**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 29 residents, with 13 residents sampled, including five residents reviewed for unnecessary medications. Based on interview, record review, and observation, the facility failed to follow physician's orders for one of the five sampled residents, Resident (R)20, regarding blood pressure (BP-the amount of force your blood uses to get through your arteries) parameters for this resident on anti-hypertensive (medication used to help control BP) medication. Findings included: - Review of Resident (R)20's electronic medical record (EMR) revealed a diagnosis of hypertension (HTN--elevated blood pressure BP). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severely impaired cognition and he had a diagnosis of HTN. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 02/16/24, did not trigger. The Quarterly MDS, dated 01/10/24, documented the staff assessment for cognition revealed severely impaired cognition and he had a diagnosis of HTN. The care plan for HTN, revised 04/01/24, instructed staff the resident received amlodipine (a HTN medication used to lower BP) 5 milligrams (mg), every day (QD). Staff were to hold the medication if the resident's systolic BP (SBP--the pressure of the blood as it pushes against the artery walls when the heart beats.) was less than 110, if the diastolic BP (DBP--the pressure your blood is pushing against your artery walls when the heart beats) was less than 40 or if the resident's pulse (the rhythmical throbbing of the arteries as blood was propelled through them) was less than 40 beats per minute. Review of the resident's EMR revealed the following physician's order: Amlodipine 5 mg, QD for HTN. Hold if the SBP was less than 110, the DBP was less than 40 or if the pulse was less than 40, ordered 12/12/23. Review of the resident's EMR, from 12/12/23 through 05/17/24, revealed the staff failed to obtain a BP before the administration of the medication from 12/12/23 through 05/07/24. From 05/08/24 through 05/20/24, the facility administered the medication to the resident when his BP was outside of the parameters on one occasion. On 05/20/24 at 09:58 AM, Licensed Nurse (LN) H confirmed staff had not obtained BP's before the administration of the amlodipine, as they should. On 05/20/24 at 12:59 PM, Administrative Nurse D stated she would look into the BP's not being taken before the administration of the amlodipine for this resident. The facility policy for Hypertension-Clinical Protocol/Guidelines, effective 04/2023, included: The nursing staff will assess and document vital signs (VS) to the physician, as needed. The facility failed to monitor this dependent residents BP before administering anti-hypertensive medication, as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 29 residents with 13 residents sampled, which included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the consultant pharmacist identified and reported the facility's staff failure to obtain blood pressures (BP-the amount of force your blood uses to get through your arteries) for one Resident (R)20 prior to administering his anti-hypertensive medication (medication used to help control BP), as ordered. Findings included: - Review of Resident (R)20's electronic medical record (EMR) revealed a diagnosis of hypertension (HTN--elevated blood pressure BP). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severely impaired cognition and he had a diagnosis of HTN. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 02/16/24, did not trigger. The Quarterly MDS, dated 01/10/24, documented the staff assessment for cognition revealed severely impaired cognition and he had a diagnosis of HTN. The care plan for HTN, revised 04/01/24, instructed staff the resident received amlodipine (a HTN medication used to lower BP) 5 milligrams (mg), every day (QD). Staff were to hold the medication if the resident's systolic BP (SBP--the pressure of the blood as it pushes against the artery walls when the heart beats.) was less than 110, if the diastolic BP (DBP--the pressure your blood is pushing against your artery walls when the heart beats) was less than 40 or if the resident's pulse (the rhythmical throbbing of the arteries as blood was propelled through them) was less than 40 beats per minute. Review of the resident's EMR revealed the following physician's order: Amlodipine 5 mg, QD for HTN. Hold if the SBP was less than 110, the DBP was less than 40 or if the pulse was less than 40, ordered 12/12/23. Review of the resident's EMR, from 12/12/23 through 05/17/24, revealed the staff failed to obtain a BP before the administration of the medication from 12/12/23 through 05/07/24. From 05/08/24 through 05/20/24, the facility administered the medication to the resident when his BP was outside of the parameters on one occasion. On 05/20/24 at 09:58 AM, Licensed Nurse (LN) H confirmed staff had not obtained BP's before the administration of the amlodipine, as they should. On 05/20/24 at 12:59 PM, Administrative Nurse D stated she would look into the BP's not being taken before the administration of the amlodipine for this resident. Administrative Nurse D stated she was responsible for receiving and monitoring the pharmacy consultant recommendations. The pharmacist was not available for an interview. The facility lacked a policy regarding pharmacy consultant responsibilities. The facility failed to monitor this dependent residents BP before administering anti-hypertensive medication, as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 29 residents with 13 residents selected for review, which included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure nursing staff followed antibiotic stewardship for one of the five residents, Resident (R) 28, with a urinary tract infection with a microorganism resistant to the prescribed antibiotic. Findings included: - Review of Resident (R)28's electronic medical record revealed diagnoses that included diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), congestive heart failure (a condition with low heart output and the body becomes congested with fluid) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status Score (BIMS) of 15, which indicated normal cognitive function. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 01/08/24, assessed the resident required partial to moderate assistance for ADLs. The Care Plan reviewed 04/16/24, instructed staff the resident received multiple medications and instructed staff to review the medications with the physician for proper dosing, timing and frequency and supporting diagnosis. A Nurse Note, dated 05/06/24, revealed the R 28 stated she had pain and thought she had a urinary tract infection and wanted a urinalysis (laboratory test to assess urine for infection). On 05/06/24, the physician instructed staff to obtain a urinalysis, culture, and sensitivity for possible urinary tract infection. Review of the Culture Report dated 05/08/24, indicated R28's urine contained greater than 100,000 colonies of the bacteria Escherichia coli, and was resistant (ineffective to the effects) to ciprofloxacin (Cipro). On 05/08/24, a Nurses' note indicated the culture results were reviewed by the physician and the physician instructed staff to administer Cipro (an antibiotic) 500 milligrams, twice a day, for seven days. Review of the Medication Administration Record (MAR) revealed the resident received Cipro from 05/08/24 through 05/14/24 for 14 doses. Review of the Culture Report dated 05/15/24, revealed R28's urine contained greater than 100,000 colonies of the bacteria Escherichia coli and was sensitive to ceftriaxone (an antibiotic that was effective in eliminating the bacteria). On 05/15/24, the physician instructed staff to administer ceftriaxone, one gram, intramuscularly (injected into the muscle), daily, for three days. Interview, on 05/16/24 at 11:51 AM with Licensed Nurse G, revealed the resident had chronic urinary tract infections. Interview, on 05/20/24 at 02:45 PM with Administrative Nurse D, revealed she would expect the nursing staff to review the culture report and inform the physician of the resistive property of the Cipro. Administrative Nurse D stated the urine continued to show greater than 100,000 colonies of Escherichia coli in the repeat culture, which was sensitive to the prescribed antibiotic, ceftriaxone. The facility policy for Infection Control Area for Review undated, instructed staff to provide an Antibiotic Stewardship Program with protocols and monitoring. The facility failed to provide effective antibiotic stewardship for R28, who received an antibiotic that was ineffective for the microorganism that caused the urinary tract infection, which resulted in subsequent antibiotic treatment that was effective for the organism identified.

The facility reported a census of 29 residents. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS), complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e., Payroll Base Journal [PBJ]), related to licensed nursing coverage 24 hours/day. Findings included: - Review of the Payroll Base Journal (PBJ) Staffing Data Report for the second quarter of fiscal year (FY) 2023 (01/01/23 through 03/31/23), documented the facility lacked Licensed Nursing Coverage 24 hours/day on Sunday (SU) 01/01/2023, Saturday (SA) 01/07/2023, (SA) 01/15/23, (SU) 01/21/23, (SA) 01/29/23, (SU) 02/05/23 (SU), (SA) 02/11/23, (SA) 03/11/23, (SU) 03/12/23, (SA) 03/18, (SA) 03/25/23, and (SU) 03/26/23. Review of the facility's time sheets for licensed nursing staff and Staff Posting on the above dates, revealed the facility with RN coverage for eight consecutive hours each of those days. The facility reported inaccurate staffing data as noted above. Review of the Payroll Base Journal (PBJ) Staffing Data Report for the third quarter of fiscal year (FY) 2023 (04/01/23 through 06/30/23), documented the facility lacked Licensed Nursing Coverage 24 hours/day on (SA) 04/08/23 (SU) 04/16/23, (SA) 04/29/23, (SA) 05/06/23, (SA) 05/13/23, (SA) 05/20 /23,(SU) 05/28/23, Monday (MO) 05/29/23, (SU) 06/04/23, (SA) 6/10/23, (SU) 06/11/23, (SA) 06/17/23, and (SU) 06/18/23. Review of the facility's time sheets for licensed nursing staff and Staff Posting on the above dates, revealed the facility with RN coverage for eight consecutive hours each of those days, 24/7 licensed nursing staff, and/or required weekend staffing. The facility reported inaccurate staffing data as noted above. On 05/20/24 10:30 AM, Administrative Staff A and Administrative Staff B confirmed the facility PBJ reporting to CMS lacked accurate data to reflect direct care provided by administrative nursing staff (RN) and licensed nurse (LN) staffing due to the removal of 30-minute meal break when licensed nurse and/or RN remained on site. Administrative Staff A and Administrative Staff B confirmed the facility had 24-hours of a LN on duty each day, RN coverage for 8 consecutive hours each day, and consistent weekend staffing. The PBJ staffing report did not reflect the facility's actual coverage as noted above. The facility lacked a policy to address the submission of accurate PBJ staffing report to CMS. The facility failed to electronically submit to Centers for Medicare and Medicaid Services, (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e., Payroll Base Journal [PBJ]), related to licensed nursing coverage 24 hours/day.

The facility reported a census of 29 residents. Based on observation, interview, and record review, the facility failed to ensure staff distributed ice to residents in a sanitary manner, failed to sanitize glucometers with appropriate sanitizing agent and failed to ensure staff administered medications in a sanitary manner to prevent the spread of infections amongst the residents. Findings included: - Observation, on 05/15/24 at 10:05 AM, revealed housekeeping staff U distributed ice to residents' mugs. The ice was in a large, uncovered container on the snack cart with the scoop stored directly in the ice. Interview, at that time with housekeeping staff U, revealed she did not know the ice should have a lid and the scoop should be kept out of the ice. Interview, on 05/15/24 at 10:15 AM, with Administrative Staff A, confirmed she would expect staff to keep the ice in a covered container and the scoop separate from the ice to prevent contamination of the ice. The facility policy Food Preparation and Service dated 2024, instructed staff to serve food in a manner that complies with safe food handling, and food should be covered when traveling a distance such as down a hallway. The facility failed to ensure staff provided ice to the residents in a sanitary manner to prevent the spread of infection. - Observation, on 05/15/24 at 11:21 AM, revealed Licensed Nurse (LN) N, obtained blood glucose from Resident (R) 7. LN N stated each resident had their own glucometer that the facility provided, but if a meter malfunctioned, the facility had an extra meter that could be used. LN N stated five residents required blood glucose monitoring with a glucometer. LN N proceeded to wipe the resident's glucometer with a sanitizing wipe. The sanitizing product did not list hepatitis as susceptible to the chemicals in the wipe. LN N stated usually the wipes had a purple top. Interview, on 05/15/24 at 11:30 AM, with Administrative Nurse D, confirmed the wipes were not appropriate for sanitizing the glucometers per the manufacturer's instructions. Interview, on 05/15/24 at 11:40 AM, with Administrative Staff A, revealed staff may have run out of the appropriate sanitizing wipes, and substituted a non-medical grade wipe. The Manufacturer's Instruction Manual Cleaning and Disinfection Procedure instructed staff to cleaning and disinfecting the meter with four brands of wipes with EPA (environmental protection agency) registration numbers. The facility failed to clean and disinfect the glucometers with appropriate manufacturer's recommended sanitizing agent to prevent the spread of infection. - Observation, on 05/20/24 at 09:00 AM, revealed Certified Medication Aide (CMA) R prepared medication to administer to Resident (R) 19. CMA R, without sanitizing hands or wearing gloves, opened three capsules of Rytary 48.75/194 milligrams (a medication for Parkinson's disease a disease which is a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) into a medicine cup. CMA R then wiped the end of a paper clip with an alcohol wipe and poked an Occuvite gel tab (a vitamin formula specifically for eye health) and expressed the gel into the medication cup. Interview, on 05/20/24 at 09:30 AM, with Administrative Nurse D, revealed she would expect staff to administer medications in a sanitary manner and with proper hand hygiene. The facility policy Handwashing/Hand Hygiene dated 2024, instructed staff to perform hand hygiene before preparing or handling medications. The facility did not provide a policy specifically for preparing medications (opening capsules). The facility failed to ensure staff prepared medications for administration in a sanitary manner to prevent the spread of infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 26 residents with three selected for review. Based on observation, interview and record review, the facility failed to monitor blood pressure 19 times for the PM dose, for one resident (R)4 of the three residents, to ensure the blood pressure was within the physician ordered parameters prior to administration of an antihypertensive medication to ensure the resident remained free of adverse effects. Findings included: - Review of Resident (R)4's electronic medical record revealed diagnoses included heart failure (a condition with low heart output and the body becomes congested with fluid), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and hemiplegia (paralysis of one side of the body). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive function. The resident required extensive assistance of two staff for bed mobility and transfers. The resident received seven days of insulin and six days of antidepressant, diuretic, and opioid medications in the seven-day look-back period. The ADL (Activities of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 09/22/22, assessed the resident was able to make his needs known and required extensive assistance from staff for ADL but was able to feed himself. The resident had a diagnosis of diabetes and took insulin. The Care Plan, reviewed 07/26/22, instructed staff the resident had hypertension and staff to obtain blood pressure readings prior to administering medication, and to obtain the blood pressure under the same conditions each time. Staff instructed to hold medications if the blood pressure was out of parameters. A Physician's Order, dated 10/23/20, instructed staff to administer Metoprolol Tartrate (a medication used to lower blood pressure), 25 milligrams (mg), twice a day (AM and PM) for hypertension. Staff instructed to hold the medication if the systolic(pressure of blood in the arteries when the heart beats, the top number of a blood pressure reading) blood pressure was less than 90 mm/mercury and/or the diastolic(minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading)blood pressure was less than 50 mm/mercury and to notify the physician if the blood pressure was above 175/09. A Physician's Order, dated 07/21/21, instructed staff to administer Dyazide 37.5-25 mg, once a day. Staff instructed to hold the medications if the systolic blood pressure was less than 90 and/or the diastolic blood pressure was less than 50 and to notify the physician if the blood pressure was above 175/90. Review of the September 2022 Medication Administration Record, (MAR), from 09/02/22 through 09/23/22, revealed the resident received the PM dose of Metoprolol 25 mg, nineteen times without monitoring the blood pressure. The September 2022, MAR, revealed staff did obtain the AM blood pressure for the Dyazide. Interview, on 01/03/22 at 03:00 PM, with Certified Medication Aide (CMA) R, revealed the MAR indicated the need to take a resident's blood pressure prior to administration of a medication by the presence of a heart icon and spaces for the blood pressure for the medication and included the parameters to hold the medication. CMA R stated if the blood pressure fell outside of the parameters, she would hold the medication and notify the nurse. Interview, on 01/03/22 at 03:15 PM, with Administrative Nurse D, confirmed the lack of blood pressure monitoring for the PM dose of metoprolol as ordered by the physician. Administrative Nurse D stated she did not know why the MAR did not contain the indication to obtain the blood pressure but did include the parameters for administration. The facility policy Hypertension-Clinical Protocol/Guidelines reviewed 05/2021, instructed staff blood pressure targets should be obtained by the practitioner for residents with hypertension. Nursing staff instructed to monitor for complications of blood pressure treatments. If complications of treatment were identified, the physician should be alerted to review the situation. The facility failed to monitor this resident's PM blood pressure prior to administration of Metoprolol, as ordered by the physician, to ensure the resident did not receive adverse effects of the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 31 residents, with 13 residents sampled, including two sampled for discharge. Based on interview and record review, the facility failed to complete a discharge summary from the facility, which included a recapitulation of resident (R)33's stay at the facility. Findings included: - Review of Resident's (R)33's, undated Physician Orders, revealed diagnoses included, malignant neoplasm of the brain (brain cancer/tumor), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), chemotherapy, and sepsis (infection of the blood). The admission Minimum Data Set (MDS) dated [DATE], documented the resident admitted on [DATE], with a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. The discharge plan addressed the goal for the resident to return to the community. He did not need a referral to the local contact agency. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 06/08/22, documentation included the resident worked with skilled therapy with the goal to return home. The Discharge Return not Anticipated MDS, dated 06/11/22, documented the resident discharged to the community. The Care Plan, (CP), dated 06/02/22, directed staff the resident wished to return to his home. The Progress Notes, (PN), dated 06/11/2022 at 02:37 PM, documented the resident as increasingly confused over the last couple hours, not recognizing family members and was not able to hold a full conversation. The family agreed they would like to take him home and use hospice services. The resident's Primary Care physician made aware and gave the order to discharge him to his home with family for end- of -life care. The PN dated 06/11/2022 at 06:16 PM, documented the resident discharged home via emergency medical service accompanied by his wife and daughter. The resident's medical record lacked a discharge summary which included the recapitulation that described the resident's course of treatment while he resided in the facility. The recapitulation included, but not limited to the resident's diagnoses, course of illness, treatment, and/or therapy, pertinent lab, radiology, consultations of the resident's stay. On 08/11/22 at 10:58 AM, Certified Nurse Aide (CNA) M stated the resident had cancer and the family decided to take him home to die. He was only at the facility for a short time. She reported the CNAs did not participate in the follow-up or charting after the resident discharged . On 08/15/22 at 12:03 PM, Licensed Nurse (LN) G stated nurses should should provide discharge instructions to the caregivers of the resident at the destination, count the medications, and ensure chain of custody is documented, and complete a discharge summary to include a recapitulation of the resident's stay. She confirmed the resident admitted to the facility from the hospital following brain surgery to remove a tumor. He declined and the wife and daughter took him home on [DATE] with hospice care. On 08/16/22 at 11:28 AM, Administrative Nurse D confirmed the resident's medical record lacked a discharge summary which included the recapitulation of his stay The facility policy Documentation of Transfer/Discharges, dated 05/2022, documentation included . information to the receiving provider will include a copy of the resident's discharge summary, and any other documentation, as applicable to ensure safe and effective transfer. The facility failed to complete a discharge summary that included a recapitulation of the resident's stay at the facility, as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 31 residents with 13 selected for review including one resident reviewed for activities of daily living (ADL's). Based on observation, interview, and record review, the facility failed to ensure one sampled resident, Resident (R)1, who required staff assistance, received appropriate personal hygiene assistance for cleaning and trimming of his fingernails. Findings included: - The medical diagnosis tab in the electronic medical record (EMR) for Resident (R)20 included a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS) dated [DATE] assessed R20 with a Brief Interview of Mental Status (BIMS) score of zero, indicating severe cognitive impairment. He did not reject care and required assistance of two or more staff for personal hygiene cares. The Cognitive Loss/Dementia Care Area Assessment dated 06/27/22 revealed R20 had inattention, disorganized thinking, was unable to express himself most of the time, and staff needed to anticipate his needs. The Quarterly MDS dated 07/12/22, revealed no changes to his BIMS score, rejection of care, and assistance needed for personal hygiene. The Care Plan dated 06/23/22 revealed R20 had a self-care performance deficit related to his dementia and required one staff to assist him with personal hygiene cares. He preferred to have a shower in the evening time on Sunday and Thursday. The bathing task, located in the EMR under the Task tab, revealed R20 received some type of bathing on 08/11/22 (Thursday) and 08/14/22 (Sunday). On 08/10/22 at 01:43 PM, observed R20 sitting up in his wheelchair in the dining room. His fingernails on his right hand had a brown substance under them and were long, some nails had a jagged edge. On 08/11/22 at 08:28 AM, observed R20 resting in his room on his bed and his fingernails of both hands were long with a brown substance underneath them. On 08/11/22 at 08:42 AM, observed Certified Medication Aide (CMA) R and Certified Nurse Aide (CNA) N assist resident up from his bed to the wheelchair and provide morning cares which included washing his face. Staff failed to provide care of his fingernails. On 08/11/22 at 02:40 PM, observed R20 sat in the recliner across from the nurse's station, his fingernails continued to be long and had a brown substance underneath them. On 08/15/22 at 12:56 PM, observed R20 sat in the wheelchair in the dining room. His fingernails continued to be long with a brown substance underneath and a few of the nails with jagged edges. On 08/15/22 at 01:51 PM, CNA O stated that fingernail care was usually done by activities, and the last time nails were done was on August sixth and would be doing them again on the seventeenth. She does the male and female resident nails unless they have diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). CNA O stated if the fingernails are bad between and need cleaning staff should provide the nail care with their shower. CNA O stated she had not showered R20 recently as he was scheduled on the evening shift for showers. On 08/16/22 at 09:11 AM, R20 observed in the dining room and no changes observed to his fingernails. On 08/16/22 at 09:13 AM, Activity Staff Z stated she does manicures and emery boarding, however, she does not clean or trim the nails, she may clip the tips if they are long and she takes care of male and female nails. Activity Staff Z stated she had never done R20's nails. On 08/16/22 at 09:18 AM, Licensed Nurse (LN) G stated that fingernail care and trimming should be done by the CNA's when a resident received their shower, unless they are diabetic, then the nurses should provide the nail care. LN G stated the CNA's would be responsible for R20's nails and stated his bathing scheduled for Sunday and Thursday on the evening shift. LN G observed R20's fingernails and confirmed his nails needed cleaning and trimming. On 08/16/22 at 11:39 AM, Administrative Staff D stated activities should provide fingernail care. She sets a date to do it and it was typically on the activity calendar. The CNA's were to clean fingernails on shower days and clip if needed or the nurse would clip them too if needed. Administrative Staff D stated she would have expected the staff to clean and trim his fingernails with his bathing completed on Sunday. The facility policy Care of Fingernails/Toenails dated 05/2022 revealed nail care included daily cleaning and regular trimming. The facility failed to provide appropriate personal hygiene assistance needed for trimming and cleaning this dependent resident's fingernails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 31 residents, with 13 residents sampled, which included three residents sampled for respiratory care. Based on observation, interview, and record review, the facility failed to provide appropriate respiratory care in maintaining respiratory equipment to prevent the spread of infection, consistent with standards of practice related to the storage and routine changing of oxygen tubing/cannula, and humidifier bottles for Resident (R) 3, R 17, and R 28. Findings included: - Review of Resident's (R)3's Physician Orders, dated 06/30/22, revealed diagnoses which included, chronic obstructive pulmonary disease (COPD a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing, history of pneumonia (inflammation of the lungs), and history of COVID-19 (an acute respiratory illness in humans caused by the coronavirus, capable of producing severe symptoms and in some cases death, especially with those with severe underlying conditions). The Annual Minimum Data Set (MDS) dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. He exhibited shortness of breath (SOB) or trouble breathing with exertion (e.g., walking, bathing, transferring), sitting at rest, and when lying flat. He used oxygen. The Care Area Assessment (CAA), dated 11/22/21, documentation lacked address of the resident's use of oxygen. The Care Plan, (CP), dated 07/20/22, directed staff the resident had COPD with altered respiratory status and difficulty breathing. Staff should provide oxygen as ordered. Oxygen at 2 liters via nasal cannula (N/C) as needed (PRN) to keep oxygen saturations (the percentage of oxygen concentration in the blood) above 88 percent (%). The Physician's Orders, dated 06/30/22, documented to provide oxygen at 2 Liters per minute as needed (PRN) by way of nasal cannula (N/C) to keep O2 (oxygen) saturation above 88%., initially ordered on 12/27/2018. On 08/10/22 at 11:27 AM, the resident's O2 cannula and tubing laid directly on the floor. The tubing and the oxygen concentrator bottle dated 07/17/22. Social Service Staff K confirmed the oxygen cannula and tubing laid directlyon the floor and the date the oxygen equipment labeled as 07/17/22. She stated the date indicated when the tubing and humidifier was last changed. She confirmed there was not a bag available for the tubing and cannula storage when it was not in use. On 08/11/22 at 10:58 AM, Certified Nurse Aide (CNA) M confirmed the resident used his oxygen. She stated the oxygen tubing and cannula should be stored in a bag when not in use to prevent the spread of infection. She reported the night shift staff were responsible for checking the oxygen equipment and changing the tubing weekly. She confirmed the dates on the humidifier bottles indicated the date they were last changed. On 08/15/22 at 12:03 PM, Licensed Nurse (LN) G reported the night shift nurse was responsible for changing the oxygen equipment and tubing weekly on Sunday nights. She reported the tubing and cannula should be stored in a bag when not in use to prevent cross contamination and the date labeled on the tubing and humidifier bottle indicated the date they were last changed. On 08/16/22 at 09:57 AM, Administrative Nurse D verified the oxygen tubing and cannula should be stored in a bag when not in use to prevent infection. She stated the nursing staff should change and label the tubing, humidifier bottles, and cannula weekly on Sunday nights. Anytime the staff noted the cannula and/or tubing on the floor or was in direct contact with an unsanitized surface, the oxygen equipment should be changed out to prevent infection. The facility's policy for Oxygen Administration, dated 06/20/21, lacked address of the maintenance, upkeep, storage, and routine changing of the oxygen cannula's, tubing and humidifier bottles to prevent infections. The facility failed to provide appropriate respiratory care in maintaining respiratory equipment to prevent the spread of infection, consistent with standards of practice related to the storage and routine changing of oxygen tubing/cannula, and humidifier bottles for this resident that required oxygen. - Review of Resident's (R)17's, Physician Orders, dated 06/22/22, revealed diagnoses which included, chronic obstructive pulmonary disease ( [COPD] progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), pulmonary embolism ( blood clot in the lung), dependence on supplemental oxygen, chronic congestive heart failure (fluid build-up around the heart), lymphedema (swelling caused by accumulation of lymph), nicotine dependence with withdrawal, and generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Significant Change in Status Minimum Data Set (MDS) dated [DATE], documented the Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. She experienced shortness of breath (SOB) with exertion, at rest, and lying flat. The resident received oxygen (O2). The ADL Functional Rehabilitation Potential Care Area Assessment (CAA), dated 12/09/21, documentation lacked address of the resident's oxygen use. The Care Plan, (CP), dated 08/02/22, directed staff the resident with diagnoses which included COPD and to give oxygen as ordered by the physician at two liters per minute to keep oxygen saturation at above 90 percent (%). The Physician Orders, dated 06/22/22, included the following orders: 1. Oxygen at two liters, as needed (PRN), to keep oxygen saturations above 90%. Initially ordered on 05/31/2017. 2. Check and document if oxygen is on (the resident) at bedtime. 3. Change the oxygen tubing and mask/cannula weekly on Sundays. On 08/10/22 at 09:57 AM, the resident's O2 tubing/cannula draped across the turn bar on the right side of the bed with the nasal prongs of the cannula in direct contact with the handle of the turn bar, the call light, and the remote control for the bed. There was not a storage bag available to cover the tubing when not in use to prevent cross contamination. The resident was short of breath and coughed at intervals. The cannula/tubing and humidifier bottle lacked labels to indicate the date they had previous been changed. On 08/10/22 at 09:57 AM, Certified Nurse Aide (CNA) P verified the above findings and proceeded to unwrap the cannula from the resident's bedrail and remote control. She then applied the oxygen cannula in the resident's nose and raised the head of the resident's bed. On 08/11/22 at 10:58 AM, CNA M confirmed the resident used her oxygen and the resident experienced shortness of breath. She stated the oxygen tubing and cannula should be stored in a bag when not in use to prevent the spread of infection. She reported the night shift staff were responsible for checking the oxygen equipment and changing the tubing weekly. She confirmed the humidifier bottles and cannula/tubing should be dated to indicate when they were last changed, and staff should date the humidifier bottles when they were last changed. On 08/11/22 at 12:45 PM, CNA P confirmed the resident used her oxygen and the resident experienced shortness of breath. She reported the oxygen tubing and cannula should be stored in a bag when not in use to prevent cross contamination and the spread of infection. She reported the night shift staff were responsible for checking the oxygen equipment and changing the tubing weekly. CNA P reported the humidifier bottles and cannula's/tubing should be dated to indicate when they are changed. On 08/15/22 at 12:03 PM, Licensed Nurse (LN) G reported the night shift nurse was responsible for changing the oxygen equipment and tubing weekly on Sunday nights. She reported the tubing and cannula should be stored in a bag when not in use to prevent cross contamination and the date labeled on the tubing and humidifier bottle indicated the date they were last changed. On 08/16/22 at 09:57 AM, Administrative Nurse D verified the oxygen tubing and cannula should be stored in a bag when not in use to prevent infection. She stated the nursing staff should change and label the tubing, humidifier bottles, and cannula weekly on Sunday nights. Anytime staff noted the cannula and/or tubing on the floor or laying in direct contact with an unsanitized surface, staff should replace the oxygen equipment to prevent infection. The facility's policy for Oxygen Administration, dated 06/20/21, lacked address of the maintenance upkeep, storage, and routine changing of the oxygen cannula's, tubing and humidifier bottles to prevent infections. The facility failed to provide appropriate respiratory care in maintaining respiratory equipment to prevent the spread of infection, consistent with standards of practice related to the storage and routine changing of oxygen tubing/cannula, and humidifier bottle for this resident that required oxygen. - Review of Resident (R)28's Physician Orders, dated 06/22/22, revealed diagnoses which included, chronic obstructive pulmonary disease ([COPD]a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and end stage heart failure (hearts inability to pump blood effectively. The Annual Minimum Data Set (MDS), dated [DATE], documented the Brief Interview for Mental Status (BIMS) score of 14, which indicated cognitively intact. The resident exhibited shortness of breath (SOB) or trouble breathing with exertion, at rest, and/or lying flat. He received Oxygen. The ADL Functional Rehabilitation Potential Care Area Assessment (CAA), dated 06/22/22, documentation did not include the address of his oxygen use and/or oxygen maintenance. The Care Plan, (CP), dated 07/05/22, directed staff the resident had COPD with altered respiratory status and difficulty breathing. Staff should provide oxygen as ordered at four liters via nasal cannula when sleeping and as needed (prn) to keep oxygen saturations (the percentage of oxygen concentration in the blood) above 88 percent (%), related to acute respiratory failure, order started 02/03/2020. The physician orders, dated 06/22/22, included the following: 1. Humidified oxygen (O2), via nasal prongs (nasal cannula)/mask, two to four liters flow, as needed (prn,) to keep oxygen saturation above 88%. 2. Oxygen at 4 liters, per nasal cannula, when sleeping, and prn to keep saturation above 88%. On 08/10/22 at 09:27 AM, the resident's oxygen concentrator humidifier bottle was dated 07/17/22, a total of 24 days. The oxygen cannula and tubing laid directly on stacked linen in the seat of the resident's recliner. The area lacked a bag to store the cannula and tubing when not in use. On 08/10/22 at 09:30 AM , Certified Nurse Aide (CNA) M confirmed the resident used his oxygen. She stated the oxygen tubing and cannula should be stored in a bag when not in use to prevent the spread of infection. She reported the night shift staff were responsible for checking the oxygen equipment and changing the tubing weekly. She confirmed the dates on the humidifier bottles indicated the date they were last changed. On 08/15/22 at 12:03 PM, Licensed Nurse (LN) G reported the night shift nurse was responsible for changing the oxygen equipment and tubing weekly on Sunday nights. She reported the tubing and cannula should be stored in a bag when not in use to prevent cross contamination. The date labeled on the tubing and humidifier bottle indicated the date they were last changed. On 08/16/22 at 09:57 AM, Administrative nurse D verified the resident's oxygen tubing and cannula should be stored in a bag when not in use to prevent infection. She stated nursing staff should change and label the tubing, humidifier bottles, and cannula weekly on Sunday nights. Anytime the staff noted the resident's cannula and/or tubing on the floor or laying in direct contact with an unsanitized surface, staff should replace the oxygen equipment with new tubing to prevent infection. The facility's policy for Oxygen Administration, dated 6/20/21, lacked address of the maintenance, upkeep, storage, and routine changing of the oxygen cannula's, tubing and humidifier bottles to prevent infections. The facility failed to provide appropriate respiratory care in maintaining respiratory equipment to prevent the spread of infection, consistent with standards of practice related to the storage and routine changing of oxygen tubing/cannula, and humidifier bottles for this resident, that required oxygen.

The facility reported a census of 31 residents with 13 residents selected for review, including six residents reviewed for unnecessary medications. Based on interview and record review the facility failed to obtain physician ordered lab for Resident (R)24, and failed to schedule an appointment, failed to check blood sugar levels as ordered, and failed to obtain lab as ordered for R16. Findings included: - The medical diagnosis tab located in the electronic medical record (EMR), for Resident (R)24 included diagnoses of hypothyroidism (condition characterized by decreased activity of the thyroid gland) and diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Care Plan dated 12/27/21, included R 24 had a diagnosis of hypothyroidism and to obtain lab/diagnostic work as ordered, report results to the medical doctor, and follow up as indicated. The Order Review Report dated 06/30/22, included these orders: 1. On 12/19/21, Levemir (insulin) pen-injector, inject 25 units, subcutaneously, every day, related to diabetes mellitus. 2. On 04/22/22, recheck the TSH (thyroid stimulating hormone-laboratory blood level used to measure levels of the hormone) in July 2022. 3. On 04/22/22, levothyroxine (medication used to treat hypothyroidism), 150 micrograms, orally, in the morning, for hypothyroidism. 4. On 04/28/22, Novolog (insulin) pen injector, subcutaneously, per sliding scale, before meals. 5. On 05/03/22, check a CMP (comprehensive metabolic profile-laboratory test that measures 14 different substances in the blood, including blood sugar levels) and a Hgb A1c (hemoglobin A1c-laboratory test used to measure average level of blood sugars over the past three months) every three months in April/July/October/January related to diabetes mellitus and hypothyroidism. Review of the electronic record under the document tab lacked laboratory results for the CMP, TSH and HgbA1c for July 2022. On 08/15/22 at 02:27 PM, Licensed Nurse (LN) G stated staff place the lab orders in the EMR to show up on the lab tab and would display notifications for the time for staff to draw the blood. The laboratory staff would fax the results to the facility, then staff should fax the results to the doctor unless the lab result was critical, then staff should call the doctor. On 08/15/22 at 02:34 PM, Administrative Nurse D stated a form is sent to an outside laboratory and they do the lab draws. The facility should use that form to mark off the lab as the results returned. The nurses would give the form to Administrative Nurse D after they check and make sure the lab results were returned to the facility. Administrative Nurse D stated she was not able to locate the forms for July 2022. On 08/16/22 at 02:51 PM, Administrative Nurse D stated the facility did not draw the TSH, CMP and the HgbA1c due in July, as ordered by the physician. The facility's policy for Lab and Diagnostic Test Results - Clinical Guidelines effective 05/2022, revealed staff would process test requisitions and arrange for tests per community and contracted lab protocol. The facility failed to obtain physician ordered laboratory to assist to manage medications ordered for R24. - The medical diagnosis located in the electronic medical record (EMR) for Resident (R)16 included diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) edema, and chronic kidney disease. The Care Plan dated 05/03/21 included R 16 had a nutritional risk related to weight fluctuations related to fluid and diagnosis of diabetes mellitus and edema. The staff were to administer medications as ordered: Glucophage (medication to help control blood sugar) and Lasix (medication to help remove excess fluid in the body). The staff were to obtain laboratory as ordered every three months and report the results to the physician: HgbA1c (hemoglobin A1c- [laboratory blood test] measures average blood sugar level over the past three months) and a CMP (comprehensive metabolic profile-[laboratory blood test]measures the levels of 14 substances in the blood and could be useful in detecting diabetes and kidney disease). The Order Review Report dated 06/30/22 included these orders: 1. On 11/01/21, check fasting blood sugars weekly on Monday, and notify the primary care provider for results less than 60 or greater than 400 related to diabetes mellitus. 2. On 05/03/22, CMP and HgbA1c every three months in January, April, July, and October. The EMR lacked results for the HgbA1c due for July 2022. The CMP, drawn on 07/07/22 revealed a BUN (measures the amount of urea nitrogen in the blood- a high level may be a sign of decreased kidney function) level of 42 (normal range 9-20) and a creatine (measures how well the kidneys are filtering waste form your blood) level of 2.4 (normal range 0.7-1.3). The primary care provider responded to the lab results on 07/11/22 and wrote on the lab report Worsening renal function needs nephrology (specialist that concerns the study of the kidneys) consult if not already seeing one. The Progress Note dated 07/11/22 at 01:41 PM, revealed lab results back with primary care provider stating worsening renal function and needed a nephrology consult if not already seeing one. Staff notified the SSD (social service director). Furthermore, review of the Diabetic Monitoring Medication Administration Record (MAR), which included the weekly fasting blood sugars on Monday, for the month of April 2022, May 2022, June 2022, July 2022, and 08/01/22-08/15/22, revealed the facility failed to obtain fasting blood sugars for the following dates on nine occasions: 04/04/22, 04/11/22, 05/02/22, 05/09/22, 05/30/22, 06/06/22, 07/11/22, 07/18/22, and 08/15/22. On 08/15/22 at 11:35 AM LN G stated staff should check the resident's fasting blood sugars every Monday, usually by the night shift. LN G checked the MAR and confirmed the blood sugar was not done for 08/15/22 and stated they should be documented on the MAR when completed. On 08/15/22 at 02:19 PM, R16 stated he has not had an appointment with a nephrologist and was not aware if he had one scheduled. He reported the facility should let him know when he has appointments. On 08/15/22 at 02:27 PM, Licensed Nurse (LN) G stated she did not know if R20 had seen a nephrologist, and the appointment book was not at the desk. Social services should take care of the appointments. When a resident had a new appointment, nursing staff should let her know and she would schedule the appointments. LN G stated lab orders are placed in the EMR to show up on the lab tab and would display like medications do for when it was time for staff to draw the blood. The laboratory staff would fax the results to the facility, then staff would fax the results to the doctor. If the lab was critical, staff would call the doctor. On 08/15/22 at 02:34 PM, Administrative D stated the HgbA1c for July was not drawn. She stated an outside lab drew the lab and a form were sent to them, and the facility uses that form to mark off the lab as the results come back. The nurses give the form to Administrative Nurse D after they check and make sure the lab results were returned back to the facility. Administrative Staff D stated she was not able to locate the forms for July and would expect the staff to obtain the lab as ordered. On 08/16/22 at 10:36 AM, Social Service staff X stated R16's family does all of his appointments, she had no notes or was not notified of the need for a nephrology consult, and R16 did not have a nephrology consult appointment made. On 08/16/22 at 11:56 AM Administrative Nurse D stated the staff leave a note in the appointment book which is located at the nurse's desk or leave a note at the desk if someone has the book. Administrative Nurse D stated she would expect the staff to notify the SSD of needed appointments and the SSD to schedule appointments ordered by the primary care provider. In addition, when staff processed the order for the fasting blood sugar, staff placed the order under the diabetic Accucheck rather than the diabetic MAR in the EMR, so the order did not display correctly for the staff to obtain. She was unaware staff missed blood sugars, as ordered by the physician. The facility policy Lab and Diagnostic Test Results - Clinical Guidelines effective 05/2022, revealed the staff will process test requisitions and arrange for tests per community and contracted lab protocol. The facility lacked a policy regarding following physician orders. The facility failed to obtain laboratory as ordered by the physician, failed to schedule a nephrology consult as ordered by the physician, and failed to obtain a fasting blood sugar as ordered by the physician for nine of 20 opportunities for this resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 31 residents with 13 residents sampled, that included six residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to act upon the pharmacist's recommendation in a timely manner, to resolve identified irregularities for two residents (R)17 related to potential duplicate therapy of respiratory treatment, dose reduction of medication used to treat pain and R 30 related to gradual dose reduction of psychoactive medication and obtaining lab recommendations. Findings included: - Review of Resident (R)17's Physician Orders, dated 06/22/22, revealed diagnoses which included, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), pulmonary embolism (blood clot in the lungs), acute pain due to trauma, chronic pain, low back pain, nondisplaced fracture (broken bone with alignment maintained) of right wrist, and pain in the left shoulder. The Significant Change in Status Minimum Data Set (MDS) dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. She required extensive assistance with activities of daily living (ADLs). She received scheduled and prn pain medications and reported almost constant pain rated 10/10 which interfered with her sleep and day to day activities. She received opioids for seven days of the look back period. The resident experienced shortness of breath or trouble breathing with exertion, at rest, and when lying flat. She received oxygen. The Mood State, and Pain Care Area Assessment, (CAA), dated 12/09/21, respectively documented the resident has chronic pain which contributed to her ADL performance. She received routine pain medication and received as needed (prn) pain medication which she utilized often. The resident refused to take her medications at times which increased her risk for a further decline in mood state. She was at-risk related to adverse drug reaction to medications. The pain made it hard for her to sleep at night and that limited what she would do, because of the pain. She reported pain in her bilateral (both) wrists, knees, lower back, ankle and experienced frequent headaches. She had her Percocet (pain medication) increased for one month. The CAA's lacked address of the use of respiratory inhalation treatments. The Care Plan, (CP), dated 8/2/22, directed staff the resident received breathing treatments which included albuterol inhaler (inhalation medication used to treat wheezing and shortness of breath) every four to six hours as needed, for SOB/wheezing, initiated 06/30/21. Staff should monitor for difficulty breathing on exertion. Give breathing treatments as ordered and monitor for effectiveness of treatments. The resident had chronic pain. She receives multiple medications to treat pain. The facility staff would follow-up on the pharmacist's monthly medication regimen review and resulting recommendation as indicated. Review of the Physician's Orders, revealed the resident received medications which included the following: 1. Methocarbamol Tablet, 500 milligram (mg), two tablets, by mouth, every eight hours, as needed for muscle spasms, related to back pain, ordered 06/10/22. 2. Orphenadrine Citrate extended release (ER) tablet, 100 mg, one tablet by mouth, two times a day, for muscle spasms, ordered 04/02/2022. 3. Zofran (Ondansetron) 4 mg, one by mouth every 8 hours as needed for nausea, ordered 05/15/22. 4. Acetaminophen 500 mg, give two tablets, by mouth every four hours as needed for pain, ordered 04/02/22. 5. Hydromorphone Hydrochloride (HCl), (Dilaudid), give two tablets by mouth every six hours, as needed for pain for 30 days, ordered 08/03/22. 6. Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083%, 3 milliliters (ml), inhale orally via nebulizer, every four hours as needed for Shortness of Breath, ordered 07/23/21. 7. Ventolin HFA Aerosol Solution (rescue inhaler)108 (90 Base) MCG/ACT (Albuterol Sulfate HFA), give two puffs, inhale orally, every six hours, as needed for COPD. The resident is able to keep at bedside and administer to self as needed, ordered 5/5/2016. Review of the pharmacist's Monthly Medication Regimen Review, revealed the following concerns: On 10/15/2021, Recommended the discontinuation of the prn order for Ondansetron 8 mg. every 12 hours, prn, due to lack of use in previous 80 days. The physician responded on 11/05/21, 21 days following the pharmacist recommendation. Additionally, the pharmacist identified a potential for duplicate medication treatment related to the use of Albuterol Solution 2.5 mg/3 ml via nebulizer every four hours prn SOB and Ipratropium-albuterol solution via nebulizer, every eight hours prn asthma ordered. As well as Ventolin HFA at bedside prn use. The physician responded on 11/03/21 (19 days later). On 04/16/2022, the pharmacist identified a potential for excessive dose medication treatment related to the use of an opioid, Percocet 10-325(narcotic) three times daily, in combination with Aripiprazole (an atypical antipsychotic) 15 mg daily, and Orpheridrine (muscle relaxant) ER 100 mg twice daily. The pharmacist requested a dose reduction of for one of these medications if clinically appropriate. The physician responded on 06/16/22, 61 days later. On 08/10/22 at 09:57 AM, the resident transferred from her wheelchair to the be with the assistance of Certified Nurse Aide (CNA) P, CNA O, and CNA Q. The resident was short of breath and reported pain rated at 9/10. Licensed Nurse (LN) G gave the resident Dilaudid two mg. The resident reported she tried to sit up in her wheelchair, but it hurt her back and the only relief was for her to lay down and get pain medication. On 08/15/22 at 01:40 PM, the resident was sat in her wheelchair leaning to the right. She reported she had just returned from the doctor and was tired and her back hurt. She requested to lay down. On 08/15/22 at 12:03 PM, LN G stated the resident would cry and get upset when she was in pain. She reported her pain level as 10/10. She has Dilaudid two mg every six hours as needed for pain, as well as muscle relaxers. LN G stated she was not aware of the pharmacy medication regimen review nor the expected turn around on follow-up. She reported that was handled by the administrative nursing staff. On 08/16/22 at 09:57 AM, Administrative Nurse D stated the pharmacist does remote pharmacy reviews, and she sends the pharmacy recommendations to the physician and puts the pharmacy reviews for the physicians that round in the facility in a communication book to review when they come to the facility. Administrative Nurse D stated that timeliness of response by the physicians was an issue. She reported that the facility often had to refax physicians and physically go to their office to obtain a response which caused delays in the follow up to the pharmacist's recommendations. She stated the expectation for routine review and follow-up to the pharmacy recommendations was seven to ten days. She agreed the follow-up to the pharmacy recommendations was not timely. The facility policy for Medication Regimen Reviews F756, dated 05/22/22, documentation included, The Director of Nursing and the Consultant Pharmacist will agree on the process and steps to be taken to care once an irregularity has been identified. The facility failed to act upon the pharmacist recommendation to resolve identified irregularities for the resident related to duplicate therapy and dose reduction of multiple medication used to treat pain. - Review of Resident's (R)30's Physician Orders, dated 06/29/22, revealed diagnoses which included, schizoaffective disorder (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), hypertension (high blood pressure), major depressive disorder ( major mood disorder), edema (swelling due to accumulation of fluid), and acute kidney failure. The Annual Minimum Data Set (MDS) dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. The resident reported little interest or pleasure in doing things, feeling down, depressed, or hopeless, trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy, poor appetite or overeating, trouble concentrating on things, such as reading the newspaper or watching television during the look back period. He required extensive assistance of staff activities of daily living (ADL). He was always incontinent of bladder and which did not improve with attempted toileting program. The resident received injections, insulin, antidepressants, anticoagulants, diuretics and opioids for seven days of the look back period. The Urinary Incontinence and Indwelling Catheter, Mood State, and Psychotropic Drug Use, Care Area Assessment (CAA), dated 08/01/22, respective documentation included the resident required extensive assistance with toileting and was incontinent of bladder. He had a diagnosis of depression with depression indicator score of nine. Additional diagnoses included schizoaffective disorder, bipolar disorder and anxiety. The resident received duloxetine (antidepressant medication) daily. Staff should monitor for side effects of medications every shift. The pharmacist reviews the resident's medications and should make recommendations which include a gradual dose reduction (GDR), per policy. The Care Plan, (CP), dated 07/29/22, directed staff to administer medications as ordered. Ask the physician to review medication for possible dose reduction every three months. Monitor medications for side effects and adverse reactions to medications. Ensure labs are drawn as ordered. Follow-up on pharmacist's monthly medication regimen reviews and recommendations. Review of the Physician orders, documentation, dated 06/29/22, revealed the following medication orders: 1. Bumex, (medication to promote the formation and excretion of urine), two milligrams (mg), daily, related to congestive heart failure, ordered 08/05/21. 2. Duloxetine Hydrochloride (HCL), 60 mg., give one capsule by mouth, daily, ordered 11/25/21, for major depressive disorder with psychotic features. Review of the Pharmacy Medication Regimen Review, revealed the following concerns: 1. On 10/15/2021, the pharmacist recommended a GDR for Duloxetine 60 mg for depression related to bipolar disorder. The physician responded to the recommendation on 11/09/21, 24 days later to accept the recommendation. 2. On 02/20/22, the pharmacist recommended a decrease of Metformin (medication to treat diabetes) from 1000 mg twice daily to 500 mg. due to elevated creatinine level (an indicator of decrease kidney function). The physician responded on 03/08/22,16 days later. 3. On 03/14/2022, the pharmacist recommended multiple labs due to previous abnormalities indicated worsening kidney function. The physician responded 39 days later with orders on 04/22/22, for multiple labs to monitor the resident for kidney function. Additionally, the facility did not obtain the labs ordered on 04/22/22 until 12 days after receiving the orders. Furthermore, on 05/12/22, seven days later, the physician discontinued the residents Aldactone, Metformin, and decrease the resident's Aspirin dose, based on the results of the labs obtained on 05/04/22. On 08/10/22 at 09:32 AM, the resident noted to have edema with redness in both legs. On 08/15/22 at 12:13 PM, LN G stated the resident had depression. The Nurse Practitioner discontinued his Aldactone. She changed his diuretic form Lasix to Bumex due to his kidney function. Pharmacists makes recommendation. She was not aware of the pharmacy medication regimen review nor the expected turn around on the follow-up. She reported that was handled by the administrative nursing staff. On 08/16/22 at 09:57 AM, Administrative Nurse D stated the pharmacist did remote pharmacy reviews, and she sends the pharmacy recommendations to the physician and puts the pharmacy reviews for the physicians that round in the facility in a communication book to review when they come to the facility. Administrative Nurse D stated that timeliness of response by the physicians was an issue. She reported that the facility often had to refax physicians and physically go to their office to obtain a response which caused delays in the follow up to the pharmacist's recommendations. She stated the expectation for routine review and follow-up to the pharmacy recommendations was seven to ten days. She agreed the follow-up to the pharmacy recommendations was not timely. The facility policy for Medication Regimen Reviews F756, dated 05/22/22, documentation included, The Director of Nursing and the Consultant Pharmacist will agree on the process and steps to be taken to care once an irregularity has been identified. The facility failed to act upon the pharmacist recommendation to resolve identified irregularities for the resident related to this resident's diuretic therapy and antidepressant therapy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 31 residents, with 13 residents sampled, including six residents sampled for unnecessary medications. Based on record review and interview, the facility failed to notify the primary care provider on 16 occasions from 06/05/22 through 08/07/22 when R29's blood sugar level was out of ordered parameters. Findings included: - The Order Summary Report dated 07/09/22 for Resident (R)29 included diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and long- term use of insulin. The Annual Minimum Data Set (MDS) dated [DATE] assessed R29 with a Brief Interview of Mental Status (BIMS) score of 15, indicating cognitively intact. The resident received a therapeutic diet and received insulin injections for seven days of the assessment period. The Nutritional Status Care Area Assessment dated 07/05/22 revealed R29 was on a carbohydrate controlled/fortified/extra calorie with meals diet. She was an insulin dependent diabetic and took oral medication as well. The Care Plan dated 09/08/21, included R29 had diabetes and to call the physician for a blood sugar greater than 400. R29 also had an order for Glucagon (medication used to treat severe low blood sugar), intramuscularly, as needed, for a blood sugar level less than 60 and not alert, and to call the primary care provider. The Order tab located in the electronic medical record (EMR), included the following orders: 1. On 09/12/21, Glucagon Emergency Kit, one milligram, inject intramuscularly, as needed, for diabetes mellitus. Administer if blood glucose is less than 60 and not alert. Call the PCP. 2. On 01/13/22, Novolog (insulin) pen solution cartridge, 100 units/milliliter (mL), inject subcutaneously, before meals and at bedtime, and only give at bedtime if blood sugar greater than 400. 3. On 01/14/21, Tresiba (insulin) solution 100 units/mL, inject subcutaneously, one time a day per sliding scale, and to call the primary care provider for a blood sugar greater than 400. The laboratory result, on 07/07/22, of the HgbA1c (laboratory test that measures average blood sugar levels over the past three months) was high at 8.3 (up from 7.5 on 04/07/22). The Diabetic Monitoring MAR (medication administration record) for June 2022, July 2022, and 08/01/22- 08/15/22 revealed these blood sugars greater than 400 that required primary care provider notification: 1. On 06/20/22 at 11:00 AM, the blood glucose level was 409. 2. On 06/30/22 at 05:00 PM, the blood glucose level was 463. 3. On 07/01/22 at 05:00 PM, the blood glucose level was 418. 4. On 07/02/22 at 11:00 AM, the blood glucose level was 479. 5. On 07/03/22 at 05:00 PM, the blood glucose level was 420. 6. On 07/05/22 at 05:00 PM, the blood glucose level was 426. 7. On 07/19/22 at 05:00 PM, the blood glucose level was 461. 8. On 08/02/22 at 09:00 PM, the blood glucose level was 407. Review of the progress notes in the EMR lacked documentation if the staff notified the primary care provider of the results greater than 400 on the above dates. The Diabetic Monitoring MAR for June 2022, July 2022, and 08/01/08/15/22 revealed these blood sugars greater less than 60 that required primary care provider notification as well as required Glucagon if not alert: 1. On 06/05/22 at 07:30 AM, the blood glucose level was 57. 2. On 06/07/22 at 11:00 AM, the blood glucose level was 57. 3. On 06/10/22 at 07:30 AM, the blood glucose level was 55. 4. On 06/14/22 at 07:30 AM, the blood glucose level was 56. 5. On 06/27/22 at 07:30 AM, the blood glucose level was 56. 6. On 07/26/22 at 09:00 PM, the blood glucose level was 58. 7. On 07/31/22 at 09:00 PM, the blood glucose level was 48. 8. On 08/07/22 at 07:30 AM, the blood glucose level was 58. The progress notes on 06/27/22 revealed breakfast given to the resident, and on 08/07/22 revealed staff administered orange juice, however, the progress notes lacked whether or not staff notified the physician. Review of the progress notes for the other eight occurrences lacked if the resident was alert and if staff notified the primary care provider of the results less than 60. On 08/10/22 at 02:16 PM, R29 stated this morning staff brought her a Glucerna supplement, she had been taking an Ensure supplement because her blood sugar would be low quite a bit of the time. R29 stated the staff check her blood sugar several times during the day and she was unable to tell when her blood sugar was low. On 08/16/22 at 09:23 AM, Licensed Nurse (LN) G stated staff should notify the physician when the blood sugar was out of parameters. Staff should document the results and notifications in the nurse's notes. When R29's blood sugar was low, staff should document it was low, even if staff were not required to give the Glucagon and the physician would still need to be notified. On 08/16/22 at 01:01 PM, Administrative Nurse D stated the EMR lacked documentation the staff notified the physician when the blood sugar levels were out of parameters, and she would expect them to notify the physician each time and document that notification in the progress notes. The facility's policy for Guidelines for Notifying Physicians of Clinical Problems effective 05/2022, included observations that might require physician action included for example significant fluctuations in blood sugar. The facility failed to notify the primary care provider on 16 occasions from 06/05/22 through 08/07/22 when R29's blood sugar level was out of ordered parameters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 31 residents with 13 selected for review including six residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure one of the sampled residents, Resident (R)1 was free unnecessary psychotropic (class of medications capable of affecting the mind, emotions, and behavior) medications. Findings included: - The medical diagnosis tab, located in the electronic medical record (EMR) for Resident (R)1 included diagnoses of Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure) and dementia (progressive mental disorder characterized by failing memory, confusion). The Quarterly Minimum Data Set (MDS) dated [DATE] assessed R1 as having a problem with short- and long-term memory, inattention, and disorganized thinking. R1 could rarely make herself understood and rarely understood others. She did not have any delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), hallucinations (sensing things while awake that appear to be real, but the mind created), behavior symptoms, or rejection of care. She received an antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medication seven days of the assessment period, and the last gradual dose reduction attempt of the antipsychotic medication was on 05/18/21 (four days after admission to the facility). A gradual dose reduction for the antipsychotic medication had not been documented by a physician as clinically contraindicated. The Annual MDS dated 05/17/22 had assessed R1 the same except for the physician documented a gradual dose reduction of the antipsychotic medication was clinically contraindicated. The Psychotropic Drug Use Care Area Assessment dated 05/18/22 revealed R1 received Seroquel (antipsychotic medication), mirtazapine (antidepressant medication), Trazadone (antidepressant medication), and Ativan (antianxiety medication). R1's medications would be reviewed monthly and would have the appropriate gradual dose reductions if necessary and side effects would be monitored routinely. The last pharmacy consultant medication review was on 04/18/22. The Care Plan dated 05/24/21 revealed R1 had a behavior problem related to her disease process. Staff were to administer medications as ordered, monitor behavior episodes, and attempt to determine underlying cause, and document behavior and potential causes. R1 would become agitated when she was either in pain or needed to use the bathroom. The Care Plan included the medication Seroquel had a Black Box Warning, which revealed the medication had not been approved for the treatment of patients with dementia-related psychosis and elderly patients with dementia-related psychosis treated with antipsychotic drugs were at increased risk of death. Additionally, the Care Plan included a problem that R1 received antipsychotic, antidepressant, and antianxiety medication related to diagnosis of anxiety and Alzheimer's dementia. The staff were to monitor/record occurrence of target behavior symptoms of pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. The Order Review Report dated 06/06/22 included an order dated 05/14/21 for Seroquel, 50 milligrams (mg), one tab, orally, three times a day for dementia without behavior disturbance. The Other section of the report lacked instructions for staff to monitor for side effects and behaviors related to the use of the medication. The monthly pharmacy Consultation Report dated 11/24/21 recommended to obtain a diagnosis of dementia with behaviors for the Seroquel. The facility contacted the physician on 11/26/21 and responded there was no supporting diagnosis available. The monthly pharmacy Consultation Report dated 04/18/22 recommended a gradual dose reduction to Seroquel to 50 mg twice daily. The physician declined the recommendation on 06/15/22. The monthly pharmacy Consultation Report dated 06/17/22 revealed an inappropriate diagnosis for Seroquel, dementia without behavioral disturbance, and should be with behaviors. The facility faxed the physician on 06/22/22 with no response. The facility called the physician on 06/22/22 and reported she does not have that diagnosis at this time. The monthly pharmacy Consultation Report dated 07/16/22 revealed it was a repeated recommendation from 06/17/22. A note on the report included unable to find supporting diagnosis, awaiting information from previous History and Physical's prior to admission. On 08/10/22 at 09:43 AM, observed R1 being transferred by two staff into a recliner in the dining room. R1 was restless and verbally rambling. On 08/11/22 at 09:06 AM, observed R1 in her reclining wheelchair in the dining room, one leg crossed over the other and moving it up and down. She sat quietly and watched movement around her. On 08/11/22 at 10:08 AM, observed R1 fidgeting in the recliner, moving leg up and down, making occasional verbal sounds. On 08/11/22 at 10:15 AM, observed Certified Nurse Aide (CNA) N propel her from the dining room in the reclining chair, when asked if she needed to go to the bathroom, R 1 clearly answered Yes. On 08/11/22 at 10:55 AM, observed R1 rambling word salad, occasional fidgeting in her reclining wheelchair. She would be still and answer a few questions clearly, then would go back to rambling and fidgeting. 08/11/33 at 12:52 PM, observed R1 rambling and crying off and on and when CNA N questioned if she needed to go the bathroom R1 responded Yeah. On 08/15/22 at 10:25 AM, observed R1 in the recliner in the dining room facing the television making repetitive verbal noises, crossing her left leg over the right then uncrossing it, arms restless. R1 responded Hi there when name spoken and smiled, then went back to making repetitive verbal noises. On 08/15/22 at 02:06 PM, CNA O stated R1 required assistance with all of her ADL's (activities of daily living) and depending on her mood or anxiety she could follow commands. CNA O stated R1 talked a lot, moved around a lot, but did not seem to be having any pain. On 08/15/22 at 03:04 PM observed R1 resting on her bed, eyes closed, was not making any verbal noises, and was resting without any movements. On 08/16/22 at 11:58 AM Administrative Staff D stated that her primary care physician did not like to address those kinds of medications/diagnosis that he did not order, in regard to the Seroquel. Administrative Nurse D stated the EMR lacked monitoring of side effects for the Seroquel and monitoring of behaviors and should be in place. The facility policy Medication Regimen Reviews F 756 effective 05/2022 included the drug regimen review shall include at the minimum unnecessary drugs given without adequate monitoring. The facility failed to adequately monitor for side effects of the antipsychotic medication and monitor for behaviors present related to use of the medication to ensure R1 was free from unnecessary medication.

The facility reported a census of 29 residents with 14 selected for review, including two reviewed for restorative services. Based on observation, interview and record review, the facility failed to ensure staff provided restorative services for one of the two residents reviewed, Resident (R)10 Findings included: - Review of R10's Physician Order Sheet, dated 02/02/21, revealed diagnoses included Sarcoidosis (a disease that causes inflammation in major organs), legal blindness, diabetes, and major depressive disorder. The Quarterly Minimum Data Set (MDS), assessed the resident's Brief Interview for Cognitive score (BIMS) was 15 indicating normal cognitive function. The resident required extensive assistance of two staff for bed mobility, dressing, toilet use and personal hygiene. The resident was dependent on staff for transfers. The resident had no limitations in range of motion in lower extremities. The Falls Care Area Assessment (CAA), dated 08/20/20, assessed the resident as a high fall risk related to poor strength and balance and required extensive assist and/or dependence of two staff for activities of daily living. The resident had a weight gain and was no longer able to bear weight and used a mechanical lift for transferring. The care plan, reviewed 01/14/21, instructed staff to provide restorative services to maintain function. Review of the electronic medical record, in the Tasks tab (a section of the record that records cares provided by the Certified Nurses' Aides (CNAs) by shift daily) contained a section titled Nursing Rehab. This section instructed staff to provide passive range of motion to the resident's bilateral upper and lower extremities for 15 minutes a day, six days a week. Observation, on 05/03/21 at 12:00 PM, revealed the resident seated in his wheelchair at the dining room table, feeding himself lunch. Interview, on 05/04/21 at 11:21 AM with Consulting Therapy Staff GG, revealed therapy discharged the resident from services on 03/15/21 for upper extremity strengthening. Staff GG stated the facility did not have dedicated restorative staff, nor did they have a formal program other than staff following their recommendations after therapy. Consulting Therapy staff GG further stated nursing services should set up their own plan for restorative therapy based on the residents individual needs. Observation, on 05/05/21 at 1:30 PM, revealed the resident required staff assistance to roll to the right and left during cares. Staff did not provide range of motion services during the care provided. Interview with CNA M and CNA N revealed they provided restorative given during activities of daily living with the resident using their arms to assist with dressing. Both staff verified they did not do repititious movements when dressing the residents. Observation, on 05/05/21 at 08:30 AM, revealed the resident seated in his wheelchair in hallway with his hands on the handrail attempting to propel himself along the handrail. The resident stated he was trying to get himself down the hall. The resident stated he did not exercise but used to use the NuStep (a device for lower extremity exercise) but staff did not assist him with it anymore. Observation, on 05/05/21 at 09:00 AM, CNA O and CNA N transferred the resident from his wheelchair to his bed with the mechanical lift. CNA N instructed the resident to turn (using the handrail) onto his left side. The resident required extensive assistance from CNA N to do so but was able to hold himself on this side. CNA N them requested the resident turn onto his right side, which required extensive assistance from CNA O who was positioned on the left side of the bed. CNA O stated staff provided restorative services to the resident two to three times a week. CNA O demonstrated passive range of motion to the resident's lower extremities by flexing and extending the knees one time. Staff O then requested the resident to flex and extend his elbows five times. The resident cooperated and continued the repetition for ten times each arm. CNA O then did passive range of motion to the resident's hands. (the resident was able to feed himself and had no contractures) Interview, on 05/05/21 at 10:15 AM, with Administrative Nurse D, revealed the CNA provided restorative services when they bathed, dressed, or ambulated the resident to the bathroom, or to the dining room (as a walk to dine.) Administrative Nurse D stated nursing staff did not assess the effectiveness of the restorative program. Administrative Nurse D stated nursing follows what therapy suggests after discharge from services. Administrative Nurse D stated the resident used to do the Nu Step and had been able to turn onto his left side and had difficult with this now. Administrative Nurse D stated the resident at times did not cooperate with staff. Administrative Nurse E stated the MDS captures electronically the amount of restorative provided by the CNA to the residents and this populates the Restorative Service on the MDS. And confirmed the resident had only one session of restorative services for 15 minutes as indicated on the 03/19/21 quarterly MDS. The facility policy Goals and Objectives, Restorative Services, revised 12/2007, instructed staff to develop rehabilitative service goals and objectives, and outline them in the plan of care to assist the resident to develop and strengthen his physiological and psychological resources. The facility failed to ensure this resident received restorative services, as care planned to maintain/improve his upper and lower extremity strength.

The facility reported a census of 29 residents. Based on record review and interview, the facility failed to provide Form CMS-10055, Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN), to four residents residing in the facility who discharged from a Medicare covered Part A stay with benefit days remaining in the last six months, resident (R)7, R9, R17, and R18. Findings included - The facility identified a list of four residents who received Medicare covered Part A services, discharged from those services with days remaining, and chose to remain in the facility. The facility provided list identified the four residents' dates of discharge from Medicare A services as follows: On 11/17/20, R18 discharged from Medicare covered Part A services with benefit days remaining. R18 continued to reside in the facility. The facility failed to issue Form CMS-10055 to R18. On 12/29/20, R7 discharged from Medicare covered Part A services with benefit days remaining. R7 continued to reside in the facility. The facility failed to issue Form CMS-10055 to R7. On 03/02/21, R17 discharged from Medicare covered Part A services. R17 continued to reside in the facility. The facility failed to issue Form CMS-10055 to R17. On 03/31/21, R9 discharged from Medicare covered Part A services. R9 continued to resident in the facility. The facility failed to issue Form CMS-10055 to R9. On 05/05/21 at 03:02 PM, Social Services X stated she issued all the forms to residents who were discharged from Medicare Part A covered services over the last year. Social Services X was unaware of the requirement to issue Form CMS-10055. The facility failed to inform these residents of potential liability for their non-covered stay when the facility failed to issue Form CMS-10055 to these four residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - A signed Physician Order Sheet, dated 04/01/21, documented R2's diagnoses included edema (swelling resulting from an excessive accumulation of fluid in the body tissues), bilateral osteoarthritis of the knee (degenerative changes to both knees, characterized by swelling and pain), and morbid obesity. An Annual Minimum Data Set (MDS), dated [DATE], documented the resident Brief Interview for Mental Status (BIMS) score as 15, indicating R2 was cognitively intact. He required extensive assistance for locomotion and used a wheelchair. The ADL (Activity of Daily Living) Functional/ Rehabilitation Potential Care Area Assessment, dated 10/02/20, documented R2 had knee pain, and required staff to propel his wheelchair throughout facility. R2's mobility care plan lacked instruction regarding use of foot pedals on his wheelchair. On 05/03/21 at 02:00 PM, R2 sat in his wheelchair, wearing gripper socks. The wheelchair lacked foot pedals. Certified Nursing Assistant (CNA) Q propelled R2 down the100 foot hallway, as his toes skimmed the ground. On 05/03/21 at 02:05PM, R2 sat in his wheelchair, wearing gripper socks. The wheelchair lacked foot pedals. CNA N propelled R2 100 feet to the dining room as his toes skimmed the ground. On 05/04/21 at 09:48 AM, R2 sat in his wheelchair, wearing gripper socks. The wheelchair lacked foot pedals. CNA M propelled R2 100 feet to the dining room as his toes skimmed along the floor. On 05/05/21 at 04:14 PM, Administrative Nurse D verified that staff should put foot pedals on R2's wheelchair when staff propel him in the wheelchair to prevent injury. The facility lacked a policy regarding the use of foot pedals when propelling residents in their wheelchair. The facility failed to ensure safe mobility for this resident when pushing him in his wheelchair, placing him at risk for accidental injury when staff propelled him without foot pedals, allowing his toes to skim along the floor. The facility reported a census of 29 residents with 14 selected for review which included six residents reviewed for accidents. Based on observation, interview and record review, the facility failed to ensure safe transfers with the use of a gait belt for three of the six residents reviewed, including Resident (R) 11, R12 and R15. Furthermore, the facility failed to ensure three residents R2, R11 and R15) of the six residents reviewed had foot pedals on their wheelchairs while staff propelled them. Findings included: - Review of resident (R) 11's Physician Order Sheet, dated 02/02/21, revealed diagnoses included heart failure and chronic pain. The Significant Change Minimum Data Set (MDS), dated 02/05/21, assessed the resident had severe cognitive deficits, required extensive assistance of one person with bed mobility transfers, dressing and toilet use. The resident's balance was not steady but was able to stabilize with assistance and had no impairment in functional range of motion in upper and lower extremities. The Fall Care Area Assessment (CAA,), dated 02/05/21, assessed the resident was at risk for falls due to balance problem, impaired mobility, poor vision, use of antidepressants and antianxiety medication. The Care Plan revised 02/11/21, instructed staff the resident transferred with limited to extensive assistance of one staff. Observation, on 05/04/21 at 9:07 AM, revealed Certified Nurse Aide (CNA) P prepared to transfer the resident from her wheelchair into her recliner staff did not apply a gait belt. The resident stood with staff assistance the resident's feet twisted and CNA P grabbed the resident by the back of her pants to hold her up. Observation, on 05/04/21 at 11:30 AM, revealed CNA N, applied a gait belt around the resident's upper chest, encircling her breasts. CNA N stated she thought this was the proper position for the gait belt. CNA N transferred the resident from her wheelchair to the commode, then back again into her wheelchair. CNA N then propelled the resident in her wheelchair, without foot pedals. The resident's feet skimmed the floor, with her toes touching the floor. CNA N stated the resident did not have pedals for her wheelchair. Interview, on 05/05/21 at 11:30 AM, with Administrative Nurse D, revealed she would expect staff to apply foot pedals to the wheelchair if staff propel a resident in the wheelchair and remove them if the resident propels themselves. The facility failed to ensure proper application and use of a gait belt during transfer and failed to ensure the resident's feet remained fully off the floor during staff propelled the wheelchair, these deficient practices created a safety hazard for the resident. - Review of resident (R)12's Physician Order Sheet,, dated 04/05/21, revealed diagnoses included peripheral vascular disorder (alteration in the veins and arteries in the extremities) major depressive disorder and behavior disorder. The Annual Minimum Data Set (MDS,) dated 06/19/20, assessed the resident with a Brief Interview for Mental Status (BIMS) score of 12 (12-8 moderate cognitive impairment.) The resident required extensive assistance of one staff for transfer, with unsteady balance. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA,) dated 06/19/20, assessed the resident required extensive assistance of one staff for most ADL functions related to weakness and lack of safety awareness. The resident required staff assistance of one for safe transfers and toileting. The care plan, reviewed 02/05/21, instructed staff the resident had joint pain in her shoulders. Staff instructed to respond promptly to resident requests for assistance. The Lift and Transfer Evaluation, dated 03/18/221, advised staff the resident could transfer to and from the bed, chair, and toilet with assistance of one to two staff. Observation, on 05/04/21 at 10:13 AM, revealed Certified Nurse Aide (CNA) M transferred the resident from her bed to the wheelchair without a gait belt. The resident grabbed the wheelchair arms and attempted to turn but had difficulty pivoting legs and her legs nearly crossed. CNA M grabbed the back of the resident's pants to assist with stabilization. CNA M then assisted the resident to transfer from her wheelchair to the commode and back into the wheelchair without a gait belt and the resident transferred with difficulty and legs nearly crossing. Interview at that time with CNA M revealed the resident used to have a transfer pole to assist with transfers, and she should have a gait belt on the resident. CNA M obtained a gait belt and attempted to transfer the resident from her wheelchair to bed and the resident could not complete the transfer. CNA P assisted with the transfer. Observation, on 05/04/21 at 03:47 PM revealed CNA N and Licensed Nurse (LN) G, transferred the resident, without a gait belt, from her wheelchair, onto the toilet. The resident grabbed the arm of the toilet riser and feet crossed, both staff provided extensive assistance during the transfer. Interview, on 05/04/21 at 10:55 AM, with Consulting Therapy staff GG, revealed the resident discharged from therapy services on 03/21/21. Therapy staff stated the resident had a transfer pole, but nursing services had the pole removed as the resident could no longer use the pole effectively. Interview, on 05/04/21 at 04:19 PM, with Administrative Nurse D, revealed staff should use a gait belt during transfers with residents. Administrative Nurse D stated the resident had severe shoulder pain in both shoulders and had difficulty with transfers. The facility policy Safe Lifting and Movement of Residents, revised 10/2009, advised staff to protect the safety and well being of staff and residents to promote quality care use appropriate techniques and devices to lift and move residents. Residents responsible for resident care will be trained in the use of gait/transfer belts. The facility failed to ensure staff utilized a gait belt and safe transfer techniques for this resident who required extensive staff assistance with transfers to prevent possible injury. This deficient practice created a safety hazard for the resident. - Review of Resident (R)15's Physician's Orders, dated 04/03/21, revealed diagnoses included metabolic encephalopathy, major depressive disorder with psychotic symptoms. The Quarterly Minimum Data Set (MDS,) dated 03/21/21, assessed the resident with a Brief Interview for Mental Status (BIMS) score of 12 (12-8 moderate cognitive impairment.)The resident required extensive assistance of one for bed mobility, transfer and walking in room. The Falls Care Area Assessment (CAA), dated 05/21/20, assessed the resident had muscle weakness and unsteadiness of feet. The Care Plan, dated 03/21/21, instructed staff the resident was at risk for falls and needed to wear non-skid footwear, to assist the resident with transfers. Observation, on 05/04/21 at 12:00 PM, revealed Certified Nurse Aide (CNA) N, applied a gait belt around the resident's upper chest encircling her breasts. CNA N assisted the resident in a standing position and pivoted into her wheelchair. CNA N them propelled the resident in her wheelchair without pedals with the resident's feet skimming the floor, with the resident unable to raise them to ensure the feet remained off the floor. CNA N stated the resident did not have foot pedals for her wheelchair. Interview, on 05/04/21 at 04:19 PM, with Administrative Nurse D, revealed staff should use a gait belt during transfers with residents. Administrative Nurse D revealed she would expect staff to apply foot pedals to the wheelchair if staff propel a resident in the wheelchair and remove them if the resident propels themselves. The facility policy Safe Lifting and Movement of Residents, revised 10/2009, advised staff to protect the safety and wellbeing of staff and residents to promote quality care use appropriate techniques and devices to lift and move residents. Staff responsible for resident care will be trained in the use of gait/transfer belts. The facility policy Equipment-General Use for All Residents, revised 08/2006, instructed staff the facility shall provide routine equipment for general use of the resident population. The facility failed to ensure proper positioning of a gait belt on this dependent resident and failed to ensure foot pedals on this resident's wheelchair to ensure the resident's feet remained fully off the floor as staff propelled the resident in her wheelchair to prevent injury. These deficient practices created a safety hazard for the resident.