**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 22 residents. The sample included 12 residents, with one reviewed for dignity. Based on observation, record review, and interview, the facility failed to promote dignity for one resident, Resident (R) 22, whose pajamas were soiled with urine from her waist down to the back of her knees. The facility further failed to promote dignity for R22 by taking her out into the common area and into an activity in her pajamas. This placed the resident at risk for impaired dignity. - The Electronic Medical Record (EMR) for R22 documented diagnoses of pressure ulcers, dementia (a progressive mental disorder characterized by failing memory and confusion), acute kidney failure (the kidney suddenly can't filter waste from the blood), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), vitamin deficiency (a deficiency of one or more essential vitamins), and pain. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R22 had severely impaired cognition. R22 was dependent upon staff for transfers and toileting hygiene. R22 required substantial assistance with dressing and lower functional impairment on both sides. The MDS documented R22 was frequently incontinent of bladder and occasionally incontinent of bowel. The Quarterly MDS, dated 02/14/25, documented R22 had severely impaired cognition. R22 required substantial assistance from staff for toileting hygiene, lower body dressing, and toileting, and had lower functional impairment on both sides. The MDS documented R22 was frequently incontinent of bladder and bowel. R22's Care Plan, dated 02/25/25, initiated on 11/05/24, directed staff to assist R22 with all activities of daily living (ADL). The care plan directed staff to allow her to do as much for herself as possible and assist her with personal hygiene. The care plan update, dated 12/31/24, directed staff to toilet her approximately every two hours. On 03/04/25 at 09:55 AM, R22 was in bed and had bilateral heel protectors on. CNA N removed the heel protectors and swung her legs over the side of the bed. R22 did not have any socks on, and her bare feet were placed on the footplate of the sit-to-stand mechanical lift. CNA B placed the sit-to-stand sling around the resident, attached it to the lift, and R22 was lifted to a standing position. R22's bed had a chuck (a disposable bed pad used to protect bedding or furniture from urinary incontinence) that was heavily soiled with urine. R22's back of her pajama pants was soiled with urine clear down to the back of her knees. When asked, Certified Nurse Aide (CNA) P stated R22 had been last toileted at 07:00 AM. R22 stated, I'm cold. CNA N stated, Don't worry, you're going to get a bath today. CNA N put a clean brief on R22 and clean pajama pants on, left her pajama top on, and socks. CNA N did not put R22's pressure-relieving boots back on. CNA N stated she was not sure how R22 obtained the pressure ulcer but thought it was from pushing on the footboard on her bed, and it just did not heal. R22 was pushed into the area by the nurse's station and CNA N stated, You didn't have breakfast, I will get you a Danish. At 10:34 AM, R22 was still out in the commons area, in pajamas, and no pressure-relieving boots. Activity staff asked R22 if she wanted to participate in the music activity and told her to lift her feet up so she could push her into the activity room. R22 lifted her toes up but her heels were dragging on the floor, and she lacked any protection on her feet. At 11:45 AM, when asked, R22 stated she had got to sleep in but was not dressed. At 12:00 PM, the Nursing Staff came into the activity room and stated, It's time for lunch and R22 stated, But I am not dressed. As R22 was taken to her room. CNA N stated, It's time for lunch, where is she going? CNA N was told that R22 was not dressed, and she did not want to go to lunch without being dressed. When CNA N was asked why she was not given a bath like R22 was told or had her pajamas covered, CNA N stated, She was supposed to get a bath, but my coworker is lazy. I told her she had to give her a bath right after lunch. R22 returned to the commons area dressed and had her pressure-relieving boots on. On 03/05/25 at 01:00 PM, Administrative Nurse D stated that R22 should not have been taken out into the commons area in her pajamas, but did not speak of why R22 was soaked with urine. The facility's Right to Dignity policy, dated 01/30/20, documented the facility will promote care for residents of the facility in a manner and in an environment that maintains and enhances each resident's dignity and respect in full recognition of the resident's individuality. The facility failed to promote care for R22 in a manner to maintain and enhance dignity and respect. This placed R22 at risk for impaired dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 22 residents. The sample included 12. Based on observation, record review, and interview, the facility failed to implement effective care plan interventions for Resident (R) 6 from falling and sustaining major injuries. This deficient practice placed R6 at risk for continued falls and injuries. Findings included: - The Electronic Medical Record (EMR) for R6 documented diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), hypertension (HTN - elevated blood pressure), chronic atrial fibrillation (rapid, irregular heartbeat), fracture (broken bone) of body of sternum (t-shaped bone of front chest) and other parts of the pelvis (bones between the lower abdomen and upper thighs that connect the spine to the legs). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R6 had moderately impaired cognition, and exhibited no behaviors. R6 had functional range of motion impairment to both sides of the lower extremities, was dependent with toileting hygiene, and lower body dressing. R6 required partial/moderate assistance with personal hygiene and substantial/maximal assistance with rolling left and right, and transfers and walking were not attempted. The MDS further documented R6 had one fall with major injury since prior assessment. R6 also had two pressure injuries presenting as deep tissue injuries (DTI - purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear) which were present on readmission to the facility. The Fall Care Area Assessment (CAA), dated 05/08/24, documented R6 fell on [DATE] in her room at 05:12 PM, was taken to the emergency room, and had a fractured pelvis. R6 returned on 04/19/24 to her room in long-term care, ordered to be on bed rest until further notice. The CAA further documented R6 had been independent in her room prior to the fall. The facility conducted another Significant Change MDS with a Fall CAA dated 08/01/24, which documented R6 had falls on 04/09/24, 06/28/24, and 07/10/24. The CAA further documented R6 fell on [DATE], and a new pelvic fracture was present. R6, now declining the restorative program, was noncompliant with staff assistance, had poor safety awareness, several interventions implemented for fall prevention, had moderately impaired cognition but R6 did not follow directions, and had fractures at the base of the third and fourth digit (fingers). R6's Fall Care Plan dated 02/14/25, documented that R6 was at high risk for falling and had an actual fall with major injury. The Care Plan documented R6 no longer wanted to be asked about restorative therapy. The interventions dated 09/30/24 were for physical therapy and were independent in her room, she used a front-wheeled walker in the hallway. On 04/18/24, a grabber was provided. On 11/23/24, floor grip strips were placed on the floor in front of her recliner and R6 wanted to be more independent. Upon review of R6 falls revealed: The Progress Note dated 04/09/24 at 05:12 PM R6 was found in her room, lying on her right side on the floor, with a walker parked against the bathroom door. R6 complained of right hip pain and had a skin tear to the right elbow. R6 was sent to the emergency room. The Incident Summary dated 04/09/24 concluded R6 reached for an item from the floor when she fell. R6 had been admitted to the hospital for treatment. The recommendation made was to provide a reacher (a device used to help grab items from out of reach). The Computerized Tomography Scan (CT-x-ray technique of imaging to create detailed images) of the pelvis report, dated 04/09/24, revealed moderately displaced fractures of the right superior and inferior pubic ramus (a break or crack in the pelvis bones). The Progress Note dated 06/28/24 at 04:06 AM documented R6 found lying on the right side with bleeding noted to the right ring and little fingers. R6 was barefooted and reported she was going to the bathroom. R6 was sent to the emergency room. The Incident Summary dated 06/28/24 documented R6 was sent to the emergency room and received one stitch in both fingers. The recommendation was to remind R6 to call for assistance when getting up and ambulating. On 07/02/24, an X-ray report revealed that the left hand had a nondisplaced fracture at the base of the fourth digit and a questionable non-displaced fracture at the base of the third digit. The Progress Notes dated 07/10/24 at 09:56 AM documented that R6 was heard yelling and found lying on the floor. The note reported R6 had got up on her own. The physician ordered an X-ray of the right hip and pelvis. The Incident Summary dated 07/10/24 documented that R6 was unattended and had gotten up out of her chair, and R6 was given a reacher (a previous intervention) and shown how to use it so she could grab items out of her reach. And that the nursing staff would take the resident to the bathroom one hour after each meal. The CT Scan (X-ray technique of imaging creates detailed images) of the pelvis, dated 07/13/24, reported an acute comminated (bone break into three or more pieces) fracture of the right ischium (part of the hip bone or over the hip bone area), and the base of the inferior pubic ramus. The Progress Note dated 08/28/24 at 04:44 PM documented R6 signed a contract stating the staff/facility was not responsible for any falls. R6 had been educated on using the call light when she needed assistance, using her walker, and wearing appropriate footwear, including gripper socks. R6 had voiced understanding and was agreeable to this. (R6 had moderately impaired cognition). The chair alarm had been discontinued. The Progress Note dated 11/15/24 at 05:37 AM documented R6 was found on the floor in her room. R6 stated she tried going to the bathroom. R6 right forearm was bleeding and bruised, along with points on her hand. The Incident Summary dated 11/15/24 documented steri-stips (adhesive wound closures) placed on R6's forearm. The recommendation/action documented staff instructed that R6 was taken to the bathroom within one hour after meals. R6 was provided a reacher due to wanting to be self-sufficient. On 03/05/25 at 09:25 AM, R6 was in her room, standing at the dresser/TV stand, looking through the top drawer. The walker was parked next to the dresser. The call light was fastened to the left armrest of her recliner. On 03/05/25 at 09:30 AM, Certified Nurse Aide (CNA) M stated R6 does what she wants, and staff tried to catch her when she was up to be near her. CNA M reported thst R6 ate most of her meals in her room, but on occasion, she would come out to see the birds in the activity room or walk up and down the halls. On 03/05/25 at 11:00 AM, Licensed Nurse (LN) G reported that R6 was very stubborn and had poor safety awareness. LN G reviewed a document risk assessment that R6 had signed a release of responsibility form for injuries related to falls. On 03/05/25 at 01:20 PM, Administrative Nurse E verified that R6 had signed a safety education and release of responsibility form when R6 had moderately impaired cognition. Administrative Nurse E reported that the charge nurses were responsible for new interventions to prevent further falls of residents with each fall. The facility's Comprehensive Person-Centered Care Plan policy, dated 03/2022, documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs and is developed and implemented for each resident. Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's conditions change. The facility failed to implement effective care plan interventions for R6 from falling. This deficient practice placed the resident at risk for continued falls and injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 22 residents. The sample included 12 residents, with one reviewed for Activities of Daily Living (ADL). Based on observation, record review, and interview, the facility failed to provide meal assistance for one resident, Resident (R) 19, who required assistance. This placed R22 at risk for further weight loss. Findings included: - The Electronic Medical Record (EMR) for R19 documented diagnoses of hypertensive heart disease (heart issues that develop due to long-term high blood pressure), atrial fibrillation (rapid, irregular heartbeat), retention of urine (lack of ability to urinate and empty the bladder), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Annual Minimum Data Set Assessment (MDS), dated [DATE], documented R19 had moderately impaired cognition. R19 required partial assistance from staff for dressing, mobility, transfers, and toileting. R19 was independent with eating. The MDS documented R19 had no chewing or swallowing issues, weighed 138 pounds (lbs.), and had no weight loss or gain. The Nutrition Care Area Assessment (CAA), dated 05/09/24, did not trigger. The Quarterly MDS, dated 11/08/24, documented R19 had moderately impaired cognition. R19 required partial assistance with dressing, ambulation, and personal hygiene. R19 was independent with eating. R19 had no chewing or swallowing issues weighed 143 lbs. and had no weight loss or gains. R19's Care Plan, dated 02/28/25, initiated on 11/17/23, documented R19 may need assistance and one staff assistance with eating depending upon how he felt that day. The update, dated 02/26/25, directed staff to follow a regular diet as ordered, monitor intake daily, and offer alternate food or a house supplement for intake less than 50%. The care plan directed staff to offer assistance if R19 had trouble unwrapping food and drinks and monitor weight closely for gain or loss. The EMR lacked documentation of how often to weigh R19. R19's Vital Sign Log-Weights recorded the following weights: 01/13/25 146.6 lbs. 01/20/25 148.6 lbs. 01/27/25 148.6 lbs. 02/03/25 146.6 lbs. 02/10/25 142 lbs. 02/25/25 134 lbs. 03/03/25 128.9 lbs. (12.07 percent [%] weight loss in 30 days) The Nutrition/Dietary Note dated 02/26/25 documented R19's intake had declined. R19's family member requested staff assist R19 with meals. The note directed staff to offer supplements at meals when he didn't eat or wanted to order alternative food. The CDM would continue to make adjustments as needed and consult the Registered Dietician (RD). The EMR lacked documentation the RD was notified of the continued weight loss. The Medication Administration Record (MAR) dated 02/28/25 directed staff to provide a house supplement as needed. The record lacked documentation that the supplement was provided to R19. The EMR recorded R19 was admitted to Hospice (specialized care that mainly aims to provide comfort and dignity to patients, by providing physical comfort and emotional, social, and spiritual support for people nearing the end of life) on 02/27/25 due to hypertensive heart failure. On 03/03/35 at 12:05 PM, R19 was taken by wheelchair to the dining room table for the noon meal. R19 leaned against a small pillow on his right side which caused him to be lower than the table. Dietary staff sat a bowl of jello, a glass of water, and his meal of onion rings, green beans, and chicken on the table. R19 tried to adjust himself to get closer to the table. CDM BB went to the table and asked R19 if she could cut his chicken up for him and he stated, Yes. R19 continued to lean slightly to the right, he was able to eat an onion ring but as he reached for his jello, it was out of his reach. R19's fingertips touched the bowl of jello but he could not get close enough to be able to eat it. R19's tablemate R21 pushed the jello closer to R19, and he attempted to take a bite but was unable to do so. At 12:16 PM, a staff member walked up to the table and stated. Do you need some help? R19 stated, If I am going to eat something, I do. The staff member sat down next to him and assisted him with two bites of food. At 12:25 PM, the staff member got up and left the dining room, and never came back. In the dining room, there were three staff members assisting other residents, two at one table and another at a different table. R19 reached for his water and slid it to the edge of the table, but was unable to pick it up to drink. R19's tablemate R21 picked up R19's water glass and held it up to his mouth so R19 could drink. After he had drank some of his water, he tried to move away from the table, dropped his napkin, and attempted to pick it up, and a staff member saw him reaching for the floor, got up, and picked it up for him. R19 attempted to move away from the table again as his tablemate R21 looked around the dining room for someone to assist R19 and as a staff member walked by he asked her to help R19. On 3/4/25 at 09:00 AM, R19 sat in his recliner in his room. His bedside table had a bowl of cream of wheat and toast. This Surveyor asked him how his breakfast was, and he stated, I haven't tried it yet because I need help, and I cannot reach it. Certified Medication Aide (CMA) R was located at the nursing station and asked if there was staff available to assist R19 with his breakfast meal. CMA R used her communication device to ask for staff to go to his room and assist him. CNA N went into his room and stated, What do you need help with? R19 stated, Everything. CNA N stated, Do I need to sit in here with you? During that interaction, CNA O walked into the room and she and CNA R discussed who was going to sit in the room and assist R19. CNA O sat down next to R19 as he tried to eat, and she looked at her cell phone. R19 was able to receive some assistance with his meal. On 03/04/25 at 09:26 AM, Administrative Staff D stated, R19 had been ill and in the hospital from [DATE] to 02/08/25. Administrative Nurse D verified that he had declined since then and staff should be aware and assist him. On 03/04/25 at 10:00 AM, CNA O stated that R19 had declined recently and stated his daughter usually assisted him with his meals. CNA O further stated that R19 did require more assistance with his care and meals. On 03/04/25 at 02:33 PM, Dietary Staff BB stated she had not notified the RD of R19's weight loss. She had provided nursing staff standing orders that the RD had provided to the facility for residents when there was a weight loss. Dietary Staff BB stated if R19 ate less than 50%, staff were to offer alternative food or a supplement. Dietary Staff document meal intakes and nursing staff are to document the supplement. Dietary Staff BB stated she had planned to notify him the next day of R19's weight loss. Dietary Staff BB stated, if a resident had a 5% weight loss in a month, staff were to provide 6 ounces (oz) of orange juice twice a day, provide med pass (nutritional supplement) 2 oz four times per day, meal fortification, multivitamins with minerals, weekly weights, and document the amount he consumed. Dietary Staff BB stated she was unaware that the nursing staff had not followed the recommendations. On 03/04/25 at 02:50 PM, Administrative Nurse E stated she would look at R19's weight loss recommendations. Administrative Nurse E stated that the dietary staff was responsible for meal intake but was not aware that R19 did not receive the supplement. On 03/05/25 at 09:20 AM, Licensed Nurse (LN) G stated that there was a fax communication to the physician on 02/18/25, that R19 had a decreased appetite but was unable to locate any documentation that he was aware of how much weight R19 had lost. She stated R19 was supposed to get a bottle of Ensure (nutritional supplement) with his meals if he ate less than 50%. LN G stated she was unsure when he had received the supplement or not. LN G stated that R19 was on Hospice services and thought that they were aware of his weight loss. On 03/05/25 at 01:00 PM, Administrative Nurse D stated staff should assist R19 with his meals. The facility's Assisting the Impaired Resident with In-Room Meals policy, dated 09/13, directed staff to ensure that the necessary non-food items are in place on the tray i.e., silverware, special devices, napkins, and straws. Position the resident so his or her head and upper body are as upright as possible, position your chair where it would be convenient for you and the resident. Feed the resident slowly and allow plenty of time between mouthfuls. Encourage the resident to eat all of his meal, but do not force him or her to eat. Document how much of the meal the resident consumes and if the resident participated. Document any changes in the resident's ability to participate with the meal and if the resident had any difficulty feeding himself, chewing, or swallowing. Notify the supervisor if the resident refused the meal or to eat. The facility failed to provide meal assistance for R19, who required assistance. This placed R22 at risk for further weight loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 22 residents. The sample included 12 residents, with two reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to prevent the development of a Stage 3 (full thickness tissue loss) pressure ulcer for one resident, Resident (R) 22 who had edema (swelling resulting from an excessive accumulation of fluid in the body tissues) in her legs. The facility also failed to implement interventions to prevent further breakdown and follow the plan of care to wear pressure-relieving boots at all times. This placed the resident at risk for further breakdown. Findings included: - The Electronic Medical Record (EMR) for R22 documented diagnoses of pressure ulcers, dementia (a progressive mental disorder characterized by failing memory and confusion), acute kidney failure (the kidney suddenly can't filter waste from the blood), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), vitamin deficiency (a deficiency of one or more essential vitamins), and pain. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R22 had severely impaired cognition. R22 was dependent upon staff for transfers, toileting hygiene, and partial assistance from staff for mobility, and lower functional impairment on both sides. The MDS documented R22 was at risk for pressure ulcers, had a deep tissue injury (DTI - purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear), received pressure-ulcer care, and had a pressure device for her bed and chair. The Pressure Ulcer Care Area Assessment (CAA), dated 11/15/24, documented R22's heels were floated whenever she was in bed or her recliner, and gel cushions were in her chairs. R22 has had a significant change in her condition due to acute issues with increased confusion with dementia, urinary tract infections (UTI - an infection in any part of the urinary system), and increased pain in both knees. R22's compression socks were not applied until the heel sore was healed. The Quarterly MDS, dated 02/14/25, documented R22 had severely impaired cognition. R22 required substantial assistance from staff for toileting hygiene, lower body dressing, and toileting, and had lower functional impairment on both sides. The MDS documented R22 was at risk for pressure ulcers, had one stage 3 pressure ulcer, received pressure ulcer care, and had a pressure device for her bed and chair. R22's Care Plan, dated 02/25/25, initiated on 11/18/25, directed staff to administer treatments as ordered and monitor for effectiveness. Float heels when in a reclining chair and bed, new wheelchair pedals on her wheelchair for a better fit, and a gel cushion for her wheelchair. The care plan further directed staff to turn/reposition R22 at least every two hours, more often as she required extensive to total assistance with repositioning R22 and required weekly treatment documentation to include measurement of each area of skin breakdown with width, length, depth, type of tissue and exudate (a mass of cells and fluid that has seeped out of blood vessels or an organ, especially in inflammation (swelling). The update, dated 12/31/24, directed staff to toilet her approximately every two hours. The update, dated 02/26/25, directed staff to have heel protectors on at all times. The Braden Scale Assessment (formal assessment for predicting pressure ulcer risk) dated 10/25/24 documented R22 was not at risk for pressure ulcers. The Braden Scale Assessment dated 11/11/25 documented R22 was at risk for pressure ulcers. The Weekly Skin Evaluation dated 11/26/24 documented R22's right heel measured 4.5 cm x 4.2 cm and had eschar. The left heel measured 0.8 cm x 1.2 cm and was scabbed. The Weekly Skin Evaluation dated 12/24/24 documented R22's right heel measured 2.5 cm x 2 cm. The Weekly Skin Evaluation dated 01/01/25 documented R22 had a right heel pressure ulcer but lacked documentation of the measurement. The Physician's Order dated 11/04/24 directed staff to provide liquaCel (protein supplement). 30 milliliters (ml), by mouth, three times per day, for vitamin deficiency. The Physician's Order dated 11/11/24 directed staff to elevate R22's feet twice per day for edema. The Physician's Order dated 11/14/24 directed staff to administer Lasix (a diuretic [medication to promote the formation and excretion of urine]). 20 milligrams (mg), each morning, compression stockings (stockings that help blood flow back into the heart and reduce pain and swelling), knee high for a minimum of 12 hours per day and lower the footrests on the wheelchair. The Nurse's Note dated 11/14/24 at 09:17 AM documented R22 had a new onset of one plus pitting edema in both of her legs and was on an antibiotic (medication that inhibits the growth of or destroys microorganisms) for a UTI. The Nurse's Note dated 11/18/24 at 10:43 AM documented R18 had pressure sores to bilateral heels. The right heel measured five centimeters (cm) x 4.2 cm, and the left heel measures 0.8 cm x 1.2 cm. Staff were directed to apply betadine (an antiseptic used to treat wounds to prevent bacteria) to both heels twice per day until healed. The Physician's Note dated 11/19/24 at 02:05 PM documented nursing staff were concerned that R22 had a blister on her right heel and now there was an area of eschar (dead tissue) on the heel. The note further documented R22 had recently been admitted and laid in bed quite a bit and that is how the blister formed. There is currently no bogginess (spongy, soft texture) underneath the blister. The eschar was firmly attached to the heel and no cellulitis around the eschar. Nursing staff should apply the Betadine, and keep it dry to prevent infection. Should the area become loose or boggy, then the nursing staff need to notify the physician and the physician would reassess. The Nurse's Note dated 11/25/24 at 12:52 PM documented R22 had an appointment at the wound clinic. The Registered Dietician Nutrition/Dietary Note dated 11/26/24 at 09:05 AM documented R22 was new to the facility and had good food and fluid intake. R22 had skin issues on her right and left heel and received protein for extra wound healing. The note documented he recommended continuing with the plan of care. The Nurse's Note dated 11/28/24 at 08:30 AM documented R22's right heel measured 4.3 cm x 3.5 cm was black/brown in color, intact blister was noted. The left heel measured 2 cm x 1 cm open area, no drainage noted, and the edges were pink. R22's heels floated when laid down and walked to the bathroom with her walker and the assistance of two staff. The Nurse's Note dated 12/05/24 at 03:54 PM documented R22's wound on her right heel started to worsen with ambulation and her exercise program was being adjusted until the wounds healed. The Physician's Order dated 12/05/24 directed staff to apply an Iodoflex (absorbs slough, soft necrotic (dead or dying) tissue, and exudate) dressing and cover with a four-by-four silicone foam dressing, to the right heel until healed. The order was discontinued on 01/22/25. The Nurse's Note dated 12/20/24 at 09:43 AM documented R22 had eschar on her right heel. The area developed as a blister because she used her heels to push herself in bed and then underneath the blister, there was a large area of eschar that continued to improve. The Wound Care Notes dated 12/30/24 documented R22 right heel measured 1.5 cm x 1.7 cm x 0.1 cm and directed staff to wear a gel cushion to the right foot to assist with pressure reduction. The EMR lacked documentation that the order was put into place. The Physician's Order dated 01/15/25 directed staff to wear heel protectors at night and remove in the morning. The Nurse's Notes dated 01/17/25 at 11:05 AM documented R22's right heel measured 1.8 cm x 2 cm x 0.1 cm, small amount of serosanguinous (semi-thick blood-tinged drainage) exudate, and surrounding tissue edema. The Wound Care Notes dated 01/22/25 documented R22's right heel measured two cm x two cm x 0.3 cm, a moderate amount of serosanguinous exudate, and surrounding tissue edema. The Wound Care Report dated 01/29/25 documented R22's right heel had a large callous/ eschar. The wound measured 1.8 cm x 2 cm x 0.1 cm, with serosanguinous exudate, and surrounding tissue edema. The staff was directed to apply Promogran Prisma (a dressing indicated for the management of all wounds healing by secondary intent which are clear of necrotic tissue) to the wound bed, activate with normal saline, cover with a four-by-four silicone dressing, change twice a week with showers and as needed. The Wound Care Report dated 02/05/25 documented R22's right heel measured 1.1 cm x 1.2 cm x 0.3 cm, with a moderate amount of serosanguinous exudate, surrounding tissue had edema. The Wound Care Report dated 02/19/25 documented R33's right heel measured 1.6 cm x 1 cm x 0.3 cm, with a moderate amount of serosanguinous exudate, and surrounding tissue edema. The facility was directed to take a multivitamin out and follow label instructions for dosing. Take Vitamin C, 1000 mg, by mouth, daily. Limit salt and increase protein in the diet. Review of the EMR lacked documentation the above recommendation was implemented. The facility was directed to apply silvercel (a sterile non-woven pad with alginate) to the wound bed and cover it with four-by-four bordered gauze, daily and as needed. The Registered Dietician Nutrition/Dietary Note dated 02/20/25 at 04/45 PM documented R22 had increased protein at meals for wound healing and currently took Liquacel to help with the wound. The RD recommended continuing the plan of care. The Physician's Order dated 02/26/25 directed staff for the heel protectors to stay on night and day to reduce pressure on the heels. On 03/04/25 at 09:55 AM, R22 was in bed and had bilateral heel protectors on. CNA N removed the heel protectors and swung her legs over the side of the bed. R22 did not have any socks on, and her bare feet were placed on the footplate of the sit-to-stand mechanical lift. CNA B placed the sit-to-stand sling around the resident, attached it to the lift, and R22 was lifted to a standing position. R22's bed had a chuck (a disposable bed pad used to protect bedding or furniture from urinary incontinence) that was heavily soiled with urine. R22's back of her pajama pants was soiled with urine clear down to the back of her knees. When asked, Certified Nurse Aide (CNA) P stated R22 had been last toileted at 07:00 AM. R22 stated, I'm cold. CNA N stated, Don't worry, you're going to get a bath today. CNA N put a clean brief on R22 and clean pajama pants on her, left her pajama top on, and socks. CNA N did not put R22's pressure-relieving boots back on. CNA N stated she was not sure how R22 obtained the pressure ulcer but thought it was from pushing on the footboard on her bed, and it just did not heal. R22 was pushed into the area by the nurse's station and CNA N stated, You didn't have breakfast, I will get you a Danish. At 10:34 AM, R22 was still out in the commons area, in pajamas, and no pressure-relieving boots. Activity staff asked R22 if she wanted to participate in the music activity and told her to lift her feet up so she could push her into the activity room. R22 lifted her toes up but her heels were dragging on the floor, and she lacked any protection on her feet. At 11:45 AM, when asked, R22 stated she had got to sleep in but was not dressed. At 12:00 PM, the Nursing Staff came into the activity room and stated, It's time for lunch and R22 stated, But I am not dressed. As R22 was taken to her room. CNA N stated, It's time for lunch, where is she going? CNA N was told that R22 was not dressed, and she did not want to go to lunch without being dressed. When CNA N was asked why she was not given a bath like R22 was told or had her pajamas covered, CNA N stated, She was supposed to get a bath, but my coworker is lazy. I told her she had to give her a bath right after lunch. R22 returned to the commons area dressed and had her pressure-relieving boots on. On 03/04/25 at 03:15 PM, LN G washed her hands, gloved, and placed a dry chuck on the floor in front of R22's recliner. LN G removed the soiled dressing from R22's right heel, removed her gloves, and donned clean gloves. LN G cleansed the right heel wound with normal saline. LN G removed soiled gloves, donned clean gloves and placed silvercel in the wound, covered the wound with a foam dressing over it. LN G stated that R22 required more assistance after she came into the facility. She was unsure how she acquired the wound but R22 had a lot of edema and her shoes were too tight. LN G stated R22 had just recently gotten the bigger pressure relieving boot and R22 would be getting a walking boot so she could participate in physical therapy. LN G stated that R22 should have the pressure-relieving boots on at all times. On 03/05/25 at 01:00 PM, Administrative Nurse D stated she could not speak as to how R22 obtained the pressure ulcer. She stated she did not know why it took two months for R22 to have pressure-relieving boots or why interventions were not put into place. Administrative Nurse D stated, that R22 should not have been taken out into the commons area in her pajamas and should have had on her boots. The facility's Wound/Pressure Ulcer Management policy, dated 07/19, documented the facility was committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being. The facility was committed to minimizing the development of in-house acquired pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable. Any resident with a wound received treatment and services consistent with the resident's goal of treatment. Typically, the goal is one of promoting healing and preventing infection unless a resident's preferences and medical condition necessitate palliative care as the primary focus. The facility failed to prevent the development of a Stage 3 for R22 who had edema in her legs. The facility also failed to implement interventions to prevent further breakdown and follow the plan of care to wear pressure-relieving boots at all times. This placed the resident at risk for further breakdown.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 22 residents. The sample included 12 residents of which five residents were reviewed for falls. Based on observation, record review, and interview, the facility failed to prevent Resident (R) 6 from falling and sustaining major injuries with ineffective interventions. This placed R6 risk for continued falls and injuries. Findings included: - The Electronic Medical Record (EMR) for R6 documented diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), hypertension (HTN - elevated blood pressure), chronic atrial fibrillation (rapid, irregular heartbeat), fracture (broken bone) of body of sternum (t-shaped bone of front chest) and other parts of the pelvis (bones between the lower abdomen and upper thighs that connect the spine to the legs). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R6 had moderately impaired cognition, and exhibited no behaviors. R6 had functional range of motion impairment to both sides of the lower extremities, was dependent with toileting hygiene, lower body dressing, required partial/moderate assistance with personal hygiene and substantial/maximal assistance with rolling left and right, and transfers and walking was not attempted. The MDS further documented R6 had one fall with major injury since prior assessment. R6 also had two pressure injuries presenting as deep tissue injuries (DTI- purple or maroon localized area of discolored intact skin or blood?filled blister due to damage of underlying soft tissue from pressure and/or shear) which were present on readmission to the facility. The Fall Care Area Assessment (CAA), dated 05/08/24, documented R6 fell on [DATE] in her room at 05:12 PM, taken to the emergency room and had fractured pelvis. R6 returned on 04/19/24 to her room in long term care, ordered to be on bed rest until further notice. The CAA further documented R6 had been independent in her room prior to the fall. The facility conducted another Significant Change MDS with a Fall CAA dated 08/01/24, which documented R6 had falls on 04/09/24, 06/28/24, and 07/10/24. The CAA further documented R6 fell on [DATE], and a new pelvic fracture was present. R6, now declining the restorative program, was noncompliant with staff assistance, had poor safety awareness, several interventions implemented for fall prevention, had moderately impaired cognition but R6 did not follow directions, and fractures at the base of the third and fourth digit (fingers). The Fall Care Plan dated 02/14/25, documented that R6 was high risk for falling and had an actual fall with major injury. The Care Plan documented R6 no longer wanted to be asked about restorative therapy. The interventions dated 09/30/24 were for physical therapy and were independent in her room, she used a front-wheeled walker in the hallway. On 04/18/24, a grabber was provided. On 11/23/24, floor grip strips were placed on the floor in front of her recliner and R6 wanted to be more independent. Upon review of R6 falls revealed: The Progress Note dated 04/09/24 at 05:12 PM R6 was found in her room, lying on her right side on the floor, with a walker parked against the bathroom door. R6 complained of right hip pain and had a skin tear to the right elbow. R6 was sent to the emergency room. The Incident Summary dated 04/09/24 concluded R6 reached for an item from the floor when she fell. R6 had been admitted to the hospital for treatment. The recommendation made was to provide a reacher (device used to help grab items from out of reach). The computerized tomography scan (CT-x-ray technique of imaging to create detailed images) of pelvis report, dated 04/09/24, revealed moderately displaced fractures of the right superior and inferior pubic ramus (a break or crack in the pelvis bones). The Progress Note dated 06/28/24 at 04:06 AM documented R6 found lying on the right side with bleeding noted to the right ring and little fingers, R6 was barefooted and reported she was going to the bathroom. R6 was sent to the emergency room. The Incident Summary dated 06/28/24 documented R6 was sent to the emergency room and received one stitch in both fingers. The recommendation was to remind R6 to call for assistance when getting up and ambulating. On 07/02/24, an X-ray report revealed that the left hand had a nondisplaced fracture at the base of the fourth digit and a questionable non-displaced fracture at the base of the third digit. The Progress Notes dated 07/10/24 at 09:56 AM documented that R6 was heard yelling and found lying on the floor. The note reported R6 had got up on her own. The physician ordered X-ray of the right hip and pelvis. The Incident Summary dated 07/10/24 documented that R6 was unattended and had gotten up out of her chair, and R6 was given a reacher (previous intervention) and shown how to use it so she could grab items out of her reach. And that the nursing staff would take the resident to the bathroom one hour after each meal. The CT-(x-ray technique of imaging creates detailed images) of pelvis, dated 07/13/24, reported an acute comminated (bone break into three or more pieces) fracture of the right ischium (part of the hip bone or over the hip bone area), and the base of the inferior pubic ramus. The Progress Note dated 08/28/24 at 04:44 PM documented R6 signed a contract stating the staff/facility was not responsible for any falls. R6 had been educated on using the call light when she needed assistance, using her walker, and wearing appropriate footwear, including gripper socks. R6 had voiced understood and was agreeable to this. (R6 had moderately impaired cognition). The chair alarm had been discontinued. The Progress Note dated 11/15/24 at 05:37 AM documented R6 was found on the floor in her room. R6 stated she tried going to the bathroom. R6 right forearm was bleeding and bruised, along with points on her hand. The Incident Summary dated 11/15/24 documented steri-stips (adhesive wound closures) placed on R6's forearm. The recommendation/action documented staff instructed that R6 was taken to the bathroom within one hour after meals. R6 was provided a reacher due to wanting to be self-sufficient. On 03/05/25 at 09:25 AM, R6 was in her room, standing at the dresser/TV stand, looking through the top drawer. The walker was parked next to the dresser. The call light was fastened to the left armrest of her recliner. On 03/05/25 at 09:30 AM, Certified Nurse Aide (CNA) M stated R6 does what she wants, and staff tries to catch her when she is up to be near her. CNA M reported R6 ate most of her meals in her room, but on occasion she will come out to see the birds in the activity room or walk up and down the halls. On 03/05/25 at 11:00 AM, Licensed Nurse (LN) G reported R6 was very stubborn and had poor safety awareness. LN G reviewed a document risk assessment that R6 had signed a release of responsibility form for injuries related to falls. On 03/05/25 at 01:20 PM, Administrative Nurse E verified R6 had signed a safety education and release of responsibility form when R6 had moderately impaired cognition. Administrative Nurse E reported that the charge nurses were responsible for new interventions to prevent further falls of residents with each fall. The facility's Safety and Supervision of Residents policy, dated 07/2017, documented that the facility strived to make the environment as free from accident hazards as possible. Resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. The individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices and monitoring the effectiveness of interventions. Resident supervision is a core component of the systems approach to safety. The facility failed to prevent R6's falls, which resulted in pelvic and finger fractures with ineffective repeated intervention. This placed the resident at risk for continued falls and injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 22 residents. The sample included 12 residents, with five residents reviewed for falls. Based on observation, record review, and interview, the facility failed to prevent Resident (R) 6 from falling and sustaining major injuries with ineffective interventions. This deficient practice placed R6 at risk for continued falls and injuries. Findings included: - The Electronic Medical Record (EMR) for R6 documented diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), hypertension (HTN - elevated blood pressure), chronic atrial fibrillation (rapid, irregular heartbeat), fracture (broken bone) of body of sternum (t-shaped bone of front chest), and other parts of the pelvis (bones between the lower abdomen and upper thighs that connect the spine to the legs). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R6 had moderately impaired cognition, and exhibited no behaviors. R6 had a functional range of motion impairment to both sides of the lower extremities and was dependent with toileting hygiene, and lower body dressing. R6 required partial/moderate assistance with personal hygiene and substantial/maximal assistance with rolling left and right, and transfers and walking wwerenot attempted. The MDS further documented R6 had one fall with major injury since the prior assessment. R6 also had two pressure injuries presenting as deep tissue injuries (DTI- purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) which were present on readmission to the facility. The Fall Care Area Assessment (CAA), dated 05/08/24, documented R6 fell on [DATE] in her room at 05:12 PM, was taken to the emergency room, and had a fractured pelvis. R6 returned on 04/19/24 to her room in long-term care, ordered to be on bed rest until further notice. The CAA further documented R6 had been independent in her room prior to the fall. The facility conducted another Significant Change MDS with a Fall CAA dated 08/01/24, which documented R6 had falls on 04/09/24, 06/28/24, and 07/10/24. The CAA further documented R6 fell on [DATE], and a new pelvic fracture was present. R6, now declining the restorative program, was noncompliant with staff assistance, had poor safety awareness, several interventions implemented for fall prevention, had moderately impaired cognition but R6 did not follow directions, and had fractures at the base of the third and fourth digit (fingers). R6's Fall Care Plan dated 02/14/25 documented that R6 was at high risk for falling and had an actual fall with major injury. The Care Plan documented R6 no longer wanted to be asked about restorative therapy. The interventions dated 09/30/24 were for physical therapy and R6 was independent in her room, she used a front-wheeled walker in the hallway. On 04/18/24, a grabber was provided. On 11/23/24, floor grip strips were placed on the floor in front of her recliner and R6 wanted to be more independent. Upon review of R6 falls revealed: The Progress Note dated 04/09/24 at 05:12 PM R6 was found in her room, lying on her right side on the floor, with a walker parked against the bathroom door. R6 complained of right hip pain and had a skin tear to the right elbow. R6 was sent to the emergency room. The Incident Summary dated 04/09/24 concluded R6 reached for an item from the floor when she fell. R6 had been admitted to the hospital for treatment. The recommendation made was to provide a reacher (a device used to help grab items from out of reach). The computerized Tomography Scan (CT-x-ray technique of imaging to create detailed images) of the pelvis report, dated 04/09/24, revealed moderately displaced fractures of the right superior and inferior pubic ramus (a break or crack in the pelvis bones). The Progress Note dated 06/28/24 at 04:06 AM documented R6 found lying on the right side with bleeding noted to the right ring and little fingers, R6 was barefooted and reported she was going to the bathroom. R6 was sent to the emergency room. The Incident Summary dated 06/28/24 documented R6 was sent to the emergency room and received one stitch in both fingers. The recommendation was to remind R6 to call for assistance when getting up and ambulating. On 07/02/24, an X-ray report revealed that the left hand had a nondisplaced fracture at the base of the fourth digit and a questionable non-displaced fracture at the base of the third digit. The Progress Notes dated 07/10/24 at 09:56 AM documented that R6 was heard yelling and found lying on the floor. The note reported R6 had got up on her own. The physician ordered an X-ray of the right hip and pelvis. The Incident Summary dated 07/10/24 documented that R6 was unattended and had gotten up out of her chair, and R6 was given a reacher (previous intervention) and shown how to use it so she could grab items out of her reach. And that the nursing staff would take the resident to the bathroom one hour after each meal. The CT (an X-ray technique of imaging creates detailed images) of the pelvis, dated 07/13/24, reported an acute comminated (bone break into three or more pieces) fracture of the right ischium (part of the hip bone or over the hip bone area), and the base of the inferior pubic ramus. The Progress Note dated 08/28/24 at 04:44 PM documented R6 signed a contract stating the staff/facility was not responsible for any falls. R6 had been educated on using the call light when she needed assistance, using her walker, and wearing appropriate footwear, including gripper socks. R6 had voiced understanding and was agreeable to this. (R6 had moderately impaired cognition). The chair alarm had been discontinued. The Progress Note dated 11/15/24 at 05:37 AM documented R6 was found on the floor in her room. R6 stated she tried going to the bathroom. R6 right forearm was bleeding and bruised, along with points on her hand. The Incident Summary dated 11/15/24 documented steri-stips (adhesive wound closures) placed on R6's forearm. The recommendation/action documented staff instructed that R6 was taken to the bathroom within one hour after meals. R6 was provided a reacher due to wanting to be self-sufficient. On 03/05/25 at 09:25 AM, R6 was in her room, standing at the dresser/TV stand, looking through the top drawer. The walker was parked next to the dresser. The call light was fastened to the left armrest of her recliner. On 03/05/25 at 09:30 AM, Certified Nurse Aide (CNA) M stated R6 does what she wants, staff tried to catch her when she was up to be near her. CNA M reported that R6 ate most of her meals in her room, but on occasion, she would come out to see the birds in the activity room or walk up and down the halls. On 03/05/25 at 11:00 AM, Licensed Nurse (LN) G reported that R6 was very stubborn and had poor safety awareness. LN G reviewed a document risk assessment that R6 had signed a release of responsibility form for injuries related to falls. On 03/05/25 at 01:20 PM, Administrative Nurse E verified that R6 had signed a safety education and release of responsibility form when R6 had moderately impaired cognition. Administrative Nurse E reported that the charge nurses were responsible for new interventions to prevent further falls of residents with each fall. The facility's Safety and Supervision of Residents policy, dated 07/2017, documented that the facility strived to make the environment as free from accident hazards as possible. Resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. The individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices and monitoring the effectiveness of interventions. Resident supervision is a core component of the system's approach to safety. The facility failed to prevent R6's falls, which resulted in pelvic and finger fractures with ineffective repeated intervention. This deficient practice placed the resident at risk for continued falls and injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 22 residents. The sample included 12 residents, of which five were reviewed for medication use. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 4's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication had an approved indication for use and that R13's as-needed (PRN) antianxiety (a class of medications that calm and relax people) medication had an end-of-use date. This placed the residents at risk of receiving unnecessary psychotropic (alters mood or thought) medication. Findings included: - R4's Electronic Medical Record (EMR) included diagnoses of insomnia (inability to sleep), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (HTN - elevated blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, hypothyroidism (a condition characterized by decreased activity of the thyroid gland), and personal history of urinary tract infections. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R4 had moderately impaired cognition, had verbal and physical behaviors directed at others and other behavioral symptoms that occurred one to three days of a seven day look back period and rejection of care behaviors that occurred four to six days of the seven day look back period. R4 required partial/moderate assistance with toileting hygiene, upper and lower body dressing, transfers, and ambulation. The MDS further documented R4 received scheduled pain medication, an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antianxiety (a class of medications that calm and relax people), an antidepressant (a class of medications used to treat mood disorders), and an opioid (medication used to treat severe pain). The antipsychotic had no gradual dose reduction (GDR) attempt or physician documentation as clinically contraindicated. R4's Care Plan, dated 12/11/24, documented R4 took a medication regime with potential and adverse side effects. The Care Plan directed staff to monitor for possible signs and symptoms of adverse drug reactions of each medication and review pharmacy recommendations. The Physician Order dated 04/18/24 directed staff to administer Aripiprazole (an antipsychotic) two milligrams (mg) mouth at bedtime for insomnia. The Physician Order dated 04/15/24 directed staff to administer Sertraline (an antidepressant) 25 mg by mouth in the morning related to depression. The Physician Order dated 09/09/24 directed staff to administer Alprazolam (and antianxiety) 0.5 mg by mouth at bedtime related to anxiety disorder. The Physician Order dated 11/26/24 directed staff to administer Norco 5-235 mg (an opioid) by mouth as needed every three hours for pain for three times a day related to pain. Review of the EMR and Consultant Pharmacist monthly review from 04/2024 to 02/2025 lacked documentation regarding the unapproved indication or risk versus benefit for the continued use of Aripiprazole for insomnia. On 03/04/25 at 11:45 AM, R4 was making her way into the dining room, sitting in a wheelchair. She was alert and pleasant with the staff. On 03/05/25 at 11:55 AM, Administrative Nurse E stated that R4's use of Aripiprazole for insomnia was not an approved indication of use. The consultant pharmacist had not notified the facility or the physician of the medication's continued use. The facility's Psychotropic Medication Use policy, dated 12/02/19, documented that the physician's order for psychotropic drugs will include both a qualifying diagnosis for drugs and a list of specific target behaviors that the staff will monitor during the drug administration. All physicians' orders for antipsychotic medications would be clear and accurate and should include a diagnosis, condition, or indication for use: and the consultant pharmacist will review the appropriateness of all medication orders for medications to be administered by clinical staff. The facility failed to ensure that R4 antipsychotic medication had an approved indication for use. This placed the resident at risk of receiving unnecessary psychotropic medication. - Resident (R) 13's Electronic Medical Record (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), altered mental status, Parkinson's (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness) disease, hypertension (HTN - elevated blood pressure), insomnia (inability to sleep), and heart failure. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R13 had severe cognitive impairment, inattention, disorganized thinking continuously, verbal behaviors directed toward others, and wandering which occurred one to three days of the look-back period. R13 required partial/moderate assistance with functional abilities and supervision or touch assistance with mobility. The MDS further documented R13 received scheduled pain medication, an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), a diuretic (a medication to promote the formation and excretion of urine), and an antiplatelet (medication to prevent blood cells from forming clots). R13's Care Plan, dated 01/28/25, documented that R13 was at risk for adverse reactions related to polypharmacy (regular use of multiple medications). The care plan directed staff to monitor for possible signs and symptoms of adverse drug reactions, request the physician to review and evaluate medications per their schedule, review pharmacy consultant recommendations, and follow up as indicated. The Physician Order dated 09/06/24 directed staff to administer Alprazolam 0.5 mg every eight hours as needed for anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition). The order lacked an end or stop date. Review of the EMR and Consultant Pharmacist monthly review from 03/2024 to 02/2025 lacked of documentation for the use of as needed Alprazolam. On 03/04/25 at 09:15 AM, R13 walked independently without her walker with a rolled blanket in her hand, repeating, Sleeping in the chair. The staff retrieved her walker and offered her toileting assistance in her room. On 03/05/25 at 11:05 AM, Administrative Nurse E stated that it was the responsibility of the charge nurse to obtain and place a stop day for PRN psychotropic medications. Administrative Nurse E reported that the consultant pharmacist should have recommended a stop date as well. The facility's Psychotropic Medication Use policy, dated 12/02/19, documented that the resident's need for psychotropic medication will be monitored, as well as when the resident has received optional benefits from the medication and when the medication dose could be lowered or discontinued. Both the physician and the nursing staff would evaluate the effectiveness of PRN orders for psychotropic drugs to manage behaviors. The facility failed to obtain a required stop date for R13 's PRN Alprazolam, which placed the resident at risk of receiving unnecessary psychotropic medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 22 residents. The sample included 12 residents, of which five were reviewed for medication use. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 4's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication had an approved indication for use and that R13's as-needed (PRN) antianxiety (a class of medications that calm and relax people) medication had an end-of-use date. This placed the residents at risk of receiving unnecessary psychotropic (alters mood or thought) medication. Findings included: - R4's Electronic Medical Record (EMR) included diagnoses of insomnia (inability to sleep), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (HTN - elevated blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, hypothyroidism (a condition characterized by decreased activity of the thyroid gland), and personal history of urinary tract infections. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R4 had moderately impaired cognition, had verbal and physical behaviors directed at others and other behavioral symptoms that occurred one to three days of a seven day look back period and rejection of care behaviors that occurred four to six days of the seven day look back period. R4 required partial/moderate assistance with toileting hygiene, upper and lower body dressing, transfers, and ambulation. The MDS further documented R4 received scheduled pain medication, an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antianxiety (a class of medications that calm and relax people), an antidepressant (a class of medications used to treat mood disorders), and an opioid (medication used to treat severe pain). The antipsychotic had no gradual dose reduction (GDR) attempt or physician documentation as clinically contraindicated. R4's Care Plan, dated 12/11/24, documented R4 took a medication regime with potential and adverse side effects. The Care Plan directed staff to monitor for possible signs and symptoms of adverse drug reactions of each medication and review pharmacy recommendations. The Physician Order dated 04/18/24 directed staff to administer Aripiprazole (an antipsychotic) two milligrams (mg) mouth at bedtime for insomnia. The Physician Order dated 04/15/24 directed staff to administer Sertraline (an antidepressant) 25 mg by mouth in the morning related to depression. The Physician Order dated 09/09/24 directed staff to administer Alprazolam (an antianxiety) 0.5 mg by mouth at bedtime related to anxiety disorder. The Physician Order dated 11/26/24 directed staff to administer Norco 5-235 mg (an opioid) by mouth as needed every three hours for pain for three times a day related to pain. Review of the EMR and Consultant Pharmacist monthly review from 04/2024 to 02/2025 lacked documentation regarding the unapproved indication or risk versus benefit for the continued use of Aripiprazole for insomnia. On 03/04/25 at 11:45 AM, R4 was making her way into the dining room, sitting in a wheelchair. She was alert and pleasant with the staff. On 03/05/25 at 11:55 AM, Administrative Nurse E stated that R4's use of Aripiprazole for insomnia was not an approved indication of use. The consultant pharmacist had not notified the facility or the physician of the medication's continued use. The facility's Psychotropic Medication Use policy, dated 12/02/19, documented that the physician's order for psychotropic drugs will include both a qualifying diagnosis for drugs and a list of specific target behaviors that the staff would monitor during the drug administration. All physicians' orders for antipsychotic medications should be clear and accurate and should include a diagnosis, condition, or indication for use: and the consultant pharmacist will review the appropriateness of all medication orders for medications to be administered by clinical staff. The facility failed to ensure that R4 antipsychotic medication had an approved indication for use. This placed the resident at risk of receiving unnecessary psychotropic medication. - Resident (R) 13's Electronic Medical Record (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), altered mental status, Parkinson's (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness) disease, hypertension (HTN - elevated blood pressure), insomnia (inability to sleep), and heart failure. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R13 had severe cognitive impairment, inattention, disorganized thinking continuously, verbal behaviors directed toward others, and wandering which occurred one to three days of the look-back period. R13 required partial/moderate assistance with functional abilities and supervision or touch assistance with mobility. The MDS further documented R13 received scheduled pain medication, an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), a diuretic (a medication to promote the formation and excretion of urine), and an antiplatelet (medication to prevent blood cells from forming clots). R13's Care Plan, dated 01/28/25, documented that R13 was at risk for adverse reactions related to polypharmacy (regular use of multiple medications). The care plan directed staff to monitor for possible signs and symptoms of adverse drug reactions, request the physician to review and evaluate medications per their schedule, review pharmacy consultant recommendations, and follow up as indicated. The Physician Order dated 09/06/24 directed staff to administer Alprazolam 0.5 mg every eight hours as needed for anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition). The order lacked an end or stop date. Review of the EMR and Consultant Pharmacist monthly review from 03/2024 to 02/2025 lacked documentation for the use of as needed Alprazolam. On 03/04/25 at 09:15 AM, R13 walked independently without her walker with a rolled blanket in her hand, repeating, Sleeping in the chair. The staff retrieved her walker and offered her toileting assistance in her room. On 03/05/25 at 11:05 AM, Administrative Nurse E stated the charge nurse was responsible for obtaining and placeing a stop day for PRN psychotropic medications. Administrative Nurse E reported that the consultant pharmacist should have recommended a stop date as well. The facility's Psychotropic Medication Use policy, dated 12/02/19, documented that the resident's need for psychotropic medication will be monitored, as well as when the resident has received optional benefits from the medication and when the medication dose could be lowered or discontinued. Both the physician and the nursing staff would evaluate the effectiveness of PRN orders for psychotropic drugs to manage behaviors. The facility failed to obtain a required stop date for R13 's PRN Alprazolam, which placed the resident at risk of receiving unnecessary psychotropic medication.

The facility had a census of 26 residents. Based on record review and interview, the facility failed to provide competent staff with the appropriate training, skills, and knowledge when two Certified Nurse Aides (CNA) administered medication to eight residents, Resident (R) 1, R2, R3,R4, R5, R6, R7, and R8, at the direction of Administrative Nurse D, because the licensed nurse on duty did not feel comfortable passing the medications. This placed the resident's at risk for medication errors and complications related to incompetent staff. Findings included: - The State Agency (SA) intake KS00184350 and KS00184390 reported on 11/25/23, the facility's Certified Medication Aide (CMA) called in due to the weather which left an agency Licensed Nurse (LN) to pass medication. The intakes alleged the Director of Nursing gave permission for two CNA on duty to assist the LN to pass medications to the residents and the administrations were documented under the LN name. On 12/05/23 at 09:11 AM, Administrative Nurse D stated there was a bad snow storm and a few of her staff called in, which included the Certified Medication Aide (CMA) that was to pass medication that evening. Administrative Nurse D further stated Licensed Nurse (LN) H, the nurse on duty, was not familiar with the residents in the facility and therefore did not feel comfortable passing the medications. Administrative Nurse D gave permission for LN H to pop the medication for the alert and oriented residents who did not need assistance, and permitted CNA M and CNA N to hand the medications to the resident. On 12/05/23 at 09:25 AM, CNA M stated LN H popped the medication for the alert and oriented residents into a cup that had the resident's name and room number. CNA M said she handed the cup of the pills to the resident to take. CNA M further stated the facility had never asked her to do that before. The facility's Administering Medications policy, dated 11/30/20, documented only persons licensed or permitted in this State to prepare, administer, and document the administration of medications may do so. New personnel authorized to administer medication would not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility. The Director of Nursing Services would supervise and direct all nursing personnel who administer mediations and/or have related functions. The facility failed to provide competent staff who possessed the appropriate training, skills, and knowledge to administer medications. This placed the resident's at risk for medication errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 25 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to review and revise Resident (R) 3's plan of care to include collaboration of care with the hospice (specialized care related to end of life) service and failed to include R16's use of antipsychotic (medication used to treat psychosis-any major mental disorder characterized by a gross impairment in reality testing) medication. The deficient practice placed R3 and R16 at risk for unmet care needs. Findings included: - R3's Electronic Medical Record (EMR) recorded diagnoses of collapsed vertebra lumbar (lower back) and thoracic (mid back) region, chronic kidney disease, chronic pain, adult failure to thrive, fracture of right pubis (pelvic area). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R3 had moderately impaired cognition, had no signs or symptoms of psychosis, delirium (sudden severe confusion, disorientation and restlessness), or exhibited behaviors. R3 was independent with activities of daily living (ADL) except for bathing which required extensive assistance of one staff. R3 was not steady but able to stabilize without staff assistance. The MDS further documented use of scheduled pain medication regimen. R3 had pain frequently which limited day to day activities, and significant weight loss. The ADL Care Area Assessment (CAA), dated 03/23/23, documented R3 had been independent with ADLs. R3 was recently placed on hospice for pain management. The Care Plan date 04/14/23, documented R3 was now on hospice cares. The care plan directed staff to educate resident on the importance of frequent position changes, use of non-skid socks per hospice nurse, administer medications as directed by the physician and hospice team. The care plan recorded the hospice nurse and care aide would be there per hospice policy, and diretced staff to involve the resident in care and decision making to maximum potential. The care plan lacked hospice provider information, disciplines making visits/providing specific cares and supplies provided by hospice. The Progress Note dated 03/17/23 at 02:33 PM documented a meeting with hospice services, durable power of attorney (DPOA) and facility staff in which the DPOA wished to utilize hospice services. The DPOA expressed explicit wishes not to utilize the term hospice to preserve resident's mental health as R3 would feel as though she was being given up on. On 05/10/23 at 02:02 PM, observation revealed hospice staff in R3's room. R3 was independently mobile in her wheelchair looking for the next activity planned to attend. Staff informed R3 bingo was scheduled at 02:30 PM. On 05/11/23 at 01:09 PM, Administrative E stated R3 had a hospice care plan, but said it lacked collaboration of services in which the facility and hospice would be responsible for cares of R3. The facility's Care Plan Revision policy, dated 10/05/18, documented the care planning process included goal setting, interventions, referrals to other health care professionals, evaluations, referrals to other health care professionals, evaluation or resident response to treatment and revision of care and treatment in order to meet the resident's needs. Changes in a resident's condition always require changes to be made in the plan of care either by change in individual approaches or by the addition of new problems to the care revisions to the care plan will be the responsibility of a Licensed Nurse in collaboration with the resident, the representative/family, direct care staff and the entire interdisciplinary team and changes will be communicated to all staff. The facility failed to care plan collaboration of hospice care and facility responsibilities on the care plan for R3 which placed the resident at risk for unmet care needs. - R16's Electronic Medical Record (EMR) recorded diagnoses of major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), dementia (progressive mental disorder characterized by failing memory, confusion )without behavioral, psychotic (any major mental disorder characterized by a gross impairment in reality testing), and mood disturbance, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), personal history of traumatic brain injury, and legal blindness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R16 had intact cognition, had no indicators of psychosis and delirium, and no behaviors exhibited. The MDS further documented R16 was independent with activity of daily living (ADL), and had non-Alzheimer's dementia. The Cognitive Loss/Dementia Care Area Assessment (CAA), date 10/28/22, documented R16 was alert and oriented to person, place and usually time, made her own decisions and was usually consistent. The CAA further documented R16 had a diagnosis of dementia, depression, and had short term memory loss. The Care Plan dated 04/12/23, documented R16 had diagnosis of psychosis, had behavioral symptoms toward others with paranoia concerning her belongings and a history of traumatic brain injury with potential for anxious mood. The care plan directed staff to medications as physician ordered, reinforce and focus on reality, allow resident to discuss anger towards the staff with caregiving issues of her belongings, and to convey an attitude of acceptance to the resident. The care plan further directed staff to maintain a calm understandable environment and approach and wanted to visit with the social service designee when upset. The care plan lacked direction related to the use of antipsychotic medications with monitoring the side effects and targeted behaviors. The Physician Order, dated 04/11/23, directed staff to administer Seroquel (an antipsychotic medication) 25 milligrams (mg) every day for unspecified psychosis not due to a substance or known physiological condition. The order lacked side effect and target behavior monitoring. The Physician Order dated 05/12/23 directed staff to administer an additional Seroquel 50 mg at bedtime. The orders then included monitoring for side effects and targeted behaviors. The Progress Note by the prescribing health care provider, dated 04/11/23 at 02:23 PM, documented R16 packed her things and reported the she was ready to leave due to voices telling her to do so. Further investigation revealed that for some time R16 had also heard family members argue out in the hallway when no family members present and verified, she had heard voices for years. The note included initiation of Seroquel to curb the voices and allow R16 to get a better nights sleep. The Progress Note date05/09/23 at 02:35 PM documented R16 came to the activity room and handed staff all her activity bucks and stated she did not need them anymore because she was moving out and going home. Later, staff went to R16's room and noticed she had all of her things in a bag. On 05/09/23 at 03:26 PM observation revealed R16 in the activity room playing cards with staff and other residents. Upon finishing the activity R16 independently left the activity room and returned to her room. Further observation revealed R16 had belongings packed into large blue plastic bags. On 05/11/23 at 01:11 PM, Administrative Nurse E stated the side effects and target behaviors for psychotropic medications should be added to the physician orders so they would be transferred to the electronic medication and treatment record. Administrative Nurse E verified this was not done, nor was the care plan updated to include the antipsychotic use to the care plan from the 04/11/23 physician ordered Seroquel. The facility's Care Plan Revision policy, dated 10/05/18, documented the care planning process included goal setting, interventions, referrals to other health care professionals, evaluations, referrals to other health care professionals, evaluation or resident response to treatment and revision of care and treatment in order to meet the resident's needs. Changes in a resident's condition always require changes to be made in the plan of care either by change in individual approaches or by the addition of new problems to the care revisions to the care plan will be the responsibility of a Licensed Nurse in collaboration with the resident, the representative/family, direct care staff and the entire interdisciplinary team and changes will be communicated to all staff. The facility failed to update R16's care plan when an antipsychotic medication was implemented which placed the resident at risk for unmet care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 25 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 16 the appropriate treatment and services to attain highest practicable mental and psychosocial (interrelation of social factors and individual thought and behavior) well-being, when staff failed to provide R16 with behavioral health services. This placed the resident at risk for unmet behavioral health care needs. Findings included: - R16's Electronic Medical Record (EMR) recorded diagnoses of major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), dementia (progressive mental disorder characterized by failing memory, confusion )without behavioral, psychotic (any major mental disorder characterized by a gross impairment in reality testing), and mood disturbance, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), personal history of traumatic brain injury, and legal blindness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R16 had intact cognition, had no indicators of psychosis and delirium (sudden severe confusion, disorientation and restlessness), and no behaviors exhibited. The MDS further documented R16 was independent with activity of daily living (ADL), and had non-Alzheimer's dementia. The Cognitive Loss/Dementia Care Area Assessment (CAA), date 10/28/22, documented R16 was alert and oriented to person, place and usually time, made her own decisions and was usually consistent. The CAA further documented R16 had a diagnosis of dementia, depression, and had short term memory loss. The Care Plan dated 04/12/23, documented R16 had diagnosis of psychosis, had behavioral symptoms toward others with paranoia concerning her belongings and a history of traumatic brain injury with potential for anxious mood. The care plan directed staff to medications as physician ordered, reinforce and focus on reality, allow resident to discuss anger towards the staff with caregiving issues of her belongings, and to convey an attitude of acceptance to the resident. The care plan further directed staff to maintain a calm understandable environment and approach and wanted to visit with the social service designee when upset. The Physician Order dated 04/11/23 directed staff to administer Seroquel (an antipsychotic medication) 25 milligrams (mg) every day for unspecified psychosis not due to a substance or known physiological condition. The order lacked side effect and target behavior monitoring. The Physician Order dated 05/12/23 directed staff to administer an additional Seroquel 50 mg at bedtime. The orders then included monitoring for side effects and targeted behaviors. The Progress Note by prescribing health care provider, dated 04/11/23 at 02:23 PM, documented R16 packed her things and reported the she was ready to leave due to voices telling her to do so. Further investigation revealed that for some time R16 had also heard family members argue out in the hallway when no family members present and verified, she had heard voices for years. The note included initiation of Seroquel to curb the voices and allow her to get better night's sleep. The Progress Note, date05/09/23 at 02:35 PM, documented R16 came to the activity room and handed staff all her activity bucks and stated she did not need them anymore because she was moving out and going home. Later, staff went to R16's room and noticed she had all of her things in a bag. R16's clinical record lacked evidence the resident was offered or provided psychological health services to address her diagnoses and behaviors. On 05/09/23 at 03:26 PM observation revealed R16 in the activity room playing cards with staff and other residents. Upon finishing the activity R16 independently left the activity room and returned to her room. Further observation revealed R16 had belongings packed into large blue plastic bags. On 05/15/23 at 12:19 PM Social Service Designee (SSD) X reported she tracked behaviors for residents and had done some one on one visits with R16 and documented the visits in the progress notes. SSD X reported she visited R16 when the resident was upset about something and visits where not routine. SSD X stated R16 had not been seen by psychological health care providers. On 05/15/23 at 12:42 PM Administrative Nurse D reported mental health consulting came to the facility on a monthly basis but confirmed R16 had not received mental health consultation prior to or after the initiation of an antipsychotic medication. Administrative Nurse D reported the resident had not been referred to mental health care. Administrative Nurse D said R16 may have refused, but said the facility did not have documentation of a refusal. The facility's Psychotropic Medication policy, dated 02/2019, documented per Centers for Medicare and Medicaid Services (CMS) regulations state that each resident's drug regimen must be free from unnecessary drugs and define what is considered and unnecessary drug. In addition, CMS regulations state that residents who have not previously used anti-psychotic drugs should not the given these drugs unless anti-psychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record. The resident's need for the psychotropic medication will be monitored as well as when the resident has received optional benefits from the medication and when the medication cam be lowered or discontinued. Both the physician and the nursing staff will evaluate the effectiveness of prn orders for psychotropic drug to manage behavior. Non-Pharmacologic Alternatives: use of alternative non-pharmacologic interventions for psychiatric disorders and problem behaviors related to dementia will be attempted prior to and during administration of antipsychotic medications including but not exclusive to: try interesting the resident in something else (redirecting) based on the resident's past routines and preferences, provide intensive one to one direct care, allow the resident to have time alone, understand that all behaviors is a form of communication of an unmet need of the resident, Talk to the resident about what is bothering them (emotional support), leave the resident and return at a later time (re-approaching), get the family involved in resident's day to day life at the facility, provide a consistent staff person to care for the same resident in order to establish an ongoing relationship between the two. The facility failed to provide R16 the appropriate treatment to attain the highest practicable mental, services to attain highest practicable mental and psychosocial well-being for the resident which placed R16 at risk for unmet behavioral health care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 25 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R) 1's physician-ordered medication regimen lacked indications for use. This placed the resident risk of unnecessary or ineffective medication therapy. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of chronic pain, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), heart failure, diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord), encounter for attention to gastrostomy (surgical creation of an artificial opening into the stomach thru the abdominal wall) and colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body), and personal history of urinary tract infections. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had modified independence with decision making, inattention, and disorganized thinking which fluctuated, no indicators of psychosis or behaviors. R1 was totally dependent with one to two staff for activities of daily living (ADLs). The MDS further documented R1 received scheduled pain medication, insulin (medication used to treat blood sugar), and antidepressant (medication used to treat depression). The Medication Care Plan, dated 04/06/23, documented R1 had medication regimen with potential reactions and adverse side effects. Upon review of the EMR of physician prescribed medications the following medications lacked an indication for use: Acidophilus (probiotic) capsule by mouth twice a day. Order dated 09/12/22. Adult Multivitamin (multivitamin-) tablet; 18 milligrams (mg) iron-400 micrograms (mcg)-25mcg: one tablet a day. No order date. Aspirin (pain reliver and blood thinner) 81 mg chewable tablet once a day. Order date 02/17/23. Claritin (allergy medication) 10 mg tablet once a day. Order date 09/12/22. Calcium 600 mg with Vitamin D3 600 mg-10mcg (400 units) chewable tablet once a day. Order date 09/12/22. Miralax (laxative) powder 17 grams/dose, one capful daily. Order date 10/18/22. Potassium chloride 10 milli-equivalent (meq) extended release capsule, two capsules two times a day. Order date 02/17/23. Albuterol sulfate solution (medication used to treat cough or obstructive airway disease) for nebulizer 2.5 mg/ 3 ml (0.083%) by inhalation three times a day. Order date 12/21/22. Upon review of the monthly Consultant Pharmacy report, the pharmacist did not identify and report the medications listed above lacked an indication for use. On 05/09/23 at 03:30 PM R1 laid in bed on her left side facing the wall. On 05/11/23 at 01:11 PM, Administrative Nurse E reported she was aware of some of R1's medication were without diagnoses and said it was the charge nurses who should be entering the diagnosis with the physician orders. Administrative Nurse E stated the medical records department did not want diagnoses entered if the resident did not already have the diagnoses. The facility's Pharmaceutical Review Per Interdisciplinary Team, policy dated 01/2020, documented to provide pharmaceutical care with outcome management, quality assurance, drug utilization review, incident review, unnecessary drug review and indications for pharmaceutical orders. To maintain the residents highest mental, physical, and psychosocial well-being. Procedure include but not limited to resident chart reviews: check medication for diagnosis and indication. The facility failed to ensure the Consultant Pharmacist identified and reported the lack an indication for use on R1's medications which placed the resident at risk for ineffective medication therapy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 25 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 1's physician-ordered medications included an indication for use. This placed the resident risk of unnecessary or ineffective medication therapy. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of chronic pain, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), heart failure, diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord), encounter for attention to gastrostomy (surgical creation of an artificial opening into the stomach thru the abdominal wall) and colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body), and personal history of urinary tract infections. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had modified independence with decision making, inattention, and disorganized thinking which fluctuated, no indicators of psychosis or behaviors. R1 was totally dependent with one to two staff for activities of daily living (ADLs). The MDS further documented R1 received scheduled pain medication, insulin (medication used to treat blood sugar), and antidepressant (medication used to treat depression). The Medication Care Plan, dated 04/06/23, documented R1 had medication regimen with potential reactions and adverse side effects. Upon review of the EMR of physician prescribed medications the following medications lacked an indication for use: Acidophilus (probiotic) capsule by mouth twice a day. Order dated 09/12/22. Adult Multivitamin (multivitamin-) tablet; 18 milligrams (mg) iron-400 micrograms (mcg)-25mcg: one tablet a day. No order date. Aspirin (pain reliver and blood thinner) 81 mg chewable tablet once a day. Order date 02/17/23. Claritin (allergy medication) 10 mg tablet once a day. Order date 09/12/22. Calcium 600 mg with Vitamin D3 600 mg-10mcg (400 units) chewable tablet once a day. Order date 09/12/22. Miralax (laxative) powder 17 grams/dose, one capful daily. Order date 10/18/22. Potassium chloride 10 milli-equivalent (meq) extended release capsule, two capsules two times a day. Order date 02/17/23. Albuterol sulfate solution (medication used to treat cough or obstructive airway disease) for nebulizer 2.5 mg/ 3 ml (0.083%) by inhalation three times a day. Order date 12/21/22. On 05/09/23 at 03:30 PM R1 laid in bed on her left side facing the wall. On 05/11/23 at 01:11 PM, Administrative Nurse E reported she was aware of some of R1's medication were without diagnoses and said it was the charge nurses who should be entering the diagnosis with the physician orders. Administrative Nurse E stated the medical records department did not want diagnoses entered if the resident did not already have the diagnoses. The facility's Pharmaceutical Review Per Interdisciplinary Team, policy dated 01/2020, documented to provide pharmaceutical care with outcome management, quality assurance, drug utilization review, incident review, unnecessary drug review and indications for pharmaceutical orders. To maintain the residents highest mental, physical, and psychosocial well-being. Procedure include but not limited to resident chart reviews: check medication for diagnosis and indication. The facility failed to ensure R1's physician-ordered medications included an indication for use. This placed the resident risk of unnecessary or ineffective medication therapy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 25 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to label two insulin (hormone that lowers the level of glucose in the blood) vials with an open date and an expiration date. This deficient practice placed Residents (R) 1 and R20 at risk to receive expired insulin. Findings included: - On [DATE] at 09:08 AM, observation of the facility's medication room revealed two opened, undated insulin vials; a Novolin R (fast acting insulin) vial for R20, and a Humulin R (fast acting insulin) vial for R1. On [DATE] at 09:08 AM, Licensed Nurse (LN) G verified staff should have dated the insulin vial when it was opened. [DATE] at 01:10 PM, Administrative Nurse D verified staff were to date insulin vials when opened. The facility's Insulin Storage policy, dated [DATE], stated opened insulin vial or flex pens would be checked every morning shift for resident identification label, date, time and initials of when opened and expiration date labeled. The facility failed to label two insulin vials with an open date and an expiration date, placing R1 and R20 at risk to receive expired and/or ineffective insulin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 25. The sample included 12 residents with five reviewed for medications. Based on observation, interview, and record review, the facility failed to implement antibiotic use protocols to avoid unnecessary and/or inappropriate antibiotic use to reduce the risk of adverse events, including antibiotic resistance, when the facility failed to monitor effectiveness and identify inappropriate extended administration of antibiotic eyedrops for Resident (R) 1. This placed the resident at risk for complications related to antibiotic use. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of chronic pain, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), heart failure, diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord), encounter for attention to gastrostomy (surgical creation of an artificial opening into the stomach thru the abdominal wall) and colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body), and personal history of urinary tract infections. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had modified independence with decision making, inattention, and disorganized thinking which fluctuated, no indicators of psychosis or behaviors. R1 was totally dependent with one to two staff for activities of daily living (ADLs), and had function range of motion impairment of upper and lower extremities. The MDS further documented R1 received scheduled pain medication, insulin (medication used to treat blood sugar), and an antidepressant (medication used to treat depression). The Physician Order dated 05/05/23, directed staff to administer Ciprofloxacin (Cipro-antibiotic) HCL 0.3 percent (%) one drop: ophthalmic (eye) three times a day. The order did not specify the diagnosis for use, or which eye/ eyes to be treated, and lacked a stop date. The Progress Note dated 05/05/23 at 05:12 PM, documented R1's eyes were watering and puffy. R1 stated that they were not bothering her. R1 had a small amount of green drainage. Staff spoke with R1's provider and received an order for Cipro eye drops three times a day for five days and an order to obtain a culture. On 05/10/23 at 01:12 PM, observation revealed R1 in the therapy room with staff preforming range of motion on R1 lower extremities. Once finished, staff brought R1 to the activity room to watch the birds. On 05/11/23 at 12:02 PM Certified Medication Aide (CMA)R reported administering R1's eye drops to both eyes. CMA R stated the diagnosis was usually on the electronic medication administration record (EMAR) and verified the EMAR lacked a diagnosis or stop date. On 05/15/23 at 10:13 AM, Licensed Nurse (LN)H verified R1's EMAR lacked instructions related to site of administration (right, left or both eyes) for the use of Cipro and the stop date. LN H stated the nurse who initiated the order should have included the information. On 05/15/23 at 12:47 PM, Administrative Nurse D reported the facility had obtained a culture of R1's eye drainage, but confirmed the antibiotic order lacked specific directions to which or both eyes and the EMAR lacked a stop date. The facility's undated Antibiotic Stewardship Program documented the Antibiotic Stewardship will ensure that every/patient/resident got an antibiotic only when one is needed, with the right agent, at the right dose and for the right duration. The facility failed to implement antibiotic use protocols to avoid unnecessary and/or inappropriate antibiotic use to reduce the risk for adverse events, including antibiotic resistance, when the facility failed to monitor effectiveness and identify inappropriate extended administration of antibiotic eyedrops for R1, which placed the resident at risk for complications related to antibiotic use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 15 residents. The sample included eight residents, with three reviewed for accidents. Based on observations, record review, and interview, the facility failed to revise one of eight care plans, Resident (R) 4. Findings included: - R4's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition and required limited assistance of one staff for bed mobility, toileting and extensive assistance of one staff for dressing. The MDS documented the resident had upper functional impairment on both sides and had no skin issues. The Skin Care Plan, dated 05/12/21, directed staff to complete weekly skin assessments and to inform the nurse of any new skin breakdown. The care plan lacked documentation of interventions to prevent bruises for the resident. The Bath Sheet, dated 09/11/21, lacked documentation the resident had any skin issues. Review of R4's nurse's notes for the period of 09/01/21 to 09/13/21 lacked documentation of any bruises on the resident. On 09/13/21 at 10:25 AM, observation revealed a purple bruise on the resident's left forearm and on top of the resident's left hand. On 09/14/21 at 01:30 PM, Certified Nurse Aide (CNA) M stated she was unaware of the bruises on the resident and stated when the resident had skin issues, she told the nurse. On 09/15/21 at 10:00 AM, Licensed Nurse (LN) G stated she was not aware the resident had any bruises and would have completed an incident report and notified the physician and family. On 09/15/21 at 10:15 AM, LN G stated she interviewed the resident who stated she had probably gotten them flinging her arms around and hitting it on something. On 09/15/21 at 10:30 AM, Administrative Nurse E stated the resident had a history of flinging her arms around and getting bruises and verified the resident's medical record lacked documentation regarding the bruises or interventions to prevent bruises in the care plan. On 09/15/21 at 10:35 AM, Administrative Nurse D verified interventions to prevent bruises should be on the care plan. The facility's Care Plan Revision policy, dated 10/05/18, documented any change in the problems, goals, specific interventions, or reasonable time frames of goals will be revised on the resident's plan of care. Revisions to the care plan would be the responsibility of a licensed nurse in collaboration with the resident, the representatives, direct care staff, and the entire interdisciplinary team and changes communicated with all staff, all shifts. The facility failed to identify and implement interventions to prevent bruising for R4, who had a history of bruising, placing the resident at risk for future injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 15 residents. The sample included eight residents, with three reviewed for accidents. Based on observation, record review, and interview, the facility failed to prevent accidents for one of three sampled residents, Resident (R) 4, who had bruises on her left forearm and hand. Findings included: - R4's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition and required limited assistance of one staff for bed mobility, toileting and extensive assistance of one staff for dressing. The MDS documented the resident had upper functional impairment on both sides and had no skin issues. The Skin Care Plan, dated 05/12/21, directed staff to complete weekly skin assessments and to inform the nurse of any new skin breakdown. The care plan lacked documentation of interventions to prevent bruises for the resident. The Bath Sheet, dated 09/11/21, lacked documentation the resident had any skin issues. Review of R4's nurse's notes for the period of 09/01/21 to 09/13/21 lacked documentation of any bruises on the resident. On 09/13/21 at 10:25 AM, observation revealed a purple bruise on the resident's left forearm and on top of the resident's left hand. On 09/14/21 at 01:30 PM, Certified Nurse Aide (CNA) M stated she was unaware of the bruises on the resident and stated when the resident had skin issues, she told the nurse. On 09/15/21 at 10:00 AM, Licensed Nurse (LN) G stated she was not aware the resident had any bruises and would have completed an incident report and notified the physician and family. On 09/15/21 at 10:15 AM, LN G stated she interviewed the resident who stated she had probably gotten them flinging her arms around and hitting it on something. On 09/15/21 at 10:30 AM, Administrative Nurse E stated the resident had a history of flinging her arms around and getting bruises and verified the resident's medical record lacked documentation regarding the bruises or interventions to prevent bruises in the care plan. On 09/15/21 at 10:35 AM, Administrative Nurse D verified staff had not notified the nurse of the resident's bruises and lack of documentation in the medical record. The facility's Skin Integrity, policy, dated 07/23/19, documented the nurse would conduct a full body skin assessment for each resident weekly to ensure no areas of concern have developed and each nurse aide would examine the resident's total body skin with each bathing experience and would report any abnormalities to the nurse using the bathing sheet. The facility failed to prevent bruises for R4, who had a history of bruising easily, placing the resident at risk for further injuries.