The facility reported a census of 19 residents with 11 residents sampled. Based on observation, interview, and record review, the facility failed to protect the dignity of Resident (R) 10, when staff transferred the resident from her room to the shower room with her buttocks exposed. The facility failed to honor the dignity of residents in the dining room, when observation revealed a container in the dining room for soiled clothing protectors was labeled bibs only, no trash, and was visible to all residents and guests in the area. These deficient practices had the potential to negatively impact each residents dignity and psychosocial well-being. Findings included: - During an observation on 02/25/25 at 02:57 PM, an unknown staff member transported R10 from her room to the shower room, with the resident seated in a shower chair. Observation revealed the resident was covered in a white sheet from her neck to her knees, but her buttocks was exposed during the transport, visible to anyone in the area. During an interview on 02/25/25 at 02:59 PM, Certified Medication Aide (CMA) R revealed when R10 received a shower, the resident was changed out of her clothes and put into the shower chair and then covered from head to toe with sheets and towels, making sure all skin was covered. CMA R stated she was unaware that R10's buttock was exposed during the transfer. During an interview on 02/25/25 at 03:37 PM, CMA S stated when residents were transferred to the shower room via shower chair, staff undress the resident in their respective room, then covered them from head to toe with a sheet or bath blanket. During interview on 02/25/25 at 03:53 PM, Licensed Nurse (LN) O reported when wheelchair dependent residents were transferred to the shower room, they should be transferred to the shower chair in their room, fully clothed, then transported to the shower room where they would be disrobed and bathed. The facility's Resident Rights policy dated 03/18/24 documented each resident will be treated with dignity and will be afforded the right to a dignified existence. The facility failed to protect the dignity of R10 when staff transferred the resident from her room to the shower room with her buttocks exposed. This deficient practice had the potential to lead to negative psychosocial effects related to dignity. - During an observation on 02/26/25 at 12:17 PM, a bin in the dining area utilized for used clothing protectors contained a lid with a label which read: bibs only, no trash. The bin was located in an area visible for all residents, staff, and visitors in the area. During interview on 03/04/25 at 11:50 AM, Administrative Staff H revealed the items the residents wore while eating (to protect their clothes from food and drink) should be referred to as a 'clothing protector' and not a 'bib'. Administrative Staff H then confirmed the container labeled bibs only, no trash would be immediately corrected. The facility identified 18 of the 19 residents utilized clothing protectors of some form during mealtimes. The facility's Resident Rights policy dated 03/18/24 documented each resident will be treated with dignity and will be afforded the right to a dignified existence. The facility failed to protect the dignity of the residents by identifying clothing protectors as 'bibs'. This deficient practice had the potential negatively affect the residents psychosocial well-being and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 19 residents with 11 residents sampled, including four residents reviewed for advanced directives (a written document which indicated the medical decisions for health care professionals when the person could not speak). Based on observation, interview, and record review, the facility failed to have a process in place to ensure each resident's code status was accurate and easily identified for Resident (R)17, R3, R14, and R171. Findings included: - Review of the facility's admission Packet provided to the survey team on [DATE] documented a request for copies of DPOA, living will, and advanced directives/DNR paperwork and lacked prompts or blank forms to be filled out by residents or resident's representatives. R17's Electronic Health Record EHR lacked a physical Do Not Resuscitate (DNR or no code - a written legal order to withhold cardiopulmonary resuscitation [CPR], in respect of the wishes of a person in case their heart stopped or they stopped breathing) form and Physician order that reflected the resident was a DNR and did not wish to receive life sustaining treatment. Review of the EHR for R17 revealed the following: The physician's order lacked an order for a DNR. The banner documented R17 was a DNR and provided a link to view an electronic copy of the DNR document, but no document was available for review. Lacked a copy of a DNR form. The Care Plan, initiated on [DATE] and revised on [DATE] documented R17 was a full code. The Care Plan, initiated on [DATE] and revised on [DATE] and [DATE], documented R17 was a DNR with a stated goal that CPR would not be performed if he was found unresponsive. Review of the physical chart for R17 revealed the following: Durable Power of Attorney for Health Care Purposes (DPOA-HC - a legal document that named a person to make healthcare decisions when the resident was no longer able to), dated [DATE], signed by the resident and lacked advanced directives regarding CPR or DNR wishes. admission orders, dated [DATE], documented code status of DNR, signed by a physician, lacked signatures from the resident (or resident representative) and a witness. Lacked a DNR form signed by resident (or resident representative), a witness and physician (or physician extender). R3's Electronic Health Record (EHR) lacked a physical DNR form and the physical chart only contained advanced directives that indicated no CPR, but lacked physician or witness signatures. Review of the Electronic Health Record (EHR) for Resident (R)3 revealed the following: The physician's orders included a DNR (no code - a written legal order to withhold cardiopulmonary resuscitation [CPR], in respect of the wishes of a person in case their heart stopped or they stopped breathing) order, dated [DATE]. The banner documented R3 was a DNR and provided a link to view an electronic copy of the DNR document, but no document was available for review. Lacked a copy of a DNR form. The Care Plan, initiated on [DATE] and revised on [DATE], documented R3 was a DNR and would not be resuscitated if needed. Review of the physical chart for R3 revealed the following: Advanced directives, dated [DATE], that indicated R3 did not wish for CPR to be performed and lacked the signature of a physician (or physician extender) and lacked a witness signature. admission orders, dated [DATE], documented code status of DNR, signed by a physician extender, lacked signatures from the resident (or resident representative) and a witness. Lacked a DNR form signed by resident (or resident representative), a witness and physician (or physician extender). R14's Electronic Health Record (EHR) lacked a physical DNR form and the physical chart only contained advanced directives that indicated no CPR, but lacked physician or witness signatures. Review of the EHR for R14 revealed the following: The physician's order documented DNR, dated [DATE]. The banner documented R14 was a DNR and provided a link to view an electronic copy of the DNR document, but no document was available for review. Lacked a copy of a DNR form. The Care Plan documented on [DATE] and revised [DATE], R14 was a DNR. Review of the physical chart for R14 revealed the following: Advanced directives, dated [DATE] that indicated that R14 did not wish for CPR to be performed and lacked the signature of a physician (or physician extender) and lacked a witness signature. admission orders, dated [DATE], documented code status of DNR, signed by a physician, lacked signatures from the resident (or resident representative) and a witness. Lacked a DNR form signed by resident (or resident representative), a witness and physician (or physician extender). R171's EHR documented the resident was a Full Code and did not wish to be intubated (the emergency maneuver where a tube is placed in a person's airway to hold it open and allow artificial ventilation) and had requested to be a Do Not Intubate (DNI - a written legal order to withhold intubation in case their heart stopped or they stopped breathing) but wanted to receive all other life sustaining treatments. Review of the EHR for R171 revealed the following: The physician's order documented full code, dated [DATE] The banner documented full code with special instructions for do not intubate. Lacked a copy of a DNI form. The Care Plan, dated [DATE], documented R171 did not want intubation as part of life-saving measures. Review of the physical chart for R171 revealed the following: DPOA, dated [DATE], signed by the resident and lacked advanced directives regarding CPR or DNR/DNI wishes. During an interview on [DATE] at 03:00 PM Certified Nurse Aide (CNA) X revealed if a resident was found unresponsive and she was unsure of whether or not CPR should be performed, she would ask other CNA staff or the nurses or look in the EHR. During an interview on [DATE] at 03:10 PM Certified Medication Aide (CMA) S revealed the location of a resident's code status was located in the resident's Medication Administration Record (MAR), in the CNA book, physical charts, and in the EHR. During an interview on [DATE] at 03:15 PM, Administrative Nurse C stated each resident's code status was documented in the EHR, on the physical chart, in the CNA book, on a sheet of paper on the wall in the bath/shower area and on a sheet of paper on the wall in the nurses' station. Administrative Nurse C was unable to locate or identify an advanced directive that indicated DNR/DNI for R171. During an interview on [DATE] at 06:16 PM, Administrative Nurse C stated if staff found a resident unresponsive, they were expected to call for other staff for assistance. Staff would then check the code status that is on the banner in the EHR for the resident and then honor the wishes documented there. Administrative Nurse C further revealed that she was responsible for updating the banner to accurately reflect each resident's preferences for code status. Administrative Nurse C confirmed the information documented above for R3, R14, R17 and R171. Administrative Nurse B stated that DNR orders on the admission orders are only valid while in the facility and are not recognized as advanced directives and/or DNR/DNI while at the hospital or while being transported by the facility staff to outside appointments. Administrative Nurse B stated when a resident was being transported outside of the facility for outings or appointments, there was no documentation with the staff member who was driving that would indicate any resident's code status. Administrative Nurse C additionally revealed that new staff and agency staff orientation lacked training regarding where to look to locate a resident's code status during an emergency. Administrative Nurse C further stated that the facility had identified missing or incomplete advanced directives/DNR in 01/2025 and provided an updated list of residents with missing or incomplete advanced directives/DNR dated [DATE] . Administrative Nurse C when asked to review R3's physical chart for advanced directives, Administrative Nurse C identified the DNR on the admission orders after over two minutes of review. Administrative Nurse C confirmed the difficulty in identifying the order and stated that staff should be able to go directly to the order without difficulty or delay. The facility's Cardiopulmonary Resuscitation (CPR) - Code Blue Adult procedure, dated [DATE], documented all residents should receive CPR immediately unless they and/or their records have a signed advanced directive. The facility's Advanced Directives policy, dated [DATE] documented an advanced directive could be in the form of a living will (a document in which the signer states his or her wishes regarding medical treatment that sustains or prolongs life, especially by invasive or extraordinary means, for use if the signer becomes mentally incompetent or unable to communicate), DPOA or a health care treatment directive. The advanced directive would be updated at the resident's request or if the resident's condition changed and was the responsibility of the social services designee (SSD) to obtain these documents. Additionally, the policy documented that copies of the advanced directives would be kept in the resident's medical record. The facility failed to have a process in place to ensure the appropriate code status was identified for four residents.

The facility reported a census of 19 residents. Based on observations, interviews and record review, the facility failed to ensure the facility had an effective system in place for the accurate accounting and reconcilliation of controlled medicaiton. Findings included: - During an observation on 02/27/25 at 09:22 AM, a medication cart narcotics count was performed with Certified Medication Aide (CMA) K. During this count with CMA K, the bottle of Lyrica pills for R9 indicated a count discrepancy. The count sheet displayed 39 pills, the hard count was 38 pills and was performed twice. The last count performed was on 02/27/25 at 06:20 AM by CMA K and Licensed Nurse (LN) V, with a recorded count of 39, signed by CMA K. The previous count 02/26/25 in the morning was performed by CMA K with a recorded count of 40 Lyrica. Review of CMA K's sworn statement dated 02/27/25 included the medication was not caught during count. CMA K documented the night nurse stated she had not taken anything from cart. CMA K took the cart around 6:20 AM to start the morning medication pass. CMA K documented they (CMA K) did count the medication cards but did not count the pills in the bottle. During an interview on 02/27/25 at 09:22 AM, CMA K reported only one person signs off on the narcotics count, and the on-coming shift signs to verify the count is correct. During an interview on 02/27/25 at 10:15 AM, LN T reported the nurse has the key for the door and drawers where medications are stored (those to be given) and for the drawer for medications to be destroyed. During an interview on 02/27/25 at 09:30 AM, Administrative Nurse C notified of the Lyrica miscount. Administrative Nurse C stated an investigation would be started immediately and once completed a copy of the investigation findings would be provided along with the facility's policy for controlled medications. Review of the facilities investigation for the Lyrica miscount revealed that the previous shift CMA S had given R9 his evening Lyrica and did not record it on the Lyrica count sheet. The 2/27/25 on-coming CMA, K, subsequently did not perform an actual count of the Lyrica and recorded the wrong number of Lyrica during her morning counts. The facility START/END OF SHIFT CMA Sign Off NARCOTICS sheet was signed 2/27/25 0600 by CMA S and CMA K. The facilities Controlled Medications policy, effective 03/01/2005 and revised 11/27/2023, reads that All controlled substances, both current and discontinued will be counted by the off-going and on-coming licensed nursing personnel. Licensed Nurses are responsible to count PRN controlled and discontinued controlled medications at the beginning and at the end of their shift. Certified Medication Aides are responsible for counting scheduled/inventory-controlled medications at the beginning and end of their shift with on-coming/off-going CMA or Licensed Nurse. Documentation of this exchange is located in the narcotic count binder where on-coming and off-going staff will sign that medication count was completed. The facility policy for controlled medication counts had contradicting information regarding count signature requirements. The facility failed to have a system in place for the accurate accounting and reconcillation of controlled substances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 19 residents with 15 residents sampled which included five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure a timely response to the pharmacist's identify and reported irregularities to the facility for four of the five residents sampled, Resident (R)8, R15, R17, and R6. Findings included: - Review of Resident (R)8's Physician Orders, dated 02/10/25, documentation included diagnoses of major depression disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in in activities), muscle weakness, dementia (a group of brain disorders that cause a progressive decline in cognitive function and memory), psychotic disturbances (a mental health disorder characterized by a disconnect from reality), mood disturbances a group of psychiatric conditions that can cause intense and persistent changes in mood, energy, and behaviors), and anxiety (a feeling of worry, nervousness, or unease). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 04, indicating severe cognitive impairment. She did not exhibit any depression indicators or behaviors. The resident was dependent on staff for substantial to maximum assistance for activities of daily living (ADLs). She received Scheduled pain medication, and psychotropic medications which included antipsychotics, and antidepressant. The physician documented clinical contraindications for psychotropic drug gradual dose reduction (GDR) on 12/07/23. The Quarterly MDS dated [DATE], documentation included an improved BIMS score of 06, however continues to indicate severe cognitive impairment. The physician documented clinical contraindications for psychotropic drug gradual dose reduction (GDR) on 01/24/25. The Cognitive loss/Dementia and Psychotropic Drug Use Care Area Assessment (CAA), dated 10/29/24 documented respectively the resident's BIMs score as 4/15. She had diagnoses of dementia, memory loss, and depression and is at risk for further cognitive loss. She received psychoactive medications for noted diagnoses which include Risperidone and Duloxetine. A licensed nurse monitors for effectiveness and adverse consequences. The pharmacist reviews the resident's medication regimen monthly and notifies the director of Nursing and physician of any identified irregularities and/or recommendations. The Care Plan dated (01/22/25), directed staff the resident had compulsive disorder, and depression which required psychotropic medication therapy. documented Administer medications as ordered. Monitor/document for side effects and effectiveness. The Electronic Health Records (EHR) Physician Orders (POS) dated 02/10/25, included the following: 1. Risperidone tablet, 0.5 milligrams (MG)(an antipsychotic)medication), give one tablet by mouth, at bedtime for compulsive disorder, ordered 05/12/2022. 2. Duloxetine HCL (antidepressant medication) capsule, delayed release sprinkle, 30 MG, by mouth, one time a day for depression. Ordered 11/02/21. 3. Monitor and document for antidepressant medications side effects each shift (ie: tearfulness, social isolation, lack of motivation to care for self or be cared for, statements of wanting to die, declination of care or food, ordered 01/17/2022. The Pharmacy Monthly Medication Regimen Review, dated 04/30/24 identified the resident as taking Duloxetine 30mg since 11/2021. The pharmacist recommended a GDR to decrease this dose to 20mg. The physician responded to the pharmacist recommendation dated 04/30/24 on 05/20/24 (20days later). The Pharmacy Monthly Medication Regimen Review, dated 05/31/24 identified the resident as currently taking Risperidone 0.5mg at bedtime and GDR was due. The pharmacist recommended a GDR to decrease the dose to 0.25mg. The physician responded to the pharmacist's recommendation dated 05/3124 on 6/05/24. The physician was not transcribed by the facility until 06/15/24 10 days following the physician response and 15 day following the pharmacists recommendation. The Pharmacy Monthly Medication Regimen Review, dated 10/31/24 identified the resident received duloxetine 30 MG since 11/2021. The pharmacist recommended a GDR to decrease dose to 20 MG. indicating the resident had a fall and urinary tract infection (UTI) early in the review period. The physician responded to the pharmacist's recommendation on 11/21/24 (21 days later). On 02/24/25 at 02:28 PM, R 8 answered direct questions. She reported she did not live at the facility. She visits her husband frequently at the facility. (R 8's husband is her roommate and resident at the facility). On 02/26/25 at12:08 PM, Certified Medication Aide, (CMA) K administered medications to the resident who sat in her recliner drinking her coffee. The resident was pleasant affect and expression during conversation she followed verbal cues and responded appropriately. On 02/25/25 at 03:36 PM, Licensed Nurse (LN) O reported the charge nurses provide oversight for effectiveness and adverse reactions to medications and notify the provider of [NAME] affects and effectiveness of psychotropic drug use which include behavior monitoring for antidepressants and psych drugs. The pharmacist reviews the resident's medication regimen monthly and reports irregularities to the director of nursing. We send the recommendations to the physician who then will respond to the recommendation which are then tracked and processed. She stated she was not sure of the expected timeline for physician response. LN O stated she would wait for response from physician/provider and would contact them directly if no response to the initial notification. On 03/03/25 at 04:56 PM, Administrative Nurse C confirmed the above findings. She stated pharmacist has access offsite to review resident's medications regimen and comes to the facility monthly the pharmacist submits the recommendations in a report. I check the dosages are then checked to make sure they are accurate. Reports are then placed in a folder and sent to the individual physician/provider or their extender. The folder may be held in house for the provider to address if the facility I aware they are coming in the facility that day. The provider response in writing on the report and places it back in the folder and will bring the folder to the facility. The expectation is to receive a response from the physician within 10-14 days at the latest. The charge nurse then processes the provider's response and noted orders , places the original in the chart, and submits a copy to the assistant director of nursing and director of nursing. She confirmed she had identified the pharmacy recommendations had not been processed in a timely manner about a year prior but had not addressed as a performance improemnt plan to date. The facility policy Drug Regimen Review, dated 03/01/24, documentation lacked address of timely follow-up to the pharmacist monthly report of identified irregularities and recommendations to prevent the potential of administration of unnecessary medications. The facility failed to ensure a timely response to the pharmacist's identify and reported irregularities and recommendations for the resident. - Review of Resident (R) 15's Physician Orders, dated 02/10/25, documentation included diagnoses of major depression disorder, chronic pain, dementia, psychotic disturbances, amnesia, anxiety disorder. The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 07, indicating severe cognitive impairment. She did not exhibit any depression indicators or behaviors. The resident was dependent on staff for substantial to maximum assistance for activities of daily living (ADLs). She received Scheduled pain medication, and an antidepressant. The Quarterly MDS dated [DATE], documentation included an decline in BIMS score of 04, however continues to indicate severe cognitive impairment. The physician documented clinical contraindications for psychotropic drug gradual dose reduction (GDR) on 01/07/25. The Cognitive loss/Dementia and Psychotropic Drug Use Care Area Assessment (CAA), dated 06/01/24 documented respectively the resident's BIMs score as 07/15. She had diagnoses of dementia, memory loss, and depression and is at risk for further depression and cognitive loss. A licensed nurse monitors for effectiveness and adverse consequences. The pharmacist reviews the resident's medication regimen monthly and notifies the director of Nursing and physician of any identified irregularities and/or recommendations. The Care Plan dated 12/05/24 directed staff the resident received Psychotropic medications for epression with psychotic features and staff should monitored for gradual dose reductions, initiated 11/26/2024 The Electronic Health Records (EHR) Physician Orders (POS) dated 02/10/25, included the following: 1. Abilify tablet, 5 milligrams (MG), give one tablet, by mouth, in the morning for depression, ordered 06/08/24. 2. Visteril capsule, 50 MG every six hours, by mouth as needed for anxiety. 3. Prozac 40 MG capsule, take by mouth daily, related to major depressive disorder, ordered 10/06/23. 4. Namenda Oral tablet 10 MG, give by mouth in the morning related to dementia, psychotic disturbances, and mood disturbances, ordered 08/20/24. 5. Aricept tablet 10 MG, give one tablet by mouth at bedtime related to dementia, behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. 6. Monitor and document for antidepressant medications side effects each shift (ie: tearfulness, social isolation, lack of motivation to care for self or be cared for, statements of wanting to die, declination of care or food, ordered 09/05/24. The Pharmacy Monthly Medication Regimen Review, dated 09/30/24, identified the resident takes Fluoxetine 40 mg since 10/2023, and was due for a dose reduction. She does continue to participate in activities many days of the month. Recommended to decrease the dose to 20mg at this time? this dose. The physician responded to the pharmacist recommendation dated 09/30/24 on 10/17/24 17 days later. 05/20/24, (20days later). The Pharmacy Monthly Medication Regimen Review, dated 11/30/24 identified the resident as currently taking Abilify since 06/08/24 and due for dose reduction. Recommended dose reduction. The pharmacist recommended a GDR to decrease the dose to 0.25mg. The physician responded to the pharmacist's recommendation dated 11/30/24 on 12/17/24. (17 days later. On 02/25/25 at 09:43 AM, resident sat in her room with door closed window shade up very sedate in her response and inquiry about concerns stated no concerns. in room starring out the window flat affect soft spoken , on inquiry she stated she had no concerns. On 02/25/25 at 03:36 PM, Licensed Nurse (LN) O reported the charge nurses provide oversight for effectiveness and adverse reactions to medications and notify the provider of [NAME] affects and effectiveness of psychotropic drug use which include behavior monitoring for antidepressants and psych drugs. The pharmacist reviews the resident's medication regimen monthly and reports irregularities to the director of nursing. We send the recommendations to the physician who then will respond to the recommendation which are then tracked and processed. She stated she was not sure of the expected timeline for physician response. LN O stated she would wait for response from physician/provider and would contact them directly if no response to the initial notification. On 03/03/25 at 04:56 PM, Administrative Nurse C confirmed the above findings. She stated pharmacist has access offsite to review resident's medications regimen and comes to the facility monthly the pharmacist submits the recommendations in a report. I check the dosages are then checked to make sure they are accurate. Reports are then placed in a folder and sent to the individual physician/provider or their extender. The folder may be held in house for the provider to address if the facility I aware they are coming in the facility that day. The provider response in writing on the report and places it back in the folder and will bring the folder to the facility. The expectation is to receive a response from the physician within 10-14 days at the latest. The charge nurse then processes the provider's response and noted orders , places the original in the chart, and submits a copy to the assistant director of nursing and director of nursing. She confirmed she had identified the pharmacy recommendations had not been processed in a timely manner about a year prior but had not addressed as a performance improvement plan to date. The facility policy Drug Regimen Review, dated 03/01/24, documentation lacked address of timely follow-up to the pharmacist monthly report of identified irregularities and recommendations to prevent the potential of administration of unnecessary medications. The facility failed to ensure a timely response to the pharmacist's identify and reported irregularities and recommendations for the resident. - Review of the Electronic Health Record (EHR) for Resident (R)17 included diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), major depressive disorder (MDD - a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), anxiety disorder (a disorder characterized by chronic free-floating anxiety and such symptoms as tension or sweating or trembling or lightheadedness or irritability etc that has lasted for more than six months) and repeated falls. The 11/22/24 Annual Minimum Data Set (MDS) documented that the Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. The assessment documented a total mood score of zero which indicated no depression. R17 received an antianxiety (- class of medications that calm and relax people with excessive anxiety, nervousness, or tension) and antidepressant (a class of medications used to treat mood disorders) medication. The ADL Functional / Rehabilitation Potential Care Area Assessment (CAA) dated 11/22/24, documented R17 had intact cognition and required assistance with activities of daily living (ADLs - activities such as walking, grooming, toileting, dressing and eating) The Psychotropic Drug Use CAA dated 11/22/24, documented R17 utilized psychoactive (also known as psychotropic medications [medications that affect the mind or mental processes]) medications. The 02/21/25 Quarterly MDS completed 08/16/24, documented a BIMS score of 15 which indicated intact cognition. The assessment documented a total mood score of three which indicated minimal depression. R17 received antianxiety and antidepressant medications. The 08/28/23 Care Plan documented on 08/28/23 and revised on 09/27/24, R17 utilized antianxiety medications included the following interventions: On 08/28/23, staff would administer antianxiety medications as ordered by the physician, revised 09/27/24. On 08/28/23, staff would monitor/document/report as needed any adverse reactions to antianxiety medications, revised 09/27/24. On 09/27/24, staff would monitor for yelling out while asleep or increased tremor and document if observed. On 09/27/24, staff would monitor R17 for confusion, amnesia (loss of memory caused by brain damage or severe emotional trauma), loss of balance, cognitive impairment and increase risk for falls with hourly visual checks while in the facility. The 08/28/23 Care Plan documented on 12/08/23 and revised on 09/27/24, R17 utilized antidepressant medications included the following interventions: On 02/20/24, staff would administer antidepressant medications as ordered by the physician and monitor for side effects and effectiveness, revised 09/27/24. On 02/20/24, staff would educate resident/family about risks, benefits and side effects of antidepressant medication use as needed, revised 09/27/24 On 02/20/24, staff would monitor/document/report adverse reactions to antidepressant therapy. Review of the EHR Physician's Orders documented the following: Klonopin (clonazepam - an antianxiety medication), one milligram (mg), give one tablet by mouth (PO) every night at bedtime (HS) related to anxiety disorder, dated 09/17/24. Cymbalta (duloxetine - an antidepressant medication) delayed release, 60mg, give one capsule PO once daily related to depression, dated 08/14/24 Review of monthly medication regimen review (MRR) and gradual dose reduction (GDR) revealed the following: On 05/31/24, the consultant pharmacist conducted a MRR and recommended to the provider a GDR of Klonopin (clonazepam) from two mg PO every night at HS to one mg PO every night at HS. The provider agreed and wrote a new order on 09/16/24 with the dose change effective on 09/17/24 which was 109 days after the recommendation was made by the pharmacist. On 06/30/24, the consultant pharmacist conducted a MRR and recommended to the provider a GDR of Cymbalta (duloxetine) from 120mg PO once daily to 60mg PO once daily. The provder agreed and wrote a new order on 08/12/24 and the facility noted the order on 08/13/24 which was 44 days after the recommendation was made by the pharmacist. During an observation on 02/26/25 at 08:42 AM, R17 was seated on the edge of his bed and appeared calm and relaxed. During an observation on 02/26/25 at 11:36 AM, R17 was seated at a table in the dining area with peers present. During an interview on 03/03/25 at 12:01 PM, Administrative Nurse C acknowledged the facility had concerns related to the MRR and GDR process and had been identified by the QAPI (quality assurance process improvement) committee but that no PIP (process improvement plan) existed. During an interview on 03/04/24 at 10:30 AM, Administrative Nurse C revealed that all MRR and GDR data had been provided to survey team and confirmed the MRR/GDR information documented above. Administrative Nurse C stated that her expectation was that the providers would respond to MRR/GDR requests from the pharmacist within two weeks (14 days). The facility policy Drug Regimen Review, dated 03/01/24, documentation lacked address of timely follow-up to the pharmacist monthly report of identified irregularities and recommendations to prevent the potential of administration of unnecessary medications. The facility failed to ensure that R17's medication remained free of unnecessary medications when the facility failed to ensure that R17's physician responded in a timely manner to a GDR request from the consultant pharmacist. The facility failed to ensure that R17's medication remained free of unnecessary medications when the facility failed to ensure that R17's physician responded in a timely manner to a GDR request from the consultant pharmacist. - Review of R6's diagnoses from the Electronic Health Record (EHR) included dementia (progressive mental disorder characterized by failing memory, confusion) with psychotic (any major mental disorder characterized by a gross impairment in reality perception), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, major depressive disorder (MDD - a major mood disorder which causes persistent feelings of sadness) and amnesia (loss of memory caused by brain damage or severe emotional trauma). The Annual Minimum Data Set (MDS) dated [DATE], documented R6 had Brief Interview of Mental Status (BIMS) score of four which indicated severely impaired cognition. The resident had a total mood severity score of 00, which indicated no depression. The assessment documented R6 received antianxiety (class of medications that calm and relax people) and antidepressant (class of medications used to treat mood disorders) medications. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 07/26/24, documented R6 had a BIMS of four. The Quarterly MDS dated 01/24/25, documented R6 had BIMS score of four which indicated severely impaired cognition. The resident had a total mood severity score of 00, which indicated no depression and no behaviors. R6 dependent on staff for all cares except personal hygiene and upper body dressing which required substantial/maximal assistance. R6 required supervision/touching assistance. The 04/07/21 Care Plan documented on 04/07/24 and revised on 09/23/24 that R6 had depression and anxiety and documented the following interventions: On 05/04/21, staff would administer medications as ordered and monitor/document side effects and effectiveness, revised 09/23/24. On 05/04/21, consultant pharmacist would perform a monthly review or per protocol. On 09/23/24, staff would monitor/document/report as needed any signs/symptoms of anxiety. Review of the EHR Physician's Orders documented the following: Trazodone (trazodone HCl), 25 milligram (mg) tablet, give one tablet by mouth (PO) every night at bedtime (HS) related to MDD, dated 02/09/24. Review of monthly medication regimen review (MRR) and gradual dose reduction (GDR) revealed the following: On 07/31/24, the consultant pharmacist conducted a MRR and recommended to the provider a GDR of trazodone 50mg tablet. The facility did not provide a copy of the provider or facility's response to the consultant pharmacist's recommendation. The facility failed to provide a copy of the consultant pharmacist's monthly MRR for 12/2024. During an observation on 02/25/25 at 02:55 PM, R6 rested in her bed with her eyes closed. During an observation on 02/26/25 from 09:00 AM to 11:24 AM R6 sat in a wheelchair close to the nurses' station with peers present. R6 was observed intermittently resting with her eyes closed while in a seated position. During an interview on 03/03/25 at 12:01 PM, Administrative Nurse C acknowledged the facility had concerns related to the MRR and GDR process and had been identified by the QAPI (quality assurance process improvement) committee but that no PIP (process improvement plan) existed. During an interview on 03/04/25 at 10:30 AM, Administrative Nurse C revealed that all MRR and GDR data had been provided to survey team and confirmed the MRR/GDR information documented above. Administrative Nurse C stated that her expectation was that the providers would respond to MRR/GDR requests from the pharmacist within two weeks (14 days). During an interview on 03/04/25 at 12:03 PM, Administrative Nurse C revealed that after receiving the MRR for R6 on 07/31/24, the consultant pharmacist was contacted via telephone and was informed that R6 was already on a lower dose of trazodone, so a GDR did not need to be performed. Administrative Nurse C confirmed that no GDR was performed for 07/2024 and that no additional written documentation existed related to the MRR dated 07/31/24. Additionally, Administrative Nurse C confirmed that she was unable to locate a MRR for 12/2024 for R6, The facility policy Drug Regimen Review, dated 03/01/24, documentation lacked address of timely follow-up to the pharmacist monthly report of identified irregularities and recommendations to prevent the potential of administration of unnecessary medications. The facility failed to ensure that R6's medication remained free of unnecessary medications when the facility failed to respond to a consultant pharmacist's recommendation on 07/31/24. Additionally, the facility failed to ensure the consultant pharmacist performed a monthly MRR for 12/2024 for R6.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 19 residents with 15 residents sampled which included five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure Residents who use psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior. receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs) related to a timely response to the pharmacist's identify and reported irregularities to the facility for four of the five residents sampled, Resident (R)8, R15, R17, and R6. Findings included: - Review of Resident (R) 8's Physician Orders, dated 02/10/25, documentation included diagnoses of major depression disorder (a mental health disorder characterized by persistently depressed mood or losoterest in in activities), muscle weakness, dementia (a group of brain disorders that cause a progressive decline in cognitive function and memory), psychotic disturbances (a mental health disorder characterized by a disconnect from reality), mood disturbances a group of psychiatric conditions that can cause intense and persistent changes in mood, energy, and behaviors), and anxiety (a feeling of worry, nervousness, or unease). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. She did not exhibit any depression indicators or behaviors. The resident was dependent on staff for substantial to maximum assistance for activities of daily living (ADLs). She received Scheduled pain medication, and psychotropic medications which included antipsychotics, and antidepressant. The physician documented clinical contraindications for psychotropic drug gradual dose reduction (GDR) on 12/07/23. The Quarterly MDS dated [DATE], documentation included an improved BIMS score of 06, however continues to indicate severe cognitive impairment. The physician documented clinical contraindications for psychotropic drug gradual dose reduction (GDR) on 01/24/25. The Cognitive Loss/Dementia and Psychotropic Drug Use Care Area Assessment (CAA), dated 10/29/24 documented she had diagnoses of dementia, memory loss, and depression and is at risk for further cognitive loss. She received psychoactive medications for noted diagnoses which include Risperidone and Duloxetine. A licensed nurse monitors for effectiveness and adverse consequences. The pharmacist reviews the resident's medication regimen monthly and notifies the director of Nursing and physician of any identified irregularities and/or recommendations. The Care Plan dated 01/22/25, directed staff the resident had compulsive disorder and depression which required psychotropic medication therapy. The staff were to administer medications as ordered, and monitor/document for side effects and effectiveness. The Electronic Health Records (EHR) Physician Orders (POS) dated 02/10/25, included the following: 1. Risperidone tablet, 0.5 milligrams (MG)(an antipsychotic)medication), give one tablet by mouth, at bedtime for compulsive disorder, ordered 05/12/2022. 2. Duloxetine HCL (antidepressant medication) capsule, delayed release sprinkle, 30 MG, by mouth, one time a day for depression. Ordered 11/02/21. 3. Monitor and document for antidepressant medications side effects each shift (ie: tearfulness, social isolation, lack of motivation to care for self or be cared for, statements of wanting to die, declination of care or food, ordered 01/17/2022. The Pharmacy Monthly Medication Regimen Review, dated 04/30/24 identified the resident as taking Duloxetine 30mg since 11/2021. The pharmacist recommended a GDR to decrease this dose to 20mg. The physician responded to the pharmacist recommendation dated 04/30/24 on 05/20/24 (20days later). The Pharmacy Monthly Medication Regimen Review, dated 05/31/24 identified the resident as currently taking Risperidone 0.5mg at bedtime and GDR was due. The pharmacist recommended a GDR to decrease the dose to 0.25mg. The physician responded to the pharmacist's recommendation dated 05/3124 on 6/05/24. The physician was not transcribed by the facility until 06/15/24 10 days following the physician response and 15 day following the pharmacists recommendation. The Pharmacy Monthly Medication Regimen Review, dated 10/31/24 identified the resident received duloxetine 30 MG since 11/2021. The pharmacist recommended a GDR to decrease dose to 20 MG. indicating the resident had a fall and urinary tract infection (UTI) early in the review period. The physician responded to the pharmacist's recommendation on 11/21/24 (21 days later). On 02/24/25 at 02:28 PM, R 8 answered direct questions. She reported she did not live at the facility. She visits her husband frequently at the facility. (R 8's husband is her roommate and resident at the facility). On 02/26/25 at12:08 PM, Certified Medication Aide, (CMA) K administered medications to the resident who sat in her recliner drinking her coffee. The resident was pleasant affect and expression during conversation she followed verbal cues and responded appropriately. On 02/25/25 at 03:36 PM, Licensed Nurse (LN) O reported the charge nurses provide oversight for effectiveness and adverse reactions to medications and notify the provider of [NAME] affects and effectiveness of psychotropic drug use which include behavior monitoring for antidepressants and psych drugs. The pharmacist reviews the resident's medication regimen monthly and reports irregularities to the director of nursing. We send the recommendations to the physician who then will respond to the recommendation which are then tracked and processed. She stated she was not sure of the expected timeline for physician response. LN O stated she would wait for response from physician/provider and would contact them directly if no response to the initial notification. On 03/03/25 at 04:56 PM, Administrative Nurse C confirmed the above findings. She stated pharmacist has access offsite to review resident's medications regimen and comes to the facility monthly the pharmacist submits the recommendations in a report. I check the dosages are then checked to make sure they are accurate. Reports are then placed in a folder and sent to the individual physician/provider or their extender. The folder may be held in house for the provider to address if the facility I aware they are coming in the facility that day. The provider response in writing on the report and places it back in the folder and will bring the folder to the facility. The expectation is to receive a response from the physician within 10-14 days at the latest. The charge nurse then processes the provider's response and noted orders , places the original in the chart, and submits a copy to the assistant director of nursing and director of nursing. She confirmed she had identified the pharmacy recommendations had not been processed in a timely manner about a year prior but had not addressed as a performance improemnt plan to date. The facility policy Drug Regimen Review, dated 03/01/24, documentation lacked address of timely follow-up to the pharmacist monthly report of identified irregularities and recommendations to prevent the potential of administration of unnecessary medications. The facility failed to ensure Residents who use psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior. receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs) related to a timely response to the pharmacist's identify and reported irregularities to the facility for the resident. - Review of Resident (R)15's Physician Orders, dated 02/10/25, documentation included diagnoses of major depression disorder, chronic pain, dementia, psychotic disturbances, amnesia, anxiety disorder. The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. She did not exhibit any depression indicators or behaviors. The resident was dependent on staff for substantial to maximum assistance for activities of daily living (ADLs). She received scheduled pain medication and an antidepressant medication. The Quarterly MDS dated [DATE], documentation included an decline in BIMS score of 04, however continues to indicate severe cognitive impairment. The physician documented clinical contraindications for psychotropic drug gradual dose reduction (GDR) on 01/07/25. The Cognitive Loss/Dementia and Psychotropic Drug Use Care Area Assessment (CAA), dated 06/01/24 documented she had diagnoses of dementia, memory loss, and depression and is at risk for further depression and cognitive loss. A licensed nurse monitors for effectiveness and adverse consequences. The pharmacist reviews the resident's medication regimen monthly and notifies the director of Nursing and physician of any identified irregularities and/or recommendations. The Care Plan dated 12/05/24 directed staff the resident received Psychotropic medications for epression with psychotic features and staff should monitored for gradual dose reductions, initiated 11/26/2024. The Electronic Health Records (EHR) Physician Orders (POS) dated 02/10/25, included the following: 1. Abilify tablet, 5 milligrams (MG), give one tablet, by mouth, in the morning for depression, ordered 06/08/24. 2. Visteril capsule, 50 MG every six hours, by mouth as needed for anxiety. 3. Prozac 40 MG capsule, take by mouth daily, related to major depressive disorder, ordered 10/06/23. 4. Namenda Oral tablet 10 MG, give by mouth in the morning related to dementia, psychotic disturbances, and mood disturbances, ordered 08/20/24. 5. Aricept tablet 10 MG, give one tablet by mouth at bedtime related to dementia, behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. 6. Monitor and document for antidepressant medications side effects each shift (ie: tearfulness, social isolation, lack of motivation to care for self or be cared for, statements of wanting to die, declination of care or food, ordered 09/05/24. The Pharmacy Monthly Medication Regimen Review, dated 09/30/24, identified the resident took Fluoxetine 40 mg since 10/2023, and was due for a dose reduction. She does continue to participate in activities many days of the month. Recommended to decrease the dose to 20mg at this time? this dose. The physician responded to the pharmacist recommendation dated 09/30/24 on 10/17/24 17 days later. 05/20/24, (20days later). The Pharmacy Monthly Medication Regimen Review, dated 11/30/24 identified the resident as currently taking Abilify since 06/08/24 and due for dose reduction. Recommended dose reduction. The pharmacist recommended a GDR to decrease the dose to 0.25mg. The physician responded to the pharmacist's recommendation dated 11/30/24 on 12/17/24. (17 days later. On 02/25/25 at 09:43 AM, resident sat in her room with door closed window shade up very sedate in her response and inquiry about concerns stated no concerns. in room starring out the window flat affect soft spoken , on inquiry she stated she had no concerns. On 02/25/25 at 03:36 PM, Licensed Nurse (LN) O reported the charge nurses provide oversight for effectiveness and adverse reactions to medications and notify the provider of [NAME] affects and effectiveness of psychotropic drug use which include behavior monitoring for antidepressants and psych drugs. The pharmacist reviews the resident's medication regimen monthly and reports irregularities to the director of nursing. We send the recommendations to the physician who then will respond to the recommendation which are then tracked and processed. She stated she was not sure of the expected timeline for physician response. LN O stated she would wait for response from physician/provider and would contact them directly if no response to the initial notification. On 03/03/25 at 04:56 PM, Administrative Nurse C confirmed the above findings. She stated pharmacist has access offsite to review resident's medications regimen and comes to the facility monthly the pharmacist submits the recommendations in a report. I check the dosages are then checked to make sure they are accurate. Reports are then placed in a folder and sent to the individual physician/provider or their extender. The folder may be held in house for the provider to address if the facility I aware they are coming in the facility that day. The provider response in writing on the report and places it back in the folder and will bring the folder to the facility. The expectation is to receive a response from the physician within 10-14 days at the latest. The charge nurse then processes the provider's response and noted orders , places the original in the chart, and submits a copy to the assistant director of nursing and director of nursing. She confirmed she had identified the pharmacy recommendations had not been processed in a timely manner about a year prior but had not addressed as a performance improvement plan to date. The facility policy Drug Regimen Review, dated 03/01/24, documentation lacked address of timely follow-up to the pharmacist monthly report of identified irregularities and recommendations to prevent the potential of administration of unnecessary medications. The facility failed to ensure residents who use psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior. receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs) related to a timely response to the pharmacist's identify and reported irregularities to the facility for the resident. - Review of the Electronic Health Record (EHR) for Resident (R)17 included diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), major depressive disorder (MDD - a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), anxiety disorder (a disorder characterized by chronic free-floating anxiety and such symptoms as tension or sweating or trembling or lightheadedness or irritability etc that has lasted for more than six months) and repeated falls. The 11/22/24 Annual Minimum Data Set (MDS) documented that the Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. The assessment documented a total mood score of zero which indicated no depression. R17 received an antianxiety (- class of medications that calm and relax people with excessive anxiety, nervousness, or tension) and antidepressant (a class of medications used to treat mood disorders) medication. The ADL Functional / Rehabilitation Potential Care Area Assessment (CAA) dated 11/22/24, documented R17 had intact cognition and required assistance with activities of daily living (ADLs - activities such as walking, grooming, toileting, dressing and eating) The Psychotropic Drug Use CAA dated 11/22/24, documented R17 utilized psychoactive (also known as psychotropic medications [medications that affect the mind or mental processes]) medications. The 02/21/25 Quarterly MDS completed 08/16/24, documented a BIMS score of 15 which indicated intact cognition. The assessment documented a total mood score of three which indicated minimal depression. R17 received antianxiety and antidepressant medications. The 08/28/23 Care Plan documented on 08/28/23 and revised on 09/27/24, R17 utilized antianxiety medications included the following interventions: On 08/28/23, staff would administer antianxiety medications as ordered by the physician, revised 09/27/24. On 08/28/23, staff would monitor/document/report as needed any adverse reactions to antianxiety medications, revised 09/27/24. On 09/27/24, staff would monitor for yelling out while asleep or increased tremor and document if observed. On 09/27/24, staff would monitor R17 for confusion, amnesia (loss of memory caused by brain damage or severe emotional trauma), loss of balance, cognitive impairment and increase risk for falls with hourly visual checks while in the facility. The 08/28/23 Care Plan documented on 12/08/23 and revised on 09/27/24, R17 utilized antidepressant medications included the following interventions: On 02/20/24, staff would administer antidepressant medications as ordered by the physician and monitor for side effects and effectiveness, revised 09/27/24. On 02/20/24, staff would educate resident/family about risks, benefits and side effects of antidepressant medication use as needed, revised 09/27/24 On 02/20/24, staff would monitor/document/report adverse reactions to antidepressant therapy. Review of the EHR Physician's Orders documented the following: Klonopin (clonazepam - an antianxiety medication), one milligram (mg), give one tablet by mouth (PO) every night at bedtime (HS) related to anxiety disorder, dated 09/17/24. Cymbalta (duloxetine - an antidepressant medication) delayed release, 60mg, give one capsule PO once daily related to depression, dated 08/14/24 Review of monthly medication regimen review (MRR) and gradual dose reduction (GDR) revealed the following: On 05/31/24, the consultant pharmacist conducted a MRR and recommended to the provider a GDR of Klonopin (clonazepam) from two mg PO every night at HS to one mg PO every night at HS. The provider agreed and wrote a new order on 09/16/24 with the dose change effective on 09/17/24 which was 109 days after the recommendation was made by the pharmacist. On 06/30/24, the consultant pharmacist conducted a MRR and recommended to the provider a GDR of Cymbalta (duloxetine) from 120mg PO once daily to 60mg PO once daily. The provder agreed and wrote a new order on 08/12/24 and the facility noted the order on 08/13/24 which was 44 days after the recommendation was made by the pharmacist. During an observation on 02/26/25 at 08:42 AM, R17 was seated on the edge of his bed and appeared calm and relaxed. During an interview on 03/03/25 at 12:01 PM, Administrative Nurse C acknowledged the facility had concerns related to the MRR and GDR process and had been identified by the QAPI (quality assurance process improvement) committee but that no PIP (process improvement plan) existed. During an interview on 03/04/24 at 10:30 AM, Administrative Nurse C revealed that all MRR and GDR data had been provided to survey team and confirmed the MRR/GDR information documented above. Administrative Nurse C stated that her expectation was that the providers would respond to MRR/GDR requests from the pharmacist within two weeks (14 days). The facility policy Drug Regimen Review, dated 03/01/24, documentation lacked address of timely follow-up to the pharmacist monthly report of identified irregularities and recommendations to prevent the potential of administration of unnecessary medications. The facility failed to ensure that R17 was free of unnecessary psychotropic medications. This deficient practice led to R17 receiving 109 unnecessary doses of an antianxiety medication and 44 unnecessary doses of an antidepressant medication and had the potential to lead to unintended side effects with negative physical and/or psychosocial effects. - Review of R6's diagnoses from the Electronic Health Record (EHR) included dementia (progressive mental disorder characterized by failing memory, confusion) with psychotic (any major mental disorder characterized by a gross impairment in reality perception), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, major depressive disorder (MDD - a major mood disorder which causes persistent feelings of sadness) and amnesia (loss of memory caused by brain damage or severe emotional trauma). The Annual Minimum Data Set (MDS) dated [DATE], documented R6 had Brief Interview of Mental Status (BIMS) score of four which indicated severely impaired cognition. The resident had a total mood severity score of 00, which indicated no depression. The assessment documented R6 received antianxiety (class of medications that calm and relax people) and antidepressant (class of medications used to treat mood disorders) medications. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 07/26/24, documented R6 had a BIMS of four. The Quarterly MDS dated [DATE], documented R6 had BIMS score of four which indicated severely impaired cognition. The resident had a total mood severity score of 00, which indicated no depression and no behaviors. R6 dependent on staff for all cares except personal hygiene and upper body dressing which required substantial/maximal assistance. R6 required supervision/touching assistance. The 04/07/21 Care Plan documented on 04/07/24 and revised on 09/23/24 that R6 had depression and anxiety and documented the following interventions: On 05/04/21, staff would administer medications as ordered and monitor/document side effects and effectiveness, revised 09/23/24. On 05/04/21, consultant pharmacist would perform a monthly review or per protocol. On 09/23/24, staff would monitor/document/report as needed any signs/symptoms of anxiety. Review of the EHR Physician's Orders documented the following: Trazodone (trazodone HCl), 25 milligram (mg) tablet, give one tablet by mouth (PO) every night at bedtime (HS) related to MDD, dated 02/09/24. Review of monthly medication regimen review (MRR) and gradual dose reduction (GDR) revealed the following: On 07/31/24, the consultant pharmacist conducted a MRR and recommended to the provider a GDR of trazodone 50mg tablet. The facility did not provide a copy of the provider or facility's response to the consultant pharmacist's recommendation. The facility failed to provide a copy of the consultant pharmacist's monthly MRR for 12/2024. During an observation on 02/25/25 at 02:55 PM, R6 rested in her bed with her eyes closed. During an observation on 02/26/25 from 09:00 AM to 11:24 AM R6 sat in a wheelchair close to the nurse's station with peers present. R6 was observed intermittently resting with her eyes closed while in a seated position. During an interview on 03/03/25 at 12:01 PM, Administrative Nurse C acknowledged the facility had concerns related to the MRR and GDR process and had been identified by the QAPI (quality assurance process improvement) committee but that no PIP (process improvement plan) existed. During an interview on 03/04/25 at 10:30 AM, Administrative Nurse C revealed that all MRR and GDR data had been provided to survey team and confirmed the MRR/GDR information documented above. Administrative Nurse C stated that her expectation was that the providers would respond to MRR/GDR requests from the pharmacist within two weeks (14 days). During an interview on 03/04/25 at 12:03 PM, Administrative Nurse C revealed that after receiving the MRR for R6 on 07/31/24, the consultant pharmacist was contacted via telephone and was informed that R6 was already on a lower dose of trazodone, so a GDR did not need to be performed. Administrative Nurse C confirmed that no GDR was performed for 07/2024 and that no additional written documentation existed related to the MRR dated 07/31/24. Additionally, Administrative Nurse C confirmed that she was unable to locate a MRR for 12/2024 for R6, The facility policy Drug Regimen Review, dated 03/01/24, documentation lacked address of timely follow-up to the pharmacist monthly report of identified irregularities and recommendations to prevent the potential of administration of unnecessary medications. The facility failed to ensure that R6 was free of unnecessary psychotropic medications with the failure to provide evidence of the facility's response for 07/31/24 MRR from the consultant pharmacist. Additionally, the facility failed to ensure the consultant pharmacist performed a monthly MRR for 12/2024. These deficient practices had the potential to lead to unnecessary doses of psychotropic medications with negative physical and/or psychosocial effects.

The facility census totaled 19 residents and one medication carts. Based on observation, interview, and record review, the facility failed to ensure the staff had secured storage of resident medications when observation onsite revealed an unlocked and unattended medication cart, not in the line of vision of the attending staff, and contained oral, topical and inhaled medications. This deficient practice placed nine cognitively impaired, independently mobile residents at risk. Findings included: - On 02/25/25 at 08:36 AM, observation revealed an unlocked and unattended medication cart which contained oral, topical, and inhaled medications in the hall between the dining area and the commons area. During an interview on 02/25/25 at 08:36 AM, Certified Medication Aide (CMA) K confirmed the medication cart should be locked when not attended or not within her line of sight. During an interview on 02/25/25 at 08:59 AM, Licensed Nurse (LN) O reported medication carts should be locked when out of the line of sight of whomever was responsible (for the medication cart). LN O further explained if the responsible person had their back turned to the cart, then the cart was not in their line of sight, and it should be locked. During an interview on 02/25/25 at 09:05 AM, Administrative Nurse C reported medication carts should be locked when not in line of sight of the CMA, and if their back was turned to the cart then it wasn't in line of sight and should be locked. Administrative Nurse C identified four confused and independently mobile residents that reside in the facility. Upon request for policy on 02/25/25 at 09:15 AM, Administrative Nurse C provided the facility policy Controlled Medications Policy and Procedure dated 12/15/23. The facility failed to provide a policy which outlined the process for medication cart control when staff are not present. The facility failed to ensure the safe and secure storage of resident medication when observation onsite revealed an unlocked and unattended medication cart, not in the line of vision of staff, in the resident dining area.

The facility reported 19 residents with 11 residents sampled. Based on observation, interview and record review the facility failed to store, prepare and serve food in a sanitary manner. This placed all residents at risk for food bourne illness. Findings included: - An observation on 02/25/25 at 10:40 AM, revealed a trash can at the hand washing sink. The trash can failed to have a foot operated lid. The lid had a flip top and closed by swinging next to the food preparation area. An observation on 02/25/25 at 11:45 AM, Dietary Aide M pushed down trash into the trash can with a gloved hand then resumed preparation of food with the same gloved hand. The facilities Food Preparation and Service Policy revised 5/21/2024 under 5. Hygiene/sanitary practices- food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of forborne illness. Under Food Service/Distribution number six revealed bare hand contact with food is prohibited. Gloves must be worn when handling foods directly. However, gloves can also become contaminated and/or soiled and must be changed between tasks. Disposable gloves are single-use items and shall be discarded after each use. The facility failed to store, prepare, and serve food in a sanitary manner. This placed all residents at risk for foodborne illness.

The facility reported a census of 19 residents with 11 residents reviewed. Based on observation, interview and record review, the facility failed to maintain a comprehensive infection control program related to laundry delivery. This failure had the potential to lead to contamination of clean linens during delivery which had the potential to negatively affect all the residents in the facility. Findings included: - On 02/25/25 at 03:30 PM, observation revealed laundry personnel transported clean resident laundry in the laundry cart through the facility halls with one of the side covers draped over the top of the cart exposing the clean laundry. During an interview on 02/25/25 at 03:30 PM, Laundry Staff Z confirmed that the laundry cart should have all sides covered when being transported down the hallway and when not attended in the hallway. During an interview on 02/26/25 at 12:57 PM, Laundry Supervisor W reported that delivery of laundry should be done with the front cover and side covers of the linen cart down and the clothes covered. During an interview on 02/26/25 at 12:57 PM, Administrative Staff H stated that all sides of the laundry cart should be down while it's transported down the halls. The facility policy Long Term Care P&P Transport of Linens to Laundry / Transport of Linens to Resident Rooms and Storage Locations dated 01/15/25, stated the sides of the linen cart are to be closed while the cart is in motion, at each destination and when clothes are removed to prevent contamination to clean linens. The facility failed to ensure that clean linens were covered during delivery and while the linen cart was unattended in the hallway. This failure had the potential to lead to contamination of clean linens during delivery.

The facility reported a census of 19 residents. Based on observation, interview, and record review the facility failed to provide a safe, functional, and sanitary environment in the laundry service area. Findings included: - During the laundry tour on 03/04/25 at 09:06 AM, with Administrative Staff H and Laundry/Housekeeping Staff W, revealed the following environmental concerns: 1. Two uncovered soiled linen bins contained soiled linen and clothing which had a sock hanging off the side of the bin. 2. The walkway tiled floor extending from the soiled linen area to the clean area, was not sanitizable due to two broken and missing floor tiles. 3. The floor in the clean linen processing area was not sanitizable due to two missing floor tiles beside the washing machine. 4. The egress from the clean linen room to the hallway entrance/exit doorway with multiple abrasions across the width of the door exposing bare wood, which was not sanitizable. On 03/04/25 at 09:26 AM, Administrative Staff H and Laundry/Housekeeping Staff W confirmed the above findings. The facility lacked a policy related to maintenance and housekeeping in the laundry. The facility failed to provide a safe, functional, and sanitary environment in the laundry service area.

The facility had a census of 29 residents. The sample included 12 residents with one reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide a bed hold notice to Resident (R)25 or their representative when the resident was sent and admitted to the hospital. This deficient practice placed R25 at risk to not be allowed to return to her former room at the facility. Findings include: - The 02/27/23 Electronic Health Records (EHR) documented that R25 had the following diagnoses: type 2 diabetes mellitus (a chronic metabolic disorder characterized by persistent high blood glucose when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), atrial fibrillation (A-FIB, a rapid, irregular heartbeat with increased risk for blood clot development), adult failure to thrive (a syndrome characterized by weight loss, decreased appetite, poor nutrition, inactivity, dehydration, and depressive symptoms) and repeated falls. The 09/30/22 Quarterly Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of seven, indicating severely impaired cognition. The 12/30/22 Significant Change MDS documented a BIMS of five, indicating severely impaired cognition. The 12/30/22 Falls Care Area Assessment (CAA) documented that R25 was at risk for fall related injuries. The 12/30/22 Cognitive CAA documented a recent fall that required hospitalization and surgery. The 02/12/22 Care Plan documented that R25 had activities of daily living deficit related to recent surgery in 12/2022. The Physician Orders in R25's EHR documented: 1. On 11/29/22, 72-hour monitoring after readmission from the hospital. 2. On 12/21/22, 72-hour monitoring after readmission from the hospital. The Progress Notes documented: 1. On 11/24/22, R25 admitted to the hospital for A-FIB. 2. On 12/01/22, R25 being monitored due to readmission from the hospital earlier that week. 3. On 12/05/22, facility staff spoke with hospital staff to ask about R25's status. 4. On 12/10/22, hospital staff called facility staff to ask for clean clothes for R25. 5. On 12/21/22, R25 readmitted to the facility after hospitalization and surgery. On 03/01/23 at 04:17 PM, Certified Nurse Aide (CNA) N revealed that R25 falls frequently and was recently hospitalized after a fall. On 03/02/23 at 08:52 AM, Administrative Nurse E revealed that R25 fell in November of 2022 and fractured her hip which required hospitalization and surgery. On 03/02/23 at 09:21 AM, Social Services X revealed that she did not issue a bed hold to the resident or family for the hospitalization related to R25's hip fracture. On 03/02/23 at 09:34 AM, Administrative Nurse D revealed that bed holds are supposed to be issued for anytime any resident leaves the facility for an anticipated period of more than 24 hours. Nursing staff are to fill out the paperwork and submit it to Social Services X. The facility failed to provide the requested policy for bed hold procedure. The facility failed to provide a bed hold notice to R25 or their representative when the resident was sent and admitted to the hospital. This deficient practice placed R25 at risk to not be allowed to return to her former room at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 29 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to develop comprehensive assessments by the failure to develop an admission Minimum data Set (MDS) within 14 calendar days after admission for Resident (R) 79 who admitted to the facility on [DATE] and failed to complete an annual comprehensive MDS for R 17 within 366 days of the previous comprehensive MDS. Findings included: - The facility admitted R79 on 01/24/23 with the diagnoses of cancer of lung and Chronic Obstructive Pulmonary Disease (COPD) - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing and received Hospice care. Review of the Electronic Medical Record on 02/28/23 at 11:00 AM revealed no admission MDS had been started for this resident. On 02/28/23 at 2:10 PM Certified Nursing Assistant (CNA) M reported the resident was an assist of one staff with pretty much all his care. It depended on what kind of day and how he felt. On 02/28/23 at 12:00 PM Administrative Nurse E and Administrative staff A revealed the MDS assessments were behind. The facility had an office person quit so those duties were moved to the MDS coordinator. She was ordering and delivering supplies along with other tasks. The MDS coordinator also worked on the floor when a nurse was needed. The nurse who was supposed to be working today tested positive for COVID this AM and Administrative Nurse D was working the floor today while the MDS coordinator ordered supplies for the building. She was aware of the late assessments but felt she could not do more than what she was doing. Review of the Resident Assessment Instrument (RAI) dated revised 2003 revealed an admission assessment must be completed by day 14. The facility failed to develop comprehensive assessments by the failure to develop an admission MDS within 14 calendar days after admission for Resident (R) 79 who admitted to the facility on [DATE]. - Review of R 17's EMR on 02/28/23 at 11:05 AM revealed an annual MDS started on 12/23/22. Only three sections were complete (resident information, preferences, and participation in assessment). The previous annual MDS had a completion date of 12/23/21. On 02/28/23 at 12:00 PM Administrative Nurse E and Administrative staff A revealed the MDS assessments were behind. The facility had an office person quit so those duties were put onto the MDS coordinator. She was ordering and delivering supplies along with other tasks. The MDS coordinator was also worked the floor when a nurse was needed on the floor. The nurse who was supposed to be working today tested positive for COVID this AM and Administrative Nurse D was working the floor today while the MDS coordinator ordered supplies for the building. She was aware of the late assessments but felt she could not do more than what she was doing. Review of the Resident Assessment Instrument (RAI) dated revised 2003 revealed an Annual Reassessment must be completed within 366 days of the most recent comprehensive assessment. The facility failed to complete an annual comprehensive MDS for R 17 within 366 days of the previous comprehensive MDS.

The facility census totaled 29 residents with 12 included in the sample. Based on interview and record review the facility failed to complete Quarterly Minimum Data Set (MDS) assessments within 92 days of the prior assessment for three of the sampled residents, including Resident (R) 20, R 5, R 14. Findings included: - Review of R 20's Electronic Medical Record revealed the resident's last MDS completed on 10/07/22. A Quarterly MDS then needed completion by 01/07/23. The facility failed to start another assessment as required for this date. - Review of R 5's EMR revealed the resident's last MDS completed on 10/14/22. A Quarterly MDS then needed completion by 01/14/23. The facility failed to start another assessment as required for this date. - Review of R 14's EMR revealed the resident's last MDS completed on 10/14/22. A Quarterly MDS then needed completion by 01/14/23. The facility failed to start another assessment as required for this date. On 02/28/23 at 12:00 PM, Administrative Nurse E and Administrative staff A revealed the MDS assessments were behind. The facility had an office person quit so those duties were given to the MDS coordinator. She was ordering and delivering supplies along with other tasks. The MDS coordinator also worked the floor when a nurse was needed on the floor. The nurse who was supposed to be working today tested positive for COVID this AM and Administrative Nurse D was working the floor today while the MDS coordinator ordered supplies for the building. She was aware of the late assessments but felt she could not do more than what she was doing. Review of the Resident Assessment Instrument (RAI) manual dated revised in 2003, revealed the Quarterly assessment must be completed within 92 days of the previous assessment. The facility failed to complete Quarterly Minimum Data Set (MDS) assessments for these three sampled residents, within the required 92 days of the prior assessment.

The facility reported a census of 29 residents with 12 selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the MDS for one sampled resident, Resident (R)13, with administration of an anticoagulant (a classification of medications used to decrease or prevent the clotting of blood). This placed the resident at risk for lack of needed cares. Findings include: - The 02/27/23 Electronic Health Records (EHR) documented that R13 had the following diagnoses: atrial fibrillation (A-FIB, a rapid, irregular heartbeat with increased risk for blood clot development), atherosclerotic heart disease (narrowing of the blood vessels supplying the heart), presence of coronary angioplasty implant (a procedure used to open clogged heart blood vessels with implantation of a small wire-mesh tube) and Parkinson's disease (a progressive disorder of the nervous system characterized by unintended/uncontrollable movements). The 08/19/22 Quarterly MDS documented a brief interview for mental status (BIMS) score of 14, indicating intact cognition. The assessment lacked documentation of anticoagulant administration use during the seven-day look-back period. The 11/18/22 Annual MDS documented a BIMS of 14, indicating intact cognition. The assessment lacked documentation of anticoagulant administration use during the seven-day look-back period. The 11/18/22 Care Area Assessment (CAA) lacked documentation related to anticoagulant therapy usage. The Care Plan documented: 1. On 02/05/20, instructed staff to monitor for side effects of anticoagulant therapy. 2. On 02/05/22, instructed staff related to the black box warning for anticoagulant therapy. 3. On 11/28/22, instructed staff to hold anti-platelet and anticoagulant for medical procedure scheduled on 12/05/22. The 11/05/21 Physician Orders in the EHR documented rivaroxaban ([Xarelto] an anticoagulant medication) to be given orally, once daily for A-FIB. The 12/2022 to 02/2023 Medication Administration Record (MAR) documented the daily administration of the rivaroxaban. On 03/01/23 at 02:07 PM, R13 revealed that he has been taking anticoagulant medication for approximately six to seven years. On 03/02/23 at 08:05 AM, Certified Medication Aide (CMA) R revealed the resident takes an anticoagulant with his morning medications. On 03/02/23 at 08:52 AM, Administrative Nurse E, MDS Coordinator revealed that the care plan instructs staff to monitor for signs and symptoms of abnormal bleeding such as bruises. Further, admitted she missed rivaroxaban as an anticoagulant on the MDSs on the 08/19/22 and 11/19/22 assessments. The facility failed to accurately complete the MDS for R13 for anticoagulant use. This placed the resident at risk for the lack of needed cares.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The 02/27/23 Electronic Health Records (EHR) documented that R22 had the following diagnoses: Parkinson's disease (a progressive disorder of the nervous system characterized by unintended/uncontrollable movements) and type 2 diabetes mellitus (a chronic metabolic disorder characterized by persistent high blood glucose when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The 07/15/22 Quarterly Minimum Data Set (MDS) documented brief interview for mental status (BIMS) of 15, indicating intact cognition. The resident required extensive one person assist with all activities of daily living (ADLs) except eating, which required setup. Resident was at risk for development of pressure ulcers/injuries without pressure relieving devices on the bed or chair. The 10/14/22 Annual MDS documented a BIMS of 14, indicating intact cognition. Resident required extensive one person assist with all activities of daily living (ADLs) except eating and toileting, which required setup. The resident was at risk for development of pressure ulcers/injuries without pressure relieving devices on the bed or chair. The 10/14/22 Pressure Ulcer/Injury Care Area Assessment (CAA) documented that the resident was at risk for development of pressure related injuries. The 11/22/22 Care Plan lacked documentation or interventions related to pressure ulcer/injury prevention or treatment. The Physician Orders in R22's EHR documented: 1. Wound care to coccyx: Felt offloading pad to surrounding wound, cutimed to wound bed, cover with Mepilex every Mon, Wed, Fri for pressure ulcer to coccyx. 2. Cutimed to open areas on buttocks, cover with mepilex. Change Monday, Wednesday, Friday. Offload AMAP- up to chair for meals then side lying in bed. For pressure injury to bottom. The Physician Orders, in R22's paper chart, documented referrals from the primary care physician to the wound clinic dated 10/30/22, 10/31/22 and 11/08/22. The 02/2022 Treatment Administration Record (TAR) documented appropriate documentation of wound care. The Progress Notes documented: 1. On 10/08/22, an area of skin breakdown to the resident's right buttock with an intervention initiated to relieve pressure on the resident's bottom while sitting in wheelchair. 2. On 10/29/22, an open area noted to the resident's left buttock with intervention initiated of wound care and a dressing placed to the wound. Notification of the primary care physician with regards to development of a new wound. 3. On 11/1/22, an order received from the physician for referral to the wound care center. 4. On 12/2/22, a description of wound care and dressing change to wounds. 5. On 12/28/22, 01/04/23, 01/11/23 and 02/15/23, nursing note entries documented the resident being transported to the wound clinic for wound care. The Assessments documented the wound to the resident's coccyx on 10/07/22, 11/18/22 and 02/24/23. On 03/01/23 at 04:13 PM, Certified Nursing Aide (CNA) N reported that the staff remind or assist the resident to change positions every two hours and that R22 sometimes declines assistance with position changes. On 03/02/23 at 08:05 AM, Certified Medication Aide (CMA) R reported that staff remind or assist R22 with position changed every two hours and was about 75% compliant with repositioning assistance/reminders from staff. On 03/02/23 at 08:52 AM, Administrative Nurse E revealed that R22 refuses Arginaid and vitamin C drink for wound healing. On 03/02/23 at 09:46 AM, Administrative Nurse D revealed that staff complete skin assessments weekly and if problems are noted, the staff notify the primary care physician. to assess whether a wound clinic referral is required. Additions to the care plan should be made as soon as new problems are discovered. The 03/01/05 Care Plan policy documents instructions for staff to address health needs/problems/conditions of the resident by identifying needs based on nursing assessment(s) and any other available information. Further instructs staff to formulate objectives in terms that are observable and measurable that staff will do to accomplish an objective. The facility failed to develop and implement a person-centered care plan related to pressure ulcer/injuries for R22. This placed the resident at risk to not receive appropriate cares and treatments. The facility census totaled 29 residents with 12 residents included in the sample. Based on interview, and record review the facility failed to develop a comprehensive care plan based on the resident needs for two of the 12 sampled residents, including: Resident (R) 79 who was admitted to the facility on [DATE] and R22 related to development of pressure ulcer/injury. Findings included: - R 79's signed physician orders dated 02/02/23 revealed the diagnoses of cancer of lung and Chronic Obstructive Pulmonary Disease (COPD) - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing and received Hospice care. Review of the Electronic Medical Record (EMR) revealed no (Minimum Data Set) MDS completed since admission on [DATE]. Review of the EMR revealed no Comprehensive Care Plan developed according to the resident needs. On 02/28/23 at 2:10 PM, Certified Nursing Assistant (CNA) M reported the resident required assist of one staff with most of his cares. It depended on what kind of day it was and how he felt. During an interview on 02/28/23 at 12:00 PM, Administrative Nurse E reported she knew the resident assessments/care plans were not done. She was doing a lot of different tasks due to a staff member quitting and shortage of licensed nurses. She was just way behind. Review of the Resident Assessment Instrument (RAI) dated revised 2003 revealed a comprehensive care plan was to be completed seven days after the MDS completion date. The facility failed to develop a comprehensive care plan based on the resident needs for Resident (R) 79 who was admitted to the facility on [DATE].

The facility reported a census of 29 residents with 12 sampled. Based on interview and record review, the facility failed to review and revise the care plan for one sampled Resident (R)25, regarding new interventions to prevent falls. This placed the R25 at risk for new injuries from repeated falls. Findings included: - The 02/27/23 Electronic Health Records (EHR) documented that R25 had the following diagnoses: type 2 diabetes mellitus (a chronic metabolic disorder characterized by persistent high blood glucose when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), atrial fibrillation (A-FIB, a rapid, irregular heartbeat with increased risk for blood clot development), adult failure to thrive (a syndrome characterized by weight loss, decreased appetite, poor nutrition, inactivity, dehydration and depressive symptoms) and repeated falls. The 09/30/22 Quarterly Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of seven, indicating severely impaired cognition. The resident required limited 1 person assist with all activities of daily living (ADLs) except eating which required setup only. The 12/30/22 Significant Change MDS documented a BIMS of five, indicating severely impaired cognition. The resident required extensive assistance of two staff for all ADLs except eating which required the assistance of one staff. The 12/30/22 Falls Care Area Assessment (CAA) documented that R25 was at risk for fall related injuries and that the risk committee will assess fall reports to determine if additional interventions need to be implemented. The 12/30/22 Cognitive CAA documented a recent fall that required hospitalization and surgery. The Care Plan documented: 1. R25 had an activities of daily living deficit related to a recent surgery in 12/2022. 2. On 02/12/22, R25 was at high risk for falls related to previous falls, gait instability, and balance problems during transfers. 3. R25 had an actual non-injury fall on 04/04/22 with the intervention for staff to leave a room light on at night. 4. R25 had an actual non-injury fall on 11/13/22 with the intervention for staff to obtain better shoes for the resident to wear. 5. R25 had an actual fall with major injury on 11/22/22 with the intervention for staff to perform hourly rounding with timed bed checks at 01:00 AM and 05:00 AM. 6. The care plan lacked documentation after actual falls on 04/19/22 or 02/17/23 of planned new interventions to prevent repeated falls with possible further injury. Review of the resident's assessments revealed fall risk screenings, dated: 1. On 03/17/22, with result of 65, indicating high risk for falling. 2. On 06/17/22, with result of 40, indicating moderate risk for falling. 3. On 6/30/22, with result of 80, indicating high risk for falling. 4. On 09/30/22, with result of 80, indicating high risk for falling. 5. On 12/21/22, with result of 75, indicating high risk for falling. 6. On 12/30/22, with result of 75, indicating high risk for falling. On 03/01/23 at 04:17 PM, Certified Nurse Aide (CNA) N reported that R25 required a pressure alarm for her bed, recliner and wheelchair due to repeated falls. Staff were supposed to perform visual checks whenever walking past her room and take her to the bathroom at least every two hours. On 03/02/23 at 08:05 AM, Certified Medication Aide (CMA) R reported that R25 doesn't remember to call for assistance and staff were to check on the resident whenever they walked by her door and at minimum once per hour. CMA R further reported that the resident has a pressure alarm that was under the resident at all times. On 03/02/23 at 08:52 AM, Administrative Nurse E reported that per the care plan; the resident has a pad alarm, was to have the assistance of one staff for all ADLs or transfers, was to utilize gripper socks and to have the door to the room always open so that staff could perform visual checks from the hallway. On 03/02/23 at 09:34 AM, Administrative Nurse D reported that after an actual fall, the fall packet should be completed by the nurse on duty. The packet included the paper forms and the documents in the EHR, which was given to the Director of Nursing (DON) and the resident's physician. The interdisciplinary team should meet once the MDS coordinator has completed a risk packet for the purpose of making a permanent addition to the care plan. Nurse D, further confirmed the lack of new interventions on the care plan after the falls on 04/19/22 and 02/17/23, to prevent further falls. The facility failed to review and revise the care plans for one Resident (R)25, regarding new interventions following two falls, to prevent repeated falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 29 residents with 6 residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the Consulting Pharmacist identified and reported blood sugar irregularities that were out of the parameters ordered by the physician for one of the six sampled residents, Resident (R) 19. Findings included: - Resident (R) 19's signed physician orders dated 02/02/23 revealed the following diagnoses: type 2 diabetes mellitus with hyperglycemia (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. No behaviors or mood issues. The Quarterly MDS, dated [DATE], had no significant changes in cognition or needs noted. The Care Plan dated 05/31/22 revealed the care plan did include interventions for the resident receiving Insulin for treatment of his diabetes. Review of the physician listed current orders, dated 02/21/23 , revealed Lantus insulin 18 units in the AM. Lispro solution sliding scale. Insulin Lispro Solution Inject as per sliding scale: if 125 - 200 = 6. 201 - 299 = 8. 300 - 399 = 10. 400 - 499 = 12. 500 - 599 = 14, subcutaneously with meals related to diabetes. Notify physician if blood sugar is less than 90. Free Style Libre 2 (continuous blood glucose monitoring). Accuchecks via Freestyle Libre AC and HS. Notify if blood sugar is less than 90. Review of the documented Accuchecks (blood sugar levels) for November 2022, revealed 8 blood sugars <90 December 2022, revealed 8 blood sugars <90 January 2023, revealed 10 blood sugars <90 February 2023, revealed 11 blood sugars <90 Review of the nurses notes, from 11/01/22- 2/28/23 revealed only one time that the staff notified the physician of blood sugar being less than 90. Nurses note, dated 02/21/23 at 05:24 PM revealed the physician saw the resident in the facility and changed the insulin order of Lantus to 18 units. Observation on 03/01/23 at 08:10 AM, revealed Licensed Nurse (LN) G in to administer the resident his AM insulin. The resident was awake and fully dressed. The resident conversed with the nurse stating he was good today. The resident reported he thought his blood sugars were good today. Sometimes they are kind of low. On 3/01/23 at 08:10 AM, LN G reported the resident got his Lantus insulin every morning and he also had sliding scale insulin. We monitor his BS with his Libre continuous blood sugar, so he does not get poked all the time. The resident was mostly independent in his room and activities. Review of the Consulting Pharmacist monthly medication reviews from 11/2022 thru 02/2023 revealed the pharmacist failure to identify the issues with the resident blood sugars being below 90 on several occasions and the reviews identified no recommendations. On 03/02/23 at 09:00 AM, Administrative Nurse D reported she expected the nurses checking the blood sugars to notify the physician as per order when they were out of the parameters set by the physician. On 03/06/23 at 11:54 AM, Consulting Pharmacist GG reported she did not see the parameter of 90 on the Medication Administration Record. She sets her own limits when reviewing blood sugars and does not get panicky unless they were under 60. She will have to look more closely at written parameters. Review of the facility policy for Pharmacy Consultant dated 03/13/16 revealed the Consulting Pharmacist will review MARs and physician orders monthly to ensure proper documentation of medication orders and administration of medication to residents. She will submit a written report from the review of the medication regimen and nursing documentation records to the attending physician and the Director of Nursing. The facility failed to ensure the Consulting Pharmacist identified and report the irregular blood sugars that were out of the parameters ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 29 residents with 6 residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure one of the six sampled residents, Resident (R) 19, remained free of unnecessary medications by the failure to report blood sugars out of the parameters ordered by the physician. Findings included: - Resident (R) 19's signed physician orders dated 02/02/23 revealed the following diagnoses: type 2 diabetes mellitus with hyperglycemia (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. No behaviors or mood issues. The Quarterly MDS dated [DATE] had no significant changes in cognition or needs. The Care Plan dated 05/31/22 revealed the care plan did include interventions for the resident receiving Insulin for treatment of his diabetes . Review of the physician orders dated 02/21/23 revealed Lantus insulin 18 units in AM . Lispro solution sliding scale. Insulin Lispro Solution Inject as per sliding scale: if 125 - 200 = 6. 201 - 299 = 8. 300 - 399 = 10. 400 - 499 = 12. 500 - 599 = 14, subcutaneously with meals related to diabetes. Notify physician if blood sugar is less than 90. Free Style Libre 2 (continuous blood glucose monitoring). Accuchecks via Freestyle Libre AC and HS. Notify if Blood sugar is less than 90. Review of the documented Accuchecks (blood sugar levels) for November 2022 revealed 8 blood sugars below 90. December 2022 revealed 8 blood sugars below 90. January 2023 revealed 10 blood sugars below 90. February 2023 revealed 11 blood sugars below 90. Review of the nurses notes, from 11/01/22- 2/28/23 revealed only one notification to the physician, out of 37 occasions of the blood sugar being less than 90. Nurses note, dated 02/21/23 at 05:24 PM, revealed the physician saw the resident in the facility and changed the insulin order of Lantus to 18 units. Observation, on 03/01/23 at 08:10 AM, revealed Licensed Nurse (LN) G in to administer the resident's AM insulin. The resident was awake and fully dressed. The resident conversed with the nurse stating he was good today. The resident reported he thought his blood sugars were good today and sometimes they were kind of low. On 3/01/23 at 08:10 AM, LN G reported the resident got his Lantus insulin every morning and he also had sliding scale insulin. We monitor his BS with his Libre continuous blood sugar, so he does not get poked all the time. The resident was mostly independent in his room and activities. On 03/02/23 at 09:00 AM Administrative Nurse D reported she expected the nurses checking the blood sugars to notify the physician as per order when they were out of the parameters set by the physician. Review of the facility policy named Accuchecks Testing dated 10/20/10 revealed Nurses were to call the physician for blood glucose less than 60 unless otherwise ordered. The facility failed to ensure Resident (R) 19 remained free of unnecessary medications by the failure to report 36 of 37 blood sugars lower and out of the parameters ordered by the physician.

The facility census totaled 29 residents with 12 residents included in the sample. Of the 29 residents five were reported to be Covid positive and were in isolation in their rooms on the 200 hallway. The facility failed to provide a safe sanitary living environment for the residents by the failure to doff personal protective equipment (PPE) prior to leaving the positive residents rooms and using large trash receptacles in the hallway for contaminated PPE, to prevent the spread of covid and infections. Findings included: - Observation, on 02/27/23 at 04:50 PM, revealed Administrative Nurse D standing in the hall after exiting a resident's room with COVID. She stood talking to another staff with no gloves on and still had on the protective blue gown. She pulled the gown by the front of the gown to remove it. She removed the gown and then walked to a hamper in the hall and placed the gown in the hamper. Another CNA was seen at the same time walking in the same hall with a PPE gown she removed and brought it to the same hamper used by the nurse for her contaminated gown. Interview, on 02/27/23 at 04:55 PM, Administrative Nurse D reported that was where the staff put their PPE when they exit the room. They do not have hampers in each of the resident's room for contaminated linen or trash. She did not know why she removed her gloves first. She had just been in a room testing a resident and while she doffed her PPE, a staff came up and was asking questions and she got sidetracked. Interview, on 02/28/23 at 07:10 AM, Administrative Staff A reported every room has a trash receptacle that the PPE should go in. There should be no soiled PPE in the halls outside the resident's room. The trash receptacles were probably not large enough was why a few staff brought their gowns out of the room. She needed to place larger bins in the resident's rooms. Observation, on 02/28/23 at 7:30 AM, revealed Certified Nurse Assistant (CNA) M donned full PPE by donning gloves, gown, a second mask over the original one and a face shield. She then entered a resident's room and gave breakfast to the resident in Styrofoam dishes on a Styrofoam tray. Upon exiting the room, the staff had no PPE other than her mask, disposing of the gown and gloves in the resident room. Observation, on 02/28/23 at 0:905 AM, revealed CNA O exit a resident with COVID's room and doff her PPE in the hall and placed in a trash receptacle in the hall. Interview, on 02/28/23 at 09:08 AM, CNA O reported there was just a small trash can in the resident room and not big enough for PPE. She thought that was why the trash bin was in the hall. Observations, on 02/28/23, of 200 hall, throughout day, revealed hand sanitizer being used by all staff. Review of the facility policy named Coronavirus (COVID-19) revised 05/10/21, revealed staff to put on a clean isolation gown upon entry into a resident's room. Remove and discard the gown, gloves in a dedicated container for waste or linen before leaving the resident room or care area. Disposable gowns are to be discarded after use. The facility failed to provide a safe sanitary living environment for the residents by the failure to doff personal protective equipment (PPE) prior to leaving the residents rooms and using large trash receptacles in the hallway, to prevent the spread of covid and infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 29 residents, with 12 residents included in the sample and five residents reviewed for immunizations. Based on interview and record review, the facility failed to ensure Resident (R)28 received her influenza vaccination and R10 received her pneumococcal vaccination. Findings included: Review of R28's medical records revealed she did not receive or was not offered an influenza vaccination upon admission to the facility on [DATE]. Review of R10's medical records revealed she did not receive or offered a pneumococcal vaccination. During an interview on 07/13/21 at 3:44 PM, Administrative Nurse A stated she expected that when a resident admits to the facility, the resident was either vaccinated, a history is gathered of previous vaccinations, or a refusal to be vaccinated was documented the resident's medical record. Review of the Nursing Procedure Manual dated January 18, 2014, revealed: Administer influenza vaccine yearly unless medically contraindicated, resident has already been immunized, or the immunization is refused .Administer Pneumovax to all nursing home residents, one time, unless previously vaccinated or medically contraindicated. The facility failed to ensure residents received or offered influenza and pneumococcal vaccinations when admitted to the facility.

The facility reported a census of 29 residents. The facility had one central kitchen where food was stored and prepared for one dining room. Based on observation, interview, and record review, the facility failed to ensure staff distributed beverages to residents in a sanitary manner. Findings included: An observation on 07/12/21 at 11:50 AM revealed during the lunch observation, Certified Medication Aide (CMA) B touched the lip of a water glass as she moved the water glass closer towards a resident so he could take his medications. CMA B also touched the lip of the styrofoam drinking cup as she removed food and drink items from a tray to place these items on the table in front of the resident. An observation on 07/13/21 at 8:42 AM revealed CMA B carried a water glass by the rim when she brought R13 her morning pills while she ate her breakfast. CMA B touched the glass by the rim again after putting the glass down and handed the glass to R13. In response to an email on 07/15/21 at 02:02 PM, Administrative Nurse A stated it was her expectation for staff to carry beverages around the middle of the glass and not by the rim. A review of the Assistance with Meals policy effective 05/21/13 revealed, All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. The facility failed to ensure staff used proper sanitary practices to distribute beverages to residents.