**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 27 residents. The sample included 12 residents, with two residents sampled for discharge. Based on observation, record review, and interview, the facility failed to provide a written notice of transfer as soon as practicable to Resident (R) 13 and their representative. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunities for healthcare service for R13. Findings Included: - The electronic medical record (EMR) for R13 documented diagnoses of congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), hypertension (high blood pressure), confusion, adult failure to thrive (includes not doing well, feeling poorly, weight loss, and poor self-care that could be seen in elderly individuals), weakness, hyperkalemia (greater than normal amount of potassium in the blood), hypokalemia (low level of potassium in the blood), and dementia (a progressive mental disorder characterized by failing memory and confusion). The admission Minimum Data Set (MDS) dated 11/06/24 documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. MDS indicated R13 was independent for eating and toileting. The MDS documented R13 needed supervision and touching for bathing. R13's Falls Care Area Assessment (CAA) dated 11/06/24 documented R13 had one fall prior to admission to long-term care. The CAA documented R13 had not had a fall since admission to long-term care. R13's CAA documented R13 required one staff assistance for transfers. The Discharge MDS dated 11 /29/24 for R13 documented an unplanned discharge to an acute hospital with an anticipated return to the facility. R13's Entry MDS dated 12/06/24 documented a reentry to the facility from an acute hospital. The Discharge MDS dated 01 /01/25 for R13 documented an unplanned discharge to an acute hospital with an anticipated return to the facility. R13's Entry MDS dated 01/09/25 documented a reentry to the facility from an acute hospital. R13's Care Plan dated 10/31/24 documented R13 had no plans to be discharged from the facility and planned to stay at the facility. A Nursing Note dated 11/29/24 documented that R13 had critical lab values and the physician requested R13 to be sent to the Emergency Department. R13 was sent by wheelchair, and R13's daughter was notified. A Nursing Note dated 01/01/25 documented that R13 was sent to the emergency room per physician, by wheelchair with staff for shortness of breath, audible wheezes, and crackles. A call was made to R13's daughter, but she did not answer, the nurse spoke to R13's son. The facility failed to provide a copy of any signed Written Notification of Transfer or Discharge for the time in the hospital from [DATE] to 03/15/24 and 01/01/25 to 01/09/25. On 02/12/25 at 12:12 PM, R13 sat at the dining room table visiting with peers. On 02/13/25 at 12:04 PM, Licensed Nurse (LN) G stated the nurse on duty calls the family with admissions and discharges, or any other pertinent information. LN G stated she did not send out a written notification of discharge. LN G stated she was unaware if anyone would send out a written notification of discharge. On 02/13/25 at 12:29 PM, Administrative Staff D stated they do not have the notification of transfer, administrative staff D stated that R13's daughter was notified when she was transferred and given an update on her condition. Administrative Nurse D stated we do not send written notifications. The facility's Admission, Transfer, and Discharge policy revised 02/13/25 documented that persons seeking to move into the facility would be provided with written and verbal information to assist the resident and or their family in deciding whether lining in the facility was appropriate for the resident's needs. All communication, written, and verbal, would be provided in a manner tailored to the resident's language and ability to understand. The information would include a description of the care and services provided by the community and the rights and obligations of persons who choose to live in the facility. The information would also include information about all changes for which the resident would be responsible. In the event there was not an opening in the facility, the person's name would be placed on a waiting list and would be notified by social service when an opening becomes available. The facility failed to provide a written notice of transfer as soon as practicable to R13 and their representative. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunities for healthcare service for R13.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 27 residents. The sample included 12 residents with two residents sampled for discharge. Based on observation, record review, and interview, the facility failed to provide a bed hold with the required information to Resident (R) 13 or their family representative when R13 transferred to the hospital. This deficient practice placed R13 at risk for impaired ability to return to the facility or his same room. Finding include: - The electronic medical record (EMR) for R13 documented a diagnoses of congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), hypertension (high blood pressure), confusion, adult failure to thrive (includes not doing well, feeling poorly, weight loss, poor self-care that could be seen in elderly individuals), weakness, hyperkalemia (greater than normal amount of potassium in the blood), hypokalemia (low level of potassium in the blood), and dementia (a progressive mental disorder characterized by failing memory and confusion). The admission Minimum Data Set (MDS) dated 11/06/24 documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. MDS indicated R13 was independent for eating and toileting. The MDS documented R13 needed supervision and touching for bathing. R13's Falls Care Area Assessment (CAA) dated 11/06/24 documented R13 had one fall before admission to long-term care. The CAA documented R13 had not had a fall since admission to long-term care. R13's CAA documented R13 required one staff assistance for transfers. The Discharge MDS dated 11 /29/24 for R13 documented an unplanned discharge to an acute hospital with an anticipated return to the facility. R13's Entry MDS dated 12/06/24 documented a reentry to the facility from an acute hospital. The Discharge MDS dated 01/01/25 for R13 documented an unplanned discharge to an acute hospital with an anticipated return to the facility. R13's Entry MDS dated 01/09/25 documented a reentry to the facility from an acute hospital. R13's Care Plan dated 10/31/24 documented R13 had no plans to be discharged from the facility and planned to stay at the facility. A Nursing Note dated 11/29/24 documented that R13 had critical lab values, physician requested R13 to be sent to the Emergency Department. R13 was sent by wheelchair, and R13's daughter was notified. A Nursing Note dated 01/01/25 documented that R13 was sent to the emergency room per the physician's order via wheelchair. R13 was accompanied by staff for shortness of breath, and audible wheezes and crackles. A call was made to R13's daughter, but she did not answer, the nurse spoke to R13's son. The facility failed to provide evidence a bed hold notification was provided to the legal representative when R13 transferred to the hospital from [DATE] to 12/06/24 and 1/1/25 to 1/09/25. On 02/12/25 at 12:12 PM, R13 sat at the dining room table visiting with peers. On 02/13/25 at 12:04 PM, licensed Nurse (LN) G stated the nurse on duty was responsible for having the resident or residents repetitively sign a bed hold. On 02/13/25 at 12:29 PM, Administrative Nurse D stated the nursing staff was responsible for notifying the family and having the resident or family representative sign the facility's bed hold. The facility's Bed Hold and Permitting Resident to Return to Facility policy revised 02/13/25 documented the facility would allow the resident whose hospitalization or therapeutic leave exceeds the bed-hold policy under the state plan to return to the facility to resident's previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident requires the services provided by the facility and was eligible for Medicaid nursing facility service or pays privately for services. If the facility determined the resident who was transferred with an expectation of returning to the facility cannot return to the facility, the facility would comply with all requirements of regulations related to transferring and discharging a resident. All information provided to a resident and or representative required a signature or receipt of the policy by the resident and or representative including bed hold information provided at the time of discharge/transfer related to hospitalization and or therapeutic leave. The bed hold policy was provided at the time of admission and bed hold information was provided at the time of discharge/transfer related to hospitalization and or therapeutic leave. The facility failed to provide a bed hold with the required information to R13 and his family representative when R13 transferred to the hospital. This deficient practice placed R13 at risk for impaired ability to return to the facility or his same room.

The facility identified a census of 27 residents. The sample included 12 residents, with one reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care. Based on interviews, record reviews, and observations, the facility failed to provide dementia-related care services for Resident (R) 10 to promote the resident's highest practicable level of well-being. This deficient practice placed R10 at risk for decreased quality of life, isolation, and impaired dignity. Findings Included: - The Medical Diagnosis section within R10's Electronic Medical Records (EMR) included diagnoses of Parkinson's Disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), generalized weakness, dementia, chronic heart failure, hypertension (high blood pressure), and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) in both knees. R10's Quarterly Minimum Data Set (MDS) dated 12/06/24 documented a Brief Interview for Mental Status (BIMS) score of seven. The score indicated severe cognitive impairment. The MDS indicated he required substantial staff assistance for dressing, personal hygiene, bathing, bed mobility, toileting, and transfers. The MDS noted he was frequently incontinent of bowel and bladder. R10's Functional Abilities Care Area Assessment (CAA) completed 06/13/24 revealed he required assistance from staff to complete his activities of daily living (ADL). The CAA indicated he required two staff and a Sit-to-Stand lift for all transfers. The CAA noted a care plan was developed to minimize his risks. R10's Dementia CAA completed 06/13/24 revealed he was at risk for cognitive loss due to his medical diagnoses. The plan instructed staff to allow him time to communicate his needs and process his thoughts. R10's Care Plan initiated 05/29/23 revealed he had required assistance and supervision with his ADLs. The plan noted he used a manual wheelchair and could propel himself. The plan noted he had dementia and Parkinson's disease but was alert and oriented and could make his needs known. The plan noted he had difficulty hearing and wore hearing aids. The plan instructed staff to give him time to process his thoughts. The plan noted he had a history of falls. The plan noted he had difficulty during mealtimes and required a plate guard for meals. The plan noted he did not like scrambled eggs but preferred hard-fried eggs. The plan lacked interventions related to his wandering and sun-downing (a condition where a person tends to become confused or disoriented toward the end of the day) behaviors. On 02/12/25 at 02:45 PM, R10 sat in his wheelchair in the dining room. R10 was confused and kept repeating Where's the visitor parking lot as he wheeled himself around the dining and television area. R10 continually circled the room asking other residents and staff Where's the visitor's lot and stated, he needed to leave. R10 was not offered activities or interventions for his sun-downing behaviors. Staff only pointed to the parking lot and did not attempt to reorient him during this episode. On 02/13/25 at 08:40 AM, R10 sat for breakfast at the dining room table. R10's plate had a large amount of scrambled eggs. R10's plate had no plate guard on it, but his silverware had adapted silverware for easy gripping. R10 received no assistance during his meals and continually yelled out Down we go as he looked at his food. At 10:10 AM, R10 remained in the same spot at the dining room table. The dining room was empty. His food remained un-eaten, and his water glass was spilled over the right side of his wheelchair onto the floor. R10's scrambled eggs remained untouched. R10 attempted multiple times to reposition his wheelchair to leave the table but his wheelchair was stuck on the table's leg. R10 indicated he did not like scrambled eggs when asked about his breakfast. At 10:28 AM, staff came into the dining room from the nurse's station and repositioned his wheelchair so he could move. R10 wheeled himself towards the center hall and sat. R10 fell asleep in his wheelchair until lunch service. On 02/13/25 at 11:20 AM, R10 was moved back to his dining room spot. R10 provided his lunch meal with no plate guard in place. R10 was given adaptive silverware. On 02/13/25 at 12:01 PM, the Certified Nurse's Aide (CNA) M stated that R10 enjoyed watching television. She stated his family provided him with a television streaming service device on his room's television. She stated that R10 has not had wandering or sundowning behaviors recently. She stated staff should attempt to reorient him and provide activities for him to prevent behaviors or disruptions. She stated staff were to help during meals and check in with him to see if he needed anything. She stated that R10 was able to wheel himself around the facility. On 02/13/25 at 12:16 PM, Licensed Nurse (LN) G stated staff was expected to provide activities for him, take him on walks, and visit with him. She stated that R10 should not be left alone during mealtimes or allowed to exhibit sundowning behaviors without staff attempting to assist him. On 02/13/25 at 12:30 PM, Administrative Nurse D stated that R10 had not displayed sundowning behaviors in a while. She stated staff were expected to engage in conversation and activities with him. She stated staff should reorient him to his surroundings and prevent behaviors from occurring. The facility's Person-Centered Dementia Care policy (undated) revealed the facility was to provide dementia-related services designed to focus on the resident's abilities and provide memory enhancement. The policy noted each resident would be provided specialized activities, nutrition, and environmental modifications. The facility failed to provide dementia-related care services for R10 to promote the resident's highest practicable level of well-being. This deficient practice placed R10 at risk for decreased quality of life, isolation, and impaired dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 27 residents. The sample included 12 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure a gradual dose reduction (GDR) was attempted or documented as contraindicated by the physician with a supporting rationale for risk versus benefit for Resident (R) 20 and R25's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication. The facility also failed to ensure R10's antipsychotic medication had a Centers for Medicare and Medicaid (CMS) approved indication or the required risk versus benefit physician documentation. These deficient practices placed these residents at risk for unnecessary medications and adverse side effects. Findings included: - R20's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), cognitive impairment, and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS documented R20 had received hyperglycemic (medication that raises blood sugar levels) medication, opioid (a class of controlled drugs used to treat pain) medication, diuretic (a medication to promote the formation and excretion of urine) medication, anticoagulant (a class of medications sued to prevent the blood from clotting) medication, antidepressant (a class of medications used to treat mood disorders) medication, and antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication. The MDS lacked indication of physician documentation of a gradual dose reduction was clinically contraindicated for R20. The MDS lacked documentation a drug regimen review was completed during the observation period for R20. R20's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 12/31/24 documented she had a diagnosis of Alzheimer's disease and a recent functional decline following a fall at home. R20's Care Plan dated 01/01/25 documented she refused her medication at times. The plan of care documented R20 would pocket her medication in her mouth at times. R20's EMR under the Orders tab revealed the following physician orders: Quetiapine (antipsychotic) (Seroquel) tablet 25 milligrams (mg) give one tablet by mouth daily for generalized anxiety dated 12/18/24. R20's clinical record lacked physician documentation of a rationale for the continued use of the antipsychotic medication, Seroquel, with no gradual dose reduction or documentation of risk versus benefit rationale. The facility was unable to provide evidence of the above physician documentation. On 02/12/25 at 03:09 PM, R20 sat at the dining room table and had her fingernails painted by the nursing staff. On 02/13/25 at 12:16 AM, Licensed Nurse (LN) G stated antipsychotic medications were to be used for potentially violent residents or aggressive behaviors. She stated they were not to be used for dementia-related behaviors. She stated dementia was not an accepted indication for Seroquel. LN G stated Administrative Nurse D would ensure there was the correct documentation for the use of antipsychotic medications. On 02/13/25 at 12:30 PM, Administrative Nurse D stated she was not sure if antipsychotics were used for dementia but stated the facility would use the medication for aggressive behaviors. Administrative Nurse D stated the facility would rely on the physician for the documentation for the rationale of the risk versus benefit of antipsychotic medication. The facility's undated Psychotropic Medication Use policy documented that psycho-pharmacologic medications are drugs that affect brain activities associated with mental processes and behavior. These drugs are also called psychoactive or psychotherapeutic medications. Psychotropic medications are divided into four broad categories: anti-psychotic, antidepressant, anti-anxiety (a class of medications that calm and relax people), antihistamine (a medication that prevents or reduces the effects of histamine, anti-convulsant (a medication that prevents or treats seizures and convulsions), all mood-altering drugs, and hypnotic (a class of medications used to induce sleep) mediations. Centers for Medicare & Medicaid Services (CMS) regulations state that each resident's drug regimen must be free from unnecessary drugs and define what was considered an unnecessary drug. In addition, CMS regulations state that residents who have not previously used anti-psychotic drugs should not be given these drugs unless anti-psychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record. Further, the regulation mandates that residents who use anti-psychotic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, to discontinue these drugs. The resident's need for the psychotropic medication would be monitored, as well as when the resident has received optional benefits from the medication and when the medication dose can be lowered or discontinued. Both the Physician and the nursing staff would evaluate the effectiveness of an as-needed order for psychotropic drugs to manage behavior. The facility failed to ensure a GDR was attempted or documented as contraindicated by the physician with a supporting rationale with risk versus benefit for antipsychotic medication Seroquel for R20. These deficient practices placed R20 at risk for unnecessary medications and adverse side effects.- The Medical Diagnosis section within R10's Electronic Medical Records (EMR) included diagnoses of Parkinson's Disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), generalized weakness, dementia (a progressive mental disorder characterized by failing memory and confusion), chronic heart failure, hypertension (high blood pressure), and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) in both knees. R10's Quarterly Minimum Data Set (MDS) dated 12/06/24 documented a Brief Interview for Mental Status (BIMS) score of seven. The score indicated severe cognitive impairment. The MDS indicated he required substantial staff assistance for dressing, personal hygiene, bathing, bed mobility, toileting, and transfers. The MDS noted she took antipsychotic medications (a class of medications used to treat major mental conditions that cause a break from reality) on a routine basis. R10's Psychotropic (alters mood or thought) Medication Care Area Assessment (CAA) completed 06/18/24 revealed he was at risk for adverse side effects and complications related to his psychotropic medication. The CAA noted he took antipsychotic medications. The CAA noted a care plan was developed to minimize his risks. R10's Care Plan initiated 05/29/23 revealed he took antipsychotic medications. The plan noted his medications had a Black Box Warning (BBW - high-risk medications with potential adverse effects). R10's EMR under Physician's Orders revealed an active order (dated 12/23/24) for staff to administer 2.5 milligrams (mg) of Olanzapine (an antipsychotic medication) by mouth daily with dinner. The order revealed the antipsychotic medication was given for dementia. R10's EMR indicated he had been on Olanzapine since 02/28/24. On 02/13/25 at 07:45 AM, R10 took his morning medications without behaviors or issues. On 02/13/25 at 12:16 AM, Licensed Nurse (LN) G stated antipsychotic medications were to be used for potentially violent residents or aggressive behaviors. She stated they were not to be used for dementia-related behaviors. She stated dementia was not an accepted indication for Olanzapine. On 02/13/25 at 12:30 PM, Administrative Nurse D stated she was not sure if antipsychotics were used for dementia, but stated the facility would use the medication for aggressive behaviors. The facility's Psychotropic Medications revised (undated) indicated antipsychotic medication was only to be used to treat specific diagnosed conditions and documented in the clinical record. The policy indicated antipsychotic medications were to be continually monitored and not used to treat crying, memory impairment, poor self-care, indifference to the surroundings, wandering, restlessness, and uncooperative behaviors. The facility failed to ensure an appropriate indication or a documented physician rationale for R10's Olanzapine medication. This placed R10 s at risk for unnecessary psychotropic medication use and related complications. - R25's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), seizure (violent involuntary series of contractions of a group of muscles), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and hypothyroidism (a condition characterized by decreased activity of the thyroid gland). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented R25 was independent with oral hygiene and eating, and needed supervision or touching assistance for bathing, dressing, and toileting. The MDS documented R25 exhibited no behaviors. The MDS documented R25 took an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication during the observation period. The Admissions MDS dated 05/08/24 documented a BIMS of three which indicated severely impaired cognition. The MDS documented R25 was independent with eating and needed supervision or touching for oral hygiene and dressing. The MDS documented R25 took an antianxiety (a class of medications that calm and relax people) medication during the look-back period. R25's Behavioral Symptoms Care Area Assessment (CAA) dated 05/08/24 documented R25's was admitted to long-term care on 5/6/24. R25 had a diagnosis of dementia and was currently taking Namenda (dementia medication). R25 also had a diagnosis of anxiety and had orders for Xanax (antianxiety medication) as needed (PRN). R25 had been tearful and sad at times since her admission. She scored a one on her MDS mood interview as she voiced, she was just occasionally (2-6 days) sad during the lookback period. R25's Care Plan dated 05/08/24 documented R25 had a Black Box Warning (BBW - highest safety-related warning that medications can have assigned by the Food and Drug Administration), R25 took an antipsychotic, and her first appointment with the physician would be the week after her admission. R25's EMR under the Orders tab documented: Seroquel (antipsychotic medication) 25 milligrams (mg) give 0.5mg tablet by mouth nightly for anxiety disorder dated 05/10/24. A review of R25's EMR revealed no physician-documented rationale for the continued use of Seroquel for anxiety disorder, or a risk vs benefit. On 02/12/25 at 09:33 AM, R25 sat at the breakfast table, talking to peers. On 02/13/25 at 09:24 AM, R25 sat in the day room, looking at the puzzle pieces. On 02/13/25 at 12:16 AM, Licensed Nurse (LN) G stated antipsychotic medications were to be used for potentially violent residents or aggressive behaviors. She stated they were not to be used for dementia-related behaviors. She stated dementia was not an accepted indication for Seroquel. On 02/13/25 at 12:30 PM, Administrative Nurse D stated she was not sure if antipsychotics were used for dementia but stated the facility would use the medication for aggressive behaviors. On 02/13/25 at 12:26 PM, Administrative Nurse D stated the Consult Pharmacist (CP) would email the MMRs to her, and she printed them from the email. Administrative Nurse D stated she would fax the MMRs to the resident's physician for a response. Administrative Nurse D stated if the physician did not respond to the MMRs, the facility's medical director was responsible for following up on the unaddressed MMR. Administrative Nurse D stated if there was no response from the physician or medical director, she was not sure what the next plan of action was. The facility's Psychotropic Medication Use policy documented psycho-pharmacologic medications are drugs that affect brain activities associated with mental processes and behavior. These drugs are also called psychoactive or psychotherapeutic medications. Psychotropic medications are divided into four broad categories: antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antidepressant (a class of medications used to treat mood disorders), antianxiety (a class of medications that calm and relax people), antihistamine (drug used in the treatment of allergies, and anti-convulsant (drug to prevent seizures, all mood-altering drugs, and hypnotic mediations(drugs to suppress the central nervous system). Centers for Medicare & Medicaid Services (CMS) regulations state that each resident's drug regimen must be free from unnecessary drugs and define what was considered an unnecessary drug. In addition, CMS regulations state that residents who have not previously used anti-psychotic drugs should not be given these drugs unless anti-psychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record. Further, the regulation mandates that residents who use anti-psychotic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, to discontinue these drugs. The resident's need for the psychotropic medication would be monitored, as well as when the resident has received optional benefits from the medication and when the medication dose can be lowered or discontinued. Both the Physician and the nursing staff would evaluate the effectiveness of as-needed orders for psychotropic drugs to manage behavior. The facility failed to ensure an appropriate indication or a documented physician rationale for R25's Seroquel medication, or a risk vs benefit. This placed R25 s at risk for unnecessary psychotropic medications and related complications.

The facility identified a census of 27 residents. The sample included 12 residents, with two residents reviewed for hospice. Based on observation, record review, and interviews, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R) 22. This placed the resident at risk for inappropriate end-of-life care. Finding Included: - R22's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of assistance with personal needs, urinary retention, diabetes mellitus (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), sinus tachycardia(normal rhythm, heart beating too fast), dysphagia (swallowing difficulty), and anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). The Significant Change in Status Minimum Data Set (MDS) for R22 dated 11/26/24 recorded a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R22 was independent in oral hygiene, and eating, and needed staff touching or verbal cues for bathing and toileting. The MDS documented R43 received hospice services during the observation period. The admission MDS for R22 dated 02/16/24 documented a BIMS of eight which indicated a modernly impaired cognition. The MDS documented R22 required substantial to maximum assistance for toileting, bathing, and oral hygiene. The MDS documented R22 was continent during the lookback period. R22's Activities of Daily Living (ADLs) - Functional status/Rehabilitation Potential Care Area Assessment (CAA) dated 11/26/24 documented R22 was admitted to long-term care from the local hospital for generalized weakness. R22 needed the assistance of one for transfers, ambulation, and daily care. The CAA documented R22 received Physical and occupational therapy due to generalized weakness. R22's Care Plan dated 11/19/24 documented R22 had a do not resuscitate code status and was receiving hospice services. R22's plan of care documented if R22 needed any specific supplies, the facility should reach out to hospice. R22's plan of care documented hospice would assist with R22's pain management and communicate with R22's physician. A review of the hospice-provided communication binder revealed R22 was admitted to hospice services on 10/31/24. On 02/11/24 at 11:44 AM, R22 sat at the dining room table visiting with peers. On 12/12/24 at 02:42 AM, R22 sat at the dining room table visiting with peers. On 02/13/24 at 11:53 AM, Certified Nursing Aide (CNA) M stated all staff had access to the resident's care plans. CNA M stated she was unsure if all supplies should be put in the resident's care plan, she stated hospice had everything the residents were receiving and when the aides and nurses came in to provide services in the hospice care plan. CNA M stated all staff could always look in the hospice binder. On 02/13/24 at 12:04 PM, Licensed Nurse (LN) G stated all residents on hospice services have a binder. LN G stated if she could not find the information in the resident's care plan, she could look in the resident's hospice binder. LN G stated oxygen and wheelchairs should be care planned. On 02/13/24 at 12:29 PM, Administrated Nurse D stated the resident's care plan should state what was provided by hospice, what equipment, what supplies, and when the hospice staff would be in the building. Administrative Nurse D stated all the supplies and equipment provided could be found in the hospice's binder. The facility failed to provide a policy related to hospice services as requested on 02/13/25. The facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for R22. This deficient practice placed the resident at risk for inappropriate end-of-life care.

The facility identified a census of 27 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to provide direct, interactive activities based on resident preferences for the residents on weekends. This deficient practice placed the affected residents at risk for decreased psychosocial well-being, boredom, and isolation. Findings Included: - A review of the facility's Activity Calendars for December 2024, January 2025, and February 2025 was completed. The calendars revealed religious services provided at 09:00 AM and 03:15 PM for Saturdays but lacked staff-led activities. The calendars revealed a devotional group was held at 09:00 AM on Sundays. The calendar revealed the residents were provided music and coloring pages on Sundays but lacked staff-led activity groups. The council reported the weekends were sometimes slow without activities. On 02/11/25 at 10:30 AM, the facility provided manicures for the residents. On 02/12/25 at 11:40 AM, the facility's Resident Counsel reported that staff-led activities rarely occurred on weekends. The council reported that the facility's previous Activity Coordinator (AC) quit in December 2024. The council reported that the facility provided religious activities on Saturdays and Sundays but lacked staff-led activities. On 02/13/25 at 12:01 PM, the Certified Nurse's Aide (CNA) M stated that the facility staff completed activities on weekdays but was not sure what activities were available on weekends outside of church services. She stated that the facility provided coloring pages, board games, and puzzles that the residents could complete on their own but was not sure of any staff-led activities. On 02/13/25 at 12:16 PM, Licensed Nurse (LN) G stated the facility provided puzzles and games for the residents on the weekends. On 02/13/25 at 12:30 PM, Administrative Nurse D stated the facility provided religious services on weekends. She stated the residents could play board games, puzzles, and self-led activities. She stated she was not sure of any staff-led activities outside of church services on the weekends. The facility's Activities Evaluation policy (undated) indicated the facility would provide ongoing individualized and group activities that promote goals, strengths, and social, and emotional support for each resident. The facility failed to provide consistent activities on the weekends which reflected the residents' interests and preferences. This deficient practice placed the affected residents at risk for boredom, isolation, and decreased quality of life.

The facility had a census of 27 residents. The sample included 12 residents, with two reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure 15 pressurized medical oxygen tanks in a safe, locked area, and out of reach of the nine cognitively impaired independently mobile residents. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings Included: - On 02/11/25 at 07:20 AM, an inspection of the facility's oxygen storage room revealed that the door was not secured. An inspection of the room revealed 15 full supplemental oxygen cylinders in the storage rack. The door closed and locked upon exit. On 02/13/25 at 08:22 AM the facility identified it had nine cognitively impaired independently mobile residents. On 02/13/25 at 12:01 PM, Certified Nurse's Aide (CNA) M stated the room was to be locked at all times due to the oxygen tanks. She stated the door had an electronic lock and staff were to ensure the door was fully closed and locked upon exiting the room. On 02/13/25 at 12:30 PM, Administrative Nurse D stated staff were expected to ensure the door was locked upon entering and exiting the room. The facility's Medical Gas Usage and Storage policy revised 02/2025 stated all pressurized containers and potentially hazardous medical equipment will be locked within a secure temperature-controlled room. The facility failed to secure 15 pressurized medical oxygen tanks in a safe, locked area, and out of reach of the nine cognitively impaired independently mobile residents. This deficient practice placed the residents at risk for preventable accidents and injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 27 residents. The sample included 12 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) recommendations were acknowledged and/or acted upon for Resident (R) 2, R20, and R25. The facility failed to ensure the CP identified and reported the non-approved indication for R10's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication. These deficient practices placed the residents at risk for unnecessary medication use and physical complications. Findings included: - R2's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and confusion), and short-term memory loss. The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS documented R2 had received an antidepressant (a class of medications used to treat mood disorders) medication, a diuretic (a medication to promote the formation and excretion of urine), and an opioid (a class of controlled drugs used to treat pain). The MDS lacked indication of physician documentation that a gradual dose reduction was clinically contraindicated for R2. The MDS lacked documentation a drug regimen review was completed during the observation period for R2. The Quarterly MDS dated 01/19/25 documented a BIMS score of 99 which indicated severely impaired cognition. The MDS documented that R2 had received an antidepressant medication, an antianxiety (a class of medications that calm and relax people) medication, a diuretic, and an opioid. The MDS lacked indication of physician documentation that a gradual dose reduction was clinically contraindicated for R2. The MDS lacked documentation a drug regimen review was completed during the observation period for R2. R2's Psychotropic Drug Use Care Area Assessment (CAA) dated 04/23/24 documented she currently took Zoloft (antidepressant) 50 milligrams (mg) daily. R2's Care Plan dated 10/28/24 documented she would not experience adverse effects related to medications. R2's EMR under the Orders tab revealed the following physician orders: Sertraline (Zoloft) tablet 100 mg, one tablet, daily for anxiety with depression dated 09/19/24. Review of R2's EMR under the Notes tab revealed a Pharmacy Review note dated 03/28/24 at 01:32 PM documented the recommendation pending. The facility provided an unaddressed and unsigned Monthly Medication Review (MMR) dated 03/28/24 upon request. On 02/11/25 at 03:30 PM, R2 walked with her walker in the hallway to the common area by the front entrance door. On 02/13/25 at 12:04 PM, Licensed Nurse (LN) G stated she made changes for any new medication orders on the MRRs when they were returned from the physician's office. On 02/13/25 at 12:26 PM, Administrative Nurse D stated the CP would email the MMRs to her, and she printed them from the email. Administrative Nurse D stated she would fax the MMRs to the resident's physician for a response. Administrative Nurse D stated if the physician failed to respond to the MMRs, the facility's medical director was responsible for following up on the unaddressed MMR. Administrative Nurse D stated if there was no response from the physician or medical director, she was not sure what the next plan of action was. The facility's Medication Regimen Review policy last revised 02/01/24 documented the purpose of this policy was to minimize or prevent adverse consequences by identifying irregularities including syndromes potentially related to medication therapy, emerging or existing adverse medication consequences, as well as the potential for adverse drug reactions, and medication errors. Medication Regimen Review (MRR) consists of the pharmacist reviewing each resident's medication regimen including psychotropic drugs and review of the resident's medical chart at least once a month in order to identify irregularities; and to identify clinically significant risks and/or adverse consequences resulting from or associated with medications. It may be necessary for the pharmacist to conduct the MRR more frequently, for example weekly, depending on the resident's condition and the risks for adverse consequences related to current medications. Findings and recommendations are reported to the Director of Nursing and the attending physician. The facility failed to ensure the physician reviewed and addressed the CP recommendations for R2. This deficient practice placed R2 at risk for unnecessary medication use, side effects, and physical complications. - R20's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), cognitive impairment, and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS documented R20 had received a hyperglycemic (medication that raises blood sugar levels) medication, an opioid (a class of controlled drugs used to treat pain) medication, a diuretic (a medication to promote the formation and excretion of urine) medication, an anticoagulant (a class of medications sued to prevent the blood from clotting) medication, an antidepressant (a class of medications used to treat mood disorders) medication, and an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication. The MDS lacked indication of physician documentation that a gradual dose reduction was clinically contraindicated for R20. The MDS lacked documentation a drug regimen review was completed during the observation period for R20. R20's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 12/31/24 documented she had a diagnosis of Alzheimer's disease and a recent functional decline following a fall at home. R20's Care Plan dated 01/01/25 documented she would refuse her medication at times. The plan of care documented R20 would pocket her medication in her mouth at times. R20's EMR under the Orders tab revealed the following physician orders: Quetiapine (antipsychotic) (Seroquel) tablet 25 milligrams (mg) give one tablet by mouth daily for generalized anxiety dated 12/18/24. Review of R20's EMR under the Notes tab revealed a Pharmacy Review note dated 05/24/24 at 12:14 PM documented the recommendation pending. The facility provided an unaddressed and unsigned Monthly Medication Review (MMR) dated 05/24/24 upon request. On 02/12/25 at 03:09 PM, R20 sat at the dining room table and had her fingernails painted by the nursing staff. On 02/13/25 at 12:04 PM, Licensed Nurse (LN) G stated she made changes for any new medication orders on the MRRs when they were returned from the physician's office. On 02/13/25 at 12:26 PM, Administrative Nurse D stated the CP would email the MMRs to her, and she printed them from the email. Administrative Nurse D stated she would fax the MMRs to the resident's physician for a response. Administrative Nurse D stated if the physician failed to respond to the MMRs, the facility's medical director was responsible for following up on the unaddressed MMR. Administrative Nurse D stated if there was no response from the physician or medical director, she was not sure what the next plan of action was. The facility's Medication Regimen Review policy last revised 02/01/24 documented the purpose of this policy was to minimize or prevent adverse consequences by identifying irregularities including syndromes potentially related to medication therapy, emerging or existing adverse medication consequences, as well as the potential for adverse drug reactions, and medication errors. Medication Regimen Review (MRR) consists of the pharmacist reviewing each resident's medication regimen including psychotropic drugs and review of the resident's medical chart at least once a month in order to identify irregularities; and to identify clinically significant risks and/or adverse consequences resulting from or associated with medications. It may be necessary for the pharmacist to conduct the MRR more frequently, for example weekly, depending on the resident's condition and the risks for adverse consequences related to current medications. Findings and recommendations are reported to the Director of Nursing and the attending physician. The facility failed to ensure the physician reviewed and addressed the CP recommendations for R2. This deficient practice placed R2 at risk for unnecessary medication use, side effects, and physical complications.- The Medical Diagnosis section within R10's Electronic Medical Records (EMR) included diagnoses of Parkinson's Disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), generalized weakness, dementia (a progressive mental disorder characterized by failing memory and confusion), chronic heart failure, hypertension (high blood pressure), and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) in both knees. R10's Quarterly Minimum Data Set (MDS) dated 12/06/24 documented a Brief Interview for Mental Status (BIMS) score of seven. The score indicated severe cognitive impairment. The MDS indicated he required substantial staff assistance for dressing, personal hygiene, bathing, bed mobility, toileting, and transfers. The MDS noted she took an antipsychotic medication (a class of medications used to treat major mental conditions that cause a break from reality) on a routine basis. R10's Psychotropic (alters mood or thought) Medication Care Area Assessment (CAA) completed 06/18/24 revealed he was at risk for adverse side effects and complications related to his psychotropic medication. The CAA noted he took antipsychotic medications. The CAA noted a care plan was developed to minimize his risks. R10's Care Plan initiated 05/29/23 revealed he took antipsychotic medications. The plan noted his medications had a Black Box Warning (BBW - high-risk medications with potential adverse effects). R10's EMR under Physician's Orders revealed an active order (dated 12/23/24) for staff to administer 2.5 milligrams (mg) of Olanzapine (an antipsychotic medication) by mouth daily with dinner. The order revealed the antipsychotic medication was given for dementia. R10's EMR indicated he had been on Olanzapine since 02/28/24. A review of R10's Monthly Medication Reviews (MMR) from 02/01/24 through 02/01/25 revealed no recommendations from the Consulting Pharmacist (CP) to review the appropriate indication for the use of R10's antipsychotic medication. On 02/13/25 at 07:45 AM, R10 took his morning medications without behaviors or issues. On 02/13/25 at 12:16 AM, Licensed Nurse (LN) G stated antipsychotic medications were to be used for potentially violent residents or aggressive behaviors. She stated they were not to be used for dementia-related behaviors. She stated dementia was not an accepted indication for Olanzapine. She stated the pharmacy reviewed each resident's orders and should have made recommendations. On 02/13/25 at 12:30 PM, Administrative Nurse D stated she was not sure if antipsychotics were used for dementia but stated the facility would use the medication for aggressive behaviors. She stated the medical director was responsible for reviewing the monthly pharmacy recommendations. The facility's Medication Regimen Review policy revised 02/2024 indicated the consulting pharmacist was to complete monthly medication reviews to identify irregularities to minimize the risks of medication errors and adverse drug reactions. The policy revealed the consulting pharmacist would make recommendations to the facility's medical provider and director of nursing. The facility's CP failed to identify and report an inappropriate indication for R10's Olanzapine medication. This placed R10 s at risk for unnecessary psychotropic medications and related complications. - R25's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), seizure (violent involuntary series of contractions of a group of muscles), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and hypothyroidism (a condition characterized by decreased activity of the thyroid gland). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented R25 was independent with oral hygiene and eating but required supervision or touching assistance for bathing, dressing, and toileting The MDS documented R25 exhibited no behaviors. The MDS documented R25 took an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication during the observation period. The Admissions MDS dated [DATE] documented a BIMS of three which indicated severely impaired cognition. The MDS documented R25 was independent with eating and required supervision or touching for oral hygiene and dressing. The MDS documented R25 took an antianxiety (a class of medications that calm and relax people) medication during the look back period. R25's Behavioral Symptoms Care Area Assessment (CAA) dated 05/08/24 documented R25's was admitted to long term care on 5/6/24. R25 had a diagnosis of dementia and currently took Namenda (dementia medication). R25 also had a diagnosis of anxiety and had orders for Xanax (antianxiety medication) as needed (PRN). R25 had been tearful and sad at times since her admission. She scored a one on her MDS mood interview as she voiced, she was just occasionally (2-6 days) sad during the lookback period. R25's Care Plan dated 05/08/24 documented she had a Black Box Warning (BBW - highest safety-related warning that medications can have assigned by the Food and Drug Administration), R25 took an antipsychotic, and her first appointment with the physician would be the week after her admission. R25's EMR under the Orders tab documented: Seroquel (antipsychotic medication) 25 milligrams (mg) give 0.5mg tablet by mouth nightly for anxiety disorder dated 05/10/24. R25's Consultant Pharmacist Recommendation to Physician dated 11/27/24 documented the physician to assess R25's Seroquel (Quetiapine) for a potential gradual dose reduction (GDR). R25's Physician/Prescriber response dated 12/11/24 documented the physician agreed and would assess a dose reduction at R25's next appointment. R25's medical record lacked documentation that the physician had addressed R25's Quetiapine. On 02/12/25 at 09:33 AM, R25 sat at the breakfast table, talking to peers. On 02/13/25 at 09:24 AM, R25 sat in the day room, looking at the puzzle pieces. On 02/13/25 at 12:04 PM, Licensed Nurse (LN) G stated she made changes for any new medication orders on the MRRs when they returned from the physician's office. On 02/13/25 at 12:26 PM, Administrative Nurse D stated the Consult Pharmacist (CP) would email the MMRs to her, and she printed them from the email. Administrative Nurse D stated she would fax the MMRs to the resident's physician for a response. Administrative Nurse D stated if the physician did not respond to the MMRs, the facility's medical director was responsible for following up on the unaddressed MMR. Administrative Nurse D stated if there was no response from the physician or medical director, she was not sure what was the next plan of action. The facility's Medication Regimen Review policy last revised 02/01/24 documented the purpose of this policy was to minimize or prevent adverse consequences by identifying irregularities including syndromes potentially related to medication therapy, emerging or existing adverse medication consequences, as well as the potential for adverse drug reactions, and medication errors. Medication Regimen Review (MRR) consists of the pharmacist reviewing each resident's medication regimen including psychotropic drugs and review of the resident's medical chart at least once a month to identify irregularities; and to identify clinically significant risks and/or adverse consequences resulting from or associated with medications. It may be necessary for the pharmacist to conduct the MRR more frequently, for example weekly, depending on the resident's condition and the risks for adverse consequences related to current medications. Findings and recommendations are reported to the Director of Nursing and the attending physician. The facility failed to ensure the physician addressed the CP recommendations for R25. This deficient practice placed R25 at risk for unnecessary medication use, side effects, and physical complications.

The facility identified a census of 27 residents. The facility identified four residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to implement adequate hand hygiene. This deficient practice placed the residents at risk for infectious diseases. Findings included: - On 02/11/25 at 08:33 AM, Certified Nurse Aide (CMA) R failed to perform hand hygiene and donned a pair of gloves, CMA R removed R10's hearing aids from the medication cart. CMA R changed the battery in one hearing aid. CMA R placed R10's hearing aids in each ear at the dining room table. CMA R doffed her gloves and failed to perform hand hygiene. CMA R pushed R10 into an area across from the dining room. CMA R failed to perform hand hygiene and donned a pair of gloves from her uniform pocket. CMA R then administered R10's inhalation medication by assisting R10 with one puff into each nostril. CMA R failed to perform hand hygiene or change gloves. CMA R then instilled R10's eye drops, she held R10's eye open and then instilled one eye drop into each eye. On 02/13/24 at 12:29 PM, Administrated Nurse D stated staff were expected to complete hand hygiene before, during, and after touching the residents. She stated staff were expected to complete hand hygiene in between glove changes and changing personal protective equipment (PPE). The Infection Prevention and Control policy revised 02/12/2025 documented the facility's health system shall establish and maintain an infection prevention and control plan including the appropriate policies and procedures for surveillance, prevention, and control of infection that reflect the hospital's mission statement. The facility was dedicated to minimizing infection risks to prevent infections in patients, personnel, volunteers, and visitors. The facility would ensure the infection prevention and control program was managed effectively: represents relevant components and functions with the hospital to implement the infection prevention and control programs to reduce, eliminate, or prevent healthcare-acquired infections and ensure that hospital leaders allocate adequate resources for the implantation and education of the infection prevention program. The facility failed to implement adequate hand hygiene. This deficient practice placed the residents at risk for infectious diseases.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 20 residents. The sample contained 12 residents, with one resident reviewed for limited range of motion. Based on observation, interview, and record review, the facility failed to provide interventions to promote maintenance of range of motion and prevent decline in the right hand, for the one sampled resident, Resident (R) 8. Findings included: - The signed Physician Order Sheet (POS), dated 09/09/21, documented R8's diagnoses included cataract (clouding of the lens of the eye) of unspecified eye, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), irritable bowel syndrome (abnormally increased motility of the small and large intestines), and stroke (damage to tissues in the brain due to a loss of oxygen to the area). An annual Minimum Data Set (MDS), dated [DATE], documented staff assessed R8 as having memory problems. She required total assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. She required extensive assistance for eating and had functional limitation in range of motion in one upper extremity, and in both lower extremities. The care plan lacked intervention to maintain range of motion ability of the right hand. On 09/15/21 at 10:13 AM, R8 sat in her Broda chair (a specialized highbacked wheelchair) in the dining room. Her right hand remained tightly in a fist. On 09/15/21 12:14 PM, R8 sat in her Broda chair in dining. The resident did not use the right hand at all during the meal as it remained in her lap. On 09/15/21 at 02:20 PM, R8's right hand remained tightly in a fist. The resident's hand lacked any type of device to open her fingers from the palm of her hand. On 09/16/21 at 10:08 AM, R8 sat in her Broda chair in the lounge. She pulled briefly at her oxygen tubing using finger/thumb grasp of her curled right hand. This action dislodged the oxygen tubing from her right ear. Her right hand then returned to the fist position. On 9/21/21 at 08:40 AM, R8 sat in her Broda chair in the dining room. Throughout her breakfast, her arms remained under the blanket. On 09/15/21 at 02:20 PM, a family member reported R8 lost the use of her left arm after her stroke. R8's right hand looked like it stayed more in the position of a fist, but she could still move it. R8 has progressive dementia, so she may need interventions to maintain movement ability in her right hand. On 09/20/21 at 02:25 PM, Certified Nursing Assistant (CNA) N stated we help her get up in the morning, we feed her and reposition her. She doesn't use the left arm, and staff put a pillow under it. CNA N did not know of anything that the staff did for the resident's right hand. She doesn't use the right hand very much, but she can move it around. The staff do not do any range of motion with her right hand. On 09/21/21 at 08:42 AM, Administrative Nurse E acknowledged that the resident's right hand was usually in a fist, but R8 was able to move it. She does not have functional use of her left side, or her right leg. On 09/21/21 at 02:54 PM, Licensed Nurse (LN) H stated R8 has dementia and has good days where she tried to reach for the spoon with the fist that was tight. The staff are not currently doing anything to keep movement in her hand. Without adequate movement the hand could stay in a fist. Something could be done now before that happened. LN H reported they could notify the doctor and ask occupational therapy for recommendations. On 09/21/21 at 02:25 PM, CNA M stated she did not provide range of motion or perform restorative exercise with residents. Someone came up from therapy to do restorative with some of the residents, but no restorative services were done by staff with R8. On 09/21/21 at 04:19 PM, Administrative Nurse D stated some intervention should be in place to keep the resident's hand from remaining in a fist position and verified there was not currently any intervention in place. Occupational therapy looked at her for the Broda chair, but they did not evaluate her right hand at that time. The facility failed to provide interventions to promote maintenance or prevent decline of range of motion in the resident's right hand.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 20 residents. The sample contained 12 residents, with two residents reviewed for accidents. Based on observation, interview and record review, the facility failed to ensure safe mobility to prevent accidents when the facility failed to provide foot pedals to the wheelchair, while transporting one of the two sampled residents, dependent Resident (R) 9. Findings included: - The signed Physician Order Sheet (POS), dated 07/28/21, documented R9 had a diagnosis of bilateral (affecting both sides) osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) of the knee. An annual Minimum Data Set (MDS), dated [DATE], documented R9's Brief Interview for Mental Status (BIMS) score was 11, indicating moderate cognitive impairment. R9 required limited assistance with locomotion on the unit. A Cognitive Loss Care Area Assessment (CAA), dated 03/17/21, documented R9's primary language was Japanese and confusion resulted when she did not understand. An Identified Risks care plan, dated 03/08/21, documented R9 used a wheelchair at times. The care plan lacked instruction regarding use of foot pedals on the wheelchair when staff propelled the resident in the wheelchair. On 09/16/21 at 09:47 AM, Certified Nursing Assistant (CNA) N propelled R9 in her wheelchair, without foot pedals, from the dining room to her room. R9's toes skimmed along on the floor throughout the travel, a distance of approximately 35 feet. On 09/16/21 at 10:02 AM, CNA M propelled R9 in her wheelchair, without foot pedals, from her room to the television lounge. R9's toes skimmed the floor throughout travel, a distance of approximately 40 feet. On 09/16/21 at 10:13 AM, Licensed Nurse (LN) G propelled R9 in her wheelchair, without foot pedals, from the television lounge to her room. R9's heels skimmed the floor for the duration of travel, a distance of approximately 40 feet. On 09/20/21 at 03:08 PM, CNA N propelled R9 in her wheelchair, without foot pedals, from the front lounge to her room. R9's heels skimmed along on the floor throughout travel, a distance of approximately 25 feet. On 09/20/21 at 03:38 PM, CNA N stated some of the residents have foot pedals on their wheelchairs. Staff use foot pedals when it is in the resident's care plan. She would ask the nurse before making any changes, but a resident's feet should not drag along the floor when staff propel them in a wheelchair. On 09/21/21 at 09:52 AM, Certified Nursing Assistant (CMA) S stated R9's knees bothered her, so she did not propel herself for long distances. When staff propel residents, they should use foot pedals because if the resident dropped their feet, they could fall out. R9 had bad knees, which could make it hard for her to keep her feet up. On 09/21/21 at 03:09 PM, LN H stated R9 had something wrong with her knees. She had a tendency to be up walking and just drop, because her knees gave out. When possible, residents using wheelchairs should propel themselves. But if staff were pushing a resident, they should use foot pedals. On 09/21/21 at 03:55 PM, Administrative Nurse D stated R9 should have foot pedals on the wheelchair when staff propel her. The facility was unable to provide a policy regarding the use of wheelchair foot pedals. The facility failed to ensure safe mobility for this resident when pushing her in her wheelchair, placing her at risk for accidental injury when staff propelled her without foot pedals, allowing her toes or heels to skim along the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 20 residents with twelve selected for review, including one Resident (R)5, reviewed for respiratory care. Based on observation, interview, and record review, the facility failed to change R5's oxygen tubing in a timely manner. This practice increased the risk of Resident (R)5 developing a respiratory infection. Findings included: - The Problem List, located in the electronic medical record (EMR), for Resident (R)5, included diagnoses of pulmonary fibrosis (lung tissue becomes damaged and thickened leading to shortness of breath), obstructive sleep apnea (intermittent airflow blockage during sleep), and chronic cough. The Quarterly Minimum Data Set (MDS), dated [DATE], assessed R5 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. He did not experience shortness of breath with exertion, lying flat, or at rest, and did require oxygen. The Annual MDS, dated 08/25/21, did not reveal any changes to R5's BIMS score, oxygen use, or shortness of breath. The Care Plan, dated 03/09/21, revealed that R5 required continuous oxygen at three liters and the staff could titrate the oxygen up to four liters with exertion to keep his oxygen saturation levels above 88%. R5 had an oxygen concentrator in his room and a portable tank on his wheelchair for ambulation. The oxygen connected to the continuous positive airway pressure (CPAP) Mid-machine (used to deliver air through a mask and tube into the airways) while sleeping. The Nursing Assessments, located under the active orders tag, located under the summary tab of the EMR, included an order, dated 07/22/21, for oxygen at three liters continuously, for hypoxia (inadequate supply of oxygen), titrate up to four liters with exertion, to maintain oxygen saturations above 88%. On 09/15/21 at 03:12 PM, R5 was resting in his recliner in his room with oxygen in place per a nasal cannula connected to an oxygen concentrator. The green extension tubing connected to the concentrator had a date labeled 07/29/21, the nasal cannula connected to the green extension tubing had a date labeled 08/24/21. The nasal cannula, connected to the portable oxygen tank, had a date labeled 08/06/21. The humidifier bottle, connected to the oxygen concentrator, lacked a date. On 09/16/21 at 08:16 AM, R5 was sitting in the dining room with oxygen in place per a nasal cannula, connected to a portable oxygen tank. On 09/16/21 at 08:23 AM, R5's green extension tubing, connected to the oxygen concentrator, had a date of 07/29/21, and the nasal cannula connected to it had a date of 09/15/21. The humidifier bottle, connected to the oxygen concentrator, lacked a date. On 09/16/29 at 12:09 PM, Certified Nurse Aide (CNA) O, was changing out the portable oxygen tank, and confirmed that the date on the nasal cannula tubing connected to it was 08/06/21. On 09/20/21 at 09:56 AM, the nasal cannula connected to the portable oxygen tank, continued to have a date of 08/06/21. The green extension tubing, connected to the oxygen concentrator, had a date of 09/15/21 and the humidifier bottle, connected to the oxygen concentrator, lacked a date. On 09/20/21 at 03:35 PM, Licensed Nurse (LN) H stated that either a nurse or a Certified Medication Aide (CMA) changed the oxygen tubing every 30 days, including the extension tubing, and wrote the date and their initials on tape to indicate the date changed. The humidifier bottles were changed every 30 days with the oxygen tubing. On 09/20/21 at 03:49 PM, Administrative Nurse D stated the oxygen tubing, including the extension tubing, and the humidifier bottles, were to be changed monthly. The items should be dated when changed. Administrative Nurse D stated that R5's tubing was due to be changed on 09/15/21. The facility policy Storage and Labeling of Nasal Cannula/Mask Tubing, dated 12/15/17, indicated that residents who receive oxygen will have their tubing/mask changed monthly on the 17th and the tubing will be marked with the date of change. The policy lacked instruction on changing and dating of the humidifier bottle. The facility failed to change R5's oxygen tubing in a timely manner. This practice increased the risk of Resident (R)5 developing a respiratory infection.

The facility reported a census of 20 residents and identified 12 of those residents with controlled medications stored in the medication cart. Based on interview and record review, the facility failed to perform an accurate system for the count of the number of controlled medications (medications that can cause physical and mental dependence) in the medication cart, increasing the risk for diversion of the medications. Findings included: - On 09/16/21 at 03:50 PM, the record used for the shift to shift count of controlled medications lacked a place for the staff to document the number of controlled medications in the medication cart. On 09/16/21 at 03:52 PM, Licensed Nurse (LN) G stated that all controlled medications were stored in the medication cart and a count was done with the off going/on coming staff that was taking over the medication cart. During the count process the staff counted the number of pills in the cards or amount of liquid in a bottle. LN G stated that the number of controlled medications in the cart were not counted during the count process. On 09/16/21 at 04:11 PM, Administrative Nurse D stated that the staff have been counting the number of pills in the card of the controlled medications but have not been counting the number of controlled medications stored in the cart and probably should. The facility policy Controlled Substance Policy, dated 08/04/20, indicated controlled substances must be validated at least weekly by two licensed individuals. The facility failed to perform an accurate count of the number of controlled medications (medications that can cause physical and mental dependence) in the medication cart, increasing the risk for diversion of the 12 residents' narcotic medications.

The facility reported a census of 20 residents with 12 selected for review, including five residents reviewed for influenza vaccinations. Based on interview and record review, the facility failed to provide consent forms to allow the resident or the resident's representative the opportunity to refuse the influenza immunization for the five residents, Resident (R)1, R5, R8, R11, and R19. Findings included: - The electronic medical record (EMR), indicated that Resident (R)19 received an influenza vaccine on 09/17/20. The other four reviewed residents' EMRs, indicated that R1, R5, R8, and R11 received an influenza vaccine on 10/14/20. The EMRs all lacked consent forms for the influenza vaccination for these five residents. On 09/21/21 at 11:48 AM, Administrative Nurse F stated that the nurse providing the vaccine would supply the vaccine information sheet and have the consent filled out. On 09/21/21 at 03:50 PM, Administrative Nurse D stated the facility does a blanket consent for treatment that the resident/representative signs and there was not a consent form provided before vaccination for the influenza vaccine. Administrative Nurse D confirmed that the Consent and Agreement of Health Care Services does not include specifically in the agreement, consent for the influenza vaccine. The facility policy Post-Acute Vaccination of Residents, dated 07/27/20, indicated that prior to offering the influenza vaccine each resident and/or representative will receive current education regarding the benefits and potential side effects of the immunization. Informed consent in the form of a discussion regarding risks, benefits, and potential side effects of vaccination will occur prior to vaccination. In the case of residents, this may be with their representative when appropriate. Residents have the right to refuse vaccinations. The facility failed to provide consent forms to allow the resident or the resident's representative the opportunity to refuse influenza immunization for the five residents.