**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 57 residents. The sample included 15 residents, with two reviewed for reasonable accommodation of needs related to assistive devices. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)2's wheelchair foot pedals were utilized while being pushed. The facility additionally failed to ensure R43 had a way to communicate her needs due to her call lights being left out of reach. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings included:- The Medical Diagnosis section within R2's Electronic Medical Records (EMR) noted diagnoses of cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, and a history of falls. R2's Quarterly Minimum Data Set (MDS) completed 06/27/25 revealed a Brief Interview for Mental Status Score of 14, indicating severe cognitive impairment. The MDS noted she had no upper or lower extremity impairments. The MDS noted she used a wheelchair for mobility. The MDS noted she required supervision or touch assistance for bed mobility, transfers, dressing, bathing, toileting, personal hygiene, and putting on footwear. The MDS noted she had a history of falls. R2's Falls Care Area Assessment (CAA) completed 06/13/25 indicated she had a history of falls related to generalized weakness and her medical diagnoses. The CAA noted she used a wheelchair. The CAA indicated that a care plan was implemented to minimize her risk of falls. R2's Care Plan initiated on 11/28/20 indicated she required assistance with her activities of daily living (ADLs). The plan noted she had a history of falls related to her medical diagnoses. The plan indicated signage was placed in her room to call for help. The plan instructed staff to ensure she wore non-skid footwear before transferring. The plan indicated that her room was to have non-skid traction tape placed on her bedroom and bathroom floors to prevent falls. The plan noted she used a wheelchair for mobility. On 08/20/25 at 11:17 AM, a Certified Nurse's Aide (CNA) stated staff were expected to use the foot pedals when pushing residents in their wheelchairs. On 08/20/25 at 11:24 AM, Administrative Nurse D stated staff should not be pushing residents in their wheelchairs without using foot pedals to prevent their feet from dragging or being a fall risk. The facility's Fall Management System, revised 03/2025, indicated the facility promoted an environment that remains free from accident hazards. The policy indicated the facility appropriately assessed and implemented interventions to prevent falls and minimize complications if falls occurred. - R43's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypothyroidism (a condition characterized by decreased activity of the thyroid gland), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major mood disorder that causes persistent feelings of sadness), muscle weakness, and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness, fracture with routine healing, and hypoxia (inadequate supply of oxygen). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R43 was rarely or never understood. The MDS documented R43 was dependent on staff for all ADLs. R43 's Tube Feeding Care Area Assessment (CAA) dated 09/18/24 documented that R43 was nothing by mouth (NPO) and received tube feeding continuously. The CAA documented R43 receives hydration through tube feeding (administration of nutritionally balanced liquefied foods or nutrients through a tube), and nursing administers the feeding and hydration per the physician's orders.R43's Care Plan dated 05/13/24 indicated R43 required staff assistance for her activities of daily living and was at risk for falls related to her medical diagnoses. The plan instructed staff to ensure her call light remained within reach and staff provided assistance as needed. On 08/18/25 at 08:34 AM, R43 lay in her bed on her back with her eyes shut. R43 had a thick yellow substance on her lips and in her mouth. On 08/19/25 at 02:12 PM, R43's call light lay between R43's bed and her roommate's bed on the floor. R43's call light was not within her reach.On 08/20/25 at 11:17 AM, the Certified Nurse Aide (CNA) M stated that call lights were to be placed within the resident's reach at all times.On 08/20/25 at 11:24 AM, Administrative Nurse D stated staff were expected to check the call light placement during each encounter to ensure the residents could communicate their needs. The facility's Fall Management System, revised 03/2025, indicated the facility promoted an environment that remains free from accident hazards. The policy indicated the facility appropriately assessed and implemented interventions to prevent falls and minimize complications if falls occurred.

The facility identified a census of 57 residents. The sample included 15 residents, with one reviewed for privacy. Based on observation, record review, and interviews, the facility failed to secure protected health information (PHI) for Resident (R) 31. This deficient practice placed R31 at risk for decreased psychosocial well-being due to a lack of privacy. Findings Included: - On 08/18/25 at 07:39 AM, a walkthrough of the 100 Hall revealed an unattended nursing cart across the hallway from the nurse's station. An inspection of the cart revealed R2's PHI displayed on the cart. At 08/18/25 at 07:40 AM, Licensed Nurse (LN) H exited a room in the 100 Hall and locked the computer screen. On 08/20/25 at 11:01 AM, LN G stated the computer was to be locked when not attended by staff to protect health information. On 08/20/25 at 11:40 AM, Administrative Nurse D stated staff were expected to lock the computer screens when they were not in use to protect the residents' PHI. A review of the facility's Resident Rights revised 09/2024 indicated the facility will ensure each resident's privacy and ensure all residents were educated and informed of their rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 57 residents. The sample included 15 residents, with two residents reviewed for the discharge process. Based on observation, record review, and interviews, the facility failed to provide a final summary of the resident's status at discharge for Resident (R) 64 and R1. This deficient practice placed R64 and R1 at risk of delayed care or uncommunicated care needs.Findings Included: - R64's “Electronic Medical Records” (EMR) documented diagnoses of malnutrition (consuming to few calories), cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), cancer of the rectum, muscle weakness, unsteadiness on feet, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dysphagia (swallowing difficulty), and anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). R64's Modification of Admissions Minimum Data Set (MDS) completed 05/13/25 noted a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented that he had an impairment of her lower extremity. The MDS documented R64 needed supervising or touching assistance with eating and oral hygiene, and partial/moderate assistance with toileting and bathing. R64’s “Functional Abilities (Self-Care Mobility) Care Area Assessment (CAA), dated 05/13/25, documented generalized muscle weakness and was on skilled services, nursing assisted with activities of daily living (ADLs) function as needed, and staff to place R64’s call light within his reach. R64’s EMR recorded a “Discharge Assessment-Return Not Anticipated MDS” documenting R64's discharge date d 06/24/25. R64’s “Care Plan,” revised 07/07/25, documented the discharge plan was to go home after therapy services. The plan of care for R64 documented the facility would develop and follow a full discharge plan with a comprehensive plan. R64’s EMR under “Progress Notes” revealed a “Nursing Note” dated 06/24/25 that documented R64’s caregiver was at the facility to pick up R64 and take him home. R64 refused his medications; he stated he wasn't going to take them, and the caregiver agreed. R64’s belongings were packed and given to him. R64 left in a personal car. Paperwork was sent with R64. R64’s “Discharge Charge Summary” was undated and lacked documentation showing recompilation of his stay in the facility. On 08/20/25 at 11:01 PM, Licensed Nurse (LN) G stated it was the responsibility of the nurse who was on duty when a resident was discharged from the facility. He stated the nurse would document in the resident's nursing notes what the facility had done for the resident, where the resident was going, what he took with him, the medications he had, what the facility did with the medications, and what follow-up appointments the resident had scheduled. On 08/20/25 at 11:24 PM, Administrative Nurse D stated it was the nurse on duty’s responsibility to document a recompilation of the resident's stay in the facility, which included where his medication was sent, where the resident was going, and what the facility had done for the resident. The facility’s “Discharge Summary” dated 09/05/25 documented that the social services and nursing staff participate in developing a discharge summary when a resident is discharged to a private residence, another nursing facility, or another type of residential facility. The discharge summary provides a recapitulation of the resident’s stay and the resident’s status at the time of discharge to ensure continuity of care. Facilities will complete the discharge summary located in PointClick Care unless state policy requires the use of a state-mandated discharge summary form. - R1's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of respiratory failure with hypoxia (inadequate supply of oxygen), dyspnea (difficulty breathing), insomnia (inability to sleep), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The “admission Minimum Data Set (MDS)” dated 03/13/25 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 was independent with activities of daily living (ADL). The Quarterly MDS dated [DATE] documented a BIMS score of 14, which indicated intact cognition. The MDS documented that R1 was independent with his ADLs. R1’s Cognitive Loss/Dementia Care Area Assessment (CAA)” dated 03/19/25 documented R1 had verbal behaviors directed toward other residents. R1's “Care Plan,” dated 07/16/25, documented nursing staff would discuss the history of hospitalization with him and family. The plan of care documented the staff would educate him and his family on his current health condition and self -manager. R1‘s EMR under the “Progress Notes” tab revealed the following “Health Status Note” on 05/30/25 at 06:36 PM: R1 was transferred to the hospital. On 08/19/25 at 11:41 AM, R1 sat outside the facility in his wheelchair during an activity. R1 visited with staff and other residents. On 08/20/25 at 11:02 AM, Licensed Nurse (LN) G stated he would have the resident sign the facility’s bed hold policy prior to the transfer to the hospital and give the resident a copy of the policy. LN G stated he called the resident’s family or their legal representative to notify them of the transfer. LN G stated he did not notify the family or representativity in writing. On 08/20/25 at 11:25 AM, Administrative Nurse D stated the written notification to the resident’s legal representative was provided by the social service department. Administrative Nurse D stated the bed hold policy was sent with the resident at the time of transfer. The facility’s “Bed-Hold Policy,” last revised 08/05/25, documented the bed-hold policy would be given upon admission, upon transfer of a resident to the hospital (if in an emergency within 24 hours), or the resident goes on therapeutic leave of absence. The facility would provide written information to the resident or resident representative, the nursing facility's policy on bed-hold periods, and the resident's return to the facility to ensure that residents are made aware of a facility’s bed-hold and reserve bed payment policy before and upon transfer to ahospital or when taking a therapeutic leave of absence from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 57 residents. The sample included 15 residents, with two residents reviewed for activities of daily living (ADL) care. Based on observation, record review, and interviews, the facility failed to ensure that cleaning of her mouth was provided for Resident (R) 43, who required assistance from staff to complete the care. This deficient practice placed R43 at risk for complications, including discomfort related to poor personal hygiene.Findings included:- R43's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypothyroidism (a condition characterized by decreased activity of the thyroid gland), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major mood disorder that causes persistent feelings of sadness), muscle weakness, Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness, fracture with routine healing), and hypoxia (inadequate supply of oxygen).The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R43 was rarely or never understood. The MDS documented R43 was dependent on staff for all ADLs. R43's Tube Feeding Care Area Assessment (CAA) dated 09/18/24 documented R43 was nothing by mouth (NPO) and received tube feeding continuously. The CAA documented R43 receives hydration through tube feeding (administration of nutritionally balanced liquefied foods or nutrients through a tube), and nursing administers the feeding and hydration per the physician's orders.R43's Care Plan dated 05/13/24 documented R43 had oral/dental health problems (inflamed gums) related to poor oral hygiene and was NPO. R43's plan of care documented mouth care was to be provided at least daily. R43's plan of care directed staff to provide mouth care daily, and staff were to report any abnormalities to nursing. On 08/18/25 at 08:34 AM, R43 laid in her bed on her back with her eyes shut. R43 had a thick yellow substance on her lips and in her mouth. On 08/20/25 at 11:01 AM, Licensed Nurse (LN) G stated that the cleaning of a resident's mouth that had an internal feeding was not documented anywhere. He stated staff know residents with internal feedings need their mouths cleaned at least every shift. On 08/20/25 at 11:17 AM, the Certified Nurse Aide (CNA) M stated it was all the nursing staff's responsibility to ensure residents stay clean. CNA M stated normally, the LN was the person who cleaned residents' mouths when the resident had an internal feeding because they were in her room more often. She stated it was all the nursing staff's responsibility to ensure the residents are clean. On 08/20/25 at 11:24 AM, Administrative Nurse D stated residents should have their mouths cleaned when a staff member sees the resident's mouth is dirty. She stated that all residents should be clean and that it was every staff member's responsibility. The facility's Activities of Daily Living policy dated 09/25/25 documented the resident would receive assistance as needed to complete activities of daily living. The quality-of-care fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care by professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 57 residents. The sample included 15 residents, with two residents reviewed for treatment/services to prevent/heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure-reducing measures were placed on Resident (R) 58's bilateral lower extremities to prevent pressure ulcers. This placed R58 at increased risk for pressure ulcer development. Findings Included:- R58's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), muscle weakness, communication deficit, need for assistance with person care, history of falling, disruption of wound, encephalopathy (a broad term for any brain disease that alters brain function or structure), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting left dominant side. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R58 was never or rarely understood. The MDS documented R58 was at risk for pressure ulcers. The MDS documented R58 needed supervision or touching assistance to roll from right to left. The MDS documented R58 had a pressure-reducing mattress in her wheelchair and her bed. R58's Pressure Ulcer/Injury Care Area Assessment (CAA) dated 05/29/24 documented R58 had a history of pressure injury. The CAA documented staff were to apply barrier cream to her buttocks for protection, and Skin-prep (liquid skin protectant) to bilateral heels.R58's Care Plan dated 05/21/25 documented R58 was at risk for skin integrity. The plan of care for R58 had a Stage 1 (pressure wound which appears reddened, does not blanche, and may be painful but is not open) on the left heel, which had healed. R58's plan of care documented to maintain intact skin with no breakdowns, R58 used a pressure-reducing mattress, and staff would perform weekly skin checks. R58's EMR under the Order tab documented the following physician orders:Bilateral boots were on even when she was in bed. Remove boots every shift to examine skin, related to disruption of wound, dated 03/14/25.Skin prep wipes were applied to the bilateral heel topically every shift related to the disruption of the wound, dated 03/14/25. The Braden Scale (a scale for predicting pressure sore risk) dated 07/25/25 documented a score of 12, which indicated a high risk for pressure wounds. On 08/19/25 at 02:14 PM, R58 laid on his bed on his back; R58's heels were directly on his mattress. On 08/20/25 at 11:01 AM, Licensed Nurse (LN) G stated that if a resident were to have boots applied to their heels, it would be a nursing duty and would be on the Treatment Administration Record (TAR). He stated it would be a nursing duty, and the nurse would ensure the boots were on the residents' feet. On 08/20/25 at 11:17 AM, Certified Nursing Aide (CNA) M stated that if a resident was to have their heels floated or boots applied to heels, it would show on the CNAs documentation and the charge nurses' documentation. She stated that all nursing staff would know that the residents' heels were to float, or boots needed to be applied to their heels. On 08/20/25 at 11:24 AM, Administrative Nurse D stated ensuring boots were applied to a resident's heels was ultimately the nursing duty and would be on the TAR. She stated the nurse could delegate the task to a CNA but would need to ensure the task was followed through. The facility's Skin Integrity and Pressure Ulcer/Injury Prevention and Management reviewed 03/31/23 documented the facility would provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 57 residents. The sample included 15 residents, with two residents reviewed for position and mobility. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 54 was given (ROM- the full movement potential of a joint, usually its range of flexion and extension) exercises to prevent contractures (abnormal permanent fixation of a joint or muscle) and help with R54's flaccid left hand. This deficient practice left R54 at risk for further decline and decreased range of motion or mobility. Findings included:- R54's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting left non-dominant side, muscle weakness, need for assistance with personal care, dysphagia (swallowing difficulty), history of falling, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of five, which indicated severely impaired cognition. The MDS documented R54 was independent with eating, needed setup or cleanup for oral hygiene, and was partial/moderate assistance from staff for toileting, bathing, and dressing. R54's Functional Abilities Care Area Assessment (CAA) dated 05/09/24 documented R54 had a cerebral infarction with one-sided weakness and used his wheelchair for locomotion. R54's Care Plan dated 08/27/24 documented R54 had weakness and a decrease in physical mobility related to a cerebral accident. The plan of care documented R54 required extensive assistance from one staff member for locomotion using a wheelchair. The plan of care documented the staff were to observe and report any immobility, contractures forming or worsening. The plan of care for R54 documented the nursing and restorative aide were to perform active ROM to the bilateral lower extremities for 20 minutes. Review of R54's EMR documented no indication that ROM exercises were performed. R54's EMR documented no refusals of ROM exercises. On 08/20/25 at 11:01 AM, Licensed Nurse (LN) G stated the facility does have a restorative Certified Nurse's Aide (CNA). He stated the facility had been understaffed, and the restorative aide had been pulled to the floor to work as a CNA and was unable to do her restorative duties. On 08/20/25 at 11:17 AM, CNA M stated she was the restorative aide. She stated the facility was now fully staffed, and there was a plan in place for her to start doing exercises daily with the residents. On 08/20/25 at 11:24 AM, Administrative Nurse D stated the facility had been short-staffed, and the restorative aide was not able to work as a restorative aide. She stated the facility did have a plan in place to ensure the restorative program was in place. The facility's Restorative Nursing policy, reviewed on 09/20/24, documented that the restorative program was to promote the resident's optimum function. A restorative program may be developed by proactively identifying, care planning, and monitoring of a resident's assessments and indicators. Nursing Assistants must be trained in the techniques that promote resident involvement in restorative activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 57 residents. The sample included 14 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities regarding the lack of monitoring antihypertensive (a class of medication used to treat high blood pressure) medications for Resident R10. These deficient practices placed these residents at risk for adverse medication effects and unnecessary medications.Findings included:- R10's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of adult failure to thrive, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), and hypertension (HTN- elevated blood pressure). The admission Minimum Data Set (MDS) dated 04/21/25 documented a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The MDS documented R10 required substantial to maximum assistance with her activities of daily living (ADLs). The Quarterly MDS dated [DATE] documented a BIMS score of 14, which indicated intact cognition. The MDS documented that R10 required substantial to maximum assistance with her ADLs. R10's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 04/24/25 documented she was alert and oriented and able to communicate her needs, but had cognitive impairment. R10's Care Plan, dated 04/15/25, documented staff would administer her medication as ordered by the physician. R10‘s EMR under the Orders tab revealed the following physician orders: Toprol XL (antihypertensive) oral tablet extended release 24-hour 25 milligram (mg) (metoprolol succinate), give three tablets by mouth at bedtime for chronic heart failure and high blood pressure dated 04/12/25. Review of R10's Medication Administration Record (MAR), Treatment Administration Record (TAR), and her EMR from 05/01/25 to 08/19/25 (111 days) lacked consistent heart monitoring for antihypertensive medication Toprol. Review of the Monthly Medication Review (MMR) from August 2024 to July 2025 lacked documented recommendations for heart monitoring for R10's antihypertensive medication orders for hold parameters and physician notification. On 08/19/25 at 11:41 AM, R10 laid asleep on her bed. R10 was covered with a blanket, call light was on the bed next to her. On 08/20/25 at 11:02 AM, Licensed Nurse (LN) G stated antihypertensive medication should be monitored. LN G stated that if an order lacked physician-ordered parameters, he would call and clarify the antihypertensive order. On 08/20/25 at 11:25 AM, Administrative Nurse D stated there should be monitoring for antihypertensive medication. Administrative Nurse D stated she would expect the CP to identify the lack of correct monitoring for medications.The facility's Pharmacy Services and Medication Regimen Review policy last reviewed 09/16/23 documented the facility maintains the resident's highest practicable level of physical, mental, and psychosocial well-being and prevents or minimizes adverse consequences related to medication therapy to the extent possible, by providing oversight by a licensed pharmacist, attending physician, medical director, and the director of nursing (DON).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 57 residents. The sample included 14 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to follow the pharmacist's recommendation for the monitoring of antihypertensive (a class of medication used to treat high blood pressure) medications for Resident R10. These deficient practices placed these residents at risk for adverse medication effects and unnecessary medications.Findings included:- R10's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of adult failure to thrive, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), and hypertension (HTN- elevated blood pressure). The admission Minimum Data Set (MDS) dated 04/21/25 documented a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The MDS documented R10 required substantial to maximum assistance with her activities of daily living (ADL). The Quarterly MDS dated [DATE] documented a BIMS score of 14, which indicated intact cognition. The MDS documented that R10 required substantial to maximum assistance with her ADLs. R10's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 04/24/25, documented she was alert and oriented and able to communicate her needs, but had cognitive impairment. R10's Care Plan, dated 04/15/25, documented staff would administer her medication as ordered by the physician. R10‘s EMR under the Orders tab revealed the following physician orders:Toprol XL (antihypertensive) oral tablet extended release 24-hour 25 milligram (mg) (metoprolol succinate), give three tablets by mouth at bedtime for chronic heart failure and high blood pressure, dated 04/12/25. Review of R10's Medication Administration Record (MAR), Treatment Administration Record (TAR), and her EMR from 05/01/25 to 08/19/25 (111 days) lacked consistent heart monitoring for antihypertensive medication Toprol. On 08/19/25 at 11:41 AM, R10 laid asleep on her bed. R10 was covered with a blanket, call light was on the bed next to her. On 08/20/25 at 11:02 AM, Licensed Nurse (LN) G stated antihypertensive medication should be monitored. LN G stated if an order lacked physician-ordered parameters, he would call and clarify the antihypertensive order. On 08/20/25 at 11:25 AM, Administrative Nurse D stated there should be monitoring for antihypertensive medication. Administrative Nurse D stated she would expect the CP to identify the lack of correct monitoring for medications.The facility was unable to provide policy-related medication monitoring.

The facility identified a census of 57 residents. The sample included 14 residents, with five reviewed for immunization status. Based on record reviews, and interviews, the facility failed to offer or obtain informed declinations or a physician-documented contraindication for the Pneumococcal Conjugate Vaccine (PCV20 - vaccination for bacterial infections), and pneumococcal (type of bacterial infection) vaccination for Resident (R) 1, R7, and R29. This placed the residents at increased risk for complications related to pneumonia. Findings included:- Review of R1's clinical record revealed the Pneumococcal Polysaccharide Vaccine (PPSV23) was offered and declined on 09/13/24. R2's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or physician-documented contraindication. Review of R7's clinical record revealed the Pneumococcal Polysaccharide Vaccine (PPSV23) was offered and declined on 10/07/24. R7's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or physician-documented contraindication. On 08/20/25 at 11:02 AM, Licensed Nurse (LN) G stated a resident was offered vaccination at the time of admission. LN G stated if the resident consented for any vaccinations, the vaccination would be ordered from the pharmacy. LN G stated the order would be placed on the Medication Administration Record (MAR). LN G stated the vaccination would be given upon delivery from the pharmacy and then documented in the resident's electronic medical record (EMR) under the Immunization tab. On 08/20/25 at 11:25 AM, Administrative Nurse D stated the residents were offered immunizations at the time of admission. Administrative Nurse D stated Administrative Nurse E was responsible to track and ensure the vaccinations offered. The facility's Pneumococcal Vaccine Policy for Residents policy, last reviewed 07/08/25, documented each resident would be offered pneumococcal immunization, unless the immunization was medically contraindicated, or the resident has already been immunized. There would be documentation in the medical record if there is reason to believe that pneumococcal vaccine(s) was given previously, but the date cannot be verified, and this had an impact upon the decision regarding administration of the vaccine(s).

The facility had a census of 57 residents. The sample included 15 residents, with four reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure 44 E pressurized medical oxygen tanks in a safe, locked area, and out of reach of the eight cognitively impaired, independently mobile residents. The facility further failed to ensure R2's fall interventions were in place. This deficient practice placed the residents at risk for preventable accidents and injuries.Findings Included:- On 08/18/25 at 07:56 AM, an inspection of the facility’s oxygen storage room revealed that the door was not secured. An inspection of the room revealed 44 full E-supplemental oxygen cylinders in the storage racks. The door had a keypad and did not lock when the door was shut. On 08/19/25 at 07:22 AM, an inspection of the facility’s oxygen storage room revealed that the door was not secured. An inspection of the room revealed 44 full E-supplement oxygen cylinders in the storage racks. The door had a keypad and did not lock when the door was shut. On 08/20/25 at 08:22 AM, the facility identified it had eight cognitively impaired, independently mobile residents. On 08/19/25 at 07:25 AM, Licensed Nurse (LN) H stated the oxygen room should be unlocked. On 08/20/25 at 11:17 AM, Certified Nurse’s Aide (CNA) M stated the room had been unlocked, and she was unsure if the room should be locked or unlocked. On 08/20/25 at 11:24 AM, Administrative Nurse D stated staff were expected to ensure the door was locked upon entering and exiting the room. She stated the room should always be locked. The facility’s “Oxygen Administration (Safety, Storage, Maintenance) revised 10/11/24 documented it was the policy of the facility to ensure that oxygen was administered and stored safely within the healthcare centers or in an outside storage area. - The Medical Diagnosis section within R2’s Electronic Medical Records (EMR) noted diagnoses of cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, and a history of falls. R2’s “Quarterly Minimum Data Set (MDS)” completed 06/27/25 revealed a Brief Interview for Mental Status Score of 14, indicating severe cognitive impairment. The MDS noted she had no upper or lower extremity impairments. The MDS noted she used a wheelchair for mobility. The MDS noted she required supervision or touch assistance for bed mobility, transfers, dressing, bathing, toileting, personal hygiene, and putting on footwear. The MDS noted she had a history of falls. R2’s “Falls Care Area Assessment (CAA)” completed 06/13/25 indicated she had a history of falls related to generalized weakness and her medical diagnoses. The CAA noted she used a wheelchair. The CAA indicated that a care plan was implemented to minimize her risks of falls. R2’s “Care Plan” initiated on 11/28/20 indicated she required assistance with her activities of daily living (ADL). The plan noted she had a history of falls related to her medical diagnoses. The plan indicated signage was placed in her room to “call for help”. The plan instructed staff to ensure she wore non-skid footwear before transferring. The plan indicated her room was to have non-skid traction tape placed on her bedroom and bathroom floors to prevent falls. A review of R2’s EMR under “Census” revealed she was moved to a new room on 08/01/25. The EMR indicated she had no falls since being moved to her new room. On 08/18/25 at 07:34 AM, an inspection of R2’s room revealed no traction tape or signage posted in R2’s bedroom or bathroom. On 08/20/25 at 11:17 AM, Certified Nurse’s Aide (CNA) M stated R2 recently moved room and her fall interventions should have been transferred to her new room. On 08/20/25 at 11:01 AM, Licensed Nurse (LN) G stated staff were expected to ensure the interventions were in place each shift and transfer the implemented fall interventions when a resident was moved to a new room. On 08/20/25 at 11:24 AM, Administrative Nurse D stated R2 was recently moved to a different room, and her fall interventions should have been transferred to her new room. She stated staff were expected to inspect her room and ensure the fall interventions were implemented. The facility’s “Fall Management System,” revised 03/2025, indicated the facility promoted an environment that remains free from accident hazards. The policy indicated the facility appropriately assessed and implemented interventions to prevent falls and minimize complications if falls occurred.

The facility reported a census of 57 residents. The facility identified four medication carts. Based on observations, record review, and interviews, the facility failed to secure medication at the nurse's station. This deficient practice placed the residents at risk for unnecessary medication and administration errors.Findings included:On 08/18/25 at 07:45 AM, an inspection of the 200 Hall revealed a bottle of ocular vitamins dated 07/07/25 left unsecured on the counter at the nurse's station. The bottle contained the warning Keep out of reach of children, in case of accidental overdose, get medical help or contact poison control center right away.On 08/18/25 at 07:50 AM, Licensed Nurse (LN) G secured the vitamins and stated the medications were to be locked up in the nurse's carts and not left out at the station. On 08/20/25 at 11:24 AM, Administrative Nurse D stated medications were to be locked up at all times and out of reach of the residents. The facility's Medication Access and Storage policy, revised 09/2024, indicated the facility was to ensure all medications and biologicals remained locked and secured to prevent tampering or exposure to the environment.

The facility identified a census of 57 residents. The facility had one kitchen. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to overflowing trash and food storage. This deficient practice placed the residents at risk for food-borne illness.Findings included:- During the initial tour on 08/18/25 at 07:33 AM, observation revealed the following:The kitchen floor was sticky. In the small one-door freezer, there was food wrapped in plastic wrap that appeared to be fish, unlabeled and undated. In the two-door freezer, there was a bottle of pink Minute Maid lemonade, a tub of ice cream, and a bag of cookie dough opened and undated.The green trash bins were overflowing with trash, next to the stove, uncovered. On 08/18/25 at 07:46 AM, Dietary Staff BB stated all foods should be dated and labeled. She stated the kitchen floor was sticky and would be cleaned. Dietary Staff BB stated that the trash should not be overflowing and should always be covered.The facility's Food Safety policy dated 05/01/25 documented that food was stored and maintained in a clean, safe, and sanitary manner following federal, state, and local guidelines to minimize contamination and bacterial growth.

The facility identified a census of 57 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to develop and implement the core elements of antibiotic stewardship to ensure an effective infection prevention and control program including antibiotic stewardship for the residents of the facility. Findings included: - Review of the Infection Control Log for tracking and trending infections from August 2024 through July 2025, lacked evidence of tracking and identification of possible infection outbreaks at the facility, lacked consistent identification of infection, and of antibiotic administration. The facility was unable to provide evidence of the documentation of continent documentation of the infection control surveillance from August 2024 through March 2025. On 08/19/25 at 03:23 PM, Administrative Nurse E, the facility's Infection Preventionist (IP), stated she had just started as the IP in April 2025. Administrative Nurse E stated she was unable to answer whether the previous IP had tracked the antibiotic administration, tracking, and trending of clusters of infections or organisms. The facility's Antibiotic Stewardship policy, last revised 07/22/25, documented the antibiotic stewardship program promoted the appropriate use of antibiotics and included a system of monitoring to improve resident outcomes and reduce antibiotic resistance. This meant that the antibiotic was prescribed for the correct indication, dose, and duration to appropriately treat the resident while also attempting to reduce the development of antibiotic-resistant organisms and/or other adverse events. The program would be managed and overseen by the Infection Preventionist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 66 residents. The sample included three residents reviewed for elopement (when a cognitively impaired resident with little or poor safety awareness exited the facility without staff knowledge). Based on observation, record review, and interview, the facility failed to ensure Resident (R)1 received adequate supervision and appropriate interventions to prevent R1 from exiting the facility. This placed R1 at risk for accidents or injuries. Findings include: - R1's Electronic Medical Record (EMR), under the Diagnosis tab documented diagnoses of metabolic encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), muscle weakness, abnormalities of gait and mobility, convulsions (involuntary series of contractions of a group of muscles), hypertension (elevated blood pressure), hypotension (low blood pressure), dizziness, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder. The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R1 required partial to moderate assistance from staff for transfers, and toileting. R1 required supervision or touch assistance with propelling in his wheelchair from staff. R1 had no behaviors and had not exhibited wandering. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated [DATE] documented R1 admitted to the facility for therapy for strengthening related to weakness. R1 used a wheelchair for locomotion. The Falls CAA dated [DATE] documented R1 used a wheelchair for locomotion. Staff were to encourage R1 to participate in exercises to prevent falls. The Quarterly MDS dated [DATE] documented a BIMS score of six which indicated severely impaired cognition. R1 was independent with transfers and required supervision or touching assistance from staff with showering and propelling in his wheelchair. R1 exhibited no behaviors and did not exhibit wandering. R1's Care Plan initiated [DATE] documented R1 had a history of attempting to leave the facility unattended and R1 had impaired safety awareness. R1 was added to the elopement book. Staff were directed to provide R1 safe wandering as R1 was an elopement risk. R1 had a WanderGuard (a bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) in place, and staff were directed to document the resident's wandering behavior and attempted diversional interventions in the behavior log. Staff were directed to observe R1 for behavior episodes and attempt to determine the underlying cause for the behavior; considering location, time of day, persons involved, and situations. Staff were directed to intervene as necessary to protect the rights and safety of others. Staff were to approach and or speak calmly, divert attention, remove R1 from the situation, and take R1 to an alternate location as needed. R1's locomotion intervention revised [DATE] documented that R1 was able to propel himself using his wheelchair. The Nursing: Elopement Risk Evaluation dated [DATE] documented that R1 was at risk for elopement, had a history of attempts to leave the facility unattended, and had impaired safety awareness. The Orders tab recorded a physician's order on [DATE] to check WanderGuard placement, and function, and to check for expiration date and notified Administrative Nurse D if the WanderGuard was expired every shift. R1's clinical record lacked any documentation of R1's elopement incident. The Notarized Witness Statement dated [DATE] by Licensed Nurse (LN) G documented that LN G was notified that R1 was outside in the courtyard with Certified Medication Aide (CMA) R and the door alarm was sounding. R1 was brought back into the building and taken to the side of the building R1 lived on. LN G stated she notified Administrative Nurse D. Administrative Nurse D requested LN G check R1's Wander Guard to see if it was on and working. LN G observed the Wander Guard on R1's ankle and LN G checked to verify it worked. LN G reported R1 had wandered in his wheelchair around the nurse's desk asking for cigarettes and was redirected. The Notarized Witness Statement dated [DATE] by CMA R documented CMA R heard the door alarm sounding for about a minute or two when CMA R went to check the doors. CMA R documented she went to the front door of the building before realizing it was not that door, but the door to the back patio. CMA R turned to go to the back patio door when R2 yelled that R1 was outside the gate, and R1 was opening the gate. CMA R proceeded to go out the back patio door to and retrieved R1 from the back parking lot. CMA R stated LN G came to assist with taking R1 back into the building. LN G asked CMA R if CMA R was outside with R1, to which CMA R stated no, she was responding to the alarm. On [DATE] at 04:55 PM the other gate in the courtyard, located roughly 18 steps from the back patio door, had no locking mechanism on the gate. When the gate was pushed from the inside of the courtyard the gate swung freely and revealed the back parking lot behind the building. The ground leading up to the gate was level concrete and the gate opened up to level pavement meeting up with the concrete. On [DATE] at 01:22 PM, R1 sat in his wheelchair facing the back patio door. R1 was dressed in clean clothes and had a nasal cannula on receiving oxygen. R1 had a WanderGuard on his right ankle. R1 responded when greeted and R1 stated it was a nice day but nothing further was said when questioned. R1 continued to look out the back patio door while speaking. On [DATE] at 01:53 PM LN G stated that she was called and told that R1 was in the courtyard. LN G stated that she was informed R1 had been outside the fence around the courtyard. LN G brought R1 back into the building and checked to make sure R1 was ok. LN G stated she told Administrative Nurse D that R1 was outside. Administrative Nurse D asked LN G to check if R1's Wander Guard worked. LN G called R1's family representative but did not call the physician related to LN G was waiting for further instructions from Administrative Nurse D. On [DATE] at 03:45 PM Certified Nurse Aide (CNA) M stated that she recalled R1 getting out to the courtyard and going through the gate but could not recall the day it occurred. CNA M stated that CMA R had responded to the door alarm before CNA M got there. CNA M revealed this was not the only time R1 had pushed through the back patio door without staff. CNA M further revealed he had done it another day, but CNA M was outside taking a smoke break, and met R1 at the door. On [DATE] at 04:35 PM Administrative Staff B stated that the door alarms go off all the time. Administrative Staff B stated R1 went out thru the door and R1 did go out to the parking lot. Administrative Staff B recalled CMA R going out to get R1 and the gate was open to the parking lot. On [DATE] at 04:44 PM, Housekeeper U stated that anyone could open the gate leading out of the courtyard to the parking lot. Housekeeper U revealed you just grabbed the silver thing, and it would open easily. On [DATE] at 04:55 PM the other gate in the courtyard, located roughly 18 steps from the back patio door, had no locking mechanism on the gate. When the gate was pushed from the inside of the courtyard the gate swung freely and revealed the back parking lot behind the building. The ground leading up to the gate was level concrete and the gate opened up to level pavement meeting up with the concrete. The facility Area of Focus: Elopement policy reviewed [DATE] documented an elopement occurred when the resident leaves the premises or a sage area without authorization and or any necessary supervision to do so. A resident who leaves a sage area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and or other medical complications, drowning, or being struck by a motor vehicle. The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. When the resident is found, the charge nurse or designee will assess the resident's physical, mental, emotional, and cognitive state and notify the physician and responsible party. The resident will be monitored as deemed necessary by the interdisciplinary team. An incident (event) report will be completed by the charge nurse or designee to include witness statements. The facility failed to ensure R1 received adequate supervision and appropriate interventions to prevent R1 from exiting the building without staff. This placed R1 at risk for accidents or injuries.

The facility identified a census of 63 residents. The sample included four residents. Based on observation, interview, and record review, the facility failed to accurately and thoroughly complete Minimum Data Sets (MDS) for Resident (R) 1. This placed the resident at risk for unidentified care needs. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, recorded diagnoses of traumatic subdural hemorrhage (a condition due to bleeding under the membrane covering the brain), respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide in your body), convulsions (involuntary series of contractions of a group of muscles), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Annual MDS dated 05/17/23 documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. R1 was independent with activities of daily living (ADL). R1's oral and dental status documented there were no dental concerns noted. The Dental Care Area Assessment (CAA) dated 05/17/23 did not trigger. The Quarterly MDS dated 08/17/23 lacked documentation of a BIMS performed by R1 or a staff assessment. R1's oral and dental status was not addressed on the MDS. The Quarterly MDS dated 11/17/23 documented a BIMS score of 11 which indicated moderately impaired cognition. R1's oral and dental status was not addressed on the MDS. The Quarterly MDS dated 02/16/24 documented R1 was rarely understood, and per staff interview, R1 had short- and long-term memory problems. R1 was independent of ADLs. R1's oral and dental status was not addressed on the MDS. R1's Oral Assessment completed by a dental vendor dated 04/03/23, under the Misc tab, recorded R1 had probable extensive decay, and moderate inflammation, and R1 stated all his top teeth hurt. Additional notes documented that two unidentified licensed nurses (LN) stated that R1 complained of tooth pain often and asked if the dental services could see him. The assessment documented R1 stated that all his upper teeth hurt. R1 appeared non-emergent at that time, but R1 was directed to let staff know if he started to have pain that kept R1 awake at night. R1 was to seek an appointment with an offsite dentist if the pain worsened. On 04/15/24 at 11:23 AM R1 lay in bed with his blankets pulled up to his chin. R1 appeared with a flat affect. R1 stated he told the nurses all the time that his teeth hurt. R1 then pointed at the front of his mouth and stated his front teeth hurt and the doctor was aware that his teeth hurt. R1 revealed his teeth were hurting at the time of the interview. On 04/15/24 at 12:00 PM Administrative Nurse E stated she usually went and asked the resident for the oral and dental status. Administrative Nurse E stated it could be tricky if a resident refused to open up his or her mouth. Administrative Nurse E stated she tried to talk with a resident if there was pain, trouble swallowing, or a concern with their teeth. Administrative Nurse E revealed she asked R1 about his oral and dental status, but R1 failed to answer and refused to open his mouth. Administrative Nurse E stated that she should have reviewed the Oral Assessment in R1's EMR under the Misc tab but failed to look for any documentation related to R1's teeth. Administrative Nurse E stated she should have marked R1's assessment as not assessed instead of leaving the area blank or documenting no issues. The facility stated they used the Resident Assessment Instrument (RAI) Manual for MDS direction and policy. The facility failed to develop an accurate and thorough MDS assessment related to R1's oral status. This placed the resident at risk for unidentified care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 63 residents. The sample included three residents reviewed for dental services. Based on record review, interview, and observation, the facility failed to identify and respond to Resident (R)1's dental needs which resulted in tooth pain and untreated dental issues. This deficient practice placed R1 at risk for pain and other complications related to dental issues. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, recorded diagnoses of traumatic subdural hemorrhage (a condition due to bleeding under the membrane covering the brain), respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide in your body), convulsions (involuntary series of contractions of a group of muscles), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated intact cognition. R1 was independent with activities of daily living (ADL). R1's oral and dental status documented there were no dental concerns noted. The Dental Care Area Assessment (CAA) dated 05/17/23 did not trigger. The Quarterly MDS dated 02/16/24 documented R1 was rarely understood, and per staff interview, R1 had short- and long-term memory problems. R1 was independent of ADLs. R1's oral and dental status was not addressed on the MDS. R1's Care Plan initiated 05/12/22 documented that R1 was independent with ADLs but may need stand-by assistance of supervision at times. R1's Care Plan lacked interventions related to dental care and dental monitoring. R1's Oral Assessment completed by the dental vendor dated 04/03/23, under the Misc tab, recorded R1 had probably extensive decay, and moderate inflammation, and R1 stated all his top teeth hurt. Additional notes documented that two unidentified licensed nurses (LN) stated that R1 complained of tooth pain often and asked if the dental services could see him. The assessment documented R1 stated that all his upper teeth hurt. R1 appeared non-emergent at that time, but R1 was directed to let staff know if he started to have pain that kept R1 awake at night. R1 was to seek an appointment with an offsite dentist if the pain worsened. A review of R1's assessments under the Assessments tab lacked oral assessments from 01/01/23 to 04/15/24. A review of R1's clinical record lacked evidence facility staff followed up on the dental concerns and needs identified on 04/03/23. R1's Plan of Care Progress Note dated 04/12/24 at 12:42 PM documented the social worker scheduled a dental visit with the dentist on 04/15/24 at 07:00 AM. R1 would have a Certified Nurse Aide (CNA) escort attending the appointment with him. On 04/15/24 at 11:23 AM R1 lay in bed with his blankets pulled up to his chin. R1 appeared with a flat affect. R1 stated he told the nurses all the time that his teeth hurt. R1 then pointed at the front of his mouth and stated his front teeth hurt and the doctor was aware that his teeth hurt. R1 revealed his teeth were hurting at the time of the interview. On 04/15/24 at 11:28 AM LN G stated that R1 had never complained of pain and ate his food with no issues. LN G stated that R1's appointment at the dentist was an emergency but LN G did not know what the emergency was. On 04/15/24 at 02:18 PM Administrative Nurse D stated she did not see R1's dental assessment done in April 2023 until recently. Administrative Nurse D stated that R1 had not reported any oral pain that she was aware of. Administrative Nurse D stated the dentist came to the facility for monthly cleaning for residents. The facility's Dental Services policy reviewed on 08/23/23 documented that the facility was responsible for assisting the resident in obtaining needed dental services, including routine dental services. The facility would provide or obtain from an outside resource routine and emergency dental services to meet the needs of each resident. The facility failed to identify and respond to R1's oral needs which resulted in tooth pain and untreated dental issues. This deficient practice placed R1 at risk for pain and other complications related to dental issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 69 residents. The sample included three residents. Based on record review, interview, and observation the facility failed to accommodate Resident (R) 1's need and preference for a transfer pole This placed R1 at risk of decreased mobility and impaired autonomy. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab recorded diagnoses of hemiplegia (paralysis of one side of the body), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), muscle weakness, need for assistance with personal care, and major depressive disorder (major mood disorder which causes persistent feelings of sadness). R1's admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R1 required supervision, verbal cues, or touching to help steady R1 during any form of mobility. R1 was independent with wheelchair mobility of at least 50 feet and making two turns. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 11/02/23 documented R1 was alert and oriented and communicated needs. R1 used a wheelchair for locomotion and required minimal assistance with ADLs. R1's Care Plan initiated on 10/27/23 directed staff to encourage R1 to participate to the fullest extent possible with each interaction. R1's Care Plan lacked direction on how R1 transferred, or assistance required. R1's Physical Therapy Evaluation and Plan of Treatment dated 10/25/23 documented R1 reported he used a transfer pole at his prior facility and was independent at baseline with a transfer pole. This treatment plan note documented the information was communicated to nursing staff and therapy asked about ordering and installing a transfer pole for R1. The Progress Note dated 01/25/24 at 02:39 PM documented a transfer pole was properly installed into R1's room, secured at both the ceiling and the floor. The transfer pole was assessed by Consultant HH and determined to be unstable; specifically, the middle of the pole was not safe to use for transfers. R1's EMR lacked any other documentation about a transfer pole. On 02/22/24 at 12:30 PM, Consultant GG stated to order equipment for residents, she went to Administrative Staff A or Administrative Nurse D. Consultant GG stated that if equipment had to be installed, facility maintenance would take care of that. Consultant GG revealed she worked with R1 at his previous facility, and he utilized a transfer pole there. Consultant GG stated that the facility had access to transfer poles and if a resident wanted a transfer pole. Consultant GG said transfer poles could be ordered and put up for the resident to aid in maintaining independence. Consultant GG further stated that R1 was very vocal and would tell staff what he wanted, so Consultant GG did not understand why she had not heard that R1 wanted a transfer pole. On 02/22/24 at 12:33 PM, Consultant HH stated that R1 worked on becoming independent with transfers and used the bed cane to aid his transfers in and out of bed. Consultant HH stated that R1 originally asked about a transfer pole, but after he worked with therapy on transfers in and out of bed, he did not mention it again. Consultant HH revealed she never asked if R1 wanted the transfer pole after he mentioned it at the first assessment. Consultant HH stated that when the transfer pole was brought in for R1 from an outside service, it was put up by maintenance. Consultant HH said she evaluated if the transfer pole was safe to use for R1. Consultant HH stated that the transfer pole bent in the middle due to the connection and she felt that particular transfer pole was unsafe for R1 to use. On 02/22/24 at 12:40 PM, R1 sat in his wheelchair and appeared clean. R1 stated he talked to everyone about his desire for a transfer pole, but he never received one from the facility. R1 stated he spoke with Administrative Staff A about the transfer pole. R1 said Administrative Staff A told him that the facility could not provide a transfer pole. R1 stated that when the outside service brought a transfer pole to the building for R1, he had to wait for maintenance to put the pole up and then for someone from therapy to evaluate if the pole was safe to use. R1 revealed that Consultant HH came and assessed the transfer pole, determined the pole was unsafe, and removed the pole. R1 became visibly upset as he talked about the transfer pole being removed from his room. R1 revealed that no one asked him if he wanted another transfer pole put up. R1 stated that he used the bed cane to transfer out of bed but pulling on that to get up caused his bed to slide when he transferred. On 02/22/24 at 01:15 PM Administrative Staff A stated R1 had a bed cane as an aid to transfers in and out of bed. Administrative Staff A stated she never heard that R1 wanted a transfer pole and had no idea where the idea came from. Administrative Staff A stated R1 had not requested to have a transfer pole. Administrative Staff A revealed she had not asked R1 if he wanted a transfer pole, even after the outside service had provided a transfer pole that was deemed unsafe for use. On 02/22/24 at 01:20 PM, Consultant GG stated she reviewed her communication with Consultant HH and stated Consultant HH texted when R1 arrived asking about the process to request a transfer pole for R1. Consultant GG stated she must have missed that communication. Consultant GG stated she had not asked R1 if he wanted a transfer pole. On 02/22/24 at 01:22 PM Administrative Nurse D stated she had not asked R1 if he wanted a transfer pole. The facility's policy Resident Rights reviewed 09/25/23 documented the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The resident has the right to receive the services and/or items included in the plan of care. the facility failed to accommodate R1's need and preference for a transfer pole to assist with bed transfers. This placed R1 at risk of decreased mobility and impaired autonomy.

The facility identified a census of 67 residents. The sample included 17 residents with two reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Residents (R) R13 and R24 were treated in a dignified manner. This deficient practice placed the residents at risk for decreased psychosocial well-being. Findings included: - On 01/02/24 at 10:22 AM, observation revealed R13 laid on her back, in her bed, on top of her blankets. R13 wore a top that did not fully cover her abdomen and she wore an adult incontinence brief. R13 was uncovered and her brief and bare legs were exposed and visible from the hallway. R13 stared off to her right and did not respond to questions. On 01/02/24 at 12:12 PM, an observation revealed the door to R24's room was open, and a strong urine odor was detected in her room. R24 was observed in bed, uncovered, with her pants down around her knees and she wore an adult incontinence brief. R24 was visible from the hallway. On 01/04/24 at 11:36 Certified Nurse Aide (CNA) M stated if a resident was in a brief, uncovered, with the door open, he would go into the room to help them cover up. He stated R13 was dependent on staff and would not have been able to cover herself back up if her covers were removed. CNA M stated R24 was a fall risk and staff left her door open to monitor her for falls. On 01/04/24 at 12:55 Licensed Nurse (LN) H stated R13 was dependent on staff and would have needed staff assistance to cover her if her blankets were removed. LN H stated if R13 was uncovered with her door open he would have expected staff to cover her up. LN H further stated R24 would use the bathroom on her own at times and lay in bed without pulling her pants up. LN H stated he expected staff to have gone into R24's room to help pull her pants up and cover her up. On 01/04/24 at 01:22 PM Administrative Nurse D stated she expected staff to provide privacy and ensure residents were decent if a resident was uncovered while they wore a brief, and their door was open. Administrative Nurse D further stated it was not appropriate to have left residents exposed. The facility's dignity policy with a reviewed date of 09/25/23, documented each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff, temporary agency staff, or volunteers must focus on maintaining and enhancing the resident's self-esteem, and self-worth, and incorporating the resident's goals, preferences, and choices. The facility failed to ensure R13 and R24 were treated in a dignified manner. This deficient practice placed the residents at risk for decreased psychosocial well-being.

The facility identified a census of 67 residents. The sample included 17 residents with two reviewed for accommodation of needs-related activities of daily living (ADLs). Based on record review, interviews, and observations, the facility failed to identify and correct environmental challenges to Resident (R) 42's mobility. The facility additionally failed to provide R65 a call light in his room. This deficient practice placed both residents at risk for a decline in ADLs. Findings included: - The Medical Diagnosis section within R42's Electronic Medical Records (EMR) included diagnoses of multiple sclerosis (MS- a progressive disease of the nerve fibers of the brain and spinal cord), major depressive disorder (major mood disorder), morbid obesity (severely overweight), sleep apnea (a disorder of sleep characterized by periods without respirations), and coronary atherosclerosis (mineral build-up on the walls of the heart's blood vessels). R42's Quarterly Minimum Data Set (MDS) completed 12/14/23 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS noted he was independent with bed mobility, toileting, dressing, personal hygiene, bathing, and transfers. The MDS indicated he used a crutch to assist his mobility. R42's Falls Care Area Assessment (CAA) completed 04/10/23 indicated he was at risk for falls. The CAA noted he had problems with transitioning from sitting to standing, surface-to-surface transfers, and walking. The CAA noted his multiple sclerosis increased his risk for falls. The CAA indicated he used dual canes to ambulate himself but had a left-side weakness. The CAA instructed staff to encourage him to use his call light to minimize the risks of falls. R42's Activities of Daily Living (ADLs) CAA completed 04/10/23 indicated he had problems with transitioning from sitting to standing, surface-to-surface transfers, and walking. The CAA noted his multiple sclerosis increased his risk for falls. The CAA indicated he used dual canes to ambulate himself but had a left-side weakness. R42's Care Plan initiated 03/31/23 indicated he was at risk for decreased self-care performances related to his ADLs. The plan noted he was able to transfer and ambulate himself using his own canes. The plan noted he was weight-bearing. The plan noted he had multiple sclerosis limiting his ability to complete ADLs. The plan noted he would use his canes to assist with his bed mobility. His care plan lacked documentation related to his left-side weakness. On 01/02/24 at 02:00 PM, R42 stated he had a difficult time exiting his room due to his roommate's bed blocking the right side of his bed. R42 stated he was right-side dominant and had to exit his bed using the left side of the bed. R42 reported he is weak on his left side and had difficulty maneuvering around with his dual support canes. An inspection of R42's side of the room revealed his roommate's bed was slanted inward with the foot of the bed two feet from R42's bed. R42 stood up on the left side of his bed but had difficulty maneuvering his left side to exit the bed area with his support canes. R42 had difficulty positioning his support canes due to the lack of room while exiting his bed area. 01/03/24 at 08:20 AM R42's roommate's bed was moved back towards the center of the room. R42 stated he could not exit through his right side due to the curtain next to his bed. On 01/04/24 at 11:30 AM Certified Nurses Aid (CNA) M stated R42 never reported concerns with his room size or getting out of his bed. She stated R42 was more independent than other residents and would come and go without staff assistance. On 01/04/24 at 12:03 PM, Licensed Nurse (LN) G stated she was unaware that R42 had difficulty getting in and out of his bed. ON 01/04/24 at 01:23 PM Administrative Nurse D stated all residents were screened upon admission and quarterly based on their needs and preferences. She stated R42 didn't alert the facility that he had difficulty in his room. A review of the facility's Activities of Daily Living policy revised 08/2023 stated the facility will ensure an environment that assists with providing care and maintaining independence. The policy indicated each resident will be comprehensively assessed for their specific individualized care needs and provided a therapeutic environment. The facility failed to identify and correct environmental challenges to R42's mobility. This deficient practice placed the resident at risk for a decline in ADLs and impaired mobility. - The Medical Diagnosis section within R65's Electronic Medical Records (EMR) included diagnoses of dysphagia (difficulty swallowing), cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), history of falling, hemiparesis (muscular weakness of one half of the body), hemiplegia (paralysis of one side of the body), and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, mask-like faces, shuffling gait, muscle rigidity and weakness). R65's Quarterly MDS completed 12/14/23 noted a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. The MDS noted he was independent for oral hygiene, meals, toileting, dressing, and bed mobility. The MDS indicated he weighed 138 lbs. but had no weight loss. The MDS failed to identify he was edentulous or his choking concerns. R65's Activities of Daily Living (ADLs) CAA completed 09/13/23 identified he was at risk for an ADL decline related to his severe cognitive impairment and medical diagnoses. The CAA instructed staff to provide ADL care assistance when needed and ensure his call light remained within reach to prevent falls or injuries. R65's Care Plan initiated on 09/08/23 indicated he was at risk for nutritional impairment related to his severe cognitive impairment, physical limitations, difficulty chewing/swallowing, and Parkinson's disease. The plan instructed staff to provide his diet as ordered, weigh him as ordered, provide mouth care daily, and ensure his call light remained within reach (09/11/23). The plan noted he required set-up and supervision assistance during meals. On 01/02/24 at 02:30 PM, R65 reported his call light button was removed from his room on Friday and never returned. An inspection of the room revealed no call light button installed on his side of the room. At 02:45 PM staff were alerted that R65's call light was not in his room. At 02:47 PM Licensed Nurse (LN) H light and Maintenance Staff U were notified of the call missing for R65. Maintenance Staff U replaced the light immediately. LN H stated the light may have been broken and removed by the weekend staff. On 01/04/24 at 11:33 AM, Administrative Nurse D stated staff should be checking to ensure the call lights were within reach and functioning during each interaction. She stated if a call light was out or not functioning the resident should be checked on in frequent intervals until it could be replaced. The facility's Resident Call System policy revised 01/2022 indicated the communication system will be maintained and function accordingly to ensure resident safety and needs are met. The policy indicated call light buttons should be always positioned within reach of the resident. The facility failed to ensure R65 had a functioning call light button installed in his room. This deficient practice placed R65 at risk for preventable accidents and delayed care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 67 residents. The sample included 17 residents with five residents reviewed for nutrition. Based on record review, interviews, and observations, the facility failed to notify Resident (R)13's physician and representative regarding a weight loss and/or change in health condition. This placed R13 at risk for continued weight loss and malnutrition due to delayed physician and representative involvement. Findings included: - R13's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of legal blindness, and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). The admission Minimum Data Set (MDS) dated [DATE] documented the Brief Interview for Mental Status (BIMS) assessment was unable to be completed. The MDS documented R13 had problems with recall ability and short-term and long-term memory. The MDS further documented R13 had severely impaired decision-making ability and never/rarely made decisions. The MDS documented R13 was dependent on staff for all activities of daily living (ADL) including repositioning and transfers. R13's Cognitive Loss / Dementia Care Area Assessment (CAA) dated 11/23/23 documented R13 was alert to name and had difficulty following commands. The CAA further documented R13 required total care with ADL and was unable to answer questions during BIMS assessment. R13's Nutritional Status CAA dated 11/23/23 documented R13 required staff to feed her due to being legally blind. R13's Care Plan with an initiated date of 11/20/23, documented R13 had a nutrition risk. R13's Care Plan with a goal initiated on 11/20/23, documented R13 would consume greater than 75% of meals and would maintain weight without significant weight changes through the review date. R13's Care Plan with an intervention initiated on 11/20/23, directed staff to weigh R13 monthly and record the results. A review of the EMR under the Weights/Vitals tab revealed an admission weight of 236.0 pounds (lbs.) on 11/16/23, a second weight of 232.0 lbs. taken on 12/02/23 and a third weight of 213.9 taken on 01/01/24 which indicated a loss of 9.36% in less than 90 days for R13. R13's EMR lacked evidence that she was weighed more than three times since her admission date on 11/16/23 or that her weight, taken on 01/01/23, of 213.9 lbs. was re-checked or addressed by the facility. R13's EMR lacked evidence that she refused to have her weight obtained. R13's EMR lacked evidence the physician or R13's representative was notified regarding the change in her health status and weight loss. On 01/03/24 at 12:27 PM R13 laid in in her room in bed. On 01/04/24 at 11:36 AM Certified Nurse Aide (CNA) M stated the CNAs obtained the weights and took the information back to the nurses. He stated the nurses would then review and compare them to what was done previously. CNA M stated the nurses provided a list of the residents who needed a weight for the CNAs to use so they would know who needed one. On 01/04/24 at 12:55 PM, LN H stated if there was a change in weight after a re-weigh, then he would notify the physician, Administrative Nurse D, and the dietitian for it to be addressed. LN H stated the nurse would have entered a progress note in the resident's EMR after notifying the physician, Administrative Nurse D, and the dietitian. LN H stated R13 was unable to refuse and depended on staff to provide for all her needs. On 01/04/24 at 01:22 PM Administrative Nurse D stated new admissions were weighed weekly for at least four weeks and then, if they were consistent in their weights, changed to monthly weights. Administrative Nurse D further stated if the resident lost weight, the physician and dietitian would be notified, and any recommendations given by the dietician would be followed. The facility did not provide a policy for notification of changes. The facility failed to notify R13's physician and representative regarding weight loss and/or change in health condition. This placed R13 at risk for continued weight loss and malnutrition due to delayed physician and representative involvement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 67 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to provide written notification to the long-term care ombudsman (LTCO) for Resident (R) 28 and R6. The facility failed to provide notice of transfer as soon as practicable to R6 or their representative. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunities for healthcare service for R28 and R6. Findings included: - The electronic medical record (EMR) for R28 documented diagnosis of hypertension (elevated blood pressure), chronic respiratory failure (when not enough oxygen passes from the lungs to the blood), and bradycardia (low heart rate, less than 60 beats per minute). The Annual Minimum Data Set (MDS) for R28 dated 07/03/23 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R28 was independent to limited assistance for activities of daily living (ADLs). The Quarterly MDS dated 10/03/23 documented R28 had a BIMS score of 15 which indicated intact cognition. R28 was independent with functional abilities. The ADLs Care Area Assessment (CAA) dated 07/03/23 documented R28 had a functional deficit due to a history of stroke and required supervision. R28 was alert and oriented and was encouraged by staff to participate in self-care to promote quality of life. R28's Discharge Status Care Plan last revised on 06/15/23 directed staff that R28's guardian wished for the resident to remain in the facility long term. Staff was to encourage the resident's guardian to discuss feelings and concerns with impending discharge. R28's Kansas Nursing Home Transfer and Discharge Notice dated 11/28/23 documented R28 was sent out to the hospital for further evaluation required by the emergency department as her needs could not be met in the facility. This notification was given to the resident as she was her own responsible party. R28's Kansas Nursing Home Transfer and Discharge Notice dated 12/14/23 documented R28 was sent out to the hospital for further evaluation required by the emergency department as her needs could not be met in the facility. This notification was given to the resident as she was her own responsible party. Upon request, the facility was unable to provide evidence the facility notified the LTCO of the facility-initiated discharges. On 01/03/24 at 08:23 AM R28 sat in her wheelchair and propelled herself down the hall to the dining area for breakfast. On 01/04/23 at 11:05 AM Administrative Staff A stated she did not believe that notification was emailed or sent to the ombudsman. Administrative Staff A stated either she or Administrative Nurse D would call to notify the ombudsman of discharges and/or transfers. On 01/04/23 at 1:22 PM Administrative Nurse D stated that family representatives and the ombudsman were called by herself or Administrative Staff A when a resident transferred and/or discharged . The Notice of Transfers and Discharges policy reviewed 08/10/23 documented that when a resident was temporarily transferred on an emergency basis to an acute care facility, notice of transfer may be provided to the resident and the resident representative as soon as practicable before the transfer. Copies of notices for emergency transfers must also still be sent to the ombudsman but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the lists meet all the requirements for content. The facility failed to provide written notification of transfer with the required information to the LTCO for R28 in a practicable amount of time, or at least monthly. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunities for healthcare service for R28. - R6's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of asthma (a disorder of narrowed airways that causes wheezing and shortness of breath) and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The Quarterly MDS dated 12/27/23 documented a BIMS score of 15 which indicated intact cognition. R6's Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 11/24/23 documented R6 was able to communicate her needs and was independent with ADLs. R6's Care Plan dated 11/15/21 documented that staff would allow R6 to make decisions about her treatment regime. A review of the EMR under the Progress Notes tab documented a Transfer to Hospital Summary Note dated 01/05/23 at 09:32 AM R6 was transferred to the hospital for evaluation. The facility was unable to provide written notification of the transfer and admission to the hospital. On 05/31/23 at 03:30 AM a Health Status Note documented R6 was transferred to the hospital for evaluation. The facility was unable to provide written notification of transfer and admission to the hospital. On 6/20/23 at 06:05 AM an Alert Note documented R6 was transferred to the hospital for evaluation. The facility was unable to provide written notification of transfer and admission to the hospital. The facility was also unable to provide evidence the LTCO was notified of the transfers. Observation on 01/03/24 at 09:38 AM R21 sat on the couch in the common area and watched TV. On 01/04/24 at 09:13 AM Administrative Staff A stated she was unable to locate written notification of transfer and admission to the hospital to the resident or her legal representative. Administrative Staff A stated the social service department was responsible for sending the written notification of transfer to the legal representatives. On 01/04/24 at 01:22 PM Administrative Nurse D stated the nurse would notify the legal representatives by phone after the resident was sent to the hospital and documented in the resident's clinical record. The facility's Notice of Transfers and Discharges policy last reviewed on 08/10/23 documented that the facility ensured that systems are implemented to provide written notification to the resident and resident representative. This written notification was provided on the Notice of Resident Discharge or Transfer Form. This information would be presented in a language and manner that the resident /resident representative could understand. The facility failed to provide written notification of the reason and location for the transfer to the hospital to R6 or her representative. This deficient practice placed R6 at risk of miscommunication and uninformed decisions.

The facility identified a census of 67 residents. The sample included 17 residents with 17 reviewed for care plan revisions. Based on observation, record review, and interviews, the facility failed to revise Resident (R)42's care plan to reflect the use of his personal knee braces. This deficient practice placed R42 at risk for impaired care due to uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R42's Electronic Medical Records (EMR) included diagnoses of multiple sclerosis (MS- a progressive disease of the nerve fibers of the brain and spinal cord), major depressive disorder (major mood disorder), morbid obesity (severely overweight), sleep apnea (a disorder of sleep characterized by periods without respirations), and coronary atherosclerosis (mineral build-up on the walls of the heart's blood vessels). R42's Quarterly Minimum Data Set (MDS) completed 12/14/23 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS noted he was independent with bed mobility, toileting, dressing, personal hygiene, bathing, and transfers. The MDS indicated he used a crutch to assist his mobility. R42's Falls Care Area Assessment (CAA) completed 04/10/23 indicated he was at risk for falls. The CAA noted he had problems with transitioning from sitting to standing, surface-to-surface transfers, and walking. The CAA noted his multiple sclerosis increased his risk for falls. The CAA indicated he used dual canes to ambulate himself but had a left-side weakness. The CAA instructed staff to encourage him to use his call light to minimize the risks of falls. R42's Activities of Daily Living (ADLs) CAA completed 04/10/23 indicated he had problems with transitioning from sitting to standing, surface-to-surface transfers, and walking. The CAA noted his multiple sclerosis increased his risk for falls. The CAA indicated he used dual canes to ambulate himself but had a left-side weakness. R42's Care Plan initiated 03/31/23 indicated he was at risk for decreased self-care performances related to his ADLs. The plan noted he was able to transfer and ambulate himself using his own canes. The plan noted he was weight-bearing. R42's plan lacked documentation related to bilateral knee braces he applies himself daily. A review of R42's EMR revealed no assessments, physician's orders, or progress notes indicating he wore knee braces. On 01/02/24 at 01:34 PM, R42 walked down the main hall to his room. R42 had knee braces on both knees. On 01/02/24 at 02:00 PM, R42 stated he wore knee braces on both his knees to help him support his positioning. R42 stated that he puts the braces on himself and takes them off when not ambulating. R42 stated he was not sure if the facility had informed staff that he wears the braces or needs staff assistance to apply them correctly. On 01/03/24 at 12:45 PM, Consultant HH stated she was not sure if the knee braces were care planned but would notify the nursing department for assessment. On 01/04/24 at 11:30 AM Certified Nurses Aid (CNA) M stated R42 often dressed himself and ambulated without staff assistance. He was not sure if R42's knee braces required staff assistance to put on. On 01/04/24 at 12:03 PM, Licensed Nurse (LN) G stated she was aware R42 wore braces but she did not think they were medically necessary. She stated he always put them on himself and never voiced concerns about needing staff help. ON 01/04/24 at 01:23 PM Administrative Nurse D stated the care plans should reflect the resident's current treatments, interventions, and preferences related to daily care. She stated R42 has been set up with a therapy evaluation for the braces. The facility's Care planning policy revised 12/2022 indicated the facility will be updated showing the residents' individualized care needs and the level of assistance required to achieve the highest practicable level of function. The policy noted the facility will provide ongoing assessment and updated interventions to meet the needs of the residents. The facility failed to revise R42's care plan to reflect the use of his personal knee braces. This deficient practice placed R42 at risk for impaired care due to uncommunicated care needs.

The facility identified a census of 67 residents. The sample included 17 residents with four reviewed for maintaining activities of daily living (ADL). Based on observation, record review, and interviews, the facility failed to provide the necessary level of assistance for Resident (R)65 during mealtime to maintain his abilities. This deficient practice placed R65 at risk for impaired nutrition and a decline in his ADL. Findings Included: - The Medical Diagnosis section within R65's Electronic Medical Records (EMR) included diagnoses of dysphagia (difficulty swallowing), cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), history of falling, hemiparesis (muscular weakness of one half of the body), hemiplegia (paralysis of one side of the body), and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, mask-like faces, shuffling gait, muscle rigidity and weakness). R65's admission Minimum Data Set (MDS) completed 09/13/23 noted he weighed 142 pounds (lbs.) and was edentulous ( no natural teeth). The MDS indicated he was at risk for coughing or choking during meals or when swallowing. R65's Quarterly MDS completed 12/14/23 noted a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. The MDS noted he was independent for oral hygiene, meals, toileting, dressing, and bed mobility. The MDS indicated he weighed 138 lbs. but had no weight loss. The MDS failed to identify he was edentulous or his choking concerns. R65's Nutrition Care Area Assessment (CAA) completed 09/13/23 indicated he was at risk for malnutrition and on a mechanically altered diet. The CAA identified he had swallowing concerns related to his medical diagnoses. R65's Activities of Daily Living (ADLs) CAA completed 09/13/23 identified he was at risk for an ADL decline related to his severe cognitive impairment and medical diagnoses. The CAA instructed staff to provide ADL care assistance when needed and ensure his call light remained within reach to prevent falls or injuries. R65's Dental CAA completed 09/13/23 indicated he was edentulous and had difficulty chewing his food. The CAA identified he was at risk for poor nutrition. R65's Care Plan initiated on 09/08/23 indicated he was at risk for nutritional impairment related to his severe cognitive impairment, physical limitations, difficulty chewing/swallowing, and Parkinson's disease. The plan instructed staff to provide his diet as ordered, weigh him as ordered, provide mouth care daily, and ensure his call light remained within reach (09/11/23). The plan noted he required set-up and supervision assistance during meals. On 01/02/24 at 08:22 AM R65 sat in his room and ate his breakfast. R65 had scrambled eggs and sausage patties. Staff were not present in his room during meal service. R65 had no call light mounted on his side of the room. R65 reported that sometimes the kitchen served meals he could not eat due to him not having teeth. He stated the kitchen usually sent sausage links that were difficult to chew. Staff were not present to monitor R65 during his meal. On 01/03/24 at 01:05 PM, R65 sat off the side of his bed and had his lunch on the bedside table. R65 coughed several times then spit out apple slices from his mouth. R65 attempted to eat another slice of apple pie and spit it out. He stated he could not eat the pie because the slices were rubber and hard to chew. An inspection of the slices revealed them to be hard to cut with silverware. Staff were not present with R65 during his meal. On 01/04/24 at 11:33 AM, Certified Nurses Aid (CNA) M stated R65 usually ate independently in his room without issues. He stated R65 did have a soft chew diet due to him being edentulous but was not sure if he required supervision during meals. He stated that R65 could express his needs if needed. He stated if a plan required supervision of a resident during meals, staff should be present during the meal. On 01/04/24 at 11:33 AM, Administrative Nurse D stated staff were expected to ensure each resident's orders and planned interventions were being followed. She stated if the care plan stated R65 required supervision during mealtimes staff should either be checking on him frequently or with him. A review of the facility's Activities of Daily Living policy revised 08/2023 stated the facility will ensure an environment that assists with providing care and maintaining independence. The policy indicated each resident will be comprehensively assessed for their specific individualized care needs and provided a therapeutic environment. The facility failed to provide the necessary level of assistance for R65 during mealtime to maintain his abilities. This deficient practice placed R65 at risk for impaired nutrition and a decline in his ADL.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R13's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of legal blindness, and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). The admission Minimum Data Set (MDS) dated [DATE] documented the Brief Interview for Mental Status (BIMS) assessment was unable to be completed. The MDS documented R13 had problems with recall ability and short-term and long-term memory. The MDS further documented R13 had severely impaired decision-making ability and never/rarely made decisions. The MDS documented R13 was dependent on staff for all activities of daily living (ADL) including repositioning and transfers. R13's Cognitive Loss / Dementia Care Area Assessment (CAA) dated 11/23/23 documented R13 was alert to name and had difficulty following commands. The CAA further documented R13 required total care with ADL and was unable to answer questions during the BIMS assessment. R13's Care Plan with an initiated date of 11/2/23, documented R13 had a self-care deficit due to limited mobility. R13's Care Plan documented an intervention dated 11/24/23 which directed staff R13 was totally dependent on two staff for repositioning and turning in bed and was dependent upon staff for all ADLs. On 01/02/24 at 10:22 AM, observation revealed R13 laid on her back, in her bed, on top of her blankets. R13 wore a top that did not fully cover her abdomen and she wore an adult incontinence brief. R13 was uncovered and her brief and bare legs were exposed and visible from the hallway. R13 stared off to her right and did not respond to questions. On 01/04/24 at 11:36 Certified Nurse Aide (CNA) M stated if a resident was in a brief, uncovered, with the door open, he would go into the room to help them cover up. He stated R13 was dependent on staff and would not have been able to cover herself back up if her covers were removed and staff should have assisted her with her covers. On 01/04/24 at 12:55 Licensed Nurse (LN) H stated R13 was dependent on staff and would have needed staff assistance to cover her if her blankets were removed. LN H stated if R13 was uncovered with her door open he would have expected staff to cover her up. On 01/04/24 at 01:22 PM Administrative Nurse D stated she expected staff to provide each resident with the care and assistance they required. The facility's Activities of Daily Living (ADLs) policy last reviewed on 08/2/23 documented the resident would receive assistance as needed to complete activities of daily living (ADLs). The facility failed to provide R13 with the necessary ADL care and assistance she required. This placed the resident at risk for impaired quality of life and decreased dignity and comfort. The facility identified a census of 67 residents. The sample included 17 residents with seven residents reviewed for activities of daily living (ADLs). Based on observations, record reviews, and interviews, the facility failed to provide consistent bathing opportunities for Residents (R)53 and R46. The facility additionally failed to provide ADL assistance to R13, a resident totally dependent on staff assistance for all ADL. These deficient practices placed the residents at risk of decreased psycho-social well-being and impaired ADL. Findings Included: - The Medical Diagnosis section within R53's Electronic Medical Records (EMR) included diagnoses of vitamin B insufficiency, anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), hemiplegia (paralysis of one side of the body), hemiparesis (weakness and paralysis on one side of the body), muscle weakness, abnormalities of gait and mobility. A review of R53's Quarterly Minimum Data Set (MDS) completed 10/10/23 noted a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. The MDS indicated he required supervision or touch assistance during personal hygiene, toileting, and bathing. The MDS indicated he was occasionally incontinent of bowel and bladder but had no toileting program in place. The MDS indicated no falls. R53's Urinary Incontinence Care Area Assessment (CAA) completed 04/12/23 indicated he had occasional urinary incontinence. The CAA indicated he used a portable urinal and staff were to provide checks and changes to prevent skin breakdown. R53's Falls CAA completed 04/12/23 noted he had bilateral lower extremity weakness with impaired balance. The CAA noted he was a fall risk and instructed staff to keep his bed in the lowest position and ensure his call light was within reach. The CAA noted he used a wheelchair for locomotion and required assistance from staff for his activities of daily living. R53's Care Plan initiated 03/31/23 indicated he was at risk for skin impairment, ADL self-care deficits, and falls related to his medical diagnoses. The plan noted he required limited assistance from staff for bathing, bed mobility, personal hygiene, and transfers. The plan indicated he preferred to be bathed twice weekly. The plan indicated he was incontinent and used a urinal and staff were to provide peri-care as needed. The plan indicated he used a portable urine and sometimes emptied it in the trash can (04/04/23). The plan also indicated he would place his urine-soaked incontinence briefs on the floor or trash can. The plan indicated R53 had a fall on 12/04/23 attempting to reach for his portable urinal. The plan instructed staff to keep his urinal within reach and use his call light (12/04/23). The plan lacked individualized interventions to maintain and promote R44's highest level of functioning related to incontinence. The plan failed to address his bowel incontinence. A review of R53's Documented Survey Report for December 2023 indicated he did not receive bathing opportunities from 12/20/23 through 01/01/24. The report lacked refusal entries. On 01/02/24 at 07:14 R53's room smelled heavily of urine. On 01/02/24 at 09:42 AM R53 reported the facility was not consistently offering bathing to him. He stated the facility assisted him during bathing due to his history of falls. He stated he had not received bathing the previous week. R53's hair was uncombed and greasy. He stated he showered last night but went over a week without one. On 01/04/24 at 11:33 AM Certified Nurses Aid (CNA) M stated R53 required limited assistance during bathing due to his balance issues. He stated each resident received two showers per week based on their preferred days. He stated bathing was documented on the shower sheet and put into the EMR system under tasks. He stated bathing refusals should also be documented after multiple attempts to complete the task. CNA M said R53 rarely refused bathing but should be documented in the EMR. On 01/04/24 at 12:30 PM, Licensed Nurse (LN) G stated bathing should be documented as completed, refused, or not available. She stated that missed bathing opportunities should be rescheduled to the next available time slot. On 01/04/24 at 01:34 PM Administrative Nurse D stated staff were expected to ensure each resident's bathing preferences were followed. She stated she expected staff to offer bathing opportunities multiple times and reschedule them if the resident was not available or preferred a different time. She stated documentation should not be left blank or incomplete and should always indicate if a bath occurred or was rescheduled. A review of the facility's Activities of Daily Living policy revised 08/2023 stated that bathing opportunities provided to the residents promote cleanliness, comfort, and provide observations of the resident's skin. The policy noted that all bathing should be documented in the resident's EMR. The policy noted that if a resident refuses to bath the staff will notify the nurse. The facility failed to provide consistent bathing opportunities for R53. This deficient practice placed him at risk for infections, decreased psycho-social well-being, and impaired ADLs.- R46's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), chronic pain, and muscle weakness. The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of five which indicated severely impaired cognition. The MDS documented that R46 required extensive assistance from one staff member for activities of daily living (ADLs). The MDS documented R46 required supervision for bathing during the observation period. The Quarterly MDS dated 12/08/23 documented a BIMS score of zero which indicated severely impaired cognition. The MDS documented that R46 required partial/moderate assistance with bathing during the observation period. R46's ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 09/21/23 documented R46 had generalized weakness and required assistance with ADLs. R46's Care Plan dated 09/14/23 documented that staff would provide a sponge bath when R46 was unable to tolerate a full bath/shower. R46's Care Plan dated 09/15/23 documented R46 required maximum assistance from staff for bathing/showering at least twice weekly and as needed. Review of the EMR under Documentation Survey Reports tab for bathing reviewed for the following dates for R37 from 10/01/23 to 01/01/24 (93 days) documented Not Applicable (NA) on 37 days on 10/01/23, 10/02/23, 10/04/23, 10/07/23, 10/08/23, 10/11/23, 10/18/23, 10/20/23, 10/21/23, 10/22/23, 10/31/23, 11/01/23,11/04/23, 11/05/23, 11/10/23, 11/14/23, 11/17/23, 11/18/23, 11/19/23, 11/22/23, 11/26/23, 11/28/23, 12/01/23, 12/02/23, 12/04/23, 12/06/23, 12/08/23, 12/11/23, 12/12/23, 12/15/23, 12/18/23, 12/21/23, 12/22/23, 12/25/23, 12/26/23, 12/29/23, and 01/01/23. The clinical record lacked evidence of R46's refusals for bathing or a bed bath was given. Observation on 01/03/24 at 09:42 AM R46 lay on his right side in bed. R46's room smelled of urine. On 01/04/24 at 12:08 PM Certified Nurse Aide (CNA) N stated R46 never refused his bath. CNA N stated R46 was given a bed bath frequently since his return from the hospital. CNA N stated the bath or the refusal to bath would be charted in the residents' EMR. On 01/04/24 at 12:19 PM, Licensed Nurse (LN) G stated she was not aware of R46's refusal to bathe. LN G stated since R46's return from a recent hospital stay he was assisted by staff with bed baths. On 01/04/24 at 01:22 PM Administrative Nurse D stated she expected staff to document the resident's EMR what care was provided or the refusal of care. Administrative Nurse D stated she would expect staff to report refusal of care such as bathing to the charge nurse, so the cause of refusal was investigated. The facility's Activities of Daily Living (ADLs) policy last reviewed on 08/2/23 documented the resident would receive assistance as needed to complete activities of daily living (ADLs). Any change in the ability to perform ADLs would be documented and reported to the licensed nurse. A resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility failed to provide consistent bathing for R46 who required assistance with bathing. This deficient practice placed R46 at risk for complications related to poor hygiene and impaired dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 67 residents. The sample included 17 with two reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R)60's low air-loss mattress pump was set up to his appropriate weight requirements and failed to provide wound care per R60's ordered treatment. The facility additionally failed to assess R8's pressure wounds upon admission. This deficient practice placed R60 and R8 at risk for complications related to skin breakdown and pressure ulcers. Findings Included: - The Medical Diagnosis section within R60's Electronic Medical Records (EMR) included diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), and osteomyelitis (local or generalized infection of the bone and bone marrow). A review of R60's admission Minimum Data Set (MDS) completed on 12/08/23 noted a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. The MDS indicated he was dependent on staff assistance for bed mobility, bathing, toileting, and transfers. The MDS indicated he had a stage four pressure ulcer (a deep wound that reaches the muscles, ligaments, or even bone). The MDS noted treatments of pressure-reducing devices, nutrition management, wound care, and non-surgical dressings were in place to treat his pressure ulcer. R60's Pressure Ulcer Care Area Assessment (CAA) completed 12/18/23 indicated he was at risk for skin breakdown and admitted to the facility with a pressure injury to his coccyx (area at the base of the spine). The CAA noted he required assistance with mobility, repositioning, and toileting. The CAA noted he was frequently incontinent of bowel and bladder related to his medical diagnoses. The CAA noted he used a pressure-reducing mattress while in bed. R60's Activities of Daily Living (ADLs) CAA completed 12/18/23 indicated he had moderate cognitive impairment but was able to understand others and express his needs. The CAA noted he required assistance with ADLs and mobility. R60's Nutritional CAA completed 12/18/23 indicated he was at risk for impairment related to his stage four pressure ulcer, cognitive loss, poor memory, and limited mobility. The CAA noted he was at risk for malnutrition. R60's Care Plan initiated on 12/01/23 indicated he was at risk for malnutrition, ADL self-care deficits, skin breakdown, and pressure ulcer development. The plan noted he had a pressure injury on his coccyx upon admission. The plan instructed staff to provide treatment as ordered, complete weekly skin checks, and ensure peri-care was provided related to incontinence. The plan instructed staff to weigh R60 per his orders due to the risk of malnutrition. The plan indicated he had a pressure-reducing mattress but did not provide guidance for the low air-loss mattress settings. R60's EMR revealed an admission Wound assessment completed 12/02/23 indicating he had a stage four pressure ulcer upon admission on his coccyx measuring 1.0 centimeters (cm) in length, 1.5cm in width, and no depth (1.0cm x 1.5cm x 0cm). R60's EMR revealed a Weekly Wound Observation completed on 12/29/23 that indicated the coccyx wound measured 1.9cm in length, 2.0cm in width, and 0.4cm in depth. The observation revealed he was seen by a plastic surgeon and would continue wound care. The observation noted he had a low air-loss mattress and wheelchair cushion in place. R60's EMR under Physician's Orders noted on the order dated 12/01/23 for a low air-loss mattress for skin integrity. The order did not identify R60's low-air-loss mattress pump settings. R60's EMR under Physician's Orders noted a wound care order dated 12/29/23 for staff to apply calcium alginate (dressing which forms a soft, gel that absorbs when it comes into contact with wound exudate) to his coccyx one time daily and cover with a foam dressing. A review of R60's Medication Administration Record (MAR) indicated the dressing was not completed on 01/01/24. A review of the EMR revealed no notes indicating the status of the treatment on 01/01/24. R60's EMR indicated he weighed 239 pounds (lbs.) on 01/01/24. A review of R60's low air-loss mattress manufacturer operation (Drive Model 14030) recommendations indicated the mattress accommodated residents up to 600 lbs. in weight. The operation manual indicated the air mattress inflated based on the resident's weight. The manual indicated the mattress pressure increased based on the heavier the weight settings. On 01/02/24 at 10:02 AM R60 rested in his bed. R60's low air-loss mattress was set to 500 lbs. with 30-minute air inflation intervals. R60 reported the facility weighed him but not every week. He stated the facility sometimes missed his daily wound care. On 01/04/24 at 07:45 AM Licensed Nurse (LN) G stated the air mattress settings were based upon the weight of R60. She stated the settings should either be listed on the care plan or in the order. She stated she was not sure why the machine was set to 500 lbs. She stated all wound treatment should be documented in the MAR after completion and was not sure why R60's treatment was not completed on 01/01/24. On 01/04/24 at 08:05 AM Administrative Nurse E stated the low air-loss mattresses with weight settings should be set according to the resident's weight and should be noted in the care plans for each resident if they preferred the mattress firmer or softer. Administrative Nurse E stated R60 preferred the setting of the bed to be firmer. On 01/04/24 at 01:30 PM Administrative Nurse D said the mattress setting should be based on R60's weight and comfort levels. She stated she was not sure why R60's calcium alginate treatment was not completed on 01/01/24. A review of the facility's Wound Prevention Policy revised 03/2023 noted the facility would ensure effective treatment to prevent and manage pressure ulcers. The policy indicated staff will closely monitor residents at risk for skin breakdown and pressure injury to ensure appropriate interventions are placed. The policy noted the facility will implement interventions to include routine skin assessments/care, proper positioning, heel protection, adequate nutrition/hydration, and pressure redistribution devices. The facility failed to ensure R60's low air-loss mattress pump was set up to his appropriate weight requirements and failed to provide wound care per R60's ordered treatment. This deficient practice placed R60 at risk for complications related to skin breakdown and pressure ulcers. - The electronic medical record (EMR) for R8 documented diagnoses of pressure ulcer of the buttock, altered mental status, and severe malnutrition (when the body does not get enough nutrients). The admission Minimum Data Set (MDS) dated 11/10/23 for R8 documented R8 had both short and long-term memory problems. R8 had severely impaired cognitive skills for daily decision-making. R8 displayed inattention and disorganized thinking. R8 was dependent on staff for all functional abilities. R8 had unhealed pressure ulcers on admission; one stage 3 (full thickness pressure injury extending through the skin into the tissue below) and two unstageable (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus) deep tissue injury (DTI- purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear). The Pressure Ulcer Care Area Assessment (CAA) dated 11/15/23 for R8 documented she had long-standing urinary incontinence and had unhealed pressure wounds. R8 was dependent on all care and bed/chair bound. Staff anticipated with all care, wound treatment was in place, low air mattress was in place. The Pressure Ulcers Care Plan initiated on 11/06/23 and revised on 11/08/23 for R8 directed staff to do weekly skin checks. Staff was to do treatments as ordered. Staff was to ensure R8 had a pressure-reducing mattress. R8's 10/31/23 hospital paperwork found in the paper chart documented R8 had a pressure injury of the right and left buttock stage three, and unstageable pressure ulcers to the right and left buttocks. Under the Assessments tab of R8's EMR documented a Braden Scale-For Predicting Pressure Sore Risk and Risk Factors assessment dated [DATE]. R8 was at high risk for pressure sores. R8 had risk factors that included decreased or impaired bed/chair mobility, an existing pressure ulcer, and urinary or bowel incontinence. The Order Summary Report for R8 documented a physician's order dated 11/06/23 to cleanse the coccyx (area at the base of the spine) and buttock open area and apply a foam dressing daily and as needed. A Weekly Skin Integrity Data Collection dated 11/13/23 documented an open area and treatment in place for a wound to the right buttock and sacrum (large triangular bone/area between the two hip bones). A Wound Observation Tool dated 11/14/23 for R8 documented a pressure wound on her right buttock that measured four centimeters (cm) in length, two cm with, and a depth of one cm. A Recommended Plan of Treatment by hospice dated 11/17/23 for R8 documented: Consult received for evaluation and treatment recommendations for multiple wounds to the sacrum, buttocks, and bilateral hips. R8 was recently admitted to hospice on 11/09/23. R8's EMR and paper chart lacked documentation of weekly skin/wound assessments and measurements from admission on [DATE] to 11/13/23. On 01/03/24 at 12:55 PM, R8 reclined in her Broda chair (specialized wheelchair with the ability to tilt and recline) in the unit's TV area, her daughter and grandson was visiting her. R8 was noted to be smacking her lips and constantly moving her jaw. On 01/04/23 at 10:43 AM Licensed Nurse (LN) H stated upon admission all residents should have a baseline skin assessment completed. LN H stated skin assessments should be done weekly by the nurse and documented in the EMR under assessments. LN H stated if a resident had pressure ulcers present on admission those should be noted when the skin assessment was done. LN H stated R8 was receiving wound care treatments from hospice currently. On 01/04/23 at 1:22 PM Administrative Nurse D stated skin assessments should be performed by the admitting nurse on admission and weekly thereafter. Administrative Nurse D was unaware that R8's skin/wounds had not been assessed on admission. Administrative Nurse D stated she was aware R8 was on hospice and that hospice was providing the wound care treatment for R8. The Skin Integrity & Pressure Ulcer/Injury Prevention and Management policy reviewed 03/31/23 documented: A comprehensive skin inspection/assessment on admission and re-admission to the center may identify pre-existing signs of possible deep tissue damage already present. A skin assessment/inspection occurred on admission/re-admission. Skin observations also occurred throughout points of care provided by the certified nurse aides (CNA) during daily care. CNAs would report to the nurse any changes or open areas identified. The nurse would complete further inspection/assessment and provide treatment if needed. A risk assessment tool (Braden Scale) determined the resident's risk for pressure injury development. A skin assessment/inspection should be performed weekly by a licensed nurse. The facility failed to ensure R8, who was admitted with pressure ulcers received the proper care to avoid the decline of a deep tissue injury and new development of a pressure injury/ulcer. This deficient practice placed R8 at risk for further skin breakdown and possible infection development.

The facility identified a census of 67 residents. The sample included 17 residents with one reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to assess ongoing patterns of incontinence to establish bowel and bladder patterns in order to identify measures to maintain or improve Resident (R)53's incontinence. This deficient practice placed R53 at risk for complications related to incontinence. Findings included: - The Medical Diagnosis section within R53's Electronic Medical Records (EMR) included diagnoses of vitamin B insufficiency, anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), hemiplegia (paralysis of one side of the body), hemiparesis (weakness and paralysis on one side of the body), muscle weakness, and abnormalities of gait and mobility. A review of R53's Quarterly Minimum Data Set (MDS) completed 10/10/23 noted a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. The MDS indicated he required supervision or touch assistance during personal hygiene, toileting, and bathing. The MDS indicated he was occasionally incontinent of bowel and bladder but had no toileting program in place. R53's Urinary Incontinence Care Area Assessment (CAA) completed 04/12/23 indicated he had occasional urinary incontinence. The CAA indicated he used a portable urinal and staff were to provide checks and changes to prevent skin breakdown. R53's Falls CAA completed 04/12/23 noted he had bilateral lower extremity weakness with impaired balance. The CAA noted he was a fall risk and instructed staff to keep his bed in the lowest position and ensure his call light was within reach. The CAA noted he used a wheelchair for locomotion and required assistance from staff for his activities of daily living (ADLs). R53's Care Plan initiated 03/31/23 indicated he was at risk for skin impairment, ADL self-care deficits, and falls related to his medical diagnoses. The plan noted he required limited assistance from staff for bathing, bed mobility, personal hygiene, and transfers. The plan indicated he was incontinent, used a portable urinal, and provided peri-care as needed. The plan indicated he sometimes emptied his portable urinal out in the trash can (04/04/23). The plan also indicated he would place his urine-soaked incontinence briefs on the floor or trash can (04/04/23). The plan instructed staff to keep his urinal within reach and use his call light (12/04/23). The plan lacked individualized interventions to maintain and promote R44's highest level of functioning related to incontinence. The plan failed to address his bowel incontinence needs. A review of R53 EMR indicated no bowel and bladder incontinence-related assessments were completed since admission to establish toileting patterns for increased incontinence. A review of R53's EMR under Documentation Survey Report between 11/01/23 and 01/04/24 indicated ongoing incontinence episodes of bowel and bladder. On 01/02/24 at 07:14 R53's room smelled heavily of urine. R53 rested asleep in his wheelchair next to the door. On 01/02/24 at 09:42 AM R53 reported that he had issues with both bowel and bladder incontinence. He reported that the facility did not have individualized toileting interventions for him. He stated staff will not offer restroom breaks in the evening or wake him up at night. On 01/04/24 at 11:30 PM, Certified Nurse Aid (CNA) M stated R53 would usually take himself to the bathroom or use his portable urinal. CNA M stated staff were to ensure his urinal and call light were within reach and provide him assistance as needed. He stated residents with incontinence issues should also be provided opportunities to use the restroom during the night to prevent them from falling out of bed. He stated residents were offered every two hours and provided care if needed. On 01/04/24 at 12:05 PM Licensed Nurse (LN) G stated residents with incontinence should be provided frequent toileting opportunities. She stated R53 often will take himself to the toilet. She stated staff should ensure R53's call light and portable urinal are within reach before he goes to bed. She stated the residents are assessed upon admission and provided interventions to maintain their ADLs. On 01/04/24 at 01:30 PM Administrative Nurse D stated each resident was assessed upon admission for the type and level of incontinence and provided interventions to maintain or improve their incontinence. She stated interventions should include frequent checks and toileting, dietary review, and interventions to prevent skin breakdown. The facility's Urinary Incontinence Management policy dated 08/2023 indicated all residents will be evaluated for bowel and bladder incontinence. The policy noted that pattern evaluations will be provided to residents for individualized continence management programs. The facility indicated the facility will identify factors related to incontinence including patterns, incontinence type, risk factors, and medically relevant diagnoses to provide effective treatment. The facility failed to assess ongoing patterns of incontinence to establish bowel and bladder patterns to maintain or improve R53's incontinence. This deficient practice placed R53 at risk for complications related to incontinence

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R13's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of legal blindness, and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). The admission Minimum Data Set (MDS) dated [DATE] documented the Brief Interview for Mental Status (BIMS) assessment was unable to be completed. The MDS documented R13 had problems with recall ability and short-term and long-term memory. The MDS further documented R13 had severely impaired decision-making ability and never/rarely made decisions. The MDS documented R13 was dependent on staff for all activities of daily living (ADL) including repositioning and transfers. R13's Cognitive Loss / Dementia Care Area Assessment (CAA) dated 11/23/23 documented R13 was alert to name and had difficulty following commands. The CAA further documented R13 required total care with ADL and was unable to answer questions during the BIMS assessment. R13's Nutritional Status CAA dated 11/23/23 documented R13 required staff to feed her due to being legally blind. R13's Care Plan with an initiated date of 11/20/23, documented R13 had a nutrition risk. R13's Care Plan with a goal initiated on 11/20/23, documented R13 would consume greater than 75% of meals and would maintain weight without significant weight changes through the review date. R13's Care Plan with an intervention initiated on 11/20/23, directed staff to weigh R13 monthly and record the results. A review of the EMR under the Weights/Vitals tab revealed an admission weight of 236.0 pounds (lbs) on 11/16/23, a second weight of 232.0 lbs taken on 12/02/23 and a third weight of 213.9 taken on 01/01/24 which indicated a loss of 9.36% in less than 90 days for R13. R13's EMR lacked evidence that she was weighed more than three times since her admission date on 11/16/23 or that her weight, taken on 01/01/23, of 213.9 lbs. was re-checked or addressed by the facility. R13's EMR lacked evidence that she refused to have her weight obtained. On 01/03/24 at 12:45 PM, an unidentified staff member attempted to feed R13 in her room. R13 was observed turning her head away when the unidentified staff member tried to give her a bite of food. The unidentified staff member brought in another staff and verified that R13 had refused to eat the offered meal before removing R13's food tray from the room. On 01/04/24 at 11:36 AM Certified Nurse Aide (CNA) M stated the CNAs obtained the weights and took the information back to the nurses. He stated the nurses would then review and compare them to what was done previously. CNA M stated the nurses provided a list of the residents who needed a weight for the CNAs to use so they would know who needed one. On 01/04/24 at 12:18 PM Licensed (LN) G stated Dietary BB would notify the registered dietitian (RD) of any weight loss and the RD would address the loss. LN G stated weights were typically done weekly or monthly; however, if a resident refused a weight, it would be documented in the resident's EMR. On 01/04/24 at 12:55 PM LN H stated new admits were supposed to be weighed daily for three days then change to weekly weights and then change to monthly weights from there. He stated that he was unsure how long the resident would have been on weekly weights before they were changed to monthly. LN H stated nurses compared new weights to the previous ones documented and if there was a change, the resident would have been re-weighed. LN H further stated if there was still a change in weight after a re-weigh, then he would notify the physician, Administrative Nurse D, and the dietitian for it to be addressed. LN H stated the nurse would have entered a progress note in the resident's EMR after notifying the physician, Administrative Nurse D, and the dietitian. LN H stated R13 was unable to refuse and depended on staff to provide for all her needs. On 01/04/24 at 01:22 PM Administrative Nurse D stated new admissions were weighed weekly for at least four weeks and then, if they were consistent in their weights, changed to monthly weights. Administrative Nurse D further stated if the resident lost weight, the physician and dietitian would be notified, and any recommendations given by the dietician would be followed. The facility's Resident at Risk policy revised on 04/25/23, documented the facility would review weights of new admissions for a minimum of one week to determine residents' baseline weight and stability. The facility failed to monitor R13's weights per acceptable standards of practice upon R13's admission. This deficient practice placed R13 at risk for continued weight loss and possible malnutrition. The facility identified a census of 67 residents. The sample included 17 residents. Based on observation, record review, and interviews, the facility failed to complete weekly weight monitoring as ordered by the physician for Resident (R)60 and failed to weigh R13 weekly upon admission per acceptable standards of practice. This deficient practice placed both residents at risk for complications related to weight loss. Findings Included: - The Medical Diagnosis section within R60's Electronic Medical Records (EMR) included diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), and osteomyelitis (local or generalized infection of the bone and bone marrow). A review of R60's admission Minimum Data Set (MDS) completed on 12/08/23 noted a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. The MDS indicated he was dependent on staff assistance for bed mobility, bathing, toileting, and transfers. The MDS noted he weighed 241 pounds (lbs.) upon admission with no swallowing concerns. R60's Activities of Daily Living (ADLs) CAA completed 12/18/23 indicated he had moderate cognitive impairment but was able to understand others and express his needs. The CAA noted he required assistance with ADLs and mobility. R60's Nutritional CAA completed 12/18/23 indicated he was at risk for impairment related to his stage four pressure ulcer, cognitive loss, poor memory, and limited mobility. The CAA noted he was at risk for malnutrition. R60's Care Plan initiated on 12/01/23 indicated he was at risk for malnutrition, ADL self-care deficits, skin breakdown, and pressure ulcer development. The plan instructed staff to provide treatment as ordered, complete weekly skin checks, and ensure peri-care was provided related to incontinence. The plan instructed staff to provide his diet and complete weighing him as ordered. R60's EMR indicated a Physician's Order date of 12/01/23 for staff to complete weekly weights every Sunday. R60's EMR indicated he weighed 240.5 lbs. upon admission [DATE]) and 239 lbs. on 01/01/24. No other weights were recorded in his EMR. R60's EMR lacked evidence the resident refused to be weighed. On 01/02/24 at 10:02 AM R60 rested in his bed. R60's low air-loss mattress was set to 500 lbs. with 30-minute air inflation intervals. R60 reported the facility weighed him but not every week. He stated the facility sometimes missed his daily wound care. On 01/04/24 at 11:30 AM Certified Nurses Aid (CNA) M stated staff completed weights on the residents based on their physician's orders. He stated direct care staff weighed the residents and entered the weights in the EMR. He stated the nurses were alerted of any changes. He stated refusals should be documented in the EMR. He stated if R60 refused, it should have been documented in the EMR or a nursing progress note. On 01/04/24 at 11:50 AM Licensed Nurse (LN) G stated each resident's weight was entered in the EMR and reviewed by the nursing staff. She stated if a resident was at risk, the facility completed more frequent weight checks and alerted the dietician for review. She stated if a resident refused weights the nurse would be alerted. She stated a progress note would be completed showing why the refusal occurred and the weights would be rescheduled. On 01/04/24 at 01:30 PM Administrative Nurse D stated the direct care staff were expected to complete the weights assigned to them or notify the nurse if not completed. She stated the nurses' progress notes should identify when cares were not being completed and why. She stated attempts to reschedule the weighing to another time should be attempted. A review of the facility's Physician's Orders policy revised 03/10/23 indicated the facility will ensure all physician's orders including medications, treatments, dietary, labs, and special procedures are followed based upon the physician's recommendations. The facility failed to complete weekly weight checks per R60's physician's orders. This deficient practice placed R60 at risk for complications related to weight loss.

The facility identified a census of 67 residents. The sample included 17 residents with two reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to maintain and store Resident (R)42's continuous positive airway pressure device (CPAP - ventilation device that blows a gentle stream of air into the nose to keep airway open during sleep) equipment in a sanitary manner. This deficient practice placed R42 at risk for complications related to respiratory infections. Findings Included: - The Medical Diagnosis section within R42's Electronic Medical Records (EMR) included diagnoses of multiple sclerosis (MS- a progressive disease of the nerve fibers of the brain and spinal cord), major depressive disorder (major mood disorder), morbid obesity (severely overweight), sleep apnea (a disorder of sleep characterized by periods without respirations), and coronary atherosclerosis (mineral build-up on the walls of the heart's blood vessels). R42's Quarterly Minimum Data Set (MDS) completed 12/14/23 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS noted he was independent with bed mobility, toileting, dressing, personal hygiene, bathing, and transfers. The MDS indicated he used a crutch to assist his mobility. The MDS indicated he used a continuous positive airway pressure device. The MDS noted he was on an antibiotic medication (medication used to treat bacterial infections). R42's Falls Care Area Assessment (CAA) completed 04/10/23 indicated he was at risk for falls. The CAA noted he had problems with transitioning from sitting to standing, surface-to-surface transfers, and walking. The CAA noted his multiple sclerosis increased his risk for falls. The CAA indicated he used dual canes to ambulate himself but had a left-side weakness. The CAA instructed staff to encourage him to use his call light to minimize the risks of falls. R42's Activities of Daily Living (ADLs) CAA completed 04/10/23 indicated he had problems with transitioning from sitting to standing, surface-to-surface transfers, and walking. The CAA noted his multiple sclerosis increased his risk for falls. The CAA indicated he used dual canes to ambulate himself but had a left-side weakness. R42's Care Plan initiated 03/31/23 indicated he was at risk for decreased self-care performances related to his ADLs. The plan noted he was able to transfer and ambulate himself using his own canes. The plan noted he was weight-bearing and able to ambulate himself. The plan noted he used a CPAP device for his sleep apnea (04/04/23). The plan instructed staff to apply his mask while going to bed or napping. The plan noted he had pneumonia (inflammation of the lungs) (12/11/23). The plan instructed staff to complete good hand hygiene techniques during care and encourage R42 to use disposable tissue for sneezing. The plan instructed staff to monitor his breathing and lung sounds. The plan indicated he received antibiotic therapy for his pneumonia (12/11/23). The plan lacked instructions to clean or maintain his CPAP. R42's EMR under Physician's Orders revealed he received Rocephin (antibiotic medication) ten-day treatment for pneumonia from 12/09/23 through 12/19/23. R42's Physician's Orders indicated staff were to clean R42's CPAP water reservoir with warm soapy water weekly and fill the CPAP humidifier with distilled water every night before use. R42's Treatment Administration Record reviewed from 10/01/23 to 01/04/23 indicated his CPAP and water reservoir were signed as being cleaned each night and refilled with distilled water. On 01/02/24 at 01:10 PM, R42's CPAP and oxygen tubing were hung above his bed. No barrier bag was used to prevent contamination. R43 reported he was never offered a bag to put his respiratory equipment in when not in use. He stated the staff never cleaned his CPAP mask or the machine's reservoir. An inspection of the mask revealed it to be soiled with debris. The machine's water reservoir was empty with brown dust/stains on the inside of it. He stated staff had not filled the reservoir before offering it to him. He stated he recently got sick with pneumonia and believed it was caused by the lack of cleaning for his mask. From 01/02/23 through 01/04/23 R43's mask remained hung above his bed, unbagged and open to air, and the reservoir remained empty with debris inside it. On 01/04/24 at 11:33 AM Certified Nurses Aid (CNA) M stated all respiratory equipment should be stored within a bag when not in use. She stated the CPAP machines should be cleaned frequently and charted in the EMR. She stated R43 was more independent and usually took care of his own equipment. On 01/04/24 at 12:30 PM Licensed Nurse (LN) G stated R43's CPAP machine should be cleaned weekly and refilled with water every two/three days. She stated the masks should be stored in a bag when not in use to prevent contamination. On 01/04/24 at 01:34 PM Administrative Nurse D stated she expected staff to ensure the proper storing and cleaning of oxygen equipment. She stated the CPAP mask should be stored in clean bags. A review of the facility's Oxygen Administration/Storage/Maintenance policy reviewed 09/2023 indicated oxygen will be administered in accordance with the physician's orders and current standards of practice. The policy indicated oxygen supplies will be changed weekly and when visibly soiled with dates indicating placement. The policy indicated oxygen tubing and masks were to be stored in provided bags to prevent environmental contamination or infections. The facility failed to maintain and store R42's CPAP equipment in a sanitary manner. This deficient practice placed R42 at risk for complications related to respiratory infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 67 residents. The sample included 17 residents with two residents reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to monitor Resident (R) 55's access site for signs of infection, and bleeding, and failed to obtain communication from the dialysis center and assess post-dialysis. These deficient practices placed R55 at risk of potential adverse outcomes and physical complications related to dialysis. Findings included: - R55's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of end-stage renal disease (ESRD-a terminal disease of the kidneys), dementia (progressive mental disorder characterized by failing memory, confusion), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Significate Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented that R55 was dependent on two staff members' assistance for activities of daily living (ADLs). The MDS documented R55 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication during the observation period. The MDS documented R46 received dialysis during the observation period. The Quarterly MDS dated 12/08/23 documented a BIMS score of zero which indicated severely impaired cognition. The MDS documented that R55 received antipsychotic medication during the observation period. The MDS documented R46 received dialysis during the observation period. R55's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 09/20/23 documented R55 was incontinent of bladder. R55's Care Plan dated 11/11/22 documented staff would observe for bleeding at the dialysis access site. A review of the EMR under the Orders tab revealed the following physician orders: Emergency care- if bleeding from the shunt, apply pressure and call 911 as needed dated 04/12/23. R55's clinical record lacked evidence of daily assessment for redness or signs of infection at the dialysis access site. Dialysis patient: Receives dialysis on Tuesday, Thursday, and Saturday dated 05/17/23. A review of R55's EMR clinical record from 12/01/23 to 12/31/23 revealed two dialysis communication sheets dated 12/05/23 and 12/21/23, which lacked evidence of communication from the dialysis provider, and a post-dialysis was completed upon return from dialysis for R55. The facility was unable to provide dialysis communication sheets for the following dates 12/02/23, 12/07/23, 12/09/23, 12/12/23,12/14/23, 12/165/23,12/198/23,23/23/23,12/26/23, 12/28/23, and 12/30/23. R55's EMR lacked evidence the dialysis provider was contacted by the facility for a verbal report. Observation on 01/03/24 at 09:37 AM R55 lay with his eyes closed on his bed. His bilateral lower extremities rested directly on the mattress. On 01/04/23 at 12:19 PM, Licensed Nurse (LN) G stated the night nurse or the Certified Medication Aide would obtain R55's vital signs prior to leaving for dialysis. LN G stated night sift would fill out the dialysis communication sheet and place the sheet in R55's dialysis bag. LN G stated the nurse would contact the dialysis provider if the communication sheet did not return. LN G stated if a verbal report was given by the dialysis, the nurse would document the report in the EMR under the Progress Notes tab. On 01/04/23 at 01:22 PM Administrative Nurse D stated R55's dialysis communication sheet was sent with him to dialysis and if the communications sheet was not returned or not filled out the nurse should contact the dialysis provider and receive a verbal report. Administrative Nurse D stated a post-assessment was to be completed upon R55's return from dialysis and documented on the dialysis communication sheet. Administrative Nurse D stated R55's dialysis access site should be assessed for infection every shift and documented on the Treatment Administration Record (TAR). The facility's Area of Focus: Dialysis policy last revised on 11/23/23 documented that the facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. The facility would assess for any signs/symptoms of infection, such as redness or edema at the vascular access site. Document in the clinical nursing record: dialysis treatment completed, order changes, condition of shunt site, complaints from resident (if applicable), and whether physician and responsible party notification. Document any pertinent or relevant observations and information including compliance/non-compliance with food and fluid restrictions. The facility failed to monitor R55's dialysis access site for signs of infection, bleeding, and the status of the dressing in place and failed to obtain communication from the dialysis center and assess post-dialysis. These deficient practices placed R55 at risk of potential adverse outcomes and physical complications related to dialysis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 67 residents. The sample included 17 residents with five sampled for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of blood pressure and pulse monitoring for Resident (R)32 before administration of Cozaar (an antihypertensive medication used to treat high blood pressure and heart failure) as ordered by the physician. The facility failed to ensure the CP identified and reported R28's blood pressure and pulse lacked monitoring as the physician ordered. The CP did not identify and report R55 was on an antipsychotic (class of medications used to treat major mental conditions that cause a break from reality) medication which lacked an appropriate indication for use or the required physician documentation. This deficient practice placed R32, R28, and R55 at risk for unnecessary medications and possible adverse side effects. Findings included: - The electronic medical record (EMR) for R32 documented diagnosis of hypertension (elevated blood pressure), and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid). The Annual Minimum Data Set (MDS) for R32 dated 11/24/23 documented a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. R32 was independent to supervision for functional abilities. R32 utilized a manual wheelchair for mobility. R32 was administered an antiplatelet (a medication that prevents blood clots) medication. The Activities of Daily Living (ADLs) Functional Care Area Assessment (CAA) dated 12/12/23 documented R32 had a BIMS score of 14 which indicated no cognitive impairment. R32 needed assistance from staff with ADLs and mobility. R32's Hypertension Care Plan last revised 06/09/22 directed staff to administer medications as ordered. Staff was directed to obtain blood pressure readings as ordered and communicate noted abnormalities with the physician. The Order Summary for R32 documented a physician's order dated 06/07/22 for Cozaar 50 milligram (mg) tablet daily for hypertension. Hold for systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) less than 110 milliliters of mercury (mm Hg) and/or a pulse less than 60 and notify the physician. The Order Summary for R32 documented a physician's order dated 06/07/23 for parameters to notify the physician if R32'sblood pressure was greater than 160/100 mm Hg or less than 90/60 mm Hg every day and evening shift. R32's October 2023 Medication Administration Record (MAR) lacked evidence staff monitored the blood pressure and pulse before Cozaar administration on 28 of 31 opportunities and lacked an evening measurement before administration on 31 out of 31 opportunities. R32's November 2023 MAR lacked physician-ordered blood pressure or pulse monitoring on 60 of 60 opportunities. R32's December 2023 MAR lacked physician-ordered blood pressure or pulse monitoring on 62 of 62 opportunities. R32's Monthly Medication Regimen Review (MRR) revealed the CP made no recommendations or identified any irregularities regarding the lack of monitoring of R32's blood pressure and pulse. On 01/03/24 at 12:45 PM 32 sat in her wheelchair at the dining table and ate lunch. On 01/04/24 at 12:55 PM, Licensed Nurse (LN) H stated that he only received the pharmacy recommendations after they had been reviewed by the director of nursing and given to the nurses to make the changes as needed. On 01/04/24 at 01:22 PM Administrative Nurse D stated that the CP did monthly MRRs and would send the recommendations to her and the physician. Administrative Nurse D stated when the responses were received back from the physician, she reviewed them and then sent them on to each unit for the nurses to address. The facility LTC Facility's Pharmacy Services and Procedures Manual last revised 08/17/23 documented that the CP would conduct MRRs if required under a Pharmacy Consultant Agreement and would make recommendations based on the information available in the residents' health record. The facility and CP would follow guidance outlined in the CMS State Operations Manual Appendix PP and current practice guidelines, for the appropriate provision of pharmaceutical care. The attending physician should address the CP's recommendations no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation. The facility failed to ensure the CP identified and reported R32 lacked physician-ordered blood pressure and pulse readings before the administration of Cozaar. This deficient practice placed R32 at risk for unnecessary medications and possible adverse side effects. - The electronic medical record (EMR) for R28 documented diagnosis of hypertension (elevated blood pressure), chronic respiratory failure (when not enough oxygen passes from the lungs to the blood), and bradycardia (low heart rate, less than 60 beats per minute). The Annual Minimum Data Set (MDS) for R28 dated 07/03/23 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R28 was independent to limited assistance for activities of daily living (ADLs). The Quarterly MDS dated 10/03/23 documented R28 had a BIMS score of 15 which indicated intact cognition. R28 was independent with functional abilities. The ADLs Care Area Assessment (CAA) dated 07/03/23 documented R28 had a functional deficit due to a history of stroke and required supervision. R28 was alert and oriented and was encouraged by staff to participate in self-care to promote quality of life. R28's Cardiovascular Status Care Plan last revised 06/15/23 directed staff to administer medications as ordered. Staff was directed to obtain blood pressure readings as ordered and communicate noted abnormalities with the physician. The Order Summary for R28 documented a physician's order dated 08/02/22 for blood pressure parameters. Notify the physician if blood pressure is more than 160/100 milliliters (mm) of mercury (Hg) or less than 90/60 mm/Hg every day and evening shift. The December 2023 Medication Administration Record (MAR) for R28 documented a physician's order dated 12/04/23 for Cozaar 25 milligrams (mg) tablet daily for hypertension. Hold for systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) less than 110 mm Hg and/or a pulse less than 60 and notify the physician. The December 2023 MAR for R28 documented a physician's order dated 12/04/23 for Cardizem (a calcium channel blocker used to treat high blood pressure and chest pain)120 mg capsule daily for hypertension. Hold and notify the physician for SBP below 110 mm/Hg or pulse below 60. R28's October 2023 Treatment Administration Record (TAR) lacked evidence staff monitored the blood pressure and pulse as the physician ordered on 31 out of 31 evening opportunities. R28's November 2023 TAR lacked evidence of the physician-ordered blood pressure or pulse monitoring on 30 of 30 evening opportunities. R28's December 2023 TAR lacked evidence of the physician-ordered blood pressure or pulse monitoring on 27 of 27 evening opportunities. R28's Monthly Medication Regimen reviews (MRRs) for the past year (December 2022 to December 2023) revealed the CP failed to identify and report that R28's blood pressure and pulse were not being monitored as ordered. On 01/03/24 at 08:23 AM R28 sat in her wheelchair and propelled herself down the hall to the dining area for breakfast. On 01/04/24 at 12:55 PM, Licensed Nurse (LN) H stated that he only received the pharmacy recommendations after they had been reviewed by the director of nursing and given to the nurses to make the changes as needed. On 01/04/24 at 01:22 PM Administrative Nurse D stated that the CP did monthly MRRs and would send the recommendations to her and the physician. Administrative Nurse D stated when the responses were received back from the physician she reviewed them and then sent them on to each unit for the nurses to address. The facility LTC Facility's Pharmacy Services and Procedures Manual last revised 08/17/23 documented that the CP would conduct MRRs if required under a Pharmacy Consultant Agreement and would make recommendations based on the information available in the residents' health record. The facility and CP would follow guidance outlined in the CMS State Operations Manual Appendix PP and current practice guidelines, for the appropriate provision of pharmaceutical care. The attending physician should address the CP's recommendations no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation. The facility failed to ensure the CP identified and reported R28 lacked physician-ordered blood pressure and pulse monitoring before the administration of Cozaar. This deficient practice placed R28 at risk for unnecessary medications and possible adverse side effects. - R55's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of end-stage renal disease (ESRD-a terminal disease of the kidneys), dementia (progressive mental disorder characterized by failing memory, confusion), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Significate Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented that R55 was dependent on two staff members' assistance for activities of daily living (ADLs). The MDS documented R55 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication during the observation period. The Quarterly MDS dated 12/08/23 documented a BIMS score of zero which indicated severely impaired cognition. The MDS documented that R55 received antipsychotic medication during the observation period. R55's Psychotropic Drug Use Care Area Assessment (CAA) dated 09/20/23 documented R55 received psychotropic medication and was at risk for adverse side effects. R55's Care Plan dated 11/18/22 documented the facility would consult with the pharmacist and physician to consider dose reduction of psychotropic medication when clinically indicated or at least quarterly. A review of the EMR under the Orders tab revealed the following physician orders: Risperidone (antipsychotic) oral tablet 0.25 milligrams (mg) give one tablet by mouth at bedtime related to dementia for four weeks dated 12/22/23. A review of the Monthly Medication Review (MMR) from January 2023 to December 2023 lacked evidence of recommendations for physician documentation for risk versus benefits for the continued use of the antipsychotic medication for R37 with a diagnosis of dementia and Alzheimer's disease. Observation on 01/03/24 at 09:37 AM R55 lay with eyes closed on his bed. His bilateral lower extremities rested directly on the mattress. On 01/04/24 at 12:19 PM Licensed Nurse (LN) G stated antipsychotic medication was given to residents with dementia if they had behaviors and for yelling out. LN G stated she did not review the MMRs because the director of nursing usually handled them. On 01/04/24 at 01:22 PM Administrative Nurse D stated a resident taking psychotropic medication would have a dose reduction and documentation for the continued use if the resident had a diagnosis of dementia. The facility's Medication Regimen review policy last revised on 08/17/23 documented the Consultant Pharmacist would conduct MRRs if required under a Pharmacy Consultant Agreement and would make recommendations based on the information available in the residents' health records. The facility and Consultant Pharmacist would follow guidance outlined in the CMS State Operations Manual Appendix PP and current practice guidelines, for the appropriate provision of pharmaceutical care. The facility failed to ensure the CP noted and recommended the need for a physician-documented rationale for the continued use of the antipsychotic medication for R55 who had a diagnosis of dementia. This deficient practice placed R55 at risk for unnecessary psychotropic medication and related complications.

The facility identified a census of 67 residents. The sample included 17 residents with five sampled for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 32's physician-ordered blood pressure and pulse were monitored prior to the administration of Cozaar (an antihypertensive medication used to treat high blood pressure and heart failure). The facility failed to ensure R28's blood pressure and pulse were monitored as the physician ordered. This deficient practice placed R32 and R28 at risk for unnecessary medications and possible adverse side effects. Findings included: - The electronic medical record (EMR) for R32 documented diagnosis of hypertension (elevated blood pressure), and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid). The Annual Minimum Data Set (MDS) for R32 dated 11/24/23 documented a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. R32 was independent to supervision for functional abilities. R32 utilized a manual wheelchair for mobility. R32 was administered an antiplatelet (a medication that prevents blood clots) medication. The Activities of Daily Living (ADLs) Functional Care Area Assessment (CAA) dated 12/12/23 documented R32 had a BIMS score of 14 which indicated no cognitive impairment. R32 needed assistance from staff with ADLs and mobility. R32's Hypertension Care Plan last revised 06/09/22 directed staff to administer medications as ordered. Staff was directed to obtain blood pressure readings as ordered and communicate noted abnormalities with the physician. The Order Summary for R32 documented a physician's order dated 06/07/22 for Cozaar 50 milligram (mg) tablet daily for hypertension. Hold for systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) less than 110 milliliters of mercury (mm Hg) and/or a pulse less than 60 and notify the physician. The Order Summary for R32 documented a physician's order dated 06/07/23 for parameters to notify the physician if R32'sblood pressure was greater than 160/100 mm Hg or less than 90/60 mm Hg every day and evening shift. A review of R32's October 2023 Medication Administration Record (MAR) lacked evidence staff monitored the blood pressure and pulse prior to Cozaar administration on 28 of 31 opportunities and lacked an evening measurement prior to administration on 31 out of 31 opportunities. Review of R32's November 2023 MAR lacked the physician-ordered blood pressure or pulse monitoring on 60 of 60 opportunities. Review of R32's December 2023 MAR lacked the physician-ordered blood pressure or pulse monitoring on 62 of 62 opportunities. On 01/03/24 at 12:45 PM R32 sat in her wheelchair at the dining table and ate lunch. On 01/04/24 at 12:55 PM, Licensed Nurse (LN) H stated that R32's blood pressure and pulse should still be monitored. LN H stated at times R32 refused to get her blood pressure taken, but that should be documented by the nurse or whoever was obtaining the blood pressure and the physician should be notified as well. LN H could not say why R32's blood pressure was not monitored as it should have been. On 01/04/24 at 01:22 PM Administrative Nurse D stated that R32's blood pressure and pulse should be monitored as ordered. Administrative Nurse D could not say why R32's blood pressure and pulse had not been monitored as ordered but said she would talk to her staff to make sure it was done now. The facility's Administration of Medications policy revised on 02/13/23 documented the facility would ensure medication was administered safely and appropriately per physician order to address resident's diagnoses and signs and symptoms. The facility failed to ensure that R32's physician ordered blood pressure and pulse was monitored prior to the administration of Cozaar. This deficient practice placed R32 at risk for unnecessary medications and possible adverse side effects. - The electronic medical record (EMR) for R28 documented diagnosis of hypertension (elevated blood pressure), chronic respiratory failure (when not enough oxygen passes from the lungs to the blood), and bradycardia (low heart rate, less than 60 beats per minute). The Annual Minimum Data Set (MDS) for R28 dated 07/03/23 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R28 was independent to limited assistance for activities of daily living (ADLs). The Quarterly MDS dated 10/03/23 documented R28 had a BIMS score of 15 which indicated intact cognition. R28 was independent with functional abilities. The ADLs Care Area Assessment (CAA) dated 07/03/23 documented R28 had a functional deficit due to a history of stroke and required supervision. R28 was alert and oriented and was encouraged by staff to participate in self-care to promote quality of life. R28's Cardiovascular Status Care Plan last revised 06/15/23 directed staff to administer medications as ordered. Staff was directed to obtain blood pressure readings as ordered and communicate noted abnormalities with the physician. The Order Summary for R28 documented a physician's order dated 08/02/22 for blood pressure parameters. Notify the physician if blood pressure is more than 160/100 milliliters of mercury (mm Hg) or less than 90/60 mm Hg every day and evening shift for blood pressure. The December 2023 Medication Administration Record (MAR) for R28 documented a physician's order dated 12/04/23 for Cozaar 25 milligrams (mg) tablet daily for hypertension. Hold for systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) less than 110 mm Hg and/or a pulse less than 60 and notify the physician. The December 2023 MAR for R28 documented a physician's order dated 12/04/23 for Cardizem (a calcium channel blocker used to treat high blood pressure and chest pain)120 mg capsule daily for hypertension. Hold and notify the physician for SBP below 110 mm Hg or pulse below 60. R28's October 2023 Treatment Administration Record (TAR) lacked evidence staff monitored the blood pressure and pulse as the physician ordered on 62 out of 62 opportunities. R28's November 2023 TAR lacked evidence of the physician-ordered blood pressure or pulse monitoring on 60 of 60 opportunities. R28's December 2023 TAR lacked evidence of the physician-ordered blood pressure or pulse monitoring on 27 of 27 opportunities. On 01/03/24 at 08:23 AM R28 sat in her wheelchair and propelled herself down the hall to the dining area for breakfast. On 01/04/24 at 12:55 PM Licensed Nurse (LN) H stated he was not aware that R28's blood pressure and pulse should have been monitored prior to her hospitalization. LN H stated at times R28's blood pressure was obtained prior to the administration of her Cozaar and Cardizem since her return from the hospital in December. LN H could not say why R28's blood pressure was not monitored as it should have been. On 01/04/24 at 01:22 PM Administrative Nurse D stated that R28's blood pressure and pulse should be monitored as ordered. Administrative Nurse D could not say why R28's blood pressure and pulse were not monitored as ordered but said she would talk to her staff to make sure it was done now. The facility's Administration of Medications policy revised on 02/13/23 documented the facility would ensure medication was administered safely and appropriately per physician order to address resident's diagnoses and signs and symptoms. The facility failed to ensure that R28's blood pressure and pulse were monitored twice daily as ordered by the physician. This deficient practice placed R28 at risk for unnecessary medications and possible adverse side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 67 residents. The sample included 17 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure an appropriate indication or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat a mental disorder characterized by gross impairment in reality testing) for Resident (R)55, who had a diagnosis of Alzheimer's and dementia (progressive mental disorder characterized by failing memory, confusion). This placed the resident at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications. Findings included: - R55's Electronic Medical Record (EMR) documented the resident had diagnoses of dementia, Alzheimer's, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Significate Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented that R55 was dependent on two staff members' assistance for activities of daily living (ADLs). The MDS documented R55 received antipsychotic medication during the observation period. R55's Psychotropic Drug Use Care Area Assessment (CAA) dated 09/20/23 documented R55 received psychotropic medication and was at risk for adverse side effects. R55's Care Plan dated 11/18/22 documented the facility would consult with the pharmacist and physician to consider dose reduction of psychotropic medication when clinically indicated or at least quarterly. R55's Psychosocial Care Plan, revised 12/24/22, documented R55 received Risperdal (risperidone-antipsychotic medication) for targeted behavior and instructed staff to watch R55 for side effects of his medication. The Physician Order Sheet, dated 01/4/23, instructed staff to administer Risperidone 0.5mg before bed for a diagnosis of severe agitation for anxiety. R55's EMR lacked a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits. On 01/2/23 at 12:18 PM, observation revealed R55 sat in his room in a Broda chair (special wheelchair with tilt and recline capability) R55 visited politely with visitors and staff. The facility's Psychotropic Medications Policy, revised 10/24/22, documented that antipsychotic medications are indicated for the treatment of behaviors only if non-drug approaches and interventions were attempted prior to their use. The facility's Drug Regimen Review Policy, revised 8/17/23, documented the pharmacist would report any irregularities to the attending physician, the facility's medical director, and the director of nursing. The facility would act upon the pharmacist's recommendations and provide an explanation as to why the recommendation was rejected. The facility failed to ensure an appropriate indication or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of R55's antipsychotic medication. This placed the resident at risk of receiving an unnecessary psychotropic medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 67 residents. The sample included 17 residents with five reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to prevent a significant medication error when Resident (R) 24 received twice the physician-ordered dose of Eliquis (medication used to thin the blood) from 11/30/23 to 01/02/24. The deficient practice placed R24 at risk for adverse effects including bleeding related to the medication error. Findings Included: - R24's Electronic Medical Record (EMR) documented diagnosis of occlusion and stenosis of the left carotid artery (narrowing, constriction, or blockage of either of the two main arteries that supply blood to the head), peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), generalized muscle weakness and cognitive communication deficit. The admission Minimum Data Set (MDS) dated 11/16/23 documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. The MDS further documented R24 used a walker and wheelchair for mobility and required partial/moderate assistance for many of her activities of daily living (ADL). The Cognitive Loss / Dementia Care Area Assessment (CAA) dated 11/16/2023, documented R24 was alert and oriented to self, place and was able to communicate basic needs. The CAA further documented R24 had weakness and a BIMS of 12. R24's Care Plan with an initiated date of 11/13/2023, documented R24 had impaired cognitive ability. An Admission/readmission Note, dated 11/29/23 at 08:14 PM, documented R24 was admitted to a hospital on [DATE] after a fall, and a change of condition was observed. The Admission/readmission Note further documented that while R24 was in a hospital she had a hemoglobin (Hgb- measure of blood that carried oxygen to the cells from the lungs and carbon dioxide away from the cells to the lungs) of 6.8 and received three units of blood. The Discharge Medications List R24 received from a hospital stay dated 11/29/23, directed R24 to continue Eliquis. The Discharge Medications List documented that the Eliquis dosage had been changed to 2.5 milligrams (mg), one tablet twice daily. Review of R24's Medication Administration Record from 12/01/23 - 01/04/24, documented an order for Eliquis 5mg, one tablet twice a day with a start date of 11/30/23 and an end date of 01/04/24. Review of R24's Medication Administration Record from 11/30/23 - 01/02/24, documented R24 received 5 mg (twice the ordered dosage) of Eliquis 67 out of 67 opportunities. On 01/04/24 at 07:50 AM inspection of a medication cart revealed medication cards for R24's Eliquis. The cards contained 5 mg tablets and instructed to give one tablet twice a day with a start date of 11/30/23. On 01/04/24 at 12:55 PM, Licensed Nurse (LN) H stated he was uncertain if R24 had a history of GI bleed. He said the nurse that did the resident's admission put in the ordered medications. LN H stated the nurse on the following shift should have audited the medications to make sure they were correct. LN H stated the nurse was supposed to clarify the ordered medications with the doctor. He further stated the pharmacy also checked ordered medications after the orders were faxed to them. LN H stated each time a resident left the facility and was readmitted , all the medications had to be re-ordered and re-entered by the nurses. On 01/04/24 at 01:22 PM Administrative Nurse D stated the admission nurse should have faxed the medications ordered on R24's discharge medications list from the hospital to the pharmacy and should have compared them in R24's EMR to ensure accuracy. Administrative Nurse D further stated the nurse scheduled to work the following shift should have reviewed the ordered medications to further ensure accuracy. Administrative Nurse D stated when a resident was discharged and then readmitted , all of the previous medications were discontinued if the resident was out of the facility for more than 24 hours. Administrative Nurse D stated medications should have been sent to the pharmacy so they could compare them to what was ordered in R24's EMR. Administrative Nurse D stated if R24 received 5 mg of Eliquis when she discharged from a hospital with an order for 2.5 mg of Eliquis that would be a medication error. Administrative Nurse D stated she would investigate R24's medications or determine if an error occurred and said she could not comment on any outcome until the investigation was completed. The facility provided an Administration of Medications policy with a reviewed date of 08/24/23, documenting that the facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms. The policy further documented staff were to check the MAR and the doctor's order before medicating and if there was a question on the drug, stop and verify all information before administering. The facility failed to prevent a significant medication error when R24. The deficient practice placed R24 at risk for other complications related to medication errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 67 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to ensure the residents were provided a safe, clean, comfortable, and homelike environment. This placed the residents at risk for decreased psychosocial well-being and impaired safety and comfort for the affected residents. Findings included: - Upon the initial tour of the building on 01/02/24 at 07:05 AM and walkthrough of the facility revealed a heavy urine smell throughout the facility. On 01/02/24 at 12:44 PM room [ROOM NUMBER] bathroom had no mirror on the wall and the paper towel dispenser was missing a cover. On 01/02/24 at 12:47 PM, the wall behind bed A in room [ROOM NUMBER] was torn up and missing paint. On 01/02/24 at 12:50 PM, room [ROOM NUMBER] was missing a plaque on the wall that showed the room number. On 01/02/24 at 01:00 PM the couch in the 100 hall tv area had an unattended cup with clear liquid in it sitting on the cushion. On 01/03/24 at 11:00 AM there was a strong urine odor noted in R24's room that could be smelled from the hallway. On 01/03/24 at 11:45 AM, a very strong urine odor was prevalent throughout the hallways on both sides, and common areas. On 01/03/24 at 11:48 AM Administrative Nurse D stated she was infomred by several staff members of the strong scent of urine throughout the building. Administrative Nurse D stated staff were directed to clean numerous residents' rooms and provide baths to the residents in those rooms noted to have a heavy urine smell. On 01/04/24 at 01:22 PM Administrative Nurse D stated there was a bath aide that was here during the week and would get as many baths done during the day as she could. Administrative Nurse D stated some of the residents in the 200-hall urinated frequently during the night and staff did their best to clean the room and bathe the residents if the resident allowed it. Administrative Nurse D stated she was unaware of issues in some of the rooms until informed by the surveyors. Administrative Nurse D stated she would meet with staff about ensuring the building and rooms were cleaned sufficiently. The facility policy Resident Belongings and Home Like Environment reviewed 07/17/23 documented: The facility would provide a safe, clean, comfortable, and homelike environment, which allowed the resident to use his or her personal belongings to the extent possible. The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safely. It was the responsibility of all facility staff to create a homelike environment and promptly address any cleaning needs. The resident room should be uncluttered and orderly, to ensure the resident could receive care and services safely, without the risk of falling or injury, while maximizing resident independence. The facility failed to ensure residents were provided a safe, clean, comfortable, and homelike environment. This placed the residents at risk of had the potential for decreased psychosocial well-being and impaired safety and comfort for the affected residents.

The facility identified a census of 67 residents. The sample included 17 residents. Based on observation, record review, and interviews, the facility failed to provide consistent weekend activities. This deficient practice placed the affected residents at risk for decreased psychosocial well-being and boredom. Findings included: - A review of the facility's Activity Calendars for October, November, and December of 2023 was completed. The review revealed Resident's Choice was the only facility-led activity on the weekends for all three months. A review of the weekday activity calendar revealed Bingo, games time, social events, manicures, and sports events. On 01/03/24 at 02:00 PM, the facility held a staff-led Bingo game in the main dining area. The game included resident involvement from both (South and North) halls. The game included snacks and prizes provided to the residents. On 01/03/24 at 01:15 PM, Resident Council members reported the weekend lacked consistent activities since the facility's Activities Coordinator left in November 2023. The council reported some of the direct care staff tried to hold activities but activities often did not get completed on the weekends. The council reported the calendar indicated Resident's Choice meaning they were provided games and movies to play and/or watch on their own. The council reported that weekends were boring. On 01/02/24 at 02:01 PM, R42 reported that residents were not made aware of the weekend activities when they occurred. He stated it often involved playing the same game over and over or watching a movie. He stated the weekend staff did their best but did not have the resources or time to do anything else. On 01/04/24 at 11:30 AM Administrative Staff A reported the facility did not have an activity coordinator since November 2023. She stated she oversaw the activities program, but the facility did not have certified activity personnel. On 01/04/23 Licensed Nurse (LN) H stated the direct care staff attempted to provide weekend activities when they could if they had time. He stated sometimes church groups would come in on Sundays and movies were played for the residents. He stated sometimes the residents arranged their own activities group. He stated the facility had not had an activity coordinator for two months, so the staff tried to keep the residents engaged. A review of the facility's Activities Program policy revised 08/2023 indicated the facility will provide ongoing and consistent activities that meet each resident social, spiritual, physical, and emotional needs. The policy indicated the facility would utilize licensed staff. The facility failed to provide consistent activities for the residents during weekends. This deficient practice placed the affected residents at risk for decreased psychosocial well-being and boredom.

The facility identified a census of 67 residents. The sample included 17 residents. Based on observation, record review, and interviews, the facility failed to provide a certified activity professional. This placed the affected residents at risk for decreased quality of life. Findings included: - A review of the facility's Activity Calendars for October, November, and December of 2023 was completed. The review revealed Resident's Choice was the only facility-led activity on the weekends for all three months. A review of the weekday activity calendar revealed Bingo, games time, social events, manicures, and sports events. On 01/03/24 at 02:00 PM, the facility held a staff-led Bingo game in the main dining area. The game included resident involvement from both (South and North) halls. The game included snacks and prizes provided to the residents. On 01/03/24 at 01:15 PM, Resident Council members reported the weekend lacked consistent activities since the facility's Activities Coordinator left in November 2023. The council reported some of the direct care staff tried to hold activities, but activities often did not get completed on the weekends. The council reported the calendar indicated Resident's Choice meaning they were provided games and movies to play and/or watch on their own. The council reported that weekends were boring. On 01/02/24 at 02:01 PM, R42 reported that residents were not made aware of the weekend activities when they occurred. He stated it often involved playing the same game over and over or watching a movie. He stated the weekend staff did their best but did not have the resources or time to do anything else. On 01/04/24 at 11:30 AM Administrative Staff A reported the facility did not have an activity coordinator since November 2023. She stated she oversaw the activities program, but the facility did not have certified activity personnel. On 01/04/23 Licensed Nurse (LN) H stated the direct care staff attempted to provide weekend activities when they could if they had time. He stated sometimes church groups would come in on Sundays and movies were played for the residents. He stated sometimes the residents arranged their own activities group. He stated the facility had not had an activity coordinator for two months, so the staff tried to keep the residents engaged. A review of the facility's Activities Program policy revised 08/2023 indicated the facility will provide ongoing and consistent activities that meet each resident social, spiritual, physical, and emotional needs. The policy indicated the facility will utilize a licensed activity professional to oversee the program. The facility failed to provide a certified activity professional. This placed the affected residents at risk for decreased quality of life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 67 residents. The sample included 17 residents with one resident reviewed for accidents and/or hazards. Based on observation, record review, and interview, the facility failed to secure hazardous materials when the facility failed to ensure a Sharps container (bin to place used needles and lancets) mounted on the side of a cart and stored in the hallway had a lid to prevent residents from reaching into the container. This deficient practice placed the 19 cognitively impaired independently mobile residents at risk for preventable injuries and accidents. The facility additionally failed to ensure R53's portable urinal was within reach resulting in a non-injury fall. This deficient practice placed R53 at risk for preventable falls and injuries. Findings Included: - On 01/02/24 at 07:30 AM a walkthrough of the facility's 200 Hallway revealed a treatment cart next to the nurse's station. An inspection of the cart revealed a mounted Sharps container on the side of the cart. The Sharps container lacked a safety cover to prevent exposure to the used lancets and hazardous materials within the container. At 07:38 AM Licensed Nurse (LN) G reported that the container should have had a safety cover on top. LN G replaced the Sharps container at 07:40 AM. On 01/04/24 at 01:10 PM Administrative Nurse D stated the nurses were responsible for ensuring the carts were secured and changed out the Sharps bin when needed. She stated the residents should not have access to the carts or the Sharps bins. The facility's Waste Management policy revised 08/2023 indicated all Sharps containers supplied to the facility were to be inspected daily for safety and removed when 3/4 full. The policy indicated the containers must be puncture-resistant to eliminate potential hazards or physical injury. The facility failed to secure hazardous materials in a defective Sharps container. This deficient practice placed the 19 cognitively impaired independently mobile residents at risk for preventable injuries and accidents. - The Medical Diagnosis section within R53's Electronic Medical Records (EMR) included diagnoses of vitamin B insufficiency, anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), hemiplegia (paralysis of one side of the body), hemiparesis (weakness and paralysis on one side of the body), muscle weakness, abnormalities of gait and mobility. A review of R53's Quarterly Minimum Data Set (MDS) completed 10/10/23 noted a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. The MDS indicated he required supervision or touch assistance during personal hygiene, toileting, and bathing. The MDS indicated he was occasionally incontinent of bowel and bladder but had no toileting program in place. The MDS indicated no falls. R53's Urinary Incontinence Care Area Assessment (CAA) completed 04/12/23 indicated he had occasional urinary incontinence. The CAA indicated he used a portable urinal and staff were to provide checks and changes to prevent skin breakdown. R53's Falls CAA completed 04/12/23 noted he had bilateral lower extremity weakness with impaired balance. The CAA noted he was a fall risk and instructed staff to keep his bed in the lowest position and ensure his call light was within reach. The CAA noted he used a wheelchair for locomotion and required assistance from staff for his activities of daily living (ADLs). R53's Care Plan initiated 03/31/23 indicated he was at risk for skin impairment, ADL self-care deficits, and falls related to his medical diagnoses. The plan noted he required limited assistance from staff for bathing, bed mobility, personal hygiene, and transfers. The plan indicated he was incontinent, used a portable urinal, and provided peri-care as needed. The plan indicated he sometimes emptied his portable urinal out in the trash can (04/04/23). The plan also indicated he would place his urine-soaked incontinence briefs on the floor or trash can (04/04/23). The plan indicated R53 fell on [DATE] attempting to reach for his portable urinal. The plan instructed staff to keep his urinal within reach and use his call light (12/04/23). The plan lacked individualized interventions to maintain and promote R44's highest level of functioning related to incontinence. The plan failed to address his bowel incontinence. The plan failed to address the fall mat next to his bed. A Progress Note dated 12/04/23 indicated staff found R53 on his knee attempting to pull himself up from the floor. The note indicated he reached for his urinal and fell out of bed. The note indicated R53 reported knee and shoulder pain, but no injuries were found. The note indicated a fall mat was added next to his bed but not added to his care plan. The facility failed to provide an investigation or evidence the facility evaluated causative factors related to R53's fall. On 01/02/24 at 09:42 AM R53 reported that he had issues with incontinence and used a portable urinal. He reported that the facility did not have individualized toileting interventions for him. He stated he fell on [DATE] because his portable toilet was left out of reach, and he attempted to reach for it. He stated staff do not provide restroom breaks or ask him in the evening for assistance. On 01/04/24 at 11:30 PM, Certified Nurse Aid (CNA) M stated R53 would usually take himself to the bathroom or use his portable urinal. CNA M stated staff were to ensure his urinal and call light were within reach and provide him assistance as needed. He stated residents with incontinence issues should also be provided opportunities to use the restroom during the night to prevent them from falling out of bed. On 01/04/24 at 12:05 PM Licensed Nurse (LN) G stated residents with incontinence should be provided frequent toileting opportunities to prevent possible falls. She stated the care plan should be updated each time a fall occurs with interventions to prevent the falls from reoccurring. She stated R53 often will take himself to the toilet. She was not sure if R53 had any falls. She stated staff should ensure R53's call light and portable are within reach before he goes to bed. On 01/04/24 at 01:30 PM Administrative Nurse D stated each resident's care plan was reviewed after falls occurred and updated according to the needed interventions. She stated the interdisciplinary team reviewed the factors related to the fall to ensure appropriate interventions were put in place. She stated staff were expected to follow the interventions based on what caused the fall. She stated residents with incontinence should be provided frequent opportunities for restroom usage. The facility's Fall Management policy revised 12/2023 indicated the facility will assess and provide intervention for residents at risk for falls. The policy noted the facility will identify potential risks and ensure environmental, physical, and psychological are addressed by the care plan and interdisciplinary team. The facility failed to ensure R53's portable urinal was within reach resulting in a non-injury fall. This deficient practice placed R53 at risk for preventable falls and injuries.

The facility reported a census of 67 residents. The Facility had four medication carts and two medication rooms. Based on observations, record reviews, and interviews, the facility failed to ensure the safe storage and handling of Resident (R)55's insulin medication (a hormone that lowers the level of glucose in the blood). This deficient practice placed the resident at risk for diversion and ineffective medication regimen. Findings Included: - On 01/02/24 at 07:35 AM a walkthrough of the facility's South Hall revealed a treatment cart by the nurse's station. An inspection of the treatment cart revealed unsecured insulin medication stored in plastic bins on top of the cart. The plastic bins contained four insulin glargine (long-acting insulin medication) auto-injector pens that belonged to R55. At 07:38 AM Licensed Nurse (LN) G stated she just left the area briefly to put her coat up. LN G stated the insulin should be supervised or locked up when not in use. She secured the insulin in the third drawer of her treatment cart. On 01/04/24 at 01:10 PM Administrative Nurse D stated medication should be locked in the treatment cart when staff step away from the carts. She stated medication should never be left unsecured or in reach of the residents. The facility's Medication Storage policy revised 06/2021 indicated all medications provided to the facility will stored in a safe manner. The policy indicated all medication rooms and carts containing medications will be secured and always supervised. The policy indicated that all drugs and biologicals were to be stored in locked compartments accessible only by licensed personnel. The policy indicated all medication rooms, carts, and supplies remain locked when not attended. The facility failed to ensure safe storage and handling of R55's medications. This deficient practice placed the residents at risk for diversion and ineffective medication regimens.

The facility identified a census of 67 residents. The sample included 17 residents. Based on record review and interview, the facility failed to provide a Registered Nurse (RN) for at least eight consecutive hours a day seven days a week. This placed the residents at risk for decreased quality of care. Findings included: - Review of the Payroll-Based Journal for Fiscal Year 2023 Quarters1 through 4 revealed the facility triggered for no RN hours on four or more weekend days during quarter one 10/15/22, 10/16/22, 10/22/22, 10/29/22, 10/30/22,11/05/22, 11/12/22, 11/13/22, 11/19/22, 11/26/22,12/03/22, 12/10/22, 12/11/22, and 12/24/22). Review of the Payroll-Based Journal for Fiscal Year 2023 Quarter2 revealed the facility triggered for no RN hours on four or more weekend days during the quarter (01/01/23, 01/15/23, 01/21/23, 02/04/23, 02/05/23, 02/12/23, 02/18/23, 02/19/23, 02/26/23, 03/12/23, 03/18/23, and 03/26/23). Upon request, the facility provided handwritten Time Clock Adjustment sheets for the dates listed above. The facility failed to provide proof of eight hours of consecutive RN coverage a day seven days a week as requested. The facility also provided an Earnings Statement for RNs for the dates requested, but the statements lacked proof of the actual punch times to verify the dates and consecutiveness that the staff members worked. On 01/04/24 at 11:30 AM Administrative Staff A stated the facility always had an RN on staff in the building every day. Administrative Nurse D stated on the weekends management staff covered the RN hours a lot of the time but she was unable to show verification or punch times for their hours worked since they were salaried employees and did not clock in/out like regular hourly staff. The facility lacked a policy regarding staffing hours. The facility failed to ensure there was RN coverage at least eight consecutive hours a day seven days a week. This placed all residents at risk of delayed care and the potential for physical or psychosocial harm.

The facility identified a census of 67 residents with one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to the storage of food. This deficient practice placed the residents at risk related to food-borne illnesses and food safety concerns. Findings included: On 01/02/24 at 07:27 AM an observation in the main kitchen area revealed three plastic storage containers with cereal inside. The containers lacked labels and were undated. On 01/02/24 at 07:35 AM an observation in the kitchen's meat freezer revealed two resealable plastic bags. One plastic bag contained ham and the other contained chicken patties. The plastic bags were not labeled and were undated. On 01/02/24 at 07:36 AM, an observation in the kitchen's meat freezer revealed one opened box of frozen beef patties. The box was open to air and the patties were uncovered. On 01/02/24 at 07:38 AM, an observation in the kitchen's dry storage area revealed one bag of dry noodles. The bag was opened and was undated. On 01/02/24 at 07:39 AM, an observation in the kitchen's dry storage area revealed one opened box of graham cracker crumbs. The box was open and the crumbs were open to air. On 01/02/24 at 07:40 AM an observation in the kitchen's dry storage area revealed one bag of tortilla chips. The bag was opened and was undated. On 01/02/24 at 07:43 AM, an observation in the kitchen's A refrigerator revealed one package of cheese slices. The package was opened and was undated. On 01/02/24 at 07:45 AM, an observation in the kitchen's A refrigerator revealed one gallon of whole milk. The gallon of milk was opened and was undated. On 01/02/24 at 07:47 AM an observation in the kitchen's vegetable freezer revealed two bags of diced green peppers. The bags were opened and undated. On 01/02/24 at 07:48 AM an observation in the kitchen's vegetable freezer revealed one resealable bag of mixed peppers/onions. The bag was not labeled or dated. On 01/02/24 at 07:49 AM, an observation in the kitchen's baking freezer revealed one bag of breadsticks. The bag was open to air and undated. On 01/02/24 at 07:50 AM an observation in the kitchen's baking freezer revealed one resealable plastic bag of cookies. The bag did not have a label and was undated. On 01/02/24 at 07:50 AM an observation in the kitchen's baking freezer revealed one plastic bag of French fries. The bag was opened and undated. On 01/02/24 at 07:54 AM, an observation in the kitchen's main area revealed three bags of hot dog buns and one loaf of bread. The bags were opened and undated. On 01/03/24 at 12:09 PM, Dietary BB stated after items were opened, staff were expected to add a date to the packaging, and any items placed into a resealable plastic bag should have been labeled and dated. Dietary BB further stated food items that were placed in a resealable bag that lacked a label and/or date should have been discarded when found. The facility's Food Safety policy with a revised date of 04/26/23, documented that Pre-packaged food is placed in a leak-proof, non-absorbent, sanitary container with a tight-fitting lid. The container is labeled with the name of the contents and the date (when the item is transferred to the new container). Use by date is noted on the label or product when applicable. The policy further documented frozen, raw meat that is placed in a cooler in a pan and labeled with the pulled and use-by dates. The facility failed to maintain sanitary dietary standards related to the storage of food. This deficient practice placed the residents at risk related to food-borne illnesses and food safety concerns.

The facility identified a census of 67 residents. Based on observation, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to the implementation of procedures to monitor and prevent Legionella disease (Legionella is a bacterium that can cause pneumonia in vulnerable populations) or other opportunistic waterborne pathogens, failed to ensure sanitary storage of respiratory equipment, failed to ensure adequate laundry temperatures for laundry including laundry from residents with infectious disease and on transmission-based precautions and failed to ensure staff performed hand hygiene between resident car. The facility further failed to ensure appropriate disposal of filled red biohazard boxes and failed to ensure the Infection Preventionist tracked and trended infections within the facility. These deficient practices placed the residents at risk for complications related to infectious diseases. Findings included: - Observation on 01/02/24 at 07:05 AM a large bag of soiled linen rested on the floor in the 200 hallways. On 01/02/24 at 07:14 AM an unlocked soiled utility room on the 200 hallway revealed a small refrigerator, which the thermometer registered a temperature of 18 degrees. The refrigerator had ice along the back of the refrigerator. Two large red biohazard boxes sat on a cart with six small red biohazard sharps containers on top of the two large red biohazard boxes. Four of the six red sharps containers were filled past the fill line on the box. A can with cat litter and a cigarette butt sat on the counter next to the sink. On 01/02/24 at 07:21 AM the clean utility room on the 200 hall had an opened box of disposable gloves and a gait belt which partially rested on the floor. A blue hand splint rested directly on the floor as well. On 01/02/24 at 07:48 AM Resident (R) 44's oxygen tubing rested on the floor next to the bed, unbagged. On 01/02/23 at 11:35 AM R42's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask hung unbagged above his bed. On 01/04/24 at 06:43 AM Certified Medication Aide (CMA) S failed to perform hand hygiene between administration of medication to R21 and administered medication and inhaler to R10. The facility provided a policy related to Legionella testing but was unable to provide a plan, a risk assessment, or a procedure related to Legionella testing. A review of the temperature logs provided by the facility water temperature logs documented temperatures below the recommended 160 degrees. The facility was unable to provide washing machine specifications upon request. On 01/04/23 at 10:39 AM Administrative Nurse E, the facility Infection Preventionist stated she had a book that she did track the facility's infections some place. Administrative Nurse E stated she completed Mcgeer's criteria after a urine analysis was obtained. Administrative Nurse E stated respiratory equipment should never touch the floor, should be dated, and changed weekly, and placed in a clean bag when not in use. Administrative Nurse E stated she was not sure how frequently a resident's CPAP mask should be replaced. Administrative Nurse E stated hand hygiene should be performed in between each resident. On 01/04/24 at 12:08 PM Certified Nurse Aide (CNA) N stated soiled linen should never be placed on the floor. CNA N stated respiratory equipment should be stored in a clean bag when not in use. On 01/04/24 at 01:22 PM Administrative Nurse D stated hand hygiene should be performed between administration of medication and any other resident care. Administrative Nurse D stated respiratory equipment should be stored in a clean bag when not in use. CPAP masks should be cleaned daily after use. Administrative Nurse D stated the Infection Preventionist, administrator, and maintenance director oversee the plan and procedure for testing for Legionella disease. Administrative Nurse D stated the nurses were responsible for ensuring red biohazard sharps containers were changed and placed in the large red biohazard container in the soiled utility rooms. Administrative Nurse D stated night shift was responsible for monitoring the specimen refrigerator in the utility room to ensure it was defrosted and at the appropriate temperature. The facility's Hand Hygiene policy last revised 06/13/23 documented that the facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility's Laundry Services policy last reviewed on 06/04/23 documented that linens should be washed using the equipment manufacturer's recommendations for appropriate chemical mix and water temperature. A review of the facility's Oxygen Administration/Storage/Maintenance policy reviewed 09/2023 indicated oxygen will be administered in accordance with the physician's orders and current standards of practice. The policy indicated oxygen supplies will be changed weekly and when visibly soiled with dates indicating placement. The policy indicated oxygen tubing and masks were to be stored in provided bags to prevent environmental contamination or infections. The facility's Antibiotic Stewardship policy last reviewed on 05/19/23 documented that the antibiotic stewardship program promoted the appropriate use of antibiotics and included a system of monitoring to improve resident outcomes and reduce antibiotic resistance. This meant that the antibiotic was prescribed for the correct indication, dose, and duration to appropriately treat the resident while also attempting to reduce the development of antibiotic-resistant organisms and/or other adverse events. The program would be managed and overseen by the Infection Preventionist. The facility failed to implement appropriate infection control practices. This placed the residents at risk for transmission of infectious diseases.

The facility identified a census of 67 residents. The sample included 17 residents. Based on observation, record review, and interviews, the facility failed to develop and implement the core elements of antibiotic stewardship to ensure an effective infection prevention and control program including antibiotic stewardship for the residents of the facility. Findings included: - Review of the Infection Control Log for tracking and trending infections from January 2023 through December 2023, lacked evidence of organism identifications, duration of antibiotic prescribed, and the infections treated. The facility was unable to provide evidence of tracking upon request. On 01/04/23 at 10:39 AM Administrative Nurse E, the facility Infection Preventionist stated she had a book that she did track the facility's infections some place. Administrative Nurse E stated she completed Mcgeer's criteria after a urine analysis was obtained. The facility's Antibiotic Stewardship policy last reviewed on 05/19/23 documented that the antibiotic stewardship program promoted the appropriate use of antibiotics and included a system of monitoring to improve resident outcomes and reduce antibiotic resistance. This meant that the antibiotic was prescribed for the correct indication, dose, and duration to appropriately treat the resident while also attempting to reduce the development of antibiotic-resistant organisms and/or other adverse events. The program would be managed and overseen by the Infection Preventionist. The facility failed to proactively apply the principles of antibiotic stewardship, for the residents of the facility from January 2023 through December 2023 to ensure antibiotics were administered in a safe and effective manner to prevent unnecessary side effects of antibiotics and antibiotic resistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified at census of 53 residents. The sample included 16 residents. One resident was sampled for reasonable accommodations of resident needs and preferences. Based on observation, record review, and interview, the facility failed to ensure that resident (R)13's call light was within reach and able to call for assistance with personal cares. This deficient practice left R13 vulnerable for not receiving proper cares/assistance in a timely manner. Findings included: - R13's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) with behavioral disturbances and cellulitis (skin infection caused by bacteria characterized by heat, redness and swelling) left lower limb. The admission Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS recorded R13 required extensive assistance of one person for all activities of daily living (ADLs) except eating, for which she was independent. R13 required assistance of one staff member for bathing. R13 had no behaviors. The MDS recorded R13 received an antipsychotic (medication used to treat psychosis), diuretic (medication used to promote excretion of fluids) and opioids (medications use to treat pain) during the lookback period. R13's Cognitive Loss Care Area Assessment (CAA) dated 01/20/22 documented staff encouraged her to use the call light for assistance with ADL's. R13 received routine antipsychotic medication, staff monitored for adverse reactions and for changes in R13 mood or behaviors. R13's Care Plan dated 01/10/22 documented staff should allow extra time for her to respond to questions or instructions. The Care Plan lacked documentation for person centered dementia care. On 04/05/22 at 08:23 AM R13 laid in the bed, yelled out help, that she must go to the bathroom. R13's roommate asked her to stop yelling. R13 started to cuss at R44 and threatened to slap her roommate across the face. R13's call light was located on the floor behind the bed under a blanket and pillow, out of reach. On 04/06/22 at 07:20 AM R13 laid on the bed. R13's, call light was out of reach, on the floor. On 04/06/22 at 02:35 PM in an interview, Certified Nurse's Aide (CNA) M stated a call light should always be in reach of the resident to call for assistance. On 04/06/22 at 03:35 PM in an interview, Licensed Nurse (LN) G stated the call light should be within reach of the resident when in their room. On 04/04/22 at 04:20 PM in an interview, Administrative Nurse E stated, stated a resident's call light should always be in reach when in their room alone. The facility policy Resident Rights last revised 11/28/16 documented: the resident had the right to a dignified existence; the resident had the right to exercise his/her rights as a resident of the facility; the resident had the right to be treated with respect and dignity; the resident had the right to reside and receive services in the facility with reasonable accommodation of the resident and preferences except when to do so would endanger the health or safety of other residents; and the resident had the right to choose activities, schedules, health care and providers of health care services consistent with his or her interests, assessments, and plan of care. The facility failed to ensure that R13's call light was within reach and call for assistance with ADL's. This placed R13 vulnerable not to receive the treatment and services to attain and/or maintain her practicable physical, mental and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 53. The sample included 16 residents. Based on interview and record review, the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASRR) for Individuals with Mental disorders and Individuals with Intellectual Disability was completed for Resident (R) 42. This placed the resident at risk for decreased or inadequate care and services related to his mental health diagnoses and intellectual disabilities. Findings include: - R42's Electronic Medical Record (EMR) recorded diagnoses of schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), epilepsy (brain disorder characterized by repeated seizures), obsessive-compulsive disorder (OCD - anxiety disorder characterized by recurrent and persistent thoughts, ideas and feelings of obsessions severe to cause marked distress, consume considerable time or significantly interfere with the resident's occupational, social or interpersonal functioning), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), mild intellectual disabilities, and psychosis (any major mental disorder characterized by a gross impairment in reality testing). The Significant Change Minimum Data Set (MDS) dated [DATE] recorded R42 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. The MDS recorded R42 was independent with no set up to supervision for most activities for daily living (ADLs), and limited assistance of one staff for personal hygiene. R42 rejected cares during the look back period but had no wandering behaviors. The Quarterly MDS dated 03/02/22 recorded R42 had a BIMS of nine which indicated moderately impaired cognition. The MDS recorded R42 required supervision with set-up assistance for all ADLs. He rejected cares during the look back period but had no wandering behaviors. The Behavior Care Area Assessment (CAA) dated 12/06/22 recorded R42 had behavior symptoms of rejection of care. Staff encouraged as much participation as possible during care activities. R42's clinical record, including EMR and paper chart, lacked evidence a PASRR was completed prior to admission or within a practicable amount of time after admission during the Coronavirus (highly contagious respiratory virus which created a national pandemic) blanket waivers. The record lacked evidence of an initial Level I and/or Level II assessment. On 04/06/22 at 05:25 PM Administrative Nurse D stated the former social worker handled all the CARE/PASRR assessments and kept them in a file in her office. Administrative Nurse D stated she reviewed the files stored in the former social workers office and was unable to find any evidence or record regarding a PASRR for R42. She indicated she did not know much about the PASRR process. Administrative Nurse D stated the facility did not currently have a social worker and she was unsure who oversaw ensuring the PASRR assessments were completed as required. The facility did not provide a policy on the PASRR process. The facility failed to ensure R42 received a PASRR screen. This placed the resident at risk for decreased or inadequate care and services related to his mental health diagnoses and intellectual disabilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 53 residents. The sample included 16 residents; three residents reviewed for activities. Based on observations, record reviews, and interviews, the facility failed to consistently provide activities for Resident (R) 205, R6, and R17. This deficient practice had the risk for a decline in physical, mental, and psychosocial well-being and independence. Findings included: - R205 admitted to facility on 01/07/22. The Diagnoses tab of R205's Electronic Medical Record (EMR) documented diagnoses of anoxic brain injury (condition caused by a complete lack of oxygen to the brain), need for assistance with personal care, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and history of falling. The admission Minimum Data Set (MDS) dated 01/14/22, documented a Brief Interview for Mental Status (BIMS) was not completed due to R205 rarely/never understood. R205 required extensive physical assistance with two staff for bed mobility and dressing; total physical dependence with one staff for eating and personal hygiene; total physical dependence with two staff for toileting and transfers. R205 considered the following activities somewhat important to him: have books, newspapers, and magazines to read, listen to music, be around animals such as pets, keep up with the news, do things with groups of people, do favorite activities, go outside to get fresh area when weather is good, and participate in religious services or practices. The Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA) dated 01/17/22 documented R205 had cognition loss related to short and long term memory loss. R205's medical record lacked evidence of a person-centered activity care plan. The Assessments tab of R205's EMR lacked an activity assessment after admission or quarterly. R205's medical record lacked evidence of activity participation. On 04/04/22 at 08:54 AM, R205 sat in his Broda (specialized wheelchair with the ability to tilt and recline) chair in the day room, he wore a helmet to protect his head from injury. No observations of activities as being performed or offered. On 04/04/22 at 04:15 PM, R205 sat in his Broda chair in the day room, helmet not on at that time. No observations of activities as being performed or offered. On 04/05/22 at 08:21 PM, R205 sat in his Broda chair at a table in the day room, helmet not on at that time but was observed on the table. No observations of activities as being performed or offered. On 04/05/22 at 11:40 AM, R205 sat in his Broda chair at table in day room, helmet not on at that time but was observed on the table. Staff conversed with resident and encouraged him to put helmet back on which he did. On 04/05/22 at 11:46 AM, R205 sat in his Broda chair at table in day room, he attempted to talk to staff walking past him, but they did not acknowledge hearing him. No observations of activities being performed or offered. On 04/05/22 at 01:51 PM, R205 laid in bed, bed had bolsters on the side to prevent falling out of bed, fall mats were on both sides of the bed. R205 appeared restless, staff were in room. On 04/06/22 at 07:30 AM, R205 sat in his Broda chair while staff propelled him into the day room. No observations of activities being performed or offered. On 04/06/22 at 09:18 AM, R205 sat in his Broda chair at table in day room, he attempted to talk to any one who passed by him but only one staff member stopped to talk to him. He appeared to want to converse with anyone. No observations of activities being performed or offered. On 04/06/22 at 02:40 PM, Certified Nurse Aide (CNA) M stated she had not received an activities calendar and she was not sure what types of activities were provided. On 04/06/22 at 03:20 PM, Certified Medication Aide (CNA) R stated she sometimes helped out with activities and the facility had been providing activities. She stated R205 was usually in the day room and he liked to talk a lot. On 04/06/22 at 03:34 PM, Licensed Nurse (LN) G stated the facility had a new activity director and did not have any activities organized. She was unfamiliar with activity assessments. On 04/06/22 at 04:32 PM, Activities Z stated she had worked at the facility almost a month. She stated she was educated about activity assessments but was unaware how often they were completed. Activities Z stated she found ideas for activities from the internet. She stated R205 usually had something that required him to use his hands. On 04/06/22 at 05:22 PM, Administrative Nurse D stated the facility did not have activities from January to February and would have utilized floor staff and hospice to provide activities. She stated social services completed activity assessments and activity care plans on admission. Since there was no activity calendar, activity supplies were not provided. The facility's Therapeutic Activities Program policy, revised 04/01/22, directed the facility implemented an ongoing resident centered activities program that incorporated the resident's interests, hobbies, and cultural preferences which was integral to maintaining and/or improving a resident's physical, mental, and psychosocial well-being and independence. The policy directed it was important for residents to have a choice about which activities they participated in, whether they were part of the formal activities program or self-directed and a resident's needs and choices for how they spend time, both inside and outside the facility, were also supported and accommodated. The policy directed individual interventions were developed based on each resident's assessed needs and the family was notified for any special requests; the individual program was provided according to a consistent scheduled identifying specific days of the week and time frame for which program occurred; and each resident's individual program included interventions that met the resident's social, emotional, physical, spiritual, and cognitive functioning needs, these approaches reflected the resident's lifestyle and interests and were incorporated into the interdisciplinary care plan. The facility failed to consistently provide activities for R205. This deficient practice had the risk for a decline in physical, mental, and psychosocial well-being and independence. - R6's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of chronic respiratory failure (condition in which the blood does not have enough oxygen or has too much carbon dioxide and the lungs are unable to carry the blood to the organs), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and bipolar (major mental illness that caused people to have episodes of severe high and low moods) mood disorder. The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R6 required limited assistance of one staff member for activities of daily living (ADL's). The MDS documented R6 required physical help of one staff member for set up or assistance as part of the bathing activity during the look back period. The MDS documented R6 received oxygen therapy during the look back period. The Quarterly MDS dated 01/05/22 documented no changes documented from previous MDS assessment. R6's Cognitive Loss Care Area Assessment (CAA) dated 10/25/21 documented she was able to communicate her needs during the look back period. R 6's Care Plan dated 11/20/19 documented staff were to converse with her while they provided care and introduce R6 to other resident's in the facility that had similar background, interests and staff to encourage/ facilitate interaction. Staff were to invite R6 to schedule activities. R6 seemed very interested in activities and go outside to smoke. R6's Care Plan dated 11/19/20 documented she enjoyed the daily newsletters and classic romance movies. R6 enjoyed subjects related to science, visiting with others and keeping her hands busy. On 04/04/22 at 09:31 AM R6 stated the facility never had activities available for her to attend. R6 stated she was bored and had nothing to do but smoke. R6 laid on her bed. On 04/05/22 at 07:25 AM R6 sat on edge of her bed faced toward the open window. On 04/05/22 at12:42 PM R6 sat on the bed, fed herself lunch in her room. On 04/05/22 at 03:29 PM R6 sat in a wheelchair next to the common area on the south hallway, stated she was waiting to go outside and smoke. On 04/06/22 at 11:17 AM R6 sat in wheelchair next to the common area, stated she was waiting to go outside and smoke. On 04/06/22 at 11:25 AM R6 pushed her wheelchair down the south hallway as she talked to the hospice staff. R6's hair was uncombed, and her clothes were clean. On 04/06/22 at 02:40 PM, Certified Nurse Aide (CNA) M stated she had not received an activities calendar and she was not sure what types of activities were provided on the evening shift. On 04/06/22 at 03:20 PM, Certified Medication Aide (CNA) R stated she sometimes helped with activities and the facility had been providing activities on dayshift, weekends and evenings. CMA R stated sometimes on the weekends a few of the residents do BINGO. On 04/06/22 at 03:34 PM, Licensed Nurse (LN) G stated the facility had a new activity director and did not have any activities organized. She was unfamiliar with activity assessments and the activities that occurred on her shift. On 04/06/22 at 04:32 PM, Activities Z stated she had worked at the facility almost a month. She stated she was educated about activity assessments but was unaware how often they were completed. On 04/06/22 at 05:22 PM, Administrative Nurse D stated the facility did not have activities from January to February and would have utilized floor staff and hospice to provide activities. She stated social services completed activity assessments and activity care plans on admission. Since there was no activity calendar, activity supplies were not provided. The facility's Therapeutic Activities Program policy, revised 04/01/22, directed the facility implemented an ongoing resident centered activities program that incorporated the resident's interests, hobbies, and cultural preferences which was integral to maintaining and/or improving a resident's physical, mental, and psychosocial well-being and independence. The policy directed it was important for residents to have a choice about which activities they participated in, whether they were part of the formal activities program or self-directed and a resident's needs and choices for how they spend time, both inside and outside the facility, were also supported and accommodated. The policy directed individual interventions were developed based on each resident's assessed needs and the family was notified for any special requests; the individual program was provided according to a consistent scheduled identifying specific days of the week and time frame for which program occurred; and each resident's individual program included interventions that met the resident's social, emotional, physical, spiritual, and cognitive functioning needs, these approaches reflected the resident's lifestyle and interests and were incorporated into the interdisciplinary care plan. The facility failed to consistently provide activities for R6. This deficient practice had the risk for a decline in physical, mental, and psychosocial well-being and independence. - R17's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia without behaviors (progressive mental disorder characterized by failing memory, confusion) and muscle weakness. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented that R17 was totally dependent on two staff members assistance for activities of daily living (ADL's). The MDS documented R17 was totally dependent on one staff member for bathing and refused care four to six days during the look back period. The Quarterly MDS dated 12/16.21 documented no changes documented from previous MDS assessment. R17's ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 10/04/21 documented he required total assistance of staff for bathing/showers and incontinence care. R17's Care Plan dated 07/17/19 documented he required maximum involvement in decision making and activities. Limit choices and cue as needed. R17's Care Plan dated 08/28/19 documented he needed assistance to attend activities. Encourage R17's family to attend activities with him to be supportive with participation. R17's Care Plan dated 10/31/19 documented he preferred music, making people laugh, and any food/social group. R17's enjoyed drinking coffee and watch TV. R17's Care Plan dated 04/28/20 documented he enjoyed sitting up front by the reception area to talk and visit most of the day while he drank coffee and looked outside. On 04/04/22 at 08:02 AM sat in high back wheelchair in the common area with his back to the TV. R17 stated he was waiting for breakfast, no fluids or items on the table in front of him. On 04/04/22 at 01:34 PM R17 s sat in high back wheelchair in common area with a wedge pillow on foot rest. On 04/05/22 at 07:46 AM staff pushed R17 in a high back wheelchair to the common area. R17 asked for a cup of coffee and was informed by staff breakfast was coming soon. At 08:09 AM R17 asked for a cup of coffee from Administrative Nurse F, who stated breakfast was coming out soon. An unidentified nursing staff delivered a breakfast tray to another resident in the common area and then pushed the food cart down the hallway. At 08:43 AM R17 received his breakfast tray in the common area on a tray which contained a cup of coffee. On 04/06/22 at 02:40 PM, Certified Nurse Aide (CNA) M stated she had not received an activities calendar and she was not sure what types of activities were provided on the evening shift. On 04/06/22 at 03:20 PM, Certified Medication Aide (CNA) R stated she sometimes helped with activities and the facility had been providing activities on dayshift, weekends and evenings. CMA R stated sometimes on the weekends a few of the residents do BINGO. On 04/06/22 at 03:34 PM, Licensed Nurse (LN) G stated the facility had a new activity director and did not have any activities organized. She was unfamiliar with activity assessments and the activities that occurred on her shift. On 04/06/22 at 04:32 PM, Activities Z stated she had worked at the facility almost a month. She stated she was educated about activity assessments but was unaware how often they were completed. On 04/06/22 at 05:22 PM, Administrative Nurse D stated the facility did not have activities from January to February and would have utilized floor staff and hospice to provide activities. She stated social services completed activity assessments and activity care plans on admission. Since there was no activity calendar, activity supplies were not provided. The facility's Therapeutic Activities Program policy, revised 04/01/22, directed the facility implemented an ongoing resident centered activities program that incorporated the resident's interests, hobbies, and cultural preferences which was integral to maintaining and/or improving a resident's physical, mental, and psychosocial well-being and independence. The policy directed it was important for residents to have a choice about which activities they participated in, whether they were part of the formal activities program or self-directed and a resident's needs and choices for how they spend time, both inside and outside the facility, were also supported and accommodated. The policy directed individual interventions were developed based on each resident's assessed needs and the family was notified for any special requests; the individual program was provided according to a consistent scheduled identifying specific days of the week and time frame for which program occurred; and each resident's individual program included interventions that met the resident's social, emotional, physical, spiritual, and cognitive functioning needs, these approaches reflected the resident's lifestyle and interests and were incorporated into the interdisciplinary care plan. The facility failed to consistently provide activities for R17. This deficient practice had the risk for a decline in physical, mental, and psychosocial well-being and independence.

The facility identified a census of 53 residents. The sample included 16 residents; three residents sampled for pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) review. Based on observations, record reviews, and interviews, the facility failed to ensure prevention of cross-contamination during wound care for Resident (R) 3 and failed to ensure heel protectors were worn at all times as ordered for R21 who had a history of heel wounds. This deficient practice had the risk for prolonged wound healing, development or worsening of wounds, and unwarranted physical complications for R3 and R21. Findings included: - The Diagnoses tab of R3's Electronic Medical Record (EMR) documented diagnoses of pressure ulcer of sacral (large triangular bone between the two hip bones) region stage three (wound that extends into the subcutaneous [beneath the skin] tissue layer) and need for assistance with personal care. The admission Minimum Data Set (MDS) dated 10/01/21 documented R3 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. R3 required extensive physical assistance with one staff for bed mobility, dressing, toileting, and personal hygiene; total physical dependence with two staff for transfers. R3 was at risk for pressure ulcers and had one unhealed stage three pressure ulcer at time of assessment. The Quarterly MDS dated 03/21/22 documented R3 had a BIMS score of 10 which indicated moderate cognitive impairment. R3 required extensive physical assistance with two staff for bed mobility, dressing, toileting, and personal hygiene; total physical dependence with two staff with transfers. R3 was at risk for pressure ulcers and did not have any unhealed pressure ulcers at the time of assessment. The Pressure Ulcer Care Area Assessment (CAA) dated 10/14/21 documented R3 had an active stage three pressure ulcer, staff provided routine continence checks and assisted with incontinence care as needed. Preventative treatments were provided as ordered and/or as needed, staff provided daily skin checks with cares, weekly skin assessments by licensed nurse and communication was made with physician for any skin change noted. R3 utilized a pressure reducing mattress and wheelchair cushion to protect skin, wound treatments were administered by licensed nurse and R3 was seen weekly by mobile wound physician until wound resolved/healed. The Care Plan last revised 10/13/21 documented R3 had actual skin impairment of a coccyx (small triangular bone at the base of the spine) stage three pressure ulcer and directed staff administered wound treatments as ordered. The Care Plan dated 10/13/21 documented R3 was at risk for skin integrity impairment and directed staff clean and dried R3 after each incontinent episode and staff performed routine continence checks and assisted/provided incontinence cares as needed. The Orders tab of R3's EMR documented an order with a start date of 03/13/22 to clean coccyx with wound cleanser, pat dry, apply skin prep (a solution when applied that forms a protective waterproof barrier on the skin) around wound, apply santyl (ointment used to help the healing of burns and skin ulcers) to entire wound bed edge to edge nickel thick, apply gentamicin (broad spectrum topical antibiotic) to hydrofera blue (moist wound dressing) prior to applying calcium alginate (highly absorptive, non-occlusive dressing) to wound base, cover with dry dressing. On 04/06/22 at 10:50 AM, Licensed Nurse (LN) H and Consultant HH entered R3's room to perform wound assessment and wound care. LN H closed the door and blinds, raised the bed, then performed hand hygiene and donned (put on) gloves. Consultant HH performed hand hygiene and donned gloves. Consultant HH stood on the left side of the bed and used the draw sheet on to roll R3 onto her right side to visualize her coccyx/sacral wound while LN H held R3 in that position from the right side of the bed. Consultant HH unfastened R3's brief and noticed she had some bowel movement in her brief. There was no dressing in place on R3's coccyx wound at that time. Consultant HH measured the wound with a wound measuring ruler that she removed from her bag, wound measured 0.5 x 0.2 x 0.3 centimeters (cm). Consultant HH stated the wound was improving. She used a tablet to take pictures of the wound. Consultant HH pulled out a wound imaging device from her bag that she stated was used to determine if there was bacteria in the wound. After she took a picture with the device, she used her tablet to take a picture of the device's readings then removed a curette (surgical instrument designed for scraping or debriding [removal of damaged tissue or foreign objects from a wound] biological tissue or debris in a biopsy, excision, or cleaning procedure) from her bag to debride the wound. After the debridement, she took another picture with the device to check for bacteria in the wound then used her tablet to take a picture of the device's readings. Consultant HH placed a piece of moist gauze in R3's wound then placed the wound imaging device back in her bag and placed the curette in the sharps container. She did not doff (remove) her gloves and perform hand hygiene at any point in this procedure. Consultant HH then switched sides with LN H who doffed gloves and performed hand hygiene before proceeding on with the dressing change. R3 continued to have bowel movement present. LN H did not clean the bowel movement before proceeding to the wound care procedure. LN H removed the moist gauze from the wound then doffed gloves, performed hand hygiene, and donned new gloves. LN H applied skin prep around the wound then applied santyl to the wound. LN H placed hydrofera blue inside the coccyx wound then applied gentamycin to the calcium alginate dressing then onto the wound. LN H pulled brief back over R3's buttocks and stated she would get the aides to come in to clean her up. LN H and Consultant HH doffed gloves then performed hand hygiene. On 04/06/22 at 03:34 PM, LN G stated she prevented pressure ulcers by repositioning residents every two hours and she prevented cross-contamination during wound care by having supplies on a sterile field and cleaning up bowel movements before procedure. She stated hand hygiene was performed during the procedure. On 04/06/22 at 04:51 PM, Administrative Nurse F stated cross-contamination was prevented during wound care by making sure resident was clean and free of bowel movement and change gloves/perform hand hygiene during the procedure. She stated staff should not put a clean dressing on a coccyx/sacral wound before cleaning up bowel movement as it could contribute to bacteria getting into the wound. On 04/06/22 at 05:09 PM, LN H stated hand hygiene and changing gloves were performed during wound care to prevent wound contamination. She stated if a resident had a bowel movement, typically she changed the resident before starting the dressing change and would not put a dressing on if bowel movement was near the wound. LN H stated she should have stopped the wound care and cleaned off the bowel movement. If the bowel movement was near the wound bed, it could contaminate the wound. On 04/06/22 at 05:22 PM, Administrative Nurse D stated pressure ulcers were prevented by offloading, providing a low-air loss mattress, barrier creams, and heel protectors if applicable. She stated cross-contamination was prevented during wound care by having field set up prior to procedure and having an extra hand if needed. Administrative Nurse D stated staff washed hands and did not go from a clean to dirty surface to prevent contamination. If there was bowel movement present during dressing changes, staff cleaned the bowel movement before changing the dressing change. The facility's Pressure Ulcer/Injury Prevention and Management policy, dated 11/27/18, directed measures to maintain and improve the patient's tissue tolerance to pressure included skin cleansing with appropriate cleanser at the time of soiling and at routine intervals. The Pressure Injury Management, Long-Term Care reference provided by facility, last revised 08/16/19, directed implementation of wound care included verifying the practitioner's order for wound care, performing hand hygiene and putting on gloves as need to comply with standard precautions. Supplies including prescribed dressings, medications, sterile gauze pads, and cleaning solution and were placed on a disinfected surface to prevent cross-contamination. Dressing change with sharp conservative bedside debridement were to be completed using sterile technique (free from bacteria of other living microorganisms). Hand hygiene was performed after removing old dressings, after cleaning wound, and after applying new dressing. The facility's Area of Focus: Basic Skin Management policy, not dated, directed wound care was provided utilizing a clean technique. The facility failed to prevent cross-contamination during wound care for R3. This deficient practice had the risk for prolonged wound healing and unwarranted physical complications for R3. - The Diagnoses tab of R21's Electronic Medical Record (EMR) documented diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance. The Annual Minimum Data Set (MDS) dated 07/22/21, documented a Brief Interview for Mental Status (BIMS) was not completed due to R21 rarely/never understood. R21 required extensive physical assistance with one staff for bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. R21 was at risk for pressure ulcers but did not have pressure ulcers at time of assessment. The Quarterly MDS dated 01/14/22, documented a BIMS was not completed due to R21 rarely/never understood. R21 required extensive physical assistance with two staff for bed mobility, transfers, locomotion, dressing, and personal hygiene. R21 was at risk for pressure ulcers but did not have pressure ulcers at time of assessment. The Pressure Ulcer/Injury Care Area Assessment (CAA), dated 08/06/21, documented R21 had an Activities of Daily Living (ADL) function impairment. The CAA did not address pressure ulcer risk. The Care Plan last revised 11/10/21, directed R21 had a risk for skin integrity impairment related to limited mobility, incontinence, and routine medication administration. The Care Plan directed staff assisted R21 with putting on and taking off heel protectors for wound prevention. The Orders tab of R21's EMR documented an order with a start date of 03/05/21 for bilateral heel protectors on at all times except during personal care for skin integrity. The Notes tab of R21's EMR revealed a Skin/Wound Note on 03/02/21 at 09:12 PM that documented R21 had a two centimeter (cm) by two cm blacken tissue on back of right heel. The doctor and family were notified. The Notes tab of R21's EMR revealed a Skin/Wound Note on 03/11/21 at 05:35 PM that documented the hospice nurse visited R21. Right heel remained unchanged with skin prep (a solution when applied that forms a protective waterproof barrier on the skin) applied every shift and heel protectors on at all times except during personal care. On 04/04/22 at 09:48 AM, R21 laid in bed, eyes closed. R21's heel protectors were not worn by R21 as ordered. The heel protectors were in R21's wheelchair. On 04/04/22 at 12:46 PM, R21 sat in her wheelchair in her room and watched television. Heel protectors were not worn by R21 as ordered. On 04/04/22 at 04:17 PM, R21 sat in her wheelchair in her room and watched television. Heel protectors were not worn by R21 as ordered. R21 had nonskid socks on. On 04/05/22 at 08:32 AM, R21 laid in bed, head of bed elevated; R21's breakfast tray was recently delivered. Heel protectors were not worn by R21 as ordered. On 04/06/22 at 11:14 AM, Certified Medication Aide (CMA) S removed R21's heel protectors and socks for surveyor observation. No redness or wounds noted on either heel. Socks and heel protectors reapplied by CMA S. On 04/06/22 at 02:40 PM, Certified Nurse Aide (CNA) M stated she prevented pressure ulcers by repositioning every two hours, making sure residents are clean and dry, and putting on heel protectors if they have them. On 04/06/22 at 03:20 PM, CMA R stated R21 was supposed to wear heel protectors all the time and that intervention was found in the care plan. On 04/06/22 at 03:34 PM, Licensed Nurse (LN) G stated she prevented pressure ulcers by repositioning residents and putting on heel protectors if applicable. She stated she has seen R21 wear heel protectors. On 04/06/22 at 05:22 PM, Administrative Nurse D stated pressure ulcers were prevented by offloading, utilizing low-air loss mattresses, protein in the diet, and barrier creams. She stated R21 had heel protectors on and the nurse could look at the care plan for that intervention. The facility's Pressure Ulcer/Injury Prevention and Management policy, dated 11/27/18, directed measures to protect the patient against the adverse effects of external mechanical forces such as pressure, friction and shear were implemented in the care plan and included: utilizing positioning devises to keep bony prominences from direct contact and heel protection/suspension should be implemented while patient is in bed. The facility's Area of Focus: Basic Skin Management policy, not dated, directed all residents had preventative measures in place that included pressure redistribution mattress on all beds, wheelchair cushions, heel boots or suspension if need, and repositioning per CNA and ADL care. The facility failed to ensure heel protectors were worn at all times for R21 who had a history of heel wounds. This deficient practice placed the resident at risk for development of pressure ulcers and wound related complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The electronic medical record (EMR) indicated the following diagnosis for R225: metabolic encephalopathy (inflammatory condition of the brain), type two diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dysphagia (swallowing difficulty), insomnia (inability to sleep), urinary retention (lack of ability to urinate and empty the bladder), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) , and constipation. A review of R225s admission Minimum Data Set (MDS) completed 03/21/22 indicated a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. The MDS indicated she had a indwelling catheter (tube placed in the bladder to drain urine into a collection bag) at the time of admission with occasional urinary continence and bowel continence not rated. The MDS indicated total dependence for staff related to hygiene, transfers, bathing, toileting, personal cares, and eating. A review of R225's Activities of Daily Living (ADL's) Care Area Assessment (CAA) dated 03/21/22 stated she had worked to regain current level of functioning after being recently hospitalized from a fall before her admission. A review of R225's Fall CAA dated 03/21/22 indicated resident required close monitoring related to her recent fall. R225's Care Plan revised 03/18/2022 noted that she had an ADL self-care deficit related to activity intolerance. The care plan stated that she was dependent on staff assist for all ADL's and encouraged to use her call light for assistance. On 03/16/22 R225's Care Plan initiated an injury prevention intervention of a helmet to protect the resident from head injuries. This intervention remained active until being resolved on 04/04/22. On 04/04/22 at 08:00 Am, an observation of the room revealed no helmet. She sat in her chair watching television. R225 stated the she has never seen or heard of a helmet since she admitted in February. She reported that staff have never asked her to wear a helmet. On 04/04/22 at 12:40 PM R225 sat in her room watching television. The resident appeared to be engaged in her television show. She did not wear an injury prevention helmet. In an interview completed on 04/06/22 at 02:20 PM with Certified Nurse Aid (CNA) M, she stated that she was not aware that R225 ever worn a protective helmet. She reported staff review the resident care plans frequently. In an interview completed on 04/06/22 at 02:50PM with Licensed Nurse (LN) G, she stated that she has cared for R225 before and may have seen her with the protective helmet on last week but R225 has been in bed all day and has not worn it. In an interview completed on 04/06/22 at 04:20PM with Administrative Nurse E, she stated that R225's protective helmet was implemented by the facility after a recent fall. She stated that the helmet was ordered but the facility was waiting for it to arrive and had discontinued the documented intervention. A review of the facility's Fall Management policy reviewed 08/2021stated the facility will assess the resident for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls. The policy stated that each resident receives adequate supervision and assistance devices to prevent accidents. The policy noted that the facility will review and revise the care plan upon a fall event and as needed thereafter. The facility failed to implement R225's care planned protective helmet. This deficient practice placed the resident at risk for injuries associated with falls - R205 admitted to facility on 01/07/22. The Diagnoses tab of R205's Electronic Medical Record (EMR) documented diagnoses of anoxic brain injury (condition caused by a complete lack of oxygen to the brain), need for assistance with personal care, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and history of falling. The admission Minimum Data Set (MDS) dated 01/14/22, documented a Brief Interview for Mental Status (BIMS) was not completed due to R205 rarely/never understood. R205 required extensive physical assistance with two staff for bed mobility and dressing; total physical dependence with one staff for eating and personal hygiene; total physical dependence with two staff for toileting and transfers. R205 had two or more noninjury falls since admission. The Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA) dated 01/17/22 documented R205 had cognition loss related to short and long term memory loss. The Falls CAA dated 01/20/22, documented R205 was at risk for falls related to diagnoses, routine medication administration, and impulsiveness. R205 had a fall prior to admission and three noninjury falls since admission to the facility. Staff encouraged R205 to use the call light for activities of daily living (ADL) needs and transfers and to wear appropriate footwear when ambulating or mobilizing in wheelchair. The Care Plan initiated on 01/08/22, directed R205 was at risk for falls and had an actual diagnosis of frequent falls related to behaviors and directed that staff assisted with ADLs as needed, assisted with transfers, and R205's call light was within reach. The care plan documented the following interventions after falls with dates initiated: 01/09/22 actual fall, fall mat, bolsters, low bed, and assist with toileting- initiated 01/09/22 Fall on 01/12/22. Position in new Broda (specialized wheelchair with the ability to tilt and recline) chair- initiated 01/12/22 01/12/22 new order for Xanax (antianxiety medication- class of medications that calm and relax people with excessive anxiety [mental or emotional reaction characterized by apprehension, uncertainty and irrational fear], nervousness, or tension]) 0.5 milligram (mg) twice a day for restlessness/agitation- initiated 01/12/22, revised 01/14/22 01/23/22 actual fall. Staff in resident's room during that shift to prevent fall. Remove furniture for safety- initiated 01/23/22, revised 01/27/22 01/24/22 actual fall. Staff to monitor until sleep during that shift, continue with plan of care- initiated 01/24/22, revised 02/05/22 Resident had actual fall on 02/04/22. Resident to be monitored for positioning, things to grab, and comfort while in Broda chair- initiated 02/04/22 Resident had actual fall on 02/18/22, non-injury, found on floor beside bed on mat- initiated 02/18/22 Actual fall on 02/18/22, non-injury, found on floor mat. Offer toileting and all needs met before laying in bed- initiated 03/11/22 03/12/22 education for staff anticipating residents needs such as pain, toileting, hydration, anxiety, and following medication regimen- initiated 03/12/22 03/13/22 resident to wear helmet at all times when out of bed to prevent injury to head in case of fall- initiated 03/14/22 Resident often refuses or takes helmet off and throws it. Use redirection to assist with putting it back on- initiated 03/14/22 Actual fall on 03/21/22. Anticipate and meet the resident's needs- initiated 03/21/22 03/22/22 hipsters for safety- initiated 03/22/22 Actual fall on 03/28/22. Continue all current interventions in place, remove bed rails from resident's bed- initiated 03/29/22 Upon request, the facility provided fall investigations for falls on 01/09/22 at 04:59 PM, 01/12/22 at 03:53 PM, 01/12/22 at 11:28 PM, 01/23/22 at 10:15 PM, 01/24/22 at 11:00 PM, 02/04/22 at 03:30 AM, 02/18/22 at 12:45 AM, 03/12/22 at 07:45 AM, 03/21/22 at 08:40 AM, 03/22/22 at 06:30 PM, 03/23/22 at 10:13 AM, and 03/28/22 at 09:24 PM. The investigations lacked evidence of a root cause analysis of the falls, to determine what caused the falls, which was needed to ensure appropriate interventions were in place to prevent further falls. On 04/04/22 at 04:15 PM, R205 sat in his Broda chair in the day room, helmet not on at that time. On 04/05/22 at 08:21 PM, R205 sat in his Broda chair at a table in the day room, helmet not on at that time but was observed on the table. On 04/05/22 at 11:40 AM, R205 sat in his Broda chair at table in day room, helmet not on at that time but was observed on the table. Staff conversed with resident and encouraged him to put helmet back on which he did. On 04/05/22 at 11:46 AM, R205 sat in his Broda chair at table in day room, he attempted to talk to staff walking past him, but they did not acknowledge hearing him. On 04/06/22 at 09:18 AM, R205 sat in his Broda chair at table in day room, he attempted to talk to anyone who passed by him but only one staff member stopped to talk to him. He appeared to want to converse with anyone. On 04/06/22 at 10:23 AM, R205's bed had 1/8 bed rails on both sides of his bed. On 04/06/22 at 02:40 PM, Certified Nurse Aide (CNA) M stated when a resident fell, she asked the resident if they were okay and stayed with the resident. CNA M stated she put the call light on to get help or if the resident had a roommate that was able to call for help, she had them do so. On 04/06/22 at 03:20 PM, Certified Medication Aide (CMA) R stated R205 usually fell because he thought he was in his car and he had to get out of the facility. She stated he wore a helmet when he was up, fall mats on both sides of the bed, and bed to the floor for fall prevention for R205. CMA R stated R205 has had the same bed rails on his bed since admission and had not heard about an intervention to remove them. On 04/06/22 at 04:08 PM, Administrative Nurse E stated after a fall occurred, she or the Director of Nursing (DON) placed new interventions on the care plan, and they tried to implement different interventions for each fall. On 04/06/22 at 05:22 PM, Administrative Nurse D stated if a fall occurred, the care plan was updated as needed and the interdisciplinary team (IDT) met to decide what happened and what interventions to put into place then the unit manager communicated the interventions to the team to implement them. She stated if a resident was found on the floor, the nurse was alerted and assessed the resident prior to moving the resident. Once resident was safe to move then staff assisted resident to the chair or to the bed. After the nurse completed the assessment, they notified the family, the doctor, and the DON. Administrative Nurse D stated the nurse interviewed the resident and any witnesses to find out the cause of the fall to decide on an intervention. The IDT met weekly and as needed, reviewed falls, made sure the assessment was completed, determined the cause of the fall, and if the intervention in place was appropriate for the fall then the care plan was updated if needed. She stated R205 had not had any new bed rails put on since admission. The facility's Fall Management policy, dated 06/04/20, directed the facility assessed the resident upon admission/readmission, quarterly, with change in condition, and with any fall event for any fall risks and identified appropriate interventions to minimize the risk of injury related to falls. The policy directed the IDT reviewed and revised the care plan, if indicated, upon completion of the comprehensive, significant change and quarterly MDS, upon a fall event, and as needed thereafter. The facility failed to implement interventions in place after a fall and thoroughly investigate falls for a root cause to determine if appropriate interventions were in place after each fall for R205. This deficient practice had the risk for further falls, possible injuries from falls, and unwarranted physical complications. The facility identified a census of 53. The sample included 16 residents with two residents reviewed for elopement. Based on observation, interviews, and record review, the facility failed to ensure a safe environment for Resident (R)42, when R42 eloped (when a cognitively impaired resident leaves the facility without staff knowledge or supervision) from the facility. This placed R42 at risk for injuries from accidents or hazards. The facility further failed to implement care planned interventions aimed to protect R225 and R205 from injuries related to falls and failed to thoroughly investigate and determine the root cause of falls for R205. This placed the residents at increased risk for injury related to falls. Findings included: - R42's Electronic Medical Record (EMR) recorded diagnoses of schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), epilepsy (brain disorder characterized by repeated seizures), obsessive-compulsive disorder (OCD - anxiety disorder characterized by recurrent and persistent thoughts, ideas and feelings of obsessions severe to cause marked distress, consume considerable time or significantly interfere with the resident's occupational, social or interpersonal functioning), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), mild intellectual disabilities, and psychosis (any major mental disorder characterized by a gross impairment in reality testing). The Significant Change Minimum Data Set (MDS) dated [DATE] recorded R42 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. The MDS recorded R42 was independent with no set up to supervision for most activities for daily living (ADLs), and limited assistance of one staff for personal hygiene. R42 rejected cares during the look back period but had no wandering behaviors. The Quarterly MDS dated 03/02/22 recorded R42 had a BIMS of nine which indicated moderately impaired cognition. The MDS recorded R42 required supervision with set-up assistance for all ADLs. He rejected cares during the look back period but had no wandering behaviors. The Behavior Care Area Assessment (CAA) dated 12/06/22 recorded R42 had behavior symptoms of rejection of care. Staff encouraged as much participation as possible during care activities. The Falls CAA recorded R42 was at risk for falls but had no falls since his readmission; staff encouraged call button use for ADL needs and transfers and encouraged R42 to don appropriate footwear when ambulating or mobilizing in wheelchair. The Elopement Risk Assessments completed on 02/19/22 documented R42 was not at risk for elopement. The Care Plan recorded interventions created on 11/11/20 and resolved on 12/07/21 which directed staff to encourage participation in activities and provide for safe wandering. The Care Plan intervention dated 11/11/20 directed R42 was qt risk for changes in mood or behavior due to medical condition. It directed staff to consult with the resident on his preferences regarding customary routine. A Behavior Note dated 03/31/22 at 11:07 AM documented Invega (antipsychotic medication used to treat schizophrenia) 117 milligram (mg) injection given in the left buttocks. R42 did not take his other medications but allowed the injection. R42 offered no resistance to the injections and Consultant GG was notified. A Nurse Note dated 03/31/22 at 01:50 PM documented R42 was yelling, clapping his hands and quoting bible verses, and yelling out the earth was coming to an end. The nurse called Consultant GG and representative. R42's representative stated she wanted R42 sent to the acute care hospital. R42 began talking loudly and walking fast but left with emergency services without requiring restraint. A Health Status Note dated 03/31/22 at 08:25 PM documented R42 returned to the facility. R42 appeared calm and quiet, moved from the stretcher to his bed. R42 quietly ate his meal and rested in his bed. An Event Note dated 04/01/22 at 09:06 AM documented at 07:50 AM R42 was outside his room and refused his medications multiple times. He walked in and out of his room. He was alert to himself some confusion. At 08.07 AM staff reported to Licensed Nurse (LN) J that R42 was outside of the building. LN J and other staff rushed outside and observed Certified Nurse Aid (CNA) P escorting R42 back to the building. R42 stated thank you, thank you, you saved my life. R42 stated he wanted blood. He was not able to tell staff how he got out of the building. Staff initiated 1:1 supervision of R42. R42 continued to refuse his medication. Staff notified Consultant GG of the occurrence. An Event Note entered on 04/01/22 at 09:33 AM documented the nurse saw resident walk by her office and was stating thank you, you saved my life. She went out to the hallway to make sure everything was ok and was informed that the resident had just been brought back in from outside. CNA P stated she found him outside. The nurse asked the resident what he was doing there, and he stated, I need to get blood from the blood bank. The nurse also tried to ask how he got out of the facility and he stated, I don't know. 1:1 was assigned at that time. An undated Witness Statement from CNA P documented she saw R42 at 07:30 AM while she was taking breakfast orders. CNA P went to the kitchen to start working on the breakfast trays and was notified by dietary staff there was a lady outside who stated she may have observed a resident in the parking lot. CNA P ran out and saw R42. CNA P returned R42 to the building with no issues. An undated Witness Statement from LN J recorded LN J saw R42 at 07:50 AM during the medication pass. LN J attempted to give R42 his morning medications. AT 08:05 AM, LN J received notification that R42 was outside the building. LN J rushed outside via the back door and observed CNA P as she walked R42 back to the building. LN J documented R42 was unable to recall how he got out of the facility. The Facility Investigation recorded at 07:50 AM LN J had contact with R42 during the medication pass. Around 08:05 AM a neighbor from the apartments in back notified dietary staff she saw a resident walking from the back of the building. Kitchen staff notified nursing staff and CNA P immediately went to the back of the building to meet the resident. R42 was behind the building, in the parking area approximately 100 feet from the facility. R42 wore a gown, jogging pants, socks and shoes. R42 returned to the building willingly. Staff assessed R42 for injuries with none noted. Staff notified R42's representative and Consultant GG. The facility updated R42's plan of care, applied a Wanderguard and implemented 1:1 supervision for R42. On 04/04/22 at 07:32 AM observation revealed all exit doors were locked. The required doors had a functioning 15 second door lock release. In an interview on 04/05/22 at 08:11 AM CNA P stated on 04/01/22 she worked with a CNA trainee and LN J. She said at around 07:30 AM she saw R42 while she and the trainee collected breakfast menus. She stated a while later, after all the menus were collected and turned in, she went to the kitchen to help get trays together. Dietary BB told CNA P there was a lady outside who stated she though she saw one of the residents outside. CNA P stated she did not speak with the lady, so she was unsure if the lady saw how the resident exited the building. CNA P stated she immediately went out back and observed R42 walking towards the bank in the parking lot. She was able to reach R42 and direct him back to the building. She stated R42 was confused and unable to say how he exited the building. CNA P said R42 had no history of exit seeking and was not at risk for elopement. She stated he did have a lot of behaviors like yelling and clapping and repeating bible quotes but did not actively seek exits or verbalize a desire to leave. CNA P stated residents who were at risk for elopements were added to the elopement book and wore a Wanderguard. CNA P stated the staff knew who was at risk and what special needs the residents required in nursing report and walking rounds. She stated all residents who were at risk for elopement received increased supervision. In a telephone interview on 04/05/22 at 09:08 AM LN J stated he was R42's nurse on 04/01/22. LN J stated he attempted to give R42 his medications that morning at 07:50 AM. LN J reported R42 took the medications and walked back to his room. LN J followed to ensure R42 took the medications. Once R42 was in his room, R42 stated he did not want to take the medications, so LN J took the medications back to the medication cart. A few minutes later, R42 walked by the medication cart a few times and walked in and out of his room. LN J stated he again offered R42's medications and R42 continued to refuse. LN J reported he entered another resident's room and exited 10 minutes later. At that time, staff alerted LN J that R42 was outside of the building. LN J stated he immediately went out the back door and observed CNA P and R42 walking back to the building. LN J reported R42 thanked staff for saving his life and reported R42 said he tried to go to the bank for some blood. LN J reported R42 continued to refuse his medications but LN J asked another nurse to attempt to get R42 to take his medications and that nurse was successful. LN J stated R42 had a history of behaviors but was not an elopement risk prior to the incident. He further reported staff were familiar with R42's behaviors and medications refusal and when that happened, staff enlisted the aid of other staff members that R42 typically responded positively to. In an interview on 04/06/22 at 05:25 PM Administrative Nurse D stated she was familiar with R42. Administrative Nurse D said R42's behavior was stable until recently when he had a big change in his behaviors. She said R42 was hospitalized due to his escalating behaviors and refusal to take his oral medications. She reported the facility was sending R42 out for acute care every two to four weeks related to his behaviors. Administrative Nurse D stated the day R42 exited the facility, he refused all his oral medications. Facility staff were able to administer his medications via injection. She stated R42 was able to identify his behaviors, but he was unable to control them and that caused R42 distress. Administrative Nurse D stated the facility checked all doors to ensure all alarms were functions and the doors were checked in the morning prior to the event and after the event and all were functioning properly. The facility's policy Behavior Management recorded the facility must provide necessary care and services which included ensuring the necessary care and services were person-centered and reflected goals for care while maximizing the residents'' safety. The facility failed to ensure a safe environment for R42, when exited the facility without staff knowledge or supervision. This placed R42 at risk for injuries from accidents or hazards.

The facility identified a census of 53 residents. The sample included 16 residents with three reviewed for catheter and incontinence care. Based on observations, record reviews, and interviews, the facility failed to provide consistent incontinence care for Resident's (R) 30 and R44, and catheter care for R225. This deficient practice placed the resident at risk for infections and impaired psychosocial well-being. Findings Included: -The electronic medical record (EMR) indicated the following diagnosis for R30: muscle weakness, major depressive disorder (major mood disorder). hypertensive heart disease (chronic high blood pressure), insomnia (difficulty falling asleep), traumatic brain injury (TBI), constipation, and abnormalities of gait and coordination. A review of R30's admission Minimum Data Set (MDS) completed 02/17/22 indicated a Brief Interview for Mental Status (BIMS) score of seven indicating intact cognition. The MDS revealed she was occasionally incontinent of bowel and bladder with no toileting program. A review of R30's Activities of Daily Living (ADL's) Care Area Assessment (CAA) dated 02/17/22 indicated that her urinary incontinence would be addressed in her care plan. The CAA indicated that she felt urgency to void at times. A review of R30's Care Plan revised 03/11/22 lacked documentation related to her bowel and bladder incontinence. A review of R30's Lookback report under Bowel and Bladder Elimination between 02/10/22 and 04/05/22 indicated that she had incontinent episodes on 12 occasions. A review of R30's assessment lacked evidence of the incontinence assessment tool was completed . In an interview completed on 04/05/22 at 02:22 PM with R30, she stated that she does have incontinence issues but reported them to the nursing staff. She reported that she is not sure if a special bowel program was started. In an interview completed on 04/06/22 at 02:20 PM with Certified Nurse Aid (CNA) M, she stated that staff can review the resident's care to see who has special precautions related to toileting and assisting residents to the restroom. She stated that she doesn't know if R30 has a special bowel program. She stated that if something was missing or not in the care plan it would be reported to the nurse. In an interview completed on 04/06/22 at 02:20PM with Licensed Nurse (LN) G, she stated that the nursing staff review resident's care plans and updates the other staff member of changes that occur. She reported that if a resident was on a special bowel program it would in the care plan. In an interview completed on 04/06/22 at 04:20PM with Administrative Nurse E, she stated that when residents first arrive a base line care plan with be completed and a comprehensive assessment with occur after the care plan has been established. She reported areas triggered on the MDS should be placed in the care plan and addressed on the comprehensive care plan. A review of the facility's Urinary Incontinence Management revised 04/2022 stated that the facility must ensure that resident's receive services and assistance to remain continent of bowel and bladder. The policy stated that each resident who is incontinent of bladder will be identified, assessed, and provided appropriate treatment and services to achieve or maintain as much normal bladder function as possible. A review of the facility's Care Plan Policy revised 10/2019 stated that the care plan identified and included a focus statement, measurable goals, interventions of identified problems. The policy indicated that the care plan must include identified issues from the resident's comprehensive assessment, CAA, and MDS. The facility failed to provide consistent incontinence care to R30. This deficient practice placed the resident at risk for infections and impaired psychosocial well-being. -The electronic medical record (EMR) indicated the following diagnosis for R44: hypertension (high blood pressure), cerebrovascular disease (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiplegia (left sided paralysis of one side of the body), dysphagia (swallowing difficulty), and muscle weakness. A review of R44's Quarterly Minimum Data Set (MDS) completed 03/10/22 indicated a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS indicated that she was frequently incontinent of urine and occasionally incontinent of bowel with no toileting program in place. Her MDS revealed she required extensive assistance from one staff member for transferring, dressing, bathing, personal hygiene, and toileting. A review of R44's Urinary Incontinence CAA dated 12/09/21 stated that staff were to provide routine checks and assistance with incontinence cares as needed. R44's Care Plan revised 12/03/21 stated that staff were to provide routine incontinence checks and provide cares when needed but failed to provided interventions related to improving or preventing incontinence episodes. A review of R44's EMR under Assessments indicated on two occasions (03/02/22 and 12/02/22) that she was a candidate for toileting program but lacked documentation it was implemented. A review of R44's Lookback report under Bowel and Bladder Elimination between 01/01/22 and 04/05/22 indicated that she had incontinent episodes on 63 occasions. On 04/04/22 at 08:35AM R44 reported that she has had bowel and bladder accidents waiting for staff to respond to the call lights. She reported that she does have problems with incontinence but does not remember if she had any special programs for it. In an interview completed on 04/06/22 at 02:20 PM with Certified Nurse Aid (CNA) M, she stated that staff can review the resident's care to see who has special precautions related to toileting and assisting residents to the restroom. She stated that she doesn't know if R44 has a special bowel program. She stated that if something was missing or not in the care plan it would be reported to the nurse. In an interview completed on 04/06/22 at 02:20PM with Licensed Nurse (LN) G, she stated that the nursing staff review resident's care plans and updates the other staff member of changes that occur. She reported that if a resident was on a special bowel program it would in the care plan. In an interview completed on 04/06/22 at 04:20PM with Administrative Nurse E, she stated that when residents first arrive a base line care plan with be completed and a comprehensive assessment with occur after the care plan has been established. She reported areas triggered on the MDS should be placed in the care plan and addressed on the comprehensive care plan. A review of the facility's Urinary Incontinence Management revised 04/2022 stated that the facility must ensure that resident's receive services and assistance to remain continent of bowel and bladder. The policy stated that each resident who is incontinent of bladder will be identified, assessed, and provided appropriate treatment and services to achieve or maintain as much normal bladder function as possible. A review of the facility's Care Plan Policy revised 10/2019 stated that the care plan identified and included a focus statement, measurable goals, interventions of identified problems. The policy indicated that the care plan must include identified issues from the resident's comprehensive assessment, CAA, and MDS. The facility failed to provide consistent incontinence care to R44. This deficient practice placed the resident at risk for infections and impaired psychosocial well-being. - The electronic medical record (EMR) indicated the following diagnosis for R225: metabolic encephalopathy (inflammatory condition of the brain), type two diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dysphagia (swallowing difficulty), insomnia (inability to sleep), urinary retention (lack of ability to urinate and empty the bladder), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) , and constipation. A review of R225s admission Minimum Data Set (MDS) completed 03/21/22 indicated a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. The MDS indicated she had a indwelling catheter (tube placed in the bladder to drain urine into a collection bag) at the time of admission with occasional urinary continence and bowel continence not rated. The MDS indicated total dependence for staff related to hygiene, transfers, bathing, toileting, personal cares, and eating. A review of R225's Activities of Daily Living (ADL's) Care Area Assessment (CAA) dated 03/21/22 stated she had worked to regain current level of functioning after being recently hospitalized from a fall before her admission. A review of R225's Urinary Incontinence CAA dated 03/21/22 indicated her goal was to regain control of her bladder and have the catheter removed. R225's Care Plan revised 03/18/2022 noted an indwelling urinary catheter related to neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system). The care plan stated to position the catheter bag and tubing below the level of her bladder and provide privacy cover. The care plan noted that staff were required to complete catheter care each shift. A review of R225's Treatment Administration Report (TAR) indicated her Foley catheter (tube inserted into the bladder to drain urine into a collection bag) was ordered and given on 03/14/22. The order instructed staff to complete catheter care and track urine output (amount of urine voided) on each shift. R225's TAR revealed missed catheter care opportunities on two occasions (3/15 and 3/29) and failed to document urine output on five occasions (3/17, 3/20, 3/23, 3/29, and 4/2). On 04/04/22 at 08:00 AM, an observation of the room revealed her in her chair watching television. Inspection of R225's catheter bag revealed a privacy cover, positioned lower than her bladder, and no leaks or obstructions. R225 appeared to be comfortable and denied pain and discomfort. In an interview completed on 04/06/22 at 02:20 PM with Certified Nurse Aid (CNA) M, she stated the CNA staff clean the catheter site each shift and are responsible for documenting the output of each resident. She reported that the CNA care staff have access to view each resident's care plan for specific instructions but also receive instructions for the nurse. In an interview completed on 04/06/22 at 02:50PM with Licensed Nurse (LN) G, she stated that CNA staff have access to the care plan. She reported that R225 can sometimes be resistive to basic cares and may refuse from time to time. A review of the Urinary Incontinence Management policy issues 04/2022 noted all residents are to be comprehensively assessed to achieve or maintain as much normal bladder function as possible. The facility failed to provide consistent catheter care to R225. This deficient practice placed the resident at risk for infections and impaired psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -The electronic medical record (EMR) indicated the following diagnosis for R23: heart failure, type one diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypertension (high blood pressure), chest pain, osteoporosis (chronic arthritis without inflammation), asthma (disorder of narrowed airways that caused wheezing and shortness of breath), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), muscle weakness, major depressive disorder (major mood disorder), and low back pain. A review of R23's Quarterly Minimum Data Set (MDS) completed [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Her MDS indicated she received oxygen therapy while a resident at the facility. A review of R23's Activities of Daily Living (ADL's) Care Area Assessment completed on [DATE] indicated that while she had been independent for bed transfers, dressing, ambulation, toileting, and personal cares, R23 was educated to utilize her call light in her room for assistance. A review of R23's Care Plan revised [DATE] indicated that she received oxygen therapy related to shortness of breath and asthma. The care plan interventions instructed staff to give two liters (L) of oxygen as ordered and as needed. R23's Medication Administration Report (MAR) in her EMR revealed an active physician's order dated [DATE] to give two liters of oxygen delivered by a nasal cannula (tubing that delivers oxygen directly through both nostrils of the nose) every evening and night shift. The physician's order revealed that oxygen tubing should be changed every Sunday evening by staff. On [DATE] at 07:41 AM R23 reported that her oxygen machine was filthy and had not been cleaned this month by staff. She stated that staff had not cleaned the filter in the machine but that she would if she could. An inspection of the oxygen machine revealed dust and debris covering the machine. An inspection of the tubing revealed it was dated [DATE]. Inspection of the external filter on the machine revealed dust covering the filter and the nasal cannula and tubing rested under the resident's blanket. An inspection of the oxygen machine revealed no plastic bag for tubing storage. On [DATE] at 09:41 AM a walkthrough of R23's room revealed her nasal cannula and tubing rested underneath her blanket on her bed. The oxygen equipment remained dirty and lacked new tubing. An inspection of the oxygen machine revealed no plastic bag for tubing storage. On [DATE] at 01:33 PM a walkthrough of R23's revealed oxygen tubing and nasal cannula again rested on her bed. An inspection of the oxygen machine revealed no plastic bag for tubing storage. The oxygen equipment remained dirty and lacked new tubing. In an interview completed on [DATE] at 02:20 PM with Certified Nurse Aid (CNA) M, she reported that nasal cannulas and oxygen tubing should be dated and stored in a plastic bag when not in use. She stated that the tubing gets changed out weekly. She stated that the tubing or nasal cannula should be replaced if contaminated. CNA M stated that staff are to make sure that the residents are using their oxygen machines but are not responsible for cleaning them. In an interview completed on [DATE] at 04:15 PM with Administrative Nurse F, she stated that the oxygen machines are cleaned by the maintenance department. She reported that the tubing should be changed out every Sunday night and staff should be storing the nasal canula and tubing in a plastic bed when not in use. A review of the facility's Oxygen Administration, Safety, and Maintenance policy revised 05/2020 stated to change oxygen supplies weekly and when visibly soiled. The plan indicated that equipment should be labeled with patient name and date when setup or changed out. The policy stated that oxygen and respiratory supplies should be stored in a bag labeled with the resident's name when not in use. The policy stated that machines with external filters should be checked daily and washed at least once a week with soap and water. The facility failed to properly clean, maintain, and store R23's oxygen therapy equipment. This deficient practice placed her at risk for complications related to respiratory therapy. -The electronic medical record (EMR) indicated the following diagnosis for R49: chronic obstructive pulmonary disorder (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing ) hypertension (high blood pressure), bipolar disorder, major depressive disorder (major mood disorder), type two diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), acute respiratory failure, hypoxia (inadequate supply of oxygen), dysphagia, lack of coordination, and insomnia (inadequate supply of oxygen). A review of R49's Significant Change Minimum Data Set (MDS) completed [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. The MDS indicated he received oxygen therapy while a resident and he required extensive assist from staff for toileting, personal hygiene, transfers, and bed mobility. A review of R49's Activities of Daily Living (ADL's) Care Area Assessment completed on [DATE] indicated he required extensive assistance for his ADL's and had a history of being verbally aggressive with staff with cares provided. A review of R49's 'Care Plan revised [DATE] indicated that he had asthma and COPD but failed to include oxygen therapy goals and interventions. R49's Medication Administration Report (MAR) in her EMR revealed an active physicians order dated [DATE] to give six liters of oxygen delivered by nasal canula (tubing that delivers oxygen directly through both nostrils of the nose) while resident is out of bed and three liters of oxygen while he is in bed. The physician's order revealed that the oxygen tubing should be changed every Sunday evening. On [DATE] at 08:12 AM R49 reported that he never uses his oxygen and often refuses when staff asks him to wear his nasal cannula. An inspection of his oxygen machine revealed the outside of the machine had collected dust and no storage bag was present for the oxygen tubing. The nasal cannula and oxygen tubing rested on the ground behind the machine. The tubing and cannula appeared dirty and visibly soiled. An inspection of the machine revealed it was dated [DATE] and expired two weeks ago. An inspection of his wheelchair's portable oxygen tank revealed no date on his oxygen tubing. On [DATE] at 07:39 AM a walkthrough of R49's room revealed his oxygen therapy tubing and nasal canula still had not been changed. R49's tubing and nasal canula were sitting on top of his dusty machine with no storage bag present. R49's oxygen machine was on and running but not being used by the resident. In an interview completed on [DATE] at 02:20 PM with Certified Nurse Aid (CNA) M, she reported that nasal cannulas and oxygen tubing should be dated and stored in a plastic bag when not in use. She stated that the tubing gets changed out weekly. She stated that the tubing or nasal cannula should be replaced if contaminated. CNA M stated that staff are to make sure that the residents are using their oxygen machines but are not responsible for cleaning them. In an interview completed on [DATE] at 04:15 PM with Administrative Nurse F, she stated that the oxygen machines are cleaned by the maintenance department. She reported that the tubing should be changed out every Sunday night and staff should be storing the nasal canula and tubing in a plastic bed when not in use. A review of the facility's Oxygen Administration, Safety, and Maintenance policy revised 05/2020 stated to change oxygen supplies weekly and when visibly soiled. The plan indicated that equipment should be labeled with patient name and date when setup or changed out. The policy stated that oxygen and respiratory supplies should be stored in a bag labeled with the resident's name when not in use. The policy stated that machines with external filters should be checked daily and washed at least once a week with soap and water. The facility failed to properly clean, maintain, and store R49's oxygen therapy equipment. This deficient practice placed him at risk for complications related to respiratory therapy. The facility identified a census of 53 residents. The sample included 16 residents, with three residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to provide necessary respiratory care and services for Resident (R) 6, R23, and R49 when the facility failed to date and store oxygen tubing (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) for R6, and failed to clean, date and store the equipment in accordance with professional standards of practice for R23 and R49. These deficient practice placed the resident's at risk for respiratory infection and/or illness. Findings included: - R6's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of chronic respiratory failure (condition in which the blood does not have enough oxygen or has too much carbon dioxide and the lungs are unable to carry the blood to the organs), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and bipolar (major mental illness that caused people to have episodes of severe high and low moods) mood disorder. The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R6 required limited assistance of one staff member for activities of daily living (ADL's). The MDS documented R6 required physical help of one staff member for set up or assistance as part of the bathing activity during the look back period. The MDS documented R6 received oxygen therapy during the look back period. The Quarterly MDS dated [DATE] documented no changes documented from previous MDS assessment. R6's ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated [DATE] documented she required limited assist by staff for bathing/showers. R6's Care Plan dated [DATE] documented oxygen via nasal cannula (a device used to deliver supplemental oxygen or increase air flow to person in need of respiratory help) or a mask at two liters per minute as needed. Review of the EMR under Orders tab revealed physician orders: Oxygen at two liters/minute via nasal cannula as needed for shortness of breath dated [DATE]. Change oxygen tubing weekly every Sunday dated [DATE]. On [DATE] at 09:31 AM R6's undated oxygen tubing and nasal cannula laid directly on floor between the oxygen concentrator and bed side table. On [DATE] at 08:51 AM R6's undated oxygen tubing and nasal cannula was coiled up and placed into the handle of the oxygen concentrator; the tubing lacked a bag. On [DATE] at 12:42 PM R6's undated oxygen tubing and nasal cannula was coiled up and placed into the handle of the oxygen concentrator; the tubing lacked a bag. On [DATE] 03:29 PM R6's undated oxygen tubing and nasal cannula was coiled up and placed into the handle of the oxygen concentrator; the tubing lacked a bag. On [DATE] at 11:25 AM R6 pushed her wheelchair down the south hallway as she talked to the hospice staff. R6's hair was uncombed, and her clothes were clean. R6's undated oxygen tubing and nasal cannula remained coiled in the handle of the oxygen concentrator. On [DATE] at 02:20 PM in an interview, with Certified Nurse Aid (CNA) M reported that nasal cannula's and oxygen tubing should be dated and stored in a plastic bag when not in use. CNA M stated that the tubing gets changed weekly. CNA M stated that the tubing or nasal cannula should be replaced if contaminated. CNA M stated that staff are to make sure that the residents are using their oxygen machines but are not responsible for cleaning them. On [DATE] at 04:15 PM in an interview, with Administrative Nurse F stated that the oxygen machines are cleaned by the maintenance department. Administrative Nurse F reported that the tubing should be changed out every Sunday night and staff should be storing the nasal cannula and tubing in a plastic bed when not in use. A review of the facility's Oxygen Administration, Safety, and Maintenance policy revised 05/2020 stated to change oxygen supplies weekly and when visibly soiled. The plan indicated that equipment should be labeled with patient name and date when setup or changed out. The policy stated that oxygen and respiratory supplies should be stored in a bag labeled with the resident's name when not in use. The policy stated that machines with external filters should be checked daily and washed at least once a week with soap and water. The facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for R6, this deficient practice placed her at risk for respiratory infection and/or illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 53 residents. The sample included 16 residents with one resident reviewed for behavioral health. Based on record review, and interviews, the facility failed to provide an environment that promoted Resident (R)42's emotional and psychosocial well-being when the facility failed to develop and implement person-centered plan of care to support R42's behavioral health needs. The facility failed to identify and implement individualized interventions specific to R42's mental health diagnoses and his behaviors and failed to identify triggers or stressors which contributed to behavioral manifestations. The facility further failed to evaluate the care and services for effectiveness related to R42's behaviors. This deficient practice placed R42 at risk for impaired psychosocial wellbeing and inadequate behavioral health care. Findings included: - R42's Electronic Medical Record (EMR) recorded diagnoses of schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), epilepsy (brain disorder characterized by repeated seizures), obsessive-compulsive disorder (OCD - anxiety disorder characterized by recurrent and persistent thoughts, ideas and feelings of obsessions severe to cause marked distress, consume considerable time or significantly interfere with the resident's occupational, social or interpersonal functioning), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), mild intellectual disabilities, and psychosis (any major mental disorder characterized by a gross impairment in reality testing). The Significant Change Minimum Data Set (MDS) dated [DATE] recorded R42 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. The MDS recorded R42 was independent with no set up to supervision for most activities for daily living (ADLs), and limited assistance of one staff for personal hygiene. R42 rejected cares during the look back period but had no wandering behaviors. The Quarterly MDS dated 03/02/22 recorded R42 had a BIMS of nine which indicated moderately impaired cognition. The MDS recorded R42 required supervision with set-up assistance for all ADLs. He rejected cares during the look back period but had no wandering behaviors. The Behavior Care Area Assessment (CAA) dated 12/06/22 recorded R42 had behavior symptoms of rejection of care. Staff encouraged as much participation as possible during care activities. R42's Care Plan recorded he had impaired cognitive ability and impaired thought processes due to major depressive disorder, anxiety disorder and epileptic syndrome. It listed interventions dated 11/11/00 which directed staff to allow R42 extra time to respond to questions and instructions; face R42 and speak clearly when communicating and refer to speech pathology. R42's Care Plan recorded R42 had a communication problem due to anger. It listed an intervention dated 12/04/20 which directed staff to encourage R42 to continue stating his thoughts even if he had difficulty. It directed staff to focus on a word or phrase that made sense or respond to the feeling R42 expressed. R42's Care Plan recorded R42 was at risk for falls related to his diagnoses of epilepsy, schizophrenia, OCD, and anxiety. It listed an intervention dated 12/07/21 which directed R42 had a fall on 12/07/21. Staff were educated regarding appropriately suing R42's as needed (PRN) antianxiety medications when R42 exhibited signs and symptoms of increased anxiety and agitation. An intervention on 12/04/21 directed staff to anticipate and meet the resident's needs. R42's Care Plan recorded R42 was at risk for changes in mood or behavior due to his medical condition. It listed interventions dated 11/11/20 which directed staff to consult with R42 on his preferences regarding his customary routines, administer his medications as ordered and psychiatric consult as indicated. R42's Care Plan recorded he received antidepressant medication, psychotropic (affecting mood or thoughts) medications due to diagnoses of depression and schizophrenia. It listed interventions dated 12/04/20 which directed staff to administer the antidepressant and psychotropic medications as ordered by the physician and monitor for side effects and effectiveness. R42' Care Plan recorded he received antianxiety medication due to anxiety. It listed an intervention dated 01/27/21 which directed staff to administer the antianxiety medication as ordered by the physician and monitor for side effects and effectiveness. R42's Care Plan recorded he had depression due to his medical diagnosis of major depressive disorder. It listed interventions dated 12/04/20 which directed staff to administer medications as ordered and to encourage R42 to express his feelings and allow him time to talk. R42's Care Plan recorded he was at risk for alteration in psychosocial well-being due to Covid (highly contagious respiratory infection) precautions. It listed interventions dated 12/04/20 which directed staff to encourage and facilitate alternative ways of communication with friends and family; observe for changes in mental status caused by situational stressors and report to R42's physician as appropriate. It directed staff to observe for psychosocial changes and report to R42's physician as appropriate and provide R42 opportunities to express his feelings related to situational stressors. R42' Care Plan lacked specific behaviors for staff to monitor and lacked description of behaviors including triggers. The plan of care lacked direction to staff on how to approach R42 when he was experiencing behaviors and lacked direction on how to redirect. The plan of care lacked specifics regarding the resident's preferred routines and lacked indicators of personal preferences and activities to support the resident's psychosocial well-being. R42's clinical record lacked evidence of assessment for Level I/Level II upon admission. (see F644) An Alert Note dated 04/24/21 recorded R42 paced up and down the hall and in and out of his room throughout the night. He was restless and agitated. R42 displayed erratic behaviors with movements that appeared uncontrolled. R42 grabbed at the right side of his neck excessively but stated nothing was wrong. The note lacked mention of physician notification or intervention. A Behavior Note dated 04/27/21 recorded R42 stood in the corner between the outside window and office window for several hours, part of the time facing the wall and part of the time facing the out toward the Tv room. The resident did not hurt himself or anyone else. The note lacked evidence of staff intervention. A Behavior Note dated 05/28/21 recorded r42 stood at the nurse's station, went behind the station, looked at papers on the nurse's desk. Staff redirected R42 several times. R42 walked from TV room to his bedroom, tapped on windows in both rooms, and stood close to the nurse and other residents which made it hard for others to get by him. R42 told staff leave me alone, I know I am doing. The note lacked documentation redirection efforts attempted and /or which efforts were successful or unsuccessful. A Health Status Note dated 07/25/21 recorded the nurse heard squealing coming from R42's room and observed R42 in bed, moving extremities but R42 did not follow directions of acknowledge the nurse. The note documented this continued for one to two minutes then R42 told the nurse I am ok when asked. The note lacked evidence of physician notification or intervention. An Event Note dated 08/12/21 recorded R42 turned the bathroom sink on and off so many times it was broken and would not turn off. The note lacked evidence of staff intervention. A Behavior Note dated 09/13/21 recorded R42 refused breakfast and his medications. The note lacked evidence the physician was notified. A Behavior Note dated 09/15/21 recorded R42 paced and attempted to enter rooms. R42 was redirected by the nurse. R42 then went through drawers in the sitting rooms, knocked on walls and doors, did not respond to redirection attempts by the nurse. R42 refused his antianxiety medication. The note lacked documentation redirection efforts attempted and /or which efforts were successful or unsuccessful and lacked evidence of physician notification. A Behavior Note dated 09/15/21 recorded R42 chanted Jesus, Jesus open the door . for over an hour. The note documented other residents in the facility yelled at R42 in response. R42 did not respond to redirection attempts from the nursing staff, only chanted louder and faster. The note lacked evidence of physician notification or intervention. A Behavior Note dated 09/16/21 recorded R42 raced up and down the hallways and named presidents, pharmacies and churches. Staff were unable to redirect. Consultant GG ordered Haldol (antipsychotic medication) 5 milligrams by mouth. R42 continued to collect trash out of people's rooms and yelled names. R42 talked loudly and walked up and down the hallway. A Health Status Note recorded R42 received a new order for Ativan (antianxiety medication) 1 milligram three times daily for agitation. A Health Status Note dated 09/20/21 recorded R42 stated he slapped his hands together to change the direction of his thoughts. A Behavior Note dated 10/06/21 recorded R42 banged loudly on the bedside table, the nurse cart. He spoke of religion, parents and dust to dust. R42 appeared agitated and was not redirectable. He continued to be loud, banged on walls and began a tirade of religion, working and dying. R42 took his Ativan but refused his other medications. The note lacked documentation redirection efforts attempted and /or which efforts were successful or unsuccessful and lacked evidence of physician notification. A Behavior Note dated 10/07/21 recorded R42 left his room after breakfast, paced and talked fast. He repeated the same things about religion and working and told staff to mind their business when he was asked not to knock on all the doors. R42 continued to knock on walls and doors. He eventually went to his room and accepted his Ativan. The note lacked evidence of nonpharmacological interventions. A Behavior Note dated 10/07/21 recorded R42 was again in the TV room, knocked on doors and windows, dug through the trash for snack wrappers and tore them apart. He took the wrappers back to his room. He had short episodes of unpredictable movements of his body. The note lacked evidence of physician notification or intervention. A Behavior Note dated 10/28/21 recorded R42 wandered in and out of other residents' rooms and stood in the doorway staring at other residents. He made unusual body movements while he stood in the hallway. R42 continued to make loud banging noises when he returned to his room. An Alert Note dated 11/12/21 recorded R42 came out of his room, pounded on the desk and yelled about religion, and his mom and dad. He went to the back door nad set off the alarm. He refused to go back to his room, yelled for several more minutes then went back to his room. The note recorded the director of nursing would contact Consultant GG for supportive care. A Health Status Note dated 11/12/21 recorded the hospice nurse and nurse aid visited R42. R42 appeared calm, spoke with the hospice staff for a shirt time. The hospice nurse stated R42 said he was homesick and wanted someone to talk to. The note recorded the hospice nurse stated she would send a social worker and a chaplain out the following week to talk to the resident. A Behavior Note dated 11/13/21 at 07:35 AM recorded R42 paced the unit and clapped his hands and attempted to grab the fire extinguisher from outside of his room. A Behavior Note dated 11/13/21 at 11:49 AM recorded R42 was calmer, took his medications and spoke with his representative. He was calmer after he spoke with his representative, he stated he was upset but could not communicate the reason. A Behavior Note dated 11/13/21 at 01:43 PM recorded R42 paced the hallway, banged on walls and doors, quoted the bible, and spoke of four gray walls. He refused offer of ice cream. Staff called R42's representative; he spoke with his representative and appeared calmer. A Behavior Note dated 11/13/21 at 05:24 PM recorded R42 continued to pace throughout the building and looked up at the ceiling. He refused his medications from four different staff members and refused snacks and his evening meals. He knocked on walls and doors to the point his knuckles were reddened. He denied pain to his knuckles. The note lacked evidence of physician notification or intervention. A Behavior Note dated 11/13/21 at 07:47 PM recorded R42 paced the lobby and unit and repeated something's stupid, something's crazy, and it's not me. The note documented redirection was not effective. The note lacked evidence of which efforts at redirection were ineffective and lacked evidence of physician notification. A Behavior Note dated 11/13/21 at 09:33 PM recorded R42 walked at fast pace and clapped his hands loudly. He yelled ambulance 911. He went to the south unit and beat on the walls. A Behavior Note dated 11/14/21 at 01:37 AM recorded R42 was combative and confrontational with staff, could not be redirected or calmed. R42 was sent to the acute care center for evaluation. An Event Note dated 11/14/21 at 10:26 AM recorded R42 returned to the facility. A Behavior Note dated 11/15/21 recorded staff called hospice for medication review due to R42 yelled and screamed and hit the walls despite his scheduled Ativan. An Alert Note dated 11/15/21 at 09:50 PM recorded R42 refused all his medications that shift after three attempts. The note lacked evidence of physician notification or intervention. A Behavior Note dated 11/17/21 recorded R42 went out of his room without any clothes on and sat at the dining room table. He was resistant to redirection and charged at the nursing staff. He laid himself on the floor and began to have seizure-like activity. He again charged at staff with a look of rage on his face. Staff notified Consultant GG who ordered R42 be sent out emergently for acute care evaluation. A Health Status Note dated 11/22/21 recorded R42 readmitted to the facility. A Behavior Note dated 12/03/21 recorded R42 clapped all night, off and on. A Behavior Note dated 12/06/21 recorded R42 clapped in room repeatedly and was very anxious. Staff reported the change to Consultant Gg who ordered Ativan PRN. A Behavior Note dated 12/07/21 recorded r42 was anxious. R42 ran in the hallway, stumbled and fell. Staff administered R42 PRN Ativan and another anxiety medication. Consultant Gg gave an order to administer 5 milligrams of Zyprexa (antipsychotic) immediately. A Health Status Note dated 12/07/21 recorded a new medication order for R42, Seroquel (antipsychotic) 25 milligrams twice daily for increased behaviors. A Behavior Note dated 01/14/22 at 09:56 recorded R42 received an injection of Ativan earlier that day, but it was not effective. R42 ran through the facility, pushing on walls, door frames, exits and he was combative and ran from staff. He went into women's rooms and yelled and screamed. He screamed bible quotes and spoke nonsensically. Staff received orders to send R42 to an acute care behavioral health setting. A Behavior Note dated 01/14/22 at 10:15 PM recorded emergency services and firefighters arrived at the facility. R42 screamed and yelled and was combative with the rescuers. Five rescuers, assisted by a facility nurse, transferred R4 onto a gurney where he was restrained and administered medication by emergency services. R42 was transported to the acute care hospital. An Admission/readmission Note dated 01/18/22 recorded R42 readmitted to the facility. A Health Status Note dated 01/28/22 at 06:50 AM recorded R42 went to the nurse station in a panic and stated I need and ambulance. I had snakes in my shoes. R42 paced back and forth in the hall. R42 was not redirectable. Staff administered an injection of Ativan which lessened R42's anxiety but R42 continued to pace around the building. A 'Behavior Note dated 01/29/22 at 03:00AM recorded R42 paced the halls all night. He undressed himself and touched his genitals in front of other residents. When staff attempted to redirect R42 to his room, R42 became very angry and aggressive. Staff were unable to redirect R42. Staff notified Administrative Nurse D who requested the resident be sent to the hospital. An Admission/readmission Note dated 01/29/22 recorded R42 returned from the hospital at 06:10 AM. A Behavior Note dated 01/29/22 at 10:48 AM recorded R42 clapped his hands quoted bible verses. R42 continued to yell, clap his hands and was hard to redirect. A Behavior Note dated 02/01/22 recorded R42 ran up nd down the hall and yelled at other residents. A Behavior Note dated 02/01/22 recorded R42 ran up and down the hall. He was verbally aggressive, an unable to be calmed. Emergency services was contacted and R42 was placed on a gurney, restrained and transported to the hospital. An Alert Note dated 02/02/22 documented R42 was admitted to an inpatient psychiatric hospital. An Admission/readmission Note dated 02/08/22 recorded r42 readmitted to the facility with diagnoses of schizophrenia aggressive behavior, hallucinations (a perception of having seen, heard, touched, tasted, or smelled something that wasn't actually there), hypertension (high blood pressure) psychosis(mental disorder characterized by a disconnection from reality) and agitation. An Orders -Administration Note dated 02/13/22 recorded R42 received an injection of Haldol 5 milligrams. R42 paced and clapped his hands loudly. He tried to clean, and dumped water all over the floor. He was not redirectable and refused oral medications. Staff obtained a new order for Haldol. An Alert Note dated 02/13/22 recorded R42 fell on the south side of the building. R42 had seizure activity. R42 was transferred to the hospital. A Behavior Note dated 03/20/22 at 06:07 PM recorded R42 refused his medications during the day shift. He had clapped excessively most of the shift. He opened and closed his blinds repeatedly. He tore the toilet lid off and flushed the toilet over and over. His clothes and hair were wet were wet. He was in the hallway and yelled you have a good evening and be careful of the graveyards and the gas stations and of [NAME], baseball, hot dogs, mam and dad, the Kansas city star, the Kansas City [NAME] and the Kansas City Chiefs. R42 refused his medication and stated he felt sick enough. The note lacked evidence of physician notification or intervention. A Behavior Note dated 03/20/22 at 07:03 PM recorded R42 screamed at a male resident. Staff were unable to redirect R42. Another resident became agitated, though staff were able to separate. Staff notified law enforcement and law enforcement arrived. R42 asked the law enforcement officers to take him to the hospital. R42 left the facility with two law enforcement officers for transport to the hospital. An Admission/readmission Note dated 03/24/22 recorded R42 returned to the facility. A Behavior Note dated 03/25/22 recorded R42 appeared anxious, sat in his room and clapped and wandered through the hallways. R42 took his medications as ordered. A Behavior Note dated 03/26/22 recorded R42 clapped his hands loudly and almost constantly. Staff asked R42 to stop clapping because it upset the other residents. R42 responded No and stated when asked why, R42 stated I can't explain it, if I could stop, I would. The note lacked evidence of physician notification or intervention. A Behavior Note dated 03/27/22 recorded R42 had not clapped as much but was still loud when he did clap. A Health Status Note dated 03/30/22 at 01:35 PM recorded R42 required coaxing to take his pills and refused his afternoon Ativan and Haldol. R42 sat in his room clapping loudly, intermittently. A Behavior Note dated 03/30/22 at 05:19 PM recorded R42 flushed his medication down the toilet. He clapped loudly. His eyes were red, and per R42, he lacked sleep and was anxious. An Orders-Administration Note dated 03/31/22 recorded R42 refused his oral medication but allowed an Invega (antipsychotic) injection. An Alert Note dated 03/31/22 at 01:50 PM recorded R42 yelled, clapped his hands, and quoted bible verse R42's representative wanted R42 sent to the hospital. A Health Status note dated 03/31/22 recorded R42 returned to the facility at 08:25 PM. An Event Note dated 04/04/22 at 09:06 AM recorded R42 refused his medication multiple times. R42 left the building unsupervised. (see F689) A Behavior Note dated 04/01/22 at 02:00 PM recorded R42's behaviors escalated, and he began to run from his one to one supervision. He yelled and threw furniture. Staff called 911. The note recorded R42 had to be taken down to the ground, handcuffed, and feet bound. R42 received an injection of versed (strong antianxiety medication typically used prior to surgery or medical procedures). Emergency discharge was initiated. On 04/06/22 at 02:35 PM in an interview, Certified Nurse's Aide (CNA) M stated she was able to review the care plans and that was where to find the instructions for the care of each of the resident. CNA M the care plan would have any specialized care listed each resident. CNA M stated she had not received any dementia or behavior training at the facility. CNA M stated that she would report any behaviors to the nurse and documented behaviors in the EMR. She said R42 was currently out of the facility. She was aware he had behaviors and sometimes started fights with other residents. She stated she was not aware of any special directives or ways to deal with or redirect R42 when he had behaviors. On 04/06/22 at 03:35 PM in an interview, Licensed Nurse (LN) G stated nursing staff review resident's care plans and updates the other staff member of changes that occur. LN G stated behavioral monitoring was completed on anyone that received an antipsychotic medication, which was completed by the charge nurse on the Medication Administration Record (MAR). LN G stated she was unaware of any specific interventios to deal with R42's behaviors. On 04/06/22 at 05:25 PM Administrative Nurse D stated the facility did not have social worker. She said since she was at the facility, R42 had been there and was usually quiet. She stated his behaviors had started to change at the end of the year in 2021 and the behaviors increased. Administrative Nurse D stated the facility was sending R42 to acute care centers every two to four weeks. R42 received oral medications and he started refusing his medications. The refusals started escalating. He was hospitalized at an acute inpatient behavioral health center. R42's medications were changed and included injections of antipsychotic medications for his behaviors. Administrative Nurse D stated R42 was able to tell you that something was going on, and he couldn't control it such as his clapping. She said R42 was loud, clapped, quoted scriptures and would go up and down the halls, bothering other residents, getting in people's space but he never struck anyone. Administrative Nurse D was unable to say if there were any nonpharmacological interventions developed to assist with R42's behaviors. The facility's Area of Focus: Behavioral Health Recommendations policy, not dated, directed providing behavioral health care and services was an integral part of the person-centered environment and staff monitored residents closely for expressions or indications of distress, assessed and planned care for concerns, accurately documented the changes including the frequency of occurrence and potential trigger's in the resident's record, shared concerns with the interdisciplinary team to determine underlying causes, ensured appropriate follow-up assessment if needed, and discussed potential modifications to the care plan. The facility's Area of Focus: Behavior Management policy, not dated, directed individualized approaches to care were provided as part of a supportive physical, mental, and psychosocial environment. The facility initiated behavior monitoring, behavior management care plan, and [NAME] as indicated by assessment findings, resident/responsible party conversations, and observations. The policy directed that the resident's medical record showed documentation of adequate indication for a medication's use and the diagnosed condition for which a medication was prescribed. The policy directed the facility monitored medications for efficacy and adverse reactions. The facility failed to provide an environment that promoted R42's emotional and psychosocial well-being when the facility failed to develop and implement person-centered plan of care to support R42's behavioral health needs. The facility failed to identify and implement individualized interventions specific to R42's mental health diagnoses and his behaviors and failed to identify triggers or stressors which contributed to behavioral manifestations. The facility further failed to evaluate the care and services for effectiveness related to R42's behaviors. This deficient practice placed R42 at risk for impaired psychosocial wellbeing and inadequate behavioral health care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 53 residents. The sample included 16 residents. Based on observation, record review, and interviews, the facility failed to provide the needed dementia (progressive mental disorder characterized by failing memory, confusion) care and services for Resident (R) 13, which placed her at risk for increased behaviors, confusion. decline in ability to maintain the highest practicable mental and psychosocial well-being. This deficient practice placed her at risk of increased confusion, isolation, and lack of appropriate activities and interaction. Findings included: - R13's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) with behavioral disturbances and cellulitis (skin infection caused by bacteria characterized by heat, redness and swelling) left lower limb. The admission Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS recorded R13 required extensive assistance of one person for all activities of daily living (ADLs) except eating, for which she was independent. R13 required assistance of one staff member for bathing. R13 had no behaviors. The MDS recorded R13 received an antipsychotic (medication used to treat psychosis), diuretic (medication used to promote excretion of fluids) and opioids (medications use to treat pain) during the lookback period. R13's Cognitive Loss Care Area Assessment (CAA) dated 01/20/22 documented staff encouraged her to use the call light for assistance with ADL's. R13 received routine antipsychotic medication, staff monitored for adverse reactions and for changes in R13 mood or behaviors. R13's Care Plan dated 01/10/22 documented staff should allow extra time for her to respond to questions or instructions. The Care Plan lacked documentation for person centered dementia care and lacked direction to staff on how to deal with R13's dementia related behaviors. On 04/03/22 at 10:15 AM R13 refused to be interviewed by the surveyor. R13 appeared agitated and did not want to anyone to approach her due to being upset. On 04/05/22 at 07:22 AM R13 laid on her bed and watched TV. No behaviors of distress noted at this time. On 04/05/22 at 08:23 AM R13 laid in the bed, yelled out help, that she has to go to the bathroom. R13's roommate asked her to stop yelling. R13 started to cuss at R44 and threatened to slap her roommate across the face. R13's call light was located on the floor behind the bed under a blanket and pillow. On 04/05/22 at 12:20 PM 13 asleep in bed. No behaviors or distress noted. On 04/06/22 at 07:20 AM R13 laid on the bed, her head turned toward the wall. R13 appeared calm, call light on the floor. On 04/06/22 at 02:35 PM in an interview, Certified Nurse's Aide (CNA) M stated she was able to review the care plans and that was where to find the instructions for the care of each of the resident. CNA M the care plan would have any specialized care listed each resident. CNA M stated she had not received any dementia training at the facility. CNA M stated that she would report any behaviors to the nurse and documented behaviors in the EMR. On 04/06/22 at 03:35 PM in an interview, Licensed Nurse (LN) G stated nursing staff review resident's care plans and updates the other staff member of changes that occur. LN G stated behavioral monitoring was completed on any one that received an antipsychotic medication, which was completed by the charge nurse on the Medication Administration Record (MAR). LN G stated the call light should be within reach of the resident when in their room. On 04/04/22 at 04:20 PM in an interview, Administrative Nurse E stated, she stated that when residents first arrive a base line care plan would be completed and a comprehensive assessment with occur after the care plan has been established. Administrative Nurse E reported areas triggered on the MDS should be placed in the care plan and addressed on the comprehensive care plan. The facility's Therapeutic Activities Program policy, revised 04/01/22, directed the facility implemented an ongoing resident centered activities program that incorporated the resident's interests, hobbies, and cultural preferences which was integral to maintaining and/or improving a resident's physical, mental, and psychosocial well-being and independence. The policy directed it was important for residents to have a choice about which activities they participated in, whether they were part of the formal activities program or self-directed and a resident's needs and choices for how they spend time, both inside and outside the facility, were also supported and accommodated. The policy directed individual interventions were developed based on each resident's assessed needs and the family was notified for any special requests; the individual program was provided according to a consistent scheduled identifying specific days of the week and time frame for which program occurred; and each resident's individual program included interventions that met the resident's social, emotional, physical, spiritual, and cognitive functioning needs, these approaches reflected the resident's lifestyle and interests and were incorporated into the interdisciplinary care plan. The facility did not provide a policy related to dementia care. The facility failed to develop and implement an adequate person-centered dementia care to receive the treatment and services to attain and/or maintain her practicable physical, mental and psychosocial well-being for R13. This deficient practice placed her at risk of increased confusion, isolation, and lack of appropriate activities and interaction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 53 residents. The sample included 16 residents; six sampled for unnecessary medication review. Based on observations, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of behavior monitoring for R39, R13, and R27 who received psychotropic (any drug that affects brain activities associated with mental processes and behavior) medications including antipsychotic (class of medications used to treat psychosis and other mental emotional conditions), medications; and the lack of an indication for administration for Lasix (diuretic- medication to promote the formation and excretion of urine) for R13. This deficient practice had the risk for unnecessary medication use and physical complications for all residents affected. Findings included: - R39 admitted to facility on 03/02/22. The Diagnoses tab of R39's Electronic Medical Record (EMR) documented diagnoses of bipolar (major mental illness that caused people to have episodes of severe high and low moods) disorder, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, developmental disorder of scholastic skills, and history of falling. The admission Minimum Data Set (MDS) dated 03/09/22, documented R39 had a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment. R39 was independent with bed mobility, transfers, walking, dressing toileting, and personal hygiene; independent with setup help for bathing. R39 received antipsychotic, antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression), and hypnotic (a class of medications used to induce sleep and treat insomnia) medications seven days in the seven-day lookback period and antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medications four days in the seven-day lookback period. The Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA) dated 03/09/22, documented R39 had cognitive loss related to a BIMS score less than 13 and staff allowed extra time for R39 to respond to questions and instructions. The Behavioral Symptoms CAA dated 03/14/22, documented R39 had behavioral symptoms related to rejection of cares and staff gave him as many choices as possible about care and activities. The Psychotropic Drug Use CAA dated 03/17/22, documented R39 had psychotropic drug use due to multiple psychiatric diagnoses. The Care Plan dated 03/03/22 documented R39 had a behavior problem and yelled loudly from his room. Staff anticipated and met his needs and explained all procedures to R39 before starting and allowed him time to adjust to changes. The Care Plan dated 03/14/22 documented R39 had potential to be verbally aggressive related to ineffective coping skills and developmental disorder and directed staff analyzed key times, places, circumstances, triggers, and what de-escalated behaviors and documented. The Orders tab of R39's EMR documented an order with a start date of 03/02/22 for fluvoxamine maleate (antidepressant) 100 milligram (mg) one time day for mood disorder; an order with a start date of 03/02/22 for trazodone hydrochloride (HCl) (antidepressant) 25 mg three times a day for bipolar; an order with start date of 03/02/22 for trazodone HCl 150 mg at bedtime for bipolar; olanzapine (antipsychotic) 7.5 mg three times a day for bipolar; an order with a start date of 03/02/22 for carbamazepine (anticonvulsant- medication used to treat seizures) 100 mg two times a day for bipolar, and an order with a start date of 03/02/22 for hydroxyzine HCl (antihistamine- medication used to treat allergies and also used to help control anxiety and tension caused by nervous and emotional conditions) 25 mg every six hours as needed for anxiety. The Orders tab of R39's EMR lacked an order for behavior monitoring. Review of R39's Medication/Treatment Administration Record (MAR/TAR) since admission revealed lack of behavior monitoring for R39. Review of R39's Medication Regiment Review (MRR) for March 2022 lacked evidence the CP identified and reported to the facility a lack of behavior monitoring. On 04/05/22 at 01:58 PM, R39 ambulated independently in day room and poured himself a cup of water with staff supervision. He sat down in a chair in the day room to watch television. On 04/06/22 at 02:40 PM, Certified Nurse Aide (CNA) M stated everybody was responsible for behavior monitoring and the CNA notified the nurse when a resident had a behavior. She stated R39 clapped his hands or yelled out in his room and sometimes refused cares. On 04/06/22 at 03:20 PM, Certified Medication Aide (CMA) R stated the nurse completed the behavior monitoring. On 04/06/22 at 03:34 PM, Licensed Nurse (LN) M stated particular residents had behavior monitoring and behavior monitoring was completed on any resident on a psychotropic medication. She stated behavior monitoring showed up on the TAR to be completed. She stated that if there were new orders with the MRRs then the nurse put the new orders in or made necessary changes. On 04/06/22 at 05:22 PM, Administrative Nurse D stated behavior monitoring was documented by the charge nurse and if residents were on certain medications that required behavior monitoring, there were two separate orders for side effects of the medication and behavior monitoring and included antidepressants, hypnotic, and psychotropic medications. She stated pharmacy reviews were emailed to the Director of Nursing (DON); reviewed by DON, unit manager, MDS director, and doctor/nurse practitioner and new orders/changes were put in by the same people. On 04/07/22 at 03:35 PM, Consultant II was unavailable for interview. The facility's Medication Regimen Review policy, dated 11/28/16, directed the CP conducted MRRs and made recommendations based on the information available in the residents' health record. The facility encouraged the physician or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR. The attending physician documented in the residents' health record that the identified irregularity was reviewed and what, if any, action was taken; if no change in the medication, the attending physician documented the rationale in the residents' health record. The policy directed the facility alerted the medical director when MRRs were not addressed by the attending physician in a timely manner. The facility maintained readily available copies of MRRs on file in facility as part of the resident's permanent health record. The facility's Area of Focus: Behavioral Health Recommendations policy, not dated, directed providing behavioral health care and services was an integral part of the person-centered environment and staff monitored residents closely for expressions or indications of distress, assessed and planned care for concerns, accurately documented the changes including the frequency of occurrence and potential trigger's in the resident's record, shared concerns with the interdisciplinary team to determine underlying causes, ensured appropriate follow-up assessment if needed, and discussed potential modifications to the care plan. The facility's Area of Focus: Behavior Management policy, not dated, directed individualized approaches to care were provided as part of a supportive physical, mental, and psychosocial environment. The facility initiated behavior monitoring, behavior management care plan, and [NAME] as indicated by assessment findings, resident/responsible party conversations, and observations. The policy directed that the resident's medical record showed documentation of adequate indication for a medication's use and the diagnosed condition for which a medication was prescribed. The policy directed the facility monitored medications for efficacy and adverse reactions. The facility's Psychotropic Medication Use policy, last revised 01/01/22, directed all medications used to treat behaviors had a clinical indication and was used in the lowest possible dose to achieve the desired therapeutic effect. All medications used to treat behaviors were monitored for efficacy, risks, benefits, and harm or adverse consequences. The facility failed to ensure the CP identified and reported the lack of behavior monitoring for R39 who received psychotropic medication including an antipsychotic. This deficient practice had the risk for unnecessary medication use and physical complications. - R13's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) with behavioral disturbances and cellulitis (skin infection caused by bacteria characterized by heat, redness and swelling) left lower limb. The admission Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS recorded R13 required extensive assistance of one person for all activities of daily living (ADLs) except eating, for which she was independent. R13 required assistance of one staff member for bathing. R13 had no behaviors. The MDS recorded R13 received an antipsychotic (medication used to treat psychosis), diuretic (medication used to promote excretion of fluids) and opioids (medications use to treat pain) during the lookback period. R13's Psychotropic Drug Use Care Area Assessment (CAA) dated 01/20/22 documented staff encouraged her to use the call light for assistance with ADL's. R13 received routine antipsychotic medication, staff monitored for adverse reactions and for changes in R13 mood or behaviors. R13's Care Plan dated 01/18/22 documented monitor for changes in mental status caused by situational stressors. Monitor for increased anxiety, changes in mood/behaviors. Review of the EMR under Orders tab revealed physician orders: Risperidone (antipsychotic) tablet one milligram (mg) by mouth in the morning for dementia with behaviors dated 01/07/22. Furosemide (diuretic) tablet 20 mg give one tablet by mouth in the morning dated 01/07/22. Review of the EMR under the Reports tab for review of Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 01/01/22 to 04/04/22 lacked behavior monitoring and indication for administration of diuretic medication for R13. Review of the Monthly Medication Review (MMR), performed by the CP, reviewed April 2021 through March 022. MMR for October 2021 and December 2021 were not available to review. The available MMR did not address the lack of behavior monitoring for an antipsychotic medication and indication for administration of diuretic medication for R13. On 04/03/22 at 10:15 AM R13 refused to be interviewed by the surveyor. R13 appeared agitated and did not want to anyone to approach her due to being upset. On 04/03/22 at 10:15 AM R13 refused to be interviewed by the surveyor. R13 appeared agitated and did not want to anyone to approach her due to being upset. On 04/05/22 at 07:22 AM R13 laid on her bed and watched TV. No behaviors of distress noted at this time. On 04/06/22 at 07:20 AM R13 laid on the bed, her head turned toward the wall. R13 appeared calm, call light on the floor. On 04/06/22 at 03:20 PM, Certified Medication Aide (CMA) R stated the charge nurse documented the behavior monitoring for the residents. CMA R stated every medication should have an indication for administration. CMA R stated she would let the charge nurse know if she noticed a medication without an indication for administration. On 04/06/22 at 03:34 PM, Licensed Nurse (LN) M stated the nurse was responsible for monitoring and documentation of behavior monitoring. LN M stated that if there were new orders with the MRRs then the nurse put the new orders in or made necessary changes. On 04/06/22 at 05:22 PM, Administrative Nurse D stated behavior monitoring was documented by the charge nurse and if residents were on certain medications that required behavior monitoring, there were two separate orders for side effects of the medication and behavior monitoring and included antidepressants, hypnotic, and psychotropic medications. She stated pharmacy reviews were emailed to the Director of Nursing (DON); reviewed by DON, unit manager, MDS director, and doctor/nurse practitioner and new orders/changes were put in by the same people. On 04/07/22 at 03:35 PM, Consultant II was unavailable for interview. The facility's Medication Regimen Review policy, dated 11/28/16, directed the CP conducted MRRs and made recommendations based on the information available in the residents' health record. The facility encouraged the physician or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR. The attending physician documented in the residents' health record that the identified irregularity was reviewed and what, if any, action was taken; if no change in the medication, the attending physician documented the rationale in the residents' health record. The policy directed the facility alerted the medical director when MRRs were not addressed by the attending physician in a timely manner. The facility maintained readily available copies of MRRs on file in facility as part of the resident's permanent health record. The facility's Area of Focus: Behavioral Health Recommendations policy, not dated, directed providing behavioral health care and services was an integral part of the person-centered environment and staff monitored residents closely for expressions or indications of distress, assessed and planned care for concerns, accurately documented the changes including the frequency of occurrence and potential trigger's in the resident's record, shared concerns with the interdisciplinary team to determine underlying causes, ensured appropriate follow-up assessment if needed, and discussed potential modifications to the care plan. The facility's Area of Focus: Behavior Management policy, not dated, directed individualized approaches to care were provided as part of a supportive physical, mental, and psychosocial environment. The facility-initiated behavior monitoring, behavior management care plan, and [NAME] as indicated by assessment findings, resident/responsible party conversations, and observations. The policy directed that the resident's medical record showed documentation of adequate indication for a medication's use and the diagnosed condition for which a medication was prescribed. The policy directed the facility monitored medications for efficacy and adverse reactions. The facility's Psychotropic Medication Use policy, last revised 01/01/22, directed all medications used to treat behaviors had a clinical indication and was used in the lowest possible dose to achieve the desired therapeutic effect. All medications used to treat behaviors were monitored for efficacy, risks, benefits, and harm or adverse consequences. The facility failed to ensure CP II recognized and reported lack of documentation of behavior monitoring for antipsychotic medication and administration of diuretic medication for R13. This had the potential risk for harmful side effects related to unnecessary medications. - R27's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dementia (progressive mental disorder characterized by failing memory, confusion), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and anxiety(mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Annual Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS recorded R27 required extensive assistance of one to staff members for all activities of daily living (ADLs) except eating and locomotion for which she was independent. R27 required assistance of two staff members for bathing. The MDS recorded R27 rejected cares daily during the lookback period. The MDS recorded R27 was at risk for pressure injuries but had no pressure injuries. She had a pressure reducing device in her chair and bed but was not on a turning/repositioning program. R27 received an antipsychotic (medication used to treat psychosis), antidepressant (medication used to treat depression) and an antibiotic (medication used to treat bacterial infections) for seven days of the look back period. The MDS documented R27 required physical assistance of one staff member for bathing during look back period. The Quarterly MDS dated 02/08/22 recorded R27 had a BIMS score of 12 which indicated moderately impaired cognition. The MDS recorded R27 required extensive assistance of one to staff members for all activities of daily living (ADLs) including locomotion and supervision of two staff for eating. R27 was totally dependent on one staff for bathing. R27 had verbal behavioral symptoms directed at other for one to three of the lookback days and rejected cares for four to six of the lookback days. The MDS recorded R27 was at risk for pressure injuries but had no pressure injuries. She had a pressure reducing device in her chair and bed but was not on a turning/repositioning program. R27 received an antipsychotic, antidepressant, antibiotic, anticoagulant (medication used to thin blood), insulin (hormone used to treat high blood glucose) and received injections during the lookback period. The MDS documented R27 was totally dependent of two or more staff for bathing activity during the look back period. R27's Psychotropic Drug Use Care Area Assessment (CAA) dated 11/22/21 documented on routine antidepressant and antipsychotic medications. R27 was at risk for adverse reactions, staff were to monitor routinely for adverse reactions and/or for changes of mood or behavior. R27's Care Plan dated 11/21 directed staff to administer psychotropic medication and antidepressant medication as ordered by the physician. monitor for any side effects and effectiveness every shift. Review of the EMR under Orders tab revealed physician orders: Escitalopram oxalate (antidepressant) tablet 10 milligrams (mg), give one tablet by mouth daily for major depressive disorder dated 02/01/22. Risperidone (antipsychotic) tablet two mg, give one tablet by mouth at bedtime for schizophrenia dated 03/29/2022. Review of the EMR under the Reports tab for review of Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 01/01/22 to 04/04/22 lacked behavior monitoring for R27. Review of the Monthly Medication Review (MMR), performed by the CP, reviewed April 2021 through March 022. MMR for October 2021 and December 2021 were not available to review. The available MMR did not address the lack of behavior monitoring for R27, on an antipsychotic medication. On 04/05/22 at 07:44 AM R27 laid on her back in bed. R27 stated she was waiting for breakfast, no behaviors or distress noted. On 04/06/22 at 03:20 PM, Certified Medication Aide (CMA) R stated the charge nurse documented the behavior monitoring for the residents. CMA R stated every medication should have an indication for administration. CMA R stated she would let the charge nurse know if she noticed a medication without an indication for administration. On 04/06/22 at 03:34 PM, Licensed Nurse (LN) M stated the nurse was responsible for monitoring and documentation of behavior monitoring. LN M stated that if there were new orders with the MRRs then the nurse put the new orders in or made necessary changes. On 04/06/22 at 05:22 PM, Administrative Nurse D stated behavior monitoring was documented by the charge nurse and if residents were on certain medications that required behavior monitoring, there were two separate orders for side effects of the medication and behavior monitoring and included antidepressants, hypnotic, and psychotropic medications. She stated pharmacy reviews were emailed to the Director of Nursing (DON); reviewed by DON, unit manager, MDS director, and doctor/nurse practitioner and new orders/changes were put in by the same people. On 04/07/22 at 03:35 PM, Consultant II was unavailable for interview. The facility's Medication Regimen Review policy, dated 11/28/16, directed the CP conducted MRRs and made recommendations based on the information available in the residents' health record. The facility encouraged the physician or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR. The attending physician documented in the residents' health record that the identified irregularity was reviewed and what, if any, action was taken; if no change in the medication, the attending physician documented the rationale in the residents' health record. The policy directed the facility alerted the medical director when MRRs were not addressed by the attending physician in a timely manner. The facility maintained readily available copies of MRRs on file in facility as part of the resident's permanent health record. The facility's Area of Focus: Behavioral Health Recommendations policy, not dated, directed providing behavioral health care and services was an integral part of the person-centered environment and staff monitored residents closely for expressions or indications of distress, assessed and planned care for concerns, accurately documented the changes including the frequency of occurrence and potential trigger's in the resident's record, shared concerns with the interdisciplinary team to determine underlying causes, ensured appropriate follow-up assessment if needed, and discussed potential modifications to the care plan. The facility's Area of Focus: Behavior Management policy, not dated, directed individualized approaches to care were provided as part of a supportive physical, mental, and psychosocial environment. The facility-initiated behavior monitoring, behavior management care plan, and [NAME] as indicated by assessment findings, resident/responsible party conversations, and observations. The policy directed that the resident's medical record showed documentation of adequate indication for a medication's use and the diagnosed condition for which a medication was prescribed. The policy directed the facility monitored medications for efficacy and adverse reactions. The facility's Psychotropic Medication Use policy, last revised 01/01/22, directed all medications used to treat behaviors had a clinical indication and was used in the lowest possible dose to achieve the desired therapeutic effect. All medications used to treat behaviors were monitored for efficacy, risks, benefits, and harm or adverse consequences. The facility failed to ensure CP II recognized and reported lack of documentation of behavior monitoring for R27 who received psychotropic medications including an antipsychotic. This had the potential risk for side effects related to unnecessary medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 53 residents. The sample included 16 residents; six sampled for unnecessary medication review. Based on observations, record review, and interviews, the facility failed to provide consistent bowel monitoring and failed to obtain an order to administer an as needed (PRN) laxative (medication used to loosen stool or stimulate a bowel movement) for Resident (R) 45; failed to ensure carvedilol (antihypertensive- medication used to treat hypertension [high blood pressure]) was not given outside ordered parameters for R205; failed to ensure an indication for administration for Lasix (diuretic- medication to promote the formation and excretion of urine) was documented for R13. This deficient practice had the risk for unnecessary medication use and physical complications. Findings included: - The Diagnoses tab of R45's Electronic Medical Record (EMR) documented diagnoses of major depressive disorder (major mood disorder) and psychotic disorder (any major mental disorder characterized by a gross impairment in reality testing) with delusions due to known physiological condition. The Annual Minimum Data Set (MDS) dated 06/29/21, documented R45 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. She required supervision with setup help only with toileting, bed mobility, transfers, walking, and eating; limited physical assistance with one staff for personal hygiene. R45 was always continent of bowel. R45 received antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medications seven days in the seven-day lookback period. The Quarterly MDS dated 03/10/22, documented R45 had a BIMS score of 13 which indicated intact cognition. She was independent with no setup help with bed mobility, transfers, walking, locomotion, and personal hygiene; independent with setup help only for dressing and eating; and supervision with setup help only with toileting. R45 was always continent of bowel. R45 received antipsychotic (class of medications used to treat psychosis and other mental emotional conditions, antianxiety (class of medications that calm and relax people with excessive anxiety [mental or emotional reaction characterized by apprehension, uncertainty and irrational fear], nervousness, or tension), and antidepressant medications seven days in the seven-day lookback period. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 07/12/21, documented R45 required supervision assistance with ADL function, risk included self-care deficit, care planned to minimize risks. The Care Plan initiated 04/23/19 documented R45 had an ADL self-care performance deficit related to cognitive and behavior problems and directed she was able to toilet independently. The Orders tab of R45's EMR documented an order with a start date of 03/24/20 for docusate sodium (laxative) 100 milligrams (mg) twice a day for bowel management. There was a lack of evidence of a PRN laxative order. The Documentation Survey Report for 01/01/22 to 04/06/22 documented a task for bowel and bladder elimination and revealed the following periods of time where no bowel movement was recorded: 01/01/22 to 01/10/22, 01/20/22 to 01/25/22, 02/03/22 to 02/08/22, and 02/17/22. The Medication Administration Record lacked evidence of a PRN laxative given during the above periods of time where no bowel movement was documented. R45's medical record lacked evidence a bowel assessment was completed for the above time frames where no bowel movement was documented. On 04/06/22 at 09:18 AM, R45 ambulated independently in hallway, appeared comfortable and without signs of distress or discomfort. On 04/06/22 at 10:24 AM, R45 stated she had issues with having bowel movements and the facility did not give her anything for it. On 04/06/22 at 02:40 PM, Certified Nurse Aide (CNA) M stated the aides monitored bowel movements and documented in Point of Care (POC- EMR system for CNA documentation). If a resident was independent, she did not ask them if they had a bowel movement. On 04/06/22 at 03:20 PM, Certified Medication Aide (CMA) R stated R45 did not have issues with bowel movements. She stated the facility had a bowel protocol and the nurse checked the computer for bowel movement alerts and let her know when to give a PRN laxative or the nurse put standing orders in the computer for her to give the resident. On 04/06/22 at 03:34 PM, Licensed Nurse (LN) M stated CNAs documented bowel movements and the nurse manager followed up to see if any residents had not had a bowel movement in three days. If a resident needed a laxative, she contacted the nurse practitioner for orders. LN M stated she did not ask independent residents about bowel movements. On 04/06/22 at 05:22 PM, Administrative Nurse D stated CNAs and nurses documented bowel movements in ADL charting if the resident had a bowel movement. If a resident had not had a bowel movement in three days, she expected staff to ask the independent resident if they had a bowel movement. If the resident needed a laxative then staff were expected to reach out to the nurse practitioner. The facility did not provide a policy on bowel management. The facility failed to provide consistent bowel monitoring and failed to obtain an order to administer a PRN laxative for R45. This deficient practice had the risk for unnecessary medication use and physical complications. - R205 admitted to facility on 01/07/22. The Diagnoses tab of R205's Electronic Medical Record (EMR) documented diagnoses of anoxic brain injury (condition caused by a complete lack of oxygen to the brain), need for assistance with personal care, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and hypertension. The admission Minimum Data Set (MDS) dated 01/14/22, documented a Brief Interview for Mental Status (BIMS) was not completed due to R205 rarely/never understood. R205 required extensive physical assistance with two staff for bed mobility and dressing; total physical dependence with one staff for eating and personal hygiene; total physical dependence with two staff for toileting and transfers. R205 received antianxiety(class of medications that calm and relax people with excessive anxiety [mental or emotional reaction characterized by apprehension, uncertainty and irrational fear], nervousness, or tension) medications three days and antidepressant (medications used to treat depression) seven days in the seven-day lookback period. The Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA) dated 01/17/22 documented R205 had cognition loss related to short- and long-term memory loss. The Delirium (sudden severe confusion, disorientation and restlessness) CAA dated 01/17/22, documented R205 was at risk for delirium related to confused episodes and directed staff provided medications as ordered. The Care Plan dated 03/11/22, documented R205 was at risk for adverse reaction related to black box warning (BBW- warnings required by the Food and Drug Administration for certain medications that carry serious safety risks) and directed staff discussed with resident and family the number and type of medications resident was taking and the potential for drug interactions and side effects from over-medication. The Orders tab of R205's EMR documented an order with a start date of 01/07/22 for carvedilol 3.125 milligrams (mg) two times a day for hypertension with instructions to hold for systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) less than 100 millimeters per Mercury (mmHg) or heart rate (pulse) less than 60 beats per minute (bpm). The Medication Administration Record for 01/01/22 to 04/06/22 revealed the following administrations for carvedilol given outside ordered parameters for R205: 01/09/22 evening (PM), 01/10/22 morning (AM), 01/15/22 PM, 01/22/22 AM, 03/09/22 AM/PM, 03/15/22 AM, 03/16/22 AM, 03/18/22 AM, 03/19/22 AM, 03/22/22 AM/PM, 03/23/22 PM, 03/26/22 AM/PM, 03/30/22 AM, and 04/02/22 AM. On 04/05/22 at 11:46 AM, R205 sat in his Broda chair at table in day room, he attempted to talk to staff walking past him, but they did not acknowledge hearing him. On 04/06/22 at 03:20 PM, Certified Medication Aide (CMA) R stated if a blood pressure or pulse was outside of ordered parameters, she held the medication then reported it to the nurse. On 04/06/22 at 03:34 PM, Licensed Nurse (LN) G stated if blood pressure or pulse was outside of ordered parameters, she held the medication and contacted the doctor. On 04/06/22 at 05:22 PM, Administrative Nurse D stated she expected staff to obtain blood pressure and/or pulse for ordered parameters and hold the medication if the blood pressure/pulse were outside ordered parameters. Staff documented if medication was held or given and if needed, documented if physician was contacted. The facility's Administration of Medications policy, last revised 07/14/21, directed all medications were administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms. The facility failed to ensure that carvedilol was not administered outside of ordered parameters for R205. This deficient practice had the risk for unnecessary medication use and physical complications. - R13's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) with behavioral disturbances and cellulitis (skin infection caused by bacteria characterized by heat, redness and swelling) left lower limb. The admission Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS recorded R13 required extensive assistance of one person for all activities of daily living (ADLs) except eating, for which she was independent. R13 required assistance of one staff member for bathing. R13 had no behaviors. The MDS recorded R13 received an antipsychotic (medication used to treat psychosis), diuretic (medication used to promote excretion of fluids) and opioids (medications use to treat pain) during the lookback period. R13's Psychotropic Drug Use Care Area Assessment (CAA) dated 01/20/22 documented staff encouraged her to use the call light for assistance with ADL's. R13 received routine antipsychotic medication, staff monitored for adverse reactions and for changes in R13 mood or behaviors. R13's Care Plan dated 01/18/22 documented monitor for changes in mental status caused by situational stressors. Monitor for increased anxiety, changes in mood/behaviors. Review of the EMR under Orders tab revealed physician orders: Furosemide (diuretic) tablet 20 mg give one tablet by mouth in the morning dated 01/07/22. Review of the EMR under the Reports tab for review of Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 01/01/22 to 04/04/22 lacked behavior monitoring and indication for administration of diuretic medication for R13. On 04/05/22 at 08:23 AM R13 laid in the bed, yelled out help, that she must go to the bathroom. R13's roommate asked her to stop yelling. R13 started to cuss at R44 and threatened to slap her roommate across the face. R13's call light was located on the floor behind the bed under a blanket and pillow. On 04/06/22 at 03:20 PM, Certified Medication Aide (CMA) R stated the charge nurse documented the behavior monitoring for the residents. CMA R stated every medication should have an indication for administration. CMA R stated she would let the charge nurse know if she noticed a medication without an indication for administration. On 04/06/22 at 03:34 PM, Licensed Nurse (LN) M stated the nurse was responsible for monitoring and documentation of behavior monitoring. LN M stated that if there were new orders with the MRRs then the nurse put the new orders in or made necessary changes. LN G stated every medication needed an indication for administration and she would call the physician to get a diagnosis or indication for use. On 04/06/22 at 05:22 PM, Administrative Nurse D stated behavior monitoring was documented by the charge nurse and if residents were on certain medications that required behavior monitoring, there were two separate orders for side effects of the medication and behavior monitoring and included antidepressants, hypnotic, and psychotropic medications. She stated pharmacy reviews were emailed to the Director of Nursing (DON); reviewed by DON, unit manager, MDS director, and doctor/nurse practitioner and new orders/changes were put in by the same people. Administrative Nurse D stated every medication or order needed an indication for administration. The facility's Administration of Medication policy revision date 07/14/21 documented a physician order that includes dosage, route, frequency, duration and other required consideration included the purpose, diagnosis or indication for use was required for administration of the medications. The facility failed to ensure R13's diuretic medication had an indication for administration, this placed her at risk for adverse consequences related to unnecessary medication and se and possible side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 53 residents. The sample included 16 residents; six sampled for unnecessary medication review. Based on observations, record review, and interviews, the facility failed to ensure an as needed (PRN) psychotropic (any drug that affects brain activities associated with mental processes and behavior) medication had a 14-day stop date or a documented rationale for extended duration for R39 and facility failed to provide behavior monitoring for R39, R13, and R27 who received psychotropic medications, including antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medications. This deficient practice had the risk for unnecessary medication use and physical complications for all residents affected. Findings included: - R39 admitted to facility on 03/02/22. The Diagnoses tab of R39's Electronic Medical Record (EMR) documented diagnoses of bipolar (major mental illness that caused people to have episodes of severe high and low moods) disorder, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, developmental disorder of scholastic skills, and history of falling. The admission Minimum Data Set (MDS) dated 03/09/22, documented R39 had a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment. R39 was independent with bed mobility, transfers, walking, dressing toileting, and personal hygiene; independent with setup help for bathing. R39 received antipsychotic, antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression), and hypnotic (a class of medications used to induce sleep and treat insomnia) medications seven days in the seven-day lookback period and antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medications four days in the seven-day lookback period. The Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA) dated 03/09/22, documented R39 had cognitive loss related to a BIMS score less than 13 and staff allowed extra time for R39 to respond to questions and instructions. The Behavioral Symptoms CAA dated 03/14/22, documented R39 had behavioral symptoms related to rejection of cares and staff gave him as many choices as possible about care and activities. The Psychotropic Drug Use CAA dated 03/17/22, documented R39 had psychotropic drug use due to multiple psychiatric diagnoses. The Care Plan dated 03/03/22 documented R39 had a behavior problem and yelled loudly from his room. Staff anticipated and met his needs and explained all procedures to R39 before starting and allowed him time to adjust to changes. The Care Plan dated 03/14/22 documented R39 had potential to be verbally aggressive related to ineffective coping skills and developmental disorder and directed staff analyzed key times, places, circumstances, triggers, and what de-escalated behaviors and documented. The Orders tab of R39's EMR documented an order with a start date of 03/02/22 for fluvoxamine maleate (antidepressant) 100 milligram (mg) one time day for mood disorder; an order with a start date of 03/02/22 for trazodone hydrochloride (HCl) (antidepressant) 25 mg three times a day for bipolar; an order with start date of 03/02/22 for trazodone HCl 150 mg at bedtime for bipolar; olanzapine (antipsychotic) 7.5 mg three times a day for bipolar; an order with a start date of 03/02/22 for carbamazepine (anticonvulsant- medication used to treat seizures) 100 mg two times a day for bipolar, and an order with a start date of 03/02/22 for hydroxyzine HCl (antihistamine andhypnotic medication used to treat allergies and also used to help control anxiety and tension caused by nervous and emotional conditions) 25 mg every six hours as needed for anxiety. The Orders tab of R39's EMR lacked an order for behavior monitoring. Review of R39's Medication/Treatment Administration Record (MAR/TAR) since admission revealed lack of behavior monitoring for R39. R39's medical record lacked evidence of a rationale for extended duration of use for hydroxyzine PRN. On 04/05/22 at 01:58 PM, R39 ambulated independently in day room and poured himself a cup of water with staff supervision. He sat down in a chair in the day room to watch television. On 04/06/22 at 02:40 PM, Certified Nurse Aide (CNA) M stated everybody was responsible for behavior monitoring and the CNA notified the nurse when a resident had a behavior. She stated R39 clapped his hands or yelled out in his room and sometimes refused cares. On 04/06/22 at 03:20 PM, Certified Medication Aide (CMA) R stated the nurse completed the behavior monitoring. On 04/06/22 at 03:34 PM, Licensed Nurse (LN) M stated particular residents had behavior monitoring and behavior monitoring was completed on any resident on a psychotropic medication. She stated behavior monitoring showed up on the TAR to be completed. On 04/06/22 at 05:22 PM, Administrative Nurse D stated behavior monitoring was documented by the charge nurse and if residents were on certain medications that required behavior monitoring, there were two separate orders for side effects of the medication and behavior monitoring and included antidepressants, hypnotic, and psychotropic medications. She stated PRN psychotropics had a 14-day duration. The facility's Area of Focus: Behavioral Health Recommendations policy, not dated, directed providing behavioral health care and services was an integral part of the person-centered environment and staff monitored residents closely for expressions or indications of distress, assessed and planned care for concerns, accurately documented the changes including the frequency of occurrence and potential trigger's in the resident's record, shared concerns with the interdisciplinary team to determine underlying causes, ensured appropriate follow-up assessment if needed, and discussed potential modifications to the care plan. The facility's Area of Focus: Behavior Management policy, not dated, directed individualized approaches to care were provided as part of a supportive physical, mental, and psychosocial environment. The facility initiated behavior monitoring, behavior management care plan, and [NAME] as indicated by assessment findings, resident/responsible party conversations, and observations. The policy directed that the resident's medical record showed documentation of adequate indication for a medication's use and the diagnosed condition for which a medication was prescribed. The policy directed the facility monitored medications for efficacy and adverse reactions. The facility's Psychotropic Medication Use policy, last revised 01/01/22, directed all medications used to treat behaviors had a clinical indication and was used in the lowest possible dose to achieve the desired therapeutic effect. All medications used to treat behaviors were monitored for efficacy, risks, benefits, and harm or adverse consequences. The policy directed that PRN psychotropic medications were ordered for no more than 14 days. The policy directed for psychotropic medications, excluding antipsychotics, that the attending physician believed a PRN order for longer than 14 days was appropriate, the attending physician could extend the prescription beyond 14 days for the resident by documenting their rationale in the resident's medical record. The facility failed to ensure a PRN psychotropic medication had a 14-day stop date or a documented rationale for extended duration for R39 and failed to provide behavior monitoring for R39 who received psychotropic medication, including an antipsychotic medication. This deficient practice had the risk for unnecessary medication use and physical complications. - R13's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) with behavioral disturbances and cellulitis (skin infection caused by bacteria characterized by heat, redness and swelling) left lower limb. The admission Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS recorded R13 required extensive assistance of one person for all activities of daily living (ADLs) except eating, for which she was independent. R13 required assistance of one staff member for bathing. R13 had no behaviors. The MDS recorded R13 received an antipsychotic (medication used to treat psychosis), diuretic (medication used to promote excretion of fluids) and opioids (medications use to treat pain) during the lookback period. R13's Psychotropic Drug Use Care Area Assessment (CAA) dated 01/20/22 documented staff encouraged her to use the call light for assistance with ADL's. R13 received routine antipsychotic medication, staff monitored for adverse reactions and for changes in R13 mood or behaviors. R13's Care Plan dated 01/18/22 documented monitor for changes in mental status caused by situational stressors. Monitor for increased anxiety, changes in mood/behaviors. Review of the EMR under Orders tab revealed physician orders: Risperidone (antipsychotic) tablet one milligram (mg) by mouth in the morning for dementia with behaviors dated 01/07/22. Review of the EMR under the Reports tab for review of Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 01/01/22 to 04/04/22 lacked behavior monitoring for R13. On 04/03/22 at 10:15 AM R13 refused to be interviewed by the surveyor. R13 appeared agitated and did not want to anyone to approach her due to being upset. On 04/05/22 at 07:22 AM R13 laid on her bed and watched TV. No behaviors of distress noted at this time. On 04/05/22 at 08:23 AM R13 laid in the bed, yelled out help, that she must go to the bathroom. R13's roommate asked her to stop yelling. R13 started to cuss at R44 and threatened to slap her roommate across the face. R13's call light was located on the floor behind the bed under a blanket and pillow. On 04/05/22 at 12:20 PM 13 asleep in bed. No behaviors or distress noted. On 04/03/22 at 10:15 AM R13 refused to be interviewed by the surveyor. R13 appeared agitated and did not want to anyone to approach her due to being upset. On 04/05/22 at 07:22 AM R13 laid on her bed and watched TV. No behaviors of distress noted at this time. On 04/06/22 at 07:20 AM R13 laid on the bed, her head turned toward the wall. R13 appeared calm, call light on the floor. On 04/06/22 at 03:20 PM, Certified Medication Aide (CMA) R stated the charge nurse documented the behavior monitoring for the residents. CMA R stated every medication should have an indication for administration. CMA R stated she would let the charge nurse know if she noticed a medication without an indication for administration. On 04/06/22 at 03:34 PM, Licensed Nurse (LN) M stated the nurse was responsible for monitoring and documentation of behavior monitoring. LN M stated that if there were new orders with the MRRs then the nurse put the new orders in or made necessary changes. On 04/06/22 at 05:22 PM, Administrative Nurse D stated behavior monitoring was documented by the charge nurse and if residents were on certain medications that required behavior monitoring, there were two separate orders for side effects of the medication and behavior monitoring and included antidepressants, hypnotic, and psychotropic medications. She stated pharmacy reviews were emailed to the Director of Nursing (DON); reviewed by DON, unit manager, MDS director, and doctor/nurse practitioner and new orders/changes were put in by the same people. The facility's Medication Regimen Review policy, dated 11/28/16, directed the CP conducted MRRs and made recommendations based on the information available in the residents' health record. The facility encouraged the physician or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR. The attending physician documented in the residents' health record that the identified irregularity was reviewed and what, if any, action was taken; if no change in the medication, the attending physician documented the rationale in the residents' health record. The policy directed the facility alerted the medical director when MRRs were not addressed by the attending physician in a timely manner. The facility maintained readily available copies of MRRs on file in facility as part of the resident's permanent health record. The facility's Psychotropic Medication Use policy, last revised 01/01/22, directed all medications used to treat behaviors had a clinical indication and was used in the lowest possible dose to achieve the desired therapeutic effect. All medications used to treat behaviors were monitored for efficacy, risks, benefits, and harm or adverse consequences. The facility failed to monitor behaviors for R13 which had the potential of unnecessary psychotropic medication administration, thus leading to possible harmful potential side effects related to unnecessary medications. - R27's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dementia (progressive mental disorder characterized by failing memory, confusion), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and anxiety(mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Annual Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS recorded R27 required extensive assistance of one to staff members for all activities of daily living (ADLs) except eating and locomotion for which she was independent. R27 required assistance of two staff members for bathing. The MDS recorded R27 rejected cares daily during the lookback period. The MDS recorded R27 was at risk for pressure injuries but had no pressure injuries. She had a pressure reducing device in her chair and bed but was not on a turning/repositioning program. R27 received an antipsychotic (medication used to treat psychosis), antidepressant (medication used to treat depression) and an antibiotic (medication used to treat bacterial infections) for seven days of the look back period. The MDS documented R27 required physical assistance of one staff member for bathing during look back period. The Quarterly MDS dated 02/08/22 recorded R27 had a BIMS score of 12 which indicated moderately impaired cognition. The MDS recorded R27 required extensive assistance of one to staff members for all activities of daily living (ADLs) including locomotion and supervision of two staff for eating. R27 was totally dependent on one staff for bathing. R27 had verbal behavioral symptoms directed at other for one to three of the lookback days and rejected cares for four to six of the lookback days. The MDS recorded R27 was at risk for pressure injuries but had no pressure injuries. She had a pressure reducing device in her chair and bed but was not on a turning/repositioning program. R27 received an antipsychotic, antidepressant, antibiotic, anticoagulant (medication used to thin blood), insulin (hormone used to treat high blood glucose) and received injections during the lookback period. The MDS documented R27 was totally dependent of two or more staff for bathing activity during the look back period. R27's Psychotropic Drug Use Care Area Assessment (CAA) dated 11/22/21 documented she was on routine antidepressant and antipsychotic medications. R27 was at risk for adverse reactions, staff were to monitor routinely for adverse reactions and/or for changes of mood or behavior. R27's Care Plan dated 11/21 directed staff to administer psychotropic medication and antidepressant medication as ordered by the physician. monitor for any side effects and effectiveness every shift. Review of the EMR under Orders tab revealed physician orders: Escitalopram oxalate (antidepressant) tablet 10 milligrams (mg), give one tablet by mouth daily for major depressive disorder dated 02/01/22. Risperidone (antipsychotic) tablet two mg, give one tablet by mouth at bedtime for schizophrenia dated 03/29/2022. Review of the EMR under the Reports tab for review of Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 01/01/22 to 04/04/22 lacked behavior monitoring for R27. On 04/05/22 at 07:44 AM R27 laid on her back in bed. R27 stated she was waiting for breakfast, no behaviors or distress noted. On 04/06/22 at 03:20 PM, Certified Medication Aide (CMA) R stated the charge nurse documented the behavior monitoring for the residents. CMA R stated every medication should have an indication for administration. CMA R stated she would let the charge nurse know if she noticed a medication without an indication for administration. On 04/06/22 at 03:34 PM, Licensed Nurse (LN) M stated the nurse was responsible for monitoring and documentation of behavior monitoring. LN M stated that if there were new orders with the MRRs then the nurse put the new orders in or made necessary changes. On 04/06/22 at 05:22 PM, Administrative Nurse D stated behavior monitoring was documented by the charge nurse and if residents were on certain medications that required behavior monitoring, there were two separate orders for side effects of the medication and behavior monitoring and included antidepressants, hypnotic, and psychotropic medications. She stated pharmacy reviews were emailed to the Director of Nursing (DON); reviewed by DON, unit manager, MDS director, and doctor/nurse practitioner and new orders/changes were put in by the same people. The facility's Medication Regimen Review policy, dated 11/28/16, directed the CP conducted MRRs and made recommendations based on the information available in the residents' health record. The facility encouraged the physician or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR. The attending physician documented in the residents' health record that the identified irregularity was reviewed and what, if any, action was taken; if no change in the medication, the attending physician documented the rationale in the residents' health record. The policy directed the facility alerted the medical director when MRRs were not addressed by the attending physician in a timely manner. The facility maintained readily available copies of MRRs on file in facility as part of the resident's permanent health record. The facility's Area of Focus: Behavioral Health Recommendations policy, not dated, directed providing behavioral health care and services was an integral part of the person-centered environment and staff monitored residents closely for expressions or indications of distress, assessed and planned care for concerns, accurately documented the changes including the frequency of occurrence and potential trigger's in the resident's record, shared concerns with the interdisciplinary team to determine underlying causes, ensured appropriate follow-up assessment if needed, and discussed potential modifications to the care plan. The facility's Area of Focus: Behavior Management policy, not dated, directed individualized approaches to care were provided as part of a supportive physical, mental, and psychosocial environment. The facility-initiated behavior monitoring, behavior management care plan, and [NAME] as indicated by assessment findings, resident/responsible party conversations, and observations. The policy directed that the resident's medical record showed documentation of adequate indication for a medication's use and the diagnosed condition for which a medication was prescribed. The policy directed the facility monitored medications for efficacy and adverse reactions. The facility's Psychotropic Medication Use policy, last revised 01/01/22, directed all medications used to treat behaviors had a clinical indication and was used in the lowest possible dose to achieve the desired therapeutic effect. All medications used to treat behaviors were monitored for efficacy, risks, benefits, and harm or adverse consequences. The facility failed to monitor behaviors for R27 which had the potential of unnecessary psychotropic medication administration, thus leading to possible harmful potential side effects related to unnecessary medications.

The facility identified a census of 53 residents. Based on observation, record review, and interview, the facility failed to ensure that resident's rights and dignity were respected by staff when Resident (R)6 was not offered to eat in the dining room at meals, and staff failed to provide drinks and meals to all residents at the table when meals were served to R17, R205, and five unidentified resident at the table; staff placed clothing protectors on residents from behind without asking the resident if they wanted one; and staff failed to provide privacy while providing cares for R21, which left these residents at risk for decreased self-esteem and decreased self-worth. Findings included: - On 04/04/22 at 09:37 AM R6 stated that she had to eat her meals in her room and not been offered the option to eat in the dining room. On 04/05 at 08:09 AM R17 sat in Broda chair (a wheelchair that provides assistance with tilt-in-space positioning and chair functionality to people who sit all day) at a table in the commons area when he reached for an unidentified residents drink on the table during breakfast. R17 had not been offered anything to drink R17 had been seated at the table since 07:45 AM and repeatedly asked staff for coffee. On 04/05/22 at 08:25 AM an unidentified staff member placed a clothing protector on two unidentified residents without asking the residents if they wanted one. The unidentified staff member also served one resident at the table their breakfast tray without speaking to the resident, then pushed the cart with the meal trays down the hallway. On 04/05/22 at 08:25 AM R205 was agitated and stated he was starving, and an unidentified staff member told him he had to wait. On 04/05/22 at 08:37 AM an unidentified staff member delivered meals trays to three other unidentified residents at a table in the commons area and did not speak to any of the residents while giving them their food off of the trays; the staff member then walked away. On 04/05/22 at 08:37 AM R205 was given his morning medications while he sat at the table in the commons area during breakfast. On 04/05/22 at 08:43 AM an unidentified dietary staff member delivered another cart with meal trays on it. R17's tray was given to him and there was no silverware or sugar on the tray. R205 asked for coffee and was not given any. On 04/06/22 at 01:56 PM Certified Nurse Aide (CNA) N and CNA O provided peri-care (cleaning of the private area) to R21. Administrative Nurse F knocked on the room door and entered the room, the privacy curtain had not been pulled over, so R21's bare buttocks could be seen from the hallway. On 04/06/22 at 02:39 PM CNA M stated that the residents had been eating in their rooms due to the COVID (highly contagious potentially life-threatening respiratory infection) outbreak and after that most of the residents chose to stay in their rooms to eat. She further stated, there was a few residents on the north hall that would come down to eat in the commons area to eat. On 04/06/22 at 03:35 PM Licensed Nurse (LN) G stated that during COVID the residents had to eat in their rooms. She had worked at the facility for about two months and there had not been anyone in the building that has had COVID during those two months. She stated some of the residents had voiced that they wanted to go eat in the main dining room. On 04/06/22 at 04:51 PM Administrative Nurse F stated that during COVID the residents were all eating in their rooms. Since then, some come out on the north hall to the commons area to eat. Some of the residents still chose to eat in their room but all residents have been offered to eat in the dining room. On 04/06/22 at 06:30 PM Administrative Nurse D stated that a lot of the residents eat in their rooms and a few might go out to the north dining room or to the commons area on both sides of the facility. Administrative Nurse D further stated that it was the resident's preference where they chose to eat. All residents had been offered the option to eat in the dining rooms. Administrative Nurse D was not sure when a resident was asked about their dining preference but said that the dietary supervisor asked those questions. Administrative Nurse D also stated that residents had in recent months brought up in Resident Council meetings that they wanted to eat in the dining rooms again. The facility policy Resident Rights last revised 11/28/16 documented: the resident had the right to a dignified existence; the resident had the right to exercise his/her right s as a resident of the facility; the resident had the right to be treated with respect and dignity; the resident had the right to reside and receive services in the facility with reasonable accommodation of the resident and preferences except when to do so would endanger the health or safety of other residents; and the resident had the right to choose activities, schedules, health care and providers of health care services consistent with his or her interests, assessments, and plan of care. The facility failed to ensure that resident's rights and dignity were respected when residents had to eat in their rooms instead of the dining room and failed to provide drinks and meal trays to all residents while the residents were seated at a table during meal times, failed to acknowledge resident requests during meal times, failed to obtain resident permission prior to placing clothing protectors, failed to interact with the residents in a positive manner, and failed to provide privacy to a resident while cares were provided to a residents, which left those residents at risk for decreased self-esteem and decreased self-worth.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified at census of 53 residents. The sample included 16 residents with 16 residents was reviewed for comprehensive care planning. Based on observation, record review, and interview, the facility failed to implement comprehensive care plans for Residents (R)30, R44, R49, R13, and R205. This deficient practice placed the residents at risk for not receiving proper cares/assistance in a timely manner. -The electronic medical record (EMR) indicated the following diagnosis for R30: muscle weakness, major depressive disorder (major mood disorder). hypertensive heart disease (chronic high blood pressure), insomnia (difficulty falling asleep), traumatic brain injury (TBI), constipation, and abnormalities of gait and coordination. A review of R30's admission Minimum Data Set (MDS) completed [DATE] indicated a Brief Interview for Mental Status (BIMS) score of seven indicating intact cognition. The MDS revealed she was occasionally incontinent of bowel and bladder with no toileting program A review of R30's Activities of Daily Living (ADL's) Care Area Assessment (CAA) dated [DATE] indicated that her urinary incontinence would be addressed in her care plan. The CAA indicated that she felt urgency to void at times. A review of R30's Care Plan revised [DATE] lacked documentation related to her bowel and bladder incontinence. A review of R30's Lookback report under Bowel and Bladder Elimination between [DATE] and [DATE] indicated that she had incontinent episodes on 12 occasions. A review of R30's assessment revealed no documentation showing incontinence assessment tool completed in the resident's chart. In an interview completed on [DATE] at 02:22 PM with R30, she stated that she does have incontinence issues but reported them to the nursing staff. She reported that she is not sure if a special bowel program was started. In an interview completed on [DATE] at 02:20 PM with Certified Nurse Aid (CNA) M, she stated that staff can review the resident's care to see who has special precautions related to toileting and assisting residents to the restroom. She stated that she doesn't know if R30 has a special bowel program. She stated that if something was missing or not in the care plan it would be reported to the nurse. In an interview completed on [DATE] at 02:20PM with Licensed Nurse (LN), she stated that the nursing staff review resident's care plans and updates the other staff member of changes that occur. She reported that if a resident was on a special bowel program it would in the care plan. In an interview completed on [DATE] at 04:20PM with Administrative Nurse E, she stated that when residents first arrive a base line care plan with be completed and a comprehensive assessment with occur after the care plan has been established. She reported areas triggered on the MDS should be placed in the care plan and addressed on the comprehensive care plan. A review of the facility's Urinary Incontinence Management revised 04/2022 stated that the facility must ensure that resident's receive services and assistance to remain continent of bowel and bladder. The policy stated that each resident who is incontinent of bladder will be identified, assessed, and provided appropriate treatment and services to achieve or maintain as much normal bladder function as possible. A review of the facility's Care Plan Policy revised 10/2019 stated that the care plan identified and included a focus statement, measurable goals, interventions of identified problems. The policy indicated that the care plan must include identified issues from the resident's comprehensive assessment, CAA, and MDS. The facility failed to develop care plan interventions related to R30's urinary and bowel incontinence. The deficient practices placed her at risk for complications related to incontinence care. -The electronic medical record (EMR) indicated the following diagnosis for R44: hypertension (high blood pressure), cerebrovascular disease (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiplegia (left sided paralysis of one side of the body), dysphagia (swallowing difficulty), and muscle weakness. A review of R44's Quarterly Minimum Data Set (MDS) completed [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS indicated that she was frequently incontinent of urine and occasionally incontinent of bowel with no toileting program in place. Her MDS revealed she required extensive assistance from one staff member for transferring, dressing, bathing, personal hygiene, and toileting. A review of R44's Urinary Incontinence CAA dated [DATE] stated that staff were to provide routine checks and assistance with incontinence cares as needed. R44's Care Plan revised [DATE] stated that staff were to provide routine incontinence checks and provide cares when needed but failed to provided interventions related to improving or preventing incontinence episodes. A review of R44's EMR under Assessments indicated on two occasions ([DATE] and [DATE]) that she was a candidate for toileting program, but lacked documentation sit was implemented. A review of R44's Lookback report under Bowel and Bladder Elimination between [DATE] and [DATE] indicated that she had incontinent episodes on 63 occasions. On [DATE] at 08:35AM R44 reported that she has had bowel and bladder accidents waiting for staff to respond to the call lights. She reported that she does have problems with incontinence but does not remember if she had any special programs for it. In an interview completed on [DATE] at 02:20 PM with Certified Nurse Aid (CNA) M, she stated that staff can review the resident's care to see who has special precautions related to toileting and assisting residents to the restroom. She stated that she doesn't know if R44 has a special bowel program. She stated that if something was missing or not in the care plan it would be reported to the nurse. In an interview completed on [DATE] at 02:20PM with Licensed Nurse (LN), she stated that the nursing staff review resident's care plans and updates the other staff member of changes that occur. She reported that if a resident was on a special bowel program it would in the care plan. In an interview completed on [DATE] at 04:20PM with Administrative Nurse E, she stated that when residents first arrive a base line care plan with be completed and a comprehensive assessment with occur after the care plan has been established. She reported areas triggered on the MDS should be placed in the care plan and addressed on the comprehensive care plan. A review of the facility's Urinary Incontinence Management revised 04/2022 stated that the facility must ensure that resident's receive services and assistance to remain continent of bowel and bladder. The policy stated that each resident who is incontinent of bladder will be identified, assessed, and provided appropriate treatment and services to achieve or maintain as much normal bladder function as possible. A review of the facility's Care Plan Policy revised 10/2019 stated that the care plan identified and included a focus statement, measurable goals, interventions of identified problems. The policy indicated that the care plan must include identified issues from the resident's comprehensive assessment, CAA, and MDS. The facility failed to develop care plan interventions related to R44's urinary and bowel incontinence. The deficient practices placed her at risk for complications related to incontinence care. -The electronic medical record (EMR) indicated the following diagnosis for R49: chronic obstructive pulmonary disorder (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) hypertension (high blood pressure), bipolar disorder, major depressive disorder (major mood disorder), type two diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), acute respiratory failure, hypoxia (inadequate supply of oxygen), dysphagia, lack of coordination, and insomnia (inadequate supply of oxygen). A review of R49's Significant Change Minimum Data Set (MDS) completed [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. The MDS indicated he received oxygen therapy while a resident and he required extensive assist from staff for toileting, personal hygiene, transfers, and bed mobility. A review of R49's Activities of Daily Living (ADL's) Care Area Assessment completed on [DATE] indicated he required extensive assistance for his ADL's and had a history of being verbally aggressive with staff with cares provided. A review of R49's 'Care Plan revised [DATE] indicated that he had asthma and COPD but failed to include oxygen therapy treatment, goals, and interventions. R49's Medication Administration Report (MAR) in the EMR revealed an active physicians order dated [DATE] to give six liters of oxygen delivered by nasal canula (tubing that delivers oxygen directly through both nostrils of the nose) while resident is out of bed and three liters of oxygen while he is in bed. The physician's order revealed that the oxygen tubing should be changed every Sunday evening. On [DATE] at 08:12 AM R49 reported that he never uses his oxygen and often refuses when staff asks him to wear his nasal cannula. An inspection of his oxygen machine revealed the outside of the machine had collected dust and no storage bag was present for the oxygen tubing. The nasal cannula and oxygen tubing rested on the ground behind the machine. The tubing and cannula appeared dirty and visibly soiled. An inspection of the machine revealed it was dated [DATE] and expired two weeks ago. An inspection of his wheelchair's portable oxygen tank revealed no date on his oxygen tubing. On [DATE] at 07:39 AM a walkthrough of R49's room revealed his oxygen therapy tubing and nasal canula still had not been changed. R49's tubing and nasal canula were sitting on top of his dusty machine with no storage bag present. R49's oxygen machine was on and running but not being used by the resident. In an interview completed on [DATE] at 02:20 PM with Certified Nurse Aid (CNA) M, she reported that nasal cannulas and oxygen tubing should be dated and stored in a plastic bag when not in use. She stated that the tubing gets changed out weekly. She stated that the tubing or nasal cannula should be replaced if contaminated. CNA M stated that staff are to make sure that the residents are using their oxygen machines but are not responsible for cleaning them. In an interview completed on [DATE] at 04:15 PM with Administrative Nurse F, she stated that the oxygen machines are cleaned by the maintenance department. She reported that the tubing should be changed out every Sunday night and staff should be storing the nasal canula and tubing in a plastic bed when not in use. A review of the facility's Care Plan Policy revised 10/2019 stated that the care plan identified and included a focus statement, measurable goals, interventions of identified problems. The policy indicated that the care plan must include identified issues from the resident's comprehensive assessment, CAA, and MDS. The facility failed to develop care plan interventions related to R49's oxygen therapy. This deficient practice placed him at risk for complications related to breathing treatments. - R205 admitted to facility on [DATE]. The Diagnoses tab of R205's Electronic Medical Record (EMR) documented diagnoses of anoxic brain injury (condition caused by a complete lack of oxygen to the brain), need for assistance with personal care, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and history of falling. The admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) was not completed due to R205 rarely/never understood. R205 required extensive physical assistance with two staff for bed mobility and dressing; total physical dependence with one staff for eating and personal hygiene; total physical dependence with two staff for toileting and transfers. R205 considered the following activities somewhat important to him: have books, newspapers, and magazines to read, listen to music, be around animals such as pets, keep up with the news, do things with groups of people, do favorite activities, go outside to get fresh area when weather is good, and participate in religious services or practices. The Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA) dated [DATE] documented R205 had cognition loss related to short- and long-term memory loss. R205's medical record lacked evidence of a person-centered activity care plan. The Assessments tab of R205's EMR lacked evidence of an activity assessment which documented the resident's current and/or past preferences, interests and hobbies. R205's medical record lacked evidence of activity participation. On [DATE] at 11:46 AM, R205 sat in his Broda chair at table in day room, he attempted to talk to staff walking past him, but they did not acknowledge hearing him. No observations of activities being performed or offered. On [DATE] at 01:51 PM, R205 laid in bed, bed had bolsters on the side to prevent falling out of bed, fall mats were on both sides of the bed. R205 appeared restless, staff were in room. On [DATE] at 09:18 AM, R205 sat in his Broda chair at table in day room, he attempted to talk to anyone who passed by him but only one staff member stopped to talk to him. He appeared to want to converse with anyone. No observations of activities being performed or offered. On [DATE] at 03:20 PM, Certified Medication Aide (CNA) R stated she sometimes helped out with activities and the facility had been providing activities. She stated R205 was usually in the day room and he liked to talk a lot. On [DATE] at 04:08 PM, Administrative Nurse E stated she, the Director of Nursing, and another nurse were responsible for updating the care plan. She stated she completed quarterly activity assessments with the MDS currently. On [DATE] at 05:22 PM, Administrative Nurse D stated the floor nurses completed a baseline care plan on admission and if any area was missed then it was corrected with the MDS then on the care plan. The facility's Area of Focus: Care Planning- Baseline, Comprehensive, and Routine Updates policy, not dated, directed the comprehensive care plan was completed within seven days of the CAAs, the care plan was updated with each MDS assessment and periodically. The facility failed to complete and implement a person-centered activity care plan for R205. This deficient practice had the risk miscommunication among staff, missed opportunities for activities, and a decline in physical, mental, and psychosocial well-being and independence for R205. - R13's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) with behavioral disturbances and cellulitis (skin infection caused by bacteria characterized by heat, redness and swelling) left lower limb. The admission Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS recorded R13 required extensive assistance of one person for all activities of daily living (ADLs) except eating, for which she was independent. R13 required assistance of one staff member for bathing. R13 had no behaviors. The MDS recorded R13 received an antipsychotic (medication used to treat psychosis), diuretic (medication used to promote excretion of fluids) and opioids (medications use to treat pain) during the lookback period. R13's Cognitive Loss Care Area Assessment (CAA) dated [DATE] documented staff encouraged her to use the call light for assistance with ADL's. R13 received routine antipsychotic medication, staff monitored for adverse reactions and for changes in R13 mood or behaviors. R13's Care Plan dated [DATE] documented staff should allow extra time for her to respond to questions or instructions. The Care Plan lacked documentation for person centered dementia care. On [DATE] at 10:15 AM R13 refused to be interviewed by the surveyor. R13 appeared agitated and did not want to anyone to approach her due to being upset. On [DATE] at 07:22 AM R13 laid on her bed and watched TV. No behaviors of distress noted at this time. On [DATE] at 08:23 AM R13 laid in the bed, yelled out help, that she must go to the bathroom. R13's roommate asked her to stop yelling. R13 started to cuss at the roommate and threatened to slap her roommate across the face. R13's call light was located on the floor behind the bed under a blanket and pillow. On [DATE] at 12:20 PM 13 asleep in bed. No behaviors or distress noted. On [DATE] at 07:20 AM R13 laid on the bed, her head turned toward the wall. R13 appeared calm, call light on the floor. On [DATE] at 02:35 PM in an interview, Certified Nurse's Aide (CNA) M stated she was able to review the care plans and that was where to find the instructions for the care of each of the resident. CNA M the care plan would have any specialized care listed each resident. CNA M stated she had not received any dementia training at the facility. CNA M stated that she would report any behaviors to the nurse and documented behaviors in the EMR. On [DATE] at 03:35 PM in an interview, Licensed Nurse (LN) G stated nursing staff review resident's care plans and updates the other staff member of changes that occur. LN G stated behavioral monitoring was completed on any one that received an antipsychotic medication, which was completed by the charge nurse on the Medication Administration Record (MAR). LN G stated the call light should be within reach of the resident when in their room. On [DATE] at 04:20 PM in an interview, Administrative Nurse E stated, she stated that when residents first arrive a base line care plan would be completed and a comprehensive assessment with occur after the care plan has been established. Administrative Nurse E reported areas triggered on the MDS should be placed in the care plan and addressed on the comprehensive care plan. The facility's Care Plan policy revised 10/2019 documented that the care plan identified and included a focus statement, measurable goals, interventions of identified problems. The policy indicated that the care plan must include identified issues from the resident's comprehensive assessment, CAA, and MDS. The facility failed to develop a person-centered care plan for R13 related to dementia treatment and services to attain and/or maintain her practicable physical, mental and psychosocial well-being. This deficient practice placed her at risk of increased confusion, isolation, and lack of appropriate activities and interaction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 53 residents. The sample included 16 residents with 11 reviewed for bathing. Based on observations, record reviews, and interviews, the facility failed to provide consistent bathing per the residents' preferences and bathing schedules for Residents (R) 30, R44, R49, R225, R6, R17, R27, R39 and R45. This deficient practice placed the residents at risk for poor hygiene and impaired psychosocial well-being. Findings Included: -The electronic medical record (EMR) indicated the following diagnosis for R30: muscle weakness, major depressive disorder (major mood disorder). hypertensive heart disease (chronic high blood pressure), insomnia (difficulty falling asleep), traumatic brain injury (TBI), constipation, and abnormalities of gait and coordination. A review of R30's admission Minimum Data Set (MDS) completed 02/17/22 indicated a Brief Interview for Mental Status (BIMS) score of seven indicating intact cognition. The MDS reported that supervision and touch assistance were required for her bathing upon admission. A review of R30's Activities of Daily Living (ADL's) Care Area Assessment (CAA) dated 02/17/22 indicated she requires assistance with ADL's and reported that here needs will be reported on her care plan. A review of R30's Care Plan revised 03/11/22 lacked documentation related to her activities of daily living and if R30 required assistance to complete her ADL's. A review of R30's Bathing Look Back report from 02/10/22 to 04/05/22 revealed she had received bathing on four occasions (2/18, 2/23, 3/4, and 3/25). The clinical record lacked evidence of further bathing attempts or refusals. On 04/04/22 at 08:30 AM R30 observed in her room watching television. She appeared well groomed and getting ready for breakfast. She appeared to be in a good mood. She reported no pain or concerns at the time of interview. In an interview completed on 04/05/22 at 02:22 PM with R30, she stated that staff often are slow to respond to resident's request. R30 reported a recent fall and is aware that she had struggled with transfers and balance while completing her ADL's. R30 appeared clean and well groomed at time of interview. In an interview completed on 04/06/22 at 02:20 PM with Certified Nurse Aid (CNA) M, she stated that residents are to receive two bathes per week. She reported that the CNA staff can log into the EMR system using tablets and document when a resident has received a bath or refused. In an interview completed on 04/06/22 at 02:20PM with Licensed Nurse (LN) G, she stated that the nursing staff will assist with bathing residents based on the care plan and personal preferences of the residents. She stated that all bathing and refusal are documented in the resident's care log. A review of the facility's Activities of Daily Livings reviewed 02/2019 stated the resident will receive assistance as needed to complete activities of daily living. The policy stated that the facility must provided basic cares including hygiene, bathing, grooming, and oral care and any resident unable to carry out their ADL's will receive the necessary services to maintain good nutrition, grooming, and personal hygiene. The facility failed to provide consistent bathing per the residents' preferences and bathing schedules for R30. This practice placed the resident at risk for poor hygiene and impaired psychosocial well-being. -The electronic medical record (EMR) indicated the following diagnosis for R44: hypertension (high blood pressure), cerebrovascular disease (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiplegia (left sided paralysis of one side of the body), dysphagia (swallowing difficulty), and muscle weakness. A review of R44's Quarterly Minimum Data Set (MDS) completed 03/10/22 indicated a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS indicated she required extensive assistance from one staff member for transferring, dressing, bathing, personal hygiene, and toileting. A review of R44's Activities of Daily Living (ADL'S) Care Area Assessment (CAA) dated 12/09/21 stated she had an ADL functional impairment related to her existing medical conditions and that she required extensive assistance for all ADL's and transfer from at least one staff member. R44's Care Plan revised 03/14/22 stated that she has an ADL self-care deficit related to her medical conditions and she is a total assist by staff for bathing. The care plan stated that she is to receive two bathing opportunities weekly and as needed. A review of R44's Bathing Look Back report from 01/01/22 to 04/05/22 revealed she had received bathing on six occasions (1/13, 1/27, 2/4, 2/24, 3/22, and 3/31). The clinical record lacked evidence of further bathing attempts or refusals. In an interview on 04/05/22 at 08:40 AM R44 reported that staff do give her baths but sometimes not twice a week. She reported that she did receive a bath this week. R44 appeared clean and well-groomed at the time of interview. In an interview completed on 04/06/22 at 02:20 PM with Certified Nurse Aid (CNA) M, she stated that residents are to receive two bathes per week. She reported that the CNA staff can log into the EMR system using tablets and document when a resident has received a bath or refused. In an interview completed on 04/06/22 at 02:20PM with Licensed Nurse (LN) G, she stated that the nursing staff will assist with bathing residents based on the care plan and personal preferences of the residents. She stated that all bathing and refusal are documented in the resident's care log. A review of the facility's Activities of Daily Livings reviewed 02/2019 stated the resident will receive assistance as needed to complete activities of daily living. The policy stated that the facility must provide basic cares including hygiene, bathing, grooming, and oral care and any resident unable to carry out their ADL's will receive the necessary services to maintain good nutrition, grooming, and personal hygiene. The facility failed to provide consistent bathing per the residents' preferences and bathing schedules for R44. This practice placed the resident at risk for poor hygiene and impaired psychosocial well-being. -The electronic medical record (EMR) indicated the following diagnosis for R49: chronic obstructive pulmonary disorder (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing)hypertension (high blood pressure), bipolar disorder, major depressive disorder (major mood disorder), type two diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), acute respiratory failure, hypoxia (inadequate supply of oxygen), dysphagia, lack of coordination, and insomnia (inadequate supply of oxygen). A review of R49's Significant Change Minimum Data Set (MDS) completed 03/02/22 indicated a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. The MDS indicated he received oxygen therapy while a resident and he required extensive assist from staff for toileting, personal hygiene, transfers, and bed mobility. A review of R49's Activities of Daily Living (ADL's) Care Area Assessment completed on 03/02/22 indicated he required extensive assistance for his ADL's and had a history of being verbally aggressive with staff with cares provided. A review of R49's 'Care Plan revised 04/04/22 indicated that he has an ADL self-care deficit related to his medical diagnosis. The plan indicated that staff should provide a sponge bath when a full bath cannot be tolerated, and he prefers having two baths each week in the evenings. A review of R49's Bathing Look Back report from 01/13/22 to 04/05/22 (82 days reviewed) revealed he had received bathing on 13 occasions (1/26, 1/27, 2/2, 2/7, 2/8, 2/12, 2/20, 2/24, 3/1, 3/7, 3/8, 3/21,and 3/28). The clinical record lacked evidence of further bathing attempts or refusals. On 04/05/22 at 08:12 AM R49 reported that he has refused bathing in the past but not always. He stated he had not received his bath for the week yet. The resident's hair appeared combed but greasy. The resident remained in bed most of the morning asleep. In an interview completed on 04/06/22 at 02:20 PM with Certified Nurse Aid (CNA) M, she stated that residents are to receive two bathes per week. She reported that the CNA staff can log into the EMR system using tablets and document when a resident has received a bath or refused. She stated that R49 has had a history of refusing cares offered by staff. In an interview completed on 04/06/22 at 02:20PM with Licensed Nurse (LN) G, she stated that the nursing staff will assist with bathing residents based on the care plan and personal preferences of the residents. She stated that all bathing and refusal are documented in the resident's care log. A review of the facility's Activities of Daily Livings reviewed 02/2019 stated the resident will receive assistance as needed to complete activities of daily living. The policy stated that the facility must provide basic cares including hygiene, bathing, grooming, and oral care and any resident unable to carry out their ADL's will receive the necessary services to maintain good nutrition, grooming, and personal hygiene. The facility failed to provide consistent bathing per the residents' preferences and bathing schedules for R49. This practice placed the resident at risk for poor hygiene and impaired psychosocial well-being. - The electronic medical record (EMR) indicated the following diagnosis for R225: metabolic encephalopathy (inflammatory condition of the brain), type two diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dysphagia (swallowing difficulty), insomnia (inability to sleep), urinary retention (lack of ability to urinate and empty the bladder), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) , and constipation. A review of R225s admission Minimum Data Set (MDS) completed 03/21/22 indicated a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. The MDS indicated total dependence for staff related to hygiene, transfers, bathing, toileting, personal cares, and eating. A review of R225's Activities of Daily Living (ADL's) Care Area Assessment (CAA) dated 03/21/22 stated she had worked to regain current level of functioning after being recently hospitalized from a fall before her admission. R225's Care Plan revised 03/18/2022 noted that she had an ADL self-care deficit related to activity intolerance. The care plan stated that she was dependent on staff assist for all ADL's and encouraged to use her call light for assistance. The care plan indicated that she prefers to shower two times per week and as needed. A review of R225's Bathing Look Back report from 03/14/22 to 04/05/22 (22 days reviewed) revealed she had received bathing on two occasions (3/18 and 3/25). The clinical record lacked evidence of further bathing attempts or refusals. On 04/04/22 at 12:40 PM R225 observed sitting in her room watching television. The resident appeared to be engaged in her television show. R225 reported that she has received bathing since her admission but not this week. She reported that she prefers to yell out to staff instead of using her call light because staff respond more quickly. In an interview completed on 04/06/22 at 02:20 PM with Certified Nurse Aid (CNA) M, she stated that residents are to receive two bathes per week. She reported that the CNA staff can log into the EMR system using tablets and document when a resident has received a bath or refused. She stated that R225 has a history of refusing cares offered by staff. In an interview completed on 04/06/22 at 02:20PM with Licensed Nurse (LN) G, she stated that the nursing staff will assist with bathing residents based on the care plan and personal preferences of the residents. She stated that all bathing and refusal are documented in the resident's care log. A review of the facility's Activities of Daily Livings reviewed 02/2019 stated the resident will receive assistance as needed to complete activities of daily living. The policy stated that the facility must provide basic cares including hygiene, bathing, grooming, and oral care and any resident unable to carry out their ADL's will receive the necessary services to maintain good nutrition, grooming, and personal hygiene. The facility failed to provide consistent bathing per the residents' preferences and bathing schedules for R225. This practice placed the resident at risk for poor hygiene and impaired psychosocial well-being. - R39 admitted to facility on 03/02/22. The Diagnoses tab of R39's Electronic Medical Record (EMR) documented diagnoses of bipolar (major mental illness that caused people to have episodes of severe high and low moods) disorder, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, developmental disorder of scholastic skills, and history of falling. The admission Minimum Data Set (MDS) dated 03/09/22, documented R39 had a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment. R39 was independent with bed mobility, transfers, walking, dressing toileting, and personal hygiene; independent with setup help for bathing. The Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA) dated 03/09/22, documented R39 had cognitive loss related to a BIMS score less than 13 and staff allowed extra time for R39 to respond to questions and instructions. The Care Plan dated 03/14/22 documented R39 had potential to be verbally aggressive related to ineffective coping skills and developmental disorder and directed staff gave the resident as many choices as possible about his care and activities. The Care Plan dated 03/02/22 documented R39 was a risk for falls and directed staff assisted him with activities of daily living (ADL) as needed. The care plan did not address how R39 performed ADLs or how much assistance he required. The Documentation Survey Report for 03/02/22 to 03/31/22 documented a task for ADL- bathing as needed (PRN) and revealed R39 received a sponge bath on 03/14/22. The Documentation Survey Report for 04/01/22 to 04/06/22 lacked a task for bathing. The facility's Shower Schedule documented showers scheduled by room number. R39's showers were scheduled for evening shift on Tuesday and Thursdays. On 04/05/22 at 01:58 PM, R39 ambulated independently in day room and poured himself a cup of water with staff supervision. He sat down in a chair in the day room to watch television. R39 wore a red shirt and jeans. On 04/06/22 at 07:35 AM, R39 stood beside a table in the day room and conversed with another resident. He appeared to be wearing the same clothes as the previous day. On 04/06/22 at 02:40 PM, Certified Nurse Aide (CNA) M stated bathing was completed by the CNAs and residents received bathing twice a week. The CNAs had a calendar they followed for who received baths that day and documented bathing on Point of Care (POC- EMR system for CNA documentation). If bathing was completed, it was documented in POC with type of bathing provided. If a resident refused bathing then she asked another aide to try then the nurse, refusals were documented as well. CNA M stated R39 refuses bathing and it was documented in POC. On 04/06/22 at 03:34 PM, Licensed Nurse (LN) G stated CNAs completed bathing and let the nurse know if a resident received a shower or if they refused. If a resident refused bathing, she tried to get resident to take a bath, if they still refused then refusals get documented in a progress note. LN G stated the unit manager audited bathing. She stated R39 did not refuse to take showers and if they received a shower then it was documented in POC. If there was a blank in the bathing documentation then she questioned if they received bathing, it the documentation stated the activity did not occur then bathing did not happen. On 04/06/22 at 05:22 PM, Administrative Nurse D stated the shower schedule went by room numbers and the facility had a bath aide during the week. Bathing was documented in the shower book and in PCC which was the most important place for documentation. Administrative Nurse D stated showers were audited weekly, if it's documented as activity did not occur then bathing did not occur and if it was not documented then it did not occur. She stated R39 refused bathing and showers were still documented if the resident was independent with setup help. The facility's ADLs policy, dated 12/11/18, directed the resident received assistance as needed to complete ADLs and any change in the ability to perform ADLs were documented and reported to licensed nurse. The Bed baths and Showers reference provided by facility, reviewed 06/14/19, directed tub baths and showers provided personal hygiene, stimulated circulation, and reduced tension for a patient and directed staff to document the procedure after completed. The facility failed to provide consistent bathing for R39. This deficient practice had the risk for poor hygiene and decreased self-esteem and dignity for R39. - The Diagnoses tab of R45's Electronic Medical Record (EMR) documented diagnoses of major depressive disorder (major mood disorder) and psychotic disorder (any major mental disorder characterized by a gross impairment in reality testing) with delusions due to known physiological condition. The Annual Minimum Data Set (MDS) dated 06/29/21, documented R45 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. She required supervision with setup help only with toileting, bed mobility, transfers, walking, and eating; limited physical assistance with one staff for personal hygiene; bathing activity did not occur during the assessment period. The Quarterly MDS dated 03/10/22, documented R45 had a BIMS score of 13 which indicated intact cognition. She was independent with no setup help with bed mobility, transfers, walking, locomotion, and personal hygiene; independent with setup help only for dressing and eating; and supervision with setup help only with toileting; and supervision with no setup help for bathing. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 07/12/21, documented R45 required supervision assistance with ADL function, risk included self-care deficit, care planned to minimize risks. The Care Plan initiated 04/23/19, directed R45 had an ADL self-care performance deficit related to cognitive and behavior problems and directed she required setup and supervision by staff with bathing/showering twice weekly during the day and as necessary. R45 needed a lot of encouragement to bathe, staff needed to keep going back and asking her as she eventually would bathe. The Documentation Survey Report for 01/01/22 to 04/06/22 documented a task for ADL bathing twice weekly and as needed (PRN). The Documentation Survey Report revealed the following bathing documentation: ADL activity itself did not occur on 01/03/22, 01/10/22, 01/20/22, 01/24/22, 01/27/22, 01/31/22, 02/03/22, 02/28/22, 03/03/22, 03/10/22, 03/24/22, and 04/04/22; lack of documentation on 01/06/22, 01/13/22, 01/17/22, 02/07/22, 02/10/22, 02/17/22, 02/21/22, 02/24/22, 03/14/22, 03/17/22, 03/21/22, and 03/31/22; received shower on 02/14/22, 03/07/22, and 03/28/22. The Shower Schedule documented showers scheduled by room number. R45 was scheduled for showers on Monday and Wednesday day shift. On 04/06/22 at 09:18 AM, R45 ambulated independently in the hallway, no signs of distress or discomfort. On 04/06/22 at 10:24 AM, R45 stated she did not receive bathing regular and she did not like that she stinks and wishes the facility would figure out why she smells. On 04/06/22 at 02:40 PM, Certified Nurse Aide (CNA) M stated bathing was completed by the CNAs and residents received bathing twice a week. The CNAs had a calendar they followed for who received baths that day and documented bathing on Point of Care (POC- EMR system for CNA documentation). If bathing was completed, it was documented in POC with type of bathing provided. If a resident refused bathing then she asked another aide to try then the nurse, refusals were documented as well. On 04/06/22 at 03:20 PM, Certified Medication Aide (CMA) stated R45 sometimes refused bathing. On 04/06/22 at 03:34 PM, Licensed Nurse (LN) G stated CNAs completed bathing and let the nurse know if a resident received a shower or if they refused. If a resident refused bathing, she tried to get resident to take a bath, if they still refused then refusals get documented in a progress note. LN G stated the unit manager audited bathing. She stated R45 took her showers and if they received a shower then it was documented in POC. If there was a blank in the bathing documentation then she questioned if they received bathing, it the documentation stated the activity did not occur then bathing did not happen. On 04/06/22 at 05:22 PM, Administrative Nurse D stated the shower schedule went by room numbers and the facility had a bath aide during the week. Bathing was documented in the shower book and in PCC which was the most important place for documentation. Administrative Nurse D stated showers were audited weekly, if it's documented as activity did not occur then bathing did not occur and if it was not documented then it did not occur. She stated R45 refused bathing and showers were still documented if the resident was independent with setup help. The facility's ADLs policy, dated 12/11/18, directed the resident received assistance as needed to complete ADLs and any change in the ability to perform ADLs were documented and reported to licensed nurse. The Bed baths and Showers reference provided by facility, reviewed 06/14/19, directed tub baths and showers provided personal hygiene, stimulated circulation, and reduced tension for a patient and directed staff to document the procedure after completed. The facility failed to provide consistent bathing for R45. This deficient practice had the risk for poor hygiene and decreased self-esteem and dignity for R45. - R6's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of chronic respiratory failure (condition in which the blood does not have enough oxygen or has too much carbon dioxide and the lungs are unable to carry the blood to the organs), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and bipolar (major mental illness that caused people to have episodes of severe high and low moods) mood disorder. The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R6 required limited assistance of one staff member for activities of daily living (ADL's). The MDS documented R6 required physical help of one staff member for set up or assistance as part of the bathing activity during the look back period. The MDS documented R6 received oxygen therapy during the look back period. The Quarterly MDS dated 01/05/22 documented no changes documented from previous MDS assessment. R6's ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 10/25/21 documented she has required limited assist by staff for bathing/showers. R6's Care Plan last revised 03/04/21 documented she required maximum assistance and a lot of encouragement from staff with her bath/showers twice weekly during the evening and as needed. Review of the EMR under Documentation Survey Reports tab for bathing reviewed from 01/01/22 to 04/04/22 (94 days) revealed R6 received two baths/showers (02/28/22 and 03/16/22). The Bathing task was documented Activity Did Not Occur 32 occasions on the following dates: 01/03/22, 01/04/22, 01/06/22, 01/13/22, 01/24/22, 01/27/22, 01/31/22, 02/01/22, 02/03/22, 02/04/22, 02/07/22, 02/08/22, 02/10/22, 02/14/22, 02/17/22, 02/21/22, 02/24/22, 03/02/22, 03/03/22, 03/07/22, 03/10/22, 03/14/22, 03/17/22, 03/19/22, 03/20/22, 03/21/22, 03/23/22, 03/24/22, 03/28/22, 03/31/22, 04/01/22 and 04/04/22. The clinical record lacked evidence of resident refusal for bathing. On 04/06/22 at 11:25 AM R6 pushed her wheelchair down the south hallway as she talked to the hospice staff. R6's hair was uncombed, and her clothes were clean. On 04/06/22 at 02:35 PM in an interview, Certified Nurses Aide (CNA) M stated residents received a bath/shower at; east two times weekly, which was documented bath/shower or the refusal in the EMR and on bath sheets. CNA M stated that when residents refused their bath/shower she would report the refusal to the charge nurse and she would wash the resident up and get them as clean as possible. On 04/06/22 at 03:25 PM in an interview, Certified Medication Aide (CMA) R stated R6 refused her bath/shower frequently. CMA R stated hospice came to the facility weekly and bathed R6 but was not sure what days that occurred. On 04/06/22 at 03:35 PM in an interview, Licensed Nurse (LN) G stated when a resident refused a bath/shower he/she would sign a bath sheet. LN G stated a progress note should be written indicating the refusal in the EMR. LN G stated R6 never refused her bath/shower. On 04/06/22 at 05:35 PM in an interview, Administrative Nurse D stated residents have preferences for bath/showers, a list was developed to by room number and by resident's choices. Administrative Nurse D stated a resident could change their bath/shower time, CNA's charted the bath/shower in the EMR and on bath sheets. Administrative Nurse D stated R6 was on hospice services, which hospice staff came out to the facility at least two times weekly to bath/shower her. Administrative Nurse D stated the facility staff would bath R6 if she refused a bath from hospice but was insure where that documentation of hospice bathing was located. The facility Activities of Daily Living policy last reviewed 04/22/19 documented the facility would identify and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. The policy documented for all ADL's the facility utilized Lippincott procedures and provided a link to click. The facility failed to ensure a shower/bath was provided for R6, who required assistance with ADL's, which had the potential to cause skin breakdown and/or skin complications due to poor personal hygiene and impaired psychosocial wellbeing. - R17's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia without behaviors (progressive mental disorder characterized by failing memory, confusion) and muscle weakness. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented that R17 was totally dependent on two staff members assistance for activities of daily living (ADL's). The MDS documented R17 was totally dependent on one staff member for bathing and refused care four to six days during the look back period. The Quarterly MDS dated 12/16.21 documented no changes documented from previous MDS assessment. R17's ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 10/04/21 documented he required total assistance of staff for bathing/showers and incontinence care. , R17's Care Pan last revised 12/20/21 documented he was totally dependent on staff to provide showers twice weekly on dayshift and as needed. Review of the EMR under Documentation Survey Reports tab for bathing reviewed from 01/01/22 to 04/04/22 (94 days) revealed R17 received ten baths/showers (01/04/22, 01/11/22, 02/01/22, 02/17/22, 03/10/22, 03/15/22, 03/16/22, 03/22/22, 03/24/22, and 03/29/22). The Bathing task was documented Activity Did Not Occur 20 occasions on the following dates: 01/13/22, 01/20/22, 01/25/22, 01/27/22, 02/01/22, 02/02/22, 02/07/22, 02/10/22, 02/24/22, 03/01/22, 03/02/22, 03/07/22, 03/14/22, 03/19/22, 03/20/22, 02/21/22, 03/22/22, 03/31/22, 04/01/22 and 04/04/22. The clinical record lacked evidence of resident refusal for bathing. On 04/05/22 at 07:46 AM R17 sat in high back wheelchair with foot pedals intact at the table in the common area, waiting for a hot cup of coffee. R17's bilateral pressure reducing boots were on lower extremities. On 04/06/22 at 02:35 PM in an interview, Certified Nurse's Aide (CNA) M stated residents received a bath/shower at least two times weekly, which was documented bath/shower or the refusal in the EMR and on bath sheets. CNA M stated that when residents refused their bath/shower she would report the refusal to the charge nurse and she would wash the resident up and get them as clean as possible. On 04/06/22 at 03:25 PM in an interview, Certified Medication Aide (CMA) R stated R17 never refused his bath/shower. CMA R stated hospice came to the facility weekly and bathed R17 but was not sure what days that occurred. On 04/06/22 at 03:35 PM in an interview, Licensed Nurse (LN) G stated when a resident refused a bath/shower he/she would sign a bath sheet. LN G stated a progress note should be written indicating the refusal in the EMR. LN G stated R17 never refused his bath/shower. On 04/06/22 at 05:35 PM in an interview, Administrative Nurse D stated residents have preferences for bath/showers, a list was developed to by room number and by resident's choices. Administrative Nurse D stated a resident could change their bath/shower time, CNA's charted the bath/shower in the EMR and on bath sheets. Administrative Nurse D stated R17 was on hospice services, which hospice staff came out to the facility at least two times weekly to bath/shower him. Administrative Nurse D stated the facility staff would bath R17 if he refused a bath from hospice but was insure where that documentation of hospice bathing was located. The facility Activities of Daily Living policy last reviewed 04/22/19 documented the facility would identify and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. The policy documented for all ADL's the facility utilized Lippincott procedures and provided a link to click. The facility failed to ensure a shower/bath was provided for R17, who required total assistance with ADL's, which had the potential to cause skin breakdown and/or skin complications due to poor personal hygiene and impaired psychosocial wellbeing. - R27's electronic medical record (EMR) from [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 53 residents and three medication carts. Based on observation, record review, and interview, the facility failed to properly date five individual insulin (a hormone which regulates blood sugar) pens in one of the three medication carts. This deficient practice left the residents being administered these insulins at risk for adverse consequences or less effective medication treatment. Findings included: - On [DATE] at 07:50 AM, the nurse's medication cart on the south 100 hall contained the following insulin pens: one Novolin N flex pen (an intermediate-acting insulin that starts to work within two to four hours, and keeps working for 12 to 18 hours) that was opened and not dated ; one Lantus pen (a long-acting insulin) that was opened and not dated; one Novolog aspart insulin pen (a short-acting insulin that lasted four to six hours) that was opened and not dated; and Basaglar Kwik Pen (a long-acting insulin) that was opened and not dated; and one Levemir (a long-acting insulin) that was opened and not dated. According to the Health Direct Pharmacy Services, Novolin, Lantus, and Basaglar insulins expired 28 days after opening. Levemir insulin expired 42 days after opening. On [DATE] at 07:55 AM Licensed Nurse (LN) I stated that all/any of the insulins should be dated when they were opened for the first use. LN I gathered the undated insulin pen and disposed of them in the sharps container in the medication room and obtained new unopened insulins to replace the undated ones and dated the new insulin pens and placed them in the medication cart. On [DATE] at 03:35 PM LN G stated that insulin pens should be dated as soon as they were opened. She said she would remove the insulin pens in the medication cart if she noticed that any of them were undated and dispose of them and get a new insulin pen out of the refrigerator on the medication storage room. On [DATE] at 06:30 PM Administrative Nurse D stated that she expected nursing staff to date insulin pens as soon as the pen was opened to be used. The staff nurses were expected to check the medications and insulin pens in their medication cart at the beginning of each shift for undated or outdated medications. The unit manager also audited the medication carts weekly. The facility policy Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles last revised [DATE] documented the following. Once any medication or biological package is opened, the facility should follow manufacturer/supplier guidelines with respect to the expiration dates for opened medications. The facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication had a shortened expiration date once opened; if a multi-dose vial of an injectable medication had been opened or accessed, the vial should be dated and discarded within 28 days unless the manufacturer specified a different date for that opened vial. The facility personnel should inspect nursing storage areas for proper storage compliance on a regularly scheduled basis. The facility failed to ensure that nursing staff properly dated resident's insulin pens when opened, which had the potential to cause adverse consequences or ineffective treatment to the residents.

The facility identified 53 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to maintain a sanitary and clean wound field when providing wound care for R3, failed to ensure that facility staff properly dated, stored and cleaned supplemental oxygen (O2) equipment for resident (R)6, R23, and R49, failed to ensure that facility staff did proper hand hygiene while passing meal trays to residents, failed to ensure that facility staff properly transported clean laundry to residents, and failed to ensure that staff sanitized/cleaned a mechanical lift (a machine that assists in the transfer of a resident) after use. These deficient practices placed the residents at risk for increased infection and transmission of communicable disease. Findings included: - On 04/06/22 at 10:50 AM, Licensed Nurse (LN) H and Consultant HH entered R3's room to perform wound assessment and wound care. LN H closed the door and blinds, raised the bed, then performed hand hygiene and donned (put on) gloves. Consultant HH performed hand hygiene and donned gloves. Consultant HH stood on the left side of the bed and used the draw sheet on to roll R3 onto her right side to visualize her coccyx/sacral wound while LN H held R3 in that position from the right side of the bed. Consultant HH unfastened R3's brief and noticed she had some bowel movement in her brief. There was no dressing in place on R3's coccyx wound at that time. Consultant HH measured the wound with a wound measuring ruler that she removed from her bag. She used a tablet to take pictures of the wound. Consultant HH pulled out a wound imaging device from her bag that she stated was used to determine if there was bacteria in the wound. After she took a picture with the device, she used her tablet to take a picture of the device's readings then removed a curette (surgical instrument designed for scraping or debriding [removal of damaged tissue or foreign objects from a wound] biological tissue or debris in a biopsy, excision, or cleaning procedure) from her bag to debride the wound. After the debridement, she took another picture with the device to check for bacteria in the wound then used her tablet to take a picture of the device's readings. Consultant HH placed a piece of moist gauze in R3's wound then placed the wound imaging device back in her bag and placed the curette in the sharps container. Consultant HH did not doff (remove) her gloves and perform hand hygiene at any point in this procedure. Consultant HH then switched sides with LN H who doffed gloves and performed hand hygiene before proceeding on with the dressing change. R3 continued to have bowel movement present. LN H removed the moist gauze from the wound then doffed gloves, performed hand hygiene, and donned new gloves. LN H did not clean the bowel movement before proceeding to the wound care procedure. LN H applied skin prep around the wound then applied Santyl (a topical medication that helps break up and remove dead skin and tissue) to the wound. LN H placed Hydrofera Blue (a dressing that provides wound protection and treats bacteria and yeast) inside the coccyx wound then applied gentamycin (a medication used to treat infection) to the calcium alginate (an absorptive dressing) dressing then onto the wound. LN H pulled brief back over R3's buttocks and stated she would get the aides to come in to clean her up. LN H and Consultant HH doffed gloves then performed hand hygiene. On 04/04/22 at 09:31 AM R6's O2 tubing was undated and lying on the floor. On 04/04/22 at 10:10 AM R49's O2 tubing was missing a date sticker. On 04/04/22 12:36 PM an unidentified staff member pushed a clothes rack that was uncovered down the hallway as he delivered clean clothes to resident rooms. On 04/04/22 at 04:11 PM R23's O2 tubing laid on his bed under the blanket, tubing was undated. On 04/05/22 at 07:25 AM R6 sat on the side of her bed her O2 tubing laid on the floor. On 04/05/22 08:14 AM R23's O2 concentrator was covered in dust, the filter was dirty, the cannula was lying on the bed under the covers, no storage bag found. R23 stated that staff had not cleaned or wiped down the filter in a while. On 04/05/22 08:23 AM, an unidentified staff member wearing gloves and a hairnet, pushed the meal cart with breakfast trays on it down the south hall. The food on the cart was covered with saran wrap. The unidentified staff member served a resident and removes the plastic wrap from the food. The unidentified staff member did not remove her gloves after serving the resident, she touched her mask and hairnet with her gloved hand, then grabbed another tray. The unidentified staff member kept the same gloves on as she continued to deliver other residents their trays. No hand hygiene was performed after she removed her gloves after serving trays. On 04/05/22 at 08:51 AM R6 sat on her bed waiting for her breakfast tray, her O2 tubing was lying on the floor. On 04/05/22 09:49 AM R49 was asleep in his bed. R49's O2 machine tubing dated 03/20/22. The nasal cannula (NC) and tubing was lying on floor behind the machine. The O2 machine was dirty/dusty and the filter needed cleaned. On 04/05/22 at 09:53 AM R49's O2 tubing and cannula was lying on the floor. On 04/05/22 at 03:29 PM R6's O2 tubing in her room was undated, coiled up and placed in handle of O2 concentrator, lacked a bag. On 04/06/22 at 11:25 AM R6's O2 tubing was undated and coiled into the handle of the O2 concentrator. On 04/06/22 at 01:47 PM CNA N and CNA O used a Hoyer lift (a mechanical lift that is used to assist with the transfer of a non-mobile resident). CNA N her washed hands and applied gloves. CNA O sanitized her hands and applied gloves. The two CNA's safely transferred R17 from his wheelchair to his bed. CNA O pushed the lift out of the room into the hallway and removed her gloves and sanitized her hands but did not sanitize the lift after use. On 04/06/22 at 02:39 PM Certified Nurse Aide (CNA) M stated that O2 tubing should be stored in a plastic bag when not being used. CNA M said if she noticed that the NC and O2 tubing was on the floor, she would pick it up and throw it away and get new and clean tubing. She stated that facility equipment like the lifts should be sanitized after each use and/or in between residents. She stated hand hygiene should be performed before serving food, before and after contact with a resident, before and after putting on or taking off gloves. Every two weeks the facility has a staff meeting and management goes over hand hygiene, how to use the lifts and abuse and neglect. On 04/06/22 at 03:35 PM Licensed Nurse (LN) G stated she thought that the O2 tubing was changed every three days or something like that. As far as she knew the filters on the concentrator was never cleaned and when the tubing was changed it was not documented anywhere that she was aware of. LN G stated that hand hygiene should be performed before and after each resident contact, after using the bathroom, when serving food trays to residents (before and after). LN G stated during wound dressing changes a sterile field should be put down to put supplies onto, hands should be washed before beginning and apply gloves, the remove the gloves after taking the dressing off and sanitize hands before applying clean gloves. She stated a resident should be cleaned up after having a bowel movement during a dressing change to avoid the bowel movement getting into the wound area, and make sure the wound area field was cleaned, then finish with the wound dressing change. On 04/06/22 at 05:10 PM wound nurse LN H stated she would have typically changed the resident before she would have continued with the wound dressing change. She would stop doing wound change if a resident had or was having a bowel movement, she would make sure that none of the bowel movement got near the wound and clean the resident, and then start doing the wound care. On 04/06/22 at 04:51 PM Administrative Nurse and Infection Preventionist F stated that hand hygiene should be done in between resident contact, after using the bathroom, when serving meals to residents and staff should not wear gloves ever while serving meal trays. Administrative Nurse F stated that all staff have hand sanitizer and she stressed to staff to not only sanitize their hand but to wash them with soap and water after every couple of residents. She further stated that the facility lifts were to be cleaned at the beginning of each shift as well as after each use. The O2 machines should be cleaned by maintenance staff. The O2 tubing was changed every Sunday night and should be dated at that time and the tubing should be stored in a plastic bag with the resident name and the date changed on the plastic bag. Administrative Nurse F stated the facility staff did not document anywhere when they changed the O2 tubing. On 04/06/22 at 05:23 PM Administrative Nurse D stated that O2 tubing was changed weekly and as needed and should be dated and stored in a plastic bag when not in use. The facility holds mandatory in-services every two weeks that hand hygiene, abuse and neglect and use of lifts. Administrative Nurse D stated hand hygiene should be performed in between residents, when serving during dining time after each tray was delivered, anytime when performing a brief change or after a resident uses the bathroom, before and after using gloves. She stated she would expect staff to clean/change a resident if the resident had had a bowel movement before wound care/dressing change was performed to avoid contamination of the wound area. Any equipment such as the lifts should be sanitized after each use. The facility policy Standard Precautions, Transmission-based Precautions revised 10/05/21 documented the following: standard precautions represent the infection prevention measures that apply to all resident care; regardless of suspected or confirmed infection status of the resident, in any setting where healthcare is being delivered. Standard precautions include: 1. Hand hygiene a. before and after all resident contact; b. contact with potentially infectious material; c. contact with blood, bodily fluids, or visibly contaminated surfaces; d. before applying gloves; e. after removal of gloves; f. prior to removal of face shields/eye protection and/or respirator during the doffing of personal protective equipment (PPE) process; g. after touching cloth face covering, face mask; h. before performing a procedure such as an aseptic (free from infection) task; i. always use soap and water if hands are visibly soiled or in the event of alcohol-based hand rub (ABHR) shortages. 2. Appropriate use of PPE (gloves, gowns, and facemasks) a. gloves are worn if potential contact with blood or bodily fluid, mucous membranes, or non-intact skin; b. gloves are removed after contact with blood or bodily fluids, mucous membranes, or non-intact skin; c. gloves are changed, and hand hygiene is performed before moving from a contaminated body site to a clean body site during resident care; d. an isolation gown is worn for direct resident contact if the resident has uncontained secretions or excretions. 3. Respiratory hygiene and cough etiquette 4. Safer sharps practices 5. Safe handling of equipment or items that are likely contaminated with infectious body fluids 6. Cleaning and disinfecting or sterilizing of potentially contaminated surfaces and equipment between resident use. The undated facility policy Area of Focus: Basic Skin Management documented: wound care is provided utilizing a clean technique. The facility policy Oxygen Administration/Safety/Storage/Maintenance revised 08/02/21 documented: Change O2 supplies weekly and when visibly soiled. Equipment should be labeled with patient name and dated when setup or changed out. The humidifier bottles should be dated and replaced every seven days regardless of the water level. Store O2 and respiratory supplies in a bag labeled with the resident's name when not in use. Clean exterior of concentrators weekly with a disinfectant (the concentrator must be stationed where there is free air movement; and external filter should be checked daily and all dust should be removed. Filters should be washed with soap and water once each week and as needed; dry with a towel and reinsert). The facility policy Laundry Services reviewed 12/31/21 documented the following: All clean linens should be stored and transported in covered carts used exclusively for this purpose and these carts should be cleaned regularly using a hospital grade disinfectant. All clean linen must be transported by methods that ensure cleanliness and protect from dust and soil during intra or inter-facility loading, transport, and unloading. Clean linen must always be kept separate from contaminated linens. The use of separate rooms, closets, or other designated spaces with a closing door provides the most secure methods for reducing the risk of accidental contamination. The facility failed to ensure and maintain a sanitary and clean wound field when providing wound care for R3, failed to ensure that facility staff properly dated, stored and cleaned supplemental O2 equipment for R6, R23, and R49, failed to ensure that facility staff did proper hand hygiene while passing meal trays to residents, failed to ensure that facility staff properly transported clean laundry to residents, and failed to ensure that staff sanitized/cleaned a mechanical lift after use. This placed the residents at risk for increased infection and transmission of communicable disease.