, encephalopathy (broad term for any brain disease that alters brain function or structure), urogenital candidiasis (yeast infection), obstructive and reflux uropathy (blocked or reduce urine flow), urinary tract infection (UTI), and weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R25 had severe cognitive impairment, disorganized thinking, and an altered level of consciousness present which fluctuated. R25 had not exhibited behaviors. R25 had no functional range of motion impairment and used a walker and wheelchair for mobility. R25 was dependent on staff for eating, oral care, toileting, bathing, upper and lower body dressing, and mobility. The MDS further documented R25 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag) and was always incontinent of bowel. He had no pain or pain treatments. R25 had a feeding tube (G-tube) and a mechanically altered diet; he received 51 percent (%) or more of his total calories through tube feeding with a fluid intake of 501 cubic centimeters (cc)/day or more. The resident received an antipsychotic (class of medications used to treat major mental conditions that cause a break from reality), antidepressant (class of medications used to treat mood disorders), antibiotic (medication to treat infections), and antiplatelet (medication to prevent blood from clotting). The antipsychotics were received on a routine basis only with no gradual dose reduction (GDR) attempted and no physician-documented GDR as clinically contraindicated. R25 also received speech and occupational therapy. The Psychotropic Drug Use Care Area Assessment (CAA), dated 02/21/24, documented R25 received an antidepressant for depression. It was hard to determine if the resident was depressed. He was not happy with his situation and would hit out at staff when they were giving care. The CAA further documented the monitoring of medication side effects and depression. R25's Care Plan dated 05/20/24 documented R25 received medications with Black Boxed Warnings (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration) or warnings of adverse consequences. The care plan directed staff to consult with the pharmacy and healthcare provider to consider dosage reduction when clinically appropriate. R25's Care Plan dated 05/20/24 documented R25 used psychotropic medications related to anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and directed staff to consult with the pharmacy and health care provider to consider dosage reduction when clinically appropriate; monitor for signs and symptoms of anxiety. The Physician Order dated 05/11/24 directed staff to administer Zyprexa (antipsychotic) 2.5 milligrams (mg) by mouth two times a day for anxiety and every six hours as needed for anxiety. The order lacked a 14-day stop date for the PRN dose. R25's EMR recorded Zyprexa 2.5 mg PRN dose was administered on 06/15/24 at 06:45 PM. The Progress Note dated 02/22/24 documented a note to the physician from the facility that R25 had more frequent yelling throughout the day and night; Tylenol PRN seemed ineffective and R25 denied pain. R25's family felt the behaviors were anxiety related, and R25 currently took Zyprexa 2.5 mg daily and Celexa (antidepressant) 20 mg daily. The physician responded by increasing R25's Zyprexa to 2.5 mg twice a day. The Consultant Pharmacist [CP] Progress Notes dated 03/28/24, 04/24/24, 05/28/24, and 06/25/24, lacked evidence the CP identified and reported related to the use of Zyprexa without an approved indication, or a documented physician rationale which included the nonpharmacological interventions which were tried and failed as well as a risk versus benefit for the use of an antipsychotic. The notes also lacked evidence the CP identified and reported the lack of the required 14-day stop date for the PRN Zyprexa. On 06/27/24 at 08:30 AM, observation revealed R25 sitting in the dining room with Certified Nurse Aide (CNA) M sitting next to him. CNA M fed the resident a ground and minced diet of eggs, ground sausage, and a thin liquid supplement. R25 ate without any signs of difficulty. CNA M reported R25 was eating well, but the resident had been in a mood for several days and had not eaten well. On 07/02/24 at 11:07 AM, CNA P reported R25 was not capable of verbalization most of the time. CNA P stated R25 occasionally punched out at the staff, but not hard, and this usually happened during bathing. CNA P reported giving R25 time and space for about 10 minutes and this helped with behaviors. On 07/02/24 at 12:20 PM Administrative Nurse D verified R25's Zyprexa had an unapproved indication of anxiety and the PRN lacked a stop date as required. The facility's Psychotropic Medication policy, dated 12/06/23, documented the purpose of the policy to evaluate behavior interventions and alternatives before using psychotropic medications and to eliminate unnecessary psychotropic medications. The resident will be free from any chemical restraint imposed for the purpose of discipline or convenience and not be required to treat the resident's medical symptoms. If the physician prescribes an antipsychotic for the resident, a registered nurse must complete the Initial Antipsychotic Medication Assessment and the Abnormal Involuntary Movement Scale in PCC. While the use of PRN psychotropic medication is not encouraged, if a PRN physician order is received, ensure that the order has clear parameters, i.e., severe agitation that does not respond to other care plan interventions. It is important to initiate other care plan interventions prior to the use of PRN psychotropic medications. PRN orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN orders. PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of the medication. The facility failed to ensure R25 had an approved indication for the use of an antipsychotic and failed to ensure R25's PRN antipsychotic had a stop date. This placed the resident at risk of receiving unnecessary psychotropic medications. - R31's Electronic Medical Record documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), essential tremors, hypertension (HTN-elevated blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) without dyskinesia (inability to execute voluntary movements). R31's Quarterly Minimum Data Set (MDS), dated [DATE], documented R31 had severe cognitive impairment, had an acute onset of mental status change, and inattention which fluctuated; R31 had not exhibited behaviors. R31 was independent with functional abilities and mobility. The MDS further documented R31 received an antipsychotic and an antianxiety medication. The antipsychotic was received on a routine basis, had no gradual dose reduction (GDR) attempt, and no physician documented GDR as clinically contraindicated. R31's Care Plan Care Plan, dated 04/14/24, documented R31 used psychotropic medication related to dementia with high anxiety. The care plan directed staff to consult with the pharmacy and healthcare provider to consider dosage reduction when clinically appropriate. The plan directed to attempt non-medication approaches such as watching television shows, giving ice cream, or providing a quiet place and one-on-one interactions in times of anxiety and agitation. The care plan documented R31 also took medication with a Black Boxed Warning (BBW- the highest safety-related warning that medications can have assigned by the Food and Drug Administration). The Physician Order dated 09/15/23, directed staff to administer Seroquel (antipsychotic) 12.5 milligrams (mg) by mouth one time a day for anxiety. The Pharmacist Consultant Review, dated 10/10/23, documented R31 had a diagnosis of dementia and received Seroquel for anxiety. Antipsychotics had Boxed Warnings for increased mortality in older adults with psychosis related to dementia. Please attempt a GDR of Seroquel with the end goal of discontinuation. The review also included a note from facility staff that R31 had noted the current dose was not helping with an increase in anxiety and agitation. The prescriber's response directed to start an antidepressant and continue Seroquel. The Pharmacist Consultant Review, dated 11/02/23, documented the order for Seroquel for anxiety and reviewed the diagnosis for the use of antipsychotic medication. The prescriber's response was to continue medication, R31 was tolerating well and had improved symptoms on the medication, The Pharmacist Consultant Review, dated 03/28/24, documented a GDR request for Seroquel, to provide clinical rationale supporting the continued use. The prescriber's response was R31 had severe dementia with agitation, was doing wonderful with treatment, and would attempt to decrease at a later date. The Progress Note, dated 06/02/24 at 10:28 AM, documented R31 had increased episodes of fixation and agitation. R31 had asked approximately 10 times that shift why the air conditioner was on; the nurse attempted explanation and redirection, but R31 continued to ask and attempted to put blankets on the vents in the television area. R31 was agitated with staff and education was provided. R31's EMR lacked evidence of a physician-documented rationale which included the nonpharmacological interventions that were attempted and failed for the continued use of Seroquel with no GDR attempts. On 06/26/24 at 02:52 PM, observation revealed R31 participating in the activity in the dining room. She wore a long sweater and carried a purse while she independently ambulated throughout the facility. On 07/02/24 at 11:23 AM, Certified Nurse Aide (CNA) P reported R31 was easily redirected when she got anxious. CNA P said it was helpful to spend one-on-one time with R31, direct her to her room, and try to resolve what might be making her anxious were also helpful to the resident. On 07/02/24 at 12:33 PM, Administrative Nurse D stated she was aware that the use of Seroquel was not approved for anxiety but R31's physician had not changed or updated the diagnosis or provided the required documentation. The facility's Psychotropic Medication policy, dated 12/06/23, documented the purpose of the policy to evaluate behavior interventions and alternatives before using psychotropic medications and to eliminate unnecessary psychotropic medications. The resident will be free from any chemical restraint imposed for the purpose of discipline or convenience and not be required to treat the resident's medical symptoms. If the physician prescribes an antipsychotic for the resident, a registered nurse must complete the Initial Antipsychotic Medication Assessment and the Abnormal Involuntary Movement Scale in PCC. While the use of PRN psychotropic medication is not encouraged, if a PRN physician order is received, ensure that the order has clear parameters, i.e., severe agitation that does not respond to other care plan interventions. It is important to initiate other care plan interventions prior to the use of PRN psychotropic medications. PRN orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN orders. PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of the medication. The facility failed to ensure R31 had an approved indication for the use of an antipsychotic. This placed the resident at risk of receiving unnecessary psychotropic medications. - R22's Electronic Medical Record (EMR) documented diagnoses of anxiety disorders (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cerebral infarction (stroke), acute and chronic kidney failure (condition in which the kidneys lose the ability to remove waste and balance fluids), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. The MDS documented R22 had no behaviors. R22 required maximal to total assistance for mobility, dressing, and toileting. R22 received antipsychotic and antidepressant medications (a class of medications used to treat mood disorders). The Psychotropic Drug Use Care Area Assessment (CAA), dated 05/10/24, stated R22 received a small dose of Zyprexa (antipsychotic) for anxiety and Celexa (antidepressant). The CAA documented R22's mood has been stable, and he was doing well. R22 was seen by the tele-psych nurse for medication changes and status. R22's Care Plan, dated 05/14/24, directed staff to allow the resident time to respond due to slower processing of cognition skills. In the presence of behaviors or anxiety, staff were to provide opportunities for positive interaction and attention. The plan directed staff to minimize the potential for the resident's disruptive behaviors by offering tasks that divert attention. The plan directed staff to consult with the pharmacy and healthcare provider to consider dosage reduction when clinically appropriate. The Physician Order, dated 05/06/24, directed staff to administer Zyprexa (olanzapine) 2.5 milligrams (mg), two times a day for anxiety. The Physician Order, dated 03/18/2024, directed staff to administer Celexa (citalopram- antidepressant drug) 40 mg, at bedtime, for depression. The Medication Administration Record (MAR)/ Treatment Administration Record (TAR) documented R22 had no behaviors related to depression which included crying, isolation, yelling, change in mood, sadness, suicidal thinking, increased sleeping, or other depressive behaviors. R22 had no signs of psychosis which included crying, hallucinations, delusions, isolation, change in mood, sadness, suicidal thinking, increased sleeping, or other depressive behaviors. The Psychiatric Practitioner Note, dated 05/06/24, stated after tapering Zyprexa on 04/04/24, staff reported increased anxiety, excessive sleeping, and agitation. The prescriber increased Celexa to 30 mg after which staff reported some decrease in anxiety. The note stated R22's agitation begins at approximately 03:00 PM, but if identified, staff can calm R22 down most of the time. The practitioner ordered staff to continue Zyprexa 2.5 mg twice daily for mood or anxiety and increase Celexa to 40 mg daily. The Psychiatric Practitioner Note, dated 06/21/24, stated R22 had a significant past psychiatric history. Staff reported increased anxiety, some frustration, and anxiety with communication due to a stroke. Staff reported R22's anxiety levels had improved since he became aware of his schedule in advance. R22 stated he was doing well and not really having too much anxiety. He reported sleeping well and denied nightmares. The practitioner documented diagnoses of mood disorder with depressive features, dementia (a progressive mental disorder characterized by failing memory, and confusion), and generalized anxiety disorder. The note documented to continue to taper Zyprexa during subsequent visits as Kansas only approved the use of antipsychotics for certain diagnoses. The practitioner ordered to continue Celexa 20 mg daily for anxiety or mood. The Consultant Pharmacist Review, dated 11/14/23, questioned the diagnosis of anxiety for the use of Zyprexa. The physician responded- yes and documented anxiety without documenting a rationale for the indication or continued use of the antipsychotic medication. The Consultant Pharmacist Review, dated 12/13/23, recommended a gradual dose reduction (GDR) for Zyprexa and Celexa. The physician responded that R22 was evaluated by the psychiatric practitioner and ordered no changes without psychiatric physician involvement. No risk versus benefit rationale was documented. The Consultant Pharmacist Review, dated 06/06/24, recommended a GDR of Celexa 40 mg. The physician responded this was a recent increase with the in-house psychiatric practitioner, a GDR would be contradictive at this time. No risk versus benefit rationale was documented. On 06/27/24 at 07:31 AM, Licensed Nurse (LN) I administered an injection to R22. R22 stated he ate a good breakfast but couldn't remember exactly what he ate. On 07/01/24 at 01:22 PM, Administrative Nurse D stated R22 was admitted with the diagnosis of anxiety for Zyprexa. She verified anxiety was an inappropriate indication for the use of Zyprexa and stated the physician had not changed it when the Pharmacist Consultant had requested. Administrative Nurse D verified the facility failed to follow up on the pharmacist consultant's recommendations to obtain an appropriate indication for use or a written rationale for the continued use of Zyprexa which included the required documentation. The facility's Psychotropic Medications policy, dated 12/06/23, stated before the administration of non-emergency psychotropic medication the staff must document observations of mood, symptoms, or behaviors that cause the resident distress and or endanger the resident or others and the response to interventions used. The care plan would be updated with non-pharmacological interventions to be used. The policy stated if staff determined that initiating a medication was warranted, staff would contact the physician and describe the behavior, attempted interventions, and recommendations. Staff were to obtain the corresponding diagnosis and medical symptom for the medication from the physician. The policy mood and behavior documentation must continue to monitor the effectiveness of the psychotropic medication. Gradual dose reductions must be done according to federal regulations. The facility should attempt gradual dose reduction of psychotropic drugs during at least two separate quarters during the first year unless clinically contraindicated. Continued use may be contraindicated if it was in accordance with relevant current standard of practice and the physician has documented the clinical rationale for why any attempted dose reeducation would be likely to impair the resident's function or cause psychiatric instability or the resident's targeted symptoms returned or worsened after the most recent attempt at a gradual dose reduction at the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability. The facility failed to ensure an appropriate indication or the required physician documentation for the continued use of antipsychotic medication for R32. This placed the resident at risk for unnecessary psychotropic medications and potential adverse effects. - R32's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory, and confusion). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition. The MDS documented R32 was independent for mobility, toileting, walking, and dressing. The MDS documented R32 received antianxiety (a class of medications that calm and relax people) and antidepressant (a class of medications used to treat mood disorders) medications. R32's Care Plan, dated 04/15/24, stated R32 used anti-anxiety medications related to dementia with anxiety disorder and directed staff to monitor and document side effects and effectiveness. Monitor R32 frequently for safety. Offer diversionary activities such as one one-on-one discussions. Offer the use of a rocking chair to ease anxiety. The plan directed staff to consult with the pharmacy and healthcare provider to consider dosage reductions when clinically appropriate. The Physician Order, dated 10/11/23, directed staff to administer paroxetine (a type of antidepressant medication), 20 milligrams (mg) daily for anxiety. The Physician Order, dated 10/20/23, directed staff to administer clonazepam (antianxiety medication that works by increasing the levels of a calming chemical in your brain) 0.5 mg daily for dementia. The Pharmacist Consultant Review, dated 03/28/24, recommended a gradual dose reduction (GDR) of paroxetine 15 mg daily and clonazepam 0.5 mg daily which the pharmacist wrote had been administered since 10/11/23. The physician declined the recommendation and wrote clinically contraindicated without writing a rationale or risk versus benefit statement. The Physician Visit Note, dated 05/24/24, documented R32 had severe dementia but had adjusted to living in the facility and seemed to be happier. The note recorded there were no changes to R32's medications. On 07/01/24 at 12:55 PM, observation revealed R32 independently ambulated from his room to the commons area and sat for a music activity. He was very polite and calm. On 07/02/24 at 10:15 AM, Administrative Nurse D verified the physician had not written a risk versus benefit statement or rationale for continuing paroxetine and clonazepam. The facility's Psychotropic Medications policy, dated 12/06/23, stated before the administration of non-emergency psychotropic medication the staff must document observations of mood, symptoms, or behaviors that cause the resident distress and or endanger the resident or others and the response to interventions used. The care plan would be updated with non-pharmacological interventions to be used. The policy stated if staff determined that initiating a medication was warranted, staff would contact the physician and describe the behavior, attempted interventions, and recommendations. Staff were to obtain the corresponding diagnosis and medical symptom for the medication from the physician. The policy mood and behavior documentation must continue to monitor the effectiveness of the psychotropic medication. Gradual dose reductions must be done according to federal regulations. The facility should attempt gradual dose reduction of psychotropic drugs during at least two separate quarters during the first year unless clinically contraindicated. Continued use may be contraindicated if it was in accordance with relevant current standard of practice and the physician has documented the clinical rationale for why any attempted dose reeducation would be likely to impair the resident's function or cause psychiatric instability or the resident's targeted symptoms returned or worsened after the most recent attempt at a gradual dose reduction at the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability. The facility failed to obtain a written risk versus benefit statement or rationale for the continued use of the psychotropic medications for R32, without attempted GDR, placing the resident at risk for unnecessary psychotropic medications and potential adverse effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 38 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and serve food under sanitary conditions for 38 residents who reside in the facility and receive meals from the facility kitchen, placing the residents at risk for foodborne illness. Findings included: -On 06/26/24 at 09:19 AM, during initial inspection of the kitchen observation revealed the walk-in refrigerator and freezer had numerous boxes directly stored on the floor. Dietary Staff (DS) BB reported the facility had received supplies the day prior, staff had not unloaded boxes, and the boxes should not have been stored on the floor. The walk-in refrigerator also contained a bag of carrots, opened with use by date of 06/03/24. The white refrigerator in the main kitchen had an open, unsealed bag of chicken patties without a label or contents or use-by date on it. Two cups, one plastic, and one Styrofoam, were stored in the bulk bin of thickener, and the ice machine drainage spout was sitting flush on the drainage grate. On 06/27/24 at 10:57 AM, observation revealed dietary staff preparing for the noon meal. During the process of plating the meal for serving DS CC donned gloves and started preparing plates for residents in the dining room. DS CC picked up the diet menu card from being pulled from being stored in the service window once, which was placed there by DS DD. DS DD was providing residents with drinks as they entered the dining room. DS CC with wisps or several inches of hair that was not contained in the hair net started to plate the food. She used gloved hands to place chopped lettuce and tomatoes as a garnish for the meal. Throughout the serving process DS CC wiped her hands on her clothing and touched her face, and other surfaces in the kitchen without changing gloves. DS BB, assisting DS CC, wore gloves used to assist with plating and serving food, left the kitchen and when returned continued wearing the same gloves. The kitchen utilized two fans, one fan blew directly on the clean area of the dishwashing machine area, and the other fan directly blew on the food service window. Both fans had grey fuzzy material on the screen and blades. The sanitation test strips in the facility kitchen had expired dates of 08/22, 04/15/15, and 09/20/23. The drawer, cabinet fronts, equipment, and table legs were sticky to the touch. On 06/27/24 at 02:10 PM, DS BB stated gloves should have been changed between tasks and serving. DS BB said the fans should be cleaned and she had notified the maintenance department about the ice machine drainage spout. DS BB reported she had not been aware that sanitation test strips had an expiration date and had ordered new ones to come when the next supplies were delivered. The facility's General Sanitation Food and Nutrition policy, dated 06/25/24, documented that the Director of Food and Nutrition Services director maintains a supply of appropriate test strips and thermometers. The facility's Food Supple Storage policy, dated 05/07/24, documented the Use By/Use or [NAME] By, phrasing will inform customers that these products should be consumed on or before the listed date on the product. The date label is for perishable products with potential safety implications or material degradation of critical performance, such as nutrition. The facility's Hand Washing and Glove Use Food Nutrition Services policy, dated 06/13/24, documented that employees do not touch any food with bare hands. Proper utensils such as tissue, spatula, tongs, and single-use gloves should be used for food handling to reduce the risk of cross-contamination. The facility's Ice Machine Use and Maintenance policy, dated 12/11/23, lacked information regarding drainage air gap space. The facility failed to store, prepare, and serve food under sanitary conditions for 38 residents who reside in the facility and receive meals from the facility kitchen, placing the residents at risk for foodborne illness.

The facility had a census of 38 residents. The sample included 12 residents. Based on record review and interview, the facility lacked evidence the required committee members, including the medical director, attended the Quality Assurance Performance Improvement (QAPI) meetings at least quarterly. This placed the residents who resided in the facility at risk for decreased quality of care. Findings included: - The facility's QAPI meeting attendance sheets documented the members including the QAPI facilitator, the administrator, the director of nursing, the infection control preventionist, the safety director, the social services designee, the activity director, an environmental services employee, the pharmacist consultant, and the medical director. A review of the sign-in sheets from July 2023 through June 2024 revealed only four members attended the November 2023 meeting. The attendance sheets revealed the medical director did not attend a QAPI meeting during the last quarter of 2023. On 07/02/24 at 01:52 PM, Administrative Staff B verified the medical director did not attend and that there was overall low attendance at the QAPI meeting in November 2023. The facility's 2024 QAPI Plan, dated 01/30/24, stated the Plan was designed to outline a comprehensive and data-driven QAPI program that focuses on improving the outcomes and experiences of the residents. The QAPI plan provides a strategic approach to the prevention, identification, reporting, investigation, analysis, and development of performance improvement activities. The facility failed to ensure the medical director attended QAPI meetings at least quarterly as required which placed residents at risk of unidentified quality care services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 37 residents. The sample included 12 residents with one reviewed for abuse. Based on observation, intervention, and record the facility failed to ensure Resident (R) 34 was free from staff abuse and/or mistreatment when Certified Nurse Aide (CNA) M forcefully took R34's bottle of apple juice from her. This deficient practice placed R34 at risk for injury or impaired psychosocial wellbeing. Findings included: - R34's Electronic Medical Record (EMR) documented diagnoses of pain, atrial fibrillation (an irregular and often very rapid heart rhythm), goiter (the irregular growth of the thyroid gland), hypertension (high blood pressure), rheumatoid arthritis (chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles) and hearing loss. The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R34 had no behaviors, and no falls. The MDS documented R34 required limited staff assistance for eating, extensive staff assistance for all other activities of daily living and she used a walker or a wheelchair. The Communication Care Area Assessment (CAA), dated 12/20/22, recorded R34 was hard of hearing but directed staff to speak close to R34 and slowly, and she was able to understand. R34 was able to communicate and make her needs known. The Nutrition Care Plan, dated 03/02/23, directed staff to invite R34 to food-related activities and offer food and beverages of choice to encourage intake. R34 was able to feed herself after set-up. The plan directed staff to provide the resident with as many choices as possible which gave the resident control over her environment and care delivery. The Skin Care Plan, dated 03/02/23, stated R34 was a high risk for skin injury and directed staff to use extra caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. The care plan directed staff to notify the nurse immediately of any new areas of skin breakdown, redness, blisters, or bruises. The Weekly Skin Assessments, dated 02/09/23, 02/16/23, 02/23/23 all stated no new skin issues. The Incident Investigation, dated 02/26/23, documented on Sunday morning, February 26, 2023, during morning care a CNA noticed a bruise on R34's arm. The CNA asked the resident what happened and R34 reported that during the night shift she had scuffle with CNA M. The morning CNA reported the allegation to the charge nurse immediately. Licensed Nurse (LN) H interviewed the resident who reported to her that CNA M had told her she did not need to finish her apple juice and to drink water instead. R34 reported CNA M tried to take the juice away from her and they fought pretty good, and that was most likely the cause of the bruise. The charge nurse notified administration, who immediately notified CNA M he was suspended until further notice. The investigation documented Administrative Nurse D interviewed R34 and performed a skin assessment to ensure no other areas of concern. The investigation stated the current bruise determined to be unrelated to this incident. The investigation stated Abuse and Neglect education was given to all staff. The undated Witness Statement by CNA M stated he gave R34 a bottle of apple juice and asked her to slow down while drinking. He stated the resident ignored him, so he reached for the bottle to set it down. CNA M stated the resident pulled away moving the bottle away from but he managed to grab the bottle and asked R34 to let go. R34 refused to let go of the bottle and tried to pull the bottle away from CNA M's hand. CNA M documented he informed the resident he would not be able to rush back to her room to get her onto the toilet, but the resident did not care. CNA M documented he tried to get R34 to let go of the bottle and had to slowly move her fingertips from the bottle when she refused. The Weekly Skin Assessment, dated 03/02/23 stated no new skin issues and lacked documentation of the current bruise on the resident's upper right arm. R34's EMR lacked evidence of an assessment of R34 after the allegation of abuse. On 03/01/23 at 01:07 PM, during the interview of the alert and oriented R34, she stated she wanted some apple juice during the night and CNA M brought it. R34 stated after one swallow, CNA M tried to take it away and told her she did not need it. R34 stated we argued and fought over the bottle and it caused a bruise on her right arm. R34 stated CNA M had never abused her before, but had been rude, talking in a demeaning way to her questioning if she really needed to use the commode or assistance with other things, and he left the door open when she was uncovered. On 03/02/23 at 02:57 PM, Administrative Staff A stated Sunday morning February 26th, a staff nurse reported to her that R34 told an aide that her and CNA M had an incident and he grabbed her. She stated LN H interviewed the resident, who identified the staff as CNA M. Administrative Staff A stated the facility suspended CNA M and started an investigation. Administrative Staff A stated the facility had received reports against CNA M from other residents, including one incident that was witnessed by an alert and oriented resident. Administrative Staff A stated she interviewed other residents and staff for any concerns. Administrative Staff A stated the facility removed him from care for any resident who complained but verified there were normally only two aides during night shifts. At 03:12 PM, Administrative Nurse D stated CNA M was argumentative with R34 and he admitted to a scuffle with the resident, and he had stated he peeled her fingertips off the glass. Administrative Nurse D stated it was R34's right to drink the juice and she was not a choking risk. On 03/06/23 at 11:38 AM, Administrative Staff A stated CNA M was still suspended, and the facility had not terminated him yet. She stated the other two occasions of alleged abuse, CNA M had not admitted to the potential abuse so the facility could not substantiate those. On 03/07/23 at 11:07 AM, Administrative Nurse D stated the assessment of R34 after the allegation of abuse was documented in risk management, not the medical record. She stated she sent an email to the State Agency on Sunday, February 26, and reported the incident to police. Administrative Nurse D stated she had assigned all staff education for resident rights, person centered care and abuse, neglect, and exploitation. The facility's Abuse and Neglect policy, dated 10/13/22, stated the resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation, The facility would not willingly employ or otherwise engage individuals who have been found guilty of abusing, exploiting or mistreating residents by a court of law or have had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, or mistreatment of residents. Upon hire and annually education and training would be provided to employees on abuse and neglect. Alleged or suspected violations of mistreatment, neglect, or abuse including injuries of unknown source would be immediately reported to the administrator or their designated authority. The individuals were to intervene in any situation to protect residents. Remove any individual from the location if necessary for protection. Call local law enforcement. The facility would have evidence that all alleged or suspected violations were thoroughly investigated and would prevent further potential abuse during the investigation. The policy stated if there was an allegation of abuse, neglect, or mistreatment, including injuries of unknown source, and or serious bodily injury, the incident would be reported to the state agency immediately, but not later than two hours, after the allegation was made. If the abuse or neglect was substantiated, the results would be reported to the licensing board or appropriate state nurse aide registry. The facility failed to ensure freedom from abuse for R34 when CNA M caused bruising to the resident's arm when he fought with her over a bottle of apple juice, placing R34 at risk for injury and further abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 37 residents. The sample included 12 residents with five reviewed for accidents. Based on observation, interview, and record review the facility failed to update the care plan with interventions aimed to prevent further falls for Resident (R) 9, who experienced 11 falls in the past 10 months. This deficient practice placed R9 at risk for further falls and potential injury. Findings included: - R9's Electronic Medical Record (EMR) documented diagnoses of dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), diarrhea (loose, watery stools that occur more frequently than usual), pain, lesion of sciatic nerve (injury to the nerve that controls the back and sides of the leg), and anxiety disorder (characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). The Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. The MDS documented R9 had delusions (unshakable belief in something that is untrue), required limited assistance of one staff for walking in her room, extensive assistance of one staff for walking in the corridor, hygiene, and extensive assistance of two staff for bed mobility, transfers, dressing and toileting. The MDS documented R9's balance was impaired, requiring human assistance to stabilize. R9 had no range of motion impairment, no falls and R9 used a walker. The MDS documented R9 was frequently incontinent of urine and bowel and received diuretic (drug to increase the excretion of water from the body) medication. The Fall Care Area Assessment (CAA), dated 02/06/23, documented R9 required assistance with ambulation, surface to surface transfers and toileting. The Fall Care Plan, dated 12/15/22, documented R9 was at risk for falls related to confusion and a history of falls. The care plan directed staff to instruct the resident to use her walker at all times; remind her not to bend over to pick up dropped items; encourage her to use a grabber or to ask for assistance. The plan diercted staff to encourage the resident to participate in activities that promoted exercise, physical activity for strengthening and improved mobility; monitor the resident for significant changes in gait, mobility, positioning device, standing/sitting balance and lower extremity joint function. R9 required supervision to extensive assist at times, and directed to encourage resident to use her walker as she would walk off without it, initiated 05/06/22. Keep resident's bathroom light turned on with the door cracked enough for the resident to see when she awakened at night to maximize resident safety, initiated 06/01/22. Review as indicated for significant changes in cognition, safety awareness and decision-making capacity, initiated 09/05/22. Review status of any medical conditions that predispose to falls or that could increase the risk of injury from falls, initiated 09/23/22. Review bowel and bladder continence status and establish and/or review toileting plan based on resident's needs. Remind staff to follow care plan toileting interventions, initiated 10/30/22. Review resident's history of recent or recurrent falls between 12:00-01:00 AM, toileting plan changed to reflect 12:00 AM, staff education done, initiated 11/07/22. The Fall Risk Assessments, dated 05/03/22, indicated a medium risk for falls, 05/31/22 indicated high, 10/30/22 indicated medium, 12/02/22 indicated high, 01/20/23 indicated high, 02/21/23 indicated high. The Fall Note, dated 05/03/22 at 11:23 PM, documented staff found R9 lying on the floor at 09:30 PM in a hallway next to a wheelchair. R9 was immediately assessed for pain and was able to perform range of motion (ROM) to both upper and lower extremities without assistance and without pain. The nurse performed a neurological check (an evaluation of a person's nervous system) even though the resident denied hitting her head. R9 used her walker and ambulated independently with staff to her room for cares and further skin assessment. The Fall Note, dated 06/01/22 at 01:00 AM, documented at 01:00 AM staff heard R9 yelling help me from her room and found R9 lying on the floor next to her bathroom door. R9 stated she thought she was going to the bathroom but was unsure. She denied pain and was able to perform full ROM to both upper and lower extremities without difficulty or discomfort. She denied hitting her head and had no bumps or bruising noted to her head. Skin check revealed no new areas of concern or bruising at that time. R9 ambulated with her wheeled walker and staff stand by assist to the bathroom where she had a continent void. The nurse noted that her room lighting was very poor and R9 did not have her night light on, nor was the light in her bathroom on. The Fall Note, dated 09/05/222 at 04:50 PM, documented staff heard R9 crying for help and found R9 on the floor on her hands and knees. R9 was oriented to person and place, denied hitting her head, and her walker was in front of her. The Fall Note, dated 09/23/22 at 09:57 PM, documented R9 fell and bumped the back of her head on the employee bathroom door. No further information documented. The Fall Note, dated 10/30/22 at 02:51 AM, documented staff heard a loud noise and found R9 in her room, sitting on the floor up against wall between tv stand and bathroom. The bathroom door was shut with the light on. R9 was groggy and unable to describe what happened. Staff helped R9 to toilet and noted a four-millimeter (mm) abrasion inside, underneath her right elbow, actively bleeding. The nurse cleaned the wound and applied ointment. The Fall Note, dated 11/7/22 at 12:45 AM, documented staff heard R9 yelling for help and found R9 sitting upright on the floor on her buttocks in front of the bathroom door. No injuries noted and no pain or discomfort noted. The Fall Note, dated 12/12/22 at 07:11 PM, documented staff found R9 sitting on the floor in front of the loveseat in the common area. Another resident stated that R9 was standing then just sat in the floor. No injuries, pain or discomfort noted. No interventions were implemented after this incident. The Fall Note, dated 01/26/23, documented at about 01:45 AM, staff found R9 lying on the floor on her right side. No wound, skin tear nor bruises were found at the time of assessment, but R9 reported pain in her right hip on which she had been lying. The nurse notified the physician of the finding and that R9's oxygen level dropped to 71% after the fall. The physician ordered oxygen and breathing treatments, labs and a chest X-ray. No interventions were implemented after this incident. The Fall Note, dated 02/14/23 at 02:51 AM, documented at 02:30 AM, staff heard someone hollering out random words and upon entering R9's room found the resident lying parallel with her bed, on her right side, with blankets wrapped around her body. Upon assessment no new skin issues, no rotation noted to legs or arms, and R9 denied pain. No interventions were implemented after this incident. The Fall Note, dated 02/21/23 at 12:20 AM, documented staff found R9 ambulating independently in the lobby area when she lost her balance and fell backwards on her bottom. She did not hit her head and no injuries were found. No interventions were implemented after this incident. The Fall Note, dated 02/21/23 at 08:05 PM, documented staff heard a thud noise and then R9 stated help me, help me. Staff found R9 lying on her right side in the commons area next to her walker and a chair. Upon assessment able to move all extremities independently, no rotation or other injuries noted. R9 stated she hurt all over. No interventions were implemented after this incident. On 03/02/23 at 07:40 AM, observation revealed R9 sat in a high back wheelchair with anti-tip bars at a table in the commons area. Her eyes were closed, glasses on, she wore tennis shoes, and had a wanderguard (elopement) alarm on her left ankle. On 03/07/23 at 01:10 PM, Administrative Nurse D verified the care plan had not been reviewed or revised after each fall with interventions to prevent further falls. She stated staff try to keep R9 independent. The facility's Fall Prevention and Management policy, dated 03/30/22, directed staff to update the care plan with any changes or new interventions and monitor the effectiveness of the interventions. The facility's Comprehensive Care Plan policy, dated 06/09/21, stated in addition to updates during a care plan review, care plans must be revised as the resident's needs or status changed. The facility failed to update R9's care plan after falls to with relevant interventions to prevent falls for R9, who experienced 11 falls in the past 10 months, placing R9 at risk for further falls and potential injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 37 residents. The sample included 12 residents with one reviewed for abuse. Based on observation, intervention, and record the facility failed to ensure staff assessed Resident (R) 34 for physical and psychosocial impact after an incident of staff to resident abuse and/or mistreatment which resulted in a bruise. This deficient practice placed R34 at risk for unidentified injuries and psychosocial impairment resulting from staff to resident abuse (Refer to F600). Findings included: - R34's Electronic Medical Record (EMR) documented diagnoses of pain, atrial fibrillation (an irregular and often very rapid heart rhythm), goiter (the irregular growth of the thyroid gland), hypertension (high blood pressure), rheumatoid arthritis (chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles) and hearing loss. The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R34 had no behaviors, and no falls. The MDS documented R34 required limited staff assistance for eating, extensive staff assistance for all other activities of daily living and she used a walker or a wheelchair. The Communication Care Area Assessment (CAA), dated 12/20/22, recorded R34 was hard of hearing but directed staff to speak close to R34 and slowly, and she was able to understand. R34 was able to communicate and make her needs known. The Nutrition Care Plan, dated 03/02/23, directed staff to invite R34 to food-related activities and offer food and beverages of choice to encourage intake. R34 was able to feed herself after set-up. The plan directed staff to provide the resident with as many choices as possible which gave the resident control over her environment and care delivery. The Skin Care Plan, dated 03/02/23, stated R34 was a high risk for skin injury and directed staff to use extra caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. The care plan directed staff to notify the nurse immediately of any new areas of skin breakdown, redness, blisters, or bruises. The Weekly Skin Assessments, dated 02/09/23, 02/16/23, 02/23/23 all stated no new skin issues. The Incident Investigation, dated 02/26/23, documented on Sunday morning, February 26, 2023, during morning care a CNA noticed a bruise on R34's arm. The CNA asked the resident what happened and R34 reported that during the night shift she had scuffle with CNA M. The morning CNA reported the allegation to the charge nurse immediately. Licensed Nurse (LN) H interviewed the resident who reported to her that CNA M had told her she did not need to finish her apple juice and to drink water instead. R34 reported CNA M tried to take the juice away from her and they fought pretty good, and that was most likely the cause of the bruise. The charge nurse notified administration, who immediately notified CNA M he was suspended until further notice. The investigation documented Administrative Nurse D interviewed R34 and performed a skin assessment to ensure no other areas of concern. The investigation stated the current bruise determined to be unrelated to this incident. The investigation stated Abuse and Neglect education was given to all staff. The undated Witness Statement by CNA M stated he gave R34 a bottle of apple juice and asked her to slow down while drinking. He stated the resident ignored him, so he reached for the bottle to set it down. CNA M stated the resident pulled away moving the bottle away from but he managed to grab the bottle and asked R34 to let go. R34 refused to let go of the bottle and tried to pull the bottle away from CNA M's hand. CNA M documented he informed the resident he would not be able to rush back to her room to get her onto the toilet, but the resident did not care. CNA M documented he tried to get R34 to let go of the bottle and had to slowly move her fingertips from the bottle when she refused. The Weekly Skin Assessment, dated 03/02/23 stated no new skin issues and lacked documentation of the current bruise on the resident's upper right arm. R34's EMR lacked evidence of an assessment of R34 after the allegation of abuse. On 03/01/23 at 01:07 PM, during the interview of the alert and oriented R34, she stated she wanted some apple juice during the night and CNA M brought it. R34 stated after one swallow, CNA M tried to take it away and told her she did not need it. R34 stated we argued and fought over the bottle and it caused a bruise on her right arm. R34 stated CNA M had never abused her before, but had been rude, talking in a demeaning way to her questioning if she really needed to use the commode or assistance with other things, and he left the door open when she was uncovered. At 03:12 PM, Administrative Nurse D stated CNA M was argumentative with R34 and he admitted to a scuffle with the resident and he had stated he peeled her fingertips off the glass. Administrative Nurse D stated it was R34's right to drink the juice and she was not a choking risk. On 03/07/23 at 11:07 AM, Administrative Nurse D verified the assessment of R34 after the allegation of abuse was not documented in R34's medical record. The facility's Abuse and Neglect policy, dated 10/13/22, stated the resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The policy stated if there was an allegation of abuse, neglect, or mistreatment, including injuries of unknown source, and or serious bodily injury, the incident would be reported to the state agency immediately, but not later than two hours, after the allegation was made. If the abuse or neglect was substantiated, the results would be reported to the licensing board or appropriate state nurse aide registry. The facility failed to ensure staff assessed R34 for physical and psychosocial impact after an allegation of abuse which resulted in a bruise. This deficient practice placed R34 at risk for unidentified injuries and psychosocial impairment resulting from staff to resident abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 37 residents. The sample included 12 residents with five reviewed for accidents. Based on observation, interview, and record review the facility failed to provide care and services to prevent falls for Resident (R) 9, who experienced 11 falls in the past 10 months. This deficient practice placed R9 at risk for further falls and potential injury. Findings included: - R9's Electronic Medical Record (EMR) documented diagnoses of dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), diarrhea (loose, watery stools that occur more frequently than usual), pain, lesion of sciatic nerve (injury to the nerve that controls the back and sides of the leg), and anxiety disorder (characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). The Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. The MDS documented R9 had delusions (unshakable belief in something that is untrue), required limited assistance of one staff for walking in her room, extensive assistance of one staff for walking in the corridor, hygiene, and extensive assistance of two staff for bed mobility, transfers, dressing and toileting. The MDS documented R9's balance was impaired, requiring human assistance to stabilize. R9 had no range of motion impairment, no falls and R9 used a walker. The MDS documented R9 was frequently incontinent of urine and bowel and received diuretic (drug to increase the excretion of water from the body) medication. The Fall Care Area Assessment (CAA), dated 02/06/23, documented R9 required assistance with ambulation, surface to surface transfers and toileting. The Fall Care Plan, dated 12/15/22, documented R9 was at risk for falls related to confusion and a history of falls. The care plan directed staff to instruct the resident to use her walker at all times; remind her not to bend over to pick up dropped items; encourage her to use a grabber or to ask for assistance. The plan diercted staff to encourage the resident to participate in activities that promoted exercise, physical activity for strengthening and improved mobility; monitor the resident for significant changes in gait, mobility, positioning device, standing/sitting balance and lower extremity joint function. R9 required supervision to extensive assist at times, and directed to encourage resident to use her walker as she would walk off without it, initiated 05/06/22. Keep resident's bathroom light turned on with the door cracked enough for the resident to see when she awakened at night to maximize resident safety, initiated 06/01/22. Review as indicated for significant changes in cognition, safety awareness and decision-making capacity, initiated 09/05/22. Review status of any medical conditions that predispose to falls or that could increase the risk of injury from falls, initiated 09/23/22. Review bowel and bladder continence status and establish and/or review toileting plan based on resident's needs. Remind staff to follow care plan toileting interventions, initiated 10/30/22. Review resident's history of recent or recurrent falls between 12:00-01:00 AM, toileting plan changed to reflect 12:00 AM, staff education done, initiated 11/07/22. The Fall Risk Assessments, dated 05/03/22, indicated a medium risk for falls, 05/31/22 indicated high, 10/30/22 indicated medium, 12/02/22 indicated high, 01/20/23 indicated high, 02/21/23 indicated high. The Fall Note, dated 05/03/22 at 11:23 PM, documented staff found R9 lying on the floor at 09:30 PM in a hallway next to a wheelchair. R9 was immediately assessed for pain and was able to perform range of motion (ROM) to both upper and lower extremities without assistance and without pain. The nurse performed a neurological check (an evaluation of a person's nervous system) even though the resident denied hitting her head. R9 used her walker and ambulated independently with staff to her room for cares and further skin assessment. The Fall Note, dated 06/01/22 at 01:00 AM, documented at 01:00 AM staff heard R9 yelling help me from her room and found R9 lying on the floor next to her bathroom door. R9 stated she thought she was going to the bathroom but was unsure. She denied pain and was able to perform full ROM to both upper and lower extremities without difficulty or discomfort. She denied hitting her head and had no bumps or bruising noted to her head. Skin check revealed no new areas of concern or bruising at that time. R9 ambulated with her wheeled walker and staff stand by assist to the bathroom where she had a continent void. The nurse noted that her room lighting was very poor and R9 did not have her night light on, nor was the light in her bathroom on. The Fall Note, dated 09/05/222 at 04:50 PM, documented staff heard R9 crying for help and found R9 on the floor on her hands and knees. R9 was oriented to person and place, denied hitting her head, and her walker was in front of her. The Fall Note, dated 09/23/22 at 09:57 PM, documented R9 fell and bumped the back of her head on the employee bathroom door. No further information documented. The Fall Note, dated 10/30/22 at 02:51 AM, documented staff heard a loud noise and found R9 in her room, sitting on the floor up against wall between tv stand and bathroom. The bathroom door was shut with the light on. R9 was groggy and unable to describe what happened. Staff helped R9 to toilet and noted a four-millimeter (mm) abrasion inside, underneath her right elbow, actively bleeding. The nurse cleaned the wound and applied ointment. The Fall Note, dated 11/7/22 at 12:45 AM, documented staff heard R9 yelling for help and found R9 sitting upright on the floor on her buttocks in front of the bathroom door. No injuries noted and no pain or discomfort noted. The Fall Note, dated 12/12/22 at 07:11 PM, documented staff found R9 sitting on the floor in front of the loveseat in the common area. Another resident stated that R9 was standing then just sat in the floor. No injuries, pain or discomfort noted. No interventions were implemented after this incident. The Fall Note, dated 01/26/23, documented at about 01:45 AM, staff found R9 lying on the floor on her right side. No wound, skin tear nor bruises were found at the time of assessment, but R9 reported pain in her right hip on which she had been lying. The nurse notified the physician of the finding and that R9's oxygen level dropped to 71% after the fall. The physician ordered oxygen and breathing treatments, labs and a chest X-ray. No interventions were implemented after this incident. The Fall Note, dated 02/14/23 at 02:51 AM, documented at 02:30 AM, staff heard someone hollering out random words and upon entering R9's room found the resident lying parallel with her bed, on her right side, with blankets wrapped around her body. Upon assessment no new skin issues, no rotation noted to legs or arms, and R9 denied pain. No interventions were implemented after this incident. The Fall Note, dated 02/21/23 at 12:20 AM, documented staff found R9 ambulating independently in the lobby area when she lost her balance and fell backwards on her bottom. She did not hit her head and no injuries were found. No interventions were implemented after this incident. The Fall Note, dated 02/21/23 at 08:05 PM, documented staff heard a thud noise and then R9 stated help me, help me. Staff found R9 lying on her right side in the commons area next to her walker and a chair. Upon assessment able to move all extremities independently, no rotation or other injuries noted. R9 stated she hurt all over. No interventions were implemented after this incident. On 03/02/23 at 07:40 AM, observation revealed R9 sat in a high back wheelchair with anti-tip bars at a table in the commons area. Her eyes were closed, glasses on, she wore tennis shoes, and had a wanderguard (elopement) alarm on her left ankle. On 03/07/23 at 01:10 PM, Administrative Nurse D verified the care plan had not been reviewed or revised after each fall with interventions to prevent further falls. She stated staff try to keep R9 independent. On 03/02/23 at 07:40 AM, observation revealed R9 sat in a high back wheelchair with anti-tip bars at a table in the commons area. Her eyes were closed, glasses on, she wore tennis shoes, and had a wanderguard (elopement) alarm on her left ankle. On 03/07/23 at 01:10 PM, Administrative Nurse D verified the falls care plan had not been reviewed and new interventions identified and implemented after each fall to prevent further falls. She stated staff try to keep R9 independent. The facility's Fall Prevention and Management policy, dated 03/30/22, directed staff to communicate fall risks and interventions to prevent falls per the 24-hour report, care plan, or meetings. The Fall Scene Huddle Worksheet was to be completed as soon as possible after a fall and used by the QAPI committee for follow up and not part of the medical record. The checklist, included in the policy, directed staff to update the care plan with any changes or new interventions and monitor the effectiveness of the interventions. The facility failed to provide supervision and identify and implement person-centered interventions to prevent falls for R9, who experienced 11 falls in the past 10 months, placing R9 at risk for further falls and potential injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 37 residents. The sample included 12 residents with one reviewed for urinary catheter (a tube placed in the body to drain and collect urine from the bladder). Based on observation, intervention, and record review, the facility failed to ensure Resident (R) 15's urinary catheter drainage bag and tubing did not touch the floor. This deficient practice placed R15 at increased risk for urinary infection related to the use of the catheter. Findings included: - R15's Electronic Medical Record (EMR) documented diagnoses of pressure ulcer (PU-injury to skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral region (at the bottom of the spine), dementia (group of thinking and social symptoms that interferes with daily functioning), diabetes mellitus (disease in which the body does not control the amount of glucose (a type of sugar) in the blood and the kidneys make a large amount of urine), and chronic kidney disease, stage 4 (kidneys are moderately or severely damaged and are not working as well as they should). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. The MDS documented R15 required extensive of assistance of one staff for eating, two staff for toileting, bed mobility, and total assistance for dressing, transfers, locomotion and hygiene. The MDS documented R15 had a urinary catheter, and one PU, present on admission, The Catheter Care Plan, dated 02/16/23, stated R15 had a urinary catheter and directed staff to provide catheter care by every shift, monitor and document abnormalities of urinary output, and report significant changes to the health care provider. The care plan documented R15 had a catheter related to infection and directed staff to monitor for and document pain or discomfort due to the catheter and signs or symptoms of discomfort on urination and frequency. The Physician Order, dated 12/19/22, directed staff to insert a urinary catheter, and change the catheter every 30 days. The Progress Note, dated 03/01/23 at 02:02 PM, documented Administrative Nurse D recatheterized R15 due to the urinary catheter had been removed during nightshift. The Progress Note, dated 03/03/23 at 11:22 AM, documented R15 was re-admitted to the facility after hospitalization for sepsis (serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death), acute kidney failure (when your kidneys suddenly become unable to filter waste products from your blood), and urinary tract infection (UTI). The note documented R15 was quiet, not verbally responding to questions, and required total assistance with all activities of daily living. On 03/06/23 at 01:08 PM, observation revealed R15 sat in a wheelchair in her room with her urinary catheter drainage bag and tubing touching the floor under her wheelchair. Further observation at 01:11 PM, Certified Nurse Aide (CNA) O wheeled R15 in her wheelchair to the therapy room down the 100 hall with approximately six inches of the catheter tubing and the privacy bag dragging on the floor. On 03/07/23 at 11:52 AM, Administrative Staff B wheeled R15, in her wheelchair, from the dining room to her room with the catheter bag and tubing dragging on the floor. On 03/06/23 at 01:11 PM, Certified Nurse Aide (CNA) O verified staff should not allow the catheter tubing and bag to drag on the floor. On 03/07/23 at 1155 AM, Administrative Nurse D verified staff should not allow a urinary catheter bag or tubing to touch the floor or be dragged on the floor. The facility's Urinary Catheter policy, dated 11/28/2022, stated the drainage bag was to be positioned so that it was not touching the floor. The facility failed to ensure R15's urinary catheter drainage bag and tubing did not touch the floor, placing R15, who had a history of UTI and sepsis, at increased risk for urinary infection related to the use of the catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 37 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to ensure a sanitary environment when Resident (R) 15's urinary catheter (a tube placed in the body to drain and collect urine from the bladder) drainage bag and tubing touched the floor int he common areas, creating the risk for communicable pathogens. This deficient practice placed R15 and the other residents using the area at risk for transmission of infectious disease. Findings included: - R15's Electronic Medical Record (EMR) documented diagnoses of pressure ulcer (PU-injury to skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral region (at the bottom of the spine), dementia (group of thinking and social symptoms that interferes with daily functioning), diabetes mellitus (disease in which the body does not control the amount of glucose (a type of sugar) in the blood and the kidneys make a large amount of urine), and chronic kidney disease, stage 4 (kidneys are moderately or severely damaged and are not working as well as they should). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. The MDS documented R15 required extensive of assistance of one staff for eating, two staff for toileting, bed mobility, and total assistance for dressing, transfers, locomotion and hygiene. The MDS documented R15 had a urinary catheter, and one PU, present on admission, The Catheter Care Plan, dated 02/16/23, stated R15 had a urinary catheter and directed staff to provide catheter care by every shift, monitor and document abnormalities of urinary output, and report significant changes to the health care provider. The care plan documented R15 had a catheter related to infection and directed staff to monitor for and document pain or discomfort due to the catheter and signs or symptoms of discomfort on urination and frequency. The Physician Order, dated 12/19/22, directed staff to insert a urinary catheter, and change the catheter every 30 days. On 03/06/23 at 01:08 PM, observation revealed R15 in a wheelchair in her room with the urinary catheter drainage bag and tubing touching the floor under her wheelchair. Further observation at 01:11 PM, Certified Nurse Aide (CNA) O wheeled R15 in her wheelchair to the therapy room down the 100 hall with approximately six inches of the catheter tubing and the privacy bag dragging on the floor the entire way. On 03/07/23 at 1152 AM, Administrative Staff B wheeled R15, in her wheelchair, from the dining room to her room with the catheter bag and tubing dragging on the floor the entire way. On 03/06/23 at 01:11 PM, Certified Nurse Aide (CNA) O verified staff should not allow the catheter tubing and bag to drag on the floor. On 03/07/23 at 1155 AM, Administrative Nurse D verified staff should not allow a urinary catheter bag or tubing to touch the floor or be dragged on the floor. The facility's Urinary Catheter policy, dated 11/28/2022, stated the drainage bag was to be positioned so that it was not touching the floor. The facility failed to ensure a sanitary environment when R15's urinary catheter drainage bag and tubing touched the floor in common areas, creating the risk for communicable pathogens. This deficient practice placed R15 and the other residents using the area at risk for transmission of infectious disease.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 33 residents. The sample included 12 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist failed to report to the Director of Nursing, medical director, or physician the lack of a proper diagnosis for one of six sampled residents, Resident (R) 29's Risperdal (class of medications used to treat major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions,) and failure to ensure behavior and side effect monitoring were being completed for R29 and R13. Findings included: - R29's Physician Order Sheet (POS) dated 08/19/21, documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance and major depressive disorder (major mood disorder). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. The MDS documented the resident required extensive assistance of one to two staff for all activities of daily living, except supervision with eating. The MDS documented the resident had physical behaviors directed towards others for 1-3 days during the look back period and antipsychotics were recorded as being received on a routine basis. The Black Box Warning Care Plan, revised on 09/07/21, documented Risperdal could lead to increased risk for death, suicidal thoughts, and behaviors. The Physician Order Sheet, dated 08/19/21, directed staff to administer Risperdal 0.5 milligrams (mg) twice a day for dementia with behavioral disturbance and lacked direction for staff to monitor behaviors and adverse side effects from the administration of Risperdal. Review of R29's Medication Regimen Reviews from September 2020 through September 2021 revealed failure to address the inappropriate diagnosis for Risperdal, failure to address behavior monitoring, and failure to address monitoring for adverse side effects of the administration of Risperdal. On 09/22/21 at 10:58 AM, Licensed Nurse (LN) G stated dementia was not an appropriate diagnosis for Risperdal and there was no direction on the Medication Administration Record (MAR) to monitor the resident for behaviors or side effects of Risperdal. On 09/27/21 at 01:50 PM, Administrative Nurse D verified the facility had not documented/monitored resident behaviors and potential adverse side effects of psychotropic medications and dementia was not an appropriate diagnosis for Risperdal. The facility's Medication: Unnecessary Rehab/Skilled policy, dated 01/18/21, documented each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: in excessive dose, for excessive durations, without adequate monitoring, without adequate indications for its use, in the presence of adverse consequences which indicate the dose should be reduced or discontinued, or any combination of the above reasons. The facility's Medication Drug Regimen Review policy, dated 12/11/20, documented the Drug Regimen Review (DRR) will identify the following: review of medications to assure that doses and duration are appropriate to each resident's clinical condition, age and co morbidities; monitoring of efficacy and adverse consequences; potential medications irregularities and response to these irregularities; medications related errors; and Gradual Dose Reduction. The Pharmacist will complete a written report noting any drug irregularities or issues of concern for each resident reviewed. The pharmacist will also complete the Medication Regimen Review Summary for QAPI Committee document. Both reports will be given to the DON upon completion of each monthly DRR. The reports must be shared with the attending physician and the location's medical director, and these reports must be acted on. The facility's Consultant Pharmacist failed to report to the Director of Nursing, the medical director, or physician the lack of an appropriate diagnosis for R29's Risperdal and failure to monitor behaviors and adverse side effects, placing the resident at risk for adverse side effects. - R13's POS, dated 08/19/21, documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance and major depressive disorder (major mood disorder). The Quarterly MDS, dated 07/14/21, documented the resident had a BIMS score of three, indicating severe cognitive impairment. The MDS documented the resident required limited to extensive assistance for dressing, bed mobility, personal hygiene, toileting, and bathing. The resident required supervision for ambulation, locomotion, transfers, and eating and wandered daily. The Black Box Warning Care Plan, revised on 06/01/21, documented Mirtazapine (class of medication used to treat mood disorders and relieve symptoms of depression) could lead to increased risk of drowsiness, dizziness, and weakness. The Physician's Order, dated 01/12/20, directed staff to administer Mirtazapine, 15 milligrams (mg) at bedtime for major depressive disorder. Review of R13's Medication Regimen Reviews for January through September 2021 revealed failure to address lack of monitoring of behavior symptoms and side effect monitoring. On 09/22/21 at 10:58 AM, Licensed Nurse (LN) G stated there was no direction on the Medication Administration Record (MAR) to monitor the resident for behaviors or side effects of Mirtazapine. On 09/27/21 at 01:50 PM, Administrative Nurse D verified that the facility was not documenting/monitoring resident behaviors and potential adverse side effects of psychotropic medications. The facility's Medication: Unnecessary Rehab/Skilled, policy dated 01/18/21, documented each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: in excessive dose, for excessive durations, without adequate monitoring, without adequate indications for its uses, in the presence of adverse consequences which indicate the dose should be reduced or discontinued, or any combination of the above reasons. The facility's Medication Drug Regimen Review policy, dated 12/11/20, documented the Drug Regimen Review (DRR) will identify the following: review of medications to assure that doses and duration are appropriate to each resident's clinical condition, age and co morbidities; monitoring of efficacy and adverse consequences; potential medications irregularities and response to these irregularities; medications related errors; and Gradual Dose Reduction. The Pharmacist will complete a written report noting any drug irregularities or issues of concern for each resident reviewed. The pharmacist will also complete the Medication Regimen Review Summary for QAPI Committee document. Both reports will be given to the DON upon completion of each monthly DRR. The reports must be shared with the attending physician and the location's medical director, and these reports must be acted on. The facility's Consultant Pharmacist failed to report to the Director of Nursing, the medical director, or physician the lack of monitoring of behaviors and adverse side effects for R13's Mirtazapine, placing the resident at risk for adverse side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 33 residents. The sample included 12 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure a proper diagnosis for one of six sampled residents, Resident (R) 29's Risperdal (class of medications used to treat major mental disorder characterized by a gross impairment in reality and other mental emotional conditions) and failure to ensure behavior and side effect monitoring were being completed for R29 and R13. Findings included: - R29's Physician Order Sheet (POS) dated 08/19/21, documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance and major depressive disorder (major mood disorder). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. The MDS documented the resident required extensive assistance of one to two staff for all activities of daily living, except supervision with eating. The MDS documented the resident had physical behaviors directed towards others for 1-3 days during the look back period and antipsychotics were recorded as being received on a routine basis. The Black Box Warning Care Plan, revised on 09/07/21, documented Risperdal could lead to increased risk for death, suicidal thoughts, and behaviors. The Physician Order Sheet, dated 08/19/21, directed staff to administer Risperdal 0.5 milligrams (mg) twice a day for dementia with behavioral disturbance and lacked direction for staff to monitor behaviors and adverse side effects from the administration of Risperdal. Review of R29's Medication Regimen Reviews from September 2020 through September 2021 revealed failure to address the inappropriate diagnosis for Risperdal, failure to address behavior monitoring, and failure to address monitoring for adverse side effects of the administration of Risperdal. On 09/22/21 at 10:58 AM, Licensed Nurse (LN) G stated dementia was not an appropriate diagnosis for Risperdal and there was no direction on the Medication Administration Record (MAR) to monitor the resident for behaviors or side effects of Risperdal. On 09/27/21 at 01:50 PM, Administrative Nurse D verified the facility had not documented/monitored resident behaviors and potential adverse side effects of psychotropic medications and dementia was not an appropriate diagnosis for Risperdal. The facility's Medication: Unnecessary Rehab/Skilled policy, dated 01/18/21, documented each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: in excessive dose, for excessive durations, without adequate monitoring, without adequate indications for its use, in the presence of adverse consequences which indicate the dose should be reduced or discontinued, or any combination of the above reasons. The facility failed to ensure an appropriate diagnosis for R29's Risperdal and failure to monitor behaviors and adverse side effects, placing the resident at risk for adverse side effects. - R13's POS, dated 08/19/21, documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance and major depressive disorder (major mood disorder). The Quarterly MDS, dated 07/14/21, documented the resident had a BIMS score of three, indicating severe cognitive impairment. The MDS documented the resident required limited to extensive assistance for dressing, bed mobility, personal hygiene, toileting, and bathing. The resident required supervision for ambulation, locomotion, transfers, and eating and wandered daily. The Black Box Warning Care Plan, revised on 06/01/21, documented Mirtazapine (class of medication used to treat mood disorders and relieve symptoms of depression) could lead to increased risk of drowsiness, dizziness, and weakness. The Physician's Order, dated 01/12/20, directed staff to administer Mirtazapine 15 milligrams (mg) at bedtime for major depressive disorder. Review of R13's Medication Regimen Reviews for January through September 2021 revealed failure to address lack of monitoring of behavior symptoms and side effect monitoring. On 09/22/21 at 10:58 AM, Licensed Nurse (LN) G stated there was no direction on the Medication Administration Record (MAR) to monitor the resident for behaviors or side effects of Mirtazapine. On 09/27/21 at 01:50 PM, Administrative Nurse D verified that the facility was not documenting/monitoring resident behaviors and potential adverse side effects of R13's psychotropic medication. The facility's Medication: Unnecessary Rehab/Skilled, policy dated 01/18/21, documented each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: in excessive dose, for excessive durations, without adequate monitoring, without adequate indications for its uses, in the presence of adverse consequences which indicate the dose should be reduced or discontinued, or any combination of the above reasons. The facility failed to monitor behaviors and adverse side effects for R13's Mirtazapine, placing the resident at risk for adverse side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to provide a safe, functional, sanitary and comfortable environment for the 33 residents who resided in the facility. Findings included: - On 09/23/21 at 08:10 AM, the environmental tour revealed the following: Front entrance/Living room area carpeting with numerous large dark stains, and numerous worn areas where the carpet backing visible. Cedar Bluff Hallway: Fluorescent ceiling light not working on hallway across from the therapy room. Numerous dark carpet stains down the hallway. [NAME] Hallway: Paint on wall by nurse's charting room peeling off the wall . Two 3 foot (ft) by 3 ft dark carpet stains where medication carts were placed. Numerous dark carpet stains down hallway. Bridgeport Hallway: Two large circular dark carpet stains by the double doors. On 09/23/21 at 08:10 AM, Maintenance Staff (MS) HH verified the above environmental findings. The facility's Preventative Maintenance Program policy, dated 01/26/21, stated the facility maintenance shall maintain a safe, functional, sanitary and comfortable environment for residents. The facility's Floor Covering Care policy, dated 01/22/21, stated to visually inspect carpet areas for spills, stains, perform spot cleaning as soon as possible and perform hot water extraction at least every two months. The facility failed to provide a safe, functional, sanitary environment, placing the 33 residents who resided in the facility at risk for not living in a home-like environment.

The facility had a census of 33 residents. Based on observation, record review, and interview, the facility failed to store drugs and biologicals under proper temperature controls in one of one medication room. Findings included: - On 09/21/21 at 09:28 AM, observation during the initial tour of the medication room revealed the temperature for the medication refrigerator lacked daily temperatures for two days in July, nine days in August, and three days in September 2021. On 09/21/21 at 09:28 AM, Licensed Nurse (LN) G verified there were missing days on the medication refrigerator temperature logs for July, August and September 2021. On 09/27/21 at 01:50 PM, Administrative Nurse D stated she expected nursing to check the temperatures of the medication refrigerator in the medication room on a daily basis to ensure it was running at the appropriate temperature for medication storage. The facility's Medications: Acquisition, Receiving, Dispensing, and Storage policy, dated 12/28/20, documented to ensure that medications are stored according to manufacturers' recommendations refrigerators holding medications (such as insulin, etc.) will be kept between 36 degrees and 46 degrees Fahrenheit. Check refrigerator temperatures daily. The facility failed to store drugs and biologicals under proper temperature controls, placing the residents at risk for receiving ineffective medications.

The facility had a census of 33 residents. Based on observation, record review, and interview, the facility failed to prepare, store, and serve meals under sanitary conditions for the 33 residents who received meals from the facility kitchen. Findings included: - On 09/21/21 at 09:00 AM, observations during the initial tour of the kitchen revealed the following: The resident snack refrigerator in the dining room was missing 11 recordings of temperatures in July, 16 recordings of temperatures in August, and 26 recordings of temperatures in September 2021. On 09/21/21 at 09:20 AM, Dietary Staff (DS) BB verified the missing temperatures on the temperature logs for July, August and September 2021 for the resident snack refrigerator in the dining room. On 09/27/21 at 01:25 PM, Administrative Nurse D stated that she expected the refrigerator temperatures to be completed twice a day per the facility policy to ensure the residents were receiving properly stored snacks. The facility's Food-Supply Storage-Food and Nutrition Services policy, dated 06/23/21, documented food from approved services is stored in sanitary conditions and is not exposed to prolonged periods of excessive heat. Internal temperatures of all refrigerators and freezers in the food and nutrition department, dining room, and nourishment areas are recorded twice daily on the Refrigerator/Freezer Temperature Log. The facility failed to prepare, store, distribute, and serve food under sanitary conditions for the 33 residents who received meals from the facility kitchen, placing the residents at risk for food borne illnesses.