The facility identified a census of 78 residents. The sample included 23 residents with five residents reviewed for activities of daily living (ADLs). Based on observations, record review, and interviews, the facility failed to promote care for Resident (R) 30, who was dependent on staff assistance for all ADLs, in a manner that preserved R30's dignity. These deficient practices placed the resident at risk for impaired psychosocial well-being and an undignified living environment. Findings included: - On 03/04/24 at 11:06 AM R30's room was located across from an open communal dining room. R30's door was open. R30 lay in her bed; she wore an incontinence brief and was uncovered from the waist down. R30 was visible from the hallway and part of the dining room while she lay in her bed, with her brief and legs exposed. Staff walked past her room in the hallway while some residents sat in the dining room. On 03/05/24 at 03:25 PM, R30's door was open. R30 lay in bed and slid her bare feet across her mattress. R30 wore only an incontinence brief, and she was uncovered. R30's exposed body was visible from the hallway and part of the dining room across from her room. There were some residents in the dining room. On 03/06/24 at 10:28 AM Certified Nurse Aide (CNA) M stated she was unsure if R30 was able to see or not. CNA M stated R30 was dependent, and staff had to do everything for her which included helping her get dressed. CNA M stated R30's door was left open so staff would keep an eye on her as R30 was a fall risk. CNA M further stated if R30 removed her clothing or blankets, CNA M would go in, cover her up, and help her get situated in bed. On 03/06/24 at 10:51 AM Licensed Nurse (LN) H stated R30 could not see very well but she was able to track to some degree. LN H stated R30 was dependent, and staff had to do everything for her which included dressing and helping her eat. LN H stated R30's door was left open for fall safety. LN H further stated that she would try and go by R30's room often to cover her up when she would pull her blanket off. LN H stated R30 was more comfortable wearing a nightgown instead of pants, and that staff were aware of her preference as they worked with her regularly. LN H stated that she was unsure if R30's clothing preferences were on her care plan. On 03/06/24 at 02:11 PM Administrative Nurse D stated she was not sure of the level of assistance R30 needed; however, she stated that she believed R30 at least required extensive assistance. Administrative Nurse D stated if R30 was in her room, in only a brief and was uncovered, that it was R30's choice as some people were comfortable that way and R30 did not always want the door shut. Administrative Nurse D further stated she believed staff knew R30's preferences as they worked with her regularly and R30's preferences did not necessarily need to be on her care plan. Administrative Nurse D further stated she expected staff to get to know the resident and their family, and stated, Let us be real here, staff are not reviewing an entire care plan. Administrative Nurse D stated the staff that cared for R30 were consistent, worked with her often, and knew what her preferences were. The facility provided a Quality of Life - Dignity policy with a last revised date of 10/22, documented that residents should be cared for in a manner that promotes and enhances their sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents should be treated with dignity and respect. Associates should promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. The facility failed to promote care for R30, who was dependent on staff assistance for all ADLs in a manner that preserved R30's dignity. These deficient practices placed the resident at risk for impaired psychosocial well-being and an undignified living environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 78 residents. The sample included 23 residents. Based on observation, record review, and interviews, the facility failed to identify a significant change in the physical condition and complete a comprehensive Significant Change Minimum Data Set (MDS) for Resident (R) 33 with the addition of hospice services. This deficient practice placed R33 at risk for unidentified care needs. Findings included: - R33's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of atrial fibrillation (rapid, irregular heartbeat), cerebrovascular accident (CVA-stroke- the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), dementia (a progressive mental disorder characterized by failing memory, confusion), and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The MDS documented R33 received hospice services during the observation period. The Quarterly MDS dated 02/28/24 documented a BIMS score of eight which indicated severely impaired cognition. The MDS documented that R33 received hospice services during the observation period. R33's Functional Abilities Care Area Assessment (CAA) dated 12/23/23 documented R33 had a CVA, and hospice services were provided to add additional support for him. R33's Care Plan dated 12/09/23 documented staff would keep hospice informed of durable medical equipment (DME) and supplies needed. Hospice would notify staff of any additional DME or supplies recommended or delivered. The plan of care dated 12/09/23 also documented the staff would adjust the provision of activities of daily living (ADL) to compensate for R33's changing abilities and staff would encourage his participation to the extent that he wished to participate. The plan of care also documented alternate bath days with hospice to promote and provide additional skin care unless R33 preferred alternate arrangements. The plan of care documented that staff would anticipate weight loss, decrease in fluid and/or caloric intake, skin alteration, ADLs, and/or cognitive decline related to terminal illness. The plan of care lacked a description of the services provided by hospice. R33's EMR under the Orders tab revealed the following physician orders: Admit to hospice with a diagnosis of CVA; the resident has six months or less of life dated 10/19/23. A review of R33's clinical record lacked evidence the facility completed a Significant Change MDS to address the resident's recent physical decline and addition of hospice services within the required timeframe. On 03/05/24 at 11:06 AM, R33 sat upright in his Broda chair (specialized wheelchair with the ability to tilt and recline) at the dining table. R33 was asleep with his head tilted to the right side. On 03/06/24 at 11:34 AM, Administrative Nurse F stated she followed the Resident Assessment Instrument (RAI) manual when completing the resident's MDS. Administrative Nurse F stated she relied on the clinical team to inform her of any changes regarding a resident's decline or admission to hospice services. Administrative Nurse F stated she was not informed of R33's admission to hospice services until December 2023 and that is when she completed the Significant Change MDS for R33. The RAI Manual documented that a Significant Change MDS must be completed no later than 14 days after a resident was admitted to hospice services. The facility's MDS Completion and Submission Timeframes policy last revised in July 2017 documented the facility would conduct and submit resident assessments in accordance with current federal and state submission timeframes. The facility failed to identify a significant change and addition of hospice services for R33's physical condition and complete a comprehensive Significant Change MDS, placing the resident at risk of not receiving needed care.

The facility identified a census of 78 residents. The sample included 23 residents. Based on observations, record reviews, and interviews, the facility failed to ensure accurate assessment and documentation on the Minimum Data Set (MDS) related to Resident (R)87's discharge location. This deficient practice had the risk of miscommunication related to R87's continued care needs. Findings Included: - The Medical Diagnosis section within R87's Electronic Medical Records (EMR) included diagnoses of atrial fibrillation (A-fib: rapid, irregular heartbeat), hypertension (high blood pressure), muscle weakness, history of sepsis (a life-threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body), syncope (fainting or passing out), and repeated falls. R87's admission MDS completed 12/13/23 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated he was dependent on staff for bed mobility, toileting, bathing, dressing, and hygiene. The MDS indicated he used a wheelchair for mobility and required staff assistance. The MDS indicated he received speech, physical, and occupational therapy services. R87's Discharge MDS completed 01/10/24 documented he was discharged to a short-term general hospital with no anticipated return. R87's Functional Abilities Care Area Assessment (CAA) completed 12/20/23 indicated he was hospitalized at an acute care facility before his admission related to a fall at his home. The CAA noted he was treated for A-Fib and diverticulitis with infection (pouch-like herniations through the muscular layer of the colon) and admitted to the skilled nursing facility. The CAA noted he had deficits with his activities of daily living (ADLs). R87's Care Plan initiated on 12/07/23 indicated he was at risk for falls, skin breakdown, weight loss, and ADL deficits related to his medical diagnoses. The plan indicated he required moderate to extensive assistance from staff related to bathing, bed mobility, dressing, and transfers. The MDS indicated his goal was to complete therapy services and discharge home. R87's EMR under Progress Notes indicated he was discharged home from the facility on 01/10/24 with physical, occupational, and nursing services. The note indicated he received his discharge paperwork and medication review. The note indicated he verbalized an understanding of his provided services and medications. The note indicated he left the facility with his personal belongings with his friend taking him home. On 03/06/24 at 11:34 AM Administrative Nurse F stated R87 was not hospitalized and left the facility as a planned discharge. She stated the MDS should have been coded as a discharge to home/community. The facility's provided Comprehensive Assessment revised 03/2022 the comprehensive assessment will be free of significant errors related to coding of the MDS and changes in the resident status. The facility failed to ensure accurate assessment and documentation on the MDS related to R87's discharge location. This deficient practice had the risk of miscommunication related to R87's continued care needs.

The facility identified a census of 78 residents. The sample included 23 residents with five residents reviewed for activities of daily living (ADLs). Based on observations, record review, and interviews, the facility failed to provide ADL assistance to Resident (R) 30, who was dependent on staff assistance for all ADLs. These deficient practices placed the residents at risk of decreased psycho-social well-being and impaired ADL. Findings included: - R30's Electronic Medical Record (EMR) documented diagnoses of restless leg syndrome (a condition that causes a very strong urge to move the legs), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS) dated 02/05/24, documented R30 had a Brief Interview for Mental Status (BIMS) score of 00 which suggested severely impaired cognition. The MDS documented R30 used a wheelchair and required substantial/maximal assistance for bathing, and upper body dressing. The MDS documented R30 was dependent on staff for toileting hygiene, lower body dressing, moving from lying to sitting position, and transfers. The MDS documented R30 had severely impaired vision with either no vision at all or only being able to see light, colors, or shapes; eyes do not appear to follow objects. The MDS Section F for resident preferences, which included R30's daily clothing choices, was not addressed. The Cognitive Loss / Dementia Care Area Assessment (CAA) dated 02/05/24, documented R30 had a diagnosis of Alzheimer's Disease and severe cognitive impairment. R30's Care Plan with an initiated date of 01/04/23, documented R30 had an ADL self-care performance deficit related to functional decline, malnutrition, weakness, and pain and was receiving hospice services. Interventions initiated on 01/04/23 documented R30 required assistance to turn and reposition in bed, personal hygiene, bathing, eating, and toileting. R30's care plan lacked the level of assistance for dressing, or clothing preferences. On 03/04/24 at 11:06 AM R30's room was located across from an open communal dining room. R30's door was open. R30 lay in her bed; she wore an incontinence brief and was uncovered from the waist down. R30 was visible from the hallway and part of the dining room while she lay in her bed, with her brief and legs exposed. Staff walked past her room in the hallway while some residents sat in the dining room. On 03/05/24 at 03:25 PM, R30's door was open. R30 lay in bed and slid her bare feet across her mattress. R30 wore only an incontinence brief, and she was uncovered. R30's exposed body was visible from the hallway and part of the dining room across from her room. There were some residents in the dining room. On 03/06/24 at 10:28 AM Certified Nurse Aide (CNA) M stated she was unsure if R30 was able to see or not. CNA M stated R30 was dependent, and staff had to do everything for her which included helping her get dressed. CNA M stated R30's door was left open so staff would keep an eye on her due to R30 was a fall risk. CNA M further stated if R30 removed her clothing or blankets, CNA M would go in cover her up, and help her get situated in bed. On 03/06/24 at 10:51 AM Licensed Nurse (LN) H stated R30 could not see very well but she was able to track to some degree. LN H stated R30 was dependent, and staff had to do everything for her which included dressing and helping her eat. LN H stated R30's door was left open for fall safety. LN H further stated that she would try and go by R30's room often to cover her up when she would pull her blanket off. LN H stated R30 was more comfortable wearing a nightgown instead of pants, and that staff were aware of her preference as they worked with her regularly. LN H stated that she was unsure if R30's clothing preferences were on her care plan. On 03/06/24 at 02:11 PM Administrative Nurse D stated she was not sure of the level of assistance R30 needed; however, she stated that she believed R30 at least required extensive assistance. Administrative Nurse D stated if R30 was in her room, in only a brief and was uncovered, that it was R30's choice as some people were comfortable that way and R30 did not always want the door shut. Administrative Nurse D further stated she believed staff knew R30's preferences as they worked with her regularly and R30's preferences did not necessarily need to be on her care plan. Administrative Nurse D further stated she expected staff to get to know the resident and their family, and stated, Let us be real here, staff are not reviewing an entire care plan. Administrative Nurse D stated the staff that cared for R30 were consistent, worked with her often, and knew what her preferences were. The facility provided a Supporting Activities of Daily Living policy with a last revised date of 02/2024, documented appropriate care and services should be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and, or resident representative and in accordance with the plan of care, including appropriate support and assistance with hygiene, bathing, dressing, grooming and oral care. The facility failed to provide ADL assistance to R30, who was dependent on staff assistance for all ADLs. These deficient practices placed the residents at risk of decreased psycho-social well-being and impaired ADL.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 78 residents. The sample included 23 residents with four residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure two residents, Resident (R) 13 and R28 received pressure-reducing interventions for pressure ulcers. This placed R13 and R28 at increased risk for pressure ulcer development. Findings included: - R13's Electronic Medical Record (EMR) documented diagnoses of venous insufficiency (poor circulation), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) with diabetic neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), generalized atherosclerosis (the buildup of fats, cholesterol, and other substances in and on the artery walls that can cause arteries to narrow, blocking blood flow), abnormalities of gait and mobility, lack of coordination and need for assistance with personal care. The admission Minimum Data Set (MDS) dated 01/11/24, documented R13 had a Brief Interview for Mental Status (BIMS) score of 10 which suggested moderately impaired cognition. The MDS documented that R13 used a wheelchair and required substantial/maximal assistance for bathing, dressing, and personal hygiene, and he was dependent on staff for mobility and transfers. The MDS further documented that R13 had two unhealed Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcers. The MDS documented R13 was frequently incontinent of urine with seven or more episodes of incontinence, but at least one episode of continent voiding. The Pressure Ulcer/Injury Care Area Assessment (CAA) dated 01/11/24, documented that R13 had experienced a functional decline, had a recent fracture, and was no weight bearing to his left lower extremity. The CAA documented R13 required assistance with turning and repositioning. The CAA further documented R13 was readmitted to the facility with Stage 2 wounds to his bilateral (both sides) buttocks. R13's Care Plan with an initiated date of 12/22/23, documented R13 had potential, or actual impairment, to skin integrity related to mobility limitations, incontinence, peripheral vascular disease, venous insufficiency, and an immobilizer to his left lower extremity. An intervention initiated on 01/25/24, documented R13 needed his heels floated. An Order with a start date of 01/08/24, directed staff to float R13's heels while in bed as tolerated, every shift for pressure prevention. R13's Treatment Administration Record (TAR) documented on 03/04/24 day shift that R13's heels were floated. R13's TAR from 03/01/24 - 03/05/24 lacked evidence R13 refused to allow staff to float his heels while in bed. On 03/04/24 at 08:18 AM R13 rested in his bed. R13's heels rested directly on his mattress and the soles of his feet were pressed against the footboard of his bed. There was no evidence of a pillow, wedge, or other device in place to float R13's heels as he lay in bed. On 03/06/24 at 10:28 AM Certified Nurse Aide (CNA) M stated she had access to the [NAME] which contained the appropriate information for her to provide appropriate care for the residents. CNA M stated any relevant skin interventions, such as floating a resident's heels, would have been found in the [NAME]. CNA M stated when floating a resident's heels, their heels could rest on a pillow, but not rest on a mattress or the footboard of the bed. CNA M stated she was not sure if staff were supposed to float R13's heels while he was in bed. On 03/06/24 at 10:51 AM Licensed Nurse (LN) H stated everyone had access to the care plan or [NAME] which would allow staff to know which residents required pressure-relieving items or interventions. LN H stated R13 was at risk for skin breakdown and his heels should have been floated while in bed. LN H further stated when staff floated R13's heels, staff would place an item under his legs so that his heels were off the bed and that the soles of his feet should not be pressed against the footboard of the bed. LN H stated if a resident refused to have their heels floated, nurses would document the refusal in the resident's TAR. On 03/06/24 at 02:11 PM, Administrative Nurse D stated heels should not rest on the bed or footboard; however, she stated the residents would move around while in bed and sometimes end up with their heels no longer floating. Administrative Nurse D stated the expectation was that staff did not place the resident's heels on the bed or footboard and would use an item such as a pillow or heel risers to float the resident's heels. Administrative Nurse D stated if a resident refused to have their heels floated, she expected the CNAs to inform the nurse on duty, and if the resident continued to refuse that should have been documented somewhere. The facility provided a Skin Observation and Wound Prevention policy with a last revised date of 10/22, documented the charge nurse should observe the condition of the resident's skin on admission and a routine basis. The policy further documented the charge nurse should initiate treatment interventions and the plan of care. The facility failed to ensure R13's heels were floated while he was in bed to prevent pressure ulcers. This placed R13 at increased risk for pressure ulcer development.- R28's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R28 was at risk of developing pressure-related injuries and there were pressure-reliving measures in place on her bed and in her wheelchair. R28 had nutritional measures in place during the observation period. The MDS documented R28 did not have any unhealed pressure-related injuries during the observation period. The Quarterly MDS dated 12/29/23 documented a BIMS score of 12 which indicated moderately impaired cognition. The MDS documented that R28 was at risk for the development of pressure-related injuries and had pressure-relieving measures in place on her bed and in her wheelchair during the observation period. The MDS documented R28 had one unhealed pressure ulcer during the observation period. R28's Pressure Ulcer Care Area Assessment (CAA) dated 10/23/23 documented pressure relieving measures in place for R28 was a low air loss mattress, cushion in her wheelchair and staff would float her heels. R28's Care Plan revised 10/25/23 documented R28 had a low air loss mattress on her bed, a pressure relieving cushion in her wheelchair, and staff would float her heels. R28's Care Plan dated 11/03/23 documented R28 was to wear Prevalon boots (special pressure reducing heel protectors) on her bilateral (both sides) extremities at all times. R28's EMR under the Orders tab revealed the following physician order: Prevalon boots at all times as tolerated. Float heels when resident refused boots dated 03/04/24. On 03/05/24 at 11:00 AM R28 laid on her bed with her head slightly elevated. R28's bilateral heels rested on a pillow at the foot of her bed. Her heels were not floated, and she was not wearing Prevalon boots. On 03/06/24 at 10:28 AM Certified Nurse Aide (CNA) M stated she had access to the [NAME] (a nursing tool that gives a brief overview of the care needs of each resident) which contained the appropriate information for her to provide appropriate care for the residents. CNA M stated any relevant skin interventions, such as floating a resident's heels, would have been found in the [NAME]. CNA M stated when floating a resident's heels, their heels could rest on a pillow, but not rest on a mattress or the footboard of the bed. CNA M stated she was not sure if the staff was supposed to float R28's heels while she was in bed, and she was sure R28 did not have any Prevalon boots. On 03/06/24 at 10:51 AM Licensed Nurse (LN) H stated everyone had access to the care plan or [NAME] which would allow staff to know which residents required pressure-relieving items or interventions. LN H stated R28 was at risk for skin breakdown and her heels should have been floated while in bed. LN H further stated when staff floated a resident's heels, staff would place an item under her legs so that her heels were off the bed. LN H was not sure if R33 was to wear Prevalon boots. LN H stated if a resident refused to have their heels floated, nurses would document the refusal in the resident's Treatment Administration Record (TAR). On 03/06/24 at 02:11 PM, Administrative Nurse D stated heels should not rest on the bed or footboard; however, she stated the residents would move around while in bed and sometimes end up with their heels no longer floating. Administrative Nurse D stated the expectation was that staff did not place the resident's heels on the bed or on a pillow or heel risers to float the resident's heels. Administrative Nurse D stated if a resident refused to have their heels floated, she expected the CNAs to inform the nurse on duty, and if the resident continued to refuse that should have been documented somewhere. The facility's Skin Observation and Wound Prevention policy with a last revised date of 10/22, documented the charge nurse should observe the condition of the resident's skin on admission and a routine basis. The policy further documented the charge nurse should initiate treatment interventions and the plan of care. The facility failed to ensure that pressure-reducing measures were placed on R28's bilateral lower extremities as ordered. This deficient practice placed these residents at risk of development of pressure ulcers, and of wound worsening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 78 residents. The sample included 23 residents with three reviewed for bowel and bladder management. Based on observations, record review, and interviews, the facility failed to ensure appropriate Foley catheter care (a tube inserted into the bladder to drain urine into a collection bag) for Resident (R)340 when staff failed to maintain the urine collection bag below R340's bladder to encourage dependent drainage. This deficient practice placed R340 at risk for complications related to urinary tract infections (UTI). Findings Included: - The Medical Diagnosis section within R340's Electronic Medical Records (EMR) included diagnoses of hypertension (high blood pressure), history of falling, recent hip fracture (broken bone), retention of urine, and cervical spondylosis (age-related breakdown of bones in her hip) R340's EMR indicated she was admitted on [DATE] and a Minimum Data Set (MDS) was not completed for review. R340's Care Plan initiated 02/29/24 indicated she had an indwelling catheter related to her urinary retention. The plan indicated staff were to check the catheter and provide care as ordered. The plan instructed staff to ensure the catheter's tubing and urine collection bag were positioned lower than her bladder. The plan instructed staff to check the catheter tubing for kinks. R340's Physician's Orders indicated an order dated 02/29/24 for staff to monitor her indwelling catheter and provide catheter care each shift. The order noted she had a size 16 French (Fr-size of the indwelling catheter) and ordered staff to ensure the urine collection bag was secured below her bladder. On 03/05/24 at 10:03 AM R340 sat in her wheelchair in her room. R340's catheter bag was placed in a dignity bag mounted on the right armrest of her wheelchair parallel to her bladder. Urine pooled in the tubing. As R340 adjusted her positioning in the chair the pooled urine back flowed towards her bladder. R340 stated she had just been admitted to the facility after a recent fall while at home. On 03/06/24 at 08:23 AM, R340 returned to her room after breakfast. R340's catheter urine collection bag and dignity bag still hung on her right armrest. Urine was visibly pooled in the tubing. On 03/06/24 at 10:01 AM Certified Nurse Aid (CNA) M stated the catheter tubing and bag should be placed below the bladder to ensure the urine drained down to the collection bag with gravity. She stated staff checked the urine collection bag position during each encounter. On 03/06/24 at 11:10 AM Licensed Nurse (LN) G stated the catheter bag should be placed in a manner that allowed the urine to flow downward to the bag. On 03/06/24 at 02:10 PM Administrative Nurse D stated staff were expected to ensure the catheter bag was placed below R340's bladder. She stated urine should not be allowed to pool in the catheter tubing. The facility's provided Urinary Cather Care policy indicated staff was expected to check each urinary catheter placement and ensure the drainage bag should be held or positioned lower than the bladder to prevent urine backflow into the tubing. The facility failed to ensure appropriate Foley catheter care and services for R340. This deficient practice placed R340 at risk for complications related to urinary tract infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 78 residents. The sample included 23 residents with one resident sampled for intravenous (IV-administered directly into the bloodstream via a vein) therapy. Based on observation, record review, and interview, the facility failed to assess and document the location, appearance, and patency (the quality of being open and unobstructed) each shift for Resident (R) 191's IV access site. This placed R191 at risk of infection and complications related to IV therapy. Findings included: - The electronic medical record (EMR) for R191 documented diagnoses of infection and inflammation reaction due to internal joint prosthesis (a device that is placed inside a person's body during a procedure to permanently replace joint), and methicillin-susceptible staphylococcus aureus infection (MSSA- a bacterial infection that develops when bacteria enter the body through a cut or wound on the skin). The admission Minimum Data Set (MDS) for R191 had not been completed yet due to her admission date of 02/27/24. The Care Area Assessments (CAA) for R191 had not been completed yet. R191's IV Medications Care Plan initiated 02/27/24 directed staff to monitor, document, and report to the physician any signs and symptoms of complications. Staff was to change the IV dressing as ordered. Staff was to check the dressing site daily. Staff was to monitor, document, and report signs and symptoms of infection or infiltration (leakage of fluid out of the vein) at the site including drainage, inflammation, swelling, redness, and warmth. The Treatment Administration Record (TAR) for R191 documented to observe the peripherally inserted central catheter (PICC - a thin, flexible tube that is inserted into a vein in the upper arm and guided into a large vein above the right side of the heart) site and document in a progress note every shift with intermittent therapy before and after administration of medications, during dressing changes and as needed for infiltration and extravasation (leakage of intravenously administered solution into surrounding tissues) every shift for PICC site observation. R191's TAR documented an order dated 03/05/24 to change the valved PICC needleless connector and transparent dressing weekly and as needed. Document upper arm circumference in centimeters (cm) and external catheter length in cm with each dressing change. Compare to previous measurements. Notify the physician if the length has changed since the last measurement. One time a day every Tuesday for PICC line maintenance and measurements. A review of R191's Progress Notes from her admission on [DATE] through 03/06/24 lacked evidence staff monitored, assessed, and documented R191's PICC line access site before and after the administration of any medication or flush including the type of access, the location of site, or any sign or symptoms of infection or infiltration. On 03/04/24 at 10:53 AM R191 lay in bed with her right arm in an immobilizer (a device used to keep the arm stable and close to the body) and elevated on a pillow. R191 had a PICC line access to her right arm. On 03/06/24 at 08:28 AM Licensed Nurse (LN) G stated that R191's PICC line access was observed and documented on each shift after administration of her medication. LN G stated she only documented on R191's PICC line if she noted any abnormal findings or complications during the administration of her antibiotic (a medication used to treat infections). On 03/06/24 at 02:40 PM Administrative Nurse D stated the facility charted the status of IV access sites by exception (only if there were abnormal findings). Administrative Nurse D stated in the TAR records that the nurse observed the access site, but nursing staff only documented the appearance of the IV site if an abnormality was noted. The facility did not provide a policy regarding the care of IV access sites. The facility failed to ensure that nursing staff appropriately assessed and documented the location, appearance, and patency of R191's PICC line IV access site. This placed R191 at risk of infection and complications related to IV therapy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 78 residents. The sample included 23 residents with seven residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities regarding the lack of dosing instructions for Voltaren (topical pain reliever medication) gel for Resident (R) 33. This deficient practice had the risk of unnecessary medication use and physical complications for R33. Findings included: - R33's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of atrial fibrillation (rapid, irregular heartbeat), cerebrovascular accident (CVA-stroke- the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), dementia (a progressive mental disorder characterized by failing memory, confusion), and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The MDS documented R33 received hospice services during the observation period. The Quarterly MDS dated 02/28/24 documented a BIMS score of eight which indicated severely impaired cognition. The MDS documented that R33 received hospice services during the observation period. R33's Functional Abilities Care Area Assessment (CAA) dated 12/23/23 documented R33 had a CVA, and hospice services were provided to add additional support for him. R33's Care Plan dated 03/22/23 documented that nursing staff would administer medications as ordered by the physician. R33's EMR under the Orders tab revealed the following physician orders: Voltaren external gel one percent (topical) apply to the neck topically three times a day for neck pain dated 03/24/23. A review of the Monthly Medication Review (MMR) provided by the facility from June 2023 through February 2024 lacked evidence of notification for a lack of dosing instructions for Voltaren. The facility provided an order dated 03/06/24 for R33's Voltaren gel that included dose instructions. On 03/05/24 at 11:06 AM, R33 sat upright in his Broda chair (specialized wheelchair with the ability to tilt and recline) at the dining table. R33 was asleep with his head tilted to the right side. On 03/06/24 at 10:52 AM, Licensed Nurse (LN) H stated she did not review or handle the MMRs provided by the pharmacist. On 03/06/24 at 02:13 PM, Administrative Nurse D stated R33's Voltaren gel should have a dose for application. Administrative Nurse D stated she would expect the CP to identify that irregularity during their monthly reviews. Administrative Nurse D stated that Voltaren orders that needed a dose added were one of the most common recommendations from the pharmacist. The facility's Medication Regimen Review (MRR) Policy dated July 2018 documented a drug regimen review was performed for each resident at the time of admission, monthly thereafter, and as indicated, based upon a resident's condition. This Medication Regimen Review (MRR) included, but was not limited to, time frames for different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. The Consulting Pharmacist would review each resident's medical record (including lab tests/results), progress notes, and other applicable documents as necessary per state and federal regulations, to determine whether irregularities exist in his/her medication regimen and complete a Medication Regimen Review (MRR). The facility would maintain copies of MRRs within resident's medical records. The facility failed to ensure the CP identified and reported irregularities in the lack of dosing instructions for Voltaren gel for R33. This deficient practice placed R33 at risk for unnecessary medication use, side effects, and physical complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 78 residents. The sample included 23 residents with five residents sampled for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure a dosage was indicated for the use of Voltaren (a topical gel used for the treatment of pain) for Resident (R) 73 and R33. This deficient practice placed R73 and R33 at risk for unnecessary medication administration and possible adverse side effects. Findings included: - The electronic medical record (EMR) for R73 documented diagnosis of effusion (accumulation of fluid) of the left knee, pain in the left knee, and fracture of the left tibia (the inner and typically larger of the two bones between the knee and the ankle) The admission Minimum Data Set (MDS) dated 02/04/24 documented R73 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R73 had a functional limitation in the range of motion on one side of both upper and lower extremities. R73 required substantial/maximal assistance to dependence with activities of daily living (ADL). R73 received scheduled pain medications. R73 frequently had pain. R73 received an opioid (a medication used for pain relief) while being a resident. The Pain Care Area Assessment (CAA) dated 02/05/24 documented R73 had a fractured left tibia and reported pain at a six out of 10 on the pain scale (0 to 10 scale with zero being no pain and 10 the worst pain imaginable) that interfered with his sleep and day to day activities. R73 received routine and as-needed pain medication. R73's Pain Care Plan initiated 01/29/24 for R73 directed staff to encourage the resident to report pain. The March 2024 Treatment Administration Record (TAR) in the EMR for R73 documented an order dated 02/15/24 for Voltaren topical gel 1% to be applied to the left knee topically every morning and a bedtime for pain. The order on the TAR lacked an indicated dose amount to apply. On 03/05/24 at 02:05 PM, R73 sat in his wheelchair with his feet on foot pedals. Staff propelled R73 down the hall. On 03/06/24 at 08:28 AM Licensed Nurse (LN) G stated she expected all medications that were to have a dosage amount. LN G stated she believed typically the dose was included in the order for Voltaren. On 03/06/24 at 02:42 PM Administrative Nurse D stated that R73's order for Voltaren under the Orders tab of the EMR did show the amount to apply for the medication. Administrative Nurse D could not state a reason why the amount to apply for the Voltaren did not show up on the MAR/TAR. The facility policy Physician Order Chart Audit last revised in July 2015 documented the resident's physician order section of the medical record and electronic orders would be reviewed every 24 hours for accuracy. The charge nurse would verify the order had been written correctly and that all medications and treatments were transcribed accurately to the electronic MAR and TAR. Notify the health care provider as indicated for any discrepancies found in the orders. The facility failed to ensure a dosage was indicated on R73's order for Voltaren. This deficient practice placed R73 at risk for unnecessary medication administration and possible adverse side effects. - R33's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of atrial fibrillation (rapid, irregular heartbeat), cerebrovascular accident (CVA-stroke- the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), dementia (a progressive mental disorder characterized by failing memory, confusion), and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The MDS documented R33 received hospice services during the observation period. The Quarterly MDS dated 02/28/24 documented a BIMS score of eight which indicated severely impaired cognition. The MDS documented that R33 received hospice services during the observation period. R33's Functional Abilities Care Area Assessment (CAA) dated 12/23/23 documented R33 had a CVA, and hospice services were provided to add additional support for him. R33's Care Plan dated 03/22/23 documented that nursing staff would administer medications as ordered by the physician. R33's EMR under the Orders tab revealed the following physician orders: Voltaren external gel one percent (topical) apply to the neck topically three times a day for neck pain dated 03/24/23. The facility provided an order dated 03/06/24 for R33's Voltaren gel that included dose instructions. On 03/05/24 at 11:06 AM, R33 sat upright in his Broda chair (specialized wheelchair with the ability to tilt and recline) at the dining table. R33 was asleep with his head tilted to the right side. On 03/06/24 at 10:52 AM, Licensed Nurse (LN) H stated she did not know if R33's Voltaren gel had dose instructions included for administration. LN H stated she would clarify the order if the order lacked dosage instructions. On 03/06/24 at 02:13 PM, Administrative Nurse D stated R33's Voltaren gel should have a dose for application. Administrative Nurse D stated she would expect there to be clarification. Of the order. The facility's Physician Order Chart Audit policy last revised in July 2015 documented the resident's physician order section of the medical record and electronic orders would be reviewed every twenty-four hours for accuracy on a designated shift. Ensure orders have been written correctly. Notify the health care provider as indicated for any discrepancies found in the orders. The facility failed to ensure dosing instructions for Voltaren gel for R33. This deficient practice placed R33 at risk for unnecessary medication use, side effects, and physical complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 78 residents. The sample included 23 residents. Based on observation, record review, and interviews, the facility failed to ensure that physician-ordered laboratory test results for Resident (R) 28 were included in R28's clinical record. This deficient practice could result in unnecessary tests and delayed treatment. Findings included: - R28's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R28 received diuretic medication (medication to promote the formation and excretion of urine) during the observation period. The Quarterly MDS dated 12/29/23 documented a BIMS score of 12 which indicated moderately impaired cognition. The MDS documented that R28 received diuretic medication during the observation period. R28 's Dehydration Care Area Assessment (CAA) dated 10/15/23 documented fluids for hydration would be provided and labs as available. R28's Care Plan dated 10/10/23 documented that nursing staff would monitor labs and report abnormal lab values to the physician. R28's EMR under the Orders tab revealed the following physician orders: Complete Blood Count (CBC-laboratory blood test) and comprehensive Metabolic Panel (CMP- laboratory blood test) on 11/22/23 dated 11/21/23. Obtain Basic Metabolic Panel (BMP-laboratory blood test) on Monday dated 11/23/23. Repeat potassium level (laboratory blood test) on 11/30/23 dated 11/27/23. Obtain potassium level on 12/05/23 for follow-up hypokalemia (low level of potassium in the blood) dated 12/01/23. Obtain CBC on 12/05/23 dated 12/02/23. Obtain CBC, and CMP on 12/21/23 for follow-up hypokalemia dated 12/19/23. Obtain CBC, BMP on 01/16/24 dated 01/12/24. A review of R28's clinical record lacked evidence of the results of the physician-ordered laboratory tests. The facility was able to provide unsigned copies of the results after a request on 03/06/24. On 03/05/24 at 11:00 AM R28 laid on her bed with her head slightly elevated. R28's bilateral heels rested on a pillow at the foot of her bed. Her heels were not floated, and she was not wearing Prevalon boots (special pressure-reducing heel protectors). On 03/06/24 at 10:05 AM, Administrative Nurse D stated she was not sure if the laboratory results for R28 were in R28's clinical record. Administrative Nurse D stated she printed the results from the laboratory provider's portal. Administrative Nurse D stated the facility expected the physicians to log into the laboratory portal and review the lab work that was ordered daily. Administrative Nurse D stated the facility nurses did not print or review the lab results or notify the physician unless a critical lab value was called to the facility. The facility's Laboratory Services and Critical Lab Values Policy last revised August 2023 documented that the purpose of this policy was to provide laboratory services to meet the needs of residents and to provide information concerning critical lab values to the healthcare provider. Reporting laboratory results, the laboratory would submit the results of tests to the community. The nurse would submit the results of laboratory tests to the healthcare provider. The facility failed to ensure that physician-ordered laboratory test results for R28 were included in R28's clinical record. This deficient practice could result in unnecessary tests and delayed treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 78 residents. The sample included 23 residents with two residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure a communication process was implemented, which included how the communication would be documented between the facility and the hospice provider, and a failed to provide a description of the services, medication, and equipment provided to Resident (R) 33 by hospice. This deficient practice created a risk for missed or delayed services and impaired physical, and psychosocial care for R33. Findings included: - R33's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of atrial fibrillation (rapid, irregular heartbeat), cerebrovascular accident (CVA-stroke- the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), dementia (a progressive mental disorder characterized by failing memory, confusion), and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The MDS documented R33 received hospice services during the observation period. The Quarterly MDS dated 02/28/24 documented a BIMS score of eight which indicated severely impaired cognition. The MDS documented that R33 received hospice services during the observation period. R33's Functional Abilities Care Area Assessment (CAA) dated 12/23/23 documented R33 had a CVA, and hospice services were provided to add additional support for him. R33's Care Plan dated 12/09/23 documented that staff would keep hospice informed of durable medical equipment (DME) and supplies needed. Hospice would notify staff of any additional DME or supplies recommended or delivered. The plan of care dated 12/09/23 also documented the staff would adjust the provision of activities of daily living (ADL) to compensate for R33's changing abilities and staff would encourage his participation to the extent that he wished to participate. The plan of care also documented alternate bath days with hospice to promote and provide additional skin care unless R33 preferred alternate arrangements. The plan of care documented that staff would anticipate weight loss, decrease in fluid and/or caloric intake, skin alteration, ADLs, and/or cognitive decline related to terminal illness. The plan of care lacked a description of the services provided by hospice. R33's EMR under the Orders tab revealed the following physician orders: Admit to hospice with a diagnosis of CVA, the resident has six months or less of life dated 10/19/23. On 03/05/24 at 11:06 AM, R33 sat upright in his Broda chair (specialized wheelchair with the ability to tilt and recline) at the dining table. R33 was asleep with his head tilted to the right side. On 03/06/24 at 10:28 AM, Certified Nurse Aide (CNA) M stated she knew which residents were on hospice services from the shift report. CNA M stated if a hospice person needed anything, she would tell the nurse. CNA M stated she did not know for sure if any of the hospice information was found on the care plan or [NAME] (a nursing tool that gives a brief overview of the care needs of each resident). On 03/06/24 at 10:52 AM, Licensed Nurse (LN) H stated all staff had access to the [NAME] and care plan to review for information regarding each resident's care. LN H stated hospice information should be on the [NAME] for the staff to be aware of the care provided by hospice. On 03/06/24 at 02:13 PM, Administrative Nurse D stated hospice information and services provided by hospice should be included in R33's care plan for collaboration of care. The facility's Hospice policy last revised on 10/20/16 documented that hospice care may be provided when ordered by the health care provider and agreed to by the resident and or legal representative. The selected hospice would have a current contract with the community which follows federal requirements. The purpose of this policy was to provide hospice care for the resident who was terminally ill and to coordinate the care of residents who elect hospice services. A designated member of the interdisciplinary group who was responsible for providing the overall coordination of hospice care with the skilled nursing community. A collaboration on a revised, integrated care plan. A significant change Minimum Data Set (MOS) would be completed per Resident Assessment Instrument (RAI) guidelines. The community and hospice staff would collaborate regularly concerning the resident's care. Hospice progress notes would be included in the resident's medical record and nursing associates would be informed of any changes recommended by the hospice staff. The facility failed to ensure a communication process was implemented, which included how the communication would be documented between the facility and the hospice provider and failed to provide a description of the services, medication, and equipment provided to R33 by hospice. This deficient practice placed R33 at risk for delayed services which could affect her mental, and psychosocial well-being.

The facility identified a census of 78 residents. The sample included 23 residents. Based on record review, observations, and interviews, the facility failed to ensure adequate infection control standards were followed during Resident (R)189's enteral meal (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food) administration and storage of R290's oxygen therapy equipment. The facility additionally failed to ensure clean linen storage. This deficient practice placed the residents at risk for infectious diseases. Findings Included: - On 03/04/24 at 07:17 AM an inspection of the 400 Hall clean linen storage closet revealed a dusty, visibly soiled vacuum cleaner stored in the closet next to uncovered clean linen. On 03/04/24 at 07:52 AM, an inspection of R290's room revealed his continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask placed face down on the nightstand next to his bed. No clean storage container was present in his room for his tubing or mask. On 03/06/24 at 08:30 AM Licensed Nurse (LN) G prepped R189 for her morning enteral nutritional meal via her percutaneous endoscope gastrostomy tube (PEG-a tube inserted through the wall of the abdomen directly into the stomach). LN G completed hand hygiene and entered R189's room. LN placed enteral feeding supplies on a clean barrier on the table. LN G washed her hands in the bathroom sink and donned protective gloves. LN G grabbed an enteral syringe (a large syringe used to assist with feedings and flushes) and attached it to the catheter port. LN G checked for residual fluid volume within R189's stomach and removed the syringe plunger. LN G placed a clean barrier over R189's stomach area and removed her gloves. LN G donned new gloves but did not complete hand hygiene in between glove changes. LN G flushed the syringe with 30 milliliters (ml) of water and then added the premixed enteral solution to the syringe. LN G completed the tube feedings without further issues or concerns. On 03/06/24 at 10:01 AM Certified Nurses Aid (CNA) M stated oxygen tubing and CPAP masks were to be stored in a plastic bag when not in use. She stated hand hygiene should be completed in between glove changes. She stated the vacuum should not be stored in the same closet as the uncovered linens. On 03/06/24 at 11:31 AM Administrative Nurse E stated staff were expected to perform hand hygiene in between changing all personal protective equipment including glove changes. She stated oxygen equipment should be stored in a clean bag to prevent contamination of the masks. She stated dirty or soiled equipment should not be stored in the same area as clean linen. On 03/06/24 at 02:13 PM Administrative Nurse D stated staff were expected to complete hand hygiene in between glove changes. She stated each resident with oxygen equipment should have been provided a bag to store when not in use. She stated soiled equipment should not be stored with clean linens. On 03/06/24 at 08:45 AM LN G stated she would complete hand hygiene in between glove changes. She stated oxygen equipment and masks should be stored in a clean barrier bag to prevent contamination and respiratory infections. The facility's provided Handwashing / Hand Hygiene policy revised 01/2021 indicated staff will complete hand hygiene before, during, and after encountering contaminated surfaces, in between changes of personal protective equipment (PPE), and when visibly soiled. The facility's provided Infection Prevention and Surveillance policy revised 01/2020 indicated the facility will ensure the separation of room and equipment storage between soiled and clean surfaces. The policy indicated clean equipment will never be stored in soiled areas to prevent cross-contamination. The facility failed to ensure appropriate infection control standards were followed during R189's enteral meal administration and storage of R290's oxygen therapy equipment. The facility additionally failed to ensure clean linen storage. This deficient practice placed the residents at risk for infectious diseases.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 78 residents. The sample included 23 residents with 10 reviewed for pneumococcal (type of bacterial infection) immunizations. Based on record review and interviews, the facility failed to ensure the resident and/or resident's representatives were informed and educated on the pneumococcal vaccination options and provided the current Vaccination Information Statements (VIS) for Residents (R) 30, R48, R50, R66, and R76. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings Included: - On 03/06/24 at 08:00 AM a review of pneumococcal immunizations was completed for R13, R20, R30, R32, R33, R48, R50, R59, R66, and R76. R30's (severely cognitively impaired resident) Electronic Medical Record (EMR) indicated she was admitted to the facility on [DATE]. The EMR noted she received the Pneumovax 23 (PPSV23-pneumococcal vaccination) before her admission in 2018. An electronically filed Informed Consent for Pneumococcal Vaccine was signed by R30's representative on 09/26/23 but lacked dates the pneumococcal vaccinations were offered, dates of the vaccination information statement (VIS), and dates the vaccination information statement was given to the representative. R48's (severely cognitively impaired resident) EMR indicated she was admitted to the facility on [DATE]. The EMR indicated her last pneumococcal vaccination was PPSV23 in 2006. An Informed Consent for Pneumococcal Vaccine was completed on 11/08/21. The consent form indicated a declination of the pneumococcal conjugate vaccine (PCV13- pneumococcal vaccination) and PPSV23. The form acknowledged her last vaccine was in 2006. The form lacked a signature or verbal consent to decline confirmation from her responsible representative. R50's (severely cognitively impaired resident) EMR indicated she was admitted to the facility on [DATE]. The EMR indicated she received a PPSV23 vaccination before her facility admission on [DATE]. An Informed Consent for Pneumococcal Vaccine completed on 09/19/23 noted that R50's resident representative declined consent for the pneumonia vaccinations. The consent form lacked dates the pneumococcal vaccinations were offered, dates of the vaccination information statement (VIS), and dates the vaccination information statement was given to her representative. R66's (severely cognitively impaired resident) EMR indicated he was admitted to the facility on [DATE]. The EMR indicated no previously documented pneumococcal vaccination for R66. R66's electronically filed Informed Consent for Pneumococcal Vaccine was signed by his representative on 09/29/23 but lacked information regarding which pneumococcal vaccination was offered and if a vaccination information statement was provided for the vaccines. R76's (severely cognitively impaired resident) EMR indicated he was admitted to the facility on [DATE]. R76's EMR indicated he had no previous pneumonia vaccinations documented. R76's electronically filed Informed Consent for Pneumococcal Vaccine was signed by his representative on 02/01/24 but lacked information regarding which pneumococcal vaccination was offered and if a vaccination information statement was provided for vaccines. On 03/06/24 at 08:20 AM R48's representative stated R48 had been in the facility for quite a while but was not offered a pneumococcal vaccination or education related to R48's pneumococcal vaccination options. She stated that R48 recently started hospice (end-of-life comfort care) services in January 2024 and may not need more vaccinations now, but the facility has not offered the vaccinations since her admission. On 03/06/24 at 08:45 AM R76's representative stated that R76 was admitted recently, and she could not remember being offered any pneumonia vaccination for R76. She stated she would not refuse them if offered. On 03/06/24 at 10:01 AM R66's representative stated he notified the facility he wanted R66 fully immunized and consented to all the vaccines. He stated that R66 received his COVID-19 (highly contagious respiratory virus) and influenza (highly contagious viral infection) vaccinations but was not aware that R66 was due for a pneumococcal vaccination. He stated the facility never offered or discussed R66's pneumococcal vaccination options with him. On 03/06/24 at 10:25 AM R50's representative stated she didn't think R50 needed another vaccination since she received one before she came to the facility but had not been informed by the facility or offered other pneumonia vaccinations since her admission. She stated she would not decline the vaccinations if newer vaccinations were out and offered to R50. On 03/06/24 at 12:04 PM, R30's representative stated the facility had not offered any pneumonia vaccinations for R30 since her admission. She stated she would not decline any immunizations to keep R30 safe or improve her health. She stated that R30 received her influenza and COVID-19 vaccinations recently but was never offered a pneumococcal vaccination. On 03/06/24 at 01:10 PM Administrative Nurse E stated the pneumonia vaccinations were offered by the floor nurses upon admission. She stated the nurses asked at the time of admission and got the orders to give the vaccines. She stated the nurses should provide education related to the vaccinations to the representative and ensure they understand the information provided to them before asking them to sign the paperwork. She stated the facility was currently working on a system to track the updated pneumococcal guidelines. On 03/06/24 at 02:13 PM Administrative Nurse D stated the vaccination consents were provided to the residents upon admission by the nurses. She stated the nurses gave the vaccinations once the physician's order was placed. She stated the nurses were expected to provide education related to the vaccinations and ensure the representatives received the VIS statements. She stated the consent and VIS statements were mailed out to the representative but said she was not sure why resident representatives were not aware of the vaccines or declinations. The facility's provided Pneumococcal Vaccine policy revised 05/2023 indicated each resident will be offered pneumococcal vaccinations when medically eligible. The policy indicates the facility will provide information and education to the resident or representative reflective of benefits and potential side effects. The policy indicated that pneumococcal vaccinations will be offered following the Centers for Disease Control (CDC) recommendations. The facility failed to ensure the resident's representatives were informed and educated on the pneumococcal vaccination options and provided a VIS for R30, R48, R50, R66, and R76. This deficient practice placed the residents at risk for complications related to infectious diseases.

The facility identified a census of 80 residents. The sample included 18 residents with three reviewed for activities of daily living (ADL's). Based on observations, record review, and interviews, the facility failed to provide R72's scheduled bathing per her preferred bathing schedule. This deficient practice placed R72 at risk for poor hygiene and related complications. Findings Included: - The Medical Diagnosis section within R72's Electronic Medical Records (EMR) included diagnoses of spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), hypertension (high blood pressure), muscle weakness, pressure ulcer right of the heal (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), unsteadiness on feet, atherosclerosis (narrowing and hardening of the blood vessels), and morbid obesity (severely overweight). R72's admission Minimum Data Set (MDS) dated 08/25/22 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated that she required extensive assistance from two staff members for bed mobility, toileting, transfers, dressing, personal hygiene, and bathing. A review of R72's ADL's Care Area Assessment (CAA) dated 08/30/22 noted that she required a Hoyer lift (total body mechanical lift used to transfer residents) for all transfers and needed one to two staff members assisting for all her ADL's. R72's Care Plan initiated 08/21/22 indicated that she was a high risk for impaired skin integrity related to her medical diagnoses. The care plan instructed staff to ensure her skin was kept clean, dry, and use lotion. The care plan noted that she required one to two staff assistance for personal hygiene, toileting, dressing, and bathing. A review of R72's Bathing Lookback report from 08/19/22 through 09/08/22 (21 days reviewed) indicated that she received only two bathing opportunities during the reviewed period (8/22 and 9/6). The review noted that she refused on two occasions (8/19 and 8/23). The report indicated that she preferred baths on Tuesday and Friday evenings. On 09/06/22 at 12:15PM R72 stated that while staff take took good care of her she could not remember getting a bath recently and would like more baths each week. She noted that she was supposed to get two baths a week but did not think she was getting them. R72 laid in her bed with her feet supported with pillows and boots to protect her heels. On 09/08/22 at 02:41PM Certified Nurses Aide (CNA) M stated that all the residents were scheduled for two showers per week based upon the resident's preferences upon admission. She stated that the residents have a right to choose the days they receive their showers. She stated that the charge nurse creates the shower list for the day and the CNA staff were responsible for completing the showers. She stated that each resident's showers were documented in the EMR. She stated that if a resident refused a shower, they would be offered another time or different type of bathing opportunity. On 09/08/22 at 03:04PM Licensed Nurse (LN) H stated that the CNA staff were responsible for completing the baths and the nurses would review that they were completed. She stated that if a resident refused a bath, the nurse would offer them a choice of anther time or day to complete the bath. A review of the facility's Supporting Activities of Daily Living policy revised 03/2018 indicated that residents should be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily livings. The facility failed to provide R72's scheduled bathing opportunities per her preferred bathing schedule. This deficient practice place her at risk for poor hygiene and related complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 80 residents. The sample included 16 residents with one resident reviewed for respiratory services. Based on observation, record review, and interviews, the facility failed to store oxygen tubing and nasal cannula (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) in a sanitary manner for Resident (R) 131. This deficient practice placed R31 at increased risk to develop a respiratory infection. Findings included: - R131's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) and dementia in other diseases classified elsewhere with behaviors disturbances (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS) was in progress. R131 admitted [DATE]. R131's Care Area Assessment (CAA) was in progress. R131's Care Plan lacked documentation related to oxygen therapy. Review of the EMR under Orders tab revealed physician orders: Oxygen tubing change every Sunday night shift dated 09/11/22. Oxygen at two liters per minute via nasal cannula as needed for hypoxia (inadequate supply of oxygen). Administer to maintain oxygen level at saturation of greater then (>) 92% dated 08/29/22. Oxygen Saturation twice a day dated 08/29/22. On 09/06/22 at 10:41 AM R131's oxygen tubing and cannula was coiled and stored unbagged in the handle of the concentrator. On 09/07/22at 09:43 AM R131's oxygen tubing and cannula was coiled and stored unbagged in the handle of the concentrator. On 09/08/22 at 01:05 PM Certified Medication Aide (CMA) R stated oxygen tubing and cannula when not in use would be wrapped in a towel and placed in a drawer. On 09/08/22 at 01:20 PM Licensed Nurse (LN) I stated oxygen tubing was changed weekly on night shift and when soiled. LN, I stated oxygen tubing should be stored in a bag when not in use. On 09/08/22 at 03:59 PM Administrative Nurse D stated oxygen tubing should be stored in a bag when not in use. The facility Oxygen Management policy last revised November 2017 documented the cannula, mask, etc. would be stored in a plastic bag when not in use. The facility failed to store oxygen equipment in accordance with professional standards of practice placing R131 at risk for developing a respiratory infection and/or illness.

The facility identified a census of 80 residents. The sample included 18 residents with seven reviewed for unnecessary medications. Based of observations, record review, and interviews, the facility failed to ensure that the physician's ordered medication parameters were followed for Resident (R)27 and R39's blood pressure medication. This deficient practice placed the resident's at risk for unnecessary medication administration and adverse side effects. Findings Included: - The Medical Diagnosis section within R27's Electronic Medical Records (EMR) included diagnoses of type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypotension (low blood pressure), quadriplegia (paralysis of the arms, legs and trunk of the body below the level of an associated injury to the spinal cord), cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), neuralgia (severe pain due to damaged nerves that causes severe burning pain), and muscle weakness. R27's admission Minimum Data Set (MDS) dated 07/18/22 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS noted that he required extensive assistance from two staff members for bed mobility, dressing, and toileting. The MDS indicated that he was totally dependent on two staff for all transfers and bathing. The MDS noted he had been taking opioid (narcotic pain medication) medication for pain. A review of R27's Pain Care Area Assessment (CAA) dated 07/25/22 noted that he has alterations with his comfort levels due to his neuralgia (severe pain due to damaged nerves) and neuritis (inflammation of a or nerves, usually causing pain and loss of function) associated with his quadriplegia. The CAA noted that staff were to assess and treat with ordered medications. R27's Care Plan initiated 07/12/22 indicated that he had an alteration in movement, pain, pulse (heart rate) and touch sensations. The care plan instructed staff to give medications as ordered. The care plan indicated that staff were to monitor and document the treatment for effectiveness and side effects. A review of R27's EMR under Physician's Order revealed an order for midodrine (medication used to treat low blood pressure). The order noted for staff to give 10 milligrams (mg) of midodrine three times daily for hypotension. The order's parameters instructed that staff were to hold the medication if R27's systolic blood pressure (SBP-relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) was greater than (>) 140 millimeters of mercury (mmHg). R27's Medication Administration Record (MAR) review between 07/12/22 through 09/08/22 (59 days reviewed) revealed that the medication had been given on eight occasions outside of the given parameters. R27's EMR lacked documentation indicating why the medication had been given and if the physician had been notified. The dates noted were 8/3, 8/20, 8/23, 8/26, 8/28, 9/1, and 9/4. On 09/07/22 at 09:40AM R27 was in his room preparing for his discharge. Staff transferred R27 from his bed to an electric wheelchair with a mechanical lift with two staff assisting. Staff weighed R27 using the lift's weight scale and transferred to his chair. On 09/08/22 at 03:04PM Licensed Nurse (LN) H stated that when a resident was admitted to the facility each medication was reviewed and parameters were added based on the type of medication. She stated that if a medication needed to be held due to the parameters, it would be noted in the chart why it was held. She stated that medications should not be given outside of the parameters unless approved by the attending physician. She stated that a note should be entered showing why the medication was given or held. On 09/08/22 at 03:45PM Administrative Nurse D stated that nursing staff were required to review the medication parameters before administering the medications and notifying the physician. She stated that medications given should always be noted. She stated that the physicians were always around to ask in person if a medication should have been given and the nurse would not have noted it if they spoke to the physician in person. The facility did not provide a medication administration policy for review. The facility failed to follow R27's physician's order parameters for his blood pressure medication. This deficient practice placed R27 at risk for unnecessary medication administration and adverse side effects. - The Medical Diagnosis section within R39's Electronic Medical Records (EMR) included diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), atherosclerotic heart disease (hardening and narrowing of the blood vessels in the heart), hypertension (high blood pressure), and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid). R39's admission Minimum Data Set (MDS) dated 08/07/22 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS noted that R39 had hypertension and heart failure. The MDS noted that she received a diuretic (medication to promote the formation and excretion of urine) and opioid (medication used to treat pain) medication. A review of R39's Activities of Daily Living (ADL'S) Care Area Assessment (CAA) dated 08/12/22 noted that she received therapy and nursing services due to decreased ADL functioning related to a fall that occurred at home. R39's Care Plan initiated 08/01/2022 indicated that she had altered cardiovascular status due to her cardiac medical diagnoses and the use of diuretic medication. The care plan noted staff should monitor for shortness of breath and cyanosis (bluish discoloration of the skin) during cares. The care plan noted that R39 took lisinopril (medication used to lower high blood pressure and treat heart failure). A review of R39's EMR under Physician's Orders revealed an order for staff to give 40 milligrams (mg) of lisinopril once daily every morning for hypertension. The order's parameters instructed that staff were to hold the medication if R39's systolic blood pressure (SBP-relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) was less than (<) 110 millimeters of mercury (mmHg). R39's Medication Administration Record (MAR) revealed that the medication was given outside of parameters on two occasions (09/06/22 and 09/07/22). A review of R39's EMR revealed a lack of documentation indicating why the medication was given outside parameters. The MAR indicated that on the morning of 09/06/22 R39's SBP was documented as 104mmHg during medication administration and on the morning of 09/07/22 her SBP was 93mmHg. On 09/07/22 at 09:00AM R39 was clean, well-groomed, and completed her bath earlier in the morning. R39 stated that she was hopefully discharging soon and looking forward to going home. R39 reported that she was receiving her medication on time but she had concerns if her blood pressure was okay when she was taking her lisinopril this morning. On 09/08/22 at 03:04PM Licensed Nurse (LN) H stated that when a resident was admitted to the facility each medication was reviewed and parameters werw added based on the type of medication. She stated that if a medication needed to be held due to the parameters, it would be noted in the chart why it was held. She stated that medications should not be given outside of the parameters unless approved by the attending physician. She stated that a note should be entered showing why the medication was given or held. On 09/08/22 at 03:45PM Administrative Nurse D stated that nursing staff are required to review the medication parameters before administering the medications and notifying the physician. She stated that medications given should always be noted. She stated that the physicians were always around to ask in person if a medication should have been given and the nurse would not have noted it down. The facility did not provide a medication administration policy for review. The facility failed to follow R39's physician's order parameters for her blood pressure medication. This deficient practice placed R39 at risk for unnecessary medication administration and adverse side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 80 residents. The sample included 18 residents with five residents sampled for unnecessary medication review. Based on observation, record review and interview, the facility failed to ensure that Resident (R)11, R64, and R131 had an appropriate diagnosis for their antipsychotic (a class of medications used to treat psychosis and other mental emotional conditions) medication Seroquel (medication used to treat certain mental/mood conditions [such as schizophrenia a psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought]). This placed R11, R64, and R31 at risk for unnecessary antipsychotic medication administration and related side effects. Findings included: - The electronic medical record (EMR) for R11 documented diagnoses of: dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion and behaviors including agitation, verbal and physical aggression, wandering and hoarding), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), delusional disorder (a type of serious mental illness in which a person cannot tell what is real from what is imagined). The Significant Change Minimum Data Set (MDS) dated [DATE] documented R11 had a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition. R11 required extensive assistance with activities of daily living (ADLS) of one to two staff. R11 received an antipsychotic medication on seven of seven days during the lookback period. R11 received an antipsychotic medication on a routine basis. The Quarterly MDS dated 06/15/22 documented R11 had a BIMS score of zero which indicated severely impaired cognition. R11 showed behaviors of inattention that fluctuated. R11 required extensive assistance of one staff member for her ADLs. R11 received antipsychotic medications on a routine basis on seven of seven days during the lookback period. The Psychotropic Drug Use Care Area Assessment (CAA) documented R11 had the potential for adverse side effects due to the use of antidepressant (a class of medications used to treat mood disorders and relieve symptoms of depression) and antipsychotic medications. Both depression with behaviors and medications used to treat them can have a negative impact on the resident. Staff was to maintain adequate control of signs and symptoms with minimal to no adverse side effects. The Anti-psychotic Care Plan revised 03/28/22 documented R11 used antipsychotic medication Seroquel related to dementia with behaviors. Staff was to administer medication as ordered. Pharmacy was to consult month and as needed. The September 2022 Medication Administration Record (MAR) documented an order for Seroquel tablet 100 milligrams (mg) to give one tablet by mouth in the morning for anxiety/agitation related to dementia with behavioral disturbance with a start date of 08/23/2022. The September 2022 MAR documented an order for Seroquel tablet 200mg to give one tablet by mouth at bedtime for standard with a start date 06/27/2022. The clinical record lacked evidence the prescribing physician documented thoroughly the indication for the medication including the benefits versus risks, the multiple attempts to implement care-planned, non-pharmacological approaches. On 09/07/22 at 01:45PM R11 sat in her wheelchair in her room her spouse present with her. R11 was actively trying to stand up from her wheelchair to reach her spouse seated in front of her. On 09/08/22 at 07:32AM R11 laid upon her bed that was in low position, fall mats present on floor beside the bed. On 09/08/22 at 02:44 PM Licensed Nurse (LN) H stated that a dementia diagnosis was not appropriate for someone on Seroquel. LN H stated a person with a diagnosis of schizophrenia would be more appropriate diagnosis for Seroquel use. LN H did not have an explanation or reason why for standard would be used as a diagnosis on an order for R11. On 09/08/22 at 04:00 PM Administrative Nurse D stated Seroquel was an antipsychotic mediation used for schizophrenia and that dementia would not be an appropriate diagnosis for Seroquel use. The facility policy Psychotropic Drug Management Policy last revised January 2022 documented that the health care provider responsibilities included that the psychotropic medication order shall include the following information: an appropriate diagnosis for the medication. The facility failed to ensure an appropriate indication for use for the antipsychotic medication Seroquel. This failure had to potential of unnecessary antipsychotic medication use and related side effects for R11. - R64's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of eight which indicated moderately impaired cognition. The MDS documented that R64 was dependent on two staff members assistance for activities of daily living (ADL's). The MDS documented R64 received antipsychotic medication class of medications used to treat psychosis {any major mental disorder characterized by a gross impairment testing} and other mental emotional conditions), antidepressant medication, (class of medications used to treat mood disorders and relieve symptoms of depression) and antibiotics (class of medication used to treat bacterial infections) for seven days during the look back period. The Quarterly MDS dated 08/10/22 documented a BIMS score of four which indicated severely impaired cognitive. The MDS documented that R64 required extensive assistance of two staff members for ADL's. The MDS documented R64 received antipsychotic medication, antidepressant medication and antibiotics for seven days during the look back period. R64's Psychotropic Drug Use Care Area Assessment (CAA) dated 12/15/21 documented a dose reduction was done 09/22/21. R64's Care Plan dated 03/03/16// documented the pharmacist consultant would review R64's medication monthly. The Care Plan dated 03/01/18 documented quetiapine (Seroquel) increased mortality in R64 with dementia related psychosis. Documentation of benefits verse risk and gradual reductions of antipsychotic medications if possible. Review of the EMR under Orders tab revealed physician orders: Seroquel tablet (antipsychotic) give 12.5 milligram (mg) by mouth at bedtime related to dementia with behavioral dated 09/22/21. The clinical record lacked evidence the prescribing physician documented thoroughly the indication for the medication including the benefits versus risks, the multiple attempts to implement care-planned, non-pharmacological approaches. On 09/07/22 at 09:54 AM R64 was asleep in bed, bed was in the lowest position and the head of her bed was slightly elevated, no distress or behaviors were noted. On 09/08/22 at 02:44 PM Licensed Nurse (LN) H stated that a dementia diagnosis was not appropriate for someone on Seroquel. LN H stated a person with a diagnosis of schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) would be more appropriate diagnosis for Seroquel use. On 09/08/22 at 04:00 PM Administrative Nurse D stated Seroquel was an antipsychotic mediation used for schizophrenia and that dementia would not be an appropriate diagnosis for Seroquel use. The facility policy Psychotropic Drug Management Policy last revised January 2022 documented that the health care provider responsibilities included that the psychotropic medication order shall include the following information: an appropriate diagnosis for the medication. The facility failed to ensure an appropriate indication for use for the antipsychotic medication Seroquel. This failure had to potential of unnecessary antipsychotic medication use and related side effects for R64. - R131's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) and dementia with behaviors disturbances (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS) was in progress. R131 admitted [DATE]. R131's Care Area Assessment (CAA) was in progress. R131's Care Plan dated 08/29/22 documented medications would be administered as ordered and monitored for effectiveness and side effects. Review of the EMR under Orders tab revealed physician orders: Quetiapine fumarate (Seroquel) oral tablet 100 milligrams (mg) give one tablet by mouth four times a day related to dementia in other diseases classified elsewhere with behavioral disturbance dated 08/29/22. The clinical record lacked evidence the prescribing physician documented thoroughly the indication for the medication including the benefits versus risks, the multiple attempts to implement care-planned, non-pharmacological approaches. On 09/07/22 at 08:33 AM R131 sat in dining room as nursing staff sat next to R31 and assisted her with breakfast. On 09/08/22 at 02:44 PM Licensed Nurse (LN) H stated that a dementia diagnosis was not appropriate for someone on Seroquel. LN H stated a person with a diagnosis of schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) would be more appropriate diagnosis for Seroquel use. On 09/08/22 at 04:00 PM Administrative Nurse D stated Seroquel was an antipsychotic mediation used for schizophrenia and that dementia would not be an appropriate diagnosis for Seroquel use. The facility policy Psychotropic Drug Management Policy last revised January 2022 documented that the health care provider responsibilities included that the psychotropic medication order shall include the following information: an appropriate diagnosis for the medication. The facility failed to ensure an appropriate indication for use for the antipsychotic medication Seroquel. This failure had to potential of unnecessary antipsychotic medication use and related side effects for R131.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 80 residents. The sample included 18 residents with seven reviewed for medication regimen review. Based of observations, record review, and interviews, the facility failed to ensure that the Consulting Pharmacist (CP) identified Resident (R)27's blood pressure medication given outside of physician ordered parameters. The CP also did not identify and report an inappropriate diagnoses for R11, R31, and R64's antipsychotic medications (class of medications used to treat psychosis and other mental emotional conditions). This placed the residents at risk for unnecessary medication and adverse side effects. Findings Included: - The Medical Diagnosis section within R27's Electronic Medical Records (EMR) included diagnoses of type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypotension (low blood pressure), quadriplegia (paralysis of the arms, legs and trunk of the body below the level of an associated injury to the spinal cord), cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), neuralgia (severe pain due to damaged nerves that causes severe burning pain), and muscle weakness. R27's admission Minimum Data Set (MDS) dated 07/18/22 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS noted that he required extensive assistance from two staff members for bed mobility, dressing, and toileting. The MDS indicated that he was totally dependent on two staff for all transfers and bathing. The MDS noted he had been taking opioid (narcotic pain medication) medication for pain. A review of R27's Pain Care Area Assessment (CAA) dated 07/25/22 noted that he had alterations with his comfort levels due to his neuralgia (severe pain due to damaged nerves) and neuritis (inflammation of a or nerves, usually causing pain and loss of function) associated with his quadriplegia. The CAA noted that staff were to assess and treat with ordered medications. R27's Care Plan initiated 07/12/22 indicated that he had an alteration in movement, pain, pulse (heart rate) and touch sensations. The care plan instructed staff to give medications as ordered. The care plan indicated that staff were to monitor and document the treatment for effectiveness and side effects. A review of R27's EMR under Physician's Order revealed an order for midodrine (medication used to treat low blood pressure). The order noted for staff to give 10 milligrams (mg) of midodrine three times daily for hypotension. The order's parameters instructed that staff were to hold the medication if R27's systolic blood pressure (SBP-relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) was greater than (>) 140 millimeters of mercury (mmHg). R27's Medication Administration Record (MAR) review from 07/12/22 throught 09/08/22 (59 days reviewed)revealed that the medication had been given on eight occasions outside of the ordered parameters. R27's EMR lacked documentation indicating why the medication had been given and if the physician had been notified. The dates noted were 8/3, 8/20, 8/23, 8/26, 8/28, 9/1, and 9/4. A review of R27's Pharmacy Medication Regimen Reviews completed for August 2022 revealed that the pharmacy had no concerns or recommendations related to R27's medications or physician's orders. On 09/07/22 at 09:40AM R27 was in his room preparing for his discharge. Staff transferred R27 from his bed to electric wheelchair with a mechanical lift with two staff assisting. R27 was weighed using the lift's weight scale and transferred to his chair. R27 completed personal hygiene and awaited his transportation for discharge. On 09/08/22 at 03:45PM Administrative Nurse D stated that nursing staff were required to review the medication parameters before administering the medications and notifying the physician. She stated that medications given should always be noted. She stated that the physicians were always around to ask in person if a medication should have been given and the nurse would not have noted it down. On 09/08/22 at 04:00 PM Administrative Nurse D stated that the pharmacy recommendations got emailed to her and all the unit managers. The unit manager was then responsible for following up with and completing the recommendations. On 09/12/2022 at 02:49PM the CP was unavailable for interview. A review of the facility's Medication Regimen Review (MRR) policy revised 07/2018 noted that a medication review is completed for each resident at the time of admission, monthly, and as indicated upon the resident's condition. The policy noted that the consulting pharmacist (CP) will identify and report medication irregularities identified during the review to the facility. The facility failed to ensure that the CP identified and reported R27's blood pressure medication was given on eight occasions outside of the ordered parameters. This deficient practice place R27 at risk for complications related to his cardiovascular health. - The electronic medical record (EMR) for R11 documented diagnoses of: dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion and behaviors including agitation, verbal and physical aggression, wandering and hoarding), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), delusional disorder (a type of serious mental illness in which a person cannot tell what is real from what is imagined). The Significant Change Minimum Data Set (MDS) dated [DATE] documented R11 had a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition. R11 required extensive assistance with activities of daily living (ADLS) of one to two staff. R11 received an antipsychotic medication on seven of seven days during the lookback period. R11 received an antipsychotic medication on a routine basis. The Quarterly MDS dated 06/15/22 documented R11 had a BIMS score of zero which indicated severely impaired cognition. R11 showed behaviors of inattention that fluctuated. R11 required extensive assistance of one staff member for her ADLs. R11 received antipsychotic medications on a routine basis on seven of seven days during the lookback period. The Psychotropic Drug Use Care Area Assessment (CAA) documented R11 had the potential for adverse side effects due to the use of antidepressant (a class of medications used to treat mood disorders and relieve symptoms of depression) and antipsychotic medications. Both depression with behaviors and medications used to treat them can have a negative impact on the resident. Staff was to maintain adequate control of signs and symptoms with minimal to no adverse side effects. The Anti-psychotic Care Plan revised 03/28/22 documented R11 used antipsychotic medication Seroquel related to dementia with behaviors. Staff was to administer medication as ordered. Pharmacy was to consult month and as needed. The September 2022 Medication Administration Record (MAR) documented an order for Seroquel tablet 100 milligrams (mg) to give one tablet by mouth in the morning for anxiety/agitation related to dementia with behavioral disturbance with a start date of 08/23/2022. The September 2022 MAR documented an order for Seroquel tablet 200mg to give one tablet by mouth at bedtime for standard with a start date 06/27/2022. Upon review of the Medication Regimen Review (MRR) for the months of January 2022 through August 2022 the CP noted no irregularities related to R11's Seroquel order. The CP only made recommendations in January 2022 and March 2022 for a gradual dose reduction of the Seroquel. The physician's response dated 04/14/22 was to decline the recommendation due to R11 being on hospice services with behaviors, combative and delusions. No changes made at that time. The clinical record lacked evidence the prescribing physician documented thoroughly the indication for the medication including the benefits versus risks, the multiple attempts to implement care-planned, non-pharmacological approaches. On 09/07/22 at 01:45PM R11 sat in her wheelchair in her room her spouse present with her. R11 was actively trying to stand up from her wheelchair to reach her spouse seated in front of her. On 09/08/22 at 07:32AM R11 laid upon her bed that was in low position, fall mats present on floor beside the bed. On 09/08/22 at 01:20 PM Licensed Nurse (LN) I stated that she did not have anything directly to do with the pharmacy recommendations and were taken care of by the unit nurse managers. On 09/08/22 at 02:44 PM Licensed Nurse (LN) H stated that the unit managers would receive the monthly pharmacy recommendations from Administrative Nurse D and the unit managers would take care of the recommendations. On 09/08/22 at 04:00 PM Administrative Nurse D stated that the pharmacy recommendations got emailed to her and all the unit managers. The unit manager was then responsible for following up with and completing the recommendations. On 09/12/22 at 01:30 PM the CP was unavailable for interview. The facility policy Medication Regimen Review Policy dated July 2018 documented the CP should review each resident's medical record, progress notes and other applicable documents as necessary per state and federal regulations, to determine whether or not irregularities exist in his/her medication regimen and complete a MRR. The facility failed to ensure the CP identified and reported an incorrect diagnosis for the antipsychotic This failure had to potential of unnecessary antipsychotic medication use and related side effects for R11. - R131's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) and dementia with behaviors disturbances (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS) was in progress. R131 admitted [DATE]. R131's Care Area Assessment (CAA) was in progress. R131's Care Plan dated 08/29/22 documented medications would be administered as ordered and monitored for effectiveness and side effects. Review of the EMR under Orders tab revealed physician orders: Quetiapine fumarate (Seroquel) oral tablet 100 milligrams (mg) give one tablet by mouth four times a day related to dementia in other diseases classified elsewhere with behavioral disturbance dated 08/29/22. The Monthly Medication Review (MMR), performed by the CP for August 2022 lacked identification of the inappropriate diagnosis for R31 who received antipsychotic medication with a diagnosis of dementia. The clinical record lacked evidence the prescribing physician documented thoroughly the indication for the medication including the benefits versus risks, the multiple attempts to implement care-planned, non-pharmacological approaches. On 09/07/22 at 08:33 AM R131 sat in dining room as nursing staff sat next to R31 and assisted her with breakfast. On 09/08/22 at 01:20 PM Licensed Nurse (LN) I stated that she did not have anything directly to do with the pharmacy recommendations and were taken care of by the unit nurse managers. On 09/08/22 at 02:44 PM Licensed Nurse (LN) H stated that the unit managers would receive the monthly pharmacy recommendations from Administrative Nurse D and the unit managers would take care of the recommendations. On 09/08/22 at 04:00 PM Administrative Nurse D stated that the pharmacy recommendations got emailed to her and all the unit managers. The unit manager was then responsible for following up with and completing the recommendations. On 09/12/22 at 01:30 PM the CP was unavailable for interview. The facility policy Medication Regimen Review Policy dated July 2018 documented the CP should review each resident's medical record, progress notes and other applicable documents as necessary per state and federal regulations, to determine whether or not irregularities exist in his/her medication regimen and complete a MRR. The facility failed to ensure the CP identified and reported an incorrect diagnosis for the antipsychotic This failure had to potential of unnecessary antipsychotic medication use and related side effects for R131. - R64's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of eight which indicated moderately impaired cognition. The MDS documented that R64 was dependent on two staff members assistance for activities of daily living (ADL's). The MDS documented R64 received antipsychotic medication class of medications used to treat psychosis {any major mental disorder characterized by a gross impairment testing} and other mental emotional conditions), antidepressant medication, (class of medications used to treat mood disorders and relieve symptoms of depression) and antibiotics (class of medication used to treat bacterial infections) for seven days during the look back period. The Quarterly MDS dated 08/10/22 documented a BIMS score of four which indicated severely impaired cognitive. The MDS documented that R64 required extensive assistance of two staff members for ADL's. The MDS documented R64 received antipsychotic medication, antidepressant medication and antibiotics for seven days during the look back period. R64's Psychotropic Drug Use Care Area Assessment (CAA) dated 12/15/21 documented a dose reduction was done 09/22/21. R64's Care Plan dated 03/03/16// documented the pharmacist consultant would review R64's medication monthly. The Care Plan dated 03/01/18 documented quetiapine (Seroquel) increased mortality in R64 with dementia related psychosis. Documentation of benefits verse risk and gradual reductions of antipsychotic medications if possible. Review of the EMR under Orders tab revealed physician orders: Seroquel tablet (antipsychotic) give 12.5 milligram (mg) by mouth at bedtime related to dementia with behavioral dated 09/22/21. The Monthly Medication Review (MMR), performed by the CP reviewed from August 2021 through August 2022 lacked identification of the inappropriate diagnosis for R64 who received antipsychotic medication with a diagnosis of dementia. The clinical record lacked evidence the prescribing physician documented thoroughly the indication for the medication including the benefits versus risks, the multiple attempts to implement care-planned, non-pharmacological approaches. On 09/07/22 at 09:54 AM R64 was asleep in bed, bed was in the lowest position and the head of her bed was slightly elevated, no distress or behaviors were noted. On 09/08/22 at 01:20 PM Licensed Nurse (LN) I stated that she did not have anything directly to do with the pharmacy recommendations and were taken care of by the unit nurse managers. On 09/08/22 at 02:44 PM Licensed Nurse (LN) H stated that the unit managers would receive the monthly pharmacy recommendations from Administrative Nurse D and the unit managers would take care of the recommendations. On 09/08/22 at 04:00 PM Administrative Nurse D stated that the pharmacy recommendations got emailed to her and all the unit managers. The unit manager was then responsible for following up with and completing the recommendations. On 09/12/22 at 01:30 PM the CP was unavailable for interview. The facility policy Medication Regimen Review Policy dated July 2018 documented the CP should review each resident's medical record, progress notes and other applicable documents as necessary per state and federal regulations, to determine whether irregularities exist in his/her medication regimen and complete an MRR. The facility failed to ensure the CP identified and reported an incorrect diagnosis for the antipsychotic This failure had to potential of unnecessary antipsychotic medication use and related side effects for R64.

The facility identified a census of 80 residents. Based of observations, record review, and interviews, the facility failed to promote adequate infection control practices related to wound care for Residents (R)72, R33, R73, and R180. This deficient practice placed the residents at risk for complications related to wound infections and increased the risk for cross contamination. Findings Included: - On 09/07/22 at 10:20AM while performing wound care to R180, Licensed Nurse (LN) G gathered supplies and placed a Chux pad (absorbent disposable barrier) under R180. LN G washed her hands and donned gloves. LN G opened the supplies onto the Chux pad. LN G then removed the old bandages and threw them into the trash can. LN G then cleaned the wound area with the same soiled gloves. LN G removed her gloves and threw them in the trash. LN G donned a new pair of gloves without completing hand hygiene and applied new bandages. LN G gathered the used supplies and repositioned R180 in a comfortable position. LN G removed her gloves and completed hand hygiene. On 09/07/22 at 10:30AM R33 received wound care from LN G. LN G washed her hands and donned gloves. LN G placed Chux pad on the floor and used scissors to remove the dressing from R33's left heel. LN G placed the soiled scissors in a container holding clean wound care supplies. LN G replaced her soiled gloves. LN G cleaned the left heel then set the heel directly onto the Chux pad. LN G used the soiled scissors to trim the new dressing and applied it to R33's left heel wound. LN G wrapped the wound with kerlix (woven absorbent gauze). On 09/08/22 at 10:51AM R73 received wound care from LN G. LN G washed her hands, donned gloves, and placed a Chux pad on the bed under R73's heel-boots. LN G removed R73's boots and rested R73's stocking feet on the Chux pad. LN G then removed R73's socks and rested the feet on Chux pad. LN G removed R73's soiled wound dressing from the left heel then placed her heel on the Chux Pad. LN G sprayed wound cleanser onto R73's heel and then placed the heel back onto the same Chux pad. LN G repeated the process with R73's right heels. LN G reapplied the soiled socks and boots and removed the barrier. LN G doffed her gloves and completed hand hygiene. On 09/08/22 at 10:50AM R72 received wound care from LN G. R72 laid in bed and wore her Prevalon boots (boots that protect heel and feet from pressure surfaces). LN G washed her hands and donned gloves. LN G lifted R72's legs and placed a Chux pad down. LN G lowered R72's legs down onto the Chux pad and removed R72's Prevalon boots and lowered her feet back down to the Chux pad. LN G removed R72's socks and lowered her bare feet back down to the Chux pad. LN G assessed R72's heels and removed the left ankle pressure injury dressing. LN G cleansed the wound with betadine wound wash and allowed wound to air dry. LN G applied pre-prepared dressing to the left ankle wound. LN G then assessed R72's left heel wound. LN G applied betadine cleaner to the left heel wound and allowed to dry but then placed left heel back down on soiled Chux pad. LN G repeated the process with the right heel and returned it directly to the soiled Chux pad. LN G put R42's same socks and Prevalon boots back on after the wound care and positioned her in a comfortable position. LN failed to change her gloves throughout the wound care. In an interview on 09/08/22 at 02:55PM with LN G, she stated that hand hygiene should have been performed throughout providing wound care. She stated that clean surfaces should never be placed on soiled or contaminated surfaces. In an interview on 09/08/22 at 03:20PM with Administrative Nurse E stated that staff are regularly trained and reminded to complete hand hygiene in between providing cares to residents. She stated that staff complete annual in-services on infection control and have monthly training on topics like hand hygiene, peri-care, and infection prevention. A review of the facility's Skin and Wound Care protocol revised 09/2017 stated that heel ulcers must be assessed frequently for evidence of infections. The noted evidence included increased drainage, color change, warmth, pain, swelling, and fever. The protocol noted for staff to clean wound with cleanser and notify the physician. The facility failed to promote adequate infection control practices related to wound care for R72, R33, R73, and R180. This deficient practice placed the residents at risk for complications related to wound infections and increased potential for spread of infectious disease