**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 53 resident with 12 residents in the sample. Based on observation, interview, and record review, the facility failed to show respect and dignity to one Resident (R)4, by not having a dignity bag for the indwelling urinary catheter (a thin, hollow tube inserted through the urethra into the urinary bladder to collect and drain urine) collection bag. Findings included: - The Physician's Orders dated 10/10/23 revealed R4 had a diagnosis of urinary retention (the lack of ability to urinate and empty the bladder). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R4 had an indwelling urinary catheter. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 10/12/23, revealed R4 arrived at the facility from the hospital with an indwelling catheter. The Care Plans dated 10/12/23 documented R4 would remain free from catheter-related trauma through review date. Monitor for signs and symptoms of discomfort on urination and frequency. Observations on 11/13/23 at 10:10 AM revealed R4's indwelling urinary catheter collection bag stored directly on the floor. The catheter bag lacked a dignity bag and was visible to residents and staff in the hall. Observation on 11/14/23 at 01:13 PM, revealed R4's indwelling urinary catheter collection bag laid directly on the floor. The catheter bag lacked a dignity bag. On 11/20/23 at 01:40 PM, Interview with Administrative Nurse B, reported her expectations regarding catheter care is for the urinary collection bag to be in a dignity bag. The facility's policy for Catheter: Care, Insertion, Removal, Drainage bags, dated 04/25/23, documented that every effort is made to keep a resident's catheter covered or out of sight. Catheter bags should be covered when up in chair and out in public or visible from door/hall. These bags should be changed when visibly soiled The facility failed to ensure R4 was treated with dignity when a privacy bag was not provided for indwelling catheter bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 53 residents which included 12 residents sampled for reviewed for transmission of Minimum Data Set, (MDS) assessments. Based on interview and record review, the facility failed to electronically transmit Resident (R)51's Discharge Return not Anticipated MDS, tracking no later than 14 days after the assessment Reference date (ARD) of 08/23/23, and/or seven days after the completion date of the MDS as required. Findings included: - On 11/20/23 at 12:30 PM, review of Resident (R)51's Discharge Return not Anticipated Minimum Data Set' (MDS), dated [DATE], revealed the MDS had not been electronically transmitted to Centers for Medicare and Medicaid Services (CMS) after the assessment Reference date (ARD) of 08/23/23, and/or seven days after the completion date of the MDS as required. On 11/20/23 at 12:50 PM, Administrative Nurse Q confirmed the facility failed to electronically submit the MDS as noted above. She reported a corporate nurse completed the assessment and she was not aware of the reason it was not electronically transmitted. She reported she exported assessments every week on Wednesdays. She reported the facility used the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, (RAI) manual for guidance related to the electronic transmission of the MDS. The 3.0 RAI Manual, dated 10/01/20, documentation included the MDS tracking must be no later than 14 days after the assessment Reference date (ARD) and/or seven days after the completion date of the MDS. The facility failed to electronically transmit the resident's Discharge Return not Anticipated MDS, tracking no later than 14 days after the assessment Reference date (ARD) and/or seven days after the completion date of the MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 53 residents. The sample of 12 residents included one resident sampled for personal hygiene related to bathing. Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain good personal hygiene for Resident (R)24, related to bathing and hair care. Findings included: - Review of Resident (R) 24's undated Physician's Orders, documentation included diagnoses of morbid (severe) obesity, communication deficit, weakness, and dementia (progressive mental disorder characterized by failing memory). The Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. Staff reported she preferred a tub bath. She required extensive assistance of staff for bed mobility, personal hygiene, and was totally dependent on staff for transfers, locomotion, toilet use, and one staff assist with bathing. The resident was always incontinent of bowel and bladder. She had a condition or chronic disease that may result in a life expectancy of less than six months and received hospice services. The Quarterly MDS, dated [DATE], documented no changes from the above. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 08/07/23, documentation included the resident exhibited gradual progression of dementia. She received hospice services and required staff to provide cues and reorientation. The Care Plan, dated 10/25/23, directed staff the resident required extensive assistance of staff for grooming and bathing. The hospice nurse aides visited the resident one to two times weekly. On 11/13/23 at 04:15 PM, the resident family member stated she had concerns that the resident did not get bathed as she should at least two times a week as she had requested. Additionally, she stated she was not sure if the resident's hair washed with each bath as she had requested, since she no longer goes to the beauty shop for shampoos. Review of the Tasks for bathing in the electronic medical record (EMR) Task Bathing scheduled for Tuesdays and Fridays. Review of the bathing tab from 10/17/23 thru 11/13/23 revealed the resident received five of the eight minimally required bathing opportunities as follows: 1. R24 received a shower on 10/30/23. 2. R24 received bed baths on 10/17/23, 10/20/23, and 11/03/23. 3. R24 received sponge baths on 11/07/23 and 11/10/23. The resident lacked a bathing opportunity from the facility staff from 10/20/23 until 10/30/23, a total of 10 days. On 11/14/23 at 10:39 AM, the resident sat in her highbacked reclining chair. The resident's hair was oily and laid flat against her head. On 11/14/23 11:18 AM, CNA Q stated the bath aide should provide residents with their scheduled showers/baths. Residents' showers or bathing opportunities should be documented in the EMR. CNA Q stated the resident gets her hair washed in beauty shop once a week, but residents that do not go to the beauty shop should get their hair washed on bathing days, at least two times a week. On 11/14/23 at 01:06 PM, Certified Nurse Assistant (CNA) Q assisted the resident from the dining room to her room and provided incontinence care. CNA Q confirmed the resident's hair appeared to be unkept. She stated she thought the beautician was to shampoo the resident's hair. CNA Q stated the resident received hospice services which should provide two additional baths to the facility provided baths. The facility should provide two baths a week which should include washing the resident's hair unless they go to the beauty shop. In addition, the facility staff should document any offers of bath or refusals of care in the EMR. On 11/14/23 at 12:30 PM, Social Service Staff P, verified the resident's representative called the business office on 11/01/23, and requested the resident not go to the beauty shop any longer. The resident should receive her shampoos with her baths by the facility staff at least twice a week. She notified the beautician that the resident would not be getting her hair done in the beauty shop but failed to notify the nursing staff. On 11/14/23 at 01:45 PM, Administrative Nurse B reviewed the EMR and confirmed the above findings. She stated although the resident received hospice services, those services did not replace the required services of the facility which included a minimum of two baths a week. Administrative Nurse B confirmed the staff should offer to provide baths and/or refusals of care. and should be documented in the resident's EMR. The facility policy for Bathing, dated 08/24/22, lacked address of bathing frequency of residents. The facility failed to ensure necessary services to maintain good personal hygiene with bathing and hair care for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 53 residents with 12 residents included in the sample, including five residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide a safe environment by failing to implement interventions prevent Resident (R) 106, with moderately impaired cognition, from having repeated falls. Findings included: - R106's signed Physician Orders dated 10/31/23 revealed the following diagnoses: peripheral vascular disease (PVD is an abnormal condition affecting the blood vessels), atrial fibrillation (rapid irregular heart rate), bradycardia (slow heart rate), shortness of breath, unsteadiness on feet, chronic respiratory failure with hypoxia (inadequate supply of oxygen). The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The resident was occasionally incontinent of urine and continent of bowel. The resident had no complaints of pain. The resident was short of breath and received oxygen (O2) per nasal cannula (NC). The Significant Change in Status MDS dated [DATE], revealed a BIMS of 10, indicating moderately impaired cognition. The resident used a walker and wheelchair for mobility and required moderate assistance with his daily care. He had no complaints of pain. The resident was short of breath and dependent on the use of O2. He had one no injury fall since the last assessment. The resident received an anticoagulant (blood thinner), diuretic (water pill), and required oxygen therapy. The Care Area Assessment (CAA) dated 10/31/23 revealed the following: The Cognitive loss/dementia CAA revealed R106 had occasional confusion and forgetfulness. He was easily re-directed and answered questions appropriately. R 106 required continuous oxygen. The Activities of daily living (ADL)Functional Rehabilitation Potential CAA revealed R106 was recently hospitalized for Pneumonia and Covid, then re-hospitalized for acute on chronic respiratory failure with hypoxia. He required skilled therapy due to returning to the facility weak and deconditioned. R106 required continuous O2 therapy. He required limited to extensive assist for cares. The resident was unable to ambulate, however he could propel himself in a wheelchair. R106's Care Plan dated 11/01/2023 included the resident required assistance with all decision making. Staff were to communicate with the resident/family regarding resident's capabilities and needs. Staff were to break tasks into one step at a time. Staff were to encourage the resident to make sure the recliner is down after transferring. Ensure dysem (a slip resistant material) to be in the resident's recliner. Remind resident not to bend over to pick up dropped items. Encourage use of a grabber or to ask for assistance. The resident received a non-injury fall on 10/03/23. The resident required extensive assistance with his walker for transfers and one staff limited assistance with ambulation. Staff were to make sure the resident wore gripper socks. The resident had a fall on 11/09/23, and staff was to re-educate the resident to use a call light for assistance, proper use of equipment (walker) and what not to use (rolling desk chair) to assist with ambulation. Staff were to monitor the resident for significant changes in gait, mobility, and positioning device, standing/sitting balance and lower extremity joint function. Give resident verbal cues to lower his lift chair so the seat is level, and he is not at risk. for sliding out. Staff was to review bowel and bladder continence status and establish and/or review toileting plan based on the resident's needs, dated 12/13/22. The Incident notes on 10/03/2023 at 01:19 PM revealed the resident fell when he transferred from his wheelchair to the toilet while Certified Nursing Assistant (CNA) N was in the room. The resident was impulsive and would not listen and wait for help to transfer and lost his balance and fell to floor. Three staff assisted the resident up and placed the resident on the toilet. The Incident notes for 11/09/2023 at 12:55 AM, revealed the resident yelled out for, help, help, help. Staff went to resident's room and found him on the floor sitting on his buttocks in-front of his recliner. He needed to go to the toilet, and did not use his call light, but instead tried to stand up without assistance and sit in his rolling computer chair so he could scoot himself into the bathroom. The rolling computer chair moved, and he fell. Staff intervention was to re-educate the resident to use a call light for assistance, however the resident's MDS indicated he had moderately impaired cognition. On 11/09/2023 at 02:58 PM, social service notes documented staff visited with the son related to his recliner chair. The resident would lift his chair up but would then slide out of his chair. He did not like the cushion in the chair and would refuse to leave the dysem in the chair. The Incident notes for 11/17/2023 revealed the resident fell from his recliner. He had a large knot formed on his left forehead and a laceration to his left temple. Staff lifted the resident with a full lift to his bed. The resident transferred to the emergency room for evaluation The resident had no fracture. Staff removed the chair remove from his reach and placed the remote on the desk. The resident was not happy about not being able to move his legs up by himself but understood after a brief teaching. (His MDS indicated he had moderate cognitive impairment). On 11/18/23 a fall risk assessment completed and had a score of 20, indicating a high risk for falls. On 11/20/2023 at 01:22 AM, staff re-educated the resident regarding not able to have his remote to his recliner due to his fall. However, he had moderate cognitive impairment.) Observation on 11/13/23 at 01:33 PM, the resident was up walking in his room with his brief pulled down to his knees. He was bent over walking and had his O2 cannula on. (The resident was not to be up without assistance per his care plan.) His lift chair was in the high standing position with the remote sitting directly in the chair. No dysem was seen in chair. Observation on 11/14/23 at 2:00 PM, the resident was in his room and leaned over his recliner with the reacher directly on the floor between his legs. He attempted to lean over and scoot the grabber reacher with his foot.) On 11/15/23 at 07:20 AM, the resident sat sleeping in his recliner in upright standing position. The resident had legs hanging down with his feet on the floor. Non-skid socks in place with no shoes on. On 11/15/23 at 08:30 AM, staff delivered the resident his breakfast tray and placed the tray on the bed side table behind the resident. The tray was out of reach of resident. The resident attempted to stand to get his breakfast tray and he had his lift chair in the high standing position. On 11/14/23 at 10:30 AM, certified nurse's aide (CNA) F reported the resident was one assist with his care. The resident would always sit in his recliner and would raise the chair to the standing position. Staff should check him often because he will get up on his own. On 11/20/23 at 07:20 AM CNA F reported the resident refused to get in his bed and he sleeps in his recliner at night. Staff have taken his controls for his lift chair away after the resident had two falls this past weekend. He was always lifting his chair and standing when he had the controls. He cannot stand on his own with the chair in the low position. On 11/20/23 at 10:30 AM, Licensed Nurse (LN)C reported the resident was on day three of a fall follow-up. The resident has not attempted to get up by himself since the remote to his chair was taken from his reach. The resident was upset and angry about the remote and wanted to be able to reposition his chair as he wanted. We have talked to him about raising his recliner and have visited with the son about a different chair. Until the resident is able to get a different chair, staff would not let him have his remote. On 11/20/23 at 1:00 PM, Administrative Nurse B reported the resident was upset about not having his remote to the chair. The resident reported to her he could breathe better with the chair up some. Administrative Nurse B reported she had met with the resident's family earlier and discussed the resident. The family reported they already this day had to take his car keys from him and did not want him to lose power over his chair also, so they requested the remote be given back to the resident. They were aware of his fall risk and were okay to give the remote back. So that is what she did. She gave him his remote and visited with him to use his call light and is going to assure the staff check on him as they should be. Review of the facility policy named Fall Prevention and Management dated 03/29/23 revealed a Proactive Approach before a fall occurs care plan the appropriate interventions, including personalizing all risk areas. Communicate fall risks and interventions to prevent a fall before it occurs per the 24-hour Report, care plan, [NAME] and stand-up meetings. Communicate any identified environmental changes and/or referral needs. The facility failed to provide a safe environment by failing to implement interventions to prevent Resident (R) 106, with moderately impaired cognition, from having repeated falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 53 with 12 residents in the sample, and five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to follow recommendation of the pharmacist for Resident (R)17, related to Abnormal Involuntary Movement scale (AIMS- a clinician-rated scale to assess severity of dyskinesias [the inability to execute voluntary movements]) testing and on R6 and R24 regarding as needed (PRN) lorazepam (a medication used for severe agitation) to obtain a new prescription every 14 days. Findings include: - Review of the R17's signed Physician Orders dated 09/11/23, revealed the diagnosis of unspecified dementia moderated without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion). Review of the Discharge Minimal Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) revealed a score of staff assessment for mental status with memory problems. R17 received seven days of antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medications and seven days of antidepressant (class of medication used to treat mood disorders and relieve symptoms of depression) medications. Review of the Significant Change MDS dated [DATE], revealed a BIMS score of four, indicating severely impaired cognition. R17 did not receive antipsychotic medication, and received antidepressant, anticoagulant (blood thinner) and seven days of diuretic(medication to promote the formation and excretion of urine). Review of the Care Plan dated 07/12/23 revealed R17 with impaired cognitive function related to forgetfulness, short- and long-term memory loss, confusion, and hallucinations (sensing things while awake that appear to be real, but the mind created). R17 received antipsychotic medication therapy related to dementia with potential for behavioral symptoms. Review of the Pharmacy reviews dated 01/05/23 revealed the recommendation for staff to complete an Assessment of Involuntary Movement (AIMS) test. R17 on olanzapine (an antipsychotic medication to treat severe agitation). Pharmacy review dated 02/07/23 requested an AIMS test to be completed on R17 for psychotropic medication. Pharmacy review dated 03/06/23 requested AIMS test to be completed for R 17 for psychotropic medication. The facility did not act upon the consulting pharmacist recommendations for the AIMs assessment until 08/01/23. Interview on 11/15/23 at 12:56 PM, Consultant Staff H reported the expectations regarding the pharmacy recommendations would be a response from the facility or the resident's physician. If a recommendation was not responded to, the consultant pharmacist would repeat the request. Interview on 11/20/23 at 02:00 PM, Administrative Nurse B reported the facility should follow up pharmacy recommendations in a timely manner. The facility's undated policy for Psychotropic Medications Rehab/Skilled revealed if a physician prescribes an antipsychotic for the resident, a registered nurse must complete the 'Initial Antipsychotic Medication Assessment and the Abnormal Involuntary Movement Scale in their electronic records. The facility failed to follow up on the pharmacist recommendation related to an AIMS assessment on R 17 while the resident received a psychotropic medication. - Review of Resident (R) 24's undated physician orders included diagnoses of major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), and dementia (- progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. The resident had a condition or chronic disease that may result in a life expectancy of less than six months. She received medications which included antidepressant, diuretic and opioid, for seven days of the look back period and antianxiety medication for two days of the look back period. The Quarterly MDS, dated 10/16/23, documented changes from above assessment included the resident did not receive antianxiety medication during the look back period. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 08/07/23, documentation included the resident had gradual progression of dementia. Her BIMS score of 03 indicated severe cognitive impairment, and she required staff to provide cues and reorientation. She received medications which included scheduled Seroquel (antipsychotic), Lexapro (antidepressant), and Ativan (antianxiety medication as needed (PRN). The Care Plan dated 10/09/23, directed staff to consult with pharmacy and the health care provider related to the resident received antipsychotic medication to consider dosage reduction when clinically appropriate. The Physician Orders, dated 10/04/23, included the following psychoactive medication orders: 1. Lorazepam/Ativan, 0.5 milligrams (MG) (Lorazepam-antianxiety medication), give one tablet by mouth, every three hours, as needed for anxiety/agitation, ordered 04/11/2023. 2. Seroquel Tablet, 25 MG (Quetiapine Fumarate-antipsychotic), give 12.5 mg, by mouth, two times a day for agitation, ordered 08/02/2023. 3. Divalproex Sodium Capsule Delayed Release Sprinkle (anticonvulsant/mood stabilizer), 125 MG, give 2 capsules by mouth, two times a day, related to bipolar disorder and major depressive disorder, dated 07/30/23. Review of the Monthly Pharmacy Medication Review, dated 02/07/23 through 11/07/23, revealed the following concerns: 1. On 05/01/2023, the consultant pharmacist identified an irregularity related to the use of Lorazepam/Ativan PRN (as needed), beyond a 14-day period. The pharmacist recommendation included requested documentation for the continued use of Lorazepam beyond the Centers for Medicare and Medicaid Services (CMS) 14 day recommended time period for PRN use, indication of the intended duration of use, and reevaluation every six months. The facility lacked evidence of any follow-up on the pharmacy recommendation. 2. On 06/05/2023, the consultant pharmacist recommended a gradual dose reduction (GDR) in the resident's psychoactive medication regimen in accordance with the CMS guidelines. The pharmacist identified the resident as receiving three different psychoactive medications without a GDR since the most recent order dates as follows: a. Escitalopram 20 mg daily, by mouth, ordered 10/28/19. b. Divalproex 125 mg, by mouth, at 07:00 AM and 01:00 PM, and 250 mg, PO at 07:00 AM and 09:00 PM, ordered 01/26/22. c. Seroquel 12.5 mg, by mouth, twice daily, ordered 09/15/22. d. Lorazepam 0.5 mg PO every 3 hours, PRN anxiety, ordered 09/15/22. The physician follow-up on the pharmacist's recommendation, dated 06/28/23, (23 day after the recommendation), was not timely. On 11/15/23 at 12:14 PM, Administrative Nurse B stated the pharmacist reviewed the resident's medication regimen monthly. Administrative Nurse B reported the recommendations should be followed up within 10 days of the facility receiving the recommendations. She confirmed the lack of follow up on the 05/01/2023 recommendations and excessive time frame beyond the expected follow up for the 06/05/23 identified irregularities. Additionally, Administrative Nurse B stated the anti-anxiety medication used PRN, should be ordered for a maximum of 14 days regardless if the resident had a renewal every 14 days for PRN orders, even if the resident received hospice services. On 11/15/23 at 12:57 PM, Consultant H reported regarding the Lorazepam, the consultant pharmacist usually sent a note if the Lorazepam is longer than 14 days to either discontinue (D/C) the medication or provide a rational for its extended use. If the resident is on Hospice, the physicians usually do not respond to the request. The facility policy Medication: Drug Regimen Review dated 02/10/23, documentation included the purpose of the medication regimen review was to prevent medication errors that could cause harm to a resident or result in resident hospitalization and to identify potential adverse events. The facility failed to act upon the identified irregularities by the consulting pharmacist on 05/01/23 and failed to act on the pharmacists recommendation in a timely manner on 06/05/23 for the resident. - R6's signed physician orders dated 10/31/23 revealed the following diagnoses that included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The resident had verbal and physical behaviors towards others. The resident required partial assist of one staff for toilet, transfers, and the resident was mobile with the use of a wheelchair. The resident was frequently incontinent. The resident received scheduled and as needed pain medication for complaints of pain at 5/10 scale. She had two or more falls with no injuries noted. She did not receive psychotropic medications. The Discharge assessment dated [DATE] revealed the resident had a unwitnessed fall with fractured hip on 07/26/23 and was sent to the hospital for care. The resident returned on 07/31/23. The Significant Change in Status MDS dated [DATE], revealed a decline in cognition with a score of 10, indicating moderate cognitive impairment. The resident had no behaviors. She required partial assist with daily care. The resident was frequently incontinent. The resident had a unstageable pressure injury to the heel and was being treated with skin prep. The resident received Hospice Services. Review of the physician orders included: Lorazepam 0.5 milligram (mg), oral (PO) every 12-hour, as needed (PRN), with a start date of 03/03/23. The order lacked a stop date. Lorazepam 0.5 mg, PO twice a day (BID), as needed, for anxiety, with a start date of 04/04/23. The order lacked a stop date. Lorazepam 0.5 mg, BID on PRN basis, start on 06/12/23. The order lacked a stop date. Lorazepam Oral Tablet 0.5 mg, 1 tablet every 6 hours, as needed, for anxiety/restlessness, with a start date of 10/13/23. The order lacked a stop date. Review of the Consulting Pharmacist monthly medication review revealed the following: On 04/01/23, the resident receives an as needed (PRN) order for anxiolytic without a stop date- lorazepam 0.5 mg PO every 12-hour PRN with start date 03/03/23 Recommend discontinuing Lorazepam. On 04/14/23, the physician declined to discontinue (DC) the lorazepam medication, however, the attending physician failed to document the rationale in the resident's medical record. On 05/01/23, the resident receiving PRN Lorazepam 0.5 mg, PO, BID, as needed, for anxiety, started on 04/04/23. Please DC. The physician failed to respond to the recommendation. On 07/03/23, the resident receiving Lorazepam on PRN basis with no stop date that started on 06/12/23. The physician replied on 07/12/23, the physician declined the recommendation, however, the attending physician failed to document the rationale in the resident's medical record. On 11/20/23 at 01:30 PM, Licensed Nurse (LN) O reported the resident has Alzheimer's and gets agitated. She received medications for behaviors. The resident has an as needed lorazepam to take when she gets agitated and that usually works well. On 11/12/23 at 12:56 PM, Interview with Consultant D regarding recommendations, she would make recommendation to the physician and would expect a response from the facility or physician. If Consultant D did not receive a response, she would repeat the request. The facility and physician failed to follow recommendation of the pharmacist for R6 regarding the stop date of Lorazepam, or a documented rationale related to the prn lorazepam.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Review of Resident (R) 24's undated physician orders included diagnoses of major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), and dementia (- progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. The resident had a condition or chronic disease that may result in a life expectancy of less than six months. She received medications which included antidepressant, diuretic and opioid, for seven days of the look back period and antianxiety medication for two days of the look back period. The Quarterly MDS, dated 10/16/23, documented changes from above assessment included the resident did not receive antianxiety medication during the look back period. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 08/07/23, documentation included the resident had gradual progression of dementia. Her BIMS score of 03 indicated severe cognitive impairment, and she required staff to provide cues and reorientation. She received medications which included scheduled Seroquel (antipsychotic), Lexapro (antidepressant), and Ativan (antianxiety medication as needed (PRN). The Care Plan dated 10/09/23, directed staff to consult with pharmacy and the health care provider related to the resident received antipsychotic medication to consider dosage reduction when clinically appropriate. The Physician Orders, dated 10/04/23, included the following psychoactive medication orders: 1. Lorazepam/Ativan, 0.5 milligrams (MG) (Lorazepam-antianxiety medication), give one tablet by mouth, every three hours, as needed for anxiety/agitation, ordered 04/11/2023. 2. Seroquel Tablet, 25 MG (Quetiapine Fumarate-antipsychotic), give 12.5 mg, by mouth, two times a day for agitation, ordered 08/02/2023. 3. Divalproex Sodium Capsule Delayed Release Sprinkle (anticonvulsant/mood stabilizer), 125 MG, give 2 capsules by mouth, two times a day, related to bipolar disorder and major depressive disorder, dated 07/30/23. Review of the Monthly Pharmacy Medication Review, dated 02/07/23 through 11/07/23, revealed the following concerns: 1. On 05/01/2023, the consultant pharmacist identified an irregularity related to the use of Lorazepam/Ativan PRN (as needed), beyond a 14-day period. The pharmacist recommendation included requested documentation for the continued use of Lorazepam beyond the Centers for Medicare and Medicaid Services (CMS) 14 day recommended time period for PRN use, indication of the intended duration of use, and reevaluation every six months. The facility lacked evidence of any follow-up on the pharmacy recommendation. 2. On 06/05/2023, the consultant pharmacist recommended a gradual dose reduction (GDR) in the resident's psychoactive medication regimen in accordance with the CMS guidelines. The pharmacist identified the resident as receiving three different psychoactive medications without a GDR since the most recent order dates as follows: a. Escitalopram 20 mg daily, by mouth, ordered 10/28/19. b. Divalproex 125 mg, by mouth, at 07:00 AM and 01:00 PM, and 250 mg, PO at 07:00 AM and 09:00 PM, ordered 01/26/22. c. Seroquel 12.5 mg, by mouth, twice daily, ordered 09/15/22. d. Lorazepam 0.5 mg PO every 3 hours, PRN anxiety, ordered 09/15/22. The physician follow-up on the pharmacist's recommendation, dated 06/28/23, (23 day after the recommendation), was not timely. On 11/15/23 at 12:14 PM, Administrative Nurse B stated the pharmacist reviewed the resident's medication regimen monthly. Administrative Nurse B reported the recommendations should be followed up within 10 days of the facility receiving the recommendations. She confirmed the lack of follow up on the 05/01/2023 recommendations and excessive time frame beyond the expected follow up for the 06/05/23 identified irregularities. Additionally, Administrative Nurse B stated the anti-anxiety medication used PRN, should be ordered for a maximum of 14 days regardless if the resident had a renewal every 14 days for PRN orders, even if the resident received hospice services. On 11/15/23 at 12:57 PM, Consultant H reported regarding the Lorazepam, the consultant pharmacist usually sent a note if the Lorazepam is longer than 14 days to either discontinue (D/C) the medication or provide a rational for its extended use. If the resident is on Hospice, the physicians usually do not respond to the request. The facility policy Medication: Drug Regimen Review dated 02/10/23, documentation included the purpose of the medication regimen review was to prevent medication errors that could cause harm to a resident or result in resident hospitalization and to identify potential adverse events. The facility failed to monitor for adverse reactions of psychotropic medications for this resident to ensure no unnecessary medicaton usage. The facility census totaled 53 residents with 12 residents included in the sample, including five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to have an appropriate end date for as needed anti-anxiety medication administered past the 14-day regulatory requirements for Residents (R6 and R24). Findings included: - R6's signed physician orders dated 10/31/23 revealed the following diagnoses that included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The resident had verbal and physical behaviors towards others. The resident required partial assist of one staff for toilet, transfers, and the resident was mobile with the use of a wheelchair. The resident was frequently incontinent. The resident received scheduled and as needed pain medication for complaints of pain at 5/10 scale. She had two or more falls with no injuries noted. She did not receive psychotropic medications. The Discharge assessment dated [DATE] revealed the resident had a unwitnessed fall with fractured hip on 07/26/23 and was sent to the hospital for care. The resident returned on 07/31/23. The Significant Change in Status MDS dated [DATE], revealed a decline in cognition with a score of 10, indicating moderate cognitive impairment. The resident had no behaviors. She required partial assist with daily care. The resident was frequently incontinent. The resident had a unstageable pressure injury to the heel and was being treated with skin prep. The resident received Hospice Services. Review of the physician orders included: Lorazepam 0.5 milligram (mg), oral (PO) every 12-hour, as needed (PRN), with a start date of 03/03/23. The order lacked a stop date. Lorazepam 0.5 mg, PO twice a day (BID), as needed, for anxiety, with a start date of 04/04/23. The order lacked a stop date. Lorazepam 0.5 mg, BID on PRN basis, start on 06/12/23. The order lacked a stop date. Lorazepam Oral Tablet 0.5 mg, 1 tablet every 6 hours, as needed, for anxiety/restlessness, with a start date of 10/13/23. The order lacked a stop date. Review of the Consulting Pharmacist monthly medication review revealed the following: On 04/01/23, the resident receives an as needed (PRN) order for anxiolytic without a stop date- lorazepam 0.5 mg PO every 12-hour PRN with start date 03/03/23 Recommend discontinuing Lorazepam. On 04/14/23, the physician declined to discontinue (DC) the lorazepam medication, however, the attending physician failed to document the rationale in the resident's medical record. On 05/01/23, the resident receiving PRN Lorazepam 0.5 mg, PO, BID, as needed, for anxiety, started on 04/04/23. Please DC. The physician failed to respond to the recommendation. On 07/03/23, the resident receiving Lorazepam on PRN basis with no stop date that started on 06/12/23. The physician replied on 07/12/23, the physician declined the recommendation, however, the attending physician failed to document the rationale in the resident's medical record. On 11/20/23 at 01:30 PM, Licensed Nurse (LN) O reported the resident has Alzheimer's and gets agitated. She receives medications for behaviors. The resident has an as needed lorazepam to take when she gets agitated and that usually works well. On 11/12/23 at 12:56 PM, Interview with Consultant D regarding recommendations, she would make recommendation to the physician and would expect a response from the facility or physician. If Consultant D did not receive a response, she would repeat the request. The facility failed to have an appropriate end date for as needed anti-anxiety medication administered past the 14-day regulatory requirements for R6.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 53 resident with 12 residents in the sample. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program, related to one resident, Resident (R) 4, related to urinary catheter care and placement, to help prevent contamination and the spread of infection. Findings included: - The Physician's Orders dated 10/10/23 revealed R4 had the following diagnosis of urinary retention (the lack of ability to urinate and empty the bladder). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R4 had a indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The Care Area Assessment (CAA) dated 10/12/23 revealed R4 arrived at the facility from the hospital with the indwelling catheter. The Care Plans dated 10/12/23, revealed urinary incontinence, R4 will remain free from catheter-related trauma through review date. Monitor for signs and symptoms of discomfort on urination and frequency. Observations on 11/13/23 at 10:10 AM, revealed the resident had an indwelling urinary catheter laid directly on the floor. The catheter collection bag lacked a barrier from the bag to the floor. Observation on 11/14/23 at 01:13 PM, revealed the catheter collection bag laid directly on the floor. Observation on 11/14/23 at 01:29 PM, revealed certified nurse's aide (CNA) J entered R4's room to applied gloves, emptied the collection bag, and placed the collection bag onto the recliner, that caused the indwelling urinary bag to rest directly on the floor. CNA J did not use an alcohol swab to clean the port after emptying the catheter bag. On 11/20/23 at 01:40 PM, Interview with Administrative Nurse B reported staff should wipe the ports of the collection bag with alcohol before reattaching the port to the tip. Staff should keep the urinary bag off the floor for infection control purposes. The facility policy, dated 04/25/23 for Catheter: Care, Insertion, Removal, Drainage bags revealed when emptying the catheter bag place a moisture resistant barrier beneath the measuring container and avoid placing the container on the floor. Open the drainage port and allow urine to drain into the measuring container placed underneath. When done clean drainage port tip with alcohol wipe and replace in the holder The facility failed to maintain an effective infection control program, related to one resident, Resident (R) 4, related to urinary catheter care and placement, to help prevent contamination and the spread of infection.

The facility reported a census of 53 residents. Based on observation, record review and interview, the facility failed to follow proper food handling practices to prevent the outbreak of foodborne illness. Findings included: - During the initial tour of the kitchen on 11/13/ at 08:30 AM, the refrigerator had the following areas of concerns: 1. One open bag of hotdogs, that lacked an opened date 2. One bag of turkey lunch meat that lacked an opened date and lack a use by date. On 11/13/23 at 08:30 AM, observation of the dry storage area revealed three bags of hot dog buns with a used by date of 10/30/23. In addition, there was one dented can of sliced beets and one dented can of fancy sauerkraut. Interview on 11/14/23 at 11:47 AM, Dietary staff I reported when the facility received a can with a dent from the vendors, staff need to take a picture of it and send it to the certified dietary manager, so the facility could get credit for the dented can, or just throw the dented cans of food in the trash. Food, including the breads should not be used if the date is past the use by date. Staff should have an opened date on all opened food items. On 11/14/23 at 11:50 AM, Dietary Staff G reported staff were to monitor the bread every Thursday, and if the bread was expired, staff should remove the bread. Staff should not use food items from dented cans. Staff should have open dates on all refrigerated items. The policy for Food -Supply Storage-Food and Nutrition Services dated 05/11/23, documented the purpose was to ensure that food is stored properly. Foods that have been opened or prepared are placed in an enclosed container, dated, labeled, and stored properly. The used by dates are checked on a regular basis; foods/fluids that have expired or are otherwise unsafe for use are discarded. The facility failed to follow proper food handling practices to prevent the outbreak of foodborne illness.

The facility census totaled 50 residents with 12 included in the sample. Based on interview and record review the facility failed to ensure one of five Certified Nurse Aide's (CNA) 12- hour annual mandatory in-service training included dementia training. Findings included: - On 01/12/22, the surveyor provided Administrative Staff A a list of five CNAs employed by the facility in excess of 12 months requesting documentation of the annual mandatory in-service trainings. Four of the five staff had the required education; however, CNA M lacked record of completed dementia training in the last 12 months from hire date. On 01/12/22 Administrative Staff A reported she could not find evidence of dementia training for CNA M. The 10/15/19 facility policy Competency and Mandatory Education Requirements revealed employees were responsible to attain and maintain competency and complete mandatory education required within their specific job description. The facility failed to ensure one of five CNA's 12-hour annual mandatory in-service training included the required dementia training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 50 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure two of five residents did not receive unnecessary medications when the facility administered as needed (PRN) psychotropic medication to Resident (R)29 beyond 14 days without a renewed physician order or rationale provided by the physician stating why R29 should continue receiving alprazolam (antianxiety medication) on a PRN basis. The facility also failed to follow the recommendation to respond to a request for a Gradual Dose Reduction (GDR) for Seroquel (an antipsychotic drug) and mirtazapine (an antidepressant drug) to ensure the lowest effective dose for R28. Findings included: - R29's Electronic Health Record (EHR) under the Medical Diagnosis tab revealed a diagnosis of (a feeling of worry, nervousness, or unease). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R29 did not receive an antianxiety medication during the seven day look back period. The Quarterly MDS dated 12/06/21 documented a BIMS score of 15 and R29 did not receive an antianxiety medication during the seven day look back period. The Care Plan dated 03/24/21 documented R29 was on hypnotic therapy related to anxiety. Interventions included to monitor R29's condition based on clinical practice guidelines or clinical standards of practice related to the use of alprazolam PRN. The 04/06/21 Physician's Orders for R29 documented an order for alprazolam 0.5 mg one tablet by mouth daily PRN for anxiety, with no stop date noted. Further review revealed the order discontinued on 10/20/21. The 10/20/21 Physician's Orders for R29 documented an order for alprazolam 0.5 mg one tablet by mouth daily PRN for anxiety, with no stop date noted. Review of the Electronic Medication Administration Record (EMAR) from March 2021 to December 2021 revealed R29 received PRN alprazolam 16 times. The May 2021 MRR documented R29 had a PRN order for alprazolam which had been in place for greater than 14 days without a stop date since 04/02/21. A recommendation was made to either discontinue the PRN alprazolam or that the provider provide a rationale for the extended use of the medication. The July 2021 MRR documented REPEATED RECOMMENDATION from 05/05/21: Please respond promptly to assure facility compliance with Federal regulations. R29 had a PRN order for alprazolam which had been in place for greater than 14 days without a stop date since 03/23/21. A recommendation was made to either discontinue the PRN alprazolam or that the provider provide a rationale for the extended use of the medication. The August 2021 MRR documented REPEATED RECOMMENDATION from 05/05/21: Please respond promptly to assure facility compliance with Federal regulations. R29 had a PRN order for alprazolam which had been in place for greater than 14 days without a stop date since 03/23/21. A recommendation was made to either discontinue the PRN alprazolam or that the provider provide a rationale for the extended use of the medication. Observation on 01/11/22 at 09:37 AM revealed R29 was alert, oriented, and calm. He did not appear to be anxious. On 01/11/22 at 09:39 AM R29 stated he took medication for anxiety when he needed it, which kept his moods good. On 01/12/22 at 01:10 PM Certified Nurse Aide (CNA) F stated she monitored, documented, and notified the charge nurse for R29's behaviors, which included if he isolated himself, appeared sad, or sighed loudly. CNA F stated R29 was cognizant, independent, and able to make his requests known. On 01/11/22 at 03:36 PM Licensed Nurse (LN) D stated behavior monitoring for a resident taking antipsychotic medication was documented in a Mood/Behavior note under Progress Notes. On 01/12/22 at 01:35 PM Administrative Nurse B stated she expected a PRN psychotropic medication to have a 14-day stop date on the order. On 01/13/22 at 08:00 AM Consultant Pharmacist I stated she would definitely expect the facility to follow up on her recommendations to discontinue PRN alprazolam which had no stop date. The facility's Psychotropic Medications policy dated 12/01/21 documented 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, her or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. The facility failed to ensure R29 did not receive unnecessary medications by not ensuring the prescribing physician provided a rationale to extend the use of PRN alprazolam beyond the 14 day limit for use of PRN psychotropic medications. - R28's pertinent diagnoses from the Physician's Orders in the Electronic Health Record (EHR) dated 11/12/21 documented major depressive disorder (major mood disorder), dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The 11/28/21 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R28 received antipsychotic, antidepressant, and antianxiety medications daily in the seven-day look back period. The 11/28/21 Psychotropic Drug Use Care Area Assessment (CAA) documented R28 had a history of depression with mood/behavior. R28 received scheduled Seroquel (antipsychotic medication), mirtazapine (antidepressant medication), and Ativan (antianxiety medication). The 11/01/21 Quarterly MDS documented R28 received an antipsychotic, antidepressant, and antianxiety medications daily in the seven-day look back period. The 01/05/22 Care Plan for R28 instructed staff to administer medications and monitor for side effects as ordered by the physician. The Physicians Orders documented an order on 11/13/20 for Seroquel (antipsychotic medication) 25 milligrams (mg) by mouth (PO) daily, an order on 01/14/21 for Ativan (antianxiety medication) 0.5 mg PO daily, and an order dated 04/28/21 for mirtazapine (antidepressant medication) 30 mg PO daily. Review of the monthly Pharmacy Medication Record Review (MRR) for January 2021 through December 2021 documented the following recommendations, which lacked facility documentation of physician follow up/response: 05/07/21, R28 received Seroquel 25 mg PO daily since 11/13/20. A recommendation was made to attempt a Gradual Dose Reduction (GDR). 10/19/21, R28 received Ativan 0.5 mg PO daily, mirtazapine 30 mg PO daily since 03/29/18, and Seroquel 25 mg PO daily. A recommendation was made to attempt a GDR for mirtazapine from 30 mg PO daily down to 15 mg PO daily. On 01/11/22 at 02:06 PM R28 sat in her room in the recliner visiting with her spouse. On 01/11/22 at 01:48 PM Licensed Nurse (LN) L stated the floor nurse could complete orders on the MRR once signed by the physician. On 01/12/22 at 01:35 PM Administrative Staff B confirmed she would expect the MRR's recommendations to be responded to in a timely manner. The Pharmaceutical Services policy dated 05/19/21 documented, A licensed pharmacist will be employed, or services obtained to: .Report any irregularities to the attending physician or the director of nursing services or both. (These reports must be acted upon and follow-up documentation maintained). The facility failed to adequately monitor the use of psychotropic medications for R28 by the failure to ensure the physician responded to the recommendations made by the consultant pharmacist to ensure the lowest effective dose received and ensure minimal side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F756 E - R29's Electronic Health Record (EHR) under the Medical Diagnosis tab revealed a diagnosis of anxiety (a feeling of worry, nervousness, or unease). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R29 did not receive an antianxiety medication during the seven day look back period. The Quarterly MDS dated 12/06/21 documented a BIMS score of 15 and R29 did not receive an antianxiety medication during the seven-day look back period. The Care Plan dated 03/24/21 documented R29 was on hypnotic therapy related to anxiety. Interventions included to monitor R29's condition based on clinical practice guidelines or clinical standards of practice related to the use of alprazolam PRN. The 04/06/21 Physician's Orders for R29 documented an order for alprazolam 0.5 mg one tablet by mouth daily PRN for anxiety, with no stop date noted. Further review revealed the order discontinued on 10/20/21. The 10/20/21 Physician's Orders for R29 documented an order for alprazolam 0.5 mg one tablet by mouth daily PRN for anxiety, with no stop date noted. Review of the Electronic Medication Administration Record (EMAR) from March 2021 to December 2021 revealed R29 received PRN alprazolam 16 times. The May 2021 MRR documented R29 had a PRN order for alprazolam which had been in place for greater than 14 days without a stop date since 04/02/21. A recommendation was made to either discontinue the PRN alprazolam or that the provider provide a rationale for the extended use of the medication. The July 2021 MRR documented REPEATED RECOMMENDATION from 05/05/21: Please respond promptly to assure facility compliance with Federal regulations. R29 had a PRN order for alprazolam which had been in place for greater than 14 days without a stop date since 03/23/21. A recommendation was made to either discontinue the PRN alprazolam or that the provider provide a rationale for the extended use of the medication. The August 2021 MRR documented REPEATED RECOMMENDATION from 05/05/21: Please respond promptly to assure facility compliance with Federal regulations. R29 had a PRN order for alprazolam which had been in place for greater than 14 days without a stop date since 03/23/21. A recommendation was made to either discontinue the PRN alprazolam or that the provider provide a rationale for the extended use of the medication. Observation on 01/11/22 at 09:37 AM revealed R29 was alert, oriented, and calm. He did not appear to be anxious. On 01/12/22 at 01:35 PM Administrative Nurse B stated she expected a PRN psychotropic medication to have a 14-day stop date on the order. On 01/13/22 at 08:00 AM Consultant Pharmacist I stated she would definitely expect the facility to follow up on her recommendations to discontinue PRN alprazolam which had no stop date. The facility's Pharmaceutical Services policy dated 05/19/21 documented A licensed pharmacist will be employed or services obtained to . Report any irregularities to the attending physician or the director of nursing services or both. (These reports must be acted upon and follow-up documentation maintained). The facility failed to follow the consultant pharmacist's recommendation to discontinue the use of PRN alprazolam after 14 days. - R17's pertinent diagnoses from the Physician's Orders in the Electronic Health Record (EHR) dated 11/08/21 documented major depressive disorder (major mood disorder), dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The 05/04/21 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R17 received no antipsychotic medications in the seven-day look back period. The 11/08/21 Quarterly MDS documented R17 received antipsychotic medications daily in the seven-day look back period. The 01/06/22 Care Plan for R17 instructed staff to administer medications and monitor for side effects as ordered by the physician. The Physicians Orders documented an order dated 11/04/19 for Tylenol 325 milligrams (mg), take two by mouth (PO) every four hours as needed, and an order dated 12/28/21 for haloperidol (antipsychotic medication) 0.5 mg PO daily. Lacked documentation of olanzapine (antipsychotic medication). Review of the monthly Pharmacy Medication Record Review (MRR) for January 2021 through December 2021 documented the following recommendations, which lacked facility documentation of physician follow-up and/or response: 03/10/21, MRR recommendation to add Not To Exceed (NTE) three grams of acetaminophen in 24 hours warning to Tylenol order. 11/15/21, MRR recommendation to change the inappropriate diagnosis of hallucinations for the medication olanzapine, to an approved diagnosis, such as mania, schizophrenia, or bipolar. On 01/11/22 at 09:06 AM an observation revealed R17 sitting in a wheelchair in her room watching TV with the window curtains open and a blanket over her lap. On 01/11/22 at 01:48 PM Licensed Nurse (LN) L stated the floor nurse could complete orders on the MRR once signed by the physician but LN L did not send the MRR's to the physicians. He stated he believed the Director of Nursing took care of that. On 01/12/22 at 01:35 PM Administrative Staff B confirmed the facility would re-send a fax two or three times and as a last resort would hand deliver the MRR to the physician. If the physician's response was not in the Pharmacy Consult notebook or folders, there probably was not a physician's response. On 01/13/22 at 08:00 AM Consultant Staff I confirmed the recommendations made and lack of follow-up, and that she would expect the physician to address her recommendations. Consultant Staff I stated she would make recommendations numerous times and had contacted the then current DON who informed her of the lack of response by the physicians and at that time she decided to pick her battles and that the facility had documented someplace else the NTE for acetaminophen products. The Pharmaceutical Services policy dated 05/19/21 documented, A licensed pharmacist will be employed, or services obtained to: .Report any irregularities to the attending physician or the director of nursing services or both. (These reports must be acted upon and follow-up documentation maintained). The facility failed to adequately monitor the use of medications for R17 by not responding to the consultant pharmacist recommendations. - R28's pertinent diagnoses from the Physician's Orders in the Electronic Health Record (EHR) dated 11/12/21 documented major depressive disorder (major mood disorder), dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The 11/28/21 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R28 received antipsychotic, antidepressant, and antianxiety medications daily in the seven-day look back period. The 11/28/21 Psychotropic Drug Use Care Area Assessment (CAA) documented R28 had a history of depression with mood/behavior. R28 received scheduled Seroquel (antipsychotic medication), mirtazapine (antidepressant medication), and Ativan (antianxiety medication). The 11/01/21 Quarterly MDS documented R28 received an antipsychotic, antidepressant, and antianxiety medications daily in the seven-day look back period. The 01/05/22 Care Plan for R28 instructed staff to administer medications and monitor for side effects as ordered by the physician. The Physicians Orders documented an order on 11/13/20 for Seroquel (antipsychotic medication) 25 milligrams (mg) PO daily, an order on 01/14/21 for Ativan (antianxiety medication) 0.5 mg PO daily, an order on 04/15/21 for Breo Ellipta (respiratory inhalant corticosteroid) inhale daily, and an order dated 04/28/21 for mirtazapine (antidepressant medication) 30 mg PO daily. Review of the monthly Pharmacy Medication Record Review (MRR) for January 2021 through December 2021 documented the following recommendations, which lacked facility documentation of physician follow-up and/or response: 01/15/21, R28 received a medication containing an inhaled corticosteroid, Breo Ellipta. A recommendation was made to update the order to include rinsing the mouth with water and do not swallow after use. 05/07/21, R28 received Seroquel 25 mg PO daily since 11/13/20. A recommendation was made to attempt a Gradual Dose Reduction (GDR). 10/19/21, R28 received Ativan 0.5 mg PO daily, mirtazapine 30 mg PO daily since 03/29/18, and Seroquel 25 mg PO daily. A recommendation was made to attempt a GDR for mirtazapine from 30 mg PO daily down to 15 mg PO daily. On 01/11/22 at 02:06 PM, R28 sat in her room in the recliner visiting with her spouse. On 01/11/22 at 01:48 PM Licensed Nurse (LN) L stated the floor nurse could complete orders on the MRR once signed by the physician but LN L did not send the MRR's to the physicians. He stated he believed the Director of Nursing took care of that. On 01/12/22 at 01:35 PM Administrative Staff B confirmed the facility would re-send a fax two or three times and as a last resort would hand deliver the MRR to the physician. If the physician's response was not in the Pharmacy Consult notebook or folders, there probably was not a physician's response. On 01/13/22 at 08:00 AM Consultant Staff I confirmed the recommendations made and lack of follow up, and that she would expect the physician to address her recommendations. Consultant Staff I stated she would make recommendations numerous times and had contacted the then current DON who informed her of the lack of response by the physicians and at that time she decided to pick her battles. The Pharmaceutical Services policy dated 05/19/21 documented, A licensed pharmacist will be employed, or services obtained to: .Report any irregularities to the attending physician or the director of nursing services or both. (These reports must be acted upon and follow-up documentation maintained). The facility failed to adequately monitor the use of medications for R28 by the failure to ensure the physician responded to the recommendations made by the consultant pharmacist to ensure the lowest effective dose received and ensure minimal side effects. The facility census totaled 50 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to follow consultant pharmacist recommendations to add Not to Exceed (NTE) cautions to Resident (R)16 and R17's orders for acetaminophen (medication used to treat minor pain and fever) to reduce the potential for liver damage, failed to add manufacturer's instructions for administration of Voltaren (topical anti-inflammatory gel used for pain relief) for R16, failed to follow recommendations to discontinue the use of as needed (PRN) Alprazolam (sedative medication) for R29, and failed to respond to the recommendation to attempt a Gradual Dose Reduction (GDR) of Mirtazapine (an antidepressant) and Seroquel (an antipsychotic) for R28. Findings included: - Resident (R) 16's Electronic Health Record (EHR) under the Medical Diagnosis tab revealed a diagnosis of pain. The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment and received both scheduled and as needed (PRN) pain medications. The Quarterly MDS dated 11/08/21 revealed a BIMS score of 11 and R16 received both scheduled and PRN pain medications. The Pain Care Area Assessment (CAA) dated 03/01/21 revealed R16's pain management included scheduled Norco (medication used to treat moderate to severe pain, containing acetaminophen) and Tylenol (acetaminophen) as needed for pain. The Care Plan dated 12/03/18 revealed R16 was on pain medication therapy related to chronic pain to her left foot and hand and occasional headaches, secondary to allergies. A review of the Physician Orders included the following: An order dated 10/29/21 for Voltaren Gel 1 percent, apply to left foot topically two times daily for pain. An order dated 02/09/18 for Norco 10-325 milligrams (mg), give one tablet by mouth two times daily for pain. An order dated 09/30/17 for Tylenol 325 mg, give two tablets by mouth every four hours as needed for pain. A review of the consultant pharmacist's Medication Regimen Review (MRR) revealed: A recommendation dated 02/10/21 to add a NTE caution of a maximum of three grams per 24 hours for Acetaminophen which was not addressed by the facility. A recommendation dated 11/15/21 to update directions for Voltaren topical gel using a dosing card as supplied by the manufacturer which was not addressed by the facility. An observation on 01/11/22 at 09:15 AM revealed R16 did not show signs or symptoms of having pain while she watched television in her room. In an interview on 01/12/22 at 08:14 AM, Certified Medication Aide (CMA) K stated R16 did not usually complain of having pain. In an interview on 01/12/22 at 03:45 PM, Administrative Nurse B stated she expected the pharmacist recommendations for the Acetaminophen NTE warning and directions for application of Voltaren to be added as recommended by the consultant pharmacist. In an interview on 01/13/22 at 8:00 AM, Consultant Pharmacist I stated she expected the facility to respond to her recommendations for NTE for Tylenol and the manufacturers' administration instructions for Voltaren. The Pharmaceutical Services policy dated 05/19/21 revealed, A licensed pharmacist will be employed or services obtained to .Report any irregularities to the attending physician or the director of nursing services or both. (These reports must be acted upon and follow-up documentation maintained). The facility failed to follow the consultant pharmacist recommendation to add a caution and directions for use of medications for R16.

The facility reported a census of 59 residents with one resident reviewed for transfer and discharge. Based on interview and record review the facility failed to notify the State of Kansas Long Term Care Ombudsman when Resident (R) 46 transferred to the hospital. Findings included: - Review of the Chart Notes dated 01/09/2020 revealed R46 went to the hospital for urinary tract infection (an infection in any part of the urinary system) and fecal impaction (a large hard mass of stool). Interview with Administration Staff X on 01/28/20 at 3:49 PM revealed the facility only notified the Ombudsman of discharge or death. Administrative Staff X stated the facility never notified the Ombudsman of hospital transfers and did not know those should be included on the monthly report. Review of the Ombudsman policy revised 02/2017 revealed when the facility issued a notice of transfer or discharge, the facility must provide the resident with a written notice that included the name, address, and telephone number of the State Long-Term Care Ombudsman. The facility failed to notify the State of Kansas Long Term Care Ombudsman when R46 transferred to the hospital.

The facility census totaled 59 residents with 20 included in the sample. Based on observation, interview and record review the facility failed to accurately assess the resident's status for hospice (end of life care), oxygen use (O2) and terminal diagnosis (life expectancy less than 6 months) on two Quarterly Minimum Data Sets (MDS) for Resident (R) 48. Findings included: - Review of R48's signed Physician Orders dated 12/30/19 revealed the following diagnoses: age-related osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), cervical disc 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). Review of the Significant Change in Status MDS dated 07/16/19 revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The resident required extensive assistance of two staff for activities of daily living (ADLs) The resident had a terminal diagnosis, received oxygen (O2) therapy, and hospice care. Review of the Quarterly MDS dated 10/07/19 revealed a BIMS score of 15 (indicating intact cognition), with no changes in ADL since the 07/16/19 MDS. The resident had a terminal diagnosis and did not received supplemental oxygen or hospice services. Review of the Quarterly MDS dated 12/30/19 revealed R48 lacked a terminal diagnosis and did not receive supplemental oxygen or hospice services. The 02/12/19 Care Plan identified R48 with a terminal diagnosis. A 07/24/19 intervention referred to hospice services. The Care Plan also noted R48's use of supplemental oxygen. Physician's Orders included 07/10/19 orders to admit R48 to a hospice of the family's choosing and use supplemental oxygen at one to two liters per minute for dyspnea (difficulty breathing) or oxygen saturation levels below 88 percent. Observation on 01/28/20 at 07:47 AM revealed R48 utilized supplemental oxygen. During an interview on 01/28/20 at 07:50 AM the resident complained of hurting today and did not note any specific pain, R48 said she just hurt. R48 told the nurse it was in her back. During an interview on 01/28/20 at 02:29 PM CNA H reported R48 used supplemental oxygen at night and also received hospice services. During an interview on 01/28/20 at 11:30 AM, Licensed Nurse (LN) C reported the resident only used O2 at night. During an interview on 01/27/20 at 02:30 PM Administrative Nurse F confirmed the 10/07/19 and 12/30/19 MDS assessments included inaccurate information related to hospice services, terminal diagnosis, and the use of oxygen therapy During an interview on 1/28/2020 at 11:50 AM Administrative Nurse B reported she expected the MDS assessments to reflect the resident's status. Review of the Assessment (MDS) policy dated 12/19 revealed Resident assessment of functional capacity will be comprehensive, accurate, standardized and reproducible . The facility failed to complete accurate MDS assessments for R48 related to the presence of a terminal diagnosis, hospice care, and use of supplemental oxygen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Review of R18's signed Physician Orders dated 10/02/19 revealed the following diagnosis: malignant neoplasm of unspecified part of right bronchus or lung (a cancerous tumor which is located in the lung and in the bronchus). Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 10, indicating moderately cognitive impairment. The MDS did not note oxygen as a special treatment procedure. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of nine, indicating moderate cognitive impairment. The MDS noted the resident received oxygen as a special treatment. Review of the Care Plan dated 12/04/19 revealed lack of information/intervention(s) regarding oxygen therapy and/or respiratory treatment(s) such as a nebulizer treatment. Review of the Physician Orders dated 10/02/19 revealed orders for continuous oxygen administered at two liters per nasal cannula. The order further instructed staff to increase the oxygen to three liters, only if oxygen saturations dropped below 90%, as needed, for hypoxia (inadequate supply of oxygen). A 10/21/19 physician order noted DuoNeb solution 0.5 - 2.5 milligram (mg)/3 milliliters (ml) nebulization solution, one vial for R18 to inhale orally via nebulizer two times a day. Interview with Certified Medication Aide (CMA) R on 01/28/20 at 02:27 PM revealed R18 told staff when was having difficulty breathing. CMA R stated the staff checked her oxygen saturation level and notified the nurse of that level. Interview with Licensed Nurse (LN) D on 01/29/20 at 12:43 PM revealed the MDS coordinator and/or the licensed nurses updated the care plan. LN D said staff updated the care plan only when there was a new antibiotic started or if the resident had a fall. Interview with Administrative Nurse B on 01/30/20 at 08:43 AM revealed she expected ordered oxygen to be on the care plan. Administrative Nurse B further stated it was never the practice of the facility to put treatments such as the nebulizer treatment on the care plan. Review of the 12/19 Care Plans policy revealed the purpose of the policy was to develop a comprehensive care plan using an interdisciplinary team approach. The facility failed to develop a comprehensive care plan for R18 to include oxygen therapy and respiratory treatment (nebulizer treatments) ordered for the resident. The facility census totaled 59 residents with 20 included in the sample. Based on observation, interview, and record review the facility failed to develop a comprehensive care plan for Resident (R) 48 as related to hospice services and R18 as related to use of supplemental oxygen and nebulizer (a device which changes liquid medication into a mist easily inhaled into the lungs) treatments. Findings included: - Review of R48's signed physician orders dated 12/30/19 revealed the following diagnoses: age-related osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), cervical disc 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). Review of the significant change in status Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. The resident had a terminal diagnosis and received hospice services. The resident received O2 therapy and Hospice care. The 10/07/19 and 12/30/19 Quarterly MDSs failed to document R48's continued use of hospice services. The Care Plan included an 07/24/19 intervention to consult with health care provider and Social Services to have hospice care for resident in the facility. The care plan lacked other interventions related to hospice services, including no evidence of coordination of care between the facility and hospice. Observation on 01/28/20 at 07:47 AM revealed R48 required extensive assistance of staff for transfers. During an interview on 01/28/20 at 07:53 AM, Certified Nurse Aide (CNA) G reported she did not know what services hospice provided when they visited. During an interview on 1/28/20 at 11:50 AM Administrative Nurse B reported she expected the care plans to reflect the resident status. Administrative Nurse B stated the care plan should have coordinated approaches with nursing and Hospice services to care for the resident. Review of the 12/19 Care Plans policy revealed the purpose of the policy was to develop a comprehensive care plan using an interdisciplinary team approach. The facility failed to develop a comprehensive care plan for R48 as related to coordination of care between hospice and the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 59 residents with 20 included in the sample. Based on observation, interview, and record review the facility failed to review/revise the care plans to reflect the use of supplemental oxygen for Resident (R) 48. Findings included: - Review of R48's signed Physician Orders dated 12/30/19 revealed the following diagnoses: age-related osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), cervical disc 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). Review of the Significant Change in Status Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The resident received oxygen (O2) therapy. The Quarterly MDS assessments completed on 10/07/19 and 12/30/19 failed to accurately reflect R48's use of oxygen. The 02/07/19 Care Plan noted R48's use of supplement oxygen and directed staff to apply oxygen at two liter per nasal cannula (prongs which fit into each nostril) as needed to keep oxygen saturation levels above 90%. A Physician's Order dated 07/10/19 directed staff to apply oxygen at 1-2 liters per minute as needed for dyspnea (shortness of breath) or oxygen saturation levels below 88%. Observation on 01/28/20 at 07:47 AM revealed R48 used supplemental oxygen. During an interview on 01/28/20 at 2:29 PM, Certified Nurses Aide (CNA) H reported R48 used oxygen only when she was in bed for the night. According to CNA H, staff set the oxygen at two liters per nasal cannula during the night. During an interview on 01/28/20 at 11:30 AM, Licensed Nurse (LN) C reported the resident only used O2 at night. LN C reported the only way she could explain the discrepancy in the O2 orders was one must have been before hospice and one after. During an interview on 01/29/20 at 10:10 AM, LN D reported staff applied oxygen at night for R48 but did not completed O2 saturation checks each time. During an interview on 01/28/20 at 11:50 AM Administrative Nurse B reported she did not know why the O2 order did not match the O2 listed on the care plan. Review of the 12/19 Care Plans policy revealed the care plan would be modified to reflect the care currently required/provided for the resident. The facility failed to review/revise R48's care plan after the resident's oxygen order changed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 59 with 20 residents in the sample. Based on observation, interview, and record review the facility failed to provide one resident with the necessary services (cleaning beneath fingernails) to maintain good grooming and good personal hygiene. Resident (R) 34 Findings included: - Review of the R34's signed Physician Orders dated 05/24/19 revealed the following diagnoses: unspecified dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion). Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment. R34 required extensive assistance of two staff for personal hygiene and total dependence on staff for bathing. Review of the Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 09/23/19 revealed R34 required extensive assistance for most ADLs due to bilateral lower extremity weakness. Review of the Care Plan dated 04/23/19 revealed R34 required assistance of one staff for bathing on Tuesdays, Saturdays, and as necessary. The Care Plan also directed staff to provide extensive assistance with personal hygiene related tasks. Observations on 01/28/20 at 08:10 AM revealed R34 seated at the dining room table and the resident's fingernails were of a medium length with unknown dark colored debris beneath the nails. Observation on 01/29/20 at 08:32 AM revealed R34 again sat at the dining room table with the unknown dark colored debris beneath the fingernails. At the time of the observation, R34 used her fingers to eat. Observation on 01/30/20 at 08:45 AM revealed R34 continued to have the dark colored debris beneath her fingernails. On 01/28/20 at 2:27 PM Certified Medication Aide (CMA) R reported the bath aides had the responsibility of cleaning resident fingernails during bath time. On 01/29/20 at 12:43 PM, Licensed Nurse D revealed the bath aides should clean fingernails during bath time. On 01/30/20 at 08:41 AM, Administrative Nurse B revealed she expected staff to clean resident fingernails during bath time as well as daily since R34 ate with her fingers. The Activities of Daily Living policy revised on 06/14/19 revealed any resident who could not carry out activities of daily living would receive necessary services to maintain good nutrition, grooming and personal and oral hygiene. The facility failed to provide R34 with the necessary services (cleaning beneath fingernails) to maintain good grooming and good personal hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 59 residents with 20 included in the sample. Based on observation, interview, and record review the facility failed to provide oxygen (O2) therapy as ordered by the physician for Resident (R) 48. Findings included: - Review of R48's signed Physician Orders dated 12/30/19 revealed the following diagnoses: age-related osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk) and Parkinson's Disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). Review of the Significant Change in Status Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The resident required extensive assistance of two staff for activities of daily living (ADL) The resident received O2 therapy. Review of the Quarterly MDS dated 10/07/19 revealed a BIMS score of 15 (indicating normal cognition) and no change in ADLs since the 07/16/19 MDS. The resident received no O2. Review of the Quarterly MDS dated 12/30/19 revealed the resident did not receive O2. The Care Plan, revised 04/30/19, revealed the resident received oxygen therapy at two liters per minute (l/min.) per nasal cannula (NC) as needed (PRN) to keep O2 saturation level above 90 percent related to ineffective gas exchange and shortness of air. The Care Plan intervention dated 02/07/19 instructed staff to monitor the resident for signs of respiratory distress and report to physician PRN. Review of the Physician Order 07/10/19 instructed staff to administer O2 at one to two l/m PRN for dyspnea (shortness of air) or O2 sat below 88% Review of the medication administration record for December 2019 and January 2020 revealed no O2 listed on the Medication Administration Record (MAR) or Treatment Administration Record (TAR). Observation on 01/28/20 at 07:47 AM revealed Certified Nursing Aide (CNA) G in the resident's room and removed the O2 cannula from the resident. The resident talked to the staff with no apparent discomfort or shortness of air observed. During an interview on 01/28/20 at 02:29 PM CNA H reported the resident required the staff to provide all her care and said the resident used her O2 when the resident was in bed for the night. CNA H stated the resident used O2 at 2 l/min. per nasal canula. During an interview on 01/28/20 at 11:30 AM Licensed Nurse C reported the resident used O2 at night, only. LN C said the nurses periodically checked her O2 sats but did not know they were not recorded on the medication administration record (MAR). LN C said the only way she could explain the discrepancy in the O2 orders was one must have been before hospice and one after her hospice admission. LN C said she did not do the care plans, so she did not know what was included on the care plan. LN C said she would make sure the O2 on the MAR so it would be documented since it was not on the MAR at the present time. During an interview on 01/29/20 at 10:10 AM LN D reported a new order on the resident's MAR as of today to check her O2 sats every shift to see if the resident needed O2. LN D confirmed the facility staff were not checking the resident's O2 levels before now, and were just doing sporadic checks, but stated the night shift placed her O2. LN D said she had not checked the resident's O2 yet this morning. During an interview on 01/28/20 at 11:50 AM Administrative Nurse B reported she did not know why the O2 order did not match the O2 listed on the care plan or why the O2 was not on the MAR or charted. The facility did not provide a policy for the use of Oxygen as requested on 01/29/20. The facility failed to provide oxygen therapy as ordered by the physician for R48.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 59 residents with 20 included in the sample and five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to provide accurate pharmaceutical services when facility staff failed to administer the correct dosage of Olanzapine (antipsychotic medication) when the physician decreased the dosage on 06/10/19 of Olanzapine to 2.5 milligrams (mg) and the staff continued to administer the 5 mg dose to Resident (R) 22. Findings included: - Review of R22's signed Physician Orders dated 12/01/19 revealed the following diagnoses: vascular dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), insomnia (inability to sleep), unspecified psychosis, (any major mental disorder characterized by a gross impairment in reality testing), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and depressive episodes (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident was independent with daily care and received as needed pain medication for frequent complaint of pain rated and eight out of 10. He received antipsychotic, antianxiety, antidepressant medications daily in the 7-day observation period. The MDS noted no recent gradual dose reduction (GDR) with GDR clinically contraindicated on 09/24/19. Review of the Annual MDS dated 11/18/19 revealed no significant changes since the MDS assessment on 08/26/19. Review of the Care Area Assessment (CAA) dated 11/18/19 revealed: Psychotropic Drug Use CAA- The resident rarely participated in activities but ate meals in the dining room. The resident's mood was stable currently, with a goal to maintain current mood and avoid complications such as increased depression or behaviors and to receive the lowest effective dose of psychotropic medications. Review of the Physician Order dated 09/20/17 revealed Olanzapine Tablet 5 mg, administer one tablet by mouth at bedtime, related to vascular dementia with behavioral disturbance. Review of the Consulting Pharmacist monthly medication regimen review revealed: 06/10/19- Please consider a GDR of Olanzapine to 2.5 mg at bedtime for dementia with behaviors with eventual goal of discontinuing the medication. The physician response noted agreement and decreased the medication dated. Review of the medication administration record (MAR) from June 2019 through January 2020 revealed the resident continued to receive Olanzapine 5 mg. Review of the Nurse Progress Note dated 01/29/20 at 04:59 PM revealed the nurse discovered a recommendation for the resident to have a GDR reduction signed by a physician June 2019 for Olanzapine which did not get changed on the MAR. The nurse sent a fax to the primary care physician and mental health physician to make them aware and how to proceed. Observation on 01/28/20 at 08:10 AM revealed the resident sat up on the bed watching television. The resident was alert with no confusion noted. Check of the medication cart on 01/29/20 with Licensed Nurse (LN) D revealed a bottle of Olanzapine 10 mg tabs with instructions to give 1/2 tab at bedtime to the resident and the current order in the computer instructed staff to administer Olanzapine 5 mg at bedtime. During an interview on 01/28/20 at 08:10 AM the resident reported he was having a good day and was ready to go to breakfast. The resident kept his television at high volume but when the TV turned off, he could hear normal voice tone and carry on a conversation. During an interview on 01/28/20 at 02:39 PM Certified Nursing Aide (CNA) H reported the resident had no behaviors that she knew of. She did not know what medications the resident received but if the resident was not acting like himself, she would let the nurse know. During an interview on 01/29/20 09:46 AM Licensed Nurse (LN) D reported the resident received Olanzapine 5 mg by mouth. LN D said she had not really seen any behaviors other than he self isolates in his room between meals. LN D said the resident exhibited no physical or verbal behaviors and said the staff did not monitor him for behaviors because he really did not have any. LN D said if the resident did have a behavior she would chart it in the nurse's notes and said that was the only place she charted behaviors. During an interview on 01/29/20 at 10:58 AM Administrative Nurse B did not know of the medication order to decrease the Olanzapine on 06/10/19. At 04:50 PM Administrative Nurse B acknowledged the dose reduction never occurred as it should have. During an interview on 1/30/20 at 11:15 AM Consultant Pharmacist HH reported if a resident was due for a dose reduction of his psychotropic medication, he checked the progress notes for charted behaviors, but he did not check every resident routinely for behaviors. The pharmacist reported he must have missed checking for a follow-up on the GDR for this resident, as he could not locate a follow-up in his records. Review of the facility policy named Physician/Practitioners Orders dated 01/20 revealed the purpose was to provide individualized care to each resident by obtaining appropriate, accurate, and timely physician orders. The facility failed to provide accurate pharmaceutical services when facility staff failed to administer the correct dosage of Olanzapine (antipsychotic medication), when the physician decreased the dosage on 06/10/19 of Olanzapine to 2.5 mg and the staff continued to administer the 5 mg dose to R22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Review of R11's signed Physician Orders dated 11/08/2019 revealed the resident had the following diagnoses: dementia without behavioral disturbances (progressive mental disorder characterized by failing memory, confusion without behavioral disturbances), traumatic subdural hemorrhage (bleeding under the membrane covering the brain), and hypertension (elevated blood pressure). Review of the Medication Administration Record (MAR) for January 2020 revealed the resident received: 1. Lisinopril (treatment of high blood pressure) tablet 20 milligrams (mg) by mouth one time daily for hypertension (10/23/19 order) 2. Amlodipine Besylate (treatment of high blood pressure) Tablet 10mg by mouth one time daily for hypertension (10/23/19 order) 3. Seroquel (Quetiapine Fumarate) (used to treat schizophrenia in adults and children who are at least [AGE] years old) 100 mg by mouth at bedtime for sleep (08/14/19 order) The Direct Care Staff Vital Sheet utilized only by CNAs and direct care staff, directed staff to contact the nurse immediately if the resident experienced a systolic blood pressure (the top number of the blood pressure reading - indicates the pressure of the blood in the arteries during the pumping phase) below 100 or greater than 150. Review of the electronic charting vital signs revealed blood pressure readings for R11 from 11/04/19 - 01/27/20. Direct Care Vital Sheet as follows: 11/14/19 at 10:10 AM 93 / 56 11/15/19 at 09:18 AM 90 / 57 11/16/19 at 03:18 PM 97 / 61 11/17/19 at 10:14 AM 91 / 62 11/18/19 at 09:16 AM 97 / 50 12/09/19 at 10:34 AM 99 / 68 01/20/20 at 08:47 AM 95 / 46 Review of the clinical record reveal no follow-up documentation noted for the blood pressures listed above. The MARs for the dates listed above revealed the staff administered Lisinopril and Amlodipine (treatment for hypertension) to R11. Review of the clinical record revealed it lacked parameters for blood pressures and behavior monitoring for the medications he was receiving. Review of the Consultant Pharmacist drug regimen reviews from 08/15/2019 through 01/13/2020 revealed, Based upon the information available at the time of the review, and assuming the accuracy and completeness of such information, it is my professional judgment that at such time, the resident's medication regimen contained no new irregularities. Interview with Licensed Nurse D (LN) D on 01/29/20 at 02:58 PM revealed she checked her residents vital signs when needed. She reported all residents who received blood pressure medications should have parameters, from their doctor, in their charts. She did not know R11 did not have parameters in his chart nor that he continued to receive two blood pressure medications on the days he had lower blood pressures. Interview with Administrative Nurse B on 01/30/2020 revealed she would expect R11 to have parameters and symptoms of low blood pressure to be listed in his chart. Administrative Nurse B said the resident admitted to the facility from hospice and took Seroquel for sleep, not for behavioral disturbances. Review of the facility policy Unnecessary Medications dated 01/2020 revealed each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: without adequate indications for its use and without adequate monitoring. The failed to identify the lack of blood pressure parameters and behavioral monitoring for R11. The facility census totaled 59 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to obtain blood sugar parameters for Resident (R) 21 and failed to obtain blood pressure parameters for R11. Findings included: - Review of the signed Physician Orders (POS) dated 01/02/20 revealed the following diagnosis: type 2 diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin.) Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating intact cognition. R21 received insulin daily during the seven-day observation period. Review of the Quarterly MDS dated 11/18/19 revealed a BIMS score of 15, indicating intact cognition. R21 received insulin daily during the seven-day observation period. Review of the Care Plan dated 06/27/18 revealed R21 with diabetes mellitus as evidenced by blood sugar readings, and signs and symptoms of hyperglycemia (greater than normal amount of glucose in the blood) and hypoglycemia (less than normal amount of sugar in the blood.) Review of the physician orders revealed the following orders: 1. 09/10/19, Accuchecks AC (before meals) and HS (bedtime) for diabetes mellitus type 2. 2. 10/04/19, NovoLOG FlexPen Solution Pen-injector 100 UNIT/ML (milliliter) (Insulin Aspart) inject 7 units subcutaneously before meals related to Type 2 Diabetes Mellitus. 3. 10/29/19, Lantus Solution 100 UNIT/ML (Insulin Glargine) inject 40 units subcutaneously at bedtime related to type 2 diabetes mellitus. There were no Physician Orders for blood sugar parameters or when to notify the physician included in R21's orders. Review of the December 2019 Electronic Medication Administration Record (EMAR)/Electronic Treatment Administration Record (ETAR) revealed on 12/08/19 at 07:00 AM R21 with a blood sugar of 53 milligrams/deciliter (mg/dL). Review of the January 2019 EMAR/ETAR revealed: On 01/08/20 at 07:00 AM R21 with a blood sugar of 51 mg/dL. On 01/19/20 at 07:00 AM R21 with a blood sugar of 51 mg/dL. On 01/20/20 at 07:00 AM R21 with a blood sugar of 45 mg/dL. Observation on 01/28/20 at 02:19 PM revealed R21 did not exhibited any signs or symptoms of blood sugar issues. Interview on 01/30/20 at 07:39 AM with Licensed Nurse (LN) K stated R21 was a diabetic and received 7 units of insulin with meals, and 40 units of insulin at bedtime. LN K stated blood sugars were checked four times a day, and said R21 did not have a sliding scale (method for using correction dose of insulin based on blood glucose readings) for insulin. LN K stated the facility used standing orders from [NAME] Hospital since so many of the residents came from there. (Review of these orders revealed the staff were to follow hypoglycemia treatment orders for blood sugars less than 60 mg/dL and the staff were to call the physician if the resident had blood sugars over 400 mg/dL). During an interview on 01/30/20 at 09:35 AM, Administrative Nurse B stated there were no standing orders for blood sugars. Administrative Nurse B stated the staff needed to place the blood sugar orders in the resident's orders. Administrative Nurse B stated she believed the staff should notify the physician if blood sugars were less than 50 (mg/dL). Review of the Blood Glucose Monitoring, Disinfecting and Cleaning policy revised 12/19 revealed: Verify that the physician's orders include blood glucose high and low parameters and when to notify the resident's physician. The facility failed to ensure the staff included blood sugar parameters and physician notification orders in R21's orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 59 with 20 residents sampled. Based on observation, interview, and record review the facility failed to ensure the facility staff were educated on a diagnosis and appropriate contact precautions for one resident. Findings included: - Upon entrance to the facility on [DATE] at approximately 07:15AM observation revealed R21 with a sign on his door that read to please see the nurse before entering the room and the supplies for contact precautions were available outside his room. A surveyor approached the nurse's station and spoke with Licensed Nurse L (LN) L to enquire about the contact precautions and was told the resident had Methicillin-resistant staphylococcus aureus (MRSA) on his foot and stated it was covered so contact precautions were not necessary. Further observation revealed multiple staff entering and exiting the resident's room without utilizing personal protective equipment (PPE). Review of R21's physicians orders revealed the resident was on Dificid Tablet (Fidaxomicin) 200 milligrams (mg), administer 1 tablet by mouth two times a day for Clostridium difficile (C-diff, an infection of the large intestine (colon) caused by the bacteria Clostridium difficile). On 01/27/20 at approximately 04:30 PM the surveyor informed Administrative Staff A the direct care staff were not utilizing contact precautions. Administrative Staff A assured the surveyor her staff would be educated on the appropriate diagnosis and the necessary precautions needed. On 01/28/20 at approximately 07:30 AM observation revealed LN G in R21's room without appropriate personal protection equipment (PPE) utilized for contact precautions. Interview with LN E on 01/28/20 at 11:51 AM revealed the staff are expected to know what type of infection a resident has in respect to the isolation and contact precautions. LN E said when a resident was diagnosed with something like C-diff there was a sign placed on the resident's door for visitors to see the nurse. LN E said the staff had to share information about resident infection and expectations of appropriate PPE. LN E said the nursing staff could also find out information about the infection issues on the informational white boards at nursing station where information about contact precautions were written. LN E said the white board specifically stated R21 had C-diff. Interview with Administrative Nurse B on 01/30/20 at 11:15 AM revealed the staff were educated on resident changes or concerns through a multilayer process. They have walking rounds from shift to shift, there are staff huddles and white boards are utilized and kept up to date with high risk problems or concerns. Nurses also talk to their aids during the day as changes occur. Interview with LN G on 01/30/20 at approximately 02:00PM revealed he was responsible for the residents in rooms 201-216 and 301-316, which included R21. LN G reported there was one resident on the same hall (R9) who was immunocompromised (cancer and received chemotherapy). Review of the facility policy Infection Prevention and Control Program dated 12/2019 revealed the facility will maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment for residents, patients, children, families, visitors and employees and to help prevent the development and transmission of communicable disease and infections. The facility did not provide a policy on C-diff as requested on 01/30/20. The facility failed to ensure the facility staff were educated on a the proper utilization and appropriate contact precautions associated with the diagnosis for R21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Review of R11's signed Physician Orders dated 11/08/2019 revealed the resident had the following diagnoses: dementia without behavioral disturbances (progressive mental disorder characterized by failing memory, confusion without behavioral disturbances), traumatic subdural hemorrhage (bleeding under the membrane covering the brain), and hypertension (elevated blood pressure). Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Metal Status (BIMS) score of three, indicating severely impaired cognition. Review of the Medication Administration Record (MAR) for January 2020 revealed the resident received 10/23/19, Lisinopril (blood pressure medication) tablet 20 milligrams (mg) by mouth one time daily for hypertension (HTN) and 10/23/19 Amlodipine Besylate Tablet (blood pressure medication) 10 mg by mouth one time daily for HTN Review of the Direct Care Staff Vital sheet instructed the staff to contact the nurse immediately if the resident had a blood pressure below 100 or greater than 150 systolic (the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries). Review of R11's blood pressures from 11/04/19 through 01/27/20 revealed the staff obtained his blood pressure approximately every seven days. The resident had blood pressures less than 100 mmHg (millimeter of mercury) systolic (normal range 120/80) on the following days: 1. 11/14/19 at 10:10 AM 93/56 mmHg 2. 11/15/19 at 09:18 AM 90/57 mmHg 3. 11/16/19 at 03:18 PM 97/61 mmHg 4. 11/17/19 at 10:14 AM 91/62 mmHg 5. 11/18/19 at 09:16 AM 97/50 mmHg 6. 12/09/19 at 10:34 AM 99/68 mmHg 7. 01/20/20 at 08:47 AM 95/46 mmHg Review of the clinical record reveal no followup documentation for the blood pressures listed above. The MAR for the dates listed above revealed the staff administered both Lisinopril and Amlodipine as treatment for HTN to R11. Review of the clinical record revealed it lacked parameters for blood pressures for the medications R11 received. Review of the Consultant Pharmacist Medication Review from 08/15/19 through 01/13/20 revealed, Based upon the information available at the time of the review, and assuming the accuracy and completeness of such information, it is my professional judgment that at such time, the resident's medication regimen contained no new irregularities. Interview with Administrative Nurse B on 01/30/20 revealed she expected the staff to ensure parameters and symptoms of low blood pressure were included in his chart. We do not usually check blood pressures daily unless there is a doctors order. Interview Consultant Pharmacist HH on 01/30/20 at 11:15 AM revealed he expected blood pressure parameters to include when staff were to notify the physician. Review of the facility policy Medication-Drug Regimen Review dated 12/2019 revealed a drug regimen review was performed for each resident at least once a month by a licensed pharmacist. This review must include a review of the resident's medical chart. The pharmacist will review medications to assure that doses and duration are appropriate to each resident's clinical condition, age and comorbidities. The pharmacist will also assure monitoring of medications for efficacy and adverse consequences and will check for potential medication irregularities and response to these irregularities; The facility failed to ensure the licensed pharmacist identified the lack of blood pressure parameters for R11 during the drug regimen review process. The facility census totaled 59 residents, with 20 included in the sample, and five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the pharmacist identified and reported missing blood sugar parameters for Resident (R) 21, failed to identify lack of monitoring for specific targeted behaviors related to antianxiety medications administered to R9, lack of blood pressure parameters for R11, and failed to identify the lack of administration of the correct dosage of Zyprexa as ordered by the physician for R22. Finding Included: - Review of R9's Physician Order Set (POS) dated 01/06/20 revealed the following diagnosis: anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R9 received antianxiety medication daily during the seven-day observation period. Review of the Annual MDS dated 10/28/19 revealed a BIMS score of 15, indicating intact cognition. R9 received antianxiety medication daily during the seven-day observation period. Review of the Psychotropic Drug Use Care Area Assessment (CAA) dated 10/28/19 revealed R9 with a diagnosis of anxiety and a goal to maintain current mood, avoid complications such as increased depression or behaviors, and to receive the lowest effective dose of psychotropic medications. Review of the Care Plan dated 05/21/19 revealed R9 with behavior symptoms and mood state related to anxiety as evidenced by the following behaviors: rude, demanding, critical of others, inconsiderate of others, negative, chronic complainer, does not like change, and was manipulative. Interventions included (Behavior #1: does not like change) if she feels things are not going the way she feels it should, she will refuse to eat or threaten not to eat for a week. She does not want to share the public puzzles. She does not want anyone helping. (Behavior #2: rude/manipulate) R9 had a history of making rude comments to other residents. Review of the Physician Orders revealed the following: 1. 03/15/19, Remeron 30 mg, give one tablet by mouth at bedtime for, generalized anxiety. 2. 04/04/19, Buspirone HCl Tablet 10 mg, give one tablet by mouth three times a day, related to anxiety disorder. 3. 07/23/19, Depakote 500 mg (milligrams), give one tablet by mouth one time a day, for mood related to anxiety disorder. 4. 7/23/19, Depakote 250 mg, give one tablet by mouth one time a day, for mood related to anxiety disorder. Review of the November 2019 Electronic Medication Administration Record (EMAR) / Electronic Treatment Administration Record (ETAR) through the January 2020 EMAR / ETAR revealed R9 received antianxiety medications as ordered. Review of the pharmacy consultant report from 02/13/19 through 01/13/20 lacked evidence the pharmacist identified the lack of consistent monitoring for specific targeted behaviors associated with the use of antianxiety medications received by R9. An observation on 01/28/20 at 08:10 AM revealed R9 self-mobilized in her wheelchair in the hallway coming from the dining room and headed to her room. R9 was calm, appropriate, and did not exhibit any negative behaviors. During an interview on 01/29/20 at 08:31 AM Certified Nurse Assistant (CNA) M stated R9 exhibited negative behaviors quite often. R9 was anxious a lot, would be out looking for medications before they were due, to include anxiety medications. CNA M stated redirection usually did not work, once R9 worked herself up it took a while for her to calm back down. CNA M stated she did not chart behaviors but would report any behaviors to either the CMA or to the charge nurse. During an interview on 01/30/20 at 07:55 AM Licensed Nurse (LN) K stated R9 had all kinds of behaviors and received Depakote. LN K stated the staff charted verbal behaviors by exception in a Behavioral Note. LN K stated R9's behaviors were mostly due to her thinking her needs have not been met. LN K stated behaviors were listed in the care plan. During an interview on 01/30/20 at 09:36 AM Administrative Nurse B stated behaviors listed in the care plan were not specific or tied to the medications R9 received. During an interview on 1/30/20 at 11:15 AM Consultant Pharmacist HH reported if a resident was due for a dose reduction of his psychotropic medication he would check the progress notes for charted behaviors, but he did not check every resident routinely for behaviors. Review of the Pharmaceutical Services policy dated September 2012 revealed, A licensed pharmacist will be employed or services obtained to: .Report any irregularities to the attending physician or the director of nursing services or both . The facility failed to ensure the pharmacist identified and reported the lack of consistent monitoring for specific targeted behaviors related to the use of antianxiety medications for R9. - Review of R21's signed Physician Orders (POS) dated 01/02/20 revealed the following diagnosis: type 2 diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin.) Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating intact cognition. R21 received insulin daily during the seven-day observation period. Review of the Quarterly MDS dated 11/18/19 revealed a BIMS score of 15, indicating intact cognition. R21 received insulin daily during the seven-day observation period. Review of the Care Plan dated 06/27/18 revealed R21 with diabetes mellitus as evidenced by blood sugar readings, and signs and symptoms of hyperglycemia (greater than normal amount of glucose in the blood) and hypoglycemia (less than normal amount of sugar in the blood.) Review of the physician orders revealed the following orders: 1. 09/10/19, Accuchecks AC (before meals) and HS (bedtime) for diabetes mellitus type 2. 2. 10/04/19, NovoLOG FlexPen Solution Pen-injector 100 UNIT/ML (milliliter) (Insulin Aspart) inject 7 units subcutaneously before meals related to Type 2 Diabetes Mellitus. 3. 10/29/19, Lantus Solution 100 UNIT/ML (Insulin Glargine) inject 40 units subcutaneously at bedtime related to type 2 diabetes mellitus. There were no Physician Orders for blood sugar parameters or when to notify the physician included in R21's orders. Review of the December 2019 Electronic Medication Administration Record (EMAR)/Electronic Treatment Administration Record (ETAR) revealed on 12/08/19 at 07:00 AM R21 with a blood sugar of 53 milligrams/deciliter (mg/dL). Review of the January 2019 EMAR/ETAR revealed: On 01/08/20 at 07:00 AM R21 with a blood sugar of 51 mg/dL. On 01/19/20 at 07:00 AM R21 with a blood sugar of 51 mg/dL. On 01/20/20 at 07:00 AM R21 with a blood sugar of 45 mg/dL. Review of the pharmacy consultant report from 02/13/19 through 01/13/20 lacked evidence the pharmacist identified the lack of blood sugar parameters, and physician notification instructions in R21's orders. Observation on 01/28/20 at 02:19 PM revealed R21 did not exhibited any signs or symptoms of blood sugar issues. Interview on 01/30/20 at 07:39 AM with Licensed Nurse (LN) K stated R21 was a diabetic and received 7 units of insulin with meals, and 40 units of insulin at bedtime. LN K stated blood sugars were checked four times a day and said R21 did not have a sliding scale (method for using correction dose of insulin based on blood glucose readings) for insulin. LN K stated the facility used standing orders from [NAME] Hospital since so many of the residents came from there. (Review of these orders revealed the staff were to follow hypoglycemia treatment orders for blood sugars less than 60 mg/dL and the staff were to call the physician if the resident had blood sugars over 400 mg/dL). During an interview on 01/30/20 at 09:35 AM Administrative Nurse B stated there were no standing orders for blood sugars. Administrative Nurse B stated the staff needed to place the blood sugar orders in the resident's orders. Administrative Nurse B stated she believed the staff should notify the physician if blood sugars were less than 50 (mg/dL). During an interview on 01/30/20 at 11:15 AM Consultant Pharmacist HH stated he expected parameters to be included in the orders as to when to notify the physician for any residents receiving AccuChecks. Review of the Pharmaceutical Services policy dated September 2012 revealed, A licensed pharmacist will be employed or services obtained to: .Report any irregularities to the attending physician or the director of nursing services or both . The facility failed to ensure the pharmacist identified and reported missing blood sugar parameters and physician notification orders in R21's orders. - Review of R22's signed Physician Orders dated 12/01/19 revealed the following diagnoses: vascular dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), insomnia (inability to sleep), unspecified psychosis, (any major mental disorder characterized by a gross impairment in reality testing), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and, depressive episodes (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating intact cognition. The resident was independent with daily care and continent of bowel and bladder. He received as needed (PRN) pain medication for frequent complaint of pain at an eight out of 10. He received antipsychotic, antianxiety, antidepressant medications daily in the 7-day observation period with no recent gradual dose reduction (GDR) with GDR clinically contraindicated on 9/24/19. Review of the Annual MDS dated 11/18/19 revealed no significant changes since assessment on 08/26/19. Review of the Care Area Assessment (CAA) dated 11/18/19 revealed: Psychotropic Drug Use CAA- The resident rarely participates in activities but ate meals in the dining room. The resident's mood was stable currently with a goal to maintain current mood and avoid complications such as increased depression or behaviors and to receive lowest effective dose of psychotropic medications. The Care Plan revised 03/17/19 revealed the resident was on antipsychotic medication therapy related to psychosis with delusions, hallucinations, and extreme anxiety that was not easily altered as evidenced by anxious behaviors, repetitive requests and, and history of insomnia. The Care Plan instructed the staff to monitor the resident for behavioral symptoms that presented a danger to the resident or others and for symptoms that were significant enough that the resident experienced inconsolable or persistent distress. Review of the Consulting Pharmacist Monthly Medication Regimen Review revealed a 06/10/19 review which noted to please consider a GDR of Olanzapine to 2.5 milligrams (mg) at bedtime (HS) with eventual goal to discontinue. The physician agreed and decreased the medication dated 06/10/19. Review of the Medication Administration Record (MAR) from June 2019 through January 2020 revealed the resident continued to receive Olanzapine 5.0 mg (antipsychotic) even though physician ordered a decrease in dose on 6/10/19. Review of the Nurses Progress Notes dated 01/29/20 at 04:59 PM revealed the nurse discovered there a recommendation for the resident to have a gradual dose reduction (GDR) signed by a physician in June 2019 for Olanzapine which did not get changed on the MAR. The nurse sent a fax to the primary care physician and mental health physician to make them aware and how they want to proceed. Observation on 01/28/20 at 08:10 AM revealed the resident sat up on the bed watching television. The resident was alert with no confusion noted. Check of the medication cart on 01/29/20 with Licensed Nurse D revealed a bottle of Olanzapine 10 mg tablets prescribed to the resident with instructions to give 1/2 tablet at HS and the current order in the computer was for 5 mg at HS. During an interview on 01/28/20 at 08:10 AM the resident reported he was having a good day and was ready to go for breakfast. The resident kept his television at high volume but when TV turned off could hear normal voice tome and carry on a conversation. During an interview on 01/28/20 at 02:39 PM Certified Nursing Aide (CNA) H reported the resident was independent in his room. The resident needed cuing to make sure he had on clean clothes and exhibited no behaviors that she knew of. She did not know what medications the resident received but if the resident was not acting like himself, she would let the nurse know. Interview on 01/29/20 at 09:46 AM with Licensed Nurse (LN) D reported the resident received Olanzapine 5 mg by mouth. LN D had not really seen any behaviors from the resident, other than he self isolated in his room between meals. LN D said the staff did not monitor him for behaviors because he really did not have any, but if he did, she would chart them in the nurses notes. LN D said that was the only place she charted behaviors. During an interview on 01/29/20 at 10:58 AM Administrative Nurse B did not know of the medication order to decrease the Olanzapine on 06/10/19. At 04:50 PM Administrative Nurse B acknowledged the dose reduction had never occurred as it should have. During an interview on 01/30/20 at 11:15 AM Consultant Pharmacist HH reported if a resident was due for a dose reduction of psychotropic medication, he checked the progress notes for charted behaviors, but he did not check every resident routinely for behaviors. The pharmacist also reported he must have missed checking for a follow-up on the GDR for this resident, as he could not locate a follow-up in his records. The Consulting Pharmacist failed to follow-up on a dose reduction dated 06/10/19 for a psychotropic medication for R22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Review of R11's clinical record revealed the resident lacked a diagnosis of Schizophrenia or Bipolar Disorder. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of seven which indicated severely impaired cognition. The resident did not exhibit behaviors during the seven-day observation period. R11 received antipsychotic medications seven of seven days during the observation period. Review of the Cognitive loss/Dementia and the Delirium Care Area Assessment (CAA) dated 08/14/2019 revealed the resident had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). He had inattention and disorganized thinking during staff interviews. He received Seroquel (progressive mental disorder characterized by failing memory, confusion) daily and Ativan (used to treat anxiety) as needed. Review of the Psychotropic Drug [medication capable of affecting the mind, emotions, and behavior] Use CAA dated 08/14/2019 revealed the resident received an antidepressant (used to alleviate depression) and anxiolytic (used to reduce anxiety) medications during the look back period. He exhibited aggressive behaviors such as hitting and yelling at staff one to three days during the look back period. His goal was to maintain current mood and avoid complications such as increased depression or behaviors and to receive the lowest effective dose of psychotropic medications. R11's Care Plan included the following: 1. 08/08/19: Directed staff to monitor resident condition based on clinical practice guidelines or clinical standards of practice related to use of Seroquel. An entry on 08/08/19 also referred to a possible drug reaction that caused aggressive physical behaviors and directed staff to attempt nonpharmacological (non-medical) interventions such as a quiet environment, with only one person to approach slowly at eye level. 2. 08/13/19: Noted R11's behavioral symptoms related to dementia such as agitation or hitting. The care plan directed staff to reposition the resident, take him to the bathroom or offer something to eat or drink if those behaviors occurred. 3. 10/10/19: Noted R11's use of antipsychotic medication for dementia and traumatic subdural hemorrhage (bleeding in the brain). The entry also noted use of Seroquel and Black Box warnings associated with use of the medication in patients with dementia related psychosis. Physician's orders revealed an 08/14/19 order for Seroquel (Quetiapine Fumarate) tablet, 100 milligrams (mg) at bedtime daily for sleep. The clinical record lacked evidence of monitoring of behaviors related to use of antipsychotic medication (Seroquel). Review of the Consultant Pharmacist monthly drug regimen reviews from 08/15/19 through 01/13/20 revealed, Based upon the information available at the time of the review, and assuming the accuracy and completeness of such information, it is my professional judgment that at such time, the resident's medication regimen contained no new irregularities. Interview with Certified Nurse Aide (CNA) J on 01/30/20 at 10:15AM revealed R11 does not like to wake up early. If they attempt to get him up before he is ready, he swats at the staff, scratches them, or will bend their fingers back. She reports this happens approximately three to four times a week. When it happens, she leaves the room and re-addresses him later. CNA J reported she reported behaviors to the nurse immediately but CNAs do not document behaviors in the clinical record. Interview with Administrative Nurse B on 01/30/20 at 10:57AM revealed R11 was admitted to the facility from hospice with Seroquel for sleep. According to Administrative Nurse B, staff requested an appropriate diagnosis for the Seroquel from the physician. The physician then elected to discontinue the medication. On 08/14/19, the physician reordered the Seroquel due to lack of sleep. Administrative Nurse B reported R11 sometimes hit, kicked or scratched but she considered those incidents products of his disease process and his way of communication rather than behaviors. Interview with Consultant Pharmacist HH on 01/30/2020 at 11:15 AM revealed he checked for resident behaviors in the documentation only if it was time for a dosage reduction of psychotropic medication but did not check resident behaviors monthly otherwise. Review of the facility policy Unnecessary Medications dated 01/2020 revealed each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: without adequate indications for its use and without adequate monitoring. The facility failed to obtain an appropriate diagnosis to support R11's use of antipsychotic medication and failed to monitor/document behaviors which indicated improvement or lack of improvement of behaviors related to use of the medication. The facility census totaled 59 residents, 20 in the sample, with five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to monitor specific targeted behaviors related to antianxiety medications administered to Resident (R) 9, failed to decrease the dosage of Zyprexa (antipsychotic medication) as ordered by the physician for R22, and failed to obtain an appropriate diagnosis to support use of antipsychotic medications (medication that is believed to be effective in the treatment of psychosis), and failed to monitor/document behaviors which indicated improvement or lack of improvement related to use of antipsychotic medications for Resident (R) 11. Finding Included: - Review of R9's Physician Order Set (POS) dated 01/06/20 revealed the following diagnosis: anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear.) Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating intact cognition. R9 received antianxiety medication daily during the seven-day observation period. Review of the Annual MDS dated 10/28/19 revealed a BIMS score of 15, indicating intact cognition. R9 received antianxiety medication daily during the seven-day observation period. Review of the Psychotropic Drug Use Care Area Assessment (CAA) dated 10/28/19 revealed R9 with a diagnosis of anxiety and a goal to maintain current mood, avoid complications such as increased depression or behaviors, and to receive the lowest effective dose of psychotropic medications. Review of the Care Plan dated 05/21/19 revealed R9 with behavior symptoms and mood state related to anxiety as evidenced by the following behaviors: rude, demanding, critical of others, inconsiderate of others, negative, chronic complainer, does not like change, and was manipulative. Interventions included (Behavior #1: does not like change) if she feels things are not going the way she feels it should, she will refuse to eat or threaten not to eat for a week. She does not want to share the public puzzles. She does not want anyone helping. (Behavior #2: rude/manipulate) R9 had a history of making rude comments to other residents. Review of the Physician Orders revealed the following: 1. 03/15/19, Remeron 30 mg, give one tablet by mouth at bedtime for, generalized anxiety. 2. 04/04/19, Buspirone HCl Tablet 10 mg, give one tablet by mouth three times a day, related to anxiety disorder. 3. 07/23/19, Depakote 500 mg (milligrams), give one tablet by mouth one time a day, for mood related to anxiety disorder. 4. 7/23/19, Depakote 250 mg, give one tablet by mouth one time a day, for mood related to anxiety disorder. Review of the November 2019 Electronic Medication Administration Record (EMAR) / Electronic Treatment Administration Record (ETAR) through the January 2020 EMAR / ETAR revealed R9 received antianxiety medications as ordered. An observation on 01/28/20 at 08:10 AM revealed R9 self-mobilized in her wheelchair in the hallway coming from the dining room and headed to her room. R9 was calm, appropriate, and did not exhibit any negative behaviors. During an interview on 01/29/20 at 08:31 AM Certified Nurse Assistant (CNA) M stated R9 exhibited negative behaviors quite often. R9 was anxious a lot, would be out looking for medications before they were due, to include anxiety medications. CNA M stated redirection usually did not work, once R9 worked herself up it took a while for her to calm back down. CNA M stated she did not chart behaviors but would report any behaviors to either the CMA or to the charge nurse. During an interview on 01/30/20 at 07:55 AM Licensed Nurse (LN) K stated R9 had all kinds of behaviors and received Depakote. LN K stated the staff charted verbal behaviors by exception in a Behavioral Note. LN K stated R9's behaviors were mostly due to her thinking her needs have not been met. LN K stated behaviors were listed in the care plan. During an interview on 01/30/20 at 09:36 AM Administrative Nurse B stated behaviors listed in the care plan were not specific or tied to the medications R9 received. Review of the Behavioral Causes and Interventions policy revised 02/17 revealed: Consistent behavior documentation done by all three shifts identifies .target behavior and allows for individualized interventions. The facility failed to ensure R9 did not receive unnecessary medication by the failure of staff to monitor for specific targeted behaviors related to the use of antianxiety medications. - Review of R22's signed Physician Orders dated 12/01/19 revealed the following diagnoses: vascular dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), insomnia (inability to sleep), unspecified psychosis, (any major mental disorder characterized by a gross impairment in reality testing), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and, depressive episodes (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating intact cognition. The resident was independent with daily care and continent of bowel and bladder. He received as needed (PRN) pain medication for frequent complaint of pain at an eight out of 10. He received antipsychotic, antianxiety, antidepressant medications daily in the 7-day observation period with no recent gradual dose reduction (GDR) with GDR clinically contraindicated on 9/24/19. Review of the Annual MDS dated 11/18/19 revealed no significant changes since assessment on 08/26/19. Review of the Care Area Assessment (CAA) dated 11/18/19 revealed: Psychotropic Drug Use CAA- The resident rarely participates in activities but ate meals in the dining room. The resident's mood was stable currently with a goal to maintain current mood and avoid complications such as increased depression or behaviors and to receive lowest effective dose of psychotropic medications. The Care Plan revised 03/17/19 revealed the resident was on antipsychotic medication therapy related to psychosis with delusions, hallucinations, and extreme anxiety that was not easily altered as evidenced by anxious behaviors, repetitive requests and, and history of insomnia. The Care Plan instructed the staff to monitor the resident for behavioral symptoms that presented a danger to the resident or others and for symptoms that were significant enough that the resident experienced inconsolable or persistent distress. Review of the Consulting Pharmacist Monthly Medication Regimen Review revealed a 06/10/19 review which noted to please consider a GDR of Olanzapine to 2.5 milligrams (mg) at bedtime (HS) with eventual goal to discontinue. The physician agreed and decreased the medication dated 06/10/19. Review of the Medication Administration Record (MAR) from June 2019 through January 2020 revealed the resident continued to receive Olanzapine (Zyprexa, antipsychotic medication) 5 mg even though the physician ordered a decrease in dosage on 06/10/19. Review of the Nurses Progress Notes dated 01/29/20 at 04:59 PM revealed the nurse discovered there a recommendation for the resident to have a gradual dose reduction (GDR) signed by a physician in June 2019 for Olanzapine which did not get changed on the MAR. The nurse sent a fax to the primary care physician and mental health physician to make them aware and how they want to proceed. Observation on 01/28/20 at 08:10 AM revealed the resident sat up on the bed watching television. The resident was alert with no confusion noted. Check of the medication cart on 1/29/20 with Licensed Nurse D revealed a bottle of Olanzapine 10 mg tablets prescribed to the resident with instructions to give 1/2 tablet at HS and the current order in the computer was for 5 mg at HS. During an interview on 01/28/20 at 08:10 AM the resident reported he was having a good day and was ready to go for breakfast. The resident kept his television at high volume but when TV turned off could hear normal voice tome and carry on a conversation. During an interview on 01/28/20 at 02:39 PM Certified Nursing Aide (CNA) H reported the resident was independent in his room. The resident needed cuing to make sure he had on clean clothes and exhibited no behaviors that she knew of. She did not know what medications the resident received but if the resident was not acting like himself, she would let the nurse know. Interview on 01/29/20 at 09:46 AM with Licensed Nurse (LN) D reported the resident received Olanzapine 5 mg by mouth. LN D had not really seen any behaviors from the resident, other than he self-isolated in his room between meals. LN D said the staff did not monitor him for behaviors because he really did not have any, but if he did, she would chart them in the nurse's notes. LN D said that was the only place she charted behaviors. During an interview on 01/29/20 at 10:58 AM Administrative Nurse B did not know of the medication order to decrease the Olanzapine on 06/10/19. At 04:50 PM Administrative Nurse B acknowledged the dose reduction had never occurred as it should have. During an interview on 01/30/20 at 11:15 AM Consultant Pharmacist HH reported if a resident was due for a dose reduction of psychotropic medication, he checked the progress notes for charted behaviors, but he did not check every resident routinely for behaviors. The pharmacist also reported he must have missed checking for a follow-up on the GDR for this resident, as he could not locate a follow-up in his records. The facility failed to decrease the dosage of an antipsychotic medication as ordered by the physician dated 06/10/19 for R22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 59 residents. The facility had one main kitchen where food was stored and prepared and a secondary area for dry storage with an additional walk in freezer. Based on observation, interview, and record review the facility failed to serve and store food under sanitary conditions, which had the ability to affect all residents of the facility. Findings included: - During the initial tour of the dietary department on 01/27/20 at approximately 07:30, observation of the walk-in refrigerator revealed six previously prepared sandwiches on a tray covered with cling wrap, and a stack of sliced cheese covered in cling wrap were not dated. During the follow up tour of the kitchen on 01/29/20 at 11:00 AM, the following concerns were identified: 1.The general appearance of the kitchen and storage rooms was not clean. The floor had debris, the hinges to the cooler had built-up dust and grime. The handles on the drawers and cabinets were sticky with built up grime. The bottom shelves of the preparation tables were littered with dust and crumbs. 2. Three large Ware-ever baking pans had pitting throughout the interior of the pan with a baked-on brown/black colored build up in the pitting and on the inside rims. Nine large cookie sheets with brown/black colored build up on the inside rim leaving an unsanitary surface. 3. A large manual can opener attached to the preparation table had a black greasy build up on the puncture blade and inside the holding bracket. 4. The stove top was covered in a black build up along with newer looking food debris. The portion of the large Vulcan baking oven located next to the stovetop was covered in a brown/black grime. 5. The steam table had old drippings on the front panel under the serving shelf. On the bottom shelf of the steam table, where the clean pans were stored, there was a large white cloth with dried brown fluid on it. During an observation of the dry food storage room [ROOM NUMBER]/29/20 at 11:22 AM, the following concerns were identified: 1. A large Panko bread crumbs bag left open to air without any type of closing device and had no open date written on it. 2. One [NAME] Swirl loaf of bread with a best if used by date of December of 2019. 3. One package of [NAME] English muffins with best used by date of December of 2018. 4. An undated 12 pack of hamburger buns with white mold. 5. An undated eight pack of hot dog buns with green mold. An observation on 01/29/20 at 11:46 AM revealed Dietary Staff (DS) DD used his bare hands to pick up a hamburger bun and place it on a plate, then picked up a baked potato and pushed it open with the palms of his hands. He then picked up a hamburger patty with a pair of tongs and placed it on the bun, then used his bare hands to put a slice of cheese on the hamburger patty. In between this process staff DD touched the steam table, the refrigerator walk-in handle, and another cart which contained pickles, tomatoes, onions etc. DS DD did not were any gloves during this time. DS DD did wash his hands before food service began, but not again during the process when he touched other items as previously described. DS DD also wore an untrimmed mustache not covered with a protective hair net. An observation on 01/29/20 at 11:46 AM revealed the facility used laminated index cards to provide staff with resident information related to their dietary needs. These cards were repeatedly handed back and forth between staff members and placed on different surfaces. Theses cards were not sanitized at any time during the food service process. DS DD touched these cards with his bare hands during the food serving process, and DS EE used the same pair of gloves to pick up the resident card then placed the bread on the plate. He also used the same pair of gloves to put cheese on hamburgers and used tongs to pick up other foods. The staff member repeatedly left the work station to gather other items. These gloves were not changed in between switching tasks. During an interview on 01/30/20 at 09:10 AM with the Certified Dietary Manager (CDM) CC stated she expected kitchen employees to wash their hands before coming into the kitchen, before and after changing gloves, anytime a body part was touched, and after using the restroom. She expected gloves to be worn while handling food with their hands. CDM CC stated bare hands were only acceptable if using a utensil, like tongs, to handle food. She explained she expected staff hair to be covered in the kitchen. CDM CC stated the facility provided hair and beard nets for use by staff. Review of the Hand Washing and Glove Use policy revised 07/18 revealed: Employees do not touch any food with bare hands-ready to eat or otherwise .Bare-hand contact with any food is prohibited. This prohibition includes all Society locations .Hands are washed thoroughly before putting gloves on and after taking gloves off .Gloves are not worn routinely when serving food, during food preparation or when completing more than one task. Utensils are used when completing multiple tasks. Gloves are changed as followed .Whenever employee changes an activity, the type of food being worked with or whenever he or she leaves the workstation. Review of the Employee Hygiene and Dress Code revised 07/18 revealed: Hairnets or hair restraints and beard nets or beard restraints are used: .When in the food preparation kitchen including dish rooms and storage areas . The facility failed to serve and store food under sanitary conditions by the failure to follow standards of practice in wearing gloves, hair/beard nets while preparing, and serving meals, and failed to properly dispose of expired foods, and properly store and date opened food packages. These failures had the ability to affect all residents.