**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 40 residents. The sample included 3 residents. Based on observation, record review, and interview, the facility failed to ensure staff immediately reported an allegation of potential abuse and neglect to the administrator. Resident (R)1 reported an allegation of potential abuse and neglect to Licensed Nurse G, after Certified Nurse Aide M did not provide assistance to R1 for urinary care and R1 had a soaked brief. LN G did not report the incident to administrative staff. This failure placed R1 at risk for continued neglect. Findings Included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), and urine retention (lack of ability to urinate and empty the bladder). R1's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R1 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 was dependent on staff with toileting. R1's Care Plan, revised 03/01/25, documented R1 had a urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag). The care plan instructed staff to assess the resident catheter quarterly and as needed (PRN) for continued use, change as the physician ordered, monitor and document intake and output, notify the physician of any signs of infection, and use a catheter strap-on the catheter. The care plan documented the resident did not use a toilet, bedpan, or bedside commode, access with checking and changing brief, and provide perineal (private area) care with every incontinent episode as R1 allows. The Facility's Investigation sheet, dated 02/17/25, documented Administrative Nurse D was called by charge nurse Licensed Nurse (LN) G at 06:38 AM on 02/17/25 to report R1 needed to talk to Administrative Nurse D as soon as she came in to work. The investigation documented Administrative Nurse D and Social Service Designee (SSD) X went in to see R1 as they arrived for work. R1 reported Certified Nurse Aide (CNA) M would not change her last night when R1 called CNA M to her room. R1 reported CMA M told her she did not need changed and left the room. R1 reported to the other aide who came in and changed R1's brief. R1's brief was soaked. The investigation documented that R1 was afraid of CNA M. The incident report documented CMA M was terminated on 02/18/25. The Witness Statement, from LN G documented on 02/14/25 on the 10 PM - 6 AM shift CNA M answered R1's call light and R1 reported to CNA M she was wet and needed to be changed, and CNA M told R1 You are not wet, you have a catheter. The statement documented that R1's catheter does leak around it. The note documented LN G attempted to educate CNA M and CNA M stated She [R1] is lying to me [CNA M] and to you [LN G], and she did her job. CNA M was unable to be educated. On 03/04/25 at 11:00 AM, observation revealed R1 sat in a wheelchair in the living room area of the facility at an activity. On 03/04/25 at 09:13 AM, Administrative Staff A verified LN G's witness statement revealed R1 had reported to LN G on the night shift starting on 02/16/25- 02/17/25 and stated she was unaware the incident had been reported to LN G. Administrative Staff A stated LN G would be getting educated on reporting the incident to administration immediately. 03/04/25 at 11:14 AM, Administrative Nurse D stated whenever there is an allegation of abuse staff should immediately report it to her and Administrative Staff A. Administrative Nurse D verified CNA M was not immediately suspended when the allegation was reported to LN G and that CNA M should have been. The facility's Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, revised 3/3/2022, documented that upon receiving a report of an allegation of resident abuse, neglect, exploitation, or mistreatment the facility would immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process. If this involved an allegation of abuse by an employee, this would be accomplished by separating the employee accused of abuse from all residents through the following or a combination of the following, if practicable: 1) suspending the employee 2) segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility. The facility staff failed to report to the administration immediately a potential allegation of abuse when staff failed to provide incontinent care for R1. Based on the reasonable person concept, this deficient practice placed the residents at risk for neglect and the potential for negative psychosocial impact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 41 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 30 had a physician's order and was assessed for the ability to safely self-administer medications left at the bedside. This placed R30 at risk for improper use of medication and related side effects. Findings included: - R30's Electronic Medical Record (EMR) documented R30 had diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, a history of transient ischemic attack (TIA- temporary episode of inadequate blood supply to the brain), and major depressive disorder (major mood disorder which causes persistent feelings of sadness). R30's Quarterly Minimum Data Set (MDS), dated [DATE], documented R30 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R30 independent with activities of daily living (ADLs). R30's Care Plan, revised 11/22/23, documented R30 requested to self-administer her inhaler medications at bedside and a safe administration of medication assessment had determined that R30 was capable of completing this task with appropriate safety awareness. The care plan documented R30 could only self-administer her inhalers; nursing would observe the response to medications that were administered and report to the physician if any adverse effects were noted. The Physician Oder, dated 06/30/23, instructed staff to allow R30 to self-administer her Symbicort (an inhaled medication that reduces inflammation in the airways), Spiriva (an inhaled medication used to relax your airways and keep them open), and albuterol (an inhaled medication used to relax muscles in airways and increases airflow to the lungs) inhalers at the bedside, two times daily. The Physician Orders, dated 06/30/23, directed staff to administer Aspirin, 81milligram (mg), delayed-release tablet, in the morning, for cerebral infarction(stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), clopidogrel bisulfate, 75mg tablet, in the morning for cerebral infarction, escitalopram oxalate, 20 mg, tablet for major depressive disorder(major mood disorder which causes persistent feelings of sadness), two potassium chloride extended-release capsules, 10 milliequivalent (meq), in the morning for hypokalemia (low potassium), one Calcium+D3 Tablet, 600-800 MG, twice a day for osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), one Colace capsule,100 mg, two times a day for constipation (difficulty passing stools), one cranberry tablet two times a day for urinary tract infection (UTI-an infection in any part of the urinary system) prevention, one Mucinex (a medication used to loosen congestion in your chest and throat, making it easier to cough out through your mouth) extended-release (ER)12 Hour, 600 mg, tablet, for cough, one oxybutynin chloride (a medication used to treat symptoms of overactive bladder, such as frequent or urgent urination, incontinence (urine leakage), and increased night-time urination), 5 mg, tablet two times daily for disorders of the bladder (hollow organ that stores urine). The Physician Order, dated 07/07/23, directed staff to administer one Norco, 5-325mg, tablet four times daily related to pain. The Physician Order, dated 07/13/23, directed staff to administer losartan potassium, 1/2 of 25mg tablet, in the morning for thalamic hemorrhage (bleeding into a part of the brain). R30's clinical record lacked evidence the facility assessed R30 for the ability to safely self-administer medications in pill or tablet form or medications other than inhalers. On 01/02/24 at 09:23 AM, observation revealed staff left the above medications on R30's bedside table unattended and R30 self-administered the medications. On 01/08/24 at 09:22 AM, Certified Medication Aide (CMA) R stated R30 had a physician order to self-administer her inhalers but could not self-administer her other medications. On 01/08/24 at 08:16 AM, Administrative Nurse D verified R30 could self-administer her inhalers but not her other medications. Administrative Nurse D stated R30 she expected staff to stay with R30 until R30 took her other medications. The facility's Administering Medications Policy, revised in December 2012, instructed staff to administer medications in accordance with the physician's orders. Residents may self-administer their medications only if the attending physician, in conjunction with the interdisciplinary care planning team, had determined that they had the decision-making capacity to do so safely. The facility failed to ensure R30 had a physician order and the ability to safely self-administer medications before leaving medications at the bedside. This placed the resident at risk for improper use of medication and related side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 41 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to honor Resident (R) 4's preference to receive three showers per week. This placed R4 at risk for decreased self-determination and impaired psychosocial well-being. Findings included: - The Electronic Medical Record (EMR) for R4 documented diagnoses of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods). The Annual Minimum Data Set (MDS), dated [DATE], documented R4 had intact cognition and required substantial to maximum assistance with showering, toileting, supervision with personal hygiene, and dressing of her upper body, and was always incontinent of bladder and bowel. The MDS further documented it was very important to R4 to choose a bath, shower, or bed bath. R4's Care Plan, dated 10/25/23, initiated on 01/04/18, documented R4 required staff assistance for bathing 2-3 times per week and as needed. The update, dated 10/27/23, documented R4 required two staff assistance for bathing twice per week. The facility's Bathing Record, for October 2023 documented R4 received three showers per week, on dayshift Monday, Wednesday, and Friday until the week of 10/23/23, when R4's showers were changed to Monday and Thursday. On 01/02/24 at 01:10 PM, R4 stated when she first came to the facility, she asked for showers five times a week and was told that she could have them three times a week and told what days she would receive them. R4 stated that now, she never knows what days the showers are because the facility switches them around so much. R4 said she does not remember when the last time she had a shower because she had not been getting even two showers a week. Observation revealed R4's hair was uncombed and greasy. On 01/04/24 at 10:00 AM, Administrative Nurse E stated that residents could have a shower every day if they wanted to, but showers were typically Monday through Friday. Administrative Nurse E said one of the Certified Nurse Aides (CNA) who gave showers had varied days off during the week, so one day she was off on Tuesday, so showers on Tuesdays were given on Wednesday; if she was off on Thursday, the showers were moved to a different day. Administrative Nurse E further stated sometimes staff had to rearrange the showers to different days if there were too many to give on a particular day. On 01/08/24 at 08:30 AM, CNA O stated shower sheets were completed at the time the resident received a shower and if they refused the shower, it was documented on that sheet and the nurse would talk with the resident to find a different time to do the shower. On 01/08/25 at 10:44 AM, Administrative Nurse D stated staff talked to the resident when the shower schedule was changed, and she was unaware R4 was unhappy her showers were not three days per week. Administrative Nurse D stated she would educate staff to make sure R4 received her showers. The facility's Resident Rights policy dated 10/2010 documented that residents have the freedom of choice and would be treated with respect, kindness, and dignity. The facility failed to honor R4's preference of receiving three showers a week which placed the resident at risk for decreased self-determination and impaired psychosocial well-being.

The facility had a census of 41 residents. The sample included 14 residents, with three reviewed for Medicare Liability Notices. Based on record review and interview, the facility failed to provide the resident (or their representative) a fully completed Advanced Beneficiary Notice (ABN) for skilled services for Resident (R) 17, R31, and R36 which included the estimated cost of services. This placed the resident at risk for uninformed care decisions. Findings included: -The Medicare Advanced Beneficiary Notice (ABN) informed the beneficiary that Medicare may not pay for future skilled therapy services and provided a cost estimate of continued services. The form included an option for the beneficiary to (1) receive specified therapy listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I am responsible for payment, but can appeal to Medicare. (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services. (3) I do not want the listed therapy services. The facility lacked documentation R17 was provided with the Center of Medicare (CMS)-10055 form when the resident's skilled services ended 09/26/23, which informed the resident (or their representative) of the estimated cost of skilled services if an appeal to Medicare was denied, leaving the resident responsible for payment of skilled services. The facility lacked documentation R31 was provided with the Center of Medicare (CMS)-10055 form when the resident's skilled services ended on 12/06/23, which informed the resident (or their representative) of the estimated cost of skilled services if an appeal to Medicare was denied, leaving the resident responsible for payment of skilled services. The facility lacked documentation R36 was provided with the Center of Medicare (CMS)-10055 form when the resident's skilled services ended 06/20/23, which informed the resident (or their representative) of the estimated cost of skilled services if an appeal to Medicare was denied, leaving the resident responsible for payment of skilled services. On 01/04/24 at 12:14 PM, Social Service X reported she had not included the estimated cost of continued services on the CMS-10055 form. The facility's Medicare Advance Beneficiary and Medicare Non-Coverage Notices policy, dated 09/2022, documented Skilled Nursing Facility Advanced Beneficiary Notice (CMS form 10055) the director of admissions or benefits coordinator believes ( upon admission or during the resident's stay) that Medicare (Part A of the fee for service Medicare Program) will not pay for an otherwise covered skilled service(s), the resident(or representative) is notified in writing why the service(s) may not be covered and of the resident's potential liability for payment of the non-covered service (s). at termination in the situation in which the facility proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for items or services that a physician had ordered and the beneficiary would like to continue receiving care, the SNF ABN is issued to the beneficiary before such extended care items or services are terminated. The resident (or representative) is informed that they may choose to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. The facility failed to provide the resident (or their representative) the completed CMS-10055 form when discharged from skilled services for R17, R31, and R36 which included the estimated cost of continued services. This placed the residents at risk of making uninformed decisions for their skilled services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 41 residents. The sample included 14 residents, with six reviewed for bathing. Based on observation, record review, and interview, the facility failed to provide consistent bathing services as care planned for one sampled resident, Resident (R) 4. This placed the resident at risk for poor hygiene. Findings included: - The Electronic Medical Record (EMR) for R4 documented diagnoses of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods). The Annual Minimum Data Set (MDS), dated [DATE], documented R4 had intact cognition and required substantial to maximum assistance with showering, toileting, supervision with personal hygiene, and dressing of her upper body, and was always incontinent of bladder and bowel. The MDS further documented it was very important to R4 to choose a bath, shower, or bed bath. R4's Care Plan, dated 10/25/23, initiated on 01/04/18, documented R4 required staff assistance for bathing 2-3 times per week and as needed. The update, dated 10/27/23, documented R4 required two staff assistance for bathing twice per week. The October 2023 Bathing Report documented R4 requested showers on Monday, Wednesday, and Friday and lacked documentation R4 received the requested three showers. The EMR lacked documentation R4 refused her bath or shower. The November 2023 Bathing Report documented R4 requested showers on Monday and Thursday and lacked documentation R4 received the requested two showers. The EMR lacked documentation R4 refused her bath or shower. The December 2023 Bathing Report documented R4 requested showers on Monday and Thursday and lacked documentation R4 received the requested two showers. The EMR lacked documentation R4 refused her bath or shower. On 01/02/24 at 01:10 PM, R4 stated when she first came to the facility, she asked for showers five times a week and was told that she could have them three times a week and told what days she would receive them. R4 stated that now, she never knows what days the showers are because the facility switches them around so much. R4 said she does not remember when the last time she had a shower because she had not been getting even two showers a week. Observation revealed R4's hair was uncombed and greasy. On 01/04/24 at 10:00 AM, Administrative Nurse E stated that residents could have a shower every day if they wanted to, but showers were typically Monday through Friday. Administrative Nurse E said one of the Certified Nurse Aides (CNA) who gave showers had varied days off during the week, so one day she was off on Tuesday, so showers on Tuesdays were given on Wednesday; if she was off on Thursday, the showers were moved to a different day. Administrative Nurse E further stated sometimes staff had to rearrange the showers to different days if there were too many to give on a particular day. On 01/08/24 at 08:30 AM, CNA O stated shower sheets were completed at the time the resident received a shower and if they refused the shower, it was documented on that sheet and the nurse would talk with the resident to find a different time to do the shower. On 01/08/25 at 10:44 AM, Administrative Nurse D stated staff talked to the resident when the shower schedule was changed, and she was unaware R4 was unhappy her showers were not three days per week. Administrative Nurse D stated she would educate staff to make sure R4 received her showers. The facility's Shower/Tub Bath policy, dated 10/2010, documented the facility provided comfort and cleanliness to the resident and directed staff to observe the condition of the resident's skin. The policy further directed staff to notify the supervisor if the resident refused the bath and to notify the physician of any skin areas that may need to be treated. The facility failed to provide R4 consistent bathing services, placing the resident at risk for poor hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R31's Electronic Medical Record (EMR) documented R31 had diagnoses of chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hypertension (HTN-elevated blood pressure), pain, weakness, hemiplegia (paralysis of one side of the body) affecting left nondominant side, pneumonia (inflammation of the lungs), respiratory failure with hypoxia (inadequate supply of oxygen), and abnormal weight loss. R31's Quarterly Minimum Data Set (MDS), dated [DATE], documented R31 had intact cognition, no delirium, or behavioral symptoms, was frequently incontinent of urine, had pain which occasionally affected sleep and interfered with therapy and day-to-day activities. The MDS further documented R31 has shortness of breath or trouble breathing when lying flat and received antibiotics, oxygen, and physical and occupational therapy. R31's Care Plan, dated 10/05/23, documented R31 had a diagnosis of chronic obstructive pulmonary disease and was at risk for shortness of breath, impaired breathing, and respiratory infections. The care plan instructed staff to administer medications as ordered and observe for effectiveness and side effects and abnormal findings to the physician. The care plan further directed staff to monitor for signs of respiratory infections/distress and report as necessary to the physician. The Physician Orders, dated 11/13/23, directed staff to administer oxygen via nasal cannula as needed to keep oxygen saturation greater than 90 percent (%). The Progress Note dated 11/13/23 at 02:51 PM, documented R31 arrived at the facility following a hospitalization for pneumonia, R31 appeared and reported shortness of breath following transfer and getting situated in the room. On 01/03/24 at 07:55 AM, observation revealed R31 lying in bed on her right side with oxygen tubing and nasal cannula on the floor and base of the over-bed table. On 01/04/24 at 07:56 AM, observation revealed R31 in bed with eyes closed. R31's oxygen tubing and nasal cannula draped over the bed cane on the right side of the bed. The observation further revealed no storage bag was attached to the oxygen concentrator. On 01/04/24 at 09:55 AM, Licensed Nurse (LN) G stated R31 received oxygen as needed and the oxygen tubing should be stored in a bag on the concentrator when not in use. On 01/08/24 at 08:50 AM, Administrative Nurse D verified oxygen tubing and nasal cannula should be stored in a blue bag attached to the oxygen concentrator when not in use, and it was the staff's responsibility to place it in the bag when R31 was not using or in need of oxygen. The facility's Departmental (Respiratory Therapy)-Prevention of Infection policy, dated 11/2011, documented that the purpose of this procedure is to guide the prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Infection control considerations related to oxygen use to keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. The facility failed to store oxygen cannula and tubing in a sanitary way for R31 which placed the resident at risk for respiratory infections. The facility had a census of 41 residents. The sample included 14 residents, with two reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to provide adequate respiratory care and services for Residents (R) 38, and R31 when staff failed to store their oxygen tubing and cannula in a sanitary manner when not in use. This placed the residents at risk for an infection. Findings included: - The Electronic Medical Record (EMR) documented R38 had diagnoses of heart failure, hemiplegia of the non-dominant side (paralysis of one side of the body), and dependence on supplemental oxygen. R38's admission 5-day Medicare Minimum Data Set (MDS), dated [DATE], documented R38 had intact cognition and required partial assistance for ambulation, was dependent upon staff for transfers, partial to moderate assistance with personal hygiene, upper functional impairment on one side, and lower functional impairment both sides. The assessment further documented R38 required oxygen use. R38's Care Plan, dated 12/13/23, documented R38 used continuous oxygen, and directed staff to change oxygen tubing and humidifier per the facility policy, check his oxygen saturation (percentage of oxygen in the blood) every shift as ordered, and if the saturation is should be greater than 90%, if not, contact the physician, elevate his head of bed as he allowed, monitor for signs and symptoms of respiratory distress and report as needed to the physician, and oxygen via nasal annular as ordered. R38's Physician's Order, dated 12/13/23 documented R38 required 3 liters of oxygen continuously related to dependence on supplemental oxygen, and directed staff to change the oxygen tubing, nasal cannula, humidifier, and clean the concentrator filter every Saturday on night shift. On 01/02/24 at 01:23 PM, observation revealed R38's oxygen tubing and cannula laid unbagged on the seat of his wheelchair, and the oxygen concentrator running. On 01/03/24 at 08:00 AM, observation revealed R38's oxygen tubing and cannula laid unbagged on the seat of his wheelchair, and the oxygen concentrator running. On 01/04/23 at 09:54 AM, observation revealed R38's oxygen tubing and cannula laid unbagged on the seat of his wheelchair, and the oxygen concentrator running. On 01/08/24 at 12:50 PM, observation revealed R38's oxygen tubing and cannula laid unbagged on his nightstand. On 01/04/24 at 10:00 AM, Certified Nurse Aide (CNA) M stated that the oxygen tubing and cannula should be put into the black bag when not in use. On 01/08/24 at 08:44 AM Administrative Nurse D stated any oxygen tubing should be in a bag when not in use. The facility's Prevention of Infection policy, dated 11/2011, documented the oxygen cannula and tubing are changed every 7 days and as needed and are kept in a plastic bag when not in use. The facility failed to provide adequate respiratory care and services for R38 when staff failed to store their oxygen tubing and cannula in a sanitary manner when not in use. This placed the resident at risk for an infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 41 residents. The sample included 14 residents with two reviewed for behaviors. Based on observation, record review, and interview, the facility failed to complete a trauma-informed care assessment for one sampled resident, Resident (R) 1, who had behaviors and past traumatic events in her life. This placed the resident at risk for unmet behavioral health needs. Findings included: - The Electronic Medical Record (EMR) for R1 documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), personality disorder (a consistently dysfunctional pattern of thinking and behavior that reflects suspicion or lack of interest in others), panic disorder (frequent and unexpected panic attacks), and schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought). The Annual Minimum Data Set (MDS}, dated [DATE], documented R1 had intact cognition, and dependent upon staff for toileting, and mobility, and required substantial to maximum assistance with dressing, and personal hygiene. The MDS further documented R1 received antipsychotics (a class of medications used to treat major mental conditions that cause a break from reality), antianxiety (a class of medications that calm and relax people), and antidepressants (a class of medications used to treat mood disorders) medication and had no behaviors. R1's EMR lacked documentation a trauma-informed care assessment was completed for R1. R1's Care Plan, dated [DATE], initiated on [DATE], directed staff to encourage R1 to choose activities that involved human contact, express her feelings, encourage compliance with medications to prevent relapse and maintain a safe environment. The care plan documented R1 visited with staff, friends, and family, had her own phone to take pictures, enjoyed massages, reading and listening to the bible, and shopping. The update, dated [DATE], directed staff to obtain behavioral/psychological consults as indicated, monitor/report as necessary to the physician any acute episodes of feelings of sadness, loss of pleasure, interest in activities, feelings of worthlessness, and observe for mania, irritability, and mood changes. The Physician's Order, dated [DATE] directed staff to administer trazadone (antidepressant medication), 150 milligrams (mg), by mouth, at bedtime, for depression, duloxetine DR (anxiety medication), 30 mg, twice daily, for anxiety, clonazepam (anxiety medication), 0.5 mg, by mouth, three times daily, for anxiety, monitor for behaviors, and observe for side effects from medication. The Physician's Order, dated [DATE], directed staff to administer Seroquel (antipsychotic medication), 200 mg, by mouth, three times daily, for anxiety, olanzapine (antipsychotic medication) 10 mg, by mouth, twice daily, for schizophrenia. The Nurse's Notes, dated [DATE] at 01:32 PM, documented R1 had several behaviors during the shift, cried that her fan needed turned on, and was tearful on multiple occasions. The note further documented that when R1 did not know staff was in her room, she would talk on the phone but started to cry when she saw the staff. The Nurse's Notes, dated [DATE] at 08:20 AM, documented R1 asked multiple staff go for her roommate's belongings who had passed away during the night. The Nurse's Notes, dated [DATE] at 07:18 PM, documented R1 continued to exhibit attention-seeking behaviors during medication pass and requested staff to constantly move items for her that she was able to do for herself. The Nurse's Notes, dated [DATE] at 05:24 AM, documented that while staff assisted R1's roommate, she yelled for staff to pick up the lid from her water cup, when staff would tell her they would assist her when they were done with her roommates cares, she got very upset, and dropped the tea and water to the floor, and cried. The note further documented, staff assisted R1 with her drinks, and as staff left the room, R1 yelled, Come back, I need you and dropped the lid and water cup on the floor. The Nurse's Notes, dated [DATE] at 10:09 AM, documented R1 continued to interrupt care with her roommate, had anxious outbursts, and continued to be demanding throughout the shift. The Nurse's Notes, dated [DATE] at 12:50 PM, documented R1 as tearful, using her call light every 15-30 minutes, very anxious, and staff unable to redirect. The Nurse's Note, dated [DATE] at 12:18 PM, documented R1 wheeled herself to the nurse's station and demanded staff stop what they were doing to check the mail for something she was waiting for. The Nurse's Note, dated [DATE] at 10:51 AM, documented R1argued with her roommate over a fan that she thought was missing and staff informed her that her roommate had returned her fan the previous day. The note further documented R1 continued to argue with the roommate the rest of the morning. The Nurse's Note, dated [DATE] at 07:54 PM, documented R1 exhibited increased anxiety, utilized her call light frequently for staff to move her tea pitcher, pick up her wallet, and called out for staff when they walked by her room. The Nurse's Note, dated [DATE] at 09:39 AM, documented R1 repeatedly called the nurse's name every 5-10 minutes during the morning medication pass, R1 was educated to use her call light when she needed help but continued to yell out the nurse's name when she saw them walk by. The Nurse's Note, dated [DATE] at 01:23 PM, documented R1 had been on her call light nonstop and was unable to tell staff what she wanted so she had staff do little things such as move something from one spot to another. On [DATE] at 01:00 PM, observation revealed R1 independently propelled herself down the hall. She appeared anxious and did not want to talk. On [DATE] at 03:30 PM, R1 stated she had lost two children, a daughter and a son. R1 stated her daughter died during a surgical procedure and stated her granddaughter visits with her. On [DATE] at 01:40 Social Service (SS) BB stated she had started completing the trauma-informed assessments about eight months ago but had not completed one for R1 yet. SS BB stated R1 did see a psychiatrist for her mental health, usually over web-based meetings. On [DATE] at 09:00 AM, Certified Nurse Aide (CNA) O stated R1 had behaviors of dropping items on the floor and hollering for staff constantly. CNA O further stated when R1 was anxious she would just talk to R1, but she was unsure of any of R1's triggers regarding her behavior. On [DATE] at 10:00 AM, Administrative Nurse E stated she had behaviors of attention seeking and had a very hard life. Administrative Nurse E further stated, the staff received computer training for behaviors and was unsure if R1 had been assessed for trauma. On [DATE] at 10:30 AM, Administrative Nurse D stated R1 was able to visit with a mental health doctor regarding her behaviors and stated R1 should have been assessed for past trauma. The facility's Trauma Informed Care policy, dated 03/19, documented to guide staff in appropriate and compassionate care specific to individuals who have experienced trauma, nursing staff are trained on screening tools, trauma assessment, and how to identify triggers associated with stigmatization and caregivers are taught strategies to help eliminate, mitigate or sensitivity, to address resident's triggers. The facility failed to complete a trauma-informed care assessment for R1 who had behaviors and loss of her children. This placed the resident at risk for unmet mental health needs.

The facility had a census of 41 residents. Based on observation, record review, and interview the facility kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor, and appearance when dietary staff failed to follow a recipe while preparing one resident's pureed diet. This placed the resident at risk for impaired nutrition. Findings included: - On 01/03/24 at 11:30 AM Dietary Staff (DS) DD, with Dietary Manager (DM) BB overlooking, stated the facility had one resident who received a pureed diet. DS BB washed hands, applied gloves, placed one four-ounce piece of twice-baked chicken into a blender container then added two ounces (oz) of brown gravy, and blended. DS DD reported it was not the right consistency, added one-half oz brown gravy, and blended to the consistency of pudding. DS DD poured it into a custard bowl and placed it on the counter. DS DD used a new blender container, placed four ounces of country vegetables into the blender container, and added two oz. of liquid from the vegetables, blended to the consistency of pudding, poured into a custard bowl, and left on the counter. DS DD removed and discarded gloves, ran both blender containers through the dishwasher, took one blender container, and used tongs to place two unmeasured amounts of spaghetti noodles into the blender container. DS DD added three one-half oz.) scoops of brown gravy, then reported was not the right consistency, and added another one-half oz scoop of brown gravy. DS DD blended to the consistency of mashed potatoes, poured into a custard bowl, and left it on the counter. DS DD took a clean blender container and placed one (2 oz) piece of chocolate chip bar into the blender container, added unmeasured milk, and blended to the consistency of mashed potatoes. On 01/03/24 at 11:40 AM, DS DD verified she had not followed a recipe and stated the dietary department did not have pureed diet recipes. On 01/03/24 at 11:45 AM, DM DD stated he was told by the facility dietician to follow the pureed diet portion sizes/dishes chart. A review of the chart revealed documentation regarding serving sizes but lacked recipes for food items. The Pureed Diet Policy, dated 2017, documented that the actual process to pureed food is a simple task when the right equipment is used. The following gives a few basic guidelines that should guarantee success. The policy instructed staff to start with a clean and sanitized food processor with a sharp blade then gather the equipment needed: scale, measuring cups, measuring spoons, spatulas, recipes, steam table pans, and spoons for tasting. The facility kitchen staff failed to follow a recipe when preparing one resident's pureed diet. This placed the residents at risk for impaired nutrition.

The facility had a census of 41 residents. The sample included 14 residents. Based on observation, record review, and interview the facility failed to provide a safe, clean comfortable, and homelike environment in the dining room. This placed the residents at risk of an unsafe and uncomfortable environment. Findings included: - On 01/02/24 at 11:35 AM, observation in the dining room revealed the floor throughout the dining room had blackish gray build up and the floor tile located next to the heater had an approximately four-inch wide by a nine-inch long missing piece of tile. On 01/04/24 at 10:40 AM, Maintenance Staff (MS) U verified the above findings and stated he had not waxed the dining room floor because the facility was going to replace it, but he did not know when. On 01/04/24 at 10:58 AM, Administrative Staff A verified the dining room floor had not been waxed for a while and stated the facility was going to purchase new flooring, so staff had not waxed the old one. Administrative Staff A said the facility received one estimate but felt like it was high; the facility then had to put the new flooring on hold due to the expense of a recent foundation repair. The facility's Maintenance Service Policy, revised in December 2009, documented that maintenance service would be provided to all areas of the building, grounds, and equipment. The maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner. The facility failed to provide a safe, clean, comfortable, and homelike environment in the dining room. This placed the residents at risk of an unsafe and uncomfortable environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 41 residents. The sample included 14 residents. Based on observation, interview, and record review, the facility failed to provide a safe environment free of chemical hazards for five cognitively impaired independently mobile residents and failed to ensure a safe environment for Resident (R) 33. The deficient practice placed the affected residents at risk for preventable accidents, falls, and related injuries. Findings included: - On 01/03/24 At 08:07 AM observation revealed a bottle of Windex Multi-Surface Cleaner and Lime Away bottles sitting on an open shelf below the fish aquarium. The Lime Away bottle was labeled to keep out of reach of children. On 01/03/24 at 08:09 AM, Administrative Nurse D, stated one of the residents cleaned the aquarium and placed the cleaning agents under the aquarium, and left them there. Administrative Nurse D verified the cleaning agents should not have been left under the aquarium and took them to have them locked up. The facility's Storage Areas, Environmental Services, dated 12/2009, documented cleaning supplies, etc., shall be stored in areas separate from food storage rooms and shall be stored as instructed on the labels of such products. The facility failed to provide an environment free of chemical hazards for five cognitively impaired, independently mobile residents who resided in the facility placing the resident at risk for preventable injuries. - The Electronic Medical Record (EMR) for R33 recorded diagnoses of dementia without behavioral disturbance (a progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cerebrovascular accident (CVA-an interruption in the flow of blood to cells in the brain), and hypertension (high blood pressure). The admission Minimum Data Set (MDS), dated [DATE], documented R33 had severely impaired cognition, and required extensive assistance from two staff for bed mobility, transfers, locomotion on and off the unit, dressing, toileting, and personal hygiene. The MDS further documented R33 had unsteady balance, upper functional impairment on one side, and had falls before admission. The Annual MDS, dated 12/01/23, documented R33 had severely impaired cognition, dependent upon staff for transfers, substantial to maximum assistance for personal hygiene and dressing, did not ambulate, had no functional impairment, and had no falls. The Fall Risk Assessments, dated 12/19/22, 12/29/22, 08/29/23, and 12/14/23, documented a high risk for falls. The Care Plan, dated 12/01/23, initiated on 12/02/22, documented R33 had visual impairment, impaired balance, poor safety awareness, and was at risk for falls. The care plan directed staff to ensure R33 wore appropriate footwear when ambulating or in a wheelchair and encouraged her to ask for assistance to transfer or ambulate. The Fall Investigation, dated 12/29/22 at 06:45 PM, documented R33 was observed on the floor on her left side beside her wheelchair in the dining room. The investigation further documented R33 stated staff had turned off the lights in the dining room so R33 thought she needed to get out of the dining room. The investigation documented the nurse and two staff assisted R33 up off the floor and transferred her into her wheelchair and assessed her with no injuries. On 01/03/24 at 02:30 PM, observation revealed R33 sat in her wheelchair with a gait belt around her waist in the bathroom. With Certified Nurse Aide (CNA) M on her right side and CNA P on her left, staff assisted her to stand. CNA M pulled down R33's pants and incontinence brief and assisted her to turn and sit down on the toilet. CNA M stated R33 had a walker in the bathroom she did not know where it went; it was usually left in the shared bathroom. CNA P went into the room next to R33's and found R33's walker in another resident's room. CNA P did not sanitize the walker and provided it to R33 then cued R33 to hold onto the walker. R33 held onto the walker and stood up. CNA M performed peri care, removed her gloves and without performing hand hygiene, pulled up R33's pants, walked R33 to her wheelchair, and sat her down. On 01/03/24 at 2:45 PM, CNA M stated R33 used the walker for short distances and had not had any recent falls. CNA M further stated R33 got up on her own a couple of times and fell. On 01/08/24 at 10:41 AM, Administrative Nurse D stated dietary staff turned off the lights on 12/29/23 while R33 was still in the dining room and did not tell anyone that she was still in there. Administrative Nurse D further stated education was provided and a mini-inservice was held regarding the fall. The facility's Falls and Fall Risk Managing policy, dated 12/07, documented that staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling., Staff would monitor and document each resident's response to interventions intended to reduce falling or the risk of falling and if the resident continued to fall, staff would reevaluate the situation, and change the current intervention. The facility failed to prevent cognitively impaired R33 from a fall after staff turned off the lights in the dining room and R33 thought she had to get up and leave. This placed the resident at risk for injury.

The facility had a census of 41 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to store drugs and biologicals for two medication storage carts placing the residents at risk for missing medications and unsafe access to medications. Findings included: - On 01/02/24 at 10:39 AM, observation revealed a treatment/medication cart in the living room area was unattended and unlocked. The unlocked drawers contained insulin (a hormone that lowers the level of glucose in the blood) for four different residents. Licensed Nurse H verified the cart should be locked when unattended. On 01/03/24 at 12:09 PM, observation revealed a medication cart in the living room area unattended and unlocked. Certified Medication Aide (CMA) R verified the medication cart should be locked when unattended. On 01/04/24 at 01:00 PM, observation revealed Resident (R) 5 in a wheelchair in the dining room attempting to open drawers on the medication cart. On 01/08/24 at 10:58 AM, Administrative Nurse D stated the medication carts should be locked if staff was not present. The facility's Storage of Medications policy, dated 12/2007, documented compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. The facility failed to store drugs and biologicals in a secure manner placing the residents at risk for missing and unsafe access to medications.

The facility had a census of 41 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to provide proper infection control practices related to point of care testing for COVID-19 (a highly contagious respiratory virus) and also failed to sanitize a resident's walker after it was used by another resident who had not been feeling well. This placed the residents at risk for infectious disease. Findings included: - On 01/03/24 at 07:45 AM, observation revealed Resident (R)25 stated she did not feel well and refused her medication. At 10:07 AM, observation revealed Certified Nurse Aide (CNA) N placed R33's silver walker in front of R25 and told her to hold onto the walker to stand up. CNA N had R25 pivot turn and sit down in her wheelchair. At 02:30 PM, observation revealed R33 sat in her wheelchair with a gait belt around her waist in the bathroom. With Certified Nurse Aide (CNA) M on her right side and CNA P on her left, staff assisted her to stand. CNA M pulled down R33's pants and incontinence brief and assisted her to turn and sit down on the toilet. CNA M stated R33 had a walker in the bathroom she did not know where it went; it was usually left in the shared bathroom. CNA P went into the room next to R33's and found R33's walker in another resident's room. CNA P did not sanitize the walker and provided it to R33 then cued R33 to hold onto the walker. R33 held onto the walker and stood up. CNA M performed peri care, removed her gloves and without performing hand hygiene, pulled up R33's pants, walked R33 to her wheelchair, and sat her down. On 01/03/24 at 02:20 PM, observation in the conference room revealed Activities Z took a COVID-19 test, waited only five minutes through the directions called for a 15-minute wait time, and then threw the used test into the trash, and left the room. Further observation of the testing area revealed a white notebook with a testing log on top of the small refrigerator, and two used COVID-19 tests with the log on top of the refrigerator. On 01/03/24 at 03:00 PM, Administrative Nurse D stated staff were supposed to get another nursing staff member or another administrative staff member to witness the COVID-19 tests, and then dispose of the test appropriately. Observation revealed Administrative Nurse D then gloved, placed the used tests into the trash, removed the trash bag and removed her gloves but did not sanitize the top of the refrigerator where the used COVID-19 tests had been. On 01/08/24 at 10:44 AM, Administrative Nurse D stated staff should have sanitized R33's walker after it had been used by another resident. The facility's COVID-19 policy guidelines dated, 05/19/23, documented the infection control preventionist should assess, monitor, and ensure compliance with all infection control practices, infections should be line listed on tracking forms, and all employees, consultants, and contractors should be educated related to virus, infection control preventions for early detection and monitoring. The facility would record all test results, both positive and negative, within the organization's tracking system. All COVID-19 testing supplies should be disposed of in biohazardous waste. The facility failed to provide proper infection control practices when testing for COVID-19 and failed to sanitize a resident's walker after it was used by another resident who had not been feeling well. This placed the residents at increased risk for infectious disease.

The facility had a census of 41 residents. The sample included 14 residents. Based on observation, record review, and interview the facility failed to provide adequate lighting in the main dining room. This put the residents at risk of not being able to see and enjoy their meals. Findings included: - On 01/02/24 at 11:35 AM, observation in the dining room revealed: A ceiling fan light fixture had three burnt-out light bulbs. A fluorescent ceiling light, approximately three feet by 18 inches had burnt-out light bulbs. On 01/04/24 at 10:40 AM, Maintenance Staff (MS) U verified the above light issues and stated he had not had time to replace the bulbs. The facility's Maintenance Service Policy, revised in December 2009, documented that maintenance service would be provided to all areas of the building, grounds, and equipment. The maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner. The facility failed to provide adequate lighting in the main dining room for the residents who ate their meals there. This placed the residents at risk of not being able to see and enjoy their meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 41 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the 41 residents who received their meals from the facility's kitchens. This placed the residents at risk for foodborne illness. Findings included: - On 01/02/24 at 08:10 AM, observation in the kitchen revealed: One unsealed unlabeled plastic bag of tater tot patties, one unsealed unlabeled plastic bag of tater tots, and one bag of unsealed, unlabeled plastic bag of chicken strips in the white upright freezer. The outside of the refrigerator freezer had numerous different-sized areas of blackish substance. Inside the refrigerator were numerous different-sized specks of food particles on the door shelves, below the bottom drawers, and the top and middle compartments of the door. The walk-in refrigerator had an open box with an uncovered bunch of celery which had a white substance on the bottom of the bunch. On 01/03/24 at 11:30 AM, observation in the kitchen revealed: The walk-in freezer had six undated personal-size deep-dish cheese pizzas and five undated (one-half gallon) different flavored ice cream. The upper cupboard doors above the microwave had numerous different-sized chips in the corkboard towards the bottom of all doors. The bottom cupboard drawers located under the serving window would not open due to broken tracking where the drawers slide in and out. The right lower bottom cabinet below the microwave was missing a piece of the door approximately one inch by 18 inches and would not open. The lazy [NAME] in the right bottom corner cabinet was stuck, Dietary Manager (DM) BB opened it with force and stated he did not know that it was a cabinet. Inside the lazy [NAME], the top shelf and the bottom shelf had numerous different size black specks, The lower cabinet underneath the serving table had the hinge bent which made the cupboard hang uneven. The pipes, approximately five feet long, located underneath the three-sink area had numerous different-sized blackish substances on them. The floor underneath the dishwasher where the clean dishes came out had 11 missing floor tiles approximately 12x12 inches (in). The five fluorescent ceiling lights, approximately three feet by one foot had numerous different-sized specks in them and the one located in the middle of the ceiling above the three sinks and oven hood had burnt-out bulbs. The ice machine drainage pipe located in the dining area by the wall next to the kitchen continuing through the wall into the kitchen was approximately one-half inch down in the drain hole. One unlabeled, undated flour container and one unlabeled, undated sugar container were located in the first room to the right of the entrance to the dry storage by the walk-in refrigerator. On 01/03/24 at 11:50 AM, observation revealed Dietary Staff (DS) DD started dishing up residents' plates. The surveyor stopped her and asked her if she normally checked the temperatures of the food items before serving. DS DD stated it depended on if there were residents in the dining room ready to eat. 01/03/24 at 11:50 AM, DM BB verified the issues in the kitchen and stated staff had a cleaning schedule to follow for each shift. 01/04/24 at 10:33, DM BB stated he expected staff to check food items' temperatures on the steam table right before they served them to the residents. The Kitchen Cleaning Rotation Sheets, dated 2016, documented tasks for morning and evening dietary staff to complete daily, monthly, and annually. The facility kitchen staff failed to store and prepare food in accordance with professional standards for food service safety. This placed the 41 residents who received their food from the facility's kitchens at risk for foodborne illness.

The facility identified a census of 37 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to protect Resident (R) 1 from verbal abuse/mistreatment from Certified Nurse's Aide (CNA) N when CNA N chastised R1 for moving around in bed, needing more assistance then other residents, and needing pillows behind her in her wheelchair. This failure placed R1 at risk for impaired psychosocial wellbeing. Findings included: - R1's Electronic Medical Record recorded R1 had diagnoses of major depressive disorder (major mood disorder) schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS), dated 09/20/22, documented R1 had a Brief Interview for Mental Status score of 15 which indicated R1 had intact cognition. The MDS further documented that R1 required extensive assistance of two staff for bed mobility, toileting, bathing, personal hygiene and was totally dependent on two staff for transfer. The Activities of Daily Living Care Area Assessment, dated 01/04/22, documented R1 required extensive assistance of two staff for bed mobility, dressing, grooming and toileting. R1 required total assistance of two staff for bathing and transferring. The Behavioral CAA, dated 01/04/22, documented R1 was noted to have frequent episodes of crying and she often felt like something was wrong. R1 would utilize one on one with nursing during times of sadness to calm down. The Mood Care Plan, dated 09/20/22, documented R1 had a mood problem and would have an improved mood state by being happier and calmer. Staff were directed to assist R1 in identifying her strengths, encourage positive coping skills, and report any signs and symptoms of depression, anxiety, or sad mood. The Health Status Note, dated 11/15/22, documented R1's family member told the facility staff R1 was having abdominal pain and abdominal distention. The facility nurse obtained R1's vital signs and all were within normal limits and noted R1 was having abdominal distention but was also within normal limits for R1. R1 and her granddaughter asked to be transported to the emergency room for evaluation. The facility van driver transported R1 and her granddaughter to the emergency room for evaluation. R1 was admitted to the hospital with constipation. On 11/21/22 at 12:30 PM, R1 sat up in a recliner in her hospital room with a half-eaten plate of food in front of her. R1 became tearful when asked about her treatment from facility staff. R1 stated she did not want to go back to the facility because she was treated so badly there. She stated she had not told anyone but her family member about the verbal abuse and rough treatment. Review of recorded video and audio on 11/21/22 at 12:45 PM revealed a video date stamped 11/02/22 at 07:02 AM which showed CNA N and CNA O repositioned R1 in bed. CNA N stated, You better stop wiggling around like that or you are going to undo everything I just did and it's so annoying. How do you want your legs CNA N then placed R1's legs across each other, first from right to left and then from left to right. R1 then stated, They can't be touching. CNA N responded, They are not touching. You know what? I am done. They are how they are and that's how they are going to stay. CNA N tossed the blankets around on the bed and then said, Stop moving! Can't you feel me trying to fasten your attends? You know the blankets aren't on you so you know I am not done! Further review of the recorded video showed CNA N and CNA O got R1 up with a full body lift. CNA N stated, You know it takes us twice as long to get you up and ready as it does anyone else. You have been told you are not to be doing this to us and keep asking for things over and over again. How do you want your pillow? You know what? Your pillows are fine. On 11/21/22 at 09:30 AM, Administrative Staff A stated the facility had no idea there was any abuse happening at the facility. Administrative Staff A stated R1 was always talking to staff and administration and the subject of abuse had never been brought up. Administrative Staff A stated the facility became aware of the complaint of abuse was the facility received a letter from R1's insurance company on 11/18/22 which requested to know the results of the abuse investigation regarding CNA N. Administrative Staff A stated CNA N had been suspended pending the result of the investigation. On 11/21/22 at 02:00 PM, CNA O stated that she was unaware of any physical or verbal abuse happening at the facility. When asked about the situation/event in the recorded footage, CNA O stated, Well some resident's can be more frustrating than others. On 11/21/22 at 02:15 PM, CNA N stated that she was unaware of any verbal or physical abuse happening at the facility. When presented with the specific situation from the video, CNA N stated, I probably didn't always treat R1 nicely because she was so needy all of the time. It's frustrating when you have a job to do and you have someone that consumes so much time. When I got frustrated like that, I should have just left the room but I didn't. On 11/21/22 at 02:30 PM, Administrative Staff A stated that CNA N was terminated from her position as a CNA at the facility because the facility did not tolerate any verbal or physical abuse of the residents in their care. The facility's Abuse Prevention, Identification, Investigation and Reporting Policy, revised 03/03/22, documented all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This includes prohibiting nursing facility staff from taking acts that will result in personal degradation including the taking of photographs or recordings in any manner that would demean or humiliate a resident, and prohibits using any time of equipment to take, keep, or distribute photographs or recordings on social media or through multimedia messages. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility failed to prevent R1 from experiencing verbal abuse and/or misreatment which placed R1 at risk for psychosocial impairment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 37 residents. The sample included 13 residents with one resident reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure R10's right to be treated with respect, dignity, related to bladder incontinence when the facility staff referred to residents as heavy wetters and placed cloth incontinent pads in R10's wheelchair. This deficient practice placed the residents at risk for negative psychosocial outcomes and decreased autonomy and dignity. Findings included: - R10's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hypertension (elevated blood pressure), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), overactive bladder (a frequent and sudden urge to urinate that may be difficult to control), and stress incontinence (is the unintentional loss of urine). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R10 required extensive assistance of two staff members for activities of daily living (ADL's). The MDS documented R10 was not on a toileting plan. The MDS documented R10 received insulin (medication to regulate blood sugar), antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression), anticoagulant medication (class of medications used to prevent the formation of blood clots), diuretic medication (medication to promote the formation and excretion of urine) for seven days and opioid medication (a class of medication used to treat pain), for dour days during the look back period. The Quarterly MDS dated 03/29/22 documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R10 required extensive assistance of two staff members for ADL's. The MDS documented R10 was not on a toileting program. The MDS documented R10 received insulin, antidepressant medication, anticoagulant medication, diuretic medication for seven days and opioid medication, for dour days during the look back period. R10's Urinary Incontinence and Indwelling Catheter Area Assessment (CAA) dated 12/10/21 documented R10 was incontinent of bladder and used incontinent products for protection and dignity. R10 received two diuretic medications as ordered, which increased her need to be toileted and needed encouragement at times. R10's Care Plan dated 01/11/18 documented she used a disposable brief that was to be changed as needed. Staff were to provide peri-care after each incontinent episode. The Care Plan dated 04/25/19 documented R10 was to be checked frequently and as required for incontinence. The care plan lacked individualized interventions related to toileting. On 05/25/22 at 01:10 PM R10 was propelled in wheelchair to room. Her pants were visibly wet along her thighs and groin area. Nursing staff toileted, provided peri-care for R10 and placed a cloth incontinent pad folded onto R10's wheelchair cushion prior to her transfer back into the wheelchair. On 05/25/22 at 01:26 PM in an interview, Certified Nurse's Aide (CNA) N stated R10 was toileted after getting out of bed in the morning, before and after each meal. CNA N stated R10 refused at times related to visitation with spouse. CNA N stated a cloth incontinent pad was placed in the wheelchair of every resident that was a heavy wetter. On 05/25/22 at 04:13 PM R10 stated she felt very bad after each incontinent episode and wished that it did not happen. On 05/26/22 at 12:51 PM in an interview, Certified Medication Aide (CMA) R stated staff offer every resident toileting every two hours. CMA R stated a cloth incontinent pad was placed in the wheelchairs of the residents that were heavy wetters. On 05/26/22 at 01:20 PM in an interview, Licensed Nurse (LN) a cloth incontinent pad in the wheelchair would be a dignity concern, there should not be an incontinent pad in the wheelchair. On 05/26/22 at in an interview, Administrative Nurse E stated a cloth incontinent pad in a resident s wheelchair would not be a dignity concern if it was their preference and that would be located on their care plan. Administrative Nurse E stated heavy wetter was not an appropriate term for a resident. The facility's Quality of Life-Dignity last revised August 2009 documented residents shall always be treated with dignity and respect. The facility Urinary Continence and Incontinence Assessment and Management policy undated documented as [art of the initial and ongoing assessment, the nursing staff and physician will screen for information related to urinary incontinence. Based on assessment, the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try mange incontinence. The facility failed to ensure R10 was treated with respect and dignity. this deficient practice placed R10 at risk for negative psychosocial outcomes and decreased autonomy and dignity

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 37 residents. The sample included 13 residents. Based on record review and interview, the facility failed to develop a discharge summary for one of the residents reviewed for discharge that included a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay and post discharge pan for Resident (R) 38. This placed the resident at risk for receiving inadequate care. Findings included: - R38's Electronic Medical Record (EMR) revealed the resident admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), dated 03/09/22, documented the resident had a Brief Interview of Mental Status score of 12, which indicated moderate cognitive impairment. The MDS documented the resident required extensive staff assistance with bed mobility, transfers, walk in room, limited staff assistance with walk in corridor, locomotion on and off unit, toilet use, and personal hygiene. R38 required supervision with eating. The MDS documented R38 expected to be discharged to the community. The Baseline Care Plan, dated 03/02/22, documented R38 required staff assistance with activities of daily living (ADLs) and was at the facility for therapy. The care plan recorded R38 wanted to return home. The Nurse's Note, dated 03/21/22 at 10:40 AM, documented R38 discharged from the facility to another facility. Review of R38's EMR lacked a discharge summary, which included a recapitulation of her stay. On 05/26/22 at 9:00 AM, Administrative Nurse D verified R38's EMR lacked a discharge summary which included a recapitulation of R38's stay and stated social service staff was responsible for completing the discharge summary. On 05/26/22 at 09:05 AM, Social Service X verified she had not completed R38's discharge summary and stated she must have forgot to complete it. The facility's Discharge Summary and Plan, revised December2016) documented when the facility anticipates resident's discharge to a private residence, another nursing care facility, a discharge summary and post-discharge plan would be developed which would assist the resident to adjust to his or her new living environment. The discharge summary would include a recapitulation to the resident's stay at the facility and final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The facility failed to develop a discharge summary that included a recapitulation of R38's stay and post discharge plan. This placed the resident at risk for receiving inadequate care.

The facility identified a census of 37 residents. The sample included 13 residents with two reviewed for activities of daily living (ADL's). Based on observation, record review, and interviews, the facility failed to provide consistent assistance and supervision with eating for Resident (R)14. This deficient practice placed the resident at risk for weight loss. Findings Included: - The electronic medical record (EMR) indicated the following diagnosis for R14: hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), cerebral infarction affecting right dominant side (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 ) osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), general anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive disorder (major mood disorder), hypertension (high blood pressure), and retention of urine (lack of ability to urinate and empty the bladder). R14's Quarterly Minimum Data Set (MDS) dated 03/22/22 noted a Brief Interview for Mental Status (BIMS) of six. The MDS noted that she required extensive assistance from two staff for bed mobility, toilet use, personal hygiene, dressing, and bathing. The MDS indicated that R14 required setup and supervision from one staff for eating. The Quarterly MDS noted she weighed 141 pounds (lbs.). R14's Nutrition Care Area Assessment (CAA) dated 11/02/21 noted that she was on a regular diet and independent with help and set-up for her meals. The CAA noted that she had consumed 76 to 100 percent of her meals. A review of R14's Care Plan revised 03/24/22 indicated that she suffered from a self-care deficit related to her medical diagnoses. The care plan stated that staff were to encourage her to go to the dining room for meals or to assist her while eating in her room. It noted that she required extensive assist from one staff during her meals. The care plan noted that staff were to monitor and report signs of dysphagia (swallowing difficulty), pocketing (holding food in the pockets of the mouth), and potential choking hazards during resident's meals. The care plan noted that R14 had be provided a divided plate as needed to assist with her independence (added 04/10/2019) and to encourage finger foods when possible (revised 07/30/21) A review of R14's Weight Lookback report indicated she weighed 157 lbs. on 11/02/21. The report indicated that her weight decreased to 140 lbs. by 05/06/22. A review of R14's EMR revealed a Dietary Note dated 12/07/21 stated that resident is needing assistance with meals. The report noted that she was having a difficult time seeing her food and recommended that she be assisted with her meals to maintain her weight versus the use of finger foods. The note recommended for staff to offer encouragement and cueing. A Staff Progress Note dated 02/20/22 indicated that R14 declined to eat breakfast and lunch with weight steadily declining for the past three months. On 05/17/22 a Dietary Note stated R14's treatment team met to discuss her weight decline of 10.4 percent in 180 days. The note referenced R14's weight loss related to her not being able to get food into her mouth. The note stated that not all utensils and finger foods worked for R14. On 05/23/22 at 08:45AM R14 slept in her reclining chair. R14's breakfast plate sat in her lap and appeared untouched. No staff were observed in her room to assist her with her meal. The food was not cut up for R14 to be able to eat the sausage and toast provided. On 05/25/22 at 10:45AM R14 slept in her reclining chair. R14's breakfast plate sat on her bedside table. The food appeared untouched and was cold. R14's roommate stated the food was delivered around 09:00 AM. On 05/26/22 at 08:03AM R14 slept sitting upright in her reclining chair wearing a bib cloth to protect her clothing. She appeared to be prepped for breakfast and her food was cut up for her to eat but not covered to prevent it from getting cold. At 08:45AM staff entered the room and woke R14 to assist her to eat breakfast. The care staff apologized to the resident explaining, I'm sorry, I forgot you wanted to eat breakfast. Staff then attempted to feed the resident the cold meal before stopping to assist her to the restroom. R14 appeared confused and disoriented but stated that the food was hard to chew and not good. On 05/26/22 at 12:52 PM with Certified Medication Aid (CMA) R, reported that residents who required assistance during meals services should not be left alone during meal service. He stated that staff can review the resident's care plan to find out if the resident has a special diet or needs during meal service. On 05/26/22 at 02:04 PM in an interview with Administrative Nurse E, she stated that resident could eat in their rooms if they chose to but staff need to be available to assist them. She reported that residents that require assistance eating should never be left alone during mealtimes and staff should assist them with their meals. She reported that R14 should have had someone in the room assisting her with her meal. On 05/31/2022 at 05:45 PM in an interview with Consultant HH, she stated that R14 has been on a gradual decline since last year. She stated that she notified physical therapy that the resident needed assistance during all meals and was told by physical therapy to try finger foods instead . She reported that the resident cannot eat by herself and needed to be encouraged to consume her meals. She reported that R14 required physical assistance from staff due to R14 not being able to see the food on her plate, use the utensils, and get the food into her mouth. She reported that R14 often had chosen to eat in her room due to her becoming anxious in the dining room to the point of her crying out to leave. A review of the facility's Assisting Impaired Resident with In-Room Meals policy revised 09/2013 stated that staff are required to ensure the resident is prepared to receive the meal before serving. The policy stated the resident should be positioned upright and head tipped slightly forward. The policy stated staff are responsible to ensure that food is served at the appropriate temperature. The facility failed to provide consistent assistance and supervision during R14's meals. This deficient practice placed the resident at risk for weight loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 38 residents. The sample included one resident reviewed for quality of care. Based on observation, record review, and interview, the facility failed to monitor Resident (R) 14's bowel movements and treat when indicated per physician orders which placed R14 at risk for digestive problems, impaired comfort, and bowel blockage. Findings included: -The Medical Diagnosis section within R14'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), cerebral infarction affecting right dominant side (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) osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), general anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive disorder (major mood disorder), hypertension (high blood pressure), and retention of urine (lack of ability to urinate and empty the bladder). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R14 had severe cognitive impairment, had verbal and other behavioral symptoms which occurred one to three days of the look back period, required extensive assistance of two staff with bed mobility, transfers, dressing, toileting and hygiene. R14 was frequently incontinent of urine and bowel. The Activity of Daily Living Care Area Assessment (CAA), dated 11/16/21, documented R14 required extensive assistance for bed mobility, toileting, grooming and personal hygiene. The CAA further documented R14 was incontinent of bowel and bladder, wore incontinent products for protection and dignity, and directed staff to provide peri care with each incontinent episode. The Care Plan directed staff to check the resident at least every two hours for incontinence, wash, rinse and dry soiled areas, and encourage adequate fluid intake. The Physician Order Sheet, dated 05/03/22, documented if R14 had no bowel movement (BM) in three days, staff were to give Milk of Magnesium (MOM-medication used for constipation) 30 cubic centimeters (cc) in the morning (AM); if no BM in four days give Dulcolax suppository (medication given rectally) prior to awakening or as needed; if no BM in five days give one fleets enema (introduction of a solution into the rectum for cleansing or therapeutic purposes) prior to awakening or as needed. The order further stated if no BM after Fleets enema notify physician as needed for constipation. Review of the medical record revealed R14 lacked BM's on 06/18, 06/19, 06/20, 06/21, 06/22, 06/23, with no physician ordered interventions administered. Further review revealed lack of BM's on 07/01, 07/02, 07/03, 07/04, and 07/05, with no physician ordered interventions. The Progress Note, dated 07/01/22, documented R14 exhibited decreased appetite, increase in drowsiness, sleeping, and anxiety; R14's crying continued with no improvement. On 07/06/22 at 08:47 AM observation revealed R14 sat in her recliner and reported she had pain all over and said oh, do something for me. On 07/06/22 at 08:52 AM Certified Nurse Aide (CNA) N stated staff record the residents' bowel movements in the electronic record. On 07/06/22 at 10:00 AM, Licensed Nurse (LN) G, reported the night shift nurse printed off a report of residents who lacked a BM in two to three days. The report was generated from the electronic record. LN G said nursing staff were to implement the bowel movement regimen from the physician orders. LN G verified staff had not implemented the bowel movement regimen orders for R14. On 07/06/22 at 12:15 PM, Administrative Nurse D verified R14's lack of BMs. Administrative Nurse D confirmed the electronic report included R14's lack of BMs, and stated nursing staff should have implemented the physician orders. The facility's Bowel Disorders Clinical Protocol, dated 09/2017, documented the staff and physician will identify risk factors related to bowel dysfunction: for example severe anxiety disorder, recent antibiotic use, or taking medications used to treat, or that may cause or contribute to dysmotility (a condition in which muscles of the digestive system become impaired). The facility failed to monitor R14's bowel movements and implement physician ordered interventions, placing the resident at risk for digestive problems, impaired comfort, and bowel blockage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 37 residents. The sample included 13 residents, with two residents reviewed for falls. Based on observation, record review, and interviews, the facility failed ensure fall interventions were implemented as care planned for Resident (R)16, which placed her at risk of major injury from falls Findings included: - R16's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), history of falls, unsteady on feet, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS documented that R16 required extensive assistance of one staff member for activities of daily living (ADL's). The MDS documented no falls for R16 during the look back period. The MDS documented R16 had received antipsychotic medication (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions), antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression), diuretic medication (medication to promote the formation and excretion of urine), and opioid medication (a class of medication used to treat pain) for seven days during the look back period. The Quarterly MDS dated 03/25/22 documented a BIMS score of eight which indicated moderately impaired cognition. The MDS documented that R16 required extensive assistance of one staff member for ADL's. The MDS documented no falls during the look back period. The MDS documented R16 received antipsychotic medication, antidepressant medication, diuretic medication, and opiod medication for seven days during the look back period. R16's Falls Care Area Assessment (CAA) dated 01/18/22 documented staff assisted her with her unsteady balance. R16's Care Plan revised 04/30/20 documented staff were to ensure the call light was in reach and encouraged her to use the call light as needed. R16 needed prompt response to all her requests. The Care Plan revised 02/21/22 documented R16 fell on [DATE] when in isolation. R16 was moved back to her previous room and educated on the call light use for assistance. On 05/23/22 at 03:01 PM R16 sat and read the paper in her recliner. Her call light laid on the floor under the bed, which was outside her reach. On 05/24/22 at 07:35 AM R16 sat asleep in recliner. Her call light was between the foot board of the bed and mattress, which was out of reach. On 05/26/22 at 12:51 PM in an interview, Certified Medication Aide (CMA) R stated notified the nurse of the fall. CMA R stated a fall packet was started for the resident a new intervention would be care planned. CMA R stated any new interventions that were placed on the care plan an Inservice sheet would be placed at the desk for all staff to review and sign. CMA R stayed that if a call light was placed as an intervention that it should always be placed in reach. On 05/26/22 at 01:20 PM in an interview, Licensed Nurse (LN) G stated fall interventions were added to the care plan after each fall to prevent future falls for the residents. LN G stated a call light should always be placed with in reach of the residents to use to call for assistance. On 05/26/22 at 02:04 PM in an interview, Administrative Nurse E stated all the charge nurses can make changes to the care plan. Administrative Nurse E stated that a call light should be in reach for all residents when in their room. The facility Managing Falls and Fall Risk policy last revised March 2018 documented the staff would monitor and document each resident's response to interventions intended to refuse falling or the risks of falling. If the interventions have been successful in preventing falling, staff would continue the interventions or reconsider whether these measures were still needed. The facility failed to ensure the fall interventions aimed at preventing future falls for R16 were implement by the staff, which placed R16 at risk of injury from falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 37 residents. The sample included 13 residents with eight reviewed for incontinence and catheter care. Based on observation, record review, and interviews, the facility failed to develop and implement incontinence care and/or catheter (tube insetred into the baldder to drain urine) cares for Residents (R) 13, R10, and R16. This deficient practice placed the residents at risk for complications related to urinary tract infections and impaired self-esteem related to incontinence. Findings Included: - The electronic medical record (EMR) indicated the following diagnosis for R13: spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), colitis (inflammation of the large intestine, characterized by severe diarrhea and ulceration of the large intestine), urge incontinence (involuntary passage of urine occurring soon after a strong sense of urgency to void), chronic obstructive pulmonary disorder (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and muscle spasms. R13's Quarterly Minimum Data Set (MDS) dated 03/22/22 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated she had an indwelling catheter related to neuromuscular dysfunction of her bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system). The MDS reported she was incontinent of bowel and bladder with no toileting program. The MDS indicated she required extensive assistance from two staff for transfers, dressing, toileting, bathing, and personal hygiene. A review of R13's Urinary Incontinence Care Area Assessment (CAA) dated 01/05/22 indicated her indwelling catheter was changed monthly and as needed. The CAA indicated that she did have bladder spasms that caused leaks around the catheter. The CAA noted that staff should provide peri-care with each episode. R13's Care Plan revised 04/11/22 noted that she required extensive assistance by two staff for toileting, bathing, dressing, and personal hygiene. The care plan indicated that she required a mechanical lift for transfers. The care plan indicated that the indwelling catheter was changed every 30 days and as needed. The care plan indicated on 02/18/21 that R13 used a 24 French (Fr -circumference of the catheter of tubing inserted). The care plan noted that staff should check the tubing for kinks, placement, and have the bag positioned away from the entrance room door for privacy. A review of R13's Urinary Incontinence Lookback indicated that she had daily occurrences of urine incontinence (5/21, 5/22, and 5/23) since returning to the facility on [DATE]. A review of R13's Progress Note on 05/24/22 noted that the resident's catheter was changed due to incorrect catheter size of 20Fr being placed while the resident was at an acute care facility on 05/18/22. The note stated that the R13 had been complaining of discomfort and leaking. A review of R13's Medication Administration Report (MAR) indicated an order dated 02/10/22 for staff to change her indwelling catheter every 28 days and as needed. The physician's order noted that the catheter size ordered was 24Fr. On 05/23/22 at 11:35AM R13 reported that she had concerns with her catheter leaking since returning on 05/20/22. She reported that the morning after she returned from an acute care facility, she woke up with her bed covered in urine. She stated that she told staff something didn't feel right with her catheter but was not sure if it was the correct size catheter. Observation of the catheter revealed that the bag was not leaking. The urine collection bag had a privacy bag placed but placed facing the room's entry door. On 05/24/22 at 02:30 PM R13 reported that her catheter still felt like it was leaking. R13 reported to nursing staff that she believes that the incorrect size catheter had been placed. R13 declined catheter care observation. In an interview on 05/26/22 at 01:20 PM with Licensed Nurse (LN) G, she stated that R13 has had a lot of leakage in the past due to bladder spams and often would think she wet when she was not. She noted that when staff mark incontinent episodes on the lookback report it may be that R13's catheter was leaking. In an interview on 05/26/22 at 02:04 PM Administrative Nurse E reported that staff should be checking why the leaking was occurring with the indwelling catheter. She stated that staff could check for catheter placement, kinks in the tubing, and then notifying the resident's urologist if the condition persist. A review of the facility's Foley Catheter Care policy indicated that catheter care will be provided to all elders with indwelling catheters at least twice daily. The policy noted that catheter care is to prevent possible urinary tract infections. The facility failed to provide ensure R13 had the physician ordered 24 Fr catheter resulting in unnecessary incontinent episodes. This deficient practice placed the resident at risk for complication related to incontinence care. - R10's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hypertension (elevated blood pressure), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), overactive bladder (a frequent and sudden urge to urinate that may be difficult to control), and stress incontinence (is the unintentional loss of urine). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R10 required extensive assistance of two staff members for activities of daily living (ADL's). The MDS documented R10 was not on a toileting plan. The MDS documented R10 received insulin (medication to regulate blood sugar), antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression), anticoagulant medication (class of medications used to prevent the formation of blood clots), diuretic medication (medication to promote the formation and excretion of urine) for seven days and opioid medication (a class of medication used to treat pain), for dour days during the look back period. The Quarterly MDS dated 03/29/22 documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R10 required extensive assistance of two staff members for ADL's. The MDS documented R10 was not on a toileting program. The MDS documented R10 received insulin, antidepressant medication, anticoagulant medication, diuretic medication for seven days and opiod medication, for dour days during the look back period. R10 's Urinary Incontinence and Indwelling Catheter Area Assessment (CAA) dated 12/10/21 documented R10 was incontinent of bladder and used incontinent products for protection and dignity. R10 received two diuretic medications as ordered, which increased her need to be toileted and needed encouragement at times. R10's Care Plan dated 01/11/18 documented she used a disposable brief that was to be changed as needed. Staff were to provide peri-care after each incontinent episode. The Care Plan dated 04/25/19 documented R10 was to be checked frequently and as required for incontinence. The care plan lacked individualized interventions related to toileting. Review of the EMR under Orders tab revealed physician orders: Bumetanide tablet (diuretic) two milligrams (mg) give 1 tab by mouth in the morning related to edema (swelling resulting from an excessive accumulation of fluid in the body tissues) dated 10/19/2017. Spironolactone-HCTZ tablet (diuretic) 25-25mg give 1 tablet by mouth in the morning related to hypertension/edema, hold parameters 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) less than(<) 90 millimeters of mercury (mmHg) or greater than (>)180mmHg diastolic blood pressure (DBP-minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) < 40mmHg or >100mmHg notify the physician. Call if BP parameters are out of bounds. SBP <90mmHg or >180mmHg, DBP <40mmHg or >100mmHg dated 04/08/22. On 05/25/22 at 01:10 PM R10 was propelled in wheelchair to room. Her pants were visibly wet along her thighs and groin area. Nursing staff toileted, provided peri-care for R10 and placed a cloth incontinent pad folded onto R10's wheelchair cushion prior to her transfer back into the wheelchair. On 05/25/22 at 01:26 PM in an interview, Certified Nurse's Aide (CNA) N stated R10 was toileted after getting out of bed in the morning, before and after each meal. CNA N stated R10 refused at times related to visitation with spouse. CNA N stated a cloth incontinent pad was placed in the wheelchair of every resident that was a heavy wetter. On 05/26/22 at 12:51 PM in an interview, Certified Medication Aide (CMA) R stated staff offer every resident toileting every two hours. CMA R stated a cloth incontinent pad was placed in the wheelchairs of the residents that were heavy wetters. On 05/26/22 at 01:20 PM in an interview, Licensed Nurse (LN) G stated every resident was on a check and change toileting schedule. LN G stated a 72-hour bowel and bladder assessment was completed on every resident at the time of their admission. LN G stated she was unaware of were and what was done with that assessment after completion. On 05/26/22 at in an interview, Administrative Nurse E stated a 72-hour bowel; and bladder assessment was completed after admission, but the data was not used to develop an individualized toileting plan. The facility Urinary Continence and Incontinence Assessment and Management policy undated documented as [art of the initial and ongoing assessment, the nursing staff and physician will screen for information related to urinary incontinence. Based on assessment, the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try mange incontinence. The facility failed to provide an individualized toileting program for R10 to promote continence, maintain her dignity and well-being. - R16's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), history of falls, unsteady on feet, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS documented that R16 required extensive assistance of one staff member for activities of daily living (ADL's). The MDS documented no falls for R16 during the look back period. The MDS documented R16 had received antipsychotic medication (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions), antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression), diuretic medication (medication to promote the formation and excretion of urine), and opioid medication (a class of medication used to treat pain) for seven days during the look back period. The Quarterly MDS dated 03/25/22 documented a BIMS score of eight which indicated moderately impaired cognition. The MDS documented that R16 required extensive assistance of one staff member for ADL's. The MDS documented no falls during the look back period. The MDS documented R16 received antipsychotic medication, antidepressant medication, diuretic medication, and opiod medication for seven days during the look back period. R16's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 01/18/22 documented she was frequently incontinent of bowel and bladder and used incontinent products for protection and dignity. Staff would provide peri-care after each incontinent episode. R16's Care Plan revised 04/30/20 documented staff were to ensure the call light was in reach and encouraged her to use the call light as needed. R16 needed prompt response to all her requests. The Care Plan revised 07/23/20 documented R16 required assistance with peri-care and was to use the call light to call for assistance. The Care Plan dated 09/23/20 documented staff was to remind R16 to use the bathroom every two hours and as needed. R16 was to call for assistance with peri-care. On 05/25/22 at 01:12PM R16 ambulated down from the front entrance door, with a walker. Her pants were wet in back, halfway down her left leg and across her buttocks. Observation revealed Activity staff Z ambulated beside R16 to her room. On 05/25/22 at 01:12PM in an interview, Activity Staff Z stated R16 was incontinent of urine and stated when R16 voids, she goes a lot. On 05/26/22 at 01:20 PM in an interview, Licensed Nurse (LN) G stated every resident was on a check and change toileting schedule. LN G stated a 72-hour bowel and bladder assessment was completed on every resident at the time of their admission. LN G stated she was unaware of were and what was done with that assessment after completion. On 05/26/22 at in an interview, Administrative Nurse E stated a 72-hour bowel; and bladder assessment was completed after admission, but the data was not used to develop an individualized toileting plan. The facility Urinary Continence and Incontinence Assessment and Management policy undated documented as [art of the initial and ongoing assessment, the nursing staff and physician will screen for information related to urinary incontinence. Based on assessment, the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try mange incontinence. The facility failed to provide an individualized toileting program for R16 to promote continence, maintain her dignity and well-being.

The facility identified a census of 37 residents. The sample included 13 residents with five residents reviewed for respiratory care. Based on observations, record reviews, and interviews, the facility failed ensure consistent respiratory care for Residents (R)13 and R32. This deficient practice placed the residents at risk for complications due to respiratory therapy. Findings Included: -The electronic medical record (EMR) indicated the following diagnosis for R13: colitis (inflammation of the large intestine, characterized by severe diarrhea and ulceration of the large intestine), urge incontinence (involuntary passage of urine occurring soon after a strong sense of urgency to void), chronic obstructive pulmonary disorder ( progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). R13's Quarterly Minimum Data Set (MDS) dated 03/22/22 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated she required extensive assistance from two staff for transfers, dressing, toileting, bathing, and personal hygiene. The MDS indicated she was receiving oxygen therapy services. A review of R13's Activities of Daily Living (ADL's) Care Area Assessment (CAA) dated 01/05/22 indicated that she required extensive assistance for bed mobility, dressing, grooming, toileting, and bathing. R13's Care Plan revised 04/11/22 identified that she required oxygen therapy related to her asthma (disorder of narrowed airways that caused wheezing and shortness of breath). The care plan instructed staff to encourage deep breathing and relaxation techniques to assist resident during episodes of shortness of breath. The care plan noted that oxygen was administered as directed by the physician's order. The care plan lacked interventions related to cleaning and servicing the oxygen equipment and tubing. R13's Medication Administration Report (MAR) in his EMR revealed an active physicians order dated 01/15/21 to give two liters of oxygen delivered by nasal canula (tubing that delivers oxygen directly through both nostrils of the nose)at bedtime. The physician's order revealed that the oxygen tubing should be changed every 30 days. On 05/23/22 at 11:48 AM R13 reported that she was upset that the machine had not been cleaned. Inspection of the oxygen machine revealed no date on the oxygen tubing identifying when the tubing had been placed. The oxygen machine filter appeared e extremely dusty with a layer of lint covering the outside of the filter. On 05/26/22 at 12:05 PM the oxygen tubing remained undated and the filter had not been cleaned or changed. In an interview completed on 05/26/22 at 12:52 PM with Certified Medication Aid (CMA) R, he stated that the oxygen tubing should be changed out once a month for the physician's order. He stated that he was unsure if the machines filter were cleaned by staff but should be cleaned by the oxygen company that services them. He reported that the oxygen tubing and nasal cannula should be stored in a bag when not in use to prevent contamination. In an interview completed on 05/26/22 at 02:04 PM with Administrative Nurse E, she stated the staff should be checking the oxygen machines tubing and storing it in the bag after each use. She reported that staff could clean the machine and change out the tubing if soiled or dirty. A review of the facility's Oxygen Administration policy revised 10/2010 outlined the facility's guidelines for safe oxygen administration. The policy stated that staff were required to check oxygen machine and supplies to the ensure the machines were in good working order. The policy lacked information related to cleaning the supplies or checking out the tubing. The facility failed to properly clean, maintain, and store R13's oxygen therapy equipment. This deficient practice placed her at risk for complications related to respiratory therapy. -The electronic medical record (EMR) indicated the following diagnosis for R32: osteomyelitis (local or generalized infection of the bone and bone marrow), major depressive disorder (major mood disorder), gastro-esophageal reflux disorder (GERD- backflow of stomach contents to the esophagus), glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow), urinary retention (lack of ability to urinate and empty the bladder), atrial fibrillation (rapid, irregular heart beat), peripheral vascular disease (PVD - abnormal condition affecting the blood vessels). R32's admission Minimum Data Set (MDS) dated 05/03/22 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS noted that he required a one person assist for transfers, walking, dressing, toileting, personal hygiene, and bathing. The MDS noted that he received oxygen therapy services. R32's Activities of Daily Living (ADL's) Care Area Assessment (CAA) dated 05/03/22 indicated that he required assistance from one staff for his ADL's and supervision related to his unsteady balance. A review of R32's Care Plan revised 05/19/22 revealed that he received oxygen therapy related to his medical diagnoses. The care plan noted that oxygen was administered as directed by the physician's order. The care plan lacked interventions related to cleaning and servicing the oxygen equipment and tubing. R32's Medication Administration Report (MAR) in his EMR revealed an active physicians order dated 04/29/22 to give two liters of oxygen delivered by nasal canula (tubing that delivers oxygen directly through both nostrils of the nose)at bedtime. The physician's order revealed that the oxygen tubing should be changed every 30 days. On 05/23/22 at 09:05 AM R32 stated that he was unsure if staff have ever cleaned the air filter on his oxygen machine Observation of the oxygen tubing revealed the tubing lacked information showing when it was placed. Observation of the machine revealed that the external filter contained dust and debris. On 05/25/22 at 02:06 PM R32's nasal cannula and oxygen tubing hung unbagged from his bedside table, next to the trash can in his room. In an interview completed on 05/26/22 at 12:52 PM with Certified Medication Aid (CMA) R, he stated that the oxygen tubing should be changed out once a month for the physician's order. He stated that he was unsure if the machines filter were cleaned by staff but should be cleaned by the oxygen company that services them. He reported that the oxygen tubing and nasal cannula should be stored in a bag when not in use to prevent contamination. In an interview completed on 05/26/22 at 02:04 PM with Administrative Nurse E, she stated the staff should be checking the oxygen machines tubing and storing it in the bag after each use. She reported that staff could clean the machine and change out the tubing if soiled or dirty. A review of the facility's Oxygen Administration policy revised 10/2010 outlined the facility's guidelines for safe oxygen administration. The policy stated that staff were required to check oxygen machine and supplies to the ensure the machines were in good working order. The policy lacked information related to cleaning the supplies or checking out the tubing. The facility failed to properly clean, maintain, and store R32's oxygen therapy equipment. This deficient practice placed him at risk for complications related to respiratory therapy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 37 residents. The sample included 13 residents with one reviewed for dialysis services (process of filtering and purifying blood using machines) . Based on observation, record review, and interviews, the facility failed to provide consistent care and services including communication between the facility and dialysis center for Resident (R)30. This deficient practice placed R30 at risk for complications related to dialysis services. Findings include: - The electronic medical record (EMR) indicated the following diagnosis for R30: chronic kidney disease, end stage renal disease (ERSD-- a terminal disease because of irreversible damage to the kidneys), atherosclerotic heart disease (hardening and narrowing of the blood vessels of the heart), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), heart failure, hyperkalemia (greater than normal amount of potassium in the blood), and need for assistance with personal care. R30's Significant Change of status Minimum Data Set (MDS) dated [DATE] noted a Brief Interview of Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. The MDS noted R30 required extensive assistance from one staff for bed mobility, dressing, personal hygiene, toileting, and bathing. The MDS noted that R30 received dialysis services. R30's Urinary Incontinence Care Area Assessment (CAA) dated 09/20/21 indicated that she required the use of incontinence products and extensive assistance from one staff for toileting. The CAA reported that she was able to let staff know when she had to use the restroom and required staff assist during toileting related to her unsteadiness and impaired balance. A review of R30's Care Plan revised 01/31/22 noted that she required extensive assist from two staff for toileting and transfers. The care plan indicated that she received hemodialysis services related to her ERSD. She received services on Tuesday, Thursday, and Saturday of each week. The care plan indicated that staff assessed the dialysis site each shift for signs of infections. A review of R30's Dialysis book revealed that communication forms were missing for 11 recent treatments (4/30, 5/3, 5/5, 5/7, 5/10, 5/12, 5/14, 5/17, 5/19, 5/21, and 5/24). Review of the reports available revealed missing documentation regarding health assessments, dialysis site assessments, incomplete communication from the dialysis facility regarding the residents scheduled treatment, and pertinent observations. A review of R30's Treatment Administration Report (TAR) and Medication Administration Report (MAR) revealed no orders for dialysis services or any record that R30's dialysis site was being assessed and documented in her medical records. On 05/26/22 at 10:05 AM R30 reported that she had dialysis three times a week (Tuesday, Thursday, and Saturday) . She reported that staff help her get prepared and assess her before she goes. She reported her treatments take about four hours to complete. R30 was unable to verify if she had another dialysis communication book. The resident appeared clean and well groomed. R30's dialysis shunt site (blood access site for dialysis) located left upper chest. No edema or signs of infection observed. Resident denied pain at shunt site. In an interview on 05/26/22 at 01:20 PM with Licensed Nurse (LN) G, she stated R30 received dialysis three days a week. She reported that sR30 took her dialysis book to her appointments and brought it back upon return. She stated that staff should assess hR30's dialysis site before each appointment and comple the book. LN G reported that all the completed dialysis communication forms should be filed into R30's dialysis book but not sure if R30 has two books or not. In an interview on 05/26/22 at 02:04 PM Administrative Nurse E reported that R30's dialysis book should have all the completed communication forms. She reported that she does not believe R30 had two books but would find them for review. The facility policy End-Stage Renal Disease, Care of a Resident with dated 09/2010 documented residents with ESRD were cared for according to currently recognized standards of care. The facility failed to provide consistent dialysis care and services, including communication between facilty and dialysis center for R30. This deficient practice placed R30 at risk for complication related to dialysis services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 37 residents. The sample included 13 residents, with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to monitor for Resident (R) 10's antihypertensive medication (class of medication used to treat hypertension [high blood pressure]) and failed to follow physician ordered parameters for monitoring of antihypertensive medication for R31 and R16. These deficient practices had the risk for side effects of unnecessary medications or complications. Findings included: - R10's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hypertension (elevated blood pressure), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), overactive bladder (a frequent and sudden urge to urinate that may be difficult to control), and stress incontinence (is the unintentional loss of urine). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R10 required extensive assistance of two staff members for activities of daily living (ADL's). The MDS documented R10 was not on a toileting plan. The MDS documented R10 received insulin (medication to regulate blood sugar), antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression), anticoagulant medication (class of medications used to prevent the formation of blood clots), diuretic medication (medication to promote the formation and excretion of urine) for seven days and opioid medication (a class of medication used to treat pain), for dour days during the look back period. The Quarterly MDS dated 03/29/22 documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R10 required extensive assistance of two staff members for ADL's. The MDS documented R10 was not on a toileting program. The MDS documented R10 received insulin, antidepressant medication, anticoagulant medication, diuretic medication for seven days and opioid medication, for dour days during the look back period. R10's Psychotropic Drug Use Assessment (CAA) dated 12/10/21 documented R10 received an antidepressant medication, anticoagulant medication, diuretic medication, and opioid medication as ordered. Staff reported no signs or symptoms of adverse reaction. The Care Plan dated 03/18/20 documented staff would monitor R10 for changes in mood and Behavior. The Care Plan lacked documentation of directions for antihypertensive medication monitoring. Review of the EMR under Orders tab revealed physician orders: Spironolactone-HCTZ tablet (diuretic) 25-25mg give 1 tablet by mouth in the morning related to hypertension/edema, hold parameters 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) less than(<) 90 millimeters of mercury (mmHg) or greater than (>)180mmHg diastolic blood pressure (DBP-minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) < 40mmHg or >100mmHg notify the physician. Call if BP parameters are out of bounds. SBP <90mmHg or >180mmHg, DBP <40mmHg or >100mmHg dated 04/08/22. The clinical record lacked evidence staff assessed R10's blood pressure prior to administering the Spironalactone-HCTZ as ordered. On 05/25/22 at 01:10 PM R10 was propelled in wheelchair to room. Her pants were visibly wet along her thighs and groin area. Nursing staff toileted, provided peri-care for R10 and placed a cloth incontinent pad folded onto R10's wheelchair cushion prior to her transfer back into the wheelchair. On 05/26/22 at 12:51 PM in an interview, Certified Medication Aide (CMA) R stated that all the staff monitor the residents for behaviors. CMA R stated documented behavior monitoring on the Treatment Administration Record (TAR). CMA R stated vital signs were obtained and charted on the Medication Administration Record (MAR) prior to administration of the medication if a physician had ordered a parameter. [NAME] stated he would notify the charge nurse if outside the ordered parameter. On 05/26/22 at 01:20 PM in an interview, Licensed Nurse (LN) G stated she did not work with the MRR. LN G stated she obtained her vital signs when possible, vital signs are charted in the MAR/TAR if a medication had a physician ordered parameters. LN G stated behavior monitoring was documented every shift on the MAR/TAR by the LN and/or the CMA. On 05/26/22 at 02:04 PM in an interview, Administrative Nurse E stated she reviewed and entered orders from the MRR's when faxed from the physician. Administrative Nurse E stated behavior monitoring was documented on the MAR/TAR every shift for residents on antidepressant medication and antipsychotic (class of medications used to treat mental illness) medication. Administrative Nurse E stated not all medication and behavior monitoring were care planned. The facility's Medication and Treatment Orders policy last revised July 2016 documented orders for medications and treatments would be consistent with principles of safe and effective order writing. The facility failed to implement daily monitoring for R10 who was on an antihypertensive medication. This deficient practice placed R10 at risk for potential harm and adverse consequences related to unnecessary medications. - R31'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), hypertension (elevated blood pressure), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Significant Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R31 required extensive assistance of two staff members for activities of daily living (ADL's). The MDS documented R31 received antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression), diuretic medication (medication to promote the formation and excretion of urine) for seven days, and antibiotic medication (class of medication used to treat bacterial infections) and opioid medication (a class of medication used to treat pain) for six days during the look back period. The Quarterly MDS dated 04/12/22 documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R31 required limited assistance of one staff member for ADL's. The MDS documented R31 received antidepressant medication, opioid medication, diuretic medication for seven days, and antianxiety medication for five days during the look back period. R31's Behavioral Symptoms Care Area Assessment (CAA) dated 02/15/22 documented she was alert and oriented with intermittent confusion noted. R31 was able to make her needs known to the staff. R31 received and antidepressant medication as ordered, and no adverse reaction was noted. R31's Care Plan dated 07/25/17 documented the CP would review medication monthly basis any sent any recommendations to the physician. Staff would monitor for and side effects from the antidepressant medication. The Care Plan dated 05/30/19 documented hypertensive medication was administered as ordered. Staff monitored for side effects such as orthostatic hypotension (blood pressure dropping with change of position), tachycardia (increased heart rate) and effectiveness. Review of the EMR under Orders tab revealed physician orders: Metoprolol succinate tablet (antihypertensive) extended release 24 Hour 100 milligrams (mg) give one tablet by mouth in the morning related to hypertension dated 06/2/2021. On 05/24/22 at 11:56 AM R31 sat reclined in a recliner in room. TV was on in room, blind pulled down and closed, no distress or behaviors noted. On 05/26/22 at 12:51 PM in an interview, Certified Medication Aide (CMA) R stated that all the staff monitor the residents for behaviors. CMA R stated documented behavior monitoring on the Treatment Administration Record (TAR). CMA R stated vital signs were obtained and charted on the Medication Administration Record (MAR) prior to administration of the medication if a physician had ordered a parameter. [NAME] stated he would notify the charge nurse if outside the ordered parameter. On 05/26/22 at 01:20 PM in an interview, Licensed Nurse (LN) G stated she did not work with the MRR. LN G stated she obtained her vital signs when possible, vital signs are charted in the MAR/TAR if a medication had a physician ordered parameters. LN G stated behavior monitoring was documented every shift on the MAR/TAR by the LN and/or the CMA. On 05/26/22 at 02:04 PM in an interview, Administrative Nurse E stated she reviewed and entered orders from the MRR's when faxed from the physician. Administrative Nurse E stated behavior monitoring was documented on the MAR/TAR every shift for residents on antidepressant medication and antipsychotic (class of medications used to treat mental illness) medication. Administrative Nurse E stated not all medication and behavior monitoring were care planned. The facility's Medication and Treatment Orders policy last revised July 2016 documented orders for medications and treatments would be consistent with principles of safe and effective order writing. The facility failed to implement daily monitoring for R31 who was on an antihypertensive medication. This deficient practice placed R31 at risk for potential harm and adverse consequences related to unnecessary medications. - R16's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), history of falls, unsteady on feet, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS documented that R16 required extensive assistance of one staff member for activities of daily living (ADL's). The MDS documented no falls for R16 during the look back period. The MDS documented R16 had received antipsychotic medication (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions), antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression), diuretic medication (medication to promote the formation and excretion of urine), and opioid medication (a class of medication used to treat pain) for seven days during the look back period. The Quarterly MDS dated 03/25/22 documented a BIMS score of eight which indicated moderately impaired cognition. The MDS documented that R16 required extensive assistance of one staff member for ADL's. The MDS documented no falls during the look back period. The MDS documented R16 received antipsychotic medication, antidepressant medication, diuretic medication, and opioid medication for seven days during the look back period. R16's Psychotropic Drug Use Care Area Assessment (CAA) dated 01/18/22 documented a diagnosis of hypertension. R16's Care Plan dated 11/27/19 documented staff was to monitor/document/report as needed any signs or symptoms of malignant (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) hypertension. Review of the EMR under Orders revealed the following physician orders: Lisinopril tablet 20 milligram (mg) give one tablet by mouth in the morning related to hypertension. Hold if 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) less than(<) 80 millimeters of mercury (mmHg) or greater than (>)180mmHg diastolic blood pressure (DBP-minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) < 40mmHg or >100mmHg notify the physician. Call if BP parameters are out of bounds. SBP <90mmHg or >180mmHg, DBP <40mmHg or >90mmHg dated 04/07/20. Review of R16's clinical recorded revealed no blood pressure monitoring noted prior to administration of the lisinopril as ordered by the physician. On 05/25/22 at 01:12PM R16 ambulated down from the front entrance door, with a walker. Her pants were wet in back, halfway down her left leg and across her buttocks. Observation revealed Activity staff Z ambulated beside R16 to her room. On 05/26/22 at 12:51 PM in an interview, Certified Medication Aide (CMA) R stated that all the staff monitor the residents for behaviors. CMA R stated documented behavior monitoring on the Treatment Administration Record (TAR). CMA R stated vital signs were obtained and charted on the Medication Administration Record (MAR) prior to administration of the medication if a physician had ordered a parameter. [NAME] stated he would notify the charge nurse if outside the ordered parameter. On 05/26/22 at 01:20 PM in an interview, Licensed Nurse (LN) G stated she did not work with the MRR. LN G stated she obtained her vital signs when possible, vital signs are charted in the MAR/TAR if a medication had a physician ordered parameters. LN G stated behavior monitoring was documented every shift on the MAR/TAR by the LN and/or the CMA. On 05/26/22 at 02:04 PM in an interview, Administrative Nurse E stated she reviewed and entered orders from the MRR's when faxed from the physician. Administrative Nurse E stated behavior monitoring was documented on the MAR/TAR every shift for residents on antidepressant medication and antipsychotic (class of medications used to treat mental illness) medication. Administrative Nurse E stated not all medication and behavior monitoring were care planned. The facility's Medication and Treatment Orders policy last revised July 2016 documented orders for medications and treatments would be consistent with principles of safe and effective order writing. The facility failed to monitor blood pressure as ordered by the physician for antihypertensive medication daily. This deficient practice placed R16 at risk for adverse consequences related to unnecessary medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 37. The sample included 13 residents with five residents reviewed for unnecessary medications. Based on observations, interviews, and record reviews, the facility failed to implement behavioral monitoring associated with antidepressant medications (class of medications used to treat mood disorders and relieve symptoms of intense sadness, hopelessness and suicidal thoughts) and the facility failed to implement a discontinuation date (stop date) for as needed psychotropic ( medications which alter thoughts or mood) medication for Residents (R) 14, R31 and R33. This deficient practice placed the residents at risk for ineffective treatment and unnecessary side effects from psychotropic medications. Fingings lncluded: -The electronic medical records (EMR) indicated the following diagnoses for R14: hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), cerebral infarction affecting right dominant side (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 ) osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), general anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive disorder (major mood disorder), and hypertension (high blood pressure). R14's Quarterly Minimum Data Set (MDS) dated 03/22/22 noted a Brief Interview for Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS noted that she had been taking antidepressant (class of medication used to treat depression) medication. R14's Psychotropic Drug Use Care Area Assessment (CAA) dated 11/02/21 noted that she received antidepressant medication related to her diagnoses of major depressive disorder and general anxiety disorder. R14's Care Plan revised 03/24/22 indicated that she received trazodone hydrochloride (antidepressant) for depression and anxiety. The care plan noted that trazodone had a black box warning (warning to identifying high risk or potentially dangerous medications) related to the risk of suicidal thoughts and behaviors. A review of R14's Medication Administration Report (MAR) revealed an active order dated 09/29/21 for staff to administer 25 milligrams (mg) of trazodone hydrochloride by mouth every eight hours as needed for anxiety and depression. The order lacked a stop or discontinuation date. A review of the Monthly Medication Reviews completed by the facilities consulting pharmacist (CP) indicated that the facility was notified that R14's trazodone order needed a stop date on the 02/2022 and 04/2022 reviews. The documentation lacked a response from the facility. A Health Status Note dated 02/11/22 noted that R14's trazodone (medication that treats depression and anxiety) was increased to 50 milligrams (mg) orally every morning from 25mg. A Behavior Note dated 02/14/22 stated that R14 remained on monitoring related to the increase of her trazodone medication. The note stated that she was anxious. It noted that staff was unable to console her. On 05/26/22 at 08:03AM R14 slept sitting upright in her reclining chair wearing a bib cloth to protect her clothing. She appeared to be prepped for breakfast and her food was cut up for her to eat but not covered to prevent it from getting cold. On 05/26/22 at 02:04 PM with Administrative Nurse E, she stated that the pharmacy reviews arrived monthly and were reviewed by nursing and the doctors. She noted that the physicians reviewed the recommendations and discussed options when they came to the facility for rounds. She said that if an irregularity was noted, the physician should provide an order to continue or change the medication order. A review of the facility's Behavioral Assessment, Intervention and Monitoring policy revised 05/2019 stated the facility will provide behavioral services as needed to attain or maintain the highest practicable physical, mental, and psychological well-being in accordance with the comprehensive assessment and plan of care. The policy indicated that when medications were prescribed the document must include the rationale for use, dosage, potential risks, duration, and plans for a gradual dose reduction (GDR). The facility failed to implement a discontinuation date for R14's trazodone medication. The deficient practice placed R14 at risk for ineffective treatment and decreased psychosocial wellbeing. - R31'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), hypertension (elevated blood pressure), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Significant Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R31 required extensive assistance of two staff members for activities of daily living (ADL's). The MDS documented R31 received antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression), diuretic medication (medication to promote the formation and excretion of urine) for seven days, and antibiotic medication (class of medication used to treat bacterial infections) and opioid medication (a class of medication used to treat pain) for six days during the look back period. The Quarterly MDS dated 04/12/22 documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R31 required limited assistance of one staff member for ADL's. The MDS documented R31 received antidepressant medication, opioid medication, diuretic medication for seven days, and antianxiety medication for five days during the look back period. R31's Behavioral Symptoms Care Area Assessment (CAA) dated 02/15/22 documented she was alert and oriented with intermittent confusion noted. R31 was able to make her needs known to the staff. R31 received and antidepressant medication as ordered, and no adverse reaction was noted. R31's Care Plan dated 07/25/17 documented the CP would review medication monthly basis any sent any recommendations to the physician. Staff would monitor for and side effects from the antidepressant medication. The Care Plan lacked documentation for behavioral monitoring for antidepressant medication. Review of the EMR under Orders tab revealed physician orders: Duloxetine HCl capsule (antidepressant) delayed release sprinkle 30 milligrams (mg) give one capsule by mouth in the morning for depression dated 03/26/2020. Review of R31's clinical record lacked evidence of behavior monitoring. On 05/24/22 at 11:56 AM R31 sat reclined in a recliner in room. TV was on in room, blind pulled down and closed, no distress or behaviors noted. On 05/26/22 at 12:51 PM in an interview, Certified Medication Aide (CMA) R stated that all the staff monitor the residents for behaviors. CMA R stated documented behavior monitoring on the Treatment Administration Record (TAR). CMA R stated vital signs were obtained and charted on the Medication Administration Record (MAR) prior to administration of the medication if a physician had ordered a parameter. [NAME] stated he would notify the charge nurse if outside the ordered parameter. On 05/26/22 at 01:20 PM in an interview, Licensed Nurse (LN) G stated she did not work with the MRR. LN G stated she obtained her vital signs when possible, vital signs are charted in the MAR/TAR if a medication had a physician ordered parameters. LN G stated behavior monitoring was documented every shift on the MAR/TAR by the LN and/or the CMA. On 05/26/22 at 02:04 PM in an interview, Administrative Nurse E stated she reviewed and entered orders from the MRR's when faxed from the physician. Administrative Nurse E stated behavior monitoring was documented on the MAR/TAR every shift for residents on antidepressant medication and antipsychotic (class of medications used to treat mental illness) medication. Administrative Nurse E stated not all medication and behavior monitoring were care planned. ` The facility's Intervention and Monitoring Behavioral Assessment last revised March 2019 documented the facility would comply with the regulatory requirements related to use of medication to manage behavioral changes. The facility failed to ensure behavioral monitoring was implemented for R31 who was taking an antidepressant medication, this deficient practice placed R31 at risk for potential harm and adverse consequences related to unnecessary medications. - R33's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hypertension (elevated blood pressure), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented that R33 required assistance of two staff members for activities of daily living (ADL's). The MDS documented R33 received antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression), anticoagulant medication (class of medications used to prevent the formation of blood clots), for six days and diuretic medication (medication to promote the formation and excretion of urine) for five days during the look back period. R33's Psychotropic Drug Use Care Area Assessment (CAA) dated 04/26/22 documented she received an antidepressant medication as ordered and the CP would review medications on admission, monthly and as needed. R33's Care Plan dated 05/11/22 documented pharmacy would review medication monthly or protocol. The Care Plan dated 05/13/22 documented facility would monitor closely for behaviors for antidepressant treatment for R33. Review of the EMR under Orders tab revealed physician orders: Sertraline HCl tablet (antidepressant) 50 milligram (mg) give one tablet by mouth at bedtime related to depression dated 05/02/2022. Review of R33's clinical record lacked evidence of behavior monitoring. On 05/24/22 at 08:00 AM R33 laid in bed, head of elevated with bedside table across abdomen as she waited for breakfast. On 05/26/22 at 12:51 PM in an interview, Certified Medication Aide (CMA) R stated that all the staff monitor the residents for behaviors. CMA R stated documented behavior monitoring on the Treatment Administration Record (TAR). CMA R stated vital signs were obtained and charted on the Medication Administration Record (MAR) prior to administration of the medication if a physician had ordered a parameter. [NAME] stated he would notify the charge nurse if outside the ordered parameter. On 05/26/22 at 01:20 PM in an interview, Licensed Nurse (LN) G stated she did not work with the MRR. LN G stated she obtained her vital signs when possible, vital signs are charted in the MAR/TAR if a medication had a physician ordered parameters. LN G stated behavior monitoring was documented every shift on the MAR/TAR by the LN and/or the CMA. On 05/26/22 at 02:04 PM in an interview, Administrative Nurse E stated she reviewed and entered orders from the MRR's when faxed from the physician. Administrative Nurse E stated behavior monitoring was documented on the MAR/TAR every shift for residents on antidepressant medication and antipsychotic (class of medications used to treat mental illness) medication. Administrative Nurse E stated not all medication and behavior monitoring were care planned. The facility Medication Regimen Reviews policy revised May 20219 documented the goal of the MRR was to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. The facility failed to ensure behavioral monitoring was implemented for R33 who was taking an antidepressant medication. This deficient practice placed R33 at risk for potential harm and adverse consequences related to unnecessary medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R31'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), hypertension (elevated blood pressure), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Significant Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R31 required extensive assistance of two staff members for activities of daily living (ADL's). The MDS documented R31 received antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression), diuretic medication (medication to promote the formation and excretion of urine) for seven days, and antibiotic medication (class of medication used to treat bacterial infections) and opioid medication (a class of medication used to treat pain) for six days during the look back period. The Quarterly MDS dated 04/12/22 documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R31 required limited assistance of one staff member for ADL's. The MDS documented R31 received antidepressant medication, opioid medication, diuretic medication for seven days, and antianxiety medication for five days during the look back period. R31's Behavioral Symptoms Care Area Assessment (CAA) dated 02/15/22 documented she was alert and oriented with intermittent confusion noted. R31 was able to make her needs known to the staff. R31 received and antidepressant medication as ordered, and no adverse reaction was noted. R31's Care Plan dated 07/25/17 documented the CP would review medication monthly basis any sent any recommendations to the physician. Staff would monitor for and side effects from the antidepressant medication. The Care Plan dated 05/30/19 documented hypertensive medication was administered as ordered. Staff monitored for side effects such as orthostatic hypotension (blood pressure dropping with change of position), tachycardia (increased heart rate) and effectiveness. The Care Plan lacked documentation for behavioral monitoring for antidepressant medication. Review of the EMR under Orders tab revealed physician orders: Duloxetine HCl capsule (antidepressant) delayed release sprinkle 30 milligrams (mg) give one capsule by mouth in the morning for depression dated 03/26/2020. Metoprolol succinate tablet(antihypertensive) extended release 24 Hour 100mg give one tablet by mouth in the morning related to hypertension dated 06/2/2021. On 05/24/22 at 11:56 AM R31 sat reclined in a recliner in room. TV was on in room, blind pulled down and closed, no distress or behaviors noted. On 05/26/22 at 12:51 PM in an interview, Certified Medication Aide (CMA) R stated that all the staff monitor the residents for behaviors. CMA R stated documented behavior monitoring on the Treatment Administration Record (TAR). CMA R stated vital signs were obtained and charted on the Medication Administration Record (MAR) prior to administration of the medication if a physician had ordered a parameter. CMA R stated he would notify the charge nurse if outside the ordered parameter. CMA R stated there was a care plan book located at the desk that staff were able to review. CMA R stated the care plan was available on the PCC for each resident. CMA R stated the MDS coordinator updated the care plan. CMA R stated any new interventions that were placed on the care plan an Inservice sheet would be placed at the desk for all staff to review and sign. On 05/26/22 at 02:04 PM in an interview, Administrative Nurse E stated she reviewed and entered orders from the MRR's when faxed from the physician. Administrative Nurse E stated behavior monitoring was documented on the MAR/TAR every shift for residents on antidepressant medication and antipsychotic (class of medications used to treat mental illness) medication. Administrative Nurse E stated not all medication and behavior monitoring were care planned. The Facility Comprehensive Person-Centered Care Plan policy last revised December 2016 documented a comprehensive, person centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. Identified problem areas and their causes and develop interventions that are targeted and meaningful to the resident. Assessments of the residents are ongoing and are plans are revised as information about the resident and the residents' conditions change. The facility failed to develop a person-centered care plan for R31 related to monitoring vital signs for antihypertensive medication and for behavior monitoring for antidepressant medication, which placed R31 at risk of not achieving and/or maintaining her highest practicable physical, mental, and psychosocial well-being. The facility identified a census of 37 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to develop an individualized person-centered care plan related to bladder incontinence for Resident (R) 10, R16, and R30 and failed in the development of person-centered care plan related to monitoring of antihypertensive medication for R31. This deficient practice placed the residents at risk of not achieving and/or maintaining their highest practicable physical, mental, and psychosocial well-being. Findings included: - R10's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hypertension (elevated blood pressure), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), overactive bladder (a frequent and sudden urge to urinate that may be difficult to control), and stress incontinence (is the unintentional loss of urine). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R10 required extensive assistance of two staff members for activities of daily living (ADL's). The MDS documented R10 was not on a toileting plan. The MDS documented R10 received insulin (medication to regulate blood sugar), antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression), anticoagulant medication (class of medications used to prevent the formation of blood clots), diuretic medication (medication to promote the formation and excretion of urine) for seven days and opioid medication (a class of medication used to treat pain), for dour days during the look back period. The Quarterly MDS dated 03/29/22 documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R10 required extensive assistance of two staff members for ADL's. The MDS documented R10 was not on a toileting program. The MDS documented R10 received insulin, antidepressant medication, anticoagulant medication, diuretic medication for seven days and opioid medication, for dour days during the look back period. R10's Urinary Incontinence and Indwelling Catheter Area Assessment (CAA) dated 12/10/21 documented R10 was incontinent of bladder and used incontinent products for protection and dignity. R10 received two diuretic medications as ordered, which increased her need to be toileted and needed encouragement at times. R10's Care Plan dated 01/11/18 documented she used a disposable brief that was to be changed as needed. Staff were to provide peri-care after each incontinent episode. The Care Plan dated 04/25/19 documented R10 was to be checked frequently and as required for incontinence. The care plan lacked individualized interventions related to toileting. Review of the EMR under Orders tab revealed physician orders: Bumetanide tablet (diuretic) two milligrams (mg) give 1 tab by mouth in the morning related to edema (swelling resulting from an excessive accumulation of fluid in the body tissues) dated 10/19/2017. Spironolactone-HCTZ tablet (diuretic) 25-25mg give 1 tablet by mouth in the morning related to hypertension/edema, hold parameters 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) less than(<) 90 millimeters of mercury (mmHg) or greater than (>)180mmHg diastolic blood pressure (DBP-minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) < 40 mmHg or >100mmHg notify the physician. Call if BP parameters are out of bounds. SBP <90 mmHg or >180mmHg, DBP <40 mmHg or >100mmHg dated 04/08/22. On 05/25/22 at 01:10 PM R10 was propelled in wheelchair to room. Her pants were visibly wet along her thighs and groin area. Nursing staff toileted, provided peri-care for R10 and placed a cloth incontinent pad folded onto R10's wheelchair cushion prior to her transfer back into the wheelchair. On 05/25/22 at 01:26 PM in an interview, Certified Nurse's Aide (CNA) N stated R10 was toileted after getting out of bed in the morning, before and after each meal. CNA N stated a cloth incontinent pad was placed in the wheelchair of every resident that was a heavy wetter. On 05/26/22 at 12:51 PM in an interview, Certified Medication Aide (CMA) R stated there was a care plan book located at the desk that staff were able to review. CMA R stated the care plan was available on the PCC for each resident. CMA R stated the MDS coordinator updated the care plan. CMA R stated any new interventions that were placed on the care plan an Inservice sheet would be placed at the desk for all staff to review and sign. On 05/26/22 at 01:20 PM in an interview, Licensed Nurse (LN) G stated every resident was on a check and change toileting schedule. LN G stated a 72-hour bowel and bladder assessment was completed on every resident at the time of their admission. LN G stated she was unaware of were and what was done with that assessment after completion. LN G stated behavior monitoring was documented every shift on the MAR/TAR by the LN and/or the CMA. On 05/26/22 at in an interview, Administrative Nurse E stated a 72-hour bowel; and bladder assessment was completed after admission, but the data was not used to develop an individualized toileting plan. Administrative Nurse E stated not all medication and behavior monitoring was not always care planned. The Facility Comprehensive Person-Centered Care Plan policy last revised December 2016 documented a comprehensive, person centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. Identified problem areas and their causes and develop interventions that are targeted and meaningful to the resident. Assessments of the residents are ongoing and are plans are revised as information about the resident and the residents' conditions change. The facility failed to develop a person-centered care plan for R10 related to an individualized toileting program, which placed R10 at risk of not achieving and/or maintaining her highest practicable physical, mental, and psychosocial well-being. - R16's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), history of falls, unsteady on feet, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS documented that R16 required extensive assistance of one staff member for activities of daily living (ADL's). The MDS documented no falls for R16 during the look back period. The MDS documented R16 had received antipsychotic medication (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions), antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression), diuretic medication (medication to promote the formation and excretion of urine), and opioid medication (a class of medication used to treat pain) for seven days during the look back period. The Quarterly MDS dated 03/25/22 documented a BIMS score of eight which indicated moderately impaired cognition. The MDS documented that R16 required extensive assistance of one staff member for ADL's. The MDS documented no falls during the look back period. The MDS documented R16 received antipsychotic medication, antidepressant medication, diuretic medication, and opiod medication for seven days during the look back period. R16's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 01/18/22 documented she was frequently incontinent of bowel and bladder and used incontinent products for protection and dignity. Staff would provide peri-care after each incontinent episode. R16's Care Plan revised 04/30/20 documented staff were to ensure the call light was in reach and encouraged her to use the call light as needed. R16 needed prompt response to all her requests. The Care Plan revised 07/23/20 documented R16 required assistance with peri-care and was to use the call light to call for assistance . The Care Plan dated 09/23/20 documented staff was to remind R16 to use the bathroom every two hours and as needed. R16 was to call for assistance with peri-care . The Care Plan lacked documentation of an individualized person centered toileting plan for R16. On 05/25/22 at 01:12PM R16 ambulated down from the front entrance door, with a walker. Her pants were wet in back, halfway down her left leg and across her buttocks. Observation revealed Activity staff Z ambulated beside R16 to her room. On 05/25/22 at 01:12PM in an interview, Activity Staff Z stated R16 was incontinent of urine and stated when R16 voids, she goes a lot. On 05/26/22 at 12:51 PM in an interview, Certified Medication Aide (CMA) R stated there was a care plan book located at the desk that staff were able to review. CMA R stated the care plan was available on the PCC for each resident. CMA R stated the MDS coordinator updated the care plan. CMA R stated any new interventions that were placed on the care plan an Inservice sheet would be placed at the desk for all staff to review and sign. On 05/26/22 at 01:20 PM in an interview, Licensed Nurse (LN) G stated every resident was on a check and change toileting schedule. LN G stated a 72-hour bowel and bladder assessment was completed on every resident at the time of their admission. LN G stated she was unaware of were and what was done with that assessment after completion. LN G stated behavior monitoring was documented every shift on the MAR/TAR by the LN and/or the CMA. LN G stated any nurse can make changes to the care plan when needed. LN G stated any individualized monitoring would be located on thecare plan. On 05/26/22 at in an interview, Administrative Nurse E stated a 72-hour bowel; and bladder assessment was completed after admission, but the data was not used to develop an individualized toileting plan. Administrative Nurse E stated not all medication and behavior monitoring was not always care planned. The Facility Comprehensive Person-Centered Care Plan policy last revised December 2016 documented a comprehensive, person centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. Identified problem areas and their causes and develop interventions that are targeted and meaningful to the resident. Assessments of the residents are ongoing and are plans are revised as information about the resident and the residents' conditions change. The facility failed to develop a person-centered care plan for R16 related to an individualized toileting program, which placed R16 at risk of not achieving and/or maintaining her highest practicable physical, mental, psychosocial well-being and adverse consequences. - The electronic medical record (EMR) indicated the following diagnosis for R30: major depressive disorder (major mood disorder), chronic kidney disease, end stage renal disease, atherosclerotic heart disease (hardening and narrowing of the blood vessels of the heart), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), heart failure, hyperkalemia (greater than normal amount of potassium in the blood), and need for assistance with personal care. R30's Significant Change of Status Minimum Data Set (MDS) dated [DATE] noted a Brief Interview of Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. The MDS indicated she was occasionally incontinent of bladder but always continent of bowel. The MDS noted that she was not on a toileting program for bowel and bladder. The MDS noted R30 required extensive assistance from one staff for bed mobility, dressing, personal hygiene, toileting, and bathing. The MDS noted that the she received dialysis services. R30's Urinary Incontinence Care Area Assessment (CAA) dated 09/20/21 indicated that she required the use of incontinence products and extensive assistance from one staff for toileting. The CAA reported that she was able to let staff know when she had to use the restroom and required staff assist during toileting related to her unsteadiness and impaired balance. A review of R30's Care Plan revised 01/31/22 noted that she required extensive assist from two staff for toileting and transfers. The care plan indicated that she has episodes of incontinence and staff were required to provide medium disposable pull-up incontinence briefs, provide peri-care after each episode, and make sure the restroom path was unobstructed. The care plan lacked documentation related to interventions preventing incontinence episodes. A review of R30's Bladder Elimination Lookback report from 02/01/22 through 05/25/22 (114 days reviewed) revealed the she had 43 bladder incontinence occurrences reported. A review of R30's Bowel Elimination Lookback report from 02/01/22 through 05/25/22 (114 days reviewed) revealed the she had 19 bowel incontinence occurrences reported. A review of R30's Continence evaluation competed on 04/18/22 indicated that she was aware of the urge to void, able to understand reminders or prompts, and motivated to be continent. On 05/26/22 at 10:05 AM R30 reported that although she would attempt to alert staff of having to use the restroom, she sometimes struggled to make it on time. She reported that staff do come in a check on her but was not aware if she was on a schedule for toileting. In an interview on 05/26/22 at 01:20 PM with Licensed Nurse (LN) G, she stated that all the residents are on a check and change. All the residents should be checked 2 hours before and after meals. She stated that the residents are provided peri-care after incontinent episodes and should be assessed for skin breakdown or infection concerns. She reported that all staff can view the resident's care plan and if something needed to be added or changed the MDS coordinator would be notified. In an interview on 05/26/22 at 02:04 PM Administrative Nurse E reported that staff should be checking on the resident's frequently for incontinence. She reported that the facility has a two-hour check and change, complete voiding logs upon admission, and provides bladder retraining if needed. She reported that toileting interventions should be listed on the resident's care plan. She reported that the assessments were completed upon admission but the data for the assessment was not utilized to provided individualized toileting programs to the residents. She reported that the resident's care plan would be reflected by their assessed continence levels. A review of the facility's Care Plans policy revised 12/2016 noted that the care plan must meet the needs of each resident's comprehensive assessment must address areas identified as concerns. The policy noted that the plan must include goals, interventions, and instructions to assist with the resident's treatment. The facility failed to develop a care plan to reduce incontinence episodes for R30. This deficient practice placed R30 at risk for complications related to incontinence.

The facility had a census of 37 residents. The sample included 13 residents. Based on record review and interview the facility failed to provide scheduled weekend activities. This placed the residents at risk for boredom and impaired psychosocial well-being. Findings included: - On 05/25/22 at 10:30 AM, during resident council meeting, the four present resident council members voiced a concern regarding the lack of scheduled resident activities on the weekends. Review of the February, March, April and May 2022 Activity Calendars revealed no scheduled resident activities for the weekends. The calendars documented family and friend visits as resident activities. On 05/25/22 at 1:12 PM, Activity Z verified the facility had no scheduled activities on the weekends for the residents and stated she would set up dominos and scrabble in the living area for resident who wanted to play them. Activity Z stated she was employed with the facility since February 2022;she was working on getting more scheduled activities on the weekend. On 05/31/22 at 10:30 AM, Administrative Nurse E stated she expected staff to have activities on the weekend whether it was games set up for residents to play, or instructions to the staff to provide some kind of activity for the residents. The facility's Activity Programs Policy, revised June 2018, documented activities are scheduled seven days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique (somewhat formal word that typically refers to a careful judgment in which someone gives an opinion about something) of the programs. The facility failed to provide scheduled weekend activities for the 37 residents who reside in the facility. This placed them at risk for boredom and impaired psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -The electronic medical records (EMR) indicated the following diagnoses for R14: hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), cerebral infarction affecting right dominant side (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 ) osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), general anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive disorder (major mood disorder), and hypertension (high blood pressure). R14's Quarterly Minimum Data Set (MDS) dated 03/22/22 noted a Brief Interview for Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS noted that she had been taking antidepressant (class of medication used to treat depression) medication. R14's Psychotropic Drug Use Care Area Assessment (CAA) dated 11/02/21 noted that she received antidepressant medication related to her diagnoses of major depressive disorder and general anxiety disorder. R14's Care Plan revised 03/24/22 indicated that she received trazodone hydrochloride (antidepressant) for depression and anxiety. The care plan noted that trazodone had a black box warning (warning to identifying high risk or potentially dangerous medications) related to the risk of suicidal thoughts and behaviors. A review of R14's Medication Administration Report (MAR) revealed an active order dated 09/29/21 for staff to administer 25 milligrams (mg) of trazodone hydrochloride by mouth every eight hours as needed for anxiety and depression. The order lacked a stop or discontinuation date. A review of the Monthly Medication Reviews completed by the facilities consulting pharmacist (CP) indicated that the facility was notified that R14's trazodone order needed a stop date on the 02/2022 and 04/2022 reviews. The documentation lacked a response from the facility. On 05/26/22 at 08:03AM R14 slept sitting upright in her reclining chair wearing a bib cloth to protect her clothing. She appeared to be prepped for breakfast and her food was cut up for her to eat but not covered to prevent it from getting cold. On 05/26/22 at 02:04 PM with Administrative Nurse E, she stated that the pharmacy reviews arrived monthly and were reviewed by nursing and the doctors. She noted that the physicians reviewed the recommendations and discussed options when they came to the facility for rounds. She said that if an irregularity was noted, the physician should provide an order to continue or change the medication order. On 05/31/2022 at 04:20PM an interview with Consultant GG, she stated that R14's trazodone medication order had been sent to the facility twice and she was awaiting the facilities response. She reported that she had sent the first report in 02/2022 but was giving the facility time to respond before sending the next review notice. A review of the facility's Medication Regimen Review policy revised 05/2019 stated that medication reviews were completed by the CP. The policy noted that the reviews were completed upon admission and at least monthly to identify medication irregularities and promote medication safety. The policy noted that the CP will provide a written report for the facility containing the resident's name, medication, irregularity, and pharmacist recommendation. The policy noted that the physician must document in the medical records the report reviewed and what action was taken. The facility failed to acknowledge and act upon the CP's recommendation for R14's trazodone medication. The deficient practice placed R14 at risk for ineffective treatment and decreased psychosocial wellbeing. The facility identified a census of 37 residents. The sample included 13 residents, with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the failure to monitor antihypertensive medication (class of medication used to treat hypertension [high blood pressure]), failure to follow physician ordered parameters for monitoring of antihypertensive medication, the lack of behavior monitoring on psychotropic (medications which alter mood or thoughts) medications and the lack of a stop date for an as needed antidepressant. These deficient practices placed Resident(R) 10, R31, R16, R33 and R14 at increased risk for side effects of unnecessary medications or complications. Findings included: - R10's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hypertension (elevated blood pressure), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), overactive bladder (a frequent and sudden urge to urinate that may be difficult to control), and stress incontinence (is the unintentional loss of urine). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R10 required extensive assistance of two staff members for activities of daily living (ADL's). The MDS documented R10 was not on a toileting plan. The MDS documented R10 received insulin (medication to regulate blood sugar), antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression), anticoagulant medication (class of medications used to prevent the formation of blood clots), diuretic medication (medication to promote the formation and excretion of urine) for seven days and opioid medication (a class of medication used to treat pain), for dour days during the look back period. The Quarterly MDS dated 03/29/22 documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R10 required extensive assistance of two staff members for ADL's. The MDS documented R10 was not on a toileting program. The MDS documented R10 received insulin, antidepressant medication, anticoagulant medication, diuretic medication for seven days and opioid medication, for dour days during the look back period. R10's Psychotropic Drug Use Assessment (CAA) dated 12/10/21 documented R10 received an antidepressant medication, anticoagulant medication, diuretic medication, and opioid medication as ordered. Staff reported no signs or symptoms of adverse reaction. R10's Care Plan dated 01/11/18 documented she used a disposable brief that was to be changed as needed. Staff were to provide peri-care after each incontinent episode. The Care Plan dated 04/25/19 documented R10 was to be checked frequently and as required for incontinence. The care plan lacked individualized interventions related to toileting. The Care Plan dated 03/18/20 documented staff would monitor R10 for changes in mood and Behavior. Review of the EMR under Orders tab revealed physician orders: Wellbutrin XL tablet extended release 24 hour 300 milligrams (mg) give one tablet by mouth in the morning related to depression dated 12/6/2021. Spironolactone-HCTZ tablet (diuretic) 25-25mg give 1 tablet by mouth in the morning related to hypertension/edema, hold parameters 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) less than(<) 90 millimeters of mercury (mmHg) or greater than (>)180mmHg diastolic blood pressure (DBP-minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) < 40mmHg or >100mmHg notify the physician. Call if BP parameters are out of bounds. SBP <90mmHg or >180mmHg, DBP <40mmHg or >100mmHg dated 04/08/22. Review of the Monthly Medication Review (MMR), performed by the CP, reviewed May 2022 through April 2022 did not address the lack behavioral monitoring for antidepressant medication for R10. CP GG on 03/27/22 wrote a recommendation to clarify with the physician the hold parameters for the antihypertensive medication. The EMR had lacked a response to CP GG recommendation. On 05/25/22 at 01:10 PM R10 was propelled in wheelchair to room. Her pants were visibly wet along her thighs and groin area. Nursing staff toileted, provided peri-care for R10 and placed a cloth incontinent pad folded onto R10's wheelchair cushion prior to her transfer back into the wheelchair. On 05/26/22 at 12:51 PM in an interview, Certified Medication Aide (CMA) R stated that all the staff monitor the residents for behaviors. CMA R stated documented behavior monitoring on the Treatment Administration Record (TAR). CMA R stated vital signs were obtained and charted on the Medication Administration Record (MAR) prior to administration of the medication if a physician had ordered a parameter. [NAME] stated he would notify the charge nurse if outside the ordered parameter. On 05/26/22 at 01:20 PM in an interview, Licensed Nurse (LN) G stated she did not work with the MRR. LN G stated she obtained her vital signs when possible, vital signs are charted in the MAR/TAR if a medication had a physician ordered parameters. LN G stated behavior monitoring was documented every shift on the MAR/TAR by the LN and/or the CMA. On 05/26/22 at 02:04 PM in an interview, Administrative Nurse E stated she reviewed and entered orders from the MRR's when faxed from the physician. Administrative Nurse E stated behavior monitoring was documented on the MAR/TAR every shift for residents on antidepressant medication and antipsychotic (class of medications used to treat mental illness) medication. Administrative Nurse E stated not all medication and behavior monitoring were care planned. On 05/31/22 at 04:55 PM in an interview, CP GG stated the facility did change the order for monitoring for antihypertensives but did not add the daily vital sign monitoring with specific directions or frequency. CP GG stated she would not always recommend behavior monitoring for all residents taking an antidepressant medication. She said she reviewed the notes documented under the Progress Note tab for documentation of behaviors by exception. The facility Medication Regimen Reviews policy revised May 20219 documented the goal of the MRR was to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. The facility failed to ensure the CP noted irregularities for R10 for lack of monitoring antihypertensive medication daily and lack of behavior monitoring for antidepressant medication. This deficient practice placed R10 at risk for potential harm and adverse consequences related to unnecessary medications. - R31'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), hypertension (elevated blood pressure), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Significant Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R31 required extensive assistance of two staff members for activities of daily living (ADL's). The MDS documented R31 received antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression), diuretic medication (medication to promote the formation and excretion of urine) for seven days, and antibiotic medication (class of medication used to treat bacterial infections) and opioid medication (a class of medication used to treat pain) for six days during the look back period. The Quarterly MDS dated 04/12/22 documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R31 required limited assistance of one staff member for ADL's. The MDS documented R31 received antidepressant medication, opioid medication, diuretic medication for seven days, and antianxiety medication for five days during the look back period. R31's Behavioral Symptoms Care Area Assessment (CAA) dated 02/15/22 documented she was alert and oriented with intermittent confusion noted. R31 was able to make her needs known to the staff. R31 received and antidepressant medication as ordered, and no adverse reaction was noted. R31's Care Plan dated 07/25/17 documented the CP would review medication monthly basis any sent any recommendations to the physician. Staff would monitor for and side effects from the antidepressant medication. The Care Plan dated 05/30/19 documented hypertensive medication was administered as ordered. Staff monitored for side effects such as orthostatic hypotension (blood pressure dropping with change of position), tachycardia (increased heart rate) and effectiveness. Review of the EMR under Orders tab revealed physician orders: Duloxetine HCl capsule (antidepressant) delayed release sprinkle 30 milligrams (mg) give one capsule by mouth in the morning for depression dated 03/26/2020. Metoprolol succinate tablet(antihypertensive) extended release 24 Hour 100mg give one tablet by mouth in the morning related to hypertension dated 06/2/2021. Review of the Monthly Medication Review (MMR), performed by the CP, reviewed May 2021 through April 2022 did not address the lack monitoring for antihypertensive medication or lack of behavior monitoring for antidepressant medication for R31. On 05/24/22 at 11:56 AM R31 sat reclined in a recliner in room. TV was on in room, blind pulled down and closed, no distress or behaviors noted. On 05/26/22 at 12:51 PM in an interview, Certified Medication Aide (CMA) R stated that all the staff monitor the residents for behaviors. CMA R stated documented behavior monitoring on the Treatment Administration Record (TAR). CMA R stated vital signs were obtained and charted on the Medication Administration Record (MAR) prior to administration of the medication if a physician had ordered a parameter. [NAME] stated he would notify the charge nurse if outside the ordered parameter. On 05/26/22 at 01:20 PM in an interview, Licensed Nurse (LN) G stated she did not work with the MRR. LN G stated she obtained her vital signs when possible, vital signs are charted in the MAR/TAR if a medication had a physician ordered parameters. LN G stated behavior monitoring was documented every shift on the MAR/TAR by the LN and/or the CMA. On 05/26/22 at 02:04 PM in an interview, Administrative Nurse E stated she reviewed and entered orders from the MRR's when faxed from the physician. Administrative Nurse E stated behavior monitoring was documented on the MAR/TAR every shift for residents on antidepressant medication and antipsychotic (class of medications used to treat mental illness) medication. Administrative Nurse E stated not all medication and behavior monitoring were care planned. On 05/31/22 at 04:55 PM in an interview, CP GG stated the facility did change the order for monitoring for antihypertensives but did not add the daily vital sign monitoring with specific directions or frequency. CP GG stated she would not always recommend behavior monitoring for all residents taking an antidepressant medication. She said she reviewed the notes documented under the Progress Note tab for documentation of behaviors by exception. The facility Medication Regimen Reviews policy revised May 20219 documented the goal of the MRR was to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. The facility failed to ensure the CP noted irregularities for R31 for lack of monitoring antihypertensive medication daily and lack of behavior monitoring for antidepressant medication. This deficient practice placed R31 at risk for potential harm and adverse consequences related to unnecessary medications. - R16's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), history of falls, unsteady on feet, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS documented that R16 required extensive assistance of one staff member for activities of daily living (ADL's). The MDS documented no falls for R16 during the look back period. The MDS documented R16 had received antipsychotic medication (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions), antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression), diuretic medication (medication to promote the formation and excretion of urine), and opioid medication (a class of medication used to treat pain) for seven days during the look back period. The Quarterly MDS dated 03/25/22 documented a BIMS score of eight which indicated moderately impaired cognition. The MDS documented that R16 required extensive assistance of one staff member for ADL's. The MDS documented no falls during the look back period. The MDS documented R16 received antipsychotic medication, antidepressant medication, diuretic medication, and opiod medication for seven days during the look back period. R16's Psychotropic Drug Use Care Area Assessment (CAA) dated 01/18/22 documented a diagnosis of hypertension. R16's Care Plan dated 11/27/19 documented staff was to monitor/document/report as needed any signs or symptoms of malignant (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) hypertension. Review of the EMR under Orders revealed the following physician orders: Lisinopril tablet 20 milligram (mg) give one tablet by mouth in the morning related to hypertension. Hold if 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) less than(<) 80 millimeters of mercury (mmHg) or greater than (>)180mmHg diastolic blood pressure (DBP-minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) < 40mmHg or >100mmHg notify the physician. Call if BP parameters are out of bounds. SBP <90mmHg or >180mmHg, DBP <40mmHg or >90mmHg dated 04/07/20. Review of the Monthly Medication Review (MMR), performed by the CP, reviewed May 2022 through April 2022 did not address the lack of blood pressure monitoring for antihypertensive medication for R16. On 05/25/22 at 01:12PM R16 ambulated down from the front entrance door, with a walker. Her pants were wet in back, halfway down her left leg and across her buttocks. Observation revealed Activity staff Z ambulated beside R16 to her room. On 05/26/22 at 12:51 PM in an interview, Certified Medication Aide (CMA) R stated that all the staff monitor the residents for behaviors. CMA R stated documented behavior monitoring on the Treatment Administration Record (TAR). CMA R stated vital signs were obtained and charted on the Medication Administration Record (MAR) prior to administration of the medication if a physician had ordered a parameter. [NAME] stated he would notify the charge nurse if outside the ordered parameter. On 05/26/22 at 01:20 PM in an interview, Licensed Nurse (LN) G stated she did not work with the MRR. LN G stated she obtained her vital signs when possible, vital signs are charted in the MAR/TAR if a medication had a physician ordered parameters. LN G stated behavior monitoring was documented every shift on the MAR/TAR by the LN and/or the CMA. On 05/26/22 at 02:04 PM in an interview, Administrative Nurse E stated she reviewed and entered orders from the MRR's when faxed from the physician. Administrative Nurse E stated behavior monitoring was documented on the MAR/TAR every shift for residents on antidepressant medication and antipsychotic (class of medications used to treat mental illness) medication. Administrative Nurse E stated not all medication and behavior monitoring were care planned. On 05/31/22 at 04:55 PM in an interview, CP GG stated the facility did change the order for monitoring for antihypertensives but did not add the daily vital sign monitoring with specific directions or frequency. The facility Medication Regimen Reviews policy revised May 20219 documented the goal of the MRR was to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. The facility failed to ensure the CP noted irregularities for R16 for lack of monitoring antihypertensive medication daily. This deficient practice placed R16 at risk for adverse consequences related to unnecessary medications. - R33's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hypertension (elevated blood pressure), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented that R33 required assistance of two staff members for activities of daily living (ADL's). The MDS documented R33 received antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression), anticoagulant medication (class of medications used to prevent the formation of blood clots), for six days and diuretic medication (medication to promote the formation and excretion of urine) for five days during the look back period. R33's Psychotropic Drug Use Care Area Assessment (CAA) dated 04/26/22 documented she received an antidepressant medication as ordered and the CP would review medications on admission, monthly and as needed. R33's Care Plan dated 05/11/22 documented pharmacy would review medication monthly or protocol. The Care Plan dated 05/13/22 documented facility would monitor closely for behaviors for antidepressant treatment for R33. Review of the EMR under Orders tab revealed physician orders: Sertraline HCl tablet (antidepressant) 50 milligram (mg) give one tablet by mouth at bedtime related to depression dated 05/02/2022. Review of the Monthly Medication Review (MMR), performed by the CP, reviewed for May 2022 lacked evidence the CO identified the lack of behavior monitoring for antidepressant medication for R33. On 05/24/22 at 08:00 AM R33 laid in bed, head of elevated with bedside table across abdomen as she waited for breakfast. On 05/26/22 at 12:51 PM in an interview, Certified Medication Aide (CMA) R stated that all the staff monitor the residents for behaviors. CMA R stated documented behavior monitoring on the Treatment Administration Record (TAR). CMA R stated vital signs were obtained and charted on the Medication Administration Record (MAR) prior to administration of the medication if a physician had ordered a parameter. [NAME] stated he would notify the charge nurse if outside the ordered parameter. On 05/26/22 at 01:20 PM in an interview, Licensed Nurse (LN) G stated she did not work with the MRR. LN G stated she obtained her vital signs when possible, vital signs are charted in the MAR/TAR if a medication had a physician ordered parameters. LN G stated behavior monitoring was documented every shift on the MAR/TAR by the LN and/or the CMA. On 05/26/22 at 02:04 PM in an interview, Administrative Nurse E stated she reviewed and entered orders from the MRR's when faxed from the physician. Administrative Nurse E stated behavior monitoring was documented on the MAR/TAR every shift for residents on antidepressant medication and antipsychotic (class of medications used to treat mental illness) medication. Administrative Nurse E stated not all medication and behavior monitoring were care planned. On 05/31/22 at 04:55 PM in an interview, CP GG stated the facility did change the order for monitoring for antihypertensives but did not add the daily vital sign monitoring with specific directions or frequency. CP GG stated she would not always recommend behavior monitoring for all residents taking an antidepressant medication. She said she reviewed the notes documented under the Progress Note tab for documentation of behaviors by exception. The facility Medication Regimen Reviews policy revised May 20219 documented the goal of the MRR was to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. The facility failed to ensure the CP noted irregularities for R33 for lack of monitoring of behavior monitoring for antidepressant medication. This deficient practice placed R33 at risk for potential harm and adverse consequences related to unnecessary medications.

The facility had a census of 37 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections when staff failed to wear a mask inside the facility, left uncovered clean laundry in a cart in the hall, and hung Resident (R) 187's personal clothing on the hand rail outside her room. The facility further failed to ensure visitors to isolation room wore proper personal protective equipment (PPE). The facility further failed to ensure staff followed infection control principles during COVID (highly contagious, potentially fatal respiratory infection) test. This placed the 37 residents at risk for infection. Findings included: - On 05/23/22 at 07:07 AM an unidentified facility staff member who was not wearing a mask answered the facility door and allowed the survey team to enter. A sign posted at the entrance directed a mask must be worn at all times in the facilty. On 05/24/22 at 03:56 PM, observation revealed as needed (PRN) Licensed Nurse (LN) H tested herself for COVID with a COVID-19 test card. She swabbed her nose and placed the swab in the sample card. LN H then used hand sanitizer and left the room with the sample card. LN H carried the sample card in her hand, and went to the medication cart, the nurses' station, and stepped inside a resident's room. LN H then stood in the hallway, in front of the nurse's station, with the COVID sample card in her hand. On 05/24/22 at 04:07 PM, observation revealed a visitor entered R 114's isolation room without donning a gown, then exited the room. Social Service X asked the visitor to wear a gown when entering the resident's room. The visitor stated she would wear a gown but was unaware she needed to. On 05/24/22 at 04:07 PM, Social Service X verified the visitor entered R114's room without proper PPE and stated visitors should be wearing the necessary PPE to enter isolation rooms. On 05/25/22 at 09:31 AM, Administrative Nurse D stated all PRN staff have to test for COVID every time they come to the facility. Administrative Nurse D stated they are to test in the conference room and should make sure they stay in the conference room until the test is complete. Administrative Nurse D stated if staff were asymptomatic, they can continue to provide cares and check testing after 15 minutes to see results. Administrative Nurse D stated staff should not carry around used COVID test card. On 05/25/22 at 12:56 PM, observation revealed an uncovered black t shirt with sequins and a black pair of slacks, on separate hangers, hung on the handrail outside R187's room. On 05/25/22 at 12:59 PM, Certified Nurse Aide (CNA) N verified the uncovered clothing on the hand rail outside R187's room and stated laundry staff do not want to gown up and bring the resident's clothing to her room, so they hang it on the railing and when staff went into the R187's room, they take the clothing to her. On 05/25/22 at 02:50 PM, observation revealed a small wire cart (chest high) with four uncovered, cloth bed pads on the top shelf, four uncovered fitted sheets and four top sheets on the bottom shelf in the hall. On 05/25/22 at 02:51 PM, Certified Medication Aide (CMA) S verified the cart of uncovered clean resident linens, and stated staff kept it in the hall in case they needed it. CMA S stated the clean linen should possibly be covered and draped a top sheet over the cart. On 05/26/22 at 07:50 AM, observation revealed a small wire cart (chest high) with four uncovered cloth bed pads on the top shelf, four uncovered fitted sheets, and four top sheets on the bottom shelf. On 5/26/22 at 07:50 AM, Administrative Nurse E verified the cart of uncovered resident linen and stated staff should keep it covered even if they are passing the items out. On 05/26/22 at 01:11 PM, Administrative Nurse E stated that laundry staff should cover a resident's personal clothing if they hang them outside the door or have staff call and see if they are going in the resident's room before they bring them up. The facility's Departmental (Environmental Services)-Laundry and Linen Policy, revised January 2014, documented clean linen would remain hygienically clean(free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts. The facility's Visitation, Infection Control During Policy, revised January 2012, documented visitation during transmission-based precautions was permitted. Family members and visitors who are providing care or have very close contact with the resident would be trained regarding the appropriate use of infection control barriers such as personal protective equipment. The facility's COVID -19 Testing Policy, revised -2/08/22, documented All facility staff (including contractors, consultants, volunteers, and caregivers) that exhibit any type of symptoms that could be considered COVID -19 would be tested. Facility staff that exhibit signs and symptoms of possible COVID would be restricted from work pending outcome of test. If test positive would follow Centers of Disease Control (CDC) return to work criteria. The facility failed to provide a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases. This placed the 37 residents at risk for infection.

The facility identified a census of 37 residents with one kitchen and one dining room. Based on observation, record review, and interviews, the facility failed to ensure sanitary food storage. This deficient practice placed the residents at risk for food-borne illness. Findings Include: - On 05/23/22 at 07:08AM an initial walk-through of the kitchen's food storage area was completed. The walkthrough revealed that the floors in the storage areas were sticky in front of the dry food storage area. Upon inspection of the kitchen's walk-in freezer unit, open but undated bags of fries, chicken strips, potato tots, hash browns, peas, and chicken bites were observed. The freezer unit blower vent had visible dust and lint buildup covering the vents blowing towards the food stored in the unit. Inspection of the kitchen's walk-in refrigerator unit revealed an open but undated bag of tortillas. The refrigerator unit blower vent had visible dust and lint buildup covering the vents blowing towards the food stored in the unit. Inspection of the dry good storage rack outside the walk-in refrigerator unit revealed a bag of open but undated marshmallows. On 05/26/22 at 09:31AM an interview was completed with Dietary Staff BB; she stated that the kitchen staff complete a deep cleaning of the kitchen monthly, but each staff is assigned an area to clean daily. She reported that staff are to clean up daily. She reported that maintenance was responsible for checking the refrigerator units for serviceability. She reported that staff were responsible for checking the food storage areas every Saturday to ensure the food is safely stored and expired foods are rotated out. She reported that open foods should have an open date. A review of the facility's Food Storage policy dated 2020 stated all food items must be labeled. The label must include the name of the food and date by which it should be sold, consumed, or discarded. The policy stated all food should be stored on shelves in a clean area free from contaminants. The facility failed to ensure sanitary food storage. This deficient practice placed the residents at risk for food-borne illness

The facility had a census of 38 residents. Based on observation, interview, and record review, the facility failed to store, prepare and serve food in a clean sanitary environment in one of one facility kitchen for the 38 residents who received meals from the facility kitchen. Findings included: - On 10/19/20 at 07:40 AM, observation during initial tour of the facility's kitchen, revealed: One missing 2 foot (ft) by 2 ft ceiling panel over the three compartment sink and one ceiling panel over the soiled dish area halfway out of place. Shelves below the food preparation table, containing large pans and steam table pans, with gritty dark colored spots on the shelves under the pans and an oily substance on the bottom shelves. Wall mounted knife holder with visible dust on top where the knives slide in. Large sugar storage bin, dated 3/22, with a cracked and taped plastic lid. On 10/21/20 at 02:30 PM, Dietary Staff (DS) BB verified the knife holder and steam table pan shelves needed cleaning, and the ceiling panel should not have been left out of place. DS BB stated the registered dietician inspected the kitchen when she was on site and gave a written report to the administrator. DS BB stated the facility did not currently have a cleaning schedule. Upon request, the facility did not provide a kitchen cleaning policy or cleaning schedule. The facility failed to store, prepare, and serve food in sanitary conditions, placing the 38 residents who received food from the kitchen at risk for food borne illness.

The facility had a census of 38 residents. Based on observation, interview, and record review, the facility failed to store, prepare and serve food in a clean sanitary environment in one of one facility kitchen for the 38 residents who received meals from the facility kitchen. Findings included: - On 10/19/20 at 07:40 AM, observation during initial tour of the facility's kitchen, revealed the floor in the main kitchen area with three broken floor tiles. On 10/21/20 at 02:30 PM, Dietary Staff (DS) BB verified the broken floor tiles needed replaced. DS BB stated the registered dietician inspected the kitchen when she was on site and gave a written report, including the broken floor tiles, to the administrator. Upon request, the facility did not provide a policy for upkeep of the kitchen floor. The facility failed to provide a sanitary and comfortable environment for the residents that resided in the facility